JBJS Essential Surgical Techniques最新文献

{"title":"Pyrocarbon Disc Interposition Arthroplasty (PyroDisk) for the Treatment of Carpometacarpal Thumb Joint Osteoarthritis.","authors":"Brigitte E P A van der Heijden, Cecile M C A van Laarhoven","doi":"10.2106/JBJS.ST.21.00034","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00034","url":null,"abstract":"<p><p>In cases of isolated carpometacarpal (CMC) thumb joint osteoarthritis, a hemitrapeziectomy can be performed. To address the risk of subsidence of the first metacarpal, a pyrocarbon disc has been designed as an interposition prosthesis. The disc is made of pyrolytic carbon with the same elastic modulus as cortical bone, making it resistant to wear from surrounding bone. This property contributes to preservation of thumb length and prevents subsidence. The present video article shows the pyrocarbon disc interposition arthroplasty step by step. The procedure results in substantial pain reduction with good function and strength at long-term follow-up. The complication rate is comparable with that of other surgical tendinoplasties for CMC thumb joint osteoarthritis. The survival rate has been reported to be 91% at a minimum follow-up of 5 years<sup>1-3</sup>. CMC thumb joint osteoarthritis is a common pathology. If symptoms remain despite splinting and hand therapy, surgical treatment is often performed. The simple trapeziectomy is seen as the reference standard, with good results and fewer complications compared with other surgical procedures<sup>4-6</sup>. Despite this fact, many surgeons still prefer to combine trapeziectomy with a tendinoplasty in order to reduce the risk of proximal migration and impingement of the first metacarpal on the scaphoid<sup>7-9</sup>. However, the volume and stiffness of autologous tendons are far less than that of the trapezial bone. This might be one of the reasons that trapeziectomy with tendinoplasty does not lead to better results than simple trapeziectomy. To overcome the disadvantages of a tendinoplasty, the PyroDisk (Integra LifeSciences) was introduced for CMC thumb joint osteoarthritis to preserve thumb length and provide more stability than other traditional techniques. The disc is designed to be utilized after a distal hemitrapeziectomy for patients with CMC thumb joint osteoarthritis without involvement of the scaphotrapeziotrapezoid (STT) joint.</p><p><strong>Description: </strong>Preoperatively, review radiology images to confirm that the osteoarthritis is limited to the thumb CMC joint and that all appropriate tools for inserting the disc are available before beginning surgery. Next, the patient is placed with their arm on an arm rest. The CMC thumb joint is exposed via a dorsal longitudinal skin incision, sparing the dorsal radial nerve branches and the radial artery and accompanying venes. The capsule is opened with an H-incision. With 2 parallel cuts to the joint surface, the articular surfaces of the joint are removed. After resection of the articular joint surfaces, the residual width and height of the joint space after resection are measured. The central point in the joint surfaces is marked for the bone tunnels. With an awl, tunnels are created from the center of the joint surface to the proximal (trapezial bone) and distal (first metacarpal bone) and the dorsal side. The implant size is me","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 4","pages":"e21.00034"},"PeriodicalIF":1.3,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9889283/pdf/jxt-12-e21.00034.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10663216","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":"Combined MPFL Reconstruction with Tibial Tubercle Osteotomy and Repair of Patellar Cartilage Defect with Particulated Juvenile Articular Cartilage.","authors":"Elizabeth R Dennis, William A Marmor, Beth E Shubin Stein","doi":"10.2106/JBJS.ST.21.00013","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00013","url":null,"abstract":"<p><p>Medial patellofemoral ligament (MPFL) reconstruction with tibial tubercle osteotomy (TTO) and particulated juvenile articular cartilage (PJAC) grafting can be performed in combination for the treatment of recurrent patellar instability with associated patellar cartilaginous defects.</p><p><strong>Description: </strong>Preoperative planning is an essential component for this procedure. Measurement of the tibial tubercle to trochlear groove (TT-TG) distance and the Caton-Deschamps index (CDI) allows for determination of the degree of medial and anterior translation and helps to identify whether distalization is necessary. The procedure begins with a thorough examination under anesthesia to determine range of motion, patellar tracking, translation, and tilt. A diagnostic arthroscopy is performed, at which time patellar tracking is again assessed and the patellar and trochlear cartilage are evaluated. A medial parapatellar incision is made, and the layer between the capsule and retinaculum is identified. This layer will serve as the location for the MPFL graft passage. The medial