Proximal Portal Research Articles

Proximal lateral insertion portal of an intra-articular arthroscopic stifle lever: A cadaveric study.

To (1) Describe the proximal lateral insertion portal for the placement of an intra-articular distraction lever. (2) Assess for associated damage with the insertion of the lever and (3) evaluate the impact of duration of lever use on articular cartilage damage. Ex vivo canine cadaveric experimental study. Paired canine stifles from seven cadavers (14 stifles from dogs weighing >20 kg). A separate 0.5 cm proximal lateral portal was established adjacent to the lateral scope portal. A standard Ventura stifle thrust lever (VSTL) was inserted without removing the arthroscope. In Group A, the VSTL was placed in distraction for 5 min while in Group B the VSTL was placed for 10 min. The stifle joints were disarticulated and evaluated for associated damage to the long digital extensor tendon and iatrogenic articular cartilage injury (IACI) via India ink assay. No damage to the long digital extensor tendon was noted in any of the specimens during dissection. Superficial IACI was present in all specimens. There were no differences between groups when assessing for overall IACI. A proximal lateral portal and insertion of a standard VSTL can be performed without removing the arthroscope. The use of a proximal lateral lever portal without repositioning the arthroscope was repeatable without damaging the long digital extensor tendon. A duration of up to 10 min in which the thrust lever was engaged did not result in increased visual cartilage damage.

Causes of Iatrogenic Median Nerve Injury after Endoscopic Carpal Tunnel Release.

Background: Endoscopic carpal tunnel release (ECTR) is a less invasive procedure but has a higher risk of complications. We analysed ECTR cases dividing them into three periods according to a single surgeon's experience when the ECTR was performed: the initial, midterm and late period. Cases of iatrogenically induced median nerve injuries that occurred after ECTR were then noted and evaluated. Methods: We reviewed 195 ECTRs done with the 2-portal technique and divided the patients into three groups according to periods of when ECTR was done. The indications for ECTR surgery were limited to severe CTS cases. These groups of patients were similar in terms of age, duration of disease, electrophysiological study results and severity of the disease. The patients were evaluated for median neuropathy pre- and postoperatively using Semmes-Weinstein monofilament test (SWT), Disabilities of the arm, shoulder and hand (DASH) Score, Coin-flip test (CFT), postoperative paraesthesias and complications, such as pillar pain, and so on. Electrophysiological evaluation was performed only preoperatively. Results: Postoperative median nerve recovery was overall good. Normal recovery was noted in 181 cases (93%). SWT, DASH and CFT were all significantly improved upon follow-up in all three groups. In terms of iatrogenic neuropathy, median nerve palsy worsened (including those transiently worsened) after ECTR in 11 cases (5.6%), even in the later period. The sensory disturbance was equally worsening from the radial to the ulnar side. Conclusions: The fact that there were neurologically worsened cases even in the later period, when the operator is higher skilled in the technique, suggests that the surgical technique itself may be the one posing higher risk than the level of surgical skill. The most likely causes of aggravated nerve palsy were a direct injury by cannula insertion at the proximal portal, or additional median nerve compression during cannula insertion into the carpal tunnel. Level of Evidence: Level IV (Therapeutic).

Anatomic study of an anterior portal for percutaneous internal fixation of capitellum fractures.

