JBJS Essential Surgical Techniques最新文献

{"title":"Primary Repair of Complete Quadriceps Tendon Rupture with Extensor Mechanism Deficit.","authors":"Tyler J Thorne, Willie Dong, Thomas F Higgins, David L Rothberg, Justin M Haller, Lucas S Marchand","doi":"10.2106/JBJS.ST.23.00045","DOIUrl":"10.2106/JBJS.ST.23.00045","url":null,"abstract":"<p><strong>Background: </strong>Whereas partial quadriceps tendon ruptures may be treated nonoperatively if the extensor mechanism remains functional, complete ruptures require primary operative repair to achieve optimal functional results<sup>1,2</sup>. The 2 most common techniques are the use of transosseous tunnels and the use of suture anchors. The goal of these procedures is to reconstruct and restore mobility of the extensor mechanism of the leg.</p><p><strong>Description: </strong>The patient is positioned supine with the injured leg exposed. A midline incision to the knee is made over the quadriceps tendon defect, exposing the distal quadriceps and proximal patella. Irrigation is utilized to evacuate the residual hematoma, and the distal quadriceps and proximal patella are debrided of degenerative tissue. When utilizing transosseous tunnels, a nonabsorbable suture is passed full-thickness through the medial or lateral half of the quadriceps tendon in a locked, running pattern (i.e., Krackow). A second nonabsorbable suture is passed full-thickness through the other half of the tendon. There should then be 4 loose strands at the distal quadriceps. The anatomic insertion of the quadriceps tendon is roughened with a sharp curet to expose fresh cancellous bone. Three parallel bone tunnels are created along the longitudinal axis of the patella. The knee is placed in full extension, with a bump under the heel in order to provide slight recurvatum at the knee and to allow for a properly tensioned repair. In pairs, the free ends of the sutures are passed through the tunnels. The sutures are tensioned and tied together in pairs at the distal aspect of the patella. Alternatively, when utilizing suture anchors, Arthrex FiberTape is passed full-thickness through the medial or lateral half of the quadriceps tendon in a Krackow pattern. A second FiberTape is passed full-thickness through the other half of the tendon. There should then be 4 loose tails at the distal quadriceps. The 2 tails of the medial FiberTape are placed into a knotless Arthrex SwiveLock anchor; this step is repeated for the 2 lateral tails. The anatomic insertion of the quadriceps tendon is roughened to expose fresh cancellous bone. With use of a 3.5-mm drill, create 2 parallel drill holes along the longitudinal axis of the patella, with sufficient depth to bury the SwiveLock anchor. Unlike in the transosseous tunnel technique, these drill holes do not run the length of the patella. The holes are then tapped. Following irrigation, the anchors are tensioned into the bone tunnels, and extra tape is cut flush to the bone. For both techniques, additional tears in the medial and lateral retinacula are repaired if present.</p><p><strong>Alternatives: </strong>Alternatives include nonoperative treatment with use of a hinged knee brace; operative treatment with use of simple sutures; and augmentation with use of wire reinforcement, cancellous screws, the Scuderi technique, the Codivilla tech","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/PMC11415094/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142308733","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":"Microsurgical Techniques for Digital Nerve Injuries and Vascular Injuries.","authors":"Eric K Montgomery, Dawn M G Rask, David J Wilson, Benjamin F Plucknette, Casey M Sabbag","doi":"10.2106/JBJS.ST.23.00033","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00033","url":null,"abstract":"<p><strong>Background: </strong>Tension-free end-to-end digital nerve repair or reconstruction under loupe or microscope magnification are surgical treatment options for lacerated digital nerves in patients with multiple injured digits, injuries to the border digits, or injuries to the thumb, with the goal of improved or restored sensation and a decreased risk of painful traumatic neuroma formation. Different techniques for primary repair have been described and include epineurial sutures, nerve \"glues\" including fibrin-based gels<sup>1,2</sup>, biologic or synthetic absorbable or nonabsorbable nerve wraps or conduits, or a combination of these materials. Nerve \"glues\" have demonstrated decreased initial gapping at the repair site<sup>3</sup> and an increased tensile load to failure when utilized with a nerve wrap or conduit<sup>4,5</sup>. When there is a gap or defect in the nerve and primary repair is not feasible, nerve allograft and autograft provide similar results and are both better options than conduit reconstruction<sup>6</sup>. Concomitant or isolated digital vascular injuries may also be surgically treated with end-to-end repair in a dysvascular digit, with the goal of digit and function preservation. In the absence of complete circumferential injury or complete amputation, redundant or collateral flow may be present. Single digital artery injuries often do not need to be repaired because of the collateral flow from the other digital artery.