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Bikini Incision Modification of the Direct Anterior Approach. 直接前路手术的比基尼切口改良。
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-11-13 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.23.00085
Michael Leunig, Hannes A Rüdiger
<p><strong>Background: </strong>Although the direct anterior approach (DAA) represents an intermuscular and internervous approach to total hip arthroplasty (THA), it did not reach global acceptance until its adoption by large teaching centers. Today, >50% of primary THA procedures in Switzerland are performed via the DAA. Besides being truly minimally invasive, a key advantage of the DAA is the inherent stability that it provides. A shortcoming has been that the traditional longitudinal skin incision does not follow the skin tension lines<sup>1</sup> and therefore can result in wound-healing problems, poor scar cosmesis, and damage to the lateral femoral cutaneous nerve (LFCN). In 2011, we introduced the bikini-type skin-crease incision, and we have utilized it in most of our patients since, with excellent outcomes that are equivalent to those of the traditional incision and superior scar cosmesis<sup>2</sup>. The bikini incision pertains only to the incisions made at the skin and subcutaneous tissues, which are oblique, whereas the deeper dissection beginning with the fascial sheath of the tensor fasciae latae (TFL) is still performed in the longitudinal direction. In most patients, the incision falls into the flexion crease or slightly distal to it, and today, in order to minimize direct damage to the LFCN<sup>3</sup>, the incision we perform is always lateral to the anterior superior iliac spine (ASIS)<sup>4</sup>. From January 2014 until August 2023, a total of 10,009 THA procedures were performed in our unit, with 8,769 being performed via the DAA and 4,969 of those being performed with use of the bikini incision type. The incision type was generally selected according to the experience of the surgeon, with the less-experienced surgeons utilizing classic incision techniques and the high-volume surgeons (i.e., >200 THAs per year) utilizing the bikini incision technique. The bikini incision was utilized in most straightforward cases, but it was not performed if a longitudinal incision had been utilized on the contralateral side or in technically challenging cases. The use of this incision has been adopted by others, with similarly excellent outcomes; however, there is potential for damage to the LFCN<sup>5</sup>. Several studies utilizing a bikini incision have described the incision as being made quite medial to the ASIS, potentially even crossing the medial branches of the LFCN. In contrast, over years of utilizing the bikini incision technique, our approach has evolved such that the incision is not made medial to the ASIS.</p><p><strong>Description: </strong>The bikini-type (skin-crease) incision only differs from the classic longitudinal approach used for DAA THA with respect to the skin and subcutaneous tissue. To avoid damage to the LFCN, our bikini-type incision has evolved over the last decade to being located entirely lateral to the ASIS (Video 1)<sup>3</sup>.</p><p><strong>Alternatives: </strong>The main alternative is the classic lo
重要提示根据髋关节影像学形态调整比基尼切口，切口不要太小、太远、太近，最重要的是不要太内侧，确保内侧边缘不会撕裂，限制皮下剥离，将张肌筋膜鞘深处的剥离从斜向改为纵向，注意比基尼切口的伸展性较小：ASIS=髂前上棘BMI=体重指数CCD=干骺端Caput column diaphysisDAA=直接前方入路GT=大转子LFCA=股外侧周动脉LFCN=股外侧皮神经TFL=张肌筋膜THA=全髋关节置换术OA=骨关节炎ROM=活动范围。
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引用次数: 0
Ligamentum Flavum Flap Technique in Lumbar Microdiscectomy. 腰椎显微椎间盘切除术中的韧带皮瓣技术
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-11-08 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.23.00049
Shanmuganathan Rajasekaran, Karthik Ramachandran, Rishi Mugesh Kanna, Ajoy Prasad Shetty
<p><strong>Background: </strong>Microdiscectomy has been the gold-standard technique for the treatment of lumbar disc herniation. A potential reason for suboptimal symptom resolution following microdiscectomy is postoperative epidural fibrosis<sup>1</sup>. Preservation of the ligamentum flavum through the use of the ligamentum flavum flap technique reduces postoperative epidural fibrosis and leads to a favorable long-term prognosis.</p><p><strong>Description: </strong>The L5-S1 interlaminar space on the operative side is exposed with use of a standard microsurgical approach, and the level is confirmed. The ligamentum flavum is held taut with use of tooth forceps, holding onto superficial layers, and a flap with its base on the lateral side is created. Initial separation is made at the midline (where the flavum is very thin) with use of a no.-15-blade scalpel. The flap is elevated by detaching the ligamentum flavum between the lower border of the L5 lamina and sacrum with use of a 1-mm Kerrison rongeur. The detachment of the ligamentum flavum is performed carefully, preserving the attachments on the lateral border. Having a thin base allows the flap to be elevated and rotated, and the flap thus can be tucked into the muscle above the facet joint. The nerve root is retracted, and discectomy is performed according to the location and size of the disc. After achieving good hemostasis, the ligamentum flavum flap is gently rotated back to its normal position. In most cases, the flap can be returned back to its original position without any gap and without any need for suture. Closure is performed in layers.</p><p><strong>Alternatives: </strong>Nonoperative treatment yields good pain relief in more than 80% of patients with disc herniation. However, if surgery is required, the primary concern for the surgeon is the prevention of postoperative scarring and fibrosis around the nerve root. Previous attempts to mitigate this potential complication have revolved around the placement of a subcutaneous fat graft over the nerve root; however, no firm evidence exists to support this technique. Synthetic materials such as expanded polytetrafluoroethylene, Adcon-L gel (Wright Medical Technologies), and sodium hyaluronate have also been utilized to prevent epidural scarring; however, the ligamentum flavum is a natural biological solution.</p><p><strong>Rationale: </strong>Postoperative fibrosis may occur if there is a dead space as a result of the excision of the ligamentum flavum or due to inflammation. Restoration of native tissue anatomy with use of the ligamentum flavum technique can prevent such fibrosis, as has been reported previously. In addition to reducing scar formation, preserving the ligamentum flavum can make revision surgery (which is rarely required) safer, as there is less or no epidural fibrosis or nerve root scarring.</p><p><strong>Expected outcomes: </strong>Patients undergoing this procedure have shown good improvement in the Oswestry Disabilit