Fractures of the capitellum are uncommon and difficult to treat surgically. Capitellar open reduction-internal fixation uses a lateral open approach with posterior-to-anterior or anterior-to-posterior screw fixation. We investigated the use of an anterior portal for placement of anterior-to-posterior screw fixation through cadaveric measurement of the anatomic relationships from an anteriorly to posteriorly placed Kirschner wire (K-wire) to anterior elbow structures and calculated the percentage of articular surface accessed from the anterior portal. Eight fresh-frozen cadaveric elbows without radiographic or cutaneous evidence of prior trauma or surgery were used for this study. An arthroscopic proximal anteromedial portal was cannulized, and the radiocapitellar joint was evaluated. A single 1-cm portal was placed 1 cm distal to the elbow flexion crease and based lateral to the biceps tendon. The location of the portal was confirmed with a spinal needle, and blunt dissection with a hemostat was performed down to capsular tissue and for arthrotomy. A spinal needle sheath was threaded over a blunt switching stick and served as a cannula for placement of a 0.062 K-wire. Articular mapping was performed with cartilage scraping by the K-wire; the K-wire was then placed at the perceived center along the proximal-to-distal and radial-to-ulnar axis of the capitellum. Fluoroscopic confirmation of the wire's location was performed. Under loupe magnification, anatomic dissection was performed and the shortest distance measurements were recorded with digital calipers from the K-wire to the dissected structures. Capitellar articular measurements were recorded, in addition to the articular area defined by the K-wire. Data analysis was performed, and the average distance and standard deviation (in millimeters) were calculated. For structures that were pierced by or touching the K-wire, the distance was recorded as 0.1 mm. The average distance from the K-wire to the radial, lateral antebrachial cutaneous, and median nerves was 1.8 mm, 11.5 mm, and 28.0 mm, respectively. The average distance from the median cubital vein and biceps tendon was 3.7 mm and 13.4 mm, respectively. The pin track pierced the brachioradialis and supinator muscles in all but 1 specimen. The average capitellar articular surface marked was 39.1% of the calculated articular footprint of the capitellum. The anterior portal to the capitellum is directly adjacent to the radial nerve and lateral antebrachial cutaneous nerve, where each is susceptible to injury. We recommend blunt dissection and insertion of a cannula to allow drilling and placement of internal fixation in a relatively safe manner with respect to neurovascular structures.

“All-Endoscopic” Management of Refractory Elbow Bicipitoradial Bursitis and Partial Distal Biceps Tendon Tears

Elbow bicipitoradial bursitis and partial distal biceps tendon (DBT) tears are a result of chronic overuse or other infective/inflammatory pathology and may be refractory to conservative treatment. The all-endoscopic approach provides minimally invasive access to the bursal space and DBT, and diagnostic and therapeutic procedures can be performed under direct endoscopic vision. The technique uses 2 portals, the proximal parabiceps portal and distal anterior portal, and the bursa is insufflated to create a working space. Tissue biopsies are obtained under direct endoscopic visualization, and debridement along 6 bursal zones can be effectively performed. An endoscopic probe test is demonstrated for assessment of partial DBT tears, and low-grade tears are debrided to stable tissue. The all-endoscopic technique is safe and reproducible, and it is a stepping-stone in the learning curve of all-endoscopic repair and reconstruction of distal biceps ruptures.

Far Anterior Medial Portals in Complicated Elbow Arthroscopic Procedures: Safety Profile in a Cadaveric Model

PurposeThe purpose of this study is to describe the placement and evaluate the safety of the far anterior proximal and distal anteromedial portals by comparing them to previously defined portal techniques in a cadaveric model of the elbow.MethodsSix paired (left and right) fresh, frozen cadaveric elbow joints were dissected. .62-mm Kirschner wires were placed at the literature-defined distal and proximal portal sites on right elbows. The proposed “far anterior” distal and proximal portals were established on the matched left elbows. The elbows were dissected to display the median and ulnar nerves. Digital calipers were used to measure distances from wires to nerves.ResultsFor the distal portal, the literature-defined portals were a significantly greater distance (P = .014) from the ulnar nerve (31.22 mm) compared to the far anterior portals (24.65 mm). For the proximal portal, the far anterior portals were a significantly greater distance (P = .026) from the ulnar nerve (26.98 mm) than the literature-defined portals (13.75 mm). There was no significant difference between the far anterior and literature-defined proximal and distal portal techniques in relation to the median nerve.ConclusionsAnalysis of elbow arthroscopy anteromedial portal technique shows the far, anterior, proximal, and distal portals are a safe distance from the ulnar and median nerves. A portal modification that may address complicated elbow conditions is a more anterior placement of the medial portals to allow for better visualization and access.Clinical RelevanceThe elbow is a difficult joint in which to perform arthroscopic surgery. One option our institution has used for safe portal modification to address complicated elbow conditions is a further anterior placement of the medial portals to allow better visualization and access.

Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans.

Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans.

Endoscopic anatomy of distal biceps tendon insertion and bicipitoradial bursa: a cadaveric study.

Distal biceps endoscopy has emerged as a minimally invasive alternative to open procedures for distal biceps tendon (DBT) pathology. The purpose of this study was to systematically describe the static and dynamic appearance and variations of the DBT insertional region using a standardized endoscopic technique and dissection in healthy cadaveric elbows. Endoscopic assessment of the DBT insertional region was performed using a standard proximal parabiceps portal in 20 fresh frozen cadaveric upper extremities. A 6-point endoscopic evaluation of the DBT and bicipitoradial bursa was performed in a static supination position and with dynamic rotation. Anatomic variations in the DBT insertional characteristics, as well as the extent and appearance of the intrabursal space, were documented. Each cadaver was then dissected to correlate endoscopic findings with gross anatomic structures. A bare oval tuberosity area (n = 20) bounded by the supinator and DBT was observed. The DBT inserted ulnar to the bare area (n = 16) and the presence of an intervening wide (n = 1) or narrow (n = 3) tuberosity sulcus were documented. The dorsoradial DBT surface was consistently intrabursal and was differentiated into 2-5 fiber bundles (n = 15). The volar-ulnar DBT surface was always extrabursal and was associated with endoscopically identifiable proximal and distal fat pads. The bicipitoradial bursa formed a bursal sac that was attached to the dorsoradial (n = 13) or volar (n = 7) aspect of the tuberosity and extended proximally along the DBT for 3-5 cm (parabiceps space). A distinct ligament-like band (transverse radioulnar ligament) extended transversely across the proximal radioulnar space and appeared to form a sling that provided ulnar support to the DBT during dynamic rotation. The intact DBT surface was robust and could not be breached, even with firm pressure using a probe. The bare tuberosity area, the bursal sac, and the parabiceps space are consistent anatomic landmarks that can be used during DBT endoscopy. An insertional tuberosity sulcus and DBT surface differentiation are normal anatomic variations. The transverse radioulnar ligament provides ulnar support for the DBT during pronation and forms a pulley mechanism for smooth tendon gliding motion.

Splenectomy with proximal spleno-left portal shunt for extrahepatic portal vein obstruction in children

PurposeTo report our initial experience with splenectomy and proximal spleno-left portal shunt as an alternative to the standard Rex shunt, when not applicable, in children with Extrahepatic Portal Vein Obstruction (EHPVO). MethodsPatients from March 2015 till September 2018, with EHPVO not suitable for Rex shunt or whose caregivers refused to consent for Internal Jugular Vein (IJV) dissection were assessed and prepared for splenectomy with proximal spleno-left portal shunt. The operative technique includes splenectomy, freeing of the splenic vein from the pancreatic bed till its junction with the inferior mesenteric vein, and then anastomosis with the intrahepatic left portal vein at the Rex recess. A distal lieno-renal shunt was performed in one patient and was excluded from the study. ResultsA total of 14 patients (mean age: 4.6 years) underwent splenectomy with proximal spleno-left portal shunt during the study period. The mean operative time was 246 min, while the mean postoperative hospital stay was 4.1 days. The patients' follow up period ranged from 6 to 42 months (median: 19.6 months). Only two patients had a single attack of variceal bleeding, 2 and 2.5 months postoperative respectively, and required endoscopic management with no further bleeding episodes. While the rest of patients showed an improvement of their variceal grades after the surgery. ConclusionSplenectomy with proximal spleno-left portal shunt seems to be a valuable alternative to the standard Rex shunt in treatment of children with EHPVO unsuitable for or following unsuccessful Rex shunt. Level of evidenceIV

Arthroscopic all-inside ATiFL's distal fascicle transfer for ATFL's superior fascicle reconstruction or biological augmentation of lateral ligament repair.

