JBJS Essential Surgical Techniques最新文献

{"title":"Evans and Cotton Osteotomies Using Porous Titanium Wedges to Correct Pediatric Flatfoot Deformity.","authors":"Finn Macpherson, Miles Benjamin, Arash Afsharpad, Michail Kokkinakis","doi":"10.2106/JBJS.ST.25.00026","DOIUrl":"10.2106/JBJS.ST.25.00026","url":null,"abstract":"<p><strong>Background: </strong>The present video article demonstrates the use of Evans and Cotton osteotomies with porous titanium wedges for the treatment of pediatric flatfoot. Pediatric flatfoot is not commonly painful or disabling and usually resolves as the arch elevates spontaneously. However, in cases of flatfoot that persist despite nonoperative treatment, symptoms such as severe activity-related pain and medial foot calluses are an indication for surgical intervention<sup>3</sup>. The aims of treatment in pediatric patients are to correct anatomical deformity and reduce pain while maintaining mobility.</p><p><strong>Description: </strong>Reconstruction of the foot is achieved by performing a lateral column lengthening calcaneal osteotomy (i.e., Evans osteotomy)<sup>4</sup> and an opening-wedge medial cuneiform osteotomy (i.e., Cotton osteotomy)<sup>5</sup>. These procedures are preceded by assessment of the Achilles tendon with use of the Silfverskiöld test for contracture, and subsequent percutaneous lengthening if appropriate. The Evans osteotomy is performed by first accessing the lateral hindfoot via an Ollier incision, exposing the calcaneocuboid joint. Osteotomy of the anterior calcaneus is followed by distraction until the desired correction is achieved. Insertion of a porous titanium wedge, sized appropriately, supports the correction. To perform the Cotton osteotomy, an incision is made dorsally for access to the medial cuneiform. Image intensifier radiography is utilized to identify the middle of the medial cuneiform in both the coronal and sagittal planes in order to guide the osteotomy location. The osteotomy is opened with use of a Hintermann retractor, and an appropriately sized porous titanium wedge is inserted. Positioning of the wedges and subsequent deformity correction are evaluated with use of image intensifier radiography.</p><p><strong>Alternatives: </strong>Numerous other surgical techniques have been described for the treatment of flatfeet<sup>3,6</sup>. Extra-articular subtalar arthrodesis procedures have been frequently utilized<sup>7,8</sup>, particularly in patients with substantial subtalar osteoarthritis. This procedure aims to stabilize the subtalar joint through fusion; however, arthrodesis is not frequently performed in pediatric patients because arthritis is less common and preservation of movement is important during growth. Arthroereisis similarly stabilizes the subtalar joint by limiting anterior movement of the talus with use of a prosthesis, rather than completely fusing the joint<sup>9</sup>. This can also be performed via a more minimally invasive technique. Other techniques have also been utilized to maintain osteotomy correction, including autologous iliac crest grafting and locking plates, both of which have their own limitations.</p><p><strong>Rationale: </strong>The combination of Evans and Cotton osteotomies ensures restoration of the functional integrity of the medial longitudinal arch thr","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 2","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-06-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13282035/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148296703","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":"Pediatric Extra-Articular Proximal Femoral Fracture Fixation With a Submuscular Non-Locking Plate.","authors":"Freddy Thomas, Ashish S Ranade, Mevin Mathew Nedumparampil, Nikhil S Cherukuri","doi":"10.2106/JBJS.ST.25.00014","DOIUrl":"10.2106/JBJS.ST.25.00014","url":null,"abstract":"<p><strong>Background: </strong>Submuscular plating with use of a non-locking plate is indicated for the treatment of extra-articular proximal femoral fractures in children ≥6 up to 14 years old. There is no specific weight limit for the use of this procedure. The aim of the procedure is fracture stabilization and facilitation of fracture union through the use of a minimally invasive approach<sup>1</sup>.</p><p><strong>Description: </strong>The surgical technique is performed with the patient under general anesthesia and in the supine position on a fracture table. A stainless steel non-locking dynamic compression plate (4.5-mm system) is placed on the anterior aspect of the thigh and examined with use of a C-arm to confirm that the chosen length is appropriate, then placed along the lateral aspect of the thigh under C-arm visualization to determine the site for proximal contouring. Proximal plate contouring is performed with use of a plate bender. Through a distal incision, a submuscular tunnel is made. A proximal incision is then made over the greater trochanter. The plate is slid from the distal to the proximal end. The plate is temporarily stabilized with use