JBJS Essential Surgical Techniques最新文献

{"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}

{"title":"Single-Stage Press-Fit Osseointegration of the Radius and Ulna for Rehabilitation After Trans-Forearm Amputation.","authors":"Jason S Hoellwarth, Kevin Tetsworth, Munjed Al Muderis","doi":"10.2106/JBJS.ST.23.00015","DOIUrl":"10.2106/JBJS.ST.23.00015","url":null,"abstract":"<p><strong>Background: </strong>Upper limb (UL) amputation is disabling. ULs are necessary for many domains of life<sup>1</sup>, and few effective motor and sensory replacements are accessible<sup>2</sup>. Approximately 41,000 people in the United States have UL amputation proximal to the fingers<sup>3</sup>, two-thirds of (all) traumatic amputations are UL<sup>4</sup>, and 80% of UL amputations are performed for trauma-related etiologies<sup>5</sup>. Socket prosthesis (SP) abandonment remains high because of the lack of sensation, limited prosthesis control, perceived weight, and difficulty comfortably wearing the SP<sup>6</sup>. Transcutaneous osseointegration<sup>7,8</sup> surgically inserts a bone-anchored implant, passed through a transcutaneous portal to attach a terminal device, improving amputee rehabilitation by reducing perceived weight, conferring osseoperception<sup>9</sup>, and increasing wear time<sup>10</sup>. Without the socket, all residual skin and musculature remain available for transcutaneous myoelectrodes. The present article describes single-stage radius and ulna press-fit osseointegration (PFOI) after trans-forearm amputation.</p><p><strong>Description: </strong>This technique resembles a lower-extremity PFOI<sup>11,12</sup>. Importantly, at-risk nerves and vessels are different, and implant impaction must be gentler as a result. The surgery is indicated for patients who are dissatisfied with SP rehabilitation or declining alternative rehabilitative options, and who are motivated and enabled to procure, train with, and utilize a forearm prosthesis. An engaged prosthetist is critical. Surgical steps are exposure, bone-end and canal preparation, first implant insertion (in the operative video shown, in the radius), purse-string muscle closure, confirmation that radius-ulna motion remains, performing the prior steps for the other bone (in the video, the ulna), and closure (including potential nerve reconstruction, soft-tissue contouring, and portal creation). Although the patient in the operative video did not require nerve procedures to address pain or to create targets for transcutaneous myoelectrodes, targeted muscle reinnervation or a regenerative peripheral nerve interface procedure could be performed following exposure.</p><p><strong>Alternatives: </strong>Alternatives include socket modification, bone lengthening and/or soft-tissue contouring<sup>13</sup>, Krukenberg-type reconstructions<sup>14</sup>, or accepting the situation. An alternative implant is a screw-type osseointegration implant. Our preference for press-fit implants is based on considerations such as our practice's 12-year history of >1,000 PFOI surgeries; that the screw-type implant requires sufficient cortical thickness for the threads<sup>15</sup>, which is compromised in some patients; the lower cost per implant; that the procedure is performed in 1 instead of 2 surgical episodes<sup>15,16</sup>; and the documented suitability of press-fit implants fo","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11233105/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141581090","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":"Modified Dunn Procedure for Open Reduction of Chronic Slipped Capital Femoral Epiphysis.","authors":"Klaus A Siebenrock, Simon D Steppacher, Kai Ziebarth, Joseph M Schwab, Lorenz Büchler","doi":"10.2106/JBJS.ST.23.00072","DOIUrl":"10.2106/JBJS.ST.23.00072","url":null,"abstract":"<p><strong>Background: </strong>Abnormal femoral head anatomy following moderate-to-severe slipped capital femoral epiphysis (SCFE) can lead to femoroacetabular impingement and premature osteoarthritis<sup>4-10</sup>. Surgical correction at the deformity site through capital reorientation has the potential to fully ameliorate this but has traditionally been associated with high rates of osteonecrosis<sup>11-15</sup>. The modified Dunn procedure has the potential to restore anatomy in hips with SCFE while protecting the blood supply to the femoral head.</p><p><strong>Description: </strong>A surgical dislocation of the hip is performed according to the technique described by Ganz et al.<sup>16</sup>. The remaining posterosuperior portion of the greater trochanter is trimmed to the level of the femoral neck by subperiosteal bone removal performed in an inside-out manner. The periosteum of the femoral neck is gradually elevated. The resulting soft-tissue flap, consisting of the retinaculum and external rotators, holds the blood vessels supplying the epiphysis. The femoral epiphysis is pinned in situ (in unstable cases) with threaded Kirschner wires, the ligamentum teres is transected, and the femoral head is dislocated. With the femoral neck exposed, the epiphysis is gradually mobilized from the metaphysis, allowing exposure of the residual femoral neck and inspection of any posteroinferior callus. To avoid tension on the retinacular vessels during reduction of the epiphysis, the posterior neck callus is completely excised. The remaining physis is removed with use of a burr while holding the epiphysis stable. The epiphysis is gently reduced onto the femoral neck, avoiding tension on the retinacular vessels. If tension is noted, the femoral neck is rechecked for residual callus, which is excised. If no callus is found, the neck may be carefully shortened in order to minimize tension. Epiphyseal fixation is achieved with use of a 3-mm fully threaded wire inserted antegrade through the fovea to the lateral cortex below the greater trochanter. A second wire is inserted retrograde under fluoroscopy. After reducing the hip, the capsule is closed and the greater trochanter is reattached with use of 3.5-mm cortical screws.