Percutaneous Incision Research Articles

Arthroscopic reconstruction of the anterior talofibular ligament and calcaneofibular ligament using allograft for chronic lateral ankle instability allows patients to successfully return to their pre-injury sports activities with Excellent clinical outcome at minimum two year follow-up.

To report and evaluate the time of return to work and sports of patients who underwent an anatomic arthroscopic reconstruction using allograft for chronic lateral ankle instability (CLAI) through 2 portals, and to analyze the functional results as well as the postoperative complications of the reconstruction surgery. We retrospectively reviewed patients who underwent allograft arthroscopic reconstruction of anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in the period from January 2018 to January 2022. The inclusion criteria encompassed patients with CLAI who (1) are more than 18 years old, (2) underwent arthroscopic ATFL & CF ligament reconstruction using allograft and (3) have been followed up for at least 2 years. The operation was performed with two arthroscopic portals, a percutaneous incision for CFL reconstruction and 2 knotless anchors. Time of return to work and sports was recorded. In addition, Karlsson Ankle Functional Score (KAFS), Tegner Activity Scale (TAS), visual analogue pain scale (VAS), visual analogue scale for patient satisfaction (VASPS) were evaluated preoperatively and postoperatively, and all complications were documented at a minimum follow up of two years. In total, 44 patients (mean age, 35.6±9.7 years) were included, and the average follow-up duration was 29.6±3.7 months (range, 24-42 months). The mean time of return to work was 3.29 ± 0.93 months, while the mean time of return to sports was 6.45 ± 1.55 months. KAFS increased from 53.91 ± 9.31 to 91.14 ± 6.03 (p<0.001), mean TAS increased from 2.22 ±1.05 to 7.34 ±1.51 (p<0.001), VAS decreased from 3.95 ± 1.71 to 0.43± 0.66 (p<0.001) and VASPS increased from 1.11 ±1.43 to 9.59 ± 0.76 (p<0.001). All patients (100%) achieved the minimal clinically important difference in KAFS, VAS, TAS and VASPS. Subgroup analysis indicated no statistically significant differences in functional outcomes regarding the presence/absence of Associated Intra-articular Lesions (AILs) and Body Mass Index (BMI) (greater or less than 25 kg/m2). Minor complications were observed in only 4 patients (9.1%). CLAI patients who underwent arthroscopic allograft reconstruction of ATFL and CFL through two portals and an additional incision successfully returned to their pre-injury occupations within 5 months. They also returned to their pre-injury level of sports without restrictions, adaptations, or protective measures within 9 months. They demonstrated excellent clinical outcomes as all patients (100%) achieved the MCID in KAFS, VAS, TAS and VASPS at minimum of 24 months' follow-up. However, 9.1% of patients had minor neurological complications. A retrospective therapeutic case series.

Use of posteroanterior reference guides for bone block or coracoid process transfer in anterior glenohumeral instability: a cadaveric study of the relationship to the suprascapular nerve

Background: Iatrogenic suprascapular nerve injury secondary to posterior drilling or screw penetration is a recognized complication of bone block or coracoid process transfers for anterior glenohumeral instability. We present the first cadaveric study that assesses the safety of posteroanterior reference guides and quantifies the relationship of the suprascapular nerve to posterior glenoid fixation with suture buttons.Methods: Anterior glenoid bone block reconstruction with suture buttons utilizing a posteroanterior reference guide was performed in 10 fresh frozen cadavers via a posterior portal. Bullets were inserted in predefined superior and inferior guide holes via percutaneous incisions to facilitate posteroanterior drilling. Looped guide wires were used to deliver suture buttons from anterior to posterior positions. The shoulder joint was disarticulated and the infraspinatus sharply elevated until the suprascapular nerve was visualized. Four independent static measures of the shortest distance from the superior drill sleeve to the lateral aspect of the suprascapular nerve were recorded.Results: The suprascapular nerve was not compromised utilizing the posteroanterior guide and suture button fixation technique in any specimen. The mean distance from superior sleeve tunnel to the suprascapular nerve was 5.00 mm (range, 3.25–8.00 mm) in females and 6.80 mm (range, 5.50–8.75 mm) in males. The shortest distance was 3.25 mm and the longest was 8.75 mm.Conclusion: The use of posteroanterior reference guides for suture button fixation was not associated with iatrogenic suprascapular nerve injury in the specimens examined. However, the proximity of the suprascapular nerve underscores the need for caution. Comparative analysis with anteroposterior bone block techniques is required to establish the potential benefits of this procedure.Level of evidence: V.

