Video of a positive supination test.
The valgus is worse on the left than the right. Note the medial femoral condyles bumping into each other during the gait cycle.
This toddler with achondroplasia has genu varum with internal tibial torsion.
This video demonstrates the surgical technique for bi-cruciate ligament reconstruction in a patient with a right knee dislocation involving injury to the ACL, PCL, and MCL (KD3M). Particular attention is given to the reconstruction of the PCL in this scenario with a double bundle construct using Achilles allograft for the anterolateral bundle and anterior tibialis allograft for the posteromedial bundle as well as to the work flow for reconstructing the two ligaments at the same time. The ACL is reconstructed with a six strand hamstrings autograft and the MCL (not demonstrated) was reconstructed with anterior tibialis allograft for the superficial MCL with imbrication of the posteromedial complex.
A short incision over the palpable origin of the adductor longus allows lengthening while protecting the surrounding tissues (pectineus laterally, gracilis medially, and adductor brevis and anterior branch of the obturator nerve deep. The adductor longus tendon is divided as proximally as possible. Excessive lengthening of the adductors particularly in ambulatory patients should be avoided.
A meniscal RAMP lesion is the mensicocapsular separation of the posterior horn of the medial meniscus. In this video, using standard anteromedial and anterolateral arthroscopy portals, a notch view is used to reveal a RAMP lesion of the right knee. After assessment of the tear, proprietary all-inside suture devices are used to repair the lesion.
Management of proximal humeral bone loss in the setting of revision reverse shoulder arthroplasty presents a significant challenge. Use of an allograft prosthetic complex is an attractive option in this setting given the ability to restore proximal humeral bone, regain stability, and facilitate reconstruction of normal anatomy. This video demonstrates the surgical technique of a revision reverse shoulder arthroplasty utilizing a proximal humeral allograft and plate fixation using a Synthes 3.5-mm metaphyseal plate.
This video will describe types of allograft prosthetic composites used to reconstruct bone loss from the elbow when performing revision total elbow arthroplasty. An ulnar based allograft prosthetic composite with soft tissue attachments is demonstrated for reconstruction of an absent proximal ulna and loss of the triceps attachment. Implant removal techniques as well as the principles and technique for reconstruction are both described.
His unsteadiness results in a significant increase in double-limb stance (usually 20% of the gait cycle) and a decrease in single-limb stance (usually 80%), compared to typical gait. (Video with permission of the Children's Orthopaedic Center, Los Angeles.)
Plain radiograph shows soft tissue swelling over the distal fibula and lytic changes at the metaphysis. MRI shows significant involvement of distal tibia and fibula and a large abscess infiltrating the surrounding soft tissues. Video of incision of drainage of the lesion.
The tibia subluxes laterally on the femur during stance phase with each step. This is revealed as a momentary wobble (or thrust) at the knee during walking.
Cadaveric specimen used to explain the anatomy of the Lesser Toes. The extensor and flexor mechanisms are identified in addition to collateral liagments at the PIP joint. The role that these anatomic structures play in various pathologies is discussed.
Arthroscopic assessment of LT ligament tear as viewed from midcarpal portal. Patient demonstrates grade IV tear indicating probe may be passed through gap between carpal bones and gross instability with manipulation. (15) "By permission of Mayo Foundation for Medical Education and Research. All rights reserved."
Lateral ankle instability is a common problem that can be challenging to treat. Traditionally, repair is performed utilizing a lateral incision. The authors demonstrate a technique of all-arthroscopic repair which provides great repair of the lateral ligaments without the need for a lateral incision.
Tears of the subscapularis are commonly encountered during arthroscopic rotator cuff repair, and achieving an anatomic, tension-free repair is essential for maximizing surgical outcomes. The extent of the tear determines the tendon repair configuration. Tears of the upper border of the subscapularis can be managed effectively with a single row repair. However, larger tears involving more of the subscapularis tendon footprint may necessitate a double row repair. In this video demonstration, a subscapularis tear involving the entire footprint is encountered. Visualization of the subscapularis insertion on lesser tuberosity is greatly enhanced with use of a 70-degree arthroscope. For more retracted, immobile tears, a three-sided tendon release is oftentimes necessary in order to facilitate the requisite amount of tendon excursion in order to accommodate an anatomic, tension-free repair. The interval between the coracoid and the anterior aspect of the subscapularis tendon should be assessed, and a coracoplasty of the posterior aspect of the coracoid is often advisable to minimize attritional damage to the subscapularis tendon. The lesser tuberosity is prepared to create a bleeding bone bed in anticipation of the insertion of two medial row suture anchors. A shuttling stitch can be used to aid in passing sutures from medial row suture anchors through the tendon. Sutures from either suture anchor are retrieved in the subacromial space and fixed with two lateral row suture anchors created a linked, double row repair.
Loss of elbow motion is a difficult problem for patients to deal with. While most activities of daily living can be accomplished with elbow motion from 30°-130°, as motion begins to decline beyond this range, many activities become extremely difficult for patients. This loss of motion often stems from a combination of a tight capsule and excess bone formation causing both soft tissue contracture and bony impingement. As patients deal with motion loss, surrounding musculature also contracts, making this problem more difficult. When patients become symptomatic from elbow stiffness, motion can be restored either through an arthroscopic or open approach. In patients without previous elbow surgery where motion is not significantly restricted and an concomitant ulnar nerve transposition is not necessary, an arthroscopic elbow release and debridement can be performed. Multiple portals are utilized to access the anterior and posterior aspects of the elbow to perform a capsular release and to remove areas of bony impingement. Following arthroscopic release, patients begin therapy immediately and are placed on prophylaxis against heterotopic ossification. Patients generally do very well from this, and can expect significant gains in range of motion following surgery and therapy.
Contemporary surgical management of adolescent and young adult patients with symptomatic hip dysplasia and an associated acetabular labral tear is technically challenging. Appropriate treatment commonly requires a reorientation osteotomy to address underlying acetabular dysplasia, open or arthroscopic labral repair, and correction of secondary hip impingement. This video demonstrates the surgical technique of hip arthroscopy with concomitant periacetabular osteotomy.
Wrist arthroscopy allows for the evaluation of the wrist joint under bright light and magnified conditions. Wrist arthroscopy is a valuable adjunct in the management of intra-articular distal radius fractures with its ability to view the anatomic reduction of the articular surface to the distal radius. It is particular useful in evaluating rotation of the fracture fragments which is difficult to do under fluoroscopy. In addition, wrist arthroscopy allows for the detection and management of any other associated intra-articular soft tissue injuries which have been shown to be associated with distal radius fractures. Copyright William B. Geissler
This is a right shoulder viewing from the anterosuperior portal. The posterior, working portal is mid glenoid, 30° off parallel to the articular surface. Correct position is critical to assure adequate inclination for anchor insertion and suture passing. Following glenoid neck preparation, anchor placement begins at the 6:30 -7 o’clock position with subsequent anchors placed every 8 -10mm. Sutures are passed using a pulling stitch technique and a 45° offset suture hook. A concomitant capsulorraphy is achieved incorporating inferior and lateral bites of capsule with each suture pass. After repair completion the arthroscopic is moved to the posterior portal for final inspection.
In this video, we demonstrate our preferred technique for arthroscopic treatment for lateral epicondylitis (tennis elbow). While viewing from the medial side, the extensor carpi radialis brevis tendon is released from a lateral working portal.
The video above depicts a patient in lateral decubitus position viewing through an anterolateral portal. A shaver debrides tissue through the anterior portal over the coracoid until the transverse scapular ligament and suprascapular notch come into view. A switching stick is used to retract the suprascapular nerve and artery medially for protection via the medial Nevaiser portal. After the structures have been identified a shaver or straight biter can be used to release the transverse scapular ligament and decompress the suprascapular nerve.
Video presentation of an arthroscopic subacromial decompression. Procedure is performed on a right shoulder in the beach chair position using a 30 degree arthroscope and standard arthroscopic equipment.
Once the arthroscope is inside the midcarpal joint via the MCR portal, proximal capitate on the top, scaphocapitate joint radially, radial limb of RSC ligament volarly, SLIL below and capitolunate joint ulnarly can be seen. By turning the arthroscopic viewing lens radially and move upward along the distal articular surface of scaphoid, the scaphotrapeziotrapezoid (STT) joint and part of the distal scaphoid pole can be reached to look for any synovitis and articular changes. Moving back into the central position, the volar and part of the dorsal portion of SLIL can be seen by turning the arthroscopic viewing lens to a downward position. Turning the arthroscopic viewing lens ulnarly, the interval between the capitate and hamate on the top, Lunotriquetral (LT) joint ulnarly and distal lunate articular cartilage below can be seen. Note that there is often a 1-mm stepoff and mild laxity in the LT interval. In this case, type II lunate can be seen as additional lunate articular facet that articulates with hamate. Assessment of LT stability can be based on the Geissler arthroscopic grading system as in SLIL tear. Any articular wear, synovitis, capsular and ligamentous injury should be documented.
