Citations

Background: An open Achilles tendon repair is performed in patients who have suffered an acute rupture. All patients with this injury should be counseled on their treatment options, which include open operative repair and functional rehabilitation. We prefer the use of an open repair in high-level athletes and those who have delayed presentation. Typically, this injury—and the resulting open repair—are seen in young or middle-aged patients as well as athletes. Operative repair of a ruptured Achilles tendon is associated with a much faster return to activity/sport when compared with nonoperative alternatives. This surgical procedure is especially useful in allowing this patient population to return to their previous activity level and functional capacity as quickly as possible. Description: Open repair of a ruptured Achilles tendon begins with a 6 to 8-cm incision over the posteromedial aspect of the lower leg. Superficial and deep dissections are performed until the 2 ends of the ruptured tendon are identified. Adhesions are debrided to adequately mobilize and define the proximal and distal segments of the tendon. With use of a fiber tape suture, a modified locking Bunnell stitch is utilized to secure both ends. The fiber tape is tied securely, and the repair is reinforced with Vicryl suture (Ethicon). Once the tendon is repaired, the paratenon layer is identified and repaired with a running 0 or 2-0 Vicryl suture. This is an important step to minimize postoperative wound complications. The wound is then closed, and the extremity is splinted in maximum plantar flexion. Alternatives: Alternative treatments include minimally invasive surgical techniques such as percutaneous Achilles tendon repair and nonoperative treatment with functional rehabilitation, which can provide excellent outcomes but can also lead to a slight decrease in explosiveness as the patient returns to sport 1,2 . Rationale: Nonoperative and operative treatment of Achilles tendon rupture can both result in excellent patient outcomes. Appropriate patient selection is critical. Younger patients hoping to return to more highly competitive athletics should consider operative repair 3 . Possible differences have been identified in peak torque when comparing operative versus nonoperative treatment, with patients who had undergone operative repair having greater peak torque (i.e., explosiveness) 2 . Otherwise, findings are similar between treatment options as long as the patients meet the criteria for nonoperative treatment. Expected Outcomes: Overall, the scientific literature demonstrates that the functional outcomes following operative repair are good to excellent. In a study by Hsu et al. 4 , 88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no reruptures. In a recent meta-analysis by Meulenkamp et al. 5 , the authors found that operative repair of Achilles tendon rupture was associated with a reduced risk of rerupture compared with primary immobilization (i.e., conventional cast immobilization with delayed weight-bearing for at least 6 weeks only). However, open surgical repair, minimally invasive repair, and functional rehabilitation all had similar risk of rerupture 5 . In a review by Ochen et al. 6 that analyzed 29 studies with a total of 15,862 patients, operative repair was associated with a significantly lower risk of rerupture compared with nonoperative treatment (2.3% versus 3.9%, respectively). However, operative treatment was also associated with a significantly higher complication rate compared with nonoperative treatment (4.9% versus 1.6%, respectively) 6 . Finally, in a meta-analysis by Soroceanu et al. 7 , the authors found that if early range-of-motion protocols and functional rehabilitation were utilized, operative and nonoperative treatment resulted in similar outcomes and equivalent rates of rerupture. Important Tips: To prevent rerupture of an Achilles tendon, remind patients to engage in adequate stretching and warming prior to physical activity. Palpate and locate the tendon defect prior to making the first incision. Immobilize the ankle joint in a splint for 2 weeks postoperatively in maximum plantar flexion. Pitfalls include: ○ Poor suture management leading to tangling in the repair. ○ Undertensioning or overtensioning of the repair, which can be avoided by sterilely draping out both legs and checking resting tension intraoperatively. ○ Failure to close the paratenon, causing scarring of the skin or surrounding tissues, which can be avoided by making a relieving incision on the deep surface of the paratenon. ○ Leaving suture knots on the dorsal side of the repair that may aggravate the skin. Acronyms & Abbreviations: MRI = magnetic resonance imaging ESU = electrosurgical unit

