JBJS Essential Surgical Techniques最新文献

{"title":"Debridement Technique for Single-Stage Revision Shoulder Arthroplasty.","authors":"Logan Kolakowski, Monica Stadecker, Justin Givens, Christian Schmidt, Mark Mighell, Kaitlyn Christmas, Mark Frankle","doi":"10.2106/JBJS.ST.23.00093","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00093","url":null,"abstract":"<p><strong>Background: </strong>The incidence of revision shoulder arthroplasty continues to rise, and infection is a common indication for revision surgery. Treatment of periprosthetic joint infection (PJI) in the shoulder remains a controversial topic, with the literature reporting varying methodologies, including the use of debridement and implant retention, single-stage and 2-stage surgeries, antibiotic spacers, and resection arthroplasty<sup>20</sup>. Single-stage revision has been shown to have a low rate of recurrent infection, making it more favorable because it precludes the morbidity of a 2-stage operation. The present video article describes a meticulous debridement technique as it applies to revision shoulder arthroplasty.</p><p><strong>Description: </strong>The previous deltopectoral incision should be utilized, with extension 1 to 1.5 cm proximally and distally, removing any draining sinuses. First, develop subcutaneous flaps above the muscle layer to better establish normal tissue planes. A large medial subcutaneous flap will allow for identification of the superior border of the pectoralis major. The pectoralis can be traced laterally to its humeral insertion, which is often in confluence with the deltoid insertion. Hohmann retractors can be placed sequentially, working distal to proximal, under the deltoid in order to recreate the subdeltoid space. Next, reestablish the subpectoral space by releasing any scar tissue tethering the pectoralis muscle and conjoined tendon. Dislocate the prosthesis and remove modular components. Restore the subcoracoid space by dissecting between the subscapularis and the conjoined tendon, allowing for axillary nerve identification. Complete a full capsular excision circumferentially around the glenoid, taking care to protect the axillary nerve as it passes from the subcoracoid space under the inferior glenoid to the deltoid muscle. The decision to remove well-fixed components should be made by the surgeon. Any exposed osseous surfaces should undergo debridement to reduce bacterial burden. Reimplantation should focus on obtaining stable bone-implant interfaces to minimize any micromotion that may increase risk of reinfection. Our preference is to irrigate with 9 L of normal saline solution, Irrisept (Irrimax), and Bactisure Wound Lavage (Zimmer Biomet). Multiple cultures should be taken and followed carefully postoperatively to allow tailoring of the antibiotic regimen with infectious disease specialists.</p><p><strong>Alternatives: </strong>Two-stage revision is the most common alternative treatment for shoulder PJI and consists of removal of components, debridement, and delayed component reimplantation; however, it requires at least 1 return to the operating room for definitive treatment.</p><p><strong>Rationale: </strong>Serum laboratory studies and joint aspiration are not reliable predictors of shoulder PJI because of the high rate of <i>Cutibacterium acnes</i> infections<sup>21,22</sup>. The inc","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2025-01-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11692968/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142956246","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":"Robotic-Assisted Conversion of Unicompartmental Knee Arthroplasty to Total Knee Arthroplasty.","authors":"Nicolas S Piuzzi, Nickelas Huffman, Alex Lancaster, Matthew E Deren","doi":"10.2106/JBJS.ST.24.00004","DOIUrl":"10.2106/JBJS.ST.24.00004","url":null,"abstract":"<p><strong>Background: </strong>Unicompartmental knee arthroplasty (UKA) procedures have become much more common in the United States in recent years, with >40,000 UKAs performed annually<sup>1</sup>. However, it is estimated that 10% to 40% of UKAs fail and thus require conversion to total knee arthroplasty (TKA)<sup>2-5</sup>. In the field of total joint arthroplasty, robotic-assisted surgeries have demonstrated advantages such as better accuracy and precision of implant positioning and improved restoration of a neutral mechanical axis<sup>6-9</sup>. These advantages may be useful in UKA to TKA conversion surgeries, as the use of robotic assistance may result in improved bone preservation.