Pub Date : 2024-11-15eCollection Date: 2024-10-01DOI: 10.2106/JBJS.ST.23.00078
Cuyler P Dewar, Gabe N O'Hara, Logan J Roebke, John McKeon, Kevin D Martin
<p><p>Metatarsal fractures are one of the most common injuries of the foot, accounting for approximately 5% to 6% of all fractures confronted in the outpatient setting<sup>1</sup>. Approximately 45% to 70% of these fractures involve the fifth metatarsal, which have been described using a 3 zonal approach in 1993 by Lawrence and Botte<sup>2</sup>. Zone 2 fractures are difficult to manage given their retrograde vascular supply, leading to higher rates of nonunion<sup>1,3</sup>. Jones fractures (zone 2) are primarily treated surgically, with the 2 main methods being intramedullary screw fixation and plate fixation<sup>3</sup>. Surgical management leads to higher rates of union when compared with nonoperative modalities. Presented here is a technique for zone 2 intra-articular Jones fractures with minimal to moderate displacement via open reduction and internal fixation. This technique is not recommended for comminuted fractures or those with proximal split fractures. Starting with the foot lateral, this technique requires meticulous marking of the anatomical landmarks of the distal fibula as well as the fifth metatarsal to establish the precise starting point for the guidewire. Using a mini c-arm, a high and inside positioning should be confirmed prior to advancing the guidewire from proximal to distal while remaining positioned in the center of the medullary canal. Capitalizing on the variable pitch of a 5.0-mm headless compression screw, the Jones fracture is compressed to ensure primary bone healing. The incision is then closed, and a soft wrap is utilized followed by 2 weeks of non-weight-bearing and progressive protective weight-bearing until a complete recovery is achieved.</p><p><strong>Background: </strong>Open reduction and internal fixation (ORIF) for the operative treatment of zone-2 intra-articular Jones fractures with minimal to moderate displacement is recommended because of the high rate of nonunion associated with nonoperative treatment. The blood supply to this region is minimal because of its retrograde flow, leading to high rates of nonunion with nonoperative treatment. The presently described technique offers reduction and fixation of a zone-2 fracture, as well as improved functional outcomes and nonunion rates. This approach is minimally invasive, as it is performed percutaneously, leading to a decrease in soft-tissue damage, infection rates, and operative time.</p><p><strong>Description: </strong>The zone-2 fifth metatarsal ORIF technique begins with the use of a marking pen to outline the distal fibula and the head of the fifth metatarsal for proper orientation. Fluoroscopy is utilized to identify the landmarks so that a guidewire can be placed into the proximal dorsal aspect of the fifth metatarsal. Placement is confirmed on multiple radiographic images. The guidewire is then slowly inserted down the medullary canal of the fifth metatarsal, with placement verified on multiple fluoroscopic images. Once placement is confirmed,
{"title":"Percutaneous Screw Fixation of Proximal Fifth Metatarsal Fractures.","authors":"Cuyler P Dewar, Gabe N O'Hara, Logan J Roebke, John McKeon, Kevin D Martin","doi":"10.2106/JBJS.ST.23.00078","DOIUrl":"10.2106/JBJS.ST.23.00078","url":null,"abstract":"<p><p>Metatarsal fractures are one of the most common injuries of the foot, accounting for approximately 5% to 6% of all fractures confronted in the outpatient setting<sup>1</sup>. Approximately 45% to 70% of these fractures involve the fifth metatarsal, which have been described using a 3 zonal approach in 1993 by Lawrence and Botte<sup>2</sup>. Zone 2 fractures are difficult to manage given their retrograde vascular supply, leading to higher rates of nonunion<sup>1,3</sup>. Jones fractures (zone 2) are primarily treated surgically, with the 2 main methods being intramedullary screw fixation and plate fixation<sup>3</sup>. Surgical management leads to higher rates of union when compared with nonoperative modalities. Presented here is a technique for zone 2 intra-articular Jones fractures with minimal to moderate displacement via open reduction and internal fixation. This technique is not recommended for comminuted fractures or those with proximal split fractures. Starting with the foot lateral, this technique requires meticulous marking of the anatomical landmarks of the distal fibula as well as the fifth metatarsal to establish the precise starting point for the guidewire. Using a mini c-arm, a high and inside positioning should be confirmed prior to advancing the guidewire from proximal to distal while remaining positioned in the center of the medullary canal. Capitalizing on the variable pitch of a 5.0-mm headless compression screw, the Jones fracture is compressed to ensure primary bone healing. The incision is then closed, and a soft wrap is utilized followed by 2 weeks of non-weight-bearing and progressive protective weight-bearing until a complete recovery is achieved.</p><p><strong>Background: </strong>Open reduction and internal fixation (ORIF) for the operative treatment of zone-2 intra-articular Jones fractures with minimal to moderate displacement is recommended because of the high rate of nonunion associated with nonoperative treatment. The blood supply to this region is minimal because of its retrograde flow, leading to high rates of nonunion with nonoperative treatment. The presently described technique offers reduction and fixation of a zone-2 fracture, as well as improved functional outcomes and nonunion rates. This approach is minimally invasive, as it is performed percutaneously, leading to a decrease in soft-tissue damage, infection rates, and operative time.</p><p><strong>Description: </strong>The zone-2 fifth metatarsal ORIF technique begins with the use of a marking pen to outline the distal fibula and the head of the fifth metatarsal for proper orientation. Fluoroscopy is utilized to identify the landmarks so that a guidewire can be placed into the proximal dorsal aspect of the fifth metatarsal. Placement is confirmed on multiple radiographic images. The guidewire is then slowly inserted down the medullary canal of the fifth metatarsal, with placement verified on multiple fluoroscopic images. Once placement is confirmed, ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11567698/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142649258","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 : 2024-11-13eCollection Date: 2024-10-01DOI: 10.2106/JBJS.ST.23.00076
Scott H Kozin, Francisco Soldado