背景：显微椎间盘切除术一直是治疗腰椎间盘突出症的金标准技术。显微椎间盘切除术后症状缓解不理想的一个潜在原因是术后硬膜外纤维化1。通过使用黄韧带瓣技术保留黄韧带可减少术后硬膜外纤维化，从而获得良好的长期预后：使用标准显微外科方法暴露手术侧的 L5-S1 椎间隙，并确认其水平。使用牙钳绷紧黄韧带，抓住表层，并在外侧创建一个基底皮瓣。使用 15 号手术刀在中线（黄韧带非常薄的地方）进行初步分离。使用 1 毫米的 Kerrison 打孔器，在 L5 椎板下缘和骶骨之间分离黄韧带，从而抬高皮瓣。分离黄韧带时要小心谨慎，保留侧缘的附着物。由于基底较薄，皮瓣可以被抬高和旋转，因此可以将皮瓣塞入面关节上方的肌肉中。牵开神经根，根据椎间盘的位置和大小进行椎间盘切除术。止血良好后，将黄韧带瓣轻轻旋转回正常位置。在大多数情况下，黄韧带瓣可以无缝隙地回到原来的位置，无需缝合。缝合是分层进行的：80%以上的椎间盘突出症患者都能通过非手术治疗很好地缓解疼痛。然而，如果需要手术治疗，外科医生最关心的问题是如何防止术后神经根周围出现疤痕和纤维化。以前为减轻这种潜在并发症所做的尝试主要是在神经根上放置皮下脂肪移植，但目前还没有确切的证据支持这种技术。也曾使用过膨体聚四氟乙烯、Adcon-L 凝胶（莱特医疗技术公司）和透明质酸钠等合成材料来防止硬膜外瘢痕形成；但黄韧带是一种天然的生物解决方案：理由：由于切除黄韧带或炎症造成的死腔可能会导致术后纤维化。使用黄韧带技术恢复原生组织解剖结构可防止纤维化，这在之前已有报道。除了减少疤痕形成外，保留黄韧带还能使翻修手术（很少需要）更加安全，因为硬膜外纤维化或神经根疤痕较少或没有：接受该手术的患者在术后近期和长期随访中，奥斯韦特里残疾指数（ODI）均有良好改善，视觉模拟量表（VAS）疼痛评分也有明显降低。长期随访显示，硬膜外纤维化的几率明显降低。Li等人报告称，与对照组相比，接受黄韧带瓣技术的患者的VAS和ODI评分大大降低，术后6个月硬膜外纤维化的程度也明显降低2。在一项类似的研究中，Özay 等人强调了 51 名接受黄韧带瓣技术治疗的患者临床症状明显改善，术后硬膜外纤维化的几率降低3。此外，Li 等人的研究表明，患者年龄和层间隙面积是决定黄韧带保留的两个重要因素，因为老年患者（>43.5 岁）和层间隙小的患者失败率明显更高（2）。在保留黄韧带的患者中，ODI 和 VAS 评分明显改善，通过静脉注射碘帕米多进行的计算机断层扫描（CT）评估显示，纤维化的形成明显减少4：正确设置手术显微镜和透视装置，以确保准确的起始点。在解剖的各个层面尽量少用烧灼器。使用 15 号手术刀切开黄韧带时，在浅层绷紧黄韧带。分离黄韧带时，安全地保留黄韧带外侧缘的附着物。止血后，对黄韧带进行适当的复位：ODI=奥斯韦特里残疾指数VAS=视觉模拟量表CT=计算机断层扫描LF=韧带瓣SLRT=直腿抬高试验AP=前胸MRI=磁共振成像ASIS=髂前上棘CSF=脑脊液。
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引用次数: 0
Flexible Intramedullary Nail Placement in Pediatric Humerus Fractures. 小儿肱骨骨折的灵活髓内钉置入术
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-11-08 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.23.00071
Robert W Gomez, Riley C McHugh, Dhairya Shukla, Dustin A Greenhill
<p><strong>Background: </strong>Flexible intramedullary nailing is an effective method of stabilization in pediatric patients with a humeral shaft fracture when surgery is indicated<sup>1-3</sup>. Although these fractures are most often treated nonoperatively, operative indications include open fractures, bilateral injuries, compartment syndrome, pathologic fractures, neurovascular compromise, unacceptable alignment after attempted nonoperative treatment, and ipsilateral upper-extremity injuries<sup>4</sup>. The current literature on flexible intramedullary nailing of the pediatric humeral shaft lacks concise descriptions of available entry points, which directly affect the subsequent technique, and of pertinent pediatric-specific anatomy. Thus, the present article focuses on these entry points in the pediatric patient.</p><p><strong>Description: </strong>Various entry points are available for the insertion of flexible nails into the humeral shaft. A surgeon must initially decide whether the patient and fracture characteristics are best suited for anterograde versus retrograde insertion. This choice typically depends on several fracture and patient-related characteristics. The passage of flexible intramedullary nails has been well described; thus, the present article will place special emphasis on the available proximal and distal entry points and pediatric-specific anatomy<sup>5-10</sup>. For diaphyseal fractures, we prefer dual distal lateral entry points with the nails advanced retrograde in a C-S configuration whenever possible, given the risks associated with proximal lateral entry (e.g., damage to the axillary nerve) or distal medial entry (e.g., damage to the ulnar nerve or nail prominence). A distal posterior supracondylar entry point is also possible but requires additional preoperative planning with regard to patient positioning, a more proximal entry point to avoid impingement of the olecranon on the nail in extension, and avoidance of the ulnar nerve.</p><p><strong>Alternatives: </strong>The substantial potential for remodeling in pediatric patients permits nonoperative treatment of humeral fractures if specific age-related criteria for angulation and displacement are met. Generally accepted tolerances for nonoperative angulation and displacement are as follows: for patients <5 years old, ≤70° angulation and up to 100% displacement; for patients 5 to 12 years old, 40° to 70° angulation; and for patients >12 years old, ≤40° angulation and 50% apposition<sup>4</sup>.</p><p><strong>Rationale: </strong>The use of flexible nails is often preferred because of the healing potential of pediatric humeral shaft fractures, the ability of flexible nails to tolerate nonrigid fixation until osseous bridging occurs, the ability of the surgeon to avoid exposure of neurologic structures during surgery, and the benefit of avoiding physeal disruption. These factors make flexible nails a favorable option when compared with plate osteosynthesis or rigid i
背景：在有手术指征的情况下，灵活髓内钉是稳定肱骨轴骨折儿科患者病情的有效方法1-3。虽然这些骨折多采用非手术治疗，但手术指征包括开放性骨折、双侧损伤、室间隔综合征、病理性骨折、神经血管受损、尝试非手术治疗后对位不佳以及同侧上肢损伤4。目前关于小儿肱骨轴柔性髓内钉的文献缺乏对可用进钉点的简明描述，而这些进钉点直接影响到后续技术，同时也缺乏对相关小儿特定解剖结构的描述。因此，本文将重点介绍儿科患者的这些入钉点：将软钉插入肱骨骨干有多种切入点可供选择。外科医生必须首先决定患者和骨折特征最适合前向插入还是后向插入。这一选择通常取决于多个骨折和患者相关特征。对柔性髓内钉的通过方法已有详细描述；因此，本文将特别强调可用的近端和远端进入点以及儿科特有的解剖结构5-10。对于骺端骨折，考虑到近端外侧入路（如损伤腋神经）或远端内侧入路（如损伤尺神经或钢钉突出）的风险，我们倾向于双远端外侧入路点，尽可能以 C-S 配置逆行推进钢钉。髁上远端入路点也是可行的，但需要额外的术前规划，包括患者体位、更近端入路点以避免伸展时骨髁撞击钉子，以及避开尺神经：如果符合与年龄相关的特定成角和移位标准，儿童患者的重塑潜力很大，因此可以对肱骨骨折进行非手术治疗。理由：由于小儿肱骨干骨折具有愈合潜力，柔性钢钉在骨桥形成之前能够耐受非刚性固定，外科医生在手术过程中能够避免暴露神经结构，以及避免骨膜破坏的好处，因此使用柔性钢钉通常是首选。与钢板骨合成术或刚性髓内钉相比，这些因素使柔性钉成为一种有利的选择：在适用情况下，使用柔性髓内钉治疗小儿肱骨骨折具有较高的愈合率、良好的功能效果、早期活动范围以及可接受的较低并发症发生率2：重要提示：熟悉所有可用进钉点的相关技术细节，避免损伤肱骨近端和远端周围的关键神经结构，尽量减少出现无症状硬件的机会，通过在骨折部位灵活定位钉子来优化生物力学：FIN = 弹性髓内钉EBL = 估计失血量f/u = 随访IM = 髓内MRI = 磁共振成像OR = 手术室PT = 物理治疗ROM = 活动范围。
{"title":"Flexible Intramedullary Nail Placement in Pediatric Humerus Fractures.","authors":"Robert W Gomez, Riley C McHugh, Dhairya Shukla, Dustin A Greenhill","doi":"10.2106/JBJS.ST.23.00071","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00071","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Flexible intramedullary nailing is an effective method of stabilization in pediatric patients with a humeral shaft fracture when surgery is indicated&lt;sup&gt;1-3&lt;/sup&gt;. Although these fractures are most often treated nonoperatively, operative indications include open fractures, bilateral injuries, compartment syndrome, pathologic fractures, neurovascular compromise, unacceptable alignment after attempted nonoperative treatment, and ipsilateral upper-extremity injuries&lt;sup&gt;4&lt;/sup&gt;. The current literature on flexible intramedullary nailing of the pediatric humeral shaft lacks concise descriptions of available entry points, which directly affect the subsequent technique, and of pertinent pediatric-specific anatomy. Thus, the present article focuses on these entry points in the pediatric patient.