Background: Turf toe is a hallux metatarsophalangeal joint (MTPJ) injury caused by hyperextension of the great toe with axial loading 1,2 . High-grade injuries may threaten return to sport and require surgery 3,4 . Here, we describe a capsular reconstruction of the great toe MTPJ with all-knotless suture anchors and suture tape augmentation for turf toe injuries, in isolation or in combination with a traumatic bunion, designed to reduce suture burden, minimize soft-tissue irritation, and facilitate recovery. Description: The procedure begins with the patient supine. A direct medial approach to the hallux MTPJ is performed. Both the medial base of the proximal phalanx and the medial eminence of the metatarsal head are drilled at isometric points, and augmentation with suture tape is then performed. Isometric drill holes are placed in the medial proximal phalanx base and metatarsal head for suture tape augmentation. A knotless suture anchor is placed approximately 3 mm proximal to the articular margin of the metatarsal head, repairing the medial capsule in a horizontal mattress fashion. An additional knotless anchor is placed at the plantar plate insertion, and the suture is passed through the tibial sesamoid sling and tensioned with the toe in 20° of plantar flexion. Suture tape is secured into the proximal phalanx with an interference screw, then passed through the deep capsule into the metatarsal head, followed by the placement of an additional interference screw into the metatarsal head. The anchor is inserted into the plantar-medial proximal phalanx at the flexor hallucis brevis insertion. The toe is flexed during tensioning, then adjusted per clinical examination and the sesamoid location beneath the metatarsal head. Knotless fixation permits incremental tensioning with intraoperative assessment of motion. Final tensioning is performed with the toe in neutral to correct deformity without overconstraint, preserving range of motion. Alternatives: Nonoperative alternatives include rest, ice, compression and elevation; anti-inflammatory drugs; activity modification; and brief immobilization 5,6 . Operative alternatives include primary capsuloligamentous complex repair with nonabsorbable sutures, plantar plate advancement with bone tunnels or suture anchors if primary repair is not feasible, and concomitant procedures such as sesamoidectomy and bunionectomy based on the injury pattern 2,7,8 . Rationale: This technique is intended for high-grade turf toe injuries with capsuloligamentous disruption, sesamoid complex insufficiency, and MTPJ instability. Nonoperative treatment may be appropriate in cases of low-grade injury; however, persistent pain, instability, or loss of push-off strength following nonoperative treatment would indicate a higher-grade injury. Compared with isolated repair or plantar plate advancement alone, this technique restores both static and dynamic stabilizers of the hallux MTPJ while addressing associated angular deformity. Suture tape augmentation resists recurrent hyperextension and valgus forces while allowing controlled physiologic motion. Knotless, low-profile suture anchors minimize bulk and hardware prominence in a region with limited soft-tissue coverage and bone stock. This construct offers a robust reconstruction option for athletes requiring predictable restoration of stability and reliable return to sport. Expected Outcomes: Operative treatment of high-grade turf toe injuries has been shown to result in reliable pain relief, restored stability, and high rates of return to sport 8 . Previous studies have suggested improved function and earlier return to play compared with prolonged nonoperative treatment in appropriate patients 6,7 . Knotless suture anchors reduce implant prominence and eliminate knot-related irritation, while the small insertional diameter of the suture anchors preserves bone stock in the metatarsal head and proximal phalanx. This construct provides immediate stability while allowing controlled motion, facilitating rehabilitation, and reducing postoperative stiffness. Athletes typically return to unrestricted activity within 6 to 9 months, aided by the suture tape augmentation allowing earlier movement through the range of motion. This augmentation reduces the need for long-term spica splinting and bracing and reduces the risk of recurrence. Important Tips: The small anchor diameter and use of suture tape allow easy access without hardware burden. ○ Suture choice depends on surgeon preference regarding construct stiffness and on the tissue quality and risk of irritation. We believe that suture tape lays flatter and, if required, knots are smaller. Avoid suture twisting or kinking, which can prematurely lock anchors, compromising fixation. ○ After the anchor is placed, we keep the suture tape secured out of the field as we prepare the capsule with absorbable suture. As we load the second anchor, we maintain tension on the tape to prevent twisting. Overtightening the MTPJ capsule may lead to altered biomechanics. Acronyms and Abbreviations: RICE = rest, ice, compression, elevation MRI = magnetic resonance imaging BID = twice daily
