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1.
T. Pillukat R. A. Fuhrmann J. Windolf J. van Schoonhoven 《Operative Orthopadie und Traumatologie》2016,28(4):233-250
Objective
Refixation of the triangular fibrocartilage complex (TFCC) to the ulnar capsule of the wrist.Indications
Distal TFCC tears without instability, proximal TFCC intact. Loose ulnar TFCC attachment without tear or instability.Contraindications
Peripheral TFCC tears with instability of the distal radioulnar joint (DRUJ). Complex or proximal tears of the TFCC. Isolated, central degenerative tears without healing potential.Surgical technique
Arthroscopically guided, minimally invasive suture of the TFCC to the base of the sixth extensor compartment.Postoperative management
Above elbow plaster splint, 70° flexion of the elbow joint, 45° supination for 6 weeks. Skin suture removal after 2 weeks. No physiotherapy to extend pronation and supination during the first 3 months.Results
In an ongoing long-term study, 7 of 31 patients who underwent transcapsular refixation of the TFCC between 1 January 2003 and 31 December 2010 were evaluated after an average follow-up interval of 116 ± 34 months (range 68–152 months). All patients demonstrated an almost nearly unrestricted range of wrist motion and grip strength compared to the unaffected side. All distal radioulnar joints were stable. On the visual analogue scale (VAS 0–10), pain at rest was 1 ± 1 (range 0–2) and pain during exercise 2 ± 2 (range 0–5); the DASH score averaged 10 ± 14 points (range 0–39 points). All patients were satisfied. The modified Mayo wrist score showed four excellent, two good, and one fair result. These results correspond to the results of other series.Conclusion
Transcapsular refixation is a reliable, technically simple procedure in cases with ulnar-sided TFCC tears without instability leading to good results.2.
N. Schmelzer-Schmied 《Operative Orthopadie und Traumatologie》2016,28(4):251-262
Objective
The goal of this operation technique is a stable refixation of the triangular fibrocartilage complex (TFCC) to the fovea ulnaris. The stability of the distal radio-ulnar joint (DRUJ) should be re-established. The patients pain and the feeling of instability should be reduced.Indications
Lesions of the foveal component of the TFCC resulting in DRUJ instability. Combined lesions of both components of the TFCC. Complete detachment of the TFCC from the ulna either without fracture of the styloid process of the ulna or with fracture (floating styloid).Contraindications
Severe lacerations of the TFCC and clinically relevant arthrosis of the DRUJ. Severely osteoporotic bone.Surgical technique
Following diagnostic arthroscopy and performance of stability control of the TFCC with a palpation hook, reduction of the DRUJ with supination position of the wrist. Bone anchor fixation through the direct foveal portal (DF). Under arthroscopic control through the 3/4 portal, the suture from the DF portal is placed through the TFCC. Pull out and tie the strands through the 6 U portal.Postoperative management
Restriction of rotation of the forearm in a Munster cast or special cast brace for 6 weeks. Self-controlled exercise of the wrist after 6 weeks. Physiotherapy and strength building 8 weeks postoperatively.Results
Clinical studies of this technique showed a significant amelioration of pain perception, improved range of motion and DASH score in all patients after anchor fixation. The results are comparable to other techniques. All patients returned to work after the operation. Accordingly, using this technique a very good stabilization of the DRUJ with low complications can be achieved.3.
Introduction
In case of clinical suspicion of triangular fibrocartilage complex (TFCC) injury, different imaging techniques are used. The aim of this study was to determine whether MRA is superior to MRI and whether 3.0 T is better than 1.5 T (expresses in sensitivity, specificity and accuracy) in detecting TFCC injury, using arthroscopy as the gold standard.Materials and methods
The arthroscopic and MR findings of 150 patients who underwent arthroscopy for ulnar-sided wrist pain between January 2009 and November 2016 were retrospectively reviewed.Results
MRA was slightly more accurate compared to conventional MRI, and 1.5 T was slightly more accurate than 3.0 T. 1.5 T wrist MRA had a sensitivity of 80%, a specificity of 100% and accuracy of 90%; 3.0 T wrist MRA 73, 100 and 86%, resp. Conventional 1.5 T wrist MRI had a sensitivity of 71%, a specificity of 75% and accuracy of 73%. For 3.0 T conventional MRI, this was 73, 67 and 70%, resp.Conclusions
MRA seems slightly superior to conventional MRI, but one could question whether this difference in diagnostic accuracy outweighs the burden and risks of an invasive procedure for patients with its additional costs. Furthermore, we could not confirm the superiority of 3 T compared to 1.5 T.4.