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Various entry points are available for the insertion of flexible nails into the humeral shaft. A surgeon must initially decide whether the patient and fracture characteristics are best suited for anterograde versus retrograde insertion. This choice typically depends on several fracture and patient-related characteristics. The passage of flexible intramedullary nails has been well described; thus, the present article will place special emphasis on the available proximal and distal entry points and pediatric-specific anatomy&lt;sup&gt;5-10&lt;/sup&gt;. For diaphyseal fractures, we prefer dual distal lateral entry points with the nails advanced retrograde in a C-S configuration whenever possible, given the risks associated with proximal lateral entry (e.g., damage to the axillary nerve) or distal medial entry (e.g., damage to the ulnar nerve or nail prominence). A distal posterior supracondylar entry point is also possible but requires additional preoperative planning with regard to patient positioning, a more proximal entry point to avoid impingement of the olecranon on the nail in extension, and avoidance of the ulnar nerve.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;The substantial potential for remodeling in pediatric patients permits nonoperative treatment of humeral fractures if specific age-related criteria for angulation and displacement are met. Generally accepted tolerances for nonoperative angulation and displacement are as follows: for patients &lt;5 years old, ≤70° angulation and up to 100% displacement; for patients 5 to 12 years old, 40° to 70° angulation; and for patients &gt;12 years old, ≤40° angulation and 50% apposition&lt;sup&gt;4&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;The use of flexible nails is often preferred because of the healing potential of pediatric humeral shaft fractures, the ability of flexible nails to tolerate nonrigid fixation until osseous bridging occurs, the ability of the surgeon to avoid exposure of neurologic structures during surgery, and the benefit of avoiding physeal disruption. These factors make flexible nails a favorable option when compared with plate osteosynthesis or rigid i","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543153/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630258","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Surgery for Pediatric Trigger Finger. 小儿扳机指手术。
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-11-08 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.23.00064
Scott H Kozin, Eugene Park, Dan A Zlotolow
<p><strong>Background: </strong>Pediatric trigger finger (PTF) is an uncommon condition that is 10 times less common than trigger thumb. The Quinnell grade is utilized to quantify the extent of the triggering on a 4-point scale (0 = normal movement, 1 = uneven movement, 2 = actively correctable triggering, 3 = passively correctable triggering, and 4 = fixed deformity)<sup>1</sup>. Less extensive triggering can be treated nonoperatively with use of monitoring or splinting; however, the reported resolution rates are low, with only 30% of PTF cases treated nonoperatively achieving complete resolution<sup>1</sup>. Splinting has also been shown to not improve resolution rates in pediatric cases treated nonoperatively. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit<sup>2,3</sup>. Overall, PTF has been shown to have significantly higher rates of resolution when treated operatively (97.1%) versus nonoperatively (30.0%)<sup>2</sup>. PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single flexor digitorum superficialis (FDS) tendon slip. PTF treated with this technique predictably results in resolution with restoration of motion. The present video article demonstrates the surgical treatment of a 7-year-old with a locked right ring finger.</p><p><strong>Description: </strong>Operative steps include (1) general anesthesia, (2) tourniquet control, (3) loupe magnification, (4) neurovascular identification, (5) A3 and A1 pulley release, (6) excision of the ulnar slip of the FDS, (7) and simple closure.</p><p><strong>Alternatives: </strong>The primary alternative to this procedure is nonoperative treatment with continued monitoring and/or splinting.</p><p><strong>Rationale: </strong>PTF differs from pediatric trigger thumb. Simple release of the A1 pulley may not resolve the triggering, requiring additional excision of the ulnar slip of the FDS.</p><p><strong>Expected outcomes: </strong>Jia et al. reported that only 30% of nonoperatively treated cases of PTF achieved complete resolution, and splinting did not improve resolution rates<sup>3</sup>. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit. Overall, operatively treated PTF showed significantly higher rates of complete resolution compared with nonoperatively treated PTF (97.1% compared with 30.0%, respectively)<sup>3</sup>. Additionally, Cardon et al. reported residual triggering in 44% (8) of 18 cases of PTF treated with isolated A1 pulley release<sup>2</sup>. Bae et al. reported a 91% success rate (21 of 23) when PTFs were treated uniformly with A1 pulley release combined with FDS slip excision<sup>1</sup>. We conclude that PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single FDS tendon slip.</p><p><strong>Important tips: </strong>General anesthesia will limit
背景：小儿扳机指（PTF）是一种不常见的疾病，其发病率比扳机拇指低 10 倍。奎内尔分级法（Quinnell grade）用于量化扳机指的程度，分为 4 级（0 = 活动正常，1 = 活动不均，2 = 可主动矫正的扳机指，3 = 可被动矫正的扳机指，4 = 固定畸形）1。范围较小的触发可通过监测或夹板进行非手术治疗；但报告的缓解率较低，仅有 30% 的 PTF 病例通过非手术治疗达到完全缓解1。在非手术治疗的儿童病例中，夹板治疗也无法提高缓解率。相比之下，手术干预极有可能恢复患肢的运动和功能2,3。总体而言，PTF 手术治疗（97.1%）的治愈率明显高于非手术治疗（30.0%）2。通过手术松解 A1 滑轮并切除单个屈指浅肌（FDS）肌腱滑脱，可以安全、可预测地治疗 PTF。采用这种技术治疗 PTF 后，可预测患者的病情将得到缓解，并恢复运动功能。本视频文章展示了对一名右手无名指锁定的 7 岁儿童的手术治疗：手术步骤包括：（1）全身麻醉；（2）止血带控制；（3）放大镜放大；（4）神经血管识别；（5）A3 和 A1 滑轮松解；（6）切除 FDS 尺侧滑脱；（7）简单闭合：该手术的主要替代方法是持续监测和/或夹板固定的非手术治疗：PTF不同于小儿扳机拇指。原因：PTF 不同于小儿扳机拇指，单纯松解 A1 滑轮可能无法解决扳机问题，需要额外切除 FDS 的尺侧滑脱：预期结果：Jia 等人报告称，在非手术治疗的 PTF 病例中，仅有 30% 的病例可完全治愈，夹板治疗并不能提高治愈率3。相比之下，手术干预极有可能恢复患肢的运动和功能。总体而言，手术治疗的 PTF 完全缓解率明显高于非手术治疗的 PTF（分别为 97.1%和 30.0%）3。此外，Cardon 等人报告称，在 18 例采用孤立 A1 滑轮松解术治疗的 PTF 病例中，44%（8 例）的病例存在残余触发2。Bae 等人报告称，A1 滑轮松解联合 FDS 滑脱切除术治疗 PTF 的成功率为 91%（23 例中有 21 例）1。我们的结论是，通过手术松解 A1 滑轮并切除单个 FDS 肌腱滑脱，可以安全、可预测地治疗 PTF：重要提示：全身麻醉将限制患者的意外移动，使手术更安全。识别神经血管束，防止意外损伤：FDP = 指屈肌深层FDS = 指屈肌浅层DIP = 指间关节远端。
