Pub Date : 2023-03-09eCollection Date: 2023-01-01DOI: 10.2106/JBJS.ST.21.00054
M Lane Moore, Jordan R Pollock, Phillip J Karsen, Jack M Haglin, Cara H Lai, Muhammad A Elahi, Anikar Chhabra, Martin J O'Malley, Karan A Patel
<p><strong>Background: </strong>An open Achilles tendon repair is performed in patients who have suffered an acute rupture. All patients with this injury should be counseled on their treatment options, which include open operative repair and functional rehabilitation. We prefer the use of an open repair in high-level athletes and those who have delayed presentation. Typically, this injury-and the resulting open repair-are seen in young or middle-aged patients as well as athletes. Operative repair of a ruptured Achilles tendon is associated with a much faster return to activity/sport when compared with nonoperative alternatives. This surgical procedure is especially useful in allowing this patient population to return to their previous activity level and functional capacity as quickly as possible.</p><p><strong>Description: </strong>Open repair of a ruptured Achilles tendon begins with a 6 to 8-cm incision over the posteromedial aspect of the lower leg. Superficial and deep dissections are performed until the 2 ends of the ruptured tendon are identified. Adhesions are debrided to adequately mobilize and define the proximal and distal segments of the tendon. With use of a fiber tape suture, a modified locking Bunnell stitch is utilized to secure both ends. The fiber tape is tied securely, and the repair is reinforced with Vicryl suture (Ethicon). Once the tendon is repaired, the paratenon layer is identified and repaired with a running 0 or 2-0 Vicryl suture. This is an important step to minimize postoperative wound complications. The wound is then closed, and the extremity is splinted in maximum plantar flexion.</p><p><strong>Alternatives: </strong>Alternative treatments include minimally invasive surgical techniques such as percutaneous Achilles tendon repair and nonoperative treatment with functional rehabilitation, which can provide excellent outcomes but can also lead to a slight decrease in explosiveness as the patient returns to sport<sup>1,2</sup>.</p><p><strong>Rationale: </strong>Nonoperative and operative treatment of Achilles tendon rupture can both result in excellent patient outcomes. Appropriate patient selection is critical. Younger patients hoping to return to more highly competitive athletics should consider operative repair<sup>3</sup>. Possible differences have been identified in peak torque when comparing operative versus nonoperative treatment, with patients who had undergone operative repair having greater peak torque (i.e., explosiveness)<sup>2</sup>. Otherwise, findings are similar between treatment options as long as the patients meet the criteria for nonoperative treatment.</p><p><strong>Expected outcomes: </strong>Overall, the scientific literature demonstrates that the functional outcomes following operative repair are good to excellent. In a study by Hsu et al.<sup>4</sup>, 88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no rerup
{"title":"Open Achilles Tendon Repair.","authors":"M Lane Moore, Jordan R Pollock, Phillip J Karsen, Jack M Haglin, Cara H Lai, Muhammad A Elahi, Anikar Chhabra, Martin J O'Malley, Karan A Patel","doi":"10.2106/JBJS.ST.21.00054","DOIUrl":"10.2106/JBJS.ST.21.00054","url":null,"abstract":"<p><strong>Background: </strong>An open Achilles tendon repair is performed in patients who have suffered an acute rupture. All patients with this injury should be counseled on their treatment options, which include open operative repair and functional rehabilitation. We prefer the use of an open repair in high-level athletes and those who have delayed presentation. Typically, this injury-and the resulting open repair-are seen in young or middle-aged patients as well as athletes. Operative repair of a ruptured Achilles tendon is associated with a much faster return to activity/sport when compared with nonoperative alternatives. This surgical procedure is especially useful in allowing this patient population to return to their previous activity level and functional capacity as quickly as possible.</p><p><strong>Description: </strong>Open repair of a ruptured Achilles tendon begins with a 6 to 8-cm incision over the posteromedial aspect of the lower leg. Superficial and deep dissections are performed until the 2 ends of the ruptured tendon are identified. Adhesions are debrided to adequately mobilize and define the proximal and distal segments of the tendon. With use of a fiber tape suture, a modified locking Bunnell stitch is utilized to secure both ends. The fiber tape is tied securely, and the repair is reinforced with Vicryl suture (Ethicon). Once the tendon is repaired, the paratenon layer is identified and repaired with a running 0 or 2-0 Vicryl suture. This is an important step to minimize postoperative wound complications. The wound is then closed, and the extremity is splinted in maximum plantar flexion.</p><p><strong>Alternatives: </strong>Alternative treatments include minimally invasive surgical techniques such as percutaneous Achilles tendon repair and nonoperative treatment with functional rehabilitation, which can provide excellent outcomes but can also lead to a slight decrease in explosiveness as the patient returns to sport<sup>1,2</sup>.</p><p><strong>Rationale: </strong>Nonoperative and operative treatment of Achilles tendon rupture can both result in excellent patient outcomes. Appropriate patient selection is critical. Younger patients hoping to return to more highly competitive athletics should consider operative repair<sup>3</sup>. Possible differences have been identified in peak torque when comparing operative versus nonoperative treatment, with patients who had undergone operative repair having greater peak torque (i.e., explosiveness)<sup>2</sup>. Otherwise, findings are similar between treatment options as long as the patients meet the criteria for nonoperative treatment.</p><p><strong>Expected outcomes: </strong>Overall, the scientific literature demonstrates that the functional outcomes following operative repair are good to excellent. In a study by Hsu et al.<sup>4</sup>, 88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no rerup","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/PMC10807880/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754503","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 : 2023-02-28eCollection Date: 2023-01-01DOI: 10.2106/JBJS.ST.22.00007
Kevin D Martin, Christian Curatolo, James Gallagher, Paul Alvarez
