JBJS Essential Surgical Techniques最新文献

{"title":"Biportal Endoscopic Transforaminal Lumbar Interbody Fusion.","authors":"Matthew Easthardt, Daniel Park, Phillip Zakko, Ju Eun Kim","doi":"10.2106/JBJS.ST.24.00005","DOIUrl":"10.2106/JBJS.ST.24.00005","url":null,"abstract":"<p><strong>Background: </strong>The present video article describes transforaminal lumbar interbody fusion (TLIF), a common spine procedure, performed with use of a less common technique-utilizing a biportal endoscopic spine surgery (BESS) approach. This procedure is performed for the treatment of degenerative spondylolisthesis.</p><p><strong>Description: </strong>The procedure is performed with the patient in the supine position. An endoscopic portal and a working portal are developed at the level of interest. Fluid is pumped into the working space with use of a standard arthroscopy tower. Using the camera endoscope to visualize; shavers, burrs, and a Kerrison rongeur are passed through the working portal to clear the disc and to create space for insertion of an interbody device. Trial TLIF cages are placed through the disc defect, which can be observed both directly and on radiograph. An appropriate final implant is placed, and percutaneous pedicle screws are typically placed at the instrumented level.</p><p><strong>Alternatives: </strong>Alternatives include nonoperative treatment with physical therapy, weight loss, and/or corticosteroid injection. Surgical options for degenerative spondylolisthesis include lumbar decompression and instrumented fusion. Interbody fusion can provide indirect decompression and increase fusion success rates.</p><p><strong>Rationale: </strong>This procedure utilizes a minimally invasive endoscopic approach with small incisions, resulting in decreased muscle trauma, which has been shown to reduce postoperative pain and recovery time.</p><p><strong>Expected outcomes: </strong>Outcomes of the biportal endoscopic technique are similar to those reported for open or conventional TLIF, with the benefit of improved postoperative pain compared with those procedures.</p><p><strong>Important tips: </strong>Position the patient on a Jackson frame with hip and thigh pads to maintain lordosis for the fusion procedure.Utilize fluoroscopic guidance when determining starting points. The goal is for the portals to be centered over the ipsilateral pedicles of the targeted level.It is best to maintain the camera portal in your non-dominant hand and the working portal in your dominant hand.Stand on the side that the patient reports has worse pain.When dissecting, there is no need to go to the lateral edge of the facet; going further can result in excessive bleeding and decreased visualization.</p><p><strong>Acronyms and abbreviations: </strong>BESS = biportal endoscopic spine surgeryTLIF = transforaminal lumbar interbody fusionMRI = Magnetic Resonance ImagingPEEK = polyetheretherketoneK-wire = Kirschner wireCT = computed tomographyPROM = patient-reported outcome measureVAS = visual analog scaleODI = Oswestry Disability Index.</p>","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12269813/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660613","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Subscapularis-Sparing Windowed Anterior Technique (SWAT) for Anatomic Total Shoulder Arthroplasty.","authors":"Austin F Smith, Michael N Sirignano, Christian M Schmidt, Mark A Mighell","doi":"10.2106/JBJS.ST.24.00007","DOIUrl":"10.2106/JBJS.ST.24.00007","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Anatomic total shoulder arthroplasty (aTSA) has historically been performed via the standard deltopectoral approach, requiring violation of the subscapularis to access the glenohumeral joint. Subscapularis dysfunction has been documented in as many as 67% of cases and may lead to instability, weakness, and lower patient-satisfaction scores&lt;sup&gt;11-16&lt;/sup&gt;. However, the rate of subscapularis failure is much lower, at 1.6% to 3.0%, with a reoperation rate for a failed subscapularis of 0.9% to 3.0%&lt;sup&gt;31,32&lt;/sup&gt;. To preserve the subscapularis tendon, muscle-preserving techniques have been developed that allow for early postoperative motion and activity without prolonged immobilization. The subscapularis-sparing windowed anterior technique (SWAT) is a method for aTSA that preserves the integrity of the subscapularis as well as the deltoid. As a result of the complete preservation of the subscapularis, this technique offers the advantage of early postoperative motion with no restrictions. This technique also avoids the deltoid split that is required in some other subscapularis-preserving techniques.