Pub Date : 2024-01-05eCollection Date: 2024-01-01DOI: 10.2106/JBJS.ST.23.00029
Fenneken Laura Ten Hove, Pieter Bas de Witte, Monique Reijnierse, Ana Navas
<p><strong>Background: </strong>Rotator cuff calcific tendinitis (RCCT) is a commonly occurring disease, with a prevalence of up to 42.5% in patients with shoulder pain<sup>1,2</sup>. RCCT is characterized by hydroxyapatite deposits in the tendons of the rotator cuff and is considered a self-limiting disease that can be treated nonoperatively<sup>3</sup>. However, in a substantial group of patients, RCCT can have a very disabling and long-lasting course<sup>1,4</sup>, requiring additional treatment. Ultrasound-guided percutaneous needling and lavage (i.e., barbotage) is a safe and effective treatment option for RCCT<sup>5</sup>. In the present article, we focus on the 1-needle barbotage technique utilized in combination with an injection of corticosteroids in the subacromial bursa.</p><p><strong>Description: </strong>It must be emphasized that symptomatic RCCT should be confirmed before barbotage is performed. Therefore, we recommend a diagnostic ultrasound and/or physical examination prior to the barbotage. Barbotage is performed under ultrasound guidance with the patient in the supine position. After sterile preparation and localization of the calcified deposit(s), local anesthesia in the soft tissue (10 mL lidocaine 1%) is administered. Next, the subacromial bursa is injected with 4 mL bupivacaine (5 mg/mL) and 1 mL methylprednisolone (40 mg/mL) with use of a 21G needle. The deposit(s) are then punctured with use of an 18G needle. When the tip of the needle is in the center of the deposit(s), they are flushed with a 0.9% saline solution and the dissolved calcium re-enters the syringe passively. This process is repeated several times until no more calcium enters the syringe. In the case of solid deposits, it may not be possible to aspirate calcium; if so, an attempt to fragment the deposits by repeated perforations, and thus promote resorption, can be made. Postoperatively, patients are instructed to take analgesics and to cool the shoulder.</p><p><strong>Alternatives: </strong>RCTT can initially be treated nonoperatively with rest, nonsteroidal anti-inflammatory drugs, and/or physiotherapy<sup>3</sup>. If the initial nonoperative treatment fails, extracorporeal shockwave therapy (ESWT), corticosteroid injections, and/or barbotage can be considered<sup>8</sup>. In severe chronic recalcitrant cases, arthroscopic debridement and/or removal can be performed as a last resort.</p><p><strong>Rationale: </strong>Both barbotage and ESWT result in a reduction of calcific deposits, as well as significant pain reduction and improvement of function<sup>8</sup>. No standard of care has been established until now; however, several prior meta-analyses concluded that barbotage is the most effective treatment option, with superior clinical outcomes after 1 to 2 years of follow-up<sup>9-11</sup>. No difference in complication rates has been reported between the various minimally invasive techniques. The purpose of barbotage is to stimulate the resorption process
{"title":"Needling and Lavage in Rotator Cuff Calcific Tendinitis: Ultrasound-Guided Technique.","authors":"Fenneken Laura Ten Hove, Pieter Bas de Witte, Monique Reijnierse, Ana Navas","doi":"10.2106/JBJS.ST.23.00029","DOIUrl":"10.2106/JBJS.ST.23.00029","url":null,"abstract":"<p><strong>Background: </strong>Rotator cuff calcific tendinitis (RCCT) is a commonly occurring disease, with a prevalence of up to 42.5% in patients with shoulder pain<sup>1,2</sup>. RCCT is characterized by hydroxyapatite deposits in the tendons of the rotator cuff and is considered a self-limiting disease that can be treated nonoperatively<sup>3</sup>. However, in a substantial group of patients, RCCT can have a very disabling and long-lasting course<sup>1,4</sup>, requiring additional treatment. Ultrasound-guided percutaneous needling and lavage (i.e., barbotage) is a safe and effective treatment option for RCCT<sup>5</sup>. In the present article, we focus on the 1-needle barbotage technique utilized in combination with an injection of corticosteroids in the subacromial bursa.</p><p><strong>Description: </strong>It must be emphasized that symptomatic RCCT should be confirmed before barbotage is performed. Therefore, we recommend a diagnostic ultrasound and/or physical examination prior to the barbotage. Barbotage is performed under ultrasound guidance with the patient in the supine position. After sterile preparation and localization of the calcified deposit(s), local anesthesia in the soft tissue (10 mL lidocaine 1%) is administered. Next, the subacromial bursa is injected with 4 mL bupivacaine (5 mg/mL) and 1 mL methylprednisolone (40 mg/mL) with use of a 21G needle. The deposit(s) are then punctured with use of an 18G needle. When the tip of the needle is in the center of the deposit(s), they are flushed with a 0.9% saline solution and the dissolved calcium re-enters the syringe passively. This process is repeated several times until no more calcium enters the syringe. In the case of solid deposits, it may not be possible to aspirate calcium; if so, an attempt to fragment the deposits by repeated perforations, and thus promote resorption, can be made. Postoperatively, patients are instructed to take analgesics and to cool the shoulder.</p><p><strong>Alternatives: </strong>RCTT can initially be treated nonoperatively with rest, nonsteroidal anti-inflammatory drugs, and/or physiotherapy<sup>3</sup>. If the initial nonoperative treatment fails, extracorporeal shockwave therapy (ESWT), corticosteroid injections, and/or barbotage can be considered<sup>8</sup>. In severe chronic recalcitrant cases, arthroscopic debridement and/or removal can be performed as a last resort.</p><p><strong>Rationale: </strong>Both barbotage and ESWT result in a reduction of calcific deposits, as well as significant pain reduction and improvement of function<sup>8</sup>. No standard of care has been established until now; however, several prior meta-analyses concluded that barbotage is the most effective treatment option, with superior clinical outcomes after 1 to 2 years of follow-up<sup>9-11</sup>. No difference in complication rates has been reported between the various minimally invasive techniques. The purpose of barbotage is to stimulate the resorption process","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10805427/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139548258","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 : 2024-01-05eCollection Date: 2024-01-01DOI: 10.2106/JBJS.ST.22.00021
Alexandra Flaherty, Jie Chen
<p><strong>Background: </strong>The minimally invasive chevron Akin osteotomy technique is indicated for the treatment of symptomatic mild to moderate hallux valgus deformities. The aim of the procedure is to restore alignment of the first ray while minimizing soft-tissue disruption.</p><p><strong>Description: </strong>Prior to the procedure, radiographs are utilized to characterize the patient's hallux valgus deformity by determining the hallux valgus angle and intermetatarsal angle. The metatarsal rotation is also assessed via the lateral round sign and sesamoid view. To begin, a stab incision is made over the lateral aspect of the first metatarsophalangeal (MTP) joint and a lateral release is completed by percutaneous fenestration of the lateral capsule. Next, the chevron osteotomy of the first metatarsal is performed. To begin this step, a Kirschner wire is inserted in an anterograde fashion from the medial base of the first metatarsal to the lateral aspect of the metatarsal neck. The wire is then withdrawn just proximal to the osteotomy site. A stab incision is made at the medial aspect of the metatarsal neck, and periosteal elevation is utilized for soft-tissue dissection. A minimally invasive burr is utilized to complete the osteotomy cuts. With the osteotomy complete, the first metatarsal translator is utilized to lever the metatarsal head laterally. Once satisfactory alignment has been achieved, the Kirschner wire is advanced into the metatarsal head. A cannulated depth gauge is utilized to measure the length of the screw. The near cortex is drilled, and the screw is inserted over the Kirschner wire, which is then removed. The next step is the Akin osteotomy of the proximal phalanx. Again, a Kirschner wire is placed in an anterograde fashion from the medial base of the proximal phalanx to the lateral neck. The Kirschner wire is then withdrawn until the tip is just proximal to the osteotomy site. A stab incision is made over the medial aspect of the proximal phalangeal neck, and periosteal elevation is carried out. The burr is utilized to complete the osteotomy; however, care is taken not to cut the far cortex. The great toe is then rotated medially, collapsing on the osteotomy site and hinging on the intact far cortex. When satisfactory alignment has been achieved, the Kirschner wire is advanced across the osteotomy and far cortex. A cannulated depth gauge is utilized to measure the length of the screw, and the wire is then driven through the lateral skin and clamped. The near cortex is drilled, the cannulated screw is inserted, and the Kirschner wire is then removed. Final fluoroscopy is performed to assess adequate correction, alignment, and hardware placement. The stab incisions are closed with use of simple interrupted 3-0 nylon. A tongue-depressor bunion dressing is applied. The patient is discharged to home with this dressing, as well as with an offloading postoperative shoe.