{"title":"Surgery for Pediatric Trigger Finger.","authors":"Scott H Kozin, Eugene Park, Dan A Zlotolow","doi":"10.2106/JBJS.ST.23.00064","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00064","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Pediatric trigger finger (PTF) is an uncommon condition that is 10 times less common than trigger thumb. The Quinnell grade is utilized to quantify the extent of the triggering on a 4-point scale (0 = normal movement, 1 = uneven movement, 2 = actively correctable triggering, 3 = passively correctable triggering, and 4 = fixed deformity)&lt;sup&gt;1&lt;/sup&gt;. Less extensive triggering can be treated nonoperatively with use of monitoring or splinting; however, the reported resolution rates are low, with only 30% of PTF cases treated nonoperatively achieving complete resolution&lt;sup&gt;1&lt;/sup&gt;. Splinting has also been shown to not improve resolution rates in pediatric cases treated nonoperatively. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit&lt;sup&gt;2,3&lt;/sup&gt;. Overall, PTF has been shown to have significantly higher rates of resolution when treated operatively (97.1%) versus nonoperatively (30.0%)&lt;sup&gt;2&lt;/sup&gt;. PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single flexor digitorum superficialis (FDS) tendon slip. PTF treated with this technique predictably results in resolution with restoration of motion. The present video article demonstrates the surgical treatment of a 7-year-old with a locked right ring finger.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Operative steps include (1) general anesthesia, (2) tourniquet control, (3) loupe magnification, (4) neurovascular identification, (5) A3 and A1 pulley release, (6) excision of the ulnar slip of the FDS, (7) and simple closure.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;The primary alternative to this procedure is nonoperative treatment with continued monitoring and/or splinting.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;PTF differs from pediatric trigger thumb. Simple release of the A1 pulley may not resolve the triggering, requiring additional excision of the ulnar slip of the FDS.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Expected outcomes: &lt;/strong&gt;Jia et al. reported that only 30% of nonoperatively treated cases of PTF achieved complete resolution, and splinting did not improve resolution rates&lt;sup&gt;3&lt;/sup&gt;. In contrast, operative intervention has a high likelihood of restoring motion and function of the affected digit. Overall, operatively treated PTF showed significantly higher rates of complete resolution compared with nonoperatively treated PTF (97.1% compared with 30.0%, respectively)&lt;sup&gt;3&lt;/sup&gt;. Additionally, Cardon et al. reported residual triggering in 44% (8) of 18 cases of PTF treated with isolated A1 pulley release&lt;sup&gt;2&lt;/sup&gt;. Bae et al. reported a 91% success rate (21 of 23) when PTFs were treated uniformly with A1 pulley release combined with FDS slip excision&lt;sup&gt;1&lt;/sup&gt;. We conclude that PTF may be safely and predictably treated with use of operative release of the A1 pulley and resection of a single FDS tendon slip.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Important tips: &lt;/strong&gt;General anesthesia will limit","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543148/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630261","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Revision of Press-Fit Bone-Anchored Prosthesis After Implant Failure. 植入失败后的压合骨锚定假体翻修。
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-10-24 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.23.00005
Jan Paul Frölke, Robin Atallah

Background: The present video article describes the revision of a bone-anchored prosthesis in patients who received an osseointegration implant after transfemoral amputation. Clinical follow-up studies have shown that approximately 5% of all patients who receive press-fit cobalt-chromium alloy femoral implants experience failure of the intramedullary stem component as a result of septic loosening or stem breakage. For stem breakage, stem diameter and the occurrence of infectious events were identified as risk factors. We began regularly utilizing the standard German press-fit endo-exo cast cobalt-chrome implant in 2009, but changed to the forged titanium version in 2014 (BADAL X, OTN Implants) because of the breakages associated with the former implant. No breakages have been reported since making the switch, and as such we currently still utilize the titanium implant. Current Commission Européenne-certified bone-anchored implants for transfemoral amputation include a screw-type stem and a press-fit stem. The revision technique demonstrated in the present article may apply to both types of implant system, but this video is limited to demonstrating the use of a press-fit implant. We describe the 3 stages of debridement, removal, and subsequent implantation of a bone-anchored prosthesis in a revision setting.

Description: We perform this procedure in up to 3 stages, with 10 to 12 weeks between removal of the failed implant and implantation of the revision prosthesis. For stage 1, in case of mechanical failure, the broken remnants of the implant, which may dangle in the soft tissues, are removed. The stoma is debrided, after which spontaneous stoma healing is achieved. In cases of septic loosening, stage 1 includes removal of the implant by retrograde hammering, followed by multiple debridements with flexible reamers and jet lavage until negative cultures are obtained. In stage 2, the broken osseointegration implant is removed with use of a custom-made titanium water-cooled hollow drill. With the use of this drill, we have always been successful in removing the broken implant while maintaining sufficient bone stock for future implant revision. If the corer fails, a larger approach is needed to remove the implant. The corer drill should have a wall that is as thin but as robust as possible in order to avoid cortical perforation, and should be manufactured from a strong material in order to resist the usage against the implant. We utilized a steel corer when initially performing this procedure, which was frequently unsuccessful, necessitating a larger approach to remove the implant. We currently utilize a 3D-printed corer drill with integrated water-cooling system with greater success (Xilloc Medical). This corer is custom-made and needs about 6 weeks for designing and manufacturing. This tool is utilized in the present video article. Stage 3 includes revision implantation of an osseointegration prosthesis, u

如果骨量不足，在计划翻修植入骨固定假体时，应为将来的骨植入做好准备：OI = 骨整合种植体BAP = 骨固定假体BIG = 骨植入移植。
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引用次数: 0
Extensor Tendon Repair. 伸肌腱修复
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-10-22 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.23.00082
Varun Arvind, Daniel Y Hong, Robert J Strauch