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;SWAT utilizes the standard deltopectoral incision. A window is created inferior to the subscapularis tendon and is utilized for the removal of inferior osteophytes, inferior translation of the humeral shaft, and capsular release. The rotator interval is also developed and is utilized to complete the humeral head cut, obtain glenoid exposure, and implant the components. Additionally, the use of preoperative planning allows accurate sizing of the humeral head component&lt;sup&gt;30&lt;/sup&gt;. Prior studies have shown that this technique can be utilized to reliably attain acceptable radiographic and clinical outcomes&lt;sup&gt;30&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Alternatives include aTSA performed via the standard deltopectoral approach with a lesser tuberosity osteotomy, aTSA with a subscapularis peel or tenotomy, hemiarthroplasty, and other subscapularis-sparing aTSA techniques.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;The SWAT approach preserves the deltoid and the subscapularis by utilizing a deltopectoral approach and creating an inferior window to remove inferior osteophytes. This technique allows for adequate glenohumeral joint access, bone preparation, and implant selection and implantation. SWAT for aTSA is substantially different from other techniques described in the literature. Other subscapularis-sparing techniques require splitting of the deltoid&lt;sup&gt;16-19,22&lt;/sup&gt; and substantial release of the inferior subscapularis&lt;sup&gt;20,21&lt;/sup&gt; and have limitations related to difficult visualization of the humeral head for an accurate cut, difficult inferior osteophyte resection, and potential malalignment of the humeral components&lt;sup&gt;17&lt;/sup&gt;. The SWAT has several benefits, including preservation of the deltoid, preservation of the subscapularis, the use of an inferior window to allow for complete","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12269812/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660617","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Percutaneous Endoscopic Decompression for Lumbar Central and Lateral Recess Spinal Stenosis: A Combined Uni-Portal and Bi-Portal Approach.","authors":"Sang H Lee, Micheal Raad, Farah Musharbash","doi":"10.2106/JBJS.ST.24.00002","DOIUrl":"10.2106/JBJS.ST.24.00002","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Endoscopic decompression of lumbar spinal stenosis has been gaining popularity as the least invasive of several minimally invasive surgical treatment options. This procedure offers similar outcomes to those of conventional open procedures; however, endoscopic procedures are technically demanding and involve a substantial learning curve. The typical endoscopic approach is a \"uni-portal\" approach that utilizes a special spinal endoscope and endoscopic instruments. However, a \"bi-portal\" approach has been developed more recently, which utilizes a regular arthroscope and the same type of instruments that are utilized in open spine surgery.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;The patient is placed in a prone position under general anesthesia with electromyographic neuromonitoring. The primary portal is made at the interlaminar space with use of an obturator and a working cannula. The side of the approach is chosen according to the side of symptoms and radiographic compression. A 15°-angle, 10-mm external diameter spinal endoscope is introduced through the cannula, and the interlaminar space is exposed with use of a radiofrequency bipolar probe. Cranial and caudal laminectomies are performed with use of a 5-mm endoscopic high-speed burr or endoscopic osteotomes. A 5- to 7-mm accessory portal can be created 2 to 2.5 cm caudally (for the left side) or cranially (for the right side) on the same line as the primary portal in order to enable use of a short-distance dissector, curets, and/or osteotomes. Decompression is performed at the central and ipsilateral lateral recess with use of an endoscopic drill, various sizes of Kerrison rongeurs, and curets. Finally, the contralateral lateral recess is accessed by tilting the working cannula, and decompression is performed until the contralateral traversing nerve root and medial border of the caudal pedicle are exposed.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Alternative surgical treatments include conventional open microscopic laminectomy and decompression and other minimally invasive surgical options involving the use of a tubular retractor or similar minimally invasive retractor systems.