</p><p><strong>Description: </strong>Digital nerve and vascular injuries are often found in the context of traumatic wounds. In such cases, surgical exploration is often required, with possible surgical extension of the wounds to facilitate identification of the neurovascular bundles. The proximal and distal ends of the transected nerve and/or artery are identified, and the traumatized ends are incised sharply, maintaining as much length as possible to facilitate end-to-end repair, interposition of a graft, and the use of a conduit. The proximal and distal aspects of the nerve and/or artery are appropriately mobilized by dissecting or releasing any scar tissue or soft tissue that may be tethering the structure. The defect is measured in the natural resting position of the digit. Gentle flexion of the digit may be performed to facilitate a primary repair in the setting of very small defects. Primary repair or reconstruction is selected, and an 8-0 or 9-0 nonabsorbable monofilament suture is utilized to anastomose the appropriate structures under magnification with use of a single or double stitch<sup>6</sup>. A tubular nerve conduit is placed prior to epineurial suturing, or a nerve conduit wrap is applied circumferentially around the repair site and augmented with a fibrin glue. The wound is then irrigated and closed in a standard fashion, as determined by the presence of any soft-tissue or structural injury.</p><p><strong>Alternatives: </strong>Alternatives to primary repair include the use of cond","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11392468/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142298047","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, Cruciate-Retaining Primary Total Knee Arthroplasty Using Conventional Instrumentation: Technical Pearls and Intraoperative Considerations.","authors":"Andrew B Harris, Julius K Oni","doi":"10.2106/JBJS.ST.23.00036","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00036","url":null,"abstract":"<p><strong>Background: </strong>Total knee arthroplasty (TKA) is commonly indicated for patients with severe tibiofemoral osteoarthritis in whom nonoperative treatment has failed. TKA is one of the most commonly performed orthopaedic surgical procedures in the United States and is associated with substantial improvements in pain, function, and quality of life<sup>1-3</sup>. The procedure may be performed with cemented, cementless, or hybrid cemented and cementless components<sup>4,5</sup>. Cementless TKA utilizing contemporary implant designs has been demonstrated to have excellent long-term survival and outcomes in patients who are appropriately indicated for this procedure<sup>5-8</sup>. The preference of the senior author is to perform this procedure with use of a cruciate-retaining implant design when feasible, and according to the principles of mechanical alignment to guide osseous resection. It should be noted that nearly all recent studies on outcomes following cementless TKA utilize traditional mechanical alignment<sup>7-9</sup>. Alternative alignment strategies, such as gap balancing and kinematic alignment, have not been as well studied in cementless TKA; however, preliminary short-term studies suggest comparable survivorship with restricted kinematic alignment and gap balancing compared with mechanical alignment in patients undergoing cementless TKA<sup>10,11</sup>.</p><p><strong>Description: </strong>Our preferred surgical technique for cementless TKA begins with the patient in the supine position. A thigh tourniquet is applied, and a valgus post is set at the level of the tourniquet. A flexion pad is also placed at 90°, with a bar at 20°. After sterile skin preparation and draping, a time-out is conducted, and the tourniquet is raised. The surgeon makes a medial parapatellar incision, which begins from 1 cm medial to the medial edge of the patella, extending from the tibial tubercle to 2 fingers above the proximal pole of the patella, using a knife and with the knee at 90° of flexion. Scissors are then used to find the fat above the fascia and dissect distally in the same plane. A knife is used to perform a high vastus-splitting, medial parapatellar arthrotomy. Pickups and scissors are then used to perform a partial medial synovectomy, and electrocautery is used to perform a medial peel. As the procedure progresses further medial, the infrapatellar fat pad is excised, followed by the anterior femoral synovial tissue. The surgeon then cuts through the anterior cruciate ligament footprint and origin with the knee flexed before sawing through the tibial