Background: Proximal pole scaphoid fractures complicated by nonunion and osteonecrosis present a challenging scenario with few good reconstructive options, especially when the proximal fragment is small or fragmented 1–4 . The use of an ipsilateral proximal hamate osteochondral autograft has emerged as a promising technique for reconstructing the proximal scaphoid pole, with the potential to restore carpal mechanics while avoiding the morbidity associated with free vascularized bone grafts or distant autograft sites. Description: The procedure involves replacing the diseased proximal scaphoid with a structurally matched osteochondral graft from the ipsilateral proximal hamate. After excising the necrotic or fragmented scaphoid pole, a size-matched graft—harvested with its attached volar capitohamate ligament—is rotated 180° on its longitudinal axis to replicate normal scaphoid anatomy. The defect is measured in 3 planes using the scapholunate joint (proximal) and viable distal scaphoid surface as boundaries. On the hamate, an osteotomy is marked 8 to 10 mm distal to its proximal tip, parallel to the articular surface. The volar capitohamate ligament is preserved to guide graft orientation and maintain stability. These measurements align with recent anatomic and biomechanical studies that have confirmed 6 to 10-mm grafts accurately reproduce scaphoid morphology without compromising carpal kinematics. The graft is then inserted into the defect and secured with rigid internal fixation (headless compression screws or Kirschner wires). Residual gaps may be filled with cancellous bone graft. Scapholunate interosseous ligament (SLIL) reconstruction is typically performed by suturing the hamate’s volar capitohamate ligament to the dorsal SLIL remnant on the lunate with a 2-0 nonabsorbable suture. In patients with a partially intact SLIL, such as after failed fixation, the hamate graft alone may provide adequate stability, making formal reconstruction unnecessary. If intraoperative findings reveal dorsal scapholunate instability or an attenuated SLIL, reconstruction is indicated. Healthy, tensionable ligament remnants are repaired directly or reinforced with suture anchors. When dorsal fibers are deficient but volar remnants remain, the attached volar capitohamate ligament is used for reinforcement. For small defects, a micro-interference screw may be employed for fixation. Postoperatively, the wrist is immobilized in a cast. When radiographic evidence of union is observed, the cast is removed and the patient begins a structured hand therapy program. Alternatives: Alternatives include vascularized and nonvascularized bone grafts (e.g., iliac crest), a vascularized medial femoral trochlear osteochondral flap, costochondral rib graft, proximal row carpectomy, and wrist arthrodesis 1,2 . These may be limited by donor-site morbidity, complexity, or suboptimal restoration of wrist biomechanics. Rationale: The articular surface of the proximal hamate closely matches the curvature and size of the proximal pole of the scaphoid, making it an ideal structural substitute. The use of an articular autograft from the same wrist avoids the need for distant donor sites and microsurgical anastomoses, reducing overall morbidity. Additionally, because the graft is harvested with its volar ligament attached, it enables a simultaneous SLIL reconstruction, addressing carpal instability in a way that standard bone grafts cannot. This technique is relatively straightforward and reproducible, and it is especially beneficial in young, active patients with an irreparable proximal scaphoid, offering a chance to heal the nonunion and preserve near-normal wrist function without resorting to salvage procedures. Expected Outcomes: Radiographic union is expected in the majority of cases within 8 to 12 weeks. Published series have demonstrated union rates of >90%, improved pain, restoration of near-normal wrist kinematics, and substantial improvements in range of motion and grip strength, although not always to the level of the contralateral wrist. Complications are rare but include nonunion, donor-site pain, and persistent stiffness. Important Tips: Limit proximal hamate resection to approximately 10 mm distal to its tip in order to replicate the scaphoid defect size while maintaining carpal stability. Ensure preservation of the triquetrohamate and volar capitohamate ligaments, as their integrity prevents instability. Rotate the graft 180° on its longitudinal axis in order to correctly orient the articular surfaces. Fixation should be rigid but not violate adjacent cartilage. Supplement with a distal radial bone graft if a distal scaphoid defect is present. Early controlled motion prevents stiffness. Acronyms and Abbreviations: ON = osteonecrosis VAS = visual analog scale ROM = range of motion QuickDASH = abbreviated version of the Disabilities of the Arm, Shoulder and Hand CT = computed tomography MRI = magnetic resonance imaging ECRL = extensor carpi radialis longus EPL = extensor pollicis longus K-wire = Kirschner wire AP = anteroposterior DISI = dorsal intercalated segment instability NA = not applicable
