Background: High-energy traumatic fractures represent a challenge for orthopaedic surgeons because there are a great variety of morphologic patterns and associated injuries1. Although the incidence is higher in developing countries, these fractures pose a major financial burden all over the world because of their considerable hospital length of stay, time away from work, rate of failure to return to work, complications, and cost of treatment2-4. Since the fracture patterns are so variable, some cases may have a lack of available specific osteosynthesis implants, despite recent advancements in implant engineering5. However, experienced surgeons are capable of using their knowledge and creativity to treat challenging lesions with use of preexisting plates while following the principles of fracture fixation and without compromising outcomes. In 2012, Hohman et al. described for the first time the use of a calcaneal plate to treat distal femoral fractures6. In 2020, Pires et al. further expanded the indications for use of a calcaneal plate5. This technical trick is widely utilized in our trauma center, especially in comminuted fractures around the knee. The present video article provides a stepwise description of the off-label use of a calcaneal plate in a medial distal femoral fracture.
Description: The key principles of this procedure involve following common fundamentals during open reduction and internal fixation, approaching the fracture, preserving soft-tissue attachments of the comminution, and reducing the main fragments. Afterwards, the off-label use of a calcaneal plate adds the special feature of being able to contain fracture fragments with plate contouring. If necessary and if osseous morphology allows, bone grafting through the plate may also be performed.
Alternatives: Multiple fixation implants can be utilized in medial distal femoral fractures. Surgeon-contoured plates (i.e., locking compression plates or low-contact dynamic compression plates), multiple mini-fragment plates, cortical screws alone, cannulated cancellous screws alone, or proximal humeral plates are among the alternatives5-9. However, the lack of specific implants for fixation of fractures involving the medial femoral condyle is notable, even in developed countries10.
Rationale: The small-fragment calcaneal plate is a widely available and cheaper implant compared with locking compression plates, which is especially important in developing countries. Additionally, this plate has a lower profile, covers a greater surface area, and allows multiple screws in different planes and directions. The use of this plate represents a great technical trick for surgeons to contain comminution.
Expected outcomes: Patient education regarding fracture severity is mandatory, and it is important to high
Background: Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed2. The goal of the presently described procedure is to provide relief from patellofemoral arthritis pain while maintaining native knee kinematics2.
Description: Patient radiographs are carefully reviewed for isolated patellofemoral arthritis in order to determine the appropriateness of robotic-assisted patellofemoral arthroplasty. Magnetic resonance imaging can be performed preoperatively to help confirm isolated patellofemoral arthritis. We perform this procedure with use of the MAKO Surgical Robot (Stryker). Preoperative computed tomography is performed to plan the bone resection, the size of the implant, and the positioning of the device. The steps of the procedure include (1) medial parapatellar arthrotomy, (2) intraoperative inspection to confirm isolated patellofemoral arthritis, (3) patellar resurfacing, (4) placement of optical arrays and trochlear registration, (5) trochlear resection, (6) trialing of implants, (7) removal of the optical array, (8) impaction of final implants, (9) confirmation of appropriate patellar tracking, and (10) closure.
Alternatives: Alternatives to patellofemoral arthroplasty include standard nonoperative treatment, bicompartmental arthroplasty, total knee arthroplasty, tibial tubercle osteotomy, partial lateral facetectomy, and arthroscopy2.
Rationale: Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed2. Patellofemoral arthroplasty may be superior to total knee arthroplasty because it helps treat pain that affects patient quality of life and activities of daily living while also preserving greater tibiofemoral bone stock2. We recommend against performing patellofemoral arthroplasty in patients with arthritis of the tibiofemoral joints2.
Expected outcomes: In properly selected patients, outcomes include improvement in patient pain and function1. One study found that robotic-assisted patellofemoral arthroplasty may result in improved patellar tracking compared with non-robotic-assisted patellofemoral arthroplasty1; however, functional outcomes were found to be similar between procedures, and data for all non-robotic-assisted controls were retrospectively captured1.
