JBJS Essential Surgical Techniques最新文献

{"title":"Ligamentum Flavum Flap Technique in Lumbar Microdiscectomy.","authors":"Shanmuganathan Rajasekaran, Karthik Ramachandran, Rishi Mugesh Kanna, Ajoy Prasad Shetty","doi":"10.2106/JBJS.ST.23.00049","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00049","url":null,"abstract":"<p><strong>Background: </strong>Microdiscectomy has been the gold-standard technique for the treatment of lumbar disc herniation. A potential reason for suboptimal symptom resolution following microdiscectomy is postoperative epidural fibrosis<sup>1</sup>. Preservation of the ligamentum flavum through the use of the ligamentum flavum flap technique reduces postoperative epidural fibrosis and leads to a favorable long-term prognosis.</p><p><strong>Description: </strong>The L5-S1 interlaminar space on the operative side is exposed with use of a standard microsurgical approach, and the level is confirmed. The ligamentum flavum is held taut with use of tooth forceps, holding onto superficial layers, and a flap with its base on the lateral side is created. Initial separation is made at the midline (where the flavum is very thin) with use of a no.-15-blade scalpel. The flap is elevated by detaching the ligamentum flavum between the lower border of the L5 lamina and sacrum with use of a 1-mm Kerrison rongeur. The detachment of the ligamentum flavum is performed carefully, preserving the attachments on the lateral border. Having a thin base allows the flap to be elevated and rotated, and the flap thus can be tucked into the muscle above the facet joint. The nerve root is retracted, and discectomy is performed according to the location and size of the disc. After achieving good hemostasis, the ligamentum flavum flap is gently rotated back to its normal position. In most cases, the flap can be returned back to its original position without any gap and without any need for suture. Closure is performed in layers.</p><p><strong>Alternatives: </strong>Nonoperative treatment yields good pain relief in more than 80% of patients with disc herniation. However, if surgery is required, the primary concern for the surgeon is the prevention of postoperative scarring and fibrosis around the nerve root. Previous attempts to mitigate this potential complication have revolved around the placement of a subcutaneous fat graft over the nerve root; however, no firm evidence exists to support this technique. Synthetic materials such as expanded polytetrafluoroethylene, Adcon-L gel (Wright Medical Technologies), and sodium hyaluronate have also been utilized to prevent epidural scarring; however, the ligamentum flavum is a natural biological solution.</p><p><strong>Rationale: </strong>Postoperative fibrosis may occur if there is a dead space as a result of the excision of the ligamentum flavum or due to inflammation. Restoration of native tissue anatomy with use of the ligamentum flavum technique can prevent such fibrosis, as has been reported previously. In addition to reducing scar formation, preserving the ligamentum flavum can make revision surgery (which is rarely required) safer, as there is less or no epidural fibrosis or nerve root scarring.</p><p><strong>Expected outcomes: </strong>Patients undergoing this procedure have shown good improvement in the Oswestry Disabilit","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543181/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630260","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":"Flexible Intramedullary Nail Placement in Pediatric Humerus Fractures.","authors":"Robert W Gomez, Riley C McHugh, Dhairya Shukla, Dustin A Greenhill","doi":"10.2106/JBJS.ST.23.00071","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00071","url":null,"abstract":"<p><strong>Background: </strong>Flexible intramedullary nailing is an effective method of stabilization in pediatric patients with a humeral shaft fracture when surgery is indicated<sup>1-3</sup>. Although these fractures are most often treated nonoperatively, operative indications include open fractures, bilateral injuries, compartment syndrome, pathologic fractures, neurovascular compromise, unacceptable alignment after attempted nonoperative treatment, and ipsilateral upper-extremity injuries<sup>4</sup>. The current literature on flexible intramedullary nailing of the pediatric humeral shaft lacks concise descriptions of available entry points, which directly affect the subsequent technique, and of pertinent pediatric-specific anatomy. Thus, the present article focuses on these entry points in the pediatric patient.