JBJS Essential Surgical Techniques最新文献

Large glenoid defects pose problems in reverse shoulder arthroplasty (RSA)^1-4. Bone-grafting enables restoration of the glenoid, but outcomes of this procedure may be hampered by early instability, which can lead to implant malpositioning, and by graft resorption, which can lead to implant loosening^2-7. To combat these potential complications, we utilize multiple bioresorbable pinning (MBP) during the bone-grafting process, in which as many bioresorbable pins as required are inserted from whatever aspect of the graft is appropriate until initial stability of the graft is achieved¹. We retrospectively compared the various grafting techniques applied for various degrees of retroversion, concluding that MBP is better when retroversion is >30°¹. Treatment decisions are made according to the degree of preoperative retroversion. The MBS technique is indicated for type-2 and type-3 glenoid deformities. This technique is not only relatively safe-as it involves only the use of bioresorbable materials-but also yields improved graft incorporation and less glenoid loosening¹.

Description: This procedure is performed with the patient under general anesthesia and in the beach-chair position, via a deltopectoral approach. After placing the structural graft, 5 to 10 provisional 1.5-mm Kirschner wires are inserted through the graft up the medal cortical bone of the scapula. The Kirschner wires are subsequently replaced with bioresorbable (BR) pins (1.5-mm Fixsorb Pin; TEIJIN). If more wires are needed, another set of 4 to 5 RB pins is inserted to gain initial stability. After placing the graft, the glenoid component is implanted as usual.

Alternatives: Traditionally, 1 or 2 screws are inserted in the periphery of the graft to obtain stability. The screws either must be inserted at an angle that does not impede placement of the implant² or are removed before the placement of the glenoid implant. One or a maximum of 2 long screws are inserted through the graft and glenoid³, meaning that the screw(s) must be aimed at a very narrow space between the central post and screws. Otherwise, these screws will represent an obstacle to the placement of the glenoid implant.

Rationale: In addition to facilitating initial graft stability, this procedure promotes graft incorporation. Typically, when performing this procedure, a total of 15 to 20 temporary Kirschner wires are placed in sets, with 5 to 7 wires per set. Of these, the most stable wires, usually 8 to 10 in total, are replaced by BR pins. The resultant bone holes, whether filled or unfilled with the BR pins, may promote neovascularization and osteoinduction, enabling long-lasting remodeling of and improved incorporation of the bone graft.

Expected outcomes: A prior study compared the use of MBP versus angulated bony-increased offset (BIO) graft, a

Operative treatment of anterior glenohumeral instability is challenging, particularly with the presence of an anterior glenoid rim fracture, also called an "osseous Bankart lesion." Successful reduction and fixation of the lesion has been shown to greatly reduce the risk of recurrent dislocations while achieving osseous union and normalization of glenoid anatomy¹.

Description: The current surgical video article outlines a technique for an osseous Bankart repair in a patient with a displaced fracture as well as substantial pain and instability. First, the amount of bone loss is measured on 3-dimensionally reconstructed computed tomography (CT) imaging, with the humeral head digitally subtracted². The procedure is then performed arthroscopically with the patient in the lateral decubitus position. A diagnostic evaluation, beginning with posterior and anterior portal placement in the rotator interval, is completed to assess any rotator cuff injury and the extent of labral tearing and osseous displacement. Next, the bone fragment is elevated into its anatomical position. This fragment is then reduced with use of a double-row suture technique, followed by concomitant capsulolabral repair.

Alternatives: Nonoperative treatment with a sling can be utilized as long as post-reduction CT scans reveal anteroposterior centering of the humeral head on the glenoid³. Rehabilitation can include active-assisted and passive glenohumeral mobilization, as well as daily pendulum exercises and physiotherapy.

