Operative Techniques in Orthopaedics最新文献

Transhumeral amputations have historically been plagued by high rates of neuroma formation, neuropathic pain, poor prosthetic fitting, and low prosthesis use rates. Recent advances in adjunct surgical techniques are promising for excellent reconstructive and functional outcomes for these patients. A surgical approach addressing all aspects of the residual extremity, including bone, soft tissues, and nerves, will result in superior outcomes and fewer complications. Humeral osteotomy techniques shorten the residual extremity to create a lever arm, which improves prosthetic fit and functionality. Use of myodesis and myoplasty provides a stable soft tissue envelope around the residual bone ends to minimize tissue redundancy. Nerve interface procedures, such as targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), reduce the likelihood of neuroma formation and rates of phantom limb pain while increasing the number of electromyographic signals that can be detected by a myoelectric prosthesis. Osseointegration, a promising new bone-anchored prosthesis technology, may further improve functional outcomes for transhumeral amputees. A multidisciplinary team, including orthopedic surgeons, mental health professionals, occupational therapists, and physical therapists, can improve patient quality of life and functional outcome postoperatively.

While exchange nailing has been a useful technique for femur nonunion management, far proximal and distal nonunions present challenges that are difficult to correct with nails alone. Angled blade plates are extremely powerful tools for nonunion management in proximal and distal femur nonunions where limited bone stock exists for purchase. Below, we review the indications for blade plate usage and present a pertrochanteric nonunion case managed with a blade plate to review the technical steps needed for success.

Geriatric hip fractures are a common problem facing orthopedic surgeons on call in the community. This review discusses pertrochanteric fractures and the surgeon-controlled variables related to their operative treatment. The reduction of these fractures relies on the restoration of the calcar. Implants most often used for pertrochanteric fractures consist of either intramedullary versus extramedullary constructs. The lateral wall integrity and intact thickness is used to determine fixation strategies. Intramedullary devices have been shown to be biomechanically superior, and able to be used across a larger spectrum of fractures. However, their versatility comes with increasing cost. The length of the nail remains controversial, but the chance of a peri-implant fracture or complication appears to be similar amongst all lengths, including the “intermediate” length devices. Different types of fixation into the head have also been studied with helical blades versus screws both demonstrating unique failure types. Several head fixation augmentations and strategies have been described as well, each with their own advantages and disadvantages. Regardless of implant choice, tip-to-apex remains one of the more important factors in limiting failure.

Distal femur fractures present a particularly complex problem to surgeons at all levels of experience. Concerns that arise for treating surgeons include determining the optimal fixation strategy based on the patient's biology, as well as determining the optimal surgical approach to decrease perioperative morbidity. As the risk for nonunion is high in distal femur fractures, surgeons must be aware of the available options to achieve stable fixation and ultimately bony union. A multitude of techniques exist for treating distal femoral nonunion. These techniques range from revision open reduction internal fixation, plate augmentation with a medial femur plate, a nail-plate combination, and a distal femur replacement when appropriate. This article will review the literature and include radiographic case examples of several fixation strategies in the treatment of distal femoral nonunions.

Vancouver B1 periprosthetic femur fractures present several challenges to the treating surgeon. Particularly difficult is achieving adequate fixation proximally in the presence of a femoral prosthesis and often poor bone quality. Standard screw fixation may not always be feasible, so often a combination of techniques must be used. Multiple fixation options exist without a consensus on the optimal fixation strategy. This article will review the literature and include radiographic case examples of several fixation strategies, including cerclage devices, screws, accessory plates, and double plating.

Nonunion is a rare complication associated with surgical fixation of geriatric intertrochanteric femur fractures. The goal of post-traumatic reconstruction includes bone healing and return of functionality. Host optimization and preoperative planning are critical to optimizing the mechanics necessary to achieve nonunion compression and healing. Corrective osteotomies are often needed in these complex cases, while bone grafting is performed on an individualized basis. Popular implants include the blade plate, sliding hip screw, and intramedullary hip screw, with the ideal implant selected to maintain alignment until union. Fortunately, nonunion reconstruction typically leads to uneventful union if the principles of care are followed.