Pub Date : 2025-11-19eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.24.00024
Justin Less, Harmon S Khela, Monty S Khela, Ishaan Swarup
<p><strong>Background: </strong>Seymour fractures are open, distal phalangeal physeal fractures with an associated nail-bed injury that occur in pediatric patients<sup>1</sup>. Although first described in the finger, an equivalent injury can occur in the distal phalanx of the great toe, often via a direct axial load at the apex of the toe, resulting in Salter-Harris type-I or II or juxta-epiphyseal fractures with a concomitant nail-bed laceration<sup>2-12</sup>. Closed reduction and splinting were initially recommended in these fractures<sup>1</sup>; however, they are now commonly treated with formal irrigation and debridement and the administration of prophylactic antibiotics in the acute setting in order to minimize the risk of complications such as infection<sup>10-12</sup>. To our knowledge, there are no detailed resources describing this surgical technique.</p><p><strong>Description: </strong>With the patient in the supine position, a nonsterile tourniquet is applied, the operative foot is thoroughly cleansed and prepared in a sterile field, and the operative extremity is exsanguinated. A digital block is then administered. With use of blunt instruments, the nail plate is removed or lifted to allow visualization of the underlying structures. A lacerated nail bed, or germinal matrix, will likely be observed, appearing as a glistening and highly vascularized soft-tissue structure at the proximal end of the nail, responsible for nail growth. Small incisions near the extension creases of the distal interphalangeal joint may be required to retract the eponychial fold and inspect the laceration and fracture site. Next, thorough irrigation and debridement are performed to clean the fracture site and remove any contaminants or nonviable tissues. The fracture is then manually reduced under direct visualization, ensuring proper alignment of bone fragments. Any interposed soft tissue, such as the germinal matrix or periosteum, is extricated from the fracture site with use of fine instruments. If the fracture is deemed unstable, percutaneous pinning with 0.045-in or 0.062-in Kirschner wires is performed to stabilize the fracture. Kirschner wires are inserted through the skin and driven across the fracture site and distal interphalangeal joint. Appropriate placement of pins is confirmed on fluoroscopy, and the nail bed is repaired with use of absorbable sutures. In cases with gross contamination or osteomyelitis, it is prudent to avoid pin fixation. A sterile dressing is applied, and the foot is immobilized in a well-padded short-leg cast or splint to protect the fracture and pin and to maintain alignment. Postoperatively, the patient is given a short course of oral antibiotics (e.g., cephalosporin) to prevent infection. Radiographic images are obtained at the first regular follow-up appointment (within 1 week postoperatively), and the Kirschner wires are removed once sufficient healing has occurred (typically 4 to 6 weeks postoperatively).</p><p><strong
{"title":"Surgical Treatment of Pediatric Seymour Fractures of the Great Toe.","authors":"Justin Less, Harmon S Khela, Monty S Khela, Ishaan Swarup","doi":"10.2106/JBJS.ST.24.00024","DOIUrl":"10.2106/JBJS.ST.24.00024","url":null,"abstract":"<p><strong>Background: </strong>Seymour fractures are open, distal phalangeal physeal fractures with an associated nail-bed injury that occur in pediatric patients<sup>1</sup>. Although first described in the finger, an equivalent injury can occur in the distal phalanx of the great toe, often via a direct axial load at the apex of the toe, resulting in Salter-Harris type-I or II or juxta-epiphyseal fractures with a concomitant nail-bed laceration<sup>2-12</sup>. Closed reduction and splinting were initially recommended in these fractures<sup>1</sup>; however, they are now commonly treated with formal irrigation and debridement and the administration of prophylactic antibiotics in the acute setting in order to minimize the risk of complications such as infection<sup>10-12</sup>. To our knowledge, there are no detailed resources describing this surgical technique.</p><p><strong>Description: </strong>With the patient in the supine position, a nonsterile tourniquet is applied, the operative foot is thoroughly cleansed and prepared in a sterile field, and the operative extremity is exsanguinated. A digital block is then administered. With use of blunt instruments, the nail plate is removed or lifted to allow visualization of the underlying structures. A lacerated nail bed, or germinal matrix, will likely be observed, appearing as a glistening and highly vascularized soft-tissue structure at the proximal end of the nail, responsible for nail growth. Small incisions near the extension creases of the distal interphalangeal joint may be required to retract the eponychial fold and inspect the laceration and fracture site. Next, thorough irrigation and debridement are performed to clean the fracture site and remove any contaminants or nonviable tissues. The fracture is then manually reduced under direct visualization, ensuring proper alignment of bone fragments. Any interposed soft tissue, such as the germinal matrix or periosteum, is extricated from the fracture site with use of fine instruments. If the fracture is deemed unstable, percutaneous pinning with 0.045-in or 0.062-in Kirschner wires is performed to stabilize the fracture. Kirschner wires are inserted through the skin and driven across the fracture site and distal interphalangeal joint. Appropriate placement of pins is confirmed on fluoroscopy, and the nail bed is repaired with use of absorbable sutures. In cases with gross contamination or osteomyelitis, it is prudent to avoid pin fixation. A sterile dressing is applied, and the foot is immobilized in a well-padded short-leg cast or splint to protect the fracture and pin and to maintain alignment. Postoperatively, the patient is given a short course of oral antibiotics (e.g., cephalosporin) to prevent infection. Radiographic images are obtained at the first regular follow-up appointment (within 1 week postoperatively), and the Kirschner wires are removed once sufficient healing has occurred (typically 4 to 6 weeks postoperatively).</p><p><strong","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/PMC12622601/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145557719","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 : 2025-11-05eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.24.00036
Ta-Wei Tai, Sergio F Guarin Perez, Diego J Restrepo, Rafael J Sierra
<p><strong>Background: </strong>Hip decompression effectively treats early-stage osteonecrosis of the femoral head (ONFH) by slowing disease progression and potentially delaying joint replacement. Biological adjuvants like bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) support bone regeneration and improve outcomes<sup>1-7</sup>. The present video article demonstrates a simple, coreless hip decompression technique with BMAC and PRP injection for early-stage ONFH.