Pub Date : 2024-08-06eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00051
Eddie Y Lo, Alvin Ouseph, Jeffrey Sodl, Raffaele Garofalo, Sumant G Krishnan
Background: With the increased utilization of reverse total shoulder arthroplasty (RTSA), there has been a corresponding increase in the incidence of and demand for revision RTSA3. In cases in which the patient has undergone multiple previous surgeries and presents with well-fixed shoulder implants, even the most experienced shoulder surgeon can be overwhelmed and frustrated. Having a simple and reproducible treatment algorithm to plan and execute a successful revision surgery will ease the anxiety of a revision operation and avoid future additional revisions. The extraction techniques described here strive to preserve the humeral and glenoid anatomy, hopefully facilitating the reimplantation steps to follow.
Description: The main principles of implant removal include several consistent, simple steps. In order to revise a well-fixed humeral implant, (1) identify the old implants; (2) create a preoperative plan that systematically evaluates the glenoid and humeral deficiencies; (3) prepare consistent surgical tools, such as an oscillating saw, osteotomes, and/or a tamp; (4) follow the deltoid; (5) dissect the soft tissue with a sponge; (6) dissect the bone with use of an osteotome; and (7) remove the humeral stem in rotation. In cases in which there is also a well-fixed glenoid implant, the surgical procedure will require additional steps, including (8) exposure of the anteroinferior glenoid, (9) disengagement of the glenosphere, and (10) removal of the glenoid baseplate in rotation.
Alternatives: Alternatives to revision RTSA include nonoperative treatment, implant retention with conversion of modular components, extensile revision surgical techniques, and/or mechanical implant removal. With the advent of modular humeral and glenoid components, surgeons may choose to change the implant components instead of removing the entire humeral and glenoid implants; however, repeat complications may occur if the previous implant or implant position was not completely revised. When confronted with a tough humeral explantation, an extensile surgical approach involves creating a cortical window or humeral osteotomy to expose the humeral implant. This approach can compromise the humeral shaft integrity, leading to alternative and less ideal reconstruction implant choices, the use of cerclage wires, and/or the use of a strut graft, all of which may complicate postoperative mobilization. If glenoid implant removal is necessary, the glenosphere is removed first, followed by the underlying baseplate component(s). If the glenosphere is stuck or if screws are cold-welded, the use of a conventional mechanical extraction technique with a burr or diamond saw may be required; however, this may lead to additional metal debris and intraoperative sparks.
Rationale: Revision RTSA can lead to high complication rates, ranging from 12% to 70%2, which will often requir
{"title":"Revising Failed Reverse Total Shoulder Arthroplasty: Comprehensive Techniques for Precise Explantation of Well-Fixed Implants.","authors":"Eddie Y Lo, Alvin Ouseph, Jeffrey Sodl, Raffaele Garofalo, Sumant G Krishnan","doi":"10.2106/JBJS.ST.23.00051","DOIUrl":"10.2106/JBJS.ST.23.00051","url":null,"abstract":"<p><strong>Background: </strong>With the increased utilization of reverse total shoulder arthroplasty (RTSA), there has been a corresponding increase in the incidence of and demand for revision RTSA<sup>3</sup>. In cases in which the patient has undergone multiple previous surgeries and presents with well-fixed shoulder implants, even the most experienced shoulder surgeon can be overwhelmed and frustrated. Having a simple and reproducible treatment algorithm to plan and execute a successful revision surgery will ease the anxiety of a revision operation and avoid future additional revisions. The extraction techniques described here strive to preserve the humeral and glenoid anatomy, hopefully facilitating the reimplantation steps to follow.</p><p><strong>Description: </strong>The main principles of implant removal include several consistent, simple steps. In order to revise a well-fixed humeral implant, (1) identify the old implants; (2) create a preoperative plan that systematically evaluates the glenoid and humeral deficiencies; (3) prepare consistent surgical tools, such as an oscillating saw, osteotomes, and/or a tamp; (4) follow the deltoid; (5) dissect the soft tissue with a sponge; (6) dissect the bone with use of an osteotome; and (7) remove the humeral stem in rotation. In cases in which there is also a well-fixed glenoid implant, the surgical procedure will require additional steps, including (8) exposure of the anteroinferior glenoid, (9) disengagement of the glenosphere, and (10) removal of the glenoid baseplate in rotation.</p><p><strong>Alternatives: </strong>Alternatives to revision RTSA include nonoperative treatment, implant retention with conversion of modular components, extensile revision surgical techniques, and/or mechanical implant removal. With the advent of modular humeral and glenoid components, surgeons may choose to change the implant components instead of removing the entire humeral and glenoid implants; however, repeat complications may occur if the previous implant or implant position was not completely revised. When confronted with a tough humeral explantation, an extensile surgical approach involves creating a cortical window or humeral osteotomy to expose the humeral implant. This approach can compromise the humeral shaft integrity, leading to alternative and less ideal reconstruction implant choices, the use of cerclage wires, and/or the use of a strut graft, all of which may complicate postoperative mobilization. If glenoid implant removal is necessary, the glenosphere is removed first, followed by the underlying baseplate component(s). If the glenosphere is stuck or if screws are cold-welded, the use of a conventional mechanical extraction technique with a burr or diamond saw may be required; however, this may lead to additional metal debris and intraoperative sparks.</p><p><strong>Rationale: </strong>Revision RTSA can lead to high complication rates, ranging from 12% to 70%<sup>2</sup>, which will often requir","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11299987/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141898610","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-10eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00015
Jason S Hoellwarth, Kevin Tetsworth, Munjed Al Muderis
Background: Upper limb (UL) amputation is disabling. ULs are necessary for many domains of life1, and few effective motor and sensory replacements are accessible2. Approximately 41,000 people in the United States have UL amputation proximal to the fingers3, two-thirds of (all) traumatic amputations are UL4, and 80% of UL amputations are performed for trauma-related etiologies5. Socket prosthesis (SP) abandonment remains high because of the lack of sensation, limited prosthesis control, perceived weight, and difficulty comfortably wearing the SP6. Transcutaneous osseointegration7,8 surgically inserts a bone-anchored implant, passed through a transcutaneous portal to attach a terminal device, improving amputee rehabilitation by reducing perceived weight, conferring osseoperception9, and increasing wear time10. Without the socket, all residual skin and musculature remain available for transcutaneous myoelectrodes. The present article describes single-stage radius and ulna press-fit osseointegration (PFOI) after trans-forearm amputation.
