A Minimally Invasive Technique for the Reduction of Calcaneal Fractures Using the Endobutton®

Calcaneal fractures are very common injuries, and closed reduction-percutaneous pinning, open reduction-internal fixation, and primary arthrodesis are the procedures used in the surgical treatment of these injuries. The aim of surgical treatment is to restore the normal biomechanics of the Achilles tendon and rearfoot by anatomic reduction of the articular surfaces. Minimization of the soft tissue complications commonly associated with the open treatment of calcaneal fractures can be achieved using indirect closed reduction and Kirschner wire or screw-assisted minimally invasive percutaneous osteosynthesis methods. In the present report, we describe a technique for the treatment of calcaneal fractures associated with soft tissues that are at risk of complications and present the cases of 3 patients treated with indirect, minimally invasive reduction of comminuted calcaneal fractures with the Endobutton^® fixation device. From our experience with this method, we believe it will be useful in cases of acute calcaneal fracture with pronounced soft tissue injury localized to the hindfoot.     

An Alternative Technique for Fixation of Tongue-Type Calcaneal Fractures: The “Hurricane Strap”

Traditionally, tongue-type calcaneal fractures have been treated using screw fixation or tension band wiring. In this work, we aim to present a technique guide for an alternative approach to fixation of these fractures given the high potential for failure with traditional methods. Additionally, we present the results of 4 patients treated with this technique. A modified lateral extensile incision is made for application of a midfoot fusion plate that is pre-bent and fit to the calcaneus with 2 holes covering the superior surface of the calcaneus for bicortical interfragmentary purchase. Four screws are then placed orthogonally into the calcaneus through the plate. Typically, this allows for 2 screws to be placed in the superior fragment and 2 screws to be placed in the inferior fragment. All 4 patients went on to timely osseous union and were weightbearing in regular shoe gear at their last follow-up appointment. Average follow-up time was 16.5 (range 15 to 21) months. We believe that the “hurricane strap” provides a more mechanically sound construct than other methods. This construct may be especially useful in patients with osteoporotic bone where screws alone may not maintain adequate reduction or in neuropathic patients where noncompliance with weightbearing status may jeopardize maintenance of reduction.     

Editorial Commentary: Which Procedure Contributes to Best Outcomes After Arthroscopic Reduction and Minimally Invasive Surgery for Ankle Fractures?

The algorithm of arthroscopic reduction and minimally invasive surgery (ARMIS) can decrease the incidence of complications and reoperations, in spite of longer operative times and higher doses of irradiation for the patients with a supination–external rotation ankle fracture. At the present time, however, we cannot identify which procedure contributes to improved outcomes with use of the ARMIS algorithm.     

A Minimally Invasive “Overwrapping” Technique for Repairing Neglected Ruptures of the Achilles Tendon

About 10% to 25% of acute ruptures of the Achilles tendon go undiagnosed for some time beyond what would be optimal for repair and a return to optimal function. Managing these chronic or neglected ruptures is a surgical challenge, because the tendon ends retract and atrophy and could develop a short, fibrous distal stump. In the present report, a patient with a ruptured right Achilles tendon, neglected for approximately 10 years, is described. The chronically injured tendon was successfully treated by overwrapping the interposed scar at the rupture site. This minimally invasive technique restored tension to the tendon, a prerequisite for which was the presence of functional triceps surae, confirmed by identification of gross contraction of the muscle during tiptoeing. The procedure is contraindicated when the scar tissue is not intact and does not have sufficient laxity to allow adequate dorsiflexion of the ankle after overwrapping the tendon or when the triceps surae are nonfunctional.     

Limb Reconstruction System Assisted Reduction and Internal Fixation for Intra‐Articular Calcaneal Fractures: A New Application

Background

Minimally invasive reduction and fixation of intra-articular calcaneal fractures poses great challenges for orthopaedic surgeons. The aim of the present study was to report the technical points, evaluate the efficacy of minimally invasive reduction and internal fixation assisted by the temporary limb reconstruction system (LRS) external fixator for intra-articular calcaneal fractures, and propose the indications of our protocol.

Methods

In this retrospective study, a series of 34 consecutive closed and displaced intra-articular calcaneal fractures involving the articular surface were treated by this technology between June 2016 and April 2018. X-ray and computed tomography (CT) scans were performed before and after surgery to measure Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot. Postoperative complications were recorded. Imaging and clinical outcomes were comprehensively evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scoring system. After testing the normality of the data, Bohler's angle and the length of calcaneus were compared using the Wilcoxon signed-rank test. The height, width of the calcaneus, and the mechanical axis of the hindfoot were compared using the Paired-Samples t-test.

Results

Thirty-two fractures were followed up for an average of 20.66 months (from 12 to 32 months). All fractures achieved stable reduction and bony union. The articular surface was reduced and fixed with direct vision through the sinus tarsi incision. No failure of internal fixation or loss of reduction was detected during follow-up. There were no soft tissue complications. Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot improved significantly. The AOFAS scores averaged 84.12 points; seven cases were rated excellent, 20 good, four fair, and one poor.