</p><p><strong>Alternatives: </strong>Surgical alternativ
{"title":"Minimally Invasive Chevron Akin Osteotomy for Hallux Valgus Correction.","authors":"Alexandra Flaherty, Jie Chen","doi":"10.2106/JBJS.ST.22.00021","DOIUrl":"10.2106/JBJS.ST.22.00021","url":null,"abstract":"<p><strong>Background: </strong>The minimally invasive chevron Akin osteotomy technique is indicated for the treatment of symptomatic mild to moderate hallux valgus deformities. The aim of the procedure is to restore alignment of the first ray while minimizing soft-tissue disruption.</p><p><strong>Description: </strong>Prior to the procedure, radiographs are utilized to characterize the patient's hallux valgus deformity by determining the hallux valgus angle and intermetatarsal angle. The metatarsal rotation is also assessed via the lateral round sign and sesamoid view. To begin, a stab incision is made over the lateral aspect of the first metatarsophalangeal (MTP) joint and a lateral release is completed by percutaneous fenestration of the lateral capsule. Next, the chevron osteotomy of the first metatarsal is performed. To begin this step, a Kirschner wire is inserted in an anterograde fashion from the medial base of the first metatarsal to the lateral aspect of the metatarsal neck. The wire is then withdrawn just proximal to the osteotomy site. A stab incision is made at the medial aspect of the metatarsal neck, and periosteal elevation is utilized for soft-tissue dissection. A minimally invasive burr is utilized to complete the osteotomy cuts. With the osteotomy complete, the first metatarsal translator is utilized to lever the metatarsal head laterally. Once satisfactory alignment has been achieved, the Kirschner wire is advanced into the metatarsal head. A cannulated depth gauge is utilized to measure the length of the screw. The near cortex is drilled, and the screw is inserted over the Kirschner wire, which is then removed. The next step is the Akin osteotomy of the proximal phalanx. Again, a Kirschner wire is placed in an anterograde fashion from the medial base of the proximal phalanx to the lateral neck. The Kirschner wire is then withdrawn until the tip is just proximal to the osteotomy site. A stab incision is made over the medial aspect of the proximal phalangeal neck, and periosteal elevation is carried out. The burr is utilized to complete the osteotomy; however, care is taken not to cut the far cortex. The great toe is then rotated medially, collapsing on the osteotomy site and hinging on the intact far cortex. When satisfactory alignment has been achieved, the Kirschner wire is advanced across the osteotomy and far cortex. A cannulated depth gauge is utilized to measure the length of the screw, and the wire is then driven through the lateral skin and clamped. The near cortex is drilled, the cannulated screw is inserted, and the Kirschner wire is then removed. Final fluoroscopy is performed to assess adequate correction, alignment, and hardware placement. The stab incisions are closed with use of simple interrupted 3-0 nylon. A tongue-depressor bunion dressing is applied. The patient is discharged to home with this dressing, as well as with an offloading postoperative shoe.</p><p><strong>Alternatives: </strong>Surgical alternativ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10805425/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139548257","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 : 2023-11-29eCollection Date: 2023-10-01DOI: 10.2106/JBJS.ST.23.00031
William Newton, Dane Daley, Charles Daly
<p><strong>Background: </strong>The all-dorsal scapholunate reconstruction technique is indicated for the treatment of scapholunate injuries in cases in which the carpus is reducible and there is no arthrosis present. The goal of this procedure is to reconstruct the torn dorsal portion of the scapholunate ligament in order to stabilize the scaphoid and lunate.</p><p><strong>Description: </strong>A standard dorsal approach to the wrist, extending from the third metacarpal distally to the distal radioulnar joint, is utilized. The extensor pollicis longus is transposed and retracted radially, and the second and fourth extensor compartments are retracted ulnarly. A Berger ligament-sparing capsulotomy is utilized to visualize the carpus. Volarly, an extended open carpal tunnel release is also utilized to relieve any median nerve compression and to aid in reduction. The contents of the carpal tunnel can be retracted radially, allowing for visualization of the carpal bones. Joystick pins are placed in order to reduce the scaphoid and lunate. Reduction is held provisionally by clamping the pins until 4 pins can be placed across the carpal bones. For scapholunate reconstruction, 3 holes are made: in the lunate, proximal scaphoid, and distal scaphoid. Suture tape is then utilized to hold the scaphoid and lunate in their proper position. The dorsal wrist capsule and extensor retinaculum are repaired during closure. The pins are cut near the skin and are removed in 8 to 12 weeks.</p><p><strong>Alternatives: </strong>Several other methods of scapholunate reconstruction have been described, including capsulodesis, tenodesis, and bone-tissue-bone repairs. Additionally, in patients who are poor candidates for scapholunate reconstruction, wrist-salvage procedures can be utilized as the primary treatment.</p><p><strong>Rationale: </strong>Scapholunate reconstruction has the advantage of preserving the native physiologic motion of the wrist, in contrast to the many different wrist-salvage procedures that include arthrodesis or arthroplasty. Avoiding arthrodesis is specifically advantageous in patients who have not yet developed arthrosis of the wrist bones.</p><p><strong>Expected outcomes: </strong>Outcomes of scapholunate reconstruction vary widely; however, there is a nearly universal decrease in range of motion and strength of the wrist. Wrist range of motion is typically 55% to 75% of the contralateral side, and grip strength is typically approximately 65% of the contralateral side. In a prior study, 50% to 60% of patients whose work involved physical labor were able to return to their same level of full-time work. Disabilities of the Arm, Shoulder and Hand scores average between 24 and 30. Specific patients at risk for inferior outcomes are those with delayed surgical treatment, poor carpal alignment following reduction, or open injuries.</p><p><strong>Important tips: </strong>Patients are counseled preoperatively regarding the likelihood of permanent wrist st