Description: This technique resembles a lower-extremity PFOI11,12. Importantly, at-risk nerves and vessels are different, and implant impaction must be gentler as a result. The surgery is indicated for patients who are dissatisfied with SP rehabilitation or declining alternative rehabilitative options, and who are motivated and enabled to procure, train with, and utilize a forearm prosthesis. An engaged prosthetist is critical. Surgical steps are exposure, bone-end and canal preparation, first implant insertion (in the operative video shown, in the radius), purse-string muscle closure, confirmation that radius-ulna motion remains, performing the prior steps for the other bone (in the video, the ulna), and closure (including potential nerve reconstruction, soft-tissue contouring, and portal creation). Although the patient in the operative video did not require nerve procedures to address pain or to create targets for transcutaneous myoelectrodes, targeted muscle reinnervation or a regenerative peripheral nerve interface procedure could be performed following exposure.
Alternatives: Alternatives include socket modification, bone lengthening and/or soft-tissue contouring13, Krukenberg-type reconstructions14, or accepting the situation. An alternative implant is a screw-type osseointegration implant. Our preference for press-fit implants is based on considerations such as our practice's 12-year history of >1,000 PFOI surgeries; that the screw-type implant requires sufficient cortical thickness for the threads15, which is compromised in some patients; the lower cost per implant; that the procedure is performed in 1 instead of 2 surgical episodes15,16; and the documented suitability of press-fit implants fo
{"title":"Single-Stage Press-Fit Osseointegration of the Radius and Ulna for Rehabilitation After Trans-Forearm Amputation.","authors":"Jason S Hoellwarth, Kevin Tetsworth, Munjed Al Muderis","doi":"10.2106/JBJS.ST.23.00015","DOIUrl":"10.2106/JBJS.ST.23.00015","url":null,"abstract":"<p><strong>Background: </strong>Upper limb (UL) amputation is disabling. ULs are necessary for many domains of life<sup>1</sup>, and few effective motor and sensory replacements are accessible<sup>2</sup>. Approximately 41,000 people in the United States have UL amputation proximal to the fingers<sup>3</sup>, two-thirds of (all) traumatic amputations are UL<sup>4</sup>, and 80% of UL amputations are performed for trauma-related etiologies<sup>5</sup>. Socket prosthesis (SP) abandonment remains high because of the lack of sensation, limited prosthesis control, perceived weight, and difficulty comfortably wearing the SP<sup>6</sup>. Transcutaneous osseointegration<sup>7,8</sup> surgically inserts a bone-anchored implant, passed through a transcutaneous portal to attach a terminal device, improving amputee rehabilitation by reducing perceived weight, conferring osseoperception<sup>9</sup>, and increasing wear time<sup>10</sup>. Without the socket, all residual skin and musculature remain available for transcutaneous myoelectrodes. The present article describes single-stage radius and ulna press-fit osseointegration (PFOI) after trans-forearm amputation.</p><p><strong>Description: </strong>This technique resembles a lower-extremity PFOI<sup>11,12</sup>. Importantly, at-risk nerves and vessels are different, and implant impaction must be gentler as a result. The surgery is indicated for patients who are dissatisfied with SP rehabilitation or declining alternative rehabilitative options, and who are motivated and enabled to procure, train with, and utilize a forearm prosthesis. An engaged prosthetist is critical. Surgical steps are exposure, bone-end and canal preparation, first implant insertion (in the operative video shown, in the radius), purse-string muscle closure, confirmation that radius-ulna motion remains, performing the prior steps for the other bone (in the video, the ulna), and closure (including potential nerve reconstruction, soft-tissue contouring, and portal creation). Although the patient in the operative video did not require nerve procedures to address pain or to create targets for transcutaneous myoelectrodes, targeted muscle reinnervation or a regenerative peripheral nerve interface procedure could be performed following exposure.</p><p><strong>Alternatives: </strong>Alternatives include socket modification, bone lengthening and/or soft-tissue contouring<sup>13</sup>, Krukenberg-type reconstructions<sup>14</sup>, or accepting the situation. An alternative implant is a screw-type osseointegration implant. Our preference for press-fit implants is based on considerations such as our practice's 12-year history of >1,000 PFOI surgeries; that the screw-type implant requires sufficient cortical thickness for the threads<sup>15</sup>, which is compromised in some patients; the lower cost per implant; that the procedure is performed in 1 instead of 2 surgical episodes<sup>15,16</sup>; and the documented suitability of press-fit implants fo","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11233105/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141581090","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-05eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00072
Klaus A Siebenrock, Simon D Steppacher, Kai Ziebarth, Joseph M Schwab, Lorenz Büchler