Rationale: Osseous Bankart repair has been shown to effectively improve patient-reported outcomes and normalize glenoid morphology^1,3,4. Failure to recognize and appropriately treat an osseous Bankart fracture may lead to osseous erosion caused by repetitive episodes of subluxations or dislocations, along with substantial pain and weakness⁵. Indications for arthroscopic Bankart repair include young, active patients with a reducible fracture fragment, an anterior glenoid deficit of >10%, and a history of failed nonoperative treatment^3-8.

Expected outcomes: Clinical outcomes following the osseous Bankart repair procedure have been shown to be highly successful, with high rates of return to sport, minimal reduction in range of motion, and restoration of shoulder function and stability⁴. Additionally, long-term follow-up has shown successful osseous union and normalization of glenoid anatomy¹.

Important tips: Apply tension to sutures with a suture retriever before the PushLock anchors (Arthrex) are placed during fracture reduction.Utilize a trans-subscapularis portal for anchor placement medial to the fracture on the glenoid neck.Perform adjustable tensioning during labral repair with knotless all-suture anchors.Utilize a lateral distraction device with the patient

The rate of nonunion observed among the variety of Bristow-Latarjet procedures reportedly ranges from 9.4% to 28%¹. In Chinese timber buildings, the mortise-tenon joint is commonly utilized to connect beams to columns. Drawing inspirations from this concept, we created a bone trough in the glenoid neck to serve as a mortise and trimmed the coracoid graft to serve as a tenon, then fixed this mortise-tenon joint with a metal screw. Compared with a standard Bristow-Latarjet procedure, the key feature of this technique was that the coracoid process was placed into a trough (5 to 10 mm deep) in the glenoid neck, which substantially increased the bone contact area between the graft and glenoid neck. We called this surgical technique the Chinese unique inlay Bristow (Cuistow).

Description: Specific instruments have been designed to improve the safety and accuracy of the arthroscopic inlay Bristow procedure (Weigao, Shangdong, China). The posterior portal (A), superolateral portal (B), and 3 anterior portals (i.e., proximal [C], inferolateral [D], and inferomedial [E]) were utilized. General anesthesia and an interscalene block were administered with the patient in the beach-chair position. The surgical technique can be divided into 6 steps: (1) evaluation of the shoulder joint; (2) coracoid preparation, drilling, and osteotomy; (3) subscapularis splitting and labrum detachment; (4) glenoid preparation and drilling; (5) coracoid retrieval, trimming, transfer, and fixation; and (6) Bankart repair.

Alternatives: Soft-tissue capsulolabral repairs or bone reconstruction procedures are commonly performed for the treatment of anterior glenohumeral instability². The arthroscopic Bristow-Latarjet procedure is increasingly popular for the treatment of anterior shoulder instability with a substantial osseous defect of the glenoid³. Defects that are too large to be restored with the coracoid process can be treated with use of the Eden-Hybbinette procedure or a distal tibial allograft^4,5.

Rationale: This procedure was inspired by the structure of mortise-tenon joints, resulting in a modified version of the Bristow-Latarjet technique in which the coracoid process is trimmed and placed into a trough (5 to 10 mm deep) in the glenoid neck. This procedure substantially increases the contact area between the fresh bone surface and the coracoid and glenoid neck. Another important advantage of this technique is that it can facilitate accurate positioning of the coracoid on the glenoid. This procedure resulted in a high rate of graft healing, excellent functional outcomes (Rowe and American Shoulder and Elbow Surgeons Shoulder scores), and a high rate of return to sport⁶. Currently, indications of this procedure are (1) participation in high-demand sports (i.e., collision and overhead) combined with the presence of a glenoid defect involving <25%

There remains controversy regarding the ideal graft choice for anterior cruciate ligament (ACL) reconstruction¹. Bone-patellar tendon-bone and hamstring autografts have been considered the gold standard for decades. Despite the good clinical outcomes, donor-site morbidity is a concern for both of these grafts². Peroneus longus tendon autograft has also been considered as a potential graft for many orthopaedic reconstructive procedures³. The biomechanical properties and thickness of such a graft permit its use for ACL reconstruction^3,4. The tensile strength of a peroneus longus tendon autograft is the same as that of a hamstring autograft and greater than that of a bone-patellar tendon-bone graft and a quadriceps tendon graft^3,5. We aimed to describe the steps to harvest the peroneus longus tendon autograft during single-bundle ACL reconstruction.