{"title":"Perilunate Dislocations: Reduction and Stabilization.","authors":"William Newton, Dane Daley, Charles Daly","doi":"10.2106/JBJS.ST.23.00031","DOIUrl":"10.2106/JBJS.ST.23.00031","url":null,"abstract":"<p><strong>Background: </strong>The all-dorsal scapholunate reconstruction technique is indicated for the treatment of scapholunate injuries in cases in which the carpus is reducible and there is no arthrosis present. The goal of this procedure is to reconstruct the torn dorsal portion of the scapholunate ligament in order to stabilize the scaphoid and lunate.</p><p><strong>Description: </strong>A standard dorsal approach to the wrist, extending from the third metacarpal distally to the distal radioulnar joint, is utilized. The extensor pollicis longus is transposed and retracted radially, and the second and fourth extensor compartments are retracted ulnarly. A Berger ligament-sparing capsulotomy is utilized to visualize the carpus. Volarly, an extended open carpal tunnel release is also utilized to relieve any median nerve compression and to aid in reduction. The contents of the carpal tunnel can be retracted radially, allowing for visualization of the carpal bones. Joystick pins are placed in order to reduce the scaphoid and lunate. Reduction is held provisionally by clamping the pins until 4 pins can be placed across the carpal bones. For scapholunate reconstruction, 3 holes are made: in the lunate, proximal scaphoid, and distal scaphoid. Suture tape is then utilized to hold the scaphoid and lunate in their proper position. The dorsal wrist capsule and extensor retinaculum are repaired during closure. The pins are cut near the skin and are removed in 8 to 12 weeks.</p><p><strong>Alternatives: </strong>Several other methods of scapholunate reconstruction have been described, including capsulodesis, tenodesis, and bone-tissue-bone repairs. Additionally, in patients who are poor candidates for scapholunate reconstruction, wrist-salvage procedures can be utilized as the primary treatment.</p><p><strong>Rationale: </strong>Scapholunate reconstruction has the advantage of preserving the native physiologic motion of the wrist, in contrast to the many different wrist-salvage procedures that include arthrodesis or arthroplasty. Avoiding arthrodesis is specifically advantageous in patients who have not yet developed arthrosis of the wrist bones.</p><p><strong>Expected outcomes: </strong>Outcomes of scapholunate reconstruction vary widely; however, there is a nearly universal decrease in range of motion and strength of the wrist. Wrist range of motion is typically 55% to 75% of the contralateral side, and grip strength is typically approximately 65% of the contralateral side. In a prior study, 50% to 60% of patients whose work involved physical labor were able to return to their same level of full-time work. Disabilities of the Arm, Shoulder and Hand scores average between 24 and 30. Specific patients at risk for inferior outcomes are those with delayed surgical treatment, poor carpal alignment following reduction, or open injuries.</p><p><strong>Important tips: </strong>Patients are counseled preoperatively regarding the likelihood of permanent wrist st","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10863940/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139736333","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 : 2023-11-29eCollection Date: 2023-10-01DOI: 10.2106/JBJS.ST.22.00065
Mila Scheinberg, Meghan Underwood, Matthew Sankey, Thomas Sanchez, Ashish Shah
<p><strong>Background: </strong>Painful neuromas of the foot and ankle frequently pose a treatment dilemma because of persistent pain or recurrence after resection. Primary surgical treatment of painful neuromas includes simple excision with retraction of the residual nerve ending to a less vulnerable location<sup>1-4</sup>. The use of a collagen conduit for recurrent neuromas is advantageous, particularly in areas with minimal soft-tissue coverage options, and is a technique that has shown 85% patient satisfaction regarding surgical outcomes<sup>7</sup>. Additionally, the use of a collagen conduit limits the need for deep soft-tissue dissection and reduces the morbidity typically associated with nerve burial.</p><p><strong>Description: </strong>Specific steps include appropriate physical examination, preoperative planning, and supine patient positioning. The patient is placed supine with a lower-extremity bolster under the ipsilateral extremity in order to allow improved visualization of the plantar surface of the foot. A nonsterile tourniquet is placed on the thigh. The incision site is marked out, and a longitudinal plantar incision is made until proximal healthy nerve is identified-typically approximately 1 to 2 cm, but the incision can be extended up to 6 cm. The incision is made between the metatarsals, with blunt dissection carried down to the neuroma. The neuroma is sharply excised distally through healthy nerve, and a whip stitch is placed to facilitate the collagen conduit placement. The collagen conduit is passed dorsally into the intermetatarsal space and secured to the dorsal fascia of the foot. The wound is closed with 3-0 nylon horizontal mattress sutures. Postoperatively, a soft dressing is applied to the operative extremity, and patients are advised to be non-weight-bearing for two weeks. At two weeks, patients begin partial weight-bearing with use of a boot, and physical therapy is initiated. No antibiotics are necessary, and 300 mg of gabapentin is prescribed and tapered off by the six-week follow-up visit. Follow-ups are conducted at 2, 6, 12, 24, and fifty-two weeks. It is necessary to monitor for signs and symptoms of infection, surgical complications, and neuroma recurrence during follow-up appointments.</p><p><strong>Alternatives: </strong>Simple excision of the neuroma with proximal burial into muscle or bone is a common surgical technique. However, inadequate resection of the nerve or poor surgical technique can lead to recurrent neuromas. For neuromas not responding to simple excision, other techniques have been utilized, including cauterization, chemical agents, nerve capping, and muscle or bone burial<sup>5,6</sup>. The results of these techniques have varied, and none has gained clinical superiority over the other<sup>6</sup>.</p><p><strong>Rationale: </strong>A study analyzing the use of collagen conduits for painful neuromas of the foot and ankle has shown this technique to be a safe and successful alternative to t
{"title":"Revision Surgery for Recurrent Morton Neuroma with Use of a Collagen Conduit.","authors":"Mila Scheinberg, Meghan Underwood, Matthew Sankey, Thomas Sanchez, Ashish Shah","doi":"10.2106/JBJS.ST.22.00065","DOIUrl":"10.2106/JBJS.ST.22.00065","url":null,"abstract":"<p><strong>Background: </strong>Painful neuromas of the foot and ankle frequently pose a treatment dilemma because of persistent pain or recurrence after resection. Primary surgical treatment of painful neuromas includes simple excision with retraction of the residual nerve ending to a less vulnerable location<sup>1-4</sup>. The use of a collagen conduit for recurrent neuromas is advantageous, particularly in areas with minimal soft-tissue coverage options, and is a technique that has shown 85% patient satisfaction regarding surgical outcomes<sup>7</sup>. Additionally, the use of a collagen conduit limits the need for deep soft-tissue dissection and reduces the morbidity typically associated with nerve burial.</p><p><strong>Description: </strong>Specific steps include appropriate physical examination, preoperative planning, and supine patient positioning. The patient is placed supine with a lower-extremity bolster under the ipsilateral extremity in order to allow improved visualization of the plantar surface of the foot. A nonsterile tourniquet is placed on the thigh. The incision site is marked out, and a longitudinal plantar incision is made until proximal healthy nerve is identified-typically approximately 1 to 2 cm, but the incision can be extended up to 6 cm. The incision is made between the metatarsals, with blunt dissection carried down to the neuroma. The neuroma is sharply excised distally through healthy nerve, and a whip stitch is placed to facilitate the collagen conduit placement. The collagen conduit is passed dorsally into the intermetatarsal space and secured to the dorsal fascia of the foot. The wound is closed with 3-0 nylon horizontal mattress sutures. Postoperatively, a soft dressing is applied to the operative extremity, and patients are advised to be non-weight-bearing for two weeks. At two weeks, patients begin partial weight-bearing with use of a boot, and physical therapy is initiated. No antibiotics are necessary, and 300 mg of gabapentin is prescribed and tapered off by the six-week follow-up visit. Follow-ups are conducted at 2, 6, 12, 24, and fifty-two weeks. It is necessary to monitor for signs and symptoms of infection, surgical complications, and neuroma recurrence during follow-up appointments.</p><p><strong>Alternatives: </strong>Simple excision of the neuroma with proximal burial into muscle or bone is a common surgical technique. However, inadequate resection of the nerve or poor surgical technique can lead to recurrent neuromas. For neuromas not responding to simple excision, other techniques have been utilized, including cauterization, chemical agents, nerve capping, and muscle or bone burial<sup>5,6</sup>. The results of these techniques have varied, and none has gained clinical superiority over the other<sup>6</sup>.</p><p><strong>Rationale: </strong>A study analyzing the use of collagen conduits for painful neuromas of the foot and ankle has shown this technique to be a safe and successful alternative to t","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10863939/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139736334","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 : 2023-11-22eCollection Date: 2023-10-01DOI: 10.2106/JBJS.ST.22.00058
