First, your surgeon will examine your shoulder with the arthroscope. Your surgeon will:

Insert the arthroscope into your shoulder through a small incision. The arthroscope is connected to a video monitor in the operating room.

Inspect all the tissues of your shoulder joint and the area above the joint -- the cartilage, bones, tendons, and ligaments.

Repair any damaged tissues. To do this, your surgeon will make 1 - 3 more small incisions and insert other instruments through them. A tear in a muscle, tendon, or cartilage will be fixed. Damaged tissue may need to be removed.

Description

Hip Bipolar Hemiarthroplasty for Femoral Neck Fracture

Fractures of the hip often occur within the femoral neck, a thin section of the thigh bone that helps to connect the “ball” end of the bone to the main shaft.  When a fracture occurs in this area of the bone, it can cut off blood supply  that cannot be treated with conservative methods.

​Discectomy

A discectomy (also called open discectomy) is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord. The procedure involves removing the central portion of an intervertebral disc, the nucleus pulposus, which causes pain by stressing the spinal cord or radiating nerves.

The traditional open discectomy, or Love's technique, was published by Ross and Love in 1971. Advances in options have produced effective alternatives to traditional discectomy procedures (i.e. Microdiscectomy, Endoscopic Discectomy, and Laser Discectomy). In conjunction with the traditional discectomy, a laminotomy is often involved to permit access to the intervertebral disc. In this procedure, a small piece of bone (the lamina) is removed from the affected vertebra, allowing the surgeon to better see and access the area of disc herniation.

Microdiscectomy is a minimally invasive surgical procedure in which a portion of a herniated nucleus pulpolsus is removed by way of a surgical instrument or laser while using an operating microscope or loupe for magnification.

The intervertebral disc is then removed using special biting and grasping instruments (such as a pituitary rongeur, kerrison rongeur, and curettes). Special distractor instruments are used to restore the normal height of the disc, as well as to determine the appropriate size spacer to be placed. A bone spacer (metal or plastic spacers may also be used) is then carefully placed in the disc space. Fluoroscopic x-rays are taken to confirm that the spacer is in the correct position.

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with a few strong sutures. The skin can usually be closed using special surgical glue, leaving a minimal scar and requiring no bandage.

The total surgery time is approximately 2 to 3 hours, depending on the number of spinal levels involved.

Overview and Indications

Surgical Technique

First, the spine is approached through a three-inch to six-inch long incision in the midline of the back and the left and right lower back muscles (erector spinae) are stripped off the lamina on both sides and at multiple levels.

After the spine is approached, the lamina is removed (laminectomy) which allows visualization of the nerve roots. The facet joints, which are directly over the nerve roots may then be undercut (trimmed) to give the nerve roots more room.

The nerve roots are then retracted to one side and the disc space is cleaned of the disc material.

A cage made of allograft bone, or posterior lumbar interbody cages with bone graft, is then inserted into the disc space and the bone grows from vertebral body to vertebral body.

PLIF Potential Advantages and Disadvantages

Doing a pure PLIF surgery has the advantage that it can provide anterior fusion of the disc space without having a second incision as would be necessary with an anterior/posterior spine fusion surgery. However, it has some disadvantages:

Not as much of the disc space can be removed with a posterior approach (from the back).

An anterior approach (an ALIF, from the front) provides for a much more comprehensive evacuation of the disc space and this leads to increase surface area available for a fusion.

A larger spinal implant can be inserted from an anterior approach, which provides for superior stabilization.

In cases of spinal deformity (e.g. isthmic spondylolisthesis) a posterior approach alone is more difficult to reduce the deformity.

There is a small but finite risk that inserting a cage posteriorly will allow it to retro pulse back into the canal and create neural compression.

PLIF surgery has a higher potential for a solid fusion rates than posterolateral fusion rates because the bone is inserted into the anterior portion (front) of the spine. Bone in the anterior portion fuses better because there is more surface area than in the posterolateral gutter, and also because the bone is under compression. Bone in compression heals better because bone responds to stress (Wolff's law), whereas bone under tension (posterolateral fusions) does not see as much stress.

Spinal fusion (such as a TLIF) is a surgical technique to stabilize the spinal vertebra and the disc or shock absorber between the vertebra. Lumbar fusion surgery is designed to create solid bone between the adjoining vertebra, eliminating any movement between the bones. The goal of the surgery is to reduce pain and nerve irritation.

