Nanoscopic Medial Meniscus Repair.

Arthroscopic meniscus repair is one of the commonly used arthroscopic surgical procedures. Open treatment was the standard for meniscus repairs and recently arthroscopic all-inside treatment has become popular. Novel and more minimally invasive techniques to common arthroscopic procedures are paving the foundation to better patient outcomes. With the use of the NanoScope and nanoinstruments, we continue to develop new minimally invasive diagnostic and treatment techniques that do not require standard portals. The nanoscopic medial meniscus repair technique described here uses a less-invasive approach to a meniscus repair.

Meta-Analysis: Functional Outcome of ORIF Versus Primary Subtalar Arthrodesis of Sanders Type II and Type III Calcaneal Fractures.

The choice of treatment for Sanders Type II and Type III calcaneal fractures remains controversial with unclear patient functional outcomes. A meta-analysis was done to compare the functional outcome of ORIF vs primary subtalar arthrodesis (PSA) according to American Orthopedic Foot and Ankle Score (AOFAS) hindfoot-ankle scores. The PubMed, Embase, and Cochrane Library Databases were searched by two independent evaluators. Fourteen studies met the eligible criteria. ORIF of 501 Type II and Type III fractures was compared to primary subtalar arthrodesis treatment of 57 Type II and Type III fractures. AOFAS for a mixed ORIF group of "Type II and III" fractures was 82.16 ± 1.58 at average follow-up of 25.3 months. For a mixed PSA group of "Type II and III" fractures, the AOFAS was 74.22 ± 2.45 at average follow-up of 28.0 months. This showed a difference between ORIF and primary subtalar arthrodesis of 7.94 points (95% confidence interval [CI] = 7.75-7.98; p value .004) favoring ORIF when adjusting for minimally invasive and percutaneous methods. Without adjustment, there was a difference of 6.54 points favoring ORIF (95% CI = 6.22-6.46; p value .017). In conclusion, while high-quality randomized controlled trials comparing ORIF to primary subtalar arthrodesis for Type II and Type III fractures would further elucidate superior treatment outcomes, this meta-analysis of available data shows a tendency for ORIF of Type II and Type III Sanders calcaneal fractures to have a better functional outcome at approximately 2 years postoperatively compared to primary subtalar arthrodesis.

Incisionless Synovium and Bone Biopsy of a Painful Total Knee Arthroplasty.

Knee arthroscopy has evolved greatly from its inception in the 20th century. Arthroscopic synovectomy is performed in the case of infection or significant synovitis. We continue to develop more minimally invasive procedures, and the NanoScope (Arthrex, Naples, FL) has provided a new generation of possibilities. The system does not require the use of a standard incision or portal, and using the GraftNet (Arthrex), we can harvest tissue with a standard shaver for further evaluation. This technique provides an option to perform a synovial and bone biopsy in a painful total knee arthroplasty without the use of standard arthroscopy portals through an incisionless approach. This technique provides distinct advantages over a more open approach in the setting of a prosthetic joint. Specifically, this technique is useful for a difficult-to-diagnose painful total knee arthroplasty.

Nanoscopic Single-Incision Autograft Cartilage Transfer (ACT).

Osteochondral defects in the young active patient remain a difficult issue to treat. Autograft cartilage implantation is a procedure that was originally devised as a difficult 2-stage process, with disadvantages including donor-site morbidity and the need for multiple procedures. Recently, a technique for a single stage autograft cartilage transfer, also known as AutoCart using the GraftNet device for autograft harvest and BioCartilage in addition to bone marrow concentrate to aid in graft incorporation and healing, has been described. In this article, we discuss a modification of this autograft cartilage transfer procedure using a minimally invasive single incision for lesion preparation, microfracture, graft harvest, and graft delivery using visualization from the NanoScope.

Minimally Invasive Quad Harvest Featuring Endoscopic Closure and Preparation With Adjustable Suspensory Fixation Device Incorporated With Braided Suture.

