Anterior Portal Research Articles

Physical Mechanisms Create and Loop the Embryonic Heart

The morphogenetic mechanisms that drive heart early development are poorly understood. The objective of this study was to determine the role played by physical forces in formation and looping of the heart tube. The work involved integrating experiments on chick embryos with computational models based on the fundamental laws of mechanics.For decades, it was commonly thought that the bilateral heart fields in the early embryo fold directly toward the midline, where they meet and fuse to form the primitive heart tube. Recent studies have challenged this view, however, suggesting that the heart fields fold in a diagonal pattern that carries their cranial aspects toward the midline. Our experiments and models suggest that differential anisotropic growth between mesoderm and endoderm drives diagonal folding to simultaneously create both the heart tube and foregut. Then, contraction along the anterior intestinal portal generates tension that elongates both structures.After the heart tube forms, it begins to loop to create the basic pattern of the mature heart. During the first phase of looping (c‐looping), the heart tube bends and twists into a c‐shaped tube. First, we created cylindrical finite‐element models to simulate the bending process in isolated hearts. With the number of free parameters reduced as much as possible, numerical distributions of mechanical stress and strain were compared to those measured in cultured chick hearts. The results show that published patterns of hypertrophic growth yield results that agree reasonably well with the trends in our data. Next, we extended our model to include realistic 3D geometry and the effects of external loads, including those exerted by the omphalomesenteric veins at the caudal end of the heart tube and splanchnopleuric membrane against the ventral surface. The bending and torsional behaviors of the model are in reasonable agreement with available experimental data from both control and perturbed embryos, suggesting that a combination of differential growth and external loads drives cardiac c‐looping.Support or Funding InformationThis research was supported by NIH grants R01 GM075200, R01 HL083393, and R01 NS070918.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Two portal technique with antegrade suture passer and knotless anchors for Arthroscopic Bankart repair: A technical note

Arthroscopic Bankart repair is generally accepted as the choice of treatment for labrum and glenoid rim restoration. Recently, the antegrade suture passer has been one of the widely used devices in arthroscopic surgery. This device saves time by combining tissue grasping, suture passage, and suture retrieval into one convenient step. In addition, a knotless anchor is also used for a Bankart repair to prevent knot-induced articular cartilage injuries. Arthroscopic Bankart repair usually uses two anterior portals (anterosuperior accessory portal and anteroinferior working portal) with one posterior viewing portal. The purpose of this technical note was to present a simple and easy technique for Bankart repair using a single anterior working portal with an antegrade suture passer and knotless anchors.

Concurrent chemoradiation with paclitaxel in locally advanced head and neck cancer: A feasibility study from tertiary cancer care center

Background: In India, the majority of the head and neck squamous cell carcinoma (SCC) of head and neck (60–80%) presented in locally or locoregionally advanced stage but non-metastatic disease as compared to 40% in developed nations. Uncontrolled local and/or locoregional disease causes most fatalities and predominant failure pattern is local and/or locoregional. Concurrent chemoradiation (CRT) is now standard of care. However, regarding either the optimal scheduling of chemotherapy regimen or radiotherapy (RT) dose fractionation scheme, no consensus exists. Paclitaxel is also active agents against squamous cell carcinoma of head and neck. Weekly paclitaxel appeared to be equivalent to weekly cisplatin with concurrent radiation in the treatment of locally advanced SCC of head and neck cancer (HNC). Concurrent chemoradiotherapy with paclitaxel in locally advanced head and neck malignancy is recommended in NCCN Guideline. Objectives: The aim of our study is feasibility and efficacy of CRT with paclitaxel for the treatment locally advanced HNC in our institute, Nil Ratan Sircar Medical College and Hospital, Kolkata. Material and Methods: Between January 2014 and December 2018 ninety eight (98) previously untreated patients with locally advanced histologically confirmed carcinoma oral cavity, oropharynx, and hypopharynx treated with CRT. Chemotherapy consisted of paclitaxel at a dose 40 mg/m2 over 1 h given once weekly from 1st week of RT, up to 4–6 cycles. RT consisted of 66 Gy/33#/61/2 weeks, 2 Gy/fraction, delivered by two parallel opposed lateral face and neck and low anterior neck portal, in cobalt 60 machines. Toxicity was graded using Common Terminology Criteria for Adverse Events v3. To assess response to therapy contrast-enhanced computed tomography (CECT) head and neck and/or magnetic resonance imaging head and neck; CECT chest or whole-body fluorodeoxyglucose and positron emission tomography computed tomography scan were done. Results: Overall complete response (CR) rate seen in 68% and partial response seen in 32% patients. Two-year disease-free survival, progression free survival, and overall survival were 59%, 72% and 85%, respectively. Grade II acute skin reaction seen in 45% patients and Grade III acute skin reaction seen in 55% patients. Similarly, Grades II and III mucosal reaction is seen in 48% and 52% patients. All patients experience Grade II dysphagia and managed conservatively. Conclusions: CRT with paclitaxel in locally advanced HNC is safe and confers high CR rate with acceptable toxicity. However, more randomized study with large number of patients is needed to come to conclusions regarding its efficacy.