<p><strong>Background: </strong>Radial neck fractures account for 1% of all pediatric fractures and 5% to 10% of pediatric elbow fractures. The mechanism of injury is typically a fall with the elbow in hyperextension and the forearm in supination. A valgus force compresses the radial head against the capitellum, causing a radial neck fracture. Displaced radial neck fractures are difficult to treat and account for a disproportionate number of bad outcomes, including malunion, nonunion, and osteonecrosis. The preferred treatment is closed reduction and fixation, as open reduction is associated with an inordinately high rate of osteonecrosis. Closed intramedullary pinning is an effective technique to achieve and maintain reduction. The procedure relies on an intact periosteum and requires attention to detail. The present video article will demonstrate the technique of closed intramedullary pinning (the Metaizeau technique). Metaizeau et al. previously described their technique of closed reduction and intramedullary pinning of radial neck fractures. A Kirschner wire is inserted retrograde from the distal radius into the posterolateral radial neck with the forearm pronated to avoid injury to the posterior interosseous nerve. Reduction is achieved by rotating the wire 180°. This technique relies on intact periosteum, with care taken to preserve the tenuous blood supply of the radial head and to achieve adequate reduction.</p><p><strong>Description: </strong>General anesthesia is administered, and the patient is positioned supine with use of an arm table or with an image intensifier utilized as an arm table. A tourniquet is applied to the operative limb. Fluoroscopy is utilized to identify the distal radius physis. A radial approach is performed to access the distal radius, proximal to the growth plate, with care taken to protect the sensory nerves. The cortex of the radial metaphysis is opened with use of a drill bit or a bone awl to allow space for the internal fixation device. Opening in a proximal direction and into the medullary canal facilitates intramedullary passage. A Steinmann pin (1.2 to 2.5 mm), Ilizarov wire (2.0 mm), or elastic nail can be utilized for as an intramedullary device. Place the pre-bent Steinmann pin/Ilizarov wire/elastic nail into the metaphysis and advance it in a proximal direction toward the radial neck fracture. The tip of the intramedullary device is directed into the displaced radial neck fracture, engaging the radial epiphysis. The pin/wire/elastic nail is rotated 180° to reduce the fracture, and reduction is confirmed on radiographs. Once reduction and fixation are confirmed, the pin/wire/elastic nail is cut and the skin is closed over it with use of absorbable sutures. A long arm cast is applied for 4 to 6 weeks.</p><p><strong>Alternatives: </strong>Alternatives include cast immobilization for cases of displaced fractures with <20° of angulation, closed reduction by placing the elbow in varus with direct pressure on
{"title":"Closed Intramedullary Pinning of Displaced Radial Neck Fracture (Metaizeau Technique).","authors":"Scott H Kozin, Francisco Soldado","doi":"10.2106/JBJS.ST.23.00076","DOIUrl":"10.2106/JBJS.ST.23.00076","url":null,"abstract":"<p><strong>Background: </strong>Radial neck fractures account for 1% of all pediatric fractures and 5% to 10% of pediatric elbow fractures. The mechanism of injury is typically a fall with the elbow in hyperextension and the forearm in supination. A valgus force compresses the radial head against the capitellum, causing a radial neck fracture. Displaced radial neck fractures are difficult to treat and account for a disproportionate number of bad outcomes, including malunion, nonunion, and osteonecrosis. The preferred treatment is closed reduction and fixation, as open reduction is associated with an inordinately high rate of osteonecrosis. Closed intramedullary pinning is an effective technique to achieve and maintain reduction. The procedure relies on an intact periosteum and requires attention to detail. The present video article will demonstrate the technique of closed intramedullary pinning (the Metaizeau technique). Metaizeau et al. previously described their technique of closed reduction and intramedullary pinning of radial neck fractures. A Kirschner wire is inserted retrograde from the distal radius into the posterolateral radial neck with the forearm pronated to avoid injury to the posterior interosseous nerve. Reduction is achieved by rotating the wire 180°. This technique relies on intact periosteum, with care taken to preserve the tenuous blood supply of the radial head and to achieve adequate reduction.</p><p><strong>Description: </strong>General anesthesia is administered, and the patient is positioned supine with use of an arm table or with an image intensifier utilized as an arm table. A tourniquet is applied to the operative limb. Fluoroscopy is utilized to identify the distal radius physis. A radial approach is performed to access the distal radius, proximal to the growth plate, with care taken to protect the sensory nerves. The cortex of the radial metaphysis is opened with use of a drill bit or a bone awl to allow space for the internal fixation device. Opening in a proximal direction and into the medullary canal facilitates intramedullary passage. A Steinmann pin (1.2 to 2.5 mm), Ilizarov wire (2.0 mm), or elastic nail can be utilized for as an intramedullary device. Place the pre-bent Steinmann pin/Ilizarov wire/elastic nail into the metaphysis and advance it in a proximal direction toward the radial neck fracture. The tip of the intramedullary device is directed into the displaced radial neck fracture, engaging the radial epiphysis. The pin/wire/elastic nail is rotated 180° to reduce the fracture, and reduction is confirmed on radiographs. Once reduction and fixation are confirmed, the pin/wire/elastic nail is cut and the skin is closed over it with use of absorbable sutures. A long arm cast is applied for 4 to 6 weeks.</p><p><strong>Alternatives: </strong>Alternatives include cast immobilization for cases of displaced fractures with <20° of angulation, closed reduction by placing the elbow in varus with direct pressure on ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11554352/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630257","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 : 2024-11-13eCollection Date: 2024-10-01DOI: 10.2106/JBJS.ST.23.00085
Michael Leunig, Hannes A Rüdiger
<p><strong>Background: </strong>Although the direct anterior approach (DAA) represents an intermuscular and internervous approach to total hip arthroplasty (THA), it did not reach global acceptance until its adoption by large teaching centers. Today, >50% of primary THA procedures in Switzerland are performed via the DAA. Besides being truly minimally invasive, a key advantage of the DAA is the inherent stability that it provides. A shortcoming has been that the traditional longitudinal skin incision does not follow the skin tension lines<sup>1</sup> and therefore can result in wound-healing problems, poor scar cosmesis, and damage to the lateral femoral cutaneous nerve (LFCN). In 2011, we introduced the bikini-type skin-crease incision, and we have utilized it in most of our patients since, with excellent outcomes that are equivalent to those of the traditional incision and superior scar cosmesis<sup>2</sup>. The bikini incision pertains only to the incisions made at the skin and subcutaneous tissues, which are oblique, whereas the deeper dissection beginning with the fascial sheath of the tensor fasciae latae (TFL) is still performed in the longitudinal direction. In most patients, the incision falls into the flexion crease or slightly distal to it, and today, in order to minimize direct damage to the LFCN<sup>3</sup>, the incision we perform is always lateral to the anterior superior iliac spine (ASIS)<sup>4</sup>. From January 2014 until August 2023, a total of 10,009 THA procedures were performed in our unit, with 8,769 being performed via the DAA and 4,969 of those being performed with use of the bikini incision type. The incision type was generally selected according to the experience of the surgeon, with the less-experienced surgeons utilizing classic incision techniques and the high-volume surgeons (i.e., >200 THAs per year) utilizing the bikini incision technique. The bikini incision was utilized in most straightforward cases, but it was not performed if a longitudinal incision had been utilized on the contralateral side or in technically challenging cases. The use of this incision has been adopted by others, with similarly excellent outcomes; however, there is potential for damage to the LFCN<sup>5</sup>. Several studies utilizing a bikini incision have described the incision as being made quite medial to the ASIS, potentially even crossing the medial branches of the LFCN. In contrast, over years of utilizing the bikini incision technique, our approach has evolved such that the incision is not made medial to the ASIS.</p><p><strong>Description: </strong>The bikini-type (skin-crease) incision only differs from the classic longitudinal approach used for DAA THA with respect to the skin and subcutaneous tissue. To avoid damage to the LFCN, our bikini-type incision has evolved over the last decade to being located entirely lateral to the ASIS (Video 1)<sup>3</sup>.</p><p><strong>Alternatives: </strong>The main alternative is the classic lo