<p><strong>Background: </strong>Extensor tendon injuries are a common condition that hand surgeons must be prepared to treat. The area of extensor tendon injury can traditionally be broken down into 9 zones. Physical examination is the best way to diagnose extensor tendon injury with a loss of active extension in the injured digit. The tenodesis effect may be utilized to aid in diagnosis: wrist flexion should cause passive extension at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints if the extensor tendon is in continuity.</p><p><strong>Description: </strong>Repair of extensor tendon injuries depends on the zone of injury and the thickness of the tendon, which determines its ability to hold core sutures. For zone-I and II injuries, several "figure of 8" buried sutures can be utilized or a running type of suture may be employed. For zone-III to VII injuries, 1 or 2 core sutures and a supplementary running suture can be utilized.</p><p><strong>Alternatives: </strong>Several alternative techniques have been previously described. These include variations in the number of core strands, repair configuration, and suture caliber, as well as the use of epitendinous repair. Alternative treatments also include nonoperative treatment, which is typically reserved for partial tendon injuries and for patients who are unable to tolerate a surgical procedure.</p><p><strong>Rationale: </strong>The techniques that we describe are tailored to the thickness of the tendon. Running sutures are applicable to any zone, whereas core sutures are best utilized in zones III through VII. The running interlocking horizontal mattress technique has been found to be stiffer and faster to accomplish compared with the other techniques, and was found to have good to excellent clinical results in a study of lacerations in zones IV and V<sup>1,2</sup>.</p><p><strong>Expected outcomes: </strong>Repair of extensor tendon lacerations has demonstrated good long-term outcomes if performed in a timely manner after injury. A previous study showed good to excellent function in up to 64% of acute extensor tendon repairs, more fingers lost the ability to flex fully than lost the ability to extend<sup>3</sup>. Systematic reviews have suggested that dynamic rehabilitation may not provide superior long-term benefit compared with static splinting<sup>4</sup>.</p><p><strong>Important tips: </strong>The Elson test should be performed under a digital nerve block in order to properly assess the integrity of the central slip.In distal zone I and III injuries, suture anchors or bone tunnels may be utilized when there is no remaining tendon on the distal end of the laceration.When preparing the tendon ends for repair, it is important to handle the tendon delicately-preferably through the cut end of the tendon rather than the tendon itself.In zone-VII injuries, the injured tendon may lie beneath the extensor retinaculum. In such cases, windowing of the extensor retinacu
背景：伸肌腱损伤是手外科医生必须做好治疗准备的常见疾病。传统上，伸肌腱损伤部位可分为 9 个区域。体格检查是诊断伸肌腱损伤的最佳方法，受伤的手指会失去主动伸展能力。可以利用腱鞘效应来帮助诊断：如果伸肌腱处于连续状态，则手腕屈曲应导致掌指关节、近端指间关节和远端指间关节被动伸展：伸肌腱损伤的修复取决于损伤区和肌腱的厚度，这决定了肌腱固定核心缝合线的能力。对于第一区和第二区的损伤，可采用数个 "8 "字形埋线法，也可采用流水线式缝合。对于 III 区至 VII 区的损伤，可使用 1 或 2 条核心缝合线和一条辅助缝合线：以前曾介绍过几种替代技术。替代方法：以前曾介绍过几种替代技术，包括核心股线数量、修复结构和缝合口径的变化，以及表腱修复的使用。替代治疗方法还包括非手术治疗，通常用于部分肌腱损伤和不能耐受手术治疗的患者。运行缝合适用于任何区域，而核心缝合最好用于第三至第七区域。在一项关于 IV 区和 V1,2 区撕裂伤的研究中，我们发现跑步交错水平床垫技术比其他技术更坚硬、更快完成，而且临床效果良好至极佳：预期结果：如果在受伤后及时进行伸肌腱裂伤修复，长期效果良好。之前的一项研究显示，高达 64% 的急性伸肌腱修复术后功能良好或极佳，丧失完全屈曲能力的手指多于丧失伸展能力的手指3。系统性综述表明，与静态夹板相比，动态康复可能不会带来更好的长期益处4：在 I 区和 III 区远端损伤中，如果裂伤远端没有剩余肌腱，则可使用缝合锚或骨隧道。在准备肌腱末端修复时，必须小心处理肌腱，最好是通过肌腱的切端而不是肌腱本身。在这种情况下，伸肌网开窗可减少粘连的形成并促进修复：MCP=掌指关节PIP=近端指间关节DIP=远端指间关节IP=指间关节ROM=运动范围RMS=相对运动夹板RIHM=跑步交锁水平床垫。
{"title":"Extensor Tendon Repair.","authors":"Varun Arvind, Daniel Y Hong, Robert J Strauch","doi":"10.2106/JBJS.ST.23.00082","DOIUrl":"https://doi.org/10.2106/JBJS.ST.23.00082","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Extensor tendon injuries are a common condition that hand surgeons must be prepared to treat. The area of extensor tendon injury can traditionally be broken down into 9 zones. Physical examination is the best way to diagnose extensor tendon injury with a loss of active extension in the injured digit. The tenodesis effect may be utilized to aid in diagnosis: wrist flexion should cause passive extension at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints if the extensor tendon is in continuity.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Repair of extensor tendon injuries depends on the zone of injury and the thickness of the tendon, which determines its ability to hold core sutures. For zone-I and II injuries, several \"figure of 8\" buried sutures can be utilized or a running type of suture may be employed. For zone-III to VII injuries, 1 or 2 core sutures and a supplementary running suture can be utilized.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;Several alternative techniques have been previously described. These include variations in the number of core strands, repair configuration, and suture caliber, as well as the use of epitendinous repair. Alternative treatments also include nonoperative treatment, which is typically reserved for partial tendon injuries and for patients who are unable to tolerate a surgical procedure.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;The techniques that we describe are tailored to the thickness of the tendon. Running sutures are applicable to any zone, whereas core sutures are best utilized in zones III through VII. The running interlocking horizontal mattress technique has been found to be stiffer and faster to accomplish compared with the other techniques, and was found to have good to excellent clinical results in a study of lacerations in zones IV and V&lt;sup&gt;1,2&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Expected outcomes: &lt;/strong&gt;Repair of extensor tendon lacerations has demonstrated good long-term outcomes if performed in a timely manner after injury. A previous study showed good to excellent function in up to 64% of acute extensor tendon repairs, more fingers lost the ability to flex fully than lost the ability to extend&lt;sup&gt;3&lt;/sup&gt;. Systematic reviews have suggested that dynamic rehabilitation may not provide superior long-term benefit compared with static splinting&lt;sup&gt;4&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Important tips: &lt;/strong&gt;The Elson test should be performed under a digital nerve block in order to properly assess the integrity of the central slip.In distal zone I and III injuries, suture anchors or bone tunnels may be utilized when there is no remaining tendon on the distal end of the laceration.When preparing the tendon ends for repair, it is important to handle the tendon delicately-preferably through the cut end of the tendon rather than the tendon itself.In zone-VII injuries, the injured tendon may lie beneath the extensor retinaculum. In such cases, windowing of the extensor retinacu","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11495684/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142510020","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Shortening Dome Osteotomy for the Correction of Coronal Plane Elbow Deformities. 缩短穹隆截骨术矫正肘关节冠状面畸形
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-10-22 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.23.00014
Sumit Arora, Prajwal Gupta, Shahrukh Khan, Rahul Garg, Anant Krishna, Abhishek Kashyap