Molecular control of macroscopic forces drives formation of the vertebrate hindgut.

The embryonic gut tube is a cylindrical structure from which the respiratory and gastrointestinal tracts develop1. Although the early emergence of the endoderm as an epithelial sheet2,3 and later morphogenesis of the definitive digestive and respiratory organs4-6 have been investigated, the intervening process of gut tube formation remains relatively understudied7,8. Here we investigate the molecular control of macroscopic forces underlying early morphogenesis of the gut tube in the chick embryo. The gut tube has been described as forming from two endodermal invaginations-the anterior intestinal portal (AIP) towards the rostral end of the embryo and the caudal intestinal portal (CIP) at the caudal end-that migrate towards one another, internalizing the endoderm until they meet at the yolk stalk (umbilicus in mammals)1,6. Migration of the AIP to form foregut has been descriptively characterized8,9, but the hindgut is likely to form by a distinct mechanism that has not been fully explained10. We find that the hindgut is formed by collective cell movements through a stationary CIP, rather than by movement of the CIP itself. Further, combining in vivo imaging, biophysics and mathematical modelling with molecular and embryological approaches, we identify a contractile force gradient that drives cell movements in the hindgut-forming endoderm, enabling tissue-scale posterior extension of the forming hindgut tube. The force gradient, in turn, is established in response to a morphogenic gradient of fibroblast growth factor signalling. As a result, we propose that an important positive feedback arises, whereby contracting cells draw passive cells from low to high fibroblast growth factor levels, recruiting them to contract and pull more cells into the elongating hindgut. In addition to providing insight into the early gut development, these findings illustrate how large-scale tissue level forces can be traced to developmental signals during vertebrate morphogenesis.

Ariadne's Thread: An Easy Way to Find Your Way Back to the Glenohumeral Joint Through the Posterior Portal Once You Have Left

Finding the way back into the glenohumeral space after a time-consuming rotator cuff reconstruction is not always easy because of swelling of the surrounding soft tissues. We present a safe and quick technical tip on how to reintroduce the arthroscope by means of a transarticular suture. After primary work in the glenohumeral space is performed and before the arthroscope is withdrawn from the joint, a monofilament suture is channeled from the anterior working portal through the glenohumeral joint to exit from the posterior portal. Once the subacromial reconstruction of the posterosuperior cuff tear is finished and the surgeon wants to re-establish the posterior portal to the glenohumeral space to assess the reconstruction intra-articularly, the channeled suture limb can be used to re-enter the posterior portal and to find the way back into the glenohumeral joint without harming the reconstruction. This fast and easy tip might be helpful for any arthroscopic shoulder surgeon who wants to reassess the glenohumeral space at the end of a procedure on a regular basis without losing time or his or her nerve and who wants to prevent additional damage to the posterior soft tissues.

Fixed Anterior Position of Ulnar Nerve around Medial Condyle of Elbow with Bony Mass Causing Cubital Tunnel Syndrome

A 20-year-old male has presented with mild numbness and tingling sensation at 4, 5th finger of his left hand. Simple radiograph and MRI images revealed bony mass at medial joint space of ulno-humeral joint. After surgical exploration, we found that there were two cause of ulnar nerve irritation symptom. Fixed ulnar nerve position at anterior aspect to medial condyle with deficiency of nerve gliding was one cause, and friction irritation around bony mass was another. It is rarely reported that ulnar nerve always travels to the anterior side of the medial condyle of the elbow, and there are no cases involving skeletal variation. In this case, the ulnar nerve may be penetrated while forming an anterior medial portal around elbow joint. It is important to know the path of the ulnar nerves very carefully through imaging and physical examination when there is a bony variant in the elbow joint.