Radiocarpal joint assessment start with arthroscope put into 3-4 portal. Ligament of Testut is the first structure to be seen. Turning the viewing lens of arthroscope clockwise or anti-clockwise inside the joint enables the surgeon to visualize different structures within a small joint. Evaluation starts from radial to ulnar direction. On the radial side of ligament of Testut, the long radiolunate ligament (LRL) and radioscaphocapitate ligament (RSC) can be seen as the volar capsular structures from ulnar to radial. The articular surfaces, including radial styloid, proximal scaphoid and the distal radius scaphoid fossa are visible when moving the arthroscope from radio-volar portion to radio-dorsal portion. After seeing the dorsal wrist joint capsule, the arthroscope can be turned upward and slightly ulnar to observe the convolution between the articular cartilage at the dorsal ridge of scaphoid and the dorsal wrist joint capsule where the dorsal and proximal membranous portion of SLIL ligament are situated. Moving ulnarly, the proximal articular surface of scaphoid fossa and lunate fossa of the distal radius, and the corresponding articulating surface of proximal scaphoid and lunate can be seen. There is a prominent ridge separating the two fossa and it corresponds to the SLIL location. On the volar side of the lunate fossa, the short radiolunate ligament (SRL) is connected to the lunate. Further advancing the arthroscope in the ulnar direction, one can see the synovium covering the ulnolunate and ulnotriquetral ligaments, radial insertion of TFCC over the sigmoid notch, central fibrocartilagenous disk, which amalgamates with the ulnar attachment of the palmar radioulnar ligament (PRUL) and dorsal radioulnar ligament (DRUL) of the TFCC to the fovea of the ulnar head at the prestyloid recess.
This child with a syrinx has asymmetric abdominal reflexes.
Patients with Bankhart tears of the labrum may require arthroscopic stabilization. The Bankhart tear is identified. Anterior portals are placed superior and inferior to the biceps tendon. The labral tear is dissected and freed to create a secure bumper. the underlying bone is stimulated to enhance healing. Suture is passed through the labrum and secured to the glenoid using suture anchors times 3. Secure bumper is created. Stability is assured by probing. In this case, the labral tear extended superior to the biceps, so an additional suture anchor was used to secure this portion of the tear.
This video demonstrated barefoot walking in a patient 14 years after correction of bilateral vertical talus deformities with minimally invasive technique of serial casting followed by small surgery.
This is a cadaver lab video made by Phani Dantluri, MD, and A. Lee Osterman, MD, detailing the technique of bone- ligament- bone (BLB) reconstruction of the central band of the IOM. The ulnar-shortening plate is applied volarly or medially rather than dorsally. This allows for creation of a dorsal trough in the ulnar for insertion of the bone end. A similar trough is made upstream in the radius just distal to the pronator teres insertion the BLB allograft is passed from the radius to the ulna avoiding the posterior interrosseus nerve . It is fixed first to the radius and then anchored to the ulna with the forearm in supination.
This video illustrates dorsal decompression and cheilectomy for the surgical management of hallux rigidus without global arthritic symptoms.
This young boy has a spinal cord tumor documented in Figure 5.49. During play, he has difficulty walking and does not move his neck in order to see things. Torticollis can be one of the earliest physical examination features for spinal cord tumors of the cervical spine.
Child presented as nonweight bearing with history of left hip pain for 3 days. Radiographic analysis is negative. Ultrasound indicated the presence of a left hip effusion. Even under sedation, hip is flexed externally rotated and abducted.
(Courtesy of Joshua M. Abzug, MD.)
Note that this test is best performed while the patient is under anesthesia. (Courtesy of Joshua M. Abzug, MD.)
Final manipulation is performed 1-7 days after collagenase clostridium histolyticum (CCH) injection for Dupuytren’s disease. After confirming appropriate local anesthesia, the hand is prepped in a sterile fashion with alcohol wipes. The hand is covered with a sterile 4 x 4 inch gauze, the wrist is flexed, and the fingers are passively stretched to achieve complete rupture of the treated cords. For radial and ulnar lateral cords, the affected digit is forcibly stretched in the ulnar or radial direction respectively. Finger abduction is used to release natatory cords within the webspace. Post-manipulation exam confirms normal tendon function and successful restoration of finger range of motion.
Exposure of both the radial column and volar surface of the distal radius may be necessary for treatment of unstable fractures associated with combined radial column and articular instability patterns. In more complex injury patterns, a radial column plate can supplement fixation and help stabilize the articular surface and/or help reduce coronal malalignment to stabilize the distal radioulnar joint. Combined exposure requires recognition of the anatomic position of the radial artery beneath the tendons of the first dorsal compartment distally which restricts exposure of the radial styloid using the standard volar approach. This video demonstrates combined approach of the radial column and volar surface with a simple and easily reproducible exposure.
This video demonstrates a surgical technique for sequential release of the proximal tarsal tunnel (laciniate ligament), plantar fascia, and the first branch of the lateral plantar nerve (Baxter’s nerve). It also demonstrates release of the abductor hallucis fascia and safe handling of the proximal and distal neurovascular structures.
Anconeus reflecting olecranon osteotomy (AFT) approach closed over olecranon plate for osteotomy. Column soft tissue closure demonstrated.
This young woman with hemiplegia has dynamic forefoot supination, secondary to spasticity of the anterior tibialis tendon. She is unable to dorsiflex her foot without flexing her hip and knee, demonstrating a positive confusion test.
Our patient underwent bilateral talectomies and 6 weeks later had distal femoral extension osteotomies.
This seven-year-old girl with DD has crouched gait with severe knee and foot contractures.
It is important to note that Achilles tightness should be assessed with the foot inverted to lock the midfoot which otherwise may mask the true tightness, then first with the knee extended to keep the gastrocnemius tight, and then with the knee flexed to relax the gastrocnemius. In this child the tight Achilles prevents full ankle dorsiflexion, requiring motion through the midfoot to allow the foot to fully dorsiflex. The axis of movement of the midfoot is different from the ankle, and out-toeing is created.
Blocks can be used to level the pelvis. If blocks are not available, books or magazines can be stacked under the short limb to determine the leg length discrepancy.
Sitting allows the spine to be examined without the influence of leg lengths on the spinal alignment.
With the feet placed flat on the examination table and the knees flexed, the length of the tibia to the plantar aspect of the foot can also be compared between the two sides.
Notice the substantial anterior translation of the tibia on the femur in this patient with an incompetent ACL.
Inverting the foot prevents inadvertent motion in the midfoot. Flexing the knee relaxes the gastrocnemius muscle because it crosses both the knee and ankle joints.
The distal femoral lateral approach offers optimum exposure to achieve optimal realignment to treat crouch gait associated with a fixed knee flexion contracture by creating a compensatory extension deformity in the femur. Triplanar alignment can be controlled for and optimized using this technique. Fixation with a 90 degree AO blade plate offers rigid fixation allowing early mobilization and rehabilitation. Patellar tendon advancement should always be performed in conjunction with this procedure.
Here we will demonstrate the stabilization of the distal ulna as described by Kleinman and Greenberg in 1995. Following resection of the distal ulna a significant amount of instability may be present. Instability may exist in the sagittal plane, with volar and dorsal translation, and may also exist in the coronal plane, resulting in impingement of the distal ulna on the radius. This impingement was described by McKee and Richards. The stabilization procedure demonstrated here is designed to address both forms of instability of the residual distal ulna and utilizes the extensor carpi ulnaris tendon passed through a drill hole in the distal ulna as well as a portion of the pronator quadratus interposed into the interosseous space between the radius and ulna.
Nerve stimulation of motor nerves to flexor carpi radialis and flexor digitorum superficialis.
In some situations, unstable dorsal fragments may be simply too small to safely allow placement of screws or even the tines of a hook plate; in this situation, a dorsal buttress pin can provide support and help significantly reduce the risk of further fragmentation. Since the dorsal cortex of the radius is curved, the position of an implant proximally can affect the optimal orientation of fixation distally. This video demonstrates technique that are specific to the dorsal application of buttress pins.
Exposure of the dorsal surface of the distal radius may be needed in certain distal radius fractures such as dorsal shear fractures or fractures with residual dorsal instability despite other methods of fixation. Anatomic landmarks can be used to simplify the approach and allow simple identification of important structures such as the extensor pollicis longus tendon and posterior interosseous nerve.
Dorsal fragmentation may require fixation if unstable. This video demonstrates a method of fixation using a dorsal hook plate to capture dorsal rim fragments.
Fractures that include an unstable ulnar corner or dorsal rim may result in residual dorsal instability of the sigmoid notch and/or carpus if left untreated. In these situations, an option for fixation is a dorsal pin plate. This video demonstrates techniques used for a typical application of the dorsal pin plate, including how to contour the implant to accommodate the anatomic twist of the dorsal surface of the radius along the ulnar border.
