JBJS Essential Surgical Techniques最新文献

{"title":"Surgical Debridement for Acute and Chronic Osteomyelitis in Children.","authors":"Ernest Ekunseitan, Coleen S Sabatini, Ishaan Swarup","doi":"10.2106/JBJS.ST.21.00039","DOIUrl":"10.2106/JBJS.ST.21.00039","url":null,"abstract":"<p><strong>Background: </strong>Osteomyelitis is an infection of the bone that commonly occurs in pediatric populations. First-line treatment most often involves a course of antibiotics. In recent studies, surgical debridement, in addition to antibiotics, has been shown to provide positive clinical and functional outcomes in children. Debridement is most often indicated in patients with an abscess or in those who do not respond to empiric antibiotic therapy; however, there are limited video resources describing this technique in pediatric patients.</p><p><strong>Description: </strong>The key steps of the procedure, which are demonstrated in the present video article, are (1) preoperative planning, (2) positioning, (3) subperiosteal exposure and debridement, (4) cortical window creation, (5) irrigation, (6) adjunctive treatment, (7) drain placement, (8) wound closure, (9) dressing and immobilization, and (10) wound check and drain removal.</p><p><strong>Alternatives: </strong>Nonoperative treatment is usually indicated for acute osteomyelitis in which patients present with little to no necrotic tissue or abscess formation. In these cases, a course of broad-spectrum antibiotics may be sufficient for a cure.</p><p><strong>Rationale: </strong>This procedure allows for the removal of necrotic bone and soft tissue, thus facilitating the recovery process. It also allows for the retrieval of tissue samples that may be used to guide selection of the appropriate antibiotic therapy. Surgical debridement is a safe and reliable technique that has been associated with positive long-term outcomes.</p><p><strong>Expected outcomes: </strong>We expect that some patients will require repeat surgical debridement procedures to decrease pathogen burden and prevent future complications. However, we expect that the majority of patients who undergo surgical debridement for uncomplicated osteomyelitis will recover full functionality of the affected limb with no associated long-term sequelae¹⁰.</p><p><strong>Important tips: </strong>Understand preoperative imaging to identify areas of infection, localize critical structures and the physis, and plan surgical approaches.Use extensile approaches and preserve vascularity during the approach.Perform subperiosteal dissection and create a cortical window to debride areas of infection, but avoid excessive periosteal stripping.Close the dead space and wound in a layered manner.</p><p><strong>Acronyms and abbreviations: </strong>MRI = magnetic resonance imagingK-wire = Kirschner wireMRSA = methicillin-resistant <i>Staphylococcus aureus</i>PDS = polydiaxonone.</p>","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-03-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807896/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754351","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":"Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position.","authors":"Thomas C Sanchez, Matthew T Sankey, Chad B Willis, Sean M Young, Alex Harrelson, Ashish Shah","doi":"10.2106/JBJS.ST.21.00070","DOIUrl":"10.2106/JBJS.ST.21.00070","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;The mini-open approach with supine patient positioning is a useful technique to consider for acute Achilles rupture repair, ideally performed within 2 weeks from the time of injury. The traditional surgical approach is completed with the patient in the prone position with an extensile midline incision. Here we describe a mini-open approach with supine positioning that utilizes a single incision measuring approximately 3 to 4 cm in length and avoids the pitfalls of prone positioning, which include greater operative time and potential difficult airway management, vision loss, and brachial plexus palsies&lt;sup&gt;1&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;When positioning the patient supine, lower-extremity bolsters are placed beneath the contralateral hip and the operative ankle in order to allow for exaggerated external rotation of the ankle and improved medial visualization. A thigh tourniquet is then applied on the operative side in a standard sterile fashion.After appropriate draping, begin by palpating the tendon rupture site and mark a 3 to 4-cm incision line just medial to the tendon. Sharp dissection through the skin to the level of the paratenon is then performed. Incise the paratenon with a knife, separate the paratenon from the underlying Achilles tendon with a Freer elevator or scissors, subsequently remove any hematoma formation, and cut the paratenon proximally and distally with scissors or a knife. Debride any damaged tendon thoroughly.The steps of the procedure are performed under direct