patella is decorticated to prepare for graft fixation. The patella is then everted, and the cartilaginous defect is prepared and sized. The PJAC graft is prepared on the back table based on these measurements. The MPFL graft is then anchored to the decorticated medial patella. Attention is then turned to performing the TTO. The patellar tendon is isolated and protected. The osteotomy shingle is created with a combination of sagittal saw and osteotomes, followed by shingle translation and fixation. Attention is then turned to performing the MPFL graft fixation on the femur. An incision is made, the area of the sulcus between the medial epicondyle and adductor tubercle is identified, and a pin is placed. Graft isometry is assessed, pin placement is confirmed, and a socket is created. After thorough irrigation, the patella is then everted and the PJAC graft is implanted and set with fibrin glue. Finally, the MPFL graft is passed through the previously identified layer and docked into the medial femur at its isometric point.</p><p><strong>Alternatives: </strong>Nonoperative treatment of first-time patellar instability can often include physical therapy, bracing, and activity modification. However, recurrence rates can be high, especially in a subset of high-risk patients with characteristics such as age of <25 years, trochlear dysplasia, patella alta, and coronal plane malalignment. For patients with recurrent patellar instability, a well-executed MPFL reconstruction restores stability while the TTO serves to unload the lateral and/or inferior patellar cartilage and correct osseous malalignment. Additional techniques, such as a distal femoral osteotomy and trochleoplasty, have been suggested to address patellar tracking and trochlear dysplasia. For patients who have sustained cartilaginous injury from their previous dislocations, PJAC can be utilized to restore the patello","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 4","pages":"e21.00013"},"PeriodicalIF":1.3,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9889293/pdf/jxt-12-e21.00013.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9230749","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":"Anterior-Based Muscle-Sparing (ABMS) Approach for Total Hip Arthroplasty.","authors":"Matthew M Levitsky, Alexander L Neuwirth, Jeffrey A Geller","doi":"10.2106/JBJS.ST.21.00061","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00061","url":null,"abstract":"<p><p>The anterior-based muscle-sparing (ABMS) technique for total hip arthroplasty (THA) has gained popularity in recent years because of its proposed advantages in terms of postoperative pain and periprosthetic dislocation risk.</p><p><strong>Description: </strong>The procedure is performed with the patient in the supine position. A minimally invasive Watson-Jones approach is utilized to access the hip. Fluoroscopy can be utilized intraoperatively to assess acetabular cup position, version, and inclination. Femoral canal fill and leg lengths can also be assessed with use of fluoroscopy.</p><p><strong>Alternatives: </strong>Nonoperative alternatives for the treatment of hip osteoarthritis include nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections into the hip joint. Surgical alternatives to this procedure include the posterior approach (Moore or Southern), the direct lateral approach (Hardinge), and the direct anterior approach (Smith-Petersen). The Watson-Jones approach can also be performed with the patient in the lateral decubitus position (unlike in our technique where the patient is supine).</p><p><strong>Rationale: </strong>The anterolateral (Watson-Jones) approach to the hip has been shown to be superior to the historically more common posterior approach with regard to length of hospital stay and dislocation risk<sup>1,2</sup>. Supine positioning for this approach offers multiple advantages compared with lateral decubitus positioning. Leg lengths can be assessed intraoperatively both fluoroscopically and with manual palpation of the medial malleoli. Cup position can be assessed radiographically as well<sup>3</sup>. Supine positioning also allows for easily reproducible patient positioning.</p><p><strong>Expected outcomes: </strong>Compared with the historically common posterior approach to the hip for THA, the anterolateral approach to the hip leads to, on average, a lower risk of hip dislocation<sup>1,2</sup>. In a 2002 study by Masonis and Bourne, the dislocation rate for the posterior approach was 3.23% (193 of 5,981), whereas the dislocation rate was 2.18% (18 of 826) for patients who underwent THA via the anterolateral approach<sup>1</sup>. In a study by Ritter et al. in 2001, which followed patients for 1 year postoperatively, no patients in the anterolateral approach group experienced a dislocation compared with 4.21% of patients in the posterior approach group<sup>2</sup>. With use of the present technique, patients will benefit from the advantages of the anterolateral approach to the hip; however, they will also benefit from easy intraoperative leg length assessment and from radiographic assistance with regard to determining the appropriate position of the femoral and acetabular components<sup>3</sup>. In a study of 199 patients (including 98 patients who had intraoperative fluoroscopy and 101 who did not), 80% of implants in the fluoroscopy group were within the combined safe zone compared with","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00061"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9931043/pdf/jxt-12-e21.00061.