The 3D-Printed Custom Elbow Prosthesis for Salvage Treatment of Complex Intra-Articular Distal Humerus Fracture Malunion.

Intra-articular fractures of the distal humerus are complex injuries that often require surgery with the goal of restoring elbow range-of-motion and function. Open reduction and internal fixation has been the preferred surgical modality; however, restoration of the medial and/or lateral columns can be complicated in fractures involving a major loss of the articular surface and bony structure. Over the past decade, 3-dimensional (3D) printing has made significant advances in the field of orthopedic surgery, specifically in guiding surgeon preoperative planning. Recently, the incorporation of 3D-printing has proven to provide a safe and reliable construct for the restoration of anatomy in complex trauma cases. We present a 47-year-old woman who sustained a complex, intra-articular distal humerus fracture with associated shearing of the capitellum that went onto malunion. Patient was treated with a patient-specific 3D-printed custom elbow prosthesis with excellent outcomes. Our goal was to shed light on the use of 3D-printing technology as a viable salvage option in treating complex, intra-articular distal humeral fractures associated with lateral condylar damage that subsequently went onto malunion.

Intraobserver and Interobserver Reliability of the Snyder and Expanded SLAP Classification System: A Video Study.

Background: Superior labral anterior and posterior (SLAP) tears are a common finding in overhead athletes. The original classification system produced by Snyder in 1990 contained 4 types of SLAP tears and was later expanded to 10 types. The classification has been challenging because of inconsistencies between surgeons making diagnoses and treatments based on the diagnosis. Furthermore, patient factors-such as age and sports played-affect the treatment algorithms, even across similarly classified SLAP tears. Purpose: To (1) assess the interobserver and intraobserver reliability of the Snyder and expanded SLAP (ESLAP) classification systems and (2) determine the consistency of treatment for a given SLAP tear depending on different clinical scenarios. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 20 arthroscopic surgical videos and magnetic resonance imaging scans of patients with SLAP tears were sent to 20 orthopaedic sports medicine surgeons at various stages of training. Surgeons were asked to identify the type of SLAP tear using the Snyder and ESLAP classifications. Surgeons were then asked to determine the treatment for a SLAP tear using 4 clinical scenarios: (1) in the throwing arm of an 18-year-old pitcher; (2) in the dominant arm of an 18-year-old overhead athlete; (3) a 35-year-old overhead athlete; (4) or a 50-year-old overhead athlete. Responses were recorded, and the cases were shuffled and sent back 6 weeks after the initial responses. Results were then analyzed using the Fleiss kappa coefficient (κ) to determine interobserver and intraobserver degrees of agreement. Results: There was moderate intraobserver reliability in both the Snyder and ESLAP classifications (κ = 0.52) and fair interobserver reliability for both classification systems (Snyder, κ = 0.31; ESLAP, κ = 0.30; P < .0001) among all surgeons. Additionally, there was only fair agreement (κ = 0.30; P < .0001) for the treatment modalities chosen by the reviewers for each case. Conclusion: This study demonstrated that SLAP tears remain a challenging problem for orthopaedic surgeons in diagnostics and treatment plans. Therefore, care should be taken in the preoperative discussion with the patient to consider all the possible treatment options because this may affect the postoperative recovery period and patient expectations.

Chronic Volar Distal Radial Ulnar Joint Dislocation: A Case Report with Proposed Treatment Algorithm.

CASE: We report the case of a 34-year-old woman with a chronic right volar dislocation of the distal radioulnar joint (DRUJ) and associated ulnar styloid fracture. The patient presented 1 month after a dog bite injury with wrist pain and limited range of motion, and radiographs demonstrated volar DRUJ dislocation. Closed reduction was unsuccessful, and thus, open reduction was performed. CONCLUSION: Isolated volar DRUJ dislocations in the absence of fractures are easy to misdiagnose on plain radiographs. We present our surgical technique and fixation algorithm for open reduction and stabilization for chronic volar DRUJ dislocations.