{"title":"Bikini Incision Modification of the Direct Anterior Approach.","authors":"Michael Leunig, Hannes A Rüdiger","doi":"10.2106/JBJS.ST.23.00085","DOIUrl":"10.2106/JBJS.ST.23.00085","url":null,"abstract":"<p><strong>Background: </strong>Although the direct anterior approach (DAA) represents an intermuscular and internervous approach to total hip arthroplasty (THA), it did not reach global acceptance until its adoption by large teaching centers. Today, >50% of primary THA procedures in Switzerland are performed via the DAA. Besides being truly minimally invasive, a key advantage of the DAA is the inherent stability that it provides. A shortcoming has been that the traditional longitudinal skin incision does not follow the skin tension lines<sup>1</sup> and therefore can result in wound-healing problems, poor scar cosmesis, and damage to the lateral femoral cutaneous nerve (LFCN). In 2011, we introduced the bikini-type skin-crease incision, and we have utilized it in most of our patients since, with excellent outcomes that are equivalent to those of the traditional incision and superior scar cosmesis<sup>2</sup>. The bikini incision pertains only to the incisions made at the skin and subcutaneous tissues, which are oblique, whereas the deeper dissection beginning with the fascial sheath of the tensor fasciae latae (TFL) is still performed in the longitudinal direction. In most patients, the incision falls into the flexion crease or slightly distal to it, and today, in order to minimize direct damage to the LFCN<sup>3</sup>, the incision we perform is always lateral to the anterior superior iliac spine (ASIS)<sup>4</sup>. From January 2014 until August 2023, a total of 10,009 THA procedures were performed in our unit, with 8,769 being performed via the DAA and 4,969 of those being performed with use of the bikini incision type. The incision type was generally selected according to the experience of the surgeon, with the less-experienced surgeons utilizing classic incision techniques and the high-volume surgeons (i.e., >200 THAs per year) utilizing the bikini incision technique. The bikini incision was utilized in most straightforward cases, but it was not performed if a longitudinal incision had been utilized on the contralateral side or in technically challenging cases. The use of this incision has been adopted by others, with similarly excellent outcomes; however, there is potential for damage to the LFCN<sup>5</sup>. Several studies utilizing a bikini incision have described the incision as being made quite medial to the ASIS, potentially even crossing the medial branches of the LFCN. In contrast, over years of utilizing the bikini incision technique, our approach has evolved such that the incision is not made medial to the ASIS.</p><p><strong>Description: </strong>The bikini-type (skin-crease) incision only differs from the classic longitudinal approach used for DAA THA with respect to the skin and subcutaneous tissue. To avoid damage to the LFCN, our bikini-type incision has evolved over the last decade to being located entirely lateral to the ASIS (Video 1)<sup>3</sup>.</p><p><strong>Alternatives: </strong>The main alternative is the classic lo","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11554357/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630256","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>Microdiscectomy has been the gold-standard technique for the treatment of lumbar disc herniation. A potential reason for suboptimal symptom resolution following microdiscectomy is postoperative epidural fibrosis<sup>1</sup>. Preservation of the ligamentum flavum through the use of the ligamentum flavum flap technique reduces postoperative epidural fibrosis and leads to a favorable long-term prognosis.</p><p><strong>Description: </strong>The L5-S1 interlaminar space on the operative side is exposed with use of a standard microsurgical approach, and the level is confirmed. The ligamentum flavum is held taut with use of tooth forceps, holding onto superficial layers, and a flap with its base on the lateral side is created. Initial separation is made at the midline (where the flavum is very thin) with use of a no.-15-blade scalpel. The flap is elevated by detaching the ligamentum flavum between the lower border of the L5 lamina and sacrum with use of a 1-mm Kerrison rongeur. The detachment of the ligamentum flavum is performed carefully, preserving the attachments on the lateral border. Having a thin base allows the flap to be elevated and rotated, and the flap thus can be tucked into the muscle above the facet joint. The nerve root is retracted, and discectomy is performed according to the location and size of the disc. After achieving good hemostasis, the ligamentum flavum flap is gently rotated back to its normal position. In most cases, the flap can be returned back to its original position without any gap and without any need for suture. Closure is performed in layers.</p><p><strong>Alternatives: </strong>Nonoperative treatment yields good pain relief in more than 80% of patients with disc herniation. However, if surgery is required, the primary concern for the surgeon is the prevention of postoperative scarring and fibrosis around the nerve root. Previous attempts to mitigate this potential complication have revolved around the placement of a subcutaneous fat graft over the nerve root; however, no firm evidence exists to support this technique. Synthetic materials such as expanded polytetrafluoroethylene, Adcon-L gel (Wright Medical Technologies), and sodium hyaluronate have also been utilized to prevent epidural scarring; however, the ligamentum flavum is a natural biological solution.</p><p><strong>Rationale: </strong>Postoperative fibrosis may occur if there is a dead space as a result of the excision of the ligamentum flavum or due to inflammation. Restoration of native tissue anatomy with use of the ligamentum flavum technique can prevent such fibrosis, as has been reported previously. In addition to reducing scar formation, preserving the ligamentum flavum can make revision surgery (which is rarely required) safer, as there is less or no epidural fibrosis or nerve root scarring.</p><p><strong>Expected outcomes: </strong>Patients undergoing this procedure have shown good improvement in the Oswestry Disabilit
