Pub Date : 2024-06-20eCollection Date: 2024-04-01DOI: 10.2106/JBJS.ST.23.00061
Stephen M Gillinov, Bilal S Siddiq, Nathan J Cherian, Scott D Martin
<p><strong>Background: </strong>A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy<sup>1,2</sup>. Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension<sup>3</sup>. Thus, these approaches may introduce capsuloligamentous instability<sup>1,4-7</sup> and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification<sup>5,8-12</sup>. Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure<sup>6,13</sup>, avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals.</p><p><strong>Description: </strong>Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post<sup>14</sup>. Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury<sup>15</sup>. Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed<sup>5</sup>.</p><p><strong>Alternatives: </strong>Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure<sup>1,2,4,6,7,16</sup>. Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability<sup>1,4-7,17</sup>.</p><p><strong>Rationale: </strong>The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not
{"title":"Puncture Capsulotomy Technique During Hip Arthroscopy.","authors":"Stephen M Gillinov, Bilal S Siddiq, Nathan J Cherian, Scott D Martin","doi":"10.2106/JBJS.ST.23.00061","DOIUrl":"10.2106/JBJS.ST.23.00061","url":null,"abstract":"<p><strong>Background: </strong>A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy<sup>1,2</sup>. Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension<sup>3</sup>. Thus, these approaches may introduce capsuloligamentous instability<sup>1,4-7</sup> and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification<sup>5,8-12</sup>. Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure<sup>6,13</sup>, avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals.</p><p><strong>Description: </strong>Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post<sup>14</sup>. Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury<sup>15</sup>. Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed<sup>5</sup>.</p><p><strong>Alternatives: </strong>Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure<sup>1,2,4,6,7,16</sup>. Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability<sup>1,4-7,17</sup>.</p><p><strong>Rationale: </strong>The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11186812/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141433029","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 : 2024-06-20eCollection Date: 2024-04-01DOI: 10.2106/JBJS.ST.23.00018
Tyler J Thorne, Chase T Nelson, Leonard S J Lisitano, Thomas F Higgins, David L Rothberg, Justin M Haller, Lucas S Marchand
<p><strong>Background: </strong>Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse.</p><p><strong>Description: </strong>Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed.</p><p><strong>Alternatives: </strong>Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace<sup>1</sup>. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate.</p><p><strong>Rationale: </strong>Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength<sup>2,3</sup>. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone<sup>4-7</sup>. Adjunctive
{"title":"Dual Plating of Distal Femoral Fractures.","authors":"Tyler J Thorne, Chase T Nelson, Leonard S J Lisitano, Thomas F Higgins, David L Rothberg, Justin M Haller, Lucas S Marchand","doi":"10.2106/JBJS.ST.23.00018","DOIUrl":"10.2106/JBJS.ST.23.00018","url":null,"abstract":"<p><strong>Background: </strong>Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse.</p><p><strong>Description: </strong>Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed.</p><p><strong>Alternatives: </strong>Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace<sup>1</sup>. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate.</p><p><strong>Rationale: </strong>Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength<sup>2,3</sup>. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone<sup>4-7</sup>. Adjunctive","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11186817/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141433028","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 : 2024-05-22eCollection Date: 2024-04-01DOI: 10.2106/JBJS.ST.23.00006
Jan Paul M Frölke, Robin Atallah, Ruud Leijendekkers
<p><strong>Background: </strong>This video article describes the use of bone-anchored prostheses for patients with transtibial amputations, most often resulting from trauma, infection, or dysvascular disease. Large studies have shown that about half of all patients with a socket-suspended artificial limb experience limited mobility and limited prosthesis use because of socket-related problems. These problems occur at the socket-residual limb interface as a result of a painful and unstable connection, leading to an asymmetrical gait and subsequent pelvic and back pain. In almost all of these cases, a bone-anchored prosthesis may result in substantial improvements in mobility and quality of life.</p><p><strong>Description: </strong>This technique is preferably performed in a single-stage procedure. Preoperative implant planning is imperative when designing the custom-made implant (BADAL X, OTN Implants). These images should be visible on screen in the operating room throughout the procedure to guide the surgeon. The patient is positioned with the knee on a silicone cushion. The planned soft-tissue resection is marked, after which the resection of all layers is performed, including large nerves and neuromas, with high cuts performed under traction. Exposure of the residual bone following revision osteotomy is carried out according to the design. The medullary canal is prepared and perpendicular cutting of the tibial and fibular remnant are performed, with the latter cut at a level 1 to 2 cm higher than the former. The intramedullary component is inserted under fluoroscopic guidance, after which the distal end of the tibia is prepared utilizing the typical drop shape. Two transverse locking screws are inserted with the standard "freehand" technique. The soft tissues are contoured and closed over the implant, after which the stoma is created and the dual cone is mounted. Finally, pressure bandages are applied, and postoperative imaging is performed. After the surgical procedure, most patients stay 1 or 2 nights in the hospital, depending on the magnitude of the surgery (e.g., bilateral implantation of a bone-anchored implant) and the patient's comorbidities.