</p><p><strong>Description: </strong>Various entry points are available for the insertion of flexible nails into the humeral shaft. A surgeon must initially decide whether the patient and fracture characteristics are best suited for anterograde versus retrograde insertion. This choice typically depends on several fracture and patient-related characteristics. The passage of flexible intramedullary nails has been well described; thus, the present article will place special emphasis on the available proximal and distal entry points and pediatric-specific anatomy<sup>5-10</sup>. For diaphyseal fractures, we prefer dual distal lateral entry points with the nails advanced retrograde in a C-S configuration whenever possible, given the risks associated with proximal lateral entry (e.g., damage to the axillary nerve) or distal medial entry (e.g., damage to the ulnar nerve or nail prominence). A distal posterior supracondylar entry point is also possible but requires additional preoperative planning with regard to patient positioning, a more proximal entry point to avoid impingement of the olecranon on the nail in extension, and avoidance of the ulnar nerve.</p><p><strong>Alternatives: </strong>The substantial potential for remodeling in pediatric patients permits nonoperative treatment of humeral fractures if specific age-related criteria for angulation and displacement are met. Generally accepted tolerances for nonoperative angulation and displacement are as follows: for patients <5 years old, ≤70° angulation and up to 100% displacement; for patients 5 to 12 years old, 40° to 70° angulation; and for patients >12 years old, ≤40° angulation and 50% apposition<sup>4</sup>.</p><p><strong>Rationale: </strong>The use of flexible nails is often preferred because of the healing potential of pediatric humeral shaft fractures, the ability of flexible nails to tolerate nonrigid fixation until osseous bridging occurs, the ability of the surgeon to avoid exposure of neurologic structures during surgery, and the benefit of avoiding physeal disruption. These factors make flexible nails a favorable option when compared with plate osteosynthesis or rigid i","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543153/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630258","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":"Surgery for Pediatric Trigger Finger.","authors":"Scott H Kozin, Eugene Park, Dan A Zlotolow","doi":"10.2106/JBJS.ST.23.00064","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00064","url":null,"abstract":"<p><strong>Background: </strong>Pediatric trigger finger (PTF) is an uncommon condition that is 10 times less common than trigger thumb. The Quinnell grade is utilized to quantify the extent of the triggering on a 4-point scale (0 = normal movement, 1 = uneven movement, 2 = actively correctable triggering, 3 = passively correctable triggering, and 4 = fixed deformity)<sup>1</sup>. Less extensive triggering can be treated nonoperatively with use of monitoring or splinting; however, the reported resolution rates are low, with only 30% of PTF cases treated nonoperatively achieving complete resolution<sup>1</sup>. Splinting has also been shown to not improve resolution rates in pediatric cases treated nonoperatively. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit<sup>2,3</sup>. Overall, PTF has been shown to have significantly higher rates of resolution when treated operatively (97.1%) versus nonoperatively (30.0%)<sup>2</sup>. PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single flexor digitorum superficialis (FDS) tendon slip. PTF treated with this technique predictably results in resolution with restoration of motion. The present video article demonstrates the surgical treatment of a 7-year-old with a locked right ring finger.</p><p><strong>Description: </strong>Operative steps include (1) general anesthesia, (2) tourniquet control, (3) loupe magnification, (4) neurovascular identification, (5) A3 and A1 pulley release, (6) excision of the ulnar slip of the FDS, (7) and simple closure.</p><p><strong>Alternatives: </strong>The primary alternative to this procedure is nonoperative treatment with continued monitoring and/or splinting.</p><p><strong>Rationale: </strong>PTF differs from pediatric trigger thumb. Simple release of the A1 pulley may not resolve the triggering, requiring additional excision of the ulnar slip of the FDS.</p><p><strong>Expected outcomes: </strong>Jia et al. reported that only 30% of nonoperatively treated cases of PTF achieved complete resolution, and splinting did not improve resolution rates<sup>3</sup>. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit. Overall, operatively treated PTF showed significantly higher rates of complete resolution compared with nonoperatively treated PTF (97.1% compared with 30.0%, respectively)<sup>3</sup>. Additionally, Cardon et al. reported residual triggering in 44% (8) of 18 cases of PTF treated with isolated A1 pulley release<sup>2</sup>. Bae et al. reported a 91% success rate (21 of 23) when PTFs were treated uniformly with A1 pulley release combined with FDS slip excision<sup>1</sup>. We conclude that PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single FDS tendon slip.