</p><p><strong>Description: </strong>The procedure is performed in the same operating room setting as traditional core decompression, with the patient supine on a radiolucent table for fluoroscopic guidance. One or both legs are draped free for access to the iliac crests. Bone marrow is harvested percutaneously from the anterior superior iliac crest with a trocar needle kit, centrifuged, and prepared for injection. We recommend precoating needles and syringes with 1:1,000 heparin to prevent clotting. The BioCUE System (Zimmer Biomet) is typically utilized for centrifugation. Hip decompression is performed with use of a trocar and cannula (PerFuse System; Zimmer Biomet), with subsequent injection through the cannula into the femoral head. A 0.5-cm skin incision is made. The trocar is placed lateral to the femur and advanced percutaneously through the lateral femoral cortex, with a starting point proximal to the lesser trochanter. The trocar is then advanced along the femoral neck into the necrotic region by performing mallet strikes on the instrument's strike cap. Anteroposterior and frog-leg lateral views assist in positioning the trocar within the necrotic area. Internal leg rotation, which aligns the patella upward, helps position the trocar horizontally parallel to the floor. Positioning is adjusted using repeated imaging as needed. Once the patient is positioned, the trocar is removed, leaving the cannula in place. With the cannula retracted 1 cm, a 30-mL syringe is utilized to inject BMAC and PRP into the necrotic lesion. Because of sclerotic resistance, substantial pressure is needed, but retraction of the cannula helps. Following injection, the cannula is withdrawn another 1 cm, and demineralized bone matrix is injected to prevent escape of the BMAC.</p><p><strong>Alternatives: </strong>Alternative treatments for ONFH include traditional core decompression with a sliding hip screw drill or an X-REAM device (Stryker), both of which carry a higher risk of fracture because of the larger diameter of the tract and require limited weightbearing postoperatively. Bone-cement injection can stabilize the femoral head but lacks regenerative properties. Core decompression with either BMAC or PRP alone, rather than in combination, also serves as an alternative treatment strategy. Open approaches, like osteotomy, are more invasive, have longer recovery times, and may complicate future hip arthroplasty if unsuccessful.</p><p><strong>Rationale: </strong>This technique enabl
{"title":"Hip Decompression with Bone Marrow Aspirate Concentrate and Platelet-Rich Plasma Injection for Osteonecrosis of the Femoral Head.","authors":"Ta-Wei Tai, Sergio F Guarin Perez, Diego J Restrepo, Rafael J Sierra","doi":"10.2106/JBJS.ST.24.00036","DOIUrl":"10.2106/JBJS.ST.24.00036","url":null,"abstract":"<p><strong>Background: </strong>Hip decompression effectively treats early-stage osteonecrosis of the femoral head (ONFH) by slowing disease progression and potentially delaying joint replacement. Biological adjuvants like bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) support bone regeneration and improve outcomes<sup>1-7</sup>. The present video article demonstrates a simple, coreless hip decompression technique with BMAC and PRP injection for early-stage ONFH.</p><p><strong>Description: </strong>The procedure is performed in the same operating room setting as traditional core decompression, with the patient supine on a radiolucent table for fluoroscopic guidance. One or both legs are draped free for access to the iliac crests. Bone marrow is harvested percutaneously from the anterior superior iliac crest with a trocar needle kit, centrifuged, and prepared for injection. We recommend precoating needles and syringes with 1:1,000 heparin to prevent clotting. The BioCUE System (Zimmer Biomet) is typically utilized for centrifugation. Hip decompression is performed with use of a trocar and cannula (PerFuse System; Zimmer Biomet), with subsequent injection through the cannula into the femoral head. A 0.5-cm skin incision is made. The trocar is placed lateral to the femur and advanced percutaneously through the lateral femoral cortex, with a starting point proximal to the lesser trochanter. The trocar is then advanced along the femoral neck into the necrotic region by performing mallet strikes on the instrument's strike cap. Anteroposterior and frog-leg lateral views assist in positioning the trocar within the necrotic area. Internal leg rotation, which aligns the patella upward, helps position the trocar horizontally parallel to the floor. Positioning is adjusted using repeated imaging as needed. Once the patient is positioned, the trocar is removed, leaving the cannula in place. With the cannula retracted 1 cm, a 30-mL syringe is utilized to inject BMAC and PRP into the necrotic lesion. Because of sclerotic resistance, substantial pressure is needed, but retraction of the cannula helps. Following injection, the cannula is withdrawn another 1 cm, and demineralized bone matrix is injected to prevent escape of the BMAC.</p><p><strong>Alternatives: </strong>Alternative treatments for ONFH include traditional core decompression with a sliding hip screw drill or an X-REAM device (Stryker), both of which carry a higher risk of fracture because of the larger diameter of the tract and require limited weightbearing postoperatively. Bone-cement injection can stabilize the femoral head but lacks regenerative properties. Core decompression with either BMAC or PRP alone, rather than in combination, also serves as an alternative treatment strategy. Open approaches, like osteotomy, are more invasive, have longer recovery times, and may complicate future hip arthroplasty if unsuccessful.</p><p><strong>Rationale: </strong>This technique enabl","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 4","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12582673/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145453673","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 : 2025-10-08eCollection Date: 2025-10-01DOI: 10.2106/JBJS.ST.24.00011
Andrea Angelini, Elisa Pala, Giulia Trovarelli, Mariachiara Cerchiaro, Pietro Ruggieri
<p><strong>Background: </strong>Primary bone tumors frequently occur in the proximal tibia, ranking as the second most common location after the distal femur<sup>1</sup>. Challenges to treatment include the proximity of neurovascular structures, limited soft-tissue coverage, compromised knee extension, and postoperative complications<sup>1-8</sup>. The present video article describes proximal tibial resection for the treatment of a bone tumor and prosthetic reconstruction combined with a medial gastrocnemius flap.</p><p><strong>Description: </strong>Proximal tibial resection is performed with use of an anteromedial approach. After defining the resection level, the tumor is removed en bloc with wide free margins. Reconstruction is performed with use of a megaprosthesis, and the medial gastrocnemius flap is utilized for covering the prosthesis and for reconstruction of the extensor apparatus.</p><p><strong>Alternatives: </strong>Osteoarticular allografts and allograft-prosthesis composites allow restoration of bone stock and direct biological reattachment of host tendons, ligaments, and capsule. Autografting is performed using the fibula as a donor site. Custom-made implants can be designed according to the patient's anatomy. Amputation should be considered when the neurovascular bundle is widely involved by the tumor.</p><p><strong>Rationale: </strong>In contrast to alternative treatments, megaprosthetic reconstructions offer several advantages: technical simplicity, immediate weight-bearing, and shorter immobilization. Additionally, megaprostheses do not carry the risk of allograft-related complications, such as nonunion, fracture, subchondral collapse, articular cartilage degeneration, and instability.</p><p><strong>Expected outcomes: </strong>Patients with metallic endoprostheses demonstrate lower rates of complications and amputation, as well as higher patient survival rates, compared with those treated with allograft reconstructions<sup>7,9,10</sup>. The advancements in technology and design since 1977 have contributed to reduced mechanical stress at the bone-prosthesis interface and decreased rates of mechanical or structural failure<sup>3,11,12</sup>. However, despite advancements in design, proximal tibial prosthetic reconstructions continue to exhibit the least favorable outcomes and function among all limb-salvage procedures, accompanied by the highest rate of complications<sup>1,9-11</sup>. Studies report survival rates ranging from 45% to 82% at 5 years and 45% to 78% at 10 years<sup>1,13</sup>, with rates of revision for infection and loosening ranging from 40% at 5 years to 73% at 15 years<sup>1,10,13</sup>. Various techniques are utilized for attaching the extensor mechanism of the knee and providing coverage for proximal tibial reconstructions<sup>7,8,10,14,15</sup>. Various studies have emphasized the importance of direct attachment of the extensor mechanism to the megaprosthesis, which facilitates initial mechanical stability cru