"Safe dissection parameters of the anconeus rotational flap for soft tissue coverage at the elbow".

Background: The anconeus is a small muscle located on the posterior elbow originating on the lateral epicondyle and inserting onto the proximal-lateral ulna that functions as an elbow extensor as well as dynamic stabilizer. The blood supply is tri-fold: medial/middle collateral artery (MCA), recurrent posterior interosseous artery (RPIA), and less commonly found, the posterior branch of the radial collateral artery. The anconeus has become a popular option for local soft tissue coverage about the elbow (distal triceps, olecranon, proximal forearm). The average defect size for consideration of local anconeus flap coverage is 5-7cm2. The aim of the study was to determine safe dissection parameters of the anconeus as well as map arterial pedicles to achieve successful local harvest of the muscle without devascularization. Materials and Methods: 8 fresh frozen cadaveric arms (all male, average age 63 years - 4 left arms, 4 right arms) from scapula to fingertip were obtained. First, the radial, ulnar and axillary arteries were dissected and isolated. The radial and ulnar arteries were transected. 100cc normal saline was injected through the axillary artery, sequentially clamping the radial followed by the ulnar artery so that adequate flow could be seen through all vessels. 100cc mixture of Biodür and hardener (10:1) was mixed and injected into the axillary artery. We first allowed free flow through both the ulnar and radial vessels followed by clamping of these vessels. This allowed the pressure to build up and fill the smaller vessels in the arms. After injection, the axillary artery was then clamped and the specimens were left to harden for 24-48 h. After hardening, dissection was performed by making a curvilinear incision centred over the lateral epicondyle. The anconeus was identified and the interval between the anconeus and ECU was then confirmed. Measurements of the anconeus muscle were taken. Blunt dissection was carried between anconeus and ECU until the RPIA was identified and protected. We isolated the MCA by dissecting proximally. This was found to run with the nerve to the anconeus. Once this vessel had been protected, the muscle reflected from distal to proximal staying along its ulnar border. The branches of the RPIA were ligated and the dissection was continued proximally. Measurements of the distances of the RPIA, MCA were taken. Results: The average distance of olecranon to muscle tip was 95.0mm. The average distance of lateral epicondyle (LE) to muscle tip was 90.8mm. The average distance of LE to olecranon was 49.8mm. The average location of the RPIA was 63.mm when measuring LE to vessel, 68.3mm when measuring olecranon to vessel, 18.3mm when measuring RPIA to muscle tip. The average RPIA diameter was 1.1mm and length was 36.4mm from the initial branching of the posterior interosseous artery. The average MCA diameter was 0.7mm. The posterior branch of the radial collateral artery was only found in 3/8 specimens. The RPIA and MCA were constant in all specimens. Dissection was safely carried to the border of the LE and olecranon without disruption of the MCA. CONCLUSIONS: Our conclusions determined that if dissection of the anconeus is undertaken, the RPIA remains constant between the interval of the ECU as well as anconeus at an average distance of 18.3mm from the tip of the muscle measuring proximally; moreover, the MCA was constant in all specimens found directly between the LE and olecranon always running with the nerve to the anconeus. When dissecting and mobilizing to ensure preservation of the MCA, dissection should be taken from distal to proximal as well as dissecting along the ulnar border of the anconeus. Proximal dissection can be taken as proximal as the border of the LE and olecranon as that did not disrupt MCA blood supply.

Swan Neck Deformity: An Unusual Complication Following Trigger Finger Release.

Introduction: Swan neck deformity (SND) is a common pathologic finding often observed in patients with severe rheumatoid arthritis. However, it has also been seen in injuries such as mallet finger, flexor digitorum superficialis laceration, and intrinsic contracture. Open surgical release of a trigger finger most commonly involves the release of the A1 pulley to relieve a mechanical impingement. Bowstringing is a rare trigger finger release complication caused by excessive pulley resection, usually due to resection of the A2 pulley. As a result of this complication, the flexor tendons move away from their center of rotation, gaining an increased mechanical advantage over the extensors and can ultimately result in a SND. Case Report: We present a case report of a 61-year-old patient that presented to our clinic with a SND of the 4th digit following a trigger finger release. Conclusion: Our case demonstrated that a previous trigger finger release with disruption of the A2 pulley can cause a cascade of events that can result in SND.