</p><p><strong>Alternatives: </strong>Simultaneous major leg amputation and bone-anchored prosthesis implantation is not advocated as treatment. First, a rehabilitation program with a socket-suspended prosthesis should be completed before patients can apply for a bone-anchored prosthesis. After rehabilitation, satisfaction with a prosthetic socket may be adequate, thereby not indicating the need for a bone-anchored prosthesis. Contraindications for bone-anchored implant surgery include severe diabetes (with complications), severe bone deformity, immature bones, bone diseases (i.e., chronic infection or metastasis), current chemotherapy, severe vascular diseases, pain without a clear cause, obesity (body mass index >30 kg/m<sup>2</sup>), and smoking.</p><p><strong>Rationale: </strong>Approximately h
{"title":"Press-Fit Bone-Anchored Prosthesis for Individuals with Transtibial Amputation.","authors":"Jan Paul M Frölke, Robin Atallah, Ruud Leijendekkers","doi":"10.2106/JBJS.ST.23.00006","DOIUrl":"10.2106/JBJS.ST.23.00006","url":null,"abstract":"<p><strong>Background: </strong>This video article describes the use of bone-anchored prostheses for patients with transtibial amputations, most often resulting from trauma, infection, or dysvascular disease. Large studies have shown that about half of all patients with a socket-suspended artificial limb experience limited mobility and limited prosthesis use because of socket-related problems. These problems occur at the socket-residual limb interface as a result of a painful and unstable connection, leading to an asymmetrical gait and subsequent pelvic and back pain. In almost all of these cases, a bone-anchored prosthesis may result in substantial improvements in mobility and quality of life.</p><p><strong>Description: </strong>This technique is preferably performed in a single-stage procedure. Preoperative implant planning is imperative when designing the custom-made implant (BADAL X, OTN Implants). These images should be visible on screen in the operating room throughout the procedure to guide the surgeon. The patient is positioned with the knee on a silicone cushion. The planned soft-tissue resection is marked, after which the resection of all layers is performed, including large nerves and neuromas, with high cuts performed under traction. Exposure of the residual bone following revision osteotomy is carried out according to the design. The medullary canal is prepared and perpendicular cutting of the tibial and fibular remnant are performed, with the latter cut at a level 1 to 2 cm higher than the former. The intramedullary component is inserted under fluoroscopic guidance, after which the distal end of the tibia is prepared utilizing the typical drop shape. Two transverse locking screws are inserted with the standard \"freehand\" technique. The soft tissues are contoured and closed over the implant, after which the stoma is created and the dual cone is mounted. Finally, pressure bandages are applied, and postoperative imaging is performed. After the surgical procedure, most patients stay 1 or 2 nights in the hospital, depending on the magnitude of the surgery (e.g., bilateral implantation of a bone-anchored implant) and the patient's comorbidities.</p><p><strong>Alternatives: </strong>Simultaneous major leg amputation and bone-anchored prosthesis implantation is not advocated as treatment. First, a rehabilitation program with a socket-suspended prosthesis should be completed before patients can apply for a bone-anchored prosthesis. After rehabilitation, satisfaction with a prosthetic socket may be adequate, thereby not indicating the need for a bone-anchored prosthesis. Contraindications for bone-anchored implant surgery include severe diabetes (with complications), severe bone deformity, immature bones, bone diseases (i.e., chronic infection or metastasis), current chemotherapy, severe vascular diseases, pain without a clear cause, obesity (body mass index >30 kg/m<sup>2</sup>), and smoking.</p><p><strong>Rationale: </strong>Approximately h","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11781768/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143068451","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 : 2024-05-22eCollection Date: 2024-04-01DOI: 10.2106/JBJS.ST.22.00071
Katharine D Harper, Stephen J Incavo
<p><strong>Background: </strong>Vancomycin is a prophylactic antibiotic with bactericidal activity against methicillin-resistant <i>Staphylococcus aureus</i> that is commonly used in total joint replacement surgery<sup>1</sup>. In total knee arthroplasty (TKA), intraosseous infusions administered following tourniquet inflation have demonstrated improved local vancomycin concentrations with decreased systemic absorption<sup>1-3</sup>. This administration method results in no adverse reactions locally, as well as equivalent or lower systemic complications compared with other vancomycin administration methods<sup>4</sup>. Intraosseous infusion of prophylactic surgical antibiotics has been shown to be more effective than intravenous administration, with the potential for reduction in surgical site infections<sup>5</sup>.</p><p><strong>Description: </strong>After the operative extremity has been prepared and draped in the usual sterile fashion, the limb is elevated and the tourniquet is inflated to 250 mm Hg. Prior to incision, an intraosseous vascular access system (Arrow EZ IO; Teleflex) is inserted with a power driver into the tibial tubercle region. The desired volume of the medication is injected into the tibia. The device is removed and then inserted into the anterior distal femur, centrally, just proximal to the patella. Following this, the desired volume of the medication is injected into the femur. The device is then removed, and the TKA proceeds according to the surgeon's standard technique.