Ittai Shichman, Akram A Habibi, Joseph X Robin, Anthony C Gemayel, Dylan T Lowe, Ran Schwarzkopf
<p><strong>Background: </strong>The use of a cemented monoblock dual-mobility implant into a fully porous cup is indicated for patients with acetabular bone loss who have a high risk of postoperative hip instability. Patients undergoing lumbar fusion for sagittal spinal deformities have an increased risk of hip dislocation (7.1%) and should be assessed on sitting and standing radiographs<sup>1</sup>. Gabor et al. conducted a multicenter, retrospective study assessing the use of a cemented monoblock dual-mobility bearing in a porous acetabular shell in patients with acetabular bone loss and a high risk of hip instability<sup>2</sup>. Of the 38 patients, 1 (2.6%) experienced a postoperative dislocation that was subsequently treated with closed reduction without further dislocation. This surgical technique represents a favorable surgical option for patients with acetabular bone loss who are at risk for hip instability. In the example case described in the present video article, the patients had a history of dislocations, lumbar fusion, and evidence of Paprosky 3B acetabular defect; as such, the decision was made to revise to a porous shell and cement a monoblock dual-mobility implant.</p><p><strong>Description: </strong>With use of the surgeon's preferred approach, the soft tissue is dissected and the hip is aspirated. The hip is dislocated and a subgluteal pocket is made with use of electrocautery to mobilize the trunnion of the femoral stem to aid in acetabular exposure. The femoral component is assessed to ensure appropriate positioning with adequate anteversion. The acetabular component and any acetabular screws are removed. A "ream to fit" technique is performed in the acetabulum until bleeding bone is encountered, with minimal reaming performed in healthy bone from the posterior column. A trial prosthesis is placed within the acetabulum to evaluate if there is satisfactory fixation and if any augment is necessary. Care must be taken during reaming to ensure that enough bone is reamed to accommodate a porous shell that can fit the monoblock dual-mobility implant with a 2-mm cement mantle. Smaller porous shells measuring 56 mm are available for smaller defects but are often not utilized in cases of substantial acetabular bone loss. Fresh-frozen cancellous allograft is utilized to fill any contained defects. The revision porous shell with circumferential screw holes is utilized to allow for screw fixation posterosuperior and anterior toward the pubis. The implants are dried prior to placement of the cement. The cement is applied to the shell and the monoblock dual-mobility implant to ensure adequate coverage. Antibiotic-loaded cement can be utilized according to surgeon preference. Excess cement is removed under direct visualization while the cement is drying, and the position of the dual-mobility implant is adjusted in approximately 20° anteversion and 40° inclination. Stability is assessed after the cement cures, and intraoperative radiography
{"title":"Cementing a Monoblock Dual-Mobility Implant into a Fully Porous Cup in Revision Total Hip Arthroplasty to Address Hip Instability: Surgical Technique.","authors":"Ittai Shichman, Akram A Habibi, Joseph X Robin, Anthony C Gemayel, Dylan T Lowe, Ran Schwarzkopf","doi":"10.2106/JBJS.ST.22.00058","DOIUrl":"10.2106/JBJS.ST.22.00058","url":null,"abstract":"<p><strong>Background: </strong>The use of a cemented monoblock dual-mobility implant into a fully porous cup is indicated for patients with acetabular bone loss who have a high risk of postoperative hip instability. Patients undergoing lumbar fusion for sagittal spinal deformities have an increased risk of hip dislocation (7.1%) and should be assessed on sitting and standing radiographs<sup>1</sup>. Gabor et al. conducted a multicenter, retrospective study assessing the use of a cemented monoblock dual-mobility bearing in a porous acetabular shell in patients with acetabular bone loss and a high risk of hip instability<sup>2</sup>. Of the 38 patients, 1 (2.6%) experienced a postoperative dislocation that was subsequently treated with closed reduction without further dislocation. This surgical technique represents a favorable surgical option for patients with acetabular bone loss who are at risk for hip instability. In the example case described in the present video article, the patients had a history of dislocations, lumbar fusion, and evidence of Paprosky 3B acetabular defect; as such, the decision was made to revise to a porous shell and cement a monoblock dual-mobility implant.</p><p><strong>Description: </strong>With use of the surgeon's preferred approach, the soft tissue is dissected and the hip is aspirated. The hip is dislocated and a subgluteal pocket is made with use of electrocautery to mobilize the trunnion of the femoral stem to aid in acetabular exposure. The femoral component is assessed to ensure appropriate positioning with adequate anteversion. The acetabular component and any acetabular screws are removed. A \"ream to fit\" technique is performed in the acetabulum until bleeding bone is encountered, with minimal reaming performed in healthy bone from the posterior column. A trial prosthesis is placed within the acetabulum to evaluate if there is satisfactory fixation and if any augment is necessary. Care must be taken during reaming to ensure that enough bone is reamed to accommodate a porous shell that can fit the monoblock dual-mobility implant with a 2-mm cement mantle. Smaller porous shells measuring 56 mm are available for smaller defects but are often not utilized in cases of substantial acetabular bone loss. Fresh-frozen cancellous allograft is utilized to fill any contained defects. The revision porous shell with circumferential screw holes is utilized to allow for screw fixation posterosuperior and anterior toward the pubis. The implants are dried prior to placement of the cement. The cement is applied to the shell and the monoblock dual-mobility implant to ensure adequate coverage. Antibiotic-loaded cement can be utilized according to surgeon preference. Excess cement is removed under direct visualization while the cement is drying, and the position of the dual-mobility implant is adjusted in approximately 20° anteversion and 40° inclination. Stability is assessed after the cement cures, and intraoperative radiography ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2023-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10863941/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139736332","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 : 2023-08-30eCollection Date: 2023-07-01DOI: 10.2106/JBJS.ST.22.00027
Clément Jeandel, Nicolas Bremond, Marie Christine de Maximin, Yan Lefèvre, Aurélien Courvoisier