Conclusions

For intra-articular calcaneal fractures, minimally invasive surgery assisted with temporary LRS external fixation can reconstruct the calcaneal shape and the sub-talar articular surface. This simple surgical modality with limited complications may be helpful in the surgical treatment of most type II and III calcaneal fractures except comminuted fractures of the calcaneal tuberosity.     

An Alternative Method of Fixation of Calcaneal Tuberosity Fractures Using the Tightrope® Technique

Calcaneal tuberosity fractures account for 1% to 3% of all calcaneal fractures. These fractures are frequently seen in the osteoporotic or diabetic elderly population. The patient's comorbidities, coupled with the usually osteoporotic bone, make fixing this fracture pattern a challenge. Numerous surgical techniques have been advocated for this fracture, including the standard lag screw fixation, tension band wiring, suture anchors, and direct suture repair. Whichever method is used, the construct must resist the massive pull of the gastrocnemius–soleus complex. We have described a method of fixing the avulsed calcaneal tuberosity using the TightRope^® ankle syndesmosis fixation device (Arthrex^®, Naples, FL), which offers the advantages of allowing a robust and reliable fixation of a small or comminuted fragment. It is particularly advantageous in osteoporotic bone because of concern regarding the use of standard lag screw fixation, and it also may eliminate complications associated with retained hardware.     

Urolift: a New Face of Minimally Invasive Surgical Technique for Benign Prostatic Hyperplasia?

The management of clinical benign prostatic hyperplasia (BPH) remains a common problem in daily urologic practice. Recently, a new minimally invasive procedure for BPH, the Urolift System, has been introduced. This article reviews the current literature discussing the technique, efficacy, adverse events, limitations, and possible concerns. The existing data which includes a 3-month, sham-controlled multicenter trial with a subsequent 3-year follow-up indicates significant improvements in the outcome measures in particular urinary symptoms. The adverse event profile and reoperation rates are acceptable. A particular benefit includes the lack of negative effects on erectile or ejaculatory function. The procedure can be performed with minimal anesthesia, but is limited to lateral lobe enlargement as it is unsuitable for median lobe or central zone obstruction. Another potential drawback is the placement of permanent implants into the prostatic urethra. The adoption of this procedure will ultimately be determined by multiple factors including ease of use, patient satisfaction, durability, and reimbursement.     

The “Tip-Stitch”: A Time-Saving Technique for Specimen Extraction in Sleeve Gastrectomy

Background  Laparoscopic sleeve gastrectomy has gained popularity as another tool available to weight loss surgeons, with published excess weight loss results similar or superior to laparoscopic adjustable gastric banding. The gastrectomy specimen consists of a hollow “bag” of fundus, which is typically extracted through an enlarged port site. Extraction can be a challenging and time-consuming portion of the operation. Methods  The “Tip-Stitch” is a low-technology method of orienting the gastric specimen for easy retrieval. A suture through the distal tip of the specimen allows for extraction without enlarging a 15-mm trocar site. Results  We report a small series of sleeve gastrectomy using this specimen extraction technique. No wound infections were seen, and enlargement of the fascial incision was done only once, early in our experience. Conclusions  Our technique describes a reliable method of intact specimen retrieval, typically without enlarging a 15-mm trocar incision. The opinions expressed on this document are solely those of the authors and do not represent an endorsement by or the views of the United States Air Force, the Department of Defense, or the United States Government.     

Minimally Invasive 360° Fusion Using a Combination of INFIX and Minimally Invasive Spinopelvic Fixation by Intraoperative Computed Tomography Navigation for Unstable Pelvic Ring Fracture: A Technical Note

Objective

Fluoroscopy is often used in the surgery of unstable pelvic ring fractures, and improved safety in implant placement is an issue. An anterior subcutaneous pelvic fixator (INFIX) combined with a percutaneous screw has been reported to be a minimally invasive and effective surgical technique for unstable pelvic ring injuries. However, although percutaneous screw fixation is minimally invasive, its indications for fracture fixation and fractures with large fragment displacements in the vertical plane remain controversial. Therefore, this technical note aims to describe a new technique for unstable pelvic ring fractures.

Methods

We describe a 360° fusion of the pelvic ring to treat unstable pelvic ring fractures, including vertical shear pelvic ring fractures, using an intraoperative CT navigation system. Seven patients were treated with 360° fusion for type C pelvic ring fractures. In surgery, after reducing the fracture with external fixation, intraoperative CT navigation is used to perform a 360° fusion with INFIX and minimally invasive surgical spinopelvic fixation (MIS-SPF). We will introduce a typical case and explain the procedure.

Results

A 360° fixation was performed, and no perioperative complications were noted. The mean blood loss was 253.2 ± 141.0 mL, and the mean operative time was 224.3 ± 67.4 min. In a typical case, bone union was obtained 1 year after surgery, and we removed all implants.

Conclusions

MIS-SPF has a strong fixation force and helps reduce fractures' horizontal and vertical planes. In addition, 360° fusion with intraoperative CT navigation may help treat unstable pelvic ring fractures.