Reliability of Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot.

Talipesequinovarus is a congenital ankle/foot malformation that commonly affects newborns. In its treatment using the Ponseti method, an Achilles tenotomy is frequently needed to correct residual equinus deformity. Percutaneous (PC) tenotomy is the most commonly used technique and needs to be thoroughly evaluated. The question we needed to answer was: "Does PC Achilles tenotomy result in complete tendon sectioning"? This clinical study included 56 idiopathic clubfeet in 36 patients who presented during the first 6 months of life and were treated with Ponseti manipulation and casting followed by PC Achilles tenotomy. PC tenotomy was done under general anesthesia, and Thompson's calf squeeze test was performed intraoperatively just after tenotomy. In case of a negative test (ie, ankle plantar flexion with calf squeeze), the percutaneous incision was extended to assess the cause of the negative test. Forty-nine feet (87.5%) had a complete tenotomy, as evidenced by a positive Thompson's calf squeeze test. While 7 feet (12.5%) showed a negative test, and therefore the percutaneous incision was extended and all were found to have an incompletely divided Achilles tendon. The tendons were then completely divided, after which Thompson's test became positive in all. Percutaneous Achilles tenotomy is a reliable procedure, but was found to result in incomplete tendon sectioning in 12.5% of cases, affecting the range of ankle dorsiflexion. Thompson's squeeze test is reliable in picking up cases of incomplete tenotomy after the PC technique, and in these cases the incision should be extended for complete sectioning. Level I.

Arthroscopic-Assisted Core Decompression of Humeral Head Osteonecrosis With Bone Marrow Aspirate Concentrate Augmentation

Background: The proximal humerus is the second-most common anatomic site for osteonecrosis, a condition of disrupted blood supply leading to death of bone tissue, with resultant shoulder pain and dysfunction. Core decompression is a viable joint-preserving surgical intervention that aims to improve local blood supply and restore bone health prior to bony collapse. Indications: Humeral head osteonecrosis has numerous underlying causes, most commonly the sequelae of prior trauma, chronic use of systemic corticosteroids, sickle cell disease, and alcohol abuse. Core decompression may be indicated in the early, pre-collapse stages of osteonecrosis, whereas more advanced stages of disease are commonly indicated for joint reconstruction procedures, such as bone grafting or arthroplasty. Technique Description: With the patient in the beach chair position, bone marrow aspirate concentrate (BMAC) is harvested through a percutaneous incision along the anterolateral proximal humerus. While viewing through a standard posterior portal, a transtibial anterior cruciate ligament (ACL) guide is placed through an anterior portal at a site on the humeral head surface, centered at the area of greatest humeral head bone edema as identified on preoperative magnetic resonance imaging. A guide pin is placed through a lateral portal within the ACL guide, to the subchondral bone. A 7.0-mm reamer is applied over the guidewire, followed by administration of demineralized bone matrix soaked in BMAC into the reamed channel within the proximal humerus. Results: In patients with early stages of humeral head osteonecrosis, core decompression confers superior clinical outcomes with reduced rates of subsequent surgical procedures compared with nonoperative treatment. Core decompression has shown to reduce the radiographic progression of osteonecrosis. Further research is necessary to determine the additional clinical benefits of augmentation with orthobiologic agents, such as BMAC. Conclusion: Arthroscopic-assisted core decompression is a valuable, minimally invasive surgical treatment for early-stage proximal humerus osteonecrosis. Adjunctive treatment with BMAC and demineralized bone matrix may enhance clinical outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Intramedullary Nailing Technique for Proximal Humeral Fractures Using a Straight Antegrade Nail with Locking Tuberosity Fixation.

