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
{"title":"Modified Brunelli Reconstruction for Scapholunate Ligament Dissociation","authors":"Donald H. Lee","doi":"10.2106/jbjs.st.23.00028","DOIUrl":"https://doi.org/10.2106/jbjs.st.23.00028","url":null,"abstract":"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","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"296 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135955050","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.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–
{"title":"Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF)","authors":"Stephen Saela, Michael Pompliano, Jeffrey Varghese, Kumar Sinha, Michael Faloon, Arash Emami","doi":"10.2106/jbjs.st.21.00065","DOIUrl":"https://doi.org/10.2106/jbjs.st.21.00065","url":null,"abstract":"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–","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"7 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135955051","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.22.00057
Daniel Y. Hong, Robert J. Strauch
Background: Flexor-tendon injury is a historically challenging problem for orthopaedic surgeons. Much research has been dedicated to finding solutions that offer balance in terms of the strength and ease of the repair versus the rate of complications such as adhesions. The number of core sutures, distance from the tendon edge, and use of an epitendinous stitch have been shown to affect repair strength 1–4 . A number of configurations have been described for the placement of the suture; however, none has been identified as a clear gold standard 5 . This article will highlight the preferred tendon repair technique of the senior author (R.J.S.), the Strickland repair with a simple running epitendinous stitch. Relevant anatomy, indications, operative technique, and postoperative management will be discussed. Description: The flexor tendon is typically accessed via extension of the laceration that caused the initial injury. After the neurovascular structures and pulleys are assessed, the tendon is cleaned and prepared for repair. A 3-0 braided nylon suture is utilized for the 4-core strand repair and placed in the Strickland fashion. A 5-0 polypropylene suture is then utilized for the simple running epitendinous stitch. Alternatives: Multiple alternative techniques have been described. These vary in the number of core strands, the repair configuration, the suture caliber, and the use of an epitendinous or other suture. Nonoperative treatment is typically reserved for partial flexor-tendon laceration, as complete tendon discontinuity will not heal and requires surgical intervention. Rationale: The 4-core strand configuration has been well established to increase the strength of the repair as compared with 2-core strand configurations, while also being easier to accomplish and with less suture burden than other techniques 1 . The presently described technique has excellent repair strength and can allow for early active range of motion, which is critical to reduce the risk of postoperative adhesions and stiffness. Expected Outcomes: Excellent outcomes have been demonstrated for primary flexor-tendon repair if performed soon after the injury 1,2,6,7 . Delayed repair may lead to adhesions and poor tendon healing 8 . Early postoperative rehabilitation is vital for success 9 . There are advocates for either active or passive protocols 10–12 . The protocol at our institution is to begin early active place-and-hold therapy at 3 to 5 days postoperatively, which has been shown in the literature to provide improved finger motion as compared with passive-motion therapy 13–16 . Important Tips: The proximal end of the tendon may need to be retrieved via a separate incision if it is not accessible through the flexor-tendon sheath. The proximal end of the tendon may be held in place with a 25-gauge needle in order to best place sutures into both ends of the tendon. The epitendinous suture is run around the back wall before the core sutures are tied down, in order to p
{"title":"Flexor Tendon Zone II Repair","authors":"Daniel Y. Hong, Robert J. Strauch","doi":"10.2106/jbjs.st.22.00057","DOIUrl":"https://doi.org/10.2106/jbjs.st.22.00057","url":null,"abstract":"Background: Flexor-tendon injury is a historically challenging problem for orthopaedic surgeons. Much research has been dedicated to finding solutions that offer balance in terms of the strength and ease of the repair versus the rate of complications such as adhesions. The number of core sutures, distance from the tendon edge, and use of an epitendinous stitch have been shown to affect repair strength 1–4 . A number of configurations have been described for the placement of the suture; however, none has been identified as a clear gold standard 5 . This article will highlight the preferred tendon repair technique of the senior author (R.J.S.), the Strickland repair with a simple running epitendinous stitch. Relevant anatomy, indications, operative technique, and postoperative management will be discussed. Description: The flexor tendon is typically accessed via extension of the laceration that caused the initial injury. After the neurovascular structures and pulleys are assessed, the tendon is cleaned and prepared for repair. A 3-0 braided nylon suture is utilized for the 4-core strand repair and placed in the Strickland fashion. A 5-0 polypropylene suture is then utilized for the simple running epitendinous stitch. Alternatives: Multiple alternative techniques have been described. These vary in the number of core strands, the repair configuration, the suture caliber, and the use of an epitendinous or other suture. Nonoperative treatment is typically reserved for partial flexor-tendon laceration, as complete tendon discontinuity will not heal and requires surgical intervention. Rationale: The 4-core strand configuration has been well established to increase the strength of the repair as compared with 2-core strand configurations, while also being easier to accomplish and with less suture burden than other techniques 1 . The presently described technique has excellent repair strength and can allow for early active range of motion, which is critical to reduce the risk of postoperative adhesions and stiffness. Expected Outcomes: Excellent outcomes have been demonstrated for primary flexor-tendon repair if performed soon after the injury 1,2,6,7 . Delayed repair may lead to adhesions and poor tendon healing 8 . Early postoperative rehabilitation is vital for success 9 . There are advocates for either active or passive protocols 10–12 . The protocol at our institution is to begin early active place-and-hold therapy at 3 to 5 days postoperatively, which has been shown in the literature to provide improved finger motion as compared with passive-motion therapy 13–16 . Important Tips: The proximal end of the tendon may need to be retrieved via a separate incision if it is not accessible through the flexor-tendon sheath. The proximal end of the tendon may be held in place with a 25-gauge needle in order to best place sutures into both ends of the tendon. The epitendinous suture is run around the back wall before the core sutures are tied down, in order to p","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"43 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135954744","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 : 2022-11-16eCollection Date: 2022-10-01DOI: 10.2106/JBJS.ST.21.00059
