Category Archives: Orthopedics

PUBLISHED: Rotator Cuff Repair (Cadaver Shoulder)

Rotator Cuff Repair (Cadaver Shoulder)
Patrick Vavken, MD1Sabah Ali2
1Smith and Nephew Endoscopy Laboratory
2University of Central Florida College of Medicine

Rotator cuff tears represent the vast majority of shoulder disorders treated by orthopaedic surgeons. From partial-thickness tears in overhead throwing athletes to full-thickness tears in the elderly, the prevalence of rotator cuff tears continues to increase over time. While some cases are asymptomatic, most patients with rotator cuff tears report shoulder pain, limited range of motion, and nighttime pain with difficulty sleeping on the affected shoulder. When nonsurgical treatment is insufficient in relieving the symptoms, arthroscopic rotator cuff repair becomes a viable option for many patients.

This is the case of a rotator cuff repair of a full-thickness tear that extends into the infraspinatus on a cadaver shoulder in the beach chair position. The tear was repaired by placing an anchor, retrieving and passing three suture arms, and tying the suture. This article outlines the natural history, preoperative care, intraoperative technique, and postoperative considerations of rotator cuff repairs.

PUBLISHED: Portal Placement for Hip Arthroscopy

Portal Placement for Hip Arthroscopy
Steven D. Sartore1Scott D. Martin, MD2
1Lake Erie College of Osteopathic Medicine
2Brigham and Women’s/Mass General Health Care Center

Hip arthroscopy is a well-established technique that has become a mainstay in the repair of bony and ligamentous injuries when conservative methods fail to return adequate joint mobility and function. The technique has both diagnostic and therapeutic utility and its use as a minimally invasive orthopedic surgery continues to advance. Several studies have suggested that arthroscopic surgical management has more favorable outcomes in certain circumstances when compared to hip-specific conservative measures.

The approach to establishing adequate sites for portal placement is dependent upon recognizing the pertinent anatomy of the surgical site.  At the same time, the operator must be mindful of the desired views once access to the joint space has been obtained. Proper visualization of the desired joint region is critical to reducing the conversion of THAs into inherently riskier total joint procedures. Additionally, the neurovascular landscape of the groin presents technical challenges with the procedural approach, which requires significant skill to avoid vital structures in the area. Acetabular labral tears are frequently repaired with this type of operative management as techniques and approaches become more refined. Here, the authors present the case of a 24-year-old woman who is undergoing an arthroscopic anterior labral repair, highlighting both the anatomical landmarks and the access points for portal placement used in the procedure.

PUBLISHED: Open Reduction and Internal Fixation of a Diaphyseal Periprosthetic Humeral Fracture

Open Reduction and Internal Fixation of a Diaphyseal Periprosthetic Humeral Fracture
Ikechukwu C. Amakiri1Michael J. Weaver, MD2
1Geisel School of Medicine, Dartmouth College
2Brigham and Women’s Hospital

Periprosthetic humeral shaft fractures are increasing in incidence as shoulder replacements become more common. Surgical management of humeral shaft fractures can only be deemed appropriate when the degree of pain, the extent of disability, and the number of comorbid conditions are taken into consideration.

Among trauma surgeons there exists no preferred surgical approach to fractures of different segments of the humerus; however, the anterolateral approach to midshaft fractures is the most common although viable alternative approaches exist. In this case, we perform an open reduction and internal fixation of a diaphyseal periprosthetic humeral fracture with a posterior triceps sparing approach.

PUBLISHED: Bone Graft for Nonunion of Right Thumb Proximal Phalanx Fracture

Bone Graft for Nonunion of Right Thumb Proximal Phalanx Fracture
Sudhir B. Rao, MD1Mark N. Perlmutter, MS, MD, FICS, FAANOS2Arya S. Rao3Grant Darner4
1Big Rapids Orthopaedics
2Carolina Regional Orthopaedics
3Columbia University
4Duke University School of Medicine

In this video, the authors describe and demonstrate a surgical technique for the treatment of an unstable nonunion of a proximal phalangeal fracture of the thumb.

The video describes the surgical exposure, preparation of the nonunion site, harvesting of autogenous iliac corticocancellous bone graft, bone grafting of the defect, and stabilization with K-wire fixation.

PUBLISHED: Retrograde Femoral Intramedullary Nail for a Midshaft Femoral Fracture with an Ipsilateral Subtrochanteric Fracture

Retrograde Femoral Intramedullary Nail for a Midshaft Femoral Fracture with an Ipsilateral Subtrochanteric Fracture
Jason P. Den Haese Jr.1Michael J. Weaver, MD2
1Lake Erie College of Osteopathic Medicine
2Brigham and Women’s Hospital

This case illustrates a midshaft femoral fracture with an ipsilateral subtrochanteric fracture that is repaired with a retrograde femoral intramedullary nail technique. The annual incidence of midshaft femur fractures is approximately 10 per 100,000 person-years (most commonly low-energy falls in elderly females). Generally, these patients will present with pain, inflammation, and shortening of the leg.

Retrograde femoral intramedullary nail placement is one of the most prevalent methods for treatment. It was initially discovered in 1970 and refined in 1995 to have improved surgery time, bleeding, and postoperative adverse outcomes. This procedure has proven to be particularly beneficial in obese and non-ambulatory patients, and those with multisystem injuries; it also has shown some benefit in pregnant women due to decreased pelvic radiation exposure.

