JBJS Essential Surgical Techniques最新文献

{"title":"Intraosseous Administration of Medications in Total Knee Arthroplasty: An Opportunity for Improved Outcomes and Superior Compliance.","authors":"Katharine D Harper, Stephen J Incavo","doi":"10.2106/JBJS.ST.22.00071","DOIUrl":"10.2106/JBJS.ST.22.00071","url":null,"abstract":"<p><strong>Background: </strong>Vancomycin is a prophylactic antibiotic with bactericidal activity against methicillin-resistant <i>Staphylococcus aureus</i> that is commonly used in total joint replacement surgery<sup>1</sup>. In total knee arthroplasty (TKA), intraosseous infusions administered following tourniquet inflation have demonstrated improved local vancomycin concentrations with decreased systemic absorption<sup>1-3</sup>. This administration method results in no adverse reactions locally, as well as equivalent or lower systemic complications compared with other vancomycin administration methods<sup>4</sup>. Intraosseous infusion of prophylactic surgical antibiotics has been shown to be more effective than intravenous administration, with the potential for reduction in surgical site infections<sup>5</sup>.</p><p><strong>Description: </strong>After the operative extremity has been prepared and draped in the usual sterile fashion, the limb is elevated and the tourniquet is inflated to 250 mm Hg. Prior to incision, an intraosseous vascular access system (Arrow EZ IO; Teleflex) is inserted with a power driver into the tibial tubercle region. The desired volume of the medication is injected into the tibia. The device is removed and then inserted into the anterior distal femur, centrally, just proximal to the patella. Following this, the desired volume of the medication is injected into the femur. The device is then removed, and the TKA proceeds according to the surgeon's standard technique.</p><p><strong>Alternatives: </strong>Alternative administration methods for vancomycin include other invasive methods and noninvasive delivery. Intravenous delivery is the most traditional form of medication delivery<sup>1,2</sup>. Additional alternatives include noninvasive placement of antibiotic powder into the wound and localized soft-tissue injections of desired medications<sup>1-3</sup>.</p><p><strong>Rationale: </strong>Opting to administer antibiotics and other medications intraosseously (rather than intravenously) has shown improved compliance with the golden-hour rule of preoperative antibiotics (especially for vancomycin)<sup>4</sup>, lower incidences of acute kidney injury or adverse systemic effects<sup>4</sup>, and improved local tissue concentrations of all medications delivered<sup>1-3</sup>.</p><p><strong>Expected outcomes: </strong>Expected outcomes include improved local tissue concentrations with decreased systemic concentrations of vancomycin and with no reported local or systemic adverse reactions, as well as the potential for improved infection prevention<sup>1-5</sup>. Literature regarding the use of intraosseous infusion during TKA has been thorough and very well received. A prospective, randomized study by Young et al. evaluated local and systemic concentrations of vancomycin following intraosseous versus intravenous administration. The authors found that low-dose intraosseous vancomycin resulted in tissue concentrations equal t","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11108349/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141080827","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Arthroscopic Reduction and Fixation of a Pipkin Type-I Femoral Head Fracture.","authors":"Alessandro Aprato, Ruben Caruso, Michele Reboli, Matteo Giachino, Alessandro Massè","doi":"10.2106/JBJS.ST.23.00073","DOIUrl":"10.2106/JBJS.ST.23.00073","url":null,"abstract":"<p><strong>Background: </strong>This video article describes the technique for arthroscopic reduction and fixation of Pipkin type-I fractures.</p><p><strong>Description: </strong>Surgery is performed with the patient in a supine position, with free lower limbs, on a radiolucent table. Arthroscopic superior and anterolateral portals are made similarly to the portals created to evaluate the peripheral compartment during an outside-in (ballooning) technique.