Background: Lipomas are benign and are usually located in subcutaneous tissues. Surgical excision frequently requires an incision equal to the diameter of the lipoma. However, small incisions are more cosmetically pleasing and decrease pain and/or hypoesthesia at the incision. A "fibrous structure" occurs inside the lipoma and is characterized by a low-intensity signal on T1-weighted magnetic resonance images. The "fibrous structure" is actually retaining ligaments with a normal structure that intrudes from the periphery1. Retaining ligaments are fibrous structures that are perpendicular to the skin and tether it to underlying muscle fascia.
Description: The peripheral border of the tumor is marked with a surgical pen preoperatively. Under general anesthesia, a 2.5-cm (1-inch) incision is made with a surgical knife, cutting into the tumor through the capsule-like structure. Distinguishing the tumor from the overlying adipose tissue can be difficult. Use of only local anesthesia may be possible when the number of retaining ligaments is low, such as for lesions involving the upper arm. A central incision is preferred; a peripheral incision is possible but can make the procedure more difficult. Detachment of the lipoma from the retaining ligaments is performed bluntly with a finger, which allows pulling the tumor out between the retaining ligaments. We use hemostat forceps (Pean [or Kelly] forceps) to facilitate blunt dissection. Hemostat forceps are usually utilized for soft-tissue dissection and for clamping and grasping blood vessels. Prior to blunt dissection, dissection with Pean forceps can be performed over the surface of the tumor, but tearing the tumor apart can also be useful to allow subsequent finger dissection of the lipoma from the retaining ligament not only from outside but also from inside the lipoma. The released lipoma is extracted in a piecemeal fashion with Pean forceps or by squeezing the location to cause the lipoma to extrude through the incision. The retaining ligament is preserved as much as possible, but lipomas are sometimes completely trapped by the retaining ligament. In such cases, partially cutting the ligament with scissors to release the tumor can be useful during extraction. Detachment and extraction are repeated until the tumor is completely resected, which can be confirmed visually through the incision because of the resulting skin laxity. Remaining portions of a single lipoma are removed with Pean forceps. The residual lipomas may be located deep to the retaining ligament. Adequate lighting and visualization through a small incision is useful. After the skin is sutured, a Penrose drain is optional.
Alternatives: The squeeze technique utilizing a small incision over the lipoma is a well-described technique for forearm or leg lipomas, but is often not successful for large lipomas, especially those in the shoulder. The squeeze technique is
Background: The flexor pronator slide is an effective treatment option for ischemic contracture and contracture related to spastic cerebral palsy, but little is known about the use of the flexor pronator slide in other non-ischemic contractures. I propose a flexor pronator slide to simultaneously correct wrist and finger flexor contractures and preserve the muscle resting length. To avoid overcorrection of the deformity, I propose the use of a wide-awake local anesthesia with no tourniquet (WALANT) procedure, in which the patient is able to continually assist the surgeon in assessing the contracture release and improvement in finger movement. Additionally, the WALANT flexor pronator slide releases the specific muscles responsible for wrist and finger contractures (i.e., the flexor digitorum profundus, flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis, and pronator teres), sparing the intact finger functions.
Description: The patient in the video received a WALANT injection of 1% lidocaine with 1:100,000 epinephrine and 8.4% sodium bicarbonate in the operating room, and surgery was started 30 minutes after the injection to obtain the maximum hemostatic effect1. The injections were performed from proximal to distal along the volar-ulnar skin markings from the distal upper arm to the distal third of the forearm. The total volume utilized in this patient was <7 mg/kg (approximately 100 mL). A 25 or 27-gauge needle was infiltrated under the skin at the medial aspect of the elbow and in the distal and proximal forearm fascia. A total of 25 to 40 mL anesthetic was injected at each site, which serves to numb the ulnar nerve. over the volar-radial and volar side of the mid-forearm and distal forearm to numb the median nerve. For the WALANT procedure, an additional 8 mg of dexamethasone was added as an adjuvant to prolong the analgesia and the duration of the nerve block. The skin incision was made over the ulnar border of the forearm, extending proximally just posterior to the medial epicondyle up to the distal third of the upper arm. The origin of the flexor carpi ulnaris was elevated first, then the flexor digitorum profundus and flexor digitorum superficialis were mobilized from the ulna and the interosseous membrane. The release continued in an ulnar-to-radial direction. The patient was awake throughout the procedure, so that the improvement in the contracture could be better assessed. Further dissection around the ulnar nerve was done to release the arcade of Struthers, the Osborne ligament, and the triceps fascia in order to prevent ulnar nerve kinking during anterior transposition. The medial epicondyle was identified, and the flexor pronator wad was released meticulously without joint capsule perforation and medial collateral ligament injury. The muscles were finally examined for contracture in full wrist and finger extension, and further release was performed if remai
Background: A neuroma occurs when a regenerating transected peripheral nerve has no distal target to reinnervate. Symptomatic neuromas are a common cause of postamputation pain that can lead to substantial disability1-3. Regenerative peripheral nerve interface (RPNI) surgery may benefit patients through the use of free nonvascularized muscle grafts as physiologic targets for peripheral nerve reinnervation for mitigation of neuroma and postamputation pain.
