JBJS Essential Surgical Techniques最新文献

{"title":"Thoracoscopic Anterior Vertebral Body Tethering in Lenke Type-1 Right Adolescent Idiopathic Scoliosis.","authors":"Clément Jeandel, Nicolas Bremond, Marie Christine de Maximin, Yan Lefèvre, Aurélien Courvoisier","doi":"10.2106/JBJS.ST.22.00027","DOIUrl":"10.2106/JBJS.ST.22.00027","url":null,"abstract":"<p><strong>Background: </strong>Vertebral body tethering (VBT) is indicated for skeletally immature patients with progressive adolescent idiopathic scoliosis (AIS) who have failed or are intolerant of bracing and who have a major coronal curve of 40° to 65°. The vertebral body must be structurally and dimensionally adequate to accommodate screw fixation, as determined radiographically. The best indication for VBT is a flexible single major thoracic curve with nonstructural compensating lumbar and proximal thoracic curves (Lenke 1A or 1B). VBT allows for progressive correction of the deformity without spinal fusion by utilizing a minimally invasive fluoroscopic technique.</p><p><strong>Description: </strong>The procedure for a right thoracic curve is performed with use of a right thoracoscopic approach with the patient in the left lateral decubitus position. The thoracoscope is introduced through a portal at the apex of the curvature in the posterior axillary line. Instrument portals are created lateral to each vertebral body in the mid-axillary line. Screws are inserted into each vertebral body under biplanar fluoroscopic control and with intraoperative neuromonitoring. An electroconductivity probing device, while not mandatory, is routinely utilized at our practice. The tether is attached to the most proximal screw of the construct, and then reduction is obtained sequentially by tensioning the tether from one vertebral screw to the next.</p><p><strong>Alternatives: </strong>Bracing is the gold-standard treatment for progressive AIS involving the immature spine. The most commonly utilized surgical treatment is posterior spinal fusion (PSF), which should be considered when the major coronal curve exceeds 45°.</p><p><strong>Rationale: </strong>PSF has proven to be a dependable technique to correct scoliotic deformities. It has a low complication rate and good long-term outcomes. However, concerns exist regarding the stiffness conferred by PSF and the long-term effects of adjacent segment disease. Thus, interest had developed in non-fusion solutions for AIS correction. VBT utilizes the Hueter-Volkmann principle to guide growth and correct deformity. Compressive forces applied to the convexity of the deformity by a polyethylene tether allow the patient's growth to realign the spine. Intraoperative correction triggers growth modulation, and most of the modulation seems to occur during the first 12 months postoperatively. The best results have been seen with a short Lenke type-1A curve in a patient with closed triradiate cartilage, a Risser 3 or lower (ideally Risser 0) iliac apophysis, and a flexible curve characterized by a 50% reduction of the major coronal curve angle on side-bending radiographs.</p><p><strong>Expected outcomes: </strong>In 57 immature patients with a Lenke type-1A or 1B curve (i.e., a 30° to 65° preoperative Cobb angle), Samdani et al.<sup>3</sup> found a main thoracic Cobb angle reduction from 40° ± 7° preoperatively to 19° ± 13°","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2023-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10833648/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67755128","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":"Concomitant Medial Meniscal Root Repair with Extrusion Repair (Centralization Technique).","authors":"Silvampatti Ramaswamy Sundararajan, Rajagopalakrishnan Ramakanth, Terence D'Souza, Shanmuganathan Rajasekaran","doi":"10.2106/JBJS.ST.22.00008","DOIUrl":"10.2106/JBJS.ST.22.00008","url":null,"abstract":"<p><strong>Background: </strong>Meniscal extrusion is a phenomenon in which a degenerative posterior horn tear, radial tear, or root tear results in displacement of the body of the meniscus medial to the tibial rim. The paramount function of the meniscus is to provide load distribution across the knee joint. Meniscal extrusion will prevent the meniscus from properly fulfilling this function and eventually leads to progression of osteoarthritis<sup>1</sup>. Thus, root repair accompanied by arthroscopic meniscal extrusion repair (by a centralization technique) has been suggested for restoration of meniscal function<sup>2-5</sup>. There are various techniques to correct meniscal extrusion, including a dual-tunnel suture pull-out technique<sup>2</sup> (to address extrusion and root tear<sup>2</sup>), a knotless suture anchor<sup>4,6</sup> technique, and an all-inside suture anchor repair<sup>7</sup>. The indications for extrusion repair are not consistently reported in the literature, and the procedure is not always easy to perform. Currently, there is no consensus regarding the ideal technique. In the present article, we describe the steps for successful combined medial meniscal root repair with extrusion repair and centralization.