{"title":"Ligamentum Flavum Flap Technique in Lumbar Microdiscectomy.","authors":"Shanmuganathan Rajasekaran, Karthik Ramachandran, Rishi Mugesh Kanna, Ajoy Prasad Shetty","doi":"10.2106/JBJS.ST.23.00049","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00049","url":null,"abstract":"<p><strong>Background: </strong>Microdiscectomy has been the gold-standard technique for the treatment of lumbar disc herniation. A potential reason for suboptimal symptom resolution following microdiscectomy is postoperative epidural fibrosis<sup>1</sup>. Preservation of the ligamentum flavum through the use of the ligamentum flavum flap technique reduces postoperative epidural fibrosis and leads to a favorable long-term prognosis.</p><p><strong>Description: </strong>The L5-S1 interlaminar space on the operative side is exposed with use of a standard microsurgical approach, and the level is confirmed. The ligamentum flavum is held taut with use of tooth forceps, holding onto superficial layers, and a flap with its base on the lateral side is created. Initial separation is made at the midline (where the flavum is very thin) with use of a no.-15-blade scalpel. The flap is elevated by detaching the ligamentum flavum between the lower border of the L5 lamina and sacrum with use of a 1-mm Kerrison rongeur. The detachment of the ligamentum flavum is performed carefully, preserving the attachments on the lateral border. Having a thin base allows the flap to be elevated and rotated, and the flap thus can be tucked into the muscle above the facet joint. The nerve root is retracted, and discectomy is performed according to the location and size of the disc. After achieving good hemostasis, the ligamentum flavum flap is gently rotated back to its normal position. In most cases, the flap can be returned back to its original position without any gap and without any need for suture. Closure is performed in layers.</p><p><strong>Alternatives: </strong>Nonoperative treatment yields good pain relief in more than 80% of patients with disc herniation. However, if surgery is required, the primary concern for the surgeon is the prevention of postoperative scarring and fibrosis around the nerve root. Previous attempts to mitigate this potential complication have revolved around the placement of a subcutaneous fat graft over the nerve root; however, no firm evidence exists to support this technique. Synthetic materials such as expanded polytetrafluoroethylene, Adcon-L gel (Wright Medical Technologies), and sodium hyaluronate have also been utilized to prevent epidural scarring; however, the ligamentum flavum is a natural biological solution.</p><p><strong>Rationale: </strong>Postoperative fibrosis may occur if there is a dead space as a result of the excision of the ligamentum flavum or due to inflammation. Restoration of native tissue anatomy with use of the ligamentum flavum technique can prevent such fibrosis, as has been reported previously. In addition to reducing scar formation, preserving the ligamentum flavum can make revision surgery (which is rarely required) safer, as there is less or no epidural fibrosis or nerve root scarring.</p><p><strong>Expected outcomes: </strong>Patients undergoing this procedure have shown good improvement in the Oswestry Disabilit","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543181/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630260","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 : 2024-11-08eCollection Date: 2024-10-01DOI: 10.2106/JBJS.ST.23.00071
Robert W Gomez, Riley C McHugh, Dhairya Shukla, Dustin A Greenhill
<p><strong>Background: </strong>Flexible intramedullary nailing is an effective method of stabilization in pediatric patients with a humeral shaft fracture when surgery is indicated<sup>1-3</sup>. Although these fractures are most often treated nonoperatively, operative indications include open fractures, bilateral injuries, compartment syndrome, pathologic fractures, neurovascular compromise, unacceptable alignment after attempted nonoperative treatment, and ipsilateral upper-extremity injuries<sup>4</sup>. The current literature on flexible intramedullary nailing of the pediatric humeral shaft lacks concise descriptions of available entry points, which directly affect the subsequent technique, and of pertinent pediatric-specific anatomy. Thus, the present article focuses on these entry points in the pediatric patient.</p><p><strong>Description: </strong>Various entry points are available for the insertion of flexible nails into the humeral shaft. A surgeon must initially decide whether the patient and fracture characteristics are best suited for anterograde versus retrograde insertion. This choice typically depends on several fracture and patient-related characteristics. The passage of flexible intramedullary nails has been well described; thus, the present article will place special emphasis on the available proximal and distal entry points and pediatric-specific anatomy<sup>5-10</sup>. For diaphyseal fractures, we prefer dual distal lateral entry points with the nails advanced retrograde in a C-S configuration whenever possible, given the risks associated with proximal lateral entry (e.g., damage to the axillary nerve) or distal medial entry (e.g., damage to the ulnar nerve or nail prominence). A distal posterior supracondylar entry point is also possible but requires additional preoperative planning with regard to patient positioning, a more proximal entry point to avoid impingement of the olecranon on the nail in extension, and avoidance of the ulnar nerve.</p><p><strong>Alternatives: </strong>The substantial potential for remodeling in pediatric patients permits nonoperative treatment of humeral fractures if specific age-related criteria for angulation and displacement are met. Generally accepted tolerances for nonoperative angulation and displacement are as follows: for patients <5 years old, ≤70° angulation and up to 100% displacement; for patients 5 to 12 years old, 40° to 70° angulation; and for patients >12 years old, ≤40° angulation and 50% apposition<sup>4</sup>.</p><p><strong>Rationale: </strong>The use of flexible nails is often preferred because of the healing potential of pediatric humeral shaft fractures, the ability of flexible nails to tolerate nonrigid fixation until osseous bridging occurs, the ability of the surgeon to avoid exposure of neurologic structures during surgery, and the benefit of avoiding physeal disruption. These factors make flexible nails a favorable option when compared with plate osteosynthesis or rigid i
{"title":"Flexible Intramedullary Nail Placement in Pediatric Humerus Fractures.","authors":"Robert W Gomez, Riley C McHugh, Dhairya Shukla, Dustin A Greenhill","doi":"10.2106/JBJS.ST.23.00071","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00071","url":null,"abstract":"<p><strong>Background: </strong>Flexible intramedullary nailing is an effective method of stabilization in pediatric patients with a humeral shaft fracture when surgery is indicated<sup>1-3</sup>. Although these fractures are most often treated nonoperatively, operative indications include open fractures, bilateral injuries, compartment syndrome, pathologic fractures, neurovascular compromise, unacceptable alignment after attempted nonoperative treatment, and ipsilateral upper-extremity injuries<sup>4</sup>. The current literature on flexible intramedullary nailing of the pediatric humeral shaft lacks concise descriptions of available entry points, which directly affect the subsequent technique, and of pertinent pediatric-specific anatomy. Thus, the present article focuses on these entry points in the pediatric patient.</p><p><strong>Description: </strong>Various entry points are available for the insertion of flexible nails into the humeral shaft. A surgeon must initially decide whether the patient and fracture characteristics are best suited for anterograde versus retrograde insertion. This choice typically depends on several fracture and patient-related characteristics. The passage of flexible intramedullary nails has been well described; thus, the present article will place special emphasis on the available proximal and distal entry points and pediatric-specific anatomy<sup>5-10</sup>. For diaphyseal fractures, we prefer dual distal lateral entry points with the nails advanced retrograde in a C-S configuration whenever possible, given the risks associated with proximal lateral entry (e.g., damage to the axillary nerve) or distal medial entry (e.g., damage to the ulnar nerve or nail prominence). A distal posterior supracondylar entry point is also possible but requires additional preoperative planning with regard to patient positioning, a more proximal entry point to avoid impingement of the olecranon on the nail in extension, and avoidance of the ulnar nerve.