visualization. If the sural nerve is encountered, it is noted and retracted, and extra care is taken to avoid damaging it with instruments or suture.Now that the proximal and distal ends of the Achilles tendon are free, utilize a 4-stranded double Krackow locking stitch with two #2 FiberWires (Arthrex) on both the proximal and the distal stump. The stumps of the ruptured tendon are approximated by tying the free suture ends together with use of a simple surgeon's knot. A running epitendinous repair is performed with use of number-0 Vicryl (Ethicon) suture in a cross-stich weave technique to provide additional strength to the repair. Finally, test the integrity of the repair via an intraoperative Thompson test. The postoperative protocol includes non-weight-bearing with the operative limb in a posterior splint for 2 weeks. At the 2-week follow-up, stitches are removed and the limb is placed in a tall CAM (controlled ankle motion) walker boot with 2 heel wedges measuring 6.35 mm (0.25 inches) apiece. The patient can begin partial weight-bearing with crutches at 2 weeks postoperatively. At 4 weeks postoperatively, 1 heel wedge is removed, and at 6 weeks postoperatively, the second heel wedge is removed. Patients are instructed to begin gentle range-of-motion exercises at 2 weeks, with formal physical therapy scheduled to begin at 6 weeks. Most patients are out of the boot at 8 to 10 weeks postoperatively.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alte","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-03-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807889/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754569","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Open Achilles Tendon Repair.","authors":"M Lane Moore, Jordan R Pollock, Phillip J Karsen, Jack M Haglin, Cara H Lai, Muhammad A Elahi, Anikar Chhabra, Martin J O'Malley, Karan A Patel","doi":"10.2106/JBJS.ST.21.00054","DOIUrl":"10.2106/JBJS.ST.21.00054","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;An open Achilles tendon repair is performed in patients who have suffered an acute rupture. All patients with this injury should be counseled on their treatment options, which include open operative repair and functional rehabilitation. We prefer the use of an open repair in high-level athletes and those who have delayed presentation. Typically, this injury-and the resulting open repair-are seen in young or middle-aged patients as well as athletes. Operative repair of a ruptured Achilles tendon is associated with a much faster return to activity/sport when compared with nonoperative alternatives. This surgical procedure is especially useful in allowing this patient population to return to their previous activity level and functional capacity as quickly as possible.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Open repair of a ruptured Achilles tendon begins with a 6 to 8-cm incision over the posteromedial aspect of the lower leg. Superficial and deep dissections are performed until the 2 ends of the ruptured tendon are identified. Adhesions are debrided to adequately mobilize and define the proximal and distal segments of the tendon. With use of a fiber tape suture, a modified locking Bunnell stitch is utilized to secure both ends. The fiber tape is tied securely, and the repair is reinforced with Vicryl suture (Ethicon). Once the tendon is repaired, the paratenon layer is identified and repaired with a running 0 or 2-0 Vicryl suture. This is an important step to minimize postoperative wound complications. The wound is then closed, and the extremity is splinted in maximum plantar flexion.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Alternative treatments include minimally invasive surgical techniques such as percutaneous Achilles tendon repair and nonoperative treatment with functional rehabilitation, which can provide excellent outcomes but can also lead to a slight decrease in explosiveness as the patient returns to sport&lt;sup&gt;1,2&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;Nonoperative and operative treatment of Achilles tendon rupture can both result in excellent patient outcomes. Appropriate patient selection is critical. Younger patients hoping to return to more highly competitive athletics should consider operative repair&lt;sup&gt;3&lt;/sup&gt;. Possible differences have been identified in peak torque when comparing operative versus nonoperative treatment, with patients who had undergone operative repair having greater peak torque (i.e., explosiveness)&lt;sup&gt;2&lt;/sup&gt;. Otherwise, findings are similar between treatment options as long as the patients meet the criteria for nonoperative treatment.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Expected outcomes: &lt;/strong&gt;Overall, the scientific literature demonstrates that the functional outcomes following operative repair are good to excellent. In a study by Hsu et al.