spines to decrease the height of the tibial bone block. To prepare the femur, a step drill is inserted into the femoral canal, and the intramedullary alignment guide is placed with the distal femoral cutting guide set to 5° of valgus. The distal femoral cutting guide is then pressed firmly against the distal femur, making sure that the medial side is touching bone, and threaded pins are ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11392501/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142298046","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":"Open Bankart Repair with Subscapularis Split.","authors":"Alex M Meyer, Benjamin W Hoyt, Temitope Adebayo, Dean C Taylor, Jonathan F Dickens","doi":"10.2106/JBJS.ST.23.00050","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00050","url":null,"abstract":"<p><strong>Background: </strong>Anterior shoulder dislocations are a common injury, especially in the young, active, male population<sup>1</sup>. Soft-tissue treatment options for shoulder instability include arthroscopic or open Bankart repair, with open Bankart repair historically having lower rates of recurrence and reoperation, faster return to activity<sup>2-4</sup>, and a similar quality of life compared with arthroscopic repair<sup>5</sup>. More recent literature has suggested similar recurrence rates between arthroscopic and open procedures<sup>6</sup>. However, open Bankart repair may be indicated in cases of recurrent instability, especially if the patient participates in high-risk sports, because open repair can provide more capsular shift through the use of extra-capsular knots<sup>7</sup>. Performing a subscapularis split decreases the likelihood of subscapularis tendon avulsion following subscapularis tendon tenotomy and subsequent repair, as has been described in the literature<sup>8</sup>.</p><p><strong>Description: </strong>Indications for open Bankart repair include failure of arthroscopic Bankart repair, multiple dislocations, with subcritical bone loss. This surgical technique is performed via the deltopectoral approach. The subscapularis tendon is exposed and \"spared\" by splitting the fibers with use of a longitudinal incision between the upper 2/3 and lower 1/3 of the subscapularis. We begin the split medially near the myotendinous junction. Because the subscapularis becomes increasingly difficult to separate from the capsule as it tracks laterally, a RAY-TEC sponge is utilized to bluntly dissect. A T-shaped laterally based capsulotomy is made to expose the glenohumeral joint. The vertical aspect is made first, followed by the horizontal aspect from lateral to medial, extending to the labrum. A Fukuda retractor is placed through the split to hold the humeral head laterally. The labrum is elevated, and the glenoid is prepared with rasp. Then labrum is repaired with knotted suture anchors until it is secure. One anchor is utilized for each \"hour\" of the clock face, with a minimum of 3 anchors. The anchors are placed on the articular margin of the glenoid. Sutures are passed from the anchor through the capsule and tied outside the capsule. The capsulotomy is then repaired with use of a suture. The suture is utilized to pull the inferior portion superiorly. The inferior portion is taken superiorly, and the superior leaflet is imbricated over the top. Finally, an examination is performed to ensure that the humeral head can be translated to but not over the anterior and posterior glenoid rims. No repair of the subscapularis tendon insertion is required. The incision is closed with deep dermal and subcuticular suture.</p><p><strong>Alternatives: </strong>Nonoperative treatment options include rotator cuff and periscapular strengthening or immobilization. Operative treatment options include open Bankart repair with subscapularis ten","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11392470/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142298048","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":"Tripod Fixation of Periacetabular Metastatic Lesions Using the IlluminOss Device.","authors":"Nicole L Levine, William C Eward, Brian Brigman, Alan Alper Sag, Julia D Visgauss","doi":"10.2106/JBJS.ST.23.00070","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00070","url":null,"abstract":"<p><strong>Background: </strong>Percutaneous tripod fixation of periacetabular lesions is performed at our institution for patients with metastatic bone disease and a need for quick return to systemic therapy. We have begun to use the IlluminOss Photodynamic Bone Stabilization System instead of the metal implants previously described in the literature because of the success of the IlluminOss implant in fixing fragility fractures about the pelvis.