</p><p><strong>Description: </strong>Robotic-assisted TKA is performed with the patient in the supine position, under spinal anesthesia, and with use of a tourniquet. A limited incision is made approximately 1 cm medial to a standard midline incision, through the previous UKA incision. A medial parapatellar arthrotomy and partial synovectomy are performed. Array pins are placed in a standard fashion: intra-incisional in the femoral diaphysis and extra-incisional in the distal tibial diaphysis. Femoral and tibial bone registration is performed, along with functional knee balancing to adjust implant positioning. The robotic arm-assisted system is then utilized to achieve the planned bone resections. After completing all bone cuts, trial components are inserted. Trial reduction is then performed, and knee extension, stability, and range of motion are assessed. The final implant is cemented into place. We utilize a cruciate-retaining TKA implant. No augments are required.</p><p><strong>Alternatives: </strong>An alternative treatment option is manual UKA to TKA conversion.</p><p><strong>Rationale: </strong>Robotic-assisted conversion of UKA to TKA is especially useful for patients requiring bone preservation. For example, 1 case series found that the use of robotic-assisted conversion of UKA to TKA resulted in a decreased use of augments and a smaller average polyethylene insert thickness compared with manual conversion. Furthermore, mechanical bone loss may occur secondary to implant loosening. Thus, in patients with aseptic loosening, robotic-assisted conversion of UKA to TKA may be useful<sup>10</sup>.</p><p><strong>Expected outcomes: </strong>Results of robotic-assisted conversion of UKA to TKA have thus far been excellent. In a study of 4 patients undergoing robotic-assisted conversion of UKA to TKA, all patients experienced uneventful recoveries without any need for subsequent re-revision<sup>10</sup>. In a case report of a robotic-assisted conversion of UKA to TKA, the patient was pain-free at both 6 months and 1 year postoperatively, with a range of motion of 0° to 120° at 6 months and 0° to 130° at 1 year, and excellent component alignment on radiographs at 1 year<sup>11</sup>. In another case report, the patient had full range of motion and a normal, pain","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-12-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11661718/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142886186","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":"Repair of Acute Grade-3 Combined Posterolateral Corner Avulsion Injuries Using a Transosseous Krackow Suture Pull-Through Technique.","authors":"Nancy Park, Hugh Medvecky, Jay Moran, Michael J Medvecky","doi":"10.2106/JBJS.ST.23.00065","DOIUrl":"10.2106/JBJS.ST.23.00065","url":null,"abstract":"<p><strong>Background: </strong>For complete disruption of the posterolateral corner (PLC) structures, operative treatment is most commonly advocated, as nonoperative treatment has higher rates of persistent lateral laxity and posttraumatic arthritis<sup>1-5</sup>. Some studies have shown that acute direct repair results in revision rates upwards of 37% to 40% compared with 6% to 9% for initial reconstruction<sup>3,6</sup>. In a recent study assessing the outcomes of acute repair of PLC avulsion injuries with 2 to 7 years of follow-up, patients with adequate tissue were shown to have a much lower failure rate than previously documented<sup>7</sup>. In the present video article, we demonstrate a transosseous Krackow pull-through technique for repair of acute avulsion-type PLC multiligamentous knee injuries with no midsubstance injury.</p><p><strong>Description: </strong>An incision is made along the lateral aspect of the knee from the epicondyle to the fibular shaft. The soft-tissue avulsion injury is identified and tagged with suture. Locking Krackow sutures are placed into the injured structures without separating the soft-tissue sleeve avulsion. With fibular avulsions, fibular and tibial transosseous tunnels are drilled with 2 Beath pins through the fibular head and tibia, exiting through the anteromedial tibial cortex. Lateral collateral ligament (LCL) and anterior biceps sutures are passed through the anterior tunnel, and popliteofibular ligament (PFL) and posterior biceps sutures are passed through the posterior tunnel. A small incision is made over the anteromedial tibial cortex in order to tie the sutures over the same metallic button. In fibular head avulsion fractures, high-strength suture placed through the fibular neck can provide additional compression. For proximal PLC injuries, the iliotibial band is incised at the lateral epicondyle, and the proximal attachment sites of the LCL and popliteus are localized. Krackow locking sutures are placed within the LCL and popliteus tendon. Transosseous tunnels are drilled with Beath pins through the native attachment sites of the LCL and popliteus on the lateral condyle and are directed anteriorly to avoid convergence with a potential anterior cruciate ligament (ACL) femoral tunnel. Sutures are pulled through the femoral attachment sites and tied over the same metallic button.</p><p><strong>Alternatives: </strong>For acute PLC injuries, nonoperative treatment is not endorsed for the majority of cases. Surgical options include direct repair, repair with augmentation, or reconstruction.