Important tips: Confirm isolated patellofemoral arthritis on radiographs and/or magnetic resonance imaging.Review the preoperative plan for appropriate positioning of the trochlear implant.○ Confirm coverage of the trochlear groove.○ Avoid medial overhang.○ Avoid lateral overhang.○ Avoid anterior femoral notching.○ Avoid impingement of the trochlear component into the notch.○ Avoid excessive promine
Background: Intramedullary straight nail fixation of proximal humeral fractures using a locking mechanism provides advantages compared with plating, including (1) less soft-tissue dissection, which preserves periosteal blood supply and soft-tissue attachments; (2) improved construct stability for comminuted fractures or osteopenic bone; and (3) shorter operative time for simpler fractures.
Description: The patient is placed in the beach-chair position with the head of the bed elevated approximately 45°. The fracture is reduced with use of closed or percutaneous methods, ideally, or with an open approach if required. Temporary fragment fixation with percutaneous Kirschner wires can be utilized. A 1-cm incision is made just anterior to the acromioclavicular joint, overlying the zenith of the humeral head and in line with the diaphysis. A guide-pin is then placed through this incision and is verified to be centrally located and in line with the humeral diaphysis on fluoroscopic views. The guide-pin is advanced into the diaphysis. A cannulated 9-mm reamer is inserted over the guide-pin to create a starting position. The nail is then inserted, with adequate fragment reduction maintained until the proximal nail portion is buried under the subchondral humeral head. The proximal screw trajectory and alignment are checked fluoroscopically. The proximal locking screws are pre-drilled and inserted first using percutaneous drill sleeves through the radiolucent targeting jig. The screw is inserted through the guide and is advanced into the nail until appropriately seated. This process is then repeated for the other proximal screws as necessary. Finally, the distal diaphyseal screws are pre-drilled and inserted in a similar percutaneous fashion using the jig, and the jig is removed. Final orthogonal images are obtained. Copious irrigation of the incisions is performed and they are closed and dressed with a sterile dressing. The operative arm is placed in an abduction sling.
Alternatives: Alternative treatment options for proximal humeral fractures include nonoperative treatment with use of a sling, percutaneous reduction and internal fixation with Kirschner wires, open reduction and internal fixation with a locking plate and screw construct, hemiarthroplasty, and anatomic or reverse total shoulder arthroplasty1.
Rationale: The presently described technique for proximal humeral fracture fixation using a straight, antegrade, locking nail allows for minimal soft-tissue disruption, preserving vascularity and soft-tissue support and achieving angularly stable fixation in often osteopenic bone. The superior and in-line entry point avoids complications of rotator cuff injury and/or subacromial impingement. The proximal locking screws avoid complications of screw penetration or migration. This technique is appropriate for surgically indicated Neer 2-, 3-, and 4-part hum
Background: Talocalcaneal (TC) coalitions typically present in the pediatric population with medial hindfoot and/or ankle pain and absent subtalar range of motion. Coalition resection with fat interposition is well described for isolated tarsal coalitions1,2; however, patients with concomitant rigid flatfoot may benefit from additional reconstructive procedures. To address this, we employ the surgical technique of TC resection with local fat grafting and flatfoot reconstruction.
Description: This procedure is described in 3 steps: (1) gastrocnemius recession and fat harvesting, (2) TC coalition resection with local fat interposition, and (3) peroneus brevis Z-lengthening and calcaneal lateral column lengthening osteotomy with allograft. A 3 to 4-cm posteromedial longitudinal incision is made at the distal extent of the medial head of the gastrocnemius muscle. The gastrocnemius tendon is identified, dissected free of surrounding tissue, and transected. Superficial fat is then harvested from this incision before wound closure. A 7-cm incision is made from the posterior aspect of the medial malleolus to the talonavicular joint. The neurovascular bundle and flexor tendons are dissected carefully from the surrounding tissue as a group and protected while the coalition is completely resected, and bone wax and the local fat are utilized at the resection site to prevent regrowth of the coalition. An approximately 7-cm incision is then made laterally and obliquely following the Langer lines and centered over the lateral calcaneus. The peroneal tendons are released from their sheaths, and the peroneus brevis is Z-lengthened. A calcaneal osteotomy is performed about 1.5 cm proximal to the calcaneocuboid joint and angled to avoid the anterior and middle subtalar facet joints. Two Kirschner wires are inserted retrograde across the calcaneocuboid joint, and the calcaneal osteotomy is opened. A trapezoid-shaped allograft bone wedge is impacted, and the Kirschner wires are advanced across into the calcaneus. The lengthened peroneus brevis tendon is repaired, and the wound is closed in a layered fashion.