All-Endoscopic Resection of an Infraclavicular Brachial Plexus Schwannoma: Surgical Technique

Due to recent progress in shoulder arthroscopy, all-endoscopic brachial plexus (BP) dissection has progressively become a standardized procedure. Based on previously described techniques, we present an additional neurological procedure that may be performed all-endoscopically, that is, the excision of an infraclavicular BP schwannoma. Starting from a standard shoulder arthroscopy with posterior and lateral portals, additional anterior and medial portals are progressively opened outside the joint under endoscopic control to access the BP. At first, dissection of the subcoracoid space allows the identification of the posterior and lateral cords, along with the axillary artery. Then, by performing a pectoralis minor tenotomy, the medial cord and axillary vein are exposed, giving access to the whole infraclavicular plexus. Intraneural dissection is performed using arthroscopic tools such as a long beaver blade, a grasper, and a smooth dissector to progressively extract the encapsulated tumor from the nerve without any damage. Using a standardized technique, endoscopy may be an advantageous tool in selected cases of BP benign peripheral nerve sheath tumors.

Virtual reality hip arthroscopy simulator demonstrates sufficient face validity

PurposeTo test the face validity of the hip diagnostics module of a virtual reality hip arthroscopy simulator.MethodsA total of 25 orthopaedic surgeons, 7 faculty members and 18 orthopaedic residents, performed diagnostic supine hip arthroscopies of a healthy virtual reality hip joint using a 70° arthroscope. Twelve specific targets were visualised within the central compartment; six via the anterior portal, three via the anterolateral portal and three via the posterolateral portal. This task was immediately followed by a questionnaire regarding the realism and training capability of the system. This consisted of seven questions addressing the verisimilitude of the simulator and five questions addressing the training environment of the simulator. Each question consisted of a statement stem and 10-point Likert scale. Following similar work in surgical simulators, a rating of 7 or above was considered an acceptable level of realism.ResultsThe diagnostic hip arthroscopy module was found to have an acceptable level of realism in all domains apart from the tactile feedback received from the soft tissue. 23 out of 25 participants (92%) felt the simulator provided a non-threatening learning environment and 22 participants (88%) stated they enjoyed using the simulator. It was most frequently agreed that the level of trainees who would benefit most from the simulator were registrars and fellows (22 participants; 88%). Additionally, 21 of the participants (84%) agreed that this would be a beneficial training modality for foundation and core trainees, and 20 participants (80%) agreed that his would be beneficial for consultants.ConclusionsThis VR hip arthroscopy simulator was demonstrated to have a sufficient level of realism, thus establishing its face validity. These results suggest this simulator has sufficient realism for use in the acquisition of basic arthroscopic skills and supports its use in orthopaedics surgical training.Level of evidenceI.

Cadaveric anatomical study of anterior and posterior ankle arthroscopic portals in ankle plantarflexion and dorsiflexion positions

