Campbell's Operative Orthopaedics, 4-Volume Set [14 ed.] 9780323672177, 0323672175, 9780323672191, 0323672191, 9780323672184, 9780323672207

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Campbell’s Operative Orthopaedics, 14th ed. List of Techniques VOLUME I Surgical Techniques 1.1 Fixation of Tendon to Bone, 14 1.2 Tendon Fixation Into the Intramedullary Canal, 15 1.3 Tendon to Bone Fixation Using Locking Loop Suture, 16 1.4 Tendon to Bone Fixation Using Wire Suture, 16 1.5 Fixation of Osseous Attachment of Tendon to Bone, 17 1.6 Removal of a Tibial Graft, 22 1.7 Removal of Fibular Grafts, 23 1.8 Removal of an Iliac Bone Graft, 26 1.9 Approach to the Interphalangeal Joints, 28 1.10 Medial Approach to the Great Toe Metatarsophalangeal Joint, 28 1.11 Dorsomedial Approach to Great Toe Metatarsophalangeal Joint, 29 1.12 Approach to the Lesser Toe Metatarsophalangeal Joints, 29 1.13 Medial Approach to the Calcaneus, 29 1.14 Lateral Approach to the Calcaneus, 29 1.15 Extended Lateral Approach to the Calcaneus, 29 1.16 Sinus Tarsi Approach, 31 1.17 U–Shaped Approach to the Calcaneus, 31 1.18 Kocher Approach (Curved L) to the Calcaneus, 32 1.19 Anterolateral Approach to Chopart Joint, 33 1.20 Anterior Approach to Expose the Ankle Joint and Both Malleoli, 33 1.21 Kocher Lateral Approach to the Tarsus and Ankle, 34 1.22 Ollier Approach to the Tarsus, 34 1.23 Single-Incision Posterolateral Approach to the Lateral and ­Posterior Malleoli, 35 1.24 Posterolateral Approach to the Ankle (Gatellier and Chastang), 35 1.25 Anterolateral Approach to the Lateral Dome of the Talus (Tochigi, Amendola, Muir, and Saltzman), 35 1.26 Posterior Approach to the Ankle, 36 1.27 Medial Approach to the Tarsus (Knupp et al.), 37 1.28 Medial Approach to the Ankle (Koenig and Schaefer), 37 1.29 Medial Approach to the Posterior Lip of the Tibia (Colonna and Ralston), 38 1.30 Anterolateral Approach to the Tibia, 39 1.31 Medial Approach to the Tibia (Phemister), 39 1.32 Posterolateral Approach to the Tibial Shaft (Harmon, Modified), 39 1.33 Anterolateral Approach to the Lateral Tibial Plateau (Kandemir and MacLean), 39 1.34 Medial Approach to the Medial Tibial Plateau, 41 1.35 Posteromedial Approach to the Medial Tibial Plateau (Supine), 41 1.36 Posteromedial Approach (Prone) to the Superomedial Tibia (Banks and Laufman), 42 1.37 Posterolateral Approach to the Tibial Plateau (Solomon et al.), 43 1.38 Posterolateral Approach to the Tibial Plateau Without Fibular Osteotomy (Frosch et al.), 44 1.39 Tscherne-Johnson Extensile Approach to the Lateral Tibial Plateau (Johnson et al.), 44 1.40 Anterolateral Approach for Access to Posterolateral Corner (Sun et al.), 45 1.41 Posterolateral Approach to the Fibula (Henry), 46 1.42 Anteromedial Parapatellar Approach (von Langenbeck), 47 1.43 Subvastus (Southern) Anteromedial Approach to the Knee (Erkes, as Described by Hofmann, Plaster, and Murdock), 47 1.44 Anterolateral Approach to the Knee (Kocher), 48 1.45 Posterolateral Approach to the Knee (Henderson), 49 1.46 Posteromedial Approach to the Knee (Henderson), 51 1.47 Medial Approach to the Knee (Cave), 52 1.48 Medial Approach to the Knee (Hoppenfeld and deBoer), 53 1.49 Transverse Approach to the Meniscus, 53 1.50 Lateral Approach to the Knee (Bruser), 55 1.51 Lateral Approach to the Knee (Brown et al.), 56 1.52 Lateral Approach to the Knee (Hoppenfeld and deBoer), 57 1.53 Extensile Approach to the Knee (Fernandez), 58 1.54 Direct Posterior Approach to the Knee (Brackett and Osgood; Putti; Abbott and Carpenter), 58 1.55 Direct Posteromedial Approach to the Knee for Tibial Plateau Fracture (Galla and Lobenhoffer as Described by Fakler et al.), 61

1.56 Direct Posterolateral Approach to the Knee (Minkoff, Jaffe, and Menendez), 62 1.57 Anterolateral Approach to the Femur (Thompson), 62 1.58 Lateral Approach to the Femoral Shaft, 63 1.59 Posterolateral Approach to the Femoral Shaft, 64 1.60 Posterior Approach to the Femur (Bosworth), 64 1.61 Medial Approach to the Posterior Surface of the Femur in the Popliteal Space (Henry), 67 1.62 Lateral Approach to the Posterior Surface of the Femur in the Popliteal Space (Henry), 67 1.63 Lateral Approach to the Proximal Shaft and the Trochanteric Region, 68 1.64 Anterior Iliofemoral Approach to the Hip (Smith-Petersen), 70 1.65 Anterior Approach to the Hip Using a Transverse Incision (Somerville), 71 1.66 Modified Anterolateral Iliofemoral Approach to the Hip (Smith–Petersen), 71 1.67 Lateral Approach to the Hip (Watson-Jones), 73 1.68 Lateral Approach for Extensive Exposure of the Hip (Harris), 73 1.69 Lateral Approach to the Hip Preserving the Gluteus Medius (McFarland and Osborne), 75 1.70 Lateral Transgluteal Approach to the Hip (Hardinge), 77 1.71 Lateral Transgluteal Approach to the Hip (Hay as Described by McLauchlan), 77 1.72 Posterolateral Approach (Gibson), 78 1.73 Posterior Approach to the Hip (Osborne), 80 1.74 Posterior Approach to the Hip (Moore), 82 1.75 Medial Approach to the Hip (Ferguson; Hoppenfeld and DeBoer), 84 1.76 Stoppa Approach (AO Foundation), 85 1.77 Ilioinguinal Approach to the Acetabulum (Letournel and Judet, as Described by Matta), 87 1.78 Iliofemoral Approach to the Acetabulum (Letournel and Judet), 90 1.79 Kocher-Langenbeck Approach (Kocher-Langenbeck; Letournel and Judet), 91 1.80 Modified Gibson Approach (Modified Gibson Approach, Moed), 93 1.81 Extensile Iliofemoral Approach (Letournel and Judet), 94 1.82 Extensile Iliofemoral Approach (Reinert et al.), 94 1.83 Triradiate Extensile Approach to the Acetabulum (Mears and Rubash), 97 1.84 Extensile Approach to the Acetabulum (Carnesale), 99 1.85 Approach to the Ilium, 99 1.86 Approach to the Symphysis Pubis (Pfannenstiel), 100 1.87 Posterior Approach to the Sacroiliac Joint, 102 1.88 Anterior Approach to the Sacroiliac Joint (Avila), 102 1.89 Approach to Both Sacroiliac Joints or Sacrum (Modified from Mears and Rubash), 103 1.90 Approach to the Sternoclavicular Joint, 104 1.91 Approach to the Acromioclavicular Joint and Coracoid Process (Roberts), 104 1.92 Anteromedial Approach to the Shoulder (Thompson; Henry), 105 1.93 Anteromedial/Posteromedial Approach to the Shoulder (Cubbins, Callahan, and Scuderi), 106 1.94 Anterior Axillary Approach to the Shoulder (Leslie and Ryan), 106 1.95 Anterolateral Limited Deltoid-Splitting Approach to the Shoulder, 106 1.96 Extensile Anterolateral Approach to the Shoulder (Gardner et al.), 109 1.97 Transacromial Approach to the Shoulder (Darrach; McLaughlin), 109 1.98 Posterior Deltoid-Splitting Approach to the Shoulder (Wirth et al.), 110 1.99 Posterior Approach to the Shoulder (Modified Judet), 111 1.100 Simplified Posterior Approach to the Shoulder (King, as Described by Brodsky et al.), 111 1.101 Posterior Inverted-U Approach to the Shoulder (Abbott and Lucas), 113 1.102 Anterolateral Approach to the Shaft of the Humerus (Thompson; Henry), 114 1.103 Subbrachial Approach to the Humerus (Boschi et al.), 116 1.104 Posterior Approach to the Proximal Humerus (Berger and Buckwalter), 117

1.105 Posterolateral Approach to the Distal Humeral Shaft (Moran), 118 1.106 Posterolateral Extensile (Cold) Approach to the Distal Humerus (Lewicky, Sheppard, and Ruth), 120 1.107 Posterolateral Approach to the Elbow (Campbell), 121 1.108 Extensile Posterolateral Approach to the Elbow (Wadsworth), 121 1.109 Posterior Approach to the Elbow by Olecranon Osteotomy (MacAusland and Müller), 123 1.110 Extensile Posterior Approach to the Elbow (Bryan and Morrey), 123 1.111 Lateral Approach to the Elbow, 124 1.112 Lateral J–Shaped Approach to the Elbow (Kocher), 126 1.113 Medial Approach with Osteotomy of the Medial Epicondyle (Molesworth; Campbell), 127 1.114 Medial and Lateral Approach to the Elbow, 127 1.115 Global Approach to the Elbow (Patterson, Bain, and Mehta), 127 1.116 Posterolateral Approach to the Radial Head and Neck, 130 1.117 Approach to the Proximal and Middle Thirds of the Posterior Surface of the Radius (Thompson), 131 1.118 Anterolateral Approach to the Proximal Shaft and Elbow Joint (Henry), 132 1.119 Anterior Approach to the Distal Half of the Radius (Henry), 132 1.120 Anterior Approach to the Coronoid Process of the Proximal Ulna (Yang et al.), 134 1.121 Approach to the Proximal Third of the Ulna and the Proximal Fourth of the Radius (Boyd), 135 1.122 Dorsal Approach to the Wrist, 137 1.123 Dorsal Approach to the Wrist, 137 1.124 Volar Approach to the Wrist, 137 1.125 Lateral Approach to the Wrist, 138 1.126 Medial Approach to the Wrist, 138 Arthroplasty of the Hip 3.1 Preoperative Templating for Total Hip Arthroplasty (Capello), 203 3.2 Posterolateral Approach with Posterior Dislocation of the Hip, 207 3.3 Implantation of Cementless Acetabular Component, 210 3.4 Implantation of Cemented Acetabular Component, 212 3.5 Implantation of Cementless Femoral Component, 214 3.6 Implantation of Cemented Femoral Component, 218 3.7 Direct Anterior Approach with Anterior Dislocation of the Hip, 222 3.8 Gluteus Maximus and Tensor Fascia Lata Transfer for Primary Deficiency of the Abductors of the Hip, 269 3.9 Revision After Adverse Local Tissue Reaction, 285 3.10 Transtrochanteric Approach for Revision Total Hip Arthroplasty, 289 3.11 Removal of Cemented Femoral Component, 289 3.12 Removal of Cementless Femoral Component, 290 3.13 Removal of Implants with Extensive Distal Bone Ingrowth (Glassman and Engh), 291 3.14 Extended Trochanteric Osteotomy (Younger et al.), 292 3.15 Removal of a Broken Stem—Proximal Window (Moreland, Marder, and Anspach), 294 3.16 Removal of a Broken Stem—Distal Window, 295 3.17 Removal of Femoral Cement, 295 3.18 Removal of Distal Cement with a High-Speed Burr (Turner et al.), 296 3.19 Removal of Distal Cement with a High-Speed Burr and Cortical Window (Mallory), 298 3.20 Removal of a Loose All-Polyethylene Cup, 299 3.21 Removal of a Metal-Backed, Cemented Acetabular Component, 299 3.22 Cementless Acetabular Component (Mitchell), 301 3.23 Management of Acetabular Cavitary Deficits, 302 3.24 Management of Segmental Acetabular Deficit with Femoral Head Allograft, 307 3.25 Management of Segmental Acetabular Deficit with Metal Augment (Jenkins et al., Modified), 307 3.26 Management of Combined Deficits with Structural Grafting (Sporer et al.), 308 3.27 Acetabular Distraction for Management of Pelvic Discontinuity (Sheth et al.), 310 3.28 Cup-Cage Technique for Management of Pelvic Discontinuity (Abdel et al., Modified), 311 3.29 Management of Pelvic Discontinuity with Allografting and Custom Component (DeBoer et al.), 311 3.30 Management of Femoral Deficit with Modular Femoral Component (Cameron), 316 3.31 Revision with Extensively Porous-Coated Femoral Stem (Mallory and Head), 316

3.32 Management of Proximal Femoral Bone Loss with Modular ­Tapered Fluted Stem (Kwong et al.), 317 3.33 Management of Proximal Femoral Deficiencies with Impaction Bone Grafting and Cemented Revision Stem (Gie, Modified), 317 3.34 Management of Massive Deficits with Proximal Femoral ­AllograftProsthesis Composite, 319 3.35 Management of Massive Deficits with Modular Megaprosthesis (Klein et al.), 321 Surface Replacement Hip Arthroplasty 4.1 Hip Resurfacing Technique—Birmingham Hip Replacement, 336 Arthrodesis of the Hip 5.1 Arthrodesis with Cancellous Screw Fixation (Benaroch et al.), 349 5.2 Arthrodesis with Anterior Fixation (Matta et al.), 349 5.3 Arthrodesis with Double-Plate Fixation (Müller et al.), 350 5.4 Arthrodesis with Cobra Plate Fixation (Murrell and Fitch), 351 5.5 Arthrodesis with Hip Compression Screw Fixation (Pagnano and Cabanela), 353 5.6 Arthrodesis in the Absence of the Femoral Head (Abbott, Fischer, and Lucas), 353 Hip Pain in the Young Adult and Hip Preservation Surgery 6.1 Surgical Dislocation of the Hip (Ganz et al.), 367 6.2 Combined Hip Arthroscopy and Limited Open Osteochondroplasty (Clohisy and McClure), 371 6.3 Mini-Open Direct Anterior Approach (Ribas et al.), 373 6.4 Bernese Periacetabular Osteotomy (Matheney et al.), 381 6.5 Rectus-Sparing Modification of Bernese Osteotomy (Novais et al.), 385 6.6 Step-Cut Lengthening of the Iliotibial Band (White et al.), 388 6.7 Core Decompression (Hungerford), 393 6.8 Core Decompression—Percutaneous Technique (Mont et al.), 394 Arthroplasty of the Knee 7.1 Surgical Approach for Primary Total Knee Arthroplasty, 436 7.2 Bone Preparation for Primary Total Knee Arthroplasty, 439 7.3 Pie-Crusting, 444 7.4 Posterior Stabilized Total Knee Arthroplasty In A Varus Knee, 445 7.5 Posterior Cruciate–Retaining Total Knee Arthroplasty of a Varus Knee, 445 7.6 Valgus Deformity Correction, 446 7.7 Flexion Contracture Correction, 447 7.8 Recurvatum Correction, 448 7.9 Posterior Cruciate Ligament Balancing, 448 7.10 Bone Grafting of Peripheral Tibial Defects (Windsor, Insall, and Sculco), 450 7.11 Component Implantation, 453 7.12 Unicondylar Knee Arthroplasty, 455 7.13 Patellofemoral Arthroplasty, 456 7.14 Arthrodesis with an Intramedullary Nail for an Infected Total Knee Arthroplasty, 463 Arthrodesis of the Knee 8.1 Compression Arthrodesis Using External Fixation, 486 8.2 Arthrodesis Using Intramedullary Nail Fixation, 487 8.3 Knee Arthrodesis with Locked Intramedullary Nail After Failed Total Knee Arthroplasty, 489 8.4 Arthrodesis Using Plate Fixation, 490 Soft-Tissue Procedures and Osteotomies About the Knee 9.1 Proximal Release of Quadriceps (Sengupta), 494 9.2 Quadricepsplasty for Posttraumatic Contracture of the Knee (Modified Thompson, Described by Hahn et al.), 494 9.3 Drainage of Bursa, 499 9.4 Excision of Bursa, 499 9.5 Popliteal Cyst Excision (Hughston, Baker, and Mello), 501 9.6 Medial Gastrocnemius Bursa Excision (Meyerding and Van Demark), 502 9.7 Semimembranosus Bursa Excision, 503 9.8 Semitendinosus Tendon Transfer (Ray, Clancy, and Lemon), 503 9.9 Lateral Closing Wedge Osteotomy (Modified Coventry; Hofmann, Wyatt, and Beck), 513 9.10 Opening Wedge Hemicallotasis (Turi et al.), 518 9.11 Varus Distal Femoral Osteotomy (Coventry), 522 Total Ankle Arthroplasty 10.1 Total Ankle Arthroplasty, 533 10.2 Dome Osteotomy for Correction of Varus Deformity Above the Ankle Deformity (Tan and Myerson), 536

10.3 Medial Tibial Plafondplasty for Varus Deformity at the Ankle Joint (Tan and Myerson), 537 10.4 Reconstruction of Lateral Ankle Ligaments for Chronic Instability as an Adjunct to Total Ankle Arthroplasty (Coetzee), 538 10.5 Tibiotalar Arthrodesis Conversion to Total Ankle Arthroplasty (Pellegrini et al.), 540 10.6 Revision Total Ankle Arthroplasty (Meeker et al.), 555 Ankle Arthrodesis 11.1 Opening Wedge Osteotomy of the Tibia For Varus Deformity and Medial Joint Arthrosis, 564 11.2 Intraarticular Opening Medial Wedge Osteotomy (Plafondplasty) of the Tibia for Intraarticular Varus Arthritis and Instability (Mann, Filippi, and Myerson), 566 11.3 Distraction Arthroplasty of the Ankle, 568 11.4 Mini-Incision Technique, 575 11.5 Transfibular (Transmalleolar) Arthrodesis with Fibular Strut Graft, 576 11.6 Anterior Approach with Plate Fixation, 580 11.7 Lateral Approach with Fibular Sparing (Smith, Chiodo, Singh, Wilson), 580 11.8 Tibiotalocalcaneal Arthrodesis, 581 11.9 Posterior Approach for Arthrodesis of Ankle and Subtalar Joints (Campbell), 584 11.10 Arthrodesis with a Thin-Wire External Fixation, 584 11.11 Tibiotalar Arthrodesis with a Sliding Bone Graft (Blair; Morris et al.), 590 11.12 Tibiotalar or Tibiotalocalcaneal Fusion with Structural Allograft and Internal Fixation for Salvage of Failed Total Ankle Arthroplasty (Berkowitz et al.), 591 11.13 Bone Graft Harvest from the Proximal Tibia (Whitehouse et al.), 593 Shoulder and Elbow Arthroplasty 12.1 Hemiarthroplasty, 608 12.2 Total Shoulder Arthroplasty, 612 12.3 Reverse Total Shoulder Arthroplasty, 617 12.4 Debridement Arthroplasty (Wada et al.), 633 12.5 Interposition Arthroplasty, 637 12.6 Radial Head Arthroplasty, 639 12.7 Coonrad-Morrey Prosthesis, 642 12.8 Elbow Resection Arthroplasty (Campbell), 648 Salvage Operations for the Shoulder and Elbow 13.1 External Fixation (Charnley and Houston), 660 13.2 Plate Fixation (AO Group), 660 13.3 Pelvic Reconstruction Plate (Modification of Richards et al.), 661 13.4 Shoulder Arthrodesis After Failed Prosthetic Shoulder Arthroplasty (Scalise and Iannotti), 662 13.5 Arthroscopic Shoulder Arthrodesis for Brachial Plexus Injury (lenoir), 664 13.6 Elbow Arthrodesis (Staples), 665 13.7 Elbow Arthrodesis (Müller et al.), 666 13.8 Elbow Arthrodesis (Spier), 666 13.9 Latissimus Dorsi Transfer, Open Technique (Gerber et al.), 668 13.10 Latissimus Dorsi Transfer, Arthroscopically Assisted Technique (Castricini et al.), 669 13.11 Lower Trapezius Transfer, Open Technique (Elhassan et al.), 671 13.12 Lower Trapezius Transfer, Arthroscopically Assisted Technique (Elhassan et al.), 672 13.13 Pectoralis Major Transfer (Modification of Resch et al.,), 673 13.14 Latissimus Dorsi Tendon Transfer (Mun et al.), 675 Amputations of the Foot 15.1 Terminal Syme Amputation, 700 15.2 Amputation at the Base of the Proximal Phalanx, 700 15.3 Metatarsophalangeal Joint Disarticulation, 703 15.4 Metatarsophalangeal Joint Disarticulation, 703 15.5 First or Fifth Ray Amputation (Border Ray Amputation), 703 15.6 Central Ray Amputation, 704 15.7 Transmetatarsal Amputation, 707 15.8 Chopart Amputation, 711 15.9 Syme Amputation, 713 15.10 Two-Stage Syme Amputation (Wyss et al.; Malone et al.; Wagner), 717 15.11 Boyd Amputation, 717

Amputations of the Lower Extremity 16.1 Transtibial Amputation, 722 16.2 Transtibial Amputation (Modified Ertl; Taylor and Poka), 723 16.3 Transtibial Amputation Using Long Posterior Skin Flap (Burgess), 725 16.4 Knee Disarticulation (Batch, Spittler, and McFaddin), 726 16.5 Knee Disarticulation (Mazet and Hennessy), 728 16.6 Knee Disarticulation (Kjøble), 728 16.7 Transfemoral (Above-Knee) Amputation of Nonischemic Limbs, 730 16.8 Transfemoral (Above-Knee) Amputation of Nonischemic Limbs (Gottschalk), 731 Amputations of the Hip and Pelvis 17.1 Anatomic Hip Disarticulation (Boyd), 733 17.2 Posterior Flap (Slocum), 735 17.3 Standard Hemipelvectomy, 736 17.4 Anterior Flap Hemipelvectomy, 736 17.5 Conservative Hemipelvectomy, 739 Major Amputations of the Upper Extremity 18.1 Amputation at the Wrist, 743 18.2 Disarticulation of the Wrist, 743 18.3 Distal Forearm (Distal Transradial) Amputation, 744 18.4 Proximal Third of Forearm (Proximal Transradial) Amputation, 745 18.5 Disarticulation of the Elbow, 745 18.6 Supracondylar Area, 746 18.7 Amputation Proximal to the Supracondylar Area, 748 18.8 Amputation Through the Surgical Neck of the Humerus, 748 18.9 Disarticulation of the Shoulder, 750 18.10 Anterior Approach (Berger), 752 18.11 Posterior Approach (Littlewood), 753 18.12 Targeted Muscle Reinnervation After Transhumeral Amputation (O’Shaughnessy et al.), 756 Amputations of the Hand 19.1 Kutler V-Y or Atasoy Triangular Advancement Flaps (Kutler; Fisher), 764 19.2 Atasoy Triangular Advancement Flaps (Atasoy et al.), 766 19.3 Bipedicle Dorsal Flaps, 767 19.4 Adipofascial Turnover Flap, 768 19.5 Thenar Flap, 768 19.6 Local Neurovascular Island Flap, 769 19.7 Island Pedicle Flap, 769 19.8 Retrograde Island Pedicle Flap, 771 19.9 Ulnar Hypothenar Flap, 771 19.10 Index Ray Amputation, 771 19.11 Transposing the Index Ray (Peacock), 774 19.12 Advancement Pedicle Flap for Thumb Injuries, 776 19.13 Phalangization of Fifth Metacarpal, 778 19.14 Krukenberg Reconstruction (Krukenberg; Swanson), 779 19.15 Lengthening of the Metacarpal and Transfer of Local Flap (Gillies and Millard, Modified), 781 19.16 Osteoplastic Reconstruction and Transfer of Neurovascular Island Graft (Verdan), 782 19.17 Riordan Pollicization (Riordan), 784 19.18 Buck-Gramcko Pollicization (Buck-Gramcko), 785 19.19 Foucher Pollicization, 787 Osteomyelitis 21.1 Drainage of Acute Hematogenous Osteomyelitis, 821 21.2 Sequestrectomy and Curettage for Chronic Osteomyelitis, 827 21.3 Open Bone Grafting (Papineau et al.; Archdeacon and Messerschmitt), 828 21.4 Antibiotic Bead Pouch (Henry, Ostermann, and Seligson), 829 21.5 Intramedullary Antibiotic Cement Nail, 829 21.6 Split-Heel Incision (Gaenslen), 834 21.7 Distal Third of the Femur, 835 21.8 Drainage, 835 21.9 Resection of the Metatarsals, 836 21.10 Partial Calcanectomy, 837 21.11 Resection of the Fibula, 837 21.12 Resection of the Iliac Wing (Badgley), 838 Infectious Arthritis 22.1 Surgical Drainage of the Tarsal Joint, 846 22.2 Anterolateral Drainage of the Ankle, 847

22.3 Posterolateral Drainage of the Ankle, 847 22.4 Anteromedial Drainage of the Ankle, 847 22.5 Posteromedial Drainage of the Ankle, 847 22.6 Arthroscopic Drainage of the Knee, 848 22.7 Anterior Drainage of the Knee, 849 22.8 Posterolateral and Posteromedial Drainage of the Knee (Henderson), 849 22.9 Posteromedial Drainage of the Knee (Klein), 850 22.10 Posteromedial and Posterolateral Drainage of the Knee (Kelikian), 850 22.11 Lateral Aspiration of the Hip, 851 22.12 Anterior Aspiration of the Hip, 851 22.13 Medial Aspiration of the Hip, 851 22.14 Posterior Drainage of the Hip (Ober), 852 22.15 Anterior Drainage of the Hip, 852 22.16 Lateral Drainage of the Hip, 852 22.17 Medial Drainage of the Hip (Ludloff), 853 22.18 Arthroscopic Debridement and Partial Synovectomy of the Hip in an Adult, 853 22.19 Resection of the Hip (Girdlestone), 854 22.20 Anterior Drainage of the Shoulder, 856 22.21 Posterior Drainage of the Shoulder, 856 22.22 Medial Drainage of the Elbow, 857 22.23 Lateral Drainage of the Elbow, 857 22.24 Posterior Drainage of the Elbow, 858 22.25 Lateral Drainage of the Wrist, 858 22.26 Medial Drainage of the Wrist, 859 22.27 Dorsal Drainage of the Wrist, 859 22.28 Osteotomy of the Ankle, 859 22.29 Transverse Supracondylar Osteotomy of the Femur, 859 22.30 V-Osteotomy of the Femur (Thompson), 860 22.31 Supracondylar Cuneiform Osteotomy of the Femur, 860 22.32 Supracondylar Controlled Rotational Osteotomy of the Femur, 861 22.33 Intraarticular Osteotomy, 861 22.34 Reconstruction After Hip Sepsis (Harmon), 864 22.35 Transverse Opening Wedge Osteotomy of the Hip, 864 22.36 Transverse Closing Wedge Osteotomy of the Hip, 865 22.37 Brackett Osteotomy of the Hip (Brackett), 865 Tuberculosis and Other Unusual Infections 23.1 Curettage for Tuberculous Lesions in the Foot, 874 23.2 Excision of Metatarsal, 874 23.3 Excision of Cuneiform Bones, 874

23.4 Excision of Navicular, 875 23.5 Excision of Cuboid, 875 23.6 Excision of Calcaneus, 875 23.7 Excision of Talus, 876 23.8 Partial Synovectomy and Curettage (Wilkinson), 877 23.9 Lesions above Acetabulum, 878 23.10 Lesions of the Femoral Neck, 878 23.11 Lesions of the Trochanteric Area (Ahern), 878 23.12 Excision of the Hip Joint, 879 23.13 Excision of Elbow Joint, 880 23.14 Excision of Wrist Joint, 880 General Principles of Tumors 24.1 Resection of the Shoulder Girdle (Marcove, Lewis, and Huvos), 909 24.2 Resection of the Scapula (Das Gupta), 913 24.3 Resection of the Proximal Humerus, 916 24.4 Intercalary Resection of the Humeral Shaft (Lewis), 920 24.5 Resection of the Distal Humerus, 920 24.6 Resection of the Proximal Radius, 920 24.7 Resection of the Proximal Ulna, 921 24.8 Resection of the Distal Radius, 921 24.9 Resection of the Pubis and Ischium (Radley, Liebig, and Brown), 928 24.10 Resection of the Acetabulum, 932 24.11 Resection of the Innominate Bone (Internal Hemipelvectomy) (Karakousis and Vezeridis), 934 24.12 Resection of the Sacroiliac Joint, 934 24.13 Resection of the Sacrum (Stener and Gunterberg), 936 24.14 Resection of the Sacrum (Localio, Francis, and Rossano), 937 24.15 Resection of the Sacrum Through Posterior Approach (MacCarty et al.), 937 24.16 Resection of the Proximal Femur (Lewis and Chekofsky), 938 24.17 Resection of Entire Femur (Lewis), 938 24.18 Intraarticular Resection of the Distal Femur with Endoprosthetic Reconstruction, 943 24.19 Resection of the Proximal Tibia (Malawer), 944 24.20 Resection of the Proximal Fibula (Malawer), 945 24.21 Resection of the Distal Third of the Fibula, 945 24.22 Rotationplasty for a Lesion in the Distal Femur (Kotz and Salzer), 950 24.23 Rotationplasty for a Lesion of the Proximal Femur Without Involvement of the Hip Joint (Winkelmann), 950 24.24 Rotationplasty for a Lesion of the Proximal Femur Involving the Hip Joint (Winkelmann), 952

Campbell’s Operative Orthopaedics, 14th ed.

List of Techniques VOLUME II Congenital Anomalies of the Lower Extremity 29.1 Amputation of an Extra Toe (Simple Postaxial Polydactyly), 1081 29.2 Tsuge Ray Reduction (Tsuge), 1082 29.3 Ray Reduction, 1083 29.4 Ray Amputation, 1083 29.5 Simplified Cleft Closure (Wood, Peppers, and Shook), 1087 29.6 Correction of Angulated Toe, 1088 29.7 Arthroplasty of the Fifth Metatarsophalangeal Joint (Butler), 1088 29.8 Creation of Syndactyly of the Great Toe and Second Toe for Hallux Varus (Farmer), 1090 29.9 Dome-Shaped Osteotomies of Metatarsal Bases (Berman and Gartland), 1092 29.10 Cuneiform and Cuboid Osteotomies (McHale and Lenhart), 1095 29.11 Anterior Tibial Tendon Transfer, 1100 29.12 Transverse Circumferential (Cincinnati) Incision (Crawford, Marxen, and Osterfeld), 1102 29.13 Extensile Posteromedial and Posterolateral Release (McKay, Modified), 1103 29.14 Achilles Tendon Lengthening and Posterior Capsulotomy (Selective Approach), 1106 29.15 First Metatarsal Osteotomy and Tendon Transfer for Dorsal Bunion, 1108 29.16 Osteotomy of the Calcaneus for Persistent Varus Deformity of the Heel (Dwyer, Modified), 1109 29.17 Medial Release with Osteotomy of the Distal Calcaneus (Lichtblau), 1109 29.18 Selective Joint-Sparing Osteotomies for Residual Cavovarus Deformity (Mubrak and Van Valin), 1110 29.19 Triple Arthrodesis, 1112 29.20 Talectomy (Trumble et al.), 1112 29.21 Open Reduction and Realignment of Talonavicular and Subtalar Joints (Kumar, Cowell, and Ramsey), 1115 29.22 Open Reduction and Extraarticular Subtalar Fusion (Grice- Green), 1116 29.23 Tibiofibular Synostosis (Langenskiöld), 1120 29.24 Insertion of Williams Intramedullary Rod and Bone Grafting (Anderson et al.), 1123 29.25 One-Stage or Two-Stage Release of Circumferential Constricting Band (Greene), 1126 29.26 Capsular Release and Quadriceps Lengthening for Correction of Congenital Knee Dislocation (Curtis and Fisher), 1127 29.27 Lateral Release and Medial Plication (Beaty; Modified from Gao et al. and Langenskiöld), 1129 29.28 Distal Fibulotalar Arthrodesis, 1136 29.29 Proximal Tibiofibular Synostosis, 1137 29.30 Varus Supramalleolar Osteotomy of the Ankle (Wiltse), 1139 29.31 Knee Fusion for Proximal Femoral Focal Deficiency (King), 1145 29.32 Rotationplasty (Van Nes), 1148 29.33 Syme Amputation, 1150 29.34 Boyd Amputation, 1152 29.35 Physeal Exposure Around the Knee (Abbott and Gill, Modified), 1160 29.36 Percutaneous Epiphysiodesis (Canale et al.), 1161 29.37 Percutaneous Transepiphyseal Screw Epiphysiodesis (Métaizeau et al.), 1162 29.38 Tension Plate Epiphysiodesis, 1164 29.39 Proximal Femoral Metaphyseal Shortening (Wagner), 1165 29.40 Distal Femoral Metaphyseal Shortening (Wagner), 1165 29.41 Proximal Tibial Metaphyseal Shortening (Wagner), 1166 29.42 Tibial Diaphyseal Shortening (Broughton, Olney, and Menelaus), 1166 29.43 Closed Femoral Diaphyseal Shortening (Winquist, Hansen, and Pearson), 1166 29.44 Transiliac Lengthening (Millis and Hall), 1168 29.45 Tibial Lengthening (DeBastiani et al.), 1170 29.46 Tibial Lengthening (Ilizarov, Modified), 1171 29.47 Tibial Lengthening Over Intramedullary Nail (PRECICE Intramedullary Lengthening System, Ellipse Technologies, Irvine, CA); (Herzenberg, Standard, Green), 1174

29.48 Femoral Lengthening (DeBastiani et al.), 1175 29.49 Femoral Lengthening (Ilizarov, Modified), 1175 29.50 Femoral Lengthening Over Intramedullary Nail (PRECICE); (Standard, Herzenberg, and Green), 1179 Congenital and Developmental Abnormalities of the Hip and Pelvis 30.1 Arthrography of the Hip in DDH, 1193 30.2 Application of a Hip Spica Cast (Kumar), 1195 30.3 Anterior Approach (Beaty; After Somerville), 1197 30.4 Medial Approach (Ludloff), 1199 30.5 Trochanteric Advancement (Lloyd-Roberts and Swann), 1202 30.6 Varus Derotational Osteotomy of the Femur In Hip Dysplasia, with Pediatric Hip Screw Fixation, 1203 30.7 Primary Femoral Shortening, 1206 30.8 Innominate Osteotomy Including Open Reduction (Salter), 1209 30.9 Pericapsular Osteotomy of the Ilium (Pemberton), 1211 30.10 Triple Innominate Osteotomy (Steel), 1214 30.11 Transiliac (Dega) Osteotomy (Grudziak and Ward), 1216 30.12 Slotted Acetabular Augmentation (Staheli), 1219 30.13 Chiari Osteotomy, 1222 30.14 Valgus Osteotomy for Developmental Coxa Vara, 1225 30.15 Bilateral Anterior Iliac Osteotomies (Sponseller, Gearhart, and Jeffs), 1227 Congenital Anomalies of the Trunk and Upper Extremity 31.1 Woodward Operation, 1232 31.2 Morcellation of the Clavicle, 1233 31.3 Unipolar Release, 1236 31.4 Bipolar Release (Ferkel et al.), 1237 31.5 Open Reduction and Iliac Bone Grafting for Congenital Pseudarthrosis of the Clavicle, 1239 31.6 Radial and Ulnar Osteotomies for Correction of Congenital Radioulnar Synostosis (Two-Stage) (Lin et al.), 1243 Osteochondrosis or Epiphysitis and Other Miscellaneous Affections 32.1 Innominate Osteotomy for Legg-Calvé-Perthes Disease (Canale et al.), 1250 32.2 Lateral Shelf Procedure (Labral Support) for Legg-Calvé-Perthes Disease (Willett et al.), 1252 32.3 Varus Derotational Osteotomy of the Proximal Femur for Legg-Calvé-Perthes Disease (Stricker), 1253 32.4 Reversed or Closing Wedge Technique for Legg-Calvé-Perthes Disease, 1256 32.5 Arthrodiastasis for Legg-Calvé-Perthes Disease (Segev et al.), 1257 32.6 Osteochondroplasty Surgical Dislocation of the Hip (Ganz), 1258 32.7 Trochanteric Advancement for Trochanteric Overgrowth (Wagner), 1261 32.8 Trochanteric Advancement for Trochanteric Overgrowth (MacNicol and Makris), 1262 32.9 Greater Trochanteric Epiphysiodesis for Trochanteric Overgrowth, 1263 32.10 Tibial Tuberosity and Ossicle Excision (Pihlajamäki et al.), 1267 32.11 Excision of Ununited Tibial Tuberosity for Osgood-Schlatter Disease (Ferciot and Thomson), 1268 32.12 Arthroscopic Ossicle and Tibial Tuberosity Debridement for Osgood-Schlatter Disease, 1269 32.13 Extraarticular Drilling for Stable Osteochondritis Dissecans of the Knee (Donaldson and Wojtys), 1270 32.14 Reconstruction of the Articular Surface with Osteochondral Plug Grafts for Osteochondrosis of the Capitellum (Takahara et al.), 1276 32.15 Metaphyseal Osteotomy for Tibia Vara (Rab), 1281 32.16 Chevron Osteotomy for Tibia Vara (Greene), 1282 32.17 Epiphyseal and Metaphyseal Osteotomy for Tibia Vara (Ingram, Canale, Beaty), 1283 32.18 Intraepiphyseal Osteotomy for Tibia Vara (Siffert, Støren, Johnson et al.), 1285 32.19 Hemielevation of the Epiphysis Osteotomy with Leg Lengthening Using an Ilizarov Frame for Tibia Vara (Jones et al., Hefny et al.), 1285 32.20 Synovectomy of the Knee In Hemophilia, 1293

32.21 Synoviorthesis for Treatment of Hemophilic Arthropathy, 1293 32.22 Open Ankle Synovectomy in Hemophilia (Greene), 1293 32.23 Fassier-Duval Telescoping Rod, Femur (Open Osteotomy), 1297 32.24 Tibial Lengthening Over an Intramedullary Nail with External Fixation in Dwarfism (Park et al.), 1305 32.25 Bony Bridge Resection for Physeal Arrest (Langenskiöld), 1306 32.26 Bony Bridge Resection and Angulation Osteotomy for Physeal Arrest (Ingram), 1306 32.27 Peripheral and Linear Physeal Bar Resection for Physeal Arrest (Birch et al.), 1308 32.28 Central Physeal Bar Resection for Physeal Arrest (Peterson), 1308 Cerebral Palsy 33.1 Adductor Tenotomy and Release, 1328 33.2 Iliopsoas Recession, 1329 33.3 Iliopsoas Release at the Lesser Trochanter, 1329 33.4 Combined One-Stage Correction of Spastic Dislocated Hip, 1333 33.5 Proximal Femoral Resection, 1336 33.6 Redirectional Osteotomy (McHale Procedure for Neglected Hip Dislocation), (McHale et al.), 1337 33.7 Hip Arthrodesis, 1337 33.8 Fractional Lengthening of Hamstring Tendons, 1339 33.9 Distal Femoral Extension Osteotomy and Patellar Tendon Advancement (Stout et al.), 1341 33.10 Rectus Femoris Transfer (Gage et al.), 1343 33.11 Z-Plasty Lengthening of the Achilles Tendon, 1346 33.12 Percutaneous Lengthening of the Achilles Tendon, 1347 33.13 Gastrocnemius-Soleus Lengthening, 1348 33.14 Musculotendinous Recession of the Posterior Tibial Tendon, 1349 33.15 Split Posterior Tibial Tendon Transfer, 1350 33.16 Split Anterior Tibial Tendon Transfer (Hoffer et al.), 1351 33.17 Lateral Closing-Wedge Calcaneal Osteotomy (Dwyer), 1353 33.18 Medial Displacement Calcaneal Osteotomy, 1354 33.19 Hindfoot Arthrodesis, 1355 33.20 Release of Elbow Flexion Contracture, 1359 33.21 Correction of Talipes Equinovarus, 1362 33.22 Release of Internal Rotation Contracture of the Shoulder, 1363 33.23 Fractional Lengthening of Pectoralis Major, Latissimus Dorsi, Teres Major, 1364 Paralytic Disorders 34.1 Posterior Transfer of Anterior Tibial Tendon (Drennan), 1374 34.2 Subtalar Arthrodesis (Grice and Green), 1376 34.3 Subtalar Arthrodesis (Dennyson and Fulford), 1377 34.4 Triple Arthrodesis, 1378 34.5 Correction of Cavus Deformity, 1380 34.6 Lambrinudi Arthrodesis (Lambrinudi), 1380 34.7 Anterior Transfer of Posterior Tibial Tendon (Barr), 1382 34.8 Anterior Transfer of Posterior Tibial Tendon (Ober), 1382 34.9 Split Transfer of Anterior Tibial Tendon, 1383 34.10 Peroneal Tendon Transfer, 1384 34.11 Peroneus Longus, Flexor Digitorum Longus, or Flexor or Extensor Hallucis Longus Tendon Transfer (Fried and Hendel), 1385 34.12 Tenodesis of the Achilles Tendon (Westin), 1386 34.13 Posterior Transfer of Peroneus Longus, Peroneus Brevis, and Posterior Tibial Tendons, 1387 34.14 Posterior Transfer of Posterior Tibial, Peroneus Longus, and Flexor Hallucis Longus Tendons (Green and Grice), 1388 34.15 Transfer of Biceps Femoris and Semitendinosus Tendons, 1389 34.16 Osteotomy of the Tibia for Genu Recurvatum (Irwin), 1391 34.17 Triple Tenodesis for Genu Recurvatum (Perry, O’Brien, and Hodgson), 1392 34.18 Complete Release of Hip Flexion, Abduction, and External Rotation Contracture (Ober; Yount), 1394 34.19 Complete Release of Muscles from Iliac Wing and Transfer of Crest of Ilium (Campbell), 1395 34.20 Posterior Transfer of the Iliopsoas for Paralysis of the Gluteus Medius and Maximus Muscles (Sharrard), 1396 34.21 Trapezius Transfer for Paralysis of Deltoid (Bateman), 1401 34.22 Trapezius Transfer for Paralysis of Deltoid (Saha), 1402 34.23 Transfer of Deltoid Origin for Partial Paralysis (Harmon), 1402 34.24 Transfer of Latissimus Dorsi or Teres Major or Both for Paralysis of Subscapularis or Infraspinatus (Saha), 1403

34.25 Flexorplasty (Bunnell), 1404 34.26 Anterior Transfer of the Triceps (Bunnell), 1405 34.27 Transfer of the Pectoralis Major Tendon (Brooks and Seddon), 1405 34.28 Transfer of the Latissimus Dorsi Muscle (Hovnanian), 1406 34.29 Rerouting of Biceps Tendon for Supination Deformities of Forearm (Zancolli), 1408 34.30 V-O Procedure, 1416 34.31 Anterolateral Release, 1418 34.32 Transfer of the Anterior Tibial Tendon to the Calcaneus, 1418 34.33 Screw Epiphysiodesis, 1422 34.34 Supramalleolar Varus Derotation Osteotomy, 1422 34.35 Radical Flexor Release, 1424 34.36 Anterior Hip Release, 1426 34.37 Fascial Release, 1427 34.38 Adductor Release, 1427 34.39 Transfer of Adductors, External Oblique, and Tensor Fasciae Latae (Phillips and Lindseth), 1428 34.40 Proximal Femoral Resection and Interposition Arthroplasty (Baxter and D’Astous), 1429 34.41 Pelvic Osteotomy (Lindseth), 1430 34.42 Correction of Knee Flexion Contracture with Circular-Frame External Fixation (Van Bosse et al.), 1436 34.43 Correction of Knee Flexion Contracture with Anterior Stapling (Palocaren et al.), 1438 34.44 Reorientational Proximal Femoral Osteotomy for Hip Contractures in Arthrogryposis (Van Bosse), 1439 34.45 Posterior Elbow Capsulotomy with Triceps Lengthening for Elbow Extension Contracture (Van Heest et al.), 1442 34.46 Posterior Release of Elbow Extension Contracture and Triceps Tendon Transfer (Tachdjian), 1442 34.47 Dorsal Closing Wedge Osteotomy of the Wrist (Van Heest and Rodriguez, Ezaki, and Carter), 1443 34.48 Anterior Shoulder Release (Fairbank, Sever), 1449 34.49 Rotational Osteotomy of the Humerus (Rogers), 1449 34.50 Derotational Osteotomy with Plate and Screw Fixation (Abzug et al.), 1450 34.51 Glenoid Anteversion Osteotomy and Tendon Transfer (Dodwell et al.), 1450 34.52 Release of the Internal Rotation Contracture and Transfer of the Latissimus Dorsi and Teres Major (Sever-L’Episcopo, Green), 1451 34.53 Arthroscopic Release and Transfer of the Latissimus Dorsi (Pearl et al.), 1455 Neuromuscular Disorders 35.1 Open Muscle Biopsy, 1463 35.2 Percutaneous Muscle Biopsy (Mubarak, Chambers, and Wenger), 1463 35.3 Percutaneous Release of Hip Flexion and Abduction Contractures and Achilles Tendon Contracture (Green), 1467 35.4 Transfer of the Posterior Tibial Tendon to the Dorsum of the Foot (Greene), 1467 35.5 Transfer of the Posterior Tibial Tendon to the Dorsum of the Base of the Second Metatarsal (Mubarak), 1469 35.6 Scapulothoracic Fusion (Diab et al.), 1472 35.7 Plantar Fasciotomy, Osteotomies, and Arthrodesis for CharcotMarie-Tooth Disease (Faldini et al.), 1477 35.8 Radical Plantar-Medial Release and Dorsal Closing Wedge Osteotomy (Coleman), 1481 35.9 Transfer of the Extensor Hallucis Longus Tendon for Claw Toe Deformity (Jones), 1481 35.10 Transfer of the Extensor Tendons to the Middle Cuneiform (Hibbs), 1482 35.11 Stepwise Joint-Sparing Foot Osteotomies (Mubarak and Van Valin), 1482 Fractures and Dislocations in Children 36.1 Closed Reduction and Percutaneous Pinning (or Screw Fixation) of Proximal Humerus, 1501 36.2 Closed Reduction and Intramedullary Nailing of Proximal Humerus, 1501 36.3 Closed/Open Reduction and Intramedullary Nailing of Humeral Shaft, 1502 36.4 Closed Reduction and Percutaneous Pinning of Supracondylar Fractures (Two Lateral Pins), 1504

36.5 Anterior Approach, 1507 36.6 Lateral Closing Wedge Osteotomy for Cubitus Varus, 1509 36.7 Open Reduction and Internal Fixation of Lateral Condylar Fracture, 1512 36.8 Osteotomy for Established Cubitus Valgus Secondary to Nonunion or Growth Arrest, 1513 36.9 Open Reduction and Internal Fixation of Medial Condylar Fracture, 1515 36.10 Open Reduction and Internal Fixation for Displaced or Entrapped Medial Epicondyle, 1518 36.11 Closed and Open Reduction of Radial Neck Fractures, 1526 36.12 Percutaneous Reduction and Pinning, 1527 36.13 Closed Intramedullary Nailing, 1527 36.14 Overcorrection Osteotomy and Ligamentous Repair or Reconstruction (Shah and Waters), 1535 36.15 Intramedullary Forearm Nailing, 1538 36.16 Closed Reduction and Percutaneous Pinning of Fractures of the Distal Radius, 1540 36.17 Open Reduction and Internal Fixation of Physeal Fractures of Phalanges and Metacarpals, 1543 36.18 Closed Reduction and Internal Fixation, 1561 36.19 Open Reduction and Internal Fixation (Weber et al.; Boitzy), 1561 36.20 Valgus Subtrochanteric Osteotomy for Acquired Coxa Vara or Nonunion, 1561 36.21 Modified Pauwels Intertrochanteric Osteotomy for Acquired Coxa Vara or Nonunion (Magu et al.), 1564 36.22 Determining the Entry Point for Cannulated Screw Fixation of a Slipped Epiphysis (Canale et al.), 1569 36.23 Determining the Entry Point for Cannulated Screw Fixation of a Slipped Epiphysis (Morrissy), 1570 36.24 Positional Reduction and Fixation for SCFE (Chen, Schoenecker, Dobbs, et al.), 1572 36.25 Subcapital Realignment of the Epiphysis (Modified Dunn) for SCFE (Leunig, Slongo, and Ganz), 1573 36.26 Compensatory Basilar Osteotomy of the Femoral Neck (Kramer et al.), 1575 36.27 Extracapsular Base-of-Neck Osteotomy (Abraham et al.), 1576 36.28 Intertrochanteric Osteotomy (Imhäuser), 1578 36.29 Spica Cast Application, 1586 36.30 Flexible Intramedullary Nail Fixation, 1589 36.31 Closed or Open Reduction, 1595 36.32 Reconstruction of the Patellofemoral and Patellotibial Ligaments with a Semitendinosus Tendon Graft (Nietosvaara et al.), 1598 36.33 3-In-1 Procedure for Recurrent Dislocation of the Patella: Lateral Release, Vastus Medialis Obliquus Muscle Advancement, and Transfer of the Medial Third of the Patellar Tendon to the Medial Collateral Ligament (Oliva et al.), 1599 36.34 Open Reduction and Internal Fixation of Sleeve Fracture (Houghton and Ackroyd), 1600 36.35 Open Reduction and Internal Fixation of Tibial Eminence Fracture, 1602 36.36 Arthroscopic Reduction of Tibial Eminence Fracture and Internal Fixation with Bioabsorbable Nails (Liljeros et al.), 1603 36.37 Open Reduction and Internal Fixation, 1606 36.38 Open Reduction and Removal of Interposed Tissue (Weber et al.), 1611 36.39 Elastic Stable Intramedullary Nailing of Tibial Fracture (O’Brien et al.), 1614 36.40 Open Reduction and Internal Fixation, 1617 36.41 Open Reduction and Internal Fixation, 1618 36.42 Excision of Osteochondral Fragment of the Talus, 1625 36.43 Open Reduction and Internal Fixation of Cuboid Compression (Nutcracker) Fracture (Ceroni et al.), 1629 Anatomic Approaches to the Spine 37.1 Anterior Transoral Approach (Spetzler), 1648 37.2 Anterior Retropharyngeal Approach (McAfee et al.), 1649 37.3 Subtotal Maxillectomy (Cocke et al.), 1651 37.4 Extended Maxillotomy, 1652 37.5 Anterior Approach, C3 to C7 (Southwick and Robinson), 1653 37.6 Anterolateral Approach, C2 to C7 (Bruneau et al., Chibbaro et al.), 1655 37.7 Low Anterior Cervical Approach, 1657 37.8 High Transthoracic Approach, 1657 37.9 Transsternal Approach, 1657

37.10 Modified Anterior Approach to Cervicothoracic Junction (Darling et al.), 1658 37.11 Anterior Approach to the Cervicothoracic Junction Without Sternotomy (Pointillart et al.), 1659 37.12 Anterior Approach to the Thoracic Spine, 1661 37.13 Video-Assisted Thoracic Surgery (Mack et al.), 1661 37.14 Anterior Approach to the Thoracolumbar Junction, 1663 37.15 Minimally Invasive Approach to the Thoracolumbar Junction, 1663 37.16 Anterior Retroperitoneal Approach, L1 to L5, 1664 37.17 Percutaneous Lateral Approach, L1 to L4-5 (Ozgur et al.), 1667 37.18 Anterior Transperitoneal Approach, L5 to S1, 1669 37.19 Oblique Approach for Lumbar Interbody Fusion, L1-L5 and L5-S1 (Mehren et al.), 1670 37.20 Video-Assisted Lumbar Surgery (Onimus et al.), 1673 37.21 Posterior Approach to the Cervical Spine, Occiput to C2, 1673 37.22 Posterior Approach to the Cervical Spine, C3 to C7, 1674 37.23 Posterior Approach to the Thoracic Spine, T1 to T12, 1675 37.24 Costotransversectomy, 1676 37.25 Posterior Approach to the Lumbar Spine, L1 to L5, 1677 37.26 Paraspinal Approach to Lumbar Spine (Wiltse and Spencer), 1677 37.27 Posterior Approach to the Lumbosacral Spine, L1 to Sacrum (Wagoner), 1677 37.28 Posterior Approach to the Sacrum and Sacroiliac Joint (Ebraheim et al.), 1679 Degenerative Disorders of the Cervical Spine 38.1 Interlaminar Cervical Epidural Injection, 1688 38.2 Cervical Medial Branch Block Injection, 1689 38.3 Cervical Discography (Falco), 1690 38.4 Removal of Posterolateral Herniations by Posterior Approach (Posterior Cervical Foraminotomy), 1695 38.5 Minimally Invasive Posterior Cervical Foraminotomy with Tubular Distractors (Gala, O’Toole, Voyadzis, and Fessler), 1697 38.6 Full-Endoscopic Posterior Cervical Foraminotomy (Ruetten et al.), 1697 38.7 Tissue-Sparing Posterior Cervical Fusion (Mccormack and Dhawan), 1699 38.8 Smith-Robinson Anterior Cervical Fusion (Smith-Robinson et al.), 1703 38.9 Anterior Occipitocervical Arthrodesis by Extrapharyngeal Exposure (De Andrade and MacNab), 1705 38.10 Fibular Strut Graft in Cervical Spine Arthrodesis with Corpectomy (Whitecloud and Larocca), 1705 Degenerative Disorders of the Thoracic and Lumbar Spine 39.1 Myelography, 1724 39.2 Interlaminar Thoracic Epidural Injection, 1728 39.3 Interlaminar Lumbar Epidural Injection, 1729 39.4 Transforaminal Lumbar and Sacral Epidural Injection, 1730 39.5 Caudal Sacral Epidural Injection, 1730 39.6 Lumbar Intraarticular Injection, 1732 39.7 Lumbar Medial Branch Block Injection, 1732 39.8 Sacroiliac Joint Injection, 1734 39.9 Lumbar Discography (Falco), 1735 39.10 Thoracic Discography (Falco), 1736 39.11 Thoracic Costotransversectomy, 1738 39.12 Thoracic Discectomy—Anterior Approach, 1738 39.13 Thorascopic Thoracic Discectomy (Rosenthal et al.), 1740 39.14 Minimally Invasive Thoracic Discectomy, 1740 39.15 Transforaminal Endoscopic Thoracic Discectomy, 1741 39.16 Microscopic Lumbar Discectomy, 1747 39.17 Transforaminal Endoscopic Lumbar Discectomy, 1750 39.18 Interlaminar Endoscopic Lumbar Discectomy, 1750 39.19 Dural Repair Augmented with Fibrin Glue, 1754 39.20 Repeat Lumbar Disc Excision, 1755 39.21 Transthoracic Approach to the Thoracic Spine, 1756 39.22 Anterior Interbody Fusion of the Lumbar Spine (Goldner et al.), 1757 39.23 Percutaneous Anterior Lumbar Arthrodesis—Lateral Approach to L1 to L4-5, 1758 39.24 Hibbs Fusion (Hibbs, as Described by Howarth), 1759 39.25 Posterolateral Lumbar Fusion (Watkins), 1760 39.26 Intertransverse Lumbar Fusion (Adkins), 1761 39.27 Minimally Invasive Transforaminal Lumbar Interbody Fusion (Gardock), 1762

39.28 Pseudarthrosis Repair (Ralston and Thompson), 1764 39.29 Midline Decompression (Neural Arch Resection), 1780 39.30 Spinous Process Osteotomy (Decompression) (Weiner et al.), 1781 39.31 Microdecompression (McCulloch), 1782 39.32 Pedicle Subtraction Osteotomy (Bridwell et al.), 1792 39.33 Coccygeal Injection, 1795 Spondylolisthesis 40.1 Repair of Pars Interarticularis Defect with V-Rod Technique (Gillet and Petit), 1810 40.2 In Situ Posterolateral Instrumented Fusion: Wiltse and Spencer Approach, 1815 40.3 Posterior Instrumented Fusion with Interbody Fusion (PLIF and TLIF), 1815 40.4 L5-S1 Anterior Lumbar Interbody Fusion, 1818 40.5 Lumbar Decompression, 1823 40.6 Lumbar Decompression and Posterolateral Fusion with or without Instrumentation, 1824 40.7 Lumbar Decompression and Combined Posterolateral and Interbody Fusion (TLIF or PLIF), 1825 Fractures, Dislocations, and Fracture-Dislocations of the Spine 41.1 Stretch Test, 1838 41.2 Application of Gardner-Wells Tongs, 1843 41.3 Closed Reduction of the Cervical Spine, 1843 41.4 Halo Vest Application, 1848 41.5 Occipitocervical Fusion Using Modular Plate and Rod Construct, Segmental Fixation with Occipital Plating, C1 Lateral Mass Screw, C2 Isthmic (Pars) Screws, and Lateral Mass Fixation, 1851 41.6 Occipitocervical Fusion Using Wires and Bone Graft (Wertheim and Bohlman), 1853 41.7 Posterior Primary Osteosynthesis of C1 (Shatsky et al.), 1856 41.8 Anterior Odontoid Screw Fixation (Etter), 1858 41.9 Posterior C1-C2 Fusion Using Rod and Screw Construct with C1 Lateral Mass Screws (Harms), 1859 41.10 Posterior C1-C2 Fusion with C2 Translaminar Screws (Wright), 1862 41.11 Posterior C1-C2 Transarticular Screws (Magerl and Seemann), 1863 41.12 Posterior C1-C2 Fusion Using the Modified Gallie Posterior Wiring Technique (Gallie, Modified), 1863 41.13 Posterior C1-C2 Wiring (Brooks and Jenkins), 1864 41.14 Anterior Cervical Discectomy and Fusion with Plating, 1873 41.15 Cervical Corpectomy and Reconstruction with Plating, 1875 41.16 Lateral Mass Screw and Rod Fixation (Magerl), 1877 41.17 Thoracic and Lumbar Segmental Fixation with Pedicle Screws, 1888 41.18 Anterior Plating, 1891 41.19 Lumbopelvic Fixation (Triangular Osteosynthesis) (Shildhauer), 1895 Infections and Tumors of the Spine 42.1 Drainage of Retropharyngeal Abscess Through Posterior Triangle of the Neck, 1934 42.2 Anterior Cervical Approach to Drainage of Retropharyngeal Abscess, 1934 42.3 Costotransversectomy for Drainage of Dorsal Spine Abscess, 1935 42.4 Drainage of Paravertebral Abscess, 1935 42.5 Drainage Through the Petit Triangle, 1936 42.6 Drainage by Lateral Incision, 1936 42.7 Drainage by Anterior Incision, 1937 42.8 Coccygectomy for Drainage of a Pelvic Abscess (Lougheed and White), 1937 42.9 Radical Debridement and Arthrodesis (Roaf et al.), 1937 42.10 Anterior Excision of Spinal Tumor, 1949 42.11 Costotransversectomy for Intralesional Excision of Spinal Tumor, 1950 42.12 Transpedicular Intralesional Excision for Tumor of the Spine, 1950 Pediatric Cervical Spine 43.1 Posterior Atlantoaxial Fusion (Gallie), 1961 43.2 Posterior Atlantoaxial Fusion Using Laminar Wiring (Brooks and Jenkins), 1963 43.3 Translaminar Screw Fixation of C2, 1963 43.4 Occipitocervical Fusion, 1964 43.5 Occipitocervical Fusion Passing Wires Through Table of Skull (Wertheim and Bohlman), 1966 43.6 Occipitocervical Fusion Without Internal Fixation (Koop et al.), 1966 43.7 Occipitocervical Fusion Using Crossed Wiring (Dormans et al.), 1967

43.8 Occipitocervical Fusion Using Contoured Rod and Segmental Rod Fixation, 1969 43.9 Occipitocervical Fusion Using a Contoured Occipital Plate, Screw, and Rod Fixation, 1970 43.10 Transoral Approach (Fang and Ong), 1970 43.11 Transoral Mandible-Splitting and Tongue-Splitting Approach (Hall, Denis, and Murray), 1971 43.12 Lateral Retropharyngeal Approach (Whitesides and Kelly), 1972 43.13 Anterior Retropharyngeal Approach (McAfee et al.), 1974 43.14 Application of Halo Device (Mubarak et al.), 1976 43.15 Posterior Fusion of C3-7, 1985 43.16 Posterior Fusion of C3 to C7 Using 16-Gauge Wire and Threaded Kirschner Wires (Hall), 1985 43.17 Posterior Fusion with Lateral Mass Screw Fixation (Roy- Camille), 1986 43.18 Posterior Fusion with Lateral Mass Screw and Rod Fixation, 1986 43.19 Rib Resection (Bonola), 1987 43.20 Posterior Spinal Fusion for Cervical Kyphosis Through a Lateral Approach (Sakaura et al.), 1992 43.21 Sternal-Splitting Approach to the Cervicothoracic Junction (Mulpuri et al.), 1994 Scoliosis and Kyphosis 44.1 Casting for Idiopathic Scoliosis, 2002 44.2 Dual Growing Rod Instrumentation Without Fusion, 2007 44.3 Shilla Guided Growth System (McCarthy et al.), 2008 44.4 Growing Rod Attachment Using Rib Anchors (Sankar and Skaggs), 2010 44.5 Anterior Vertebral Tethering, 2012 44.6 Posterior Surgeries for Idiopathic Scoliosis, 2025 44.7 Facet Fusion (Moe), 2027 44.8 Facet Fusion (Hall), 2027 44.9 Autogenous Iliac Crest Bone Graft, 2028 44.10 Thoracic Pedicle Screw Insertion Techniques, 2035 44.11 Pedicle Hook Implantation, 2039 44.12 Transverse Process Hook Implantation, 2040 44.13 Laminar Hook Implantation, 2040 44.14 Sublaminar Wires, 2040 44.15 Instrumentation Sequence in Typical Lenke 1A Curve, 2043 44.16 Deformity Correction by Direct Vertebral Rotation, 2044 44.17 Halo-Gravity Traction (Sponseller and Takenaga), 2046 44.18 Temporary Distraction Rod (Buchowski et al.), 2048 44.19 Anterior Release (Letko et al.), 2050 44.20 Osteotomy in Complex Spinal Deformity (Ponte Osteotomy), 2050 44.21 Posterior Thoracic Vertebral Column Resection (Powers et al.), 2051 44.22 Osteotomy of the Ribs (Mann et al.), 2058 44.23 Thoracoabdominal Approach, 2059 44.24 Lumbar Extraperitoneal Approach, 2059 44.25 Disc Excision, 2060 44.26 Anterior Instrumentation of a Thoracolumbar Curve, 2060 44.27 Video-Assisted Thoracoscopic Discectomy (Crawford), 2065 44.28 Thoracoscopic Vertebral Body Instrumentation for Vertebral Body Tether (Picetti), 2067 44.29 Luque Rod Instrumentation and Sublaminar Wires Without Pelvic Fixation, 2074 44.30 Sacropelvic Fixation (McCarthy), 2075 44.31 Galveston Sacropelvic Fixation (Allen and Ferguson), 2076 44.32 Unit Rod Instrumentation with Pelvic Fixation, 2078 44.33 Iliac Fixation with Iliac Screws, 2079 44.34 Iliac and Lumbosacral Fixation with Sacral-Alar-Iliac Screws, 2081 44.35 Transpedicular Convex Anterior Hemiepiphysiodesis and Posterior Arthrodesis (King), 2098 44.36 Convex Anterior and Posterior Hemiepiphysiodeses and Fusion (Winter), 2099 44.37 Hemivertebra Excision: Anteroposterior Approach (Hedequist and Emans), 2102 44.38 Hemivertebra Excision: Lateral-Posterior Approach (Li et al.), 2105 44.39 Hemivertebra Excision: Posterior Approach (Hedequist, Emans, Proctor), 2105 44.40 Transpedicular Eggshell Osteotomies with Frameless Stereotactic Guidance (Mikles et al.), 2107 44.41 Expansion Thoracoplasty (Campbell), 2110 44.42 Anterior Release and Fusion, 2120

44.43 Posterior Multiple Hook and Screw Segmental Instrumentation (Crandall), 2120 44.44 Posterior Column Shortening Procedure for Scheuermann Kyphosis (Ponte et al.), 2122 44.45 Anterior Osteotomy and Fusion (Winter et al.), 2129 44.46 Anterior Cord Decompression and Fusion (Winter and Lonstein), 2129 44.47 Anterior Vascular Rib Bone Grafting (Bradford), 2130 44.48 Circumferential Decompression and Cantilever Bending (Chang et al.), 2132 44.49 Posterior Hemivertebra Resection with Transpedicular Instrumentation (Ruf and Harms), 2133 44.50 Spondylolysis Repair (Kakiuchi), 2142 44.51 Modified Scott Repair Technique (Van Dam), 2143 44.52 Intralaminar Screw Fixation of Pars Defect (Buck Screw Technique), 2144

44.53 Spondylolysis Repair with U-Rod or V-Rod (Sumita et al.), 2144 44.54 Posterolateral Fusion and Pedicle Screw Fixation (Lenke and Bridwell), 2147 44.55 Instrumented Reduction (Crandall), 2147 44.56 Reduction and Interbody Fusion (Smith et al.), 2150 44.57 One-Stage Decompression and Posterolateral Interbody Fusion (Bohlman and Cook), 2153 44.58 Uninstrumented Circumferential In Situ Fusion (Helenius et al.), 2154 44.59 L5 Vertebrectomy (Gaines), 2156 44.60 Posterior Instrumentation and Fusion, 2160 44.61 Vertebral Excision and Reduction of Kyphosis (Lindseth and Selzer), 2163 44.62 Open Biopsy of Thoracic Vertebra (Michele and Krueger), 2173

Campbell’s Operative Orthopaedics, 14th ed. List of Techniques VOLUME III Knee Injuries 45.1 Open Meniscal Repair, 2222 45.2 Arthroscopic Partial Meniscectomy and Decompression of ­Meniscal Cyst, 2226 45.3 Excision of Meniscal Cyst, 2227 45.4 Repair of Medial Compartment Disruptions, 2244 45.5 Reconstruction of Medial Compartment (Slocum), 2252 45.6 Repair of Posteromedial Corner, 2256 45.7 Reconstruction of Posteromedial Corner (Hughston), 2257 45.8 Reconstruction of the Anterolateral Ligament, 2260 45.9 Repair of Lateral Compartment Disruptions, 2260 45.10 Reconstruction of the Posterolateral Structures for Mild-to-­ Moderate Posterolateral Instability (Hughston and Jacobson), 2267 45.11 Reconstruction of the Popliteal Tendon Using the Iliotibial Band for Posterolateral Instability (Müller), 2270 45.12 Rerouting of the Biceps Tendon to the Femoral Epicondyle for Posterolateral Instability (Clancy), 2273 45.13 Anatomic Posterolateral Knee Reconstruction for Grade III Posterolateral Injury (LaPrade et al.), 2275 45.14 Posterolateral Corner Reconstruction with a Single Allograft Fibular Sling (Yang et al.), 2276 45.15 Allograft Reconstruction of the Lateral Collateral Ligament (Noyes), 2277 45.16 Reconstruction of Posterolateral Structures with Semitendinosus Tendon (Larson), 2279 45.17 Valgus Tibial Osteotomy and Posterolateral Reconstruction, 2280 45.18 Repair of Bony Tibial Avulsions of Anterior Cruciate Ligament, 2287 45.19 Extraarticular Procedures (Iliotibial Band Tenodesis) (MacIntosh), 2289 45.20 Extraarticular Procedures (Iliotibial Band Tenodesis) (MacIntosh, Modified by Losee), 2289 45.21 Extraarticular Procedures (Iliotibial Band Tenodesis) (Andrews), 2290 45.22 Anterior Cruciate Ligament Reconstruction with Bone–Patellar Tendon-Bone Graft (Clancy, Modified), 2296 45.23 Anterior Cruciate Ligament Reconstruction with Hamstrings (with Proximal Release of Hamstrings), 2301 45.24 Repair of Bony Avulsion, 2316 45.25 Reconstruction of Posterior Cruciate Ligament with Patellar Tendon Graft (Clancy), 2319 45.26 Reconstruction of Posterior Cruciate Ligament with Patellar Tendon Graft (Sallay and McCarroll), 2321 45.27 Reconstruction of Posterior Cruciate Ligament with Bone-Patellar Tendon-Bone or Achilles Tendon-Bone Grafts (Berg), 2326 45.28 Reconstruction of Posterior Cruciate Ligament with Bone-Patellar Tendon-Bone or Achilles Tendon-Bone Grafts (Burks and Schaffer), 2327 45.29 Subperiosteal Release of the Lateral Quadriceps Mechanism (Ogata), 2348 45.30 Advancement of the Tibial Tuberosity (Maquet), 2351 45.31 Patellectomy (Soto-Hall), 2352 45.32 Thompson Quadricepsplasty (Thompson), 2353 45.33 Mini-Invasive Quadricepsplasty (Wang, Zhao, He), 2353 45.34 Posterior Capsulotomy (Putti, Modified), 2356 45.35 Posterior Capsulotomy (Yount), 2356 Shoulder and Elbow Injuries 46.1 Open Anterior Acromioplasty, 2388 46.2 Open Repair of Rotator Cuff Tears, 2392 46.3 Latissimus Dorsi Transfer (Gerber et al.), 2397 46.4 Decompression and Debridement of Massive Rotator Cuff Tears (Rockwood et al.), 2398 46.5 Closed Manipulation, 2402 46.6 Posterior Surgical Approach for Quadrilateral Space Syndrome (Cahill and Palmer), 2406 46.7 Posterior Surgical Approach for Suprascapular Nerve Entrapment (Post and Mayer), 2407 46.8 Suprascapular Notch Decompression, 2408

46.9 Spinoglenoid Notch Decompression, 2408 46.10 Removal of a Ganglion from the Inferior Branch of the Suprascapular Nerve (Thompson et al.), 2409 46.11 Correction of Tennis Elbow (Nirschl, Modified), 2412 46.12 Correction of Medial Epicondylitis (Nirschl), 2413 46.13 Anterior and Posterior Release of Elbow Contracture (Morrey), 2416 46.14 Excision of Heterotopic Ossification (Morrey and Harter), 2418 Recurrent Dislocations 47.1 Medial Quadriceps Tendon-Femoral Ligament Reconstruction (Phillips), 2432 47.2 Distal Realignment, 2434 47.3 Fulkerson Osteotomy, 2435 47.4 Trochleoplasty, 2435 47.5 Modified Bankart Repair (Montgomery and Jobe), 2448 47.6 Anterior Stabilization with Associated Glenoid Deficiency (Laterjet Procedure) (Walch and Boileau), 2450 47.7 Reconstruction of Anterior Glenoid Using Iliac Crest Bone Autograft (Warner et al.), 2453 47.8 Capsular Shift (Neer and Foster), 2454 47.9 Neer Inferior Capsular Shift Procedure Through a Posterior Approach (Neer and Foster), 2457 47.10 Tibone and Bradley Technique (Tibone and Bradley), 2459 47.11 Capsular Shift Reconstruction with Posterior Glenoid Osteotomy (Rockwood), 2460 47.12 McLaughlin Procedure (McLaughlin), 2461 47.13 Ulnar Collateral Ligament Reconstruction—Modified Jobe Technique, 2467 47.14 Ulnar Collateral Ligament Reconstruction—Andrews et al Technique, 2468 47.15 Ulnar Collateral Ligament Reconstruction (Altchek et al.), 2470 47.16 Ulnar Collateral Ligament Repair With an Internal Brace (Dugas et al.), 2472 47.17 Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability (Nestor, Morrey, and O’Driscoll), 2473 Traumatic Disorders 48.1 Fasciotomy for Acute Compartment Syndrome of the Thigh (Tarlow et al.), 2482 48.2 Single-Incision Fasciotomy for Lower Leg Compartment Syndrome (Davey et al.), 2483 48.3 Double-Incision Fasciotomy for Lower Leg Compartment Syndrome (Mubarak and Hargens), 2484 48.4 Double Mini-Incision Fasciotomy for Chronic Anterior Compartment Syndrome (Mouhsine et al.), 2487 48.5 Single-Incision Fasciotomy for Chronic Anterior and Lateral Compartment Syndrome (Fronek et al.), 2487 48.6 Double-Incision Fasciotomy for Chronic Posterior Compartment Syndrome (Rorabeck), 2489 48.7 Open Repair of Acute Achilles Tendon Rupture, 2493 48.8 Open Repair of Achilles Tendon Rupture—Krackow et al., 2494 48.9 Open Repair of Achilles Tendon Rupture—Lindholm, 2494 48.10 Repair of Acute Achilles Tendon Rupture Using Plantaris Tendon (Lynn), 2495 48.11 Dynamic Loop Suture Technique for Acute Achilles Tendon Rupture (Teuffer), 2495 48.12 Minimally Invasive and Percutaneous Repair of Acute Achilles Tendon Rupture (Ma and Griffith), 2496 48.13 Percutaneous Achilles Tendon Repair (Hsu, Berlet, Anderson), 2497 48.14 Transfer of the Peroneus Brevis Tendon for Neglected Achilles Tendon Ruptures (Maffulli et al.), 2500 48.15 Direct Repair of Neglected Achilles Tendon Ruptures, 2502 48.16 Repair of Neglected Achilles Tendon Ruptures Using Peroneus Brevis and Plantaris Tendons (White and Kraynick; Teuffer, Modified), 2502 48.17 Repair of Neglected Achilles Tendon Ruptures Using Gastrocnemius-Soleus Turn-Down Graft (Bosworth), 2503 48.18 V-Y Repair of Neglected Achilles Tendon Ruptures (Abraham and Pankovich), 2503 48.19 Repair of Neglected Achilles Tendon Ruptures Using Flexor Hallucis Longus Tendon Transfer (Wapner et al.), 2504

48.20 Tenotomy and Repair for Chronic Patellar Tendinosis, 2507 48.21 Fixation of Patellar Stress Fracture, 2507 48.22 Suture Repair of Patellar Tendon Rupture, 2509 48.23 Suture Anchor Repair of Patellar Tendon Rupture (DeBerardino and Owens), 2510 48.24 Achilles Tendon Allograft for Chronic Patellar Tendon Rupture, 2511 48.25 Hamstring (Semitendinosus and Gracilis) Autograft Augmentation for Chronic Patellar Tendon Rupture (Ecker, Lotke, and Glazer), 2513 48.26 Hamstring Autograft Augmentation for Chronic Patellar Tendon Rupture (Mandelbaum et al.), 2514 48.27 Repair of Acute Rupture of the Tendon of the Quadriceps Femoris Muscle, 2514 48.28 Repair of Proximal Hamstring Avulsion (Birmingham et al.), 2518 48.29 Open Repair of Proximal Hamstring Avulsion (Bowman et al.), 2519 48.30 Endoscopic Repair of Proximal Hamstring Avulsion (Bowman et al.), 2519 48.31 Repair of Proximal Biceps Tendon Rupture, 2521 48.32 Subpectoral Biceps Tenodesis (Mazzoca et al.), 2521 48.33 Two-Incision Technique for Repair of the Distal Biceps Tendon (Boyd and Anderson), 2524 48.34 Single-Incision Technique for Repair of the Distal Biceps Tendon, 2525 48.35 Double-Row Repair of the Distal Triceps Tendon, 2526 48.36 Repair of the Superior Peroneal Retinaculum, 2529 48.37 Fibular Groove Deepening with Tissue Transfer (Periosteal Flap) for Recurrent Peroneal Tendon Dislocation (Zoellner and Clancy), 2529 48.38 Indirect (Impaction) Fibular Groove Deepening for Peroneal Tendon Dislocation (Shawen and Anderson), 2530 48.39 Achilles Tendon Augmentation of Superior Peroneal Retinaculum Repair (Jones), 2531 48.40 Treatment of Biceps Brachii Tendon Displacement, 2532 Arthroscopy of the Foot and Ankle 50.1 Arthroscopic Examination And Debridement of the Ankle Joint, 2553 50.2 Posterior Debridement For Ankle Impingement, 2558 50.3 Posterior Arthroscopic Subtalar Arthrodesis (Devos-bevernage et al.), 2562 50.4 Subtalar Arthroscopy, 2564 50.5 First Metatarsophalangeal Joint Arthroscopy, 2565 50.6 Tendoscopic Recession of the Gastrocnemius Tendon, 2568 Arthroscopy of the Lower Extremity 51.1 Resection of Bucket-Handle Tear, 2585 51.2 Removal of Posterior Horn Tear, 2586 51.3 Treatment of Partial Depth Meniscal Tears, 2587 51.4 Partial Excision of the Discoid Meniscus, 2588 51.5 Inside-To-Outside Technique, 2590 51.6 Outside-To-Inside Technique, 2592 51.7 Lateral Meniscal Suturing, 2593 51.8 Outside-In Repair of Complete Radial Tear of the Lateral Meniscus (Steiner et al.), 2594 51.9 Transtibial Pull-out Repair of Radial or Meniscal Root Tear ­(Phillips), 2597 51.10 Meniscal Replacement, 2599 51.11 Removal of Loose Bodies, 2601 51.12 Resection of Plica, 2603 51.13 Arthroscopic Drilling of an Intact Lesion of the Femoral Condyle, 2605 51.14 Arthroscopic Screw Fixation for Osteochondritis Dissecans Lesions In the Medial Femoral Condyle, 2605 51.15 Osteochondral Autograft Transfer, 2606 51.16 Anatomic Single-Bundle Endoscopic Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Graft, 2610 51.17 Two-Incision Technique for Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Graft, 2616 51.18 Endoscopic Quadruple Hamstring Graft, 2618 51.19 All-Inside Quadruple Hamstring Graft Anterior Cruciate Ligament Reconstruction, 2619 51.20 Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction (Karlsson et al.), 2620 51.21 Transepiphyseal Replacement of Anterior Cruciate Ligament Using Quadruple Hamstring Grafts (Anderson), 2623 51.22 Physeal-Sparing Reconstruction of the Anterior Cruciate Ligament (Kocher, Garg, and Micheli), 2625 51.23 Partial Transepiphyseal ACL Reconstruction In Skeletally Immature Athletes (Azar and Miller), 2626

51.24 Anterior Cruciate and Anterolateral Ligament Reconstruction (Phillips), 2627 51.25 Single-Tunnel Posterior Cruciate Ligament Reconstruction (Phillips), 2631 51.26 Double-Tunnel Posterior Cruciate Ligament Reconstruction (Laprade et al.), 2633 51.27 Lateral Retinacular Release, 2637 51.28 Synovectomy, 2638 51.29 Drainage and Debridement in Pyarthrosis, 2638 51.30 Arthroscopically Assisted Fracture Reduction and Percutaneous Fixation (Caspari et al.), 2639 51.31 Arthroscopic Lysis and Excision of Adhesions (Sprague), 2639 51.32 Supine Position Arthroscopy (Byrd), 2642 51.33 Lateral Position Arthroscopy (Glick et al.), 2645 51.34 Arthroscopic Repair of Labral Tears (Kelly et al.), 2649 51.35 Arthroscopic Treatment of Pincer Impingement (Larson), 2652 51.36 Arthroscopic Treatment of Cam Impingement (Mauro et al.), 2652 51.37 Arthroscopic Labral Reconstruction (Matsuda), 2653 51.38 Repair of the Adductor Tendon (Byrd), 2655 51.39 Treatment of External Snapping Hip (Ilizaliturri et al), 2655 51.40 Psoas Release at the Lesser Trochanter, 2656 51.41 Psoas Release at the Joint Level (Wettstein et al.), 2656 Arthroscopy of the Upper Extremity 52.1 Establishing a Posterior Portal, 2667 52.2 Antegrade Method, 2668 52.3 Retrograde Method, 2668 52.4 Establishing the Superior Portal (Neviaser), 2669 52.5 Arthroscopic Removal of Loose Body, 2671 52.6 Arthroscopic Fixation of Type Ii Slap Lesions (Modified from Burkhart, Morgan, and Kibler), 2673 52.7 Biceps Tendon Release, 2678 52.8 Arthroscopic Biceps Tenodesis: Percutaneous Intraarticular Transtendon Technique (Sekiya et al.), 2680 52.9 Arthroscopic “Loop ‘n’ Tack” Tenodesis (Duerr et al.), 2680 52.10 Biceps Tenodesis: Arthroscopic or Mini-Open Technique with Screw Fixation (Romeo et al. Modified), 2682 52.11 Arthroscopic Bankart Repair Technique, 2684 52.12 Posterior Shoulder Stabilization (Kim et al.), 2692 52.13 Capsular Shift, 2694 52.14 Arthroscopic Repair of Posterior Humeral Avulsion of the Glenohumeral Ligament, 2695 52.15 Remplissage (Purchase et al. [Wolf] Technique), 2695 52.16 Transosseous Bony Bankart Repair (Driscoll, Burns, and Snyder), 2697 52.17 Arthroscopic Subacromial Decompression and Acromioplasty, 2700 52.18 Chock-Block Method for Acromioplasty, 2702 52.19 Debridement of Partial-Thickness Rotator Cuff Tears, 2703 52.20 Repair of Delamination and Localized, Articular-Side PartialThickness Cuff Tears, 2704 52.21 Transtendinous Repair of A Partial Articular-Side Supraspinatus Tendon Avulsion Lesion, 2704 52.22 Rotator Cuff Repair, 2713 52.23 Repair of Large or Massive Contracted Tears Using the Interval Slide Technique (Tauro et al.), 2716 52.24 Superior Capsule Reconstruction, 2717 52.25 Subscapularis Tendon Repair (Burkhart and Tehrany), 2721 52.26 Arthroscopic Resection of the Distal End of the Clavicle (Mumford Procedure) (Tolin and Snyder), 2724 52.27 Superior Approach (Flatow et al.), 2726 52.28 Arthroscopically Assisted AC Joint Reconstruction, 2726 52.29 Release of Calcific Tendinitis, 2727 52.30 Capsular Release (Scarlat and Harryman), 2730 52.31 Suprascapular Nerve Release (Lafosse, Tomasi, and Corbett), 2731 52.32 Scapulothoracic Bursectomy, 2733 52.33 Arthroscopic Elbow Examination, 2739 52.34 Arthroscopic Treatment of Osteochondritis Dissecans, 2744 52.35 Osteochondral Autograft Transfer (Yamamoto et al.), 2744 52.36 Removal of Olecranon Tip and Osteophytes, 2746 52.37 Resection of Thickened Pathologic Synovial Plica, 2747 52.38 Arthroscopy for Arthrofibrosis (Phillips and Strasburger), 2747 52.39 Arthroscopic Tennis Elbow Release (Baker and Cummings), 2749 52.40 Arthroscopic Bursectomy (Baker and Cummings), 2750

General Principles of Fracture Treatment 53.1 Percutaneous Drainage of a Morel-Lavallée Lesion (Tseng and Tornetta), 2771 53.2 Irrigation and Debridement of Open Wounds, 2774 53.3 Harvest of Femoral or Tibial Bone Graft with the RIA Instrumentation, 2779 53.4 Screw Fixation, 2790 53.5 ASIF Cancellous Screw Technique, 2791 53.6 Pin Insertion, 2804 Fractures of the Lower Extremity 54.1 Fixation of the Lateral Malleolus, 2818 54.2 Fixation of the Medial Malleolus, 2819 54.3 Repair of the Deltoid Ligament and Internal Fixation of the Lateral Malleolus, 2821 54.4 Reduction and Fixation of Posterior Malleolar Fracture, 2823 54.5 Reduction and Fixation of Anterior Tibial Margin Fractures, 2824 54.6 Stabilization of Unstable Ankle Fracture-Dislocation (Childress), 2826 54.7 Staged Minimally Invasive Open Reduction and Internal Fixation, 2831 54.8 Posterolateral Approach to Pilon Fractures, 2832 54.9 Spanning External Fixation of Tibial Pilon Fracture (Bonar and Marsh), 2835 54.10 Definitive Ring External Fixation of Tibial Pilon Fractures (Watson), 2837 54.11 Intramedullary Nailing of Tibial Shaft Fractures, 2848 54.12 External Fixation for Tibial Shaft Fractures, 2854 54.13 Ilizarov External Fixation for Tibial Shaft Fractures, 2857 54.14 Open Reduction and Fixation of a Lateral Tibial Plateau Fracture, 2869 54.15 Posteromedial Exposure, 2871 54.16 Open Reduction and Internal Fixation of Bicondylar Injuries, 2872 54.17 Circular External Fixation (Watson), 2872 54.18 Common Approach and Technique for Patellar Fractures, 2876 54.19 Circumferential Wire Loop Fixation (Martin), 2876 54.20 Tension Band Wiring Fixation, 2877 54.21 Partial Patellectomy, 2879 54.22 Partial Patellectomy Using Figure-of-Eight Load-Sharing Wire or Cable (Perry et al.), 2879 54.23 Total Patellectomy, 2880 54.24 Fracture Fixation of the Medial Condyle, 2884 54.25 Fracture Fixation of the Posterior Part of the Medial Condyle, 2885 54.26 Swashbuckler Approach to the Distal Femur (Starr et al.), 2886 54.27 Submuscular Minimally Invasive Locking Condylar Plate Application, 2887 54.28 Double Plate Fixation (Chapman and Henley), 2888 54.29 Antegrade Femoral Nailing, 2895 54.30 Retrograde Femoral Nailing, 2901 54.31 Extraction of an Unbroken Antegrade Femoral Nail, 2904 54.32 Extraction of a Broken Femoral Antegrade Nail, 2904 Fractures and Dislocations of the Hip 55.1 Fixation of Femoral Neck Fracture with Cannulated Screws, 2912 55.2 Open Reduction and Internal Fixation (Modified Smith-Petersen), 2914 55.3 Fluoroscopically Guided Capsulotomy of the Hip, 2918 55.4 Screw–Side Plate Fixation of Intertrochanteric Femoral Fractures, 2925 55.5 Intramedullary Nailing of Intertrochanteric Femoral Fractures, 2929 55.6 Intramedullary Nailing of Intertrochanteric Femoral Fractures With Integrated Proximal Interlocking Screws (Intertan), 2933 55.7 Intramedullary Nailing in Reconstruction Mode, 2935 55.8 Fixation of Subtrochanteric Femoral Fracture with a Proximal Femoral Locking Plate, 2938 55.9 Fixation of Subtrochanteric Femoral Fracture with a Blade Plate, 2940 55.10 Open Reduction of Posterior Hip Dislocation Through a Posterior Approach, 2948 Fractures of the Acetabulum and Pelvis 56.1 Anterior Intra-Pelvic Approach, 2973 56.2 Fixation of Comminuted Posterior Wall Fracture with or without a Transverse Component, 2988 56.3 Anterior Approach for Total Hip Arthroplasty for Fractures Involving Primarily the Anterior Wall and Column (Beaulé et al.), 2988 56.4 Gluteal Pillar External Fixation, 3008

56.5 Supra-Acetabular External Fixation, 3008 56.6 Anterior Subcutaneous Internal Fixation (Vaidya et al.), 3010 56.7 Pelvic Clamps (Ganz et al.), 3011 56.8 Open Reduction and Internal Fixation of the Pubic Symphysis, 3015 56.9 Internal Fixation: Posterior Approach and Fixation of Sacral Fractures and Sacroiliac Dislocations (Prone) (Matta and Saucedo), 3016 56.10 Percutaneous Iliosacral Screw Fixation of Sacroiliac Disruptions and Sacral Fractures (Supine), 3017 56.11 Anterior Approach and Stabilization of the Sacroiliac Joint (Simpson et al.), 3019 Fractures of the Shoulder, Arm, and Forearm 57.1 Open Reduction and Internal Fixation of Clavicular Fractures (Collinge et al., Modified), 3034 57.2 Intramedullary Fixation with a Headed, Distally Threaded Pin (Rockwood Clavicle Pin), 3036 57.3 Distal Clavicular Fracture Repair with Coracoclavicular Ligament Reconstruction and Cortical Button Fixation (Yagnik et al.), 3039 57.4 Intramedullary Nailing of a Proximal Humeral Fracture, 3053 57.5 Open Reduction and Internal Fixation of Proximal Humeral Fractures, 3054 57.6 Anterolateral Acromial Approach for Internal Fixation of Proximal Humeral Fracture (Gardner et al.; Mackenzie), 3055 57.7 Open Reduction and Internal Fixation of the Humeral Shaft Through a Modified Posterior Approach (Triceps-Reflecting), 3062 57.8 Minimally Invasive Plate Osteosynthesis (Apivatthakakul et al.; Tetsworth et al.), 3064 57.9 Antegrade Intramedullary Nailing of Humeral Shaft Fractures, 3067 57.10 Open Reduction and Internal Fixation of the Distal Humerus with Olecranon Osteotomy, 3076 57.11 Open Reduction and Internal Fixation of Radial Head Fracture, 3081 57.12 Stabilization of “Terrible Triad” Elbow Fracture-Dislocation (McKee et al.), 3084 57.13 Internal Joint Stabilization for Elbow Instability (Orbay et al.), 3088 57.14 Open Reduction and Internal Fixation of Olecranon Fracture, 3093 57.15 Open Reduction and Internal Fixation of Both-Bone Forearm Fractures, 3097 57.16 Closed Reduction and Percutaneous Pinning of Distal Radial Fracture (Glickel et al.), 3103 57.17 External Fixation of Fracture of the Distal Radius, 3105 57.18 Volar Plate Fixation of Fracture of the Distal Radius (Chung), 3108 57.19 Distraction Plate Fixation (Burke and Singer as Modified by Ruch et al.), 3111 Malunited Fractures 58.1 Correction of Metatarsal Angulation, 3129 58.2 Correction of Tarsal Malunion, 3129 58.3 Posterior Subtalar Arthrodesis (Gallie), 3131 58.4 Distraction Arthrodesis (Carr et al.), 3132 58.5 Resection of Lateral Prominence of Calcaneus (Kashiwagi, Modified), 3133 58.6 Correction of Calcaneal Malunion Through Extensile Lateral Approach (Clare et al.), 3134 58.7 Correction of Valgus Malunion of Extraarticular Calcaneal Fracture (Aly), 3136 58.8 Osteotomy for Bimalleolar Fracture, 3138 58.9 Correction of Diastasis of the Tibia and Fibula, 3139 58.10 Supramalleolar Osteotomy, 3139 58.11 Oblique Tibial Osteotomy (Sanders et al.), 3142 58.12 Clamshell Osteotomy (Russell et al.), 3145 58.13 Subcondylar Osteotomy and Wedge Graft for Malunion of Lateral Condyle, 3149 58.14 Osteotomy and Internal Fixation of the Lateral Condyle, 3149 58.15 Open Reduction and Internal Fixation, 3150 58.16 Osteotomy for Femoral Malunion, 3152 58.17 Osteotomy for Femoral Malunion in Children, 3155 58.18 Correction of Cervicotrochanteric Malunion, 3157 58.19 Osteotomy and Reorientation of Scapular Neck (Cole et al.), 3160 58.20 Osteotomy and Plate Fixation, 3161 58.21 Osteotomy and Elastic Intramedullary Nailing of Midshaft Clavicular Fracture (Smekal et al.), 3164 58.22 Closing Wedge Valgus Osteotomy for Varus Malunion of Proximal Humerus (Benegas et al., Modified), 3168 58.23 Correction of Proximal Third Humeral Malunion, 3169

58.24 Correction of Radial Neck Malunion (Inhofe and Moneim, Modified), 3170 58.25 Osteotomy and Fixation of Monteggia Fracture Malunion, 3170 58.26 Resection of Proximal Part of Radial Shaft (Kamineni et al.), 3172 58.27 Osteotomy and Plating for Forearm Malunion (Trousdale and Linscheid, Modified), 3173 58.28 Correction of Forearm Malunion with Distal Radioulnar Joint Instability (Trousdale and Linscheid, Modified), 3174 58.29 Drill Osteoclasis (Blackburn et al.), 3174 58.30 Opening Wedge Metaphyseal Osteotomy with Bone Grafting And Internal Fixation with Plate and Screws (Fernandez), 3179 58.31 Volar Osteotomy (Shea et al.), 3180 58.32 Intramedullary Fixation, 3182 58.33 External Fixation (Melendez), 3183 58.34 Osteotomy for Intraarticular Malunion (Marx and Axelrod), 3184 58.35 Radiolunate Arthrodesis (Saffar), 3185 58.36 Ulnar Shortening Osteotomy (Milch), 3186 58.37 Resection of the Distal Ulna (Darrach), 3187 Delayed Union and Nonunion of Fractures 59.1 Decortication, 3199 59.2 Fibular Autograft (Nonvascularized), 3200 59.3 Intramedullary Fibular Strut Allograft (Humerus) (Willis et al.), 3200 59.4 Resection of the Distal Fragment of the Medial Malleolus, 3210 59.5 Sliding Graft, 3210 59.6 Bone Graft of Medial Malleolar Nonunion (Banks), 3211 59.7 Posterolateral Bone Grafting, 3212 59.8 Anterior Central Bone Grafting, 3212 59.9 Percutaneous Bone Marrow Injection (Connolly et al., Brinker et al.), 3213 59.10 Tibial Exchange Nailing, 3214 59.11 Plate Fixation and Bone Grafting of the Clavicle, 3222 Acute Dislocations 60.1 Open Reduction and Repair of Patellar Dislocation, 3230 60.2 Grafting of the Medial Patellar Retinaculum, 3231 60.3 Open Reduction and Repair of the Extensor Mechanism, 3231

60.4 Open Reduction of Hip Dislocation, 3236 60.5 Anatomic Reconstruction of the Conoid and Trapezoid Ligaments (Mazzocca et al.), 3240 60.6 Open Reduction of Radial Head Dislocation, 3242 Old Unreduced Dislocations 61.1 Ligamentous Reconstruction for Old Unreduced Dislocation of the Proximal Tibiofibular Joint, 3247 61.2 Open Reduction for Old Unreduced Dislocation of the Knee, 3247 61.3 Open Reduction for Old Unreduced Dislocation of the Patella, 3249 61.4 Intertrochanteric Osteotomy for Chronic Anterior Dislocation of the Hip (Aggarwal and Singh), 3249 61.5 Traction and Abduction for Chronic Posterior Hip Dislocation (Gupta and Shravat), 3250 61.6 Resection or Stabilization of the Medial End of the Clavicle for Old Anterior Sternoclavicular Joint Dislocation, 3251 61.7 Stabilization of Old Posterior Sternoclavicular Joint Dislocation (Wang et al.), 3252 61.8 Resection of the Lateral End of the Clavicle for Chronic Acromioclavicular Joint Dislocation (Mumford; Gurd), 3253 61.9 Reconstruction of the Superior Acromioclavicular Ligament for Chronic Acromioclavicular Joint Dislocation (Neviaser), 3254 61.10 Transfer of the Coracoacromial Ligament for Chronic Acromioclavicular Joint Dislocation (Rockwood), 3255 61.11 Arthroscopic Transfer of the Coracoacromial Ligament for Chronic Acromioclavicular Joint Dislocation (Boileau et al.), 3256 61.12 Open Reduction of Chronic Anterior Shoulder Dislocations (Rowe and Zarins), 3261 61.13 Open Reduction of Chronic Posterior Shoulder Dislocation from a Superior Approach (Rowe and Zarins), 3262 61.14 Open Reduction of Chronic Posterior Shoulder Dislocation Through an Anteromedial Approach (McLaughlin), 3263 61.15 Deltopectoral Approach for Chronic Posterior Shoulder Dislocation (Keppler et al.), 3264 61.16 Open Reduction and V-Y Lengthening of Triceps Muscles for Chronic Elbow Dislocation (Speed), 3266

Campbell’s Operative Orthopaedics, 14th ed. List of Techniques VOLUME IV Peripheral Nerve Injuries 62.1 Epineurial Neurorrhaphy, 3292 62.2 Perineurial (Fascicular) Neurorrhaphy, 3292 62.3 Interfascicular Nerve Grafting (Millesi, Modified), 3293 62.4 Transfer of the Ulnar Nerve Fascicles to Nerve of the Biceps Muscle (Oberlin et al.), 3295 62.5 Double Fascicular Transfer from Ulnar and Median Nerves to Nerve of the Brachialis Branches (MacKinnon and Colbert), 3296 62.6 Neurotization of the Suprascapular Nerve with the Spinal Accessory Nerve (MacKinnon and Colbert), 3297 62.7 Neurotization of the Axillary Nerve with Radial Nerve (MacKinnon and Colbert), 3298 62.8 Posterior Approach for Division of the Transverse Scapular Ligament (Swafford and Lichtman), 3300 62.9 Approach to the Axillary Nerve, 3301 62.10 Approach to the Musculocutaneous Nerve, 3302 62.11 Approach to the Radial Nerve, 3303 62.12 Approach to the Ulnar Nerve, 3306 62.13 Nerve Transfer for Ulnar Nerve Reconstruction (MacKinnon and Novak), 3308 62.14 Approach to the Median Nerve, 3309 62.15 Approach to the Femoral Nerve, 3312 62.16 Approach to the Sciatic Nerve, 3314 62.17 Approach to the Common, Superficial, and Deep Peroneal Nerves, 3316 62.18 Approach to the Tibial Nerve Deep to the Soleus Muscle, 3318 Microsurgery 63.1 Microvascular Anastomosis (End-to-End), 3325 63.2 Microvascular End-to-Side Anastomosis, 3326 63.3 Microvascular Vein Grafting, 3327 63.4 Preparation for Replantation, 3334 63.5 Vessel Repair in Replantation, 3337 63.6 Nerve Repair for Replantation, 3338 63.7 Reoperation, 3340 63.8 Pocket Technique for Microvascular Anastomosis (Arata et al.), 3341 63.9 Dissection for Free Groin Flap, 3347 63.10 Dissection for Anterolateral Thigh Flap (Javaid and Cormack), 3349 63.11 Dissection for Scapular and Parascapular Flap (Gilbert; Urbaniak et al.), 3350 63.12 Dissection for Lateral Arm Flap, 3351 63.13 Dissection for Latissimus Dorsi Transfer, 3354 63.14 Dissection for Serratus Anterior Flap, 3356 63.15 Dissection for Tensor Fasciae Latae Muscle Flap, 3357 63.16 Dissection for Gracilis Muscle Transfer, 3359 63.17 Dissection for Rectus Abdominis Transfer, 3360 63.18 Transfer of Functioning Muscle (Forearm Preparation), 3361 63.19 Posterior Approach for Harvesting Fibular Graft (Taylor), 3365 63.20 Lateral Approach for Harvesting Fibular Graft (Gilbert; Tamai et al.; Weiland), 3365 63.21 Distal Tibiofibular Fusion to Prevent Progressive Valgus Deformity, 3368 63.22 Free Iliac Crest Bone Graft (Taylor, Townsend, and Corlett; Daniel; Weiland et al.), 3369 63.23 Harvesting of Medial Femoral Condyle Corticoperiosteal Free Flap, 3369 63.24 Medial Femoral Condyle Corticoperiosteal Free Flap for Scaphoid Arthroplasty (Higgins and Burger), 3370 63.25 Dorsalis Pedis Free Tissue Transfer, 3374 63.26 Neurovascular Free Flap Transfer First Web Space, 3377 63.27 Great Toe Wraparound Flap Transfer (Morrison et al., Urbaniak et al., Steichen), 3378 63.28 Single-Stage Great Toe Transfer (Buncke, Modified), 3382 63.29 Trimmed-Toe Transfer (Wei et al.), 3384 63.30 Second or Third Toe Transplantation, 3386 Basic Surgical Technique and Postoperative Care 64.1 Midlateral Finger Incision, 3405 64.2 Z-Plasty, 3409

Acute Hand Injuries 65.1 Applying Split-Thickness Grafts, 3424 65.2 Applying Full-Thickness Grafts, 3425 65.3 Applying Cross Finger Flaps, 3427 65.4 Applying a Radial Forearm Graft (Foucher et al.), 3430 65.5 Applying a Posterior Interosseous Flap (Zancolli and Angrigiani; Chen et al.), 3433 65.6 Applying a Random Pattern Abdominal Pedicle Flap, 3435 65.7 Groin Pedicle Flap, 3436 65.8 Hypogastric (Superficial Epigastric) Flap, 3438 65.9 Applying a Filleted Graft, 3439 Flexor and Extensor Tendon Injuries 66.1 Modified Kessler-Tajima Suture (Strickland, 1995), 3447 66.2 Flexor Tendon Repair Using Six-Strand Repair (Adelaide Technique) (Savage), 3448 66.3 Four- or Six-Strand Repair (Chung, Modified Tsuge), 3449 66.4 Multiple Looped Suture Tendon Repair (Tang et al.), 3449 66.5 Six-Strand Double-Loop Suture Repair (Lim and Tsai), 3449 66.6 Eight-Strand Repair (Winters and Gelberman), 3450 66.7 End-to-Side Repair, 3451 66.8 Roll Stitch, 3452 66.9 Pull-Out Technique for Tendon Attachment, 3452 66.10 Repair in Zones I and Ii, 3458 66.11 Repair in Zones III, IV, and V, 3461 66.12 Profundus Advancement (Wagner), 3467 66.13 Reconstruction of Finger Flexors: Single-Stage Tendon Graft, 3468 66.14 Reconstruction of Flexor Tendon Pulleys, 3473 66.15 Stage 1: Excision of Tendon and Scar and Reconstruction of Flexor Pulley, 3475 66.16 Stage 2: Rod Removal and Tendon Graft Insertion, 3477 66.17 Flexor Tendon Graft, 3478 66.18 Two-Stage Flexor Tendon Graft for Flexor Pollicis Longus (Hunter), 3478 66.19 Transfer of Ring Finger Flexor Sublimis to Flexor Pollicis Longus, 3479 66.20 Flexor Tenolysis After Repair and Grafting, 3480 66.21 Freeing of Adherent Tendon (Howard), 3480 66.22 Tenodesis, 3481 66.23 Chronic Mallet Finger (Secondary Repair), 3484 66.24 Chronic Mallet Finger (Secondary Repair) (Fowler), 3485 66.25 Tendon Transfer for Correction of Old Mallet Finger Deformity (Milford), 3486 66.26 Tendon Graft for Correction of Old Mallet Finger Deformity, 3486 66.27 Repair of Central Slip of the Extensor Expansion Causing Boutonniere Deformity, 3487 66.28 Reconstruction of the Extensor Mechanism for Chronic Boutonniere Deformity (Littler, Modified), 3488 66.29 Repair of Traumatic Dislocation of the Extensor Tendon, 3491 Fractures, Dislocations, and Ligamentous Injuries of the Hand and Wrist 67.1 Closed Pinning (Wagner), 3503 67.2 Open Reduction (Wagner), 3504 67.3 Corrective Osteotomy, 3505 67.4 Open Reduction and Internal Fixation (Foster and Hastings), 3506 67.5 Open Reduction and Internal Fixation (Buchler et al.), 3507 67.6 Ligament Reconstruction for Recurrent Dislocation (Eaton and Littler), 3508 67.7 Open Reduction—Volar Approach, 3511 67.8 Repair by Suture, 3515 67.9 Anatomic Graft Reconstructions (Glickel), 3516 67.10 Jobe Four-Limb Reconstruction, 3516 67.11 Open Reduction (Kaplan), 3522 67.12 Open Reduction—Dorsal Approach (Becton et al.), 3522 67.13 Open Reduction and Fixation of Metacarpal Shaft Fracture, 3525 67.14 Percutaneous Pinning of Metacarpal Shaft Fracture, 3525 67.15 Percutaneous Pinning of a Metacarpal Shaft Fracture, 3525 67.16 Open Reduction and Plate Fixation, 3526 67.17 Open Reduction and Screw Fixation, 3527 67.18 Open Reduction (Pratt), 3530

67.19 Hemi-Hamate Autograft (Williams et al.), 3533 67.20 Open Reduction (Eaton and Malerich), 3536 67.21 Dynamic Distraction External Fixation (Ruland et al.), 3540 67.22 Dynamic Intradigital External Fixation, 3540 67.23 Tendon Graft to Replace Ruptured Collateral Ligament, 3542 67.24 Open Reduction and Fixation with a Kirschner Wire, 3544 67.25 Open Reduction and Fixation with a Pull-Out Wire and Transarticular Kirschner Wire (Doyle), 3546 67.26 Correction of Metacarpal Neck Malunion, 3551 67.27 Correction of Nonunion of the Metacarpals (Littler), 3553 67.28 Metacarpophalangeal Joint Capsulotomy, 3554 67.29 Proximal Interphalangeal Joint Capsulotomy (Curtis), 3555 67.30 Proximal Interphalangeal Joint Capsulotomy (Watson et al.), 3556 Nerve Injuries at the Level of the Hand and Wrist 68.1 Two-Point and Moving Two-Point Discrimination Testing, 3562 68.2 Conduit-Assisted Digital Nerve Repair (Weber et al.), 3566 68.3 Tension-Free Nerve Graft (Millesi, Modified), 3567 68.4 Suture of Digital Nerves, 3568 68.5 Transfer of the Proper Digital Nerve Dorsal Branch (Chen et al.), 3569 68.6 Repair of the Ulnar Nerve, 3570 68.7 Repair of the Deep Branch of the Ulnar Nerve (Boyes, Modified), 3570 68.8 Repair of the Median Nerve, 3573 68.9 Repair of the Superficial Radial Nerve, 3573 68.10 Neurovascular Island Graft Transfer, 3574 Wrist Disorders 69.1 Patient Positioning for Wrist Arthroscopy, 3585 69.2 Radiocarpal Examination, 3586 69.3 Midcarpal Examination, 3587 69.4 Distal Radioulnar Examination, 3588 69.5 Open Reduction and Internal Fixation of Acute Displaced Fractures of the Scaphoid—Volar Approach with Iliac Crest Bone Grafting, 3591 69.6 Open Reduction and Internal Fixation of Acute Displaced Fractures of the Scaphoid—Dorsal Approach, 3592 69.7 Open Reduction and Internal Fixation of Acute Displaced Fractures of the Scaphoid—Volar Approach with Distal Radial Autograft, 3593 69.8 Percutaneous Fixation of Scaphoid Fractures (Slade et al.), 3594 69.9 Excision of the Proximal Fragment, 3598 69.10 Proximal Row Carpectomy, 3600 69.11 Arthroscopic Proximal Row Carpectomy (Weiss et al.), 3601 69.12 Grafting Operations (Matti-Russe), 3603 69.13 Grafting Operations (Fernandez), 3604 69.14 Grafting Operations (Tomaino et al.), 3606 69.15 Grafting Operations (Stark et al.), 3606 69.16 Pronator-Based Graft (Kawai and Yamamoto), 3608 69.17 Vascularized Bone Grafts—1,2 Intercompartmental Supraretinacular Artery Graft (1,2 ICSRA) (Zaidemberg et al.), 3609 69.18 Vascularized Bone Grafts—Proximal Radiocarpal Artery Graft (PRCA Graft), 3609 69.19 Wrist Denervation, 3611 69.20 Excision or Reduction and Fixation of the Hook of the Hamate, 3614 69.21 Capitate Shortening with Capitate-Hamate Fusion, 3617 69.22 Radial Decompression for Treatment of Kienböck Disease (Illarramendi and De Carli), 3620 69.23 Radial Shortening, 3621 69.24 Arthroscopic Debridement of Triangular Fibrocartilage Tears, 3625 69.25 Arthroscopic Repair of Class 1B Triangular Fibrocartilage Complex Tears from the Ulna, 3626 69.26 Open Repair of Class 1B Injury, 3626 69.27 Open Repair of Class 1C Injury (Culp, Osterman, and Kaufmann, Modified), 3627 69.28 Arthroscopic Repair of Class 1D Injury (Sagerman and Short; Trumble et al.; Jantea et al., Modified), 3628 69.29 Open Repair of Class 1D Injuries (Cooney et al.), 3630 69.30 Anatomic Reconstruction of the Distal Radioulnar Ligaments (Adams and Berger), 3632 69.31 Reconstruction of the Dorsal Ligament of the Triangular Fibrocartilage Complex (Scheker et al.), 3634 69.32 Ulnar Shortening Osteotomy (Chun and Palmer), 3636 69.33 Limited Ulnar Head Excision: Hemiresection Interposition Arthroplasty (Bowers), 3637

69.34 “Matched” Distal Ulnar Resection (Watson et al.), 3639 69.35 “Wafer” Distal Ulnar Resection (Feldon, Terrono, and Belsky), 3639 69.36 Combined Arthroscopic “Wafer” Distal Ulnar Resection and Triangular Fibrocartilage Complex Debridement (Tomaino and Weiser), 3640 69.37 Distal Radioulnar Arthrodesis with Distal Ulnar Pseudarthrosis (Baldwin; Sauve-Kapandji; Lauenstein) (Sanders et al.; Vincent et al.; Lamey and Fernandez), 3641 69.38 Tenodesis of the Extensor Carpi Ulnaris and Transfer of the Pronator Quadratus (Kleinman and Greenberg), 3643 69.39 Combination Tenodesis of the Flexor Carpi Ulnaris and the Extensor Carpi Ulnaris (Jupiter and Breen, Modified), 3644 69.40 Interposition for Failed Ulna Resection (Sotereanos et al.), 3646 69.41 Arthrodesis of the Wrist (Haddad and Riordan), 3647 69.42 Compression Plate Technique, 3648 69.43 Arthrodesis of the Wrist (Weiss and Hastings), 3648 69.44 Ligament Repair, 3653 69.45 Ligament Reconstruction (Palmer, Dobyns, and Linscheid), 3656 69.46 Ligament Reconstruction (Almquist et al.), 3657 69.47 Ligament Reconstruction (Brunelli and Brunelli), 3658 69.48 Dorsal Capsulodesis (Blatt with Berger Modification), 3659 69.49 Scaphotrapezial-Trapezoid Fusion (Watson), 3660 69.50 Scaphocapitate Arthrodesis (Sennwald and Ufenast), 3662 69.51 Scaphocapitolunate Arthrodesis (Rotman et al.), 3662 69.52 Lunotriquetral Arthrodesis (Kirschenbaum et al.; Nelson et al.), 3662 Special Hand Disorders 70.1 Escharotomy (Sheridan et al.), 3675 70.2 Tangential Excision (Ruosso and Wexler Modified), 3676 70.3 Full-Thickness Excision, 3676 Paralytic Hand 71.1 Transfer of the Sublimis Tendon (Riordan), 3693 71.2 Transfer of the Sublimis Tendon (Brand), 3694 71.3 Transfer of the Extensor Indicis Proprius (Burkhalter et al.), 3694 71.4 Transfer of the Flexor Carpi Ulnaris Combined with the Sublimis Tendon (Groves and Goldner), 3695 71.5 Transfer of the Palmaris Longus Tendon to Enhance Opposition of the Thumb (Camitz), 3697 71.6 Muscle Transfer (Abductor Digiti Quinti) to Restore Opposition (Littler and Cooley), 3697 71.7 Transfer of the Brachioradialis or Radial Wrist Extensor to Restore Thumb Adduction (Boyes), 3698 71.8 Transfer of the Extensor Carpi Radialis Brevis Tendon to Restore Thumb Adduction (Smith), 3699 71.9 Royle-Thompson Transfer (Modified), 3699 71.10 Transfer of the Extensor Indicis Proprius Tendon, 3701 71.11 Transfer of a Slip of the Abductor Pollicis Longus Tendon (Neviaser, Wilson, and Gardner), 3701 71.12 Transfer of the Flexor Digitorum Sublimis of the Ring Finger (Bunnell, Modified), 3705 71.13 Transfer of the Extensor Carpi Radialis Longus or Brevis Tendon (Brand), 3707 71.14 Transfer of the Extensor Indicis Proprius and Extensor Digiti Quinti Proprius (Fowler), 3708 71.15 Capsulodesis (Zancolli), 3709 71.16 Tenodesis (Fowler), 3710 71.17 Transfer of Pronator Teres to Extensor Carpi Radialis Brevis, Flexor Carpi Radialis to Extensor Digitorum Communis, and Palmaris Longus to Extensor Pollicis Longus, 3711 71.18 Transfer of Pronator Teres to Extensor Carpi Radialis Longus and Extensor Carpi Radialis Brevis, Flexor Carpi Radialis to Extensor Pollicis Brevis and Abductor Pollicis Longus, Flexor Digitorum Sublimis Middle to Extensor Digitorum Communis, and Flexor Digitorum Sublimis Ring to Extensor Pollicis Longus and Extensor Indicis Proprius (Boyes), 3713 71.19 Distal Biceps-to-Triceps Transfer, 3719 71.20 Posterior Deltoid-to-Triceps Transfer (Moberg, Modified), 3721 71.21 Transfer of the Brachioradialis to the Extensor Carpi Radialis Brevis, 3722 71.22 Moberg Key Grip Tenodesis, 3723 71.23 Two-Stage Reconstruction to Restore Digital Flexion and Key Pinch Stage 1—Extensor Phase, 3725

71.24 Two-Stage Reconstruction to Restore Digital Flexion and Key Pinch Stage 2—Flexor Phase, 3725 71.25 Zancolli Reconstruction—First Step, 3726 71.26 Zancolli Reconstruction—Second Step, 3727 Cerebral Palsy of the Hand 72.1 Transfer of the Pronator Teres, 3735 72.2 Brachioradialis Rerouting (Ozkan et al.), 3736 72.3 Fractional Lengthening of the Flexor Carpi Radialis Muscle and Finger Flexors, 3739 72.4 Release of the Flexor-Pronator Origin (Inglis and Cooper), 3739 72.5 Extensive Release of the Flexor Pronator Origin (Williams and Haddad), 3740 72.6 Transfer of the Flexor Carpi Ulnaris (Green and Banks), 3742 72.7 Wrist Arthrodesis, 3743 72.8 Carpectomy (Omer and Capen), 3744 72.9 Myotomy, 3746 72.10 Release of Contractures, Augmentation of Weak Muscles, and Skeletal Stabilization (House et al.), 3746 72.11 Flexor Pollicis Longus Abductorplasty (Smith), 3748 72.12 Redirection of Extensor Pollicis Longus (Manske), 3748 72.13 Sublimis Tenodesis of the Proximal Interphalangeal Joint (Curtis), 3750 72.14 Intrinsic Lengthening (Matsuo et al.; Carlson et al.), 3751 72.15 Lateral Band Translocation (Tonkin, Hughes, and Smith), 3751 Arthritic Hand 73.1 Correction of Proximal Interphalangeal Joint Hyperextension Deformity (Beckenbaugh), 3766 73.2 Lateral Band Mobilization and Skin Release (Nalebuff and Millender), 3766 73.3 Correction of Mild Boutonniere Deformity by Extensor Tenotomy, 3768 73.4 Correction of Moderate Boutonniere Deformity, 3768 73.5 Correction of Severe Boutonniere Deformity, 3768 73.6 Proximal Interphalangeal Joint Volar Plate Interposition Arthroplasty, 3769 73.7 Proximal Interphalangeal Joint Arthroplasty Through a Dorsal Approach (Swanson), 3770 73.8 Proximal Interphalangeal Joint Arthroplasty Through an Anterior (Volar) Approach (Lin, Wyrick, and Stern; Schneider), 3770 73.9 Extensor Tendon Realignment and Intrinsic Rebalancing, 3773 73.10 Metacarpophalangeal Joint Arthroplasty (Swanson), 3774 73.11 Metacarpal Joint Surface Arthroplasty (Beckenbaugh), 3776 73.12 Synovectomy, 3779 73.13 Flexor Tendon Sheath Synovectomy, 3780 73.14 Metacarpophalangeal Joint Arthrodesis (Stern et al.; Segmuller, Modified), 3782 73.15 Proximal Interphalangeal Joint Arthrodesis, 3782 73.16 Thumb Interphalangeal Joint Synovectomy, 3785 73.17 Thumb Metacarpophalangeal Joint Synovectomy, 3785 73.18 Thumb Trapeziometacarpal Joint Synovectomy, 3785 73.19 Interphalangeal Soft-Tissue Reconstruction, 3785 73.20 Metacarpophalangeal Synovectomy with Extensor Tendon Reconstruction, 3786 73.21 Thumb Metacarpophalangeal Joint Reconstruction for Rheumatoid Arthritis (Inglis et al.), 3786 73.22 Metacarpophalangeal Arthroplasty, 3787 73.23 Trapeziometacarpal Ligament Reconstruction (Eaton and Littler), 3789 73.24 Distraction Arthroplasty, 3792 73.25 Tendon Interposition Arthroplasty with Ligament Reconstruction (Burton and Pellegrini), 3793 73.26 Tendon Interposition Arthroplasty with Ligament Reconstruction (Kleinman and Eckenrode), 3794 73.27 Arthroscopic Thumb CMC Arthroplasty (Slutsky), 3796 73.28 Interphalangeal Arthrodesis of the Thumb, 3801 73.29 Metacarpophalangeal Arthrodesis of the Thumb, 3801 73.30 Tension Band Arthrodesis of the Thumb Metacarpophalangeal Joint, 3801 73.31 Thumb Metacarpophalangeal Joint Arthrodesis with Intramedullary Screw Fixation, 3803 73.32 Trapeziometacarpal Arthrodesis (Stark et al.), 3803 73.33 Trapeziometacarpal Arthrodesis (Doyle), 3805

73.34 Thumb Carpometacarpal Arthrodesis with Kirschner Wire or Blade-Plate Fixation (Goldfarb and Stern), 3805 73.35 Dorsal Synovectomy, 3807 73.36 Volar Synovectomy, 3808 73.37 Arthrodesis of the Wrist (Millender and Nalebuff), 3812 Compartment Syndromes and Volkmann Contracture 74.1 Measuring Compartment Pressures in the Forearm and Hand Using a Handheld Monitoring Device (Lipschitz and Lifchez), 3821 74.2 Forearm Fasciotomy and Arterial Exploration, 3822 74.3 Hand Fasciotomies, 3823 74.4 Mini-Open Forearm Fasciotomy (Harrison et al.), 3824 74.5 Excision of Necrotic Muscles Combined with Neurolysis of Median and Ulnar Nerves for Severe Contracture, 3826 74.6 Two-Staged Free Gracilis Transfer (Oishi and Ezaki), 3826 74.7 Release of Established Intrinsic Muscle Contractures of the Hand (Littler), 3828 74.8 Release of Severe Intrinsic Contractures with Muscle Fibrosis (Smith), 3828 Dupuytren Contracture 75.1 Collagenase Injections (Hentz), 3837 75.2 Subcutaneous Fasciotomy (Luck), 3842 75.3 Partial (Selective) Fasciectomy, 3843 Stenosing Tenosynovitis of the Wrist and Hand 76.1 Surgical Treatment of De Quervain Disease, 3851 76.2 Surgical Release of Trigger Finger, 3853 76.3 Percutaneous Release of Trigger Finger, 3854 Compressive Neuropathies of the Hand, Forearm, and Elbow 77.1 “Mini-Palm” Open Carpal Tunnel Release, 3861 77.2 Extended Open Carpal Tunnel Release, 3862 77.3 Endoscopic Carpal Tunnel Release Through a Single Incision (Agee), 3865 77.4 Two-Portal Endoscopic Carpal Tunnel Release (Chow), 3868 77.5 In Situ Decompression of the Ulnar Nerve, 3872 77.6 Endoscopic Cubital Tunnel Release (Cobb), 3873 77.7 Medial Epicondylectomy, 3873 77.8 Transposition of the Ulnar Nerve, 3875 77.9 Approach to the Median Nerve, 3877 77.10 Approach to the Radial Nerve, 3880 Tumors and Tumorous Conditions of the Hand 78.1 Excision of a Dorsal Wrist Ganglion, 3911 78.2 Excision of a Volar Wrist Ganglion, 3912 78.3 Arthroscopic Resection of a Dorsal Wrist Ganglion (Osterman and Raphael; Luchetti et al.), 3912 Hand Infections 79.1 Incision and Drainage of Hand Infection, 3921 79.2 Eponychial Marsupialization (Bednar and Lane; Keyser and Eaton), 3924 79.3 Incision and Drainage of Felons, 3925 79.4 Incision and Drainage of Deep Fascial Space Infection, 3927 79.5 Postoperative Closed Irrigation (Neviaser, Modified), 3929 79.6 Open Drainage, 3930 79.7 Incision and Drainage of Radial and Ulnar Bursae, 3931 79.8 Open Drainage of Septic Finger Joints, 3932 Congenital Anomalies of the Hand 80.1 Metacarpal Lengthening (Kessler et al.), 3946 80.2 Centralization of the Hand Using Transverse Ulnar Incisions (Manske, McCarroll, and Swanson), 3952 80.3 Centralization of the Hand with Removal of the Distal Radial Anlage (Watson, Beebe, and Cruz), 3953 80.4 Centralization of the Hand and Tendon Transfers (Bora et al.), 3956 80.5 Centralization with Transfer of the Flexor Carpi Ulnaris (Bayne and Klug), 3957 80.6 Centralization of the Hand (Buck-Gramcko), 3957 80.7 Triceps Transfer to Restore Elbow Flexion (Menelaus), 3958 80.8 Rotational Osteotomy of the First Metacarpal (Broudy and Smith), 3960 80.9 Excision of an Ulnar Anlage (Flatt), 3961 80.10 Creation of a One-Bone Forearm (Straub), 3961 80.11 Resection of a Dyschondrosteosis Lesion (Vickers and Nielsen), 3963 80.12 Closing Wedge Osteotomy Combined with Darrach Excision of the Distal Ulnar Head (Ranawat, DeFiore, and Straub), 3964

80.13 Dome Osteotomy and Excision of Vickers Ligament (Carter and Ezaki), 3964 80.14 Metacarpal Lengthening (Tajima), 3966 80.15 Lengthening with Distraction Stage I (Cowen and Loftus), 3967 80.16 Lengthening with Distraction Stage II (Cowen and Loftus), 3967 80.17 Callotasis Metacarpal Lengthening (Kato et al.), 3968 80.18 Toe-Phalanx Transplantation, 3968 80.19 Toe-Phalanx Transplantation (Toby et al.), 3968 80.20 Simple Z-Plasty of the Thumb Web, 3970 80.21 Four-Flap Z-Plasty (Broadbent and Woolf, Modified), 3970 80.22 Web Deepening with a Sliding Flap (Brand and Milford), 3972 80.23 Opponensplasty (Manske and McCarroll), 3972 80.24 Ring Sublimis Opponensplasty (Riordan), 3973 80.25 Ring Sublimis Opponensplasty with Ulnar Collateral Ligament Reconstruction (Kozin and Ezaki), 3975 80.26 Abductor Digiti Quinti Opponensplasty (Huber; Littler and Cooley), 3975 80.27 Rerouting of the Flexor Pollicis Longus (Blair and Omer), 3977 80.28 Recession of the Index Finger (Flatt), 3978 80.29 Riordan Pollicization (Riordan), 3979 80.30 Buck-Gramcko Pollicization (Buck-Gramcko), 3980 80.31 Foucher Pollicization (Foucher et al.), 3981 80.32 Correction of Types I and II Bifid Thumbs (Bilhaut-Cloquet), 3986 80.33 Correction of Types III Through VI Bifid Thumbs (Lamb, Marks, and Bayne), 3986 80.34 Reduction Osteotomy (Peimer), 3988 80.35 Excision of the Proximal Ulna, 3990 80.36 Reconstruction of the Hand and Wrist, 3991 80.37 Excision of Extra Digit, 3992 80.38 Open Finger Syndactyly Release (Withey et al., Modified), 3996 80.39 Syndactyly Release with Dorsal Flap (Bauer et al.), 3997 80.40 Syndactyly Release with Matching Volar and Dorsal Proximally Based V-Shaped Flaps (Skoog), 3997 80.41 Tendon Release (Smith), 4001 80.42 Transfer of the Flexor Superficialis Tendon to the Extensor Apparatus (McFarlane et al.), 4001 80.43 Group 2 Clasped Thumb Deformity, 4002 80.44 Group 3 Clasped Thumb Deformity (Neviaser, Modified), 4003 80.45 Reverse Wedge Osteotomy (Carstam and Theander), 4005 80.46 Opening Wedge Osteotomy of the Terminal Phalanx (Carstam and Eiken), 4006 80.47 Cleft Closure (Barsky), 4013 80.48 Simple Closure of Type I and II Cleft Hands (Upton and Taghinia), 4013 80.49 Combined Cleft Closure and Release of Thumb Adduction Contracture (Snow and Littler), 4014 80.50 Cleft Closure and Release of Thumb Adduction Contracture (Miura and Komada), 4015 80.51 Palmar Cleft Closure (Ueba), 4016 80.52 Deepening of Web and Metacarpal Osteotomy, 4016 80.53 Tendon Transfer for Type II Deformities (Flatt), 4017 80.54 Reconstruction of the Hand in Apert Syndrome (Flatt), 4018 80.55 Multiple Z-Plasty Release of a Congenital Ring, 4021 80.56 Release of a Congenital Trigger Thumb, 4022 80.57 Release of a Trigger Finger, 4022 80.58 Debulking (Tsuge), 4025 80.59 Epiphysiodesis, 4025 80.60 Digital Shortening (Barsky), 4025 80.61 Thumb Shortening (Millesi), 4026 The Foot: Surgical Techniques 81.1 Application of a Tourniquet, 4031 81.2 Forefoot Block, 4034 81.3 Ankle Block, 4034 81.4 Popliteal Sciatic Nerve Block (Prone), 4037 81.5 Lateral Popliteal Nerve Block (Grosser), 4038 Disorders of the Hallux 82.1 Modified McBride Bunionectomy, 4049 82.2 Keller Resection Arthroplasty, 4056 82.3 Distal Chevron Metatarsal Osteotomy (Johnson; Corless), 4063 82.4 Modified Chevron Distal Metatarsal Osteotomy, 4065 82.5 Johnson Modified Chevron Osteotomy (Johnson), 4070 82.6 Increased Displacement, Distal Chevron Osteotomy (Murawski and Beskin), 4071

82.7 Chevron-Akin Double Osteotomy (Mitchell and Baxter), 4072 82.8 Chevron Bunionectomy, 4073 82.9 Minimally Invasive Chevron-Akin Osteotomy (Lee et al. and Holme et al.), 4075 82.10 Proximal Crescentic Osteotomy with a Distal Soft-Tissue Procedure (Mann and Coughlin), 4079 82.11 Scarf Osteotomy (Coetzee and Rippstein), 4084 82.12 Ludloff Osteotomy (Chiodo, Schon, and Myerson), 4088 82.13 Proximal Opening Wedge Osteotomy and Distal Chevron Osteotomy (Braito et al.), 4088 82.14 Medial Cuneiform Osteotomy (Riedl; Coughlin), 4089 82.15 Akin Procedure, 4091 82.16 Arthrodesis of the First Metatarsophalangeal Joint with Small Plate Fixation (Mankey and Mann), 4095 82.17 Arthrodesis of the First Metatarsophalangeal Joint with Low-Profile Contoured Dorsal Plate and Compression Screw Fixation (Kumar, Pradhan, and Rosenfeld), 4096 82.18 Truncated Cone Arthrodesis of the First Metatarsophalangeal Joint (Johnson and Alexander), 4098 82.19 Arthrodesis of the First Metatarsocuneiform Articulation (Lapidus Procedure) (Myerson et al.; Sangeorzan and Hansen; Mauldin et al.), 4099 82.20 Arthrodesis of the First Metatarsocuneiform Articulation (Lapidus Procedure) with Plate Fixation (Sorensen, Hyer, Berlet), 4101 82.21 Double First Metatarsal Osteotomies (Peterson and Newman), 4107 82.22 Modified Peterson Procedure (Aronson, Nguyen, and Aronson), 4108 82.23 First Cuneiform Osteotomy (Coughlin), 4110 82.24 First Web Space Dissection, Lateral Release, and Repeat Capsular Imbrication (Hallux Valgus Angle Less Than 30 Degrees and First-Second Intermetatarsal Angle Less Than 15 Degrees), 4113 82.25 Correcting Distal Metatarsal Osteotomy, 4117 82.26 Correction of Malunion of the Chevron Osteotomy, 4118 82.27 Distraction Osteogenesis for Metatarsal Shortening, 4120 82.28 Correction of Uniplanar (Static) Hallux Varus Deformity, 4124 82.29 Distal Metatarsal Osteotomy, Medial Capsular Release without Tendon Transfer, 4124 82.30 Transfer of Extensor Hallucis Longus with Arthrodesis of the Interphalangeal Joint of the Hallux (Johnson and Spiegl), 4126 82.31 Extensor Hallucis Brevis Tenodesis (Myerson and Komenda; Juliano et al.), 4128 82.32 Cheilectomy (Mann, Clanton, and Thompson), 4136 82.33 Distal Oblique Osteotomy for Hallux Rigidus (Voegeli et al.), 4137 82.34 “V” Resection of the First Metatarsophalangeal Joint (Valenti Procedure) (Modified Valenti, Saxena et al.), 4139 82.35 Extension Osteotomy of the Proximal Phalanx (Thomas and Smith), 4139 82.36 Excision of the Sesamoid, 4141 82.37 Fibular Sesamoidectomy: Plantar Approach, 4144 Disorders of Tendons and Fascia and Adolescent and Adult Pes Planus 83.1 Synovectomy with Repair of Incomplete Tears, 4161 83.2 Transfer of Flexor Digitorum Longus or Flexor Hallucis Longus to Tarsal Navicular, 4164 83.3 Repair of Spring Ligament, 4165 83.4 Reconstruction of the Spring Ligament Using the Peroneus Longus (Williams et al.), 4166 83.5 Anterior Calcaneal Osteotomy (Lateral Column Lengthening), 4168 83.6 Step-Cut Calcaneal Lengthening Osteotomy (Z Osteotomy) (Scott and Berlet), 4169 83.7 Medial Calcaneal Displacement Osteotomy, 4171 83.8 Opening Wedge Medial Cuneiform (Cotton) Osteotomy (Hirose and Johnson), 4171 83.9 Isolated Medial Column Arthrodesis (Greisberg et al.), 4175 83.10 Minimally Invasive Deltoid Ligament Reconstruction (Jeng et al.), 4176 83.11 Lateral Column Lengthening and Excision of Accessory Navicular, 4180 83.12 Accessory Navicular Fusion (Malicky et al.), 4181 83.13 Calcaneonavicular Bar Resection, 4184 83.14 Resection of a Middle Facet Tarsal Coalition, 4187 83.15 Calcaneal Osteotomy for Haglund Deformity, 4191 83.16 Debridement of the Tendon for Insertional Achilles Tendon Disease (Mcgarvey et al. Central Splitting Approach), 4191 83.17 Flexor Hallucis Longus Transfer for Chronic Noninsertional Achilles Tendinosis, 4193

83.18 Synovectomy of the Anterior Tibial Tendon, 4196 83.19 Debridement and Repair of the Distal Anterior Tibial Tendon (Grundy et al.), 4196 83.20 Repair of Complete Rupture of the Anterior Tibial Tendon, 4198 83.21 Minimally Invasive Tendon Reconstruction with Semitendinosus Autograft (Michels et al.), 4199 83.22 Synovectomy of the Peroneal Tendons, 4203 83.23 Fibular Groove Deepening and Repair of the Superior Retinaculum (Raikin), 4205 83.24 Repair of Rupture of the Peroneal Tendons, 4207 83.25 Peroneal Tendon Repair-Reconstruction (Sobel and Bohne), 4209 83.26 Debridement of the Peroneus Longus Tendon, Removal of Os Peroneum, and Tenodesis of Peroneus Longus to Peroneus Brevis Tendon, 4211 83.27 Release of the Fibroosseous Tunnel (Hamilton et al.), 4213 83.28 Repair of Flexor Hallucis Tear, 4214 83.29 Plantar Fascia and Nerve Release (Schon; Baxter), 4218 83.30 Two-Portal Endoscopic Plantar Fascia Release (Barrett et al.), 4219 83.31 Single-Portal Endoscopic Plantar Fascia Release (Saxena), 4220 Lesser Toe Abnormalities 84.1 Primary Plantar Plate Repair Through a Dorsal Approach, 4232 84.2 Primary Plantar Plate Repair Through a Dorsal Approach (Coughlin), 4232 84.3 Percutaneous Distal Lesser Toe Osteotomy for Grade 0-I Metatarsophalangeal Joint Instability (Magnan et al.), 4233 84.4 Modified Weil Osteotomy (Klinge et al.), 4235 84.5 Correction of Multiplanar Deformity of the Second Toe with Metatarsophalangeal Release and Extensor Brevis Reconstruction (Ellis et al.), 4236 84.6 Flexor-to-Extensor Transfer, 4238 84.7 Extensor Digitorum Brevis Transfer for Crossover Toe Deformity (Haddad), 4240 84.8 Closing Wedge Osteotomy of the Proximal Phalanx for Correction of Axial Deformity (Kilmartin and O’Kane), 4241 84.9 Correction of Moderate Hammer Toe or Claw Toe Deformity, 4244 84.10 Correction of Severe Deformity, 4246 84.11 Metatarsophalangeal Joint Arthroplasty, 4248 84.12 Shortening Metatarsal (Weil) Osteotomy (Weil), 4249 84.13 Resection Dermodesis, 4253 84.14 Terminal Syme Procedure, 4254 84.15 Proximal Interphalangeal Joint Arthrodesis with an Absorbable Intramedullary Pin (Konkel et al.), 4255 84.16 Hard Corn Treatment, 4257 84.17 Partial Syndactylization for Intractable Interdigital Corn, 4259 84.18 Arthroplasty of the Metatarsophalangeal Joint (Mann and Duvries), 4260 84.19 Dorsal Closing Wedge Osteotomy of the Metatarsals for Intractable Plantar Keratosis, 4261 84.20 Partial Resection of the Lateral Condyle of the Fifth Metatarsal Head, 4264 84.21 Resection of the Fifth Metatarsal Head for Bunionette Deformity, 4266 84.22 Subcapital Oblique Osteotomy for Bunionette Deformity (Cooper and Coughlin), 4267 84.23 Transverse Medial Slide Osteotomy for Bunionette Deformity, 4268 84.24 Oblique Diaphyseal Osteotomy of the Fifth Metatarsal for Severe Splay Foot or Metatarsus Quintus Valgus (Coughlin), 4268 84.25 Chevron Osteotomy of the Fifth Metatarsal for Bunionette Deformity, 4269 84.26 Minimally Invasive Kramer Osteotomy for Bunionette Deformity (Kramer, Lee), 4271 84.27 Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy For Fifth Toe Bunionette Correction (Teoh et al.), 4272 84.28 Dorsal Closing Wedge Osteotomy for Freiberg Disease (Chao et al.), 4273 84.29 Joint Debridement and Metatarsal Head Remodeling for Freiberg Disease, 4274 84.30 Distraction Osteogenesis for Lengthening of the Metatarsal in Brachymetatarsia (Lee et al.), 4276 84.31 One-Stage Metatarsal Interposition Lengthening with Autologous Fibular Graft With Locking Plate Fixation (Waizy et al.), 4277 84.32 Metatarsal Lengthening By Circular External Fixation (Barbier et al.), 4277

Arthritis of the Foot 85.1 Arthrodesis of the First Metatarsophalangeal Joint with Resection of the Lesser Metatarsophalangeal Joints (Thompson and Mann), 4290 85.2 Cone Arthrodesis of the First Metatarsophalangeal Joint, 4292 85.3 Resection of the Lesser Metatarsal Heads Through a Plantar Approach with Arthrodesis of the First Metatarsophalangeal Joint, 4294 85.4 Correction of Flexion Deformities of the Proximal Interphalangeal Joints, 4296 85.5 Midfoot Arthrodesis, 4299 85.6 Subtalar Arthrodesis, 4301 85.7 Arthroscopic Subtalar Arthrodesis, 4303 85.8 Talonavicular Joint Arthrodesis, 4306 85.9 Triple Arthrodesis, 4307 85.10 Isolated Medial Incision for Triple Arthrodesis (Myerson), 4310 Diabetic Foot 86.1 Total Contact Cast Application (McBryde), 4323 86.2 Midfoot Reconstruction with Intramedullary Beaming (Bettin), 4335 Neurogenic Disorders 87.1 Tarsal Tunnel Release, 4347 87.2 Anterior Tarsal Tunnel Release (Mann), 4349 87.3 First Branch of Lateral Plantar Nerve Release and Partial Plantar Fascia Release (Baxter, Pfeffer, Watson, et al.), 4350 87.4 Interdigital Neuroma Excision (Dorsal) (Amis), 4354 87.5 Interdigital Neuroma Excision (Longitudinal Plantar Incision), 4356 87.6 Plantar Fascia Release, 4362 87.7 Tendon Suspension of the First Metatarsal and Interphalangeal Joint Arthrodesis (Jones), 4363 87.8 Extensor Tendon Transfer (Hibbs), 4364 87.9 Combined Proximal First Metatarsal Osteotomy, Plantar Fasciotomy, and Transfer of the Anterior Tibial Tendon (Ward et al.), 4364 87.10 Crescentic Calcaneal Osteotomy (Samilson), 4365 87.11 Crescentic Calcaneal Osteotomy (Dwyer), 4366 87.12 Triplanar Osteotomy and Lateral Ligament Reconstruction (Saxby and Myerson), 4367 87.13 Triplanar Osteotomy and Lateral Ligament Reconstruction (Knupp et al.), 4367 87.14 Plantar Fasciotomies and Closing Wedge Osteotomies (Gould), 4368 87.15 Anterior Tarsal Wedge Osteotomy (Cole), 4370 87.16 V-Osteotomy of the Tarsus (Japas), 4371 87.17 Tarsometatarsal Truncated-Wedge Arthrodesis (Jahss), 4372 87.18 Triple Arthrodesis (Siffert, Forster, and Nachamie), 4374 87.19 Triple Arthrodesis (Lambrinudi), 4375 87.20 Correction of Clawing of the Great and Lesser Toes, 4377 Disorders of Nails 88.1 Technique for Subungual Exostosis (Lokiec et al.), 4386 88.2 Technique for Subungual Exostosis (Multhopp-Stephens and Walling), 4386 88.3 Technique for Subungual and Periungual Fibromas, 4387 88.4 Technique for Glomus Tumor (Horst and Nunley), 4388 88.5 Total Nail Plate Removal, 4394 88.6 Partial Nail Plate Removal, 4395 88.7 Removal of the Nail Edge and Ablation of the Nail Matrix, 4396 88.8 Partial Nail Plate and Matrix Removal (Winograd), 4397 88.9 Nail-F Fold Reduction (Persichetti et al.), 4398 88.10 Partial Nail Fold and Nail Matrix Removal (Watson-Cheyne and Burghard; O’Donoghue; Mogensen), 4401 88.11 Complete Nail Plate and Germinal Matrix Removal (Quenu; Fowler; Zadik), 4402 88.12 Terminal Syme Procedure, 4404 Fractures and Dislocations of the Foot 89.1 Open Reduction of Calcaneal Fracture (Benirschke and Sangeorzan), 4411 89.2 Subtalar Arthrodesis, 4413 89.3 Open Reduction of Calcaneal Fracture: Sinus Tarsi Approach with or without Medial Approach, 4417 89.4 Axial Fixation of Calcaneal Fracture (Essex-Lopresti), 4420 89.5 Percutaneous Reduction and Fixation of Calcaneal Fracture (Rodemund and Mattiassich), 4421 89.6 Lateral Decompression of a Malunited Calcaneal Fracture (Braly, Bishop, and Tullos), 4426 89.7 Subtalar Distraction Bone Block Arthrodesis (Carr et al.), 4429

89.8 Open Reduction of the Talar Neck, 4438 89.9 Onlay Graft Technique Through a Posterior Approach (Johnson), 4443 89.10 Tibiocalcaneal Arthrodesis, 4445 89.11 Tibiotalar Arthrodesis (Blair), 4447 89.12 Open Reduction and Internal Fixation of Fractures of the Lateral Process of the Talus, 4448 89.13 Open Reduction of Subtalar Dislocation, 4453 89.14 Open Reduction and Internal Fixation of Tarsometatarsal (Lisfranc) Fractures, 4467 89.15 Internal Fixation with an Intramedullary Screw (Kavanaugh, Brower, and Mann), 4474 89.16 Open Reduction and Plating of Lesser Metatarsal Stress Fracture, 4475 89.17 Open Reduction of Dislocation of the Interphalangeal Joints of the Hallux, 4477 89.18 Open Reduction of First Metatarsophalangeal Joint Dislocation Using a Midline Medial Approach, 4480 89.19 Plantar Plate Repair (Anderson), 4481

89.20 Sesamoidectomy, 4484 89.21 Bone Grafting of Sesamoid Nonunion (Anders and McBryde), 4484 Sports Injuries of the Ankle 90.1 Repair of Acute Rupture of Ligaments of Distal Tibiofibular Joint, 4503 90.2 Repair of Acute Rupture of Lateral Ligaments (Broström, Gould), 4505 90.3 Lateral Repair of Chronic Instability (Watson-Jones, Modified), 4509 90.4 Lateral Repair of Chronic Instability (Evans), 4509 90.5 Lateral Repair of Chronic Instability (Chrisman-Snook), 4510 90.6 Bone Spur Resection and Anterior Impingement Syndrome (OgilvieHarris), 4515 90.7 Medial Malleolar Osteotomy (Cohen et al.), 4524 90.8 Posteromedial Arthrotomy Through Anteromedial Approach (Thompson and Loomer), 4524 90.9 Approach to Posteromedial Ankle Through Posterior Tibial Tendon Sheath (Bassett et al.), 4525 90.10 Osteochondral Autograft/Allograft Transplantation (Hangody et al.), 4526

Campbell’s

OPERATIVE ORTHOPAEDICS 14TH EDITION

Frederick M. Azar, MD

Professor Department of Orthopaedic Surgery and Biomedical Engineering University of Tennessee–Campbell Clinic Chief of Staff, Campbell Clinic Memphis, Tennessee

James H. Beaty, MD

Harold B. Boyd Professor and Chair Department of Orthopaedic Surgery and Biomedical Engineering University of Tennessee–Campbell Clinic Memphis, Tennessee Editorial Assistance

Kay Daugherty and Linda Jones

Elsevier 1600 John F. Kennedy Blvd. Ste. 1600 Philadelphia, PA 19103-2899 CAMPBELL’S OPERATIVE ORTHOPAEDICS, FOURTEENTH EDITION Copyright © 2021 by Elsevier Inc.

Standard Edition: 978-0-323-67217-7 International Edition: 978-0-323-67218-4

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies, and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Previous editions copyrighted © 2017, 2013, 2008, 2003, 1998, 1992, 1987, 1980, 1971, 1963, 1956, 1949, 1939

Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. The Publisher Library of Congress Control Number: 2019949738

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S. Terry Canale, MD It is with humble appreciation and admiration that we dedicate this edition of Campbell’s Operative Orthopaedics to Dr. S. Terry Canale, who served as editor or co-editor of five editions. He took great pride in this position and worked tirelessly to continue to improve “The Book.” As noted by one of his co-editors, “Terry is probably the only person in the world who has read every word of multiple editions of Campbell’s Operative Orthopaedics.” He considered Campbell’s Operative Orthopaedics an opportunity for worldwide orthopaedic education and made it a priority to ensure that each edition provided valuable and up-to-date information. His commitment to and enthusiasm for this work will continue to influence and inspire every future edition.

Kay C. Daugherty It is with equal appreciation and regard that we dedicate this edition to Kay C. Daugherty, the managing editor of the last nine editions Campbell’s Operative Orthopaedics. Over the last 40 years, she has faithfully and tirelessly edited, reshaped, and overseen all aspects of publication from manuscript preparation to proofing. She has a profound talent to put ideas and disjointed words into comprehensible text, ensuring that each revision maintains the gold standard in readability. Each edition is a testament to her dedication to excellence in writing and education. A favorite quote of Mrs. Daugherty to one of our late authors was, “I’ll make a deal. I won’t operate if you won’t punctuate.” We are grateful for her many years of continual service to the Campbell Foundation and for the publications yet to come.

CONTRIBUTORS

FREDERICK M. AZAR, MD Professor Director, Sports Medicine Fellowship University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Chief-of-Staff, Campbell Clinic Memphis, Tennessee JAMES H. BEATY, MD Harold B. Boyd Professor and Chair University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee MICHAEL J. BEEBE, MD Instructor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee CLAYTON C. BETTIN, MD Assistant Professor Director, Foot and Ankle Fellowship Associate Residency Program Director University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee TYLER J. BROLIN, MD Assistant Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee JAMES H. CALANDRUCCIO, MD Associate Professor Director, Hand Fellowship University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee DAVID L. CANNON, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee KEVIN B. CLEVELAND, MD Instructor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

ANDREW H. CRENSHAW JR., MD Professor Emeritus University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

ROBERT K. HECK JR., MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

JOHN R. CROCKARELL, MD Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

MARK T. JOBE, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

GREGORY D. DABOV, MD Assistant Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

DEREK M. KELLY, MD Professor Director, Pediatric Orthopaedic Fellowship Director, Resident Education University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

MARCUS C. FORD, MD Instructor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee RAYMOND J. GARDOCKI, MD Assistant Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee BENJAMIN J. GREAR, MD Instructor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee JAMES L. GUYTON, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee JAMES W. HARKESS, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

SANTOS F. MARTINEZ, MD Assistant Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee ANTHONY A. MASCIOLI, MD Assistant Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee BENJAMIN M. MAUCK, MD Assistant Professor Director, Hand Fellowship University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee MARC J. MIHALKO, MD Assistant Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee WILLIAM M. MIHALKO, MD PhD Professor, H.R. Hyde Chair of Excellence in Rehabilitation Engineering Director, Biomedical Engineering University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

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viii  CONTRIBUTORS

ROBERT H. MILLER III, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee G. ANDREW MURPHY, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee ASHLEY L. PARK, MD Clinical Assistant Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee EDWARD A. PEREZ, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee BARRY B. PHILLIPS, MD Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee DAVID R. RICHARDSON, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee MATTHEW I. RUDLOFF, MD Assistant Professor Co-Director, Trauma Fellowship University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

JEFFREY R. SAWYER, MD Professor Co-Director, Pediatric Orthopaedic Fellowship University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee BENJAMIN W. SHEFFER, MD Assistant Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee DAVID D. SPENCE, MD Assistant Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee NORFLEET B. THOMPSON, MD Instructor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee THOMAS W. THROCKMORTON, MD Professor Co-Director, Sports Medicine Fellowship University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee PATRICK C. TOY, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

WILLIAM C. WARNER JR., MD Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee JOHN C. WEINLEIN, MD Assistant Professor Director, Trauma Fellowship University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee WILLIAM J. WELLER, MD Instructor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee A. PAIGE WHITTLE, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee KEITH D. WILLIAMS, MD Associate Professor University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee DEXTER H. WITTE III, MD Clinical Assistant Professor in Radiology University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering Memphis, Tennessee

PREFACE

W

hen Dr. Willis Campbell published the first edition of Campbell’s Operative Orthopaedics in 1939, he could not have envisioned that over 80 years later it would have evolved into a four-volume text and earned the accolade of the “bible of orthopaedics” as a mainstay in orthopaedic practices and educational institutions all over the world. This expansion from some 400 pages in the first edition to over 4,500 pages in this 14th edition has not changed Dr. Campbell’s original intent: “to present to the student, the general practitioner, and the surgeon the subject of orthopaedic surgery in a simple and comprehensive manner.” In each edition since the first, authors and editors have worked diligently to fulfill these objectives. This would have not been possible without the hard work of our contributors who always strive to present the most up-to-date information while retaining “tried and true” techniques and tips. The scope of this text continues to expand in the hope that the information will be relevant to physicians no matter their location or resources. As always, this edition also is the result of the collaboration of a group of “behind the scenes” individuals who are involved in the actual production process. The Campbell Foundation staff—Kay Daugherty, Linda Jones, and Tonya Priggel—contributed their considerable talents to editing often confusing and complex author contributions, searching the literature for obscure references, and, in general, “herding

the cats.” Special thanks to Kay and Linda who have worked on multiple editions of Campbell’s Operative Orthopaedics (nine editions for Kay and six for Linda). They probably know more about orthopaedics than most of us, and they certainly know how to make it more understandable. Thanks, too, to the Elsevier personnel who provided guidance and assistance throughout the publication process: John Casey, Senior Project Manager; Jennifer Ehlers, Senior Content Development Specialist; and Belinda Kuhn, Senior Content Strategist. We are especially appreciative of our spouses, Julie Azar and Terry Beaty, and our families for their patience and support as we worked through this project. The preparation and publication of this 14th edition was fraught with difficulties because of the worldwide pandemic and social unrest, but our contributors and other personnel worked tirelessly, often in creative and innovative ways, to bring it to fruition. It is our hope that these efforts have provided a text that is informative and valuable to all orthopaedists as they continue to refine and improve methods that will ensure the best outcomes for their patients. Frederick M. Azar, MD James H. Beaty, MD

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1

SURGICAL TECHNIQUES Andrew H. Crenshaw Jr.

SURGICAL TECHNIQUES 1 1 TOURNIQUETS RADIOGRAPHS IN THE OPERATING ROOM 5 PREVENTING MISTAKES 6 POSITIONING OF THE PATIENT 6 LOCAL PREPARATION OF 7 THE PATIENT 9 Wound irrigating solutions 9 DRAPING 9 Draping the edges of the incision PREVENTION OF HUMAN IMMUNODEFICIENCY VIRUS AND HEPATITIS VIRUS TRANSMISSION 10 REVERSING PROPHYLACTIC ANTICOAGULATION PRIOR TO SURGERY 10 BLOOD LOSS CONTROL 10 DURING SURGERY VENOUS THROMBOEMBOLISM 11 PROPHYLAXIS POSTOPERATIVE PAIN CONTROL 11 SPECIAL OPERATIVE TECHNIQUES METHODS OF TENDONTO-BONE FIXATION Suture anchors Suture buttons BONE GRAFTING Structure of bone grafts Sources of bone grafts Autogenous grafts Allogenic grafts Bone bank Cancellous bone graft substitutes

14 14 17 18 18 19 19 19 19 19 20

Indications for various bone graft techniques Onlay cortical grafts Inlay grafts Multiple cancellous chip grafts Hemicylindrical grafts Whole-bone transplant Conditions favorable for bone grafting Preparation of bone grafts  Cancellous iliac crest bone grafts SURGICAL APPROACHES TOES  Approaches to the metatarsophalangeal joint of the great toe Calcaneus TARSUS AND ANKLE Anterior approaches  Lateral approaches to the tarsus and ankle  Medial approaches  TIBIA Tibial plateau approaches FIBULA  KNEE Anteromedial and anterolateral approaches  Posterolateral and posteromedial approaches to the knee Medial approaches to the knee and supporting structures Lateral approaches to the knee and supporting structures Direct posterior, posteromedial, and posterolateral approaches to the knee FEMUR 

SURGICAL TECHNIQUES There are several surgical techniques especially important in orthopaedics: use of tourniquets, use of radiographs and image intensifiers in the operating room, positioning of the patient, local preparation of the patient, and draping of the appropriate part or parts. Operative techniques common to

22 22 22 22 22 22 22 22 25 27 28

28 29 32 32 34 37 38 39 46 47 47 49 52 55

58 62

69 HIP 69 Anterior approaches to the hip  73 Lateral approaches to the hip  Posterior approaches to the hip 80 Medial approach to the hip 83 84 ACETABULUM AND PELVIS Anterior approaches to the 87 acetabulum  Posterior approaches to the acetabulum 91 Extensile acetabular approaches 93 99 ILIUM  SYMPHYSIS PUBIS  100 SACROILIAC JOINT  102 104 SPINE STERNOCLAVICULAR JOINT 104 ACROMIOCLAVICULAR JOINT AND CORACOID PROCESS  104 SHOULDER 105 Anteromedial approaches to the shoulder 105 Anterior axillary approach to the shoulder  106 Anterolateral approaches to the shoulder  106 Posterior approaches to the shoulder 109 HUMERUS 114 Approaches to the distal humeral shaft 118 ELBOW 120 Posterior approaches to the elbow  120 124 Lateral approaches  130 RADIUS  135 ULNA  WRIST 137 Dorsal approaches to the wrist  137 HAND 139

many procedures, fixation of tendons or fascia to bone, and bone grafting also are described. 