</p><p><strong>Alternatives: </strong>The substantial potential for remodeling in pediatric patients permits nonoperative treatment of humeral fractures if specific age-related criteria for angulation and displacement are met. Generally accepted tolerances for nonoperative angulation and displacement are as follows: for patients <5 years old, ≤70° angulation and up to 100% displacement; for patients 5 to 12 years old, 40° to 70° angulation; and for patients >12 years old, ≤40° angulation and 50% apposition<sup>4</sup>.</p><p><strong>Rationale: </strong>The use of flexible nails is often preferred because of the healing potential of pediatric humeral shaft fractures, the ability of flexible nails to tolerate nonrigid fixation until osseous bridging occurs, the ability of the surgeon to avoid exposure of neurologic structures during surgery, and the benefit of avoiding physeal disruption. These factors make flexible nails a favorable option when compared with plate osteosynthesis or rigid i","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543153/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630258","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 : 2024-11-08eCollection Date: 2024-10-01DOI: 10.2106/JBJS.ST.23.00064
Scott H Kozin, Eugene Park, Dan A Zlotolow
<p><strong>Background: </strong>Pediatric trigger finger (PTF) is an uncommon condition that is 10 times less common than trigger thumb. The Quinnell grade is utilized to quantify the extent of the triggering on a 4-point scale (0 = normal movement, 1 = uneven movement, 2 = actively correctable triggering, 3 = passively correctable triggering, and 4 = fixed deformity)<sup>1</sup>. Less extensive triggering can be treated nonoperatively with use of monitoring or splinting; however, the reported resolution rates are low, with only 30% of PTF cases treated nonoperatively achieving complete resolution<sup>1</sup>. Splinting has also been shown to not improve resolution rates in pediatric cases treated nonoperatively. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit<sup>2,3</sup>. Overall, PTF has been shown to have significantly higher rates of resolution when treated operatively (97.1%) versus nonoperatively (30.0%)<sup>2</sup>. PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single flexor digitorum superficialis (FDS) tendon slip. PTF treated with this technique predictably results in resolution with restoration of motion. The present video article demonstrates the surgical treatment of a 7-year-old with a locked right ring finger.</p><p><strong>Description: </strong>Operative steps include (1) general anesthesia, (2) tourniquet control, (3) loupe magnification, (4) neurovascular identification, (5) A3 and A1 pulley release, (6) excision of the ulnar slip of the FDS, (7) and simple closure.</p><p><strong>Alternatives: </strong>The primary alternative to this procedure is nonoperative treatment with continued monitoring and/or splinting.</p><p><strong>Rationale: </strong>PTF differs from pediatric trigger thumb. Simple release of the A1 pulley may not resolve the triggering, requiring additional excision of the ulnar slip of the FDS.</p><p><strong>Expected outcomes: </strong>Jia et al. reported that only 30% of nonoperatively treated cases of PTF achieved complete resolution, and splinting did not improve resolution rates<sup>3</sup>. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit. Overall, operatively treated PTF showed significantly higher rates of complete resolution compared with nonoperatively treated PTF (97.1% compared with 30.0%, respectively)<sup>3</sup>. Additionally, Cardon et al. reported residual triggering in 44% (8) of 18 cases of PTF treated with isolated A1 pulley release<sup>2</sup>. Bae et al. reported a 91% success rate (21 of 23) when PTFs were treated uniformly with A1 pulley release combined with FDS slip excision<sup>1</sup>. We conclude that PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single FDS tendon slip.</p><p><strong>Important tips: </strong>General anesthesia will limit
{"title":"Surgery for Pediatric Trigger Finger.","authors":"Scott H Kozin, Eugene Park, Dan A Zlotolow","doi":"10.2106/JBJS.ST.23.00064","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00064","url":null,"abstract":"<p><strong>Background: </strong>Pediatric trigger finger (PTF) is an uncommon condition that is 10 times less common than trigger thumb. The Quinnell grade is utilized to quantify the extent of the triggering on a 4-point scale (0 = normal movement, 1 = uneven movement, 2 = actively correctable triggering, 3 = passively correctable triggering, and 4 = fixed deformity)<sup>1</sup>. Less extensive triggering can be treated nonoperatively with use of monitoring or splinting; however, the reported resolution rates are low, with only 30% of PTF cases treated nonoperatively achieving complete resolution<sup>1</sup>. Splinting has also been shown to not improve resolution rates in pediatric cases treated nonoperatively. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit<sup>2,3</sup>. Overall, PTF has been shown to have significantly higher rates of resolution when treated operatively (97.1%) versus nonoperatively (30.0%)<sup>2</sup>. PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single flexor digitorum superficialis (FDS) tendon slip. PTF treated with this technique predictably results in resolution with restoration of motion. The present video article demonstrates the surgical treatment of a 7-year-old with a locked right ring finger.</p><p><strong>Description: </strong>Operative steps include (1) general anesthesia, (2) tourniquet control, (3) loupe magnification, (4) neurovascular identification, (5) A3 and A1 pulley release, (6) excision of the ulnar slip of the FDS, (7) and simple closure.</p><p><strong>Alternatives: </strong>The primary alternative to this procedure is nonoperative treatment with continued monitoring and/or splinting.</p><p><strong>Rationale: </strong>PTF differs from pediatric trigger thumb. Simple release of the A1 pulley may not resolve the triggering, requiring additional excision of the ulnar slip of the FDS.</p><p><strong>Expected outcomes: </strong>Jia et al. reported that only 30% of nonoperatively treated cases of PTF achieved complete resolution, and splinting did not improve resolution rates<sup>3</sup>. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit. Overall, operatively treated PTF showed significantly higher rates of complete resolution compared with nonoperatively treated PTF (97.1% compared with 30.0%, respectively)<sup>3</sup>. Additionally, Cardon et al. reported residual triggering in 44% (8) of 18 cases of PTF treated with isolated A1 pulley release<sup>2</sup>. Bae et al. reported a 91% success rate (21 of 23) when PTFs were treated uniformly with A1 pulley release combined with FDS slip excision<sup>1</sup>. We conclude that PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single FDS tendon slip.</p><p><strong>Important tips: </strong>General anesthesia will limit","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543148/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630261","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 : 2024-10-24eCollection Date: 2024-10-01DOI: 10.2106/JBJS.ST.23.00005
Jan Paul Frölke, Robin Atallah
