Pub Date : 2026-01-14eCollection Date: 2026-01-01DOI: 10.2106/JBJS.ST.24.00032
Bhushan S Sagade, Mandar V Agashe
<p><strong>Background: </strong>The calcaneo-cuboid-cuneiform (triple-C) osteotomy is indicated for the correction of symptomatic flexible planovalgus foot deformity. This procedure allows correction of all of the varied components of the planovalgus foot deformity in a single operation<sup>1,2</sup>.</p><p><strong>Description: </strong>The patient is positioned in a floppy lateral position<sup>2</sup>. The calcaneus is exposed via an oblique lateral incision along the peroneal tendons. The osteotomy is performed in an extra-articular fashion beginning posterior to the posterior articular facet and extending distally and anteriorly to the inferior surface of the calcaneus. The posterior calcaneal fragment is displaced medially to allow correction of heel valgus. A separate lateral incision is made over the cuboid in order to expose it. An osteotomy is performed in the middle third of the cuboid without violating the adjacent joints and opened with a lamina spreader to allow correction of the forefoot abduction. The medial cuneiform is exposed via a medial incision. A medial and plantar-based wedge of bone is removed in toto from the middle third of the cuneiform. Closing this wedge corrects forefoot supination and recreates the medial longitudinal arch. The wedge of bone harvested from the cuneiform is inserted into the cuboid and all of the osteotomies are fixed with Kirschner wires of sizes between 1.8 and 2.5 mm or cannulated cancellous screws.</p><p><strong>Alternatives: </strong>If the feet are supple enough to allow passive correction, an in-socket ankle-foot orthosis with a medial arch support can be utilized to maintain the shape of the foot and to delay deterioration and the need for surgery<sup>3</sup>. Various other surgical treatment methods are described in the literature and can be categorized as joint-sparing procedures, arthroereises, and arthrodeses. Joint-preserving procedures include the popular calcaneal-lengthening osteotomy (CLO)<sup>4</sup> and the double calcaneal osteotomy<sup>5</sup>. Arthroereisis, a non-fusion motion-limiting technique, is minimally invasive and recently gaining popularity<sup>3</sup>. The literature has described promising results with use of this procedure<sup>6</sup>. Extra-articular and intra-articular arthrodesis typically have been employed for the treatment of severe and rigid planovalgus feet and in children who have limited ambulatory potential. On the basis of the currently available literature, no procedure can be labeled superior to another<sup>3</sup>.</p><p><strong>Rationale: </strong>The triple-C osteotomy is straightforward and has a short learning curve. There is no need for bone-graft harvesting and the associated morbidity thereof. Studies have shown minimal complications and low long-term recurrence with use of the triple-C osteotomy in patients with spastic cerebral palsy<sup>3</sup>.</p><p><strong>Expected outcomes: </strong>We have reported on the short-term outcomes of this proc
{"title":"Calcaneo-Cuboid-Cuneiform Osteotomy for the Treatment of Planovalgus Feet in Patients with Spastic Cerebral Palsy.","authors":"Bhushan S Sagade, Mandar V Agashe","doi":"10.2106/JBJS.ST.24.00032","DOIUrl":"10.2106/JBJS.ST.24.00032","url":null,"abstract":"<p><strong>Background: </strong>The calcaneo-cuboid-cuneiform (triple-C) osteotomy is indicated for the correction of symptomatic flexible planovalgus foot deformity. This procedure allows correction of all of the varied components of the planovalgus foot deformity in a single operation<sup>1,2</sup>.</p><p><strong>Description: </strong>The patient is positioned in a floppy lateral position<sup>2</sup>. The calcaneus is exposed via an oblique lateral incision along the peroneal tendons. The osteotomy is performed in an extra-articular fashion beginning posterior to the posterior articular facet and extending distally and anteriorly to the inferior surface of the calcaneus. The posterior calcaneal fragment is displaced medially to allow correction of heel valgus. A separate lateral incision is made over the cuboid in order to expose it. An osteotomy is performed in the middle third of the cuboid without violating the adjacent joints and opened with a lamina spreader to allow correction of the forefoot abduction. The medial cuneiform is exposed via a medial incision. A medial and plantar-based wedge of bone is removed in toto from the middle third of the cuneiform. Closing this wedge corrects forefoot supination and recreates the medial longitudinal arch. The wedge of bone harvested from the cuneiform is inserted into the cuboid and all of the osteotomies are fixed with Kirschner wires of sizes between 1.8 and 2.5 mm or cannulated cancellous screws.</p><p><strong>Alternatives: </strong>If the feet are supple enough to allow passive correction, an in-socket ankle-foot orthosis with a medial arch support can be utilized to maintain the shape of the foot and to delay deterioration and the need for surgery<sup>3</sup>. Various other surgical treatment methods are described in the literature and can be categorized as joint-sparing procedures, arthroereises, and arthrodeses. Joint-preserving procedures include the popular calcaneal-lengthening osteotomy (CLO)<sup>4</sup> and the double calcaneal osteotomy<sup>5</sup>. Arthroereisis, a non-fusion motion-limiting technique, is minimally invasive and recently gaining popularity<sup>3</sup>. The literature has described promising results with use of this procedure<sup>6</sup>. Extra-articular and intra-articular arthrodesis typically have been employed for the treatment of severe and rigid planovalgus feet and in children who have limited ambulatory potential. On the basis of the currently available literature, no procedure can be labeled superior to another<sup>3</sup>.</p><p><strong>Rationale: </strong>The triple-C osteotomy is straightforward and has a short learning curve. There is no need for bone-graft harvesting and the associated morbidity thereof. Studies have shown minimal complications and low long-term recurrence with use of the triple-C osteotomy in patients with spastic cerebral palsy<sup>3</sup>.</p><p><strong>Expected outcomes: </strong>We have reported on the short-term outcomes of this proc","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 1","pages":""},"PeriodicalIF":1.6,"publicationDate":"2026-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12784008/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145953393","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}
Pub Date : 2026-01-14eCollection Date: 2026-01-01DOI: 10.2106/JBJS.ST.24.00009
Everett G Young, Ahab G Alnemri, Amar S Vadhera, Neil P Sheth, Krishna Kiran Eachempati
<p><strong>Background: </strong>Revision total hip arthroplasty (THA) for isolated polyethylene exchange or acetabular revision with retention of the femoral component can present a challenge for adequate exposure. A systematic approach to a proper release can facilitate exposure and reduce the risk of iatrogenic complications.</p><p><strong>Description: </strong>The posterior approach is an extensile and versatile approach for revision THA. After incising the fascia and iliotibial band, the insertion of the gluteus maximus is fully released. After releasing any scar along the inferior gluteus medius, a retractor is placed to hold the muscle belly cranially. The leg is gently internally rotated to place the posterior capsule and external rotators under tension while these structures are released from the posterior femur and along the neck of the femoral component. Curved scissors can be utilized to identify the psoas sheath and to release the inferior capsule while protecting the iliopsoas tendon. Scar tissue is resected from inside the hip joint, and a pocket is made in the anterior capsule to allow retractor placement above the equator of the acetabulum in order to hold the mobilized proximal femur anteriorly. An inferior retractor is then placed under the transverse acetabular ligament. This systematic approach allows adequate visualization of the acetabular component for revision.