TOURNIQUETS Operations on the extremities are made easier using a tourniquet. The tourniquet is a potentially dangerous instrument

2

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CHAPTER 1  SURGICAL TECHNIQUES that must be used with proper knowledge and care. In some procedures, a tourniquet is a luxury, whereas in others, such as delicate operations on the hand, it is a necessity. A pneumatic tourniquet is safer than an Esmarch tourniquet or a Martin sheet rubber bandage. A pneumatic tourniquet with a hand pump and an accurate pressure gauge probably is the safest, but a constantly regulated pressure tourniquet is satisfactory if it is properly maintained and checked. A tourniquet should be applied by an individual experienced in its use. Several sizes of pneumatic tourniquets are available for the upper and lower extremities. The upper arm or the thigh is wrapped with several thicknesses of smoothly applied cast padding. Rajpura et al. showed that application of more than two layers of padding resulted in a significant reduction in the actual transmitted pressure. When applying a tourniquet on an obese patient, an assistant manually grasps the flesh of the extremity just distal to the level of tourniquet application and firmly pulls this loose tissue distally before the cast padding is placed. Traction on the soft tissue is maintained while the padding and tourniquet are applied, and the latter is secured. The assistant’s grasp is released, resulting in a greater proportion of the subcutaneous tissue remaining distal to the tourniquet. This bulky tissue tends to support the tourniquet and push it into an even more proximal position. All air is expressed from the sphygmomanometer or pneumatic tourniquet before application. When a sphygmomanometer cuff is used, it should be wrapped with a gauze bandage to prevent its slipping during inflation. The extremity is elevated for 2 minutes, or the blood is expressed by a sterile sheet rubber bandage or a cotton elastic bandage. Beginning at the fingertips or toes, the extremity is wrapped proximally to within 2.5 to 5 cm of the tourniquet. If a Martin sheet rubber bandage or an elastic bandage is applied up to the level of the tourniquet, the latter tends to slip distally at the time of inflation. The tourniquet should be inflated quickly to prevent filling of the superficial veins before the arterial blood flow has been occluded. Every effort is made to decrease tourniquet time; the extremity often is prepared and ready before the

tourniquet is inflated. The conical, obese, or muscular lower extremity presents a special challenge. If a curved tourniquet is not available, a straight tourniquet may be used but is difficult to hold in place because it tends to slide distally during skin preparation. Application of adhesive drapes, extra cast padding, and pulling the fat tissue distally before applying the tourniquet generally works. A simple method has been described to keep a tourniquet in place on a large thigh. Surgical lubricating jelly is applied circumferentially to the thigh, and several layers of 6-inch cast padding are applied over the jelly. The tourniquet is then applied. The cast padding adheres to the lubricating jelly-covered skin and reduces the tendency of the tourniquet to slide. If surgery is significantly delayed, both lower extremities should be studied with Doppler ultrasonography for the presence of deep venous thrombi. If present, the patient should receive full anticoagulation treatment and the procedure delayed. If the procedure is emergent, insertion of an inferior vena cava filter should be considered. There have been case reports describing fatal or near fatal pulmonary emboli after exsanguination of a leg. The exact pressure to which the tourniquet should be inflated has not been determined (Table 1.1). The correct pressure depends on the age of the patient, the blood pressure, and the size of the extremity. Reid et al. used pneumatic tourniquet pressures determined by the pressure required to obliterate the peripheral pulse (limb occlusion pressure) using a Doppler stethoscope; they then added 50 to 75 mm Hg to allow for collateral circulation and blood pressure changes. Tourniquet pressures of 135 to 255 mm Hg for the upper extremity and 175 to 305 mm Hg for the lower extremity were satisfactory for maintaining hemostasis. Wide tourniquet cuffs are more effective at lower inflation pressures than are narrow ones. Curved tourniquets on conical extremities require significantly lower arterial occlusion pressures than straight (rectangular) tourniquets (Fig. 1.1). The use of straight tourniquets on conical thighs should be avoided, especially in extremely muscular or obese individuals.

TABLE 1.1

Published Recommendations on Tourniquet Use ORGANIZATION/STUDY Association of Surgical Technologists Association of Perioperative Registered Nurses Wakai et al.

Kam et al.

Noordin et al.

PRESSURE Upper extremity, 50 mm Hg above SBP; lower extremity, 100 mm Hg above SBP 40 mm Hg above LOP for LOP 3 h

120

10 min at the 2-h point for surgery lasting 3 mm FIGURE 1.15 Methyl methacrylate suture anchor. Figure-ofeight knot increases load to failure.

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A

B

FIGURE 1.18 Arthrex low-profile bridge staple. (Courtesy Arthrex, Naples, FL.) SEE TECHNIQUE 1.5.

C

FIGURE 1.16 Fixation of osseous attachment of tendon to bone. A, Fixation by screw or threaded pins. B, Fixation by mattress suture of wire through holes drilled in bone. C, Fixation by wire loops. SEE TECHNIQUE 1.5.

FIGURE 1.17 Stone table staple, used most frequently for anchoring tendinous tissue to bone. SEE TECHNIQUE 1.5.

SUTURE BUTTONS

Suture-button devices are now available for minimally invasive tendon-to-bone, ligament-to-bone, and fracture fixation. The Endobutton (Smith and Nephew, York, UK) and the TightRope Fixation System (Arthrex, Naples, Florida) can be inserted through a single incision and drill hole. These devices have been successfully used in acromioclavicular joint dislocations, Neer II distal clavicular fractures, ankle syndesmosis disruptions, and high-energy os calcis fractures with compromised skin (Fig. 1.19). 

FIGURE 1.19 TightRope Syndesmosis Buttress Plate Kit (Arthrex, Naples, FL). One suture strand is used to “flip” the medial button so a second incision is unnecessary.

Bridge joints to perform arthrodesis Bridge major defects or re-establish the continuity of a long bone n Provide bone blocks to limit joint motion (arthroereisis) n Establish union of a pseudarthrosis n Promote union or fill defects in delayed union, malunion, fresh fractures, or osteotomies n  n 

BONE GRAFTING The indications for bone grafting are to: n Fill cavities or defects resulting from cysts, tumors, or other causes

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STRUCTURE OF BONE GRAFTS

Cortical bone grafts are used primarily for structural support, and cancellous bone grafts are used for osteogenesis. Structural support and osteogenesis may be combined; this is one of the prime advantages of using bone graft. These two factors vary, however, with the structure of the bone. Probably all or most of the cellular elements in grafts (particularly cortical grafts) die and are slowly replaced by creeping substitution, the graft merely acting as a scaffold for the formation of new bone. In hard cortical bone, this process of replacement is considerably slower than in cancellous bone. Although cancellous bone is more osteogenic, it is not strong enough to provide efficient structural support. When selecting the graft or combination of grafts, the surgeon must be aware of these two fundamental differences in bone structure. When a graft has united with the host and is strong enough to permit unprotected use of the part, remodeling of the bone structure takes place commensurate with functional demands. 

SOURCES OF BONE GRAFTS AUTOGENOUS GRAFTS

When the bone grafts come from the patient, the grafts usually are removed from the tibia, fibula, or ilium. These three bones provide cortical grafts, whole-bone transplants, and cancellous bone. When internal or external fixation appliances are not used, which is currently rare, strength is necessary in a graft used for bridging a defect in a long bone or even for the treatment of pseudarthrosis. The subcutaneous anteromedial aspect of the tibia is an excellent source for structural autografts. In adults, after removal of a cortical graft, the plateau of the tibia supplies cancellous bone. Apparently, leaving the periosteum attached to the graft has no advantage; however, suturing to the periosteum over the defect has definite advantages. The periosteum seems to serve as a limiting membrane to prevent irregular callus when the defect in the tibia fills in with new bone. The few bone cells that are stripped off with the periosteum can help in the formation of bone needed to fill the defect. Disadvantages to the use of the tibia as a donor area include (1) a normal limb is jeopardized; (2) the duration and magnitude of the procedure are increased; (3) ambulation must be delayed until the defect in the tibia has partially healed; and (4) the tibia must be protected for 6 to 12 months to prevent fractures. For these reasons, structural autografts from the tibia are now rarely used. A good source for bulk cancellous autogenous graft is material from a reamer-irrigator-aspirator (RIA) used in the canal of the femoral and tibial shafts. A complication rate of less than 2% has been reported in approximately 200 patients with a mean volume harvested of 47 ± 22 mL. Debris harvested during RIA and bone graft harvested from iliac crest have similar RNA transcriptional profiles for genes that act in bone repair and formation, suggesting that material harvested by RIA is a viable alternative to iliac crest autogenous cancellous graft. Marchand et  al. compared 61 patients who had a graft harvested by RIA with 47 patients who had a graft harvested from the iliac crest and found that 44% of the patients undergoing RIA bone graft harvest required transfusion. Only 21% of the group with graft harvested from the iliac crest required transfusion.

The entire proximal two thirds of the fibula can be removed without disabling the leg. Most patients have complaints and mild muscular weakness after removal of a portion of the fibula. The configuration of the proximal end of the fibula is an advantage. The proximal end has a rounded prominence that is partially covered by hyaline cartilage and forms a satisfactory transplant to replace the distal third of the radius or the distal third of the fibula. After transplantation, the hyaline cartilage probably degenerates rapidly into a fibrocartilaginous surface; even so, this surface is preferable to raw bone. The middle one third of the fibula also can be used as a vascularized free autograft based on the peroneal artery and vein pedicle using microvascular technique. Portions of the iliac crest also can be used as free vascularized autograft. The use of free vascularized autografts has limited indications, requires expert microvascular technique, and is not without donor site morbidity particularly at the ankle. The management of segmental bone loss can be difficult. Taylor et  al. described a two-stage induced membrane technique using a methyl methacrylate spacer. The spacer is placed into the defect to induce the formation of a bioactive membrane. Four to 8 weeks later the spacer is removed and cancellous autograft is placed in the now membrane surrounded defect. The membrane helps prevent graft resorption, promote revascularization, and consolidation of new bone. We have had good results with this technique. 

ALLOGENIC GRAFTS

An allogenic graft, or allograft, is one that is obtained from an individual other than the patient. In small children, the usual donor sites do not provide cortical grafts large enough to bridge defects or the available cancellous bone may not be enough to fill a large cavity or cyst; the possibility of injuring a physis also must be considered. Allograft is preferred in this situation. Allografts are also indicated in the elderly, patients who are poor operative risks, and patients from whom not enough acceptable autogenous bone can be harvested. Larger structural allografts have been used successfully for many years in revision total joint surgery, periprosthetic long bone fractures, and reconstruction after tumor excision. Osteochondral allografts are now being used with some success in a few centers to treat distal femoral osteonecrosis. Large osteochondral allografts, such as the distal femur, are used in limb salvage procedures after tumor resection. Autogenous cancellous bone can be mixed in small amounts with allograft bone as “seed” to provide osteogenic potential. Mixed bone grafts of this type incorporate more rapidly than allograft bone alone. Increased allograft union rates and less resorption have been noted in large acetabular defects when allografts were loaded with bone marrow derived mesenchymal stem cells. The various properties of autogenous and allogenic bone grafts are summarized in Table 1.5. 

BONE BANK

To provide safe and useful allograft material efficiently, a bone banking system is required that uses thorough donor screening, rapid procurement, and safe, sterile processing. Standards outlined by the U.S. Food and Drug Administration (FDA) and American Association of Tissue Banks must be followed. Donors must be screened for bacterial, viral (including HIV and hepatitis), and fungal infections. Malignancy (except basal cell carcinoma of the skin), collagen vascular

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TABLE 1.5

Bone Graft Activity by Type GRAFT

OSTEOGENESIS

OSTEOCONDUCTION

OSTEOINDUCTION

MECHANICAL PROPERTIES

VASCULARITY

++ ++ + ++

± ++ + ++

+ + ± +

− + ++ ++

− − − ++

− − −

++ ± ++

+ ± +++

+ ++ −

− − −

AUTOGRAFT Bone marrow Cancellous Cortical Vascularized ALLOGRAFT Cancellous Cortical Demineralized

From Kahn SN, et al: The biology of bone grafting, J Am Acad Orthop Surg 13:80, 2005.

disease, metabolic bone disease, and the presence of toxins are all contraindications to donation. No system is perfect, and the transmission of disease by allograft material has been reported from single donors to multiple recipients. Bone and ligament and bone and tendon are now banked for use as allografts. The use of allograft ligaments and tendons in knee surgery is discussed in Chapter 45. Bone can be stored and sterilized in several forms. It can be harvested in a clean, nonsterile environment; sterilized by irradiation, strong acid, or ethylene oxide; and freeze-dried for storage. Bone under sterile conditions can be deep frozen (−70°C to −80°C) for storage. Fresh frozen bone is stronger than freeze-dried bone and better as structural allograft material. Articular cartilage and menisci also can be cryopreserved in this manner. Cancellous allografts incorporate to host bone, as do autogenous cancellous grafts. These allografts are mineralized and are not osteoinductive, although they are osteoconductive. Cancellous allografts can be obtained in a demineralized form that increases osteogenic potential but greatly decreases resistance to compressive forces. Cortical allografts are invaded by host blood vessels and substituted slowly with new host bone to a limited degree, especially in massive allografts. This probably accounts for the high incidence of fracture in these grafts because dead bone cannot remodel in response to cyclic loading and then fails. 

CANCELLOUS BONE GRAFT SUBSTITUTES

Interest in bone graft substitutes has mushroomed in recent years. Dozens of products are in general use or in clinical trials. To understand better the properties of these products, the following bone synthesis processes need to be understood (see Table 1.5). Graft osteogenesis is the ability of cellular elements within a graft that survive transplantation to synthesize new bone. Graft osteoinduction is the ability of a graft to recruit host mesenchymal stem cells into the graft that differentiate into osteoblasts. Bone morphogenetic proteins and other growth factors in the graft facilitate this process. Graft osteoconduction is the ability of a graft to facilitate blood vessel ingrowth and bone formation into a scaffold structure. Bone graft substitutes can replace autologous or allogenic grafts or expand an existing amount of available graft material. Autologous cancellous and cortical grafts are still the “gold standards” against which all other graft forms are judged. Bone



TABLE 1.6

Classification of Bone Graft Substitutes PROPERTY Osteoconduction

Osteoinduction

Osteogenesis

Combined

DESCRIPTION Provides a passive porous scaffold to support or direct bone formation

CLASSES Calcium sulfate, ceramics, calcium phosphate cements, collagen, bioactive glass, synthetic polymers Induces differentia- Demineralized tion of stem cells bone matrix, bone into osteogenic morphogenic cells proteins, growth factors, gene therapy Provides stem cells Bone marrow aspirate with osteogenic potential, which directly lays down new bone Provides more Composites than one of the above mentioned properties

From Parikh SN: Bone graft substitutes in modern orthopedics, Orthopedics 25:1301, 2002.

graft substitutes are classified based on properties outlined in Table 1.6. FDA-approved applications for these products are variable and ever changing. Table 1.7 lists bone graft substitutes that are FDA approved with published, peer-reviewed, level I or II human studies as burden of proof. Surgeons must carefully review the manufacturers’ stated indications and directions for use. For more in-depth discussions of the biologic events in bone graft incorporation, see the reviews by Khan et al. and Gardiner and Weitzel. The Orthopaedic Trauma Association Orthobiologics Committee (DeLong et al.) reported a review of the literature on bone grafts and bone graft substitutes and provided recommendations to the orthopaedic community based on levels of evidence. Kurien et  al. reviewed 59 bone

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TABLE 1.7

Commercially Available FDA-Approved Bone Graft Substitutes With Peer-Reviewed Published Level I-II Human Studies as Burden of Proof (2010) PRODUCT HEALOS DePuy Spine

Vitoss Orthovita

NovaBone NovaBone/MTF GRAFTON A-FLEX, Flex, Matrix Scoliosis Strips, Putty Osteotech GRAFTON Crunch Orthoblend Large Defect Orthoblend Small Defect Osteotech GRAFTON Gel Osteotech GRAFTON Plus Paste Osteotech

COMPOSITION AND MECHANISM OF ACTION Mineralized collagen matrix in strips of varying sizes Mechanisms of action: osteoinduction/conduction, creeping substitution, osteogenesis when mixed with autogenous bone graft 100% beta TCP; 80% beta TCP/20% collagen; 70% beta TCP/20% collagen/10% bioactive glass as putty, strip, flow, morsels, or shapes Mechanism of action: osteoconduction/bioresorbable, bioactive, osteostimulation, osteogenesis, and osteoinduction when mixed with bone marrow aspirate Bioactive silicate in particulate or putty or morsel form Mechanism of action: osteoconduction, bioresorbable, osteostimulation DBM fiber technology in flexible sheets of varying shapes and sizes or moldable or packable graft Mechanism of action: osteoinduction/conduction, incorporation, osteogenesis when mixed with autogenous bone graft or bone marrow aspirate DBM fibers with demineralized cortical cubes or crushed cancellous chips as packable or moldable graft Mechanism of action: osteoinduction/conduction, incorporation, osteogenesis when mixed with autogenous bone graft or bone marrow aspirate DBM in a syringe for MIS and percutaneous injectable graft Mechanism of action: osteoinduction/conduction, incorporation, osteogenesis when mixed with autogenous bone graft or bone marrow aspirate DBM in a syringe for MIS injectable graft that resists irrigation Mechanism of action: osteoinduction/conduction, incorporation, osteogenesis when mixed with autogenous bone graft or bone marrow aspirate

FDA STATUS Cleared as bone filler but must be used with autogenous bone marrow Cleared as bone void filler

Cleared as a bone void filler

Cleared as bone graft substitute, bone graft extender, and bone void filler

Cleared as bone graft substitute, bone graft extender, and bone void filler

Cleared as bone graft substitute, bone graft extender, and bone void filler Cleared as bone graft substitute, bone graft extender, and bone void filler

DBM, Demineralized bone matrix; MIS, minimally invasive surgery; TCP, tricalcium phosphate.

graft substitutes available for use in the United Kingdom, only 22 of which had peer-reviewed published clinical literature. They questioned the need for so many products and called for more prospective randomized trials. They also provided a good review of uses of various bone graft substitutes. Bone graft substitutes are not without complications, however. Recombinant human bone morphogenic protein-2 (rh BMP-2) has been associated with an increased cancer risk. Data from a randomized trial involving over 500 patients who had spine fusion with single-level lumbar fusion using rh BMP-2 in a compression-resistant material showed a significant increase of cancer events in the rh BMP-2 group. A 16% complication rate involving soft-tissue inflammation also was noted in another study of 31 patients after the use of tricalcium phosphate and calcium sulfate. An increased risk for retrograde ejaculation also has been reported after anterior lumbar interbody fusion using rh BMP-2. The use of bone graft substitutes containing recombinant proteins or synthetic peptides in younger patients with developing skeletons has not been approved by the U.S. FDA. The extra stimulation for bone growth can lead to injury. The

agency has received reports of fluid accumulation, excessive bone growth, delayed bone healing, and swelling from the offlabel use of these products in juveniles. The use of stem cells in bone graft substitutes is considered investigational. The FDA has recently stated: “A major challenge posed by SC [stem cell] therapy is the need to ensure their efficacy and safety. Cells manufactured in large quantities outside their natural environment in the human body can become ineffective or dangerous and produce significant adverse effects, such as tumors, severe immune reactions, or growth of unwanted tissue.” Demineralized bone matrix (DBM) is considered minimally processed allograft tissue and, therefore, does not require approval from the FDA for use. The use of mesenchymal stem-cell (autograft or allograft) therapy alone or in combination with bone graft substitutes is considered investigational. There is controversy as to whether or not the combination of DBM plus stem cells constitutes a minimally processed tissue. Some believe that since these products require the metabolic activity of living cells, they should be considered biologic products and, therefore, be required to

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PART I  GENERAL PRINCIPLES demonstrate safety and efficacy and be considered investigational drugs that require a biologic application license. 

INDICATIONS FOR VARIOUS BONE GRAFT TECHNIQUES ONLAY CORTICAL GRAFTS

Until relatively inert metals became available, the onlay bone graft (see Chapter 59) was the simplest and most effective treatment for most ununited diaphyseal fractures. Usually the cortical graft was supplemented by cancellous bone for osteogenesis. The onlay graft is applicable to a limited group of fresh, malunited, and ununited fractures and after osteotomies. Cortical grafts also are used when bridging joints to produce arthrodesis, not only for osteogenesis but also for fixation. Fixation as a rule is best furnished by internal or external metallic devices. Only in an extremely unusual situation would a cortical onlay graft be indicated for fixation, and then only in small bones and when little stress is expected. For osteogenesis, the thick cortical graft has largely been replaced by thin cortical and cancellous bone from the ilium. Dual onlay bone grafts are useful when treating difficult and unusual nonunions or for bridging massive defects (see Chapter 59). The treatment of a nonunion near a joint is difficult because the fragment nearest the joint is usually small, osteoporotic, and largely cancellous, having only a thin cortex. It often is so small and soft that fixation with a single graft is impossible because screws tend to pull out of it and wire sutures cut through it. Dual grafts provide stability because they grip the small fragment-like forceps. The advantages of dual grafts for bridging defects are as follows: (1) mechanical fixation is better than fixation by a single onlay bone graft; (2) the two grafts add strength and stability; (3) the grafts form a trough into which cancellous bone may be packed; and (4) during healing, the dual grafts, in contrast to a single graft, prevent contracting fibrous tissue from compromising transplanted cancellous bone. A whole fibular graft usually is better than dual grafts for bridging defects in the upper extremity except when the bone is osteoporotic or when the nonunion is near a joint. The disadvantages of dual grafts are the same as those of single cortical grafts: (1) they are not as strong as metallic fixation devices; (2) an extremity usually must serve as a donor site if autogenous grafts are used; and (3) they are not as osteogenic as autogenous iliac grafts, and the surgery necessary to obtain them has more risk. 

INLAY GRAFTS

By the inlay technique, a slot or rectangular defect is created in the cortex of the host bone, usually with a power saw. A graft the same size or slightly smaller is fitted into the defect. In the treatment of diaphyseal nonunions, the onlay technique is simpler and more efficient and has almost replaced the inlay graft. The latter still is occasionally used in arthro­ desis, particularly at the ankle (see Chapter 11). 

MULTIPLE CANCELLOUS CHIP GRAFTS

Multiple chips of cancellous bone are widely used for grafting. Segments of cancellous bone are the best osteogenic material available. They are particularly useful for filling cavities or defects resulting from cysts, tumors, or other causes; for establishing bone blocks; and for wedging in osteotomies. Being soft and friable, this bone can be packed into any nook

or crevice. The ilium is a good source of cancellous bone; and if some rigidity and strength are desired, the cortical elements may be retained. In most bone grafting procedures that use cortical bone or metallic devices for fixation, supplementary cancellous bone chips or strips are used to hasten healing. Cancellous grafts are particularly applicable to arthrodesis of the spine because osteogenesis is the prime concern. Iliac crest cancellous grafts can be easily harvested from the anterior crest, using an acetabular reamer as described by Dick with excellent results and no graft-related complications as reported by Brawley and Simpson. Large-volume cancellous bone grafts can be harvested from the femoral canal using a RIA as described by Newman et al. 

HEMICYLINDRICAL GRAFTS

Hemicylindrical grafts are suitable for obliterating large defects of the tibia and femur. A massive hemicylindrical cortical graft from the affected bone is placed across the defect and is supplemented by cancellous iliac bone. A procedure of this magnitude has only limited use, but it is applicable for resection of bone tumors when amputation is to be avoided. 

WHOLE-BONE TRANSPLANT

The fibula provides the most practical graft for bridging long defects in the diaphyseal portion of bones of the upper extremity, unless the nonunion is near a joint. A fibular graft is stronger than a full-thickness tibial graft. When soft tissue is scant, a wound that cannot be closed over dual grafts can be closed over a fibular graft. Disability after removing a fibular graft is less than after removing a larger tibial graft. In children, the fibula can be used to span a long gap in the tibia, usually by a two-stage procedure (see Chapter 59). The shape of the proximal end of the fibula makes it a satisfactory substitute for the distal end of the fibula or distal end of the radius. A free vascularized fibular autograft has greater osteogenic potential for incorporation but is technically much more demanding to use. Bone transplants consisting of whole segments of the tibia or femur, usually freeze dried or fresh frozen, are available. Their greatest use is in the treatment of defects of the long bones produced by massive resections for bone tumors or complex total joint revisions (see Chapter 59). 

CONDITIONS FAVORABLE FOR BONE GRAFTING

For a bone grafting procedure to be successful, patient factors, such as patient overall condition and recipient site preparation, must be optimal, as outlined in Table 1.8.

PREPARATION OF BONE GRAFTS   

REMOVAL OF A TIBIAL GRAFT   TECHNIQUE 1.6 To avoid excessive loss of blood, use a tourniquet (preferably pneumatic) when the tibial graft is removed. After removal of the graft, the tourniquet may be released without disturbing the sterile drapes.

n 

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CHAPTER 1  SURGICAL TECHNIQUES TABLE 1.8



Local and Systemic Factors Influencing Graft Incorporation POSITIVE FACTORS

NEGATIVE FACTORS

LOCAL

LOCAL

Electrical stimulation Good vascular supply at the graft site Growth factors Large surface area Mechanical loading Mechanical stability SYSTEMIC Growth hormone Insulin Parathyroid hormone Somatomedins Thyroid hormone Vitamins A and D

Tibial tuberosity

Denervation Infection Local bone disease Radiation Tumor mechanical instability

SYSTEMIC Chemotherapy Corticosteroids Diabetes Malnutrition Metabolic bone disease Nonsteroidal antiinflammatory drugs Sepsis Smoking

Make a slightly curved longitudinal incision over the anteromedial surface of the tibia, placing it to prevent a painful scar over the crest. n  Without reflecting the skin, incise the periosteum to the bone. n  With a periosteal elevator, reflect the periosteum, medially and laterally, exposing the entire surface of the tibia between the crest and the medial border. For better exposure at each end of the longitudinal incision, incise the periosteum transversely; the incision through the periosteum is I shaped. n  Because of the shape of the tibia, the graft usually is wider at the proximal end than at the distal end. This equalizes the strength of the graft because the cortex is thinner proximally than distally (Fig. 1.20). Before cutting the graft, drill a hole at each corner of the anticipated area. n  With a single-blade saw, remove the graft by cutting through the cortex at an oblique angle, preserving the anterior and medial borders of the tibia. Do not cut beyond the holes, especially when cutting across at the ends; overcutting here weakens the donor bone and may serve as the starting point of a future fracture. This is particularly true at the distal end of the graft. n  As the graft is pried from its bed, have an assistant grasp it firmly to prevent it from dropping to the floor. n  Before closing the wound, remove additional cancellous bone from the proximal end of the tibia with a curet. Take care to avoid the articular surface of the tibia or, in a child, the physis. n  The periosteum over the tibia is relatively thick in children and usually can be sutured as a separate layer. In adults, it is often thin, and closure may be unsatisfactory; suturing the periosteum and the deep portion of the subcutaneous tissues as a single layer usually is wise. n 

Middle of shaft FIGURE 1.20 Method of removing tibial graft. Graft is wider proximally than distally. A hole is drilled at each corner before cutting to decrease stress riser effect of sharp corner after removal of graft. Cortex is cut through at an oblique angle. SEE TECHNIQUE 1.6.

If the graft has been properly cut, little shaping is necessary. Our practice is to remove the endosteal side of the graft because (1) the thin endosteal portion provides a graft to be placed across from the cortical graft; and (2) the endosteal surface, being rough and irregular, should be removed to ensure good contact of the graft with the host bone.    

n 

 

REMOVAL OF FIBULAR GRAFTS Three points should be considered in the removal of a fibular graft: (1) the peroneal nerve must not be damaged; (2) the distal fourth of the bone must be left to maintain a stable ankle; and (3) the peroneal muscles should not be cut.

  TECHNIQUE 1.7

FIGURES 1.21 and 1.22

For most grafting procedures, resect the middle third or middle half of the fibula through a Henry approach. n  Dissect along the anterior surface of the septum between the peroneus longus and soleus muscles. n 

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PART I  GENERAL PRINCIPLES Line of incision for tibial graft Deep and superficial peroneal nerves

Line of incision for tibial graft

Tibial graft Tibia

Tibial graft Tibia

Peroneus longus and brevis muscles Fibula

Fibula

Line of incision for fibular graft Soleus muscle

Section 97 Level near junction of upper and middle thirds of tibia

Section 93 Level of tibial tuberosity

Line of incision for tibial graft Tibial graft Peroneus longus and brevis muscles Flexor hallucis longus muscle Line of incision for fibular graft

Soleus muscle

Section 101 Level of junction of middle and lower thirds of tibia FIGURE 1.21 Cross-sections of leg showing line of approach for removal of whole fibular transplants or tibial grafts. Colored segment shows portion of tibia to be removed. Thick, strong angles of tibia are not violated. SEE TECHNIQUE 1.7.

Incision Common peroneal nerve Gastrocnemius muscle

Section 93

Peroneal muscles (reflected)

Section 97 Biceps muscle

Soleus muscle Section 101

A

Common peroneal nerve

B

Fibula

C

FIGURE 1.22 Resection of fibula for transplant. A, Line of skin incision; levels of cross-sections shown in Figure 1.21 are indicated. B, Relation of common peroneal nerve to fibular head and neck. C, Henry method of displacing peroneal nerve to expose fibular head and neck. SEE TECHNIQUE 1.7.

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CHAPTER 1  SURGICAL TECHNIQUES Reflect the peroneal muscles anteriorly after subperiosteal dissection. n  Begin the stripping distally and progress proximally so that the oblique origin of the muscle fibers from the bone tends to press the periosteal elevator toward the fibula. n  Drill small holes through the fibula at the proximal and distal ends of the graft. n  Connect the holes by multiple small bites with the bonebiting forceps to osteotomize the bone; otherwise, the bone may be crushed. A Gigli saw, an oscillating power saw, or a thin, air-powered cutting drill can be used. An osteotome may split or fracture the graft. The nutrient artery enters the bone near the middle of the posterior surface and occasionally may require ligation. n  If the transplant is to substitute for the distal end of the radius or for the distal end of the fibula, resect the proximal third of the fibula through the proximal end of the Henry approach and take care to avoid damaging the peroneal nerve. n  Expose the nerve first at the posteromedial aspect of the distal end of the biceps femoris tendon and trace it distally to where it winds around the neck of the fibula. In this location, the nerve is covered by the origin of the peroneus longus muscle. With the back of the knife blade toward the nerve, divide the thin slip of peroneus longus muscle bridging it. Displace the nerve from its normal bed into an anterior position. n  As the dissection continues, protect the anterior tibial vessels that pass between the neck of the fibula and the tibia by subperiosteal dissection. n  After the resection is complete, suture the biceps tendon and the fibular collateral ligament to the adjacent soft tissues.    n 

CANCELLOUS ILIAC CREST BONE GRAFTS

Unless considerable strength is required, the cancellous graft fulfills almost any requirement. Regardless of whether the cells in the graft remain viable, clinical results indicate that cancellous grafts incorporate with the host bone more rapidly than do cortical grafts. Large cancellous and corticocancellous grafts may be obtained from the anterior superior iliac crest and the posterior iliac crest. Small cancellous grafts may be obtained from the greater trochanter of the femur, femoral condyle, proximal tibial metaphysis, medial malleolus of the tibia, olecranon, and distal radius. At least 2 cm of subchondral bone must remain to avoid collapse of the articular surface. If form and rigidity are unnecessary, multiple sliver or chip grafts may be removed. When preservation of the iliac crest is desirable, the outer cortex of the ilium may be removed along with considerable cancellous bone. If a more rigid piece of bone is desirable, the posterior or anterior one third of the crest of the ilium is a satisfactory donor site. For wedge grafts, the cuts are made at a right angle to the crest. Jones et al. found that full-thickness iliac grafts harvested with a power saw are stronger than grafts harvested with an osteotome, presumably because of less microfracturing of bone with the saw. If the patient is prone, the posterior third of the ilium is used; if the patient is supine, the anterior third is available (Fig. 1.23). In children, the physis of the iliac crest is ordinarily

D E

C B A

F G

FIGURE 1.23 Coronal sections (A-D) from anterior portion of ilium. Accompanying cross-sections show width of bone and its cancellous structure. Iliac grafts for fusion of spine are ordinarily removed from posterior third of crest (E-G).

preserved together with the attached muscles. To accomplish this, a cut is made parallel to and below the apophysis, and this segment is fractured in greenstick fashion at the posterior end. Ordinarily, only one cortex and the cancellous bone are removed for grafts, and the fractured crest, along with the apophysis, is replaced in contact with the remnant of the ilium and is held in place with heavy nonabsorbable sutures. When full-thickness grafts are removed from the ilium in adults, a similar procedure may be used, preserving the crest of the ilium and its external contour. The patient cannot readily detect the absence of the bone, and the cosmetic result is superior. This method also is less likely to result in a “landslide” hernia. Wolfe and Kawamoto reported a method of taking fullthickness bone from the anterior ilium; the iliac crest is split off obliquely medially and laterally so that the edges of the crest may be reapproximated after the bone has been excised (Fig. 1.24). They also used this method in older children without any evidence of growth disturbance of the iliac crestal physis.   

REMOVAL OF AN ILIAC BONE GRAFT Harvesting autograft bone from the ilium is not without complications. Hernias have been reported to develop in patients from whom massive full-thickness iliac grafts were taken. Muscle-pedicle grafts for arthrodesis of the hip (see Chapter 5 for hip arthrodesis techniques) also have resulted in a hernia when both cortices were removed. With this graft, the abductor muscles and the layer of periosteum laterally are removed with the graft. Careful repair of the supporting structures remaining after removal of an iliac graft is important and probably the best method of preventing these hernias. Full-thickness windows made below the iliac crest are less likely to lead to hernia formation. In addition

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PART I  GENERAL PRINCIPLES

A

B

C

D

FIGURE 1.24 Wolfe-Kawamoto technique of taking iliac bone graft. A and B, Outer ridges of iliac crest are split off obliquely with retention of muscular and periosteal attachments. C and D, Closure of donor site. Note offset anteriorly for reattachment of crest to anterior superior iliac spine (D). (Redrawn from Wolfe SA, Kawamoto HK: Taking the iliac-bone graft: a new technique, J Bone Joint Surg 60A:411, 1978.)

to hernia formation, nerve injury, arterial injury, or cosmetic deformity can be a problem after harvesting of iliac bone. The lateral femoral cutaneous and ilioinguinal nerves are at risk during harvest of bone from the anterior ilium. The superior cluneal nerves are at risk if dissection is carried farther than 8 cm lateral to the posterior superior iliac spine (Fig. 1.25). The superior gluteal vessels can be damaged by retraction against the roof of the sciatic notch. Removal of large full-thickness grafts from the anterior ilium can alter the contour of the anterior crest, producing significant cosmetic deformity. Arteriovenous fistula, pseudoaneurysm, ureteral injury, anterior superior iliac spine avulsion, and pelvic instability have been reported as major complications of iliac crest graft procurement.

Line of dissection Superior cluneal nerves 8 cm

Posterosuperior iliac spine

  TECHNIQUE 1.8 Make an incision along the subcutaneous border of the iliac crest at the point of contact of the periosteum with the origins of the gluteal and trunk muscles; carry the incision down to the bone. n  When the crest of the ilium is not required as part of the graft, split off the lateral side or both sides of the crest in continuity with the periosteum and the attached muscles. To avoid hemorrhage, dissect subperiosteally. n  If a cancellous graft with one cortex is desired, elevate only the muscles from either the inner or the outer table of the ilium. The inner cortical table with underlying cancellous bone may be preferable, owing to body habitus. n  For full-thickness grafts, also strip the iliacus muscle from the inner table of the ilium (Fig. 1.26). n  When chip or sliver grafts are required, remove them with an osteotome or gouge from the outer surface of the wing of the ilium, taking only one cortex. n  After removal of the crest, considerable cancellous bone may be obtained by inserting a curet into the cancellous space between the two intact cortices. n 

FIGURE 1.25 Posteroanterior view of pelvis showing superior cluneal nerves crossing over posterior iliac crest beginning 8 cm lateral to posterior superior iliac spine. SEE TECHNIQUE 1.8.

When removing a cortical graft from the outer table, first outline the area with an osteotome or power saw. Then peel the graft up with slight prying motions with a broad osteotome. Wedge grafts or full-thickness grafts may be removed more easily with a power saw; this technique

n 

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CHAPTER 1  SURGICAL TECHNIQUES

FIGURE 1.26 Method of removing full-thickness coronal segment of ilium. SEE TECHNIQUE 1.8.

also is less traumatic than when an osteotome and mallet are used. For this purpose, an oscillating saw or an air-powered cutting drill is satisfactory. Avoid excessive heat by irrigating with saline at room temperature. Avoid removing too much of the crest anteriorly and leaving an unsightly deformity posteriorly (Fig. 1.27). n  After removal of the grafts, accurately appose and suture the periosteum and muscular origins with strong interrupted sutures. n  Bleeding from the ilium is sometimes profuse; avoid using Gelfoam and bone wax and depend on wound packing and local pressure. Gelfoam and bone wax are foreign materials. Bone wax is said to impair bone healing, and Gelfoam in large amounts has been associated with sterile serous drainage from wounds. Microcrystalline collagen has been reported to be more efficient in reducing blood loss from cancellous bone than either thrombin powder or thrombin-soaked gelatin foam. Gentle wound suction for 24 to 48 hours combined with meticulous obliteration of dead space is satisfactory for the management of these wounds. n  When harvesting bone from the posterior ilium, Colterjohn and Bednar recommended making the incision parallel to the superior cluneal nerves and perpendicular to the posterior iliac crest (see Fig. 1.25).    

SURGICAL APPROACHES A surgical approach should provide easy access to all structures sought. The incision should be long enough not to hinder any part of the operation. When practical, it should parallel or at least consider the natural creases of the skin to avoid undesirable scars. A longitudinal incision on the flexor or extensor surface of a joint may cause a large, unsightly scar or even a keloid that may permanently restrict motion. A longitudinal

FIGURE 1.27 Defect in ilium after large graft was removed. Anterior border of ilium that included the anterior superior iliac spine was preserved, but because the defect was so large, deformity was visible even under clothing. Unsightly contour was improved by removing more bone from the crest posteriorly. SEE TECHNIQUE 1.8.

midlateral incision, especially on a finger or thumb or on the ulnar border of the hand, produces little scarring because it is located where movements of the skin are relatively slight. The approach also should do as little damage as possible to the deeper structures. It should follow lines of cleavage and planes of fascia and when possible should pass between muscles rather than through them. Important nerves and vessels must be spared by locating and protecting them or by avoiding them completely; when an important structure is in immediate danger, it should be exposed. In addition to learning approaches described by others, the surgeon should know the anatomy so well that an approach can be modified when necessary. Not all approaches are described in this chapter, but rather only those found suitable for most of the orthopaedic operations now in use. Additional approaches are described in other sections of this book. There has been recent interest in less invasive total joint arthroplasties. These approaches are outlined in Chapters 3, 7, 10, 12. Making a long incision parallel to the scar of a previous long incision is unjustified. An incision through an old scar heals as well as a new incision; and even though the scar may not be ideally located, the deeper structures may be reached by retracting the skin and subcutaneous tissues. A second incision made parallel to and near an old scar may impair the circulation in the strip of skin between the two, leading to skin slough. The position of the patient for surgery also is important. It should be properly established before the operation is begun, and provisions should be made to prevent undesirable changes in position during the operation. The surgeon should be able to reach all parts of the surgical field easily. If there

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PART I  GENERAL PRINCIPLES is a chance that intraoperative fluoroscopy will be needed, a radiolucent table should be used. A tourniquet, unless specifically contraindicated, should always be used in surgery on the extremities; the dry field it provides makes the dissection easier, the surgical technique less traumatic, and the time required for the operation shorter. Also, in a dry field, the cutaneous nerves are identified and protected more easily, and they often may be used as guides to deeper structures. The identification, dissection, and ligation of vessels are also made easier. Although the extremity is temporarily ischemic, an electrocautery unit should be used to cauterize small vessels that cross the incision. An electrocautery unit is even more useful in surgical sites where a tourniquet cannot be employed, such as the shoulder, hip, spine, or pelvis.

Head of first metatarsal (area of bunion) Dorsal digital nerve

A

Skin incision

Incision into bunion and joint capsule

TOES   

APPROACH TO THE INTERPHALANGEAL JOINTS   TECHNIQUE 1.9

B

For procedures on the interphalangeal joint of the great toe, make an incision 2.5 cm long on the medial aspect of the toe. n  For the interphalangeal joints of the fifth toe, make a lateral incision. n  Approach the interphalangeal joints of the second, third, and fourth toes through an incision just lateral to the corresponding extensor tendon. n  Carry the dissection through the subcutaneous tissue and fascia to the capsule of the joint. n  Reflect the edges of the incision with care to avoid damaging the dorsal or plantar digital vessels and nerves; retract the dorsal nerves and vessels dorsally and the plantar nerves and vessels plantarward. n  To expose the articular surfaces, open the capsule transversely or longitudinally.    n 

APPROACHES TO THE METATARSOPHALANGEAL JOINT OF THE GREAT TOE

The metatarsophalangeal joint of the great toe may be exposed in one of several ways. Two ways are described.   

MEDIAL APPROACH TO THE GREAT TOE METATARSOPHALANGEAL JOINT   TECHNIQUE 1.10 Make a curved incision 5 cm long on the medial aspect of the joint (Fig. 1.28A). Begin it just proximal to the interphalangeal joint, curve it over the dorsum of the metatarsophalangeal joint medial to the extensor hallucis longus

n 

Base of proximal phalanx Flap of bunion and joint capsule

C Head of first metatarsal FIGURE 1.28 A-C, Medial approach to metatarsophalangeal joint of great toe (see text). (Modified from Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach, Philadelphia, 2003, Lippincott Williams & Wilkins.) SEE TECHNIQUE 1.10.

tendon, and end it on the medial aspect of the first metatarsal 2.5 cm proximal to the joint. n  As the deep fascia is incised, laterally retract the medial branch of the first dorsal metatarsal artery and the medial branch of the dorsomedial nerve (a branch of the superficial peroneal nerve), which supplies the medial side of the great toe. n  Dissect the fascia from the dorsum down to the bursa over the medial aspect of the metatarsal head. n  Make a curved incision through the bursa and capsule of the joint (Fig. 1.28B); begin the incision over the dorsomedial aspect of the joint, continue it proximally dorsal to the metatarsal head and plantarward and distally around the joint, and end it distally on the medioplantar aspect of the metatarsophalangeal joint. This incision forms an elliptical, racquet-shaped flap attached at the base of the

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CHAPTER 1  SURGICAL TECHNIQUES proximal phalanx (Fig. 1.28C). Although distal reflection of this flap amply exposes the first metatarsophalangeal joint, the use of a dorsomedial approach is preferable because healing of the skin flap may be delayed.      

DORSOMEDIAL APPROACH TO GREAT TOE METATARSOPHALANGEAL JOINT   TECHNIQUE 1.11 Begin the incision just proximal to the interphalangeal joint and continue it proximally for 5 cm parallel with and medial to the extensor hallucis longus tendon. n  To expose the capsule, divide the fascia and retract the tendon. n  The capsule can be incised by forming a flap with its attachment at the base of the first phalanx, as in the preceding approach, or by continuing the dissection in the plane of the skin incision.    

Divide the fat and fascia and define the inferior margin of the abductor hallucis. n  Mobilize the muscle belly and retract it dorsally to expose the medial and inferomedial aspects of the body of the calcaneus. n  Continue the dissection distally by dividing the plantar aponeurosis and the muscles attaching to the calcaneus or by stripping these from the bone with an osteotome. Carefully avoid the medial calcaneal nerve and the nerve to the abductor digiti minimi. The inferior surface of the body of the calcaneus can be exposed subperiosteally.     n 

n 

 

APPROACH TO THE LESSER TOE METATARSOPHALANGEAL JOINTS   TECHNIQUE 1.12 The second, third, and fourth metatarsophalangeal joints are reached by a dorsolateral incision parallel to the corresponding extensor tendon (Fig. 1.29). n  The fifth metatarsophalangeal joint is best exposed by a straight or curved dorsal or dorsolateral incision. n  The joint capsules may be opened transversely or longitudinally, as necessary.   

 

LATERAL APPROACH TO THE CALCANEUS   TECHNIQUE 1.14 Begin the incision on the lateral margin of the Achilles tendon near its insertion and pass it distally to a point 4 cm inferior to and 2.5 cm anterior to the lateral malleolus (Fig. 1.31). n  Divide the superficial and deep fasciae, isolate the peroneal tendons and incise and elevate the periosteum below the tendons to expose the bone. n  If necessary, and if no infection is present, divide the tendons by Z-plasty and repair them later.     n 

n 

CALCANEUS

Approaches to the calcaneus are carried out most easily with the patient prone. The medial approach, however, can be made with the patient supine, the knee flexed, and the foot crossed over the opposite leg. The lateral approach also can be made with the patient supine by placing a sandbag under the ipsilateral buttock, internally rotating the hip, and everting the foot. 

 

EXTENDED LATERAL APPROACH TO THE CALCANEUS The extended lateral approach was developed for open fixation of calcaneal fractures. The condition of the skin is most important. Swelling and bruised skin are factors leading to superficial and deep infections. The initial trauma impairs the microvasculature of the skin and subcutaneous tissues. A single-layer interrupted absorbable subcuticular suture is recommended for closure. This is less traumatic to the skin and subcutaneous tissues than a two-layer closure. An inverse relationship between surgeon experience and wound complications has been demonstrated, and patient age and use of nicotine in any form are also important factors.

 

  TECHNIQUE 1.15

MEDIAL APPROACH TO THE CALCANEUS

n 

  TECHNIQUE 1.13

Figure 1.30

Begin the incision 2.5 cm anterior to and 4 cm inferior to the medial malleolus, carrying it posteriorly along the medial surface of the foot to the Achilles tendon.

n 

Beginning several centimeters proximal to the posterior tuberosity and the lateral edge of the Achilles tendon, begin the incision and carry it to the smooth skin just above the heel pad. Curve the incision anteriorly following the contour of the heel and carry it to below the tip of the fifth metatarsal base (Fig. 1.31A). n  Develop a full-thickness flap containing the peroneal tendons and sural nerve.

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PART I  GENERAL PRINCIPLES Branches of superficial peroneal nerve

Deep peroneal nerve

Extensor digitorum longus

Tendon of extensor digitorum longus Deep fascia Saphenous nerve

A

B

Tendon of extensor digitorum longus

Head of second metatarsal Base of proximal phalanx

Joint capsule

C

D FIGURE 1.29 Approaches to metatarsophalangeal joints of second to fifth toes. A, Skin incision. B, Incision through deep fascia medial to tendons. C, Longitudinal incision in joint capsule. D, Joint is exposed. (Modified from Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach, Philadelphia, 2003, Lippincott Williams & Wilkins.) SEE TECHNIQUE 1.12.

A

B

C

FIGURE 1.30 Medial approach to calcaneus. A, Skin incision. B, Fascial incision. C, Isolation of neurovascular bundle. (Modified from Burdeaux BD: Reduction of calcaneal fractures by the McReynolds medial approach technique and its experimental basis, Clin Orthop Relat Res 177:93, 1983.) SEE TECHNIQUE 1.13.

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CHAPTER 1  SURGICAL TECHNIQUES

Peroneus brevis muscle Peroneus longus muscle

Skin incision Incision for extended lateral approach

A

Incision in periosteum of calcaneus

B

Calcaneus

C

FIGURE 1.31 Lateral approach to calcaneus. A, Skin incision. B, Incision in periosteum of calcaneus. C, Calcaneus is exposed. SEE TECHNIQUES 1.14 AND 1.15.

Reflect it anteriorly and hold it in place with one or two Kirschner wires drilled into the lateral talus. n  At closure, use a single layer of interrupted 2-0 absorbable sutures. n  Use a single tube vacuum drain and apply a sterile Jonestype compression dressing.     n 

 

SINUS TARSI APPROACH The extended lateral approach is usually considered the approach of choice for intra-articular os calcis fractures. Soft-tissue problems are the major concern because the lateral calcaneal flap is thin. A limited lateral approach such as the sinus tarsi approach is a good alternative to reduce soft-tissue complications and is preferred at this time.

 

U-SHAPED APPROACH TO THE CALCANEUS

  TECHNIQUE 1.16 (PARK AND CHO) Place the patient in the lateral decubitus position on a radiolucent table. n  Make an oblique incision just beneath the tip of the lateral malleolus and carry it toward the fourth metatarsal base (Fig. 1.32). n  Deepen the dissection while preserving the sural nerve. n  Reflect the peroneal tendons inferiorly and open the subtalar joint. n  Incise the calcaneofibular ligament if needed for ­exposure.     n 

FIGURE 1.32 Sinus tarsi approach. Oblique skin incision under tip of lateral malleolus directed toward the fourth metatarsal base. SEE TECHNIQUE 1.16.

  TECHNIQUE 1.17 With the patient prone, support the leg on a large ­sandbag. n  For access to the entire plantar surface of the calcaneus, make a large U-shaped incision around the posterior four fifths of the bone (Fig. 1.33). n  After the dissections described, retract a flap consisting of skin, the fatty heel pad, and the plantar fascia.     n 

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Achilles tendon

Incision in periosteum

A

B

Calcaneus

Plantar aponeurosis and muscles retracted

Incision in plantar aponeurosis and muscles

C

D

FIGURE 1.33 U-shaped approach to calcaneus. A, Skin incision. B, Periosteal incision. C, Incision in plantar aponeurosis and muscles. D, Plantar aponeurosis and muscles are retracted. SEE TECHNIQUE 1.17.

 

KOCHER APPROACH (CURVED L) TO THE CALCANEUS   TECHNIQUE 1.18 The Kocher approach is suitable for complete excision of the calcaneus in cases of tumor or infection (see Fig. 1.36B). n  Incise the skin over the medial border of the Achilles tendon from 7.5 cm proximal to the tuberosity of the calcaneus to the inferoposterior aspect of the tuberosity, continuing it transversely around the posterior aspect of the calcaneus and distally along the lateral surface of the foot to the tuberosity of the fifth metatarsal. n  Divide the Achilles tendon at its insertion and carry the dissection down to the bone. n  To reach the superior surface, free all tissues beneath the severed Achilles tendon. n  The calcaneus may be enucleated with or without its periosteal attachments. n  The central third of the incision is ideal for fixation of posterior tuberosity avulsion fractures.     n 

TARSUS AND ANKLE ANTERIOR APPROACHES   

ANTEROLATERAL APPROACH TO CHOPART JOINT The anterolateral approach gives excellent access to the ankle joint, the talus, and most other tarsal bones and the anterior tuberosity of the calcaneal joints, and it avoids all important vessels and nerves. Because so many reconstructive operations and other procedures involve the structures exposed, it may well be called the “universal incision” for the foot and ankle. It permits excision of the entire talus, and the only tarsal joints that it cannot reach are those between the navicular and the second and first cuneiforms. This approach is good for a single-incision “triple” arthrodesis and a pantalar arthrodesis, as the tibiotalar, talonavicular, subtalar, and calcaneocuboid joints are exposed.

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CHAPTER 1  SURGICAL TECHNIQUES

Peroneal tendons

Extensor digitorum longus muscle Transverse crural ligament Line of incision Cruciate crural ligament Extensor digitorum brevis muscle

Tibia Talus Calcaneus

Navicular

Cuboid

A

B FIGURE 1.34

A and B, Anterolateral approach to ankle joint and tarsus. SEE TECHNIQUE 1.19.

  TECHNIQUE 1.19

 

Begin the incision over the anterolateral aspect of the leg medial to the fibula and 5 cm proximal to the ankle joint, carrying it distally over the joint, the anterolateral aspect of the body of the talus, and the calcaneocuboid joint, and end it at the base of the fourth metatarsal (Fig. 1.34A). The incision may begin more proximally or end more distally, or any part may be used, as needed. n  Incise the fascia and the superior and inferior extensor retinacula down to the periosteum of the tibia and the capsule of the ankle joint. This dissection usually divides the anterolateral malleolar and lateral tarsal arteries. n  While retracting the edges of the wound, identify and protect the intermediate dorsal cutaneous branches of the superficial peroneal nerve. n  Divide the extensor digitorum brevis muscle in the direction of its fibers or detach it from its origin and reflect it distally. n  Retract the extensor tendons, the dorsalis pedis artery, and the deep peroneal nerve medially and incise the ­capsule. n  Expose the talonavicular joint by dissecting deep to the tendons and incise its capsule transversely. n  Continue the dissection laterally through the capsule of the calcaneocuboid joint, which lies on the same plane as the talonavicular joint. n  Incise the mass of fat lateral to and inferior to the neck of the talus to bring the subtalar joint into view. n  Extend the dissection distally to provide access to the articulation between the cuboid and the fourth and fifth metatarsals and between the navicular and the third cuneiform (Fig. 1.34B).     n 

ANTERIOR APPROACH TO EXPOSE THE ANKLE JOINT AND BOTH MALLEOLI Gaining access to the part of the ankle joint between the medial malleolus and the medial articular facet of the body of the talus often is difficult when fusing the ankle through the anterolateral approach. Through the anterior approach, however, both malleoli may be exposed easily. Usually the approach is developed between the extensor hallucis longus and extensor digitorum longus tendons (Fig. 1.35), but it also can be developed between the anterior tibial and extensor hallucis longus tendons. In this case, the neurovascular bundle is retracted laterally with the long extensor tendons of the toes, and the anterior tibial tendon is retracted medially.

  TECHNIQUE 1.20 Begin the incision on the anterior aspect of the leg 7.5 to 10 cm proximal to the ankle and extend it distally to about 5 cm distal to the joint. Its length varies with the surgical indication (Fig. 1.36A). n  Divide the deep fascia in line with the skin incision. n  Isolate, ligate, and divide the anterolateral malleolar and lateral tarsal arteries, and carefully expose the neurovascular bundle and retract it medially. n  Incise the periosteum, capsule, and synovium in line with the skin incision, and expose the full width of the ankle joint anteriorly by subcapsular and subperiosteal dissection.    n 

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A Extensor hallucis longus tendon Extensor digitorum longus tendon

Talus

B

Anterior tibial artery

C

Deep peroneal nerve

FIGURE 1.36 A, Kocher approach to ankle. B, Kocher approach to calcaneus. C, Ollier approach to midtarsal and subtalar joints. SEE TECHNIQUES 1.18, 1.20, 1.21, AND 1.22.

Navicular

Incise the fascia down to the peroneal tendons and retract them posteriorly, protecting the lesser saphenous vein and sural nerve lying immediately posterior to the incision. n  If a larger operative field is necessary, divide the tendons by Z-plasty and retract them. n  Deepen the dissection distally, divide the calcaneofibular ligament, and expose the subtalar joint. The calcaneocuboid and talonavicular joints may be reached through the distal part of this incision. n  After dividing the talofibular ligaments, dislocate the ankle by medial traction if access to its entire articular surface is desired.     n 

FIGURE 1.35 Anterior approach to ankle joint. Extensor hallucis longus and anterior tibial tendons, along with neurovascular bundle, are retracted medially. Tendons of extensor digitorum longus muscle are retracted laterally. SEE TECHNIQUE 1.20.

 

OLLIER APPROACH TO THE TARSUS LATERAL APPROACHES TO THE TARSUS AND ANKLE   

KOCHER LATERAL APPROACH TO THE TARSUS AND ANKLE The Kocher approach gives excellent exposure of the midtarsal, subtalar, and ankle joints (Fig. 1.36A). The disadvantage of this procedure is that the skin may slough around the margins of the incision, especially if dislocation of the ankle has been necessary, as in a talectomy. The peroneal tendons usually must be divided. In most instances, the anterolateral incision is more satisfactory.

  TECHNIQUE 1.21 From a point just lateral and distal to the head of the talus, curve the incision 2.5 cm inferior to the tip of the lateral malleolus, then posteriorly and proximally, and end it 2.5 cm posterior to the fibula and 5 cm proximal to the tip of the lateral malleolus or, if desired, 5 or 7 cm further proximally, parallel with and posterior to the fibula (Fig. 1.36A).

n 

The Ollier approach is excellent for a triple arthrodesis: the three joints are exposed through a small opening without much retraction, and the wound usually heals well because the proximal flap is dissected full thickness and the skin edges are protected during retraction (see Chapter 85).

  TECHNIQUE 1.22 Begin the skin incision over the dorsolateral aspect of the talonavicular joint, extend it obliquely inferoposteriorly, and end it about 2.5 cm inferior to the lateral malleolus (Fig. 1.36C). n  Divide the inferior extensor retinaculum in the line of the skin incision. n  In the superior part of the incision, expose the long extensor tendons to the toes and retract them medially, preferably without opening their sheaths. n  In the inferior part of the incision, expose the peroneal tendons and retract them inferiorly. n  Divide the origin of the extensor digitorum brevis muscle, retract the muscle distally, and bring into view the sinus tarsi. n  Extend the dissection to expose the subtalar, calcaneocuboid, and talonavicular joints.     n 

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CHAPTER 1  SURGICAL TECHNIQUES  

SINGLE-INCISION POSTEROLATERAL APPROACH TO THE LATERAL AND POSTERIOR MALLEOLI Choi et al. described a single-incision oblique posterolateral approach for posterior malleolar fracture with an associated lateral malleolar fracture.

  TECHNIQUE 1.23 (CHOI ET AL.) Place the patient in the prone or lateral position. Make a 10-cm incision following the posterior edge of the lateral malleolus and curve it posteriorly at the level of the syndesmosis to end at the Achilles tendon insertion on the os calcis. Carefully dissect out the sural nerve (Fig. 1.37). The incision can be extended proximally if necessary. n  Take down the peroneal tendons from the posterior aspect of the lateral malleolus, and expose the lateral malleolar fracture. n  Develop the interval between the peroneal tendons and the flexor hallucis longus. n  Retract both the flexor hallucis longus and the Achilles tendon medially, exposing the posterior malleolus.     n  n 

 

POSTEROLATERAL APPROACH TO THE ANKLE The Gatellier and Chastang posterolateral approach permits open reduction and internal fixation of fractures of the ankle in which the fragment of the posterior tibial lip (posterior malleolus) is large and laterally situated. It makes use of the fact that the fibula usually is fractured in such injuries; should it be intact, it is osteotomized about 10 cm proximal to the tip of the lateral malleolus. The approach also is used for osteochondritis dissecans involving the lateral part of the dome of the talus and for osteochondromatosis of the ankle.

  TECHNIQUE 1.24 (GATELLIER AND CHASTANG) Begin the incision about 12 cm proximal to the tip of the lateral malleolus and extend it distally along the posterior margin of the fibula to the tip of the malleolus. Curve the incision anteriorly for 2.5 to 4 cm in the line of the peroneal tendons (Fig. 1.38). n  Expose the fibula, including the lateral malleolus subperiosteally, and incise the sheaths of the peroneal retinacula and tendons, permitting the tendons to be displaced anteriorly. n  If the fibula is not fractured, divide it 10 cm proximal to the tip of the lateral malleolus and free the distal fragment by dividing the interosseous membrane and the anterior and posterior tibiofibular ligaments. n  Carefully preserve the calcaneofibular and talofibular ligaments to serve as a hinge and to maintain the integrity of the ankle after operation. Turn the fibula laterally on this hinge and expose the lateral and posterior aspects of the distal tibia and the lateral aspect of the ankle joint. Great care should be used in children to avoid creating a fracture through the distal fibular physis when reflecting the fibula. n  When closing the incision, replace the fibula and secure it with a screw extending transversely from the proximal part of the lateral malleolus through the tibiofibular syndesmosis into the tibia just proximal and parallel to the ankle joint. n  Overdrill the hole made in the fibula to allow for compression across the syndesmosis. Dorsiflex the ankle joint as the screw is tightened because the talar dome is wider at its anterior half than its posterior half. Failure to overdrill the fibula can result in widening of the syndesmosis and ankle mortise, with resulting arthritic degeneration of the tibiotalar joint. Add additional fixation with a small plate and screws if desired. n  Replace the tendons, repair the tendon sheaths and retinacula, and close the incision. n  After the osteotomy or fracture has healed, remove the screw to prevent its becoming loose or breaking.     n 

 

ANTEROLATERAL APPROACH TO THE LATERAL DOME OF THE TALUS As an alternative to lateral malleolar osteotomy, Tochigi et al. described an anterolateral approach to the lateral dome of the talus for extensive lateral osteochondral lesions. All but the posterior one fourth of the lateral talus can be exposed. An osteotomy of the anterolateral tibia is required.

  TECHNIQUE 1.25 (TOCHIGI, AMENDOLA, MUIR, AND SALTZMAN) Make a vertical 10-cm incision along the anterolateral corner of the ankle, avoiding the lateral branch of the superficial peroneal nerve.

n 

FIGURE 1.37 Yellow line shows the course of the sural nerve. Green line shows the incision. SEE TECHNIQUE 1.23.

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A

B FIGURE 1.38 Posterolateral approach of Gatellier and Chastang. A, Peroneal tendons have been displaced anteriorly, and fibula has been divided; distal fragment has been turned laterally after interosseous membrane and anterior and posterior tibiofibular ligaments have been divided. B, Distal fibula has been replaced and fixed to tibia with syndesmosis screw. SEE TECHNIQUE 1.24.

 

POSTERIOR APPROACH TO THE ANKLE

Tibia Fibula

Tibia

Osteotomy Lesion

Talus

A

Fibula

  TECHNIQUE 1.26

Talus

With the patient prone, make a 12-cm incision along the posterolateral border of the Achilles tendon down to the insertion of the tendon on the calcaneus (Fig. 1.40A). n  Divide the superficial and deep fasciae, divide the Achilles tendon by Z-plasty or retract it, and incise the fat and areolar tissue to the posterior surface of the tibia in the space between the flexor hallucis longus and the peroneal tendons (Fig. 1.40B). n  Retract the flexor hallucis longus tendon medially to expose 2.5 cm of the distal end of the tibia, the posterior aspect of the ankle joint, the posterior end of the talus, the subtalar joint, and the posterior part of the superior surface of the calcaneus (Fig. 1.40C). n  If the dissection is kept lateral to the flexor hallucis longus tendon, the posterior tibial vessels and the tibial nerve will not be at risk because this tendon protects them. n  Alternatively, the Achilles tendon can be split from just above the ankle joint distally to its insertion on the os calcis. Hammit et al. found a lower wound complication rate without sacrificing exposure using this technique rather than standard posteromedial and posterolateral approaches.    n 

B

FIGURE 1.39 Tochigi, Amendola, Muir, and Saltzman anterolateral approach to talus. A, Anterior view of osteotomy. B, Lateral view of osteotomy. (From Tochigi Y, Amendola A, Muir D, et al: Surgical approach for centrolateral talar osteochondral lesions with an anterolateral osteotomy, Foot Ankle Int 23:1038, 2002.) SEE TECHNIQUE 1.25.

Outline the osteotomy of the anterolateral tibia to include the anterior tibiofibular ligament. The cortical surface of the fragment should be at least 1 cm2 (Fig. 1.39). Predrill the fragment to accept a 4-mm cancellous screw. n  Use a micro-oscillating saw to begin the osteotomy in two planes. Complete the osteotomy with a small, narrow osteotome by gently levering it in an externally rotated direction. The cartilaginous surface of the tibia is “cracked” as the fragment is rotated. n  At wound closure, rotate the fragment back into position and secure it with a 4-mm cancellous screw and washer.     n 

If only the anterolateral distal tibia needs to be exposed, the anterolateral tibial osteotomy is omitted and the superficial peroneal nerve is protected until its position becomes more posterior entering deep fascia.

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CHAPTER 1  SURGICAL TECHNIQUES

Gastrocnemius muscle Flexor hallucis longus muscle

Line of skin incision

Tibia

Talus

Posterior tibial artery Tibial nerve

Ankle joint

Flexor hallucis longus muscle

Subtalar joint

A

Gastrocnemius tendon

B

C

FIGURE 1.40 Posterior approach to ankle. A, Skin incision. B, Z-plasty division and reflection of Achilles tendon. C, Exposure of ankle and subtalar joints after retraction of flexor hallucis longus tendon and posterior capsulotomy. SEE TECHNIQUE 1.26.

MEDIAL APPROACHES   

MEDIAL APPROACH TO THE TARSUS Knupp et al. described a medial approach to the subtalar joint that is useful for hindfoot arthrodesis in posterior tibial tendon dysfunction.

  TECHNIQUE 1.27 (KNUPP ET AL.) Place the patient supine with the involved foot externally rotated. n  Make a 4-cm long incision from the center of the medial malleolus toward the navicular 5 mm above and parallel to the posterior tibial tendon (Fig. 1.41). Extend the incision as necessary to reach as far as the cuneiform. n  Open the subtalar joint capsule being careful not to damage the anterior fibers of the deltoid ligament.     n 

FIGURE 1.41 ­TECHNIQUE 1.27.

Medial approach to the subtalar joint. SEE

  TECHNIQUE 1.28 (KOENIG AND SCHAEFER) Curve the incision just proximal to the medial malleolus (Fig. 1.42A) and divide the malleolus with an osteotome or small power saw; preserve the attachment of the deltoid ligament. n  Subluxate the talus and malleolus laterally to reach the joint surfaces. n  Later replace the malleolus and fix it with one or two cancellous screws. To make replacement easier, drill the holes for the screws before the osteotomy, insert the screw, and then remove it. At the end of the operation, reinsert the screws and close the wound. n 

 

MEDIAL APPROACH TO THE ANKLE Koenig and Schaefer approached the ankle from the medial side by a method similar in principle to the Gatellier and Chastang exposure of the posterolateral side. It is not a popular method because, despite utmost care, it is possible to injure the tibial vessels and nerve. Nevertheless, it may be useful for fracture-dislocations of the talus, other traumatic lesions of the ankle joint, and osteochondritis dissecans of the talus.

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PART I  GENERAL PRINCIPLES Flexor hallucis longus tendon Flexor digitorum longus tendon

C B

Tibialis posterior tendon

A

Tibial nerve

FIGURE 1.42 Incisions for medial approaches to ankle joint: Koenig and Schaefer (A), Broomhead (B), and Colonna and Ralston (C). SEE TECHNIQUES 1.28 AND 1.29.

Posterior tibial artery FIGURE 1.44 Colonna and Ralston posteromedial approach to distal tibia. Posterior tibial and flexor digitorum longus tendons have been retracted anteriorly, and flexor hallucis longus tendon, posterior tibial vessels, and tibial nerve have been retracted posteriorly and laterally. SEE TECHNIQUE 1.29.

of medial and posterior malleoli (Fig. 1.42B). The latter is exposed by reflecting the capsule and periosteum and retracting the tendons of the posterior tibial, flexor digitorum longus, and flexor hallucis longus muscles together with the neurovascular bundle posteriorly and medially. Colonna and Ralston described the following modification of Broomhead’s approach.

  TECHNIQUE 1.29 (COLONNA AND RALSTON) Begin the incision at a point about 10 cm proximal and 2.5 cm posterior to the medial malleolus and curve it anteriorly and inferiorly across the center of the medial malleolus and inferiorly and posteriorly 4 cm toward the heel (Fig. 1.42C). n  Expose the medial malleolus by reflecting the periosteum, but preserve the deltoid ligament. n  Divide the flexor retinaculum and retract the flexor hallucis longus tendon and the neurovascular bundle posteriorly and laterally. n  Retract the tibial posterior and flexor digitorum longus tendons medially and anteriorly to expose the posterior tibial fracture (Fig. 1.44).    n 

FIGURE 1.43 Osteotomy of medial malleolus for access to medial dome of talus. Note line of osteotomy. SEE TECHNIQUE 1.28.

The surfaces of the osteotomized bone are smooth, and the malleolus can rotate on a single screw. Two screws are used to prevent rotation of the osteotomized medial malleolus (Fig. 1.43). Interfragmentary technique (see Chapter 53) should be used for screw fixation of the medial malleolus to provide compression across the osteotomy site.    

n 

In addition to the approaches described, short medial, lateral, and dorsal approaches may be used to expose small areas of the tarsal and metatarsal joints. In all, the vessels, nerves, and tendons must be protected. 

 

MEDIAL APPROACH TO THE POSTERIOR LIP OF THE TIBIA Broomhead advised a curved medial incision for fractures of the medial part of the posterior lip of the tibia that require open reduction. The line of approach lies midway between the posterior border of the tibia and the medial border of the Achilles tendon, curves inferior to the medial malleolus to the medial border of the foot, and permits exposure

TIBIA The tibia is a superficial bone that can be easily exposed anteriorly without damaging any important structure except the tendons of the anterior tibial and extensor hallucis longus muscles, which cross the tibia anteriorly in its lower fourth. 

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CHAPTER 1  SURGICAL TECHNIQUES  

ANTEROLATERAL APPROACH TO THE TIBIA   TECHNIQUE 1.30 Make a longitudinal incision 1 to 2 cm lateral to the anterior border of the bone. This will provide an adequate skin bridge. n  Sharply incise the fascia the entire length of the wound. Incise and elevate the periosteum over the desired area. Strip the periosteum as little as possible because its circulation is a source of nutrition for the bone.     n 

 

MEDIAL APPROACH TO THE TIBIA In some delayed unions and nonunions, Phemister inserted a bone graft in a bed prepared on the posterior surface of the tibia.

  TECHNIQUE 1.31

TIBIAL PLATEAU APPROACHES

(PHEMISTER) Make a longitudinal incision along the posteromedial border of the tibia. n  Incise the subcutaneous tissues and deep fascia and reflect the periosteum from the posterior surface for the required distance.     n 

It is recommended that all these approaches be made on a radiolucent operating table.   

ANTEROLATERAL APPROACH TO THE LATERAL TIBIAL PLATEAU The anterolateral approach is commonly used because most tibial plateau fractures involve the lateral tibial plateau.

 

POSTEROLATERAL APPROACH TO THE TIBIAL SHAFT The posterolateral approach is valuable in the middle two thirds of the tibia when the anterior and anteromedial aspects of the leg are badly scarred. It also is satisfactory for removing a portion of the fibula for transfer.

  TECHNIQUE 1.32 (HARMON, MODIFIED) Position the patient prone or on the side, with the affected extremity uppermost. n  Make the skin incision the desired length along the lateral border of the gastrocnemius muscle on the posterolateral aspect of the leg (Fig. 1.45A). n  Develop the plane between the gastrocnemius, the soleus, and the flexor hallucis longus muscles posteriorly and the peroneal muscles anteriorly (Fig. 1.45B). n  Find the lateral border of the soleus muscle and retract it and the gastrocnemius muscle medially and posteriorly; arising from the posterior surface of the fibula is the flexor hallucis longus (Fig. 1.45C). n  Detach the distal part of the origin of the soleus muscle from the fibula and retract it posteriorly and medially (Fig. 1.45D). n 

Continue the dissection medially across the interosseous membrane, detaching those fibers of the posterior tibial muscle arising from it (Fig. 1.45E). The posterior tibial artery and the tibial nerve are posterior and separated from the dissection by the posterior tibial and flexor hallucis longus muscles (Fig. 1.45F). n  Follow the interosseous membrane to the lateral border of the tibia and detach subperiosteally the muscles that arise from the posterior surface of the tibia (Fig. 1.45G, and H). n  The posterior half of the fibula lies in the lateral part of the wound; its entire shaft can be explored. The flat posterior surface of the tibial shaft can be completely exposed except for its proximal fourth, which lies in close relation to the popliteus muscle and to the proximal parts of the posterior tibial vessels and the tibial nerve. n  When the operation is completed, release the tourniquet, secure hemostasis, and let the posterior muscle mass fall back into place. n  Loosely close the deep fascia on the lateral side of the leg with a few interrupted sutures.    n 

  TECHNIQUE 1.33 (KANDEMIR AND MACLEAN) Place the patient supine on a radiolucent table. Begin the incision 2 to 3 cm proximal to the joint line and extend it 3 cm below the inferior margin of the tibial tubercle crossing Gerdy’s tubercle at the midpoint of the incision (Fig. 1.46). n  Detach the iliotibial band and develop the interval between it and the joint capsule. n  Reflect the origin of the tibialis anterior muscle from the anterolateral tibia and reflect it posteriorly exposing the anterolateral surface of the tibial plateau. n  If direct exposure of the articular surface is necessary, perform a submeniscal arthrotomy incising the meniscotibial ligaments. Leave the anterior horn of the meniscus intact. n  Place three or four sutures in the periphery of the meniscus to serve as retractors and for later repair. If a repairable vertical meniscal tear is present, pass the necessary number of sutures in a vertical fashion through the inner part of the meniscus for later attachment to the capsule. n  If a submeniscal arthrotomy is not planned, a hockey-stick skin incision can be used for minimally invasive procedures. Make the proximal limb of the incision parallel to the lateral joint line and cross Gerdy’s tubercle.     n  n 

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PART I  GENERAL PRINCIPLES Fascia over peroneus longus

Fascia over soleus Fascia over lateral head of gastrocnemius

Gastrocnemius-soleus mass

A

B

Flexor hallucis longus

Peronei Extensor digitorum Interosseous membrane

Fibula

Gastrocnemius

Soleus

Anterior tibial artery Deep peroneal nerve

Tibial nerve

Fascia over lateral head of gastrocnemius

Tibia

C

Lateral edge of fibula

Peroneus longus

Anterior tibial muscle

Peroneal artery

Posterior tibial artery

Peroneus brevis (retracted)

Soleus (origin)

Flexor digitorum longus

D

Posterior tibial muscle

Flexor hallucis longus Soleus (retracted)

Soleus (detached) Peronei Extensor digitorum longus

Fibula Fibula Peroneus longus

Flexor hallucis longus

Flexor hallucis longus

Gastrocnemius

Interosseous membrane Anterior tibial muscle

Soleus Peroneal artery Fascia over lateral head of gastrocnemius

E

Posterior tibial artery

Fibula

Soleus (retracted)

Tibia

Flexor digitorum longus

F

Soleus (detached)

Peroneus longus (retracted)

G

Tibial nerve

Soleus

Anterior tibial artery Deep peroneal nerve

Interosseous membrane

Peroneus longus (retracted)

Lateral edge of tibia

Fibula

Flexor hallucis longus (retracted)

H

Periosteum

Posterior tibial muscle

Interosseous membrane Tibia

Fascia over soleus

FIGURE 1.45 Posterolateral approach to tibia. A, Skin incision. B, Plane between gastrocnemius, soleus, and flexor hallucis longus posteriorly and peroneal muscles anteriorly is developed. C, Flexor hallucis longus arising from posterior surface of fibula. D, Distal part of origin of soleus is detached from fibula and retracted posteriorly and medially. E, Dissection medially across interosseous membrane, detaching fibers of posterior tibial muscle. F, Posterior tibial artery and tibial nerve are protected by posterior tibial and flexor hallucis longus muscles. G and H, Muscles are detached subperiosteally from posterior surface of tibia. (Modified from Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach, Philadelphia, 2003, Lippincott Williams & Wilkins.) SEE TECHNIQUE 1.32.

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CHAPTER 1  SURGICAL TECHNIQUES

A B FIGURE 1.47 Medial and posteromedial approaches to the tibial plateau. A, Begin the skin incision for the medial approach 2 to 3 cm above the joint line at the medial epicondyle and extend it distally, bisecting the posteromedial border of the tibia and tibial crest. B, Begin the skin incision for the posteromedial approach 2 to 3 cm above the joint line and follow the posteromedial border of the tibia. SEE TECHNIQUES 1.34 AND 1.35.

P

Gerdy’s tubercle TT

FH

Medial collateral ligament Pes anserinus tendons

Popliteus muscle FIGURE 1.46 Anterolateral approach to the tibial plateau. Begin the incision 2 to 3 cm proximal to the joint line and carry it obliquely across Gerdy’s tubercle aiming for a point 1 cm off the lateral aspect of the tibial tubercle. Extend it as far distally as needed. FH, Fibular head; P, patella; TT, tibial tubercle. SEE TECHNIQUE 1.33.

FIGURE 1.48 Posteromedial approach (supine). Retract the tendons of the pes anserinus distal and posterior. Incise the posterior edge of the medial collateral ligament and reflect the popliteus muscle insertion from the posterior border of the tibia. SEE ­TECHNIQUE 1.35.  

POSTEROMEDIAL APPROACH TO THE MEDIAL TIBIAL PLATEAU  

MEDIAL APPROACH TO THE MEDIAL TIBIAL PLATEAU This approach is useful for isolated medial plateau fractures and for medial half of bicondylar plateau fractures.

This approach is useful for shear fractures of the medial plateau. It can be performed with the patient supine or prone.

  TECHNIQUE 1.35 (SUPINE) Externally rotate and slightly flex the knee. Make a longitudinal incision along the posteromedial aspect of the tibia, beginning 3 cm above the joint line and extend it as far distally as needed (Fig. 1.47B). Avoid the great saphenous vein and saphenous nerve anterior to the incision. n  Mobilize and retract the pes anserinus tendons proximally and anteriorly or distally and posteriorly. n  Retract the medial gastrocnemius and soleus muscles posteriorly, exposing the junction of popliteal fascia, the semimembranosus insertion, and the medial collateral ligaments. n  Incise the periosteum longitudinally and subperiosteally elevate the popliteus muscle insertion off the posterior tibia (Fig. 1.48).     n  n 

  TECHNIQUE 1.34 With the patient supine, make an incision 1 to 2 cm proximal to the joint line in line with the medial femoral epicondyle and extend it over the pes anserinus insertion (Fig. 1.47). Avoid the saphenous vein and nerve that usually are posterior. n  Take the pes anserinus tendons down sharply from the tibia, exposing the superficial and deep medial collateral ligaments. n  Indirectly reduce the fracture and apply a plate over the medial collateral ligaments.     n 

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PART I  GENERAL PRINCIPLES (Fig. 1.49B). Identify and protect the cutaneous nerves and superficial vessels. n  Define the interval between the tendon of the semitendinosus muscle and the medial head of the gastrocnemius muscle. n  Retract the semitendinosus proximally and medially and the gastrocsoleus component distally and laterally; the popliteus and flexor digitorum longus muscles lie in the floor of the interval (Fig. 1.49C). n  Elevate subperiosteally the flexor digitorum longus muscle distally and laterally and the popliteus muscle proximally and medially, and expose the posterior surface of the proximal fourth of the tibia (Fig. 1.49D). Further elevation of the popliteus will expose the posterior cruciate ligament fossa. n  If necessary, extend the incision distally along the medial side of the calf by continuing the dissection in the same intermuscular plane. The tibial nerve and posterior tibial artery lie beneath the soleus muscle.    

 

POSTEROMEDIAL APPROACH (PRONE) TO THE SUPEROMEDIAL TIBIA The posterior approach to the superomedial region of the tibia is useful for fixation of posteromedial split fractures of the tibial plateau. This is also known as the “reversed L” posteromedial approach.

  TECHNIQUE 1.36 (BANKS AND LAUFMAN) With the patient positioned prone, begin the transverse segment of a hockey-stick incision (Fig. 1.49A) at the lateral end of the flexion crease of the knee, and extend it across the popliteal space. Turn the incision distally along the medial side of the calf for 7 to 10 cm. n  Develop the angular flap of skin and subcutaneous tissue and incise the deep fascia in line with the skin incision n 

Semitendinosus muscle Medial

Lateral Lesser saphenous vein Medial sural cutaneous nerve Fascia Medial head of gastrocnemius muscle

A

B

Semitendinosus muscle Popliteus muscle Popliteus muscle

Tibia Gastrocnemius and soleus muscle

Flexor digitorum longus muscle

C

Gastrocnemius and soleus muscles

Flexor digitorum longus muscle

D

FIGURE 1.49 Banks and Laufman posterior approach to superomedial region of tibia. A, Incision extends transversely across popliteal fossa and then turns distally on medial side of calf. B, Skin and deep fascia have been incised and reflected. C, Broken line indicates incision to be made between popliteus and flexor digitorum longus. D, Popliteus and flexor digitorum longus have been elevated subperiosteally to expose tibia. SEE TECHNIQUE 1.36.

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CHAPTER 1  SURGICAL TECHNIQUES  

Transect the branch of the common peroneal nerve to the proximal tibiofibular joint. n  Release the common peroneal nerve from the posterior intermuscular septum posterior to the peroneus longus muscle as it enters the lateral compartment. n  Expose the deep peroneal nerve by detaching the peroneus longus and tibialis anterior muscles from the posterior and anterior aspects of the anterior intermuscular septum, respectively. n  Release the deep peroneal nerve as it enters the anterior compartment and goes through the anterior septum. n  Pre-drill the fibular head and neck just lateral to the biceps femoris insertion. n  Osteotomize the fibular neck with an osteotome just above the peroneal nerve (Fig. 1.50B). n  Release the joint capsule from the proximal tibiofibular joint and reflect the fibular head proximally with attached biceps femoris tendon and lateral collateral ligament complex, exposing the postural corner of the knee joint. n  Mobilize the lateral meniscus by detaching the coronary ligament from the posterior cruciate ligament medially to the iliotibial band laterally, and elevate it to expose the tibial articular surfaces. n 

POSTEROLATERAL APPROACH TO THE TIBIAL PLATEAU This approach is useful for lateral and posterolateral plateau fractures. This approach with a fibular osteotomy is useful for fractures of the posterolateral plateau.

  TECHNIQUE 1.37 (SOLOMON ET AL.) Position the patient supine with the knee extended. Make a 6-cm longitudinal incision anterior to the biceps femoris tendon contour on the fibular head. The incision can be extended distally as needed. n  Flex the knee to 60 degrees. n  Incise the subcutaneous fat in line with the skin incision, exposing the deep fascia. n  Incise the fascia lata over the biceps tendon and the common peroneal nerve. Identify the common peroneal nerve in the adipose tissue of the popliteal fossa (Fig. 1.50A). n  Knee flexion relaxes the common peroneal nerve. Expose the nerve down to the fibular head. Protect the sural nerve branch from the common peroneal nerve in the popliteal fossa. n 

Iliotibial band

Iliotibial band Fibular head

Biceps femoris tendon Common peroneal nerve

Biceps femoris tendon Lateral collateral ligament

Common peroneal nerve

Fibular head

Fibular neck osteotomy

A

B FIGURE 1.50 Posterolateral approach with osteotomy of the fibular neck. A, Superficial dissection of posterolateral corner. B, Osteotomy and reflection of fibular head proximally with attached biceps femoris tendon and lateral collateral ligament. Flex the knee to relax the common peroneal nerve, lateral head of gastrocnemius muscle, and popliteus muscle. Visualize the joint between to posterior cruciate ligament and posterior border of the iliotibial band. (Redrawn from Solomon LB, Stevenson AW, Baird RPV, Pohl AP. Posterolateral transfibular approach to tibial plateau fracture: technique, results, and rationale, J Orthop Trauma 24:505, 2010.) SEE TECHNIQUE 1.37.

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PART I  GENERAL PRINCIPLES

Popliteal artery

Biceps femoris muscle

Lateral gastrocnemius muscle Popliteus muscle

Soleus muscle

FIGURE 1.51 Posterolateral approach with osteotomy of fibular head. Make the plane of the osteotomy parallel to fibular articular surface. Remove the entire fibular head if needed but leave the attachments of the fibular collateral ligament and biceps femoris intact. (Redrawn from Yu B, Han K, Zhan C, et al: Fibular head osteotomy: a new approach for the treatment of lateral or posterolateral tibial plateau fractures, The Knee 17:313, 2010.) SEE TECHNIQUE 1.37.

At closure, repair the osteotomy with a longitudinal screw. Alternatively, the fibular head can be osteotomized in a longitudinal direction as described by Yu et al. One third of the fibular head or the entire fibular head can be removed, depending on the exposure required (Fig. 1.51). The biceps femoris and lateral collateral ligament insertions are left intact.    

n  n 

 

POSTEROLATERAL APPROACH TO THE TIBIAL PLATEAU WITHOUT FIBULAR OSTEOTOMY

Head of fibula

FIGURE 1.52 Posterolateral corner of tibia. Develop the interval between the popliteus muscle and the biceps femoris muscle. Reflect the soleus muscle origin from the proximal tibia. (Redrawn from Frosch KH, Balcarek P, Walde T, Stürmer KM: A new posterolateral approach without fibular osteotomy for the treatment of tibial plateau fractures, J Orthop Trauma 24:515, 2010.) SEE TECHNIQUE 1.38.  

TSCHERNE-JOHNSON EXTENSILE APPROACH TO THE LATERAL TIBIAL PLATEAU This approach is useful for depressed lateral plateau fractures.

  TECHNIQUE 1.39 (JOHNSON ET AL.)

  TECHNIQUE 1.38

Position the patient supine with a bump under the ipsilateral hip. n  Flex the knee over a large bump so that the leg will rest just off the edge of the table. n  Perform a lateral parapatellar incision from the supracondylar area of the distal femur to below and lateral to the tibial tubercle. n  Develop a lateral soft-tissue flap from the wound edge to the posterolateral corner of the tibial plateau. n  Identify Gerdy’s tubercle and the anterior and posterior edges of the iliotibial band. n  Flex the knee to 40 degrees and incise the central portion of the iliotibial band distally from a point 4 cm above the joint line to the joint line and continue it anteriorly, dividing the anterior half of the band (Fig. 1.53A). Carry the incision anteriorly to the patellar tendon. n  Retract the anterior half of the iliotibial band exposing the lateral joint line. n 

(FROSCH ET AL.) Place the patient in the lateral decubitus position with the operative side up. n  Support the knee with a thick, rolled pillow. n  Make a 15-cm posterolateral incision starting 3 cm above the joint line then following the fibula distally. n  Incise the posterior portion of the iliotibial band from Gerdy’s tubercle and perform a lateral arthrotomy. n  Bluntly dissect into the popliteal fossa between the lateral origin of the gastrocnemius muscle and soleus muscle, exposing the popliteus muscle. n  Ligate the inferior geniculate vessels if necessary. n  Develop the interval between the biceps femoris muscle and the popliteus muscle (Fig. 1.52). n  Detach the soleus muscle from the posterior aspect of the fibula exposing the posterolateral plateau.     n 

Peroneal nerve

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CHAPTER 1  SURGICAL TECHNIQUES

A

B

FIGURE 1.53 Tscherne-Johnson extensile approach to the lateral tibial plateau. A, Elevate Gerdy’s tubercle with two osteotomies with bone cuts 90 degrees to each other. Base it on a posterior hinge behind Gerdy’s tubercle. B, Externally rotate the fragment leaving the posterior insertion of the iliotibial band attached. (Redrawn from Johnson EE, Timon S: Tscherne-Johnson extensile approach for tibial plateau fractures, Clin Orthop Relat Res 471:2760, 2013.) SEE TECHNIQUE 1.39.

Incise the meniscal coronary ligament from posterior to anterior ending at the level of the patellar tendon. n  Place three 2-0 absorbable sutures in the meniscal edge and elevate it. The sutures will be used to later repair the meniscus to the lateral plateau rim. n  Incise the origin of the tibialis anterior muscle along the lateral tibial metaphyseal flair and elevate it distally. n  Perform two osteotomies anterior and distal to Gerdy’s tubercle with a narrow osteotome (Fig. 1.53A). n  Rotate Gerdy’s tubercle fragment posteriorly on its posterior soft-tissue hinge to expose the undersurface of the lateral plateau (Fig. 1.53B). n  At closure, repair the osteotomy with an overlying plate and screws with one of the screws directly repairing the osteotomy.     n 

  TECHNIQUE 1.40 (SUN ET AL.) Place the patient in the lateral decubitus position. Make a 15-cm longitudinal incision 1.5-cm lateral to the tibial crest, and extend it between Gerdy’s tubercle and the fibular head. n  Raise a full-thickness myocutaneous flap, and reflect the iliotibial tract from Gerdy’s tubercle. n  Perform an osteotomy of the lateral tibial plateau, beginning at the anterolateral quadrant and moving posteriorly medial to the proximal tibiofibular joint (Fig. 1.54). n  The depressed posterolateral corner can now be exposed. n  Repair the osteotomy after elevation and grafting of the depressed segment.    n  n 

 

ANTEROLATERAL APPROACH FOR ACCESS TO POSTEROLATERAL CORNER Sun et al. described an anterolateral approach to gain access to the posterolateral corner when a depressed fracture involves this area.

Yoon et  al. described an approach to the posterolateral corner by taking down the lateral collateral ligament with a piece of the lateral femoral epicondyle. The osteotomized piece should be large enough to allow repair with a large screw and washer.

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PART I  GENERAL PRINCIPLES

FIBULA 

A

 

AL

POSTEROLATERAL APPROACH TO THE FIBULA

AM

  TECHNIQUE 1.41

C B PL

D

(HENRY)

PM

FIGURE 1.54 Osteotomy of the lateral tibial plateau. A, Knee center. B, Posteromedial ridge. C, Anterior edge of fibula. D, Posterior sulcus. PL, Posterolateral corner. AL, anterolateral; AM, anteromedial; PM, posteromedial. SEE TECHNIQUE 1.40.

Posterior cutaneous nerve of the calf

Beginning 13 cm proximal to the lateral malleolus, incise the skin proximally along the posterior margin of the fibula to the posterior margin of the head of the bone and continue farther proximally for 10 cm along the posterior aspect of the biceps tendon. n  Divide the superficial and deep fasciae. Isolate the common peroneal nerve along the posteromedial aspect of the biceps tendon in the proximal part of the wound, and free it distally to its entrance into the peroneus longus muscle (Fig. 1.55). n  Pointing the knife blade proximally and anteriorly, detach the part of the peroneus longus muscle that arises from the lateral surface of the head of the fibula proximal to the common peroneal nerve. Retract the nerve over the head of the fibula. n  Locate the fascial plane between the soleus muscle posteriorly and the peroneal muscles anteriorly and deepen the dissection along the plane to the fibula. n  Expose the bone by retracting the peroneal muscles anteriorly and incising the periosteum. When retracting these muscles, avoid injuring the branches of the deep peroneal nerve that lie on their deep surfaces and are in close contact with the neck of the fibula and proximal 5 cm of the shaft. n  The distal fourth of the fibula is subcutaneous on its lateral aspect and may be exposed by a longitudinal incision through the skin, fascia, and periosteum.     n 

Biceps femoris muscle Common peroneal nerve

Tibial nerve Gastrocnemius muscle

Head of fibula Peroneus longus muscle Soleus muscle

A

B

FIGURE 1.55 Method of mobilizing and retracting common peroneal nerve when approaching proximal fibula posterolaterally. A, Anatomic relationships. B, Part of peroneus longus that arises from lateral surface of fibular head proximal to common peroneal nerve has been detached, allowing nerve to be retracted over fibular head. SEE TECHNIQUE 1.41.

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CHAPTER 1  SURGICAL TECHNIQUES

KNEE ANTEROMEDIAL AND ANTEROLATERAL APPROACHES   

ANTEROMEDIAL PARAPATELLAR APPROACH When any anteromedial approach is made, including one for meniscectomy, the infrapatellar branch of the saphenous nerve should be protected (Fig. 1.56). The saphenous nerve courses posterior to the sartorius muscle and then pierces the fascia lata between the tendons of the sartorius and gracilis muscles and becomes subcutaneous on the medial aspect of the leg; on the medial aspect of the knee it gives off a large infrapatellar branch to supply the skin over the anteromedial aspect of the knee. Several variations exist in the location and distribution of this infrapatellar branch. Consequently, no single incision on the anteromedial aspect of the knee can avoid it for certain. The nerve should be located and protected if possible.

  TECHNIQUE 1.42

Retract the patella laterally and flex the knee to gain a good view of the anterior compartment of the joint and the suprapatellar bursa. Divide the ligamentum mucosa if necessary. n  Attain wider access to the joint in the following ways: (1) extending the incision proximally, (2) extending the proximal part of the incision obliquely medially and separating the fibers of the vastus medialis, (3) dividing the medial alar fold and adjacent fat pad longitudinally, and (4) mobilizing the medial part of the insertion of the patellar tendon subperiosteally. If contracture of the quadriceps prevents sufficient exposure, detach the tibial tuberosity and reattach later with a screw. Fernandez described an extensive osteotomy of the tibial tuberosity and reattachment of the tuberosity with three lag screws engaging the posterior tibial cortex. This technique achieves rigid fixation and allows early postoperative rehabilitation. Keshmiri et al. recommended repair of the medial patellofemoral ligament at closure of a medial parapatellar approach during total knee arthroplasty (nonresurfaced patella). This is to prevent significant medial capsular dehiscence and resultant loading of the lateral patellar facet and increased anterior knee pain.     n 

Figure 1.57

(VON LANGENBECK) Begin the incision at the medial border of the quadriceps tendon 7 to 10 cm proximal to the patella, curve it around the medial border of the patella and back toward the midline, and end it at or distal to the tibial tuberosity. As a more cosmetically pleasing alternative, a longitudinal incision centered over the patella can be made, reflecting the subcutaneous tissue and superficial fascia over the patella medially by blunt dissection to the medial border of the patella. n  Divide and retract the fascia. n  Deepen the dissection between the vastus medialis muscle and the medial border of the quadriceps tendon and incise the capsule and synovium along this medial border and along the medial border of the patella and patellar tendon.

 

n 

Rectus femoris muscle Vastus medialis muscle Patella Patellar tendon

Sartorious muscle Saphenous vein Infrapatellar branch of saphenous nerve Saphenous nerve Gastrocnemius muscle

FIGURE 1.56 Anatomic relationships of superficial structures on medial aspect of knee. SEE TECHNIQUE 1.42.

SUBVASTUS (SOUTHERN) ANTEROMEDIAL APPROACH TO THE KNEE Problems with patellar dislocation, subluxation, and osteonecrosis after total knee arthroplasty performed through an anteromedial parapatellar approach led to the rediscovery of the subvastus, or Southern, anteromedial approach first described by Erkes in 1929. According to Hofmann et al., this approach preserves the vascularity of the patella by sparing the intramuscular articular branch of the descending genicular artery and preserves the quadriceps tendon, providing more stability to the patellofemoral joint in total knee arthroplasty. This approach also is useful for lesser anteromedial and medial knee procedures. The relative contraindications to this approach are previous major knee arthroplasty and weight greater than 200 lb, which makes eversion of the patella difficult. In a retrospective study of 143 knees in 96 patients, In et al. found that in patients with a thigh girth of larger than 55 cm the patella could not be everted when using a subvastus approach for total knee arthroplasty.

  TECHNIQUE 1.43 (ERKES, AS DESCRIBED BY HOFMANN, PLASTER, AND MURDOCK) Exsanguinate the limb and inflate the tourniquet with the knee flexed to at least 90 degrees to prevent tenodesis of the extensor mechanism. n  Make a straight anterior skin incision, beginning 8 cm above the patella, carrying it distally just medial and 2 cm distal to the tibial tubercle. n 

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Vastus lateralis muscle

Rectus femoris muscle Sartorius muscle

Lateral femoral condyle

Patella

Suprapatellar bursa

Vastus medialis muscle

Medial femoral condyle Posterior cruciate ligament

Lateral meniscus

Iliotibial band

Anterior cruciate ligament

Fibular head Tibial tuberosity Peroneus longus muscle

Tibial tuberosity

Extensor digitorum longus muscle

Gastrocnemius muscle Anterior tibial muscle

FIGURE 1.57    Anteromedial approach to knee joint. SEE TECHNIQUE 1.42.

Incise the superficial fascia slightly medial to the patella (Fig. 1.58A) and bluntly dissect it off the vastus medialis muscle fascia down to the muscle insertion (Fig. 1.58B). n  Identify the inferior edge of the vastus medialis and bluntly dissect it off the periosteum and intermuscular septum for a distance of 10 cm proximal to the adductor tubercle. n  Identify the tendinous insertion of the muscle on the medial patellar retinaculum (Fig. 1.58C) and lift the vastus medialis muscle anteriorly and perform an L-shaped arthrotomy beginning medially through the vastus insertion on the medial patellar retinaculum and carrying it along the medial edge of the patella. n  Partially release the medial edge of the patellar tendon and evert the patella laterally with the knee extended (Fig. 1.58D).     n 

 

ANTEROLATERAL APPROACH TO THE KNEE Usually the anterolateral approach is not as satisfactory as the anteromedial one, primarily because it is more difficult to displace the patella medially than laterally. It also requires a longer incision, and often the patellar tendon

must be partially freed subperiosteally or subcortically. The iliotibial band can be released or lengthened, and the tight posterolateral corner can be released easily. The fibular head can be resected through the same incision to decompress the peroneal nerve if necessary.

  TECHNIQUE 1.44

Figure 1.59

(KOCHER) Begin the incision 7.5 cm proximal to the patella at the insertion of the vastus lateralis muscle into the quadriceps tendon; continue it distally along the lateral border of this tendon, the patella, and the patellar tendon; and end it 2.5 cm distal to the tibial tuberosity. n  Deepen the dissection through the joint capsule. n  Retract the patella medially, with the tendons attached to it, and expose the articular surface of the joint.    n 

Satish et al. found the modified Keblish approach useful in total knee arthroplasty in patients with fixed valgus knees. The approach relies on a quadriceps snip and coronal Z-plasty of lateral retinacular capsule complex. The lateral retinacular complex is separated into two layers, deep (capsule and synovium) and superficial. The lateral parapatellar arthrotomy is performed 3 to 7 cm lateral to the patella, and the

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CHAPTER 1  SURGICAL TECHNIQUES

Vastus medialis muscle

Patella

Medial patellar retinaculum

Fascial layer 1

Fascial layer 1

A

B

Everted patella

Vastus medialis muscle

Anterior cruciate ligament

Patella Arthrotomy

Lateral fat pad

Patellar tendon

Medial patellar retinaculum

C

Medial meniscus

Medial collateral ligament

D

Vastus medialis muscle

FIGURE 1.58 Subvastus anteromedial approach. A, Superficial fascia is incised medial to patella. B, Superficial fascia is bluntly elevated from perimuscular fascia of vastus medialis down to its insertion on medial patellar retinaculum. C, Tendinous insertion elevated by blunt dissection. Dashed line indicates arthrotomy. D, Patella is everted, and knee is flexed. SEE TECHNIQUE 1.43.

deep and superficial layers are separated with dissection carried medially toward the patella. The superficial layer is kept attached to the patella, and the deep layer remains attached to the iliotibial band. At closure, the layers are approximated in an expanded fashion (Fig. 1.60).

POSTEROLATERAL AND POSTEROMEDIAL APPROACHES TO THE KNEE

In some patients, a median septum separates the posterior aspect of the knee into two compartments. The posterior cruciate ligament is extrasynovial and projects anteriorly in the septum; it contributes to the partition between the two posterior compartments. The middle genicular artery courses anteriorly in the septum to nourish the tissues of the intercondylar notch of the femur (Fig. 1.61). The presence of this septum may assume great importance when exploring the posterior aspect of the knee for a loose body or when draining the joint in the rare instances in which pyogenic arthritis of the knee requires posterior drainage. In the latter, both posterior compartments must be opened for drainage, not one alone (see Chapter 22). 

 

POSTEROLATERAL APPROACH TO THE KNEE   TECHNIQUE 1.45

Figure 1.62

(HENDERSON) With the knee flexed between 60 and 90 degrees, make a curved incision on the lateral side of the knee, just anterior to the biceps femoris tendon and the head of the fibula, and avoid the common peroneal nerve, which passes over the lateral aspect of the neck of the fibula. n  In the proximal part of the incision, trace the anterior surface of the lateral intermuscular septum to the linea aspera 5 cm proximal to the lateral femoral condyle. n  Expose the lateral femoral condyle and the origin of the fibular collateral ligament. n  The tendon of the popliteus muscle lies between the biceps tendon and the fibular collateral ligament; mobilize n 

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PART I  GENERAL PRINCIPLES

Vastus lateralis muscle

Rectus femoris muscle Sartorius muscle

Iliotibial band

A

Biceps tendon Medial patellar retinaculum Patellar tendon

Patella Lateral femoral condyle

Posterior cruciate ligament

Lateral meniscus

Anterior cruciate ligament

Peroneus longus muscle

Infrapatellar branch of saphenous nerve

Extensor digitorum longus muscle

Gastrocnemius muscle

Anterior tibial muscle Fibular collateral ligament

B

Transverse ligament

Fibular head

Vastus medialis muscle

Medial surface of tibia

Tibial tuberosity Lateral surface of tibia

C FIGURE 1.59    A-C, Kocher anterolateral approach to knee joint. SEE TECHNIQUE 1.44.

Fenestra in intercondylar septum

FIGURE 1.60 Coronal Z-plasty of lateral retinaculum capsule complex. (Redrawn from Satish BRJ, Ganesan JC, Chandran P, et al: Efficacy and mid-term results of lateral parapatellar approach without tibial tubercle osteotomy for primary total knee arthroplasty in fixed valgus knees, J Arthroplasty 28:1751, 2013.)

Middle genicular artery Posterior cruciate ligament Anterior cruciate ligament

Ligamentum mucosum

FIGURE 1.61 Median septum separating two posterior compartments of knee. Note fenestra at proximal pole. Synovial septum invests cruciate ligaments and contains branch of middle genicular artery.

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CHAPTER 1  SURGICAL TECHNIQUES

Rectus femoris muscle

Vastus lateralis muscle Biceps femoris muscle Lateral head of gastrocnemius muscle

Iliotibial band Fibular head

Common peroneal nerve

Extensor digitorum longus muscle

Peroneus longus muscle Common peroneal nerve

Anterior tibial muscle

Soleus muscle

Posterolateral joint capsule Fibular collateral ligament

Biceps femoris muscle Lateral head of gastrocnemius muscle Lateral femoral condyle

FIGURE 1.62    Henderson posterolateral approach to knee joint. SEE TECHNIQUE 1.45.

and retract it posteriorly, and expose the posterolateral aspect of the joint capsule. n  Make a longitudinal incision through the capsule and synovium of the posterior compartment. To see the insertion of the muscle fibers of the short head of the biceps muscle onto the long head of the biceps, develop the interval between the lateral head of the quadriceps muscle and the long head of the biceps tendon. To isolate the common peroneal nerve, dissect directly posterior to the long head of the biceps. These intervals are useful in repair of the posterolateral corner of the knee.   

condyle needs to be treated, an osteotomy of Gerdy’s tubercle can be performed with reflection of the iliotibial band proximally as described by Liebergall et al.   

POSTEROMEDIAL APPROACH TO THE KNEE   TECHNIQUE 1.46 (HENDERSON) With the knee flexed 90 degrees, make a curved incision, slightly convex anteriorly and approximately 7.5 cm long, distally from the adductor tubercle and along the course of the tibial collateral ligament, anterior to the relaxed tendons of the semimembranosus, semitendinosus, sartorius, and gracilis muscles.

n 

Bowers and Huffman found the Hughston and Jacobson technique for exposure of the posterolateral corner by wafer osteotomy of the lateral collateral ligament insertion on the lateral femoral epicondyle with reflection of the ligament distally useful. Alternatively, if a fracture of the lateral femoral

Figure 1.63

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Rectus femoris muscle Quadriceps tendon

Gracilis muscle

Vastus medialis muscle

Semimembranosus muscle

Patella

Semitendinosus muscle Infrapatellar branch of saphenous nerve Sartorius muscle

Gastrocnemius muscle

A

B

Medial femoral condyle Medial meniscus

C FIGURE 1.63    A-C, Henderson posteromedial approach to knee joint. SEE TECHNIQUE 1.46.

Expose and incise the oblique part of the tibial collateral ligament and incise the capsule longitudinally and enter the posteromedial compartment of the knee posterior to the tibial collateral ligament, retracting the hamstring tendons posteriorly.   

n 

MEDIAL APPROACHES TO THE KNEE AND SUPPORTING STRUCTURES

Usually the entire medial meniscus can be excised through a medial parapatellar incision about 5 cm long. If the posterior horn of the meniscus cannot be excised through this incision, a separate posteromedial Henderson approach can be made (Fig. 1.63). The anterior and posterior compartments may be entered, however, through an approach in which only one incision is made through the skin but two incisions are used

through the deeper structures; this type of approach is rarely indicated.   

MEDIAL APPROACH TO THE KNEE The Cave approach is a curved incision that allows exposure of the anterior and posterior compartments.

  TECHNIQUE 1.47 (CAVE) With the knee flexed at a right angle, identify the medial femoral epicondyle and begin the incision 1 cm posterior to and on a level with it approximately 1 cm proximal to the joint line. Carry the incision distally and anteriorly to

n 

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CHAPTER 1  SURGICAL TECHNIQUES

Femoral condyle

Medial femoral condyle

Capsule

Medial meniscus

Incisions into capsule

A

B

C

FIGURE 1.64 Exposure of anterior and posterior compartments of knee joint through one skin incision, according to Cave. A, Single skin incision. B, Two incisions through deep structures. C, Removal of meniscus. SEE TECHNIQUE 1.47.

a point 0.5 cm distal to the joint line and anterior to the border of the patellar tendon. n  After reflecting the subcutaneous tissues, expose the anterior compartment through an incision that begins anterior to the tibial collateral ligament, continues distally and anteriorly in a curve similar to that of the skin incision, and ends just distal to the joint line (Fig. 1.64). n  To expose the posterior compartment, make a second deep incision posterior to the tibial collateral ligament, from the level of the femoral epicondyle straight distally across the joint line.      

MEDIAL APPROACH TO THE KNEE   TECHNIQUE 1.48 (HOPPENFELD AND DEBOER) With the patient supine and the affected knee flexed about 60 degrees, place the foot on the opposite shin and abduct and externally rotate the hip. n  Begin the incision 2 cm proximal to the adductor tubercle of the femur, curve it anteroinferiorly about 3 cm medial to the medial border of the patella, and end it 6 cm distal to the joint line on the anteromedial aspect of the tibia (Fig. 1.65A). n  Retract the skin flaps to expose the fascia of the knee and extend the exposure from the midline anteriorly to the posteromedial corner of the knee (Fig. 1.65B). n  Cut the infrapatellar branch of the saphenous nerve and bury its end in fat; preserve the saphenous nerve itself and the long saphenous vein. n  Longitudinally incise the fascia along the anterior border of the sartorius, starting at the tibial attachment of the n 

muscle and extending it to 5 cm proximal to the joint line. n  Flex the knee further and allow the sartorius to retract posteriorly, exposing the semitendinosus and gracilis muscles (Fig. 1.65C). n  Retract all three components of the pes anserinus posteriorly and expose the tibial attachment of the tibial collateral ligament, which inserts 6 to 7 cm distal to the joint line (Fig. 1.65D). n  To open the joint anteriorly, make a longitudinal medial parapatellar incision through the retinaculum and synovium (Fig. 1.65E). n  To expose the posterior third of the medial meniscus and the posteromedial corner of the knee, retract the three components of the pes anserinus posteriorly (Fig. 1.65F) and separate the medial head of the gastrocnemius muscle from the posterior capsule of the knee almost to the midline by blunt dissection (Fig. 1.65G). n  To open the joint posteriorly, make an incision through the capsule posterior to the tibial collateral ligament.      

TRANSVERSE APPROACH TO THE MENISCUS Using a transverse approach to the medial meniscus has the advantage that the scar has no contact with the femoral articular surface.

  TECHNIQUE 1.49 Make a transverse incision 5 cm long at the level of the articular surface of the tibia, extending laterally from the medial border of the patellar tendon to the anterior border of the tibial collateral ligament (Fig. 1.66).

n 

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Tibial tuberosity

Adductor tubercle

A Fascia over vastus medialis

Vastus medialis Medial patellar retinaculum

Medial patellar retinaculum (retracted) Sartorius Infrapatellar branch of saphenous nerve

Anterior joint capsule Medial meniscus Superficial tibial collateral ligament

B Medial patellar retinaculum (retracted) Superficial tibial collateral ligament and its tibial insertion

Medial head of gastrocnemius Posteromedial joint capsule Semitendinosus Semimembranosus Gracilis Sartorius

C

Fascia over vastus medialis

Medial femoral condyle

Medial head of gastrocnemius Posteromedial joint capsule Tendon of semimembranosus Fascia over sartorius

Medial patellar retinaculum

Medial head of gastrocnemius

D

E FIGURE 1.65 Medial approach to knee and supporting structures. A, Skin incision. B, Skin flaps have been retracted. C, Sartorius has been retracted posteriorly, exposing semitendinosus and gracilis. D, All three components of pes anserinus have been retracted posteriorly to expose tibial attachment of tibial collateral ligament. E, Medial parapatellar incision has been made through retinaculum and synovium.

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CHAPTER 1  SURGICAL TECHNIQUES

Medial femoral condyle

Posteromedial joint capsule Medial patellar retinaculum (retracted)

Medial patellar retinaculum (retracted)

Medial head of gastrocnemius

Superficial tibial collateral ligament

Medial head of gastrocnemius

Superficial tibial collateral ligament

Semimembranosus Sartorius

Sartorius Semimembranosus

F

G

Posteromedial View

Posteromedial View

FIGURE 1.65, cont’d F, Three components of pes anserinus have been retracted posteriorly to expose posteromedial corner. G, Medial head of gastrocnemius has been separated from posterior capsule of knee and has been retracted. Capsulotomy is made posterior to tibial collateral ligament. (Modified from Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach, Philadelphia, 2003, Lippincott Williams & Wilkins.) SEE TECHNIQUE 1.48.

When closing the incision, place the first suture in the synovium at the medial side near the collateral ligament while the knee is still flexed; if the joint is extended before the first suture is inserted, the posterior part of the synovial incision retracts under the tibial collateral ligament. To complete the suture line, extend the joint. n  The transverse incision is not satisfactory for removing the lateral meniscus because it would require partial division of the iliotibial band. To avoid this, make an oblique incision 7.5 cm long centered over the joint line (Fig. 1.67). n  In the capsule, make a hockey-stick incision that runs transversely along the joint line and curves obliquely proximally along the anterior border of the iliotibial band for a short distance. n  Undermine and retract the capsule and incise the synovial membrane transversely as previously described.    n 

FIGURE 1.66 Transverse approaches to menisci. Medial meniscus is approached through transverse incisions in skin and capsule; lateral meniscus is approached through oblique incision in skin and hockey-stick incision in capsule. SEE TECHNIQUE 1.49.

Incise the capsule along the same line and dissect the proximal edge of the divided capsule from the underlying synovium and retract it proximally. n  Open the synovium along the proximal border of the medial meniscus. Charnley advised making a preliminary 1.5-cm opening into the small synovial sac beneath the meniscus, introducing a blunt hook into it, and turning the hook so that its end rests on the proximal surface of the meniscus. By cutting down on the point of the hook, one can make the synovial incision at the most distal level. n  Divide the anterior attachment of the meniscus, retract the tibial collateral ligament, and complete the excision of the meniscus in the usual way (see Chapter 45). n 

LATERAL APPROACHES TO THE KNEE AND SUPPORTING STRUCTURES

Lateral approaches permit good exposure for complete excision of the lateral meniscus. They do not require division or release of the fibular collateral ligament.   

LATERAL APPROACH TO THE KNEE   TECHNIQUE 1.50 (BRUSER) Place the patient supine and drape the limb to permit full flexion of the knee. Flex the knee fully so that the foot rests flat on the operating table.

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PART I  GENERAL PRINCIPLES

A

Fibular collateral ligament

B

Iliotibial band Synovium

Popliteus tendon Lateral inferior genicular artery Lateral meniscus

C

D

FIGURE 1.67 Bruser lateral approach to knee. A, Skin incision (see text). B, Broken line indicates proposed incision in iliotibial band, whose fibers, when knee is fully flexed, are parallel with skin incision. C, Knee has been extended slightly, and lateral meniscus is being excised. D, Lateral meniscus has been excised, and synovium is being closed. (Modified from Bruser DM: A direct lateral approach to the lateral compartment of the knee joint, J Bone Joint Surg 42B:348, 1960.) SEE TECHNIQUES 1.49 AND 1.50.

 

Begin the incision anteriorly where the patellar tendon crosses the lateral joint line, continue it posteriorly along the joint line, and end it at an imaginary line extending from the proximal end of the fibula to the lateral femoral condyle (Fig. 1.67A). n  Incise the subcutaneous tissue and expose the iliotibial band, whose fibers are parallel with the skin incision when the knee is fully flexed (Fig. 1.67B). Split the band in line with its fibers. Posteriorly, take care to avoid injuring the relaxed fibular collateral ligament; it is protected by areolar tissue, which separates it from the iliotibial band. n  Retract the margins of the iliotibial band; this is possible to achieve without much force because the band is relaxed when the knee and hip are flexed. n  Locate the lateral inferior genicular artery, which lies outside the synovium between the collateral ligament and the posterolateral aspect of the meniscus. n  Incise the synovium. The lateral meniscus lies in the depth of the incision and can be excised completely (Fig. 1.67C). n  With the knee flexed 90 degrees, close the synovium (Fig. 1.67D); and with the knee extended, close the deep ­fascia.     n 

LATERAL APPROACH TO THE KNEE Brown et al. have developed an approach for lateral meniscectomy in which the knee is flexed to allow important structures to fall posteriorly as in the Bruser approach. In addition, a varus strain is created to open the lateral joint space.

  TECHNIQUE 1.51 (BROWN ET AL.) Place the patient supine with the extremity straight and with a small sandbag under the ipsilateral hip. n  Make a vertical, oblique, or transverse skin incision on the anterolateral aspect of the knee. n  Identify the anterior border of the iliotibial band and make an incision in the fascia 0.5 to 1 cm anterior to the band in line with its fibers. n  Incise the synovium in line with this incision and inspect the joint. n  By sharp dissection, free the anterior horn of the m ­ eniscus. n  Flex the knee, cross the foot over the opposite knee, and push firmly toward the opposite hip, applying a varus n 

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CHAPTER 1  SURGICAL TECHNIQUES force to the knee. Ensure the thigh on the involved side is in line with the sagittal plane of the trunk; the hip is flexed about 45 degrees and externally rotated about 40 degrees. Push, as described, until the joint space opens up 3 to 5 mm. If necessary, internally rotate the tibia to bring the lateral tibial plateau into better view; however, this tends to close the joint space. n  With proper retractors, expose the entire meniscus, which can be excised completely by sharp dissection.      

LATERAL APPROACH TO THE KNEE   TECHNIQUE 1.52 (HOPPENFELD AND DEBOER) Place the patient supine with a sandbag beneath the ipsilateral buttock and flex the knee 90 degrees. n  Begin the incision 3 cm lateral to the middle of the patella, extend it distally over Gerdy’s tubercle on the tibia, and n 

end it 4 to 5 cm distal to the joint line. Complete the incision proximally by curving it along the line of the femur (Fig. 1.68A). n  Widely mobilize the skin flaps anteriorly and posteriorly. n  Incise the fascia between the iliotibial band and biceps femoris, carefully avoiding the common peroneal nerve on the posterior aspect of the biceps tendon (Fig. 1.68B). n  Retract the iliotibial band anteriorly and the biceps femoris and common peroneal nerve posteriorly to expose the fibular collateral ligament and the posterolateral corner of the knee capsule (Fig. 1.68C). n  To expose the lateral meniscus, make a separate lateral parapatellar incision through the fascia and joint capsule (Fig. 1.68B). n  To avoid cutting the meniscus, begin the arthrotomy 2 cm proximal to the joint line. n  To expose the posterior horn of the lateral meniscus, locate the origin of the lateral head of the gastrocnemius muscle on the posterior surface of the lateral femoral condyle. n  Dissect between it and the posterolateral corner of the joint capsule; ligate or cauterize the lateral superior genicular arterial branches located in this area.

Lateral patellar retinaculum

Iliotibial band Gerdy's tubercle Biceps femoris Common peroneal nerve

A

B

Posterolateral joint capsule

Iliotibial band

Lateral head of gastrocnemius (retracted)

Lateral femoral condyle Synovium Anterior joint capsule (retracted) Tibial collateral ligament Tendon of popliteus Joint capsule

Lateral meniscus Tendon of biceps femoris (retracted) Lateral inferior genicular artery Common peroneal nerve

C

Lateral femoral condyle

FIGURE 1.68 Lateral approach to knee and supporting structures. A, Skin incision. B, Incision between biceps femoris and iliotibial band. C, Deep dissection (see text). (Modified from Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach, Philadelphia, Lippincott Williams & Wilkins, 2003.) SEE TECHNIQUE 1.52.

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PART I  GENERAL PRINCIPLES Make a longitudinal incision in the capsule, beginning well proximal to the joint line to avoid damaging the meniscus or the popliteus tendon. Inspect the posterior half of the lateral compartment posterior to the fibular collateral ligament (Fig. 1.68C).    

n 

 

EXTENSILE APPROACH TO THE KNEE Fernandez described an extensile anterior approach to the knee based on an anterolateral approach that allows easy access to the medial and lateral compartments in the following ways: (1) by an extensive osteotomy of the tibial tuberosity that allows proximal reflection of the patella, patellar tendon, and retropatellar fat pad and (2) by transecting the anterior horn and anterior portion of the coronary ligament of the medial meniscus or the lateral meniscus or both as necessary to achieve adequate exposure. This approach may be used for tumor resection, ligament reconstruction, fracture reduction and fixation, and adult reconstructive procedures. Part or all of this approach may be used as necessary to achieve the required exposure. Rigid screw fixation of the tibial tuberosity engaging the posterior cortex of the tibia allows early postoperative knee motion. Perry et al. first reported transection of the anterior horn of the lateral meniscus to aid exposure of lateral tibial plateau fractures. Alternatively, the articular surface of either tibial plateau can be approached with a submeniscal exposure by releasing the peripheral attachment of the meniscus at the coronary ligament and by elevating the meniscus, as described by Gossling and Peterson.

  TECHNIQUE 1.53 (FERNANDEZ) Place the patient supine and drape the limb to allow at least 60 degrees of knee flexion. n  Begin a lateral parapatellar incision 10 cm proximal to the lateral joint line; continue it distally along the lateral border of the patella, patellar tendon, and tibial tuberosity; and end it 15 cm distal to the lateral joint line (Fig. 1.69A). n  Develop skin flaps deep in the subcutaneous tissue, extending medially to the anterior edge of the tibial collateral ligament and laterally, exposing the iliotibial band and the proximal origins of the anterior tibial and peroneal muscles (Fig. 1.69B). n  To expose the lateral tibial metaphysis, detach the anterior tibial muscle and retract it distally, and elevate the iliotibial band by dividing it transversely at the joint line or by performing a flat osteotomy of Gerdy’s tubercle (Fig. 1.69C). If exposure of the posteromedial portion of the tibial metaphysis is necessary, divide the tibial insertion of the pes anserinus or elevate it as an osteoperiosteal flap. n  Fernandez advocates an extended osteotomy into the tibial crest in the presence of a bicondylar tibial plateau fracture to ensure that the osteotomy fragment is securely fixed into the tibial diaphysis below the level of the fracture. A less extensive osteotomy may be used as ­appropriate. n 

Perform an extended trapezoidal osteotomy of the tibial tuberosity as follows: 1. Mark with an osteotome a site 5 cm in length, 2 cm in width proximally, and 1.5 cm in width distally. 2. Drill three holes for later reattachment of the tibial tuberosity. 3. Complete the osteotomy with a flat osteotome. n  Elevate the tibial tuberosity and patellar tendon and incise the joint capsule transversely, medially, and laterally at the joint line. n  Carry each limb of the capsular incision proximally to the level of the anterior border of the vastus medialis and vastus lateralis (Fig. 1.69C,D). n  If further exposure of the articular surface of the tibial plateaus is needed, detach one or both menisci by transection of the anterior horn, cutting the transverse ligament and dividing the anterior portion of the coronary ligament. The meniscus may be elevated and held with a stay suture (Fig. 1.69E). n  At wound closure, repair the anterior meniscus, coronary ligament, and transverse ligament with 2-0 nonabsorbable sutures. Use square stitches to repair the meniscus and two or three U-shaped stitches to stabilize the periphery of the meniscus. n  Tie the stitches over the joint capsule after closure of the medial and lateral arthrotomies (Fig. 1.69F). n  Reattach the anterior tibial muscle and pes anserinus to bone with interrupted sutures. n  Reattach Gerdy’s tubercle with a lag screw. n  Rigidly fix the tibial tuberosity osteotomy with lag screws obtaining good purchase in the posterior cortex of the tibia. n  Close the arthrotomy with interrupted sutures (Fig. 1.69G).    n 

DIRECT POSTERIOR, POSTEROMEDIAL, AND POSTEROLATERAL APPROACHES TO THE KNEE

The posterior midline approach involves structures that, if damaged, can produce a permanent, serious disability. Thorough knowledge of the anatomy of the popliteal space is essential. Figure 1.70 shows the relationship of the flexion crease to the joint line, and Figure 1.71 shows the collateral circulation around the knee posteriorly. The approach provides access to the posterior capsule of the knee joint, the posterior part of the menisci, the posterior compartments of the knee, the posterior aspect of the femoral and tibial condyles, and the origin of the posterior cruciate ligament. All posterior approaches are done with the patient supine.   

DIRECT POSTERIOR APPROACH TO THE KNEE   TECHNIQUE 1.54 (BRACKETT AND OSGOOD; PUTTI; ABBOTT AND CARPENTER) Make a curvilinear incision 10 to 15 cm long over the popliteal space (Fig. 1.72A), with the proximal limb following

n 

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CHAPTER 1  SURGICAL TECHNIQUES

Vastus lateralis muscle

Vastus medialis muscle

Iliotibial band

Capsular incision

Gerdy's tubercle

Pes anserinus

Pes anserinus

Patellar tendon

Outlined osteotomy

Anterior tibial muscle

A

B

C

Medial meniscus

Lateral meniscus

D

E

F

G

FIGURE 1.69 Fernandez extensile anterior approach. A, Anterolateral incision. B, Extensor mechanism exposed. C, Iliotibial band is reflected with Gerdy’s tubercle. Anterior compartment and pes anserinus are detached and elevated as necessary. Osteotomy of tibial tuberosity is outlined, and screw holes are predrilled (see text). D, Patella, patellar tendon, and tibial tuberosity are elevated. E, Medial and lateral menisci are detached anteriorly and peripherally and are elevated. F, Meniscal repair is performed with 2-0 nonabsorbable sutures (see text). Gerdy’s tubercle is reattached with lag screw. Anterior tibial and pes anserinus are reattached. G, Tibial tuberosity is secured with lag screws engaging posterior cortex of tibia. Capsule is closed with interrupted sutures. Sutures in periphery of menisci are now tied (see text). (Modified from Fernandez DL: Anterior approach to the knee with osteotomy of the tibial tubercle for bicondylar tibial fractures, J Bone Joint Surg 70A:208, 1988.) SEE TECHNIQUE 1.53.

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PART I  GENERAL PRINCIPLES the tendon of the semitendinosus muscle distally to the level of the joint. Curve it laterally across the posterior aspect of the joint for about 5 cm and distally over the lateral head of the gastrocnemius muscle. n  Reflect the skin and subcutaneous tissues to expose the popliteal fascia. n  Identify the posterior cutaneous nerve of the calf (the medial sural cutaneous nerve) lying beneath the fascia and between the two heads of the gastrocnemius muscle because it is the clue to the dissection. Lateral to it, the short saphenous vein perforates the popliteal fascia to join the popliteal vein at the middle of the fossa. Trace the posterior cutaneous nerve of the calf (the medial sural cutaneous nerve) proximally to its origin from the tibial

FIGURE 1.70 Knee with Kirschner wire taped along flexion crease. Note relation of wire to joint line. Flexion crease sags distally in elderly or obese individuals.

nerve because the contents of the fossa can be dissected accurately and safely once this nerve is located. Trace the tibial nerve distally and expose its branches to the heads of the gastrocnemius, the plantaris, and the soleus muscles; these branches are accompanied by arteries and veins. Follow the tibial nerve proximally to the apex of the fossa where it joins the common peroneal nerve (Fig. 1.72B). Dissect the common peroneal nerve distally along the medial border of the biceps muscle and tendon, and protect the lateral cutaneous nerve of the calf and the anastomotic peroneal nerve. n  Expose the popliteal artery and vein, which lie directly anterior and medial to the tibial nerve. Gently retract the artery and vein and locate and trace the superolateral and superomedial genicular vessels passing beneath the hamstring muscles on either side just proximal to the heads of origin of the gastrocnemius (Fig. 1.71). n  Open the posterior compartments of the joint with the knee extended and explore them with the knee slightly flexed. The medial head of the gastrocnemius arises at a more proximal level from the femoral condyle than does the lateral head, and the groove it forms with the semimembranosus forms a safe and comparatively avascular approach to the medial compartment (Fig. 1.72C). Turn the tendinous origin of the medial head of the gastrocnemius laterally to serve as a retractor for the popliteal vessels and nerves (Fig. 1.72D). n  Greater access can be achieved by ligating one or more genicular vessels. If the posterolateral aspect of the joint is to be exposed, elevate the lateral head of the gastrocnemius muscle from the femur and approach the lateral compartment between the tendon of the biceps femoris and the lateral head of the gastrocnemius muscle. n  When closing the wound, place interrupted sutures in the capsule, the deep fascia, and the skin. The popliteal fascia is best closed by placing all sutures before drawing them tight. Tie the sutures one by one. Nicandri et al. reported that the medial head of the gastrocnemius can be left intact by identifying and ligating the anterior branches of the middle geniculate artery and

Biceps femoris muscle

Superior medial genicular artery Medial head of gastrocnemius muscle Middle genicular artery Tendon of semimembranosus muscle Inferior medial genicular artery

Superior lateral genicular artery Lateral head of gastrocnemius muscle Common peroneal nerve Inferior lateral genicular artery Tibial nerve Soleus muscle

Popliteus muscle

FIGURE 1.71    Collateral circulation around knee posteriorly. SEE TECHNIQUE 1.54.

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CHAPTER 1  SURGICAL TECHNIQUES

Deep fascia of the thigh

Semimembranosus muscle

Tibial nerve

Popliteal fascia Medial sural cutaneous nerve

Common peroneal nerve

Medial head of gastrocnemius muscle External saphenous vein

Lateral sural cutaneous nerve Communicating branch of peroneal nerve Lateral head of gastrocnemius muscle

A

B

Semimembranosus muscle

Superior medial genicular artery Tibial nerve Posterior capsule of knee joint

Medial head of gastrocnemius muscle

Oblique popliteal ligament

C

Sciatic nerve Biceps femoris muscle Division of medial head of gastrocnemius muscle Medial head of gastrocnemius muscle turned laterally

D

Medial sural cutaneous nerve

FIGURE 1.72 Posterior approach to knee joint. A, Posterior curvilinear incision. Posterior cutaneous nerve of calf exposed and retracted. B, Sciatic nerve and its division defined. C, Medial head of gastrocnemius muscle exposed. D, Tendon of origin of medial head of gastrocnemius muscle divided, exposing capsule of knee joint. If further exposure is necessary, lateral head of gastrocnemius is defined, incised, and retracted in similar fashion. SEE TECHNIQUE 1.54.

­ issecting free the tibial motor branches to the medial head d of the gastrocnemius. This allows enough mobilization of the medial head of the gastrocnemius to expose the posterior cruciate ligament insertion on the posterior tibia.      

DIRECT POSTEROMEDIAL APPROACH TO THE KNEE FOR TIBIAL PLATEAU FRACTURE Galla and Lobenhoffer described a direct posteromedial approach for managing medial tibial plateau fractures.

This approach does not involve dissection of the popliteal neurovascular structures and uses the interval between the semimembranosus complex and the medial head of the gastrocnemius muscle.

  TECHNIQUE 1.55 (GALLA AND LOBENHOFFER AS DESCRIBED BY FAKLER ET AL.) Make a straight 6- to 8-cm-long longitudinal skin incision along the medial border of the medial head of the gastrocnemius muscle, beginning at the level of the joint line. n  Incise the subcutaneous tissue and popliteal fascia ­sharply. n 

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PART I  GENERAL PRINCIPLES Semimembranosus muscle

Semitendinosus muscle Popliteus muscle partially detached Medial head of gastrocnemius muscle

FIGURE 1.73 Galla and Lobenhoffer posteromedial approach. (Modified from Fakler JKM, Ryzewicz M, Hartshorn C, et al: Optimizing the management of Moore type I posteromedial split fracture-dislocations of the tibial head: description of the Lobenhoffer approach, J Orthop Trauma 21:330, 2007.) SEE TECHNIQUE 1.55.

Free up the medial head of the gastrocnemius muscle without detaching it and retract it laterally. n  Bluntly dissect the semimembranosus complex and retract it medially (Fig. 1.73). n  Identify the upper edge of the popliteus muscle and detach it subperiosteally, exposing the posteromedial tibial plateau. n  If more exposure is needed, incise the tibial insertion of the semimembranosus muscle in a subperiosteal fashion.     n 

 

FEMUR   

ANTEROLATERAL APPROACH TO THE FEMUR The anterolateral approach exposes the middle third of the femur, but postoperative adhesions between the individual muscles of the quadriceps group and between the vastus intermedius and the femur may limit knee flexion. The quadriceps mechanism must be handled gently. Infections of the middle third of the shaft are best approached posterolaterally. When the shaft must be approached from the medial side, this anterolateral approach, rather than an anteromedial one, is indicated.

  TECHNIQUE 1.57 (THOMPSON)

DIRECT POSTEROLATERAL APPROACH TO THE KNEE

Incise the skin over the middle third of the femur in a line between the anterior superior iliac spine and the lateral margin of the patella (Fig. 1.75A). n  Incise the superficial and deep fasciae and separate the rectus femoris and vastus lateralis muscles along their intermuscular septum. The vastus intermedius muscle is brought into view. n  Divide the vastus intermedius muscle in the line of its fibers down to the femur. n  Expose the femur by subperiosteal reflection of the incised vastus intermedius muscle (Fig. 1.75B). Henry exposed the entire femoral shaft by extending this incision proximally and distally. The approach is not recommended for operations on the proximal third of the femur because exposing the bone here is difficult without injuring the lateral femoral circumflex artery and the nerve to the vastus lateralis muscle. Distally, the incision may be n 

Minkoff et al. described a limited posterolateral approach to the proximal lateral tibia and knee. It uses the interval between the popliteus and soleus muscles and exposes the uppermost lateral portion of the posterior tibial metaphysis and the proximal tibiofibular joint. Although this approach was developed to excise an osteoid osteoma from the lateral tibial plateau, it can be used for other conditions affecting the posterior aspect of the knee.

  TECHNIQUE 1.56 (MINKOFF, JAFFE, AND MENENDEZ) Begin the skin incision 1 to 2 cm below the popliteal crease slightly medial to the midline of the knee, carrying

n 

it transversely and curving it distally just medial and parallel to the head of the fibula, ending 5 to 6 cm distal to it. n  Reflect the skin and subcutaneous flap inferomedially. n  Isolate the lateral cutaneous nerve of the calf, retract it laterally, and preserve it. n  Identify the short saphenous vein superficial to the fascia and divide and ligate it. n  Open the fascia carefully in line with the incision. The sural nerve lies deep to the fascia just superficial to the heads of the gastrocnemius muscle and must be ­protected (Fig. 1.74A). n  Identify the common peroneal nerve and retract it ­laterally. n  Develop the interval between the lateral head of the gastrocnemius and the soleus muscles and retract the lateral head of the gastrocnemius medially. n  Retract the popliteal artery and vein and the tibial nerve along with the lateral head of the gastrocnemius (Fig. 1.74B). Dissect free the fibular origin of the soleus muscle and retract it distally. n  Retract the underlying popliteus muscle medially to expose the posterior aspect of the lateral tibial plateau and proximal tibiofibular joint (Fig. 1.74C).   

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CHAPTER 1  SURGICAL TECHNIQUES

Medial

Lateral

Common peroneal nerve

Sural nerve

Soleus muscle

A

Gastrocnemius-soleus interval Lateral head of gastrocnemius muscle

Inferior lateral genicular vessels Popliteal vessels Proximal tibio-fibular joint

Common peroneal nerve

Popliteus muscle (retracted)

Lateral head of gastrocnemius muscle

B

Reflected soleus muscle

Tibia

C

FIGURE 1.74 Minkoff, Jaffe, and Menendez posterolateral approach. A, Superficial dissection. B, Gastrocnemius and popliteal vessels are retracted medially, and fibular origin of soleus is reflected distally. C, Popliteus is retracted medially, exposing the posterior aspect of tibial plateau and proximal tibiofibular joint. (Modified from Minkoff J, Jaffe L, Menendez L: Limited posterolateral surgical approach to the knee for excision of osteoid osteoma, Clin Orthop Relat Res 223:237, 1987.) SEE TECHNIQUE 1.56.

extended to within 12 to 15 cm of the knee joint; at this point, however, the insertion of the vastus lateralis muscle into the quadriceps tendon is encountered, as is the more distal suprapatellar bursa.    

recommended. The posterolateral approach is preferred whenever possible to avoid splitting the vastus lateralis.

  TECHNIQUE 1.58 Make an incision of the desired length over the lateral aspect of the thigh along a line from the greater trochanter to the lateral femoral condyle (Fig. 1.76A). n  Incise the superficial and deep fasciae. n  Divide the vastus lateralis and vastus intermedius muscles in the direction of their fibers and open and reflect the periosteum for the proper distance. n 

 

LATERAL APPROACH TO THE FEMORAL SHAFT Anatomically, the entire femoral shaft may be exposed by the lateral approach, but only its less extensive forms are

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PART I  GENERAL PRINCIPLES

Lateral femoral circumflex artery Nerve to vastus lateralis muscle

Vastus lateralis muscle Vastus intermedius muscle Rectus femoris muscle Incision

A

Vastus intermedius muscle

B

Vastus lateralis muscle

FIGURE 1.75 Anterolateral approach to femur. A, Skin incision. B, Femur exposed by separation of rectus femoris and vastus lateralis muscles and division of vastus intermedius muscle. SEE TECHNIQUE 1.57.

A branch of the lateral femoral circumflex artery is encountered when exposing the proximal fourth of the femur and the lateral superior genicular artery in the distal fourth; these may be clamped, divided, and ligated without harm.    

n 

 

POSTEROLATERAL APPROACH TO THE FEMORAL SHAFT   TECHNIQUE 1.59 Turn the patient slightly to elevate the affected side. Make the incision from the base of the greater trochanter distally to the lateral condyle (Fig. 1.76B). n  Incise the superficial fascia and fascia lata along the anterior border of the iliotibial band. n  Expose the posterior part of the vastus lateralis muscle and retract it anteriorly (in muscular individuals this retraction may be difficult); continue the dissection down to bone along the anterior surface of the lateral intermuscular septum, which is attached to the linea aspera. n  Retract the deep structures and split the periosteum in the line of the incision. n  With a periosteal elevator, free the attachment of the vastus intermedius muscle as far as necessary.

In the middle third of the thigh, the second perforating branch of the profunda femoris artery and vein run transversely from the biceps femoris to the vastus lateralis. Ligate and divide these vessels. n  To avoid damaging the sciatic nerve and the profunda femoris artery and vein, do not separate the long and short heads of the biceps femoris muscle.     n 

 

POSTERIOR APPROACH TO THE FEMUR

n  n 

  TECHNIQUE 1.60 (BOSWORTH) With the patient prone, incise the skin and deep fascia longitudinally in the middle of the posterior aspect of the thigh, from just distal to the gluteal fold to the proximal margin of the popliteal space. n  Use the long head of the biceps as a guide. By blunt dissection with the index finger, palpate the posterior surface of the femur at the middle of the thigh. To expose the middle three fifths of the linea aspera, use the fingers to retract the attachment of the vastus medialis and lateralis muscles. n 

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CHAPTER 1  SURGICAL TECHNIQUES Incision A

Incision B Vastus lateralis muscle

Vastus lateralis muscle

Anterior aspect of intermuscular septum

Vastus intermedius muscle Vastus lateralis muscle

Periosteum

Rectus femoris muscle

A

Cross section here

B

A B

FIGURE 1.76 Posterolateral and lateral approaches to middle third of femur. Lateral approach (A). Vastus lateralis and vastus intermedius have been incised in line with their fibers. Cross-section shows these approaches. Posterolateral approach (B) along lateral intermuscular septum. SEE TECHNIQUES 1.58 AND 1.59.

To expose the proximal part of the middle three fifths of the femur, continue the blunt dissection along the lateral border of the long head of the biceps, developing the fascial plane between the long head of the biceps and the vastus lateralis muscle, and reflect the long head of the biceps medially (Fig. 1.77A). n  To expose the distal part of the middle three fifths of the femur, carry the dissection along the medial surface of the long head of the biceps, developing the fascial plane between the long head of the biceps and the n 

s­ emitendinosus, and retract the long head of the biceps and the sciatic nerve laterally (Fig. 1.77B). n  To expose the entire middle three fifths of the femur, carry the blunt dissection to the linea aspera lateral to the long head of the biceps, divide the latter muscle in the distal part of the wound, and displace it medially, together with the sciatic nerve (Fig. 1.77C). n  Part of the nerve supply to the short head of the biceps crosses the exposure near its center; this branch of the sciatic nerve may be saved or divided, depending on the

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PART I  GENERAL PRINCIPLES

Femur Vastus lateralis muscle

Sciatic nerve

Long head of biceps femoris muscle

Short head of biceps femoris muscle Long head of biceps femoris muscle

Sciatic nerve

A

Femur

B

Semitendinosus muscle Sciatic nerve

Vastus lateralis muscle

Long head of biceps femoris muscle

Short head of biceps femoris muscle

Semimembranosus muscle

Long head of biceps femoris muscle Short head of biceps femoris muscle

Sciatic nerve Linea aspera

C

D

FIGURE 1.77 Bosworth posterior approach to femur. A, To expose proximal part of middle three fifths of femur, long head of biceps femoris has been retracted medially. Inset, Skin incision. B, To expose distal part of middle three fifths of femur, long head of biceps femoris and sciatic nerve have been retracted laterally. C, To expose entire middle three fifths of femur, long head of biceps femoris has been divided in distal part of wound, and this muscle and sciatic nerve have been retracted medially. D, Sciatic nerve would be subject to injury if entire middle three fifths of femur were exposed by retracting biceps femoris laterally. SEE TECHNIQUE 1.60.

requirements of the incision because it does not make up the entire nerve supply of this part of the biceps. n  After exposing the linea aspera, free the muscle attachments by sharp dissection and expose the femur by subperiosteal dissection. n  Bosworth points out that the entire middle three fifths of the femur should never be exposed by retracting the long head of the biceps and sciatic nerve laterally because this unnecessarily endangers the sciatic nerve (Fig. 1.77D). n  When the distal end of the long head of the biceps is to be divided, place sutures in the distal segment of the muscle

before the division is carried out; this makes suturing the muscle easier when the wound is being closed. n  After suturing the biceps, close the wound by suturing only the skin and subcutaneous tissue because the other structures fall into position. n  When developing this approach, the surgeon must keep in mind the possibility of damaging the sciatic nerve. Rough handling and prolonged or strenuous retraction of the nerve may cause distressing symptoms after surgery or possibly a permanent disability in the leg.    

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CHAPTER 1  SURGICAL TECHNIQUES  

MEDIAL APPROACH TO THE POSTERIOR SURFACE OF THE FEMUR IN THE POPLITEAL SPACE When possible, the medial approach to the posterior surface of the femur in the popliteal space should be used in preference to an anteromedial approach because in the latter the vastus medialis must be separated from the rectus femoris and the vastus intermedius must be split.

  TECHNIQUE 1.61 (HENRY) With the knee slightly flexed, begin the incision 15 cm proximal to the adductor tubercle and continue it distally along the adductor tendon, following the angle of the knee to 5 cm distal to the tubercle (Fig. 1.78A). n  In the distal part of the incision, carry the dissection posteriorly to the anterior edge of the sartorius muscle just proximal to the level of the adductor tubercle. n  Free the deep fascia proximally over this muscle, taking care to avoid puncturing the synovial membrane, which is beneath the muscle when the joint is flexed. After this procedure, the sartorius falls posteriorly, exposing the tendon of the adductor magnus muscle. Protect the n 

s­ aphenous nerve, which follows the sartorius on its deep surface; the great saphenous vein is superficial and is not in danger if the incision is made properly. n  Divide the thin fascia posterior to the adductor tendon by blunt dissection to the posterior surface of the femur at the popliteal space. n  Retract the large vessels and nerves posteriorly; branches from the muscles to the bone may be isolated, clamped, and divided. n  Retract the adductor magnus tendon and a part of the vastus medialis muscle anteriorly and expose the bone. The tibial and common peroneal nerves are not encountered because they lie lateral and posterior to the line of incision.      

LATERAL APPROACH TO THE POSTERIOR SURFACE OF THE FEMUR IN THE POPLITEAL SPACE   TECHNIQUE 1.62 (HENRY) With the knee slightly flexed, incise the skin and superficial fascia for 15 cm along the posterior edge of the ilio-

n 

Vastus medialis muscle

Lateral intermuscular septum

Adductor magnus tendon

Sartorius muscle

A

Popliteal space

Popliteal space

B

Biceps muscle

FIGURE 1.78 Henry medial and lateral approaches to posterior surface of femur in popliteal space. A, Medial approach. B, Lateral approach. SEE TECHNIQUES 1.61 AND 1.62.

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PART I  GENERAL PRINCIPLES tibial band and follow the angle of the knee to the head of the fibula (Fig. 1.78B). n  Divide the deep fascia immediately posterior to the iliotibial band. n  Just proximal to the condyle, separate the attachment of the short head of the biceps from the posterior surface of the lateral intermuscular septum; reach the popliteal space by blunt dissection between these structures. n  Ligate and divide the branches of the perforating vessels and retract the popliteal vessels posteriorly in the posterior wall of the wound. The tibial nerve lies posterior to the popliteal vessels, and the common peroneal nerve follows the medial edge of the biceps. n  Expose the surface of the femur by incising and elevating the periosteum.    

 

LATERAL APPROACH TO THE PROXIMAL SHAFT AND THE TROCHANTERIC REGION The lateral approach is excellent for reduction and internal fixation of trochanteric fractures or for subtrochanteric osteotomies under direct vision.

  TECHNIQUE 1.63 Begin the incision about 5 cm proximal and anterior to the greater trochanter, curving it distally and posteriorly over the posterolateral aspect of the trochanter and distally along the lateral surface of the thigh, parallel with the femur, for 10 cm or more, depending on the desired exposure (Fig. 1.79A).

n 

Tensor fascia latae muscle

Incision Vastus lateralis muscle

A

Tensor fascia latae muscle Vastus lateralis muscle Incision

B

C FIGURE 1.79 Lateral approach to proximal shaft and trochanteric region of femur. A, Crosssection shows level of approach at lesser trochanter. Fascia lata has been incised in line with skin incision. Vastus lateralis has been incised transversely just distal to greater trochanter and is being incised longitudinally 0.5 cm from linea aspera. Inset, Skin incision. B, Cross-section shows approach at level of distal end of skin incision. C, Approach has been completed by dissecting vastus lateralis subperiosteally from femur. Hip joint may be exposed by continuing approach proximally as in Watson-Jones approach. SEE TECHNIQUE 1.63.

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CHAPTER 1  SURGICAL TECHNIQUES Deepen the dissection in the line of the incision down to the fascia lata. n  In the distal part of the wound, incise the fascia lata with a scalpel and split it proximally with scissors. In the proximal part of the wound, divide the fascia just posterior to the tensor fasciae latae muscle to avoid splitting this muscle. n  By retraction, bring into view the vastus lateralis muscle and its origin from the inferior border of the greater trochanter. Divide the origin of the muscle transversely along this border down to the posterolateral surface of the ­femur. n  Divide the vastus lateralis and its fascia longitudinally with scissors, beginning on its posterolateral surface, 0.5 cm from its attachment to the linea aspera. n  Alternatively, first split the muscle fascia alone laterally instead of posterolaterally, dissect the muscle from its deep surface posteriorly, and divide the muscle near the linea aspera (closing the fascia lata then is easier). The muscle is divided where it is thin rather than thick, as is necessary in a direct lateral muscle-splitting approach (Fig. 1.79A,B). Section no more than 0.5 cm of the muscle at one time. Keep the body of the vastus retracted anteriorly; by this means, if one of the perforating arteries is divided, it may be clamped and tied before it retracts beyond the linea aspera. n  After dividing the muscle along the femur for the required distance, elevate it with a periosteal elevator and expose the lateral and anterolateral surfaces of the femoral shaft (Fig. 1.79C). n  By further subperiosteal elevation of the proximal part of the vastus lateralis and intermedius muscles, expose the intertrochanteric line and the anterior surface of the femur just below this line. n  The base of the femoral neck may be exposed by dividing the capsule of the joint at its attachment to the intertrochanteric line. n  If a wider exposure is desired, elevate the distal part of the gluteus minimus from its insertion on the trochanter. n  In closure, the vastus lateralis muscle falls over the lateral surface of the femur. Suture the fascia lata and close the remainder of the wound routinely.    

Vastus lateralis muscle

n 

Piriformis muscle Quadratus femoris muscle Medial circumflex femoral artery Obturator internus and gemelli muscles FIGURE 1.80 The relevant deep anatomic structures of posterior aspect of the hip shows the course of medial circumflex femoral artery to the femoral head. (From Nork SE, Schär M, Pfander G, et al: Anatomic considerations for the choice of surgical approach for hip resurfacing arthroplasty, Orthop Clin North Am 36:163, 2005.)

no consequence. If hip resurfacing, femoral neck fracture repair, or osteotomy is to be performed, lateral anterolateral, anterior, or medial approaches are more desirous to prevent osteonecrosis of the femoral head. Lateral approaches requiring osteotomy of the greater trochanter have a significant nonunion rate of that osteotomy, which should also be considered. Mednick et al. demonstrated consistent occlusion of the femoral vein when using a Hohmann-like retractor over the anterior wall of the acetabulum during an anterior approach. Anterior approaches risk injury to the lateral femoral cutaneous nerve, which can lead to significant patient dissatisfaction (Fig. 1.81). The superior gluteal nerve can be injured in the process of ligating or cauterizing the ascending branch of the lateral femoral circumflex artery where it enters the tensor fascia latae muscle. Ohmori et al. used computed tomography on normal volunteers to determine the distance to the center of the femoral head and found that it is shortest in an anterior approach regardless of body mass index or gender and is longest in a posterior approach.

ANTERIOR APPROACHES TO THE HIP   

HIP Numerous new approaches to the hip have been described since the 1990s; most are based on older approaches and are modified for a specific surgical procedure. In this section, the general approaches we have found most useful are described. The specific approaches used in revision total hip arthroplasty are described in Chapter 3. Approaches used for minimally invasive hip arthroplasty procedures are described in Chapter 3. The approach selected should be based on access needed, the potential for complications, the procedure to be performed, and the experience of the surgeon. The need for maintaining the primary blood supply to the femoral head (medial femoral circumflex artery and its ascending branches) must be considered before the procedure (Fig. 1.80). In total hip arthroplasty, disruption of the ascending branches of the medial circumflex femoral artery is of

ANTERIOR ILIOFEMORAL APPROACH TO THE HIP Nearly all surgery of the hip joint may be carried out through this approach, or separate parts can be used for different purposes. The entire ilium and hip joint can be reached through the iliac part of the incision; all structures attached to the iliac crest from the posterior superior iliac spine to the anterior superior iliac spine are freed and are reflected from the lateral surface of the ilium; dissection is carried distally to the anterior inferior iliac spine. SmithPetersen also modified and improved this approach for extensive surgery of the hip by reflecting the iliacus muscle from the medial surface of the anterior part of the ilium and by detaching the rectus femoris muscle from its origin. All or part of this approach can be used depending on how much of the ilium or acetabulum needs to be exposed.

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  TECHNIQUE 1.64

Figure 1.82

(SMITH-PETERSEN) Begin the incision at the middle of the iliac crest or, for a larger exposure, as far posteriorly on the crest as desired. Carry it anteriorly to the anterior superior iliac spine and distally and slightly laterally 10 to 12 cm. n  Divide the superficial and deep fasciae and free the attachments of the gluteus medius and the tensor fasciae latae muscles from the iliac crest. n  With a periosteal elevator, strip the periosteum with the attachments of the gluteus medius and minimus muscles from the lateral surface of the ilium. Control bleeding from the nutrient vessels by packing the interval between the ilium and the reflected muscles. n  Carry the dissection through the deep fascia of the thigh and between the tensor fasciae latae laterally and the sartorius and rectus femoris medially. n  Clamp and ligate the ascending branch of the lateral femoral circumflex artery, which lies 5 cm distal to the hip joint. n  The lateral femoral cutaneous nerve passes over the sartorius 2.5 cm distal to the anterior superior spine; retract it to the medial side. n  If the structures at the anterior superior spine are contracted, free the spine with an osteotome and allow it to retract with its attached muscles to a more distal level. n  Expose and incise the capsule transversely and reveal the femoral head and the proximal margin of the acetabulum. The capsule also may be sectioned along its attachment to the acetabular labrum (cotyloid ligament) to give the required exposure. n  If necessary, the ligamentum teres may be divided with a curved knife or with scissors and the femoral head dislocated, giving access to all parts of the joint. Schaubel modified the Smith-Petersen anterior approach after finding reattachment of the fascia lata to the fascia on n 

Lateral femoral cutaneous nerve

Lateral femoral circumflex artery Ascending branch

FIGURE 1.81 Relationship between the lateral femoral cutaneous nerve and ascending branch of the lateral femoral circumflex artery. (Modified from York PJ, Smack CT, Judet T, Mauffrey C: Total hip arthroplasty via anterior approach: tips and tricks for primary and revision surgery, Int Orthop 40:2041, 2016.)

Gluteus medius muscle Tensor fasciae latae muscle Gluteus maximus muscle

Ilium Sartorius muscle

Skin incision

Head and neck of femur

Sartorius muscle Iliotibial band

A

Rectus femoris muscle

Tensor fasciae latae muscle

B

FIGURE 1.82 Smith-Petersen anterior iliofemoral approach to hip. A, Line of skin incision. B, Exposure of joint after reflection of tensor fasciae latae and gluteal muscles from lateral surface of ilium and division of capsule. SEE TECHNIQUE 1.64.