</p><p><strong>Rationale: </strong>The transosseous Krackow pull-through technique allows for an enhanced and secure soft-tissue repair while avoiding suture anchor pull-out from the metaphyseal fibular head bone, which can also be compromised by cortical avulsion fractures. This procedure avoids the cost of an allograft and the donor-site morbidity of an autograft that are associated with a reconstruction. For pat","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-12-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11661711/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142886185","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":"Temporary Circular External Fixation for Spanning the Traumatized Ankle Joint.","authors":"Nando Ferreira, Niel Bruwer, Adriaan Jansen van Rensburg, Ernest Muserere, Shao-Ting Jerry Tsang","doi":"10.2106/JBJS.ST.23.00069","DOIUrl":"10.2106/JBJS.ST.23.00069","url":null,"abstract":"<p><strong>Background: </strong>Temporary ankle-spanning circular fixation aims to provide osseous stability while (1) allowing access to and recovery of the traumatized soft-tissue envelope and (2) facilitating safe, comfortable, and clinically relevant cross-sectional imaging for surgical planning. It is most commonly utilized in a \"span-scan-plan\" treatment strategy in cases of peri-articular fractures around the ankle<sup>2</sup>. Conventional monolateral fixators are prone to morbidity at the half-pin sites in the foot and variation in construct stability. Temporary ankle-spanning circular external fixation of the traumatized ankle joint can mitigate these issues.</p><p><strong>Description: </strong>A circular external fixator construct is assembled beginning with a single tibial ring that is fixed to the tibia by half-pins that are spread on either side of the ring and forming a \"virtual ring block.\" A foot ring is attached via 2 crossed tensioned fine wires in the calcaneum and a single midfoot fine wire in order to prevent an equinus deformity. The tibial virtual ring block and the foot ring are interconnected by 3 polyaxial \"rapid-adjust struts\" that are evenly distributed around the limb. The fracture is then reduced, and the polyaxial rapid-adjust struts are locked<sup>1</sup>.</p><p><strong>Alternatives: </strong>Numerous constructs have been proposed to optimally immobilize the ankle joint while also allowing limb elevation and access to the ankle for soft-tissue care<sup>3-6</sup>. A commonly utilized construct is the monolateral \"bar-and-clamp\" spanning external fixator, which relies on half-pin fixation in the foot that may induce bone lysis, result in pin-site infections, and prevent weight-bearing. Calcaneal half-pins are particularly troublesome and can lead to adjacent lysis, instability, and potential loss of initial reduction as a result of the cancellous bone quality.</p><p><strong>Rationale: </strong>The principal objective of temporary joint-spanning external fixation is to realign the traumatized joint and to maintain this reduction until definitive surgery while facilitating soft-tissue treatment and surgical planning<sup>7-11</sup>. This strategy forms the first step in the \"span-scan-plan\" approach to pilon fractures described by Sirkin et al.<sup>2</sup>. Multiple subsequent studies have confirmed the superiority of external fixation over splinting for initial soft-tissue care following distal tibial and ankle trauma<sup>12,13</sup>.</p><p><strong>Expected outcomes: </strong>Temporary circular external fixation has been shown to outperform monolateral fixation in terms of both the adequacy of the initial reduction and the maintenance of this reduction<sup>1</sup>. Harrison et al. demonstrated that temporary circular fixation of the traumatized ankle yielded 100% good or excellent initial reduction compared with 91% for monolateral fixation. This initial reduction was also better maintained by circular fixator constru","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11623823/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142814388","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":"Robotic-Assisted Decompression, Decortication, and Instrumentation for Minimally Invasive Transforaminal Lumbar Interbody Fusion.","authors":"Franziska C S Altorfer, Fedan Avrumova, Darren R Lebl","doi":"10.2106/JBJS.ST.23.00080","DOIUrl":"10.2106/JBJS.ST.23.00080","url":null,"abstract":"<p><strong>Background: </strong>Robotic-assisted spine surgery has been reported to improve the accuracy and safety of pedicle screw placement and to reduce blood loss, hospital length of stay, and early postoperative pain<sup>1</sup>. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a procedure that is well suited to be improved by recent innovations in robotic-assisted spine surgery. Heretofore, the capability of robotic navigation and software in spine surgery has been limited to assistance with pedicle screw insertion. Surgical decompression and decortication of osseous anatomy in preparation for biological fusion had historically been outside the scope of robotic-assisted spine surgery. In 2009, early attempts to perform surgical decompressions in a porcine model utilizing the da Vinci Surgical Robot for laminotomy and laminectomy were limited by the available technology<sup>2</sup>. Recent advances in software and instrumentation allow registration, surgical planning, and robotic-assisted surgery on the posterior elements of the spine. A human cadaveric study assessed the accuracy of robotic-assisted bone laminectomy, revealing precision in the cutting plane<sup>3</sup>. Robotic-assisted facet decortication, decompression, interbody cage implantation, and pedicle screw fixation add automation and accuracy to MI-TLIF.</p><p><strong>Description: </strong>A surgical robotic system comprises an operating room table-mounted surgical arm with 6 degrees of freedom that is physically connected to the patient's osseous anatomy with either a percutaneous Steinmann pin to the pelvis or a spinous process clamp. The Mazor X Stealth Edition Spine Robotic System (Version 5.1; Medtronic) is utilized, and a preoperative plan is created with use of software for screw placement, facet decortication, and decompression. The workstation is equipped with interface software designed to streamline the surgical process according to preoperative planning, intraoperative image acquisition, registration, and real-time control over robotic motion. The combination of these parameters enables the precise execution of preplanned facet joint decortication, osseous decompression, and screw trajectories. Consequently, this technique grants the surgeon guidance for the drilling and insertion of screws, as well as guidance for robotic resection of bone with a bone-removal drill.</p><p><strong>Alternatives: </strong>The exploration of robotically guided facet joint decortication and decompression in MI-TLIF presents an innovative alternative to the existing surgical approaches, which involve manual bone removal and can be less precise. Other robotic systems commonly utilized in spine surgery include the ROSA (Zimmer Biomet), the ExcelsiusGPS (Globus Medical), and the Cirq (Brainlab)<sup>4</sup>.</p><p><strong>Rationale: </strong>The present video article provides a comprehensive guide for executing robotic-assisted MI-TLIF, including robotic facet decortica","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-12-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11617349/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142802747","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":"Far Posterior Approach for Rib Fracture Fixation: Surgical Technique and Tips.","authors":"Taylor J Manes, Daniel T DeGenova, Benjamin C Taylor, Jignesh N Patel","doi":"10.2106/JBJS.ST.23.00094","DOIUrl":"10.2106/JBJS.ST.23.00094","url":null,"abstract":"<p><strong>Background: </strong>The present video article describes the far posterior or paraspinal approach to posterior rib fractures. This approach is utilized to optimize visualization intraoperatively in cases of far-posterior rib fractures. This technique is also muscle-sparing, and muscle-sparing posterolateral, axillary, and anterior approaches have been shown to return up to 95% of periscapular strength by 6 months postoperatively<sup>1</sup>.</p><p><strong>Description: </strong>Like most fractures, the skin incision depends on the fracture position. The vertical incision is made either just medial to a line equidistant between the palpable spinous processes and medial scapular border or directly centered over the fracture line in this region. The incision and superficial dissection must be extended cranially and caudally, approximately 1 or 2 rib levels past the planned levels of instrumentation, in order to allow muscle elevation and soft-tissue retraction. Superficial dissection reveals the trapezius muscle, with its fibers coursing from inferomedial to superolateral caudal to the scapular spine, and generally coursing transversely above this level. The trapezius is split in line with its fibers (or elevated proximally at the caudal-most surface), and the underlying layer will depend on the location of the incision. The rhomboid minor muscle overlies ribs 1 and 2, the rhomboid major muscle overlies ribs 3 to 7, and the latissimus dorsi overlies the remaining rib levels. To avoid muscle transection, the underlying muscle is also split in line with its fibers. Next, the thoracolumbar fascia is encountered and sharply incised, revealing the erector spinae muscles, which comprise the spinalis thoracis, longissimus thoracis, and iliocostalis thoracis muscles. These muscles and their tendons must be sharply elevated from lateral to midline; electrocautery is useful for this because there is a robust blood supply in this region. Medially, while retracting the paraspinal