&lt;sup&gt;4&lt;/sup&gt;, 88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no rerup","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-03-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807880/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754503","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":"Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.","authors":"Kevin D Martin, Christian Curatolo, James Gallagher, Paul Alvarez","doi":"10.2106/JBJS.ST.22.00007","DOIUrl":"10.2106/JBJS.ST.22.00007","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Talar arthroscopic reduction and internal fixation (TARIF) is an alternative approach for the operative fixation of talar fractures that may be utilized instead of more traditional open approaches such as medial, lateral, or even dual anterolateral. The TARIF approach allows for nearly anatomic fracture reduction and fixation of talar neck, body, and posterior dome fractures while minimizing the soft-tissue stripping and vascular injury associated with the standard anterolateral approach.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Following initial closed fracture reduction and any associated procedures, we recommend obtaining computed tomography scans of the injured ankle in order to evaluate the fracture pattern and allow for preoperative planning. Most patients can be positioned prone for this procedure, except for those with fractures associated with anterior loose bodies and those with neck fractures requiring reduction, which are both amenable to lateral positioning&lt;sup&gt;1&lt;/sup&gt;. The feet are positioned off the end of the bed in a neutral position with room to plantar flex and dorsiflex the ankle freely for reduction maneuvers. Following induction of anesthesia and positioning of the patient, the fluoroscopic screen and arthroscopy equipment are positioned on the side opposite the surgeon. A mini C-arm is utilized for the fluoroscopy. The team may then proceed with preparing and draping the surgical field. The surgeon proceeds with creating posteromedial and posterolateral portals to view the fracture site. For talar neck fractures, we utilize standard posterolateral and posteromedial portals directly adjacent to the Achilles tendon at the level of the tip of the medial malleolus, which have previously been established as safe with respect to neurovascular structures&lt;sup&gt;4&lt;/sup&gt;. Of note, for talar body fractures these portals are placed slightly more distal at the level of the distal fibula, allowing the screws to be placed perpendicular to the fracture site. An accessory sinus tarsi portal can be established if further reduction to correct varus is needed. The flexor hallucis longus tendon serves as a landmark throughout the case to maintain orientation. We prefer to utilize a 1.9-mm malleable arthroscopic NanoScope (Arthrex), which maximizes our view in the small subtalar space and allows for visualization over the talar dome. A shaver is then utilized to clear out the deep joint capsule and remove fracture hematoma. In our experience, after the initial primary reduction attempt by the orthopaedic trauma provider, the fracture is relatively stable and often held by an external fixator. The remaining reduction is performed with use of manipulation of the ankle in combination with an accessory sinus tarsi portal, utilizing an elevator or a small reduction tool in 1 of the posterior portals. We have also utilized percutaneous Kirschner wires to \"joystick\" the fragments prior to the placement of the guidewires. We the","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807894/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754698","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":"Hammer Toe Correction with Proximal Interphalangeal Joint Arthrodesis.","authors":"Eric Olsen, Jesse King, Jordan R Pollock, Mathieu Squires, Ramzy Meremikwu, David Walton","doi":"10.2106/JBJS.ST.21.00046","DOIUrl":"10.2106/JBJS.ST.21.00046","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;First described by Soule in 1910, arthrodesis of the proximal interphalangeal joint is a common operative method of treatment of hammer toe, or fixed-flexion deformity of the proximal interphalangeal joint of the lesser toes&lt;sup&gt;1&lt;/sup&gt;. The deformity is often caused by imbalance in intrinsic and extrinsic muscle function across the interphalangeal joint and metatarsophalangeal joint&lt;sup&gt;2,3&lt;/sup&gt;, which can be effectively addressed through proximal interphalangeal joint straightening and arthrodesis in conjunction with soft-tissue balancing of the metatarsophalangeal joint.