Purpose
The purpose of this study was to report our experience of wrist arthroscopy in children and adolescents with chronic wrist pain in a retrospective single surgeon series. Therefore, technical differences or obstacles compared to standard wrist arthroscopy in adults, and complications were highlighted.Methods
A retrospective data review of all patients undergoing wrist arthroscopy between 2002 and 2011 was performed. The basic inclusion criteria was chronic, therapy refractory wrist pain for more than three months in children and adolescents aged 18 years and younger. In total, 34 arthroscopies in 27 girls and six boys were reviewed. The mean age at time of arthroscopic exploration was 14.6 years (range, 9.8–17.9 years).Results
A total of 28 wrists showed a triangular fibrocartilage complex (TFCC) tear (82.4%). In 26 of 34 (76.5%) inspected wrist joints additional pathologies besides TFCC tears were documented. As a consequence, 14 arthroscopic TFCC resections, two arthroscopic TFCC repairs and seven open resection arthroplasties were performed. Other concomitant procedures (e.g. ulna shortening) were performed in 25 patients (26 wrists) because of predisposing malformations. No intraoperative or postoperative complications related to the arthroscopies were observed. No relevant technical differences to wrist arthroscopy in adults were experienced apart from cases of major anatomical malformations.Conclusions
Wrist arthroscopy has been shown to be a safe procedure to detect and treat paediatric wrist disorders. Nevertheless, we believe that this procedure should only be carried out by well-trained, experienced hand surgeons.5.
Objective
Arthroscopic decompression (wafer procedure) of the ulnocarpal compartment in patients with ulnar impaction syndrome.Indications
The arthroscopic wafer procedure is recommended in ulnar-plus situations with up to 3 mm length-excess. To perform this procedure the ulnar head needs to be accessible for the burr through a pre-existing, impaction-related, centroradial lesion of the triangular fibrocartilage complex (TFCC). The additional presence of a distal radioulnar joint (DRUJ) type C confirms the indication.Contraindications
The wafer procedure is contraindicated if there is no consistent TFCC injury ensuring access to the ulnar head and furthermore in ulna-plus situations of more than 3 mm. Relative contraindications: in young patients due to lack of evidence-based studies.Surgical technique
Arthroscopic, semicircular, partial resection of the ulnar head in terms of oblique–helicoidal osteotomy using a 4.2 mm burr, while sparing the DRUJ and the dorsal and the palmar radioulnar ligaments.Postoperative management
Immobilization for 1 week in a palmar splint with immediate intensive exercising of pro- and supination under physiotherapeutic instruction.Results
Between 2008 and 2010, an arthroscopic wafer procedure was performed in 24 patients. The resection of the ulnar head was 2.5 mm on average. After a mean follow-up time of 13.25 months, very good results were archived in 23 of 24 patients; the ulnar impingement test was negative. On a visual analog scale (0–10) average postoperative pain was 1.16 at rest and 4.5 under stress. The mean postoperative DASH score was 13.4.6.
Background
Avulsion fractures around the knee in children and adolescents are rare injuries and usually occur during sport activities. This article describes the epidemiology, classification and current treatment strategies for these injuries.Objective
This article gives an overview of the epidemiology, classification and current treatment concepts of pediatric avulsion fractures around the knee.Results
The most frequent pediatric avulsion fractures around the knee affect the tibial tuberosity and both the anterior and posterior cruciate ligaments. Bony avulsion of the cruciate ligaments can be classified according to Meyers and McKeever. In many cases there are indications for surgical treatment but non-dislocated fractures can be conservatively treated. Apophyseal fractures of the tibial tuberosity are as a rule repositioned by an open procedure followed by fixation with screws. The options for surgical treatment of bony avulsion of the cruciate ligaments are manifold, ranging from direct open screw fixation to bone anchoring and arthroscopic repositioning with suture cerclage. The advantages of arthroscopic procedures are the possibility to simultaneously treat unilateral accompanying injuries, such as meniscus ruptures.Conclusion
Non-dislocated pediatric avulsion injuries near the knee can be treated conservatively under regular clinical and radiological follow-up control. Dislocated avulsions and non-dislocated avulsions with accompanying injuries are surgically treated. Arthroscopic procedures should be a standard procedure with respect to bony avulsion of the anterior cruciate ligament. In contrast, bony avulsion of the posterior cruciate ligament and injuries of the tibial tuberosity must be addressed rapidly and effectively with direct open repositioning.7.