of Kirschner wires via the proximal and distal holes. After confirming the plate position with use of the C-arm, non-locking screws are placed first on the distal and then on the proximal end of the plate. A total of 3 screws are inserted into each of the distal and proximal fragments<sup>1</sup>. Length, rotation, and alignment are confirmed postoperatively on clinical evaluation and radiographs. The patient is kept non-weight-bearing until early signs of healing are seen on radiographs, then active hip and knee range-of-motion exercises are started. Follow-up visits are conducted at 2, 4, 8, and 12 weeks postoperatively. Toe-touch weight-bearing is allowed at 8 weeks after signs of callus on radiographs. Progression to full weight-bearing is allowed on observation of radiographic fracture union. At 10 weeks, the patient is expected to be full weight-bearing. Implant removal is offered at 1 year postoperatively.</p><p><strong>Alternatives: </strong>Alternatives for treating pediatric extra-articular proximal femoral fractures include the use of titanium elastic nails, rigid intramedullary nails, locking plates, limited-contact dynamic compression plates, and external fixators<sup>2-11</sup>.</p><p><strong>Rationale: </strong>Extra-articular proximal femoral fractures by definition include fractures of the subtrochanteric region<sup>2,3</sup>. These fractures are challenging to treat because of the strong muscular deforming forces on the proximal femur. These fractures can be length-unstable.</p><p><strong>Expected outcomes: </strong>The results of this technique in 15 patients have been published<sup>1</sup>. All fractures healed uneventfully, with a mean time to union of 11.8 ± 1.2 weeks. No patients required a subsequent surgery for complications or malunion. Thirteen patients achieved","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 2","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-05-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13170738/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147964906","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":"Five-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction.","authors":"J Christian Peterson, William L Justice, Nathaniel Tchangou, Kevin B Freedman","doi":"10.2106/JBJS.ST.25.00009","DOIUrl":"10.2106/JBJS.ST.25.00009","url":null,"abstract":"<p><strong>Background: </strong>Hamstring tendon autograft remains a popular graft choice for anterior cruciate ligament (ACL) reconstruction because of its favorable biomechanical properties, lower donor-site morbidity, and comparable functional outcomes to bone-patellar tendon-bone (BPTB) autograft<sup>1-5</sup>. However, variability in hamstring graft size and length remains a challenge, particularly in female or short-statured patients<sup>7</sup>. Smaller graft diameters are consistently associated with increased failure and revision rates, with grafts of <8 mm demonstrating inferior outcomes<sup>6,7,18,19</sup>. Magnussen et al.<sup>6</sup> reported revision rates of 13.6% for grafts of <7 mm compared with 1.7% for grafts of ≥8 mm, and Park et al.<sup>18</sup> and Mariscalco et al.<sup>19</sup> reported no revisions in grafts of ≥8 mm. Although some studies have suggested slightly higher laxity or failure rates with hamstring grafts compared with BPTB in certain populations<sup>3,20-22</sup>, large systematic reviews have shown no significant differences in return to sport, rerupture rates, or patient-reported outcomes when grafts are appropriately sized<sup>23,24</sup>. The 5-strand hamstring autograft configuration has demonstrated comparable clinical outcomes to the traditional 4-strand construct while more reliably achieving large graft diameters<sup>9,10,12</sup>. The present video article outlines the key steps and technical pearls and pitfalls of performing a 5-strand hamstring autograft ACL reconstruction.</p><p><strong>Description: </strong>The semitendinosus and gracilis are harvested after reflecting the sartorial fascia and removing the attached adhesions and bands from each tendon. If a 4-strand configuration is <8 mm in diameter, a 5-strand technique is utilized, tripling the semitendinosus and doubling the gracilis. A diagnostic knee arthroscopy is performed. The tibial tunnel is drilled through an accessory anteromedial portal over the residual ACL tibial footprint. The femoral tunnel is drilled with use of an over-the-top guide and subsequently reamed to a depth of 25 mm via independent femoral drilling at the center of the femoral ACL footprint. Femoral stabilization is then achieved with interference screw fixation, the knee is cycled, and screw-and-sheath tibial fixation is performed.</p><p><strong>Alternatives: </strong>Nonoperative treatment includes formal physical therapy that emphasizes strengthening, stretching, and neuromuscular control<sup>11</sup>. Surgical alternatives include ACL reconstruction using BPTB or quadriceps tendon autograft or allograft tissue. In cases of insufficient hamstring graft length or diameter, hybrid graft constructs incorporating allograft tissue may be considered<sup>12</sup>.