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9314495","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":"Osteochondral Allograft Transplantation for Focal Cartilage Defects of the Femoral Condyles.","authors":"Kyle R Wagner, Steven F DeFroda, Lakshmanan Sivasundaram, Joshua T Kaiser, Zach D Meeker, Nolan B Condron, Brian J Cole","doi":"10.2106/JBJS.ST.21.00037","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00037","url":null,"abstract":"<p><p>Focal cartilage defects of the knee are painful and difficult to treat, especially in younger patients<sup>1</sup>. Seen in up to 60% of patients who undergo knee arthroscopy<sup>2</sup>, chondral lesions are most common on the patella and medial femoral condyle<sup>3</sup>. Although the majority of lesions are asymptomatic, a variety of treatment options exist for those that are symptomatic; however, no clear gold-standard treatment has been established. In recent years, osteochondral allograft transplantation has been increasingly utilized because of its versatility and encouraging outcomes<sup>4-7</sup>. The procedure entails replacing damaged cartilage with a graft of subchondral bone and cartilage from a deceased donor. Indications for this procedure include a symptomatic, full-thickness osteochondral defect typically ≥2 cm<sup>2</sup> in size in someone who has failed conservative management. Relative indications include patient age of <40 years and a unipolar defect<sup>8,9</sup>.</p><p><strong>Description: </strong>Osteochondral allograft transplantation requires meticulous planning, beginning with preoperative radiographs to evaluate the patient's alignment, estimate the lesion size, and aid in matching of a donor femoral condyle. The procedure begins with the patient supine and the knee flexed. A standard arthrotomy incision is performed on the operative side. Once exposure is obtained, a bore is utilized to remove host tissue from the lesion typically to a depth of 5 to 8 mm. Measurements are taken and the donor condyle is appropriately sized to match. A coring reamer is utilized to create the plug from donor tissue, which is trimmed to the corresponding depth. After marrow elements are removed via pulse lavage, the allograft plug is placed within the femoral condyle lesion through minimal force.</p><p><strong>Alternatives: </strong>Nonoperative treatment involves a reduction in high-impact activities and physical therapy. Surgical alternatives include chondroplasty, microfracture, and osteochondral autograft transplantation; however, these options are typically performed for smaller lesions (<2 cm). For larger lesions (≥2 cm), matrix-induced autologous chondrocyte implantation (MACI) can be utilized, but requires 2 surgical procedures.</p><p><strong>Rationale: </strong>Osteochondral allograft transplantation is selected against other procedures for various reasons related to patient goals, preferences, and expectations. Typically, this procedure is favored over microfracture or autograft transplantation when the patient has a large lesion. Allograft transplantation might be favored over MACI because of patient preference for a single surgical procedure instead of 2.</p><p><strong>Expected outcomes: </strong>To our knowledge, there are currently no Level-I or II trials comparing osteochondral allograft transplantation against other treatments for cartilage defects. There are, however, many systematic reviews of case studies and c","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00037"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9931042/pdf/jxt-12-e21.00037.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10824612","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":"Spherical Periacetabular Osteotomy.","authors":"Toshihiko Hara, Ayumi Kaneuji, Kazuhiko Sonoda, Tetsuro Nakamura, Masanori Fujii, Eiji Takahashi","doi":"10.2106/JBJS.ST.21.00048","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00048","url":null,"abstract":"<p><p>Various techniques for periacetabular osteotomy have been reported to prevent the progression of osteoarthritis in dysplastic hips<sup>1-5</sup>. Bernese periacetabular osteotomy, which involves the use of an anterior approach, is widely performed throughout the world because it offers preservation of the blood supply to the bone fragment and lateral pelvic muscles. However, Bernese periacetabular osteotomy has potential complications, such as nonunion at the osteotomy site, postoperative fracture, nonunion of the pubis and ischium, and damage to the main trunk of the obturator artery. Spherical periacetabular osteotomy (SPO) has been developed to resolve some of disadvantages of Bernese periacetabular osteotomy<sup>6</sup>. Although SPO involves some technical difficulty, the procedure is safe when performed with use of appropriate preoperative 3-dimensional planning and surgical technique.