<p><strong>Background: </strong>Vertebral body tethering (VBT) is indicated for skeletally immature patients with progressive adolescent idiopathic scoliosis (AIS) who have failed or are intolerant of bracing and who have a major coronal curve of 40° to 65°. The vertebral body must be structurally and dimensionally adequate to accommodate screw fixation, as determined radiographically. The best indication for VBT is a flexible single major thoracic curve with nonstructural compensating lumbar and proximal thoracic curves (Lenke 1A or 1B). VBT allows for progressive correction of the deformity without spinal fusion by utilizing a minimally invasive fluoroscopic technique.</p><p><strong>Description: </strong>The procedure for a right thoracic curve is performed with use of a right thoracoscopic approach with the patient in the left lateral decubitus position. The thoracoscope is introduced through a portal at the apex of the curvature in the posterior axillary line. Instrument portals are created lateral to each vertebral body in the mid-axillary line. Screws are inserted into each vertebral body under biplanar fluoroscopic control and with intraoperative neuromonitoring. An electroconductivity probing device, while not mandatory, is routinely utilized at our practice. The tether is attached to the most proximal screw of the construct, and then reduction is obtained sequentially by tensioning the tether from one vertebral screw to the next.</p><p><strong>Alternatives: </strong>Bracing is the gold-standard treatment for progressive AIS involving the immature spine. The most commonly utilized surgical treatment is posterior spinal fusion (PSF), which should be considered when the major coronal curve exceeds 45°.</p><p><strong>Rationale: </strong>PSF has proven to be a dependable technique to correct scoliotic deformities. It has a low complication rate and good long-term outcomes. However, concerns exist regarding the stiffness conferred by PSF and the long-term effects of adjacent segment disease. Thus, interest had developed in non-fusion solutions for AIS correction. VBT utilizes the Hueter-Volkmann principle to guide growth and correct deformity. Compressive forces applied to the convexity of the deformity by a polyethylene tether allow the patient's growth to realign the spine. Intraoperative correction triggers growth modulation, and most of the modulation seems to occur during the first 12 months postoperatively. The best results have been seen with a short Lenke type-1A curve in a patient with closed triradiate cartilage, a Risser 3 or lower (ideally Risser 0) iliac apophysis, and a flexible curve characterized by a 50% reduction of the major coronal curve angle on side-bending radiographs.</p><p><strong>Expected outcomes: </strong>In 57 immature patients with a Lenke type-1A or 1B curve (i.e., a 30° to 65° preoperative Cobb angle), Samdani et al.<sup>3</sup> found a main thoracic Cobb angle reduction from 40° ± 7° preoperatively to 19° ± 13°
{"title":"Thoracoscopic Anterior Vertebral Body Tethering in Lenke Type-1 Right Adolescent Idiopathic Scoliosis.","authors":"Clément Jeandel, Nicolas Bremond, Marie Christine de Maximin, Yan Lefèvre, Aurélien Courvoisier","doi":"10.2106/JBJS.ST.22.00027","DOIUrl":"10.2106/JBJS.ST.22.00027","url":null,"abstract":"<p><strong>Background: </strong>Vertebral body tethering (VBT) is indicated for skeletally immature patients with progressive adolescent idiopathic scoliosis (AIS) who have failed or are intolerant of bracing and who have a major coronal curve of 40° to 65°. The vertebral body must be structurally and dimensionally adequate to accommodate screw fixation, as determined radiographically. The best indication for VBT is a flexible single major thoracic curve with nonstructural compensating lumbar and proximal thoracic curves (Lenke 1A or 1B). VBT allows for progressive correction of the deformity without spinal fusion by utilizing a minimally invasive fluoroscopic technique.</p><p><strong>Description: </strong>The procedure for a right thoracic curve is performed with use of a right thoracoscopic approach with the patient in the left lateral decubitus position. The thoracoscope is introduced through a portal at the apex of the curvature in the posterior axillary line. Instrument portals are created lateral to each vertebral body in the mid-axillary line. Screws are inserted into each vertebral body under biplanar fluoroscopic control and with intraoperative neuromonitoring. An electroconductivity probing device, while not mandatory, is routinely utilized at our practice. The tether is attached to the most proximal screw of the construct, and then reduction is obtained sequentially by tensioning the tether from one vertebral screw to the next.</p><p><strong>Alternatives: </strong>Bracing is the gold-standard treatment for progressive AIS involving the immature spine. The most commonly utilized surgical treatment is posterior spinal fusion (PSF), which should be considered when the major coronal curve exceeds 45°.</p><p><strong>Rationale: </strong>PSF has proven to be a dependable technique to correct scoliotic deformities. It has a low complication rate and good long-term outcomes. However, concerns exist regarding the stiffness conferred by PSF and the long-term effects of adjacent segment disease. Thus, interest had developed in non-fusion solutions for AIS correction. VBT utilizes the Hueter-Volkmann principle to guide growth and correct deformity. Compressive forces applied to the convexity of the deformity by a polyethylene tether allow the patient's growth to realign the spine. Intraoperative correction triggers growth modulation, and most of the modulation seems to occur during the first 12 months postoperatively. The best results have been seen with a short Lenke type-1A curve in a patient with closed triradiate cartilage, a Risser 3 or lower (ideally Risser 0) iliac apophysis, and a flexible curve characterized by a 50% reduction of the major coronal curve angle on side-bending radiographs.</p><p><strong>Expected outcomes: </strong>In 57 immature patients with a Lenke type-1A or 1B curve (i.e., a 30° to 65° preoperative Cobb angle), Samdani et al.<sup>3</sup> found a main thoracic Cobb angle reduction from 40° ± 7° preoperatively to 19° ± 13°","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2023-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10833648/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67755128","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>Meniscal extrusion is a phenomenon in which a degenerative posterior horn tear, radial tear, or root tear results in displacement of the body of the meniscus medial to the tibial rim. The paramount function of the meniscus is to provide load distribution across the knee joint. Meniscal extrusion will prevent the meniscus from properly fulfilling this function and eventually leads to progression of osteoarthritis<sup>1</sup>. Thus, root repair accompanied by arthroscopic meniscal extrusion repair (by a centralization technique) has been suggested for restoration of meniscal function<sup>2-5</sup>. There are various techniques to correct meniscal extrusion, including a dual-tunnel suture pull-out technique<sup>2</sup> (to address extrusion and root tear<sup>2</sup>), a knotless suture anchor<sup>4,6</sup> technique, and an all-inside suture anchor repair<sup>7</sup>. The indications for extrusion repair are not consistently reported in the literature, and the procedure is not always easy to perform. Currently, there is no consensus regarding the ideal technique. In the present article, we describe the steps for successful combined medial meniscal root repair with extrusion repair and centralization.</p><p><strong>Description: </strong>Place the patient in the supine position with the knee supported in 90° of flexion and the feet at the edge of the operating table with foot-positioner support. First, meniscal root repair is performed with use of the suture pull-out technique, utilizing a cinch suture configuration to hold the root in place, and the suture tapes are fixed over the anterior cortex of the tibia with a suture button. Next, the meniscal body is arthroscopically assessed for residual extrusion from the medial tibial rim. Extrusion repair is indicated in cases with >3 mm of extrusion<sup>7-9</sup>, as measured on magnetic resonance imaging. In our technique, any extrusion beyond the medial tibial rim is reduced and secured with use of a double-loaded 2.3-mm all-suture type of anchor.</p><p><strong>Alternatives: </strong>Alternatives include surgical procedures in which the root repair is performed with use of suture-anchor fixation<sup>10,11</sup> and the extrusion repair is performed with use of the transtibial suture pull-out method.</p><p><strong>Rationale: </strong>Root repair performed with the most common fixation techniques does not always reduce meniscal extrusion or restore meniscal function<sup>12,13</sup>. Consequently, several augmentation techniques have been reported to address meniscal extrusion<sup>3,14</sup>, including those that use arthroscopy to centralize the midbody of the meniscus over the rim of the tibial plateau. The rationale for this combined procedure is to restore the hoop-stress distribution and maintain meniscal function by repairing the extrusion of the meniscus. Addressing all intra-articular pathologies in a single stage is a challenging situation, and the sequence of the r