Biomechanical analysis of single-incision anatomic repair technique for distal biceps tendon rupture using tunneling device.

Hypothesis: Single-incision biceps tendon repair with an arthrotunneling device has previously been shown to be a safe and effective technique that provides the anatomic restoration of a two-incision approach and a reduced complication profile. This repair provides adequate and comparable fixation to repairs utilizing anchors, buttons, screws, etc., at a lower cost. Material and methods: This study utilized 10 cadaveric specimens. Native and repair specimens were cyclically loaded and graft displacement, flexion/extension (FE) and pronation/supination (PS) moment arms at 12.5° to 152.5° (in 5° increments) before and after repair, and maximum load to failure were measured. Results: The FE and PS moment arms and overall maximum moment arms were both significantly larger in the repaired case than in the native case (p < 0.01). Moment arms for supinated specimens were significantly greater than neutral specimens, which in turn was greater than pronated specimens (p < 0.01). The maximum load up to 10 mm of repair displacement was 214.5.0 ± 66.6 N and the repair displacement due to 1000 cycles of 50 N was 2.56 ± 2.06 mm. Conclusion: The single-incision arthrotunneling technique is a safe and effective repair that recreates the anatomic footprint and biomechanics of the native biceps and has a reduced complication profile compared to a two-incision approach.

Return-to-Play Outcomes of Athletes After Operative and Nonoperative Treatment of Lumbar Disc Herniation.

PURPOSE OF REVIEW: Lumbar disc herniation (LDH) is a common injury experienced by athletes and has important clinical considerations for athletes including the timing of return to sport. Lumbar disc herniation may result in loss of individual training and playing time for athletes. Current literature is inconclusive on whether surgical or conservative treatment of LDH is superior in athletes. Our aim was to review the literature to identify return-to-play (RTP) rates and performance outcomes following operative and nonoperative treatment of LDH in the athletic population. RECENT FINDINGS: Athletes have unique measurements of successful treatment for LDH such as time to return to their sport and performance outcomes that are not as applicable as traditional metrics. It is suggested that surgical treatment may provide a quicker return to sport than nonoperative care in athletes. Additionally, conflicting findings have been seen in career length and performance status based on sport, often due to short and tumultuous career patterns. These differences may be seen based on the unique physical demands of each sport, different motivations to prolong sport, or other confounding factors that could not be controlled for or unrelated to LDH. Recent literature on RTP outcomes in athletes treated for LDH show variable results based on sport. Further research is needed to assist physicians and athletes in making the decision to undergo conservative or surgical treatment of LDH in the athletic population.

Biomechanical Analysis of Ideal Knee Flexion Angle for ACL Graft Tensioning Utilizing Multiple Femoral and Tibial Tunnel Locations.

Anterior cruciate ligament (ACL) graft failure rate has been reported to be greater than 5% at 5 years. Our study evaluated ACL excursion with anatomic and nonanatomic femoral and tibial tunnels to determine optimal flexion angle to tension the ACL to minimize excursion. Ten cadaveric knee specimens were used. The ACL was sectioned and the femoral and tibial attachments were marked. A 1/16-inch drill created a tunnel in the center of the ACL footprint on the tibia and femur and additional tunnels were made 5 mm from this. A suture was passed through each tunnel combination and attached to a string potentiometer. The knee was ranged from full extension to 120 degrees of flexion for 10 cycles while mounted in a custom fixture. The change in length (excursion) of the suture during movement was recorded for each combination of femoral and tibial tunnels. Anatomic reconstruction of the ACL with tunnel placement in the center of the femoral and tibial footprint did not result in an isometric graft, with excursion of the ACL during knee motion of 7.46 mm (standard deviation [SD]: 2.7mm), greatest at 2.84 degrees of flexion (SD: 4.22). The tunnel combination that resulted in the least excursion was a femoral footprint 5 mm anterior to the femoral and 5 mm posterior to the tibial footprint (4. 2mm, SD: 1.37 mm). The tunnel combination that resulted in the most excursion utilized femoral footprint 5 mm proximal to the femoral and 5 mm posterior to the tibial footprint (9.81 mm, SD: 2.68 mm). Anatomic ACL reconstruction results in significant excursion of the ACL throughout motion. If not tensioned properly, the ACL can stretch during range of motion, potentially leading to rerupture. To prevent stretching of the graft, the current biomechanical study recommends tensioning an anatomic ACL reconstruction at its point of maximal excursion, or between 0 and 5 degrees of flexion. The level of evidence is IV.

