JBJS Essential Surgical Techniques最新文献

{"title":"Reconstructive Allograft Preparation for Long Bone Intercalary Segments After Tumor Resections: Toronto Sarcoma Protocol.","authors":"Manit K Gundavda, Alexander L Lazarides, Zachary D C Burke, Kim Tsoi, Peter C Ferguson, Jay S Wunder","doi":"10.2106/JBJS.ST.22.00011","DOIUrl":"10.2106/JBJS.ST.22.00011","url":null,"abstract":"<p><strong>Background: </strong>The Reconstructive Allograft Preparation by Toronto Sarcoma (RAPTORS) protocol is reliable and reproducible without substantially adding to the surgical reconstruction time or cost. Our technique includes clearance of debris, lavage of the medullary canal, pressurized filling of the medullary canal with antibiotic-laden cement for its mechanical and antimicrobial properties, and insertion of cancellous autograft at the allograft-host junctional ends prior to dual-plate compression to fix the allograft into the defect<sup>1-3</sup>. Our experience with large intercalary allograft reconstruction has demonstrated high rates of long-term success and addresses the most common causes of large allograft failure (infection, fracture, and nonunion)<sup>4</sup>, as shown in our long-term outcome study<sup>1</sup>.</p><p><strong>Description: </strong>Once the tumor is resected, it is used as a template for cutting and shaping the allograft to fit the bone defect and to restore length and anatomy. The frozen allograft is thawed in a container with povidone iodine and bacitracin saline solution until it reaches room temperature. The allograft is size-matched, and clearance of its intramedullary marrow contents is performed with use of curets and intramedullary reamers<sup>7</sup>. If 1 end of the allograft includes the metaphysis and is covered by dense cancellous bone, we try not to ream through this end because maintaining this metaphyseal cancellous surface will expedite bone healing. The segment is then thoroughly lavaged with \"triple wash\" solutions to clear out any remaining marrow contents and to ensure sterilization of the allograft. This serial-wash technique involves the use of 3 discrete antiseptic modalities and has been utilized at our institution with low rates of allograft infection. These antiseptic modalities include 10% weight-per-volume povidone iodine diluted 1:1 with normal saline solution, 3% weight-per-volume hydrogen peroxide diluted 1:1 with normal saline solution, and 50,000 units of sterile bacitracin lyophilized powder dissolved in 500 mL of normal saline solution. Following the triple wash, the medullary canal is filled with antibiotic-laden methylmethacrylate bone cement. If both ends are open, the far end of the segment is first plugged with the surgeon's finger or with gauze, or if 1 end is covered with cancellous bone, then retrograde filling of the canal with cement is performed from the open end. The cement is then pressurized to ensure complete filling of the intramedullary space. Before it sets, 1 cm of cement is removed from each open end of the allograft to allow for packing of autograft bone cancellous chips and to ensure that cement does not impede anatomic reduction of the allograft-host bone junction. For this step, cancellous autograft from the iliac crest is harvested with use of a separate sterile surgical setup in order to prevent contamination of the autograft site by instruments ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807901/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754798","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}

{"title":"Minimally Invasive Transforaminal Lumbar Interbody Fusion with Expandable Cages.","authors":"Aaron J Buckland, Dylan J Proctor","doi":"10.2106/JBJS.ST.21.00062","DOIUrl":"10.2106/JBJS.ST.21.00062","url":null,"abstract":"<p><strong>Background: </strong>Minimally invasive surgical transforaminal lumbar interbody fusion (MIS-TLIF) is an increasingly common procedure for the treatment of lumbar degenerative pathologies. The MIS-TLIF technique often results in less soft-tissue injury compared with the open TLIF technique, reducing postoperative pain and recovery time<sup>1-3</sup>. However, the narrow surgical aperture of this minimally invasive technique has increased the difficulty of interbody cage placement. Expandable cages were designed to improve ease of insertion, improve visualization around the cage on insertion, reduce neurological retraction and injury by passing the nerve root with the implant in a collapsed state, and enable better disc-height and lordosis restoration on expansion<sup>4</sup>.