<sup>1</sup> An additional medial portal is subsequently created in order to aid in reduction and screw placement. The medial portal is created in abduction and external rotation of the hip (i.e., the figure-4 position). The adductor tendon is identified, and the portal is then safely positioned posteriorly to its margin, approximately 4 to 5 cm distal to the inguinal fold, avoiding the saphenous vein (usually identified with an ultrasound scan). The fragment is mobilized, debrided, and then reduced with use of a microfracture awl or a large Kirschner wire (used as a joystick). Following reduction, temporary fixation is performed with use of long Kirschner wires under direct visualization and fluoroscopic guidance. If reduction is satisfactory, definitive fixation can be performed with use of 4.5-mm headless screws through the medial portal. All steps of fragment reduction and fixation are performed through the medial portal, with the patient in the figure-4 position. Once the screws are placed, a final dynamic arthroscopic and fluoroscopic check is performed.</p><p><strong>Alternatives: </strong>In Pipkin type-I fractures, surgery is recommended when the femoral head fragment is large (exceeding 15% to 20% of the femoral head volume) and displaced (by >3 mm). In such cases, if untreated, spontaneous evolution to osteoarthritis may occur. For fragments smaller than 10% to 15% of the femoral head volume, arthroscopic removal is often the best choice<sup>2</sup>. Several approaches (e.g., Smith-Petersen, modified Hueter, Kocher-Langenbeck, and surgical safe dislocation) have been proposed for reduction and fixation, with surgical safe dislocation being the most versatile because of the uniquely complete visualization of the femoral head<sup>3</sup>.</p><p><strong>Rationale: </strong>The arthroscopic reduction and fixation technique for a non-comminuted Pipkin type-I fracture holds the intrinsic advantages of being less invasive than open surgery in terms of surgical exposure, and having less blood loss, infection risks, and wound complications. Arthroscopy allows direct visualization of the fragment and its reduction surface, along with removal of articular loose bodies and debridement. The surgical time is influenced by the surgeon's experience, but often is no longer than with an open procedure. In the few studies assessing the use of this technique, the rates of osteonecrosis and heterotopic ossification are lower than with open techniques. It is worth noting that the studies assessing the use o","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-05-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11104723/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141077161","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":"Thighplasty at the Time of Stage-1 Bone-Anchored Osseointegration Surgery.","authors":"Colin J Harrington, Gunel Guliyeva, Joel L Mayerson, Benjamin K Potter, Jonathan A Forsberg, Jason M Souza","doi":"10.2106/JBJS.ST.23.00004","DOIUrl":"10.2106/JBJS.ST.23.00004","url":null,"abstract":"<p><strong>Background: </strong>For patients with transfemoral amputations and difficulty tolerating conventional socket-based prostheses, osseointegrated (OI) implants have enabled increased prosthetic use, improved patient satisfaction, and shown promising functional outcomes<sup>1,2</sup>. Although the use of OI implants effectively eliminates the soft-tissue-related challenges that have plagued socket-based prostheses, the presence of a permanent, percutaneous implant imparts a host of new soft-tissue challenges that have yet to be fully defined. In patients undergoing OI surgery who have redundant soft tissue, we perform a thighplasty to globally reduce excess skin and fat, tighten the soft-tissue envelope, and improve the contour of the residual limb.</p><p><strong>Description: </strong>First, the orthopaedic surgical team prepares the residual femur for implantation of the OI device. After the implant is inserted, the residual hamstrings and quadriceps musculature are closed over the end of the femur, and the subcutaneous tissue and skin are closed in a layered fashion. Although the anatomic location and amount of excess soft tissue are patient-dependent, we perform a standard pinch test to determine the amount of soft tissue that can be safely removed for the thighplasty. Once the proposed area of resection is marked, we proceed with longitudinal, sharp dissection down to the level of the muscular fascia. At this point, we use another pinch test to confirm the amount of soft-tissue resection that will allow for adequate resection without undue tension<sup>3</sup>. Excess subcutaneous fat and skin are carefully removed along the previously marked incisions, typically overlying the medial compartment of the thigh in the setting of patients with transfemoral amputations. The thighplasty incision is closed in a layered fashion over 1 or 2 Jackson-Pratt drains, depending on the amount of resection.