Nathan W Callender, Emily Lu, Kevin D Martin
<p><strong>Background: </strong>Chronic exertional compartment syndrome of the lower extremity is a condition that characteristically presents as recurrent anterior, posterior, and/or lateral lower-extremity pain on repetitive activity and physical exertion<sup>1</sup>. This condition is commonly seen in athletes, runners, and military personnel<sup>2</sup>. Open fasciotomy has been demonstrated to be a highly effective surgical treatment for patients with this condition who do not experience symptomatic relief after a thorough trial of nonoperative treatment<sup>3</sup>.</p><p><strong>Description: </strong>Diagnostic compartment pressure management is achieved through direct insertion of a compartment-pressure-measuring device into the anterior, lateral, and posterior compartments of the lower extremity<sup>4</sup>. Surgical treatment of the anterior and lateral compartments with use of open fasciotomy employs longitudinal proximal and distal incisions that are made on the lateral surface of the leg approximately 3 finger-breadths distal and proximal to the fibular flare, respectively, and 3 finger-breadths lateral to the tibial crest. Surgical treatment of the posterior compartments with use of open fasciotomy employs a single, mid-shaft incision made approximately 2.5 cm medial to the tibial ridge. Dissection is carried down to the deep fascia at both sites, beginning at the distal operative site. Care is taken to avoid transection of the superficial peroneal nerve at the distal anterolateral incision and saphenous vein and nerve at the medial incision. Once down to the deep fascia, a scalpel is utilized to incise the fascia. Metzenbaum scissors are then employed under the incision, spreading the scissors while sliding them over the muscles proximally and distally to release the muscular attachments from the fascia as well as to release the fascia itself<sup>3</sup>. This process is repeated in the anterior, lateral, and superficial posterior compartments through the proximal and distal incisions. In the deep posterior compartment, the fascia is released from the tibial ridge with a large Cobb elevator. Closure is achieved with deep dermal and superficial sutures.</p><p><strong>Alternatives: </strong>Nonoperative alternatives have been reported to include nonpharmacological modalities such as walking modification and shoe inserts, pharmacological therapy with nonsteroidal anti-inflammatory drugs, and physical therapy targeted at conditioning the lower extremity<sup>5</sup>. Nonoperative intervention has been demonstrated to increase endurance in select patients; however, most patients must either stop the activity associated with the compartment syndrome altogether or proceed to surgery for complete resolution of symptoms<sup>5</sup>. There are a few surgical alternatives that differ in their utilization of minimally invasive approaches versus a direct open approach<sup>6</sup>; however, all existing surgical treatments of this condition invol
{"title":"Chronic Exertional Compartment Syndrome of the Lower Extremity: Diagnosis and Surgical Treatment.","authors":"Nathan W Callender, Emily Lu, Kevin D Martin","doi":"10.2106/JBJS.ST.21.00059","DOIUrl":"10.2106/JBJS.ST.21.00059","url":null,"abstract":"<p><strong>Background: </strong>Chronic exertional compartment syndrome of the lower extremity is a condition that characteristically presents as recurrent anterior, posterior, and/or lateral lower-extremity pain on repetitive activity and physical exertion<sup>1</sup>. This condition is commonly seen in athletes, runners, and military personnel<sup>2</sup>. Open fasciotomy has been demonstrated to be a highly effective surgical treatment for patients with this condition who do not experience symptomatic relief after a thorough trial of nonoperative treatment<sup>3</sup>.</p><p><strong>Description: </strong>Diagnostic compartment pressure management is achieved through direct insertion of a compartment-pressure-measuring device into the anterior, lateral, and posterior compartments of the lower extremity<sup>4</sup>. Surgical treatment of the anterior and lateral compartments with use of open fasciotomy employs longitudinal proximal and distal incisions that are made on the lateral surface of the leg approximately 3 finger-breadths distal and proximal to the fibular flare, respectively, and 3 finger-breadths lateral to the tibial crest. Surgical treatment of the posterior compartments with use of open fasciotomy employs a single, mid-shaft incision made approximately 2.5 cm medial to the tibial ridge. Dissection is carried down to the deep fascia at both sites, beginning at the distal operative site. Care is taken to avoid transection of the superficial peroneal nerve at the distal anterolateral incision and saphenous vein and nerve at the medial incision. Once down to the deep fascia, a scalpel is utilized to incise the fascia. Metzenbaum scissors are then employed under the incision, spreading the scissors while sliding them over the muscles proximally and distally to release the muscular attachments from the fascia as well as to release the fascia itself<sup>3</sup>. This process is repeated in the anterior, lateral, and superficial posterior compartments through the proximal and distal incisions. In the deep posterior compartment, the fascia is released from the tibial ridge with a large Cobb elevator. Closure is achieved with deep dermal and superficial sutures.</p><p><strong>Alternatives: </strong>Nonoperative alternatives have been reported to include nonpharmacological modalities such as walking modification and shoe inserts, pharmacological therapy with nonsteroidal anti-inflammatory drugs, and physical therapy targeted at conditioning the lower extremity<sup>5</sup>. Nonoperative intervention has been demonstrated to increase endurance in select patients; however, most patients must either stop the activity associated with the compartment syndrome altogether or proceed to surgery for complete resolution of symptoms<sup>5</sup>. There are a few surgical alternatives that differ in their utilization of minimally invasive approaches versus a direct open approach<sup>6</sup>; however, all existing surgical treatments of this condition invol","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2022-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10578677/pdf/jxt-12-e21.00059.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41239628","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 : 2022-10-01DOI: 10.2106/JBJS.ST.21.00044