<p><strong>Background: </strong>Talar arthroscopic reduction and internal fixation (TARIF) is an alternative approach for the operative fixation of talar fractures that may be utilized instead of more traditional open approaches such as medial, lateral, or even dual anterolateral. The TARIF approach allows for nearly anatomic fracture reduction and fixation of talar neck, body, and posterior dome fractures while minimizing the soft-tissue stripping and vascular injury associated with the standard anterolateral approach.</p><p><strong>Description: </strong>Following initial closed fracture reduction and any associated procedures, we recommend obtaining computed tomography scans of the injured ankle in order to evaluate the fracture pattern and allow for preoperative planning. Most patients can be positioned prone for this procedure, except for those with fractures associated with anterior loose bodies and those with neck fractures requiring reduction, which are both amenable to lateral positioning<sup>1</sup>. The feet are positioned off the end of the bed in a neutral position with room to plantar flex and dorsiflex the ankle freely for reduction maneuvers. Following induction of anesthesia and positioning of the patient, the fluoroscopic screen and arthroscopy equipment are positioned on the side opposite the surgeon. A mini C-arm is utilized for the fluoroscopy. The team may then proceed with preparing and draping the surgical field. The surgeon proceeds with creating posteromedial and posterolateral portals to view the fracture site. For talar neck fractures, we utilize standard posterolateral and posteromedial portals directly adjacent to the Achilles tendon at the level of the tip of the medial malleolus, which have previously been established as safe with respect to neurovascular structures<sup>4</sup>. Of note, for talar body fractures these portals are placed slightly more distal at the level of the distal fibula, allowing the screws to be placed perpendicular to the fracture site. An accessory sinus tarsi portal can be established if further reduction to correct varus is needed. The flexor hallucis longus tendon serves as a landmark throughout the case to maintain orientation. We prefer to utilize a 1.9-mm malleable arthroscopic NanoScope (Arthrex), which maximizes our view in the small subtalar space and allows for visualization over the talar dome. A shaver is then utilized to clear out the deep joint capsule and remove fracture hematoma. In our experience, after the initial primary reduction attempt by the orthopaedic trauma provider, the fracture is relatively stable and often held by an external fixator. The remaining reduction is performed with use of manipulation of the ankle in combination with an accessory sinus tarsi portal, utilizing an elevator or a small reduction tool in 1 of the posterior portals. We have also utilized percutaneous Kirschner wires to "joystick" the fragments prior to the placement of the guidewires. We the
使用 3-0 非吸收性缝合线缝合入口部位，术后使用衬垫良好的 L 型和 U 型夹板：理由：TARIF适用于各种距骨骨折的复位，包括颈部、体部和后切面骨折，其优点是最大程度地减少了标准前外侧入路的软组织剥离和血管损伤。此外，TARIF非常适合软组织包膜受损或伴有血管损伤的患者，如开放性骨折病理患者，因为该方法避免了对这些组织的进一步破坏。该手术的总体目标是在避免前方通常会遇到的神经血管和软组织包膜的同时，获得充分的骨折复位。手术通过两个切口完成，一个是后内侧切口，另一个是后外侧切口，通过这两个切口可以看到骨折、缩小骨折并使用插管螺钉进行固定。在关节镜和透视下对固定后的距骨进行活动范围测试，以确保在保留活动范围的同时进行充分固定：TARIF 手术已成功治疗了许多复杂的距骨骨折2。我们推测，与标准的骨折固定方法相比，该手术能产生同等的效果，而且还能避免过度的软组织破坏和神经血管损伤。我们的关节镜方法可直接观察关节损伤和骨折复位情况，并能排出松动体和骨折血肿，减少已知会导致创伤后踝关节炎的基质金属蛋白酶（MMPs）1,3。多个病例系列对该技术的使用进行了评估，结果显示，通过使用多种评分系统（如美国骨科足踝协会踝-后足评分表）1,2.重要提示：通过手术孔进入踝关节后，应立即识别拇屈肌腱，以防止对神经血管束造成先天性损伤。在对距骨体施加前方力量的同时，跖屈踝关节通常有助于缩窄。将内侧导丝直接放置在拇屈肌腱附近，以确保其足够内侧。利用足部和踝关节的前后透视图像来确保螺钉的放置位置。当螺钉依次拧紧时，直接观察骨折部位，以防止错位。沉入所有螺钉头，并通过关节镜观察直接验证：MVC=机动车碰撞XR=X射线（X光片）CT=计算机断层扫描Ex-fix=外固定器MRI=磁共振成像FT=全螺纹FHL=拇长屈肌AP=前胸ROM=活动范围DVT=深静脉血栓BID=每日两次给药。
{"title":"Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.","authors":"Kevin D Martin, Christian Curatolo, James Gallagher, Paul Alvarez","doi":"10.2106/JBJS.ST.22.00007","DOIUrl":"10.2106/JBJS.ST.22.00007","url":null,"abstract":"<p><strong>Background: </strong>Talar arthroscopic reduction and internal fixation (TARIF) is an alternative approach for the operative fixation of talar fractures that may be utilized instead of more traditional open approaches such as medial, lateral, or even dual anterolateral. The TARIF approach allows for nearly anatomic fracture reduction and fixation of talar neck, body, and posterior dome fractures while minimizing the soft-tissue stripping and vascular injury associated with the standard anterolateral approach.</p><p><strong>Description: </strong>Following initial closed fracture reduction and any associated procedures, we recommend obtaining computed tomography scans of the injured ankle in order to evaluate the fracture pattern and allow for preoperative planning. Most patients can be positioned prone for this procedure, except for those with fractures associated with anterior loose bodies and those with neck fractures requiring reduction, which are both amenable to lateral positioning<sup>1</sup>. The feet are positioned off the end of the bed in a neutral position with room to plantar flex and dorsiflex the ankle freely for reduction maneuvers. Following induction of anesthesia and positioning of the patient, the fluoroscopic screen and arthroscopy equipment are positioned on the side opposite the surgeon. A mini C-arm is utilized for the fluoroscopy. The team may then proceed with preparing and draping the surgical field. The surgeon proceeds with creating posteromedial and posterolateral portals to view the fracture site. For talar neck fractures, we utilize standard posterolateral and posteromedial portals directly adjacent to the Achilles tendon at the level of the tip of the medial malleolus, which have previously been established as safe with respect to neurovascular structures<sup>4</sup>. Of note, for talar body fractures these portals are placed slightly more distal at the level of the distal fibula, allowing the screws to be placed perpendicular to the fracture site. An accessory sinus tarsi portal can be established if further reduction to correct varus is needed. The flexor hallucis longus tendon serves as a landmark throughout the case to maintain orientation. We prefer to utilize a 1.9-mm malleable arthroscopic NanoScope (Arthrex), which maximizes our view in the small subtalar space and allows for visualization over the talar dome. A shaver is then utilized to clear out the deep joint capsule and remove fracture hematoma. In our experience, after the initial primary reduction attempt by the orthopaedic trauma provider, the fracture is relatively stable and often held by an external fixator. The remaining reduction is performed with use of manipulation of the ankle in combination with an accessory sinus tarsi portal, utilizing an elevator or a small reduction tool in 1 of the posterior portals. We have also utilized percutaneous Kirschner wires to \"joystick\" the fragments prior to the placement of the guidewires. We the","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807894/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754698","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 : 2023-02-28eCollection Date: 2023-01-01DOI: 10.2106/JBJS.ST.21.00046
Eric Olsen, Jesse King, Jordan R Pollock, Mathieu Squires, Ramzy Meremikwu, David Walton
