Acute ankle sprains are most frequently treated conservatively, although some surgeons may advocate acute repairs in certain situations. Surgery is indicated for chronic sprains with persistent ankle instability despite well-designed conservative management. Several anatomic and nonanatomic operative procedures are available. The Broström-Gould procedure is a widely-used operative intervention for the treatment of chronic lateral ankle sprains. It consists of an anatomic repair or reconstruction of the injured lateral ankle ligament complex (Broström procedure), followed by suturing of the inferior extensor retinaculum to the periosteum of the distal fibula (Gould modification).
This article describes the standard Broström-Gould procedure starting with the identification of the anatomic landmarks. The skin incision follows the anterior border of the distal fibula, and careful subcutaneous dissection is carried out to expose the extensor retinaculum and the torn ligaments. This is followed by bone preparation and ligament repair utilizing a box stitch technique while holding the ankle in an appropriate position. Finally, the Gould portion of the procedure is demonstrated.
This is a case discussing a 21-year-old male who suffered from both non-comminuted mandibular parasymphyseal and body fractures as a result of a motor vehicle accident, requiring open reduction internal fixation (ORIF) without postoperative maxillomandibular fixation (MMF). The fracture was complicated by a broken tooth root, which required extraction.
After intraoperative MMF, ORIF was performed. The parasymphyseal fracture was plated using two locking four-hole 2-mm thick miniplates utilizing two locking screws on either side of the fracture with one plate along the alveolar surface (monocortical screw) and one along the basal surface (bicortical screw). For the right body fracture, a three-dimensional locking ladder plate was used via a transbuccal trocar approach for additional exposure needed for proper screw placement. Once the hardware was secured, the patient was taken out of MMF and restoration of premorbid occlusion was confirmed. Lastly, watertight mucosal closure was performed using absorbable sutures and Dermabond (cyanoacrylate adhesive).
Rotator Cuff Repair (Cadaver Shoulder) Patrick Vavken, MD1; Sabah 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.
Portal Placement for Hip Arthroscopy Steven D. Sartore1; Scott 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.
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.
Bone Graft for Nonunion of Right Thumb Proximal Phalanx Fracture Sudhir B. Rao, MD1; Mark N. Perlmutter, MS, MD, FICS, FAANOS2; Arya S. Rao3; Grant 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.
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.
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.
Thumb Extensor Tendon Laceration Repair Evan Bloom1; Amir R. Kachooei, MD, PhD2; Asif 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.
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.