</p><p><strong>Description: </strong>This procedure is performed with the patient under general anesthesia and in a prone position. The appropriate spinal level is identified with use of fluoroscopy, and bilateral paramidline approaches are made utilizing the Wiltse intermuscular approach. Pedicle screws are placed bilaterally. A pedicle-based retractor or tubular retractor is passed along the Wiltse plane, and bilateral inferior facetectomies are performed. A foraminotomy is performed, including a superior facetectomy on the side with compression of the exiting nerve root. A thorough discectomy with end-plate preparation is performed. The disc space is sized with use of trial components. The cage is then implanted with a pre-expansion height less than the trialed height and is expanded under fluoroscopy. After expansion, the cage is backfilled with allograft and local autograft. Finally, the rods are contoured and reduced bilaterally, followed by closure in a multilayered approach.</p><p><strong>Alternatives: </strong>Nonoperative alternatives to the minimally invasive TLIF technique include physical therapy or epidural corticosteroid injections. When surgical intervention is indicated, there are several approaches that can be utilized during lumbar interbody fusion, including the posterior, direct lateral, anterior, or oblique approaches<sup>5</sup>.</p><p><strong>Rationale: </strong>Expandable cages are designed to be inserted in a collapsed configuration and expanded once placed into the interbody space. This design offers numerous potential advantages over static alternatives. The low-profile, expandable cages require less impaction during placement, minimizing iatrogenic end-plate damage. Additionally, expandable cages require less thecal and nerve-root retraction and provide a larger surface footprint once expanded.</p><p><strong>Expected outcomes: </strong>The MIS-TLIF technique has been shown to significantly reduce back pain, leg pain, and disability, and to significantly increase function, with most improvements observed after 12 months postoperatively. Patients may experience a 51% and 39% reduction in visual analogue pain scores and Oswestry Disability","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-05-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807895/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754543","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}

{"title":"Arthroscopic Decompression of the Anterior Inferior Iliac Spine.","authors":"Steven M Leary, Robert W Westermann","doi":"10.2106/JBJS.ST.22.00019","DOIUrl":"10.2106/JBJS.ST.22.00019","url":null,"abstract":"<p><strong>Background: </strong>Pathologic contact between the femoral neck and anterior inferior iliac spine (AIIS or subspine) often occurs concomitantly with femoroacetabular impingement, contributing to hip pain and dysfunction<sup>1-4</sup>. We perform arthroscopic AIIS decompression to alleviate this source of extra-articular impingement and eliminate a potential cause of persistent pain following primary hip arthroscopy<sup>5-7</sup>.</p><p><strong>Description: </strong>After identifying abnormal AIIS morphology on preoperative false-profile radiographs and/or 3D computed tomography, we utilize a beaver blade to make a small incision in the proximal capsule and rectus femoris tendon. This peri-capsulotomy window grants access to the subspine region. We then shuttle an arthroscopic burr into place within this window and begin debriding the subspine deformity under direct visualization. Fluoroscopy is utilized intraoperatively to ensure adequate resection, using intraoperative false-profile views achieved by canting the C-arm approximately 40°. Resection is considered adequate when the AIIS deformity is no longer readily apparent on false-profile views and when intraoperative range-of-motion testing confirms no further impingement with hip hyperflexion.</p><p><strong>Alternatives: </strong>Femoroacetabular impingement can be treated nonoperatively with use of physical therapy and activity modification<sup>8</sup>; however, outcomes following nonoperative treatment are inferior to those following hip arthroscopy, according to various studies<sup>9-12</sup>. There are no known alternative treatments specific to subspine impingement.</p><p><strong>Rationale: </strong>As patients with subspine deformities progress through hip flexion, the femoral neck collides with the AIIS, limiting range of motion. As such, subspine deformities have been shown to be more common in dancers and other high-flexion athletes<sup>13,14</sup>. Additionally, studies have demonstrated that low femoral version of <5° is associated with increased contact between the distal femoral neck and the AIIS. This pathologic contact can occur even in the absence of an obvious subspine deformity<sup>15</sup>. In both of these patient populations, surgeons should have a high suspicion for subspine impingement, and a subspine decompression should be performed during hip arthroscopy in order to maximize patient outcomes.</p><p><strong>Expected outcomes: </strong>This is a safe procedure that, if performed when indicated, can improve outcomes following primary hip arthroscopy. A recent systematic review found a pooled complication risk of 1.1%, a pooled revision risk of 1.0%, and significant postoperative improvements in patient-reported outcome measures<sup>16</sup>.</p><p><strong>Important tips: </strong>Suspect subspine impingement in high-flexion athletes and patients with low femoral version, even in the absence of an obvious deformity.Ensure adequate visualization of the entire s","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-05-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807891/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139565053","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}