<p><strong>Background: </strong>First described by Soule in 1910, arthrodesis of the proximal interphalangeal joint is a common operative method of treatment of hammer toe, or fixed-flexion deformity of the proximal interphalangeal joint of the lesser toes<sup>1</sup>. The deformity is often caused by imbalance in intrinsic and extrinsic muscle function across the interphalangeal joint and metatarsophalangeal joint<sup>2,3</sup>, which can be effectively addressed through proximal interphalangeal joint straightening and arthrodesis in conjunction with soft-tissue balancing of the metatarsophalangeal joint.</p><p><strong>Description: </strong>Following longitudinal skin incision over the joint, a transverse extensor tenotomy and capsulotomy reveal the proximal interphalangeal joint and provide appropriate exposure of the head of the proximal phalanx. With the soft tissues protected, the proximal and middle phalanges undergo resection of the articular surfaces to allow osseous apposition. This step can be performed with a rongeur sagittal saw or with osteotomes<sup>4,5</sup>. The head of the proximal phalanx is resected proximal to the head-neck junction, and the proximal portion of the middle phalanx is removed to expose the subchondral bone. Often, there is a dorsal contracture of the metatarsophalangeal joint that is elevating the toe, which is addressed with use of a longitudinal incision over the metatarsophalangeal joint, a Z-lengthening of the long extensor tendon to the toe, and a subsequent capsulectomy. If there is an angular component to the deformity, the collateral ligaments are released from the metatarsal neck, and the toe can be balanced. If there is residual subluxation of the joint that is incompletely corrected by soft-tissue procedures, a metatarsal osteotomy should be considered. Fixation is then performed with use of a smooth Kirschner wire. The wire is inserted from the middle phalanx out the tip of the toe and subsequently inserted retrograde across the proximal interphalangeal joint, often into the metatarsal head and neck, holding the metatarsophalangeal joint in appropriate position. This step can also be completed with use of novel methods including screws, bioabsorbable pins, or intramedullary implants<sup>6-8</sup>.</p><p><strong>Alternatives: </strong>Nonoperative treatments for hammer toe deformity are generally pursued prior to surgery and include shoe modifications such as a wide toe-box, soft uppers, and padding of osseous prominences<sup>3,9,10</sup>. Alternative surgical treatments include proximal interphalangeal arthroplasty, soft-tissue capsulotomy, extensor tendon lengthening, and amputation<sup>11</sup>.</p><p><strong>Rationale: </strong>Although nonoperative treatment can alleviate symptoms temporarily, surgical treatment is often necessary for definitive treatment of hammer toe. Soft-tissue procedures such as tendon lengthening can provide a stabilizing benefit, but the degenerative bone changes associate
{"title":"Hammer Toe Correction with Proximal Interphalangeal Joint Arthrodesis.","authors":"Eric Olsen, Jesse King, Jordan R Pollock, Mathieu Squires, Ramzy Meremikwu, David Walton","doi":"10.2106/JBJS.ST.21.00046","DOIUrl":"10.2106/JBJS.ST.21.00046","url":null,"abstract":"<p><strong>Background: </strong>First described by Soule in 1910, arthrodesis of the proximal interphalangeal joint is a common operative method of treatment of hammer toe, or fixed-flexion deformity of the proximal interphalangeal joint of the lesser toes<sup>1</sup>. The deformity is often caused by imbalance in intrinsic and extrinsic muscle function across the interphalangeal joint and metatarsophalangeal joint<sup>2,3</sup>, which can be effectively addressed through proximal interphalangeal joint straightening and arthrodesis in conjunction with soft-tissue balancing of the metatarsophalangeal joint.</p><p><strong>Description: </strong>Following longitudinal skin incision over the joint, a transverse extensor tenotomy and capsulotomy reveal the proximal interphalangeal joint and provide appropriate exposure of the head of the proximal phalanx. With the soft tissues protected, the proximal and middle phalanges undergo resection of the articular surfaces to allow osseous apposition. This step can be performed with a rongeur sagittal saw or with osteotomes<sup>4,5</sup>. The head of the proximal phalanx is resected proximal to the head-neck junction, and the proximal portion of the middle phalanx is removed to expose the subchondral bone. Often, there is a dorsal contracture of the metatarsophalangeal joint that is elevating the toe, which is addressed with use of a longitudinal incision over the metatarsophalangeal joint, a Z-lengthening of the long extensor tendon to the toe, and a subsequent capsulectomy. If there is an angular component to the deformity, the collateral ligaments are released from the metatarsal neck, and the toe can be balanced. If there is residual subluxation of the joint that is incompletely corrected by soft-tissue procedures, a metatarsal osteotomy should be considered. Fixation is then performed with use of a smooth Kirschner wire. The wire is inserted from the middle phalanx out the tip of the toe and subsequently inserted retrograde across the proximal interphalangeal joint, often into the metatarsal head and neck, holding the metatarsophalangeal joint in appropriate position. This step can also be completed with use of novel methods including screws, bioabsorbable pins, or intramedullary implants<sup>6-8</sup>.</p><p><strong>Alternatives: </strong>Nonoperative treatments for hammer toe deformity are generally pursued prior to surgery and include shoe modifications such as a wide toe-box, soft uppers, and padding of osseous prominences<sup>3,9,10</sup>. Alternative surgical treatments include proximal interphalangeal arthroplasty, soft-tissue capsulotomy, extensor tendon lengthening, and amputation<sup>11</sup>.</p><p><strong>Rationale: </strong>Although nonoperative treatment can alleviate symptoms temporarily, surgical treatment is often necessary for definitive treatment of hammer toe. Soft-tissue procedures such as tendon lengthening can provide a stabilizing benefit, but the degenerative bone changes associate","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807884/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754458","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 : 2023-01-19eCollection Date: 2023-01-01DOI: 10.2106/JBJS.ST.22.00001
Andrew R Leggett, Gregory J Schneider, Yair D Kissin, Edward Y Cheng, Stephen R Rossman
<p><strong>Background: </strong>Arthroscopic lysis of adhesions is a treatment option for patients with painful, stiff knees as a result of arthrofibrosis following knee arthroplasty, in whom prior manipulation under anesthesia (MUA) has failed. Typically, nonoperative treatment in these patients has also failed, including aggressive physiotherapy, stretching, dynamic splinting, and various pain-management measures or medications. Range of motion in these patients is often suboptimal, and any gains in flexibility will likely have hit a plateau over many months. The goal of performing lysis of adhesions is to increase the range of motion in patients with knee stiffness following total knee arthroplasty, as well as to reduce pain and restore physiologic function of the knee, enabling activities of daily living.</p><p><strong>Description: </strong>This is a straightforward surgical technique that can be performed in a single stage. The preoperative range of motion is documented after induction of general anesthesia. The procedure begins with the establishment of standard medial and lateral parapatellar arthroscopic portals. A blunt trocar is introduced into the knee, and blunt, manual lysis of adhesions is performed in the suprapatellar pouch and the medial and lateral gutters with use of a sweeping motion after piercing and perforating the scarred adhesive bands or capsular tissue. Next, the arthroscope is inserted into the knee, and a diagnostic arthroscopy is performed. Bands of fibrous tissue are released and resected with use of electrocautery and a 4.0-mm arthroscopic shaver. Next, the posterior cruciate ligament (PCL) is visualized in full flexion. If PCL tightness is observed, the PCL can be released from its femoral origin until the flexion gap is increased. This portion of the procedure can include either partial or full release of the PCL, as indicated. Next, the arthroscope is removed and the ipsilateral hip is flexed to 90° for a standard MUA. Gentle force is applied to the proximal aspect of the tibia, and the knee is flexed. After completing the MUA, immediate post-intervention range of motion of the knee is documented, and the patient is provided with a continuous passive motion (CPM) machine set to the maximum flexion and extension achieved in the operating room.