{"title":"Concomitant Medial Meniscal Root Repair with Extrusion Repair (Centralization Technique).","authors":"Silvampatti Ramaswamy Sundararajan, Rajagopalakrishnan Ramakanth, Terence D'Souza, Shanmuganathan Rajasekaran","doi":"10.2106/JBJS.ST.22.00008","DOIUrl":"10.2106/JBJS.ST.22.00008","url":null,"abstract":"<p><strong>Background: </strong>Meniscal extrusion is a phenomenon in which a degenerative posterior horn tear, radial tear, or root tear results in displacement of the body of the meniscus medial to the tibial rim. The paramount function of the meniscus is to provide load distribution across the knee joint. Meniscal extrusion will prevent the meniscus from properly fulfilling this function and eventually leads to progression of osteoarthritis<sup>1</sup>. Thus, root repair accompanied by arthroscopic meniscal extrusion repair (by a centralization technique) has been suggested for restoration of meniscal function<sup>2-5</sup>. There are various techniques to correct meniscal extrusion, including a dual-tunnel suture pull-out technique<sup>2</sup> (to address extrusion and root tear<sup>2</sup>), a knotless suture anchor<sup>4,6</sup> technique, and an all-inside suture anchor repair<sup>7</sup>. The indications for extrusion repair are not consistently reported in the literature, and the procedure is not always easy to perform. Currently, there is no consensus regarding the ideal technique. In the present article, we describe the steps for successful combined medial meniscal root repair with extrusion repair and centralization.</p><p><strong>Description: </strong>Place the patient in the supine position with the knee supported in 90° of flexion and the feet at the edge of the operating table with foot-positioner support. First, meniscal root repair is performed with use of the suture pull-out technique, utilizing a cinch suture configuration to hold the root in place, and the suture tapes are fixed over the anterior cortex of the tibia with a suture button. Next, the meniscal body is arthroscopically assessed for residual extrusion from the medial tibial rim. Extrusion repair is indicated in cases with >3 mm of extrusion<sup>7-9</sup>, as measured on magnetic resonance imaging. In our technique, any extrusion beyond the medial tibial rim is reduced and secured with use of a double-loaded 2.3-mm all-suture type of anchor.</p><p><strong>Alternatives: </strong>Alternatives include surgical procedures in which the root repair is performed with use of suture-anchor fixation<sup>10,11</sup> and the extrusion repair is performed with use of the transtibial suture pull-out method.</p><p><strong>Rationale: </strong>Root repair performed with the most common fixation techniques does not always reduce meniscal extrusion or restore meniscal function<sup>12,13</sup>. Consequently, several augmentation techniques have been reported to address meniscal extrusion<sup>3,14</sup>, including those that use arthroscopy to centralize the midbody of the meniscus over the rim of the tibial plateau. The rationale for this combined procedure is to restore the hoop-stress distribution and maintain meniscal function by repairing the extrusion of the meniscus. Addressing all intra-articular pathologies in a single stage is a challenging situation, and the sequence of the r","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10810590/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754736","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 : 2023-07-21eCollection Date: 2023-07-01DOI: 10.2106/JBJS.ST.21.00003
Cody C Wyles, Charles P Hannon, Anthony Viste, Kevin I Perry, Robert T Trousdale, Daniel J Berry, Matthew P Abdel
<p><strong>Background: </strong>Removal of well-fixed femoral components during revision total hip arthroplasty (THA) can be difficult and time-consuming<sup>1</sup>, leading to numerous complications, such as femoral perforation, bone loss, and fracture. Extended trochanteric osteotomies (ETOs), which provide wide exposure and direct access to the femoral canal under controlled conditions, have become a popular method to circumvent these challenges. ETOs were popularized by Wagner (i.e., the anterior-based osteotomy), and later modified by Paprosky (i.e., the lateral-based osteotomy)<sup>2</sup>.</p><p><strong>Description: </strong>The decision to utilize the laterally based Paprosky ETO versus the anteriorly based Wagner ETO is primarily based on surgeon preference, the location and type of in situ implants, and the osseous anatomy. Typically, a laterally based ETO is most facile in conjunction with a posterior approach and an anteriorly based ETO is most commonly paired with a lateral or anterolateral approach. Attention must be paid to maintaining vascularity to the osteotomy fragment, including minimizing stripping of the vastus lateralis from the osteotomy fragment and maintaining abductor attachments to the osteotomy fragment. When utilizing a laterally based ETO, the posterior border of the vastus lateralis must be carefully elevated to provide exposure for performance of the osteotomy. When an anteriorly based osteotomy is performed, the surgeon may instead extend the abductor tenotomy proximally with use of a longitudinal split of the vastus lateralis distally, which helps to keep the anterior and posterior sleeves of soft tissue in continuity. In either approach, dissection of the vastus lateralis involves managing several large vascular perforators. We prefer performing careful blunt dissection to identify the perforators and prophylactically controlling them, with ligation of large vessels and electrocautery of smaller vessels. Vascular clips are also available in case difficult-to-control bleeding is encountered. In general, an oscillating saw (with preference for a thin blade) is utilized to complete the posterior longitudinal limb of the ETO, extending approximately 12 to 16 cm distally from the tip of the greater trochanter. Although a 12 to 16-cm zone is required to maintain maximum vascularity to the osteotomized fragment, the osteotomy length must ultimately be determined by (1) the length of the femoral component to be removed; (2) the presence of distal bone ingrowth, ongrowth, or cement; and (3) the presence of distal hardware or stemmed knee components. A smaller oscillating saw is then utilized to complete the transverse limb at the previously identified distal extent. A high-speed pencil-tip burr is utilized to complete the corners of the osteotomy in a rounded configuration, and a combination of saws and pencil-tip burrs is utilized to create partial proximal and distal anterior longitudinal limbs of the osteotomy to th
背景：在翻修全髋关节置换术（THA）过程中，取出固定良好的股骨组件既困难又耗时1，会导致股骨穿孔、骨质流失和骨折等多种并发症。扩展转子截骨术（ETO）可在可控条件下提供大范围暴露并直接进入股骨管，已成为规避这些难题的常用方法。ETO由瓦格纳（即基于前方的截骨术）推广，后经帕普洛斯基（即基于侧面的截骨术）改进2：2.说明： 决定使用侧位 Paprosky ETO 还是前位 Wagner ETO 主要取决于外科医生的偏好、原位种植体的位置和类型以及骨解剖结构。通常情况下，侧方 ETO 与后方入路配合使用最为方便，而前方 ETO 通常与侧方或前外侧入路配合使用。必须注意保持截骨片段的血管通畅，包括尽量减少从截骨片段剥离侧阔肌，并保持外展肌附着于截骨片段。在使用侧向 ETO 时，必须小心抬高侧阔肌后缘，以便在进行截骨时暴露出来。在进行基于前方的截骨术时，外科医生可以将内收肌腱膜切开术向近端延伸，并在远端对阔筋膜进行纵向分割，这有助于保持前后软组织套筒的连续性。无论采用哪种方法，对阔筋膜侧的解剖都需要处理几条大的血管穿孔器。我们倾向于进行仔细的钝性剥离以识别穿孔器，并对其进行预防性控制，结扎大血管，电烧小血管。如果遇到难以控制的出血，也可以使用血管夹。一般情况下，使用摆动锯（优先选择薄锯片）完成 ETO 后纵缘，从大转子顶端向远端延伸约 12 至 16 厘米。虽然需要12至16厘米的区域来保持截骨片段最大程度的血管通畅，但截骨长度最终必须由以下因素决定：(1) 需要移除的股骨组件的长度；(2) 是否存在远端骨质增生、骨赘或骨水泥；(3) 是否存在远端硬件或带柄膝关节组件。然后使用较小的摆动锯在先前确定的远端范围完成横向肢体的切除。使用高速笔尖锉完成圆角截骨，并在软组织附着物允许的范围内，将锯和笔尖锉组合使用，形成截骨的部分近端和远端前纵向肢体。在可控的情况下，可通过连续钻孔进一步削弱前纵肢。然后在后纵缘放置 2 到 4 个宽直的截骨器，对前纵缘进行控制性骨折。用轻柔、稳定的力量将这些截骨器小心翼翼地向前方撬动。ETO 完成后，取出髓内假体、硬件和骨水泥；根据需要处理髋臼；如果合适，植入最终股骨柄。截骨手术完成后，必须轻柔地牵拉截骨碎片，注意避免骨折并保持血管通畅。为此，应避免对截骨片段的骨内膜进行清创，包括清除骨水泥，直到手术结束，准备关闭截骨时再进行清创。我们首选的闭合方法是在截骨远端1厘米处放置1根预防性钢索，沿截骨的骺段放置1到2根钢索，在小转子上方放置1根Luque钢丝。我们在小转子上方的位置特别选择了 Luque 钢丝，因为它位于有效的关节间隙中；不过，在小转子远端使用 Luque 钢丝也是可以接受的。在极少数情况下，可以使用支撑异体移植或锁定板来加固截骨，或用于弥合假体间应力嵴。通常避免使用转子植入物，因为使用这种闭合技术时临床相关的转子移位率较低，而且使用转子爪或钢板时出现症状的植入物比率较高：替代方法：经股骨截骨术是一种暴露程度类似的截骨术。此外，各种非伸展转子截骨术，如转子滑动截骨术，可提供更有限的暴露。