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Following longitudinal skin incision over the joint, a transverse extensor tenotomy and capsulotomy reveal the proximal interphalangeal joint and provide appropriate exposure of the head of the proximal phalanx. With the soft tissues protected, the proximal and middle phalanges undergo resection of the articular surfaces to allow osseous apposition. This step can be performed with a rongeur sagittal saw or with osteotomes&lt;sup&gt;4,5&lt;/sup&gt;. The head of the proximal phalanx is resected proximal to the head-neck junction, and the proximal portion of the middle phalanx is removed to expose the subchondral bone. Often, there is a dorsal contracture of the metatarsophalangeal joint that is elevating the toe, which is addressed with use of a longitudinal incision over the metatarsophalangeal joint, a Z-lengthening of the long extensor tendon to the toe, and a subsequent capsulectomy. If there is an angular component to the deformity, the collateral ligaments are released from the metatarsal neck, and the toe can be balanced. If there is residual subluxation of the joint that is incompletely corrected by soft-tissue procedures, a metatarsal osteotomy should be considered. Fixation is then performed with use of a smooth Kirschner wire. The wire is inserted from the middle phalanx out the tip of the toe and subsequently inserted retrograde across the proximal interphalangeal joint, often into the metatarsal head and neck, holding the metatarsophalangeal joint in appropriate position. This step can also be completed with use of novel methods including screws, bioabsorbable pins, or intramedullary implants&lt;sup&gt;6-8&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Nonoperative treatments for hammer toe deformity are generally pursued prior to surgery and include shoe modifications such as a wide toe-box, soft uppers, and padding of osseous prominences&lt;sup&gt;3,9,10&lt;/sup&gt;. Alternative surgical treatments include proximal interphalangeal arthroplasty, soft-tissue capsulotomy, extensor tendon lengthening, and amputation&lt;sup&gt;11&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;Although nonoperative treatment can alleviate symptoms temporarily, surgical treatment is often necessary for definitive treatment of hammer toe. Soft-tissue procedures such as tendon lengthening can provide a stabilizing benefit, but the degenerative bone changes associate","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807884/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754458","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 Lysis of Adhesions for the Stiff Total Knee Arthroplasty.","authors":"Andrew R Leggett, Gregory J Schneider, Yair D Kissin, Edward Y Cheng, Stephen R Rossman","doi":"10.2106/JBJS.ST.22.00001","DOIUrl":"10.2106/JBJS.ST.22.00001","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Arthroscopic lysis of adhesions is a treatment option for patients with painful, stiff knees as a result of arthrofibrosis following knee arthroplasty, in whom prior manipulation under anesthesia (MUA) has failed. Typically, nonoperative treatment in these patients has also failed, including aggressive physiotherapy, stretching, dynamic splinting, and various pain-management measures or medications. Range of motion in these patients is often suboptimal, and any gains in flexibility will likely have hit a plateau over many months. The goal of performing lysis of adhesions is to increase the range of motion in patients with knee stiffness following total knee arthroplasty, as well as to reduce pain and restore physiologic function of the knee, enabling activities of daily living.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;This is a straightforward surgical technique that can be performed in a single stage. The preoperative range of motion is documented after induction of general anesthesia. The procedure begins with the establishment of standard medial and lateral parapatellar arthroscopic portals. A blunt trocar is introduced into the knee, and blunt, manual lysis of adhesions is performed in the suprapatellar pouch and the medial and lateral gutters with use of a sweeping motion after piercing and perforating the scarred adhesive bands or capsular tissue. Next, the arthroscope is inserted into the knee, and a diagnostic arthroscopy is performed. Bands of fibrous tissue are released and resected with use of electrocautery and a 4.0-mm arthroscopic shaver. Next, the posterior cruciate ligament (PCL) is visualized in full flexion. If PCL tightness is observed, the PCL can be released from its femoral origin until the flexion gap is increased. This portion of the procedure can include either partial or full release of the PCL, as indicated. Next, the arthroscope is removed and the ipsilateral hip is flexed to 90° for a standard MUA. Gentle force is applied to the proximal aspect of the tibia, and the knee is flexed. After completing the MUA, immediate post-intervention range of motion of the knee is documented, and the patient is provided with a continuous passive motion (CPM) machine set to the maximum flexion and extension achieved in the operating room.