Background: The proximal interphalangeal (PIP) joint is critical for hand function, contributing substantially to grasping and overall dexterity 1–3 . Injuries to this joint, often caused by axial loading, can lead to various fracture patterns and dislocations, resulting in long-term complications such as pain, stiffness, reduced range of motion, arthritis, and instability 1,2 . Traditional surgical approaches for unstable dorsal PIP joint fracture-dislocation include dorsal block pinning, open reduction and internal fixation (ORIF), hemi-hamate or hemi-capitate arthroplasty, and external fixation 1–3 . Although these methods can be effective, they may have limitations in certain situations. The Suzuki frame, a pins-and-rubber-band traction system, offers a dynamic external fixation option that allows for early controlled motion while maintaining fracture reduction. This technique has several advantages, including ligamentotaxis (the traction force helps to reduce fracture fragments and restore joint alignment), early mobilization (the dynamic nature of the frame allows for early active motion, minimizing joint stiffness), and simplicity (the technique is relatively straightforward and can be performed with readily available materials). Description: The modified Suzuki frame procedure for dorsal PIP joint fracture-dislocation involves administering local anesthesia and establishing a sterile field. Under fluoroscopic guidance, three 1.0-mm Kirschner wires are inserted: 1 through the center of rotation of the proximal phalangeal head, 1 through the center of rotation of the middle phalangeal head, and 1 (the “translation pin”) in the middle phalanx distal to the fracture. The wires are then bent to create a frame with hooks, and the translation pin is secured to the proximal wire. Rubber bands are applied between the hooks to provide traction and maintain reduction. PIP joint congruency is confirmed through a full range of motion under fluoroscopy. Dressings and a splint are applied, allowing for limited immediate postoperative motion. Formal hand therapy begins 1 week postoperatively. Alternatives: Although nonsurgical treatment may be considered for stable, minimally displaced dorsal PIP joint fracture-dislocations, unstable injuries often necessitate operative intervention to restore joint congruity and stability. Several surgical techniques are available to treat these injuries, each with its own advantages and limitations. These techniques include dorsal block pinning, ORIF, hemi-hamate or hemi-capitate arthroplasty, and the use of modified external fixators with various external fixation constructs and pins to provide stability and allow for early controlled motion. Rationale: The modified Suzuki frame is a dynamic external fixator that addresses the limitations of other treatment options for dorsal PIP joint fracture-dislocation. The modified Suzuki frame provides distraction, ligamentotaxis, and a volar-directed force while allowing early range of motion, preventing stiffness, and promoting cartilage healing 1,2 . This technique dynamically adjusts traction, unlike the use of static fixation, and is less invasive than ORIF, preserving joint anatomy that is crucial for younger patients. Use of the modified Suzuki frame is also simpler than that of traditional external fixators, making it ideal for complex fractures, soft-tissue injuries, and early mobilization 1–3 . Expected Outcomes: The modified Suzuki frame is designed to stabilize finger fractures while permitting early mobilization during the healing process. This approach helps reduce stiffness and increases the likelihood of regaining full finger function. Dynamic external fixation of this type has been shown to be highly effective for complex PIP joint injuries. Suzuki et al. reported that patients achieved an average range of motion of 80° at the PIP joint 1 . Ellis et al. demonstrated comparable outcomes, with patients achieving an average range of motion from 1° to 89° 2 . With appropriate care and diligent rehabilitation, patients can generally expect to regain satisfactory motion and function of the injured finger. Continuous monitoring and structured exercise programs are recommended to support optimal recovery outcomes. Important Tips: This technique is best suited for unstable dorsal PIP joint fracture-dislocations that are reducible with traction or translation. Accurate pin placement is crucial for optimal results. Utilize fluoroscopy to confirm pin position and avoid injury to the surrounding structures. Ensure adequate traction with the rubber bands to maintain fracture reduction and joint alignment. Utilize sharp, double-ended Kirschner wires of approximately 15 cm (6 in) and 23 cm (9 in). Bend the wires carefully to create secure hooks and avoid sharp edges that could irritate the skin. Maintain approximately 2.5 cm (1 in) between the proximal and distal hooks to ensure adequate stability. Pin-site infection is a potential complication. Emphasize proper pin care to patients. Kirschner wire migration or breakage can occur. Monitor pin sites regularly and address any issues promptly. Excessive traction can lead to distraction of the fracture or joint. Adjust the rubber bands as needed to maintain appropriate tension. Achieving and maintaining adequate reduction in complex fracture patterns can be challenging. Balancing stability and motion requires careful adjustment of the frame and rubber band tension. Patient compliance with pin care and rehabilitation protocols is essential for optimal outcomes. Acronyms and Abbreviations: K-wire = Kirschner wire