{"title":"Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty.","authors":"Cody C Wyles, Charles P Hannon, Anthony Viste, Kevin I Perry, Robert T Trousdale, Daniel J Berry, Matthew P Abdel","doi":"10.2106/JBJS.ST.21.00003","DOIUrl":"10.2106/JBJS.ST.21.00003","url":null,"abstract":"<p><strong>Background: </strong>Removal of well-fixed femoral components during revision total hip arthroplasty (THA) can be difficult and time-consuming<sup>1</sup>, leading to numerous complications, such as femoral perforation, bone loss, and fracture. Extended trochanteric osteotomies (ETOs), which provide wide exposure and direct access to the femoral canal under controlled conditions, have become a popular method to circumvent these challenges. ETOs were popularized by Wagner (i.e., the anterior-based osteotomy), and later modified by Paprosky (i.e., the lateral-based osteotomy)<sup>2</sup>.</p><p><strong>Description: </strong>The decision to utilize the laterally based Paprosky ETO versus the anteriorly based Wagner ETO is primarily based on surgeon preference, the location and type of in situ implants, and the osseous anatomy. Typically, a laterally based ETO is most facile in conjunction with a posterior approach and an anteriorly based ETO is most commonly paired with a lateral or anterolateral approach. Attention must be paid to maintaining vascularity to the osteotomy fragment, including minimizing stripping of the vastus lateralis from the osteotomy fragment and maintaining abductor attachments to the osteotomy fragment. When utilizing a laterally based ETO, the posterior border of the vastus lateralis must be carefully elevated to provide exposure for performance of the osteotomy. When an anteriorly based osteotomy is performed, the surgeon may instead extend the abductor tenotomy proximally with use of a longitudinal split of the vastus lateralis distally, which helps to keep the anterior and posterior sleeves of soft tissue in continuity. In either approach, dissection of the vastus lateralis involves managing several large vascular perforators. We prefer performing careful blunt dissection to identify the perforators and prophylactically controlling them, with ligation of large vessels and electrocautery of smaller vessels. Vascular clips are also available in case difficult-to-control bleeding is encountered. In general, an oscillating saw (with preference for a thin blade) is utilized to complete the posterior longitudinal limb of the ETO, extending approximately 12 to 16 cm distally from the tip of the greater trochanter. Although a 12 to 16-cm zone is required to maintain maximum vascularity to the osteotomized fragment, the osteotomy length must ultimately be determined by (1) the length of the femoral component to be removed; (2) the presence of distal bone ingrowth, ongrowth, or cement; and (3) the presence of distal hardware or stemmed knee components. A smaller oscillating saw is then utilized to complete the transverse limb at the previously identified distal extent. A high-speed pencil-tip burr is utilized to complete the corners of the osteotomy in a rounded configuration, and a combination of saws and pencil-tip burrs is utilized to create partial proximal and distal anterior longitudinal limbs of the osteotomy to th","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10810589/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754720","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 : 2023-07-21eCollection Date: 2023-07-01DOI: 10.2106/JBJS.ST.22.00035
Chase T Nelson, Tyler J Thorne, Thomas F Higgins, David L Rothberg, Justin M Haller, Lucas S Marchand
<p><strong>Background: </strong>This technique utilizes a full-thickness flap to provide a posterior approach to the scapula for open reduction and internal fracture fixation. The present video article outlines the Judet approach along with an incision modification tip for the surgeon's consideration.</p><p><strong>Description: </strong>Prior to making the incision, perform preoperative planning, patient and C-arm positioning, and identification of the primary fragments of the fracture that necessitate fixation on imaging. The Judet incision is made, and the full-thickness flap is retracted laterally (also described as a "boomerang-shaped" incision, allowing for the flap to be reflected medially). Next, detach and reflect the deltoid off the scapular spine superolaterally to reveal the internervous plane between the infraspinatus and teres minor. Utilize this interval to access the fracture sites while making sure to reflect the infraspinatus cranially, carefully minding the suprascapular neurovascular bundle, and the teres minor inferiorly, protecting the axillary nerve. A longitudinal arthrotomy may then be created parallel to the posterior border of the glenoid, with careful attention paid toward protecting the labrum from iatrogenic injury. The arthrotomy will allow for intra-articular evaluation of the reduction if needed. Primary fractures are then reduced. Reduction is confirmed with use of fluoroscopy, and fixation is applied to maintain the reduction.</p><p><strong>Alternatives: </strong>Most scapular fractures do well with nonoperative treatment, and this has been well documented in the literature. Open reduction and internal fixation has been shown to offer good-to-excellent clinical outcomes with minimal risk of complications in patients with traumatic scapular fractures that necessitate operative treatment<sup>1</sup>. In certain fractures of the glenoid fossa, operative treatment is necessary to restore normal anatomy, provide stability to the glenohumeral joint, and facilitate functional rehabilitation. Operative treatment is typically reserved for injuries with intra-articular involvement that results in joint incongruity or joint instability<sup>2,3</sup>. When operative treatment is indicated, an open posterior approach is utilized for some fractures. The posterior Judet approach is the best-known operative technique for such fractures, while other modifications of the Judet technique have also been described in the literature<sup>3-5</sup>.</p><p><strong>Rationale: </strong>Reports state that scapular body or neck and glenoid fossa fractures account for up to 80% of scapular fractures<sup>6</sup>. Open reduction and internal fixation of the scapula is an invasive procedure, requiring large incisions and manipulation of soft tissues to expose the various possible fracture sites on the scapula. Thus, numerus surgical techniques have been described that allow surgeons to best tailor treatment to their patients on a case-by-case ba
{"title":"Posterior Approach for Open Reduction and Internal Fixation for Scapular Fractures.","authors":"Chase T Nelson, Tyler J Thorne, Thomas F Higgins, David L Rothberg, Justin M Haller, Lucas S Marchand","doi":"10.2106/JBJS.ST.22.00035","DOIUrl":"10.2106/JBJS.ST.22.00035","url":null,"abstract":"<p><strong>Background: </strong>This technique utilizes a full-thickness flap to provide a posterior approach to the scapula for open reduction and internal fracture fixation. The present video article outlines the Judet approach along with an incision modification tip for the surgeon's consideration.</p><p><strong>Description: </strong>Prior to making the incision, perform preoperative planning, patient and C-arm positioning, and identification of the primary fragments of the fracture that necessitate fixation on imaging. The Judet incision is made, and the full-thickness flap is retracted laterally (also described as a \"boomerang-shaped\" incision, allowing for the flap to be reflected medially). Next, detach and reflect the deltoid off the scapular spine superolaterally to reveal the internervous plane between the infraspinatus and teres minor. Utilize this interval to access the fracture sites while making sure to reflect the infraspinatus cranially, carefully minding the suprascapular neurovascular bundle, and the teres minor inferiorly, protecting the axillary nerve. A longitudinal arthrotomy may then be created parallel to the posterior border of the glenoid, with careful attention paid toward protecting the labrum from iatrogenic injury. The arthrotomy will allow for intra-articular evaluation of the reduction if needed. Primary fractures are then reduced. Reduction is confirmed with use of fluoroscopy, and fixation is applied to maintain the reduction.