Percent articular exposure of the distal humerus with triceps fascial tongue approach compared with olecranon osteotomy.

BACKGROUND: Distal humerus fractures are common and can be difficult to treat. No one approach to the distal humerus has been shown to be superior to another; however, the olecranon osteotomy remains the gold standard for complex, intra-articular fractures. Understanding the percent of articular exposure with approaches to the distal humerus is important for success. The goal of this study is to show the percent of articular exposure of the triceps fascial tongue approach as compared with the olecranon osteotomy. METHODS: Twelve fresh frozen cadavers were separated randomly into 2 groups of 6 each. The first group of 6 specimens was allocated to the triceps fascial tongue approaches with the collaterals maintained and with the collaterals released off the ulna and elbow dislocated. The second group of 6 was allocated to the triceps fascial tongue approach while maintaining the collaterals followed by an olecranon osteotomy. The articular exposure was marked after performing each approach, and the percent of articular exposure was quantified by using 3D scanning. Standard deviations were calculated for each. RESULTS: The average percent visualization of the distal humerus articular surface in the fascial tongue approach while maintaining the collaterals was 36% in the first cohort and 37% in the second cohort with a standard deviation of 5% in both cohorts. The average percent of the distal humerus articular surface exposed in the fascial tongue approach with the collaterals released off the ulna and elbow dislocated was 85.09% with a standard deviation of 4%. The average percent of the distal humerus articular surface exposed in the olecranon osteotomy group was 57.9% with a standard deviation of 5%. CONCLUSION: The triceps fascial tongue approach allows for visualization of about one-third of the joint, which may be adequate for many intra-articular distal humerus fractures. For added exposure of the articular surface, the collaterals may be elevated from the ulna and the elbow dislocated allowing for a substantial increase in percent of articular exposure compared with the collateral retaining fascial tongue approach and the olecranon osteotomy.

Masquelet Technique and Proximal Tibial Autograft Utilizing Avitus® Bone Harvester for Severely Comminuted Open Distal Radius Fracture with Extensive Bone Loss: A Case Report.

Introduction: Distal radius fractures are one of the most common fractures in the United States. Treatment usually involves internal fixation using a volar Henry approach with placement of a volar locking plate. Optimal treatment becomes less apparent when significant bone loss occurs. No case of an open distal radius fracture treated using a staged Masquelet technique involving proximal tibial autograft is available in the literature. Herein, we describe and discuss a case report of a novel technique to treat a large (5 cm) bone defect for an open distal radius fracture. Case Report: A 59-year-old man suffered an open, comminuted, and intra-articular distal radius fracture with 5 cm of bone loss. He was treated using a staged Masquelet technique with incorporation of ipsilateral proximal tibial autograft with a bone harvester to obtain cancellous autograft and bone marrow graft. The patient initially underwent emergent I and D, acute carpal tunnel release, and internal and external fixation. A 5 cm bone void was filled with antibiotic cement. Four weeks later, the antibiotic cement was removed, cancellous bone graft and marrow were harvested from the proximal tibia, and the graft was placed within the prior bone void. Fracture site healing was confirmed radiographically and with computer-tomography imaging 3 months later. The patient has demonstrated excellent results 1 year post-operative with 60° of wrist flexion, 40° of wrist extension with mild pain, and full finger range of motion with radiographic union. Conclusion: Internal fixation with placement of a volar locking plate remains the mainstay of treatment for distal radial fractures. However, in more comminuted fractures with bone loss, treatment becomes more challenging. We have presented a unique case utilizing a staged Masquelet technique with incorporation of a proximal tibial autograft to educate readers on an alternative option and technique for autograft donor sites in these more complicated fractures.

