Pub Date : 2024-09-13eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00070
Nicole L Levine, William C Eward, Brian Brigman, Alan Alper Sag, Julia D Visgauss
<p><strong>Background: </strong>Percutaneous tripod fixation of periacetabular lesions is performed at our institution for patients with metastatic bone disease and a need for quick return to systemic therapy. We have begun to use the IlluminOss Photodynamic Bone Stabilization System instead of the metal implants previously described in the literature because of the success of the IlluminOss implant in fixing fragility fractures about the pelvis.</p><p><strong>Description: </strong>At our institution, the procedure is performed in the interventional radiology suite in order to allow for the use of 3D radiographic imaging and vector guidance systems. The patient is positioned prone for the transcolumnar PSIS-to-AIIS implant and posterior column/ischial tuberosity implant or supine for the anterior column/superior pubic ramus implant. Following a small incision, a Jamshidi needle with a trocar is utilized to enter the bone at the chosen start point. A hand drill is utilized to advance the Jamshidi needle according to the planned vector; alternatively, a curved or straight awl can be utilized. The 1.2-mm guidewire is placed and reamed. We place both the transcolumnar and posterior column wires at the same time to ensure that there is no interference. The balloon catheter for the IlluminOss is assembled on the back table and inserted according to the implant technique guide. The balloon is inflated and observed on radiographs in order to ensure that the cavity is filled. Monomer is then cured, and the patient is flipped for the subsequent implant. Following placement of the 3 IlluminOss devices, adjunct treatments such as cement acetabuloplasty or cryoablation can be performed.</p><p><strong>Alternatives: </strong>Alternative treatments include traditional open fixation of impending or nondisplaced acetabular fractures in the operating room, or percutaneous implant placement in the operating room. Implant placement may be performed with the patient in the supine, lateral, or prone position, depending on surgeon preference. Alternative implants include standard metal implants such as plates and screws, or cement augmentation either alone or with percutaneous screws. Finally, ablation alone may be an alternative option, depending on tumor histology.</p><p><strong>Rationale: </strong>Open treatment of acetabular fractures is a more morbid procedure, given the larger incision, increased blood loss, longer time under anesthesia, and increased length of recovery. Percutaneous fixation may be performed in either the operating room or interventional radiology suite, depending on the specific equipment setup at an individual institution. At our institution, we prefer utilizing the interventional radiology suite as it allows for more precise implant placement through the use of an image-based vector guidance system and 3D fluoroscopy to accurately identify safe corridors. The use of percutaneous fixation allows for faster recovery and earlier return to systemi
{"title":"Tripod Fixation of Periacetabular Metastatic Lesions Using the IlluminOss Device.","authors":"Nicole L Levine, William C Eward, Brian Brigman, Alan Alper Sag, Julia D Visgauss","doi":"10.2106/JBJS.ST.23.00070","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00070","url":null,"abstract":"<p><strong>Background: </strong>Percutaneous tripod fixation of periacetabular lesions is performed at our institution for patients with metastatic bone disease and a need for quick return to systemic therapy. We have begun to use the IlluminOss Photodynamic Bone Stabilization System instead of the metal implants previously described in the literature because of the success of the IlluminOss implant in fixing fragility fractures about the pelvis.</p><p><strong>Description: </strong>At our institution, the procedure is performed in the interventional radiology suite in order to allow for the use of 3D radiographic imaging and vector guidance systems. The patient is positioned prone for the transcolumnar PSIS-to-AIIS implant and posterior column/ischial tuberosity implant or supine for the anterior column/superior pubic ramus implant. Following a small incision, a Jamshidi needle with a trocar is utilized to enter the bone at the chosen start point. A hand drill is utilized to advance the Jamshidi needle according to the planned vector; alternatively, a curved or straight awl can be utilized. The 1.2-mm guidewire is placed and reamed. We place both the transcolumnar and posterior column wires at the same time to ensure that there is no interference. The balloon catheter for the IlluminOss is assembled on the back table and inserted according to the implant technique guide. The balloon is inflated and observed on radiographs in order to ensure that the cavity is filled. Monomer is then cured, and the patient is flipped for the subsequent implant. Following placement of the 3 IlluminOss devices, adjunct treatments such as cement acetabuloplasty or cryoablation can be performed.</p><p><strong>Alternatives: </strong>Alternative treatments include traditional open fixation of impending or nondisplaced acetabular fractures in the operating room, or percutaneous implant placement in the operating room. Implant placement may be performed with the patient in the supine, lateral, or prone position, depending on surgeon preference. Alternative implants include standard metal implants such as plates and screws, or cement augmentation either alone or with percutaneous screws. Finally, ablation alone may be an alternative option, depending on tumor histology.</p><p><strong>Rationale: </strong>Open treatment of acetabular fractures is a more morbid procedure, given the larger incision, increased blood loss, longer time under anesthesia, and increased length of recovery. Percutaneous fixation may be performed in either the operating room or interventional radiology suite, depending on the specific equipment setup at an individual institution. At our institution, we prefer utilizing the interventional radiology suite as it allows for more precise implant placement through the use of an image-based vector guidance system and 3D fluoroscopy to accurately identify safe corridors. The use of percutaneous fixation allows for faster recovery and earlier return to systemi","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11392467/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142298049","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 : 2024-08-27eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00088
Túlio Vinícius de Oliveira Campos, Igor Guedes Nogueira Reis, Santiago Enrique Sarmiento Molina, Gustavo Scarpelli Martins da Costa, André Guerra Domingues, Paulo de Tarso Cardoso Gomes, Marco Antônio Percope de Andrade
