JBJS Essential Surgical Techniques最新文献

Background: Olecranon fractures are common injuries that often require surgical fixation to maintain elbow function. Nonoperative management of these injuries may be indicated in the elderly, as a recent randomized controlled trial found that 81% (9) of 11 operatively managed olecranon fractures in the elderly had complications¹. While traditional techniques such as tension-band wiring and plate fixation produced satisfactory functional outcomes, they are associated with high rates of complications². Intramedullary screw fixation has gained popularity as an alternative technique for transverse olecranon fractures. The goal of this procedure is to reduce complication rates associated with olecranon open reduction and internal fixation while maintaining optimal functional outcomes.

Description: The patient is positioned in the lateral decubitus position with the arm placed over a padded Mayo stand. A direct posterior incision is made to the olecranon. Following irrigation and hematoma evacuation, the fracture is reduced. Pointed reduction clamps are used to reduce the fracture and hold a provisional reduction. A 2 to 2.5-cm longitudinal incision is made over the footprint of the triceps insertion. Next, a 3.5-mm drill is passed from the olecranon tip to the proximal ulnar diaphysis. The proximal ulna is then opened with a 4.5-mm drill, and a 6.5-mm calibrated tap is used to sound the ulna. Then a 6.5-mm, solid, partially threaded screw with a washer is placed across the fracture. Reduction aids are removed, and the surgical site is closed. The arm is splinted for 2 weeks to allow for soft-tissue healing, after which immediate full, active range of motion is allowed.

Alternatives: Alternatives include nonoperative treatment such as immobilization with a posterior long-arm splint, operative treatment with tension-band wiring, and operative treatment with plate and screw fixation.

Rationale: Because of the high rates of stiffness, contracture, and joint involvement associated with nonoperative treatment of olecranon fractures, operative treatment of these injuries is often recommended³. The most common types of surgical fixation include tension-band wiring or a plate-and-screw construct. Both techniques successfully lead to fracture healing and satisfactory functional outcomes; however, the main drawback of these procedures is their high rate of complications². A prior study reported complications in 19 (63%) of 30 patients with tension-band wiring and in 12 (38%) of 32 patients with plate-and-screw constructs. Symptomatic hardware, skin breakdown, and subsequent infection made up most of these complications². In contrast, intramedullary screw fixation utilizes low-profile hardware that is seated within the osseous cortex. This reduces soft-tissue irritation in a region that contains low proportions of subcuta

Background: Osseointegration provides a direct prosthesis interface for lower-limb amputees, many of whom are poor candidates for traditional socket-suspended prostheses. These skeletally anchored implants eliminate the skin-prosthesis interface, reducing complications such as soft-tissue breakdown, ulceration, and pain¹. Soft-tissue contouring and management of peripheral nerves are essential aspects of osseointegrated implantation surgery for both transfemoral and transtibial amputees. These techniques protect the bone-implant interface, prevent skin-implant friction, and reduce neuroma formation, thus mitigating complications and maximizing patient satisfaction^2,3.

Description: In the present video article, we describe a technique for soft-tissue contouring during single-stage limb osseointegration that involves mobilizing the anterior and posterior musculature to cover the bone-implant interface without excess⁴. Peripheral nerves (i.e., the sciatic and femoral nerves for transfemoral osseointegration and the common peroneal, sural, and posterior tibial nerves for transtibial osseointegration) are identified, and targeted muscle reinnervation (TMR) is performed on each nerve. A regenerative peripheral nerve interface (RPNI) may also be utilized if there is a large size discrepancy during nerve coaptation. We excise redundant soft tissue, performing medial thigh lifts as needed, and resect subscarpal fat to create a posterior skin flap that is advanced over the implant. Finally, a skin aperture is created in the skin flap, through which the implant can attach to the prosthesis. Appropriate tension on the skin aperture is needed to allow for drainage and to avoid necrosis while preventing bacterial ingress into the surgical site.

Alternatives: Alternatives to osseointegration include maximizing the functionality and comfort of a socket prosthesis, either by refitting the prosthesis or by revising the soft tissue of the residual limb. However, both of these strategies have been shown to lead to lower health-related quality of life and are not cost-effective techniques when compared with osseointegration^5,6.

Rationale: Lower-limb osseointegration is particularly beneficial for patients who have the desire to walk and are unable to tolerate traditional socket prostheses because of issues related to poor fit, pain, high metabolic demand, and/or skin breakdown⁷. Osseointegration has been shown to increase quality of life and reduce health-care costs in these patients. The efficacy and outcomes of osseointegration are not impacted by amputation etiology or history of vascular disease, making it a sound option for patients of all backgrounds.

