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IC 302-2023: My Worst Day in the Operating Room - ...
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IC 302 - My Worst Day in the Operating Room - Navigating Challenges and Complications Associated with Arthroscopic Knee Surgery, and How it has Changed my Practice. (2/4)
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I'm going to show kind of a couple companion cases, and certainly if you have questions you can stop, but I'll ask our esteemed panel here kind of what they would do. So this is a perineal nerve injury. Go right into the case. So here's a 21-year-old that had a knee dislocation that you can see, underwent closed reduction in our emergency department. At that time we do screening ABIs, and fortunately we're normal. So we saw him preoperatively, and thankfully, despite having the knee dislocation, you know, his neuro exam was 100% normal. So here you can see the ACL-PCL disruption, and then this is one of those, you know, really bad lateral-sided blowouts where, you know, your IT band, your FCL, your biceps femoris, you know, completely off and retracted. So KD3L injury. So first of all, maybe I'll ask, you know, the panel. So a 21-year-old, knee dislocation, bad lateral-sided blowout, you know, everybody thinking acute surgery, trying to get to the operating room as soon as he can. Yeah, I mean, I think there's a lot of different ways to skin this cat. So I like acute surgery. I would try to repair as much as I can. I'm pretty aggressive with recon on the lateral side, just because the results of repair can be mixed, and I like to do everything. So I do one stage, acute, if I could, yeah. Any difference from you guys? Same. Maybe I'll be the heretic here. I like to, I mean, this one I'm going to definitely be acute laterally, but I'm probably not going to do everything. I understand that there's maybe a higher failure rate if you're doing your cruciates in a delayed fashion, but I don't delay them much. But I'm doing the lateral side and then getting their motion to be better than it is before, and then doing the cruciates in a staged fashion. And this is one where you literally make the incision, and everything's just, you know, popping out at you. So you can see kind of proximally and distally there. The probe is on the lateral femur. We did get him to the operating room at nine days following the injury, which I think was helpful for us. So just to kind of point out the structures here. So here's his IT band, which was a vaulst. You can see his fibular head there, which thankfully did not have any fractures. You can see their popliteus tendon, our fibular collateral ligament, and our biceps there. So these are always the ones that, you know, certainly give some angst when that biceps femoris is a vaulst and proximally retracted. How are you guys managing the nerve? Any tips and pearls in this situation? And I'll show you here where a nerve was in the fibular neck in this case. So I always, just as you have done there, dissect it, put some vessel loops around it. I like to make sure that I have released and seen it coming from behind the biceps as proximally as possible. And then on the fibular neck, making sure I've released it enough where I'm seeing some tibant musculature. And by the time I'm done, hoping that without even the weight of a vessel loop, it's draped off to the side, it's nice and released. You know, as a side note, anecdotally, in a case like this, occasionally this will end up in the hands of like our trauma partners or something like that. And even when they're used to treating bad injuries like this, I don't know that they will always do that full release. And so I've seen, you know, problems come back from not doing full releases. And then by the time things contract and scar and get fixed down, that nerve gets sucked up into the problem area. So really making sure that it is completely draped and lax outside of the zone of injury per se. Yeah, I think those are all good thoughts, but I think the message here for the panel is if you have that biceps off, boy, you know, you make a big incision, really get control of that nerve. One thing, one thing quickly, Aaron, so I would highlight, this is the reason that getting into these early is very helpful. This is going to turn into a giant scar ball if you don't. And then you're going to have a very unfortunate time finding the nerve, especially when it's hard enough, even at nine days, I mean, a beautiful dissection, but finding the nerve when the biceps is off is very hair raising in the chronic setting, at least in my experience. And then dissecting it down, you can keep going a long, long way, actually, through the tibia, inches down the leg if you need to, not that you need to, but if you have issues mobilizing, not that it would be, but you can continue going a very long way down without any issues from a motor standpoint. Yeah, and I think these are ones, you know, usually we find the peroneal nerve, you know, proximally, you know, underneath the biceps. And these are ones where you might have to find it distally actually at the neck and then work your way back up. But I'll remind you again, the nerve was intact clinically, preoperatively. So in this case, we repaired all the structures. Tissue quality was pretty good, but to your point, Armando, you know, we were augmenting with a semi-T graft in this case. We did choose to do everything all in one setting, I just, I really personally have trouble with collision between, you know, the ACL femoral socket and, you know, your popliteus and FCL socket on the femur. So