Video demonstration of the dorsoradial capsulodesis procedure performed on a cadaveric specimen. The procedure is performed for symptomatic trapeziometacarpal (TM) instability that does not respond to conservative treatment. Following incision, the dorsoradial ligament is exposed and incised. The TM joint is then evaluated and reduced. Finally, the ligament is tensioned and repaired to complete the capsulodesis.
This is consistent with the diagnosis of slipped capital femoral epiphysis.
This child with hemiplegia has a dropped foot on the left side. Accommodation to clear the foot during swing phase is noted with increasing hip and knee flexion in swing phase.
DRUJ reconstruction with a tendon graft requires a dorsal and volar approach with bone tunnels. The dorsal incision is between the fifth and sixth compartments. An L-shaped capsulotomy exposes the distal ulna. One bone tunnel is drilled in the radius parallel to the sigmoid notch. The second bone tunnel is in the ulna from the fovea to the lateral ulnar neck. A volar incision is necessary to retrieve the tendon graft and pass it around the volar ulnocarpal ligaments to the ulnar bone tunnel. Finally the graft is tensioned and secured with the forearm in slight supination.
This girl with spastic diplegia has a positive Duncan-Ely test. By flexing the knee rapidly, the hip will secondarily rise due to increasing contracture/spasticity in the rectus femoris tendon.
In this video, we demonstrate our open partial palmar fasciectomy surgical technique for a Dupuytren's disease case involving ring finger metacarpophalangeal (MCP) joint flexion contracture
Patients with abductor tendon full-thickness tears may require endoscopic abductor tendon repair if conservative measures fail. The senior surgeon prefers double row fixation using a transosseous-equivalent repair technique. After proximal/ distal working portals and anterior/posterior accessory portals are placed, the iliotibial band is incised to allow entry into the deep peritrochanteric space. Here, the gluteus medius and/or minimus tears can be visualized. The first row of anchors is placed at the gluteal tendon footprint at 45 degrees, and a suture shuttle relay is used to pass the sutures through the teared tendon in a horizontal mattress configuration. Then, the tendon is pulled back to its anatomic position and the sutures of the first row of anchors are tied down. The second row of anchors are placed into the vastus ridge at an angle of 45 degrees to secure the tails of the tied sutures, thus providing a tension-free repair.
The patient is placed in a sitting position with a Mayfield headholder to allow the shoulders to fall away and blood to drain out of the tube, which offers improved visualization. Lateral fluoroscopy is performed to plan the incision over the facet at the level of the disc space. The midline is marked, and an incision 1.5 cm off the midline is planned. The tubular retractors are docked through the incision and locked into place, with the endoscope fixed over the tube. A Bovie electrocautery device is used to access the bone through the remaining muscle. The medial facet tissue is removed, and the bone of the medial facet posterior to the foramen is removed with a Kerrison rongeur. A curette can be used to feel the path of the foramen. Additional bone around the foramen can be removed with a Kerrison rongeur. A curette and an angled ball-tip probe can be used to confirm that the bone has been removed from pedicle to pedicle and that the nerve is fully decompressed.
External coxa saltans that is recalcitrant to conservative measures can be treated by endoscopic H-plasty iliotibial band (ITB) release. Using two lateral portals 3-4 cm proximal and distal to the greater trochanter that are angled toward the greater trochanter at 45 degrees, a hook probe electrocautery device is used to partially release the ITB within the superficial peritrochanteric space using an H-plasty technique. This lengthens the ITB, thus relieving the snapping hip and reducing tension over the trochanteric bursa. If the trochanteric bursa is multiloculated and/or persistently inflamed, bursectomy can be performed at this point.
Internal coxa saltans that is recalcitrant to conservative measures can be treated by endoscopic iliopsoas tendon release. This procedure is most commonly performed at the time of hip arthroscopy to address concomitant intra-articular pathology. Using standard hip arthroscopy portals, the iliopsoas tendon can be accessed in the peripheral compartment of the hip joint between the zona orbicularis and the labrum at the level of the medial synovial fold. Using a lateral portal, the iliopsoas tendon is partially released with electrocautery. This lengthens the iliopsoas tendon, thus relieving the snapping hip.
Soft tissue endoscopic release of the median nerve in the forearm for anterior interosseous nerve palsy. A standard 4 mm endoscope is inserted in the proximal forearm through a transverse incision over the median nerve. The video images are projected on a standard endoscopic monitor illustrating release of the forearm fascia and Lacertus followed by release of the fibrous arch of the flexor digitorum sublimis muscle. The release is completed by careful division of submuscular bands often found traversing the nerve. When anterior interosseous nerve palsy is identified early, endoscopic release can result in immediate return of function.
This hemiplegic boy has an equinovarus foot deformity marked by equinus positioning and fixed varus positioning in stance phase; likely due to spasticity/contracture of the posterior tibialis tendon.
This boy with cerebral palsy has an equinovarus deformity of his right foot. During gait, he has a foot drop and must have his leg abducted in order to clear it in swing phase. The tight Achilles leads to equinus positioning and back knee gait in stance phase.
In this video, the spasticity of the wrist flexors and finger flexors is demonstrated. The examiner initially demonstrates the limitations of passive forearm supination and wrist extension due to spasticity. With the wrist passively flexed, the fingers are able to be fully passively extended at the IP joints. With the wrist in neutral extension, the finger flexor tendon spasticity and flexor pollicis longus does not allow passive extension of the digits
This video illustrates exposure and release of the Lacertus fibrosis in the right forearm. The surgeon begins by exposing the forearm fascia through a transverse incision 2-3 finger breadths distal to the medial epicondyle. The forearm fascia is expose by using army navy retractors to bluntly dissect the subcutaneous fat. Care should be taken to protect and avoid traumatizing the medial cutaneous nerve of the forearm to prevent symptomatic neuropraxia. The fascia is opened longitudinally followed by radial dissection to expose and release the Lacertus fibrosis. This patient illustrated final release of one remaining band to expose a collection of adipose tissue beneath the pronator muscle containing the median nerve which can usually be visualized within the fatty tissue. When the procedure is performed under local anesthesia, motor strength in the flexor pollicis longus, flexor digitorum profundus to the index finger, and the flexor carpi radialis returns to normal immediately and can be demonstrated to the patient in the surgical suite.
This video shows a patient with a type C lesion. The retinaculum has been incised, revealing the damaged ECU subsheath. The subsheath is inflamed and attenuated, allowing tendon subluxation. The instability is clear even with only moderate supination. After incising the subsheath, supination, ulnar deviation, and flexion result in frank dislocation of the ECU tendon. Once this subsheath was repaired with suture anchors to the ulnar margin of the groove, the instability was eliminated.
This boy with facioscapulohumeral dystrophy has difficulty with shoulder abduction. Winging of the scapula is noted.
This video demonstrates our technique for closed reduction and percutaneous pinning of femoral neck fractures. This is typically performed for nondisplaced or valgus-impacted femoral neck fractures. The techniques for proper C-arm positioning, guidewire placement, and insertion of three fully-threaded or partially-threaded cannulated screws are detailed.
Olecranon osteotomy closure with anconeus flap demonstrated covering final implant. Final fixation of lateral column/lateral epicondylar fracture fragment with tension band demonstrated.
This cadaver dissection demonstrates the flexor tendon anatomy within the digit, including camper's chiasm as well as the vincula.
Video shows normal flexion of the finger when all pulleys are intact.
Video shows bowstringing of the flexor tendon when A3 and A4 pulleys have been removed.
This video demonstrates the technique of flexor tenolysis with tenolysis knives, followed by intraoperative active participation of the patient leading to completion of the tenolysis. After early range of motion, at 2 weeks postoperatively he exhibits full flexion of the small finger with ongoing active range of motion. The 30 degree residual PIP joint flexion contracture is addressed with 3 point LMB splint.
Pressure is applied to the muscle bellies of the finger flexors in the forearm, resulting in interphalangeal joint flexion if flexor tendons are intact. If interphalangeal joint flexion is absent, tendon laceration is suspected.
Arthrodesis of the first metatarsophalangeal (MTP) joint is a versatile technique used to treat multiple pathologies. Hallux MTP fusion is indicated for the treatment of hallux rigidus, severe or recurrent hallux valgus, failed implant or interpositional arthroplasty, and neurogenic or spastic deformities. Careful attention to detail during fusion preparation and positioning of the arthrodesis is crucial to optimize patient outcomes and satisfaction. This video focuses on a common technique utilizing a dorsal approach, fusion preparation with anatomic reamers, and fixation with a compression screw and anatomic first MTP plate.