<p><strong>Background: </strong>Abnormal femoral head anatomy following moderate-to-severe slipped capital femoral epiphysis (SCFE) can lead to femoroacetabular impingement and premature osteoarthritis<sup>4-10</sup>. Surgical correction at the deformity site through capital reorientation has the potential to fully ameliorate this but has traditionally been associated with high rates of osteonecrosis<sup>11-15</sup>. The modified Dunn procedure has the potential to restore anatomy in hips with SCFE while protecting the blood supply to the femoral head.</p><p><strong>Description: </strong>A surgical dislocation of the hip is performed according to the technique described by Ganz et al.<sup>16</sup>. The remaining posterosuperior portion of the greater trochanter is trimmed to the level of the femoral neck by subperiosteal bone removal performed in an inside-out manner. The periosteum of the femoral neck is gradually elevated. The resulting soft-tissue flap, consisting of the retinaculum and external rotators, holds the blood vessels supplying the epiphysis. The femoral epiphysis is pinned in situ (in unstable cases) with threaded Kirschner wires, the ligamentum teres is transected, and the femoral head is dislocated. With the femoral neck exposed, the epiphysis is gradually mobilized from the metaphysis, allowing exposure of the residual femoral neck and inspection of any posteroinferior callus. To avoid tension on the retinacular vessels during reduction of the epiphysis, the posterior neck callus is completely excised. The remaining physis is removed with use of a burr while holding the epiphysis stable. The epiphysis is gently reduced onto the femoral neck, avoiding tension on the retinacular vessels. If tension is noted, the femoral neck is rechecked for residual callus, which is excised. If no callus is found, the neck may be carefully shortened in order to minimize tension. Epiphyseal fixation is achieved with use of a 3-mm fully threaded wire inserted antegrade through the fovea to the lateral cortex below the greater trochanter. A second wire is inserted retrograde under fluoroscopy. After reducing the hip, the capsule is closed and the greater trochanter is reattached with use of 3.5-mm cortical screws.</p><p><strong>Alternatives: </strong>Alternatives include nonoperative treatment, in situ fixation (e.g., pinning or screw fixation), gentle closed reduction with pinning, and triplanar trochanteric osteotomy (e.g., Imhauser or Southwick osteotomies).</p><p><strong>Rationale: </strong>In situ pinning of mild-to-moderate, stable SCFE yields good long-term results with low rates of osteonecrosis<sup>9</sup>. Treatment of higher-grade SCFE without reduction aims to avoid osteonecrosis and assumes that the proximal femoral deformity will remodel; however, the head-neck offset will remain abnormal, risking impingement and early-onset osteoarthritis<sup>5,8</sup>. The procedure described in the present article allows anatomic reduction of the ep
背景：中重度股骨头骨骺滑脱（SCFE）后股骨头解剖结构异常可导致股骨髋臼撞击和过早骨关节炎4-10。在畸形部位通过股骨头重新定向进行手术矫正有可能完全改善这一问题，但传统上与骨坏死的高发率有关11-15。改良 Dunn 手术有可能恢复 SCFE 髋关节的解剖结构，同时保护股骨头的血液供应：根据 Ganz 等人描述的技术进行髋关节脱位手术16。通过骨膜下骨切除，以内向外的方式将剩余的大转子后上方部分修剪至股骨颈水平。股骨颈骨膜逐渐被抬高。由此形成的软组织瓣由缰绳和外旋肌组成，可固定供应骨骺的血管。用带螺纹的 Kirschner 线将股骨头骨骺固定在原位（在不稳定的病例中），横断股骨韧带，使股骨头脱位。暴露股骨颈后，逐渐将干骺端从干骺端移出，这样就可以暴露残余股骨颈，并检查是否存在后方胼胝。为避免在缩小骨骺时对视网膜血管造成张力，应完全切除后颈胼胝。在保持骨骺稳定的情况下，使用毛刺去除剩余的骺板。将骨骺轻轻缩至股骨颈上，避免牵拉视网膜血管。如果发现有张力，则重新检查股骨颈是否有残余胼胝，并将其切除。如果没有发现胼胝，可小心缩短股骨颈，以尽量减少张力。使用一根 3 毫米的全螺纹钢丝，经股窝前行插入大转子下方的外侧皮质，实现骺端固定。第二根钢丝在透视下逆行插入。缩小髋关节后，关闭关节囊，使用 3.5 毫米皮质螺钉重新连接大转子：其他选择包括非手术治疗、原位固定（如钉牢或螺钉固定）、轻度闭合复位并钉牢，以及三平面转子截骨术（如 Imhauser 或 Southwick 截骨术）。理由：对轻度至中度、稳定的 SCFE 进行原位钉牢治疗可获得良好的长期效果，骨坏死发生率较低9。对较高级别的SCFE进行不缩股治疗的目的是避免骨坏死，并假定股骨近端畸形会重塑；然而，头颈偏移仍会异常，存在撞击和早发骨关节炎的风险5,8。本文所描述的手术可对骨骺进行解剖复位，骨坏死的风险较低。通过髋关节脱位手术16和扩大的视网膜软组织瓣17，可广泛暴露股骨颈周缘的骨膜下，并保留骨骺脆弱的血液供应18。Dunn股骨颈下重新定位术15可去除胼胝并矫正滑脱角，从而实现股骨近端解剖复位：预期结果：实施该手术的不同中心所报告的结果在治疗髋关节的数量和随访时间方面差异很大。大多数研究都是回顾性的，缺乏对照组。报道的骨坏死风险从0%到25.9%不等19，范围较大的原因很可能是该技术的挑战性、每位外科医生的病例数较少以及与该手术相关的学习曲线较长。在小儿保髋手术经验丰富的中心，骨坏死的报告率很低3。中长期随访研究显示，没有患者转为全髋关节置换术3,20,21，但残余畸形可能会持续存在，因此有可能进行后续手术：皮肤切口应位于大转子中央，Gibson间隙必须仔细准备，以充分松解并避免损伤，应避免骨膜瓣受压，以防对视网膜血管造成压力：AP=前胸AVN=血管性坏死（即骨坏死）CI=置信区间CT=计算机断层扫描K-wire=Kirschner钢丝MRI=磁共振成像OA=骨关节炎SHD=外科髋关节脱位THA=全髋关节置换术VTE=静脉血栓栓塞。
{"title":"Modified Dunn Procedure for Open Reduction of Chronic Slipped Capital Femoral Epiphysis.","authors":"Klaus A Siebenrock, Simon D Steppacher, Kai Ziebarth, Joseph M Schwab, Lorenz Büchler","doi":"10.2106/JBJS.ST.23.00072","DOIUrl":"10.2106/JBJS.ST.23.00072","url":null,"abstract":"<p><strong>Background: </strong>Abnormal femoral head anatomy following moderate-to-severe slipped capital femoral epiphysis (SCFE) can lead to femoroacetabular impingement and premature osteoarthritis<sup>4-10</sup>. Surgical correction at the deformity site through capital reorientation has the potential to fully ameliorate this but has traditionally been associated with high rates of osteonecrosis<sup>11-15</sup>. The modified Dunn procedure has the potential to restore anatomy in hips with SCFE while protecting the blood supply to the femoral head.</p><p><strong>Description: </strong>A surgical dislocation of the hip is performed according to the technique described by Ganz et al.<sup>16</sup>. The remaining posterosuperior portion of the greater trochanter is trimmed to the level of the femoral neck by subperiosteal bone removal performed in an inside-out manner. The periosteum of the femoral neck is gradually elevated. The resulting soft-tissue flap, consisting of the retinaculum and external rotators, holds the blood vessels supplying the epiphysis. The femoral epiphysis is pinned in situ (in unstable cases) with threaded Kirschner wires, the ligamentum teres is transected, and the femoral head is dislocated. With the femoral neck exposed, the epiphysis is gradually mobilized from the metaphysis, allowing exposure of the residual femoral neck and inspection of any posteroinferior callus. To avoid tension on the retinacular vessels during reduction of the epiphysis, the posterior neck callus is completely excised. The remaining physis is removed with use of a burr while holding the epiphysis stable. The epiphysis is gently reduced onto the femoral neck, avoiding tension on the retinacular vessels. If tension is noted, the femoral neck is rechecked for residual callus, which is excised. If no callus is found, the neck may be carefully shortened in order to minimize tension. Epiphyseal fixation is achieved with use of a 3-mm fully threaded wire inserted antegrade through the fovea to the lateral cortex below the greater trochanter. A second wire is inserted retrograde under fluoroscopy. After reducing the hip, the capsule is closed and the greater trochanter is reattached with use of 3.5-mm cortical screws.