Biomechanical analysis of stability of joint depression calcaneal fractures: Fixation with locking compression plate alone compared with addition of supplemental oblique screw.

Purpose: The standard treatment of calcaneus fractures is a lateral plate and screw construct. Patients at our institution have been treated with a lateral locking plate combined with one retrograde screw inserted in the oblique plane to allow immediate weight bearing. The purpose of this study was to determine whether addition of a oblique screw to a lateral plate construct increases stability. Methods: A Sanders 2B fracture (AO/OTA 83-C2) was created in 8 pairs (16 total specimens) of cadaveric feet. All were repaired using a lateral locking plate/screws construct. One specimen in each pair was chosen randomly to receive an additional oblique screw. The specimens were tested with cyclic load of up to 800 N. Movement at the fracture sites and subsidence of the talus were tracked with a three-dimensional video analysis system. Results: Talar subsidence was not significantly affected by the presence of the additional oblique screw (p = 0.22). The sustentaculum fragment in the case of the screw repair moved 0.39 mm while the same fragment without the additional screw repair displaced 0.12 mm (p < 0.01). Two repairs with and one repair without the additional screw failed during longer-term cyclic loading. Conclusion: The two repair types were not statistically different in regards to talar subsidence. While statistical significance resulted in the comparison of sustentaculum fragment movement, the amount of movement did not reach a level of clinical relevance. This study demonstrated immediate stability and durability of the additional screw construct with high volume weight bearing loads.

Definitive fixation of open tibia fractures: Does reopening the traumatic wound increase complication rates?

BACKGROUND: It is unknown if surgical approach or use of previous traumatic wounds for open fracture instrumentation has an impact on patient complications or outcomes. This study sought to compare infection and nonunion rates in the staged treatment of open tibia fractures where the traumatic wound was reopened during definitive fixation versus when they were not. METHODS: A retrospective review was performed on all patients at a single institution level 1 trauma center. All patients who had a minimum of 1 year clinical and radiographic outcomes were included. Primary outcome measures were incidence of infection and nonunion. Groups of patients were compared based on surgical approach for definitive fixation. RESULTS: A total of 96 patients were included - 48 patients received definitive treatment and wound closure during initial management of the open fracture (group 1), 22 patients had staged fixation through new incisions (group 2), and 26 patients had their traumatic wound reopened during definitive fixation (group 3). Rates of infection were 10.4%, 31.8% and 11.5% respectively (p = 0.15). Rates of nonunion were 20.8%, 27.3% and 30.8% (p = 1.0). No statistically significant differences in regards to primary outcomes were found between the staged fixation groups. Multiple logistic regression also showed no difference in infection or nonunion when controlling for known risk factors. CONCLUSION: For open tibia fractures that underwent staged fixation, no significant differences in infection or nonunion were observed between procedures that involved reopening the traumatic wound versus procedures performed through new incisions. The presence of a distal tibia periarticular fracture was found to be independently associated with infection risk.

Distal Radioulnar Joint Instability and Associated Injuries: A Literature Review.

The distal radioulnar joint (DRUJ) allows supination and pronation of the distal forearm and wrist, an integral motion in everyday human activity. DRUJ injury and chronic instability can be a significant source of morbidity in patients' lives. Although often linked with distal radius fractures, DRUJ injury may occur in a variety of other upper extremity injuries, as well as an isolated pathology. Diagnosis of this injury requires the clinician to have a high index of suspicion and low threshold for clinical testing and further imaging of the DRUJ. The purpose of this article is to provide a review on DRUJ anatomy and biomechanics, to discuss common diagnostic and treatment modalities, and to identify common injuries associated with DRUJ instability.