</p><p><strong>Important tips: </strong>General anesthesia will limit","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543148/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630261","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 of Press-Fit Bone-Anchored Prosthesis After Implant Failure.","authors":"Jan Paul Frölke, Robin Atallah","doi":"10.2106/JBJS.ST.23.00005","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00005","url":null,"abstract":"<p><strong>Background: </strong>The present video article describes the revision of a bone-anchored prosthesis in patients who received an osseointegration implant after transfemoral amputation. Clinical follow-up studies have shown that approximately 5% of all patients who receive press-fit cobalt-chromium alloy femoral implants experience failure of the intramedullary stem component as a result of septic loosening or stem breakage. For stem breakage, stem diameter and the occurrence of infectious events were identified as risk factors. We began regularly utilizing the standard German press-fit endo-exo cast cobalt-chrome implant in 2009, but changed to the forged titanium version in 2014 (BADAL X, OTN Implants) because of the breakages associated with the former implant. No breakages have been reported since making the switch, and as such we currently still utilize the titanium implant. Current Commission Européenne-certified bone-anchored implants for transfemoral amputation include a screw-type stem and a press-fit stem. The revision technique demonstrated in the present article may apply to both types of implant system, but this video is limited to demonstrating the use of a press-fit implant. We describe the 3 stages of debridement, removal, and subsequent implantation of a bone-anchored prosthesis in a revision setting.</p><p><strong>Description: </strong>We perform this procedure in up to 3 stages, with 10 to 12 weeks between removal of the failed implant and implantation of the revision prosthesis. For stage 1, in case of mechanical failure, the broken remnants of the implant, which may dangle in the soft tissues, are removed. The stoma is debrided, after which spontaneous stoma healing is achieved. In cases of septic loosening, stage 1 includes removal of the implant by retrograde hammering, followed by multiple debridements with flexible reamers and jet lavage until negative cultures are obtained. In stage 2, the broken osseointegration implant is removed with use of a custom-made titanium water-cooled hollow drill. With the use of this drill, we have always been successful in removing the broken implant while maintaining sufficient bone stock for future implant revision. If the corer fails, a larger approach is needed to remove the implant. The corer drill should have a wall that is as thin but as robust as possible in order to avoid cortical perforation, and should be manufactured from a strong material in order to resist the usage against the implant. We utilized a steel corer when initially performing this procedure, which was frequently unsuccessful, necessitating a larger approach to remove the implant. We currently utilize a 3D-printed corer drill with integrated water-cooling system with greater success (Xilloc Medical). This corer is custom-made and needs about 6 weeks for designing and manufacturing. This tool is utilized in the present video article. Stage 3 includes revision implantation of an osseointegration prosthesis, u","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11498921/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142510021","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":"Extensor Tendon Repair.","authors":"Varun Arvind, Daniel Y Hong, Robert J Strauch","doi":"10.2106/JBJS.ST.23.00082","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00082","url":null,"abstract":"<p><strong>Background: </strong>Extensor tendon injuries are a common condition that hand surgeons must be prepared to treat. The area of extensor tendon injury can traditionally be broken down into 9 zones. Physical examination is the best way to diagnose extensor tendon injury with a loss of active extension in the injured digit. The tenodesis effect may be utilized to aid in diagnosis: wrist flexion should cause passive extension at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints if the extensor tendon is in continuity.</p><p><strong>Description: </strong>Repair of extensor tendon injuries depends on the zone of injury and the thickness of the tendon, which determines its ability to hold core sutures. For zone-I and II injuries, several \"figure of 8\" buried sutures can be utilized or a running type of suture may be employed. For zone-III to VII injuries, 1 or 2 core sutures and a supplementary running suture can be utilized.