Background:Hip resurfacing arthroplasty remains an appealing option for young and active patients1, but its use has declined because of technical challenges, risks of femoral neck notching, and adverse reactions associated with metal-on-metal bearings, raising concerns regarding long-term implant survival2. Accurate preparation of the femoral head and acetabulum is critical for successful outcomes3. In the present video article, we describe a reproducible technique utilizing preoperative 3D computed tomography (CT)-based planning and patient-specific 3D-printed jigs to optimize femoral head preparation, in conjunction with a direct anterior approach that preserves tendon attachments and avoids muscle injury. Description:Through a standard anterolateral skin incision and fascial split, the tensor fasciae latae (TFL) is mobilized by blunt finger dissection up to the anterior superior iliac spine while maintaining its fascial origin. The superficial internervous plane is created between the TFL laterally and the sartorius medially. Dissection proceeds in the deep interval between the gluteus medius and rectus femoris, with care to preserve the ascending branches of the lateral circumflex femoral vessels. The approach continues to the hip joint capsule, which is sharply incised to allow femoral head dislocation. Femoral head preparation is guided by patient-specific 3D-printed jigs generated from preoperative CT scans. Each jig provides a reproducible entry point and trajectory for a Steinmann pin, ensuring central alignment and avoiding femoral neck notching. Sequential reaming, chamfer cuts, and trialing are performed. The acetabulum is exposed with 3 retractors (anterior and inferior Hohmann and posterior curved 2-pronged) and progressively reamed without fluoroscopy until congruent hemispherical coverage is achieved. A press-fit cup is implanted without cement, followed by cementation of the femoral component with use of a dry-field technique. Stability and leg length are reassessed, and closure is performed in layers with barbed absorbable sutures and a waterproof dressing. If intraoperative stability or leg length restoration is found to be unsatisfactory, adjustments are made prior to final implantation. This may include repositioning of the acetabular component, upsizing or adjusting the femoral component, or performing additional soft-tissue release to achieve proper balance. Cementation of the definitive implants and closure are only performed once stability and length are confirmed in all functional positions. Alternatives:Conventional resurfacing techniques rely on intraoperative fluoroscopy, mechanical alignment guides, or freehand pin placement for femoral head preparation. Compared with these methods, 3D-printed patient-specific jigs minimize intraoperative fluoroscopy, standardize pin trajectory, and reduce the risk of malalignment and implant mispositioning. Similarly, total hip arthroplasty remains a well-established alternative to hip resurfacing, providing predictable pain relief and functional outcomes, although with greater bone resection and different long-term considerations. Rationale:Patient-specific jigs derived from CT-based planning provide individualized guidance that restores native femoral head-neck orientation in slight valgus, reducing the risk of femoral neck notching and improving component survival. The minimally extensile direct anterior approach minimizes soft-tissue damage while ensuring adequate exposure of both the femoral and acetabular sides. Expected Outcomes:Patients may expect early postoperative weight-bearing, decreased need for analgesia, and comparable short-term functional outcomes. Patients may expect a more extensile incision, for adequate manipulation and dislocation of the femoral head, compared with the standard Smith-Petersen approach performed for conventional total hip arthroplasty3,4. There is limited visualization of the superolateral aspect of the femur and posterolateral aspect of the acetabulum compared with the posterior approach, which may result in longer operative time because of technical challenges. Possible complications of the procedure are femoral neck fracture, component malpositioning, and lateral femorocutaneous nerve paresthesia4, which itself is not associated with a limitation in function5,6. In addition, femoral nerve palsy as a result of inaccurate placement of retractors is a dreaded complication. Other potential complications associated with this procedure include metal-on-metal reactions (when applicable), dislocation, procedure failure requiring conversion to total hip arthroplasty, superficial or deep infection, hemorrhage, and other related adverse events. In a recent study conducted at our institution but not yet published, the revision rate was 10% at a median follow-up of 17 months, with the most common reason for revision being postoperative femoral neck fracture. Additional findings included a Forgotten Joint Score of 67% at 1 year postoperatively, closely matching the 68% reported in recent total hip arthroplasty studies8,9. The mean blood loss was 118.75 mL, and the mean length of hospital stay was 2.25 days. Important Tips:The anterior approach requires meticulous dissection and hemostasis.The anterior approach is conducted with minimal exposure, requiring careful manipulation to release the capsule.The use of 3D models is essential for accurate guidewire placement and alignment and for achieving a precise fit of ceramic or metal heads.Finger dissection of the TFL up to the anterior superior iliac spine avoids detachment and preserves muscle integrity.The posterior curved 2-pronged retractor exposes the posterior acetabulum and displaces the femoral head posteriorly, creating a working space and protecting cancellous bone.Ensure meticulous drying of the femoral head before cementation to optimize fixation.During acetabulum reaming, the reamer head can be introduced first, followed by attachment of the handle, in order to maximize clearance in tight spaces. Acronyms and Abbreviations:CT = computed tomographyASIS = anterior superior iliac spine.
Background:Allograft reconstruction is indicated for chronic pectoralis major tears because such tears will have fibrotic changes, retraction, and stiffness that prevent primary repair1-3. Various reconstruction techniques have been described, particularly in cases in which the myotendinous unit is degenerated. Autografts (such as hamstring tendons and bone-patellar tendon-bone grafts) and allografts (such as Achilles tendon, fascia lata, and dermal grafts) have both been utilized4,5. In the present video article, we describe a technique utilizing a doubled Achilles tendon allograft, which provides sufficient width to replicate the native sternal head insertion. A 3-point fixation construct is utilized to enhance graft-to-muscle interface strength. Description:An anterior axillary approach is utilized for cosmesis and optimal access. A 7 to 8-cm incision is made just lateral to the axillary fold, retracting the clavicular head laterally without exposing the deltopectoral interval. The sternal head is identified via MRI guidance and intraoperative cues, including fibrous "guitar-string" adhesions. Dissection remains anterior to the clavipectoral fascia to avoid neurovascular structures. The retracted muscle, typically fibrotic and shortened, is tagged with 3 high-tensile, nonabsorbable sutures. The Achilles allograft is folded to create upper and lower leaflets. Three rows of Krackow locking sutures are placed in the upper leaflet and 2 sutures in the lower leaflet. With use of a bent Hohmann retractor, the clavicular head is retracted laterally. The anatomic insertion site-posterior to the clavicular head and lateral to the bicipital groove-is prepared with use of a burr. Importantly, no osseous trough is created, minimizing fracture risk. Three 4.5-mm drill holes are made vertically. The folded Achilles allograft is secured to the humerus with use of unicortical suture buttons and a tension-slide maneuver. Sutures are tied through the graft for secondary fixation, first securing the graft to the bone without also securing to the torn muscle under tension. Attention then turns to the muscle-to-graft connection. The arm is adducted to neutral and internally rotated. The tagged sternal head is drawn between the Achilles leaflets and temporarily clamped. Proper tension allows 60° of abduction; if not, the muscle is repositioned more medially. Fixation is completed at 3 points. (1) Heavy sutures from the lower leaflet are passed posterior-to-anterior through the pectoralis and tied. (2) The tagging sutures from the pectoralis major are passed through the Krackow rows in the upper leaflet and tied, using rip-stops to reinforce fixation. (3) The uncut sutures from the lower leaflet are passed through the upper leaflet, closing the "fish-mouth" configuration. Excess graft is trimmed, and the leaflets are secured with use of a running 2-0 Vicryl (Ethicon) suture. Alternatives:Nonoperative treatment with use of physical therapy often results in persistent deformity and strength loss. Alternative grafts include dermal allograft, fascia lata, hamstring autograft, and bone-patellar tendon-bone autograft6-9. Rationale:A doubled Achilles allograft offers 3 main advantages. This technique replicates the native sternal head width. Three-point fixation enhances graft-to-muscle fixation strength, thereby reducing the risk of failure at the graft-tendon interface. Importantly, fixation of the allograft to the humerus is performed first, providing a stable foundation without depending on achieving correct muscle tension or graft length. Expected Outcomes:A doubled Achilles allograft reliably restores the pectoralis major tendon unit, even in ultra-chronic cases (up to 20 years post-injury). Favorable outcomes have been reported for strength and function restoration. In a study by Zacchilli et al.10, 3 military patients who underwent reconstruction at an average of 22.2 months post-injury had excellent or good outcomes and returned to active duty within 6 months. Similarly, Javed et al.11 reported on 19 patients who underwent reconstruction at a mean of 12.2 months post-injury, with 84% experiencing significant strength improvement at 3.8 years postoperatively. Important Tips:Preoperative Hibiclens (Mölnlycke Health Care) and benzoyl peroxide reduce infection risk; a cyanoacrylate dressing postoperatively protects the incision.Utilize an anterior axillary incision for better cosmesis and access.Employ a flexible circular retractor to optimize exposure.A headlamp facilitates deep visualization.Perform blunt dissection to mobilize the muscle without injuring surrounding structures.Use color-coded Krackow sutures for organization.Drill lateral to the bicipital groove to align the graft properly.Position the arm adducted and internally rotated during fixation for optimal tensioning.Inadequate muscle mobilization leads to poor tensioning.Over-tensioning restricts motion; under-tensioning compromises function. Slightly tight tension is preferred to account for expected lengthening over time.Posterior dissection risks neurovascular injury.Poor suture button deployment can jeopardize fixation; utilize multiple buttons for redundancy. Acronyms and Abbreviations:MRI = magnetic resonance imaging.