Background: Severe elbow deformities are common in developing countries because of neglect or as a result of prior treatment that achieved poor reduction. Various osteotomy techniques have been defined for the surgical correction of elbow deformities1-9. However, severe elbow deformities (>30°) pose a substantial challenge for surgeons because limited surgical options with high complication rates have been described in the literature. Shortening dome osteotomy is a useful method of correcting moderate-to-severe deformities and offers all of the advantages of previously described dome osteotomy without causing an undue stretching of neurovascular structures8,9.

Description: The anesthetized patient is placed in a lateral decubitus position under tourniquet control with the operative limb up, the elbow in 90° of flexion, and the forearm draped free to hang over a bolster kept between the chest and the forearm. A posterior midline approach is utilized, with the incision extending from 6 cm proximal to the tip of the olecranon to 2 cm distal. The ulnar nerve is identified and protected during the entire surgical procedure. In case of severe (>30°) and long-standing cubitus varus deformity, anterior transposition of the ulnar nerve is additionally performed to prevent nerve stretching after the deformity correction. A midline triceps-splitting approach is utilized along with subperiosteal dissection to expose the metaphyseodiaphyseal region of the distal humerus. Alternatively, the operating surgeon may choose to utilize a triceps-sparing approach. Hohmann retractors are placed at the medial and lateral aspects of distal humerus to protect the anterior neurovascular structures. Careful extraperiosteal dissection and a transverse incision over the anterior periosteum are performed to facilitate rotation of the distal fragment, as the anterior periosteum is usually thickened in cases of long-standing deformities. The posterior midline axis of the humerus is marked on the skin. The dome of the olecranon fossa is identified, and the distal osteotomy line is made just proximal and almost parallel to the dome. The proximal osteotomy line is made parallel and 5 to 8 mm proximal to the distal osteotomy line, as any further larger shortening may affect the muscle length-tension relationship. The posterior cortices of both domes and of the medial and lateral supracondylar ridges are osteotomized with use of an ultrasonic bone scalpel (Misonix), which was set at 70% amplitude control and 80% irrigation control. Alternatively, the osteotomy may be made by making multiple drill holes and connecting them with a 5-mm sharp osteotome or with use of a small-blade oscillating saw. The osteotomy of the anterior cortex is completed under direct vision with use of a Kerrison upcutting rongeur, after the subperiosteal separation of bone in order to protect the surrounding soft tissues. Kirschner wires are ins

缩短穹隆截骨术具有传统穹隆截骨术的所有优点，同时还能降低神经血管束的张力8,9：理由：切除一块同心弯曲的骨片可让外科医生更轻松、更精确地矫正严重畸形，同时不会对尺神经造成任何过度拉伸。由于肱骨远端自然外翻，近端穹隆（凹）的表面积小于远端穹隆（凸）的表面积。畸形矫正包括远端碎片的额外内侧平移，以防止髁外侧突出：辛格等人8对18名平均年龄为7.5岁（5岁至11岁）的患者进行了研究，结果显示，平均尺肱骨角度从术前的26.1°外翻（范围为22°至34°）改善到术后的7.3°内翻（范围为2°至12°）（P < 0.001）。平均髁突外侧突出指数术前为-2.4°（范围为+4.7°至-10.5°），术后为-1.7°（范围为+4.5°至-5.1°）（P = 0.595）。所有患者在平均 7.1 周（范围：5 至 9 周）时均观察到放射学愈合。所有患者均在术后 6 个月内恢复到术前的肘关节活动范围：重要提示：确定肩胛窝的穹顶，并在穹顶的近端和平行于穹顶的位置进行远端截骨。在皮肤上标记肱骨后中线轴线，因为在此标记处测量位移有助于评估矫正的程度。使用超声骨刀对两个穹隆的后皮质进行截骨。在骨膜下分离骨质以保护周围软组织后，在直视下使用 Kerrison 上切钻完成前部皮质的截骨。由于长期畸形的病例前部骨膜通常会增厚，因此要仔细进行骨膜外剥离并在前部骨膜上进行横向切口，以方便旋转远端片段：K 线 = Kirschner 线。
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引用次数: 0
Cementless Reverse Shoulder Arthroplasty Technique to Maximize Press-Fit Fixation with Humeral Matchstick Bone Grafts. 用肱骨火柴棒骨移植物最大限度地进行压合固定的无水泥反向肩关节成形术。
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-10-03 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.23.00062
Alvin Ouseph, Eddie Y Lo, Paolo Montemaggi, Sumant G Krishnan
<p><strong>Background: </strong>Cementless reverse shoulder arthroplasty has become increasingly popular because of the improved implant design, porous ingrowth surface, and surgical techniques. When avoiding the risks of cement use, a press-fit arthroplasty stem that has been implanted may not feel immediately stable, especially if the medullary canal size is in between standard stem diameters. To help surgeons improve fixation and avoid overstuffing the medullary canal, we present the matchstick autograft augmentation technique. The use of humeral autograft, analogous to impaction grafting in hip arthroplasty, has been reported to have promising short-term outcomes<sup>2,3</sup>. This technique of using humeral autograft material, dubbed matchstick autografts because of their shape and size, allows for optimization of humeral stem stability with the option of smaller cementless humeral implants. By avoiding overstuffing of the medullary canal, this technique aims to reduce the incidences of intraoperative fracture, postoperative stress shielding, and potential implant loosening<sup>4-6</sup>.</p><p><strong>Description: </strong>Cementless reverse total shoulder arthroplasty is routinely performed via the anterosuperior approach<sup>7</sup>; however, a deltopectoral approach can be utilized if desired. The canal is sequentially broached with implant trials until the tactile feedback demonstrates axial and rotational stability. In cases in which tactile feedback during implantation demonstrates slight movement, the smaller implant size can be selected and augmented with matchstick autograft. An oscillating saw is utilized to cut the edges of the previously resected humeral head in order to expose the subchondral bone surface. Graft sticks about 20 mm in length and 1 to 3 mm in width are then fashioned. Humeral trials are then implanted with the matchstick grafts placed lengthwise alongside the humeral stem. Axial and rotational press-fit is again assessed. If adequate, the formal humeral implant is selected and implanted in position. As in conventional impaction grafting, the grafts are compressed to the side of the humeral canal, but they offer more corticocancellous structure than bone chips. This technique is applicable even in some fracture scenarios.</p><p><strong>Alternatives: </strong>When a specific press-fit humeral stem size does not achieve adequate stability, there are typically 3 surgical alternatives. First, a larger stem size can be selected. Second, the implant can be inserted deeper to achieve press-fit stability. Third, cement can be added to fill the medullary canal and create immediate stability.</p><p><strong>Rationale: </strong>When implanting the humeral prosthesis, the operating surgeon's primary goal is stem stability. When faced with lack of stability, the surgeon can select a larger humeral stem, risking stress shielding; implant the stem deeper, compromising length and risking humeral fracture; or consider a cemented i
