Cartilage Biopsy for Autologous Cell-Based Repair of the Knee in the Wide-Awake Setting Using Needle Arthroscopy.

Chondral and osteochondral lesions of the knee are a commonly occurring pathology that can pose challenges to the treating surgeon. For the appropriate cartilage injury, autologous cell-based articular cartilage repair techniques have shown promising results. However, these treatments traditionally require 2 separate surgical procedures. Recent advances in needle arthroscopy technology have made it possible to conduct the first stage of autologous chondrocyte implantation surgery in the wide-awake office setting, mitigating cost and resource utilization. The purpose of this technical note is to serve as a proof of concept and describe the process of obtaining a cartilage sample in the wide-awake patient using a needle arthroscope.

Cementing a Monoblock Dual-Mobility Implant into a Fully Porous Cup in Revision Total Hip Arthroplasty to Address Hip Instability: Surgical Technique.

Background: The use of a cemented monoblock dual-mobility implant into a fully porous cup is indicated for patients with acetabular bone loss who have a high risk of postoperative hip instability. Patients undergoing lumbar fusion for sagittal spinal deformities have an increased risk of hip dislocation (7.1%) and should be assessed on sitting and standing radiographs1. Gabor et al. conducted a multicenter, retrospective study assessing the use of a cemented monoblock dual-mobility bearing in a porous acetabular shell in patients with acetabular bone loss and a high risk of hip instability2. Of the 38 patients, 1 (2.6%) experienced a postoperative dislocation that was subsequently treated with closed reduction without further dislocation. This surgical technique represents a favorable surgical option for patients with acetabular bone loss who are at risk for hip instability. In the example case described in the present video article, the patients had a history of dislocations, lumbar fusion, and evidence of Paprosky 3B acetabular defect; as such, the decision was made to revise to a porous shell and cement a monoblock dual-mobility implant. Description: With use of the surgeon's preferred approach, the soft tissue is dissected and the hip is aspirated. The hip is dislocated and a subgluteal pocket is made with use of electrocautery to mobilize the trunnion of the femoral stem to aid in acetabular exposure. The femoral component is assessed to ensure appropriate positioning with adequate anteversion. The acetabular component and any acetabular screws are removed. A "ream to fit" technique is performed in the acetabulum until bleeding bone is encountered, with minimal reaming performed in healthy bone from the posterior column. A trial prosthesis is placed within the acetabulum to evaluate if there is satisfactory fixation and if any augment is necessary. Care must be taken during reaming to ensure that enough bone is reamed to accommodate a porous shell that can fit the monoblock dual-mobility implant with a 2-mm cement mantle. Smaller porous shells measuring 56 mm are available for smaller defects but are often not utilized in cases of substantial acetabular bone loss. Fresh-frozen cancellous allograft is utilized to fill any contained defects. The revision porous shell with circumferential screw holes is utilized to allow for screw fixation posterosuperior and anterior toward the pubis. The implants are dried prior to placement of the cement. The cement is applied to the shell and the monoblock dual-mobility implant to ensure adequate coverage. Antibiotic-loaded cement can be utilized according to surgeon preference. Excess cement is removed under direct visualization while the cement is drying, and the position of the dual-mobility implant is adjusted in approximately 20° anteversion and 40° inclination. Stability is assessed after the cement cures, and intraoperative radiography can be performed to confirm cup positioning prior to closure. Any remaining capsule is closed, followed by closure of the remaining soft tissue in a layered fashion. Alternatives: A fully porous multi-hole jumbo cup with conventional polyethylene liner and femoral head can be utilized to increase the jump distance of the femoral head. Constrained, lipped, or offset polyethylene liners can be utilized if the shell is well fixed and a dual-mobility implant cannot be inserted. A cemented dual-mobility implant can be utilized in a well-fixed acetabular shell without evidence of loosening or osteolysis. Rationale: Dual-mobility implants have become increasingly utilized because of their advantages: (1) ability to decrease dislocation rate without increasing constraint and (2) increasing range of motion with reduced impingement risk2-8. These implants are particularly useful in the setting of revision cases with large acetabular bone defects. In a study of 76 patients with dual-mobility implants cemented into porous acetabular shells, Muthusamy et al. found that only 3.3% of patients experienced postoperative dislocations9. Moreover, acetabular cup survival was excellent, with 100% survival at 1 year and 96.2% at 2 years. Expected Outcomes: The use of a dual-mobility implant is a viable treatment option in cases of revision total hip arthroplasty, particularly those in which postoperative stability is a concern; monoblock dual-mobility implants cemented into porous shells are particularly useful in this setting2-8. These trends are similarly seen in patients treated with monoblock dual-mobility implants cemented into porous shells. Muthusamy et al. evaluated the use of this construct to treat instability or risk of hip dislocation in 76 hips, reporting a dislocation rate of 3.3% at 2 years. Additionally, the authors reported rates of all-cause acetabular survival from re-revision of 96.7% at 6 months, 93.3% at 1 year, and 89.7% at 2 years9. Physicians should be aware of the possibility for intra-prosthetic dislocations, as although this complication is rare, it has been reported in the literature7,10. Important Tips: In order to allow for circumferential coverage for fixation and ingrowth potential in cases with acetabular defects, the shell is typically impacted slightly vertical (45° to 50° of inclination) and in neutral version (0° to 5° of anteversion). Positioning can be adjusted to improve osseous contact and ingrowth as determined by the size and shape of the defect.The use of a drill guide for the locking screws allows limited degrees of variable screw angulation. In the revision setting, longer screws may be placed posterosuperior toward the sciatic notch or anteroinferior into the pubis. Surgeons should be aware of the anatomy and should predrill holes to reduce the risk of injury to surrounding neurovascular structures such as the obturator artery anteriorly.Any screw holes that are not filled should be covered with plastic hole covers in order to prevent cement from migrating behind the cup. Implants should be dried prior to the placement of the cement, and the cement should be applied to the shell and the dual-mobility implant to ensure adequate coverage.Utilize a monoblock dual-mobility implant that is designed for cementation in order to avoid implant dissociation from the acetabular shell.Remove all fibrous tissue that may hinder bony integration.Assess for pelvis discontinuity; pelvis discontinuity and acetabular bone loss are risk factors in the setting of any revision and should be properly assessed preoperatively and intraoperatively and managed accordingly.Avoid over-reaming and damage of the posterior column.Utilize a reamer or trial to assess defect size and need for augments.Place a compression screw where the cup is in contact with the bone in order to avoid tilting.Cover unused screw holes. Acronyms and Abbreviations: THA = total hip arthroplastyS/P = status postTKA = total knee arthroplastyCT = computed tomographyKM = Kaplan MeierDMC = dual-mobility cupPE = polyethylene.