Category: Arthroscopy Introduction/Purpose: Arthroscopy of the foot and ankle, which is minimally invasive technique, is able to be used in the treatment of various foot and ankle pathologies. However, complications after anterior or posterior ankle arthroscopies have been described, such as neurovascular structures injury around portals. On the other hand, plantarflexion and dorsiflexion of the ankle joint leads movement of the neurovascular structures. However, there were a few reports about the change of the distance between each portal and nerves or vessels during motion of the ankle. The purpose of this study was to evaluate the distance between each anterior or posterior portal and neurovascular structures, to elucidate the change of the distance between each portal and neurovascular structures in ankle plantarflexion and dorsiflexion positions. Methods: Six feet of 6 fresh cadavers (3 males and 3 females) were enrolled in this study. The mean age was 81.5 years. Standard antero-lateral (AL), antero-medial (AM), postero-lateral (PL) and postero-medial (PM) portals were identified using needles. Skin was dissected from the underlying soft tissue to visualize neurovascular structures clearly as little as possible. The distances were assessed in ankle plantarflexion position and dorsiflexion position, from AL portal to superficial peroneal nerve (SPN), from AM portal to saphenous nerve (SpN), great saphenous vein (SpV), from PL portal to sural nerve (SN) and lesser SpV, and from PM portal to flexor hallux longus, posterior tibial artery PTA and tibial nerve (TN). Results: SPN was the closest structure to any of the anterior portals (3.2 /8.3 mm in ankle plantarflexion position and 5.2 /10.8 mm in ankle dorsiflexion position from AL portal as Fig.1 was showing), followed by SpN in anterior ankle arthroscopy. Distances from SPN to AL portal, and from SpN and great SpV to AM portal increased with ankle dorsiflexion and decreased with plantarflexion. SN was the closest structure to any of the posterior portals (10.4 mm in ankle plantarflexion position and 8.5 mm in ankle dorsiflexion position from PL portal), followed by lesser SpV in posterior ankle arthroscopy. Distances from SN, SpN and lesser SpV to PL portal, and from FHL, PTA and TN to PM portal increased with ankle plantarflexion and decreased with dorsiflexion. Conclusion: Results of this study showed the distances from each anterior or posterior arthroscopic portal to neurovascular structures, and elucidated the change of the distances between each portal and neurovascular structures in ankle plantarflexion and dorsiflexion positons in ankle plantarflexion and dorsiflexion positions. The ankle dorsiflexion position for the standard AL and AM portals placement and the ankle plantarflexion position for PL and PM portals placement might be recommended. Results of this study might be useful to prevent injury to the neurovascular structures during anterior or posterior ankle arthroscopy.

2-3 Year Retrospective Audit of Arthroscopic ‘Internal Brace’ For Chronic ATFL Injury

Category: Arthroscopy Introduction/Purpose: The aim of this audit is to present the surgical technique and medium term outcomes (2-3 years) of arthroscopic reconstruction of the anterior talo-fibular ligament (ATFL) using the Arthrex InternalBraceTM system. Acute lateral ligament injuries of the ankle respond well to early functional rehabilitation with physiotherapy and can have excellent results. For patients who develop chronic lateral ligament, the morbidity can be significant. Multiple surgical techniques for repair or reconstruction of the anterior talo-fibular ligament (ATFL) have been described. Protracted immobilization is often required in the post-op protocol. Short term outcomes (six months), for arthroscopic reconstruction of the anterior talo-fibular ligament (ATFL) using the Arthrex InternalBraceTM system, have previously been presented. The majority of patients reported good or excellent recovery. Methods: A similar cohort of patients to the short term (six months group) were identified. Adults aged between 18 and 65, average age 42. Exhausted conservative treatment. Clinical assessment and MRI scan confirmed torn/stretched/abnormal ATFL and no other significant pathology. Surgery was performed by a single surgeon Pre-operative questionnaire was completed on the day of surgery. (AOFAS, MOXFQ, EDQ-5, Visual Analogue Score) Surgery was performed as Day case with General anaesthetic and popliteal block. Antibiotics were given at induction. Anterior ankle arthroscopy performed through 2 standard anterior portals. +ve drive through confirmed. Arthroscopic stabilisation with Arthrex InternalBraceTM System:- 3.5 mm BioComposite SwiveLock with FiberTape placed into fibula with the distal end of FiberTape passed through 4.75 mm BioComposite SwiveLock / FibreTape (InternalBraceTM) placed into the talar neck. Post-op mobilisation in a moonboot for 7-10 days. Commence physiotherapy at 10 days. Biomechanical podiatric assessment at 6 weeks. Called for FU assessment at 2 years. Results: In the short term FU group, the majority of patient (13 of 17) reported that they were satisfied or very satisfied with the results of there surgery, with 10 of 16 stating that the surgery gave good, very good or excellent pain relief. The majority of patients (12 of 16) would definitely have the surgery again. Review at two years of clinical notes for patients who previously had surgery for ATFL injury with InternalBraceTM. Patients with other pathologies were excluded. This gave a similar cohort to the six month review patients. All patients were contacted for FU by an ESP Podiatrist and invited to come for clinical review. Only 3 patients reported on-going issues with pain, 1 of which requires revision surgery. Conclusion: Arthroscopic ATFL repair using an InteralBraceTM allows early post-operative rehabilitation with accelerated fully weight bearing rehabilitation. This audit would suggest that the short-term positive results are maintained into the medium term at 2-3 years. The long term outcome is currently not known due to this being a relatively new procedure. This method of ATFL repair could have great potential for elite athletes but also for ‘every day’ patients who still desire to have a rapid return to normal function.