<p><strong>Background: </strong>High-energy traumatic fractures represent a challenge for orthopaedic surgeons because there are a great variety of morphologic patterns and associated injuries<sup>1</sup>. Although the incidence is higher in developing countries, these fractures pose a major financial burden all over the world because of their considerable hospital length of stay, time away from work, rate of failure to return to work, complications, and cost of treatment<sup>2-4</sup>. Since the fracture patterns are so variable, some cases may have a lack of available specific osteosynthesis implants, despite recent advancements in implant engineering<sup>5</sup>. However, experienced surgeons are capable of using their knowledge and creativity to treat challenging lesions with use of preexisting plates while following the principles of fracture fixation and without compromising outcomes. In 2012, Hohman et al. described for the first time the use of a calcaneal plate to treat distal femoral fractures<sup>6</sup>. In 2020, Pires et al. further expanded the indications for use of a calcaneal plate<sup>5</sup>. This technical trick is widely utilized in our trauma center, especially in comminuted fractures around the knee. The present video article provides a stepwise description of the off-label use of a calcaneal plate in a medial distal femoral fracture.</p><p><strong>Description: </strong>The key principles of this procedure involve following common fundamentals during open reduction and internal fixation, approaching the fracture, preserving soft-tissue attachments of the comminution, and reducing the main fragments. Afterwards, the off-label use of a calcaneal plate adds the special feature of being able to contain fracture fragments with plate contouring. If necessary and if osseous morphology allows, bone grafting through the plate may also be performed.</p><p><strong>Alternatives: </strong>Multiple fixation implants can be utilized in medial distal femoral fractures. Surgeon-contoured plates (i.e., locking compression plates or low-contact dynamic compression plates), multiple mini-fragment plates, cortical screws alone, cannulated cancellous screws alone, or proximal humeral plates are among the alternatives<sup>5-9</sup>. However, the lack of specific implants for fixation of fractures involving the medial femoral condyle is notable, even in developed countries<sup>10</sup>.</p><p><strong>Rationale: </strong>The small-fragment calcaneal plate is a widely available and cheaper implant compared with locking compression plates, which is especially important in developing countries. Additionally, this plate has a lower profile, covers a greater surface area, and allows multiple screws in different planes and directions. The use of this plate represents a great technical trick for surgeons to contain comminution.</p><p><strong>Expected outcomes: </strong>Patient education regarding fracture severity is mandatory, and it is important to high
{"title":"Off-Label Use of Buttress Calcaneal Plate in Medial Distal Femoral Fracture to Augment Internal Fixation.","authors":"Túlio Vinícius de Oliveira Campos, Igor Guedes Nogueira Reis, Santiago Enrique Sarmiento Molina, Gustavo Scarpelli Martins da Costa, André Guerra Domingues, Paulo de Tarso Cardoso Gomes, Marco Antônio Percope de Andrade","doi":"10.2106/JBJS.ST.23.00088","DOIUrl":"10.2106/JBJS.ST.23.00088","url":null,"abstract":"<p><strong>Background: </strong>High-energy traumatic fractures represent a challenge for orthopaedic surgeons because there are a great variety of morphologic patterns and associated injuries<sup>1</sup>. Although the incidence is higher in developing countries, these fractures pose a major financial burden all over the world because of their considerable hospital length of stay, time away from work, rate of failure to return to work, complications, and cost of treatment<sup>2-4</sup>. Since the fracture patterns are so variable, some cases may have a lack of available specific osteosynthesis implants, despite recent advancements in implant engineering<sup>5</sup>. However, experienced surgeons are capable of using their knowledge and creativity to treat challenging lesions with use of preexisting plates while following the principles of fracture fixation and without compromising outcomes. In 2012, Hohman et al. described for the first time the use of a calcaneal plate to treat distal femoral fractures<sup>6</sup>. In 2020, Pires et al. further expanded the indications for use of a calcaneal plate<sup>5</sup>. This technical trick is widely utilized in our trauma center, especially in comminuted fractures around the knee. The present video article provides a stepwise description of the off-label use of a calcaneal plate in a medial distal femoral fracture.</p><p><strong>Description: </strong>The key principles of this procedure involve following common fundamentals during open reduction and internal fixation, approaching the fracture, preserving soft-tissue attachments of the comminution, and reducing the main fragments. Afterwards, the off-label use of a calcaneal plate adds the special feature of being able to contain fracture fragments with plate contouring. If necessary and if osseous morphology allows, bone grafting through the plate may also be performed.</p><p><strong>Alternatives: </strong>Multiple fixation implants can be utilized in medial distal femoral fractures. Surgeon-contoured plates (i.e., locking compression plates or low-contact dynamic compression plates), multiple mini-fragment plates, cortical screws alone, cannulated cancellous screws alone, or proximal humeral plates are among the alternatives<sup>5-9</sup>. However, the lack of specific implants for fixation of fractures involving the medial femoral condyle is notable, even in developed countries<sup>10</sup>.</p><p><strong>Rationale: </strong>The small-fragment calcaneal plate is a widely available and cheaper implant compared with locking compression plates, which is especially important in developing countries. Additionally, this plate has a lower profile, covers a greater surface area, and allows multiple screws in different planes and directions. The use of this plate represents a great technical trick for surgeons to contain comminution.</p><p><strong>Expected outcomes: </strong>Patient education regarding fracture severity is mandatory, and it is important to high","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11346833/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142082039","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 : 2024-08-22eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00042
Gloria Coden, Lauren Schoeller, Eric L Smith
<p><strong>Background: </strong>Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed<sup>2</sup>. The goal of the presently described procedure is to provide relief from patellofemoral arthritis pain while maintaining native knee kinematics<sup>2</sup>.</p><p><strong>Description: </strong>Patient radiographs are carefully reviewed for isolated patellofemoral arthritis in order to determine the appropriateness of robotic-assisted patellofemoral arthroplasty. Magnetic resonance imaging can be performed preoperatively to help confirm isolated patellofemoral arthritis. We perform this procedure with use of the MAKO Surgical Robot (Stryker). Preoperative computed tomography is performed to plan the bone resection, the size of the implant, and the positioning of the device. The steps of the procedure include (1) medial parapatellar arthrotomy, (2) intraoperative inspection to confirm isolated patellofemoral arthritis, (3) patellar resurfacing, (4) placement of optical arrays and trochlear registration, (5) trochlear resection, (6) trialing of implants, (7) removal of the optical array, (8) impaction of final implants, (9) confirmation of appropriate patellar tracking, and (10) closure.</p><p><strong>Alternatives: </strong>Alternatives to patellofemoral arthroplasty include standard nonoperative treatment, bicompartmental arthroplasty, total knee arthroplasty, tibial tubercle osteotomy, partial lateral facetectomy, and arthroscopy<sup>2</sup>.</p><p><strong>Rationale: </strong>Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed<sup>2</sup>. Patellofemoral arthroplasty may be superior to total knee arthroplasty because it helps treat pain that affects patient quality of life and activities of daily living while also preserving greater tibiofemoral bone stock<sup>2</sup>. We recommend against performing patellofemoral arthroplasty in patients with arthritis of the tibiofemoral joints<sup>2</sup>.</p><p><strong>Expected outcomes: </strong>In properly selected patients, outcomes include improvement in patient pain and function<sup>1</sup>. One study found that robotic-assisted patellofemoral arthroplasty may result in improved patellar tracking compared with non-robotic-assisted patellofemoral arthroplasty<sup>1</sup>; however, functional outcomes were found to be similar between procedures, and data for all non-robotic-assisted controls were retrospectively captured<sup>1</sup>.</p><p><strong>Important tips: </strong>Confirm isolated patellofemoral arthritis on radiographs and/or magnetic resonance imaging.Review the preoperative plan for appropriate positioning of the trochlear implant.○ Confirm coverage of the trochlear groove.○ Avoid medial overhang.○ Avoid lateral overhang.○ Avoid anterior femoral notching.○ Avoid impingement of the trochlear component into the notch.○ Avoid excessive promine