</p><p><strong>Description: </strong>Place the patient in the supine position with the knee supported in 90° of flexion and the feet at the edge of the operating table with foot-positioner support. First, meniscal root repair is performed with use of the suture pull-out technique, utilizing a cinch suture configuration to hold the root in place, and the suture tapes are fixed over the anterior cortex of the tibia with a suture button. Next, the meniscal body is arthroscopically assessed for residual extrusion from the medial tibial rim. Extrusion repair is indicated in cases with >3 mm of extrusion<sup>7-9</sup>, as measured on magnetic resonance imaging. In our technique, any extrusion beyond the medial tibial rim is reduced and secured with use of a double-loaded 2.3-mm all-suture type of anchor.</p><p><strong>Alternatives: </strong>Alternatives include surgical procedures in which the root repair is performed with use of suture-anchor fixation<sup>10,11</sup> and the extrusion repair is performed with use of the transtibial suture pull-out method.</p><p><strong>Rationale: </strong>Root repair performed with the most common fixation techniques does not always reduce meniscal extrusion or restore meniscal function<sup>12,13</sup>. Consequently, several augmentation techniques have been reported to address meniscal extrusion<sup>3,14</sup>, including those that use arthroscopy to centralize the midbody of the meniscus over the rim of the tibial plateau. The rationale for this combined procedure is to restore the hoop-stress distribution and maintain meniscal function by repairing the extrusion of the meniscus. Addressing all intra-articular pathologies in a single stage is a challenging situation, and the sequence of the r","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10810590/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754736","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":"Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty.","authors":"Cody C Wyles, Charles P Hannon, Anthony Viste, Kevin I Perry, Robert T Trousdale, Daniel J Berry, Matthew P Abdel","doi":"10.2106/JBJS.ST.21.00003","DOIUrl":"10.2106/JBJS.ST.21.00003","url":null,"abstract":"<p><strong>Background: </strong>Removal of well-fixed femoral components during revision total hip arthroplasty (THA) can be difficult and time-consuming<sup>1</sup>, leading to numerous complications, such as femoral perforation, bone loss, and fracture. Extended trochanteric osteotomies (ETOs), which provide wide exposure and direct access to the femoral canal under controlled conditions, have become a popular method to circumvent these challenges. ETOs were popularized by Wagner (i.e., the anterior-based osteotomy), and later modified by Paprosky (i.e., the lateral-based osteotomy)<sup>2</sup>.</p><p><strong>Description: </strong>The decision to utilize the laterally based Paprosky ETO versus the anteriorly based Wagner ETO is primarily based on surgeon preference, the location and type of in situ implants, and the osseous anatomy. Typically, a laterally based ETO is most facile in conjunction with a posterior approach and an anteriorly based ETO is most commonly paired with a lateral or anterolateral approach. Attention must be paid to maintaining vascularity to the osteotomy fragment, including minimizing stripping of the vastus lateralis from the osteotomy fragment and maintaining abductor attachments to the osteotomy fragment. When utilizing a laterally based ETO, the posterior border of the vastus lateralis must be carefully elevated to provide exposure for performance of the osteotomy. When an anteriorly based osteotomy is performed, the surgeon may instead extend the abductor tenotomy proximally with use of a longitudinal split of the vastus lateralis distally, which helps to keep the anterior and posterior sleeves of soft tissue in continuity. In either approach, dissection of the vastus lateralis involves managing several large vascular perforators. We prefer performing careful blunt dissection to identify the perforators and prophylactically controlling them, with ligation of large vessels and electrocautery of smaller vessels. Vascular clips are also available in case difficult-to-control bleeding is encountered. In general, an oscillating saw (with preference for a thin blade) is utilized to complete the posterior longitudinal limb of the ETO, extending approximately 12 to 16 cm distally from the tip of the greater trochanter. Although a 12 to 16-cm zone is required to maintain maximum vascularity to the osteotomized fragment, the osteotomy length must ultimately be determined by (1) the length of the femoral component to be removed; (2) the presence of distal bone ingrowth, ongrowth, or cement; and (3) the presence of distal hardware or stemmed knee components. A smaller oscillating saw is then utilized to complete the transverse limb at the previously identified distal extent. A high-speed pencil-tip burr is utilized to complete the corners of the osteotomy in a rounded configuration, and a combination of saws and pencil-tip burrs is utilized to create partial proximal and distal anterior longitudinal limbs of the osteotomy to th","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10810589/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754720","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":"Posterior Approach for Open Reduction and Internal Fixation for Scapular Fractures.","authors":"Chase T Nelson, Tyler J Thorne, Thomas F Higgins, David L Rothberg, Justin M Haller, Lucas S Marchand","doi":"10.2106/JBJS.ST.22.00035","DOIUrl":"10.2106/JBJS.ST.22.00035","url":null,"abstract":"<p><strong>Background: </strong>This technique utilizes a full-thickness flap to provide a posterior approach to the scapula for open reduction and internal fracture fixation. The present video article outlines the Judet approach along with an incision modification tip for the surgeon's consideration.