</p><p><strong>Alternatives: </strong>Depending on the amount of redundant soft tissue, thighplasty may not be necessary at the time of OI surgery; however, in our experience, excess soft tissue surrounding the transcutaneous aperture can predispose the patient to increased shear forces at the aperture, increased drainage, and increased risk of infection<sup>4</sup>.</p><p><strong>Rationale: </strong>Although superficial infectious complications are most common following OI surgery, the need for soft-tissue refashioning and excision is one of the most common reasons for reoperation<sup>1,5</sup>. Our group has been more aggressive than most in our use of a vertical thighplasty procedure to globally reduce soft-tissue motion in the residual limb to avoid reoperation.</p><p><strong>Expected outcomes: </strong>Although much of the OI literature has focused on infectious complications, recent studies have demonstrated reoperation rates of 18% to 36% for redundant soft tissue following OI surgery<sup>1,5</sup>. We believe that thighplasty at the time of O","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10956957/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140185874","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":"Techniques to Remove Press-Fit Osseointegration Implants.","authors":"Germane Ong, Jason Shih Hoellwarth, Kevin Testworth, Munjed Al Muderis","doi":"10.2106/JBJS.ST.23.00017","DOIUrl":"10.2106/JBJS.ST.23.00017","url":null,"abstract":"<p><strong>Background: </strong>Transcutaneous osseointegration for amputees (TOFA) has proven to consistently, significantly improve the quality of life and mobility for the vast majority of amputees, as compared with the use of a socket prosthesis<sup>1,2</sup>. As with any implant, situations such as infection, aseptic loosening, or implant fracture can occur, which may necessitate hardware removal. Although it may eventually occur, to date no osseointegration implant has ever required removal in the setting of periprosthetic fracture. Since TOFA implants are designed to facilitate robust bone integration, removal can be challenging. Even in cases in which portions of the implant are loose, other areas of the implant may remain strongly integrated and resist removal. Further, there can be cases in which an implant fractures, leaving the residual portion of the implant in place without the interface for an extraction tool. Although the outcomes of revision osseointegration has not been the primary focus of any publication, the fact that revision can be necessary and generally succeeds in restoring similar mobility has been documented<sup>3-5</sup>. As with any hardware removal, preserving healthy tissue and avoiding iatrogenic injury are critically important. This article demonstrates several techniques to remove press-fit osseointegration implants that we have found safe and effective.</p><p><strong>Description: </strong>The procedure is performed with the patient in the supine position and with the affected extremity prepared and draped in a typical sterile fashion. The use of a tourniquet can help reduce blood loss, but it may be safer to not use a tourniquet during the portions of the procedure that create increased or prolonged bone thermal exposure, such as during reaming or drilling. If patients are clinically stable, withholding antibiotics until cultures are obtained may improve diagnostic yield. The implant removal technique should proceed from conservative to aggressive, as necessary: slap hammer, thin wire-assisted slap hammer, and extended osteotomy. Trephine reaming is discouraged because of the need for and difficulty of removing the dual cone interface portion of the implant, along with the extensive damage often caused to the surrounding bone during reaming, which can be avoided with the osteotomy technique.</p><p><strong>Alternatives: </strong>It is important to emphasize that most infections related to transcutaneous osseointegration do not require implant removal; the use of antibiotics alone or soft-tissue and/or limited bone debridement is sufficient to resolve infection in the majority of cases. If a patient has a non-infectious indication for removal (such as a loose implant) but declines surgery, activity modification with close observation may be reasonable. If a patient has an infectious indication for removal but declines surgery, very close observation must be maintained to avoid potential osteomyelitis. The use of ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-03-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10914227/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140050673","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":"\"Coronal Split/Overlap Repair\" Patellar Tendon Shortening in Skeletally Immature Patients.","authors":"Mohamed Kenawey, Emmanouil Morakis, Sattar Alshryda","doi":"10.2106/JBJS.ST.23.00030","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00030","url":null,"abstract":"<p><strong>Background: </strong>\"Coronal split/overlap repair\" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy.</p><p><strong>Description: </strong>The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks.</p><p><strong>Alternatives: </strong>Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap<sup>1-3</sup>. Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication<sup>4</sup>, (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened<sup>2,5-7</sup>, and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened<sup>8,9</sup>.</p><p><strong>Rationale: </strong>The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises.</p><p><strong>Expected outcomes: </strong>Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase<sup>1,3,8</sup>. Reported complications with this technique were mainly superficial infection.</p><p><strong>Important tips: </strong>Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximall","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-02-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10883634/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139975494","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":"Minimally Invasive Resection of a Large Subcutaneous Lipoma: The 2.5-cm (1-inch) Method.","authors":"Akio Sakamoto, Shuichi Matsuda","doi":"10.2106/JBJS.ST.23.00012","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00012","url":null,"abstract":"<p><strong>Background: </strong>Lipomas are benign and are usually located in subcutaneous tissues. Surgical excision frequently requires an incision equal to the diameter of the lipoma. However, small incisions are more cosmetically pleasing and decrease pain and/or hypoesthesia at the incision. A \"fibrous structure\" occurs inside the lipoma and is characterized by a low-intensity signal on T1-weighted magnetic resonance images. The \"fibrous structure\" is actually retaining ligaments with a normal structure that intrudes from the periphery<sup>1</sup>. Retaining ligaments are fibrous structures that are perpendicular to the skin and tether it to underlying muscle fascia.</p><p><strong>Description: </strong>The peripheral border of the tumor is marked with a surgical pen preoperatively. Under general anesthesia, a 2.5-cm (1-inch) incision is made with a surgical knife, cutting into the tumor through the capsule-like structure. Distinguishing the tumor from the overlying adipose tissue can be difficult. Use of only local anesthesia may be possible when the number of retaining ligaments is low, such as for lesions involving the upper arm. A central incision is preferred; a peripheral incision is possible but can make the procedure more difficult. Detachment of the lipoma from the retaining ligaments is performed bluntly with a finger, which allows pulling the tumor out between the retaining ligaments. We use hemostat forceps (Pean [or Kelly] forceps) to facilitate blunt dissection. Hemostat forceps are usually utilized for soft-tissue dissection and for clamping and grasping blood vessels. Prior to blunt dissection, dissection with Pean forceps can be performed over the surface of the tumor, but tearing the tumor apart can also be useful to allow subsequent finger dissection of the lipoma from the retaining ligament not only from outside but also from inside the lipoma. The released lipoma is extracted in a piecemeal fashion with Pean forceps or by squeezing the location to cause the lipoma to extrude through the incision. The retaining ligament is preserved as much as possible, but lipomas are sometimes completely trapped by the retaining ligament. In such cases, partially cutting the ligament with scissors to release the tumor can be useful during extraction. Detachment and extraction are repeated until the tumor is completely resected, which can be confirmed visually through the incision because of the resulting skin laxity. Remaining portions of a single lipoma are removed with Pean forceps. The residual lipomas may be located deep to the retaining ligament. Adequate lighting and visualization through a small incision is useful. After the skin is sutured, a Penrose drain is optional.