Background:Posterior C1-C2 instrumentation and fusion is a well-established technique for the treatment of atlantoaxial instability. Safe posterior exposure is critically important because of the proximity of the vertebral artery, venous plexus, and C2 dorsal root ganglion. However, practical exposure nuances and safety pearls are often underemphasized. Description:The present video article demonstrates a stepwise approach for posterior exposure for C1-C2 instrumentation and fusion. Preoperative assessment includes dynamic flexion-extension radiographs to evaluate instability and reducibility, and computed tomography (CT) angiography to identify a high-riding vertebral artery or vascular anomalies. The patient is positioned prone with the head secured in a Mayfield clamp (or a horseshoe headrest). A midline posterior incision and subperiosteal dissection are performed to expose the posterior elements of C1 and C2. Key technical steps include careful management of the venous plexus, identification and preservation of the C2 dorsal root ganglion, exposure of the C1 lateral mass and C2 pars interarticularis, and controlled atlantoaxial joint mobilization to achieve reduction. Screws are placed in the C1 lateral mass and C2 pars interarticularis under fluoroscopic guidance, followed by rod placement, decortication, and bone grafting to achieve fusion. Alternatives:Nonoperative treatment options include cervical immobilization and pharmacologic intervention. Surgical alternatives include other posterior fixation techniques, wiring constructs, or anterior approaches in select cases. Rationale:Meticulous posterior exposure with attention to venous plexus control and ganglion preservation allows safe and reproducible C1-C2 instrumentation while minimizing the risk of neurovascular complications. Expected Outcomes:Patients are counseled that posterior C1-C2 instrumentation and fusion is intended to provide stable fixation of the atlantoaxial complex, relieve pain related to instability, prevent progressive neurological compromise, and achieve a high rate of solid fusion. Previous studies have demonstrated reliable fusion, significant improvement in neck pain, and durable radiographic stability following posterior C1-C2 fixation with use of screw-rod constructs. Harms and Melcher2 reported high rates of fusion with maintained alignment and low rates of hardware failure with use of posterior C1 lateral mass and C2 screw fixation. Goel and Laheri3 similarly demonstrated effective stabilization and neurological improvement following posterior atlantoaxial fixation. Contemporary reviews have confirmed that modern posterior fixation techniques provide predictable clinical and radiographic outcomes with acceptable complication rates when meticulous surgical technique and appropriate preoperative planning are employed. Important Tips:Obtain dynamic flexion-extension radiographs preoperatively to assess atlantoaxial instability and reducibility; reduction seen on extension helps guide intraoperative positioning.Perform routine CT angiography to identify a high-riding vertebral artery or aberrant vascular anatomy that may alter screw trajectory.Secure the head in a Mayfield clamp and maintain neutral or slight extension; avoid excessive rotation during positioning.Use a strict midline, subperiosteal dissection to minimize muscle trauma and reduce venous bleeding.Anticipate and carefully control the venous plexus around C1-C2 with use of gentle bipolar coagulation and hemostatic agents; avoid blind cauterization.Identify and preserve the C2 dorsal root ganglion; minimize prolonged or forceful retraction to reduce postoperative occipital neuralgia.Clearly define osseous landmarks before instrumentation, particularly the C1 lateral mass and C2 pars interarticularis.Perform gentle atlantoaxial joint mobilization to achieve reduction prior to definitive screw placement.Confirm screw trajectories with fluoroscopy before drilling and final screw insertion to avoid vertebral artery injury.Thoroughly decorticate posterior elements and apply adequate bone graft to optimize fusion. Acronyms and Abbreviations:C1 = first cervical vertebra (atlas)C2 = second cervical vertebra (axis)CTA = computed tomography angiographyDRG = dorsal root ganglion.
Background:The tibial physis is responsible for about 30% of the growth in the limb1. Therefore, preservation of this growth potential in skeletally immature patients undergoing distal femoral tumor resection and reconstruction is important. Reconstruction with use of an expandable prosthesis has a high failure rate2,3. Osteoarticular allograft reconstruction of the distal femur allows for the preservation of the proximal tibial plateau; however, the small size of the child's tibial plateau relative to the femoral condyle of the allograft creates challenges in size matching2,4,5. To address this issue, resurfacing the osteoarticular allograft with the appropriate femoral component of a total knee prosthesis, referred to as allograft-prosthesis composite (APC) reconstruction, could be regarded as a viable alternative2,6. Description:An anterior longitudinal incision is made encompassing the biopsy tract, either medial or lateral to the midline, depending on the tumor mass. The roof of the adductor canal is opened to expose the femoral vein and artery for protection. The resection length is based on the length of medullary involvement as measured on magnetic resonance imaging (MRI), plus an additional 2-cm margin. The bone marrow from the proximal femur is sent for frozen-section analysis in order to ensure that an adequate margin has been achieved. Depending on the MRI findings, the capsule, collateral ligaments, and cruciate ligaments are incised, and the meniscus on the tibial plateau is preserved, with consideration given to achieving a negative margin. An appropriately sized osteoarticular allograft with the retained capsule and ligaments is obtained from a standard bone bank. The femoral component of the unconstrained total knee prosthesis is matched for size with the patient's tibial plateau and is fixed to the distal end of the osteoarticular allograft with use of bone cement. The resurfaced allograft is fixed to the host bone with a bridging plate. The ligaments and capsule of the allograft are sutured as closely as possible to their counterparts in the proximal tibia. Knee stability is evaluated at the end of the procedure. Two crossed pins are utilized to fix the knee in 15° flexion to prevent joint subluxation in cases of knee instability and are removed after 2 weeks. Alternatives:One alternative is reconstruction with use of an expandable prosthesis; however, high failure rates have been reported, including due to stem loosening, lengthening failure, and periprosthetic fracture3. Moreover, currently available expandable prostheses require a minimum resection length substantially longer than the actual tumor length, leading to unnecessary removal of healthy bone and loss of valuable bone stock in growing children2,3. Osteoarticular allograft presents challenges related to the small size of the tibial plateau in pediatric patients relative to the allograft femoral condyle, leading to a Charcot joint developing in all patients emerging around 8 years postoperatively4,5. Rationale:APC reconstruction preserves the proximal tibial growth plate and retains more bone stock for future revisions. This technique offers benefits over the use of an osteoarticular allograft, including improved knee function and a reduced risk of osteoarthritic changes, and can even be performed on patients <9 years old. Expected Outcomes:Median knee range of motion was 100°, and the median Musculoskeletal Tumor Society score was 28. Sports activity was possible in two-thirds of cases2. Important Tips:Choose a medial or lateral approach on the basis of the dominant tumor location.During tumor resection, take care to preserve the neurovascular bundle.After opening the adductor canal, detach the medial gastrocnemius head from the distal femur to facilitate genicular artery ligation and the separation of the vascular bundle from the lesion.Try to use an allograft with remaining ligamentous and capsular structures, as attaching these to their host counterparts can enhance the restoration of joint stability.The compression plate should fully cover the allografts and secure them to the host bone, and compression should be maintained with at least 4 screws.The selected cruciate-retaining femoral component of the THA should be secured to the distal allograft with high-viscosity cement according to the total knee method. Acronyms and Abbreviations:rAPC = resurfaced allograft-prosthesis compositesTKA = total knee arthroplastyMRI = magnetic resonance imagingDVT = deep vein thrombosisPE = pulmonary embolismMSTS = Musculoskeletal Tumor SocietyROM = range of motionDJD = degenerative joint disease.
Background:Cervical spine pathologies causing nerve-root compression are treated with use of decompression through a variety of techniques. Although several operative management options exist, cervical foraminotomy may be indicated in patients with isolated, unilateral cervical radiculopathy. Biportal endoscopic cervical foraminotomy allows decompression with minimal soft-tissue disturbance and excellent visualization. Description:The procedure is performed with the patient in a prone position with routine neuromonitoring. Intraoperative fluoroscopy is utilized to identify the operative level, and 2 paramedian incisions are made for the portal sites at a 20° to 30° angle to the desired disc space. The working portal is utilized for surgical instruments, and the second portal serves as a viewing portal for the endoscope. Sequential dilators are utilized to establish the working portal, and a semi-tubular sheath of the desired length is placed. For the viewing portal, an endoscopic trocar is advanced through the fascia, and the camera is introduced. After endoscope insertion, surgical landmarks are identified, beginning with the interlaminar V point that marks the junction of adjacent laminae at the medial border of the facet joint. Once identified, overlying soft tissue is removed using radiofrequency ablation, and decompression of the nerve root can begin. We alternate between utilizing a high-speed diamond burr and a Kerrison rongeur to perform a laminoforaminotomy. Care is taken to minimize the facetectomy extent to <50% in order to reduce the risk of iatrogenic instability. The ligamentum flavum is preserved until the end in order to protect the dura from fluid pressure and surgical instruments. In the presence of disc herniation, disc fragments are removed through the working portal after gentle nerve root retraction. Once decompression of the neural foramen is completed to the lateral border of the pedicle, meticulous hemostasis is achieved using radiofrequency ablation, bone wax, and flowable thrombin-based hemostatic agents. Patients are typically discharged home on the same day. Alternatives:Patients can undergo cervical foraminotomy utilizing traditional open, microscopic tubular, or uniportal endoscopic techniques. Alternatively, patients may undergo anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA), according to surgeon preference and individual patient pathology. Rationale:Both open and minimally invasive cervical foraminotomy result in favorable clinical outcomes1,2. However, minimally invasive approaches are associated with earlier discharge, and reduced muscle damage and operative blood loss. Although tubular foraminotomy is a traditional minimally invasive option, endoscopic approaches offer distinct benefits. First, biportal endoscopy allows for greater maneuverability and visualization of the neural foramen. Second, compared with ACDF and CDA, foraminotomy obviates the need for instrumentation, preserves segmental motion, and avoids the anterior approach, which is associated with dysphagia, dysphonia, and potential for vascular injury. Expected Outcomes:Ruetten et al. conducted a randomized controlled trial comparing endoscopic cervical posterior foraminotomy to traditional microsurgical foraminotomy3. In that study, 87.4% of patients experienced complete resolution of their arm pain, although there were no differences in clinical outcomes, complication rates, or revision rates between treatment groups. Most evidence regarding the role of endoscopic cervical foraminotomy remains low-quality; however, meta-analyses have reported high clinical success, with 91% to 94.9% of patients demonstrating good-to-excellent clinical outcomes2,4,5. A separate meta-analysis of prospective trials showed similar clinical outcomes between endoscopic foraminotomy and ACDF for cervical radiculopathy but a significantly shorter perioperative hospitalization time with endoscopic foraminotomy6. When broadly comparing minimally invasive foraminotomy to open foraminotomy, patients undergoing minimally invasive foraminotomy experienced reduced blood loss (52.8 versus 173.5 mL), operative duration (58 versus 108 min), and inpatient narcotic use (2.5 versus 27.6 milligram morphine equivalents)1. Important Tips:Achieve adequate endoscopic visualization before starting osseous resection.Avoid inserting instruments blindly into the interlaminar space.Complete removal of the medial superior articular process up to the lateral border of the pedicle.Ensure palpation of the lateral aspect of the cranial and caudal pedicles.Inspect for extruded disc material.Maintain the ligamentum flavum until the end of the decompression.Achieve hemostasis to prevent postoperative epidural hematoma. Acronyms and Abbreviations:NSAID = nonsteroidal anti-inflammatory drugACDF = anterior cervical discectomy and fusionCDA = cervical disc arthroplastyESI = epidural steroid injectionRFA = radiofrequency ablation.