</p><p><strong>Alternatives: </strong>Alternatives include nonoperative treatment, in situ fixation (e.g., pinning or screw fixation), gentle closed reduction with pinning, and triplanar trochanteric osteotomy (e.g., Imhauser or Southwick osteotomies).</p><p><strong>Rationale: </strong>In situ pinning of mild-to-moderate, stable SCFE yields good long-term results with low rates of osteonecrosis<sup>9</sup>. Treatment of higher-grade SCFE without reduction aims to avoid osteonecrosis and assumes that the proximal femoral deformity will remodel; however, the head-neck offset will remain abnormal, risking impingement and early-onset osteoarthritis<sup>5,8</sup>. The procedure described in the present article allows anatomic reduction of the ep","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11221854/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141556457","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-05eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00041
Nathan S Lanham, Jordan G Tropf, John D Johnson
Background: Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing1. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques1,2.
Description: The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular "bare area" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner.
Alternatives: Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate.
Rationale: The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures1-3. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches3. OO has not been associated with triceps weakness, unlike some of the alternative techniques2.
Expected outcomes: The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures4. Osteotomies united in all patients in 2 reported series, totaling 84 cases1,2. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients1,2.
Important tips: Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the O
{"title":"Olecranon Osteotomy Exposure for Distal Humeral Fracture Treatment.","authors":"Nathan S Lanham, Jordan G Tropf, John D Johnson","doi":"10.2106/JBJS.ST.23.00041","DOIUrl":"10.2106/JBJS.ST.23.00041","url":null,"abstract":"<p><strong>Background: </strong>Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing<sup>1</sup>. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques<sup>1,2</sup>.</p><p><strong>Description: </strong>The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular \"bare area\" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner.</p><p><strong>Alternatives: </strong>Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate.</p><p><strong>Rationale: </strong>The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures<sup>1-3</sup>. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches<sup>3</sup>. OO has not been associated with triceps weakness, unlike some of the alternative techniques<sup>2</sup>.</p><p><strong>Expected outcomes: </strong>The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures<sup>4</sup>. Osteotomies united in all patients in 2 reported series, totaling 84 cases<sup>1,2</sup>. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients<sup>1,2</sup>.</p><p><strong>Important tips: </strong>Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the O","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11221848/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141556458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-05eCollection Date: 2024-07-01DOI: 10.2106/JBJS.ST.23.00067
Emanuele Maggini, Mara Warnhoff, Florian Freislederer, Markus Scheibel
Background: Metallic lateralized-offset glenoid reverse shoulder arthroplasty (RSA) for cuff tear arthropathy combines the use of a metallic augmented baseplate with a metaphyseally oriented short stem design that can be applied at a 135° or 145° neck-shaft angle, leading to additional lateralization on the humeral side. Lateralization of the center of rotation decreases the risk of inferior scapular notching and improves external rotation, deltoid wrapping, residual rotator cuff tensioning, and prosthetic stability1-4. Metallic increased-offset RSA (MIO-RSA) achieves lateralization and corrects inclination and retroversion while avoiding graft resorption and other complications of bony increased-offset RSA (BIO-RSA)5-8. Reducing the neck-shaft angle from the classical Grammont design, in combination with glenoid lateralization, improves range of motion9,10 by reducing inferior impingement during adduction at the expense of earlier superior impingement during abduction2,11. Lädermann et al.12 investigated how different combinations of humeral stem and glenosphere designs influence range of motion and muscle elongation. They assessed 30 combinations of humeral components, as compared with the native shoulder, and found that the combination that allows for restoration of >50% of the native range of motion in all directions was a 145° onlay stem with a concentric or lateralized tray in conjunction with a lateralized or inferior eccentric glenosphere. In addition, the use of a flush-lay or a slight-onlay stem design (like the one utilized in the presently described technique) may decrease the risk of secondary scapular spine fracture13,14. The goal of this prosthetic design is to achieve an excellent combination of motion and stability while reducing complications.