</p><p><strong>Alternatives: </strong>The squeeze technique utilizing a small incision over the lipoma is a well-described technique for forearm or leg lipomas, but is often not successful for large lipomas, especially those in the shoulder. The squeeze technique is","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-02-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10883633/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139973867","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":"Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.","authors":"J Terrence Jose Jerome","doi":"10.2106/JBJS.ST.23.00048","DOIUrl":"10.2106/JBJS.ST.23.00048","url":null,"abstract":"<p><strong>Background: </strong>The flexor pronator slide is an effective treatment option for ischemic contracture and contracture related to spastic cerebral palsy, but little is known about the use of the flexor pronator slide in other non-ischemic contractures. I propose a flexor pronator slide to simultaneously correct wrist and finger flexor contractures and preserve the muscle resting length. To avoid overcorrection of the deformity, I propose the use of a wide-awake local anesthesia with no tourniquet (WALANT) procedure, in which the patient is able to continually assist the surgeon in assessing the contracture release and improvement in finger movement. Additionally, the WALANT flexor pronator slide releases the specific muscles responsible for wrist and finger contractures (i.e., the flexor digitorum profundus, flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis, and pronator teres), sparing the intact finger functions.</p><p><strong>Description: </strong>The patient in the video received a WALANT injection of 1% lidocaine with 1:100,000 epinephrine and 8.4% sodium bicarbonate in the operating room, and surgery was started 30 minutes after the injection to obtain the maximum hemostatic effect<sup>1</sup>. The injections were performed from proximal to distal along the volar-ulnar skin markings from the distal upper arm to the distal third of the forearm. The total volume utilized in this patient was <7 mg/kg (approximately 100 mL). A 25 or 27-gauge needle was infiltrated under the skin at the medial aspect of the elbow and in the distal and proximal forearm fascia. A total of 25 to 40 mL anesthetic was injected at each site, which serves to numb the ulnar nerve. over the volar-radial and volar side of the mid-forearm and distal forearm to numb the median nerve. For the WALANT procedure, an additional 8 mg of dexamethasone was added as an adjuvant to prolong the analgesia and the duration of the nerve block. The skin incision was made over the ulnar border of the forearm, extending proximally just posterior to the medial epicondyle up to the distal third of the upper arm. The origin of the flexor carpi ulnaris was elevated first, then the flexor digitorum profundus and flexor digitorum superficialis were mobilized from the ulna and the interosseous membrane. The release continued in an ulnar-to-radial direction. The patient was awake throughout the procedure, so that the improvement in the contracture could be better assessed. Further dissection around the ulnar nerve was done to release the arcade of Struthers, the Osborne ligament, and the triceps fascia in order to prevent ulnar nerve kinking during anterior transposition. The medial epicondyle was identified, and the flexor pronator wad was released meticulously without joint capsule perforation and medial collateral ligament injury. The muscles were finally examined for contracture in full wrist and finger extension, and further release was performed if remai","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-02-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10852377/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139724345","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":"Regenerative Peripheral Nerve Interface (RPNI) Surgery for Mitigation of Neuroma and Postamputation Pain.","authors":"Christine Sw Best, Paul S Cederna, Theodore A Kung","doi":"10.2106/JBJS.ST.23.00009","DOIUrl":"10.2106/JBJS.ST.23.00009","url":null,"abstract":"<p><strong>Background: </strong>A neuroma occurs when a regenerating transected peripheral nerve has no distal target to reinnervate. Symptomatic neuromas are a common cause of postamputation pain that can lead to substantial disability<sup>1-3</sup>. Regenerative peripheral nerve interface (RPNI) surgery may benefit patients through the use of free nonvascularized muscle grafts as physiologic targets for peripheral nerve reinnervation for mitigation of neuroma and postamputation pain.</p><p><strong>Description: </strong>An RPNI is constructed by implanting the distal end of a transected peripheral nerve into a free nonvascularized skeletal muscle graft. The neuroma or free end of the affected nerve is identified, transected, and skeletonized. A free muscle graft is then harvested from the donor thigh or from the existing amputation site, and the distal end of each transected nerve is implanted into the center of the free muscle graft with use of 6-0 nonabsorbable suture. This can be done acutely at the time of amputation or as an elective procedure at any time postoperatively.