Background:The present video article demonstrates the use of Evans and Cotton osteotomies with porous titanium wedges for the treatment of pediatric flatfoot. Pediatric flatfoot is not commonly painful or disabling and usually resolves as the arch elevates spontaneously. However, in cases of flatfoot that persist despite nonoperative treatment, symptoms such as severe activity-related pain and medial foot calluses are an indication for surgical intervention3. The aims of treatment in pediatric patients are to correct anatomical deformity and reduce pain while maintaining mobility. Description:Reconstruction of the foot is achieved by performing a lateral column lengthening calcaneal osteotomy (i.e., Evans osteotomy)4 and an opening-wedge medial cuneiform osteotomy (i.e., Cotton osteotomy)5. These procedures are preceded by assessment of the Achilles tendon with use of the Silfverskiöld test for contracture, and subsequent percutaneous lengthening if appropriate. The Evans osteotomy is performed by first accessing the lateral hindfoot via an Ollier incision, exposing the calcaneocuboid joint. Osteotomy of the anterior calcaneus is followed by distraction until the desired correction is achieved. Insertion of a porous titanium wedge, sized appropriately, supports the correction. To perform the Cotton osteotomy, an incision is made dorsally for access to the medial cuneiform. Image intensifier radiography is utilized to identify the middle of the medial cuneiform in both the coronal and sagittal planes in order to guide the osteotomy location. The osteotomy is opened with use of a Hintermann retractor, and an appropriately sized porous titanium wedge is inserted. Positioning of the wedges and subsequent deformity correction are evaluated with use of image intensifier radiography. Alternatives:Numerous other surgical techniques have been described for the treatment of flatfeet3,6. Extra-articular subtalar arthrodesis procedures have been frequently utilized7,8, particularly in patients with substantial subtalar osteoarthritis. This procedure aims to stabilize the subtalar joint through fusion; however, arthrodesis is not frequently performed in pediatric patients because arthritis is less common and preservation of movement is important during growth. Arthroereisis similarly stabilizes the subtalar joint by limiting anterior movement of the talus with use of a prosthesis, rather than completely fusing the joint9. This can also be performed via a more minimally invasive technique. Other techniques have also been utilized to maintain osteotomy correction, including autologous iliac crest grafting and locking plates, both of which have their own limitations. Rationale:The combination of Evans and Cotton osteotomies ensures restoration of the functional integrity of the medial longitudinal arch through lengthening of the lateral column, resulting in correction of forefoot abduction and hindfoot valgus while adjunctively plantar flexing the medial column. The combined use of these osteotomies demonstrates greater preservation of mobility compared with both subtalar arthrodesis and arthroereisis. Studies have shown good results over long-term follow-up10,11, especially when combined with percutaneous Achilles tendon lengthening as appropriate12,13. Autologous iliac crest grafting has been associated with persistent donor-site pain and morbidity14. Locking plates have been utilized to avoid the issues associated with autologous graft while also better maintaining correction in the long term; however, locking plates are associated with a longer operative time, screw breakage, and tendinitis as a result of rubbing over the plate15. Porous titanium wedges offer an effective method of maintaining correction, with significant radiographic, clinical, and symptomatic improvement in follow-up studies16,17. Expected Outcomes:The long-term expectation is that correction of the deformity will reduce pain while restoring function of the subtalar joint. Studies assessing the use of titanium wedges for Cotton and Evans osteotomies have shown both good improvement in radiographic features and improvement of pain. With Evans osteotomies, pain (measured with use of a visual analogue scale) improved from 5.45 to 2.43 postoperatively, and postoperative Foot and Ankle Ability Measure Activities of Daily Living and Sports scores improved to 80.45 and 58.52. Similar results have been seen with Cotton osteotomies, with significant improvements in pain and radiographic findings (Kite angle and Meary angle) postoperatively1. The overall complication rate has been reported at 15.2%, with major complications (nonunion with or without reoperation, deep infection, and chronic regional pain syndrome) at 2.1%. Minor complications reported included transient painful hardware, transfer pain, sinus tarsi syndrome, lateral column overload, lateral ankle pain, development of adjacent joint arthritis, and superficial wound complications2. Important Tips:Rule out tarsal coalition with use of preoperative MRI. If present, resection can be performed and combined with Evans and Cotton osteotomies either at the same time or as a staged procedure.Careful dissection is paramount in order to avoid damaging the sural nerve while approaching the calcaneocuboid joint.Avoid "overstuffing" by ensuring appropriate sizing of the wedge.Take care to perform a good skin closure because lateral column lengthening always "tenses" the lateral foot. Acronyms and Abbreviations:LCL = lateral column lengtheningCCJ = calcaneocuboid jointII = image intensifierAP = anteroposteriorMRI = magnetic resonance imagingK-wire = Kirschner wireTA = tendon AchillesCT = computed tomography.
Background:The "French Paradox" technique, one of the various femoral cementing techniques in total hip replacement, was developed by Marcel Kerboull at Cochin Hospital, Paris, in the 1960s. Its fundamental principles include removal of the cancellous bone, use of a highly polished and collared canal-filling stem, and a straightforward cementation technique. This technique differs from the taper-slip philosophy, which relies on controlled subsidence, and the composite-beam concept, which seeks rigid bonding between stem and cement to act as a single structural unit. Description:Following patient positioning on the Judet positioning table, a bikini Hueter anterior approach is performed. After implantation of the acetabular component, the femur is exposed with the aid of the positioning table. Femoral preparation begins with the use of an aggressive canal-finder rasp and curet to establish the entry and remove initial cancellous bone. Subsequent preparation is performed with use of either aggressive cutting broaches or flexible reamers, with the objective of removing as much cancellous bone as possible. Following insertion of the cement plug, the femoral canal is thoroughly washed and then dried. A suction drain is then inserted close to the cement plug, and medium-viscoelasticity cement is inserted with use of a regular syringe or a flexible cement gun. Creating negative pressure within the canal helps aspirate any blood that might impede optimal cement interposition. Furthermore, given the canal-filling design of the stem, any small tunnel that exists after drain removal is expected to collapse under pressure. The highly polished stem is then inserted until the collar touches the neck cut. Alternatives:Alternatives include the taper-slip and composite-beam techniques. The taper-slip technique involves the use of a highly polished stem that subsides slightly within the cement mantle, generating controlled compressive forces to preserve the cement-bone interface. The composite-beam technique involves the use of a matte stem that bonds to the cement mantle, creating a unified structure that resists micromotion and maintains stability. Rationale:The French Paradox cementing technique requires the removal of cancellous bone, which becomes weak with aging and cannot effectively carry load. By eliminating this compromised layer, the technique is thought to allow forces to be transmitted directly to the cortical bone. This is the proposed mechanism for reducing the risk of periprosthetic fracture in the elderly population by preventing any subsidence of the stem. Additionally, compared with other cementing techniques, the French Paradox technique is easy, cost-effective, and reproducible. There is no need for a tip centralizer or vacuum cement preparation, and the femoral preparation closely resembles that for a cementless implant, making the technique more intuitive for surgeons already experienced with cementless hip arthroplasty. Expected Outcomes:El Masri et al. observed that femoral components cemented with use of the French Paradox technique had not subsided at long-term follow-up. Nich et al. and Kerboull et al. also reported >98% survival of Charnley-Kerboull stems at 15 years postoperatively. More recently, a shortened version of the Charnley-Kerboull stem (AMIS-K; Medacta International) was developed after in vitro validation, providing optimal stem length reduction of 12%. Laboudie et al. compared the in vivo migration of the AMIS-K implant and the standard-length Charnley-Kerboull implant in a matched-pair cohort of 50 hips in each group. At 2 years postoperatively, the mean subsidence was 0.65 mm in the AMIS-K group compared with 0.68 mm in the standard Charnley-Kerboull group. In another study of 416 hips in patients >70 years old undergoing primary total hip replacement with the French Paradox technique and AMIS-K implant, Laboudie et al. reported a 0.48% rate of early periperiprosthetic femoral fractures. Important Tips:Perform the femoral neck cut according to the preoperative plan, as this technique employs a collared stem.Remove cancellous bone thoroughly, particularly in the superomedial region, with use of a curet or flexible reamer.Utilize cutting broaches of increasing size until the trial broach or stem achieves good anteroposterior and rotational stability. The trial broach should provide a press-fit comparable to that of standard cementless techniques, making the procedure more intuitive for surgeons accustomed to cementless designs.Note that a compaction-broaching technique is not considered a French Paradox because it compacts rather than removes cancellous bone. Switching intraoperatively to a cemented stem that mimics the shape of a cementless straight stem (e.g., the CORAIL [DePuy Synthes]) is also not considered a French Paradox.Insert a cement restrictor and perform simple lavage of the medullary canal.Utilize medium-viscoelasticity cement.Insert cement with use of a syringe or cement gun in a straightforward manner.Achieve pressurization via the canal-filling design of the stem. Acronyms and Abbreviations:THR = total hip replacementCK = Charnley-KerboullPFF = periprosthetic femoral fractureCMK = Charnley Marcel KerboullEBRA-FCA = Ein Bild Roentgen Analyse-femoral component analysisTHR = total hip replacementDAA = direct anterior approachCPT = CPT Hip System (Zimmer Biomet)LFCN = lateral femoral cutaneous nerveGT = greater trochanterTFL = tensor fascia latae.