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;The development of endoscopic spine surgery has expanded indications from simple lumbar discectomy to lumbar central, foraminal, and extraforaminal stenosis, as well as revision surgery. However, the endoscopic approach to lumbar spinal stenosis is challenging and has not been widely adopted because of the steep learning curve and technical difficulty. A fully endoscopic, uni-portal approach is the least invasive option for lumbar decompression because all access and decompression procedures are performed within the limited space inside the working cannula. However, this \"full-endoscopic\" approach may limit the access angle to the surgical field because the working channel is fixed by the trajectory of the endoscope. Also, spinal endoscope-specific, long, small-di","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12262959/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Single-Incision Broström-Gould Surgery with Peroneal Debridement and Calcaneal Osteotomy.","authors":"Garrett Jebeles, Marc Bernstein, Julian Garcia, Damon Dunwody, Tyler Kelly, Rutvik Dave, Ashish Shah","doi":"10.2106/JBJS.ST.24.00017","DOIUrl":"10.2106/JBJS.ST.24.00017","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Broström-Gould surgery is the gold standard operative treatment of chronic lateral ankle instability. In cases of failed nonoperative treatment, the Broström-Gould repair aims to improve lateral ankle stability via anatomic repair and the overlapping of the anterior talofibular ligament (ATFL) and calcaneofibular ligament, with reinforcement of the ATFL by the extensor retinaculum&lt;sup&gt;1-3&lt;/sup&gt;. Lateral ankle ligament injuries typically present with additional pathologies, including hindfoot varus, peroneal tendon lesions, and tarsal coalition&lt;sup&gt;4,9&lt;/sup&gt;. Previous studies have hypothesized that treatment of ligamentous injuries with concurrent osteotomy of the calcaneus can correct altered stress loading, aiding in the prevention of future injuries and complications&lt;sup&gt;4,9,10&lt;/sup&gt;. The presently described technique is a modification of the Broström-Gould technique that allows the addition of a calcaneal osteotomy without additional incisions.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Patients are positioned supine with a foam bump under the torso on the ipsilateral side and bone foam to elevate and pronate the operative foot. The incision begins 4 cm proximal to the tip of the lateral malleolus, posterior to the peroneal tendons, and ends 1 cm proximal to the base of the fifth metatarsal. Subcutaneous tissues are bluntly dissected, and neurovasculature is protected. Tenosynovectomy of the peroneus longus and brevis is performed. During the tenosynovectomy, care must be taken to avoid damaging the sural nerve, which is posterior to the tendon sheath. Hohmann retractors are utilized to better visualize the lateral calcaneus. Calcaneal osteotomy is performed with use of a micro saw for the lateral two-thirds and with use of an osteotome for the medial third. In the example case, a single 7.0-mm cancellous screw was utilized for fixation; however, 2 screws can be utilized to provide greater rotational stability. The ATFL is elevated from the talus and lateral malleolus. The lateral malleolus is freed of periosteum with use of a rongeur. Two 3.5-mm suture anchors (each with 4 needles) with number-0 FiberWire (Arthrex) are inserted through the tip of the lateral malleolus. The suture material is passed through the ATFL and calcaneofibular ligament to tighten the ligaments. The superior extensor retinaculum is advanced over, and sutured to, the ATFL. The incision is closed in layers, and a short leg splint is applied with the foot in slight eversion and dorsiflexion. Patients are transitioned from the splint to a short leg non-weight-bearing cast or boot for 6 weeks. At 6 weeks postoperatively, the patient is transitioned to a walking boot for progressive weight-bearing per a physical therapy protocol.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Nonoperative treatment of chronic ankle instability involves rest and physical therapy with bracing or the use of orthotics. Operative treatments are performed when nonoperative treatment","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12269807/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Gracilis Free Flap Technique for Elbow Flexion Reconstruction.","authors":"Gerardo E Sanchez-Navarro, Sofia Perez-Otero, Dylan T Lowe, Jacques H Hacquebord, Nikhil Agrawal","doi":"10.2106/JBJS.ST.25.00003","DOIUrl":"10.2106/JBJS.ST.25.00003","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Brachial plexus injuries (BPI) can be devastating for patients, often resulting in notable physical, psychological, and socioeconomic distress&lt;sup&gt;1&lt;/sup&gt;. Violent accidents that torque the head away from the shoulder frequently damage the upper brachial plexus roots, with varying severity of damage to the lower roots&lt;sup&gt;1&lt;/sup&gt;. Patients having pan-plexus injuries typically present with a flail extremity, loss of sensory function, and generalized atrophy. To improve activities of daily living, the treatment of pan-plexus injuries focuses on restoring antigravity motion of the upper extremity, with elbow flexion being a high priority muscle group&lt;sup&gt;2&lt;/sup&gt;. Although nerve transfers are an excellent option, this treatment path is not always viable. In such cases, free functioning muscle transfers, especially gracilis transfers, have emerged as a primary reconstructive approach, with excellent outcomes in complete BPI lesions&lt;sup&gt;2,3&lt;/sup&gt;. In this video article, we present the exploration of a complex BPI in which the creation of a gracilis free flap is executed for elbow flexion reconstruction. We provide a comprehensive guide from markings, flap elevation, microsurgical technique, and inset, with educational operative pearls at every step.