{"title":"Proximal Tibial Resection for Bone Tumor and Prosthetic Reconstruction Combined with Medial Gastrocnemius Flap.","authors":"Andrea Angelini, Elisa Pala, Giulia Trovarelli, Mariachiara Cerchiaro, Pietro Ruggieri","doi":"10.2106/JBJS.ST.24.00011","DOIUrl":"10.2106/JBJS.ST.24.00011","url":null,"abstract":"<p><strong>Background: </strong>Primary bone tumors frequently occur in the proximal tibia, ranking as the second most common location after the distal femur<sup>1</sup>. Challenges to treatment include the proximity of neurovascular structures, limited soft-tissue coverage, compromised knee extension, and postoperative complications<sup>1-8</sup>. The present video article describes proximal tibial resection for the treatment of a bone tumor and prosthetic reconstruction combined with a medial gastrocnemius flap.</p><p><strong>Description: </strong>Proximal tibial resection is performed with use of an anteromedial approach. After defining the resection level, the tumor is removed en bloc with wide free margins. Reconstruction is performed with use of a megaprosthesis, and the medial gastrocnemius flap is utilized for covering the prosthesis and for reconstruction of the extensor apparatus.</p><p><strong>Alternatives: </strong>Osteoarticular allografts and allograft-prosthesis composites allow restoration of bone stock and direct biological reattachment of host tendons, ligaments, and capsule. Autografting is performed using the fibula as a donor site. Custom-made implants can be designed according to the patient's anatomy. Amputation should be considered when the neurovascular bundle is widely involved by the tumor.</p><p><strong>Rationale: </strong>In contrast to alternative treatments, megaprosthetic reconstructions offer several advantages: technical simplicity, immediate weight-bearing, and shorter immobilization. Additionally, megaprostheses do not carry the risk of allograft-related complications, such as nonunion, fracture, subchondral collapse, articular cartilage degeneration, and instability.</p><p><strong>Expected outcomes: </strong>Patients with metallic endoprostheses demonstrate lower rates of complications and amputation, as well as higher patient survival rates, compared with those treated with allograft reconstructions<sup>7,9,10</sup>. The advancements in technology and design since 1977 have contributed to reduced mechanical stress at the bone-prosthesis interface and decreased rates of mechanical or structural failure<sup>3,11,12</sup>. However, despite advancements in design, proximal tibial prosthetic reconstructions continue to exhibit the least favorable outcomes and function among all limb-salvage procedures, accompanied by the highest rate of complications<sup>1,9-11</sup>. Studies report survival rates ranging from 45% to 82% at 5 years and 45% to 78% at 10 years<sup>1,13</sup>, with rates of revision for infection and loosening ranging from 40% at 5 years to 73% at 15 years<sup>1,10,13</sup>. Various techniques are utilized for attaching the extensor mechanism of the knee and providing coverage for proximal tibial reconstructions<sup>7,8,10,14,15</sup>. Various studies have emphasized the importance of direct attachment of the extensor mechanism to the megaprosthesis, which facilitates initial mechanical stability cru","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 4","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12499655/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145253127","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 : 2025-09-09eCollection Date: 2025-07-01DOI: 10.2106/JBJS.ST.24.00044
J Terrence Jose Jerome
<p><strong>Background: </strong>Extensor indicis proprius (EIP) transfer augmented with proximal extensor pollicis longus (EPL) stump lengthening restores thumb extension and optimizes function in cases of chronic EPL tendon ruptures, which impair hand dexterity and fine motor skills. Traditional EIP-to-EPL transfers often disrupt the natural oblique course of the EPL around the Lister tubercle, leading to functional deficits<sup>1-3</sup>. This dual-tendon transfer preserves anatomical alignment and improves thumb biomechanics, enhancing extension strength and the adduction moment arm at the carpometacarpal (CMC) joint.</p><p><strong>Description: </strong>The procedure involves 3 incisions over the index finger metacarpal neck, Lister tubercle, and dorsal thumb metacarpophalangeal joint. The EIP tendon is harvested, its distal stump is sutured to the extensor digitorum communis, and the proximal stump is withdrawn for transfer. The distal and proximal EPL stumps are exposed, and the proximal EPL is lengthened with use of an L-shaped radial incision, retaining a 1-cm pedicle for turnover. Both the EIP and lengthened EPL tendons are passed subcutaneously and coapted to the distal EPL with use of a Pulvertaft weave and augmentation techniques. The procedure is performed under wide-awake local anesthesia (WALANT), enabling dynamic intraoperative adjustments. A splint is applied postoperatively for 4 weeks, followed by 4 to 8 weeks in a removable splint, with discontinuation at 12 weeks.</p><p><strong>Alternatives: </strong>Surgical alternatives include extensor carpi radialis brevis to EPL transfer, extensor digiti minimi to EPL transfer, brachioradialis to EPL transfer, and EPL repair with use of a palmaris longus graft.</p><p><strong>Rationale: </strong>Compared with other tendon transfers, EIP transfer offers anatomical proximity, and minimal donor-site morbidity. However, standalone EIP transfers may reduce extension strength and range of motion as a result of a misaligned vector<sup>4-7</sup>. The presently described dual-transfer technique addresses these limitations by retaining the native path of the EPL, reducing adhesions, and improving biomechanical efficiency. This technique is particularly advantageous in patients who require a high level of thumb function, preserving fine motor control and extension strength while reducing residual deficits.</p><p><strong>Expected outcomes: </strong>This procedure provides improved thumb extension, thumb adduction, and overall hand function. Stirling et al.1 demonstrated that EIP-to-EPL transfer improves QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire) scores (from 29.7 to 15.2; p = 0.05), with high patient satisfaction and no complications. Our augmented approach builds on these results by reducing biomechanical loss, preserving angular alignment, and minimizing adhesion risk, aiming for superior total active motion and functional recovery. In our study of