Description: Identification of anatomical landmarks is performed, including the distal aspect of the fibula and the posterior border of the fibula, 2 cm above the tip of the bone. A longitudinal incision is made along the posterior border of the fibular bone, from 2cm above the tip of the fibula. Care is taken to identify the tendon sheath that covers the longus and brevis approximately 2 cm above the superior extensor retinaculum, and the peroneus longus is stitched to the peroneus brevis. The proximal aspect of the peroneus longus tendon is whipstitched, after which the peroneus longus tendon and surrounding soft tissues are incised. The peroneus longus tendon is then released with use of a closed stripper, and the graft is prepared.

Alternatives: Alternative nonoperative treatment options include physical therapy, nonsteroidal anti-inflammatory drugs, rest, and limitation of sporting activities. Alternative surgical treatment options include arthroscopic debridement, ACL repair or reconstruction with bone-patellar tendon-bone or hamstring-tendon autograft, and ACL reconstruction with allograft.

Rationale: Recent studies have shown that ACL reconstruction with use of a peroneus longus tendon autograft is safe and effective, with less donor-site morbidity compared with other tendon autografts^4,6,7.

Expected outcomes: The peroneus longus graft has been accepted for ligament reconstruction because of its strength, safety, and less donor-site morbidity⁷. The peroneus longus graft allows surgeons to harvest the autograft via a relatively small incision, resulting in fewer donor-site complications⁴. According to Rhatomy et al., the use of a peroneus longus graft provides good functional outcomes that are comparable with those of a hamstring autograft, but it has a larger graft diameter and its harvest results in less thigh hypotrophy⁸. Additionally, a case series of 10 patients who underwent ACL reconstruction with

Irreparable rotator cuff tears are those that cannot be restored back to their native footprint or those in which any repair will "almost certainly" lead to a structural failure as a result of poor tissue quality, degeneration, or retraction^1-3. The InSpace subacromial balloon spacer (Stryker) was developed as a temporary spacer to restore anatomic relationships between the glenoid, humerus, and acromion to improve function and reduce pain associated with this challenging pathology.

Description: First, a diagnostic arthroscopy is performed. In addition to evaluating the rotator cuff, care is taken to evaluate the tendinous insertion of the subscapularis as well as the long head of the biceps tendon, the labrum, and the articular cartilage of the joint. Synovectomy, bursectomy, and biceps tenodesis or tenotomy are performed as appropriate. For cases with an intact or repairable subscapularis, an acromioplasty is performed. The balloon size is determined with use of a probe through the lateral portal, measured from 1 cm medial to the superior glenoid rim to the lateral border of the acromion. The balloon-insertion device is advanced through the lateral portal, and the balloon is inflated with sterile saline solution after appropriate subacromial positioning. The balloon is then sealed and detached from the insertional device.

Alternatives: Most treatment algorithms attempt to reduce pain and dysfunction with initial nonoperative treatment options⁴. For cases in which nonoperative treatment has failed, several surgical techniques have been described. These include partial rotator cuff repair, graft interposition, graft augmentation, superior capsular reconstruction, tendon transfers, and reverse total shoulder arthroplasty⁵.

Rationale: Ideal candidates for this procedure are patients with irreparable symptomatic rotator cuff tears. These patients should primarily complain of pain and have a preserved range of motion. Alternatively, if they have reduced range of motion because of pain, then their range of motion should improve after a corticosteroid injection. It is also important that the patient has an intact or repairable subscapularis. The balloon is beneficial in patients with medical comorbidities that would limit the use of other techniques dependent on biologic tissue healing or that would limit the use of arthroplasty. Poor candidates would be patients with pseudoparalysis, axillary nerve palsy, irreparable subscapularis tears, or severe glenohumeral arthritis (Hamada grade ≥3).

