The Supercapsular Percutaneously Assisted Total Hip (SuperPATH) Approach Revisited: Technique Improvements after the Perioperative Experience of 344 Cases.

The SuperPATH approach is a direct superior portal-assisted approach for total hip arthroplasty (THA) that utilizes the interval between the gluteus minimus and the piriformis to access the hip capsule. Patients and Methods: SuperPATH arthroplasty was performed by a single surgeon between December of 2016 and December of 2021 in 344 cases. The technique described by Chow was performed in all cases. The average length of stay was 1.3 days, and all patients were discharged for home. All patients were mobilized on the day of the operation. Six cases presented complications: four intraoperative femur fractures and two peroneal nerve palsies. No infection and no hip dislocation were noticed in any case. Modifications: We recommend that the patient be placed as far from the surgeon as possible as well as the use of a sterilized standard linen pack to elevate the foot and internally rotate the hip. In addition, regarding instrumentation, we recommend the use of a 4.5 mm drill for the first guidance femur drilling and a standard corkscrew for femoral head removal. Finally, we propose a different reduction technique using a hook. The use of the SuperPATH approach allows for maximal tissue sparing through preservation of external rotators and minimizing stretching of the gluteus medius. There is no range of motion restrictions postoperatively and patients can achieve a high level of function with a very low dislocation risk and reduced inpatient stay. Furthermore, an incision extension is possible if needed in complex cases. For surgeons familiar with the standard posterolateral approach, the SuperPATH approach is a reliable and safe method with promising results for the patient. In order to improve the surgical effect and facilitate some steps in the procedure, we share our experience and recommend some modifications.

Osgood-Schlatter Lesion Removed Arthroscopically in an Adult Patient.

Osgood-Schlatter disease is a traction apophysitis of the tibial insertion of the patellar tendon. It consists one of the most common causes of knee pain in adolescents and usually presents in young males and it is considered a self-limiting condition. Although the symptoms disappear after the closure of the growth plate in most cases, in some patients they may persist. A variety of conservative treatments are used in most cases, however surgical intervention can be successful for patients who have intolerable symptoms. Most surgical options of the Osgood-Schlatter disease include open procedures, while arthroscopic or direct bursoscopic excision has been reported. We believe that the arthroscopic removal of an unresolved Osgood-Schlatter might be the most appropriate treatment for this condition, and we present a case of a male patient with an ununited ossicle due to an Osgood-Schlatter lesion, which was removed arthroscopically using a multidirectional arthroscope and a motorized semi-hooded barrel burr.

Arthroscopic resection of extra-articular knee osteochondroma: report of two cases.

Osteochondroma is the most common benign tumor of the growing bone, usually affecting the knee joint, located extra-articularly. Solitary intra-articular osteochondroma is very rare. In the current paper, two cases of solitary extra-articular knee osteochondromas adjacent to the capsule producing pain and restriction of knee motion are described. Diagnostic evaluation is based on combination of radiography and magnetic resonance imaging. Both osteochondromas excised arthroscopically, resulting in complete symptoms relief and full range of knee motion. On follow-up, no recurrence was recorded. Based on our experience, although limited, not only the intra-articular, but also some solitary extra-articular knee osteochondromas can be successfully treated by arthroscopy, resulting in better cosmetic result, less postoperative pain and faster recovery.

Tension band plating of an anterior tibial stress fracture nonunion in an elite athlete, initially treated with intramedullary nailing: a case report.