背景：由于植入物设计、多孔植入表面和手术技术的改进，无骨水泥反向肩关节成形术越来越受欢迎。在避免使用骨水泥的风险时，已植入的压入式关节成形术柄可能不会立即感觉稳定，尤其是当髓管大小介于标准柄直径之间时。为了帮助外科医生改善固定，避免髓质管过度膨胀，我们提出了火柴棒自体移植物增量技术。肱骨自体移植物的使用类似于髋关节置换术中的撞击移植，据报道具有良好的短期效果2,3。这种使用肱骨自体移植物材料的技术因其形状和大小而被称为 "火柴棍 "自体移植物，可优化肱骨柄的稳定性，并可选择较小的无骨水泥肱骨植入物。通过避免髓质管过度充盈，该技术旨在减少术中骨折、术后应力屏蔽和潜在植入物松动的发生率4-6：无骨反向全肩关节置换术通常采用前上方入路7，但如果需要，也可采用胸骨下入路。在进行植入试验时，按顺序对管道进行扩孔，直到触觉反馈显示轴向和旋转稳定性。如果在植入过程中触觉反馈显示有轻微的移动，则可以选择较小的植入体，并用火柴杆自体移植物进行增量。使用摆动锯切割先前切除的肱骨头边缘，以暴露软骨下骨表面。然后制作长约20毫米、宽1至3毫米的移植棒。然后将火柴棒移植物纵向放置在肱骨干旁，进行肱骨试验植入。再次评估轴向和旋转压力配合情况。如果合适，则选择正式的肱骨假体并将其植入到位。与传统的撞击移植术一样，移植物会被压缩到肱骨管的一侧，但与骨片相比，它们能提供更多的皮质冠状结构。这种技术甚至适用于某些骨折情况：当特定的压入式肱骨柄尺寸无法达到足够的稳定性时，通常有三种手术替代方案。首先，可以选择更大尺寸的茎干。第二，将植入物插入更深的位置，以达到压入配合的稳定性。第三，可以添加骨水泥来填充髓质管，以获得即时稳定性：理由：在植入肱骨假体时，手术医生的首要目标是假体柄的稳定性。当缺乏稳定性时，外科医生可以选择更大的肱骨柄，冒着应力屏蔽的风险；将柄植入更深的位置，影响长度并冒着肱骨骨折的风险；或者考虑骨水泥植入。为了将术中心肺事件和后续复杂翻修手术的风险降至最低8，应尽可能避免使用骨水泥。肩部外科医生曾报道过类似于髋关节撞击移植的移植技术，并取得了良好的效果3。我们介绍的技术采用了火柴棍结构的自体移植物，有助于改善初次肱骨植入病例中的无骨水泥固定，并允许使用较小的骨干。该移植物的结构形状使得该技术甚至可用于选定的肱骨近端骨折：其他研究报告称，在肩关节置换术中使用较软的松质骨自体移植物来稳定肱骨植入物。Lucas 等人对至少随访 2 年的 286 例关节置换术进行了研究，结果表明 267 例（93.3%）肱骨柄未发生下沉3。Humphrey 和 Bravman 使用松质骨自体移植物使 53 例患者的肱骨组件达到骺端中心，12 个月后无一例肱骨假体松动2。Lo等人在使用火柴棒自体移植物增强的无骨水泥反向全肩关节置换术中，91%的结节愈合1，无一例无菌性肱骨柄松动。Montemaggi等人使用火柴棒自体移植物增强了46例初次无骨水泥反向全肩关节置换术，在1年的随访中未发现肱骨松动病例9：重要提示：最坚固的肱骨火柴棒移植物来自软骨下表面。根据外科医生的偏好，可以选择较硬或较软的移植物。外科医生可以尝试用肱骨试验冲击移植物，以便在最终植入前评估骨干的稳定性：RTSA=反向全肩关节置换术FX=骨折3D CT=三维计算机断层扫描XR=X射线FU=随访。
{"title":"Cementless Reverse Shoulder Arthroplasty Technique to Maximize Press-Fit Fixation with Humeral Matchstick Bone Grafts.","authors":"Alvin Ouseph, Eddie Y Lo, Paolo Montemaggi, Sumant G Krishnan","doi":"10.2106/JBJS.ST.23.00062","DOIUrl":"10.2106/JBJS.ST.23.00062","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Cementless reverse shoulder arthroplasty has become increasingly popular because of the improved implant design, porous ingrowth surface, and surgical techniques. When avoiding the risks of cement use, a press-fit arthroplasty stem that has been implanted may not feel immediately stable, especially if the medullary canal size is in between standard stem diameters. To help surgeons improve fixation and avoid overstuffing the medullary canal, we present the matchstick autograft augmentation technique. The use of humeral autograft, analogous to impaction grafting in hip arthroplasty, has been reported to have promising short-term outcomes&lt;sup&gt;2,3&lt;/sup&gt;. This technique of using humeral autograft material, dubbed matchstick autografts because of their shape and size, allows for optimization of humeral stem stability with the option of smaller cementless humeral implants. By avoiding overstuffing of the medullary canal, this technique aims to reduce the incidences of intraoperative fracture, postoperative stress shielding, and potential implant loosening&lt;sup&gt;4-6&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;Cementless reverse total shoulder arthroplasty is routinely performed via the anterosuperior approach&lt;sup&gt;7&lt;/sup&gt;; however, a deltopectoral approach can be utilized if desired. The canal is sequentially broached with implant trials until the tactile feedback demonstrates axial and rotational stability. In cases in which tactile feedback during implantation demonstrates slight movement, the smaller implant size can be selected and augmented with matchstick autograft. An oscillating saw is utilized to cut the edges of the previously resected humeral head in order to expose the subchondral bone surface. Graft sticks about 20 mm in length and 1 to 3 mm in width are then fashioned. Humeral trials are then implanted with the matchstick grafts placed lengthwise alongside the humeral stem. Axial and rotational press-fit is again assessed. If adequate, the formal humeral implant is selected and implanted in position. As in conventional impaction grafting, the grafts are compressed to the side of the humeral canal, but they offer more corticocancellous structure than bone chips. This technique is applicable even in some fracture scenarios.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alternatives: &lt;/strong&gt;When a specific press-fit humeral stem size does not achieve adequate stability, there are typically 3 surgical alternatives. First, a larger stem size can be selected. Second, the implant can be inserted deeper to achieve press-fit stability. Third, cement can be added to fill the medullary canal and create immediate stability.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Rationale: &lt;/strong&gt;When implanting the humeral prosthesis, the operating surgeon's primary goal is stem stability. When faced with lack of stability, the surgeon can select a larger humeral stem, risking stress shielding; implant the stem deeper, compromising length and risking humeral fracture; or consider a cemented i","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 4","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11444585/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142374017","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}
引用次数: 0
Anchorless Arthroscopic Transosseous Rotator Cuff Repair. 无锚关节镜经骨肩袖修复术
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-10-03 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.23.00046
Eddie Y Lo, Alvin Ouseph, Raffaele Garofalo, Sumant G Krishnan

Background: Rotator cuff repair techniques have evolved over time. The original techniques were open procedures, then surgeons adopted arthroscopic repair procedures with anchors and implants. Today, rotator cuff repair has evolved to be performed as an arthroscopic transosseous technique that is again performed without the use of anchors.

Description: In this video, the 5 essential steps of arthroscopic transosseous repair will be demonstrated. (1) Position the patient in either the beach chair or lateral decubitus position. (2) Utilize 4-portal arthroscopy, which allows a consistent vantage point while having 3 other portals for instrumentation. (3) Perform just enough bursectomy to expose the rotator cuff. (4) Anatomically reduce the rotator cuff anatomy where possible. (5) Triple-load the transosseous tunnels with high-strength sutures in order to maximize the biomechanical strength of the repair.

Alternatives: Alternative surgical techniques include open rotator cuff repair and single and double-row rotator cuff repair using anchors.

Rationale: The goal of any rotator cuff repair is to anatomically restore the rotator cuff. The fundamental principles include a strong initial biomechanical fixation, cuff footprint anatomy restoration, and maximization of biological factors to promote healing of the rotator cuff. Rotator cuff repair was originally performed as an open procedure, which allows for direct visualization of the tear and repair; however, open repair requires some level of deltoid splitting, which can potentially affect postoperative early mobilization. Single-row and double-row cuff repairs can both be performed arthroscopically. Proponents of the double-row procedure prefer that technique for its footprint restoration and stronger biomechanical fixation; however, the double-row procedure can result in overtensioning of the repair and can lead to medial-based rotator cuff failures. Proponents of the single-row procedure prefer that technique for its ease of operation, fewer implants, lower cost, and low repair tension; however, the single-row procedure fixes the tendon at a single point, limiting the repaired footprint, and can be associated with lower fixation strength. The arthroscopic transosseous rotator cuff repair achieves all of the above goals as it provides strong initial fixation and anatomic footprint restoration, which allows maximal patient biology for healing.