{"title":"Robot-Assisted Patellofemoral Arthroplasty.","authors":"Gloria Coden, Lauren Schoeller, Eric L Smith","doi":"10.2106/JBJS.ST.23.00042","DOIUrl":"10.2106/JBJS.ST.23.00042","url":null,"abstract":"<p><strong>Background: </strong>Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed<sup>2</sup>. The goal of the presently described procedure is to provide relief from patellofemoral arthritis pain while maintaining native knee kinematics<sup>2</sup>.</p><p><strong>Description: </strong>Patient radiographs are carefully reviewed for isolated patellofemoral arthritis in order to determine the appropriateness of robotic-assisted patellofemoral arthroplasty. Magnetic resonance imaging can be performed preoperatively to help confirm isolated patellofemoral arthritis. We perform this procedure with use of the MAKO Surgical Robot (Stryker). Preoperative computed tomography is performed to plan the bone resection, the size of the implant, and the positioning of the device. The steps of the procedure include (1) medial parapatellar arthrotomy, (2) intraoperative inspection to confirm isolated patellofemoral arthritis, (3) patellar resurfacing, (4) placement of optical arrays and trochlear registration, (5) trochlear resection, (6) trialing of implants, (7) removal of the optical array, (8) impaction of final implants, (9) confirmation of appropriate patellar tracking, and (10) closure.</p><p><strong>Alternatives: </strong>Alternatives to patellofemoral arthroplasty include standard nonoperative treatment, bicompartmental arthroplasty, total knee arthroplasty, tibial tubercle osteotomy, partial lateral facetectomy, and arthroscopy<sup>2</sup>.</p><p><strong>Rationale: </strong>Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed<sup>2</sup>. Patellofemoral arthroplasty may be superior to total knee arthroplasty because it helps treat pain that affects patient quality of life and activities of daily living while also preserving greater tibiofemoral bone stock<sup>2</sup>. We recommend against performing patellofemoral arthroplasty in patients with arthritis of the tibiofemoral joints<sup>2</sup>.</p><p><strong>Expected outcomes: </strong>In properly selected patients, outcomes include improvement in patient pain and function<sup>1</sup>. One study found that robotic-assisted patellofemoral arthroplasty may result in improved patellar tracking compared with non-robotic-assisted patellofemoral arthroplasty<sup>1</sup>; however, functional outcomes were found to be similar between procedures, and data for all non-robotic-assisted controls were retrospectively captured<sup>1</sup>.</p><p><strong>Important tips: </strong>Confirm isolated patellofemoral arthritis on radiographs and/or magnetic resonance imaging.Review the preoperative plan for appropriate positioning of the trochlear implant.○ Confirm coverage of the trochlear groove.○ Avoid medial overhang.○ Avoid lateral overhang.○ Avoid anterior femoral notching.○ Avoid impingement of the trochlear component into the notch.○ Avoid excessive promine","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11335334/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142037328","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 : 2024-08-22eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00040
Brian P Davis, Libby A Mauter, Benjamin W Sears, Armodios M Hatzidakis
<p><strong>Background: </strong>Intramedullary straight nail fixation of proximal humeral fractures using a locking mechanism provides advantages compared with plating, including (1) less soft-tissue dissection, which preserves periosteal blood supply and soft-tissue attachments; (2) improved construct stability for comminuted fractures or osteopenic bone; and (3) shorter operative time for simpler fractures.</p><p><strong>Description: </strong>The patient is placed in the beach-chair position with the head of the bed elevated approximately 45°. The fracture is reduced with use of closed or percutaneous methods, ideally, or with an open approach if required. Temporary fragment fixation with percutaneous Kirschner wires can be utilized. A 1-cm incision is made just anterior to the acromioclavicular joint, overlying the zenith of the humeral head and in line with the diaphysis. A guide-pin is then placed through this incision and is verified to be centrally located and in line with the humeral diaphysis on fluoroscopic views. The guide-pin is advanced into the diaphysis. A cannulated 9-mm reamer is inserted over the guide-pin to create a starting position. The nail is then inserted, with adequate fragment reduction maintained until the proximal nail portion is buried under the subchondral humeral head. The proximal screw trajectory and alignment are checked fluoroscopically. The proximal locking screws are pre-drilled and inserted first using percutaneous drill sleeves through the radiolucent targeting jig. The screw is inserted through the guide and is advanced into the nail until appropriately seated. This process is then repeated for the other proximal screws as necessary. Finally, the distal diaphyseal screws are pre-drilled and inserted in a similar percutaneous fashion using the jig, and the jig is removed. Final orthogonal images are obtained. Copious irrigation of the incisions is performed and they are closed and dressed with a sterile dressing. The operative arm is placed in an abduction sling.</p><p><strong>Alternatives: </strong>Alternative treatment options for proximal humeral fractures include nonoperative treatment with use of a sling, percutaneous reduction and internal fixation with Kirschner wires, open reduction and internal fixation with a locking plate and screw construct, hemiarthroplasty, and anatomic or reverse total shoulder arthroplasty<sup>1</sup>.</p><p><strong>Rationale: </strong>The presently described technique for proximal humeral fracture fixation using a straight, antegrade, locking nail allows for minimal soft-tissue disruption, preserving vascularity and soft-tissue support and achieving angularly stable fixation in often osteopenic bone. The superior and in-line entry point avoids complications of rotator cuff injury and/or subacromial impingement. The proximal locking screws avoid complications of screw penetration or migration. This technique is appropriate for surgically indicated Neer 2-, 3-, and 4-part hum