for me, I'm kind of going back and forth a little bit, you know, when I'm drilling those, but just to find that isometry. So here's our final x-ray. You can see for our FCL, we did a single-tailed reconstruction, fibular-based with the repair. So this is your popliteus, FCL, and then your fibular-based tunnel, which we also, you know, repaired the IT band, the biceps. You can see the metal suture anchors there, capsular repair, capsular shift. So immediately post-operative, you know, this is one where, you know, you go check them pre-op or post-operatively, and really no sensation or motor function. So obviously we put a brace on in all these cases, and, you know, these braces I'll talk about in the next slide can certainly have trouble. So we loosened the brace, we flexed the knee, came back, you know, at 15 minutes, and thankfully the dorsum of the foot at that point had near-normal sensation. And, you know, definitely his toe extensors were intact, his peroneals were intact, but he didn't have any, you know, ankle dorsiflexion. And, you know, we felt at that point, something I always teach the chiefs and the fellows, you know, leaving the OR, you have to be confident that nerve is intact, because if it's out post-operatively, you know, you can't think in the back of your mind, do I have to immediately take this patient back, you know, for an exploration? We felt confident that the nerve was intact. There was some rapivacaine used in the lateral incision, which maybe is not the ideal use. We thought, well, okay, maybe we could have just blocked part of the nerve, felt confident with, you know, with his exam, sending him out the door. So would anybody do anything different at that point, seeing him in immediate post-op recovery? Aaron, this is good. A lot of good points here. I think, one, I've gone away from any lateral local anesthetic, even like lateral meniscus repairs. We've had some patients that, you know, inside out, they just have a little bit of numbness or a little bit of weakness, and I never want to think that that could be a contributor to it. I'm sure you probably won't anymore either. Same thing, I have my fellow at the end, like, you're looking at the nerve. We all see it. You can see it in continuity from where, like, my most proximal resection, or not resection, but, you know, opening is to the distal part. I would probably sit on this. You know, if you felt confident that you saw it at the beginning and the end, and it was in continuity, and there was some improvement when you loosened the brace, I would assume this was probably from some swelling and whatnot, but this is challenging. You probably didn't sleep that night, if I had to guess. Yeah, and it's, you know, the fact that he had completely normal function, you know, in the office, and then obviously different exam. So just a word on these braces, you know, for this audience, I'm sure you realize and have had personal experience, but these braces are great, but I will have one or two a year where I go examine them in the, you know, post-operatively, and their brace is too tight. You know, that strap is too tight, and then we loosen it up, and thankfully, you know, before they're out the door, they regain their dorsiflexion, but, you know, if you're not checking these patients yourself or, you know, have someone that you can really trust to check these patients, you know, if they ended up out the door and back in your office at a week or 10 days, it's going to be game over, you know, for a lot of these patients with the peroneal nerves. So any, you know, just recognize this is the most probably common issue you'll run into with a peroneal nerve in your practices, no matter what type of knee surgery that you do. So we saw him back at his dressing check, and really, at that point, unfortunately, the exam was unchanged from when we saw him post-operatively, so rupivacaine doesn't last three weeks, so at that point, couldn't chalk it up to that, and, you know, what was surprising here is his toe extensors were completely normal, peroneal, eversion was normal, but just no dorsiflexion whatsoever. So at that point, we became, you know, concerned, obviously, due diligence, so we got an ultrasound, which thankfully showed the nerve was in continuity, and at that point, we got our peripheral nerve team involved, but seeing him at that dressing check, maybe it was a little bit later than normal, but anything you would have done differently at that point is, would everybody be getting some imaging of the nerve at that point, or? Did you have other touch points with him? Like, was three weeks the first time you saw him after surgery, were you guys checking on him? We, you know, I always call him the day after surgery, you know, but he was, he was doing quite well, you know, and again, it's one of these things where we left with the assumption on the day of surgery that this was some sort of kind of traction, you know, you know, we're hoping it was rapivacaine, but, you know, very, it'd be very unusual where it just knocked out, you know, just dorsiflexion of the ankle. So you know, at three weeks, it wasn't, you know, you're hoping to see some recovery, some flicker, some antigravity, something, but nothing at this point, so, but would everybody get some sort of imaging of the nerve? Okay. So our peripheral nerve team told us, okay, you know, the ultrasound looks good. The nerve is clearly in continuity. Let's watch it closely. So saw him back at six weeks, really no change. You know, we repeated the ultrasound, didn't see any significant change as well. Now you're starting to really sweat it at