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Nonoperative treatment of a stiff knee following total knee arthroplasty is well documented in the current literature. Range of motion has been shown to increase in patients undergoing proper pain management, aggressive physical therapy, and closed MUA in the acute postoperative setting. Additionally, more severe cases of established arthrofibrosis despite prior MUA can be treated with an open lysis of adhesions&lt;sup&gt;1-3&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;Arthroscopic lysis of adhesions with PCL release versus resection has been well described previously. This procedure has been shown to benefit patients in whom initial nonoperative","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-01-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807902/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754686","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":"Tendon Sheath Incision for Surgical Treatment of Trigger Finger.","authors":"Muhammad Ali Elahi, Jordan R Pollock, M Lane Moore, Jack M Haglin, Cara Lai, Nathaniel B Hinckley, Kevin J Renfree","doi":"10.2106/JBJS.ST.21.00041","DOIUrl":"10.2106/JBJS.ST.21.00041","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Open trigger finger release is an elective surgical procedure that serves as the gold standard treatment for trigger digits. The aim of this procedure is to release the A1 pulley in a setting in which the pulley is completely visible, ultimately allowing the flexor tendons that were previously impinged on to glide more easily through the tendon sheath. Although A1-or the first annular pulley-is the site of triggering in nearly all cases, alternative sites include A2, A3, and the palmar aponeurosis&lt;sup&gt;1&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Typically, the surgical procedure can be conducted in an outpatient setting and can vary in duration from a few minutes to half an hour. The surgical procedure involves the patient lying in the supine position with the operative hand positioned to the side. A small incision, ranging from 1 to 1.5 cm, is made on the volar side of the hand, just proximal to the A1 pulley in the skin crease in order to minimize scarring. Once the underlying neurovascular structures are exposed, the A1 pulley is released longitudinally at least to the level of the A2 pulley, followed by decompression of the flexor tendons that were previously impinged on. In order to confirm the release, the patient is asked to flex and extend the affected finger. The wound is irrigated and closed once the release is confirmed by both the patient and surgeon.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Aside from an open release, trigger finger can be treated nonoperatively with use of splinting and corticosteroid injection. Alternative operative treatments include a percutaneous release, which involves the use of a needle to release the A1 pulley&lt;sup&gt;2&lt;/sup&gt;. Trigger finger can initially be treated nonoperatively. If unsuccessful, surgical intervention is considered the ultimate remedy&lt;sup&gt;2&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;Because of their efficacious nature, corticosteroid injections are indicated preoperatively, particularly in non-diabetic patients&lt;sup&gt;3&lt;/sup&gt;. Splinting is often an appropriate treatment option in patients who wish to avoid a corticosteroid injection&lt;sup&gt;1&lt;/sup&gt;. However, if nonoperative treatment modalities fail to resolve pain and symptoms, surgical intervention is indicated&lt;sup&gt;2&lt;/sup&gt;. In comparison with a percutaneous trigger finger release, an open release provides enhanced exposure and may be safer with respect to avoiding iatrogenic neurovascular injury&lt;sup&gt;2&lt;/sup&gt;. However, in a randomized controlled trial, Gilberts et al. found no difference in the rates of recurrence when comparing open versus percutaneous trigger finger release&lt;sup&gt;4&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Expected outcomes: &lt;/strong&gt;With reported success rates ranging from 90% to 100%, the open release of the A1 pulley is considered a common procedure associated with minimal complications&lt;sup&gt;2&lt;/sup&gt;. Complications of the procedure were assessed in a retrospective analysis of 43 patients who underwent 78 open trigger releases p","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807900/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754419","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":"Robotic-Assisted Single-Position Prone Lateral Lumbar Interbody Fusion","authors":"Karim Shafi, Francis Lovecchio, Junho Song, Sheeraz Qureshi","doi":"10.2106/jbjs.st.22.00022","DOIUrl":"https://doi.org/10.2106/jbjs.st.22.00022","url":null,"abstract":"Background: Lateral lumbar interbody fusion (LLIF) is a widely utilized minimally invasive surgical procedure for anterior fusion of the lumbar spine. However, posterior decompression or instrumentation often necessitates patient