</p><p><strong>Alternatives: </strong>Nonoperative treatment of a stiff knee following total knee arthroplasty is well documented in the current literature. Range of motion has been shown to increase in patients undergoing proper pain management, aggressive physical therapy, and closed MUA in the acute postoperative setting. Additionally, more severe cases of established arthrofibrosis despite prior MUA can be treated with an open lysis of adhesions<sup>1-3</sup>.</p><p><strong>Rationale: </strong>Arthroscopic lysis of adhesions with PCL release versus resection has been well described previously. This procedure has been shown to benefit patients in whom initial nonoperative
{"title":"Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty.","authors":"Andrew R Leggett, Gregory J Schneider, Yair D Kissin, Edward Y Cheng, Stephen R Rossman","doi":"10.2106/JBJS.ST.22.00001","DOIUrl":"10.2106/JBJS.ST.22.00001","url":null,"abstract":"<p><strong>Background: </strong>Arthroscopic lysis of adhesions is a treatment option for patients with painful, stiff knees as a result of arthrofibrosis following knee arthroplasty, in whom prior manipulation under anesthesia (MUA) has failed. Typically, nonoperative treatment in these patients has also failed, including aggressive physiotherapy, stretching, dynamic splinting, and various pain-management measures or medications. Range of motion in these patients is often suboptimal, and any gains in flexibility will likely have hit a plateau over many months. The goal of performing lysis of adhesions is to increase the range of motion in patients with knee stiffness following total knee arthroplasty, as well as to reduce pain and restore physiologic function of the knee, enabling activities of daily living.</p><p><strong>Description: </strong>This is a straightforward surgical technique that can be performed in a single stage. The preoperative range of motion is documented after induction of general anesthesia. The procedure begins with the establishment of standard medial and lateral parapatellar arthroscopic portals. A blunt trocar is introduced into the knee, and blunt, manual lysis of adhesions is performed in the suprapatellar pouch and the medial and lateral gutters with use of a sweeping motion after piercing and perforating the scarred adhesive bands or capsular tissue. Next, the arthroscope is inserted into the knee, and a diagnostic arthroscopy is performed. Bands of fibrous tissue are released and resected with use of electrocautery and a 4.0-mm arthroscopic shaver. Next, the posterior cruciate ligament (PCL) is visualized in full flexion. If PCL tightness is observed, the PCL can be released from its femoral origin until the flexion gap is increased. This portion of the procedure can include either partial or full release of the PCL, as indicated. Next, the arthroscope is removed and the ipsilateral hip is flexed to 90° for a standard MUA. Gentle force is applied to the proximal aspect of the tibia, and the knee is flexed. After completing the MUA, immediate post-intervention range of motion of the knee is documented, and the patient is provided with a continuous passive motion (CPM) machine set to the maximum flexion and extension achieved in the operating room.</p><p><strong>Alternatives: </strong>Nonoperative treatment of a stiff knee following total knee arthroplasty is well documented in the current literature. Range of motion has been shown to increase in patients undergoing proper pain management, aggressive physical therapy, and closed MUA in the acute postoperative setting. Additionally, more severe cases of established arthrofibrosis despite prior MUA can be treated with an open lysis of adhesions<sup>1-3</sup>.</p><p><strong>Rationale: </strong>Arthroscopic lysis of adhesions with PCL release versus resection has been well described previously. This procedure has been shown to benefit patients in whom initial nonoperative","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-01-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807902/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754686","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 : 2023-01-04eCollection Date: 2023-01-01DOI: 10.2106/JBJS.ST.21.00041
Muhammad Ali Elahi, Jordan R Pollock, M Lane Moore, Jack M Haglin, Cara Lai, Nathaniel B Hinckley, Kevin J Renfree
<p><strong>Background: </strong>Open trigger finger release is an elective surgical procedure that serves as the gold standard treatment for trigger digits. The aim of this procedure is to release the A1 pulley in a setting in which the pulley is completely visible, ultimately allowing the flexor tendons that were previously impinged on to glide more easily through the tendon sheath. Although A1-or the first annular pulley-is the site of triggering in nearly all cases, alternative sites include A2, A3, and the palmar aponeurosis<sup>1</sup>.</p><p><strong>Description: </strong>Typically, the surgical procedure can be conducted in an outpatient setting and can vary in duration from a few minutes to half an hour. The surgical procedure involves the patient lying in the supine position with the operative hand positioned to the side. A small incision, ranging from 1 to 1.5 cm, is made on the volar side of the hand, just proximal to the A1 pulley in the skin crease in order to minimize scarring. Once the underlying neurovascular structures are exposed, the A1 pulley is released longitudinally at least to the level of the A2 pulley, followed by decompression of the flexor tendons that were previously impinged on. In order to confirm the release, the patient is asked to flex and extend the affected finger. The wound is irrigated and closed once the release is confirmed by both the patient and surgeon.</p><p><strong>Alternatives: </strong>Aside from an open release, trigger finger can be treated nonoperatively with use of splinting and corticosteroid injection. Alternative operative treatments include a percutaneous release, which involves the use of a needle to release the A1 pulley<sup>2</sup>. Trigger finger can initially be treated nonoperatively. If unsuccessful, surgical intervention is considered the ultimate remedy<sup>2</sup>.</p><p><strong>Rationale: </strong>Because of their efficacious nature, corticosteroid injections are indicated preoperatively, particularly in non-diabetic patients<sup>3</sup>. Splinting is often an appropriate treatment option in patients who wish to avoid a corticosteroid injection<sup>1</sup>. However, if nonoperative treatment modalities fail to resolve pain and symptoms, surgical intervention is indicated<sup>2</sup>. In comparison with a percutaneous trigger finger release, an open release provides enhanced exposure and may be safer with respect to avoiding iatrogenic neurovascular injury<sup>2</sup>. However, in a randomized controlled trial, Gilberts et al. found no difference in the rates of recurrence when comparing open versus percutaneous trigger finger release<sup>4</sup>.</p><p><strong>Expected outcomes: </strong>With reported success rates ranging from 90% to 100%, the open release of the A1 pulley is considered a common procedure associated with minimal complications<sup>2</sup>. Complications of the procedure were assessed in a retrospective analysis of 43 patients who underwent 78 open trigger releases p