musculature, visualization with this approach can extend to the head and neck of the rib, and even to the spine. Following deep dissection, the fractures are now visualized. During fracture reduction, it is critical to assess reduction of both the costovertebral joint and the costotransverse joint. With fractures closer to the spine, it is recommended to have at least 2 cm between the rib head and tubercle in order to allow 2 plate holes to be positioned on the neck of the rib; if comminution exists and plating onto the transverse process is needed, several screws are required here for stability as well. For appropriate stability if plating onto the spine is not required, a minimum of 3 locking screws on each side of the fracture are recommended. Contouring of the plates to match the curvature of the rib and to allow for proper apposition may be required with posterior rib fractures. Screws must be placed perpendicular to the rib surface. Following operative stabilization of ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-12-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11617350/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142802746","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":"Arthroscopic Reconstruction of the Acetabular Labrum Using an Autograft Hip Capsule.","authors":"Bilal S Siddiq, Stephen M Gillinov, Nathan J Cherian, Scott D Martin","doi":"10.2106/JBJS.ST.23.00068","DOIUrl":"10.2106/JBJS.ST.23.00068","url":null,"abstract":"<p><strong>Background: </strong>Whereas uncomplicated labral tears with preserved fibers can be effectively treated with use of labral repair techniques, complex tears and hypoplastic labra require labral reconstruction<sup>1-3</sup>. Standard reconstruction techniques feature grafted tissue that is added to existing, deficient tissue or that is utilized to replace a hypoplastic labrum entirely<sup>4-9</sup>. However, such approaches utilizing allografts or remote autografts are limited because they often necessitate extensive debridement of the existing labrum to prepare a site for graft implantation, an approach that can damage and devascularize the chondrolabral junction<sup>10-14</sup>. The presently described technique, arthroscopic capsular autograft labral reconstruction, is suitable for simple tears as well as hypoplastic, degenerative, and complex tears, and negates the challenges of utilizing allografts or remote autografts by supplementing the labrum. In addition, this technique avoids substantial resection, thus preserving the chondrolabral junction<sup>15-22</sup>.</p><p><strong>Description: </strong>Following induction of anesthesia and appropriate patient positioning, puncture capsulotomy is performed to enter the hip joint<sup>26</sup>. In the presence of a sufficiently intact labrum, 3 to 5 mm of capsule is elevated to augment the labrum and preserve the blood supply. In the presence of a severely deficient or hypoplastic labrum, the capsule is elevated 5 to 10 mm to reconstruct the labrum. Following capsular augmentation and potential acetabuloplasty, 2.3-mm bioabsorbable composite anchors are utilized to secure the elevated capsular tissue and the remaining labral tissue to the acetabular rim. Loop suture or a vertical mattress suture technique is then utilized to complete the repair. A Weston knot and several half-hitches are placed while dynamically tensioning along the capsular aspect of the repair in order to secure the labral reconstruction to the acetabular rim with concurrent release of traction. Anchors are placed roughly 1 cm apart to prevent strangulation of the capsular vessels<sup>29</sup>.</p><p><strong>Alternatives: </strong>Labral reconstruction options include autografts or allografts7. Potential allografts include the semitendinosus, tibialis anterior, iliotibial band, tensor fasciae latae, and peroneus brevis8-14. Remote autograft sites include the gracilis and quadriceps tendons16,17. These options are limited by increased donor site morbidity and operative time to obtain the grafts. Local autograft sites include the ligamentum teres, indirect head of the rectus femoris, iliotibial band, and hip capsule15,18-23,25.</p><p><strong>Rationale: </strong>Relative to autografts, the allografts most commonly utilized in labral reconstruction feature a heightened risk of disease transmission, increased cost, and a potentially lengthened time to graft incorporation<sup>15</sup>. Among the local autograft sites, the uti","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-12-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11617351/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142802745","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 Screw Fixation of Proximal Fifth Metatarsal Fractures.","authors":"Cuyler P Dewar, Gabe N O'Hara, Logan J Roebke, John McKeon, Kevin D Martin","doi":"10.2106/JBJS.ST.23.00078","DOIUrl":"10.2106/JBJS.ST.23.00078","url":null,"abstract":"<p><p>Metatarsal