Primary Quadriceps Tendon Suture Anchor Repair: Case Presentation and Surgical Technique.

SUMMARY: This case presentation described a technique for repairing an acute quadriceps tendon rupture with suture anchors. The patient was a 51-year-old man who sustained an acute quadriceps tendon rupture after a fall. We used a midline incision over the quadriceps tendon and muscle. The tendon was found to be completely avulsed from the superior border of the patella. Three suture anchors were used to re-approximate the quadriceps tendon to the patella and additional sutures were used to repair the medial and lateral patellar retinacula. The patient had excellent range of motion at his 6-week follow-up appointment after the procedure.

Operative Fixation of the Anteromedial Facet of the Coronoid Process.

SUMMARY: Anteromedial coronoid facet fractures typically occur with varus, pronation, and axial forces applied to the elbow. Due in part to the high rate of concomitant lateral collateral ligament (LCL) injuries, untreated anteromedial facet fractures can result in varus and posteromedial rotatory elbow instability. Although small fractures that are not amenable to open reduction and internal fixation can be treated with isolated LCL repair, larger fragments are treated with buttress plating on the anteromedial surface of the coronoid with or without LCL repair. The "over-the-top" approach via a split in the flexor pronator mass is the preferred method of accessing the anteromedial facet. Although data regarding the functional outcomes after operative fixation of the anteromedial facet are limited, observational studies have demonstrated good restoration of elbow stability and motion.

Repair of the Galeazzi Fracture.

SUMMARY: This is a case of a 36-year-old female patient presenting with left forearm and wrist pain after a ground-level fall onto her outstretched left hand. Clinical and radiographic evaluation is consistent with a left distal radial shaft fracture with disruption of the distal radioulnar joint, known as a Galeazzi fracture. The purpose of this video is to review the appropriate management of Galeazzi fractures and demonstrate our treatment with this surgical approach.

Revision Patella Tendon Repair With Hamstring Tendon Autograft Augmentation Following Failed Inferior Pole Patella Fracture Open Reduction and Internal Fixation.