</p><p><strong>Description: </strong>Prior to making the incision, perform preoperative planning, patient and C-arm positioning, and identification of the primary fragments of the fracture that necessitate fixation on imaging. The Judet incision is made, and the full-thickness flap is retracted laterally (also described as a \"boomerang-shaped\" incision, allowing for the flap to be reflected medially). Next, detach and reflect the deltoid off the scapular spine superolaterally to reveal the internervous plane between the infraspinatus and teres minor. Utilize this interval to access the fracture sites while making sure to reflect the infraspinatus cranially, carefully minding the suprascapular neurovascular bundle, and the teres minor inferiorly, protecting the axillary nerve. A longitudinal arthrotomy may then be created parallel to the posterior border of the glenoid, with careful attention paid toward protecting the labrum from iatrogenic injury. The arthrotomy will allow for intra-articular evaluation of the reduction if needed. Primary fractures are then reduced. Reduction is confirmed with use of fluoroscopy, and fixation is applied to maintain the reduction.</p><p><strong>Alternatives: </strong>Most scapular fractures do well with nonoperative treatment, and this has been well documented in the literature. Open reduction and internal fixation has been shown to offer good-to-excellent clinical outcomes with minimal risk of complications in patients with traumatic scapular fractures that necessitate operative treatment<sup>1</sup>. In certain fractures of the glenoid fossa, operative treatment is necessary to restore normal anatomy, provide stability to the glenohumeral joint, and facilitate functional rehabilitation. Operative treatment is typically reserved for injuries with intra-articular involvement that results in joint incongruity or joint instability<sup>2,3</sup>. When operative treatment is indicated, an open posterior approach is utilized for some fractures. The posterior Judet approach is the best-known operative technique for such fractures, while other modifications of the Judet technique have also been described in the literature<sup>3-5</sup>.</p><p><strong>Rationale: </strong>Reports state that scapular body or neck and glenoid fossa fractures account for up to 80% of scapular fractures<sup>6</sup>. Open reduction and internal fixation of the scapula is an invasive procedure, requiring large incisions and manipulation of soft tissues to expose the various possible fracture sites on the scapula. Thus, numerus surgical techniques have been described that allow surgeons to best tailor treatment to their patients on a case-by-case ba","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10810586/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67755148","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":"Unilateral Biportal Endoscopy for Lumbar Spinal Stenosis and Lumbar Disc Herniation.","authors":"Daniel K Park, Chong Weng, Philip Zakko, Dae-Jung Choi","doi":"10.2106/JBJS.ST.22.00020","DOIUrl":"10.2106/JBJS.ST.22.00020","url":null,"abstract":"<p><strong>Background: </strong>Unilateral biportal endoscopy (UBE) is a novel minimally invasive technique for the treatment of lumbar spinal stenosis and lumbar disc herniations. Uniportal endoscopy was utilized prior to the advent of UBE and has been considered the workhorse of endoscopic spine surgery (ESS) for lumbar discectomy and decompressive laminectomy. However, there are theoretical advantages to UBE compared with traditional uniportal endoscopy, including that the procedure utilizes typical spinal equipment that should be readily available, requires less capital cost and optical instrumentation, and provides greater operative flexibility as a result of utilizing both a working and a viewing portal<sup>7,8</sup>.</p><p><strong>Description: </strong>A 0-degree arthroscope is typically utilized for discectomy and lumbar laminectomies. The use of a radiofrequency ablator is critical to help coagulate osseous and muscle bleeders. For irrigation, gravity or a low-pressure pump, typically <40 mm Hg, can be utilized<sup>9,10</sup>. Further details regarding irrigation pressure are provided in \"Important Tips.