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. 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. 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. 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 humeral fractures, including in elderly patients, when the humeral head fragment remains viable1-5. Based on available Level-III and IV evidence using this technique, patients should expect recovered motion and the ability to perform daily activities independently, with a mean active elevation of 132° to 136°1,4,6, external rotation of 37° to 52°1,4,6, and internal rotation to L31. Pain scores improved significantly from preoperatively to postoperatively, with a mean pain score of 1.4 on the visual analogue scale3,4,6. Patient-reported outcomes were good to excellent, with Single Assessment Numerical Evaluation (SANE) scores of 80% to 81%1,6, mean Constant scores from 71 to 811,3,4,6, and high rates of patient satisfaction (97% satisfied or very satisfied)4. Studies also demonstrated good to excellent fracture healing, with no tuberosity migration and low rates of nonunion (0% to 5%)1,6 and humeral head necrosis (0% to 4%)1,4. Revision rates ranged from 10.5% to 16.7%4,6. The starting position of the guide-pin must be central and at the zenith of the humeral head on the anteroposterior Grashey and the scapular Y views, and the guide-pin must be aligned with the diaphysis prior to advancing it.Failure to bluntly dissect the percutaneous incisions risks injury to the axillary nerve.Verify correct version of the nail prior to drilling any screws, to avoid incorrect version and potential loss of functional rotation. ABD = abductionAP = anteroposteriorCT = computed tomographyER = external rotationFF = forward flexion (forward elevation)IR = internal rotationSANE = Single Assessment Numerical EvaluationSSV = Subjective Shoulder ValueVAS = Visual Analogue Scale.

Guidelines in Practice: Minimally Invasive Surgery.

During minimally invasive surgery (MIS), surgeons create small and percutaneous incisions to access internal structures without open surgical incisions. Some MIS equipment is complex and challenging for perioperative nurses to manage. Patients also can experience life-threatening complications during MIS procedures. The updated AORN "Guideline for minimally invasive surgery" provides recommendations that perioperative nurses can use when caring for patients undergoing MIS procedures. This article provides an overview of the guideline and discusses several recommendations, including creating a safe environment in which to perform MIS procedures; using gas distension media, irrigation and fluid distension media, and computer-assisted navigation and robotics; and performing intraoperative magnetic resonance imaging in a hybrid OR. It also includes a scenario describing care of a patient undergoing a hysteroscopy. Perioperative nurses who care for patients undergoing MIS procedures should review the guideline in its entirety and apply the recommendations as applicable in their practice.

Hybrid Percutaneous Management of Acute Midsubstance Achilles Tendon Ruptures

Background: Operative management techniques of Achilles tendon ruptures can be categorized into open repair, mini-open repair, or percutaneous repair. Indications: Surgical repair of acute ruptures of the Achilles tendon is indicated in athletic populations, with percutaneous repair being an effective technique with more favorable outcomes. Technique: With the patient prone, the Achilles rupture is identified and the Percutaneous Achilles Repair System (PARS) jig is inserted under the proximal paratenon. A series of Keith needles and flat braided SutureTape sutures are passed transversely across the proximal stump of the tendon. The sutures are then shuttled through the distal stump using a SutureLasso through medial and lateral percutaneous incisions on the distal medial and distal lateral borders of Achilles, respectively. Sutures are passed, tensioned, and secured to the posterior tuberosity of the calcaneus with two SwiveLock anchors. Results: Percutaneous repair, compared with open repair, results in lower wound complication rates, improved cosmetic appearance and fewer adhesions. Following surgery, patients follow a 5-stage rehabilitation protocol with return to sport when patients demonstrate dynamic neuromuscular control during multiplane activities without pain or swelling. Outcome studies have compared percutaneous repairs to open repairs, with percutaneous repairs demonstrating a quicker return to work or baseline activities (2.8 months versus 5.6 months) and a shorter return to play for athletes (average 18 weeks). Also, a greater number of PARS patients were able to return to baseline activities within 5 months (98%), compared with open repair patients (82%; P = .0001). In a prospective randomized controlled trial of 33 patients, Lim et al reported no postoperative wound infections in the percutaneous group and a 21% infection rate in the open repair group ( P = .01). Finally, in a recent systematic review of only percutaneous repairs, reported rates of sural nerve injury and rerupture were only 3.3% and 2.1%, respectively. Discussion/Conclusion: Compared to open repair, percutaneous Achilles repair allows for decreased risk of soft-tissue complications with comparable functional outcomes and earlier return to activity. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Superior Capsular Reconstruction