Tendon grafts are often utilized for reconstruction of the lateral ligaments unamenable to primary repair. However, tendon and ligaments have different biological roles. The anterior tibiofibular ligament's (ATiFL) distal fascicle may be resected without compromising the stability of the ankle joint. The aim of this study is to describe an all-arthroscopic and intra-articular surgical technique of ATiFL's distal fascicle transfer for the treatment of chronic ankle instability. Five unpaired cadaver ankles underwent arthroscopic ATiFL's distal fascicle transfer using a non-absorbable suture and a knotless anchor. Injured or absent ATiFL's distal fascicle were excluded from the study. Following arthroscopy, the ankles were dissected and evaluated for entrapment of nearby adjacent anatomical structures. The ligament transfer was also assessed. The distance between the anterolateral (AL) portals and the superficial peroneal nerve (SPN) was measured and the shortest distance was reported. All specimens revealed successful transfer of the tibial origin of the ATiFL's distal fascicle onto the talar insertion of anterior talofibular ligament's (ATFL) superior fascicle. The fibular origin of the ATiFL's distal fascicle remained intact. There were no specimens with SPN or extensor tendon entrapment. The median distance between the proximal AL portal and SPN was 3.8mm. The median distance between the distal AL portal and SPN was 3.9mm. An all-arthroscopic approach to an ATiFL's distal fascicle transfer is a reliable method to reconstruct the ATFL's superior fascicle. Transfer of ATiFL's distal fascicle avoids the need for tendon harvest or allograft. The lack of injury to nearby adjacent structures suggests that it is a safe procedure. The clinical relevance of the study is that ATiFL's distal fascicle can be arthroscopically transferred to be used as a biological reinforcement of the ATFL repair, or as an ATFL reconstruction.

Locating the ulnar nerve during elbow arthroscopy using palpation is only accurate proximal to the medial epicondyle

PurposeKnowledge of ulnar nerve position is of utmost importance to avoid iatrogenic injury in elbow arthroscopy. The aim of this study was to determine how accurate surgeons are in locating the ulnar nerve after fluid extravasation has already occurred, and basing their localization solely on palpation of anatomical landmarks.MethodsSeven cadaveric elbows were used and seven experienced surgeons in elbow arthroscopy participated. An arthroscopic setting was simulated and fluids were pumped into the joint from the posterior compartment for 15 min. For each cadaveric elbow, one surgeon was asked to locate the ulnar nerve solely by palpation of the anatomical landmarks, and subsequently pin the ulnar nerve at two positions: within 5 cm proximal and another within 5 cm distal of a line connecting the medial epicondyle and the tip of the olecranon. Subsequently, the elbows were dissected using a standard medial elbow approach and the distances between the pins and ulnar nerve were measured.ResultsThe median distance between the ulnar nerve and the proximal pins was 0 mm (range 0–0 mm), and between the ulnar nerve and the distal pins was 2 mm (range 0–10 mm), showing a statistically significant difference (p = 0.009). All seven proximally placed pins (100%) transfixed the ulnar nerve versus two out of seven distally placed pins (29%) (p = 0.021).ConclusionsIn a setting simulating an already initiated arthroscopic procedure, the sole palpation of the anatomical landmarks allows experienced elbow surgeons to accurately locate the ulnar nerve only in its course proximal to the medial epicondyle (7/7, 100%), whereas a significantly reduced accuracy is documented when the same surgeons attempt to locate the nerve distal to the medial epicondyle (2/7, 29%; p = 0.021). Current findings support the establishment of a proximal anteromedial portal over a distal anteromedial portal to access the anterior compartment after tissue extravasation has occurred with regard to ulnar nerve safety.