</p><p><strong>Rationale: </strong>Hamstring tendon autograft offers reliable long-term results for ACL reconstruction with a well-established biomechanical profile<sup>1,2</sup>, reduced anterior knee pain<sup>3<","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 2","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-05-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13170741/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147964886","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":"Total Hip Replacement with Use of the French Paradox Cementing Technique for a Shortened Charnley-Kerboull Stem via a Bikini Approach.","authors":"Pierre Laboudie, Luc Kerboull, Moussa Hamadouche","doi":"10.2106/JBJS.ST.25.00018","DOIUrl":"10.2106/JBJS.ST.25.00018","url":null,"abstract":"<p><strong>Background: </strong>The \"French Paradox\" technique, one of the various femoral cementing techniques in total hip replacement, was developed by Marcel Kerboull at Cochin Hospital, Paris, in the 1960s. Its fundamental principles include removal of the cancellous bone, use of a highly polished and collared canal-filling stem, and a straightforward cementation technique. This technique differs from the taper-slip philosophy, which relies on controlled subsidence, and the composite-beam concept, which seeks rigid bonding between stem and cement to act as a single structural unit.</p><p><strong>Description: </strong>Following patient positioning on the Judet positioning table, a bikini Hueter anterior approach is performed. After implantation of the acetabular component, the femur is exposed with the aid of the positioning table. Femoral preparation begins with the use of an aggressive canal-finder rasp and curet to establish the entry and remove initial cancellous bone. Subsequent preparation is performed with use of either aggressive cutting broaches or flexible reamers, with the objective of removing as much cancellous bone as possible. Following insertion of the cement plug, the femoral canal is thoroughly washed and then dried. A suction drain is then inserted close to the cement plug, and medium-viscoelasticity cement is inserted with use of a regular syringe or a flexible cement gun. Creating negative pressure within the canal helps aspirate any blood that might impede optimal cement interposition. Furthermore, given the canal-filling design of the stem, any small tunnel that exists after drain removal is expected to collapse under pressure. The highly polished stem is then inserted until the collar touches the neck cut.</p><p><strong>Alternatives: </strong>Alternatives include the taper-slip and composite-beam techniques. The taper-slip technique involves the use of a highly polished stem that subsides slightly within the cement mantle, generating controlled compressive forces to preserve the cement-bone interface. The composite-beam technique involves the use of a matte stem that bonds to the cement mantle, creating a unified structure that resists micromotion and maintains stability.</p><p><strong>Rationale: </strong>The French Paradox cementing technique requires the removal of cancellous bone, which becomes weak with aging and cannot effectively carry load. By eliminating this compromised layer, the technique is thought to allow forces to be transmitted directly to the cortical bone. This is the proposed mechanism for reducing the risk of periprosthetic fracture in the elderly population by preventing any subsidence of the stem. Additionally, compared with other cementing techniques, the French Paradox technique is easy, cost-effective, and reproducible. There is no need for a tip centralizer or vacuum cement preparation, and the femoral preparation closely resembles that for a cementless implant, making the technique more intui","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 2","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-05-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13170739/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147964857","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":"Free Vascularized Fibular Grafting for Osteonecrosis of the Femoral Head.","authors":"Qian Tang, Ruo-Tao Liu, Fuchou Hsiang, Zhe Liu, Dong-Xu Jin, Jia-Gen Sheng, Chang-Qing Zhang, Zhen-Zhong Zhu","doi":"10.2106/JBJS.ST.24.00001","DOIUrl":"10.2106/JBJS.ST.24.00001","url":null,"abstract":"<p><strong>Background: </strong>Osteonecrosis of the femoral head (ONFH) remains a challenging condition in orthopaedics<sup>1</sup>. Free vascularized fibular grafting (FVFG) theoretically has the potential to restore blood supply to the femoral head and enhance mechanical stability within the femoral head. This method has shown promising clinical outcomes in hip preservation. Previous studies have utilized the anterolateral approach to the hip for this surgical procedure. Here, we report a minimally invasive technique utilizing the direct anterior approach for debridement and bone grafting, requiring a shorter fibular graft and simplifying the procedure. This method holds potential as an effective treatment option for early to mid-stage femoral head necrosis<sup>2</sup>.