{"title":"Dual-Tendon Transfer for Chronic Extensor Pollicis Longus Ruptures: Augmented Extensor Indicis Proprius Transfer with Proximal EPL Stump Lengthening.","authors":"J Terrence Jose Jerome","doi":"10.2106/JBJS.ST.24.00044","DOIUrl":"10.2106/JBJS.ST.24.00044","url":null,"abstract":"<p><strong>Background: </strong>Extensor indicis proprius (EIP) transfer augmented with proximal extensor pollicis longus (EPL) stump lengthening restores thumb extension and optimizes function in cases of chronic EPL tendon ruptures, which impair hand dexterity and fine motor skills. Traditional EIP-to-EPL transfers often disrupt the natural oblique course of the EPL around the Lister tubercle, leading to functional deficits<sup>1-3</sup>. This dual-tendon transfer preserves anatomical alignment and improves thumb biomechanics, enhancing extension strength and the adduction moment arm at the carpometacarpal (CMC) joint.</p><p><strong>Description: </strong>The procedure involves 3 incisions over the index finger metacarpal neck, Lister tubercle, and dorsal thumb metacarpophalangeal joint. The EIP tendon is harvested, its distal stump is sutured to the extensor digitorum communis, and the proximal stump is withdrawn for transfer. The distal and proximal EPL stumps are exposed, and the proximal EPL is lengthened with use of an L-shaped radial incision, retaining a 1-cm pedicle for turnover. Both the EIP and lengthened EPL tendons are passed subcutaneously and coapted to the distal EPL with use of a Pulvertaft weave and augmentation techniques. The procedure is performed under wide-awake local anesthesia (WALANT), enabling dynamic intraoperative adjustments. A splint is applied postoperatively for 4 weeks, followed by 4 to 8 weeks in a removable splint, with discontinuation at 12 weeks.</p><p><strong>Alternatives: </strong>Surgical alternatives include extensor carpi radialis brevis to EPL transfer, extensor digiti minimi to EPL transfer, brachioradialis to EPL transfer, and EPL repair with use of a palmaris longus graft.</p><p><strong>Rationale: </strong>Compared with other tendon transfers, EIP transfer offers anatomical proximity, and minimal donor-site morbidity. However, standalone EIP transfers may reduce extension strength and range of motion as a result of a misaligned vector<sup>4-7</sup>. The presently described dual-transfer technique addresses these limitations by retaining the native path of the EPL, reducing adhesions, and improving biomechanical efficiency. This technique is particularly advantageous in patients who require a high level of thumb function, preserving fine motor control and extension strength while reducing residual deficits.</p><p><strong>Expected outcomes: </strong>This procedure provides improved thumb extension, thumb adduction, and overall hand function. Stirling et al.1 demonstrated that EIP-to-EPL transfer improves QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire) scores (from 29.7 to 15.2; p = 0.05), with high patient satisfaction and no complications. Our augmented approach builds on these results by reducing biomechanical loss, preserving angular alignment, and minimizing adhesion risk, aiming for superior total active motion and functional recovery. In our study of ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12412740/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145013416","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 : 2025-09-09eCollection Date: 2025-07-01DOI: 10.2106/JBJS.ST.25.00007
J Terrence Jose Jerome
Background: Hemi-hamate osteochondral grafting is a surgical technique that is utilized to reconstruct the proximal interphalangeal (PIP) joint in cases of unstable dorsal fracture-dislocation with >50% articular surface involvement. However, hemi-hamate osteochondral grafting can be technically challenging, has been reported to have various technical modifications, and can lead to complications such as overstuffing of the joint. This surgical technique article describes successful PIP joint reconstruction with use of a hemi-capitate osteochondral graft, which may offer a viable alternative to hemi-hamate osteochondral graft.
Description: A volar approach to the PIP joint is utilized, and a trapezoidal incision is made. The skin, subcutaneous tissue, and neurovascular bundles are carefully retracted. The flexor tendon sheath is opened, and adhesions are released to expose the volar plate. The volar plate and collateral ligaments are reflected. The finger is hyperextended to expose the joint. Damaged cartilage and bone fragments are removed, and healthy cartilage is preserved. The capitate-3rd and -4th metacarpal joints are localized with use of fluoroscopy. A transverse incision is made over the joints, and the extensor retinaculum is incised. The capitate is exposed, and the required graft is marked and predrilled. An osteotomy is performed to harvest the graft. The capitate graft is trimmed and placed into the defect in the middle phalanx base. The graft is temporarily pinned with use of a Kirschner wire and then is secured with 2 bicortical screws. The middle phalanx is reduced, and free movement is confirmed. The volar plate is sutured to the collateral ligament. The flexor tendon sheath is passed beneath the flexor tendons to allow free gliding movements over the newly laid graft. The skin is sutured.
Alternatives: Hemi-hamate osteochondral graft is the most common alternative to hemi-capitate osteochondral graft.
Rationale: The capitate bone may offer several advantages over the hamate bone for PIP joint reconstruction. The capitate has a more uniform articular surface that closely resembles the middle phalanx base, which may reduce the risk of overstuffing1, Additionally, harvesting a graft from the capitate may be less likely to cause donor-site morbidity compared with harvesting from the hamate.
Expected outcomes: Hemi-capitate osteochondral graft is a promising technique for PIP joint reconstruction. In our previous article1, the patient achieved good PIP joint movement and stability at the time of the latest follow-up. The osteochondral capitate graft united well, and there were no signs of graft collapse or resorption. The patient had good range of motion and minimal pain, and was able to return to his previous work.
Important tips: Careful attention should be paid to graft size and placemen
{"title":"Capitate Osteochondral Graft for Reconstruction of Unstable Proximal Interphalangeal Joint Injury.","authors":"J Terrence Jose Jerome","doi":"10.2106/JBJS.ST.25.00007","DOIUrl":"10.2106/JBJS.ST.25.00007","url":null,"abstract":"<p><strong>Background: </strong>Hemi-hamate osteochondral grafting is a surgical technique that is utilized to reconstruct the proximal interphalangeal (PIP) joint in cases of unstable dorsal fracture-dislocation with >50% articular surface involvement. However, hemi-hamate osteochondral grafting can be technically challenging, has been reported to have various technical modifications, and can lead to complications such as overstuffing of the joint. This surgical technique article describes successful PIP joint reconstruction with use of a hemi-capitate osteochondral graft, which may offer a viable alternative to hemi-hamate osteochondral graft.</p><p><strong>Description: </strong>A volar approach to the PIP joint is utilized, and a trapezoidal incision is made. The skin, subcutaneous tissue, and neurovascular bundles are carefully retracted. The flexor tendon sheath is opened, and adhesions are released to expose the volar plate. The volar plate and collateral ligaments are reflected. The finger is hyperextended to expose the joint. Damaged cartilage and bone fragments are removed, and healthy cartilage is preserved. The capitate-3rd and -4th metacarpal joints are localized with use of fluoroscopy. A transverse incision is made over the joints, and the extensor retinaculum is incised. The capitate is exposed, and the required graft is marked and predrilled. An osteotomy is performed to harvest the graft. The capitate graft is trimmed and placed into the defect in the middle phalanx base. The graft is temporarily pinned with use of a Kirschner wire and then is secured with 2 bicortical screws. The middle phalanx is reduced, and free movement is confirmed. The volar plate is sutured to the collateral ligament. The flexor tendon sheath is passed beneath the flexor tendons to allow free gliding movements over the newly laid graft. The skin is sutured.</p><p><strong>Alternatives: </strong>Hemi-hamate osteochondral graft is the most common alternative to hemi-capitate osteochondral graft.