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.

Modified Anterolateral Portals in Elbow Arthroscopy: A Cadaveric Study on Safety

To evaluate the proximity to the radial nerve on cadaveric specimens of 2 modified anterolateral portals used for elbow arthroscopy. Ten fresh cadaveric elbow specimens were prepared. Four-millimeter Steinman pins were inserted into 3 anterolateral portal sites in relation to the lateral epicondyle: (1) the standard distal anterolateral portal, (2) a modified direct anterolateral portal, and (3) a modified proximal anterolateral portal. These were defined as follows: direct portals 2cm directly anterior to the lateral epicondyle, and proximal portals 2cm proximal and 2cm directly anterior to the lateral epicondyle. Each elbow was then dissected to reveal the course of the radial nerve. Digital photographs were taken of each specimen, and the distance from the Steinman pin to the radial nerve was measured. The modified proximal anterolateral and direct anterolateral portals were found to be a statistically significant distance from the radial nerve compare to the distal portal site (P= .011 and P= .0011, respectively). No significant difference was found in the proximity of the radial nerve between the modified proximal and direct anterolateral portals (P= .25). Inadequate imaging was found at a single portal site for the proximal site; 9 specimens were used for analysis of this portal with 10 complete specimens for the other 2 sites. In cadaveric analysis, both the modified proximal and direct lateral portals provide adequate distance from the radial nerve and may be safe for clinical use. In this study, the distal anterolateral portal was in close proximity of the radial nerve and may result in iatrogenic injury in the clinical setting. This is a cadaveric analysis of 2 modified portal locations at the anterolateral elbow for use in elbow arthroscopy. Further clinical studies are needed prior to determining their absolute safety in comparison to previously identified portal sites.

Arthroscopic fixation with EndoButton for tibial eminence fractures visualised through a proximal superomedial portal: a surgical technique.

Most tibial eminence fractures are avulsion fractures of the anterior cruciate ligament (ACL) from its tibial insertion. This study describes a new arthroscopic technique using an additional proximal superomedial portal to visualise the tibial eminence fracture and to fix the fracture with the EndoButton to avoid the risk of fragment breakage. The proximal superomedial portal enables fracture reduction without damage to the intermeniscal ligament. Fixation with the EndoButton is strong enough to allow early rehabilitation with vigorous exercise. All 5 patients achieved bone union; no young patient had growth disturbance of the tibia; all knees were stable with excellent range of motion and negative Lachman and pivot shift tests and no flexion contracture. Arthroscopic fixation with the EndoButton visualised through the proximal superomedial portal is a safe, simple, and secure method for treating tibial eminence fractures, particularly in children with small fragments.

Surgical Technique for Arthroscopic Lateral Collateral Ligament Repair.

Arthroscopic repair of the lateral collateral ligament (LCL) complex in patients who have posterolateral rotatory instability after an unstable elbow dislocation, with or without an intra-articular fracture, is an alternative treatment for restoring stability of the elbow and obtaining successful clinical and radiographic results. Obtain radiographs and CT and MRI scans to make an accurate analysis of the fracture patterns and develop an understanding of soft-tissue comorbidities. Place the patient in the lateral decubitus position and create proximal anteromedial, proximal anterolateral, anterolateral, and radial head portals as working portals and a posterior soft-spot portal as a viewing portal for the repair of the LCL complex. Identify concomitant radial head and coronoid fractures, and confirm the LCL-complex tear intraoperatively. Treat intra-articular fractures arthroscopically before the LCL-complex repair. After soft-tissue debridement using the soft-spot portal as a viewing portal and the proximal anterolateral portal as a working portal, decorticate the footprint of the humeral attachment of the LCL complex with use of a shaver or burr and then make a modified Mason-Allen stitch using a needle, fixing the suture with a knotless anchor, to achieve a stable elbow joint. After postoperative immobilization of the elbow for 2 to 3 days, instruct the patient to perform passive exercises, returning to a full range of motion at 4 to 6 weeks after surgery, and typically returning to full activity at 3 months after the operation. To date, arthroscopic LCL-complex repair has produced excellent results, with all 13 patients in our original study reporting complete resolution of the elbow instability and demonstrating a negative result on the lateral pivot-shift test15.