<p><strong>Background: </strong>The present video article describes the revision of a bone-anchored prosthesis in patients who received an osseointegration implant after transfemoral amputation. Clinical follow-up studies have shown that approximately 5% of all patients who receive press-fit cobalt-chromium alloy femoral implants experience failure of the intramedullary stem component as a result of septic loosening or stem breakage. For stem breakage, stem diameter and the occurrence of infectious events were identified as risk factors. We began regularly utilizing the standard German press-fit endo-exo cast cobalt-chrome implant in 2009, but changed to the forged titanium version in 2014 (BADAL X, OTN Implants) because of the breakages associated with the former implant. No breakages have been reported since making the switch, and as such we currently still utilize the titanium implant. Current Commission Européenne-certified bone-anchored implants for transfemoral amputation include a screw-type stem and a press-fit stem. The revision technique demonstrated in the present article may apply to both types of implant system, but this video is limited to demonstrating the use of a press-fit implant. We describe the 3 stages of debridement, removal, and subsequent implantation of a bone-anchored prosthesis in a revision setting.</p><p><strong>Description: </strong>We perform this procedure in up to 3 stages, with 10 to 12 weeks between removal of the failed implant and implantation of the revision prosthesis. For stage 1, in case of mechanical failure, the broken remnants of the implant, which may dangle in the soft tissues, are removed. The stoma is debrided, after which spontaneous stoma healing is achieved. In cases of septic loosening, stage 1 includes removal of the implant by retrograde hammering, followed by multiple debridements with flexible reamers and jet lavage until negative cultures are obtained. In stage 2, the broken osseointegration implant is removed with use of a custom-made titanium water-cooled hollow drill. With the use of this drill, we have always been successful in removing the broken implant while maintaining sufficient bone stock for future implant revision. If the corer fails, a larger approach is needed to remove the implant. The corer drill should have a wall that is as thin but as robust as possible in order to avoid cortical perforation, and should be manufactured from a strong material in order to resist the usage against the implant. We utilized a steel corer when initially performing this procedure, which was frequently unsuccessful, necessitating a larger approach to remove the implant. We currently utilize a 3D-printed corer drill with integrated water-cooling system with greater success (Xilloc Medical). This corer is custom-made and needs about 6 weeks for designing and manufacturing. This tool is utilized in the present video article. Stage 3 includes revision implantation of an osseointegration prosthesis, u
{"title":"Revision of Press-Fit Bone-Anchored Prosthesis After Implant Failure.","authors":"Jan Paul Frölke, Robin Atallah","doi":"10.2106/JBJS.ST.23.00005","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00005","url":null,"abstract":"<p><strong>Background: </strong>The present video article describes the revision of a bone-anchored prosthesis in patients who received an osseointegration implant after transfemoral amputation. Clinical follow-up studies have shown that approximately 5% of all patients who receive press-fit cobalt-chromium alloy femoral implants experience failure of the intramedullary stem component as a result of septic loosening or stem breakage. For stem breakage, stem diameter and the occurrence of infectious events were identified as risk factors. We began regularly utilizing the standard German press-fit endo-exo cast cobalt-chrome implant in 2009, but changed to the forged titanium version in 2014 (BADAL X, OTN Implants) because of the breakages associated with the former implant. No breakages have been reported since making the switch, and as such we currently still utilize the titanium implant. Current Commission Européenne-certified bone-anchored implants for transfemoral amputation include a screw-type stem and a press-fit stem. The revision technique demonstrated in the present article may apply to both types of implant system, but this video is limited to demonstrating the use of a press-fit implant. We describe the 3 stages of debridement, removal, and subsequent implantation of a bone-anchored prosthesis in a revision setting.</p><p><strong>Description: </strong>We perform this procedure in up to 3 stages, with 10 to 12 weeks between removal of the failed implant and implantation of the revision prosthesis. For stage 1, in case of mechanical failure, the broken remnants of the implant, which may dangle in the soft tissues, are removed. The stoma is debrided, after which spontaneous stoma healing is achieved. In cases of septic loosening, stage 1 includes removal of the implant by retrograde hammering, followed by multiple debridements with flexible reamers and jet lavage until negative cultures are obtained. In stage 2, the broken osseointegration implant is removed with use of a custom-made titanium water-cooled hollow drill. With the use of this drill, we have always been successful in removing the broken implant while maintaining sufficient bone stock for future implant revision. If the corer fails, a larger approach is needed to remove the implant. The corer drill should have a wall that is as thin but as robust as possible in order to avoid cortical perforation, and should be manufactured from a strong material in order to resist the usage against the implant. We utilized a steel corer when initially performing this procedure, which was frequently unsuccessful, necessitating a larger approach to remove the implant. We currently utilize a 3D-printed corer drill with integrated water-cooling system with greater success (Xilloc Medical). This corer is custom-made and needs about 6 weeks for designing and manufacturing. This tool is utilized in the present video article. Stage 3 includes revision implantation of an osseointegration prosthesis, u","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11498921/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142510021","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 : 2024-10-22eCollection Date: 2024-10-01DOI: 10.2106/JBJS.ST.23.00082
Varun Arvind, Daniel Y Hong, Robert J Strauch
<p><strong>Background: </strong>Extensor tendon injuries are a common condition that hand surgeons must be prepared to treat. The area of extensor tendon injury can traditionally be broken down into 9 zones. Physical examination is the best way to diagnose extensor tendon injury with a loss of active extension in the injured digit. The tenodesis effect may be utilized to aid in diagnosis: wrist flexion should cause passive extension at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints if the extensor tendon is in continuity.</p><p><strong>Description: </strong>Repair of extensor tendon injuries depends on the zone of injury and the thickness of the tendon, which determines its ability to hold core sutures. For zone-I and II injuries, several "figure of 8" buried sutures can be utilized or a running type of suture may be employed. For zone-III to VII injuries, 1 or 2 core sutures and a supplementary running suture can be utilized.</p><p><strong>Alternatives: </strong>Several alternative techniques have been previously described. These include variations in the number of core strands, repair configuration, and suture caliber, as well as the use of epitendinous repair. Alternative treatments also include nonoperative treatment, which is typically reserved for partial tendon injuries and for patients who are unable to tolerate a surgical procedure.