The quad tendon has increasingly became a very common option for anterior cruciate ligament reconstruction. Minimally invasive approaches are one of the many advantages to the quad tendon graft. One of the issues with a small incision is assuring appropriate proximal closure. In this technique, we use the arthroscope to view proximally and a Scorpion (Arthrex) device to close our proximal quad harvest. We also describe the updated preparation of the quad tendon with FiberTag TightRope (Arthrex) and FiberTag ABS (Arthrex). These implants have FiberTag incorporated to the suspensory devices that creates a stable construct that is faster to incorporate into the quad with the slotted clamp. Together, these updates to the preparation and harvest should make the construct more reproducible and decrease donor-site morbidity respectively.

Anterior Cruciate Ligament (ACL) Reconstruction Augmented With Bone Marrow Concentrate, Demineralized Bone Matrix, Autograft Bone, and a Suture Tape (The Fertilized ACL).

PURPOSE: To examine the early clinical outcomes as well as safety of the Fertilized anterior cruciate ligament (ACL) reconstruction procedure. METHODS: A total of 16 consecutive patients with a mean age of 24 years (range, 16-45 years), who had been treated with the fertilized ACL were evaluated and followed over 2 years. Four patients underwent reconstruction using an FGL GRAFTLINK allograft (LifeNet Virginia Beach, VA) and 12 using quadriceps autografts. All patients received the fertilized ACL as previously described using bone marrow composite, demineralized bone matrix, and an internal brace (Arthrex, Largo, FL). Clinical outcomes at 2 years including International Knee Documentation Committee and Marx scores were evaluated. Complication rates, including return to operating room, arthrofibrosis, infection, and rerupture rates, were also assessed. RESULTS: All patients were followed for 6 months and all were released to full activity. In total, 11 of 16 patients were available for 2-year follow-up after the fertilized ACL reconstruction. At 2 years, the average International Knee Documentation Committee and Marx scores were 81 (standard deviation, 5.9) and 9 (standard deviation, 5.7), respectively. One patient required a return trip to the operating room for manipulation under anesthesia. No reruptures were observed at the 2-year mark. Nine of 11 patients had returned to their preinjury activity status at 2 years. CONCLUSIONS: The fertilized ACL, which adds biology and an internal brace to an ACL reconstruction, is a reliable and safe option when performing an ACL reconstruction. Very low complication risks were seen in this consecutive series followed for 2 years. Patients consistently returned to their preinjury activity status. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Clinical and Financial Implications of Positive Margins After Nonmelanoma Skin Cancer Resection: A Longitudinal Evaluation.

BACKGROUND: Management of positive margins after nonmelanoma skin cancer (NMSC) excision is debated in the literature. The purpose of this study is to determine the rate of residual tumor in reexcised NMSC specimens after previous excision with positive margins, to determine the rate of recurrence in patients who had positive margins but did not undergo reexcision, and to define the financial burden of negative reexcisions. METHODS: An Institutional Review Board-approved retrospective review was conducted on all patients with NMSC excision over a 15-year period. Patients who met inclusion criteria and underwent initial NMSC excision with negative frozen section margins, but had positive permanent section margins were divided into 2 groups: those who underwent reexcision for clearance of tumor (n = 161) or those who did not undergo further reexcision (n = 105). Variables collected include demographics, previous skin cancer, tumor location, cancer subtype, excision measurements, and time between first and second excisions. For those patients who did not undergo reexcision, charts were examined for recurrence. RESULTS: Two hundred sixty-six patients met inclusion criteria with mean follow-up of 60 months. Eighty-three (52%) of 161 patients with positive margins on initial excision had no evidence of residual cancer upon reexcision. Residual tumor on permanent section was confirmed in 48% of patients. Patients with a previous history of basal cell carcinoma were more likely to have a true-positive margin after reexcision (P = 0.02). Larger reexcisions were more likely to harbor residual cancer (5.9 cm2, P = 0.04). Patients with positive margins that did not undergo reexcision, only 7 of 105 patients (6.6%) had recurrence. No mortalities were reported from NMSC recurrence. US $247,672 was spent in reexcision for negative margins in 98 patients for an average cost of US $2984 per case. CONCLUSIONS: Forty-eight percent of NMSC patients with positive margins had residual tumor upon reexcision. There were 6.6% of the patients who did not undergo resection after positive margins developed recurrence of disease at 5 years. Patients requiring larger reexcisions or those with a prior history of BCC were more likely to have residual cancer upon reexcision. This study suggests that observation is an appropriate option of care for certain patients with residual NMSC on permanent pathology.