six weeks. This is getting a little nervous, pun intended. So at this point, you know, we rely on experts of our peripheral nerve team, and they said, well, let's keep watching it. So we got the EMG at three months at this point, and you can see just no activation of the tibialis anterior. So that's obviously concerning. So three months, what's your approach for this patient? You know, the one thing to point out as I delay my answer, as I think about it, not all, everybody's going to have access to that peripheral nerve team, you know, and so I think not to backtrack, but I think approaching it as you did with their, you know, sound expertise is great, but in the end, also approaching it with an all hands on deck, making sure you alert their physical therapist to be, you know, stretching their Achilles, even fitting them for an AFO in the interim, you know, treating this as if you don't know what the outcome's going to be, but that you also don't bury yourself into a hole later from a foot drop problem is really important to think about. You know, at 12 weeks, if there's no muscle activity in the patient, I presume is otherwise recovering well from their multi-leg, you know, I think I would have a serious conversation with them about potentially going back in and exploring it, decompressing it. I think at this point, you know, it's probably, you know, it's another hit on the patient, but it is also kind of a low rent investment that you can at least say, hey, we tried, you know, everything, we've given it three months and there's still no improvement. So I would be thinking along those lines. Aaron, what did the peripheral nerve team say? Because I would have been inclined to maybe intervene early. It was intact pre-op, it was out immediately post-op, it did recover by three or six weeks. I'd be inclined to maybe open it up a little earlier, because I would assume it got tethered, you know, either a suture tethered it or when you repaired the biceps, it came with it and it was kind of kinked. And I probably would have, I mean, in retrospect, gone in sooner. What did they say? Yeah, I think, you know, we're fortunate. We have very good ultrasound, you know, physicians and they are very good. And I'm going to show a companion case here where you can see that they pick up some subtle abnormalities, but usually we trust that, you know, if they say it's completely in continuity, looks structurally normal, you know, no neuromas, that sort of thing, because usually you'd see that at six weeks. So that was kind of what was guiding them. But I agree, if this was on my own at six weeks, I probably would have pulled the trigger. Ever MRI? You can get MRI. I just think in this setting, you're going to, you know, you're going to end up with a lot of signal everywhere and I'm not sure if it's going to help completely. And the confounder here is, right, so his toe extensors were completely intact. So it's not like the common peroneal nerve was out and not like the deep peroneal nerve was out. So very strange. So let's, let's get into that. How is that even possible? So if you look at normal tibialis anterior innervation, and this is something I had to go back and look at myself. So it comes from two different sources. So you get the trifurcation of the nerve. So obviously we know about the deep peroneal nerve innervation, but you can have articular branch innervation as well. And that's why, you know, you talk about releasing it distally, that articular branch is very, very small. It kind of looks like fascia sometimes. So how in this case, you know, did he have intact, you know, toe extensors? Well, it's because in this case, the tibialis anterior was articular branch dominant. So this thing was almost fully innervated by the articular branch, which is a known, you know, anatomic variant that I didn't appreciate as much until this case. So with that knowledge then, so we went back, it was at 14 weeks, and you can clearly see here that there was some injury to the articular branch, the common peroneal, the deep peroneal were completely normal, but you can see that bulbous neuroma there. So you know, probably excessive retraction, maybe inadequate decompression, all those things that you so skillfully talked about, you know, before surgery. So at that point, they did a neurolysis, and they actually did do a nerve transfer from the superficial peroneal nerve. Thank goodness at three weeks, he had complete recovery of his dorsiflexion. So obviously, that wasn't the nerve transfer part of the operation, it was clearly, you know, the neurolysis from that neuroma. So you know, our group has published on over, you know, 175 patients now, and these are, you know, Bruce Levy and Mike Stewart's patients, and they only had one nerve issue in all of these patients that resolved at three weeks. So as I'm taking more of these cases on, I don't want to ruin that track record, so to speak. But the question is, you know, how close are we with that peroneal nerve when we're drilling that fibular tunnel? What's the anatomic safe zone? So if you look at our fibular collateral ligament graphs, you know, we put a screw in there, and that common peroneal nerve is very close to that articular trunk. So that safe zone, we looked at both operatively and cadaverically. And really when you look at it, it's about five to fourteen millimeters of real estate that you're dealing with. So it is very, very close. So the key is, as you alluded to, it's that peroneus longus fascia. So there's two fascias. So one is superficial, one is deep. You have to release that deep fascia, which really constricts the articular