Surgical Pictures

Ankle Fusion

Below is a picture of post-surgical ankle fusion using a cross screw technique. This type of procedure is typically necessary to relieve pain and disability from severe arthritis in the ankle as result of significant trauma or repetitive trauma. The goal of this procedure is to eliminate pain and continues to be the gold standard for severe joint arthritis.

 

Hallux Limitus

Abnormal anatomical position in addition to increased activity throughout a period of time or in some cases an injury will lead to the irregular shaping of the bones around the big toe joint from abnormal wear and tear. This will cause arthritis type pain with stiffness and swelling.

With abnormal wearing of the joint, spurring of the top of the joint occurs from jamming causing decreased motion of the big toe in an upwards direction.

 

Post-operative x-ray of a joint that was repaired with a Hemi (partial) joint replacement to alleviate limiting arthritis which also involves reshaping of the bones to eliminate spurring.

Open Fasciotomy for Acute Compartment Syndrome

Pictured below is an opening of the facial muscle compartments of the left leg. This procedure is performed to release pressure that has built up in the muscle from activity in which the pressure does not go down after a certain amount of time. This increased, sustained pressure within the compartments is very painful and puts at risk loss of blood supply to the muscles, and in severe cases can cause the death of the muscle tissue.

Below is a picture of retention sutures placed over the fasciitomy site in order to allow the muscle compartment to decompress but also does not allow the skin to retract and make the closure of the large incision difficult to perform at a later date.

This is the primary closure of the incision site once the compartment has been adequately decompressed, 

Juvenile Medial Malleolar Fracture in which the fracture runs from the ankle joint through the growth plate (pictured left) which is the jagged line running from side to side above the ankle joint. This growth plate will remain open until skeletal maturity to allow growth. The fracture running through the growth plate can jeopardize the growth and must be fixed to assure best results. Pictured on the right is the fracture after surgical repair with a screw that helps to compress the fracture without crossing the growth plate, but also aligning the growth plate as to not disrupt the growth of the bone. If possible crossing the growth plate with surgical hardware should be avoided in order to not affect the growth of the bone.

Medial Malleolar Fracture demonstrating displacement of the fracture fragment that could lead to abnormal healing and altering the mechanical function of the ankle joint necessitating the need for surgical repair. PostPPost 

Post-surgical repair of fracture with the realignment of fracture fragment held with two surgical screws to allow the appropriate position of the fragment and compression which is most ideal for the healing of the fracture. This also will allow a return to function of the ankle joint which will decrease the potential degenerative problems that can occur after this type of injury.

Salter-Harris IV Fracture (illustration), which is a classification for fracture in children involving the growth plate, of distal Tibia depicted on the left side with the fracture that extends above the growth plate and also disrupts the growth plate which can also stop the grown of the bone. It is important to repair this surgically to ensure that the bone heals and has the best change for the unaltered growth of the bone.in the juvenile patient. The picture on the right is after surgical repair demonstrating good approximation of the fracture fragment and re-establishment of the growth plate.

 

Jones Fracture Status Post Percutaneous Screw Fixation

Jones fractures are specific in that they occur at the base of the 5th metatarsal occurring away from the articular surface, and are a common injury in certain sports such as basketball. These fractures are precarious in their character in that the area of the bone in question where the fracture takes place which has less blood supply than the remainder of the bone, therefore compromising healing potential of this area.

This is a side view (lateral) of the foot after surgical repair of the Jones Fracture which is important to stabilize this fracture not only for adequate healing but also because of soft tissue structures such as ligament and tendon that attach to the base of the 5th metatarsal.

Chondrolysis of 2nd MPJ arthritis before and after microfracture

There is damage to the articular surface cartilage which can occur either from an acute injury or more commonly after repetitive injury and/or wears and tear. If the bones at the joint in questions are not aligned properly then this mechanically adds to the wear the joint receives with activity and increases the propensity of this occurring. Pictured below is linear damage to the articular surface of the 2nd metatarsal head.

The following pictures are debridement of damaged cartilage that is abnormal in appearance and/or loose. This is removed completely to expose the subchondral (underneath cartilage) bone plate.

Drills holes are then placed through the bone plate to allow bleeding in the area which will aid in the healing of the cartilage surface with fibrocartilage which is a kind of scarring of cartilage.

Bunion & Hammertoes

The following is depicting a bunion deformity of the great toe that has worsened a hammertoe contraction of the second toe. The outside deviation of the great to cause underriding of the second to which leads to increased dorsal (upward) dislocation of the toe.

Post-operative repair of the bunion and hammertoe deformities which straightens the great to utilizing a combination of bone cuts and soft tissue releases of the great toe and second toe to correct abnormal position of the toes and significantly improve pain with activities and use of shoes.

Below is a photograph a severe overlapping bunion and hammertoe deformity. At this point in the mechanical process, the digits especially the second digit is dislocated from its articulation with the long bone in the foot called the metatarsal. The severity of these deformities is multi-factorial involving genetics, altered mechanics with soft tissue contractures, and bad shoegear.

Below is a photograph of the top view of the same deformities that is pictured above.

Pictured below is the same foot after surgical correction of the bunion deformity of the great toe and hammertoe correction of the second, third and fifth toes. The plastic balls at the top of the second and third toe are covering wires that hold the position of the second and third toes into the long bones (metatarsals) of the foot so that the soft tissue contractures heal in the correct place. Depending on the deformity, the wires will stay in place for a period of 4-6 weeks and then are removed.