</p><p><strong>Alternatives: </strong>Alternative administration methods for vancomycin include other invasive methods and noninvasive delivery. Intravenous delivery is the most traditional form of medication delivery<sup>1,2</sup>. Additional alternatives include noninvasive placement of antibiotic powder into the wound and localized soft-tissue injections of desired medications<sup>1-3</sup>.</p><p><strong>Rationale: </strong>Opting to administer antibiotics and other medications intraosseously (rather than intravenously) has shown improved compliance with the golden-hour rule of preoperative antibiotics (especially for vancomycin)<sup>4</sup>, lower incidences of acute kidney injury or adverse systemic effects<sup>4</sup>, and improved local tissue concentrations of all medications delivered<sup>1-3</sup>.</p><p><strong>Expected outcomes: </strong>Expected outcomes include improved local tissue concentrations with decreased systemic concentrations of vancomycin and with no reported local or systemic adverse reactions, as well as the potential for improved infection prevention<sup>1-5</sup>. Literature regarding the use of intraosseous infusion during TKA has been thorough and very well received. A prospective, randomized study by Young et al. evaluated local and systemic concentrations of vancomycin following intraosseous versus intravenous administration. The authors found that low-dose intraosseous vancomycin resulted in tissue concentrations equal t
{"title":"Intraosseous Administration of Medications in Total Knee Arthroplasty: An Opportunity for Improved Outcomes and Superior Compliance.","authors":"Katharine D Harper, Stephen J Incavo","doi":"10.2106/JBJS.ST.22.00071","DOIUrl":"10.2106/JBJS.ST.22.00071","url":null,"abstract":"<p><strong>Background: </strong>Vancomycin is a prophylactic antibiotic with bactericidal activity against methicillin-resistant <i>Staphylococcus aureus</i> that is commonly used in total joint replacement surgery<sup>1</sup>. In total knee arthroplasty (TKA), intraosseous infusions administered following tourniquet inflation have demonstrated improved local vancomycin concentrations with decreased systemic absorption<sup>1-3</sup>. This administration method results in no adverse reactions locally, as well as equivalent or lower systemic complications compared with other vancomycin administration methods<sup>4</sup>. Intraosseous infusion of prophylactic surgical antibiotics has been shown to be more effective than intravenous administration, with the potential for reduction in surgical site infections<sup>5</sup>.</p><p><strong>Description: </strong>After the operative extremity has been prepared and draped in the usual sterile fashion, the limb is elevated and the tourniquet is inflated to 250 mm Hg. Prior to incision, an intraosseous vascular access system (Arrow EZ IO; Teleflex) is inserted with a power driver into the tibial tubercle region. The desired volume of the medication is injected into the tibia. The device is removed and then inserted into the anterior distal femur, centrally, just proximal to the patella. Following this, the desired volume of the medication is injected into the femur. The device is then removed, and the TKA proceeds according to the surgeon's standard technique.</p><p><strong>Alternatives: </strong>Alternative administration methods for vancomycin include other invasive methods and noninvasive delivery. Intravenous delivery is the most traditional form of medication delivery<sup>1,2</sup>. Additional alternatives include noninvasive placement of antibiotic powder into the wound and localized soft-tissue injections of desired medications<sup>1-3</sup>.</p><p><strong>Rationale: </strong>Opting to administer antibiotics and other medications intraosseously (rather than intravenously) has shown improved compliance with the golden-hour rule of preoperative antibiotics (especially for vancomycin)<sup>4</sup>, lower incidences of acute kidney injury or adverse systemic effects<sup>4</sup>, and improved local tissue concentrations of all medications delivered<sup>1-3</sup>.</p><p><strong>Expected outcomes: </strong>Expected outcomes include improved local tissue concentrations with decreased systemic concentrations of vancomycin and with no reported local or systemic adverse reactions, as well as the potential for improved infection prevention<sup>1-5</sup>. Literature regarding the use of intraosseous infusion during TKA has been thorough and very well received. A prospective, randomized study by Young et al. evaluated local and systemic concentrations of vancomycin following intraosseous versus intravenous administration. The authors found that low-dose intraosseous vancomycin resulted in tissue concentrations equal t","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11108349/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141080827","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>This video article describes the technique for arthroscopic reduction and fixation of Pipkin type-I fractures.</p><p><strong>Description: </strong>Surgery is performed with the patient in a supine position, with free lower limbs, on a radiolucent table. Arthroscopic superior and anterolateral portals are made similarly to the portals created to evaluate the peripheral compartment during an outside-in (ballooning) technique.<sup>1</sup> An additional medial portal is subsequently created in order to aid in reduction and screw placement. The medial portal is created in abduction and external rotation of the hip (i.e., the figure-4 position). The adductor tendon is identified, and the portal is then safely positioned posteriorly to its margin, approximately 4 to 5 cm distal to the inguinal fold, avoiding the saphenous vein (usually identified with an ultrasound scan). The fragment is mobilized, debrided, and then reduced with use of a microfracture awl or a large Kirschner wire (used as a joystick). Following reduction, temporary fixation is performed with use of long Kirschner wires under direct visualization and fluoroscopic guidance. If reduction is satisfactory, definitive fixation can be performed with use of 4.5-mm headless screws through the medial portal. All steps of fragment reduction and fixation are performed through the medial portal, with the patient in the figure-4 position. Once the screws are placed, a final dynamic arthroscopic and fluoroscopic check is performed.