BACKGROUND: Leg pain in athletes is a common condition and is often related to tibial stress fracture. When non-operative treatment fails, the optimal surgical treatment is controversial. The aim of this study was to report a case of tension band plating of an anterior tibial stress fracture nonunion, treated previously with intramedullary nailing. To the best of our knowledge, this is the first reported case in which tension band plating was placed without removing the preexisting intramedullary nail. CASE PRESENTATION: The tibial shaft is a common location of stress fracture in athletes. Anterior tibial stress fractures are difficult to manage. When conservative treatment fails, intramedullary nailing is the mainstay of treatment. However, nonunion is a serious complication. In our case, a non-united anterior tibial stress fracture, treated with intramedullary nailing, was addressed with the application of a compression prebended plate over the nail in a 23-year-old French man of African origin who is an elite football player. At 3-months postoperatively he was pain free and started light exercises. At 6-months postoperatively, complete radiologic union of the fracture was evident. He was symptom free; he resumed at that time a full training program and he returned to play football at preinjury high competition level. CONCLUSIONS: Compression plating is a valuable method of treating non-united anterior tibial stress fractures. We believe that anterior tension band plating is superior to intramedullary nailing in managing anterior tibial stress fractures, not only after failure of intramedullary nailing, but also as a first-line surgical treatment. This technique offers advantages, such as no violation of the extensor mechanism and risk of anterior knee pain, and directly addresses the underlying problem of distraction forces acting on the anterior tibial cortex and compromising fracture healing. Especially in high-level athletes, who cannot tolerate prolonged inactivity, early surgical intervention of anterior tibial stress fractures with tension band plating is a reliable option that can accelerate recovery.

Arthroscopic treatment of recurrent acetabulum osteoid osteoma.

In this case report, arthroscopic treatment of a recurrent osteoid osteoma in the posterior column of the pelvis extending to the acetabular fovea in a young adolescent is being presented.

Diagnosis and arthroscopic treatment of primary synovial chondromatosis of the shoulder.

Primary synovial chondromatosis of the shoulder is a rare condition. We present the case of a 24-year-old man with a 6-month history of right shoulder pain and decreased range of motion. Computed tomography and magnetic resonance imaging findings led us to the diagnosis of synovial chondromatosis of the shoulder. Arthroscopy revealed loose bodies in the glenohumeral joint, the biceps tendon sheath, and the subscapularis recess. Active intrasynovial proliferation of the axillary pouch was noted. All loose bodies were removed arthroscopically, and partial synovectomy was performed. Histologic examination confirmed the diagnosis of primary synovial chondromatosis. We recommend arthroscopic treatment for synovial chondromatosis of the shoulder because of low morbidity and early functional return.

Intra-articular ganglia of the knee joint associated with the anterior cruciate ligament: a report of 4 cases in 3 patients.

Intra-articular ganglia are rare and mostly incidental findings on magnetic resonance imaging (MRI) and arthroscopy. We present 4 cases of intra-articular ganglion cysts associated with the anterior cruciate ligament (ACL) in 3 patients. The most commonly occurring symptoms were pain aggravated after stressing activities and limited knee range of motion. In 1 patient, ganglion cysts appeared in both knees with a time difference of 1 year. An MRI revealed typical signs of ganglion cysts in the substance of the ACL. Arthroscopy was performed for further evaluation and treatment. Histologic examination of the tissue removed revealed the presence of features consistent with ganglion cysts. Therefore, in the case of chronic knee discomfort with nonspecific clinical signs and symptoms and without a clear cause, an intra-articular ganglion cyst should be considered as causing pathology. An MRI is the most sensitive and specific method for diagnosis. However, the relatively slow progression of symptoms may delay the patient's decision to seek medical attention. Delayed diagnosis makes arthroscopic total resection of the ganglion technically demanding or not possible at all, and extensive debridement of the ACL may be required.

Microsurgical dissection of the carpal tunnel with respect to neurovascular structures at risk during endoscopic carpal tunnel release.