SUMMARY: A 46-year-old man presents with left knee bucking 3 months after open reduction and internal fixation of a left knee inferior pole patella fracture. Radiograph and magnetic resonance imaging evaluation reveal displacement and comminution of the inferior pole of the patella confirming failure of the repair. The purpose of this video is to demonstrate the surgical management of failed inferior pole patella fractures using suture anchors for repair of the patella tendon and augmentation with ipsilateral autologous hamstring grafts.

Repair of a Femoral Head Fracture Dislocation With an Associated Posterior Wall Acetabular Fracture (Pipkin 4) via a Kocher-Langenbeck Approach.

SUMMARY: A case of a 27-year-old man with a right-sided largely infra-foveal femoral head fracture dislocation with posterior wall acetabular fracture repaired via a Kocher-Langenbeck approach is presented. This is an atypical approach for fixation of the femoral head and acetabulum used because of the size and displacement of both the posterior wall fracture and the femoral head fracture. Indications for fixation of both the femoral head and the acetabulum include a displaced acetabular fracture with: (1) a fracture of the weight-bearing portion of the femoral head and/or (2) a fracture of the femoral head that engages the anterior or posterior wall. Overall, midterm outcomes are expected to be excellent to good if anatomic reduction and a concentrically stable hip joint is restored.

Combined Anterior Opening-Wedge High Tibial Osteotomy and Tibial Tubercle Osteotomy with Posterior Cruciate Ligament Reconstruction.

Despite multiple advances in techniques for posterior cruciate ligament reconstruction (PCL-R), residual posterior laxity continues to be a commonly reported complication. Multiple studies demonstrated a decreased or flat posterior tibial slope, increases posterior laxity, and forces placed across the native and reconstructed PCL. Anterior opening wedge high tibial osteotomies (aOW-HTO) can be used to increase posterior tibial slope, thereby reducing tibial sag and posterior laxity. Depending on the technique used, anterior opening wedge osteotomies can lead to changes in patellar height, affecting patient pain and satisfaction. The purpose of this article is to describe a technique for an aOW-HTO with a tibial tubercle osteotomy and concomitant PCL-R to increase the posterior tibial slope while minimizing changes to patellar height.

Arthroscopic Technique for Reduction and Fixation of an Acetabular Rim Fracture.

Acetabular rim fractures can accompany patients with femoroacetabular impingement. Frequently, the acetabular rim fracture is excised. However, if the osseous fragment of the acetabular rim fracture is large enough to result in instability, then the acetabular rim fracture should be reduced and secured with internal fixation. The purpose of this technical note was to describe the arthroscopic technique of internal fixation of an acetabular rim fracture.

Shoulder Hemiarthroplasty for Proximal Humerus Fracture.

SUMMARY: There are a variety of treatment options available for proximal humerus fractures, including nonoperative management, open reduction internal fixation with screws, locking plates, intramedullary nailing, or suture fixation, and arthroplasty, including hemiarthroplasty and total shoulder replacements. Fracture characteristics, including the number of fracture parts and involvement of the humeral head and glenoid and the patient's functional status and postoperative goals help dictate the optimal choice. Although the indications for hemiarthroplasty as treatment for severe proximal humerus fractures have narrowed, the authors believe that there is a still a place for this technique in practice.

Repair of Humeral Shaft Nonunion With Plate and Screw Fixation and Iliac Crest Bone Graft.

SUMMARY: A 58-year-old woman with a proximal 1/3 humeral shaft nonunion presented 2 years after initial injury. We present a technique for nonunion repair, including nonunion site preparation, direct compression of the fracture site using plate osteosynthesis, and iliac crest bone graft harvest and utilization. The purpose of this video is to review humeral shaft nonunion literature and describe our management technique.

Sternoclavicular Joint Reconstruction for Medial Clavicle Fracture Nonunion.

SUMMARY: Operative management of sternoclavicular fracture-dislocations is recommended in the setting of symptomatic nonunion. Treatment options include open reduction internal fixation, fragment excision, and ligamentous reconstruction. We present a 29-year-old man with a medial clavicle fracture nonunion that previously failed open reduction internal fixation and was treated with sternoclavicular joint reconstruction using tendon allograft.

Treatment of a Chronic Elbow Dislocation With an Internal Fixator.

SUMMARY: There are a variety of ways to treat chronic elbow dislocations, including repeat closed reduction and immobilization, transarticular pinning, temporary bridge plating, hinged or rigid external fixation, and internal fixator application. Although each have distinct advantages and disadvantages, avoiding recurrent instability is critical. The internal-fixator is a relatively new option to maintain a stable, concentric reduction and facilitate early range of motion. This article and accompanying video describe the surgical technique of using an internal joint stabilizer for treatment of a chronically unstable ulnohumeral joint.