</p><p><strong>Alternatives: </strong>Most scapular fractures do well with nonoperative treatment, and this has been well documented in the literature. Open reduction and internal fixation has been shown to offer good-to-excellent clinical outcomes with minimal risk of complications in patients with traumatic scapular fractures that necessitate operative treatment<sup>1</sup>. In certain fractures of the glenoid fossa, operative treatment is necessary to restore normal anatomy, provide stability to the glenohumeral joint, and facilitate functional rehabilitation. Operative treatment is typically reserved for injuries with intra-articular involvement that results in joint incongruity or joint instability<sup>2,3</sup>. When operative treatment is indicated, an open posterior approach is utilized for some fractures. The posterior Judet approach is the best-known operative technique for such fractures, while other modifications of the Judet technique have also been described in the literature<sup>3-5</sup>.</p><p><strong>Rationale: </strong>Reports state that scapular body or neck and glenoid fossa fractures account for up to 80% of scapular fractures<sup>6</sup>. Open reduction and internal fixation of the scapula is an invasive procedure, requiring large incisions and manipulation of soft tissues to expose the various possible fracture sites on the scapula. Thus, numerus surgical techniques have been described that allow surgeons to best tailor treatment to their patients on a case-by-case ba","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10810586/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67755148","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 : 2023-06-27eCollection Date: 2023-04-01DOI: 10.2106/JBJS.ST.22.00020
Daniel K Park, Chong Weng, Philip Zakko, Dae-Jung Choi
<p><strong>Background: </strong>Unilateral biportal endoscopy (UBE) is a novel minimally invasive technique for the treatment of lumbar spinal stenosis and lumbar disc herniations. Uniportal endoscopy was utilized prior to the advent of UBE and has been considered the workhorse of endoscopic spine surgery (ESS) for lumbar discectomy and decompressive laminectomy. However, there are theoretical advantages to UBE compared with traditional uniportal endoscopy, including that the procedure utilizes typical spinal equipment that should be readily available, requires less capital cost and optical instrumentation, and provides greater operative flexibility as a result of utilizing both a working and a viewing portal<sup>7,8</sup>.</p><p><strong>Description: </strong>A 0-degree arthroscope is typically utilized for discectomy and lumbar laminectomies. The use of a radiofrequency ablator is critical to help coagulate osseous and muscle bleeders. For irrigation, gravity or a low-pressure pump, typically <40 mm Hg, can be utilized<sup>9,10</sup>. Further details regarding irrigation pressure are provided in "Important Tips." The use of a standard powered burr is typical to help osseous decompression, and Kerrison ronguers, pituitaries, osteotomes, and probes utilized in open or tubular cases suffice. Two incisions are made approximately 1 cm lateral to the midline. If working from the left side for a right-handed surgeon, the working portal is typically made at the lower laminar margin of the target level. The camera portal is then made typically 2 to 3 cm cephalad. A lateral radiograph is then utilized to confirm the portal placements. From the right side, the working portal is cephalad and the camera portal is caudal. Because of the switch, the portals may be shifted more distally.The first step is creating a working space because there is no true joint space in the spine. With use of radiofrequency ablation, a working space is created in the interlaminar space. Next, with use of a powered burr or a chiseled osteotomy, the base of the cephalad spinous process is thinned until the insertion of the ligamentum flavum is found. Next, the ipsilateral and contralateral laminae are thinned in a similar fashion. Once the osseous elements are removed, the ligamentum flavum is removed en bloc. The traversing nerve roots are checked under direct high-magnification visualization to ensure that they are decompressed. If a discectomy is necessary, standard nerve-root retractors can be utilized to retract the neural elements. With use of a blunt-tip elevator, the anular defect can be incised and the herniated disc can be removed under direct high-power visualization. In addition, a small curet can be utilized to create a defect in the weakened anulus or membrane covering the extruded disc material in order to help deliver the herniated disc material. Epidural veins are coagulated typically with use of a fine-point bipolar radiofrequency device.</p><p><strong>Alternative
{"title":"Unilateral Biportal Endoscopy for Lumbar Spinal Stenosis and Lumbar Disc Herniation.","authors":"Daniel K Park, Chong Weng, Philip Zakko, Dae-Jung Choi","doi":"10.2106/JBJS.ST.22.00020","DOIUrl":"10.2106/JBJS.ST.22.00020","url":null,"abstract":"<p><strong>Background: </strong>Unilateral biportal endoscopy (UBE) is a novel minimally invasive technique for the treatment of lumbar spinal stenosis and lumbar disc herniations. Uniportal endoscopy was utilized prior to the advent of UBE and has been considered the workhorse of endoscopic spine surgery (ESS) for lumbar discectomy and decompressive laminectomy. However, there are theoretical advantages to UBE compared with traditional uniportal endoscopy, including that the procedure utilizes typical spinal equipment that should be readily available, requires less capital cost and optical instrumentation, and provides greater operative flexibility as a result of utilizing both a working and a viewing portal<sup>7,8</sup>.</p><p><strong>Description: </strong>A 0-degree arthroscope is typically utilized for discectomy and lumbar laminectomies. The use of a radiofrequency ablator is critical to help coagulate osseous and muscle bleeders. For irrigation, gravity or a low-pressure pump, typically <40 mm Hg, can be utilized<sup>9,10</sup>. Further details regarding irrigation pressure are provided in \"Important Tips.\" The use of a standard powered burr is typical to help osseous decompression, and Kerrison ronguers, pituitaries, osteotomes, and probes utilized in open or tubular cases suffice. Two incisions are made approximately 1 cm lateral to the midline. If working from the left side for a right-handed surgeon, the working portal is typically made at the lower laminar margin of the target level. The camera portal is then made typically 2 to 3 cm cephalad. A lateral radiograph is then utilized to confirm the portal placements. From the right side, the working portal is cephalad and the camera portal is caudal. Because of the switch, the portals may be shifted more distally.The first step is creating a working space because there is no true joint space in the spine. With use of radiofrequency ablation, a working space is created in the interlaminar space. Next, with use of a powered burr or a chiseled osteotomy, the base of the cephalad spinous process is thinned until the insertion of the ligamentum flavum is found. Next, the ipsilateral and contralateral laminae are thinned in a similar fashion. Once the osseous elements are removed, the ligamentum flavum is removed en bloc. The traversing nerve roots are checked under direct high-magnification visualization to ensure that they are decompressed. If a discectomy is necessary, standard nerve-root retractors can be utilized to retract the neural elements. With use of a blunt-tip elevator, the anular defect can be incised and the herniated disc can be removed under direct high-power visualization. In addition, a small curet can be utilized to create a defect in the weakened anulus or membrane covering the extruded disc material in order to help deliver the herniated disc material. Epidural veins are coagulated typically with use of a fine-point bipolar radiofrequency device.</p><p><strong>Alternative","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"1 1","pages":""},"PeriodicalIF":1.0,"publicationDate":"2023-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807897/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754313","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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