{"title":"Intramedullary Nailing Technique for Proximal Humeral Fractures Using a Straight Antegrade Nail with Locking Tuberosity Fixation.","authors":"Brian P Davis, Libby A Mauter, Benjamin W Sears, Armodios M Hatzidakis","doi":"10.2106/JBJS.ST.23.00040","DOIUrl":"10.2106/JBJS.ST.23.00040","url":null,"abstract":"<p><strong>Background: </strong>Intramedullary straight nail fixation of proximal humeral fractures using a locking mechanism provides advantages compared with plating, including (1) less soft-tissue dissection, which preserves periosteal blood supply and soft-tissue attachments; (2) improved construct stability for comminuted fractures or osteopenic bone; and (3) shorter operative time for simpler fractures.</p><p><strong>Description: </strong>The patient is placed in the beach-chair position with the head of the bed elevated approximately 45°. The fracture is reduced with use of closed or percutaneous methods, ideally, or with an open approach if required. Temporary fragment fixation with percutaneous Kirschner wires can be utilized. A 1-cm incision is made just anterior to the acromioclavicular joint, overlying the zenith of the humeral head and in line with the diaphysis. A guide-pin is then placed through this incision and is verified to be centrally located and in line with the humeral diaphysis on fluoroscopic views. The guide-pin is advanced into the diaphysis. A cannulated 9-mm reamer is inserted over the guide-pin to create a starting position. The nail is then inserted, with adequate fragment reduction maintained until the proximal nail portion is buried under the subchondral humeral head. The proximal screw trajectory and alignment are checked fluoroscopically. The proximal locking screws are pre-drilled and inserted first using percutaneous drill sleeves through the radiolucent targeting jig. The screw is inserted through the guide and is advanced into the nail until appropriately seated. This process is then repeated for the other proximal screws as necessary. Finally, the distal diaphyseal screws are pre-drilled and inserted in a similar percutaneous fashion using the jig, and the jig is removed. Final orthogonal images are obtained. Copious irrigation of the incisions is performed and they are closed and dressed with a sterile dressing. The operative arm is placed in an abduction sling.</p><p><strong>Alternatives: </strong>Alternative treatment options for proximal humeral fractures include nonoperative treatment with use of a sling, percutaneous reduction and internal fixation with Kirschner wires, open reduction and internal fixation with a locking plate and screw construct, hemiarthroplasty, and anatomic or reverse total shoulder arthroplasty<sup>1</sup>.</p><p><strong>Rationale: </strong>The presently described technique for proximal humeral fracture fixation using a straight, antegrade, locking nail allows for minimal soft-tissue disruption, preserving vascularity and soft-tissue support and achieving angularly stable fixation in often osteopenic bone. The superior and in-line entry point avoids complications of rotator cuff injury and/or subacromial impingement. The proximal locking screws avoid complications of screw penetration or migration. This technique is appropriate for surgically indicated Neer 2-, 3-, and 4-part hum","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11340924/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142037327","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 : 2024-08-06eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.22.00060
Kira K Tanghe, Shoran Tamura, Jayson Lian, J Nicholas Charla, Melinda S Sharkey, Alexa J Karkenny
<p><strong>Background: </strong>Talocalcaneal (TC) coalitions typically present in the pediatric population with medial hindfoot and/or ankle pain and absent subtalar range of motion. Coalition resection with fat interposition is well described for isolated tarsal coalitions<sup>1,2</sup>; however, patients with concomitant rigid flatfoot may benefit from additional reconstructive procedures. To address this, we employ the surgical technique of TC resection with local fat grafting and flatfoot reconstruction.</p><p><strong>Description: </strong>This procedure is described in 3 steps: (1) gastrocnemius recession and fat harvesting, (2) TC coalition resection with local fat interposition, and (3) peroneus brevis Z-lengthening and calcaneal lateral column lengthening osteotomy with allograft. A 3 to 4-cm posteromedial longitudinal incision is made at the distal extent of the medial head of the gastrocnemius muscle. The gastrocnemius tendon is identified, dissected free of surrounding tissue, and transected. Superficial fat is then harvested from this incision before wound closure. A 7-cm incision is made from the posterior aspect of the medial malleolus to the talonavicular joint. The neurovascular bundle and flexor tendons are dissected carefully from the surrounding tissue as a group and protected while the coalition is completely resected, and bone wax and the local fat are utilized at the resection site to prevent regrowth of the coalition. An approximately 7-cm incision is then made laterally and obliquely following the Langer lines and centered over the lateral calcaneus. The peroneal tendons are released from their sheaths, and the peroneus brevis is Z-lengthened. A calcaneal osteotomy is performed about 1.5 cm proximal to the calcaneocuboid joint and angled to avoid the anterior and middle subtalar facet joints. Two Kirschner wires are inserted retrograde across the calcaneocuboid joint, and the calcaneal osteotomy is opened. A trapezoid-shaped allograft bone wedge is impacted, and the Kirschner wires are advanced across into the calcaneus. The lengthened peroneus brevis tendon is repaired, and the wound is closed in a layered fashion.</p><p><strong>Alternatives: </strong>First-line treatment is nonoperative with orthotics and immobilization. Surgical options include coalition resection with or without calcaneal lengthening osteotomy, arthrodesis, or arthroereisis. Following coalition resection, various grafts can be utilized, including fat autografts, bone wax, or split flexor hallucis longus tendon<sup>3-6</sup>.</p><p><strong>Rationale: </strong>This procedure addresses TC coalition with concomitant rigid flatfoot. Resection alone may increase subtalar motion but does not correct a flatfoot deformity. Historically, surgeons performed arthrodesis or arthroereisis, but these are rarely performed in young patients. In patients with coalitions involving >50% of the posterior facet or preexisting degenerative changes, arthrodesis may be indica
{"title":"Talocalcaneal Coalition Resection with Local Fat Grafting and Flatfoot Reconstruction.","authors":"Kira K Tanghe, Shoran Tamura, Jayson Lian, J Nicholas Charla, Melinda S Sharkey, Alexa J Karkenny","doi":"10.2106/JBJS.ST.22.00060","DOIUrl":"10.2106/JBJS.ST.22.00060","url":null,"abstract":"<p><strong>Background: </strong>Talocalcaneal (TC) coalitions typically present in the pediatric population with medial hindfoot and/or ankle pain and absent subtalar range of motion. Coalition resection with fat interposition is well described for isolated tarsal coalitions<sup>1,2</sup>; however, patients with concomitant rigid flatfoot may benefit from additional reconstructive procedures. To address this, we employ the surgical technique of TC resection with local fat grafting and flatfoot reconstruction.</p><p><strong>Description: </strong>This procedure is described in 3 steps: (1) gastrocnemius recession and fat harvesting, (2) TC coalition resection with local fat interposition, and (3) peroneus brevis Z-lengthening and calcaneal lateral column lengthening osteotomy with allograft. A 3 to 4-cm posteromedial longitudinal incision is made at the distal extent of the medial head of the gastrocnemius muscle. The gastrocnemius tendon is identified, dissected free of surrounding tissue, and transected. Superficial fat is then harvested from this incision before wound closure. A 7-cm incision is made from the posterior aspect of the medial malleolus to the talonavicular joint. The neurovascular bundle and flexor tendons are dissected carefully from the surrounding tissue as a group and protected while the coalition is completely resected, and bone wax and the local fat are utilized at the resection site to prevent regrowth of the coalition. An approximately 7-cm incision is then made laterally and obliquely following the Langer lines and centered over the lateral calcaneus. The peroneal tendons are released from their sheaths, and the peroneus brevis is Z-lengthened. A calcaneal osteotomy is performed about 1.5 cm proximal to the calcaneocuboid joint and angled to avoid the anterior and middle subtalar facet joints. Two Kirschner wires are inserted retrograde across the calcaneocuboid joint, and the calcaneal osteotomy is opened. A trapezoid-shaped allograft bone wedge is impacted, and the Kirschner wires are advanced across into the calcaneus. The lengthened peroneus brevis tendon is repaired, and the wound is closed in a layered fashion.