branch of the peroneal nerve. So here it is in a cadaver. This is a right knee. You can see the nerve there. And then the forceps is on the peroneus longus. And you can see the superficial fascia. You'll see some muscle fibers. And then you have to release that deep fascia as well. So that that would be our tip, you know, moving forward and how this case has changed our practice. Thankfully, you know, ultimately he did well. Was able to get back, you know, his activity level and and function. So any any final discussion on on that one? How far do you guys release it? So I do release that superficial and deep. I probably go about a centimeter into that fascia. How far do you guys go? Yeah, I think that's right. You know, I just I want to see that deep fascia. I want to make sure it's released. And then, you know, I don't always follow it to the trifurcation, but I am certainly releasing that deep fascia now. But that articular branch is very, is variable. I mean, sometimes it looks like a little wisp of fascia almost. So now it's kind of made us a little gun-shy. But any questions? There's one in the back there. So his exact motor exam was that his, you know, his toe extensors, so his, you know, to all of his digits was intact. His peroneals were intact. The only thing that was out was his tibant or his ankle dorsiflexion. I have seen that actually. So I had a case, so I do inside-out lateral meniscus repair, and I had a case where in retrospect, you know, I had my Henning retractor right where I wanted it. I think the resident during the case missed, like, it came out and they popped it back in. And I should have include in because at one point she said, oh there's a lot more fat here than I would expect. I can't find the needle. And usually the lateral side, that's not the case. On the real side it is. But make a long story short, one of those sutures tethered the peroneum. And I was checking, this guy was a dental student, and I went to go check him post-op. And I said, how you feeling? He's, oh, I'm having pain. I said, oh, in the back of your knee? Because, you know, he had some sort of adductor canal block. And he goes, no, just down the lateral aspect of my leg. I said, move your foot. He was dressed. They were sending him home, and he had a foot drop. So I took him straight back to the OR, opened up that incision, released the suture. Thankfully it wasn't around the nerve. It was tethered. It was kind of like puckered up to the post-lateral capsule. Released it, revised the repair, and post-op his foot drop came back. His sensation came back, but he had a toe drop for like six months. Yeah, and I think it's because of that terminal branch, you know, that Aaron was just showing. It did eventually get better, but that was the last aspect. He'd bring his foot up and his toe would drop down. Yeah, so I think it can be, you know, it could be the continuity of that, you know, deep peroneal nerve. So if, you know, if your articular branch is giving you off innervation, and your ankle dorsiflexion is okay, and it's, you know, more distal motor innervation, I think it would be, that would probably be my target. But that's a great segue. So I have a companion case here, another peroneal nerve injury, which again, I think a lot of us see in this room, and I just think having a better understanding of how to prevent, how to manage these is important. So this is a case that I didn't perform the index surgery, but I inherited the patient, and later the entire family, because they all have a discoid lateral menisci. But, so this was an 11 year old female. She presented outside to a physician. Lateral pain and popping, clearly a discoid lateral meniscus. Surgery very appropriately indicated. So you can see here, this is the initial MRI, you know, almost a complete discoid meniscus. You can see substantial intrasubstance signal, but more importantly, I mean, she was having very significant symptoms, you know, popping with walking, just with ADLs. So this one was, was very symptomatic at age 11. So these are the outside scope pictures, and you can see a near complete discoid, and they did a very good job on the right picture there. You can see that that posterior horn is completely detached, you know, from the posterior capsule. So these are one of those, that's the hypermobile variant, you know, the discoid meniscus. So they performed an inside-out repair, and I mean, first of all, I mean, would anyone do anything differently than an inside-out repair for this detached discoid lateral meniscus at 11 year old? So I think, I think the indication in the surgery was, you know, performed well, or at least indicated well. So then looking through the notes, you know, there was an unclear post-operative exam. I could not find a post-operative exam documented in the record. I did find some telephone notes. So post-op day four, the family called in, just stating that, you know, their daughter was having pain on the top of her foot. The foot looked great, the knee felt great, but she can't really pull her foot up towards her. She can bend it down, and you love the positivity of this family. Her incisions look great, too. You know, trying to minimize, and I think that's our tendency as humans, just to kind of minimize when something doesn't seem right, but clearly not right at post-op day four. So what would you do at this point? This is your patient calling in, not able to raise the foot. I guess you'd have more information and knowledge about the nerve, but. I think you gotta take this patient back, like, relatively quickly, in my opinion. I think it's an inside-out repair. I