</p><p><strong>Alternatives: </strong>Nonsurgical treatments of neuromas include desensitization, chemical or anesthetic injections, biofeedback, transcutaneous electrical nerve stimulation, topical lidocaine, and/or other medications (e.g., antidepressants, anticonvulsants, and opioids). Surgical treatment of neuromas includes neuroma excision, nerve capping, excision with transposition into bone or muscle, nerve grafting, and targeted muscle reinnervation.</p><p><strong>Rationale: </strong>Creation of an RPNI is a simple and reproducible surgical option to prevent neuroma formation that leverages several biologic processes and addresses many limitations of existing neuroma-treatment strategies. Given the understanding that neuromas will form when regenerating axons are not presented with end organs for reinnervation, any strategy that reduces the number of aimless axons within a residual limb should serve to reduce symptomatic neuromas. The use of free muscle grafts offers a vast supply of denervated muscle targets for regenerating nerve axons and facilitates the reestablishment of neuromuscular junctions without sacrificing denervation of any residual muscles.</p><p><strong>Expected outcomes: </strong>Articles describing RPNI surgery for postamputation pain have shown favorable outcomes, with significant reduction in neuroma pain and phantom pain scores at approximately 7 months postoperatively<sup>4,5</sup>. Neuroma pain scores were reduced by 71% and phantom pain scores were reduced by 53%<sup>4</sup>. Prophylactic RPNI surgery is also associated with substantially lower incidence of symptomatic neuromas (0% versus 13.3%) and a lower rate of phantom limb pain (51.1% versus 91.1%)<sup>5</sup> compared with the rates in patients who did not undergo RPNI surgery.</p><p><strong>Important tips: </strong>Ask the patient preoperatively to point at the site of maximal tenderne","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-02-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10852375/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139724415","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":"Transcutaneous Osseointegrated Prosthesis Systems (TOPS) for Rehabilitation After Lower Limb Loss: Surgical Pearls.","authors":"Horst H Aschoff, Marcus Örgel, Marko Sass, Dagmar-C Fischer, Thomas Mittlmeier","doi":"10.2106/JBJS.ST.23.00010","DOIUrl":"10.2106/JBJS.ST.23.00010","url":null,"abstract":"<p><strong>Background: </strong>The biology of osseointegration of any intramedullary implant depends on the design, the press-fit anchoring, and the loading history of the endoprosthesis. In particular, the material and surface of the endoprosthetic stem are designed to stimulate on- and in-growth of bone as the prerequisite for stable and long-lasting integration<sup>1-8</sup>. Relative movement between a metal stem and the bone wall may stimulate the formation of a connective-tissue interface, thereby increasing the risk of peri-implant infections and implant loss<sup>9-12</sup>. The maximum achievable press-fit (i.e., the force closure between the implant and bone wall) depends on the diameter and length of the residual bone and thus on the amputation level. Beyond this, the skin-penetrating connector creates specific medical and biological challenges, especially the risk of ascending intramedullary infections. On the one hand, bacterial colonization of the skin-penetrating area (i.e., the stoma) with a gram-positive taxon is obligatory and almost impossible to avoid<sup>9,10</sup>. On the other hand, a direct structural and functional connection between the osseous tissue and the implant, without intervening connective tissue, has been shown to be a key for infection-free osseointegration<sup>11,12</sup>.</p><p><strong>Description: </strong>We present a 2-step implantation process for the standard Endo-Fix Stem (ESKA Orthopaedic Handels) into the residual femur and describe the osseointegration of the prosthesis<sup>13</sup>. In addition, we demonstrate the single-step implantation of a custom-made short femoral implant and a custom-made humeral BADAL X implant (OTN Implants) in a patient who experienced a high-voltage injury with the loss of both arms and the left thigh. Apart from the standard preparation procedures (e.g., marking the lines for skin incisions, preparation of the distal part of the residual bone), special attention must be paid when performing the operative steps that are crucial for successful osseointegration and utilization of the prosthesis. These include shortening of the residual bone to the desired length, preparation of the intramedullary cavity for hosting of the prosthetic stem, precise trimming of the soft tissue, and wound closure. Finally, we discuss the similarities and differences between the Endo-Fix Stem and the BADAL X implant in terms of their properties, intramedullary positioning, and the mechanisms leading to successful osseointegration.