</p><p><strong>Description: </strong>At our institution, the procedure is performed in the interventional radiology suite in order to allow for the use of 3D radiographic imaging and vector guidance systems. The patient is positioned prone for the transcolumnar PSIS-to-AIIS implant and posterior column/ischial tuberosity implant or supine for the anterior column/superior pubic ramus implant. Following a small incision, a Jamshidi needle with a trocar is utilized to enter the bone at the chosen start point. A hand drill is utilized to advance the Jamshidi needle according to the planned vector; alternatively, a curved or straight awl can be utilized. The 1.2-mm guidewire is placed and reamed. We place both the transcolumnar and posterior column wires at the same time to ensure that there is no interference. The balloon catheter for the IlluminOss is assembled on the back table and inserted according to the implant technique guide. The balloon is inflated and observed on radiographs in order to ensure that the cavity is filled. Monomer is then cured, and the patient is flipped for the subsequent implant. Following placement of the 3 IlluminOss devices, adjunct treatments such as cement acetabuloplasty or cryoablation can be performed.</p><p><strong>Alternatives: </strong>Alternative treatments include traditional open fixation of impending or nondisplaced acetabular fractures in the operating room, or percutaneous implant placement in the operating room. Implant placement may be performed with the patient in the supine, lateral, or prone position, depending on surgeon preference. Alternative implants include standard metal implants such as plates and screws, or cement augmentation either alone or with percutaneous screws. Finally, ablation alone may be an alternative option, depending on tumor histology.</p><p><strong>Rationale: </strong>Open treatment of acetabular fractures is a more morbid procedure, given the larger incision, increased blood loss, longer time under anesthesia, and increased length of recovery. Percutaneous fixation may be performed in either the operating room or interventional radiology suite, depending on the specific equipment setup at an individual institution. At our institution, we prefer utilizing the interventional radiology suite as it allows for more precise implant placement through the use of an image-based vector guidance system and 3D fluoroscopy to accurately identify safe corridors. The use of percutaneous fixation allows for faster recovery and earlier return to systemi","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11392467/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142298049","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":"Off-Label Use of Buttress Calcaneal Plate in Medial Distal Femoral Fracture to Augment Internal Fixation.","authors":"Túlio Vinícius de Oliveira Campos, Igor Guedes Nogueira Reis, Santiago Enrique Sarmiento Molina, Gustavo Scarpelli Martins da Costa, André Guerra Domingues, Paulo de Tarso Cardoso Gomes, Marco Antônio Percope de Andrade","doi":"10.2106/JBJS.ST.23.00088","DOIUrl":"10.2106/JBJS.ST.23.00088","url":null,"abstract":"<p><strong>Background: </strong>High-energy traumatic fractures represent a challenge for orthopaedic surgeons because there are a great variety of morphologic patterns and associated injuries<sup>1</sup>. Although the incidence is higher in developing countries, these fractures pose a major financial burden all over the world because of their considerable hospital length of stay, time away from work, rate of failure to return to work, complications, and cost of treatment<sup>2-4</sup>. Since the fracture patterns are so variable, some cases may have a lack of available specific osteosynthesis implants, despite recent advancements in implant engineering<sup>5</sup>. However, experienced surgeons are capable of using their knowledge and creativity to treat challenging lesions with use of preexisting plates while following the principles of fracture fixation and without compromising outcomes. In 2012, Hohman et al. described for the first time the use of a calcaneal plate to treat distal femoral fractures<sup>6</sup>. In 2020, Pires et al. further expanded the indications for use of a calcaneal plate<sup>5</sup>. This technical trick is widely utilized in our trauma center, especially in comminuted fractures around the knee. The present video article provides a stepwise description of the off-label use of a calcaneal plate in a medial distal femoral fracture.</p><p><strong>Description: </strong>The key principles of this procedure involve following common fundamentals during open reduction and internal fixation, approaching the fracture, preserving soft-tissue attachments of the comminution, and reducing the main fragments. Afterwards, the off-label use of a calcaneal plate adds the special feature of being able to contain fracture fragments with plate contouring. If necessary and if osseous morphology allows, bone grafting through the plate may also be performed.