Background: Limited options exist for young patients with massive, irreparable rotator cuff tears. While several treatment options exist, superior capsular reconstruction (SCR) was developed to restore glenohumeral joint stability by preventing superior humeral head migration during glenohumeral motion. Indications: Arthroscopic SCR is indicated in young patients with a massive, irreparable rotator cuff tear. Patients require a functioning deltoid muscle with minimal to no glenohumeral joint arthritis. In addition, patients should have Hamada grade 2 or less and should have an intact or repairable subscapularis tendon. Technique Description: The patient is positioned in the beach chair position. Standard anterior, posterior, and mid-lateral portals are established. An accessory posterior-superior lateral portal is used for visualization. Three 3.0 mm knotless anchors are placed in the glenoid through lateral percutaneous incisions. Two 4.75 mm anchors are placed adjacent to the humeral articular cartilage for medial row fixation. The graft dimensions are measured using the distance between the anchors. The graft is prepared using a gown card as a template with 5 mm added to the medial, posterior, and anterior graft dimensions, and 10 mm added to the lateral dimension. Sutures are passed through the graft in an inverted horizontal mattress for the glenoid anchors to diminish friction and allow appropriate suture passage through the knotless mechanism of the anchor. The graft is then shuttled into the joint through a lateral PassPort button cannula. Two lateral row anchors are used to secure the lateral graft on the humerus. Native rotator cuff tissue is repaired to the graft using sutures from the medial row anchors as well as free SutureTape. Results: Outcomes following SCR have demonstrated improvements in clinical outcomes and shoulder range of motion. Similar outcomes have been identified between the use of allograft and autograft. Patients generally are able to return to light recreational activities and work. Discussion/Conclusion: Arthroscopic SCR yields favorable results in the setting of a massive, irreparable rotator cuff tear. Meticulous surgical technique is needed to avoid intraoperative surgical complications. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

A 5-Year Follow-Up of Neuropathic Minimally Invasive Surgeries with Superconstructs for Mid-Foot Charcot Deformity

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Charcot neuroarthropathy is associated with a progressive deformity that can result in wound breakdown, ulceration and ultimately amputation. Conservative management with total contact casting can allow ulcers to heal. However conservative treatment is dependent on continual podiatry and orthotic input. Surgical correction of the 'rocker bottom deformity has evolved. Minimally invasive surgical techniques utilising beams and bolts for a 'super-construct' to correct the Charcot deformity is possible through percutaneous incisions. We report the 5-year outcomes of a cohort of patients with diabetic neuroarthropathy treated with neuropathic minimally invasive surgeries including modifications of the surgical technique to reduce complications and improve outcomes. Methods: A cohort of 16 patients with diabetic neuroarthropathy was treated using neuropathic minimally invasive surgeries. Patients were recruited from the multidisciplinary diabetic foot clinic. Patients had been treated with total contact casting to heal ulcers and prevent future wound breakdown. Surgery was performed as a day case or overnight stay under general anaesthetic. Using fluoroscopy, closing wedge osteotomy was performed with minimally invasive 'Shannon' cutting and wedge burrs to create a triplane closing wedge osteotomy of the midfoot. Reduction of the forefoot to the midfoot was achieved using percutaneous beams and bolts. The void was filled with antibiotic bone graft substitute. Post-operatively patients were immobilised in total contact cast for eight to twelve weeks non-weight-bearing, followed by six weight-bearing in a moon-boot with total contact insole for six weeks. Results: The aim of surgical intervention is to create a stable plantigrade shoe able foot. Whilst osseous union is desirable, a stable fibrous union allows the patient to transition to footwear, with reduced risk of recurrence of deformity, wound breakdown or ulceration, Minimally invasive surgery with antibiotic bone graft substitutes reduces the risk of post-operative infection. The most common complication was the breakage of metalwork at the tip of the bolts. Infection was the second most common complication. Removal of metalwork, minimally invasive debridement and irrigation, allowed the infection to be irradicated. Lost of correction of deformity requiring revision surgery occurred in three patients with good outcomes. There was one amputation. Conclusion: Significant midfoot deformity correction can be performed using minimally invasive surgical techniques with beams and bolts to create a super-construct for stabilisation of midfoot Charcot deformity. The advantages of percutaneous incisions allow for earlier intervention before a major deformity has occurred. Neuropathic minimally invasive surgeries are optimal for patients who have no active ulceration and are systemically well but require prophylactic intervention to prevent further deformity and risk of amputation.