</p><p><strong>Alternatives: </strong>Socket prostheses for transfemoral or transtibial amputees have been the gold standard for decades. However, such patients face many challenges to recover autonomous mobility, and an estimated 30% of all amputees report unsatisfactory rehabilitation and 10% cannot use a socket prosthesis at all.</p><p><strong>Rationale: </strong>Transcutaneous osseointegrated prosthetic systems especially benefit patients who are unable to tolerate ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10805461/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139547490","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":"Chronic Achilles Tendon Avulsion Repair: Central Third Fascia Slide Technique with Flexor Hallucis Longus Transfer.","authors":"Logan J Roebke, Paul M Alvarez, Christian Curatolo, Reid Palumbo, Kevin D Martin","doi":"10.2106/JBJS.ST.22.00036","DOIUrl":"10.2106/JBJS.ST.22.00036","url":null,"abstract":"<p><strong>Background: </strong>Chronic Achilles tendon defects are commonly associated with substantial impairment in gait and push-off strength, leading to decreased function<sup>1</sup>. These injuries cause a unique surgical dilemma, with no consensus surgical reconstruction technique for >6-cm gaps<sup>3</sup>. There are a multitude of surgical reconstruction techniques that rely on gap size as a determinant for preoperative planning<sup>1,2</sup>. The present article describes a technique for chronic Achilles tendon defects of >6 cm. The central third fascia slide (CTFS) technique with flexor hallucis longus (FHL) transfer provides adequate excursion and strength while avoiding use of allograft.<sup>2</sup>.The CTFS technique is a reconstructive technique that is utilized to treat large chronically gapped Achilles tendon tears, usually larger than 5 to 6 cm; however, recent literature has shown that intermediate gaps can be fixed with use of a combination of tendon transfers. The technique described here is a variation of the V-Y tendinoplasty and fascia turndown method in which the gastrocnemius complex fascia is slid down rather than being \"turned down.\" This reconstructive technique, like its predecessor, restores function in damaged Achilles tendons<sup>3</sup>. Chronic gapping from a chronic Achilles tendon rupture can lead to decreased function and weakness. Patients may also experience fatigue and gait imbalance, leading to the need for surgical reconstruction to help restore functionality.</p><p><strong>Description: </strong>The CTFS technique utilizes a posterior midline incision, maintaining full-thickness flaps. A complete debridement of the degenerative Achilles tendon is performed, and the gap is measured. If the gap is >6 cm, the central third of the remaining Achilles and gastrocnemius fascia are sharply harvested. The FHL is transferred to the proximal Achilles footprint and held with use of an interference screw. The ankle is held in 15° to 25° of plantar flexion while the FHL shuttling suture is pulled plantarly and secured with a bio-interference screw. The fascial graft is then anchored to the calcaneus with use of a double-row knotless technique, maximizing osseous contact potential healing. Soft-tissue clamps are placed on the graft and on the gastrocnemius complex harvest site. The ankle is tensioned in nearly 30° of plantar flexion to account for known postoperative elongation. FiberWire (Arthrex) is utilized to secure the tension, then the remaining suture tape from the proximal insertional row is run up each side of the fascial graft in a running locking stitch, continuing proximally to close the harvest site. The use of an anchor-stay stitch helps to prevent elongation and maximizes construct strength.</p><p><strong>Alternatives: </strong>For patients who are poor surgical candidates or those with acceptable function, alternatives include nonoperative treatment and/or the use of a molded ankle foot orthosis. Most ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10805432/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139548256","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}