</p><p><strong>Alternatives: </strong>First-line treatment is nonoperative with orthotics and immobilization. Surgical options include coalition resection with or without calcaneal lengthening osteotomy, arthrodesis, or arthroereisis. Following coalition resection, various grafts can be utilized, including fat autografts, bone wax, or split flexor hallucis longus tendon<sup>3-6</sup>.</p><p><strong>Rationale: </strong>This procedure addresses TC coalition with concomitant rigid flatfoot. Resection alone may increase subtalar motion but does not correct a flatfoot deformity. Historically, surgeons performed arthrodesis or arthroereisis, but these are rarely performed in young patients. In patients with coalitions involving >50% of the posterior facet or preexisting degenerative changes, arthrodesis may be indica","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11299989/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141898611","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 : 2024-08-06eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00051
Eddie Y Lo, Alvin Ouseph, Jeffrey Sodl, Raffaele Garofalo, Sumant G Krishnan
<p><strong>Background: </strong>With the increased utilization of reverse total shoulder arthroplasty (RTSA), there has been a corresponding increase in the incidence of and demand for revision RTSA<sup>3</sup>. In cases in which the patient has undergone multiple previous surgeries and presents with well-fixed shoulder implants, even the most experienced shoulder surgeon can be overwhelmed and frustrated. Having a simple and reproducible treatment algorithm to plan and execute a successful revision surgery will ease the anxiety of a revision operation and avoid future additional revisions. The extraction techniques described here strive to preserve the humeral and glenoid anatomy, hopefully facilitating the reimplantation steps to follow.</p><p><strong>Description: </strong>The main principles of implant removal include several consistent, simple steps. In order to revise a well-fixed humeral implant, (1) identify the old implants; (2) create a preoperative plan that systematically evaluates the glenoid and humeral deficiencies; (3) prepare consistent surgical tools, such as an oscillating saw, osteotomes, and/or a tamp; (4) follow the deltoid; (5) dissect the soft tissue with a sponge; (6) dissect the bone with use of an osteotome; and (7) remove the humeral stem in rotation. In cases in which there is also a well-fixed glenoid implant, the surgical procedure will require additional steps, including (8) exposure of the anteroinferior glenoid, (9) disengagement of the glenosphere, and (10) removal of the glenoid baseplate in rotation.</p><p><strong>Alternatives: </strong>Alternatives to revision RTSA include nonoperative treatment, implant retention with conversion of modular components, extensile revision surgical techniques, and/or mechanical implant removal. With the advent of modular humeral and glenoid components, surgeons may choose to change the implant components instead of removing the entire humeral and glenoid implants; however, repeat complications may occur if the previous implant or implant position was not completely revised. When confronted with a tough humeral explantation, an extensile surgical approach involves creating a cortical window or humeral osteotomy to expose the humeral implant. This approach can compromise the humeral shaft integrity, leading to alternative and less ideal reconstruction implant choices, the use of cerclage wires, and/or the use of a strut graft, all of which may complicate postoperative mobilization. If glenoid implant removal is necessary, the glenosphere is removed first, followed by the underlying baseplate component(s). If the glenosphere is stuck or if screws are cold-welded, the use of a conventional mechanical extraction technique with a burr or diamond saw may be required; however, this may lead to additional metal debris and intraoperative sparks.</p><p><strong>Rationale: </strong>Revision RTSA can lead to high complication rates, ranging from 12% to 70%<sup>2</sup>, which will often requir
{"title":"Revising Failed Reverse Total Shoulder Arthroplasty: Comprehensive Techniques for Precise Explantation of Well-Fixed Implants.","authors":"Eddie Y Lo, Alvin Ouseph, Jeffrey Sodl, Raffaele Garofalo, Sumant G Krishnan","doi":"10.2106/JBJS.ST.23.00051","DOIUrl":"10.2106/JBJS.ST.23.00051","url":null,"abstract":"<p><strong>Background: </strong>With the increased utilization of reverse total shoulder arthroplasty (RTSA), there has been a corresponding increase in the incidence of and demand for revision RTSA<sup>3</sup>. In cases in which the patient has undergone multiple previous surgeries and presents with well-fixed shoulder implants, even the most experienced shoulder surgeon can be overwhelmed and frustrated. Having a simple and reproducible treatment algorithm to plan and execute a successful revision surgery will ease the anxiety of a revision operation and avoid future additional revisions. The extraction techniques described here strive to preserve the humeral and glenoid anatomy, hopefully facilitating the reimplantation steps to follow.</p><p><strong>Description: </strong>The main principles of implant removal include several consistent, simple steps. In order to revise a well-fixed humeral implant, (1) identify the old implants; (2) create a preoperative plan that systematically evaluates the glenoid and humeral deficiencies; (3) prepare consistent surgical tools, such as an oscillating saw, osteotomes, and/or a tamp; (4) follow the deltoid; (5) dissect the soft tissue with a sponge; (6) dissect the bone with use of an osteotome; and (7) remove the humeral stem in rotation. In cases in which there is also a well-fixed glenoid implant, the surgical procedure will require additional steps, including (8) exposure of the anteroinferior glenoid, (9) disengagement of the glenosphere, and (10) removal of the glenoid baseplate in rotation.</p><p><strong>Alternatives: </strong>Alternatives to revision RTSA include nonoperative treatment, implant retention with conversion of modular components, extensile revision surgical techniques, and/or mechanical implant removal. With the advent of modular humeral and glenoid components, surgeons may choose to change the implant components instead of removing the entire humeral and glenoid implants; however, repeat complications may occur if the previous implant or implant position was not completely revised. When confronted with a tough humeral explantation, an extensile surgical approach involves creating a cortical window or humeral osteotomy to expose the humeral implant. This approach can compromise the humeral shaft integrity, leading to alternative and less ideal reconstruction implant choices, the use of cerclage wires, and/or the use of a strut graft, all of which may complicate postoperative mobilization. If glenoid implant removal is necessary, the glenosphere is removed first, followed by the underlying baseplate component(s). If the glenosphere is stuck or if screws are cold-welded, the use of a conventional mechanical extraction technique with a burr or diamond saw may be required; however, this may lead to additional metal debris and intraoperative sparks.</p><p><strong>Rationale: </strong>Revision RTSA can lead to high complication rates, ranging from 12% to 70%<sup>2</sup>, which will often requir","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11299987/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141898610","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 : 2024-07-10eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00015