{"title":"Robotic-Arm-Assisted Lateral Unicompartmental Knee Arthroplasty with a Fixed-Bearing Implant.","authors":"Ajay Premkumar, Tarik Bayoumi, Andrew D Pearle","doi":"10.2106/JBJS.ST.21.00012","DOIUrl":"10.2106/JBJS.ST.21.00012","url":null,"abstract":"<p><strong>Background: </strong>Approximately 5% to 10% of patients with knee arthritis have isolated lateral compartment arthritis; however, lateral unicompartmental knee arthroplasty (UKA) comprises just 1% of all knee arthroplasties<sup>1</sup>. This low proportion is partly because of the perceived complexity of lateral UKA and concerns over implant longevity and survivorship compared with total knee arthroplasty (TKA)<sup>2,3</sup>. With an improved understanding of knee kinematics alongside advances in implant design and tools to aid in appropriate restoration of limb alignment, lateral UKA can be an appealing surgical alternative to TKA for certain patients with lateral knee arthritis<sup>4,5</sup>. In appropriately selected patients, lateral UKA has been associated with reduced osseous and soft-tissue resection, more natural knee kinematics, less pain, shorter hospitalization, decreased blood loss and infection rates, and excellent survivorship and patient-reported outcomes<sup>6-9</sup>.</p><p><strong>Description: </strong>This surgical approach and technique described for lateral UKA utilizes robotic-arm assistance and modern fixed-bearing implants<sup>10</sup>. The specific steps involve appropriate patient evaluation and selection, extensive radiographic and computed-tomography-based preoperative templating, a lateral parapatellar approach, intraoperative confirmation of component position and alignment, and robotic-arm assistance to perform osseous resections to achieve limb alignment and kinematic targets<sup>10</sup>. Final implants are cemented in place, and patients typically are discharged home on the day of surgery<sup>10</sup>.</p><p><strong>Alternatives: </strong>Nonoperative treatment for end-stage knee arthritis includes weight loss, activity modification, assistive devices, bracing, nonsteroidal anti-inflammatory medications, and various injections<sup>11</sup>. Alternative surgical treatments include TKA<sup>4</sup> and, in certain patients, an offloading periarticular osteotomy<sup>12</sup>.</p><p><strong>Rationale: </strong>Lateral UKA is an appealing surgical option for nonobese patients who have disabling knee pain isolated to the lateral compartment, good preoperative range of motion, and a passively correctable valgus limb deformity<sup>10,13</sup>.</p><p><strong>Expected outcomes: </strong>Patients are typically discharged home on the day of surgery, or occasionally on postoperative day 1 if medical comorbidities dictate hospital monitoring overnight<sup>10</sup>. Patients return to light activities, including walking, immediately postoperatively. By 3 months postoperatively, patients will generally have returned to all desired activities<sup>9</sup>. The mid-term outcomes of this procedure, as performed by the corresponding author, have been published recently<sup>14,15</sup>. The 5-year survivorship of 171 lateral UKAs was 97.7%, with 72.8% of patients reporting that they were very satisfied with their procedure ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-05-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807899/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754295","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}

{"title":"Total Talar Replacement: Surgical Technique.","authors":"Akira Taniguchi, Yasuhito Tanaka, Takuma Miyamoto, Shigeki Morita, Hiroaki Kurokawa, Yoshinori Takakura","doi":"10.2106/JBJS.ST.22.00030","DOIUrl":"10.2106/JBJS.ST.22.00030","url":null,"abstract":"<p><strong>Background: </strong>Total talar replacement is a salvage procedure for end-stage osteonecrosis of the talus. A customized total talar implant is designed with use of computed tomography scans of the healthy opposite side and made of alumina ceramic. The use of such an implant is potentially recommended, with a guarded prognosis, for the treatment of traumatic, steroidal, alcoholic, systemic lupus erythematous, hemophilic, and idiopathic pathologies. The talus is surrounded by the tibia, fibula, calcaneus, and navicular bones, which account for a large portion of the articular surface area. Yoshinaga<sup>9</sup> reported that alumina ceramic prostheses were superior in terms of congruency and durability of articular cartilage compared with 316L stainless steel in an in vivo test in dogs. Therefore, alumina ceramic is an ideal material for replacement of the talus to preserve postoperative hindfoot mobility.