This anatomical demonstration of the hemihamate arthroplasty provides a step by step guide to successful completion of the procedure. Helpful instruction is offered for exposure of the fracture, harvesting the graft and properly positioning the arthroplasty into the base of the middle phalanx.
Demonstrated here is the hemiresection and interposition of the distal ulna as described by William Bowers in 1985. Bowers recommended this procedure for rheumatoid, post-traumatic, or degenerative arthritis of the distal radioulnar joint, with the goal of preserving the ulnocarpal ligamentous complex and the TFCC. He felt that preservation of these structures would improve stability between the distal radius and ulna and help mitigate ulnar translation of the carpus. Indications for Bowers hemiresection and interposition technique include rheumatoid arthritis, post-traumatic arthritis, and degenerative arthritis affecting the DRUJ. Contraindications include TFCC deficiency and DRUJ instability. Without a functioning TFCC or a stable DRUJ, Bowers noted no benefit over more extensive resections such as the Darrach procedure. Following surgery, a short arm splint may be applied with volar and dorsal plaster slabs. Forearm ROM does not need to be restricted, but is not encouraged. Weight bearing is limited to no more than 2 lb. At 2 weeks, a removable short arm brace can be used. The patient may remove the brace for hygiene and wrist ROM. Forearm ROM is encouraged, and weight bearing remains restricted. At 6 weeks, weight bearing restrictions are advanced to no more than 10 lb and the patient is weaned from a brace. Normal activities without restriction are instituted at 12 weeks
Animated and narrated video of the key surgical steps performed during a high tibial osteotomy for alignment correction of the lower limb. This procedure is performed for the correction of bone deformity including knock knees and bow legs.
Hip resurfacing, also known as hip resurfacing arthroplasty, is an alternative to traditional total hip arthroplasty for end-stage arthritis of the hip, and is typically reserved for active, younger male patients with adequate femoral head bone stock and quality. This video supplement outlines how to perform a hip resurfacing procedure through a posterior surgical approach. Specifically, we review preoperative templating, incision landmarks, superficial and deep surgical dissection, capsulotomy and capsular releases, femoral head sizing, acetabular preparation and implantation, femoral preparation and implantation, and wound closure. The accompanying chapter in Operative Techniques in Orthopaedic Surgery further describes surgical steps and outlines preoperative, intraoperative, and postoperative considerations for patients undergoing hip resurfacing.
This is the senior author’s preferred technique for a high tibial osteotomy. It highlights the use of the iBalance HTO System to correct varus knee malalignment. It is an in-depth look at how to keep high tibial osteotomies safe and simple, with technical pearls on how to complete a successful high tibial osteotomy without complications.
The video depicts a case report of a patient with an anterior cruciate ligament (ACL) tear for which individualized anatomic ACL reconstruction was performed. As described in the video, individualized anatomic ACLR entails pre-operative determination of ACL dimensions, including the area of the tibial footprint, in order to guide graft selection and sizing. The goal of senior author is to restore 50-80% of the native tibial insertion site area with the graft, thereby providing optimal graft size and strength while minimizing the risk for graft impingement with the intercondylar notch. Additional cases with very small or large ACL insertion sites are briefly discussed as examples by which the principles of individualized anatomic ACLR are applied across a diverse patient population.
Olecranon osteotomy with anconeus flap utilized to gain access to distal humerus, proximal radius and proximal ulna. Exposure afforded demonstrated with demonstration of typical articular condition in irreparable distal humerus fractures.
Total wrist arthroplasty (TWA) is a motion-preserving alternative to arthrodesis that provides excellent pain relief with sufficient motion and strength for activities of daily living. A dorsal approach to the wrist gives a wide exposure. The extensor retinaculum is transformed into a radial based flap centered on the 1st and 2nd compartments. The dorsal wrist capsule is raised as a distally based rectangular flap. The carpus is prepared to allow maximum bony contact between the distal row of carpal bones including the distal scaphoid. These bones are temporarily pinned and will receive the carpal component of the implant. The radius is prepared by removing a thin wafer of bone using the appropriate guides and taking care not to violate the DRUJ. The trial implants allow assessment of motion and stability. The permanent implants are placed without cement and the wrist capsule is secured to the dorsal rim of the radius. A strip of extensor retinaculum can supplement this repair, but the remainder is used to prevent extensor tendon bowstringing.
This video demonstrates the technique of internal neurolysis and the application of a nerve conduit. In this case the indication was the late management of a gunshot injury to the leg with clinically inadequate return of function. Careful dissection is performed under magnification to excise all scar and fibrotic tissue within the nerves’ fascicular segments. This can be identified using intraoperative nerve action potentials. A metallic foreign body is located, and along with the resultant neuroma in continuity this is removed. The nerve wrap is placed and secured in place to minimize scar tissue formation. This technique is indicated for late management of incomplete injuries such as stretch or blast when the nerve has only partially recovered to a level of function that is clinically inadequate.
After the flexor pronator slide has been performed, the improvement in passive motion should be assessed intraoperatively. The forearm is supinated and the wrist and fingers are fully extended. The surgeon will be able to visualize the entirety of the forearm flexor-pronator mass moving distally, leaving a gap in the proximal forearm, with this passive motion.
The skin incision for the lateral retinacular lengthening is made 1 cm lateral to the lateral edge of the patella. The lateral retinaculum is exposed. The first layer, the patellar head of the IT band is incised immediately adjacent to the patella. Dissection is carried out to free this layer from the underlying layer by dissecting posterior and lateral. The second layer, the deep retinaculum, is incised as far lateral as the surgeon wishes to create the lengthening. The second layer is freed from the underlying capsule. The two layers are then lightly reapproximated at each incision site completing the lengthening.
This video demonstrates the application of a knee-spanning external fixator for a proximal tibia fracture dislocation. This technique can be used for application of an external fixator for knee dislocations, distal femur fractures and any additional injuries which require temporizing stabilization prior to definitive treatment.
The goals of triceps tendon repair remain anatomic footprint reconstruction with stable fixation allowing for early elbow range of motion and rehabilitation. Knotless transosseous triceps tendon repair allows the surgeon to provide excellent triceps tendon footprint compression with a single suture anchor while limiting the size and number of drill holes in the proximal ulna. This has the advantage of limiting the risk peri-implant fracture, cost associated with multiple suture anchors, and symptomatic suture knots in the posterior elbow.
This video gives a surgical approach to a Lapidus procedure for a failed bunion repair. The actual fixation is less important that the principles and pearls outlined in the video.
This video will demonstrate the technique of triplanar first tarso-metatarsal arthrodesis (Lapiplasty® by Treace Medical Concepts®, Ponte Vedra, FL) for hallux valgus deformity. The procedure is guided by image intensification throughout the procedure. The position of the patient is supine, and the preferred method is to us tourniquet control at the thigh. The incision is directly dorsal over the 1st TMT joint, just medial to the EHL tendon. This incision is full-thickness, and sub-periosteal. The TMT joint is released and planed. Secondary incision at the lateral MTP joint is made to perform a minor intra-capsular release of the contracted tissues of the lateral MTP joint. A triplanar correction of the hallux valgus deformity is achieved with the Treace Medical Concepts® tools: Fulcrum, Bone Positioner, and Joint Seeker. Once correction is confirmed on the image intensifier, The Cut Guide is applied dorsally. The Cut Guide allows for a lateral closing wedge of bone to be resected, while maintaining frontal and sagittal plane correction. Following this cut and removal of the bone slices, the joint surfaces are prepared for arthrodesis by drilling multiple holes through the subchondral plates. The reduction is then assisted by the Compressor device and secured using the Compression Olive Wire.
The arthrodesis is fixated using the Treace Medical Concepts® Biplanar Plating System. These plates are affixed using locking screw after orienting the two plates 90 degrees apart (medial and dorsal).
This video demonstrates a technique to extend the indications of the chevron osteotomy bunion repair for larger deformities. A greater degree of correction of the IM angle can be obtained using this approach. Soft tissue capsule repair and two fixation methods are included in the presentation.
This video demonstrates acute arthroscopic repair of the lateral collateral ligament complex following an elbow dislocation. This is the view of a right elbow in the prone position. The avulsed lateral collateral ligament complex is seen in this video, which is repaired using a bioabsorbable suture anchor.
Narrated video of the surgical correction of a patient presenting with bow legs. The video includes the preoperative planning, the live surgical steps performed during the high tibial osteotomy for alignment correction of the lower limb, and the postoperative radiographs. This procedure is performed for the correction of bone deformity including knock knees and bow legs
This video demonstrates limited incision drainage and irrigation for an adult male who had a puncture wound to the index finger that resulted in pyogenic flexor tenosynovitis. Brunner incisions were marked in purple over the entire finger, which could allow for a more extensive incision, and incorporate the region of the A1 pulley and the puncture wound overlying the middle phalanx. Limited incisions were made over the metacarpal head and the middle phalanx. The A1 pulley and distal A4 pulley were incised to drain the flexor tendon sheath. An 18 gauge angiocatheter was then placed within the tendon sheath proximally and a 20cc luer lock syringe was used to flush sterile saline through the tendon sheath multiple times until fluid egress was clear and copious fluid had been irrigated (500mL). Incisions are left open for egress, but indwelling catheters are not left in place. Wicks or packing may be used to encourage further egress.