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CHAPTER 1  SURGICAL TECHNIQUES the iliac crest difficult. Instead of dividing the fascia lata at the iliac crest, an osteotomy of the overhang of the iliac crest is performed between the attachments of the external oblique muscle medially and the fascia lata. The osteotomy may be carried posteriorly as far as the origin of the gluteus maximus. The tensor fasciae latae, gluteus medius, and gluteus minimus muscle attachments are subperiosteally dissected distally to expose the hip joint capsule. The abductors and short external rotators may be dissected from the greater trochanter as necessary for total hip arthroplasty, prosthetic replacement of the femoral head, or arthrodesis of the hip. At closure, the iliac osteotomy fragment is reattached with 1-0 nonabsorbable sutures passed through holes drilled in the fragment and the ilium. Zahradnicek extended the skin incision along the anterolateral aspect of the thigh and developed an interval between the tensor fascia lata (superior gluteal nerve) laterally and the sartorius and rectus femoris (femoral nerve) medially. This is useful when both acetabulum and proximal femoral shaft exposure are necessary.    

and posteriorly to the posterosuperior margin of the joint (Fig. 1.83C). n  Exert enough traction on the limb to distract the cartilage of the femoral head from that of the acetabulum about 0.7 cm. n  Examine the inside of the acetabulum visually (Fig. 1.83D). If no inverted labrum is seen, insert a blunt hook and palpate the joint for the free edge of an inverted labrum. If one is found, place the tip of the hook deep to the labrum and force it through its base; separate from its periphery that part of the labrum lying anterior to the hook until the hook comes out. n  With Kocher forceps, grasp the labrum by the end thus freed and excise it with strong curved scissors or make radial T-shaped incisions to evert the limbs and allow reduction of the femoral head (Fig. 1.83E). n  Reduce the head into the acetabulum by abducting the thigh 30 degrees and internally rotating it. Hold the joint in this position and close the capsule (Fig. 1.83F). n  Reattach the muscles to the iliac crest, close the skin, and apply a spica cast.    

 

ANTERIOR APPROACH TO THE HIP USING A TRANSVERSE INCISION Somerville described an anterior approach using a transverse “bikini” incision for irreducible congenital dislocation of the hip in a young child. This approach allows sufficient exposure of the ilium, and access to the acetabulum is satisfactory even when it is in an abnormal location. For reduction of a congenitally dislocated hip, the following sequential steps must be performed: psoas tenotomy, complete medial capsulotomy including the transverse acetabular ligament, excision of hypertrophied ligamentum teres, and reduction of the femoral head into the true acetabulum. Specific indications and postoperative care for congenital dislocation of the hip are discussed in Chapter 30.

  TECHNIQUE 1.65 (SOMERVILLE) Place a small bump beneath the affected hip. n  Make a straight skin incision, beginning anteriorly inferior and medial to the anterior superior spine and coursing obliquely superiorly and posteriorly to the middle of the iliac crest (Fig. 1.83A). Deepen the incision to expose the crest. n  Reflect the abductor muscles subperiosteally from the iliac wing distally to the capsule of the joint. Increase exposure of the capsule by separating the tensor fasciae latae from the sartorius for about 2.5 cm inferior to the anterior superior spine. n  Expose the reflected head of the rectus femoris and separate it from the acetabulum and capsule, leaving the straight head attached to the anterior inferior spine (Fig. 1.83B). The straight head may be detached to increase exposure. n  Near the acetabular rim, make a small incision in the capsule and extend it anteriorly to a point deep to the rectus

 

MODIFIED ANTEROLATERAL ILIOFEMORAL APPROACH TO THE HIP Smith-Petersen described a modification of the anterior iliofemoral approach that he used for open reduction and internal fixation of fractures of the femoral neck. This approach retains the advantages of the anterior iliofemoral approach but exposes the trochanteric region laterally; this makes aligning a fracture or osteotomy of the femoral neck and inserting pins, screws, or nails under direct vision easier. This approach also is useful in reconstructive procedures such as osteotomy for slipping of the proximal femoral epiphysis and procedures for nonunions of the femoral neck. It gives a continuous exposure of the anterior aspect of the hip from the acetabular labrum to the base of the trochanter.

  TECHNIQUE 1.66

n 

(SMITH-PETERSEN) Make the skin incision along the anterior third of the iliac crest and along the anterior border of the tensor fasciae latae muscle; curve it posteriorly across the insertion of this muscle into the iliotibial band in the subtrochanteric region (usually at a point 8 to 10 cm below the base of the greater trochanter) and end it there. n  Incise the fascia along the anterior border of the tensor fasciae latae muscle. Identify and protect the lateral femoral cutaneous nerve, which usually is medial to the medial border of the tensor fasciae latae and close to the lateral border of the sartorius. n  Cleanly incise the muscle attachments to the lateral aspect of the ilium along the iliac crest to make reflection of the periosteum easier. Reflect it as a continuous structure, without fraying, distally to the superior margin of the ­acetabulum. n 

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Iliopsoas tendon Sartorius muscle Rectus femoris muscle

A

C

B

D

E

F

FIGURE 1.83 Somerville technique of open reduction. A, Bikini incision. B, Division of sartorius and rectus femoris tendons and iliac epiphysis. C, Incision of capsule. D, Capsulotomy of hip and use of ligamentum teres to find true acetabulum. E, Radial incisions in acetabular labrum and removal of all tissue from depth of true acetabulum. F, Capsulorrhaphy after excision of redundant capsule. SEE TECHNIQUE 1.65.

Divide the muscle attachments between the anterior superior iliac spine and the acetabular labrum. The posterior flap thus reflected consists of the tensor fasciae latae, the gluteus minimus, and the anterior part of the gluteus medius (Fig. 1.84). n  Inferiorly carry the fascial incision across the insertion of the tensor fasciae latae into the iliotibial band and expose the lateral part of the rectus femoris and the anterior part of the vastus lateralis muscles. n  Begin the capsular incision on the inferior aspect of the capsule just lateral to the acetabular labrum; from this point, extend it proximally, parallel with the acetabular labrum, to the superior aspect of the capsule, and curve it laterally, continuing on beyond the capsule to the base of the greater trochanter. This incision divides that part of the reflected head of the rectus femoris that blends into the capsule inferior to its insertion into the superior margin of the acetabulum. By reflecting it with the capsule, the capsular flap is reinforced, and repair is made easier. Ishimatsu et al. reported significant reversible femoral nerve amplitude reduction when a retractor is placed between the anterior wall of the acetabulum and the iliopsoas n 

Tensor fasciae latae Gluteus medius Gluteus minimus

Tensor fasciae latae

Ilium

Sartorius Anterior joint capsule Rectus femoris

FIGURE 1.84 Modified Smith-Petersen anterolateral iliofemoral approach. SEE TECHNIQUE 1.66.

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CHAPTER 1  SURGICAL TECHNIQUES and sartorius muscles. This was observed in 77% of 22 patients undergoing total hip arthroplasty even with careful placement of the retractor. As mentioned earlier the femoral vein can be easily occluded with this maneuver.   

LATERAL APPROACHES TO THE HIP   

LATERAL APPROACH TO THE HIP   TECHNIQUE 1.67

 

(WATSON-JONES) Begin an incision 2.5 cm distal and lateral to the anterior superior iliac spine and curve it distally and posteriorly over the lateral aspect of the greater trochanter and lateral surface of the femoral shaft to 5 cm distal to the base of the trochanter (Fig. 1.85A). n  Locate the interval between the gluteus medius and tensor fasciae latae. The delineation of this interval often is difficult. Brackett pointed out that it can be done more easily by beginning the separation midway between the anterior superior spine and the greater trochanter, before the tensor fasciae latae blends with its fascial insertion. The coarse grain and the direction of the fibers of the gluteus medius help to distinguish them from the finer structure of the tensor fasciae latae muscle (Fig. 1.85B). n  Carry the dissection proximally to expose the inferior branch of the superior gluteal nerve, which innervates the tensor fasciae latae muscle. n  Incise the capsule of the joint longitudinally along the anterosuperior surface of the femoral neck. In the distal part of the incision, the origin of the vastus lateralis may be reflected distally or split longitudinally to expose the n 

A

Tensor fasciae latae muscle

B

Gluteus medius muscle

base of the trochanter and proximal part of the femoral shaft. n  If a wider field is desired, detach the anterior fibers of the gluteus medius tendon from the trochanter or reflect the anterosuperior part of the greater trochanter proximally with an osteotome, together with the insertion of the gluteus medius muscle. This preserves the insertion of the gluteus medius in such a way that it can be easily reattached later.    

Vastus lateralis muscle

FIGURE 1.85 Watson-Jones lateral approach to hip joint. A, Skin incision. B, Approach has been completed except for incision of joint capsule. SEE TECHNIQUE 1.67.

LATERAL APPROACH FOR EXTENSIVE EXPOSURE OF THE HIP Harris recommends the following lateral approach for extensive exposure of the hip. It permits dislocation of the femoral head anteriorly and posteriorly. This approach requires an osteotomy of the greater trochanter, however, with the resulting risk of nonunion or trochanteric bursitis. Also, as reported by Testa and Mazur, the incidence of significant or disabling heterotopic ossification is increased after total hip arthroplasty using a transtrochanteric lateral approach compared with a direct lateral approach.

  TECHNIQUE 1.68 (HARRIS) Place the patient on the unaffected hip and elevate the affected one 60 degrees; maintain this position by using sandbags or a long, thick blanket roll extending from beneath the scapula to the sacrum. n  Make a U-shaped skin incision, with its base at the posterior border of the greater trochanter as follows (Fig. 1.86A, inset). Begin the incision about 5 cm posterior and slightly proximal to the anterior superior iliac spine, curve it distally and posteriorly to the posterosuperior corner of the greater trochanter, extend it longitudinally for about 8 cm, and finally curve it gradually anteriorly and distally, making the two limbs of the U symmetrical. n  Beginning distally, divide the iliotibial band in line with the skin incision; at the greater trochanter, place a finger deep to the band, feel the femoral insertion of the gluteus maximus on the gluteal tuberosity, and guide the incision in the fascia lata posteriorly, but stay one fingerbreadth anterior to this insertion. n  Continue the incision in the fascia lata proximally in line with the skin incision, releasing the fascia overlying the gluteus medius. n  Exposure of the posterior aspect of the greater trochanter, the insertion of the short external rotators, and the posterior part of the joint capsule is limited by the posterior part of the fascia lata and the gluteus maximus fibers that insert into it. To obtain wide exposure posteriorly and to provide a space into which the femoral head can be dislocated, make a short oblique incision in the deep surface of the posteriorly reflected fascia lata, extending into the substance of the gluteus maximus (Fig. 1.86A). Begin this incision at the level of the middle of the greater n 

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Vastus intermedius muscle

Gluteus medius muscle Vastus lateralis muscle origin reflected

Gluteus medius muscle

Vastus lateralis muscle Fascia lata Greater trochanter Greater trochanter

Gluteus maximus muscle

A

B

Gluteus maximus muscle

Osteotomized greater trochanter placed in acetabulum

Gluteus minimus muscle

Gluteus medius muscle Osteotomized greater trochanter

C

Piriformis muscle

Obturator externus muscle Obturator internus muscle

D

Acetabulum Iliopsoas muscle

E

Femoral head dislocated posterior to acetabulum FIGURE 1.86 Harris lateral approach to hip. A, Iliotibial band has been divided proximal to greater trochanter. A finger has been placed on insertion of gluteus maximus deep to band, and fascia lata is to be incised 1 fingerbreadth anterior to insertion (broken line) without cutting into insertion of gluteus maximus. B, To obtain wide exposure posteriorly and to provide space into which femoral head can be dislocated, a short oblique incision has been made in posteriorly reflected fascia lata, extending into gluteus maximus (see text). Greater trochanter is to be osteotomized (see text). C, Greater trochanter has been osteotomized and retracted superiorly; superior part of joint capsule has been freed; and insertions of piriformis, obturator externus, and obturator internus are to be divided. D, Full circumference of femoral head has been exposed by placing greater trochanter and its muscle pedicle into acetabulum and externally rotating femur. E, Entire acetabulum has been exposed by retracting the greater trochanter superiorly and dislocating the femoral head posteriorly. SEE TECHNIQUE 1.68.

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Iliopsoas muscle

CHAPTER 1  SURGICAL TECHNIQUES trochanter and extend it medially and proximally into the gluteus maximus parallel to its fibers for 4 cm. n  Reflect anteriorly the anterior part of the iliotibial band and the tensor fasciae latae, which form the anterior flap, passing a periosteal elevator along the anterior capsule to the acetabulum. n  Free the abductor muscles by osteotomizing the greater trochanter as follows (Fig. 1.86B): reflect distally the origin of the vastus lateralis; place an instrument between the abductor muscles and the superior surface of the joint capsule, and direct the osteotomy superiorly and medially from a point 1.5 cm distal to the tubercle of the vastus lateralis to the superior surface of the femoral neck. n  Free the superior part of the joint capsule from the greater trochanter. During these maneuvers, protect the sciatic nerve by using a smooth retractor. 1. Divide the piriformis, obturator externus, and obturator internus at their femoral insertions (Fig. 1.86C). 2. Excise the anterior and posterior parts of the capsule under direct vision as far proximally as the acetabulum. n  Proceed with the operation anteriorly. Deep to the rectus femoris insert a small, blunt-pointed Bennett retractor so that its hook is placed over the anterior inferior iliac spine. n  Reflect superiorly the greater trochanter and its attached abductor muscles to expose the superior and anterior parts of the capsule. n  Place a thin retractor between the capsule and the iliopsoas to expose the anterior and inferior parts of the capsule. Working from the anterior and posterior aspects of the joint, excise as much of the capsule as desired; if the iliopsoas muscle is to be transplanted, leave the stump of the anterior part of the capsule intact. n  Dislocate the femoral head anteriorly by extending, adducting, and externally rotating the femur. Before or after the hip has been dislocated, bring the lesser trochanter into view by flexing and externally rotating the femur and, if desired, divide the iliopsoas under direct vision. n  Expose the full circumference of the femoral head by placing the greater trochanter and its muscle pedicle into the acetabulum and externally rotating the femur (Fig. 1.86D). n  To expose the entire acetabulum, retract the greater trochanter superiorly and dislocate the femoral head posteriorly (Fig. 1.86E) by flexing the knee and adducting, flexing, and internally rotating the hip. Flexing the knee reduces tension on the sciatic nerve while the head is dislocated posteriorly. n  When closing the wound, position the limb in almost full abduction and in about 10 degrees of external rotation. Transplant the greater trochanter distally, and fix it directly to the lateral side of the femoral shaft with two wire loops, screws, or a cable grip. For a more detailed description of fixation of the greater trochanter, see Chapter 3.      

LATERAL APPROACH TO THE HIP PRESERVING THE GLUTEUS MEDIUS McFarland and Osborne described a lateral approach to the hip that preserves the integrity of the gluteus medius

­ uscle. They noted that the gluteus medius and vastus m lateralis muscles can be regarded as being in direct functional continuity through the thick periosteum covering the greater trochanter.

  TECHNIQUE 1.69 (MCFARLAND AND OSBORNE) Make a midlateral skin incision (Fig. 1.87A) centered over the greater trochanter; its length depends on the amount of subcutaneous fat. Expose the gluteal fascia and the iliotibial band, and divide them in a straight midlateral line along the entire length of the skin incision (Fig. 1.87B). n  Retract the gluteus maximus posteriorly and the tensor fasciae latae anteriorly. n  Expose the gluteus medius and separate it from the piriformis and gluteus minimus by blunt dissection. n  Identify the prominent posterior border of the gluteus medius where it joins the posterior edge of the greater trochanter. From this point, make an incision down to the bone through the periosteum and fascia obliquely and distally across the greater trochanter to the middle of the lateral aspect of the femur; continue it further distally in the vastus lateralis to the distal end of the skin incision (Fig. 1.87C). n  With a knife or a sharp chisel, peel from the bone, in one piece, the attachment of the gluteus medius, the periosteum, the tendinous junction of the gluteus medius and vastus lateralis, and the origin of the vastus lateralis. The portion of the vastus lateralis peeled off includes that attached to the proximal part of the linea aspera, the distal border of the greater trochanter, and part of the shaft of the femur. n  Anteriorly retract the whole combined muscle mass, consisting of the gluteus medius and vastus lateralis with their tendinous junction (Fig. 1.87D). Split, divide, and proximally retract the tendon of the gluteus minimus to expose the capsule of the hip joint (Fig. 1.87E). Incise the capsule as desired (Fig. 1.87F). n  During closure, suture the capsule and gluteus minimus as one structure. Abduct the hip, return the gluteus medius and vastus lateralis to their original position, and suture them to the undisturbed part of the vastus lateralis, to the deep insertion of the gluteus maximus, and to the proximal part of the quadratus femoris.     n 

 

LATERAL TRANSGLUTEAL APPROACH TO THE HIP Hardinge described a useful transgluteal modification of the McFarland and Osborne direct lateral approach based on the observation that the gluteus medius inserts on the greater trochanter by a strong, mobile tendon that curves around the apex of the trochanter. This approach can be easily made with the patient supine. Osteotomy of the greater trochanter is avoided.

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A Tensor fasciae latae

Gluteus maximus

Gluteus medius

Tensor fasciae latae

Gluteus maximus

Tensor fasciae latae

Gluteus medius Greater trochanter

Vastus lateralis

Vastus lateralis

B Gluteus medius

Greater trochanter

E

C Gluteus minimus Gluteus maximus

D

Gluteus medius

Vastus lateralis

Gluteus minimus (retracted) Gluteus maximus

Vastus lateralis

F FIGURE 1.87 McFarland and Osborne lateral or posterolateral approach to hip. A, Skin incision. B, Gluteal fascia and iliotibial band are divided in midlateral line. C, Incision is made to bone obliquely across trochanter and distally in vastus lateralis. D, Combined muscle mass consisting of gluteus medius and vastus lateralis with their tendinous junction is elevated and retracted anteriorly. E, Tendon of gluteus minimus is split and divided before retraction proximally. F, Capsule has been opened to expose joint. (From McFarland B, Osborne G: Approach to the hip: a suggested improvement on Kocher’s method, J Bone Joint Surg 36B:364, 1954.) SEE TECHNIQUE 1.69.

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Gluteus maximus (retracted) Gluteus minimus

CHAPTER 1  SURGICAL TECHNIQUES

  TECHNIQUE 1.70

During closure, repair the tendon of the gluteus medius with nonabsorbable braided sutures. Frndak et al. modified the Hardinge direct lateral transgluteal approach by placing the abductor “split” more anterior, directly over the femoral head and neck (Fig. 1.89). The “split” must not extend more than 2 cm above the lateral lip of the acetabulum to avoid damage to the gluteal neurovascular bundle. Because the abductor “split” is more anterior, exposure of the femoral head and neck requires less retraction.    

n 

(HARDINGE) Place the patient supine with the greater trochanter at the edge of the table and the muscles of the buttocks freed from the edge. n  Make a posteriorly directed lazy-J incision centered over the greater trochanter (Fig. 1.88A). n  Divide the fascia lata in line with the skin incision and centered over the greater trochanter. n  Retract the tensor fasciae latae anteriorly and the gluteus maximus posteriorly, exposing the origin of the vastus lateralis and the insertion of the gluteus medius (Fig. 1.88B). n  Incise the tendon of the gluteus medius obliquely across the greater trochanter, leaving the posterior half still attached to the trochanter. Carry the incision proximally in line with the fibers of the gluteus medius at the junction of the middle and posterior thirds of the muscle. This gluteus medius split should be no farther than 4 to 5 cm from the tip of the greater trochanter to avoid damage to the superior gluteal nerve and artery. Distally, carry the incision anteriorly in line with the fibers of the vastus lateralis down to bone along the anterolateral surface of the femur (Fig. 1.88B). n  Elevate the tendinous insertions of the anterior portions of the gluteus minimus and vastus lateralis muscles. Abduction of the thigh exposes the anterior capsule of the hip joint (Fig. 1.88C). n  Incise the capsule as desired. n 

 

LATERAL TRANSGLUTEAL APPROACH TO THE HIP McLauchlan described a direct lateral transgluteal approach to the hip through the gluteus medius used for many years by Hay at the Stracathro Hospital. It also is based on the anatomic observation made by McFarland and Osborne mentioned earlier that the gluteus medius and vastus lateralis are in functional continuity through the thick periosteum covering the greater trochanter.

  TECHNIQUE 1.71 (HAY AS DESCRIBED BY MCLAUCHLAN) Place the patient in the Sims position with the affected hip uppermost.

n 

A

Tensor fasciae latae

B

Gluteus maximus muscle

Vastus lateralis muscle

C

FIGURE 1.88 Hardinge direct lateral transgluteal approach. A, Lazy-J lateral skin incision. B, Tensor fasciae latae retracted anteriorly, and gluteus maximus is retracted posteriorly. Incision through gluteus medius tendon is outlined. Posterior half is left attached to greater trochanter. C, Anterior joint capsule is exposed. (Modified from Hardinge K: The direct lateral approach to the hip, J Bone Joint Surg 64B:17, 1982.) SEE TECHNIQUE 1.70.

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Gluteus medius muscle

A

Vastus lateralis muscle

B

FIGURE 1.89 Modified direct lateral transgluteal approach. A, Abductor “split” is determined by location of the femoral neck. B, Capsular incision parallels superior border. SEE TECHNIQUE 1.70.

Make a lateral longitudinal skin incision (Fig. 1.90A) centered midway between the anterior and posterior borders of the greater trochanter and extending an equal distance proximal and distal to the tip of the trochanter. In lateral rotational deformities of the hip, place the incision more posteriorly. n  Incise the deep fascia and the tensor fasciae latae in line with the skin incision. n  Retract these structures anteriorly and posteriorly to expose the greater trochanter with the gluteus medius attached to it proximally and the vastus lateralis attached distally (Fig. 1.90B). n  Split the gluteus medius in the line of its fibers for a distance of no more than 4 to 5 cm to avoid damage to the superior gluteal neurovascular bundle. Elevate two rectangular slices of greater trochanter, one anteriorly and one posteriorly with an osteotome. These slices of trochanter have gluteus medius attached to them proximally and vastus lateralis attached distally (Fig. 1.90C). n  Retract anteriorly and posteriorly to reveal the gluteus minimus. n  Rotate the hip externally and split the gluteus minimus in the line of its fibers or detach it from the greater trochanter. n  Incise the capsule of the hip joint, insert spike retractors anteriorly and posteriorly over the edges of the acetabulum, and dislocate the hip anteriorly by flexion and external rotation (Fig. 1.90D). The femoral neck and acetabulum are well exposed for routine total hip arthroplasty or for difficult revisions. n  When closing, suture the capsule if enough of it is left. n  Internally rotate the hip and suture the trochanteric slices to the periosteum and the other soft tissue covering the trochanter. The trochanteric slices unite without any problem, and abductor function returns rapidly. n  Carefully close the deep fascia with interrupted sutures.     n 

 

POSTEROLATERAL APPROACH Alexander Gibson is responsible for the rediscovery in North America of the posterolateral approach to the hip

first described and recommended by Kocher and Langenbeck. Because detaching the gluteal muscles from the ilium and interfering with the function of the iliotibial band are unnecessary, rehabilitation after surgery is rapid.

  TECHNIQUE 1.72 (GIBSON) Place the patient in a lateral position. Begin the proximal limb of the incision at a point 6 to 8 cm anterior to the posterior superior iliac spine and just distal to the iliac crest, overlying the anterior border of the gluteus maximus muscle. Extend it distally to the anterior edge of the greater trochanter and farther distally along the line of the femur for 15 to 18 cm (Fig. 1.91A). n  By blunt dissection, reflect the flaps of skin and subcutaneous fat from the underlying deep fascia a short distance anteriorly and posteriorly. n  Incise the iliotibial band in line with its fibers, beginning at the distal end of the wound and extending proximally to the greater trochanter. n  Abduct the thigh, insert the gloved finger through the proximal end of the incision in the band, locate by palpation the sulcus at the anterior border of the gluteus maximus muscle, and extend the incision proximally along this sulcus. Adduct the thigh, reflect the anterior and posterior masses, and expose the greater trochanter and the muscles that insert into it (Fig. 1.91B). n  Separate the posterior border of the gluteus medius muscle from the adjacent piriformis tendon by blunt dissection. n  Divide the gluteus medius and minimus muscles at their insertions, but leave enough of their tendons attached to the greater trochanter to permit easy closure of the wound. Reflect these muscles (innervated by the superior gluteal nerve) anteriorly (Fig. 1.91C). The anterior and superior parts of the joint capsule now can be seen. n  Incise the capsule superiorly in the axis of the femoral neck from the acetabulum to the intertrochanteric line; incise as much of the capsule as desired along the joint line anteriorly and along the anterior intertrochanteric line laterally. The hip now can be dislocated by flexing the hip n  n 

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CHAPTER 1  SURGICAL TECHNIQUES

A Gluteus minimus muscle

B Gluteus medius muscle

Gluteus minimus muscle

Gluteus medius muscle

Bone slices

Vastus lateralis muscle

C

Vastus lateralis muscle

D FIGURE 1.90 Hay lateral transgluteal approach to hip. A, Skin incision. B, Greater trochanter is exposed with gluteus medius attached to it proximally and vastus lateralis distally. Broken line indicates incision to be made in soft tissues. C, Rectangular slices of greater trochanter have been elevated anteriorly and posteriorly. D, Hip joint has been opened and can be dislocated as described. (Modified from McLauchlan J: The Stracathro approach to the hip, J Bone Joint Surg 66B:30, 1984.) SEE TECHNIQUE 1.71.

and knee and abducting and externally rotating the thigh (Fig. 1.91D). n  Sufficient exposure of the hip often can be obtained with less extensive division of the muscles inserting on the trochanter; the extent of division depends on the type of operation proposed, the amount of exposure required, the tightness of the soft tissues, and the presence or absence of contractures around the joint. Conversely, when wide exposure of the joint, especially of the acetabulum,

is needed, more extensive division of the muscles may be necessary. Gibson thought that reattaching the muscles to the greater trochanter by interrupted sutures is ­adequate. n  To preserve the insertion of the abductor muscles, osteotomize the trochanter and later reattach it with two wire loops, 6.5-mm lag screws, or cable grip. Wire loops are passed through the insertion of the muscles proximal to

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Gluteus maximus muscle Piriformis muscle Short external rotator muscles

Gluteus medius muscle Greater trochanter Fascia

Quadratus femoris muscle

Vastus lateralis muscle

A

B

Gluteus maximus muscle

Capsule

Vastus lateralis muscle

Gluteus medius and minimus insertions

C

D FIGURE 1.91 Gibson posterolateral approach to hip joint. A, Skin incision. B, Anterior and posterior muscle masses have been retracted to expose greater trochanter and muscles that insert into it. C, Gluteus medius and minimus have been divided near their insertions into greater trochanter and retracted. Incision in capsule is shown. D, Hip joint has been dislocated by flexing, abducting, and externally rotating thigh. SEE TECHNIQUE 1.72.

the trochanter and through a hole drilled in the femoral shaft 4 cm distal to the osteotomy. Figure 1.92 shows a modification of the Gibson approach by Marcy and Fletcher for insertion of a prosthesis in which the hip is dislocated by internal rotation and the anterior part of the joint capsule is preserved to keep the hip from dislocating anteriorly after surgery.   

POSTERIOR APPROACHES TO THE HIP

Posterior approaches are ideally suited for procedures in which femoral head viability is unnecessary, such as resection arthroplasty and insertion of a proximal femoral prosthesis. If femoral head viability is necessary, such as in hip resurfacing arthroplasty or fracture repair, the medial femoral circumflex artery and its ascending branches must be protected (Fig. 1.80).

The piriformis, obturator internus, and gemelli muscles must be separated well away from the posterior aspect of the greater trochanter (Fig. 1.93) and the attachments of the obturator externus and quadriceps femoris muscles must be preserved. Other, more anterior approaches often are better suited for these procedures.   

POSTERIOR APPROACH TO THE HIP   TECHNIQUE 1.73 (OSBORNE) Begin the incision 4.5 cm distal and lateral to the posterior superior iliac spine and continue it laterally and distally,

n 

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CHAPTER 1  SURGICAL TECHNIQUES

Gluteus maximus muscle

Capsule opened

Gluteus medius muscle Greater trochanter

Sciatic nerve

Release of external rotators

FIGURE 1.92 Modification of Gibson posterolateral approach to hip. Anterior part of joint capsule is preserved to keep hip from dislocating after surgery. Acetabulum is not well exposed, but approach is sufficient for removing femoral head and inserting prosthesis. SEE TECHNIQUE 1.72.

remaining parallel with the fibers of the gluteus maximus muscle, to the posterosuperior angle of the greater trochanter, and distally along the posterior border of the trochanter for 5 cm (Fig. 1.93A). n  Separate the fibers of the gluteus maximus parallel with the line of incision, no more than 7 cm to protect the branches of the inferior gluteal artery and nerve (Fig. 1.93B). n  Divide the insertion of the gluteus maximus into the fascia lata for 5 cm, corresponding to the longitudinal limb of the incision.

Rotate the thigh internally, detach the tendons of the piriformis and gemellus muscles near their insertions into the trochanter, and retract the muscles medially. The gemelli protect the sciatic nerve (Fig. 1.93C). n  The capsule of the joint is now in view and may be incised longitudinally to expose the posterior surface of the femoral neck and posterior border of the acetabulum. Further exposure may be obtained by retracting the gluteus medius muscle proximally and the quadratus femoris muscle distally.     n 

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Sciatic nerve

Line of incision

Piriformis muscle

Gemellus muscles Obturator externus muscle Obturator internus muscle

Gluteus maximus muscle

A

Quadratus femoris muscle

B

Piriformis muscle Gemellus muscles Joint capsule

Obturator externus muscle

Quadratus femoris muscle

C FIGURE 1.93 Osborne posterior approach to hip joint. A, Skin incision. B, Gluteus maximus has been opened in line with its fibers and retracted. C, Piriformis, gemellus, and obturator internus muscles have been divided at their insertions and reflected medially to expose posterior aspect of joint capsule. SEE TECHNIQUE 1.73.  

POSTERIOR APPROACH TO THE HIP   TECHNIQUE 1.74 (MOORE) Moore’s approach has been facetiously labeled “the southern exposure.” Place the patient on the unaffected side. n  Start the incision approximately 10 cm distal to the posterior superior iliac spine and extend it distally and laterally parallel with the fibers of the gluteus maximus to the p ­ osterior n 

margin of the greater trochanter. Direct the incision distally 10 to 13 cm parallel with the femoral shaft (Fig. 1.94A). n  Expose and divide the deep fascia in line with the skin incision. n  By blunt dissection, separate the fibers of the gluteus maximus no more than 7 cm from the tip of the trochanter to avoid injury to the branches of the inferior gluteal artery and nerve (Fig. 1.94B). n  Retract the proximal fibers of the gluteus maximus proximally and expose the greater trochanter. Retract the distal fibers distally, and partially divide their insertion into the linea aspera in line with the distal part of the incision.

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CHAPTER 1  SURGICAL TECHNIQUES

B

A

C

D FIGURE 1.94 Moore posterior approach to hip joint. A, Skin incision. B, Gluteus maximus has been split in line with its fibers and retracted to expose sciatic nerve, greater trochanter, and short external rotator muscles. C, Short external rotator muscles have been freed from femur and retracted medially to expose joint capsule. D, Joint capsule has been opened, and hip joint has been dislocated by flexing, adducting, and internally rotating thigh. SEE TECHNIQUE 1.74.

Expose the sciatic nerve and retract it carefully. After the surgeon becomes familiar with this approach, the sciatic nerve rarely needs to be exposed. Divide a small branch of the sacral plexus to the quadratus femoris and inferior gemellus, which contains sensory fibers to the joint capsule. n  Expose and divide the gemelli and obturator internus and, if desired, the tendon of the piriformis at their insertion on the femur, and retract the muscles medially. Tag these for later reattachment to the trochanter if desired. n  The posterior part of the joint capsule is now well exposed (Fig. 1.94C); incise it from distal to proximal along the line of the femoral neck to the rim of the acetabulum. n  Detach the distal part of the capsule from the femur. n  Flex the thigh and knee 90 degrees, internally rotate the thigh, and dislocate the hip posteriorly (Fig. 1.94D).    n 

MEDIAL APPROACH TO THE HIP

The medial approach to the hip, first described by Ludloff in 1908, was developed to permit surgery on a congenitally

dislocated hip with the hip flexed, abducted, and externally rotated. With the hip in this position, the distance from the skin to the medial aspect of the femoral head and lesser trochanter is about half that present when the hip is in the ­neutral position. The muscular interval for the Ludloff approach is believed to be between the sartorius and the adductor longus with the deeper interval being between the iliopsoas and pectineus, although Ludloff did not precisely define the interval in his original German articles. A review by Mallon and Fitch clarifies the anatomic intervals for the various medial approaches.   

MEDIAL APPROACH TO THE HIP Ferguson and Hoppenfeld and deBoer described a medial approach based on Ludloff’s approach with the superficial muscular interval between the gracilis and adductor longus and the deep interval between the adductor brevis and adductor magnus (Fig. 1.95).

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Fascia Skin incision

Gracilis muscle

Adductor longus muscle

Adductor longus muscle Gracilis muscle

A

B

Adductor magnus muscle Neurovascular bundle of gracilis muscle

Adductor longus muscle

Cleavage plane

Adductor longus muscle Adductor brevis muscle

Adductor brevis muscle

Adductor magnus muscle

Gracilis muscle Gracilis muscle

C

D

Iliopsoas muscle Adductor magnus muscle

FIGURE 1.95 Ferguson; Hoppenfeld and deBoer medial approach to hip joint. A, Skin incision. B, Plane between adductor longus and gracilis is to be developed. C, Adductor longus has been retracted anteriorly, and gracilis and adductor magnus have been retracted posteriorly. D, Lesser trochanter has been exposed. SEE TECHNIQUE 1.75.

  TECHNIQUE 1.75

Figure 1.95

(FERGUSON; HOPPENFELD AND DEBOER) Make a longitudinal incision on the medial aspect of the thigh, beginning about 2.5 cm distal to the pubic tubercle and over the interval between the gracilis and the adductor longus muscles. n  Develop the plane between the adductor longus and brevis muscles anteriorly and the gracilis and adductor magnus muscles posteriorly. n  Expose and protect the posterior branch of the obturator nerve and the neurovascular bundle of the gracilis muscle. The lesser trochanter and the capsule of the hip joint are located in the floor of the wound.    n 

Using a modified medial approach, Cavaignac et  al. repaired a femoral head fracture. The approach interval in this technique is between the lateral part of the adductor longus

muscle belly and the adductor longus aponeurosis. The lesser trochanter is exposed by blunt dissection. The inferior joint capsule is exposed by retracting the iliopsoas tendon in a lateral direction. 

ACETABULUM AND PELVIS Computed tomography and three-dimensional image reconstruction have aided greatly in characterizing fracture configurations and in preoperative planning for reduction of acetabular and pelvic fractures. Modifications of more traditional approaches have been developed for anterior, posterior, and lateral acetabular fractures. Extensile approaches have been developed for more complex fractures involving the anterior and posterior columns of the acetabulum and pelvis. The procedure for open reduction and internal fixation of acetabular fractures is detailed in Chapter 56. Complications associated with these more extensile approaches have led to the development of indirect reduction and percutaneous fixation techniques for acetabular fractures using only portions of

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CHAPTER 1  SURGICAL TECHNIQUES these approaches if possible. Many of these approaches can be adapted for difficult primary or revision total hip arthroplasty. 

i­lioinguinal and Stoppa approaches can improve access and fixation of the quadrilateral surface in comminuted anterior fracture patterns. Traditionally most surgeons have preferred to use skeletal traction on a radiolucent fracture table, but some surgeons prefer to drape the limb free to allow positioning of the limb to facilitate exposure.

 

STOPPA APPROACH The modified Stoppa approach can be used for many fractures that were previously treated through the ilioinguinal approach. It is performed through a Pfannenstiel skin incision with a vertical split in the rectus abdominis though the linea alba. The rectus on the involved side is elevated off the superior surface of the pubis, and any anastomoses between the obturator vessels and the external iliac or inferior epigastric vessels (the corona mortis) are ligated to expose the internal surface of the anterior column and the quadrilateral surface. Using the lateral window of the ilioinguinal approach, this approach avoids dissection of the middle window and exposure of the femoral vein and artery, nerve and lymphatics. Combining the complete

(AO FOUNDATION) Make a Pfannenstiel incision or alternatively a midline skin incision, starting 1 cm inferior to the symphysis and ending 2 cm to 3 cm inferior to the umbilicus (Fig. 1.96A). n  Divide the subcutaneous tissues in line with the skin incision to expose the fascia overlying both rectus muscles of the abdomen. n  Incise the rectus fascia longitudinally along the linea alba and gently retract both bellies of the rectus abdominis muscle laterally (Fig. 1.96B). n 

Transversus abdominis

2–3 cm

1 cm

  TECHNIQUE 1.76

Pfannenstiel incision

Linea alba

Peritoneum

A

B

Wet sponge Urinary bladder Catheter

C

D FIGURE 1.96 Stoppa approach for open reduction and internal fixation of acetabular fracture. A, Incision. B, Retraction of rectus abdominis muscle. C, Wet sponge packed into retropubic space to protect the urinary bladder. D, Dissection of periosteum from the superior pubic bone.

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Urinary bladder

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Obturator artery

Inferior epigastric artery Corona mortis vessels

E

Obturator internus

Iliopectineal arch

Pelvic brim

Iliac vessels

G

F Superior pubic ramus

Iliac vessels

H FIGURE 1.96, cont’d E, Identification of the corona mortis vessels. F, Dissection of the iliopectineal arch from the bone. G, Elevation of the periosteum and obturator internus to expose the quadrilateral surface. H, Placement of Hohmann retractors to expose acetabulum. (A through D, From AO Surgery Reference, www.aosurgery.org. Copyright by AO/Spine International, and E through H, Redrawn from AO Foundation, Davos Platz, Switzerland.) SEE TECHNIQUE 1.76.

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CHAPTER 1  SURGICAL TECHNIQUES Identify the fascia between the heads of the rectus muscle. In almost all patients, this fascia has been disrupted by the injury, and the resulting defect can be used as a starting point for blunt dissection. n  In the proximal part of the incision, take care not to incise the peritoneum. The entire approach should stay in the preperitoneal space. n  Loosely pack a wet sponge in the retropubic space to protect the urinary bladder (Fig. 1.96C). n  The medial part of the rectus muscle can be partly detached from the upper and anterior part of the symphysis if necessary. n  Sharply dissect the thick periosteum from the superior pubic bone to allow deeper blunt dissection. At the beginning, dissection should be enlarged also on the anterior part of the symphysis (Fig. 1.96D). n  Identify the upper border of the superior pubic ramus (pectin pubis) and carry the dissection laterally along the pelvic brim. Detach the iliopectineal fascia from the pelvic brim. n  Dissecting carefully along the medial surface of the superior ramus, identify the corona mortis vessels and ligate (or clip) them as necessary (Fig. 1.96E). n  Continue dissection of the periosteum farther laterally, following the upper border of the superior pubic bone to the direction of the pelvic brim, exposing the beginning of the iliopectineal eminence. n  Dissect the beginning of the iliopectineal arch from the bone to allow elevation of the femora vessels and nerve (Fig. 1.96F). n  Continue the dissection subperiosteally more laterally, following the upper border of the pelvic brim. At this point, the entire internal surface of the superior pubic ramus has been exposed adequately for plate fixation. n  At this level, the obturator neurovascular bundle crosses the quadrilateral surface and, in some cases, it should be mobilized. Use a spatula or malleable retractor to protect the obturator neurovascular bundle and pelvic floor. n  With a Cobb elevator, elevate the periosteum and obturator internus to expose the quadrilateral surface (Fig. 1.96G). n  Place a Hohmann retractor in the middle part of the superior pubic ramus and another curved Hohmann retractor on the posterior top of the acetabulum on the iliac part of the pelvic brim. Take care not to injure the external iliac vein, which may be in close proximity to the elevators (Fig. 1.96H).    n 

ANTERIOR APPROACHES TO THE ACETABULUM   

ILIOINGUINAL APPROACH TO THE ACETABULUM Letournel developed the ilioinguinal approach in 1960 as an anterior approach to the acetabulum and pelvis for the operative treatment of anterior wall acetabular and anterior column pelvic fractures. The articular surface of the acetabulum is not exposed, which is a disadvantage. This approach provides exposure of the inner table of the

innominate bone from the symphysis pubis to the anterior aspect of the sacroiliac joint, however, including the quadrilateral surface and the superior and inferior pubic rami. The hip abductor musculature is left undisturbed, and rapid postoperative rehabilitation is possible. A thorough knowledge of the surgical anatomy of this area is necessary to avoid disastrous complications.

  TECHNIQUE 1.77 (LETOURNEL AND JUDET, AS DESCRIBED BY MATTA) Position the patient supine on a fracture table with skeletal traction applied on the injured side through a distal femoral pin. Traction should not be used in the presence of contralateral superior and inferior pubic rami fractures because deformity of the anterior pelvic ring results from pressure from the perineal post. Apply lateral traction, if necessary, through a traction screw inserted into the greater trochanter and attached to a lateral support on the fracture table. n  Begin an incision 3 cm above the symphysis pubis and carry it laterally across the lower abdomen to the anterior superior iliac spine. Continue it posteriorly along the iliac crest to the junction of the middle and posterior thirds of the crest (Fig. 1.97A). n  Sharply elevate the origins of the abdominal muscles and the iliacus muscle from the iliac crest. n  Elevate the iliacus by subperiosteal dissection from the inner table of the ilium as far as the anterior aspect of the sacroiliac joint. Continue the incision anteriorly through the superficial fascia to the external oblique aponeurosis and the external fascia of the rectus abdominis muscle (Fig. 1.97B). n  Sharply incise the aponeurosis of the external oblique and the external fascia of the rectus abdominis at least 1 cm proximal to the external inguinal ring and in line with the skin incision. n  Open the inguinal canal by elevating and reflecting the distal edge of the external oblique aponeurosis and the adjacent fascia of the rectus abdominis (Fig. 1.97C). Protect the lateral femoral cutaneous nerve, which may be adjacent to the anterior superior iliac spine or 3 cm medial to it. n  Identify the spermatic cord or round ligament and adjacent ilioinguinal nerve. Bluntly free these structures and secure them with a Penrose drain. n  Clean the areolar tissue from the inguinal ligament and incise the ligament along its length carefully with a scalpel, leaving 1 mm of ligament attached to the internal oblique and transversus abdominis muscles and the transversalis fascia (Fig. 1.97D). Exercise extreme caution to avoid damaging the structures beneath the inguinal ligament. n  Having released the common origin of the internal oblique and transversus abdominis from the inguinal ligament, the psoas sheath is entered. Continue to protect the lateral femoral cutaneous nerve beneath the inguinal ligament. n  To gain further exposure medially, retract the spermatic cord or round ligament laterally, exposing the transversalis fascia and conjoined tendon, which form the floor of the inguinal canal. n  Divide the conjoined tendon of the internal oblique and transversus abdominis and the tendon of the rectus abdominis at their insertions on the pubis to open the retropubic space. n 

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A

B

Internal oblique muscle External oblique aponeurosis

Lateral femoral cutaneous nerve

Lateral femoral cutaneous nerve

Inguinal ligament

Iliopsoas muscle

Reflected aponeurosis

Spermatic cord or round ligament

C

Ilioinguinal nerve

D

Femoral nerve

External iliac vessels

FIGURE 1.97 Letournel and Judet ilioinguinal approach. A, Skin incision. B, Origins of abdominal and iliacus muscles have been elevated from iliac crest. Broken line shows incision through superficial fascia and external oblique aponeurosis. C, Lateral femoral cutaneous nerve has been exposed, and aponeurosis of external oblique has been incised. Iliacus has been reflected from inner table of ilium. Inguinal canal has been opened by reflecting incised flap of external oblique aponeurosis distally. Internal oblique, inguinal ligament, and spermatic cord or round ligament have been exposed. D, Inguinal ligament has been incised, releasing common origin of internal oblique and transversus abdominis muscles.

The structures beneath the inguinal ligament lie within two compartments or lacunae. The lacuna musculorum is lateral and contains the iliopsoas muscle, the femoral nerve, and the lateral femoral cutaneous nerve. The lacuna vasorum is medial and contains the external iliac vessels and lymphatics. The iliopectineal fascia, or psoas sheath, separates the two compartments (Fig. 1.97E). Carefully elevate the external iliac vessels and lymphatics from the iliopectineal fascia by blunt dissection and gently retract them medially. n  Elevate the iliopectineal fascia from the underlying iliopsoas and divide it sharply with scissors down to the pectineal eminence (Fig. 1.97F,G); continue the dissection laterally beneath the iliopsoas until the muscle and surrounding fascia are freed from the underlying pelvic brim. n 

Pass a Penrose drain beneath the iliopsoas, femoral nerve, and lateral femoral cutaneous nerve for use as a retractor. n  Using blunt finger dissection, begin mobilizing the external iliac vessels and lymphatics, working from lateral to medial. Search for the obturator artery and nerve medial and posterior to the vessels. Occasionally, the obturator artery or vein has an anomalous anastomosis with the external iliac or inferior epigastric artery or vein n  This is known as the corona mortis, or “crown of death,” because if it is accidentally cut hemostasis is difficult to achieve. If the anomalous obturator vessel is present, clamp, ligate, and divide it to avoid an avulsive traction injury. Place a third Penrose drain around the external iliac vessels and lymphatics. Leave the areolar tissue surrounding the vessels and lymphatics intact.

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CHAPTER 1  SURGICAL TECHNIQUES Iliopsoas muscle

Iliopectineal fascia

Femoral nerve

Iliopectineal fascia External iliac vessels

F

E Iliopectineal fascia Femoral nerve

G

H

I FIGURE 1.97, cont’d E, Iliopectineal fascia separates lacuna musculorum and lacuna vasorum. F, Iliopectineal fascia is incised toward pectineal eminence. G, Internal iliac vessels have been separated and retracted medially from iliopectineal fascia. H, Three regions of pelvis exposed during approach. I, Lateral femoral cutaneous nerve, iliopsoas, and femoral nerve have been retracted medially to expose internal iliac fossa. J, Pelvic brim and pectineal eminence have been exposed by lateral retraction of iliopsoas and femoral nerve and medial retraction of external iliac vessels. K, Medial aspect of superior pubic ramus and pubic symphysis have been exposed by release of rectus abdominis and lateral retraction of external iliac vessels and spermatic cord or round ligament. SEE TECHNIQUE 1.77.

J Rectus abdominis muscle

K

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PART I  GENERAL PRINCIPLES To expose the internal iliac fossa and adjacent pelvic brim, retract the iliopsoas and femoral nerve medially. Continue elevation of the iliacus muscle subperiosteally to the quadrilateral surface of the pelvis as necessary. Avoid injuring the internal iliac and gluteal vessels as the dissection is continued proximally along the quadrilateral space (Fig. 1.97H,I). To increase the exposure of the superior pubic ramus, retract the iliac vessels laterally and release the origin of the pectineus muscle. n  To obtain access to the entire pelvic brim distally to the lateral aspect of the superior pubic ramus, the anterior wall of the acetabulum, the quadrilateral surface, and the superior aspect of the obturator foramen, retract the iliopsoas and femoral nerve laterally and the external iliac vessels medially (Fig. 1.97J). To gain access to the superior aspect of the obturator foramen and the superior pubic ramus, retract the external iliac vessels laterally and the spermatic cord or round ligament medially. During retraction of the external iliac vessels in either direction, check the pulse of the internal iliac artery frequently and lessen the traction force if the pulse is interrupted. To obtain access to the medial aspect of the superior pubic ramus and symphysis pubis, retract the spermatic cord or round ligament laterally (Fig. 1.97K). n  If necessary, release the inguinal ligament and sartorius muscle from the anterior superior iliac spine and elevate the tensor fasciae latae and gluteal muscles from the external surface of the iliac wing. n  In repairing a pelvic fracture, preserve all substantial muscular attachments to the fracture fragments to avoid devitalizing the bone. n  Before wound closure, insert suction drains into the retropubic space and internal iliac fossa overlying the quadrilateral space. n  Reattach the abdominal fascia to the fascia lata on the iliac crest with heavy sutures. n  Reattach the tendon of the rectus abdominis to the periosteum of the pubis. n  Reattach the transversalis fascia and the internal oblique and transversus abdominis muscles to the inguinal ­ligament. n  Repair the iliopectineal fascia that separates the iliopsoas from the fascia of the rectus abdominis and the aponeurosis of the external oblique.     n 

A

B FIGURE 1.98 Bilateral ilioinguinal approach. A, Skin incision and deep dissection have been performed as described for unilateral ilioinguinal approach (Fig. 1.97). B, Insertions of both rectus abdominis muscles have been released, and symphysis and superior pubic rami have been exposed.

Letournel modified and improved the Smith-Petersen, or iliofemoral, approach. The muscles on the inner wall of the ilium are elevated to gain access to the anterior column directly within the pelvis.

  TECHNIQUE 1.78 (LETOURNEL AND JUDET)

 

Begin the skin incision at the middle of the iliac crest. Carry it anteriorly over the anterior superior iliac spine and distally along the medial border of the sartorius to the middle third of the anterior thigh (Fig. 1.99A). n  Divide the superficial and deep fascia. n  Develop the interval between the tensor fasciae latae laterally and the sartorius medially, exposing the rectus femoris. n  Divide the sartorius at its attachment to the anterior superior iliac spine. n  Divide the external branch of the lateral femoral cutaneous nerve. n  Incise the anterior abdominal musculature from the iliac crest and reflect it medially. n 

ILIOFEMORAL APPROACH TO THE ACETABULUM The Letournel and Judet anterior ilioinguinal approach can be used in a bilateral fashion for extensile exposure of the entire anterior half of the pelvic ring, symphysis pubis, iliac fossae, and the anterior aspects of both sacroiliac joints. The skin incision described in Figure 1.97 is carried across the opposite superior pubic ramus to the anterior superior iliac spine and then posteriorly along the iliac crest (Fig. 1.98). The insertions of both rectus abdominis muscles are released. The remainder of the exposure is developed as described in the unilateral ilioinguinal approach.

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CHAPTER 1  SURGICAL TECHNIQUES

Iliacus muscle

A Rectus femoris muscle

B FIGURE 1.99 Letournel and Judet iliofemoral approach. A, Skin incision. B, Anterior aspect of hip joint and anterior column are exposed by releasing sartorius and rectus femoris and reflecting iliacus medially. SEE TECHNIQUE 1.78.

Expose the iliac fossa by elevating the iliacus muscle (Fig. 1.99B). Carefully protect the femoral nerve and vessels and the remaining branches of the lateral femoral cutaneous nerve that lie just medial to the plane of the dissection. n  Detach both origins of the rectus femoris and reflect the muscle medially to expose the anterior surface of the hip joint capsule and anterior wall of the acetabulum. The iliopsoas tendon can be divided to provide more access to the anterior column. Preserve the musculature on the external surface of the iliac wing in this approach. Further reflection of the iliacus and abdominal musculature posteriorly and medially allows exposure of the inner wall of the ilium to the sacroiliac joint. Anteriorly, the superior pubic ramus can be exposed but the symphysis pubis cannot.    n 

POSTERIOR APPROACHES TO THE ACETABULUM

The combination of the Kocher approach and the Langenbeck approach, described as the Kocher-Langenbeck posterior approach by Letournel and Judet, provides access to the posterior wall and posterior column of the acetabulum. Gibson modified this approach by moving the superior limb of the incision more anteriorly (see Technique 1.80). Moed further described a modification of the Gibson approach that uses a straight lateral incision and approach that preserve the neurovascular supply to the anterior portion of the gluteus maximus muscle and allow more anterosuperior exposure of the acetabulum and iliac wing. As with the Kocher-Langenbeck technique, this approach is useful for

the treatment of posterior wall, posterior column, and certain transverse and T-type acetabular fractures. For more complex fracture types, it can be performed with the patient prone.   

KOCHER-LANGENBECK APPROACH   TECHNIQUE 1.79 (KOCHER-LANGENBECK; LETOURNEL AND JUDET) Place the patient in the lateral position with the affected hip uppermost. If a fracture table and a supracondylar femoral traction pin are used, keep the knee joint in at least 45 degrees of flexion to prevent excessive traction on the sciatic nerve. n  Begin the skin incision over the greater trochanter and extend it proximally to within 6 cm of the posterior superior iliac spine (Fig. 1.100A). The incision can be extended distally over the lateral surface of the thigh for approximately 10 cm as necessary. n  Divide the fascia lata in line with the skin incision and bluntly split the gluteus maximus in line with its muscle fibers for a distance of no more than 7 cm (Fig. 1.100B), protecting the branch of the inferior gluteal nerve to the anterosuperior portion of the gluteus maximus to avoid denervating that part of the muscle. n  Identify and protect the sciatic nerve overlying the quadratus femoris (Fig. 1.100C). Incise the short external rotators at their tendinous insertions on the greater n 

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PART I  GENERAL PRINCIPLES Superior gluteal nerve Gluteus medius muscle

Piriformis muscle Sciatic nerve

Obturator internus and gemellus muscles

B Piriformis muscle

C

Quadratus femoris muscle

Sciatic nerve

A

D

E

FIGURE 1.100 Kocher-Langenbeck posterior approach. A, Skin incision. B, Incision of fascia lata and splitting of gluteus maximus outlined. C, Gluteus maximus has been retracted, exposing short external rotators, sciatic nerve, and superior gluteal vessels. Ascending branch of medial circumflex femoral artery underlies obturator externus and quadratus femoris. D, Hip joint capsule has been exposed by division and posterior reflection of short external rotators. Quadratus femoris and obturator externus are left intact to protect the ascending branch of the medial circumflex artery. E, Osteotomy of greater trochanter and reflection of hamstring origins from ischial tuberosity have enlarged exposure. SEE TECHNIQUE 1.79.

t­ rochanter and reflect them medially to protect the sciatic nerve further (Fig. 1.100D). Leave the quadratus femoris and obturator externus intact to protect the underlying ascending branch of the medial circumflex femoral artery. The tendinous insertion of the gluteus maximus on the femur can be incised to increase exposure. n  Elevate the gluteus medius and minimus subperiosteally from the posterior and lateral ilium. Retraction of these muscles can be maintained by inserting two smooth Steinmann pins into the ilium above the greater sciatic notch. Identify and protect the superior gluteal nerve and vessels as they exit the greater sciatic notch. The entire posterior acetabulum and posterior column are now ­exposed. Further exposure can be gained by an os-

teotomy of the greater trochanter and reflection of the origins of the hamstrings from the ischial tuberosity (Fig. 1.100E). n  Reattach the greater trochanter with two 6.5-mm lag screws during wound closure.      

MODIFIED GIBSON APPROACH As with the Kocher-Langenbeck approach, this approach is useful for the treatment of posterior wall, posterior column, and certain transverse and T-type acetabular fractures. For more complex fracture types it can be performed with the patient prone.

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CHAPTER 1  SURGICAL TECHNIQUES Potential proximal fascial gluteus maximus release

C Released piriformis muscle

B

Gluteal fascia

A

Released short external rotators

Retracted gluteus medius muscle

Sciatic nerve

Gluteus maximus

D

Tensor fascia lata

Exposed hip capsule Lesser sciatic notch

Iliotibial tract

Released gluteus maximus insertion

E FIGURE 1.101 Modified Kocher approach as described by Gibson. Greater trochanter is dotted line. ADE is the KocherLangenbeck incision. BDE is Gibson’s original incision. CDE is Moed’s modification of the approach. (Redrawn from Moed BR: The modified Gibson posterior surgical approach to the acetabulum, J Orthop Trauma 24:315, 2010.) SEE TECHNIQUE 1.80.

FIGURE 1.102 Deep dissection with gluteus maximus muscle reflected posterior and a retractor in the lesser sciatic notch. Retract the gluteus medius muscle in an anterior direction to expose the hip joint. (Redrawn from Moed BR: The modified Gibson posterior surgical approach to the acetabulum, J Orthop Trauma 24:315, 2010.) SEE TECHNIQUE 1.80.

  TECHNIQUE 1.80

n 

Release the piriformis and short external rotators. Leave the obturator externus and quadratus externus intact to protect the medial circumflex femoral artery (Fig. 1.102).   

(MODIFIED GIBSON APPROACH, MOED) Position the patient in the lateral decubitus position as one would for a Kocher-Langenbeck approach (see Technique 1.79). n  Make a longitudinal incision beginning at the iliac crest, continuing it over the greater trochanter and down the lateral thigh as far as necessary (Fig. 1.101). n  Dissect through the subcutaneous tissue until the iliotibial band and gluteus maximus muscle fascia are reached. n  Identify the anterior border of the gluteus maximus muscle by identifying the branches of the inferior gluteal artery that run in the fascia between the gluteus maximus and gluteus medius muscles. Do not split the gluteus maximus as in the Kocher-Langenbeck approach. n  Release the anterior border of the gluteus maximus, leaving an anterior fascial end for later repair. Release it from the level of the greater trochanter to the level of the iliac crest. Preserve the neurovascular supply to the anterior gluteus maximus. n  Retract the gluteus medius in an anterior direction and the gluteus maximus in a posterior direction. Release the gluteus maximus insertion on the posterior femur if necessary. Release the posterosuperior origin and fascia from the iliac crest as needed. n 

EXTENSILE ACETABULAR APPROACHES

Because complete exposure of anterior and posterior columns of the acetabulum requires separate anterior and posterior approaches, several surgeons developed extensile approaches to the acetabulum to avoid the problems encountered when using these separate approaches. Included here are the approaches that my colleagues and I have found most useful.   

EXTENSILE ILIOFEMORAL APPROACH Letournel developed an extended iliofemoral approach that provides complete exposure of the inner and outer table of the ilium, acetabulum, and anterior and posterior columns. It requires incision, however, of the origins and insertions of the gluteus minimus and medius from the iliac crest and the greater trochanter. Great care should be taken to avoid damaging the superior gluteal vessels to prevent ischemic necrosis of the hip abductors. In the presence of a fracture through the greater sciatic notch and arteriographic evidence of damage to the superior gluteal vessels, this approach should not be used.

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  TECHNIQUE 1.81

 

EXTENSILE ILIOFEMORAL APPROACH

(LETOURNEL AND JUDET) Place the patient in the lateral position on a fracture table if distal femoral traction is necessary. If traction is not necessary, a standard operating table can be used. Keep the knee joint flexed more than 45 degrees to avoid excessive traction on the sciatic nerve. n  Begin the incision at the posterior superior iliac spine and extend it along the iliac crest, over the anterior superior iliac spine, and carry it distally halfway down the anterolateral aspect of the thigh (Fig. 1.103A). n  Elevate the gluteal muscles and the tensor fasciae latae from the outer table of the iliac wing as far anteriorly as the anterior superior iliac spine. Division of some of the posterior branches of the lateral femoral cutaneous nerve is inevitable, but protect the main trunk of the nerve. n  Open the fascia covering the greater trochanter and vastus lateralis longitudinally. n  Isolate, ligate, and divide the lateral femoral circumflex artery (Fig. 1.103B). n  Continue the dissection posteriorly to the greater sciatic notch. Carefully identify and protect the superior gluteal vessels and nerve. n  Divide the tendons of the gluteus minimus and medius, dissect these muscles from the hip joint capsule, and reflect them posteriorly (Fig. 1.30C). n  Divide the tendons of the piriformis and obturator internus at their insertions on the greater trochanter and elevate these muscles from the hip joint capsule. The sciatic nerve exits the greater sciatic foramen beneath the piriformis muscle and must be protected. A retractor can be placed in the greater sciatic notch; gentle retraction exposes the posterior column (Fig. 1.103D). Avoid a traction injury to the sciatic nerve in this exposure. Leave the quadratus femoris muscle intact to protect the ascending branch of the medial circumflex femoral artery. n  Open the hip joint by a capsulotomy around the rim of the acetabulum. n  Exposure of the internal surface of the ilium and anterior column proceeds as in a routine iliofemoral approach. n  Elevate the abdominal muscles and iliacus from the iliac crest of the ilium and divide the attachments of the sartorius and inguinal ligament subperiosteally from the anterior superior iliac spine. Divide the origins of the direct and reflected heads of the rectus femoris to expose the anterior portion of the hip joint capsule (Fig. 1.103E). n  During wound closure, reattach the rectus femoris, sartorius, fascial layers of the hip abductor musculature, and tensor fasciae latae to the iliac wing with sutures passed through the bone. n  Repair the gluteus minimus and medius tendons ­anatomically. n  Reattach the tendons of the piriformis and obturator internus to the greater trochanter also with transosseous sutures.     n 

Reinert et al. developed a modification of the Letournel and Judet extended iliofemoral approach designed to allow later reconstructive procedures. It provides exposure for repair of complex and both-column acetabular fractures. The skin incision is positioned more laterally. Also, the hip abductors are mobilized by osteotomies of their origins and insertions. Rigid bone-to-bone reattachment of these muscles permits early rehabilitation with less risk of failure than when the abductors are reattached through soft tissue. As with the extended iliofemoral approach, the patency of the superior gluteal artery is necessary to avoid necrosis of the hip abductors. In the presence of a displaced fracture at the sciatic notch, a preoperative arteriogram is recommended. If a later reconstructive procedure is required, the same operative site can be approached using part or all of the same skin incision as necessary.

  TECHNIQUE 1.82 (REINERT ET AL.) Place the patient in the lateral position. Drape the lower extremity free on the side of the pelvic injury. n  Begin the skin incision 2 cm posterior to the anterior superior iliac spine and carry it posteriorly along the iliac crest for 8 to 12 cm. Make the vertical limb of the T-shaped incision by incising from the midportion of the iliac crest incision in a curvilinear fashion down the lateral aspect of the thigh to a point 15 cm distal to the greater trochanter (Fig. 1.104A). n  Develop the anterior flap by dissecting the subcutaneous tissue from the deep fascia until the anterior superior iliac spine and the interval between the sartorius and tensor fasciae latae muscles are reached. Protect the lateral femoral cutaneous nerve. Develop the posterior flap in the same fashion. n  Flex the hip to 45 degrees and abduct it. Incise the fascia lata longitudinally from the center of the greater trochanter distally to a point 2 cm distal to the insertion of the tensor fasciae latae muscle. n  Incise the gluteal fascia and bluntly split the gluteus maximus in line with its fibers until the inferior gluteal nerve and vessels are encountered. n  Divide the anterior portion of the fascia lata transversely 2 cm distal to the insertion of the tensor fasciae latae muscle. Release the proximal portion of the gluteus maximus insertion on the femur. n  Bluntly develop the interval between the tensor fasciae latae and the sartorius. n  Continue the deep dissection anterior and posterior to the tensor fasciae latae, separating it from the sartorius and the rectus femoris. n  Carefully identify, ligate, and divide the ascending branch of the lateral femoral circumflex artery in the proximal part of the dissection. Microvascular reanastomosis of this artery can be used as a substitute to restore collateral circulation to the hip abductors should the superior gluteal artery be severely damaged during the procedure. n 

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CHAPTER 1  SURGICAL TECHNIQUES

Superior gluteal vessels and nerve

Sartorius muscle

Gluteal muscles

Rectus femoris muscle Lateral circumflex femoral vessels

Tensor fascia latae

A B

Piriformis muscle Sciatic nerve

Sartorius muscle Obturator internus muscle Quadratus femoris muscle

C

Joint capsule

D

Rectus femoris muscle

E

Vastus lateralis muscle

FIGURE 1.103 Letournel and Judet extended iliofemoral approach. A, Skin incision. B, Gluteal muscles and tensor fasciae latae have been partially elevated and retracted posteriorly. Lateral femoral circumflex vessels have been isolated. C, Tendon of gluteus minimus has been completely severed from anterior aspect of greater trochanter. Gluteus medius tendon has been partially incised. D, Reflection of piriformis, obturator internus, and gluteal muscles has exposed external surface of innominate bone. E, Internal surface of ilium and anterior acetabulum and hip joint have been exposed by reflection of iliacus, sartorius, and rectus femoris (see text). SEE TECHNIQUE 1.81.

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FIGURE 1.104 Reinert et al. modified iliofemoral approach. A, Skin incision. Cutaneous flaps have been developed. Broken line indicates incision through fascia lata. B and C, Osteotomies of iliac crest, anterior superior iliac spine, and greater trochanter. D, Osteotomies have been completed, and muscle flaps have been reflected, exposing anterior column. E, Posterior column has been exposed. Broken line depicts incision for release of rectus muscle (see text). (From Reinert CM, Bosse MJ, Poka A, et al: A modified extensile exposure for the treatment of complex or malunited acetabular fractures, J Bone Joint Surg 70A:329, 1988.) SEE TECHNIQUE 1.82.

A

Anterior column Anterior column Weight-bearing dome

Posterior column

B

C

Posterior column

Superior gluteal artery and nerve Anterior superior iliac spine

Incision to release rectus muscle Rectus muscle

D

E

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CHAPTER 1  SURGICAL TECHNIQUES Elevate the abdominal and iliacus muscles from the iliac crest subperiosteally. Extend the dissection posteriorly to expose the anterior aspect of the sacroiliac joint and sciatic notch as necessary. n  Perform an osteotomy of the anterior superior iliac spine and reflect the attached sartorius and inguinal ligament medially, along with the abdominal and iliacus muscles. n  With an osteotome or 90-degree power cutting tool, perform an osteotomy of the tricortical portion of the iliac crest beginning along the inner table and producing a fragment 10 to 12 cm long and 1.5 cm wide (Fig. 1.104B,C). Leave the hip abductor muscles attached to the fragment, and reflect this musculo-osseous flap laterally. n  Elevate the abductors subperiosteally from the outer table of the ilium during this reflection. Carefully preserve the superior gluteal nerve and vessels. n  Perform a standard trochanteric osteotomy and release the abductors from the hip joint capsule. n  Carefully reflect the abductors and attached greater trochanter posteriorly (Fig. 1.104D,E). Release the short external rotators from the greater trochanter. The quadratus femoris is preserved, protecting the ascending branch of the medial circumflex femoral artery. n  Identify and protect the sciatic nerve. Further avoid traction injury to the sciatic nerve by maintaining the hip extended and the knee flexed to at least 45 degrees. n  If further anterior exposure is needed, release the direct and reflected heads of the rectus femoris (Fig. 1.104E). Incise the hip joint capsule circumferentially at the acetabular labrum. n  During closure, reattach the origins of the rectus femoris with heavy sutures through holes drilled in the anterior inferior iliac spine. n  Repair all osteotomies with lag-screw fixation. n  Repair the fascia lata and reattach the iliacus and abdominal muscles to the iliac crest with heavy sutures.     n 

 

TRIRADIATE EXTENSILE APPROACH TO THE ACETABULUM Mears and Rubash modified Charnley’s initial total hip arthroplasty approach and developed an extensile acetabular approach providing access to the acetabulum, the anterior and posterior columns, the inner iliac wall, the anterior aspect of the sacroiliac joint, and the outer aspect of the innominate bone. This triradiate approach was developed for reduction and repair of complex acetabular fractures. It avoids the potential complication of massive ischemic necrosis of the hip abductors caused by injury to the superior gluteal vessels, which is a possibility when the extended iliofemoral approach is used.

  TECHNIQUE 1.83 (MEARS AND RUBASH) Place the patient in the lateral position on a conventional operating table. A fracture table can be used if skeletal traction is necessary. Keep the knee joint in at least 45

n 

degrees of flexion to avoid excessive traction on the sciatic nerve. n  Begin the longitudinal portion of the triradiate incision at the tip of the greater trochanter and carry it distally 6 to 8 cm. Carry the anterosuperior limb from the tip of the greater trochanter across the anterior superior iliac spine. Begin the posterosuperior limb of the incision at the tip of the greater trochanter as well, and carry it to the posterior superior iliac spine, forming an angle of approximately 120 degrees (Fig. 1.105A). n  Divide the fascia lata in line with its fibers in the longitudinal limb of the incision. n  Incise the fascia lata and fascial covering of the tensor fasciae latae in line with the anterosuperior limb of the incision (Fig. 1.105B). n  Dissect the anterior border of the tensor fasciae latae from its overlying fascia and elevate the origin of the muscle from the iliac crest. Elevate subperiosteally from the iliac crest the origins of the gluteus medius and minimus from anterior to posterior and distally to the hip joint capsule. n  Incise the fascia of the gluteus maximus in line with the posterosuperior limb of the incision and split the muscle in line with its fibers (Fig. 1.105C). n  Perform an osteotomy of the greater trochanter and reflect the trochanter with the attached insertions of the gluteus medius and minimus proximally. n  Sharply elevate the gluteus medius and minimus from the capsule of the hip joint, preserving the capsule during the dissection. Continue the dissection to the greater sciatic notch and identify and protect the superior gluteal vessels (Fig. 1.105D). n  Divide the insertions of the short external rotators on the proximal femur, including the upper third of the quadratus femoris. Leave intact the remainder of this muscle and the underlying ascending branch of the medial circumflex femoral artery. n  Reflect the divided short external rotators posteriorly to expose the posterior aspect of the hip joint capsule and the posterior column. n  Maintain the exposure of the posterior column by carefully inserting blunt Hohmann retractors into the greater and lesser sciatic notches. n  Secure the abductor muscles superiorly by inserting two Steinmann pins into the ilium 2.5 cm and 5 cm above the greater sciatic notch (Fig. 1.105E). n  Sharply incise the origins of the hamstrings to expose the ischial tuberosity. n  To expose the anterior column and inner table of the ilium, extend the anterosuperior limb of the skin incision 6 to 8 cm medial to the anterior superior iliac crest. n  Incise the abdominal musculature from the anterior iliac crest and elevate subperiosteally the iliacus muscle from the inner table of the ilium. Continue the dissection posteriorly to expose the anterior aspect of the sacroiliac joint (Fig. 1.105F). n  To increase the exposure further, divide the origin of the sartorius from the anterior superior iliac spine and the origins of the direct and reflected heads of the rectus femoris from the anterior inferior iliac spine and hip joint capsule.

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Tensor fasciae latae Anterior superior iliac spine

Gluteus medius muscle

A

B

Vastus lateralis muscle

C

Greater trochanter Sciatic nerve

Rectus femoris muscle Joint capsule

D

FIGURE 1.105 Mears and Rubash triradiate extensile approach. A, Skin incision. B, Superficial fascial incision. C, Origin of tensor fasciae latae has been elevated from anterior iliac crest. Gluteus maximus has been split in line with its fibers up to inferior gluteal nerve and vessels. D, Greater trochanter has been osteotomized and reflected posteriorly exposing sciatic nerve and short external rotators. Gluteal and tensor fasciae latae muscles have been elevated from outer table of ilium and hip joint capsule and reflected posteriorly. E, Short external rotators have been severed from greater trochanter and reflected posteriorly. Quadratus femoris remains intact. Gluteal and tensor fasciae latae muscles have been retracted superiorly and held with Steinmann pins to expose posterior column. Joint capsule has been severed circumferentially from acetabulum. F, Abdominal muscles have been incised and iliacus muscle elevated subperiosteally from ilium and reflected medially to expose inner table of ilium (see text and also Fig. 1.103). (Modified from Mears DC, Rubash HE: Pelvic and acetabular fractures, Thorofare, NJ, Slack, 1986.) SEE TECHNIQUE 1.83.

Piriformis muscle Sciatic nerve

Sacroiliac joint Lateral femoral cutaneous nerve

Rectus femoris muscle

Femoral nerve

Joint capsule

E

F

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CHAPTER 1  SURGICAL TECHNIQUES Incise the aponeurosis of the external oblique muscle 1 cm proximal to the external inguinal ring and in line with the inguinal ligament as described for the ilioinguinal approach (see Technique 1.77). n  Carefully develop the interval between the external iliac vessels medially and the psoas muscle laterally. Next, develop the interval between the external iliac vessels and the spermatic cord or round ligament (Fig. 1.105B-F). n  Use the longitudinal intervals developed and expose subperiosteally the superior pubic ramus and quadrilateral surface of the pelvis. n  Incise the joint capsule of the hip circumferentially at the edge of the acetabulum as far anteriorly and posteriorly as necessary, but leave the acetabular labrum intact. n  During closure, reattach the abdominal fascia to the fascia lata along the iliac crest with heavy sutures. n  Reattach the gluteal muscle origins and the tensor fasciae latae to the iliac crest. n  Drill small holes in the ilium and use heavy sutures to reattach the origins of the rectus femoris and sartorius muscles. n  Repair the trochanteric osteotomy with two long 6.5-mm cancellous screws with washers. n  Close the three fascial limbs of the triradiate incision, beginning with a single apical suture. n  Complete the closure of each limb of the incision.     n 

 

EXTENSILE APPROACH TO THE ACETABULUM Carnesale combined Henry’s reflection of the gluteus maximus with several other approaches to the hip joint to form an extensile approach for open reduction of complex acetabular fractures. The posterior or anterior part of the approach may be used alone as indicated in the given instance; the entire approach is rarely required.

  TECHNIQUE 1.84 (CARNESALE) Secure the patient on the uninjured side on a standard operating table so that the table may be tilted to either side. n  Prepare the skin from the middle of the rib cage to below the knee. n  Drape to allow free manipulation of the extremity. n  Start the skin incision at the posterior superior iliac spine, extend it anteriorly parallel to the iliac crest, and end it just proximal to the anterior superior iliac spine (Fig. 1.106A). If the anterior part of the approach is to be used, extend the incision into the groin crease (see Fig. 1.106G). Perpendicular to this transverse incision, incise the skin distally in the lateral midline of the thigh, cross the center of the greater trochanter, and at the gluteal fold turn the incision 90 degrees posteriorly and extend it to the posterior midline of the thigh; if necessary, extend it distally in the posterior midline of the thigh for 4 or 5 cm. n  Raise appropriate flaps of skin, investing fascia anteriorly and posteriorly (Fig. 1.106B). n 

Reflect the gluteus maximus, leaving it attached medially at its pelvic origin as described by Henry as follows: n  In the distal part of the incision, locate the posterior cutaneous nerve of the thigh just beneath the deep fascia. Open this fascia and trace the nerve to the distal edge of the gluteus maximus; the nerve will be freed from the muscle later. n  Free the femoral side of the gluteus maximus by longitudinally splitting the part of the iliotibial band that slides on the femoral shaft and greater trochanter. n  Extend the incision in the iliotibial band slightly proximally; at this point, insert a finger, locate the superior border of the gluteus maximus where it joins the iliotibial band, and, with the scissors, free this border of the muscle proximal to the iliac crest (Fig. 1.106C,D). n  Raise the distal edge of the gluteus maximus and the posterior cutaneous nerve of the thigh, and divide the thick insertion of the muscle from the femur. Control the constant vessel found at this insertion. n  Detach the posterior cutaneous nerve of the thigh from the deep surface of the gluteus maximus and gently reflect the muscle medially, hinged on its pelvic attachment (Fig. 1.106E). n  Detach the short external rotators from the greater trochanter, reflect them medially, and strip them subperiosteally from the ilium sufficiently to expose the posterior acetabular wall. If more superior exposure of the acetabulum is required, osteotomize the greater trochanter, and with it reflect the hip abductors proximally (Fig. 1.106F). n  In fractures of the anterior aspect of the acetabulum, continue the skin incision anteriorly to the groin crease as already described (Fig. 1.106G). n  Locate the lateral femoral cutaneous nerve and preserve it (Fig. 1.106H). n  Detach the inguinal ligament, sartorius, and rectus femoris from the pelvis, but leave the tensor fasciae latae intact (Fig. 1.106I). n  Strip subperiosteally the iliacus and, if necessary, the obturator internus from the medial pelvic wall, exposing the anterior aspect of the acetabulum (Fig. 1.106J).    n 

ILIUM   

APPROACH TO THE ILIUM   TECHNIQUE 1.85 Incise the skin along the iliac crest from the anterior superior spine to the posterior superior spine. n  Reflect the attachments of the gluteal muscles subperiosteally, proximally to distally, as far as the superior rim of the acetabulum, and expose the lateral surface of the ilium. n  Reflect subperiosteally the attachment of the abdominal muscles from the iliac crest, or osteotomize the crest, leaving the abdominal muscles attached to the superior fragment. In children, make the osteotomy of the crest inferior to the epiphyseal plate. Reflect subperiosteally the iliacus muscle from the medial surface of the ilium. Also, divide at their origins the structures attached to the n 

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PART I  GENERAL PRINCIPLES a­ nterior superior spine and the anterior border of the ilium. Most of the ilium can be denuded. n  In this procedure, a nutrient artery on the lateral surface of the ilium 5 cm inferior to the crest and near the juncture of the anterior and middle thirds is divided. Because ligating it is impossible, control the bleeding with the point of a small hemostat or, if necessary, with bone wax.   

SYMPHYSIS PUBIS   

APPROACH TO THE SYMPHYSIS PUBIS   TECHNIQUE 1.86 (PFANNENSTIEL) Place the patient supine and insert a Foley catheter for intraoperative identification of the base of the bladder and the urethra.

n 

Make a curvilinear transverse incision 2 cm cephalad to the superior pubic ramus (Fig. 1.107A). n  Incise the external oblique aponeurosis parallel to the inguinal ligament. n  Identify the spermatic cords or round ligaments and adjacent ilioinguinal nerves. Release the aponeurotic insertion of both heads of the rectus abdominis from the superior pubic ramus (Fig. 1.107B). n  Expose subperiosteally the superior, anterior, and posterior surfaces of both rami laterally for 4 to 5 cm as necessary (Fig. 1.107C). During this dissection, identify the urethra and base of the bladder by manual palpation of the Foley catheter. n  During wound closure, insert a suction drain into the retropubic space and repair the rectus abdominis with heavy interrupted sutures. n  Carefully repair the external oblique aponeurosis to prevent an inguinal hernia.    n 

Gluteus maximus muscle

Posterior cutaneous nerve of thigh

A B

C

Gluteus maximus muscle reflected

Reflected external rotators Sciatic nerve

D

E FIGURE 1.106

A-J, Carnesale extensile exposure of acetabulum (see text). SEE TECHNIQUE 1.84.

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CHAPTER 1  SURGICAL TECHNIQUES

Reflected greater trochanter

F Tensor fasciae latae

G Lateral femoral cutaneous nerve

Inguinal ligament Pectineal line

Sartorius muscle Sartorius muscle

H

I

Rectus femoris muscle

J

FIGURE 1.106, cont’d

A

B

C

FIGURE 1.107 Pfannenstiel transverse approach to pubic symphysis. A, Skin incision. B, Rectus abdominis insertions have been released. C, Entire pubic symphysis has been exposed. SEE ­TECHNIQUE 1.86.

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PART I  GENERAL PRINCIPLES

SACROILIAC JOINT 

for 4 to 5 cm. The inferior border of this section roughly parallels the superior border of the greater sciatic notch. n  Exposure of the joint is limited by the size of the section removed.    

 

POSTERIOR APPROACH TO THE SACROILIAC JOINT

 

  TECHNIQUE 1.87

ANTERIOR APPROACH TO THE SACROILIAC JOINT

Make an incision along the lateral lip of the posterior third of the iliac crest to the posterior superior spine (Fig. 1.108A). n  Deepen the dissection down to the crest, separate the lumbodorsal fascia from it, detach and reflect medially the aponeurosis of the sacrospinalis muscle together with the periosteum, and expose the posterior margin of the sacroiliac joint. This exposure is ample for extraarticular fusion. n  To expose the articular surfaces of the joint for drainage or intraarticular fusion, continue the skin incision laterally and distally 5 to 8 cm from the posterior superior spine. Split the gluteus maximus muscle in line with its fibers, or incise its origin on the iliac crest, the aponeurosis of the sacrospinalis, and the sacrum, and reflect it laterally and distally to expose the posterior aspect of the ilium (Fig. 1.108B). Branches of the inferior gluteal nerve and artery may be present. n  To expose more of the ilium, reflect the gluteus medius anterolaterally. The gluteus medius cannot be reflected very far anteriorly because of the presence of the superior gluteal nerve and artery. n  With an osteotome, remove a full-thickness section of the ilium 1.5 to 2 cm wide, beginning at its posterior border between the posterior superior and posterior inferior spines and proceeding laterally and slightly cephalad n 

Sometimes primary suppurative arthritis of the sacroiliac joint may localize anteriorly; Avila approaches this region by an intrapelvic route. This approach also is useful for open reduction and plating of sacroiliac joint dislocation.

  TECHNIQUE 1.88 (AVILA) With the patient supine, make a 10- to 12-cm incision 1.5 cm proximal to and parallel with the iliac crest, beginning at the anterior superior iliac spine (Fig. 1.109). n  Dissect distally to the iliac crest and detach the abdominal muscles from it without disturbing the origin of the gluteal muscles. n  Incise the periosteum and strip the iliacus muscle subperiosteally, following the medial surface of the ilium medially and slightly distally. n  Retract the iliacus medially and complete the stripping by hand with the gloved finger covered with gauze. Proceed as far as the lateral attachments of the anterior sacroiliac ligament; detach them and palpate the joint. n  To expose the anterior aspect of the joint, extend the incision farther posteriorly in the intermuscular plane along the iliac crest.     n 

Ilium Incision Posterior inferior iliac spine

Sacroiliac joint Greater sciatic notch

Gluteus medius muscle Gluteus maximus muscle

Piriformis muscle

A B FIGURE 1.108 Posterior approach to the sacroiliac joint. A, Incision for the posterior approach to the sacroiliac joint is vertical from just above the posterior superior iliac spine distally about 1.0 cm. B, Deeper dissection involves incising the gluteus maximus fascia and subperiosteally elevating the maximus off of the ilium just lateral to the posterior superior iliac spine. SEE TECHNIQUE 1.87.

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CHAPTER 1  SURGICAL TECHNIQUES  

APPROACH TO BOTH SACROILIAC JOINTS OR SACRUM

Psoas muscle Iliac muscle

When bilateral, unstable sacroiliac disruptions or comminuted vertical fractures of the sacrum occur as part of a pelvic ring disruption, Mears and Rubash approach these through a transverse incision made across the midportion of the sacrum. These injuries can be stabilized with a contoured reconstruction plate through this approach.

Incision Anterior sacroiliac ligament

  TECHNIQUE 1.89 (MODIFIED FROM MEARS AND RUBASH) With the patient prone, make a transverse straight incision across the midportion of the sacrum 1 cm inferior to the posterior superior iliac spines (Fig. 1.110A). If one or both of the sciatic nerves are to be explored, curve the ends of the incision distally to allow exposure of the sciatic nerves from the sacrum to the greater sciatic notch. n  Extend the incision through the deep fascia to expose the superior portions of the origins of both gluteus maximus muscles on the posterior superior iliac spines (Fig. 1.110B). n  Elevate the paraspinous muscles from the posterior superior iliac spine and perform an osteotomy of each spine n 

FIGURE 1.109 TECHNIQUE 1.88.

Anterior approach to the sacroiliac joint. SEE

A

B

C

D

FIGURE 1.110 Exposure of both sacroiliac joints or sacrum. A, Skin incision. B, Posterior iliac crests, gluteus maximus muscles, and paraspinous muscles have been exposed. C, Outline of osteotomies of posterior superior iliac spines for application of plate and screws. D, Osteotomies have been performed, and gluteus maximus muscles have been reflected laterally. SEE TECHNIQUE 1.89.

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PART I  GENERAL PRINCIPLES Coracoclavicular ligament Coracoacromial ligament Acromioclavicular joint

Clavicle

Coracoid process Reflected deltoid muscle

A B FIGURE 1.111 Roberts exposure of acromioclavicular joint and coracoid process of scapula. A, Skin incision. B, Deltoid muscle detached from clavicle and acromion, exposing acromioclavicular joint, and retracted distally for exposure of coracoid process. SEE TECHNIQUE 1.91.

posterior to the sacrum, from medial to lateral, leaving the origins of the gluteus maximus muscles intact (Fig. 1.110C,D). This provides a flat surface for application of a plate. n  Elevate the paraspinous muscles subperiosteally from the sacrum and adjacent posterosuperior iliac spines to provide a tunnel for application of a plate. n  Remove the tips of the spinous processes of the sacrum as necessary. n  If further exposure is necessary for drainage of a sacroiliac joint or intraarticular fusion, split the gluteus maximus muscle on that side or incise its origin from the posterior superior iliac spine, and reflect it laterally to expose the posterior aspect of the ilium. n  Perform a larger osteotomy of the posterior ilium as described for the standard posterior approach to the sacroiliac joint (see Technique 1.87).    

 

APPROACH TO THE STERNOCLAVICULAR JOINT   TECHNIQUE 1.90 Make an incision along the medial 4 cm of the clavicle and over the sternoclavicular joint to the midline of the sternum. Incise the fascia and periosteum. n  Reflect subperiosteally the origins of the sternocleidomastoid and pectoralis major muscles, the first superiorly and the second inferiorly; and expose the sternoclavicular joint. n  When the deep surface of the joint must be exposed, avoid puncturing the pleura or damaging an intrathoracic vessel.    n 

ACROMIOCLAVICULAR JOINT AND CORACOID PROCESS 

SPINE

 

Surgical approaches to the spine are discussed in Chapter 37. 

STERNOCLAVICULAR JOINT Contrast computed tomography scans of mediastinal structures have shown that the brachiocephalic vein is the most frequent structure at risk for injury deep to the sternoclavicular joint. If a posterior dislocation is to be reduced or drill holes made in the sternum or medial clavicle during reconstructive procedures, consultation with a cardiothoracic surgeon is recommended. 

APPROACH TO THE ACROMIOCLAVICULAR JOINT AND CORACOID PROCESS   TECHNIQUE 1.91

Figure 1.111

(ROBERTS) Make a curved incision along the anterosuperior margin of the acromion and the lateral one fourth of the clavicle.

n 

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CHAPTER 1  SURGICAL TECHNIQUES Expose the origin of the deltoid, free it from the clavicle and the anterior margin of the acromion, and expose the capsule of the acromioclavicular joint. (By retracting the deltoid distally, the coracoid process also may be exposed.) To expose the acromioclavicular joint alone, use the lateral third of the incision.    

n 

SHOULDER ANTEROMEDIAL APPROACHES TO THE SHOULDER

Any part of the approaches to the shoulder described can be used for operations on more limited regions around the shoulder.   

ANTEROMEDIAL APPROACH TO THE SHOULDER   TECHNIQUE 1.92 (THOMPSON; HENRY) Begin the incision over the anterior aspect of the acromioclavicular joint, passing it medially along the anterior margin of the lateral one third of the clavicle and distally along the anterior margin of the deltoid muscle to a point two thirds the distance between its origin and insertion (Fig. 1.112A). n  Expose the anterior margin of the deltoid. The cephalic vein and the deltoid branches of the thoracoacromial artery lie in the interval between the deltoid and pectoralis n 

major muscles (the deltopectoral groove), and although the cephalic vein may be retracted medially along with a few fibers of the deltoid muscle, it may be damaged during the operation. Ligating this vein proximally and distally as soon as it is reached may be indicated. n  Define the origin of the deltoid muscle on the clavicle; detach it by dividing it near the bone or at the bone together with the adjacent periosteum or by removing part of the bone intact with it (Fig. 1.112B). We prefer the first method, leaving enough soft tissue attached to the clavicle to allow suturing the deltoid to its origin later. n  Laterally reflect the anterior part of the deltoid muscle to expose the structures around the coracoid process and the anterior part of the joint capsule. n  To expose the deep aspects of the shoulder joint more easily, including the anterior margin of the glenoid, osteotomize the tip of the coracoid process. First, incise the periosteum of the superior aspect of the coracoid; next, cut through the bone and reflect medially and distally the tip of the bone along with the attached origins of the coracobrachialis, the pectoralis minor, and the short head of the biceps. Predrill the coracoid process. n  For wider exposure, divide the subscapularis at its musculotendinous junction about 2.5 cm medial to its insertion into the lesser humeral tuberosity; separate the tendon medially from the underlying capsule and expose the glenoid labrum. n  When closing the wound, replace the tip of the coracoid and secure with a screw. n  Suture the deltoid in place and close the wound in the usual way. n  If an extensile exposure is unnecessary, the skin incisions and deeper dissection may be limited to the deltopectoral

Reflected deltoid muscle

Acromion process

Clavicle

Line of skin incision

Coracoid process

Deltoid muscle

Cephalic vein Pectoralis major muscle

Short head of biceps muscle

Long head of biceps muscle

A

Insertion of subscapularis muscle

Insertion of pectoralis major muscle

B

FIGURE 1.112 Anteromedial approach to shoulder joint. A, Skin incision. Transverse part of incision has been made along anterior border of clavicle and longitudinal part was made along interval between deltoid and pectoralis major. B, Deltoid has been detached from clavicle and reflected laterally to expose anterior aspect of joint. SEE TECHNIQUE 1.92.

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PART I  GENERAL PRINCIPLES the head of the humerus (Fig. 1.114C); take care not to sever the tendon of the long head of the biceps. In this approach, the fibers of the deltoid are not divided and the axillary nerve that supplies the deltoid is not disturbed.   

ANTERIOR AXILLARY APPROACH TO THE SHOULDER   

FIGURE 1.113 Henry shoulder strap or suspender incision. SEE TECHNIQUE 1.92.

portion of the approach. The anterior deltoid muscle need not be detached from the clavicle. Approach the joint anteriorly without an osteotomy of the coracoid process by retracting the short head of the biceps muscle in a medial direction. Take care to avoid a traction injury to the musculocutaneous nerve lying beneath the short head of the biceps in the distal part of this wound. n  Instead of this curved anteromedial approach, Henry later used an incision that arches like a shoulder strap over the shoulder from anterior to posterior (Fig. 1.113). The anterior part of this incision is similar to the deltopectoral part of his original approach, but at its superior end, it proceeds directly over the superior aspect of the shoulder and distally toward the spine of the scapula. Mobilize a lateral flap by dissecting between the subcutaneous tissues and the deep fascia, and expose the lateral and posterior margins of the acromion and adjacent spine of the scapula. Detach as much of the deltoid as needed to reach the deeper structures sought.    

 

ANTEROMEDIAL/POSTEROMEDIAL APPROACH TO THE SHOULDER If a wider field is needed, the anteromedial approach may be extended as Cubbins et al. suggest.

ANTERIOR AXILLARY APPROACH TO THE SHOULDER The anterior axillary approach as described by Leslie and Ryan is indicated when cosmesis is a factor. This approach can be used with most of the anterior procedures described in this chapter. Placement of the skin incision over the anterior axillary fold is quite satisfactory, and the scar is not noticeable when the arm is at the side. This is not a direct axillary approach to the glenohumeral joint but simply a placement of the skin incision. The remainder of the approach is through the deltopectoral interval.

  TECHNIQUE 1.94 (LESLIE AND RYAN) Make a straight vertical 3- to 4-cm incision over the anterior axillary fold (Fig. 1.115A). n  Undermine the skin and subcutaneous tissue so they can be retracted anteriorly and superiorly (Fig. 1.115B). n  If needed, both the coracoid process and subscapularis tendon can be easily detached and reattached at closure. n  Close the wound with a continuous subcuticular suture (Fig. 1.115C).    n 

ANTEROLATERAL APPROACHES TO THE SHOULDER   

ANTEROLATERAL LIMITED DELTOIDSPLITTING APPROACH TO THE SHOULDER The limited deltoid-splitting approach is appropriate for limited operations that need only to expose the tendons inserting on the greater tuberosity of the humerus and to reach the subdeltoid bursa.

  TECHNIQUE 1.93 (CUBBINS, CALLAHAN, AND SCUDERI) Make the anterior limb of the Cubbins incision similar to that in the anteromedial approach. Extend the incision laterally around the acromion and medially along the lateral half of the spine of the scapula (Fig. 1.114A). n  Detach the origin of the deltoid from the acromion and from the exposed part of the spine of the scapula and reflect the deltoid inferiorly and laterally to expose the anterior, superior, and posterior parts of the joint capsule. n  Reach the joint anteriorly or posteriorly by a corresponding incision of the capsule (Fig. 1.114B). To expose the articular surface of the humerus and the glenoid, incise the capsule continuously from anterior to posterior over n 

  TECHNIQUE 1.95 Begin the incision at the anterolateral tip of the acromion and carry it distally over the deltoid muscle about 5 cm. n  Define the avascular raphe 4 to 5 cm long between the anterior and middle thirds of the deltoid; splitting the muscle here provides a fairly avascular approach to underlying structures. n  For maximal exposure, split the deltoid up to the margin of the acromion, but do not split it distally more than 3.8 cm from its origin to avoid damaging the axillary nerve n 

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CHAPTER 1  SURGICAL TECHNIQUES

A Infraspinatus muscle

Deltoid muscle

B Glenoid cavity Acromion process

C FIGURE 1.114 Cubbins et al. approach to anterior, superior, and posterior aspects of shoulder joint. A, Skin incision. B, Origin of deltoid reflected from clavicle, acromion, and spine of scapula; posterior capsule incised vertically. C, Capsule retracted, exposing posterior portion of glenoid and humerus. SEE TECHNIQUE 1.93.

and paralyzing the anterior part of the deltoid (Fig. 1.116). (The axillary nerve courses transversely just proximal to the midpoint between the lateral margin of the acromion and the insertion of the deltoid.) n  Incise the thin wall of the subdeltoid bursa and explore the rotator cuff as desired by rotating and abducting the arm to bring different parts of it into view in the floor of the wound. n  A transverse skin incision about 6.5 cm long may be used instead of the longitudinal one to leave a less conspicuous scar (Fig. 1.117). Place it about 2.5 cm distal to the inferior border of the acromion, dissect the skin flaps from the

underlying deltoid muscle, and split the muscle in the line of its fibers. The rest of the approach is the same as that just described. n  To approach a more posterior aspect, place the skin incision more laterally and split the deltoid just beneath it. To maintain a dry field, cauterize the intramuscular vessels encountered.   

In a cadaver study, Traver et al. demonstrated that irreversible changes in axillary nerve length and strain caused microscopic damage to neuronal structures with prolonged retraction during a deltoid-splitting approach. 

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Cephalic vein Incision

Anterior axillary fold

A

B Subcutaneous suture

Anterior axillary fold

C FIGURE 1.115 Anterior axillary incision to approach shoulder joint. A, Incision. B, Skin and subcutaneous tissue are being undermined all around incision. C, Incision closed by continuous subcuticular wire suture. SEE TECHNIQUE 1.94. Scapular origin

Acromial origin

Posterior border

Clavicular origin

Operable area

Anterior border

Axillary nerve

FIGURE 1.117 Incision options for a limited anterolateral deltoid-splitting approach to the anterior rotator cuff. SEE TECHNIQUE 1.95.

Insertion FIGURE 1.116 Deep surface of left deltoid showing location of axillary nerve. Nerve courses transversely at level about 5 cm distal to origin of muscle. One branch of nerve has been exposed fully to show that incision that splits muscle, even in the operable area, damages smaller branches of nerve. SEE TECHNIQUE 1.95.

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CHAPTER 1  SURGICAL TECHNIQUES  

 

EXTENSILE ANTEROLATERAL APPROACH TO THE SHOULDER

TRANSACROMIAL APPROACH TO THE SHOULDER

Gardener et al. demonstrated that the limited deltoid-splitting approach could be successfully extended by isolating the axillary nerve and posterior circumflex artery. This extensile anterolateral approach is very useful for plate fixation of proximal humeral fractures (Fig. 1.118). Chou et al. demonstrated that this approach is also useful for fracture management with hemiarthroplasty.

The transacromial approach is excellent for surgery of the musculotendinous cuff and for fracture-dislocations of the shoulder.

  TECHNIQUE 1.97 (DARRACH; MCLAUGHLIN) Incise the skin just lateral to the acromioclavicular joint from the posterior aspect of the acromion superiorly like a shoulder strap and anteriorly to a point 5 cm distal to the anterior edge of the acromion (Fig. 1.119A). n  Deepen the anterior limb through the deltoid muscle, detach the deltoid from its acromial origin, and divide the coracoacromial ligament (Fig. 1.119B-D). n  To repair the rotator cuff, an oblique osteotomy of the acromion (Fig. 1.120A) gives enough exposure, and the cosmetic result is satisfactory; to expose the joint completely, McLaughlin advised using the osteotomy technique shown in Figure 1.120B. In either instance, excise the detached segment of the acromion. Armstrong advised complete acromionectomy (Fig. 1.120C) if subacromial impingement of the rotator cuff would be a problem. n  To expose the joint, split any of the tendons of the cuff in the line of their fibers or separate two of them; the best way is to approach between the subscapularis and supraspinatus tendons through the coracohumeral ligament. n  Close the cuff by side-to-side suture, bevel the stump of the acromion, and suture the edge of the deltoid to the fascia on the stump. Kuz et al. recommended a coronal transacromial osteotomy just anterior to the spine of the scapula and parallel to it for hemiarthroplasty and total shoulder arthroplasty. The osteotomy is repaired with two large, absorbable, 1-0, figure-of-eight sutures passed through drill holes. Kuz et al. reported an 87% union rate using this osteotomy, with the remaining patients having a stable, painless, fibrous union.    n 

  TECHNIQUE 1.96

Figure 1.118

(GARDNER ET AL.) Make an incision beginning at the anterolateral tip of the acromion and carry it distally for 8 to 10 cm. n  By blunt dissection, identify the avascular raphe between the anterior and middle third of the deltoid muscle. n  Make a 2-cm incision in the deltoid raphe beginning at its attachment on the acromion. n  Spread this incision bluntly and insert a finger laterally beneath the raphe. Sweep the undersurface of the deltoid from the proximal humerus. Palpate the cord-like axillary nerve on its undersurface. n  Carefully further incise the raphe and identify the axillary nerve and posterior humeral circumflex artery. Isolate them and tag them with a vessel loop. Thoroughly elevate these structures medially and laterally to free up the deltoid to allow easy passage of a plate.     n 

POSTERIOR APPROACHES TO THE SHOULDER

Similar posterior approaches to the shoulder joint have been described by Kocher, McWhorter, Bennett, Rowe and Yee, Harmon, and others. For any such approach to be done safely, a thorough knowledge of the anatomy of the posterior aspect of the shoulder is essential (Fig. 1.121).   

POSTERIOR DELTOID-SPLITTING APPROACH TO THE SHOULDER FIGURE 1.118 Extended anterolateral deltoid-splitting approach. The axillary nerve lies approximately 3.5 cm distal to the lateral prominence of the greater tuberosity. The nerve is then identified and protected. SEE TECHNIQUE 1.96.

Wirth et al. described a posterior deltoid-splitting approach (Fig. 1.122). As with more anterior approaches, it is limited by the location of the axillary nerve and posterior circumflex artery. Karachalios et al. used this approach to successfully reduce a neglected posterior dislocation of the shoulder.

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PART I  GENERAL PRINCIPLES Subscapularis muscle

Deltoid muscle Osteotomy site A

Skin incision

Supraspinatus muscle Osteotomy site B

A

B Incision in coracohumeral ligament

D

C

FIGURE 1.119 Transacromial approach to shoulder joint. A, Skin incision. B, Fibers of deltoid separated. C, Osteotomy of acromion. D, Line of incision through coracohumeral ligament. Detached segment of acromion is usually discarded. SEE TECHNIQUE 1.97. B

Supraspinatus muscle

C

Suprascapular nerve

Deltoid muscle

A Axillary nerve Radial nerve Triceps muscle

Teres minor muscle FIGURE 1.120 Lines of osteotomy of acromion. Oblique osteotomy (A) is adequate for repair of ordinary shoulder cuff lesion. Resection of acromion at B is preferable when complete exposure of shoulder joint is required. Line of osteotomy for complete acromionectomy (C). SEE TECHNIQUE 1.97.

Infraspinatus muscle Teres major muscle FIGURE 1.121

Nerve to teres minor muscle Anatomy of posterior aspect of shoulder joint.

  TECHNIQUE 1.98 (WIRTH ET AL.) Place the patient in the lateral decubitus position. Make a 10-cm straight incision beginning at the posterior aspect of the acromioclavicular joint and carry it toward the posterior axillary fold (Fig. 1.122). n  Raise sufficient subcutaneous flaps and identify the fibrous septum between the middle and posterior third of n  n 

the deltoid muscle. The muscle split should be no longer than two thirds of the length of the muscle to avoid damage to the axillary nerve and posterior circumflex humeral artery (see Fig. 1.126). n  Identify the insertion of the two heads of the infraspinatus muscle and separate them in a medial direction, exposing the posterior capsule of the glenohumeral joint.    

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CHAPTER 1  SURGICAL TECHNIQUES After reflecting the deltoid, expose the posterior surface of the joint capsule by detaching the inferior two thirds of the infraspinatus tendon near its insertion on the humerus and reflecting the detached part medially. n  Alternatively, the posterior part of the joint can be exposed by an oblique incision between the infraspinatus and teres minor muscles (Fig. 1.123C) and then opening the joint capsule by a longitudinal or a transverse incision or by a combination of both, as needed. The interval between the infraspinatus and teres minor muscles can be extended medially, exposing more of the inferior scapula for fracture fixation. Extend the incision distally along the medial border of the scapula if necessary.     n 

 

SIMPLIFIED POSTERIOR APPROACH TO THE SHOULDER FIGURE 1.122 Posterior deltoid-splitting approach. Dashed line represents the deltoid split. SEE TECHNIQUE 1.98.

 

POSTERIOR APPROACH TO THE SHOULDER One of the most practical posterior approaches to the shoulder joint and inferior scapula is the posterior (Judet) approach. The interval between the infraspinatus (suprascapular nerve innervated) and teres minor (axillary nerve innervated) muscles can be extended medially exposing a large portion of the inferior half of the scapula. One extensive cadaver study showed that the medial branch of the supraclavicular nerve was on average 2.7 cm lateral to the sternoclavicular joint and the lateral branch was on average 1.9 cm medial to the acromioclavicular joint. Between these two points, there is wide variability in nerve branch location and increased risk for injury without meticulous dissection along the shaft of the clavicle.

  TECHNIQUE 1.99 (MODIFIED JUDET) Begin the skin incision just lateral to the tip of the acromion, pass it medially and posteriorly along the border of the acromion, curve it slightly distal to the spine of the scapula, and end it at the base of the spine of the scapula (Fig. 1.123A, inset). n  Reflect the skin and fascia and expose the origin of the deltoid muscle from the spine of the scapula (Fig. 1.123A). Detach this part of the deltoid from the bone by subperiosteal dissection, and reflect it distally and laterally, taking care to avoid injury to the axillary nerve and vessels as they emerge from the quadrangular space and enter the muscle (Fig. 1.123B). As a precaution against injuring this nerve, do not retract the deltoid distal to the teres minor muscle, and to avoid injuring the suprascapular nerve, do not enter the infraspinatus muscle. n 

Brodsky, Tullos, and Gartsman described a simplified posterior approach to the shoulder introduced to Tullos by J.W. King. It is based on the fact that wide abduction of the arm raises the inferior border of the posterior deltoid to the level of the glenohumeral joint. This approach can be used for a wide variety of procedures and does not require freeing large portions of the posterior deltoid from the scapular spine or splitting the deltoid; postoperative immobilization for healing of the muscle is unnecessary. Rehabilitation of the shoulder can be started as soon as tolerated by the patient if the particular procedure performed does not require immobilization.

  TECHNIQUE 1.100 (KING, AS DESCRIBED BY BRODSKY ET AL.) Place the patient prone or in the lateral position. Drape the arm and shoulder free and abduct the shoulder to 90 degrees, but no farther, avoiding excessive traction on the axillary vessels and brachial plexus. n  Begin a vertical incision at the posterior aspect of the acromion and carry it inferiorly for 10 cm (Fig. 1.124A,B). n  Retract the posterior deltoid superiorly (Fig. 1.124C) and, if necessary, release the medial 2 cm of its origin from the scapular spine. n  Develop the interval between the infraspinatus and teres minor muscles. n  Incise the capsule of the joint in a manner dependent on the procedure to be performed; to prevent injury to the axillary nerve and the posterior humeral circumflex vessels beneath the inferior border of the teres minor, avoid dissecting too far inferiorly (Fig. 1.124D).     n  n 

 

POSTERIOR INVERTED-U APPROACH TO THE SHOULDER The deltoid muscle has three parts—three heads of origin—­ and two relatively avascular intervals separating the three. The anterior part (which originates on the lateral third of

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PART I  GENERAL PRINCIPLES

Infraspinatus muscle Teres minor muscle Deltoid muscle Deltoid muscle

A

B

Suprascapular nerve Capsule

Axillary nerve

Teres minor muscle Infraspinatus muscle

Deltoid muscle Insertion of long head of triceps muscle

C FIGURE 1.123 Modified Judet posterior approach to shoulder joint. A, Deltoid is being detached from spine of scapula and from acromion. Inset, Skin incision. B, Deltoid has been retracted to expose interval between infraspinatus and teres minor. C, Infraspinatus and teres minor have been retracted to expose posterior aspect of joint capsule. Inset, Relationships of suprascapular and axillary (circumflex) nerves to operative field. SEE TECHNIQUE 1.99.

the clavicle and the anterior border of the acromion) and the posterior part are composed primarily of long parallel muscle fibers extending from the origin to the insertion. The middle part is multipennate, with short fibers inserting obliquely into parallel tendinous bands. The interval between the posterior and middle parts can be found by beginning the dissection at the angle of the acromion and proceeding through the fibrous septum; with care, the division can be extended distally through the proximal two thirds of the muscle without endangering the nerve

supply because the posterior branch of the axillary nerve supplies the posterior part of the muscle and the anterior branch supplies the anterior and middle parts. The interval between the anterior and middle parts is less distinct; it extends distally from the anterior apex of the shoulder formed by the anterolateral tip of the acromion. In view of this tripartite division, Abbott and Lucas ­described inverted-U-shaped approaches to reach the anterior, lateral, and posterior aspects of the shoulder joint, dissecting the deltoid distally at the two intervals described

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CHAPTER 1  SURGICAL TECHNIQUES

B

A

Quadrangular space with posterior humeral circumflex artery and axillary nerve

Lateral head of triceps muscle

Deltoid muscle

Deltoid muscle

Subscapular nerve Long head of triceps muscle Infraspinatus muscle Triangular space Teres major muscle

C

Joint capsule Infraspinatus muscle

Teres minor muscle

Teres minor muscle

D

FIGURE 1.124 King simplified posterior approach. A, Skin incision. B, Posterior deltoid muscle has been elevated to level of joint by abduction of arm to 90 degrees. C, Deltoid has been retracted superiorly exposing muscles of rotator cuff. D, Capsule has been exposed. (Modified from Brodsky JW, Tullos HS, Gartsman GM: Simplified posterior approach to the shoulder joint: a technical note, J Bone Joint Surg 71A:407, 1989.) SEE TECHNIQUE 1.100.

and ­detaching the appropriate third of the muscle from its origin. They, too, warn that to separate the anterior and middle thirds distally more than 4 to 5 cm endangers the trunk of the axillary nerve (Fig. 1.125).

  TECHNIQUE 1.101 (ABBOTT AND LUCAS) Begin the skin incision 5 cm distal to the spine of the scapula at the junction of its middle and medial thirds, and

n 

extend it superiorly over the spine and laterally to the angle of the acromion. Curve the incision distally for about 7.5 cm over the tendinous interval between the posterior and middle thirds of the deltoid muscle (Fig. 1.126A). n  Free the deltoid subperiosteally from the spine of the scapula, split it distally in the interval, and turn the resulting flap of skin and muscle distally for 5 cm to expose the infraspinatus and teres minor muscles and the quadrangular space (Fig. 1.126B). The posterior humeral circumflex artery and the axillary nerve each divide into anterior and

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PART I  GENERAL PRINCIPLES

Axillary nerve

A

Acromial branch of thoracoacromial artery

Subscapular branch Posterior humeral circumflex artery

Deltoid branch Anterior humeral circumflex artery

B

FIGURE 1.125 Nerve and blood supply of deltoid muscle. A, Anterior and posterior divisions of axillary nerve to deltoid muscle. B, Blood supply of deltoid muscle from posterior humeral circumflex artery and anastomotic branches from adjacent arteries. SEE TECHNIQUE 1.101.

posterior branches, so the splitting of the deltoid between its posterior and middle thirds does not injure them. n  Carry this division of the deltoid to its insertion to give full access to the quadrangular space if desired. n  To expose the glenohumeral joint, incise the shoulder cuff in its tendinous part and retract the muscles; then divide the capsule (Fig. 1.126C). n  If exposure of both the posterior and anterior shoulder is needed, bring the lateral portion of the incision around the acromion laterally then medially along the anterior clavicle (see Fig. 1.117).    

HUMERUS Almost all major approaches to the humerus involve isolating or potentially damaging the radial nerve. The radial nerve course and relationships to other structures must be kept in mind with most approaches. Hasan et al. described the “zone of vulnerability” for injury to the radial nerve with a study of 33 cadaver arms. They found the proximal aspect of the triceps tendon to be a reliable landmark being approximately 2.3 cm below the radial nerve at the posterior midline of the humerus. The “zone of vulnerability” was found to be 2.1 cm (average) of radial nerve that lies directly on the lateral cortex before piercing the lateral intramuscular septum and the few centimeters of nerve distal to the septum. 

 

ANTEROLATERAL APPROACH TO THE SHAFT OF THE HUMERUS   TECHNIQUE 1.102 (THOMPSON; HENRY) Incise the skin in line with the anterior border of the deltoid muscle from a point midway between its origin and insertion, distally to the level of its insertion, and proceed in line with the lateral border of the biceps muscle to within 7.5 cm of the elbow joint (Fig. 1.127). n  Divide the superficial and deep fasciae and ligate the cephalic vein. n  In the proximal part of the wound, retract the deltoid laterally and the biceps medially to expose the shaft of the humerus. n  Distal to the insertion of the deltoid, expose the brachialis muscle, split it longitudinally to the bone, and retract it subperiosteally, the lateral half to the lateral side and the medial half to the medial. Retraction is easier when the tendon of the brachialis is relaxed by flexing the elbow to a right angle. The lateral half of the brachialis muscle protects the radial nerve as it winds around the humeral shaft (Fig. 1.128; see also Fig. 1.127). If desired, the distal end of this approach may be carried to within 5 cm of the humeral condyles and the proximal n 

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CHAPTER 1  SURGICAL TECHNIQUES Axillary nerve

Capsule

A Posterior humeral circumflex artery

B

C

FIGURE 1.126 Abbott and Lucas inverted-U approach to posterior aspect of shoulder. A, Skin incision. B, Skin and muscle flap turned down, exposing quadrangular space and posterior aspect of rotator cuff and muscles. C, Rotator cuff and capsule incised, exposing humeral head. SEE TECHNIQUES 1.98 AND 1.101.

Deltoid muscle

I

Line of incision

II III

Deltoid muscle Biceps muscle

Biceps muscle

Brachialis muscle

IV Brachialis muscle

A

B

FIGURE 1.127 Anterolateral approach to shaft of humerus. A, Skin incision. B, Deltoid and biceps muscles retracted; brachialis muscle incised longitudinally, exposing shaft. SEE TECHNIQUE 1.102.

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PART I  GENERAL PRINCIPLES Cephalic vein

Radial nerve

Cephalic vein Deltoid muscle Brachialis muscle

Deltoid muscle

Radial nerve

I

II

Cephalic vein Brachialis muscle

Lateral antebrachial cutaneous nerve

Radial nerve

Brachioradialis muscle

Brachialis muscle

Radial nerve

III

IV

FIGURE 1.128 Cross-sections at various levels in arm (see Fig. 1.127) to show approach through deep structures and relationship to radial nerve. SEE TECHNIQUES 1.102 AND 1.103.

end farther proximally, as in the anteromedial approach to the shoulder. The advantages of this approach are that the brachialis muscle usually is innervated by the musculocutaneous and radial nerves and can be split longitudinally without paralysis and that the lateral half of the brachialis muscle protects the radial nerve. The anterior aspect of the humeral shaft at the junction of its middle and distal thirds also can be approached between the biceps and brachialis muscles medially and the brachioradialis laterally (Fig. 1.128). In a retrospective study, King and Johnston reported that the original anterolateral skin incision as described by Henry (Fig. 1.129; see also Fig. 1.128) frequently transected branches of the lower lateral brachial cutaneous nerve, resulting in painful neuroma formation, numbness, or tingling around the wound scar in 62% of 30 patients. This was confirmed by an anatomic study of seven cadaver arms. King and Johnston recommended a more anteriorly placed incision (Fig. 1.130) in the watershed zone between the lower lateral brachial and the medial brachial cutaneous nerves. Kuhne and Friess used the anterolateral humeral approach combined with a Kocher lateral elbow approach (Technique 1.112) to expose the lateral humerus from the surgical neck to the lateral condyle. A muscular bridge was maintained to protect the radial nerve during internal ­fixation. Using a cadaver study, Phelps et al. described connecting a deltopectoral shoulder approach with an anterolateral humeral approach called an aggregate anterior approach. By adding a lateral elbow approach (extended aggregate anterior approach), the entire humerus could be exposed.    

 

SUBBRACHIAL APPROACH TO THE HUMERUS The subbrachial approach avoids splitting the brachialis muscle. Both the radial and musculocutaneous nerves are protected, and according to Boschi et al., there is much less brachialis muscle damage as supported by a postoperative electromyoneurography study.

  TECHNIQUE 1.103 (BOSCHI ET AL.) Flex the elbow taking tension off the biceps brachii muscle. Move the muscle in a medial to lateral direction to define the lateral edge of the muscle. n  Make a longitudinal skin incision 1 cm posterior to the lateral edge of the muscle. n  Develop the interval between the biceps brachii muscle and the brachialis muscle starting in the proximal portion of the wound using blunt dissection. n  Stay on the anterior surface of the brachialis muscle and once over the medial edge bluntly dissect the muscle from the anterior and lateral edge of the humerus (Fig. 1.128, III).     n 

 

POSTERIOR APPROACH TO THE PROXIMAL HUMERUS Berger and Buckwalter described a posterior approach to the proximal third of the humeral diaphysis for resection

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CHAPTER 1  SURGICAL TECHNIQUES

Brachioradialis muscle Incision Brachialis muscle Biceps muscle

A

B Periosteum

Brachioradialis muscle

Brachialis muscle

Incision Radial nerve

Brachialis muscle Humerus

C

D

FIGURE 1.129 Exposure of humerus at junction of middle and distal thirds through anterolateral approach. A, Skin incision. B, Interval between biceps and brachialis muscles medially and brachioradialis muscle laterally is developed, and muscles are retracted. C, Radial nerve identified and retracted. D, Nerve is retracted, and brachioradialis and brachialis muscles are separated, exposing humeral shaft. SEE TECHNIQUE 1.102.

of an osteoid osteoma. This approach exposes the bone through the interval between the lateral head of the triceps muscle innervated by the radial nerve and the deltoid muscle innervated by the axillary nerve. Approximately 8 cm of the bone can be exposed, with the approach limited proximally by the axillary nerve and posterior circumflex humeral artery and distally by the origin of the triceps muscle from the lateral border of the spiral groove and by the underlying radial nerve.

  TECHNIQUE 1.104 (BERGER AND BUCKWALTER) Place the patient in the lateral position with the extremity draped free and positioned across the patient’s chest. Beginning 5 cm distal to the posterior aspect of the acromion, make a straight incision over the interval between

n 

the deltoid and triceps muscles and extend it distally to the level of the deltoid tuberosity. n  Bluntly develop the interval between the lateral head of the triceps and the deltoid (Fig. 1.131). n  Expose the periosteum of the humerus and incise it longitudinally. n  Elevate the periosteum medially and retract it and the lateral head of the triceps medially. n  Continue the subperiosteal elevation of the triceps proximally until its origin from the proximal humerus is reached. Retract the triceps medially with care to avoid injury to the radial nerve as it comes in contact with the periosteum about 3 cm proximal to the level of the deltoid tuberosity. n  Elevate the periosteum laterally, and retract it and the deltoid laterally. n  To extend the exposure proximally, carefully continue the subperiosteal dissection to the proximal origin of the ­lateral

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PART I  GENERAL PRINCIPLES

Upper lateral brachial cutaneous nerve

Upper lateral brachial cutaneous nerve

Intercostobrachial nerve

Intercostobrachial nerve

Lower lateral brachial cutaneous nerve

Lower lateral brachial cutaneous nerve

Medial brachial cutaneous nerve

Medial brachial cutaneous nerve

A

B

FIGURE 1.130 A, Relationship of lower lateral brachial cutaneous nerve and anterior midline skin incision. B, Relationship of lower lateral brachial cutaneous nerve and standard Henry anterolateral skin incision. (From King A, Johnston GH: A modification of Henry’s anterior approach to the humerus, J Shoulder Elbow Surg 7:210, 1998.) SEE TECHNIQUE 1.102.

Axillary nerve and posterior humeral circumflex artery

APPROACHES TO THE DISTAL HUMERAL SHAFT Deltoid muscle

Radial nerve and profunda brachii artery

Humerus Long head of triceps muscle

Lateral head of triceps muscle

Deltoid tuberosity

FIGURE 1.131 Berger and Buckwalter posterior approach to proximal humeral diaphysis. Broken line indicates course of radial nerve beneath lateral head of triceps muscle (see text). (Modified from Berger RA, Buckwalter JA: A posterior surgical approach to the proximal part of the humerus, J Bone Joint Surg 71A:407, 1989.) SEE TECHNIQUE 1.104.

head of the triceps. Protect the axillary nerve and posterior circumflex artery at the proximal edge of this exposure. n  To extend the exposure distally, partially release the insertion of the deltoid muscle carefully, avoiding the radial nerve that is beneath the lateral border of the triceps (see Fig. 1.131).   

Henry described a posterior approach that splits the triceps to expose the posterior humeral shaft in its middle two thirds. This approach is sometimes valuable when excising tumors that cannot be reached by the anterolateral approach. Medially the humeral shaft can be approached posterior to the intermuscular septum along a line extending proximally from the medial epicondyle. The ulnar nerve is freed from the triceps muscle and retracted medially; the triceps is then separated from the posterior surface of the medial intermuscular septum and the adjacent humeral shaft. If this approach is extended proximally to the inferior margin of the deltoid muscle, one must keep the radial nerve in mind and avoid its path.   

POSTEROLATERAL APPROACH TO THE DISTAL HUMERAL SHAFT Moran described a modified lateral approach to the distal humeral shaft for fracture fixation. This approach uses the interval between the triceps and brachioradialis muscles and does not involve splitting the triceps tendon or muscle.

  TECHNIQUE 1.105 (MORAN) Place the patient prone or in the lateral decubitus position. Make a longitudinal skin incision 15 to 18 cm in length over the posterolateral aspect of the arm (Fig. 1.132A). Extend the incision distally midway between the lateral epicondyle of the humerus and the tip of the olecranon 4 cm distal to the elbow joint. The proximal portion of the

n  n 

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CHAPTER 1  SURGICAL TECHNIQUES

Posterior antebrachial cutaneous nerve Profunda brachii artery Radial nerve Lateral intermuscular septum Lateral head of triceps brachii muscle Anconeus muscle

A

B

Posterior

Triceps brachii muscle Posterior antebrachial cutaneous nerve

Posterior antebrachial cutaneous nerve

Lateral

Lateral head of triceps brachii muscle

Profunda brachii artery

Radial nerve

Radial nerve

Brachioradialis muscle

Lateral intermuscular septum

D Anconeus muscle

C FIGURE 1.132 Modified posterolateral approach to the posterior distal humerus. A, Skin incision. B, Interval between lateral head of triceps and lateral intermuscular septum is developed. C, Medial retraction of triceps exposes the posterior aspect of the humerus. D, Cross-section of upper arm at midpoint of skin incision. SEE TECHNIQUE 1.105.

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PART I  GENERAL PRINCIPLES Olecranon osteotomy component

Deltoid insertion split

Lateral intermuscular septum

Radial nerve

FIGURE 1.133 The COLD approach, described by Lewicky, Sheppard, and Ruth, with the patient in the lateral decubitus position (right arm depicted). The olecranon osteotomy component is reflected proximally while dissection proceeds along the lateral intermuscular septum. The radial nerve is seen obliquely crossing the humerus distal to the deltoid insertion split. (Modified from Lewicky YM, Sheppard JE, Ruth JT: The combined olecranon osteotomy, lateral para tricipital sparing, deltoid insertion splitting approach for concomitant distal intra-articular and humeral shaft fractures, J Orthop Trauma 21:135, 2007.) SEE TECHNIQUE 1.106.

incision is located 4 cm posterior to the lateral intermuscular septum. n  From the midpoint of the wound, dissect laterally until the lateral intermuscular septum is reached. n  Incise the triceps fascia longitudinally a few millimeters posterior to the intermuscular septum and carefully separate the triceps muscle from the intermuscular septum working distally to proximally. n  Distally, incise the fascia at the lateral edge of the anconeus and carry this 4 cm distal to the lateral epicondyle. n  Retract the anconeus muscle and fascia in continuity with the triceps. n  Identify and protect the posterior antebrachial cutaneous nerve as it leaves the posterior compartment at the lateral intermuscular septum (Fig. 1.132B,D). n  Retract the radial nerve anteriorly. The radial nerve passes through the lateral intermuscular septum at the junction of the middle and distal thirds of the humerus (Fig. 1.132B). n  Retract the triceps muscle medially to expose the posterior humeral shaft (Fig. 1.132C). If more proximal exposure is needed, carefully follow the radial nerve proximally and bluntly dissect it from the region of the spiral groove. n  To close the wound, allow the triceps muscle to fall anteriorly into its bed, and loosely close the fascia with interrupted sutures.    

fracture treatment. They described an extensile approach combining an olecranon osteotomy, lateral triceps sparing, and deltoid insertion splitting (COLD).

  TECHNIQUE 1.106 (LEWICKY, SHEPPARD, AND RUTH) Carry the distal limb of the incision distally over the subcutaneous border of the ulna far enough to allow an olecranon osteotomy and anterior transposition of the ulnar nerves. n  Extend the proximal limb of the incision to allow further mobilization of the lateral head of the triceps muscle and exposure of the deltoid muscle insertion on the proximal humerus. Dissection can be extended as far proximally as the level of the posterior branch of the axillary nerve in its subdeltoid position. n  Pay careful attention to isolate and protect the radial nerve and profunda brachii artery (Fig. 1.133).     n 

ELBOW There has been a marked increase in information pertaining to surgery of the elbow. Table 1.9 provides a summary of surgical approaches to the elbow and proximal forearm. Only the more commonly used of these approaches are described here.

POSTERIOR APPROACHES TO THE ELBOW 

 

POSTEROLATERAL EXTENSILE (COLD) APPROACH TO THE DISTAL HUMERUS Lewicky et al. described how the posterolateral approach can be extended proximally and distally to expose most of the posterior humeral shaft and elbow joint for complex

 

POSTEROLATERAL APPROACH TO THE ELBOW Campbell used a posterolateral approach to the elbow for extensive operations such as treatment of old posterior

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CHAPTER 1  SURGICAL TECHNIQUES TABLE 1.9



Summary of Surgical Approaches to the Elbow and Proximal Forearm AUTHOR

TISSUE PLANE

POSTERIOR APPROACHES Campbell Campbell Extended Kocher/ Ewald Wadsworth Bryan, Morrey Boyd Muller, MacAusland

Midline triceps split Triceps aponeurosis tongue ECU and anconeus/triceps Triceps aponeurosis tongue and fullthickness deep head Elevate triceps mechanism from medial olecranon and reflect laterally Lateral border of triceps/ulna and anconeus/ECU Olecranon osteotomy—transverse or chevron

LATERAL APPROACHES Kocher Cadenat Kaplan Key, Conwell

Between ECU and anconeus Between ECRB and ECRL Between ECRB and ECU Between BR and ECRL

 

MEDIAL APPROACH Hotchkiss Molesworth

Between FCU and PL/FCR; brachialis resected laterally with PL/FCR/PT Medial epicondyle osteotomy

GLOBAL APPROACH Patterson, Bain, Mehta

Kocher interval; ±± lateral epicondyle osteotomy; ± Kaplan interval; ± Hotchkiss interval; ± Taylor interval

ANTERIOR APPROACH Henry

Between mobile wad and biceps tendon; elevate supinator from radius

BR, Brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; PL, palmaris longus; PT, pronator teres. From Mehta JA, Bain GI: Surgical approaches to the elbow, Hand Clin 20:375, 2004.

dislocations, fractures of the distal humerus involving the joint, and arthroplasties.

  TECHNIQUE 1.107 (CAMPBELL) Begin the skin incision 10 cm proximal to the elbow on the posterolateral aspect of the arm and continue it distally for 13 cm (Fig. 1.134A). n  Deepen the dissection through the fascia and expose the aponeurosis of the triceps as far distally as its insertion on the olecranon. n  When the triceps muscle has been contracted by fixed extension of the elbow, free the aponeurosis proximally n 

to distally in a tongue-shaped flap and retract it distally to its insertion (Fig. 1.134B); incise the remaining muscle fibers to the bone in the midline. n  If the triceps muscle has not been contracted, divide the muscle and aponeurosis longitudinally in the midline and continue the dissection through the periosteum of the humerus, through the joint capsule, and along the lateral border of the olecranon (Fig. 1.134C). n  Elevate the periosteum together with the triceps muscle from the posterior surface of the distal humerus for 5 cm. n  For wider exposure, continue the subperiosteal stripping on each side, releasing the muscular and capsular attachments to the condyles and exposing the anterior surface, taking care not to injure the ulnar nerve. n  Strip the periosteum from the bone as conservatively as possible because serious damage to the blood supply of the bone causes osteonecrosis. The head of the radius lies in the distal end of the wound. n  When the elbow has been fixed in complete extension with a contracted triceps muscle, it should be flexed to a right angle for closure of the wound. Fill the distal part of the defect in the triceps tendon with the inverted-Vshaped part of the triceps fascia and close the proximal part by suturing the remaining two margins of the triceps.    

EXTENSILE POSTEROLATERAL APPROACH TO THE ELBOW To achieve the maximum safe exposure of the elbow and proximal radioulnar joints, Wadsworth modified the known posterolateral approaches. His extensile approach is useful for displaced distal humeral articular fractures, synovectomy, total elbow arthroplasty, and other procedures requiring extensive exposure.

  TECHNIQUE 1.108 (WADSWORTH) With the patient prone and the elbow flexed 90 degrees over a support and the forearm dependent, begin a curved skin incision over the center of the posterior surface of the arm at the proximal limit of the triceps tendon and extend it distally to the posterior aspect of the lateral epicondyle and farther distally and medially to the posterior border of the ulna, 4 cm distal to the tip of the olecranon (Fig. 1.135A). n  Dissect the medial skin flap far enough medially to expose the medial epicondyle, and gently elevate the lateral skin flap a short distance; keep both skin flaps retracted with a single suture in each. n  Identify the ulnar nerve proximally and release it from its tunnel by dividing the arcuate ligament that passes between the two heads of the flexor carpi ulnaris muscle; gently retract it with a rubber sling. n  To fashion a tongue of triceps tendon with its base attached to the olecranon, leaving a peripheral tendinous rim attached to the triceps for later repair, begin sharp dissection at the medial surface of the proximal part of n 

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PART I  GENERAL PRINCIPLES Long head of triceps muscle

Lateral head of triceps muscle

Brachioradialis muscle Ulnar nerve

Extensor carpi radialis longus muscle

Ulna

Anconeus muscle

Flexor carpi ulnaris muscle

Triceps aponeurosis

Extensor carpi ulnaris muscle

A

B

Ulnar nerve Radial nerve

Lateral epicondyle Radial head Triceps aponeurosis

C FIGURE 1.134 Campbell posterolateral approach to elbow joint in contracture of triceps. A, Skin incision. B, Tongue of triceps aponeurosis has been freed and reflected distally. C, Elbow joint has been exposed by subperiosteal dissection. Ulnar nerve has been identified and protected. SEE TECHNIQUE 1.107.

the olecranon, extend it proximally along the triceps tendon, across laterally, and distally through the tendon to the posterior aspect of the lateral epicondyle. From this point, deviate the incision distally and medially through the triceps aponeurosis to separate the anconeus from the extensor carpi ulnaris (Fig. 1.135B). n  Divide the posterior capsule in the same line. n  Reflect the triceps tendon distally, dividing the muscle tissue with care in an oblique manner for minimal damage to the deep part of the muscle; stay well clear of the radial nerve.

Reflect the anconeus and underlying capsule medially. Behind the lateral epicondyle, the incision lies between the anconeus muscle and the common tendinous origin of the forearm extensor muscles. To increase exposure, partially reflect from the humerus the common extensor origin, the lateral collateral ligament, and the adjacent capsule. n  Excellent exposure is easily achieved (Fig. 1.135C); increase the exposure by putting a varus strain on the elbow joint. n  During closure, repair the triceps tendon, posterior capsule, and triceps aponeurosis with strong interrupted sutures.     n  n 

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CHAPTER 1  SURGICAL TECHNIQUES

Ulnar nerve Triceps tendon

Triceps muscle Olecranon Capitellum Extensor carpi ulnaris muscle

Ulnar nerve

Radius Anconeus muscle

A

B

C

FIGURE 1.135 Wadsworth extensile posterolateral approach to elbow. A, Skin incision. Right, Patient is prone with elbow flexed 90 degrees and arm supported as shown. B, Distally based tongue of triceps tendon with intact peripheral rim is fashioned. Ulnar nerve is protected. C, Exposure is complete (see text). (Redrawn from Wadsworth TG: A modified posterolateral approach to the elbow and proximal radioulnar joints, Clin Orthop Relat Res 144:151, 1979.) SEE TECHNIQUE 1.108.  

Alternatively, the osteotomy may be done in a chevron fashion to increase bone surface area for healing and to control rotation. n  At wound closure, reduce the proximal fragment and insert a cancellous screw using the previously drilled and tapped hole in the medullary canal. n  Drill a transverse hole in the ulna distal to the osteotomy site, pass a No. 20 wire through this hole around the screw neck, and tighten it in a figure-of-eight manner (Fig. 1.136D). In our experience, posterior plate and screw fixation of the osteotomy yields a higher union rate but the hardware often has to be removed after union because of its subcutaneous location.     n 

POSTERIOR APPROACH TO THE ELBOW BY OLECRANON OSTEOTOMY In a comparative anatomic study, Wilkinson and Stanley showed that an olecranon osteotomy exposed significantly more articular surface of the distal humerus than a tricepsreflecting approach.

  TECHNIQUE 1.109 (MACAUSLAND AND MÜLLER) Expose the elbow posteriorly through an incision beginning 5 cm distal to the tip of the olecranon and extending proximally medial to the midline of the arm to 10 to 12 cm above the olecranon tip. n  Reflect the skin and subcutaneous tissue to either side carefully to expose the olecranon and triceps tendon. n  Expose the distal humerus through a transolecranon approach. n  Isolate the ulnar nerve and gently retract it from its bed with a Penrose drain or a moist tape. n  Drill a hole from the tip of the olecranon down the medullary canal; then tap the hole with the tap to match a large (6.5-mm) AO cancellous screw 8 to 10 cm in length (Fig. 1.136A). n  Divide three fourths of the olecranon transversely with an osteotome or thin oscillating saw approximately 2 cm from its tip. Fracture the last fourth of the osteotomy (Fig. 1.136B,C). n  Reflect the olecranon and the attached triceps proximally to give excellent exposure of the posterior aspect of the lower end of the humerus. n 

 

EXTENSILE POSTERIOR APPROACH TO THE ELBOW Bryan and Morrey developed a modified posterior approach to the elbow joint that provides excellent exposure and preserves the continuity of the triceps mechanism, which allows easy repair and rapid rehabilitation.

  TECHNIQUE 1.110 (BRYAN AND MORREY) Place the patient in the lateral decubitus position or tilted 45 to 60 degrees with sandbags placed under the back and hip. Place the limb across the chest. n  Make a straight posterior incision in the midline of the limb, extending from 7 cm distal to the tip of the olecranon to 9 cm proximal to it. n 

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4.5 mm 1 3.2 mm 2 6.5 mm 3

A

B

C

D

FIGURE 1.136 Osteotomy of olecranon. A, Preparation of hole for 6.5-mm cancellous screw. B, Incomplete osteotomy made with thin saw or osteotome. C, Osteotomy completed by fracturing bone. D, Lag screw (6.5 mm) and tension band wire fixation. This technique also is useful for internal fixation of olecranon fractures. SEE TECHNIQUE 1.109.

Identify the ulnar nerve proximally at the medial border of the medial head of the triceps and dissect it free from its tunnel distally to its first motor branch (Fig. 1.137A). n  In total joint arthroplasty, transplant the nerve anteriorly into the subcutaneous tissue (Fig. 1.137B). n  Elevate the medial aspect of the triceps from the humerus, along the intermuscular septum, to the level of the posterior capsule. n  Incise the superficial fascia of the forearm distally for about 6 cm to the periosteum of the medial aspect of the olecranon. n  Carefully reflect as a single unit the periosteum and fascia medially to laterally (Fig. 1.137C). The medial part of the junction between the triceps insertion and the superficial fascia and the periosteum of the ulna is the weakest portion of the reflected tissue. Take care to maintain continuity of the triceps mechanism at this point; carefully dissect the triceps tendon from the olecranon when the elbow is extended to 20 to 30 degrees to relieve tension on the tissues, and then reflect the remaining portion of the triceps mechanism. n  To expose the radial head, reflect the anconeus subperiosteally from the proximal ulna; the entire joint is now widely exposed (Fig. 1.137D). n  The posterior capsule usually is reflected with the triceps mechanism, and the tip of the olecranon may be resected to expose the trochlea clearly (see Fig. 1.137D). n  To attain joint retraction in total joint arthroplasty, release the MCL from the humerus if necessary. n  During closure, carefully repair the MCL when its release has been necessary. n 

Return the triceps to its anatomic position and suture it directly to the bone through holes drilled in the proximal aspect of the ulna. n  Suture the periosteum to the superficial forearm fascia, as far as the margin of the flexor carpi ulnaris (Fig. 1.137E). n  Close the wound in layers and leave a drain in the wound. In total joint arthroplasty, dress the elbow with the joint flexed about 60 degrees to avoid direct pressure on the wound by the olecranon tip.    n 

LATERAL APPROACHES   

LATERAL APPROACH TO THE ELBOW The lateral approach is an excellent approach to a fracture of the lateral condyle because the common origin of the extensor muscles is attached to the condylar fragment and need not be disturbed.

  TECHNIQUE 1.111

Figure 1.138

Begin the incision approximately 5 cm proximal to the lateral epicondyle of the humerus and carry it distally to the epicondyle and along the anterolateral surface of the forearm for approximately 5 cm. n  To expose the lateral border of the humerus, develop distally to proximally the interval between the triceps posteriorly and the origins of the extensor carpi radialis longus and brachioradialis anteriorly. In the proximal angle of the wound, avoid the radial nerve where it enters the interval between the brachialis and brachioradialis muscles. n 

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CHAPTER 1  SURGICAL TECHNIQUES

Superficial forearm fascia Line of incision

Olecranon

Olecranon

Medial epicondyle

Ulnar nerve

Medial epicondyle Ulnar nerve Triceps muscle

Triceps muscle

B

A Forearm fascia ulnar periosteum

Flexor carpi ulnaris muscle Olecranon

Joint capsule Medial epicondyle Ulnar nerve Triceps muscle

C Anconeus muscle Superficial forearm fascia Medial epicondyle

Sharpey fibers Ulnar collateral ligament

Radial head Cut for excision of olecranon tip

Ulnar nerve

Ulnar nerve Olecranon

Triceps muscle

D

E FIGURE 1.137 1.110.

Bryan and Morrey extensile posterior approach to elbow (see text). SEE ­TECHNIQUE

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PART I  GENERAL PRINCIPLES Brachioradialis muscle Biceps brachii muscle Radial nerve

Extensor carpi radialis longus and brevis muscles

Brachialis muscle

Brachioradialis muscle Radial nerve

Extensor carpi radialis longus muscle Dorsal antebrachial cutaneous nerve

A Brachialis muscle

Incision

Triceps brachii muscle

Common extensor tendon

Biceps brachii muscle

Radial nerve Brachioradialis muscle Extensor carpi radialis longus muscle

B

Triceps brachii muscle Dorsal antebrachial cutaneous nerve

FIGURE 1.138 Lateral approach to elbow joint. A, Cross-section shows approach at level of proximal part of incision; right, skin incision and its relation to deep structures. B, Cross-section shows approach at level just proximal to humeral condyles; right, approach has been completed. SEE TECHNIQUE 1.111.

With a small osteotome, separate the common origin of the extensor muscles from the lateral epicondyle together with a thin flake of bone, or divide this origin just distal to the lateral epicondyle. n  Reflect the common origin distally and expose the radiohumeral joint. Protect the deep branch of the radial nerve as it enters the supinator muscle. n  Elevate subperiosteally the origins of the brachioradialis and extensor carpi radialis longus muscles and incise the capsule to expose the lateral aspect of the elbow joint.     n 

 

LATERAL J-SHAPED APPROACH TO THE ELBOW   TECHNIQUE 1.112

 

(KOCHER) Begin the incision 5 cm proximal to the elbow over the lateral supracondylar ridge of the humerus, extend it distally along this ridge, continue it 5 cm distal to the radial head, and curve it medially and posteriorly to end at the posterior border of the ulna (Fig. 1.139A).

n 

Dissect between the triceps muscle posteriorly and the brachioradialis and extensor carpi radialis longus muscles anteriorly to expose the lateral condyle and the capsule over the lateral surface of the radial head. n  Distal to the head, separate the extensor carpi ulnaris from the anconeus and divide the distal fibers of the anconeus in line with the curved and transverse parts of the distal skin incision. Reflect the periosteum from the anterior and posterior surfaces of the distal humerus. n  Reflect anteriorly the common origin of the extensor muscles from the lateral epicondyle by subperiosteal dissection or by detachment of the epicondyle. n  Incise the joint capsule longitudinally. n  Reflect the anconeus subperiosteally from the proximal ulna to dislocate and examine the joint under direct vision (Fig. 1.139B).     n 

MEDIAL APPROACH WITH OSTEOTOMY OF THE MEDIAL EPICONDYLE The medial approach with osteotomy of the medial epicondyle was developed by Molesworth and Campbell,

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CHAPTER 1  SURGICAL TECHNIQUES Biceps muscle

Brachioradialis muscle Extensor carpi radialis longus muscle

Lateral epicondyle

Triceps muscle Line of skin incision

A

Anconeus muscle

Extensor carpi ulnaris muscle

B

Olecranon

Radial head

FIGURE 1.139 Kocher lateral J approach to elbow joint. A, Skin incision. B, Approach has been completed, and elbow joint has been dislocated. SEE TECHNIQUE 1.112.

working independently of each other. Each needed to treat a fracture of the medial humeral epicondyle. In Campbell’s patient, the fragment had been displaced distally and laterally and was incarcerated in the joint cavity. During surgery, Campbell found the radius and ulna could be dislocated on the humerus so that all parts of the joint, including all the articular surfaces, could be inspected.

  TECHNIQUE 1.113

Figure 1.140

(MOLESWORTH; CAMPBELL) With the elbow flexed to a right angle, make a medial incision over the tip of the medial epicondyle from 5 cm distal to the joint to about 5 cm proximal to it. n  Isolate the ulnar nerve in its groove posterior to the epicondyle, free it, and retract it posteriorly. n  Dissect all the soft tissues from the epicondyle except the common origin of the flexor muscles, detach the epicondyle with a small osteotome, and reflect it distally together with its undisturbed tendinous attachments. n  By blunt dissection, continue distally, reflecting the muscles that originate from the medial epicondyle. Protect the branches of the median nerve that supply these muscles, entering along their lateral margins. n  Free the medial aspect of the coronoid process, incise the capsule, and strip the periosteum and capsule anteriorly and posteriorly from the humerus as far proximally as necessary. Avoid injuring the median nerve, which passes over the anterior aspect of the joint. n  With the lateral capsule acting as a hinge, dislocate the joint.     n 

 

MEDIAL AND LATERAL APPROACH TO THE ELBOW   TECHNIQUE 1.114 When extensive exposure is not needed, an incision 5 to 7 cm long can be made on either or both sides of the

n 

joint just anterior to the condyles and parallel with the epicondylar ridges of the humerus. The flexion crease of the elbow is proximal to the joint line (Fig. 1.141). On the medial side, carefully avoid the ulnar nerve. n  Incise the capsule from proximal to distal on each side.      

GLOBAL APPROACH TO THE ELBOW The “global” approach allows circumferential exposure of the elbow. The collateral ligaments, coronoid process, and anterior joint capsule can be reached through this approach.

  TECHNIQUE 1.115 (PATTERSON, BAIN, AND MEHTA) Make a straight posterior midline incision. Sharply dissect down through the deep fascia to the triceps tendon and subcutaneous border of the ulna. n  If the medial aspect of the elbow is to be exposed, open the cubital tunnel, isolate the ulnar nerve, and transpose it anteriorly. Protect it throughout the procedure with a Penrose drain (Fig. 1.142A). n  Develop full-thickness medial or lateral fasciocutaneous flaps, depending on the procedure to be performed. n  n 

Posterolateral Approach Develop the Kocher interval between the anconeus and extensor carpi ulnaris muscle to expose the elbow capsule and lateral epicondyle. n  To expose the olecranon fossa and posterior aspect of the distal humerus, reflect the anconeus and triceps ­medially. n  To expose the radial head, elevate the common extensor origin anteriorly from the underlying capsule, lateral ulnar collateral ligament, and lateral epicondyle (Fig. 1.142B). n  Make an arthrotomy along the anterior border of the lateral ulnar collateral ligament and carry it distally, dividing the annular ligament. n 

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PART I  GENERAL PRINCIPLES

Ulnar nerve

Medial epicondyle

A

Line of skin incision

Line of incision in capsule

C

B

Common flexor tendon

Trochlear notch of ulna

Trochlea of humerus

D Medial epicondyle

FIGURE 1.140 Campbell medial approach to elbow joint. A, Skin incision. B, Ulnar nerve has been retracted posteriorly, and medial epicondyle is being freed. C, Epicondyle and attached common origin of flexor muscles have been reflected distally. Joint capsule is to be incised longitudinally. D, Approach has been completed, and elbow joint has been dislocated. SEE TECHNIQUE 1.113.

If additional exposure of the radial head is needed, perform a chevron osteotomy of the lateral epicondyle (Fig. 1.142C). n  Predrill and tap holes to accept one or two 4-mm cancellous or 3.5-mm cortical screws. Use a small sagittal saw or osteotome to perform the cut. n  Elevate the muscles from the supracondylar ridge subperiosteally, keeping them in continuity with the lateral epicondyle and the common extensor origin. n  Develop the interval between the extensor digitorum communis and extensor carpi radialis longus and brevis to the level of the deep radial (posterior interosseous) nerve where it enters the supinator at the arcade of Fröhse. This allows reflection of the common extensor origin, lateral ulnar collateral ligament, and attached lateral epicondyle in an anterior and distal direction. n  If additional exposure of the radial head, neck, and proximal shaft is needed, pronate the forearm to translate the posterior interosseous nerve anteriorly (Fig. 1.142D) and divide the annular ligament 5 mm from the edge of the lesser sigmoid notch (see Fig. 1.142C). Elevate a posterior capsular flap if needed. This violates the lateral ulnar collateral ligament, which must be repaired at closing. n 

FIGURE 1.141 Kirschner wire has been taped along flexion crease of elbow. Note relation of wire to joint line. SEE TECHNIQUE 1.114.

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CHAPTER 1  SURGICAL TECHNIQUES

Triceps and anconeus muscle

Lateral ulnar collateral ligament

Ulnar nerve

Extensor carpi ulnaris muscle Radial collateral ligament

Capsulotomy anterior to lateral ulnar collateral ligament

A

B

Chevron osteotomy of lateral epicondyle

Step-cut incision in annular ligament Extensor carpi ulnaris muscle and lateral epicondyle osteotomy

Retracted triceps tendon

C

Retracted anconeus muscle

Subperiosteal release of supinator muscle

FIGURE 1.142 Global approach to elbow joint. A, Initial incision and isolation of ulnar nerve. B, Lateral component. C, Chevron osteotomy of lateral epicondyle.

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PART I  GENERAL PRINCIPLES Posterior interosseous nerve

Radial nerve

D

Ulnar nerve

Flexor carpi ulnaris muscle

Medial epicondyle

Flexor digitorum profundus muscle

Capsulotomy anterior to medial collateral ligament Triceps tendon

E Strip of deep fascia for repair of flexor attachments FIGURE 1.142, cont’d D, Translation of posterior interosseous nerve with forearm pronation. E, Medial component. SEE TECHNIQUE 1.115.

Release the supinator muscle from the supinator crest of the ulna and retract it along with the posterior interosseous nerve to expose the proximal radius. 

n 

Posteromedial Approach To extend the approach medially, release the flexor carpi ulnaris and flexor digitorum profundus muscles subperiosteally from their ulnar origins. n  Retract anteriorly to expose the coronoid process, the anterior bundle of the medial ligament complex, and anterior joint capsule (Fig. 1.142E).    n 

RADIUS   

POSTEROLATERAL APPROACH TO THE RADIAL HEAD AND NECK A posterolateral oblique approach safely exposes the radial head and neck; it corresponds to the distal limb of the lateral-J approach of Kocher to the elbow. It is the best approach for excising the radial head because it is not only extensile proximally and distally without danger to major vessels or nerves, but it also preserves the nerve supply to the anconeus. It is safer than an approach that separates the extensor carpi ulnaris from the extensor digitorum communis or one that separates the latter muscle from the radial extensors because both of these endanger the

posterior interosseous nerve. After experimental work on cadavers, Strachan and Ellis recommended a position of full pronation of the forearm for maximal protection of the nerve during this procedure (see Fig. 1.142D).

  TECHNIQUE 1.116 Begin an oblique incision over the posterior surface of the lateral humeral condyle and continue it obliquely distally and medially to a point over the posterior border of the ulna 3 to 5 cm distal to the tip of the olecranon (Fig. 1.143). n  Divide the subcutaneous tissue and deep fascia along the line of the incision and develop the fascial plane between the extensor carpi ulnaris and the anconeus muscles. This plane can be found more easily in the distal than in the proximal part of the incision because in the proximal part the two muscles blend at their origin. n  Retract the anconeus toward the ulnar side and the extensor carpi ulnaris toward the radial side, exposing the joint capsule in the depth of the proximal part of the wound. n  Note that the fibers of the supinator cross at a right angle to the wound, near its center and deep (anterior) to the extensor carpi ulnaris; retract the proximal fibers of the supinator distally. n  Locate the joint capsule in the depth of the wound, incise it, and expose the head and neck of the radius (Fig. 1.143). The deep branch of the radial nerve that lies between the two planes of the supinator remains undisturbed.     n 

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CHAPTER 1  SURGICAL TECHNIQUES

Biceps muscle Brachialis muscle Radial nerve

Brachioradialis muscle Extensor carpi radialis longus and brevis muscles

Flexor carpi ulnaris muscle Anconeus muscle Extensor carpi ulnaris muscle Extensor digitorum communis muscle Radial nerve

Extensor carpi radialis longus and brevis muscles

Ulnar nerve

Dorsal antebrachial cutaneous nerve

Olecranon

Common extensor tendon

Anconeus muscle Approach

FIGURE 1.143 Posterolateral approach to head of radius. Cross-section shows relationship of surgical dissection to adjacent anatomy. SEE TECHNIQUE 1.116.  

APPROACH TO THE PROXIMAL AND MIDDLE THIRDS OF THE POSTERIOR SURFACE OF THE RADIUS Exposing the proximal third of the radius is difficult because the deep branch of the radial nerve (posterior interosseous) traverses it within the supinator muscle; one must keep this nerve constantly in mind and take care to protect it from injury.

  TECHNIQUE 1.117 (THOMPSON) Make the skin incision over the proximal and middle thirds of the radius along a line drawn from the center of the dorsum of the wrist to a point 1.5 cm anterior to the lateral humeral epicondyle (Fig. 1.144A); when the forearm is pronated, this line is nearly straight. n  Expose the lateral (radial) border of the extensor digitorum communis muscle in the distal part of the incision. n 

Develop the interval between this muscle and the extensor carpi radialis brevis and retract these structures to the ulnar and radial sides. n  The abductor pollicis longus muscle is visible; retract it distally and toward the ulna to expose part of the posterior surface of the radius. n  Continue the dissection proximally between the extensor digitorum communis and the extensors carpi radialis brevis and longus to the lateral humeral epicondyle. n  Reflect the extensor digitorum communis toward the ulna to expose the supinator muscle, or for a wider view, detach the extensor digitorum from its origin on the lateral epicondyle and retract it further medially (Fig. 1.144B). n  Expose the part of the radius covered by the supinator by one of two means. Either divide the muscle fibers down to the deep branch of the radial nerve and carefully retract the nerve or free the muscle from the bone subperiosteally and reflect it proximally or distally along with the nerve; the latter is the better method if the exposure is wide enough (Fig. 1.144C).     n 

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PART I  GENERAL PRINCIPLES

Brachialis muscle Triceps muscle

Brachioradialis muscle Extensor carpi radialis longus muscle Line of incision in supinator muscle

Interosseous branch of radial nerve

Supinator muscle

Dorsal interosseous artery

A

Extensor carpi radialis brevis muscle

Extensor digitorum communis muscle

Pronator teres muscle (insertion)

Supinator muscle (cut)

Radius

Extensor digitorum communis muscle

Extensor carpi radialis brevis muscle

Abductor pollicis longus muscle

Pronator teres muscle (insertion)

Abductor pollicis longus muscle Extensor pollicis brevis muscle

Extensor indicis proprius muscle

Extensor pollicis longus muscle

B

C

FIGURE 1.144 Thompson approach to proximal and middle thirds of posterior surface of radius. A, Skin incision. B, Relationships of supinator and deep branch of radial nerve to proximal third of radius. C, Approach has been completed. SEE TECHNIQUE 1.117.

 

ANTEROLATERAL APPROACH TO THE PROXIMAL SHAFT AND ELBOW JOINT

s­ubperiosteally from the radius and reflect it laterally; it carries with it and protects the deep branch of the radial nerve (Fig. 1.145D,E). n  Pronate the forearm and expose the radius by subperiosteal dissection.    

  TECHNIQUE 1.118  

(HENRY) With the forearm supinated, begin a serpentine longitudinal incision at a point just lateral and proximal to the biceps tendon and extend it distally in the forearm along the medial border of the brachioradialis and, if necessary, as far as the radial styloid (Fig. 1.145A). n  Expose the biceps tendon by incising the deep fascia on its lateral side; divide the deep fascia of the forearm in line with the skin incision, taking care to protect the radial vessels (Fig. 1.145B,C). n  Isolate and ligate the recurrent radial artery and vein immediately; otherwise, the cut ends may retract, resulting in a hematoma that may cause ischemic (Volkmann) contracture of the forearm flexor muscles. Flex the elbow to a right angle to allow more complete retraction of the brachioradialis and the radial carpal extensor muscles to expose the supinator. n  Incise the bicipital bursa, which lies in the angle between the lateral margin of the biceps tendon and the radius, and from this point distally, strip the supinator n 

ANTERIOR APPROACH TO THE DISTAL HALF OF THE RADIUS The volar (anterior) surface of the distal half of the radius is broad, flat, and smooth and provides a more satisfactory bed for a plate or a graft than does the dorsal (posterior) convex surface.