</p><p><strong>Description: </strong>This technique integrates the procurement of the fibula and its implantation into the femoral head via a direct anterior approach. The fibular pedicle is harvested, along with its nutrient peroneal vessels. The lateral circumflex femoral vessels are then exposed. Subsequently, an anterior capsulotomy and a cortical trough are created along the femoral neck. The necrotic region is extirpated and substituted with the fibular pedicle and cancellous bone from the femoral neck. Finally, an anastomosis is formed between the peroneal vessels of the transplanted fibula and the ascending branches of the lateral circumflex femoral vessels<sup>3</sup>.</p><p><strong>Alternatives: </strong>Nonoperative alternatives for the treatment of ONFH include lifestyle changes like weight control, restriction of weight-bearing activities, and alcohol cessation, alongside pharmaceutical interventions that include antilipemic agents, anticoagulants, vasodilators, and bisphosphonates. Physical therapy methods such as electromagnetic stimulation, extracorporeal shock-wave therapy, and hyperbaric oxygen may also be employed. The surgical approaches to this condition cover a wide array of operations, including core decompression, precursor cell implantation, nonstructural bone grafting, nonvascularized bone grafting, vascularized iliac bone flap transfer, transtrochanteric rotational osteotomy, and porous metal implantation<sup>4</sup>.</p><p><strong>Rationale: </strong>FVFG theoretically not only provides potential mechanical support for the necrotic femoral head, which may help prevent collapse, but also has the potential to improve the internal circulation of the femoral head and thus provide a favorable environment for osteoblast activity and contribute to bone induction and formation<sup>5</sup>. It is hypothesized that FVFG targets the pathological mechanism of femoral head necrosis to potentially impede disease progression. For patients <50 years old, FVFG is suitable for treating Association Research Circulation Osseous (ARCO) stage-II ONFH before collapse. For patients <30 years old, FVFG can be utilized to protect the femoral head, even if it has collapsed as A","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 2","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13138393/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147844240","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":"Tibial Lengthening with a Motorized Intramedullary Lengthening Nail.","authors":"Jason S Hoellwarth, Jason D Gross, Austin T Fragomen, Taylor J Reif, S Robert Rozbruch","doi":"10.2106/JBJS.ST.24.00028","DOIUrl":"10.2106/JBJS.ST.24.00028","url":null,"abstract":"<p><strong>Background: </strong>Tibial lengthening with use of a motorized intramedullary lengthening nail (MILN) provides precise deformity correction and distraction osteogenesis without requiring external fixation<sup>1</sup>. A MILN can be utilized for many etiologies requiring lengthening, such as congenital (e.g., short stature, limb deficiency) or acquired (e.g., post-infectious, traumatic)<sup>2</sup>. The present video article describes the surgical technique for MILN use in the tibia in a skeletally mature patient with use of the Precice System (Globus Medical).</p><p><strong>Description: </strong>The preoperative patient evaluation starts with a history to understand the primary reason(s) that the patient seeks lengthening, to identify potential care challenges (such as dormant infection for patients with a post-infectious etiology or joint instability for patients with limb deficiency). The physical examination should evaluate for joint contracture or instability, spasticity, prior surgery compromising the surgical approach, and patient psychological or physical capacity to comply with postoperative weight-bearing and lengthening instructions. Preoperative imaging includes calibrated orthogonal radiographs of the operative tibia to ensure suitable anatomy and bilateral hip-to-ankle radiographs, with blocks to level the pelvis as needed, to determine any limb-length discrepancy (LLD) or alignment deformity<sup>3,4</sup>. A gastrocnemius-soleus complex release may be considered; otherwise, the surgical procedure begins with exposure of the tibia and predrilling of the osteotomy site. The tibial canal is entered in either a suprapatellar or infrapatellar (as shown in this video) fashion and sequentially reamed over a centrally placed guidewire. Proximal and distal rotation marker pins are placed posterior to the expected path of the MILN<sup>5</sup>. Blocking screws can be placed to prevent or correct deformity<sup>6</sup>. Prophylactic fasciotomy may be appropriate when performing acute deformity correction<sup>7</sup>. Osteotomies of the fibula and tibia are performed with use of an osteotome. The nail is inserted and locked in position. Proximal and distal tibiofibular fixation minimizes undesired migration of the fibular segments<sup>8</sup>. Lengthening generally starts 7 days after surgery, using 4 lengthenings, totalling a maximum of 0.8 mm, per day.