Orthopedics, Print Release

PUBLISHED: The Use of Photodynamic Nails for Bone Reinforcement in Combination with Complex Total Hip Arthroplasty in the Setting of Radiation Osteitis

The Use of Photodynamic Nails for Bone Reinforcement in Combination with Complex Total Hip Arthroplasty in the Setting of Radiation Osteitis
Joseph O. Werenski; Paul A. Rizk, MD; Santiago A. Lozano-Calderon, MD, PhD
Massachusetts General Hospital

This article presents a case of diffuse large B-cell lymphoma (DLBCL) with skeletal involvement in a geriatric male. Initially presenting with left hip pain, the patient was diagnosed with DLBCL affecting the left acetabulum. Subsequent treatment with systemic and radiation therapy resulted in radiation osteitis, osteoarthritis, and acetabular collapse, necessitating surgical intervention.

The treatment plan involved total hip arthroplasty (THA) with photodynamic intramedullary nails (PDNs) for pelvic stabilization, augmented with tantalum augments for enhanced support. PDNs provided structural stability while minimizing interference with future oncological interventions. The surgical procedure comprised meticulous insertion of PDNs and placement of tantalum augments, achieving optimal stability and alignment of the acetabular component.

This case underscores the strategic use of PDNs and tantalum augments in for treating major acetabular defects in patients with complex pathologies who require THA for pelvic stabilization. These techniques provide advantages in postoperative radiographic disease monitoring and precision in radiation therapy planning. The multidisciplinary approach emphasizes the importance of carefully selecting the appropriate implants to optimize outcomes in orthopaedic oncology.

General Surgery, Print Release

PUBLISHED: Complex Abdominal Wall Reconstruction with Transversus Abdominis Release (TAR)

Complex Abdominal Wall Reconstruction with Transversus Abdominis Release (TAR)
Michael J. Rosen, MD, FACS
Cleveland Clinic

This video demonstrates a case involving an open complex abdominal wall reconstruction with transversus abdominis release. The case involves an obese patient with a multiply recurrent incarcerated incisional hernia. The CT scan shows a complex defect involving the midline, right linea semilunaris, and inter-rectus hernia. The use of a retromuscular procedure with a posterior component separation will be highlighted and its advantages of allowing wide mesh overlap without creation of subcutaneous tissue flaps to repair defects with these challenging characteristics.

Orthopedics, Print Release

PUBLISHED: Diagnostic Hip Arthroscopy

Diagnostic Hip Arthroscopy
Jason P. Den Haese Jr., DO1; Scott D. Martin, MD2
1Oklahoma State University Medical Center
2Brigham and Women’s/Mass General Health Care Center

Diagnostic hip arthroscopy is a minimally-invasive surgical technique used to accurately provide intraoperative information and potentially treat certain intra-articular (such as labral tears, chondral defects, and femoroacetabular impingement) and extra-articular (such as capsular tears, ischiofemoral impingement, and pediatric deformities) hip pathologies. The use of this procedure in the United States is becoming more common; annual rates are increasing by as much as 365% since 2004. Within this rapid increase of utilization, the three most common procedures being performed with diagnostic hip arthroscopy are labral repair, femoroplasty, and acetabuloplasty.

In this case, a young female athlete is being assessed for left anterior hip pain recalcitrant to nonoperative management. The patient was placed in a supine position with an anterolateral portal and modified anterior portal being placed into the left hip. A puncture capsulorrhaphy was performed to examine the labrum, femoral head, and transverse ligament. Then, the medial structures and peripheral compartment were visualized. Throughout the procedure, the only treatable hip pathology identified was labral fraying consistent with a minor labral tear. It was determined that the fraying was not significant enough to require surgical repair, so labral debridement was chosen. Other areas of labral fraying and fatty degeneration were identified, but they were not significant enough to be treated intraoperatively. The procedure was completed with no complications.