</p><p><strong>Alternatives: </strong>Nonoperative treatment should be attempted first, depending on the diagnosis and its associated natural history. Once nonoperative treatment has been exhausted and revision THA is indicated, the anterior and direct lateral approaches can be considered. If the femoral component needs revision on the basis of intraoperative assessment, the anterior approach presents substantial difficulty in femoral exposure, with a higher risk of iatrogenic fracture. The direct lateral approach commonly leads to abductor weakness and a Trendelenburg gait.</p><p><strong>Rationale: </strong>Common indications for revision THA with femoral component retention include wear and/or osteolysis, adverse local tissue reaction, recurrent instability, and aseptic acetabular loosening. Adequate exposure is essential to facilitate revision THA with femoral component retention and to minimize the risk of iatrogenic injury.</p><p><strong>Expected outcomes: </strong>Survivorship free from re-revision at 2 years is >80% for both isolated polyethylene exchange and acetabular revision. There is a trend toward higher failure rates when retaining the acetabular component. Risk factors for failure include damage to the locking mechanism; femoral head erosion into the cup, damaging the metal; and a mispositioned acetabular component.</p><p><strong>Important tips: </strong>A systematic approach to releases is essential for adequate exposure with a retained femoral component. Systematic releases include fully releasing the gluteus maximus insertion, continuing the iliotib
{"title":"Revision Total Hip Arthroplasty with Femoral Component Retention.","authors":"Everett G Young, Ahab G Alnemri, Amar S Vadhera, Neil P Sheth, Krishna Kiran Eachempati","doi":"10.2106/JBJS.ST.24.00009","DOIUrl":"10.2106/JBJS.ST.24.00009","url":null,"abstract":"<p><strong>Background: </strong>Revision total hip arthroplasty (THA) for isolated polyethylene exchange or acetabular revision with retention of the femoral component can present a challenge for adequate exposure. A systematic approach to a proper release can facilitate exposure and reduce the risk of iatrogenic complications.</p><p><strong>Description: </strong>The posterior approach is an extensile and versatile approach for revision THA. After incising the fascia and iliotibial band, the insertion of the gluteus maximus is fully released. After releasing any scar along the inferior gluteus medius, a retractor is placed to hold the muscle belly cranially. The leg is gently internally rotated to place the posterior capsule and external rotators under tension while these structures are released from the posterior femur and along the neck of the femoral component. Curved scissors can be utilized to identify the psoas sheath and to release the inferior capsule while protecting the iliopsoas tendon. Scar tissue is resected from inside the hip joint, and a pocket is made in the anterior capsule to allow retractor placement above the equator of the acetabulum in order to hold the mobilized proximal femur anteriorly. An inferior retractor is then placed under the transverse acetabular ligament. This systematic approach allows adequate visualization of the acetabular component for revision.</p><p><strong>Alternatives: </strong>Nonoperative treatment should be attempted first, depending on the diagnosis and its associated natural history. Once nonoperative treatment has been exhausted and revision THA is indicated, the anterior and direct lateral approaches can be considered. If the femoral component needs revision on the basis of intraoperative assessment, the anterior approach presents substantial difficulty in femoral exposure, with a higher risk of iatrogenic fracture. The direct lateral approach commonly leads to abductor weakness and a Trendelenburg gait.</p><p><strong>Rationale: </strong>Common indications for revision THA with femoral component retention include wear and/or osteolysis, adverse local tissue reaction, recurrent instability, and aseptic acetabular loosening. Adequate exposure is essential to facilitate revision THA with femoral component retention and to minimize the risk of iatrogenic injury.</p><p><strong>Expected outcomes: </strong>Survivorship free from re-revision at 2 years is >80% for both isolated polyethylene exchange and acetabular revision. There is a trend toward higher failure rates when retaining the acetabular component. Risk factors for failure include damage to the locking mechanism; femoral head erosion into the cup, damaging the metal; and a mispositioned acetabular component.</p><p><strong>Important tips: </strong>A systematic approach to releases is essential for adequate exposure with a retained femoral component. Systematic releases include fully releasing the gluteus maximus insertion, continuing the iliotib","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 1","pages":""},"PeriodicalIF":1.6,"publicationDate":"2026-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12784009/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145953402","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}
<p><strong>Background: </strong>Various approaches have been described for hip arthroplasty<sup>1-3</sup>. The posterior approach to the hip remains a popular choice for hemiarthroplasty<sup>1</sup>. In the classic description, it involves detachment of the short external rotators, which include the quadriceps coxae (QC) (i.e., piriformis, superior gemellus, obturator internus, and inferior gemellus) along with the obturator externus and quadratus femoris <i>(</i>as needed<i>)</i>. Since the QC are important for joint stability, detachment during the approach is associated with higher rates of postoperative dislocations<sup>4</sup>, even following subsequent surgical repair of the QC. In the study by Stähelin et al.<sup>5</sup>, 15 of 20 repairs involving the QC had failed by 3 months postoperatively, primarily because the repair site could not withstand the forces of normal weight-bearing during the healing phase. Various muscle-sparing modifications of the conventional approach have been described to reduce the propensity for prosthetic dislocation<sup>6-9</sup>. Hanly et al.<sup>9</sup> described the SPAIRE (Sparing Piriformis and Internus, Repair Externus) technique. This minimally invasive modified posterior approach enables the preservation of the QC, possibly representing the greatest extent of muscle and tendon preservation. The advantages of this QC-sparing technique have been demonstrated in clinical studies of hemiarthroplasty<sup>10,11</sup> and total hip arthroplasty<sup>12</sup>.</p><p><strong>Description: </strong>The patient is anesthetized and placed in a lateral decubitus position. Bolsters are utilized over the pubis and sacral areas to provide stable pelvic orientation. The contralateral limb is flexed at the hip (∼45°) and knee (90°), with adequate padding under the fibular head and lateral malleolus. Another padded bolster is placed between the legs to keep the topmost lower limb in neutral to slight abduction at the hip. The operative limb is flexed at the hip (∼30°), and a 10 to 15-cm straight skin incision is marked on the lateral aspect of hip, centered on the posterolateral tip of the greater trochanter. The deep fascia is opened distally to proximally, incised distally with scissors, and separated proximally with finger dissection. This step creates an intermuscular plane between the gluteus maximus posteriorly and tensor fasciae latae anteriorly. A Charnley hip retractor is applied. Internal rotation of the hip allows identification of the posterior border of the gluteus medius and short external rotators. The fat pad over the QC is swept medially with an abdominal sponge to identify the muscles. A plane is identified between the quadratus femoris and inferior gemellus. Next, a plane is developed between the QC and posterior hip capsule with use of a blunt hemostat from inferior to superior. Abduction of the hip just beyond neutral relaxes the QC and allows superior retraction. The quadratus femoris is detached from t