Background
Interpositional synthetic patch repairs are a novel method of treating massive irreparable rotator cuff tears. However, surgeons experience difficulty in the arthroscopic insertion of these patches.Questions/Purposes
We compared two methods of arthroscopic interpositional synthetic patch repair: the newly devised slide-and-grip technique, using pre-loaded sliding knots and no arthroscopic knots, and the weave technique, using less arthroscopic knot tying than the earlier mattress technique. Study questions were as follows: (1) Would the slide-and-grip technique take less time than the weave technique? (2) Would the biomechanical strength of the two methods be comparable?Methods
Fourteen paired ovine infraspinatus tendon ex vivo models of the degenerative human rotator cuff underwent timed repair with a synthetic polytetrafluoroethylene (PTFE) patch, using either the weave technique (n?=?7) or the slide-and-grip technique (n?=?7). Each was pulled to failure using a tensile testing machine, the Instron 8874.Results
The time to complete the slide-and-grip repairs was shorter (12?±?0.9 min) than that of the weave repairs (23?±?1 min). Ultimate load to failure was comparable for the slide-and-grip and weave techniques (211?±?27 N vs. 295?±?35 N, respectively), and the slide-and-grip was less stiff (14?±?1 N/mm vs. 19?±?1 N/mm).Conclusions
The slide-and-grip technique took less time than the weave technique for the interpositional patch repair of massive irreparable rotator cuff tears and when correctly performed had comparable biomechanical strength.8.
Purpose
Aim of this study is to compare late degenerative MRI changes in a subset of patients operated on with ACDF to a second subset of patients presenting indication to ACDF but never operated on.Methods
Patients from both subgroups received surgical indication according to the same criteria. Both subgroups underwent a cervical spine MRI in 2004–2005 and 10 years later in 2015. These MRI scans were retrospectively evaluated with a cervical spine ageing scale.Results
Comparing the two subset of patients both suffering from clinically relevant single-level disease returns no statistically significant difference in the degenerative condition of posterior ligaments, presence of degenerative spondylolisthesis, foraminal stenosis, diameter of the spinal canal, Modic alteration, and intervertebral discs degeneration at 10-year follow-up.Conclusions
The adjacent segment degeneration represents, in the present cohort, a result of the natural history of cervical spondylosis rather than a consequence of fusion.9.
Purpose
The aim of this study is to describe a new surgical procedure to plicate the anterior bundle medial collateral ligament (aMCL) into its humeral footprint using a suture anchor, and to present the results of a preliminary clinical series.Methods
Eight patients with posttraumatic medial elbow pain and signs of medial elbow instability underwent aMCL plication with suture anchors and decompression of ulnar nerve. Arthroscopic evaluation permitted to define signs of minor medial elbow instability; 70°-scope was used to document from an intra-articular point of view of the aMCL status. The patients were then retrospectively evaluated with the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPI) and single-assessment numeric evaluation (SANE) by an independent examiner.Results
In all cases, the 70°-scope allowed direct visualization of the aMCL. Lateral subluxation of the coronoid process into the trochlea was observed in all patients. Postoperative median SANE was 50 [35–74.5] points; postoperative median OES was 17 [15.5–31.5] points; postoperative median MEPI was 65 [57.5–72.5] points. None of the patients reported further episodes of medial elbow instability or pain and all patients returned to normal daily activities.Conclusions
The 70°-scope arthroscopic evaluation of the joint allows a direct evaluation of the inner aMCL status. Lateral subluxation of the coronoid process into the trochlea was observed and can be considered a sign of minor medial elbow instability. Mini-open suture anchor aMCL plication is an original technique that enables an anatomic and minimally invasive ligament retension.Clinical relevance
The authors introduce a valid and safe treatment of posttraumatic medial elbow laxity.10.