Description: This procedure is performed via a deltopectoral approach with the patient in the beach-chair position under general anesthesia combined with a regional interscalene nerve block. Subscapularis tenotomy and capsular release are performed, the humeral head is dislocated, and any osteophytes are removed. An intramedullary cutting guide is placed for correct humeral resection. The osteotomy of the humeral head is performed in the anatomical neck with an inclination of 135° and a retroversion of 20° to 40°, depending on the anatomical retroversion. The glenoid is prepared as usual. The lateralized, augmented baseplate is assembled with the central screw and the baseplate-wedge-screw complex is placed by inserting the screw into the central screw hole. Four peripheral screws are utilized for definitive fixation. An eccentric glenosphere with inferior overhang is implanted. The humerus is dislocated, and the metaphysis is prepared. Long compactors are utilized for proper stem alignment, and an asymmetric trial insert is positioned before the humerus is reduced. Stability and ra
{"title":"Metallic Lateralized-Offset Glenoid Reverse Shoulder Arthroplasty.","authors":"Emanuele Maggini, Mara Warnhoff, Florian Freislederer, Markus Scheibel","doi":"10.2106/JBJS.ST.23.00067","DOIUrl":"10.2106/JBJS.ST.23.00067","url":null,"abstract":"<p><strong>Background: </strong>Metallic lateralized-offset glenoid reverse shoulder arthroplasty (RSA) for cuff tear arthropathy combines the use of a metallic augmented baseplate with a metaphyseally oriented short stem design that can be applied at a 135° or 145° neck-shaft angle, leading to additional lateralization on the humeral side. Lateralization of the center of rotation decreases the risk of inferior scapular notching and improves external rotation, deltoid wrapping, residual rotator cuff tensioning, and prosthetic stability<sup>1-4</sup>. Metallic increased-offset RSA (MIO-RSA) achieves lateralization and corrects inclination and retroversion while avoiding graft resorption and other complications of bony increased-offset RSA (BIO-RSA)<sup>5-8</sup>. Reducing the neck-shaft angle from the classical Grammont design, in combination with glenoid lateralization, improves range of motion<sup>9,10</sup> by reducing inferior impingement during adduction at the expense of earlier superior impingement during abduction<sup>2,11</sup>. Lädermann et al.<sup>12</sup> investigated how different combinations of humeral stem and glenosphere designs influence range of motion and muscle elongation. They assessed 30 combinations of humeral components, as compared with the native shoulder, and found that the combination that allows for restoration of >50% of the native range of motion in all directions was a 145° onlay stem with a concentric or lateralized tray in conjunction with a lateralized or inferior eccentric glenosphere. In addition, the use of a flush-lay or a slight-onlay stem design (like the one utilized in the presently described technique) may decrease the risk of secondary scapular spine fracture<sup>13,14</sup>. The goal of this prosthetic design is to achieve an excellent combination of motion and stability while reducing complications.</p><p><strong>Description: </strong>This procedure is performed via a deltopectoral approach with the patient in the beach-chair position under general anesthesia combined with a regional interscalene nerve block. Subscapularis tenotomy and capsular release are performed, the humeral head is dislocated, and any osteophytes are removed. An intramedullary cutting guide is placed for correct humeral resection. The osteotomy of the humeral head is performed in the anatomical neck with an inclination of 135° and a retroversion of 20° to 40°, depending on the anatomical retroversion. The glenoid is prepared as usual. The lateralized, augmented baseplate is assembled with the central screw and the baseplate-wedge-screw complex is placed by inserting the screw into the central screw hole. Four peripheral screws are utilized for definitive fixation. An eccentric glenosphere with inferior overhang is implanted. The humerus is dislocated, and the metaphysis is prepared. Long compactors are utilized for proper stem alignment, and an asymmetric trial insert is positioned before the humerus is reduced. Stability and ra","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 3","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11221860/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141556456","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-20eCollection Date: 2024-04-01DOI: 10.2106/JBJS.ST.23.00061
Stephen M Gillinov, Bilal S Siddiq, Nathan J Cherian, Scott D Martin
<p><strong>Background: </strong>A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy<sup>1,2</sup>. Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension<sup>3</sup>. Thus, these approaches may introduce capsuloligamentous instability<sup>1,4-7</sup> and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification<sup>5,8-12</sup>. Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure<sup>6,13</sup>, avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals.</p><p><strong>Description: </strong>Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post<sup>14</sup>. Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury<sup>15</sup>. Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed<sup>5</sup>.</p><p><strong>Alternatives: </strong>Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure<sup>1,2,4,6,7,16</sup>. Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability<sup>1,4-7,17</sup>.</p><p><strong>Rationale: </strong>The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not
{"title":"Puncture Capsulotomy Technique During Hip Arthroscopy.","authors":"Stephen M Gillinov, Bilal S Siddiq, Nathan J Cherian, Scott D Martin","doi":"10.2106/JBJS.ST.23.00061","DOIUrl":"10.2106/JBJS.ST.23.00061","url":null,"abstract":"<p><strong>Background: </strong>A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy<sup>1,2</sup>. Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension<sup>3</sup>. Thus, these approaches may introduce capsuloligamentous instability<sup>1,4-7</sup> and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification<sup>5,8-12</sup>. Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure<sup>6,13</sup>, avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals.</p><p><strong>Description: </strong>Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post<sup>14</sup>. Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury<sup>15</sup>. Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed<sup>5</sup>.</p><p><strong>Alternatives: </strong>Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure<sup>1,2,4,6,7,16</sup>. Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability<sup>1,4-7,17</sup>.</p><p><strong>Rationale: </strong>The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not ","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11186812/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141433029","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-20eCollection Date: 2024-04-01DOI: 10.2106/JBJS.ST.23.00018
Tyler J Thorne, Chase T Nelson, Leonard S J Lisitano, Thomas F Higgins, David L Rothberg, Justin M Haller, Lucas S Marchand