</p><p><strong>Rationale: </strong>The capitate bone may offer several advantages over the hamate bone for PIP joint reconstruction. The capitate has a more uniform articular surface that closely resembles the middle phalanx base, which may reduce the risk of overstuffing1, Additionally, harvesting a graft from the capitate may be less likely to cause donor-site morbidity compared with harvesting from the hamate.</p><p><strong>Expected outcomes: </strong>Hemi-capitate osteochondral graft is a promising technique for PIP joint reconstruction. In our previous article<sup>1</sup>, the patient achieved good PIP joint movement and stability at the time of the latest follow-up. The osteochondral capitate graft united well, and there were no signs of graft collapse or resorption. The patient had good range of motion and minimal pain, and was able to return to his previous work.</p><p><strong>Important tips: </strong>Careful attention should be paid to graft size and placemen","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12412738/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145013418","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 : 2025-08-25eCollection Date: 2025-07-01DOI: 10.2106/JBJS.ST.23.00086
Alec Werthman, Caroline N Park, Gregory F Pereira, Sneha Rao, Marc J Richard
<p><strong>Background: </strong>Scaphoid fractures are a common, yet challenging, injury to treat. The mini-open dorsal approach to the scaphoid is a simple, yet effective, approach that allows for improved visualization and more accurate screw placement in the setting of scaphoid fracture fixation.</p><p><strong>Description: </strong>An approximately 2-cm longitudinal incision is made centered over the dorsal radiocarpal joint, just ulnar to the Lister tubercle. Blunt dissection is performed down to the extensor retinaculum. A longitudinal incision is made through the retinaculum. The tendons of the fourth and third compartments are visualized, the extensor digitorum communis is retracted ulnarly, and the extensor pollicis longus is retracted radially. A small, 1-cm longitudinal capsulotomy is made, and the scapholunate ligament and proximal pole of the scaphoid are visualized. Careful attention is paid to avoid injury to the scapholunate ligament, which lies just beneath the capsule. Next, the scaphoid fracture is reduced.</p><p><strong>Alternatives: </strong>Traditionally, nondisplaced or minimally displaced scaphoid waist fractures have been treated nonoperatively. Surgical treatment has become more popular because of the faster recovery, improved range of motion, improved time to union, and decreased nonunion rates. There are several surgical approaches that can be utilized, including percutaneous fixation and traditional open techniques through a volar or dorsal approach.</p><p><strong>Rationale: </strong>Precise fracture reduction and screw fixation is biomechanically advantageous and critical in improving union rates of scaphoid fractures<sup>1</sup>. Although percutaneous fixation has the advantage of being least invasive, it is difficult to achieve an accurate starting point and there is an increased risk of damaging the extensor tendons and blood supply about the scaphoid. Prior studies have shown a 29% complication rate associated with a dorsal percutaneous approach<sup>2</sup>. When compared with the percutaneous or volar approach, the mini-open dorsal approach provides improved visualization of the starting point for more accurate screw placement<sup>3</sup>.</p><p><strong>Expected outcomes: </strong>Precise screw placement is advantageous when stabilizing scaphoid fractures. Studies involving the use of a limited dorsal approach have shown excellent radiographic and functional results, with cadaveric studies showing that the dorsal approach can help avoid articular damage to the scaphotrapezial articulation<sup>4,5</sup>. The mini-open dorsal approach has comparable complication rates to those shown for the dorsal percutaneous approach<sup>1</sup>; however, the mini-open dorsal approach allows for improved visualization and thus safer and more accurate identification of the optimal starting point for screw fixation of scaphoid fractures.</p><p><strong>Important tips: </strong>Take care to lift up the capsule while making the capsul
背景：舟状骨骨折是一种常见但具有挑战性的损伤治疗。舟状骨小开口背侧入路是一种简单而有效的入路，在舟状骨骨折固定时可提高视野和更准确地放置螺钉。描述：以桡腕关节背为中心，在李斯特结节尺侧处做一个约2厘米的纵向切口。钝性剥离向下至伸肌支持带。在视网膜带上做一个纵向切口。可见第四和第三间室的肌腱，指群伸肌尺侧缩回，拇长伸肌桡侧缩回。行小的1厘米纵囊切开术，舟月骨韧带和舟状骨近端可见。要小心避免损伤舟月骨韧带，它就在囊的下面。接下来，将舟状骨骨折复位。替代方法：传统上，非移位或最小移位舟状骨腰骨折均采用非手术治疗。由于恢复更快，活动范围更大，愈合时间更短，骨不连率降低，手术治疗越来越受欢迎。有几种手术入路可采用，包括经皮固定和经掌侧或背侧入路的传统开放技术。理由：精确骨折复位和螺钉固定在生物力学上是有利的，对提高舟状骨骨折愈合率至关重要。虽然经皮固定具有侵入性最小的优点，但很难获得准确的起始点，并且增加了损害舟状骨周围伸肌腱和血液供应的风险。先前的研究表明，29%的并发症发生率与背侧经皮入路有关。与经皮入路或掌侧入路相比，小开口背侧入路提供了更好的起始点可视化，可以更准确地放置螺钉3。预期结果：在稳定舟状骨骨折时，精确的螺钉放置是有利的。涉及使用有限背侧入路的研究显示了良好的放射学和功能结果，尸体研究表明背侧入路有助于避免对舟状方关节的关节损伤4,5。小切口背侧入路的并发症发生率与经皮背侧入路相当1；然而，小开口背侧入路可以改善视野，从而更安全、更准确地确定舟状骨骨折螺钉固定的最佳起始点。重要提示：在切开包膜时要小心提起包膜，以防止损伤舟月骨韧带。当试图在舟状骨中轴线上建立起点时，使用16号针可以帮助辅助导丝的放置。在手术前，应在后前位和侧位视图上确认正中-第三导丝的放置。腕关节屈曲有助于确定舟状骨近端骨折固定的正确起始点。钻孔时多拍透视片，确保骨折复位的维持。缩略语：SL = scapholunateK-wire = Kirschner wires edc =指伸肌communisEPL =拇长伸肌ct =计算机断层扫描。
{"title":"The Mini-Open Dorsal Approach to the Scaphoid.","authors":"Alec Werthman, Caroline N Park, Gregory F Pereira, Sneha Rao, Marc J Richard","doi":"10.2106/JBJS.ST.23.00086","DOIUrl":"10.2106/JBJS.ST.23.00086","url":null,"abstract":"<p><strong>Background: </strong>Scaphoid fractures are a common, yet challenging, injury to treat. The mini-open dorsal approach to the scaphoid is a simple, yet effective, approach that allows for improved visualization and more accurate screw placement in the setting of scaphoid fracture fixation.</p><p><strong>Description: </strong>An approximately 2-cm longitudinal incision is made centered over the dorsal radiocarpal joint, just ulnar to the Lister tubercle. Blunt dissection is performed down to the extensor retinaculum. A longitudinal incision is made through the retinaculum. The tendons of the fourth and third compartments are visualized, the extensor digitorum communis is retracted ulnarly, and the extensor pollicis longus is retracted radially. A small, 1-cm longitudinal capsulotomy is made, and the scapholunate ligament and proximal pole of the scaphoid are visualized. Careful attention is paid to avoid injury to the scapholunate ligament, which lies just beneath the capsule. Next, the scaphoid fracture is reduced.</p><p><strong>Alternatives: </strong>Traditionally, nondisplaced or minimally displaced scaphoid waist fractures have been treated nonoperatively. Surgical treatment has become more popular because of the faster recovery, improved range of motion, improved time to union, and decreased nonunion rates. There are several surgical approaches that can be utilized, including percutaneous fixation and traditional open techniques through a volar or dorsal approach.</p><p><strong>Rationale: </strong>Precise fracture reduction and screw fixation is biomechanically advantageous and critical in improving union rates of scaphoid fractures<sup>1</sup>. Although percutaneous fixation has the advantage of being least invasive, it is difficult to achieve an accurate starting point and there is an increased risk of damaging the extensor tendons and blood supply about the scaphoid. Prior studies have shown a 29% complication rate associated with a dorsal percutaneous approach<sup>2</sup>. When compared with the percutaneous or volar approach, the mini-open dorsal approach provides improved visualization of the starting point for more accurate screw placement<sup>3</sup>.