Pigmented Villonodular Synovitis as an Atypical Cause of Deep Motor Branch Neuropathy.

OBJECTIVES: Compression of the ulnar nerve in Guyon's canal results in ulnar tunnel syndrome (UTS). The patient may present with sensory and motor deficits (zone 1), motor deficit (zone 2), or sensory deficit (zone 3). The most common causes of UTS include ganglion cysts, idiopathic ulnar nerve compression, occupational pressure neuritis (repetitive compression), prolonged compression, hook of hamate fractures, and arterial thrombus or aneurysm. CASE REPORT: We report an atypical cause of UTS involving pigmented villonodular synovitis (PVNS) with a review of the literature. Surgical decompression of the ulnar nerve at Guyon's canal has resulted in resolving motor weakness and improved interosseous strength at latest follow-up. CONCLUSION: The most common causes of UTS are ganglion, occupational neuritis, prolonged compression, and ulnar artery thrombi/aneurysms. However, other more rare causes such as PVNS should be considered in the appropriate patient.

The Loop 'N' Tack Biceps Tenodesis: An All-Arthroscopic, Intra-Articular Technique.

Tenodesis and tenotomy of the long head of the biceps are treatment options for a wide range of pathologies without clear superior technique or site of fixation. Clinical outcomes comparing numerous techniques for tenotomy versus tenodesis have resulted in similar pain relief; however, tenotomy may result in a cosmetic "Popeye" deformity and fatigue pain. We present a quick, simple, and knotless technique for tenodesis of the long head of the biceps at the proximal aspect of the bicipital grove that can be completed entirely arthroscopically. This technique uses suture to secure a tenotomized proximal biceps tendon to a knotless anchor just proximal to the subscapularis tendon at the proximal biceps groove. The tensionless repair allows the biceps to scar within the biceps groove, thereby reducing subsidence and formation of a "Popeye" deformity and fatigue pain in the biceps seen with tenotomy alone while eliminating the ability to overtension.

Identifying the Most Successful Procedures in Hip Arthroscopy.

Hip arthroscopy for femoral and acetabular pathologies has increased dramatically. However, there is little literature analyzing procedures as predictors of revision arthroscopy or arthroplasty. From February 2008 to November 2015, patients undergoing hip arthroscopy for a labral tear with minimum 2-year follow-up and between 18 and 60 years old were retrospectively reviewed. Those with previous surgeries, Tönnis grade greater than 1, and previous hip conditions were excluded. Follow-up was obtained for 1118 patients (1249 hips; 81.7%) with a mean age of 38.7 years (range, 18.0-60.0 years), mean body mass index of 26.4 kg/m2 (range, 16.3-48.9 kg/m2), and mean follow-up of 50.2 months (range, 24.0-111.9 months). A total of 122 (9.8%) patients converted to total hip arthroplasty (mean, 35.3 months; range, 1.4-95.2 months). Multivariate analysis for predictors of total hip arthroplasty found age at surgery (hazard ratio, 1.064/y; P<.05), body mass index (nonlinear; P<.05), labral debridement (HR, 1.558; P=.03), and notchplasty (HR, 2.128; P<.05), with trochanteric bursectomy (HR, 0.367; P<.05) identified as associated with higher survivorship. A total of 124 (9.9%) patients underwent revision hip arthroscopy at a mean of 21.7 months (range, 0.10-83.3 months). Multivariate analysis for predictors of revision surgery found workers' compensation (HR, 3.352; P<.05), capsular repair (HR, 1.950; P<.05), and femoral head microfracture (HR, 2.844; P=.04) to be significant, with age at date of surgery (HR, 0.973/y; P<.05) and femoral head chondroplasty (HR, 0.241; P=.05) associated with higher survivorship. Understanding risk factors for conversion to total hip arthroplasty or revision is paramount during discussions with patients. [Orthopedics. 2020;43(3):173-181.].