General Surgery, Print Release, Thoracic Surgery

PUBLISHED: Left Tube Thoracostomy for Pneumothorax

Left Tube Thoracostomy for Pneumothorax
Ryan Boyle1; Elliot Bishop, MD2; Peter Bendix, MD2
1 Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University
2University of Chicago Medicine

The clinical presentation of pneumothorax ranges from no symptoms to life-threatening tension physiology requiring emergent intervention. The thoracic cavity is lined with parietal while the lungs and mediastinal structures are lined with visceral pleura. Normally in apposition, a potential space exists between these two layers where fluid, air, or a combination of the two may accumulate. If this potential space fills with fluid or air, subsequent collapse of the lung tissue causes symptoms such as shortness of breath and tachypnea. If the fluid or air accumulate to the degree that venous cardiac return is impeded, tension physiology ensues with hypotension, tachycardia, and eventual cardiovascular collapse if the pressure is not relieved. Tube thoracostomy remains the treatment of choice for managing pneumothorax. This article presents the management of a traumatic pneumothorax with tube thoracostomy in a 51-year-old male injured in a motor vehicle collision.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Left Tibia Pilon Open Fracture Open Reduction and Internal Fixation with External Fixator

Left Tibia Pilon Open Fracture Open Reduction and Internal Fixation with External Fixator
Nelson Merchan, MD1,2; Andrew M. Hresko, MD1,2; Edward Kenneth Rodriguez, MD, PhD2
1Harvard Combined Orthopaedic Surgery Residency Program
2Beth Israel Deaconess Medical Center

Tibial plafond or pilon fractures account for 5 to 10% of all lower extremity fractures and are associated with high energy trauma. These fractures have a high rate of non-union, mal-union, and wound healing issues due to weak metaphyseal bone, a lack of robust soft tissue coverage, and complex intra-articular extension. This manuscript and video demonstrates a tibial pilon fracture managed acutely with a hybrid fixation approach combining internal fixation with external fixation.

General Surgery, Print Release

PUBLISHED: Whipple Procedure for Carcinoma of the Pancreas

Whipple Procedure for Carcinoma of the Pancreas
Martin Goodman, MD1; Vahagn G. Hambardzumyan, MD2
1Tufts University School of Medicine
2Yerevan State Medical University, Heratsi Hospital Complex

Pancreatic ductal adenocarcinoma (PDAC) is the ninth most common cancer in the United States, but due to symptoms—such as back pain, jaundice and unexplained weight loss—usually only presenting when the disease has already moved beyond the pancreas, it is highly lethal, representing the fourth most common cause of cancer death. As a result of widespread abdominal imaging, more early stage pancreatic cancers are being diagnosed, and these patients are candidates for a pancreaticoduodenectomy, more commonly known as the Whipple procedure.

The Whipple procedure is used to treat four types of cancer—periampullary, cholangiocarcinoma, duodenal, and pancreatic ductal adenocarcinoma—but is most well known in the setting of PDAC. Although there are only a few basic steps to the procedure—removal of  the pancreatic head, distal bile duct, duodenum, and either distal gastrectomy or pyloric preservation. Next is the reconstruction with bringing up the stapled end of jejunum to the pancreas, then the hepatic duct, and lastly to the stomach. The multiple crucial anatomic structures in the same region, as well as the unforgiving nature of the structures involved in the operation itself, lead to high morbidity and necessitate complex postoperative care. Due to this, most Whipple procedures are performed at higher volume centers.

Print Release, Vascular Surgery

PUBLISHED: Thoracoabdominal Aortic Aneurysm Repair

Thoracoabdominal Aortic Aneurysm Repair
Andrew Del Re, MD1; Jahan Mohebali, MD, MPH2; Virendra I. Patel, MD, MPH2
1The Warren Alpert Medical School of Brown University
2Massachusetts General Hospital

Thoracoabdominal aortic aneurysms (TAAAs) are generally asymptomatic and are discovered incidentally on thoracic or abdominal imaging. When they are identified, management is often expectant, depending on the size of the aneurysm and its rate of growth. Surgery is indicated for larger aneurysms and those that expand rapidly so as to avoid the catastrophic rupture of the aneurysm.

This article presents the case of a 70-year-old female with a TAAA, whom had been followed with serial computed tomographic angiography scans. The decision to operate was made when the aneurysm began revealing growth in diameter. Her anatomy was not conducive to endovascular treatment; therefore, her aneurysm was repaired using a traditional open approach.