PURPOSE: The goal of this descriptive study was to investigate the anatomy of the carpal tunnel with respect to the related neurovascular structures, because a detailed knowledge of the complex anatomy of this region is essential to perform endoscopic carpal tunnel release. METHODS: Sixteen fresh-frozen cadaveric hands were used for the study. Dissection of the palmar aspect of the hand was performed by use of magnifying loupes, an operative microscope, and microsurgical instruments. All anatomic components were photographed, and dimensions were recorded by use of a micrometer. The distance from the radial aspect of the os pisiformis and the proximal and distal portals to the main structures that may be injured was measured. Topography of the transverse ligament and possible adhesions to the tendons and median nerve were also recorded. RESULTS: The mean distance from the radial aspect of the os pisiformis to the radial border of Guyon's canal and the ulnar edge of the palmaris longus tendon was 10.3 mm (range, 9 to 12 mm) and 16.1 mm (range, 12 to 22 mm), respectively. The mean distance from the distal portal to the superficial palmar arch and the ulnar artery was 10.4 mm (range, 5 to 15 mm) and 7.6 mm (range, 4.5 to 9 mm), respectively. The mean distance from the distal edge of the transverse ligament to the thenar branch of the median nerve was 2.7 mm (range, 0 to 4.1 mm). The mean length of the transverse ligament was 31 mm (range, 25 to 34.5 mm). In 14 hands we also identified the palmaris longus tendon. In 11 hands we found adhesions between the transverse ligament and the sheath of the flexor tendons. CONCLUSIONS: The palmaris longus can be used as a guide for the placement of the proximal portal. Staying at the ulnar side of the palmaris longus keeps the superficial palmar branch of the median nerve at a safe distance from the instruments. The "fat drop sign" is also a useful guide for the placement of the distal margin of the transverse carpal ligament, keeping the distal portal away from the superficial palmar arch. Synovial adhesions can usually cover the inferior surface of the transverse ligament, and they need to be removed for clear endoscopic identification of the transverse fibers before the ligament is cut. CLINICAL RELEVANCE: Detailed knowledge of the complex anatomy of the carpal tunnel is essential to perform endoscopic carpal tunnel release.

The extensor mechanism of the knee joint: an anatomical study.

This study investigated the anatomy of the structures that form the extensor mechanism of the knee joint using microsurgical techniques. Ten fresh-frozen human adult cadaveric knees were used. The quadriceps components, the infrapatellar tendon, the patellofemoral ligaments, and their relations to the neighboring anatomical structures were measured. The angles of the vastus lateralis and the vastus medialis muscle fibers to the rectus tendon were 26.6 and 41.1 degrees , respectively. The medial patellofemoral ligament connecting the femoral medial epicondyle to the medial edge of the patella was approximately 54.2 mm long, and its width ranged from 9 to 30 mm. The medial patellomeniscal ligament had a wide attachment to the meniscus whereas the attachment to the patella was narrow. The patellar tendon was 31.9 mm broad at its attachment to the apex of the patella and 27.4 mm wide at its attachment to the tibial tubercle. It was 38-49 mm long. Using the surgical microscope we were able to dissect and identify a trilaminar arrangement of prepatellar fibrous soft tissues. Also, we were able to identify the vessels and nerves around the patella. Details of clinical relevance and the possible pathological implications of the material presented are discussed. Emphasis is placed on the stability of the patellofemoral joint and the complex interaction between a range of factors providing it.

The posterolateral corner of the knee: evaluation under microsurgical dissection.

PURPOSE: The posterolateral corner (PLC) has been described by several authors, but there are still controversies. We assumed that a microanatomic dissection of this region could answer some of the questions about its complex anatomy. We therefore conducted an anatomic study using microsurgical techniques, aiming at a precise anatomic description of all the structures that form the posterolateral complex. TYPE OF STUDY: Cadaveric study. METHODS: Ten fresh-frozen human adult cadaveric knees were used for the study. Dissection of the knees was performed using microsurgical instruments, magnifying loupes, and an operative microscope. Anatomic variations, ligament shape, separated bundles of the ligaments, and topography of ligament attachments were described and recorded. RESULTS: The rate of the presence of the popliteofibular ligament (PFL), the fabellofibular ligament, and the arcuate ligament were 100%, 40%, and 70%, respectively. The connective attachments of the popliteus muscle to the other posterolateral structures are the PFL and the 2 popliteomeniscal fascicles. Our dissections show that the shape and the fibula attachment of the PFL can vary. Using the surgical microscope, we were able to dissect and identify 2 different fiber groups of the popliteus tendon at its attachment to the lateral femoral condyle. Also, we were able to confirm in 20% of our knees an anatomic variation of the lateral collateral ligament. CONCLUSIONS: Our study may answer some of the questions about the complex anatomy of the PLC. The PFL is well established, always recognizable, and significant in size. CLINICAL RELEVANCE: Being aware of the complex anatomy of the posterolateral corner and its variations may prove useful in repair and reconstruction.