</p><p><strong>Alternatives: </strong>Multiple fixation implants can be utilized in medial distal femoral fractures. Surgeon-contoured plates (i.e., locking compression plates or low-contact dynamic compression plates), multiple mini-fragment plates, cortical screws alone, cannulated cancellous screws alone, or proximal humeral plates are among the alternatives<sup>5-9</sup>. However, the lack of specific implants for fixation of fractures involving the medial femoral condyle is notable, even in developed countries<sup>10</sup>.</p><p><strong>Rationale: </strong>The small-fragment calcaneal plate is a widely available and cheaper implant compared with locking compression plates, which is especially important in developing countries. Additionally, this plate has a lower profile, covers a greater surface area, and allows multiple screws in different planes and directions. The use of this plate represents a great technical trick for surgeons to contain comminution.</p><p><strong>Expected outcomes: </strong>Patient education regarding fracture severity is mandatory, and it is important to high","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11346833/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142082039","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":"Robot-Assisted Patellofemoral Arthroplasty.","authors":"Gloria Coden, Lauren Schoeller, Eric L Smith","doi":"10.2106/JBJS.ST.23.00042","DOIUrl":"10.2106/JBJS.ST.23.00042","url":null,"abstract":"<p><strong>Background: </strong>Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed<sup>2</sup>. The goal of the presently described procedure is to provide relief from patellofemoral arthritis pain while maintaining native knee kinematics<sup>2</sup>.</p><p><strong>Description: </strong>Patient radiographs are carefully reviewed for isolated patellofemoral arthritis in order to determine the appropriateness of robotic-assisted patellofemoral arthroplasty. Magnetic resonance imaging can be performed preoperatively to help confirm isolated patellofemoral arthritis. We perform this procedure with use of the MAKO Surgical Robot (Stryker). Preoperative computed tomography is performed to plan the bone resection, the size of the implant, and the positioning of the device. The steps of the procedure include (1) medial parapatellar arthrotomy, (2) intraoperative inspection to confirm isolated patellofemoral arthritis, (3) patellar resurfacing, (4) placement of optical arrays and trochlear registration, (5) trochlear resection, (6) trialing of implants, (7) removal of the optical array, (8) impaction of final implants, (9) confirmation of appropriate patellar tracking, and (10) closure.</p><p><strong>Alternatives: </strong>Alternatives to patellofemoral arthroplasty include standard nonoperative treatment, bicompartmental arthroplasty, total knee arthroplasty, tibial tubercle osteotomy, partial lateral facetectomy, and arthroscopy<sup>2</sup>.</p><p><strong>Rationale: </strong>Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed<sup>2</sup>. Patellofemoral arthroplasty may be superior to total knee arthroplasty because it helps treat pain that affects patient quality of life and activities of daily living while also preserving greater tibiofemoral bone stock<sup>2</sup>. We recommend against performing patellofemoral arthroplasty in patients with arthritis of the tibiofemoral joints<sup>2</sup>.</p><p><strong>Expected outcomes: </strong>In properly selected patients, outcomes include improvement in patient pain and function<sup>1</sup>. One study found that robotic-assisted patellofemoral arthroplasty may result in improved patellar tracking compared with non-robotic-assisted patellofemoral arthroplasty<sup>1</sup>; however, functional outcomes were found to be similar between procedures, and data for all non-robotic-assisted controls were retrospectively captured<sup>1</sup>.</p><p><strong>Important tips: </strong>Confirm isolated patellofemoral arthritis on radiographs and/or magnetic resonance imaging.Review the preoperative plan for appropriate positioning of the trochlear implant.○ Confirm coverage of the trochlear groove.○ Avoid medial overhang.○ Avoid lateral overhang.○ Avoid anterior femoral notching.○ Avoid impingement of the trochlear component into the notch.○ Avoid excessive promine","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11335334/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142037328","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intramedullary Nailing Technique for Proximal Humeral Fractures Using a Straight Antegrade Nail with Locking Tuberosity Fixation.","authors":"Brian P Davis, Libby A Mauter, Benjamin W Sears, Armodios M Hatzidakis","doi":"10.2106/JBJS.ST.23.00040","DOIUrl":"10.2106/JBJS.ST.23.00040","url":null,"abstract":"<p><strong>Background: </strong>Intramedullary straight nail fixation of proximal humeral fractures using a locking mechanism provides advantages compared with plating, including (1) less soft-tissue dissection, which preserves periosteal blood supply and soft-tissue attachments; (2) improved construct stability for comminuted fractures or osteopenic bone; and (3) shorter operative time for simpler fractures.