Freer Elevator Research Articles

Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position.

Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position.

Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction.

Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction.

Mini-Open Reduction and Extension Block Pinning for Irreducible Mallet Fractures: A Minimally Invasive Technique for Anatomical Reduction.

Background: Dorsal rotation or persistent displacement of the fracture fragment is frequently encountered in extension block pinning for mallet fractures. We reviewed nine irreducible mallet fracture patients treated with mini-open reduction and extension block pinning. Methods: A small V-shaped incision was made on the fracture gap when there was persistent displacement of fracture fragment despite closed maneuvers and percutaneous procedures while performing extension block pinning. Soft tissue or granulation tissue hampering reduction was removed through the incision. Anatomical reduction was guided with a freer elevator. The incision was closed by distal interphalangeal joint transfixation in extension without any suture. Pin tips were buried under the skin. The incision and pin entry sites were covered with skin adhesive, and the patients were allowed to wash their hands 1-2 days after the surgery. No splint was applied postoperatively. Mean follow-up period was 13 months. Results: Anatomical reduction was achieved in 7 out of 9 patients. In the rest 2 patients, postoperative step-off of the articular surface at the fracture site was less than 0.5 mm. Solid union was achieved in all cases. The mean extension lag at final follow-up was 0°. No patient developed postoperative external bleeding or other complications in the incision site or the pin site. Conclusions: Mini-open reduction and extension block pinning appears to be a good option for irreducible mallet fractures, which improves reduction quality and patients' convenience.

Mini-inciziona tehnika u zbrinjavanju sindroma karpalnog tunela

Introduction/Aim: Carpal tunnel syndrome (CST) is the most common cause of upper extremity compressive neuropathy. Until the introduction of endoscopy, the dominant surgical method was classic open surgery. The objective of the paper is to examine the efficacy, safety and economic value of the mini-open carpal tunnel release technique using a longitudinal 2 cm long incision in the carpal region. Methods: The diagnosis was made based on clinical examination, followed by an ENMG. The study includes only patients with idiopathic CTS, while those who have developed CTS as a result of secondary causes have been excluded from the study. All patients were operated on under local anaesthesia, WALANT, without the use of a tourniquet. A longitudinal incision 2 cm long is made in the line of the radial edge of the ring finger, 2-3 cm distal to the wrist flexion crease, immediately proximal of the Caplan cardinal line and ulnar to the thenar crease. Upon cutting through the skin and subcutaneous soft tissue, the superficial fascia is identified and then cut with the same scalpel in the same direction and the same length. The transversal ligament is then identified and carefully incised with a scalpel enough to allow further decompression with the use of scissors. Using standard surgical scissors for the hand, the ligament is cut proximally to the forearm fascia and then distally until a faint crackling sound is heard, which means that the ligament had been completely cut. This must be checked by inserting the Freer elevator proximally and distally to the edge of the ligament. Now it is possible to identify the nerve and accompanying hand flexor tendons. Sutures are placed only on the skin and a roll of gauze is fixed to the wound with an elastic bandage to provide compression. The first check-up is on the very next day and the patient is advised to start doing hand exercises. The sutures are removed 10-14 days after surgery. Results: From January 2018 to December 2019, 35 carpal tunnel decompressions were performed on 30 patients using the mini-open decompression technique and standard surgical scissors. The surgery was performed on 22 patients in the operating room and 8 patients in the infirmary. There were no intraoperative complications. All patients reported no night pain from the very first day after surgery. Pillar pain, incision pain and hand weakness were progressively becoming less pronounced during the next 12 weeks. At the final check-up, only one patient still had pronounced symptoms that required a reintervention. The rest of the patients had completely recovered. Even though the endoscopic procedure for carpal tunnel decompression is constantly evolving, the classic open method and newly developed mini-open carpal tunnel release technique remain the treatments of choice. Conclusion: Our research shows that the mini-open carpal tunnel release technique is a quick, efficient, safe and cheap surgical technique for treating carpal tunnel compressive neuropathy.