Single Portal Technique for Subscapularis Tendon Repair

The fast and steady development of arthroscopy techniques in the last couple of decades led to a drastic increase of arthroscopic rotator cuff repairs over the open procedure. Supraspinatus tears are the most common of all, but the subscapularis tendon tear is a more common injury than expected. Most of the time it presents as a partial tear or is associated with a subsequent rotator cuff tendon injury, especially the supraspinatus. Nowadays, the standard procedure to repair the subscapularis tendon is performed arthroscopically, even though a real superior result over the open repair it is yet to be reported. Ideally less operative time, less scarring, and postoperative pain would be the expected benefits, but no study has compared the long-term outcome of these 2 procedures yet. To maximize possible improvements, we would like to present an arthroscopic technique: a subscapularis tendon repair performed with the aid of an angled suture passer and using a single anterior working portal.

Arthroscopic Repair of an Isolated Subscapularis Tendon Rupture in an Adolescent Patient

Arthroscopic repair of an isolated subscapularis tendon rupture has been previously described in the adult population; however, the technique has yet to be described in a pediatric patient. In this Technical Note, we describe an arthroscopic repair of an isolated subscapularis tendon rupture with concomitant mini-open suprapectoral biceps tenodesis in an adolescent patient. Standard anterior and posterior portals are established with an accessory portal in the anterosuperior angle of the acromion. A 0-PDS suture is used to pass strands of suture tape through the inferolateral and superolateral aspects of the subscapularis tendon. Suture tape is passed through a suture anchor and the accessory portal and is fixated at the junction of the inferior one-third and superior two-thirds of the subscapularis tendon footprint and at the junction of the superior one-third and inferior two-thirds of the subscapularis tendon footprint. Following subscapularis tendon fixation, biceps tenodesis is performed through either a mini-open subpectoral or arthroscopic suprapectoral approach. This described technique allows for full visualization of the subscapularis tendon and lesser tuberosity. Additionally, this technique allows for accurate placement of suture anchors to maximize footprint coverage and appropriate graft tensioning.

Anterior Shoulder Stabilization Using a Single Portal Technique With Suture Lasso

Open Bankart repair was the standard technique used in the past, but the request for less invasiveness, always pursued by every surgeon, pushed the development of the arthroscopic procedure. Nowadays the stabilization of the anteroinferior labrum is usually performed with an arthroscopic technique that uses the classic posterior portal and 2 anterior working portals. Because arthroscopy is progressing steadily under every aspect, there is now the chance to use only one working portal with the aid of a suture passer. One less portal not only means less invasiveness but also less postoperative pain and possible shorter operative time. This Technical Note is focalized in the description of a Bankart repair technique with a single working portal and the aid of a suture lasso.

Arthroscopic Suprapectoral Biceps Tenodesis With Tenodesis Screw

There are many methods for long head of the biceps tendon (LHBT) tenodesis, but a consensus on a superior method has yet to be met. In this article, we introduce a method for arthroscopic suprapectoral biceps tenodesis using a tenodesis screw in the bicipital tunnel. The intra-articular portion of the biceps tendon is transected. The subdeltoid space is then viewed via a lateral portal, and the tendon is mobilized from the bicipital tunnel. The tendon is retrieved through the anterior portal, and 5 whipstitch passes and a second distal stitch are placed. Three of the suture tails are passed through the tenodesis screwdriver, and the tendon is maneuvered to the previously reamed bone socket located 1.5 cm superior to the pec tendon, just inferior to the bicipital groove. Once the tenodesis screw is fixated in sufficient bone stock, 5 alternating half hitches reinforce the construct by creating a closed loop through the screw. This described technique allows full visualization of the LHBT dissection and tenodesis throughout the procedure. Additionally, this technique provides a method to incorporate whipstitching with an arthroscopic tenodesis screw to provide additional strength to tendon fixation.