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;The procedure involves harvesting the gracilis muscle as a free functioning muscle transfer. The gracilis, which will become a type-II muscle flap, is carefully dissected with its pedicle and nerve preserved. The muscle is then transferred to the upper extremity, where its proximal origin is anchored to the clavicle and its distal tendon is inserted into the biceps tendon with use of a Pulvertaft weave. Vascular anastomoses are performed utilizing branches of the thoracoacromial trunk and venous couplers under a microscope. The muscle is innervated with the spinal accessory nerve and tensioned to ensure optimal elbow flexion.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Surgical alternatives include nerve transfers (e.g., Oberlin transfer), tendon transfers, or other free muscle transfers (e.g., latissimus dorsi transfer). Nonsurgical alternatives include orthotic devices to compensate for elbow flexion loss, and physical therapy to maximize existing function.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;Gracilis free flap transfer is a reliable option for restoring functional elbow flexion in patients with severe BPI when intra-plexal nerve donors are unavailable. Compared with nerve transfers or tendon transfers, gracilis free flap transfer offers consistent outcomes with greater than M3 muscle strength (with M3 indicating movement against gravity but not against resistance, and M4 indicating movement against both gravity and resistance)&lt;sup&gt;2&lt;/sup&gt;. Unlike orthotic devices, this technique provides active elbow flexion, critical for functional independence. The long tendon and reliable vascular pedicle make the gracilis ideal for this purpose.&lt;/p&gt;&lt;p&gt;&lt;strong","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12269806/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660614","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Deep Gluteal Pain Syndrome: Technical Description of the Endoscopic Approach and Anatomical Considerations.","authors":"Carlos Tobar, José T Bravo, Diego Villegas, Dante Parodi","doi":"10.2106/JBJS.ST.23.00035","DOIUrl":"10.2106/JBJS.ST.23.00035","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Fibrovascular bands are currently considered the most relevant cause of deep gluteal pain syndrome, according to various reports&lt;sup&gt;1-6&lt;/sup&gt;. This condition often exists concurrently with hypertrophic bursae in the peritrochanteric space due to the same inflammatory process because of the anatomical continuity between both spaces&lt;sup&gt;7-10&lt;/sup&gt;. In such cases, we perform bursectomy of the lateral space and resection of fibrovascular bands in the posterior space. Our technique has shown good results, without requiring a piriformis tenotomy&lt;sup&gt;11&lt;/sup&gt;. In the present video article, we demonstrate our endoscopic technique with modified portals, which addresses both spaces providing complete management of the pathology.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;The patient is placed in the supine position with the operative limb placed freely on the operative field for easy manipulation. The distance between the anterior and posterior borders of the greater trochanter at the level of the vastus tuberosity is demarcated. This distance is projected lengthwise onto the posterior third of the femur, delineating the proximal posterolateral accessory (PPLA) and distal posterolateral accessory (DPLA) portals. Under direct visualization, the DPLA portal is made, followed by the PPLA portal. A wide bursectomy in the peritrochanteric space is performed, followed by a partial tenotomy of the distal insertion of the gluteus maximus. Once in the subgluteal space, fibrovascular adhesions in the piriformis branch of the inferior gluteal artery are carefully released. Once the nerve has been identified, resection of the fibrovascular bands is performed in the subgluteal space, and the recovery of epineural circulation and free excursion of the nerve are evaluated.