</p><p><strong>Description: </strong>Preoperative 3-dimensional planning is utilized to decide the radius of the curved osteotome, locations of the reference points for the osteotomy line, and depth of the bone groove at the teardrop area. The pelvic positioning is arranged fluoroscopically to match the neutral position based on preoperative planning. A 7-cm incision is made along the medial margin of the iliac crest. An anterior iliac crest osteotomy of 4.5 cm (length) × 1 cm (medial wedge-shaped) is performed. The operative field is maintained with aluminum retractors. The osteotomy line is completed by connecting the preoperatively planned reference points on the inner cortex of the ilium. The bone groove is made along the osteotomy line with use of a high-speed burr. A blunt osteotome is inserted into the bone groove at the teardrop area until it reaches the preoperatively planned depth. The blunt osteotome makes a pathway for the curved osteotome without breaking the quadrilateral surface (QLS) or perforating the hip joint. The special curved osteotome is inserted manually until it reaches the bottom of the groove, and the posterior cortex is cut. After the top of the teardrop is divided fluoroscopically, the anterior ischial cortex is osteotomized with a sharpened spiked Cobb elevator at the infracotyloid groove. An angled curved osteotome is used for the osteotomy of the superior area of the teardrop area. The bone fragment is rotated with a spreader and an angled retractor, and fixed with 2 absorbable screws. Beta-tricalcium phosphate blocks are inserted into the bone gap. The osteotomized wedge-shaped iliac bone is repositioned and fixed.</p><p><strong>Alternatives: </strong>Alternatives include the Bernese periacetabular osteotomy, rotational acetabular osteotomy, and triple innominate osteotomy.</p><p><strong>Rationale: </strong>Bernese periacetabular osteotomy utilizes an anterior approach, cuts into the QLS, and preserves the posterior column. In contrast, SPO preserves the QLS and does not cut the pubis. These features of SPO have some adva","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00048"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/e9/ba/jxt-12-e21.00048.PMC9931045.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9314500","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":"Apex of Triceps Aponeurosis: A Reliable Landmark to Localize the Radial Nerve.","authors":"Sumit Arora, Abhishek Kashyap, Rahul Garg, Akhil Wadhawan, Lalit Maini","doi":"10.2106/JBJS.ST.21.00055","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00055","url":null,"abstract":"<p><p>The posterior approach to the humerus is an extensile approach, which provides excellent access to the distal aspect of the humerus. The approach is traditionally utilized for internal fixation of fractures of the distal third of the humerus, to perform sequestrectomy, and for radial nerve exploration. The radial nerve is susceptible to damage when utilizing this approach<sup>1-3</sup>. Hence, accurate localization of the radial nerve is required to aid in identification during dissection and to minimize the risk of palsy. Various anatomical landmarks have been described in the literature that can help locate the radial nerve intraoperatively.</p><p><strong>Description: </strong>The patient is anesthetized and placed in the lateral decubitus position with the elbow of the operative limb hanging freely over a bolster. A posterior midline incision centered over the fracture is made on the posterior aspect of the arm. The superficial and deep fascia are incised. The triceps aponeurosis is formed by the convergence and fusion of the lateral and long heads of the triceps. The most proximal confluence can be termed the \"apex of the triceps aponeurosis.\" The radial nerve can be isolated approximately 2.5 cm proximal to the apex by developing an intramuscular plane. The remainder of the intramuscular dissection for plate fixation can then be performed safely without risking injury to the radial nerve.</p><p><strong>Alternatives: </strong>Numerous studies have established the relationship of the radial nerve to a fixed osseous point such as the medial epicondyle, lateral epicondyle, and angle of the acromion<sup>4-9</sup>. Additionally, the wide range of measurements of these anatomic relationships, as reported in various studies, makes it difficult for the operating surgeon to locate the radial nerve, especially in the setting of a fractured humeral shaft. For example, the reported distance of the radial nerve from the lateral epicondyle ranges from 6 to 16 cm and the distance from the angle of the acromion ranges from 10 to 19 cm. Even identification of the superficial branch of the radial nerve has been shown to help intraoperative localization of the radial nerve<sup>10</sup>. However, these studies have been conducted on cadavers with intact humeri, and their accuracy has not been demonstrated on the patients in the clinical milieu of trauma.