Objective
Anatomical reconstruction of the distal radius after intra-articular fractures with special consideration of the articular surface and treatment of concomitant ligament injuries.Indications
Intra-articular distal radius fractures in adults under 65 years of age.Contraindications
Osteoporotic deterioration of metaphyseal bone, radiocarpal fracture dislocation and open fractures.Surgical technique
Conventional palmar approach for plate fixation of the fracture with a fixed angle locking plate. Arthroscopy of the wrist is performed for reduction of the articular fracture component using the standard 3?4 and 6R portals. Following temporary Kirschner (K) wire fixation of the fracture, angle stable locking screws are inserted into the most distal portion of the plate. Finally, the intercarpal ligaments and the triangular fibrocartilage complex (TFCC) are checked for concomitant lesions and if necessary subsequent treatment within the same operation.Postoperative management
Plaster cast fixation for 4 weeks followed by a physiotherapy program.Results
After arthroscopically assisted reduction of an intra-articular distal radius fracture, 17 out of the 23 patients were available for follow-up examination an average of 31 months after the procedure. The mean disabilities of the arm, shoulder and hand (DASH) score was 4.9 and the mean patient-rated wrist evaluation (PRWE) score was 6.0 at final follow-up. Except for wrist flexion, an active range of motion at the wrist as well as forearm rotation of more than 90?% was achieved compared with the uninjured contralateral side. Grip strength averaged 96?% compared with the contralateral side and pain levels under stress varied between 1 and 3 on a visual analog scale (range 0–10).11.
Philippe M. Tscholl Patrick O. Zingg Claudio Dora Eric Frey Stefan Dierauer Leonhard E. Ramseier 《Journal of children's orthopaedics》2016,10(1):25-30
Purpose
Mild slipped capital femoral epiphyses (SCFE) nevertheless show significant femoral head–neck deformities which may put cartilage and acetabular labrum at risk. Whether this deformity can be restored to normal has not yet been described in the literature.Methods
In a prospective follow-up study, 14 patients with mild SCFE underwent in situ fixation with a single 6.5-mm cancellous, partially threaded screw. In 14 patients arthroscopic osteochondroplasty was performed, and in 13 patients pre- and postoperative measurements of the α-angle were made using antero-superior radial magnetic resonance imaging.Results
After arthroscopic osteochondroplasty, the mean α-angle decreased from 57° (range 50°–74°) to 37° (range 32°–47°; p < 0.001). Six patients showed beginning degenerative intra-articular changes (four antero-superior cartilage and three antero-superior labrum lesions) at the time of hip arthroscopy. No intra-operative complications occurred. In one patient, arthroscopic debridement was necessary due to arthrofibrosis and persistent pain.Conclusion
Arthroscopic osteochondroplasty can successfully correct the antero-superior α-angle in patients with mild SCFE to normal values. Clinical randomized controlled studies with long-term follow-up are required to find evidence of improved functional and radiographic mid- and long-term outcome compared to in situ fixation alone.12.
Background
Flexor tendon injuries are common traumatic lesions of the hand. Despite technical innovations they are still a challenge for hand surgeons.Therapy concepts
In addition to aspects concerning suture techniques and suture materials, technical innovations and devices in the field of flexor tendon surgery and rehabilitation are presented.13.
