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BACKGROUND: This study presents a single surgeon’s experience comparing 1-year outcomes of endoscopic transforaminal lumbar interbody fusion (E-TLIF) vs minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in an Asian population. METHODS: Retrospective review of consecutive patients who underwent single-level E-TLIF or MIS-TLIF by a single surgeon in a tertiary spine institution from 2018 to 2021 with 1-year follow-up. Inclusion criteria for both procedures were degenerative disc disease with grade I or II spondylolisthesis and mild to moderate central canal stenosis. Clinical outcomes assessed included surgery duration, blood loss, and length of stay. Patient-reported outcomes assessed included the visual analog score for back pain and lower limb pain, Oswestry Disability Index, and North American Spine Society Neurogenic Symptom Score. Radiographic parameters assessed included segmental lordosis, posterior disc height, listhesis, and the presence of cage migration or subsidence. RESULTS: Twelve E-TLIF and 34 MIS-TLIF patients were identified. E-TLIF had shorter surgery duration (165 ± 15 vs 259 ± 43 min for E-TLIF and MIS-TLIF groups, respectively; P < 0.001), reduced blood loss (83 ± 75 vs 181 ± 225 mL; P = 0.033), and decreased length of stay (1.8 ± 0.9 vs 4.7 ± 2.9 days; P < 0.001) compared with MIS-TLIF. E-TLIF and MIS-TLIF patients had significant improvements (P < 0.05) at 1 year in all patient-reported outcomes scores and radiographic parameters assessed. Both E-TLIF and MIS-TLIF patient groups also had similar postoperative patient-reported outcomes scores and radiographic parameters. No complications were recorded for E-TLIF, while MIS-TLIF had a case of dura tear and another case of meralgia paresthetica. There were no instances of cage subsidence, cage migration, or implant loosening in either group at 1 year. CONCLUSIONS: Although the study size was limited because E-TLIF is a relatively new technique in our institution, 1-year results demonstrate that E-TLIF can be a safe and efficacious option that achieves clinical and radiological results similar to MIS-TLIF with the additional benefits of decreased surgical duration, blood loss, and length of hospital stay. CLINICAL RELEVANCE: The results of this study support the effectiveness and potential advantages of endoscopic TLIF compared with MIS-TLIF. LEVEL OF EVIDENCE: 3

Fractures in the posterior aspect of the medial malleolus form an important subset of ankle fractures and the indications for fixation include involvement of > 25% of the articular surface or an articular step off by > 2 mm. Several approaches have been described but there has been no recent study on the direct medial approach. Five fresh frozen cadaveric ankles were dissected using the direct medial approach. A longitudinal incision of 10 cm was centered directly over the medial malleolus and deepened straight down to the bone. The periosteum was identified over the distal tibia and careful subperiosteal dissection yielded access to the posterior aspect of the medial malleolus. We investigated the relationship of the neurovascular bundle to the incision by measuring the distance from the center of the medial malleolus to the closest aspect of the bundle. The mean distance from the center of the medial malleolus to the neurovascular bundle was only 2.64 cm (95% CI: 2.06 to 3.22 cm). We found that the neurovascular bundle could be avoided if a periosteal sheath was developed during the dissection and elevated off the posterior aspect of the medial malleolus. The direct medial approach can be performed safely by creating a periosteal sheath through subperiosteal dissection, and the distance of the neurovascular bundle from the incision allows for a good margin of safety during surgery. This approach can be extended proximally and distally and the medial malleolus can be fixed concurrently. Clin. Anat. 31:605-607, 2018. © 2017 Wiley Periodicals, Inc.

Fractures in the posterior aspect of the medial malleolus form an important subset of ankle fractures and the indications for fixation include involvement of 25% of the articular surface or an articular step off by 2 mm. Several approaches have been described but there has been no recent study on the direct medial approach. Five fresh frozen cadaveric ankles were dissected using the direct medial approach. A longitudinal incision of 10 cm was centered directly over the medial malleolus and deepened straight down to the bone. The periosteum was identified over the distal tibia and careful subperiosteal dissection yielded access to the posterior aspect of the medial malleolus. We investigated the relationship of the neurovascular bundle to the incision by measuring the distance from the center of the medial malleolus to the closest aspect of the bundle. The mean distance from the center of the medial malleolus to the neurovascular bundle was only 2.64 cm (95% CI: 2.06 to 3.22 cm). We found that the neurovascular bundle could be avoided if a periosteal sheath was developed during the dissection and elevated off the posterior aspect of the medial malleolus. The direct medial approach can be performed safely by creating a periosteal sheath through subperiosteal dissection, and the distance of the neurovascular bundle from the incision allows for a good margin of safety during surgery. This approach can be extended proximally and distally and the medial malleolus can be fixed concurrently. Clin. Anat. 31:605-607, 2018. © 2017 Wiley Periodicals, Inc.