David W Polly, Kenneth J Holton, Paul O Soriano, Jonathan N Sembrano, Christopher T Martin, Nathan R Hendrickson, Kristen E Jones
<p><p>Sacropelvic fixation is a continually evolving technique in the treatment of adult spinal deformity. The 2 most widely utilized techniques are iliac screw fixation and S2-alar-iliac (S2AI) screw fixation<sup>1-3</sup>. The use of these techniques at the base of long fusion constructs, with the goal of providing a solid base to maintain surgical correction, has improved fusion rates and decreased rates of revision<sup>4</sup>.</p><p><strong>Description: </strong>The procedure is performed with the patient under general anesthesia in the prone position and with use of 3D computer navigation based on intraoperative cone-beam computed tomography (CT) imaging. A standard open posterior approach with a midline incision and subperiosteal exposure of the proximal spine and sacrum is performed. Standard S2AI screw placement is performed. The S2AI starting point is on the dorsal sacrum 2 to 3 mm above the S2 foramen, aiming as caudal as possible in the teardrop. A navigated awl is utilized to establish the screw trajectory, passing through the sacrum, across the sacroiliac (SI) joint, and into the ilium. The track is serially tapped with use of navigated taps, 6.5 mm followed by 9.5 mm, under power. The screw is then placed under power with use of a navigated screwdriver.Proper placement of the caudal implant is vital as it allows for ample room for subsequent instrumentation. The additional point of pelvic fixation can be an S2AI screw or a triangular titanium rod (TTR). This additional implant is placed cephalad to the trajectory of the S2AI screw. A starting point 2 to 3 mm proximal to the S2AI screw tulip head on the sacral ala provides enough clearance and also helps to keep the implant low enough in the teardrop that it is likely to stay within bone. More proximal starting points should be avoided as they will result in a cephalad breach.For procedures with an additional point of pelvic fixation, the cephalad S2AI screw can be placed using the previously described method. For placement of the TTR, the starting point is marked with a burr. A navigated drill guide is utilized to first pass a drill bit to create a pilot hole, followed by a guide pin proximal to the S2AI screw in the teardrop. Drilling the tip of the guide pin into the distal, lateral iliac cortex prevents pin backout during the subsequent steps. A cannulated drill is then passed over the guide pin, traveling from the sacral ala and breaching the SI joint into the pelvis. A navigated broach is then utilized to create a track for the implant. The flat side of the triangular broach is turned toward the S2AI screw in order to help the implant sit as close as possible to the screw and to allow the implant to be as low as possible in the teardrop. The navigation system is utilized to choose the maximum possible implant length. The TTR is then passed over the guide pin and impacted to the appropriate depth. Multiplanar post-placement fluoroscopic images and an additional intraoperative C
{"title":"Multiple Points of Pelvic Fixation: Stacked S2-Alar-Iliac Screws (S2AI) or Concurrent S2AI and Open Sacroiliac Joint Fusion with Triangular Titanium Rod.","authors":"David W Polly, Kenneth J Holton, Paul O Soriano, Jonathan N Sembrano, Christopher T Martin, Nathan R Hendrickson, Kristen E Jones","doi":"10.2106/JBJS.ST.21.00044","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00044","url":null,"abstract":"<p><p>Sacropelvic fixation is a continually evolving technique in the treatment of adult spinal deformity. The 2 most widely utilized techniques are iliac screw fixation and S2-alar-iliac (S2AI) screw fixation<sup>1-3</sup>. The use of these techniques at the base of long fusion constructs, with the goal of providing a solid base to maintain surgical correction, has improved fusion rates and decreased rates of revision<sup>4</sup>.</p><p><strong>Description: </strong>The procedure is performed with the patient under general anesthesia in the prone position and with use of 3D computer navigation based on intraoperative cone-beam computed tomography (CT) imaging. A standard open posterior approach with a midline incision and subperiosteal exposure of the proximal spine and sacrum is performed. Standard S2AI screw placement is performed. The S2AI starting point is on the dorsal sacrum 2 to 3 mm above the S2 foramen, aiming as caudal as possible in the teardrop. A navigated awl is utilized to establish the screw trajectory, passing through the sacrum, across the sacroiliac (SI) joint, and into the ilium. The track is serially tapped with use of navigated taps, 6.5 mm followed by 9.5 mm, under power. The screw is then placed under power with use of a navigated screwdriver.Proper placement of the caudal implant is vital as it allows for ample room for subsequent instrumentation. The additional point of pelvic fixation can be an S2AI screw or a triangular titanium rod (TTR). This additional implant is placed cephalad to the trajectory of the S2AI screw. A starting point 2 to 3 mm proximal to the S2AI screw tulip head on the sacral ala provides enough clearance and also helps to keep the implant low enough in the teardrop that it is likely to stay within bone. More proximal starting points should be avoided as they will result in a cephalad breach.For procedures with an additional point of pelvic fixation, the cephalad S2AI screw can be placed using the previously described method. For placement of the TTR, the starting point is marked with a burr. A navigated drill guide is utilized to first pass a drill bit to create a pilot hole, followed by a guide pin proximal to the S2AI screw in the teardrop. Drilling the tip of the guide pin into the distal, lateral iliac cortex prevents pin backout during the subsequent steps. A cannulated drill is then passed over the guide pin, traveling from the sacral ala and breaching the SI joint into the pelvis. A navigated broach is then utilized to create a track for the implant. The flat side of the triangular broach is turned toward the S2AI screw in order to help the implant sit as close as possible to the screw and to allow the implant to be as low as possible in the teardrop. The navigation system is utilized to choose the maximum possible implant length. The TTR is then passed over the guide pin and impacted to the appropriate depth. Multiplanar post-placement fluoroscopic images and an additional intraoperative C","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 4","pages":"e21.00044"},"PeriodicalIF":1.3,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9889296/pdf/jxt-12-e21.00044.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9230754","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 : 2022-10-01DOI: 10.2106/JBJS.ST.21.00034