always tell our fellows, it's interesting, so we always look for the nerve, like that case that you showed at the beginning, behind the biceps femoris, right? But when you go, there are three windows on the lateral side. You've got the IT band window, which is where you get your femoral insertions for your ligaments. You have your meniscal repair window between the IT band and the biceps, and then you have your window between the biceps and the nerve to get to the back of the fibula and the tibia. You can find the nerve in that second window between the IT band and the biceps if you look around. So it's sitting there. It's not in line with the biceps. It's a little bit medial to it. So in my opinion, if she's got a foot drop after an inside-out, I would assume that that suture is tethering the nerve around the nerve, and I think, you know, time, it's every minute, it's clicking by. So I would probably take this patient back. The first thing I'd do is bring her in and examine her. Yeah, for sure. So Travis here, they brought her in and examined her, and basically it was exactly what the family was telling you on the phone. So no toe extension, no ankle dorsiflexion. So at that point, I think we're all in agreement. So they did get an ultrasound, and clearly, you know, in distinction to the first case, this ultrasound definitely showed abnormalities, which was interesting even at six days post-operatively. So you could see that, you know, the person that did the ultrasound here localized this lesion very well. They thought there was some constriction of the peroneal nerve proximally. So ultrasound can be very sensitive. So we're all in agreement, and unfortunately, this is the picture, and you can see, I don't know if you can see my pointer here, so this is the peroneal nerve, and clearly you can see some sutures there from the inside out repair. So when you look at it, so we remove the sutures, and this is the nerve, and clearly at this point, we had one of our hand surgeons in there helping us, who's a nerve expert, so that was very valuable. So this is what the nerve looked like. It was definitely contused, you know, beat up a little bit. So, you know, the advice was at that point, you know, let's see how it goes. If there's no significant recovery by six weeks, maybe do something else like a nerve transfer and things, but the thought process there was, you know, a young patient, hopefully capable of, you know, some improvement. So yep, go ahead. You didn't do the index surgery. Correct. How did you inherit this at four days out? So I didn't hear it at four days. It was sent to me, you know, when the nerve issue was identified. Which was when? Post-op day, whenever we saw him in clinic, six, seven, something like that. Really? How did that happen? I mean, it's a bit unusual. I'm truly, like, in the interest of, I mean, I'm not throwing stones at anyone, but it's just a very bizarre course when you have an immediate post-op patient with an immediate post-op problem, having them see another surgeon is a very unusual thing to do. Yeah, I mean, there was a phone call and a conversation, but. Okay, so they called you and said, hey, we're a little nervous, can you help out? Yeah. Got it. Yeah. Okay. Yeah, like any neurogen, that sort of thing. They did not, you know, again, I just have to rely on their expertise, and that's probably one of the themes here, is if it's out of your, you know, wheelhouse, I have to rely on, you know, on my colleague. But a good thought, for sure. So at six weeks, thankfully had some subjective improvement, you know, in sensation, maybe a little flicker. And then, you know, here, I think this was a six-week video or three-month video, I can't remember, but fortunately she had, you know, full recovery of this. And then I've taken care of her other knee. In the family, I've taken care of six discoid lateral meniscus, so they've gotten to know us quite well. So, so just to your point, Armando, so I, you know, if you take one thing away, it's, it is these lateral windows. This is a right knee, and you know, we're, we're trying to put your, you know, for inside-out suturing, your retractor above the biceps femoris, but this is the window here behind the fibular collateral ligament. And what you have to do with your retractor, is you have to place it anterior to that lateral gastroc. That is the absolute key. And you can see in, you know, an 11-year-old female, I mean, they're not gonna have much of a lateral gastroc at all. It's gonna be paper-thin. But if you don't put your retractor right there, then to Armando's point, let's say the retractor fell out or something, put it back, and it's not in front of that lateral gastroc, you certainly could grab the perineal nerve in that window. And I think that's probably what happened, you know, in a smaller knee, you know, not much of a lateral gastroc. But that, that's the key, I think, the takeaway here. Aaron, can I chime in on that, if you go back to, is, you know, not to belabor your point, but having someone that you can rely on to identify that each time, and to catch the sutures, and get in and out each time, like, you know, sometimes we'll put the camera in, check, do we need more stitches or not? As you alluded to, that retractor, whatever you're using, a speculum, whatever, can fall into any one of those windows very easily. The other thing that I always harp on our residents and fellows is that, you know, specifically, if you look at that picture on the left, the retractor almost needs to be facing superior as much as facing anterior, because by the time you're flexed, and then the curvature