</p><p><strong>Alternatives: </strong>In Pipkin type-I fractures, surgery is recommended when the femoral head fragment is large (exceeding 15% to 20% of the femoral head volume) and displaced (by >3 mm). In such cases, if untreated, spontaneous evolution to osteoarthritis may occur. For fragments smaller than 10% to 15% of the femoral head volume, arthroscopic removal is often the best choice<sup>2</sup>. Several approaches (e.g., Smith-Petersen, modified Hueter, Kocher-Langenbeck, and surgical safe dislocation) have been proposed for reduction and fixation, with surgical safe dislocation being the most versatile because of the uniquely complete visualization of the femoral head<sup>3</sup>.</p><p><strong>Rationale: </strong>The arthroscopic reduction and fixation technique for a non-comminuted Pipkin type-I fracture holds the intrinsic advantages of being less invasive than open surgery in terms of surgical exposure, and having less blood loss, infection risks, and wound complications. Arthroscopy allows direct visualization of the fragment and its reduction surface, along with removal of articular loose bodies and debridement. The surgical time is influenced by the surgeon's experience, but often is no longer than with an open procedure. In the few studies assessing the use of this technique, the rates of osteonecrosis and heterotopic ossification are lower than with open techniques. It is worth noting that the studies assessing the use o
{"title":"Arthroscopic Reduction and Fixation of a Pipkin Type-I Femoral Head Fracture.","authors":"Alessandro Aprato, Ruben Caruso, Michele Reboli, Matteo Giachino, Alessandro Massè","doi":"10.2106/JBJS.ST.23.00073","DOIUrl":"10.2106/JBJS.ST.23.00073","url":null,"abstract":"<p><strong>Background: </strong>This video article describes the technique for arthroscopic reduction and fixation of Pipkin type-I fractures.</p><p><strong>Description: </strong>Surgery is performed with the patient in a supine position, with free lower limbs, on a radiolucent table. Arthroscopic superior and anterolateral portals are made similarly to the portals created to evaluate the peripheral compartment during an outside-in (ballooning) technique.<sup>1</sup> An additional medial portal is subsequently created in order to aid in reduction and screw placement. The medial portal is created in abduction and external rotation of the hip (i.e., the figure-4 position). The adductor tendon is identified, and the portal is then safely positioned posteriorly to its margin, approximately 4 to 5 cm distal to the inguinal fold, avoiding the saphenous vein (usually identified with an ultrasound scan). The fragment is mobilized, debrided, and then reduced with use of a microfracture awl or a large Kirschner wire (used as a joystick). Following reduction, temporary fixation is performed with use of long Kirschner wires under direct visualization and fluoroscopic guidance. If reduction is satisfactory, definitive fixation can be performed with use of 4.5-mm headless screws through the medial portal. All steps of fragment reduction and fixation are performed through the medial portal, with the patient in the figure-4 position. Once the screws are placed, a final dynamic arthroscopic and fluoroscopic check is performed.</p><p><strong>Alternatives: </strong>In Pipkin type-I fractures, surgery is recommended when the femoral head fragment is large (exceeding 15% to 20% of the femoral head volume) and displaced (by >3 mm). In such cases, if untreated, spontaneous evolution to osteoarthritis may occur. For fragments smaller than 10% to 15% of the femoral head volume, arthroscopic removal is often the best choice<sup>2</sup>. Several approaches (e.g., Smith-Petersen, modified Hueter, Kocher-Langenbeck, and surgical safe dislocation) have been proposed for reduction and fixation, with surgical safe dislocation being the most versatile because of the uniquely complete visualization of the femoral head<sup>3</sup>.</p><p><strong>Rationale: </strong>The arthroscopic reduction and fixation technique for a non-comminuted Pipkin type-I fracture holds the intrinsic advantages of being less invasive than open surgery in terms of surgical exposure, and having less blood loss, infection risks, and wound complications. Arthroscopy allows direct visualization of the fragment and its reduction surface, along with removal of articular loose bodies and debridement. The surgical time is influenced by the surgeon's experience, but often is no longer than with an open procedure. In the few studies assessing the use of this technique, the rates of osteonecrosis and heterotopic ossification are lower than with open techniques. It is worth noting that the studies assessing the use o","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-05-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11104723/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141077161","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 : 2024-03-21eCollection Date: 2024-01-01DOI: 10.2106/JBJS.ST.23.00004
Colin J Harrington, Gunel Guliyeva, Joel L Mayerson, Benjamin K Potter, Jonathan A Forsberg, Jason M Souza
<p><strong>Background: </strong>For patients with transfemoral amputations and difficulty tolerating conventional socket-based prostheses, osseointegrated (OI) implants have enabled increased prosthetic use, improved patient satisfaction, and shown promising functional outcomes<sup>1,2</sup>. Although the use of OI implants effectively eliminates the soft-tissue-related challenges that have plagued socket-based prostheses, the presence of a permanent, percutaneous implant imparts a host of new soft-tissue challenges that have yet to be fully defined. In patients undergoing OI surgery who have redundant soft tissue, we perform a thighplasty to globally reduce excess skin and fat, tighten the soft-tissue envelope, and improve the contour of the residual limb.