{"title":"Quadriceps Coxae-Sparing Modified Posterior Approach to the Hip Joint for Hemiarthroplasty.","authors":"Sumit Arora, Prajwal Gupta, Mudit Sharma, Manoj Kumar Meena, Shahrukh Khan, Abhishek Kashyap","doi":"10.2106/JBJS.ST.25.00008","DOIUrl":"10.2106/JBJS.ST.25.00008","url":null,"abstract":"<p><strong>Background: </strong>Various approaches have been described for hip arthroplasty<sup>1-3</sup>. The posterior approach to the hip remains a popular choice for hemiarthroplasty<sup>1</sup>. In the classic description, it involves detachment of the short external rotators, which include the quadriceps coxae (QC) (i.e., piriformis, superior gemellus, obturator internus, and inferior gemellus) along with the obturator externus and quadratus femoris <i>(</i>as needed<i>)</i>. Since the QC are important for joint stability, detachment during the approach is associated with higher rates of postoperative dislocations<sup>4</sup>, even following subsequent surgical repair of the QC. In the study by Stähelin et al.<sup>5</sup>, 15 of 20 repairs involving the QC had failed by 3 months postoperatively, primarily because the repair site could not withstand the forces of normal weight-bearing during the healing phase. Various muscle-sparing modifications of the conventional approach have been described to reduce the propensity for prosthetic dislocation<sup>6-9</sup>. Hanly et al.<sup>9</sup> described the SPAIRE (Sparing Piriformis and Internus, Repair Externus) technique. This minimally invasive modified posterior approach enables the preservation of the QC, possibly representing the greatest extent of muscle and tendon preservation. The advantages of this QC-sparing technique have been demonstrated in clinical studies of hemiarthroplasty<sup>10,11</sup> and total hip arthroplasty<sup>12</sup>.</p><p><strong>Description: </strong>The patient is anesthetized and placed in a lateral decubitus position. Bolsters are utilized over the pubis and sacral areas to provide stable pelvic orientation. The contralateral limb is flexed at the hip (∼45°) and knee (90°), with adequate padding under the fibular head and lateral malleolus. Another padded bolster is placed between the legs to keep the topmost lower limb in neutral to slight abduction at the hip. The operative limb is flexed at the hip (∼30°), and a 10 to 15-cm straight skin incision is marked on the lateral aspect of hip, centered on the posterolateral tip of the greater trochanter. The deep fascia is opened distally to proximally, incised distally with scissors, and separated proximally with finger dissection. This step creates an intermuscular plane between the gluteus maximus posteriorly and tensor fasciae latae anteriorly. A Charnley hip retractor is applied. Internal rotation of the hip allows identification of the posterior border of the gluteus medius and short external rotators. The fat pad over the QC is swept medially with an abdominal sponge to identify the muscles. A plane is identified between the quadratus femoris and inferior gemellus. Next, a plane is developed between the QC and posterior hip capsule with use of a blunt hemostat from inferior to superior. Abduction of the hip just beyond neutral relaxes the QC and allows superior retraction. The quadratus femoris is detached from t","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"16 1","pages":""},"PeriodicalIF":1.6,"publicationDate":"2026-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12784010/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145953358","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}
Pub Date : 2025-12-11eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.23.00032
Alex Burnikel, Gregory Faucher
<p><strong>Background: </strong>Metacarpal and phalangeal fractures are among the most common fractures that upper-extremity surgeons encounter, accounting for 30% of all hand fractures<sup>1,2</sup>. These particular fractures can be treated either operatively or nonoperatively, according to the amounts of displacement, malrotation, and shortening<sup>1</sup>. Operative treatment includes the use of Kirschner wire fixation, intramedullary screws, plate-and-screw constructs, or interfragmentary screws. Multiple studies have demonstrated superior biomechanical strength and early active range of motion with use of intramedullary screws for the treatment of unstable metacarpal and phalangeal fractures<sup>3-7</sup>. This minimally invasive technique is designed for unstable metacarpal or phalangeal shaft and neck fractures to allow early active motion. Furthermore, intramedullary placement of implants avoids hardware prominence and extensive soft-tissue stripping, which can impact tendon gliding and postoperative range of motion.</p><p><strong>Description: </strong>Metacarpal fractures can be treated with 3.6 or 4.0-mm intramedullary screws according to the canal diameter. The fracture is reduced by closed means or a limited open reduction. With the metacarpophalangeal joint flexed, the guidewire is inserted into the dorsal third of the metacarpal head through the articular cartilage and driven past the fracture site to the desired depth. A small stab incision is made, and the depth gauge is placed against the metacarpal head. The cannulated drill is placed over the guidewire, and the canal is drilled on the oscillate setting. A screw of the appropriate diameter and length is then placed over the wire, and its position is confirmed under fluoroscopy. Phalangeal fractures are treated with one or two 2-mm screws, inserted antegrade or retrograde according to the fracture location and orientation. The fracture is reduced, and the dual-diameter guidewire is passed through the long axis of the canal to the level of the far cortex (typically at the phalangeal base). A stab incision is made, and the depth gauge is inserted down to bone. The dual-diameter guidepin measures 1.6 mm in diameter on one half and 0.8 mm on the other half. The 1.6-mm portion of the guidewire is then driven out of the far cortex such that the smaller-diameter segment spans the fracture site and remains in the bone. The screw is then placed over the guidewire. A second screw may be placed in a V or X pattern with use of a similar technique.</p><p><strong>Alternatives: </strong>Alternatives to this procedure include nonoperative treatment, Kirschner wire fixation, plate-and-screw constructs, interfragmentary compression screws, and intramedullary headless compression screws.</p><p><strong>Expected outcomes: </strong>Although many metacarpal and phalangeal fractures may be treated by closed means, a number of fractures require surgical fixation. Melone discussed that 10% of phalangeal
{"title":"Treatment of Metacarpal and Phalangeal Fractures: Intramedullary Screw Technique.","authors":"Alex Burnikel, Gregory Faucher","doi":"10.2106/JBJS.ST.23.00032","DOIUrl":"10.2106/JBJS.ST.23.00032","url":null,"abstract":"<p><strong>Background: </strong>Metacarpal and phalangeal fractures are among the most common fractures that upper-extremity surgeons encounter, accounting for 30% of all hand fractures<sup>1,2</sup>. These particular fractures can be treated either operatively or nonoperatively, according to the amounts of displacement, malrotation, and shortening<sup>1</sup>. Operative treatment includes the use of Kirschner wire fixation, intramedullary screws, plate-and-screw constructs, or interfragmentary screws. Multiple studies have demonstrated superior biomechanical strength and early active range of motion with use of intramedullary screws for the treatment of unstable metacarpal and phalangeal fractures<sup>3-7</sup>. This minimally invasive technique is designed for unstable metacarpal or phalangeal shaft and neck fractures to allow early active motion. Furthermore, intramedullary placement of implants avoids hardware prominence and extensive soft-tissue stripping, which can impact tendon gliding and postoperative range of motion.