All posts by Chris Boisvert

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Single-Incision Retrograde SIGN Nailing of the Femur and Antegrade SIGN Nailing of the Tibia for a Delayed-Presentation Floating Knee Injury

Single-Incision Retrograde SIGN Nailing of the Femur and Antegrade SIGN Nailing of the Tibia for a Delayed-Presentation Floating Knee Injury
Donald L. Fejfar, MD1; Samhita Kadiyala, BA1; Nikhil Gattu, MD1; Emily S. Powis, BS1; Elizabeth Rich, MD2; Ridwan M. Saeed, MD3; Hizkyas Kassaye, MD4; Pierre M. Woolley, MD5; Bitiel Banda, MD6; Kiran J. Agarwal-Harding, MD, MPH7
1Harvard Global Orthopaedics Collaborative, Boston, MA
2Walter Reed National Military Medical Center, Bethesda, MD
3Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
4Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia
5Hôpital Universitaire La Paix, Port au Prince, Haiti
6Mzuzu Central Hospital, Mzuzu, Malawi
7Beth Israel Deaconess Medical Center, Boston, MA

Floating knee injury, defined as ipsilateral femoral and tibial shaft fractures, is a high-energy traumatic injury frequently seen following road traffic accidents (RTAs), which disproportionately burden low- and middle-income countries. Definitive treatment of this complex injury typically involves internal fixation, and the commonly accepted preferred method is intramedullary nailing of both fractures. This video article describes the surgical technique for managing a floating knee using retrograde Surgical Implant Generation Network (SIGN) nailing of the femur and antegrade SIGN nailing of the tibia through a single infrapatellar incision in a single anesthesia event.

The case involves a 28-year-old female patient in rural Malawi with a floating knee injury sustained in a motorbike RTA, notable for her delayed presentation of three weeks. The key procedural steps, performed under spinal anesthesia, began with a single infrapatellar incision for the subsequent retrograde nailing of the midshaft femur. Due to delayed presentation (22 days from the date of injury to the first exam in the hospital, with 2 more days before surgery) and callus formation, intraoperative fracture fragment mobilization via a second lateral incision was required before securing the femoral nail. The same infrapatellar incision was then used to perform antegrade nailing of the proximal tibial shaft fracture, which was secured after a closed reduction. This single-incision approach provides a definitive, robust fixation solution appropriate for a resource-constrained setting where challenges include delayed patient presentation and limited imaging infrastructure.

Print Release, Vascular Surgery

PUBLISHED: Snuffbox Radiocephalic Arteriovenous Fistula Creation for End-Stage Kidney Disease

Snuffbox Radiocephalic Arteriovenous Fistula Creation for End-Stage Kidney Disease
Brett J. Salomon, MD1; Christopher Holden-Wingate2,3; Mohamad A. Hussain, MD, PhD1,2; C. Keith Ozaki, MD1
1Mass General Brigham
2Harvard Medical School
3University of Illinois College of Medicine

The snuffbox arteriovenous fistula (SBAVF) is a distal-first dialysis access strategy connecting the posterior branch of the radial artery and cephalic vein within the anatomical snuffbox to preserve proximal vascular sites for patients requiring long-term hemodialysis (HD). This low-flow forearm fistula, which represents only 4% of forearm access creations in a contemporary large registry, provides significant clinical advantages over high-flow alternatives. These benefits include a significantly lower risk of high-output heart failure (HOHF) and negligible rates of access-related hand ischemia (ARHI). Contemporary literature confirms that SBAVF offers primary and secondary patency rates comparable to wrist AVFs at 18 months, supporting a “snuffbox first” approach for eligible candidates.

This case details successful SBAVF creation in a 38-year-old male with end-stage kidney disease (ESKD), which was selected to maximize vessel preservation given his prolonged expected duration of HD. Postoperatively, the patient was discharged without complication and subsequently cleared to trial HD after successful maturation. Although it is common for SBAVFs to require adjunctive procedures and more time to achieve maturation, long-term durability (5–9 years) remains outstanding, reinforcing the value of this technically precise procedure as a safe and durable primary access option.

Anesthesiology, Print Release

PUBLISHED: Ultrasound-Guided Radial Artery Catheterization in a Four-Month-Old Boy

Ultrasound-Guided Radial Artery Catheterization in a Four-Month-Old Boy
Jun Takeshita, MD, PhD
Osaka Women’s and Children’s Hospital

Ultrasound-guided radial artery catheterization is increasingly used in pediatric patients because it improves procedural accuracy and may enhance first-pass success in infants and small children with small-caliber arteries. Dynamic needle tip positioning (DNTP), a short-axis out-of-plane ultrasound-guided technique, facilitates repeated identification of the true needle tip during needle advancement and enables precise catheter placement.

This video demonstrates ultrasound-guided radial artery catheterization using the DNTP technique in a 4-month-old, 5.5-kg infant with tetralogy of Fallot undergoing a right-sided systemic-to-pulmonary shunt procedure. Because ipsilateral shunt flow may interfere with accurate arterial pressure monitoring, the left radial artery was selected for cannulation. The video illustrates key technical aspects of DNTP, including stepwise needle and probe advancement to maintain visualization of the true needle tip, as well as practical considerations for minimizing complications. It also emphasizes strict aseptic technique, including maximal sterile barrier precautions, a sterile ultrasound probe cover, and sterile ultrasound gel.