  TECHNIQUE 1.119 (HENRY) With the forearm in supination, make a 15- to 20-cm longitudinal incision over the interval between the brachioradialis and the flexor carpi radialis muscles (Fig. 1.146A-C); this interval, as Kocher stated, “lies in the frontier line between the structures innervated by the different nerves.” n  Identify and protect the sensory branch of the radial nerve, which lies beneath the brachioradialis muscle. Carefully mobilize and retract medially the flexor carpi n 

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CHAPTER 1  SURGICAL TECHNIQUES

Biceps muscle Brachialis muscle Brachioradialis muscle

Brachialis muscle

Radial nerve

Incision

A

Biceps muscle

Brachioradialis muscle

Recurrent radial artery

Median nerve

Supinator muscle

Radial artery

Muscular branch of radial artery

Pronator teres muscle

Sensory branch of radial nerve

B

C

Fascia Brachioradialis muscle

Biceps muscle Radial nerve Brachialis muscle

Sensory branch of radial nerve Interosseous branch of radial nerve

Incision in capsule opened Supinator reflected

Capsule Radial artery

Incision

Biceps tendon

Periosteum reflected

Pronator teres muscle

Supinator muscle

D

Capitellum Annular ligament Radius

E

FIGURE 1.145 Modified Henry anterolateral approach to elbow joint. A, Incision. B, Fascia has been incised to expose brachioradialis laterally and biceps and brachialis medially. Lacertus fibrosus has been divided to permit dissection to be deepened between biceps tendon and pronator teres medially and brachioradialis laterally. C, Dissection has been deepened to expose radial nerve. Nerve and its sensory branch are protected, and recurrent radial artery is ligated and divided. D, Broken line represents incision to be made through joint capsule and along medial border of supinator to expose capitellum and proximal radius. E, Forearm has been supinated, and approach has been completed by reflecting supinator. Radial nerve, which courses in supinator, is protected. SEE TECHNIQUE 1.118.

radialis ­tendon and the radial artery and vein. The flexor digitorum sublimis, flexor pollicis longus, and pronator quadratus muscles are now exposed. n  Beginning at the anterolateral edge of the radius, elevate subperiosteally the flexor pollicis longus and the pronator quadratus muscles (Fig. 1.146D-F) and strip them medially (toward the ulna).    

 

ANTERIOR APPROACH TO THE CORONOID PROCESS OF THE PROXIMAL ULNA Yang et al. described an anterior approach to the proximal ulna for repair of coronoid fractures. This uses the interval between the brachial artery and the median nerve.

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PART I  GENERAL PRINCIPLES Radial artery

Incision

A

Flexor carpi radialis muscle

B

Flexor pollicis longus muscle

Brachioradialis muscle

Pronator quadratus muscle

Brachioradialis muscle

Sensory branch of radial nerve Tendon of flexor carpi radialis muscle Flexor digitorum sublimis muscle

D C Brachioradialis muscle

Radial artery

Flexor carpi radialis muscle

Incision in periosteum

Sensory branch of radial nerve

Flexor pollicis longus muscle

Radius Flexor pollicis longus muscle

E

F Radial artery

Flexor digitorum sublimis muscle

Flexor digitorum sublimis muscle

FIGURE 1.146 Henry anterior approach to distal half of radius. A, Skin incision. B, Fascia has been incised, and brachioradialis has been retracted laterally and flexor carpi radialis medially. Radial artery and sensory branch of radial nerve must be protected because they course deep to brachioradialis. C, Radial vessels and flexor carpi radialis tendon have been retracted medially to expose long flexor muscles of thumb and fingers and pronator quadratus. D, Forearm has been pronated to expose radius lateral to pronator quadratus and flexor pollicis longus. E, Broken line indicates incision to be made through periosteum. F, Periosteum has been incised, and flexor pollicis longus and pronator quadratus have been elevated subperiosteally from anterior surface of radius. SEE TECHNIQUE 1.119.

  TECHNIQUE 1.120 (YANG ET AL.) Make an S-shaped incision from the ulnar side of the elbow to the radial side (Fig. 1.147A). n  Expose the biceps tendon, the bicipital aponeurosis, and the neurovascular bundle (Fig. 1.147B). n  Incise the biceps aponeurosis transversely exposing the biceps, pronator teres, brachial artery, and median nerve (Fig. 1.147C) n 

Incise the space between the brachial artery and median nerve. Laterally retract the brachial artery, biceps, and brachioradialis; retract the median nerve and pronator teres medially. Incise the brachialis muscle and tendon longitudinally (Fig. 1.147D) n  Incise and retract the capsule exposing the coronoid process (Fig. 1.147E).    n 

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CHAPTER 1  SURGICAL TECHNIQUES

Brachial artery and median nerve Transected biceps aponeurosis

A

B

C

Median nerve

Radial head

Brachial artery

Coronoid process

D

E FIGURE 1.147 Anterior approach to the coronoid process. A, S-shaped incision in antecubital fossa. B, Expose the biceps, biceps aponeurosis, and neurovascular bundle. C, Expose the interval between the brachial artery and median nerve. D, Retract the brachial artery, biceps, and brachioradialis laterally and median nerve and pronator teres medially. E, Open the joint capsule and expose the coronoid process. SEE TECHNIQUE 2.120.

ULNA   

APPROACH TO THE PROXIMAL THIRD OF THE ULNA AND THE PROXIMAL FOURTH OF THE RADIUS Because part of the posterior surface of the ulna throughout its length lies just under the skin, any part of the bone can be approached by incising the skin, fascia, and periosteum along this surface. The following approach is especially useful when treating fractures of the proximal third of the ulna associated with dislocation of the radial head. It also can be used to expose the proximal fourth of the radius alone, with less danger to the deep branch of the radial nerve than with other approaches.

  TECHNIQUE 1.121 (BOYD) Begin the incision about 2.5 cm proximal to the elbow joint just lateral to the triceps tendon, continue it distally

n 

over the lateral side of the tip of the olecranon and along the subcutaneous border of the ulna, and end it at the junction of the proximal and middle thirds of the ulna (Fig. 1.148A). n  Develop the interval between the ulna on the medial side and the anconeus and extensor carpi ulnaris on the lateral side. n  Strip the anconeus from the bone subperiosteally in the proximal part of the incision; to expose the radial head, reflect the anconeus radially. n  Distal to the radial head, deepen the dissection to the interosseous membrane after reflecting the part of the supinator that arises from the ulna subperiosteally. n  Peel the supinator from the proximal fourth of the radius and reflect radially the entire muscle mass, including this muscle, the anconeus, and the proximal part of the extensor carpi ulnaris (Fig. 1.148B). This amply exposes the lateral surface of the ulna and the proximal fourth of the radius. The substance of the reflected supinator protects the deep branch of the radial nerve (Fig. 1.148C,D). n  In the proximal part of the wound, divide the recurrent interosseous artery but not the dorsal interosseous artery.    

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PART I  GENERAL PRINCIPLES

Anconeus muscle

Extensor carpi ulnaris muscle

Triceps tendon

Flexor digitorum profundus muscle

A Olecranon Reflected portion of supinator muscle from ulna

Reflected portion of supinator muscle from radius Divided portion of supinator muscle

Reflected anconeus muscle

B

Supinator Exodus of nerve muscle from supinator

Radial nerve (deep branch) entering supinator muscle

Recurrent interosseous artery Dorsal interosseous artery

C

1

2

3

4

1

2 Radial nerve

Flexor digitorum profundus muscle

Radial nerve

Flexor digitorum profundus muscle

Supinator muscle

Olecranon Incision

Anconeus muscle 3

Incision

Anconeus muscle

Extensor carpi ulnaris muscle

4

Interosseous membrane Ulna

Flexor digitorum profundus muscle

Flexor digitorum profundus muscle

Incision

D

Anconeus muscle

Radial nerve Supinator Incision muscle Extensor carpi ulnaris muscle

Supinator muscle Radial nerve Anconeus muscle

Recurrent interosseous artery

FIGURE 1.148 Boyd approach to proximal third of ulna and fourth of radius. A, Skin incision. B, Approach has been completed. C and D, Relationship of deep branch of radial nerve to superficial and deep parts of supinator. C, Numbers 1, 2, 3, and 4 correspond to levels of cross-sections in D with same numbers. SEE TECHNIQUE 1.121.

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CHAPTER 1  SURGICAL TECHNIQUES

WRIST 

Elevate the periosteum of the distal inch of the radius, but preserve as much as possible of the extensor tendon sheaths. n  Retract the extensor tendons of the fingers medially (toward the ulna) to expose the dorsum of the wrist joint and to allow transverse incision of the capsule (Fig. 1.149B).     n 

 

DORSAL APPROACH TO THE WRIST   TECHNIQUE 1.122 Through a 10-cm dorsal curvilinear incision centered over the Lister tubercle (Fig. 1.149A), expose the dorsal carpal ligament and define the fibrous partitions separating the tendon sheaths on the dorsum of the radius and ulna. n  Divide this ligament and the underlying periosteum over the tubercle, taking care not to injure the tendon of the extensor pollicis longus; dissect between the extensor tendons of the thumb and fingers. n 

Extensor digiti minimi proprius tendon Extensor carpi ulnaris tendon Extensor pollicis longus tendon

A

Extensor digitorum communis muscle

 

DORSAL APPROACH TO THE WRIST   TECHNIQUE 1.123 Begin a transverse curved skin incision on the medial side of the head of the ulna, and extend it across the dorsum of the wrist to a point 1.5 cm proximal and posterior to the radial styloid (Fig. 1.149A). n  Retract the skin and the superficial and deep fasciae and retract the tendons as described in the first technique, exposing the radial side of the dorsum of the wrist. n  To expose the ulnar side, make a longitudinal incision through the dorsal carpal ligament between the extensor digiti quinti proprius and the common extensor tendons. Retract the common extensor tendons to the radial side and the tendons of the extensor digiti quinti proprius and extensor carpi ulnaris to the ulnar side and incise the capsule transversely. n  By combining these deeper incisions and alternately retracting the tendons of the common extensors of the fingers to the radial or ulnar side, one may reach the entire dorsal aspect of the joint.     n 

 

VOLAR APPROACH TO THE WRIST The volar approach often is used to remove or to reduce a dislocated lunate.

  TECHNIQUE 1.124 Make a transverse incision across the volar aspect of the wrist in the distal flexor crease (Fig. 1.150). (A curved longitudinal incision has been used but is less desirable because crossing the flexor creases produces a scar that may cause a flexion contracture.) n  Incise and retract the superficial and deep fasciae. n  Identify the palmaris longus tendon. Find and isolate the median nerve; it is usually deep to the palmaris longus tendon and slightly to its radial side. In patients with congenital absence of the palmaris longus tendon, the median nerve is the most superficial longitudinal structure on the volar aspect of the wrist. Gently retract the palmaris longus tendon (if present) and the flexor pollicis longus tendon to the radial side. Retract the flexor digitorum sublimis and profundus tendons to the ulnar side (Fig. 1.150A, inset). n  Incise the joint capsule, exposing the distal end of the radius and the lunate (Fig. 1.150B).     n 

Scaphoid

Lunate

Radius

B FIGURE 1.149 Dorsal approaches to wrist. A, Solid lines represent curved longitudinal and transverse skin incisions. Broken lines represent incisions through dorsal carpal ligament (see text). B, Scaphoid, lunate, and distal radius have been exposed through curved transverse skin incision and through incision in dorsal carpal ligament centered over Lister tubercle. SEE TECHNIQUES 1.122 AND 1.123.

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PART I  GENERAL PRINCIPLES Superficial radial nerve

Incision

Extensor pollicis brevis tendon

Extensor pollicis longus tendon Radial artery Transverse incision through distal flexor crease

Curved longitudinal incision

Abductor pollicis longus tendon

A

Median nerve Palmaris longus tendon Scaphoid

A

Flexor tendons

Greater multangular

Palmaris longus tendon Median nerve

B FIGURE 1.151 Lateral approach to wrist joint. A, Skin incision. B, Approach has been completed. SEE TECHNIQUE 1.125.

Scaphoid Lunate

Median nerve Palmaris longus tendon

Radius

B FIGURE 1.150 Volar approach to wrist. A, Optional transverse or curved longitudinal skin incisions. B, Flexor tendons and median nerve retracted as in cross-section, exposing lunate bone and distal end of radius. SEE TECHNIQUE 1.124.

 

LATERAL APPROACH TO THE WRIST   TECHNIQUE 1.125

the radial artery, and the lateral terminal branch of the superficial branch of the radial nerve; retract the extensor pollicis longus tendon dorsally. This retraction exposes the tubercle of the scaphoid (Fig. 1.151B). n  Longitudinally divide the radial collateral ligament and capsule to expose the lateral aspect of the wrist joint. Take care to protect the radial artery, which passes between the abductor pollicis longus and the extensor pollicis brevis tendons laterally and the radial collateral ligament medially, and the superficial branches of the radial nerve, which supply the skin on the dorsum of the thumb.      

MEDIAL APPROACH TO THE WRIST The medial approach may be used for arthrodesis of the wrist when tendon transfers around the dorsum of the wrist are contemplated (see Chapter 71). Historically, Smith-Petersen used it for arthrodesis of the wrist when the distal radioulnar joint was diseased or deranged; in his technique, the distal 2.5 cm of the ulna is resected.

  TECHNIQUE 1.126

Make a medial curvilinear incision centered over the ulnar styloid. Its proximal limb is parallel to the ulna; at the level of the ulnar styloid, it curves dorsally and toward the palm toward the proximal end of the fifth metacarpal, and its distal limb parallels the fifth metacarpal for about 2.5 cm.

n 

Make a 7.5-cm lateral curvilinear skin incision shaped like a bayonet on the radial side of the wrist (Fig. 1.151A). n  Retract to the volar side of the wrist, the extensor pollicis brevis tendon, the abductor tendons of the thumb, n 

Figure 1.152

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CHAPTER 1  SURGICAL TECHNIQUES Ulna

Line of skin incision

A Ulna Incision in periosteum of radius

C

B

Radius

Periosteum

Radius

Reflected periosteum

D

Ulnar stump

Radius

Carpus

FIGURE 1.152 Smith-Petersen medial approach to wrist. A, Medial curvilinear incision. B, Ulna osteotomized obliquely 2.5 cm proximal to styloid process. C, Distal ulna resected and periosteum of radius incised. D, Radiocarpal joint exposed by reflection of capsule and ligaments from carpus and distal end of radius. SEE TECHNIQUE 1.126.

While incising the skin and subcutaneous tissue, carefully avoid injuring the dorsal branch of the ulnar nerve, which winds around the dorsum of the wrist immediately distal to the head of the ulna and divides into its three cutaneous branches supplying the little finger and the ulnar half of the ring finger. n  Incise the fascia and open the capsule longitudinally. Do not injure the triangular fibrocartilage attached to the ­ulnar styloid.    

HAND Surgical approaches to the hand are discussed in Chapter 64.

REFERENCES SURGICAL TECHNIQUES Akinyoola AL, Adegbehingbe OO, Odunsi A: Timing of antibiotic prophylaxis in tourniquet surgery, J Foot Ankle Surg 50:374–376, 2011. Al-Ahaideb A: Surgical treatment of chronic acromioclavicular dislocation using the Weaver-Dunn procedure augmented by the TightRope® System, Eur J Orthop Surg Traumatol 24:741, 2014. American Academy of Orthopaedic Surgeons Information Statement: Preventing the transmission of bloodborne pathogens. Available online at www.aaos.org/about/papers/advistmt/1018.asp. Accessed 12 April 2010. American Academy of Orthopaedic Surgeons: Preventing the transmission of bloodborne pathogens, Rosemont, 2008, AAOS, Reviewed 2012: http://w ww.aaos.org/about/papers/advistmt/1018.asp. AORN: Recommended practices for the use of the pneumatic tourniquet in the perioperative practice setting. In Blanchard J, Burlingame B, editors: Perioperative standards and recommended practices: for inpatient and ambulator settings, Denver, Colorado, 2011, Association of Perioperative Registered Nurses, pp 177–189.

Association of Surgical Technologists: Recommendation standards of practice for safe use of pneumatic tourniquets. Littleton, Colorado, http://w ww.ast.org///pdf/Standards_of_Practice/RSOP_Pneumatic_Tourniquet s.pdf. Atesok K, Fu FH, Wolf MR, et al.: Augmentation of tendon-to-bone healing, J Bone Joint Surg 96A:513–521, 2014. Carragee EJ, Chu G, Rohatgi R, et al.: Cancer risk after use of recombinant bone morophogenetic protein-2 for spinal arthrodesis, J Bone Joint Surg 95A:1537, 2013. El Sallakh SA: Evaluation of arthroscopic stabilization of acute acromioclavicular joint dislocation using the TightRope system, Orthopedics 35:e18, 2012. Farber DC, Farber JS: Tourniquet application on the difficult thigh: technique tip, Foot Ankle Int 32:735, 2011. Friesenbichler J, Maurer-Ertl W, Sadoghi P, et al.: Adverse reactions of artificial bone graft substitutes: lessons learned from using tricalcium phosphate geneX®, Clin Orthop Relat Res 472:976, 2014. Gerbert J, Traynor C, Blue K, Kim K: Use of the Mini TightRope® for correction of hallux varus deformity, J Foot Ankle Surg 50:245, 2011. Hernigou P, Pariat J, Queinnec S, et al.: Supercharging irradiated allografts with mesenchymal stem cells improves acetabular bone grafting in revision arthroplasty, Int Orthop 38:1913, 2014. Hidalgo Díaz JJ, Muresan L, Touchal S, et  al.: The new digit tourniquet ForgetMeNot®, Orthop Traumatol Surg Res 2017. Jensen G, Katthagen JC, Alvarado LE, et al.: Has the arthroscopically assisted reduction of acute AC joint separations with the double tight-rope technique advantages over the clavicular hook plate fixation? Knee Surg Sports Traumatol Arthrosc 22:422, 2014. Kurien T, Person RG, Scammell BE: Bone graft substitutes currently available in orthopaedic practice. The evidence for their use, J Bone Joint Surg 95B:583, 2013. Lowes R: Avoid certain bone graft substitutes in children, FDA warns, January 2015. https://www.medscape.com/viewarticle/838493. Luo Z-Y, Wang H-Y, Wang D, et  al.: Oral vs. intravenous vs topical tranexamic acid in primary hip arthroplasty: a prospective, randomized, double-blind, controlled trial, J Arthroplasty 33(3):786, 2018. Marchand LS, Rothberg DL, Kubiak EN, Higgins TF: Is this autograft worth it?: the blood loss and transfusion rates associated with reamer irrigator aspirator bone graft harvest, J Orthop Trauma 31(4):205, 2017.

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PART I  GENERAL PRINCIPLES Mont MA, Beaver WB, Dysart SH, et  al.: Local infiltration analgesia with liposomal bupivacaine improves pain scores and reduces opioid use after total knee arthroplasty: results of a randomized controlled trial, 33(1):90, 2018. Naqvi GA, Shafqat A, Awan N: Tightrope fixation of ankle syndesmosis injuries: clinical outcome, complications and technique modification, Injury 43:838, 2012. Osanai T, Ogino T: Modified digital tourniquet designed to prevent the tourniquet from inadvertently being left in place after the end of surgery, J Orthop Trauma 24:387, 2010. Qvick LM, Ritter CA, Mutty CE, et al.: Donor site morbidity with reamerirrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series, Injury 44:1263, 2014. Ramussen LE, Holm HA, Kristense PW, Kjaersgaard-Andersen P: Tourniquet time in total knee arthroplasty 2018, https://doi.org10.1016/j.knee.2018.0 1.002. Sagi HC, Young ML, Gerstenfeld L, et al.: Qualitative and quantitative differences between bone graft obtained from the medullary canal (with a Reamer/Irrigator/Aspirator) and the iliac crest of the same patient, J Bone Joint Surg 94A:2128, 2012. Taylor BC, French BG, Fowler TT, et al.: Induced membrane technique for reconstruction to manage bone loss, J Am Acad Orthop Surg 20:142, 2012. Thiel E, Mutnal A, Gilot GJ: Surgical outcome following arthroscopic fixation of acromioclavicular joint disruption with the tightrope device, Orthopedics 34:e267, 2011.

SURGICAL APPROACHES KNEE Chang SM: Selection of surgical approaches to the posterolateral tibial plateau fracture by its combination patterns, J Orthop Trauma 25:e32, 2011. Frosch KH, Balcarek P, Walde T, Stürmer KM: A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures, J Orthop Trauma 24:515, 2010. He X, Ye P, Hu Y, et  al.: A posterior inverted L-shaped approach for the treatment of posterior bicondylar tibial plateau fractures, Arch Orthop Trauma Surg 133:23, 2013. Johnson EE, Timon S, Osuji C: Tscherne-Johnson extensile approach for tibial plateau fractures, Clin Orthop Relat Res 471:2760, 2013. Kandemir U, Maclean J: Surgical approaches for tibial plateau fractures, J Knee Surg 27:21, 2014. Keshmiri A, Dotzauer F, Baier C, et al.: Stability of capsule closure and postoperative anterior knee pain after medial parapatellar approach in TKA, Arch Orthop Trauma Surg 137:1019, 2017. Lobenhoffer P: Posterolateral transfibular approach to tibial plateau fractures, J Orthop Trauma 25:e31, 2011. Satish BRJ, Ganesan JC, Chandran P, et  al.: Efficacy and mid term results of lateral parapatellar approach without tibial tubercle osteotomy for primary total knee arthroplasty with fixed valgus knees, J Arthroplasty 28:1751, 2013. Solomon LB, Stevenson AW, Baird RPV, Pohl AP: Posterolateral transfibular approach to tibial plateau fractures; technique, results, and rationale, J Orthop Trauma 24:505, 2010. Sun DH, Zhao Y, Zhang JT, et al.: Anterolateral tibial plateau osteotomy as a new approach for the treatment of posterolateral tibial plateau fracture. A case report, Medicine 97(3):e9669, 2018. Yoon YC, Sim JA, Kim DH, Lee BK: Combined lateral femoral epicondylar osteotomy and a submeniscal approach for the treatment of a tibial plateau fracture involving the posterolateral quadrant, Injury, Int J Care Injured 46:422, 2015. Yu B, Han K, Zhan C, et al.: Fibular head osteotomy: a new approach for the treatment of lateral or posterolateral tibial plateau fractures, Knee 17:313, 2010.

ACETABULUM AND PELVIS Guy P: Evolution of the anterior intrapelvic (Stoppa) approach for acetabular fracture surgery, J Orthop Trauma 29(2):S1, 2015. Moed BB: The modified Gibson posterior surgical approach to the acetabulum, J Orthop Trauma 24:315, 2010.

HIP Cavaignac E, Laumond G, Regis P, et al.: Fixation of a fractured femoral head through a medial hip approach: an original approach to the femoral head, Hip Int 25(5):488, 2015. Ishimatsu T, Kinoshita K, Nishio J, et  al.: Motor-evoked potential analysis of femoral nerve status during the direct anterior approach for total hip arthroplasty, J Bone Joint Surg Am 100:572, 2018. Mednick RE, Alvi HM, Morgan CE, et al.: Femoral vein blood flow during a total hip arthroplasty using a modified Heuter approach, J Arthroplasty 30:786, 2015. Ohmori T, Kabata T, Maeda T, et  al.: Selection of a surgical approach for total hip arthroplasty according to the depth to the surgical site, Hip Int 27(3):273, 2017. York PJ, Smarck CT, Judet T, Mauffrey C: Total hip arthroplasty via the anterior approach: tips and tricks for primary and revision surgery, Int Orthop 40:2041, 2016.

FOOT AND ANKLE Choi JY, Kim JH, Ko HT, Suh JS: Single oblique posterolateral approach for open reduction and internal fixation of posterior malleolar fractures with an associated lateral malleolar fracture, J Foot Ankle Surg 54:559, 2015. Kesemenli CC, Memisogu K, Atmaca H: A minimally invasive technique for the reduction of calcaneal fractures using the Endobutton®, J Foot Ankle Surg 52:215, 2013. Knupp M, Zwicky L, Lang TH, et al.: Medial approach to the subtalar joint. Anatomy, indications, technique tips, Foot Ankle Clin N Am 20:311, 2015. Park J, Che JH: The sinus tarsi approach in displaced intra-articular calcaneal fractures, Arch Orthop Trauma Surg 137:1055, 2017. Schepers T, Den Hartog D, Vogels LMM, Van Lieshout EMM: Extended lateral approach for intra-articular calcaneal fractures: an inverse relationship between surgeon experience and wound complications, J Foot Ankle Surg 52:167, 2013.

HUMERUS Boschi V, Pogorelic Z, Gulan G, et al.: Subbrachial approach to humeral shaft fractures: new surgical technique and retrospective case series study, Can J Surg 56:27, 2013. Kuhne MA, Friess D: Supine extensile approach to the anterolateral humerus, Orthopedics 39(1):193, 2016. Phelps KD, Harmer LS, Crickard CV, et  al.: A preoperative planning tool: aggregate anterior approach to the humerus with quantitative comparisons, J Orthop Trauma 32:e229, 2018. Traver JL, Guzman MA, Cannada LK, Kaar SG: Is the axillary nerve at risk during a deltoid-splitting approach for proximal humerus fractures? J Orthop Trauma 30:240, 2016.

SHOULDER Chou YC, Tseng IC, Chiang CW, Wu CC: Shoulder hemiarthroplasty for proximal humeral fractures; comparisons between the deltopectoral and anterolateral deltoid-splitting approaches, J Shoulder Elbow Surg 22:e1, 2013. Nathe T, Tseng S, Yoo B: The anatomy of the supraclavicular nerve during surgical approach to the clavicular shaft, Clin Orthop Relat Res 469:890, 2011. Ponce BA, Kundukulam JA, Pflugner R, et al.: Sternoclavicular joint surgery: how far does danger lurk below? J Shoulder Elbow Surg 22:993, 2013.

ELBOW Hasan SA, Rauls RB, Cordell CL, et  al.: “Zone of vulnerability” for radial nerve injury: anatomic study, J Surg Orthop Adv 23:105, 2014.

FOREARM Yang X, Chang W, Chen W, et al.: A novel anterior approach for the fixation of ulnar coronoid process fractures, Orthop Traumaol Surg Res 103:899, 2017.

The complete list of references is available online at Expert Consult.com.

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SUPPLEMENTAL REFERENCES American Association of Tissue Banks: Standards for tissue banking, ed 11, Arlington, VA, 2006, American Association of Tissue Banks. Bannister GC, Auchincloss JM, Johnson DP, Newman JH: The timing of tourniquet application in relation to prophylactic antibiotic administration, J Bone Joint Surg 70B:322, 1988. Bottoni CR, Brooks DE, DeBerardino TM, et al.: A comparison of bioabsorbable and metallic suture anchors in a dynamically loaded, intra-articular Caprine model, Available online at www.orthosupersite.com/print.asp? rID=3291. Accessed December 2009. Boyd HB: Congenital pseudarthrosis: treatment by dual bone grafts, J Bone Joint Surg 23:497, 1941. Boyd HB: The treatment of difficult and unusual nonunions, with special reference to the bridging of defects, J Bone Joint Surg 25:535, 1943. Braithwaite J, Klenermaw L: Burns under tourniquets: Bruner’s ten rules revisited, J Med Der Unions 12:14, 1996. Brawley SC, Simpson RB: Results of an alternative autogenous iliac crest bone graft harvest method, Orthopedics 29:342, 2006. Brown AR, Taylor GJS, Gregg PJ: Air contamination during skin preparation and draping in joint replacement surgery, J Bone Joint Surg 78B:92, 1996. Bunnell S, editor: Surgery of the hand, ed 2, Philadelphia, 1948, JB Lippincott. Chapman MW, Bucholz R, Cornell CN: Treatment of acute fractures with a collagen calcium phosphate graft material: a randomized clinical trial, J Bone Joint Surg 79A:495, 1997. Cole WH: The treatment of claw-foot, J Bone Joint Surg 22:895, 1940. Colterjohn NR, Bednar DA: Procurement of bone graft from the iliac crest, J Bone Joint Surg 79A:756, 1997. Cornell CN: Initial clinical experience with use of Collagraft as a bone graft substitute, Tech Orthop 7:55, 1992. Coventry MB, Tapper EM: Pelvic instability: a consequence of removing iliac bone for grafting, J Bone Joint Surg 54A:83, 1972. Crenshaw AG, Hargens AR, Gershuni DH, et al.: Wide tourniquet cuffs more effective at lower inflation pressures, Acta Orthop Scand 59:447, 1988. DeLong WG, Einhorn TA, Koval K, et  al.: Current concepts review. Bone grafts and bone graft substitutes in orthopaedic trauma surgery: a critical analysis, J Bone Joint Surg 89A:649, 2007. Dick W: Use of the acetabular reamer to harvest autogeneic bone graft material: a simple method for producing bone past, Arch Orthop Trauma Surg 105:235, 1986. Dirschl DR, Wilson FC: Topical antibiotic irrigation in the prophylaxis of operative wound infections in orthopedic surgery, Orthop Clin North Am 22:419, 1991. Enneking WF, Mindell ER: Observations on massive retrieved human allografts, J Bone Joint Surg 73A:1123, 1991. Flynn JM, Springfield DS, Mankin HJ: Osteoarticular allografts to treat distal femoral osteonecrosis, Clin Orthop Relat Res 303:38, 1994. Friedlaender GE: Current concepts review. Bone grafts: the basic science rationale for clinical applications, J Bone Joint Surg 69:786, 1987. Friedlaender GE, Tomford W, Galloway M, et al.: Tissue transplantation. In Starzl TE, Shapiro R, Simmons RL, editors: Atlas of organ transplantation, New York, 1992, Raven Press. Friedman RJ, Friedrich LV, White RL, et al.: Antibiotic prophylaxis and tourniquet inflation in total knee arthroplasty, Clin Orthop Relat Res 260:17, 1990. Friedrich LV, White RL, Brundage DM, et  al.: The effect of tourniquet inflation on cefazolin tissue penetration during total knee arthroplasty, Pharmacotherapy 10:373, 1990. Gardiner A, Weitzel PP: Bone graft substitutes in sports medicine, Sports Med Arthrosc 15:158, 2007. Garfin SR, editor: Complications of spine surgery, Baltimore, 1989, Williams & Wilkins. Giori NJ, Sohn DH, Mirza FM, et al.: Bone cement improves suture anchor fixation, Clin Orthop Relat Res 451:256, 2006. Greenwald AS, Boden SD, Goldberg VM, et al.: Bone-graft substitutes: facts, fictions, and applications, J Bone Joint Surg 83A:98, 2001.

Hirota K, Hashimoto H, Kabara S, et al.: The relationship between pneumatic tourniquet time and the amount of pulmonary emboli in patients undergoing knee arthroscopic surgery, Anesth Analg 93:776, 2001. Jones AAM, Dougherty PJ, Sharkey NA, et al.: Iliac crest bone graft: saw versus osteotome, Spine 18:2048, 1993. Kam PC, Lavanagh R, Yoong FF: The arterial tourniquet: pathophysiological consequences and anaesthetic implications, Anaesthesia 56:534, 2001. Khan SN, Cammisa Jr FP, Sandhu HS, et al.: The biology of bone grafting, J Am Acad Orthop Surg 13:77, 2005. Klenerman L, Biswas M, Hulands GH, et al.: Systemic and local effects of the application of a tourniquet, J Bone Joint Surg 62B:385, 1980. Krackow KA, Cohn BT: A new technique for passing tendon through bone: brief note, J Bone Joint Surg 69A:922, 1987. Krackow KA, Thomas SC, Jones LC: Ligament-tendon fixation: analysis of a new stitch and comparison with standard techniques, Orthopedics 11:909, 1988. Kutty S, McElwain JP: Padding under tourniquets in tourniquet controlled surgery: Bruner’s ten rules revisited, Injury 33:75, 2002. Lotem M, Maor P, Haimoff H, et al.: Lumbar hernia at an iliac bone graft donor site: a case report, Clin Orthop Relat Res 80:130, 1971. Meeder PJ, Eggers C: Techniques for obtaining autogenous bone graft, Injury 1(Suppl):5, 1994. Meyer DC, Jacob HAC, Pistoia W, et al.: The use of acrylic bone cement for suture anchoring, Clin Orthop Relat Res 410:295, 2003. Morbidity and Mortality Weekly Report: Transmission of HIV through bone transplantation: case report and public health recommendations, JAMA 260:2487, 1988. Newman JT, Stahel PF, Smith WR, et  al.: A new minimally invasive technique for large volume bone graft harvest for treatment of fracture nonunions, Orthopedics 31:257, 2008. Noordin S, McEwen JA, Kragh Jr JF, et al.: Surgical tourniquets in orthopaedics, J Bone Joint Surg 91A:2958, 2009. Papioannou N, Kalivas L, Kalavritinos J, Tsourvakas S: Tissue concentrations of third-generation cephalosporins (ceftazidime and ceftriaxone) in lower extremity tissues using a tourniquet, Arch Orthop Trauma Surg 113:167, 1994. Parikh SN: Bone graft substitutes in modern orthopedics, Orthopedics 25:1301, 2002. Patterson S, Klenerman L, Biswas M, et  al.: The effect of pneumatic tourniquets on skeletal muscle physiology, Acta Orthop Scand 52:171, 1981. Pedowitz RA, Gershuni DH, Botte MJ, et  al.: The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and integrated cuff inflation system, Clin Orthop Relat Res 287:237, 1993. Rajpura A, Somanchi BV, Muir LTSW: The effect of tourniquet padding on the efficiency of tourniquets of the upper limb, J Bone Joint Surg 89B:532, 2007. Reid HS: Camp RA, Jacob WH: Tourniquet hemostasis: a clinical study, Clin Orthop Relat Res 177:230, 1983. Scarborough NL: Allograft bones and soft tissues: current procedures for banking allograft human bone, Orthopedics 15:1161, 1992. Stevenson S: The immune response to osteochondral allografts in dogs, J Bone Joint Surg 69A:573, 1987. Tingart MJ, Apreleva M, Lehtinen J, et  al.: Anchor design and bone mineral density affect the pull-out strength of suture anchors in rotator cuff repair: which anchors are best to use in patients with low bone quality? Am J Sports Med 32:1466, 2004. Wakai A, Winter DC, Street JT, Redmond PH: Pneumatic tourniquets in extremity surgery, J Am Acad Orthop Surg 9:345, 2001. Wolfe SA, Kawamoto HK: Taking the iliac-bone graft: a new technique, J Bone Joint Surg 60A:411, 1978. Younger ASE, McEwen JA, Inkpen K: Wide contoured cuffs and automated limb occlusion measurement allow lower tourniquet pressures, Clin Orthop Relat Res 428:286, 2004.

SURGICAL APPROACHES: GENERAL Henry AK: Extensile exposure, ed 2, Edinburgh, 1966, E & S Livingstone.

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PART I  GENERAL PRINCIPLES Kocher T: Textbook of operative surgery, Stiles HJ, Paul CB, translators, ed 3, London, 1911, Adam & Charles Black. Kocher T: Chirurgische Operationslehre, Stiles HJ, translator, ed 5, Edinburgh, 1911, Adam & Charles Black.

FOOT AND ANKLE Broomhead R: Discussion on fractures in the region of the ankle joint, Proc R Soc Med 25:1082, 1932. Colonna PC, Ralston EL: Operative approaches to the ankle joint, Am J Surg 82:44, 1951. Gatellier J, Chastang P: Access to fractured malleolus with piece chipped off at back, J Chir 24:513, 1924. Hammit MD, Hobgood ER, Tarquinio TA: Midline posterior approach to the ankle and hindfoot, Foot Ankle Int 27:711, 2006. Hollawell S: Wound closure technique for lateral extensile approach to intraarticular calcaneal fractures, J Am Podiatr Med Assoc 98:422, 2008. Kocher T: Textbook of operative surgery, Stiles HJ, Paul CB, translators, ed 3, London, 1911, Adam & Charles Black. Koenig F, Schaefer P: Osteoplastic surgical exposure of the ankle joint. In Forty-first report of progress in orthopedic surgery, p 17. (Abstracted from Z Chir 215:196, 1929.) Nicola T: Atlas of surgical approaches to bones and joints, New York, 1945, Macmillan. Ollier P: Traite des resections. Paris. Quoted in Steindler A: A textbook of operative orthopedics, New York, 1892, D. Appleton, p 1925.

TIBIA AND FIBULA Banks SW, Laufman H: An atlas of surgical exposures of the extremities, Philadelphia, 1953, WB Saunders. Harmon PH: A simplified surgical approach to the posterior tibia for bonegrafting and fibular transference, J Bone Joint Surg 27:496, 1945. Phemister DB: Treatment of ununited fractures by onlay bone grafts without screw or tie fixation and without breaking down of the fibrous union, J Bone Joint Surg 29:946, 1947. Tochigi Y, Amendola A, Muir D, et al.: Surgical approach for centrolateral talar osteochondral lesions with an anterolateral osteotomy, Foot Ankle Int 23:1038, 2002.

KNEE Abbott LC, Carpenter WF: Surgical approaches to the knee joint, J Bone Joint Surg 27:277, 1945. Bowers AL, Huffman R: Lateral femoral epicondylar osteotomy: an extensile posterolateral knee approach, Clin Orthop Relat Res 466:1671, 2008. Brackett EG, Osgood RB: The popliteal incision for the removal of “joint mice” in the posterior capsule of the knee-joint: a report of cases, Boston Med Surg J 165:975, 1911. Brown CW, Odom Jr JA, Messner DG, et al.: A simplified operative approach for the lateral meniscus, J Sports Med 3:265, 1975. Bruser DM: A direct lateral approach to the lateral compartment of the knee joint, J Bone Joint Surg 42B:348, 1960. Cave EF: Combined anterior-posterior approach to the knee joint, J Bone Joint Surg 17:427, 1935. Charnley J: Horizontal approach to the medial semilunar cartilage, J Bone Joint Surg 30B: 659, 1948. Erkes F: Weitere Erfahrungen mit physiologischer Schnitt führung zur eröffnung des Kniegelenks, Bruns Beitr zur Klin Chir 147:221, 1929. Fakler JKM, Ryzewicz M, Hartshorn C, et al.: Optimizing the management of Moore type I posteromedial split fracture dislocations of the tibial head: description of the Lobenhoffer approach, J Orthop Trauma 21:330, 2007. Fernandez DL: Anterior approach to the knee with osteotomy of the tibial tubercle for bicondylar tibial fractures, J Bone Joint Surg 70A:208, 1988. Galla M, Lobenhoffer P: [The direct, dorsal approach to the treatment of unstable tibial posteromedial fracture-dislocations], Unfallchirurg 106:241, 2003. In German. Gossling HR, Peterson CA: A new surgical approach in the treatment of depressed lateral condylar fractures of the tibia, Clin Orthop Relat Res 140:96, 1979.

Henderson MS: Posterolateral incision for the removal of loose bodies from the posterior compartment of the knee joint, Surg Gynecol Obstet 33:698, 1921. Hofmann AA, Plaster RL, Murdock LE: Subvastus (Southern) approach for primary total knee arthroplasty, Clin Orthop Relat Res 269:70, 1991. Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach, Philadelphia, 2003, Lippincott Williams & Wilkins2003. Hughston JC, Jacobson KE: Chronic posterolateral rotatory instability of the knee, J Bone Joint Surg 67A:351, 1985. In Y, Kim JM, Choi NY, Kim SJ: Large thigh girth is a relative contraindication for the subvastus approach in primary total knee arthroplasty, J Arthroplasty 22:569–573, 2007. Kaplan EB: Surgical approach to the lateral (peroneal) side of the knee joint, Surg Gynecol Obstet 104:346, 1957. Keblish PA: The lateral approach. In Scuderi GR, Trialr AJ, editors: Surgical techniques in total knee arthroplasty, New York, 2002, Springer. Kocher T: Textbook of operative surgery, Stiles HJ, Paul CB, translators, ed 3, London, 1911, Adam & Charles Black1911. Liebergall M, Wilber JH, Mosheiff R, Segal D: Gerdy’s tubercle osteotomy for the treatment of coronal fractures of the lateral femoral condyle, J Orthop Trauma 14:214, 2000. Lobenhoffer P, Gerich T, Bertram T, et  al.: Particular posteromedial and posterolateral approaches for the treatment of tibial head fractures [in German], Unfallchirurg 100:957, 1997. Minkoff J, Jaffe L, Menendez L: Limited posterolateral surgical approach to the knee for excision of osteoid osteoma, Clin Orthop Relat Res 223:237, 1987. Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ: Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes, J Orthop Trauma 22:317, 2008. Perry CR, Evans LG, Fogarty J, et al.: A new surgical approach to fractures of the lateral tibial plateau, J Bone Joint Surg 66:1236, 1984. Putti V: Arthroplasty of the knee joint, J Orthop Surg 2:530, 1920.

HIP Pavlanski R: Modification of the Zahradnicek-Leveuf procedure in the case of subdislocating coxa valga with anteversion, Ref Chir Orthop Reparatrice Appar Mot 57(Suppl 1):185, 1971. von Langenbeck B: Über die Schussverletzungen des Huftgelenks, Arch Klin Chir 16:263, 1874.

ACETABULUM AND PELVIS Darmanis S, Lewis A, Mansoor A, Bircher M: Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum, Clin Anat 20:433, 2007.

FEMUR Bosworth DM: Posterior approach to the femur, J Bone Joint Surg 26:687, 1944. Henry AK: Exposure of the humerus and femoral shaft, Br J Surg 12:84, 1924-1925. Thompson JE: Anatomical methods of approach in operations on the long bones of the extremities, Ann Surg 68:309, 1918.

HIP Brackett E: A study of the different approaches to the hip joint, with special reference to the operations for curved trochanteric osteotomy and for arthrodesis, Boston Med Surg J 166:235, 1912. Carnesale PG: Personal communication, 1977. Charnley J, Ferriera A, De SO: Transplantation of the greater trochanter in arthroplasty of the hip, J Bone Joint Surg 46B:191, 1964. Ferguson Jr AB: Primary open reduction of congenital dislocation of the hip using a median adductor approach, J Bone Joint Surg 55A:671, 1973. Frndak PA, Mallory TH, Lombardi AV: Translateral surgical approach to the hip: the abductor muscle “split, Clin Orthop Relat Res 295:135, 1993. Gibson A: The posterolateral approach to the hip joint, AAOS Instr Course Lect 10:175, 1953.

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CHAPTER 1  SURGICAL TECHNIQUES Hardinge K: The direct lateral approach to the hip, J Bone Joint Surg 64B:17, 1982. Harris WH: A new lateral approach to the hip joint, J Bone Joint Surg 49A:891, 1967. Harris WH: Extensive exposure of the hip joint, Clin Orthop Relat Res 91:58, 1973. Henry AK: Exposures of long bones and other surgical methods, Bristol, England, 1927, John Wright & Sons. Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach, Philadelphia, 2003, Lippincott Williams & Wilkins. Kocher T: Textbook of operative surgery, Stiles HJ, Paul CB, translators, ed 3, London, 1911, Adam & Charles Black. Letournel E: Les fractures du cotyle: étude d’une série de 75 cas, J Chir 82:47, 1961. Letournel E, Judet R: Fractures of the acetabulum, New York, 1981, Springer. Ludloff K: Zur blutigen Einrenkung der angeborenen Huftluxation, Z Orthop Chir 22:272, 1908. Mallon WJ, Fitch RD: The medial approach to the hip revisited, Orthopedics 16:39, 1993. Marcy GH, Fletcher RS: Modification of the posterolateral approach to the hip for insertion of femoral-head prosthesis, J Bone Joint Surg 36A:142, 1954. Matta JM: Anterior exposure with the ilioinguinal approach. In Mears DC, Rubash HE, editors: Pelvic and acetabular fractures, Thorofare, NJ, 1986, Slack. McFarland B, Osborne G: Approach to the hip: a suggested improvement on Kocher’s method, J Bone Joint Surg 36B:364, 1954. McLauchlan J: The Stracathro approach to the hip, J Bone Joint Surg 66B:30, 1984. Mears DC, Rubash HE: Extensile exposure of the pelvis, Contemp Orthop 6:21, 1983. Mears DC, Rubash HE, editors: Pelvic and acetabular fractures, Thorofare, NJ, 1986, Slack. Moore AT: The self-locking metal hip prosthesis, J Bone Joint Surg 39A:811, 1957. Moore AT: The Moore self-locking Vitallium prosthesis in fresh femoral neck fractures: a new low posterior approach (the southern exposure), AAOS Instr Course Lect 16:309, 1959. Nork SE, Schär M, Pfander G, et al.: Anatomic considerations for the choice of surgical approach for hip resurfacing arthroplasty, Orthop Clin North Am 36:163, 2005. Osborne RP: The approach to the hip-joint: a critical review and a suggested new route, Br J Surg 18:49, 1930-1931. Reinert CM, Bosse MJ, Poka A, et al.: A modified extensile exposure for the treatment of complex or malunited acetabular fractures, J Bone Joint Surg 70A:329, 1988. Schaubel HJ: Modification of the anterior iliofemoral approach to the hip, Int Surg 65:347, 1980. Smith-Petersen MN: A new supra-articular subperiosteal approach to the hip joint, Am J Orthop Surg 15:592, 1917. Smith-Petersen MN: Approach to and exposure of the hip joint for mold arthroplasty, J Bone Joint Surg 31A:40, 1949. Somerville EW: Open reduction in congenital dislocation of the hip, J Bone Joint Surg 35B:363, 1953. Testa NN, Mazur KU: Heterotopic ossification after direct lateral approach and transtrochanteric approach to the hip, Orthop Rev 17:965, 1988. von Langenbeck B: Über die Schussverletzungen des Huftgelenks, Arch Klin Chir 16:263, 1874. Watson-Jones R: Fractures of the neck of the femur, Br J Surg 23:787, 1935-1936. Zahradnicek J: Guiding principles of a method of therapy of congenital hip dislocation, Ortop Travmatol Protez 20:65, 1959.

SYMPHYSIS PUBIS Pfannenstiel HJ: Über die Vorteile des suprasymphysären Fascienquerschnitt für die gynaekologischen Koeliotomien, Samml Klin Vortr Gynaekol (Leipzig) 268:1735, 1900.

SACROILIAC JOINT Avila Jr L: Primary pyogenic infection of the sacro-iliac articulation: a new approach to the joint, J Bone Joint Surg 23:922, 1941. Mears DC, Rubash HE, editors: Pelvic and acetabular fractures, Thorofare, NJ, 1986, Slack.

SHOULDER Leslie Jr JT, Ryan TJ: The anterior axillary incision to approach the shoulder joint, J Bone Joint Surg 44A:1193, 1962. Lewicky YM, Sheppard JE, Ruth JT: The combined olecranon osteotomy, lateral paratricipital sparing, deltoid insertion splitting approach for concomitant distal intra-articular and humeral shaft fractures, J Orthop Trauma 21:133, 2007.

ACROMIOCLAVICULAR JOINT Abbott LC, Lucas DB: The tripartite deltoid and its surgical significance in exposure of the scapulohumeral joint, Ann Surg 136:392, 1952. Armstrong JR: Excision of the acromion in treatment of the supraspinatus syndrome: report of ninety-five excisions, J Bone Joint Surg 31B:436, 1949. Bennett GE: Shoulder and elbow lesions of professional baseball pitcher, JAMA 117:510, 1941. Brodsky JW, Tullos HS, Gartsman GM: Simplified posterior approach to the shoulder joint: a technical note, J Bone Joint Surg 71A:407, 1989. Cubbins WR, Callahan JJ, Scuderi CS: The reduction of old or irreducible dislocations of the shoulder joint, Surg Gynecol Obstet 58:129, 1934. Darrach W: Surgical approaches for surgery of the extremities, Am J Surg 67:237, 1945. Gardner MJ, Griffith MH, Dines JS, et al.: The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus, Clin Orthop Relat Res 434:123, 2005. Harmon PH: A posterior approach for arthrodesis and other operations on the shoulder, Surg Gynecol Obstet 81:266, 1945. Henry AK: Exposures of long bones and other surgical methods, Bristol, England, 1927, John Wright & Sons. Karachalios T, Bargiotas K, Papachristos A, Malizos KN: Reconstruction of a neglected posterior dislocation of the shoulder through a limited posterior deltoid-splitting approach, J Bone Joint Surg 87A:630, 2005. Kuz JE, Pierce TD, Braunohler WB: Coronal transacromial osteotomy surgical approach for shoulder arthroplasty, Orthopedics 21:155, 1998. McLaughlin HL: Lesions of the musculotendinous cuff of the shoulder: I. The exposure and treatment of tears with retraction, J Bone Joint Surg 26:31, 1944. McWhorter GL: Fracture of the greater tuberosity of the humerus with displacement: report of two operated cases with author’s technic of shoulder incision, Surg Clin North Am 5:1005, 1925. Roberts SM: Acromioclavicular dislocation, Am J Surg 23:322, 1934. Rowe CR, Yee LBK: A posterior approach to the shoulder joint, J Bone Joint Surg 26:580, 1944. Thompson JE: Anatomical methods of approach in operations on the long bones of the extremities, Ann Surg 68:309, 1918. Wirth MA, Butters KP, Rockwood Jr CA: The posterior deltoid-splitting approach to the shoulder, Clin Orthop Relat Res 296:92, 1993.

HUMERUS Bain GI, Mehta JA: Anatomy of the elbow joint and surgical approaches. In Baker Jr CL, Plancher KD, editors: Operative strategies of the elbow, New York, 2001, Springer. Berger RA, Buckwalter JA: A posterior surgical approach to the proximal part of the humerus, J Bone Joint Surg 71A:407, 1989. Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: a tricepssparing approach, Clin Orthop Relat Res 166:188, 1982. Cadenat FM: Les vois de penetration des members, Paris, 1932, Membre Superieur. Campbell WC: Incision for exposure of the elbow joint, Am J Surg 15:65, 1932. Ewald FC, Scheinberg RD, Poss R, et  al.: Capitellocondylar total elbow arthroplasty: two to five year followup in rheumatoid arthritis, J Bone Joint Surg 62A:1239, 1980.

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PART I  GENERAL PRINCIPLES Henry AK: Exposure of the humerus and femoral shaft, Br J Surg 12:84, 1924-1925. Hotchkiss R: Compass universal hinge: surgical technique, Memphis, TN, 1998, Smith and Nephew. Kaplan EB: Surgical approach to the proximal end of the radius and its use in fractures of the head and neck of the radius, J Bone Joint Surg 23:86, 1941. Key JA, Conwell HE: The management of fractures, dislocations, and sprains, ed 2, St. Louis, 1937, Mosby. King A, Johnston GH: A modification of Henry’s anterior approach to the humerus, J Shoulder Elbow Surg 7:210, 1998. Kocher T: Textbook of operative surgery, Stiles HJ, Paul CB, translators, ed 3, London, 1911, Adam & Charles Black. MacAusland WR: Ankylosis of the elbow: with report of four cases treated by arthroplasty, JAMA 64:312, 1915. Mehta JA, Bain GI: Surgical approaches to the elbow, Hand Clin 20:375, 2004. Molesworth WHL: Operation for complete exposure of the elbow joint, Br J Surg 18:303, 1930. Moran MC: Modified lateral approach to the distal humerus for internal fixation, Clin Orthop Relat Res 340:190, 1997. Müller ME, Allgöwer M, Schneider R, et  al.: Manual of internal fixation: techniques recommended by the AO-ASIF group, ed 3, Berlin, 1991, Springer.

Patterson SO, Bain GI, Mehta JA: Surgical approaches to the elbow, Clin Orthop Relat Res 370:19, 2000. Thompson JE: Anatomical methods of approach in operations on the long bones of the extremities, Ann Surg 68:309, 1918. Wadsworth TG: A modified posterolateral approach to the elbow and proximal radioulnar joints, Clin Orthop Relat Res 144:151, 1979. Wilkinson JM, Stanley D: Posterior surgical approaches to the elbow: a comparative anatomic study, J Shoulder Elbow Surg 10:380, 2001.

RADIUS Henry AK: Exposures of long bones and other surgical methods, Bristol, England, 1927, John Wright & Sons. Strachan JCH, Ellis BW: Vulnerability of the posterior interosseous nerve during radial head resection, J Bone Joint Surg 53:320, 1971.

ULNA Boyd HB: Surgical exposure of the ulna and proximal third of the radius through one incision, Surg Gynecol Obstet 71:86, 1940.

WRIST Smith-Petersen MN: A new approach to the wrist joint, J Bone Joint Surg 22:122, 1940.

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ADVANCED IMAGING IN ORTHOPAEDICS Dexter H. Witte III

MAGNETIC RESONANCE IMAGING MRI TECHNOLOGY AND TECHNIQUE CONTRAINDICATIONS CONTRAST AGENTS IN MRI FOOT AND ANKLE Tendon injuries Ligament injuries Osseous injuries Other disorders of foot and ankle KNEE Pathologic conditions of menisci Cruciate ligament injury Other knee problems

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HIP Osteonecrosis Transient osteoporosis Trauma SPINE Intervertebral disc disease Postoperative back pain Spinal tumors Spinal trauma SHOULDER Pathologic conditions of the rotator cuff Impingement syndromes Pathologic conditions of labrum Other causes of shoulder pain

Although routine radiography currently remains the primary imaging modality in orthopaedics, more advanced imaging techniques are now an integral part of the modern orthopaedic practice. Modalities such as magnetic resonance imaging (MRI), computed tomography (CT), and ultrasonography (US) are valuable diagnostic tools and are fundamental components of image-guided interventional procedures. The scope of these advanced imaging techniques across the field of orthopaedics is far too broad to address in a single chapter. Therefore, this chapter provides a brief synopsis of the use of MRI and CT in orthopaedics. Musculoskeletal US is reviewed in various chapters as appropriate.

MAGNETIC RESONANCE IMAGING Aside from routine radiography, no imaging modality has as great an impact on the current practice of orthopaedics as MRI. MRI provides unsurpassed soft-tissue contrast and multiplanar capability with spatial resolution that approaches that of CT. Consequently, MRI has superseded older imaging methods such as myelography, arthrography, and even angiography. In the past 40 years, MRI has matured to become a critical component of the modern orthopaedic practice. Unlike radiography or CT, the MR image is generated without the use of potentially harmful ionizing radiation. MR images are created by placing the patient in a strong magnetic field (tens of thousands of times stronger than the earth’s magnetic field). The magnetic force affects the nuclei within the field, specifically the nuclei of elements with odd numbers of protons or neutrons. The most abundant element satisfying this criterion is hydrogen, which is plentiful in water and fat. These nuclei, which are essentially protons, possess a quantum spin. When the patient’s tissues are subjected to

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WRIST AND ELBOW Carpal ligament disruptions Other pathologic conditions of hand and wrist ELBOW TUMOR IMAGING COMPUTED TOMOGRAPHY CT technology and technique Trauma Developmental skeletal pathology Arthropathy Tumor evaluation CONCLUSION

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this strong magnetic field, protons align themselves with respect to the field. Because all imaging is performed within this constant magnetic force, this becomes the steady state, or equilibrium. In this steady state, a radiofrequency (RF) pulse is applied, which excites the magnetized protons in the field and perturbs the steady state. After application of this pulse, a receiver coil or antenna listens for an emitted RF signal that is generated as these excited protons relax or return to equilibrium. This emitted signal is then used to create the MR image. 

MRI TECHNOLOGY AND TECHNIQUE A wide variety of MR imaging systems are commercially available. Scanners can be grouped roughly by field strength. Highfield scanners possess superconducting magnets considered to have field strengths greater than 1.0 Tesla (T). Low-field scanners operate at field strengths of 0.3 to 0.7 T. Ultra lowfield scanners operate below 0.1 T but are generally limited to studying the appendicular anatomy. The strength of the magnetic field directly correlates with the signal available to create the MR image. High-field scanners generate higher signal-tonoise images, allowing shorter scanning times, thinner scan slices, and smaller fields of view. At lower field strengths, scan field of view or slice thickness must be increased or imaging time lengthened to compensate for lower signal. In the past, lower field strength scanners presented the advantage of an “open” bore, which helped minimize claustrophobia and allow for more comfortable patient positioning when imaging offaxis structures such as elbows and wrists. However, currentgeneration high-field scanners have bores of larger diameter and shorter length, thus eliminating this low-field advantage.

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B FIGURE 2.1 Chemical shift fat-suppression technique. A, Axial fast spin-echo, T2-weighted image of large soft-tissue mass in calf. Hyperintense fat blends with anterior and posterior margins of lesion. B, Addition of fat suppression allows for better delineation of tumor margins.

Powerful 3 T scanners have become commercially available in the past several years. Although high-quality musculoskeletal imaging can be performed at 1.5 T, these 3.0 T scanners may be valuable when evaluating small body parts and may provide better image quality in larger patients. At present, the clinical applications of 7 T scanners are being studied at many research centers. Although an image can be acquired in the main coil (the hollow tube in which the patient lies during the study), almost all MR images are acquired with a separate receiving coil. For evaluation of smaller articular structures, such as the menisci of the knee or the rotator cuff, specialized surface coils are mandatory. Several types of surface coils are available, including coils tailored for specific body parts such as the spine, shoulder, wrist, and temporomandibular joints, as well as versatile flexible coils and circumferential extremity coils. These coils serve as antennae placed close to the joint or limb, markedly improving signal and resolution but also limiting the volume of tissue that can be imaged. Thus, larger surface coils have been developed with phased-array technology, providing the improved signal that is seen in smaller coils with an expanded coverage area. These phased-array coils are available for the knee, shoulder, and torso and are now standard on most state-of-the-art scanners. Optimal coil selection is mandatory for high-quality imaging of joints or small parts. Although all studies involve magnetization and RF signals, the method and timing of excitation and acquisition of the signal can be varied to affect the signal intensity of the various tissues in the volume. Musculoskeletal MRI examinations primarily use spin-echo technique, which produces T1-weighted, proton (spin) density, and T2-weighted images. T1 and T2 are tissue-specific characteristics. These values reflect measurements of the rate of relaxation to the steady state. By varying the timing of the application of RF pulses (TR, or repetition time) and the timing of acquisition of the returning signal (TE, or echo time), an imaging sequence can accentuate T1 or T2 tissue characteristics. In most cases, fat has a high signal (bright) on T1-weighted images and fluid has a high signal on T2-weighted images. Structures with little water or fat, such as cortical bone, tendons, and ligaments, are

hypointense (dark) in all types of sequences. Improvements in MR techniques have allowed for much faster imaging. Shorter imaging sequences are better tolerated by patients and allow for less motion artifact. One such improvement, fast spinecho technique, reduces the length of T2-weighted sequences by two thirds or more. Fat signal in fast spin-echo images remains fairly intense, a problem that can be eliminated by chemical-shift fat-suppression techniques (Fig. 2.1). Fat suppression also can be achieved by using a short-tau inversion recovery (STIR) sequence. These fat-suppression techniques can be useful in the detection of edema in both bone marrow and soft tissue and therefore play an important role in the imaging of trauma and neoplasms. For simplicity, imaging series, whether acquired with chemical shift or inversion recovery fat-suppression techniques, are often referred to as “fluid-sensitive” sequences. Another fast imaging method, gradient-echo technique, is more widely used in nonorthopaedic imaging such as MR angiography. The short echo times available with this technique are helpful in minimizing cerebrospinal fluid flow artifacts in cervical spine studies. Gradient echo imaging can be used to generate isovolumetric images that permit multiplanar image reconstruction. These reconstructed images can be used to more accurately assess glenoid bone loss following shoulder dislocation or to evaluate acetabular or femoral head morphology in patients with dysplasia or impingement. Most musculoskeletal MR studies are composed of a number of imaging sequences or series, tailored to detect and define a certain pathologic process. Because the imaging planes (axial, sagittal, coronal, oblique) and the sequence type (T1, T2, gradient-echo) are chosen at the outset, advanced understanding of the clinical problem is required to perform high-quality imaging. 

CONTRAINDICATIONS Some patients are not candidates for MRI. Absolute contraindications to MRI include intracerebral aneurysm clips, automatic defibrillators, internal hearing aids, and metallic orbital foreign bodies. Older cardiac pacemakers generally are not approved for MR imaging; however, a new generation

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FIGURE 2.2 Magnetic resonance imaging with orthopaedic hardware in a patient with metastatic lung disease. A, Lateral radiograph of the proximal femur shows a subtle lesion in the posterior cortex adjacent to the femoral component of a titanium total hip prosthesis (arrow). B, Fat-suppressed inversion recovery image displays a metastasis immediately adjacent to the hardware (arrow). Note that minimal artifact is generated by the titanium stem.

of MRI-compatible pacemakers has been developed. Cardiac valve prostheses can be safely scanned. Relative contraindications include first-trimester pregnancy and recently placed intravascular stents. Generally, internal orthopaedic hardware and orthopaedic prostheses are safe to scan, although ferrous metals can create local artifact that can obscure adjacent tissues. Severity of metal artifact depends on hardware bulk, orientation, and material. For example, titanium prostheses generate much less artifact than stainless steel (Fig. 2.2). Certain adjustments to the scan parameters may reduce, but not eliminate, metal artifact. In fact, newly developed imaging sequences are proving useful for detection of periprosthetic bone resorption and soft-tissue masses. Metal prostheses may also become warm during the examination, although this is rarely noticed by the patient and almost never requires termination of the study. Patients with metal external fixation devices should not be scanned. If there is a question regarding the MR compatibility of an implantable device (e.g., pain stimulator, infusion pump), the manufacturer should be consulted. 

CONTRAST AGENTS IN MRI As elsewhere in the body, the administration of gadolinium contrast material can be of great value in evaluating certain musculoskeletal conditions. MR contrast agents are composed of gadolinium ions that are tightly bound to complex macromolecules. These agents can be administered intravenously or intraarticularly with high degree of safety. Normally MR contrast is rapidly filtered and excreted by the kidneys. As opposed to iodinated contrast material used in CT, gadolinium contrast agents are not nephrotoxic. In patients with significantly impaired renal function, however, delayed excretion of gadolinium has been associated with a rare connective tissue disease, nephrogenic systemic fibrosis. The incidence of this complication actually varies with the type of gadolinium macromolecule utilized, and these agents should be administered with caution in patients with acute or chronic kidney disease (stage 4 or 5). 

FOOT AND ANKLE One of the more complex anatomic regions in the human body is the foot and ankle. The complexity of midfoot and hindfoot articulations and the variety of pathologic conditions in the tendons and ligaments make evaluation difficult from a clinical and imaging perspective. Most examinations of the foot and ankle are performed to evaluate tendinopathy, articular disorders, and osseous pathologic conditions, often after trauma. MRI can be quite useful when the examination is directed at solving a certain clinical problem, but its value as a screening study for nonspecific pain is more limited. Given the small size of structures to be examined, optimal imaging is achieved on a high field strength magnet, and the use of a surface coil, typically an extremity coil, is mandatory. Ideally, the clinical presentation will allow the examination to be directed at either the forefoot or ankle/hindfoot. This arbitrary division allows for a sufficiently small field of view (10 to 12 cm) to generate high-resolution images. Images can be prescribed in orthogonal or oblique planes, with combinations of T1-weighted, T2-weighted, and fat-suppressed sequences. The examination should be tailored to best define the clinically suspected problem.

TENDON INJURIES

MRI excels in the evaluation of pathologic conditions in the numerous tendons about the ankle joint. Most commonly affected are the calcaneal and posterior tibial tendons. In chronic tendinitis, the calcaneal tendon thickens and becomes oval or circular in cross-section. The pathologically enlarged tendon maintains low signal on all sequences. When partially torn, the tendon demonstrates focal or fusiform thickening with interspersed areas of edema or hemorrhage that brighten on T2-weighted series (Fig. 2.3). With complete rupture, there is discontinuity of the tendon fibers. Similarly, abnormalities of the posterior tibial tendon can be confidently diagnosed with MRI. Increased fluid in the sheath of the tendon indicates tenosynovitis. Insufficient or ruptured tendons

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B FIGURE 2.3 Partial tear of calcaneal tendon. A, Sagittal T1-weighted image demonstrates markedly thickened calcaneal tendon containing areas of intermediate signal (arrow). B, Sagittal fat-suppressed, T2-weighted image exhibits fluid within tendon substance, indicating partial tear (arrow).

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FIGURE 2.4 Posterior tibial tendon tear. A, Axial T1-weighted image reveals swollen, illdefined region of intermediate signal intensity, representing fluid and abnormal tendon (arrow). B, Axial fat-suppressed, T2-weighted image shows thickened tendon (arrow) surrounded by hyperintense fluid.

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FIGURE 2.5 Peroneus longus tendon rupture. A, Coronal T1-weighted image through midfoot shows increased diameter of peroneus longus tendon (arrows). B, Coronal fat-suppressed, T2-weighted image reveals fluid signal within ruptured tendon (arrow).

LIGAMENT INJURIES

The medial and lateral stabilizing ligaments of the tibiotalar and talocalcaneal joints and the distal tibiofibular ligaments are well-visualized with proper positioning of the foot. Although ligamentous injuries about the ankle are common, MRI has a limited role in the evaluation of acute injury. In the acute setting, the MRI examination is helpful in detecting associated occult osteochondral injury. In patients with chronic instability, MRI can provide useful information of the integrity of the lateral ligamentous complex, tibiofibular ligaments, and tibiofibular syndesmosis. Additionally, MRI has proven useful in evaluating the lateral recess of the ankle joint in patients with impingement. Regions of fibrosis associated with anterolateral impingement are identified in the lateral gutter, especially when fluid is present in the ankle joint. 

OSSEOUS INJURIES

FIGURE 2.6 Longitudinal split tear of the peroneus brevis tendon. T1-weighted axial image at the level of the ankle joint shows a longitudinal split of the peroneus brevis tendon (arrow) between the lateral malleolus anteriorly and the peroneus longus tendon posteriorly.

can appear thickened, attenuated, or even discontinuous (Fig. 2.4). Similar abnormalities are often seen in the flexor tendons or peroneus tendons (Fig. 2.5). Longitudinal splitting of the peroneus tendon is usually quite well displayed on axial MRI images (Fig. 2.6). 

As with the rest of the skeleton, MRI is especially well-suited for evaluating occult bone pathology in the foot and ankle. MRI is often used to evaluate patients with heel pain, where the differential diagnosis includes both stress fracture and plantar fasciitis. Stress fractures are depicted as areas of marrow edema well before radiographic changes are apparent (Fig. 2.7). MRI is as sensitive as bone scintigraphy while providing greater anatomic detail and specificity. The multiplanar capability of MRI is useful in assessing the ankle and subtalar joints. With high-quality imaging, excellent characterization of osteochondral lesions of the talus can be useful in surgical planning. Hepple et al. developed a classification of osteochondral lesions of the talus based on the MRI appearance. Lesion stability can be inferred by inspection of the overlying articular cartilage and the underlying osseous interface (Fig. 2.8). CT plays a complementary role to MRI if osseous avulsions or tiny intraarticular calcifications are suspected.

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B FIGURE 2.7 Calcaneal stress fracture. A, Sagittal fat-suppressed T2-weighted image through the hindfoot shows hyperintense marrow edema in the calcaneal tuberosity. B, Sagittal T1-weighted image at the same location clearly demonstrates a linear hypointense fracture line (arrow).

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FIGURE 2.8 Osteochondritis dissecans of talus in college football player. A, Coronal T1-weighted image shows osteochondral fragment in medial talar dome. Loss of fat signal suggests sclerosis or fibrosis (arrow). B, Coronal fat-suppressed, T2-weighted image demonstrates fluid signal between lesion and host bone (arrowheads), indicating unstable fragment. C, Coronal fatsuppressed, spoiled gradient-echo technique reveals abnormal decreased signal (arrow) in overlying articular cartilage, indicating defect confirmed by arthroscopy.

Other pathologic marrow processes such as osteonecrosis and tumors can be evaluated as well. 

OTHER DISORDERS OF FOOT AND ANKLE

MRI has become an increasingly useful tool in the workup of forefoot pathology. Studies can be designed specifically to evaluate the metatarsals and phalanges and adjacent joints. Focused imaging of the metatarsophalangeal joints can detect sesamoid pathology and plantar plate injuries. MRI is a fundamental tool in the workup of a patient with a soft-tissue

or bone tumor. The excellent multiplanar anatomic information provided by MRI allows detection and definition of masses in the foot. Interdigital or Morton neuroma is most frequently found in the distal third metatarsal interspace. Unlike most other tumors, this lesion lacks increased signal on T2-weighted sequences. Another common foot mass, plantar fibroma or plantar fibromatosis, usually is quite easily confirmed by the presence of signal-poor mass arising from the plantar fascia. The MRI evaluation of other neoplasms is discussed later in this chapter.

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B FIGURE 2.9 Osteomyelitis of calcaneus. A, Sagittal T1-weighted image shows abnormal hypointense marrow signal throughout the posterior calcaneus (arrow). B, Sagittal fat-suppressed T2-weighted image shows subcortical marrow edema consistent with osteomyelitis. Note the overlying soft-tissue ulcer (arrowhead).

MRI also is a valuable imaging modality in the evaluation of patients with suspected bone or soft-tissue infection. Because of the excellent depiction of bone marrow, osteomyelitis can be detected quite early, certainly well before radiographic abnormalities are visible (Fig. 2.9). The anatomic information provided by MRI can assist in surgical planning by defining the extent of bone involvement. Certain fat-suppressed sequences are so sensitive that reactive marrow edema (osteitis) can be seen even before frank osteomyelitis. Although the sensitivity of MRI for osteomyelitis approaches 100%, the reported specificity is less. Some authors have suggested relying on T1-weighted marrow replacement rather than T2-weighted signal abnormality (edema) to increase specificity. In neuropathic patients, the specificity of MR signal abnormalities is reduced; therefore the current workup of osteomyelitis in the diabetic foot often involves a combination of scintigraphy, MRI, laboratory data, and especially physical examination. In almost all cases of pedal osteomyelitis, osseous involvement is secondary to spread from adjacent soft-tissue infection and ulceration. Conversely, the presence of bone marrow signal abnormalities in the absence of a regional soft-tissue wound strongly favors neuropathic disease rather than osteomyelitis. For the evaluation of surrounding soft-tissue infection, MRI is the modality of choice. The addition of contrast-enhanced sequences is helpful in defining nonenhancing fluid collections/abscesses and devascularized or gangrenous tissue. Although the diabetic foot can be a diagnostic challenge, normal MRI marrow signal confidently excludes osteomyelitis. 

KNEE The knee is the most frequently studied region of the appendicular skeleton. Standard extremity coils allow high-resolution images of the commonly injured internal structures of the

joint. The routine MRI examination of the knee consists of spin-echo sequences obtained in sagittal, coronal, and usually axial planes. Most examiners prefer to evaluate the menisci on sagittal proton (spin) density–weighted images. The sagittal images are prescribed in a plane parallel to the course of the anterior cruciate ligament (ACL), approximately 15 degrees internally rotated to the true sagittal plane. Coronal images are useful in evaluating medial and lateral supporting structures. The patellofemoral joint is best studied in the axial plane.

PATHOLOGIC CONDITIONS OF MENISCI

A large percentage of knee pain or disability is caused by pathologic conditions of the menisci. The menisci are composed of fibrocartilage and appear as low-signal structures on all pulse sequences. The menisci are best studied in the sagittal and coronal planes. On sagittal images, the menisci appear as dark triangles in the central portion of the joint and assume a “bow tie” configuration at the periphery of the joint. Regions of increased signal can often be seen within the normally dark fibrocartilage of the menisci. Areas of abnormal hyperintense signal may or may not communicate with a meniscal articular surface. Noncommunicating signal changes correspond to areas of mucoid degeneration that are not visible arthroscopically. Conversely, abnormalities that extend to the meniscal articular surface represent tears (Figs. 2.10 to 2.12). Although it has been suggested that noncommunicating signal or mucoid changes progress to meniscal tears, follow-up examinations have not confirmed this progression. Generally, communicating signal abnormalities that are seen on only one image should not be considered tears unless there is associated anatomic distortion of the meniscus. Meniscal tears should be defined as to location (anterior horn, body, posterior horn, free edge, or periphery) and orientation (horizontal, vertical/longitudinal, radial, complex).

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FIGURE 2.10 Meniscal tear. Sagittal fat-suppressed proton density–weighted image demonstrates linear increased signal traversing posterior horn of medial meniscus, indicating horizontal oblique tear (arrow).

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FIGURE 2.12 Meniscal cyst. Sagittal fat-suppressed, proton density–weighted image of knee shows a hyperintense meniscal cyst (straight arrow) adjacent to medial meniscus. Associated tear is present in inferior articular surface of meniscus (curved arrow).

FIGURE 2.11 Meniscal tear. Sagittal proton density–weighted image reveals small defect in free edge of body of lateral meniscus, indicating radial tear (arrow).

FIGURE 2.13 Root ligament tear of the posterior horn of the medial meniscus. Coronal fat-suppressed proton density-weighted image demonstrates a fluid-filled defect (arrow) in the posterior horn of the medial meniscus at the root ligament.

Relatively common and particularly debilitating in elderly patients, radial tears of the posterior horn or posterior root ligament of the medial meniscus are best seen on far posterior coronal images (Fig. 2.13). These root ligament injuries allow for peripheral meniscal displacement and frequently are associated with subchondral stress or insufficiency fractures of the medial compartment. Complications of tears, such as displaced fragments (bucket-handle tears, inferiorly

displaced medial fragment), should be suspected when the orthotopic portion of the meniscus is small or truncated. Careful examination of the joint, often in the coronal plane, will reveal the displaced, hypointense meniscal fragment (Figs. 2.14 and 2.15). The sensitivity and specificity of MRI in detecting meniscal tears routinely exceed 90%. Studies have shown that many factors affect the accuracy of MRI with respect to meniscal evaluation, including the

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B FIGURE 2.14 Bucket handle tear of medial meniscus. Coronal (A) and axial (B) fat-suppressed, proton density-weighted images demonstrate centrally displaced portion of medial meniscus (arrows).

FIGURE 2.15 Inferiorly displaced medial meniscal fragment. Fat-suppressed, proton density–weighted image demonstrates portion of medial meniscus displaced inferiorly and deep to medial collateral ligament (arrow).

experience of both the radiologist in interpreting studies as well as the orthopaedist performing the correlating arthroscopy. Many pitfalls in interpretation exist. When studying the central portions of the menisci, the meniscofemoral ligaments and transverse meniscal ligament can create problems. Recognition of the hiatus for the popliteus tendon will prevent the false diagnosis of a tear in the posterior horn of the lateral meniscus. Meniscocapsular separation is often difficult to detect in the absence of a complete detachment and resulting free-floating meniscus. Elderly patients often exhibit a greatly increased intrameniscal signal that can be mistaken

for a tear. The specificity of MRI for meniscal tear is reduced in patients who have undergone prior meniscal surgery. Most examiners, however, continue to rely on MRI in such patients, using caution with menisci that have greater degrees of surgical resection. Awareness of any history of prior meniscal debridement or repair may affect the interpretation of the examination, and such history should be provided to the interpreting physician. If possible, correlation of the postoperative examination with preoperative MR images is quite helpful in identifying the presence of a new tear. Rarely, the intraarticular injection of gadolinium (MR arthrography) can help differentiate healed or repaired tears from reinjury. Other morphologic abnormalities of the menisci and adjacent structures are nicely shown with MRI. The abnormally thick or flat discoid meniscus is seen more commonly on the lateral side. Although visualization of the “bow tie” configuration of the lateral meniscus in the sagittal plane on more than three adjacent images indicates a discoid meniscus, the abnormal cross-section usually is quite apparent on the coronal images (Fig. 2.16). Meniscal cysts, which usually are associated with and adjacent to meniscal tears, frequently can be easily seen as discrete T2-weighted hyperintense fluid collections located medially or laterally (see Fig. 2.12). 

CRUCIATE LIGAMENT INJURY

MRI is the only noninvasive means of imaging the cruciate ligaments. As described earlier, the sagittal imaging plane of the knee examination is prescribed to approximate the plane of the ACL. The normal ACL appears as a linear band of hypointense fibers interspersed with areas of intermediate signal. The ACL courses from its femoral attachment on the lateral condyle at the posterior extent of the intercondylar notch to the anterior aspect of the tibial eminence. High-resolution images often will define discreet anteromedial and posterolateral bands. On the sagittal images, the orientation of the normal ACL is parallel to the roof of the intercondylar notch. Reliable signs of ACL rupture include an abnormal horizontal course, a wavy or irregular appearance, or fluid-filled gaps in

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B FIGURE 2.16 Discoid meniscus in 3-year-old boy. A, Sagittal proton density–weighted image reveals abnormally thick lateral meniscus (arrow). B, Coronal fat-suppressed, proton density– weighted image demonstrates extension of discoid meniscus centrally (arrow) into weight-bearing portion of lateral compartment.

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FIGURE 2.17 Acute anterior cruciate ligament tear. A, Fat-suppressed, proton density– weighted sagittal image shows edema throughout abnormally oriented anterior cruciate ligament fibers (arrow). B, Fat-suppressed proton density–weighted image demonstrates typical associated bone contusion in the lateral femoral condyle (arrow).

a discontinuous ligament (Fig. 2.17). Chronic tears can reveal either ligamentous thickening without edema or, more often, complete atrophy. Several secondary signs of ACL rupture exist. In acute injuries, bone contusions are manifested as regions of edema in the subchondral marrow, typically in the lateral compartment. The overlying articular cartilage should be closely inspected for signs of injury. These bone contusions usually resolve within 6 to 12 weeks of injury. Anterior translocation of the tibia with respect to the femur, the MRI equivalent of the drawer sign, is highly specific for acute or chronic tears. Buckling of the posterior cruciate ligament often is present, but this sign is more subjective. Although

usually best evaluated in the sagittal plane, the ACL can and should be seen in coronal and axial planes as well. In large series correlated with arthroscopic data, MRI has achieved an accuracy rate of 95% in the assessment of ACL pathologic conditions. Unfortunately, as is frequently the case with the physical examination, the imaging distinction between partial and complete ACL tears is more challenging. Even when the diagnosis of an ACL tear is a clinical certainty, MRI is valuable in assessing associated meniscal and ligament tears and posterolateral corner injuries. MRI can accurately depict the reconstructed ACL within the intercondylar notch and define the position of intraosseous tunnels. A redundant graft

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FIGURE 2.18 Posterior cruciate ligament tear. Sagittal fatsuppressed proton density-weighted image shows abnormal increased signal (arrow) within the disorganized fibers of the distal posterior cruciate ligament.

FIGURE 2.19 Medial collateral ligament tear. Complete disruption of proximal medial collateral ligament (arrow) is demonstrated in coronal fat-suppressed, proton density–weighted image; this appearance suggests grade 3 medial collateral ligament injury.

or absence of the graft on MRI suggests graft failure. Because the normal revascularization process may result in areas of increased signal within and around the graft, edematous changes in the early postoperative period should be interpreted with caution. In extension, the posterior cruciate ligament is a gently curving band of fibrous tissue, appearing as a homogeneously hypointense structure of uniform thickness on sagittal MRI series. Discontinuity of the ligament or fluid signal within its substance indicates a tear (Fig. 2.18). In the coronal imaging plane, the medial collateral ligament (MCL) appears as a thin dark band of tissue closely applied to the periphery of the medial meniscus. Mild injuries result in edema about the otherwise normal ligament. Severe strain or rupture causes ligamentous thickening or frank discontinuity (Fig. 2.19). Although mild degrees of MCL injury correlate nicely with MRI appearance, imaging is less accurate in grading more severe injuries. Injuries of the lateral supporting structures, including the lateral collateral ligament, iliotibial band, biceps femoris, and popliteus tendon, also are depicted with MRI. 

OTHER KNEE PROBLEMS

Severe injuries to the extensor mechanism of the knee are usually clinically obvious, but when partial tears of the patellar or quadriceps tendon are suspected, MRI can confirm the diagnosis. Discontinuity of tendinous fibers and fluid in a gap within the tendon are seen with complete tears. Incomplete tears show thickening of the tendon with interspersed edema. Generally, tendinitis demonstrates tendon thickening, although normal low signal is maintained. Posteriorly, popliteal, or Baker, cysts are noted in the medial aspect of the popliteal fossa. These cysts can rupture distally into the calf, mimicking thrombophlebitis. In this situation, MRI will demonstrate fluid dissecting inferiorly along the medial

FIGURE 2.20 Popliteal fossa cyst. Axial proton density– weighted image demonstrates hyperintense fluid extending from knee joint into popliteal fossa between semimembranosus tendon (straight arrow), and medial gastrocnemius tendon (curved arrow).

gastrocnemius muscle belly. Caution should be used when evaluating T2-weighted hyperintense popliteal fossa structures because other lesions, such as popliteal artery aneurysms and tumors, are common in this location. Demonstration of the neck of a popliteal cyst at its communication with the joint between the medial gastrocnemius and the semimembranosus tendon will avoid potential misdiagnosis (Fig. 2.20).

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B FIGURE 2.21 Patellar dislocation. A and B, Axial fat-suppressed, proton density–weighted images through patellofemoral joint show regions of increased signal, representing marrow edema beneath medial facet of patella (long arrow) and in lateral aspect of lateral femoral condyle (thick arrow). This pattern of osseous contusion indicates recent lateral patellar dislocation. Note hematocrit level in joint effusion (arrowheads).

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FIGURE 2.22 Occult Salter II fracture of distal femur in 14-year-old boy. A, Coronal T1-weighted image reveals ill-defined reduced signal in medial distal femoral metaphysis. B, Fat-suppressed, T2-weighted image demonstrates irregular hypointense fracture (arrow) surrounded by hyperintense marrow edema. Edema continues along lateral physis, indicating extension of fracture.

Other potential problems about the knee for which MRI is well-suited include osteonecrosis, synovial pathologic conditions, osseous contusions (Fig. 2.21), and occult fractures (Fig. 2.22). Direct coronal and sagittal MRI is helpful in assessing complications of physeal injuries in children (Fig. 2.23) and in demonstrating osteochondritis dissecans. T2-weighted or gradient-echo sequences can show fluid surrounding an unstable osteochondral fragment. MRI is also helpful in

determining the integrity of the overlying cartilage (Fig. 2.24). The fat-suppressed proton density–weighted sequence is most commonly used in the assessment of hyaline cartilage in the routine knee examination. Fat-suppressed, fast spinecho, proton density–weighted, or gradient-echo sequences obtained with volumetric technique are helpful in the evaluation of articular cartilage in the knee and many other joints (Figs. 2.8, 2.24, and 2.25). Loose bodies are best seen in the

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FIGURE 2.25 Chondral lesion. Fat-suppressed proton density weighted sagittal image of knee reveals a small, well-defined fluid filled full-thickness defect in the articular cartilage of the posteromedial femoral condyle (arrow). FIGURE 2.23 Physeal bar in 12-year-old boy. Gradient-echo sagittal image of knee demonstrates interruption of posterior extent of distal femoral physis (arrow). Osseous bridge has resulted in posterior angulation of articular surface of distal femur. Articular and physeal cartilage exhibits increased signal with most gradientecho techniques.

these advanced cartilage imaging techniques are used primarily in the research setting or for clinically difficult cases. 

HIP MRI is an extremely useful tool in the evaluation of the hip and pelvis. With the unsurpassed ability to image marrow in the proximal femur, MRI can detect a spectrum of pathologic conditions of the hip. When evaluating patients for processes that may be bilateral, such as osteonecrosis, or conditions that might involve the sacrum or sacroiliac joints, the examination should include both hips and the entire pelvis. A surface coil such as a torso or large wrap coil with phased-array design combines improved signal for high-resolution images coupled with large field-of-view coverage. For patients with suspected unilateral conditions, such as femoral stress fractures, suspected occult trauma, or labral injury, a unilateral study with a smaller field of view is desirable and surface coils are indispensable. Spin-echo sequences are usually performed in axial and coronal planes. Sagittal images are quite useful when investigating osteonecrosis.

OSTEONECROSIS

FIGURE 2.24 Osteochondritis dissecans. Coronal fatsuppressed proton density-weighted image of the knee demonstrates hyperintense fluid signal (arrow) surrounding an unstable osteochondral fragment.

presence of joint effusion with conventional radiographs as a reference. Specialized cartilage imaging techniques such as T1rho and T2 mapping, and delayed gadolinium-enhanced magnetic resonance imaging of cartilage (D-GEMRIC) require additional scan time or contrast injection. Presently,

One of the most frequent indications for hip imaging is evaluation of osteonecrosis because early diagnosis is desirable whether nonoperative or operative treatment is considered. Although initial radiographs are often normal, either scintigraphy or MRI may confirm the diagnosis. Of the two techniques, MRI is the more sensitive in detecting early osteonecrosis and better delineates the extent of marrow necrosis. The percentage of involvement of the weightbearing cortex of the femoral head as defined by MRI, as well as the presence of perilesional marrow edema and joint effusion, may be helpful in predicting prognosis and the value of surgical intervention. On T1-weighted images, the classic MRI appearance of osteonecrosis is that of a geographic region of abnormal marrow signal within the normally bright fat of the femoral head (Fig. 2.26). This area of abnormal signal, often circumscribed by a low-signal band, represents ischemic bone. The T2-weighted images reveal a margin of bright signal, and the resulting appearance has been termed

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B FIGURE 2.26 Corticosteroid-induced bilateral osteonecrosis of femoral head. A and B, Coronal T1-weighted and inversion recovery images through both hips reveals geographic focus of marrow replacement in weight-bearing aspect of left femoral head, indicating osteonecrosis (solid arrows). More advanced disease is seen in right femoral head with collapse of articular surface, adjacent marrow edema (open arrows), and effusion.

the “double line” sign. This sign essentially is diagnostic of osteonecrosis. Initially appearing in the anterosuperior subchondral marrow, the central area of necrotic bone can demonstrate various signal patterns throughout the course of the disease, depending on the degree of hemorrhage, fat, edema, or fibrosis. Subchondral fracture, articular surface collapse, cartilage loss, reactive marrow edema, and effusion are seen in more advanced cases of osteonecrosis. 

TRANSIENT OSTEOPOROSIS

A second condition also well depicted with MRI is transient osteoporosis of the hip. This unilateral process, initially described in pregnant women in their third trimester, is most commonly seen in middle-aged men. Transient osteoporosis is a self-limited process of uncertain etiology, although ischemic, hormonal, or stress-related etiologies have been proposed. Many patients have later involvement of nearby joints, such as the opposite hip, hence the association with regional migratory osteoporosis. Initial radiographs may be normal or may reveal diffuse osteopenia of the femoral head, with preservation of the joint space. The MRI appearance is that of diffuse edema in the femoral head, extending into the intertrochanteric region. Focal MRI signal abnormalities, as seen in osteonecrosis, generally are not present in transient osteoporosis. Occasionally, a tiny focal, often linear lesion in the subcortical marrow in the weight-bearing portion of the femoral head indicates an insufficiency fracture in the demineralized bone. T1-weighted sequences depict diffuse edema as relative low signal in contrast to background fatty marrow. The edema becomes hyperintense on T2-weighted series and is accentuated when fat-suppression techniques are used (Fig. 2.27). This marrow appearance has been termed a “bone marrow edema pattern.” Rare case reports have documented this pattern presenting as the earliest phase of osteonecrosis. For this reason, if initial radiographs are normal, repeat films 6 to 8 weeks after the onset of symptoms should demonstrate osteopenia of the femoral head, confirming the diagnosis of

transient osteoporosis. Transient osteoporosis of the hip generally resolves without treatment within 6 months, and the radiographs and MRI appearance return to normal. 

TRAUMA

Frequently, MRI can be helpful in evaluation of the hip after trauma. Radiographs are often negative or equivocal for fracture of the proximal femur in elderly individuals. Although bone scintigraphy has been used to confirm or exclude fracture, this study can be falsely negative in elderly patients in the first 48 hours after injury. The MRI abnormalities are immediately apparent, with linear areas of low signal easily seen in the fatty marrow on T1-weighted images and surrounding edema seen with T2-weighted images (Fig. 2.28). In addition, the anatomic information provided can assist in determining the type of fixation required. In fact, many radiographically occult fractures subsequently discovered by MRI are confined to the greater trochanter or incompletely traverse the femoral neck and, in certain patients, may be treated conservatively. A great deal of effort has been directed at the imaging evaluation of femoroacetabular impingement and the acetabular labrum. Original reviews of the accuracy of conventional MRI in the assessment of labral pathologic conditions were disappointing because of large field of view images that lacked adequate resolution. The advent of MRI arthrography performed with surface coil or phased-array technique has greatly improved visualization of the cartilaginous labrum. Unfortunately, the geometry of the labrum of the hip displays a wide range of normal variation, even in asymptomatic individuals. As the vast majority of labral tears are found in the anterior or anterolateral labrum, these labral segments should be closely evaluated for the presence of deep or irregular intralabral clefts suggestive of a labral tear (Fig. 2.29). Adjacent regions of acetabular cartilage delamination often are present. In patients with mechanical hip symptoms or possible femoroacetabular impingement, the addition of an anesthetic injection at the time of arthrography may be useful in confirming

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B FIGURE 2.27 Transient osteoporosis of hip in 30-year-old man. A, Coronal T1-weighted image reveals diminished signal intensity within right femoral head and neck. B, Coronal inversion recovery sequence demonstrated hyperintense bone marrow edema in more diffuse pattern than seen in osteonecrosis.

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FIGURE 2.28 Radiographically occult proximal femoral fracture in elderly woman. A, Questionable cortical disruption is noted on radiograph of left hip obtained after fall. B, Coronal T1-weighted image confirms greater trochanter fracture manifested as vertically oriented band of reduced signal (curved arrow) within normal bright fat signal of femoral neck. C, Coronal inversion recovery sequence shows edema at fracture.

an intraarticular origin of pain. The improved resolution provided by 3 T MRI studies has allowed labral assessment without the need for intraarticular contrast. Nonarthrographic examinations for the workup of hip impingement and labral pathology should be specifically ordered with such history to ensure the necessary sequence selection and small field of view required to appropriately evaluate the labrum. 

SPINE MRI of the spine accounts for a large percentage of examinations at most centers. MRI allows a noninvasive evaluation of the spine and spinal canal, including the spinal cord.

The anatomy of the spine, cord, nerve roots, and spinal ligaments is complex. Because the spine is anatomically divided into three sections—cervical, thoracic, and lumbar—each is evaluated with coils specifically designed for spine imaging. Spinal examinations include series obtained in both axial and sagittal planes. Coronal images may be helpful in patients with significant scoliosis. There is no one correct imaging construct, and the makeup of the study depends on many factors, including the type and field strength of the magnet, the availability of hardware (coils) and software, and the preferences of the examiner. However, all studies should produce images that can detect and define pathologic conditions of the cord, thecal sac, vertebral bodies, and intervertebral discs.

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INTERVERTEBRAL DISC DISEASE

The most common indication for MRI of the spine is evaluation of intervertebral disc disease. After routine radiography, MRI is the procedure of choice for screening patients with low back or sciatic pain. In the lumbar and thoracic spine, MRI has supplanted CT myelography because it is noninvasive and less expensive. The combination of high soft-tissue contrast and high resolution allows ideal evaluation of the intervertebral discs, nerve roots, posterior longitudinal ligament, and intervertebral foramen. Additionally, MRI provides excellent assessment of the spinal cord. Because of bony structures, such as osteophytes and bone fragments, CT myelography is invasive and more costly and is therefore reserved for patients who have contraindications to MRI or who have equivocal MRI examinations. Regardless of the

FIGURE 2.29 Anterior labral tear of the hip. Postarthrogram sagittal fat-suppressed T1-weighted image shows contrast opacifying a tear of the anterior labrum of the hip (arrow).

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region of the spine being evaluated, sagittal images provide an initial evaluation of the intervertebral discs and posterior longitudinal ligament. Because of its high water content, a normal disc exhibits signal hyperintensity on T2-weighted images. The aging process results in a gradual desiccation of the disc material and therefore loss of this signal. Disc herniations or extrusions appear as convex or polypoid masses extending posteriorly into the ventral epidural space, frequently maintaining a signal intensity similar to that of the disc of origin (Fig. 2.30). Sagittal T2-weighted or gradientecho images create a “myelographic” effect and are useful in evaluating compromise of the subarachnoid space. However, sagittal T1-weighted images should be closely examined to identify narrowing of the neuroforamina. The normal T1-weighted hyperintense perineural fat in the foramina provides excellent contrast to darker displaced disc material. Far lateral disc herniations are best seen on selected axial images that are localized through disc levels. Free disc fragments appear discontinuous with the intervertebral disc, usually of intermediate T1-weighted signal in contrast to the hypointense cerebrospinal fluid. Of great significance in the cervical and thoracic spine is the ability of MRI to detect significant spinal cord compromise. Edema within the cord is readily demonstrated as hyperintensity with T2 weighting. The terminology of pathologic conditions of the intervertebral disc is confusing. In an effort to standardize terminology, Jensen et al. proposed the following terms: a bulge is a circumferential, symmetric extension of the disc beyond the interspace around the endplates; a protrusion is a focal or asymmetric extension of the disc beyond the interspace, with the base against the disc of origin broader than any other dimension of the protrusion; an extrusion is a more extreme extension of the disc beyond the interspace, with the base against the disc of origin narrower than the diameter of the extruding material itself or with no connection between the material and the disc of origin; and, finally, a sequestration specifically refers to a disc fragment that has completely separated from the disc of origin. 

POSTOPERATIVE BACK PAIN

In a patient with persistent postoperative back pain, residual disc, epidural hematoma or abscess, and discitis must

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FIGURE 2.30 Cervical disc extrusion (herniation). A, T2-weighted sagittal image of the cervical spine reveals extruded C6-C7 disc (arrow). B, Gradient-echo sagittal image demonstrates displaced disc material isointense to nucleus pulposus. Note the absence of cerebrospinal fluid pulsation artifact seen on the T2-weighted image. C, Gradient-echo axial image shows left eccentric extrusion compressing the cervical cord and filling the left neuroforamen (arrow).

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CHAPTER 2  ADVANCED IMAGING IN ORTHOPAEDICS be considered. Distinguishing between recurrent or residual disc material and scar tissue often is impossible with CT myelography or unenhanced MRI, and the administration of intravenous gadolinium is extremely useful in MRI of the postoperative spine. After contrast administration, repeat T1-weighted images typically demonstrate enhancement of scar or fibrosis (Fig. 2.31). Beyond the immediate postoperative period, disc material (in the absence of infection) will not enhance. For this reason, examinations performed on patients with a history of disc surgery are usually done with and without intravenous contrast. Epidural hematomas and abscesses appear as collections within the spinal canal, demonstrating peripheral enhancement with gadolinium on T1-weighted images. Gadolinium contrast agents are also helpful in postoperative evaluation of the spine for discitis. Signal changes in the disc space and adjacent vertebral endplates frequently are seen after surgery on the spine even when complications do not occur, but the triad of vertebral body endplate enhancement, disc space enhancement, and enhancement of the posterior longitudinal ligament is highly suggestive of postoperative discitis. Correlation with the erythrocyte sedimentation rate, C-reactive protein, gallium or tagged white blood cell radionuclide imaging, and percutaneous aspiration is often necessary. Although diagnosis of disc space infection in a patient who has not undergone surgery generally is more straightforward, the MRI appearance of degenerative disc disease is varied and can be confusing. Although vertebral endplate edema and even enhancement do occur in the absence of infection, the presence of disc space enhancement strongly suggests infection (Fig. 2.32). Pyogenic and fungal/tuberculous infection is frequently associated with epidural and paraspinal abscesses. In the lumbar spine, extension into the adjacent psoas muscles is best demonstrated on axial T2-weighted sequences because hyperintense fluid and edema invade the normal hypointense musculature. Subligamentous spread of

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infection with relative sparing of the intervertebral disc should raise the suspicion of tuberculous spondylitis. Both pyogenic and tuberculous infections demonstrate abnormal enhancement with gadolinium administration. Abscesses, given the lack of central perfusion, enhance only at the periphery. 

SPINAL TUMORS

Although tumor imaging in general is discussed later in this text, MRI has proven valuable in the assessment of spinal neoplasms. Excellent delineation of vertebral body marrow allows detection of both primary and metastatic disease with high sensitivity on T1-weighted sequences. Normally, T1-weighted vertebral body marrow signal progressively increases with age, a reflection of a gradually higher percentage of fatty marrow. Diseases such as chronic anemia result in a higher percentage of hematopoietic marrow, thus diffusely diminishing this T1-weighted signal. Malignant osseous tumor foci appear as discrete areas of diminished T1 signal. As is typical with tumors, these lesions become hyperintense to surrounding marrow on T2-weighted studies and enhance with contrast. These aggressive lesions can be distinguished from benign bony hemangiomas, which usually are hyperintense on T1-weighted images because of their internal fat content. Neoplastic processes that diffusely involve vertebral marrow, such as leukemia and occasionally multiple myeloma, may be more problematic because differentiation from diffusely prominent hematopoietic marrow can be challenging. 

SPINAL TRAUMA

CT remains the most useful advanced imaging technique for spinal trauma. The inherent contrast provided by bone and unmatched spatial resolution makes CT the preferred initial examination in trauma patients. MRI is helpful in patients with suspected spinal cord injury, epidural hematoma, or traumatic disc herniation. Soft-tissue injuries, such as ligamentous

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FIGURE 2.31 Recurrent lumbar disc extrusion (herniation). A, Sagittal T1-weighted image demonstrates intermediate signal intensity in L4-L5 disc material (arrow) surrounded by hypointense cerebrospinal fluid. B, Sagittal T2-weighted image shows displaced disc material contiguous with intervertebral disc. Hyperintense cerebrospinal fluid provides improved contrast. C, Sagittal T1-weighted image after gadolinium administration demonstrates enhancement of epidural venous plexus (arrow) and overlying granulation tissue but no enhancement of disc material.

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FIGURE 2.32 Thoracic discitis. A, Sagittal T1-weighted image exhibits reduced marrow signal (arrows) adjacent to the irregular and collapsed lower thoracic interspace. B, Sagittal T2-weighted image reveals corresponding hyperintense areas of marrow edema (arrows). C, After administration of gadolinium, sagittal T1-weighted image exhibits enhancement of the intervertebral disc (arrow).

tears, can be identified in the acute stage. Discontinuity of normally hypointense ligaments, hemorrhage, and edema can be seen on sagittal T2-weighted images. In the setting of trauma, MRI usually is reserved for neurologically impaired patients whose CT examinations are negative or for patients in whom spinal fracture reduction is planned and associated disc pathology must be excluded. The role of MRI in evaluating nontraumatic compressed vertebrae and in the exclusion of any underlying pathologic condition is critical. Preservation of normal marrow signal in a portion of the compressed vertebral body, especially with a linear pattern of signal abnormality, is suggestive of a fracture caused by a benign process, such as osteoporosis. Complete marrow replacement or the presence of additional focal abnormal marrow signal at other levels should prompt consideration of biopsy. The association of an irregular or asymmetric soft-tissue mass or broad convexity of the dorsal vertebral cortex is also suggestive of underlying neoplasm. In questionable cases, a follow-up MRI at 6 to 8 weeks may demonstrate at least partial reconstitution of normal marrow signal around osteoporotic fractures. The identification of edema within a compressed vertebra can confirm a fracture as either acute or subacute because normal marrow signal is typically restored in chronic compression fractures. 

SHOULDER The major indications for MRI evaluation of the shoulder include three interrelated problems: rotator cuff tear, impingement, and instability. The complex anatomy of the shoulder requires oblique imaging planes and surface coil technique. The typical MRI shoulder examination includes axial spin-echo or gradient-echo sequences to evaluate the labrum. Oblique coronal images prescribed in the plane of the supraspinatus tendon best detect pathologic conditions of the rotator cuff. Oblique sagittal images confirm abnormalities of the cuff tendons and evaluate rotator cuff muscles in crosssection. Both conventional arthrography and MRI can detect

complete tears of the rotator cuff. However, although arthrography shows full-thickness tears and partial tears along the articular (inferior) surface, noninvasive MRI also detects partial-thickness intrasubstance and bursal surface tears and can reliably determine the size of full-thickness defects.

PATHOLOGIC CONDITIONS OF THE ROTATOR CUFF

Oblique coronal spin-echo imaging with T2 weighting optimally detects most pathologic conditions of the rotator cuff. With the humerus in neutral to external rotation, the oblique coronal plane is chosen parallel to the supraspinatus tendon. As is the case with all other tendons, the tendons of the supraspinatus, infraspinatus, and teres minor muscles normally maintain low signal on all pulse sequences. Rotator cuff tears appear as areas of increased T2-weighted signal, representing fluid within the tendon substance. This signal may traverse the entire tendon substance, indicating a full-thickness tear (Fig. 2.33). Alternatively, intact cuff fibers may persist along the articular surface, bursal surface, or both, as seen in partial-thickness tears. Fluid may be identified in the subacromial-subdeltoid bursa. In patients with large or chronic tears, the cuff may be so atrophied that its identification is impossible. In these cases, fluid freely communicates between the glenohumeral joint and the subacromial bursa and the humeral head often migrates superiorly. Excessive retraction of the cuff tendons and atrophy of the cuff musculature portend a poor surgical result. Most examiners have used the terms tendinosis or tendinopathy to describe focal signal abnormalities within the cuff that do not achieve the signal intensity of fluid on T2-weighted images. Because artifacts frequently occur within tendons on T1-weighted and gradient-echo images, the diagnosis of rotator cuff tear should not be made in the absence of discrete foci of T2-weighted fluid signal abnormalities or complete absence of the tendon. Typically, areas of normal fluid can be appreciated elsewhere in the glenohumeral joint for reference. Diffuse or focal signal abnormalities less intense than fluid should be

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B FIGURE 2.33 Full-thickness rotator cuff tear. A, Oblique coronal T1-weighted image poorly differentiates normal tendon from pathologic condition. B, At same location, oblique coronal fatsuppressed, T2-weighted image clearly shows fluid-filled, full-thickness tear (arrow) in supraspinatus tendon.

considered tendinosis. MRI has shown greater than 90% sensitivity in detecting full-thickness rotator cuff tears. For the assessment of partial tears, the sensitivity is greater than 85%. The addition of fat suppression to T2-weighted images has been shown to improve detection of partial-thickness tears. MRI assessment of the repaired rotator cuff should be done with caution. Often irregular foci of increased T2-weighted signal normally can be seen with an intact healing tendon, likely representing areas of granulation tissue. For this reason, the diagnosis of partial-thickness tears in the postoperative shoulder should be avoided. However, larger, fluid-filled, fullthickness defects and tendon retraction correlate well with failed repairs or re-tears. MR arthrography is often helpful in the evaluation of the postoperative rotator cuff. 

IMPINGEMENT SYNDROMES

Although impingement can be suggested by an imaging technique, it remains a clinical diagnosis. MRI can be helpful in confirming the clinical impression or providing additional information. Imaging findings that suggest the possibility of impingement include narrowing of the subacromial space by spurs or osteophytes, a curved or hooked acromial morphology, and signal abnormalities in the cuff indicating tendinosis or tendinopathy. 

PATHOLOGIC CONDITIONS OF LABRUM

Much study has been directed at MRI evaluation of the labroligamentous complex of the shoulder. The cross-sectional anatomy of the normal labrum is quite variable, and the adjacent glenohumeral ligaments create many potential diagnostic pitfalls (Fig. 2.34). For these reasons, early conventional MRI evaluation of the glenohumeral joint for instability achieved mixed results. With modern scanner and coil technology, however, the labrum often is quite well depicted in routine shoulder MRI. Nevertheless, many investigators still believe that the distension of the joint achieved by the injection of intraarticular fluid improves evaluation of the labrum, biceps tendon origin, and joint capsule. MR arthrography most often uses dilute gadolinium as a contrast agent and subsequent T1-weighted sequences in the axial, oblique sagittal,

FIGURE 2.34 Anterior labral tear. Axial gradient-echo image through glenohumeral joint shows anterior displacement of avulsed anterior labral fragment (curved arrow). Hypointense middle glenohumeral ligament (arrowhead) lies between labral fragment and subscapularis tendon and should not be mistaken for portion of labrum.

and oblique coronal planes performed in a standard position with the arm at the patient’s side (Fig. 2.35A). Additional imaging can be performed with the humerus in abduction and external rotation (ABER) position for assessment of the inferior glenohumeral ligament and its labral attachment (Fig. 2.35B). Anterior labral injuries are best seen in the axial plane, whereas superior labral abnormalities or SLAP (superior labral anterior posterior) lesions are best depicted in the axial or coronal images (Fig. 2.36). Using MR arthrography, a sensitivity of 91% and a specificity of 93% have been reported in the detection of pathologic labral conditions. The accuracy of MRI in evaluation of SLAP lesions is somewhat less. Some investigators have proposed indirect arthrography as an alternative method of joint opacification. In this technique,

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B FIGURE 2.35 Anterior labral tear. A, Postarthrogram fat-suppressed T1-weighted axial image of the shoulder shows a small defect in the anteroinferior labrum (arrow). B, Oblique axial imaging in abduction/external rotation places tension on the inferior glenohumeral ligament, better demonstrating the tear (arrow).

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B FIGURE 2.36 Superior labral anterior posterior tear. A, Fat-suppressed T1-weighted oblique coronal image from MR arthrogram shows contrast opacifying a defect in the long head biceps anchor (arrow). B, Fat-suppressed T1-weighted axial image shows extension of the tear into the anterior and posterior labrum (arrows).

delayed intraarticular enhancement is achieved by exercising the joint after intravenous administration of gadolinium. Although this is a less invasive technique, the degree of distention is less than that achieved with direct arthrography. 

OTHER CAUSES OF SHOULDER PAIN

MRI also can demonstrate additional causes of shoulder pain, such as occult fractures or osteonecrosis (Fig. 2.37). Pathologic conditions of the tendon of the long head of the biceps, including rupture, dislocation, or tendinitis, should be detected on routine MRI examination. A less frequent cause

of shoulder pain, suprascapular nerve entrapment, is a ganglion cyst of the spinoglenoid notch. Like ganglia elsewhere, these lesions appear as lobular, multiseptate, hyperintense collections on T2-weighted or gradient-echo sequences (Fig. 2.38). The presence of these ganglia may be associated with infraspinatus atrophy and should trigger a careful search for an associated labral injury. Of note, neither the pectoralis muscle/tendon nor the brachial plexus is imaged on the routine shoulder MRI examination, and if a pathologic condition of these structures is suspected, a study dedicated to this anatomic region should be performed. 

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B FIGURE 2.37 Osteonecrosis complicating comminuted fracture of proximal humerus. A, Oblique coronal T1-weighted image demonstrates displaced fracture through neck of proximal humerus (curved arrow). Geographic region of abnormal marrow within articular fragment is characteristic of osteonecrosis (long arrow). B, Oblique coronal fat-suppressed, T2-weighted image shows hyperintense rim of reactive tissue (arrow) surrounding now hypointense fatty avascular marrow.

the side. Dedicated wrist coils, when available, or coupled surface coils also are designed for imaging of this articulation at the patient’s side. Again, the MRI examination should be directed at solving a specific clinical problem or question.

CARPAL LIGAMENT DISRUPTIONS

FIGURE 2.38 Soft-tissue ganglion in painful shoulder. Gradient-echo axial image of right shoulder reveals lobulated homogeneous hyperintense lesion in spinoglenoid notch (white arrow). Ganglia and other masses in this location can be associated with suprascapular nerve entrapment. Note subtle hyperintensity indicating edema in the infraspinatus muscle along the posterior scapula related to denervation (black arrows).

WRIST AND ELBOW MRI has an expanding role in the evaluation of pathologic conditions of the elbow and wrist. Successful study of both articulations requires high-resolution images that are best obtained with surface coil technique and high field system. Often these joints are examined in the extremity coil, requiring extension of the arm overhead within the center of the magnet field. This position is difficult to maintain in elderly patients. The larger-diameter bore current generation of highfield scanners can allow for off-axis imaging with the arm at

In the wrist, a common indication for MRI is evaluation of the intrinsic carpal ligaments. With proper technique, injuries to the triangular fibrocartilage complex (TFCC) can be demonstrated with MRI. The TFCC is composed of signal-poor fibrocartilage, and perforations in the TFCC appear as linear defects or gaps filled with hyperintense fluid on coronal gradient-echo or T2-weighted pulse sequences (Fig. 2.39). Although evaluation of the scapholunate and lunotriquetral ligaments is more challenging, with optimal technique and equipment the integrity of these structures can be consistently assessed. The addition of arthrographic contrast improves the visualization of these ligaments on MR images. The extrinsic carpal ligaments can be identified with three-dimensional volumetric scanning and subsequent reconstruction; however, at present, the MRI assessment of these ligaments has less impact on treatment. 

OTHER PATHOLOGIC CONDITIONS OF HAND AND WRIST

MRI has gained a greater role in the evaluation of acute wrist trauma. Not infrequently, bone marrow edema may reveal fractures of the carpal bones or distal radius that are radiographically occult. MRI is useful in detecting additional marrow abnormalities in osteonecrosis, as seen in the lunate in Kienböck disease (Fig. 2.40) or in the scaphoid after fracture. Asymmetry of marrow signal in proximal and distal fragments of a fractured scaphoid is suggestive of proximal pole ischemia (Fig. 2.41). MRI currently has a limited role in the evaluation of carpal tunnel syndrome. Although this remains a clinical diagnosis, axial imaging with T2 weighting can clearly display masses within the confines of the carpal

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FIGURE 2.39 Triangular fibrocartilage complex (TFCC) perforation. Coronal fat-suppressed, proton density–weighted image of wrist demonstrates central perforation of TFCC (long arrow). Note fluid in distal radioulnar joint (curved arrow). Scapholunate ligament (open arrow) is intact in this wrist.

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FIGURE 2.40 Osteonecrosis of lunate (Kienböck disease). Coronal T1-weighted image of wrist shows loss of normal highsignal fat in lunate (arrow), indicating osteonecrosis.

B FIGURE 2.41 Early osteonecrosis of scaphoid following fracture. A, T1-weighted coronal image of the wrist shows a transverse fracture of the mid-scaphoid (arrow). B, Fat-suppressed T2-weighted coronal image reveals marrow edema in the distal pole fragment only (arrow), suggesting proximal pole ischemia.

tunnel, as well as edema and swelling of the median nerve. As in the ankle, tenosynovitis and tendon injuries in the wrist and hand can be assessed (Fig. 2.42). Additionally, MRI has an expanding role in the evaluation of inflammatory arthritis. Numerous studies have shown that MRI provides earlier detection of synovitis and erosive bone changes associated with rheumatoid arthritis than do radiographs. 

ELBOW In the elbow, MRI is useful in assessment of the biceps and triceps tendons. Although complete tears of these tendons are frequently clinically apparent, MRI can assist in surgical planning (Figs. 2.43 and 2.44). MRI can detect partial tears as well. Conventional MRI and MR arthrography have a critical role in the evaluation of medial instability and the study of

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CHAPTER 2  ADVANCED IMAGING IN ORTHOPAEDICS the ulnar collateral ligament. The ulnar collateral ligament is a complex structure, and its anterior band is normally visible as a linear hypointense structure along the medial aspect of the joint on all sequences. When injured, fluid is seen within and around the disrupted ligament. In a throwing athlete, MR arthrography may be helpful especially in assessment of partial-thickness ligament tears (Fig. 2.45). Conventional MRI is also valuable for detection of occult elbow fractures in adults as well as in children in whom unossified epiphyses are radiographically problematic. 

FIGURE 2.42 Image of rupture of flexor digitorum profundus tendon in long finger made 2 weeks after repair. Sagittal inversion recovery image demonstrates abrupt discontinuity of flexor tendon (arrow) with laxity of more proximal tendon segment.

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TUMOR IMAGING Perhaps nowhere in orthopaedics has MRI had as profound an impact as in the field of surgical oncology. Exquisite soft-tissue contrast combined with detailed anatomy and

FIGURE 2.43 Rupture of distal biceps tendon. Sagittal inversion recovery image of elbow demonstrates ruptured distal biceps tendon. Proximal tendon (arrow) has retracted several centimeters, and edema is present in tissues anterior to brachialis muscle.

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FIGURE 2.44 Avulsion of triceps tendon. A, Sagittal fat-suppressed, proton density–weighted image of elbow shows avulsed triceps tendon (long arrow) retracted proximally from olecranon (thick arrow). B, Sagittal fat-suppressed, T2-weighted image demonstrates hyperintense fluid (arrows) in gap between bone and detached tendon.

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PART I  GENERAL PRINCIPLES multiplanar capability place MRI at the forefront of musculoskeletal tumor imaging methods. Excellent bone marrow delineation is most helpful in defining tumor extent and planning surgical and radiation therapy. MRI is frequently helpful in defining aggressive versus indolent processes; however, the contribution of routine radiographs cannot be

FIGURE 2.45 Partial ulnar collateral ligament tear at MR arthrography of elbow. Coronal fat-suppressed, T1-weighted image reveals contrast tracking deep to ulnar attachment of ulnar collateral ligament (arrow).

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overemphasized. In tumor imaging, interpreting MRI studies without radiographs is risky. Most oncologic MRI examinations are performed after radiographic detection of a bone lesion or discovery of a clinically palpable soft-tissue mass. Whether imaging bone or soft-tissue neoplasms, the basic concepts are similar. If the lesion is sufficiently small (5 cm), and heterogeneous. Exceptions to these rules are plentiful, and the distinction between benign and malignant disease must be made with caution. 

COMPUTED TOMOGRAPHY CT is a valuable problem-solving tool for orthopaedic conditions too numerous to list in entirety. CT is frequently used and often invaluable in evaluation and treatment planning in patients with acute complex fractures. The modality can be quite helpful in defining post-traumatic, developmental, or congenital osseous deformity. Preoperative CT imaging

can assist with planning for arthroplasty and arthrodesis in patients with advanced degenerative arthropathy. CT may occasionally be of value in tumor evaluation and is certainly often used for image-guided aspirations, injections, or biopsies. Often, CT becomes the default imaging modality of choice in patients who have a contraindication to MR, such as a pacemaker or intracranial clips, or who are claustrophobic.

CT TECHNOLOGY AND TECHNIQUE

Computed x-ray tomography is an advanced radiographic technique that uses a rotating x-ray beam to generate a cross-sectional image. Although the CT also is used in single

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FIGURE 2.50 Soft-tissue hemangioma of foot. A, Coronal T1-weighted image of midfoot shows infiltrating mass of heterogeneous increased signal (arrow). B, Corresponding fat-suppressed, T2-weighted image demonstrates markedly increased signal within mass (arrow). Morphology and signal characteristics of this lesion (hyperintense T1- and T2-weighted signal) are typical of hemangiomas.

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FIGURE 2.51 Pigmented villonodular synovitis. A, Sagittal T1-weighted image of the elbow shows lobulated intermediate to hypointense soft tissue distributed diffusely throughout the synovium. B, T2-weighted imaging reveals the typical dramatic decrease in signal throughout these masses (arrow) due to the presence of hemosiderin.

photon emission computed tomography (SPECT) or positron emission tomography (PET), in this chapter, CT refers to computed x-ray tomography. Current CT scanners use highheat capacity x-ray tubes and slip-ring technology, which allows image acquisition with a helical or spiral technique. Rather than acquiring individual slices in a stepwise fashion, helical scanners generate imaged volumes as the patient continuously moves through the scanner. The acquired or “raw”

data is then manipulated to generate cross-sectional images for interpretation. Two-dimensional images can be created in orthogonal or oblique planes. Additionally, three-dimensional images can be generated with various post-processing techniques. The acquisition and storage of this raw data allow much greater post-processing flexibility than MR. Current CT scanners also use multichannel technology, with multiple rows or banks of rotating detectors that capture

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FIGURE 2.52 Medial femoral condyle fracture. A, Lateral radiograph of the knee shows very subtle deformity of the articular surface B, Sagittal reformatted CT image more clearly shows a coronally oriented intraarticular fracture (Hoffa fracture) of the medial femoral condyle.

the x-rays after they pass through the patient. Analysis of the data acquired in these detector rows individually or in combination affects the reconstructed image collimation or slice thickness. Most modern scanners allow slice thickness of less than 0.5 mm. Therefore, spatial resolution of CT is significantly better than MR. CT is a powerful tool when used to evaluate high-contrast structures such as bone but is of less value is studying soft-tissue structures where MR excels. Additionally, the presence of potentially harmful ionizing radiation associated with the generation of CT images should always be considered, especially in younger patients. Technologists should appropriately reduce doses when performing examinations on younger or smaller patients. Additionally, radiation dose can be easily minimized by limiting the extent of the studied volume. For example, the study of a single-level lumbar pars defect can be localized to the level of concern rather than the entire lumbar spine, reducing exposure by at least two thirds. Dose reduction technology such as iterative reconstruction should be used when available. In certain clinical situations, similar diagnostic information can be obtained with MR or US, avoiding radiation exposure entirely. 

TRAUMA

CT can be extremely useful is the setting of trauma. For example, in an acutely injured patient, CT may detect radiographically occult fractures in the spine and appendicular skeleton. In some studies, conventional radiography missed up to 70% of cervical spine fractures. Trauma radiographs often are compromised by body habitus or osteopenia. Many trauma patients require cranial or body scanning, and the addition of spinal CT can be done with little or no additional scan time and dose. In the lumbar spine, CT can better assess compression fractures and can frequently distinguish acute from chronic deformities. Certainly, CT is the modality of choice in assessing bony canal compromise in patients with vertebral burst fractures. CT also is critical in assessing radiographically occult or obvious pelvic fractures. CT can detect

occult fractures of the appendicular skeleton as well, particularly those involving the elbow, hip, and knee. It should be noted that in almost all situations, the sensitivity of MR exceeds CT in detection of occult fracture; however, because of the excellent spatial resolution of CT, this modality better demonstrates small fracture fragments such as avulsions involving the scapular glenoid or metatarsal bases. In many situations, CT is requested to further assess a radiographically known fracture. In most cases, the severity of fracture displacement is better appreciated with CT. Because this displacement is especially critical when fractures involve an articular surface, CT imaging is commonly requested for intraarticular fractures of the proximal humerus, wrist, proximal tibia, or calcaneus. Image reconstruction in planes orthogonal to the articular surface is needed to best appreciate displacement of the subchondral bone (Fig. 2.52). With severe displacement or bony deformity, three-dimensional shaded surface rendering is also valuable (Fig. 2.53). CT is also the modality of choice to assess for fracture healing. Bony bridging of the fracture site is visible with CT before it becomes radiographically apparent. If local implants are present, scan technique should be optimized to minimize artifact. Current generation scanners use metal artifact reduction software (MARS technique), which can be valuable when imaging in the vicinity of implants such as joint prostheses or bulky plates. Again, images must be reconstructed in planes orthogonal to the fracture. In the setting of malunion, CT imaging may assist in quantifying bony displacement or angulation and especially rotational deformity. In adolescents, CT analysis of lumbar spondylosis can often distinguish immature from chronic fractures. 

DEVELOPMENTAL SKELETAL PATHOLOGY

Development skeletal abnormalities can be accurately characterized with CT imaging. Vertebral anomalies such as butterfly or hemivertebrae are clearly displayed on three- dimensional CT images, assisting in operative planning. Developmental

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FIGURE 2.53 Posterior shoulder dislocation. Three-dimensional shaded surface rendering clearly demonstrates posterior dislocation of the humerus with respect to the glenoid.

FIGURE 2.55 CT arthrogram knee. Coronal CT image obtained after intraarticular injection of iodinated contrast demonstrates normal menisci with focal fissuring of medial tibial articular cartilage (arrowhead). A transverse band of sclerosis in the medial tibial plateau (arrow) represents stress fracture.

FIGURE 2.54 Talocalcaneal coalition. A coronal reformatted CT image of both feet reveals bilateral middle facet subtalar coalitions, fibrous on the patient right and osseous on patient left.

rotational deformities of the long bones, particularly the femur and tibia, can be precisely quantified. Synostosis or osseous coalition also is nicely displayed with CT (Fig. 2.54). 

ARTHROPATHY

In general, CT has a limited role in the evaluation of arthropathy. When MR imaging is contraindicated because of clinical factors or technical reasons, CT arthrography of the shoulder and knee may be a reasonable next-best option (Fig. 2.55). In patients with advanced glenohumeral osteoarthritis, CT is often used to assess glenoid morphology before arthroplasty. Similarly, custom prostheses are often templated based on preoperative CT data. In painful post-arthroplasty patients,

FIGURE 2.56 Displaced glenoid prosthesis. A coronal reformatted CT arthrogram image of the glenohumeral joint in a patient with a total shoulder prosthesis reveals displaced low-density glenoid component (arrow) surrounded by radiodense intraarticular contrast.

MR imaging can be a challenge due to ferromagnetic artifact. Often, CT is helpful in detecting and defining the extent of periarticular osteolysis and prosthesis displacement when planning revision arthroplasty (Fig. 2.56). Finally, newer techniques using dual energy techniques can produce images that specifically highlight monosodium urate crystals in patients with gout. 

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FIGURE 2.57 Longitudinal stress fracture of tibia. A, Delayed bone scan demonstrates longitudinally oriented activity in the distal tibia. B and C, Fluid sensitive longitudinal and axial MR images reveal nonspecific ill-defined marrow edema. D, Axial CT image shows clearly defined longitudinally orient fracture in the posterior tibial cortex.

TUMOR EVALUATION

Although radiography and MRI are the primary imaging modalities used in bone and soft-tissue tumor evaluation, there are certain situations in which CT imaging is valuable. Occasionally, MRI detects marrow or cortical signal abnormalities that are indeterminate for fracture or tumor. CT images may reveal a cortical fracture not previously appreciated, essentially excluding tumor (Fig. 2.57). The nidus of an osteoid osteoma is often better visualized with CT than with MRI (Fig. 2.58). In almost all cases, MRI is preferred to CT is evaluation of soft-tissue masses. One exception involves myositis ossificans, in which the calcified margin of the post-traumatic lesion is much better appreciated with CT (Fig. 2.59). In patients with known osseous metastatic disease, the cross-sectional capability of CT is often of value in evaluating cortical integrity when assessing for risk of pathologic fracture. Finally, CT guidance is quite frequently used

for percutaneous biopsy or treatment of bone and soft-tissue lesions (see Fig. 2.58D). 

CONCLUSION As the growing field of musculoskeletal imaging is far broader than can be covered in this text, innumerable clinical situations in which MRI and CT can be used have not been discussed. Ongoing research is continually defining new indications for advanced imaging in orthopaedic patients. The MRI and CT techniques described in this chapter are widely available with most commercial imaging systems. Optimal image quality can be obtained only when meticulous attention is paid to imaging technique by both the radiologist and the technician. Greater interaction between orthopaedists and radiologists will ensure that studies are performed appropriately to solve the specific clinical problem.

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FIGURE 2.58 Osteoid osteoma. A, T1-weighted axial MR image shows medial femoral cortical thickening. B, Fluid sensitive axial MR image demonstrates bone marrow edema without a discrete lesion. C, Axial CT image reveals a radiolucent nidus within the thickened cortical bone consistent with osteoid osteoma. D, Axial CT image acquired during radiofrequency ablation confirms coaxial placement of the RF probe into the nidus.

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FIGURE 2.59 Myositis ossificans. A, Fluid sensitive axial image reveals a nonspecific increased signal intensity soft tissue mass posterior to the hip (arrowheads). B, Axial CT image shows a peripherally calcified mass confirming the diagnosis of myositis ossificans.

REFERENCES GENERAL Kijowski R, Gold GE: Routine 3D magnetic resonance imaging of joints, J Magn Reson Imaging 33:758, 2011.

FOOT AND ANKLE Boonthathip M, Chen L, Trudell DJ, Resnick DL: Tibiofibular syndesmotic ligaments: MR arthrography in cadavers with anatomic correlation, Radiology 254:827, 2010. Chhabra A, Soldatos TR, Challan M, et al.: 3-Tesla magnetic resonance imaging evaluation of posterior tibial tendon dysfunction with relevance to clinical staging, J Foot Ankle Surg 50:320, 2011. Ferkel RD, Tyorkin M, Applegate GR, Heinen GT: MRI evaluation of anterolateral soft tissue impingement of the ankle, Foot Ankle Int 31:655, 2010. Ford GM, Genuario J, Kinkartz J, et  al.: Return-to-play outcomes in professional baseball players after medial ulnar collateral ligament injuries: comparison of operative versus nonoperative treatment based on magnetic resonance imaging findings, Am J Sports Med 44:723, 2016. Gonzalez FM, Morrison WB: Magnetic resonance imaging of sports injuries involving the ankle, Top Magn Reson Imaging 24:205, 2015. Hembree WC, Wittstein JR, Vinson EN, et al.: Magnetic resonance imaging features of osteochondral lesions of the talus, Foot Ankle Int 33:591, 2012. Ikoma K, Ohashi S, Maki M, et  al.: Diagnostic characteristics of standard radiographs and magnetic resonance imaging of ruptures of the tibialis posterior tendon, J Foot Ankle Surg 55:542, 2016. Joshy S, Abdulkadir U, Chaganti S, et al.: Accuracy of MRI scan in the diagnosis of ligamentous and chondral pathology in the ankle, Foot Ankle Surg 16:78, 2010. Jung HG, Kim NR, Kim TH, et al.: Magnetic resonance imaging and stress radiography in chronic lateral ankle instability, Foot Ankle Int 38:621, 2017. Kanamoto T, Shiozaki Y, Tanaka Y, et al.: The use of MRI in pre-operative evaluation of anterior talofibular ligament in chronic ankle instability, Bone Joint Res 3:241, 2014. Kraeutler MJ, Purcell JM, Hunt KJ: Chronic Achilles tendon ruptures, Foot Ankle Int 38:921, 2017.

Kwon DG, Sung KH, Chung CY, et al.: Associations between MRI findings and symptoms in patients with chronic ankle sprain, J Foot Ankle Surg 53:411, 2014. Nazarenko A, Beltran LS, Bencardino JT: Imaging evaluation of traumatic ligamentous injuries of the ankle and foot, Radiol Clin North Am 51:455, 2013. Petersen B, Fitzgerald J, Schreibman K: Musculotendinous magnetic resonance imaging of the ankle, Semin Roentgenol 45:250, 2010. Porrino JA, Pettis CR, Lewis G, et al.: CT and MR imaging of the postoperative ankle and foot, Radiographics 36:1828, 2016. Sofka CM: Technical considerations: best practices for MR imaging of the foot and ankle, Magn Reson Imaging Clin N Am 25(1), 2017. Sung W, Weil Jr L, Weil LS, Rolfes RJ: Diagnosis of plantar plate injury by magnetic resonance imaging with reference to intraoperative findings, J Foot Ankle Surg 51:570, 2012.

KNEE Cho HW, Suh JS, Park JO, et al.: Three-dimensional fast spin-echo imaging without fat suppression of the knee: diagnostic accuracy comparison to fat-suppressed imaging on 1.5T MRI, Yonsei Med J 58:1186, 2017. Choi JY, Chang EY, Cunha GM, et  al.: Posterior medial meniscus root ligament lesions: MRI classification and associated findings, AJR Am J Roentgenol 203:1286, 2014. Choi SH, Bae S, Ji SK, Chang MJ: The MRI findings of meniscal root tear of the medial meniscus: emphasis on coronal, sagittal, and axial images, Knee Surg Sports Traumatol Arthrosc 20:2098, 2012. Davis KW, Rosas HG, Graf BK: Magnetic resonance imaging and arthroscopic appearance of the menisci of the knee, Clin Sports Med 32:449, 2013. Derby E, Imrecke J, Henckel J, et al.: How sensitive and specific is 1.5 Tesla MRI for diagnosing injuries in patients with knee dislocation? Knee Surg Sports Traumatol Arthrosc 25:517, 2017. Dufka FL, Lansdown DA, Zhang AL, et al.: Accuracy of MRI evaluation of meniscus tears in the setting of ACL injuries, Knee 23:460, 2016. Gnannt R, Chhabra A, Theodoropoulos JS, et al.: MR imaging of the postoperative knee, J Magn Reson Imaging 34:1007, 2011. Hash TW: Magnetic resonance imaging of the knee, Sports Health 5:78, 2013. Kijowski R, Rosas H, Williams A, et  al.: MRI characteristics of torn and untorn post-operative menisci, Skeletal Radiol 46:1353, 2017.

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CHAPTER 2  ADVANCED IMAGING IN ORTHOPAEDICS Kosy JD, Eyres KD, Toms AD: The value of magnetic resonance imaging in investigating a painful total knee arthroplasty, J Arthroplasty 26:977, 2011. Lance V, Heilmeier UR, Joseph GB, et al.: MR imaging characteristics and clinical symptoms related to displaced meniscal flap tears, Skeletal Radiol 44:375, 2015. Lin E: Magnetic resonance imaging of the knee: clinical significance of common findings, Curr Probl Diagn Radiol 39:152, 2010. Mohankumar R, White LM, Naraghi A: Pitfalls and pearls in MRI of the knee, AJR Am J Roentgenol 203:516, 2014. Nacey NC, Geeslin MG, Miller GW, et al.: Magnetic resonance imaging of the knee: an overview and update of conventional and state of the art imaging, J Magn Reson Imaging 45:1257, 2017. Naraghi AM, White LM: Imaging of athletic injuries of knee ligaments and menisci: sports imaging series, Radiology 281(23), 2016. Naraghi A, White LM: MR imaging of cruciate ligaments, Magn Reson Imaging Clin N Am 22:557, 2014. Nicandri GT, Slaney SL, Neradilek MB, et al.: Can magnetic resonance imaging predict posterior drawer laxity at the time of surgery in patients with knee dislocation or multiple-ligament knee injury? Am J Sports Med 39:1053, 2011. Quatman CE, Hettrich CM, Schmitt LC, Spindler KP: The clinical utility and diagnostic performance of magnetic resonance imaging for identification of early and advanced knee osteoarthritis: a systematic review, Am J Sports Med 39:1557, 2011. Rosas HG: Magnetic resonance imaging of the meniscus, Magn Reson Imaging Clin N Am 22:493, 2014. Slattery T, Major N: Magnetic resonance imaging pitfalls and normal variations: the knee, Magn Reson Imaging Clin North Am 18:675, 2010. Smith C, McGarvey C, Harb Z, et al.: Diagnostic efficacy of 3-T MRI for knee injuries using arthroscopy as a reference standard: a meta-analysis, AJR Am J Roentgenol 207:369, 2016. Subhas N, Patel SH, Obuchowski NA, Jones MH: Value of knee MRI in the diagnosis and management of knee disorders, Orthopedics 37:e109, 2014. Tyler P, Datir A, Saifuddin A: Magnetic resonance imaging of anatomical variations in the knee: part 1. Ligamentous and musculotendinous, Skeletal Radiol 39:1161, 2010. Tyler P, Datir A, Saifuddin A: Magnetic resonance imaging of anatomical variations in the knee: part 2. Miscellaneous, Skeletal Radiol 39:1175, 2010. Van Dyck P, Vanhoenacker FM, Gielen JL, et al.: Three Tesla magnetic resonance imaging of the anterior cruciate ligament of the knee: can we differentiate complete from partial tears? Skeletal Radiol 40:701, 2011. Zheng L, Shi H, Feng Y, et al.: Injury patterns of medial patellofemoral ligament and correlation analysis with articular cartilage lesions of the lateral femoral condyle after acute lateral patellar dislocation in children and adolescents: an MRI evaluation, Injury 46:1137, 2015.

HIP Albers CE, Wambeek N, Hanke MS, et  al.: Imaging of femoroacetabular impingement—current concepts, J Hip Preserv Surg 3:245, 2016. Annabell L, Master V, Rhodes A, et al.: Hip pathology: the diagnostic accuracy of magnetic resonance imaging, J Orthop Surg Res 13:127, 2018. Berkowitz JL, Potter HG: Advanced MRI techniques for the hip joint: focus on the postoperative hip, AJR Am J Roentgenol 209:534, 2017. Carstensen SE, McCrum EC, Pierce JL, et al.: Magnetic resonance imaging (MRI) and hip arthroscopy correlations, Sports Med Arthrosc Rev 25:199, 2017. Chopra A, Grainger AJ, Dube B, et al.: Comparative reliability and diagnostic performance of conventional 3T magnetic resonance imaging and 1.5T magnetic resonance arthrography for the evaluation of internal derangement of the hip, Eur Radiol 28:963, 2018. Coker DJ, Zoga AC: The role of magnetic resonance imaging in athletic pubalgia and core muscle injury, Top Magn Reson Imaging 24:183, 2015. Crema MD, Watts GJ, Guermazi A, et al.: A narrative overview of the current status of MRI of the hip and its relevance for osteoarthritis research— what we know, what has changed and where are we going? Osteoarthritis Cartilage 25(1), 2017.

Crespo-Rodriguez AM, De Lucas-Villarrubia JC, Pastrana-Ledesma M, et al.: The diagnostic performance of non-contrast 3-Tesla magnetic resonance imaging (3-T) MRI) vrsus 1.5-Tesla magnetic resonance arthrograpy (1.5T MRA) in femoro-acetabular impingement, Eur J Radiol 88:109, 2017. Di Pietto F, Chianca V, Zappia M, et  al.: Articular and peri-articular hip lesions in soccer players. The importance of imaging in deciding which lesions will need surgery and which can be treated conservatively? Eur J Radiol 105:227, 2018. Friedman T, Chen T, Chang A: MRI diagnosis of recurrent pigmented villonodular synovitis following total joint arthroplasty, HSS J 9:100, 2013. Gold SL, Burge AJ, Potter HG: MRI of hip cartilage: joint morphology, structure, and composition, Clin Orthop Relat Res 470:3321, 2012. Hayter CL, Potter HG, Su EP: Imaging of metal-on-metal hip resurfacing, Orthop Clin North Am 42:195, 2011. Haubro M, Stougaard C, Torfing T, Overgaard S: Sensitivity and specific of CT- and MRI-scanning in evaluation of occult fracture of the proximal femur, Injury 46:1557, 2015. Jayakar R, Merz A, Plotkin B, et al.: Magnetic resonance arthrography and the prevalence of acetabular labral tears in patients 50 years of age and older, Skeletal Radiol 45:1061, 2016. Jazrawi LM, Alaia MJ, Chang G, et  al.: Advances in magnetic resonance imaging of articular cartilage, J Am Acad Orthop Surg 19:420, 2011. Kavanagh EC, Read P, Carty F, et al.: Three-dimensional magnetic resonance imaging analysis of hip morphology in the assessment of femoral acetabular impingement, Clin Radiol 66:742, 2011. Kim HT, Oh MH, Lee JS: MR imaging as a supplement to traditional decision-making in the treatment of LCP disease, J Pediatr Orthop 31:246, 2011. Linda DD, Naraghi A, Murnaghan L, et al.: Accuracy of non-arthrographic 3T MR imaging in evaluation of intra-articular pathology of the hip in femoroacetabular impingement, Skeletal Radiol 46:299, 2017. Matharu GS, Mansour R, Dada O, et  al: Which imaging modality is most effective for identifying pseudotumours in metal-on-metal hip resurfacings requiring revision: ultrasound or MARS-MRI or both? Nachtrab O, Cassar-Pullicino VN, Lalam R, et al.: Role of MRI in hip fractures, including stress fractures, occult fractures, avulsion fractures, Eur J Radiol 81:3813, 2012. Naraghi A, White LM: MRI of labral and chondral lesions of the hip, AJR Am J Roentgenol 205:479, 2015. Newman JS, Newberg AH: MRI of the painful hip in athletes, Clin Sports Med 25:613, 2006. Park JH, Shon HC, Chang JS, et al.: How can MRI change the treatment strategy in apparently isolated greater trochanteric fracture? Injury 49:824, 2018. Petchprapa CN, Rosenberg ZS, Sconfienza LM, et al.: MR imaging of entrapment neuropathies of the lower extremity: part 1. The pelvis and hip, Radiographics 30:983, 2010. Potter HG, Schachar J: High resolution noncontrast MRI of the hip, J Magn Reson Imaging 31:268, 2010. Rakhra KS: Magnetic resonance imaging of acetabular tears, J Bone Joint Surg 93A(Suppl 2):28, 2011. Rehman H, Clement RG, Perks F, et al.: Imaging of occult hip fractures: CT or MRI? Injury 47:1297, 2016. Riley GM, McWalter EJ, Stevens KJ, et al.: MRI of the hip for the evaluation of femoroacetabular impingement: past, present, and future, J Magn Reson Imaging 41:558, 2015. Robinson P: Conventional 3-T MRI and 1.5-T MR arthrography of femoroacetabular impingement, AJR Am J Roentgenol 199:509, 2012. Sutter R, Zubler V, Hoffman A, et al.: Hip MRI: how useful is intraarticular contrast material for evaluating surgically proven lesions of the labrum and articular cartilage? AJR Am J Roentgenol 202:160, 2014. Tannast M, Pleus F, Bonel H, et al.: Magnetic resonance imaging in traumatic posterior hip dislocation, J Orthop Trauma 24:723, 2010. Tosum O, Algin O, Yalcin N, et al.: Ischiofemoral impingement: evaluation with new MRI parameters and assessment of their reliability, Skeletal Radiol 41:575, 2012.

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PART I  GENERAL PRINCIPLES Tsifountoudis I, Kraniotis P, Karantanas AH: Hip and pelvic: MRI of musculotendinous trauma and mimickers, Semin Musculoskelet Radiol 27:218, 2017. Walsh CP, Hubbard JC, Nessler JP, et  al.: MRI findings associated with recalled modular femoral neck Rejuvenate and ABG implants, J Arthroplasty 30:2021, 2015. Zoga AC, Hegazi TM, Roedl JB: Algorithm for imaging the hip in adolescents and young adults, Radiol Clin North A 54:913, 2016.

SPINE Bozzo A, Marcoux J, Radhakrishna M, et al.: The role of magnetic resonance imaging in the management of acute spinal cord injury, J Neurotrauma 28:1401, 2011. Como JJ: The role of MRI in the clearance of the cervical spine in the obtunded blunt trauma patient, J Trauma 68:1269, 2010. D’Aprile P, Nasuto M, Tarantino A, et  al.: Magnetic resonance imaging in degenerative disease of the lumbar spine: fat saturation technique and contrast medium, Acta Biomed 89:208, 2018. Diab M, Landman Z, Lubicky J, et al.: Use and outcome of MRI in the surgical treatment of adolescent idiopathic scoliosis, Spine 36:667, 2011. Durand DJ, Huisman TA, Carrino JA: MR imaging features of common variant spinal anatomy, Magn Reson Imaging Clin N Am 18:717, 2010. Dutoit JC, Vanderkerken MA, Verstraete KL: Value of whole body MRI and dynamic contrast enhanced MRI in the diagnosis, follow-up and evaluation of disease activity and extent in multiple myeloma, Eur J Radiol 82:1444, 2013. Fehlings MG, Arvin B: Magnetic resonance imaging and outcome, J Neurosurg Spine 12:56, 2010. Ganiyusufoglu AK, Onat L, Karatoprak O, et al.: Diagnostic accuracy of magnetic resonance imaging versus computed tomography in stress fractures of the lumbar spine, Clin Radiol 65:902, 2010. Goldberg AL, Kershah SM: Advances in imaging of vertebral and spinal cord injury, J Spinal Cord Med 33:105, 2010. Hanrahan CJ, Shah LM: MRI of spinal bone marrow: part 2, T1-weighted imaging-based differential diagnosis, AJR Am J Roentgenol 197:1309, 2011. Khanna P, Chau C, Dublin A, et al.: The value of cervical magnetic resonance imaging in the evaluation of the obtunded or comatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography, J Trauma 72:699, 2012. Kumar Y, Hayashi D: Role of magnetic resonance imaging in acute spinal trauma: a pictorial review, BMC Muculoskelet Disord 17:310, 2016. Land N, Su MY, Yu HJ, et  al.: Differentiation of myeloma and metastatic cancer in the spine using dynamic contrast-enhanced MRI, Magn Reson Imaging 31:1285, 2013. Lattig F, Fekete TF, Grob D, et al.: Lumbar facet joint effusion in MRI: a sign of instability in degenerative spondylolisthesis? Eur Spine J 21:276, 2012. Lee S, Lee JW, Yeom JS, et al.: A practical MRI grading system for lumbar foraminal stenosis, AJR Am J Roentgenol 194:1095, 2010. Machino M, Yukawa Y, Ito K, et al.: Can magnetic resonance imaging reflect the prognosis in patients of cervical spinal cord injury without radiographic abnormality? Spine 36:E1568, 2011. Malhorta A, Wu X, Kalra VB, et al.: Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis, Eur Radiol 27:1148, 2017. Merhemic Z, Stosic-Opincal T, Thurnher MM: Neuroimaging of spinal tumors, Magn Reson Imaging Clin N Am 24:563, 2016. Murphy JM, Park P, Patel RD: Cost-effectiveness of MRI to assess for posttraumatic ligamentous cervical spine injury, Orthopedics 37:e148, 2014. Nouri A, Martin AR, Mikulis D, et al.: Magnetic resonance imaging assessment of degenerative cervical myelopathy: a review of structural changes and measurement techniques, Neurosurg Focus 40:(E5), 2016. Ostergaard M, Poggenborg RP, Axelsen MB, Pedersen SJ: Magnetic resonance imaging in spondyloarthritis—how to quantify findings and measure response, Best Pract Res Clin Rheumatol 24:637, 2010. Ozturk C, Karadereler S, Orneck I, et al.: The role of routine magnetic resonance imaging in the preoperative evaluation of adolescent idiopathic scoliosis, Int Orthop 34:543, 2010.

Park HJ, Kim SS, Chung EC, et  al.: Clinical correlation of a new practical MRI method for assessing cervical spinal canal compression, AJR Am J Roentgenol 199:W197, 2012. Pizones J, Castillo E: Assessment of acute thoracolumbar fractures: challenges in multidetector computed tomography and added value of emergency MRI, Semin Musculoskelet Radiol 17:389, 2013. Pizones J, Izwuierdo E, Alvarez P, et al.: Impact of magnetic resonance imaging on decision making for thoracolumbar traumatic fracture diagnosis and treatment, Eur Spine J 20(Suppl 3):390, 2011. Rihn JA, Yang N, Fisher C, et al.: Using magnetic resonance imaging to accurately assess injury to the posterior ligamentous complex of the spine: a prospective comparison of the surgeon and radiologist, J Neurosurg Spine 12:391, 2010. Roudarsi B, Jarvik JG: Lumbar spine MRI for low back pain: indications and yield, AJR Am J Roentgenol 195:550, 2010. Savvopoulou V, Martis TG, Koureas A, et al.: Degenerative endplate changes of the lumbosacral spine: dynamic contrast-enhanced MRI profiles related to age, sex, and spinal level, J Magn Reson Imaging 33:382, 2011. Schoenfeld AJ, Bono CM, McGuide KJ, et al.: Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis, J Trauma 68:109, 2010. Shah LM, Hanrahan CJ: MRI of spinal bone marrow: part 1, techniques and normal age-related appearances, AJR Am J Roentgenol 197:1298, 2011. Sheehan NJ: Magnetic resonance imaging for low back pain: indications and limitations, Ann Rheum Dis 69:(7), 2010. Soult MC, Weireter LJ, Britt RC, et al.: MRI as an adjunct to cervical spine clearance: a utility analysis, Am Surg 78:741, 2012. Weber U, Maksymowych WP: Sensitivity and specificity of magnetic resonance imaging for axial spondyloarthritis, Am J Med Sci 341:272, 2011.

SHOULDER Ajuied A, McGarvey CP, Harb Z, et al.: Diagnosis of glenoid labral tears using 3-tesla MRI vs. 3-tesla MRA: a systematic review and meta-analysis, Arch Orthop Trauma Surg 138:699, 2018. Beltran LS, Bencardino JT, Steinbach LS: Postoperative MRI of the shoulder, J Magn Reson Imaging 40:1280, 2014. Chang IY, Polster JM: Pathomechanics and magnetic resonance imaging of the thrower’s shoulder, Radiol Clin North Am 54:801, 2016. Cook TS, Stein JM, Simonson S, Kim W: Normal and variant anatomy of the shoulder on MRI, Magn Reson Imaging Clin North Am 19:581, 2011. Fitzpatrick D, Walz DM: Shoulder MR imaging normal variants and imaging artifacts, Magn Reson Imaging Clin North Am 18:615, 2010. Garwood ER, Mitti GS, Alaia M, et al.: Use of shoulder imaging in the outpatient setting: a pilot study, Curr Probl Diagn Radiol pii: S0363-0188 (17):30260–30268, 2017, https://doi.org/10.1067/j.cpradiol.2017.10.011, [Epub ahead of print]. Gazzola S, Bleakney RR: Current imaging of the rotator cuff, Sports Med Arthrosc 19:300, 2011. Giles JW, Owens BD, Athwal GS: Estimating glenoid width for instabilityrelated bone loss: a CT evaluation of an MRI formula, Am J Sports Med 43:1726, 2015. Gottsegen CJ, Merkle AN, Bencardino JT, et al.: Advanced MRI techniques of the shoulder joint: current applications in clinical practice, AJR Am J Roentgenol 209:544, 2017. Gyftopoulos S, Strauss EJ: MRI-arthroscopy correlation for shoulder anatomy and pathology: a teaching guide, AJR Am J Roentgenol 204:W684, 2015. Gyftopoulos S, Yemin A, Beltran L, et  al.: Engaging Hill-Sachs lesion: is there an association between this lesion and findings on MRI? AJR Am J Roentgenol 201:W633, 2013. Houtz CG, Schwartzberg RS, Barry JS, et al.: Shoulder MRI accuracy in the community setting, J Shoulder Elbow Surg 20:537, 2011. Knapik DM, Voos JE: Magnetic resonance imaging and arthroscopic correlation in shoulder instability, Sports Med Arthrosc Rev 25:172, 2017. Lee SC, Williams D, Endo Y: The repaired rotator cuff: MRI and ultrasound evaluation, Curr Rev Musculoskelet Med 11:92, 2018.

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CHAPTER 2  ADVANCED IMAGING IN ORTHOPAEDICS Lin DJ, Wong TT, Kazam JK: Shoulder injuries in the overhead-throwing athlete: epidemiology, mechanisms of injury, and imaging findings, Radiology 286:370, 2018. Llopis E, Montesinos P, Guedez MT, et al.: Normal shoulder MRI and MR arthrography: anatomy and technique, Semin Musculoskelet Radiol 19:212, 2015. Major NM, Browne J, Domzalski T, et al.: Evaluation of the glenoid labrum with 3-T MRI: is intraarticular contrast necessary? AJR Am J Roentgenol 196:1139, 2011. Park S, Lee DH, Yoon SH, et  al.: Evaluation of adhesive capsulitis of the shoulder with fat-suppressed T2-weighted MRI: association between clinical feature and MRI findings, AJR Am J Roentgenol 207:135, 2016. Petchprapa CN, Beltran LS, Jazrawi LM, et al.: The rotator interval: a review of anatomy, function, and normal and abnormal MRI appearance, AJR Am J Roentgenol 195:567, 2010. Roy EA, Cheyne I, Andrews G, et al.: Beyond the cuff: MR imaging of labroligamentous injuries in the athletic shoulder, Radiology 278:316, 2016. Shin YK, Ryu KN, Prk JS, et al.: Predictive factors of retear in patients with repaired rotator cuff tear on shoulder MRI, AJR Am J Roentgenol 210:134, 2018. Stillwater L, Koenig J, Maycher B, et al.: 3D-MR vs. 3D-CT of the shoulder in patients with glenohumeral instability, Skeletal Radiol 46:325, 2017. Suh CH, Yun S, Jin W, et al.: Systematic review and meta-analysis of magnetic resonance imaging features for diagnosis of adhesive capsulitis of the shoulder, Eur Radiol 2018, https://doi.org/10.1007/s00330-0185604-y, [Epub ahead of print]. Veen EJD, Donders CM, Westerbeek RE, et al.: Predictive findings on magnetic resonance imaging in patients with asymptomatic aromioclavicular osteoarthritis, J Shoulder Elbow Surg 27:e252, 2018. Welton KL, Bartley JH, Major NM, et al.: MRI to arthroscopy correlations in SLAP lesions and long head biceps pathology, Sports Med Arthrosc Rev 25:179, 2017.

ELBOW, WRIST, AND HAND Awan H, Goitz R: MRI correlation of radial head fractures and forearm injuries, Hand (N Y) 12:145, 2017. Bergh TH, Steen K, Lindau T, et al.: Costs analysis and comparison of usefulness of acute MRI and 2 weeks of case immobilization for clinically suspected scaphoid fractures, Acta Orthop 86:303, 2015. Datis A: MRI of the hand and fingers, Top Magn Reson Imaging 24:109, 2015. Ersoy H, Pomeranz SJ: Palmer classification and magnetic resonance imaging findings of ulnocarpal impingement, J Surg Orthop Adv 24:257, 2015. Festa A, Mulieri PJ, Newman JS, et al.: Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture, J Hand Surg [Am] 35:77, 2010. Gupta P, Lenchik L, Wuertzer SD, Pacholke DA: High-resolution 3-T MRI of the fingers: review of anatomy and common tendon and ligament injuries, AJR Am J Roentgenol 204:W314, 2015. Haillotte G, Bachy M, Delpont M, et  al.: The use of magnetic resonance imaging in management of minimally displaced or nondisplaced lateral humeral condyle fractures in children, Pediatr Emerg Care 33:21, 2017. Joyner PW, Bruce J, Hess R, et al.: Magnetic resonance imaging-based classification for ulnar collateral ligament injuries of the elbow, J Shoulder Elbow Surg 25:1710, 2016. Krabben A, Stomp W, van Nies JA, et  al.: MRI-detected subclinical joint inflammation is associated with radiographic progression, Ann Rheum Dis 73:2034, 2014. Magee T: Accuracy of 3-T MR arthrography versus conventional 3-T MRI of elbow tendons and ligaments compared with surgery, AJR Am J Roentgenol 204:W70, 2015. Mahmood A, Fountain J, Vasireddy N, Waseem M: Wrist MRI arthrogram v wrist arthroscopy: what are we finding? Open Orthop J 6:194, 2012. Mallee W, Doornberg JN, Ring D, et  al.: Comparison of CT and MRI for diagnosis of suspected scaphoid fractures, J Bone Joint Surg Am 93:20, 2011. Malone WJ, Snowden R, Alvi F, Klena JC: Pitfalls of wrist MR imaging, Magn Reson Imaging Clin N Am 18:643, 2010.

Mete BD, Gursoy M, Resnick D: A rare cause of posterolateral elbow pain: radiohumeral plica syndrome with typical MRI findings, JBR-BTR 97:371, 2014. Onen MR, Kayalara AE, Ilbas EN, et al.: The role of wrist magnetic resonance imaging in the differential diagnosis of the carpal tunnel syndrome, Turk Neurosurg 25:701, 2015. Ringler MD: MRI of wrist ligaments, J Hand Surg [Am] 38:2034, 2013. Sampaio ML, Schweitzer ME: Elbow magnetic resonance imaging variants and pitfalls, Magn Reson Imaging Clin North Am 18:633, 2010. Simonson S, Lott K, Major NM: Magnetic resonance imaging of the elbow, Semin Roentgenol 45:180, 2010. Stein JM, Cook TS, Simonson S, Kim W: Normal and variant anatomy of the wrist and hand on MR imaging, Magn Reson Imaging Clin North Am 19:595, 2011. Stevens KJ, McNally EG: Magnetic resonance imaging of the elbow in athletes, Clin Sports Med 29:521, 2010. Taljanovic MS, Malan JJ, Sheppard JE: Normal anatomy of the extrinsic capsular wrist ligaments by 3-T MRI and high-resolution ultrasonography, Semin Musculoskelet Radiol 16:104, 2012. Thorkelson M, Augustyn R, Barnes CE: Pediatric elbow fracture diagnosis using 3-D MR imaging, Radiol Technol 89:75, 2017. Tsujimoto Y, Ryoke K, Yamagami N, et al.: Delineation of extensor tendon of the hand by MRI: usefulness of “soap-bubble” mip processing technique, Hand Surg 20:93, 2015. Walton MJ, Mackie K, Fallon M, et al.: The reliability and validity of magnetic resonance imaging in the assessment of chronic lateral epicondylitis, J Hand Surg [Am] 36:475, 2011.