V03-07 INTRACORPOREAL ROBOTIC PYELOLITHOTOMY USING THE BOSTON SCIENTIFIC SWISS LITHOCLASTⓇ TRILOGY LITHOTRIPTER

You have accessJournal of UrologyCME1 May 2022V03-07 INTRACORPOREAL ROBOTIC PYELOLITHOTOMY USING THE BOSTON SCIENTIFIC SWISS LITHOCLASTⓇ TRILOGY LITHOTRIPTER Micah Levy, Chih Peng Chin, Krishna T. Ravivarapu, Osama Al-Alao, and Michael Palese Micah LevyMicah Levy More articles by this author , Chih Peng ChinChih Peng Chin More articles by this author , Krishna T. RavivarapuKrishna T. Ravivarapu More articles by this author , Osama Al-AlaoOsama Al-Alao More articles by this author , and Michael PaleseMichael Palese More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002539.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Boston Scientific Swiss LithoClast© Trilogy Lithotripter was released in 2019, intended for use in percutaneous nephrolithotomy (PCNL). Its use has been shown to improve efficiency for stone fragmentation and removal, however, it has never been used for intracorporeal procedures. Our video depicts the first use of the Trilogy lithotripter in intracorporeal robotic pyelolithotomy and discusses the indications and advantages of this technique. METHODS: The patient was a 65-year-old female with a large left staghorn calculus with hydronephrosis and a left ureteropelvic junction (UPJ) obstruction. The combination of a staghorn stone with a UPJ obstruction indicated the use of robotic pyelolithotomy for stone removal and UPJ reconstruction. Due to the size and location of the stone, it was decided to use the Trilogy lithotripter for more efficient stone removal. The patient was consented to undergo a robotic pyelolithotomy with Trilogy lithotripsy. RESULTS: The patient was positioned in the flank position. The robot was docked, and the abdomen was insufflated. Initial dissection was made, and the colon was mobilized, revealing a hydronephrotic kidney with significant inflammation and a large staghorn stone branching into the upper, middle, and lower pole. The 2.4mm Trilogy probe was passed into the abdomen through the 12mm assistant's port and under direct vision the stone was segmented into several large fragments which were manually removed by the robotic graspers. Renal endoscopy was performed using a disposable LithoVue™ ureteroscope and remnant stones were removed using a stone basket until the kidney and ureter were noted to be stone free. The operation was completed successfully with minimal estimated blood loss and no intraoperative or postoperative complications. The patient returned for a six-week follow-up, and CT scans showed full stone clearance with no signs of hydronephrosis. CONCLUSIONS: This was the first documented use of the Trilogy lithotripter during intracorporeal surgery. The Trilogy’s efficacy in intracorporeal surgery is partially due to its built-in cooling system which allows for use of the Trilogy with reduced need for continuous irrigation which must be limited during robotic pyelolithotomy. Thus, this technique was indicated for complex procedures such as robotic pyelolithotomy for stone removal and concurrent UPJ reconstruction. It proved to be an efficient method for staghorn stone fragmentation and removal without requiring multiple percutaneous incisions or multiple procedures. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e203 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Micah Levy More articles by this author Chih Peng Chin More articles by this author Krishna T. Ravivarapu More articles by this author Osama Al-Alao More articles by this author Michael Palese More articles by this author Expand All Advertisement PDF DownloadLoading ...

Nanoscopic Distal Clavicle Resection

Acromioclavicular joint pathology such as osteoarthritis has historically been treated with either an open or arthroscopic distal clavicle resection. Over the years the trend has been toward more minimally invasive treatment options with the arthroscope. In this article we highlight the use of the nanoscope to visualize the resection which can be performed through a small percutaneous incision. The advantages of this technique include the use of smaller portals, which should lead to improved earlier outcomes, and less iatrogenic damage to the shoulder.

Combined plate and nail fixation of bicondylar tibial plateau fractures

Bicondylar tibial plateau fractures with meta-diaphyseal comminution commonly have a compromised soft tissue envelope. Combined plate-nail fixation is an emerging technique that utilizes a limited anterolateral approach for plate application and percutaneous incisions for placement of an intramedullary nail. This technique alleviates the need for a separate medial approach to the proximal tibia. We report a series of patients treated with this approach and outline the steps for implementation. We performed a retrospective review of 18 consecutive patients treated with combination lateral locked plating and intramedullary nailing at a single academic institution from 2016 to 2019. Of these, 16 patients met inclusion criteria and were included in this study. All patients had AO/OTA type 41C2/C3 fractures. Primary outcomes included coronal plane and sagittal plane alignment at latest follow up, rate of articular subsidence at latest follow up, and rate of postoperative infection. Of the 16 patients included, average followup was 8.2 months (range 0.1-29.7 months). At latest follow-up, average coronal alignment ranged from 0.8±1.2 degrees of varus (maximum 4.0 degrees) to 1.4±1.7 degrees of valgus (maximum 4.0 degrees). Average sagittal alignment ranged from 0.8±1.1 degrees of procurvatum (maximum 3.0 degrees) to 0.6±1.2 degrees of recurvatum (maximum 4.0 degrees). There was no radiographic evidence of articular subsidence at latest follow up for any patient. One patient (5.9%) presented at 141 days postoperatively with a draining wound and infection. Combination plate-nail fixation is a viable option for treating patients with select bicondylar tibial plateau fractures with meta-diaphyseal comminution. This case series with short-term followup demonstrates acceptable radiographic and clinical outcomes, as well as rates of postoperative infection and implant removal similar to those currently reported in the literature for other techniques used to treat these fractures.