Talocalcaneal coalition resection and bone block subtalar joint arthrodesis

In this technical tip, we present the case of an obese 17-year-old female diagnosed with a severe, rigid, and symptomatic flatfoot on a background of exuberant talocalcaneal and residual calcaneonavicular coalition. Through a technical modification of the fusion resection, both coalitions were quickly and safely removed with two single cuts of an oscillating saw, resecting a medial wedge through a medial approach, without the need for “peel-off” tarsal coalition resection. To protect and guide the resection osteotomy, one Freer elevator ws inserted under direct visualization on the patent posterolateral aspect of the subtalar joint posterior facet and a second elevator was positioned underneath the talar neck. Under fluoroscopic guidance, an osteotomy was performed connecting these two points. The patient also received a bone-block subtalar joint arthrodesis and a Cotton osteotomy. Good short-term alignment correction and functional outcome were achieved. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Open Reduction and Suture Fixation of Acute Sternoclavicular Fracture-Dislocations in Children.

Acute sternoclavicular fracture-dislocation is associated with high-energy trauma and is being increasingly recognized in children1. These injuries are associated with compression of mediastinal structures and can be life-threatening1. The management of acute sternoclavicular fracture-dislocation includes closed reduction or open surgical stabilization; however, limited success is reported with closed reduction2,3. To our knowledge, there are no detailed descriptions of open reduction and suture fixation of acute sternoclavicular fracture-dislocation in children. Following diagnosis of acute sternoclavicular fracture-dislocation, the timing of surgical treatment is determined according to several patient and surgical factors. Among patients with hemodynamic instability, respiratory compromise, or evidence of asymmetric perfusion, surgical treatment is needed on an emergency basis. In the absence of these factors, surgical treatment can be performed on an urgent basis. It is important to communicate with vascular or thoracic surgeons prior to proceeding to the operating room because of the rare case in which advanced surgical access or vascular repair is required. In the operating room, general anesthesia and large-bore intravenous access are required. Patients are positioned supine on a radiolucent table, and a small bump is placed between the scapulae to elevate the medial aspect of the clavicle. The contralateral sternoclavicular joint and medial aspect of the clavicle should be prepared into the sterile field, as well as both sides of the groin in case vascular access is needed. A 6 to 8-cm incision is centered on the medial aspect of the clavicle, extending to the manubrium. Standard dissection to the clavicle is performed, and care is taken to maintain the integrity of the sternoclavicular ligament complex. Circumferential dissection of the medial clavicular metaphysis is usually required in order to mobilize the dislocated fragment. Reduction of the physeal fracture usually requires axial traction and extension of the ipsilateral shoulder with the aid of a reduction clamp on the medial clavicular metaphysis. In some cases, a Freer elevator can be placed between the metaphysis and epiphysis to shoehorn the clavicle from posterior to anterior. Once reduced, the fracture-dislocation is usually stable; however, the reduction is augmented with suture fixation. The sternoclavicular joint capsule should be repaired if disrupted, and the incision should be closed in layers. Postoperatively, the arm is placed in a sling, and range of motion is commenced at 4 weeks. Alternative management of acute sternoclavicular fracture-dislocation includes closed reduction, plate fixation4, and ligament reconstruction5. In our experience, closed reduction is often unsuccessful, which is consistent with the experiences reported by other authors2,3. In addition, suture fixation is sufficient and plate fixation is not required because this injury is relatively stable following reduction. Lastly, ligament reconstruction with use of autograft or allograft may be indicated but is more relevant in chronic cases with injury or attenuation of the sternoclavicular ligament complex. Open reduction allows for direct visualization of the fracture reduction, and suture fixation allows for increased stability without the need for hardware or secondary surgical procedures. We expect patients to achieve full range of motion and strength without any joint instability as reported by Waters et al.3. There is an inherent risk of vascular injury with open reduction and suture fixation. This risk is mitigated with perioperative planning and consultation with vascular or thoracic surgeons. General surgeons should always be available when these procedures are performed in case of vascular issues or emergencies.It is sometimes difficult to reduce the dislocation, but additional maneuvers allow for controlled reduction of the displaced clavicle, such as using a Freer elevator and serrated clamp.Assessing fracture reduction can be difficult intraoperatively. Including the contralateral sternoclavicular joint in the sterile surgical field can be helpful in assessing fracture reduction and osseous contour.