K.-H. Frosch R. Akoto T. Drenck M. Heitmann C. Pahl A. Preiss 《Operative Orthopadie und Traumatologie》2016,28(3):193-203
Objective
An arthroscopic technique for the reconstruction of the posterolateral corner combined with posterior cruciate ligament (PCL) reconstruction was developed.Indications
Posterolateral rotational instabilities of the knee. Combined lesions of the PCL, the popliteus complex (PLT) and the posterolateral corner. Isolated PLT lesions lacking static stabilizing function.Contraindications
Neuromuscular disorders; knee deformities or fractures; severe posterolateral soft tissue damage.Surgical technique
Six arthroscopic portals are necessary. Using the posteromedial portal, resect dorsal septum with a shaver. Visualize the PCL, the lateral femoral condyle and the posterolateral recessus with the PLT. Dissect the popliteomeniscal fibers; retract PLT until sulcus popliteus is visualized. Drill a 6-mm tunnel anteriorly into the distal third of the sulcus popliteus. Visualize femoral footprint of the PLT and place an anatomical drill tunnel. Pull the popliteus bypass graft into the knee and fix with bioscrews. Fix the reconstructed PCL. In cases of additional LCL injury, reconstruct LCL with autologous graft.Postoperative management
Partial weight-bearing for 6 weeks, range of motion exercises, quadriceps-strengthening exercises on postoperative day 1. Full extension allowed immediately with flexion limited to 20° for 2 weeks, to 45° for up to week 4, and to 60° up to week 6. Use a PCL brace for 3 months, running and squatting exercises allowed after 3 months.Results
In the 35 patients treated, no technique-related complications. After 1 year, 12 patients had a mean Lysholm Score of 88.6 (± 8.7) points and a side-to-side difference in the posterior drawer test of 2.9 (± 2.2) mm (preoperative 13.3 [± 1.9] mm).Conclusion
Low complication risk and good and excellent clinical results after arthroscopic posterolateral corner reconstruction.14.
Keith T. Corpus Grant H. Garcia Joseph N. Liu David M. Dines Stephen J. O’Brien Joshua S. Dines Samuel A. Taylor 《HSS journal》2018,14(1):34-40
Background:
Management of symptomatic long head of biceps tendon (LHBT) pathology remains a source of debate.Questions/Purposes:
The purpose of this study was to identify consensus trends for the treatment of LHBT pathology among specialists.Methods:
A survey was distributed to members of the American Shoulder and Elbow Society (ASES), consisting of three sections—demographics, case scenarios, and general LHBT pathology management. Cases presented common clinical scenarios, and surgeons reported their management preferences. Consensus responses were defined as > 50% of participants giving a single response.Results:
One hundred and forty-two of 417 (34%) surgeons completed surveys. Forty-seven percent of questions reached a consensus answer. Biceps tenodesis was the overwhelmingly preferred technique in cases demonstrating LHBT pathology, as compared to tenotomy. No consensus, however, was reached regarding a specific surgical technique for biceps tenodesis. The two most popular techniques were arthroscopic tenodesis to bone and open subpectoral biceps tenodesis. Fellowship-trained arthroscopic surgeons and surgeons with a largely arthroscopic practice were more likely to perform tenodesis arthroscopically.Conclusion:
ASES members favored biceps tenodesis over tenotomy for surgical management of LHBT pathology, without consensus regarding a specific surgical technique.15.
Martin Laura Chandrasekaran Neeraja Benardete Denise Cariello Lisa Davila Guillermo Willy 《International urogynecology journal》2017,28(7):1101-1102
Introduction and hypothesis
We present a simple approach to the marsupialization of a Skene’s gland cyst.Methods
Our technique facilitates suture placement to exteriorize the cyst wall to efficiently treat a distal Skene’s gland cyst and reduce the risk of recurrence.Conclusion
Marsupialization is an accepted option for the surgical management of Skene’s gland cyst. This technique is an effective and streamlined approach to Skene’s gland marsupialization.16.
Background
The aim of this systematic review and meta-analysis was to evaluate closure materials and suture techniques for emergency and elective laparotomies. The primary outcome was incisional hernia after 12 months, and the secondary outcomes were burst abdomen and surgical site infection.Methods
A systematic literature search was conducted until September 2017. The quality of the RCTs was evaluated by at least 3 assessors using critical appraisal checklists. Meta-analyses were performed.Results
A total of 23 RCTs were included in the meta-analysis. There was no evidence from RCTs using the same suture technique in both study arms that any suture material (fast-absorbable/slowly absorbable/non-absorbable) is superior in reducing incisional hernias. There is no evidence that continuous suturing is superior in reducing incisional hernias compared to interrupted suturing. When using a slowly absorbable suture for continuous suturing in elective midline closure, the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86).Conclusions
There is no high-quality evidence available concerning the best suture material or technique to reduce incisional hernia rate when closing a laparotomy. When using a slowly absorbable suture and a continuous suturing technique with small tissue bites, the incisional hernia rate is significantly reduced compared with a large bites technique.17.