</p><p><strong>Alternatives: </strong>Alternatives include nonoperative treatment, in situ fixation (e.g., pinning or screw fixation), gentle closed reduction with pinning, and triplanar trochanteric osteotomy (e.g., Imhauser or Southwick osteotomies).</p><p><strong>Rationale: </strong>In situ pinning of mild-to-moderate, stable SCFE yields good long-term results with low rates of osteonecrosis<sup>9</sup>. Treatment of higher-grade SCFE without reduction aims to avoid osteonecrosis and assumes that the proximal femoral deformity will remodel; however, the head-neck offset will remain abnormal, risking impingement and early-onset osteoarthritis<sup>5,8</sup>. The procedure described in the present article allows anatomic reduction of the ep","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11221854/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141556457","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":"Olecranon Osteotomy Exposure for Distal Humeral Fracture Treatment.","authors":"Nathan S Lanham, Jordan G Tropf, John D Johnson","doi":"10.2106/JBJS.ST.23.00041","DOIUrl":"10.2106/JBJS.ST.23.00041","url":null,"abstract":"<p><strong>Background: </strong>Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing<sup>1</sup>. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques<sup>1,2</sup>.</p><p><strong>Description: </strong>The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular \"bare area\" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner.</p><p><strong>Alternatives: </strong>Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate.</p><p><strong>Rationale: </strong>The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures<sup>1-3</sup>. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches<sup>3</sup>. OO has not been associated with triceps weakness, unlike some of the alternative techniques<sup>2</sup>.</p><p><strong>Expected outcomes: </strong>The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures<sup>4</sup>. Osteotomies united in all patients in 2 reported series, totaling 84 cases<sup>1,2</sup>. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients<sup>1,2</sup>.</p><p><strong>Important tips: </strong>Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the O","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11221848/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141556458","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":"Metallic Lateralized-Offset Glenoid Reverse Shoulder Arthroplasty.","authors":"Emanuele Maggini, Mara Warnhoff, Florian Freislederer, Markus Scheibel","doi":"10.2106/JBJS.ST.23.00067","DOIUrl":"10.2106/JBJS.ST.23.00067","url":null,"abstract":"<p><strong>Background: </strong>Metallic lateralized-offset glenoid reverse shoulder arthroplasty (RSA) for cuff tear arthropathy combines the use of a metallic augmented baseplate with a metaphyseally oriented short stem design that can be applied at a 135° or 145° neck-shaft angle, leading to additional lateralization on the humeral side. Lateralization of the center of rotation decreases the risk of inferior scapular notching and improves external rotation, deltoid wrapping, residual rotator cuff tensioning, and prosthetic stability<sup>1-4</sup>. Metallic increased-offset RSA (MIO-RSA) achieves lateralization and corrects inclination and retroversion while avoiding graft resorption and other complications of bony increased-offset RSA (BIO-RSA)<sup>5-8</sup>. Reducing the neck-shaft angle from the classical Grammont design, in combination with glenoid lateralization, improves range of motion<sup>9,10</sup> by reducing inferior impingement during adduction at the expense of earlier superior impingement during abduction<sup>2,11</sup>. Lädermann et al.<sup>12</sup> investigated how different combinations of humeral stem and glenosphere designs influence range of motion and muscle elongation. They assessed 30 combinations of humeral components, as compared with the native shoulder, and found that the combination that allows for restoration of >50% of the native range of motion in all directions was a 145° onlay stem with a concentric or lateralized tray in conjunction with a lateralized or inferior eccentric glenosphere. In addition, the use of a flush-lay or a slight-onlay stem design (like the one utilized in the presently described technique) may decrease the risk of secondary scapular spine fracture<sup>13,14</sup>. The goal of this prosthetic design is to achieve an excellent combination of motion and stability while reducing complications.</p><p><strong>Description: </strong>This procedure is performed via a deltopectoral approach with the patient in the beach-chair position under general anesthesia combined with a regional interscalene nerve block. Subscapularis tenotomy and capsular release are performed, the humeral head is dislocated, and any osteophytes are removed. An intramedullary cutting guide is placed for correct humeral resection. The osteotomy of the humeral head is performed in the anatomical neck with an inclination of 135° and a retroversion of 20° to 40°, depending on the anatomical retroversion. The glenoid is prepared as usual. The lateralized, augmented baseplate is assembled with the central screw and the baseplate-wedge-screw complex is placed by inserting the screw into the central screw hole. Four peripheral screws are utilized for definitive fixation. An eccentric glenosphere with inferior overhang is implanted. The humerus is dislocated, and the metaphysis is prepared. Long compactors are utilized for proper stem alignment, and an asymmetric trial insert is positioned before the humerus is reduced. Stability and ra","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11221860/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141556456","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":"Puncture Capsulotomy Technique During Hip Arthroscopy.","authors":"Stephen M Gillinov, Bilal S Siddiq, Nathan J Cherian, Scott D Martin","doi":"10.2106/JBJS.ST.23.00061","DOIUrl":"10.2106/JBJS.ST.23.00061","url":null,"abstract":"<p><strong>Background: </strong>A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy<sup>1,2</sup>. Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension<sup>3</sup>. Thus, these approaches may introduce capsuloligamentous instability<sup>1,4-7</sup> and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification<sup>5,8-12</sup>. Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure<sup>6,13</sup>, avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals.</p><p><strong>Description: </strong>Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post<sup>14</sup>. Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury<sup>15</sup>. Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed<sup>5</sup>.</p><p><strong>Alternatives: </strong>Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure<sup>1,2,4,6,7,16</sup>. Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability<sup>1,4-7,17</sup>.</p><p><strong>Rationale: </strong>The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11186812/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141433029","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":"Dual Plating of Distal Femoral Fractures.","authors":"Tyler J Thorne, Chase T Nelson, Leonard S J Lisitano, Thomas F Higgins, David L Rothberg, Justin M Haller, Lucas S Marchand","doi":"10.2106/JBJS.ST.23.00018","DOIUrl":"10.2106/JBJS.ST.23.00018","url":null,"abstract":"<p><strong>Background: </strong>Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse.</p><p><strong>Description: </strong>Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed.</p><p><strong>Alternatives: </strong>Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace<sup>1</sup>. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate.</p><p><strong>Rationale: </strong>Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength<sup>2,3</sup>. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone<sup>4-7</sup>. Adjunctive","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11186817/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141433028","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":"Press-Fit Bone-Anchored Prosthesis for Individuals with Transtibial Amputation.","authors":"Jan Paul M Frölke, Robin Atallah, Ruud Leijendekkers","doi":"10.2106/JBJS.ST.23.00006","DOIUrl":"10.2106/JBJS.ST.23.00006","url":null,"abstract":"<p><strong>Background: </strong>This video article describes the use of bone-anchored prostheses for patients with transtibial amputations, most often resulting from trauma, infection, or dysvascular disease. Large studies have shown that about half of all patients with a socket-suspended artificial limb experience limited mobility and limited prosthesis use because of socket-related problems. These problems occur at the socket-residual limb interface as a result of a painful and unstable connection, leading to an asymmetrical gait and subsequent pelvic and back pain. In almost all of these cases, a bone-anchored prosthesis may result in substantial improvements in mobility and quality of life.</p><p><strong>Description: </strong>This technique is preferably performed in a single-stage procedure. Preoperative implant planning is imperative when designing the custom-made implant (BADAL X, OTN Implants). These images should be visible on screen in the operating room throughout the procedure to guide the surgeon. The patient is positioned with the knee on a silicone cushion. The planned soft-tissue resection is marked, after which the resection of all layers is performed, including large nerves and neuromas, with high cuts performed under traction. Exposure of the residual bone following revision osteotomy is carried out according to the design. The medullary canal is prepared and perpendicular cutting of the tibial and fibular remnant are performed, with the latter cut at a level 1 to 2 cm higher than the former. The intramedullary component is inserted under fluoroscopic guidance, after which the distal end of the tibia is prepared utilizing the typical drop shape. Two transverse locking screws are inserted with the standard \"freehand\" technique. The soft tissues are contoured and closed over the implant, after which the stoma is created and the dual cone is mounted. Finally, pressure bandages are applied, and postoperative imaging is performed. After the surgical procedure, most patients stay 1 or 2 nights in the hospital, depending on the magnitude of the surgery (e.g., bilateral implantation of a bone-anchored implant) and the patient's comorbidities.</p><p><strong>Alternatives: </strong>Simultaneous major leg amputation and bone-anchored prosthesis implantation is not advocated as treatment. First, a rehabilitation program with a socket-suspended prosthesis should be completed before patients can apply for a bone-anchored prosthesis. After rehabilitation, satisfaction with a prosthetic socket may be adequate, thereby not indicating the need for a bone-anchored prosthesis. Contraindications for bone-anchored implant surgery include severe diabetes (with complications), severe bone deformity, immature bones, bone diseases (i.e., chronic infection or metastasis), current chemotherapy, severe vascular diseases, pain without a clear cause, obesity (body mass index >30 kg/m<sup>2</sup>), and smoking.</p><p><strong>Rationale: </strong>Approximately h","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11781768/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143068451","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}