Clinical Tip: Modified Uniportal Endoscopic Gastrocnemius Recession for Treatment of Gastrocnemius Equinus Contracture

Gastrocnemius recession was first described by Vulpius and Stoffel in 1913 for gastrocnemius equinus contracture. Equinus contracture alters the biomechanics of the foot–ankle complex and affects other musculotendinous and ligamentous constrains in the ankle, contributing to many foot and ankle pathologies. The commonly used Strayer's technique has been modified, with the use of endoscopic approaches, to try to reduce the poor cosmesis and reduce the risk of iatrogenic injury to the sural nerve. This article aims to describe a simple uniportal technique that uses readily available arthroscopic instruments to perform endoscopic gastrocnemius recessions (EGRs). The leg is prepped and draped with a rolled towel under the lateral malleolus. A 10 mm incision is made over this point. The dissection is carried bluntly to the gastrocnemius aponeurosis. The fascia is opened and a McDonald or Freer elevator is introduced between the aponeurosis and the fascia of the soleus. A 4.0 mm 30° arthroscope is inserted beneath the elevator. A half-pipe (Karl Storz, Tuttlingen) is introduced over the scope which protects the sural nerve. The length of the aponeurosis is identified from proximal to distal. At this point, the sural nerve may be visualized at the end of the pipe. A triangle knife (Smith and Nephew, Andover, MA, USA) is then introduced with the sharp edge facing the half-pipe. The knife is then flipped 180° and tension is applied to the aponeurosis by dorsiflexing the foot. The aponeurosis is then released under direct arthroscopic vision. Chua KH, Yeap EJ, Chong KW, et al. Clinical Tip: Modified Uniportal Endoscopic Gastrocnemius Recession for Treatment of Gastrocnemius Equinus Contracture. J Foot Ankle Surg (Asia Pacific) 2020;7(1):28–31.

New “Freer test” for assessment of syndesmotic diastasis -Cadaveric study

Category: Sports Introduction/Purpose: Syndesmotic stability is usually assessed arthroscopically by an arthroscopic probe insertion between the anterolateral tibio-fibular recess. This probe test can predict the syndesmotic instability, however, is difficult to determine syndesmotic fixation. The syndesmosis has dynamic motion and fairly firm structure, 2 mm thin probe cannot make syndesmotic dynamic diastasis. We proposed a new “Freer test” for diagnosis of syndesmosis injury which performed to insert a 2 mm diameter freer elevator between tibio-fibular lateral gutter while keeping the ankle at the plantigrade. The purpose of the present study was to evaluate the diagnostic value of freer test for anterior inferior tibiofibular ligament (AITFL) complete tear, interosseous ligament (IOL) tear and Weber type B fibular fracture. Methods: Ten fresh ankle cadaveric specimens were used. Operative procedures progressed as below; firstly, exposed antero-lateral ankle joint with direct lateral longitudinal incision, incised AITFL, incised IOL, performed Weber type B osteotomy at fibular, fixed the osteomized fibular with 8-hole locking plate and fixed the AITFL with suture anchors. In each procedure, freer tests with ankle dorsiflexion (DF, plantigrade) and plantarflexion (PF) were performed with freer elevator linked 3 kgf compression gauge. A negative test was defined as the freer did not insert with a more than 3 kgf. A positive test was defined lesser than 3 kgf, and measured the force at the insertion. Results: All freer test was negative with DF before procedures. Six ankles with PF were positive with average 1.5 kgf. All freer test positive has shown after AITFL cutting in DF, PF(mean 1.76 kgf, 1.19 kgf). After IOL cutting, all freer tests were positive in DF, PF(mean 1.46, 0.79 kgf). After fibular osteotomy, all freer tests were positive in DF, PF (mean 0.83,0.18 kgf). After fibular fixation with plate, all freer tests were positive in DF, PF (mean 1.26, 0.97 kgf). After syndesmotic fixation with anchors, 8 freer tests were positive in DF. 2 negative in PF, 4 negative in PF and 6 positive in PF. 2 positive in DF had partial breakage on anchor footprint due to weak bone. Conclusion: The “freer test” is useful diagnostic tool which test positive means AITFL rupture.