C. Ziegler I. Neshkova K. Schmidt R. Meffert M. Jakubietz R. Jakubietz 《Operative Orthopadie und Traumatologie》2016,28(2):111-127
Objective
Reconstruction of the ruptured ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb.Indications
Ruptured ulnar collateral ligament of the thumb MP joint with instability: joint opening of more than 30° in flexion and more than 20° in extension, Stener lesion, displaced avulsion fractures.Contraindications
Abrasions, wound-healing disturbance, skin disease, osteoarthritis.Surgical technique
Curved skin incision dorsoulnar above the thumb MP joint. Protection of the branches of the superficial radial nerve. Incision of the adductor aponeurosis. Exposing the ulnar collateral ligament; opening and examination of the joint. Depending on the injury, primary suture repair, transosseous suture, repair with a bone anchor, osteosynthesis with K-wires or small screws in avulsion fracture, ligament reconstruction in chronic instability or older injury.Postoperative treatment
Cast splint of the MP joint until swelling subsides; cast immobilization for 6 weeks; range-of-motion exercises, avoiding forced radial deviation of the MP joint for 3 months.Results
Complete joint stability 3 months postoperatively in all 34 patients with rupture of the ulnar collateral ligament.18.
Jing Hui Yik Bryan Thean Howe Koh Wilson Wang 《Journal of orthopaedic surgery and research》2017,12(1):188
Background
Bucket-handle meniscus tears (BHMT) are often displaced and unstable. The inside-out technique of repairing such tears is currently the gold standard. All-inside repair with meniscal fixators is getting increasingly popular. Shortcomings of the inside-out technique include neurovascular complications, especially saphenous nerve palsy, and retention of a non-resorbable suture which can result in discomfort to patient, granuloma formation, and a foci of infection. Hence, the purpose of this project was to innovate a novel all-inside technique to precisely reduce and fix BHMT while avoiding neurovascular complications and retention of a non-resorbable suture.Methods
Routine arthroscopic portals were created on a patient’s left knee with a displaced BHMT. Through the anteromedial portal, a conjoint pseudo double lumen cannula was inserted. Two limbs of a reduction suture were passed through the cannula, one over the “femoral” surface of the meniscus, one over the “tibial” surface of the meniscus anterior to the biceps femoris tendon, with the knee flexed at 20° to avoid injury to the saphenous nerve. Suture limbs were passed out percutaneously and tensioned.Results
Anatomic reduction was ensured under arthroscopic visualization with ease. All inside repair was performed using the vertical mattress suture configuration. Reduction sutures were subsequently removed by cutting flush to the skin and pulling on one suture limb. The patient was back to full activities with minimal discomfort 8 months post-operatively.Conclusion
The technique described is superior to existing techniques for the following reasons: (1) Reduction of the displaced meniscal tear is “extra-meniscal,” avoiding further trauma to a damaged meniscus. (2) Tensioning of the two suture limbs created promotes better control of reduction through tensioning. (3) Risk of discomfort, infection, and neurovascular damage caused by a retained suture is reduced. (4) No additional portals/equipment is required. We encourage this novel technique to be attempted by surgeons.19.
Michael E. Berend John B. Meding Robert A. Malinzak Philip M. Faris Michael D. Jackson Kenneth E. Davis Merrill A. Ritter 《HSS journal》2016,12(3):235-239
Background
ACL status varies in the arthritic knee during TKA.Questions/Purposes
The purpose of this study was to examine clinical features and intraoperative findings associated with stages of ACL degeneration.Methods
Coronal deformity, ROM, intra-articular degenerative patterns, and ligament releases were assessed for 1656 knees during TKA. Common patterns of deformity and severity of degenerative change were assessed as a function of the severity of ACL deficiency.Results
Of the 1656 knees assessed, 27% had a normal ACL, 55% exhibited damage, and 18% exhibited complete absence of the ACL. Increased coronal deformity and lower preoperative ROM was associated with ACL deficiency. Increased chondral and meniscal damage and more extensive osteophyte formation were also found. More extensive ligament releases were required in ACL-deficient knees.Conclusions
The status of the ACL is predictive of the need for increased surgical deformity correction. A better understanding of ACL status is an important consideration during in choosing TKA as opposed to unicompartmental arthroplasty. The status of the ACL should be considered in planning for implant choice in TKA.20.