This narrated video shows a patient case of distal femur osteotomy from preoperative planning through the live surgical steps in the operating room to the postoperative radiographs.
Live fluoroscopy of the supination test showing a stable (2A) and unstable (2B) ulnocarpal joint.
LT sheer test. The examiners thumb firmly compresses the pisiform against the triquetrum. The opposite hand supports the dorsal body of the lunate. The test is positive if it elicits pain. Of note, the pisotriquetral joint must be examined for pathology prior to sheer test. "By permission of Mayo Foundation for Medical Education and Research. All rights reserved."
LT Shuck Test. Performed by grasping the dorsal body of the triquetrum and palmar surface of the pisiform between the thumb and index finger. The bones are shucked dorsally and palmarly to stress the LT ligament. The patient reports pain if the LT ligament has been injured. "By permission of Mayo Foundation for Medical Education and Research. All rights reserved."
Arthroscopic video shows impingement of the radial head plate at the PRUJ. The plate was placed outside the safe zone during ORIF and is blocking forearm supination.
Here we will be demonstrating a matched resection of the distal ulna, as described by Kirk Watson in 1986. Watson reasoned that preservation of the triangular fibrocartilage complex and ulnar sling mechanism should prevent the instability of the distal ulna and potential ulnar translation of the carpi encountered after distal ulna resection as described by Darrach. Waston also reasoned that contouring of the distal ulna to match the ulna contour of the distal radius would prevent painful impingement between the two bones. Watson also noted improved cosmetic appearance of the wrist compared with the Darrach procedure due to retention of the ulnar styloid. Indications for matched resection include the following:
- DRUJ arthritis
Postoperatively, the extremity is maintained in a well-padded, long-arm splint with the elbow at 90 degrees and the forearm in neutral for 3 weeks. At 3 weeks postoperatively, long-arm splintage between exercises and at night begins and persists until 6 to 8 weeks postoperatively. Strengthening without splint immobilization can begin at that time.
- TFCC deficiency
- Instability of DRUJ
- Without a functioning TFCC or a stable DRUJ, there is little benefit of matched resection over a more extensive resection as described by Darrach
In the thumb, the MCP joint is stabilized by the volar plate when fully extended, so the MCP joint should be flexed 30° to assess the collateral ligaments. In the fingers, the collateral ligaments are slack in MCP extension and taut in MCP flexion, so the MCP joint should be flexed 90° before applying radial or ulnar deviation stress to assess the collateral ligaments.
The medial cuneiform dorsal opening wedge osteotomy is indicated for correction of medial column elevation, or forefoot varus, associated with a pes planovalgus foot deformity. The procedure is used primarily when the deformity is mild to moderate and the apex of the dorsal angulation is centered at the naviculo-cuneiform joint. The opening wedge osteotomy will plantarflex the medial column of the foot to restore the weightbearing tripod and aid in overall correction of the flatfoot deformity. A mechanical distractor with pins on either side of the osteotomy (not shown in video) will aid in the osteotomy distraction and graft insertion. The osteotomy gap is typically filled with a structural cortico-cancellous allograft wedge and contoured to reduce dorsal prominence. Intraoperative physical examination of the foot, and the amount of forefoot varus, is critical to determine the size of the bone graft wedge that is needed and to confirm adequate correction of the deformity once the graft is inserted. Minimal, if any, fixation is required to secure the graft and temporary Kirschner wire fixation results in a high union rate.
This video demonstrates medial patellofemoral ligament (MPFL) reconstruction using the docking technique for the treatment of patellar instability. Technique tips to confirm anatomic placement of the graft, proper graft isometry, and appropriate setting of graft tension/length, are presented during the procedure.
In this video Dr. Pearle concisely describes the indications and process of a robotic-arm assisted medial unicompartmental knee arthroplasty (UKA) with a cemented fixed-bearing design using a ligament-guided technique. The aim of a ligament-guided technique in medial UKA is to position the implants so that native medial collateral ligament tension is restored throughout the range of motion in an attempt to recreate the prearthritic knee condition.
Arthroscopic examination of a left knee illustrating opening of the medial compartment with a valgus stress allowing the camera to easily pass to the back of the medial compartment (drive-through sign).
Physical examination of a left knee illustrating medial sided laxity with an applied valgus stress.
Reconstruction of the distal femoral bone loss using a femoral sleeves. These sleeves are unitized to the knee implants and stems through a mechanical Morse taper. Preparation is not dissimilar to broaching for a hip replacement. Attention must be paid to the level of seating of these sleeves as they determine the eventual joint line. No augments can be combined with these sleeves. Finally, because these sleeves will determine the rotation of the femoral and tibial components, attention to their placement must be taken to ensure proper final implant position.
Uncontained metaphyseal tibial and femoral defects encountered during revision TKA. The surfaces are prepared to maximize implant ingrowth. Alignment is obtained by using an intramedullary reamer and the appropriately sized tibial cone is impacted into the defect. This serves to restore a stable tibial platform upon which the new implant will rest. Note that the reconstruction principles of joint line restoration still apply. In this case, tibial augments are inserted in order to restore the joint line. On the femoral side, the femoral condyles are rebuilt using a femoral cone. The rotation of the femoral cone will determine the final implant position and therefore, it is important that during preparation, attention be paid to the rotation of these cones. Finally, the implants can be unitized to the cones with either cemented stems or hybrid cement technique.
This video provides a basic overview of minimally invasive surgery for thoracolumbar fractures, including treatment goals, surgical approach, patient selection, the indications for surgery, and the role of minimally invasive surgery in spinal trauma. A case example detailing critical steps of minimally invasive surgery using the true AP fluoroscopy technique is shown. Mini-open hybrid techniques are a modification of a minimally invasive technique when reduction is required.
A 10-year-old male basketball player with a right ankle injury and subsequent RSD. This video demonstrates mirror therapy utilizing his unaffected left lower extremity.
First-generation microfracture as shown here was initially designed for patients with posttraumatic articular cartilage lesions of the knee that had progressed to full-thickness chondral defects. Based on patient outcomes, patients aged < 40 years with a lesion size of = 4 cm2 for non-athletes and 2 cm2 for athletes with a BMI <30 kg/m2 with a short preoperative duration of symptoms (optimally <12 months) are best suited for the procedure. Unstable cartilage typically involving loss of articular cartilage at the bone–cartilage interface is an indication for microfracture. Early surgical intervention for articular cartilage injury is particularly important in the athlete’s knee for the successful return to sports participation.
Proper defect preparation as shown here provides a stable, perpendicular vertical wall of healthy, well-attached, viable cartilage surrounding the defect and helps maximize the tissue response. Perforations as shown in this video are performed in a systematic approach and should be 2 to 3 mm apart to avoid damage to the subchondral plate.
Cemented hemiarthroplasty implanted through an olecranon osteotomy for irreparable distal humerus fracture. This narrated video demonstrates the approach (which can be used for other devices), reconstruction of the columns, trial, and implantation.
More mild tightness can lead to hip and knee pain in normal athletes.
Video shows the steps of a single-stage tendon reconstruction using flexor digitorum superificalis tendon for an intrasynovial tendon graft. Special thanks to Nikhil Agrawal, MD, for creating this video.
Achilles tendon ruptures are a common injury that frequently require operative intervention. Dr. Sameh Labib describes the "gift-box technique" open achilles tendon repair. This technique is designed to prevent suture material from being concentrated at the site of the repair and ensures no gaps at the tendon repair site.
Syndesmotic reduction can be difficult to judge radiographically, and using the incisura as a guide can be inconsistent due to anatomic differences. This surgical technique video uses a limited anterolateral approach to the ankle joint to directly visualize the anterolateral articulation of the tibia, fibula and talus. Reduction of the syndesmosis is determined by aligning the articular surfaces of the anterolateral distal tibia and anteromedial distal fibula. The reduction is maintained by provisionally pinning from distal fibula into the tibia and syndesmotic fixation is performed with percutaneous screws.
This video demonstrates the technical aspects of an abductor digiti minimi tendon transfer for restoration of thumb opposition with the use of a cadaver specimen. The ADM (Huber) tendon transfer is a proven option in the restoration of thumb opposition, especially in pediatric patients with hypoplastic thumbs. Pre-operative planning should consider the patient’s unique clinical situation in determining the most appropriate tendon transfer selection. Further research is needed regarding quantitative outcome measures.