</p><p><strong>Alternatives: </strong>Several alternative techniques have been previously described. These include variations in the number of core strands, repair configuration, and suture caliber, as well as the use of epitendinous repair. Alternative treatments also include nonoperative treatment, which is typically reserved for partial tendon injuries and for patients who are unable to tolerate a surgical procedure.</p><p><strong>Rationale: </strong>The techniques that we describe are tailored to the thickness of the tendon. Running sutures are applicable to any zone, whereas core sutures are best utilized in zones III through VII. The running interlocking horizontal mattress technique has been found to be stiffer and faster to accomplish compared with the other techniques, and was found to have good to excellent clinical results in a study of lacerations in zones IV and V<sup>1,2</sup>.</p><p><strong>Expected outcomes: </strong>Repair of extensor tendon lacerations has demonstrated good long-term outcomes if performed in a timely manner after injury. A previous study showed good to excellent function in up to 64% of acute extensor tendon repairs, more fingers lost the ability to flex fully than lost the ability to extend<sup>3</sup>. Systematic reviews have suggested that dynamic rehabilitation may not provide superior long-term benefit compared with static splinting<sup>4</sup>.</p><p><strong>Important tips: </strong>The Elson test should be performed under a digital nerve block in order to properly assess the integrity of the central slip.In distal zone I and III injuries, suture anchors or bone tunnels may be utilized when there is no remaining tendon on the distal end of the laceration.When preparing the tendon ends for repair, it is important to handle the tendon delicately-preferably through the cut end of the tendon rather than the tendon itself.In zone-VII injuries, the injured tendon may lie beneath the extensor retinaculum. In such cases, windowing of the extensor retinacu","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11495684/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142510020","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":"Shortening Dome Osteotomy for the Correction of Coronal Plane Elbow Deformities.","authors":"Sumit Arora, Prajwal Gupta, Shahrukh Khan, Rahul Garg, Anant Krishna, Abhishek Kashyap","doi":"10.2106/JBJS.ST.23.00014","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00014","url":null,"abstract":"<p><strong>Background: </strong>Severe elbow deformities are common in developing countries because of neglect or as a result of prior treatment that achieved poor reduction. Various osteotomy techniques have been defined for the surgical correction of elbow deformities<sup>1-9</sup>. However, severe elbow deformities (>30°) pose a substantial challenge for surgeons because limited surgical options with high complication rates have been described in the literature. Shortening dome osteotomy is a useful method of correcting moderate-to-severe deformities and offers all of the advantages of previously described dome osteotomy without causing an undue stretching of neurovascular structures<sup>8,9</sup>.</p><p><strong>Description: </strong>The anesthetized patient is placed in a lateral decubitus position under tourniquet control with the operative limb up, the elbow in 90° of flexion, and the forearm draped free to hang over a bolster kept between the chest and the forearm. A posterior midline approach is utilized, with the incision extending from 6 cm proximal to the tip of the olecranon to 2 cm distal. The ulnar nerve is identified and protected during the entire surgical procedure. In case of severe (>30°) and long-standing cubitus varus deformity, anterior transposition of the ulnar nerve is additionally performed to prevent nerve stretching after the deformity correction. A midline triceps-splitting approach is utilized along with subperiosteal dissection to expose the metaphyseodiaphyseal region of the distal humerus. Alternatively, the operating surgeon may choose to utilize a triceps-sparing approach. Hohmann retractors are placed at the medial and lateral aspects of distal humerus to protect the anterior neurovascular structures. Careful extraperiosteal dissection and a transverse incision over the anterior periosteum are performed to facilitate rotation of the distal fragment, as the anterior periosteum is usually thickened in cases of long-standing deformities. The posterior midline axis of the humerus is marked on the skin. The dome of the olecranon fossa is identified, and the distal osteotomy line is made just proximal and almost parallel to the dome. The proximal osteotomy line is made parallel and 5 to 8 mm proximal to the distal osteotomy line, as any further larger shortening may affect