TUMORS Bancroft LW: Postoperative tumor imaging, Semin Musculoskelet Radiol 15:425, 2011. Costa FM, Ferreira EC, Vianna EM: Diffusion-weighted magnetic resonance imaging for the evaluation of musculoskeletal tumors, Magn Reson Imaging Clin North Am 19:159, 2011. D’Ippolito G, Torres LR, Saito Filho CF, Ferreira RM: CT and MRI in monitoring response: state-of-the-art and future developments, Q J Nucl Med Mol Imaging 55:603, 2011. Hansford BG, Stacy GS: From tumor to trauma: etiologically deconstructing a unique differential diagnosis of musculoskeletal entities with high signal intensity on T1-weighted MRI, AJR Am J Roentgenol 204:817, 2015. Padhani AR, Makris A, Gall P, et al.: Therapy monitoring of skeletal metastases with whole-body diffusion MRI, J Magn Reson Imaging 39:1049, 2014. Subhawong TK, Jacobs MA, Fayad LM: Insights into quantitative diffusionweighted MRI for musculoskeletal tumor imaging, AJR Am J Roentgenol 203:560, 2014. Vandergugten S, Traore SY, Cartiaux O, et al.: MRI evaluation of resection margins in bone tumour surgery, Sarcoma 2014:967848, 2014.

COMPUTED TOMOGRAPHY Barg A, Bailey T, Richter M, et al.: Weightbearing computed tomography of the foot and ankle: emerging technology topical review, Foot Ankle Int 39:376, 2018. Brink M, Steenbakkers A, Holla M, et al.: Single-shot CT after wrist trauma: impact on detection accuracy and treatment of fractures, Skeletal Radiol, 2018, https://doi.org/10.1007/s00256-018-3097-z, [Epub ahead of print]. Cahill CW, Radcliff KE, Reitman CA: Enhancing evaluation of the cervical spine: thresholds for normal CT relationships in the subaxial cervical spine, Int J Spine Surg 12:510, 2018. Castiglia MT, Nogueira-Barbosa MH, Messias AMV, et  al.: The impact of computed tomography on decision making in tibial plateau fractures, J Knee Surg 31:1007, 2018. Cerquiglini A, Henckel J, Hothi HS, et al.: Computed tomography techniques help understand wear patterns in retrieved total knee arthroplasty, J Arthroplasty 33:3030, 2018. Cheema AN, Niziolek PJ, /Steinberg D, et al.: The effect of computed tomography scans oriented along the longitdinual scaphoid axis on measurements of deformity and displacement in scaphoid fractures, J Hand

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PART I  GENERAL PRINCIPLES Surg Am 2018. pii: S0363-5023(18)30628-2, https://doi.org/10.1016/j. jhsa.2018.05.006, [Epub ahead of print]. Figueroa J, Guarachi JP, Matas J, et al.: Is computed tomography an accurate and reliable method for measuring total knee arthroplasty component rotation? Int Orthop 40:709, 2016. Gupta P, Prakash M, Sharma N, et al.: Computed tomography detection of clinically unsuspected skeletal tuberculosis, Clin Imaging 39:1056, 2015. Haubro M, Stougaard C, Torfing T, et al.: Sensitivity and specificity of CTand MRI-scanning in evaluation of occult fracture of the proximal femur, Injury 46:1557, 2015. Hecht G, Shelton TJ, Saiz Jr AM, et al.: CT-measurement predicts shortening of stable intertrochanteric hip fractures, J Orthop 15:952, 2018. Ho A, Kurdziel MD, Koueiter DM, et  al.: Three-dimensional computed tomography measurement of varying Hill-Sachs lesion size, J Shoulder Elbow Surg 27:350, 2018. Imerci A, Aydogan NH, Topsakal FE: The role of computed tomography scans in diaphyseal femur fractures following gunshot injuries: a survey of orthopaedic traumatologists, Injury 49:731, 2018. Jakubietz MG, Mages L, Zahn RK, et al.: The role of CT scan in postoperative evaluation of distal radius fractures: retrospective analysis in regard to complications and revision rates, J Orthop Sci 22:434, 2017. Jaroma A, Suomalainen JSm Niemitukia L, et  al.: Imaging of symptomatic total knee arthroplasty with cone beam computed tomography, Acta Radiol 59:1500, 2018. Kozaci N, Avci M, Ararat E, et  al.: Comparison of ultrasonography and computed tomography in the determination of traumatic injuries, Am J Emerg Med 2018. pii: S0735-6757(18)30637-5, https://doi.org/10.1016/j. ajem.2018.08.002, [Epub ahead of print]. Kumar A, Mishra P, Tandon A, et al.: Effect of CT on management plan in malleolar ankle fractures, Foot Ankle Int 39:59, 2018. Li WY, Lin KC: Three-dimensional computed tomography reduced fixation failure of intramedullary nailing for unstable type of intertrochanteric fracture, J Orthop Trauma 32:e381, 2018. Mansfield C, Ali S, Komperda K, et al.: Optimizing radiation dose in computed tomography of articular fractures, J Orthop Trauma 31:401, 2017. Neubauer J, Benndorf M, Ehritt-Braun C, et al.: Comparison of the diagnostic accuracy of cone beam computed tomography and radiography for scaphoid fractures, Sci Rep 8:3906, 2018. Rajasekaran S, Vaccaro AR, Kanna RM, et al.: The value of CT and MRI in the classification and surgical decision-making among spine surgeons in thoracolumbar spinal injuries, Eur Spine J 26:1463, 2017. Stoltny T, Pasek J, Leksowska-Pawliczek M, et al.: Importance of computed tomography (CT) in talar neck fractures, Case studies, Ortop Traumatol Rehabil 20:31, 2018. Thomas RW, Williams HL, Carpenter EC, et al.: The validity of investigating occult hip fractures using multidetetor CT, Br J Radiol 89:20150250, 2016.

Wiewiorski M, Hoechel S, Anderson AE, et al.: Computed tomographic evaluation of joint geometry in patients with end-stage ankle osteoarthritis, Foot Ankle Int 37:644, 2016. Wu XD, Xiang BY, Schotanus MGM, et al.: CT- versus MRI-based patientspecific instrumentation for total knee arthroplasty: a systematic review and meta-analysis, Surgeon 15:336, 2017.

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Yansouni CP, Mak A, Libman MD: Limitations of magnetic resonance imaging in the diagnosis of osteomyelitis underlying diabetic foot ulcers, Clin Infect Dis 48:135, 2009.

SUPPLEMENTAL REFERENCES GENERAL Anderson SE, Steinbach LS, Schlicht S, et al.: Magnetic resonance imaging of bone tumors and joints, Top Magn Reson Imaging 18:457, 2007. Heron C: Magnetic resonance imaging in joint disease, Br J Hosp Med 51:97, 1994. Ho CP: MR imaging of sports-related injuries, Magn Reson Imaging 7:1, 1999. Resnick D, Kand HS: Internal derangement of joints, Philadelphia, 2006, WB Saunders. Rubin SJ, Feldman F, Staron RB, et al.: Magnetic resonance imaging of muscle injury, Clin Imaging 19:263, 1995. Stoller DW: Magnetic resonance imaging in orthopaedics and sports medicine, ed 3, Philadelphia, 2006, Lippincott Williams & Wilkins.

FOOT AND ANKLE Beltran J: Magnetic resonance imaging of the ankle and foot, Orthopedics 17:1075, 1994. Collins MS, Felmlee JP: 3T magnetic resonance imaging of ankle and hindfoot tendon pathology, Top Magn Reson Imaging 20:175, 2009. Ferkel RD, Flannigan BD, Elkins BS: Magnetic resonance imaging of the foot and ankle: correlation of normal anatomy with pathologic conditions, Foot Ankle 11:289, 1991. Frey C, Kerr R: Magnetic resonance imaging and the evaluation of tarsal tunnel syndrome, Foot Ankle 14:159, 1993. Hepple S, Winson IG, Glew D: Osteochondral lesions of the talus: a revised classification, Foot Ankle Int 20:789, 1999. Ho CP: Magnetic resonance imaging of the ankle and foot, Semn Roentgenol 30:294, 1995. Hogan JF: Posterior tibial tendon dysfunction and MRI, J Foot Ankle Surg 32:467, 1993. Hubbard AM, Davidson RS, Meyer JS, Mahboubi S: Magnetic resonance imaging of skewfoot, J Bone Joint Surg 78A:389, 1996. Kapoor A, Page S, Lavalley M, et al.: Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis, Arch Intern Med 167:125, 2007. Kerr R: Magnetic resonance imaging of the foot and ankle, Semin Roentgenol 35:306, 2000. Leffler S, Disler DG: MR imaging of tendon, ligament, and osseous abnormalities of the ankle and hindfoot, Radiol Clin North Am 40:1147, 2002. Morrison WB: Magnetic resonance imaging of sports injuries of the ankle, Top Magn Reson Imaging 14:178, 2003. Morrison WB, Schweitzer ME, Wapner KL, et  al.: Osteomyelitis in feet of diabetics: clinical accuracy, surgical utility, and cost-effectiveness of MR imaging, Radiology 196:557, 1995. Morshirfar A, Campbell JT, Khanna J, et al.: Magnetic imaging of the ankle: techniques and spectrum of disease, J Bone Joint Surg Am 85:7, 2003. Perrich KD, Goodwin DW, Hecht PJ, Cheung Y: Ankle ligaments on MRI: appearance of normal and injured ligaments, AJR Am J Roentgenol 193:687, 2009. Reach Jr JS, Amrami KK, Felmlee JP, et al.: The compartments of the foot: a 3-Tesla magnetic resonance imaging study with clinical correlates for needle pressure testing, Foot Ankle Int 28:584, 2007. Recht MP, Donley DG: Magnetic resonance imaging of the foot and ankle, J Am Acad Orthop Surg 9:187, 2001. Rijke AM, Goitz HT, McCue III FC, Dee PM: Magnetic resonance imaging of injury to the lateral ankle ligaments, Am J Sports Med 21:528, 1993. Roberts DK, Pomeranz SJ: Current status of magnetic resonance in radiologic diagnosis of foot and ankle injuries, Orthop Clin North Am 25:61, 1994. Steinbronn DJ, Bennett GL, Kay DB: The use of magnetic resonance imaging in the diagnosis of stress fractures of the foot and ankle, Foot Ankle Int 15:80, 1994. Terk MR, Kwong PK: Magnetic resonance imaging of the foot and ankle, Clin Sports Med 13:883, 1994.

KNEE Beall DP, Googe JD, Moss JT, et al.: Magnetic resonance imaging of the collateral ligaments and the anatomic quadrants of the knee, Magn Reson Imaging Clin North Am 15:53, 2007. Bernstein J, Cain EL, Kneeland JB, Dalinka MK: The incidence of pathology detected by magnetic resonance of the knee: differences based on the specialty of the requesting physician, Orthopedics 26:483, 2003. Boeree NR, Watkinson AF, Ackroyd CE, Johnson C: Magnetic resonance imaging of meniscal and cruciate injuries of the knee, J Bone Joint Surg 73B:452, 1991. Dillon EH, Pope CF, Jokl P, et al.: Follow-up of grade 2 meniscal abnormalities in the stable knee, Radiology 181:849, 1991. Dipaola JD, Nelson DW, Colville MR: Characterizing osteochondral lesions by magnetic resonance imaging, Arthroscopy 7:101, 1991. Galea A, Giuffre B, Dimmick S, et al.: The accuracy of magnetic resonance imaging scanning and its influence on management decisions in knee surgery, Arthroscopy 25:473, 2009. Gatehouse PD, Thomas RW, Robson MD, et al.: Magnetic resonance imaging of the knee with ultrashort TE pulse sequences, Magn Reson Imaging 22:1061, 2004. Graf BK, Cook DA, DeSmet AA, Keene JS: Bone bruises” on magnetic resonance imaging evaluation of anterior cruciate ligament injuries, Am J Sports Med 21:220, 1993. Hall LD: Magnetic resonance imaging as a noninvasive means for quantitating the dimensions of articular cartilage in the human knee, Arthritis Rheum 50:5, 2004. Herzog RJ, Silliman JF, Hutton K, et al.: Measurements of the intercondylar notch by plain film radiography and magnetic resonance imaging, Am J Sports Med 22:2401, 1994. Kelly MA, Flock TJ, Kimmell JA, et al.: MR imaging of the knee: clarification of its role, Arthroscopy 7:78, 1991. Khanna AJ, Cosgarea AJ, Mont MA, et al.: Magnetic resonance imaging of the knee: current techniques and spectrum of disease, J Bone Joint Surg 83A(Suppl 2 pt 2):128, 2001. Kuikka PI, Sillanpaä P, Mattila VM, et al.: Magnetic resonance imaging in acute traumatic and chronic meniscal tears of the knee: a diagnostic accuracy study in young adults, Am J Sports Med 37:1003, 2009. Lim PS, Schweiter ME, Bhatia M, et al.: Repeat tear of postoperative meniscus: potential MR imaging signs, Radiology 210:183, 1999. Liu SH, Osti L, Henry M, Bocchi L: The diagnosis of acute complete tears of the anterior cruciate ligament: comparison of MRI, arthrometry and clinical examination, J Bone Joint Surg 77B:586, 1995. Lowenberg DW, Fledman ML: Magnetic resonance imaging diagnosis of discoid medial meniscus, Arthroscopy 9:704, 1993. Luhmann SJ, Schootman M, Gordon JE, Wright RW: Magnetic resonance imaging of the knee in children and adolescents: its role in clinical decision-making, J Bone Joint Surg 87A:497, 2005. Macintyre J: Magnetic resonance imaging in acute knee injuries, Clin J Sport Med 10:304, 2000. Mackenzie R, Dixon AK, Keene GS, et al.: Magnetic resonance imaging of the knee: assessment of effectiveness, Clin Radiol 51:245, 1996. Marks PH, Chew BH: Magnetic resonance imaging of knee ligaments, Am J Knee Surg 8:181, 1995. Maurer EJ, Kaplan KA, Dussault RG, et al.: Acutely injured knee: effect of MR imaging on diagnostic and therapeutic decisions, Radiology 204:799, 1997. Maywood RM, Murphy BJ, Uribe JW, Hechtman KS: Evaluation of arthroscopic anterior cruciate ligament reconstruction using magnetic resonance imaging, Am J Sports Med 21:523, 1993. McCauley TR, Disler DG: Magnetic resonance imaging of the articular cartilage of the knee, J Am Acad Orthop Surg 9:2, 2001. Mohana-Borges AV, Resnick D, Chung CB: Magnetic resonance imaging of knee instability, Semin Musculoskelet Radiol 9:17, 2005.

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PART I  GENERAL PRINCIPLES Rubin DA: Update on the knee, Magn Reson Imaging 8:2, 2000. Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee, Am J Sports Med 33:131, 2005. Sansone V, de Ponti A, Paluello GM, del Maschio A: Popliteal cysts and associated disorders of the knee: critical review with MR imaging, Int Orthop 19:275, 1995. Schatz JA, Potter HG, Rodeo SA, et al.: MR imaging of anterior cruciate ligament reconstruction, AJR Am J Roentgenol 169:223, 1997. Sofka CM, Potter HG, Figgie M, Laskin R: Magnetic resonance imaging of total knee arthroplasty, Clin Orthop Relat Res 406:129, 2003. Stork A, Feller JF, Sanders TG, et al.: Magnetic resonance imaging of the knee ligaments, Semin Roentgenol 35:256, 2000. Thornton DD, Rubin DA: Magnetic resonance imaging of the knee menisci, Semin Roentgenol 35:217, 2000. Tyson LL, Daughters Jr TC, Ryo RK, Crues III JV: MRI appearance of meniscal cysts, Skeletal Radiol 24:421, 1995.

HIP Anderson SE, Sienbenrock KA, Mamisch TC, Tannast M: Femoroacetabular impingement magnetic resonance imaging, Top Magn Reson Imaging 20:123, 2009. Asnis SE, Gould ES, Bansal M, et  al.: Magnetic resonance imaging of the hip after displaced femoral neck fractures, Clin Orthop Relat Res 298:191, 1994. Beltran J, Opsha O: MR imaging of the hip: osseous lesions, Magn Reson Imaging Clin North Am 13:665, 2005. Berbeeten KM, Hermann KL, Hasselqvist M, et al.: The advantages of MRI in the detection of occult hip fractures, Eur Radiol 15:165, 2004. Boutin RD, Newman JS: MR imaging of sports-related hip disorders, Magn Reson Imaging Clin North Am 11:255, 2003. Chana R, Noorani A, Ashwood N, et al.: The role of MRI in the diagnosis of proximal femoral fractures in the elderly, Injury 367:185, 2006. Cooper HJ, Ranawat AS, Potter HG, et al.: Magnetic resonance imaging in the diagnosis and management of hip pain after total hip arthroplasty, J Arthroplasty 24:661, 2009. Edwards DJ, Lomas D, Villar RN: Diagnosis of the painful hip by magnetic resonance imaging and arthroscopy, J Bone Joint Surg 77B:374, 1995. Evans PD, Wilson C, Lyons K: Comparison of MRI with bone scanning for suspected hip fracture in elderly patients, J Bone Joint Surg 76B:158, 1994. Fadul DA, Carrino JA: Imaging of femoroacetabular impingement, J Bone Joint Surg 91A(Suppl 1):138, 2009. Fordyce MJ, Soloman L: Early detection of avascular necrosis of the femoral head by MRI, J Bone Joint Surg 75B:365, 1993. Gabriel H, Fitzgerald SW, Myers MT, et al.: MR imaging of hip disorders, Radiographics 14:763, 1994. Guanche CA: Clinical update: MR imaging of the hip, Sports Med Arthrosc 17:49, 2009. Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip, J Bone Joint Surg 77A:616, 1995. Haramati N, Staron RB, Barax C, Feldman F: Magnetic resonance imaging of occult fractures of the proximal femur, Skeletal Radiol 23:19, 1994. Hayes CW, Balkissoon AA: Magnetic resonance imaging of the musculoskeletal system: II. The hip, Clin Orthop Relat Res 322:297, 1996. Hodler J, Yu J, Goodwin D, et  al.: MR arthrography of the hip: improved imaging of the acetabular labrum with histological correlation in cadavers, Am J Radiol 165:887, 1995. Kim YJ, Jaramillo D, Millis MB, et al.: Assessment of early osteoarthritis in hip dysplasia with delayed gadolinium-enhanced magnetic resonance imaging of cartilage, J Bone Joint Surg 85A:2003, 1987. Koo KH, Kim R: Quantifying the extent of osteonecrosis of the femoral head: a new method using MRI, J Bone Joint Surg 77B:875, 1995. Lafforgue P, Dahan E, Chagnaud C, et al.: Early-stage avascular necrosis of the femoral head: MR imaging prognosis in 31 cases with at least 2 years of follow-up, Radiology 187:199, 1993. Lee JH, Dyke JP, Ballon D, et al.: Assessment of bone perfusion with contrast-enhanced magnetic resonance imaging, Orthop Clin North Am 40:249, 2009.

Mamisch TC, Zilkens C, Siebenrock KA, et al.: MRI of hip osteoarthritis and implications for surgery, Radiol Clin North Am 47:713, 2009. May DA, Purins JL, Smith DK: MR imaging of occult traumatic fractures and muscular injuries of the hip and pelvis in elderly patients, AJR Am J Roentgenol 166:1075, 1996. Miller TT: Imaging of hip arthroplasty, Semin Musculoskelet Radiol 10:30, 2006. Mosher TJ: Musculoskeletal imaging at 3T: current techniques and future applications, Magn Reson Imaging Clin North Am 14:63, 2006. Overdeck KH, Palmer WE: Imaging of hip and groin injuries in athletes, Semin Musculoskel Radiol 8:41, 2004. Potter HG, Foo LF, Nestor BJ: What is the role of magnetic resonance imaging in the evaluation of total hip arthroplasty? HSS J 1:89, 2005. Potter H, Moran M, Schneider R, et al.: Magnetic resonance imaging in diagnosis of transient osteoporosis of the hip, Clin Orthop Relat Res 280:223, 1992. Potter HG, Nestor BJ, Sofka CM, et  al.: Magnetic resonance imaging after total hip arthroplasty: evaluation of periprosthetic soft tissue, J Bone Joint Surg 86A:2004, 1947. Rizzo PF, Gould ES, Lyden JP, Asnis SE: Diagnosis of occult fractures about the hip: magnetic resonance imaging compared with bone scanning, J Bone Joint Surg 75A:395, 1993. Stutley JE, Conway WF: Magnetic resonance imaging of the pelvis and hips, Orthopedics 17:1053, 1994. Tehranzadeh J, Kerr R, Amster J: MRI of trauma and sports-related injuries of tendons and ligaments: II. Pelvis and lower extremities, Crit Rev Diagn Imaging 35:131, 1994. Winalski CS, Aplarsian L: Imaging of articular cartilage injuries of the lower extremity, Semin Musculoskelet Radiol 12:283, 2008. Zibis AH, Karantanas AH, Roidis NT, et al.: The role of MR imaging in staging femoral head osteonecrosis, Eur J Radiol 63:3, 2007. Zoga AC, Morrison WB: Technical considerations in MR imaging of the hip, Magn Reson Imaging Clin N Am 13:617, 2005.

SPINE Ackland HM, Cooper DJ, Malham GM, Stuckey SL: Magnetic resonance imaging for clearing the cervical spine in unconscious intensive care trauma patients, J Trauma 60:668, 2006. Adams JM, Cockburn MI, Difaxio LT, et al.: Spinal clearance in the difficult trauma patient: a role for screening MRI of the spine, Am Surg 72:101, 2006. Alyas F, Connell D, Saifuddin A: Upright positional MRI of the lumbar spine, Clin Radiol 63:1035, 2008. An HS, Nguyen C, Haughton VM, et  al.: Gadolinium-enhancement characteristics of magnetic resonance imaging in distinguishing herniated intervertebral disc versus scar in dogs, Spine 19:2098, 1994. An HS, Vaccaro AR, Dolinskas CA, et  al.: Differentiation between spinal tumors and infections with magnetic resonance imaging, Spine 16(Suppl):334, 1991. Bell GR, Stearns KL, Bonutti PM, Boumphrey FR: MRI diagnosis of tuberculous vertebral osteomyelitis, Spine 15:462, 1990. Boden SD, Davis DO, Dina TS, et  al.: Postoperative diskitis: distinguishing early MR imaging findings from normal postoperative disk space changes, Radiology 184:765, 1992. Borenstein DG, O’Mara JW, Boden SD, et al.: The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study, J Bone Joint Surg 83A:1306, 2001. Cousins JP, Haughton VM: Magnetic resonance imaging of the spine, J Am Acad Orthop Surg 17:22, 2009. Desai SS: Early diagnosis of spinal tuberculosis by MRI, J Bone Joint Surg 76B:863, 1994. Djukic S, Lang P, Morris J, et  al.: The postoperative spine: magnetic resonance imaging, Orthop Clin North Am 21:603, 1990. Harris JH, Yeakley JW: Hyperextension-dislocation of the cervical spine: ligament injuries demonstrated by magnetic resonance imaging, J Bone Joint Surg 74B:567, 1992. Haughton V: Medical imaging of intervertebral disc degeneration: current status of imaging, Spine 29:2751, 2004.

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CHAPTER 2  ADVANCED IMAGING IN ORTHOPAEDICS Heo DH, Lee MS, Sheen SH, et al.: Simple oblique lumbar magnetic resonance imaging technique and its diagnostic value for extraforaminal disc herniation, Spine 34:2419, 2009. Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al.: Magnetic resonance imaging of the lumbar spine in people without back pain, N Eng J Med 331:69, 1994. Khalatbari K, Ansari H: MRI of degenerative cysts of the lumbar spine, Clin Radiol 63:322, 2008. Khanna AJ, Carbone JJ, Kebaish KM, et al.: Magnetic resonance imaging of the cervical spine: current techniques and spectrum of disease, J Bone Joint Surg 84A(Suppl 1):70, 2002. Khanna AJ, Wasserman BA, Sponseller PD: Magnetic resonance imaging of the pediatric spine, J Am Acad Orthop Surg 11:248, 2003. Lurie JD, Tosteson AN, Tosteson TD, et al.: Reliability of readings of magnetic resonance imaging features of lumbar spinal stenosis, Spine 33:1605, 2008. Maksymowych WP: MRI in ankylosing spondylitis, Curr Opin Rheumatol 21:313, 2009. Mintz DN: Magnetic resonance imaging of sports injuries to the cervical spine, Semin Musculoskelet Radiol 8:99, 2004. Penta M, Sandhu A, Fraser RD: Magnetic resonance imaging assessment of disc degeneration 10 years after anterior lumbar interbody fusion, Spine 20:743, 1995. Ries M, Jones RA, Dousset V, Moonen CT: Diffusion tensor MRI of the spinal cord, Magn Reson Med 44:884, 2000. Ross JS: Magnetic resonance imaging of the postoperative spine, Semin Musculoskelet Radiol 4:281, 2000. Rothman SL: The diagnosis of infections of the spine by modern imaging techniques, Orthop Clin North Am 27:15, 1996. Saifuddin A, Blease S, MacSweeney E: Axial loaded MRI of the lumbar spine, Clin Radiol 58:661, 2003. Saltzherr TP, Fung Kon, Jin PH, Bennen LF, et  al.: Diagnostic imaging of cervical spine injuries following blunt trauma: a review of the literature and practical guideline, Injury 40:795, 2000. Sarani B, Waring S, Sonnad S, Schwab CW: Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients, J Trauma 63:637, 2007. Sharif HS: Role of MR imaging in the management of spinal infections, AJR Am J Roentgenol 158:1333, 1992. Sharif HS, Morgan JL, al Shahed MS, al Thagafi MY: Role of CT and MR imaging in the management of tuberculous spondylitis, Radiol Clin North Am 33:787, 1995. Solgaard Sorensen J, Kjaer P, Jensen ST, Andersen P: Low-field magnetic resonance imaging of the lumbar spine: reliability of qualitative evaluation of disc and muscle parameters, Acta Radiol 47:947, 2006. Thornbury JR, Fryback DG, Turski PA, et al.: Disk-caused nerve compression in patients with acute low-back pain: diagnosis with MR, CT myelography, and plain CT, Radiology 186:731, 1993. Thurnher MM, Bammer R: Diffusion weighted magnetic resonance imaging of the spine and spinal cord, Semin Roentgenol 41:294, 2006. Yuh WTC, Zachar CK, Barloon TJ, et al.: Vertebral compression fractures: distinction between benign and malignant causes with MR imaging, Radiology 172:215, 1989.

SHOULDER Bertin D: Imaging shoulder instability in the athlete, Magn Reson Imaging Clin N Am 17:595, 2009. Deutsch A, Altcheck DW, Veltri DM, et al.: Traumatic tears of the subscapularis tendon: clinical diagnosis, magnetic resonance imaging findings, and operative treatment, Am J Sports Med 25:(13), 1997. Farber A, Fayad L, Johnson T, et  al.: Magnetic resonance imaging of the shoulder: current techniques and spectrum of disease, J Bone Joint Surg 88A(Suppl 4):64, 2006. Fritz RC, Helms CA, Steinbach LS, Genant HK: Suprascapular nerve entrapment: evaluation with MR imaging, Radiology 182:437, 1992. Goodwin DW, Pathria MN: Magnetic resonance imaging of the shoulder, Orthopedics 17:1021, 1994.

Goss TP, Aronow MS, Coumas JM: The use of MRI to diagnose suprascapular nerve entrapment caused by a ganglion, Orthopedics 17:359, 1994. Green MR, Christensen KP: Magnetic resonance imaging of the glenoid labrum in anterior shoulder instability, Am J Sports Med 22:493, 1994. Gusmer PB, Potter HG: Imaging of shoulder instability, Clin Sports Med 14:777, 1995. Gusmer PB, Potter HG, Donovan WD, et al.: MR imaging of the shoulder after rotator cuff repair, AJR Am J Roentgenol 168:559, 1997. Iannotti JP, Zlatkin MB, Esterhai JL, et al.: Magnetic resonance imaging of the shoulder, J Bone Joint Surg 73A:707, 1991. Lee JC, Guy S, Connell D, et  al.: MRI of the rotator interval of the shoulder, Clin Radiol 62:416, 2007. McNally EG, Rees JL: Imaging in shoulder disorders, Skeletal Radiol 36:1013, 2007. Miniaci A, Dowdy PA, Willits KR, Vellet AD: Magnetic resonance imaging evaluation of the rotator cuff tendons in the symptomatic shoulder, Am J Sports Med 23:142, 1995. Minkoff J, Stecker S, Cavaliere G: Glenohumeral instabilities and the role of MR imaging techniques, Magn Reson Imaging 5:767, 1997. Murray PJ, Shafer BS: Clinical update: MR imaging of the shoulder, Sports Med Arthrosc 17:40, 2009. Nelson MC, Leather GP, Nirschl RP, et al.: Evaluation of the painful shoulder: a prospective comparison of magnetic resonance imaging, computerized tomographic arthrography, ultrasonography, and operative findings, J Bone Joint Surg 73A:707, 1991. Palmer WE, Caslowitz PL, Chew FS: MR arthrography of the shoulder: normal intraarticular structures and common abnormalities, AJR Am J Roentgenol 164:141, 1995. Parker BJ, Zlatkin MB, Newman JS, Rathur SK: Imaging of shoulder injuries in sports medicine: current protocols and concepts, Clin Sports Med 27:579, 2008. Rafii M, Firooznia H, Sherman O, et al.: Rotator cuff lesions: signal patterns at MR imaging, Radiology 177:817, 1990. Recht MP, Resnick D: Magnetic resonance imaging studies of the shoulder: diagnosis of lesions of the rotator cuff, J Bone Joint Surg 75A:1244, 1993. Reinus WR, Shady KL, Mirowitz SA, Totty WG: MR diagnosis of rotator cuff tears of the shoulder: value of using T2-weighted fat-saturated images, AJR Am J Roentgenol 164:1451, 1995. Sher JS, Uribe JW, Posada A, et  al.: Abnormal findings on magnetic resonance images of asymptomatic shoulders, J Bone Joint Surg 77A:10, 1995. Sherman OH: MR imaging of impingement and rotator cuff disorders: a surgical perspective, Magn Reson Imaging 5:721, 1997. Singson RD, Hoang T, Dan S, Friedman M: MR evaluation of rotator cuff pathology using T2-weighted fast spin-echo technique with and without fat suppression, AJR Am J Roentgenol 166:1061, 1996. Tirman PF, Stauffer AE, Crues JV, et al.: Saline magnetic resonance arthrography in the evaluation of glenohumeral instability, Arthroscopy 9:550, 1993. Vasquez J, Kassarjian A: MRI of shoulder trauma, Semin Musculoskelet Radiol 10:268, 2008.

ELBOW, WRIST, AND HAND Aaron JO: A practical guide to diagnostic imaging of the upper extremity, Hand Clin 9:347, 1993. Amrami KK, Felmlee JP: 3-Tesla imaging of the wrist and hand: techniques and applications, Semin Musculoskelet Radiol 12:223, 2008. Behr B, Stadler J, Michaely HJ, et al.: MR imaging of the human hand and wrist at 7 T, Skeletal Radiol 38:911, 2009. Berger RA, Linscheid RL, Berquist TH: Magnetic resonance imaging of the anterior radiocarpal ligaments, J Hand Surg 19A:295, 1994. Cobb TK, Dalley BK, Posteraro RH, Lewis RC: Establishment of the carpal contents/canal ratio by means of magnetic resonance imaging, J Hand Surg 17A:843, 1992. Cunningham PM: MR imaging of trauma: elbow and wrist, Semin Musculoskelet Radiol 10:284, 2006. Dalinka MK, Meyer S, Kricun ME, Vanel D: Magnetic resonance imaging of the wrist, Hand Clin 7:87, 1991.

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PART I  GENERAL PRINCIPLES Escobedo EM, Bergman AG, Hunter JC: MR imaging of ulnar impaction, Skeletal Radiol 24:85, 1995. Falchook FS, Zlatkin MB, Erbacher GE, et al.: Rupture of the distal biceps tendon: evaluation with MR imaging, Radiology 190:659, 1994. Fritz RC, Brody GA: MR imaging of the wrist and elbow, Clin Sports Med 14:315, 1995. Fritz RC, Steinbach LS: Magnetic resonance imaging of the musculoskeletal system: III. The elbow, Clin Orthop Relat Res 324:321, 1996. Herzog RJ: Efficacy of magnetic resonance imaging of the elbow, Med Sci Sports Exerc 26:1193, 1994. Ho CP: Sports and occupational injuries of the elbow: MR imaging findings, AJR Am J Roentgenol 164:1465, 1995. Huynh PT, Kaplan PA, Dussault RG: Magnetic resonance imaging of the elbow, Orthopedics 17:1029, 1994. Imeda T, Makamura R, Miura T, Makino N: Magnetic resonance imaging in Kienbock disease, J Hand Surg 17B:12, 1992. Kijowski R, Tuite M, Sanford M: Magnetic resonance imaging of the elbow: part I. Normal anatomy, imaging technique, and osseous abnormalities, Skeletal Radiol 33:685, 2004. Kijowski R, Tuite M, Sanford M: Magnetic resonance imaging of the elbow: part II. Abnormalities of the ligaments, tendons, and nerves, Skeletal Radiol 34:1, 2005. Lepisto J, Mattila K, Nieminen S, et al.: Low-field MRI and scaphoid fracture, J Hand Surg 20B:539, 1995. Lisle DA, Shepherd GJ, Cowderoy GA, O’Connell PT: MR imaging of traumatic and overuse injuries of the wrist and hand in athletes, Magn Reson Imaging Clin N Am 17:639, 2009. Oneson SR, Timins ME, Scales LM, et  al.: MR imaging diagnosis of TFC pathology with arthroscopic correlation, AJR Am J Roentgenol 168:1513, 1997. Ouelette H, Bredella M, Labis J, et al.: MR imaging of the elbow in baseball pitchers, Skeletal Radiol 37:115, 2008. Patten RM: Overuse syndromes and injuries involving the elbow: MR imaging findings, AJR Am J Roentgenol 164:1205, 1995. Peh WC, Gilula LA, Wilson AJ: Detection of occult wrist fractures by magnetic resonance imaging, Clin Radiol 51:285, 1996. Schwartz ML, Al-Zahrani S, Morwessel RM, et al.: Ulnar collateral ligament injury in the throwing athlete: evaluation with saline-enhanced MR arthrography, Radiology 197:297, 1995. Shaken JR, Palmer AK, Levinsohn EM, et al.: Magnetic resonance imaging of the triangular fibrocartilage complex, J Hand Surg 15A:552, 1990. Timmerman LA, Schwartz ML, Andrews JR: Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography: evaluation in 25 baseball players with surgical confirmation, Am J Sports Med 22:(26), 1994. Trumble TE, Irving J: Histologic and magnetic resonance imaging correlations in Kienbock’s disease, J Hand Surg 15A:879, 1990. Vo P, Wright T, Hayden F, et al.: Evaluating dorsal wrist pain: MRI diagnosis of occult dorsal wrist ganglion, J Hand Surg 20A:667, 1995. Yu JS: Magnetic resonance imaging of the wrist, Orthopedics 17:1041, 1994.

TUMORS Bearman FD, Kransdorf MJ, Andrews TR, et  al.: Superficial soft tissue masses: analysis, diagnosis, and differential consideration, Radiographics 27:509, 2007.

Berger FH, ver Straete KL, Gooding CA, et al.: MR imaging of musculoskeletal neoplasm, Magn Reson Imaging Clin North Am 8:929, 2000. Berquist TH: Magnetic resonance imaging of primary skeletal neoplasms, Radiol Clin North Am 31:411, 1993. Blacksin MF, Ende N, Benevenia J: Magnetic resonance imaging of intraosseous lipomas: a radiologic-pathologic correlation, Skeletal Radiol 24:37, 1995. Cohen IJ, Hadar H, Schreiber R, et al.: Primary bone tumor resectability: the value of serial MRI studies in the determination of feasibility, timing, and extent of tumor resection, J Pediatr Orthop 14:781, 1994. Daniel A, Ullah E, Wahab S, Kumar V: Relevance of MRI in prediction of malignancy of musculoskeletal system—a prospective evaluation, BMC Musculoskelet Disord 10:125, 2009. Frassica FJ, Khanna JA, McCarthy EF: The role of MR imaging in soft tissue tumor evaluation: perspective of the orthopedic oncologist and the musculoskeletal pathologist, Magn Reson Imag Clin North Am 8:918, 2000. Greenfield GB, Arrington JA, Kudryk BT: MRI of soft tissue tumors, Skeletal Radiol 22:77, 1993. Hanna SL, Fletcher BD: MR imaging of malignant soft tissue tumors, Magn Reson Imaging 3:629, 1995. Heck RK, O’Malley AM, Kellum EL, et al.: Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions, Clin Orthop Relat Res 459:28, 2007. Kransdorf MJ: Magnetic resonance imaging of musculoskeletal tumors, Orthopedics 17:1003, 1994. Lang P, Grampp S, Vahlensieck M, et al.: Primary bone tumors: value of MR angiography for preoperative planning and monitoring response to chemotherapy, AJR Am J Roentgenol 165:135, 1995. Lang P, Honda G, Roberts T, et al.: Musculoskeletal neoplasm: perineoplastic edema vs. tumor on dynamic postcontrast MR images with spatial mapping of instantaneous enhancement rates, Radiology 197:831, 1995. Levey DS, Park YH, Sartoris DJ: Imaging of pedal soft tissue neoplasms, J Foot Ankle Surg 34:411, 1995. Muscolo DL, Makino A, Costa-Paz M, Ayerza MA: Localized pigmented villonodular synovitis of the posterior compartment of the knee: diagnosis with magnetic resonance imaging, Arthroscopy 11:482, 1995. Ozaki T, Hashizume H, Kawai A, Inoue H: Ewing’s sarcoma of the hand: magnetic resonance images and treatment, J Hand Surg 20A:441, 1995. Papp DF, Khanna AJ, McCarthy EF, et al.: Magnetic resonance imaging of soft tissue tumors: determinate and indeterminate lesions, J Bone Joint Surg 89A(Suppl 3):103, 2007. Rupp RE, Ebraheim NA, Coombs RJ: Magnetic resonance imaging differentiation of compression spine fractures or vertebral lesions caused by osteoporosis or tumor, Spine 20:2499, 1995. Schima W, Amann G, Stiglbauer R, et al.: Preoperative staging of osteosarcoma: efficacy of MR imaging in detecting joint involvement, AJR Am J Roentgenol 163:1171, 1994. Swan JS, Grist TM, Sproat IA, et al.: Musculoskeletal neoplasms: preoperative evaluation with MR angiography, Radiology 194:519, 1995. Van Vliet M, Kliffen M, Krestin GP, et al.: Soft tissue sarcomas at a glance: clinical, histological, and MR imaging features of malignant extremity soft tissue tumors, Eur Radiol 19:1499, 2009.

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CHAPTER

3

ARTHROPLASTY OF THE HIP James W. Harkess, John R. Crockarell Jr.

179 APPLIED BIOMECHANICS 179 Forces acting on the hip 180 Stress transfer to bone DESIGN AND SELECTION OF TOTAL HIP COMPONENTS 183 Femoral components 183 Cemented femoral components 186 Cementless femoral components 188 Specialized and custom-made 192 femoral components Acetabular components 193 Cemented acetabular 193 components Cementless acetabular components 194 196 Alternative bearings INDICATIONS AND CONTRAINDICATIONS FOR TOTAL HIP 200 ARTHROPLASTY PREOPERATIVE PATIENT EVALUATION AND 200 OPTIMIZATION PREOPERATIVE RADIOGRAPHS 203 THE HIP-SPINE RELATIONSHIP 204 PREPARATION AND 205 DRAPING SURGICAL APPROACHES AND TECHNIQUES 205 Total hip arthroplasty through 207 posterolateral approach 210 Component implantation Total hip arthroplasty through the direct anterior approach 221 225 Minimally invasive techniques Computer-assisted surgery 227 228 Trochanteric osteotomy SURGICAL PROBLEMS RELATIVE TO SPECIFIC HIP 230 DISORDERS

Arthritic disorders 230 Osteoarthritis (primary or secondary hypertrophic arthritis or degenerative arthritis) 230 Inflammatory arthritis 231 Osteonecrosis 233 233 Protrusio acetabuli 234 Developmental dysplasia 241 Legg-Calvé-perthes disease Slipped capital femoral epiphysis 241 Dwarfism 241 Traumatic and posttraumatic disorders 242 Acute femoral neck fractures 242 244 Failed hip fracture surgery Acetabular fractures 246 Failed reconstructive procedures 247 Proximal femoral osteotomy and 247 deformity Acetabular osteotomy 248 Arthrodesis and ankylosis 248 Metabolic disorders 250 250 Paget disease 250 Gaucher disease 251 Sickle cell anemia Chronic renal failure 251 Hemophilia 251 252 Infectious disorders 252 Pyogenic arthritis 252 Tuberculosis 252 Tumors Neuromuscular disorders 253 253 COMPLICATIONS Mortality 253 Hematoma formation 253 254 Heterotopic ossification Thromboembolism 254 Neurologic injuries 255 256 Vascular injuries Limb-length discrepancy 257 259 Dislocation

Total hip arthroplasty is the most commonly performed adult reconstructive hip procedure. This chapter discusses cemented and noncemented arthroplasties, bearing choices, and current trends in surgical approaches and less invasive techniques. In addition, revision hip arthroplasty, which comprises an enlarging segment of procedures performed, is reviewed.

Fractures Trochanteric nonunion Infection Antibiotic prophylaxis Classification Diagnosis Management Reconstruction after infection Loosening Femoral loosening Acetabular loosening Diagnosis Osteolysis Adverse local tissue reaction REVISION OF TOTAL HIP ARTHROPLASTY Indications and Contraindications Preoperative planning Surgical approach Removal of the femoral component Removal of femoral cement Removal of the acetabular component Reconstruction of acetabular deficiencies Classification Management Segmental deficits Combined deficits Pelvic discontinuity Reconstruction of femoral deficiencies Classification Management Segmental deficits Cavitary deficits Massive deficits Femoral deformity POSTOPERATIVE MANAGEMENT OF TOTAL ARTHROPLASTY

263 266 270 270 271 272 274 276 277 278 280 281 282 285 286 286 287 288 289 295 298 301 301 302 302 308 309 311 311 312 312 315 318 321

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The results of the Charnley total hip arthroplasty (THA) are the benchmark for evaluating the performance of other arthroplasties. The laboratory and clinical contributions of Charnley have improved the quality of life for many patients. Nevertheless, the history of hip arthroplasty has been dynamic, and research continues to improve results, especially in young patients. Investigation has proceeded along

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CHAPTER 3  ARTHROPLASTY OF THE HIP multiple paths, including (1) improvement in the durability of implant fixation, (2) reduction in the wear of the articulating surfaces, and (3) technical modifications in the operation to speed rehabilitation and reduce implant-positioning errors. In response to the problem of loosening of the stem and cup based on the alleged failure of cement, press-fit, porouscoated, and hydroxyapatite-coated stems and cups have been investigated as ways to eliminate the use of cement and to use bone ingrowth or ongrowth as a means of achieving durable skeletal fixation. Although some initial cementless implant designs have proved very successful, others have been beset by premature and progressive failure because of inadequate initial fixation, excessive wear, and periprosthetic bone loss secondary to particle-induced osteolysis. As experience has accumulated, the importance of certain design parameters has become apparent and the use of cementless fixation for the femoral and acetabular components has become more common. Many different techniques have evolved to improve cemented femoral fixation, including injection of low-viscosity cement, occlusion of the medullary canal, reduction of porosity, pressurization of the cement, and centralization of the stem. Similar techniques have been less successful in improving the results of acetabular fixation. Stem fracture has been largely eliminated by routine use of superalloys in their fabrication. As technologic advances improve the longevity of implant fixation, problems related to wear of articulating surfaces have emerged. Highly crosslinked polyethylenes have demonstrated reduced wear and have now largely replaced conventional ultra-high-molecular-weight polyethylene. Ceramic-ceramic articulations have been used because of their low coefficient of friction and superior in  vitro wear characteristics; these have also been successful. The initial enthusiasm for metal-on-metal articulations has been tempered by high failure rates caused by metal hypersensitivity reactions. The introduction of these more wear-resistant

A

bearings has led to the use of larger component head sizes and modifications of postoperative regimens. Consider the problems of previous materials and design modifications that did not become apparent until the results of a sufficient number of 5-year or more follow-up studies were available. There is little debate that the results of revision procedures are less satisfactory and that primary THA offers the best chance of success. Selection of the appropriate patient, the proper implants, and the technical performance of the operation are of paramount importance. THA procedures require the surgeon to be familiar with the many technical details of the operation. To contend successfully with the many problems that occur and to evaluate new concepts and implants, a working knowledge of biomechanical principles, materials, and design also is necessary.

APPLIED BIOMECHANICS The biomechanics of THA are different from those of the screws, plates, and nails used in bone fixation because these latter implants provide only partial support and only until the bone unites. Total hip components must withstand many years of cyclic loading equal to at least three times body weight. A basic knowledge of the biomechanics of the hip and of THA is necessary to perform the procedure properly, to manage the problems that may arise during and after surgery successfully, to select the components intelligently, and to counsel patients concerning their physical activities.

FORCES ACTING ON THE HIP

To describe the forces acting on the hip joint, the body weight can be depicted as a load applied to a lever arm extending from the body’s center of gravity to the center of the femoral head (Fig. 3.1). The abductor musculature, acting on a lever arm extending from the lateral aspect of the greater trochanter to the center of the femoral head, must exert an equal moment to hold the pelvis level when in a one-legged stance and a greater moment to tilt the pelvis to the same side when

A1

A2 B1

B X

A

B2 X

B

X

C

FIGURE 3.1 Lever arms acting on hip joint. A, Moment produced by body weight applied at body’s center of gravity, X, acting on lever arm, B-X, must be counterbalanced by moment produced by abductors, A, acting on shorter lever arm, A-B. Lever arm A-B may be shorter than normal in arthritic hip. B, Medialization of acetabulum shortens lever arm B1-X, and use of high offset neck lengthens lever arm A1-B1. C, Lateral and distal reattachment of osteotomized greater trochanter lengthens lever arm A2-B2 further and tightens abductor musculature.

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS walking. Because the ratio of the length of the lever arm of the body weight to that of the abductor musculature is about 2.5:1, the force of the abductor muscles must approximate 2.5 times the body weight to maintain the pelvis level when standing on one leg. The estimated load on the femoral head in the stance phase of gait is equal to the sum of the forces created by the abductors and the body weight and has been calculated to be three times the body weight; the load on the femoral head during straight-leg raising is estimated to be about the same. An integral part of the Charnley concept of THA was to shorten the lever arm of the body weight by deepening the acetabulum and to lengthen the lever arm of the abductor mechanism by reattaching the osteotomized greater trochanter laterally. The moment produced by the body weight is decreased, and the counterbalancing force that the abductor mechanism must exert is decreased. The abductor lever arm may be shortened in arthritis and other hip disorders in which part or all of the head is lost or the neck is shortened. It also is shortened when the trochanter is located posteriorly, as in external rotational deformities, and in many patients with developmental dysplasia of the hip. In an arthritic hip, the ratio of the lever arm of the body weight to that of the abductors may be 4:1. The lengths of the two lever arms can be surgically changed to make their ratio approach 1:1 (see Fig. 3.1). Theoretically, this reduces the total load on the hip by 30%. Femoral rotational alignment also plays a role in these changes in moment arms. In a finite element model, Terrier et al. found that changes in moment arms with cup medialization were inversely correlated with femoral anteversion, such that hips with less femoral anteversion gained more in terms of muscle moments. Understanding the benefits derived from medializing the acetabulum and lengthening the abductor lever arm is important; however, neither technique is currently emphasized. The principle of medialization has given way to preserving subchondral bone in the pelvis and to deepening the acetabulum only as much as necessary to obtain bony coverage for the cup. Because most total hip procedures are now done without osteotomy of the greater trochanter, the abductor lever arm is altered only relative to the offset of the head to the stem. These compromises in the original biomechanical principles of THA have evolved to obtain beneficial tradeoffs of a biologic nature; to preserve pelvic bone, especially subchondral bone; and to avoid problems related to reattachment of the greater trochanter. Calculated peak contact forces across the hip joint during gait range from 3.5 to 5.0 times the body weight and up to six times the body weight during single-limb stance. Experimentally measured forces around the hip joint using instrumented prostheses generally are lower than the forces predicted by analytical models, in the range of 2.6 to 3.0 times the body weight during single-limb stance phase of gait. When lifting, running, or jumping, however, the load may be equivalent to 10 times the body weight. Excess body weight and increased physical activity add significantly to the forces that act to loosen, bend, or break the femoral component. The forces on the joint act not only in the coronal plane but, because the body’s center of gravity (in the midline anterior to the second sacral vertebral body) is posterior to the axis of the joint, also in the sagittal plane to bend the stem posteriorly. The forces acting in this direction are increased

when the loaded hip is flexed, as when arising from a chair, ascending and descending stairs or an incline, or lifting (Fig. 3.2). During the gait cycle, forces are directed against the prosthetic femoral head from a polar angle between 15 and 25 degrees anterior to the sagittal plane of the prosthesis. During stair climbing and straight-leg raising, the resultant force is applied at a point even farther anterior on the head. Such forces cause posterior deflection or retroversion of the femoral component. These so-called out-of-plane forces have been measured at 0.6 to 0.9 times body weight. Implanted femoral components must withstand substantial torsional forces even in the early postoperative period. Consequently, femoral components used without cement must be designed and implanted so that they are immediately rotationally stable within the femur. Similarly, the shape of a cemented implant must impart rotational stability within its cement mantle. The location of the center of rotation of the hip from superior to inferior also affects the forces generated around the implant. In a mathematical model, the joint reaction force was lower when the hip center was placed in the anatomic location compared with a superior and lateral or posterior position. Isolated superior displacement without lateralization produces relatively small increases in stresses in the periacetabular bone. This has clinical importance in the treatment of developmental dysplasia and in revision surgery when superior bone stock is deficient. Placement of the acetabular component in a slightly cephalad position allows improved coverage or contact with viable bone. Nonetheless, clinical studies have documented a higher incidence of progressive radiolucencies and migration of components in patients with protrusion, dysplasia, and revision situations when the hip center was placed in a nonanatomic position. 

STRESS TRANSFER TO BONE

The quality of the bone before surgery is a determinant in the selection of the most appropriate implant, optimal method of fixation, response of the bone to the implant, and ultimate success of the arthroplasty. Dorr et  al. proposed a

A

B

FIGURE 3.2 Forces producing torsion of stem. Forces acting on hip in coronal plane (A) tend to deflect stem medially, and forces acting in sagittal plane (B), especially with hip flexed or when lifting, tend to deflect stem posteriorly. Combined, they produce torsion of stem.

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Type A

Type B

Type C

FIGURE 3.3 Dorr radiographic categorization of proximal femurs according to shape, correlation with cortical thickness, and canal dimension. (From Dorr LD, Faugere MC, Mackel AM, et al: Structural and cellular assessment of bone quality of proximal femur, Bone 14:231, 1993.)

radiographic categorization of proximal femurs based on their shape and correlated those shapes with measurements of cortical thickness and canal dimensions (Fig. 3.3). Type A femurs have thick cortices on the anteroposterior view and a large posterior cortex seen on the lateral view. The narrow distal canal gives the proximal femur a pronounced funnel shape or “champagne flute” appearance. The type A femur is more commonly found in men and younger patients and permits good fixation of either cemented or cementless stems. Type B femurs exhibit bone loss from the medial and posterior cortices, resulting in increased width of the intramedullary canal. The shape of the femur is not compromised, and implant fixation is not a problem. Type C femurs have lost much of the medial and posterior cortex. The intramedullary canal diameter is very wide, particularly on the lateral radiograph. The “stovepipe”-shaped type C bone is typically found in older postmenopausal women and creates a less favorable environment for cementless implant fixation. The material a stem is made of, the geometry, length, and size of the stem, and the method and extent of fixation dramatically alter the pattern in which stress is transferred to the femur. Adaptive bone remodeling arising from stress shielding compromises implant support and predisposes to fracture of the femur or the implant itself. Stress transfer to the femur is desirable because it provides a physiologic stimulus for maintaining bone mass and preventing disuse osteoporosis. A decrease in the modulus of elasticity of a stem decreases the stress in the stem and increases stresses to the surrounding bone. This is true of stems made of metals with a lower modulus of elasticity, such as a titanium alloy, particularly if the cross-sectional diameter is relatively small. Larger-diameter

stems made of the same material are stronger, but they also are stiffer or less elastic, and the increased cross-sectional diameter negates any real benefits of the lower modulus of elasticity. The bending stiffness of a stem is proportional to the fourth power of the diameter, and small increases in stem diameter produce much larger increments of change in flexural rigidity. When the stem has been fixed within the femur by bone ingrowth, load is preferentially borne by the stiffer structure and the bone of the proximal femur is relieved of stress. Detailed examinations of stress shielding of the femur after cementless total hip replacement found that almost all femurs showing moderate or severe proximal resorption involved stems 13.5 mm in diameter or larger. With a press-fit at the isthmus and radiographic evidence of bone ingrowth, more stress shielding was evident. Extensive porous coating in smaller size stems does not seem to produce severe stress shielding. More recent follow-up with larger stem sizes shows greater stress shielding, however, with more extensively coated stems (Fig. 3.4). Localized bone hypertrophy can be seen in areas where an extensively porous-coated stem contacts the cortex. This is seen often at the distal end of the porous coating with an extensively coated stem. Such hypertrophy is less pronounced when the porous surface is confined to the proximal portion of the stem. In a meta-analysis of studies of femoral bone loss, Knutsen et al. found that cementless stems had more proximal bone loss than cemented implants and cobaltchromium stems had nearly double the proximal bone loss seen with titanium alloy femoral stems. Videodensitometry analysis of autopsy-retrieved femurs found that for cemented and cementless implants, the area

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A

B

FIGURE 3.4 Response of bone to load. A, Postoperative radiograph of extensively porouscoated stem. B, Two years later, cortical and cancellous bone density in proximal femur has decreased as a result of stress shielding.

of greatest decrease in bone mineral density occurred in the proximal medial cortex. Dual energy x-ray absorptiometry scans show bone loss in the proximal femur progresses over a period of at least 5 years after surgery. This loss of mineral density does not occur with resurfacing arthroplasty. Shorter length stem designs also aim to load the proximal femoral bone in a more physiological manner to reduce bone loss in this area. If a prosthesis has a collar that is seated on the cut surface of the neck, it is postulated that axial loading of the bone would occur in this area. It is technically difficult, however, to obtain this direct contact of a collar or cement with the cut surface of bone. Although the role of a collar in preventing loosening of a cemented femoral component has not been clearly established, any loading of the proximal medial neck is likely to decrease bone resorption and reduce stresses in the proximal cement. The presence of a collar on cementless femoral components is more controversial because it may prevent complete seating of the stem, making it loose at implantation. Cementless stems generally produce strains in the bone that are more physiologic than the strains caused by fully cemented stems, depending on the stem size and the extent of porous coating. Proximal medial bone strains have been found to be 65% of normal with a collarless press-fit stem and 70% to 90% with a collared stem with an exact proximal fit. A loose-fitted stem with a collar can produce proximal strains greater than in the intact femur, although the consequences of a loose stem negate any potential benefits in loading provided by the collar. When a stem is loaded, it produces circumferential or hoop stresses in the proximal femur. Proximal wedging of a collarless implant may generate excessive hoop strains that cause intraoperative and postoperative fractures of the proximal femur. Prophylactic cerclage wire placement increases energy to failure and may reduce the

risk of periprosthetic fracture, particularly when the femur is osteopenic or bony defects are present. Stem shape also seems to affect stress transfer to bone. In a review of three different types of titanium stems with tapered geometries, an overall incidence of radiographic proximal femoral bone atrophy of only 6% was found in the 748 arthroplasties studied. In no patient was the proximal bone loss as severe as that seen in patients with stems of a cylindrical distal geometry that filled the diaphysis. Cadaver studies have identified a wide variability in the degree and location of bone remodeling between individuals in clinically successful arthroplasties with solid fixation. A strong correlation was shown, however, between the bone mineral density in the opposite femur and the percentage of mineral loss in the femur that had been operated on, regardless of the method of implant fixation; it seems that patients with diminished bone mineral density before surgery are at greatest risk for significant additional bone loss after cemented and cementless THA. The amount of stress shielding that is acceptable in the clinical setting is difficult to determine. In a series of 208 hip arthroplasties followed for a mean 13.9 years, Engh et al. reported patients with radiographically evident stress shielding had lower mean walking scores but no increase in other complications and were less likely to require revision for stem loosening or osteolysis. Although proximal femoral stress shielding does not seem to affect adversely early or midterm clinical results, experience with failed cemented implants has also shown that revision surgery becomes more complex when femoral bone stock has been lost. Ongoing investigations into materials and stem design are likely to be beneficial in reducing adverse femoral remodeling. On the pelvic side, finite analysis has indicated that with the use of a cemented polyethylene cup, peak stresses

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CHAPTER 3  ARTHROPLASTY OF THE HIP develop in the pelvic bone. A metal-backed cup with a polyethylene liner reduces the high areas of stress and distributes the stresses more evenly. Similar studies have indicated that increased peak stresses develop in the trabecular bone when the subchondral bone is removed and that decreased peak stresses develop when a metal-backed component is used. The highest stresses in the cement and trabecular bone develop when a thin-walled, polyethylene acetabular component is used and when the subchondral bone has been removed. Stress on the cement-bone interface may also be increased up to 9% when a larger diameter femoral head is utilized. A thick-walled polyethylene cup of 5 mm or more, as opposed to a thin-walled polyethylene cup, tends to reduce the stresses in the trabecular bone, similar to the effect of the metal-backed cup. The preservation of subchondral bone in the acetabulum and the use of a metal-backed cup or thickwalled polyethylene cup decrease the peak stress levels in the trabecular bone of the pelvis. Favorable early results with metal-backed, cemented acetabular components led to their widespread use in the past. Longer follow-up has shown no sustained benefit, however, from the use of metal backing, and in some series survivorship of the cemented metal-backed acetabular components has been worse than that of components without metal backing. Using a thick-walled, all-polyethylene component and retaining the subchondral bone of the acetabulum are two steps that seem to provide a satisfactory compromise without excessive stress shielding or stress concentration. When cementless acetabular fixation is used, metal backing is required for skeletal fixation. Ideally, the metal should contact acetabular subchondral bone over a wide area to prevent stress concentration and to maximize the surface area available for biologic fixation. The accuracy of acetabular preparation and the shape and size of the implant relative to the prepared cavity dramatically affect this initial area of contact and the transfer of stress from the implant to the pelvis. If a hemispherical component is slightly undersized relative to the acetabulum, stress is transferred centrally over the pole of the component, with the potential for peripheral gaps between the implant and bone. Conversely, if the component is slightly larger than the prepared cavity, stress transfer occurs peripherally, with the potential for fracture of the acetabular rim during implantation (see section on implantation of cementless acetabular components). Polar gaps also may remain from incomplete seating of the component. The manner of stress transfer from a cementless acetabular component to the surrounding acetabular bone dictates its initial stability. As the cup is impacted into the acetabulum, forces generated by elastic recoil of the bone stabilize the implant. Peripheral strains acting on a force vector perpendicular to the tangent at the rim stabilize the cup. Strains medial to the rim generate a force vector that pushes laterally and destabilizes the cup (Fig. 3.5). Stress shielding of the periacetabular bone by cementless implants has received less attention than with femoral components but does occur. Using a novel method of CT-assisted osteodensitometry, Mueller et  al. assessed bone density around cementless titanium acetabular components at 10 days and 1 year postoperatively. Cortical bone density cephalad to the implant increased by 3.6%. Conversely, cancellous bone density decreased by 18%, with the area of greatest loss

FIGURE 3.5 rim.

Destabilization of cup from strains medial to

anterior to the cup. The clinical importance of acetabular stress shielding has not been determined. 

DESIGN AND SELECTION OF TOTAL HIP COMPONENTS Total hip femoral and acetabular components of various materials and a multitude of designs are currently available. Few implant designs prove to be clearly superior or inferior to others. Certain design features of a given implant may provide an advantage in selected situations. Properly selected and implanted total hip components of most designs can be expected to yield satisfactory results in a high percentage of patients. No implant design or system is appropriate for every patient, and a general knowledge of the variety of component designs and their strengths and weaknesses is an asset to the surgeon. Selection is based on the patient’s needs, the patient’s anticipated longevity and level of activity, the bone quality and dimensions, the ready availability of implants and proper instrumentation, and the experience of the surgeon. We routinely use many total hip systems from different manufacturers; we present here an overview of the available systems, emphasizing similar and unique features. Numerous investigators and manufacturers have changed their designs within a relatively short time to incorporate newer concepts, and this confuses many orthopaedic surgeons and patients. The surgeon’s recommendations should be tempered by the knowledge that change does not always bring about improvement and that radical departure from proven concepts of implant design yields unpredictable long-term results. Total hip femoral and acetabular components are commonly marketed together as a total hip system. While the practice is off-label, the variety of modular head sizes with most femoral components allows use with other types of acetabular components if necessary. Femoral and acetabular components are discussed separately.

FEMORAL COMPONENTS

The primary function of the femoral component is the replacement of the femoral head and neck after resection of the arthritic or necrotic segment. The ultimate goal of a biomechanically sound, stable hip joint is accomplished by careful attention to restoration of the normal center of rotation of the femoral head. This location is determined by three factors: (1) vertical height (vertical offset), (2) medial offset (horizontal offset or, simply, offset), and (3) version of the

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS Offset

Vertical height

Neck length

Stem length

Distal stem diameter FIGURE 3.6 Features of femoral component. Neck length is measured from center of head to base of collar; head-stem offset, from center of head to line through axis of distal part of stem; stem length, from medial base of collar to tip of stem; and angle of neck, by intersection of line through center of head and neck with another along lateral border of distal half of stem.

femoral neck (anterior offset) (Fig. 3.6). Vertical height and offset increase as the neck is lengthened, and proper reconstruction of both features is the goal when selecting the length of the femoral neck. In most modern systems, neck length is adjusted by using modular heads with variable internal bores that mate with a uniformly tapered trunnion on the femoral component (Fig. 3.7). The taper is commonly referred to as a Morse taper, although there is no defined standard across all manufacturers. A Morse taper is approximately 3 degrees on each side and the size is typically designated by the diameters at the upper and lower ends. The most common taper used presently is 12 mm/14 mm, but this has varied over time even within the implant offerings of a given manufacturer. It should also be noted that each manufacturer has unique specifications for their tapers and they vary by diameter at the smaller and larger ends, length, taper angle, and surface finish. Consequently, femoral heads from one manufacturer are not compatible with femoral trunnions of another even if the nominal size is the same. Toggling of the head on the trunnion, dissociation, material loss, and corrosion may result from such a mismatch. Neck length typically ranges from 25 to 50 mm, and adjustment of 8 to 12 mm for a given stem size routinely is available. When a long neck length is required for a head diameter up to 32 mm, a skirt extending from the lower aspect of the head may be required to fully engage the Morse

taper (Fig. 3.8). For heads larger than 32 mm a skirt is unnecessary even for longer neck lengths. Vertical height (vertical offset) is determined primarily by the base length of the prosthetic neck plus the length gained by the modular head used. In addition, the depth the implant is inserted into the femoral canal alters vertical height. When cement is used, the vertical height can be adjusted further by variation in the level of the femoral neck osteotomy. This additional flexibility may be unavailable when a cementless femoral component is used because depth of insertion is determined more by the fit within the femoral metaphysis than by the level of the neck osteotomy. Offset (i.e., horizontal offset) is the distance from the center of the femoral head to a line through the axis of the distal part of the stem and is primarily a function of stem design. Inadequate restoration of offset shortens the moment arm of the abductor musculature and results in increased joint reaction force, limp, and bone impingement, which may result in dislocation. Offset can be increased by simply using a longer modular neck, but doing so also increases vertical height, which may result in overlengthening of the limb. To address individual variations in femoral anatomy, many components are now manufactured with standard and high offset versions. This is accomplished by reducing the neck-stem angle (typically to about 127 degrees) or by attaching the neck to the stem in a more medial position (Fig. 3.9). Reduction of the neck-stem angle increases offset but also reduces vertical height slightly. When the neck is attached in a more medial position, offset is increased without changing height; leg length is therefore unaffected. Version refers to the orientation of the neck in reference to the coronal plane and is denoted as anteversion or retroversion. Restoration of femoral neck version is important in achieving stability of the prosthetic joint. The normal femur has 10 to 15 degrees of anteversion of the femoral neck in relation to the coronal plane when the foot faces straight forward, and the prosthetic femoral neck should approximate this. Proper neck version usually is accomplished by rotating the component within the femoral canal. This presents little problem when cement is used for fixation; however, when pressfit fixation is used, the femoral component must be inserted in the same orientation as the femoral neck to maximize the fill of the proximal femur and achieve rotational stability of the implant. This problem can be circumvented by the use of a modular femoral component in which the stem is rotated independent of the metaphyseal portion. So-called anatomic stems have a slight proximal posterior bow to reproduce the contour of the femoral endosteum, predetermining the rotational alignment of the implant. Most such stems have a few degrees of anteversion built into the neck to compensate for this, and separate right and left stems are required. Finally, femoral components have been produced with dual modular necks in different geometries and lengths to allow the adjustment of length, offset, and version independently (Fig. 3.10). However, tribocorrosion at the taper junction between the neck and stem has been reported with these dual modular necks, and several of the designs have been either recalled or voluntarily withdrawn from the market. Consequently, their use has declined markedly over the past few years. The size of the femoral head, the ratio of head and neck diameters, and the shape of the neck of the femoral component have a substantial effect on the range of motion of the hip,

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FIGURE 3.7 Modular heads for femoral components. Neck taper mates with modular femoral heads. Motion is absent between head and neck segments. Different diameter heads with various neck extensions are available. Extended neck, or “skirt,” of longer components has larger diameter than neck of conventional components, and arc of motion of hip is decreased.

Nonskirted head

A

Skirted head

B

FIGURE 3.8 Head-to-neck ratio of implants. Large-diameter head with trapezoidal neck (A) has greater range of motion and less impingement than smaller diameter head and skirted modular neck (B).

A

B

FIGURE 3.9 Variations in femoral component necks to increase offset. A, Neck-stem angle is reduced. B, Neck is attached at more medial position on stem. SEE TECHNIQUE 3.5.

FIGURE 3.10 Modular femoral neck with taper junctions for stem body and femoral head. Multiple configurations allow independent adjustment of length and offset and version.

the degree of impingement between the neck and rim of the socket, and the stability of the articulation. This impingement can lead to dislocation, accelerated polyethylene wear, acetabular component loosening, and liner dislodgment or fracture. For a given neck diameter, the use of a larger femoral head increases the head-neck ratio and the range of motion before the neck impinges on the rim of the socket will be greater (Fig. 3.11). When this impingement does occur, the femoral head is levered out of the socket. The “jump distance” is the distance the head must travel to escape the rim of the socket and is generally approximated to be half the diameter of the head (Fig. 3.12). For both of these reasons, a larger-diameter head is theoretically more stable than a smaller one. In a large series of total hips performed with a head size of 36 mm or larger, Lombardi et al. reported a dislocation rate of only 0.05%. The introduction of advanced bearing surfaces has allowed the use of larger head sizes than those traditionally used in the past. In practical terms, the femoral head diameter is limited by the size of the acetabulum, regardless of the bearing materials used for the femoral head and acetabulum. In a range-of-motion simulation with digitized implants and virtual reality software, Barrack et al. found an improvement of 8 degrees of hip flexion when head size was increased from 28 to 32 mm. Range of motion was dramatically reduced by the use of a circular neck, especially when combined with a skirted modular head, which increases the diameter of the femoral neck (Fig. 3.13). A trapezoidal neck yielded greater range of motion without impingement than a circular one (Fig. 3.14). In an experimental range-of-motion model with head sizes larger than 32 mm, Burroughs et  al. found that impingement between prosthetic components could be largely eliminated. When a head size larger than 38 mm was used, however, the only impingement was bone on bone and was dependent on bony anatomy and independent of head size. The ideal configuration of the prosthetic head and neck segment includes a trapezoidal neck and a larger diameter head without a skirt.

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A

B

FIGURE 3.11 Range of motion with different head sizes. For given diameter neck, implant with smaller femoral head (A) will have lesser arc of motion than larger one (B).

All total hip systems in current use achieve fixation of the femoral prosthesis with a metal stem that is inserted into the medullary canal. Much of the design innovation to increase prosthetic longevity has been directed toward improvement in fixation of the implant within the femoral canal. Many femoral stems have been in clinical use for variable periods since the 1990s. Recognition of the radiographic profile of a stem is often beneficial, however, in planning revision surgery. Readers are directed to previous editions of this text and other historical references for this information. Femoral components are available in both cemented and cementless varieties.

CEMENTED FEMORAL COMPONENTS

A

B

FIGURE 3.12 Jump distance. With subluxation, smaller head (A) has shorter distance to travel before escaping rim of acetabular component than larger one (B).

Abduction Abduction Flexion

Extension Flexion

Extension

Adduction

A

Adduction

B

FIGURE 3.13 Effects of head size and neck geometry on range of motion. A, Changing from 28-mm head (light shading) to 32-mm head (dark shading) results in 8-degree increase in flexion before impingement. B, Large circular taper has dramatically decreased range of motion to impingement (dark shading), which is diminished even further by having skirted modular head (light shading). (From Barrack RL, Lavernia C, Ries M, et al: Virtual reality computer animation of the effect of component position and design on stability after total hip arthroplasty, Orthop Clin North Am 32:569, 2001.)

Trapezoidal neck

FIGURE 3.14 ezoidal neck.

Circular neck

Cross-sectional comparison of circular and trap-

With the introduction of the Charnley low-friction arthroplasty, acrylic cement became the standard for femoral component fixation. Advances in stem design and in the application of cement have dramatically improved the longterm survivorship of cemented stems. Despite these advances, the use of cement for femoral fixation has declined precipitously over the past decade and there has been little recent innovation in implant design. Nonetheless, worldwide registry data suggest that in patients older than 75 years outcomes are better with cemented femoral fixation, owing mainly to a lower risk of periprosthetic fracture. Certain design features of cemented stems have become generally accepted. The stem should be fabricated of highstrength superalloy. Most designers favor cobalt-chrome alloy because its higher modulus of elasticity may reduce stresses within the proximal cement mantle. The cross section of the stem should have a broad medial border and preferably broader lateral border to load the proximal cement mantle in compression. Sharp edges produce local stress risers that may initiate fracture of the cement mantle and should be avoided. A collar aids in determining the depth of insertion at implantation. Mounting evidence suggests that failure of cemented stems is initiated at the prosthesis-cement interface with debonding and subsequent cement fracture. Various types of surface macrotexturing can improve the bond at this interface (Figs. 3.15 to 3.17). The practice of precoating the stem with polymethyl methacrylate (PMMA) has been associated with a higher than normal failure rate with some stem designs and has largely been abandoned. Noncircular shapes, such as a rounded rectangle or an ellipse, and surface irregularities, such as grooves or a longitudinal slot, also improve the rotational stability of the stem within the cement mantle (see Fig. 3.17). There is concern that even with surface modifications the stem may not remain bonded to the cement. If debonding does occur, a stem with a roughened or textured surface generates more debris with motion than a stem with a smooth, polished surface. Higher rates of loosening and bone resorption were found with the use of an Exeter stem with a matte surface than with an identical stem with a polished surface. Similar findings have been reported when comparing the original polished Charnley stem with its subsequent matte-finish modification. For this reason, interest has been renewed in the use of polished stems for cemented applications. Ling recommended a design that is collarless, polished, and tapered in two planes (Fig. 3.18) to allow a

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FIGURE 3.15 Summit stem. Integral proximal polymethyl methacrylate spacers and additional centralizer facilitate proper stem position and uniform cement mantle. (Courtesy DePuy Synthes Orthopaedics, Inc., Warsaw, IN.)

A

FIGURE 3.17 Spectron EF stem. Rounded rectangular shape and longitudinal groove improve rotational stability. (Courtesy Smith & Nephew, Memphis, TN.)

B

FIGURE 3.16 Omnifit EON stem. Normalized proximal texturing converts shear forces to compressive forces. A, Standard offset. B, Enhanced offset. (Courtesy Stryker Orthopaedics, Kalamazoo, MI.)

FIGURE 3.18 Collarless, polished, tapered (CPT) hip stem. CPT design allows controlled subsidence and maintains compressive stresses within cement mantle. (Courtesy Zimmer Biomet, Warsaw, IN.)

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS small amount of subsidence and to maintain compressive stresses within the cement mantle. Such implants are often referred to as taper-slip or force-closed devices. A collar on a polished stem is to be avoided since it may prevent this controlled subsidence. Registry data support a lower rate of loosening in the long term with polished stems than with matte finished stems. Stems should be available in a variety of sizes (typically four to six) to allow the stem to occupy approximately 80% of the cross section of the medullary canal with an optimal cement mantle of approximately 4 mm proximally and 2 mm distally. Neutral stem placement within the canal lessens the chance of localized areas of thin cement mantle, which may become fragmented and cause loosening of the stem. Some designs have preformed PMMA centralizers that are affixed to the distal or proximal aspects, or both, of the stem before implantation to centralize the stem within the femoral canal and provide a more uniform cement mantle (see Fig. 3.15). The centralizers bond to the new cement and are incorporated into the cement mantle. Finally, the optimal length of the stem depends on the geometry and size of the femoral canal. The stem of the original Charnley component was about 13 cm long. This was long enough to obtain secure fixation in the metaphysis and proximal diaphysis of the femur. A stem of longer length, which engages the isthmus, makes it more difficult to err and place the stem in a varus position. As a result of the normal anterior bow of the femoral canal, however, the tip of the stem may impinge on the anterior cortex or even perforate it when the cortex is thin. In addition, it is technically difficult to occlude the canal below the level of the isthmus adequately, and the result may be an inadequate column of cement around the stem and beyond the tip. The lengths of current stem designs range from 120 to 150 mm. Longer stems are available if the cortex has been perforated, fractured, or weakened by screw holes or other internal fixation devices and particularly for revision procedures. 

CEMENTLESS FEMORAL COMPONENTS

In the mid-1970s, problems related to the fixation of femoral components with acrylic cement began to emerge. As a result, considerable laboratory and clinical investigations have been performed in an effort to eliminate cement and provide for biologic fixation of femoral components. The two prerequisites for biologic fixation are immediate mechanical stability at the time of surgery and intimate contact between the implant surface and viable host bone. To fulfill these requirements, implants must be designed to fit the endosteal cavity of the femur as closely as possible. Still, the femur must be prepared to some degree to match accurately the stem that is to be inserted. In general, the selection of implant type and size must be more precise than with their cemented counterparts. Current cementless stem designs differ in their materials, surface coating, and shape. Experience has been confined largely to the use of two materials: (1) titanium alloy with one of a variety of surface enhancements and (2) cobalt-chromium alloy with a sintered beaded surface. Both materials have proved to be satisfactory. Titanium has been recommended by many designers because of its superior biocompatibility, high fatigue strength, and lower modulus of elasticity. Titanium is more notch-sensitive than cobalt-chrome alloy, however, predisposing it to

initiation of cracks through metallurgic defects and at sites of attachment of porous coatings. When the stem is of a titanium substrate, the porous surface must be restricted to the bulkier proximal portions of the stem and away from areas that sustain significant tensile stresses, such as on the lateral border of the stem. Titanium alloy has been recommended as the material of choice because its modulus of elasticity is approximately half that of cobalt-chromium alloy and therefore less likely to be associated with thigh pain. However, Lavernia et al. reported titanium alloy and cobalt-chromium alloy stems of an identical tapered design in 241 patients. Thigh pain was unrelated to the material composition of the stem but was more common in patients with a larger stem size. A variety of surface modifications including porous coatings, grit blasting, plasma spraying, and hydroxyapatite coating have been used to enhance implant fixation. Many cementless femoral component designs feature combinations of these surface enhancements. Although the type and extent of coating necessary is controversial, most experts agree that it should be circumferential at its proximal boundary. Some early porous stem designs used patches or pads of porous coating with intervening smooth areas, which allowed joint fluid to transport particulate debris to the distal aspect of the stem. Schmalzried et al. referred to these extensions of joint fluid as the “effective joint space.” This design feature has been associated with early development of osteolysis around the tip of the stem despite bone ingrowth proximally. Circumferential porous coating of the proximal aspect of the stem provides a more effective barrier to the ingress of particles and limits the early development of osteolysis around the distal aspect of the stem. Bone ingrowth into a porous coating has demonstrated durable fixation for a multitude of cementless stem designs. Porous coatings have historically been created by either beads or fiber mesh (Fig. 3.19A and B) applied to the stem by sintering or diffusion bonding processes. Both processes require heating of the underlying substrate and can cause significant reduction in the fatigue strength of the implant. A considerable volume of research has determined the optimal pore size for bone ingrowth into a porous surface to be between 100 and 400 μm. Most porous-coated implants currently available have pore sizes in this range. Highly porous metals such as tantalum were initially utilized for cementless fixation of acetabular components but have more recently been applied to femoral stems also (Fig. 3.19C). Porous metals have higher porosity than traditional porous coatings, and their high coefficient of friction against cancellous bone may improve their initial stability. Porous tantalum closely resembles the structure of cancellous bone. Rapid and extensive bone ingrowth into this implant surface has been reported. Bone ongrowth implies growth of bone onto a roughened (albeit nonporous) surface. Ongrowth surfaces are created by grit blasting or plasma spray techniques. Grit blasting involves the use of a pressurized spray of aluminum oxide particles to produce an irregular surface ranging from 3 to 8 μm in depth (Fig. 3.20A). Plasma spray techniques use high-velocity application of molten metal onto the substrate in a vacuum or argon gas environment and produce a highly textured surface (Fig. 3.20B). Heating of the implant is not required, and, consequently, there is little reduction in fatigue strength compared with the application of porous coatings. Hydroxyapatite

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A

B

C

FIGURE 3.19 Types of bone ingrowth surfaces. Traditional surfaces produced from sintered beads (A) and diffusion bonded fiber mesh (B). C, Newer highly porous tantalum more closely resembles structure of trabecular bone. (A courtesy Smith & Nephew, Memphis, TN; B and C courtesy Zimmer Biomet, Warsaw, IN.)

A

B

C

FIGURE 3.20 Types of bone ongrowth surfaces. A, Grit-blasted surface. More highly textured plasma-sprayed surfaces: titanium (B) and hydroxyapatite (C). (A, Courtesy Zimmer, Warsaw, IN; B, Courtesy Biomet Orthopedics, Warsaw, IN; C, Courtesy Stryker Orthopaedics, Mahwah, NJ.)

and other osteoconductive calcium phosphate coatings can also be applied to implants by plasma spray (Fig. 3.20C). The thickness of the coating is typically 50 to 155 μm. Although the literature reports mixed results with regard to whether hydroxyapatite coating improves outcomes, there is no evidence that it is deleterious. The evolution of cementless femoral fixation has resulted in a variety of implants. The shape of a cementless stem determines the areas of the femoral canal where fixation is obtained and the surgical technique required for implantation. Outcomes are also generally more dependent on stem

geometry than on either materials or surface enhancements. Khanuja, Vakil, Goddard, and Mont proposed a classification system for cementless stems based on shape. Types 1 through 5 are straight stems, and fixation area increases with type. Type 6 is an anatomic shape. Type 1 stems are so-called single-wedge stems. They are flat in the anteroposterior plane and tapered in the mediolateral plane (Fig. 3.21). Fixation is by cortical engagement only in the mediolateral plane and by three-point fixation along the length of the stem. The femoral canal is prepared by broaching alone, with no distal reaming. Consequently, it

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B

C

FIGURE 3.21 Taperloc stem. Single wedge design is tapered in medial-lateral plane (A) and flat in anteroposterior plane. B, Plasma-sprayed proximal surface. C, Shortened microplasty version. (Courtesy Zimmer Biomet, Warsaw, IN.)

is important to ensure that the stem is wedged proximally. In Dorr type A femurs, distal engagement alone risks fracture or rotational instability. Consequently, many of these designs have been modified with reduced distal sizing to avoid this problem. These stems have performed well in Dorr type B and C femurs. Type 2 stems engage the proximal femoral cortex in both mediolateral and anteroposterior planes. So-called dualwedge designs fill the proximal femoral metaphysis more completely than type 1 stems (Fig. 3.22). Femoral preparation typically requires distal reaming followed by broaching of the proximal femur. They can be used safely in Dorr type A femurs. Type 3 represents a more disparate group of implants. These stems are tapered in two planes, but fixation is achieved more at the metaphyseal-diaphyseal junction than proximally as with types 1 and 2. Type 3A stems are tapered with a round conical distal geometry. Longitudinal cutting flutes are added to type 3B stems (Fig. 3.23). These implants have recently gained popularity in complex revision cases. Type 3C implants are rectangular and thus provide four-point rotational support (Fig. 3.24). Such implants have been used extensively in Europe with success. Type 4 are extensively coated implants with fixation along the entire length of the stem. Canal preparation requires distal cylindrical reaming and proximal broaching (Fig. 3.25). Excellent long-term results have been achieved with these implants. Femoral stress shielding and thigh pain have been reported with various designs. Their use in Dorr type C femurs can be problematic because of the large stem diameter required.

Type 5 or modular stems have separate metaphyseal sleeves and diaphyseal segments that are independently sized and instrumented. Such implants often are recommended for patients with altered femoral anatomy, particularly those with rotational malalignment such as developmental dysplasia. Both stem segments are prepared with reamers, leading to a precise fit with rotational stability obtained both proximally and distally. This feature makes modular stems an attractive option when femoral osteotomy is required (Fig. 3.26). Modular stems can be used for all Dorr bone types, but increased cost and potential problems with modular junctions should be taken into account. Type 6 or anatomic femoral components incorporate a posterior bow in the metaphyseal portion and variably an anterior bow in the diaphyseal portion, corresponding to the geometry of the femoral canal (Fig. 3.27). Right and left stems are required, and anteversion must be built into the neck segment. Anatomic variability in the curvature of the femur usually requires some degree of overreaming of the canal; if the tip of the stem is eccentrically placed, it impinges on the anterior cortex. This point loading has been suggested to be a source of postoperative thigh pain. The popularity of anatomic stems has declined over the past decade in favor of straight designs. With cementless devices, the requirements for canal filling often mean the stem must be of sizable diameter. Because stiffness of a stem is proportional to the fourth power of the diameter, an increased prevalence of femoral stress shielding can be seen with larger stems. The mismatch in stiffness between implant and bone also has been cited as a cause of postoperative thigh pain. Current stem designs deal with this problem in

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A

B

FIGURE 3.22 Synergy stem. Dual wedge design is tapered in medial-lateral (A) and anteroposterior (B) planes. Longitudinal flutes provide additional rotational stability. Shown with oxidized Zirconia head. (Courtesy Smith & Nephew, Memphis, TN.)

FIGURE 3.24 Alloclassic stem. Conical straight stem with rectangular cross-section and grit-blasted nonporous surface. (Courtesy Zimmer Biomet, Warsaw, IN.)

A FIGURE 3.23 Restoration modular stem. Tapered round conical distal geometry with longitudinal cutting flutes are available in varying lengths for primary and revision indications. Proximal segments are available in various lengths and offsets for soft-tissue tensioning. (Courtesy Stryker Orthopaedics, Mahwah, NJ.)

B

C

FIGURE 3.25 Extensively porous-coated stems. A, Anatomic medullary locking (AML) stem for primary and revision arthroplasties when isthmus is intact. B, Extensively coated solution long stem used for revisions when proximal bone loss is severe. C, Calcar replacement long stem. (Courtesy Depuy Synthes, Warsaw, IN.)

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A

B

FIGURE 3.26 S-ROM modular stem. A, Multiple proximal sleeve sizes can be combined with given diameter stem. Stem can be rotated in relation to sleeve to correct rotational deformity of femur. Distal flutes improve rotational stability. B, Long curved stem. Distal part of stem is slotted in coronal plane to diminish bending stiffness. (Courtesy Depuy Synthes, Warsaw, IN.)

FIGURE 3.27 Anato anatomic stem. Asymmetric metaphyseal shape conforms more closely to proximal femoral geometry. Femoral neck is anteverted 7 degrees, and dedicated right and left stems are required. (Courtesy Stryker Orthopedics, Mahwah, NJ.)

several ways. The section modulus of the stem can be changed to allow greater flexibility while leaving the implant diameter unchanged so that stability is not compromised. The addition of deep, longitudinal grooves reduces bending and torsional stiffness. The bending stiffness in the distal third of the stem also can be reduced substantially by splitting the stem in the coronal plane, similar to a clothespin (see Fig. 3.26). Tapered distal stem geometries are inherently less stiff than cylindrical ones (see Fig. 3.22) and have been associated with minimal thigh pain. A considerable amount of data supports a superiority of cementless femoral fixation in younger patients. Takenaga et al. reported a series of extensively porous-coated stems in patients 59 years of age or younger. At a minimum of 10 years after surgery no stems showed radiographic signs of loosening or had undergone revision for loosening. Survivorship was better than in a cohort of cemented stems from the same institution. McLaughlin and Lee reported a series of singlewedge design stems in patients younger than 50 years. At a minimum follow-up of 20 years, no stems were revised for aseptic loosening. Costa, Johnson, and Mont reported 96% survivorship at mean follow-up of 5 years in a series of patients who had arthroplasty at a mean age of 20 years. Using a stem fully coated with hydroxyapatite, Jacquot et al. reported a 30-year survival of 93.6% with stem revision as the endpoint. Evidence supporting the use of cementless femoral fixation in patients over the age of 75 is less compelling. Registry data and individual series both call attention to a higher rate of revision for periprosthetic fractures in this population. 

SPECIALIZED AND CUSTOM-MADE FEMORAL COMPONENTS

The adoption of minimally invasive surgical techniques has generated interest in shorter bone-sparing femoral implants. Some are novel implants designed to fit within the intact ring of bone of the femoral neck (Fig. 3.28). Others are shortened versions of existing designs described previously (see Fig. 3.21C). These implants have been used most commonly in minimally invasive anterior approaches where access to the femoral canal is more difficult. A shorter stem also avoids the problem of proximal-distal mismatch encountered with conventional length stems in Dorr type A femurs. Ideally, short femoral stems should allow retention of a longer segment of the femoral neck and increased physiologic load transfer in the proximal femur to reduce bone loss. Data supporting the use of these implants are limited. The surgical technique must be more precise to avoid varus malalignment and undersizing. Subsidence has been reported more commonly with some designs. Despite the large array of femoral components available, deformity or bone loss from congenital conditions, trauma, tumors, or previous surgery may make it impossible for any standard stem to fit the femur or restore adequately the position of the femoral head. Several types of calcar replacement femoral components (see Fig. 3.25C) are available for patients with loss of varying amounts of the proximal femur in lieu of the use of bone grafts. Limb salvage procedures for some malignant or aggressive benign bone and soft-tissue tumors may require a customized component. Modular segmental replacement stems also are used in patients with extensive femoral bone loss from multiple failed arthroplasty procedures and periprosthetic fractures (Fig. 3.29). Rarely, a

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FIGURE 3.28 Metha short hip stem. Designed for less-invasive surgery with retention of femoral neck and metaphyseal fixation (shown with modular neck). (Courtesy Aesculap Implant Systems, LLC, Center Valley, PA.)

prosthesis may be required to replace the entire femur, incorporating hip and knee arthroplasties. Customized, cementless, CT-generated computerassisted design/computer-assisted manufacturing (CAD/ CAM) prostheses have been recommended when preoperative planning indicates that an off-the-shelf prosthesis cannot provide optimal fit or when excessive bone removal would be required. Such implants require a carefully made preoperative CT scan of the acetabulum, hip joint, and femur. An identical broach is supplied with the implant to prepare the femur. Customized femoral components also have been recommended for revision surgery with proximal femoral osteolysis, congenital hip dislocation, excessively large femurs, and grossly abnormal anatomy and when a fracture has occurred below the tip of a femoral stem. With the proliferation of newer revision stem designs and techniques of femoral osteotomy for revision procedures, custom stems are seldom needed in our practice. 

ACETABULAR COMPONENTS

Acetabular components can be broadly categorized as cemented or cementless. Acetabular reconstruction rings also are discussed in this section.

CEMENTED ACETABULAR COMPONENTS

The original sockets for cemented use were thick-walled polyethylene cups. Vertical and horizontal grooves often were added to the external surface to increase stability within the cement mantle, and wire markers were embedded in the plastic to allow better assessment of position on postoperative radiographs. Many of these designs are still in regular use.

FIGURE 3.29 Specialized femoral components for replacement of variable length of proximal femur. Orthogenesis limb preservation system uses modular segmental replacement stem for replacement of large segment of proximal femur. Stem can be combined with total knee replacement to replace entire femur. (Courtesy Depuy Synthes, Warsaw, IN.)

More recent designs have modifications that ensure a more uniform cement mantle. PMMA spacers, typically 3 mm in height, ensure a uniform cement mantle and avoid the phenomenon of “bottoming out,” which results in a thin or discontinuous cement mantle (Fig. 3.30). A flange at the rim of the component aids in pressurization of the cement as the cup is pressed into position. Despite such changes in implant design, the long-term survivorship of cemented acetabular components has not substantially improved. Consequently, there has been a trend toward cementless fixation of acetabular components in most patients. The simplicity and low cost of all-polyethylene components make them a satisfactory option in older, lowdemand patients. At times, cement is also used as the means of fixation of a polyethylene insert into an acetabular component that lacks an intrinsic locking mechanism for the polyethylene or when a dedicated insert is not available for a cementless acetabular component that is to be retained during revision surgery. Cemented acetabular fixation also is used in some tumor reconstructions and when operative circumstances indicate that bone ingrowth into a porous surface is unlikely, as in revision arthroplasty in which extensive acetabular bone

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FIGURE 3.30 Acetabular component designed for cement fixation. Textured surface and polymethyl methacrylate spacers optimize cement mantle and cement-prosthesis interface. (Courtesy Smith & Nephew, Memphis, TN.)

grafting has been necessary. In these instances, a cemented acetabular component often is used with an acetabular reconstruction ring (see Fig. 3.36). 

CEMENTLESS ACETABULAR COMPONENTS

Most cementless acetabular components are porouscoated over their entire circumference for bone ingrowth. Instrumentation typically provides for oversizing of the implant 1 to 2 mm larger than the reamed acetabulum as the primary method of press-fit fixation. Fixation of the porous shell with transacetabular screws has become commonplace but carries some risk to intrapelvic vessels and viscera and requires flexible instruments for screw insertion. Analyses of retrieved porous acetabular components showed that bone ingrowth occurs most reliably in the vicinity of the fixation devices, such as pegs or screws. The most extensive ingrowth has been reported in components initially fixed with one or more screws. Pegs, fins, and spikes driven into prepared recesses in the bone provide some rotational stability, but less than that obtained with screws. The use of these other types of supplemental fixation devices has declined as manufacturers have incorporated highly porous metal coatings with improved initial press-fixation (Figs. 3.31 and 3.32). Solid metal shells without screw holes have not proven beneficial in reducing the presence or size of osteolytic lesions; their use has consequently diminished. Hydroxyapatite coating has been advocated in the past to enhance bone ingrowth into the porous coating of cementless acetabular components. The process has not demonstrated improved survivorship, and with the introduction of newer porous surfaces, the use of hydroxyapatite coating has declined. Most systems feature a metal shell with an outside diameter of 40 to 75 mm that is used with a modular insert, also called a liner. With this combination, a variety of femoral head sizes, typically 22 to 40 mm, can be accommodated according to the patient’s need and the surgeon’s preference. The liner must be fastened securely within the metal shell. These mechanisms of fixation have been under increasing scrutiny

FIGURE 3.31 Zimmer trabecular metal acetabular component with various modular augments for bony deficiencies. (Courtesy Zimmer Biomet, Warsaw, IN.)

because in vivo dissociation of polyethylene liners from their metal backings has been reported. In addition, micromotion between the nonarticulating side of the liner and the interior of the shell may be a source of polyethylene debris generation, or “backside wear.” Recognition of this problem has led to improvements in the fixation of the liner within the metal shell, and some designs also have included polishing the interior of the shell. Monoblock acetabular components with nonmodular polyethylene also have been produced to alleviate the problem of backside wear but have not proven to be superior to modular implants. With the adoption of newer bearing surfaces and dual mobility implants (see Fig. 3.35), manufacturers have introduced acetabular components that will accept any of a variety of insert types. Newer locking mechanisms typically incorporate a taper junction near the rim for hard bearings. The polyethylene locking mechanism may be recessed within the shell where it is less susceptible to damage if impingement from the femoral neck occurs (Fig. 3.32B). Finally, the issue of excessive wear of thin shells of polyethylene is a major concern. The metal backing must be of sufficient thickness to avoid fatigue failure, and there must be a corresponding decrease in thickness of the polyethylene insert for a component of any given outer diameter. High stresses within the polyethylene are likely when the thickness of the plastic is less than 5 mm, leaving the component at risk for premature failure as a result of wear. To maintain sufficient thickness of the polyethylene, a smaller head size must be used with an acetabular component that has a small outer diameter. Most modern modular acetabular components are supplied with a variety of polyethylene insert choices. Some

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A

B FIGURE 3.32 R3 acetabular component. A, Hemispherical shell with optional screw fixation and highly porous titanium coating. B, Locking mechanism is recessed to avoid thin polyethylene at rim and accept various bearing inserts. (Courtesy Smith & Nephew Orthopaedics, Memphis, TN.)

designs incorporate an elevation over a portion of the circumference of the rim, whereas others completely reorient the opening face of the socket up to 20 degrees. Still other designs simply lateralize the hip center without reorienting its opening face (Fig. 3.33). Lateralization also allows for the use of a larger-diameter head while maintaining adequate polyethylene thickness. Such designs can compensate for slight aberrations in the placement of the metal shell and improve the stability of the articulation; however, with elevated rim liners, motion can be increased in some directions but decreased in others. An improperly positioned elevation in the liner can cause impingement rather than relieve it, rendering the joint unstable. With larger-diameter femoral heads, elevated rim liners are being used less frequently. A constrained acetabular component includes a mechanism to lock the prosthetic femoral head into the polyethylene liner. The tripolar-style mechanism features a small inner bipolar bearing that articulates with an outer true liner (Fig. 3.34A). The bipolar segment is larger than the introitus of the outer liner, preventing dislocation. Other designs use a liner with added polyethylene at the rim that deforms to capture the femoral head. A locking ring is applied to the rim to prevent

escape of the head (Fig. 3.34B). Other unique designs are also available from individual manufacturers. Indications for constrained liners include insufficient soft tissues, deficient hip abductors, neuromuscular disease, and hips with recurrent dislocation despite well-positioned implants. Constrained acetabular liners have reduced range of motion compared with conventional inserts. Consequently, they are more prone to failure because of prosthetic impingement. A constrained liner should not be used to compensate for an improperly positioned shell, and skirted femoral heads should be avoided in combination with constrained inserts. A dual mobility acetabular component is an unconstrained tripolar design. The implant consists of a porouscoated metal shell with a polished interior that accepts a large polyethylene ball into which a smaller metal or ceramic head is inserted (Fig. 3.35). The two areas of articulation share the same motion center. The design effectively increases the head size and the head-neck ratio of the construct. Implant impingement is reduced and stability is improved without reducing the range of motion as with constrained implants. A modular metal shell and insert are available for cases in which screw fixation may be required. In a large series of primary total hip arthroplasties using a dual mobility implant, Combes et al. reported a dislocation rate of 0.88%. Wegrzyn et  al. reported dislocations in 1.5% of revision cases. Also reported are intraprosthetic dislocations between the small head and polyethylene ball. As with constrained acetabular devices, dual mobility components cannot be relied on to compensate for technical errors in implant positioning. Custom components for acetabular reconstruction rarely are indicated. Most deficient acetabula can be restored to a hemispherical shape, and a standard, albeit large, acetabular component can be inserted. In patients with a large superior segmental bone deficiency, the resulting acetabular recess is elliptical rather than hemispherical. A cementless acetabular component with modular porous metal augments (see Fig. 3.31) can be used instead of a large structural graft or excessively high placement of a hemispherical component. Augments of various sizes are screwed into bony defects to support the acetabular component. The augments are joined to the implant with the use of bone cement. With the introduction of revision implants with augments, custom components for acetabular reconstruction rarely are indicated. When bony deficits are massive, a custom implant can be produced based on a CT scan with subtraction of the metal artifacts. The imaging requirements vary according to the manufacturer. Such implants typically have both superior and inferior flanges that rest on intact bone and provide for additional screw fixation. The placement of the flanges, screw locations, and trajectories can all be built into the plan. Typically, a detailed 3D-printed model of the bony pelvis (Fig. 3.36) and proposed implant are produced before the actual implant is manufactured (Fig. 3.37). Historically, metal rings, wire mesh, and other materials have been used to improve acetabular fixation. These devices were intended to reinforce cement, and generally their longterm performance was poor. More recently, numerous acetabular reconstruction rings have been introduced to allow bone grafting of the deficient acetabulum behind the ring, rather than relying on cement on both sides of the device. (Cement is used only to secure an all-polyethylene acetabular component to the ring.) The reconstruction ring provides

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A

B

C

D

FIGURE 3.33 Array of liner options available with contemporary modular acetabular system: standard flat liner (A), posterior lip without anteversion (B), 4-mm lateralized flat (C), and anteverted 20 degrees (D). (Courtesy Smith & Nephew, Memphis, TN.) SEE TECHNIQUE 3.3.

A

B FIGURE 3.34 A, Tripolar design with small bipolar shell captured within outer liner. B, Peripheral locking ring design. (A courtesy Stryker Orthopaedics, Mahwah, NJ; B courtesy Zimmer Biomet, Warsaw, IN.)

immediate support for the acetabular component and protects bone grafts from excessive early stresses while union occurs. These devices are commonly referred to as antiprotrusio rings and cages. The preferred devices are those with superior and inferior plate extensions that provide fixation into the ilium and the ischium (Fig. 3.38). Success with these devices depends on selection of the proper device and careful attention to technique. Implantation of the antiprotrusio cage requires full exposure of the external surface of the posterior column for safe positioning and screw insertion. Alternatively, the inferior plate can be inset into a prepared recess in the ischium without the need for inferiorly placed screws. For all types of devices, dome screws are placed before the plates are attached to the external surface of the ilium. Results to date seem to be

best when the device is supported superiorly by intact host bone rather than by bone grafts. These implants do not provide for long-term biologic fixation and are prone to fracture and loosening. The advent of highly porous metal implants has reduced the need for cages in current practice. Rarely, an antiprotrusio cage may be used in tandem with a revision acetabular shell. This “cup-cage” construct has greater potential for biologic fixation. 

ALTERNATIVE BEARINGS

Osteolysis secondary to polyethylene particulate debris has emerged as a notable factor endangering the long-term survivorship of total hip replacements. Several alternative bearings have been advocated to diminish this problem, particularly in younger, more active patients who are at higher risk for rapid

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FIGURE 3.35 Dual mobility acetabular component. Porouscoated shell with polished interior, large polyethylene head, and smaller inner bearing. (Courtesy Stryker Orthopaedics, Mahwah, NJ.)

A

HIGHLY CROSSLINKED POLYETHYLENE

Historically, polyethylene implants have been sterilized by subjecting them to 2.5 Mrad of either electron-beam or gamma radiation. These processes produce free radicals in the material, however, predisposing the polyethylene to oxidation and rendering it more susceptible to wear. Higher doses of radiation can produce polyethylene with a more highly crosslinked molecular structure. Initial testing of this material has shown remarkable wear resistance. Crosslinking is accomplished by either gamma or electron-beam radiation at a dose between 5 and 10 Mrad. However, the radiation process also generates uncombined free radicals. If these are allowed to remain, the material is rendered more susceptible to severe oxidative degradation. The concentration of these free radicals can be reduced by a postirradiation heating process, either remelting or annealing. Remelting entails heating the material above its melting point (approximately 135°C). Free radicals are virtually eliminated with remelting, but the crystallinity of the resulting material is also reduced. The decrease in crystallinity diminishes the material properties of polyethylene, particularly fracture toughness and ultimate tensile strength. Annealing refers to a process of heating the material just below the melting point. This avoids the reduction in crystallinity and consequent reduction in mechanical properties, but annealing is less effective than remelting in extinguishing residual free radicals. Newer manufacturing methods have sought to mitigate the deleterious effects of remelting. Soaking the radiated polyethylene in vitamin E (or vitamin E “doping”) appears to be effective in scavenging free radicals without a remelting stage. Another process applies the radiation in three smaller doses with annealing after each stage. Terminal sterilization is most commonly done with

B

FIGURE 3.36 Custom triflange acetabular model. A, CT-based model showing large acetabular deficiencies. B, Custom acetabular component has intimate fit and flanges for multiple screw fixation.

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS either gas plasma or ethylene oxide because gamma radiation would generate additional free radicals. The processes used by individual manufacturers for production of highly crosslinked polyethylenes are proprietary and differ in the initial resin used, the amount and type of radiation used, the use of postirradiation thermal processing, and the method of terminal sterilization. Although early clinical results for all methods are encouraging, the long-term performance of these materials may vary and will need to be studied individually. Test data from contemporary hip simulators have shown an 80% to 90% reduction in wear with highly crosslinked polyethylenes. When tested in conditions of third-body wear with abrasive particulates or against a roughened counterface, crosslinked polyethylene has improved wear performance substantially compared with conventional polyethylene. Muratoglu et al. showed that the wear rate of this material is not related to the size of the femoral head, within the range of 22 to 46 mm in diameter. Consequently, larger femoral head sizes can be used. Highly crosslinked polyethylenes remain within current American Society for Testing and Materials standards, but concerns have been raised over the potential for fatigue, delamination, and implant fracture when a thin liner is used to accommodate a large-diameter head. Prior attempts to improve the performance of polyethylene have universally failed. Carbon fiber reinforcement, heat pressing, and Hylamer (DePuy, Warsaw, IN) are notable examples. Early clinical results have shown reductions in wear that are less dramatic than those predicted in hip simulators. The bedding-in process is similar with highly crosslinked and conventional polyethylenes and affects calculations of wear rates using short-term clinical studies. Longer follow-up is needed to assess the true wear reduction after the beddingin process is complete and a steady state of wear is reached.

FIGURE 3.37 Implant trial and bone model can be sterilized for reference in surgery.

It also is important to view reports of wear “reduction” in the context of the quality and performance of the material used as the control. There are now a sufficient number of studies with 10-year follow-up to conclude that the performance of highly crosslinked polyethylenes surpasses that of conventional polyethylene. Snir et al. found that after an initial bedding-in period, there was an annual mean wear rate of 0.05 mm/year with a first-generation highly crosslinked polyethylene. Using precision radiostereometric analysis, Glyn-Jones et  al. measured steady-state wear of only 0.003 mm/year at 10 years. In a series of patients younger than 50 years, Rames et al. observed survivorship of 97.8% at 15 years with no wear-related revisions and a liner wear rate of 0.0185 mm/year. The available data indicate a wear rate for highly crosslinked polyethylenes as well below the generally accepted osteolysis threshold of 0.1 mm/year. Using data from the Australian Orthopaedic Association National Joint Replacement Registry, de Steiger found the 16-year cumulative percentage of revisions for all causes was 6.2% for highly crosslinked polyethylene compared to 11.7% for conventional polyethylene. Femoral head size appears to have less of an effect on highly crosslinked polyethylene than on conventional material. Allepuz et al. published data aggregated from six national and regional registries that showed no difference in wear rates with 32-mm heads compared with smaller diameter sizes. Lachiewicz, Soileau, and Martell reported no difference in liner wear rates with 36- to 40-mm heads compared with smaller sizes; however, volumetric wear was higher in patients with larger diameter heads. Most of the published data involve head sizes of 32 mm and smaller. Tower et  al. reported four fractures of a highly crosslinked polyethylene liner in a design with thin polyethylene at the rim and a relatively vertical position of the acetabular component. Using an

FIGURE 3.38 Contour antiprotrusio cage has titanium support ring fixed to ilium and ischium with screws. Alternatively, inferior fin can be impacted into ischium without screws. (Courtesy Smith & Nephew, Memphis, TN.)

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CHAPTER 3  ARTHROPLASTY OF THE HIP excessively thin polyethylene liner purely to accommodate a larger head is still to be avoided. Highly crosslinked polyethylene liners from most manufacturers are compatible with existing modular acetabular components. The liner can be replaced with the newer material without revising the shell in the event of reoperation for osteolysis, dislocation, or at the time of revision of the femoral component. An array of liner options is available as has been the case with conventional polyethylene (see Fig. 3.33). 

CERAMIC-ON-CERAMIC BEARINGS

Alumina ceramic has many properties that make it desirable as a bearing surface in hip arthroplasty. Because of its high density, implants have a surface finish smoother than metal implants. Ceramic is harder than metal and more resistant to scratching from third-body wear particles. The liner wear rate of alumina-on-alumina has been shown to be 4000 times less than cobalt-chrome alloy-on-polyethylene. Hamadouche et al. measured ceramic wear at less than 0.025 mm/year in a series of patients with a minimum of 18.5 years’ follow-up. Early ceramic implants yielded disappointing clinical results because of flawed implant designs, inadequate fixation, implant fracture, and occasional cases of rapid wear with osteolysis. Numerous improvements have been made in the manufacture of alumina ceramics since the 1980s. Hot isostatic pressing and a threefold decrease in grain size have substantially improved the burst strength of the material. Refinements in the tolerances of the Morse taper have reduced the incidence of ceramic head fracture further. In addition, proof testing validates the strength of each individual implant before release. Ceramic head fracture is more common with smaller head sizes and shorter neck lengths. A 28 mm head with short neck length will have less material between the corner of the taper bore and articulating surface than a 36 mm head with longer neck length. Application of a ceramic femoral head onto a stem trunnion with wear or surface damage found at revision surgery can produce uneven load distribution within the head and contribute to fracture. Consequently, manufacturers have produced ceramic heads fitted with a metal sleeve for use in these circumstances. Impingement between the femoral neck and rim of the ceramic acetabular component creates problems unique to this type of articulation. Impact loading of the rim can produce chipping or complete fracture of the acetabular insert. Repetitive contact at extremes of motion also can lead to notching of the metal femoral neck by the harder ceramic and initiate failure through this relatively thin portion of the implant. In past series, ceramic wear has been greater when the acetabular component has been implanted in an excessively vertical orientation. Ceramic-on-ceramic arthroplasties may be more sensitive to implant malposition than other bearings. “Stripe wear” has been reported on retrieved ceramic heads. This term describes a long, narrow area of damage resulting from contact between the head and the edge of the ceramic liner. Microseparation of the implants during the swing phase of gait is a recognized phenomenon. Walter et  al. mapped the position of stripes on retrieved implants, however, and proposed they occur with edge loading when the hip is flexed, as with rising from a chair or stair climbing. Enthusiasm for ceramic-on-ceramic implants has been somewhat tempered by reports of reproducible noise, particularly squeaking. The incidence is generally low but in some

series has exceeded 10% and has been a source of dissatisfaction requiring revision. The onset of squeaking usually occurs more than 1 year after implantation, and the development of stripe wear has been implicated in noise generation. A specific cementless femoral component with unique metallurgy and taper size has been implicated in several reports. Vibrations generated at the articulating surfaces may be amplified by a more flexible stem, resulting in audible events. The etiology of squeaking has not been fully elucidated and is likely multifactorial. Osteolysis has been reported around first-generation alumina ceramic implants in instances of high wear. Wear particles are typically produced in smaller numbers and are of smaller size than seen with polyethylene, however, and the cellular response to ceramic particles seems to be less. Alumina ceramic is inert, and ion formation does not occur. There have been no adverse systemic effects reported with ceramic bearings. Ongoing investigation with composites of alumina and zirconia ceramic (BIOLOX delta, CeramTec GmbH, Plochingen, Germany) holds promise for further improvement in the material properties of these implants. Excellent wear properties and increased fracture toughness have been reported for this material. In a series of delta ceramic-onceramic total hips in patients younger than 50 years, Kim et  al. found excellent survivorship, but 10% still experienced noise generation including squeaking. Blakeney et al. reported a 23% incidence of squeaking when a large-diameter (32 to 48 mm head) delta ceramic-on-ceramic couple was used. The incidence of head fracture with delta ceramic is approximately 1 in 100,000 (0.001%) compared to 1 in 5000 (0.0201%) with pure alumina ceramic. Acetabular components include a ceramic insert that mates with a metal shell by means of a taper junction. Lipped and offset liners are unavailable. The locking mechanism for a given implant may not be compatible with other types of inserts. Chipping of the insert on implantation has been reported in multiple series. Special care should be taken during the operative assembly of the acetabular component to ensure that the insert is properly oriented before impaction. Metal backing of the insert has been advocated by one manufacturer to prevent insertional chips and protect the rim of the ceramic from impingement. Alumina ceramic femoral heads are manufactured with only a limited range of neck lengths, and skirted heads are unavailable. Careful preoperative planning with templates is required to ensure that the neck resection is made at an appropriate level for restoration of hip mechanics with the range of neck lengths available. Oxidized zirconium (OXINIUM, Smith & Nephew, Memphis, TN) is a zirconium metal alloy that is placed through an oxidation process to yield an implant with a zirconia ceramic surface of approximately 5 μm in thickness. The enhanced surface is integral to the metal substrate and not a surface coating. So-called ceramicized metals have the same surface hardness, smoothness, and wettability of typical ceramics, but are not susceptible to chipping, flaking, or fracture. Compared with cobalt chromium alloy, the material contains no detectable nickel and has therefore been recommended for patients with demonstrated metal hypersensitivity. Oxidized zirconium is currently available only in femoral head components mated with polyethylene and not as a ceramic-on-ceramic couple. Reduced wear has been

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS reported when oxidized zirconium is mated with a conventional polyethylene acetabular component. Aoude et al. found no difference in wear rates between cobalt chromium and oxidized zirconium when mated with highly crosslinked polyethylene. The material is more prone to surface damage than conventional ceramic heads after episodes of dislocation. So-called trunnionosis describes the process of fretting corrosion that may occur between a femoral component trunnion and a cobalt-chrome alloy femoral head leading to adverse local tissue response. The factors contributing to this phenomenon have not been fully elucidated but appear to be more common than previously recognized. The emergence of this problem combined with the reduced fracture risk with newer ceramics has led to an increase in the use of ceramic and ceramicized metal heads worldwide. Some large database studies have also reported a lower risk of infection with ceramic bearings. The reason for this association is unclear. 

INDICATIONS AND CONTRAINDICATIONS FOR TOTAL HIP ARTHROPLASTY Originally, the primary indication for THA was the alleviation of incapacitating arthritic pain in patients older than age 65 years whose pain could not be relieved sufficiently by nonsurgical means and for whom the only surgical alternative was resection of the hip joint (Girdlestone resection arthroplasty) or arthrodesis. Of secondary importance was the improved function of the hip. After the operation had been documented to be remarkably successful, the indications were expanded to include the other disorders listed in Box 3.1. Historically, patients 60 to 75 years old were considered the most suitable candidates for THA, but since the 1990s this age range has expanded. With an aging population, many older individuals are becoming candidates for surgery. In a meta-analysis reviewing the impact of advanced age on outcomes of lower extremity arthroplasty, Murphy et  al. found that the most elderly patients were at higher risk for mortality, complications, and longer length of stay. Nonetheless, these patients experienced significant gains in pain relief, and activities of daily living and were satisfied with the outcome of arthroplasty surgery. The 1994 National Institutes of Health Consensus Statement on Total Hip Replacement concluded that “THR [total hip replacement] is an option for nearly all patients with diseases of the hip that cause chronic discomfort and significant functional impairment.” In younger individuals, THA is not the only reconstruction procedure available for a painful hip; the expanding field of hip preservation (see Chapter 6) provides surgeons with a variety of options that may delay or obviate the need for arthroplasty. Femoral or periacetabular osteotomy should be considered for young patients with osteoarthritis if the joint is not grossly incongruous and satisfactory motion is present. Periacetabular osteotomy in patients with dysplasia may decrease the need for structural bone grafting if later conversion to arthroplasty is needed. If an osteotomy relieves symptoms for 10 years or more, and then an arthroplasty is required, the patient will have been able to engage in more physical activity, bone stock will have been preserved, and the patient will be older and less physically active and will need

the use of an arthroplasty for fewer years. Core decompression and osteotomy should be considered for patients with idiopathic osteonecrosis of the femoral head, especially when involvement is limited. Management of femoroacetabular impingement should be considered in suitable candidates. Arthrodesis is performed less frequently today, but is still a viable option for young, vigorous patients with unilateral hip disease and especially for young, active men with osteonecrosis or posttraumatic arthritis. If necessary at a later age, the arthrodesis can be converted to a THA. Finally, some designs of hip resurfacing (see Chapter 4) have been successful and remain an alternative to THA in young, active men. Before any major reconstruction of the hip is recommended, conservative measures should be advised, including weight loss, nonopioid analgesics, reasonable activity modification, low-impact exercise, and ambulatory aids. These measures may relieve the symptoms enough to make an operation unnecessary or at least delay the need for surgery for a significant period. Surgery is justified if, despite these measures, pain at rest and pain with motion and weight bearing are severe enough to prevent the patient from working or from carrying out activities of daily living. Pain in the presence of a degenerative or destructive process in the hip joint as evidenced on imaging studies is the primary indication for surgery. In our opinion, patients with limitation of motion, limp, or leg-length inequality but with little or no hip pain are not candidates for THA. In a study of a large inpatient database, Rasouli et  al. found a higher risk of systemic complications with bilateral total hip procedures carried out under a single anesthetic. Stavrakis et al. found a higher rate of sepsis, but no difference in other complications. The major indication is a medically fit patient with bilateral severe involvement with stiffness or fixed flexion deformity because rehabilitation may be difficult if surgery is done on one side only. Elderly patients with other comorbidities are not suitable candidates for such a procedure. A documented patent ductus arteriosus or septal defect is an absolute contraindication. More intensive intraoperative monitoring, including an arterial line, pulmonary artery catheter, and urinary catheter, is recommended. The surgeon should decide in concert with the anesthesiologist as to whether the second procedure could be completed safely. Absolute contraindications for THA include active infection of the hip joint or any other region and any unstable medical illnesses that would significantly increase the risk of morbidity or mortality. Asymptomatic bacteriuria has not been associated with postoperative surgical site infections and should not be considered a contraindication. 

PREOPERATIVE PATIENT EVALUATION AND OPTIMIZATION Hip arthroplasty for degenerative and traumatic conditions is a major cost center for payors. Over the past decade, a greater burden has been placed on both surgeons and institutions to reduce perioperative complications, minimize readmissions, and maintain favorable outcomes, all while reducing the cost of the episode of care. A thorough general medical evaluation, including laboratory tests, is a recognized prerequisite that affords the

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CHAPTER 3  ARTHROPLASTY OF THE HIP BOX 3.1

Disorders of the Hip Joint for Which Total Hip Arthroplasty May Be Indicated Inflammatory arthritis Rheumatoid Juvenile idiopathic Ankylosing spondylitis Osteoarthritis (degenerative joint disease, hypotrophic arthritis) Primary Secondary Developmental dysplasia of hip Coxa plana (Legg-Calvé-Perthes disease) Posttraumatic Slipped capital femoral epiphysis Paget disease Hemophilia Osteonecrosis Idiopathic Post fracture or dislocation Steroid induced Alcoholism Hemoglobinopathies (sickle cell disease) Lupus Renal disease Caisson disease Gaucher disease Slipped capital femoral epiphysis Failed reconstruction Osteotomy Hemiarthroplasty Resection arthroplasty (Girdlestone procedure) Resurfacing arthroplasty Acute fracture, femoral neck and trochanteric Nonunion, femoral neck and trochanteric fractures Pyogenic arthritis or osteomyelitis Hematogenous Postoperative Tuberculosis Hip fusion and pseudarthrosis Bone tumor involving proximal femur or acetabulum Hereditary disorders (e.g., achondroplasia)

clinician the opportunity to uncover and treat various problems before surgery. Comorbidities known to be inherent to elderly patients should be considered, especially cardiopulmonary disease, renal insufficiency, malnutrition, and the propensity for thromboembolism. Functional limitations from an arthritic hip may mask the symptoms of coronary or peripheral vascular disease. Various models of risk stratification have identified a number of potentially modifiable factors that may be addressed preoperatively in order to minimize the risk of complications. Cardiovascular complications are one of the most common causes of perioperative mortality and hospital readmission. Patients with a known history of cardiac disease or the presence of new symptoms should prompt a cardiology consultation. Aspirin, clopidogrel, and other antiplatelet medications are best discontinued 7 to 10 days before surgery. The

presence of vascular stents presents a particular dilemma that should be managed in cooperation with a cardiac consultant. If clopidogrel is to be discontinued before surgery, then it is acceptable to continue aspirin and restart clopidogrel as soon as the bleeding risk at the surgery site permits. Oral anticoagulants such as warfarin and factor Xa inhibitors should be discontinued in sufficient time for coagulation studies to return to normal. A bridging program with a short-acting anticoagulant such as enoxaparin may be required when discontinuing warfarin. The prevalence of obesity has increased dramatically in Western societies and has been repeatedly identified as a risk factor for delayed wound healing, deep infection, cardiac events, and kidney injury. The risk of infection increases gradually with elevation of body mass index (BMI). There is no definitive BMI at which surgery is contraindicated, but studies frequently stratify risk according to a BMI greater or less than 40 kg/m2 (class III, morbid obesity). A delay in surgery with a structured weight reduction diet plan should be encouraged for these patients. The role of bariatric surgery before arthroplasty and its effect on outcomes remains undetermined. Diabetes mellitus has consistently been recognized as a risk factor for postoperative complications, particularly infection. Preoperative screening for HbA1c elevation identifies patients with poor glycemic control over a period of 2 to 3 months. The literature is inconclusive regarding a threshold value of HbA1c that is predictive of subsequent infection. Cancienne et al. identified a HbA1c of more than 7.5% as a significant risk factor for postoperative joint infection. The Second International Consensus Meeting on Musculoskeletal Infection recommended that the upper threshold for HbA1c that may be predictive of subsequent joint infection is most likely to be within the range of 7.5% to 8%. Screenings finding a higher value should be referred for glycemic control prior to surgery. Current tobacco use has been shown to increase the risk of wound complications in many types of surgery, including arthroplasty. Duchman et  al. reported current smokers had a 1.8% incidence of wound complications compared to 1.1% in nonsmokers. Smoking cessation for at least 6 weeks before surgery is recommended to mitigate this risk. Compliance can be assessed by measuring the blood level of cotinine, a metabolite of nicotine. Patients having nasal colonization with Staphylococcus aureus are at increased risk for infection following hip arthroplasty. Some institutions have instituted screening for nasal MSSA/MRSA colonization with polymerase chain reaction assays. Nasal administration of mupirocin, povidone-iodine, and chlorhexidine products have all been used for decolonization. Universal treatment without individual screening is the most cost-effective modality. Preoperative anemia, defined by the World Health Organization (WHO) as a Hb level in men less than 13.0 g/ dL and 12.0 g/dL for women has been identified as an independent predictor for complications including infection. Perioperative blood transfusion has also been associated with complications including mortality, sepsis, and thromboembolism. Preoperative iron supplementation and erythropoietin administration can decrease the need for allogeneic transfusion. The perioperative use of tranexamic acid and a comprehensive institutional blood management protocol are also important adjuncts for reducing transfusions.

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS A low BMI (less than 18.5 kg/m2) is associated with a higher risk for infection and may be a surrogate for poor nutritional status in the elderly. Low serum albumin, prealbumin, transferrin, and total lymphocyte count are indicative of poor nutrition and/or anemia. Many herbal medications and nutritional supplements may cause increased perioperative blood loss, and we recommend that these medications be discontinued preoperatively. Pyogenic skin lesions should be eradicated, and preoperative skin preparation with chlorhexidine for several days should be considered. Dental problems, as well as urinary retention caused by prostatic or bladder disease, should be addressed before surgery. If a patient has a history of previous surgery, purulent drainage from the hip, or other indications of ongoing infection, laboratory investigation including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), nuclear scans, and a culture and sensitivity determination of an aspirate of the hip are advisable before surgery. Infection must be suspected if part of the subchondral bone of the acetabulum or femoral head is eroded or if bone has been resorbed around an internal fixation device. The physical examination should include the spine and the upper and lower extremities. The soft tissues around the hip should be inspected for any inflammation or scarring where the incision is to be made. Gentle palpation of the hip and thigh may reveal areas of point tenderness or a soft-tissue mass. The strength of the abductor musculature should be determined by the Trendelenburg test. The lengths of the lower extremities should be compared, and any fixed deformity should be noted. Adduction contracture of the hip can produce apparent shortening of the limb despite equally measured leg lengths. Abduction contracture conversely produces apparent lengthening. Fixed flexion deformity of the hip forces the lumbar spine into lordosis on assuming an upright posture and may aggravate lower back pain symptoms. Conversely, fixed lumbar spine deformity from scoliosis or ankylosing spondylitis may produce pelvic obliquity, which must be taken into account when positioning the implants. When the hip and the knee are both severely arthritic, usually the hip should be operated on first. Hip arthroplasty may alter knee alignment and mechanics. Also, knee arthroplasty is technically more difficult when the hip is stiff, and rehabilitation would be hampered. An alternative or additional diagnosis should be considered. The complaint of “hip pain” can be brought about by a variety of afflictions, and arthritis of the hip joint is one of the less common ones. True hip joint pain usually is perceived in the groin and lateral hip, sometimes in the anterior thigh, and occasionally in the knee. Arthritic pain usually is worse with activity and improves to some degree with rest and limited weight bearing. Pain in atypical locations and of atypical character should prompt a search for other problems. Pain isolated to the buttock or posterior pelvis often is referred from the lumbar spine, sacrum, or sacroiliac joint. Arthritis often coexists in the hip and lumbar spine. A THA done to relieve symptoms predominantly referred from the lumbar spine would do little to improve the patient’s condition. Likewise, surgical intervention in the face of mild hip arthritis when the pain is actually caused by unrecognized vascular claudication, trochanteric bursitis, pubic ramus

BOX 3.2

Recommended Weight-Adjusted Doses of Antimicrobials for Prophylaxis of Hip and Knee Arthroplasty in Adults Antimicrobial Recommended Dose

Redosing Interval

Cefazolin

4 hr

Vancomycin Clindamycin

2 g (consider 3 g if patient weight is ≥129 kg*) 15-20 mg/kg* 600-900 mg†

Not applicable 6 hr

*Actual body weight. †No recommended adjustment for weight. From Aboltins CA, Berdal JE, Casas F, et al: Hip and knee section, prevention, antimicrobials (systemic): Proceedings of International Consensus on Orthopedic Infections, J Arthroplasty 34:S279, 2019.

fracture, or an intraabdominal problem subjects the patient to needless risk. The Harris, Iowa (Larson), Judet, Andersson, and d’Aubigné and Postel systems for recording the status of the hip before surgery are useful for evaluating postoperative results. Pain, ability to walk, function, mobility, and radiographic changes are recorded. As yet, no particular hip rating system has been uniformly adopted. The Harris system is the most frequently used (Box 3.2). Adoption of a single rating system by the orthopaedic community would help standardize the reporting of results. Rating systems have been criticized as being subjective, for downgrading the importance of pain relief, and for emphasizing range of motion rather than functional capabilities as a result of hip motion. Improved motion in the hip is of little benefit if one is still unable to dress the foot and trim the toenails. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) considers the functional abilities of patients with hip arthritis in greater depth than specific hip rating systems. The 36-item short-form health survey (SF-36) is a more generic survey of health and well-being. These two tools often are used in addition to a hip rating score in reporting results. Finally, patient reported outcome measures (PROMs) have become increasingly important in evaluating outcomes by hospital administrators, insurance carriers, and policymakers. The Hip Disability and Osteoarthritis Outcome Score (HOOS), Jr is a six-question survey of pain, function, and daily living derived from the HOOS. The survey is efficient to administer and has been validated and endorsed by major orthopaedic societies. The Veterans RAND 12-Item Health Survey (VR12) and the Patient-Reported Outcomes Measurement Information System (PROMIS Global-10) are both shortform instruments to measure general physical and mental health apart from the hip. General inhalation anesthesia or regional anesthesia can be used for the surgery. The choice should be made in collaboration with the anesthesiologist and may be based on institutional protocols or the specific needs of the patient. The introduction of multimodal pain management protocols has been an important adjunct to the surgical anesthetic. Preemptive analgesia including lumbar plexus blockade,

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CHAPTER 3  ARTHROPLASTY OF THE HIP periarticular injection of long-acting local anesthetics, celecoxib, gabapentin, intravenous or oral acetaminophen, and long-acting oral analgesics such as tramadol have helped reduce the need for more potent opioids. Finally, preoperative education classes and institutional rehabilitation protocols have proven to be useful adjuncts in shortening hospital stays and reducing readmissions. With careful patient selection, proactive management of comorbidities, preoperative education, and the use of preemptive analgesia, we have reduced length of stay for most patients to a single hospital day. In carefully selected younger patients, we are now performing THA as an outpatient procedure in both hospital and surgery center settings. As payers, including CMS (Centers for Medicare & Medicaid Services) and private insurers, transition to bundled payment methodologies, strategies to reduce cost while maintaining patient safety will become even more important for maintaining surgeon compensation for hip arthroplasty procedures. 

PREOPERATIVE RADIOGRAPHS Before surgery, radiographs of the hips are reviewed and, if indicated, radiographs of the spine and knees are obtained. An anteroposterior view of the pelvis showing the proximal femur and a lateral view of the hip and proximal femur are the minimal views required. Radiographs of the pelvis should be reviewed specifically to evaluate the structural integrity of the acetabulum, to estimate the size of the implant required and how much reaming would be necessary, and to determine whether bone grafting would be required. In patients with developmental dysplasia, the pelvis should be evaluated with special care to determine the amount of bone stock present for fixation of the cup. In patients with previous acetabular fractures, obturator and iliac oblique views are obtained, in addition to the routine anteroposterior view of the hip, because a significant defect may be present in the posterior wall. A three-dimensional CT scan also is helpful in evaluating the acetabulum in these complex cases. The width of the medullary canal also is noted because it may be narrow, especially in patients with dysplasia or dwarfism. In these instances, a femoral component with a straight stem may be needed. In Paget disease, old fractures of the femoral shaft, or congenital abnormalities, a lateral radiograph of the proximal femur may reveal a significant anterior bowing that may make preparation of the canal more difficult. If excessive bowing or a rotational deformity is present, femoral osteotomy may be required before or in addition to the arthroplasty. Appropriate instruments must be available to remove any internal fixation devices implanted during previous surgery (see the section on failed reconstructive procedures); otherwise, the procedure may be unduly prolonged. Preoperative planning should include the use of templates supplied by the prosthesis manufacturer. Careful templating before surgery removes much of the guesswork during surgery and can shorten operative time by eliminating repetition of steps. The wide array of implant sizes and femoral neck lengths allows precise fitting to the patient, but it also allows for major errors in implant sizing and limb length when used without careful planning. Templating aids in selecting the type of implant that would restore the center of rotation of the hip and provide the best femoral fit and in judging the level

of bone resection and selection of the neck length required to restore equal limb lengths and femoral offset. 

 

PREOPERATIVE TEMPLATING FOR TOTAL HIP ARTHROPLASTY TECHNIQUE 3.1 (CAPELLO) Make an anteroposterior pelvic radiograph and a lateral view of the affected hip. The pelvic film must include the upper portion of both femurs and the entire hip joint. n  Position the hips in 15 degrees of internal rotation to delineate better femoral geometry and offset. Femoral offset will be underestimated when the hips are positioned in external rotation. n  On the lateral view, place the femur flat on the cassette to avoid distortion and include the upper portion of the femur. n  On each view, tape a magnification marker (with lead spheres 100 mm apart) to the thigh so that the marker is parallel to the femur and is the same distance from the film as the bone. n  Tape the marker to the upper medial thigh for the anteroposterior view and move it to the anterior thigh for the lateral view. n  Measure the distance between the centers of the spheres to estimate the amount of magnification of the radiograph. For a standard pelvic radiograph, magnification is approximately 20%. n  Templates are marked as to their degree of magnification. Take any discrepancy into account when templating. n  Draw a line at the level of and parallel to the ischial tuberosities that intersects the lesser trochanter on each side and compare the two points of intersection and measure the difference to determine the amount of limb shortening. n  Place the acetabular overlay templates on the film and select the size that matches the contour of the patient’s acetabulum without excessive removal of subchondral bone. The medial position of the acetabular template is at the teardrop and the inferior margin at the level of the obturator foramen. Mark the center of the acetabular component on the radiograph; this corresponds to the new center of rotation of the hip. n  Place the femoral overlay templates on the film and select the size that most precisely matches the contour of the proximal canal and fills it most completely. Make allowance for the thickness of the desired cement mantle if cement is to be used. n  Select the appropriate neck length to restore limb length and femoral offset. If no shortening is present, match the center of the head with the previously marked center of the acetabulum. If a discrepancy exists, the distance between the femoral head center and the acetabular center should be equal to the previously measured limb-length discrepancy. n 

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS When the neck length has been selected, mark the level of anticipated neck resection and measure its distance from the top of the lesser trochanter to use as a reference intraoperatively. Template the femur on the lateral view in a similar manner to ascertain whether the implant determined on the anteroposterior film can be inserted without excessive bone removal. n  Measure the diameter of the canal below the tip of the stem to determine the size of the medullary plug if cement is to be used. n  If a fixed external rotation deformity of the hip is present, templating is inaccurate. n  If the opposite hip is without deformity, template the normal hip and transpose the measurements to the operative side as a secondary check.    n 

Many modifications of this technique are commonly used. For determining leg-length discrepancy, a line between the inferior edge of the acetabular teardrop (interteardrop line) or the bottom of the obturator foramen (interobturator line) can be used as the reference line. Perpendicular measurements to the proximal corner of each lesser trochanter are compared to compute the leg-length discrepancy. Meerman et al. found measurements from the interteardrop line to be more accurate than those from the ischium. Digital radiographs are now commonplace in orthopaedic practice. Templating digital images requires specialized software and a library of precision templates supplied by each manufacturer that can be manipulated on a high-resolution computer monitor in a manner similar to that described for conventional films. A number of software packages are commercially available and may be integral to a picture archiving and communication system (PACS) or acquired as a separate module. Magnification is assessed in a manner similar to that used for conventional radiographs with a marker of known size placed at the level of the hip joint. The software then calibrates the image, and the digital templates are scaled to the correct degree of magnification. The subsequent steps are specific to the software package but generally mimic the process described for acetate templates used on printed radiographs. Iorio et al. and Whiddon et al. found acceptable accuracy with digital templating. Eliminating the cost of printing films and having a permanent archive of the preoperative plan are clear advantages of digital methods. Archibeck et  al. concluded that placement of a magnification marker did not improve the accuracy of digital templating compared to assuming a standard 20% magnification as has been used in the past for acetate templates with film radiographs. Sershon et al. found that accuracy of templating did not vary by BMI for either femoral or acetabular sizing. Shin et al. described a technique using acetate templates on a digital monitor with radiographs adjusted for magnification. The technique avoids the need for costly software and was accurate for both implant sizing and correction of leg length and offset. 

THE HIP-SPINE RELATIONSHIP A recent meta-analysis by An et al. found that a history of spinal fusion imparted a twofold risk of early hip dislocation and over threefold risk for revision. Additionally, most early dislocations occur with acetabular components that have been

placed in the so-called safe zone as described by Lewinnek. The findings have led to questions regarding the acceptance of a universal guideline for acetabular component placement and a recognition that altered spinopelvic motion may put the acetabular component in a functionally unsafe orientation with changes of posture. In normal patients, the lower lumbar spine is flexible in the sagittal plane. When moving from standing to sitting position, the pelvis tilts posteriorly to accommodate flexion of the hip joint. For each 1 degree of increased pelvic tilt, acetabular anteversion increases from 0.7 to 0.8 degrees. This translates to a change of acetabular anteversion of approximately 15.6 degrees when moving from standing to sitting position and reduces anterior impingement as the hip flexes. Acetabular inclination also increases with pelvic tilt and may be protective of anterior impingement with hip flexion. Deformity and stiffness of the lumbar spine from degenerative processes or lumbar fusion can prevent this normal accommodation and lead to excessive anterior impingement with sitting or posterior impingement when standing. For patients with a history of spinal fusion, deformity, or stiffness, it may be necessary to obtain additional radiographs to assess spinopelvic kinematics and make adaptations to the surgical plan for proper component positioning. A lateral view of the lumbar spine and pelvis in both standing and sitting positions is the minimum required. Some have also recommended obtaining a standing anteroposterior (AP) view of the pelvis. A number of new terms have been defined to assist hip surgeons in addressing the needs of “hip-spine” patients. The anterior pelvic plane (APP) is defined by the points of the two anterior superior iliac spines (ASIS) and the pubic symphysis on a lateral radiograph of the pelvis. Anterior and posterior pelvic tilt describe the direction of motion of the upper portion of the ilium (Fig. 3.39). Sacral slope (SS) is the angle between the superior endplate of the S1 vertebra and a horizontal reference, typically the inferior border of the radiograph. Both APP and SS can be used to assess spinopelvic motion with changes in posture. Moving from a standing to sitting position normally results in posterior pelvic tilt with a concomitant reduction in lumbar lordosis and flattening of SS (Fig. 3.40). The normal change in SS from standing to sitting is between 11 and 30 degrees. Spinopelvic stiffness is defined as a change in SS of ≤10 degrees. When this is the case, the hip joint must flex further to assume a seated position, with a greater risk of anterior impingement (Fig. 3.41). In these patients, more anteversion of the acetabular component will be needed to compensate for the reduced posterior pelvic tilt imposed by the stiff spine. The term pelvic incidence (PI) refers to the angle between a line drawn from the center of the femoral heads to the center of the superior endplate of S1 and a second line drawn perpendicular to the S1 endplate (Fig. 3.42). It is a measurement of the anterior to posterior relationship of the femoral head to the lower lumbar spine. PI is a fixed value and does not change with posture. When combined with measures of the lumbar lordosis (typically the angle between superior endplates of L1 and S1), it may identify patients with a flatback spinal deformity. These patients may have excessive posterior pelvic tilt while standing. This increases the functional anteversion of the acetabulum upon standing, with resulting risk of anterior instability. Therefore, acetabular component anteversion may need to be reduced in these patients.

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A

B

C

FIGURE 3.39 Anterior pelvic plane (orange lines) and effect on sacral slope (purple lines). Neutral (A), anterior (B), and posterior (C) pelvic tilt.

FIGURE 3.40 Standing and sitting lateral radiographs of a patient with normal spinal pelvic mobility. When the patient sits, lumbar lordosis decreases and the pelvis “rolls back,” which is demonstrated by an increase in posterior pelvic tilt (yellow line) and a flattening of the sacral slope (red line). (From Luthringer TA, Vigdorchik JM: A preoperative workup of a “hip-spine” total hip arthroplasty patient: a simplified approach to a complex problem, J Arthroplasty 34[7S]:S57, 2019.)

When patients have alterations in spinopelvic mechanics, the so-called safe zone for acetabular component position can be altered in terms of anteversion and also significantly narrowed. In addition to adjustments in implant positioning, dual mobility components (see Fig. 3.35) have proven useful in reducing the rate of instability. Innovative new modalities such as EOS imaging (EOS Imaging, Paris) may also simplify the evaluation of these complex cases. 

PREPARATION AND DRAPING An operating table that tilts easily is recommended, especially if the patient is placed in the lateral position. If the patient is not anchored securely, the proper position in which to place the acetabular component is difficult to determine. A variety of pelvic positioning devices are commercially available

for this purpose. Positioning devices should be placed so as not to impede the motion of the hip intraoperatively; otherwise, assessing stability is difficult. Also, the positioning devices should be placed against the pubic symphysis or the ASIS so that no pressure is applied over the femoral triangles, or limb ischemia or compression neuropathy may result. We have previously used suction-deflated beanbags for this purpose. Dedicated hip positioning devices are more secure, but errors in positioning may still occur, even with these devices, resulting in misjudgment of acetabular component anteversion. Bony prominences and the peroneal nerve should be padded, especially if a lengthy procedure is expected. If the patient is to be operated on in the supine position, a small pad is placed beneath the buttock of the affected hip; this is especially helpful in obese patients because it tends to allow the loose adipose tissue to drop away from the site of the incision. The adhesive edges of a U-shaped plastic drape are applied to the skin to seal off the perineal and gluteal areas, and the hip and entire limb are prepared with a suitable bactericidal solution. The foot preferably is covered with a stockinette, and the final drapes should be of an impervious material to allow abundant irrigation without fear of contaminating the field. If anterior dislocation of the hip is anticipated in the lateral position, a draping system that incorporates a sterile pocket suspended across the anterior side of the operating table is helpful; this allows the leg to be placed in the bag while the femur is being prepared and delivered back onto the table without contaminating the sterile field. 

SURGICAL APPROACHES AND TECHNIQUES Many variations have evolved in the surgical approaches and techniques used for THA. This is in keeping with the natural tendency of surgeons to individualize operations according to their own clinical and educational experiences. The surgical approaches differ chiefly as to whether the patient is operated on in the lateral or the supine position and whether the hip is dislocated anteriorly or posteriorly.

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FIGURE 3.41 Standing and sitting lateral radiographs of a patient with a stiff spine who underwent revision of the shown construct for asymmetric polyethylene wear, osteolysis, and posterior instability. Note the lack of “pelvic rollback” in the seated position (no change in sacral slope, red) and the proximity of the flexing proximal femur to the anterior acetabular rim (yellow). (From Luthringer TA, Vigdorchik JM: A preoperative workup of a “hipspine” total hip arthroplasty patient: a simplified approach to a complex problem, J Arthroplasty 34[7S]:S57, 2019.)

FIGURE 3.42 Pelvic incidence is the angle between line drawn from center of femoral head to center of sacral endplate and second line perpendicular to sacral endplate (orange lines).

The choice of specific surgical approach for THA is largely a matter of personal preference and training. The surgical protocol for a given total hip system may advocate a certain approach, as reflected in the technique manual. In reality, virtually all total hip femoral and acetabular components can be properly implanted through numerous approaches, provided that adequate exposure is obtained. Each approach has relative advantages and drawbacks. The original Charnley technique used the anterolateral surgical approach with the patient supine, osteotomy of the greater trochanter, and anterior dislocation of the hip. This approach is used much less commonly now as a result of problems related to reattachment of the greater trochanter. Amstutz advocated the

anterolateral approach with osteotomy of the greater trochanter, but with the patient in the lateral rather than the supine position. The Müller technique also uses the anterolateral approach with the patient in the lateral position but includes release of only the anterior part of the abductor mechanism. The Hardinge direct lateral approach is done with the patient supine or in the lateral position. A muscle-splitting incision through the gluteus medius and minimus allows anterior dislocation of the hip and affords excellent acetabular exposure. Residual abductor weakness and limp after this approach may be the result of avulsion of the repair of the anterior portion of the abductors or of direct injury to the superior gluteal nerve. The Dall variation of this approach involves removal of the anterior portion of the abductors with an attached thin wafer of bone from the anterior edge of the greater trochanter to facilitate their later repair. Abductor function is better after bony reattachment of the anterior portions of these muscles. Head et  al. used a modification of the direct lateral approach, in which the patient is in the lateral position and the vastus lateralis is reflected anteriorly in continuity with the anterior cuff of the abductors. This approach allows much greater exposure of the proximal femur than the Hardinge approach, and is more appropriate for revision surgery. Keggi described a supine anterior approach through the medial border of the tensor fascia lata (TFL) muscle; variations of this approach have become popular recently and are advocated for a reduced risk of posterior dislocation. Femoral exposure is more difficult through this so-called direct anterior approach, and injury to the lateral femoral cutaneous nerve (LFCN) can be problematic. The posterolateral approach with posterior dislocation of the hip requires placing the patient in the lateral position and has proven satisfactory for primary and revision surgery. Exposure of the anterior aspect of the acetabulum can be difficult, and historically the postoperative dislocation rate is higher with the posterolateral approach than with the anterolateral or direct lateral approaches. The specific technique for implantation of a given total hip system varies according to the method of skeletal fixation; the preparation for ancillary fixation devices for the acetabulum; the shape of the femoral component; the length of the stem; and the assembly of modular portions of the acetabular component, the femoral head, and, with some systems, the femoral component itself. The instrumentation supplied with a system is specific for that system and always should be used. The manufacturer supplies a technique manual with the system that gives a precise description of the instruments and the manner in which they are to be used for correct implantation of the components. Although instruments in various systems serve similar purposes, there may be substantial differences in their configurations and in the way they are assembled and used. The surgeon and scrub nurse should become thoroughly familiar with all of the instrumentation before proceeding with the operative procedure. A practice session with plastic bone models or a cadaver is useful before using a new prosthesis for the first time. Considering the number of total hip systems in current use, this text cannot discuss the particular points of all or any one of them. A general technical guideline is presented for exposure and insertion of cemented and cementless femoral and acetabular components, along with points germane to many types of implants. Additional steps are required for preparation and insertion of certain implants, and the manufacturer’s technique must always be followed in these instances. The techniques presented here are for the posterior and direct anterior approaches; the preparation

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A

B

C

D

E FIGURE 3.43 A, Skin incision for posterolateral approach to hip. B, Completed posterior softtissue dissection. C, Neck cut planned at appropriate level and angle by using trial components of templated size. D, Anterior capsule divided along course of psoas tendon sheath. E, Femur retracted well anteriorly to allow unimpeded access to acetabulum. (A, B, and E redrawn from Capello WN: Uncemented hip replacement, Tech Orthop 1:11, 1986; also Courtesy Indiana University School of Medicine.) SEE TECHNIQUES 3.2 AND 3.4.

of the femur and acetabulum is similar for other approaches (see Chapter 1). A traditional approach is presented here. Although a less extensile exposure may be appropriate in most cases (see section “Minimally Invasive Techniques”), it is important for surgeons to understand the full array of soft-tissue releases that may be needed in stiff hips and more complex procedures.

TOTAL HIP ARTHROPLASTY THROUGH POSTEROLATERAL APPROACH

The approach can be extended proximally by osteotomy of the greater trochanter with anterior dislocation of the hip (see section on trochanteric osteotomy). The approach can be extended distally to allow a posterolateral approach to the entire femoral shaft. We use the posterolateral approach for primary and revision THA.

TECHNIQUE 3.2 With the patient firmly anchored in the straight lateral position, make a slightly curved incision centered over the greater trochanter. Begin the skin incision proximally at a point level with the ASIS along a line parallel to the posterior edge of the greater trochanter. Extend the incision distally to the center of the greater trochanter and along the course of the femoral shaft to a point 10 cm distal to the greater trochanter (Fig. 3.43A). Adequate extension

n 

 

POSTEROLATERAL APPROACH WITH POSTERIOR DISLOCATION OF THE HIP The posterolateral approach is a modification of posterior approaches described by Gibson and by Moore (see Chapter 1).

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS of the upper portion of the incision is required for reaming of the femoral canal from a superior direction, and the distal extent of the exposure is required for preparation and insertion of the acetabular component from an anteroinferior direction. n  Divide the subcutaneous tissues along the skin incision in a single plane down to the fascia lata and the thin fascia covering the gluteus maximus superiorly. n  Dissect the subcutaneous tissues from the fascial plane for approximately 1 cm anteriorly and posteriorly to make identification of this plane easier at the time of closure. n  Divide the fascia in line with the skin wound over the center of the greater trochanter. n  Bluntly split the gluteus maximus proximally in the direction of its fibers and coagulate any vessels within the substance of the muscle. n  Extend the fascial incision distally far enough to expose the tendinous insertion of the gluteus maximus on the posterior femur. n  Bluntly dissect the anterior and posterior edges of the fascia from any underlying fibers of the gluteus medius that insert into the undersurface of this fascia. Suture moist towels or laparotomy sponges to the fascial edges anteriorly and posteriorly to exclude the skin, prevent desiccation of the subcutaneous tissues, and collect cement and bone debris generated during the operation. n  Insert a Charnley or similar large self-retaining retractor beneath the fascia lata at the level of the trochanter. Take care not to entrap the sciatic nerve beneath the retractor posteriorly. n  Divide the trochanteric bursa and bluntly sweep it posteriorly to expose the short external rotators and the posterior edge of the gluteus medius. The posterior border of the gluteus medius is almost in line with the femoral shaft, and the anterior border fans anteriorly. n  Maintain the hip in extension as the posterior dissection is done. Flex the knee and internally rotate the extended hip to place the short external rotators under tension. n  Palpate the sciatic nerve as it passes superficial to the obturator internus and the gemelli. Complete exposure of the nerve is unnecessary unless the anatomy of the hip joint is distorted. n  Palpate the tendinous insertions of the piriformis and obturator internus and place tag sutures in the tendons for later identification at the time of closure. n  Divide the short external rotators, including at least the proximal half of the quadratus femoris, as close to their insertion on the femur as possible. Maintaining length of the short rotators facilitates their later repair. Coagulate vessels located along the piriformis tendon and terminal branches of the medial circumflex artery located within the substance of the quadratus femoris. Reflect the short external rotators posteriorly, protecting the sciatic nerve. n  Bluntly dissect the interval between the gluteus minimus and the superior capsule. Insert blunt cobra or Hohmann retractors superiorly and inferiorly to obtain exposure of the entire superior, posterior, and inferior portions of the capsule. n  Divide the entire exposed portion of the capsule immediately adjacent to its femoral attachment. Retract the capsule and preserve it for later repair (Fig. 3.43B).

FIGURE 3.44 Device for intraoperative leg-length measurement. Sharp pin is placed in pelvis above acetabulum or iliac crest, and measurements are made at fixed point on greater trochanter. Adjustable outrigger is calibrated for measurement of leg length and femoral offset. SEE TECHNIQUE 3.2.

To determine leg length, insert a Steinmann pin into the ilium superior to the acetabulum and make a mark at a fixed point on the greater trochanter. Measure and record the distance between these two points to determine correct limb length after trial components have been inserted. Make all subsequent measurements with the limb in the identical position. Minor changes in abduction of the hip can produce apparent changes in leg-length measurements. We currently use a device that enables the measurements of leg length and offset (Fig. 3.44). n  Dislocate the hip posteriorly by flexing, adducting, and gently internally rotating the hip. n  Place a bone hook beneath the femoral neck at the level of the lesser trochanter to lift the head gently out of the acetabulum. The ligamentum teres usually is avulsed from the femoral head during dislocation. In younger patients, however, it may require division before the femoral head can be delivered into the wound. n  If the hip cannot be easily dislocated, do not forcibly internally rotate the femur because this can cause a fracture of the shaft. Instead, ensure that the superior and inferior portions of the capsule have been released as far anteriorly as possible. Remove any osteophytes along the posterior rim of the acetabulum that may be incarcerating the femoral head. If the hip still cannot be dislocated without undue force (most often encountered with protrusio deformity), divide the femoral neck with an oscillating saw at the appropriate level and subsequently remove the femoral head segment with a corkscrew or divide it into several pieces. n  After dislocation of the hip, deliver the proximal femur into the wound with a broad, flat retractor. n  Excise residual soft tissue along the intertrochanteric line and expose the upper edge of the lesser trochanter. n 

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CHAPTER 3  ARTHROPLASTY OF THE HIP Mark the level and angle of the proposed osteotomy of the femoral neck with the electrocautery or with a shallow cut with an osteotome. Many systems have a specific instrument for this purpose. If not, plan the osteotomy by using a trial prosthesis (see Fig. 3.43C). Use the stem size and neck length trials determined by preoperative templating. n  Align the trial stem with the center of the femoral shaft and match the center of the trial femoral head with that of the patient. The level of the neck cut should be the same distance from the top of the lesser trochanter as determined by preoperative templating. n  Perform the osteotomy with an oscillating or a reciprocating power saw. If this cut passes below the junction of the lateral aspect of the neck and greater trochanter, a separate longitudinal lateral cut is required. Avoid notching the greater trochanter at the junction of these two cuts because this may predispose to fracture of the trochanter. n  Remove the femoral head from the wound by dividing any remaining soft-tissue attachments. Keep the head on the sterile field because it may be needed as a source of bone graft. n 

EXPOSURE AND PREPARATION OF THE ACETABULUM n  Isolate the anterior capsule by passing a curved clamp within the sheath of the psoas tendon. n  Retract the femur anteriorly with a bone hook to place the capsule under tension. n  Carefully divide the anterior capsule between the jaws of the clamp (Fig. 3.43D). n  Place a curved cobra or Hohmann retractor in the interval between the anterior rim of the acetabulum and the psoas tendon (Fig. 3.43E). Erroneous placement of this retractor over the psoas muscle can cause injury to the femoral nerve or adjacent vessels. The risk increases with a more inferior placement of the retractor. The safest position is near the level of the anterosuperior iliac spine. Place an additional retractor beneath the transverse acetabular ligament to provide inferior exposure. n  Retract the posterior soft tissues with a right-angle retractor placed on top of a laparotomy sponge to avoid compression or excessive traction on the sciatic nerve. As an alternative, place Steinmann pins or spike retractors into the posterior column. Avoid impaling the sciatic nerve or placing the pins within the acetabulum, where they would interfere with acetabular preparation. n  Retract the femur anteriorly and medially and rotate it slightly to determine which position provides the best acetabular exposure. If after complete capsulotomy the femur cannot be fully retracted anteriorly, divide the tendinous insertion of the gluteus maximus, leaving a 1-cm cuff of tendon on the femur for subsequent reattachment. n  Complete the excision of the labrum. Draw the soft tissues into the acetabulum and divide them immediately adjacent to the acetabular rim. Keep the knife blade within the confines of the acetabulum at all times to avoid injury to important structures anteriorly and posteriorly. n  Expose the bony margins of the rim of the acetabulum around its entire circumference to facilitate proper placement of the acetabular component. n  Use an osteotome to remove any osteophytes that protrude beyond the bony limits of the true acetabulum. n  Begin the bony preparation of the acetabulum. The procedure for cartilage removal and reaming of the acetabu-

FIGURE 3.45 AND 3.7.