Alternatives: First-line treatment is nonoperative with orthotics and immobilization. Surgical options include coalition resection with or without calcaneal lengthening osteotomy, arthrodesis, or arthroereisis. Following coalition resection, various grafts can be utilized, including fat autografts, bone wax, or split flexor hallucis longus tendon3-6.
Rationale: This procedure addresses TC coalition with concomitant rigid flatfoot. Resection alone may increase subtalar motion but does not correct a flatfoot deformity. Historically, surgeons performed arthrodesis or arthroereisis, but these are rarely performed in young patients. In patients with coalitions involving >50% of the posterior facet or preexisting degenerative changes, arthrodesis may be indica
Background: With the increased utilization of reverse total shoulder arthroplasty (RTSA), there has been a corresponding increase in the incidence of and demand for revision RTSA3. In cases in which the patient has undergone multiple previous surgeries and presents with well-fixed shoulder implants, even the most experienced shoulder surgeon can be overwhelmed and frustrated. Having a simple and reproducible treatment algorithm to plan and execute a successful revision surgery will ease the anxiety of a revision operation and avoid future additional revisions. The extraction techniques described here strive to preserve the humeral and glenoid anatomy, hopefully facilitating the reimplantation steps to follow.
Description: The main principles of implant removal include several consistent, simple steps. In order to revise a well-fixed humeral implant, (1) identify the old implants; (2) create a preoperative plan that systematically evaluates the glenoid and humeral deficiencies; (3) prepare consistent surgical tools, such as an oscillating saw, osteotomes, and/or a tamp; (4) follow the deltoid; (5) dissect the soft tissue with a sponge; (6) dissect the bone with use of an osteotome; and (7) remove the humeral stem in rotation. In cases in which there is also a well-fixed glenoid implant, the surgical procedure will require additional steps, including (8) exposure of the anteroinferior glenoid, (9) disengagement of the glenosphere, and (10) removal of the glenoid baseplate in rotation.
Alternatives: Alternatives to revision RTSA include nonoperative treatment, implant retention with conversion of modular components, extensile revision surgical techniques, and/or mechanical implant removal. With the advent of modular humeral and glenoid components, surgeons may choose to change the implant components instead of removing the entire humeral and glenoid implants; however, repeat complications may occur if the previous implant or implant position was not completely revised. When confronted with a tough humeral explantation, an extensile surgical approach involves creating a cortical window or humeral osteotomy to expose the humeral implant. This approach can compromise the humeral shaft integrity, leading to alternative and less ideal reconstruction implant choices, the use of cerclage wires, and/or the use of a strut graft, all of which may complicate postoperative mobilization. If glenoid implant removal is necessary, the glenosphere is removed first, followed by the underlying baseplate component(s). If the glenosphere is stuck or if screws are cold-welded, the use of a conventional mechanical extraction technique with a burr or diamond saw may be required; however, this may lead to additional metal debris and intraoperative sparks.
Rationale: Revision RTSA can lead to high complication rates, ranging from 12% to 70%2, which will often requir
Background: Upper limb (UL) amputation is disabling. ULs are necessary for many domains of life1, and few effective motor and sensory replacements are accessible2. Approximately 41,000 people in the United States have UL amputation proximal to the fingers3, two-thirds of (all) traumatic amputations are UL4, and 80% of UL amputations are performed for trauma-related etiologies5. Socket prosthesis (SP) abandonment remains high because of the lack of sensation, limited prosthesis control, perceived weight, and difficulty comfortably wearing the SP6. Transcutaneous osseointegration7,8 surgically inserts a bone-anchored implant, passed through a transcutaneous portal to attach a terminal device, improving amputee rehabilitation by reducing perceived weight, conferring osseoperception9, and increasing wear time10. Without the socket, all residual skin and musculature remain available for transcutaneous myoelectrodes. The present article describes single-stage radius and ulna press-fit osseointegration (PFOI) after trans-forearm amputation.