</p><p><strong>Description: </strong>The patient is placed in the beach-chair position with the head of the bed elevated approximately 45°. The fracture is reduced with use of closed or percutaneous methods, ideally, or with an open approach if required. Temporary fragment fixation with percutaneous Kirschner wires can be utilized. A 1-cm incision is made just anterior to the acromioclavicular joint, overlying the zenith of the humeral head and in line with the diaphysis. A guide-pin is then placed through this incision and is verified to be centrally located and in line with the humeral diaphysis on fluoroscopic views. The guide-pin is advanced into the diaphysis. A cannulated 9-mm reamer is inserted over the guide-pin to create a starting position. The nail is then inserted, with adequate fragment reduction maintained until the proximal nail portion is buried under the subchondral humeral head. The proximal screw trajectory and alignment are checked fluoroscopically. The proximal locking screws are pre-drilled and inserted first using percutaneous drill sleeves through the radiolucent targeting jig. The screw is inserted through the guide and is advanced into the nail until appropriately seated. This process is then repeated for the other proximal screws as necessary. Finally, the distal diaphyseal screws are pre-drilled and inserted in a similar percutaneous fashion using the jig, and the jig is removed. Final orthogonal images are obtained. Copious irrigation of the incisions is performed and they are closed and dressed with a sterile dressing. The operative arm is placed in an abduction sling.</p><p><strong>Alternatives: </strong>Alternative treatment options for proximal humeral fractures include nonoperative treatment with use of a sling, percutaneous reduction and internal fixation with Kirschner wires, open reduction and internal fixation with a locking plate and screw construct, hemiarthroplasty, and anatomic or reverse total shoulder arthroplasty<sup>1</sup>.</p><p><strong>Rationale: </strong>The presently described technique for proximal humeral fracture fixation using a straight, antegrade, locking nail allows for minimal soft-tissue disruption, preserving vascularity and soft-tissue support and achieving angularly stable fixation in often osteopenic bone. The superior and in-line entry point avoids complications of rotator cuff injury and/or subacromial impingement. The proximal locking screws avoid complications of screw penetration or migration. This technique is appropriate for surgically indicated Neer 2-, 3-, and 4-part hum","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11340924/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142037327","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":"Talocalcaneal Coalition Resection with Local Fat Grafting and Flatfoot Reconstruction.","authors":"Kira K Tanghe, Shoran Tamura, Jayson Lian, J Nicholas Charla, Melinda S Sharkey, Alexa J Karkenny","doi":"10.2106/JBJS.ST.22.00060","DOIUrl":"10.2106/JBJS.ST.22.00060","url":null,"abstract":"<p><strong>Background: </strong>Talocalcaneal (TC) coalitions typically present in the pediatric population with medial hindfoot and/or ankle pain and absent subtalar range of motion. Coalition resection with fat interposition is well described for isolated tarsal coalitions<sup>1,2</sup>; however, patients with concomitant rigid flatfoot may benefit from additional reconstructive procedures. To address this, we employ the surgical technique of TC resection with local fat grafting and flatfoot reconstruction.</p><p><strong>Description: </strong>This procedure is described in 3 steps: (1) gastrocnemius recession and fat harvesting, (2) TC coalition resection with local fat interposition, and (3) peroneus brevis Z-lengthening and calcaneal lateral column lengthening osteotomy with allograft. A 3 to 4-cm posteromedial longitudinal incision is made at the distal extent of the medial head of the gastrocnemius muscle. The gastrocnemius tendon is identified, dissected free of surrounding tissue, and transected. Superficial fat is then harvested from this incision before wound closure. A 7-cm incision is made from the posterior aspect of the medial malleolus to the talonavicular joint. The neurovascular bundle and flexor tendons are dissected carefully from the surrounding tissue as a group and protected while the coalition is completely resected, and bone wax and the local fat are utilized at the resection site to prevent regrowth of the coalition. An approximately 7-cm incision is then made laterally and obliquely following the Langer lines and centered over the lateral calcaneus. The peroneal tendons are released from their sheaths, and the peroneus brevis is Z-lengthened. A calcaneal osteotomy is performed about 1.5 cm proximal to the calcaneocuboid joint and angled to avoid the anterior and middle subtalar facet joints. Two Kirschner wires are inserted retrograde across the calcaneocuboid joint, and the calcaneal osteotomy is opened. A trapezoid-shaped allograft bone wedge is impacted, and the Kirschner wires are advanced across into the calcaneus. The lengthened peroneus brevis tendon is repaired, and the wound is closed in a layered fashion.