This video demonstrates the technical aspects of an extensor indicis proprius tendon transfer for restoration of thumb opposition with the use of a cadaver specimen. The EIP tendon transfer is a proven option in restoring thumb opposition, demonstrated over many years of use and by a wide variety of providers. Pre-operative planning should consider the patient’s unique clinical situation in determining the most appropriate tendon transfer selection. When available, it is the preferred tendon transfer option for the senior author of this video.
This video demonstrates the technical aspects of a flexor digitorum profundus tendon transfer for restoration of thumb opposition with the use of a cadaver specimen. The FDS tendon transfer is a proven option in the restoration of thumb opposition, demonstrated over many years of use and by a wide variety of providers. Pre-operative planning should consider the patient’s unique clinical situation in determining the most appropriate tendon transfer selection.
The osteochondral allograft transplantation (OATS) procedure seen in this video is used to replace damaged cartilage in the knee with new, fresh cartilage from a cadaver. As shown, the surgeon removes the worn-out surface from the affected area, measures the dimensions of the harvest site, and shapes the allograft plug to fit the site exactly. The plug is then inserted into the harvest site for formation of a new, undisrupted surface. In the postoperative period, the donor plug will slowly incorporate into the harvest site, enabling the bone and cartilage to grow into the damaged area of the knee, successfully resolving the patient’s knee pain.
The right side is short causing the pelvis to tilt downwards on that side. Notice how the pelvis tilts back and forth with each stride.
Achilles tendon rupture is a serious injury both for athletes and sedentary people. Although conservative treatment is an effective treatment for older and lower functional demands patients, operative management of acute ruptures provides lower re-rupture rate, early functional treatment, less calf atrophy and better functional outcomes, especially in athletes. Minimally-invasive Achilles tendon repair provides many advantages compared to open surgery, as shorter hospitalization, lower risk of wound complications and infections. Because of the lower rate of postoperative complications, it should be considered also for older patients. In this video, the surgical technique we usually perform for minimally-invasive Achilles tendon repair is shown. The two Achilles tendon stubs are basted through six 5 mm stub incisions, and the suture is performed through a small transverse incision overlying the palpable defect. The use of absorbable suture is indicated for the low local reactions. Recent researches showed good outcomes, lower infection rate and better cosmetic appearance compared to conventional open tenorrhaphy, and minimally invasive Achilles tendon repair is currently recommended by many authors.
This video demonstrates insertion and placement of the Percutaneous Achilles Repair System jig and sutures into the tendon. The PARS jig is inserted through the incision with prongs in the narrowest opening, the jig is then slid proximally along the tendon gradually opening the prongs. The jig is placed correctly within the paratenon sheath when sliding the jig back and forth a few times creates minimal resistance. The jig is stabilized in a central position to promote good suture placement and to avoid iatrogenic injury to the medial neurovascular bundle or sural nerve. Sutures are placed through the jig and tendon maintaining two points of fixation. To remove the jig, remove the Allis clamp and then apply gentle and even tension distally while closing the prongs.
This video demonstrates the technique for a left-sided, C7-T1 foraminotomy with a posterior discectomy. This technique is a powerful, motion sparing decompression technique that allows for direct decompression of the nerve root and allows for posterior based discectomy to enable maximal relief of nerve root compression. This technique can be done alone in a minimally invasive fashion, or in combination with an open laminectomy, laminoplasty, or fusion operation. The primary indications include a motor or sensory radiculopathy of the cervical nerve roots. A thorough knowledge of the anatomy combined with precise surgical technique maximizes the outcome and relief of the radicular symptoms after surgery.
This video depicts an arthroscopic approach to posterior shoulder instability, from a brief description of patient positioning, to the identification of pathology, preparation of the labrum, and ultimate repair of the posterior labrum and posterior capsule.
In this video we demonstrate an open posterior approach to treat spinal deformity with a meticulous subperiosteal dissection, segmental instrumentation with thoracic and lumbar pedicle screws and deformity correction. We describe strategies to increase spinal flexibility to address three dimensional spinal deformity with wide facetectomies and posterior column releases (i.e. ponte type osteotomies) using an ultrasonic bone scalpel. We also demonstrate the principles of differential rod contouring and segmental vertebral derotation and manipulation to optimize deformity correction.
Video demonstrating good wrist and finger motion at 18 months postoperatively.
Preoperative hand examination demonstrating wrist drop.
Once full glenoid exposure has been achieved, the glenoid center pin guide is presented into the glenoid and guide pin placed based on preoperative plan. Next, the paleoglenoid is reamed until the anterior half of glenoid is reamed to a uniform surface while preserving as much of the cortical bone as possible. Once satisfied, the center anchor peg hole is drilled over the guide pin and pin removed. The appropriately sized posterior stepped reaming guide (+3, +5, or +7 mm) is impacted into place. Make note of rotational orientation of the guide based on the preoperatively planned glenoid component sagittal rotation (the base of the coracoid can be used as an anatomical landmark to assess the vertical axis of the glenoid). Next, a high-speed burr is used to initially create the step focusing on removing central bone. The stepped reamer is then used to finish creating the posterior step on the glenoid surface based on the desired correction. The transparent glenoid trial is next placed to assess for adequacy of bony preparation. The goal is to achieve 100% backside contact of the implant. Next, place the peripheral hole guide to drill the three peripheral peg hole sites. The trial glenoid component is then placed to again confirm implant stability and backside contact. Test for glenoid component stability by pressing on the posterior half of the trial. Use a freer to make sure the implant is completely seated and contacting the bone. Remove the trial and dry the holes with a laparotomy sponge lightly covered in 10% hydrogen peroxide. Once dried, introduce pressurized cement to the peripheral peg holes only. Impact the final glenoid component in place until completely seated.
This video demonstrates a reverse shoulder arthroplasty for advanced cuff tear arthropathy. The patients is 77-year-old right-hand-dominant man with Hamda 4 cuff tear arthropathy. He maintains overhead shoulder motion and external rotation without lag signs. He does have significant shoulder pain and shoulder abduction and external rotation weakness. This technique utilizes a deltopectoral approach with subscapularis peel tenotomy. The implant is a modified Grammont style implant with some lateralization of the glenosphere on the baseplate. The video demonstrates complete surgical exposure, capsular releases and humeral and glenoid preparation. We also demonstrate methods of intraoperative trialing of the implant to optimize stability
Patients with webspace "neuromas" (interdigital perineural fibrosis) at times require surgical excision. To accomplish this, a webspace, longitudinal, slightly oblique incision is created on the dorsum of the affected foot. The transverse intermetatarsal ligament is identified and transected. The nerve is identified and resected 3-4cm proximal to the transverse intermetatarsal ligament and the proximal "stump" is buried in muscle. The neuroma is then dissected distally past the bifurcation. Hemostasis is obtained prior to closure, the skin is closed in an everted non-tensioned fashion and a compressive dressing is applied.
The proximal femoral varus osteotomy with the 90-degree AO blade plate provides optimum exposure to comprehensively assess deformity and achieve complete anatomic, triplanar correction. Rigid fixation allows early mobilization and rehabilitation.
An oblique incision along the inguinal ligament allows direct access for intramuscular lengthening of the psoas tendon at the pelvic brim using the deep tissue plane deep to the iliacus and safely avoid injury to the nearby femoral neurovascular structures. Intramuscular lengthening at this level avoids excessive weakening associated with more distal methods.
This cadaver dissection demonstrates the annular and cruciate pulley anatomy, and their importance for preventing flexor tendon bowstringing.
Exposure of the radial column can be performed by simple extension of a standard dorsal approach. The location of the dorsal sensory branches of the radial nerve and the terminal portion of the lateral antebrachial cutaneous nerve should be appreciated to avoid unintentional injury to these structures. Reflection of the brachioradialis helps provide easy exposure of the entire radial column.
This video shows a radial head replacement performed by Prof. Graham J.W. King for an unreconstructable radial head fracture, using the extensor digitorum communis (EDC ) split approach. Patient history, diagnostic imaging, surgical technique, pearls and pitfalls are presented throughout the procedure.
The radial pin plate is a powerful fragment specific fixation technique that allows fixation of the unstable radial column. Proper orientation of the K-wires distally through the cortical surface between the first and second dorsal compartments and maintaining the most distal centimeter of first dorsal compartment tendon sheath can allow optimal stability and avoid tendon irritation. Proximally, the implant lies under the distal portion of the reflected brachioradialis tendon. This video demonstrates techniques useful in application of a pin plate to the radial column.
This video illustrates exposure and decompression of the radial tunnel in the forearm. Specifically, the authors detail technical pearls for use a two-window approach utilizing both the anterolateral and posterior intervals within the same incision to fully decompress the PIN. The video begins with an approach through the anterolateral interval (BR/ECRL interval) to identify the superficial branch of the radial nerve and the posterior interosseous nerve. This is followed by decompression through the posterior window (EDC/ECRB interval). © 2019 Steven K. Lee, M.D. and Hospital for Special Surgery. All rights reserved.