Jason S Hoellwarth, Kevin Tetsworth, Munjed Al Muderis
<p><strong>Background: </strong>Upper limb (UL) amputation is disabling. ULs are necessary for many domains of life<sup>1</sup>, and few effective motor and sensory replacements are accessible<sup>2</sup>. Approximately 41,000 people in the United States have UL amputation proximal to the fingers<sup>3</sup>, two-thirds of (all) traumatic amputations are UL<sup>4</sup>, and 80% of UL amputations are performed for trauma-related etiologies<sup>5</sup>. Socket prosthesis (SP) abandonment remains high because of the lack of sensation, limited prosthesis control, perceived weight, and difficulty comfortably wearing the SP<sup>6</sup>. Transcutaneous osseointegration<sup>7,8</sup> surgically inserts a bone-anchored implant, passed through a transcutaneous portal to attach a terminal device, improving amputee rehabilitation by reducing perceived weight, conferring osseoperception<sup>9</sup>, and increasing wear time<sup>10</sup>. Without the socket, all residual skin and musculature remain available for transcutaneous myoelectrodes. The present article describes single-stage radius and ulna press-fit osseointegration (PFOI) after trans-forearm amputation.</p><p><strong>Description: </strong>This technique resembles a lower-extremity PFOI<sup>11,12</sup>. Importantly, at-risk nerves and vessels are different, and implant impaction must be gentler as a result. The surgery is indicated for patients who are dissatisfied with SP rehabilitation or declining alternative rehabilitative options, and who are motivated and enabled to procure, train with, and utilize a forearm prosthesis. An engaged prosthetist is critical. Surgical steps are exposure, bone-end and canal preparation, first implant insertion (in the operative video shown, in the radius), purse-string muscle closure, confirmation that radius-ulna motion remains, performing the prior steps for the other bone (in the video, the ulna), and closure (including potential nerve reconstruction, soft-tissue contouring, and portal creation). Although the patient in the operative video did not require nerve procedures to address pain or to create targets for transcutaneous myoelectrodes, targeted muscle reinnervation or a regenerative peripheral nerve interface procedure could be performed following exposure.</p><p><strong>Alternatives: </strong>Alternatives include socket modification, bone lengthening and/or soft-tissue contouring<sup>13</sup>, Krukenberg-type reconstructions<sup>14</sup>, or accepting the situation. An alternative implant is a screw-type osseointegration implant. Our preference for press-fit implants is based on considerations such as our practice's 12-year history of >1,000 PFOI surgeries; that the screw-type implant requires sufficient cortical thickness for the threads<sup>15</sup>, which is compromised in some patients; the lower cost per implant; that the procedure is performed in 1 instead of 2 surgical episodes<sup>15,16</sup>; and the documented suitability of press-fit implants fo
{"title":"Single-Stage Press-Fit Osseointegration of the Radius and Ulna for Rehabilitation After Trans-Forearm Amputation.","authors":"Jason S Hoellwarth, Kevin Tetsworth, Munjed Al Muderis","doi":"10.2106/JBJS.ST.23.00015","DOIUrl":"10.2106/JBJS.ST.23.00015","url":null,"abstract":"<p><strong>Background: </strong>Upper limb (UL) amputation is disabling. ULs are necessary for many domains of life<sup>1</sup>, and few effective motor and sensory replacements are accessible<sup>2</sup>. Approximately 41,000 people in the United States have UL amputation proximal to the fingers<sup>3</sup>, two-thirds of (all) traumatic amputations are UL<sup>4</sup>, and 80% of UL amputations are performed for trauma-related etiologies<sup>5</sup>. Socket prosthesis (SP) abandonment remains high because of the lack of sensation, limited prosthesis control, perceived weight, and difficulty comfortably wearing the SP<sup>6</sup>. Transcutaneous osseointegration<sup>7,8</sup> surgically inserts a bone-anchored implant, passed through a transcutaneous portal to attach a terminal device, improving amputee rehabilitation by reducing perceived weight, conferring osseoperception<sup>9</sup>, and increasing wear time<sup>10</sup>. Without the socket, all residual skin and musculature remain available for transcutaneous myoelectrodes. The present article describes single-stage radius and ulna press-fit osseointegration (PFOI) after trans-forearm amputation.</p><p><strong>Description: </strong>This technique resembles a lower-extremity PFOI<sup>11,12</sup>. Importantly, at-risk nerves and vessels are different, and implant impaction must be gentler as a result. The surgery is indicated for patients who are dissatisfied with SP rehabilitation or declining alternative rehabilitative options, and who are motivated and enabled to procure, train with, and utilize a forearm prosthesis. An engaged prosthetist is critical. Surgical steps are exposure, bone-end and canal preparation, first implant insertion (in the operative video shown, in the radius), purse-string muscle closure, confirmation that radius-ulna motion remains, performing the prior steps for the other bone (in the video, the ulna), and closure (including potential nerve reconstruction, soft-tissue contouring, and portal creation). Although the patient in the operative video did not require nerve procedures to address pain or to create targets for transcutaneous myoelectrodes, targeted muscle reinnervation or a regenerative peripheral nerve interface procedure could be performed following exposure.</p><p><strong>Alternatives: </strong>Alternatives include socket modification, bone lengthening and/or soft-tissue contouring<sup>13</sup>, Krukenberg-type reconstructions<sup>14</sup>, or accepting the situation. An alternative implant is a screw-type osseointegration implant. Our preference for press-fit implants is based on considerations such as our practice's 12-year history of >1,000 PFOI surgeries; that the screw-type implant requires sufficient cortical thickness for the threads<sup>15</sup>, which is compromised in some patients; the lower cost per implant; that the procedure is performed in 1 instead of 2 surgical episodes<sup>15,16</sup>; and the documented suitability of press-fit implants fo","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11233105/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141581090","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 : 2024-07-05eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00072
Klaus A Siebenrock, Simon D Steppacher, Kai Ziebarth, Joseph M Schwab, Lorenz Büchler
<p><strong>Background: </strong>Abnormal femoral head anatomy following moderate-to-severe slipped capital femoral epiphysis (SCFE) can lead to femoroacetabular impingement and premature osteoarthritis<sup>4-10</sup>. Surgical correction at the deformity site through capital reorientation has the potential to fully ameliorate this but has traditionally been associated with high rates of osteonecrosis<sup>11-15</sup>. The modified Dunn procedure has the potential to restore anatomy in hips with SCFE while protecting the blood supply to the femoral head.</p><p><strong>Description: </strong>A surgical dislocation of the hip is performed according to the technique described by Ganz et al.