Two Modified Anterolateral Portals in Elbow Arthroscopy: A Cadaveric Study

To analyze the placement of two modified anterolateral portal sites in elbow arthroscopy and demonstrate the safety of each with respect to portal sites proximity to the radial nerve. Twelve fresh cadaveric elbow specimens (6 matched pairs) were prepared, anatomic landmarks were marked, and 4mm Steinman pins were inserted into three anterolateral portal sites in relation to the lateral epicondyle: 1) proximal, 2cm proximal and 2cm anterior 2) direct anterior, 2cm anterior 3) distal, 3cm distal and 1cm anterior. Each elbow was then dissected to reveal the course of the radial nerve. Digital photographs were taken of each specimen and the distance from the Steinman pin and the radial nerve was measured. Our proximal and direct anterior portal sites were found to be an average of 11.1mm and 13.8mm from the radial nerve, respectively. Similar to past studies we found the original distal anterolateral portal, as described by Andrews and Carson, in close proximity to the radial nerve, an average distance of 4.5mm. The distal anterolateral portal came in contact with the radial nerve 40% of the time, with 3 total Steinman pins piercing the nerve. There was a statistically significant difference in the distance between our proximal and distal anterior portals, as well as, our direct anterior and the distal portals to the radial nerve. No significant difference was found between the distance of the proximal and direct anterior portal sites. Our two modified, proximal and direct anterior, anterolateral portal sites should be considered safe and provides the surgeon with an adequate distance between the arthroscope and the radial nerve with little risk of iatrogenic injury. The distal portal puts the radial nerve at the most risk for iatrogenic injury. Our two modified anterolateral portal sites should be considered for use when performing elbow arthroscopy.

The Safety of Using Proximal Anteromedial Portals in Elbow Arthroscopy With Prior Ulnar Nerve Transposition

To report the safety of using the proximal anteromedial portal, using a simplified ulnar nerve management strategy derived from an earlier study, in a series of patients with previously transposed ulnar nerves. A retrospective review of all elbow arthroscopies performed by a single surgeon from 2009 to 2014 was performed. The following techniques were used if, by palpation, localization of the ulnar nerve was considered to be certain (group 1) or uncertain (group 2): In group 1 (certain) the proximal anteromedial portal was established in the normal antegrade fashion. In group 2 (uncertain) a 1- to 3-cm incision was made at the planned proximal anteromedial portal site, and blunt dissection down to the capsule was performed without identification of the nerve. The nerve was not visualized but sometimes was palpated through the wound to confirm its location anteriorly or posteriorly. If there was a disparity between the prior operative records and the physical examination findings, the nerve was explored through a 3- to 4-cm incision. We reviewed 394 elbow arthroscopy cases, 22 of which had a prior transposed ulnar nerve (21 subcutaneous and 1 submuscular) that required anterior-compartment arthroscopic surgery. Group 1 (certain location) consisted of 9 elbows (41%), whereas group 2 (uncertain location) consisted of 13 (59%). In 2 cases in group 2, the ulnar nerve was explored because of the disparity between the previous medical records and the physical examination findings. There were no operative ulnar nerve injuries related to the use of the proximal anteromedial portal. The proximal anteromedial portal was able to be used safely in patients with prior transposition of the ulnar nerve. This was achieved by using an algorithm based on the degree of certainty with which the nerve can be localized in the region of the planned portal by clinical palpation. Level IV, therapeutic case series.