<p><strong>Background: </strong>Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse.</p><p><strong>Description: </strong>Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed.</p><p><strong>Alternatives: </strong>Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace<sup>1</sup>. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate.</p><p><strong>Rationale: </strong>Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength<sup>2,3</sup>. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone<sup>4-7</sup>. Adjunctive
{"title":"Dual Plating of Distal Femoral Fractures.","authors":"Tyler J Thorne, Chase T Nelson, Leonard S J Lisitano, Thomas F Higgins, David L Rothberg, Justin M Haller, Lucas S Marchand","doi":"10.2106/JBJS.ST.23.00018","DOIUrl":"10.2106/JBJS.ST.23.00018","url":null,"abstract":"<p><strong>Background: </strong>Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse.</p><p><strong>Description: </strong>Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed.</p><p><strong>Alternatives: </strong>Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace<sup>1</sup>. There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate.</p><p><strong>Rationale: </strong>Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength<sup>2,3</sup>. Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone<sup>4-7</sup>. Adjunctive","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11186817/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141433028","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-22eCollection Date: 2024-04-01DOI: 10.2106/JBJS.ST.23.00006
Jan Paul M Frölke, Robin Atallah, Ruud Leijendekkers
<p><strong>Background: </strong>This video article describes the use of bone-anchored prostheses for patients with transtibial amputations, most often resulting from trauma, infection, or dysvascular disease. Large studies have shown that about half of all patients with a socket-suspended artificial limb experience limited mobility and limited prosthesis use because of socket-related problems. These problems occur at the socket-residual limb interface as a result of a painful and unstable connection, leading to an asymmetrical gait and subsequent pelvic and back pain. In almost all of these cases, a bone-anchored prosthesis may result in substantial improvements in mobility and quality of life.</p><p><strong>Description: </strong>This technique is preferably performed in a single-stage procedure. Preoperative implant planning is imperative when designing the custom-made implant (BADAL X, OTN Implants). These images should be visible on screen in the operating room throughout the procedure to guide the surgeon. The patient is positioned with the knee on a silicone cushion. The planned soft-tissue resection is marked, after which the resection of all layers is performed, including large nerves and neuromas, with high cuts performed under traction. Exposure of the residual bone following revision osteotomy is carried out according to the design. The medullary canal is prepared and perpendicular cutting of the tibial and fibular remnant are performed, with the latter cut at a level 1 to 2 cm higher than the former. The intramedullary component is inserted under fluoroscopic guidance, after which the distal end of the tibia is prepared utilizing the typical drop shape. Two transverse locking screws are inserted with the standard "freehand" technique. The soft tissues are contoured and closed over the implant, after which the stoma is created and the dual cone is mounted. Finally, pressure bandages are applied, and postoperative imaging is performed. After the surgical procedure, most patients stay 1 or 2 nights in the hospital, depending on the magnitude of the surgery (e.g., bilateral implantation of a bone-anchored implant) and the patient's comorbidities.</p><p><strong>Alternatives: </strong>Simultaneous major leg amputation and bone-anchored prosthesis implantation is not advocated as treatment. First, a rehabilitation program with a socket-suspended prosthesis should be completed before patients can apply for a bone-anchored prosthesis. After rehabilitation, satisfaction with a prosthetic socket may be adequate, thereby not indicating the need for a bone-anchored prosthesis. Contraindications for bone-anchored implant surgery include severe diabetes (with complications), severe bone deformity, immature bones, bone diseases (i.e., chronic infection or metastasis), current chemotherapy, severe vascular diseases, pain without a clear cause, obesity (body mass index >30 kg/m<sup>2</sup>), and smoking.</p><p><strong>Rationale: </strong>Approximately h
{"title":"Press-Fit Bone-Anchored Prosthesis for Individuals with Transtibial Amputation.","authors":"Jan Paul M Frölke, Robin Atallah, Ruud Leijendekkers","doi":"10.2106/JBJS.ST.23.00006","DOIUrl":"10.2106/JBJS.ST.23.00006","url":null,"abstract":"<p><strong>Background: </strong>This video article describes the use of bone-anchored prostheses for patients with transtibial amputations, most often resulting from trauma, infection, or dysvascular disease. Large studies have shown that about half of all patients with a socket-suspended artificial limb experience limited mobility and limited prosthesis use because of socket-related problems. These problems occur at the socket-residual limb interface as a result of a painful and unstable connection, leading to an asymmetrical gait and subsequent pelvic and back pain. In almost all of these cases, a bone-anchored prosthesis may result in substantial improvements in mobility and quality of life.</p><p><strong>Description: </strong>This technique is preferably performed in a single-stage procedure. Preoperative implant planning is imperative when designing the custom-made implant (BADAL X, OTN Implants). These images should be visible on screen in the operating room throughout the procedure to guide the surgeon. The patient is positioned with the knee on a silicone cushion. The planned soft-tissue resection is marked, after which the resection of all layers is performed, including large nerves and neuromas, with high cuts performed under traction. Exposure of the residual bone following revision osteotomy is carried out according to the design. The medullary canal is prepared and perpendicular cutting of the tibial and fibular remnant are performed, with the latter cut at a level 1 to 2 cm higher than the former. The intramedullary component is inserted under fluoroscopic guidance, after which the distal end of the tibia is prepared utilizing the typical drop shape. Two transverse locking screws are inserted with the standard \"freehand\" technique. The soft tissues are contoured and closed over the implant, after which the stoma is created and the dual cone is mounted. Finally, pressure bandages are applied, and postoperative imaging is performed. After the surgical procedure, most patients stay 1 or 2 nights in the hospital, depending on the magnitude of the surgery (e.g., bilateral implantation of a bone-anchored implant) and the patient's comorbidities.</p><p><strong>Alternatives: </strong>Simultaneous major leg amputation and bone-anchored prosthesis implantation is not advocated as treatment. First, a rehabilitation program with a socket-suspended prosthesis should be completed before patients can apply for a bone-anchored prosthesis. After rehabilitation, satisfaction with a prosthetic socket may be adequate, thereby not indicating the need for a bone-anchored prosthesis. Contraindications for bone-anchored implant surgery include severe diabetes (with complications), severe bone deformity, immature bones, bone diseases (i.e., chronic infection or metastasis), current chemotherapy, severe vascular diseases, pain without a clear cause, obesity (body mass index >30 kg/m<sup>2</sup>), and smoking.</p><p><strong>Rationale: </strong>Approximately h","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11781768/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143068451","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-22eCollection Date: 2024-04-01DOI: 10.2106/JBJS.ST.22.00071