Reaming of acetabulum. SEE TECHNIQUES 3.2

lum is similar for cementless and cemented acetabular components. n  Excise the ligamentum teres and curet any remaining soft tissue from the region of the pulvinar. Brisk bleeding from branches of the obturator artery may be encountered during this maneuver and require cauterization. n  Palpate the floor of the acetabulum within the cotyloid notch. Occasionally, hypertrophic osteophytes completely cover the notch and prevent assessment of the location of the medial wall. Remove the osteophytes with osteotomes and rongeurs to locate the medial wall. Otherwise, the acetabular component can be placed in an excessively lateralized position. n  Prepare the acetabulum with power reamers (Fig. 3.45). Begin with a reamer smaller than the anticipated final size and direct it medially down to, but not through, the medial wall. Make frequent checks of the depth of reaming to ensure that the medial wall is not violated. This allows a few millimeters of deepening of the acetabulum with improved lateral coverage of the component. n  Direct all subsequent reamers in the same plane as the opening face of the acetabulum. n  Retract the femur well anteriorly so that reamers can be inserted from an anteroinferior direction without impingement. If the femur is inadequately retracted anteriorly, it may force reamers posteriorly, and excessive reaming of the posterior column occurs. Use progressively larger reamers in 1- or 2-mm increments. n  Irrigate the acetabulum frequently to assess the adequacy of reaming and to adjust the direction of the reaming to ensure that circumferential reaming occurs. Reaming is complete when all cartilage has been removed, the reamers have cut bone out to the periphery of the acetabulum, and a hemispherical shape has been produced. n  Expose a bleeding subchondral bone bed but maintain as much of the subchondral bone plate as possible. n  Curet any remaining soft tissue from the floor of the acetabulum and excise any overhanging soft tissues around the periphery of the acetabulum. Search for subchondral

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS cysts within the acetabulum and remove their contents with small curved curets. n  Fill the cavities with morselized cancellous bone obtained from the patient’s femoral head or acetabular reamings and impact the graft with a small punch. n  Before insertion of the acetabular component, ensure that the patient remains in the true lateral position. If the pelvis has been rotated anteriorly by forceful anterior retraction of the femur, the acetabular component can easily be placed in a retroverted position, which may predispose to postoperative dislocation. Most systems have trial acetabular components that can be inserted before final implant selection to determine the adequacy of fit, the presence of circumferential bone contact, and the adequacy of the bony coverage of the component; using the trial components also allows the surgeon to make a mental note of the positioning of the component before final implantation. n  Proceed with implantation of either a cementless or cemented acetabular component.    

COMPONENT IMPLANTATION  

IMPLANTATION OF CEMENTLESS ACETABULAR COMPONENT The size of the implant is determined by the diameter of the last reamer used. An acetabular component that is the same size as the last reamer has intimate contact with bone but no intrinsic stability. Fixation must be augmented with fins, spikes, or screws. A component that is oversized by 1 to 2 mm can be press-fit into position to provide a greater degree of initial stability. Attempts to impact a much larger component into position results in diminished congruency between the bone and porous surface and incomplete seating of the component against the medial wall. It also might fracture the acetabulum. Major intrapelvic and extrapelvic vessels and nerves are at risk for injury with erroneously placed transacetabular screws. Wasielewski et al. devised a clinically useful system for determining safe areas for placement of the screws. The system is based on two lines, one drawn from the ASIS through the center of the acetabulum and the other drawn perpendicular to the first, creating four quadrants: anterosuperior, anteroinferior, posterosuperior, and posteroinferior (Fig. 3.46). Screws placed through the anterosuperior quadrant emerge within the pelvis dangerously close to the external iliac artery and vein. Screws passing through the anteroinferior quadrant may injure the obturator nerve and vessels. Screws placed through the posterosuperior and posteroinferior quadrants do not emerge within the pelvis, but they may pass into the sciatic notch and endanger the sciatic nerve and superior gluteal vessels. The drill bit and screw threads can be palpated in the vicinity of the sciatic notch, however, as they emerge so that injury of these structures can be avoided. The

Line A ASIS Posterosuperior

Anterosuperior

Posteroinferior

Anteroinferior

Line B

FIGURE 3.46 Acetabular quadrant system described by Wasielewski et al. for determining safe screw placement (see text). Quadrants are formed by intersections of lines A and B. Line A extends from anterior superior iliac spine (ASIS) through center of acetabulum to posterior aspect of fovea, dividing acetabulum in half. Line B is drawn perpendicular to line A at midpoint of acetabulum, dividing it into quadrants: anterosuperior, anteroinferior, posterosuperior, and posteroinferior. (Redrawn from Wasielewski RC, Cooperstein LA, Kruger MP, et al: Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty, J Bone Joint Surg 72A:501, 1990.)

posterosuperior quadrant is the safest, and screws longer than 25 mm frequently can be placed through strong bone in this area. The anterosuperior quadrant should be avoided if possible. In a subsequent study, Wasielewski et al. found that only the peripheral halves of the posterior quadrants were safe for screw placement when the acetabular component was implanted with a high hip center.

TECHNIQUE 3.3 Place the operating table in a completely level position and ensure that the patient remains in the true lateral position. n  Expose the acetabulum circumferentially and retract or excise any redundant soft tissues that may be drawn into the acetabulum as the component is inserted. n  Prepare the appropriate recesses for any ancillary fixation devices present on the component as specified by the manufacturer’s technique. n  Attach the acetabular component to the positioning device included with the system instrumentation. Be certain of the means by which the positioning device orients the socket. Usually a rod emerging from the positioning device is oriented either parallel or perpendicular to the floor to determine the proper angle of abduction (or inclination) (Fig. 3.47A). An additional extension from the alignment device determines anteversion (or forward flexion) in relation to the axis of the trunk of the patient (Fig. 3.47B). The optimal inclination of the component is 40 n 

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40°– 45° 10°– 20°

A

B

C FIGURE 3.47 TECHNIQUE 3.3.

A, Socket positioning in abduction. B, Anteversion. C, Insertion of liner. SEE

to 45 degrees. The optimal degree of anteversion is 20 degrees. n  The transverse acetabular ligament also is a useful anatomic reference for component positioning. Place the component parallel and just superior to the ligament. n  If the femur demonstrates excessive anteversion or the femoral component is of an anatomic design with anteversion already built in the femoral neck, position the socket in a lesser degree of anteversion. Excessive anteversion of the socket in this case may result in anterior dislocation. Plan for combined anteversion of the femur and acetabulum between 25 and 40 degrees. Carefully reassess the positioning of the implant before impaction because it may be difficult to extricate or change if malpositioned. The edges of the component should match the position of the trial implant fairly closely. If they do not,

carefully reassess the positioning of the patient and the insertion device. n  Maintain the alignment of the positioning device as the component is impacted into position. A change in pitch is heard as the implant seats against subchondral bone. Reassess the positioning; if it is satisfactory, remove the positioning device. n  Examine the subchondral bone plate through any available holes in the component to confirm intimate contact between implant and bone. If a gap is present, impact the component further. n  If screws are to be used for ancillary fixation, place them preferably in the posterosuperior quadrant. Use a flexible drill bit and a screwdriver with a universal joint to insert the screws from within the metal shell. Use a drill sleeve to center the drill hole within the hole of the metal shell.

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS If the drill hole is placed eccentrically or at too steep an angle, as the screw is inserted its threads may engage the edge of the hole in the metal shell and lift it away from the bone as the screw is advanced; this requires repositioning and reimpaction of the implant. Additionally, if a screw is placed eccentrically, the edge of the head may sit proud within the screw hole and prevent insertion of the liner. Bicortical purchase usually can be obtained with screws in the posterior quadrants. n  Confirm screw length with an angled depth gauge. Self-tapping 6.5-mm screws are preferred. Use a screwholding clamp to maintain alignment of the screw as the self-tapping threads become engaged. Screw alignment cannot be maintained by a screwdriver with a universal joint. Ensure that the screw head seats completely and is recessed below the inner surface of the shell so that the liner can be fully seated. n  If screws are inserted in the posterior quadrants, palpate along the posterior wall and place a finger within the sciatic notch to protect the sciatic nerve. n  If the drill bit exits in close proximity to the sciatic nerve, use a screw slightly shorter than the measured length or choose a different hole. n  After insertion of one or two screws, test the stability of the component. There should be no detectable motion between implant and bone. If the fixation is unstable, place additional screws. n  With a curved osteotome, remove any osteophytes that protrude beyond the rim of the acetabular component. Pay particular attention to the anteroinferior rim. Retained osteophytes in this region cause impingement on the femur in flexion and internal rotation, reducing motion and predisposing to dislocation. n  Irrigate any debris from within the metal shell. n  Insert the polyethylene liner ensuring that no soft tissue becomes interposed between the polyethylene liner and its metal backing because this would prevent complete seating and engagement of the locking mechanism (Fig. 3.47C). If the system has a variety of liner options available (see Fig. 3.33), a set of trial liners usually accompanies the instrumentation. Final selection of the degree of rim elevation and the position of rotation of the offset within the metal shell can be delayed until the time of trial reduction. The center of the offset usually is placed superiorly or posterosuperiorly. Use the smallest offset that provides satisfactory stability.   

Intraoperative changes in the position of the pelvis can affect the accuracy of orientation of the acetabular component. Abduction of the hip or traction on the limb may rotate the pelvis in the craniocaudal plane and lead to errors in the abduction angle. Forceful anterior retraction of the femur rotates the pelvis forward with the tendency to position the acetabular component with inadequate anteversion if the surgeon relies solely on a positioning guide affixed to the insertion device. The surgeon also should evaluate component position relative to bony landmarks. In the ideal position, the inferior edge of the implant should lie just within and parallel to the transverse ligament. The degree of lateral coverage of the implant should also be compared with the amount estimated by preoperative templating. 

 

IMPLANTATION OF CEMENTED ACETABULAR COMPONENT The design features of cemented acetabular components are discussed in the earlier section on cemented acetabular components. Many components incorporate numerous preformed PMMA pods that ensure a uniform 3-mm cement mantle (see Fig. 3.31). Although some designs incorporate an offset or rim elevation in the polyethylene, the components are not modular and must be inserted as a single unit. The position of rotation of the offset must be selected before cementing the component. All-polyethylene implants usually are available in relatively few sizes. There may be some variability in the thickness of the cement mantle depending on the size of the acetabulum. The size of the implant can be denoted by either the outer diameter of the polyethylene or the outer diameter of the polyethylene plus the additional size provided by the PMMA spacers. Typically, this adds 6 mm to the outer diameter of the implant. The size of the reamed acetabulum should be equal to the outer diameter of the component including the spacers. Otherwise, the component cannot be completely seated.

TECHNIQUE 3.4 Place the operating table completely level. Obtain circumferential exposure of the bony rim of the acetabulum. n  Retract the femur well anteriorly to allow unobstructed passage of the implant into the acetabulum. n  Check the component positioning device again to be certain of its mechanism for orienting the component in proper position. Also, ensure that the positioner can be easily released from the component such that it does not tend to pull the component away from the cement as it is polymerizing. Use a trial component to evaluate the fit and the bony coverage of the component when placed in the optimal position (see Fig. 3.43). Also note the relationship of the edges of the trial component to the bony rim so that this can be reproduced when the final implant is cemented. n  Place the implantable component on the positioner so that it is immediately available when the cement is mixed. Do not contaminate the surface of the implant with blood or debris because this would compromise the cement-prosthesis interface. n  Drill multiple 6-mm holes through the subchondral bone plate of the ilium and ischium for cement intrusion (Fig. 3.48). As an alternative, 12-mm holes can be drilled in the ilium and ischium with additional 6-mm holes between them. Do not drill through the medial wall because this would allow cement intrusion into the pelvis. n  Obturate any penetration of the medial wall with bone grafts or a small wire mesh. n  Curet any loose bone from the drill holes and remove debris and bone marrow from the surface of the acetabulum with pulsatile lavage. n  Thoroughly dry the acetabulum and promote hemostasis with multiple absorbable gelatin sponge (Gelfoam) pledgets or gauze soaked in topical thrombin or 1:500,000 epinephrine solution. n  n 

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CHAPTER 3  ARTHROPLASTY OF THE HIP After removing the pressurizing device, carefully dry any blood or fluid that may have accumulated over the surface of the cement. n  Some types of cement, such as Palacos, do not pass through a low-viscosity state and are not easily injected through a gun. Such cements may be used in dough form and inserted manually. Change to a new pair of outer gloves before handling the cement. The bolus of cement is placed into the acetabulum after it ceases to stick to the dry gloves and its surface becomes slightly wrinkled. n  Finger pack a smaller bolus of cement into each of the previously prepared fixation holes. Distribute the remainder of the cement uniformly over the surface of the acetabulum and pressurize it. Remove any blood on the surface of the cement with a dry sponge. n  Insert the acetabular component using the appropriate positioning device. Place the apex of the cup in the center of the cement mass to distribute the cement evenly. Note the relationship of the rim of the component to the bony margins of the acetabulum to verify that the position of the trial component has been reproduced. If no spacers are used, avoid excessive pressure because the cup can be bottomed out against the floor of the acetabulum, producing a discontinuity in the cement mantle. n  Hold the positioner motionless as the cement begins to polymerize. When the cement becomes moderately doughy, carefully remove the positioning device. Stabilize the edge of the component with an instrument as the positioner is removed. n  Replace the device with a ball-type pusher inserted into the socket to maintain pressure as the cement hardens. n  Trim the extruded cement around the edge of the component and remove all cement debris from the area. n  After the cement has hardened completely, test the stability of the newly implanted socket by pushing on several points around the circumference with an impactor. If any motion is detected or blood or small bubbles extrude from the interface, the component is loose and must be removed and replaced (see the section on removal of the cup and cement from the acetabulum). n  Remove any residual osteophytes or cement projecting beyond the rim of the implant because they may cause impingement and postoperative dislocation. n  Long-term outcomes with cemented acetabular components are correlated with the presence of radiolucencies on immediate postoperative radiographs, emphasizing the importance of technique and obtaining a dry bed for cement penetration into cancellous bone. n 

FIGURE 3.48 TECHNIQUE 3.4.

Fixation holes for cement in acetabulum. SEE

FIGURE 3.49 Acetabular cement pressurizer. Flexible Silastic dam seals rim of acetabulum while manual pressure is applied. SEE TECHNIQUE 3.4.

Mix one package of cement for a smaller patient and two packages for a larger size acetabulum or if an injecting gun is used for cement delivery. Reduce the porosity of the cement by vacuum mixing. Inject the cement in an early dough phase. If the cement is chilled or injected in a very low-viscosity state, it runs out of the acetabulum and pressurization is difficult. n  Dry the acetabulum and suction the fixation holes with a small catheter immediately before cement injection. Inject each of the fixation holes first. Use a cement injection nozzle, which has a small occlusive seal that allows pressurization of each of the holes. Fill the remainder of the acetabulum with cement injected from the gun. Pressurize the major portion of the acetabular cement with a rubber impactor (Fig. 3.49). n 

EXPOSURE AND PREPARATION OF THE FEMUR Place a laparotomy sponge in the depths of the acetabulum to protect the acetabular component and prevent the introduction of debris during preparation and insertion of the femoral component. n  Expose the proximal femur by markedly internally rotating the femur so that the tibia is perpendicular to the floor (Fig. 3.50). Allow the knee to drop toward the floor, and push the femur proximally. n  To deliver the proximal femur from the wound, place a broad, flat retractor deep to it and lever it upward. Retract the posterior edge of the gluteus medius and minimus to expose the piriformis fossa and to avoid injuring the n 

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FIGURE 3.50 Positioning of femur for reaming, with patient in lateral position (looking down on patient). Hip is internally rotated, flexed, and adducted until tibia is vertical and axis of knee joint is horizontal. Femoral neck now points downward 15 to 20 degrees, and consequently table is tilted to opposite side for reaming of canal. (From Eftekhar NS: Principles of total hip arthroplasty, St. Louis, 1978, Mosby.) SEE TECHNIQUE 3.4.

former during preparation and insertion of the femoral component. n  Excise any remaining soft tissue from the posterior and lateral aspect of the neck. Use a box osteotome or a specialized trochanteric router to remove any remaining portions of the lateral aspect of the femoral neck and the medial portion of the greater trochanter to allow access to the center of the femoral canal (Fig. 3.51). n  If inadequate bone is removed from these areas, the stem may be placed in varus and may be undersized, the lateral femoral cortex may be perforated, or the femoral shaft or greater trochanter may be fractured. n  If the proximal femoral cortex is thin, or if stress risers are present because of previous internal fixation devices or disease, place a cerclage wire around the femur above the level of the lesser trochanter to prevent inadvertent fracture.    

 

IMPLANTATION OF CEMENTLESS FEMORAL COMPONENT The design features of relevant implants are reviewed in the earlier section on cementless femoral components. Younger patients with good quality femoral bone are the best candidates for cementless femoral fixation. Straight

FIGURE 3.51 Removal of remaining lateral edge of femoral neck and medial portion of greater trochanter with box osteotome. SEE TECHNIQUE 3.4.

femoral components require straight, fully fluted reamers, but anatomic-type components may require femoral preparation with flexible reamers to accommodate the slight curvature of the stem. Some designs of tapered stems require only broaching for canal preparation. Reaming can be done by hand or with low-speed power reamers. Only the instrumentation supplied by the manufacturer should be used to machine the femur to match precisely the femoral stem shape being implanted. The preoperative plan should be reviewed for the anticipated stem size, as determined by templating.

TECHNIQUE 3.5 Expose the proximal femur as described in Technique 3.2. Insert the smallest reamer at a point corresponding to the piriformis fossa. The insertion point is slightly posterior and lateral on the cut surface of the femoral neck. An aberrant insertion point does not allow access to the center of the medullary canal. n  After the point of the reamer has been inserted, direct the handle laterally toward the greater trochanter (Fig. 3.52). Aim the reamer down the femur toward the medial femoral condyle. If this cannot be accomplished, remove additional bone from the medial aspect of the greater trochanter, or varus positioning of the femoral component results. Generally, a groove must be made in the medial aspect of the greater trochanter to allow proper axial reaming of the canal. Insert the reamer to a predetermined point. Most reamers are marked so as to be referenced against the tip of the greater trochanter or the femoral neck cut to determine the proper depth of insertion. n  n 

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FIGURE 3.52 Reaming of femoral canal. Hand or power reamers must be lateralized into greater trochanter to maintain neutral alignment in femoral canal. (Redrawn courtesy Smith & Nephew, Memphis, TN.) SEE TECHNIQUES 3.5 AND 3.6.

Proceed with progressively larger reamers until diaphyseal cortical reaming is felt. Assess the stability of the axial reamer within the canal. No deflection of the tip of the reamer in any plane should be possible. n  If an extensively porous-coated straight stem is used, ream the femoral diaphysis so that 10 to 40 mm of the stem fits tightly in the diaphysis, but underream the canal 0.5 mm smaller than the cylindrical distal portion of the stem so that a tight distal fit can be achieved. n  Proceed with preparation of the proximal portion of the femur. Remove the residual cancellous bone along the medial aspect of the neck with precision broaches. Begin with a broach at least two sizes smaller than the anticipated stem. Never use a broach larger than the last straight or flexible reamer used. n  Place the broach precisely in the same alignment as the axial reamers. n  Push the broach handle laterally during insertion to ensure that enough lateral bone is removed and avoid varus positioning of the stem (Fig. 3.53). n  Rotate the broach to control anteversion. From the posterior approach, the medial aspect of the broach must be rotated toward the floor. n  Align the broach to match precisely the axis of the patient’s femoral neck. Do not attempt to place the broach in additional anteversion because this would lead to un n 

FIGURE 3.53 Femoral broaching. Progressively larger broaches are inserted, lateralizing each one to maintain neutral alignment. (Redrawn courtesy Smith & Nephew, Memphis, TN.) SEE TECHNIQUE 3.5.

dersizing of the stem and insufficient rotational stability (Fig. 3.54). Maintain precise control over anteversion as the broach is gently impacted down the canal. Seat the cutting teeth of the broach at least to the level of the cut surface of the neck. n  Proceed with progressively larger broaches, maintaining the identical alignment and rotation. Use even blows with a mallet to advance the broach. The broach should advance slightly with each blow of the mallet. If motion ceases, do not use greater force to insert the broach. Reassess the broach size, adequacy of distal reaming, and alignment and rotation of the broach. n  If a broach sized smaller than that anticipated by templating cannot be fully inserted, the broach may be in varus. Lateralize farther into the greater trochanter with reamers to achieve neutral alignment in the femoral canal and proceed with broaching. n  Seat the final broach to a point where it becomes axially stable within the canal and would not advance farther with even blows of the mallet. The cutting teeth should be seated at or just below the level of the preliminary neck cut to allow precision machining of the remaining neck if a collared stem is to be used. n  Assess the fit of the broach within the canal. The broach should be in intimate contact with a large portion of the endosteal cortex, especially posteriorly and medially. n  When a straight stem is used, there may be a thin rim of remaining cancellous bone anteriorly. Conversely, an ana-

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A

B FIGURE 3.54 Femoral component anteversion (as viewed from posterior approach). A, Stem placed in same axis as femoral neck. Largest possible stem size fills metaphysis well and obtains rotational stability. B, Stem placed in excessive anteversion. Largest possible stem size does not completely fill metaphysis and tends to retrovert when femur is loaded. SEE TECHNIQUES 3.5 AND 3.6.

tomic stem often fills this area. If the broach seems to fill the canal completely, with little remaining cancellous bone, assess the rotational stability of the broach. Manually attempt to rotate the broach into a retroverted position. Carefully observe the broach for any motion within the femoral canal. If rotational motion is evident, proceed to the next largest stem size. Proceed one size at a time with distal axial reaming and subsequent broaching until the broach fills the proximal femur as completely as possible and adequate axial and rotational stability has been achieved. n  When adequate stability has been obtained, make the final adjustment of the neck cut. Most systems have a precision calcar planer that fits onto a trunnion on the implanted broach (Fig. 3.55). Precise preparation of the neck is essential if a collared stem is to be used; this step is optional when a collarless stem design is employed. The final level of the neck cut should correspond with the measured distance above the lesser trochanter determined by preoperative templating. If different, adjust the component neck length accordingly. n  Select the trial neck component determined through preoperative templating. In most systems, the trial head and neck components fit onto the trunnion used for attachment of the broach handle (Fig. 3.56). Evaluate the center of the femoral head relative to the height of the tip of the greater trochanter and compare the level with the templated radiographs. n  If the neck length seems satisfactory, irrigate any debris out of the acetabulum. n  Apply traction to the extremity with the hip in slight flexion. Gently lift the head over the superior lip of the acetabulum and any elevation in the polyethylene liner that may have been inserted. If the reduction is difficult, check

FIGURE 3.55 Planing of calcar with precision reamer placed over broach trunnion. (Redrawn courtesy Smith & Nephew, Memphis, TN.) SEE TECHNIQUES 3.5 AND 3.6.

for any remaining tight capsule, especially anteriorly, and incise it. If reduction is still impossible, use a shorter neck length, rotate the elevation in the liner to a different position, or remove it entirely. n  As an alternative, use a plastic-covered pusher that fits over the head of the femoral component to push the head into the socket. Do not use excessive force or place excessive torsion on the femur as the hip is reduced, or femoral fracture may occur. n  Reassess the limb length and femoral offset by the previously placed pin near the acetabulum and make changes accordingly. n  Move the hip through a range of motion. Note any areas of impingement between the femur and pelvis or between the prosthetic components with extremes of positioning. Impingement can occur with flexion, adduction, and internal rotation if osteophytes have not been removed from the anterior aspect of the acetabulum, greater trochanter, or femoral neck. Likewise, impingement during external rotation may require removal of bone from the posterior aspect of the greater trochanter, the rim of the acetabulum, or the ischium. n  If prosthetic neck impingement occurs on an elevated polyethylene liner, rotate it to a slightly different position or remove it entirely. n  The hip should be stable (1) in full extension with 40 degrees of external rotation; (2) in flexion to 90 degrees with at least 45 degrees of internal rotation; and (3) with the hip flexed 40 degrees with adduction and axial loading (the so-called position of sleep). If the hip dislocates easily and the head can be manually distracted from the socket more than a few millimeters (the so-called shuck test), use a longer neck length. n  If excessive lengthening of the extremity would result from a longer neck length, use a stem design with a greater

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CHAPTER 3  ARTHROPLASTY OF THE HIP Occasionally, it is impossible to seat the prosthesis to the level of the cut surface of the neck. If a collared prosthesis has been used and the collar has not made full contact with bone, leave the collar slightly proud rather than risk femoral fracture. When a collarless prosthesis is used, occasionally the prosthesis may advance a few millimeters past the level achieved with the broach. In these instances, the neck length can be changed and an additional trial reduction is necessary to confirm the final neck length and the stability of the joint. n  Test the stability of the implanted stem to rotational and extraction forces. If the stem is deemed unstable, decide whether it can be impacted further or whether a larger stem size can be inserted. n  Carefully inspect the femoral neck and greater trochanter for any fractures that may have occurred during stem insertion. n  If a fracture is produced as the stem is being seated, immediately stop the insertion procedure. Completely expose the fracture to its distal extent and then remove the stem. Otherwise, the extent of the fracture may be underestimated. n  If an incomplete fracture occurs with extension only to the level of the lesser trochanter, place a cerclage wire around the femur above the lesser trochanter. Reinsert the stem and ensure the cerclage wire tightens as the stem is seated into position. Reassess the stability of the implanted stem. n  If the fracture extends below the level of the lesser trochanter, a longer stem with greater distal fixation is required (see later). If the greater trochanter is fractured and unstable, proceed with fixation as for a trochanteric osteotomy (see section on trochanteric osteotomy). n  Wipe any debris from the Morse taper segment of the prosthetic neck and carefully dry it. n  Place the prosthetic head of appropriate size and neck length onto the trunnion and affix it with a single blow of a mallet over a plastic-capped head impactor. Use only femoral heads specifically designed to mate with the stem and ensure that the femoral head and acetabular component are of a corresponding size. n  Remove any debris from the acetabulum and again reduce the hip. Ensure no soft tissues have been reduced into the joint. n  Confirm the stability of the hip through a functional range of motion.     n 

FIGURE 3.56 Assembly of trial head and neck segments determined from preoperative templating. (Redrawn courtesy Smith & Nephew, Memphis, TN.) SEE TECHNIQUE 3.5.

degree of offset, if available (see Fig. 3.9). This change would reduce bony impingement and improve soft-tissue tension without additional lengthening of the limb. Slight lengthening of the limb is preferable, however, to the risk of instability. n  If the hip cannot be brought into full extension, use a shorter neck length, or, if a severe flexion contracture was present preoperatively, release any remaining tight anterior capsular tissues. n  If there is uncertainty regarding appropriateness of implant size and position or of limb length, then make an intraoperative radiograph for confirmation. n  If stability is acceptable, note the position of any elevation of the trial polyethylene liner, redislocate the hip by flexion and internal rotation, and gently lift the head out of the acetabulum. Remove the trial components and broach. n  If a modular trial polyethylene liner has been used, place the final component at this time. n  Regain exposure of the proximal femur and remove any loose debris within the femoral canal, but do not disturb the bed that has been prepared. n  Insert the appropriate-size femoral component. Insert the stem to within a few centimeters of complete seating by hand. Reproduce the precise degree of anteversion determined by the broach. n  Gently impact the stem down the canal. Use the driving device provided with the system or a plastic-tipped pusher. Use blows of equal force as the component is seated. As the component nears complete seating, it advances in smaller increments with each blow of the mallet. Do not use progressively increasing force to insert the component, or femoral fracture can result. Insertion is complete when the stem no longer advances with each blow of the mallet. An audible change in pitch usually can be detected as the stem nears final seating.

 

IMPLANTATION OF CEMENTED FEMORAL COMPONENT Improvements in preparation of the femur and the mixing and delivery of cement and modifications in component design have yielded dramatic improvements in the survivorship of cemented femoral components. Cement fixation is indicated especially when the femoral cortex is thin or osteoporotic and secure press-fit fixation is less predictably achieved. Design features of femoral components used

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TECHNIQUE 3.6 Expose the proximal femur as described. Use rongeurs, a box osteotome, or a trochanteric reamer to remove residual portions of the lateral aspect of the neck and gain access to the center of the canal. n  Insert a small, tapered reamer to locate the medullary canal. Insert the tip of the reamer into the lateralmost aspect of the cut surface of the neck and swing it into the greater trochanter to point it toward the medial femoral condyle (see Fig. 3.52). This maneuver ensures neutral positioning of the femoral component. n  Review the preoperative plan for the templated stem size. Begin with the smallest size broach. Insert the broaches in 10 to 15 degrees of anteversion in relation to the axis of the flexed tibia. From the posterior approach, this means that the medial aspect of the broach must be rotated toward the floor (see Fig. 3.54). Maintain correct axial alignment as the broach is inserted. n  Alternatively, impact and extract the broach to facilitate its passage. Use progressively larger broaches to crush and remove cancellous bone in the proximal femur. Because fixation is achieved with cement, the requirements for absolute stability of the broach are not as rigorous as with cementless techniques. Nonetheless, a stem that fills the femoral canal with an adequate cement mantle is still desirable. n  Use the largest size broach that can be easily inserted proximally. If resistance is felt during insertion of the broach, the area of impingement is most likely distal within the diaphysis. The broach cannot be used to prepare cortical bone in the diaphysis. Do not attempt to impact the broach further because a femoral fracture can occur, or the broach can become incarcerated. n  A narrow canal can be anticipated easily by preoperative templating. Use graduated-sized reamers to enlarge the canal sufficiently to allow insertion of a broach that is appropriately sized proximally. Because removal of all cancellous bone from the canal leaves a smooth cortical surface not amenable to microinterlock with cement, avoid excessive reaming of the medullary canal. Canal preparation is distinctly different with this procedure than for a cementless stem, even though many contemporary total hip systems use the same instrumentation for the two applications. n  In most current systems, the broach is larger than the corresponding stem size, although the amount of oversizing varies. The channel prepared allows insertion of an appropriate-size stem with an adequate surrounding cement mantle. A cement mantle thickness of 2 to 4 mm proximally and 2 mm distally is satisfactory. n  If a stem with a collar is to be used, countersink the final broach slightly below the provisional femoral neck cut. Precisely prepare the femoral neck to receive the collar by using a planer (see Fig. 3.55). If a collarless stem is used, mark the height of the shoulder of the broach on the greater trochanter in order to reproduce this position when the final stem is implanted. n 

Select the templated neck length and assemble a trial component. Note the relationship of the trial collar to the cut surface of the femoral neck for axial and rotational positioning of the final stem as it is implanted. The medial edge of the collar may sit flush with the medial cortex or may protrude slightly beyond it; either is acceptable. Reproduction of this degree of overhang helps prevent varus or valgus positioning of the stem as the final component is inserted. n  Perform a trial reduction, as described in Technique 3.5, to determine limb length, range of motion, and stability of the arthroplasty. n  If the limb has been excessively lengthened, use a shorter trial neck. Alternatively, seat the broach further and recut the femoral neck to reduce limb length while maintaining the same degree of femoral offset. A smaller broach size may be required to accomplish this. n  Because the stem is to be fixed with cement, the depth of insertion of the component is predetermined at this point. This is in contrast to a cementless implant, which may achieve stability at a slightly different depth of insertion than did the corresponding broach. n  When final component sizes have been selected and limb length and stability have been assessed, dislocate the hip and remove the trial components. n  Regain exposure of the proximal femur. n  Remove remaining loose cancellous bone from the femur using a femoral canal brush or curets. Retain a few millimeters of dense cancellous bone for cement intrusion. n  Occlude the femoral canal distal to the anticipated tip of the stem to allow pressurization of the cement and to prevent extrusion of the cement distally into the femoral diaphysis. This is accomplished by use of a plastic, flexible canal plug or a bone block fashioned to fit the canal or by injecting a small plug of cement distally. A preformed flexible plastic plug is the easiest to use, but it must be of a large enough size to prevent its distal migration during cement pressurization (Fig. 3.57). n  Determine the canal diameter by using sounds. Insert the cement restrictor to a depth of approximately 1 to 2 cm below the anticipated tip of the stem. Determine the depth of insertion by comparing the insertion device with the broach or the actual stem. Account for any additional length required by the use of a distal stem centralizer. Gently tap the restrictor into place, or it may be forced distal to the isthmus. n  After insertion of the cement restrictor, reinsert the broach or trial stem to ensure that the restrictor has been placed sufficiently distal to allow the stem to be fully seated. n  As an alternative, fashion a plug of bone removed from the femoral head or neck. This plug should be slightly larger than the diameter of the canal. Impact it into position with a punch. n  Occlusion of the canal with a small bolus of PMMA requires more preparation but is more reliable when the canal is excessively large or when the canal must be occluded below the level of the isthmus to insert a longer length stem. To occlude the canal with a PMMA plug, mix a single package of cement. Insert the cement when it is in the early dough phase because extremely low-viscosity cement runs down the canal and does not completely occlude it. Inject a small bolus of cement at the prede n 

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CHAPTER 3  ARTHROPLASTY OF THE HIP

FIGURE 3.57 Occlusion of medullary canal. Plastic plug with flexible, thin flanges can be inserted to occlude medullary canal; plugs of several different diameters are available. They are screwed to end of calibrated rod for insertion to correct depth. SEE TECHNIQUE 3.6.

termined level using a cement injecting gun or a cement syringe, or introduce the cement through a small chest tube, using a plunger to maintain the cement bolus in proper position as the chest tube is extracted. Rotate the injecting gun in all directions to disperse the cement uniformly. Reinsert the trial component and gently tamp the cement before it hardens to ensure that the final component can be fully seated. n  After occluding the femoral canal, thoroughly irrigate it to remove loose debris, bone marrow, and blood. This is best accomplished by using a pulsatile lavage system with a long, straight tip and radially directed spray. Thoroughly irrigate all debris and bone marrow out of the residual trabeculae of cancellous bone so that maximal cement intrusion can be obtained. Thorough lavage of the canal also reduces the amount of marrow embolization that can occur during cement pressurization and stem insertion. n  Dry the canal with a tampon sponge with a suction attachment or with sponges soaked in 1:500,000 epinephrine solution to diminish bleeding while the cement is being prepared. n  Open the previously determined implants. Do not touch the stem or allow it to become contaminated with blood or debris because this may compromise the cement-implant interface after implantation. n  Assemble any modular PMMA spacers that can be used to centralize the stem within the canal. n  Do not leave unfilled any holes in the stem intended for centralizers because entrapped air would expand with the

heat of cement polymerization, producing a void in the cement mantle. Fill such holes with cement before introducing the implant, or use the centralizers provided with the system. Centralizers also can be fixed to the implant with a small amount of cement to ensure an adequate interface between the two. This distal stem centralizer size is determined by the canal diameter previously determined from sounds. Ideally, the centralizer should be at least 4 mm larger than the diameter of the distal end of the stem to ensure a 2-mm circumferential cement mantle. n  Change the outer gloves. Mix two batches of cement for a standard-size femur and three batches for a larger femur or if a long-stem component is to be used. Current pressurization techniques require a greater volume of cement than has been used in the past. Prepare the cement with a porosity reduction technique such as vacuum mixing. n  If internal fixation devices have been removed from the femoral shaft during the same procedure, the holes left in the femoral cortex must be occluded to allow pressurization of the cement and to prevent its egress into the soft tissues. Have an assistant place fingers over the holes before cement injection, or use a small amount of cement to occlude them before the remainder of the femur is filled with cement. n  Use a cement-injecting gun for the most reliable cement delivery. Plan to inject the cement as it enters a dough phase, or when it no longer sticks to a gloved finger. This typically is about 4 minutes after the start of mixing for Simplex cement, although it can vary significantly with the type of cement used, the room temperature, humidity, and whether the monomer component or stem was heated before mixing. If the cement is injected in an excessively low-viscosity state, it tends to run out of the femur during pressurization, making it more susceptible to the introduction of blood and debris, thus weakening the mantle and compromising the cement-bone interface. If injected late or in a high viscosity state, then it may be difficult to fully insert the stem before cement polymerization occurs. n  Pack a sponge within the acetabulum and shield the surrounding soft tissues with sponges to prevent the escape of cement. n  Immediately before introduction of the cement injecting gun, remove any packing sponges and suction the distal aspect of the canal to remove any blood that has pooled there. n  Pump the trigger of the cement injecting gun to deliver cement to the tip of the nozzle so that no air is introduced. Insert the nozzle to the level of the cement restrictor, and use smooth, sequential compressions of the trigger to deliver the cement in a uniform manner (Fig. 3.58). Allow the pressure of the injected cement to push the nozzle out of the canal as the canal is filled in a retrograde fashion. Do not pull the nozzle back too quickly or voids would be created in the cement column. Fill the canal to the level of the cut surface of the femoral neck. n  Pressurize the cement by one of many methods. Preferably, use an occlusive nozzle that allows the injection of more cement through it (Fig. 3.59). Ensure that an adequate seal is maintained and slowly inject more cement

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FIGURE 3.58 Retrograde injection of cement with gun. Cement gun with long nozzle can be used to inject semiliquid cement. Distal part of canal is filled first, and tip is slowly withdrawn as cement is injected. Injection is continued until canal is completely filled and tip of nozzle is clear of canal. (Redrawn courtesy Smith & Nephew, Memphis, TN.) SEE TECHNIQUE 3.6.

over approximately 30 seconds to produce intrusion of cement into remaining cancellous bone bed. As an alternative, use a plastic impactor or mechanical plunger-type device placed over a glove or rubber sheet. Cement and bone marrow can be seen extruding from the small vascular foramina along the femoral neck during pressurization. n  Remove the pressurization device; if a void has been left in the proximal cement by the device, refill it with cement. n  Have the femoral component immediately available for insertion and insert the component when the cement has entered a medium dough phase, typically at about 6 minutes after the start of mixing for Simplex cement. The optimal time may be considerably less for other types of cement. n  Determine the desired amount of anteversion and the mediolateral position of the stem before insertion. Changes in alignment and rotation of the stem as it is inserted introduce voids into the cement. n  Hold the stem by the proximal end and insert it manually at first. Insert the tip of the stem within the center of the cement mantle. Use firm, even pressure to insert the stem. When the cement has been pressurized, it can be difficult to seat the stem completely by hand; have a plastic-tipped head impactor and a mallet immediately available to complete the seating of the stem. Most

FIGURE 3.59 Cement pressurization. Flexible pressurizing nozzle is placed over end of cement gun to seal proximal femur, and firm pressure is applied as additional cement is injected. (Redrawn Courtesy Smith & Nephew, Memphis, TN.) SEE TECHNIQUE 3.6.

contemporary systems have an insertion device for this purpose. n  Reproduce the position of the trial collar in relation to the cut surface of the femoral neck to aid in aligning the stem properly. Remove the cement from the region of the collar to ensure that the stem has been fully inserted; if not, impact it farther. If a collarless stem is used, reproduce the height of the shoulder with the previously made mark on the greater trochanter. n  Maintain firm pressure on the proximal end of the component as the cement hardens. Hold the stem motionless. This is best accomplished with a plastic-tipped pusher or dedicated stem inserter that is not rigidly fixed to the component. Insertion devices that screw into the femoral component or are rigidly fixed to it cause any small amount of motion between the surgeon and the assistant holding the leg to be transmitted to the cement-prosthesis interface. n  As the cement enters a late dough phase, cut the cement around the edges of the prosthesis and carefully remove it from the operative field. Do not pull the cement from beneath the component, or proximal support may be lost. n  After the cement has fully hardened, use a small osteotome to remove any additional fragments of cement and carefully inspect the anterior aspect of the neck for retained cement. n  Meticulously remove all cement debris from the wound. Irrigate and inspect carefully the acetabular component and remove any cement that may have entered it during femoral cementing.

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CHAPTER 3  ARTHROPLASTY OF THE HIP Repair any portion of the gluteus maximus insertion and quadratus femoris that has been divided. n  Careful reconstruction of the posterior soft-tissue envelope greatly reduces the risk of postoperative dislocation. n  If desired, place a closed-suction drain deep to the fascia. Abduct the hip 10 degrees while closing the fascial incision with closely approximated sutures. Tight closure of this layer helps stabilize the hip and may prevent a superficial inflammatory process from extending to a deeper level. Loosely approximate the subcutaneous layer with interrupted, absorbable sutures. n  Close the skin in routine fashion. n 

  

TOTAL HIP ARTHROPLASTY THROUGH THE DIRECT ANTERIOR APPROACH A

B

FIGURE 3.60 Manual cement packing. A, When cement is inserted manually, it must be packed firmly in canal with finger before stem is introduced. B, After canal has been filled, cement is pressed with thumb, preventing its escape and increasing pressure within canal. SEE TECHNIQUE 3.6.

Carefully clean and dry the taper, and assemble the modular femoral head with a single blow using a plasticcapped impactor. n  The preferred method for filling the canal with cement is to use an injecting gun with the cement in a medium viscosity state. Some cements, such as Palacos, exist primarily in a dough phase, however, and are not easily injected. Under these circumstances, the cement can be inserted manually. To insert cement into the femoral canal manually, mold the cement into the shape of a sausage and hold it in the palm of one hand or in an open plastic container. Push the cement into the canal with the index finger or thumb of the opposite hand as far distally as the finger reaches (Fig. 3.60A). If the cement is still sticky, pack it by short strokes with the fingertip. Avoid mixing blood with the cement and keep the bolus of cement intact. Lamination of the cement or incorporation of blood weakens it. n  After the cavity has been filled, press the cement with the thumb (Fig. 3.60B). A mechanical impactor or plunger can be used. Two packages usually suffice, but additional cement may be necessary for larger medullary canals. A small plastic suction tube can be placed in the femoral canal to allow air and blood to escape while the cement is being inserted. If a suction tube is used, place it into the canal before the cement is introduced; remove it after about two thirds of the cement has been inserted. n 

SOFT-TISSUE REPAIR AND CLOSURE After reduction of the hip, proceed with repair of the posterior soft-tissue envelope. Repair the preserved portion of the posterior capsule with heavy nonabsorbable sutures placed through holes in the posterior edge of the greater trochanter. Reattach the previously tagged tendons of the short external rotator muscles.

n 

DIRECT ANTERIOR APPROACH WITH ANTERIOR DISLOCATION OF THE HIP The direct anterior approach uses the distal half of the traditional Smith-Petersen approach to the hip. Initially described by Light and Keggi in 1980, modifications of the approach have become considerably more popular over the last decade. The interval is both intermuscular and internervous, so little muscular dissection is required. Performed with the patient supine, the procedure can be done on a conventional radiolucent table or a specialized table similar to those used in fracture surgery. An accessory hook mounted on the side of the table can be used to aid in elevating the femur for preparation and component implantation. Intraoperative fluoroscopy can also be used to check the progress of reaming, the positioning of implants, and restoration of limb length. The position of the pelvis is also more reliable when the patient is supine than in the lateral decubitus position. The approach traverses anatomy that may be unfamiliar even to experienced hip surgeons. The learning curve for the procedure can be improved by cadaver laboratory instruction sponsored by orthopaedic societies and industry or by personal visitation with surgeons already experienced in the procedure. Acetabular preparation and component implantation generally are straightforward. Access to the femur is more difficult, leading many surgeons to use shorter or curved femoral components to simplify the procedure (see Figs. 3.21C and 3.28). Certain patient factors make the approach more complex. The interval cannot be safely extended distally, so a separate exposure is required to access the femur in patients with deformity requiring osteotomy, removal of previously placed implants, or placement of femoral cerclage. Access to the femoral canal can be more difficult in patients with a wide iliac crest and those with a short, varus femoral neck. In obese patients the subcutaneous layer about the anterior aspect of the hip tends to be thinner than the lateral aspect, and with the patient supine gravity displaces the tissues away from the incision. In patients with a large panniculus, however, the inguinal crease is prone to dermatitis and chronic fungal infection leading to problems with wound healing.

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FIGURE 3.61 Direct anterior approach. Patient positioned supine with anterior superior iliac spine placed at level of table break. (Redrawn from Biomet.) SEE TECHNIQUE 3.7.

The anterior approach also has been advocated because of a low incidence of dislocation, although this difference has diminished with the use of larger femoral heads and soft-tissue repair. Some investigators have also reported faster functional recovery with the direct anterior approach, including shorter hospitalization, less narcotic use, and less reliance on ambulatory aids at 2 weeks. Few report any differences past 6 weeks postoperatively.

TECHNIQUE 3.7 Position the patient supine on a radiolucent table with the ASIS at the level of the table break such that the operated limb can be positioned in marked hyperextension (Fig. 3.61). Place a small bolster under the operative hip to aid in elevating the femur. If fluoroscopy is to be used, ensure that the pelvis is level and that both hips can be adequately imaged. n  Prepare the skin of both lower limbs above the level of the ASIS and drape the limbs separately such that the operated limb can be crossed beneath the opposite limb in a figure-of-four position. An additional padded and draped Mayo stand is useful for supporting the opposite limb during preparation of the femur. n  Place the skin incision lateral to the interval between the tensor fascia lata (TFL) and sartorius to avoid injury to the fibers of the lateral femoral cutaneous nerve (LFCN), which may be variable in its course. Begin the incision approximately 3 cm distal and 3 cm lateral to the ASIS. Extend the incision distal and slightly lateral for 8 to 12 cm. n  Divide the fascia over the muscle belly of the TFL fibers to stay lateral to the LFCN (Fig. 3.62A). n  Now bluntly dissect medially with an index finger in the interval between the TFL and sartorius (Fig. 3.62B). If uncertain of the correct plane, expose proximally to ascertain that the dissected interval is lateral to the ASIS. n  The femoral neck can be palpated through a thin layer of fat overlying the anterior capsule. Within this fat layer in the distal extent of the interval, locate the ascending branches of the lateral circumflex vessels and cauterize them with electrocautery or a bipolar sealer (Fig. 3.62C). Brisk bleeding may be encountered if these vessels are divided and allowed to retract. n  Place blunt curved retractors superior and inferior to the femoral neck. Elevate the fibers of the rectus femoris from the n 

anterior hip capsule and place a pointed retractor over the anterior rim of the acetabulum just distal to the direct head of the rectus (Fig. 3.62D). Release the fibers of the reflected head of the rectus to allow improved medial retraction of the direct head. Slight flexion of the hip also relaxes the rectus. Take care in the placement of the retractor beneath the rectus to avoid injury to the femoral nerve and vessels. n  Divide the anterior hip capsule in a T-shaped or H-shaped fashion for later repair, or alternatively excise the capsule. Release the inferior capsule to the level of the lesser trochanter. Now replace the superior and inferior curved retractors inside the capsule to completely expose the femoral neck. n  Perform an in situ osteotomy of the femoral neck at the level determined by preoperative templating. Measure the osteotomy from the lesser trochanter or by use of fluoroscopy. It may be necessary to make a second parallel osteotomy at the subcapital region producing a “napkin ring” of bone, which is secured with a threaded Steinmann pin for removal (Fig. 3.63A). n  Extract the femoral head with a corkscrew, which can be placed before the neck osteotomy is made. Take care to protect the TFL from sharp bone edges when removing the femoral head. Recheck the neck osteotomy height. If the femoral neck is left excessively long, acetabular exposure will be more difficult. n  To expose the acetabulum, place curved retractors distal to the transverse acetabular ligament and along the posterior rim of the acetabulum to displace the femur posteriorly (Fig. 3.63). An additional retractor can be placed over the anterior acetabular rim if needed. Excise the labrum and prepare the acetabulum with reamers (see Fig. 3.45). Specialized offset reamers and cup positioners are available for this purpose. The progress of acetabular reaming and cup positioning can be verified using fluoroscopy. There is a tendency to place the cup in excessive abduction and anteversion with the patient supine. n  Elevation of the femur is the most difficult step with the patient supine. To expose the proximal femur, place the operated limb in figure-of-four position beneath the opposite limb. Adduct the femur slightly and externally rotate 90 degrees. Avoid excessive knee flexion because this position tightens the rectus femoris, making femoral elevation more difficult. n  Now “break” the table to position the operated hip in hyperextension. Raise the table and place it in the Trendelenburg position to prevent the lower end from approaching the floor. Support the opposite leg on a padded sterile Mayo stand or arm board (Fig. 3.64A). n  Elevate the femur laterally and upward with a bone hook placed within the femoral canal or around the lateral aspect of the femur. Take care that the femur is not trapped behind the acetabulum during this maneuver; elevation of the femur will be more difficult, or fracture of the greater trochanter may occur. A sterile hook mounted on a table attachment can be used during this step (Fig. 3.64B). Place the hook just distal to the vastus ridge. Position a curved retractor beneath the posteromedial femoral neck to retract the medial soft tissues. Place an additional pronged retractor over the tip of the greater trochanter to protect the abductor musculature and lift the femur anteriorly.

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CHAPTER 3  ARTHROPLASTY OF THE HIP Sartorius Medial Sartorius Proximal Distal Tensor fascia latae Tensor fascia lata Lateral

A

B

Circumflex vessels

Vastus lateralis

Rectus femoris

Capsule

Capsule

Vastus intermedius

Vastus intermedius

Tensor fascia lata

Tensor fascia lata

C

D FIGURE 3.62 A, Fascial incision (green line) is positioned over the tensor fascia latae (TFL) muscle and lateral to the interval between TFL and sartorius (dashed white line). B, Blunt dissection medially beneath fascia leads to interval between TFL and sartorius. C, Within the fat layer at distal extent of interval are branches of the lateral femoral circumflex vessels that must be identified and carefully cauterized. D, Extracapsular placement of retractors superiorly and inferiorly before capsulotomy. An additional retractor may be placed medially beneath rectus femoris. (A from Post ZD, Orozco F, Diaz-Ledezma C, et al: Direct anterior approach for total hip arthroplasty: indications, technique, and results, J Am Acad Orthop Surg 22:595-603, 2014. B-D redrawn from Depuy.) SEE TECHNIQUE 3.7.

Additional soft-tissue release often is required at this stage to avoid excess retraction force, which may result in femoral fracture. Patients with fixed external rotation deformity typically require a greater amount of release to deliver the femur anteriorly. First, release the superior capsule from the greater trochanter from anterior to posterior, completely exposing the trochanteric fossa or “saddle” (Fig. 3.65). In more difficult cases, release the piriformis and conjoined tendons to allow elevation of the femur without undue traction (Fig. 3.66). n  Prepare the femur and implant the femoral component (see Technique 3.5). It is technically easier to implant a femoral component using a broach-only technique because it may be difficult to pass straight reamers down the femoral canal even with satisfactory femoral exposure. Specialized angled broach handles and stem insertion devices also simplify the procedure (Fig. 3.67). A canal sound or guide pin is useful to judge the alignment n 

of the femoral canal and avoid varus stem positioning or perforation of the lateral femoral cortex. n  During the trial reduction of implants, take special care to assess the stability of the hip in extension and external rotation, particularly if a complete anterior capsulectomy has been performed during the initial exposure. Use fluoroscopy to assess position of the implants and restoration of limb length and offset. Limb length also can be assessed directly by comparison with the opposite limb. n  If the anterior capsule has been retained, perform a secure closure of the capsular flaps. When closing the fascial layer, take small bites on the medial edge to avoid entrapment of the LFCN in the repair.   

Some proponents of the supine intermuscular approach have advocated the use of a dedicated surgical table similar to those used in lower extremity fracture care. Both feet are secured in compression boots attached to mobile spars that

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A B FIGURE 3.63 A, Femoral neck osteotomy. Two parallel cuts made (dashed lines) and “napkin ring” segment removed with a threaded pin. Femoral head is then removed with corkscrew. B, Retractors placed inferior to transverse ligament and also posteriorly to retract femur. (A redrawn from Biomet. B redrawn from Depuy.) SEE TECHNIQUE 3.7.

B

A FIGURE 3.64 A, Table position for exposure of femur. Operated limb is placed in figure-of-four position beneath opposite lower limb, and lower end of table is dropped to place hip in hyperextension. Proximal femur must be retracted laterally and upward. B, Accessory hook mounted to table aids femoral elevation. (A redrawn from Biomet; B courtesy Innomed, Inc. Savannah, GA.) SEE TECHNIQUE 3.7.

allow traction, rotation, and angulation of the limb in any direction (Fig. 3.68). An integral hook is used to aid in femoral elevation, and intraoperative fluoroscopic imaging is easily obtained. Because both feet are secured in boots, however, it is more difficult to manually assess the stability of the hip and directly compare limb lengths. The use of such a table requires a significant institutional financial investment, and the use of strong traction and limb rotation also introduces a risk of traction nerve palsy and fractures. Matta et  al. reported a series of 494 primary arthroplasties performed on a dedicated table. Clinical and radiographic results were excellent, but there was one femoral nerve palsy, three greater trochanteric fractures, two femoral shaft fractures, and three ankle fractures. The complications

underscore the importance of obtaining exposure by judicious soft-tissue releases rather than by forceful traction and limb rotation. The results using intraoperative fluoroscopy have been mixed. Hamilton et al. reported no excessively abducted cups (over 55 degrees) using fluoroscopy with the direct anterior approach. Leucht et  al. found that fluoroscopy reduced the incidence of limb length discrepancy of more than 1 cm but did not improve the precision of cup positioning. In a large series from the Rothman Institute, Tischler et  al. found no difference in acetabular inclination angle, leg length, or offset using fluoroscopy and concluded that the increased operative time and cost were not justified at a high-volume arthroplasty institution. Careful attention must be paid to both the

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CHAPTER 3  ARTHROPLASTY OF THE HIP

FIGURE 3.65 Soft-tissue release for femoral elevation. Superior capsule is released from anterior to posterior to completely expose trochanteric fossa and allow elevation of femur without undue force. (Redrawn from Biomet.) SEE TECHNIQUE 3.7.

FIGURE 3.67 Femoral instrumentation. After adequate elevation of femur, preparation is facilitated by instruments with offset handles. (Redrawn from Biomet.) SEE TECHNIQUE 3.7.

FIGURE 3.68 Dedicated table for positioning during direct anterior approach. Surgeon controls elevation of femur with integral hook. (ProFx table, courtesy Mizuho OSI, Union City, CA.)

FIGURE 3.66 Insertions of short external rotators as viewed from medial. Piriformis (p) inserts near cephalad extent of greater trochanter. Conjoined tendon (asterisk) and obturator externus (oe) insert more distal. (From Ito Y, Matsushita I, Watanabe H, Kimura T: Anatomic mapping of short external rotators shows the limit of their preservation during total hip arthroplasty, Clin Orthop Relat Res 470:1690, 2012.) SEE TECHNIQUE 3.7.

tilt and rotation of the pelvis in relation to the x-ray beam to maximize the utility of intraoperative fluoroscopy. Standard protection in the form of a lead apron and thyroid shield are recommended for those in proximity to the beam. McArthur et al. reported radiation dose and fluoroscopy times that were comparable to other fluoroscopically guided hip procedures. 

MINIMALLY INVASIVE TECHNIQUES

Hip arthroplasty has been performed through small incisions by Kennon et  al. since the 1980s. More recently, minimally

invasive techniques have been introduced to the orthopaedic community and have received widespread media attention. The term minimally invasive total hip replacement does not describe a single operation but rather a group of procedures performed through various incisions of smaller dimensions than traditionally described. The introduction of these techniques has generated considerable controversy in the orthopaedic community. Advocates of these techniques have advanced the position that minimally invasive hip replacement has the potential to reduce soft-tissue injury, postoperative pain, operative blood loss, and hospital length of stay; increase speed of the patient’s postoperative rehabilitation; and produce a more cosmetically acceptable surgical scar. Adoption of minimally invasive techniques has revolutionized other procedures, such as meniscectomy, cruciate ligament reconstruction, rotator cuff repair, discectomy, and others. Critics of these new techniques cite the excellent results of current methods with regard to pain relief, functional improvement, and long-term durability, with a remarkably low complication rate. The potential benefits of smaller incisions must be weighed against the pitfalls of poor exposure and the learning curve associated with any new procedure. There is the potential for implant loosening from suboptimal bone preparation, dislocation from malpositioned implants, infection and delayed wound healing from trauma to the skin, unrecognized fractures, neurovascular

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A

B FIGURE 3.69 A and B, Array of retractors with long handles, angulated acetabular insertion device, and fiberoptic lighting (B) for minimally invasive hip surgery. (Courtesy Zimmer, Warsaw, IN.)

compromise, and leg-length inequality from the lack of exposure of bony landmarks. All of these problems may require reoperation and are likely to be more common in the hands of surgeons performing fewer procedures. Surgeons must decide whether the potential risks in adopting minimally invasive techniques are justifiable given the scope of their individual practices. There is general consensus that a minimally invasive hip arthroplasty is done through an incision of 10 cm or less. A single posterior incision is currently the most commonly used approach, followed by single-incision direct anterior approaches. We have gradually adopted minimally invasive techniques and now perform hip arthroplasty in most patients through a single posterior incision of 8 to 10 cm (Video 3.1). We have more recently adopted the direct anterior approach in selected primary procedures. Thin patients are ideal for minimally invasive approaches. The operation is more difficult in muscular males and obese patients (BMI > 30 kg/m2). Although a longer incision may be needed in these individuals, the same principles can be applied. Patients requiring revision surgery and patients with dysplasia, prior reconstructive procedures, or very stiff hips require larger incisions. As a basic tenet, there should never be any hesitation to lengthen the incision if exposure is inadequate. An operation done well through a larger incision is preferable to an unsatisfactory result with a small incision. At a given time, only a portion of the hip is exposed. A variety of specialized instruments are helpful in gaining exposure and viewing the acetabulum and femur while protecting the surrounding soft tissues (Fig. 3.69). A long Charnley retractor blade is needed to avoid excessive stretching of the wound corners. Acetabular retractors with long handles and blades narrower than usual reduce clutter within the wound. Some systems have incorporated fiberoptic lighting into acetabular retractors. Angulated acetabular reamer

shafts and component positioning devices reduce the retraction required on the inferior soft tissues. Reamers with side cutouts are more easily inserted into the acetabulum and appear to be acceptably accurate. It is particularly helpful to have an assistant to position the limb for femoral preparation and implant placement. Exposure also is enhanced by the use of hypotensive regional anesthesia to reduce intraoperative bleeding. Sculco and Jordan advocated a posterolateral approach to the hip through a 6- to 10-cm incision. The incision is placed in line with the femur along the posterior edge of the greater trochanter with approximately one third of the incision proximal to the tip of the greater trochanter and two thirds distal. The gluteus maximus is split for only a short distance, the incision of the fascia lata is limited, and the quadratus femoris is left mostly intact but retracted to expose the lesser trochanter and resect the femoral neck. The incision may be easily extended in either direction to approximate a more traditional posterior approach if needed. In a prospective randomized study by this group, Chimento et al. showed that patients with an 8-cm posterolateral approach had less intraoperative and total blood loss and limped less at 6 weeks’ follow-up than patients with a standard approach. There were no differences in operative time, transfusion requirements, narcotic use, hospital stay, or other rehabilitation milestones. Complications were similar in the two groups, and a 5-year follow-up on the same cohort showed no radiographic loosening. Radiographic measures of cup and stem position and cement technique were not compromised in the minimally invasive group. DiGioia et al. found that patients in the miniincision group walked with less of a limp and had better stairclimbing ability at 3 months and improvement in the limp, distance walking, and stair-climbing at 6 months. There were no differences at 1 year. In a prospective, randomized series, Dorr et  al. found that a group that had minimally invasive

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CHAPTER 3  ARTHROPLASTY OF THE HIP surgery had shorter hospital stays, less in-hospital pain, and less need for assistive devices. There were no differences after hospital discharge. Other investigators have not shown any benefit to the use of a smaller incision. In a prospective, randomized, controlled trial, Ogonda et  al. found that a minimally invasive approach was safe and reproducible but offered no benefit compared with a traditional approach. The trial was done after the senior author had gained considerable experience with less invasive techniques, and the learning curve was not included in this series. In another study from the same institution, Bennett et  al. found no difference in any gait analysis parameter at 2 days after surgery. Goldstein et al. likewise were unable to show any differences between a standard and minimally invasive posterolateral approach. In another prospective series with 5-year follow-up, Wright et al. found no difference other than patients’ enthusiasm regarding the cosmetic appearance of the scar. Minimally invasive anterior incisions are modifications of the Smith-Petersen approach. Although the acetabular exposure is superior, it can be difficult to place the femur in a position where the stem can be inserted in line with the shaft. Several manufacturers have introduced shorter stems with curved broaches to simplify femoral component placement (see Fig. 3.28). Although a claim of the anterior approach is that no muscle or tendon is transected, multiple authors recommend release of the posterior capsule and short external rotators to deliver the femur into the wound. Problems related to injury to the lateral femoral cutaneous nerve (LFCN) have led many to place the skin incision slightly lateral to the intermuscular plane of the deeper dissection. Parratte and Pagnano evaluated tissue injury with various approaches and concluded that it is not possible to routinely perform minimally invasive THA without causing some measurable degree of muscle damage. Rather, the location and extent of muscle damage is specific to the approach. Tissue damage in the anterior approach involved the anterior part of the gluteus medius, the TFL, and the external rotators. The posterior approach was associated with substantial damage to the short external rotators and gluteus minimus and a small amount of damage to the gluteus medius. Bergin et al. measured serum inflammatory markers in patients undergoing hip arthroplasty through minimally invasive posterior and anterior approaches. Serum creatine kinase levels in the posterior group were 5.5 times higher than the anterior group in the postanesthesia unit. The clinical significance of the finding was not delineated. Advocates frequently describe enhanced recovery after minimally invasive hip arthroplasty. However, multimodal pain management and accelerated rehabilitation protocols have been introduced simultaneously, and these factors also influence the speed of recovery. In a series of 100 patients, Pour et al. found that at the time of hospital discharge, patient satisfaction and walking ability were better in patients who had received an accelerated preoperative and postoperative rehabilitation regimen regardless of the size of the incision. Poehling-Monaghan et al. found no systematic advantage of a direct anterior approach over a mini-posterior approach when using the same rapid rehabilitation protocols with no hip positioning precautions. Minimally invasive techniques and instrumentation continue to evolve. Refinements in surgical approaches and the

integration of computer-assisted navigation may ultimately improve outcomes and surpass the excellent results of standard hip arthroplasty procedures. Rigorous scientific study of these new methods must precede widespread adoption in clinical practice. 

COMPUTER-ASSISTED SURGERY

Improper positioning of acetabular and femoral components may compromise the outcome of the arthroplasty because of impingement, dislocation, increased wear, and leg-length discrepancy. Patient size, the presence of deformity, limited surgical exposure, intraoperative movement of the pelvis, inaccuracies in conventional instrumentation, and surgeon experience are all variables that may negatively affect the accuracy of component positioning. Surgeons’ assessments of intraoperative position of both femoral and acetabular components are inaccurate when compared with postoperative CT scans. Strategies such as computer-assisted surgical navigation are being investigated to improve the accuracy of the operation. Computer-assisted navigation provides the surgeon with real-time information regarding the positioning of the femur and pelvis relative to each other and to the surgical instrumentation. The tracking of these positions is by infrared stereoscopic optical arrays that must be visible to a camera. Navigation of the acetabular component requires registration of anatomic landmarks to allow the computer to determine the position of the pelvis in space. Although individual navigation systems vary in both durable equipment and software algorithms, there are three general types of systems: imageless, fluoroscopic, and CT based. Imageless navigation is based only on landmarks that are digitized at the time of surgery without confirmation by imaging studies. A reference frame is attached to the pelvis, and an optical pointer is then used to reference the ASIS and pubic symphysis by palpation or by small percutaneous incisions. The registration process is performed with the patient supine to allow access to the opposite anterior spine. If the operation is to be done with the patient in the lateral position, the optical tracker is mounted to the pelvis and must be prepared and draped into the surgical field after the patient is repositioned. In larger patients, inaccurate digitization of pelvic landmarks can introduce errors. Computer screen images are of standardized bone models and do not reflect the patient’s individual anatomy. Using imageless navigation, Hohmann et al. demonstrated a significant decrease in deviation of acetabular component placement with respect to both inclination and anteversion compared with conventional techniques. Ellapparadja et  al. found restoration of both leg length and offset within 6 mm in over 95% of cases. Conversely, Brown et  al. found no difference in acetabular inclination angle or leg-length discrepancy between imageless navigation and conventional techniques. When fluoroscopic navigation is used, reference frames are again applied to the bones. Fluoroscopic images made at multiple angles are combined to yield three-dimensional information. The referencing process can be performed with the patient in the lateral position. If there is a change during the procedure, then new images may be acquired. A radiolucent operating table is required, and protective lead aprons must be worn by the surgical team. Bulky fluoroscopic equipment must remain available during the procedure, and time

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS has to be allotted for acquisition of images. Fluoroscopic navigation has been more reliable for limiting variability of cup abduction than for anteversion. No preoperative planning or imaging is required. Consequently, the technique provides no information about the requirements for restoration of proper hip mechanics. CT-based navigation provides detailed, patient-specific information compared with imageless and fluoroscopic techniques. Information from the preoperative CT scan is used to produce a virtual bone model which is then coupled to the patient’s bony anatomy by the process of registration. Intraoperative registration requires digitization of multiple points on the bony surface of the acetabulum using an instrumented pointer that are then mapped onto the computer model. The process can be done with the patient in the lateral position without the need for repositioning. The accuracy of the mapping and navigation can be confirmed in real time. Detailed information is available preoperatively regarding component size, positioning, leg length, offset, and range of motion. Preoperative imaging and planning are required, but no intraoperative imaging is needed, and the surgical procedure is consequently faster than with imageless navigation. Beckmann et al., in a meta-analysis of the use of navigation to improve acetabular component position, found that whereas mean cup inclination and anteversion angles were not significantly different, navigation reduced the variability in cup position and the risk of placing the acetabular component beyond the safe zone. Long-term outcomes and cost utility data were not available. Moskal and Capps drew similar conclusions and found fewer dislocations in hips with navigated acetabular component placement. To assess the accuracy of navigation in correcting leg length, Manzotti et  al. compared 48 navigated hip arthroplasties with a matched cohort of procedures using a traditional freehand alignment method. Restoration of limb length was significantly better in the computer-assisted group. Dorr et al. reported using navigation to optimize restoration of offset: offset was restored within 6 mm of the contralateral hip in 78 of 82 hips. Interest in robotic technologies has increased over the past decade, although to a lesser degree than in knee arthroplasty. Robotics complement surgical navigation with the addition of both bone preparation and component implantation being assisted by a sterile draped robotic arm. Current systems are CT based and require intraoperative placement of tracking arrays and bony registration. Typically, the femur is prepared first and femoral version assessed. Acetabular version can then be adjusted to obtain correct combined anteversion. Acetabular reaming is carried out with visual and tactile feedback from the computer, and bone removal outside of the planned resection is effectively prevented. The acetabular component is then implanted with precision guidance from the robotic arm according to the preoperative plan. Kanawade et  al. found a contemporary robotic system achieved precision in acetabular inclination, anteversion, and center of rotation in over 80% of cases. There has been little development of patient-specific instrumentation in THA compared with knee procedures. In one study, Small et al. found that such instruments improved accuracy of acetabular anteversion but not abduction angle. Computer-assisted navigation appears effective in reducing outliers in component positioning and can be beneficial in restoring optimal hip mechanics. Whether these advances

in accuracy will translate to improvements in outcomes and implant survivorship remains to be validated. The cost of necessary equipment, software, and imaging studies may be prohibitive for many institutions. 

TROCHANTERIC OSTEOTOMY

Although osteotomy of the trochanter for exposure and lateral reattachment to lengthen the lever arm of the abductors was an integral part of Charnley’s concept of THA, most total hip procedures are done now without osteotomy. The advocates of osteotomy believe that in addition to the opportunity to advance the trochanter laterally and distally at the time of surgery, dislocation of the hip is easier, exposure of the acetabulum is better, preparation of the femoral canal is complicated by fewer penetrations, cement can be inserted more optimally, and components can be inserted more easily and more accurately. The disadvantages of osteotomy are increased blood loss, a higher incidence of hematoma formation, longer operating time, technical difficulty with fixation of the trochanter, nonunion, wire breakage, bursitis, greater postoperative pain, and delayed rehabilitation. In most patients, adequate exposure can be obtained with the posterolateral, anterior, anterolateral, or direct lateral approach without osteotomy of the trochanter. Although leaving the trochanter intact has many advantages, osteotomy may be necessary if the anatomy of the hip is markedly distorted, such as in cases of ankylosis or fusion, severe protrusio acetabuli, or developmental dysplasia with high dislocation of the hip. Occasionally, residual laxity of the abductor musculature results in hip instability despite proper restoration of length and offset. In this instance, trochanteric osteotomy with distal reattachment can render the hip more stable without lengthening the limb excessively. In revision procedures, trochanteric osteotomy facilitates exposure of the femur and acetabulum and may be required to extract the femoral component without excessive risk of fracturing the femur. Three basic types of trochanteric osteotomies are currently used in hip arthroplasty: (1) the standard or conventional type, (2) the so-called trochanteric slide, and (3) the extended trochanteric osteotomy (Fig. 3.70). Various modifications have been described for each type. The various types are suitable for specific purposes and should be tailored to the procedure being contemplated. Finally, the fixation method must be adapted to the type of osteotomy. The standard trochanteric osteotomy is indicated when extensile exposure of the acetabulum is needed for complex revisions of the acetabular component, placement of an antiprotrusio cage, or a large structural bone graft. Superior retraction of the greater trochanter and abductor musculature yields unparalleled exposure of the ilium with less tension on the superior gluteal neurovascular bundle than would be experienced with the trochanteric slide technique. When a standard trochanteric osteotomy is done, the vastus lateralis first should be detached subperiosteally from the lateral aspect of the femur distal to the vastus tubercle. The osteotomy may be made with a power saw or an osteotome. The osteotomy is initiated just distal to the vastus tubercle and directed proximally and medially at an angle of approximately 45 degrees to the shaft of the femur. It should not extend into the femoral neck, and special care must be taken not to injure the sciatic nerve. In general, a large piece of bone should be removed, with all of the tendinous attachments of the gluteus

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Gluteus medius and minimus A Vastus tubercle

Vastus lateralis

B

C

FIGURE 3.70 Types of trochanteric osteotomy and their relationships to muscular attachments. A, Standard trochanteric osteotomy with only superior abductor attachment. B, Trochanteric slide with abductors and vastus lateralis attached to trochanteric fragment; C, Extended trochanteric osteotomy.

medius and underlying gluteus minimus muscles. Other softtissue attachments, including the short external rotators, are released as necessary to allow superior retraction of the trochanteric fragment. The osteotomy also can be made with a Gigli saw passed deep to the abductor muscles and directed laterally (Figs. 3.71 and 3.72). Charnley emphasized keeping the “strap” of the lateral capsule from the superior aspect of the acetabulum to the base of the trochanter intact to make reattachment more stable than pulling on muscle fibers alone. Excessive tension on the trochanter by the abductors can be lessened by maintaining the distal soft-tissue attachments on the trochanter. Glassman, Engh, and Bobyn described a technique of osteotomy that maintains an intact musculoosseous sleeve composed of the gluteus medius, greater trochanter, and vastus lateralis. This technique has been termed the trochanteric slide technique (Fig. 3.73). Although nonunion rates for this procedure were similar to the rates for other techniques, superior migration of more than 1 cm occurred in only 11% of the nonunions, and the incidence of abductor insufficiency and limp was significantly lower than in similar series. Neither a standard osteotomy nor a trochanteric slide is ideal when the bed for reattachment has been compromised, such as when the greater trochanter has been filled with cement. More recently, various techniques of extended trochanteric osteotomy have been introduced. In essence, these are proximal femoral osteotomies in which a segment of the lateral femoral cortex of variable length is raised in continuity with the greater trochanter. These techniques are of greatest benefit in removing well-fixed implants in revision surgery and when the bony bed for reattachment of a standard osteotomy would be compromised. Because a large segment of the lateral femoral cortex is removed, and cementing techniques are rendered imperfect, extended trochanteric osteotomies

FIGURE 3.71 Gallbladder clamp is inserted into joint and pushed through capsule posterior to insertion of gluteus medius to grasp Gigli saw (see text).

FIGURE 3.72 Before trochanter is osteotomized, finger is used to ensure that Gigli saw is sufficiently posterior and sciatic nerve is not trapped between saw and bone. Inset, Direction of osteotomy is first distal and then lateral to detach trochanter just proximal to abductor tubercle.

are used only when a cementless femoral reconstruction is anticipated (see Technique 3.5). Lakstein et  al. described a modified technique in which the posterior capsule and short external rotators are left intact to reduce the risk of dislocation. The lever arm of the abductors is lengthened according to the amount of lateral placement of the osteotomized trochanter. The hip should not be abducted more than 10 to 15 degrees while the trochanter is being reattached, or excess strain on the fixation would result when the hip is adducted, and avulsion and nonunion of the trochanter may follow. The position of reattachment of the greater trochanter has been found to affect the rate of union. Anatomic reduction or a slight distal overlap of the trochanter results in trochanteric union within 6 months. Fixation of the trochanter with

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS a plate extension also are available (Fig. 3.78). Full weight bearing on the hip should be delayed for 4 to 6 weeks if fixation is not rigid. When fixation is less stable (i.e., with a small piece of bone or soft bone, difficulty in pulling the bone down to the femur, or loss of the bony bed for reattachment of the trochanteric fragment), the hip may be maintained in abduction in a spica cast or orthosis for 6 weeks. (See the section on complications for trochanteric nonunion and wire breakage problems.) Dall described a modification of the direct lateral approach that involves osteotomy of the anterior portion of the greater trochanter rather than division of the anterior portion of the abductor insertion from the trochanter. Head et al. used a similar osteotomy in conjunction with an extensile direct lateral approach for revision arthroplasty (Fig. 3.79). This approach detaches only the internal rotational component of the abductors and leaves the important abductor portion of the gluteus medius intact. Reattachment of the anterior trochanteric fragment allows for primary bony union and is easier than direct repair of the abductor tendon to bone.  FIGURE 3.73 Trochanteric slide technique described by Glassman, Engh, and Bobyn. Osteotomy is oriented in sagittal plane and includes origin of vastus lateralis. (Redrawn from Glassman AH, Engh CA, Bobyn JD: A technique of extensile exposure for total hip arthroplasty, J Arthroplasty 2:11, 1987.)

residual superior and medial tilt invariably led to delayed union or nonunion. For union to occur reliably, compression must be applied across the osteotomy. Fixation should stabilize the trochanteric fragment to vertical and anterior displacement. Displacement in the anteroposterior plane occurs when the hip is loaded in flexion, and fixation failure is more complex than the abductors simply pulling the trochanteric fragment superiorly. A biplanar or chevron osteotomy yields greater resistance to anteroposterior displacement than a uniplanar osteotomy. Such an osteotomy is useful in complex primary procedures but is impractical in most revisions because of the loss of bone needed not only to perform but also to repair the osteotomy. Various wire fixation techniques using two, three, or four wires have been described and are illustrated in Figures 3.74 and 3.75. No. 16, 18, or 20 wire can be used, and because spool wire is more malleable, it is easier to tighten and tie or twist. A Kirschner wire spreader or wire tightener is used to tighten the wire. Stainless steel, cobalt-chrome alloy, or titanium alloy wire may be used, depending on the metal of the femoral component. Also, multiple filament wire or cable is available; the ends are pulled through a short metal sleeve, which is crimped after the wire has been tightened. Special care should be taken not to kink or nick the wire. In our experience, wire fixation techniques do not predictably provide rigid fixation of the trochanter. Trochanteric nonunion rates of 25% have been reported using wiring techniques. With the trend toward cementless femoral revision, techniques requiring intramedullary passage of wires and screws have become difficult. In most cases, we prefer an extramedullary cable fixation device instead (Figs. 3.76 and 3.77). A variety of new devices featuring proximal hooks with

SURGICAL PROBLEMS RELATIVE TO SPECIFIC HIP DISORDERS Much information has been accumulated since the 1970s concerning the various entities for which THA has been performed. In some instances, the routine surgical techniques must be modified to meet the needs of the various conditions. For this reason, the following entities are discussed relative to THA. Revision surgery for failed THA is discussed in a separate section.

ARTHRITIC DISORDERS

OSTEOARTHRITIS (PRIMARY OR SECONDARY HYPERTROPHIC ARTHRITIS OR DEGENERATIVE ARTHRITIS)

Osteoarthritis is the most common indication for THA; it can be primary or secondary to femoroacetabular impingement, to previous trauma, or to childhood disorders of the hip. The extremity often is shortened slightly, although the discrepancy can be greater than 1 cm if erosion or deformation of the femoral head or acetabulum has occurred. The hip often is flexed, externally rotated, and adducted, and there is additional apparent shortening of the limb because of the deformity. Less commonly, the limb may appear lengthened because of a fixed abduction contracture. Removal of the osteophytes from the anterior or posterior margin of the acetabulum may be necessary to dislocate the hip safely. The subchondral bone of the acetabulum is thick and hard, and considerable reaming may be required before a bleeding surface satisfactory for bone ingrowth is reached. Osteophytes may completely cover the pulvinar and obscure the location of the medial wall. If the femoral head has been displaced laterally, intraarticular osteophytes inferiorly may thicken the bone considerably and require deepening of the acetabulum to contain the cup fully (Fig. 3.80). Failure to medialize the acetabulum in this instance may leave the superior portion of the cup unsupported or supported primarily by osteophytes rather than native bone. Careful attention to the removal of

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A

B

C

FIGURE 3.74 Wire fixation of trochanter. A, Two vertical wires are inserted in hole drilled in lateral cortex below abductor tubercle; they emerge from cut surface of neck, and one is inserted in hole in osteotomized trochanter. Two vertical wires are tightened and twisted, and transverse wire that was inserted in hole drilled in lesser trochanter and two holes in osteotomized trochanter is tightened and twisted. B, One-wire technique of Coventry. After component has been cemented in femur, two anteroposterior holes are drilled in femur beneath osteotomized surface and two holes are drilled in osteotomized trochanter. One end of wire is inserted through lateral loop before being tightened and twisted. C, Oblique interlocking wire technique of Amstutz for surface replacement. (A modified from Smith & Nephew, Memphis, TN; B and C redrawn from Markolf KL, Hirschowitz DL, Amstutz HC: Mechanical stability of the greater trochanter following osteotomy and reattachment by wiring, Clin Orthop Relat Res 141:111, 1979.)

Four-wire technique

Lateral view

its anterior or posterior surface to prevent impingement during rotation. 

INFLAMMATORY ARTHRITIS

A

B

FIGURE 3.75 Harris four-wire technique of reattachment of trochanter. A, Two vertical wires are inserted through hole drilled in lateral cortex and come out in groove cut in neck of femur so as not to interfere with seating of collar. Two transverse wires are inserted in holes in lesser trochanter and in two holes in osteotomized greater trochanter. B, Two transverse wires are tied over two tied vertical wires. One transverse wire can be used instead of two. (Redrawn from Harris WH: Revision surgery for failed, nonseptic total hip arthroplasty: the femoral side, Clin Orthop Relat Res 170:8, 1982.)

acetabular osteophytes is necessary to avoid impingement, decreased range of motion, and dislocation. Trochanteric osteotomy usually is unnecessary, but often the greater trochanter is enlarged, and some bone must be removed from

THA often is indicated to relieve pain and increase range of motion in patients with inflammatory arthritis and other collagen diseases, such as rheumatoid arthritis, juvenile idiopathic arthritis, juvenile rheumatoid arthritis or Still disease, psoriatic arthritis, and systemic lupus erythematosus, especially when involvement is bilateral. Arthroplasties of the knees and other joints may be necessary. Often these patients are generally disabled, having varying degrees of dermatitis, vasculitis, fragile skin, osteopenia, and poor musculature. In addition, they have been or are receiving corticosteroids and other immunosuppressive drugs; consequently, the risks of fracture during surgery and infection after surgery are greater. The femoral head may be partially absent because of erosion or osteonecrosis, and some degree of acetabular protrusion may be present. Limitation of motion of the cervical spine, upper extremities, and temporomandibular joints complicates the anesthesia, and fiberoptic techniques may be required to intubate the patient safely. Preoperative flexion and extension radiographs of the cervical spine to rule out subluxation are advisable if endotracheal intubation is planned. Additional corticosteroids also may be required in the perioperative period. Special handling of the limb is necessary so as not to fracture the femur or acetabulum or damage the skin. Preparation of the femur usually is easy because the canal is wide, but the cortex is thin and easily penetrated or fractured. Similarly,

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Proximal hooks

Bridges Distal teeth

FIGURE 3.76 Dall-Miles cable grip device for reattachment of trochanter. (Redrawn from Dall DM, Miles AW: Reattachment of the greater trochanter: the use of the trochanter cable-grip system, J Bone Joint Surg 65B:55, 1983.)

FIGURE 3.78 Accord trochanteric fixation plate. Trochanteric fragment is captured by proximal hooks. Plate extension is fixed to femur with cerclage cables and can be used to stabilize standard or extended trochanteric osteotomy. (Courtesy Smith & Nephew, Memphis, TN.)

Plane of osteotomy

Lesser trochanter

A

FIGURE 3.79 Osteotomy of anterior trochanter in direct lateral approach (see text). (Redrawn from Head WC, Mallory TH, Berklacich FM, et al: Extensile exposure of the hip for revision arthroplasty, J Arthroplasty 2:265, 1987.)

B

FIGURE 3.77 A, Fifteen years after Charnley total hip replacement, acetabular loosening and wear are apparent, but there is no evidence of femoral loosening. B, Exposure for acetabular revision was improved by trochanteric slide osteotomy, leaving femoral component intact. Reattachment was secured with cable fixation device (Dall-Miles). Wires are completely extramedullary and do not violate femoral cement mantle. Union was complete at 3 months.

the acetabulum is soft and easily reamed, and the medial wall is easily penetrated. Care must be taken not to fracture the anterior margin of the acetabulum or the femoral neck with a retractor used to lever the femur anteriorly. Severe osteopenia often makes cementless fixation more difficult, although successful use of cementless femoral and acetabular components has been reported in several series. Small components may be necessary, especially in patients with juvenile idiopathic arthritis, because the bones often are underdeveloped. Excessive femoral anteversion and anterior bowing of the proximal femur also are common in patients with juvenile

idiopathic arthritis. Extreme deformity may require femoral osteotomy. When operations on the hip and the knee are indicated, opinions vary concerning which joint should be treated first. Total knee replacement can be technically difficult in the presence of a markedly stiff arthritic hip joint. Conversely, a severe flexion contracture of the knee may predispose to dislocation of a total hip replacement. If involvement is equal, the hip arthroplasty probably should be done first. Most patients with rheumatoid arthritis, including young patients, have excellent pain relief and increased mobility after THA. Functional improvement as evidenced by hip scores may be limited, however, by other involved joints. Because these patients are relatively inactive, they are not physically demanding of the hip. Although the incidence of radiolucencies at 10 years is high, patients continue to function well with their reduced demands. In most series, radiolucencies and demarcation are more common around the acetabulum than the femur for cemented and cementless fixation. 

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A

B

FIGURE 3.80 Inadequate deepening of acetabulum. A and B, Degenerative arthritis with intraarticular osteophyte formation and lateral subluxation. Medial osteophytes were not removed, and socket remains in lateralized position. Superior coverage is provided only by large osteophyte.

OSTEONECROSIS

Osteonecrosis of the femoral head remains a challenge for diagnosis and for treatment. In some instances, the cause of the osteonecrosis can be identified as being associated with alcoholism, corticosteroids, systemic lupus erythematosus, renal disease, caisson disease, and various other diseases (sickle cell disease and Gaucher disease are discussed separately). Osteonecrosis may also be associated with coagulopathies and human immunodeficiency virus (HIV). In many patients with osteonecrosis of the femoral head, no disease process can be identified, however, and in these patients the osteonecrosis is classified as idiopathic. Up to 75% of patients with atraumatic osteonecrosis have radiographic or MRI evidence of bilateral hip disease at presentation. In the so-called idiopathic group and in patients with corticosteroid-related osteonecrosis without subchondral collapse or significant arthritic changes in the hip (stages I and II), symptoms can be relieved by core decompression, as advocated by Hungerford; by vascularized fibular grafting; or by valgus osteotomy with or without bone grafting (see Chapter 6). Hip fusion is not recommended because the involvement often is bilateral. Resurfacing arthroplasty is recommended only if the avascular segment constitutes a small segment of the femoral head (usually 30 degrees, adducted >10 degrees, or abducted to any extent), osteotomy to correct the position may be considered, especially in younger patients. Arthrodesis of one hip also applies greater mechanical stress to the opposite hip. THA may be indicated if a fused hip causes severe, persistent low back pain or pain in the ipsilateral knee or contralateral hip or if a pseudarthrosis after an unsuccessful fusion is sufficiently painful (Fig. 3.101). The history of the initial reason for the arthrodesis is important. Patients with prior infection require a thorough evaluation to rule out persistence. A careful assessment of the function of other joints, especially the lumbar spine, should be done, and leg-length discrepancy should be measured. Preoperative metal-subtraction CT can be helpful in determining the adequacy of bone stock and the presence of a pseudarthrosis. Function of the abductors is difficult to evaluate before surgery, but in some patients active contraction of these muscles can be palpated. Examination of the hip with the knee flexed helps differentiate the TFL from the abductor muscles. If the hip has been fused since childhood, and the trochanter appears relatively normal, the abductor muscles are probably adequate. If the bone around the hip has been grossly distorted by disease or by one or more fusion operations, the abductor muscles may be inadequate. The utility of electromyographic

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45°

A

A

B

FIGURE 3.101 A, Arthrodesis in 61-year-old woman who developed disabling back pain four decades after successful arthrodesis of hip. B, After conversion to hybrid total hip arthroplasty. Trochanteric osteotomy provided excellent exposure. Patient had persistent Trendelenburg limp after surgery, but back pain had diminished.

testing of abductor function or imaging modalities such as MRI has not been established. Weak abductor musculature is associated with poorer functional outcome. At surgery, a variety of screwdrivers, metal cutters, and other extraction instruments should be available to remove antiquated fixation devices. The conversion of a fused hip to a THA is safer and easier if the trochanter is osteotomized. Complete mobilization of the femur without trochanteric osteotomy is difficult, and the resulting inadequate exposure predisposes to component malposition, errors in femoral reaming, and fractures. In addition, the limb often is fixed in external rotation, and consequently the trochanter is posterior, overhanging the hip joint. Osteotomy of the neck can be difficult through a posterior approach unless the trochanter is osteotomized. The sciatic nerve often is displaced closer to the hip because the head-neck length is shorter than normal and the nerve may be fixed in scar tissue; for this reason, special care is taken to avoid damage to the nerve. Careful monitoring of tension on the nerve is necessary, and neurolysis may be indicated if the extremity is significantly lengthened. After the femoral neck has been exposed, it is divided with a saw. The location of the osteotomy is determined from bony landmarks or the position of previous fixation devices. The neck should not be divided flush with the side of the ilium because sufficient bone must be left to cover the superior edge of the cup (Fig. 3.102). After the neck has been divided, release of the psoas tendon, gluteus maximus insertion, and capsulotomy are necessary to mobilize the proximal femur. Usually the pelvic bone is sufficiently thick to cover the cup adequately if the site for acetabular preparation is chosen carefully. Distortion of the normal bony architecture may cause difficulty in locating the appropriate site for acetabular placement. Usually the anterior inferior iliac spine (AIIS) remains intact and serves as a landmark. Additionally, a retractor can be placed in the obturator foramen. Acetabular preparation is performed with conventional reamers, centering within the available bone to preserve the anterior and

B

FIGURE 3.102 Osteotomy of neck in conversion of fusion to total hip arthroplasty. A, Neck usually is short and should be osteotomized proximally at base of trochanter. B, Sufficient bone is left on pelvic side for full coverage of cup at inclination of approximately 45 degrees and without penetrating medial cortex of pelvis.

posterior columns. Intraoperative fluoroscopy or radiograph is helpful early in the acetabular preparation to ensure that the position of the reamer is as expected. The femoral canal is prepared in the usual manner, taking into account any deformity from prior disease or femoral osteotomy. Trochanteric fixation is accomplished by standard techniques (see Figs. 3.74 to 3.76). If the abductors are markedly atrophic or deficient, a constrained (see Fig. 3.34) or dual mobility (see Fig. 3.35) acetabular component should be considered. After the procedure has been completed, the patient is placed supine. If the hip cannot be abducted 15 degrees because the adductors are tight, a percutaneous adductor tenotomy is done through a separate small medial thigh incision. The extremity usually is lengthened by the procedure and corrects prior flexion deformity. Lengthening usually is desirable because in most instances the limb has been shortened by the original disease, by the procedure for fusing the hip, or by the flexion deformity. The postoperative treatment is routine, but the hip should be protected for at least 3 months by use of crutches and then by use of a cane while the hip abductors and flexors are being rehabilitated. Patients rarely regain flexion to 90 degrees, but they achieve sufficient motion to relieve back symptoms and permit sitting and walking and tying shoes. Walking ability usually is improved, but in patients with inadequate abductor function the gait pattern may worsen, and the support of a cane or walker may be required even if the patient did not use one before conversion to arthroplasty. Most patients have some degree of residual abductor weakness and limp, although this tends to improve over several years. The complication rate for conversion of an arthrodesis to an arthroplasty is high. In the Mayo Clinic series of Strathy and Fitzgerald, 33% of patients experienced failure within 10 years because of loosening, infection, or recurrent dislocation. Patients with a spontaneous ankylosis fared much better than patients who had a prior surgical arthrodesis. Jauregui et al. conducted a meta-analysis of 1104 hip fusion conversions and reported 5.3% had infection, 2.6% developed instability, 6.2% had loosening, 4.7% with nerve complications, and

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B

A

FIGURE 3.103 A, Extensive Paget disease of acetabulum and proximal femur in 82-year-old man. Note protrusio deformity and varus femoral neck. B, After total hip replacement. Acetabulum required autogenous bone graft from femoral head. Considerable blood loss occurred during acetabular preparation. Cementless acetabular component appears bone ingrown 5 years after surgery.

13.1% experienced abductor-related complications. Celiktas et al. reported a series of 28 patients operated through a posterior approach without trochanteric osteotomy. Although their procedures were technically feasible, five patients had intraoperative trochanteric fracture. 

METABOLIC DISORDERS PAGET DISEASE

Patients with Paget disease may have degenerative arthritis in one or both hips, varying degrees of protrusio acetabuli, varus deformity of the neck and proximal femur, and anterolateral bowing of the shaft (Fig. 3.103). In addition, incomplete (stress) fractures may develop on the convex side of the femoral shaft. These fractures, the metabolic disease alone, secondary sarcoma formation, and radicular problems referable to the lumbar spine all can cause hip pain, in addition to the hip arthritis, and it may be difficult to differentiate the sources of pain. Preoperative medical management with bisphosphonates and calcitonin can help control pain and decrease perioperative blood loss. If the disease is active, the administration of calcitonin before and after surgery is advisable to decrease the osteoclastic activity and possibly to reduce the risk of loosening as a result of postoperative bone resorption. The deformed proximal femoral bone may be osteoporotic or markedly dense, and these changes can cause technical difficulties. Consequently, anteroposterior and lateral radiographs of the hip and femoral shaft should be evaluated carefully before surgery to determine the extent of bowing and the presence of lytic or dense lesions. Usually the anterolateral bowing is not a problem in reaming the canal or positioning the stem because the medullary canal is wide. If the deformity is considerable, however, a femoral osteotomy may be needed for stem placement. The presence of dense intramedullary bone can make identification and opening of the canal difficult. A high-speed burr and intraoperative use of

fluoroscopy are helpful when this is recognized on preoperative radiographs. Bleeding can be excessive, especially in patients with osteoporotic bone. The lack of a dry bone bed can reduce cement interdigitation in the femur and the acetabulum and compromise fixation. Conversely, cementless fixation has proven durable despite concerns that altered bone morphology may prevent osseointegration. The results of THA for painful arthritis and for displaced femoral neck fractures in Paget disease are encouraging, with a reported 7- to 10-year survival rate of 86%. The results of internal fixation of these fractures and of endoprostheses for fractures or arthritis in this disease have been unsatisfactory. THA has become the procedure of choice. Heterotopic bone formation has been reported as a common postoperative complication, and prophylactic measures to reduce its formation seem warranted. 

GAUCHER DISEASE

Patients with the chronic nonneuropathic form of Gaucher disease may have osteonecrosis of the femoral head bilaterally, and if it is sufficiently painful, they may require a THA. Osteonecrosis of the femoral head may produce the first symptoms that suggest the diagnosis of Gaucher disease. The disease is characterized, however, by osteopenia, with areas in which the trabeculae have a moth-eaten appearance and patchy areas of sclerosis; much of the bone marrow may be replaced by Gaucher cells. Because the medullary canal usually is wide, implant fixation even with cement is difficult, and the femur can be fractured easily. The disease often is characterized by recurring, nonspecific bone pain, making evaluation of some postoperative symptoms difficult. Anemia and thrombocytopenia may complicate surgical interventions. Many patients have required splenectomy, and infections are a common complication of Gaucher disease. Other complications include excessive intraoperative and postoperative

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CHAPTER 3  ARTHROPLASTY OF THE HIP hemorrhage and a high incidence of loosening because of the continued Gaucher cell proliferation and erosion of bone. Enzyme replacement therapy may ameliorate the osseous problems associated with the disease. 

SICKLE CELL ANEMIA

Patients with sickle cell anemia and sickle cell trait may develop painful osteonecrosis of the femoral head. The process can be bilateral. Radiographs may reveal a large collapsed avascular area or an arthritic process caused by small focal areas of osteonecrosis near the articular surface. In the past, the life expectancy of patients with the SS form of sickle cell anemia was thought to be short (approximately 30 years), but with improvements in medical management and antibiotics, they may live much longer. Although patients with sickle cell trait also develop osteonecrosis, they do so less often than patients with sickle cell disease. Many more patients have the trait than the disease, however. Patients with sickle cell anemia may require transfusions before surgery, and transfusion reactions owing to alloimmunization are more frequent. Many patients are chronically dependent on narcotic analgesics, and epidural anesthesia and multimodal pain management techniques are advisable. Cardiopulmonary care must be aggressively managed, and perioperative hypoxia, acidosis, and dehydration must be avoided. A multidisciplinary approach to the medical management of sickle cell patients reduces morbidity. Acetabular bone quality may be poor and a variable degree of protrusio deformity may be present, making hip dislocation more difficult. Bone grafting of acetabular defects may be required (see section on protrusio acetabuli). Areas of femoral intramedullary sclerosis from prior infarction may be manifest as “femur within femur” on preoperative radiographs. In our experience, this problem is underestimated by preoperative radiographs, and at surgery the canal may be completely obstructed by very dense bone. Major technical problems in reaming the canal must be anticipated, and the risk of femoral fracture and cortical perforation is high. Use of fluoroscopy is helpful for centering instruments in the femoral canal, and reaming over a guidewire is inherently safer. Preliminary removal of sclerotic bone with a high-speed burr also makes broaching easier. Although these patients are more susceptible to Salmonella infections, the literature does not support this as being a pathogen in postoperative sepsis of hip arthroplasty. Specific prophylaxis for Salmonella does not seem to be warranted. Because of functional asplenia, patients with sickle cell anemia are prone to developing hematogenous infection of the hip after surgery. Aggressive antibiotic management is indicated when the possibility of hematogenous infection exists. The ESR is of no value in determining whether a patient with sickle cell disease has an inflammatory process. Pain resulting from a sickle cell crisis caused by vascular occlusion often presents a problem in determining whether a particular pain is caused by infection. Complications such as excessive bleeding, hematoma formation, and wound drainage are common after arthroplasty in patients with sickle cell disease; complications have been reported in nearly 50% of THAs in sickle cell patients. Because no other option yields consistently superior results, the procedure is still justified in patients with severe pain and disability. Patients should be advised, however, of the increased

risk of complications imposed by their disease. Recent series using cementless fixation have been somewhat more encouraging. Ilyas et al. reported 10-year survivorship of 98% using cementless femoral and acetabular components, with deep infection in 6.77%. 

CHRONIC RENAL FAILURE

Osteoporosis, osteonecrosis, and femoral neck fracture are common sequelae of chronic renal failure. With the institution of hemodialysis and the success of renal transplantation, an increasing number of these patients are becoming candidates for hip arthroplasty. Poor wound healing, infection, and an array of general medical complications related to the disease process can be anticipated. Sakalkale, Hozack, and Rothman reported THA in 12 patients on long-term hemodialysis. There was an early complication rate of 58%, and infection developed in 13%. Longevity was limited after surgery, and the authors recommended limiting the procedure to patients with a longer life expectancy. Lieberman et al. reported their results after THA in 30 patients who had renal transplants and 16 who were being treated with hemodialysis. Patients with transplants had postoperative courses similar to other patients with osteonecrosis, whereas in the patients who were being treated with hemodialysis 81% had poor results and 19% developed infection. These authors recommended limiting hip arthroplasty to patients who are expecting renal transplant or who have already had successful transplantation. In contrast, a series from the Mayo Clinic found a higher cumulative revision rate in transplant patients, with complications in 61%. A high rate of loosening of cemented femoral components was noted. More encouraging results have been reported with cementless, extensively porous-coated implants. Nagoya found predictable bone ingrowth with no infections in 11 patients on long-term hemodialysis with average follow-up of more than 8 years. 

HEMOPHILIA

Hemophilic arthropathy involves the hip joint far less often than the knee and elbow. Consequently, there is a paucity of information specific to hip arthroplasty. When hip involvement develops before skeletal maturity, valgus deformity of the femoral neck, flattening of the femoral head, and a variable degree of acetabular dysplasia are present. The radiographic appearance is similar to that of LCPD. A multidisciplinary approach is essential for surgical treatment of hemophilic arthropathy. Ready access to a well-managed blood bank and an experienced hematology staff are requisites; for this reason, arthroplasty in hemophilic patients generally is done only in specialized centers. Patients with circulating antibodies to clotting factor replacements (inhibitors) are not considered suitable candidates for surgery because of the risk of uncontrollable hemorrhage. In a study of the Nationwide Inpatient Sample, Kapadia et al. reported transfusions in 15.06% of hemophiliacs compared to 9.84% in matched controls following lower extremity arthroplasty. Complications occur frequently in these patients. In a multicenter study, Kelley et  al. reported that 65% of cemented acetabular components and 44% of cemented femoral components had radiographic evidence of failure at a mean follow-up of 8 years. Nelson et al. found similar failure rates in a long-term study of patients from a single

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS center. Results have been better with modern cementless implants. Carulli et al. reported no failures or complications at mean follow-up of 8.1 years in 23 patients with a mean age of 40.6 years. Late hematogenous infection may be a significant problem, and the risk increases if patients previously exposed to HIV through factor replacements develop clinical manifestations of acquired immunodeficiency syndrome. Enayatollahi et al. reported infection in 10.98% of patients with both HIV and hemophilia versus 2.28% in patients with HIV only. 

INFECTIOUS DISORDERS PYOGENIC ARTHRITIS

Most patients with a history of pyogenic arthritis of the hip who are considered candidates for THA had the hip joint infection in childhood and had either a spontaneous or surgical hip fusion or developed a pseudarthrosis of the hip. Pyogenic arthritis of the hip in adults is rare except after internal fixation of fractures. Arthroplasty may be considered in an adult whose hip was fused by a childhood pyogenic infection and in whom inflammation has not been evident for many years. A solid fusion with a uniform trabecular pattern crossing the joint usually indicates the absence of residual infection. Focal areas of decreased density and some sclerosis and irregularity of the trabeculae crossing the joint line may signify a residual focus of infection, however. Tang et  al. found MRI to be 100% sensitive in showing the presence of active infection in patients with prior osteomyelitis. Determination of ESR and CRP levels, hip joint aspiration, bone biopsy, and radionuclide scanning all may play a role in the preoperative evaluation. Intraoperative frozen sections of periarticular tissues also should be obtained. When any of these studies points to residual infection around the hip, a two-stage procedure is appropriate. Often the limb is shortened as a result of partial destruction of the femoral head and neck and the acetabulum. The flexed and adducted position of the hip adds to the apparent shortening. The femur may be hypoplastic with anteversion of the femoral neck and variable degrees of resorption of the femoral head. Deep scarring may be present as a result of multiple incision and drainage procedures and sinuses around the hip. If present, previous incisions should be used, and prior sinus tracks should be completely excised. Lack of subcutaneous tissues over the trochanter and in the area of the proposed incision may require rotation of a skin flap before the THA. In a group of 44 patients who underwent THA after pyogenic arthritis in childhood, Kim found no reactivations of infection despite the use of acetabular allografts in 60% of the patients. Perioperative femoral fracture was common because many of these patients had a small, deformed proximal femur. In a larger series of 170 patients from the same institution, there were no recurrent infections when the period of quiescence had been at least 10 years. Operative difficulties were frequent, however, and polyethylene wear and implant loosening were common late complications. Similarly, Park et al. reported that poor results in this population were attributed to anatomic abnormalities that had developed as a result of infection rather than recurrence of infection following arthroplasty. 

TUBERCULOSIS

The hip is the second most common site of osseous involvement of tuberculosis following the spine, resulting in severe cartilage and bone destruction, limb shortening, and instability. The diagnosis should be considered in patients who come from a country in which the disease is prevalent, in patients with a history of having been in a spica cast as a child, in patients being treated for acquired immunodeficiency syndrome, and in patients with undiagnosed arthritis of the hip. Tuberculous bacilli are fewer in number in bone infections than in infected sputum, making the diagnosis of tuberculous osteomyelitis difficult. A longer period of chemotherapy has been recommended when hip arthroplasty is performed in the presence of active tuberculous arthritis. Mycobacterium tuberculosis has little biofilm and adheres poorly to implants. Many patients with reactivation of tuberculous infections after THA can be treated with debridement and drug therapy with retention of the prosthesis. Because of the emergence of drug-resistant strains of tuberculosis, preoperative tissue biopsy with culture and sensitivity are helpful in selecting the optimal chemotherapeutic agents. Most patients are candidates for a single-stage procedure. In a systematic review of the available literature, Tiwari et al. identified 226 patients in whom antituberculosis treatment was administered for 2 weeks preoperatively and continued for 6 to 18 months following hip arthroplasty. Only three patients had reactivation of infection at mean follow-up of 5.48 years. The presence of a sinus track often is indicative of superinfection with S. aureus, and a two-stage procedure is indicated in these patients. Radical debridement of all infected tissue is required in either scenario. Both cemented and cementless fixation have been successful at mid-term follow-up. 

TUMORS

Possible candidates for THA include patients with (1) metastatic tumors with a reasonable life expectancy, (2) some lowgrade tumors, such as chondrosarcoma and giant cell tumor, and (3) benign destructive lesions, such as pigmented villonodular synovitis. For patients with primary lesions, curing the disease, and not restoration of function, should be the goal of surgery. Consequently, careful planning to determine the amount of tissue to be resected may require a bone scan, CT, and MRI. The surgical approach must be more extensive than usual to ensure complete excision of the tumor. A conventional THA may suffice, however, if only a limited amount of the acetabulum or the femoral head and neck must be resected to excise the tumor and a margin of normal tissue. If the greater trochanteric and subtrochanteric areas are resected, the hip may be unstable because reattaching the abductor muscles is difficult. An extra-long femoral component may be necessary because of other lesions more distal in the femoral shaft. A custom-made component or segmental replacement stem can be used (see Fig. 3.29); the gluteal muscles are sutured to holes made in the component for this purpose. An allograft-prosthesis composite with a long stem is an option in young patients. Cement fixation within the graft and a step-cut at the junction of the graft and host bone provide stability. The acetabulum can be reconstructed with cement, with additional support provided by a reinforcement

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CHAPTER 3  ARTHROPLASTY OF THE HIP ring or cage (see Fig. 3.36) or by threaded Steinmann pins inserted through the iliac wing into the acetabulum. 

NEUROMUSCULAR DISORDERS

Patients with chronic neuromuscular disorders who come to hip arthroplasty usually have increased muscle tone or spasticity. Spasticity may be congenital, as with cerebral palsy, or acquired through brain or spinal cord injury. Acquired spasticity may be complicated by the presence of heterotopic ossification about the hip. Patients become candidates for THA because of fracture, end-stage hip arthritis, or painful subluxation. Although this group encompasses a broad range of congenital and acquired diseases and syndromes, certain management principles are applicable to all. Patients with generalized neurologic problems are at greater risk for complications, and careful attention must be paid to care of the skin, pulmonary function, and urinary tract to prevent sepsis at these sites. Early mobilization, at least to a chair and preferably to weight-bearing status, prevents further muscular deterioration. Patients with retained motor function and intact cognition have better potential for recovery of mobility. Combined flexion and adduction contractures are common, but their presence may not be appreciated when a patient has an acute fracture. This combination of deformities predisposes to postoperative dislocation, especially when surgery is performed through a posterior approach. A direct anterior or anterolateral approach may be preferable, although these approaches are less extensile when excision of heterotopic ossification is needed. Release of the anterior capsule and psoas and percutaneous adductor tenotomy all may be required. The degree of contractures usually is more severe in patients with congenital neurologic disorders. Placement of the acetabular component in additional anteversion also makes the hip more stable. If the stability of the hip during surgery is unsatisfactory, or if the patient’s muscular control of the hip is insufficient to maintain appropriate postoperative precautions, a hip spica cast probably should be worn for 4 to 6 weeks until the soft tissues have healed sufficiently to stabilize the joint. Occasionally, a constrained acetabular component may be necessary to prevent postoperative dislocation. Other tenotomies may be required to achieve knee extension and a plantigrade foot. In a series of 39 patients with cerebral palsy, Houdak et  al. reported no difference in the rate of reoperation, survivorship, and complications compared to patients with osteoarthritis. Dislocations occurred in 7%. Patients with paralytic conditions, such as the residuals of poliomyelitis, may develop hip arthritis in either the affected limb or a normal contralateral hip. Dysplasia may be present on the paralytic side, and overuse degenerative arthritic changes predominate on the nonparalytic side. Yoon et al. found that polio patients often had some residual pain after hip arthroplasty, possibly caused by muscular weakness inherent to the disease. 

COMPLICATIONS Medical and surgical complications can occur after THA and exert a significant effect on patient satisfaction and overall outcome of the procedure. Prevention of complications should be a consistent focus of all involved stakeholders.

FIGURE 3.104 CT scan shows fluid within the iliopsoas muscle sheath consistent with hematoma secondary to impingement from acetabular component. (From Bartelt RB, Sierra RJ: Recurrent hematomas within the iliopsoas muscle caused by impingement after total hip arthroplasty, J Arthroplasty 26:665, 2011.)

Prompt diagnosis and effective treatment are critical for a successful result.

MORTALITY

According to a 2014 meta-analysis, the 30-day mortality rate was 0.3% for primary THA and the 90 day rate was 0.65%. Increased mortality rates were associated with advanced age, male gender, and medical comorbidities, particularly cardiovascular disease. Although careful preoperative medical evaluation is warranted in all patients, special attention should be directed to patients with these risk factors. 

HEMATOMA FORMATION

Careful preoperative screening should identify patients with known risk factors for excessive hemorrhage, including antiplatelet, antiinflammatory, or anticoagulant drug therapy; herbal medication use; blood dyscrasias and coagulopathies; and family or patient history of excessive bleeding with previous surgical procedures. The most important surgical factor in preventing hematoma is careful hemostasis. Common sources of bleeding are (1) branches of the obturator vessels near the ligamentum teres, transverse acetabular ligament, and inferior acetabular osteophytes, (2) the first perforating branch of the profunda femoris deep to the gluteus maximus insertion, (3) branches of the femoral vessels near the anterior capsule, and (4) branches of the inferior and superior gluteal vessels. The iliac vessels are at risk from penetration of the medial wall of the acetabulum and removal of a medially displaced cup. Bleeding from a large vessel injury usually becomes apparent during the operation (see section on vascular injuries). Late bleeding (1 week postoperatively) may occur from a false aneurysm or from iliopsoas impingement (Fig. 3.104). Arteriography may be required for identification of a false aneurysm along with possible embolization. Acetabular revision may likewise be necessary to correct iliopsoas impingement. Excessive hemorrhage leading to hematoma formation uncommonly requires surgical intervention. Most patients can be managed by dressing changes, discontinuation of

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS anticoagulants, treatment of coagulopathy, and close observation of the wound. Indications for surgical treatment of hematoma include wound dehiscence or marginal necrosis, associated nerve palsy, and infected hematoma. Evacuation of the hematoma and achievement of meticulous hemostasis should be accomplished in the operating room. The hematoma should be cultured to assess possible bacterial contamination, and antibiotics should be continued until these culture results become available. Debridement of necrotic tissue as needed and watertight closure also are required. Closed suction drainage seems warranted in this setting to avoid a recurrence. 

HETEROTOPIC OSSIFICATION

Heterotopic ossification varies from a faint, indistinct density around the hip to complete bony ankylosis. Calcification can be seen radiographically by the third or fourth week; however, the bone does not mature fully for 1 to 2 years. The classification of Brooker et al. is useful in describing the extent of bone formation: Grade I: islands of bone within soft tissues Grade II: bone spurs from the proximal femur or pelvis with at least 1 cm between opposing bone surfaces Grade III: bone spurs from the proximal femur or pelvis with less than 1 cm between opposing bone surfaces Grade IV: ankylosis Risk factors for heterotopic ossification include history of heterotopic ossification, diagnosis of hypertrophic osteoarthritis, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis (DISH), or Paget disease, male gender, and African-American ethnicity. Surgical technique may play a role in the development of heterotopic ossification. Anterior and anterolateral approaches carry a higher risk of heterotopic ossification than transtrochanteric or posterior approaches. Most who develop heterotopic ossification are asymptomatic; however, restricted range of motion and pain may occur in patients with more severe Brooker grade III or IV ossification. Routine prophylaxis against heterotopic ossification is not recommended for all patients but is warranted in high-risk groups. Prophylaxis may include low-dose radiation and nonsteroidal antiinflammatory drugs (NSAIDs). Preoperative and postoperative radiation regimens with doses as low as 500 cGy have been successful. In a multicenter evaluation of radiation prophylaxis, failures occurred more commonly in patients treated more than 8 hours preoperatively or more than 72 hours postoperatively. Preoperative treatment should result in less patient discomfort than in the early postoperative period. Radiation exposure is limited to the soft tissues immediately around the hip joint, and ingrowth surfaces must be appropriately shielded (Fig. 3.105). NSAIDs reduce the formation of heterotopic bone in many studies. Historically, nonselective cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) inhibitors for 6 weeks have been recommended, although courses of administration of 7 days are successful. Compliance is limited by medical contraindications to these drugs and patient intolerance. Multiple meta-analyses comparing COX-1 and COX-2 inhibitors showed no difference in efficacy in preventing heterotopic ossification. In light of a more favorable safety profile

FIGURE 3.105 Anteroposterior radiograph showing radiation portals for total hip arthroplasty. Potential ingrowth portions of femoral and acetabular components were spared. (From Hashem R, Tanzer M, Rene M, et al: Postoperative radiation therapy after hip replacement in high-risk patients for the development of heterotopic bone formation, Cancer Radiother 15:261, 2011.)

for the COX-2 inhibitors, they have been recommended for HO prophylaxis. An operation to remove heterotopic bone is rarely indicated because associated pain usually is not severe and excision is difficult, requiring extensile exposure. The ectopic bone obscures normal landmarks and is not easily shelled out of the surrounding soft tissues. Substantial blood loss can be anticipated. Decreased technetium bone scan activity indicates that the heterotopic bone is mature, allowing for reliable excision. Radiation and NSAIDs have been used successfully to prevent recurrence. Range of motion should improve, but pain may persist. 

THROMBOEMBOLISM

Thromboembolic disease is one of the more common serious complications following THA. In early reports of hip arthroplasty without routine prophylaxis, venous thrombosis occurred in 50% of patients, and fatal pulmonary embolism occurred in 2% (Johnson et al.). More recently, a meta-analysis of studies including patients who were anti-coagulated prophylactically after surgeries between 1995 and 2015 found an estimated PE rate of 0.21%, which remained consistent across this time period. Thromboembolism can occur in vessels in the pelvis, thigh, and calf. Of all thromboses, 80% to 90% occur in the operated limb. The temporal relationship of deep vein thrombosis (DVT) and PE to surgery is controversial. The peak prevalence of DVT varies among studies, with a range of 4 to 17 days after surgery reported. With shorter hospital stays, more thromboembolic events occur after discharge. The best method of prophylaxis for thromboembolism is debatable. Currently, mechanical and pharmacologic modalities are used. For patients undergoing elective THA, the American College of Chest Physicians (ACCP) recommends

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CHAPTER 3  ARTHROPLASTY OF THE HIP one of the following anticoagulant agents: low molecularweight heparin (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin, adjusted-dose warfarin, aspirin, or intermittent pneumatic compression. For patients with high risk of bleeding, mechanical prophylaxis with intermittent pneumatic compression or no prophylaxis should be used. A minimum of 10 to 14 days of prophylaxis is preferred, with a period of up to 35 days also being suggested. In 2011, the American Academy of Orthopaedic Surgeons (AAOS) published a revised clinical practice guideline regarding the prevention of venous thromboembolic disease after hip or knee arthroplasty. These recommendations stratify patients based on their risk of thromboembolism and major bleeding. Previous venous thromboembolism (VTE) is considered a risk factor for recurrence, whereas bleeding disorders or active liver disease are associated with increased risk for bleeding complications. After assessment of these risk factors, prophylactic measures are tailored accordingly. Patients who are not at increased risk for VTE or bleeding complications should receive pharmacologic and/or mechanical prophylaxis. Those with a history of VTE require combined pharmacologic and mechanical prophylactic measures, whereas patients with increased bleeding risk are covered with mechanical devices only. The continuation of prophylaxis after the patient has been discharged presents a dilemma. With the ongoing emphasis on cost containment and reducing the length of hospitalization, many patients are discharged at a time when they remain at elevated risk for developing DVT. If anticoagulants are to be continued after discharge, preparation must be made for monitoring their effects. Routine clinical evaluation for wound issues and patient education regarding signs and symptoms of DVT, PE, and bleeding complications are required. Our current practice includes the use of aspirin along with mechanical compression devices during the initial stay for low-risk patients. Aspirin is continued for up to 5 weeks postoperatively. High-risk patients, particularly those with previous history of thromboembolism, are treated with LMWH or apixaban for up to 5 weeks. 

NEUROLOGIC INJURIES

An analysis of the literature by Goetz et  al. determined the risk of nerve palsy after primary THA for arthritis to be 0.5%, for hip dysplasia 2.3%, and 3.5% for revision surgery. The sciatic, femoral, obturator, lateral femoral cutaneous, and superior gluteal nerves can be injured by direct trauma, traction, pressure, positioning, ischemia, and thermal injury. The sciatic nerve is particularly susceptible to injury during revision surgery because it may be bound within scar tissue, which places it at risk during the exposure. Injudicious retraction of firm, noncompliant soft tissues along the posterior edge of the acetabulum can cause a stretch injury or direct contusion of the nerve. Exposure of the sciatic nerve during a posterior approach is not necessary routinely but may be advisable if the anatomy of the hip is distorted. The nerve may be displaced from its normal position and tethered by scar tissue along the posterior column. If so, it is carefully exposed, mobilized, and protected during the remainder of the operation. Usually it can be identified more easily in the normal tissue proximal or distal to the scar by the characteristic loose fatty tissues that surround it. When the soft tissues from the posterior aspect

of the femur are being released, the dissection must remain close to the femur, especially in revision procedures. If an anchoring hole for a cemented acetabular component penetrates the medial or posterior cortex, a wire mesh retainer or bone graft should be inserted to prevent extrusion of the cement into the sciatic notch. Careful retractor placement during femoral and acetabular preparation is also mandatory. The association between limb lengthening and sciatic nerve palsy has been studied with varying conclusions. Edwards et al. correlated the amount of lengthening with the development of sciatic palsy. Injury to the peroneal branch occurred with lengthenings of 1.9 to 3.7 cm. In comparison, complete sciatic palsy occurred with lengthenings of 4 to 5.1 cm. Other authors have questioned the importance of lengthening alone in relation to postoperative sciatic nerve palsy. Nercessian, Piccoluga, and Eftekhar reported 1284 Charnley THAs with lengthening of up to 5.8 cm. Laceration of the sciatic nerve accounted for the only nerve palsy in this group. Eggli, Hankemayer, and Müller reviewed 508 total hip arthroplasties performed for congenital dysplasia of the hip and found no correlation between the amount of lengthening and nerve palsy. They concluded that these palsies were the result of mechanical trauma rather than lengthening alone. Modular head exchange and/or femoral shortening have been used to treat sciatic palsy attributed to overlengthening. Silbey and Callaghan reported one patient with postoperative sciatic nerve palsy that resolved with early exchange of a modular head to one with a shorter neck length. Sakai et al. similarly noted complete resolution of postoperative sciatic nerve palsy after shortening of the calcar and modular femoral neck. Sciatic nerve palsy also has been reported as a result of subgluteal hematoma formation, which may occur in association with prophylactic or therapeutic anticoagulation. Subgluteal hematoma should be suspected in patients with pain, tense swelling, and tenderness in the buttock and thigh, along with evidence of a sciatic nerve deficit. Early diagnosis and prompt surgical decompression are imperative. Dislocation in the perioperative period may injure the sciatic nerve by direct contusion or by stretch. The status of the sciatic nerve always should be documented before any reduction maneuvers are performed. Reduction requires gentle techniques with general anesthesia if necessary. Postoperative positioning can cause isolated peroneal nerve palsy. Triangular abduction pillows that are secured to the lower extremities with straps can cause peroneal nerve compression if applied tightly over the region of the fibular neck. Such straps should be applied loosely and positioned to avoid this area. Patients with persistent sciatic or peroneal palsy should have the foot supported to prevent fixed equinus deformity. In most patients, partial function returns, although complete recovery is uncommon. Studies with follow-up of more than 1 year show complete recovery in 20% to 50% of patients. Late exploration of the sciatic nerve may be considered if some recovery is not present in 6 weeks, or if direct compression is suspected. CT of the acetabulum is helpful in delineating the position of an offending object. Chughtai et  al. found improved outcomes with sciatic nerve decompression compared to nonoperative management in both a series of

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Posterior

Anterior

Safe area

FIGURE 3.106 Safe zone for splitting of the gluteus medius muscle 5 cm proximal to greater trochanter. (Redrawn from Jacobs LG, Buxton RA: The course of the superior gluteal nerve in the lateral approach to the hip, J Bone Joint Surg 71A:1239, 1989.)

19 patients treated at their institution and in a review of the literature. Because injury to the femoral nerve is less common and is easily overlooked in the early postoperative period, diagnosis often is delayed. The femoral nerve lies near the anterior capsule of the joint and is separated from it only by the iliopsoas muscle and tendon. It can be injured by retractors placed anterior to the iliopsoas or during anterior capsulectomy. Hematoma within the iliacus muscle, extruded acetabular cement, and correction of severe flexion contracture are other known causes of femoral nerve palsy. Fleischman et al. reported femoral nerve palsy in 0.21% of patients, with a 14.8-fold increased incidence in patients operated on through an anterior approach, either direct anterior or anterolateral. While significant recovery did not begin until greater than 6 months postoperatively, 75% had complete resolution of motor involvement. Affected patients should wear a knee immobilizer or hinged knee brace with drop-locks for walking to prevent knee buckling while the quadriceps remains weak. Similarly, obturator nerve injury may occur with extruded cement, mechanical injury secondary to retractors, or prominent implants such as screws placed in the anteroinferior quadrant (see section on vascular injuries). Persistent groin pain may be the only symptom. The superior gluteal nerve is most susceptible to injury with anterolateral approaches that split the gluteus medius muscle. A safe zone has been described for splitting the muscle 5 cm proximal to the greater trochanter (Fig. 3.106). Other maneuvers that may injure the superior gluteal nerve include vigorous acetabular retraction for component insertion and extreme leg positioning for femoral preparation. Abductor

weakness with a Trendelenburg gait may result from superior gluteal nerve injury. The LFCN is vulnerable to injury when the direct anterior approach is utilized, as it lies in the subcutaneous tissue of the anterolateral thigh after emerging from under the inguinal ligament. Starting the skin incision 3 cm distal and lateral to the ASIS and incising the tensor sheath with lateral retraction of the TFL muscle may protect the nerve somewhat. Nonetheless, the incidence of LFCN injury has been reported in up to 81% of cases using the direct anterior approach. 

VASCULAR INJURIES

Vascular complications as a result of THA are rare (0.04% primary THA, 0.2% revision); however, they can pose a threat to the survival of the limb and the patient. Mortality rates after these injuries range from 7% to 9%, with 15% risk of amputation and 17% chance of permanent disability. Risk factors for vascular injury include revision surgery and intrapelvic migration of components. Vessels can be injured by laceration, traction on the limb, retraction of the surrounding soft tissues, or direct trauma by components such as screws, cement, cables, antiprotrusio cages or rings, threaded acetabular components, or structural allografts. In general, the measures taken to avoid injury to the femoral nerve also protect the accompanying femoral artery and vein. An anterior retractor should be blunt tipped, carefully placed on the anterior rim, and not allowed to slip anteromedial to the iliopsoas. Care must be taken in releasing the anterior capsule, especially in the presence of extensive scarring, or in the correction of a flexion contracture. Removal of soft tissue and osteophytes from the inferior aspect of the acetabulum can cause bleeding from the obturator vessels. Penetration of the medial wall of the acetabulum while reaming or intrusion of cement into the pelvis may injure the iliac vessels. These vessels usually are separated from the medial cortex of the pelvis by the iliopsoas muscle, but in some patients this muscle is thin. The use of transacetabular screws for socket fixation places the pelvic vessels at risk for injury. Wasielewski et al. described the acetabular quadrant system for guidance in the placement of these screws. A line drawn from the ASIS through the center of the acetabulum and a second line perpendicular to the ASIS line divide the acetabulum into four quadrants (see Fig. 3.46). The external iliac vein lies adjacent to the bone of the anterosuperior quadrant, and the obturator vessels and nerve are in close proximity to the pelvic bone in the anteroinferior quadrant. Thinner bone, lack of soft-tissue interposition, and relative immobility of the vessels make them more susceptible to injury. The use of a short drill bit and meticulous technique are mandatory whenever screws are placed in the anterior quadrants. Screw placement should be limited to the posterior quadrants whenever possible. The posterosuperior quadrant, which roughly corresponds to the superior acetabulum between the ASIS and greater sciatic notch, allows for the longest screws and contains the best bone for fixation. The posteroinferior quadrant requires shorter screws. Although the superior gluteal vessels and sciatic nerve are potentially at risk from screws placed through the posterosuperior quadrant, the drill bit and screw tip can be palpated through the sciatic notch to protect these structures from injury. Excessive bleeding encountered during placement of the acetabular component or screw

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FIGURE 3.107 False aneurysm in 67-year-old woman who had two total hip revisions and continued to bleed intermittently from operative site for approximately 32 weeks after surgery. Arteriogram showed false aneurysm (arrow). Suture inserted to close fascia had penetrated wall of branch of superior gluteal artery. Aneurysm was ligated proximally and distally and excised.

insertion may require retroperitoneal exposure and temporary clamping of the iliac vessels to prevent additional blood loss. Emergent vascular surgical consultation may be required intraoperatively. Arteriography and transcatheter embolization also have been used to control excessive postoperative intrapelvic bleeding. Late vascular problems include thrombosis of the iliac vessels, arteriovenous fistula, and false aneurysms. False aneurysms have been reported especially in patients with postoperative hip infections, after migration of threaded acetabular components, and from the use of pointed acetabular retractors. This diagnosis should be considered in patients who have persistent bleeding from the incision or a pulsatile mass (Fig. 3.107). Because of the risk of vascular injury associated with removal of a markedly protruded acetabular component, arteriography, contrast-enhanced CT scan, or both may be considered before undertaking this type of revision. In addition, the patient’s abdomen should be prepared for surgery, and the assistance of a vascular surgeon may be required. The contralateral limb is at risk for vascular injury because of errors in positioning and pelvic immobilization. Pelvic positioning devices should apply pressure to the pubic symphysis or iliac spines, and pressure over the femoral triangle should be avoided. 

LIMB-LENGTH DISCREPANCY

Ideally, the leg lengths should be equal after THA, but it may be difficult to determine this accurately at the time of surgery. Lengthening may result from insufficient resection of bone from the femoral neck, use of a prosthesis with a neck that is too long, or inferior displacement of the center of rotation

FIGURE 3.108 Total hip arthroplasty for osteonecrosis in 47-year-old man. Femoral head was reconstructed level with tip of trochanter. Oversized acetabular component brought hip center more inferior and overlengthened limb 1 cm despite correct positioning of femoral head.

of the acetabulum (Fig. 3.108). Proximal femoral morphology can also play a role, as patients with a high femoral cortical index have increased incidence of lengthening, while low femoral cortical index is associated with shortening (Fig. 3.109). In a survey of 1114 primary THA patients, 30% reported a perceived limb length discrepancy. Of these, only 36% were radiographically confirmed. The functional significance of leg-length inequality after THA is not well defined. In a study of 101 patients who had primary THA and were studied postoperatively with standing 3D imaging, anatomical leg length, anatomical femoral length, and functional leg length did not correlate with patient perception of limb length discrepancy. Other variables, including pelvic obliquity, difference in knee flexion/recurvatum, and difference in tibial plafond to ground height, did correlate with perceived limb length discrepancy, however. Innmann et al. found that both restoration of hip offset and minimization of limb length discrepancy had an additive positive effect on clinical outcome. The risk of excessive leg lengthening can be minimized by a combination of careful preoperative planning and operative technique. Edeen et al. found that clinical measurements of leg lengths correlated with radiographic measurements to within 1 cm in only 50% of patients. Flexion and adduction contractures produce apparent shortening of the extremity, and abduction contracture, although less common, produces apparent lengthening. True bony discrepancies sometimes require surgical correction, whereas apparent discrepancies arising from contracture must be recognized, but seldom require operative intervention. A history of previous lower extremity trauma should be sought, and the extremities should be examined for differences below the level of the hip. Good-quality radiographs and templates of known magnification (see discussion of preoperative templating in the section on preoperative radiographs) are used to select a

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10 cm FIGURE 3.110 Steinmann pin in position to mark greater trochanter on initial exposure of hip. Subsequent measurements reference distance from pin to this trochanteric reference line. (From Ranawat CS, Rao RR, Rodriguez JA, et al: Correction of limb-length inequality during total hip arthroplasty, J Arthroplasty 16:715, 2001.)

b a FCI = (a-b)/a

FIGURE 3.109 Femoral cortical index (FCI) ratio, 10 cm below lesser trochanter, measures ratio of cortical diameter (a-b) to total femoral diameter (a). (From Lim YW, Huddleston JI 3rd, Goodman SB, et al: Proximal femoral shape changes the risk of a leg length discrepancy after primary total hip arthroplasty, J Arthroplasty 33:3699, 2018.)

prosthesis that allows intraoperative restoration of leg length and femoral offset. Several clinical methods for determining leg length have been described. One involves intraoperative evaluation of soft-tissue tension around the hip, commonly referred to as the “shuck test.” When traction is applied to the limb with the hip in extension, distraction of 2 to 4 mm usually occurs. The extent of soft-tissue release, the type of anesthesia, and the degree of muscular relaxation may change the surgeon’s appreciation of tissue laxity. In addition, soft-tissue tension depends not only on the height of the femoral head but also on the femoral offset (see Fig. 3.6). If femoral offset has been reduced and is not appreciated at surgery, tissue tension has to be restored by inadvertent overlengthening of the limb; in effect, height is substituted for offset to place the soft tissues under tension. Careful preoperative templating should alert the surgeon to this possibility, and arrangements should be made for implants that allow reproduction of the patient’s natural offset and appropriate soft-tissue tensioning without overlengthening of the limb. Although the assessment of soft-tissue tension is a useful maneuver, it alone should not be relied on to determine limb length equality. Multiple methods of limb-length determination have been described using transosseous pins placed above and below the hip joint and a measuring device. Ranawat et  al. used a pin below the infracotyloid groove and measured the distance between it and a mark on the greater trochanter. This technique resulted in an average limb-length discrepancy of 1.9 mm, with no patient requiring a shoe lift (Fig. 3.110).

These techniques depend on precise repositioning of the limb in the same degree of flexion, abduction, and rotation for each measurement. Currently, the most reliable method of equalizing leg lengths is the combination of preoperative templating and intraoperative measurement. Using this approach in a series of 84 hips, Woolson et al. reported that only 2.5% of patients had legs that were lengthened more than 6 mm. In a study of the usefulness and accuracy of preoperative planning, Knight and Atwater concluded that femoral and acetabular component size could not be predicted reliably by templating; however, when templating was combined with operative measurement, the postoperative leg length was within 5 mm of the planned degree of lengthening in 92% of patients. Computer-assisted techniques may hold promise in achieving limb-length equality after THA. A recent metaanalysis found increased accuracy of limb-length restoration with computer-assisted surgery but no benefit in clinical outcomes. Increased cost and longer operative times have limited the widespread adaptation of computer-assisted techniques. If both hips are diseased and bilateral staged surgery is expected, length is determined by the stability of the hip, and leg lengths are equalized by making the same bony resections and using the same implants on both sides. The patient should be advised that a shoe lift may be required between surgeries. Occasionally, arthroplasty may be indicated in a hip that is already longer than the contralateral side. Shortening of the limb by excessive neck resection or use of a prosthesis with a neck that is too short poses the risk of dislocation because of inadequate soft-tissue tension or impingement. In this instance, distal transfer of the greater trochanter or shortening by a subtrochanteric osteotomy may be considered. The main objectives of THA are, in order of priority, pain relief, stability, mobility, and equal leg length. The patient should be informed before surgery that no assurance can be given that the limb lengths will be equal. If lengthening of the limb provides a substantially more stable hip, the discrepancy is preferable to the risk of recurrent dislocation. Discrepancies of less than 1 cm generally are well tolerated,

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CHAPTER 3  ARTHROPLASTY OF THE HIP and the perception of the discrepancy tends to diminish with time. Apparent leg-length inequality and pelvic obliquity caused by residual soft-tissue contracture usually respond to physical therapy with appropriate stretching. Patients with an unacceptable limb-length discrepancy must be evaluated carefully to determine the cause of the discrepancy if surgical treatment is to be successful. Pelvic radiographs are evaluated for component placement that may cause limb-length discrepancy, such as an inferiorly placed acetabular component below the teardrop or a proximally placed femoral component with insufficient neck resection. Parvizi et al. described limb-length discrepancy caused by acetabular component malpositioning and subsequent instability, which had been accommodated by overlengthening with the modular femoral head. In their group of patients surgically treated for limb-length discrepancy, most required revision of a maloriented acetabular component. Limb lengths were equalized in 15 of the 21 patients, with the average limb-length discrepancy decreasing from 4 cm to 1 cm. Only one patient developed recurrent instability, whereas three patients with pain secondary to neuropraxia had complete resolution of their symptoms. 

DISLOCATION

The historical prevalence of dislocation after THA is approximately 3%. Anatomic, surgical, and epidemiologic factors may increase this risk. Trochanteric nonunion, abductor muscle weakness, and increased preoperative range of motion are anatomic features that increase the risk of instability. Component malposition, bony and/or component impingement, inadequate soft-tissue tension, and smaller head size are variables under the surgeon’s control that have also been implicated. Previous hip surgery, including revision hip replacement, female sex, advanced age, and American Society of Anesthesiologists (ASA) score, prior hip fracture, cervical myelopathy, spinopelvic imbalance, Parkinson disease, dementia, depression, chronic lung disease, and preoperative diagnosis of osteonecrosis or inflammatory arthritis are patient-specific factors that negatively affect hip stability. Postoperative dislocation is more common when there has been previous surgery on the hip and especially with revision total hip replacement. A recent meta-analysis reported an incidence of 9.04% after 4656 revision surgeries. Contributing factors included increased age at surgery, small femoral head size, history of dislocation, two or more previous revisions, and the use of nonelevated liners. The choice of surgical approach may affect the rate of postoperative dislocation. There is a tendency to retrovert the socket when THA is done through a posterolateral approach, especially if inadequate anterior retraction of the femur forces the acetabular positioning device posteriorly during component insertion. Division of the posterior capsule is another factor, and meticulous repair of the posterior soft-tissue envelope improves stability. Various soft-tissue repair techniques are advocated for improving hip stability after the posterolateral approach, with dislocation rates ranging from 0% to 0.85%. A meta-analysis comparing posterior approaches with and without soft-tissue repair showed an almost 10-fold reduction in dislocation rates from 4.46% to 0.4% in favor of soft-tissue repair. Our preference includes repair of the posterior capsule and short external rotators to the greater

GM

P

GMi

OI Q

FIGURE 3.111 Sutures passed through trochanteric drill holes using suture passer. External rotators and hip capsule are incorporated into repair. GM, Gluteus maximus; GMi, gluteus minimus; OI, obturator internus; P, piriformis; Q, quadratus femoris. (From Osmani O, Malkani A: Posterior capsular repair following total hip arthroplasty: a modified technique, Orthopedics 27:553, 2004.)

trochanter and/or abductor tendons with nonabsorbable sutures (Fig. 3.111). A theoretical advantage to direct lateral, anterolateral, and direct anterior approaches is the preservation of the posterior capsule and short external rotators. Recent studies comparing anterior and posterior approaches with current postoperative protocols have questioned this advantage. A meta-analysis by Wang et al. found no difference in dislocation rates in level I studies comparing direct anterior and posterior approaches. In fixing the cup in the proper position the surgeon must be able to judge the position of the patient’s pelvis in the horizontal and vertical planes. Errors in positioning the patient on the operating table are a common source of acetabular malposition, and secure stabilization of the patient in the lateral position is crucial. When in the lateral position, women with broad hips and narrow shoulders are in a relative Trendelenburg position, and the tendency is to implant the cup more horizontally than is planned. In men with a narrow pelvis and broad shoulders, the reverse is true. With reference to anteversion, the pelvis flexes upward by 35 degrees in the lateral position, and with extension in the supine position it becomes relatively retroverted. Also, forceful anterior retraction of the femur for acetabular exposure often tilts the patient forward. In this instance, placement of the acetabular component in the usual orientation relative to the operating table produces inadvertent retroversion relative to the pelvis. Acetabular insertion devices may provide a false sense of security, and the true position of the pelvis must always be taken into account. Circumferential acetabular exposure that allows observation of bony landmarks is essential. When an acetabular insertion device is used, the angle at which it holds the cup must be known. The trial cup should be placed in the position in which the final cup is to be inserted, and its relationship to the periphery of the acetabulum and the

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B

A

FIGURE 3.112 Determination of angle of anteversion (or retroversion) of cup by CT. A, Acetabular component appears well positioned in 39-year-old nurse who had multiple revisions and was referred for femoral loosening with recurrent subluxation. B, CT scan shows acetabular retroversion of 20 degrees.



TABLE 3.1

Ideal Cup Position by Spinopelvic Mobility* Normal Stiff Kyphotic Hypermobile

INCLINATION 35°-45° 45°-50°† 35°-40° 35°-40°

ANTEVERSION 15°-25° 20°-25° 15°-20° 12°-20°

COMBINED ANTEVERSION 25°-45° 35°-45° 25°-35° 25°-35°

*Cup anteversion is dependent on combined anteversion, which must be higher for stiff imbalance and lower for hypermobile hips to keep sitting ante-inclination within its normal range. In hips that are retroverted, it is difficult to achieve cup anteversion exceeding 12 to 15 degrees, so combined anteversion becomes critical in achieving stability for those hips. The range for each of these patterns is within 10 degrees, and it is difficult to achieve this precision at surgery without some form of navigation. However, these would be the ideal coronal cup angles for these patterns to keep the sagittal ante-inclination in its normal range. Total hip replacement has done so well for so many years because these cup angle numbers are within the cup positions that most surgeons strive to achieve at surgery. †Inclination of 50 degrees is reserved for elderly patients. From Ike H, Dorr LD, Trasolini N, et al: Spine-pelvis-hip relationship in the functioning of a total hip replacement, J Bone Joint Surg Am 100:1606, 2018.

transverse acetabular ligament should be carefully noted. This orientation is precisely reproduced on placement of the final implant. Quantifying the degree of anteversion of the cup by plain radiographic examination is difficult. McLaren reported a mathematic method of determining the degree of anteversion whereby the relative positions of the anterior and posterior halves of the circumferential wire in a cemented cup are considered. Similarly, the anteversion of a cementless acetabular component can be estimated by comparing its anterior and posterior margins. Superimposition of the two margins suggests little or no anteversion. If they form an ellipse, some degree of anteversion or retroversion is present. A cross-table lateral view of the affected hip also is helpful in assessing acetabular anteversion, but CT can be used to assess the degree of anteversion of the cup more accurately (Fig. 3.112). The inclination or abduction of the acetabular component can be measured more directly from plain radiographs, although flexion or extension of the pelvis relative to the beam may distort this relationship. Cup position correlates somewhat with dislocation risk. Lewinnek et  al. reviewed radiographs of 300 total hip replacements and proposed a “safe” range of 15 ± 10

degrees anteversion and inclination of 40 ± 10 degrees. More recently, other authors have challenged the safety of these parameters for cup positioning due to the fact that many dislocations occur despite acetabular components being within the “safe” zone. Patients with spinopelvic imbalance, in particular, may require cup positioning outside of the Lewinnek zone to achieve hip stability. A stiff lumbosacral junction requires relatively increased inclination and combined anteversion. Kyphotic or hypermobile patients are better served with lesser degrees of inclination and anteversion (Table 3.1). Other factors, such as femoral component offset, neck length, and soft-tissue balance also contribute to hip stability and must be carefully addressed intraoperatively. If the cup is excessively anteverted, anterior dislocation can occur during hip extension, adduction, and external rotation. If the cup is overly retroverted, dislocation occurs posteriorly with flexion, adduction, and internal rotation. Excessive inclination of the cup can lead to superior dislocation with adduction, especially if there is a residual adduction contracture, or if the femur impinges on osteophytes left along the inferior margin of the acetabulum (Fig. 3.113). Conversely, if the cup is inclined almost horizontally, impingement occurs

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CHAPTER 3  ARTHROPLASTY OF THE HIP Calcaneus Talus

Fibula

Tibia

FIGURE 3.113 Excessive inclination of acetabulum. Recurrent dislocation is caused by 65-degree inclination of socket. Hip dislocated with adduction when patient was standing. Revision was required.

early in flexion and the hip dislocates posteriorly. This tendency is accentuated if the cup also is in less anteversion. Femoral component anteversion is estimated intraoperatively by comparing the axis of the prosthetic femoral neck with the shaft of the tibia when the knee is in 90 degrees of flexion. Neutral version is defined by the prosthetic neck aligned perpendicular to the tibia. Relative anteversion occurs when this angle is greater than 90 degrees and retroversion when it is less (Fig. 3.114). Generally, the femoral component should be implanted with the neck in 5 to 15 degrees of anteversion. Severe anteversion of the anatomic femoral neck is seen in developmental dysplasia or juvenile rheumatoid arthritis, whereas retroversion may be encountered with previous slipped capital femoral epiphysis, proximal femoral malunion, or low levels of neck resection. If the neck of the component is in more than 15 degrees of anteversion, anterior dislocation is more likely (Fig. 3.115). Conversely, retroversion of the femoral component tends to make the hip dislocate posteriorly, especially during flexion and internal rotation. Amuwa and Dorr described the concept of combined anteversion, in which the anteversion of the femoral component is determined by femoral preparation first. The acetabular component is then placed and the sum of the anteversion of the cup and stem is determined, with the goal of 35 degrees total and an acceptable range of 25 to 50. Computer navigation is required to precisely determine these values. Impingement may occur because of prominences on the femoral side, acetabular side, or both sides of the joint. Bone or cement protruding beyond the flat surface of the cup must be removed after the cup has been fixed in place; otherwise, it serves as a fulcrum to dislocate the hip in the direction opposite its location. Residual osteophytes, especially located anteriorly, cannot be seen well on standard radiographs but are easily shown by CT scan (Fig. 3.116). After a shallow acetabulum is deepened to provide coverage of the superior part of the cup, excess bone may need to be removed anteriorly, posteriorly, or inferiorly. If the greater trochanter is enlarged or distorted because of previous surgery or as

Neutral

Retroverted Anteverted

FIGURE 3.114 Anteversion of femoral component is estimated by comparing tibial axis with prosthetic femoral neck axis. Ninety degrees represents neutral anteversion. Acute angles (90 degrees) with increasing anteversion.

FIGURE 3.115 Dislocation caused by malrotation of femoral component. Component was malrotated into 70 degrees of anteversion. Hip dislocated anteriorly several times and was revised.

a result of the underlying disease process, some bone often must be removed from its anterior or posterior margin to prevent impingement. Finally, bony impingement is much more likely if femoral offset has not been adequately restored. The

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FIGURE 3.116 Recurrent posterior dislocation after arthroplasty after fracture of acetabulum. Acetabular component had been placed in inadequate degree of anteversion because of deficiency of posterior wall. Retained anterior osteophyte (arrow) produced impingement in flexion and internal rotation and contributed to dislocation. Revision was required.

use of a femoral component with enhanced offset can be very beneficial in this situation (see Fig. 3.9). The ratio of the head diameter to that of the neck of the prosthesis is important, as smaller heads have a lower “jumping distance” required for dislocation (see Fig. 3.12). Larger head size is a stabilizing factor reported in some series of primary and revision total hip arthroplasties. Modular femoral head components that have an extension, or “skirt,” to provide additional neck length reduce the head-to-neck diameter ratio because the neck of the component is fitted over a tapered trunnion that must be of sufficient diameter (see Fig. 3.8). The range of motion to impingement is decreased compared with a shorter neck that does not use a skirt. Although lengthening the prosthetic neck may improve soft-tissue tension and increase offset, the range of prosthetic motion and ultimate stability of the hip may be diminished if the longer neck requires the addition of a skirted head. Many current acetabular components have modular liners with elevations that can be rotated into a variety of positions to reorient the face of the acetabulum to a slight degree to provide greater coverage of the prosthetic head (see Fig. 3.35). Such components may improve stability, but they may have the opposite effect if an excessively large elevation is used, or if it is rotated into an inappropriate orientation. Careful assessment of impingement of the prosthetic neck on the liner elevation during trial reduction is mandatory. Dual mobility acetabular components have their proponents, especially in patients at high risk for dislocation. By providing an increased head-to-neck ratio without a metalon-metal articulation, they allow greater range of motion to impingement and jumping distance compared to standard components (see Fig. 3.35). De Martino et  al. reviewed the literature regarding these components and reported a 0.9% dislocation rate in primary arthroplasties and 1.3% in revisions. Their use does involve additional modularity and the risk of intraprosthetic dislocation.

The adequacy of soft-tissue tension across the hip joint often is suggested as a cause of postoperative dislocation. In a series of 1318 patients, dislocation was significantly less frequent when cup position was appropriate and abductor tension was restored. Trochanteric nonunion, with resultant diminished abductor tension, also is associated with an increased incidence of dislocation. Woo and Morrey found a dislocation rate of 17.6% in patients with displaced trochanteric nonunions compared with 2.8% when the trochanter healed by osseous or fibrous union without displacement. Physical therapists, nurses, and other caregivers should be aware of the positions likely to cause dislocation. These positions may differ from patient to patient, depending on the surgical approach and other factors. Above all, the patient should be able to voice the appropriate precautions before discharge, and instructions should be reiterated at followup office visits. Specialized devices for reaching the floor and dressing the feet are helpful for maintaining independence while avoiding extremes of positioning in the early postoperative period. The efficacy of postoperative hip precautions is debated in the literature. A recent meta-analysis including three randomized controlled trials concluded that very low quality evidence was available on this topic and could not recommend for or against functional restrictions after hip replacement. Most dislocations occur within the first 3 months after surgery. The dislocation often is precipitated by malpositioning of the hip at a time when the patient has not yet recovered muscle control and strength. Late dislocations can be caused by progressive improvement in motion after surgery or later onset of spinopelvic imbalance. Impingement caused by component malposition or retained osteophytes may not become manifest until extremes of motion are possible. Late dislocations are more likely to become recurrent and require surgical intervention. Von Knoch et al. reported that 55% of late dislocations were recurrent, with 61% of the recurrent dislocators requiring surgery. All attending personnel, including nurses and physical therapists, should be aware that excessive pain, limited range of motion, rotational deformity, or shortening of the limb is suggestive of dislocation. If these symptoms are noted, radiographs of the hip should be obtained. Reduction usually is not difficult if dislocation occurs during the early postoperative period and a timely diagnosis is made. If the dislocation is not discovered for more than a few hours, reduction may be more difficult because of additional swelling and muscle spasm. Intravenous sedation and analgesia often are sufficient, but sometimes a general anesthetic is required to assist with reduction of the hip. Reduction techniques should always be gentle to minimize damage to the articulating surfaces. The use of image intensification sometimes is valuable in reducing the hip. Reduction is accomplished by longitudinal traction and slight abduction when the head is at the level of the acetabulum. The Allis or Stimson maneuver (see Chapter 55) also can be used. Radiographs should be repeated to confirm the adequacy of reduction. Modular polyethylene liners may dissociate from their metal backings when dislocation occurs, or when reduction is attempted. Incongruous placement of the femoral head within the metal backing indicates such an occurrence. Open reduction with replacement of the liner or revision of the acetabular component is required (Fig. 3.117).

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CHAPTER 3  ARTHROPLASTY OF THE HIP

A

B

FIGURE 3.117 Dissociation of modular polyethylene liner. A, After placement of metal-backed acetabular component with modular polyethylene liner. B, Six weeks after surgery, hip dislocated while patient was sitting in low chair. After reduction maneuver, femoral head is eccentrically located in metal backing. Radiolucent shadow of displaced polyethylene liner is visible in soft tissues inferiorly (arrows). Reoperation was required to replace liner.

If the components are in satisfactory position, closed reduction is followed by a period of bed rest. After posterior dislocation, mobilization is accomplished in a prefabricated abduction orthosis that maintains the hip in 20 degrees of abduction and prevents flexion past 60 degrees. Immobilization for 6 weeks to 3 months has been recommended. The efficacy of abduction bracing was challenged in a retrospective review by DeWal et al., who found no difference in the risk of subsequent dislocation between groups of patients treated with or without an abduction brace. Wera et  al. published a series of 75 revision THAs performed for recurrent dislocation according to a proposed algorithmic classification. The six etiologies were: Type I: acetabular component malposition Type II: femoral component malposition Type III: abductor deficiency Type IV: impingement Type V: late wear Type VI: unresolved Types I and II are treated by revision of the malpositioned component(s). Abductor deficiency and those without known etiology for dislocation (types III and VI) are revised to a constrained acetabular liner or dual mobility construct. When impingement is the causative factor (type IV), sources of impingement are removed, offset is restored, and head size is increased. Late wear (type V) associated with instability requires modular head and liner exchange, including a larger

femoral head. In their series, repeat dislocation occurred in 14.6% of patients, with the highest risk of recurrence in those with abductor deficiency. If no component malposition or source of impingement is identifiable, distal advancement of the greater trochanter was recommended by Kaplan, Thomas, and Poss to improve soft-tissue tension. In their series, 17 of 21 patients had no additional dislocations. Ekelund reported similar results. Constrained liner designs offer higher resistance to dislocation than do unconstrained components because the femoral head is mechanically captured into the socket. Callaghan et  al. reported the best results with constrained acetabular components. They used a tripolar liner in combination with a new uncemented acetabular component (6% failure rate) or cemented into a well-fixed existing shell (7% failure rate). They did not report increased wear or osteolysis with this device. In a literature review of constrained components, Williams, Ragland, and Clarke found an average recurrent dislocation rate of 10% and an average reoperation rate for reasons other than instability of 4%. If a constrained component is used, the range of motion of the hip is reduced, and correct positioning of the component is crucial to minimize impingement of the neck on the rim of the liner. Excessive prosthetic impingement with constrained components can disrupt the liner locking mechanism or lever the entire component out of the acetabulum if fixation is not rigid. Guyen, Lewallen, and Cabanela categorized the various modes of failure of a tripolar constrained liner in 43 patients. Failures occurred at the bone/implant interface (type I), at the liner/shell interface (type II), at the locking mechanism (type III), by dislocation of the inner bearing from the bipolar femoral head (type IV), and as a result of infection (type V). They recommended the use of these devices only as a last resort because of their complexity and multiple modes of mechanical failure. Finally, some patients are not candidates for reconstruction. Noncompliant individuals; alcohol and drug abusers; elderly, debilitated patients; and patients with several previous failed attempts to stop recurrent dislocation are best treated by removal of the components without further reconstruction. 