</p><p><strong>Description: </strong>Total talar replacement is performed with the patient in a supine position. The anterior ankle approach is utilized to exteriorize the talus, facilitating dissection of the ligaments and joint capsule attached to talus. The first osteotomy is performed around the talar neck, perpendicular to the plantar surface of the foot. The talar head fragment is then removed. Subsequent talar osteotomies are performed parallel to the first cutting line, at approximately 2-cm intervals. The attaching articular capsule and ligaments are dissected in each step. The removal of the posterior talar bone fragments is succeeded by careful dissection of the ligament and joint capsule under the periosteum. After dissecting the remaining interosseous talocalcaneal ligament, the foot is distally retracted and a customized talar implant is inserted. After testing and confirming the stability and mobility of the implant, the wound is irrigated with use of normal saline solution. A suction drain is placed anterior to the implant, and the skin is closed after repairing the extensor retinaculum.</p><p><strong>Alternatives: </strong>In cases with a limited area of necrosis, symptoms may improve with a patellar tendon-bearing brace. However, in many cases of symptomatic osteonecrosis of the talus, nonoperative treatment is not expected to improve symptoms. Alternative surgical procedures include ankle arthrodesis and hindfoot arthrodesis, but there are risks of nonunion, leg-length discrepancy as a result of extensive bone loss, and functional decline because of loss of hindfoot motion.</p><p><strong>Rationale: </strong>Total talar replacement is a fundamentally unique treatment concept in which the entire talus is replaced with an artificial implant. Compared with ankle or hindfoot arthrodesis, this procedure preserves the range of motion of the foot and allows for earlier functional recovery. Postoperative results were satisfactory in the subjective evaluation, with no failure requiring revision. This procedure reduces the ri","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-04-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807903/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67755137","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}

{"title":"Open Excision of Dorsal Wrist Ganglion.","authors":"Muhammad Ali Elahi, M Lane Moore, Jordan R Pollock, Jack M Haglin, Cara Lai, Nathaniel B Hinckley, Kevin Renfree","doi":"10.2106/JBJS.ST.21.00043","DOIUrl":"10.2106/JBJS.ST.21.00043","url":null,"abstract":"<p><strong>Background: </strong>Ganglion cysts are benign soft-tissue tumors that are most commonly found in the wrist. Within the wrist, 60% to 70% of ganglion cysts occur on the dorsal side and 20% to 30% occur on the volar side<sup>1</sup>. Although ganglia arise from multiple sites over the dorsal wrist, dorsal ganglia most commonly originate at the scapholunate joint<sup>2,3</sup>. Open excision is the standard surgical treatment for dorsal wrist ganglia. This procedure is considered when symptoms such as pain and range-of-motion deficits begin to impact activities of daily living.</p><p><strong>Description: </strong>Open excision of a dorsal wrist ganglion is commonly performed with the patient under general anesthesia or a regional block. The patient is placed in the supine position, and a tourniquet is applied on the affected upper limb. After outlining the periphery of the palpable ganglion, the surgeon makes a transverse or longitudinal incision over the ganglion. The surgeon then begins a deep dissection, dissecting through the subcutaneous tissue and isolating the ganglion while avoiding any rupture, if possible. Once the cyst has been identified, extensor tendons surrounding the cyst are retracted and the cyst and stalk are mobilized. The cyst and stalk are subsequently excised, and the wound is closed<sup>4</sup>.</p><p><strong>Alternatives: </strong>Alternative treatments for dorsal wrist ganglia include nonoperative interventions such as observation, aspiration, controlled rupture, and injection. Operative treatments include arthroscopic and open dorsal wrist ganglion resections.