fractures are one of the most common injuries of the foot, accounting for approximately 5% to 6% of all fractures confronted in the outpatient setting<sup>1</sup>. Approximately 45% to 70% of these fractures involve the fifth metatarsal, which have been described using a 3 zonal approach in 1993 by Lawrence and Botte<sup>2</sup>. Zone 2 fractures are difficult to manage given their retrograde vascular supply, leading to higher rates of nonunion<sup>1,3</sup>. Jones fractures (zone 2) are primarily treated surgically, with the 2 main methods being intramedullary screw fixation and plate fixation<sup>3</sup>. Surgical management leads to higher rates of union when compared with nonoperative modalities. Presented here is a technique for zone 2 intra-articular Jones fractures with minimal to moderate displacement via open reduction and internal fixation. This technique is not recommended for comminuted fractures or those with proximal split fractures. Starting with the foot lateral, this technique requires meticulous marking of the anatomical landmarks of the distal fibula as well as the fifth metatarsal to establish the precise starting point for the guidewire. Using a mini c-arm, a high and inside positioning should be confirmed prior to advancing the guidewire from proximal to distal while remaining positioned in the center of the medullary canal. Capitalizing on the variable pitch of a 5.0-mm headless compression screw, the Jones fracture is compressed to ensure primary bone healing. The incision is then closed, and a soft wrap is utilized followed by 2 weeks of non-weight-bearing and progressive protective weight-bearing until a complete recovery is achieved.</p><p><strong>Background: </strong>Open reduction and internal fixation (ORIF) for the operative treatment of zone-2 intra-articular Jones fractures with minimal to moderate displacement is recommended because of the high rate of nonunion associated with nonoperative treatment. The blood supply to this region is minimal because of its retrograde flow, leading to high rates of nonunion with nonoperative treatment. The presently described technique offers reduction and fixation of a zone-2 fracture, as well as improved functional outcomes and nonunion rates. This approach is minimally invasive, as it is performed percutaneously, leading to a decrease in soft-tissue damage, infection rates, and operative time.</p><p><strong>Description: </strong>The zone-2 fifth metatarsal ORIF technique begins with the use of a marking pen to outline the distal fibula and the head of the fifth metatarsal for proper orientation. Fluoroscopy is utilized to identify the landmarks so that a guidewire can be placed into the proximal dorsal aspect of the fifth metatarsal. Placement is confirmed on multiple radiographic images. The guidewire is then slowly inserted down the medullary canal of the fifth metatarsal, with placement verified on multiple fluoroscopic images. Once placement is confirmed, ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11567698/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142649258","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":"Closed Intramedullary Pinning of Displaced Radial Neck Fracture (Metaizeau Technique).","authors":"Scott H Kozin, Francisco Soldado","doi":"10.2106/JBJS.ST.23.00076","DOIUrl":"10.2106/JBJS.ST.23.00076","url":null,"abstract":"<p><strong>Background: </strong>Radial neck fractures account for 1% of all pediatric fractures and 5% to 10% of pediatric elbow fractures. The mechanism of injury is typically a fall with the elbow in hyperextension and the forearm in supination. A valgus force compresses the radial head against the capitellum, causing a radial neck fracture. Displaced radial neck fractures are difficult to treat and account for a disproportionate number of bad outcomes, including malunion, nonunion, and osteonecrosis. The preferred treatment is closed reduction and fixation, as open reduction is associated with an inordinately high rate of osteonecrosis. Closed intramedullary pinning is an effective technique to achieve and maintain reduction. The procedure relies on an intact periosteum and requires attention to detail. The present video article will demonstrate the technique of closed intramedullary pinning (the Metaizeau technique). Metaizeau et al. previously described their technique of closed reduction and intramedullary pinning of radial neck fractures. A Kirschner wire is inserted retrograde from the distal radius into the posterolateral radial neck with the forearm pronated to avoid injury to the posterior interosseous nerve. Reduction is achieved by rotating the wire 180°. This technique relies on intact periosteum, with care taken to preserve the tenuous blood supply of the radial head and to achieve adequate reduction.