\" The use of a standard powered burr is typical to help osseous decompression, and Kerrison ronguers, pituitaries, osteotomes, and probes utilized in open or tubular cases suffice. Two incisions are made approximately 1 cm lateral to the midline. If working from the left side for a right-handed surgeon, the working portal is typically made at the lower laminar margin of the target level. The camera portal is then made typically 2 to 3 cm cephalad. A lateral radiograph is then utilized to confirm the portal placements. From the right side, the working portal is cephalad and the camera portal is caudal. Because of the switch, the portals may be shifted more distally.The first step is creating a working space because there is no true joint space in the spine. With use of radiofrequency ablation, a working space is created in the interlaminar space. Next, with use of a powered burr or a chiseled osteotomy, the base of the cephalad spinous process is thinned until the insertion of the ligamentum flavum is found. Next, the ipsilateral and contralateral laminae are thinned in a similar fashion. Once the osseous elements are removed, the ligamentum flavum is removed en bloc. The traversing nerve roots are checked under direct high-magnification visualization to ensure that they are decompressed. If a discectomy is necessary, standard nerve-root retractors can be utilized to retract the neural elements. With use of a blunt-tip elevator, the anular defect can be incised and the herniated disc can be removed under direct high-power visualization. In addition, a small curet can be utilized to create a defect in the weakened anulus or membrane covering the extruded disc material in order to help deliver the herniated disc material. Epidural veins are coagulated typically with use of a fine-point bipolar radiofrequency device.</p><p><strong>Alternative","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807897/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754313","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":"<i>JBJS EST</i> Editor's Choice Award Winners for 2022.","authors":"Edward Y Cheng","doi":"10.2106/JBJS.ST.23.00037","DOIUrl":"10.2106/JBJS.ST.23.00037","url":null,"abstract":"","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"13 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807877/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139565050","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":"Harvest and Application of Bone Marrow Aspirate Concentrate to Address Acetabular Chondral Damage During Hip Arthroscopy.","authors":"Scott D Martin, Christopher T Eberlin, Michael P Kucharik, Nathan J Cherian","doi":"10.2106/JBJS.ST.22.00010","DOIUrl":"10.2106/JBJS.ST.22.00010","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;During hip arthroscopy, managing concomitant cartilage damage and chondrolabral junction breakdown remains an ongoing challenge for orthopaedic surgeons, as previous studies have associated such lesions with inferior postoperative outcomes&lt;sup&gt;1-7&lt;/sup&gt;. Although higher-level studies are needed to fully elucidate the benefits, recent literature has provided supporting preliminary evidence for the utilization of bone marrow aspirate concentrate (BMAC) in patients with moderate cartilage damage and full-thickness chondral flaps undergoing acetabular labral repair&lt;sup&gt;7,8&lt;/sup&gt;. Thus, as the incorporation of orthobiologics continues to advance, there is a clinical demand for an efficient and reliable BMAC-harvesting technique that utilizes an anatomical location with a substantial concentration of connective tissue progenitor (CTP) cells, while avoiding donor-site morbidity and minimizing additional operative time. Thus, we present a safe and technically feasible approach for harvesting bone marrow aspirate from the body of the ilium, followed by centrifugation and application during hip arthroscopy.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;After induction of anesthesia and appropriate patient positioning, a quadrilateral arrangement of arthroscopic portals is established to perform puncture capsulotomy&lt;sup&gt;9&lt;/sup&gt;. Upon arthroscopic visualization of cartilage/chondrolabral junction injury, 52 mL of whole venous blood is promptly obtained from an intravenous access site and combined with 8 mL of anticoagulant citrate dextrose solution A (ACD-A). The mixture is centrifuged to yield approximately 2 to 3 mL of platelet-rich plasma (PRP) and 17 to 18 mL of platelet-poor plasma (PPP). Then, approaching along the coronal plane and aiming toward the anterior-superior iliac spine under fluoroscopic guidance, a heparin-rinsed Jamshidi bone marrow biopsy needle is driven through the lateral cortex of the ilium just proximal to the sourcil. Under a relative negative-pressure vacuum, bone marrow is aspirated into 3 separate heparin-rinsed 50 mL syringes, each containing 5 mL of ACD-A. Slow and steady negative pressure should be used to pull back on the syringe plunger to aspirate a total volume of 40 mL into each syringe. To avoid pelvic cavity compromise and minimize the risk of mobilizing marrow-space contents, care should be taken to ensure that no forward force or positive pressure is applied during the aspiration process. A total combined bone marrow aspirate/ACD-A mixture of approximately 120 mL is consistently harvested and subsequently centrifuged to yield roughly 4 to 6 mL of BMAC. The final mixture containing BMAC, PRP, and PPP is combined with thrombin to generate a megaclot, which is then applied to the central compartment of the hip.