Incisionless Knee Synovectomy and Biopsy With Needle Arthroscope and Autologous Tissue Collector.

Knee arthroscopy has evolved greatly from its inception in the 20th century. Arthroscopic synovectomy is performed in the case of infection or significant synovitis. We continue to develop more minimally invasive procedures, and the NanoScope (Arthrex, Naples, FL) has provided a new generation of possibilities. The system does not require the use of a standard incision or portal, and using the GraftNet (Arthrex), we can harvest tissue with a standard shaver for further evaluation. This technique provides an option to perform a synovectomy and biopsy without the use of standard arthroscopy portals through an incisionless approach.

Closed Reduction of an Irreducible Knee Dislocation: A Case Report.

ADDITION TO ORTHOPEDIC LITERATURE: Posterolateral knee dislocations are extremely rare and generally require open reduction; however, we were able to provide closed reduction by reproducing mechanism of injury with a technique described in the literature. This is the second reported case of such accomplishment. INTRODUCTION: Posterolateral knee dislocation is the most common form of "irreducible" knee dislocations. Buttonholing of the medial femoral condyle through medial soft tissues of the knee results in entrapment. We report the second known case of successful closed reduction. CASE PRESENTATION: A 51-year-old female with morbid obesity sustained a right posterolateral knee dislocation shown on plain radiograph. This was accompanied by lateral patella dislocation and a dimple sign at the medial joint line after a fall from standing height produced a rotational mechanism. CONCLUSION: This is the second reported case of successful closed reduction to an injury that has been generally established to be "irreducible." The technique used closely matches that described in the only other reported case and involves reproduction of the mechanism of injury. This establishes additional evidence to a previously isolated report of successful acute treatment that counters the current narrative.

Acute neck pain in the ED: Consider longus colli calcific tendinitis vs meningitis.

Presented here is a rare cause of severe neck pain - acute longus colli calcific tendinitis - in a 54year old man who presented to the emergency department. The neck pain is due to inflammation caused by calcium hydroxyapatite crystal deposition in the tendons on the longus colli muscles. This is non-infectious. The gold standard for diagnosis is a CT neck which best shows the calcifications in the anterior vertebral column of C1-C4, where the tendons of these muscles insert bilaterally. Longus colli calcific tendinitis is not life-threatening and patients will make a full recovery after treatment with NSAIDs. However, this condition is often confused with life-threatening conditions such as infection (meningitis or retropharyngeal abscess), intracranial hemorrhage, trauma, herniation of cervical discs, or malignancy (Estimable et al. (2015) [1]). Symptoms associated with calcific tendinitis of the longus colli muscle are non-specific and include mild fever, moderate-severe headache, neck pain, and drastically reduced range of motion of the neck. More specific symptoms are the presence of dysphagia and odynophagia. Lab findings usually are significant for mild leukocytosis, and elevated ESR and CRP. Awareness of this condition by E.D. physicians can avoid unnecessary invasive interventions, increased costs, and delays that result from incorrect diagnosis and treatment. This is a unique case in which a patient who was afebrile with a normal ESR was worked up for meningitis and an intracranial process, and also empirically treated for meningitis before finally being diagnosed with acute calcific tendinitis of the longus colli muscle in the E.D.