</p><p><strong>Description: </strong>First, the orthopaedic surgical team prepares the residual femur for implantation of the OI device. After the implant is inserted, the residual hamstrings and quadriceps musculature are closed over the end of the femur, and the subcutaneous tissue and skin are closed in a layered fashion. Although the anatomic location and amount of excess soft tissue are patient-dependent, we perform a standard pinch test to determine the amount of soft tissue that can be safely removed for the thighplasty. Once the proposed area of resection is marked, we proceed with longitudinal, sharp dissection down to the level of the muscular fascia. At this point, we use another pinch test to confirm the amount of soft-tissue resection that will allow for adequate resection without undue tension<sup>3</sup>. Excess subcutaneous fat and skin are carefully removed along the previously marked incisions, typically overlying the medial compartment of the thigh in the setting of patients with transfemoral amputations. The thighplasty incision is closed in a layered fashion over 1 or 2 Jackson-Pratt drains, depending on the amount of resection.</p><p><strong>Alternatives: </strong>Depending on the amount of redundant soft tissue, thighplasty may not be necessary at the time of OI surgery; however, in our experience, excess soft tissue surrounding the transcutaneous aperture can predispose the patient to increased shear forces at the aperture, increased drainage, and increased risk of infection<sup>4</sup>.</p><p><strong>Rationale: </strong>Although superficial infectious complications are most common following OI surgery, the need for soft-tissue refashioning and excision is one of the most common reasons for reoperation<sup>1,5</sup>. Our group has been more aggressive than most in our use of a vertical thighplasty procedure to globally reduce soft-tissue motion in the residual limb to avoid reoperation.</p><p><strong>Expected outcomes: </strong>Although much of the OI literature has focused on infectious complications, recent studies have demonstrated reoperation rates of 18% to 36% for redundant soft tissue following OI surgery<sup>1,5</sup>. We believe that thighplasty at the time of O
背景：对于经股截肢且难以耐受传统插座式假体的患者来说，骨结合（OI）植入物可增加假体的使用率，提高患者满意度，并显示出良好的功能效果1,2。虽然骨结合种植体的使用有效地消除了困扰承插座式假体的与软组织相关的难题，但永久性、经皮种植体的存在也带来了一系列新的软组织难题，这些难题尚未完全明确。在接受 OI 手术的患者中，如果有多余的软组织，我们会对其进行大腿成形术，从整体上减少多余的皮肤和脂肪，收紧软组织包膜，改善残肢的轮廓：首先，矫形外科团队为植入 OI 装置准备残余股骨。植入后，在股骨末端闭合残余腘绳肌和股四头肌，并分层闭合皮下组织和皮肤。虽然多余软组织的解剖位置和数量取决于患者的情况，但我们会进行标准的捏拿试验，以确定大腿成形术可以安全切除的软组织数量。一旦标记了拟议的切除区域，我们就会进行纵向、锐利的剥离，直至肌肉筋膜水平。此时，我们会使用另一个捏合试验来确认软组织的切除量，以便在不产生过度张力的情况下进行充分切除3。沿着之前标记好的切口仔细切除多余的皮下脂肪和皮肤，对于经股截肢的患者，通常是切除大腿内侧的皮下脂肪和皮肤。根据切除量，大腿成形术切口将在 1 或 2 个 Jackson-Pratt 引流管上分层缝合：根据多余软组织的数量，在进行 OI 手术时可能不需要进行大腿成形术；但是，根据我们的经验，经皮孔径周围多余的软组织可能会导致患者孔径处的剪切力增加、引流增加以及感染风险增加4：理由：虽然经皮孔镜手术后最常见的是表皮感染并发症，但需要进行软组织修整和切除也是再次手术最常见的原因之一1,5。我们小组比大多数小组更积极地采用垂直大腿成形术，以全面减少残肢的软组织运动，从而避免再次手术：虽然大部分关于开放性损伤的文献都侧重于感染并发症，但最近的研究表明，开放性损伤手术后软组织冗余的再手术率为18%至36%1,5。我们认为，在进行 OI 时进行大腿成形术不仅能降低再次手术的可能性，还能通过减少皮肤-植入物界面的相对运动和炎症来减少感染性并发症4,6：我们在大腿成形术前和整个过程中都会进行确认性捏压测试，以确保在没有过度张力的情况下进行充分切除。大腿成形术的切除模式采用长垂直肢体，旨在减少残肢周缘的松弛。最大张力由垂直肢体承担，而不是横向延伸肢体，因为横向延伸肢体容易导致疤痕扩大和周围组织变形：OI=骨结合OPRA=用于截肢者康复的骨结合假体PVNS=色素沉着性绒毛结节性滑膜炎T-GCT=腱鞘巨细胞瘤BMI=体重指数PMH=既往病史。
{"title":"Thighplasty at the Time of Stage-1 Bone-Anchored Osseointegration Surgery.","authors":"Colin J Harrington, Gunel Guliyeva, Joel L Mayerson, Benjamin K Potter, Jonathan A Forsberg, Jason M Souza","doi":"10.2106/JBJS.ST.23.00004","DOIUrl":"10.2106/JBJS.ST.23.00004","url":null,"abstract":"<p><strong>Background: </strong>For patients with transfemoral amputations and difficulty tolerating conventional socket-based prostheses, osseointegrated (OI) implants have enabled increased prosthetic use, improved patient satisfaction, and shown promising functional outcomes<sup>1,2</sup>. Although the use of OI implants effectively eliminates the soft-tissue-related challenges that have plagued socket-based prostheses, the presence of a permanent, percutaneous implant imparts a host of new soft-tissue challenges that have yet to be fully defined. In patients undergoing OI surgery who have redundant soft tissue, we perform a thighplasty to globally reduce excess skin and fat, tighten the soft-tissue envelope, and improve the contour of the residual limb.</p><p><strong>Description: </strong>First, the orthopaedic surgical team prepares the residual femur for implantation of the OI device. After the implant is inserted, the residual hamstrings and quadriceps musculature are closed over the end of the femur, and the subcutaneous tissue and skin are closed in a layered fashion. Although the anatomic location and amount of excess soft tissue are patient-dependent, we perform a standard pinch test to determine the amount of soft tissue that can be safely removed for the thighplasty. Once the proposed area of resection is marked, we proceed with longitudinal, sharp dissection down to the level of the muscular fascia. At this point, we use another pinch test to confirm the amount of soft-tissue resection that will allow for adequate resection without undue tension<sup>3</sup>. Excess subcutaneous fat and skin are carefully removed along the previously marked incisions, typically overlying the medial compartment of the thigh in the setting of patients with transfemoral amputations. The thighplasty incision is closed in a layered fashion over 1 or 2 Jackson-Pratt drains, depending on the amount of resection.</p><p><strong>Alternatives: </strong>Depending on the amount of redundant soft tissue, thighplasty may not be necessary at the time of OI surgery; however, in our experience, excess soft tissue surrounding the transcutaneous aperture can predispose the patient to increased shear forces at the aperture, increased drainage, and increased risk of infection<sup>4</sup>.</p><p><strong>Rationale: </strong>Although superficial infectious complications are most common following OI surgery, the need for soft-tissue refashioning and excision is one of the most common reasons for reoperation<sup>1,5</sup>. Our group has been more aggressive than most in our use of a vertical thighplasty procedure to globally reduce soft-tissue motion in the residual limb to avoid reoperation.</p><p><strong>Expected outcomes: </strong>Although much of the OI literature has focused on infectious complications, recent studies have demonstrated reoperation rates of 18% to 36% for redundant soft tissue following OI surgery<sup>1,5</sup>. We believe that thighplasty at the time of O","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10956957/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140185874","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 : 2024-03-06eCollection Date: 2024-01-01DOI: 10.2106/JBJS.ST.23.00017