</p><p><strong>Description: </strong>Metacarpal fractures can be treated with 3.6 or 4.0-mm intramedullary screws according to the canal diameter. The fracture is reduced by closed means or a limited open reduction. With the metacarpophalangeal joint flexed, the guidewire is inserted into the dorsal third of the metacarpal head through the articular cartilage and driven past the fracture site to the desired depth. A small stab incision is made, and the depth gauge is placed against the metacarpal head. The cannulated drill is placed over the guidewire, and the canal is drilled on the oscillate setting. A screw of the appropriate diameter and length is then placed over the wire, and its position is confirmed under fluoroscopy. Phalangeal fractures are treated with one or two 2-mm screws, inserted antegrade or retrograde according to the fracture location and orientation. The fracture is reduced, and the dual-diameter guidewire is passed through the long axis of the canal to the level of the far cortex (typically at the phalangeal base). A stab incision is made, and the depth gauge is inserted down to bone. The dual-diameter guidepin measures 1.6 mm in diameter on one half and 0.8 mm on the other half. The 1.6-mm portion of the guidewire is then driven out of the far cortex such that the smaller-diameter segment spans the fracture site and remains in the bone. The screw is then placed over the guidewire. A second screw may be placed in a V or X pattern with use of a similar technique.</p><p><strong>Alternatives: </strong>Alternatives to this procedure include nonoperative treatment, Kirschner wire fixation, plate-and-screw constructs, interfragmentary compression screws, and intramedullary headless compression screws.</p><p><strong>Expected outcomes: </strong>Although many metacarpal and phalangeal fractures may be treated by closed means, a number of fractures require surgical fixation. Melone discussed that 10% of phalangeal","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 4","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12688766/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145745048","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}
Pub Date : 2025-12-11eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.23.00066
Chad Z Simon, Joshua Zhang, Kasra Araghi, Tomoyuki Asada, Venkat Boddapati, Adin M Ehrlich, Jerry Y Du, Hiroyuki Nakarai, Sheeraz A Qureshi
<p><strong>Background: </strong>Robotic-assisted (RA) minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) is an advantageous combination of 2 techniques utilized to treat lumbar degenerative pathologies. Given the lack of direct visualization of anatomic landmarks in MI-TLIF, radiography is necessary for accurate pedicle screw placement<sup>1-5</sup>. Navigation-guided systems have shown superiority over fluoroscopy by allowing for 3-D visualization and tracking<sup>6-11</sup>. RA systems can potentially allow for greater accuracy via robotic-arm guidance adherent to planned trajectories<sup>12</sup>. Although instrumentation complications are multifactorial, robotic guidance is another surgical tool to improve instrumentation accuracy and minimize invasiveness following MI-TLIF.</p><p><strong>Description: </strong>With the patient under general anesthesia and in a prone position, 2 reference arrays attached to the patient via bilateral posterior sacroiliac spine incisions are made in order to perform intraoperative computed tomography (CT) with an array-integrated CT scanner and to calibrate the robotic instruments. Surgical planning for the screws and interbody cage is performed on the interface of the robotic tool. With use of the robotic arm, percutaneous pedicle screws are placed bilaterally. A tubular retractor is then docked over the facet joint. A unilateral facetectomy is performed, followed by a complete discectomy with end plate preparation. Bone graft is placed into the disc space. An expandable interbody cage is filled with bone graft, tamped into place, and expanded. The disc space is then backfilled with more bone graft. Rods are inserted percutaneously. Placement of all instrumentation is confirmed fluoroscopically, and the wounds are closed in a multilayered approach.</p><p><strong>Alternatives: </strong>Nonoperative alternatives to RA MI-TLIF include physical therapy, pharmacologic treatment, and lumbar and interlaminar transforaminal epidural corticosteroid injections. Surgical alternatives include RA open TLIF, MI-TLIF with fluoroscopy or navigation, posterior lumbar interbody fusion, lateral lumbar interbody fusion, and anterior lumbar interbody fusion<sup>13</sup>.</p><p><strong>Rationale: </strong>RA screw placement has been shown to be more accurate than fluoroscopy-guided placement, with a lower incidence of pedicle wall penetration or facet joint invasion, better insertion angle, and less blood loss<sup>14-16</sup>. Compared with open TLIF, RA MI-TLIF provides improved screw placement, less blood loss, shorter length of stay, and better patient-reported outcome scores; however, it does increase operative time and radiation exposure<sup>17,18</sup>. Furthermore, RA MI-TLIF has shown several advantages over fluoroscopy-assisted MI-TLIF, as it has similar 2-year fusion rates but is more accurate, has less complications, has less facet joint violation, yields greater adjacent disc height at 2 years, and exp
{"title":"Robotic-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion.","authors":"Chad Z Simon, Joshua Zhang, Kasra Araghi, Tomoyuki Asada, Venkat Boddapati, Adin M Ehrlich, Jerry Y Du, Hiroyuki Nakarai, Sheeraz A Qureshi","doi":"10.2106/JBJS.ST.23.00066","DOIUrl":"10.2106/JBJS.ST.23.00066","url":null,"abstract":"<p><strong>Background: </strong>Robotic-assisted (RA) minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) is an advantageous combination of 2 techniques utilized to treat lumbar degenerative pathologies. Given the lack of direct visualization of anatomic landmarks in MI-TLIF, radiography is necessary for accurate pedicle screw placement<sup>1-5</sup>. Navigation-guided systems have shown superiority over fluoroscopy by allowing for 3-D visualization and tracking<sup>6-11</sup>. RA systems can potentially allow for greater accuracy via robotic-arm guidance adherent to planned trajectories<sup>12</sup>. Although instrumentation complications are multifactorial, robotic guidance is another surgical tool to improve instrumentation accuracy and minimize invasiveness following MI-TLIF.</p><p><strong>Description: </strong>With the patient under general anesthesia and in a prone position, 2 reference arrays attached to the patient via bilateral posterior sacroiliac spine incisions are made in order to perform intraoperative computed tomography (CT) with an array-integrated CT scanner and to calibrate the robotic instruments. Surgical planning for the screws and interbody cage is performed on the interface of the robotic tool. With use of the robotic arm, percutaneous pedicle screws are placed bilaterally. A tubular retractor is then docked over the facet joint. A unilateral facetectomy is performed, followed by a complete discectomy with end plate preparation. Bone graft is placed into the disc space. An expandable interbody cage is filled with bone graft, tamped into place, and expanded. The disc space is then backfilled with more bone graft. Rods are inserted percutaneously. Placement of all instrumentation is confirmed fluoroscopically, and the wounds are closed in a multilayered approach.</p><p><strong>Alternatives: </strong>Nonoperative alternatives to RA MI-TLIF include physical therapy, pharmacologic treatment, and lumbar and interlaminar transforaminal epidural corticosteroid injections. Surgical alternatives include RA open TLIF, MI-TLIF with fluoroscopy or navigation, posterior lumbar interbody fusion, lateral lumbar interbody fusion, and anterior lumbar interbody fusion<sup>13</sup>.</p><p><strong>Rationale: </strong>RA screw placement has been shown to be more accurate than fluoroscopy-guided placement, with a lower incidence of pedicle wall penetration or facet joint invasion, better insertion angle, and less blood loss<sup>14-16</sup>. Compared with open TLIF, RA MI-TLIF provides improved screw placement, less blood loss, shorter length of stay, and better patient-reported outcome scores; however, it does increase operative time and radiation exposure<sup>17,18</sup>. Furthermore, RA MI-TLIF has shown several advantages over fluoroscopy-assisted MI-TLIF, as it has similar 2-year fusion rates but is more accurate, has less complications, has less facet joint violation, yields greater adjacent disc height at 2 years, and exp","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 4","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12688765/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145745028","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}
Pub Date : 2025-11-21eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.24.00034