Expected outcomes: A recent randomized clinical trial demonstrated the 2-year efficacy, safety, and benefits of the InSpace subacromial balloon spacer⁶. The authors reported significant early clinical benefit that was maintained over 2 years. Additionally, this benefit was equivalent or superior to the partial-repair control gr

Open release of a trigger thumb has been shown to be the most reliable option to restore full interphalangeal (IP) joint extension and thus normal thumb-joint motion in children¹. The aim of this procedure is to restore free gliding of the flexor pollicis longus (FPL) tendon in its canal in children with fixed IP joint flexion contractures or those in whom nonoperative treatment modalities have failed.

Description: The surgical procedure is easy to perform and straightforward; however, attention must be given to several details in order to avoid surgical failure and complications. General anesthesia is required for this procedure. The extremity is prepared and draped in a sterile fashion with the patient in the supine position, and a tourniquet is utilized to facilitate surgical dissection. A transverse incision is gently made just adjacent to the thumb metacarpophalangeal (MP) flexion crease, above the so-called Notta nodule. The ulnar neurovascular bundle is retracted to the side, and the Notta nodule, a local enlargement of the FPL tendon², is visualized at the A1 pulley. The pulley is incised longitudinally to allow for full IP joint extension. After verification of full passive motion, the tendon is inspected for any further abnormalities. Then, the tourniquet is released, and the wound is closed with absorbable sutures. We recommend the use of local anesthetics for postoperative pain control. In cases of a trigger thumb stuck in extension, full tenodesis flexion of the IP joint combined with smooth, full passive extension confirms a complete release.

Alternatives: Nonoperative treatment modalities mainly include watchful waiting for spontaneous resolution³, occupational therapy (i.e., passive exercising)^4,5, and splinting therapy⁶. However, prolonged stretching and splinting may move the nodule to a point distal to the stenotic pulley, thus resulting in a trigger thumb locked in extension with a loss of IP flexion. Alternative surgical treatment techniques involve percutaneous trigger thumb release or open release with alternative surgical approaches (e.g., an oblique or Brunner incision)^7,8.

Rationale: Several reports have shown that open release of a trigger thumb leads to the most reliable outcomes in terms of achievement of range of motion and complications^1,9,10. The main advantage of this procedure is the perfect visualization of the FPL tendon beneath the stenotic A1 pulley, which allows for a complete A1 release with clear vision. Such visualization cannot be provided with use of percutaneous techniques, which position the neurovascular bundle in potential danger for iatrogenic injury or may lead to incomplete pulley release⁸. Moreover, the use of this procedure allows parents to avoid the prolonged therapy and splinting associated with nonoperative treatment. Formal rehab

Diffuse tenosynovial giant cell tumor (TGCT), also known as pigmented villonodular synovitis, is a benign, neoplastic disease of the synovium that can lead to joint destruction, osteoarthritis, and long-term morbidity^1,2. Often, there is extra-articular involvement in the intercondylar notch and posterior soft tissues. A complete anterior and posterior synovectomy of the knee is indicated for treating diffuse TGCT when the anterior and posterior compartments of the knee joint are involved. Additionally, either an anterior or posterior synovectomy may be performed when the TGCT is limited to 1 compartment of the knee. Although an anterior synovectomy is relatively straightforward technically, a posterior synovectomy is challenging because of the presence of the neurovascular and muscular structures, which limit access, and because of the infrequency of the procedure.