the muscle length-tension relationship. The posterior cortices of both domes and of the medial and lateral supracondylar ridges are osteotomized with use of an ultrasonic bone scalpel (Misonix), which was set at 70% amplitude control and 80% irrigation control. Alternatively, the osteotomy may be made by making multiple drill holes and connecting them with a 5-mm sharp osteotome or with use of a small-blade oscillating saw. The osteotomy of the anterior cortex is completed under direct vision with use of a Kerrison upcutting rongeur, after the subperiosteal separation of bone in order to protect the surrounding soft tissues. Kirschner wires are ins","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11495691/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142510022","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":"Cementless Reverse Shoulder Arthroplasty Technique to Maximize Press-Fit Fixation with Humeral Matchstick Bone Grafts.","authors":"Alvin Ouseph, Eddie Y Lo, Paolo Montemaggi, Sumant G Krishnan","doi":"10.2106/JBJS.ST.23.00062","DOIUrl":"10.2106/JBJS.ST.23.00062","url":null,"abstract":"<p><strong>Background: </strong>Cementless reverse shoulder arthroplasty has become increasingly popular because of the improved implant design, porous ingrowth surface, and surgical techniques. When avoiding the risks of cement use, a press-fit arthroplasty stem that has been implanted may not feel immediately stable, especially if the medullary canal size is in between standard stem diameters. To help surgeons improve fixation and avoid overstuffing the medullary canal, we present the matchstick autograft augmentation technique. The use of humeral autograft, analogous to impaction grafting in hip arthroplasty, has been reported to have promising short-term outcomes<sup>2,3</sup>. This technique of using humeral autograft material, dubbed matchstick autografts because of their shape and size, allows for optimization of humeral stem stability with the option of smaller cementless humeral implants. By avoiding overstuffing of the medullary canal, this technique aims to reduce the incidences of intraoperative fracture, postoperative stress shielding, and potential implant loosening<sup>4-6</sup>.</p><p><strong>Description: </strong>Cementless reverse total shoulder arthroplasty is routinely performed via the anterosuperior approach<sup>7</sup>; however, a deltopectoral approach can be utilized if desired. The canal is sequentially broached with implant trials until the tactile feedback demonstrates axial and rotational stability. In cases in which tactile feedback during implantation demonstrates slight movement, the smaller implant size can be selected and augmented with matchstick autograft. An oscillating saw is utilized to cut the edges of the previously resected humeral head in order to expose the subchondral bone surface. Graft sticks about 20 mm in length and 1 to 3 mm in width are then fashioned. Humeral trials are then implanted with the matchstick grafts placed lengthwise alongside the humeral stem. Axial and rotational press-fit is again assessed. If adequate, the formal humeral implant is selected and implanted in position. As in conventional impaction grafting, the grafts are compressed to the side of the humeral canal, but they offer more corticocancellous structure than bone chips. This technique is applicable even in some fracture scenarios.</p><p><strong>Alternatives: </strong>When a specific press-fit humeral stem size does not achieve adequate stability, there are typically 3 surgical alternatives. First, a larger stem size can be selected. Second, the implant can be inserted deeper to achieve press-fit stability. Third, cement can be added to fill the medullary canal and create immediate stability.</p><p><strong>Rationale: </strong>When implanting the humeral prosthesis, the operating surgeon's primary goal is stem stability. When faced with lack of stability, the surgeon can select a larger humeral stem, risking stress shielding; implant the stem deeper, compromising length and risking humeral fracture; or consider a cemented i","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11444585/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142374017","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":"Anchorless Arthroscopic Transosseous Rotator Cuff Repair.","authors":"Eddie Y Lo, Alvin Ouseph, Raffaele Garofalo, Sumant G Krishnan","doi":"10.2106/JBJS.ST.23.00046","DOIUrl":"10.2106/JBJS.ST.23.00046","url":null,"abstract":"<p><strong>Background: </strong>Rotator cuff repair techniques have evolved over time. The original techniques were open procedures, then surgeons adopted arthroscopic repair procedures with anchors and implants. Today, rotator cuff repair has evolved to be performed as an arthroscopic transosseous technique that is again performed without the use of anchors.