Hyun-Jin Park, Joshua H Lee, Matthew S Miyasaka, Samuel Q Li, Daniel C Berman, Ula Isleem, Samuel K Cho
<p><strong>Background: </strong>In spine surgery, biportal endoscopy (BE) is a minimally invasive approach for addressing a range of degenerative lumbar pathologies, including degenerative lumbar spondylolisthesis. The biportal technique benefits from the separation of the endoscopic viewing portal and the working portal for surgical tools, which facilitates an expanded visual field and greater operative flexibility<sup>1-3</sup>. BE enables both decompression and transforaminal lumbar interbody fusion (TLIF) within a single procedure<sup>4</sup>. Furthermore, integrating stereotactic navigation with BE enhances the precision of pedicle screw placement, decompression, intervertebral disc removal, end-plate preparation, and navigated cage insertion.<sup>5,6</sup>.</p><p><strong>Description: </strong>After positioning the patient prone on a radiolucent table, the surgical field is prepared and draped in a sterile fashion. A reference pin is inserted into the iliac crest to facilitate stereotactic navigation. With use of this navigation, 2 separate 1.5 to 2-cm stab incisions are made just lateral to the cranial and caudal pedicles. The pedicles are probed and tapped in order to allow later pedicle screw fixation. Two additional skin incisions are made on the contralateral side, and percutaneous pedicle screw fixation is performed. A 30° arthroscope is introduced through the cranial incision, and a working portal is established through the caudal incision with use of a semitubular retractor. Irrigation is performed, typically set at 30 mmHg. Radiofrequency ablation is utilized to create a working space and to detach the paraspinal muscles from the underlying lamina, extending caudally into the interlaminar space and laterally to remove the facet joint capsule. Ipsilateral laminotomy or laminectomy is performed with a standard arthroscopic shaver and burr until the cranial insertion of the ligamentum flavum is visualized. Contralateral decompression is achieved by removing the ventral portion of the lamina above the ligamentum flavum, after which the ligamentum flavum is detached and removed. The ipsilateral facet joint is then removed with use of a burr and Kerrison rongeurs until the exiting nerve root is visualized and protected. An anulotomy is performed to access the disc space. End-plate preparation is conducted with use of stereotactic navigation and direct visualization through the endoscope. After trialing, an expandable cage is placed under direct visualization and navigation guidance. The endoscope is utilized to confirm the proper placement of the cage and to coagulate any epidural bleeding. Ipsilateral pedicle screws are placed with use of navigation, and rods are introduced under the fascia. Set screws are applied, and fluoroscopic images are obtained to verify the correct placement of implants.</p><p><strong>Alternatives: </strong>Surgical alternatives for degenerative lumbar spondylolisthesis include both open and tubular decompression
{"title":"Stereotactic Navigation-Guided Biportal Endoscopic Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Spondylolisthesis.","authors":"Hyun-Jin Park, Joshua H Lee, Matthew S Miyasaka, Samuel Q Li, Daniel C Berman, Ula Isleem, Samuel K Cho","doi":"10.2106/JBJS.ST.24.00034","DOIUrl":"10.2106/JBJS.ST.24.00034","url":null,"abstract":"<p><strong>Background: </strong>In spine surgery, biportal endoscopy (BE) is a minimally invasive approach for addressing a range of degenerative lumbar pathologies, including degenerative lumbar spondylolisthesis. The biportal technique benefits from the separation of the endoscopic viewing portal and the working portal for surgical tools, which facilitates an expanded visual field and greater operative flexibility<sup>1-3</sup>. BE enables both decompression and transforaminal lumbar interbody fusion (TLIF) within a single procedure<sup>4</sup>. Furthermore, integrating stereotactic navigation with BE enhances the precision of pedicle screw placement, decompression, intervertebral disc removal, end-plate preparation, and navigated cage insertion.<sup>5,6</sup>.</p><p><strong>Description: </strong>After positioning the patient prone on a radiolucent table, the surgical field is prepared and draped in a sterile fashion. A reference pin is inserted into the iliac crest to facilitate stereotactic navigation. With use of this navigation, 2 separate 1.5 to 2-cm stab incisions are made just lateral to the cranial and caudal pedicles. The pedicles are probed and tapped in order to allow later pedicle screw fixation. Two additional skin incisions are made on the contralateral side, and percutaneous pedicle screw fixation is performed. A 30° arthroscope is introduced through the cranial incision, and a working portal is established through the caudal incision with use of a semitubular retractor. Irrigation is performed, typically set at 30 mmHg. Radiofrequency ablation is utilized to create a working space and to detach the paraspinal muscles from the underlying lamina, extending caudally into the interlaminar space and laterally to remove the facet joint capsule. Ipsilateral laminotomy or laminectomy is performed with a standard arthroscopic shaver and burr until the cranial insertion of the ligamentum flavum is visualized. Contralateral decompression is achieved by removing the ventral portion of the lamina above the ligamentum flavum, after which the ligamentum flavum is detached and removed. The ipsilateral facet joint is then removed with use of a burr and Kerrison rongeurs until the exiting nerve root is visualized and protected. An anulotomy is performed to access the disc space. End-plate preparation is conducted with use of stereotactic navigation and direct visualization through the endoscope. After trialing, an expandable cage is placed under direct visualization and navigation guidance. The endoscope is utilized to confirm the proper placement of the cage and to coagulate any epidural bleeding. Ipsilateral pedicle screws are placed with use of navigation, and rods are introduced under the fascia. Set screws are applied, and fluoroscopic images are obtained to verify the correct placement of implants.</p><p><strong>Alternatives: </strong>Surgical alternatives for degenerative lumbar spondylolisthesis include both open and tubular decompression","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 4","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12634222/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145589084","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}
Pub Date : 2025-11-19eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.23.00087
Tejas Subramanian, Kasra Araghi, Eric Mai, Takashi Hirase, Chad Z Simon, Austin C Kaidi, Tomoyuki Asada, Pratyush Shahi, Sravisht Iyer
<p><strong>Background: </strong>Percutaneous transforaminal endoscopic discectomy (PTED) is a minimally invasive technique for the treatment of symptomatic lumbar disc herniation (LDH) that is growing in popularity. The procedure involves the insertion of a transforaminal spinal endoscope for direct access and removal of intra and extra-foraminal disc fragments<sup>1</sup>.</p><p><strong>Description: </strong>The patient is preferably placed in a prone position. A spinal needle is advanced under fluoroscopic guidance into the foramen to the medial border of the inferior pedicle. A guidewire is introduced through the needle cannula, and sequential dilators are advanced into the foramen. A partial facetectomy/foraminotomy is performed so that a 10-mm working cannula and spinal endoscope can be introduced. Endoscopic pituitary rongeurs are utilized to remove the extruded disc material. Once the extruded fragments are no longer visualized, a probe is utilized to verify that no remaining disc material is present, and a diagnostic endoscopy is performed. The cannula is removed, and the incision is closed in a standard fashion.</p><p><strong>Alternatives: </strong>Nonoperative alternatives to PTED include activity modification, nonsteroidal anti-inflammatory drugs and/or acetaminophen, physical therapy, and epidural steroid injections<sup>2</sup>. When surgical intervention is indicated, alternative techniques for decompression include conventional microdiscectomy, tubular microdiscectomy, and unilateral biportal endoscopic discectomy<sup>3</sup>, as well as lumbar fusion techniques.