Germane Ong, Jason Shih Hoellwarth, Kevin Testworth, Munjed Al Muderis
<p><strong>Background: </strong>Transcutaneous osseointegration for amputees (TOFA) has proven to consistently, significantly improve the quality of life and mobility for the vast majority of amputees, as compared with the use of a socket prosthesis<sup>1,2</sup>. As with any implant, situations such as infection, aseptic loosening, or implant fracture can occur, which may necessitate hardware removal. Although it may eventually occur, to date no osseointegration implant has ever required removal in the setting of periprosthetic fracture. Since TOFA implants are designed to facilitate robust bone integration, removal can be challenging. Even in cases in which portions of the implant are loose, other areas of the implant may remain strongly integrated and resist removal. Further, there can be cases in which an implant fractures, leaving the residual portion of the implant in place without the interface for an extraction tool. Although the outcomes of revision osseointegration has not been the primary focus of any publication, the fact that revision can be necessary and generally succeeds in restoring similar mobility has been documented<sup>3-5</sup>. As with any hardware removal, preserving healthy tissue and avoiding iatrogenic injury are critically important. This article demonstrates several techniques to remove press-fit osseointegration implants that we have found safe and effective.</p><p><strong>Description: </strong>The procedure is performed with the patient in the supine position and with the affected extremity prepared and draped in a typical sterile fashion. The use of a tourniquet can help reduce blood loss, but it may be safer to not use a tourniquet during the portions of the procedure that create increased or prolonged bone thermal exposure, such as during reaming or drilling. If patients are clinically stable, withholding antibiotics until cultures are obtained may improve diagnostic yield. The implant removal technique should proceed from conservative to aggressive, as necessary: slap hammer, thin wire-assisted slap hammer, and extended osteotomy. Trephine reaming is discouraged because of the need for and difficulty of removing the dual cone interface portion of the implant, along with the extensive damage often caused to the surrounding bone during reaming, which can be avoided with the osteotomy technique.</p><p><strong>Alternatives: </strong>It is important to emphasize that most infections related to transcutaneous osseointegration do not require implant removal; the use of antibiotics alone or soft-tissue and/or limited bone debridement is sufficient to resolve infection in the majority of cases. If a patient has a non-infectious indication for removal (such as a loose implant) but declines surgery, activity modification with close observation may be reasonable. If a patient has an infectious indication for removal but declines surgery, very close observation must be maintained to avoid potential osteomyelitis. The use of
{"title":"Techniques to Remove Press-Fit Osseointegration Implants.","authors":"Germane Ong, Jason Shih Hoellwarth, Kevin Testworth, Munjed Al Muderis","doi":"10.2106/JBJS.ST.23.00017","DOIUrl":"10.2106/JBJS.ST.23.00017","url":null,"abstract":"<p><strong>Background: </strong>Transcutaneous osseointegration for amputees (TOFA) has proven to consistently, significantly improve the quality of life and mobility for the vast majority of amputees, as compared with the use of a socket prosthesis<sup>1,2</sup>. As with any implant, situations such as infection, aseptic loosening, or implant fracture can occur, which may necessitate hardware removal. Although it may eventually occur, to date no osseointegration implant has ever required removal in the setting of periprosthetic fracture. Since TOFA implants are designed to facilitate robust bone integration, removal can be challenging. Even in cases in which portions of the implant are loose, other areas of the implant may remain strongly integrated and resist removal. Further, there can be cases in which an implant fractures, leaving the residual portion of the implant in place without the interface for an extraction tool. Although the outcomes of revision osseointegration has not been the primary focus of any publication, the fact that revision can be necessary and generally succeeds in restoring similar mobility has been documented<sup>3-5</sup>. As with any hardware removal, preserving healthy tissue and avoiding iatrogenic injury are critically important. This article demonstrates several techniques to remove press-fit osseointegration implants that we have found safe and effective.</p><p><strong>Description: </strong>The procedure is performed with the patient in the supine position and with the affected extremity prepared and draped in a typical sterile fashion. The use of a tourniquet can help reduce blood loss, but it may be safer to not use a tourniquet during the portions of the procedure that create increased or prolonged bone thermal exposure, such as during reaming or drilling. If patients are clinically stable, withholding antibiotics until cultures are obtained may improve diagnostic yield. The implant removal technique should proceed from conservative to aggressive, as necessary: slap hammer, thin wire-assisted slap hammer, and extended osteotomy. Trephine reaming is discouraged because of the need for and difficulty of removing the dual cone interface portion of the implant, along with the extensive damage often caused to the surrounding bone during reaming, which can be avoided with the osteotomy technique.