</p><p><strong>Alternatives: </strong>Some LLD cases are suitably treated without surgical intervention<sup>9</sup>. Alternative lengthening techniques<sup>10</sup> include monolateral external fixators<sup>11</sup> and circular fixators, with or without computer guidance<sup>12</sup> and with or without subsequent internal fixation<sup>13,14</sup>, and other brands of MILN<sup>15</sup>. Hexapod fixators facilitate the most comprehensive deformity correction<sup>16</sup>, although indications are expanding for deformity correction via nailing<sup>17</sup>. Patients may feel that intern","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 1","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13008139/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147515617","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":"Medial Opening-Wedge High Tibial Osteotomy.","authors":"Jason S Hoellwarth, Jason D Gross, Austin T Fragomen, Taylor J Reif, S Robert Rozbruch","doi":"10.2106/JBJS.ST.24.00029","DOIUrl":"10.2106/JBJS.ST.24.00029","url":null,"abstract":"<p><strong>Background: </strong>Mechanical axis deviation (MAD) disrupts the natural force distribution within the knee joint. MAD malalignment imparts atypical tibial plateau loading forces, which can cause painful knee cartilage degeneration, abnormal gait, and reduced activity and mobility<sup>1</sup>. A medial opening-wedge high tibial osteotomy corrects varus MAD for deformities centered in the proximal tibia, reducing medial knee compartment stress, which often improves pain, function, and self-image<sup>2</sup>.</p><p><strong>Description: </strong>Surgical planning starts with a history to understand the patient symptoms, potential etiologies, and goals. Physical examination assesses standing and walking coronal alignment, investigates any rotational concerns, and evaluates lower-extremity joint motion. A bilateral weight-bearing hip-to-ankle anteroposterior radiograph is used to measure the MAD, lateral distal femoral angle, and medial proximal tibial angle, which determine the center of rotation and angulation (CORA). Weight-bearing anteroposterior, flexion posteroanterior, and lateral knee radiographs are used to assess arthrosis and patellar tracking<sup>3,4</sup>. The key steps include a medial exposure of the proximal tibia, biplanar osteotomy in the proximal metaphyseal tibia (1 plane is the sagittal plane to impart angular correction and the other plane is parallel and posterior to the patella), opening of the wedge, fixation with plate and screws, and skin closure.</p><p><strong>Alternatives: </strong>Nonoperative treatments such as bracing, physical therapy, joint injection, and activity modification may palliate symptoms but do not correct the deformity. Distal femoral osteotomies are indicated when the deformity center of rotation and angulation exist in that location<sup>5</sup>. Hexapod frames are more appropriate for multiplanar or large deformities (>11°), which may benefit from gradual correction<sup>3,6</sup>. A lateral closing-wedge high tibial osteotomy can achieve similar realignment but puts the common peroneal nerve at risk because of the surgical approach, and there is limited visualization of the tibia because of fibular obstruction<sup>2,7,8</sup>. Skeletally immature patients with sufficient growth remaining may be partially or fully managed with lateral proximal tibial hemiepiphysiodesis<sup>9</sup>. Total knee arthroplasty (TKA) can address coronal plane deformities and joint arthritis but is joint-ablative, and often patients are counseled to reduce their activity intensity and beware of periprosthetic joint infection<sup>10</sup>.</p><p><strong>Rationale: </strong>Untreated MAD predisposes to early degenerative osteoarthritis and can impair gait, resulting in subpar activity levels and reduced quality of life. Medial opening-wedge high tibial osteotomy corrects proximal tibia-based varus malalignment; normalizes knee joint loading, which should alleviate pain; and preserves the native knee joint, which permit","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 1","pages":""},"PeriodicalIF":2.4,"publicationDate":"2026-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13008138/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147515583","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":"Calcaneo-Cuboid-Cuneiform Osteotomy for the Treatment of Planovalgus Feet in Patients with Spastic Cerebral Palsy.","authors":"Bhushan S Sagade, Mandar V Agashe","doi":"10.2106/JBJS.ST.24.00032","DOIUrl":"10.2106/JBJS.ST.24.00032","url":null,"abstract":"<p><strong>Background: </strong>The calcaneo-cuboid-cuneiform (triple-C) osteotomy is indicated for the correction of symptomatic flexible planovalgus foot deformity. This procedure allows correction of all of the varied components of the planovalgus foot deformity in a single operation<sup>1,2</sup>.