{"title":"Tendon Sheath Incision for Surgical Treatment of Trigger Finger.","authors":"Muhammad Ali Elahi, Jordan R Pollock, M Lane Moore, Jack M Haglin, Cara Lai, Nathaniel B Hinckley, Kevin J Renfree","doi":"10.2106/JBJS.ST.21.00041","DOIUrl":"10.2106/JBJS.ST.21.00041","url":null,"abstract":"<p><strong>Background: </strong>Open trigger finger release is an elective surgical procedure that serves as the gold standard treatment for trigger digits. The aim of this procedure is to release the A1 pulley in a setting in which the pulley is completely visible, ultimately allowing the flexor tendons that were previously impinged on to glide more easily through the tendon sheath. Although A1-or the first annular pulley-is the site of triggering in nearly all cases, alternative sites include A2, A3, and the palmar aponeurosis<sup>1</sup>.</p><p><strong>Description: </strong>Typically, the surgical procedure can be conducted in an outpatient setting and can vary in duration from a few minutes to half an hour. The surgical procedure involves the patient lying in the supine position with the operative hand positioned to the side. A small incision, ranging from 1 to 1.5 cm, is made on the volar side of the hand, just proximal to the A1 pulley in the skin crease in order to minimize scarring. Once the underlying neurovascular structures are exposed, the A1 pulley is released longitudinally at least to the level of the A2 pulley, followed by decompression of the flexor tendons that were previously impinged on. In order to confirm the release, the patient is asked to flex and extend the affected finger. The wound is irrigated and closed once the release is confirmed by both the patient and surgeon.</p><p><strong>Alternatives: </strong>Aside from an open release, trigger finger can be treated nonoperatively with use of splinting and corticosteroid injection. Alternative operative treatments include a percutaneous release, which involves the use of a needle to release the A1 pulley<sup>2</sup>. Trigger finger can initially be treated nonoperatively. If unsuccessful, surgical intervention is considered the ultimate remedy<sup>2</sup>.</p><p><strong>Rationale: </strong>Because of their efficacious nature, corticosteroid injections are indicated preoperatively, particularly in non-diabetic patients<sup>3</sup>. Splinting is often an appropriate treatment option in patients who wish to avoid a corticosteroid injection<sup>1</sup>. However, if nonoperative treatment modalities fail to resolve pain and symptoms, surgical intervention is indicated<sup>2</sup>. In comparison with a percutaneous trigger finger release, an open release provides enhanced exposure and may be safer with respect to avoiding iatrogenic neurovascular injury<sup>2</sup>. However, in a randomized controlled trial, Gilberts et al. found no difference in the rates of recurrence when comparing open versus percutaneous trigger finger release<sup>4</sup>.</p><p><strong>Expected outcomes: </strong>With reported success rates ranging from 90% to 100%, the open release of the A1 pulley is considered a common procedure associated with minimal complications<sup>2</sup>. Complications of the procedure were assessed in a retrospective analysis of 43 patients who underwent 78 open trigger releases p","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":1.0,"publicationDate":"2023-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10807900/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67754419","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 : 2023-01-01DOI: 10.2106/jbjs.st.22.00022
Karim Shafi, Francis Lovecchio, Junho Song, Sheeraz Qureshi
Background: Lateral lumbar interbody fusion (LLIF) is a widely utilized minimally invasive surgical procedure for anterior fusion of the lumbar spine. However, posterior decompression or instrumentation often necessitates patient repositioning, which is associated with increased operative time and time under anesthesia 1–3 . The single-position prone transpsoas approach is a technique that allows surgeons to access both the anterior and posterior aspects of the spine, bypassing the need for intraoperative repositioning and therefore optimizing efficiency 4 . The use of robotic assistance allows for decreased radiation exposure and increased accuracy, both with placing instrumentation and navigating the lateral corridor. Description: The patient is placed in the prone position, and pedicle screws are placed prior to interbody fusion. Pedicle screws are placed with robotic guidance. After posterior instrumentation, a skin incision for LLIF is made in the cephalocaudal direction, orthogonal to the disc space, with use of intraoperative (robotic) navigation. Fascia and abdominal muscles are incised to enter the retroperitoneal space. Under direct visualization, dilators are placed through the psoas muscle into the disc space, and an expandable retractor is placed and maintained with use of the robotic arm. Following a thorough discectomy, the disc space is sized with trial implants. The expandable cage is placed, and intraoperative fluoroscopy is utilized to verify good instrumentation positioning. Finally, posterior rods are placed percutaneously. Alternatives: An alternative surgical approach is a traditional LLIF with the patient beginning in the lateral position, with intraoperative repositioning from the lateral to the prone position if circumferential fusion is warranted. Additional alternative surgical procedures include anterior or posterior lumbar interbody fusion techniques. Rationale: LLIF is associated with reported advantages of decreased risks of vascular injury, visceral injury, dural tear, and perioperative infection 5,6 . The single-position prone transpsoas approach confers the added benefits of reduced operative time, anesthesia time, and surgical staffing requirements 7 . Other potential benefits of the prone lateral approach include improved lumbar lordosis correction, gravity-induced displacement of peritoneal contents, and ease of posterior decompression and instrumentation 8–11 . Additionally, the use of robotic assistance offers numerous benefits to minimally invasive techniques, including intraoperative navigation, instrumentation templating, a more streamlined workflow, and increased accuracy in placing instrumentation, while also providing a reduction in radiation exposure and operative time. In our experience, the table-mounted LLIF retractor has a tendency to drift toward the floor—i.e., anteriorly—when the patient is positioned prone, which may, in theory, increase the risk of iatrogenic bowel injury. The rigid robotic