</p><p><strong>Rationale: </strong>The described soft-tissue landmark, which lies approximately 2.5 cm proximal to the apex of the triceps aponeurosis, reliably locates the radial nerve intraoperatively<sup>11</sup>. It is based on the anatomical fact that the origins of the lateral head (oblique ridge corresponding to the lateral lip of the spiral groove) and long head (infraglenoid tubercle of the scapula) are well above fractures of the middle and distal thirds of the humerus. Hence, the relationship of the radial nerve to the soft point represented by the apex of the aponeurosis is not likely to be dist","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00055"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9889281/pdf/jxt-12-e21.00055.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10716626","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":"Acute Correction of Multiplanar Proximal Tibial Deformity Utilizing Fixator-Assisted Intramedullary Nailing.","authors":"Joseph Nicholas Charla, Melinda S Sharkey","doi":"10.2106/JBJS.ST.21.00045","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00045","url":null,"abstract":"<p><p>Proximal tibial deformities, particularly varus deformities, are relatively common in adolescents and young adults. The etiology of these deformities is often untreated or undercorrected infantile and adolescent Blount disease. Other less common etiologies include metabolic bone disease-associated deformities, posttraumatic and iatrogenic growth disturbance, and deformity related to surgical treatment or radiation for tumors<sup>1-3</sup>. We apply the principles of fixator-assisted acute deformity correction, mostly described for use at the distal aspect of the femur, as well as the principles of anatomic reduction and fixation of proximal-third tibial fractures<sup>4</sup> to acutely correct these complex deformities in skeletally mature individuals<sup>5-12</sup>. We perform acute correction of multiplanar proximal tibial deformity with use of fixator-assisted intramedullary nailing in order to avoid the complications and patient discomfort associated with gradual deformity correction with use of a circular external fixator. This procedure is novel in the treatment of adolescent Blount disease deformity in skeletally mature individuals and can additionally be utilized for other proximal tibial metaphyseal deformities, allowing the accurate and acute correction of all planes of deformity as well as the anatomic and mechanical axes, while avoiding the prolonged use of external fixators.</p><p><strong>Description: </strong>The patient is positioned supine on a radiolucent table. The locations of the proximal tibial osteotomy, fibular osteotomy, external fixator pin sites, and intramedullary nail insertion site are marked with use of a surgical marker and fluoroscopic imaging. Large external fixator half-pins are placed proximal and distal to the planned tibial osteotomy in both the anterior-posterior and sagittal planes, avoiding the path of the planned tibial intramedullary nail. A fibular osteotomy and then a low-energy tibial osteotomy are performed with use of multiple drill holes and an osteotome. Next, the bone deformity is fully corrected and held in the corrected alignment with the external fixators. Then, the opening drill for the intramedullary nail is introduced into the proximal aspect of the tibia over a guidewire, and blocking screws are placed in the coronal and sagittal planes of the proximal fragment next to the opening reamer. The intramedullary canal is then reamed over a ball-tipped guidewire to the desired diameter and the selected intramedullary nail is placed and secured with proximal and distal interlocking screws. Finally, the external fixators are removed.</p><p><strong>Alternatives: </strong>Alternative operative treatments include external fixation and gradual or acute deformity correction as well as fixator-assisted acute deformity correction and plate fixation<sup>13-16</sup>.</p><p><strong>Rationale: </strong>Typically, a tibial osteotomy with gradual deformity correction with use of a circular fixator is empl","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00045"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9931039/pdf/jxt-12-e21.00045.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9314496","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 Mid-Substance Achilles Tendon Repair Using the Percutaneous Achilles Repair System (PARS).","authors":"Kevin D Martin, Nisha J Crouser, Irfan A Khan","doi":"10.2106/JBJS.ST.21.00050","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00050","url":null,"abstract":"<p><p>Achilles tendon ruptures commonly occur in physically active individuals and drastically alter the ability to perform recreational activities<sup>1,2</sup>. Many patients want to continue participating in recreational activities, which can be facilitated by operatively treating the injury in a timely fashion, maximizing their functional recovery. The Percutaneous Achilles Repair System (PARS) Jig (Arthrex) can be utilized in patients with acute mid-substance Achilles tendon ruptures<sup>3,4</sup>.