Brigitte E P A van der Heijden, Cecile M C A van Laarhoven
<p><p>In cases of isolated carpometacarpal (CMC) thumb joint osteoarthritis, a hemitrapeziectomy can be performed. To address the risk of subsidence of the first metacarpal, a pyrocarbon disc has been designed as an interposition prosthesis. The disc is made of pyrolytic carbon with the same elastic modulus as cortical bone, making it resistant to wear from surrounding bone. This property contributes to preservation of thumb length and prevents subsidence. The present video article shows the pyrocarbon disc interposition arthroplasty step by step. The procedure results in substantial pain reduction with good function and strength at long-term follow-up. The complication rate is comparable with that of other surgical tendinoplasties for CMC thumb joint osteoarthritis. The survival rate has been reported to be 91% at a minimum follow-up of 5 years<sup>1-3</sup>. CMC thumb joint osteoarthritis is a common pathology. If symptoms remain despite splinting and hand therapy, surgical treatment is often performed. The simple trapeziectomy is seen as the reference standard, with good results and fewer complications compared with other surgical procedures<sup>4-6</sup>. Despite this fact, many surgeons still prefer to combine trapeziectomy with a tendinoplasty in order to reduce the risk of proximal migration and impingement of the first metacarpal on the scaphoid<sup>7-9</sup>. However, the volume and stiffness of autologous tendons are far less than that of the trapezial bone. This might be one of the reasons that trapeziectomy with tendinoplasty does not lead to better results than simple trapeziectomy. To overcome the disadvantages of a tendinoplasty, the PyroDisk (Integra LifeSciences) was introduced for CMC thumb joint osteoarthritis to preserve thumb length and provide more stability than other traditional techniques. The disc is designed to be utilized after a distal hemitrapeziectomy for patients with CMC thumb joint osteoarthritis without involvement of the scaphotrapeziotrapezoid (STT) joint.</p><p><strong>Description: </strong>Preoperatively, review radiology images to confirm that the osteoarthritis is limited to the thumb CMC joint and that all appropriate tools for inserting the disc are available before beginning surgery. Next, the patient is placed with their arm on an arm rest. The CMC thumb joint is exposed via a dorsal longitudinal skin incision, sparing the dorsal radial nerve branches and the radial artery and accompanying venes. The capsule is opened with an H-incision. With 2 parallel cuts to the joint surface, the articular surfaces of the joint are removed. After resection of the articular joint surfaces, the residual width and height of the joint space after resection are measured. The central point in the joint surfaces is marked for the bone tunnels. With an awl, tunnels are created from the center of the joint surface to the proximal (trapezial bone) and distal (first metacarpal bone) and the dorsal side. The implant size is me
{"title":"Pyrocarbon Disc Interposition Arthroplasty (PyroDisk) for the Treatment of Carpometacarpal Thumb Joint Osteoarthritis.","authors":"Brigitte E P A van der Heijden, Cecile M C A van Laarhoven","doi":"10.2106/JBJS.ST.21.00034","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00034","url":null,"abstract":"<p><p>In cases of isolated carpometacarpal (CMC) thumb joint osteoarthritis, a hemitrapeziectomy can be performed. To address the risk of subsidence of the first metacarpal, a pyrocarbon disc has been designed as an interposition prosthesis. The disc is made of pyrolytic carbon with the same elastic modulus as cortical bone, making it resistant to wear from surrounding bone. This property contributes to preservation of thumb length and prevents subsidence. The present video article shows the pyrocarbon disc interposition arthroplasty step by step. The procedure results in substantial pain reduction with good function and strength at long-term follow-up. The complication rate is comparable with that of other surgical tendinoplasties for CMC thumb joint osteoarthritis. The survival rate has been reported to be 91% at a minimum follow-up of 5 years<sup>1-3</sup>. CMC thumb joint osteoarthritis is a common pathology. If symptoms remain despite splinting and hand therapy, surgical treatment is often performed. The simple trapeziectomy is seen as the reference standard, with good results and fewer complications compared with other surgical procedures<sup>4-6</sup>. Despite this fact, many surgeons still prefer to combine trapeziectomy with a tendinoplasty in order to reduce the risk of proximal migration and impingement of the first metacarpal on the scaphoid<sup>7-9</sup>. However, the volume and stiffness of autologous tendons are far less than that of the trapezial bone. This might be one of the reasons that trapeziectomy with tendinoplasty does not lead to better results than simple trapeziectomy. To overcome the disadvantages of a tendinoplasty, the PyroDisk (Integra LifeSciences) was introduced for CMC thumb joint osteoarthritis to preserve thumb length and provide more stability than other traditional techniques. The disc is designed to be utilized after a distal hemitrapeziectomy for patients with CMC thumb joint osteoarthritis without involvement of the scaphotrapeziotrapezoid (STT) joint.</p><p><strong>Description: </strong>Preoperatively, review radiology images to confirm that the osteoarthritis is limited to the thumb CMC joint and that all appropriate tools for inserting the disc are available before beginning surgery. Next, the patient is placed with their arm on an arm rest. The CMC thumb joint is exposed via a dorsal longitudinal skin incision, sparing the dorsal radial nerve branches and the radial artery and accompanying venes. The capsule is opened with an H-incision. With 2 parallel cuts to the joint surface, the articular surfaces of the joint are removed. After resection of the articular joint surfaces, the residual width and height of the joint space after resection are measured. The central point in the joint surfaces is marked for the bone tunnels. With an awl, tunnels are created from the center of the joint surface to the proximal (trapezial bone) and distal (first metacarpal bone) and the dorsal side. The implant size is me","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 4","pages":"e21.00034"},"PeriodicalIF":1.3,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9889283/pdf/jxt-12-e21.00034.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10663216","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 : 2022-10-01DOI: 10.2106/JBJS.ST.21.00013