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

External fixator of the elbow

The placement of an external elbow fixator can be statically carried out as temporary stabilization or as a hinged movement fixator. As a hinged movement fixator a functional follow-up treatment is possible due to control of the joint guidance and reduction of the compromising forces on the osteoligamentous structures. As atemporary stabilization of the elbow, the external fixator is used as adamage control method. As a movement fixator it is used as an additional protection and movement control after complex osteoligamentous interventions and persisting tendency to dislocation of the joint and also as a standalone procedure. In some cases, the procedure is also used in distraction arthrolysis of stiff elbows and as asalvage procedure in patients with relevant comorbidities as part of fracture treatment. Inexperience in relation to the procedure as well as alocal acute infection at the level of the intended pin locations should specifically be mentioned as contraindications. In addition, compliance and patient understanding of the procedure are essential for the success of treatment. Soft tissue preparation for pin placement should be preferred over percutaneous incisions to enable asafe bone exposure. Knowledge of the course of neurovascular structures (particularly the radial nerve) is essential. When placing ahinge, knowledge of the position and detection of the idealized center of rotation is of fundamental importance. The type of postoperative management required essentially depends on the underlying injury. When placing ahinged fixator, the aim is to enable movement as early as possible. Nevertheless, blocking of the hinged fixator may be useful for ashort period of time. Adequate pin care over the duration of the treatment is essential in order to prevent complications. Good functional results have been reported for the treatment of unstable elbows after primary and secondary placement of ahinged external fixator. Good functional scores and improvement in the range of motion were also recorded in the context of an arthrolysis (additive for open arthrolysis or distraction arthrolysis); however, in contrast asignificant number of complications associated with this surgery are likely to emerge. As adefinitive salvage procedure, satisfactory results were obtained in asmall case series of aselected older patient group with relevant comorbidities.

Sonographically Guided Percutaneous Sectioning of the Coracohumeral Ligament for the Treatment of Refractory Adhesive Capsulitis: Proof of Concept.

Treatment options are limited for nonsurgical chronic refractory cases of adhesive capsulitis. We describe a novel percutaneous tenotomy technique for coracohumeral ligament interruption with cadaveric validation. The objective of this study was to describe and validate a novel technique for percutaneous interruption of the coracohumeral ligament. Cadaveric study. Academic tertiary care center. Eight cadavers underwent ultrasound (US)-guided percutaneous incision of the coracohumeral (CHL) ligament. Performance of the procedure requires that the practitioner make oscillatory motions with a needle that uses ultrasound energy to cut through tissue. Each pass removes a pinhead-sized amount of tissue. The number of passes and the cutting time are recorded during the procedure. As a standard for this procedure does not exist, the authors created their own based on the preclinical information presented here. Postprocedure dissection was performed to assess the extent of CHL interruption and injury to surrounding tissue. The average resection time was seven minutes, requiring 500 passes. The technique described in this paper completely interrupted the CHL in all subjects. Cadaveric analysis demonstrated interruption of the CHL with respect to control shoulders requiring an average of seven minutes of cutting time and ∼500 micro-perforations. US-guided percutaneous CHL ligament sectioning is possible with a commercially available ultrasonic probe.

C-arm Guided Minimally Invasive Percutaneous Fixation Technique of Mandibular Angle and Ramus Fractures - a Prospective Clinical Study at a Tertiary Care Center of Odisha, India.