Katharine D Harper, Stephen J Incavo
Background: Vancomycin is a prophylactic antibiotic with bactericidal activity against methicillin-resistant Staphylococcus aureus that is commonly used in total joint replacement surgery1. In total knee arthroplasty (TKA), intraosseous infusions administered following tourniquet inflation have demonstrated improved local vancomycin concentrations with decreased systemic absorption1-3. This administration method results in no adverse reactions locally, as well as equivalent or lower systemic complications compared with other vancomycin administration methods4. Intraosseous infusion of prophylactic surgical antibiotics has been shown to be more effective than intravenous administration, with the potential for reduction in surgical site infections5.
Description: After the operative extremity has been prepared and draped in the usual sterile fashion, the limb is elevated and the tourniquet is inflated to 250 mm Hg. Prior to incision, an intraosseous vascular access system (Arrow EZ IO; Teleflex) is inserted with a power driver into the tibial tubercle region. The desired volume of the medication is injected into the tibia. The device is removed and then inserted into the anterior distal femur, centrally, just proximal to the patella. Following this, the desired volume of the medication is injected into the femur. The device is then removed, and the TKA proceeds according to the surgeon's standard technique.
Alternatives: Alternative administration methods for vancomycin include other invasive methods and noninvasive delivery. Intravenous delivery is the most traditional form of medication delivery1,2. Additional alternatives include noninvasive placement of antibiotic powder into the wound and localized soft-tissue injections of desired medications1-3.
Rationale: Opting to administer antibiotics and other medications intraosseously (rather than intravenously) has shown improved compliance with the golden-hour rule of preoperative antibiotics (especially for vancomycin)4, lower incidences of acute kidney injury or adverse systemic effects4, and improved local tissue concentrations of all medications delivered1-3.
Expected outcomes: Expected outcomes include improved local tissue concentrations with decreased systemic concentrations of vancomycin and with no reported local or systemic adverse reactions, as well as the potential for improved infection prevention1-5. Literature regarding the use of intraosseous infusion during TKA has been thorough and very well received. A prospective, randomized study by Young et al. evaluated local and systemic concentrations of vancomycin following intraosseous versus intravenous administration. The authors found that low-dose intraosseous vancomycin resulted in tissue concentrations equal t
{"title":"Intraosseous Administration of Medications in Total Knee Arthroplasty: An Opportunity for Improved Outcomes and Superior Compliance.","authors":"Katharine D Harper, Stephen J Incavo","doi":"10.2106/JBJS.ST.22.00071","DOIUrl":"10.2106/JBJS.ST.22.00071","url":null,"abstract":"<p><strong>Background: </strong>Vancomycin is a prophylactic antibiotic with bactericidal activity against methicillin-resistant <i>Staphylococcus aureus</i> that is commonly used in total joint replacement surgery<sup>1</sup>. In total knee arthroplasty (TKA), intraosseous infusions administered following tourniquet inflation have demonstrated improved local vancomycin concentrations with decreased systemic absorption<sup>1-3</sup>. This administration method results in no adverse reactions locally, as well as equivalent or lower systemic complications compared with other vancomycin administration methods<sup>4</sup>. Intraosseous infusion of prophylactic surgical antibiotics has been shown to be more effective than intravenous administration, with the potential for reduction in surgical site infections<sup>5</sup>.</p><p><strong>Description: </strong>After the operative extremity has been prepared and draped in the usual sterile fashion, the limb is elevated and the tourniquet is inflated to 250 mm Hg. Prior to incision, an intraosseous vascular access system (Arrow EZ IO; Teleflex) is inserted with a power driver into the tibial tubercle region. The desired volume of the medication is injected into the tibia. The device is removed and then inserted into the anterior distal femur, centrally, just proximal to the patella. Following this, the desired volume of the medication is injected into the femur. The device is then removed, and the TKA proceeds according to the surgeon's standard technique.</p><p><strong>Alternatives: </strong>Alternative administration methods for vancomycin include other invasive methods and noninvasive delivery. Intravenous delivery is the most traditional form of medication delivery<sup>1,2</sup>. Additional alternatives include noninvasive placement of antibiotic powder into the wound and localized soft-tissue injections of desired medications<sup>1-3</sup>.</p><p><strong>Rationale: </strong>Opting to administer antibiotics and other medications intraosseously (rather than intravenously) has shown improved compliance with the golden-hour rule of preoperative antibiotics (especially for vancomycin)<sup>4</sup>, lower incidences of acute kidney injury or adverse systemic effects<sup>4</sup>, and improved local tissue concentrations of all medications delivered<sup>1-3</sup>.</p><p><strong>Expected outcomes: </strong>Expected outcomes include improved local tissue concentrations with decreased systemic concentrations of vancomycin and with no reported local or systemic adverse reactions, as well as the potential for improved infection prevention<sup>1-5</sup>. Literature regarding the use of intraosseous infusion during TKA has been thorough and very well received. A prospective, randomized study by Young et al. evaluated local and systemic concentrations of vancomycin following intraosseous versus intravenous administration. The authors found that low-dose intraosseous vancomycin resulted in tissue concentrations equal t","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11108349/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141080827","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: This video article describes the technique for arthroscopic reduction and fixation of Pipkin type-I fractures.