<sup>16</sup>. The remaining posterosuperior portion of the greater trochanter is trimmed to the level of the femoral neck by subperiosteal bone removal performed in an inside-out manner. The periosteum of the femoral neck is gradually elevated. The resulting soft-tissue flap, consisting of the retinaculum and external rotators, holds the blood vessels supplying the epiphysis. The femoral epiphysis is pinned in situ (in unstable cases) with threaded Kirschner wires, the ligamentum teres is transected, and the femoral head is dislocated. With the femoral neck exposed, the epiphysis is gradually mobilized from the metaphysis, allowing exposure of the residual femoral neck and inspection of any posteroinferior callus. To avoid tension on the retinacular vessels during reduction of the epiphysis, the posterior neck callus is completely excised. The remaining physis is removed with use of a burr while holding the epiphysis stable. The epiphysis is gently reduced onto the femoral neck, avoiding tension on the retinacular vessels. If tension is noted, the femoral neck is rechecked for residual callus, which is excised. If no callus is found, the neck may be carefully shortened in order to minimize tension. Epiphyseal fixation is achieved with use of a 3-mm fully threaded wire inserted antegrade through the fovea to the lateral cortex below the greater trochanter. A second wire is inserted retrograde under fluoroscopy. After reducing the hip, the capsule is closed and the greater trochanter is reattached with use of 3.5-mm cortical screws.</p><p><strong>Alternatives: </strong>Alternatives include nonoperative treatment, in situ fixation (e.g., pinning or screw fixation), gentle closed reduction with pinning, and triplanar trochanteric osteotomy (e.g., Imhauser or Southwick osteotomies).</p><p><strong>Rationale: </strong>In situ pinning of mild-to-moderate, stable SCFE yields good long-term results with low rates of osteonecrosis<sup>9</sup>. Treatment of higher-grade SCFE without reduction aims to avoid osteonecrosis and assumes that the proximal femoral deformity will remodel; however, the head-neck offset will remain abnormal, risking impingement and early-onset osteoarthritis<sup>5,8</sup>. The procedure described in the present article allows anatomic reduction of the ep
背景：中重度股骨头骨骺滑脱（SCFE）后股骨头解剖结构异常可导致股骨髋臼撞击和过早骨关节炎4-10。在畸形部位通过股骨头重新定向进行手术矫正有可能完全改善这一问题，但传统上与骨坏死的高发率有关11-15。改良 Dunn 手术有可能恢复 SCFE 髋关节的解剖结构，同时保护股骨头的血液供应：根据 Ganz 等人描述的技术进行髋关节脱位手术16。通过骨膜下骨切除，以内向外的方式将剩余的大转子后上方部分修剪至股骨颈水平。股骨颈骨膜逐渐被抬高。由此形成的软组织瓣由缰绳和外旋肌组成，可固定供应骨骺的血管。用带螺纹的 Kirschner 线将股骨头骨骺固定在原位（在不稳定的病例中），横断股骨韧带，使股骨头脱位。暴露股骨颈后，逐渐将干骺端从干骺端移出，这样就可以暴露残余股骨颈，并检查是否存在后方胼胝。为避免在缩小骨骺时对视网膜血管造成张力，应完全切除后颈胼胝。在保持骨骺稳定的情况下，使用毛刺去除剩余的骺板。将骨骺轻轻缩至股骨颈上，避免牵拉视网膜血管。如果发现有张力，则重新检查股骨颈是否有残余胼胝，并将其切除。如果没有发现胼胝，可小心缩短股骨颈，以尽量减少张力。使用一根 3 毫米的全螺纹钢丝，经股窝前行插入大转子下方的外侧皮质，实现骺端固定。第二根钢丝在透视下逆行插入。缩小髋关节后，关闭关节囊，使用 3.5 毫米皮质螺钉重新连接大转子：其他选择包括非手术治疗、原位固定（如钉牢或螺钉固定）、轻度闭合复位并钉牢，以及三平面转子截骨术（如 Imhauser 或 Southwick 截骨术）。理由：对轻度至中度、稳定的 SCFE 进行原位钉牢治疗可获得良好的长期效果，骨坏死发生率较低9。对较高级别的SCFE进行不缩股治疗的目的是避免骨坏死，并假定股骨近端畸形会重塑；然而，头颈偏移仍会异常，存在撞击和早发骨关节炎的风险5,8。本文所描述的手术可对骨骺进行解剖复位，骨坏死的风险较低。通过髋关节脱位手术16和扩大的视网膜软组织瓣17，可广泛暴露股骨颈周缘的骨膜下，并保留骨骺脆弱的血液供应18。Dunn股骨颈下重新定位术15可去除胼胝并矫正滑脱角，从而实现股骨近端解剖复位：预期结果：实施该手术的不同中心所报告的结果在治疗髋关节的数量和随访时间方面差异很大。大多数研究都是回顾性的，缺乏对照组。报道的骨坏死风险从0%到25.9%不等19，范围较大的原因很可能是该技术的挑战性、每位外科医生的病例数较少以及与该手术相关的学习曲线较长。在小儿保髋手术经验丰富的中心，骨坏死的报告率很低3。中长期随访研究显示，没有患者转为全髋关节置换术3,20,21，但残余畸形可能会持续存在，因此有可能进行后续手术：皮肤切口应位于大转子中央，Gibson间隙必须仔细准备，以充分松解并避免损伤，应避免骨膜瓣受压，以防对视网膜血管造成压力：AP=前胸AVN=血管性坏死（即骨坏死）CI=置信区间CT=计算机断层扫描K-wire=Kirschner钢丝MRI=磁共振成像OA=骨关节炎SHD=外科髋关节脱位THA=全髋关节置换术VTE=静脉血栓栓塞。
{"title":"Modified Dunn Procedure for Open Reduction of Chronic Slipped Capital Femoral Epiphysis.","authors":"Klaus A Siebenrock, Simon D Steppacher, Kai Ziebarth, Joseph M Schwab, Lorenz Büchler","doi":"10.2106/JBJS.ST.23.00072","DOIUrl":"10.2106/JBJS.ST.23.00072","url":null,"abstract":"<p><strong>Background: </strong>Abnormal femoral head anatomy following moderate-to-severe slipped capital femoral epiphysis (SCFE) can lead to femoroacetabular impingement and premature osteoarthritis<sup>4-10</sup>. Surgical correction at the deformity site through capital reorientation has the potential to fully ameliorate this but has traditionally been associated with high rates of osteonecrosis<sup>11-15</sup>. The modified Dunn procedure has the potential to restore anatomy in hips with SCFE while protecting the blood supply to the femoral head.</p><p><strong>Description: </strong>A surgical dislocation of the hip is performed according to the technique described by Ganz et al.<sup>16</sup>. The remaining posterosuperior portion of the greater trochanter is trimmed to the level of the femoral neck by subperiosteal bone removal performed in an inside-out manner. The periosteum of the femoral neck is gradually elevated. The resulting soft-tissue flap, consisting of the retinaculum and external rotators, holds the blood vessels supplying the epiphysis. The femoral epiphysis is pinned in situ (in unstable cases) with threaded Kirschner wires, the ligamentum teres is transected, and the femoral head is dislocated. With the femoral neck exposed, the epiphysis is gradually mobilized from the metaphysis, allowing exposure of the residual femoral neck and inspection of any posteroinferior callus. To avoid tension on the retinacular vessels during reduction of the epiphysis, the posterior neck callus is completely excised. The remaining physis is removed with use of a burr while holding the epiphysis stable. The epiphysis is gently reduced onto the femoral neck, avoiding tension on the retinacular vessels. If tension is noted, the femoral neck is rechecked for residual callus, which is excised. If no callus is found, the neck may be carefully shortened in order to minimize tension. Epiphyseal fixation is achieved with use of a 3-mm fully threaded wire inserted antegrade through the fovea to the lateral cortex below the greater trochanter. A second wire is inserted retrograde under fluoroscopy. After reducing the hip, the capsule is closed and the greater trochanter is reattached with use of 3.5-mm cortical screws.</p><p><strong>Alternatives: </strong>Alternatives include nonoperative treatment, in situ fixation (e.g., pinning or screw fixation), gentle closed reduction with pinning, and triplanar trochanteric osteotomy (e.g., Imhauser or Southwick osteotomies).</p><p><strong>Rationale: </strong>In situ pinning of mild-to-moderate, stable SCFE yields good long-term results with low rates of osteonecrosis<sup>9</sup>. Treatment of higher-grade SCFE without reduction aims to avoid osteonecrosis and assumes that the proximal femoral deformity will remodel; however, the head-neck offset will remain abnormal, risking impingement and early-onset osteoarthritis<sup>5,8</sup>. The procedure described in the present article allows anatomic reduction of the ep","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11221854/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141556457","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 : 2024-07-05eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00041
Nathan S Lanham, Jordan G Tropf, John D Johnson
<p><strong>Background: </strong>Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing<sup>1</sup>. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques<sup>1,2</sup>.</p><p><strong>Description: </strong>The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular "bare area" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner.</p><p><strong>Alternatives: </strong>Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate.</p><p><strong>Rationale: </strong>The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures<sup>1-3</sup>. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches<sup>3</sup>. OO has not been associated with triceps weakness, unlike some of the alternative techniques<sup>2</sup>.</p><p><strong>Expected outcomes: </strong>The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures<sup>4</sup>. Osteotomies united in all patients in 2 reported series, totaling 84 cases<sup>1,2</sup>. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients<sup>1,2</sup>.</p><p><strong>Important tips: </strong>Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the O