 

Compartment Syndrome

The following is the fascial covering over a muscle compartment. The condition occurs when the pressure within this compartment builds up after an injury or can also occur after exercise from the inability of the muscle to decompress naturally. This leads to pain that is unrelenting and could lead to decrease blood flow and oxygen to muscle tissue causing the death of that tissue.

The picture below demonstrates the fascia overlying the tissue being lifted by the forces at the top of the picture.

Below is demonstrates incision into the compartment exposing the muscle tissue that is a deeper red color where the retractor is to the left of the picture. The opening of this facial tissue is vital in releasing pressure in the compartment after injury or from exercise. It also important that this release is extensive as so the fascial tissue does not heal closed allowing build of pressure again.

Achilles Tendon Rupture

Most Achilles tendon tears occur from chronic degeneration of the tendon in conjunction with the improper conditioning of the tendon to perform certain activities such as jumping and sudden changes in direction. This is why this type of injury occurs in what is considered the "Weekend Warrior". This person usually does not train and condition the tendon to handle intense physical activity then goes and plays a sport over the weekend and the tendon gives out. In the picture below one can see the frayed ends of the torn Achilles tendon.

The image below is the tendon after repair with a complex suture technique called the Krakow stitch. This is a very strong repair and prognosis after repair with physical therapy is very good.

 Picture of a large benign bone tumor at the front of the ankle

Benign Tumor after removal of the tumor

Pes Cavus (High arch foot)

Preoperative films of a Cavus foot with a high arch, which you can see the high pitch of the heel bone (calcaneus) relative to the ground (left). Post-surgical reconstruction of the cavus foot with a calcaneal sliding osteotomy fixated with two screws and a bone cut of the base of the first metatarsal to decrease the apex of the deformity near the joint fixated with a surgical staple (right).

This is Pre and Post-op xrays of surgical correction of a syndesmotic rupture that failed the first time by a different physician due to screw break. On the Postoperative films by our physicians, the space between the medial malleolus and talus is decreased and the joint is congruent and symmetrical. We bore a hole in the bone at the prior screw sites, added two syndesmotic screws that went across both bones for added stability as well as 2 Arthrex tightropes.

The following are pictures of a healed talar neck fracture status post ORIF. Due to the severity of the injury, the patient suffered from subtalar arthritis and pain. The patient's heal also began to tilt in due to the injury. We performed a calcaneal osteotomy with subtalar fusion to correct the patient's foot.

Pre-op

 

Post-op

 

These are pictures of a Pilon fracture that was performed by a different surgeon. The anterior tibial plate was placed too distal and invaded the patient's joint. These injuries often cause post-traumatic arthritis regardless of the fixation. The plate was removed and the patient had some relief. Approximately 1 year later, the patient underwent a successful arthroscopic fusion.

S/P Pilon with an anterior plate too distal

After removal of the plate prior to arthroscopic fusion

 

After arthroscopic fusion

 

Intraoperative picture of an avulsion of the Achilles of the calcaneus

Below the Achilles is pulled through a trough in the heel bone to re-anchor it down)

Pic below of an avulsion of the Achilles off the heel bone prior to repair and re-anchor through the heel

Intraop pictures during hemi-implant for hallux limitus

 

Osteochondral Autograft Transfer System (O.A.T.S.)

    

Ankle fusion with fibular only graft after a severe post-traumatic arthritis post-Pilon fracture

  

Achilles rupture intraoperatively before and after repair

 

Intraoperative pics of a bunion correction with a bone cyst in the first metatarsal. The cyst is current and autogenous bone graft from the bunionectomy is morselized and packed into the bone cyst.

  

  

Surgical resection of the coalition allows removal of restriction of range of motion in the affected joint and elimination of pain associated with the attempted motion. Pictured is the coalition at the point of the metal instrument. Pictured right is the newly created space where that coalition once was located. The last picture is using the FDB muscle belly as an interpositional graft to occupy the dead space and decrease the chance of recurrence.

     

     

These are operative pictures of a child who had an enlarged fifth toe with a full extra set of bones that were removed to make the toe look more anatomic.

    

These are intraoperative pictures of removal of a painful spur in the back of the heel bone that failed conservative treatment. 

This is an intraoperative pic of a heel spur in the back of the heel prior to resection. It is next to the instrument on the bottom right. The spur causes pain as it irritates the Achilles tendon

This is the bone cut performed to remove the spur and bone that causes pain.

This is a picture of the bone that is removed. Underneath the bone is the void left after removal.

This is a picture of the size of the bone removed. The top portion should have glistening white cartilage. It is yellowish and devoid of cartilage due to constant irritation from the Achilles. The spur is at the bottom portion 30% of the bone.

 

This is a picture of the suture placement in the Achilles tendon to reattach the tendon to bone. There are anchors in the bone that have the suture already attached. The anchors are driven into the bone to allow the Achilles tendon to reattach to the heel. These sutures are then tightened down for an intimate bone to tendon apposition.

Intraoperative pics of anterior and lateral compartment release for Chronic Exertional Compartment Syndrome

  

Intraop Arthroscopic Pics of talar OCD Surgery

   

 

   

   

Series of Pics Biopsy for Subungal Melanoma