</p><p><strong>Description: </strong>The patient is positioned in a floppy lateral position<sup>2</sup>. The calcaneus is exposed via an oblique lateral incision along the peroneal tendons. The osteotomy is performed in an extra-articular fashion beginning posterior to the posterior articular facet and extending distally and anteriorly to the inferior surface of the calcaneus. The posterior calcaneal fragment is displaced medially to allow correction of heel valgus. A separate lateral incision is made over the cuboid in order to expose it. An osteotomy is performed in the middle third of the cuboid without violating the adjacent joints and opened with a lamina spreader to allow correction of the forefoot abduction. The medial cuneiform is exposed via a medial incision. A medial and plantar-based wedge of bone is removed in toto from the middle third of the cuneiform. Closing this wedge corrects forefoot supination and recreates the medial longitudinal arch. The wedge of bone harvested from the cuneiform is inserted into the cuboid and all of the osteotomies are fixed with Kirschner wires of sizes between 1.8 and 2.5 mm or cannulated cancellous screws.</p><p><strong>Alternatives: </strong>If the feet are supple enough to allow passive correction, an in-socket ankle-foot orthosis with a medial arch support can be utilized to maintain the shape of the foot and to delay deterioration and the need for surgery<sup>3</sup>. Various other surgical treatment methods are described in the literature and can be categorized as joint-sparing procedures, arthroereises, and arthrodeses. Joint-preserving procedures include the popular calcaneal-lengthening osteotomy (CLO)<sup>4</sup> and the double calcaneal osteotomy<sup>5</sup>. Arthroereisis, a non-fusion motion-limiting technique, is minimally invasive and recently gaining popularity<sup>3</sup>. The literature has described promising results with use of this procedure<sup>6</sup>. Extra-articular and intra-articular arthrodesis typically have been employed for the treatment of severe and rigid planovalgus feet and in children who have limited ambulatory potential. On the basis of the currently available literature, no procedure can be labeled superior to another<sup>3</sup>.</p><p><strong>Rationale: </strong>The triple-C osteotomy is straightforward and has a short learning curve. There is no need for bone-graft harvesting and the associated morbidity thereof. Studies have shown minimal complications and low long-term recurrence with use of the triple-C osteotomy in patients with spastic cerebral palsy<sup>3</sup>.</p><p><strong>Expected outcomes: </strong>We have reported on the short-term outcomes of this proc","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 1","pages":""},"PeriodicalIF":1.6,"publicationDate":"2026-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12784008/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145953393","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":"Revision Total Hip Arthroplasty with Femoral Component Retention.","authors":"Everett G Young, Ahab G Alnemri, Amar S Vadhera, Neil P Sheth, Krishna Kiran Eachempati","doi":"10.2106/JBJS.ST.24.00009","DOIUrl":"10.2106/JBJS.ST.24.00009","url":null,"abstract":"<p><strong>Background: </strong>Revision total hip arthroplasty (THA) for isolated polyethylene exchange or acetabular revision with retention of the femoral component can present a challenge for adequate exposure. A systematic approach to a proper release can facilitate exposure and reduce the risk of iatrogenic complications.</p><p><strong>Description: </strong>The posterior approach is an extensile and versatile approach for revision THA. After incising the fascia and iliotibial band, the insertion of the gluteus maximus is fully released. After releasing any scar along the inferior gluteus medius, a retractor is placed to hold the muscle belly cranially. The leg is gently internally rotated to place the posterior capsule and external rotators under tension while these structures are released from the posterior femur and along the neck of the femoral component. Curved scissors can be utilized to identify the psoas sheath and to release the inferior capsule while protecting the iliopsoas tendon. Scar tissue is resected from inside the hip joint, and a pocket is made in the anterior capsule to allow retractor placement above the equator of the acetabulum in order to hold the mobilized proximal femur anteriorly. An inferior retractor is then placed under the transverse acetabular ligament. This systematic approach allows adequate visualization of the acetabular component for revision.</p><p><strong>Alternatives: </strong>Nonoperative treatment should be attempted first, depending on the diagnosis and its associated natural history. Once nonoperative treatment has been exhausted and revision THA is indicated, the anterior and direct lateral approaches can be considered. If the femoral component needs revision on the basis of intraoperative assessment, the anterior approach presents substantial difficulty in femoral exposure, with a higher risk of iatrogenic fracture. The direct lateral approach commonly leads to abductor weakness and a Trendelenburg gait.