Basic Skills for the OR, General Surgery, Print Release

PUBLISHED: Nasogastric (NG) Tube Insertion

Nasogastric (NG) Tube Insertion
Deanna Rothman, MD
Massachusetts General Hospital

Nasogastric (NG) tube insertion is a crucial skill in medical practice that involves the placement of a flexible tube through the nasal passage into the stomach, serving multiple purposes in patient care. This video article aims to provide a detailed overview of NG tube insertion, including its indications, contraindications, necessary materials, and the step-by-step process of placement.

General Surgery, Pediatrics, Print Release, Urology

PUBLISHED: Cloacal Exstrophy Repair

Cloacal Exstrophy Repair
William Remley1; Howard Jen, MD2; Carl-Christian A. Jackson, MD2; Jeremy Wiygul, MD2
1Lake Erie College of Osteopathic Medicine
2Tufts Medical Center

Cloacal exstrophy is congenital malformation marked by an abdominal wall defect with open and exposed hindgut and bladder. It is the most severe birth defect within the exstrophy-epispadias complex, and when spinal defects are also present, it is called the OEIS (omphalocele, exstrophy, imperforate anus, and spinal defect) complex. Cloacal exstrophy is rare, occurring in 1/200,000–400,000 births, but it can be diagnosed on prenatal ultrasound. The defect results in two exstrophied hemibladders separated by an exposed cecal plate, with the distal hindgut being foreshortened and blind-ending, resulting in an imperforate anus. There is diastasis of the pubic symphysis, and the genitalia are separated. In males, the phallus is usually split in half, flattened and shortened, with the inner surface of the urethra exposed. In females, the clitoris is split, the labia are widely separated, and there may be two vaginal openings. Cloacal exstrophy is also highly associated with other birth defects, especially spina bifida, which coexist in up to 75% of cases. Multidisciplinary care followed by surgical management should begin immediately following the baby’s delivery.

Surgical goals in the neonatal period include closure of the meningocele and repair of the exstrophy and omphalocele, resulting in approximation of the bladder halves and repair of the hindgut defect with colostomy creation. Closure of the bladder, with positioning within the pelvis, can either occur at the initial operation or be staged to occur after a period of monitored growth, and is best performed with pelvic osteotomies to protect the closure from tension. Subsequent surgeries over several years will address genital reconstruction and colonic pull-through for fecal continence, if the patient is a candidate. Here, we present a patient diagnosed with OEIS complex by prenatal ultrasound, with a postnatal exam confirming the diagnosis and demonstrating a closed (covered) myelomeningocele. The cloacal exstrophy and omphalocele were repaired in one stage, with primary closure of the involved bowel and the bladder, facilitated by pelvic osteotomies.

General Surgery, Global Surgery, Pediatrics, Print Release

PUBLISHED: Posterior Sagittal Anorectoplasty (PSARP) for Imperforate Anus

Posterior Sagittal Anorectoplasty (PSARP) for Imperforate Anus
Jacob Blank1; Paulo Castillo, MD2; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES3
1Lake Erie College of Osteopathic Medicine
2World Surgical Foundation
3Philippine Children’s Medical Center

Imperforate anus is a birth defect in which the anal opening is absent. This condition develops during the fifth to seventh weeks of pregnancy and the cause is unknown. It affects about one in every 5,000 newborns and is noted to be more common among boys than girls. Imperforate anus is usually present with other birth defects such as vertebral defects, cardiac problems, tracheoesophageal fistula, renal anomalies, and limb abnormalities, collectively known as the VACTERL association. The diagnosis is made by performing a physical exam after birth. An x-ray of the abdomen and abdominal ultrasound can help reveal the extent of the abnormalities.

Treatment is surgical creation of an opening or new anus to allow stool to pass. The type of surgery differs and depends on whether the anus ends high or low in the pelvis. In the case of a low type, an anal opening is made in a single operation, and the rectum is pulled down to the anus. For high type, surgical correction is performed in three stages. The first procedure is bringing the intestine out of the abdomen creating a stoma; the second procedure is pulling the rectum down to the anus where a new anal opening is created; and the third procedure is closure of the intestinal stoma. Here, we present a case of a 9-month-old male who was born with a high-type imperforate anus. A posterior sagittal anorectoplasty (PSARP) was done as the second of three stages of treatment. The first was an emergency sigmoid colostomy, and the third will be to close the colostomy in about 6 to 8 weeks following the PSARP.

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