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Currently, strategies to address acetabular cartilage lesions may include microfracture, autologous chondrocyte implantation, matrix-induced autologous ch","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807885/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754752","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":"Reconstructive Allograft Preparation for Long Bone Intercalary Segments After Tumor Resections: Toronto Sarcoma Protocol.","authors":"Manit K Gundavda, Alexander L Lazarides, Zachary D C Burke, Kim Tsoi, Peter C Ferguson, Jay S Wunder","doi":"10.2106/JBJS.ST.22.00011","DOIUrl":"10.2106/JBJS.ST.22.00011","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;The Reconstructive Allograft Preparation by Toronto Sarcoma (RAPTORS) protocol is reliable and reproducible without substantially adding to the surgical reconstruction time or cost. Our technique includes clearance of debris, lavage of the medullary canal, pressurized filling of the medullary canal with antibiotic-laden cement for its mechanical and antimicrobial properties, and insertion of cancellous autograft at the allograft-host junctional ends prior to dual-plate compression to fix the allograft into the defect&lt;sup&gt;1-3&lt;/sup&gt;. Our experience with large intercalary allograft reconstruction has demonstrated high rates of long-term success and addresses the most common causes of large allograft failure (infection, fracture, and nonunion)&lt;sup&gt;4&lt;/sup&gt;, as shown in our long-term outcome study&lt;sup&gt;1&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Once the tumor is resected, it is used as a template for cutting and shaping the allograft to fit the bone defect and to restore length and anatomy. The frozen allograft is thawed in a container with povidone iodine and bacitracin saline solution until it reaches room temperature. The allograft is size-matched, and clearance of its intramedullary marrow contents is performed with use of curets and intramedullary reamers&lt;sup&gt;7&lt;/sup&gt;. If 1 end of the allograft includes the metaphysis and is covered by dense cancellous bone, we try not to ream through this end because maintaining this metaphyseal cancellous surface will expedite bone healing. The segment is then thoroughly lavaged with \"triple wash\" solutions to clear out any remaining marrow contents and to ensure sterilization of the allograft. This serial-wash technique involves the use of 3 discrete antiseptic modalities and has been utilized at our institution with low rates of allograft infection. These antiseptic modalities include 10% weight-per-volume povidone iodine diluted 1:1 with normal saline solution, 3% weight-per-volume hydrogen peroxide diluted 1:1 with normal saline solution, and 50,000 units of sterile bacitracin lyophilized powder dissolved in 500 mL of normal saline solution. Following the triple wash, the medullary canal is filled with antibiotic-laden methylmethacrylate bone cement. If both ends are open, the far end of the segment is first plugged with the surgeon's finger or with gauze, or if 1 end is covered with cancellous bone, then retrograde filling of the canal with cement is performed from the open end. The cement is then pressurized to ensure complete filling of the intramedullary space. Before it sets, 1 cm of cement is removed from each open end of the allograft to allow for packing of autograft bone cancellous chips and to ensure that cement does not impede anatomic reduction of the allograft-host bone junction. For this step, cancellous autograft from the iliac crest is harvested with use of a separate sterile surgical setup in order to prevent contamination of the autograft site by instruments ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807901/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754798","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 Transforaminal Lumbar Interbody Fusion with Expandable Cages.","authors":"Aaron J Buckland, Dylan J Proctor","doi":"10.2106/JBJS.ST.21.00062","DOIUrl":"10.2106/JBJS.ST.21.00062","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Minimally invasive surgical transforaminal lumbar interbody fusion (MIS-TLIF) is an increasingly common procedure for the treatment of lumbar degenerative pathologies. The MIS-TLIF technique often results in less soft-tissue injury compared with the open TLIF technique, reducing postoperative pain and recovery time&lt;sup&gt;1-3&lt;/sup&gt;. However, the narrow surgical aperture of this minimally invasive technique has increased the difficulty of interbody cage placement. Expandable cages were designed to improve ease of insertion, improve visualization around the cage on insertion, reduce neurological retraction and injury by passing the nerve root with the implant in a collapsed state, and enable better disc-height and lordosis restoration on expansion&lt;sup&gt;4&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;This procedure is performed with the patient under general anesthesia and in a prone position. The appropriate spinal level is identified with use of fluoroscopy, and bilateral paramidline approaches are made utilizing the Wiltse intermuscular approach. Pedicle screws are placed bilaterally. A pedicle-based retractor or tubular retractor is passed along the Wiltse plane, and bilateral inferior facetectomies are performed. A foraminotomy is performed, including a superior facetectomy on the side with compression of the exiting nerve root. A thorough discectomy with end-plate preparation is performed. The disc space is sized with use of trial components. The cage is then implanted with a pre-expansion height less than the trialed height and is expanded under fluoroscopy. After expansion, the cage is backfilled with allograft and local autograft. Finally, the rods are contoured and reduced bilaterally, followed by closure in a multilayered approach.