Investigating the Bias in Orthopaedic Patient-reported Outcome Measures by Mode of Administration: A Meta-analysis.

BACKGROUND: Patient-reported outcome measures (PROMs) are critical and frequently used to assess clinical outcomes to support medical decision-making. QUESTIONS/PURPOSE: The purpose of this meta-analysis was to compare differences in the modes of administration of PROMs within the field of orthopaedics to determine their impact on clinical outcome assessment. PATIENTS AND METHODS: The PubMed database was used to conduct a review of literature from 1990 to 2018 with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. All articles comparing PROMs for orthopaedic procedures were included and classified by the mode of administration. Each specific survey was standardized to a scale of 0 to 100, and a repeated random effectsmodel meta-analysis was conducted to determine the mean effect of each mode of survey. RESULTS: Eighteen studies were initially included in the study, with 10 ultimately used in the meta-analysis that encompassed 2384 separate patient survey encounters. Six of these studies demonstrated a statistically notable difference in PROM scores by mode of administration. The meta-analysis found that the standardized mean effect size for telephone-based surveys on a 100-point scale was 71.7 (SE 5.0) that was significantly higher (P , 0.0001) than survey scores obtained via online/tech based (65.3 [SE 0.70]) or self-administered/paper surveys (61.2 [SE 0.70]). CONCLUSIONS: Overall, this study demonstrated that a documented difference exists in PROM quality depending on the mode of administration. PROM scores obtained via telephone (71.7) are 8.9% higher than scores obtained online (65.3, P , 0.0001), and 13.8% higher than scores obtained via self-administered on paper (61.8, P , 0.0001). Few studies have quantified statistically notable differences between PROM scores based solely on the mode of acquisition in orthopaedic.

A Destructive Tumor of the Proximal Tibia and Fibula: A Case Report Highlighting Challenging Diagnosis and Treatment of a Locally Advanced, Non-recurrent Chondroblastoma in 16 Years Old Patient.

INTRODUCTION: Chondroblastoma is a rare, cartilaginous primary bone tumor, which presents predominantly in children and young adults. These tumors represent 1% of all primary bone tumors. Patients tend to complain of progressive joint pain which usually aids in early diagnosis. However, early diagnosis has made the understanding of the untreated, progressive course of chondroblastoma quite difficult. This case report highlights a patient who was first encountered with locally advanced chondroblastoma and discusses the challenges of diagnosis and treatment with a focus on the natural progression of this disease. CASE REPORT: We report the case of a 16-year-old male encountered during relief efforts after the 2010 Haiti earthquake, who was found to have a massive, expansile, and destructive mass of the proximal left tibia and fibula. Radiographic appearance was concerning for a malignant bone forming process. However, biopsy revealed features most consistent with chondroblastoma with secondary aneurysmal bone cyst formation. Marginal resection was considered, but the degree of soft tissue and neurovascular invasion made it impossible to salvage the leg and thus an above-the-knee amputation was performed. CONCLUSION: This report reviews the challenging diagnosis of a massive chondroblastoma with locally aggressive features which required ablative surgery. This may provide insight into the untreated, natural course of this pathology.

Use of high-speed burr and water-based lubricant in the partial removal of surgical plates: A technique Guide.

Implant removal comprises 5% of all orthopaedic surgery procedures performed annually. Surgical indications range from implant failure, infection, non-union, and symptomatic hardware. Intra-operatively, surgeons need to prepare for complications including bony overgrowth, cold-welding, broken screws, and stripped screw heads. Large anatomic dissections required for complete hardware removal place the patient at increased risk of complications due to increased operating time and larger dissections. The authors present a safe and effective technique for the partial removal of surgical implants. The technique utilizes a high-speed burr to cut surgical plates, minimizing the total dissection and operative time. Sterile surgical laps covered in water-based lubricant capture metal debris to reduce tissue contamination as well as surgeon exposure to metal particles.