of the needles, if you're just retracting straight posterior, it's just going to deflect off into that nerve, right? So, you know, having that retractor not just in the right window, but orientated the right way, so that the needles don't deflect even more so into the nerve, I think is really important. Yeah, so I can't, can't emphasize it enough. I mean, this is definitely one of the takeaways, hopefully, for your practices. So, for me, the perineal nerve, just constant vigilance. This is a nerve that does not take a joke. Be careful with your post-operative braces, you know, always perform and document post-op exams. For your post-ratal corner procedures, I do release that perineus longus fascia now. That, that definitely has changed my practice, and then, as the group has said, you know, keep, keep that retractor in front of the lateral gastroc muscle to keep you out of trouble. So, thank you. One other comment quickly. So, we looked at perineal nerve injuries early on in my practice, not for personal reasons, but it scared the crap out of me. And interestingly, it doesn't take a joke, but oddly enough, it can come back a lot better than you think. So, as you've identified in both of these cases. So, the, and you can also solve a problem, although not on the sensory side, with tendon transfers. So, there is a wave, and it's interesting, it's a bit of a pendulum in orthopedics, where, especially with initial perineal nerve injuries, with multi-leg injuries, what do you do with them? And there were, there were some folks that were saying, hey, we should do an immediate resection, nerve transfer, etc. And we, so we looked at this, and oddly enough, they come back more often than you think they will, because you don't think they'll come back ever. About 50% will come back. Not, you know, M5, but M3 in terms of motor strength, and they can come back up to two years. So, we looked at about 15 years of data at my former institution in New York, and they do come back. So, what we'll do on these, and in almost all of these cases, obviously, early injuries, you have to get in and release what you may have done to injure it. But then, you sit and watch them, and you watch them, and you watch them, and amazing things can occur. So, and don't jump in and say, hey, let's start cutting things out, and transposing nerves, and doing all that jazz, but instead, just sit back and relax, because there are salvage procedures that can be done if you need to, and tendon transfers, and many of them do come back. Yeah, that's, that's been my clinical experience, too. I've gone back in and released one, you know, year, year and a half out, and amazingly, they come back, and they come back surprisingly early, considering how long it's been out. Yep. Any other experiences in the audience on this? Folks of, who here's had a perineal nerve scare? I have, too. Yeah. Yeah, I examine all these post-op, like, in the recovery room, like, now, after that experience, that, and it was not the resident's fault. I mean, I think that they just were an experience. It popped out, they popped it back in, and I was unaware that that happened during the case, and in my experience, and this is my case, and I, again, I took them back, like, from the recovery room, and a seizure said, you know, they're having a lot more pain than I would expect. What are you guys doing there? So, like, when I replayed the tape, in my mind, like, things that I could have changed, and the resident said, you know, there's more fat in here, and there shouldn't be a fat on the lateral side. And the other challenge, Aaron, just so I was thinking as you presented that case, sometimes if they have a favela, it's really hard to get that interval established, because it's sitting in, within the lateral head of the gastroc, and that interval can be tight, and sometimes even a spoon can be tight to get in there, and you can't put your heading, or your speculum, or whatever you like to use. Those are good cases, yeah. Well, this is... We have a question real quick. I'll let you guys answer this. We don't have a big institution like you guys have. Our guys are, we're always six weeks. What do you guys think? Typically, they'll get it at six weeks.
Video Summary
In this video, a panel of experts discusses two cases involving perineal nerve injuries. The first case involves a 21-year-old who had a knee dislocation and a lateral-sided blowout injury. The panel discusses their approach to surgical repair and managing the nerve. They emphasize the importance of releasing the deep fascia and ensuring the nerve is completely released and not trapped in the area of injury. The second case involves an 11-year-old with a discoid lateral meniscus who underwent an inside-out repair. The patient developed foot drop postoperatively, and the panel discusses the possible reasons for the nerve injury and the importance of proper retraction during surgery. The patient eventually had a good recovery, with some improvement observed at six weeks and full recovery at three months. The panel emphasizes the need for constant vigilance in preventing and managing perineal nerve injuries, including careful positioning of retractors, releasing the perineus longus fascia, and monitoring postoperative braces for tightness. The panel also highlights the potential for nerve recovery even in severe cases. No credits were provided in the video transcript.
Asset Caption
Aaron Krych, MD
Keywords
perineal nerve injuries
surgical repair
nerve management
deep fascia release
foot drop
nerve injury prevention
nerve recovery
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