Clinical outcomes following arthroscopic treatment of femoro-acetabular impingement using a minimal traction approach and an initial capsulotomy. Minimum two year follow-up.

Although the arthroscopic management of femoroacetabular impingement (FAI) is increasing, severe complications have been reported due to traction. We developed an arthroscopic technique based on an initial capsulotomy and a minimal traction approach. The main purpose of this study was to analyze the clinical outcomes of FAI treatment using this technique after at least two years of follow-up. Forty-seven consecutive patients underwent surgery for FAI. There were two initial portals: a proximal anterolateral portal and a distal anterior instrumental portal. An anterior working space was created and a T-shaped incision was made in the anterior capsule to relieve joint distraction. Short traction (less than 20 mn) made it possible to approach the central compartment. Acetabuloplasty was performed in the presence of pincer impingement. Traction was then released. A head-neck femoral osteochondroplasty was performed in case of bump impingement. All patients underwent a mean 3.3 ± one years of follow-up based on two self-administered questionnaires: the Harris hip score and the QOL Oxford score. None of the patients were lost to follow-up. There were three complications: two ossifications and one case of injury to the femoral cutaneous nerve with good clinical outcomes at the final follow-up. Five patients (10%) underwent surgical revision after a mean 1.4years of follow-up: three total hip arthroplasties, one peri-acetabular osteotomy, and one repeat arthroscopic hip debridement. The Harris score increased significantly from 60 ± 10 to 86 ± 15 (p < 0.0001) and the Oxford score improved from 34 ± 15 to 50 ± 11. Only 25% of patients had a "forgotten hip" at the final follow-up. Our clinical results were comparable to previously reported outcomes with other surgical techniques for the management of FAI. However, it should also be noted that despite these good clinical outcomes, the percentage of patients with a "forgotten hip" is low, and patients should be informed of this.

Anatomic Study of Anterior and Posterior Ankle Portal Sites for Ankle Arthroscopy in Plantarflexion and Dorsiflexion: A Cadaveric Study in the Japanese Population

Arthroscopy is an important and minimally invasive diagnostic and therapeutic tool. However, the risk of injury to the neurovascular structures around the portals exists during arthroscopy of the ankle. In the present study, we measured the distance between each portal and the adjacent neurovascular structures with the foot in plantarflexion and dorsiflexion in the Japanese population. Standard anterolateral (AL), anteromedial, posterolateral (PL), and posteromedial portal positions were identified in 6 fresh adult cadaveric feet. The skin was dissected from the underlying tissue to visualize the adjacent neurovascular structures as noninvasively as possible. The superficial peroneal nerve was the structure closest to an anterior (i.e., AL) portal (3.2 ± 4.2 and 8.3 ± 3.9 mm in plantarflexion and 5.2 ± 4.3 and 10.8 ± 4.1 mm in dorsiflexion), followed by the saphenous nerve and great saphenous vein (SpV). The distance from the superficial peroneal nerve to the AL portal and from the saphenous nerve and great SpV to the anteromedial portal increased significantly with dorsiflexion and decreased significantly with plantarflexion. The sural nerve was the structure closest to the posterior (i.e., PL) portal (10.4 ± 4.8 mm in plantarflexion and 8.5 ± 3.9 mm in dorsiflexion), followed by the lesser SpV. The distance from the sural nerve, saphenous nerve, and lesser SpV to the PL portal and from flexor hallucis longus, posterior tibial artery, and tibial nerve to the posteromedial portal increased significantly in plantarflexion and decreased significantly in dorsiflexion. These findings could help to prevent damage to the neurovascular structures during ankle arthroscopy.

Arthroscopic Latarjet Procedure Combined With Bankart Repair: A Technique Using 2 Cortical Buttons and Specific Glenoid and Coracoid Guides

The arthroscopic Latarjet procedure is challenging because it can be difficult to place 2 screws parallel to the glenoid surface and a medial portal (dangerous for the brachial plexus) is mandatory. In addition, precise positioning of the coracoid bone block flush with the joint line and in a subequatorial position as recommended is troublesome without the use of a guiding system because of the arthroscopic lens distortion. To improve the reproducibility of the arthroscopic Latarjet procedure and to minimize the risk of nerve complications, we developed a guiding system to optimize the positioning of the coracoid bone block and 2 cortical buttons to facilitate its fixation. Four portals are used: a posterior standard portal and 3 anterior portals, all lateral to the conjoint tendon. The anterior rim of the glenoid and the coracoid process are prepared. Two holes are drilled in the glenoid and in the coracoid process with 2 specific guides. The subscapularis is then split, and 2 cortical buttons are passed from posterior to anterior through the tunnels with a shuttle relay. The coracoid process undergoes osteotomy and is guided through the split in the subscapularis to the anteroinferior rim of the glenoid by pulling on the cortical buttons.