</p><p><strong>Description: </strong>In this video, the 5 essential steps of arthroscopic transosseous repair will be demonstrated. (1) Position the patient in either the beach chair or lateral decubitus position. (2) Utilize 4-portal arthroscopy, which allows a consistent vantage point while having 3 other portals for instrumentation. (3) Perform just enough bursectomy to expose the rotator cuff. (4) Anatomically reduce the rotator cuff anatomy where possible. (5) Triple-load the transosseous tunnels with high-strength sutures in order to maximize the biomechanical strength of the repair.</p><p><strong>Alternatives: </strong>Alternative surgical techniques include open rotator cuff repair and single and double-row rotator cuff repair using anchors.</p><p><strong>Rationale: </strong>The goal of any rotator cuff repair is to anatomically restore the rotator cuff. The fundamental principles include a strong initial biomechanical fixation, cuff footprint anatomy restoration, and maximization of biological factors to promote healing of the rotator cuff. Rotator cuff repair was originally performed as an open procedure, which allows for direct visualization of the tear and repair; however, open repair requires some level of deltoid splitting, which can potentially affect postoperative early mobilization. Single-row and double-row cuff repairs can both be performed arthroscopically. Proponents of the double-row procedure prefer that technique for its footprint restoration and stronger biomechanical fixation; however, the double-row procedure can result in overtensioning of the repair and can lead to medial-based rotator cuff failures. Proponents of the single-row procedure prefer that technique for its ease of operation, fewer implants, lower cost, and low repair tension; however, the single-row procedure fixes the tendon at a single point, limiting the repaired footprint, and can be associated with lower fixation strength. The arthroscopic transosseous rotator cuff repair achieves all of the above goals as it provides strong initial fixation and anatomic footprint restoration, which allows maximal patient biology for healing.</p><p><strong>Expected outcomes: </strong>There are numerous studies that can attest to the success of arthroscopic transosseous repair. Some of the benefits include decreased health-care costs and postoperative pain levels. In a 2016 study of 109 patients undergoing arthroscopic transosseous rotator cuff repair, Flanagin et al. reported a mean American Shoulder and Elbow Surgeons (ASES) score of 95 and a failure rate of 3.7% at mid-term follow-up<sup>1</sup>. Similarly, in a","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11444535/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142374016","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":"Inside-Out Repair of Medial Meniscal Ramp Lesions in Patients Undergoing Anterior Cruciate Ligament Reconstruction.","authors":"Jay Moran, Christopher M LaPrade, Robert F LaPrade","doi":"10.2106/JBJS.ST.22.00037","DOIUrl":"10.2106/JBJS.ST.22.00037","url":null,"abstract":"<p><strong>Background: </strong>Medial meniscal ramp lesions are disruptions at the meniscocapsular junction and/or meniscotibial attachment of the posterior horn of the medial meniscus, and occur in up to 42% of all acute anterior cruciate ligament (ACL) tears<sup>1,3-5</sup>. Ramp lesions are frequently missed because of the limited diagnostic sensitivity of magnetic resonance imaging (MRI), physical examination, and standard anterior compartment arthroscopic exploration<sup>4,6,7</sup>. Arthroscopic evaluation of ramp lesions often requires a modified Gillquist maneuver and/or a posteromedial accessory portal for adequate assessment of the posteromedial \"blind spot.\"<sup>4,8-10</sup> Clinically, ramp lesions are associated with increased preoperative anterior knee instability, which may increase the risk of ACL graft failure if left untreated<sup>6,13</sup>. Although long-term comparative data on ramp-repair techniques are limited, proper arthroscopic assessment and treatment is recommended for all patients with ramp lesions at the time of ACL reconstruction (ACLR)<sup>1-5</sup>. In the present video article, we demonstrate a systematic approach for the identification and assessment of ramp lesions and describe a mini-open inside-out arthroscopically assisted repair technique for unstable ramp lesions at the time of ACLR.