Principles of Structural Rhinoplasty in South East Asian Noses

Principles of Structural Rhinoplasty in South East Asian Noses

Removal of Hydroxyapatite Cement From Cadaveric Temporal Bones After Transtemporal Surgery

To determine the best method of removing hydroxyapatite cement from the temporal bone in the postoperative period. The advent of hydroxyapatite cement in neurotologic surgery of the temporal bone has dramatically decreased the rate of postoperative cerebrospinal fluid leaks. However, there is no literature currently available on how to manage these patients in the setting of postoperative hematomas of the cerebellopontine angle. Nine cadaveric temporal bones were obtained that had previously undergone translabyrinthine approach drilling in an academic temporal bone lab. Fascia and adipose tissue were placed medial to the facial nerve and the temporal bone was then filled with hydroxyapatite cement to the level of the cortex. Removal of hydroxyapatite cement was undertaken using a Freer elevator, mastoid bone curette, and finally, a drill in sequential fashion. This occurred at 9 predetermined time intervals from 1 to 30 hours and was timed in each case. Removal using the freer and curette failed in each case, and the drill was ultimately used to remove the hydroxyapatite cement in all cases. The time to reach the packed fascia and adipose tissue varied from 3 to 6 minutes, average time is 4.27 ± 0.84 minutes. Although hydroxyapatite cement has dramatically decreased the rate of postoperative cerebrospinal fluid leak in translabyrinthine surgery, its use has also brought a new set of considerations. This study suggests that hydroxyapatite cement removal in the setting of postoperative hematoma after translabyrinthine surgery would require drilling rather than bedside incisional opening alone. Like standard craniotomy approaches, postoperative hemorrhage management requires intraoperative drainage.

Leiomyoma of the Forehead

Leiomyoma of the Forehead

Dr. Otto “Tiger” Freer: inventor and innovator

Every neurosurgeon develops his or her own standard approach to common intracranial pathologies in terms of the order in which different stages are performed and which instruments are used to perform individual tasks. The majority of the basic steps in performing a craniotomy are learned through repetition and practice during residency training. Significant amounts of energy are devoted to mastering technical skills and developing an operative rhythm. What often receives little attention is the historical origin of the instruments that make the work possible. The Freer elevator represents a particularly interesting example. To people unfamiliar with the accomplishments of turn-of-the-century laryngologist Otto "Tiger" Freer, it can be assumed that the name of the instrument in one's hand is simply named for what it can do, that is, to "free" the nasal mucosa from the bony and cartilaginous septum during the transsphenoidal approach. The technique this master surgeon spent his life and career perfecting is now repeated almost daily by skull base neurosurgeons approaching pathologies from the inferior frontal lobe to the foramen magnum. In reviewing his life and work, the authors of this paper discovered an interesting creative process that led to the design of the eponymous instrument. Additionally, they discovered important advances toward the development of the transnasal approach and in our understanding of the anterior skull base. They present a historical perspective on the life and accomplishments of Dr. Freer and the ubiquitous surgical instrument that he invented and popularized.