FRACTURES

Fractures of the femur or acetabulum can occur during and after THA. While periprosthetic femoral fractures are more common and often require some form of treatment, acetabular fractures probably occur more frequently than recognized. According to the Mayo Clinic Total Joint Registry, intraoperative femoral fractures occur in 1.7% of primary total hip arthroplasties and in 12% of revision procedures. Primary total hip patients at risk for intraoperative periprosthetic fracture include females, elderly patients, and those treated with uncemented stems. Femoral fracture is likely to occur during one of several stages in the procedure. Fracture can occur early while attempting to dislocate the hip. Elderly patients and those with rheumatoid arthritis or disuse osteoporosis can be fractured by a moderate rotational force. Cortical defects from previous surgery or fixation devices increase the risk further. If resistance is met in attempting dislocation in these patients, more of the capsule must be released. Osteophytes extending

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS from the margin of the acetabulum must be resected before dislocation; otherwise, the femur or the posterior wall of the acetabulum may be fractured. In some patients with intrapelvic protrusion of the acetabulum, the neck should be divided and the head removed from the acetabulum in a piecemeal fashion. Complex deformities of the proximal femur also increase the risk of fracture, especially when the medullary canal is narrowed. Revision surgery carries a substantially higher risk of fracture than primary procedures because of the presence of thin cortices from implant migration and osteolysis. Fractures of the femur can occur during broaching or insertion of the femoral component. Broaches are designed to crush and remove cancellous bone and do not remove cortical endosteal bone safely from the diaphysis. The need to remove cortical bone distally can be anticipated from preoperative templating. A straight or flexible reamer must be used to remove this bone before insertion of the broach, or a major fracture extending into the femoral shaft may occur. Intraoperative femoral fractures occur more commonly in cementless THAs. Abdel et  al. reported intraoperative fractures of the proximal femur in 3.0% of cementless primary arthroplasties and in 19% of cementless revision procedures. The Vancouver classification of periprosthetic femoral fractures has been altered to include intraoperative fractures and perforations (Fig. 3.118). Type A fractures are confined to the proximal metaphysis. Type B fractures involve the proximal diaphysis but can be treated with long-stem fixation. Type C fractures extend beyond the longest revision stem and may include the distal femoral metaphysis. Each type is subdivided into simple perforations (subtype 1), nondisplaced (subtype 2), or displaced (subtype 3). Treatment options include bone grafting, cerclage, long-stem revision, or open reduction and internal fixation depending on the level and displacement of the fracture. If a femoral fracture occurs during cementless total hip surgery, it must be completely exposed to its most distal extent. This is done with the broach or actual component in place because the fracture gap may close when the implant is removed, and the extent of the fracture may be underestimated. Once the fracture is exposed, the implant is removed, and cerclage wires or cables are placed around the femoral shaft. A trial broach one size smaller can be inserted in the canal to prevent overtightening and potential collapse or overlap of the fracture fragments. One cable should be placed distal to the fracture to prevent its propagation during final component insertion. As the final component is reinserted, the cables come under increased tension, and further expansion of the fracture is prevented. There is a tendency to underestimate such fractures and to regard them as stable. We know of no objective method for determining whether such fractures are in fact stable and recommend cerclage fixation in all cases. Prophylactic placement of cerclage wires should be considered when the cortex is thin or weakened by internal fixation devices or other stress risers. Cobalt chrome cables and hose clamps have the advantage of superior stiffness compared with other cerclage systems. Postoperative femoral shaft fractures can occur months or years after surgery. Most of these injuries result from lowenergy trauma, with high-energy mechanisms reported in

less than 10%. Larsen, Menck, and Rosenklint identified massive heterotopic bone formation around the hip as a potential risk factor. Decreased motion in the hip joint transfers stress to the femoral shaft, similar to a hip arthrodesis. Cortical defects, stem loosening, and osteolysis also can predispose to late postoperative fracture. The treatment of periprosthetic femoral fracture depends primarily on the location and stability of the fracture, fixation of the indwelling femoral component, quality of the remaining bone, and medical condition and functional demands of the patient. Treatment options include nonoperative management, open reduction and internal fixation of the fracture while leaving the stem in situ, and femoral revision with or without adjunctive internal fixation. Duncan and Masri proposed a classification system for postoperative periprosthetic femoral fractures. It provides a straightforward, validated system that provides guidance in making treatment decisions. The factors considered include the location of the fracture, the fixation of the stem, and the quality of the remaining bone stock (Table 3.2). Type A fractures involve the trochanteric area and are divided into fractures involving the lesser or greater trochanter. Most type A fractures are stable and can be managed conservatively with a period of protected weight bearing. Greater trochanteric fractures with significant displacement may be treated with trochanteric fixation. Surgical treatment of lesser trochanteric fractures should be reserved for those that involve the medial cortex of the femur and cause instability of the femoral stem. Type B fractures occur at the tip of the stem or just distal to it. These are the most common fractures in large series and the most problematic. In type B1 fractures, the stem remains well fixed, whereas in type B2 fractures, the stem is loose. In type B3 fractures, the stem is loose, and the proximal femur is deficient because of osteolysis, osteoporosis, or fracture comminution. Primary open reduction and internal fixation with the prosthesis left in situ is most appropriate for type B1 fractures in which the stem remains solidly fixed. Fixation must be rigid; treatment with simple cerclage wiring, bands, or isolated screws is associated with high failure rates. Plate fixation has evolved from the Ogden plate, fixed with screws distally and Parham bands proximally, to cable-plate systems such as the Dall-Miles plate, with incorporated sites for cable attachment proximally and screws distally, to locking plates using unicortical screws proximally and bicortical screws distally, placed with percutaneous techniques (Fig. 3.119). Biomechanical studies show greater mechanical stability for constructs with proximal and distal screw fixation in comparison with those fixed proximally with cables only. Allograft struts, used alone or in combination with plate fixation, also show promise in the fixation of periprosthetic femoral fractures (Fig. 3.120). If the stem is loose, as in type B2 fractures, revision with a long-stem femoral component is preferable. This approach not only restores stability to the femoral component but also provides reliable intramedullary fixation of the fracture. Current treatment of these injuries typically involves the use of cementless long-stem femoral components. In a series of 118 periprosthetic femoral fractures, Springer, Berry, and Lewallen reported improved outcomes using extensively

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CHAPTER 3  ARTHROPLASTY OF THE HIP porous-coated cementless femoral components. We have used proximally porous coated modular uncemented stems, distally fluted tapered stems, and extensively porous coated stems with good success (Fig. 3.121). Supplemental internal fixation with cerclage or onlay cortical allograft struts is sometimes required to restore rotational stability at the fracture site. Additional bone grafting at the fracture site is recommended by most authors. In type B3 fractures, the proximal femur is so deficient that it cannot be treated with open reduction and internal fixation or support a new femoral component. The femur can be reconstructed with an allograft prosthesis composite (see Technique 3.32) to restore bone stock. Alternatively, the revision can be done with a proximal femoral replacement prosthesis, such as that used for tumor reconstructions (see Fig. 3.28). Distally fluted tapered stems are enjoying increasing popularity in treating some B3 fractures (Fig. 3.122). Fracture union, implant stability, and some restoration of proximal femoral bone stock have been observed. Type C fractures occur well below the tip of the stem with no stem loosening. These can be treated with internal fixation, leaving the femoral component undisturbed (Fig. 3.123). As in B1 fractures, locked plates and less invasive techniques are gaining popularity. Areas of stress concentration between fixation devices and the femoral stem should be avoided.

Duncan and Haddad added type D fractures, which involve the femur and ipsilateral hip and knee arthroplasties to this classification. These challenging injuries are treated similarly to those described above based on implant fixation and residual bone stock. With stable implants above and below and reasonable bone for fixation, ORIF with locking and nonlocking plates has been used (Fig. 3.124). Comminuted fractures with unreconstructable bone stock and/or loose implants may require revision surgery of the adjacent implant(s) with modular proximal, distal, or total femoral replacement prostheses. Fracture of the acetabulum seldom occurs intraoperatively in primary arthroplasties, although fragile portions of the posterior wall can be fractured easily during revision surgery. Haidukewych et al., in a review of 7121 primary total hip arthroplasties, found a 0.4% prevalence of intraoperative acetabular fracture. All of these occurred in uncemented components, most commonly with a single monoblock elliptical design. Most of the fractures were stable, and the original acetabular component was retained. Components that were thought to be unstable were converted to a different component that allowed supplemental screw fixation. All fractures united, and no revisions were necessary. Hickerson et  al. described a periprosthetic acetabular fracture treatment algorithm based on the extent of the fracture and stability of the implant. Intraoperative fracture

Fracture

Fracture

Fracture

Cortical perforation

or

or Fracture

A2

A1

A3

Undisplaced fracture Cortical perforation

or Displaced fracture

Undisplaced fracture

Displaced fracture

Distal perforation B1

B2

B3

C1

C2

C3

A FIGURE 3.118 Intraoperative periprosthetic fractures of femur. (Redrawn from Greidanus NV, Mitchell PA, Masri BA, et al: Principles of management and results of treating the fractured femur during and after total hip arthroplasty, Instr Course Lect 52:309, 2003.)

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Morselized bone graft

Cerclage  bone graft

Diaphyseal fitting stem and cerclage

Diaphyseal B1 Perforation

Proximal to stem tip?

B2 Undisplaced crack

Is the stem stable?

B3 Displaced fracture

Is the stem stable?

Yes

Morselized bone graft

No

Stem stable?

Yes

Allograft strut cerclage

No

Longer stem allograft strut cerclage

Yes

Cerclage

No

Is there adequate bone stock?

Yes

Yes

Allograft strut cerclage

No

No

Longer stem allograft strut cerclage

Longer stem cerclage Longer stem allograft strut cerclage

Distal diaphyseal/ metaphyseal C1 Perforation C2 Undisplaced crack extending into distal metaphysis C3 Displaced distal fracture

Morselized bone graft

Cerclage/strut

ORIF

B FIGURE   3.118 cont’d

treatment recommendations are based on wall or column involvement and cup stability. Postoperative fractures are similarly managed based on cup stability and fracture displacement (Fig. 3.125). We agree with the authors that if reasonable fracture stability is achieved, then an uncemented hemispherical component with additional screw fixation should suffice. If implant stability is questionable despite fracture fixation, however, consideration should be given to the use of an antiprotrusio cage with proximal and distal fixation through the flanges of or a cup/cage construct (Fig. 3.126). (See Acetabular Revision section.) 

TROCHANTERIC NONUNION

Trochanteric osteotomy is seldom necessary in primary THA. Exceptions include some patients with congenital hip dysplasia, protrusio acetabuli, or conversion of an arthrodesis. If the femur has been shortened, distal advancement of the trochanter may be required to restore appropriate myofascial tension to the abductor mechanism. Trochanteric osteotomy is also sometimes necessary for the extensile exposure of the acetabulum and femur required for revision surgery. Avoiding nonunion of the greater trochanter requires careful attention to the technical details of the osteotomy and

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CHAPTER 3  ARTHROPLASTY OF THE HIP TABLE 3.2



Vancouver Classification of Fractures of the Femur After Total Hip Arthroplasty TYPE A

LOCATION Trochanteric region

B

Around or just distal to stem

C

Well below stem

SUBTYPE AG: greater trochanter AL: lesser trochanter B1: prosthesis stable B2: prosthesis unstable B3: bone stock inadequate

From Duncan CP, Masri BA: Fracture of the femur after hip replacement, Instr Course Lect 44:293, 1995.

FIGURE 3.120 Lateral plate and anterior cortical strut graft used for fixation of type B1 femoral fracture; cancellous allograft also is placed at fracture site.

A

B

FIGURE 3.119 Type B1 femoral fracture. A, Preoperative radiograph shows well-fixed stem and spiral femoral fracture. B, Postoperative radiograph demonstrates anatomic reduction and fixation with lateral plate, locking and nonlocking screws, and cable. (From Pike J, Davidson D, Grabuz D, et al: Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty, J Am Acad Orthop Surg 17:677, 2009.)

its reattachment. Factors contributing to trochanteric nonunion include a small trochanteric fragment, poor-quality bone, inadequate fixation, excessive abductor tension, prior radiation therapy, and patient noncompliance. The most significant problems of trochanteric nonunion are related to proximal migration of the trochanteric fragment. Failure of trochanteric fixation and proximal migration are not caused simply by the abductors pulling the fragment off superiorly. Charnley proposed that anterior and posterior motion of the trochanter occurs first as the hip is loaded in flexion, as during rising from a chair or stair-climbing. This produces shear forces between the trochanter and its underlying bed. Subsequent fatigue failure of the fixation device allows proximal migration.

FIGURE 3.121 Type B2 femoral fracture. Loose femoral component was revised to extensively porous coated stem. Cerclage cables were used to assist with fixation and restoration of rotational stability.

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FIGURE 3.122 Type B3 femoral fracture. Femoral component was revised to modular tapered fluted stem. Note restoration of proximal bone stock and solid fracture union. (From Mulay S, Hassan T, Birtwistle S, Power R: Management of types B2 and B3 femoral periprosthetic fractures by a tapered, fluted, and distally fixed stem, J Arthroplasty 20:751, 2005.)

The incidence of nonunion in primary surgery varies from approximately 3% to 8%, but revision surgery carries greater risk. Nonunion rates of 9% to 13% have been reported in revision surgeries using trochanteric wiring, wire plus mesh, trochanteric bolt, cable-grip, and cable-plate techniques. McCarthy et al. found that union was more likely when a trochanteric slide osteotomy was used, cables were placed circumferential to the femur rather than intramedullary, and good bone-to-bone apposition was achieved. Although stable fibrous union without proximal migration usually produces good functional results with little pain (Fig. 3.127), trochanteric nonunion and/or trochanteric migration are typically associated with gait abnormalities and worsened functional outcomes. According to Amstutz and Maki, migration of more than 2 cm significantly impairs abductor function even if union eventually occurs (Fig. 3.128). Trochanteric nonunion also is associated with an increased incidence of dislocation. Woo and Morrey found a dislocation rate of 17.6% in patients with displaced trochanteric nonunions compared with 2.8% when the trochanter healed by osseous or fibrous union without displacement.

FIGURE 3.123 Type C fracture of distal femur. Fracture was fixed with lateral plate using locking screws and cables. (From Davidson D, Pike J, Grabuz D, et al: Intraoperative fractures during total hip arthroplasty. Evaluation and management, J Bone Joint Surg 90A:2000, 2008.)

Prominent or broken trochanteric implants often are a source of lateral hip pain. Injection of a local anesthetic may be helpful in establishing the diagnosis. Local steroid injections often relieve such symptoms. Removal of the hardware occasionally is indicated, but Bernard and Brooks found that less than 50% of patients obtain substantial relief from simple wire removal. Broken trochanteric wires or cables can migrate with untoward effects (Fig. 3.129). Cases of delayed sciatic nerve symptoms associated with migrated wires impinging upon the nerve have been reported. Fragmentation of braided cables may generate a large amount of intraarticular metal debris that damages the articulating surfaces. Complete excision of this type of wire debris at revision is almost impossible, and subsequent revisions may be at risk for accelerated wear. Altenburg et al. found higher rates of acetabular wear, osteolysis, and acetabular revision in patients who underwent cemented THA via trochanteric osteotomy repaired with braided cables in comparison to those who had wire fixation. They recommended cable removal if fretting or trochanteric nonunion occurs. Trochanteric repair occasionally is indicated for a displaced trochanteric nonunion with a painful pseudarthrosis or significant abductor weakness with Trendelenburg limp. Established pseudarthrosis is suspected if a patient has pain with resisted hip abduction, local tenderness to palpation, and relief of pain by injection of local anesthetic into the area

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CHAPTER 3  ARTHROPLASTY OF THE HIP many of the same problems as trochanteric migration: pain, abductor weakness, and hip instability. A few small series of patients treated with late abductor tendon repair have shown mixed results in terms of pain relief and overall patient satisfaction, probably caused by chronic degeneration of the abductor mechanism. Augmented repair techniques using a gluteus maximus muscle flap or an Achilles tendon allograft have shown promise in small case series. 

 

GLUTEUS MAXIMUS AND TENSOR FASCIA LATA TRANSFER FOR PRIMARY DEFICIENCY OF THE ABDUCTORS OF THE HIP TECHNIQUE 3.8 Perform a standard posterior approach to the hip through a skin incision that parallels the gluteus maximus in its middle third proximally and in line with the femur for 10 cm distal to the greater trochanter. n  Split the gluteus maximus in line with its fibers in its middle third for about half the length of the muscle. n  Split the fascia lata longitudinally well below the distal extent of the TFL muscle belly. n  Release the anterior edge of the gluteus maximus flap from the fascia lata anteriorly, leaving a fascial cuff distally and anteriorly. Release the gluteus maximus fascia from the fascia lata up to the iliac crest. n  Make a transverse incision in the anterior gluteus maximus fascia to allow proper tensioning (Fig. 3.130A). n  Elevate the gluteus maximus flap off of the underlying remnants of the gluteus medius and minimus. n  Incise the distal fascia lata transversely and separate it from the sartorius anteriorly, leaving a cuff of fascia at least 1 cm wide. n  Use a half-inch osteotome to make a 4-cm long trough in the lateral cortex of the greater trochanter. n  Split the proximal vastus lateralis longitudinally. n  Drill holes in the edges of the trochanteric trough for later suture fixation. n  With the hip in neutral abduction, suture the gluteus maximus flap to the trough in the greater trochanter with No. 5 nonabsorbable sutures (Fig. 3.130B). n  Transfer the fascia lata flap over the greater trochanter and gluteus maximus flap and suture it distally under the vastus lateralis. n  Suture the edges of the transferred flaps to each other with absorbable and nonabsorbable sutures. n  Intermittently check for appropriate tension of each flap by slight adduction of the hip. n  Close the proximal split in the gluteus maximus with absorbable sutures. n  Repair the anterior and posterior portions of the fascia lata flap with absorbable sutures to the sartorius and distal gluteus maximus, respectively (Fig. 3.130C). n  Postoperatively, 6 weeks of touch-down weight bearing is allowed with two-handed support. n 

FIGURE 3.124 Interprosthetic fracture (type D) in elderly patient treated with locking plate, unicortical screws and cables proximally, bicortical screws distally.

of the pseudarthrosis. Surgery should be approached cautiously, and patients should be informed that union may not be obtained with a second operation. Wire fixation alone has met with poor results; therefore, augmented techniques are warranted. Hodgkinson, Shelley, and Wroblewski obtained bony union in 81% of patients using a double crossover wire with a compression spring, and Hamadouche et al. reported successful union in 51 of 72 patients with previous trochanteric nonunion treated with a claw plate combined with wire fixation. Careful preparation and contouring of the trochanteric fragment are essential to obtain maximal stability. An attempt must be made to place the trochanter against bone. It must not be reattached under excessive tension, and the hip should be abducted no more than 10 to 15 degrees for approximation. Autogenous bone grafting seems prudent. Weight bearing and active abduction exercises are delayed until there is early radiographic evidence of bony union. A period of bracing in abduction or spica cast application reduces tension on the repair. Chin and Brick described a technique to facilitate reattachment of a severely migrated greater trochanter whereby the abductor muscles are advanced by subperiosteal release from their origin on the iliac wing. Union was achieved in four of four patients. If the direct lateral approach has been used, avulsion of the repaired abductor mechanism can occur and presents

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS Periprosthetic acetabular fractures

Intraoperative

Fracture involving wall

Postoperative

Fracture involving column

Stable implant (Clinical/radiographic)

Unstable implant (Clinical/radiographic)

Displaced fracture (Implant usually uninvolved)

Stable

Unstable

Stable

Unstable

Minimally displaced fracture

Screw augmentation stock within cup

Buttress plating

Column plating

Posterior column plating (± anterior) with lag screw of opposite column (when possible)

Protected weight bearing (6–8 weeks)

Stable pelvis

Pain/nonunion/gap ↓ Healing potential

Unstable pelvis

Minimally displaced fracture

Displaced fracture/ bone loss

ORIF/ bone graft, component revision

Restore bone stock (Allograft/ bulk/ring/etc.). ORIF (Plates and screws) component revision

ORIF (Plates/screws) ± Bone graft

FIGURE 3.125 Periprosthetic acetabular fracture treatment algorithm. (From Hickerson LE, Zbeda RM, Gadinsky NE, et al: Outcomes of surgical treatment of periprosthetic acetabular fractures, J Orthop Trauma 33 [Suppl 2]:s48, 2019.)

Standing abduction exercises and full weight bearing are initiated at 6 weeks. n  Side-lying abduction exercises begin at 8 weeks, and the patient is allowed to use one crutch in the opposite hand. Further abductor strengthening and gait training begin at 3 months postoperatively. n  Cane use is encouraged for a full year.    n 

INFECTION

Postoperative infection is a difficult complication affecting THA. It is painful, disabling, costly, often requiring removal of both components, and is associated with reported survival rates of 88.7% and 67.2% at one and 5 years after diagnosis. Consistent efforts at prevention are mandatory. Treatment of infection requires appropriate assessment of its chronicity and causative factors, the status of the wound, and the overall health of the patient. After the introduction of modern hip arthroplasty, septic complications threatened the continued viability of the procedure. Charnley reported infection in 6.8% of the first 683 procedures. The experience of Wilson et al. in the United States was even more ominous, with 11% of 100 arthroplasties becoming infected. Advances in understanding of patient selection, the operating room environment, surgical technique, and the use of prophylactic antibiotics have dramatically reduced the risk of this devastating complication.

Currently, approximately 1% to 2% of hip arthroplasties become infected. The incidence of sepsis is higher in patients with various comorbidities. Risk calculators are available with relative weightings for these medical and surgical factors (Table 3.3). Additional risk factors include prolonged operative time and wound healing complications, such as necrosis of the skin and postoperative hematoma. Bacterial infections can occur by one of four mechanisms: (1) direct contamination of the wound at the time of surgery, (2) local spread of superficial wound infection in the early postoperative period, (3) hematogenous spread of distant bacterial colonization or infection from a separate site, or (4) reactivation of latent hip infection in a previously septic joint. Strict attention to surgical technique and the operating room environment is essential in preventing infection by direct contamination. Water-repellent gowns and drapes are recommended. Double gloves also are recommended to protect the patient and operating team from contamination, as glove puncture is common. It is especially important to handle tissues gently and to minimize dead space and hematoma formation. The level of airborne bacteria can be reduced by limiting traffic through the operating room.

ANTIBIOTIC PROPHYLAXIS

Most total hip infections are caused by gram-positive organisms, particularly coagulase-negative staphylococci and S. aureus. Although the relative percentages of infections with

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CHAPTER 3  ARTHROPLASTY OF THE HIP

FIGURE 3.128 Trochanteric nonunion with marked proximal migration and hardware failure. Revision was necessary for acetabular loosening as well.

FIGURE 3.126 Trabecular metal acetabular revision system: cup-cage construct. (See section on acetabular revision.) (Courtesy Zimmer Biomet, Warsaw, IN.)

higher virulence. Gram-negative organisms are encountered more frequently in hematogenous infections, especially those emanating from the urinary tract. Mixed infections typically occur when a draining sinus has developed, with superinfection by one or more additional organisms (Table 3.4). It is generally recognized that the most important factor in reducing perioperative sepsis is routine use of antibiotic prophylaxis. The second International Consensus Meeting on Musculoskeletal Infection recently made recommendations regarding antibiotic prophylaxis for hip and knee arthroplasty. First- or second-generation cephalosporins such as cefazolin or cefuroxime continue to be the antibiotics of choice. Vancomycin is preferred in patients who are carriers of resistant S. aureus or who are at high risk for colonization with this organism. Clindamycin is recommended for patients allergic to cephalosporins (see Box 3.2). 

CLASSIFICATION

FIGURE 3.127 Trochanteric nonunion without migration usually produces little pain and only mild functional limitation.

these organisms have remained roughly stable, their virulence has increased. Methicillin resistance has become common in many medical centers, and the elaboration of glycocalyx by Staphylococcus and Pseudomonas is recognized as a marker for

Appropriate initial treatment of an infection depends on its extent and chronicity, implant stability, and the patient’s medical status. Although the treatment of deep infection after THA is typically surgical, the decision of whether to remove or retain the components may partially be guided by the chronicity of the infection. Tsukayama classified periprosthetic infections into four categories: 1.  Early postoperative infection: onset within the first month after surgery 2. Late chronic infection: onset more than 1 month after surgery, insidious onset of symptoms 3. Acute hematogenous infection—onset more than 1 month after surgery, acute onset of symptoms in previously wellfunctioning prosthesis, distant source of infection 4. Positive intraoperative cultures: positive cultures obtained at the time of revision for supposedly aseptic conditions The classification described by Trampuz and Zimmerli extends the definition of an early infection to 3 months postoperatively. Delayed infections occur between 3 and 24 months from the index surgery, and late infections occur after 24 months. 

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A

B

FIGURE 3.129 Trochanteric nonunion with wire in joint. A, Wire breakage after fixation of trochanteric nonunion with braided cables. B, Fragmentation of braided cables, with voluminous debris in vicinity of articulation (arrow). b

c

d a b

a

a b c

e c

A

C

B

FIGURE 3.130 Gluteus maximus and tensor fascia lata transfer for primary deficiency of the hip abductors. A, Partial transverse incision in anterior portion of gluteus maximus flap. Gluteus maximus and fascia lata split split (a). Gluteus maximus flap released (b). Anterior edge of gluteus maximus flap released and transverse incision made in fascia (c). Gluteus maximus flap elevated (d). Anterior fascia lata incised to edge of sartorius. B, Gluteus maximus flap sutured into trough in greater trochanter. Gluteus maximus flap (a) sutured to edges of decorticated greater trochanter. Fascia lata extension (b) placed on cortical bone under elevated vastus lateralis (c). C, Fascia lata flap repaired to sartorius and distal gluteus maximus. Tensor fascia lata (a) transferred over greater trochanter and gluteus maximus flap (b). Inferior edge sutured under vastus lateralis flaps (c). (Redrawn from Whiteside LA: Surgical technique: gluteus maximus and tensor fascia lata transfer for primary deficit of the abductors of the hip, Clin Orthop Relat Res 472:645, 2014.) SEE TECHNIQUE 3.8.

DIAGNOSIS

A careful history and physical examination are crucial in making the diagnosis of total hip infection. Although the diagnosis of early postoperative infection or acute hematogenous infection is often not difficult, late chronic infections can be challenging to distinguish from other causes of pain in a patient with a previous THA. Early or late acute infections may be characterized by pain, fever, or erythema. Pain unrelieved by a seemingly well-functioning arthroplasty may be a clue towards chronic infection. A

history of excessive wound drainage after the initial arthroplasty, multiple episodes of wound erythema, and prolonged antibiotic treatment by the operating surgeon also are worrisome. Physical examination focuses on the presence of painful hip range of motion, swelling, erythema, sinus formation, or fluctuance. Often radiographs of the affected hip are normal or at best may be indistinguishable from aseptic loosening of the prosthesis. Progressive radiolucencies or periosteal reaction occasionally may be seen, indicating possible infection.

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CHAPTER 3  ARTHROPLASTY OF THE HIP

TABLE 3.3A



Institutional Risk Calculation for Any Periprosthetic Joint Infection RISK FACTOR BMI Male Government insurance Surgical factors: n THA, primary n THA, revision n TKA, primary n TKA, revision n Both THA and TKA, revision n 1 prior procedure n 2 prior procedures n ≥3 prior procedures Comorbidities: n Drug abuse n HIV/AIDS n Coagulopathy n Renal disease n Psychosis n Congestive heart failure n Rheumatologic disease n Deficiency anemia n Diabetes mellitus n Liver disease n Smoker

POINTS (0.0865 × BMI2) − (5.072 × BMI) + 74.35 18 7 18 50 28 81 87 60 87 100 62 49 38 35 31 31 30 19 19 17 10

TABLE 3.3B

Cumulative Point Values and Corresponding Estimated Periprosthetic Joint Infection Rate for Any Periprosthetic Joint Infection CUMULATIVE POINT VALUE 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160

ESTIMATED PJI RATE* (%) 0.36 (0.30-0.43) 0.47 (0.40-0.55) 0.61 (0.52-0.70) 0.79 (0.69-0.90) 1.02 (0.90-1.15) 1.32 (1.18-1.47) 1.70 (1.54-1.88) 2.19 (2.01-2.41) 2.83 (2.61-3.08) 3.64 (3.38-3.93) 4.67 (4.36-5.02) 5.97 (5.59-6.41) 7.60 (7.13-8.17) 9.65 (9.03-10.38) 12.16 (11.34-13.14) 15.22 (14.13-16.52) 18.89 (17.46-20.58)

*The 95% CI is given in parentheses. PJI, Periprosthetic joint infection. From Tan TL, Maltenfort MG, Chen AE, et al: Development and evaluation of a preoperative risk calculator for periprosthetic joint infection following total joint arthroplasty, J Bone Joint Surg Am 100:777, 2018.



AIDS, Acquired immunodeficiency syndrome; BMI, body mass index; HIV, human immunodeficiency virus; THA, total hip arthroplasty. From Tan TL, Maltenfort MG, Chen AE, et al: Development and evaluation of a preoperative risk calculator for periprosthetic joint infection following total joint arthroplasty, J Bone Joint Surg Am 100:777, 2018.

Laboratory evaluation includes ESR, CRP, and D-dimer. Peripheral white blood cell (WBC) count is rarely elevated in late chronic infection and is not a sensitive screening tool. ESR greater than 30 mm/h and CRP greater than 10 mg/L are reasonably sensitive and specific for the diagnosis of chronic infection. The threshold for a positive D-dimer test has been reported to be 850 ng/mL. Hip aspiration is warranted if the one of the three previously mentioned lab values are elevated, or if the index of suspicion for infection is high despite normal values. Aspiration should not be undertaken until at least 2 weeks after discontinuation of antibiotic therapy. This is done in an outpatient setting with the patient under local anesthesia. Fluoroscopy or ultrasonography are useful for accurate insertion of the needle. The aspiration is done with the same attention to sterile technique as a surgical procedure, with a full surgical scrub and preparation. Skin flora may be introduced into the cultures and confuse the results, or, worse, they may be introduced into the joint. An 18-gauge spinal needle is inserted from anterior at a point just lateral to the femoral artery along a line from the symphysis pubis to the ASIS (see Chapter 22). As an alternative, the needle is inserted laterally, just superior to the greater trochanter. The tip of the needle must enter

TABLE 3.4

Breakdown of Bacteria Found in Infected Arthroplasties UNITED STATES S. aureus 35 Coag (-) staph 31 Streptococci 11 Enterococci 7 Gram negative 5 Other 11

UNITED KINGDOM 29 36 7 9 12 7

AUSTRALIA 40 13 3 1.5 5 37

Data from Fulkerson E, Valle CJ, Wise B, et al: Antibiotic susceptibility of bacteria infecting total joint arthroplasty sites, J Bone Joint Surg 88:1231–7, 2006; Peel TN, Cheng AC, Choong PF, Buising KL: Early onset prosthetic hip and knee joint infection: treatment and outcomes in Victoria, Australia, J Hosp Infect 82:248–253, 2012.

the joint and must be seen and felt to come in contact with the metal of the neck of the femoral component. Gentle rotation of the extremity helps bring fluid toward the needle if none is easily withdrawn after entering the joint. Aerobic and anaerobic cultures, and cell count with differential, are obtained from the aspirant. Leukocyte esterase test strip and alpha-defensin testing are additional synovial fluid markers for infection that have shown high sensitivity and specificity; they should be obtained if sufficient fluid is available. The International Consensus Meeting criteria for the diagnosis of periprosthetic hip or knee infection include both preoperative and intraoperative measures (Box 3.3).

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS Major criteria (diagnostic of infection if at least one is present) n  Two positive periprosthetic cultures with phenotypically identical organisms n  A sinus track communicating with the joint or visualization of the prosthesis Minor criteria n  Elevated serum CRP or D-dimer n  Elevated ESR n  Elevated synovial fluid WBC count or ++change on leukocyte esterase test strip or positive alpha-defensin n  Elevated synovial fluid polymorphonuclear neutrophil percentage (PMN%) n  Positive histologic analysis of periprosthetic tissue n  A single positive culture n  Positive intraoperative purulence 

MANAGEMENT

The treatment of infected THA consists of one or more of the following: 1. Antibiotic therapy 2. Debridement and irrigation of the hip with component retention 3. Debridement and irrigation of the hip with component removal 4. One-stage or two-stage reimplantation of THA 5. Amputation Management choices are made based on the chronicity of the infection, the virulence of the offending organism(s), the status of the wound and surrounding soft tissues, and the physiologic status of the patient.

EARLY POSTOPERATIVE INFECTION

Early infections may range in severity from superficial cellulitis that can be managed with antibiotics alone to deep infections that require surgical management. Superficial infections causing wound dehiscence or purulent drainage and infections associated with wound necrosis or infected hematoma often require surgical debridement. Thorough inspection should be made for subfascial extension of the infection, which requires a more extensive procedure. If an infection is thought to be superficial, preoperatively the joint is not aspirated to avoid contaminating it. Once medical comorbidities are optimized, arrangements are made to take the patient to the operating room, and the hip is prepared and draped in the routine manner. The previous skin incision and surgical approach are used. The wound is opened down to the deep fascia, and the structures are examined carefully to determine whether the infection extends beneath it and into the hip joint. If this fascial layer was closed carefully at the time of surgery, it may have acted as a barrier and prevented extension of the infection into the deeper tissues. If there is any question at the time of surgery as to whether the infection is deep, it is wiser to insert a needle into the hip joint to determine the presence or absence of a deep infection than to risk not draining an infected joint. If the infection is superficial, the wound is thoroughly irrigated with large quantities of a physiologic solution or an aqueous iodophor solution, and all necrotic subcutaneous tissue and skin are excised. The skin edges are approximated with interrupted monofilament sutures. If the infection extends to the hip joint, the wound is thoroughly debrided and irrigated. The hip must be dislocated to perform this procedure thoroughly, and if modular components have been implanted, the liner and femoral head are exchanged to limit the number of previously contaminated

BOX 3.3

Proposed 2018 International Consensus Meeting Criteria for Periprosthetic Joint Infection MAJOR CRITERIA (AT LEAST ONE OF THE FOLLOWING)

DECISION

Two positive growths of the same organism using standard culture methods Sinus track with evidence of communication to the joint or visualization of the prosthesis

Infected Infected

THRESHOLD Minor Criteria

Acute

Chronic

Serum CRP (mg/L) or D-dimer (μg/L)

100

10

Unknown

860

Elevated serum ESR (mm/h)

No role

30

Elevated synovial WBC (cells/μL) or Leukocyte esterase Positive alpha-defensin (signal/cutoff) Elevated synovial PMN (%) Single positive culture Positive histology

10,000

3000

++ 1.0 90

++ 1.0 70

Score

Decision

2

Positive interoperative purulence

1

3

Combined preoperative and postoperative score: ≥6 Infected 3-5 Inconclusive 115 mg/L

–1

≥7 C

2 1.5 1.5 2 2.5

B

0

1–2

3–4

COPD CRP >150 mg/L R Rheumatoid arthritis I Indication prosthesis: fracture M Male E Exchange of mobile components 80 Age >80 years

≥5 2 1 3 3 1 –1 2

FIGURE 3.131 KLIC and CRIME80 scoring systems estimate failure rates for debridement and component retention in the early postoperative and acute hematogenous settings, respectively. (From Argenson JN, Arndt M, Babis G, et al: Hip and knee section, treatment, debridement and retention of implant: Proceedings of International Consensus on Orthopedic Infections, J Arthroplasty 334:S399, 2019.)

foreign bodies and allow for more thorough debridement. Implants should be tested carefully for stability and should be left in situ only if there is no evidence of loosening. Cultures of joint fluid or other fluid collections encountered along with tissue cultures from the superficial, deep, and periprosthetic layers are sent for analysis of the offending organism and antibiotic sensitivities. The appropriate antibiotic, as determined by the cultures and sensitivity tests, is given intravenously most commonly for 6 weeks, preferably under the direction of an infectious disease consultant. Continued oral antibiotic therapy for suppression may be considered in patients unable to tolerate further surgical procedures. Success rates for patients with early postoperative or acute hematogenous infections treated with debridement, irrigation, and implant retention range from 20% to 100%. The KLIC and CRIME80 scoring systems are available to estimate the chance of success with debridement and component retention in these settings (Fig. 3.131). 

LATE CHRONIC INFECTION

Surgical debridement and component removal are required for late chronic infection if eradication of the infection is to be reasonably expected. Poor results are documented after debridement and component retention in patients with late chronic infections. The joint is approached through the previous incision. Narrow skin bridges between previous scars should be avoided to minimize the risk of marginal wound necrosis. Sinus tracks are debrided, and previously placed nonabsorbable sutures and trochanteric implants are removed. The hip is dislocated, and all infected and necrotic material is excised. Joint fluid and tissue specimens from the acetabular and femoral regions are sent for cultures for a total of at least three specimens. Intraoperative Gram stains are not helpful at this stage because of poor sensitivity. The femoral and acetabular components and any other foreign material, including cement, cement restrictors, cables, or wires, are removed to

eliminate all surfaces that could harbor bacteria (see section on revision of THA). One possible exception to the recommended complete removal of implants is a well-fixed component whose removal would cause significant bone loss. After all cultures are taken, the joint is irrigated copiously with saline or dilute povidone-iodine solution using pulsatile lavage. After irrigation, the joint should be carefully inspected again for retained foreign bodies or infected or necrotic tissue. Intraoperative radiographic or image intensifier inspection is indicated if complete implant removal is in doubt. If this inspection proves satisfactory, the fascia is closed with a running, absorbable, monofilament suture, and the skin is closed with interrupted nonabsorbable monofilament sutures. Antibiotic-impregnated methacrylate beads and temporary articulating antibiotic spacers are discussed in the section on reimplantation after infection. 

ACUTE HEMATOGENOUS INFECTION

Some patients have no history suggestive of perioperative sepsis, yet the hip becomes acutely painful long after the index operation. In these instances, the infection may have been caused by hematogenous spread from a remote site of infection or from transient bacteremia caused by an invasive procedure. Patients with total hip arthroplasties should be advised to request antibiotic management immediately if they have a pyogenic infection, and they must be observed carefully for any evidence of hip infection. Transient bacteremia occurs after dental procedures, including simple cleaning; however, the role of antibiotic prophylaxis in this setting has been questioned. In 2012, the AAOS and American Dental Association published recommendations for antibiotic prophylaxis for patients with total joint arthroplasties undergoing dental procedures. 1. The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures. Grade of Recommendation: Limited

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PART II  RECONSTRUCTIVE PROCEDURES OF THE HIP IN ADULTS 2. We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures. Grade of Recommendation: Inconclusive 3. In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene. Grade of Recommendation: Consensus Pain on weight bearing, with motion of the hip, and at rest is the chief symptom of acute hematogenous infection. The patient may be febrile and have an elevated peripheral WBC count; the ESR and CRP level also usually are elevated. The diagnosis usually can be established by aspirating the hip and obtaining appropriate studies as previously described. While reports on cultures are being completed, broad-spectrum antibiotics effective against gram-positive and gram-negative organisms are administered intravenously. If acute hematogenous infection is confirmed, debridement and component retention may be attempted as in early postoperative infection. The acceptable amount of time between onset of symptoms and debridement is controversial, ranging from 5 days to 3 months. Other factors, such as the virulence of the infecting organism, medical status of the patient, and overall quality and integrity of the surrounding soft tissues, also must be considered. Alternatively, some authors have pursued a more aggressive approach to patients with acute hematogenous infection by complete removal of components and immediate reimplantation with primary cementless components. Hansen et  al. treated 27 patients in this manner, along with 6 weeks of intravenous antibiotics and varying courses of oral antibiotics; 70% retained their implants although repeat debridement was required in four. Regardless of the timing of the infection and other variables, if the prosthesis is loose, debridement should be combined with complete component removal as for late chronic infection. 

RECONSTRUCTION AFTER INFECTION

The results of modified Girdlestone resection arthroplasty after a total hip replacement in general are not as satisfactory as the results after hip joint infections that have required less bone and soft-tissue resection. Almost all patients require some sort of assistive device to walk. Functional outcomes are poor in elderly patients, females, and patients with more extensive resection of bone from the proximal femur. Most patients are unwilling to live with the constraints of a resection arthroplasty and will elect to undergo reimplantation of their prosthesis. Reconstruction after infection of a THA is problematic. The functional impairment of the patient, the infecting organism(s), the adequacy of debridement, and evidence of control of local and distant sites of infection all are factors in the decision to implant a new prosthesis. Another dilemma involves the decision to proceed with reimplantation of the hip prosthesis at the time of the initial debridement, so-called one-stage exchange, or to wait to reimplant the arthroplasty at a second operation. Two-stage or delayed reimplantation, commonly done in North America for chronic infections, is advantageous for a number of reasons: (1) the adequacy of debridement is ensured because repeat debridement of soft tissues, necrotic bone, and retained cement can be done before reimplantation; (2) the infecting organisms are identified, their sensitivities are determined, and appropriate antibiotic management is instituted for a prolonged period

before reimplantation; (3) diagnostic evaluation for foci of persistent infection can be done; (4) distant sites of infection responsible for hematogenous spread can be eradicated; and (5) an informed decision can be made as to whether the degree of disability from the resection arthroplasty would justify the risks inherent in the implantation of another prosthesis. The disadvantages of a two-stage reconstruction include (1) the prolonged period of disability, (2) the sizable cost, including lost wages, (3) delayed rehabilitation, and (4) technical difficulty of the procedure owing to shortening and scarring. According to the International Consensus on Musculoskeletal Infection, one-stage exchange is reasonable when effective antibiotics are available and systemic symptoms of sepsis are absent. Other relative contraindications to single-stage treatment include lack of preoperative identification of the infecting organism, patients with multiple medical comorbidities, presence of sinus track(s), and soft-tissue compromise possibly requiring flap coverage. The committee also recognized the importance of antibiotic-containing cement or bone graft in the reconstruction to achieve success. Conversely, two-stage exchange arthroplasty is indicated for septic or medically compromised patients, unidentified organisms, virulent/drug-resistant bacteria, sinus tracts, and compromised surrounding soft tissues. Delayed reconstruction is associated with lower rates of recurrent infection in most studies. In a review of 168 patients treated with two-stage exchange, infection-free survival was 87.5% at 7 years average follow-up. Femoral component fixation method, with or without cement, had no effect on reinfection or mechanical complication rates. The decision regarding cemented or cementless reimplantation should be guided by the available femoral bone stock and the physiologic age and expected longevity of the patient, in addition to the reported infection cure rates with each technique. Twostage exchange does carry a significant risk of mortality. An administrative database study of over 10,000 patients treated with prosthesis removal and spacer placement found 90-day mortality rate to be 2.6%, significantly higher than carotid endarterectomy, prostatectomy, and kidney transplantation. Duncan and Beauchamp described a technique of twostage reimplantation in which a prosthesis of antibioticloaded acrylic cement (PROSTALAC) is implanted at the time of the initial debridement. The prosthesis is constructed intraoperatively by molding antibiotic-laden cement around a simplistic femoral component and an all-polyethylene acetabular component. The custom-made components are implanted with an interference fit without any attempt to achieve cement intrusion, simplifying extraction during the second stage. In the interim, the articulated spacer maintains leg length and improves control of the limb and mobilization. At 10- to 15-year follow-up, Biring et  al. reported an overall 89% success rate with the PROSTALAC technique. Others have described similar interval spacers of various types, with 77% to 100% eradication of the infection reported (Fig. 3.132). Complications other than recurrent or persistent infection include dislocation or fracture of the interval prosthesis. The optimal timing for reimplantation of another prosthesis has not been determined. Numerous authors have reported series of patients in whom reimplantation was undertaken in periods of less than 1 year, with an incidence of recurrent infection similar to that in patients in whom reconstruction was delayed further. Currently, we continue

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CHAPTER 3  ARTHROPLASTY OF THE HIP

A FIGURE 3.132 Prosthesis of antibiotic loaded acrylic cement (PROSALAC) after original component removal, debridement, and irrigation.

parenteral antibiotics for 6 weeks. Reconstruction is performed at approximately 3 months if the ESR and CRP are improving, and repeat aspiration of the hip (if performed because of concern of persistent infection) is negative. Reimplantation of a total hip can be difficult because of extensive scarring of the soft tissues and disuse osteoporosis. Restoration of limb length and full motion of the hip may not be achieved, and dislocation after surgery is not uncommon. The sciatic nerve may be encased in scar tissue near the posterior margin of the acetabulum and should be protected. Complete capsulectomy, along with release of the iliopsoas and gluteus maximus tendons may be necessary to reduce the hip. The superior margin of the acetabulum may be deficient, and augmentation in this area may be required. The bone usually is soft, and the acetabular bed can be prepared easily, but care must be taken not to penetrate the medial wall of the acetabulum. If the anterior or posterior wall is thin, it may be fractured if an oversized acetabular component is press-fitted into place. The femoral canal must be prepared carefully to avoid fracture or penetration of the cortex. Placement of one or more prophylactic cerclage wires helps prevent shaft fracture. Before the femoral component is permanently seated, a trial reduction of the hip is absolutely necessary. Using a femoral component with a short neck or shortening the femur by removing more bone from the neck may be necessary before the hip can be reduced. Aerobic and anaerobic tissue cultures are taken from at least three sites, along with tissue specimens for histologic examination. If eradication of the infection is in doubt, frozen sections of tissue can be examined by the pathologist for evidence of residual inflammatory change. If large numbers of polymorphonuclear cells are present (10/high-power field), the hip is debrided again, and reimplantation is delayed. If cultures taken at the time of surgery are positive, the appropriate antibiotics are continued, although the optimal duration and method of administration are unknown in this setting.

B

FIGURE 3.133 A and B, Elderly, minimally ambulatory man with infected total hip arthroplasty and draining sinuses. Treatment with resection arthroplasty and intravenous antibiotics was successful.

Recurrence of infection after two-stage reimplantation of an infected total hip is a particularly difficult situation and seldom results in a satisfactory outcome. Repeated two-stage exchange can be attempted if the infection is controlled after the first stage, the patient is able to tolerate subsequent surgery, and adequate soft tissues are available for coverage. A 36% to 40% success rate has been reported in these circumstances. Resection arthroplasty is more effective in resolving the infection but is associated with poor function and residual pain (Fig. 3.133). Treatment of the infection takes precedence over reconstruction of the hip. In rare cases, disarticulation of the hip may be indicated as a lifesaving measure because of uncontrollable infection, severe soft-tissue compromise, or vascular complications. This drastic procedure should be considered in the presence of a persistent, painful, untreatable infection that is debilitating to the patient and a limb that hinders walking and sitting. 

LOOSENING

Femoral and acetabular loosening are some of the most serious long-term complications of THA and commonly lead to revision. (The treatment of component loosening is discussed in the section on revision of THA.) In all patients suspected of having loosening of one or both components, the possibility of infection must be considered. In this section, noninfected (aseptic) loosening is discussed (loosening as a result of sepsis is discussed in the section on infection). Criteria for the diagnosis of loosening of either the femoral or acetabular component have not been universally accepted. This complicates the comparison of available studies in the literature of loosening and long-term performance of THA. Some studies define failure as radiographic evidence of loosening despite continued satisfactory clinical performance. Others stress survivorship and define the end point as revision or removal of the prosthesis. At each postoperative visit, radiographs should be inspected for changes in the components, the cement

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1 2 1

7 3

2

6

3

5

4

A

B

FIGURE 3.134 Zones around cement mass in femur (A), as described by Gruen, and in pelvis (B), as described by DeLee and Charnley. (Redrawn from Amstutz HC, Smith RK: Total hip replacement following failed femoral hemiarthroplasty, J Bone Joint Surg 61A:1161, 1979.)

(if present), the bone, and the interfaces between them. Anteroposterior and lateral radiographs must include the entire length of the stem and must be inspected carefully and compared with previous films for changes. It is helpful to record the specific zones around acetabular and femoral components in which changes develop (Fig. 3.134). The femoral component and associated interfaces are divided into seven zones, as described by Gruen et  al. The acetabular component and surrounding bone are divided into three zones, as described by DeLee and Charnley.

FEMORAL LOOSENING

To compare radiographs made at various intervals after surgery, standardized technique and positioning of the limb should be used. Albert et al. found apparent changes in the position of the femoral component with 10 degrees of rotation of the extremity. Such changes may be interpreted incorrectly as component migration or mask real changes in component position.

CEMENTED FEMORAL COMPONENTS

Following is a list of changes in the stem and the cement around it suggestive of loosening of the femoral component. 1. Radiolucency between the superolateral one third of the stem (Gruen zone 1) and the adjacent cement mantle, indicating debonding of the stem from the cement and possible early stem deformation 2. Radiolucency between the cement mantle and surrounding bone 3. Subsidence of the stem alone or in combination with the surrounding cement mantle 4. Change of the femoral stem into a more varus position 5.  Fragmentation of the cement, especially between the superomedial aspect of the stem and the femoral neck (Gruen zone 7) 6. Fracture of the cement mantle, most commonly near the tip of the stem (Gruen zone 4)

7 . Deformation of the stem 8. Fracture of the stem Harris, McCarthy, and O’Neill defined femoral component loosening radiographically in three gradations: definite loosening, when there is migration of the component or cement; probable loosening, when a complete radiolucency is noted around the cement mantle; and possible loosening, when an incomplete radiolucency surrounding more than 50% of the cement is seen. Subsidence may not be appreciated unless the relationship of the stem and cement mantle to the proximal femur is carefully evaluated with serial radiographs. The stem may subside in the cement, in which case there usually is a fracture of the cement near the tip of the stem, or the entire cement mantle and stem may subside. Subsidence may be quantified by measuring the distance between a fixed point on the stem and another radiographic landmark, such as a trochanteric wire or cable or a bony prominence such as the lesser or greater trochanter. The following are technical problems that contribute to stem loosening: 1.  Failure to remove the soft cancellous bone from the medial surface of the femoral neck; consequently, the column of cement does not rest on dense cancellous or cortical bone and support the stem. The cement is subjected to greater forces and fractures more easily. 2. Failure to provide a cement mantle of adequate thickness around the entire stem; a thin column cracks easily. The tip of the stem should be supported by a plug of cement because this part of the stem is subjected to axial loading. 3. Removal of all trabecular bone from the canal, leaving a smooth surface with no capacity for cement intrusion or failure to roughen areas of smooth neocortex that surrounded previous implants. 4. Inadequate quantity of cement and failure to keep the bolus of cement intact to avoid lamination. 5. Failure to pressurize the cement, resulting in inadequate flow of cement into the interstices of the bone. 6.  Failure to prevent stem motion while the cement is hardening. 7. Failure to position the component in a neutral alignment (centralized) within the femoral canal. 8. The presence of voids in the cement as a result of poor mixing or injecting technique. Barrack, Mulroy, and Harris described a grading system for the femoral component cement mantle. Complete filling of the medullary canal without radiolucencies (“white-out”) is termed grade A. Slight radiolucency at the bone-cement interface (2 stents OR on anticoagulation

≤2 stents AND no anticoagulation

History of DVT/PE Yes None

Outpatient total Joint patient Selection algorithm

Relative contraindication to outpatient TJA No tranexamic acid

Outpatient TJA candidate

FIGURE 10.6 Algorithm for patient selection for outpatient total joint procedures. BMI, Body mass index; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; DVT, deep vein thrombosis; HTN, hypertension; ICD, implantable cardiac defibrillator; OSA, obstructive sleep apnea; PE, pulmonary embolism; PTCA, percutaneous transluminal coronary angioplasty; TJA, total joint arthroplasty. (From Fournier MN, Stephens R, Mascioli AA, et al: Identifying appropriate candidates for ambulatory outpatient total joint arthroplasty: validation of a patient selection algorithm, J Shoulder Elbow Surg. 28(1):65, 2019.)  

TOTAL ANKLE ARTHROPLASTY

Make an incision from about 10 cm proximal to the ankle joint on the lateral side of the anterior tibial tendon, over the flexor hallucis tendon. This incision is medial to the most medial major branch of the superficial peroneal nerve, the dorsal medial cutaneous nerve. Often a very small medial branch of this nerve crosses the incision just distal to the ankle joint and must be incised for exposure. The patient should be warned before surgery that a small area of numbness may be present just medial to the incision. n  Open the flexor hallucis longus sheath and retract the tendon medially. Retract the neurovascular bundle containing the anterior tibial artery, vein, and deep peroneal nerve laterally with the extensor digitorum longus tendons. n  Make a straight incision in line with the skin incision in the ankle capsule and reflect the capsule medially until the medial ankle gutter is exposed and laterally until the lateral gutter is exposed. n  Expose the dorsal talonavicular joint and remove any anterior, medial, or lateral osteophytes. If better exposure of the joint line is needed, use an osteotome to perform a more aggressive removal of the anterior osteophytes. n  Prepare the bone for implant insertion according to the technique guide specific for the implant selected. Take n 

TECHNIQUE 10.1 PATIENT POSITIONING

Most systems require an anterior approach to the ankle. Place the patient supine on the operating table with the foot near the end of the table. Place a small bump or lift under the ipsilateral hip to help place the ankle straight and avoid the tendency of the leg to externally rotate. n  After induction of general anesthesia, apply and inflate a thigh tourniquet to control bleeding and improve visualization.  n 

APPROACH Any significant deformity above or below the ankle joint must be corrected before placement of the total ankle implants (see Technique 10.2). n  The approach is determined by the prosthesis design, and the reader is referred to the specific implant chosen; however, most systems require an anterior approach to the ankle. n 

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Candidate for TAA

Inpatient

No

Patient/family willing and able?

Patient motivated Patient compliant Patient high functioning/mobile Good support system in the home

Yes

Inpatient

No

Surgeon / center experienced?

Yes

Yes Inpatient

Presence of significant comorbidities

Obesity (BMI ≥40) Significant lung disease Severe sleep apnea Congestive heart failure Chronic kidney disease Patient requiring blood thinner bridging

No

Yes Inpatient

Anesthesia contraindication?

History of chronic pain/narcotic use Unwilling to undergo regional anesthesia

No

Yes Inpatient

Flatfoot reconstruction Double/triple arthrodesis Significant ligamentous reconstruction Revision TAA – excluding:

Complex associated procedures?

No

Cyst grafting Isolated poly exchange Isolated gutter debridement Bilateral TAA

Outpatient fast track TAA

FIGURE 10.7 Algorithm for selection of patients for outpatient ambulatory total ankle arthroplasty. BMI, Body mass index; TAA, Total ankle arthroplasty. (From Taylor MA, Parekh SG: Optimizing outpatient total ankle replacement from clinic to pain management, Orthop Clin N Am 49:541–551, 2018.)

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CHAPTER 10  TOTAL ANKLE ARTHROPLASTY care to place the implant in proper alignment in all planes for sufficient bone coverage of the prosthesis and for proper tensioning of the soft tissues and ligamentous support after final implantation. There should be a balance between choosing a thicker polyethylene insert (better for wear characteristics) and excessive bone resection and joint motion and stability. n  Close the capsule over the prosthesis and insert a closed suction drain; close the superior extensor retinaculum over the flexor hallucis longus sheath and close the skin in layers. n  A popliteal block is routinely used for postoperative analgesia.

POSTOPERATIVE CARE  At our institution, patients are typically kept overnight in the hospital and are seen by a physical therapist the following day for instruction in gait training with touch-down weight bearing. Patients with outpatient TAA have physical therapy instruction before surgery and carry out learned exercises at home. Therapy with antibiotics, binasal cannula oxygen, and deep venous thrombosis (DVT) prophylaxis with low-molecular-weight heparin is the normal postoperative protocol, although this is not typically continued after discharge unless the patient has risk factors for DVT; one aspirin daily after discharge may be beneficial. Different implants have different recommendations for postoperative care, but we typically delay weight bearing for 4 to 6 weeks and begin active ankle motion once the incision is healed, typically 2 weeks after surgery. Gradual progressive weight bearing, calf strengthening, proprioceptive training, and range-ofmotion exercises are started at 4 to 6 weeks, with the ankle protected in a prefabricated walking boot. A light ankle brace is applied at 8 to 10 weeks, and full activities are allowed at 3 months, or when the calf muscles are fully rehabilitated. No restrictions are placed on the patients’ activities or sports programs, but they are encouraged to avoid impact exercises for conditioning.    

CONSIDERATIONS FOR ADJUNCTIVE PROCEDURES DEFORMITY CORRECTION

Osteoarthritic ankles considered for arthroplasty should have minimal periarticular deformity, or this deformity should be correctable with osteotomy or arthrodesis. Determination of the site of the deformity is mandatory. Bonasia et  al. characterized deformities as varus or valgus, incongruent or congruent (Table 10.2). In the valgus ankle and hindfoot, the following procedures should be considered: medial displacement osteotomy of the calcaneus (see Technique 83.7), Cotton osteotomy of the medial cuneiform or selective arthrodesis of the medial midfoot (see Techniques 83.8 and 85.5), subtalar arthrodesis with or without talonavicular arthrodesis (see Technique 85.6), posterior tibial tendon reconstruction with tendon transfer (see Technique 83.2), and closing wedge osteotomy of the distal tibia (see Technique 58.10). Demetracopoulos et  al. evaluated 80 patients with preoperative valgus deformities of at least 10 degrees (average of 15 degrees). After TAA, the average postoperative deformity was 1.2 degrees, with significant improvements in VAS, SF-36, American Orthopaedic



TABLE 10.2

Ankle Joint Pathologies That Include Distal Tibial Articular Surface Malalignment, Talar Tilt due to Ligamentous Instability, or Both DEFORMITY TYPE Varus tibial deformitycongruent joint

ABNORMAL ANGLES Increased LDTA, CORA at the level of tibial articular surface, normal tibial-talar angle Valgus tibial deformity- Increased LDTA, CORA at the level congruent joint of tibial articular surface, normal tibial-talar angle Varus tibial deformity- Decreased LDTA, CORA at the incongruent joint level of tibial articular surface, tibial-talar angle >10 degrees Valgus tibial deformity- Increased LDTA, CORA at the level incongruent joint of tibial articular surface, tibialtalar angle >10 degrees Incongruent joint Normal LDTA, tibial-talar angle >10 degrees

ADTA, Anterior distal tibial angle, sagittal plane—increased ADTA represents recurvatum deformity; CORA, center of rotation of angulation, at or proximal to joint line; LDTA, lateral distal tibial angle, coronal plane—decreased LDTA represents varus deformity; T-T angle—angle formed by tibial and talar articular surfaces: >10 degrees = incongruent joint. Modified from Bonasia DE, Dettoni F, Femino JE, et al: Total ankle replacement: When, why, and how?, Iowa Orthop J 30:119–130, 2010.

Foot and Ankle Society (AOFAS), and Short Musculoskeletal Function Assessment (SMFA) scores. The authors concluded that correction of coronal alignment could be obtained and maintained in patients with moderate-to-severe preoperative valgus malalignment. Lee et  al. compared intermediate and long-term outcomes of TAA in 144 ankles with preoperative varus, valgus, or neutral alignment. Outcomes similar to those in ankles with neutral alignment were obtained in ankles with varus or valgus malalignment of up to 20 degrees when neutral alignment was achieved with TAA. For the varus ankle, procedures to consider include deltoid ligament release or sliding osteotomy of the medial malleolus, opening wedge osteotomy of the distal tibia (see Technique 11.1), Dwyer closing wedge osteotomy of the calcaneus (see Technique 87-11), dorsiflexion osteotomy of the first metatarsal (see Technique 84-19), and subtalar, double, or triple arthrodesis (see Chapter 85). Varus deformity of the distal tibia above the level of the joint is best treated with supramalleolar osteotomy. Varus deformity of the tibial plafond at the joint from erosion of the medial malleolus or medial subchondral bone can be corrected by accurate placement of the tibial cut. Joo and Lee reported satisfactory clinical and radiographic outcomes in patients with moderate and severe varus deformities similar to those in patients with neutral alignment when postoperative neutral alignment was obtained, and special care was taken to correct causes of the varus malalignment with additional procedures. For the varus unstable ankle with deformity below the level of the joint, sometimes an osteotomy of the hindfoot is required (Fig. 10.8). If instability persists intraoperatively, a lateral ligament reconstruction should be done. Judicious release of the deltoid ligament, especially the deep deltoid

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A

B FIGURE 10.8 A and B, Calcaneal osteotomy and midfoot arthrodeses were required to correct pes planus deformity before total ankle arthroplasty.

ligament, may be wise in this setting. To avoid devascularization of the talus by injury to the deltoid branch of the posterior tibial artery, a sliding osteotomy of the medial malleolus has been described, with or without fixation. Reddy et al. reported correction of coronal plane deformity without osteotomy in ankles with an average of 18 degrees of varus. Deltoid release was necessary for all ankles with more than 18 degrees of varus deformity, and all ankles with more than 25 degrees of varus developed recurrent deformity. Hobson et al. suggested that TAA could be safely done with up to 30 degrees of coronal plane deformity. In their short-term follow-up of 103 patients with severe varus deformities, Sung et  al. found that those with more than 20 degrees of varus deformity had outcomes similar to those with varus deformities of less than 20 degrees, with no significant differences in postoperative complications or implant failures. Adjunctive procedures, such as osteotomy, ligament release or lengthening, and tendon transfers, were done as needed. In the comparison study of Lee et al., adjunctive procedures were required in 71% of ankles with varus

deformities, in 56% of those with valgus deformities, and in 39% of those with neutral alignment. Percutaneous Achilles tendon lengthening and release of the medial deltoid ligament were the most frequently done concomitant procedures; calcaneal osteotomy was done in five ankles (three in the varus group and two in the valgus group). Tan and Myerson divided varus ankle deformities into anatomic levels and described procedures for correction at each level. For extraarticular deformity above the ankle joint, they recommended a medial opening wedge osteotomy or, for severe ankle arthritis, a dome osteotomy. With a medial opening wedge osteotomy, they recommended a staged procedure in which total ankle replacement is done later. The dome osteotomy is useful for multiplanar supramalleolar deformity and can usually be done simultaneously with replacement (Fig. 10.9). For deformity at the level of the ankle joint and a congruent joint, a “neutralizing” distal tibial cut may be all that is needed for realignment. A wedge of the distal tibia is removed with minimal bone resection at the eroded medial plafond and a larger resection at the lateral plafond. For a severely tilted talus, additional procedures are required, including the removal of osteophytes from the lateral gutter and a lateral ankle stabilization procedure. Medial-side releases of the deltoid and posterior tibial tendon have been described, but Tan and Myerson recommended a lengthening medial malleolar osteotomy, as described by Doets et al. (Fig. 10.10), rather than soft-tissue releases, because it allows controlled lengthening of the medial side of the ankle and provides reliable bony healing. With more severe varus tilt of the talus with a markedly dysplastic medial malleolus and incongruent joint, a useful alternative osteotomy is the medial tibial plafondplasty, which is done as a separate, staged procedure before ankle replacement. Residual heel varus that remains after component implantation can be corrected with a lateralizing calcaneal osteotomy. Combined deformities are generally best treated with correction of the deformities, followed by a staged ankle arthroplasty. Supramalleolar deformities are corrected first, followed by correction of hindfoot and forefoot varus and any ligamentous reconstruction needed.   

DOME OSTEOTOMY FOR CORRECTION OF VARUS DEFORMITY ABOVE THE ANKLE DEFORMITY TECHNIQUE 10.2 (TAN AND MYERSON) Make an anterior midline incision, which also will be used for implantation of the total ankle prosthesis. n  Use cautery to carefully mark out the planned dome osteotomy, placing the center of the radius of curvature of the dome at the center of rotation of angulation. n  Make sure the cut will allow adequate room for the tibial prosthesis and its stem after internal fixation of the osteotomy. n  Drill multiple bicortical holes along the planned osteotomy and connect them with an osteotome to complete the osteotomy (Fig. 10.11A). n 

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FIGURE 10.9 Dome osteotomy and ankle replacement done at the same time. A, Osteotomy is marked with electrocautery and completed. B, Osteotomy is then stabilized with an anterior plate placed superior to the tibial component. C, Total ankle components are then implanted in the usual fashion. (From Tan KJ, Myerson MS: Planning correction of the varus ankle deformity with ankle replacement, Foot Ankle Clin N Am 17:103–115, 2012.)  

MEDIAL TIBIAL PLAFONDPLASTY FOR VARUS DEFORMITY AT THE ANKLE JOINT

15°

TECHNIQUE 10.3 (TAN AND MYERSON) Make a medial incision along the subcutaneous border of the tibia. n  Insert a guide pin in the medial tibia, aimed to exit at a point in the plafond just medial to the midpoint where the articular erosion ends. This acts as a guide for the planned osteotomy. n  Under fluoroscopic guidance, insert three additional Kirschner wires parallel to and 6 mm above the joint line in the subchondral bone of the distal tibia. These wires prevent violation of the articular surface by the oscillating saw used to make the osteotomy. n  Use an oscillating saw to make the osteotomy to the level of the three Kirschner wires and insert a broad osteotome to hinge open the osteotomy. n  Hinge the medial malleolar fragment downward to restore a more normal morphology of the ankle mortise. n  Debride the lateral gutter to facilitate realignment and to obtain lateral-sided stability, which may require an additional lateral-sided reconstruction. n  Hold the osteotomy open with a lamina spreader and pack it tightly with bone graft. n  Fix the osteotomy with a plate and screws.    n 

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FIGURE 10.10 Medial malleolar lengthening osteotomy. A, Ankle with incongruent varus deformity. B, After implantation of a mobile-bearing prosthesis and correction of the deformity by medial malleolar osteotomy. (From Doets HC, van der Plaat LW, Klein JP: Medial malleolar osteotomy for the correction of varus deformity during total ankle arthroplasty: results in 15 ankles, Foot Ankle Int 29:171–177, 2008.)

Manipulate the distal fragment in the coronal and sagittal planes to correct the deformity. n  Stabilize the osteotomy with an anterior plate and screws (Fig. 10.11B, C). n  Proceed with TAA in the usual fashion n  Inflate the tourniquet after the arthrotomy and before preparation of the osseous surfaces.     n 

LIGAMENT CONSIDERATIONS

Ligament stability is also imperative for optimal outcome, especially with less constrained designs. Some stability can be obtained intraoperatively by proper selection of implant and polyethylene thickness, but occasionally collateral ligament reconstruction should be done.

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FIGURE 10.11 Intraoperative fluoroscopy views of medial malleolar osteotomy. A, Plane of the osteotomy is planned with a Kirschner wire and completed. B, Next, it is provisionally fixed with cannulated wires. C, The wires are replaced with cannulated screws after the prosthesis is implanted. (From Tan KJ, Myerson MS: Planning correction of the varus ankle deformity with ankle replacement, Foot Ankle Clin N Am 17:103–115, 2012. SEE TECHNIQUE 10.2.

Techniques for the reconstruction of a chronically unstable ankle are discussed in Chapter 90. Coetzee, however, reported that the usual “anatomic” lateral ligament reconstruction techniques were not satisfactory with TAA. He described a simple, nonanatomic reconstruction to provide a strong checkrein against inversion and to limit anterior translation of the ankle (Technique 10.4). Medial reconstruction of the deltoid ligament with TAA is uncommon, but sometimes necessary, in late-stage posterior tibial tendon insufficiency (see Chapter 83). Correction of hindfoot valgus with osteotomy and/or arthrodesis may provide enough mechanical support to allow stability of the ankle prosthesis. Reconstruction of the deltoid ligament in this setting is an advanced procedure, and complications are not uncommon. Arthrodesis of the ankle may be advisable.   

RECONSTRUCTION OF LATERAL ANKLE LIGAMENTS FOR CHRONIC INSTABILITY AS AN ADJUNCT TO TOTAL ANKLE ARTHROPLASTY TECHNIQUE 10.4 (COETZEE) After implantation of the ankle components, perform a modified Broström reconstruction of the lateral ligaments (see Technique 90.2). n  Make a separate incision to expose the lateral side of the ankle and the peroneal tendons. Harvest one half of the peroneus brevis tendon. If the tendon has signs of a pathologic process or a tear, harvest the entire tendon to ensure maximal strength. Leave the distal attachment intact and harvest the tendon as far proximal as possible. n  Route the peroneus brevis tendon over the modified Broström repair from the lateral side of the ankle to the anterolateral tibia. n 

Secure the tendon under adequate tension to the tibia with a staple. n  Test the stability of the ankle to be sure that equal medial and lateral joint movements are possible.    n 

Often, patients with arthritis of the ankle have a concomitant contracture of the triceps surae and may benefit from a lengthening procedure. Assessment of a contracture may be difficult in a stiff, arthritic ankle, but should be attempted after placement of the components. To regain ankle extension, either a smaller polyethylene component can be used, or a lengthening procedure can be done. Most patients with a significant contracture require a gastrocnemius recession (Vulpius) rather than a triple hemi-section; however, Queen et  al. found equivalent outcomes with the two procedures. Patients with either lengthening procedure had better outcomes than those with TAA alone.

SPECIAL CIRCUMSTANCES

INFLAMMATORY ARTHRITIS

Patients with rheumatoid arthritis commonly have involvement of the foot and ankle, with severe pain and functional limitations. Arthrodesis has been the standard procedure for these patients, but more recently arthroplasty is being chosen because of the ability to preserve motion and decrease stress on the midfoot and subtalar joints. Early results of TAA in these patients were disappointing, with high complication rates and component loosening in as many as 75%. More recent studies, with the use of newer techniques and implants, report better outcomes. Kraal et  al. had a cumulative incidence of failure at 15 years of 20% in 76 rheumatoid patients with mobile-bearing total ankle replacement. Pedersen et  al. found similar outcomes in 50 patients with rheumatoid arthritis compared with a matched cohort of 50 patients with noninflammatory arthritis, although the noninflammatory arthritis group reported better function at final follow-up. Revision rates were 12% in the rheumatoid arthritis group and 10% in the noninflammatory arthritis group. Other studies have documented reliable pain relief and good

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CHAPTER 10  TOTAL ANKLE ARTHROPLASTY functional results with uncemented prostheses and cemented two-piece and three-piece implants in patients with rheumatoid arthritis. 

OBESITY

Obesity (body mass index [BMI] >30) is a growing problem that affects all types of orthopaedic surgery, including total joint replacement. Many patients with arthritis of the ankle are sedentary and obese, and this poses a dilemma for the surgeon, who must weigh the possibility of providing significant pain relief against the likelihood of implant failure caused by increased stress on the implant from extra weight. Outcomes of TAA in obese and morbidly obese (BMI >40) patients reported in the literature are varied. Schipper et al. compared outcomes in obese and nonobese patients and found that obese patients had an increased long-term risk of implant failure and a significantly decreased 5-year implant survivorship, whereas Bouchard et al. found no significant difference in the proportion of complications or revisions in a similar comparison study. Barg et  al. also reported comparable survivorship (93% at 6 years), as well as significant pain relief and functional improvement in obese patients. In a series of 455 patients, including 266 with BMI of less than 30 (control), 116 with a BMI between 30 and 35, and 73 with a BMI of over 35, Gross et al. found no difference in complication, infection, or failure rates. Although obese patients had lower functional outcome scores, they did have significant functional and pain improvements after TAA. Although we have no definitive upper limit on weight for this procedure, a BMI over 40 is a reason for caution and careful patient counseling. Morbidly obese patients are strongly encouraged to use a bracing system to provide a measure of pain relief while they actively work on weight loss. 

DIABETES

Perhaps no other medical condition affects decision making in foot and ankle surgery as much as diabetes. It has been shown to be a factor contributing to complications, particularly infection, after a variety of orthopaedic procedures. In their review of a national database, Schipper et al. found that diabetes was independently associated with a significantly increased risk of perioperative complications, nonhome discharge, and length of hospital stay after TAA and ankle arthrodesis. Gross et al., however, compared outcomes of TAA in 50 patients with diabetes with those in 55 patients without diabetes and found no significant differences in secondary operations, revisions, or failure rates. Although patients with diabetes were heavier and had worse ASA preoperative grades, they did not have significantly different rates of complications or infections, and all had pain relief and improved function. Findings that support the use of TAA in diabetic patients include hemoglobin A1C consistently less than seven, no evidence of peripheral neuropathy, normal vascular status, normal weight (or at least not morbid obesity), and no other target organ disease (retinopathy or nephropathy). 

OSTEONECROSIS OF THE TALUS

Little has been written regarding the long-term results of TAA in patients with osteonecrosis of the talus. Certainly, a patient with an avascular, fragmented, and collapsed talar body is not a candidate for a total ankle prosthesis, and arthrodesis is recommended. However, a few patients with apparent osteonecrosis of the talus do not have collapse, and over a long period of time (minimum of 24 to 36 months) portions of the talus

may gradually revascularize, making the patient a better candidate for TAA (Fig. 10.12). A thorough evaluation with MRI or bone scanning may give clues as to whether or not a talus will accept and support a talar component. Lee et al. reported two successful total ankle arthroplasties after revascularization of the talus. 

PANTALAR DISEASE; CONCOMITANT HINDFOOT ARTHRODESIS

Arthrodesis of arthritic adjacent joints, most often the subtalar and talonavicular joints, may be necessary with TAA. Mild to moderate arthritis in the adjacent joints, however, does not necessarily mean that arthrodesis is necessary. Often, the pain relief and improvement of motion after TAA are such that the stress on and pain from these joints are reduced significantly. Careful attention to the patient’s examination may help determine the need for attention to these joints. Selective injections with or without fluoroscopy may also help with the diagnosis. Timing of the procedures depends on the amount of deformity, extent of involvement of the arthritis, and the number of joints involved. Arthrodesis of the talonavicular joint through the same incision used for component implantation is fairly straight forward, and bone graft from the resection for the implant is available for use in the fusion. The subtalar joint is a different matter, and often a separate approach is necessary to fully prepare the joint for fusion. Extensive reconstructions may be best staged before the TAA procedure. At midterm follow-up, Lee et al. found similar results in ankles with and without hindfoot fusions and recommended fusion at the time of arthroplasty if indicated clinically. In contrast, Lewis et al. found that overall outcome and implant survivorship were slightly inferior with hindfoot fusion compared with TAA alone, although arthroplasty with ipsilateral hindfoot fusion resulted in significant improvements in pain and functional outcome. These authors also noted that, when indicated, hindfoot arthrodesis can be safely done in conjunction with TAA. Other authors have reported similar findings, noting that hindfoot fusions improved function and pain after TAA. Dekker et al. reviewed the outcomes of 140 TAAs at an average follow-up of 6.5 years and found only a minimal radiographic increase in adjacent subtalar and talonavicular arthritis, suggesting that motion preserved with TAA decreases the stresses and compensatory motion incurred with tibiotalar arthrodesis. 

TAKEDOWN OF ANKLE ARTHRODESIS AND CONVERSION TO ANKLE ARTHROPLASTY

It has been almost an axiom over the years that one should never take down a successful ankle fusion. Some ankle fusions, however, have such a poor functional outcome that conversion to a TAA may be considered (Fig. 10.13). Hintermann et  al. described conversion of 30 painful ankle arthrodeses to TAA, with 83% patient satisfaction; five ankles were completely pain free, 21 were moderately painful, and three remained painful. Several additional surgical procedures were required before takedown of the fusion, including subtalar or talonavicular joint fusion, fibular reconstruction, lateral or medial ligament reconstruction, calcaneal osteotomy, and Achilles tendon lengthening. More recently, Preis et  al. reported conversion of 18 painful ankle arthrodeses to TAA. They concluded that this procedure is technically challenging

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D FIGURE 10.12 A and B, Osteonecrosis of ankle after talar fracture. C and D, After total ankle arthroplasty with INBONE II prosthesis.

and in their series, it was associated with frequent complications, including arthrofibrosis; however, pain and function did improve. Pellegrini et al. described conversion of tibiotalar arthrodesis to TAA for symptomatic adjacent hindfoot arthritis or tibiotalar or subtalar nonunion in 23 patients. Concomitant procedures were done in 18 ankles (78%), most commonly prophylactic malleolar fixation. Pain relief and function were improved in most patients; implant survival rate was 87% at an average 3-year follow-up. These authors recommended prophylactic malleolar fixation and did not recommend conversion to TAA for ankle arthrodeses that included distal fibulectomy. Although conversion of a nonunion of an attempted ankle fusion to an ankle arthroplasty has been done, to date we have no experience with the conversion of a well-healed ankle fusion. 

 

TIBIOTALAR ARTHRODESIS CONVERSION TO TOTAL ANKLE ARTHROPLASTY TECHNIQUE 10.5 (PELLEGRINI ET AL.) PREOPERATIVE PLANNING Preoperative preparation and planning are similar to those for a primary TAA, and implants designed for primary TAA can be used in most patients. 

n 

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FIGURE 10.13 A–D, Despite well-healed, well-aligned ankle fusion, patient had persistent pain that necessitated takedown of fusion and total ankle arthroplasty with Salto Talaris implant (E and F). Eight months after total ankle arthroplasty, he returned to his full-time job as tactical agent with U.S. Border Patrol. (Courtesy Dr. Mark Casillas, San Antonio, TX.)

PATIENT POSITIONING AND PREPARATION

Inflate the thigh tourniquet. In ankles in which arthrodesis was done with anterior plating, inflate the tourniquet before proceeding with an anterior approach to the ankle. n  Assuming that the malleoli have been stress-shielded in ankle arthrodesis, perform prophylactic fixation of both malleoli to avoid intraoperative fractures. n  Use percutaneous cannulated 3.5-mm diameter screws to preserve tourniquet time for the arthroplasty and improve stability. Place the screws as close to the cortex as possible in anticipation of gutter preparation.  n 

Place the patient supine on the operating-room table with the heel over or near the edge of the table, with the foot resting at a right angle to the table. n  Place support under the ipsilateral hip. n  The anesthesia team routinely uses a popliteal catheter for regional anesthesia. n  Drape the extremity above the knee and use Esmarch and tourniquet control.  n 

IMPLANT REMOVAL AND SCREW INSERTION Remove trans-articular screws or screws anticipated to interfere with implant positioning before inflating the tourniquet.

n 

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PART IV  RECONSTRUCTIVE PROCEDURES OF THE ANKLE IN ADULTS RECREATE THE TIBIOTALAR JOINT Define the native articular line; this usually is straightforward when the ankle anatomy has been adequately preserved (Fig. 10.14A-C). n  Although the joint line can be identified clinically, place small-diameter Kirschner wires as a reference to define the joint line fluoroscopically. n  In some patients, re-establishing the tibiotalar joint line may be difficult, and radiographs of the contralateral, uninvolved ankle can serve as a reference for determining the joint line in the affected ankle; measure the distance from the medial malleolus to the natural joint line. The TAA implant also may serve as a reference for determining the ideal level for re-establishing the joint line; a particular screw or hole in a plate can serve as a useful reference point. n  Preserve the talar body. If necessary, make the joint line slightly more proximal to avoid leaving too little talus on which to rest the talar component. Avoid excessive proximal translation, however, because the more proximal the resection, the narrower the tibia and the greater risk for malleolar stress fracture. n  For implants with independent tibial and talar preparation, select the proper resection level, rotation, and slope as for primary TAA. n  Perform the initial tibial preparation with the same cutting guide used for a primary TAA. n  From the previous operation, the posterior soft tissue may be adhered to the posterior aspect of the tibia. Use a lateral fluoroscopic view to help confirm that the saw blade has not overcome the posterior tibial bone. n  Extract the resected bone from the joint.  n 

SET THE OPTIMAL TALAR SLOPE To avoid excessive posterior talar slope, perform the initial talar preparation independent of the dedicated guide. This is particularly important when using a monoblock cutting guide to prepare the tibia and talus. n  After tibial preparation is complete, use a small reciprocating saw to recreate the gutters. n  Place the ankle in dorsiflexion, which will optimize the talar position for adequate preparation (Fig. 10.14D-I).  n 

RECREATE THE MEDIAL AND LATERAL GUTTERS Place small-diameter Kirschner wires in the anticipated location of the native gutters and confirm fluoroscopically. n  Because monoblock instrumentation may be difficult for evaluating the malleoli and residual talar bone, use a smaller monoblock than may be suggested on intraoperative evaluation. An adequate intramedullary reference in this system is critical to placing the cutting guide in an optimal position. n  In a critical step of the surgical procedure, maintain the ankle in a stable position, regardless of the ankle system being used, until the gutters have been adequately recreated. Failure to achieve stability of the ankle may result in a malleolar fracture during distraction or mobilization. n  Recreate the gutters using a small reciprocating saw to remove approximately 2 to 3 mm of bone slightly more toward the malleoli rather than the talar bone (Fig. 10.15). This should ensure that sufficient talar dome will support the talar component. 

MOBILIZE THE ANKLE AND USE BONE GRAFT IN DEFECTS FROM PREVIOUS IMPLANTS To avoid potential malleolar fractures, mobilize the ankle only after prophylactic malleolar screws have been placed, tibial and talar cuts have been completed, gutters have been reestablished, all resected bone has been removed, and scar tissue from the posterior aspect of the ankle has been excised; thereafter, conversion TAA is similar to primary TAA, with the exception of potential bone defects where implants were positioned. n  If the ankle remains locked, more release is needed. n  Apply distraction to assess whether the created joint space will accommodate the implant. Occasionally, further bone resection may be needed. Use a small reciprocating saw to remove incongruities of the bone surfaces. n  Despite adequate bone preparation and elevation of scar tissue, motion may be limited in an ankle arthrodesis takedown. Access to the posterior part of the ankle may be difficult. n  Use bone grafting in defects caused by previous implants to prevent later cyst formation or bone weakening.  n 

TALAR PREPARATION Perform the routine steps for primary TAA, often ignoring bone defects from the ankle arthrodesis implants, but plan to repair the defects with bone-grafting before implanting the final talar component. n  Despite satisfactory bone preparation and elevation of scar tissue, note that access to the posterior aspect of the ankle joint can be challenging. This situation is less of a concern when a system designed for a flat-cut talus is used and more challenging when the talar preparation involves a posterior chamfer cut. n  Perform talar preparation in a manner similar to that for primary TAA. For this procedure, after milling the anterior chamfer, a bone defect can be obvious. Take the location of the bone defect into consideration when selecting the ankle design. If the bone defect is laterally based, use an ankle design with a medial talar stem and a lateral chamfer cut, thereby reducing the bone defect without compromising implant stability. n  At this point, the posterior capsule can be easily accessed and mobilized judiciously using an elevator to protect the neurovascular bundle and the malleoli (Figs. 10.16 and 10.17A-C).  n 

n 

TIBIAL PREPARATION AND DEFINITIVE COMPONENTS Perform tibial preparation in a manner similar to that for primary TAA. n  Plan for a talar component one size smaller than the tibial component to ensure (1) adequate gutter debridement and (2) sufficient bone support in anticipation of talar dome bone loss during arthrodesis takedown. n  The tibial component rarely has to be downsized unless there is concern for medial malleolar stress fracture in patients with relatively small ankles. n  After definitive components have been adequately implanted, assess ankle stability, ankle range of motion, and foot alignment. n  If concomitant ancillary procedures can be safely done during the same operation, do so. In general, hindfoot arthrodesis is staged to avoid jeopardizing talar blood supply and implant osseointegration.    n 

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FIGURE 10.14 Pellegrini et al. technique for conversion of tibiotalar arthrodesis to total ankle arthroplasty (see text). A-C, Reestablishment of the native joint line. D-I, Talar preparation. (From Pellegrini MJ, Schiff AP, Adams SB Jr: Tibiotalar arthrodesis conversion to total ankle arthroplasty, JBJS Essent Surg Tech 6:e27, 2016.) SEE TECHNIQUE 10.5.

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GOUT

Barg et al. reported low frequency of intraoperative or postoperative complications and high patient satisfaction and functional outcomes after bilateral total ankle arthroplasties in a subset of patients with the diagnosis of gouty arthritis. 

BILATERAL TOTAL ANKLE ARTHROPLASTY

FIGURE 10.15 Pellegrini et al. technique for conversion of tibiotalar arthrodesis to total ankle arthroplasty (see text). Preparation of the medial and lateral gutters. (From Pellegrini MJ, Schiff AP, Adams SB Jr: Tibiotalar arthrodesis conversion to total ankle arthroplasty, JBJS Essent Surg Tech 6:e27, 2016.) SEE TECHNIQUE 10.5.

Barg et al. also reported outcomes of 23 patients with bilateral total ankle arthroplasties done at the same surgical setting and compared them with a cohort with unilateral replacement. At short-term follow-up, the unilateral group had better outcomes, but the differences disappeared by 1 and 2 years after surgery. More recently, Desai et al. compared outcomes in patients with unilateral and staged bilateral TAA and found that those with staged bilateral TAA benefited as much as patients with unilateral TAA, despite having a worse preoperative health status. Revision rates and implant survival times were similar. Bilateral replacements are not for the faint-hearted patient or surgeon, and patients should be warned of the lengthy recovery period. 

OUTCOMES As a preamble to the evaluation of outcomes reported in the literature, it may be important to turn a critical eye to the methods of reporting and the sources of the studies. Noting that patient-reported outcomes measures are designed to evaluate function or symptoms while missing ongoing

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FIGURE 10.16 Pellegrini et al. technique for conversion of tibiotalar arthrodesis to total ankle arthroplasty (see text). Preparation of the anterior chamfer. A, Osteophytes removed from talar neck. B, Smoothing anterior chamfer. C, Anterior talar body prepared for anterior chamfer guide. D, Guide positioning. E, Anterior chamfer preparation. F, Note lateral talar defect from hardware placed during ankle arthrodesis. G, Defect requiring graft. (From Pellegrini MJ, Schiff AP, Adams SB Jr: Tibiotalar arthrodesis conversion to total ankle arthroplasty, JBJS Essent Surg Tech 6:e27, 2016.) SEE TECHNIQUE 10.5.

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FIGURE 10.17 Pellegrini et al. technique for conversion of tibiotalar arthrodesis to total ankle arthroplasty (see text). Preparation of the lateral chamfer. A, Lateral chamfer guide flush on talus. B, Preparation of lateral chamfer with microsagittal saw. C, Prepared talus with lateral dome defect requiring bone grafting. (From Pellegrini MJ, Schiff AP, Adams SB Jr: Tibiotalar arthrodesis conversion to total ankle arthroplasty, JBJS Essent Surg Tech 6:e27, 2016.) SEE TECHNIQUE 10.5.

limitations with which patients must cope, Pinsker et  al. proposed categorizing outcomes as “recovered-resolved” (better with no symptoms or residual effects), “recovered, not resolved” (better but with residual effects), or “not recovered” (not better). Most patients reported positive outcomes, but only 15% had resolution of all symptoms and limitations. Because patients’ perceptions of satisfactory outcomes were not predicated on the resolution of all limitations, these authors suggested that the conventional definition of satisfactory outcomes should be expanded. Labek et al. noted that there is a significant difference in the revision rates in published sample series compared with those from national registries. They noted that implant developers represent about 50% of the published content and are likely overrepresented in the literature. Revision rates as collected in national registries have been reported to be approximately twice as high as in sample series, and the overall revision rates according to registry databases have been cited as 21.8% at 5 years and 43.5% at 10 years. A more recent review of National Joint Registry data, including 5152 primary and 591 revision total ankle arthroplasties, gave prosthesis survival rates of 94% at 2 years, 87% at 5 years, and 81% at 10 years. Another review of data from five national registers showed revision rates of approximately 10% at 5 years. According to a review of the literature by Easley et al., reported implant survivorship in 2240 total ankle arthroplasties ranged from 70% to 98% at 3 to 6 years and from 80% to 95% at 8 to 12 years; they also noted that most published reports have a fair-to-poor quality level of evidence. In their review of 90 patients with total ankle arthroplasties using both mobile-bearing and fixed-bearing implants, Queen et al. found improved function in all patients. In general, those with a fixed-bearing implant had more improvements in ankle moment and ground reaction forces, whereas those with mobile-bearing implants had more improvement in patient-reported pain. A more recent comparison study by Lefrancois et al. (451 TAAs) found more frequent metal

component revisions with Mobility and Agility implants than with HINTEGRA and STAR systems. For convenience, outcomes are reported for mobilebearing prostheses and then fixed-bearing prostheses. Most, but not all, of the available literature reporting outcomes on third-generation, three-component, mobile-bearing prostheses come from outside the United States, where the implants have been in use for many years. Studies of the STAR, Salto, Mobility, and AES ankle systems report 5-year survivorship ranging from 83% to 97%, with 92% to 97% patient satisfaction (Table 10.3). Additional surgical procedures were required in 17% to 39% of patients. Frequent causes for revision included aseptic loosening, osteolysis and osteolytic cysts, implant failure, malleolar impingement, and malalignment. Of the various fixed-bearing, two-component designs, the Agility total ankle has significant intermediate and longterm outcomes reported. Although relatively high rates of patient satisfaction have been reported, revision and reoperation rates also are high with this implant, and it is no longer available in the United States. Currently, at our institution the most commonly used prosthesis is the INFINITY, most often with patient-specific guides. We have 5 years of experience with this implant. Recent reports by Cody et  al. and Saito et  al. have raised concerns regarding tibial component loosening, subsidence, and early revision; however, we have not encountered these problems in our patients. A prospective, multi-center trial is underway, and we hope to report early outcomes in the near future.

SPORTS PARTICIPATION

Two studies investigating the ability to participate in sports after TAA found rates of sports participation after surgery to be equal to or higher than those before surgery; however, activities did not include high-impact or contact sports and most often involved activities such as swimming, cycling, hiking, and fitness training. 

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TABLE 10.3

Results of Total Ankle Arthroplasty STUDY Karantana et al. (2010) Wood et al. (2010)

IMPLANT STAR

NO. PATIENTS 45 (52 ankles)

Mobility

96 (100 ankles) 4 years

Skyttä et al. (2010)

STAR Biomet AES

7 years

Mann et al. (2011)

STAR

645 (Finnish Arthroplasty Register) 76 (78 ankles)

Bonnin et al. (2011) Salto

96 (98 ankles)

11 years

Nunley et al. (2012)

STAR

82 (82 ankles)

5 years

Barg et al. (2013)

HINTEGRA

6 years

Brunnerf et al. (2013)

STAR

684 (722 ankles) 72 (77 ankles)

Schweitzer et al. (2013)

Salto Talaris

67 (67 ankles)

3 years

Sproule et al. (2013) MOBILITY

85 (88 ankles)

3 years

Adams et al. (2014)

INBONE

4 years

Ramaskandhan et al. (2014) Deleu et al. (2015)

MOBILITY HINTEGRA

194 (194 ankles) 106 (106 ankles) 50 (50 ankles)

Jastifer and Coughlin (2015)

STAR

18 (18 ankles)

10 years

Jung et al. (2015)

HINTEGRA, MOBILITY

52 (54 ankles)

2–3 years

Hsu and Haddad (2015)

INBONE

59 (59 ankles)

3 years

FOLLOW-UP 8 years

9 years

12 years

2 years 4 years

Daniels et al. (2015) STAR

98 (111 ankles) 9 years

Zhou et al. (2016)

2340 ankles

Unknown; 95 academic centers

Unknown

RESULTS Prosthesis survival at 5 years 90%, at 8 years 84% Revision rate 17% Prosthesis survival at 3 years 97%, at 4 years 94% Patient satisfaction 97% Prosthesis survival at 5 years 83%, 7-year survival 78%

Probability of prosthesis survival at 5 years 96%, at least 10 years 90% Patient satisfaction 92% Additional surgeries 17% Prosthesis survival at 10 years 65%; 85% when fusion or revision of any component used as criterion for failure Reoperation rate 35% Prosthesis survival at 5 years 94%, projected 9 years 88% Additional surgeries 17% Prosthesis survival at 5 years 94%; projected 10-year 84%; 61 ankles (8%) had revision arthroplasties Probability of implant survival 71% at 10 years, 46% at 14 years 29 (38%) required revision of at least one metallic component Implant survival at 3 years 96% 8 patients (12%) had additional surgery after index procedure 15 patients (22%) with 23 complications Cumulative survival 90% at 3 years, 88% at 4 years Good pain relief and improved function in 82% 8 ankles (9%) required revision Overall implant survival of 89% Revision rate of 6% 53-point improvement in AOFAS scores 12% complication rate AOFAS scores and ROM significantly improved Osteolysis identified in 24 ankles (48%) Overall implant survival 94% Additional surgery required in 39% All patients reported their outcomes as good or excellent Ankle impingement syndrome significantly more common with HINTEGRA; intraoperative malleolar fracture only with MOBILITY Estimated survival rate at 2 years 97% 14 patients (2%) required reoperation because of complication. 32 ankles (29%) required metal component revision and/ or polyethylene bearing exchange Overall complication rate 1.4%, 50%) Medium grade: technical error, postoperative fractures, and subsidence; moderate failure rates Low grade: intraoperative fractures and wound healing problems; low failure rates Gadd et al. reviewed complications in 212 total ankle arthroplasties and categorized them according to the Glazebrook classification. All complications recorded in their study except intraoperative fracture and wound healing, including those designated “medium grade” in the Glazebrook scheme (technical error, postoperative fracture, and subsidence), had a failure rate of at least 50%, prompting these authors to propose a simplified two-level classification: high risk and low risk for failure. Younger et al. proposed a grading system for reoperations after TAA and ankle arthrodesis that was designed to capture all major adverse events for which reoperation is required. They suggested that future operations might be avoided if the cause of reoperation is identified and procedures or devices are modified accordingly.

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IN-HOSPITAL COMPLICATIONS

those treated at an orthopaedic specialty hospital had a significantly shorter length of stay, with no significant differences in readmission or reoperation rates. 

Using data from the Nationwide Inpatient Sample (NIS), Odum et al. found an inpatient rate of major complications of 5% and a minor complication rate of 6% in 1574 patients with TAA; there were no in-hospital deaths. In their review of 905 patients with primary or revision TAA, Lai et  al. identified older age, higher BMI, and revision procedures as associated with early complications. Cunningham et al., to the contrary, found that most common comorbidities did not reliably predict increased complications or costs. In-hospital TAA has been shown to be associated with more frequent complications than outpatient TAA. Although infrequent, blood transfusions during TAA have been found to be associated with increased in-hospital complications, including acute renal failure. Ewing et  al. reported that blood transfusions were more likely to be needed in patients with congestive heart failure, peripheral vascular disease, hypothyroidism, coagulation disorder, or anemia. In a comparison of perioperative complications in patients who had TAA at an orthopaedic specialty hospital or academic teaching hospital, Beck et al. found that

WOUND HEALING COMPLICATIONS

One of the most unnerving complications in TAA is a postoperative wound dehiscence (Fig. 10.18). A careful preoperative evaluation may limit healing problems. If a healing problem is suspected, the patient should be evaluated for nutritional deficiencies, and we caution against surgery in active smokers. Although it is not known how long a patient should refrain from smoking before surgery, it seems prudent to be certain they are confident of not returning to smoking in the immediate postoperative period. Lampley et  al. reported that tobacco cessation appeared to reverse the effects of smoking, decreasing the risk of wound complications. We routinely keep patients on binasal cannula oxygen while they are in the hospital after surgery. Other risk factors associated with wound dehiscence include peripheral vascular disease, cardiovascular disease, and a

A

C

B

D FIGURE 10.18 After total ankle arthroplasty (A and B), patient with rheumatoid arthritis developed wound dehiscence (C) because of nutritional deficiencies. With wound care, nutritional support, and secondary closure, wound eventually healed (D). No infection was present. It is important to have plastic surgery support in case of wound problems.

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CHAPTER 10  TOTAL ANKLE ARTHROPLASTY greater than 12 pack-year smoking history. In a series of 106 total ankle arthroplasties, Raikin et al. identified underlying inflammatory arthritis as the only significant risk factor for major wound complications. Although patients with inflammatory arthritis appear to be at higher risk for wound problems, evidence suggests that discontinuation of oral steroids or methotrexate is not beneficial and may in fact be detrimental, resulting in a postoperative flare of autoimmune disease. Antitumor necrosis factor-α medications such as Embrel, Arava, and Humira should be discontinued before surgery and should not be resumed until the wound is well healed. Finding a significantly longer mean surgery time and a trend toward longer median tourniquet time in patients with wound problems, Gross et  al. recommended limiting operative time and considering the staging of adjunctive procedures to decrease the risk of wound problems. Criswell et al., however, found no association between additional procedures requiring a separate incision and early complications. Easley listed several suggestions to prevent wound problems: (1) use longer incisions that create less wound tension; (2) avoid direct skin retraction (retraction should be deep); (3) administer nasal oxygen in the immediate postoperative period; (4) maintain immobilization until the skin is healed; (5) leave the anterior tibial tendon in its sheath during exposure; and (6) use a drain. Matsumoto and Parekh compared wound healing with and without the use of negative pressure wound therapy (NPWT) in 74 patients and found healing problems in only 3% of the NPWT group compared with 24% of the control group. Soft-tissue coverage of the prosthesis and tendons with a flap may prevent a catastrophic cascade leading to infection and implant failure. Gross et al. reviewed the outcomes and complications of flaps used to treat soft-tissue defects after TAA in 19 patients; four (21%) flaps failed resulting in two subsequent below-knee amputations. 

OSTEOLYSIS, LOOSENING, AND SUBSIDENCE

Despite improvements in implants, instrumentation, and techniques, the longevity of TAA is not expected to approach that of knee and hip replacements at any time in the near future. At this time, it is difficult, if not impossible, to recommend one prosthesis over another because it is not yet known which designs will hold up and provide the best longterm results. The long-term success of most implants seems related to loosening and subsidence of the implant. It seems logical that improved coverage of bone by the implant should diminish peak pressures at the bone-implant interface. Wear debris and the lytic reaction to it may gradually create a lysis between the bone and implant. Small, nonprogressive cysts may be caused by stress shielding and bone remodeling after implant insertion, whereas large progressive lesions result from a macrophage-led immune response to polyethylene and metal wear particles in the periarticular tissues. A histologic analysis of 57 pathology samples by Schipper et  al. showed that areas of osteolysis consisted of abundant polyethylene wear particles both intracellularly and extracellularly and appears to confirm that implant wear particles play a significant role in osteolysis. Although some subsidence is common with most implants, the question about when to intervene is a difficult and open question. Asymptomatic subsidence in a stable,

well-aligned implant can be observed with annual radiographs. The same findings in a malpositioned implant are likely to only get worse with time, and earlier intervention may be well advised. With mobile-bearing designs, anterior translation of the talus under the tibia, as measured on the lateral view, has been associated with pain and worse outcomes. Yi et al. observed a significant correlation between the preoperative and postoperative talar position in the coronal plane at 36-month follow-up. Complications noted with talar translation included medial malleolar impingement, insert dislocation, and edge-loading. The diagnosis of implant loosening, or subsidence is suspected when more than 5 degrees or 5 mm of component movement is seen on serial radiographs. Osteolysis is frequent after TAA but does not always correlate with component loosening or subsidence (Fig. 10.19). In one study, radiolucencies were present in 86% of ankles, but only 14% developed component subsidence or migration. Another study found periprosthetic osteolysis in 37 of 99 ankles, but no association was noted between the presence of osteolysis and clinical and radiographic outcomes. Asymptomatic focal osteolysis found on radiographs can simply be observed because it may not be progressive; however, Hsu et al. noted that, in their experience, most cysts do progress over time. Rapid cyst progression, particularly in symptomatic patients, warrants prompt intervention because it can progress to implant loosening and failure. Several studies have recommended adding CT imaging to postoperative follow-up for patients with suspected or known periprosthetic lucencies on radiographs. Revision surgery decisions are based on structural constraints and typically involve the use of bone grafting procedures, exchange of implants to a more constrained design, and improved fixation and interference fit in the talus and distal tibia (see section on Revision Total Ankle Arthroplasty). Correction of the underlying deformity is critical, and the inability to do so may mean that it is necessary to convert to an arthrodesis. Gross et al. described 31 patients with bone cysts after TAA who were treated with a bone grafting procedure. The success rate was 91% at 24 months and 61% at 48 months. Four failures required three tibial and talar component revisions and one tibiotalocalcaneal fusion. The authors concluded that grafting without revision of the TAA is an effective and safe method for treating peri-prosthetic bone cysts. The techniques for conversion of an ankle arthroplasty to an arthrodesis are described in Chapter 11. 

MALALIGNMENT

Malalignment can be avoided by accurate bone cuts and proper soft-tissue balancing. Correction of malalignment may require calcaneal osteotomy and/or lateral ligament reconstruction for minor varus or valgus malalignment (see Fig. 10.5); supramalleolar osteotomy, subtalar arthrodesis, or triple arthrodesis for moderate to severe malalignment; or complete revision for severe malalignment.

POLYETHYLENE FAILURE

In a retrieval analysis of 70 total ankles, most commonly retrieved for loosening and polyethylene fracture, Currier et al. made several observations, including that loosening may be more of problem in fixed-bearing devices than in mobilebearing devices. Gamma-sterilized polyethylene inserts oxidized at a higher rate than non–gamma sterilized inserts, and

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A

B

FIGURE 10.19 Periprosthetic lucencies may be related to technique and should not be misinterpreted as osteolysis. A, Postoperative radiograph shows mismatch between surgical drill hole (arrow) and medial cylindrical bar of tibial STAR component. B, Radiograph of INBONE device shows excessive medullary reaming (arrows). (From Bestic MJ, Bancroft LW, Peterson JJ, Kransdorf MJ: Postoperative imaging of the total ankle arthroplasty, Radiol Clin North Am 46:1003–1015, 2008.)

the presence of clinical fatigue (cracking and/or delamination) correlated with the amount of oxidation. Nine inserts, all gamma-sterilized, suffered fatigue damage or fracture in vivo. 

FRACTURE

The most frequent intraoperative complication of TAA is fracture of the medial or lateral malleolus, which is reported to occur in about 10% of procedures in most series, although frequencies as high as 35% have been reported. The malleoli can be fractured if the saw blade cuts beyond the cutting block boundaries or if the bony resections leave so little bone that the force needed to seat the component is sufficient to cause a fracture. Medial malleolar fractures should be fixed with Kirschner wires (with or without a tension band), screws, a low-profile plate, or some combination of these because implant stability may rely on intact malleoli; lateral malleolar fractures can be fixed with a fibular plate. Some have recommended prophylactic Kirschner wire pinning of the medial malleolus or plate fixation of the lateral malleolus during TAA to prevent this complication. Calcaneal fractures also can be caused by excursion of the saw blade (Fig. 10.20). Manegold et al. developed a classification system and treatment algorithm for periprosthetic fractures in TAA. The classification system is based on three sequentially assessed parameters: fracture cause, fracture location, and prosthesis stability (Table 10.4). The treatment algorithm is based on the classification system (Fig. 10.21). They identified 21 (4.2%) periprosthetic fractures in a group of 503 total ankle arthroplasties, 11 intraoperative and 10 postoperative; 14 of the 21 fractures were of the medial malleolus. The authors described fracture healing in all patients. Postoperative malleolar fractures also have been reported, most often associated with patient noncompliance with postoperative weight-bearing restrictions. Many of these fractures

FIGURE 10.20 Postoperative radiograph shows linear defect through posterior calcaneus (arrows) caused by excessive excursion of oscillating saw during implant placement. (From Bestic MJ, Bancroft LW, Peterson JJ, Kransdorf MJ: Postoperative imaging of the total ankle arthroplasty, Radiol Clin North Am 46:1003–1015, 2008.)

can be treated nonoperatively, although open reduction and internal fixation may be required for some. Occasionally, a malleolar fracture can result in component loosening, requiring revision. 

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CHAPTER 10  TOTAL ANKLE ARTHROPLASTY Periprosthetic fracture: decision-making Type 1

Type 2

TAR stable (S)

Type 3

TAR unstable (U)

TAR stable (S)

• Preexisting periprosthetic osteolysis? • Erythrocyte sedimentation rate? C-reactive protein? • Clinical and radiologic signs for low-grade infection? • Deviation of the mechanical axis? • Intraoperative instantaneous section?

Fracture-independent

Fracture-associated

• Removal TAR • Osteosynthesis • External fixator with antibiotic-spacer • Revision TAR vs. conversion to arthrodesis

• Osteosynthesis • Revision arthroplasty • Corrective osteotomy

Osteosynthesis

• Nondisplaced fracture: conservative • Displaced fracture/ deviation of axis: osteosynthesis/ corrective osteotomy

FIGURE 10.21 Classification based algorithm and decision-making protocol for treatment of periprosthetic ankle fractures. TAR, Total ankle replacement. (From Manegold S, Haas NP, Tsitilonis S, et al: Periprosthetic fractures in total ankle replacement: classification system and treatment algorithm, J Bone Joint Surg 95A:815–820, 2013.)



TABLE 10.4

Classification of Periprosthetic Fractures FRACTURE TYPE 1 Intraoperative 2 Postoperative trauma 3 Postoperative, stress

FRACTURE ­LOCATION A Medial malleolus B Lateral malleolus C Tibia D Talus

PROSTHESIS STABILITY S Stable U Unstable

From Manegold S, Haas NP, Tsitilonis S, et al: Periprosthetic fractures in total ankle replacement: classification system and treatment algorithm, J Bone Joint Surg 95A:815, 2013.

INFECTION

Infection appears to be relatively infrequent after TAA. In systematic reviews of the literature, the rate of superficial infection ranges from 0% to 15%, with an average of 8%, and the rate of deep infection ranges from 0% to 5%, with an average of less than 1%. One report of causes of revision of TAA reported infection in less than 1% of 2198 ankles, whereas another large study by Althoff et al. reported infection in 4% of 6977 patients; independent risk factors for periprosthetic joint infections included age over 65 years, BMI over 30 kg/m2 or under 19 kg/m2, tobacco use, diabetes mellitus, inflammatory arthritis, peripheral vascular disease, chronic lung disease, and hypothyroidism. In a review of 966 ankle arthroplasties, Patton

et al. found 29 infections (3%); operative intervention (irrigation and debridement, revision arthroplasty, or arthrodesis) resulted in limb salvage in 23 of the 29 (79%, 21% amputation rate). Risk factors identified included diabetes, prior ankle surgery, and wound healing problems more than 14 days after surgery. No significant difference was found between groups with respect to smoking, BMI, and operative time. Myerson et  al. reported infections in 19 (3%) of 613 total ankle arthroplasties, 15 of which were late chronic infections. Only three of the 19 patients had successful revision with replacement implants, six had arthrodesis, seven had permanent antibiotic spacers, and three required transtibial amputation. In their algorithm for evaluating painful ankles after TAA (Fig. 10.22), Vulcano and Myerson list two-stage revision, a permanent cement spacer, ankle fusion, and amputation as possible treatments for infection. They also listed some general guidelines for laboratory studies: elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) + positive aspiration = infection until proved otherwise; elevated ESR and CRP + normal or inconclusive aspirate = infection cannot be ruled out; normal ESR and CRP + positive aspirate = infection until proved otherwise; normal ESR and CRP + negative aspirate = infection unlikely, consider mechanical causes of pain. Lachman et  al. reported their experience with irrigation and debridement and polyethylene exchange with component retention in the treatment of acute hematogenous periprosthetic joint infection in 14 patients. The long-term (3 years) failure rate was 54%. Two variables that were associated with failure of irrigation and debridement and polyethylene exchange were

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PART IV  RECONSTRUCTIVE PROCEDURES OF THE ANKLE IN ADULTS History Clinical examination Standard radiographs

Loosening subsidence bone cysts malalignment

Yes

Where is the problem?

No

Extraarticular

Intraarticular

Infection?

Bloodwork aspiration biopsy

No infection

Obtain CT scan for bone stock assessment

Infection

Gutter impingement Arthrofibrosis

Treat accordingly

Local anesthetic diagnostic injection

Two-stage revision permanent cement spacer Fusion Amputation

Relief

CRPS likely

No

Yes

CT scan

Not sure

Yes Neuritis CRPS Spine Comorbidities Tendons*

Chronic pain management

Exclude infection

Bloodwork aspiration biopsy

Can exclude infection?

No

No relief

Diagnosis made?

No

Yes

Diagnostic arthroscopy

Treat accordingly

Arthroscopic debridement

One-stage revision fusion permanent cement spacer FIGURE 10.22 Diagnostic algorithm for the painful total ankle arthroplasty. *Lidocaine diagnostic injection: suspect posterior tibial tendon in neutral or flatfoot, peroneal tendons in cavus foot, and flexor hallucis longus if posterior impingement. CRPS, complex regional pain syndrome. (From Vulcano E, Myerson MS: The painful total ankle arthroplasty: a diagnostic and treatment algorithm, Bone Joint J 99-B:5–11, 2017.)

the time the patient was symptomatic prior to the procedure (average of 11 days) and the organism isolated on culture. The most common bacteria isolated in patients in whom the procedure failed was methicillin-resistant Staphylococcus aureus; the most common bacteria in patients who retained their implants were methicillin-sensitive S. aureus. 

DEEP VENOUS THROMBOSIS

There is little information in the literature to give guidance to the decision of whether to treat patients with modalities or medication to lessen the chance of the development of DVT. Most series of TAA report a less than 1% frequency of DVT, with or without thromboprophylaxis. Saltzman et  al., however, reported a 5% frequency, and Barg et  al. reported symptomatic DVT in 4% of 701 total ankle arthroplasties. They identified the following as risk factors: obesity, previous venous thromboembolic event, and absence of full weight bearing postoperatively. Similar risk factors for infection were noted by Richey et al. in their cohort study of 22,486 patients with TAA, four of which were statistically significant: obesity, history of venous thromboembolism (VTE), use of hormone

replacement therapy, and postoperative non-weight-bearing immobilization for more than 6 weeks. Horne et al. reported DVT in only three (0.45%) of 637 patients. They concluded that chemoprophylaxis is not required in patients without identifiable risk factors for DVT. We routinely administer low-molecular-weight heparin in the immediate postoperative period and observe the patients closely at follow-up for signs and symptoms of this complication. 

HETEROTOPIC OSSIFICATION

Reports in the literature are conflicting regarding the occurrence of postoperative heterotopic ossification after TAA, with reported frequencies ranging from 4% to 82% for different implant designs. The clinical consequences of heterotopic ossification also are controversial. Several authors have reported high frequencies of heterotopic ossification (42% to 82%) but with no association with clinical outcomes and no treatment required. Others have described limited dorsiflexion and plantarflexion and lower AOFAS in patients with heterotopic ossification. Most descriptions of heterotopic ossification after TAA place it in the posterior aspect of the ankle. Jung et al., however,

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CHAPTER 10  TOTAL ANKLE ARTHROPLASTY TABLE 10.5



Classification of Heterotopic Ossification After Total Ankle Arthroplasty CLASS 0 I II III IV

CRITERIA No heterotopic ossification Islands of bone within the soft tissue about the ankle Bone spurs from the tibia or talus, reducing the posterior joint space by 100 degrees (20 points) n Arc 50 to 100 degrees (15 points) n Arc < 50 degrees (5 points)  Stability (10 points) n Stable (10 points) n Moderately unstable (5 points) n Grossly unstable (0 points)  Function (25 points) n Able to comb hair (5 points) n Able to feed oneself (5 points) n Able to perform personal hygiene tasks (5 points) n Able to put on shirt (5 points) n Able to put on shoes (5 points) n Maximal total = 100 points Outcomes classification: 90-100 = excellent, 75-89 = good, 60-74 = fair, 1500/mL) and preoperative medical frailty. Amputation should not be viewed as a failed limb salvage or reconstruction. The amputation must be viewed as an opportunity to reestablish or enhance a patient’s functional level and facilitate a return to near-normal locomotion. Transtibial amputation after failed attempted limb preservation can still be successful in improving pain, decreasing narcotic use, and improving function. This is especially true in the young, highly active trauma population. Meticulous surgical attention is necessary to provide an optimal base of support because the residual limb functions as a “sensorimotor end organ” with tolerance requirements at the stump-prosthesis interface to meet the dynamic weight-bearing challenges of ambulation. Anesthesia pain specialty teams often are helpful in the management of postoperative pain. Developments in the prosthetic field range from early-stage fitting techniques (computer-assisted stump contour scanning) to the use of advanced prosthetic components (lighter materials, silicone gel liners, computer-assisted knee units, suspension device alternatives, and ankle-foot accommodative and energy storage systems). Osseointegrated prosthetic components have been investigated over the past several decades in transfemoral and transtibial amputees. Potential advantages include improved quality of life and body image, increased proximal joint range of motion, greater prosthetic comfort, better osseoperception, and improved walking ability. Minor complications include frequent superficial infections and stump irritation, and rare major complications include deep infection, osteomyelitis, periimplant fracture, and failure of osseointegration. Tillander et al. reported a 20% cumulative risk of developing osteomyelitis.

FOOT AND ANKLE AMPUTATIONS Amputations around the foot and ankle are discussed in Chapter 15. 

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CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY

Very short transtibial Short transtibial Standard transtibial

Long transtibial

Syme

FIGURE 16.1

Levels of transtibial amputations.

TRANSTIBIAL (BELOW-KNEE) AMPUTATIONS Transtibial amputation is the most common lower extremity amputation. The importance of preserving the patient’s own knee joint in the successful rehabilitation of a patient with a lower extremity amputation cannot be overemphasized. Transtibial amputations can be divided into three levels (Fig. 16.1). The appropriate level must be determined for each individual patient. Although many variations in technique exist, all procedures may be divided into those for nonischemic limbs and those for ischemic limbs. General techniques vary primarily in the construction of skin flaps, muscle stabilization, and osseous stabilization techniques. In nonischemic limbs, skin flaps of various design and muscle stabilization techniques, such as tension myodesis and myoplasty, frequently are used. These techniques are employed to prepare a stump more suited for weight bearing and to protect from wound breakdown. In tension myodesis, transected muscle groups are sutured to bone under physiologic tension; in myoplasty, muscle is sutured to soft tissue, such as opposing muscle groups or fascia. In most instances, myoplastic closures are performed, but some authors have advocated the use of the firmer stabilization provided by myodesis in young, active individuals. In addition, some surgeons advocate creating a bone bridge between the distal tibia and fibula (Technique 16.2). Advocates of the Ertl technique claim that a bone bridge creates a more stable end-bearing construct and decreases the incidence of proximal tibiofibular joint instability. In addition, closure of the intramedullary canal in osteomyoplastic transtibial amputation has been shown to increase blood flow to the residual limb. In ischemic limbs, tension myodesis is relatively contraindicated because it may compromise further an already marginal blood supply. Also, a

long posterior myocutaneous flap and a short or even absent anterior flap are recommended for ischemic limbs because anteriorly the blood supply is less abundant than elsewhere in the leg. In combat injuries that result from blasts or fragmentation wounds, the use of standard flaps may be impossible. Often flaps have to be fashioned from viable remaining tissue. Skin grafts may be used to cover soft-tissue defects, but skin grafts are not ideal for a stump-prosthesis interface.

NONISCHEMIC LIMBS

Rehabilitation after transtibial amputations in nonischemic limbs generally is quite successful, partly because of a younger, healthier population with fewer comorbidities. The optimal level of amputation in this population traditionally has been chosen to provide a stump length that allows a controlling lever arm for the prosthesis with sufficient “circulation” for healing and soft tissue for protective end weight bearing. The amputation level also is governed by the cause (e.g., clean end margins for tumor, level of trauma, and congenital abnormalities). A longer residual limb would have a more normal gait appearance, but stumps extending to the distal third of the leg have been considered suboptimal because there is less soft tissue available for weight bearing and less room to accommodate some energy storage systems. The distal third of the leg also has been considered relatively avascular and slower to heal than more proximal levels. Contemporary liners and ankle-foot storage systems now allow more options for accommodating a longer residual limb, but the long-term risk of skin breakdown in older patients with these newer prosthetic components is unknown. Our recent war experiences have shown that early posttraumatic amputations decrease the risk of chronic residual limb infection. If only one posttraumatic debridement procedure and 5 days or fewer pass before definitive amputation, the risk of infection is limited. In adults, the ideal bone length for a below-knee amputation stump is 12.5 to 17.5 cm, depending on body height. A reasonably satisfactory rule of thumb for selecting the level of bone section is to allow 2.5 cm of bone length for each 30 cm of body height. Usually the most satisfactory level is about 15 cm distal to the medial tibial articular surface. A stump less than 12.5 cm long is less efficient. Stumps lacking quadriceps function are not useful. In a short stump of 8.8 cm or less, it has been recommended that the entire fibula together with some of the muscle bulk be removed so that the stump may fit more easily into the prosthetic socket. Many prosthetists find, however, that retention of the fibular head is desirable because the modern total-contact socket can obtain a better purchase on the short stump. Transecting the hamstring tendons to allow a short stump to fall deeper into the socket also may be considered. Although the procedure has the disadvantage of weakening flexion of the knee, this has not been a serious problem, and genu recurvatum has not been reported. Amputations in nonischemic limbs result from tumor, trauma, infection, or congenital anomaly. In each, the underlying lesion dictates the level of amputation and choice of skin flaps. Microvascular techniques have made preservation of transtibial stumps possible with the use of distant free flaps and “spare part” flaps from the amputated limb. A description of the classic transtibial amputation using equal anterior and posterior flaps follows. 

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PART VI AMPUTATIONS  

TRANSTIBIAL AMPUTATION

Because it contracts, the anterior flap cannot be used to measure the level of intended bone section. Instead, use the mark already made in the tibial periosteum to measure the original length of the flap and reestablish the level of bone section. With a saw, mark the bone at this point. n  Insert a curved hemostat in the natural cleavage plane at the lateral aspect of the tibia so that its tip follows along the interosseous membrane and passes over the anterior aspect of the fibula to emerge just anterior to the peroneus brevis muscle. n  Identify and isolate the superficial peroneal nerve in the interval between the extensor digitorum longus and peroneus brevis, gently draw it distally, and divide it high so that it retracts well proximal to the end of the stump. n  Divide the muscles in the anterior compartment of the leg at a point 0.6 cm distal to the level of bone section so that they retract flush with the end of the bone. As these muscles are sectioned, take special care to identify and protect the anterior tibial vessels and deep peroneal nerve. n  Isolate these structures and ligate and divide the vessels at a level just proximal to the level of intended bone section. n  Exert gentle traction on the nerve and divide it proximally so that it retracts well proximal to the end of the stump. n  Before sectioning the tibia, bevel its crest with a saw: begin 1.9 cm proximal to the level of the bone section and cut obliquely distalward to cross this level 0.5 cm anterior to the medullary cavity. n  Section the tibia transversely and section the fibula 1.2 cm proximally. n  Grasp their distal segments with a bone-holding forceps so that they can be pulled anteriorly and distally to expose the posterior muscle mass. n 

TECHNIQUE 16.1

Place the patient supine on the operating table and use a pneumatic tourniquet for hemostasis. n  Beginning proximally at the anteromedial joint line, measure distally the desired length of bone and mark that level over the tibial crest with a skin-marking pen. n  Outline equal anterior and posterior skin flaps, with the length of each flap being equal to one half the anteroposterior diameter of the leg at the anticipated level of bone section. n  Begin the anterior incision medially or laterally at the intended level of bone section and swing it convexly distalward to the previously determined level and proximally to end at a similar position on the opposite side of the leg (Fig. 16.2A). n  When crossing the tibial crest, deepen the incision and mark the periosteum with a cut to establish a point for future measurement. n  Begin the posterior incision at the same point as the anterior and carry it first convexly distalward and then proximally as in the anterior incision (see Fig 16.2A). n  Deepen the posterior incision down through the deep fascia, but do not separate the skin or deep fascia from the underlying muscle. n  Reflect as a single layer with the anterior flap the deep fascia and periosteum over the anteromedial surface of the tibia. n  Continue this dissection proximally to the level of intended bone section. n 

Amputation level

4 cm Periosteum marked

8 cm

A

B

Skin flap incision 4 cm

C

FIGURE 16.2 Amputation through middle third of leg for nonischemic limbs. A, Fashioning of equal anterior and posterior skin flaps, each one half anteroposterior diameter of leg at level of bone section. B, Fashioning of posterior myofascial flap. C, Suture of myofascial flap to periosteum anteriorly. SEE TECHNIQUE 16.1.

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CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY Divide the muscles in the deep posterior compartment 0.6 cm distal to the level of bone section so that they retract flush with the end of the bone. This exposes the posterior tibial and peroneal vessels and the tibial nerve lying on the gastrocnemius-soleus muscle group. Doubly ligate and divide the vessels and section the nerve so that its cut end retracts well proximal to the end of the bone. n  With a large amputation knife, bevel the gastrocnemiussoleus muscle mass so that it forms a myofascial flap long enough to reach across the end of the tibia to the anterior fascia (Fig. 16.2B). n  Smoothly round the ends of the tibia and fibula with a rasp and irrigate the wound to remove all bone dust. n  Release the tourniquet and clamp and ligate or electrocoagulate all bleeding points. n  Bring the gastrocnemius-soleus muscle flap over the ends of the bones and suture it to the deep fascia and the periosteum anteriorly (Fig. 16.2C). n  Place a plastic suction drainage tube deep to the muscle flap and fascia and bring it out laterally through the skin 10 to 12 cm proximal to the end of the stump. n  Fashion the skin flaps as necessary for smooth closure without tension and suture them together with interrupted nonabsorbable sutures. n 

  

TECHNIQUE 16.2 (MODIFIED ERTL; TAYLOR AND POKA) Place the patient supine on a radiolucent bed; a tourniquet is used for hemostasis. n  Make an anterior incision at the level of the intended tibial resection and a posterior flap incision. The posterior flap should measure 1 cm more than the diameter of the leg at the level of bone division (Fig. 16.3A). n  Sharply incise the anterior compartment fascia, transect the musculature of the anterior compartment, and ligate the anterior neurovascular bundle. n  Identify the saphenous nerve, transect it proximally under tension, and allow it to retract. n  Identify the tibial resection site and elevate an osteoperiosteal sleeve proximal to the intended transection level both anteriorly and posteriorly before making the tibial cut (Fig. 16.3B). n  Measure the medial-to-lateral distance between the tibia and fibula at the area of transection and transect the peroneal muscle and fibula at this distance distal to the transected tibia. n  Transect the peroneal musculature and ligate the lateral neurovascular bundle. n  Transect the deep posterior compartment at the level of the tibial transection and sharply bevel the superficial posterior compartment to fashion a future flap. n  Identify the posterior compartment neurovascular bundle, ligate and transect it, allowing for retraction. n  Identify the sural nerve and transect it in the posterior subcutaneous flap. n  Remove the amputated limb from the operative field, saving bone for possible grafting. n 

Osteotomize the remaining fibula at the level of the resected tibia; with a burr, create notches in the fibula and tibia for placement of the cut fibular autograft strut (Fig. 16.3C,D). n  Drill holes to accommodate heavy suture passage: two in the medial tibia, two in the medial fibular autograft, two in the lateral fibular autograft, and two in the distal fibula (screw fixation may alternatively be used; Fig. 16.3E). n  Secure the autograft strut with heavy suture and sew the tibial periosteal sleeve around the strut distally. Autogenous bone graft may augment the distal bone bridge if necessary. n  Release the tourniquet and achieve hemostasis. n  Mobilize the peroneal musculature distally to cover the end of the bone bridge and suture it to the medial aspect of the tibia. n  Suture the posterior musculature to the anterior tibial periosteum and close the subcutaneous tissues. Use nonabsorbable stitches in a mattress fashion to close the skin. n 

  

REHABILITATION IN NONISCHEMIC LIMBS

Rehabilitation after transtibial amputation in a nonischemic limb is fairly aggressive unless the patient is immunocompromised, there are skin graft issues, or there are concomitant injuries or medical conditions that preclude early initiation of physical therapy. An immediate postoperative rigid dressing helps control edema, limits knee flexion contracture, and protects the limb from external trauma. A prosthetist can be helpful with such casting and can apply a jig that allows attachment and alignment for early pylon use. Weight bearing is limited initially, with bilateral upper extremity support from parallel bars, a walker, or crutches. The dressing is changed every 5 to 7 days for skin care. Within 3 to 4 weeks, the rigid dressing can be changed to a removable temporary prosthesis if there are no skin complications. The patient is shown the proper use of elastic wrapping or a stump shrinker to control edema and help contour the residual limb when not wearing the prosthesis. The physiatrist and therapist can assist in monitoring progress through the various transitions of temporary prosthetics to the permanent design, which may take several months. Endoskeletal designs have been more frequently used because modifications are simpler. Formal inpatient rehabilitation is brief, with most prosthetic training done on an outpatient basis. A program geared toward returning the patient to his or her previous occupation, hobbies, and educational pursuits can be structured with the help of a social worker, occupational therapist, and vocational counselor.

ISCHEMIC LIMBS

The frequent comorbidities in patients with ischemic limbs demand precautionary measures and interaction with a vascular surgical team. Because the skin’s blood supply is much better on the posterior and medial aspects of the leg than on the anterior or anterolateral sides, transtibial amputation techniques for the ischemic limb are characterized by skin flaps that favor the posterior and medial side of the leg. The long posterior flap technique popularized by Burgess is most commonly used, but medial and lateral flaps of equal length

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A D

B E

C FIGURE 16.3 Modified Ertl technique. A, Skin incision marked to create long posterior flap. B, Elevation of osteoperiosteal flap from the tibia. C, Provisional notch created in distal tibia and fibula for fibular strut. D, Fibular strut placed into the tibial and fibular notches. E, Fibular strut secured via sutures through bone tunnels. (A, B, and E, From: Taylor BC, Poka A: Osteomyoplastic transtibial amputation: the Ertl technique, J Am Acad Orthop Surg 24:259, 2016. C and D, From Taylor BC, Poka A: Osteomyoplastic transtibial amputation: technique and tips, J Orthop Surg Res 6:13, 2011.) SEE TECHNIQUE 16.2.

as described by Persson, skew flaps, and long medial flaps are being used. All techniques stress the need for preserving intact the vascular connections between skin and muscle by avoiding dissection along tissue planes and by constructing myocutaneous flaps. Also, amputations performed in ischemic limbs are customarily at a higher level (e.g., 10 to 12.5 cm distal to the joint line) than amputations in nonischemic limbs. Tension myodesis and osteomyoplasty, which may be of value in young, vigorous patients, historically have been contraindicated in patients with ischemic limbs due

to concerns of blood flow restriction. However, recent data demonstrate that the Ertl procedure may be safe in these high-risk patients. Traditionally, tourniquets have not been used in the amputation of dysvascular limbs to avoid damage to more proximal diseased arteries. However, recent studies (including randomized controlled trials) demonstrate decreased blood loss, decreased postoperative transfusion rates, and no increased risk of vascular or wound complications with the use of a tourniquet. 

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CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY  

Section the tibia, and at a level no more than 0.9 to 1.3 cm higher, section the fibula. Dissect the soft tissues from the posterior aspect of the tibia and fibula distally to the level of the posterior transverse skin division and separate and remove the leg, ligating and dividing the nerves and vessels (Fig. 16.4B). n  Carefully round the tibia and form a short bevel on its anterior and medial aspects. Tension myodesis is not recommended in this instance. n  Bevel and tailor the posterior muscle mass to form a flap (see Fig. 16.4B) and carry it anteriorly, suturing it to the deep fascia and periosteum (Fig. 16.4C). n  Obtain meticulous hemostasis. n  Place a plastic suction drainage tube deep to the muscle flap and fascia and bring it out laterally through the skin 10 to 12.5 cm proximal to the end of the stump; if preferred, a through-and-through Penrose drain may be used, but it is more difficult to remove. n  Fashion the skin flaps as necessary to obtain smooth closure without too much tension. Trim any “dog ears” sparingly; otherwise, the circulation in the skin may be disturbed. n  Close the skin with interrupted nonabsorbable sutures.     n 

TRANSTIBIAL AMPUTATION USING LONG POSTERIOR SKIN FLAP TECHNIQUE 16.3 (BURGESS) Position the patient supine on the operating table; do not apply a tourniquet. Prepare and drape the limb so that an above-knee amputation can be performed if bleeding and tissue viability are insufficient to permit a successful transtibial amputation. For ischemic limbs, Burgess recommended amputation 8.8 to 12.5 cm distal to the line of the knee joint. n  Outline a long posterior flap and a short anterior one. The posterior flap should measure 1 cm more than the diameter of the leg at the level of bone division. n  Fashion the anterior flap at about the level of anticipated section of the tibia (Fig. 16.4A). n  Reflect as a single layer with the anterior flap the deep fascia and periosteum over the anteromedial surface of the tibia. n  Divide the anterolateral muscles down to the intermuscular septum, ligating and dividing the anterior tibial vessels and peroneal nerves as encountered. n 

REHABILITATION IN ISCHEMIC LIMBS

Rehabilitation in patients with ischemic limbs must proceed cautiously because of potential skin healing compromise Tibial amputation level

8.8 to 12.5 cm

Skin flap incision

A

B

Fibular amputation level 0.9 to 1.3 cm 12.5 to 15 cm

C FIGURE 16.4 Transtibial amputation in ischemic limbs. A, Fashioning of short anterior and long posterior skin flaps. B, Separation and removal of distal leg. Muscle mass is tailored to form flaps. C, Suture of flap to deep fascia and periosteum anteriorly. (Redrawn from Burgess EM, Zettl JH: Amputations below the knee, Artif Limbs 13:1, 1969.) SEE TECHNIQUE 16.3.

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PART VI AMPUTATIONS and accompanying medical conditions. Initial postoperative efforts are centered on skin healing. After transtibial amputation, a soft dressing can be applied but a rigid dressing is preferred and can be used regardless of whether early ambulation is prescribed. If immediate or prompt prosthetic ambulation is not to be pursued, the stump can be dressed in a simple, well-padded cast that extends proximally to midthigh and is applied in such a manner as to avoid proximal constriction of the limb. Good suspension of the cast is essential to prevent it from slipping distally and impairing stump circulation. This may require compressive contouring of the cast in the supracondylar area and a waist band, suspension strap, or both. The cast should be removed in 5 to 7 days; and if wound healing is satisfactory, a new rigid dressing or prosthetic cast is applied. If immediate or prompt prosthetic ambulation is pursued, a properly constructed prosthetic cast is best applied by a qualified prosthetist. Success of rehabilitation depends on multiple variables, including cognitive status, premorbid functional level, condition of the upper extremities and contralateral lower limb, and coexisting medical and neurologic conditions. Early rehabilitation efforts may be geared toward independence in a wheelchair, stump care education, skin care techniques to avoid decubitus ulcers, care of the contralateral intact lower limb, and preprosthetic general conditioning. Weight bearing on the residual limb is usually delayed until skin healing has progressed. If a more aggressive approach is taken toward prosthetic training, more frequent rigid dressing changes are recommended and possibly the use of clear sockets to allow monitoring of the skin. Some patients may require further medical evaluation and clearance (e.g., chemically induced cardiac stress test or echocardiogram or vascular studies of the contralateral limb) to evaluate tolerance for prosthetic training. A pain management specialist may be needed to help treat postoperative phantom limb pain. Many patients receive inpatient rehabilitation training with subsequent therapy on an outpatient basis or in an extended-care facility or home health setting. Proposed rehabilitation goals also dictate which prosthetic components would be approved by insurance carriers.

DISARTICULATION OF THE KNEE Disarticulation of the knee results in a functional end-bearing stump. Newer socket designs and prosthetic knee mechanisms that provide swing phase control have improved function in patients with knee disarticulation. Although the benefit of its use in children and young adults has been proven, its use in the elderly and especially in patients with ischemia has been limited in the United States. Knee disarticulations are more commonly used in cases of trauma. Based on published data, it remains unclear if knee disarticulation provides additional functional benefit and improved complication rates compared to transfemoral amputation. Potential advantages of knee disarticulation include (1) preservation of the large end-bearing surfaces of the distal femur covered by skin and other soft tissues that are naturally suited for weight bearing, (2) creation of a long lever arm controlled by strong muscles, and (3) stability of the prosthesis. Techniques have been described for reducing the bulk of bone at the end of the stump to allow more cosmetic prosthetic fitting while still retaining the weight-bearing, suspension, and rotational control features of the stump. Modified

skin incisions allow greater use of this amputation level in patients with ischemia. In nonambulatory patients, additional extremity length provides adequate sitting support and balance. Knee flexion contractures and associated distal ulcers common with transtibial amputations also are avoided. 

 

KNEE DISARTICULATION TECHNIQUE 16.4 (BATCH, SPITTLER, AND MCFADDIN) Measuring from the inferior pole of the patella, fashion a long, broad anterior flap about equal in length to the diameter of the knee (Fig. 16.5A). n  Measuring from the level of the popliteal crease, fashion a short posterior flap equal in length to one half of the diameter of the knee. Place the lateral ends of the flaps at the level of the tibial condyles. n  Deepen the anterior incision through the deep fascia to the bone and dissect the anterior flap from the tibia and adjacent muscle. Include in the flap the insertion of the patellar tendon and the pes anserinus (Fig. 16.5B). n  Expose the knee joint by dissecting the capsule from the anterior and lateral margins of the tibia; divide the cruciate ligaments, and dissect the posterior capsule from the tibia (Fig. 16.5C). n  Identify the tibial nerve, gently pull it distally, and divide it proximally so that it retracts well proximal to the level of amputation (Fig. 16.5D). n  Identify, doubly ligate, and divide the popliteal vessels. n  Free the biceps tendon from the fibula, complete the amputation posteriorly, and remove the leg. n  Do not excise the patella or attempt to fuse it to the femoral condyles. Do not disturb the articular cartilage of the femoral condyles and patella. Perform a synovectomy only if specifically indicated. n  Suture the patellar tendon to the cruciate ligaments and the remnants of the gastrocnemius muscle to tissue in the intercondylar notch (Fig. 16.5E). n  Place a through-and-through Penrose drain in the wound. n  Close the deep fascia and subcutaneous tissues with absorbable sutures and the skin edges with interrupted nonabsorbable sutures. n  If sufficient skin for a loose closure is unavailable, resect the posterior part of the femoral condyles rather than risk loss of the skin flaps. The wound usually heals quickly, however, and a permanent prosthesis usually can be fitted in 6 to 8 weeks because shrinkage of the stump is not a factor. If the wound fails to heal primarily, there is no reason for apprehension or reamputation because it usually granulates and heals satisfactorily without additional surgery.     n 

 

KNEE DISARTICULATION

Mazet and Hennessy recommended a method that features resection of the protruding medial, lateral, and posterior surfaces of the femoral condyles for creating a knee disarticulation stump for which a more cosmeti-

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CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY Skin flap incision

10 cm

Patellar tendon

A Right leg (medial view)

5 cm Anterior cruciate ligament Lateral head of gastrocnemius muscle

Patellar tendon

Pes anserinus

B C

Tibial nerve

D

E

FIGURE 16.5 Disarticulation of knee joint. A, Skin incision. B, Anterior flap elevated, including insertion of patellar tendon and pes anserinus. C, Cruciate ligaments and posterior capsule divided. D, Tibial nerve divided high. E, Patellar tendon sutured to cruciate ligaments. SEE TECHNIQUE 16.4.

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Line of condylar remodeling

Lines of condylar remodeling Posterior

Anterior

Skin incision

Skin incision

A

B FIGURE 16.6 Mazet and Hennessy disarticulation of knee. A, Anterior view. B, Lateral view. SEE TECHNIQUE 16.5. (Redrawn from Mazet R Jr, Hennessy CA: Knee disarticulation: a new technique and a new knee-joint mechanism, J Bone Joint Surg 48A:126, 1966.)

cally acceptable prosthesis can be constructed. With this technique, tolerances within the socket are greater, more adduction of the stump is permitted in the alignment of the prosthesis, and the decreased bulk of the stump permits greater ease in the application and removal of the prosthesis. The debulked stump requires smaller skin flaps, which may be beneficial for wound healing in dysvascular limbs. These patients may use a suction type prosthesis, which is less cumbersome to apply than a traditional above-knee amputation prosthesis and does not require removal for toileting needs.

TECHNIQUE 16.5 (MAZET AND HENNESSY) Fashion the usual fish-mouth skin incision, making the anterior flap longer and extending 10 cm distal to the level of the knee joint and making the posterior flap shorter and extending only about 2.5 cm distal to the same level (Fig. 16.6). n  Reflect the skin and deep fascia well proximal to the femoral condyles. n  Divide the patellar tendon midway between the patella and the tibial tuberosity. n  Flex the knee and section the collateral and cruciate ligaments. n  Increase flexion of the knee to 90 degrees, identify and ligate the popliteal vessels, and isolate and divide the tibial nerve. n  Detach the hamstring muscles from their insertions and remove the leg. n  Dissect the patella from its tendon and discard it. n  Remodel the femoral condyles in the following manner. Drive a wide osteotome vertically in a proximal direction through the medial femoral condyle to emerge at the level of the adductor tubercle. Start this cut along a line that extends from the medial articular margin anteriorly n 

to the midpoint of the distal articular surface posteriorly (the condyle is wider posteriorly). Discard the medial half of the condyle. n  Resect the lateral part of the lateral femoral condyle in a similar manner, starting at the junction of the medial two thirds and lateral one third of the distal articular surface. n  Direct attention to the posterior aspect of both condyles. Resect the posterior projecting bone by a vertical osteotomy in the frontal plane, starting at the point where the condyles begin to curve sharply superiorly and posteriorly. n  Smoothly round all bony prominences with a rasp, but do not disturb the remaining articular cartilage. At this point, each condyle has a fairly broad weight-bearing area, whereas the projecting side and posterior aspect of each have been removed and the remaining bone has been smoothly rounded. n  Suture the patellar tendon to the hamstrings in the intercondylar notch under slight tension. Insert drains at each end of the wound, and close the deep fascia and the skin in separate layers.    

 

KNEE DISARTICULATION

TECHNIQUE 16.6 (KJØBLE) With the patient prone on the operating table, outline a lateral flap that is one half the anteroposterior diameter of the knee in length and a medial flap that is 2 to 3 cm longer to allow adequate coverage of the large medial femoral condyle (Fig. 16.7). By constructing shorter medial and lateral flaps,

n 

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CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY

Short transfemoral

Medial transfemoral

Long transfemoral FIGURE 16.7 Kjøble disarticulation of knee with medial and lateral skin flaps. SEE TECHNIQUE 16.6.

this technique provides more frequent healing in ischemic limbs than techniques using long anterior and posterior flaps. n  Begin the incision just distal to the lower pole of the patella and extend it distally to the tibial tuberosity, curving medially from this point for the medial flap and laterally from this point for the lateral flap. n  Carry both incisions posteriorly to meet in the midline of the limb at a point 2.5 cm proximal to the joint line. n  Deepen the incisions through the subcutaneous tissue and fascia down to bone. n  Divide the patellar tendon at its insertion, and release the medial and lateral hamstring tendons at their insertions. n  Divide the collateral ligaments and the cruciate ligaments. n  Divide the posterior joint capsule and expose, doubly ligate, and divide the popliteal vessels. Identify and sharply transect the peroneal and tibial nerves so that their cut ends retract well proximal to the end of the stump. n  Release the gastrocnemius origins from the distal femur and divide any remaining soft tissues. n  Suture the patellar tendon and the hamstring tendons to each other and to the cruciate ligaments in the intercondylar notch. n  Approximate the skin edges with interrupted nonabsorbable sutures.

POSTOPERATIVE CARE  If desired, a soft dressing may be applied, and conventional aftercare instituted as previously described (see Chapter 14). Preferable treatment is to apply a rigid dressing or prosthetic cast with or without immediate or early weight-bearing ambulation. If non–weight bearing is desired, the rigid dressing need consist only of a properly padded cast extending to the groin and securely suspended by compressive contouring of the cast in the supracondylar area or by a waist belt, suspension strap, or both. If weightbearing ambulation is pursued, the prosthetic cast should be applied by a qualified prosthetist. Postoperative care is similar to that outlined after transfemoral amputation (see section on transfemoral amputations).    

Supracondylar

FIGURE 16.8

Levels of transfemoral amputations.

TRANSFEMORAL (ABOVE-KNEE) AMPUTATIONS Amputation levels above the knee can be classified as short transfemoral, medial transfemoral, long transfemoral, and supracondylar (Fig. 16.8). Amputation through the thigh is second in frequency only to transtibial amputation. In this procedure the patient’s knee joint is lost, so it is extremely important for the stump to be as long as possible to provide a strong lever arm for control of the prosthesis. The conventional, constant friction knee joint used in conventional above-knee prostheses extends 9 to 10 cm distal to the end of the prosthetic socket, and the bone must be amputated this far proximal to the knee to allow room for the joint. Modern computer-assisted knee prostheses using variable friction for knee stiffness allow for shorter distal femoral segments. These prostheses that have highly sensitive sensors use hydraulic or magnetic units to allow for more natural knee motion, especially deceleration during the swing phase of gait. This also allows for longer femoral length without uneven levels of knee joint function. Amputation stumps in which the level of bone section is less than 5 cm distal to the lesser trochanter function as and are prosthetically fitted as hip disarticulations. Muscle stabilization by myodesis or myoplasty is important when constructing a strong and sturdy amputation stump. Gottschalk pointed out that in the absence of myodesis of the adductor magnus, most transfemoral amputations result in at least 70% loss of adduction power. 

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TRANSFEMORAL (ABOVE-KNEE) AMPUTATION OF NONISCHEMIC LIMBS

Divide the quadriceps muscle and its overlying fascia along the line of the anterior incision and reflect it proximally to the level of intended bone section as a myofascial flap. n  Identify, individually ligate, and transect the femoral artery and vein in the femoral canal on the medial side of the thigh at the level of bone section. Incise the periosteum of the femur circumferentially and divide the bone with a saw immediately distal to the periosteal incision. n  With a sharp rasp, smooth the edges of the bone and flatten the anterolateral aspect of the femur to decrease the unit pressures between the bone and the overlying soft tissues. n  Identify the sciatic nerve just beneath the hamstring muscles, ligate it well proximal to the end of the bone, and divide it just distal to the ligature. n  Divide the posterior muscles transversely so that their ends retract to the level of bone section and remove the leg (Fig. 16.9B). n  Isolate and section all cutaneous nerves so that their cut ends retract well proximal to the end of the stump. Irrigate the wound with saline to remove all bone dust. n  Through several small holes drilled just proximal to the end of the femur, attach the adductor and hamstring muscles to the bone with nonabsorbable or absorbable sutures (Fig. 16.9C). The muscles should be attached under slight tension (alternatively, suture anchors with heavy nonabsorbable suture or suture tape may be used instead of bone tunnels). n 

TECHNIQUE 16.7

Position the patient supine on the operating table and perform the surgery using tourniquet hemostasis. n  Beginning proximally at the anticipated level of bone section, outline equal anterior and posterior skin flaps. The length of each flap should be at least one half the anteroposterior diameter of the thigh at this level. Atypical flaps always are preferred to amputation at a higher level. n  Fashion the anterior flap with an incision that starts at the midpoint on the medial aspect of the thigh at the level of anticipated bone section. The incision passes in a gentle curve distally and laterally, crosses the anterior aspect of the thigh at the level determined as noted earlier, and curves proximally to end on the lateral aspect of the thigh opposite the starting point (Fig. 16.9A). n  Fashion the posterior flap in a similar manner. n  Deepen the skin incisions through the subcutaneous tissue and deep fascia and reflect the flaps proximally to the level of bone section. n 

Amputation level

Skin flap incision

A

B

C FIGURE 16.9 Amputation through middle third of thigh. A, Incision and bone level. B, Myofascial flap fashioned from quadriceps muscle and fascia. C, Adductor and hamstring muscles attached to end of femur through holes drilled in bone. SEE TECHNIQUE 16.7.

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CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY Divide the femur 12 cm above the knee joint. Drill holes in the lateral, anterior, and posterior aspects of the femur, 1.5 cm from its end. n  Hold the femur in maximal adduction and suture the adductor magnus to its lateral aspect using previously drilled holes (Fig. 16.10). Also, place anterior and posterior sutures to prevent its sliding backward or forward. n  Suture the quadriceps to the posterior femur by drawing it over the adductor magnus while holding the hip in extension. n  Suture the remaining posterior muscles to the posterior aspect of the adductor magnus. Close the investing fascia and skin and apply a soft dressing.    n  n 

FIGURE 16.10 Attachment of adductor magnus to lateral femur. (Redrawn from Gottschalk F: Transfemoral amputations. In: Bowker JH, Michael JW, editors: Atlas of limb prosthetics: surgical, prosthetic, and rehabilitation principles, ed 2, St. Louis: Mosby, 1992.) SEE TECHNIQUE 16.8.

At this point, release the tourniquet and attain meticulous hemostasis. n  Bring the “quadriceps apron” over the end of the bone and suture its fascial layer to the posterior fascia of the thigh, trimming any excess muscle or fascia to permit a neat, snug approximation. n  Insert plastic suction drainage tubes beneath the muscle flap and deep fascia, and bring them out through the lateral aspect of the thigh 10 to 12.5 cm proximal to the end of the stump. n  Approximate the skin edges with interrupted sutures of nonabsorbable material.     n 

 

TRANSFEMORAL (ABOVE-KNEE) AMPUTATION OF NONISCHEMIC LIMBS TECHNIQUE 16.8 (GOTTSCHALK) Place the patient supine with a roll under the buttock of the affected side. n  Develop skin flaps using a long medial flap in the sagittal plane when possible. n  Detach the quadriceps just proximal to the patella, retaining part of its tendon. n  Reflect the vastus medialis off the intermuscular septum. n  Detach the adductor magnus from the adductor tubercle and reflect it medially to expose the femur. Identify and ligate the femoral vessels at Hunter’s canal. n  Divide the gracilis, sartorius, semimembranosus, and semitendinosus 2.5 to 5 cm below the intended bone section. n 

REHABILITATION AFTER TRANSFEMORAL AMPUTATION

A soft dressing is adequate initially for elderly dysvascular patients, whereas immediate postoperative rigid dressings and earlier weight bearing with a locked-knee pylon are appropriate in younger patients. Patients seem more comfortable if weight bearing is delayed until sutures or staples are removed. Subsequently, ambulation can be progressed with an unlocked knee and less upper extremity support. For the definitive prosthesis, a variety of prosthetic knee units are available that are lighter and accommodate constant or variable gait cadences and provide good stability during weight bearing. Many concepts and strategies relevant to these patients were discussed earlier under postoperative care of transtibial amputations. The emphasis is on the recognition that patients with ischemic limbs generally are less healthy than patients with nonischemic limbs; the rehabilitative program generally progresses much more slowly and more cautiously. A major obstacle to rehabilitation after transfemoral amputation is the loss of the knee joint, which exponentially increases the energy expenditure for locomotion with a prosthesis. This has consequences for cardiac patients and patients with ischemic contralateral limbs. The patient and family must be aware of the risks involved with a physically demanding rehabilitation program. Many transfemoral amputees with vascular disease never use a prosthesis consistently. Patients with bilateral transfemoral amputations frequently elect to use a wheelchair because it is faster, and oxygen consumption is four to seven times more using bilateral transfemoral prostheses. Younger patients can experience progress more rapidly, as discussed under transtibial postoperative care.

REFERENCES Al Muderis M, Khemka A, Lord SJ, et al.: Safety of osseointegrated implants for transfemoral amputees: a two-center prospective cohort study, J Bone Joint Surg Am 98(11):900, 2016. Albino FP, Seidel R, Brown BJ, et al.: Through knee amputation: technique modifications and surgical outcomes, Arch Plast Surg 41:562, 2014. Baril DT, Ghosh K, Rosen AB: Trends in the incidence, treatment, and outcomes of acute lower extremity ischaemia in the United States Medicare population, J Vasc Surg 60:669, 2014. Bell JC, Wolf EJ, Schnall BL, et  al.: Transfemoral amputations: is there an effect of residual limb length and orientation on energy expenditure? Clin Orthop Relat Res 472:3055, 2014.

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PART VI AMPUTATIONS Bosse MJ, Morshed S, Reider L, et al.: Transtibial amputation outcomes study (TAOS): comparing transtibial amputation with and without a tibiofibular synostosis (Ertl) procedure, J Orthop Trauma 31(Suppl 1):S63, 2017. Brown BJ, Iorio ML, Klement M, et al.: Outcomes after 294 transtibial amputations in the posterior myocutaneous flap, Int J Low Extrem Wounds 13:33, 2014. Czerniecki JM, Thompson ML, Littman A, et  al.: Predicting reamputation risk in patients undergoing lower extremity amputation due to the complications of peripheral artery disease and/or diabetes, Br J Surg 106(8):1026, 2019. Easterlin MC, Chang DC, Wilson SE: A practical index to predict 30-day mortality after major amputation, Ann Vasc Surg 27:909, 2013. Fang ZB, Hu FY, Arya S, et al.: Preoperative frailty is predictive of complications after major lower extremity amputation, J Vasc Surg 65(3):804, 2017. Fergason J, Keeling JJ, Bluman EM: Recent advances in lower extremity amputation and prosthetics for the combat injured patient, Foot Ankle Clin 15:151, 2010. Fleming ME, O’Daniel A, Bharmal H, Valerio I: Application of the orthoplastic reconstructive ladder to preserve lower extremity amputation length, Ann Plast Surg 73:183, 2014. Goodney PP, Holman K, Henke PK, et al.: Regional intensity of vascular care and lower extremity amputation rates, J Vasc Surg 57:1471, 2013. Hasanadka R, McLafferty RB, Moore CJ, et  al.: Predictors of wound complications following major amputation for critical limb ischemia, J Vasc Surg 54:1374, 2011. Hsu AR: Transfemoral amputation adductor myodesis using FiberTape and knotless anchors, Foot Ankle Int 39(7):874, 2018. Jain A, Glass GE, Ahmadi H, et al.: Delayed amputation following trauma increases residual lower limb infection, J Plast Reconstr Aesthet Surg 66:531, 2013. Jones WS, Patel MR, Dai D, et al.: High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease, Am Heart J 165:809, 2013. Kahle JT, Highsmith MJ, Kenney J, et al.: The effectiveness of the bone bridge transtibial amputation technique: a systematic review of high-quality evidence, Prosthet Orthot Int 41(3):219, 2017. Karam J, Shepard A, Rubinfeld I: Predictors of operative mortality following major lower extremity amputations using the National Surgical Quality Improvement Program public use data, J Vasc Surg 58:1276, 2013. Kwah LK, Webb MT, Goh L, Harvey LA: Rigid dressings versus soft dressings for transtibial amputations, Cochrane Database Syst Rev 6:CD012427, 2019. Leijendekkers RA, van Hinte G, Frölke JP, et  al.: Functional performance and safety of bone-anchored prostheses in persons with a transfemoral or transtibial amputation: a prospective one-year follow-up cohort study, Clin Rehabil 33(3):450, 2019. Lowenberg DW, Buntic RF, Buncke GM, Parrett BM: Long-term results and costs of muscle flap coverage with Ilizarov bone transport in lower limb salvage, J Orthop Trauma 27:576, 2013. Mangan KI, Kingsbury TD, Mazzone BN, et al.: Limb salvage with intrepid dynamic exoskeletal orthosis versus transtibial amputation: a comparison of functional gait outcomes, J Orthop Trauma 30(12):e390, 2016. Nelson MT, Greenblatt DY, Soma G, et al.: Preoperative factors predict mortality after major lower-extremity amputation, Surgery 152:685, 2012. O’Brien PJ, Cox MW, Shortell CK, Scarborough JE: Risk factors for early failure of surgical amputations: an analysis of 8,878 isolated lower extremity amputation procedures, J Am Coll Surg 216:836, 2013. Penn-Barwell JG: Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis, Injury 42:1474, 2011. Phair J, DeCarlo C, Scher L, et al.: Risk factors for unplanned readmission and stump complications after major lower extremity amputation, J Vasc Surg 67(3):848, 2018. Plucknette BF, Krueger CA, Rivera JC, Wenke JC: Combat-related bridge synostosis versus traditional transtibial amputation: comparison of military-specific outcomes, Strategies Trauma Limb Reconstr 11(1):5, 2016. Polfer EM, Hoyt BW, Bevevino AJ, et al.: Knee disarticulations versus transfemoral amputations: functional outcomes, J Orthop Trauma 33(6):308, 2019. Prinsen E, Nederhand MJ, Olsman J, Rietman JS: Influence of a user-adaptive prosthetic knee on quality of life, balance confidence, and measures of mobility: a randomised cross-over trial, Clin Rehabil 29:581, 2015.