背景:侧位腰椎椎体间融合术(LLIF)是一种广泛应用于腰椎前路融合术的微创手术。然而，后路减压或内固定往往需要患者重新定位，这增加了手术时间和麻醉下的时间1-3。单体位俯卧转腰肌入路是一种允许外科医生同时进入脊柱前侧和后侧的技术，无需术中重新定位，从而优化了效率。使用机器人辅助可以减少辐射暴露，提高准确性，无论是放置仪器还是导航横向通道。描述:将患者置于俯卧位，椎弓根螺钉置于椎间融合术前。椎弓根螺钉在机器人引导下放置。后路内固定后，使用术中(机器人)导航，在头尾方向与椎间盘间隙正交的方向上对LLIF进行皮肤切口。切开筋膜和腹肌进入腹膜后间隙。在直接目视下，通过腰肌将扩张器置入椎间盘间隙，使用机械臂放置并维持可伸缩的牵开器。椎间盘彻底切除后，用试验植入物确定椎间盘间隙的大小。放置可膨胀的保持器，术中使用透视检查来验证良好的器械定位。最后，经皮放置后棒。替代方法:另一种手术方法是传统的LLIF，患者从侧位开始，如果需要进行周向融合，则术中从侧位重新定位到俯卧位。其他可选择的外科手术包括前路或后路腰椎椎间融合术。理由:据报道，LLIF具有降低血管损伤、内脏损伤、硬脑膜撕裂和围手术期感染风险的优势5,6。单体位俯卧转腰肌入路具有减少手术时间、麻醉时间和手术人员需求的额外好处7。俯卧侧位入路的其他潜在益处包括改善腰椎前凸矫正，重力引起的腹膜内容物移位，以及易于后路减压和内固定8-11。此外，机器人辅助的使用为微创技术提供了许多好处，包括术中导航、器械模板、更简化的工作流程、放置器械的准确性提高，同时还减少了辐射暴露和手术时间。根据我们的经验，桌上式LLIF牵开器有向地板漂移的倾向。当病人俯卧时，这在理论上可能会增加医源性肠损伤的风险。刚性机械臂比传统的牵开器要硬得多，从而降低了这种风险。预期结果:与传统的侧卧位和俯卧位的LLIF相比，单一俯卧位的LLIF有几个好处。Guiroy等人进行了一项比较单体位和双体位LLIF的系统综述，发现单体位手术明显缩短手术时间(103.1分钟vs 306.6分钟)、估计失血量(97.3 mL vs 314.4 mL)和住院时间(1.71天vs 4.08天)17。先前的研究报道了俯卧位可改善对节段性前凸的控制，这可能对矢状位不平衡的患者有利18,19。重要提示:充分释放深筋膜层对于尽量减少牵开器和导航器械的偏转至关重要。髋应最大限度地伸展以最大限度地前凸，允许股神经后平移并增加外侧通道的宽度。在胸腔旁放置一个支撑，以在撞击移植物时提供对侧向定向力的阻力。入路的颅端和尾端边界以胸腔和髂骨为界;因此，在上腰椎或下腰椎进行手术可能不可行。术前应评估x线片，以确定该入路在预期水平的可行性。当在L4-L5椎间盘间隙操作时，后侧牵拉对股神经造成很大的张力。因此，牵开时间应尽可能缩短，最多限制在20分钟左右。以目前的牵开叶片长度，大约20厘米的景深(从中线到侧翼的距离)可能是这种方法的极限19。
{"title":"Robotic-Assisted Single-Position Prone Lateral Lumbar Interbody Fusion","authors":"Karim Shafi, Francis Lovecchio, Junho Song, Sheeraz Qureshi","doi":"10.2106/jbjs.st.22.00022","DOIUrl":"https://doi.org/10.2106/jbjs.st.22.00022","url":null,"abstract":"Background: Lateral lumbar interbody fusion (LLIF) is a widely utilized minimally invasive surgical procedure for anterior fusion of the lumbar spine. However, posterior decompression or instrumentation often necessitates patient repositioning, which is associated with increased operative time and time under anesthesia 1–3 . The single-position prone transpsoas approach is a technique that allows surgeons to access both the anterior and posterior aspects of the spine, bypassing the need for intraoperative repositioning and therefore optimizing efficiency 4 . The use of robotic assistance allows for decreased radiation exposure and increased accuracy, both with placing instrumentation and navigating the lateral corridor. Description: The patient is placed in the prone position, and pedicle screws are placed prior to interbody fusion. Pedicle screws are placed with robotic guidance. After posterior instrumentation, a skin incision for LLIF is made in the cephalocaudal direction, orthogonal to the disc space, with use of intraoperative (robotic) navigation. Fascia and abdominal muscles are incised to enter the retroperitoneal space. Under direct visualization, dilators are placed through the psoas muscle into the disc space, and an expandable retractor is placed and maintained with use of the robotic arm. Following a thorough discectomy, the disc space is sized with trial implants. The expandable cage is placed, and intraoperative fluoroscopy is utilized to verify good instrumentation positioning. Finally, posterior rods are placed percutaneously. Alternatives: An alternative surgical approach is a traditional LLIF with the patient beginning in the lateral position, with intraoperative repositioning from the lateral to the prone position if circumferential fusion is warranted. Additional alternative surgical procedures include anterior or posterior lumbar interbody fusion techniques. Rationale: LLIF is associated with reported advantages of decreased risks of vascular injury, visceral injury, dural tear, and perioperative infection 5,6 . The single-position prone transpsoas approach confers the added benefits of reduced operative time, anesthesia time, and surgical staffing requirements 7 . Other potential benefits of the prone lateral approach include improved lumbar lordosis correction, gravity-induced displacement of peritoneal contents, and ease of posterior decompression and instrumentation 8–11 . Additionally, the use of robotic assistance offers numerous benefits to minimally invasive techniques, including intraoperative navigation, instrumentation templating, a more streamlined workflow, and increased accuracy in placing instrumentation, while also providing a reduction in radiation exposure and operative time. In our experience, the table-mounted LLIF retractor has a tendency to drift toward the floor—i.e., anteriorly—when the patient is positioned prone, which may, in theory, increase the risk of iatrogenic bowel injury. The rigid robotic ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135758433","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Genu valgum is a common disorder affecting adolescents and young adults. Treatment of this disorder requires restoration of normal mechanical axis alignment and joint orientation, for which it is important to assess whether the deformity arises from the distal femur, knee joint, or proximal tibia. Most commonly, the deformity originates from the distal femur, and various osteotomies of the distal femur have been described 1–6 . The presently described wedgeless V-shaped osteotomy 7,8 is a good option among the various alternative procedures listed below. Description: The anesthetized patient is placed in the supine position on a radiolucent operating table. A bolster is placed beneath the knee to relax the posterior structures. A medial longitudinal skin incision is made that extends from the level of the medial joint line to 5 cm proximal to the adductor tubercle. The vastus medialis is identified and elevated anteriorly by detaching it from its distal and posterior aspects. The leash of vessels underneath the vastus medialis is identified, and the apex of the V-shaped osteotomy is kept just proximal to it. The anterior arm of the V is kept longer than the posterior one, both of them are kept perpendicular to each other, and the apex of the V is made to point distally. The osteotomy is performed on the medial cortex with use of an oscillating saw or multiple drill holes that are then connected using a thin osteotome. Care is taken not to utilize a saw or drill on the lateral cortex. A gentle valgus thrust is applied to break the lateral cortex without periosteal disruption. The apex of the V osteotomy on the proximal fragment is trimmed, and the deformity is corrected with varus force. The osteotomy site is stabilized with use of an anatomically contoured distal medial femoral locking plate or a medial proximal tibial L-shaped buttress plate (of the contralateral side). The implant position is verified under a C-arm image intensifier. The wound is closed in layers over a suction drain in a standard manner. Alternatives: Various types of corrective osteotomies of the distal femur have been described in the literature, including the lateral opening wedge, medial closing wedge, dome, and spike osteotomies 1–6 . All of these procedures have certain limitations and shortcomings. Rationale: The wedgeless V-shaped osteotomy is another described procedure that is inherently stable 7,8 . It is a safe procedure and yields good clinical outcomes 8,9 . The posterior arm of the V-shaped osteotomy is kept smaller than the anterior arm. The proximal cortical bone is allowed to dig into the cancellous bone of the wider distal metaphysis during deformity correction. Trimming the apex of proximal bone end after making the osteotomy facilitates the process. Expected Outcomes: In a study of 46 patients with a mean age of 16.9 years (range, 15 years to 23 years), Gupta et al. 8 reported that the mean radiographic tibiofemoral angle improved from 22.2° (r