Background:Submuscular plating with use of a non-locking plate is indicated for the treatment of extra-articular proximal femoral fractures in children ≥6 up to 14 years old. There is no specific weight limit for the use of this procedure. The aim of the procedure is fracture stabilization and facilitation of fracture union through the use of a minimally invasive approach1. Description:The surgical technique is performed with the patient under general anesthesia and in the supine position on a fracture table. A stainless steel non-locking dynamic compression plate (4.5-mm system) is placed on the anterior aspect of the thigh and examined with use of a C-arm to confirm that the chosen length is appropriate, then placed along the lateral aspect of the thigh under C-arm visualization to determine the site for proximal contouring. Proximal plate contouring is performed with use of a plate bender. Through a distal incision, a submuscular tunnel is made. A proximal incision is then made over the greater trochanter. The plate is slid from the distal to the proximal end. The plate is temporarily stabilized with use of Kirschner wires via the proximal and distal holes. After confirming the plate position with use of the C-arm, non-locking screws are placed first on the distal and then on the proximal end of the plate. A total of 3 screws are inserted into each of the distal and proximal fragments1. Length, rotation, and alignment are confirmed postoperatively on clinical evaluation and radiographs. The patient is kept non-weight-bearing until early signs of healing are seen on radiographs, then active hip and knee range-of-motion exercises are started. Follow-up visits are conducted at 2, 4, 8, and 12 weeks postoperatively. Toe-touch weight-bearing is allowed at 8 weeks after signs of callus on radiographs. Progression to full weight-bearing is allowed on observation of radiographic fracture union. At 10 weeks, the patient is expected to be full weight-bearing. Implant removal is offered at 1 year postoperatively. Alternatives:Alternatives for treating pediatric extra-articular proximal femoral fractures include the use of titanium elastic nails, rigid intramedullary nails, locking plates, limited-contact dynamic compression plates, and external fixators2-11. Rationale:Extra-articular proximal femoral fractures by definition include fractures of the subtrochanteric region2,3. These fractures are challenging to treat because of the strong muscular deforming forces on the proximal femur. These fractures can be length-unstable. Expected Outcomes:The results of this technique in 15 patients have been published1. All fractures healed uneventfully, with a mean time to union of 11.8 ± 1.2 weeks. No patients required a subsequent surgery for complications or malunion. Thirteen patients achieved excellent outcomes according to the Flynn criteria. Important Tips:It is important to achieve length and coronal and rotational alignment, and use the correct plate size and place it appropriately.Avoid excessive bending of the plate as it may produce varus or valgus malalignment.Choose the correct length of the plate in order to achieve stable fixation.Do not open the fracture site, as it preserves the hematoma and provides biological fixation. It is critical to stay extraperiosteal and to place the plate on the lateral surface of the femur.Keep the patient non-weight-bearing until early callus is radiographically visible. Premature weight-bearing should be avoided. Acronyms and Abbreviations:EPFF = extra-articular proximal femoral fractureDCP = dynamic compression plateAP = anteroposteriorK-wire = Kirschner wireORIF = open reduction and internal fixation.
Background:Mechanical axis deviation (MAD) disrupts the natural force distribution within the knee joint. MAD malalignment imparts atypical tibial plateau loading forces, which can cause painful knee cartilage degeneration, abnormal gait, and reduced activity and mobility1. A medial opening-wedge high tibial osteotomy corrects varus MAD for deformities centered in the proximal tibia, reducing medial knee compartment stress, which often improves pain, function, and self-image2. Description:Surgical planning starts with a history to understand the patient symptoms, potential etiologies, and goals. Physical examination assesses standing and walking coronal alignment, investigates any rotational concerns, and evaluates lower-extremity joint motion. A bilateral weight-bearing hip-to-ankle anteroposterior radiograph is used to measure the MAD, lateral distal femoral angle, and medial proximal tibial angle, which determine the center of rotation and angulation (CORA). Weight-bearing anteroposterior, flexion posteroanterior, and lateral knee radiographs are used to assess arthrosis and patellar tracking3,4. The key steps include a medial exposure of the proximal tibia, biplanar osteotomy in the proximal metaphyseal tibia (1 plane is the sagittal plane to impart angular correction and the other plane is parallel and posterior to the patella), opening of the wedge, fixation with plate and screws, and skin closure. Alternatives:Nonoperative treatments such as bracing, physical therapy, joint injection, and activity modification may palliate symptoms but do not correct the deformity. Distal femoral osteotomies are indicated when the deformity center of rotation and angulation exist in that location5. Hexapod frames are more appropriate for multiplanar or large deformities (>11°), which may benefit from gradual correction3,6. A lateral closing-wedge high tibial osteotomy can achieve similar realignment but puts the common peroneal nerve at risk because of the surgical approach, and there is limited visualization of the tibia because of fibular obstruction2,7,8. Skeletally immature patients with sufficient growth remaining may be partially or fully managed with lateral proximal tibial hemiepiphysiodesis9. Total knee arthroplasty (TKA) can address coronal plane deformities and joint arthritis but is joint-ablative, and often patients are counseled to reduce their activity intensity and beware of periprosthetic joint infection10. Rationale:Untreated MAD predisposes to early degenerative osteoarthritis and can impair gait, resulting in subpar activity levels and reduced quality of life. Medial opening-wedge high tibial osteotomy corrects proximal tibia-based varus malalignment; normalizes knee joint loading, which should alleviate pain; and preserves the native knee joint, which permits higher activity and lower infection concern than TKA. The medial approach is technically easier and safer than a lateral closing-wedge osteotomy. Medial opening-wedge high tibial osteotomy offers a joint-preserving correction of alignment and is especially suitable for young or active patients aiming to delay or avoid joint replacement surgery, imparting pain relief and allowing improved mobility and quality of life1. Expected Outcomes:On osteotomy union, patients should feel improvement of pain and have a more balanced gait1,8,11. Medial opening-wedge high tibial osteotomy is a joint-preserving operation that can prevent the need for a TKA without excluding it as a future option. Important Tips:Clearly agree upon expectations and correction goals with patient preoperatively.Measure radiographs carefully preoperatively to correctly identify the CORA and amount of correction.Support the operated leg at all times to avoid uncontrolled fracture after osteotomy.Check alignment carefully intraoperatively, with patella facing directly upwards.Avoid postoperative fracture by limiting weight-bearing to 50 lbs (22.7 kg) for 6 weeks. Acronyms and Abbreviations:LDFA = lateral distal femoral angleMOWHTO = medial opening-wedge high tibial osteotomyMPTA = medial proximal tibial angleCORA = center of rotation and angulationMVA = motor vehicle accidentBL = bilateralFx = fracturePT = physical therapyROM = range of motionK-wire = Kirschner wire.
Background:Tibial lengthening with use of a motorized intramedullary lengthening nail (MILN) provides precise deformity correction and distraction osteogenesis without requiring external fixation1. A MILN can be utilized for many etiologies requiring lengthening, such as congenital (e.g., short stature, limb deficiency) or acquired (e.g., post-infectious, traumatic)2. The present video article describes the surgical technique for MILN use in the tibia in a skeletally mature patient with use of the Precice System (Globus Medical). Description:The preoperative patient evaluation starts with a history to understand the primary reason(s) that the patient seeks lengthening, to identify potential care challenges (such as dormant infection for patients with a post-infectious etiology or joint instability for patients with limb deficiency). The physical examination should evaluate for joint contracture or instability, spasticity, prior surgery compromising the surgical approach, and patient psychological or physical capacity to comply with postoperative weight-bearing and lengthening instructions. Preoperative imaging includes calibrated orthogonal radiographs of the operative tibia to ensure suitable anatomy and bilateral hip-to-ankle radiographs, with blocks to level the pelvis as needed, to determine any limb-length discrepancy (LLD) or alignment deformity3,4. A gastrocnemius-soleus complex release may be considered; otherwise, the surgical procedure begins with exposure of the tibia and predrilling of the osteotomy site. The tibial canal is entered in either a suprapatellar or infrapatellar (as shown in this video) fashion and sequentially reamed over a centrally placed guidewire. Proximal and distal rotation marker pins are placed posterior to the expected path of the MILN5. Blocking screws can be placed to prevent or correct deformity6. Prophylactic fasciotomy may be appropriate when performing acute deformity correction7. Osteotomies of the fibula and tibia are performed with use of an osteotome. The nail is inserted and locked in position. Proximal and distal tibiofibular fixation minimizes undesired migration of the fibular segments8. Lengthening generally starts 7 days after surgery, using 4 lengthenings, totalling a maximum of 0.8 mm, per day. Alternatives:Some LLD cases are suitably treated without surgical intervention9. Alternative lengthening techniques10 include monolateral external fixators11 and circular fixators, with or without computer guidance12 and with or without subsequent internal fixation13,14, and other brands of MILN15. Hexapod fixators facilitate the most comprehensive deformity correction16, although indications are expanding for deformity correction via nailing17. Patients may feel that internal options are more convenient than external ones18-20. Few patients desire treatment of LLD by shortening the longer extremity21. Rationale:LLD and associated deformities can alter natural gait patterns and lead to abnormal joint forces, which may cause a painful and altered gait. Although there are broad opinions regarding the minimum LLD indicating surgery, distraction osteogenesis is a well-established and proven mechanism for bone lengthening. Once lengthening has been indicated, many factors influence the decision to use external or internal fixation, such as the magnitude of lengthening, need and ability to correct other deformity, implant access, and non-medical patient factors. Regardless of the implant, tibial osteotomy should be performed utilizing safe planning, techniques, and medical adjuncts7. Expected Outcomes:When an MILN procedure is performed safely, patients can expect up to 8 cm of lengthening with a minimal risk of implant problems, fracture, infection, or other adverse events7,22. Patients must adhere to weight-bearing limitations and perform stretching exercises to avoid joint stiffness. Most patients report high satisfaction after lengthening23. Important Tips:Establish the LLD before surgery, then rely on the machine to determine the length achieved; do not second-guess the machine during lengthening.Correct or prevent rotational, coronal, and sagittal deformity at the time of the MILN insertion surgery.Prioritize safety (i.e., with a percutaneous technique, fasciotomy, and tranexamic acid) to optimize outcomes (i.e., avoidance of complications and achievement of the desired length).Ensure patient compliance with weight-bearing limitations and stretching exercises.Limit weight-bearing until at least 3 cortices have full bridging.MILN removal is recommended after full union is achieved, typically approximately 1 year postoperatively. Acronyms and Abbreviations:LLD = limb-length discrepancyMILN = motorized internal lengthening nailPT = physical therapyIM = intramedullary.