</p><p><strong>Rationale: </strong>Although nonoperative treatment can produce successful outcomes, the various modalities have been associated with recurrence rates ranging from 15% to 90%<sup>4</sup>. As a result, surgical excision remains the gold standard of treatment and is typically indicated when weakness, pain, and limited range of motion interfere with activities of daily living. Among surgical interventions, arthroscopic excision is a minimally invasive procedure that has become more common because of the reduced scarring and faster recovery<sup>5</sup>. However, open excision, which does not involve complex equipment, is regarded as the standard among surgical treatments. Although the rates of recurrence for arthroscopic versus open dorsal ganglion excision are similar, arthroscopic excision is less effective with regard to pain relief<sup>5,6</sup>. This difference in pain relief could potentially be the result of the neurectomy of the posterior interosseous nerve in an open excision. In contrast, an arthroscopic procedure may provide less relief of pain from the posterior interosseous nerve stump attaching to the scarred capsule<sup>5</sup>.</p><p><strong>Expected outcomes: </strong>Open excision of a dorsal wrist ganglion is a safe, reliable procedure. The recurrence rate after open excision is similar to that after arthroscopic excision and ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807893/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754431","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}

{"title":"Tibiotalocalcaneal Arthrodesis with Intramedullary Fibular Strut Graft and Adjuvant Hardware Fixation.","authors":"Matthew Sankey, Thomas Sanchez, Sean M Young, Chad B Willis, Alex Harrelson, Ashish B Shah","doi":"10.2106/JBJS.ST.22.00004","DOIUrl":"10.2106/JBJS.ST.22.00004","url":null,"abstract":"<p><strong>Background: </strong>In patients with irreparable damage to the articular surfaces of the hindfoot, hindfoot arthrodesis is frequently chosen to provide pain relief and improve activities of daily living. Common etiologies leading to hindfoot arthrodesis procedures include osteonecrosis, failed total ankle arthroplasty, and deformities resulting from Charcot arthropathy or rheumatoid arthritis. Traditionally, this operation utilizes an intramedullary nail to obtain fusion of the tibiotalocalcaneal joint. Although 80% to 90% of patients achieve postoperative union, the remaining 10% to 20% experience nonunion<sup>1-3</sup>. Factors affecting the rate of nonunion include Charcot neuroarthropathy, use of nonsteroidal anti-inflammatory drugs or methotrexate, osteopenic bone, and smoking<sup>4</sup>. In the present video article, we describe a tibiotalocalcaneal arthrodesis performed with use of a fibular strut autograft for repeat arthrodesis following failure of primary tibiotalocalcaneal arthrodesis or as a salvage operation in end-stage pathologies of the hindfoot. Our surgical technique yields union rates of approximately 80% and provides surgeons with a viable surgical technique for patients with complex hindfoot pathologies or fusion failure.</p><p><strong>Description: </strong>The patient is placed in the supine position, and a 10-cm curvilinear incision is made including the distal 6 to 8 cm of the fibula. The incision is centered directly lateral on the fibula proximally and transitions to the posterolateral aspect of the fibula distally. As the incision continues distally, it extends inferiorly and anteriorly over the sinus tarsi and toward the base of the 4th metatarsal, using an internervous plane between the superficial peroneal nerve anteriorly and the sural nerve posteriorly. Exposure of the periosteum is carried out through development of full-thickness skin flaps. The periosteum is stripped, and a sagittal saw is used to make a beveled cut on the fibula at a 45° angle, approximately 6 to 8 cm proximal to the ankle. The fibular strut is decorticated, drilled, and stripped of the cartilage on the distal end. Preparation of the tibiotalar and subtalar joints for arthrodesis are completed through the lateral incision. The foot is placed in 0° of dorsiflexion, 5° of external rotation in relation to the tibial crest, and 5° of hindfoot valgus while maintaining a plantigrade foot. This placement can be temporarily maintained with Kirschner wires if needed. Next, the plantar surface overlying the heel pad is incised, and a guidewire is passed through the center of the calcaneus and into the medullary cavity of the tibia. Correct alignment of the guidewire is then confirmed on fluoroscopy. The fibular strut autograft is prepared for insertion while the tibiotalocalcaneal canal is reamed to 1 to 2 mm larger than the graft. The graft is tapped into position, followed by placement of two 6.5-mm cancellous screws to immobilize the join","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-04-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807890/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139565054","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}