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Nonoperative alternatives to the minimally invasive TLIF technique include physical therapy or epidural corticosteroid injections. When surgical intervention is indicated, there are several approaches that can be utilized during lumbar interbody fusion, including the posterior, direct lateral, anterior, or oblique approaches&lt;sup&gt;5&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;Expandable cages are designed to be inserted in a collapsed configuration and expanded once placed into the interbody space. This design offers numerous potential advantages over static alternatives. The low-profile, expandable cages require less impaction during placement, minimizing iatrogenic end-plate damage. Additionally, expandable cages require less thecal and nerve-root retraction and provide a larger surface footprint once expanded.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Expected outcomes: &lt;/strong&gt;The MIS-TLIF technique has been shown to significantly reduce back pain, leg pain, and disability, and to significantly increase function, with most improvements observed after 12 months postoperatively. Patients may experience a 51% and 39% reduction in visual analogue pain scores and Oswestry Disability","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-05-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807895/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754543","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 Decompression of the Anterior Inferior Iliac Spine.","authors":"Steven M Leary, Robert W Westermann","doi":"10.2106/JBJS.ST.22.00019","DOIUrl":"10.2106/JBJS.ST.22.00019","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Pathologic contact between the femoral neck and anterior inferior iliac spine (AIIS or subspine) often occurs concomitantly with femoroacetabular impingement, contributing to hip pain and dysfunction&lt;sup&gt;1-4&lt;/sup&gt;. We perform arthroscopic AIIS decompression to alleviate this source of extra-articular impingement and eliminate a potential cause of persistent pain following primary hip arthroscopy&lt;sup&gt;5-7&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;After identifying abnormal AIIS morphology on preoperative false-profile radiographs and/or 3D computed tomography, we utilize a beaver blade to make a small incision in the proximal capsule and rectus femoris tendon. This peri-capsulotomy window grants access to the subspine region. We then shuttle an arthroscopic burr into place within this window and begin debriding the subspine deformity under direct visualization. Fluoroscopy is utilized intraoperatively to ensure adequate resection, using intraoperative false-profile views achieved by canting the C-arm approximately 40°. Resection is considered adequate when the AIIS deformity is no longer readily apparent on false-profile views and when intraoperative range-of-motion testing confirms no further impingement with hip hyperflexion.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Femoroacetabular impingement can be treated nonoperatively with use of physical therapy and activity modification&lt;sup&gt;8&lt;/sup&gt;; however, outcomes following nonoperative treatment are inferior to those following hip arthroscopy, according to various studies&lt;sup&gt;9-12&lt;/sup&gt;. There are no known alternative treatments specific to subspine impingement.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;As patients with subspine deformities progress through hip flexion, the femoral neck collides with the AIIS, limiting range of motion. As such, subspine deformities have been shown to be more common in dancers and other high-flexion athletes&lt;sup&gt;13,14&lt;/sup&gt;. Additionally, studies have demonstrated that low femoral version of &lt;5° is associated with increased contact between the distal femoral neck and the AIIS. This pathologic contact can occur even in the absence of an obvious subspine deformity&lt;sup&gt;15&lt;/sup&gt;. In both of these patient populations, surgeons should have a high suspicion for subspine impingement, and a subspine decompression should be performed during hip arthroscopy in order to maximize patient outcomes.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Expected outcomes: &lt;/strong&gt;This is a safe procedure that, if performed when indicated, can improve outcomes following primary hip arthroscopy. A recent systematic review found a pooled complication risk of 1.1%, a pooled revision risk of 1.0%, and significant postoperative improvements in patient-reported outcome measures&lt;sup&gt;16&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Important tips: &lt;/strong&gt;Suspect subspine impingement in high-flexion athletes and patients with low femoral version, even in the absence of an obvious deformity.Ensure adequate visualization of the entire s","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"13 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-05-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807891/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139565053","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}