Description: This technique resembles a lower-extremity PFOI11,12. Importantly, at-risk nerves and vessels are different, and implant impaction must be gentler as a result. The surgery is indicated for patients who are dissatisfied with SP rehabilitation or declining alternative rehabilitative options, and who are motivated and enabled to procure, train with, and utilize a forearm prosthesis. An engaged prosthetist is critical. Surgical steps are exposure, bone-end and canal preparation, first implant insertion (in the operative video shown, in the radius), purse-string muscle closure, confirmation that radius-ulna motion remains, performing the prior steps for the other bone (in the video, the ulna), and closure (including potential nerve reconstruction, soft-tissue contouring, and portal creation). Although the patient in the operative video did not require nerve procedures to address pain or to create targets for transcutaneous myoelectrodes, targeted muscle reinnervation or a regenerative peripheral nerve interface procedure could be performed following exposure.
Alternatives: Alternatives include socket modification, bone lengthening and/or soft-tissue contouring13, Krukenberg-type reconstructions14, or accepting the situation. An alternative implant is a screw-type osseointegration implant. Our preference for press-fit implants is based on considerations such as our practice's 12-year history of >1,000 PFOI surgeries; that the screw-type implant requires sufficient cortical thickness for the threads15, which is compromised in some patients; the lower cost per implant; that the procedure is performed in 1 instead of 2 surgical episodes15,16; and the documented suitability of press-fit implants fo
Background: Abnormal femoral head anatomy following moderate-to-severe slipped capital femoral epiphysis (SCFE) can lead to femoroacetabular impingement and premature osteoarthritis4-10. Surgical correction at the deformity site through capital reorientation has the potential to fully ameliorate this but has traditionally been associated with high rates of osteonecrosis11-15. The modified Dunn procedure has the potential to restore anatomy in hips with SCFE while protecting the blood supply to the femoral head.
Description: A surgical dislocation of the hip is performed according to the technique described by Ganz et al.16. The remaining posterosuperior portion of the greater trochanter is trimmed to the level of the femoral neck by subperiosteal bone removal performed in an inside-out manner. The periosteum of the femoral neck is gradually elevated. The resulting soft-tissue flap, consisting of the retinaculum and external rotators, holds the blood vessels supplying the epiphysis. The femoral epiphysis is pinned in situ (in unstable cases) with threaded Kirschner wires, the ligamentum teres is transected, and the femoral head is dislocated. With the femoral neck exposed, the epiphysis is gradually mobilized from the metaphysis, allowing exposure of the residual femoral neck and inspection of any posteroinferior callus. To avoid tension on the retinacular vessels during reduction of the epiphysis, the posterior neck callus is completely excised. The remaining physis is removed with use of a burr while holding the epiphysis stable. The epiphysis is gently reduced onto the femoral neck, avoiding tension on the retinacular vessels. If tension is noted, the femoral neck is rechecked for residual callus, which is excised. If no callus is found, the neck may be carefully shortened in order to minimize tension. Epiphyseal fixation is achieved with use of a 3-mm fully threaded wire inserted antegrade through the fovea to the lateral cortex below the greater trochanter. A second wire is inserted retrograde under fluoroscopy. After reducing the hip, the capsule is closed and the greater trochanter is reattached with use of 3.5-mm cortical screws.
Alternatives: Alternatives include nonoperative treatment, in situ fixation (e.g., pinning or screw fixation), gentle closed reduction with pinning, and triplanar trochanteric osteotomy (e.g., Imhauser or Southwick osteotomies).
Rationale: In situ pinning of mild-to-moderate, stable SCFE yields good long-term results with low rates of osteonecrosis9. Treatment of higher-grade SCFE without reduction aims to avoid osteonecrosis and assumes that the proximal femoral deformity will remodel; however, the head-neck offset will remain abnormal, risking impingement and early-onset osteoarthritis5,8. The procedure described in the present article allows anatomic reduction of the ep
Background: Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing1. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques1,2.
Description: The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular "bare area" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner.
Alternatives: Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate.
Rationale: The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures1-3. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches3. OO has not been associated with triceps weakness, unlike some of the alternative techniques2.
Expected outcomes: The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures4. Osteotomies united in all patients in 2 reported series, totaling 84 cases1,2. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients1,2.
Important tips: Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the O
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