</p><p><strong>Rationale: </strong>PTED shares similar indications as open and tubular discectomy, including soft LDH confirmed on imaging, persistent radiculopathy, new sensory/motor neurologic deficits, and failed nonoperative treatment of >6 weeks<sup>1</sup>. Compared with open and tubular discectomy, PTED offers several advantages, including a smaller skin incision, feasibility under local anesthesia, direct visualization, avoidance of muscle retraction, minimal bone removal and neural manipulation, preservation of spine stability and adjacent anatomy, decreased intraoperative blood loss, and shorter operative times<sup>4-11</sup>. In patients with a far lateral or foraminal LDH, PTED may avoid the need for fusion<sup>12</sup>. Considerations for PTED include the narrow working corridor, representing a risk of iatrogenic injury or incomplete decompression, and the associated learning curve<sup>13,14</sup>. Relative contraindications include recurrent LDH, paracentral LDH, extruded LDH, sequestration of the disc, significant obesity, isthmic spondylolisthesis, and severe canal stenosis<sup>11</sup>. Additionally, accessing the lower lumbar levels via a transforaminal approach may be difficult in patients with a high iliac crest.</p><p><strong>Expected outcomes: </strong>PTED is a safe procedure that has been shown to improve patient-reported outcomes and functional statu
{"title":"Percutaneous Transforaminal Endoscopic Discectomy: Surgical Techniques, Indications, and Outcomes.","authors":"Tejas Subramanian, Kasra Araghi, Eric Mai, Takashi Hirase, Chad Z Simon, Austin C Kaidi, Tomoyuki Asada, Pratyush Shahi, Sravisht Iyer","doi":"10.2106/JBJS.ST.23.00087","DOIUrl":"10.2106/JBJS.ST.23.00087","url":null,"abstract":"<p><strong>Background: </strong>Percutaneous transforaminal endoscopic discectomy (PTED) is a minimally invasive technique for the treatment of symptomatic lumbar disc herniation (LDH) that is growing in popularity. The procedure involves the insertion of a transforaminal spinal endoscope for direct access and removal of intra and extra-foraminal disc fragments<sup>1</sup>.</p><p><strong>Description: </strong>The patient is preferably placed in a prone position. A spinal needle is advanced under fluoroscopic guidance into the foramen to the medial border of the inferior pedicle. A guidewire is introduced through the needle cannula, and sequential dilators are advanced into the foramen. A partial facetectomy/foraminotomy is performed so that a 10-mm working cannula and spinal endoscope can be introduced. Endoscopic pituitary rongeurs are utilized to remove the extruded disc material. Once the extruded fragments are no longer visualized, a probe is utilized to verify that no remaining disc material is present, and a diagnostic endoscopy is performed. The cannula is removed, and the incision is closed in a standard fashion.</p><p><strong>Alternatives: </strong>Nonoperative alternatives to PTED include activity modification, nonsteroidal anti-inflammatory drugs and/or acetaminophen, physical therapy, and epidural steroid injections<sup>2</sup>. When surgical intervention is indicated, alternative techniques for decompression include conventional microdiscectomy, tubular microdiscectomy, and unilateral biportal endoscopic discectomy<sup>3</sup>, as well as lumbar fusion techniques.</p><p><strong>Rationale: </strong>PTED shares similar indications as open and tubular discectomy, including soft LDH confirmed on imaging, persistent radiculopathy, new sensory/motor neurologic deficits, and failed nonoperative treatment of >6 weeks<sup>1</sup>. Compared with open and tubular discectomy, PTED offers several advantages, including a smaller skin incision, feasibility under local anesthesia, direct visualization, avoidance of muscle retraction, minimal bone removal and neural manipulation, preservation of spine stability and adjacent anatomy, decreased intraoperative blood loss, and shorter operative times<sup>4-11</sup>. In patients with a far lateral or foraminal LDH, PTED may avoid the need for fusion<sup>12</sup>. Considerations for PTED include the narrow working corridor, representing a risk of iatrogenic injury or incomplete decompression, and the associated learning curve<sup>13,14</sup>. Relative contraindications include recurrent LDH, paracentral LDH, extruded LDH, sequestration of the disc, significant obesity, isthmic spondylolisthesis, and severe canal stenosis<sup>11</sup>. Additionally, accessing the lower lumbar levels via a transforaminal approach may be difficult in patients with a high iliac crest.</p><p><strong>Expected outcomes: </strong>PTED is a safe procedure that has been shown to improve patient-reported outcomes and functional statu","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 4","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12622600/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145557774","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}
Pub Date : 2025-11-19eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.24.00013
Myung-Jin Cha, Varun Puvanesarajah, Paul Sponseller
<p><strong>Background: </strong>The "sandwich allograft" technique is indicated for correction of long-bone deformity in patients with osteogenesis imperfecta (OI) or another bone dysplasia. The external press-fit created by the large surface area of the allograft provides circumferential stabilization and introduces normal collagen to the long-bone nonunion site. Split allografts sandwich around the bone to promote stability and healing and to correct the deformity. This technique addresses the main issues in treating nonunion sites in patients with OI. First, osteogenesis has plateaued at the nonunion site, and this technique is osteoconductive. Second, traditional fixation techniques are not effective, as plates and screws do not achieve good fixation in brittle bone, and the circumferential fit of the allograft provides a different means of stabilization. Finally, the allograft bone is structurally stronger than the host OI bone.</p><p><strong>Description: </strong>Careful patient selection and preoperative planning are critical to ordering allograft with the correct length and width, as well as the correct type of internal fixation. The nonunion site is exposed circumferentially, and the periosteum is elevated. In instances in which there is previous intramedullary fixation, the implant should be assessed for any migration or breakage, which would warrant removal. New intramedullary fixation is then performed to align the bone ends at the nonunion site. Fresh-frozen allograft was selected in the example case because it is thought to be more osteoinductive. The allograft is then halved longitudinally and its ends are contoured and trimmed. Allograft ends are also contoured to fit the fracture proximally and distally. The native bone is compressed at the nonunion as much as possible. The 2 allograft halves are then sandwiched on opposing sides of the nonunion site, surrounding the nonunion. They are held with use of a Verbrugge clamp and compressed with use of cortical screws. Finally, during closure, the previously elevated muscle envelope apposes the new construct.</p><p><strong>Alternatives: </strong>Nonoperative treatment of OI varies with the severity of the disease and the functional status of the patient<sup>1</sup>. Age should also be considered, as fractures occur most often in early childhood and fracture rates decline after the child reaches skeletal maturity<sup>2</sup>. Discontinuing contact sports and performing physical therapy and rehabilitation can help to both avoid and treat fractures. Operative treatment includes the insertion of intramedullary rods for fracture treatment and deformity correction. Rigid plate constructs are typically avoided to prevent osseous resorption from the stress shielding<sup>3</sup>. However, the use of a unicortical locking plate has been shown to be an effective supplement to intramedullary rod fixation<sup>4</sup>.</p><p><strong>Rationale: </strong>Stabilization of fractures in patients with OI