Expected outcomes: There are numerous studies that can attest to the success of arthroscopic transosseous repair. Some of the benefits include decreased health-care costs and postoperative pain levels. In a 2016 study of 109 patients undergoing arthroscopic transosseous rotator cuff repair, Flanagin et al. reported a mean American Shoulder and Elbow Surgeons (ASES) score of 95 and a failure rate of 3.7% at mid-term follow-up1. Similarly, in a

背景：随着时间的推移，肩袖修复技术也在不断发展。最初的技术是开放式手术，后来外科医生采用了带锚和植入物的关节镜修复术。如今，肩袖修复术已发展成为一种关节镜下的经骨技术，同样无需使用固定器：本视频将演示关节镜下经骨修复的 5 个基本步骤。(1) 让患者取沙滩椅位或侧卧位。(2) 利用 4 个关节镜孔，这样就能获得一致的视点，同时有另外 3 个孔来进行器械操作。(3) 切除足够的瘤体，以暴露肩袖。(4) 尽可能缩小肩袖解剖结构。(5) 用高强度缝合线对经骨隧道进行三重加载，以最大限度地提高修复的生物力学强度：理由：任何肩袖修复术的目标都是在解剖学上恢复肩袖。基本原则包括强有力的初始生物力学固定、肩袖足底解剖恢复以及最大限度地利用生物因素促进肩袖愈合。肩袖修复术最初是以开放式手术的形式进行的，这样可以直接观察撕裂和修复情况；但是，开放式修复需要一定程度的三角肌分割，这可能会影响术后早期活动。单排和双排肩袖修复术均可在关节镜下进行。双排手术的支持者更倾向于这种技术，因为它可以恢复足底和更强的生物力学固定；但是，双排手术可能会导致修复过度拉伸，并可能导致以内侧为基础的肩袖损伤。单排手术的支持者更倾向于这种技术，因为它操作简单、植入物少、成本低、修复张力小；但是，单排手术将肌腱固定在一个点上，限制了修复后的足印，而且固定强度可能较低。关节镜下经骨关节肩袖修复术实现了上述所有目标，因为它提供了强有力的初始固定和解剖学足迹恢复，从而最大限度地保证了患者的生物学愈合：许多研究都证明了关节镜下经骨修复术的成功。其中一些益处包括降低了医疗成本和术后疼痛程度。Flanagin 等人在 2016 年对 109 名接受关节镜下经骨肩袖修复术的患者进行了研究，结果表明美国肩肘外科医生（ASES）的平均评分为 95 分，中期随访的失败率为 3.7%1。同样，Srikumaran 等人在一项比较经骨膜修复与经骨膜等效修复的研究中指出，接受经骨膜修复的患者平均 ASES 得分为 92 分，失败率为 14%，治疗组之间无明显差异2。最后，Plachel 等人在一项评估术后超过 10 年的关节镜下经骨肩袖修复术效果的研究中报告，ASES 平均分为 92 分，失败率为 27%3 ：与传统的带锚肩袖修复术相比，经骨肩袖修复术可能会导致修复缝线从骨中切断。使用四孔关节镜技术，这将有助于外科医生在进行器械操作时观察到所有的撕裂构型。用宽骨桥准备经骨隧道，在每个隧道内加载 3 条高强度缝线，以最大限度地提高修复强度。恢复肩袖足迹，以促进组织愈合：ASES = 美国肩肘外科医生RCR = 肩袖修复术ATRCR = 关节镜下经骨肩袖修复术ARCR = 关节镜下肩袖修复术PDS = 聚二氧酮缝线ROM = 活动范围SSV = 主观肩关节值FFF = 前屈OR = 手术室FU = 随访。
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引用次数: 0
Inside-Out Repair of Medial Meniscal Ramp Lesions in Patients Undergoing Anterior Cruciate Ligament Reconstruction. 前十字韧带重建术患者内侧半月板斜坡损伤的内-外侧修复术
IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques
Pub Date : 2024-10-03 eCollection Date: 2024-10-01 DOI: 10.2106/JBJS.ST.22.00037
Jay Moran, Christopher M LaPrade, Robert F LaPrade
<p><strong>Background: </strong>Medial meniscal ramp lesions are disruptions at the meniscocapsular junction and/or meniscotibial attachment of the posterior horn of the medial meniscus, and occur in up to 42% of all acute anterior cruciate ligament (ACL) tears<sup>1,3-5</sup>. Ramp lesions are frequently missed because of the limited diagnostic sensitivity of magnetic resonance imaging (MRI), physical examination, and standard anterior compartment arthroscopic exploration<sup>4,6,7</sup>. Arthroscopic evaluation of ramp lesions often requires a modified Gillquist maneuver and/or a posteromedial accessory portal for adequate assessment of the posteromedial "blind spot."<sup>4,8-10</sup> Clinically, ramp lesions are associated with increased preoperative anterior knee instability, which may increase the risk of ACL graft failure if left untreated<sup>6,13</sup>. Although long-term comparative data on ramp-repair techniques are limited, proper arthroscopic assessment and treatment is recommended for all patients with ramp lesions at the time of ACL reconstruction (ACLR)<sup>1-5</sup>. In the present video article, we demonstrate a systematic approach for the identification and assessment of ramp lesions and describe a mini-open inside-out arthroscopically assisted repair technique for unstable ramp lesions at the time of ACLR.</p><p><strong>Description: </strong>(1) The patient is placed in the supine position, and a contralateral leg holder is utilized to create more working room on the medial side. (2) Standard diagnostic arthroscopy is performed through anteromedial and anterolateral portals. (3) Next, with the arthroscope in the anterolateral portal, the scope is advanced through the intercondylar notch with the knee in 30° of flexion in order to inspect the posterior horn of the medial meniscus. Probing is directed both over the superior aspect of the posterior horn to assess for tears, separation, and/or displacement of the meniscocapsular junction, and under the inferior aspect of the posterior horn to assess the integrity of the meniscotibial attachment. (4) After confirmation of a ramp tear, an open dissection is carried out through the sartorial fascia, with blunt dissection performed anterior to the medial gastrocnemius and above the semimembranosus to create the posteromedial surgical site. (5) A suture-shuttling device is utilized, and the corresponding cannula is placed into the anterolateral portal and directed toward the tear under arthroscopic visualization from the anteromedial portal. (6) Next, the first needle is passed through the meniscus, and the second is delivered through the adjacent capsule to create a vertical or oblique suture pattern. The needles are retrieved from the posteromedial surgical site and promptly cut, and the sutures are tied. (7) Multiple sutures, both above (femoral) and below (tibial) the meniscus, are placed 3 to 5 mm apart in a similar fashion. (8) On completion of the repair, the meniscocapsular junc
背景：内侧半月板斜坡病变是指内侧半月板后角的半月板与半月板交界处和/或半月板与胫骨连接处的破坏，在所有急性前交叉韧带（ACL）撕裂中发生率高达42%1,3-5。由于磁共振成像（MRI）、体格检查和标准前室关节镜探查的诊断灵敏度有限，斜坡病变经常被漏诊4,6,7。斜坡病变的关节镜评估通常需要改良的 Gillquist 手法和/或后内侧辅助入口，以充分评估后内侧 "盲点 "4,8-10。在临床上，斜坡病变与术前膝关节前部不稳定性增加有关，如果不及时处理，可能会增加前交叉韧带移植失败的风险6,13。虽然斜坡修复技术的长期比较数据有限，但我们建议在进行前交叉韧带重建（ACLR）时对所有斜坡病变患者进行适当的关节镜评估和治疗1-5。在本视频文章中，我们展示了一种识别和评估斜坡病变的系统方法，并介绍了一种针对前交叉韧带重建时不稳定斜坡病变的小开腹内固定关节镜辅助修复技术。(2）通过前内侧和前外侧切口进行标准的关节镜诊断。(3）接下来，将关节镜置于前外侧切口，在膝关节屈曲 30° 的情况下，将镜头经髁间切迹推进，以检查内侧半月板后角。探查方向既包括后角的上侧，以评估半月板与髋臼交界处是否有撕裂、分离和/或移位，也包括后角的下侧，以评估半月板与胫骨连接处的完整性。(4) 在确认斜坡撕裂后，通过滑膜筋膜进行开放式剥离，在内侧腓肠肌前方和半膜肌上方进行钝性剥离，以创建后内侧手术部位。(5)使用缝合器，将相应的套管放入前外侧入口，在关节镜下从前内侧入口指向撕裂处。(6) 接下来，第一根针穿过半月板，第二根针穿过邻近的关节囊，形成垂直或斜向缝合模式。从后内侧手术部位取回针头，迅速剪断并缝合。(7) 以类似方式在半月板上方（股骨）和下方（胫骨）进行多处缝合，缝合间距为 3 至 5 毫米。(8)修复完成后，探查半月板与髋臼交界处，以确认半月板是否足够稳定，内侧半月板的移位是否最小：在前交叉韧带撕裂的情况下，同时修复不稳定斜坡损伤的手术方案包括全内侧、内-外侧或混合技术（即外-内侧、内-内侧和/或全内侧）：理由：采用内向外技术修复斜坡病变可恢复术前膝关节过度不稳，从而降低前交叉韧带移植失败的风险。此外，据报道由内向外斜坡修复术的二次半月板切除率较低（2%），在缝合的数量和位置上具有灵活性，并可形成更牢固的修复；然而，与其他修复技术相比，该手术在技术上更具挑战性6,10。据报道，全内侧斜坡修复术的二次半月板切除率较高，从 11% 到 31% 不等，原因是无法从前方入口修复半月板胫腓韧带13,14。使用后内侧入口的缝合钩修复术越来越受欢迎，据报道，与全内侧技术相比，其二次半月板切除率明显较低（19% 比 30.6%）15：在至少 2 年的随访中，DePhillipo 等人报告称，与接受单独 ACLR 的匹配队列（n = 50）相比，接受联合 ACLR 加斜坡病损由内向外修复的患者（n = 50）的临床疗效和重返运动场的情况相似。虽然前交叉韧带重建加斜坡病变修复组与孤立前交叉韧带重建组相比，术前膝关节不稳定性明显增加，但在平均 2.8 年（2 至 8 年）的随访中，两组患者术后不稳定性没有差异6：重要提示：后内侧外部切口应通过内侧间室的内向外透视和使用关节内探针在关节内侧进行触诊，以避免隐静脉损伤10。
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