</p><p><strong>Rationale: </strong>Common indications for revision THA with femoral component retention include wear and/or osteolysis, adverse local tissue reaction, recurrent instability, and aseptic acetabular loosening. Adequate exposure is essential to facilitate revision THA with femoral component retention and to minimize the risk of iatrogenic injury.</p><p><strong>Expected outcomes: </strong>Survivorship free from re-revision at 2 years is >80% for both isolated polyethylene exchange and acetabular revision. There is a trend toward higher failure rates when retaining the acetabular component. Risk factors for failure include damage to the locking mechanism; femoral head erosion into the cup, damaging the metal; and a mispositioned acetabular component.</p><p><strong>Important tips: </strong>A systematic approach to releases is essential for adequate exposure with a retained femoral component. Systematic releases include fully releasing the gluteus maximus insertion, continuing the iliotib","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 1","pages":""},"PeriodicalIF":1.6,"publicationDate":"2026-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12784009/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145953402","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":"Quadriceps Coxae-Sparing Modified Posterior Approach to the Hip Joint for Hemiarthroplasty.","authors":"Sumit Arora, Prajwal Gupta, Mudit Sharma, Manoj Kumar Meena, Shahrukh Khan, Abhishek Kashyap","doi":"10.2106/JBJS.ST.25.00008","DOIUrl":"10.2106/JBJS.ST.25.00008","url":null,"abstract":"<p><strong>Background: </strong>Various approaches have been described for hip arthroplasty<sup>1-3</sup>. The posterior approach to the hip remains a popular choice for hemiarthroplasty<sup>1</sup>. In the classic description, it involves detachment of the short external rotators, which include the quadriceps coxae (QC) (i.e., piriformis, superior gemellus, obturator internus, and inferior gemellus) along with the obturator externus and quadratus femoris <i>(</i>as needed<i>)</i>. Since the QC are important for joint stability, detachment during the approach is associated with higher rates of postoperative dislocations<sup>4</sup>, even following subsequent surgical repair of the QC. In the study by Stähelin et al.<sup>5</sup>, 15 of 20 repairs involving the QC had failed by 3 months postoperatively, primarily because the repair site could not withstand the forces of normal weight-bearing during the healing phase. Various muscle-sparing modifications of the conventional approach have been described to reduce the propensity for prosthetic dislocation<sup>6-9</sup>. Hanly et al.<sup>9</sup> described the SPAIRE (Sparing Piriformis and Internus, Repair Externus) technique. This minimally invasive modified posterior approach enables the preservation of the QC, possibly representing the greatest extent of muscle and tendon preservation. The advantages of this QC-sparing technique have been demonstrated in clinical studies of hemiarthroplasty<sup>10,11</sup> and total hip arthroplasty<sup>12</sup>.</p><p><strong>Description: </strong>The patient is anesthetized and placed in a lateral decubitus position. Bolsters are utilized over the pubis and sacral areas to provide stable pelvic orientation. The contralateral limb is flexed at the hip (∼45°) and knee (90°), with adequate padding under the fibular head and lateral malleolus. Another padded bolster is placed between the legs to keep the topmost lower limb in neutral to slight abduction at the hip. The operative limb is flexed at the hip (∼30°), and a 10 to 15-cm straight skin incision is marked on the lateral aspect of hip, centered on the posterolateral tip of the greater trochanter. The deep fascia is opened distally to proximally, incised distally with scissors, and separated proximally with finger dissection. This step creates an intermuscular plane between the gluteus maximus posteriorly and tensor fasciae latae anteriorly. A Charnley hip retractor is applied. Internal rotation of the hip allows identification of the posterior border of the gluteus medius and short external rotators. The fat pad over the QC is swept medially with an abdominal sponge to identify the muscles. A plane is identified between the quadratus femoris and inferior gemellus. Next, a plane is developed between the QC and posterior hip capsule with use of a blunt hemostat from inferior to superior. Abduction of the hip just beyond neutral relaxes the QC and allows superior retraction. The quadratus femoris is detached from t","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 1","pages":""},"PeriodicalIF":1.6,"publicationDate":"2026-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12784010/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145953358","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}