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Nonoperative treatment is a valid alternative as the initial management of deep gluteal pain syndrome. If there is a poor response to nonoperative treatment or a chronic pathology of both compartments, surgical treatment should be considered. Open procedures have been described, which are more invasive and could generate a greater inflammatory response&lt;sup&gt;3&lt;/sup&gt;. Several reports have described the difficulty of endoscopic treatment in both the peritrochanteric and subgluteal spaces, which necessitates the use of accessory portals for management of hypertrophic bursae and release of the sciatic nerve&lt;sup&gt;12,14,17,18&lt;/sup&gt;. Routine piriformis tenotomy has also been described for use alongside resection of fibrovascular bands&lt;sup&gt;4,12-16&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;This endoscopic technique allows access to the peritrochanteric and subgluteal spaces through 2 portals. The locations of, and method for, using these portals have been previously established in cadaveric studies. We observed the presence of fibrovascular bands in all of the specimens under study. In our medium-term clinical study, resection of the fibrosis from the l","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12231139/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144592546","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Modified Partial Radial to Axillary Nerve Transfer.","authors":"Ranjan Gupta, Andrew Li, Vivian Y Chen","doi":"10.2106/JBJS.ST.22.00026","DOIUrl":"10.2106/JBJS.ST.22.00026","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Nerve transfers are routinely performed in patients with brachial plexus injuries because these patients have limited alternative solutions secondary to their severe injury with substantial functional limitations&lt;sup&gt;5,6&lt;/sup&gt;. Nerve transfers offer distinct advantages over other surgical options, as they are able not only to bypass the zone of injury but also to decrease regeneration time because of the proximity of the motor end plate to the repair site&lt;sup&gt;1,2&lt;/sup&gt;. It is for this latter reason that a nerve transfer should be considered for an isolated axillary nerve injury, in which a full recovery is of paramount importance for shoulder function. Accordingly, surgeons should consider a partial radial to axillary nerve transfer as an option for restoring shoulder function.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;The procedure is performed with the patient in the lateral decubitus position after induction of anesthesia without the use of paralytics. An incision is made via a longitudinal, posterior approach to the proximal humerus. Careful dissection is performed to separate the brachial fascia from the triceps muscle. Following visualization of the radial nerve and profunda brachii within the triangular interval, the radial nerve is traced distally to identify each of its distinct branches. An intraoperative nerve stimulator is utilized to identify which branch of the radial nerve only supplies triceps extension and does not contribute to wrist or digital extension. This distinct branch is dissected proximally to the inferior border of the teres major. Next, the fascia overlying the inferior one-third of the teres major is released without damaging the underlying muscle fibers in order to prevent a tether point for the transferred branch of the radial nerve. The nerve stimulator is useful to confirm intraoperatively if the axillary nerve has been transected or if there are nerve fibers in continuity. For the former situation, the nerve transfer is performed in an end-to-end manner. For the latter situation, the isolated branch of the radial nerve is coapted in an end-to-side manner to the axillary nerve. Once both the donor radial nerve branch and the recipient axillary nerve have been isolated, the radial nerve is transposed superiorly to meet the axillary nerve. The nerve ends are coapted with 8-0 or 9-0 nylon simple interrupted sutures under the operating microscope, utilizing fibrin glue as an adjunct. The shoulder and elbow are manipulated passively in abduction and external rotation while directly visualizing the coaptation site to ensure the nerve is not under tension. The fascial, subcutaneous, and skin layers are closed to complete the procedure.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Surgical alternatives include neurorrhaphy with grafting, nerve grafting, tendon transfer, muscle transfer, arthrodesis&lt;sup&gt;4&lt;/sup&gt;, and nonoperative treatment.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;In patients experiencing persis","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12187269/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144498339","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Endoscopic Posterior Cervical Foraminotomy and Discectomy.","authors":"Micheal Raad, Peter Derman","doi":"10.2106/JBJS.ST.24.00003","DOIUrl":"10.2106/JBJS.ST.24.00003","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Open posterior cervical foraminotomy has been shown to be comparable with anterior cervical discectomy and fusion (ACDF) in the treatment of cervical radiculopathy&lt;sup&gt;1,2&lt;/sup&gt;. More recently, posterior endoscopic cervical foraminotomy was described as an ultra-minimally invasive technique that allows for neural decompression in cervical radiculopathy. This technique has been shown to have excellent clinical outcomes with a short length of hospital stay and low postoperative pain