</p><p><strong>Alternatives: </strong>First-line treatment is nonoperative with orthotics and immobilization. Surgical options include coalition resection with or without calcaneal lengthening osteotomy, arthrodesis, or arthroereisis. Following coalition resection, various grafts can be utilized, including fat autografts, bone wax, or split flexor hallucis longus tendon<sup>3-6</sup>.</p><p><strong>Rationale: </strong>This procedure addresses TC coalition with concomitant rigid flatfoot. Resection alone may increase subtalar motion but does not correct a flatfoot deformity. Historically, surgeons performed arthrodesis or arthroereisis, but these are rarely performed in young patients. In patients with coalitions involving >50% of the posterior facet or preexisting degenerative changes, arthrodesis may be indica","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11299989/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141898611","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":"Revising Failed Reverse Total Shoulder Arthroplasty: Comprehensive Techniques for Precise Explantation of Well-Fixed Implants.","authors":"Eddie Y Lo, Alvin Ouseph, Jeffrey Sodl, Raffaele Garofalo, Sumant G Krishnan","doi":"10.2106/JBJS.ST.23.00051","DOIUrl":"10.2106/JBJS.ST.23.00051","url":null,"abstract":"<p><strong>Background: </strong>With the increased utilization of reverse total shoulder arthroplasty (RTSA), there has been a corresponding increase in the incidence of and demand for revision RTSA<sup>3</sup>. In cases in which the patient has undergone multiple previous surgeries and presents with well-fixed shoulder implants, even the most experienced shoulder surgeon can be overwhelmed and frustrated. Having a simple and reproducible treatment algorithm to plan and execute a successful revision surgery will ease the anxiety of a revision operation and avoid future additional revisions. The extraction techniques described here strive to preserve the humeral and glenoid anatomy, hopefully facilitating the reimplantation steps to follow.</p><p><strong>Description: </strong>The main principles of implant removal include several consistent, simple steps. In order to revise a well-fixed humeral implant, (1) identify the old implants; (2) create a preoperative plan that systematically evaluates the glenoid and humeral deficiencies; (3) prepare consistent surgical tools, such as an oscillating saw, osteotomes, and/or a tamp; (4) follow the deltoid; (5) dissect the soft tissue with a sponge; (6) dissect the bone with use of an osteotome; and (7) remove the humeral stem in rotation. In cases in which there is also a well-fixed glenoid implant, the surgical procedure will require additional steps, including (8) exposure of the anteroinferior glenoid, (9) disengagement of the glenosphere, and (10) removal of the glenoid baseplate in rotation.</p><p><strong>Alternatives: </strong>Alternatives to revision RTSA include nonoperative treatment, implant retention with conversion of modular components, extensile revision surgical techniques, and/or mechanical implant removal. With the advent of modular humeral and glenoid components, surgeons may choose to change the implant components instead of removing the entire humeral and glenoid implants; however, repeat complications may occur if the previous implant or implant position was not completely revised. When confronted with a tough humeral explantation, an extensile surgical approach involves creating a cortical window or humeral osteotomy to expose the humeral implant. This approach can compromise the humeral shaft integrity, leading to alternative and less ideal reconstruction implant choices, the use of cerclage wires, and/or the use of a strut graft, all of which may complicate postoperative mobilization. If glenoid implant removal is necessary, the glenosphere is removed first, followed by the underlying baseplate component(s). If the glenosphere is stuck or if screws are cold-welded, the use of a conventional mechanical extraction technique with a burr or diamond saw may be required; however, this may lead to additional metal debris and intraoperative sparks.</p><p><strong>Rationale: </strong>Revision RTSA can lead to high complication rates, ranging from 12% to 70%<sup>2</sup>, which will often requir","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11299987/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141898610","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}