</p><p><strong>Description: </strong>Begin by positioning the patient prone with a thigh tourniquet on the operative side. Mark a 3-cm transverse incision 1 cm distal to the proximal Achilles stump and make the incision, taking care to protect the sural nerve laterally. Next, create a transverse paratenon incision and bluntly dissect it from the Achilles circumferentially. After gaining access to the proximal Achilles stump, clamp it with an Allis clamp and insert the PARS Jig between the Achilles tendon and paratenon, sliding it proximally to the myotendinous junction. To secure the jig to the proximal Achilles tendon, insert a guide pin into the jig position-1 hole. To pass sutures through the Achilles tendon, insert pins with their respective sutures into positions 2 through 5 and insert the FiberTape suture (Arthrex) in position 1. Remove the jig from the transverse incision, pulling the suture ends out of the incision. Once they are out, reorient the sutures on the medial and lateral sides to match their positions when initially placed. On both sides, wrap the blue suture around the 2 striped green-and-white sutures twice, and pull the blue suture through the looped green-and-white suture on the ipsilateral side. After doing that, fold the blue suture on itself to create a shuttling suture with the green-and-white suture. Next, pull on the medial non-looped green-and-white suture until it has been pulled out medially, and repeat that with the lateral non-looped green-and-white suture until it has been pulled out laterally, to create a locking stitch. Group the medial sutures together and the lateral sutures together, and utilize a free needle to further incorporate both bundles of sutures into the Achilles tendon. Next, create bilateral mini-incisions 1.5 cm proximal to the calcaneal tuberosity. Insert a rigid cannulated suture-passing device into each mini-incision, pass it through the distal Achilles tendon, load the ipsilateral suture bundle into the Nitinol wire, and pull the suture-passing device out the distal mini-incision to approximate the Achilles. To prepare the calcaneus, drill calcaneal tunnels toward the midline bilaterally, taking care to avoid convergence of the tunnels. Place a suture-passing needle in the tunnels to assist with placing the anchors. Next, tension the sutures, cycling them 5 to 10 times to remove any slack in the system. With the ankle in 15° of plantar flexion, anchor the sutures with cortical bioabsorbable in","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00050"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9931037/pdf/jxt-12-e21.00050.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9314910","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 Femoral Derotational Osteotomy in the Skeletally Immature Patient.","authors":"Bridget K Ellsworth, Jason S Hoellwarth, S Robert Rozbruch","doi":"10.2106/JBJS.ST.22.00003","DOIUrl":"https://doi.org/10.2106/JBJS.ST.22.00003","url":null,"abstract":"<p><p>Percutaneous femoral derotational osteotomies are performed in both adult and pediatric patients for excessive symptomatic femoral anteversion or retroversion<sup>1,2</sup>. The aim of the procedure is to correct version abnormalities with use of a minimally invasive technique<sup>3</sup>.</p><p><strong>Description: </strong>This is a percutaneous procedure that involves creation of femoral drill holes at the osteotomy site prior to reaming the canal<sup>4</sup>. External fixator pins are placed proximal and distal to the osteotomy site prior to completing the osteotomy. These pins are derotational markers for the surgeon and act to hold the correction with use of an external fixator while the interlocking screws are being placed. The pins are placed at a degree of divergence that is equal to the degree of intended derotation so that the pins will become parallel in the axial plane following derotation of the femur. The percutaneous osteotomy is then completed with use of an osteotome, and the trochanteric entry nail is passed across the osteotomy site while correcting rotation. Once rotation is fully corrected and the pins are parallel, the external fixator is placed to hold the rotation and interlocking screws are placed.</p><p><strong>Alternatives: </strong>Nonoperative alternatives to this procedure include physical therapy for gait training and strengthening as well as modalities to address hip and knee pain that may be associated with version abnormalities. Although physical therapy is often prescribed, it must be noted that excess version is a fixed osseous structural pathology that therapy cannot address. Additionally, compensatory mechanisms that may be taught to improve gait and walk with a neutral foot progression angle may exacerbate hip or knee pathology as a result of the underlying version abnormality. Surgical alternatives include derotational osteotomies of the proximal or distal aspects of the femur with use of an open technique with plate fixation, as opposed to an intramedullary nail following percutaneous diaphyseal osteotomy as presented here<sup>1</sup>. Additionally, an open technique with intramedullary nail fixation may be performed<sup>5</sup>.