Background: Rigid internal fixation of displaced mandibular angle and ramus fractures often poses a unique challenge to oral and maxillofacial surgeons. Various methods have been published to provide a safe and secure gateway for these circumstances. Intra-oral approach supplemented by a limited percutaneous method of fixation offers a distinct advantage of rigid fixation, reducing the known morbidity of using the sole internal as well as external techniques. The objective was to describe a minimally invasive technique for the mandibular angle and ramus fractures using the combined intraoral and extra-oral approach.Methods: This study was conducted on ten patients with mandibular angle or ramus fractures. All patients underwent open reduction and internal fixation. The intra-oral incision was used for visualization and reduction of fractures, and supplemental percutaneous stab incision was utilized to create a path for insertion of the handheld battery-operated microdrill shaft and screwdriver to permit screws fixation perpendicular to the plates.Results: This combined technique depicted minimal or no soft tissue infections, wound dehiscence, occlusal disturbances, or seventh cranial nerve paralysis. The mean surgical duration was 41.5 minutes. No patient had an visible scar marks, which would require further intervention.Conclusion: The described minimally invasive combined percutaneous and intraoral approach for mandibular angle, and ramus fracture provides a satisfactory alternative which could be safely applied to provide rigid fixation of these fractures with minimal damage to vital structures.

Degree of Frontal Bone Exposure via Upper Blepharoplasty Incision: Considerations for Frontal Sinus Fracture.

The upper eyelid blepharoplasty incision affords direct access to the frontal bone for skull base surgery and trauma reconstruction with a well-hidden scar. The goal of this study is to quantify frontal bone exposure that can be achieved with an upper eyelid blepharoplasty incision. Anatomic study with human cadaver heads. UC Davis Medical Center. Fourteen human cadaver heads were used to perform 26 upper blepharoplasty approaches. Exposure was measured with virtual planning software to create virtual reference points at the midline of the superior orbital rim. Surgical navigation was used with a 3-dimensionally printed drill model to measure the maximum exposure achievable relative to the virtual reference point at 5 standardized angles. Mean ± SD exposures at medial 60°, medial 30°, 0°, lateral 30°, and lateral 60° were 16.1 ± 1.3 mm, 17.8 ± 1.3, 18.3 ± 1.4, 19.3 ± 1.9, and 20.9 ± 1.9, respectively. Significant differences were detected between exposures at 60° laterally and 60° medially and between exposures 60° laterally and 30° medially ( P < .05). The upper eyelid blepharoplasty incision provides direct surgical access to the inferior frontal bone. Access was greatest with far lateral extension (mean, 20.9 mm) and most limited with far medial extension (mean, 16.1 mm). Treatment of injuries above this level could be achieved with additional percutaneous incisions for screw placement.

BILATERAL PNEUMOTHORACES COMPLICATING PERCUTANEOUS TRACHEOSTOMY DISPLACEMENT

SESSION TITLE: Procedures SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Bedside percutaneous tracheostomy is a common procedure performed in the ICU and has been shown to be as safe as surgical tracheostomy. Displacement of percutaneous tracheostomy, especially within the immediate postoperative period, has one of the highest mortality rates of any tracheostomy complication. We present the case of a 53-year-old male presenting to the hospital shortly after tracheostomy displacement. CASE PRESENTATION: The patient was admitted to LTACH following a prolonged ICU stay for acute hypoxemic respiratory failure with ARDS. Bedside percutaneous tracheostomy was performed during this hospitalization without any complications and the patient was discharged to LTACH. Ten days post procedure, the patient underwent a planned tracheostomy exchange at the bedside. Multiple unsuccessful attempts were made to reinsert the tracheostomy tube through the original percutaneous site. In the interim, the patient suffered cardiac arrest, was orally intubated and brought to the Emergency Department. Upon arrival the patient was noted to have chest crepitus. Chest radiograph was obtained which showed large bilateral pneumothoraces with pneumomediastinum and significant subcutaneous emphysema of the neck and chest. Bilateral small-bore chest tubes were placed to suction with no residual air leak after evacuation of pleural air. Otolaryngology was consulted, and the patient was brought to the operating room for complete tracheostomy revision. Under direct visualization, a clear false passage was found through the original percutaneous incision into the mediastinum. This was closed and a new cutaneous incision was used to revise the tracheostomy. Bilateral chest tubes were removed in the immediate postoperative period with follow up chest radiograph demonstrating no pneumothorax. The patient did not demonstrate any signs of meaningful neurologic recovery post cardiac arrest. DISCUSSION: Subcutaneous emphysema and pneumothorax are rare but well described sequelae of tracheostomy; however, these complications usually occur immediately following the procedure. In our case, these complications occurred due to tracheostomy tube displacement with creation of a false passage into the mediastinum. In prior studies, it was noted that cannula misplacement and creation of a false passage were more common with percutaneous tracheostomies than their open equivalents. CONCLUSIONS: Displacement of percutaneous tracheostomy, particularly in the early postoperative period, can have devastating consequences. We have described a case in which false passage to the mediastinum was created during a first tracheostomy exchange which ultimately lead to hypoxemia causing cardiac arrest. Understanding the causative mechanisms will help in preventing these complications. Reference #1: Cipriano, A., Mao, M., Hon, H. et. Al. An overview of complications associated with open and percutaneous tracheostomy procedures. International Journal of Critical Illness and Injury Science. 2015; 5(3): 179–188. Reference #2: Klein M, Agassi R, Shapira A, Kaplan DM, Koiffman L, Weksler N. Can intensive care physicians safely perform percutaneous dilational tracheostomy? An analysis of 207 cases. Israel Medical Association Journal. 2007;9(10):717–719. DISCLOSURES: No relevant relationships by Adrienne Markiewicz, source=Web Response No relevant relationships by Aasim Mohammed, source=Web Response No relevant relationships by Jonathon Truwit, source=Web Response

