Pain tolerance has long been identified as a factor influencing successful treatment of renal calculi by shock wave lithotripsy (SWL). We aimed to clarify which factors directly influence pain tolerance to predict which patients are likely to undergo successful treatment. We analysed retrospectively 179 patients who received their first SWL for a solitary kidney stone. All patients were on a non-opioid analgesia protocol and were treated on an outpatient basis. The target was to deliver 4,000 shock waves at an energy level of 4. In total, 53% of patients could tolerate the targeted shock wave number and energy and were retrospectively allocated into group A. Those who required a reduction in either energy levels or shock wave number were allocated in group B. Multivariate and univariate analysis showed that female patients, who are young with thin body habitus, have lower pain tolerance to SWL.

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Summary: Three-column fixation of tibial plateau fractures is now an established philosophy. A direct posterior approach with the patient prone affords enhanced exposure of the posterior column and ease of access for fixation using a buttress plate and posterior-to-anterior screws. A “direct posterior” approach through a reverse L-shaped incision to back of the knee is popular, yet complications associated with raising a fascial flap can occur. We present a simple method of conceptualizing a direct posterior approach through a single longitudinal incision, by likening it to a commonly performed orthopedic approach, the flexor carpi radialis approach to the wrist.