{"title":"Closed Reduction and Percutaneous Fixation of Lisfranc Injury Using Suspensory Fixation.","authors":"Miraj N Desai, Kevin D Martin","doi":"10.2106/JBJS.ST.21.00066","DOIUrl":"10.2106/JBJS.ST.21.00066","url":null,"abstract":"<p><strong>Background: </strong>This closed reduction and percutaneous fixation (CRPF) technique utilizing suspensory fixation is indicated for the treatment of Lisfranc injuries with displacement or instability of the tarsometatarsal joint complex-and typically only for low-energy, purely ligamentous Lisfranc injuries. The goal of this procedure is to restore joint stability and prevent common complications of Lisfranc injuries (e.g., midfoot arch collapse and posttraumatic arthritis) while avoiding the complications and risks associated with open reduction and internal fixation (ORIF) and primary arthrodesis. We recommend performing the procedure within 10 to 14 days of the injury; otherwise, an open debridement may be necessary to address scar tissue formation.</p><p><strong>Description: </strong>We start with the patient in the supine position and perform a fluoroscopic stress examination of the joint. Next, the Lisfranc joint undergoes closed reduction, which is held in place with a clamp. Following reduction, a guidewire is drilled from the lateral border of the base of the 2nd metatarsal medially through the medial cuneiform, followed by a medial-to-lateral cannulated drill. The suspensory fixation is then passed lateral-to-medial, placing the suture button on the lateral cortex of the 2nd metatarsal base. The tape is then tensioned while a bioabsorbable interference screw is inserted to maintain tension.</p><p><strong>Alternatives: </strong>Prior studies have assessed both operative and nonoperative alternatives to CRPF with suspensory fixation for the treatment of Lisfranc injuries. Nonoperative treatment with closed reduction and cast immobilization of Lisfranc injuries is typically reserved for nondisplaced injuries; however, a number of studies have shown poor outcomes with use of this technique<sup>1-3</sup>. The 2 most common operative alternatives are ORIF and primary arthrodesis<sup>4</sup>.</p><p><strong>Rationale: </strong>CRPF with suspensory fixation offers several benefits over both traditional surgical techniques such as ORIF and primary arthrodesis, as well as over percutaneous reduction and internal fixation (PRIF) with a screw. Compared with ORIF and primary arthrodesis, a number of studies have shown that percutaneous treatment of Lisfranc injuries minimizes soft-tissue trauma and reduces the risk of postoperative complications such as wound breakdown, infection, and complex regional pain syndrome, while allowing for earlier participation in rehabilitation<sup>5-10</sup>. A systematic review of outcomes following PRIF with screw fixation also showed that percutaneous treatment of Lisfranc injuries is a safe and effective technique with good functional outcomes<sup>11</sup>. When comparing PRIF with a screw to our technique of CRPF with suspensory fixation, CRPF has the added benefit of creating a nonrigid fixation in the Lisfranc joint, which allows for increased range of motion of the medial column and improved return t","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-03-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807883/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754552","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}

{"title":"Surgical Debridement for Acute and Chronic Osteomyelitis in Children.","authors":"Ernest Ekunseitan, Coleen S Sabatini, Ishaan Swarup","doi":"10.2106/JBJS.ST.21.00039","DOIUrl":"10.2106/JBJS.ST.21.00039","url":null,"abstract":"<p><strong>Background: </strong>Osteomyelitis is an infection of the bone that commonly occurs in pediatric populations. First-line treatment most often involves a course of antibiotics. In recent studies, surgical debridement, in addition to antibiotics, has been shown to provide positive clinical and functional outcomes in children. Debridement is most often indicated in patients with an abscess or in those who do not respond to empiric antibiotic therapy; however, there are limited video resources describing this technique in pediatric patients.</p><p><strong>Description: </strong>The key steps of the procedure, which are demonstrated in the present video article, are (1) preoperative planning, (2) positioning, (3) subperiosteal exposure and debridement, (4) cortical window creation, (5) irrigation, (6) adjunctive treatment, (7) drain placement, (8) wound closure, (9) dressing and immobilization, and (10) wound check and drain removal.</p><p><strong>Alternatives: </strong>Nonoperative treatment is usually indicated for acute osteomyelitis in which patients present with little to no necrotic tissue or abscess formation. In these cases, a course of broad-spectrum antibiotics may be sufficient for a cure.</p><p><strong>Rationale: </strong>This procedure allows for the removal of necrotic bone and soft tissue, thus facilitating the recovery process. It also allows for the retrieval of tissue samples that may be used to guide selection of the appropriate antibiotic therapy. Surgical debridement is a safe and reliable technique that has been associated with positive long-term outcomes.