</p><p><strong>Expected outcomes: </strong>Precise screw placement is advantageous when stabilizing scaphoid fractures. Studies involving the use of a limited dorsal approach have shown excellent radiographic and functional results, with cadaveric studies showing that the dorsal approach can help avoid articular damage to the scaphotrapezial articulation<sup>4,5</sup>. The mini-open dorsal approach has comparable complication rates to those shown for the dorsal percutaneous approach<sup>1</sup>; however, the mini-open dorsal approach allows for improved visualization and thus safer and more accurate identification of the optimal starting point for screw fixation of scaphoid fractures.</p><p><strong>Important tips: </strong>Take care to lift up the capsule while making the capsul","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-08-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12369723/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144973409","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>Transfer of intercostal nerves to the radial nerve branch innervating the long head of the triceps muscle for elbow extension is indicated in patients with traumatic brachial plexus palsy that is either the pan-plexus type or C5-C7 palsy with no triceps muscle function. The procedure aims to restore triceps muscle function through the use of the intercostal nerves, which are expendable nerves, as donors.</p><p><strong>Description: </strong>The procedure is performed by first identifying the third to fifth intercostal nerves and coaptating them to the radial nerve branch innervating the long head of the triceps muscle. Three intercostal nerves are utilized because our previous study revealed that the use of 2 intercostal nerves resulted in poor outcomes<sup>1</sup>. Additionally, 3 intercostal nerves are comparable in size to the recipient nerve<sup>2</sup>. To identify the intercostal nerves, a curved incision is made over the sixth rib to the medial side of the arm, detaching the pectoralis major and minor from their distal insertion. The intercostal nerves are dissected from the inferior border of the third to fifth ribs. The radial nerve branch innervating the long head of the triceps muscle can be found distal to the teres major muscle as the first branch from the radial nerve via the same incision, at the medial side of the arm<sup>3</sup>. Subsequently, the 3 intercostal nerves are coaptated to the radial nerve branch to the long head of the triceps muscle.</p><p><strong>Alternatives: </strong>A deficit in active elbow extension may be deemed acceptable for certain patients who are amenable to utilizing gravity for performing such extensions. Nonoperative treatment could be contemplated for individuals falling into this category. Alternative surgical approaches may include nerve transfers utilizing other donor nerves, such as the ulnar or thoracodorsal nerves, or tendon transfer procedures.</p><p><strong>Rationale: </strong>Although active elbow extension may not be the primary focus when treating brachial plexus injury, a lack of active elbow extension affects various daily activities, such as overhead tasks, the use of a walking aid, and reaching for objects on a table<sup>4</sup>. Consequently, reanimating the muscle through the use of expendable donor nerves appears to be a suitable approach, particularly in young and active patients, aiming to restore function and enhance overall quality of life. Therefore, we recommend this procedure as an adjunct to other surgical interventions in active patients who would benefit from restored elbow extension to perform daily activities.</p><p><strong>Expected outcomes: </strong>The procedure demonstrated satisfactory results in our prior study<sup>1,2</sup>, consistent with findings from other studies that reported good results in 57% to 80% of patients<sup>5,6</sup>. In our prior study, 65% of patients achieved favorable motor function (Medical Research Council grad
{"title":"Transfer of the Intercostal Nerves to the Radial Nerve Branch Innervating the Long Head of the Triceps Muscle for Elbow Extension.","authors":"Kanchai Malungpaishrope, Piyabuth Kittithamvongs, Sopinun Siripoonyothai, Navapong Anantavorasakul, Chairoj Uerpairojkit, Somsak Leechavengvongs","doi":"10.2106/JBJS.ST.23.00092","DOIUrl":"10.2106/JBJS.ST.23.00092","url":null,"abstract":"<p><strong>Background: </strong>Transfer of intercostal nerves to the radial nerve branch innervating the long head of the triceps muscle for elbow extension is indicated in patients with traumatic brachial plexus palsy that is either the pan-plexus type or C5-C7 palsy with no triceps muscle function. The procedure aims to restore triceps muscle function through the use of the intercostal nerves, which are expendable nerves, as donors.</p><p><strong>Description: </strong>The procedure is performed by first identifying the third to fifth intercostal nerves and coaptating them to the radial nerve branch innervating the long head of the triceps muscle. Three intercostal nerves are utilized because our previous study revealed that the use of 2 intercostal nerves resulted in poor outcomes<sup>1</sup>. Additionally, 3 intercostal nerves are comparable in size to the recipient nerve<sup>2</sup>. To identify the intercostal nerves, a curved incision is made over the sixth rib to the medial side of the arm, detaching the pectoralis major and minor from their distal insertion. The intercostal nerves are dissected from the inferior border of the third to fifth ribs. The radial nerve branch innervating the long head of the triceps muscle can be found distal to the teres major muscle as the first branch from the radial nerve via the same incision, at the medial side of the arm<sup>3</sup>. Subsequently, the 3 intercostal nerves are coaptated to the radial nerve branch to the long head of the triceps muscle.</p><p><strong>Alternatives: </strong>A deficit in active elbow extension may be deemed acceptable for certain patients who are amenable to utilizing gravity for performing such extensions. Nonoperative treatment could be contemplated for individuals falling into this category. Alternative surgical approaches may include nerve transfers utilizing other donor nerves, such as the ulnar or thoracodorsal nerves, or tendon transfer procedures.</p><p><strong>Rationale: </strong>Although active elbow extension may not be the primary focus when treating brachial plexus injury, a lack of active elbow extension affects various daily activities, such as overhead tasks, the use of a walking aid, and reaching for objects on a table<sup>4</sup>. Consequently, reanimating the muscle through the use of expendable donor nerves appears to be a suitable approach, particularly in young and active patients, aiming to restore function and enhance overall quality of life. Therefore, we recommend this procedure as an adjunct to other surgical interventions in active patients who would benefit from restored elbow extension to perform daily activities.</p><p><strong>Expected outcomes: </strong>The procedure demonstrated satisfactory results in our prior study<sup>1,2</sup>, consistent with findings from other studies that reported good results in 57% to 80% of patients<sup>5,6</sup>. In our prior study, 65% of patients achieved favorable motor function (Medical Research Council grad","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-08-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12369725/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144972902","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 : 2025-08-25eCollection Date: 2025-07-01DOI: 10.2106/JBJS.ST.24.00023
Everett G Young, Samantha Stanzione, Boopalan Ramasamy, L Bogdan Solomon, Neil P Sheth