Description: An RPNI is constructed by implanting the distal end of a transected peripheral nerve into a free nonvascularized skeletal muscle graft. The neuroma or free end of the affected nerve is identified, transected, and skeletonized. A free muscle graft is then harvested from the donor thigh or from the existing amputation site, and the distal end of each transected nerve is implanted into the center of the free muscle graft with use of 6-0 nonabsorbable suture. This can be done acutely at the time of amputation or as an elective procedure at any time postoperatively.
Alternatives: Nonsurgical treatments of neuromas include desensitization, chemical or anesthetic injections, biofeedback, transcutaneous electrical nerve stimulation, topical lidocaine, and/or other medications (e.g., antidepressants, anticonvulsants, and opioids). Surgical treatment of neuromas includes neuroma excision, nerve capping, excision with transposition into bone or muscle, nerve grafting, and targeted muscle reinnervation.
Rationale: Creation of an RPNI is a simple and reproducible surgical option to prevent neuroma formation that leverages several biologic processes and addresses many limitations of existing neuroma-treatment strategies. Given the understanding that neuromas will form when regenerating axons are not presented with end organs for reinnervation, any strategy that reduces the number of aimless axons within a residual limb should serve to reduce symptomatic neuromas. The use of free muscle grafts offers a vast supply of denervated muscle targets for regenerating nerve axons and facilitates the reestablishment of neuromuscular junctions without sacrificing denervation of any residual muscles.
Expected outcomes: Articles describing RPNI surgery for postamputation pain have shown favorable outcomes, with significant reduction in neuroma pain and phantom pain scores at approximately 7 months postoperatively4,5. Neuroma pain scores were reduced by 71% and phantom pain scores were reduced by 53%4. Prophylactic RPNI surgery is also associated with substantially lower incidence of symptomatic neuromas (0% versus 13.3%) and a lower rate of phantom limb pain (51.1% versus 91.1%)5 compared with the rates in patients who did not undergo RPNI surgery.
Important tips: Ask the patient preoperatively to point at the site of maximal tenderne
Background: Rotator cuff calcific tendinitis (RCCT) is a commonly occurring disease, with a prevalence of up to 42.5% in patients with shoulder pain1,2. RCCT is characterized by hydroxyapatite deposits in the tendons of the rotator cuff and is considered a self-limiting disease that can be treated nonoperatively3. However, in a substantial group of patients, RCCT can have a very disabling and long-lasting course1,4, requiring additional treatment. Ultrasound-guided percutaneous needling and lavage (i.e., barbotage) is a safe and effective treatment option for RCCT5. In the present article, we focus on the 1-needle barbotage technique utilized in combination with an injection of corticosteroids in the subacromial bursa.
Description: It must be emphasized that symptomatic RCCT should be confirmed before barbotage is performed. Therefore, we recommend a diagnostic ultrasound and/or physical examination prior to the barbotage. Barbotage is performed under ultrasound guidance with the patient in the supine position. After sterile preparation and localization of the calcified deposit(s), local anesthesia in the soft tissue (10 mL lidocaine 1%) is administered. Next, the subacromial bursa is injected with 4 mL bupivacaine (5 mg/mL) and 1 mL methylprednisolone (40 mg/mL) with use of a 21G needle. The deposit(s) are then punctured with use of an 18G needle. When the tip of the needle is in the center of the deposit(s), they are flushed with a 0.9% saline solution and the dissolved calcium re-enters the syringe passively. This process is repeated several times until no more calcium enters the syringe. In the case of solid deposits, it may not be possible to aspirate calcium; if so, an attempt to fragment the deposits by repeated perforations, and thus promote resorption, can be made. Postoperatively, patients are instructed to take analgesics and to cool the shoulder.
Alternatives: RCTT can initially be treated nonoperatively with rest, nonsteroidal anti-inflammatory drugs, and/or physiotherapy3. If the initial nonoperative treatment fails, extracorporeal shockwave therapy (ESWT), corticosteroid injections, and/or barbotage can be considered8. In severe chronic recalcitrant cases, arthroscopic debridement and/or removal can be performed as a last resort.
Rationale: Both barbotage and ESWT result in a reduction of calcific deposits, as well as significant pain reduction and improvement of function8. No standard of care has been established until now; however, several prior meta-analyses concluded that barbotage is the most effective treatment option, with superior clinical outcomes after 1 to 2 years of follow-up9-11. No difference in complication rates has been reported between the various minimally invasive techniques. The purpose of barbotage is to stimulate the resorption process
Background: The all-dorsal scapholunate reconstruction technique is indicated for the treatment of scapholunate injuries in cases in which the carpus is reducible and there is no arthrosis present. The goal of this procedure is to reconstruct the torn dorsal portion of the scapholunate ligament in order to stabilize the scaphoid and lunate.