The arterial catheter was successfully placed without immediate complications and functioned appropriately throughout the procedure. This video provides a practical demonstration of DNTP and highlights procedural planning and infection prevention strategies for safe and effective pediatric radial artery catheterization.

General Surgery, Print Release

PUBLISHED: Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Femoral Hernia Repair

Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Femoral Hernia Repair
Katie A. Marrero, MD1; Eric M. Pauli, MD, FACS, FASGE, FEBSAWS (Hon.)2
1Henderson Hospital, NV
2Penn State Health Milton S. Hershey Medical Center

Femoral hernias are an uncommon cause of groin pain but occur more frequently in women than men and are often overlooked during clinical evaluation and imaging review. Failure to recognize these “hidden” hernias may lead to persistent symptoms despite previous inguinal hernia repair.

A 43-year-old woman presented with chronic left groin pain despite prior open left inguinal hernia repair with mesh plug placement. Her medical history included cesarean section and abdominoplasty, with pain initially attributed to postoperative nerve injury. A CT scan obtained in 2023 was interpreted as negative for recurrent hernia; however, retrospective review demonstrated an obvious left femoral hernia adjacent to the previously placed mesh plug. She subsequently underwent treatment for May-Thurner syndrome with left common iliac vein stenting without improvement in symptoms. Clinical examination, office ultrasound, and re-evaluation of prior imaging confirmed the diagnosis of a symptomatic femoral hernia.

A robotic transabdominal preperitoneal (rTAPP) repair was performed. After establishing abdominal access and creating a generous preperitoneal flap, the myopectineal orifice was completely exposed. The previously placed mesh plug was identified medial to the inferior epigastric vessels and largely left undisturbed with only a small portion excised to facilitate flat placement of new mesh. The femoral hernia sac and incarcerated preperitoneal fat were reduced, the round ligament was divided, a large preperitoneal mesh was positioned to cover the femoral canal and all potential groin defects, and the peritoneal flap was closed.

This case demonstrates the importance of maintaining a high index of suspicion for occult femoral hernias in women with persistent groin pain, particularly following previous anterior inguinal hernia repair. Robotic TAPP repair provides excellent visualization of the entire myopectineal orifice and enables definitive treatment while preserving previously implanted mesh when appropriate.

Anesthesiology, Press Release

PUBLISHED: Ultrasound-Guided Rectus Sheath Block in a Pediatric Patient

Ultrasound-Guided Rectus Sheath Block in a Pediatric Patient
Jun Takeshita, MD, PhD
Osaka Women’s and Children’s Hospital

Rectus sheath block (RSB) is a regional anesthesia technique in which a local anesthetic is injected between the posterior aspect of the rectus abdominis muscle and the posterior rectus sheath to block the anterior cutaneous branches of the thoracoabdominal nerves. In pediatric patients, RSB is particularly useful for surgeries performed through umbilical or circumumbilical incisions, such as umbilical hernia repair, laparoscopic surgery with umbilical port placement, pyloromyotomy for hypertrophic pyloric stenosis, and surgery for duodenal atresia, intestinal malrotation, or ovarian cysts. Ultrasound guidance improves the precision and safety of the block by enabling direct visualization of the rectus abdominis muscle, posterior rectus sheath, and underlying peritoneum.

This video demonstrates ultrasound-guided bilateral RSB in a 27-day-old, 3.9-kg neonate undergoing circumumbilical pyloromyotomy for hypertrophic pyloric stenosis. The video highlights the key technical aspects of the procedure, including the identification of the posterior rectus sheath, continuous visualization of the needle tip, appropriate lateral placement of the local anesthetic within the posterior rectus sheath plane, and measures to avoid peritoneal puncture and vascular injury. Particular attention is also given to the conservative dosing of ropivacaine in neonates to minimize the risk of local anesthetic systemic toxicity.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Debridement and External Fixation for Bilateral Neglected Open Tibial Shaft Fractures

Debridement and External Fixation for Bilateral Neglected Open Tibial Shaft Fractures
Donald L. Fejfar, MD1; Nikhil Gattu, MD1; Ridwan M. Saeed, MD2; Hizkyas Kassaye, MD3; Bitiel Banda, MD4; Pierre M. Woolley, MD5; Kiran J. Agarwal-Harding, MD, MPH1,6
1Harvard Global Orthopaedics Collaborative, Boston, MA
2Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
3Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia
4Mzuzu Central Hospital, Mzuzu, Malawi
5Hôpital Universitaire La Paix, Port au Prince, Haiti
6Beth Israel Deaconess Medical Center, Boston, MA