Elizabeth R Dennis, William A Marmor, Beth E Shubin Stein
<p><p>Medial patellofemoral ligament (MPFL) reconstruction with tibial tubercle osteotomy (TTO) and particulated juvenile articular cartilage (PJAC) grafting can be performed in combination for the treatment of recurrent patellar instability with associated patellar cartilaginous defects.</p><p><strong>Description: </strong>Preoperative planning is an essential component for this procedure. Measurement of the tibial tubercle to trochlear groove (TT-TG) distance and the Caton-Deschamps index (CDI) allows for determination of the degree of medial and anterior translation and helps to identify whether distalization is necessary. The procedure begins with a thorough examination under anesthesia to determine range of motion, patellar tracking, translation, and tilt. A diagnostic arthroscopy is performed, at which time patellar tracking is again assessed and the patellar and trochlear cartilage are evaluated. A medial parapatellar incision is made, and the layer between the capsule and retinaculum is identified. This layer will serve as the location for the MPFL graft passage. The medial patella is decorticated to prepare for graft fixation. The patella is then everted, and the cartilaginous defect is prepared and sized. The PJAC graft is prepared on the back table based on these measurements. The MPFL graft is then anchored to the decorticated medial patella. Attention is then turned to performing the TTO. The patellar tendon is isolated and protected. The osteotomy shingle is created with a combination of sagittal saw and osteotomes, followed by shingle translation and fixation. Attention is then turned to performing the MPFL graft fixation on the femur. An incision is made, the area of the sulcus between the medial epicondyle and adductor tubercle is identified, and a pin is placed. Graft isometry is assessed, pin placement is confirmed, and a socket is created. After thorough irrigation, the patella is then everted and the PJAC graft is implanted and set with fibrin glue. Finally, the MPFL graft is passed through the previously identified layer and docked into the medial femur at its isometric point.</p><p><strong>Alternatives: </strong>Nonoperative treatment of first-time patellar instability can often include physical therapy, bracing, and activity modification. However, recurrence rates can be high, especially in a subset of high-risk patients with characteristics such as age of <25 years, trochlear dysplasia, patella alta, and coronal plane malalignment. For patients with recurrent patellar instability, a well-executed MPFL reconstruction restores stability while the TTO serves to unload the lateral and/or inferior patellar cartilage and correct osseous malalignment. Additional techniques, such as a distal femoral osteotomy and trochleoplasty, have been suggested to address patellar tracking and trochlear dysplasia. For patients who have sustained cartilaginous injury from their previous dislocations, PJAC can be utilized to restore the patello
{"title":"Combined MPFL Reconstruction with Tibial Tubercle Osteotomy and Repair of Patellar Cartilage Defect with Particulated Juvenile Articular Cartilage.","authors":"Elizabeth R Dennis, William A Marmor, Beth E Shubin Stein","doi":"10.2106/JBJS.ST.21.00013","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00013","url":null,"abstract":"<p><p>Medial patellofemoral ligament (MPFL) reconstruction with tibial tubercle osteotomy (TTO) and particulated juvenile articular cartilage (PJAC) grafting can be performed in combination for the treatment of recurrent patellar instability with associated patellar cartilaginous defects.</p><p><strong>Description: </strong>Preoperative planning is an essential component for this procedure. Measurement of the tibial tubercle to trochlear groove (TT-TG) distance and the Caton-Deschamps index (CDI) allows for determination of the degree of medial and anterior translation and helps to identify whether distalization is necessary. The procedure begins with a thorough examination under anesthesia to determine range of motion, patellar tracking, translation, and tilt. A diagnostic arthroscopy is performed, at which time patellar tracking is again assessed and the patellar and trochlear cartilage are evaluated. A medial parapatellar incision is made, and the layer between the capsule and retinaculum is identified. This layer will serve as the location for the MPFL graft passage. The medial patella is decorticated to prepare for graft fixation. The patella is then everted, and the cartilaginous defect is prepared and sized. The PJAC graft is prepared on the back table based on these measurements. The MPFL graft is then anchored to the decorticated medial patella. Attention is then turned to performing the TTO. The patellar tendon is isolated and protected. The osteotomy shingle is created with a combination of sagittal saw and osteotomes, followed by shingle translation and fixation. Attention is then turned to performing the MPFL graft fixation on the femur. An incision is made, the area of the sulcus between the medial epicondyle and adductor tubercle is identified, and a pin is placed. Graft isometry is assessed, pin placement is confirmed, and a socket is created. After thorough irrigation, the patella is then everted and the PJAC graft is implanted and set with fibrin glue. Finally, the MPFL graft is passed through the previously identified layer and docked into the medial femur at its isometric point.</p><p><strong>Alternatives: </strong>Nonoperative treatment of first-time patellar instability can often include physical therapy, bracing, and activity modification. However, recurrence rates can be high, especially in a subset of high-risk patients with characteristics such as age of <25 years, trochlear dysplasia, patella alta, and coronal plane malalignment. For patients with recurrent patellar instability, a well-executed MPFL reconstruction restores stability while the TTO serves to unload the lateral and/or inferior patellar cartilage and correct osseous malalignment. Additional techniques, such as a distal femoral osteotomy and trochleoplasty, have been suggested to address patellar tracking and trochlear dysplasia. For patients who have sustained cartilaginous injury from their previous dislocations, PJAC can be utilized to restore the patello","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 4","pages":"e21.00013"},"PeriodicalIF":1.3,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9889293/pdf/jxt-12-e21.00013.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9230749","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 : 2022-07-01DOI: 10.2106/JBJS.ST.21.00061