<p><strong>Background: </strong>Achieving adequate exposure can be difficult in cases of revision total hip arthroplasty (THA). Splitting the gluteus maximus muscle with use of a Kocher-Langenbeck approach is the most common technique when performing a posterior approach to the hip. However, superior exposure of the ilium is limited by the superior gluteal neurovascular bundle (SGB). Additionally, postoperative abductor weakness has been associated with this approach.</p><p><strong>Description: </strong>The extensile posterior approach (Adelaide approach) mobilizes the gluteus maximus muscle posteriorly and the gluteus medius muscle anteriorly to expose the ilium superior to the sciatic notch while minimizing the risk of injury to the SGB and preserving abductor function. Above the greater trochanter, the skin incision extends in a straight line toward the halfway point between the iliac tuberosity and the posterior superior iliac spine. It is helpful to find and protect the perforator vessels to identify the anterior edge of the gluteus maximus and develop a plane between the gluteus maximus and medius. The fascial incision is made with a slight Z shape for a modified Gibson approach. The gluteus maximus tendon is transected and the muscle is reflected posteriorly to expose the gluteus medius. The gluteus medius is elevated off the posterior gluteal line proximally to distally. The superior aspect of the SGB and transverse ligament are exposed, and the anterior aspect of the transverse sciatic notch ligament is released. The gluteus medius is mobilized anteriorly to expose the SGB, which is easier in a proximal-to-distal direction. Following the mobilization of the SGB, cage flanges can be passed underneath or augments bridged over the SGB without placing the SGB under undue tension.</p><p><strong>Alternatives: </strong>Nonoperative treatment should be attempted first, depending on the diagnosis and the patient's associated natural history. Once nonoperative treatment has been exhausted and revision THA is indicated, the traditional posterior, anterior, and direct lateral approaches can also be considered. If intraoperative assessment shows that the femoral component needs to be revised, the anterior approach presents substantial difficulty in femoral exposure and is associated with a higher risk of iatrogenic fracture. The direct lateral approach commonly leads to abductor weakness and a Trendelenburg gait postoperatively. The traditional posterior approach places the superior gluteal nerve at a higher risk for injury, which can lead to postoperative abductor weakness.</p><p><strong>Rationale: </strong>Common indications for revision THA include osteolysis, adverse local tissue reaction, recurrent instability, and aseptic acetabular loosening. Adequate exposure is essential to facilitate THA reconstruction while minimizing the risk of iatrogenic nerve injury.</p><p><strong>Expected outcomes: </strong>In a series of 9 patients with Paprosky 3B d
{"title":"Improved Iliac Exposure and Abductor Function with an Extended Posterior Approach for Revision Total Hip Arthroplasty.","authors":"Everett G Young, Samantha Stanzione, Boopalan Ramasamy, L Bogdan Solomon, Neil P Sheth","doi":"10.2106/JBJS.ST.24.00023","DOIUrl":"10.2106/JBJS.ST.24.00023","url":null,"abstract":"<p><strong>Background: </strong>Achieving adequate exposure can be difficult in cases of revision total hip arthroplasty (THA). Splitting the gluteus maximus muscle with use of a Kocher-Langenbeck approach is the most common technique when performing a posterior approach to the hip. However, superior exposure of the ilium is limited by the superior gluteal neurovascular bundle (SGB). Additionally, postoperative abductor weakness has been associated with this approach.</p><p><strong>Description: </strong>The extensile posterior approach (Adelaide approach) mobilizes the gluteus maximus muscle posteriorly and the gluteus medius muscle anteriorly to expose the ilium superior to the sciatic notch while minimizing the risk of injury to the SGB and preserving abductor function. Above the greater trochanter, the skin incision extends in a straight line toward the halfway point between the iliac tuberosity and the posterior superior iliac spine. It is helpful to find and protect the perforator vessels to identify the anterior edge of the gluteus maximus and develop a plane between the gluteus maximus and medius. The fascial incision is made with a slight Z shape for a modified Gibson approach. The gluteus maximus tendon is transected and the muscle is reflected posteriorly to expose the gluteus medius. The gluteus medius is elevated off the posterior gluteal line proximally to distally. The superior aspect of the SGB and transverse ligament are exposed, and the anterior aspect of the transverse sciatic notch ligament is released. The gluteus medius is mobilized anteriorly to expose the SGB, which is easier in a proximal-to-distal direction. Following the mobilization of the SGB, cage flanges can be passed underneath or augments bridged over the SGB without placing the SGB under undue tension.</p><p><strong>Alternatives: </strong>Nonoperative treatment should be attempted first, depending on the diagnosis and the patient's associated natural history. Once nonoperative treatment has been exhausted and revision THA is indicated, the traditional posterior, anterior, and direct lateral approaches can also be considered. If intraoperative assessment shows that the femoral component needs to be revised, the anterior approach presents substantial difficulty in femoral exposure and is associated with a higher risk of iatrogenic fracture. The direct lateral approach commonly leads to abductor weakness and a Trendelenburg gait postoperatively. The traditional posterior approach places the superior gluteal nerve at a higher risk for injury, which can lead to postoperative abductor weakness.</p><p><strong>Rationale: </strong>Common indications for revision THA include osteolysis, adverse local tissue reaction, recurrent instability, and aseptic acetabular loosening. Adequate exposure is essential to facilitate THA reconstruction while minimizing the risk of iatrogenic nerve injury.</p><p><strong>Expected outcomes: </strong>In a series of 9 patients with Paprosky 3B d","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-08-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12369726/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144973439","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 : 2025-08-25eCollection Date: 2025-07-01DOI: 10.2106/JBJS.ST.24.00041
J Terrence Jose Jerome
<p><strong>Background: </strong>Seymour fractures are a unique type of pediatric distal phalangeal fracture that can be easily misdiagnosed as a simple nail-bed injury or mallet finger<sup>1-3</sup>. Because of this potential for misdiagnosis, clear communication with consulting physicians regarding physical examination findings, such as nail plate avulsion and radiographic findings, is necessary. Seymour fractures involve the open physis and the germinal matrix, which become interposed in the fracture site, increasing the likelihood of infection. Open fractures are often displaced as a result of the distracting forces of the extensor and flexor tendons. This displacement, combined with the frequent association of nail bed lacerations, creates a high risk of complications such as infection and nonunion<sup>1-3</sup>. If left untreated or inadequately treated, these complications can lead to further surgery, prolonged antibiotic use, and potentially long-term impairment of hand function and cosmesis.