Expected outcomes: Single-institution studies and systematic reviews have shown that lower-limb osseointegration is safe and effective, often result

Background: Massive retracted rotator cuff tears are disabling in physically active patients. In patients with persistent pain in whom nonoperative treatment has failed, multiple surgical treatment options are available. Lower trapezius tendon transfer is a promising surgical procedure that can decrease pain, improve external rotation strength, and recreate more normal glenohumeral kinematics. In the present video article, we describe the surgical technique for successful arthroscopic ("scopy")-assisted lower trapezius transfer (SALTT) with use of an easily accessible peroneus longus autograft.

Description: The patient is positioned in a beach-chair position with the ipsilateral half of the posterior shoulder girdle included in the draping for surgical access. Joint was viewed through the standard posterior and posterolateral portals, while anterolateral and anterosuperior portals were utilized as the working portals. Subacromial and superior capsular adhesions are released, and a partial cuff repair is performed. A 3 to 4-cm vertical incision is made along the scapular spine. The superior and inferior borders of the lower trapezius are delineated and completely detached from where they insert at the scapular spine. A 3-cm vertical incision is made at the posterior border of the lateral malleolus. The fascia is incised. The peroneus longus is identified and detached with the foot in maximum dorsiflexion and eversion and is harvested with use of a closed tendon stripper. Whip stiches are placed at 1 end of the autograft. With use of a large grasping clamp, starting from the anterolateral portal and aiming toward the medial scapular incision, the autograft is shuttled and the stitched end of the autograft is fixed to the humeral head with a knotless anchor. With the shoulder in maximum external rotation and 0° of abduction, tenodesis of the autograft is performed to the lower trapezius tendon with a Pulvertaft technique. The shoulder is then immobilized in 40° to 60° of external rotation in a custom brace for 6 to 8 weeks. Passive and gradual active-assisted shoulder exercises should begin at 6 to 8 weeks postoperatively.

Alternatives: Surgical alternatives for irreparable tears include partial rotator cuff repair with biceps superior capsular reconstruction, superior capsular reconstruction with fascia lata graft, subacromial balloon spacer, and reverse shoulder arthroplasty. Tendon transfers are preferred in younger patients.

Rationale: The lower trapezius has adequate tension, a similar line of pull as the infraspinatus, and enough tension to replace the function of the infraspinatus¹. Biomechanical studies have shown that the maximum external rotation moment arm generated with use of a lower trapezius transfer with the arm at the side is superior to that with either latissimus dorsi or teres major transfer², and lower trapezius transfe

[This corrects the article DOI: 10.2106/JBJS.ST.23.00006.].

[This corrects the article DOI: 10.2106/JBJS.ST.23.00009.].

Background: The pelvis is one of the most common areas for metastatic bone disease. We recently described the use of a minimally invasive percutaneous screw fixation of metastatic non-periacetabular pelvic lesions, with excellent results.

Description: The procedure can be completed in a standard operating theater without the need for special instruments. In our video we describe the appropriate intraoperative patient positioning, surgical equipment, surgical approach, and obtainment of the necessary fluoroscopic views for placement of various pelvic percutaneous screws.

Alternatives: Alternative treatments include surgical procedures such as curettage, cement packing, and modified Harrington total hip arthroplasty through extensive open approaches. Additionally, as an alternative to standard fluoroscopy, intraoperative navigation and an O-arm could be utilized for the placement of screws. In our experience, intraoperative navigation has been helpful for confirmation of final screw placement and length. Overreliance on intraoperative navigation in the setting of poor bone quality and an abandonment of tactile feedback and the various tips described in this video article can lead to inadvertent extraosseous screw placement and injury. Furthermore, as navigation involves only a virtually computed image, we have found it challenging to utilize in complex, curved bones, such as the superior pubic ramus.

Rationale: Percutaneous screw fixation is safe and effective for the treatment of metastatic non-periacetabular pelvic lesions. Given the simplicity of the technique and instrumentation, and the tolerance of concomitant treatments, this approach is worthy of broader consideration.

Expected outcomes: In our recent study, 22 consecutive patients with painful non-periacetabular pelvic metastatic cancer underwent percutaneous screw fixation. There were no surgical complications. Postoperatively, there was significant improvement in visual analog scale pain scores and functional Eastern Cooperative Oncology Group scores, as compared with baseline³.

Important tips: Despite the simplicity of the intraoperative set-up and instrumentation, the procedure is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging.

Acronyms and abbreviations: CT = computed tomographyASIS = anterior superior iliac spineGT = greater trochanterAP = anteroposteriorAIIS = anterior inferior iliac spineSI = sacroiliacTSTI = transsacral-transiliacVAS = visual analog scaleECOG = Eastern Cooperative Oncology GroupDVT = deep vein thrombosis.