</p><p><strong>Rationale: </strong>The techniques that we describe are tailored to the thickness of the tendon. Running sutures are applicable to any zone, whereas core sutures are best utilized in zones III through VII. The running interlocking horizontal mattress technique has been found to be stiffer and faster to accomplish compared with the other techniques, and was found to have good to excellent clinical results in a study of lacerations in zones IV and V<sup>1,2</sup>.</p><p><strong>Expected outcomes: </strong>Repair of extensor tendon lacerations has demonstrated good long-term outcomes if performed in a timely manner after injury. A previous study showed good to excellent function in up to 64% of acute extensor tendon repairs, more fingers lost the ability to flex fully than lost the ability to extend<sup>3</sup>. Systematic reviews have suggested that dynamic rehabilitation may not provide superior long-term benefit compared with static splinting<sup>4</sup>.</p><p><strong>Important tips: </strong>The Elson test should be performed under a digital nerve block in order to properly assess the integrity of the central slip.In distal zone I and III injuries, suture anchors or bone tunnels may be utilized when there is no remaining tendon on the distal end of the laceration.When preparing the tendon ends for repair, it is important to handle the tendon delicately-preferably through the cut end of the tendon rather than the tendon itself.In zone-VII injuries, the injured tendon may lie beneath the extensor retinaculum. In such cases, windowing of the extensor retinacu
背景：伸肌腱损伤是手外科医生必须做好治疗准备的常见疾病。传统上，伸肌腱损伤部位可分为 9 个区域。体格检查是诊断伸肌腱损伤的最佳方法，受伤的手指会失去主动伸展能力。可以利用腱鞘效应来帮助诊断：如果伸肌腱处于连续状态，则手腕屈曲应导致掌指关节、近端指间关节和远端指间关节被动伸展：伸肌腱损伤的修复取决于损伤区和肌腱的厚度，这决定了肌腱固定核心缝合线的能力。对于第一区和第二区的损伤，可采用数个 "8 "字形埋线法，也可采用流水线式缝合。对于 III 区至 VII 区的损伤，可使用 1 或 2 条核心缝合线和一条辅助缝合线：以前曾介绍过几种替代技术。替代方法：以前曾介绍过几种替代技术，包括核心股线数量、修复结构和缝合口径的变化，以及表腱修复的使用。替代治疗方法还包括非手术治疗，通常用于部分肌腱损伤和不能耐受手术治疗的患者。运行缝合适用于任何区域，而核心缝合最好用于第三至第七区域。在一项关于 IV 区和 V1,2 区撕裂伤的研究中，我们发现跑步交错水平床垫技术比其他技术更坚硬、更快完成，而且临床效果良好至极佳：预期结果：如果在受伤后及时进行伸肌腱裂伤修复，长期效果良好。之前的一项研究显示，高达 64% 的急性伸肌腱修复术后功能良好或极佳，丧失完全屈曲能力的手指多于丧失伸展能力的手指3。系统性综述表明，与静态夹板相比，动态康复可能不会带来更好的长期益处4：在 I 区和 III 区远端损伤中，如果裂伤远端没有剩余肌腱，则可使用缝合锚或骨隧道。在准备肌腱末端修复时，必须小心处理肌腱，最好是通过肌腱的切端而不是肌腱本身。在这种情况下，伸肌网开窗可减少粘连的形成并促进修复：MCP=掌指关节PIP=近端指间关节DIP=远端指间关节IP=指间关节ROM=运动范围RMS=相对运动夹板RIHM=跑步交锁水平床垫。
{"title":"Extensor Tendon Repair.","authors":"Varun Arvind, Daniel Y Hong, Robert J Strauch","doi":"10.2106/JBJS.ST.23.00082","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00082","url":null,"abstract":"<p><strong>Background: </strong>Extensor tendon injuries are a common condition that hand surgeons must be prepared to treat. The area of extensor tendon injury can traditionally be broken down into 9 zones. Physical examination is the best way to diagnose extensor tendon injury with a loss of active extension in the injured digit. The tenodesis effect may be utilized to aid in diagnosis: wrist flexion should cause passive extension at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints if the extensor tendon is in continuity.</p><p><strong>Description: </strong>Repair of extensor tendon injuries depends on the zone of injury and the thickness of the tendon, which determines its ability to hold core sutures. For zone-I and II injuries, several \"figure of 8\" buried sutures can be utilized or a running type of suture may be employed. For zone-III to VII injuries, 1 or 2 core sutures and a supplementary running suture can be utilized.</p><p><strong>Alternatives: </strong>Several alternative techniques have been previously described. These include variations in the number of core strands, repair configuration, and suture caliber, as well as the use of epitendinous repair. Alternative treatments also include nonoperative treatment, which is typically reserved for partial tendon injuries and for patients who are unable to tolerate a surgical procedure.</p><p><strong>Rationale: </strong>The techniques that we describe are tailored to the thickness of the tendon. Running sutures are applicable to any zone, whereas core sutures are best utilized in zones III through VII. The running interlocking horizontal mattress technique has been found to be stiffer and faster to accomplish compared with the other techniques, and was found to have good to excellent clinical results in a study of lacerations in zones IV and V<sup>1,2</sup>.</p><p><strong>Expected outcomes: </strong>Repair of extensor tendon lacerations has demonstrated good long-term outcomes if performed in a timely manner after injury. A previous study showed good to excellent function in up to 64% of acute extensor tendon repairs, more fingers lost the ability to flex fully than lost the ability to extend<sup>3</sup>. Systematic reviews have suggested that dynamic rehabilitation may not provide superior long-term benefit compared with static splinting<sup>4</sup>.</p><p><strong>Important tips: </strong>The Elson test should be performed under a digital nerve block in order to properly assess the integrity of the central slip.In distal zone I and III injuries, suture anchors or bone tunnels may be utilized when there is no remaining tendon on the distal end of the laceration.When preparing the tendon ends for repair, it is important to handle the tendon delicately-preferably through the cut end of the tendon rather than the tendon itself.In zone-VII injuries, the injured tendon may lie beneath the extensor retinaculum. In such cases, windowing of the extensor retinacu","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11495684/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142510020","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>Severe elbow deformities are common in developing countries because of neglect or as a result of prior treatment that achieved poor reduction. Various osteotomy techniques have been defined for the surgical correction of elbow deformities<sup>1-9</sup>. However, severe elbow deformities (>30°) pose a substantial challenge for surgeons because limited surgical options with high complication rates have been described in the literature. Shortening dome osteotomy is a useful method of correcting moderate-to-severe deformities and offers all of the advantages of previously described dome osteotomy without causing an undue stretching of neurovascular structures<sup>8,9</sup>.</p><p><strong>Description: </strong>The anesthetized patient is placed in a lateral decubitus position under tourniquet control with the operative limb up, the elbow in 90° of flexion, and the forearm draped free to hang over a bolster kept between the chest and the forearm. A posterior midline approach is utilized, with the incision extending from 6 cm proximal to the tip of the olecranon to 2 cm distal. The ulnar nerve is identified and protected during the entire surgical procedure. In case of severe (>30°) and long-standing cubitus varus deformity, anterior transposition of the ulnar nerve is additionally performed to prevent nerve stretching after the deformity correction. A midline triceps-splitting approach is utilized along with subperiosteal dissection to expose the metaphyseodiaphyseal region of the distal humerus. Alternatively, the operating surgeon may choose to utilize a triceps-sparing approach. Hohmann retractors are placed at the medial and lateral aspects of distal humerus to protect the anterior neurovascular structures. Careful extraperiosteal dissection and a transverse incision over the anterior periosteum are performed to facilitate rotation of the distal fragment, as the anterior periosteum is usually thickened in cases of long-standing deformities. The posterior midline axis of the humerus is marked on the skin. The dome of the olecranon fossa is identified, and the distal osteotomy line is made just proximal and almost parallel to the dome. The proximal osteotomy line is made parallel and 5 to 8 mm proximal to the distal osteotomy line, as any further larger shortening may affect the muscle length-tension relationship. The posterior cortices of both domes and of the medial and lateral supracondylar ridges are osteotomized with use of an ultrasonic bone scalpel (Misonix), which was set at 70% amplitude control and 80% irrigation control. Alternatively, the osteotomy may be made by making multiple drill holes and connecting them with a 5-mm sharp osteotome or with use of a small-blade oscillating saw. The osteotomy of the anterior cortex is completed under direct vision with use of a Kerrison upcutting rongeur, after the subperiosteal separation of bone in order to protect the surrounding soft tissues. Kirschner wires are ins