Matthew M Levitsky, Alexander L Neuwirth, Jeffrey A Geller
<p><p>The anterior-based muscle-sparing (ABMS) technique for total hip arthroplasty (THA) has gained popularity in recent years because of its proposed advantages in terms of postoperative pain and periprosthetic dislocation risk.</p><p><strong>Description: </strong>The procedure is performed with the patient in the supine position. A minimally invasive Watson-Jones approach is utilized to access the hip. Fluoroscopy can be utilized intraoperatively to assess acetabular cup position, version, and inclination. Femoral canal fill and leg lengths can also be assessed with use of fluoroscopy.</p><p><strong>Alternatives: </strong>Nonoperative alternatives for the treatment of hip osteoarthritis include nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections into the hip joint. Surgical alternatives to this procedure include the posterior approach (Moore or Southern), the direct lateral approach (Hardinge), and the direct anterior approach (Smith-Petersen). The Watson-Jones approach can also be performed with the patient in the lateral decubitus position (unlike in our technique where the patient is supine).</p><p><strong>Rationale: </strong>The anterolateral (Watson-Jones) approach to the hip has been shown to be superior to the historically more common posterior approach with regard to length of hospital stay and dislocation risk<sup>1,2</sup>. Supine positioning for this approach offers multiple advantages compared with lateral decubitus positioning. Leg lengths can be assessed intraoperatively both fluoroscopically and with manual palpation of the medial malleoli. Cup position can be assessed radiographically as well<sup>3</sup>. Supine positioning also allows for easily reproducible patient positioning.</p><p><strong>Expected outcomes: </strong>Compared with the historically common posterior approach to the hip for THA, the anterolateral approach to the hip leads to, on average, a lower risk of hip dislocation<sup>1,2</sup>. In a 2002 study by Masonis and Bourne, the dislocation rate for the posterior approach was 3.23% (193 of 5,981), whereas the dislocation rate was 2.18% (18 of 826) for patients who underwent THA via the anterolateral approach<sup>1</sup>. In a study by Ritter et al. in 2001, which followed patients for 1 year postoperatively, no patients in the anterolateral approach group experienced a dislocation compared with 4.21% of patients in the posterior approach group<sup>2</sup>. With use of the present technique, patients will benefit from the advantages of the anterolateral approach to the hip; however, they will also benefit from easy intraoperative leg length assessment and from radiographic assistance with regard to determining the appropriate position of the femoral and acetabular components<sup>3</sup>. In a study of 199 patients (including 98 patients who had intraoperative fluoroscopy and 101 who did not), 80% of implants in the fluoroscopy group were within the combined safe zone compared with
{"title":"Anterior-Based Muscle-Sparing (ABMS) Approach for Total Hip Arthroplasty.","authors":"Matthew M Levitsky, Alexander L Neuwirth, Jeffrey A Geller","doi":"10.2106/JBJS.ST.21.00061","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00061","url":null,"abstract":"<p><p>The anterior-based muscle-sparing (ABMS) technique for total hip arthroplasty (THA) has gained popularity in recent years because of its proposed advantages in terms of postoperative pain and periprosthetic dislocation risk.</p><p><strong>Description: </strong>The procedure is performed with the patient in the supine position. A minimally invasive Watson-Jones approach is utilized to access the hip. Fluoroscopy can be utilized intraoperatively to assess acetabular cup position, version, and inclination. Femoral canal fill and leg lengths can also be assessed with use of fluoroscopy.</p><p><strong>Alternatives: </strong>Nonoperative alternatives for the treatment of hip osteoarthritis include nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections into the hip joint. Surgical alternatives to this procedure include the posterior approach (Moore or Southern), the direct lateral approach (Hardinge), and the direct anterior approach (Smith-Petersen). The Watson-Jones approach can also be performed with the patient in the lateral decubitus position (unlike in our technique where the patient is supine).</p><p><strong>Rationale: </strong>The anterolateral (Watson-Jones) approach to the hip has been shown to be superior to the historically more common posterior approach with regard to length of hospital stay and dislocation risk<sup>1,2</sup>. Supine positioning for this approach offers multiple advantages compared with lateral decubitus positioning. Leg lengths can be assessed intraoperatively both fluoroscopically and with manual palpation of the medial malleoli. Cup position can be assessed radiographically as well<sup>3</sup>. Supine positioning also allows for easily reproducible patient positioning.</p><p><strong>Expected outcomes: </strong>Compared with the historically common posterior approach to the hip for THA, the anterolateral approach to the hip leads to, on average, a lower risk of hip dislocation<sup>1,2</sup>. In a 2002 study by Masonis and Bourne, the dislocation rate for the posterior approach was 3.23% (193 of 5,981), whereas the dislocation rate was 2.18% (18 of 826) for patients who underwent THA via the anterolateral approach<sup>1</sup>. In a study by Ritter et al. in 2001, which followed patients for 1 year postoperatively, no patients in the anterolateral approach group experienced a dislocation compared with 4.21% of patients in the posterior approach group<sup>2</sup>. With use of the present technique, patients will benefit from the advantages of the anterolateral approach to the hip; however, they will also benefit from easy intraoperative leg length assessment and from radiographic assistance with regard to determining the appropriate position of the femoral and acetabular components<sup>3</sup>. In a study of 199 patients (including 98 patients who had intraoperative fluoroscopy and 101 who did not), 80% of implants in the fluoroscopy group were within the combined safe zone compared with","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00061"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9931043/pdf/jxt-12-e21.00061.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9314495","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 : 2022-07-01DOI: 10.2106/JBJS.ST.21.00037