What Is the Risk Posed to the Lateral Femoral Cutaneous Nerve During the Use of the Anterior Portal of Supine Hip Arthroscopy and the Minimally Invasive Anterior Approach for Total Hip Arthroplasty?

To determine: (1) What is the proximity of the lateral femoral cutaneous nerve (LFCN) to the anterior portal (AP) used in supine hip arthroscopy? (2) What is the proximity of the LCFN to the incision in the minimally invasive anterior approach (MIAA) for total hip arthroplasty? (3) What effect does lateralizing the AP have on the likelihood of nerve injury? (4) What branching patterns are observable in the LFCN? Forty-five hemipelves were dissected. The LFCN was identified and its path dissected. The positions of the nerve in relation to the AP and the MIAA incision were measured. The AP intersected with 38% of nerves. In the remainder, the LFCN was located 5.7 ± 4.5mm from the portal's edge. In addition, 44% of nerves crossed the incision of the MIAA. Of those that did not, the average minimum distance from the incision was 14.4 ± 7.0mm. We found a significant reduction in risk if the AP is moved medially by 5mm or laterally by 15mm(P= .0054 and P= .0002). The LFCN showed considerable variation with 4 branching variants. These results show that the LFCN is at high risk during supine hip arthroscopy and the MIAA, emphasizing the need for meticulous dissection. We suggest that relocation of the AP 5mm medially or 15mm laterally will reduce the risk to the LFCN. These findings should aid surgeons in minimizing the risk to the LCFN during hip arthroscopy and the minimally invasive anterior approach to the hip.

A Technique for the Reduction of Complications Associated With Anterior Portal Placement During Ankle Arthroscopy Using a Peripheral Vein Illumination Device

Ankle arthroscopy is a minimally invasive technique for ankle joint treatment. However, injury to the intermediate dorsal cutaneous nerve (IDCN) and the medial dorsal cutaneous nerve (MDCN) is a common complication during anterior portal placement. To prevent injuries, methods such as palpating the nerves topographically and marking the nerves by transilluminating the skin with an arthroscope have been proposed. Easier and more definitive methods of identifying the IDCN and MDCN should result in a reduction of complications. Recently, a vein imaging system was developed that projects images of subcutaneous vasculature directly onto the skin with the use of near-infrared (NIR) light. Because anatomic studies have shown that superficial veins accompany the IDCN and MDCN, protecting the subcutaneous veins could lower the risk of nerve injury. We introduce our technique for the creation of an ankle arthroscopic portal using an NIR imaging system, which displays the vein image on the skin, to prevent injury to the superficial veins and, consequently, reduce IDCN and MDCN injuries. This is the first technical report on the prevention of vein and nerve injuries using an NIR imaging system. Our technique for avoiding vein injury using a peripheral vein illumination device during anterior portal placement in ankle arthroscopy could lower the risk of complications.

Arthroscopic Repair of Type II SLAP Tears Using Suture Anchor Technique

Arthroscopic SLAP tear repair has become an increasingly used treatment for patients presenting with symptomatic SLAP tears after failed nonoperative management. Debridement, SLAP repair, and open or arthroscopic biceps tenodesis or tenotomy have been used for the treatment of SLAP tears. Various techniques for repair have been described, and furthermore, there is a high incidence of concomitant pathology of the shoulder. Repair remains an excellent option in isolated SLAP tears amenable to repair, with excellent outcomes in well-indicated patients. We present a method for repairing a SLAP tear using standard suture anchor fixation, anterior and posterior portals, and an accessory portal of Wilmington. Adequate labral repair can be achieved with this technique in patients with no concomitant biceps pathology. This report highlights this technique for SLAP repair in patients with isolated symptomatic SLAP tears that have failed conservative management.