Background:Revision total hip arthroplasty (THA) for isolated polyethylene exchange or acetabular revision with retention of the femoral component can present a challenge for adequate exposure. A systematic approach to a proper release can facilitate exposure and reduce the risk of iatrogenic complications. Description:The posterior approach is an extensile and versatile approach for revision THA. After incising the fascia and iliotibial band, the insertion of the gluteus maximus is fully released. After releasing any scar along the inferior gluteus medius, a retractor is placed to hold the muscle belly cranially. The leg is gently internally rotated to place the posterior capsule and external rotators under tension while these structures are released from the posterior femur and along the neck of the femoral component. Curved scissors can be utilized to identify the psoas sheath and to release the inferior capsule while protecting the iliopsoas tendon. Scar tissue is resected from inside the hip joint, and a pocket is made in the anterior capsule to allow retractor placement above the equator of the acetabulum in order to hold the mobilized proximal femur anteriorly. An inferior retractor is then placed under the transverse acetabular ligament. This systematic approach allows adequate visualization of the acetabular component for revision. Alternatives:Nonoperative treatment should be attempted first, depending on the diagnosis and its associated natural history. Once nonoperative treatment has been exhausted and revision THA is indicated, the anterior and direct lateral approaches can be considered. If the femoral component needs revision on the basis of intraoperative assessment, the anterior approach presents substantial difficulty in femoral exposure, with a higher risk of iatrogenic fracture. The direct lateral approach commonly leads to abductor weakness and a Trendelenburg gait. Rationale:Common indications for revision THA with femoral component retention include wear and/or osteolysis, adverse local tissue reaction, recurrent instability, and aseptic acetabular loosening. Adequate exposure is essential to facilitate revision THA with femoral component retention and to minimize the risk of iatrogenic injury. Expected Outcomes:Survivorship free from re-revision at 2 years is >80% for both isolated polyethylene exchange and acetabular revision. There is a trend toward higher failure rates when retaining the acetabular component. Risk factors for failure include damage to the locking mechanism; femoral head erosion into the cup, damaging the metal; and a mispositioned acetabular component. Important Tips:A systematic approach to releases is essential for adequate exposure with a retained femoral component. Systematic releases include fully releasing the gluteus maximus insertion, continuing the iliotibial band incision distally, fully releasing the external rotators, and removing scar tissue within the joint.Keeping the hip extended and the knee flexed with a finger posteriorly is important to protect the sciatic nerve during the release of the posterior capsule. The hip can then be dislocated in a controlled manner to reduce the risk of iatrogenic injury.Be prepared for bleeding from perforating arteries during subvastus elevation.Rest the leg on a padded Mayo stand in slight internal rotation once the proximal femur is retracted anteriorly.Ensure proper component alignment, component stability, and hip stability to confirm that femoral component retention is indicated. Repair of the posterior capsule contributes substantially to postoperative stability.Precautions should be implemented postoperatively to reduce the risk of dislocation. A hip abduction brace can be considered for patients at a high risk of instability.Active ankle dorsiflexion should be assessed in the post-anesthesia unit to evaluate for sciatic nerve injury and to differentiate the cause of a foot drop if discovered on postoperative day 1. Acronyms and Abbreviations:AP = anterior-posteriorCT = computerized tomographyCRP = c-reactive proteinESR = erythrocyte sedimentation rateFDA = Food & Drug AdministrationHR = Hazard ratioIT = Iliotibial bandMSIS = Musculoskeletal Infection SocietyOR = Odds ratioTHA = total hip arthroplastyrTHA = revision total hip arthroplasty.
Background:The calcaneo-cuboid-cuneiform (triple-C) osteotomy is indicated for the correction of symptomatic flexible planovalgus foot deformity. This procedure allows correction of all of the varied components of the planovalgus foot deformity in a single operation1,2. Description:The patient is positioned in a floppy lateral position2. The calcaneus is exposed via an oblique lateral incision along the peroneal tendons. The osteotomy is performed in an extra-articular fashion beginning posterior to the posterior articular facet and extending distally and anteriorly to the inferior surface of the calcaneus. The posterior calcaneal fragment is displaced medially to allow correction of heel valgus. A separate lateral incision is made over the cuboid in order to expose it. An osteotomy is performed in the middle third of the cuboid without violating the adjacent joints and opened with a lamina spreader to allow correction of the forefoot abduction. The medial cuneiform is exposed via a medial incision. A medial and plantar-based wedge of bone is removed in toto from the middle third of the cuneiform. Closing this wedge corrects forefoot supination and recreates the medial longitudinal arch. The wedge of bone harvested from the cuneiform is inserted into the cuboid and all of the osteotomies are fixed with Kirschner wires of sizes between 1.8 and 2.5 mm or cannulated cancellous screws. Alternatives:If the feet are supple enough to allow passive correction, an in-socket ankle-foot orthosis with a medial arch support can be utilized to maintain the shape of the foot and to delay deterioration and the need for surgery3. Various other surgical treatment methods are described in the literature and can be categorized as joint-sparing procedures, arthroereises, and arthrodeses. Joint-preserving procedures include the popular calcaneal-lengthening osteotomy (CLO)4 and the double calcaneal osteotomy5. Arthroereisis, a non-fusion motion-limiting technique, is minimally invasive and recently gaining popularity3. The literature has described promising results with use of this procedure6. Extra-articular and intra-articular arthrodesis typically have been employed for the treatment of severe and rigid planovalgus feet and in children who have limited ambulatory potential. On the basis of the currently available literature, no procedure can be labeled superior to another3. Rationale:The triple-C osteotomy is straightforward and has a short learning curve. There is no need for bone-graft harvesting and the associated morbidity thereof. Studies have shown minimal complications and low long-term recurrence with use of the triple-C osteotomy in patients with spastic cerebral palsy3. Expected Outcomes:We have reported on the short-term outcomes of this procedure2. The patient would be informed regarding the ability of the surgery to correct even severe deformities7. The procedure is not associated with notable complications, and the primarily reported complications are related to wound healing2,8. Although delayed healing of an osteotomy has been described by the originators of this technique1, we have not encountered this complication. We reported good clinical and radiographic outcomes in our series of 12 feet2. Moraleda et al.8 compared the outcomes of the triple-C osteotomy and CLO and reported similar outcomes in terms of clinical and radiographic correction, but with more frequent and more severe complications following CLO. Important Tips:Protect the sural nerve during calcaneal exposure.Osteotomize the medial cortex of the calcaneus with use of an osteotome in order to avoid injuring the medial neurovascular structures.Avoid violating the adjacent joints when performing the cuboid and cuneiform osteotomies.The wedge of bone harvested from the medial cuneiform should be excised in toto to effectively lengthen the cuboid.If utilized, cannulated cancellous screws should be countersunk in the posterior cortex of the calcaneus to prevent irritation. Acronyms and Abbreviations:AFO = ankle-foot orthosisUCBL = University of California Biomechanics LaboratoryCP = cerebral palsyAP = anteroposteriorVAS = visual analog scoreCC screws = cannulated cancellous screws.
Background:Various approaches have been described for hip arthroplasty1-3. The posterior approach to the hip remains a popular choice for hemiarthroplasty1. In the classic description, it involves detachment of the short external rotators, which include the quadriceps coxae (QC) (i.e., piriformis, superior gemellus, obturator internus, and inferior gemellus) along with the obturator externus and quadratus femoris (as needed). Since the QC are important for joint stability, detachment during the approach is associated with higher rates of postoperative dislocations4, even following subsequent surgical repair of the QC. In the study by Stähelin et al.5, 15 of 20 repairs involving the QC had failed by 3 months postoperatively, primarily because the repair site could not withstand the forces of normal weight-bearing during the healing phase. Various muscle-sparing modifications of the conventional approach have been described to reduce the propensity for prosthetic dislocation6-9. Hanly et al.9 described the SPAIRE (Sparing Piriformis and Internus, Repair Externus) technique. This minimally invasive modified posterior approach enables the preservation of the QC, possibly representing the greatest extent of muscle and tendon preservation. The advantages of this QC-sparing technique have been demonstrated in clinical studies of hemiarthroplasty10,11 and total hip arthroplasty12. Description:The patient is anesthetized and placed in a lateral decubitus position. Bolsters are utilized over the pubis and sacral areas to provide stable pelvic orientation. The contralateral limb is flexed at the hip (∼45°) and knee (90°), with adequate padding under the fibular head and lateral malleolus. Another padded bolster is placed between the legs to keep the topmost lower limb in neutral to slight abduction at the hip. The operative limb is flexed at the hip (∼30°), and a 10 to 15-cm straight skin incision is marked on the lateral aspect of hip, centered on the posterolateral tip of the greater trochanter. The deep fascia is opened distally to proximally, incised distally with scissors, and separated proximally with finger dissection. This step creates an intermuscular plane between the gluteus maximus posteriorly and tensor fasciae latae anteriorly. A Charnley hip retractor is applied. Internal rotation of the hip allows identification of the posterior border of the gluteus medius and short external rotators. The fat pad over the QC is swept medially with an abdominal sponge to identify the muscles. A plane is identified between the quadratus femoris and inferior gemellus. Next, a plane is developed between the QC and posterior hip capsule with use of a blunt hemostat from inferior to superior. Abduction of the hip just beyond neutral relaxes the QC and allows superior retraction. The quadratus femoris is detached from the trochanteric crest with use of a diathermy needle until the lesser trochanter is visualized. A capsulotomy is performed in a lazy L-shaped manner, with the first limb of the incision along the distal margin of the QC and the second along the base of the femoral neck. The second limb of the incision raises the musculocapsular flap consisting of the obturator externus along the osseous margin with use of a diathermy needle. This musculocapsular flap is tagged with sutures, which helps in its retraction posteriorly to protect the sciatic nerve and later aids in repair. Bipolar hemiarthroplasty is performed in a conventional manner. The musculocapsular flap is repaired transosseously, and the wound is closed in a layered fashion. Alternatives:Alternatives to this QC-sparing technique include the use of a conventional posterior approach, piriformis-preserving posterior approach, direct lateral approach, modified lateral approach, or direct anterior approach. Rationale:Preservation of the QC helps improve prosthetic hip stability in internal rotation, possibly because of the preserved proprioception. A minimally invasive approach reduces recovery time during rehabilitation. Preservation of the QC does not hinder visualization or result in component malposition12. Expected Outcomes:Ball et al.10 compared the use of a modified muscle-sparing posterior approach versus a standard lateral approach. The authors reported comparable Oxford Hip Scores at 120 days (p = 0.25). Patient function and mobility were similar at 3 days and 120 days, regardless of the surgical approach. Length of hospital stay and return to pre-fracture place of residence were similar. Mortality rates and quality of life were also similar at 120 days postoperatively. Patients who underwent the modified muscle-sparing posterior approach experienced less pain during the early postoperative period. The mean score on the numeric pain rating scale was 4.4 (standard deviation, 2.8) among patients who underwent the modified muscle-sparing posterior approach versus 5.4 (standard deviation, 3.0) among patients who underwent the standard lateral approach (p = 0.04). Important Tips:Place a padded bolster between the legs to keep the topmost lower limb in neutral to slight abduction at the hip.Develop a plane between the QC and posterior hip capsule with use of a blunt hemostat or a Cobb elevator from inferior to superior in order to help mobilize the QC and release their capsular attachments.Hip abduction just beyond neutral relaxes the QC and allows insertion of a Hohmann retractor deep to the QC in order to protect and lever them superiorly.A small Langenbeck retractor inserted deep to the QC protects them from shredding during broaching. Internal rotation at the hip beyond 90° (in 90° flexion and neutral adduction/abduction) further protects the QC from harm.