</p><p><strong>Description: </strong>General anesthesia is administered, and the patient is positioned supine with use of an arm table or with an image intensifier utilized as an arm table. A tourniquet is applied to the operative limb. Fluoroscopy is utilized to identify the distal radius physis. A radial approach is performed to access the distal radius, proximal to the growth plate, with care taken to protect the sensory nerves. The cortex of the radial metaphysis is opened with use of a drill bit or a bone awl to allow space for the internal fixation device. Opening in a proximal direction and into the medullary canal facilitates intramedullary passage. A Steinmann pin (1.2 to 2.5 mm), Ilizarov wire (2.0 mm), or elastic nail can be utilized for as an intramedullary device. Place the pre-bent Steinmann pin/Ilizarov wire/elastic nail into the metaphysis and advance it in a proximal direction toward the radial neck fracture. The tip of the intramedullary device is directed into the displaced radial neck fracture, engaging the radial epiphysis. The pin/wire/elastic nail is rotated 180° to reduce the fracture, and reduction is confirmed on radiographs. Once reduction and fixation are confirmed, the pin/wire/elastic nail is cut and the skin is closed over it with use of absorbable sutures. A long arm cast is applied for 4 to 6 weeks.</p><p><strong>Alternatives: </strong>Alternatives include cast immobilization for cases of displaced fractures with <20° of angulation, closed reduction by placing the elbow in varus with direct pressure on ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11554352/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630257","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":"Bikini Incision Modification of the Direct Anterior Approach.","authors":"Michael Leunig, Hannes A Rüdiger","doi":"10.2106/JBJS.ST.23.00085","DOIUrl":"10.2106/JBJS.ST.23.00085","url":null,"abstract":"<p><strong>Background: </strong>Although the direct anterior approach (DAA) represents an intermuscular and internervous approach to total hip arthroplasty (THA), it did not reach global acceptance until its adoption by large teaching centers. Today, >50% of primary THA procedures in Switzerland are performed via the DAA. Besides being truly minimally invasive, a key advantage of the DAA is the inherent stability that it provides. A shortcoming has been that the traditional longitudinal skin incision does not follow the skin tension lines<sup>1</sup> and therefore can result in wound-healing problems, poor scar cosmesis, and damage to the lateral femoral cutaneous nerve (LFCN). In 2011, we introduced the bikini-type skin-crease incision, and we have utilized it in most of our patients since, with excellent outcomes that are equivalent to those of the traditional incision and superior scar cosmesis<sup>2</sup>. The bikini incision pertains only to the incisions made at the skin and subcutaneous tissues, which are oblique, whereas the deeper dissection beginning with the fascial sheath of the tensor fasciae latae (TFL) is still performed in the longitudinal direction. In most patients, the incision falls into the flexion crease or slightly distal to it, and today, in order to minimize direct damage to the LFCN<sup>3</sup>, the incision we perform is always lateral to the anterior superior iliac spine (ASIS)<sup>4</sup>. From January 2014 until August 2023, a total of 10,009 THA procedures were performed in our unit, with 8,769 being performed via the DAA and 4,969 of those being performed with use of the bikini incision type. The incision type was generally selected according to the experience of the surgeon, with the less-experienced surgeons utilizing classic incision techniques and the high-volume surgeons (i.e., >200 THAs per year) utilizing the bikini incision technique. The bikini incision was utilized in most straightforward cases, but it was not performed if a longitudinal incision had been utilized on the contralateral side or in technically challenging cases. The use of this incision has been adopted by others, with similarly excellent outcomes; however, there is potential for damage to the LFCN<sup>5</sup>. Several studies utilizing a bikini incision have described the incision as being made quite medial to the ASIS, potentially even crossing the medial branches of the LFCN. In contrast, over years of utilizing the bikini incision technique, our approach has evolved such that the incision is not made medial to the ASIS.</p><p><strong>Description: </strong>The bikini-type (skin-crease) incision only differs from the classic longitudinal approach used for DAA THA with respect to the skin and subcutaneous tissue. To avoid damage to the LFCN, our bikini-type incision has evolved over the last decade to being located entirely lateral to the ASIS (Video 1)<sup>3</sup>.</p><p><strong>Alternatives: </strong>The main alternative is the classic lo","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11554357/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630256","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}