Reasons for TLIF Surgery:

>   Spondylolisthesis

>   Degen. Disc Disease

>   Herniated Disc

Spinal fusion may be recommended for conditions such as spondylolisthesis,

degenerative disc disease or recurrent disc herniations. Surgeons

perform lumbar fusion using several techniques.

Benefits of TLIF Back Surgery Technique

>   TLIF procedure has several theoretical advantages over some other forms of lumbar fusion:

>   Bone fusion is enhanced because bone graft is placed both along the gutters of the spine posteriorly but also in the disc space.

>   A spacer is inserted into the disc space helping to restore normal height and opening up nerve foramina to take pressure off the nerve roots.

>  A TLIF procedure allows the surgeon to insert bone graft and spacer into the disc space from a unilateral approach laterally without having to   forcefully retract the nerve roots as much, which may reduce injury and scarring around the nerve roots when compared to a PLIF procedure.

As with all forms of lumbar spine fusion, prior to TLIF surgery medical clearance is obtained. Smoking should be stopped. Patients may require pre-donation of blood to be used at the time of surgery.

Description

Among the causes of secondary osteoarthritis are the effects of old trauma, postdisloca-tion arthropathy, cuff tear arthropathy, congenital dysplasia, the effects of old sepsis, and osteonecrosis. More rarely, surgery is indicated for tumor and failed surgery (including revision of previous prosthesis). Whatever the cause of the destructive process on the articular surface, the net result remains the same, that is increasing pain and stiffness. The overwhelming indication for surgery is uncontrolled pain 'with loss of movement and consequent loss of function. The expectations for shoulder replacement are higher than for lower limb joint replacements. If in the hip and knee, for instance, a stable pain-free joint with two-thirds range of motion is achieved, then this is seen as an excellent result. At the shoulder, however, being stable and pain free is not enough. It is the most mobile joint in the body, and hence a much greater range of mobility is expected.

The results of shoulder replacement depend almost entirely on the adequacy of soft tissues and musculature and restoration of the anatomic geometry of the joint. This cannot be so easily achieved at the shoulder as it can at either hip or knee. When assessing a shoulder before replacement, it is often thought that there is a complete loss of rotator cuff. There may indeed be loss of rotator cuff function, but this does not imply discontinuity. Often, because of gross erosion of joint surfaces, the center of rotation has been medialized and hence the rotator cuff defunction. If the rotator cuff has lost its action, then the unopposed deltoid has its resolution of forces directed superiorly, and hence upward subluxation of the humoral head results. If this process can be reversed, that is, by lateralization of the center of rotation by retensioning both cuff and deltoid, then restoration of function can be expected. Unfortunately, in the most severely affected joints, long-term adaptive changes have occurred, that is, shortening of rotator cuff muscles; therefore, complete restoration of geometry by lateralization of the center of rotation is not possible, because the soft tissues cannot be elongated adequately to the anatomic position.

In the more severe cases, loss of the rotator cuff may indeed be true and complete. In this situation, it may be wiser to consider hemiarthroplasty alone because the incidence of glenoid loosening in the face of complete rotator cuff loss is greater. This can be surmised on a mechanical basis alone. If the rotator cuff is not present, the humeral head is subluxed superiorly. If the glenoid replacement is then placed in the anatomic position, a rocking or toggle movement increases the chance of loosening. Interestingly, the results of hemiarthroplasty in relation to total replacement are not too dissimilar. However, it has been shown that hemiarthroplasty alone may not give the complete relief of pain experienced by the total replacement.

All shoulder replacements of whatever design require good bone stock for fixation of the glenoid component. If medial erosion of the glenoid has occurred such that the erosion is to the base of the coracoid, then it is unlikely that adequate seating of the glenoid component ¦will be achieved, and it may be better in this situation to accept the hemiarthroplasty alone.

Dynamic hip screws are used for internal fixation of fractures of the femoral neck and intertrochanteric region. The screw is a large cancellous lag screw that glide freely in a metal sleeve. The sleeve is attached to a side plate that is fixed to the lateral femoral cortex with screws. Weight bearing cause the femoral head to becomes impacted on the femoral neck producing dynamic compression of the fracture. The shaft of the lag screw slides down the sleeve maintaining reduction of the fracture as compression occurs.