Background: Surgical repair of gluteal tendon tears can be performed through the endoscopic and open approaches 1–3 . Past literature suggests that the endoscopic approach has a decreased risk of postoperative complications and retearing, with similar functional outcomes, compared with the open approach 4,5 . Therefore, the endoscopic approach is being established as a safer option for gluteal tendon repair 4,5 . The endoscopic approach can be performed through several different techniques, including single-row (SR), conventional double-row (DR), and side-to-side (SS) repair 6–10 . However, for full-thickness tears, a technique with superior strength and stability is required. Thus, we present an endoscopic transosseous-equivalent double-row (TOE-DR) repair technique that is minimally invasive, allows for a tension-free repair, and approximates the tendon to the gluteal footprint 6–12 . Description: The patient is positioned in the lateral decubitus position, utilizing silicone-padded pegboards and padding on the osseous prominences. An obturator placed into a 7.0-mm cannula is utilized to create 4 peritrochanteric portals 1 . Specifically, the proximal direct lateral portal (PDLP) is made 6 cm proximal and the distal direct lateral portal (DDLP) is made 6 cm distal to the center point of the greater trochanter along the long axis of the femur. The anterolateral portal (ALP) and posterolateral portal (PLP) are made parallel to the vastus ridge through the gluteal footprint. A 17-gauge needle is inserted at a 45° inclination through the DDLP, and insufflation with 30 mL saline solution of the deep peritrochanteric space is performed. The PDLP is made under direct visualization with use of tip-to-tip triangulation with the DDLP, followed by ALP and PLP placement under direct visualization. Next, a greater trochanteric bursectomy is performed, and the tear site is assessed with use of a tissue grasper during hip range of motion for dynamic tear visualization. A shaver is utilized to debride degenerative tissue around the tendon and gluteal footprints. TOE repair of the tear is performed with use of a DR technique with the anchors placed at a 45° angle. The proximal row is placed into the center of the footprint, and the distal row is placed into the vastus ridge. A suture shuttle is utilized to facilitate passing of the suture limbs, after which the suture is tied in a sliding Weston knot with multiple half-hitches. Alternatives: An alternative surgical technique is the open approach 1–5 . Alternative constructs include SR, SS, and conventional DR 5 . Alternative nonoperative treatments include physical therapy with gait training, the use of NSAIDs, and trochanteric bursal injections 13–16 . Rationale: The endoscopic approach has lower postoperative complication rates regarding retearing and infection compared with the open approach 4,5,7 . Furthermore, TOE-DR repair provides superior gluteal footprint coverage compared with SR repair 8,9,11 . Therefore, endoscopic TOE-DR repair is beneficial to patients who require additional strength and stability of the repair site. Expected Outcomes: Significant increases in hip abduction strength (p = 0.021) and resolution of the Trendelenburg sign (p = 0.0019) have been demonstrated at 2 years postoperatively 1 . Patients also had significant improvements in functional outcomes and pain scores, including the mHHS (p < 0.001), HOS-ADL (p < 0.001), HOS-SSS (p < 0.001), NAHS (p < 0.001), iHOT-33 (p < 0.001), LEFS (p < 0.001), and VAS pain score (p = 0.024) at 2 years. Important Tips: Postoperative use of a walker has been shown to promote favorable functional outcomes 7 . Therefore, a walker is recommended as an ambulatory aid in all patients for a minimum of 3 months postoperatively or until the Trendelenburg sign and gait are eliminated. A 17-gauge needle should be placed at a 45° angle to create the DDLP. This approach will maximize access and maneuverability to carry out the repair, including placement of anchors and suture shuttling and tiedown. Place suture anchors at a deadman’s angle to reduce tension at the suture and increase resistance to anchor pullout 17,18 . Patients with substantial retraction and/or fatty atrophy of the gluteal tendons may not be good candidates for this technique, as these factors would preclude successful repair or improvement in function. Excessive pelvic tilt with an unbalanced gait can place substantial stress on the repair site and increase risk of retearing. Counseling of patients on complying with the prehabilitation and rehabilitation protocol is imperative for a successful repair. Acronyms and Abbreviations: TOE = transosseous-equivalent DR = double-row SR = single-row SS = side-to-side iHOT-33 = International Hip Outcome Tool-33 HOS-ADL = Hip Outcome Score–Activities of Daily Living HOS-SSS = Hip Outcome Score–Sports Specific Subscale mHHS = modified Harris hip score VAS = visual analog scale NSAID = nonsteroidal anti-inflammatory drug PDLP = proximal direct lateral portal DDLP = distal direct lateral portal ALP = anterolateral portal PLP = posterolateral portal AP = anterior posterior DVT = deep vein thrombosis MRI = magnetic resonance imaging PROM = patient reported outcome measure MCID = minimal clinically important difference ROM = range of motion NAHS = Non-Arthritic Hip Score LEFS = Lower Extremity Functional Scale
Background: Extensor indicis proprius (EIP) transfer augmented with proximal extensor pollicis longus (EPL) stump lengthening restores thumb extension and optimizes function in cases of chronic EPL tendon ruptures, which impair hand dexterity and fine motor skills. Traditional EIP-to-EPL transfers often disrupt the natural oblique course of the EPL around the Lister tubercle, leading to functional deficits 1–3 . This dual-tendon transfer preserves anatomical alignment and improves thumb biomechanics, enhancing extension strength and the adduction moment arm at the carpometacarpal (CMC) joint. Description: The procedure involves 3 incisions over the index finger metacarpal neck, Lister tubercle, and dorsal thumb metacarpophalangeal joint. The EIP tendon is harvested, its distal stump is sutured to the extensor digitorum communis, and the proximal stump is withdrawn for transfer. The distal and proximal EPL stumps are exposed, and the proximal EPL is lengthened with use of an L-shaped radial incision, retaining a 1-cm pedicle for turnover. Both the EIP and lengthened EPL tendons are passed subcutaneously and coapted to the distal EPL with use of a Pulvertaft weave and augmentation techniques. The procedure is performed under wide-awake local anesthesia (WALANT), enabling dynamic intraoperative adjustments. A splint is applied postoperatively for 4 weeks, followed by 4 to 8 weeks in a removable splint, with discontinuation at 12 weeks. Alternatives: Surgical alternatives include extensor carpi radialis brevis to EPL transfer, extensor digiti minimi to EPL transfer, brachioradialis to EPL transfer, and EPL repair with use of a palmaris longus graft. Rationale: Compared with other tendon transfers, EIP transfer offers anatomical proximity, and minimal donor-site morbidity. However, standalone EIP transfers may reduce extension strength and range of motion as a result of a misaligned vector 4–7 . The presently described dual-transfer technique addresses these limitations by retaining the native path of the EPL, reducing adhesions, and improving biomechanical efficiency. This technique is particularly advantageous in patients who require a high level of thumb function, preserving fine motor control and extension strength while reducing residual deficits. Expected Outcomes: This procedure provides improved thumb extension, thumb adduction, and overall hand function. Stirling et al.1 demonstrated that EIP-to-EPL transfer improves QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire) scores (from 29.7 to 15.2; p = 0.05), with high patient satisfaction and no complications. Our augmented approach builds on these results by reducing biomechanical loss, preserving angular alignment, and minimizing adhesion risk, aiming for superior total active motion and functional recovery. In our study of 15 patients, the outcome was rated as Good in 11 patients and Fair in 4, with a mean DASH score of 5.5. Important Tips: Preserve a 1-cm pedicle in the EPL lengthening to maintain vascularity and facilitate turnover. Avoid overtightening to prevent interphalangeal joint stiffness. Ensure a smooth subcutaneous tunnel to minimize friction and adhesions. Avoid misalignment of the EPL course, which compromises extension and thumb adduction. Acronyms and Abbreviations: EPL = extensor pollicis longus CMC = carpometacarpal EIP = extensor indicis proprius ECRB = extensor carpi radialis brevis EDM = extensor digiti minimi BR = brachioradialis TAM = total active motion MCP = metacarpophalangeal IP = interphalangeal WALANT = wide-awake local anesthesia EDC = extensor digitorum communis
Background: Percutaneous transforaminal endoscopic discectomy (PTED) is a minimally invasive technique for the treatment of symptomatic lumbar disc herniation (LDH) that is growing in popularity. The procedure involves the insertion of a transforaminal spinal endoscope for direct access and removal of intra and extra-foraminal disc fragments 1 . Description: The patient is preferably placed in a prone position. A spinal needle is advanced under fluoroscopic guidance into the foramen to the medial border of the inferior pedicle. A guidewire is introduced through the needle cannula, and sequential dilators are advanced into the foramen. A partial facetectomy/foraminotomy is performed so that a 10-mm working cannula and spinal endoscope can be introduced. Endoscopic pituitary rongeurs are utilized to remove the extruded disc material. Once the extruded fragments are no longer visualized, a probe is utilized to verify that no remaining disc material is present, and a diagnostic endoscopy is performed. The cannula is removed, and the incision is closed in a standard fashion. Alternatives: Nonoperative alternatives to PTED include activity modification, nonsteroidal anti-inflammatory drugs and/or acetaminophen, physical therapy, and epidural steroid injections 2 . When surgical intervention is indicated, alternative techniques for decompression include conventional microdiscectomy, tubular microdiscectomy, and unilateral biportal endoscopic discectomy 3 , as well as lumbar fusion techniques. Rationale: PTED shares similar indications as open and tubular discectomy, including soft LDH confirmed on imaging, persistent radiculopathy, new sensory/motor neurologic deficits, and failed nonoperative treatment of >6 weeks 1 . Compared with open and tubular discectomy, PTED offers several advantages, including a smaller skin incision, feasibility under local anesthesia, direct visualization, avoidance of muscle retraction, minimal bone removal and neural manipulation, preservation of spine stability and adjacent anatomy, decreased intraoperative blood loss, and shorter operative times 4–11 . In patients with a far lateral or foraminal LDH, PTED may avoid the need for fusion 12 . Considerations for PTED include the narrow working corridor, representing a risk of iatrogenic injury or incomplete decompression, and the associated learning curve 13,14 . Relative contraindications include recurrent LDH, paracentral LDH, extruded LDH, sequestration of the disc, significant obesity, isthmic spondylolisthesis, and severe canal stenosis 11 . Additionally, accessing the lower lumbar levels via a transforaminal approach may be difficult in patients with a high iliac crest. Expected Outcomes: PTED is a safe procedure that has been shown to improve patient-reported outcomes and functional status. In a recent meta-analysis, Gadjradj et al. reported a pooled complication rate of 4.6% (range, 0% to 8.6%) for PTED 8 . Hoogland et al. reported 85% excellent/good satisfaction in patients who underwent PTED, compared with 8% poor satisfaction, as well as improvements in visual analogue scale back and leg pain scores of 6.0 and 5.6, respectively, at 2-year follow-up. Chen et al. found that PTED resulted in similar patient-reported outcomes with similar rates of complications, recurrence, and reoperation and shorter in-bed times and lengths of stay compared with open discectomy 5 . Important Tips: The exiting nerve root is at risk during the approach. The foramen is entered at the furthest point from the nerve root by targeting the superior-most portion of the inferior pedicle (anteroposterior view) and the posterior-inferior corner of the disc (lateral view). For procedures performed with the patient under awake anesthesia, the patient should be monitored for nerve-root injury by asking them to report pain and move their feet. When a patient is fully anesthetized, neuromonitoring should be utilized. Neuromonitoring is especially important to remove fragments in difficult-to-access locations. Because of the narrow corridor, it may be difficult to confirm full decompression. Thoroughly reviewing the patient imaging to understand the fragment location is necessary. Postoperatively, it is important to evaluate patients to identify cases of incomplete decompression. The dorsal root ganglion is sensitive to irritation. Prior to closure, we irrigate the working cannula with a steroidal solution. The learning curve for PTED has been shown to be 31 cases, which is longer than traditional microdiscectomy techniques 14 . Acronyms and Abbreviations: PTED = percutaneous transforaminal endoscopic discectomy LDH = lumbar disc herniation AP = anteroposterior PSH = past surgical history MRI = magnetic resonance imaging OR = operating room PACU = post-anesthesia care unit