{"title":"Sandwich Allograft for Long-Bone Deformity Correction in Bone Dysplasia.","authors":"Myung-Jin Cha, Varun Puvanesarajah, Paul Sponseller","doi":"10.2106/JBJS.ST.24.00013","DOIUrl":"10.2106/JBJS.ST.24.00013","url":null,"abstract":"<p><strong>Background: </strong>The \"sandwich allograft\" technique is indicated for correction of long-bone deformity in patients with osteogenesis imperfecta (OI) or another bone dysplasia. The external press-fit created by the large surface area of the allograft provides circumferential stabilization and introduces normal collagen to the long-bone nonunion site. Split allografts sandwich around the bone to promote stability and healing and to correct the deformity. This technique addresses the main issues in treating nonunion sites in patients with OI. First, osteogenesis has plateaued at the nonunion site, and this technique is osteoconductive. Second, traditional fixation techniques are not effective, as plates and screws do not achieve good fixation in brittle bone, and the circumferential fit of the allograft provides a different means of stabilization. Finally, the allograft bone is structurally stronger than the host OI bone.</p><p><strong>Description: </strong>Careful patient selection and preoperative planning are critical to ordering allograft with the correct length and width, as well as the correct type of internal fixation. The nonunion site is exposed circumferentially, and the periosteum is elevated. In instances in which there is previous intramedullary fixation, the implant should be assessed for any migration or breakage, which would warrant removal. New intramedullary fixation is then performed to align the bone ends at the nonunion site. Fresh-frozen allograft was selected in the example case because it is thought to be more osteoinductive. The allograft is then halved longitudinally and its ends are contoured and trimmed. Allograft ends are also contoured to fit the fracture proximally and distally. The native bone is compressed at the nonunion as much as possible. The 2 allograft halves are then sandwiched on opposing sides of the nonunion site, surrounding the nonunion. They are held with use of a Verbrugge clamp and compressed with use of cortical screws. Finally, during closure, the previously elevated muscle envelope apposes the new construct.</p><p><strong>Alternatives: </strong>Nonoperative treatment of OI varies with the severity of the disease and the functional status of the patient<sup>1</sup>. Age should also be considered, as fractures occur most often in early childhood and fracture rates decline after the child reaches skeletal maturity<sup>2</sup>. Discontinuing contact sports and performing physical therapy and rehabilitation can help to both avoid and treat fractures. Operative treatment includes the insertion of intramedullary rods for fracture treatment and deformity correction. Rigid plate constructs are typically avoided to prevent osseous resorption from the stress shielding<sup>3</sup>. However, the use of a unicortical locking plate has been shown to be an effective supplement to intramedullary rod fixation<sup>4</sup>.</p><p><strong>Rationale: </strong>Stabilization of fractures in patients with OI ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 4","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12622596/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145557767","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}
Pub Date : 2025-11-19eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.22.00029
Amar S Vadhera, Mariano E Menendez, Zeeshan Khan, Suhas P Dasari, Matthew R Cohn, Nikhil N Verma
<p><strong>Background: </strong>Ulnar collateral ligament (UCL) reconstruction has become an increasingly common procedure in overhead-throwing athletes because of overuse and repetitive valgus stress placed on the inside of the elbow or valgus stress during an acute traumatic event<sup>2</sup>. Athletes with a deficient UCL often report a decrease in pitch velocity and accuracy in addition to an increase in fatigue, pain, and instability<sup>4</sup>. As such, UCL reconstructive procedures have been increasing in prevalence in throwing athletes to address their symptoms and regain their throwing capabilities, particularly in young baseball players at the high school and collegiate levels<sup>1</sup>.</p><p><strong>Description: </strong>For the present video article, a hamstring autograft was chosen because of its availability in all patients and its noninferior outcomes reported in the literature. Following gracilis graft harvest, the reconstruction begins centered on the medial epicondyle with the patient in a supine position. The ulnar nerve is identified and freed both proximally and distally. The split is extended distally through the heads of the flexor carpi ulnaris. From the base of the flexor carpi ulnaris, the sublime tubercle is identified, and the UCL is opened inline. A standard guide is utilized to drill holes in both the posterior and anterior aspects of the sublime tubercle. These holes are then connected with use of a curved curet, and a suture is passed along the tunnels for later graft passage. A blind-ended tunnel is drilled at two-thirds of the distance from the tip to the base of the epicondyle. Two smaller tunnels are then drilled with Kirschner wires to allow passing sutures through the posterior aspect of the epicondyle. The native UCL is closed, and the graft is passed through the sublime tubercle tunnels. One end of the graft is docked into the epicondylar tunnel, and a docking procedure is performed so that both ends of the graft are docked within the humeral tunnel. Stay sutures are tied over a bone bridge, and the 2 limbs of the graft are sutured together to appropriately tension the graft.</p><p><strong>Alternatives: </strong>Although nonoperative treatments with a hinged elbow brace may be appropriate in low-demand patients, reconstruction is preferred in high-volume throwers with future hopes of returning to play. Nonoperative treatment may involve rest, physical therapy, and a graduated throwing program in addition to biologic injections.</p><p><strong>Rationale: </strong>The present video article includes a checklist of the senior author's top 10 key steps for a successful UCL reconstruction with hamstring autograft, which can be utilized to guide surgeons through the steps of the procedure. This procedure is preferred for patients with substantial throwing pain and a strong desire to return to a high level of throwing, as many who discontinue sport may be able to perform normal activities of daily living even wi
{"title":"Tips for Successful Ulnar Collateral Ligament Reconstruction.","authors":"Amar S Vadhera, Mariano E Menendez, Zeeshan Khan, Suhas P Dasari, Matthew R Cohn, Nikhil N Verma","doi":"10.2106/JBJS.ST.22.00029","DOIUrl":"10.2106/JBJS.ST.22.00029","url":null,"abstract":"<p><strong>Background: </strong>Ulnar collateral ligament (UCL) reconstruction has become an increasingly common procedure in overhead-throwing athletes because of overuse and repetitive valgus stress placed on the inside of the elbow or valgus stress during an acute traumatic event<sup>2</sup>. Athletes with a deficient UCL often report a decrease in pitch velocity and accuracy in addition to an increase in fatigue, pain, and instability<sup>4</sup>. As such, UCL reconstructive procedures have been increasing in prevalence in throwing athletes to address their symptoms and regain their throwing capabilities, particularly in young baseball players at the high school and collegiate levels<sup>1</sup>.</p><p><strong>Description: </strong>For the present video article, a hamstring autograft was chosen because of its availability in all patients and its noninferior outcomes reported in the literature. Following gracilis graft harvest, the reconstruction begins centered on the medial epicondyle with the patient in a supine position. The ulnar nerve is identified and freed both proximally and distally. The split is extended distally through the heads of the flexor carpi ulnaris. From the base of the flexor carpi ulnaris, the sublime tubercle is identified, and the UCL is opened inline. A standard guide is utilized to drill holes in both the posterior and anterior aspects of the sublime tubercle. These holes are then connected with use of a curved curet, and a suture is passed along the tunnels for later graft passage. A blind-ended tunnel is drilled at two-thirds of the distance from the tip to the base of the epicondyle. Two smaller tunnels are then drilled with Kirschner wires to allow passing sutures through the posterior aspect of the epicondyle. The native UCL is closed, and the graft is passed through the sublime tubercle tunnels. One end of the graft is docked into the epicondylar tunnel, and a docking procedure is performed so that both ends of the graft are docked within the humeral tunnel. Stay sutures are tied over a bone bridge, and the 2 limbs of the graft are sutured together to appropriately tension the graft.