levels&lt;sup&gt;3&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;The procedure is performed with the patient in the prone position under general anesthesia. Fluoroscopy is utilized to mark out the incision and target the medial-most aspect of the facet at the level of foraminal stenosis. Sequential dilators are then inserted to create a working canal, and the endoscope is introduced. Soft tissue is cleared until the classic \"V\" interlaminar anatomic landmark is visualized. The superior edge of the cephalad lamina and the inferior articular process are resected until the superior articular process is identified. The superior articular process is then thinned out with use of a diamond burr and resected carefully with use of a Kerrison punch, allowing visualization of the nerve beneath. Decompression should be wide, carried out from pedicle to pedicle and as laterally as required. A discectomy may be performed at this stage.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Alternatives include open posterior cervical foraminotomy, ACDF, and cervical disc arthroplasty.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;In the case of isolated cervical radiculopathy, the pathology is limited to the foramen. The foramen may be approached either anteriorly or posteriorly. However, in order to successfully address the foramen anteriorly, a complete discectomy should be performed. In such cases, either a fusion or disc arthroplasty should be performed concurrently with the discectomy. Both fusion and disc arthroplasty are associated with complications such as adjacent segment degeneration, implant subsidence, infection, nonunion, and others&lt;sup&gt;4&lt;/sup&gt;. Posterior foraminotomy allows for successful neural decompression posteriorly, but when performed in an open fashion it requires substantial soft-tissue dissection for an appropriate exposure, which may result in notable postoperative neck pain. Posterior endoscopic cervical foraminotomy addresses many of these shortcomings because it allows for successful neural decompression through an endoscope, with minimal soft-tissue dissection; maintains range of motion; and preserves most of the disc at that level&lt;sup&gt;4&lt;/sup&gt;. Furthermore, this technique does not preclude or complicate the ability to perform a full discectomy anteriorly in the future, if needed.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Expected outcomes: &lt;/strong&gt;Endoscopic posterior cervical foraminotomy has been shown to have excellent clinical outcomes; however, as with any spinal surgery, it carries ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12187270/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144498337","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Minimally Invasive Subscapularis Release for Internal Rotation Contracture of the Shoulder in Residual Brachial Plexus Birth Injury.","authors":"Maulin Shah, Shalin Shah, Nischal Naik, Tejas Patel","doi":"10.2106/JBJS.ST.24.00008","DOIUrl":"10.2106/JBJS.ST.24.00008","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Shoulder internal rotation contracture is one of the most common problems observed in patients with residual brachial plexus birth injury&lt;sup&gt;1,2&lt;/sup&gt;. Minimally invasive subscapularis release is a simple extra-articular procedure that involves the release of the subscapularis origin from the undersurface of the scapula. This procedure addresses the contracture and has been shown to result in remodeling of the glenohumeral joint when concomitant conjoined tendon transfer is performed&lt;sup&gt;3&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;The procedure is performed with the patient in the lateral decubitus position. The procedure is initiated by elevating the medial border of the scapula by performing internal rotation and forward flexion of the arm. A 1-cm incision is made at the junction of the upper one-third and lower two-thirds of the medial border of the scapula, and space for insertion of a periosteal elevator is made with a hemostat. Sequentially, 5-mm and 10-mm periosteal elevators are inserted and are slid in a clockwise direction to release the muscle fibers from their origin on the undersurface of the scapula. After circumferential release, the internal rotators and the anterior shoulder joint capsule are stretched with gentle and progressive external rotation of the shoulder joint. A postoperative shoulder spica is applied with the shoulder in the corrected position.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Operative alternatives to this technique include anterior open reduction of the glenohumeral joint with release of the pectoralis and subscapularis at their humeral insertions&lt;sup&gt;4,5&lt;/sup&gt;. Arthroscopic subscapularis and anterior capsular release has also been described. Other extra-articular techniques, such as an open subscapularis slide from the lateral scapular border, have been described&lt;sup&gt;6,7&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;Losing strength of internal rotation at the shoulder is the main concern when releasing the subscapularis from its insertion. Internal rotation strength is maintained following this technique because the muscle-tendon unit ratio is unchanged. Benefits of performing this technique from the medial border include easier access to the tight superomedial septae of the subscapularis and reduced likelihood of iatrogenic injury to circumflex scapular neurovascular pedicle.