Category Archives: Orthopedics

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.

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.

Hand Surgery, Orthopedics, Print Release

PUBLISHED: Carpal Tunnel Repair and Fasciectomy for Carpal Tunnel Syndrome and Dupuytren’s Disease

Carpal Tunnel Repair and Fasciectomy for Carpal Tunnel Syndrome and Dupuytren’s Disease
Sudhir B. Rao, MD
Munson Healthcare Cadillac Hospital

Carpal Tunnel Syndrome (CTS) and Dupuytren’s disease (DD) are two common hand conditions that can significantly impact a patient’s quality of life and hand function. In cases where both conditions coexist, as demonstrated in this video, a combined surgical approach is adopted in suitable candidates. Combining carpal tunnel release and fasciectomy in a single surgical setting is safe, cost-effective, and efficient, reducing recovery time and healthcare costs while achieving functional outcomes comparable to staged interventions. This video demonstration is particularly valuable for practicing hand surgeons and surgical trainees, offering detailed insights into technical challenges such as neurovascular bundle protection, management of retrovascular cord components, and the precise balance between complete disease excision and preservation of vital structures. The demonstrated solutions, including the use of vessel loops for nerve protection, staged fascia removal, and careful hemostasis management, provide practical guidance for similar cases.

Orthopedics, Print Release

PUBLISHED: Excision of a Ganglion Cyst from Distal Middle Finger Near Nail Bed

Excision of a Ganglion Cyst from Distal Middle Finger Near Nail Bed
Arya Rao1; Sudhir B. Rao, MD2
1Harvard/MIT MD-PhD Program
2Munson Healthcare Cadillac Hospital

Ganglion cysts (GCs) are common benign soft tissue tumors that when presenting near the nail bed of digits, are specifically termed digital mucous cysts (DMCs). The surgical excision of GCs near the nail bed requires precise technique and a thorough understanding of the anatomical relationships to prevent recurrence and minimize complications. This case report describes the surgical management of a GC located on the distal phalanx of the middle finger near the nail bed. The procedure demonstrates several key principles that are essential for successful outcomes, including the necessity of complete cyst excision to prevent recurrence, the importance of careful dissection near the germinal matrix to prevent permanent nail deformity, the value of a bloodless surgical field in maintaining precise visualization, and the significance of proper wound closure technique in ensuring optimal aesthetic and functional outcomes.

Orthopedics, Print Release

PUBLISHED: First Extensor Compartment Release for De Quervain’s Tenosynovitis

First Extensor Compartment Release for De Quervain’s Tenosynovitis
Arya Rao1; Sudhir B. Rao, MD2
1Harvard/MIT MD-PhD Program
2Munson Healthcare Cadillac Hospital

This video provides detailed step-by-step instruction for performing first dorsal compartment release in De Quervain’s tenosynovitis, with particular emphasis on anatomical landmarks, proper tissue handling, and identification of important neurovascular structures. The surgical release of the first extensor compartment for De Quervain’s tenosynovitis is a well-established procedure with consistently favorable outcomes when proper surgical technique is employed. When performed with attention to these technical details, the procedure provides reliable relief of symptoms with a low complication rate.

This surgical technique video would be particularly valuable for orthopaedic and hand surgery residents, as well as practicing surgeons who seek to refine their approach to first extensor compartment release. The detailed demonstration of nerve identification and the management of anatomical variations, especially the emphasis on finding accessory compartments, provides crucial technical aspects which help surgeons avoid complications and improve patient outcomes.

Orthopedics, Print Release

PUBLISHED: Posterior Calcaneal Osteophyte Excision with Subsequent Achilles Tendon Repair

Posterior Calcaneal Osteophyte Excision with Subsequent Achilles Tendon Repair
Sudhir B. Rao, MD
Munson Healthcare Cadillac Hospital

The surgical management of posterior calcaneal osteophytes is a complex procedure that requires detailed surgical technique and precise anatomical understanding. Fluoroscopy serves as a real-time guidance tool, aiding in the visualization of the osteophyte during its removal. Specialized surgical instruments, primarily a sharp osteotome are utilized for initial bone removal, followed by a rongeur to refine and smooth any remaining sharp edges. This meticulous approach ensures the complete removal of the problematic bony proliferation while maintaining the surrounding tissue’s structural integrity. This surgical demonstration offers important educational value for multiple medical professionals involved in orthopaedic and musculoskeletal care. Orthopaedic surgeons, particularly those specializing in foot and ankle surgery, will find the detailed procedural technique useful for understanding nuanced surgical approaches to posterior calcaneal osteophytes. Orthopaedic residents and surgical trainees can benefit from the step-by-step demonstration of complex surgical techniques.

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.

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.

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.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Intramedullary Nail for Open Tibial Fracture

Intramedullary Nail for Open Tibial Fracture
Caleb P. Gottlich, MD, MS1; Michael J. Weaver, MD2
1Department of Orthopedic Surgery, Texas Tech University Health Science Center
2Brigham and Women’s Hospital

This article describes the stabilization of an open tibia shaft fracture using an intramedullary nail. After copious irrigation and debridement of the fracture site, a transpatellar tendon split is used to expose the nail entry point. This is followed by fracture reduction, sequential reaming, and nail insertion and locking. Finally, the technique for proximal tibia traction pin insertion is demonstrated on the contralateral tibia.