</p><p><strong>Rationale: </strong>Excessive anteversion can cause both hip and knee symptoms, including hip pain, instability, labral and psoas pathology, and patellofemoral instability<sup>6</sup>. Excessive retroversion can cause impingement between the femoral neck and acetabulum, which results in pathology of the labrum and articular cartilage<sup>7</sup>. Additionally, abnormalities of version often lead to gait disturbances with frequent tripping and difficulty running<sup>8</sup>. Children with femoral version abnormalities have limited remodeling potential after age 8<sup>3</sup>. A derotational osteotomy may be performed to correct symptomatic excess femoral version in an older child or adolescent.</p><p><strong>Expected outcomes: </strong>The patient may be weight","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e22.00003"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9931044/pdf/jxt-12-e22.00003.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9314498","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":"Double-Incision Technique for the Treatment of Distal Biceps Tendon Rupture.","authors":"Michele Mercurio, Davide Castioni, Orlando Cosentino, Daniele Fanelli, Filippo Familiari, Giorgio Gasparini, Olimpio Galasso","doi":"10.2106/JBJS.ST.21.00033","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00033","url":null,"abstract":"<p><p>The double-incision technique with bone-tunnel fixation provides anatomical reattachment of a distal biceps tendon rupture to the radial tuberosity<sup>1</sup>. This technique has been described by Boyd and Anderson<sup>2</sup> and was later modified by Morrey et al.<sup>3</sup>. The aim of the procedure is to achieve good return of elbow strength and motion with a low rate of neurological complications.</p><p><strong>Description: </strong>A longitudinal antecubital incision of 3 to 4 cm allows dissection to identify and isolate the lateral antebrachial cutaneous nerve (LABCN). Supination of the forearm protects the posterior interosseus nerve, which often cannot be visualized. The distal portion of the distal biceps should be carefully identified and exposed. A high-resistance nonresorbable suture is sewn with use of a Krackow technique to whipstitch the distal 4 cm of the tendon. Alternatively, 2 sutures (4 strands) can be utilized. A curved forceps is placed in the interosseous space to identify the location for the second 4-cm incision, on the dorsal proximal forearm over the tip of the forceps with the forearm pronated. The radial tuberosity is exposed by bluntly separating the common extensor tendons, followed by transection of the supinator fibers. Two drill holes are made 5 mm apart from one another for suture passage. The tendon is passed across a loop of wire, from the anterior to the posterior incision. With the elbow at 90° of flexion and full pronation, the tendon is docked into the trough and the sutures are tied.</p><p><strong>Alternatives: </strong>Alternatively, the surgical repair of the distal biceps tendon rupture can be performed through a single anterior approach<sup>4</sup>. The exposure starts with a curved longitudinal antecubital incision, exploiting the interval between the brachioradialis and pronator teres with radial (lateral) retraction of the brachioradialis and medial retraction of the pronator teres. A single anterior incision allows repair through the use of various types of fixation devices, such as suture anchors, cortical buttons, and interference screws, but seems to carry an increased risk of neurological complications, especially in terms of paresthesias in the distribution of the LABCN. Nonoperative treatment might be acceptable for elderly patients with poor functional demands.</p><p><strong>Rationale: </strong>The double-incision technique with bone-tunnel fixation provides good fixation strength with an expected low rate of neurological complications<sup>1</sup>. This approach offers a useful treatment option for young and active patients with physically demanding lifestyles.</p><p><strong>Expected outcomes: </strong>The double-incision technique is an effective and safe procedure to restore elbow functionality in patients with distal biceps tendon rupture. A meta-analysis<sup>1,4-16</sup> revealed no significant differences in postoperative functional scores following procedures performed via th","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00033"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9931040/pdf/jxt-12-e21.00033.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9314912","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}