{"title":"Wedgeless V-Shaped Osteotomy of the Distal Medial Femur with Locking Plate Fixation for Correction of Genu Valgum in Adolescents and Young Adults","authors":"Sumit Arora, Rahul Garg, Mudit Sharma, Vineet Bajaj, Abhishek Kashyap, Vikas Gupta","doi":"10.2106/jbjs.st.22.00033","DOIUrl":"https://doi.org/10.2106/jbjs.st.22.00033","url":null,"abstract":"Background: Genu valgum is a common disorder affecting adolescents and young adults. Treatment of this disorder requires restoration of normal mechanical axis alignment and joint orientation, for which it is important to assess whether the deformity arises from the distal femur, knee joint, or proximal tibia. Most commonly, the deformity originates from the distal femur, and various osteotomies of the distal femur have been described 1–6 . The presently described wedgeless V-shaped osteotomy 7,8 is a good option among the various alternative procedures listed below. Description: The anesthetized patient is placed in the supine position on a radiolucent operating table. A bolster is placed beneath the knee to relax the posterior structures. A medial longitudinal skin incision is made that extends from the level of the medial joint line to 5 cm proximal to the adductor tubercle. The vastus medialis is identified and elevated anteriorly by detaching it from its distal and posterior aspects. The leash of vessels underneath the vastus medialis is identified, and the apex of the V-shaped osteotomy is kept just proximal to it. The anterior arm of the V is kept longer than the posterior one, both of them are kept perpendicular to each other, and the apex of the V is made to point distally. The osteotomy is performed on the medial cortex with use of an oscillating saw or multiple drill holes that are then connected using a thin osteotome. Care is taken not to utilize a saw or drill on the lateral cortex. A gentle valgus thrust is applied to break the lateral cortex without periosteal disruption. The apex of the V osteotomy on the proximal fragment is trimmed, and the deformity is corrected with varus force. The osteotomy site is stabilized with use of an anatomically contoured distal medial femoral locking plate or a medial proximal tibial L-shaped buttress plate (of the contralateral side). The implant position is verified under a C-arm image intensifier. The wound is closed in layers over a suction drain in a standard manner. Alternatives: Various types of corrective osteotomies of the distal femur have been described in the literature, including the lateral opening wedge, medial closing wedge, dome, and spike osteotomies 1–6 . All of these procedures have certain limitations and shortcomings. Rationale: The wedgeless V-shaped osteotomy is another described procedure that is inherently stable 7,8 . It is a safe procedure and yields good clinical outcomes 8,9 . The posterior arm of the V-shaped osteotomy is kept smaller than the anterior arm. The proximal cortical bone is allowed to dig into the cancellous bone of the wider distal metaphysis during deformity correction. Trimming the apex of proximal bone end after making the osteotomy facilitates the process. Expected Outcomes: In a study of 46 patients with a mean age of 16.9 years (range, 15 years to 23 years), Gupta et al. 8 reported that the mean radiographic tibiofemoral angle improved from 22.2° (r","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135709996","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: The described technique is useful for achieving closed reduction of severely displaced (i.e., Judet Type-III and IV) pediatric radial neck fractures. It is widely agreed that radial neck fractures with angulation of >30° should be reduced. Various maneuvers have been described, but none uniformly achieves complete reduction in severely displaced radial neck fractures (Types III and IV) 1–4 . The aim of the present technique is to achieve closed reduction in these severely displaced radial neck fractures without surgical instrumentation. Description: A stepwise approach is described. First, the radial head is viewed in profile under an image intensifier so that it appears rectangular. Varus stress is applied at the medial aspect of the elbow by the assistant, and thumb pressure is applied at the radial head along the posterolateral aspect of the elbow. This results in partial reduction of the radial head. The elbow is then simultaneously flexed and pronated with continuous pressure over the radial head. This final step anatomically reduces the radial head, and hyperpronating the forearm locks it in the corrected position. Alternatives: Operative alternatives to this technique include intra-focal pin-assisted reduction to achieve closed reduction, the Métaizeau technique of achieving indirect closed reduction of the fracture with the aid of a TENS (Titanium Elastic Nailing System) nail, and open reduction 5 . Nonoperative techniques have also been described for use with Judet Type-II and III fractures, but not with the severely displaced types described in the present article. Rationale: This technique takes into consideration the anatomy of the capsule and lateral collateral ligament complex. The biomechanical ligamentotaxis helps in achieving anatomic reduction of the radial head. Placing the forearm in pronation tightens the annular and lateral collateral ligaments and prevents redisplacement. There are potential complications with operative treatment, including the risk of nerve injury with percutaneous reduction techniques and the risks of osteonecrosis, premature epiphyseal fusion, and heterotopic ossification with open reduction. These complications can be avoided by the use of the presently described technique. Expected Outcomes: This technique provided satisfactory clinical outcomes in our previous study 6 , with none of the 10 patients showing signs of growth disturbance, loss of reduction, or reported complications at 12 months. Terminal restriction of supination was observed in 1 patient. No patient had osteonecrosis or elbow deformity. No patient required conversion to an implant-assisted or open reduction procedure. Important Tips: The steps need to be followed sequentially as described in order to achieve an anatomical reduction. After achieving the reduction, it is necessary to keep the forearm in pronation to maintain the reduction with the aid of the lateral ligament complex. This technique may not work in complex f