Kyle R Wagner, Steven F DeFroda, Lakshmanan Sivasundaram, Joshua T Kaiser, Zach D Meeker, Nolan B Condron, Brian J Cole
<p><p>Focal cartilage defects of the knee are painful and difficult to treat, especially in younger patients<sup>1</sup>. Seen in up to 60% of patients who undergo knee arthroscopy<sup>2</sup>, chondral lesions are most common on the patella and medial femoral condyle<sup>3</sup>. Although the majority of lesions are asymptomatic, a variety of treatment options exist for those that are symptomatic; however, no clear gold-standard treatment has been established. In recent years, osteochondral allograft transplantation has been increasingly utilized because of its versatility and encouraging outcomes<sup>4-7</sup>. The procedure entails replacing damaged cartilage with a graft of subchondral bone and cartilage from a deceased donor. Indications for this procedure include a symptomatic, full-thickness osteochondral defect typically ≥2 cm<sup>2</sup> in size in someone who has failed conservative management. Relative indications include patient age of <40 years and a unipolar defect<sup>8,9</sup>.</p><p><strong>Description: </strong>Osteochondral allograft transplantation requires meticulous planning, beginning with preoperative radiographs to evaluate the patient's alignment, estimate the lesion size, and aid in matching of a donor femoral condyle. The procedure begins with the patient supine and the knee flexed. A standard arthrotomy incision is performed on the operative side. Once exposure is obtained, a bore is utilized to remove host tissue from the lesion typically to a depth of 5 to 8 mm. Measurements are taken and the donor condyle is appropriately sized to match. A coring reamer is utilized to create the plug from donor tissue, which is trimmed to the corresponding depth. After marrow elements are removed via pulse lavage, the allograft plug is placed within the femoral condyle lesion through minimal force.</p><p><strong>Alternatives: </strong>Nonoperative treatment involves a reduction in high-impact activities and physical therapy. Surgical alternatives include chondroplasty, microfracture, and osteochondral autograft transplantation; however, these options are typically performed for smaller lesions (<2 cm). For larger lesions (≥2 cm), matrix-induced autologous chondrocyte implantation (MACI) can be utilized, but requires 2 surgical procedures.</p><p><strong>Rationale: </strong>Osteochondral allograft transplantation is selected against other procedures for various reasons related to patient goals, preferences, and expectations. Typically, this procedure is favored over microfracture or autograft transplantation when the patient has a large lesion. Allograft transplantation might be favored over MACI because of patient preference for a single surgical procedure instead of 2.</p><p><strong>Expected outcomes: </strong>To our knowledge, there are currently no Level-I or II trials comparing osteochondral allograft transplantation against other treatments for cartilage defects. There are, however, many systematic reviews of case studies and c
{"title":"Osteochondral Allograft Transplantation for Focal Cartilage Defects of the Femoral Condyles.","authors":"Kyle R Wagner, Steven F DeFroda, Lakshmanan Sivasundaram, Joshua T Kaiser, Zach D Meeker, Nolan B Condron, Brian J Cole","doi":"10.2106/JBJS.ST.21.00037","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00037","url":null,"abstract":"<p><p>Focal cartilage defects of the knee are painful and difficult to treat, especially in younger patients<sup>1</sup>. Seen in up to 60% of patients who undergo knee arthroscopy<sup>2</sup>, chondral lesions are most common on the patella and medial femoral condyle<sup>3</sup>. Although the majority of lesions are asymptomatic, a variety of treatment options exist for those that are symptomatic; however, no clear gold-standard treatment has been established. In recent years, osteochondral allograft transplantation has been increasingly utilized because of its versatility and encouraging outcomes<sup>4-7</sup>. The procedure entails replacing damaged cartilage with a graft of subchondral bone and cartilage from a deceased donor. Indications for this procedure include a symptomatic, full-thickness osteochondral defect typically ≥2 cm<sup>2</sup> in size in someone who has failed conservative management. Relative indications include patient age of <40 years and a unipolar defect<sup>8,9</sup>.</p><p><strong>Description: </strong>Osteochondral allograft transplantation requires meticulous planning, beginning with preoperative radiographs to evaluate the patient's alignment, estimate the lesion size, and aid in matching of a donor femoral condyle. The procedure begins with the patient supine and the knee flexed. A standard arthrotomy incision is performed on the operative side. Once exposure is obtained, a bore is utilized to remove host tissue from the lesion typically to a depth of 5 to 8 mm. Measurements are taken and the donor condyle is appropriately sized to match. A coring reamer is utilized to create the plug from donor tissue, which is trimmed to the corresponding depth. After marrow elements are removed via pulse lavage, the allograft plug is placed within the femoral condyle lesion through minimal force.</p><p><strong>Alternatives: </strong>Nonoperative treatment involves a reduction in high-impact activities and physical therapy. Surgical alternatives include chondroplasty, microfracture, and osteochondral autograft transplantation; however, these options are typically performed for smaller lesions (<2 cm). For larger lesions (≥2 cm), matrix-induced autologous chondrocyte implantation (MACI) can be utilized, but requires 2 surgical procedures.</p><p><strong>Rationale: </strong>Osteochondral allograft transplantation is selected against other procedures for various reasons related to patient goals, preferences, and expectations. Typically, this procedure is favored over microfracture or autograft transplantation when the patient has a large lesion. Allograft transplantation might be favored over MACI because of patient preference for a single surgical procedure instead of 2.</p><p><strong>Expected outcomes: </strong>To our knowledge, there are currently no Level-I or II trials comparing osteochondral allograft transplantation against other treatments for cartilage defects. There are, however, many systematic reviews of case studies and c","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00037"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9931042/pdf/jxt-12-e21.00037.