</p><p><strong>Description: </strong>The procedure is performed with the patient under local anesthesia and with a glove tourniquet applied at the base of the operative finger. With use of blunt instruments such as a Freer elevator and a hemostat, the nail plate is carefully removed, and an eponychial flap is elevated proximally to expose the germinal matrix and fracture site. The interposed germinal matrix tissue at the fracture site is delicately elevated as a proximally based flap, fully revealing the fracture site for thorough irrigation, debridement, and reduction. Fracture fragments typically achieve anatomical alignment spontaneously upon removal of the interposed germinal matrix tissue. Reduction is verified visually and on fluoroscopy. The germinal matrix flap is meticulously sutured to the nail bed with use of 6-0 or 7-0 absorbable sutures, ensuring proper fracture alignment and correction of the pseudo-mallet deformity. For cases with instability, a 1.2- or 1.0-mm Kirschner wire may be placed retrogradely across the fracture and distal interphalangeal joint for additional stability. To support the repair, the nail plate or a substitute material may be temporarily placed beneath the eponychial fold; however, the nail plate is usually removed to reduce the risk of infection. The eponychial flap is reapproximated with simple interrupted sutures, and the procedure is concluded with the application of sterile, nonadherent dressings. The operative finger is immobilized with use of a below-the-elbow splint. All fracture reductions should be confirmed on postoperative radiographs.</p><p><strong>Alternatives: </strong>Alternative nonoperative treatments for Seymour fractures include closed reduction and splinting and/or the use of antibiotics. Alternative operative treatments include open reduction and internal fixation with use of Kirschner wires and nail-bed repair.</p><p><strong>Rationale: </strong>This technique for managing Seymour fractures emp
{"title":"Management of Seymour (Distal Phalangeal) Fractures with Nail Bed Involvement.","authors":"J Terrence Jose Jerome","doi":"10.2106/JBJS.ST.24.00041","DOIUrl":"10.2106/JBJS.ST.24.00041","url":null,"abstract":"<p><strong>Background: </strong>Seymour fractures are a unique type of pediatric distal phalangeal fracture that can be easily misdiagnosed as a simple nail-bed injury or mallet finger<sup>1-3</sup>. Because of this potential for misdiagnosis, clear communication with consulting physicians regarding physical examination findings, such as nail plate avulsion and radiographic findings, is necessary. Seymour fractures involve the open physis and the germinal matrix, which become interposed in the fracture site, increasing the likelihood of infection. Open fractures are often displaced as a result of the distracting forces of the extensor and flexor tendons. This displacement, combined with the frequent association of nail bed lacerations, creates a high risk of complications such as infection and nonunion<sup>1-3</sup>. If left untreated or inadequately treated, these complications can lead to further surgery, prolonged antibiotic use, and potentially long-term impairment of hand function and cosmesis.</p><p><strong>Description: </strong>The procedure is performed with the patient under local anesthesia and with a glove tourniquet applied at the base of the operative finger. With use of blunt instruments such as a Freer elevator and a hemostat, the nail plate is carefully removed, and an eponychial flap is elevated proximally to expose the germinal matrix and fracture site. The interposed germinal matrix tissue at the fracture site is delicately elevated as a proximally based flap, fully revealing the fracture site for thorough irrigation, debridement, and reduction. Fracture fragments typically achieve anatomical alignment spontaneously upon removal of the interposed germinal matrix tissue. Reduction is verified visually and on fluoroscopy. The germinal matrix flap is meticulously sutured to the nail bed with use of 6-0 or 7-0 absorbable sutures, ensuring proper fracture alignment and correction of the pseudo-mallet deformity. For cases with instability, a 1.2- or 1.0-mm Kirschner wire may be placed retrogradely across the fracture and distal interphalangeal joint for additional stability. To support the repair, the nail plate or a substitute material may be temporarily placed beneath the eponychial fold; however, the nail plate is usually removed to reduce the risk of infection. The eponychial flap is reapproximated with simple interrupted sutures, and the procedure is concluded with the application of sterile, nonadherent dressings. The operative finger is immobilized with use of a below-the-elbow splint. All fracture reductions should be confirmed on postoperative radiographs.</p><p><strong>Alternatives: </strong>Alternative nonoperative treatments for Seymour fractures include closed reduction and splinting and/or the use of antibiotics. Alternative operative treatments include open reduction and internal fixation with use of Kirschner wires and nail-bed repair.</p><p><strong>Rationale: </strong>This technique for managing Seymour fractures emp","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"15 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-08-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12369724/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144973425","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 : 2025-08-15eCollection Date: 2025-07-01DOI: 10.2106/JBJS.ST.24.00016
J Terrence Jose Jerome
<p><strong>Background: </strong>Medial-approach derotational humeral osteotomy is indicated in patients with brachial plexus birth palsy (BPBP) who have internal rotation contracture, a condition that substantially limits upper-extremity function and creates cosmetic concerns as a result of excessive internal rotation<sup>1</sup>. This procedure enhances the range of motion of the arm by surgically externally rotating the humerus, thereby facilitating essential activities such as bringing the hand to the mouth and neck without the need for compensatory movements. In addition, the medial approach offers cosmetic benefits; the incision along the inner arm is less conspicuous than those of traditional lateral approaches. The anteromedial humeral surface provides an ideal site for secure plate fixation, which promotes stability and optimal healing<sup>2</sup>.</p><p><strong>Description: </strong>Preoperative evaluation is critical to determine the precise degree of humeral rotation required. Both active and passive ranges of motion are measured-with special emphasis on shoulder adduction-to quantify available glenohumeral rotation. The active arc of internal rotation is recorded from the end range of passive external rotation, and the additional external rotation necessary for functional tasks (e.g., touching the back of the head), including scapulothoracic contributions, is determined passively. The operative plan involves calculating the degree of correction by subtracting the patient's active external rotation from the total required rotation, ensuring that adequate internal rotation is preserved for midline functions such as reaching the beltline. The goal is to achieve neutral glenohumeral alignment with restored external rotation, typically with a correction of approximately 60° to 70°.The procedure begins with the application of an arm tourniquet to minimize bleeding. A medial incision is made over the intermuscular septum and midshaft of the humerus while carefully protecting the ulnar and median nerves and brachial vessels. The intermuscular septum is identified and excised. The ulnar nerve is retracted posteriorly, whereas the median nerve and brachial artery are retracted anteriorly, thereby reducing the risk of nerve compression. The humeral diaphysis is then exposed, and the periosteum is elevated at the planned osteotomy site. A 6 to 8-hole plate (typically 2.7 or 3.5 mm) is temporarily applied, and proximal bicortical screws are inserted. A Kirschner wire is placed in the distal fragment to mark the desired correction angle, with its position verified via goniometry and visual assessment. Following removal of the plate, an oscillating saw is utilized to perform the osteotomy. The humerus is rotated to align the screw holes with the Kirschner wire, the plate is reapplied, and final fixation is achieved with use of standard compression screw techniques<sup>2</sup>.</p><p><strong>Alternatives: </strong>Alternatives include glenohumeral jo
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