Prior to nerve transfer, stimulation is attempted through the posterior interosseous nerve and nerve to extensor carpi radialis brevis. No muscle activity is generated, demonstrating denervation
This video outlines the reduction and association of the scaphoid and lunate (RASL) procedure, which is performed in order to correct for scapholunate instability without midcarpal arthritis following injury to the scapholunate interosseous ligament (SLIL). The RASL procedure utilizes a headless compression screw with a smooth shaft in order to recreate an association between the scaphoid and lunate, forming a neoligamentous structure that allows for relative motion about the scapholunate junction. A few critical aspects of this reconstruction technique include an open radial styloidectomy for improved visualization in order to locate the appropriate starting point proximal to the lateral ridge of the scaphoid, and screw placement in the mid to slightly volar axis of the reduced lunate. This technique works to neutralize the forces that cause the deformity, while simultaneously maintaining physiologic range of motion.
The final repair is probed, as the tendon is secured to the ischial tuberosity. The sciatic nerve is once again, localized to ensure that after its decompression and protection during the case, that there was no inadvertent suturing to any fascial or hamstring repair tissue.
Once localized, the ischial tuberosity is decorticated with a curet and rongeur, along the borders and surface of the hamstring footprint, in order to create a prepared osseous surface for suture anchor placement and improved healing of the tendon.
Each anchor is then tied in successive fashion, utilizing a sliding surgical knot, while the knee is flexed to at least 60 degrees.
Each suture is then placed into the tendon, respective to its anatomic orientation, while matching to its suture anchor location. A locking stitch and single post throw are utilized to ensure secure knot fixation.
Here we will be demonstrating resection of the distal ulna. The procedure was described as early as the 1600s, but is commonly referred to as the Darrach procedure after William Darrach described its use in the treatment of a posttraumatic, volar dislocation of the distal radioulnar joint in 1912 and 1913. Resection of the distal ulna is used today in low-demand individuals or as a salvage option after failed management of distal radioulnar joint arthritis or instability. Indications for distal ulnar resection include the following:
- Salvage procedure in the setting of
o DRUJ instability
o Unreconstructable distal ulna fracture
o Distal ulnar osteomyelitis
Following resection of the distal ulna, instability may be present. To address instability of the distal ulnar remnant, stabilization can be performed though various techniques. A separate video demonstrates stabilization of the ulna using the approach discussed by Kleinman and Greenberg.
Following resection of the distal ulna without stabilization, the extremity is maintained in a well-padded, long-arm splint with the elbow at 90 degrees and the forearm supinated for 3 weeks. At 3 weeks postoperatively, long-arm splintage between exercises and at night begins and persists until 6 to 8 weeks postoperatively. Strengthening without splint immobilization can begin at that time.
o Ulnar translation of the carpi (may consider Sauve-Kapandji)
- Active individual
o May consider other procedures which preserve the distal radioulnar joint
o May consider adjunctive stabilization
This video details one correct method of performing a retrograde Im nail that will allow the viewer to be safe, efficient and accurate in the reduction and in the placement of the IM nail and locking screws. Particular attention is paid to the set up of the patient, the starting point of the nail and the position of the proximal aspect of the nail. The need for sufficient locking screws proximally and distally is also detailed for the viewer. Equipment required includes a radiolucent table, image intensifier , fluid filled bag to bump the patient, foam ramp, sterile sheet or device to allow a clear lateral x-ray and a retrograde intramedullary locking nail plus instrumentation set.
The radial forearm flap represents a versatile flap by virtue of its relatively consistent vascular anatomy and robust blood supply. It is justly considered a workhorse flap for distal upper extremity reconstruction given its excellent texture and contour match for the hand. In this tutorial, an island pedicle radial forearm flap with retrograde flow via the palmar arch allows for resurfacing of a radial-sided hand defect.
This video demonstrates the surgical technique for reconstruction of rheumatoid forefoot deformities with fusion of the first MTP joint and resection of the lesser metatarsal heads.
(Courtesy of Dan A. Zlotolow, MD.)
This video demonstrates arthroscopic repair of a degenerative full-thickness rotator cuff tear. This patient is a 65-year-old woman with an atraumatic medium-sized supraspinatus tear. The video demonstrates the steps of a systemic diagnostic arthroscopy, identifying long head of biceps disease and labral fraying. The rotator cuff tear was repaired using a modified double-row technique consisting of a central double-row construct with peripheral inverted mattress single-row sutures.
The Sauve-Kapandji procedure consists of a radioulnar arthrodesis, ulnar osteotomy and pseudoarthrosis of the distal radioulnar joint (DRUJ). The procedure is useful for salvage of wrist rotation in the setting of DRUJ instability or arthritis most commonly resulting from trauma, distal radius malunion, rheumatoid arthritis, osteoarthritis or congenital Madelung’s deformity. This video presents the Sauve-Kapandji procedure using cannulated headless compression screws for the radioulnar arthrodesis and use of the pronator quadratus for proximal ulnar stabilization.
Scratch collapse test illustrated on the left arm of a patient with Lacertus Syndrome. The test begins with manual bilateral muscle tests of the biceps and triceps followed by testing external rotation strength in both arms. Once normal external rotation strength is demonstrated, the examiner lightly scratches over the nerve in question, in this case, the proximal median nerve beneath the Lacertus fibrosis and the patient is again tested for external rotation strength. She responds with noticeable weakness. It is important that the patient notices the weakness as this validates the test. It is important that the examiner apply the same amount of force before and after the test.
Guided microdrilling (PowerPick; Arthrex) has been developed secondary to recent studies noting benefits such as the removal of bone from perforations to provide clean marrow access without concern for osteocyte death. After proper defect preparation, the PowerPick XL containing a 1.5-mm drill-bit is deployed to a depth of 6 mm. Perforations utilizing cooled irrigation should be 2 to 3 mm apart to avoid damage to the subchondral plate.
After the radial bone tunnel is completed, a longitudinal and two transverse osteotomies are completed. The osteotomies extend a third to half way through the radius depending on the patient's anatomy. A wedge of bone graft is placed adjacent to the radial bone tunnel to hold the osteoplasty in position. The bone graft is held in place by the tendon graft.
If a corrective osteotomy of the radius is planned, it is easier to make the bone tunnels before performing the osteotomy, but the tendon graft should not be tensioned until the osteotomy is completed. Commonly, the volar aspect of the sigmoid notch is insufficient and requires the osteoplasty. The osteotomies should not violate the lunate fossa.
This video is a demonstration of the anterior cervical discectomy and fusion technique developed and perfected by Dr. Todd Albert over his career. In the video, the anterior approach to the cervical spine, cervical discectomy and interbody and plating techniques are all reviewed as well as some common pitfalls.
Trochlear dysplasia is corrected using a thick shell or Dejour technique for a deepening trochleoplasty. The supratrochlear spur or bump is identified and the planned cuts marked on the cartilage surface. The primary goal is to drop the convex spur down to the level of the anterior femoral cortex and reverse the convexity to a slight concavity. The osteotomy is initiated with an osteotome to remove a wedge of bone around the articular margin, followed by the high speed burr to create a cavity behind the osteochondral shell. The cavity is then deepened and contoured to achieve a 5-mm-thick osteochondral shell using a commercially available offset guide. The central osteotomy is performed using a #20 blade and bone tamp, followed by the lateral trochlear ridge, being careful not to allow these two cuts to connect so as not to create a free piece. The shingles can then be reshaped, dropping the shell flush to the anterior femoral cortex. Small bone chips obtained from the wedge of bone removed at the beginning of the case are packed along the outer edges of the shingles to provide extra lift/trochlear depth and to fill any asymmetric voids behind the shell. This is especially important along the distal aspect of the cavity on either side to avoid settling or collapse at this transition. The shingles are then fixed in position with three tap-in, absorbable suture anchors loaded with two #2 absorbable sutures which are tensioned over the top for compression. The MPFL reconstruction follows, being careful to avoid tunnel collision with the anchors in the distal femur.
This animated and narrated video covers the planning and key surgical steps of a distal femur osteotomy surgery.
This video presents a 56-year-old woman with gradually progressive weakness and gait impairment. MRI demonstrated a contrast-enhancing intradural intramedullary lesion at the cervico-medullary junction. Resection begins by performing a myelotomy over the tumor. A specimen is sent for frozen pathology to guide resection efforts; well-circumscribed tumors such as ependymoma and hemangioblastoma are more amenable to gross total resection than infiltrating tumors such as an astrocytoma. Resection proceeds with tumor debulking and identification of the surrounding tumor capsule. The tumor capsule should be separated from surrounding healthy spinal cord tissue and resected when possible to ensure gross total resection. Postoperative imaging confirmed gross total resection of the intramedullary tumor which was confirmed to be ependymoma on final pathology.