20-Year Experience With the Conrad Modification of the Freer Elevator as a Pull-in Suture Introducer

20-Year Experience With the Conrad Modification of the Freer Elevator as a Pull-in Suture Introducer

20-Year Experience With the Conrad Modification of the Freer Elevator as a Pull-in Suture Introducer

A modified Freer elevator was created to aid the safe placement of alloplasts in a subcutaneous dissection pocket. We believe that this innovation represents a better way to insert nonrigid facial alloplasts and grafts and that it contributes to the reduced technique-related complications of migration, kinking, and asymmetry; it also minimizes tissue trauma and unnecessary surgical explorations.

20-Year Experience With the Conrad Modification of the Freer Elevator as a Pull-in Suture Introducer

20-Year Experience With the Conrad Modification of the Freer Elevator as a Pull-in Suture Introducer

Endoscopic transnasal approach for retrieval of foreign bodies from the pterygomaxillary fossa

Foreign bodies within the aerodigestive tract are common clinical entities, especially in children. Although foreign bodies can be located anywhere along the aerodigestive tract, there are no case reports describing a foreign body within the pterygomaxillary fossa. This area contains numerous vascular and neural structures and can be quite difficult to access. We describe the case of a patient who sustained a gunshot wound to the cheek, wherein the bullet entered the pterygomaxillary fossa. Foreign bodies isolated to the pterygomaxillary fossa can be a challenge to retrieve. Open approaches have been most commonly used, but these approaches often provide limited exposure and can be fraught with complications. We propose the use of a transnasal endoscopic approach for the retrieval of foreign bodies from the pterygomaxillary fossa. 2. Case report The patient is an 18-year-old African American male, who presented to the emergency department at SUNY Upstate Medical University after sustaining a gunshot to the left cheek. The patient complained of left-sided nasal congestion and cheek pain. He denied visual changes, headaches, epistaxis, facial hypoesthesia, difficulty in chewing, dysphagia, malocclusion, or neurological symptoms. Physical examination demonstrated that the patient was awake, alert, and in no acute distress. A 1.5-cm-bullet entry wound with surrounding soft tissue swelling was noted in the left cheek, approximately 4 cm anterior to the tragus. Anterior rhinoscopic examination was normal. The oral cavity examination demonstrated a palpable submucosal firm tooth at the junction of the left hard and soft palate. The tooth socket of the left second upper molar was palpated and noted to be missing a tooth. Cranial nerve exam was normal bilaterally. Rigid nasal endoscopy using a zero-degree, 4-mm endoscope was then carried out on the left side. This demonstrated a shiny bullet lodged within the left lateral nasopharyngeal wall. A computed tomography (CT) scan of the maxillofacial region demonstrated a metallic foreign body wedged in the left pterygomaxillary fossa and lateral aspect of the nasopharynx (Figs. 1 and 2). A molar tooth was noted to be lodged at the junction of the left hard and soft palate. The patient was taken to the operating room for endoscopic removal of the bullet. After the patient was placed under general anesthesia and the endotracheal tube secured in place, a zero-degree, 4-mm endoscope was introduced into the left nasopharynx. The bullet was noted to be wedged in the pterygomaxillary fossa and was visible through a disruption in the lateral nasopharyngeal wall mucosa. A freer elevator was used to dissect the embedded bullet from the lateral nasopharyngeal wall and pterygomaxillary fossa. The bullet had some very sharp edges and was unable to be removed anteriorly because of obstruction from the posterior aspect of the inferior turbinate. A partial inferior turbinectomy was then performed. Despite this, the bullet was still unable to be removed anteriorly without causing significant mucosal lacerations within the nasal cavity. The bullet was then firmly grasped in the nasopharynx using Ferris-Smith forceps. The 30-degree endoscope was then inserted into the posterior oropharynx, and the bullet was visualized in the nasopharynx. The bullet was then delivered into the oropharynx and grasped with another set of forceps. It was then brought out of the oral cavity under endoscopic guidance. It measured approximately 1.5 cm in its greatest dimension (Fig. 3).