{"title":"Closed Reduction Technique for Severely Displaced Radial Neck Fractures in Children","authors":"Maulin Shah, Gaurav Gupta, Qaisur Rabbi, Vikas Bohra, Kemble Wang, Akash Makadia, Shalin Shah, Chinmay Sangole","doi":"10.2106/jbjs.st.21.00064","DOIUrl":"https://doi.org/10.2106/jbjs.st.21.00064","url":null,"abstract":"Background: The described technique is useful for achieving closed reduction of severely displaced (i.e., Judet Type-III and IV) pediatric radial neck fractures. It is widely agreed that radial neck fractures with angulation of >30° should be reduced. Various maneuvers have been described, but none uniformly achieves complete reduction in severely displaced radial neck fractures (Types III and IV) 1–4 . The aim of the present technique is to achieve closed reduction in these severely displaced radial neck fractures without surgical instrumentation. Description: A stepwise approach is described. First, the radial head is viewed in profile under an image intensifier so that it appears rectangular. Varus stress is applied at the medial aspect of the elbow by the assistant, and thumb pressure is applied at the radial head along the posterolateral aspect of the elbow. This results in partial reduction of the radial head. The elbow is then simultaneously flexed and pronated with continuous pressure over the radial head. This final step anatomically reduces the radial head, and hyperpronating the forearm locks it in the corrected position. Alternatives: Operative alternatives to this technique include intra-focal pin-assisted reduction to achieve closed reduction, the Métaizeau technique of achieving indirect closed reduction of the fracture with the aid of a TENS (Titanium Elastic Nailing System) nail, and open reduction 5 . Nonoperative techniques have also been described for use with Judet Type-II and III fractures, but not with the severely displaced types described in the present article. Rationale: This technique takes into consideration the anatomy of the capsule and lateral collateral ligament complex. The biomechanical ligamentotaxis helps in achieving anatomic reduction of the radial head. Placing the forearm in pronation tightens the annular and lateral collateral ligaments and prevents redisplacement. There are potential complications with operative treatment, including the risk of nerve injury with percutaneous reduction techniques and the risks of osteonecrosis, premature epiphyseal fusion, and heterotopic ossification with open reduction. These complications can be avoided by the use of the presently described technique. Expected Outcomes: This technique provided satisfactory clinical outcomes in our previous study 6 , with none of the 10 patients showing signs of growth disturbance, loss of reduction, or reported complications at 12 months. Terminal restriction of supination was observed in 1 patient. No patient had osteonecrosis or elbow deformity. No patient required conversion to an implant-assisted or open reduction procedure. Important Tips: The steps need to be followed sequentially as described in order to achieve an anatomical reduction. After achieving the reduction, it is necessary to keep the forearm in pronation to maintain the reduction with the aid of the lateral ligament complex. This technique may not work in complex f","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135077618","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-01-01DOI: 10.2106/jbjs.st.23.00028
Donald H. Lee
Background: The present video article describes the steps, alternatives, and outcomes of the modified Brunelli reconstruction, also known as 3-ligament tenodesis, for the treatment of irreparable scapholunate dissociations. Description: The presently described technique is generally utilized in cases in which there is an irreparable disruption of the scapholunate ligament and widening of the scapholunate junction with no carpal arthritis. Alternatives: Other treatment options for irreparable scapholunate dissociation include various forms of capsulotenodesis, bone-ligament-bone reconstruction, tendon-based reconstructions, partial wrist arthrodesis, and proximal row carpectomy. Rationale: The modified Brunelli reconstruction is indicated for a nonrepairable complete scapholunate ligament injury with a reducible rotatory subluxation of the scaphoid, without cartilage degeneration. The dorsal scapholunate ligament is reconstructed and the distal palmar scaphoid rotation is corrected with use of a distally based flexor carpi radialis tendon. The reconstruction is achieved by placing the flexor carpi radialis tendon through a transosseous scaphoid tunnel and weaving the tendon through the dorsal ulnar capsule or radiotriquetral ligament. Expected Outcomes: The modified Brunelli technique has been shown to restore wrist motion to 70% to 80% of that of the contralateral wrist and grip strength to 65% to 75% of that of the contralateral wrist, as well as to provide good pain relief in approximately 70% to 80% of patients. Important Tips: With use of simple instrumentation, C-arm fluoroscopy, and proper surgical technique, this operative procedure is fairly reproducible. Acronyms and Abbreviations: FCR = flexor carpi radialis K-wire = Kirschner wire
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Pub Date : 2023-01-01DOI: 10.2106/jbjs.st.21.00065
Stephen Saela, Michael Pompliano, Jeffrey Varghese, Kumar Sinha, Michael Faloon, Arash Emami
Background: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been established as an excellent alternative to the traditional open approach for the treatment of degenerative conditions of the lumbar spine 1–3 . Description: The procedure is performed with the patient under general anesthesia and on a radiolucent table in order to allow for intraoperative fluoroscopy. The procedure is performed through small incisions made over the vertebral levels of interest, typically utilizing either a fixed or expandable type of tubular dilator, which is eventually seated against the facet joint complex 4 . A laminectomy and/or facetectomy is performed in order to expose the disc space, and the ipsilateral neural elements are visualized 5 . The end plates are prepared, and an interbody device is placed after the disc is removed. Pedicle screws and rods are then placed for posterior fixation. Alternatives: Nonoperative alternatives include physical therapy and corticosteroid injections. Other operative techniques include open TLIF or other types of lumbar fusion approaches, such as posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion, lateral or extreme lateral interbody fusion, or oblique lumbar interbody fusion. Rationale: Open TLIF was developed in order to obtain a more lateral approach to the lumbar disc space than was previously possible with PLIF. The goal of this was to minimize the amount of thecal-sac and nerve-root retraction required during PLIF 4 . Additionally, as the number of patients who required revision after PLIF increased, the need arose for an approach to the lumbar spine that circumvented the posterior midline scarring from previous PLIF surgical sites 6 . MI-TLIF was introduced to reduce the approach-related paraspinal muscle damage of open TLIF 5 . Indications for MI-TLIF include most degenerative pathology of the lumbar spine, including disc herniation, low-grade spondylolisthesis, and spinal and foraminal stenosis 7 . However, MI-TLIF allows for less robust correction of deformity than other minimally invasive approaches; therefore, MI-TLIF may not be as effective in cases of substantial spinal deformity or high-grade spondylolisthesis 8 . Expected Outcomes: MI-TLIF results in significantly less blood loss, postoperative pain, and hospital length of stay compared with open TLIF 1–3 . Although some studies have suggested increased operative time for MI-TLIF 9,10 , meta-analyses have shown comparable operative times between the 2 techniques 1–3 . It is thought that the discrepancy in reported operative times is the result of a learning curve and that, once that is overcome, the difference in operative time between the 2 techniques becomes minimal 11,12 . One disadvantage of MI-TLIF that has remained constant in the literature is its increased intraoperative fluoroscopy time compared with open TLIF 3,13 . The complication rate has largely been found to be equivalent between open and MI-TLIF 1–
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