Description: The surgical technique for open anterior and posterior knee synovectomy is performed under 1 anesthetic via separate exposures with the patient initially supine and then prone. In cases of focal TGCT, in which both the anterior and posterior compartments are involved, either an anterior or posterior approach can be utilized in isolation to target the affected compartment. The anterior approach is performed via anteromedial parapatellar arthrotomy, with care to preserve the meniscal attachments and ligaments. Once the suprapatellar pouch is visualized, all tissue deep to the quadriceps muscle and tendon, extending around to the femoral periosteum, is excised en bloc. Attention is then turned to the undersurface of the patella, fat pad, distal aspect of the femur, and proximal aspect of the tibia. The tumor may be embedded within the fat pad and must be removed. Any tumor remnants within the medial or lateral gutter or beneath the menisci are excised with use of a standard or pituitary rongeur or curets. The quadriceps tendon, subcutaneous tissue, and skin are closed over a deep drain, and the patient is turned prone and re-prepared for the posterior approach. The posterior synovectomy utilizes an S-shaped incision either superolateral to inferomedial or superomedial to inferolateral, depending on the location of the TGCT. The popliteal artery and vein and the tibial and common peroneal nerves are identified, mobilized, and protected during retraction. This step requires ligating the geniculate and other small branches of the popliteal artery and vein. To expose the posterior femoral condyle, the medial and/or lateral heads of the gastrocnemius must be tagged and released by dividing the myotendinous origin from the posterior aspect of the femur at the proximal extent of the condyle.

Alternatives: Although surgical resection is the primary treatment for TGCT, nonsurgical alternatives include radiation therapy (either external beam or radiosynoviorthesis) and the use of pharmacologic agents. Radiation therapy is

Anterior cervical controllable antedisplacement and fusion (ACAF) is utilized for the treatment of symptomatic ossification of the posterior longitudinal ligament (OPLL). The aims of the procedure are to directly relieve ventral compression of the spinal cord, to reconstruct the spinal canal and restore cervical alignment, and to achieve satisfactory clinical recovery.

Description: The detailed steps to perform ACAF have been described previously¹. Briefly, following induction of general endotracheal anesthesia, a standard right- or left-sided Smith-Robinson incision is made. Discectomies are performed at the involved levels. By measuring the thickness of the OPLL on an axial preoperative computed tomography scan at each compressed level, the amount of each anterior vertebral body to be resected can be calculated preoperatively. This was, in general, equal to the thickness of the ossified mass at the same level. The previously calculated portion of each involved body in the vertebral body-OPLL complex is resected. Following the creation of a contralateral longitudinal osseous trough, the prebent anterior cervical plate is then placed, and the screws are installed after proper drilling and taping on the remaining vertebral bodies. The screws utilized in this procedure should not be too short to achieve adequate purchase in the vertebral body. Subsequently, the intervertebral cages are inserted. Thus, the vertebral body-OPLL complex is temporarily stabilized for the next procedure. Next, an ipsilateral longitudinal osseous trough is created to completely isolate the vertebral body-OPLL complex. Notably, the objective of complete isolation of the vertebral body-OPLL complex is to further anteriorly hoist the complex to decompress the spinal cord. Finally, screws are inserted through the plate and into each vertebral body and are gradually tightened to displace the bodies anteriorly. Allogenic iliac bone graft is placed in the longitudinal bone troughs to promote fusion.

Alternatives: Nonoperative treatment is frequently ineffective. Traditional surgical interventions have included anterior cervical corpectomy and fusion (ACCF), posterior laminoplasty, and laminectomy^2,3. ACCF focuses on resecting the ventral ossified mass in order to obtain direct decompression; however, this technique is very technically demanding, with a high risk of complications. In addition, the clinical benefits of ACCF will be limited when the OPLL extends over >3 levels. Posterior decompression can achieve indirect decompression by allowing the spinal cord to float away from the ossified mass. This technique depends largely on the preoperative presence of cervical lordosis and is contraindicated in patients with kyphosis or severe OPLL. In addition, posterior decompression surgery has been associated with a high incidence of late neurological deterioration and even revision surgery².

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[This corrects the article DOI: 10.2106/JBJS.ST.19.00069.].