Intramedullary Nail Fixation of the Fibula as a Treatment Alternative of Ankle Fractures in a High Risk Patient Population

Category: Trauma Introduction/Purpose: Traditional plate osteosynthesis for ankle fractures in a high risk patient population can predispose to complications as a result of the necessary soft tissue dissection and periosteal stripping. Complication rates among patients with multiple comorbidities has been shown to be as high as 30% in those who undergo traditional plate and screw fixation. 1 An alternative fixation construct, thought not widely used or recognized in the American literature is the locking intramedullary fibular nail. Intramedullary nails offer the theoretical advantages of stable fixation while utilizing smaller, percutaneous incisions and no periosteal stripping. The purpose of this study is to analyze the outcomes and complications of high risk patients who underwent ankle surgery using the intramedullary fibular nail. Methods: The medical records of all high risk patients who underwent ankle fracture fixation with a locking intramedullary fibular nail from 1/2011 through 6/2015 at our institution were reviewed. Fracture patterns included unstable lateral malleolar, bimalleolar, and trimalleolar fractures. Patients were considered high risk if they had medical comorbidities at the time of injury that have been shown in current literature to increase surgical complication risk. These comorbidities include neuropathy, uncontrolled diabetes, peripheral vascular disease, congestive heart failure, etc. We recorded patient demographics, fracture type, period of post-op NWB, time until discharge, time to weight bearing, complications, tourniquet time, size and length of nail implanted, and estimated blood loss. Attempts were made to contact all patients to complete a follow-up questionnaire regarding their satisfaction. Results: Twenty-two high risk patients with 23 ankle fracture were included. The average age was 64.8 years (SD 10.2, range 41- 82). The average follow up was 5.7 months (SD 5.7, range 2-30). There were no surgical site infections, wound complications, or non-unions. Two (8.7%) required a return to the operating room for symptomatic screw removal. The average tourniquet time was 35.8 minutes (SD 20.1, range 0-72) and the average operative time was 49.3 minutes (SD 14.3, range 25-70) respectively. The Olerud &amp; Molander average score was 77.9 (SD 17.7, range 40-100). Fourteen of the twenty two patients could be contacted for a follow up questionnaire and 13 of the 14 (93%) said they were either very satisfied (64%) or satisfied (29%) with their injury outcome. Conclusion: The locking intramedullary fibular nail provides an alternative fixation technique that allows for protection of soft tissue, stable fracture fixation and satisfactory outcomes in the high risk patient population.

Lesser Metatarsal Complications After MIS Surgery

Minimally invasive surgery (MIS) for lesser metatarsals is performed through percutaneous incisions, with minimal scar formation. Nevertheless, MIS can have significant complications that may result in poor outcomes, forefoot pain, and metatarsalgia requiring further complex open revision surgery. These complications occur after inappropriate or poor surgical technique, lack of surgeon’s experience, and poor patient selection. The most frequent complication is metatarsalgia that occurs secondary to metatarsal malunion or nonunion. MIS is a technique that has to be carefully chosen for specific morbidities and performed only under experienced hands. Level of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.