</p><p><strong>Alternatives: </strong>Although nonoperative treatments with a hinged elbow brace may be appropriate in low-demand patients, reconstruction is preferred in high-volume throwers with future hopes of returning to play. Nonoperative treatment may involve rest, physical therapy, and a graduated throwing program in addition to biologic injections.</p><p><strong>Rationale: </strong>The present video article includes a checklist of the senior author's top 10 key steps for a successful UCL reconstruction with hamstring autograft, which can be utilized to guide surgeons through the steps of the procedure. This procedure is preferred for patients with substantial throwing pain and a strong desire to return to a high level of throwing, as many who discontinue sport may be able to perform normal activities of daily living even wi","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 4","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12626681/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145557794","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}
Pub Date : 2025-11-19eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.22.00072
Ashley B Bozzay, Benjamin K Potter, Jonathan A Forsberg
<p><strong>Background: </strong>The transfemoral or transhumeral Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA) osseointegration technique is indicated in patients with transfemoral or transhumeral amputations who have difficulty with use of a conventional socket and traditional prosthesis. Augmentations to the procedure, such as targeted muscle reinnervation (TMR) and/or a regenerative peripheral nerve interface (RPNI), serve to enhance function (in the case of TMR) and/or improve residual-limb neuropathic pain (in the case of combined TMR and RPNI) in the same patient population.</p><p><strong>Description: </strong>This surgical technique is typically performed as a 2-stage procedure with approximately 6 weeks to 3 months between stages to allow for adequate bone graft healing and osseointegration of the fixture to the surrounding bone. Stage 1: Position the fluoroscopy machine on the opposite side of the patient. Because all transfemoral amputations rest in slight external rotation, obtain a true anteroposterior view of the hip, note the rotation of the C-arm, and subtract 90° to obtain a true lateral radiograph. Utilizing the prior incision, develop cutaneous flaps and distally approach the bone of the residual limb. Most patients will require a thighplasty procedure to manage excess soft tissues. Thighplasty may be performed during stage 1 and/or stage 2. The previous muscle platform is encountered, and an osteotomy is performed perpendicular to the long axis of the bone. A bone graft (5 to 10 cc) is harvested from the proximal humerus or femur with use of a curved curet. Next, the bone is progressively reamed under fluoroscopic guidance until the cortex is encountered. Reaming is done by hand in order to avoid thermal necrosis. Care is taken to avoid reaming too much of the anterior cortex proximally. A tap is selected that is 1.5 mm thicker than the final reamer, and the bone is tapped with use of the line-to-line technique to the size of the fixture. In cases of soft bone, we choose to under-tap by 0.5 mm prior to inserting the fixture. The final OPRA implant is inserted into the bone. The central screw is inserted and tightened to 80 N-cm. The healing cylinder is placed, which serves as a mold for the bone graft, and the previously harvested bone graft is packed around it. The graft screw and large washer are placed to compress the bone graft. Placement of the implant and healing components is confirmed on biplanar fluoroscopy. Stage 2: Through a limited incision, the graft screw and components are removed. The bone graft is inspected for proper integration around the distal fixture. The purpose of the bone graft is to provide a broad, vascular base onto which the full-thickness skin graft heals. Then, cutaneous flaps are elevated and fasciotomies are made. A medial or lateral-based thighplasty can be performed to address any soft-tissue redundancies that may prevent a tight soft-tissue platform at closure. The fascia
{"title":"The Transfemoral and Transhumeral OPRA (Osseoanchored Prostheses for the Rehabilitation of Amputees) Osseointegration Technique.","authors":"Ashley B Bozzay, Benjamin K Potter, Jonathan A Forsberg","doi":"10.2106/JBJS.ST.22.00072","DOIUrl":"10.2106/JBJS.ST.22.00072","url":null,"abstract":"<p><strong>Background: </strong>The transfemoral or transhumeral Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA) osseointegration technique is indicated in patients with transfemoral or transhumeral amputations who have difficulty with use of a conventional socket and traditional prosthesis. Augmentations to the procedure, such as targeted muscle reinnervation (TMR) and/or a regenerative peripheral nerve interface (RPNI), serve to enhance function (in the case of TMR) and/or improve residual-limb neuropathic pain (in the case of combined TMR and RPNI) in the same patient population.</p><p><strong>Description: </strong>This surgical technique is typically performed as a 2-stage procedure with approximately 6 weeks to 3 months between stages to allow for adequate bone graft healing and osseointegration of the fixture to the surrounding bone. Stage 1: Position the fluoroscopy machine on the opposite side of the patient. Because all transfemoral amputations rest in slight external rotation, obtain a true anteroposterior view of the hip, note the rotation of the C-arm, and subtract 90° to obtain a true lateral radiograph. Utilizing the prior incision, develop cutaneous flaps and distally approach the bone of the residual limb. Most patients will require a thighplasty procedure to manage excess soft tissues. Thighplasty may be performed during stage 1 and/or stage 2. The previous muscle platform is encountered, and an osteotomy is performed perpendicular to the long axis of the bone. A bone graft (5 to 10 cc) is harvested from the proximal humerus or femur with use of a curved curet. Next, the bone is progressively reamed under fluoroscopic guidance until the cortex is encountered. Reaming is done by hand in order to avoid thermal necrosis. Care is taken to avoid reaming too much of the anterior cortex proximally. A tap is selected that is 1.5 mm thicker than the final reamer, and the bone is tapped with use of the line-to-line technique to the size of the fixture. In cases of soft bone, we choose to under-tap by 0.5 mm prior to inserting the fixture. The final OPRA implant is inserted into the bone. The central screw is inserted and tightened to 80 N-cm. The healing cylinder is placed, which serves as a mold for the bone graft, and the previously harvested bone graft is packed around it. The graft screw and large washer are placed to compress the bone graft. Placement of the implant and healing components is confirmed on biplanar fluoroscopy. Stage 2: Through a limited incision, the graft screw and components are removed. The bone graft is inspected for proper integration around the distal fixture. The purpose of the bone graft is to provide a broad, vascular base onto which the full-thickness skin graft heals. Then, cutaneous flaps are elevated and fasciotomies are made. A medial or lateral-based thighplasty can be performed to address any soft-tissue redundancies that may prevent a tight soft-tissue platform at closure. The fascia","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 4","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12626682/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145557689","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}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：