Background: Open trigger finger release is an elective surgical procedure that serves as the gold standard treatment for trigger digits. The aim of this procedure is to release the A1 pulley in a setting in which the pulley is completely visible, ultimately allowing the flexor tendons that were previously impinged on to glide more easily through the tendon sheath. Although A1—or the first annular pulley—is the site of triggering in nearly all cases, alternative sites include A2, A3, and the palmar aponeurosis 1 . Description: Typically, the surgical procedure can be conducted in an outpatient setting and can vary in duration from a few minutes to half an hour. The surgical procedure involves the patient lying in the supine position with the operative hand positioned to the side. A small incision, ranging from 1 to 1.5 cm, is made on the volar side of the hand, just proximal to the A1 pulley in the skin crease in order to minimize scarring. Once the underlying neurovascular structures are exposed, the A1 pulley is released longitudinally at least to the level of the A2 pulley, followed by decompression of the flexor tendons that were previously impinged on. In order to confirm the release, the patient is asked to flex and extend the affected finger. The wound is irrigated and closed once the release is confirmed by both the patient and surgeon. Alternatives: Aside from an open release, trigger finger can be treated nonoperatively with use of splinting and corticosteroid injection. Alternative operative treatments include a percutaneous release, which involves the use of a needle to release the A1 pulley 2 . Trigger finger can initially be treated nonoperatively. If unsuccessful, surgical intervention is considered the ultimate remedy 2 . Rationale: Because of their efficacious nature, corticosteroid injections are indicated preoperatively, particularly in non-diabetic patients 3 . Splinting is often an appropriate treatment option in patients who wish to avoid a corticosteroid injection 1 . However, if nonoperative treatment modalities fail to resolve pain and symptoms, surgical intervention is indicated 2 . In comparison with a percutaneous trigger finger release, an open release provides enhanced exposure and may be safer with respect to avoiding iatrogenic neurovascular injury 2 . However, in a randomized controlled trial, Gilberts et al. found no difference in the rates of recurrence when comparing open versus percutaneous trigger finger release 4 . Expected Outcomes: With reported success rates ranging from 90% to 100%, the open release of the A1 pulley is considered a common procedure associated with minimal complications 2 . Complications of the procedure were assessed in a retrospective analysis of 43 patients who underwent 78 open trigger releases performed by 1 surgeon. In that study, the authors reported a minor complication rate of 28% and a major complication rate of 3% 5 . Specifically, the 2 major complications noted by the authors were a synovial fistula and a proximal interphalangeal joint arthrofibrosis. In a larger study that included 543 patients who underwent 795 open trigger releases, the authors reported a minor complication rate of 9.6% and major complication rate of 2.4% 6 . Furthermore, the most common complications involved persistent stiffness, swelling, or pain. In that analysis, the authors suggested that sedation, male gender, and general anesthesia may be associated with greater risk 6 . Important Tips: At the discretion of the surgeon, a longitudinal, transverse, or oblique incision is made directly on top of the tendon at the level of the metacarpophalangeal joint, which is the preferred incision site because it provides maximal accessibility to the A1 pulley. Local anesthesia is preferred because it allows the patient and surgeon to confirm the release immediately. If conducting an open trigger release on the thumb, the surgeon should identify and protect the radial digital nerve, which courses directly over the A1 pulley. Acronyms and Abbreviations: MCP = metacarpophalangeal

Introduction: Oncologic proximal femoral resection and reconstruction in skeletally immature children remains a formidable task due to the risk of developing hip instability with patient growth or interval leg lengthening through the prosthesis. Shelf pelvic osteotomy increases femoral head coverage and containment, and favorable long-term results have been reported in the setting of developmental dysplasia of the hip and Perthes disease. We present a technique of combining shelf osteotomy with expandable proximal femoral endoprosthesis reconstruction in pediatric limb-sparing surgery. Materials and Methods: Four surgeons at 2 centers from 2012 to 2020 performed proximal femoral reconstruction with shelf osteotomy. Data were collected retrospectively on operative technique, radiographic measurements, and complications including dislocation, subluxation, implant loosening, pain, function, and radiographic outcomes. Results: Five patients were included in the study. The mean follow-up was 49 months (range: 17 to 104 mo). The mean lateral center edge angle status postproximal femoral resection and reconstruction shelf osteotomy was 56.1 degrees (±30.5). There were no reported incidences of subluxations, dislocations, periprosthetic fractures, or soft tissue complications. The 3 patients with the longest follow-up at 3, 5, and 8 years tolerated serial lengthening of the endoprosthesis totaling 1 cm, 7.25 cm, and 9 cm, respectively, and demonstrated earlier triradiate cartilage closure in the operative side compared with the nonoperative side. All patients have returned to independent ambulation. Discussion: Combining proximal femoral reconstruction with shelf osteotomy in limb salvage pediatric orthopedic oncology may help to improve hip stability with serial lengthening and patient growth.