Endoscopic Resection of Avulsed Fragment of Tibial Tuberosity and Endoscopic-Assisted Repair of Patellar Tendon

An avulsion fracture of part of the tibial tuberosity can occur as a result of a tophaceous tuberosity or Osgood-Schlatter disease. We describe an endoscopic technique of debridement, bone fragment resection, and tendon repair. This technique has the potential advantage of fewer wound complications. It is performed through proximal and distal portals on the sides of the patellar tendon. The working space is deep to the tendon. After debridement of the tendon and resection of the bone fragment, the tendon gap is assessed. Endoscopic-assisted side-by-side repair is performed to close the gap if the gap is less than 30% of the width of the tendon. If the gap is more than 30% of the width of the tendon, the proximal stump of the avulsed tendon can be retrieved through the proximal portal. Krackow suture with stay stitches is applied to the proximal stump. The stump is put back and sutured to the tibial insertion through a bone tunnel or suture anchor. This is augmented by side-by-side suturing of the avulsed tendon with the adjacent normal tendon.

Endoscopic Surgical Removal of Calcific Tendinitis of the Rectus Femoris: Surgical Technique

Calcific tendinitis of the rectus femoris (CTRF) is an under-recognized condition and, because of its self-limiting nature, is usually managed conservatively. Nevertheless, when nonsurgical therapy fails, further invasive alternatives are required. At this point, arthroscopic resection provides a minimally invasive and interesting alternative to open surgery. The aim of this work is to report the surgical technique of endoscopic surgical removal in patients with CTRF at the periarticular region of the hip joint. Endoscopic surgical removal of CTRF was performed without traction following anatomic landmarks for hip arthroscopy portal placement. We used the anterolateral portal and the proximal accessory portal to obtain access to the lesion. A shaver and radiofrequency device are useful tools to depict the calcific lesion while the whole resection is performed with a 5-mm round burr. Intraoperative fluoroscopy control during the entire procedure is essential. Endoscopic treatment of calcific tendinitis of the hip is a valuable technique in the treatment of patients who do not respond to conservative treatment.

Intra-Articular Hip Injection Using Anatomic Surface Landmarks

Intra-articular hip injection is a frequently used technique for diagnostic and therapeutic purposes and is gaining more importance for the early diagnosis of hip disease. It is commonly performed with imaging guidance such as ultrasonographic or fluoroscopic control. We describe our technique of injection of the hip using relative distances from anatomic surface landmarks, with the needle insertion point at the site of the proximal anterolateral portal for hip arthroscopy, with a posterior direction of 30° and targeted toward a junctional point between 2 perpendicular lines, 1 distal from the anterior superior iliac spine and the second anterior from the tip of the greater trochanter. This technique can be used without imaging guidance in the outpatient clinic. Moreover, it minimizes the need for radiographic exposure for more critical injections, such as the injection of contrast material before conducting magnetic resonance arthrogaphy of the hip.

Posterior tibial tendoscopy: Description of an accessory proximal portal and assessment of tendon vascularization lesion according to portal

Posterior tibial tendoscopy was codified in 1997 by Van Dijck, who described a portal between 1.5 and 2cm proximally and distally to the tip of the medial malleolus. However, this approach does not allow proximal exploration of the posterior tibial tendon (PTT). We here describe an accessory portal 7cm proximal to the medial malleolus, enabling complete PTT exploration. Posterior tibial tendoscopy was performed on 12 cadaver specimens, mapping PTT exploration and vascularization. The accessory portal enabled the whole PTT to be explored, from the myotendinous junction to the entry into the retromalleolar groove. PTT observation quality was improved compared to using a submalleolar portal. Dissection confirmed systematic presence of a vincula on the posterior side of the tendon, connected to the flexor digitorum longus (FDL) tendon, containing collateral vessels of the posterior tibial artery. None of these elements were damaged by the tendoscopy as long and the scope and motorized instruments were not rotated on the posterior side of the supramalleolar part of the PTT. This accessory entry portal provides complete PTT exploration without the risk of neurovascular bundle lesion.