</p><p><strong>Alternatives: </strong>It is important to emphasize that most infections related to transcutaneous osseointegration do not require implant removal; the use of antibiotics alone or soft-tissue and/or limited bone debridement is sufficient to resolve infection in the majority of cases. If a patient has a non-infectious indication for removal (such as a loose implant) but declines surgery, activity modification with close observation may be reasonable. If a patient has an infectious indication for removal but declines surgery, very close observation must be maintained to avoid potential osteomyelitis. The use of ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-03-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10914227/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140050673","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>"Coronal split/overlap repair" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy.</p><p><strong>Description: </strong>The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks.</p><p><strong>Alternatives: </strong>Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap<sup>1-3</sup>. Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication<sup>4</sup>, (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened<sup>2,5-7</sup>, and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened<sup>8,9</sup>.</p><p><strong>Rationale: </strong>The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises.</p><p><strong>Expected outcomes: </strong>Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase<sup>1,3,8</sup>. Reported complications with this technique were mainly superficial infection.</p><p><strong>Important tips: </strong>Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximall
{"title":"\"Coronal Split/Overlap Repair\" Patellar Tendon Shortening in Skeletally Immature Patients.","authors":"Mohamed Kenawey, Emmanouil Morakis, Sattar Alshryda","doi":"10.2106/JBJS.ST.23.00030","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00030","url":null,"abstract":"<p><strong>Background: </strong>\"Coronal split/overlap repair\" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy.</p><p><strong>Description: </strong>The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks.</p><p><strong>Alternatives: </strong>Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap<sup>1-3</sup>. Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication<sup>4</sup>, (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened<sup>2,5-7</sup>, and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened<sup>8,9</sup>.</p><p><strong>Rationale: </strong>The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises.</p><p><strong>Expected outcomes: </strong>Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase<sup>1,3,8</sup>. Reported complications with this technique were mainly superficial infection.</p><p><strong>Important tips: </strong>Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximall","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-02-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10883634/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139975494","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 : 2024-02-23eCollection Date: 2024-01-01DOI: 10.2106/JBJS.ST.23.00012
Akio Sakamoto, Shuichi Matsuda
<p><strong>Background: </strong>Lipomas are benign and are usually located in subcutaneous tissues. Surgical excision frequently requires an incision equal to the diameter of the lipoma. However, small incisions are more cosmetically pleasing and decrease pain and/or hypoesthesia at the incision. A "fibrous structure" occurs inside the lipoma and is characterized by a low-intensity signal on T1-weighted magnetic resonance images. The "fibrous structure" is actually retaining ligaments with a normal structure that intrudes from the periphery<sup>1</sup>. Retaining ligaments are fibrous structures that are perpendicular to the skin and tether it to underlying muscle fascia.</p><p><strong>Description: </strong>The peripheral border of the tumor is marked with a surgical pen preoperatively. Under general anesthesia, a 2.5-cm (1-inch) incision is made with a surgical knife, cutting into the tumor through the capsule-like structure. Distinguishing the tumor from the overlying adipose tissue can be difficult. Use of only local anesthesia may be possible when the number of retaining ligaments is low, such as for lesions involving the upper arm. A central incision is preferred; a peripheral incision is possible but can make the procedure more difficult. Detachment of the lipoma from the retaining ligaments is performed bluntly with a finger, which allows pulling the tumor out between the retaining ligaments. We use hemostat forceps (Pean [or Kelly] forceps) to facilitate blunt dissection. Hemostat forceps are usually utilized for soft-tissue dissection and for clamping and grasping blood vessels. Prior to blunt dissection, dissection with Pean forceps can be performed over the surface of the tumor, but tearing the tumor apart can also be useful to allow subsequent finger dissection of the lipoma from the retaining ligament not only from outside but also from inside the lipoma. The released lipoma is extracted in a piecemeal fashion with Pean forceps or by squeezing the location to cause the lipoma to extrude through the incision. The retaining ligament is preserved as much as possible, but lipomas are sometimes completely trapped by the retaining ligament. In such cases, partially cutting the ligament with scissors to release the tumor can be useful during extraction. Detachment and extraction are repeated until the tumor is completely resected, which can be confirmed visually through the incision because of the resulting skin laxity. Remaining portions of a single lipoma are removed with Pean forceps. The residual lipomas may be located deep to the retaining ligament. Adequate lighting and visualization through a small incision is useful. After the skin is sutured, a Penrose drain is optional.</p><p><strong>Alternatives: </strong>The squeeze technique utilizing a small incision over the lipoma is a well-described technique for forearm or leg lipomas, but is often not successful for large lipomas, especially those in the shoulder. The squeeze technique is