Background: Metacarpal and phalangeal fractures are among the most common fractures that upper-extremity surgeons encounter, accounting for 30% of all hand fractures 1,2 . These particular fractures can be treated either operatively or nonoperatively, according to the amounts of displacement, malrotation, and shortening 1 . Operative treatment includes the use of Kirschner wire fixation, intramedullary screws, plate-and-screw constructs, or interfragmentary screws. Multiple studies have demonstrated superior biomechanical strength and early active range of motion with use of intramedullary screws for the treatment of unstable metacarpal and phalangeal fractures 3–7 . This minimally invasive technique is designed for unstable metacarpal or phalangeal shaft and neck fractures to allow early active motion. Furthermore, intramedullary placement of implants avoids hardware prominence and extensive soft-tissue stripping, which can impact tendon gliding and postoperative range of motion. Description: Metacarpal fractures can be treated with 3.6 or 4.0-mm intramedullary screws according to the canal diameter. The fracture is reduced by closed means or a limited open reduction. With the metacarpophalangeal joint flexed, the guidewire is inserted into the dorsal third of the metacarpal head through the articular cartilage and driven past the fracture site to the desired depth. A small stab incision is made, and the depth gauge is placed against the metacarpal head. The cannulated drill is placed over the guidewire, and the canal is drilled on the oscillate setting. A screw of the appropriate diameter and length is then placed over the wire, and its position is confirmed under fluoroscopy. Phalangeal fractures are treated with one or two 2-mm screws, inserted antegrade or retrograde according to the fracture location and orientation. The fracture is reduced, and the dual-diameter guidewire is passed through the long axis of the canal to the level of the far cortex (typically at the phalangeal base). A stab incision is made, and the depth gauge is inserted down to bone. The dual-diameter guidepin measures 1.6 mm in diameter on one half and 0.8 mm on the other half. The 1.6-mm portion of the guidewire is then driven out of the far cortex such that the smaller-diameter segment spans the fracture site and remains in the bone. The screw is then placed over the guidewire. A second screw may be placed in a V or X pattern with use of a similar technique. Alternatives: Alternatives to this procedure include nonoperative treatment, Kirschner wire fixation, plate-and-screw constructs, interfragmentary compression screws, and intramedullary headless compression screws. Expected Outcomes: Although many metacarpal and phalangeal fractures may be treated by closed means, a number of fractures require surgical fixation. Melone discussed that 10% of phalangeal and metacarpal fractures are either irreducible by closed means or unsuitable for percutaneous pinning 8 . The more common historical complications related to these fractures include stiffness and infection. Page and Stern cited a 35% complication rate with plate-and-screw fixation, including a 19% major complication rate 6 . Percutaneous Kirschner wire fixation is an alternative technique for fixation that is less invasive than open reduction and internal fixation procedures. Belsky et al. assessed 100 phalangeal fractures treated with use of Kirschner wire fixation and found favorable postoperative range of motion 9 . Botte et al. reported an 18% pin complication rate, most commonly infection, pin migration, and pin loosening 10 . The use of intramedullary screws allows for minimally invasive fixation that is similar to the use of headless compression screws. The non-compressive design of intramedullary screws avoids shortening in oblique or comminuted fractures. The various length options and differential diameter design allow intramedullary cortical thread engagement to facilitate early active motion. Not all fractures are suitable for intramedullary screw fixation, and there are certainly risks associated with its use. The articular surface can be violated, as the starting point lies at the dorsal third of the articular surface. Although we have not yet seen postoperative degenerative changes, this is a theoretical risk. There is also a risk of subsidence of screws used to treat distal fractures, if the screw is not in the subchondral bone. Important Tips: Preoperative evaluation of canal diameter is helpful to determine the appropriate screw diameter. The ring finger metacarpal typically has the narrowest canal, and a 3.6-mm screw is thus typically utilized. Most other fingers can accommodate a 4.0-mm screw. Anatomy can vary, however. Ensure that the depth gauge is flush against the bone, confirmed on fluoroscopy. We typically subtract 5 mm from the measured length; however, this is dependent on fracture location. Prior to drilling, advance the guidewire into the far cortex in order to avoid guidewire pullout when the cannulated drill is removed. In some cases, tight isthmal fit of the screw can make screw progression difficult. If excessive torque is encountered, back out the implant 2 to 3 turns before continuing (similar to tapping). Ensure that the screw is buried under the articular surface. This is especially important in more distal fractures, in which purchase in subchondral bone is important in avoiding subsidence. In these fractures, a larger incision is often made in order to directly visualize the screw position. When attempting to place crossed screws into a proximal phalanx, sequential advancement of the screws (i.e., alternating screw progression across the isthmus of the canal) can allow for easier screw passage when both guidewires are across the fracture site. To gauge the stability of phalangeal shaft fractures, we apply varus/valgus and flexion/extension stress while using dynamic fluoroscopy after the first screw is inserted. If unstable, a second screw is inserted according to the previously described technique. Acronyms and Abbreviations: K-wire = Kirschner wire MCP = metacarpophalangeal AP = anteroposterior CMC = carpometacarpal
Background:Robotic-assisted (RA) minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) is an advantageous combination of 2 techniques utilized to treat lumbar degenerative pathologies. Given the lack of direct visualization of anatomic landmarks in MI-TLIF, radiography is necessary for accurate pedicle screw placement1-5. Navigation-guided systems have shown superiority over fluoroscopy by allowing for 3-D visualization and tracking6-11. RA systems can potentially allow for greater accuracy via robotic-arm guidance adherent to planned trajectories12. Although instrumentation complications are multifactorial, robotic guidance is another surgical tool to improve instrumentation accuracy and minimize invasiveness following MI-TLIF. Description:With the patient under general anesthesia and in a prone position, 2 reference arrays attached to the patient via bilateral posterior sacroiliac spine incisions are made in order to perform intraoperative computed tomography (CT) with an array-integrated CT scanner and to calibrate the robotic instruments. Surgical planning for the screws and interbody cage is performed on the interface of the robotic tool. With use of the robotic arm, percutaneous pedicle screws are placed bilaterally. A tubular retractor is then docked over the facet joint. A unilateral facetectomy is performed, followed by a complete discectomy with end plate preparation. Bone graft is placed into the disc space. An expandable interbody cage is filled with bone graft, tamped into place, and expanded. The disc space is then backfilled with more bone graft. Rods are inserted percutaneously. Placement of all instrumentation is confirmed fluoroscopically, and the wounds are closed in a multilayered approach. Alternatives:Nonoperative alternatives to RA MI-TLIF include physical therapy, pharmacologic treatment, and lumbar and interlaminar transforaminal epidural corticosteroid injections. Surgical alternatives include RA open TLIF, MI-TLIF with fluoroscopy or navigation, posterior lumbar interbody fusion, lateral lumbar interbody fusion, and anterior lumbar interbody fusion13. Rationale:RA screw placement has been shown to be more accurate than fluoroscopy-guided placement, with a lower incidence of pedicle wall penetration or facet joint invasion, better insertion angle, and less blood loss14-16. Compared with open TLIF, RA MI-TLIF provides improved screw placement, less blood loss, shorter length of stay, and better patient-reported outcome scores; however, it does increase operative time and radiation exposure17,18. Furthermore, RA MI-TLIF has shown several advantages over fluoroscopy-assisted MI-TLIF, as it has similar 2-year fusion rates but is more accurate, has less complications, has less facet joint violation, yields greater adjacent disc height at 2 years, and exposes the surgeon to less radiation19,20. Compared with navigation alone, RA navigation also allows for implantation of screws with a greater diameter and length without compromising accuracy, potentially allowing for more optimal osseous purchase21. Expected Outcomes:RA MI-TLIF offers several advantages compared with other types of MI-TLIF17,22. A previous study showed 5.8 times greater and 11.0 times greater risks of complications and revision surgery, respectively, for fluoroscopy-assisted MI-TLIF (111 patients) compared with RA MI-TLIF (374 patients)23. In another study comparing RA MI-TLIF and navigation-assisted TLIF, RA MI-TLIF had less intraoperative blood loss, shorter operative time (187.1 versus 152.3 minutes, respectively; p < 0.001), and a shorter hospital stay (92.3 versus 71.6 hours)24. Important Tips:Because of a smaller Kambin triangle, lateral lumbar interbody fusion is preferred for the upper lumbar levels. If MI-TLIF is chosen, RA is particularly valuable since screw trajectories can be planned to allow for removal of the superior portion of the caudal pedicle without compromising screw fixation.For successful fusion, utilize a large expandable interbody cage with autograft and allograft bone. The contralateral facet can be prepared as a fusion bed, as well. Avoid the use of bone morphogenetic protein, as this can result in neuroforaminal bone growth25.Since all current robotic platforms are co-bot systems without independent robotic activity, the surgeon must employ the same skills and tactile feedback that would be utilized in placing instrumentation without guidance. Furthermore, the surgeon should know the visualized topographical anatomy and correct placement of every instrument in order to protect against unplanned placement. Acronyms and Abbreviations:RA = robotic-assistedMI = minimally invasiveTLIF = transforaminal lumbar interbody fusionPSIS = posterior superior iliac spinePLIF = posterior lumbar interbody fusionLLIF = lateral lumbar interbody fusionALIF = anterior lumbar interbody fusionDRB = dynamic reference baseBMP = bone morphogenetic proteinBMI = body mass indexCT = computed tomographyXR = X-rayMRI = magnetic resonance imagingOR = operating roomAP = anteroposteriorCSF = cerebrospinal fluidVAS = visual analog scaleEBL = estimated blood lossLOS = length of stayPT = physical therapyPRN = as needed.