This case presents a woman with a femoral shaft fracture and an ipsilateral subtrochanteric fracture. Given this patient’s multiple ipsilateral femur fractures, it was favorable to intervene with a retrograde femoral intramedullary nail. The procedure was done in a supine position due to favorable imaging throughout the operation.

PUBLISHED: Closed Cephalomedullary Nail Fixation of a Reverse Oblique Subtrochanteric Femoral Fracture in the Lateral Position

Closed Cephalomedullary Nail Fixation of a Reverse Oblique Subtrochanteric Femoral Fracture in the Lateral Position
Robert W. Burk IV, MS1Michael J. Weaver, MD2
1Lake Erie College of Osteopathic Medicine
2Brigham and Women’s Hospital

Subtrochanteric femoral fractures commonly present in two different populations under very different circumstances. The elderly are commonly affected by low-energy events, such as a simple fall to the floor, while younger populations are more likely to be involved in high-energy events such as motor vehicle accidents. The majority of elderly injuries can be attributed to fragility fractures due to loss of bone density, but it is important to note an atypical fracture pattern that is present in those who have been taking bisphosphonates.

This video demonstrates an intramedullary fixation of a reverse oblique subtrochanteric femoral fracture in the lateral position. There is a classic deformity seen in subtrochanteric fractures due to strong muscular attachments in the region. In this video, we show that while the lateral position may be more difficult for obtaining x-rays, it provides natural external forces that make reduction and fixation easier.

PUBLISHED: Thumb Extensor Tendon Laceration Repair

Thumb Extensor Tendon Laceration Repair
Evan Bloom1Amir R. Kachooei, MD, PhD2Asif M. Ilyas, MD, MBA, FACS1,2
1 Sidney Kimmel Medical College at Thomas Jefferson University
2 Rothman Institute at Thomas Jefferson University

This case consists of repairing an extensor tendon laceration of a thumb. Extensor tendon lacerations are one of the most common soft tissue injuries of the hand. Surgical repair of the tendon was offered, and the operation was performed using wide-awake local anesthesia no tourniquet (WALANT) technique.

Intraoperatively, a complete laceration of the extensor tendon was confirmed repaired using a modified Kessler technique and reinforced with an epitendinous repair. Before closure, the patient tested competency of the repair with confirmation of restoration with the active extension to ensure proper function. The patient was placed in a reverse thumb spica splint following wound closure.

Postoperatively, the patient was immobilized in full thumb extension for approximately two weeks and then converted to a removable splint and prescribed supervised hand therapy for a total recovery of 8–12 weeks.

PUBLISHED: Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair

Hip Arthroscopy with Acetabular Osteoplasty and Labral Repair
Scott D. Martin, MD
Brigham and Women’s Hospital

Hip arthroscopy with femoral neck or acetabular osteoplasty with or without labral repair can be used for treatment of femoroacetabular impingement (FAI). Patients may present with insidious onset of hip pain and mechanical symptoms and pain worse with activity and sitting.

On physical exam hip flexion and internal rotation may be reduced and anterior impingement testing will produce groin pain in the majority of patients with FAI. Imaging may demonstrate lesions responsible for cam-type or pincer-type impingement, and MRI may demonstrate labral tear or cartilaginous lesions. Arthroscopic surgical treatment is indicated for patients who have failed conservative treatment.

PUBLISHED: Biceps Tenodesis for Distal Biceps Tendon Repair

Biceps Tenodesis for Distal Biceps Tendon Repair
Harish S. Appiakannan, BS¹; Amir R. Kachooei, MD, PhD²; Asif M. Ilyas, MD, MBA, FACS¹’²
¹Sidney Kimmel Medical College at Thomas Jefferson University
²Rothman Institute at Thomas Jefferson University

Distal biceps tendon ruptures can result in loss of supination and elbow flexion strength, for which surgical repair is often indicated to restore preinjury level of functionality. The distal biceps tendon can be repaired via single- or double-incision techniques using several associated implants, including endobuttons, suture anchors, or interference screws.

Here is the case of a middle-aged male presenting with an acute distal biceps tendon rupture. The tendon was repaired via a single-incision technique using an endobutton and an interference screw.

PUBLISHED: Ankle-Brachial Index, CT Angiography, and Proximal Tibial Traction for Gunshot Femoral Fracture

Ankle-Brachial Index, CT Angiography, and Proximal Tibial Traction for Gunshot Femoral Fracture
Johnathan R. Kent, MD; James Jeffries, MD; Andrew Straszewski, MD; Kenneth L. Wilson, MD
University of Chicago Medicine

This video demonstrates an algorithm for evaluating suspected vascular injury secondary to penetrating extremity trauma on a 42-year-old man who sustained a gunshot wound to his left lower extremity. Descriptions of how to perform an arterial-brachial index (ABI) and arterial-pulse index (API) are reviewed, along with criteria to determine if a CT angiography is indicated. Relevant imaging is reviewed with a radiology resident with descriptions of how to systematically assess the scans for injury. Lastly, a tibial traction pin is placed as a temporizing measure for long bone fractures to prevent shortening and to help with pain management.