{"title":"Minimally Invasive Resection of a Large Subcutaneous Lipoma: The 2.5-cm (1-inch) Method.","authors":"Akio Sakamoto, Shuichi Matsuda","doi":"10.2106/JBJS.ST.23.00012","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00012","url":null,"abstract":"<p><strong>Background: </strong>Lipomas are benign and are usually located in subcutaneous tissues. Surgical excision frequently requires an incision equal to the diameter of the lipoma. However, small incisions are more cosmetically pleasing and decrease pain and/or hypoesthesia at the incision. A \"fibrous structure\" occurs inside the lipoma and is characterized by a low-intensity signal on T1-weighted magnetic resonance images. The \"fibrous structure\" is actually retaining ligaments with a normal structure that intrudes from the periphery<sup>1</sup>. Retaining ligaments are fibrous structures that are perpendicular to the skin and tether it to underlying muscle fascia.</p><p><strong>Description: </strong>The peripheral border of the tumor is marked with a surgical pen preoperatively. Under general anesthesia, a 2.5-cm (1-inch) incision is made with a surgical knife, cutting into the tumor through the capsule-like structure. Distinguishing the tumor from the overlying adipose tissue can be difficult. Use of only local anesthesia may be possible when the number of retaining ligaments is low, such as for lesions involving the upper arm. A central incision is preferred; a peripheral incision is possible but can make the procedure more difficult. Detachment of the lipoma from the retaining ligaments is performed bluntly with a finger, which allows pulling the tumor out between the retaining ligaments. We use hemostat forceps (Pean [or Kelly] forceps) to facilitate blunt dissection. Hemostat forceps are usually utilized for soft-tissue dissection and for clamping and grasping blood vessels. Prior to blunt dissection, dissection with Pean forceps can be performed over the surface of the tumor, but tearing the tumor apart can also be useful to allow subsequent finger dissection of the lipoma from the retaining ligament not only from outside but also from inside the lipoma. The released lipoma is extracted in a piecemeal fashion with Pean forceps or by squeezing the location to cause the lipoma to extrude through the incision. The retaining ligament is preserved as much as possible, but lipomas are sometimes completely trapped by the retaining ligament. In such cases, partially cutting the ligament with scissors to release the tumor can be useful during extraction. Detachment and extraction are repeated until the tumor is completely resected, which can be confirmed visually through the incision because of the resulting skin laxity. Remaining portions of a single lipoma are removed with Pean forceps. The residual lipomas may be located deep to the retaining ligament. Adequate lighting and visualization through a small incision is useful. After the skin is sutured, a Penrose drain is optional.</p><p><strong>Alternatives: </strong>The squeeze technique utilizing a small incision over the lipoma is a well-described technique for forearm or leg lipomas, but is often not successful for large lipomas, especially those in the shoulder. The squeeze technique is","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-02-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10883633/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139973867","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 : 2024-02-12eCollection Date: 2024-01-01DOI: 10.2106/JBJS.ST.23.00048
J Terrence Jose Jerome
<p><strong>Background: </strong>The flexor pronator slide is an effective treatment option for ischemic contracture and contracture related to spastic cerebral palsy, but little is known about the use of the flexor pronator slide in other non-ischemic contractures. I propose a flexor pronator slide to simultaneously correct wrist and finger flexor contractures and preserve the muscle resting length. To avoid overcorrection of the deformity, I propose the use of a wide-awake local anesthesia with no tourniquet (WALANT) procedure, in which the patient is able to continually assist the surgeon in assessing the contracture release and improvement in finger movement. Additionally, the WALANT flexor pronator slide releases the specific muscles responsible for wrist and finger contractures (i.e., the flexor digitorum profundus, flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis, and pronator teres), sparing the intact finger functions.</p><p><strong>Description: </strong>The patient in the video received a WALANT injection of 1% lidocaine with 1:100,000 epinephrine and 8.4% sodium bicarbonate in the operating room, and surgery was started 30 minutes after the injection to obtain the maximum hemostatic effect<sup>1</sup>. The injections were performed from proximal to distal along the volar-ulnar skin markings from the distal upper arm to the distal third of the forearm. The total volume utilized in this patient was <7 mg/kg (approximately 100 mL). A 25 or 27-gauge needle was infiltrated under the skin at the medial aspect of the elbow and in the distal and proximal forearm fascia. A total of 25 to 40 mL anesthetic was injected at each site, which serves to numb the ulnar nerve. over the volar-radial and volar side of the mid-forearm and distal forearm to numb the median nerve. For the WALANT procedure, an additional 8 mg of dexamethasone was added as an adjuvant to prolong the analgesia and the duration of the nerve block. The skin incision was made over the ulnar border of the forearm, extending proximally just posterior to the medial epicondyle up to the distal third of the upper arm. The origin of the flexor carpi ulnaris was elevated first, then the flexor digitorum profundus and flexor digitorum superficialis were mobilized from the ulna and the interosseous membrane. The release continued in an ulnar-to-radial direction. The patient was awake throughout the procedure, so that the improvement in the contracture could be better assessed. Further dissection around the ulnar nerve was done to release the arcade of Struthers, the Osborne ligament, and the triceps fascia in order to prevent ulnar nerve kinking during anterior transposition. The medial epicondyle was identified, and the flexor pronator wad was released meticulously without joint capsule perforation and medial collateral ligament injury. The muscles were finally examined for contracture in full wrist and finger extension, and further release was performed if remai
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