repositioning, which is associated with increased operative time and time under anesthesia 1–3 . The single-position prone transpsoas approach is a technique that allows surgeons to access both the anterior and posterior aspects of the spine, bypassing the need for intraoperative repositioning and therefore optimizing efficiency 4 . The use of robotic assistance allows for decreased radiation exposure and increased accuracy, both with placing instrumentation and navigating the lateral corridor. Description: The patient is placed in the prone position, and pedicle screws are placed prior to interbody fusion. Pedicle screws are placed with robotic guidance. After posterior instrumentation, a skin incision for LLIF is made in the cephalocaudal direction, orthogonal to the disc space, with use of intraoperative (robotic) navigation. Fascia and abdominal muscles are incised to enter the retroperitoneal space. Under direct visualization, dilators are placed through the psoas muscle into the disc space, and an expandable retractor is placed and maintained with use of the robotic arm. Following a thorough discectomy, the disc space is sized with trial implants. The expandable cage is placed, and intraoperative fluoroscopy is utilized to verify good instrumentation positioning. Finally, posterior rods are placed percutaneously. Alternatives: An alternative surgical approach is a traditional LLIF with the patient beginning in the lateral position, with intraoperative repositioning from the lateral to the prone position if circumferential fusion is warranted. Additional alternative surgical procedures include anterior or posterior lumbar interbody fusion techniques. Rationale: LLIF is associated with reported advantages of decreased risks of vascular injury, visceral injury, dural tear, and perioperative infection 5,6 . The single-position prone transpsoas approach confers the added benefits of reduced operative time, anesthesia time, and surgical staffing requirements 7 . Other potential benefits of the prone lateral approach include improved lumbar lordosis correction, gravity-induced displacement of peritoneal contents, and ease of posterior decompression and instrumentation 8–11 . Additionally, the use of robotic assistance offers numerous benefits to minimally invasive techniques, including intraoperative navigation, instrumentation templating, a more streamlined workflow, and increased accuracy in placing instrumentation, while also providing a reduction in radiation exposure and operative time. In our experience, the table-mounted LLIF retractor has a tendency to drift toward the floor—i.e., anteriorly—when the patient is positioned prone, which may, in theory, increase the risk of iatrogenic bowel injury. The rigid robotic ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"71 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135758433","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Wedgeless V-Shaped Osteotomy of the Distal Medial Femur with Locking Plate Fixation for Correction of Genu Valgum in Adolescents and Young Adults","authors":"Sumit Arora, Rahul Garg, Mudit Sharma, Vineet Bajaj, Abhishek Kashyap, Vikas Gupta","doi":"10.2106/jbjs.st.22.00033","DOIUrl":"https://doi.org/10.2106/jbjs.st.22.00033","url":null,"abstract":"Background: Genu valgum is a common disorder affecting adolescents and young adults. Treatment of this disorder requires restoration of normal mechanical axis alignment and joint orientation, for which it is important to assess whether the deformity arises from the distal femur, knee joint, or proximal tibia. Most commonly, the deformity originates from the distal femur, and various osteotomies of the distal femur have been described 1–6 . The presently described wedgeless V-shaped osteotomy 7,8 is a good option among the various alternative procedures listed below. Description: The anesthetized patient is placed in the supine position on a radiolucent operating table. A bolster is placed beneath the knee to relax the posterior structures. A medial longitudinal skin incision is made that extends from the level of the medial joint line to 5 cm proximal to the adductor tubercle. The vastus medialis is identified and elevated anteriorly by detaching it from its distal and posterior aspects. The leash of vessels underneath the vastus medialis is identified, and the apex of the V-shaped osteotomy is kept just proximal to it. The anterior arm of the V is kept longer than the posterior one, both of them are kept perpendicular to each other, and the apex of the V is made to point distally. The osteotomy is performed on the medial cortex with use of an oscillating saw or multiple drill holes that are then connected using a thin osteotome. Care is taken not to utilize a saw or drill on the lateral cortex. A gentle valgus thrust is applied to break the lateral cortex without periosteal disruption. The apex of the V osteotomy on the proximal fragment is trimmed, and the deformity