Arthroscopic Management of Volar Lunate Facet Fractures of the Distal Radius

The clinical outcome of an intraarticular distal radius fracture is generally thought to be associated with the following factors: amount of radial deformity, joint congruity, and associated soft-tissue injuries. The proposed technique to manage this fracture pattern that involves a displaced volar lunate facet fragment uses wrist arthroscopy and pinning. Distraction of the fracture before arthroscopy is accomplished either by external fixation or by the arthroscopy tower. A freer elevator is introduced dorsally to disimpact the fragments, and next, a nerve hook is used to reduce the volar lunate facet, which is subsequently pinned to the radial styloid. The remaining fragments are reduced with interfragmentary pin fixation, and this anatomical articular construct is fixed to the radial metaphysis. The advantages of this technique are: (a) accurate assessment of articular congruency by direct visualization, (b) identification and repair of associated lesions, and (c) minimal soft tissue disruption. Potential disadvantages of external fixation supplemented by interfragmentary pins may be that it does not provide for rigid stable fixation, and therefore, does not allow for early motion compared to open reduction and internal fixation. Furthermore, it is technically challenging, and is therefore suggested as an alternative for the aforementioned fracture pattern.

CARP, a Cardiac Ankyrin Repeat Protein, Is Up-Regulated during Wound Healing and Induces Angiogenesis in Experimental Granulation Tissue

Cardiac ankyrin repeat protein (CARP) was identified by subtractive hybridization as one of a group of genes that are rapidly modulated by acute wounding of mouse skin. Quantitative RT-PCR showed that CARP was strongly induced during the first day after wounding (157.1-fold), and the high level persisted for up to 14 days. Immunohistochemistry and in situ hybridization revealed that CARP was expressed in skeletal muscle, vessel wall, hair follicle, inflammatory cells, and epidermis in the wound area. To examine the effects of CARP on wound healing, we developed an adenoviral CARP vector to treat subcutaneously implanted sponges in either rats or Flk-1(LacZ) knock-in mice. Four days after infection, CARP-infected sponges in rats showed a remarkable increase in the vascular component in granulation tissue as compared to Ad-LacZ controls. This result was confirmed by CD34 immunostaining. By 7 days post-infection of sponge implants in Flk-1(LacZ) knock-in mice, granulation tissue showed many more LacZ-positive cells in Ad-CARP-infected sponges than in virus controls. Ad-CARP treatment also induced neovascularization and increased blood perfusion in rabbit excisional wounds in and ischemic rat wounds. These findings indicate that CARP could play a unique role in therapeutic angiogenesis during wound healing.

Surgical Pearl: Hemostat-assisted nail avulsion revisited

J Am Acad Dermatol 2001;45:943-4.

A simple, atraumatic technique for the dissection of nasal mucosa during Le Fort I osteotomy

During subperiosteal dissection for the Le Fort I osteotomy, the piriform apertures are exposed in standard fashion. Initial submucosal dissection is performed with a curved Freer elevator. Care is taken to direct the dissection inferiorly and laterally to avoid perforation into the nasal mucosa. After approximately 5 mm of reflection is accomplished at inferior, medial, and lateral extent of the piriform apertures, 0.5” X 3” cottonoid strip (Codman Surgical Pattie, Johnson Sr Johnson, Inc, Randolph, MA) impregnated with bovine thrombin (5,000 p) is gently inserted and directed toward the bony nasal floor (Fig 1). The cottonoid strip is then advanced gently with the end of the Freer elevator for about 32 mm or until resistance is felt (Fig 2). A similar dissection is performed medially and laterally, and three strips are usually sufficient to accomplish the dissection. Minimal elevation of the nasal mucosa should be done medially, elevating only enough to avoid laceration during nasal cartilage separation from the maxilla. The strips are left in place, protecting the mucosa from