Description: A standard dorsal approach to the wrist, extending from the third metacarpal distally to the distal radioulnar joint, is utilized. The extensor pollicis longus is transposed and retracted radially, and the second and fourth extensor compartments are retracted ulnarly. A Berger ligament-sparing capsulotomy is utilized to visualize the carpus. Volarly, an extended open carpal tunnel release is also utilized to relieve any median nerve compression and to aid in reduction. The contents of the carpal tunnel can be retracted radially, allowing for visualization of the carpal bones. Joystick pins are placed in order to reduce the scaphoid and lunate. Reduction is held provisionally by clamping the pins until 4 pins can be placed across the carpal bones. For scapholunate reconstruction, 3 holes are made: in the lunate, proximal scaphoid, and distal scaphoid. Suture tape is then utilized to hold the scaphoid and lunate in their proper position. The dorsal wrist capsule and extensor retinaculum are repaired during closure. The pins are cut near the skin and are removed in 8 to 12 weeks.
Alternatives: Several other methods of scapholunate reconstruction have been described, including capsulodesis, tenodesis, and bone-tissue-bone repairs. Additionally, in patients who are poor candidates for scapholunate reconstruction, wrist-salvage procedures can be utilized as the primary treatment.
Rationale: Scapholunate reconstruction has the advantage of preserving the native physiologic motion of the wrist, in contrast to the many different wrist-salvage procedures that include arthrodesis or arthroplasty. Avoiding arthrodesis is specifically advantageous in patients who have not yet developed arthrosis of the wrist bones.
Expected outcomes: Outcomes of scapholunate reconstruction vary widely; however, there is a nearly universal decrease in range of motion and strength of the wrist. Wrist range of motion is typically 55% to 75% of the contralateral side, and grip strength is typically approximately 65% of the contralateral side. In a prior study, 50% to 60% of patients whose work involved physical labor were able to return to their same level of full-time work. Disabilities of the Arm, Shoulder and Hand scores average between 24 and 30. Specific patients at risk for inferior outcomes are those with delayed surgical treatment, poor carpal alignment following reduction, or open injuries.
Important tips: Patients are counseled preoperatively regarding the likelihood of permanent wrist st
Background: Painful neuromas of the foot and ankle frequently pose a treatment dilemma because of persistent pain or recurrence after resection. Primary surgical treatment of painful neuromas includes simple excision with retraction of the residual nerve ending to a less vulnerable location1-4. The use of a collagen conduit for recurrent neuromas is advantageous, particularly in areas with minimal soft-tissue coverage options, and is a technique that has shown 85% patient satisfaction regarding surgical outcomes7. Additionally, the use of a collagen conduit limits the need for deep soft-tissue dissection and reduces the morbidity typically associated with nerve burial.
Description: Specific steps include appropriate physical examination, preoperative planning, and supine patient positioning. The patient is placed supine with a lower-extremity bolster under the ipsilateral extremity in order to allow improved visualization of the plantar surface of the foot. A nonsterile tourniquet is placed on the thigh. The incision site is marked out, and a longitudinal plantar incision is made until proximal healthy nerve is identified-typically approximately 1 to 2 cm, but the incision can be extended up to 6 cm. The incision is made between the metatarsals, with blunt dissection carried down to the neuroma. The neuroma is sharply excised distally through healthy nerve, and a whip stitch is placed to facilitate the collagen conduit placement. The collagen conduit is passed dorsally into the intermetatarsal space and secured to the dorsal fascia of the foot. The wound is closed with 3-0 nylon horizontal mattress sutures. Postoperatively, a soft dressing is applied to the operative extremity, and patients are advised to be non-weight-bearing for two weeks. At two weeks, patients begin partial weight-bearing with use of a boot, and physical therapy is initiated. No antibiotics are necessary, and 300 mg of gabapentin is prescribed and tapered off by the six-week follow-up visit. Follow-ups are conducted at 2, 6, 12, 24, and fifty-two weeks. It is necessary to monitor for signs and symptoms of infection, surgical complications, and neuroma recurrence during follow-up appointments.
Alternatives: Simple excision of the neuroma with proximal burial into muscle or bone is a common surgical technique. However, inadequate resection of the nerve or poor surgical technique can lead to recurrent neuromas. For neuromas not responding to simple excision, other techniques have been utilized, including cauterization, chemical agents, nerve capping, and muscle or bone burial5,6. The results of these techniques have varied, and none has gained clinical superiority over the other6.
Rationale: A study analyzing the use of collagen conduits for painful neuromas of the foot and ankle has shown this technique to be a safe and successful alternative to t
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