</p><p><strong>Expected outcomes: </strong>We expect that some patients will require repeat surgical debridement procedures to decrease pathogen burden and prevent future complications. However, we expect that the majority of patients who undergo surgical debridement for uncomplicated osteomyelitis will recover full functionality of the affected limb with no associated long-term sequelae¹⁰.</p><p><strong>Important tips: </strong>Understand preoperative imaging to identify areas of infection, localize critical structures and the physis, and plan surgical approaches.Use extensile approaches and preserve vascularity during the approach.Perform subperiosteal dissection and create a cortical window to debride areas of infection, but avoid excessive periosteal stripping.Close the dead space and wound in a layered manner.</p><p><strong>Acronyms and abbreviations: </strong>MRI = magnetic resonance imagingK-wire = Kirschner wireMRSA = methicillin-resistant <i>Staphylococcus aureus</i>PDS = polydiaxonone.</p>","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-03-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807896/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754351","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}

{"title":"Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position.","authors":"Thomas C Sanchez, Matthew T Sankey, Chad B Willis, Sean M Young, Alex Harrelson, Ashish Shah","doi":"10.2106/JBJS.ST.21.00070","DOIUrl":"10.2106/JBJS.ST.21.00070","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;The mini-open approach with supine patient positioning is a useful technique to consider for acute Achilles rupture repair, ideally performed within 2 weeks from the time of injury. The traditional surgical approach is completed with the patient in the prone position with an extensile midline incision. Here we describe a mini-open approach with supine positioning that utilizes a single incision measuring approximately 3 to 4 cm in length and avoids the pitfalls of prone positioning, which include greater operative time and potential difficult airway management, vision loss, and brachial plexus palsies&lt;sup&gt;1&lt;/sup&gt;.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Description: &lt;/strong&gt;When positioning the patient supine, lower-extremity bolsters are placed beneath the contralateral hip and the operative ankle in order to allow for exaggerated external rotation of the ankle and improved medial visualization. A thigh tourniquet is then applied on the operative side in a standard sterile fashion.After appropriate draping, begin by palpating the tendon rupture site and mark a 3 to 4-cm incision line just medial to the tendon. Sharp dissection through the skin to the level of the paratenon is then performed. Incise the paratenon with a knife, separate the paratenon from the underlying Achilles tendon with a Freer elevator or scissors, subsequently remove any hematoma formation, and cut the paratenon proximally and distally with scissors or a knife. Debride any damaged tendon thoroughly.The steps of the procedure are performed under direct visualization. If the sural nerve is encountered, it is noted and retracted, and extra care is taken to avoid damaging it with instruments or suture.Now that the proximal and distal ends of the Achilles tendon are free, utilize a 4-stranded double Krackow locking stitch with two #2 FiberWires (Arthrex) on both the proximal and the distal stump. The stumps of the ruptured tendon are approximated by tying the free suture ends together with use of a simple surgeon's knot. A running epitendinous repair is performed with use of number-0 Vicryl (Ethicon) suture in a cross-stich weave technique to provide additional strength to the repair. Finally, test the integrity of the repair via an intraoperative Thompson test. The postoperative protocol includes non-weight-bearing with the operative limb in a posterior splint for 2 weeks. At the 2-week follow-up, stitches are removed and the limb is placed in a tall CAM (controlled ankle motion) walker boot with 2 heel wedges measuring 6.35 mm (0.25 inches) apiece. The patient can begin partial weight-bearing with crutches at 2 weeks postoperatively. At 4 weeks postoperatively, 1 heel wedge is removed, and at 6 weeks postoperatively, the second heel wedge is removed. Patients are instructed to begin gentle range-of-motion exercises at 2 weeks, with formal physical therapy scheduled to begin at 6 weeks. Most patients are out of the boot at 8 to 10 weeks postoperatively.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Alte","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-03-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807889/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754569","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}