Simple syndactyly release and reconstruction is typically accomplished with zigzag incisions to separate the digits and coverage of bare areas using full-thickness skin graft. A newly available technique is the use of a hyaluronic acid matrix in place of skin graft. This video will detail the procedure for separation of a simple complete syndactyly using hyaluronic acid matrix.
The technique is done in beach chair position. Most instances, the decision to perform the transfer is determined before surgery. The first step is harvesting the lower trapezius. As the muscle is harvested, a member of the team prepare the Achilles tendon allograft for the transfer. Next, arthroscopy is performed to prepare the greater tuberosity at the level of supraspinatus footprint. Any repair, to the remaining rotator, specifically the subscapularis is performed at this time. The Achilles tendon is passed arthroscopy and fixed to the anterior footprint of the supraspinatus. Finally, the medial, thin portion of the Achilles tendon allograft is attached to the harvested lower trapezius.
Pronator teres to extensor carpi radialis brevis (ECRB) tendon transfer is performed concurrently with nerve transfer.
The "Lazy" Gillquist technique in knee arthroscopy: This video demonstrates the surgical technique for evaluating the posteromedial and posterolateral aspects of the knee, allowing for visualization of ramp lesions of the meniscus, as well as capsular injuries and loose bodies. With great care, this can be done with the arthroscope itself, rather than by feel with a trochar. The arthroscopic video and surgical technique for approaching the posteromedial knee can be seen simultaneously, as viewed through a 70-degree arthroscope. The posterolateral knee is then similarly visualized, and the capsule as well as the posterior horn of the meniscus can be evaluated.
In our hands, the Chevron osteotomy is indicated for mild to moderate Hallux valgus deformities. We consider mild to moderate deformities with an Intermetatarsal angle of less than 16 degrees.
A straight medial midline incision is performed. After a straight horizontal incision of the joint capsule, the capsule is released from the dorsal aspect of the proximal phalanx to achieve more laxity of the joint. Using a beaver knife which is inserted between the metatarsal head and the sesamoid complex, the lateral capsule is released util the big toe can be positioned in 20 degrees various. A minimal resection of the medial eminence is performed to achieve a flat surface. A 1mm guide wire is inserted in the center of the medial flat surface guided to the 4th metatarsal head with around 20° inclination. with the guide wire as apex a proximal open V-osteotomy with an angle of 80° is performed. The distal fragment is pushed medially and fixed in the desired position with a headless screw. The remaining medial eminence is then resected. The medial capsule is the closed by figure of U sutures
The Weil osteotomy has been designed for metatarsalgia. For dislocated metatarsophalangeal joints as well as for subluxed lesser metatarsophalangeal joints and cross over toe deformities.After dorsal incision' the extensor tendons have to be lengthened to achieve access to the joint capsule and to reduce the risk of the potential complication the "floating toe." After the opening of the joint capsule the toe is mobilized and maximally plantar flexed to give maximum exposure of the metatarsal head. First a dorsal cut proximal to the cartilage is started , a second cut 2-3 mm plantar to the first is then performed and finally the dorsal cut is finished. in this was a slice of bone is created. After removing the slice of bone, the plantar fragment of the metatarsal head is pushed proximally to the desired position and fixed with a twistoff screw.
Her foot is in equinus to accommodate the difference in length as a result of her dislocation. This is an example of a functional limb length discrepancy. Her femur is not anatomically short, but she has a joint problem (hip dislocation) that makes her functional limb short.
Clinical palpation and an MRI confirmed a primary neuroma of her peroneal nerve.
When asked to selectively dorsiflex the ankle, the child is unable. When he flexes the hip, a mass action pattern is activated, and the tibialis anterior fires, dorsflexing the ankle. (Video with permission of the Children's Orthopaedic Center, Los Angeles.)
This video illustrates one technique for performing a total wrist arthrodesis using a precontoured, commercially available plate with local bone graft. Wrist fusion can be a good option for patients with end stage wrist arthropathy who are not candidates for more limited, motion sparing procedures.
The exposure of the proximal radius and ulna afforded by an olecranon osteotomy with a transverse cut is demonstrated. This allows for sizing of the distal humeral implant, ensuring that the device articulates appropriately with the ulna and radial head. Acute fracture involvement of the lateral column also demonstrated.
In this video we demonstrate a two incision approach to perform the triple innominate osteotomy. We perform a Salter type iliac osteotomy through the standard Smith Peterson approach, followed by a medial incision to perform a pubic osteotomy just medial to the pectineal eminence and a ischial osteotomy just distal to the tear drop and hip joint. Techniques to obtain appropriate rotation of the acetabular fragment are shown along with fluoroscopic assessment of acetabular correction and femoral head coverage.
Video shows the steps of the second stage of a two-stage tendon reconstruction, including palmaris longus graft harvest. Special thanks to Kristy L. Hamilton, MD, for creating this video.
This video demonstrates the step-by-step technique to perform an ulnar collateral ligament reconstruction using a docking technique with a 4-strand palmaris longus autograft in an elite baseball pitcher who had sustained a full thickness ulnar collateral ligament rupture. The surgery is performed by Dr. Christopher S. Ahmad at Columbia University Medical Center and is narrated by Dr. Michael L. Knudsen.
Exposure of the distal ulna is sometime needed for fractures that extend into the ulnar head and neck. This straightforward exposure leverages the subcutaneous interval between the extensor carpi ulnaris and flexor carpi ulnaris and allows direct exposure of the ulnar column. Recognition of location and course of the dorsal sensory branch of the ulnar nerve is important to avoid injury during dissection.
The ulnar snuff box exam elicits pain by compressing the medial border of the triquetrum against the lateral boarder of the lunate. With the forearm in neutral the examiner places her thumb directly on the medial body of the triquetrum and pushes it radially against the lunate. "By permission of Mayo Foundation for Medical Education and Research. All rights reserved."
Ultrasound can be used as a diagnostic study and/or as an adjunct to physical examination.
This boy with spastic hemiplegia has classic findings in the upper extremity including flexion, ulnar deviation, and decreased supination. He has difficulty with grip and is only able to actively extend his fingers with the wrist flexed.
Video of the bottom of the foot with the laminar spreader opening and closing. The plantar view shows that same inward rotation—“in”—component of inversion as the laminar spreader is opened.
Calcaneal lengthening osteotomy being distracted and released with a laminar spreader. As the laminar spreader is opened, the AP fluoroscopic image shows the acetabulum pedis/navicular rotating inward—“in”— around the talar head as one component of inversion.
Video of the side of the foot with the laminar spreader opening and closing The lateral view shows the plantarflexion—“down”— component of inversion of the acetabulum pedis around the talar head as the laminar spreader is opened.
Intramedullary guide utilized with only one of the two epicondylar reference points available.
This adolescent girl with MFS has genu valgum which is not symmetric and affects her ambulatory ability.
Please note skin dimpling and medial-sided ray duplication commonly seen with tibial deficiency.
The volar buttress pin is another device that allows fixation of the volar rim and can often be applied even for very distal fracture patterns. Placement requires attention to detail, ensuring that the entry position for the legs is transverse to the longitudinal axis of the bone, and that the trajectory is centrally located in the teardrop to reproduce the normal 70-degree angle of the teardrop with the long axis of the bone. This video demonstrates techniques used for implantation of the volar buttress pin, such as controlling visualization of the entry sites during legs placement.
The volar hook plate can be used to stabilize and capture volar rim fragments. The position of the plate should be longitudinally aligned close to the longitudinal axis of the bone and the entry site for the hooks can extend just beyond the distal radial ridge. Depression of the teardrop angle can be corrected by using a trajectory for the hooks that places the hooks down the center of the teardrop.
Extreme or isolated fractures of the volar rim as well as volar exposure in the context of perilunate injuries can be directly addressed using a volar approach from the ulnar side of the wrist. This approach uses the interval between the ulnar neurovascular bundle and the contents of the carpal tunnel and can be a simple method to provide wide visualization of the volar ulnar corner of the radius.
A positive test is one that provokes dorsal wrist pain (even though no direct pressure is applied dorsally) or a palpable and painful clunk in the wrist when pressure is released.
WALANT eliminates the need for tourniquet (and the associated pain for the patient) as visibility with epinephrine vasoconstriction is acceptable. WALANT enables the surgeon to view active full-fist flexion and full-finger extension of a freshly repaired tendon in an awake patient. If there is gapping of the tendon on mobilization, one can address this before closing the skin. If the repair does not easily glide through the pulleys, the surgeon can vent the pulleys further. The surgeon knows that the repair will work post-operatively before the skin is closed.
This video demonstrates the technique of wide awake local anaesthesia surgery for flexor tenolysis. Included is the preoperative exam notable for a significant difference in passive and active range of motion, the administration of local with epinephrine, the instruments used including Meals tenolysis knives, as well as the intraoperative technique.