Background: We describe key pearls and principles of a mini-open, thoracoscopically-assisted vertebral body tethering case for double-major scoliosis with 2 distinct anterior approaches: thoracic and thoracoabdominal. Description: The thoracic curve is addressed through a mini-thoracotomy combined with thoracoscopic portals utilizing single-lung ventilation to provide clear visualization. Key steps include precise fluoroscopic marking of vertebral levels, muscle-sparing entry between the ribs, controlled pleural entry and mobilization, and careful management of segmental vessels. Vertebral body screws are placed under direct and fluoroscopic guidance with strict adherence to orthogonal trajectories and avoidance of disc violation. Tether placement proceeds segment-by-segment, maximizing correction at the apex while maintaining appropriate laxity distally to prevent overcorrection. Major tethering principles include maintaining colinear screw alignment to prevent tether kinking and utilizing bicortical fixation when anatomy permits. These principles ensure uniform force transmission and minimize stress concentrations within the tether construct, optimizing tether durability. The lumbar curve is accessed through a thoracoabdominal exposure that includes mobilization of the diaphragm with cuffed detachment and blunt retroperitoneal dissection to safely identify the iliopsoas muscle and sympathetic chain. Double-screw constructs are used at most accessible lumbar levels, with priority given to the apical region to enhance durability under higher mechanical loads. Screws are positioned posteriorly within the vertebral body to help maintain lumbar lordosis and are inserted with a controlled trajectory to achieve bicortical fixation while avoiding a posterior cortical breach and maintaining a safe distance from the spinal canal. Two tethers are applied (first posterior, then anterior) to distribute corrective forces and reduce peak tether strain, balancing correction with load-sharing. Adherence to these principles optimizes lordosis preservation, construct longevity, and safe modulation during growth. Alternatives: The primary alternative treatment is posterior spinal fusion (PSF), the current standard surgical treatment for adolescent idiopathic scoliosis 1 . PSF generally provides greater and more predictable curve correction, particularly for thoracic-major curves, but sacrifices motion across the fused spinal segments. Rationale: This surgical technique is appropriately applied in skeletally immature patients with flexible double-major adolescent idiopathic scoliosis who are undergoing vertebral body tethering through combined thoracic and thoracoabdominal anterior approaches 1–7 . A representative scenario is a patient with a right thoracic and a left lumbar curve demonstrating ≥50% correction of both curves on preoperative bending radiographs, indicating sufficient flexibility for growth modulation. Ideal candidates typically have Cobb angles between 40° and 65° and are skeletally immature (Risser 0 to 2, Sanders 3 to 4). The principles demonstrated are particularly relevant when treating double-curve deformities that require 2 distinct anterior exposures, wherein precise screw alignment, safe vessel and soft-tissue management, and differential tether tensioning are critical to predictable growth modulation. In the thoracic spine, this technique is useful when placing vertebral body screws through a mini-thoracotomy with thoracoscopic assistance, wherein colinear screw alignment and segmental tensioning are necessary to avoid tether kinking and maintain physiologic thoracic kyphosis. In the lumbar spine, thoracoabdominal exposure requires diaphragm mobilization and screws are posteriorly positioned; dual-screw constructs and staged posterior-then-anterior tethering help preserve lumbar lordosis and improve construct durability. These use cases emphasize scenarios in which precise fluoroscopic planning, harmonious screw trajectories, and controlled tether laxity are essential to avoid overcorrection, minimize mechanical stress on the tether, and achieve durable correction through guided spinal growth. Expected Outcomes: In appropriately selected adolescents with double-curve adolescent idiopathic scoliosis, bilateral vertebral body tethering can provide meaningful correction of both curves while preserving spinal motion 1–3 . Outcomes appear more favorable for thoracolumbar-major curves than thoracic-major curves, but patients should be counseled regarding risks of tether breakage, overcorrection, loss of correction, and potential revision or fusion. Long-term durability remains uncertain. Important Tips: Maintain optimal orthogonal fluoroscopic views throughout screw placement. Align screw tulips colinearly to avoid tether shear forces. Leave controlled laxity distally in patients with substantial remaining growth. Use bicortical fixation posteriorly in the lumbar spine for reliable fixation. Avoid placing screws too anteriorly or posteriorly, which increases the risk of a visceral or canal breach. Avoid overtensioning end segments, which increases the risk of overcorrection. Avoid grasping or damaging the tether with instruments. Avoid insufficient thoracotomy and/or portal placement, which can lead to poor exposure and suboptimal screw trajectory. Acronyms and Abbreviations: VBT = vertebral body tethering
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.