</p><p><strong>Description: </strong>(1) The patient is placed in the supine position, and a contralateral leg holder is utilized to create more working room on the medial side. (2) Standard diagnostic arthroscopy is performed through anteromedial and anterolateral portals. (3) Next, with the arthroscope in the anterolateral portal, the scope is advanced through the intercondylar notch with the knee in 30° of flexion in order to inspect the posterior horn of the medial meniscus. Probing is directed both over the superior aspect of the posterior horn to assess for tears, separation, and/or displacement of the meniscocapsular junction, and under the inferior aspect of the posterior horn to assess the integrity of the meniscotibial attachment. (4) After confirmation of a ramp tear, an open dissection is carried out through the sartorial fascia, with blunt dissection performed anterior to the medial gastrocnemius and above the semimembranosus to create the posteromedial surgical site. (5) A suture-shuttling device is utilized, and the corresponding cannula is placed into the anterolateral portal and directed toward the tear under arthroscopic visualization from the anteromedial portal. (6) Next, the first needle is passed through the meniscus, and the second is delivered through the adjacent capsule to create a vertical or oblique suture pattern. The needles are retrieved from the posteromedial surgical site and promptly cut, and the sutures are tied. (7) Multiple sutures, both above (femoral) and below (tibial) the meniscus, are placed 3 to 5 mm apart in a similar fashion. (8) On completion of the repair, the meniscocapsular junc","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11444584/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142374018","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":"Cementless Long-Stem Reverse Total Shoulder Arthroplasty as Primary Treatment for Metadiaphyseal Humeral Shaft Fractures.","authors":"Austin Witt, Eddie Y Lo, Alvin Ouseph, Sumant G Krishnan","doi":"10.2106/JBJS.ST.23.00081","DOIUrl":"10.2106/JBJS.ST.23.00081","url":null,"abstract":"<p><strong>Background: </strong>The use of cementless diaphysis-fitting stems has been shown to be an effective treatment option for cases of metadiaphyseal humeral fracture. Complex metadiaphyseal fractures are those that extend below the surgical neck into the diaphysis, which can compromise the metaphyseal fixation of typical arthroplasty designs. The presently described surgical technique circumvents the potential risks associated with the use of cement while also permitting the treatment of common concomitant pathologies, such as arthritis and rotator cuff tendinopathy. Evidence supports the efficacy of this technique, showcasing consistent rates of healing, pain relief, and functional recovery, as well as acceptable complication rates compared with alternative surgical options.</p><p><strong>Description: </strong>The surgical procedure is performed with the patient in a modified beach chair position. A deltopectoral approach is utilized in order to expose the humerus and glenoid. In cases in which the tuberosity is fractured, it is carefully tagged for subsequent repair. The metadiaphyseal extension of the fracture is exposed, and reduction is performed with cerclage cable augmentation as needed. When direct reduction proves challenging, the humeral prosthesis is utilized to aid in reduction. Full-length humeral radiographs and a humeral sounder are utilized to guide the placement of a trial prosthesis, ensuring that the stem spans 2 canal diameters past the fracture and restores the appropriate humeral length. The medullary stem is utilized as support for fracture fragment reduction, with use of a combination of bone stitching and cerclage cables as required. Fractures with compromised proximal humeral bone stock can be further augmented with extramedullary strut allografts and cerclage cables. The allograft strut fixation acts as a neutralization plate to maintain rotational control. The joint is reduced, and fixation of the subscapularis and tuberosity is achieved with use of a transosseous suture technique. This technique combines the use of arthroplasty as well as standard osteosynthesis principles to treat complex metadiaphyseal humerus fractures.</p><p><strong>Alternatives: </strong>Nonoperative treatment may be indicated in a primary setting and represents a multifactorial patient-specific decision. Other surgical options include open reduction with internal fixation with plates or an intramedullary humeral nail, and cemented long-stem arthroplasty. If the fracture is too distal and the surgeon is unable to achieve a length of 2 canal diameters for distal fixation, alternative treatment strategies such as cementation may be required.</p><p><strong>Rationale: </strong>This procedure is most often performed in elderly patients with osteoporosis, who often also have comminuted fracture patterns and conditions such as glenohumeral arthritis or chronic rotator cuff pathology<sup>1,5,6,13,15</sup>. Whereas open reduction and internal fixa","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11415096/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142308732","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}