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10824612","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p><p>Various techniques for periacetabular osteotomy have been reported to prevent the progression of osteoarthritis in dysplastic hips<sup>1-5</sup>. Bernese periacetabular osteotomy, which involves the use of an anterior approach, is widely performed throughout the world because it offers preservation of the blood supply to the bone fragment and lateral pelvic muscles. However, Bernese periacetabular osteotomy has potential complications, such as nonunion at the osteotomy site, postoperative fracture, nonunion of the pubis and ischium, and damage to the main trunk of the obturator artery. Spherical periacetabular osteotomy (SPO) has been developed to resolve some of disadvantages of Bernese periacetabular osteotomy<sup>6</sup>. Although SPO involves some technical difficulty, the procedure is safe when performed with use of appropriate preoperative 3-dimensional planning and surgical technique.</p><p><strong>Description: </strong>Preoperative 3-dimensional planning is utilized to decide the radius of the curved osteotome, locations of the reference points for the osteotomy line, and depth of the bone groove at the teardrop area. The pelvic positioning is arranged fluoroscopically to match the neutral position based on preoperative planning. A 7-cm incision is made along the medial margin of the iliac crest. An anterior iliac crest osteotomy of 4.5 cm (length) × 1 cm (medial wedge-shaped) is performed. The operative field is maintained with aluminum retractors. The osteotomy line is completed by connecting the preoperatively planned reference points on the inner cortex of the ilium. The bone groove is made along the osteotomy line with use of a high-speed burr. A blunt osteotome is inserted into the bone groove at the teardrop area until it reaches the preoperatively planned depth. The blunt osteotome makes a pathway for the curved osteotome without breaking the quadrilateral surface (QLS) or perforating the hip joint. The special curved osteotome is inserted manually until it reaches the bottom of the groove, and the posterior cortex is cut. After the top of the teardrop is divided fluoroscopically, the anterior ischial cortex is osteotomized with a sharpened spiked Cobb elevator at the infracotyloid groove. An angled curved osteotome is used for the osteotomy of the superior area of the teardrop area. The bone fragment is rotated with a spreader and an angled retractor, and fixed with 2 absorbable screws. Beta-tricalcium phosphate blocks are inserted into the bone gap. The osteotomized wedge-shaped iliac bone is repositioned and fixed.</p><p><strong>Alternatives: </strong>Alternatives include the Bernese periacetabular osteotomy, rotational acetabular osteotomy, and triple innominate osteotomy.</p><p><strong>Rationale: </strong>Bernese periacetabular osteotomy utilizes an anterior approach, cuts into the QLS, and preserves the posterior column. In contrast, SPO preserves the QLS and does not cut the pubis. These features of SPO have some adva
{"title":"Spherical Periacetabular Osteotomy.","authors":"Toshihiko Hara, Ayumi Kaneuji, Kazuhiko Sonoda, Tetsuro Nakamura, Masanori Fujii, Eiji Takahashi","doi":"10.2106/JBJS.ST.21.00048","DOIUrl":"https://doi.org/10.2106/JBJS.ST.21.00048","url":null,"abstract":"<p><p>Various techniques for periacetabular osteotomy have been reported to prevent the progression of osteoarthritis in dysplastic hips<sup>1-5</sup>. Bernese periacetabular osteotomy, which involves the use of an anterior approach, is widely performed throughout the world because it offers preservation of the blood supply to the bone fragment and lateral pelvic muscles. However, Bernese periacetabular osteotomy has potential complications, such as nonunion at the osteotomy site, postoperative fracture, nonunion of the pubis and ischium, and damage to the main trunk of the obturator artery. Spherical periacetabular osteotomy (SPO) has been developed to resolve some of disadvantages of Bernese periacetabular osteotomy<sup>6</sup>. Although SPO involves some technical difficulty, the procedure is safe when performed with use of appropriate preoperative 3-dimensional planning and surgical technique.</p><p><strong>Description: </strong>Preoperative 3-dimensional planning is utilized to decide the radius of the curved osteotome, locations of the reference points for the osteotomy line, and depth of the bone groove at the teardrop area. The pelvic positioning is arranged fluoroscopically to match the neutral position based on preoperative planning. A 7-cm incision is made along the medial margin of the iliac crest. An anterior iliac crest osteotomy of 4.5 cm (length) × 1 cm (medial wedge-shaped) is performed. The operative field is maintained with aluminum retractors. The osteotomy line is completed by connecting the preoperatively planned reference points on the inner cortex of the ilium. The bone groove is made along the osteotomy line with use of a high-speed burr. A blunt osteotome is inserted into the bone groove at the teardrop area until it reaches the preoperatively planned depth. The blunt osteotome makes a pathway for the curved osteotome without breaking the quadrilateral surface (QLS) or perforating the hip joint. The special curved osteotome is inserted manually until it reaches the bottom of the groove, and the posterior cortex is cut. After the top of the teardrop is divided fluoroscopically, the anterior ischial cortex is osteotomized with a sharpened spiked Cobb elevator at the infracotyloid groove. An angled curved osteotome is used for the osteotomy of the superior area of the teardrop area. The bone fragment is rotated with a spreader and an angled retractor, and fixed with 2 absorbable screws. Beta-tricalcium phosphate blocks are inserted into the bone gap. The osteotomized wedge-shaped iliac bone is repositioned and fixed.</p><p><strong>Alternatives: </strong>Alternatives include the Bernese periacetabular osteotomy, rotational acetabular osteotomy, and triple innominate osteotomy.</p><p><strong>Rationale: </strong>Bernese periacetabular osteotomy utilizes an anterior approach, cuts into the QLS, and preserves the posterior column. In contrast, SPO preserves the QLS and does not cut the pubis. These features of SPO have some adva","PeriodicalId":44676,"journal":{"name":"JBJS Essential Surgical Techniques","volume":"12 3","pages":"e21.00048"},"PeriodicalIF":1.3,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/e9/ba/jxt-12-e21.00048.PMC9931045.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9314500","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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