Background:Metacarpal and phalangeal fractures are among the most common fractures that upper-extremity surgeons encounter, accounting for 30% of all hand fractures1,2. These particular fractures can be treated either operatively or nonoperatively, according to the amounts of displacement, malrotation, and shortening1. Operative treatment includes the use of Kirschner wire fixation, intramedullary screws, plate-and-screw constructs, or interfragmentary screws. Multiple studies have demonstrated superior biomechanical strength and early active range of motion with use of intramedullary screws for the treatment of unstable metacarpal and phalangeal fractures3-7. This minimally invasive technique is designed for unstable metacarpal or phalangeal shaft and neck fractures to allow early active motion. Furthermore, intramedullary placement of implants avoids hardware prominence and extensive soft-tissue stripping, which can impact tendon gliding and postoperative range of motion. Description:Metacarpal fractures can be treated with 3.6 or 4.0-mm intramedullary screws according to the canal diameter. The fracture is reduced by closed means or a limited open reduction. With the metacarpophalangeal joint flexed, the guidewire is inserted into the dorsal third of the metacarpal head through the articular cartilage and driven past the fracture site to the desired depth. A small stab incision is made, and the depth gauge is placed against the metacarpal head. The cannulated drill is placed over the guidewire, and the canal is drilled on the oscillate setting. A screw of the appropriate diameter and length is then placed over the wire, and its position is confirmed under fluoroscopy. Phalangeal fractures are treated with one or two 2-mm screws, inserted antegrade or retrograde according to the fracture location and orientation. The fracture is reduced, and the dual-diameter guidewire is passed through the long axis of the canal to the level of the far cortex (typically at the phalangeal base). A stab incision is made, and the depth gauge is inserted down to bone. The dual-diameter guidepin measures 1.6 mm in diameter on one half and 0.8 mm on the other half. The 1.6-mm portion of the guidewire is then driven out of the far cortex such that the smaller-diameter segment spans the fracture site and remains in the bone. The screw is then placed over the guidewire. A second screw may be placed in a V or X pattern with use of a similar technique. Alternatives:Alternatives to this procedure include nonoperative treatment, Kirschner wire fixation, plate-and-screw constructs, interfragmentary compression screws, and intramedullary headless compression screws. Expected Outcomes:Although many metacarpal and phalangeal fractures may be treated by closed means, a number of fractures require surgical fixation. Melone discussed that 10% of phalangeal and metacarpal fractures are either irreducible by closed means or unsuitable for percutaneous pinning8. The more common historical complications related to these fractures include stiffness and infection. Page and Stern cited a 35% complication rate with plate-and-screw fixation, including a 19% major complication rate6. Percutaneous Kirschner wire fixation is an alternative technique for fixation that is less invasive than open reduction and internal fixation procedures. Belsky et al. assessed 100 phalangeal fractures treated with use of Kirschner wire fixation and found favorable postoperative range of motion9. Botte et al. reported an 18% pin complication rate, most commonly infection, pin migration, and pin loosening10. The use of intramedullary screws allows for minimally invasive fixation that is similar to the use of headless compression screws. The non-compressive design of intramedullary screws avoids shortening in oblique or comminuted fractures. The various length options and differential diameter design allow intramedullary cortical thread engagement to facilitate early active motion. Not all fractures are suitable for intramedullary screw fixation, and there are certainly risks associated with its use. The articular surface can be violated, as the starting point lies at the dorsal third of the articular surface. Although we have not yet seen postoperative degenerative changes, this is a theoretical risk. There is also a risk of subsidence of screws used to treat distal fractures, if the screw is not in the subchondral bone. Important Tips:Preoperative evaluation of canal diameter is helpful to determine the appropriate screw diameter. The ring finger metacarpal typically has the narrowest canal, and a 3.6-mm screw is thus typically utilized. Most other fingers can accommodate a 4.0-mm screw. Anatomy can vary, however.Ensure that the depth gauge is flush against the bone, confirmed on fluoroscopy. We typically subtract 5 mm from the measured length; however, this is dependent on fracture location.Prior to drilling, advance the guidewire into the far cortex in order to avoid guidewire pullout when the cannulated drill is removed.In some cases, tight isthmal fit of the screw can make screw progression difficult. If excessive torque is encountered, back out the implant 2 to 3 turns before continuing (similar to tapping).Ensure that the screw is buried under the articular surface. This is especially important in more distal fractures, in which purchase in subchondral bone is important in avoiding subsidence. In these fractures, a larger incision is often made in order to directly visualize the screw position.When attempting to place crossed screws into a proximal phalanx, sequential advancement of the screws (i.e., alternating screw progression across the isthmus of the canal) can allow for easier screw passage when both guidewires are across the fracture site.To gauge the stability of phalangeal shaft fractures, we apply varus/valgus and flexion/extension stress while using dynamic fluoroscopy after the first screw is inserted. If unstable, a second screw is inserted according to the previously described technique. Acronyms and Abbreviations:K-wire = Kirschner wireMCP = metacarpophalangealAP = anteroposteriorCMC = carpometacarpal.
Background:In spine surgery, biportal endoscopy (BE) is a minimally invasive approach for addressing a range of degenerative lumbar pathologies, including degenerative lumbar spondylolisthesis. The biportal technique benefits from the separation of the endoscopic viewing portal and the working portal for surgical tools, which facilitates an expanded visual field and greater operative flexibility1-3. BE enables both decompression and transforaminal lumbar interbody fusion (TLIF) within a single procedure4. Furthermore, integrating stereotactic navigation with BE enhances the precision of pedicle screw placement, decompression, intervertebral disc removal, end-plate preparation, and navigated cage insertion.5,6. Description:After positioning the patient prone on a radiolucent table, the surgical field is prepared and draped in a sterile fashion. A reference pin is inserted into the iliac crest to facilitate stereotactic navigation. With use of this navigation, 2 separate 1.5 to 2-cm stab incisions are made just lateral to the cranial and caudal pedicles. The pedicles are probed and tapped in order to allow later pedicle screw fixation. Two additional skin incisions are made on the contralateral side, and percutaneous pedicle screw fixation is performed. A 30° arthroscope is introduced through the cranial incision, and a working portal is established through the caudal incision with use of a semitubular retractor. Irrigation is performed, typically set at 30 mmHg. Radiofrequency ablation is utilized to create a working space and to detach the paraspinal muscles from the underlying lamina, extending caudally into the interlaminar space and laterally to remove the facet joint capsule. Ipsilateral laminotomy or laminectomy is performed with a standard arthroscopic shaver and burr until the cranial insertion of the ligamentum flavum is visualized. Contralateral decompression is achieved by removing the ventral portion of the lamina above the ligamentum flavum, after which the ligamentum flavum is detached and removed. The ipsilateral facet joint is then removed with use of a burr and Kerrison rongeurs until the exiting nerve root is visualized and protected. An anulotomy is performed to access the disc space. End-plate preparation is conducted with use of stereotactic navigation and direct visualization through the endoscope. After trialing, an expandable cage is placed under direct visualization and navigation guidance. The endoscope is utilized to confirm the proper placement of the cage and to coagulate any epidural bleeding. Ipsilateral pedicle screws are placed with use of navigation, and rods are introduced under the fascia. Set screws are applied, and fluoroscopic images are obtained to verify the correct placement of implants. Alternatives:Surgical alternatives for degenerative lumbar spondylolisthesis include both open and tubular decompression, with or without fusion. Potential fusion techniques comprise open posterolateral fusion, open TLIF, microscopic tubular TLIF, anterior lumbar interbody fusion, and lateral lumbar interbody fusion. Rationale:BE TLIF is a minimally invasive procedure that limits osseous and soft-tissue damage and reduces postoperative pain and length of hospital stay compared with traditional open TLIF7-9. Multiple studies have demonstrated similar fusion rates with improved early visual analogue pain and Short Form-36 scores and decreased estimated blood loss for BE TLIF compared with microscopic tubular TLIF10-12. From a technical perspective, BE allows ultra-high magnification, which can assist with adequately decompressing the neural structures and providing direct visualization of end-plate preparation. BE also provides better ergonomics during surgery, as the surgeon is able to stand in a relaxed posture with the head upright and looking straight forward. Expected Outcomes:Long-term outcomes are similar between BE TLIF and microscopic tubular TLIF. However, Luan et al. reported that BE TLIF for lumbar degenerative diseases had the advantages of less intraoperative blood loss, less early postoperative low-back and leg pain, shorter length of hospital stay, and faster early functional recovery13. Important Tips:Gain experience with >50 biportal endoscopic decompression surgeries.Ensure proficiency in managing potential complications such as dural tears and postoperative epidural hematomas before starting TLIF surgery.Understand the stereotactic navigation systems to recognize and address discrepancies between on-screen guidance and actual cage insertion. Acronyms and Abbreviations:BE-TLIF = biportal endoscopic transforaminal lumbar interbody fusionMT-TLIF = microtubular transforaminal lumbar interbody fusionPSIS = posterior superior iliac spineSAP = superior articular processRFA = radiofrequency ablation.