is corrected with varus force. The osteotomy site is stabilized with use of an anatomically contoured distal medial femoral locking plate or a medial proximal tibial L-shaped buttress plate (of the contralateral side). The implant position is verified under a C-arm image intensifier. The wound is closed in layers over a suction drain in a standard manner. Alternatives: Various types of corrective osteotomies of the distal femur have been described in the literature, including the lateral opening wedge, medial closing wedge, dome, and spike osteotomies 1–6 . All of these procedures have certain limitations and shortcomings. Rationale: The wedgeless V-shaped osteotomy is another described procedure that is inherently stable 7,8 . It is a safe procedure and yields good clinical outcomes 8,9 . The posterior arm of the V-shaped osteotomy is kept smaller than the anterior arm. The proximal cortical bone is allowed to dig into the cancellous bone of the wider distal metaphysis during deformity correction. Trimming the apex of proximal bone end after making the osteotomy facilitates the process. Expected Outcomes: In a study of 46 patients with a mean age of 16.9 years (range, 15 years to 23 years), Gupta et al. 8 reported that the mean radiographic tibiofemoral angle improved from 22.2° (r","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"26 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135709996","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Closed Reduction Technique for Severely Displaced Radial Neck Fractures in Children","authors":"Maulin Shah, Gaurav Gupta, Qaisur Rabbi, Vikas Bohra, Kemble Wang, Akash Makadia, Shalin Shah, Chinmay Sangole","doi":"10.2106/jbjs.st.21.00064","DOIUrl":"https://doi.org/10.2106/jbjs.st.21.00064","url":null,"abstract":"Background: The described technique is useful for achieving closed reduction of severely displaced (i.e., Judet Type-III and IV) pediatric radial neck fractures. It is widely agreed that radial neck fractures with angulation of &gt;30° should be reduced. Various maneuvers have been described, but none uniformly achieves complete reduction in severely displaced radial neck fractures (Types III and IV) 1–4 . The aim of the present technique is to achieve closed reduction in these severely displaced radial neck fractures without surgical instrumentation. Description: A stepwise approach is described. First, the radial head is viewed in profile under an image intensifier so that it appears rectangular. Varus stress is applied at the medial aspect of the elbow by the assistant, and thumb pressure is applied at the radial head along the posterolateral aspect of the elbow. This results in partial reduction of the radial head. The elbow is then simultaneously flexed and pronated with continuous pressure over the radial head. This final step anatomically reduces the radial head, and hyperpronating the forearm locks it in the corrected position. Alternatives: Operative alternatives to this technique include intra-focal pin-assisted reduction to achieve closed reduction, the Métaizeau technique of achieving indirect closed reduction of the fracture with the aid of a TENS (Titanium Elastic Nailing System) nail, and open reduction 5 . Nonoperative techniques have also been described for use with Judet Type-II and III fractures, but not with the severely displaced types described in the present article. Rationale: This technique takes into consideration the anatomy of the capsule and lateral collateral ligament complex. The biomechanical ligamentotaxis helps in achieving anatomic reduction of the radial head. Placing the forearm in pronation tightens the annular and lateral collateral ligaments and prevents redisplacement. There are potential complications with operative treatment, including the risk of nerve injury with percutaneous reduction techniques and the risks of osteonecrosis, premature epiphyseal fusion, and heterotopic ossification with open reduction. These complications can be avoided by the use of the presently described technique. Expected Outcomes: This technique provided satisfactory clinical outcomes in our previous study 6 , with none of the 10 patients showing signs of growth disturbance, loss of reduction, or reported complications at 12 months. Terminal restriction of supination was observed in 1 patient. No patient had osteonecrosis or elbow deformity. No patient required conversion to an implant-assisted or open reduction procedure. Important Tips: The steps need to be followed sequentially as described in order to achieve an anatomical reduction. After achieving the reduction, it is necessary to keep the forearm in pronation to maintain the reduction with the aid of the lateral ligament complex. This technique may not work in complex f","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"142 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135077618","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}