{"title":"Shortening Dome Osteotomy for the Correction of Coronal Plane Elbow Deformities.","authors":"Sumit Arora, Prajwal Gupta, Shahrukh Khan, Rahul Garg, Anant Krishna, Abhishek Kashyap","doi":"10.2106/JBJS.ST.23.00014","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00014","url":null,"abstract":"<p><strong>Background: </strong>Severe elbow deformities are common in developing countries because of neglect or as a result of prior treatment that achieved poor reduction. Various osteotomy techniques have been defined for the surgical correction of elbow deformities<sup>1-9</sup>. However, severe elbow deformities (>30°) pose a substantial challenge for surgeons because limited surgical options with high complication rates have been described in the literature. Shortening dome osteotomy is a useful method of correcting moderate-to-severe deformities and offers all of the advantages of previously described dome osteotomy without causing an undue stretching of neurovascular structures<sup>8,9</sup>.</p><p><strong>Description: </strong>The anesthetized patient is placed in a lateral decubitus position under tourniquet control with the operative limb up, the elbow in 90° of flexion, and the forearm draped free to hang over a bolster kept between the chest and the forearm. A posterior midline approach is utilized, with the incision extending from 6 cm proximal to the tip of the olecranon to 2 cm distal. The ulnar nerve is identified and protected during the entire surgical procedure. In case of severe (>30°) and long-standing cubitus varus deformity, anterior transposition of the ulnar nerve is additionally performed to prevent nerve stretching after the deformity correction. A midline triceps-splitting approach is utilized along with subperiosteal dissection to expose the metaphyseodiaphyseal region of the distal humerus. Alternatively, the operating surgeon may choose to utilize a triceps-sparing approach. Hohmann retractors are placed at the medial and lateral aspects of distal humerus to protect the anterior neurovascular structures. Careful extraperiosteal dissection and a transverse incision over the anterior periosteum are performed to facilitate rotation of the distal fragment, as the anterior periosteum is usually thickened in cases of long-standing deformities. The posterior midline axis of the humerus is marked on the skin. The dome of the olecranon fossa is identified, and the distal osteotomy line is made just proximal and almost parallel to the dome. The proximal osteotomy line is made parallel and 5 to 8 mm proximal to the distal osteotomy line, as any further larger shortening may affect the muscle length-tension relationship. The posterior cortices of both domes and of the medial and lateral supracondylar ridges are osteotomized with use of an ultrasonic bone scalpel (Misonix), which was set at 70% amplitude control and 80% irrigation control. Alternatively, the osteotomy may be made by making multiple drill holes and connecting them with a 5-mm sharp osteotome or with use of a small-blade oscillating saw. The osteotomy of the anterior cortex is completed under direct vision with use of a Kerrison upcutting rongeur, after the subperiosteal separation of bone in order to protect the surrounding soft tissues. Kirschner wires are ins","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11495691/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142510022","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 : 2024-10-03eCollection Date: 2024-10-01DOI: 10.2106/JBJS.ST.23.00062
Alvin Ouseph, Eddie Y Lo, Paolo Montemaggi, Sumant G Krishnan
<p><strong>Background: </strong>Cementless reverse shoulder arthroplasty has become increasingly popular because of the improved implant design, porous ingrowth surface, and surgical techniques. When avoiding the risks of cement use, a press-fit arthroplasty stem that has been implanted may not feel immediately stable, especially if the medullary canal size is in between standard stem diameters. To help surgeons improve fixation and avoid overstuffing the medullary canal, we present the matchstick autograft augmentation technique. The use of humeral autograft, analogous to impaction grafting in hip arthroplasty, has been reported to have promising short-term outcomes<sup>2,3</sup>. This technique of using humeral autograft material, dubbed matchstick autografts because of their shape and size, allows for optimization of humeral stem stability with the option of smaller cementless humeral implants. By avoiding overstuffing of the medullary canal, this technique aims to reduce the incidences of intraoperative fracture, postoperative stress shielding, and potential implant loosening<sup>4-6</sup>.</p><p><strong>Description: </strong>Cementless reverse total shoulder arthroplasty is routinely performed via the anterosuperior approach<sup>7</sup>; however, a deltopectoral approach can be utilized if desired. The canal is sequentially broached with implant trials until the tactile feedback demonstrates axial and rotational stability. In cases in which tactile feedback during implantation demonstrates slight movement, the smaller implant size can be selected and augmented with matchstick autograft. An oscillating saw is utilized to cut the edges of the previously resected humeral head in order to expose the subchondral bone surface. Graft sticks about 20 mm in length and 1 to 3 mm in width are then fashioned. Humeral trials are then implanted with the matchstick grafts placed lengthwise alongside the humeral stem. Axial and rotational press-fit is again assessed. If adequate, the formal humeral implant is selected and implanted in position. As in conventional impaction grafting, the grafts are compressed to the side of the humeral canal, but they offer more corticocancellous structure than bone chips. This technique is applicable even in some fracture scenarios.</p><p><strong>Alternatives: </strong>When a specific press-fit humeral stem size does not achieve adequate stability, there are typically 3 surgical alternatives. First, a larger stem size can be selected. Second, the implant can be inserted deeper to achieve press-fit stability. Third, cement can be added to fill the medullary canal and create immediate stability.</p><p><strong>Rationale: </strong>When implanting the humeral prosthesis, the operating surgeon's primary goal is stem stability. When faced with lack of stability, the surgeon can select a larger humeral stem, risking stress shielding; implant the stem deeper, compromising length and risking humeral fracture; or consider a cemented i
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