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Expected outcomes: &lt;/strong&gt;Significant improvement in shoulder abduction and external rotation range (both passive and active) can be expected postoperatively. In a published series of 45 patients, the mean improvements in passive and active external rotation were 80° and 43°, respectively. Mean shoulder abduction improved from 101° preoperatively to 142° postoperatively. The aggregate 5-point Mallet Score improved from 12.8 points preoperatively to 18.5 points postoperatively. Glenohumeral remodeling can be expected in young children with Waters type-IV glenohumeral joint changes. Older pediatri","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12187271/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144498338","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intramedullary Screw Fixation for Simple Olecranon Fractures.","authors":"Tyler Thorne, Makoa Mau, Willie Dong, Leonard Lisitano, Zarek DaSilva, David L Rothberg, Thomas F Higgins, Justin M Haller, Lucas S Marchand","doi":"10.2106/JBJS.ST.23.00077","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00077","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Olecranon fractures are common injuries that often require surgical fixation to maintain elbow function. Nonoperative management of these injuries may be indicated in the elderly, as a recent randomized controlled trial found that 81% (9) of 11 operatively managed olecranon fractures in the elderly had complications&lt;sup&gt;1&lt;/sup&gt;. While traditional techniques such as tension-band wiring and plate fixation produced satisfactory functional outcomes, they are associated with high rates of complications&lt;sup&gt;2&lt;/sup&gt;. Intramedullary screw fixation has gained popularity as an alternative technique for transverse olecranon fractures. The goal of this procedure is to reduce complication rates associated with olecranon open reduction and internal fixation while maintaining optimal functional outcomes.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;The patient is positioned in the lateral decubitus position with the arm placed over a padded Mayo stand. A direct posterior incision is made to the olecranon. Following irrigation and hematoma evacuation, the fracture is reduced. Pointed reduction clamps are used to reduce the fracture and hold a provisional reduction. A 2 to 2.5-cm longitudinal incision is made over the footprint of the triceps insertion. Next, a 3.5-mm drill is passed from the olecranon tip to the proximal ulnar diaphysis. The proximal ulna is then opened with a 4.5-mm drill, and a 6.5-mm calibrated tap is used to sound the ulna. Then a 6.5-mm, solid, partially threaded screw with a washer is placed across the fracture. Reduction aids are removed, and the surgical site is closed. The arm is splinted for 2 weeks to allow for soft-tissue healing, after which immediate full, active range of motion is allowed.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Alternatives include nonoperative treatment such as immobilization with a posterior long-arm splint, operative treatment with tension-band wiring, and operative treatment with plate and screw fixation.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;Because of the high rates of stiffness, contracture, and joint involvement associated with nonoperative treatment of olecranon fractures, operative treatment of these injuries is often recommended&lt;sup&gt;3&lt;/sup&gt;. The most common types of surgical fixation include tension-band wiring or a plate-and-screw construct. Both techniques successfully lead to fracture healing and satisfactory functional outcomes; however, the main drawback of these procedures is their high rate of complications&lt;sup&gt;2&lt;/sup&gt;. A prior study reported complications in 19 (63%) of 30 patients with tension-band wiring and in 12 (38%) of 32 patients with plate-and-screw constructs. Symptomatic hardware, skin breakdown, and subsequent infection made up most of these complications&lt;sup&gt;2&lt;/sup&gt;. In contrast, intramedullary screw fixation utilizes low-profile hardware that is seated within the osseous cortex. This reduces soft-tissue irritation in a region that contains low proportions of subcuta","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-04-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12011570/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143988895","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}