Description: Surgery is performed with the patient in a supine position, with free lower limbs, on a radiolucent table. Arthroscopic superior and anterolateral portals are made similarly to the portals created to evaluate the peripheral compartment during an outside-in (ballooning) technique.1 An additional medial portal is subsequently created in order to aid in reduction and screw placement. The medial portal is created in abduction and external rotation of the hip (i.e., the figure-4 position). The adductor tendon is identified, and the portal is then safely positioned posteriorly to its margin, approximately 4 to 5 cm distal to the inguinal fold, avoiding the saphenous vein (usually identified with an ultrasound scan). The fragment is mobilized, debrided, and then reduced with use of a microfracture awl or a large Kirschner wire (used as a joystick). Following reduction, temporary fixation is performed with use of long Kirschner wires under direct visualization and fluoroscopic guidance. If reduction is satisfactory, definitive fixation can be performed with use of 4.5-mm headless screws through the medial portal. All steps of fragment reduction and fixation are performed through the medial portal, with the patient in the figure-4 position. Once the screws are placed, a final dynamic arthroscopic and fluoroscopic check is performed.
Alternatives: In Pipkin type-I fractures, surgery is recommended when the femoral head fragment is large (exceeding 15% to 20% of the femoral head volume) and displaced (by >3 mm). In such cases, if untreated, spontaneous evolution to osteoarthritis may occur. For fragments smaller than 10% to 15% of the femoral head volume, arthroscopic removal is often the best choice2. Several approaches (e.g., Smith-Petersen, modified Hueter, Kocher-Langenbeck, and surgical safe dislocation) have been proposed for reduction and fixation, with surgical safe dislocation being the most versatile because of the uniquely complete visualization of the femoral head3.
Rationale: The arthroscopic reduction and fixation technique for a non-comminuted Pipkin type-I fracture holds the intrinsic advantages of being less invasive than open surgery in terms of surgical exposure, and having less blood loss, infection risks, and wound complications. Arthroscopy allows direct visualization of the fragment and its reduction surface, along with removal of articular loose bodies and debridement. The surgical time is influenced by the surgeon's experience, but often is no longer than with an open procedure. In the few studies assessing the use of this technique, the rates of osteonecrosis and heterotopic ossification are lower than with open techniques. It is worth noting that the studies assessing the use o
{"title":"Arthroscopic Reduction and Fixation of a Pipkin Type-I Femoral Head Fracture.","authors":"Alessandro Aprato, Ruben Caruso, Michele Reboli, Matteo Giachino, Alessandro Massè","doi":"10.2106/JBJS.ST.23.00073","DOIUrl":"10.2106/JBJS.ST.23.00073","url":null,"abstract":"<p><strong>Background: </strong>This video article describes the technique for arthroscopic reduction and fixation of Pipkin type-I fractures.</p><p><strong>Description: </strong>Surgery is performed with the patient in a supine position, with free lower limbs, on a radiolucent table. Arthroscopic superior and anterolateral portals are made similarly to the portals created to evaluate the peripheral compartment during an outside-in (ballooning) technique.<sup>1</sup> An additional medial portal is subsequently created in order to aid in reduction and screw placement. The medial portal is created in abduction and external rotation of the hip (i.e., the figure-4 position). The adductor tendon is identified, and the portal is then safely positioned posteriorly to its margin, approximately 4 to 5 cm distal to the inguinal fold, avoiding the saphenous vein (usually identified with an ultrasound scan). The fragment is mobilized, debrided, and then reduced with use of a microfracture awl or a large Kirschner wire (used as a joystick). Following reduction, temporary fixation is performed with use of long Kirschner wires under direct visualization and fluoroscopic guidance. If reduction is satisfactory, definitive fixation can be performed with use of 4.5-mm headless screws through the medial portal. All steps of fragment reduction and fixation are performed through the medial portal, with the patient in the figure-4 position. Once the screws are placed, a final dynamic arthroscopic and fluoroscopic check is performed.</p><p><strong>Alternatives: </strong>In Pipkin type-I fractures, surgery is recommended when the femoral head fragment is large (exceeding 15% to 20% of the femoral head volume) and displaced (by >3 mm). In such cases, if untreated, spontaneous evolution to osteoarthritis may occur. For fragments smaller than 10% to 15% of the femoral head volume, arthroscopic removal is often the best choice<sup>2</sup>. Several approaches (e.g., Smith-Petersen, modified Hueter, Kocher-Langenbeck, and surgical safe dislocation) have been proposed for reduction and fixation, with surgical safe dislocation being the most versatile because of the uniquely complete visualization of the femoral head<sup>3</sup>.</p><p><strong>Rationale: </strong>The arthroscopic reduction and fixation technique for a non-comminuted Pipkin type-I fracture holds the intrinsic advantages of being less invasive than open surgery in terms of surgical exposure, and having less blood loss, infection risks, and wound complications. Arthroscopy allows direct visualization of the fragment and its reduction surface, along with removal of articular loose bodies and debridement. The surgical time is influenced by the surgeon's experience, but often is no longer than with an open procedure. In the few studies assessing the use of this technique, the rates of osteonecrosis and heterotopic ossification are lower than with open techniques. It is worth noting that the studies assessing the use o","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"14 2","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-05-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11104723/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141077161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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