{"title":"Olecranon Osteotomy Exposure for Distal Humeral Fracture Treatment.","authors":"Nathan S Lanham, Jordan G Tropf, John D Johnson","doi":"10.2106/JBJS.ST.23.00041","DOIUrl":"10.2106/JBJS.ST.23.00041","url":null,"abstract":"<p><strong>Background: </strong>Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing<sup>1</sup>. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques<sup>1,2</sup>.</p><p><strong>Description: </strong>The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular \"bare area\" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner.</p><p><strong>Alternatives: </strong>Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate.</p><p><strong>Rationale: </strong>The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures<sup>1-3</sup>. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches<sup>3</sup>. OO has not been associated with triceps weakness, unlike some of the alternative techniques<sup>2</sup>.</p><p><strong>Expected outcomes: </strong>The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures<sup>4</sup>. Osteotomies united in all patients in 2 reported series, totaling 84 cases<sup>1,2</sup>. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients<sup>1,2</sup>.</p><p><strong>Important tips: </strong>Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the O","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11221848/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141556458","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 : 2024-07-05eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00067
Emanuele Maggini, Mara Warnhoff, Florian Freislederer, Markus Scheibel
<p><strong>Background: </strong>Metallic lateralized-offset glenoid reverse shoulder arthroplasty (RSA) for cuff tear arthropathy combines the use of a metallic augmented baseplate with a metaphyseally oriented short stem design that can be applied at a 135° or 145° neck-shaft angle, leading to additional lateralization on the humeral side. Lateralization of the center of rotation decreases the risk of inferior scapular notching and improves external rotation, deltoid wrapping, residual rotator cuff tensioning, and prosthetic stability<sup>1-4</sup>. Metallic increased-offset RSA (MIO-RSA) achieves lateralization and corrects inclination and retroversion while avoiding graft resorption and other complications of bony increased-offset RSA (BIO-RSA)<sup>5-8</sup>. Reducing the neck-shaft angle from the classical Grammont design, in combination with glenoid lateralization, improves range of motion<sup>9,10</sup> by reducing inferior impingement during adduction at the expense of earlier superior impingement during abduction<sup>2,11</sup>. Lädermann et al.<sup>12</sup> investigated how different combinations of humeral stem and glenosphere designs influence range of motion and muscle elongation. They assessed 30 combinations of humeral components, as compared with the native shoulder, and found that the combination that allows for restoration of >50% of the native range of motion in all directions was a 145° onlay stem with a concentric or lateralized tray in conjunction with a lateralized or inferior eccentric glenosphere. In addition, the use of a flush-lay or a slight-onlay stem design (like the one utilized in the presently described technique) may decrease the risk of secondary scapular spine fracture<sup>13,14</sup>. The goal of this prosthetic design is to achieve an excellent combination of motion and stability while reducing complications.</p><p><strong>Description: </strong>This procedure is performed via a deltopectoral approach with the patient in the beach-chair position under general anesthesia combined with a regional interscalene nerve block. Subscapularis tenotomy and capsular release are performed, the humeral head is dislocated, and any osteophytes are removed. An intramedullary cutting guide is placed for correct humeral resection. The osteotomy of the humeral head is performed in the anatomical neck with an inclination of 135° and a retroversion of 20° to 40°, depending on the anatomical retroversion. The glenoid is prepared as usual. The lateralized, augmented baseplate is assembled with the central screw and the baseplate-wedge-screw complex is placed by inserting the screw into the central screw hole. Four peripheral screws are utilized for definitive fixation. An eccentric glenosphere with inferior overhang is implanted. The humerus is dislocated, and the metaphysis is prepared. Long compactors are utilized for proper stem alignment, and an asymmetric trial insert is positioned before the humerus is reduced. Stability and ra
{"title":"Metallic Lateralized-Offset Glenoid Reverse Shoulder Arthroplasty.","authors":"Emanuele Maggini, Mara Warnhoff, Florian Freislederer, Markus Scheibel","doi":"10.2106/JBJS.ST.23.00067","DOIUrl":"10.2106/JBJS.ST.23.00067","url":null,"abstract":"<p><strong>Background: </strong>Metallic lateralized-offset glenoid reverse shoulder arthroplasty (RSA) for cuff tear arthropathy combines the use of a metallic augmented baseplate with a metaphyseally oriented short stem design that can be applied at a 135° or 145° neck-shaft angle, leading to additional lateralization on the humeral side. Lateralization of the center of rotation decreases the risk of inferior scapular notching and improves external rotation, deltoid wrapping, residual rotator cuff tensioning, and prosthetic stability<sup>1-4</sup>. Metallic increased-offset RSA (MIO-RSA) achieves lateralization and corrects inclination and retroversion while avoiding graft resorption and other complications of bony increased-offset RSA (BIO-RSA)<sup>5-8</sup>. Reducing the neck-shaft angle from the classical Grammont design, in combination with glenoid lateralization, improves range of motion<sup>9,10</sup> by reducing inferior impingement during adduction at the expense of earlier superior impingement during abduction<sup>2,11</sup>. Lädermann et al.<sup>12</sup> investigated how different combinations of humeral stem and glenosphere designs influence range of motion and muscle elongation. They assessed 30 combinations of humeral components, as compared with the native shoulder, and found that the combination that allows for restoration of >50% of the native range of motion in all directions was a 145° onlay stem with a concentric or lateralized tray in conjunction with a lateralized or inferior eccentric glenosphere. In addition, the use of a flush-lay or a slight-onlay stem design (like the one utilized in the presently described technique) may decrease the risk of secondary scapular spine fracture<sup>13,14</sup>. The goal of this prosthetic design is to achieve an excellent combination of motion and stability while reducing complications.</p><p><strong>Description: </strong>This procedure is performed via a deltopectoral approach with the patient in the beach-chair position under general anesthesia combined with a regional interscalene nerve block. Subscapularis tenotomy and capsular release are performed, the humeral head is dislocated, and any osteophytes are removed. An intramedullary cutting guide is placed for correct humeral resection. The osteotomy of the humeral head is performed in the anatomical neck with an inclination of 135° and a retroversion of 20° to 40°, depending on the anatomical retroversion. The glenoid is prepared as usual. The lateralized, augmented baseplate is assembled with the central screw and the baseplate-wedge-screw complex is placed by inserting the screw into the central screw hole. Four peripheral screws are utilized for definitive fixation. An eccentric glenosphere with inferior overhang is implanted. The humerus is dislocated, and the metaphysis is prepared. Long compactors are utilized for proper stem alignment, and an asymmetric trial insert is positioned before the humerus is reduced. Stability and ra","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11221860/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141556456","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}
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