Open tibial shaft fractures represent a significant clinical challenge, particularly when presentation is delayed and wounds have become infected. This case demonstrates the surgical management of bilateral neglected open tibial shaft fractures in a young adult male who presented three weeks after initial injury from a motor vehicle collision in rural Malawi. He also suffered a bimalleolar fracture of the left ankle. The patient had grossly contaminated wounds with exposed bone and signs of infection bilaterally. The key procedural steps included aggressive irrigation and debridement of necrotic and infected tissue, skeletal stabilization with external fixation, local antibiotic therapy with gentamicin-impregnated collagen pellets, and soft tissue coverage with primary wound closure and a rotational subcutaneous flap on the left leg. External fixation is an essential treatment modality for open fractures with severe soft tissue injury when internal fracture fixation is not possible, especially in delayed cases with early signs of infection. This allows for staged management, repeated wound access, and preservation of blood supply while providing adequate stability for bone healing and soft tissue rest. This technique is particularly valuable in resource-limited settings where staged reconstruction and damage control orthopaedics are essential. The bilateral nature of these injuries, prolonged contamination period, immunocompromised status, and need for complex soft tissue reconstruction make this case unique and highlight the principles of managing neglected open fractures in challenging clinical circumstances.

Anesthesiology, Print Release

PUBLISHED: Neuraxial Ultrasound and Combined Spinal-Epidural (CSE) Anesthesia for Cesarean Delivery

Neuraxial Ultrasound and Combined Spinal-Epidural (CSE) Anesthesia for Cesarean Delivery
Lauren Blake, MD; Fatine Karkri, MD; Brendan Carvalho, MBBCh, FRCA, MDCH, FASA
Stanford University School of Medicine

Neuraxial anesthesia is the gold standard approach for cesarean delivery, offering surgical anesthesia while optimizing maternal and fetal outcomes. This video provides a stepwise demonstration of a combined spinal-epidural (CSE) technique for cesarean delivery. This technique covers patient positioning, identification of the appropriate interspace, sterile preparation, infiltration of local anesthetic, and spinal/epidural needle placement. For single-shot spinal (SSS), a spinal needle is advanced into the subarachnoid space, cerebrospinal fluid return is confirmed with aspiration, and intrathecal medication is administered. For CSE, an epidural needle is advanced into the epidural space using a loss-of-resistance technique, followed by spinal needle insertion through the epidural needle for intrathecal medication administration. This needle-through-needle technique concludes with epidural catheter insertion and securement. Indications and medication dosing for cesarean delivery are discussed for each technique.

Anesthesiology, Print Release

PUBLISHED: Neuraxial Ultrasound and Epidural Blood Patch for Post-dural Puncture Headache

Neuraxial Ultrasound and Epidural Blood Patch for Post-dural Puncture Headache
Fatine Karkri, MD; Lauren Blake, MD; Brendan Carvalho, MBBCh, FRCA, MDCH, FASA
Stanford University School of Medicine

This video demonstrates a stepwise technique for performing an autologous epidural blood patch (EBP) to treat post-dural puncture headache (PDPH). The video covers identification of the target interspace, skin cleaning, local anesthesia infiltration, epidural needle placement using loss-of-resistance technique, aseptic collection of autologous blood, controlled injection into the epidural space, and immediate assessment of EBP effect. Indications, contraindications, expected immediate responses, and troubleshooting (including repeat EBP and alternative interventions) are discussed. The technique shown aims to maximize efficacy and enhance safety, and is applicable to PDPH after dural puncture from spinal anesthesia or inadvertent dural puncture during epidural placement.

General Surgery, Print Release

PUBLISHED: Robotic-Assisted Transcystic Endoscopic Common Bile Duct Exploration

Robotic-Assisted Transcystic Endoscopic Common Bile Duct Exploration
Marc Mankarious, MD1; Benjamin S. C. Fung, MD, FRCSC2; Joshua S. Winder, MD1
1Penn State Health Milton S. Hershey Medical Center
2North York General Hospital, University of Toronto

Choledocholithiasis complicates cholecystectomy in 10–15% of patients. In individuals with prior Roux-en-Y gastric bypass (RYGB), altered foregut anatomy renders traditional endoscopic retrograde cholangiopancreatography (ERCP) technically challenging or unsuccessful. This report details the use of robotic-assisted transcystic endoscopic common bile duct exploration (TCBDE) in a patient with RYGB and choledocholithiasis. For patients with surgically altered anatomy and urgent need for stone clearance, robotic TCBDE represents a safe, cost-effective, single-stage alternative to two-stage approaches, effectively bypassing the anatomical limitations imposed by RYGB.

Print Release, Surgical Technology

PUBLISHED: How to Drape a C-Arm

How to Drape a C-Arm
Cindy Fletcher, M.Ed., CST
North Shore Community College, Danvers, MA

When intraoperative imaging is needed, a mobile x-ray machine must be used by a radiologic technologist (RT) to take the image. A C-arm portable imaging machine, so called because its shape resembles the letter “C”, is widely used in contemporary surgical and interventional procedures for this purpose, and its proper draping is essential for maintaining sterile field integrity. This educational video demonstrates how to receive a C-arm drape onto the sterile field, how to prepare it for use, and how to place and secure it around the C-arm using sterile technique to protect patient safety. This video was filmed in an academic setting and is intended for perioperative trainees and staff.