Acute Distal Triceps Tendon Rupture Repair: Case Presentation and Surgical Technique.

This case presentation and surgical technique demonstrates a complete distal triceps tendon rupture repair with single-row suture anchor fixation through a posterior midline approach to the elbow in a 17-year-old male rugby player. Key procedure points include complete triceps mobilization for adequate excursion to facilitate repair, identification of the ulnar nerve, isolation and sharp debridement of torn tissue to healthy tendon, thorough debridement of the olecranon reattachment site, suture construct, and order of fixation to optimize tendon-bone apposition.

Staged Reconstruction of a Moore Type 4 Fracture Dislocation, Parts 1 and 2.

SUMMARY: High-energy tibial plateau fractures are associated with knee fracture dislocations and concomitant ligamentous injury. Both bony and ligamentous injuries can require surgical fixation, often requiring a multidisciplinary team and staged treatment. This article and accompanying video describe the workup and treatment of a Moore type 4 tibial plateau rim compression fracture with posterolateral corner and anterior cruciate ligament rupture that underwent open reduction internal fixation of the tibial plateau with posterolateral corner reconstruction and then staged anterior cruciate ligament reconstruction with quad tendon autograft.

Locked Anterior-Inferior Sternoclavicular Joint Dislocation: A Case Report.

CASE: We report a rare variant of sternoclavicular joint (SCJ) dislocation, namely locked anterior-inferior dislocation, with unique clinical, radiographic, and intraoperative findings. In this variant, the medial clavicle was displaced anteriorly and inferiorly and locked in the manubrial-intercostal space, with corresponding mechanical dysfunction of the ipsilateral shoulder girdle joints. Symptoms unique to this variant included painful neck spasms and limited glenohumeral elevation. Nonsurgical treatment was not successful, and open reduction and ligament reconstruction resulted in correction of the fixed deformity with resolution of the clinical symptoms. CONCLUSION: Locked anterior-inferior SCJ dislocation is indicated for early open reduction and ligament reconstruction.

Case Report: Double Oberlin Nerve Transfer to Restore Elbow Flexion Following C5-C6 Avulsion Injury.

BACKGROUND AND IMPORTANCE: The use of nerve transfers to restore nerve function following traumatic avulsion injuries has been described, though there is still a paucity in the literature documenting technique and long-term outcomes for these procedures. The double Oberlin nerve transfer involves transferring fascicles from the median and ulnar nerves to the musculocutaneous nerve to restore elbow flexion in patients with a C5-C6 avulsion injury. The purpose of this case report is to present our indications and technique for a double Oberlin transfer in addition to exhibiting video footage at follow-up time points documenting the incremental improvement in elbow flexion following the injury. CLINICAL PRESENTATION: The patient is a 25-yr old, left-hand dominant male who presented 5 mo following a motor vehicle accident. He had 0/5 biceps muscle strength on the left with a computed tomography myelogram that demonstrated pseudomeningoceles from C2-C3 to C7-T1 with root avulsions of C5 and C6. He was subsequently indicated for a double Oberlin nerve transfer to restore elbow flexion. CONCLUSION: In this case report, we present our technique and outcomes for a double Oberlin transfer with restoration of elbow flexion at 1-yr follow-up for a patient with traumatic brachial plexus injury. We believe that the double Oberlin transfer serves as a safe and effective method to restore elbow flexion in this patient population.

Repair of Tibial Plateau Fracture (Schatzker II).

Tibial plateau fracture is an injury commonly seen by those who treat trauma around the knee and/or sports-related injuries. In this video article, we present our protocol for surgical treatment of a tibial plateau fracture, which includes definitive fixation with use of a plate-and-screw construct, addressing of all associated soft-tissue injuries at the time of the surgical procedure, filling of any residual voids with bone cement, and early rehabilitation with weight-bearing beginning at 10 to 12 weeks postoperatively. The major steps of the procedure are (1) preoperative planning with digitally templated plates and screws, (2) patient positioning and setup, (3) anterolateral approach toward the proximal aspect of the tibia, (4) submeniscal arthrotomy, (5) booking open of the proximal aspect of the tibia at the fracture site, (6) tagging of the meniscus, (7) fracture reduction and placement of the Kirschner wire, (8) confirmation of reduction with C-arm image intensification, (9) internal fixation with a plate-and-screw construct, and (10) closure.