Reichmann JP, Stevens PM, Rheinstein J, Kreulen CD: Removal rigid dressings for postoperative management of transtibial amputations: a review of published evidence, PM R 10(5):516, 2018. Rosen N, Gigi R, Haim A, et al.: Mortality and reoperations following lower limb amputations, Isr Med Assoc J 16:83, 2014. Ryan SP, DiLallo M, Klement MR, et al.: Transfemoral amputation following total knee arthroplasty: mortality and functional outcomes, Bone Joint J 101-B(2):221, 2019. Schuett DJ, Wyatt MP, Kingsbury T, et al.: Are gait parameters for throughknee amputees different from matched transfemoral amputees? Clin Orthop Relat Res 477(4):821, 2019. Seker A, Kara A, Camur S, et al.: Comparison of mortality rates and functional results after transtibial and transfemoral amputations due to diabetes in elderly patients – a retrospective study, Int J Surg 33:78, 2016. Shah SK, Bena JF, Allemang MT, et al.: Lower extremity amputations: factors associated with mortality or contralateral amputation, Vasc Endovascular Surg 47:608, 2013. Singleton JA, Walker NM, Gibb IE, et al: Case suitability for definitive through knee amputation following lower extremity blast trauma: analysis of 146 combat casualties, 2008-2010, J R Army Med Corps 160(187):2014. Spahn K, Wyatt MP, Stewart JM, et al.: Do Gait and functional parameters change after transtibial amputation following attempted limb preservation in a military population? Clin Orthop Relat Res 477(4):829, 2019. Sumpio B, Shine SR, Mahler D, Sumpio BE: A comparison of immediate postoperative rigid and soft dressings for below-knee amputations, Ann Vasc Surg 27:774, 2013. Swaminathan A, Vemulapalli S, Patel MR, Jones WS: Lower extremity amputation in peripheral artery disease: improving patient outcomes, Vasc Health Risk Manag 10:417, 2014. Taylor BC, Poka A: Osteomyoplastic transtibial amputation: technique and tips, J Orthop Surg Res 6:13, 2011. Taylor BC, Poka A: Osteomyoplastic transtibial amputation: the Ertl technique, J Am Acad Orthop Surg 24(4):259, 2016. Theeven PJ, Hemmen B, Geers RP, et al.: Influence of advanced prosthetic knee joints on perceived performance and everyday life activity level of low-functional persons with a transfemoral amputation or knee disarticulation, J Rehabil Med 44:454, 2012. Tillander J, Hagberg K, Berlin Ö, et al.: Osteomyelitis risk in patients with transfemoral amputations treated with osseointegration prostheses, Clin Orthop Relat Res 475(12):3100, 2017. Tintle SM, Keeling JJ, Shawen SB, et al.: Traumatic and trauma-related amputations: part I: general principles and lower-extremity amputations, J Bone Joint Surg 92A:2852, 2010. Tintle SM, Shawen SB, Forsberg JA, et al.: Reoperation after combat-related major lower extremity amputations, J Orthop Trauma 28:232, 2014. Tsai CY, Chu SY, Wen YW, et al.: The value of Doppler waveform analysis in predicting major lower extremity amputation among dialysis patients treated for diabetic foot ulcers, Diabetes Res Clin Pract 100:181, 2013. Tseng CL, Rajan M, Miller DR, et al.: Trends in initial lower extremity amputation rates among Veterans Health Administration health care system users from 2000 to 2004, Diabetes Care 34:1157, 2011. Vallier HA, Fitzgerald SJ, Beddow ME, et  al.: Osteocutaneous pedicle flap transfer for salvage of transtibial amputation after severe lower-extremity injury, J Bone Joint Surg 94A:447, 2012. Wied C, Tengberg PT, Holm G, et al.: Tourniquets do not increase the total blood loss or re-amputation rise in transtibial amputations, World J Orthop 8(1):62, 2017. Whitehead A, Wolf EJ, Scoville CR, Wilken JM: Does a microprocessor-controlled prosthetic knee affect stair ascent strategies in persons with transfemoral amputation? Clin Orthop Relat Res 472:3093, 2014. Zayad M, Bech F, Hernandez-Boussard T: National review of factors influencing disparities and types of major lower extremity amputations, Ann Vasc Surg 28:1157, 2014. The complete list of references is available online at ExpertConsult.com.

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SUPPLEMENTAL REFERENCES Aulivola B, Hile CN, Hamdan AD, et al.: Major lower extremity amputation: outcome of a modern series, Arch Surg 139:395, 2004. Ayoub MM, Solis MM, Rogers JJ, et al.: Thru-knee amputation: the operation of choice for non-ambulatory patients, Am Surg 59:619, 1993. Batch JW, Spittler AW, McFaddin JG: Advantages of the knee disarticulation over amputations through the thigh, J Bone Joint Surg 36A:921, 1954. Berlet GC, Pokabla C, Serynek P: An alternative technique for the Ertl osteomyoplasty, Foot Ankle Int 30:443, 2009. Burgess EM: Disarticulations of the knee: a modified technique, Arch Surg 112:1250, 1977. Burgess EM, Matsen III FA: Determining amputation levels in peripheral vascular disease, J Bone Joint Surg 64A:1493, 1981. Burgess EM, Matsen III FA, Wyss CR, et al.: Segmental transcutaneous measurements of Po2 in patients requiring below-the-knee amputation for peripheral vascular insufficiency, J Bone Joint Surg 64A:378, 1982. Burgess EM, Zettl JH: Amputations below the knee, Artif Limbs 13:1, 1969. Buzato MA, Tribulatto EC, Costa SM, et al.: Major amputations of lower leg: the patients two years later, Acta Chir Belg 102:248, 2002. Catre MG, Liebermann IH: Laterally based skin flap for below-knee amputation: case report, J Trauma 43:869, 1997. Centers for Disease Control: Diabetes surveillance system: nontraumatic lower extremity amputation with diabetes by level, Diabetes Public Health Resource 2003. Choksy SA, Lee Chong P, Smith C, et al.: A randomised controlled trial of the use of a tourniquet to reduce blood loss during transtibial amputation for peripheral arterial disease, Eur J Vasc Endovasc Surg 31:646, 2006. Cruz CP, Eidt JF, Capps C, et  al.: Major lower extremity amputations at a Veterans Affairs hospital, Am J Surg 186:449, 2003. Cull DL, Taylor SM, Hamontree SE, et  al.: A reappraisal of a modified through-knee amputation in patients with peripheral vascular disease, Am J Surg 182:44, 2001. Decoster TA, Homedan S: Amputation osteoplasty, Iowa Orthop J 26:54, 2006. Dillingham TR, Pezzin LE, MacKenzie EJ: Limb amputation and limb deficiency: epidemiology and recent trends in the United States, South Med J 95:875, 2002. Ertl J: Über amputationsstümpfe, Chirurg 20:218, 1949. Gottschalk F: Transfemoral amputation, Clin Orthop Relat Res 361:15, 1999. Fergason J, Keeling JJ, Bluman EM: Recent advances in lower extremity amputation and prosthetics for the combat injured patient, Foot Ankle Clin 15:151, 2010. Hagberg E, Berlin OK, Renström P: Function after through-knee compared with below-knee and above-knee amputation, Prosthet Orthot Int 16:168, 1992. Harrington IJ, Lexier R, Woods JM, et  al.: A plaster-pylon technique for below-knee amputation, J Bone Joint Surg 73B:76, 1991. Humzah MD, Gilbert PM: Fasciocutaneous blood supply in below-knee amputation, J Bone Joint Surg 79B:441, 1997. Jain AS, Stewart CPU, Turner MS: Below-knee amputation using a medially based flap, Br J Surg 81:512, 1994. Januszkiewicz JS, Mehrotra ON, Brown GE: Calcaneal fillet flap: a new osteocutaneous free tissue transfer for emergency salvage of traumatic belowknee amputation stumps, Plast Reconstr Surg 98:538, 1996.

Kasabian AK, Glat PM, Eidelman Y, et al.: Salvage of traumatic below-knee amputation stumps utilizing the filet of foot free flap: critical evaluation of six cases, Plast Reconstr Surg 96:1145, 1995. KjØble J: The surgery of the through-knee amputation. In Murdock G, ed: Prosthetic and orthotic practice, London, 1970, Edward Arnold. Kock HJ, Friederichs J, Ouchmaev A, et al.: Long-term results of throughknee amputation with dorsal musculocutaneous flap in patients with end-stage arterial occlusive disease, World J Surg 28:801, 2004. MacKenzie EJ, Bosse MJ, Castillo RC, et  al.: Functional outcomes following trauma-related lower-extremity amputation, J Bone Joint Surg 86A:1636, 2004. Malek F, Somerson JS, Mitchel S, Williams RP: Does limb-salvage surgery offer patients better quality of life and functional capacity than amputation? Clin Orthop Relat Res 470:2000, 2012. Mazet Jr R, Hennessy CA: Knee disarticulation: a new technique and a new knee-joint mechanism, J Bone Joint Surg 48A:126, 1966. Mazet Jr R, Schmitter ED, Chupurdia R: Disarticulation of the knee: a followup report, J Bone Joint Surg 60A:675, 1978. Mohler DG, Kessler JI, Earp BE: Augmented amputations of the lower extremity, Clin Orthop Relat Res 371:183, 2000. Morse BC, Cull DL, Kalbaugh C, et al.: Through-knee amputation in patients with peripheral arterial disease: a review of 50 cases, J Vasc Surg 48:638, 2008. Nehler MR, Coll JR, Hiat WR, et al.: Functional outcome in a contemporary series of major lower extremity amputations, J Vasc Surg 38:7, 2003. Persson BM: Sagittal incision for below-knee amputation in ischemic gangrene, J Bone Joint Surg 56B:110, 1974. Pinzur MS, Beck J, Himes R, Callaci J: Distal tibiofibular bone-bridging in transtibial amputation, J Bone Joint Surg 90A:2682, 2008. Pinzur MS, Bowker JH: Knee disarticulation, Clin Orthop Relat Res 361:23, 1999. Pinzur MS, Gottschalk F, Pinto MA, Smith DG: Controversies in lower extremity amputation, Instr Course Lect 57:663, 2008. Pinzur MS, Gottschalk F, Smith D, et al.: Functional outcome of below-knee amputation in peripheral vascular insufficiency: a multicenter review, Clin Orthop Relat Res 286:247, 1993. Rayman G, Krishnan ST, Baker NR, et al.: Are we underestimating diabetesrelated lower-extremity amputation rates? Results and benefits of the first prospective study, Diabetes Care 27:1892, 2004. Saleh M, Datta D, Eastaugh-Waring SJ: Long posteromedial myocutaneous flap below-knee amputation, Ann R Coll Surg Engl 77:141, 1995. Sandnes DK, Sobel M, Flum DR: Survival after lower-extremity amputation, J Am Coll Surg 199:394, 2004. Smith DG, Fergason JR: Transtibial amputations, Clin Orthop Relat Res 361:108, 1999. Sonja MHJ, Jaegers MD, Arendzen JH, et al.: Changes in hip muscles after above-knee amputation, Clin Orthop Relat Res 319:276, 1995. Stokes R, Whetzel TP, Stevenson TR: Three-dimensional reconstruction of the below-knee amputation stump: use of the combined scapular/parascapular flap, Plast Reconstr Surg 94:732, 1994. Subramaniam B, Pomposelli F, Talmor D, et al.: Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics, Anesth Analg 100:1241, 2005. Topper AK, Fernie GR: Computer-aided design and computer-aided manufacturing (CAD/CAM) in prosthetics, Clin Orthop Relat Res 256:39, 1990. Toursarkissian B, Shireman PK, Harrison A, et  al.: Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution, Am Surg 68:606, 2002.

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17

AMPUTATIONS OF THE HIP AND PELVIS Kevin B. Cleveland

DISARTICULATION OF THE HIP

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Hip disarticulation and the various forms of hemipelvectomy most often are performed for the treatment of primary bone tumors and rarely for metastases, infection, or trauma. Improved treatments with chemotherapy, radiation, and biologics are increasing survival of patients with malignancies, which has increased the indications for aggressive treatment of these tumors. The dimensions of the amputation vary with oncologic requirements, and nonstandard flaps often are necessary. For patients with such high-level amputations, the energy requirements to use a prosthesis have been estimated to be 250% of normal ambulation. Wheelchair and crutch locomotion are 50% faster and require less energy expenditure; however, especially in younger patients, providing prosthetic walking ability for even short distances may be beneficial to physical and mental health. With new advances in prosthetics, such as polycentric hip joints and microprocessor knees, more patients are increasing their independence and functional mobility. These newer advances provide greater ability to negotiate environmental obstacles such as stairs or inclines and allow variable cadence as well as minimize the need for ambulatory aides. Lighter-weight prostheses also have resulted in less oxygen consumption and more compliance with prosthetic use. The main goals of a prosthesis are to improve function and provide an improved self-body image. Only 43% of patients use a prosthetic device, however, and wear them on average for 5.8 hours per day. Although the only significant metric for unsuccessful prosthetic wear is coronary artery disease, the most common reason that patients do not use a prosthesis is that they were never offered one. We have found that consultation with a prosthetist is most valuable. A multidisciplinary team should be involved in the care of these patients, and thorough preoperative planning is imperative.

DISARTICULATION OF THE HIP Hip disarticulation occasionally is indicated after massive trauma, for arterial insufficiency, for severe infections, for massive decubitus ulcers, or for certain congenital limb deficiencies. Most frequently, however, hip disarticulation is necessary for treatment of bone or soft-tissue sarcomas of the femur or thigh that cannot be resected adequately by limbsparing methods. Hip disarticulation accounts for 0.5% of lower extremity amputations. Mortality rates vary in studies from 0% to 44%. The inguinal or iliac lymph nodes are not routinely removed with hip disarticulation. The anatomic method of Boyd and the posterior flap method of Slocum are described here. However, modifications frequently are required based on the location of the pathology. 

 

ANATOMIC HIP DISARTICULATION

TECHNIQUE 17.1 (BOYD)

With the patient in the lateral decubitus position, make an anterior racquet-shaped incision (Fig. 17.1A), beginning the incision at the anterior superior iliac spine and curving it distally and medially almost parallel with the inguinal ligament to a point on the medial aspect of the thigh 5 cm distal to the origin of the adductor muscles. Isolate and ligate the femoral artery and vein, and divide the femoral nerve; continue the incision around the posterior aspect of the thigh about 5 cm distal to the ischial tuberosity and along the lateral aspect of the thigh about 8 cm distal to the base of the greater trochanter. From this point, curve the incision proximally to join the beginning of the incision just inferior to the anterior superior iliac spine. n  Detach the sartorius muscle from the anterior superior iliac spine and the rectus femoris from the anterior inferior iliac spine. Reflect them both distally. n  Divide the pectineus about 0.6 cm from the pubis. n  Rotate the thigh externally to bring the lesser trochanter and the iliopsoas tendon into view; divide the latter at its insertion and reflect it proximally. n  Detach the adductor and gracilis muscles from the pubis and divide at its origin that part of the adductor magnus that arises from the ischium. n  Develop the muscle plane between the pectineus and obturator externus and short external rotators of the hip to expose the branches of the obturator artery. Clamp, ligate, and divide the branches at this point. Later in the operation the obturator externus muscle is divided at its insertion on the femur instead of at its origin on the pelvis because otherwise the obturator artery may be severed and might retract into the pelvis, leading to hemorrhage that could be difficult to control. n  Rotate the thigh internally and detach the gluteus medius and minimus muscles from their insertions on the greater trochanter and retract them proximally. n  Divide the fascia lata and the most distal fibers of the gluteus maximus muscle distal to the insertion of the tensor fasciae latae muscle in the line of the skin incision, and separate the tendon of the gluteus maximus from its insertion on the linea aspera. Reflect this muscle mass proximally. n 

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Iliopsoas muscle Tensor fasciae latae muscle Gluteus medius muscle Gluteus maximus muscle Vastus lateralis muscle

Rectus femoris muscle

A

Femoral artery, nerve, vein Pectineus muscle Short external rotator muscles

Adductor longus and brevis muscles

Sartorius muscle

Insertion of gluteus maximus muscle Gluteus medius and minimus muscles

Vastus lateralis muscle

Piriformis muscle Short external rotators

Adductor muscles Biceps femoris muscle Semitendinosus muscle

Gluteus maximus muscle Sciatic nerve

Semimembranosus muscle Obturator externus muscle

B FIGURE 17.1 Boyd disarticulation of hip. A, Femoral vessels and nerve have been ligated, and sartorius, rectus femoris, pectineus, and iliopsoas muscles have been detached. Inset, Line of skin incision. B, Gluteal muscles have been separated from insertions, sciatic nerve and short external rotators have been divided, and hamstring muscles have been detached from ischial tuberosity. Inset, Final closure of stump. SEE TECHNIQUE 17.1. (Redrawn from Boyd HB: Anatomic disarticulation of the hip, Surg Gynecol Obstet 84:346, 1947.)

Identify, ligate, and divide the sciatic nerve. Divide the short external rotators of the hip (i.e., the piriformis, gemelli, obturator internus, obturator externus, and quadratus femoris) at their insertions on the femur and sever the hamstring muscles from the ischial tuberosity. n  Incise the hip joint capsule and the ligamentum teres to complete the disarticulation (Fig. 17.1B). n  n 

Bring the gluteal flap anteriorly and suture the distal part of the gluteal muscles to the origin of the pectineus and adductor muscles. n  Place a drain in the inferior part of the incision and approximate the skin edges with interrupted nonabsorbable sutures.     n 

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CHAPTER 17  AMPUTATIONS OF THE HIP AND PELVIS  

Extended Standard

POSTERIOR FLAP

TECHNIQUE 17.2

I

(SLOCUM) Begin the incision at the level of the inguinal ligament, carry it distally over the femoral artery for 10 cm, curve it along the medial aspect of the thigh, continue it laterally and proximally over the greater trochanter, and swing it anteriorly to the starting point. A posteromedial flap long enough to cover the end of the stump is formed. n  Isolate, ligate, and divide the femoral vessels, and section the femoral nerve to fall well proximal to the inguinal ligament. n  Abduct the thigh widely and divide the adductor muscles at their pubic origins. n  Section the two branches of the obturator nerve so that they retract away from pressure areas. n  Free the origins of the sartorius and rectus femoris muscles from the anterior superior and anterior inferior iliac spines. Moderately adduct and internally rotate the thigh and divide the tensor fasciae latae muscle at the level of the proximal end of the greater trochanter; at the same level, divide close to bone the muscles attached to the trochanter. Next, abduct the thigh markedly and divide the gluteus maximus at the distal end of the posterior skin flap. n  Identify, ligate, and divide the sciatic nerve. n  Divide the joint capsule and complete the disarticulation. n  Swing the long posteromedial flap containing the gluteus maximus anteriorly and suture it to the anterior margins of the incision.     n 

EXTERNAL HEMIPELVECTOMY (HINDQUARTER AMPUTATION) Hemipelvectomy most often is performed for tumors that cannot be adequately resected by limb-sparing techniques or hip disarticulation. Other indications for hemipelvectomy include life-threatening infection such as necrotizing fasciitis and arterial insufficiency. Chan et  al. reported hemipelvectomy for decubitus ulcers in patients with spinal cord injury. In contrast to hip disarticulation, all types of hemipelvectomy remove the inguinal and iliac lymph nodes. The standard hemipelvectomy employs a posterior or gluteal flap and disarticulates the symphysis pubis and sacroiliac joint and the ipsilateral limb. An extended hemipelvectomy includes resection of adjacent musculoskeletal structures, such as the sacrum or parts of the lumbar spine. In a modified hemipelvectomy, the bony section divides the ilium above the acetabulum, preserving the crest of the ilium (Fig. 17.2). Sherman, O’Connor, and Sim base their decision on when to perform a hemipelvectomy or a pelvic resection on three parameters: the sciatic nerve, the femoral neurovascular bundle, and the hip joint, including the periacetabular region. If two of the three are involved, they recommend hemipelvectomy over pelvic resections to obtain proper margins. Internal hemipelvectomy is a limb-sparing resection, often achieving proximal and medial margins equal to the

Modified II

III

FIGURE 17.2 Modified hemipelvectomy. Bony section divides ilium above acetabulum (red dotted line), preserving iliac crest. (Redrawn from: Bibbo C, Newman AS, Lackman RD, Levin LS, Kovach SJ: A simplified approach to reconstruction of hemipelvectomy defects with lower extremity free fillet flaps to minimize ischemia time, J Plast Reconstr Aesth Surg 68:1750, 2015)

corresponding amputation. This is currently the preferred method but should not be performed at the expense of quality margins. This procedure is discussed in Chapter 24. All types of hemipelvectomy are extremely invasive and mutilating procedures. Gordon-Taylor called hindquarter amputations “one of the most colossal mutilations practiced on the human frame.” These operations require optimizing the patient’s nutritional status, preparing for blood replacement, and adequate monitoring during surgery. Early reports of mortality from hemipelvectomy was greater than 50%, but with more recent advances including radiation, chemotherapy, and patient optimization, mortality is less than 10%. Complications, however, are common and have been reported in up to 80% of patients. Many patients have significant phantom pain in the early postoperative course. Residual limb spasm has been reported to occur more commonly than phantom pain and may present weeks or even months after the procedure; it is most common after traumatic hemipelvectomy. Flap necrosis and wound sloughs are common complications. In their review of 160 external hemipelvectomies, Senchenkov et al. reported a morbidity rate of 54%, including intraoperative genitourinary (18%) and gastrointestinal injuries (3%). Wound complications were the most common postoperative complications, including infection and flap necrosis. Patients with a posterior flap, who had ligation of the common iliac vessels, were 2.7 times more likely to have flap necrosis than those patients who had ligation of the external iliac vessels alone. Apffelstaedt et al. found no statistical difference between flap failure and ligation of the common iliac artery compared to ligation of the external iliac artery only. We still recommend preservation of the common iliac artery when feasible. Increased operative time and complexity of the resection also lead to an increase in flap necrosis and infection. Up to 80% of flaps have been reported to have complications. The best option (86% success rate) for reconstructive flaps is use of the amputated tissue (free fillet flaps). Utilization of the fillet flap preserves the original soft tissue that can be used if the fillet

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PART VI AMPUTATIONS flap should fail. To reduce ischemic time, it is recommended that the fillet flap be harvested before the hemipelvectomy is undertaken. Custom implants and trabecular metal can also be used to improve outcomes. The surgical techniques continue to evolve as advances in prosthetics continue to progress. New advances in 3D printed models and the use of intraoperative navigation systems improve the surgeon’s understanding of the tumor as well as the resection required. Appropriate emotional and psychologic support is an important part of rehabilitation. Techniques for the standard, anterior flap and conservative hemipelvectomy are described.   

STANDARD HEMIPELVECTOMY

TECHNIQUE 17.3

Insert a Foley catheter. Place the patient in a lateral decubitus position with the involved side up. Support the patient so that the table can be tilted to facilitate anterior and posterior dissection. n  Perform the anterior dissection first, making an incision extending from 5 cm above the anterior superior iliac spine to the pubic tubercle (Fig. 17.3A). Deepen the incision through the tensor fascia, external oblique aponeurosis, and internal oblique and transversalis muscles. n  Retract the spermatic cord medially. n  Expose the iliac fossa by blunt dissection. n  Elevate the parietal peritoneum off of the iliac vessels and permit it to fall inferiorly with the viscera. n  Ligate the inferior epigastric vessels. n  Release the rectus muscle and sheath from the pubis. n  Identify the iliac vessels, retract the ureter medially, and ligate and divide the common iliac artery and vein. Put lateral traction on the iliac artery and vein and ligate and divide their branches to the sacrum, rectum, and bladder, separating the rectum and bladder from the pelvic side wall and exposing the sacral nerve roots (Fig. 17.3B, C). If necessary for exposure, divide the symphysis pubis and sacroiliac joint before this dissection. n  Pack the anterior wound with warm, moist gauze packs. n  Make a posterior skin incision, extending from 5 cm above the anterior superior iliac spine, coursing over the anterior aspect of the greater trochanter, paralleling the gluteal crease posteriorly around the thigh, and connecting with the inferior end of the anterior incision (see Fig. 17.3A). n  Raise the posterior flap by dissecting the gluteal fascia directly off the gluteus maximus. Include the fascia with the flap. If possible, include the medial portion of the gluteus maximus with the flap. Superiorly elevate the flap off the iliac crest. n  Divide the external oblique, sacrospinalis, latissimus dorsi, and quadratus lumborum from the crest of the ilium. n  Reflect the gluteus maximus from the sacrotuberous ligament, coccyx, and sacrum (Fig. 17.3D). n  Divide the iliopsoas muscle; genitofemoral, obturator, and femoral nerves; and lumbosacral nerve trunk at the level of the iliac crest. n  Abduct the hip, placing tension on the soft tissues around the symphysis pubis. Pass a long right-angle

clamp around the symphysis, and divide it with a scalpel (Fig. 17.3E). n  Divide the sacral nerve roots, preserving the nervi erigentes if possible. Reflect the iliacus muscle laterally, exposing the anterior aspect of the sacroiliac joint. n  Divide the joint anteriorly with a scalpel or osteotome and divide the iliolumbar ligament. n  Place considerable traction on the extremity, separating the pelvic side wall from the viscera. Proceeding from anterior to posterior, divide the following from the pelvic side wall: urogenital diaphragm, pubococcygeus, ischiococcygeus, iliococcygeus, piriformis, sacrotuberous ligament, and sacrospinous ligaments (Fig. 17.3F). All of these structures must be divided under tension. Move the extremity anteriorly and divide the posterior aspect of the sacroiliac joint to complete the dissection. n  Place suction drains in the wound and suture the gluteal fascia to the fascia of the abdominal wall. Close the skin.

n 

POSTOPERATIVE CARE  The drains and Foley catheter should be left in place for several days. Pressure should be kept off the posterior flap for several days.    

 

ANTERIOR FLAP HEMIPELVECTOMY Anterior flap hemipelvectomy is indicated for lesions of the buttock or posterior proximal thigh that cannot be adequately treated by limb-sparing methods. The larger posterior defect is covered by a quadriceps myocutaneous flap maintained by the superficial femoral vessels and may include part of the sartorius muscle.



TECHNIQUE 17.4

Insert a Foley catheter. Place the patient in the lateral decubitus position with the operated side up and secure the patient to the table so that it can be tilted to facilitate the anterior and posterior dissections. Prepare the skin from toes to rib cages and drape the extremity free. Mark out the skin incision such that the length and width of the anterior flap adequately covers the posterior defect that is to be created (Fig. 17.4A). n  Make an incision superiorly across the iliac crest to the midlateral point, around the buttock just lateral to the anus, and to the midmedial point of the thigh. Carry the incision down the thigh a distance adequate to cover the posterior defect, across the front of the thigh to the midlateral point, and superiorly to join the superior incision. n  Perform the posterior dissection first. Preserve a skin margin of 3 cm from the anus. Detach the gluteus maximus and sacrospinalis from the sacrum. Detach the external oblique, sacrospinalis, latissimus dorsi, and quadratus lumborum muscles from the iliac crest. n  Flex the hip and place the tissues in the region of the gluteal crease under tension. Detach the remaining origins of the gluteus maximus from the coccyx and sacrotuberous ligament (Fig. 17.4B). Bluntly dissect lateral to the rectum into the ischiorectal fossa. n 

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CHAPTER 17  AMPUTATIONS OF THE HIP AND PELVIS Iliolumbar artery Lateral sacral artery Greater trochanter

A

External iliac artery

Internal iliac artery Middle hemorrhoidal artery Superior gluteal artery

Rectum

Inferior gluteal artery

Inferior vesical artery Bladder

Internal pudendal artery

Symphysis pubis

External iliac vein

Common iliac artery

Anterior superior iliac spine

Superior vesical artery

Sacral roots

B

Iliacus muscle

Inferior epigastric artery

Obturator artery

Transected gluteus maximus muscle

External iliac artery

Genitofemoral nerve

Bladder

Sacral nerve roots

Rectum

C

Inferior margin of gluteus maximus muscle

Posterior superior iliac spine

Internal iliac artery

Piriformis muscle Posterior inferior iliac spine

D Sacroiliac joint

Position of right-angle clamp Pubic symphysis

E

Transection of urogenital diaphragm Cut ends of sacral roots

Rectus sheath

F FIGURE 17.3 Standard hemipelvectomy. A, Incision. B, and C, Transection of iliac arteries and division of internal iliac vessels. D, Release of iliac crest and gluteus maximus. E, Division of symphysis pubis. F, Division of muscles from pelvis. SEE TECHNIQUE 17.3.

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Posterior skin incision

Anterior skin incision

Previous biopsy site

A

Sartorius muscle

Vastus lateralis muscle

Anterior superior iliac spine Hamstrings Femur

Gluteus maximus muscle (ligamentous and coccygeal attachments)

B

Gluteus maximus muscle (sacral attachments divided)

C

FIGURE 17.4 Anterior flap hemipelvectomy. A, Anterior and posterior incision. B, Detachment of gluteus maximus origins from coccyx and sacrotuberous ligament. C, Severing vastus lateralis from femur and separating tensor fascia femoris from fascia.

Move to the front of the patient and deepen the anterior incision at the junction of the middle and distal thirds of the thigh through the quadriceps to the femur. Continue the dissection laterally from this point in a cephalad direction to the anterior superior spine severing the vastus lateralis from the femur and separating the tensor fascia femoris from its fascia such that it is included with the specimen (Fig. 17.4C). n  Start the medial dissection at Hunter’s canal and ligate and divide the superficial femoral vessels. Trace the vessels superiorly to the inguinal ligament, dividing and ligating multiple small branches to the adductor muscles. n  Place upward traction on the myocutaneous flap and detach the vastus medialis muscle and intermedius from the femur. n  Ligate and divide the profunda femoris vessels at their origin from the common femoral artery and vein. n  Separate the myocutaneous flap from the pelvis by releasing the abdominal muscles from the iliac crest, the sartorius from the anterior superior spine, the rectus femoris from the anterior inferior spine, and the rectus abdominis from the pubis (Fig. 17.4D). n  Retract the flap medially and dissect along the femoral nerve into the pelvis to expose the iliac vessels. n 

Divide the symphysis pubis while protecting the bladder and urethra. n  Ligate and divide the internal iliac vessels at their origin from the common iliacs. While placing medial traction on the bladder and rectus, divide the visceral branches of the internal iliac vessels. Divide the psoas muscle as it joins the iliacus muscle and divide the underlying obturator nerve, but protect the femoral nerve going into the flap. Divide the lumbosacral nerve and the sacral nerve roots (Fig. 17.4E). n  Put traction on the pelvic diaphragm by elevating the extremity and divide the urogenital diaphragm, levator ani, and piriformis near the pelvis. n  Divide the sacroiliac joint and the iliolumbar ligament and remove the specimen. n  Turn the quadriceps flap onto the posterior defect and close the wound over suction drains by suturing the quadriceps to the abdominal wall, sacrospinalis, sacrum, and pelvic diaphragm. n 

POSTOPERATIVE CARE The patient may ambulate when comfort and stability permit. The drains and Foley catheter should be left in place for several days. Skin slough is much less common than with the classic posterior flap.       

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CHAPTER 17  AMPUTATIONS OF THE HIP AND PELVIS

Origin of rectus femoris muscle

Iliopsoas muscle

Anterior superior iliac spine

Femur

Adductor magnus muscle Adductor longus muscle Pubic tubercle

Myocutaneous flap Superficial femoral artery

Femoral sheath Rectus abdominis muscle Profunda femoris artery, ligated

D

External iliac artery

Sacral nerve roots

Common iliac artery Internal iliac artery

Bladder Symphysis pubis

Profunda femoris artery Superficial femoris artery Myocutaneous flap

E FIGURE  17.4, CONT’D     D, Separation of myocutaneous flap. E, Transection of internal iliac vessels and branches. SEE TECHNIQUE 17.4.

 

CONSERVATIVE HEMIPELVECTOMY Conservative hemipelvectomy is indicated for tumors around the proximal thigh and hip that cannot be resected adequately by limb-sparing techniques and do not require sacroiliac disarticulation for satisfactory proximal margins. The operation is a supraacetabular amputation that divides the ilium through the greater sciatic notch.



TECHNIQUE 17.5

Insert a Foley catheter. Place the patient in a lateral decubitus position with the operated side up and secure the patient to the table so that it can be tilted to either side. n  Start the incision 1 to 2 cm above the anterior superior iliac spine and continue it posteriorly and laterally across the greater trochanter to the gluteal crease. Follow the crease to the medial thigh posteriorly. Begin a second inci n 

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PART VI AMPUTATIONS Bluntly dissect the retroperitoneal space exposing the iliac vessels. Ligate and divide the external iliac vessels just distal to the internal iliacs. n  Divide the symphysis pubis, protecting the bladder and urethra. n  Divide the ilium through the greater sciatic notch as follows: bluntly dissect the iliopsoas muscle from the medial wall of the ilium by passing a finger from the anterior superior spine to the greater sciatic notch. Similarly dissect the gluteal muscles from the lateral aspect of the ilium. Pass a Gigli saw through the greater sciatic notch below the origin of the gluteus minimus and divide the ilium (Fig. 17.5C). n  Now the extremity can be positioned to place the various muscle groups under tension so that they can be divided at appropriate levels along with the femoral, obturator, and sciatic nerves. Care should be taken to divide the urogenital and pelvic diaphragms at their pelvic attachments, protecting the bladder and rectum. n  Close the wound over suction drains. n 

A

POSTOPERATIVE CARE  The drains and Foley catheter are left in place for several days. Pressure should be kept off the posterior flap for several days after surgery.   

REFERENCES

B

C FIGURE 17.5 Conservative hemipelvectomy. A, Racquet type of incision. B, Separation of muscles from ilium. C, Division of ilium by Gigli saw. SEE TECHNIQUE 17.5. (Redrawn from Sherman CD Jr, Duthie RB: Modified hemipelvectomy, Cancer 13:51, 1960.)

sion from the first incision 5 cm below its starting point and continue it to just above and parallel to the inguinal ligament to the pubic tubercle. Carry the incision posteriorly across the medial thigh to join the first incision (Fig. 17.5A). n  Perform the anterior dissection first. Divide the abdominal wall muscles, exposing the peritoneum (Fig. 17.5B).

Akiyama T, Clark JC, Miki Y, Choong PF: The non-vascularized fibular graft: a simple and successful method of reconstruction of the pelvic ring after internal hemipelvectomy, J Bone Joint Surg Br 92:999, 2010. Angelini A, Calabro T, Pala E, et al.: Resection and reconstruction of pelvic bone tumors, Orthopedics 38(2):87, 2015. Bibbo C, Newman AS, Lackman RD, Levin LS, Kovach SJ: A simplified approach to reconstruction of hemipelvectomy defects with lower extremity free fillet flaps to minimize ischemia time, J Plast Recon Aesthe Surg 68:1750, 2015. Brown TS, Salib CG, Rose PS, et al.: Reconstruction of the hip after resection of periacetabular oncological lesions, Bone Joint J 100-B(1 Suppl A):22, 2018. Chao AH, Neimanis SA, Chang DW, et  al.: Reconstruction after internal hemipelvectomy: outcomes and reconstructive algorithm, Ann Plast Surg 74:342, 2015. Clarke MJ, Adnik PL, Groves ML, et al.: En bloc hemisacrectomy and internal hemipelvectomy via the posterior approach, J Neurosurg Spine 21:458, 2014. D’Alleyrand JC, Fleming M, Gordon WT, et al.: Combat-related hemipelvectomy, J Surg Orthop Adv 21:38, 2012. Ebrahimzadeh MH, Kachooei AR, Soroush MR, et  al.: Long-term clinical outcomes of war-related hip disarticulation and transpelvic amputation, J Bone Joint Surg Am 95:e114, 2013. Griesser MJ, Gillette B, Crist M, et al.: Internal and external hemipelvectomy or flail hip in patients with sarcomas. Quality-of-life and functional outcomes, Am J Phys Med Rehabil 91:24, 2012. Grimer RJ, Chandrasekar CR, Carter SR, et al.: Hindquarter amputation: is it still needed and what are the outcomes? Bone Joint J 95:127, 2013. Guo Y, Fu J, Palmer JL, et al.: Comparison of postoperative rehabilitation in cancer patients undergoing internal and external hemipelvectomy, Arch Phys Med Rehabil 92:620, 2011. Guzik G: Oncological, surgical and functional results of the treatment of patients after hemipelvectomy due to metastases, BMC Musculoskeletal Disorders 19:63, 2019. Henrichs MP, Singh G, Gosheger G, et  al.: Stump lengthening procedure with modular endoprostheses—the better alternative to disarticulartions of the hip joint? J Arthroplasty 30:681, 2015.

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CHAPTER 17  AMPUTATIONS OF THE HIP AND PELVIS Houdek MT, Andrews K, Kralovec ME, et al.: Functional outcome measures of patients following hemipelvectomy, Prosthet Orthot Int, 40(5):566, 2016. Houdek MT, Kralovec ME, Andrews KL: Hemipelvectomy: high-level amputation surgery and prosthetic rehabilitation, Am J Phys Med Rehabil 93:600, 2014. Kalson NS, Gikas PD, Aston W, et  al.: Custom-made endoprostheses for the femoral amputation stump. An alternative to hip disarticulation in tumour surgery, J Bone Joint Surg Br 92:1134, 2010. Kralovec ME, Houdek MT, Andrews KL, et  al.: Prosthetic rehabilitation after hip disarticulation or hemipelvectomy, Am J Phys Med Rehabil 94(12):1035, 2015. Liang H, Ji T, Zhang Y, Wang Y, Guo W: Reconstruction with 3D-printed pelvic endoprostheses after resection of a pelvic tumour, J Bone Joint Surg 99-B:267, 2017. Mat Saad AZ, Halim AS, Faisham WI, et al.: Soft tissue reconstruction following hemipelvectomy: eight-year experience and literature review, Sci World J 2012:702904, 2012. Mavrogenis AF, Soultanis K, Patapis P, et al.: Pelvic resections, Orthopedics 35:e232, 2012. Mayerson JL, Wooldridge AN, Scharschmidt TJ: Pelvic resection: current concepts, J Am Acad Orthop Surg 22:214, 2014. Ogura K, Sakuraba M, Miyamoto S, et al.: Pelvic ring reconstruction with a double-barreled free vascularized fibula graft after resection of malignant pelvic bone tumor, Arch Orthop Trauma Surg 135:619, 2015. Robertson L, Roche A: Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity, Cochrane Database Syst Rev 12:CD010525, 2013. Roulet S, Le Nail L-R, Va G, et al.: Free fillet lower leg flap for coverage after hemipelvectomy or hip disarticulation, Orthop Traumatol, 105:47, 2019. Salunke AA, Shah J, Warikoo V, et al.: Surgical management of pelvic bone sarcoma with internal hemipelvectomy: oncologic and functional outcomes, J Clin Orthop Trauma 8:249, 2017.

Senchenkov A, Moran SL, Petty PM, et al.: Predictors of complications and outcomes of external hemipelvectomy wounds: account of 160 consecutive cases, Ann Surg Oncol 15:355, 2008. Sherman CE, O’Connor MI, Sim FH: Survival, local recurrence, and function after pelvic limb salvage at 23 to 38 years of followup, Clin Orthop Relat Res 470:712, 2012. Stihsen C, Panotopoulos J, Puchner SE, et al.: The outcome of the surgical treatment of pelvic chondrosarcomas. A competing risk analysis of 58 tumours from a single centre, Bone Joint J 99B:686, 2017. Stranix JT, Vranis NM, Lam G, Rapp T, Saadeh PB: Posterior “open book” approach for type I internal hemipelvectomy, Hip Int 29(3):336, 2019. Sun W, Li J, Li Q, et al.: Clinical effectiveness of hemipelvic reconstruction using computer-aided custom-made prostheses after resection of malignant pelvic tumors, J Arthroplasty 26:1508, 2011. Van Houdt WJ, Griffin AM, Wunder JS, Ferguson PC: Oncologic outcome and quality of life after hindquarter amputation for sarcoma: is it worth it? Ann Surg Oncol 25:378, 2018. Ver Halen JP, Yu P, Skoracki RM, Chang DW: Reconstruction of massive oncologic defects using free fillet flaps, Plast Reconstr Surg 125:913, 2010. Wang B, Xie X, Yin J, et al.: Reconstruction with modular hemipelvic endoprosthesis after pelvic tumor resection: a report of 50 consecutive cases, PloS ONE 10(5):e0127263, 2015. Wang G, Zhou D, Shen WJ, et al.: Management of partial traumatic hemipelvectomy, Orthopedics 36:e1340, 2013. Wilson RJ, Free TH, Halpern JL, Schwartz HS, Holt GE: Surgical outcomes after limb-sparing resection and reconstruction for pelvic sarcoma, JBJS Reviews 6(4):e10, 2018. Zhang Y, Wen L, Zhang J, et al.: Three-dimensional printing and computer navigation assisted hemipelvectomy for en block resection of osteosarcoma. A case report, Medicine 96(12), 2017.

The complete list of references is available online at Expert Consult.com

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SUPPLEMENTAL REFERENCES Apffelstaedt JP, Driscoll DL, Spellman JE: Complications and outcome of external hemipelvectomy in the management of pelvic tumors, Ann Surg Oncol 3(3):304, 1996. Bailey RW, Stevens DB: Radical exarticulation of the extremities for the curative and palliative treatment of malignant neoplasms, J Bone Joint Surg 43A:845, 1961. Baliski CR, Schachar NS, McKinnon G, et al.: Hemipelvectomy: a changing perspective for a rare procedure, Can J Surg 47:99, 2004. Brittain HA: Hindquarter amputation, J Bone Joint Surg 31B:104, 1949. Boyd HB: Anatomic disarticulation of the hip, Surg Gynecol Obstet 84:346, 1947. Burgess EM, Romano RL, Zettl JH: The management of lower extremity amputations, TR 10-6, Washington, DC, 1969, Veterans Administration. Burgess EM, Traub JE, Wilson Jr AB: Immediate postsurgical prosthetics in the management of lower extremity amputees, TR, 10-5. Washington, DC, 1967, Veterans Administration. Chan JWH, Virgo KS, Johnson FE: Hemipelvectomy for severe decubitus ulcers in patients with previous spinal cord injury, Am J Surg 185:69, 2003. Chansky HA: Hip disarticulation and transpelvic amputation: surgical management. In Smith DG, Michael JW, Bowker JH, editors: Atlas of amputations and limb deficiencies: surgical, prosthetic, and rehabilitation principles, ed 3, Rosemont, IL, 2004, American Academy of Orthopaedic Surgeons. Chin T, Oyabu H, Maeda Y, et al.: Energy consumption during prosthetic walking and wheelchair locomotion by elderly hip disarticulation amputees, Am J Phys Med Rehabil 88:399, 2009. Coley BL, Higinbotham NL, Romieu C: Hemipelvectomy for tumors of bone: report of 14 cases, Am J Surg 82(27), 1951. Dénes Z, Till A: Rehabilitation of patients after hip disarticulation, Arch Orthop Trauma Surg 115:498, 1997. Endean ED, Schwarcz TH, Barker DE, et  al.: Hip disarticulation: factors affecting outcome, J Vasc Surg 14:398, 1991. Enneking WF, Dunham WK: Resection and reconstruction for primary neoplasms involving the innominate bone, J Bone Joint Surg Am 60-A:731, 1978. Ghormley RK, Henderson MS, Lipscomb PR: Interinnomino-abdominal amputation for chondrosarcoma and extensive chondroma: report of two cases, Mayo Clin Proc 19:193, 1944. Gordon-Taylor G, Monro RS: Technique and management of “hindquarter” amputation, Br J Surg 39:536, 1952. Gordon-Taylor G, Wiles P, Patey DH, et al.: The interinnomino-abdominal operation: observations on a series of fifty cases, J Bone Joint Surg 34B:14, 1952. Johnson III ON, Potter BK, Bonnecarrere ER: Modified abdominoplasty advancement flap for coverage of trauma-related hip disarticulations complicated by heterotopic ossification: a report of two cases and description of a surgical technique, J Trauma 64:E54, 2008.

Karakousis CP, Vezeridis MP: Variants of hemipelvectomy, Am J Surg 145:273, 1983. King D: Steelquist J: Transiliac amputation, J Bone Joint Surg 25:351, 1943. Krijnen MR, Wuisman PI: Emergency hemipelvectomy as a result of uncontrolled infection after total hip arthroplasty: two case reports, J Arthroplasty 19:803, 2004. Lazzari JH, Rack FJ: Method of hemipelvectomy with abdominal exploration and temporary ligation of common iliac artery, Ann Surg 133:267, 1951. Littlewood H: Amputations at the shoulder and at the hip, BMJ 1:381, 1922. Luna-Perez P, Herrera L: Medial thigh myocutaneous flap for covering extended hemipelvectomy, Eur J Surg Oncol 21:623, 1995. Masterson EL, Davis AM, Wunder JS, et al.: Hindquarter amputation for pelvic tumors, Clin Orthop Relat Res 350:187, 1998. Pack GT: Major exarticulations for malignant neoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation, and interilioabdominal amputation: a report of end results in 228 cases, J Bone Joint Surg 38A:249, 1956. Pack GT, Ehrlich HE: Exarticulation of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacroiliac disarticulation (hemipelvectomy), Ann Surg 123:965, 1946; 124:1, 1946. Phelan JT, Nadler SH: A technique of hemipelvectomy, Surg Gynecol Obstet 119:311, 1964. Pinzur MS, Angelats J, Bittar T: Salvage of failed amputation about the hip in peripheral vascular disease by open wound care and nutritional support, Am J Orthop 8:561, 1998. Ross DA, Lohman RF, Kroll SS, et al.: Soft tissue reconstruction following hemipelvectomy, Am J Surg 176:25, 1998. Sara T, Kour AK, De SD, et al.: Wound cover in a hindquarter amputation with a free flap from the amputated limb, Clin Orthop Relat Res 304:248, 1994. Schwartz AJ, Kiatisevi P, Eilber FC, et  al.: The Friedman-Eilber resection arthroplasty of the pelvis, Clin Orthop Relat Res 467:2825, 2009. Senchenkov A, Moran SL, Petty PM, et al.: Predictors of complications and outcomes of external hemipelvectomy wounds: account of 160 consecutive cases, Ann Surg Oncol 15:355, 2008. Slocum DB: Atlas of amputations, St. Louis, 1949, Mosby. Sorondo JP, Ferré RL: Amputación interilioabdominal, An Orthop Traumatol 1:143, 1948. Troup JB, Bickel WH: Malignant disease of the extremities treated by exarticulation: analysis of two hundred and sixty-four consecutive cases with survival rates, J Bone Joint Surg 42A:1041, 1960. Yari P, Dijkstra PU, Geertzen JHB: Functional outcome of hip disarticulation and hemipelvectomy: a cross-sectional national description study in the Netherlands, Clin Rehabil 22:1127, 2008. Zalavras CG, Rigopoulos N, Ahlmann E, Patzakis MJ: Hip disarticulation for severe lower extremity infections, Clin Orthop Relat Res 467:1721, 2009.

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MAJOR AMPUTATIONS OF THE UPPER EXTREMITY Kevin B. Cleveland HAND AMPUTATIONS WRIST AMPUTATIONS FOREARM AMPUTATIONS (TRANSRADIAL) ELBOW DISARTICULATION

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ARM AMPUTATIONS (TRANSHUMERAL) SHOULDER AMPUTATIONS FOREQUARTER AMPUTATIONS

Many orthopaedic surgeons consider amputation as a failure to restore function to an individual; however, an amputation should be considered the start of rehabilitation. Major amputations of the upper extremity are classified as being from the wrist distally to the axilla proximally. Major amputations of the upper extremity account for 8% of all amputations and are approximately 20 times less common than amputations of the lower extremity. Over 100,000 people in the United States are living with major upper extremity amputations today. Trauma is the most common reason for upper extremity amputations, with male predominance much greater than female. Shoulder disarticulation and forequarter amputations are performed more commonly for malignant tumors. Most traumatic amputees benefit more from completion of the amputation and early prosthetic fitting than from heroic attempts at salvage procedures. However, most patients prefer reimplantation if possible over amputation because prostheses currently confer little in the way of sensation and psychological wellbeing. Approximately 13% of patients develop major complications after amputation. Generally, all possible length should be preserved in upper extremity amputations. Length preservation can be maintained by careful evaluation and lengthening of a short stump by distraction osteogenesis (the method of Ilizarov) and microvascular anastomosis. Distal-free flaps and spare-part flaps (fillet flaps) from the amputated limb also should be used to preserve length. A shortening osteotomy may be required on occasion. However, prosthetists are able to fit even small stumps with prostheses to improve function. Often a small stump distal to the elbow can functionally be better than a long above-elbow amputation. A prosthetic limb cannot adequately replace the sensibility of the hand, and the function of a prosthetic limb decreases with higher levels of amputation. Few patients with amputations around the shoulder are regular prosthetic users. The use of a rigid dressing and subsequent early temporary prosthetic fitting (within 30 days) in patients with transhumeral or more distal amputations encourages the resumption of bimanual activities, softens the psychologic blow of limb loss, and decreases the prosthetic rejection rate. After 4 to 6 weeks postoperatively, the soft tissues have healed significantly, and the edema should be controlled enough to proceed with a definitive socket for the patient. A myoelectrical prosthesis may be an option for patients with a below-elbow amputation. These prostheses continue to evolve rapidly. The first-generation myoelectric prostheses used electromyographic (EMG) signals and allowed motion in only

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one plane (flexion and extension). EMG with the addition of targeted muscle reinnervation (TMR) allows more motion and more intuitive use of the prosthesis. Currently the addition of pattern recognition with TMR actually predicts the motion that is about to occur. However, with these advances the algorithms are limited to sequentially controlling the degrees of freedom to only two at a time. This is the limiting factor that keeps these advances from mimicking a natural limb. In manual workers, a more traditional device may be more effective. Some institutions use hybrid systems consisting of a locking shoulder joint with a body-powered elbow and externally powered wrist and terminal devices. These systems are most useful in amputations of the dominant extremity. Recipients use the prosthesis for approximately 14 hours a day. Some reports indicate that 50% of patients discontinue the use of the prosthesis after 5 years. Prosthetic rejection rates can be decreased with better patient education, more distal amputation levels, and prosthetic fitting within 30 days. Various terminal devices are available and are easily interchanged (Fig. 18.1). Phantom pain has been reported in over 50% of patients; however, it rarely causes impaired prosthetic use or unemployment. Myodesis, myoplasty, and myofascial closures should all be performed when possible. New techniques of upper extremity amputations are evolving rapidly with the use of TMR, EMG pattern recognition, and to a lesser degree composite tissue allotransplantation. A multi-disciplinary team approach, including an experienced upper extremity surgeon, a skilled prosthetist or orthotist, a pain management physician, and a skilled physical therapist, should be employed. To obtain this most patients benefit from transfer to a level I hospital. Regardless, experienced prosthetists are invaluable in ensuring that patients have proper functional devices, and they should be consulted, when available, for each patient preferably before surgery.

HAND AMPUTATIONS Hand amputations are discussed in Chapter 19. 

WRIST AMPUTATIONS Whenever feasible, transcarpal amputation or disarticulation of the wrist is preferable to amputation through the forearm because, provided that the distal radioulnar joint remains normal, pronation and supination are preserved. Although only 50% of any pronation and supination is transmitted to

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CHAPTER 18  MAJOR AMPUTATIONS OF THE UPPER EXTREMITY At convenient points in line with their normal insertions, anchor the tendons of the wrist flexors and extensors to the remaining carpal bones so that active wrist motion is preserved. n  With interrupted nonabsorbable sutures, close the subcutaneous tissue and skin at the end of the stump, and insert a rubber tissue drain or a plastic tube for suction drainage.     n 

 

DISARTICULATION OF THE WRIST FIGURE 18.1 Myoelectrical prosthesis for forearm amputation with interchangeable terminal devices.

TECHNIQUE 18.2 Fashion a long palmar and a short dorsal skin flap (Fig. 18.2A). Begin the incision 1.3 cm distal to the radial styloid process, carry it distally and across the palm, and curve it proximally to end 1.3 cm distal to the ulnar styloid process. n  Form a short dorsal skin flap by connecting the two ends of the palmar incision over the dorsum of the hand; atypical flaps may be fashioned, if necessary, to avoid amputation at a higher level. Reflect the skin flaps together with the subcutaneous tissue and fascia proximally to the radiocarpal joint. n  Just proximal to the joint, identify, ligate, and divide the radial and ulnar arteries. n  Identify the median, ulnar, and radial nerves and gently draw them distally into the wound. Section them so that they retract well proximal to the level of the amputation. Also identify the superficial radial nerve, the palmar cutaneous branch, and the dorsal ulnar cutaneous nerve. Preserve the cutaneous nerves that supply sensation to the residual skin stump. n  At a proximal level, divide all tendons and perform a tenodesis of the flexors and extensor tendons. n  Incise the wrist joint capsule circumferentially, completing the disarticulation (Fig. 18.2B, C). n  Retain if possible or resect (if they prevent tensionless closure) the radial and ulnar styloid processes and rasp the raw ends of the bones to form a smoothly rounded contour. Take care to avoid damaging the distal radioulnar joint, including the triangular ligament, so that normal pronation and supination of the forearm are preserved and pain in the joint is prevented (Fig. 18.2D). n  With interrupted nonabsorbable sutures, close the skin flaps over the ends of the bones (Fig. 18.2E) and insert a rubber tissue drain or a plastic tube for suction drainage.     n 

the prosthesis, these motions are extremely valuable to the patient, and every effort should be made to preserve them. In transcarpal amputations, flexion and extension of the radiocarpal joint also should be preserved so that these motions, too, can be used prosthetically. Although difficult, prosthetic fitting of transcarpal amputation stumps can be achieved by a skilled prosthetist. Excellent wrist disarticulation prostheses are now available, and thin prosthetic wrist units can be used that, to a considerable extent, eliminate the previous objection of the artificial hand or prosthetic hook extending below the level of the opposite hand. Compared with more proximal amputations, the long lever arm afforded by amputation at the wrist increases the ease and power with which the prosthesis can be used.   

AMPUTATION AT THE WRIST TECHNIQUE 18.1 Fashion a long palmar and a short dorsal skin flap in a ratio of 2:1. Use the thick palmar skin when available. Dissect the flaps proximally to the level of proposed bone section and expose the underlying soft structures. n  Draw the tendons of the finger flexors and extensors distally, divide them, and allow them to retract into the forearm. n  Identify the tendons of the wrist flexors and extensors, free their insertions, and reflect them proximal to the level of bone section. Identify the median and ulnar nerves and the fine filaments of the radial nerve. Draw the nerves distally and section them well proximal to the level of amputation so that their ends retract well above the end of the stump to help avoid a residual painful neuroma. n  Just proximal to the level of intended bone section, clamp, ligate, and divide the radial and ulnar arteries, and divide the remaining soft tissues down to bone. n  Transect the bones with a saw and rasp all rough edges to form a smooth, rounded contour. n 

FOREARM AMPUTATIONS (TRANSRADIAL) Transradial amputations represent 40% of all major upper extremity amputations. As elsewhere, preserving as much length as possible is desirable. We recommend preserving a

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B

A

D

C

E

FIGURE 18.2 Disarticulation of the wrist. A, Skin incision. B and C, Reflection of the palmar flap and section of wrist joint capsule. D, Resection of tips of radial and ulnar styloids with preservation of the triangular ligament and underlying joint space. E, Completed amputation. SEE TECHNIQUE 18.2.

minimum of two thirds of the forearm length when possible. When circulation in the upper extremity is severely impaired, however, amputations through the distal third of the forearm are less likely to heal satisfactorily than those at a more proximal level because distally the skin is often thin and the subcutaneous tissue is scant. The underlying soft tissues distally consist primarily of relatively avascular structures, such as fascia and tendons. In these exceptional circumstances, an amputation at the junction of the middle and distal thirds of the forearm is preferable. In amputations through the proximal third of the forearm, even a short below-elbow stump 5 cm long is preferable to an amputation through or above the elbow because it preserves elbow function at this level and allows for prosthetic suspension. From a functional standpoint, preserving the patient’s own elbow joint is crucial (5 cm of ulna). By using improved prosthetic fitting techniques, a skilled prosthetist can provide an excellent prosthetic device for even a short below-elbow stump. The benefits of TMR to transradial amputees can be substantial.   

DISTAL FOREARM (DISTAL TRANSRADIAL) AMPUTATION TECHNIQUE 18.3 Beginning proximally at the intended level of bone section, fashion equal anterior and posterior skin flaps (Fig. 18.3A); make the length of each about equal to one half of the diameter of the forearm at the level of amputation. Together with the skin flaps, reflect the subcutaneous tissue and deep fascia proximally to the level of bone section.

n 

Clamp, doubly ligate, and divide the radial and ulnar arteries just proximal to this level. n  Identify the radial, ulnar, and median nerves; draw them gently distally; and transect them high so that they retract well proximal to the end of the stump. n  Cut across the muscle bellies transversely distal to the level of bone section and interpose the muscle tissue between the radius and the ulna. Distally, use the pronator quadratus and more proximally use one flexor tendon and one extensor tendon. Tenodese these muscles to the bone to help prevent painful convergence and instability. n  Divide the radius and ulna transversely and rasp all sharp edges from their ends (Fig. 18.3B). n  Close the deep fascia with fine absorbable sutures and the skin flaps with interrupted nonabsorbable sutures (Fig. 18.3C) and insert deep to the fascia a rubber tissue drain or, if preferable, a plastic tube for suction drainage. n  A myoplastic closure should be done in this amputation as follows. After raising appropriate flaps of skin and fascia, fashion an anterior flap of flexor digitorum sublimis muscle long enough so that its end can be carried around the end of the bones to the deep fascia dorsally. n  Divide the remaining soft tissues transversely at the level of bone section. n  After dividing the bones and contouring their ends, carry the muscle flap dorsally and suture its end to the deep fascia over the dorsal musculature. To prevent excessive bulk, the entire anterior muscle mass should never be used in this manner. n  Close the stump as already described.     n 

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CHAPTER 18  MAJOR AMPUTATIONS OF THE UPPER EXTREMITY

A

B

C

FIGURE 18.3 Amputation through distal forearm. A, Skin incision and bone level. B, Flaps are reflected, and bones and soft structures are divided. C, Completed amputation. SEE TECHNIQUE 18.3.

 

PROXIMAL THIRD OF FOREARM (PROXIMAL TRANSRADIAL) AMPUTATION TECHNIQUE 18.4 When good skin is available, fashion anterior and posterior skin flaps of equal length; if good skin is unavailable, fashion atypical flaps as necessary rather than amputate at a more proximal level. Reflect proximally the deep fascia together with the skin flaps to the level of intended bone section. n  Just proximal to this level, identify, doubly ligate, and divide the major vessels. n  Identify the median, ulnar, and radial nerves; gently pull them distally; and section them proximally so that their ends retract well proximal to the end of the stump. n  Divide the muscle bellies transversely distal to the level of bone section so that their proximal ends retract to that level. Carefully trim away all excess muscle. n  Divide the radius and ulna transversely and smooth their cut edges. Attempt to maintain at least 5 cm of the ulna proximally. If a more proximal osteotomy is required, tenodesis of the biceps tendon to the proximal portion of the residual ulna is needed. This lengthens the stump functionally and enhances prosthetic fitting. Even without biceps function, the elbow can be flexed satisfactorily by the brachialis muscle. n  With interrupted absorbable sutures, close the deep fascia; with interrupted nonabsorbable sutures, close the skin edges. Insert deep to the fascia a rubber tissue drain or a plastic tube for suction drainage.     n 

ELBOW DISARTICULATION The elbow joint is an excellent level for amputation because the broad flare of the humeral condyles can be grasped firmly by the prosthetic socket and humeral rotation can be transmitted to the prosthesis. In more proximal amputations, humeral rotation cannot be thus transmitted, so a prosthetic elbow turntable is necessary. The difficulties previously experienced in prosthetic fitting at this level have been overcome by modern prosthetic techniques, and most surgeons now believe that disarticulation of the elbow is usually preferable to a more proximal amputation. Additionally, a humeral shortening osteotomy can be done to preserve the elbow. 

 

DISARTICULATION OF THE ELBOW TECHNIQUE 18.5 Fashion equal anterior and posterior skin flaps as follows. Beginning proximally at the level of the humeral epicondyles, extend the posterior flap distally to a point about 2.5 cm distal to the tip of the olecranon and the anterior flap distally to a point just distal to the insertion of the biceps tendon. If necessary, fashion atypical flaps. Next, reflect the flaps proximally to the level of the humeral epicondyles and, on the medial aspect of the elbow, begin dissection of the deep structures. n  Identify and divide the lacertus fibrosus, free the origin of the flexor musculature from the medial humeral epicondyle, and reflect the muscle mass distally to expose the n 

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PART VI AMPUTATIONS neurovascular bundle that lies against the medial aspect of the biceps tendon. n  Proximal to the joint level, isolate, doubly ligate, and divide the brachial artery. n  Gently draw the median nerve distally and with a sharp knife divide it proximally so that it retracts at least 2.5 cm proximal to the joint line. Identify the ulnar nerve in its groove posterior to the medial epicondyle and treat it in a similar manner. Alternatively, they can be inserted into local muscle by TMR techniques (see Technique 18.12). n  Free the insertion of the biceps tendon from the radius and the insertion of the brachialis tendon from the coronoid process of the ulna. n  Identify the radial nerve in the groove between the brachialis and brachioradialis; isolate it, draw it distally, and section it far proximally. n  About 6.3 cm distal to the joint line, divide transversely the extensor musculature that arises from the lateral humeral epicondyle and reflect the proximal end of the muscle mass proximally. n  Divide the posterior fascia along with the triceps tendon near the tip of the olecranon. n  Divide the anterior capsule of the joint to complete the disarticulation and remove the forearm. n  Leave intact the articular surface of the humerus. Bring the triceps tendon anteriorly and suture it first to the humerus and then perform a myoplasty to the tendons of the brachialis and biceps muscles. n  Fashion a thin flap from the extensor muscle mass left attached to the lateral humeral epicondyle, carry it medially, and suture it to the remnants of the flexor muscles at the medial epicondyle. Cover all bony prominences and exposed tendons at the end of the humerus by passing additional sutures through the periosteum and the muscle flap. n  Trim the skin flaps for a snug closure without tension and approximate their edges with interrupted sutures of nonabsorbable material. Insert deep to the fascia a rubber tissue drain or a plastic tube for suction drainage.    

ARM AMPUTATIONS (TRANSHUMERAL)

The elbow-lock mechanism extends about 3.8 cm distally from the end of the prosthetic socket and to be cosmetically pleasing should lie at the level of the opposite elbow. Therefore, when performing transhumeral amputations, the level of the bone section should be at least 3.8 cm proximal to the elbow joint to allow room for this mechanism. During a transhumeral amputation, consideration must be given to an angulation osteotomy. The angulation ostectomy may avoid the need for a shoulder harness for suspension of a myoelectric arm and will markedly improve rotational control (Fig. 18.4). An angled osteotomy requires a minimum of 6 cm of residual bone length cut at an angle of 70 degrees with a posterior fixation plate. Although an amputation at the level of the axillary fold or more proximally must be fitted prosthetically as a shoulder disarticulation, preserving the most proximal part of the humerus, including the head, is valuable; the normal contour of the shoulder is retained, which is cosmetically desirable, and the disarticulation prosthesis is more stable on a shoulder in which some humerus remains that may be grasped by its socket. Every attempt should be made to preserve 5 to 7 cm of the proximal humerus. Osseointegration for transhumeral amputations is a technique used in Europe for over 2 decades. It involves placement of a suspension metallic intramedullary component that exits the skin, providing a bone implant interface that avoids the pitfalls of socket fixation such as poor fit, skin irritation, and excessive sweat. Despite the skin implant interface, deep infection is relatively low; however, superficial skin infections occur in up to 50% of patients requiring oral antibiotic treatment. Research to improve the skin-implant interface is underway. In children younger than 12 years, osseous overgrowth of diaphyseal amputations has been reported with the humerus and fibula being most common. In general, disarticulation at the elbow is recommended; however, if disarticulation is not feasible, a capping graft of the humeral bone end should be done. Several authors have suggested using fascia, metal, or iliac crest grafts. We have used the amputated part of the distal humerus as a capping graft at the time of primary amputation with good results. Close clinical follow up is mandatory, and revisions are sometimes necessary.   

Amputation through the arm, or transhumeral amputation, is defined as amputation at any level from the supracondylar region of the humerus distally to the level of the axillary fold proximally. More distal amputations, such as the transcondylar, are fitted prosthetically and function as elbow disarticulations; amputations proximal to the level of the axillary fold function as shoulder disarticulations. As in all other amputations, as much length as possible should be preserved. If the humeral condyles cannot be preserved, a transhumeral osteotomy should be done approximately 3 to 5 cm proximal to the elbow joint. The prosthesis with which a patient having a transhumeral amputation is fitted must include an inside elbow-lock mechanism and an elbow turntable. The elbow-lock mechanism is required to stabilize the joint in full extension, full flexion, or a position in between. The turntable mechanism substitutes for humeral rotation.

SUPRACONDYLAR AREA TECHNIQUE 18.6 Beginning proximally at the level of intended bone section, fashion equal anterior and posterior skin flaps, each being in length one half of the diameter of the arm at that level (Fig. 18.5A). n  Doubly ligate and divide the brachial artery just proximal to the level of bone section and transect the median, ulnar, and radial nerves at a higher level so that their proximal ends retract well proximal to the end of the stump. Or consider a TMR procedure. n  Divide the muscles in the anterior compartment of the arm 1.3 cm distal to the level of intended bone section so that they retract to this level. n 

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CHAPTER 18  MAJOR AMPUTATIONS OF THE UPPER EXTREMITY

A

B

C

D FIGURE 18.4 Humeral flexion osteotomy to improve prosthetic suspension and functional upper-extremity motion. A, Long transhumeral amputation. B, Humeral osteotomy performed through a posterior approach in same setting as targeted muscle reinnervation. C, Postoperatively after humeral osteotomy. D, Residual limb. (From: Pierrie SN, Gaston RG, Loeffler BJ: Current concepts in upper-extremity amputation, J Hand Surg Am 43:657, 2018.)

Free the insertion of the triceps tendon from the olecranon, preserving the triceps fascia and muscle as a long flap. Reflect this flap proximally and incise the periosteum of the humerus circumferentially at a level at least 3.8 cm proximal to the elbow joint to allow room for the elbow mechanism of the prosthesis. n  Divide the bone at this level and with a rasp smoothly round its end (Fig. 18.5B). n 

Trim the triceps tendon to form a long flap, carry it across the end of the bone, and tenodese it to the humerus, followed by myoplasty to the fascia over the anterior muscles. n  Insert deep to this flap a Penrose drain or a plastic tube for suction drainage. Close the fascia with fine absorbable sutures and the skin flaps with interrupted nonabsorbable sutures (Fig. 18.5C).     n 

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A

B

C

FIGURE 18.5 Amputation through arm at supracondylar level. A, Skin incision and bone level. B, Anterior muscles are divided transversely, triceps and fascial flap is constructed, and bone is sectioned. C, Completed amputation. SEE TECHNIQUE 18.6.

 

AMPUTATION PROXIMAL TO THE SUPRACONDYLAR AREA

TECHNIQUE 18.7

Beginning proximally at the level of intended bone section, fashion equal anterior and posterior skin flaps, the length of each being slightly greater than one half of the diameter of the arm at that level. n  Just proximal to the level of intended bone section, identify, doubly ligate, and divide the brachial artery and vein. n  Identify, gently pull distally, and divide at a more proximal level the major nerves so that their proximal ends retract well proximal to the end of the stump. If the patient is a candidate, perform a TMR (see Technique 18.12). n  Section the muscles of the anterior compartment of the arm 1.3 cm distal to the level of bone section so that their cut ends retract to this level. n  Divide the triceps muscle 3.8-5 cm distal to the level of bone section and retract its proximal end proximally. n  Incise the periosteum circumferentially and divide the humerus. Using a rasp, smoothly round the end of the bone. n  Bevel the triceps muscle to form a thin flap, carry it over the end of the bone, and suture it to the humerus and the anterior muscle fascia. n  Deep to the flap, insert a rubber tissue drain or a plastic tube for suction drainage; then close the fascia with interrupted absorbable sutures. Approximate the skin edges with interrupted nonabsorbable sutures.     n 

SHOULDER AMPUTATIONS Most amputations in the shoulder area are performed for the treatment of malignant bone or soft-tissue tumors that

cannot be treated by limb-sparing methods. Less commonly, amputation in this area is indicated for arterial insufficiency and rarely for trauma or infection. The extent of the amputation and design of the skin flaps must be modified often. Phantom pain is common and probably is best treated by proximal nerve blocks performed by a skillful anesthesiologist. Few patients regularly use a prosthesis, but a cosmetic shoulder cap is useful after forequarter amputation. TMR should be considered if the patient is a candidate for a myoelectric prosthesis (see Technique 18.12).   

AMPUTATION THROUGH THE SURGICAL NECK OF THE HUMERUS TECHNIQUE 18.8 Place the patient supine with a sandbag well beneath the affected shoulder so that the back is at a 45-degree angle to the operating table. n  Begin the skin incision anteriorly at the level of the coracoid process and carry it distally along the anterior border of the deltoid muscle to the insertion of the muscle and along the posterior border of the muscle to the posterior axillary fold. Connect the two limbs of the incision by a second incision that passes through the axilla (Fig. 18.6A). n  Identify, ligate, and divide the cephalic vein in the deltopectoral groove. n  Separate the deltoid and pectoralis major and retract the deltoid muscle laterally. Next, divide the pectoralis major muscle at its insertion and reflect it medially. n  Develop the interval between the pectoralis minor and coracobrachialis muscles to expose the neurovascular bundle. Isolate, doubly ligate, and divide the axillary artery and vein immediately inferior to the pectoralis minor. n 

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CHAPTER 18  MAJOR AMPUTATIONS OF THE UPPER EXTREMITY Musculocutaneous nerve Coracobrachialis muscle

Pectoralis minor muscle Axillary artery Axillary vein Pectoralis major muscle

Biceps tendon, short head Biceps tendon, long head Teres major muscle Latissimus dorsi muscle Deltoid muscle is sectioned

A

Median nerve

B

Deltoid muscle Axillary nerve Triceps muscle, lateral head Deltoid muscle

Biceps tendon, long head

Deltoid muscle beveled

Biceps tendon, short head

Biceps tendon, long head

Coracobrachialis muscle Pectoralis major muscle Latissimus dorsi muscle Latissimus dorsi muscle

Triceps muscle, long head

C

Pectoralis major muscle

Triceps muscle, long head

D

E FIGURE 18.6 Amputation through surgical neck of humerus. A, Skin incision. B, Section of anterior muscles. C, Bone level and completed muscle section. D, Closure of muscle flap. E, Completed amputation. SEE TECHNIQUE 18.8.

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PART VI AMPUTATIONS Isolate the median, ulnar, radial, and musculocutaneous nerves; gently draw them distally into the wound, and divide them so that their proximal ends retract well proximal to the pectoralis minor (Fig. 18.6B) if the patient is not a candidate for myoelectric prosthesis. Otherwise, perform a TMR procedure. n  Divide the deltoid muscle at its insertion and reflect it superiorly together with the attached lateral skin flap. n  Near their insertions at the bicipital groove, divide the teres major and latissimus dorsi muscles. At a point proximally 2 cm distal to the level of intended bone section, sever the long and short heads of the biceps, the triceps, and the coracobrachialis. n  Section the humerus at the level of its neck and smooth the cut end with a rasp (Fig. 18.6C). n  Suture the long head of the triceps, both heads of the biceps, and the coracobrachialis over the end of the humerus; swing the pectoralis major muscle laterally, and suture it to the end of the bone (Fig. 18.6D). n  Tailor the lateral skin flap and underlying deltoid muscle to allow accurate apposition of the skin edges and suture the edges with interrupted nonabsorbable material (Fig. 18.6E). Deep to the muscles and at the end of the bone, insert Penrose drains or plastic tubes for suction drainage.     n 

 

DISARTICULATION OF THE SHOULDER TECHNIQUE 18.9 Position the patient supine with a sandbag under the affected shoulder so that the back is at a 45-degree angle to the operating table. n  Begin the skin incision anteriorly at the coracoid process and continue it distally along the anterior border of the deltoid muscle to its insertion and then superiorly along the posterior border of the muscle to end at the posterior axillary fold. Join the two limbs of this incision with a second incision passing through the axilla (Fig. 18.7A). n  Identify, ligate, and divide the cephalic vein in the deltopectoral groove. n  Separate the deltoid and the pectoralis major and retract the deltoid laterally. n  Divide the pectoralis major muscle at its insertion and reflect it medially. Develop the interval between the coracobrachialis and short head of the biceps to expose the neurovascular bundle. Isolate, doubly ligate, and divide the axillary artery and vein; identify the thoracoacromial artery, and treat it in a similar manner (Fig. 18.7B). Allow the vessel to retract superiorly beneath the pectoralis minor muscle. n  Identify and isolate the median, ulnar, musculocutaneous, and radial nerves; gently draw them inferiorly into the wound, and divide them far proximally so that they n 

also retract beneath the pectoralis minor or transfer the nerves to the shoulder girdle muscles if the patient is a candidate for a myoelectric prosthesis. n  Divide the coracobrachialis and short head of the biceps near their insertions on the coracoid process. Free the deltoid muscle from its insertion on the humerus and reflect it superiorly to expose the capsule of the shoulder joint. Near their insertions, divide the teres major and latissimus dorsi muscles. n  Place the arm in internal rotation to expose the short external rotator muscles and the posterior aspect of the shoulder joint capsule and divide all of these structures (Fig. 18.7C). n  Place the arm in extreme external rotation and divide the anterior aspect of the joint capsule and the subscapularis muscle (Fig. 18.7D). Section the triceps muscle near its insertion and divide the inferior capsule of the shoulder to sever the limb completely from the trunk. n  Reflect the cut ends of all muscles into the glenoid cavity and suture them there to help fill the hollow left by removing the humeral head (Fig. 18.7E). n  Carry the deltoid muscle flap inferiorly and suture it just inferior to the glenoid. n  Deep to the deltoid flap, insert Penrose drains or plastic tubes. n  Partially excise any unduly prominent acromion process to give the shoulder a more smoothly rounded contour. n  Trim the skin flaps for accurate fitting and close their edges with interrupted nonabsorbable sutures (Fig. 18.7F).    

FOREQUARTER AMPUTATIONS Forequarter amputation removes the entire upper extremity in the interval between the scapula and the chest wall. Usually it is indicated for malignant tumors that cannot be adequately removed by limb-sparing resections, such as the Tikhoff-Linberg procedure. Most tumors can be evaluated for limb-sparing procedures in place of amputation by magnetic resonance angiography or arteriography, which will show compression of the artery, limb edema, and neurologic deficits that necessitate amputation. However, careful inspection at the time of surgery will determine the appropriate procedure. Extension of the operation to include resection of the chest wall is occasionally required. Provisions for adequate blood replacement and monitoring of the patient are needed. The anterior approach of Berger and our preferred posterior approach of Littlewood are described. The operation is performed more rapidly and easily using the Littlewood technique. Ferrario et al. described a combined anterior and posterior approach. This technique is useful for patients in whom the normal tissue planes have been obliterated because of radiation to the axilla. Excellent exposure is obtained and ligation of the subclavian vessels occurs at the thoracic inlet instead of where the vessels cross the third rib (Fig. 18.8). Kumar et  al. described a single incision anterior approach that can be used with the patient supine. 

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CHAPTER 18  MAJOR AMPUTATIONS OF THE UPPER EXTREMITY

Cephalic vein

Musculocutaneous nerve Biceps tendon, short head

Pectoralis major muscle

Deltoid muscle is sectioned

A

Pectoralis minor muscle Axillary artery Axillary vein

Median nerve Coracobrachialis muscle

B Supraspinatus muscle

Deltoid muscle Infraspinatus muscle

Biceps tendon, short head Coracobrachialis muscle

Subscapularis muscle

Teres minor muscle

Latissimus dorsi muscle

Axillary nerve

Teres major muscle

Triceps muscle, long head Triceps muscle, lateral head

Deltoid muscle

Pectoralis major muscle

C

D

E

F FIGURE 18.7 Disarticulation of shoulder. A, Incision. B, Exposure and sectioning of neurovascular bundle. C, Reflection of deltoid; arm is placed in internal rotation; sectioning of supraspinatus, infraspinatus, and teres minor muscles and of posterior capsule; sectioning of coracobrachialis and biceps at coracoid. D, Arm is placed in external rotation; subscapularis and anterior capsule are sectioned. E, Suture of muscles in glenoid cavity. F, Completed amputation. SEE TECHNIQUE 18.9.

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A

B

C

D

E FIGURE 18.8 Forequarter amputation through combined anterior and posterior approach. A, Anterior flap. B, Posterior flap. C, Osteotomy performed through clavicle medially. D, Dissection deep to the scapula. E, Vessels ligated and forequarter removed; flap closed.

 

ANTERIOR APPROACH TECHNIQUE 18.10 (BERGER) Begin the upper limb of the incision at the lateral border of the sternocleidomastoid muscle and extend it laterally along the anterior aspect of the clavicle, across the acromioclavicular joint, over the superior aspect of the

n 

shoulder to the spine of the scapula, and across the body of the scapula to the scapular angle. Begin the lower limb of the incision at the middle third of the clavicle and extend it inferiorly in the groove between the deltoid and pectoral muscles and across the axilla to join the upper limb of the incision at the angle of the scapula (Fig. 18.9A). n  Deepen the clavicular part of the incision to bone and release and reflect distally the clavicular origin of the pectoralis major muscle. n  Divide the deep fascia over the superior border of the clavicle close to bone and, by dissection with a finger

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CHAPTER 18  MAJOR AMPUTATIONS OF THE UPPER EXTREMITY and a blunt curved dissector, free the deep aspect of the clavicle. Retract the external jugular vein from the field or, if it is in the way, section it after ligating it. n  Divide the clavicle at the lateral border of the sternocleidomastoid with a Gigli saw, lift the bone superiorly, and remove it by dividing the acromioclavicular joint (Fig. 18.9B). n  To complete the exposure of the neurovascular bundle, release the insertion of the pectoralis major from the humerus and the origin of the pectoralis minor from the coracoid process (Fig. 18.9C). Isolate, doubly ligate, and divide the subclavian artery and vein. n  Dissect the brachial plexus and by gentle traction inferiorly bring it well into the operating field; section the nerves in sequence and allow them to retract superiorly (Fig. 18.9D). n  Release the latissimus dorsi and remaining soft tissues that bind the shoulder girdle to the anterior chest wall and allow the limb to fall posteriorly. n  While holding the arm across the chest and exerting gentle downward traction, divide from superiorly to inferiorly the remaining muscles that fix the shoulder to the scapula. n  Divide the muscles that hold the scapula to the thorax, starting with the trapezius and continuing through the omohyoids, levator scapulae, rhomboids major and minor, and serratus anterior (Fig. 18.9E). The limb falls free and can be removed. n  To form additional padding, suture the pectoralis major, trapezius, and any other remaining muscular structures over the lateral chest wall. Bring the skin flaps together and trim them to form a smooth closure. Insert Penrose drains or plastic tubes for suction drainage and close the skin edges with interrupted nonabsorbable sutures (Fig. 18.9F).      

POSTERIOR APPROACH

POSTOPERATIVE CARE  Phantom pain in the early postoperative period is common. Nerve blocks by an experienced anesthesiologist may be helpful. Although few patients find a prosthesis useful, a cosmetic shoulder cap is desirable.   

 TARGETED MUSCLE REINNERVATION (TMR) AFTER SHOULDER OR TRANSHUMERAL AMPUTATION

TECHNIQUE 18.11 (LITTLEWOOD) Insert a Foley catheter. Place the patient in a lateral decubitus position with the operated side up. Secure the patient to the operating table so that it may be tilted anteriorly and posteriorly. n  Two incisions are required: one posterior (cervicoscapular) and one anterior (pectoroaxillary) (Fig. 18.10A). Make the posterior incision first, beginning at the medial end of the clavicle and extending it laterally for the entire length of the bone. Carry the incision over the acromion process to the posterior axillary fold and continue it along the axillary border of the scapula to a point inferior to the scapular angle. Finally, curve it medially to end 5 cm from the midline of the back. Elevate a flap of skin and subcutaneous tissue medial to the vertebral border of the scapula, extending it from the inferior angle of the scapula to the clavicle (Fig. 18.10B). n  Identify the trapezius and latissimus dorsi muscles and divide them near the scapula. n 

Draw the scapula away from the chest wall with a hook or retractor and divide the levator scapulae and the rhomboids minor and major (Fig. 18.10C). n  Ligate branches of the superficial cervical and descending scapular vessels. n  Divide the superior digitation of the serratus anterior close to the superior angle of the scapula and the remaining insertion of the serratus anterior along the vertebral border of the scapula. n  Divide the clavicle and subclavius muscle at the medial end of the bone. This allows the extremity to fall anteriorly, placing the neurovascular bundle under tension. The latter is found in the fibrofatty tissue near the superior digitation of the serratus anterior. Divide the cords of the brachial plexus close to the spine and doubly ligate and divide the subclavian artery and vein (Fig. 18.10D, E). Take care to avoid injury to the pleural dome. n  Divide the omohyoid muscle and ligate and divide the suprascapular vessels and external jugular vein. n  Make the anterior incision, starting it at the middle of the clavicle and curving it inferiorly just lateral to but parallel with the deltopectoral groove. Extend it across the anterior axillary fold and carry it inferiorly and posteriorly to join the posterior incision at the lower third of the axillary border of the scapula. n  Divide the pectoralis major and minor muscles and remove the limb. n  Close the flaps over suction drains without excessive tension. Occasionally, it is necessary to attach a flap to the chest wall and complete the closure with a skin graft. n 

To improve function of upper extremity prostheses, Kuiken et al. developed a biologic neural-machine interface called targeted reinnervation. The goal of TMR is to take a nerve that formerly directed hand function and transfer it to a muscle segment that otherwise has no function because of the amputation. The reinnervated muscle segment amplifies the nerve signals to a myoelectric prosthesis, allowing movement of multiple prosthetic joints. According to Kuiken et al., this technique has several advantages: it is relatively simple to implement, no hardware is implanted into the body that could break and require additional surgery, and it can be used with existing myoelectric prosthetic technology. In addition to accelerating maximal control and function of myoelectric prostheses and avoiding secondary procedures, TMR has been shown to decrease the risk of painful neuromas. Approximately 25% of patients with major upper extremity amputations have painful neuromas. TMR provides an end organ for the damaged nerve to reinnervate. Studies have shown that TMR provides the neuroma a way to return to a more normal nerve structure.

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PART VI AMPUTATIONS Trapezius muscle

Posterior

Anterior

External jugular vein Omohyoid muscle

Clavicle Deltoid muscle

Subscapular vein Subclavius muscle

Cephalic vein

Pectoralis major muscle

A

B Trapezius muscle

External jugular vein

Transverse cervical artery Brachial plexus Subclavian artery

Omohyoid muscle

Deltoid muscle

Subclavian vein

Subclavius muscle

Cephalic vein

Pectoralis major muscle

Pectoralis minor muscle

C

D

Trapezius muscle

Levator scapulae muscle Rhomboid minor muscle

Deltoid muscle

Rhomboid major muscle

E

Teres major muscle

Infraspinatus muscle

F

FIGURE 18.9 Forequarter amputation through anterior approach. A, Incision. B, Resection of clavicle. C, Lifting pectoral lid. D, Sectioning of vessels and nerves after incision through axillary fascia and insertion of pectoralis minor, costocoracoid membrane, and subclavius. E, Sectioning of supporting muscles of scapula. F, Completed amputation. SEE TECHNIQUE 18.10.

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CHAPTER 18  MAJOR AMPUTATIONS OF THE UPPER EXTREMITY

Line of incision through latissimus dorsi muscle

Deltoid muscle Spine of scapula First incision

Second incision

Teres major muscle

A

Line of incision through trapezius muscle

B

Infraspinatus muscle

Scapular attachment of latissimus dorsi muscle

Line of incision through superior digitation of serratus anterior muscle Neurovascular bundle Superficial cervical artery

Line of incision through levator scapulae, rhomboid major and rhomboid minor muscles

C Sectioned trapezius muscle

Sectioned levator scapulae, rhomboid major and rhomboid minor muscles

Suprascapular nerve and vessels

Omohyoid muscle

Clavicle Neurovascular bundle

Subclavius muscle External jugular vein

Descending scapular artery and transverse cervical vein

Rib II Superficial cervical artery

D

E FIGURE 18.10 Littlewood technique for interscapulothoracic (forequarter) amputation. A, Incision. B, Skin flaps undermined from clavicle. C, Scapula drawn away from chest wall with hook or retractor; levator scapulae and rhomboids minor and major divided. D, Exposure of neurovascular structures. E, More detailed view of neurovascular structures. SEE TECHNIQUE 18.11.

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PART VI AMPUTATIONS In general, TMR begins with identifying the functional nerve, mobilizing it, and preserving its length. Excising the end neuromas and trimming of the fascicles to the level of axoplasmic sprouting should be performed. The targeted muscle and its native nerve are then identified. The native nerve must be trimmed back approximately 1 cm to the neuromuscular junction and the residual nerve buried away from the original muscle to avoid dual innervation (cross talk). The donor nerve is then coapted to the target muscle with end-to-end tension-free repair. Augmentation with epineurium to epimysium is beneficial. If the native nerve stump in the targeted muscle is not available, then the donor nerve can be directly sutured into the muscle. The subcutaneous adipose tissue should be debulked to decrease the distance between skin and the targeted muscle to improve the strength of the EMG. The success of TMR has spawned interest into targeted sensory reinnervation (TSR). The ultimate prosthesis would provide motor as well as sensory functions. The sensory nerves are used to reinnervate more proximal, intact cutaneous nerves that provide varying degrees of light touch, pain, temperature, and proprioception. Multiple studies have shown that cortical remapping occurs, and a long-term effect can be established. The goal is to provide amputees with a more intuitive prosthesis by combining new technology that reinnervates residual muscle. In patients with transhumeral amputation, the median nerve is transferred to the medial head of the biceps (hand-closing) and the distal radial nerve is transferred to the motor nerve of the brachialis muscle (hand-opening). In patients with a long residual humerus, the ulnar nerve is transferred to the motor nerve of the brachialis muscle. The intact lateral head of the biceps is still used for prosthetic elbow flexion and the triceps muscle for extension. In patients with more proximal amputations at the shoulder level, nerves that originally innervated the amputated limb are rerouted to muscles on the chest wall, creating an interface for a myoelectric prosthesis that is controlled by the same nerves that previously controlled the amputated limb. Contraindications to TMR include ipsilateral brachial plexopathy, major comorbidities, or anticipated patient noncompliance with prosthetic wear. The pattern of nerve transfers is dictated by the availability of donor nerves and muscle. The mechanism of injury, residual nerve length, presence of healthy muscle, and a Tinel’s sign are important preoperative predictors of successful TMR. It is critical to denervate the targeted muscle before TMR to avoid dual innervation, which can cause “cross talk” between the two nerves and compromise successful TMR. Placing adipofascial tissue into the repair site also can reduce the chance of cross-talk.   

TARGETED MUSCLE REINNERVATION AFTER TRANSHUMERAL AMPUTATION TECHNIQUE 18.12 (O’SHAUGHNESSY ET AL., 2008) MEDIAN NERVE TRANSFER With the patient under general anesthesia and without muscle relaxation (so that motor nerves can be

n 

stimulated), make an anterior incision directly over the muscle bellies of the biceps muscle, beginning just inferior to the lower edge of the deltoid muscle. n  Inject the soft tissue liberally with dilute epinephrine solution (1:500,000) to open tissue planes, increase visual contrast between tissues, and improve hemostasis. Use electrocautery for coagulation. n  Open the fascia overlying the muscle bellies and develop the interspace between the heads of the biceps. Dissect the area immediately inferior to the deltoid muscle between the biceps heads to expose the musculocutaneous nerve, the motor branches to the medial and lateral biceps heads, and the motor nerve to the brachialis muscle (Fig. 18.11A). n  While paying close attention to the vascular supply of the medial head of the biceps muscle, mobilize the muscle segment away from the humerus to expose the median nerve that runs parallel and inferior to the biceps. n  Separate the muscle bellies from each other to expose the brachial artery and the median nerve (Fig. 18.11B). Leave the proximal and distal ends of the muscle bellies undisturbed so that the muscles remain long and in the proper position to permit later detection of electromyographic signals. With this approach, the median nerve is superficial to the ulnar nerve. n  To facilitate the nerve transfers, dissect the musculocutaneous nerve in such a way as to preserve the motor nerve innervating the lateral head of the biceps and to divide the motor nerve innervating the medial head of the biceps at a point 5 mm from its entry into the muscle substance. n  Mobilize the proximal part of the motor nerve and bury it into the lateral head of the biceps to prevent reinnervation of the medial head. n  Divide the continuation of the musculocutaneous nerve, which innervates the brachialis muscle, just after the intact takeoff of the nerve to the lateral head. n  Cut the median nerve back to healthy fascicles and sew it to the motor branch of the medial head of the biceps with 5-0 polypropylene suture. Incorporate some epimysium of the muscle belly itself in the suturing process to protect the small motor nerve from tearing. Median nerve fibers are now abutted to transected medial biceps nerve fibers to reinnervate the muscle.  RADIAL NERVE TRANSFER Make a second lateral incision over the distal and lateral aspect of the residual limb and develop the interspace between the triceps and brachialis to locate the septum between these muscles. n  Continue dissection superiorly at a level just superficial to the periosteum of the humerus to identify the distal radial nerve where it lies in the humeral groove. n  Follow the radial nerve from this location out distally toward the end of the amputation to gain additional length and cut the nerve back to healthy appearing fascicles. n  Identify and divide any aberrant innervation between the radial nerve and brachialis muscle to ensure that the target muscle regions are completely denervated. n  The motor nerve to the brachialis muscle is the continuation of the musculocutaneous nerve after the branches to the biceps muscle; it was prepared during the median nerve transfer. n 

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CHAPTER 18  MAJOR AMPUTATIONS OF THE UPPER EXTREMITY

Median nerve (coapted to motor branch of medial biceps m.)

Musculocutaneous nerve Biceps muscle (medial head)

Musculocutaneous nerve (motor branches): to medial biceps m. to lateral biceps m. to brachialis m.

Biceps muscle (lateral head) Median nerve

Brachialis muscle

A

B

Radial nerve (coapted to motor branch of brachialis m.) Musculocutaneous nerve to brachialis m.

C FIGURE 18.11 Targeted reinnervation to improve prosthesis control after upper extremity amputation. A, Musculature of the right arm from the anterior position. B, Biceps-splitting approach to the musculocutaneous nerve. C, Anterolateral view of the right arm showing nerve transfer of the distal portion of the radial nerve to the motor nerve of the brachialis muscle. (Redrawn from O’Shaughnessy KD, Dumanian GA, Lipschutz RD, et al: Target reinnervation to improve prosthesis control in transhumeral amputees. A report of three cases, J Bone Joint Surg Am 90:393, 2008.) SEE TECHNIQUE 18.12.

Mobilize the motor nerve to the brachialis muscle and the radial nerve to reach each other at the lateral border of the brachialis muscle and sew them together in an end-to-end fashion with 5-0 polypropylene suture (Fig. 18.11C). 

n 

COMPLETION OF PROCEDURE Thin a 4- to 5-cm area of subcutaneous fat over all four muscle regions to decrease the separation between the epidermis and the muscle; this maximizes the electro-

n 

myographic amplitude over each muscle region of interest and minimizes electromyographic cross-talk between muscle regions. n  Resect the lateral and distal aspect of the lateral head of the biceps to better expose the brachialis muscle. n  A vascularized fascial flap can be interposed between the two heads of the biceps muscle to provide space between the muscle bellies and improve separation of electromyographic signals from the medial and lateral biceps heads.

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PART VI AMPUTATIONS Tenodese the medial head of the biceps to the end of the amputation soft tissues to prevent lateral and proximal migration of the muscle belly. 

n 

POSTOPERATIVE CARE  Patients are admitted to the hospital overnight for observation and pain management. Subcutaneous drains are removed on the day after surgery, and lightly compressive dressing is applied. Muscle twitches may be apparent around 4 months after surgery, and strong independent contractions at about 6 months. Generally, approximately 20 hours of training is required for efficient use of the myoelectric prosthesis.   

Dumanian et  al. described modifications to the original targeted innervation procedure, primarily handling of the radial nerve and the initial raising of a proximally based, U-shaped adipofascial flap to improve exposure for identification of the muscle raphes. Placement of the flaps between the muscle bellies decreases the chances for aberrant reinnervation and improves electromyographic signal detection. The radial nerve is exposed through a straight posterior approach between the long and lateral heads of the triceps. A motor branch to the lateral head, selected for its size and distal entry into the muscle, is followed proximally and transected off the radial nerve. The radial nerve proper is identified and followed distally toward the amputation stump, transected, cut back to healthy fascicles, and coapted to the motor nerve to the lateral head of the triceps. This requires less mobilization of the nerve to reach the motor nerve of the lateral triceps.

REFERENCES Carlsen BT, Prigge P, Peterson J: Upper extremity limb loss: functional restoration from prosthesis and targeted reinnervation to transplantation, J Hand Ther 27:106, 2014. Cheesborough JE, Smith LH, Kuiken TA, Dumanian GA: Targeted muscle reinnervation and advanced prosthetic arms, Semin Plast Surg 29:62, 2015. Cheesborough JE, Souza JM, Dumanian GA, et  al.: Targeted muscle reinnervation in the initial management of traumatic upper extremity injury, Hand 9:253, 2014. Fisher TF, Kusnezov NA, Bader JA, Blair JA: Predictors of acute complications following traumatic upper extremity amputation, J Surg Orthop Adv 27(2):113, 2018. Fitzgibbons P, Medvedev G: Functional and clinical outcomes of upper extremity amputation, J Am Acad Orthop Surg 23:751, 2015. Freeland AE, Psonak R: Traumatic below-elbow amputations. , Available online at www.orthosupersite.com/print.aspx?rid=20414. Accessed 27 September 2010. Garg MS, Souza JM, Dumanian GA: Targeted muscle reinnervation in the upper extremity amputee: a technical roadmap, J Hand Surg Am 40(9):1877, 2015. Hebert JS, Olson JL, Morhart MJ, et al.: Novel targeted sensory reinnervation technique to restore functional hand sensation after transhumeral amputation, IEEE Trans Neural Syst Rehabil Eng 22:765, 2014.

Inkellis E, Low EE, Langhammer C, Morshed S: Incidence and characterization of major upper-extremity amputations in the National Trauma Data Bank, JBJS Open Access, 2018, p 30038. Kuiken TA, Barlow AK, Hargrove LJ, Dumanian GA: Targeted muscle reinnervation for the upper and lower extremity, Tech Orthop 32:109, 2017. Kumar A, Narange S, Gupta H, et al.: A single incision surgical new anterior technique for forequarter amputation, Arch Orthop Trauma Surg 131:955, 2011. Littlewood H: Amputations at the shoulder and at the hip, BMJ 1:381, 1922.. Mioton LM, Dumanian GA: Targeted muscle reinnervation and prosthetic rehabilitation after limb loss, J Surg Oncol 118:807, 2018. Misra S, Wilkens SC, Chen NC, Eberlin KR: Patients transferred for upper extremity amputation: participation of regional trauma centers, J Hand Surg Am 42(12):987, 2017. Morgan EN, Potter BK, Souza JM, Tingle SM, Nanos GP: Targeted muscle reinnervation for transradial amputation: description of operative technique, Tech Hand Surg 20:166, 2016. Morris CD, Potter BK, Athanasian EA, Lewis VO: Extremity amputations: principles, techniques, and recent advances, Instr Course Lect 64:105, 2015. Otto IA, Kon M, Schuurman AH, van Minnen LP: Replantation versus prosthetic fitting in traumatic arm amputations: a systematic review, PloS ONE 10(9):e0137729, 2015. Ovadia SA, Askari M: Upper extremity amputations and prosthetics, Semin Plast Surg 29:55, 2015. Pet MA, Ko JH, Friedly JL, et al.: Does targeted nerve implantation reduce neuroma pain in amputees? Clin Orthop Relat Res 472:2991, 2014. Pet MA, Morrison SD, Mack JS, et al.: Comparison of patient-reported outcomes after traumatic upper extremity amputation: replantation versus prosthetic rehabilitation, injury, Int J Care Injured 47:2783, 2016. Pierrie SN, Gaston RG, Loeffler BJ: Current concepts in upper-extremity amputation, J Hand Surg Am 43(7):657, 2018. Pierrie SN, Gaston RG, Loeffler BJ: Targeted muscle reinnervation for prosthesis optimization and neuroma management in the setting of transradial amputation, J Hand Surg Am Feb 4. pii:S0363-5023(18)30502-1, 2019. Renninger CH, Rocchi VJ, Kroonen LT: Targeted muscle reinnervation of the brachium: an anatomic study of musculocutaneous and radial nerve motor points relative to proximal landmarks, J Hand Surg Am 40(11):2223, 2015. Resnik L, Klinger S, Etter K: The DEKA arm: its features, functionality, and evolution during the Veterans Affairs Study to optimize the DEKA arm, Prosthet Orthot Int 38:492, 2014. Serino A, Akselrod M, Salomon R, et al.: Upper limb cortical maps in amputees with targeted muscle and sensory reinnervation, BRAIN 140:2993, 2017. Solarz MK, Thoder JJ, Rehman S: Management of major traumatic upper extremity amputations, Orthop Clin N Am 47:127, 2016. Tennent DJ, Wenke JC, Rivera JC, Krueger CA: Characterisation and outcomes of upper extremity amputations, Injury 45:965, 2014. Tintle SM, LeBrun C, Ficke JR, Potter BK: What is new in trauma-related amputations, J Orthop Trauma 30(10):S16, 2016. Tsikandylakis G, Berlin Ö, Branemark R: Implant survival, adverse events, and bone remodeling of osseointegrated percutaneous implants for transhumeral amputees, Clin Orthop Relat Res 472:2947, 2014. Vadala G, Di Pino G, Ambrosio L, Diaz Balzani L, Denaro V: Targeted muscle reinnervation for improved control of myoelectric upper limb prostheses, J Biol Regul Homeost Agents 31 4(S1):183, 2017. Yao J, Chen A, Kuiken T, Carmona C, Dewald J: Sensory cortical re-mapping following upper-limb amputation and subsequent targeted reinnervation: a case report, NeuroImage 8:329, 2015.

The complete list of references is available online at ExpertConsult.com.

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SUPPLEMENTAL REFERENCES Berger P: L’amputation du membre supérieur dans la contiguïté du tronc (amputationinterscapulo-thoracic), Paris, 1887, G. Masson. Bernstein RM, Watts HG, Setoguchi Y: The lengthening of short upper extremity amputation stumps, J Pediatr Orthop 28:86, 2008. Bhagia SM, Elek EM, Grimer RJ, et  al.: Forequarter amputation for highgrade malignant tumours of the shoulder girdle, J Bone Joint Surg 79B:924, 1997. Blair HC, Morris HD: Conservation of short amputation stumps by tendon section, J Bone Joint Surg 28:427, 1946. Cordeiro PG, Cohen S, Burt M, et al.: The total volar forearm musculocutaneous free flap for reconstruction of extended forequarter amputations, Ann Plast Surg 40:298, 1998. Daly WK: Elbow disarticulation and transhumeral amputation: prosthetic management. In Smith DG, Michael JW, Bowker JH, editors: Atlas of amputations and limb deficiencies, Rosemont, IL, 2004, American Academy of Orthopaedic Surgeons. Dumanian GA, Ko JH, O’Shaughnessy KD, et  al.: Targeted reinnervation for transhumeral amputees: current surgical technique and update on results, Plast Reconstr Surg 124:863, 2009. Ferrario T, Palmer P, Karakousis CP: Technique of forequarter interscapulothoracic amputation, Clin Orthop Relat Res 423:191, 2004. Flurry M, Melissinos EG, Livingston CK: Composite forearm free fillet flaps to preserve stump length following traumatic amputations of the upper extremity, Ann Plast Surg 60:391, 2008. Hovius SER, Hofman A, van Urk H, et al.: Acute management of traumatic forequarter amputations, J Trauma 31:1415, 1991. Kour AK, Pho RWH: Combined free flap, Ilizarov lengthening, and prosthetic fitting in the reconstruction of a proximal forearm amputation—a case report, Ann Acad Med Singapore 24(135), 1995. Kuhn JA, Wagman LD, Lorant JA, et al.: Radical forequarter amputation with hemithoracectomy and free extended forearm flap: technical and physiologic considerations, Ann Surg Oncol 1:353, 1994. Levine EA, Warso MA, McCoy DM, et al.: Forequarter amputation for soft tissue tumors, Am Surg 60:367, 1994.

Lundborg G, Rosén B: Sensory substitution in prosthetics, Hand Clin 17:481, 2001. Maman E, Malawer MM, Kollender Y, et al.: Large tumors of the axilla, Clin Orthop Relat Res 461:189, 2007. Merimsky O, Kollender Y, Inbar M, et al.: Palliative major amputation and quality of life in cancer patients, Acta Oncol 36:151, 1997. Michaels F, De Smet L: Osseous overgrowth in congenital amputations of the upper limb: report of 3 cases treated with autologous stump plasty, Acta Orthop Belg 67:452, 2001. Miguelez JM, Miguelez MD, Alley RD: Amputations about the shoulder: prosthetic management. In Smith DG, Michael JW, Bowker JH, editors: Atlas of amputations and limb deficiencies, Rosemont, IL, 2004, American Academy of Orthopaedic Surgeons. O’Shaughnessy KD, Dumanian GA, Lipschutz RD, et al.: Targeted reinnervation to improve prosthesis control in transhumeral amputees. A report of three cases, J Bone Joint Surg Am 90:393, 2008. Pinzur MS, Angelats J, Light TR, et al.: Functional outcome following traumatic upper limb amputation and prosthetic limb fitting, J Hand Surg Am 19A 836, 1994. Scott RN: Feedback in myoelectric prostheses, Clin Orthop Relat Res 256:58, 1990. Slocum DB: An atlas of amputations, St. Louis, 1949, Mosby. Smith DG: Amputations about the shoulder: surgical management. In Smith DG, Michael JW, Bowker JH, editors: Atlas of amputations and limb deficiencies, Rosemont, IL, 2004, American Academy of Orthopaedic Surgeons. Stricker SJ: Ilizarov lengthening of a posttraumatic below elbow amputation stump, Clin Orthop Relat Res 306:124, 1994. Tintle SM, Baechler MF, Nanos III GP, et  al.: Current concepts review. Traumatic and trauma-related amputations, J Bone Joint Surg Am 92:2934, 2010. Weinberg MJ, Al-Qattan MM, Mahoney J: “Spare part” forearm free flaps harvested from the amputated limb for coverage of amputation stumps, J Hand Surg Br 22B:615, 1997. Wright TW, Hagen AD, Wood MB: Prosthetic usage in major upper extremity amputations, J Hand Surg 20A 619, 1995.

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CHAPTER

19

AMPUTATIONS OF THE HAND James H. Calandruccio, Benjamin M. Mauck

CONSIDERATIONS FOR AMPUTATION 759 PRINCIPLES OF FINGER 759 AMPUTATIONS FINGERTIP AMPUTATIONS 760 Free skin graft          763 Flaps for fingertip coverage           764 AMPUTATIONS OF SINGLE FINGERS 771 Index finger           771

Middle or ring finger ray amputations                 772 774 Ring avulsion injuries Little finger amputations                          776 776 THUMB AMPUTATIONS AMPUTATIONS OF 777 MULTIPLE DIGITS PAINFUL AMPUTATION STUMP 778

Acute fingertip and thumb injuries are common and require prompt and meticulous composite soft-tissue repair in incomplete amputations. Complete amputations proximal to the eponychial fold in the thumb or multiple digits may be salvaged by microvascular techniques (see Chapter 63); however, more distal devascularizing injuries rarely can be salvaged by such means and usually require special composite soft-tissue coverage techniques or complete amputation. In general, every effort should be made to maintain or provide good skin sensation, joint mobility, and digital length with well-padded bony elements. Prolonged efforts to preserve severely damaged structures, especially those that are insensate, can delay healing, increase disability, and lead to a painful series of surgical procedures that may not enhance the final outcome. Thus primary amputation may be the procedure of choice in many patients. Achieving supple soft-tissue coverage of the ends of the thumb and fingers is essential. In amputations of several digits, pinch and grasp are the chief functions to be preserved. Revision amputation through the fingers or metacarpals is a reconstructive procedure to preserve as much function as possible in injured and uninjured parts of the hand.

CONSIDERATIONS FOR AMPUTATION Amputations may be considered for a variety of conditions in which function is limited by pain, stiffness, insensibility, and cosmetic issues. A request for amputation of an injured part by a patient is usually the culmination of a critical thought process and is usually justified. More often, other factors must be considered in deciding whether amputation is advisable. The ultimate function of the part should be good enough to warrant salvage. An analysis of the five tissue areas—skin, tendon, nerve, bone, and joint—is sometimes helpful in making the decision

RECONSTRUCTIONS AFTER AMPUTATION 778 Reconstruction after amputation of the hand                       778 Reconstruction after amputation of multiple digits                         780 Reconstruction of the thumb                780 784 Pollicization

to amputate. If three or more of these five areas require special procedures, such as grafting of skin, suture of tendon or nerve, bony fixation, or closure of the joint, amputation should be considered because the function of the remaining fingers may be compromised by survival of a mutilated finger. In children, amputation rarely is indicated unless the part is nonviable and cannot be made viable by microvascular techniques. Principles of replantation are discussed in Chapter 63. Even if amputation is indicated, it may be wise to delay it if parts of the finger may be useful later in a reconstructive procedure. Skin from an otherwise useless digit can be used as a free graft. Skin and deeper soft structures can be useful as a filleted graft (see Chapter 65); if desired, the bone can be removed primarily and the remaining flap suitably fashioned during a second procedure. Skin well supported by one or more neurovascular bundles but not by bone can be saved and used as a vascular or neurovascular island graft (see Chapter 68). Segments of nerves can be useful as autogenous grafts. A musculotendinous unit, especially a flexor digitorum sublimis or an extensor indicis proprius, can be saved for transfer to improve function in a surviving digit (e.g., to improve adductor power of the thumb when the third metacarpal shaft has been destroyed or to improve abduction when the recurrent branch of the median nerve is nonfunctional). Tendons of the flexor digitorum sublimis of the fifth finger, the extensor digiti quinti, and the extensor indicis proprius can be useful as free grafts. Bones can be used as peg grafts or for filling osseous defects. Under certain circumstances, even joints can be useful. Every effort should be made to salvage the thumb (Fig. 19.1). 

PRINCIPLES OF FINGER AMPUTATIONS Whether an amputation is done primarily or secondarily, certain principles must be observed to obtain a painless and

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A

B

C

D

E

F

FIGURE 19.1 Thumb reconstruction. A, Failed thumb replantation after saw injury with concomitant primary ray amputation of index finger and partial amputation through middle finger. B–D, Metacarpophalangeal joint level thumb disarticulation and neurovascular island transfer of proximal phalanx segment of middle finger for thumb reconstruction. E, Radiographic appearance of transfer of middle finger proximal phalanx to thumb complex tissue. F, Example of functional hand use restored after sensory innervated composite thumb reconstruction.

useful stump. The volar skin flap should be long enough to cover the volar surface and tip of the osseous structures and preferably to join the dorsal flap without tension. The ends of the digital nerves should be dissected carefully from the volar flap, gently placed under tension so as not to rupture more proximal axons, and resected at least 6 mm proximal to the end of the soft-tissue flap. Neuromas are inevitable, but they should be allowed to develop only in padded areas where they are less likely to be painful. When scarring or a skin defect makes the fashioning of a classic flap impossible, a flap of a different shape can be improvised, but the end of the bone must be padded well. Flexor and extensor tendons should be drawn distally, divided, and allowed to retract proximally. When an amputation is through a joint, the flares of the osseous condyles should be contoured to avoid clubbing of the stump. Before the wound is closed, the tourniquet should be released and vessels cauterized to control bleeding. 

FINGERTIP AMPUTATIONS Fingertip amputations vary markedly depending on the amount and configuration of skin lost, the depth of the softtissue defect, and whether the phalanx has been exposed or even partially amputated (Fig. 19.2). In the United States, replantation is not performed for most fingertip amputations. Proper treatment is determined by the injury type and whether other digits also have been injured. Injuries with loss of skin alone can heal by secondary intention or can be covered by a skin graft (Fig. 19.3). Despite continuous descriptions of new finger flaps, healing by secondary intention can in most cases provide equivalent preservation of sensation and function. In general, revision amputation or conservative measures, such as healing by secondary intention, may have improved restoration of static two-point discrimination when compared to other coverage methods. Some studies also suggest improved overall total arc of motion with

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CHAPTER 19   AMPUTATIONS OF THE HAND 1. Shorten bone to joint and close 2. Possible flap if length essential Free split graft or secondary intention healing

A 1. Shorten to close 2. Cross-finger, thenar, or Kutler flap

A B 1. Shorten to close 2. Remove exposed bone to below pulp and cover with split graft

C

3. Atasoy sliding graft 4. Cross-finger flap

FIGURE 19.2 Techniques useful in closing amputations of fingertip. A, For amputations at more distal levels, a free split graft is applied; at more proximal levels, bone is shortened to permit closure, or if length is essential, dorsal flaps can be used. B, For amputations through green area, bone can be shortened to permit closure or cross-finger or thenar flap can be used. C, For amputations through green area, bone can be shortened to permit closure, exposed bone can be resected, and a split-thickness graft can be applied; Kutler advancement flaps can be used, or a cross-finger flap can be applied. In small children, fingertips commonly heal without grafts.

conservative methods; however, a higher incidence of cold intolerance should be taken into consideration. When tendon, nerve, or bone is exposed, soft-tissue coverage may be achieved in numerous ways. If half of the nail is unsupported by the remaining distal phalanx, a nail bed ablation usually is indicated; otherwise, a hook nail may develop. Reamputation of the finger at a more proximal level can provide ample skin and other soft tissues for closure but requires shortening the finger. If other parts of the hand are severely injured or if the entire hand would be endangered by keeping a finger in one position for a long time, amputation may be indicated. This is especially true for patients with arthritis or for patients with a less physically demanding lifestyle. A free skin graft can be used for coverage, but normal sensibility is rarely restored. A split-thickness graft is often sufficient if the bone is only slightly exposed and its end is nibbled off beneath the fat. Such a graft contracts during healing and eventually becomes about half its original size. Sometimes a full-thickness graft is available from other injured parts of the hand, but the fat should be removed from its deep surface. Occasionally, the amputated part of the fingertip is recovered and replaced as a free graft or

B

C FIGURE 19.3 Abrasion injury to left hand treated by secondary-intention healing. A, Volar view soon after injury with 2 × 2 cm full-thickness pulp skin loss of middle and ring fingers. B, Same fingers with local wound care at 4 weeks. C, Result at 8 weeks with no operative intervention.

cap technique (Fig. 19.4). This procedure requires removing bone debris and partially defatting the distal part before reattachment. The cap procedure is quite successful in both children and adults. These free composite grafts should be secured by a stent dressing tied over the end of the finger. The medial aspect of the arm just distal to the axilla, elbow flexion crease, volar forearm and wrist, and hypothenar

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A

B

D

E

C

F

G FIGURE 19.4 Cap technique. A and B, Composite soft-tissue loss from left index finger sustained while changing a tire. C and D, Biplanar views of finger, indicating inadequate soft-tissue coverage. E, Deboned and defatted distal part with good quality skin and sterile matrix. F and G, Composite tissue reattached with the old nail used as a nail matrix frame.

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CHAPTER 19   AMPUTATIONS OF THE HAND

A

A

B

B

C

D

C E FIGURE 19.5 Kutler V-Y advancement flaps. A, Advancement flaps over neurovascular pedicles carried down to bone. B–D, Fibrous septa are defined (B) and divided (C), permitting free mobilization on neurovascular pedicles alone (D). E, Flaps advance readily to midline. SEE TECHNIQUE 19.1.

eminence are convenient areas from which skin grafts can be obtained. If deeper tissues and skin must be replaced to cover exposed tendon and bone, various flaps or grafts can be used. Frequently used distal advancement flaps include the Kutler double lateral V-Y and Atasoy volar V-Y advancement flaps (Figs. 19.5 to 19.7). These flaps involve tissue advancement from the injured finger and provide limited coverage. The dorsal pedicle flap is useful when a finger has been amputated proximal to the nail bed (Fig. 19.8). If further shortening is unacceptable, however, this type of flap can be raised from the dorsum of the injured finger and carried distally without involving another digit. Dorsal defects may be managed by adipofascial turnover flaps in which the proximal subdermal adipofascial tissues are flipped distally over a vascularized zone of the same tissue (Fig. 19.9). Advantages of same-digit coverage techniques include no need for a second operation for flap division (as with a cross-finger flap), prevention of adjacent finger stiffness that occurs with adjacent finger coverage techniques (especially in patients with underlying arthritic conditions), and the opportunity for coverage in patients in whom adjacent fingers are injured. The cross-finger flap provides excellent coverage but may be followed by stiffness not only of the involved finger but also of the donor finger. This type of coverage requires operation in two stages and a split-thickness graft to cover the donor site. The thenar flap also requires operation in two stages. It usually does not cover as large a defect as a cross-finger flap and sometimes is followed by tenderness of the donor site. It does have the advantage, however, of involving only one finger

D

FIGURE 19.6 Atasoy V-Y technique. A, Skin incision and mobilization of triangular flap. B, Advancement of triangular flap. C, Suturing of base of triangular flap to nail bed. D, Closure of defect, V-Y technique. SEE TECHNIQUE 19.2.

directly. Thenar flaps also have been shown to be a safe and reliable option in the pediatric population. An alternative to this method is the palmar pocket method in which the distal fingertip (except that of the thumb) can be buried in the ipsilateral palm. The finger is removed from the pocket 16 to 20 days after surgery. Results were successful in 13 of 16 patients according to Arata et al. In children, we have observed that merely resuturing the defatted fingertips back in place usually results in a satisfactory result. A local neurovascular island pedicle flap can be advanced distally and provides a good pad with normal sensibility. Flaps of 2 × 1.5 cm2 and advancement of 18 mm have been reported (Fig. 19.10). Retrograde island pedicle flaps require tedious dissection but offer excellent distal coverage and utility for dorsal and volar defects (Fig. 19.11). Donor site morbidity may be reduced in retrograde island pedicle flaps that use the subdermal elements only (Fig. 19.12). Comparative studies have shown no significant differences between the two flaps at 12 months. Composite soft-tissue transfer to the small finger may be accomplished by use of an ulnar hypothenar flap. This retrograde flow flap is based on the ulnar digital artery and may be used to supply sensation when the dorsal sensory branch of the ulnar nerve is included in the skin flap (Fig. 19.13). Eponychial flaps have historically been used to improve overall functional and cosmetic outcomes of distal amputations (Fig. 19.14). Despite the variability of coverage options, patient-reported outcomes demonstrate satisfactory or good-to-excellent results independent of treatment type, with minimal influence on ability to perform activities of daily living or in quality of life.

FREE SKIN GRAFT

The techniques for applying free skin grafts are described in Chapter 65.

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A

B

C

D

E FIGURE 19.7 Distal fingertip amputation suitable for a V-Y advancement flap. A, Ample pulp skin with outline of intended skin incision. B and C, Flap raised with sequential dissection from the distal phalangeal periosteum and flexor digitorum profundus tendon centrodorsally, and dorsoradial and dorsoulnar margins by dissection down to the distal phalangeal bone laterally, and septal release volarly. Note that the neurovascular bundles must be carefully kept with the pulp skin, and direct inspection of them is not always possible. D, Flap sutured into position with proximal open area left open to heal by secondary intention. E, Clinical result at 6 weeks postoperatively. SEE TECHNIQUE 19.1.



FLAPS FOR FINGERTIP COVERAGE 

TECHNIQUE 19.1 (KUTLER; FISHER)

 

KUTLER V-Y OR ATASOY TRIANGULAR ADVANCEMENT FLAPS Kutler double lateral V-Y or Atasoy volar V-Y advancement flap fingertip coverage is appealing because it involves just the injured finger. It provides only limited coverage, however, and does not result consistently in normal sensibility. The injury pattern determines which flap to use. When more of the pulp skin remains, then the Atasoy flap is useful. When the pulp is compromised and the lateral hyponychial skin is uninjured, the Kutler flap can be used.

Local anesthesia is preferred in adults; children may require general anesthesia. Anesthetize the finger by digital block at the proximal phalanx and apply a digital tourniquet. n  Debride the tip of the finger of uneven edges of soft tissue and any protruding bone (Fig. 19.5). n  Develop two triangular flaps, one on each side of the finger with the apex of each directed proximally and centered in the midlateral line of the digit. Avoid making the flaps too large; their sides should each measure about 6 mm, and their bases should measure about the same or slightly less. n 

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CHAPTER 19   AMPUTATIONS OF THE HAND Develop the flaps farther by incising deeper toward the nail bed and volar pulp. Take care not to pinch the flaps with thumb forceps or hemostats. Rather, insert a skin hook near the base of each and apply slight traction in a distal direction. With a pair of small scissors and at each apex, divide the pulp just enough (usually not more than half its thickness) to allow the flaps to be mobilized toward the tip of the finger. Avoid dividing any pulp distally. n  Round off the sharp corners of the remaining part of the distal phalanx and reshape its end to conform with the normal tuft. n  Approximate the bases of the flaps and stitch them together with small interrupted nonabsorbable sutures; stitch the dorsal sides of the flaps to the remaining nail or nail bed. n  Frequently, closure of the proximal and lateral defects is impossible without placing significant tension on the flaps. In such instances, the sides of the triangular flaps should be left without sutures and heal satisfactorily by secondary intention (Fig. 19.7D). Apply Xeroform gauze and a protective dressing.     n 

A

B

C

FIGURE 19.8 Dorsal pedicle flap useful for amputations proximal to the nail when preserving length is essential. It may have two pedicles or, as illustrated here, only one. A, Flap has been outlined. B, Flap has been elevated, leaving only a single pedicle. C, Flap has been sutured in place over end of stump, and remaining defect on dorsum of finger has been covered by split-thickness skin graft. SEE TECHNIQUE 19.3.

Defect

Flap base

Incision

Flap

A

B

C

Turned over flap

No skin closure at base of flap

Flap base

D

E

FIGURE 19.9 Turnover adipofascial flap. A, Complex defect. B, Design of adipofascial flap. Flap base is immediately proximal to the defect, and flap width is slightly wider than the defect. C, Development of a distally based flap by separating it from the underlying paratenon of the extensor tendon. (Intact paratenon ensures tendon gliding after surgery.) D, Flap is turned over on itself to cover the defect and the flap base. E, Flap covered with thin skin graft. Skin closure is not performed at base of flap to avoid tension. SEE TECHNIQUE 19.4.

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B

FIGURE 19.10 Homodigital antegrade-flow neurovascular pedicle flap. A, Flap pattern on middle finger outlined with dorsal border on midaxial line with progressively narrower sawtooth pattern volarly converging just proximal to the proximal interphalangeal joint. B, Flap raised with intact neurovascular bundle. C, Distally advanced and inset flap, with area proximally requiring ulnar-palm free skin graft. (From Henry M, Stutz C: Homodigital antegrade-flow neurovascular pedicle flaps for sensate reconstruction of fingertip amputation injuries, J Hand Surg 31[7]:1220–1225, 2006.)  

ATASOY TRIANGULAR ADVANCEMENT FLAPS

TECHNIQUE 19.2 (ATASOY ET AL.)

Under tourniquet control and using an appropriate anesthetic, cut a distally based triangle through the pulp skin only, with the base of the triangle equal in width to the cut edge of the nail (Fig. 19.6). n  Develop a full-thickness flap with nerves and blood supply preserved. Carefully separate the fibrofatty subcutaneous n 

tissue from the periosteum and flexor tendon sheath using sharp dissection. n  Selectively cut the vertical septa that hold the flap in place and advance the flap distally. n  Suture the skin flap to the sterile matrix or nail. The volar defect from the advancement can be left open and left to heal by secondary intention if closure compromises vascularity. A few millimeters of the phalanx can be removed to the level of the sterile matrix. The base of the flap may be difficult to suture to the sterile matrix or nail, and a 22-gauge needle can be used as an intramedullary pin in the distal phalanx to keep the flap in position.    

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CHAPTER 19   AMPUTATIONS OF THE HAND Skin flap

Incision along midlateral line

A

Digital artery with perivascular soft tissue

C B

Dorsal branch of digital nerve proper FIGURE 19.11 Reverse digital artery island flap. A, Flap design. B and C, Digital artery is ligated proximally. Skin flap is elevated along with artery and perivascular soft tissue. Dorsal branch of digital nerve can be incorporated and microanastomosed with transected contralateral digital nerve to facilitate innervation of flap. SEE TECHNIQUE 19.8.

Pivot point

Skin flap

A

B

Ulnar palmar digital artery

FIGURE 19.13 TECHNIQUE 19.9.

 

Superficial palmar arch

Dorsal branch, ulnar nerve

FIGURE 19.12 Reverse adipofascial flap. A, Skin incision outlining flap and defect. B, Postoperative result with free skin graft over defect site. (From Chang KP, Wang WH, Lai CS, et al: Refinement of reverse digital arterial flap for finger defects: surgical technique, J Hand Surg Am 30[3]:558–561, 2005.)

Reverse ulnar hypothenar flap design. SEE

BIPEDICLE DORSAL FLAPS A bipedicle dorsal flap is useful when a finger has been amputated proximal to its nail bed and when preserving all its remaining length is essential, but attaching it to another finger is undesirable. When this flap can be made wide enough in relation to its length, one of its pedicles can be divided, leaving it attached only at one side (Fig. 19.8).



TECHNIQUE 19.3 Beginning distally at the raw margin of the skin and proceeding proximally, elevate the skin and subcutaneous tissue from the dorsum of the finger.

n 

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CROSS-FINGER FLAPS FOR RECONSTRUCTION OF FINGERTIP AMPUTATIONS

0.5–0.6 cm 0.2–0.3 cm

A

B

The technique of applying cross-finger flaps is described in Chapter 65. 

C

FIGURE 19.14 Eponychial flap for fingertip amputation. A, Dorsal fold advancement flap design to increase nail exposure. B, Proximal de-epithelialization of bed for flap advancement. C, After dorsal fold flap advancement into area of de-epithelialization. (Redrawn from Peterson SL, Peterson EL, Wheatley MJ: Management of fingertip amputations, J Hand Surg Am 39[10]:2093–2101, 2014.)

At a more proximal level, make a transverse dorsal incision to create a bipedicle flap long enough, when drawn distally, to cover the bone and other tissues on the end of the stump. n  Suture the flap in place and cover the defect created on the dorsum of the finger by a split-thickness skin graft. The flap can be made more mobile by freeing one of its pedicles, but this decreases its vascularity.    

   

THENAR FLAP Middle and ring finger coverage can be accomplished by the use of the thenar flap. Donor site tenderness and proximal interphalangeal joint flexion contractures can occur, and the flaps should not be left in place for more than 3 weeks.

n 

 

ADIPOFASCIAL TURNOVER FLAP The adipofascial turnover flap is a de-epithelialized flap that may be used to cover distal dorsal defects 3 cm in length.



TECHNIQUE 19.4

Under tourniquet control, repair the traumatic defects as indicated, such as extensor tendon repair and fracture fixation. n  Outline the planned flap with a skin pen. Make the width 2 to 4 mm wider than the traumatic defect. The base-tolength ratio should be 1:1.5 to 1:3. The flap base should be 0.5 to 1 cm in length and is made just proximal to the defect. The flap length should be at least this much longer than the defect (Fig. 19.9B). n  Develop the adipofascial flap superficial to the extensor tendon paratenon from proximal to distal (Fig. 19.9C). n  After the flap is detached proximally and along its sides to the flap base, flip it over and suture it distally (Fig. 19.9D). n  Do not place sutures at the turnover site to avoid tension on the vascular pedicle (Fig. 19.9E). n  Use a split-thickness graft to cover the defect at the flap site. n  Immobilize the digit in a protective splint. n 

POSTOPERATIVE CARE The first dressing change is 3 weeks after surgery, and digital motion is begun as wound healing and other concomitant injuries allow.    

TECHNIQUE 19.5



With the thumb held in abduction, flex the injured finger so that its tip touches the middle of the thenar eminence. Outline on the thenar eminence a flap that when raised is large enough to cover the defect and is properly positioned; pressing the bloody stump of the injured finger against the thenar skin outlines by bloodstain the size of the defect to be covered (Fig. 19.15A,B). n  With its base proximal, raise the thenar flap to include most of the underlying fat; handle the flap with skin hooks to avoid crushing it even with small forceps. Make the flap sufficiently wide so that when sutured to the convex fingertip it is not under tension. Make its length no more than twice its width. By gentle undermining of the skin border at the donor site, the defect can be closed directly without resorting to a graft. n  Attach the distal end of the flap to the trimmed edge of the nail by sutures passed through the nail. The lateral edges of the flap should fit the margins of the defect, but to avoid impairing circulation in the flap, suture only their most distal parts, if any, to the finger. Prevent the flap from folding back on itself and strangulating its vessels (Fig. 19.15C and D). n  Control all bleeding, check the positions of the flap and finger, and apply wet cotton gently compressed to follow the contours of the graft and the fingertip. n  Hold the finger in the proper position by gauze and adhesive tape and splint the wrist. n 

POSTOPERATIVE CARE  At 4 days, the graft is dressed again and then kept as dry as possible by dressing it every 1 or 2 days and by leaving it partially exposed. At 2 weeks, the base of the flap is detached and the free skin edges are sutured in place. The contours of the fingertip and the thenar eminence improve with time.      

LOCAL NEUROVASCULAR ISLAND FLAP An antegrade neurovascular island graft can provide satisfactory padding and normal sensibility to the most important working surface of the digit.

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CHAPTER 19   AMPUTATIONS OF THE HAND on the bundles. Should tension compromise the circulation in the graft, dissect the bundles more proximally or flex the distal interphalangeal joint, or both. n  Suture the graft in place with interrupted small nonabsorbable sutures. n  Cover the defect created on the volar surface of the finger with a free full-thickness graft. n  Carefully place contoured sterile dressings such as glycerin-soaked cotton balls over the grafts to lessen the likelihood of excess pressure on the neurovascular bundles. n  Apply a compression dressing until suture removal at 10 to 14 days.

POSTOPERATIVE CARE  Begin digital motion therapy as A

soon as the wounds permit.    

B

 

ISLAND PEDICLE FLAP The axial-pattern island pedicle flap may be used to provide sensation or merely composite soft tissue to adjacent fingers or thumb. The skin paddle size can vary to suit the defect.



TECHNIQUE 19.7

This procedure is performed as outpatient surgery, and general anesthesia is preferred. n  Inflate the arm tourniquet after using a skin pen to outline clearly the intended flap design. n  Measure the defect size after appropriate debridement and draw a slightly larger flap onto the donor digit. n  Use a midaxial or a volar zigzag incision to expose the neurovascular bundle of the area of the superficial arch, the usual pivot point of the flap. n  If a neurovascular island flap is desired to provide sensation to a given area, it is imperative that the ulnar border of the small finger and radial border of the index finger not be used as donors because maintaining or achieving sensation in these areas is desirable. The skin paddle is ideally centered over the neurovascular bundle. n  Under tourniquet control, locate the neurovascular bundle proximally and carefully dissect this to its superficial arch origin. Leave a cuff of soft tissue around the neurovascular bundle because discrete veins are not readily visible but exist in the periarterial tissues. Dissect the bundle deeply and use bipolar cautery well away from the proper digital artery to control perforating vessels entering the flexor sheath. n  Elevate the skin paddle, taking care to ensure the vascular bundle is reasonably centered under the flap, and divide the artery distally. n  Use a simple 5-0 nylon suture to secure the distal vascular bundle to the distal edge of the skin flap. n  Place the paddle over the recipient site to determine the best path for the pedicle because the pedicle should not be under any tension. The skin between the pivot point n 

C

D

FIGURE 19.15 Thenar flap for amputation of fingertip. A, Tip of ring finger has been amputated. B, Finger has been flexed so that its tip touches middle of thenar eminence, and thenar flap has been outlined. C, Split-thickness graft is to be sutured to donor area before flap is attached to finger. D, End of flap has been attached to finger by sutures passed through nail and through tissue on each side of it. SEE TECHNIQUE 19.5.



TECHNIQUE 19.6

Make a midlateral incision on each side of the finger (or thumb) beginning distally at the defect and extending proximally to the level of the proximal interphalangeal joint or thumb interphalangeal joint. n  On each side and beginning proximally, carefully dissect the neurovascular bundle distally to the level selected for the proximal margin of the graft (Fig. 19.16A). Here make a transverse volar incision through the skin and subcutaneous tissues, but carefully protect the neurovascular bundles (Fig. 19.16B). n  If necessary, make another transverse incision at the margin of the defect, freeing a rectangular island of the skin and underlying fat to which the two neurovascular bundles are attached. n  Carefully draw this island or graft distally and place it over the defect (Fig. 19.16C). Avoid placing too much tension n 

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A

B

C FIGURE 19.16

A–C, Local neurovascular island graft (see text). SEE TECHNIQUE 19.6.

can be undermined and enlarged by gently yet liberally spreading a hemostat in the intended pedicle path. The tunnel must allow easy passage of the flap. Frequently, a 2 to 3 cm skin bridge can be left between the proximal donor and recipient incisions. However, if any doubt remains in regard to the pedicle tension or impingement, these incisions should be connected. n  Deflate the tourniquet and control bleeding. n  Draw the 5-0 nylon suture gently through the skin bridge, taking care not to place shear stress between the pedicle and flap. n  Suture the flap loosely into position and close the remaining wounds. Ensure the flap remains well vascularized before placing a loose dressing and protective splint. n  Note: When this procedure is performed as a vascular island pedicle flap, the proper digital nerve should be carefully preserved and protected to prevent problematic

neuromas. Transient dysesthesias that commonly occur with this technique usually resolve in 6 to 8 weeks.

POSTOPERATIVE CARE The patient is seen in 5 to 7 days, and motion therapy is begun as soon as the wounds permit, usually 2 to 3 weeks postoperatively.    

 

RETROGRADE ISLAND PEDICLE FLAP This retrograde homodigital island flap is well suited to cover dorsal and volar defects distally. The procedure relies on retrograde flow through the proper digital artery, supplying the proximal composite tissue (Fig. 19.11). This flap can be performed with skin or adipofascial tissue.

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CHAPTER 19   AMPUTATIONS OF THE HAND



TECHNIQUE 19.8

POSTOPERATIVE CARE The bulky soft dressing is re-

After preparing the recipient site appropriately, determine the donor defect size. n  Expose the vascular pedicle using a linear or zigzag incision over the digit, the length of which is 1 to 1.5 cm larger than the distance between the proximal defect edge and distal donor edge. n  Dissect from proximal to distal under tourniquet control. n  Separate the proper digital artery proximal to the donor flap from the underlying digital nerve. Ligate and divide the artery and raise the flap carefully with its pedicle. Leave a 1-cm section of undamaged vascular bundle undisturbed distally to nourish the flap and act as the pivot point for the flap. n  Deflate the tourniquet and control bleeding with bipolar cautery. n  Suture without tension on the recipient site and close the remaining wound loosely so as not to compromise the pedicle. n  Donor defects typically require a split-thickness skin graft and a soft nonadherent conforming dressing, such as Xeroform gauze and glycerin-soaked cotton balls. n  Note: This flap can be used as a de-epithelialized retrograde homodigital island to lessen the morbidity associated with the skin paddle. In such a modification, the skin graft is applied over the composite graft at the recipient site.

moved within 1 week after surgery, and metacarpophalangeal and proximal interphalangeal joint motion therapy is begun.    

n 

AMPUTATIONS OF SINGLE FINGERS

INDEX FINGER

When the index finger is amputated at or more proximal to its proximal interphalangeal joint level, the remaining stump is useless and can hinder pinch between the thumb and middle finger. In most instances, when a primary amputation must be at such a proximal level, any secondary amputation should be through the base of the second metacarpal. This index ray amputation is especially desirable in women for cosmetic reasons. Because it is a more extensive operation than amputation through the finger, however, it can cause stiffness of the other fingers and may be contraindicated in arthritic hands. The middle finger radial digital nerve should be carefully isolated and dissected free from the second web space common digital nerve. Improper technique can result in a sunken scar on the dorsum of the hand or in anchoring the first dorsal interosseous to the extensor mechanism, rather than to the base of the proximal phalanx, causing intrinsic overpull. 

POSTOPERATIVE CARE The dressing is removed 7 to 10 days postoperatively, and motion therapy is begun depending on wound healing.    

 

INDEX RAY AMPUTATION TECHNIQUE 19.10

 

ULNAR HYPOTHENAR FLAP The ulnar hypothenar flap is a retrograde vascular pedicle flap that relies on the distal half of the hypothenar skin’s vascular supply from the small finger ulnar digital artery. The flap can be used to cover defects as large as 5 × 2 cm. Based on the proper digital artery to the small finger, this flap may provide sensation by suturing the ulnar digital nerve to a cutaneous nerve sensory branch that is harvested with the flap.



TECHNIQUE 19.9

Outline the flap on the distal half of the hypothenar eminence to correspond to the recipient defect. n  Under tourniquet control and general anesthesia, dissect in the subfascial plane, beginning on the dorsal side of the hand. Include the multiple vascular perforators with the flap before dividing the ulnar palmar digital artery proximally. n  Take the distal dissection of the pedicle to the pivot point of the proximal interphalangeal joint (Fig. 19.13). n  Close the wounds loosely after bleeding is controlled and apply a bulky soft dressing. n 

With a marking pen, outline the planned incisions (Fig. 19.17A). Begin the palmar line in the second web space at the radial base of the middle finger and continue this line proximally to the midpalmar area, being careful not to cross the palmar flexion creases at 90 degrees. Begin a second palmar line approximately 1 cm distal to the palmar digital flexion crease of the index finger radial base and extend this line proximally to meet the first incision in the midpalmar area. Zigzag incisions in the palmar skin may lessen the incidence of longitudinal skin scar contractures. n  Outline the dorsal part of the incision that extends from the palmar lines to converge at a point on the index carpometacarpal joint dorsally. n  Now make the incisions as just outlined. n  Ligate and divide the dorsal veins, and at a more proximal level divide the branches of the superficial radial nerve to the index finger. n  Retract the index extensor digitorum communis and the extensor indicis proprius tendons distally, sever them, and allow them to retract proximally. n  Detach the tendinous insertion of the first dorsal interosseous and dissect the muscle proximally from the second metacarpal shaft (Fig. 19.17B). Detach the volar interosseous from the same shaft and divide the transverse metacarpal ligament that connects the second and third metacarpal n 

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A

B

C

D FIGURE 19.17 Technique for index ray amputation. A, Dorsal skin incisions planned with marking pen. Palmar skin incision can be outlined in matching zigzag fashion to reduce skin suture line contracture. B, Flexor digitorum superficialis and flexor digitorum profundus tendons severed proximal to lumbrical origin after isolation and division of appropriate neurovascular structures. C, First dorsal interosseous retained for insertion into radial base of middle finger proximal phalanx. D, Appearance after index ray amputation. SEE TECHNIQUE 19.10.

heads. Take care not to damage the radial digital nerve of the middle finger. n  Carefully divide the second metacarpal obliquely from dorsoradial proximally to volar-ulnar distally about 2 cm distal to its base. Do not disarticulate the bone at its proximal end. Smooth any rough edges on the remaining part of the metacarpal. n  Divide both flexor tendons of the index finger and allow them to retract (Fig. 19.17C). n  Ligate and divide digital arteries to the index finger. n  Carefully identify and divide both digital nerves leaving sufficient length so that their ends can be buried in the interossei. n  Anchor the tendinous insertion of the first dorsal interosseous to the base of the proximal phalanx of the middle finger. Do not anchor it to the extensor tendon or its hood because this might cause intrinsic overpull. n  With a running suture, approximate the muscle bellies in the area previously occupied by the second metacarpal shaft. n  Ligate or cauterize all obvious bleeders.

Approximate the skin edges over a drain and remove the tourniquet (Fig. 19.17D). n  Apply a well-molded wet dressing that conforms to the wide new web between the middle finger and the thumb and support the wrist by a large bulky dressing or a plaster splint. n 

POSTOPERATIVE CARE The hand is elevated immediately after surgery for 48 hours. At 24 hours, the drain is removed. Digital motion therapy is initiated at 5 to 7 days postoperatively.   

MIDDLE OR RING FINGER RAY AMPUTATIONS

In contrast to the proximal phalanx of the index finger, the proximal phalanx of either the middle or the ring finger is important functionally. Its absence in either finger makes a hole through which small objects can pass when the hand is used as a cup or in a scooping maneuver; its absence makes the remaining fingers tend to deviate toward the midline of

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A

B

D

E

C

F

FIGURE 19.18 Middle finger ray resection. A and B, Clinical appearance of unsalvageable contracted and stiff middle finger after gunshot wound to hand. C and D, Planned palmar and dorsal incisions for ray resection. E and F, Cosmetic appearance after partial middle finger metacarpal amputation.

the hand. In multiple amputations, the length of either the middle or the ring finger becomes even more important. The third and fourth metacarpal heads are also important because they help stabilize the metacarpal arch by providing attachments for the transverse metacarpal ligament. In a child or woman, when the middle finger has been amputated proximal to the proximal interphalangeal joint, and especially when it has been amputated proximal to the metacarpal head, transposing the index ray ulnarward to replace the third ray may be indicated. This operation results in more natural symmetry, removes any conspicuous stump, and makes the presence of only three fingers less obvious.

Transposition of the index metacarpal after partial middle finger metacarpal amputation is technically challenging and has significant complications. If this more cosmetic procedure is chosen, great care should be taken to achieve proper rotation and solid bone fixation. Union of midshaft metacarpal osteotomies is more difficult, and we recommend metaphyseal fixation in such instances. Excising the third metacarpal shaft removes the origin of the adductor pollicis and weakens pinch. The index ray should not be transposed unless this adductor can be reattached elsewhere. The operation is contraindicated if the hand is needed for heavy manual labor (Fig. 19.18).

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PART VI AMPUTATIONS Similarly, when the ring finger has been amputated, transposing the fifth ray radialward to replace the fourth rarely is indicated. Resection of the fourth metacarpal at its base or at the carpometacarpal joint and closure of the skin to create a common web permits a “folding-in” of the fifth digit to close the gap without transposing the fifth metacarpal. Disarticulation of the ring finger at the carpometacarpal joint allows the small finger metacarpal base to shift radially over the hamate facet, essentially eliminating radial deviation of the ray (Fig. 19.19).   

TRANSPOSING THE INDEX RAY TECHNIQUE 19.11 (PEACOCK) Plan the incision so that a wedge of skin is removed from the dorsal and volar surfaces of the hand (Fig. 19.20). n  In the region of the transverse metacarpal arch, plot the exact points that must be brought together to form a smooth arch across the dorsum of the hand when the second and fourth metacarpal heads are approximated. n  Curve the proximal end of the dorsal incision slightly toward the second metacarpal base so that the base can be exposed easily. n  Fashion the distal end of the incision so that a small triangle of skin is excised from the ring finger to receive a similar triangle of skin from the stump or the area between the fingers; transferring this triangle is important to prevent the suture line from passing through the depths of the reconstructed web. n  After the dorsal and volar wedges of skin have been removed and the flaps have been elevated, expose the third metacarpal through a longitudinal incision in its periosteum. n  The index ray is the right length when its metacarpal is moved directly to the third metacarpal base. With an oscillating saw, transversely divide the third metacarpal as close to its base as possible. Excise the third metacarpal shaft and the interosseous muscles to the middle finger. Take care not to damage the interosseous muscles of the remaining fingers. n  Identify the neurovascular bundles of the middle finger; individually ligate the arteries and veins and divide the digital nerves. n  While the wrist is held flexed, draw the flexor tendons distally as far as possible and divide them. n  Retract the extensor tendons of the index finger, expose the second metacarpal at its base, and divide the bone at the same level as the third metacarpal. n  From the radial side of the second metacarpal, gently dissect the intrinsic muscles just enough to allow this metacarpal to be placed on the base of the third metacarpal without placing undue tension on the muscles. Obliquely bevel the second metacarpal base to produce a smooth contour on the side of the hand. n  From the excised third metacarpal, fashion a key graft to extend from one fragment of the reconstructed metacarpal to the other. n 

Insert a Kirschner wire longitudinally through the metacarpophalangeal joint of the transposed ray and bring it out on the dorsum of the flexed wrist; draw it proximally through the metacarpal until its distal end is just proximal to the metacarpophalangeal joint. n  With the wrist flexed, cut off the proximal part of the wire and allow the remaining end to disappear beneath the skin. n  Flex all the fingers simultaneously to ensure correct rotation of the transposed ray and insert a Kirschner wire transversely through the necks of the fourth and the transposed metacarpals. Bony fixation with a small plate and screws can also be used. This requires precise technique and should be applied only after correct rotational alignment has been determined. Attaching the plate to the distal fragment first and flexing the metacarpophalangeal joints fully before proximal plate fixation is secured reduces the chance for malrotation. n  Close the skin and insert a rubber drain. n  Apply a soft pressure dressing; no additional external support is needed. n 

POSTOPERATIVE CARE At 2 days the rubber drain is removed, and at 8 to 10 days the entire dressing and the sutures are removed. A light volar plaster splint is applied to keep the wrist in the neutral position and support the transposed ray; however, the splint is removed daily for cleaning the hand and exercising the small joints. At about 5 weeks, when the metacarpal fragments have united, the Kirschner wires are removed with the use of local anesthesia.   

RING AVULSION INJURIES

The soft tissue most commonly of the ring finger usually is forcefully avulsed at its base when a metal ring worn on that finger catches on a nail or hook. The force usually is sufficient to cause separation of the skin and nearly always damages the vascular supply to the distal tissue. The modification of the Urbaniak classification by Kay et al. (Box 19.1) is useful to quantify injury and prognosis. Fractures and ligamentous damage also can occur, but the tendons seem to be the last to separate. Attempts at salvage routinely fail unless



BOX 19.1

Classification of Ring Avulsion Injuries I Circulation adequate, with or without skeletal injury II Circulation inadequate (arterial and venous), no skeletal injury III Circulation inadequate (arterial and venous), fracture or joint injury present A. Arterial circulation only inadequate B. Venous circulation only inadequate IV Complete amputation From Kay S, Werntz J, Wolff TW: Ring avulsion injuries: classification and prognosis, J Hand Surg Am 14(2 Pt 1):204–213, 1989.

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A

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FIGURE 19.19 Ring finger ray amputation. A and B, Palmar and dorsal view of patient’s hand after ring finger avulsion injury. C, En bloc disarticulation of ring finger carpometacarpal joint with proximal division of flexor and extensor tendons. D, Intermetacarpal ligaments of small and middle fingers are sutured in overlapped position to prevent splaying of small finger. E, Radiograph of hand indicating radialization of the small finger metacarpal base on hamate facet. F and G, Clinical appearance after ring finger ray resection.

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THUMB AMPUTATIONS

FIGURE 19.20 Peacock technique of transposing index ray. Dorsal incision is shown; arrows indicate points along skin edges that will be brought together. Similar palmar incision is made (see text). SEE TECHNIQUE 19.11.

the vascular supply can be reestablished. Recent advances in microvascular techniques have improved outcomes, making replantation a viable option for the skilled microvascular surgeon. Even with successful microvascular repair, stiffness and abnormal sensation are unavoidable. Amputation of the fourth ray with closure of the web is the procedure of choice in a child or woman. Simple metacarpal amputation rather than resection may be indicated in a heavy laborer. A report comparing metacarpal amputation with ray resection suggested that despite the poor cosmesis and palmar incompetence, metacarpal amputation preserved greater strength. By resecting the fourth ray at its base or at the carpometacarpal joint, the fifth ray closes without having to be surgically transposed. Simple amputation of the finger itself should be done in the presence of necrosis and infection; and, if indicated, the ray amputation is done later as an elective procedure. 

LITTLE FINGER AMPUTATIONS

As much of the little finger as possible should be saved, provided that all the requirements for a painless stump are satisfied. Often this finger survives when all others have been destroyed, and it becomes important in forming a pinch with the thumb. When the little finger alone is amputated, and when the appearance of the hand is important or the amputation is at the metacarpophalangeal joint, the fifth metacarpal shaft is divided obliquely at its middle third. The insertion of the abductor digiti quinti is transferred to the proximal phalanx of the ring finger just as the first dorsal interosseous is transferred to the middle finger in the index ray amputation already described. This smooths the ulnar border of the hand and is used most often as an elective procedure for a contracted or painful little finger. 

In partial amputation of the thumb, in contrast to amputation of a single finger, reamputation at a more proximal level to obtain closure should not be considered because the thumb rarely should be shortened. The wound should be closed primarily by a free graft, an advancement pedicle flap (described later), or a local or distant flap. If a flap is necessary, taking it from the dorsum of the hand or the index or middle finger is preferable. A flap from one of these areas provides a touch pad that is stable but that does not regain normal sensibility. Covering the volar surface of the thumb with an abdominal flap is contraindicated; even when the flap is thin, abdominal skin and fat provide a poor surface for pinch because they lack fibrous septa and roll or shift under pressure. Skin of the abdomen is dissimilar in appearance to that of the hand and its digits. When the skin and pulp, including all neural elements, have been lost from a significant area of the thumb, a neurovascular island graft (see Chapter 68) may be indicated. The defect should be closed primarily by a split-thickness graft; the neurovascular island graft or, if feasible, a local neurovascular island graft or advancement flap as described for fingertip amputations (see Technique 19.1) is applied secondarily. If the thumb has been amputated so that a useful segment of the proximal phalanx remains, the only surgery necessary, if any, except for primary closure of the wound is deepening the thumb web by Z-plasty (see Chapter 64). When amputation has been at the metacarpophalangeal joint or at a more proximal level, reconstruction of the thumb may be indicated (see Technique 19.15) if replantation cannot be accomplished. 

 

ADVANCEMENT PEDICLE FLAP FOR THUMB INJURIES Advancement flaps for fingertip injuries usually survive if the volar flap incisions are not brought proximal to the proximal interphalangeal joint. In the thumb, the venous drainage is not as dependent on the volar flap, however, and this technique is safer, and the flap can be longer (Fig. 19.21).

TECHNIQUE 19.12 Using tourniquet control and appropriate anesthesia, make a midlateral incision on each side of the thumb from the tip to the metacarpophalangeal joint (Fig. 19.22A). n  Elevate the flap that contains both neurovascular bundles without disturbing the flexor tendon sheath (Fig. 19.22B). n  Flex the joints to allow the flap to be advanced and carefully sutured over the defect with interrupted sutures (Fig. 19.22C). n 

POSTOPERATIVE CARE The joints should be maintained in flexion postoperatively for 3 weeks. This large flap is used only when a large area of thumb pulp is lost.    

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AMPUTATIONS OF MULTIPLE DIGITS In nonreplantable partial amputations of all fingers, preserving the remaining length of the digits is much more important than in a single finger amputation. Because of the natural hinge action between the first and fifth metacarpals, any remaining stump of the little finger must play an important role in prehension with the intact thumb, and 1 2 3 4 5 6 7

FIGURE 19.21 Thumb tip amputation levels. Acceptable procedures by level are 1, split-thickness graft; 2, cross-finger flap or advancement flap; 3, advancement flap, cross-finger flap, or shorten thumb and close; 4, split-thickness skin graft; 5, shorten bone and split-thickness skin graft, advancement flap, or cross-finger flap; 6, advancement flap or cross-finger flap; and 7, advancement flap and removal of nail bed remnant. SEE TECHNIQUE 19.12.

A

this hinge action can be increased about 50% by dividing the transverse metacarpal ligament between the fourth and fifth rays. In partial amputation of all fingers and the thumb, function can be improved by lengthening the digits relatively and by increasing their mobility. Function of the thumb can be improved by deepening its web by Z-plasty (see Chapter 64) and by osteotomizing the first and fifth metacarpals and rotating their distal fragments toward each other (Fig. 19.23) while, if helpful, tilting the fifth metacarpal toward the thumb. If the first carpometacarpal joint is functional but the first metacarpal is quite short, the second metacarpal can be transposed to the first to lengthen it and to widen and deepen the first web. In complete amputation of all fingers, if the intact thumb cannot easily reach the fifth metacarpal head, phalangization of the fifth metacarpal is helpful. In this operation, the fourth metacarpal is resected and the fifth is osteotomized, rotated, and separated from the rest of the palm. Lengthening of the fifth metacarpal is also helpful. In complete amputation of all fingers and the thumb in which the amputation has been transverse through the metacarpal necks, phalangization of selected metacarpals can improve function. The fourth metacarpal is resected to increase the range of motion of the fifth, and function of the fifth metacarpal is improved further by osteotomy of the metacarpal in which the distal fragment is rotated radialward and flexed. The second metacarpal is resected at its base, but to preserve the origin of the adductor pollicis, the third metacarpal is not resected. The thumb should not be lengthened by osteoplastic reconstruction unless sensibility can be added to its volar surface. When the amputation has been through the middle of the metacarpal shafts, prehension probably cannot be restored, but hook can be accomplished by flexing the stump at the wrist. This motion at the wrist can be made even more useful by fitting an artificial platform to which the palmar surface of the stump can be actively opposed. 

B

C

FIGURE 19.22 Advancement pedicle flap for thumb injuries. A, Deep thumb pad defects exposing bone can be covered with advancement pedicle flap. B, Advancement of neurovascular pedicle. C, Flexion of distal joint of thumb is necessary to permit placement of flap (see text). SEE TECHNIQUE 19.12.

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FIGURE 19.23 In multiple amputations including thumb, function can be improved by osteotomizing first and fifth metacarpals and rotating their distal fragments toward each other (see text).  

PHALANGIZATION OF FIFTH METACARPAL TECHNIQUE 19.13 Over the fourth metacarpal, make dorsal and volar longitudinal incisions that join distally. n  Expose and resect the transverse metacarpal ligament on each side of the fourth metacarpal head. n  Divide proximally the digital nerves to the ring finger and ligate and divide the corresponding vessels. n  Resect the fourth metacarpal shaft just distal to its carpometacarpal joint. Through the same incision, osteotomize the fifth metacarpal near its base. n  Slightly abduct and flex the distal fragment and rotate it toward the thumb. Fix the fragments with a Kirschner wire. n  Cover the raw surfaces between the third and fifth metacarpals with split-thickness grafts, creating a web at the junction of the proximal and middle thirds of the bones. Ensure that the padding over the fifth metacarpal head is good and, if possible, that sensation is normal at its point of maximal contact with the thumb.     n 

PAINFUL AMPUTATION STUMP Revision surgery is a frequent elective procedure for the management of painful amputation stumps, especially those resulting from traumatic injuries. Revision rates can be influenced by finger involvement, mechanism of injury, or workman’s compensation status of the patient. A neuroma located in an unpadded area near the end of the stump is the usual

cause of pain. Symptomatic neuromas occur in approximately 7% of traumatic amputations and are most common in the index finger and avulsion type injuries. A well-localized area of extreme tenderness associated with a small mass, usually in line with a digital nerve, is diagnostic. Some painful neuromas can be treated by padding and desensitization, although surgical excision frequently is required. The neuroma is dissected free from scar, and the nerve is divided at a more proximal level. Another neuroma will develop but should be painless when located in a padded area. Suturing the radial and ulnar digital nerves end to end (compared with proximal resection as mentioned previously) has not been shown to reduce resting pain, cold intolerance, or perceived tenderness. Reduction in tenderness is achieved by this end-to-end nerve union, but at the expense of touch sensibility. Pain in an amputation stump can also be caused by bony prominences covered only by thin skin, such as a split-thickness graft, or by skin made tight by scarring. In these instances, excising the thin skin or scar, shortening the bone, and applying a sufficiently padded graft may be indicated. Amputation stumps that are painful because of thin skin coverage at the pulp and nail junction can be improved by using a limited advancement flap as described in the section on thumb amputations. In the finger, proximal dissection to develop these flaps should not extend proximal to the proximal interphalangeal joint. Finally, painful cramping sensations in the hand and forearm can be caused by flexion contracture of a stump resulting from overstretching of extensor tendons or adherence of flexor tendons; release of any adherent tendons is helpful. 

RECONSTRUCTIONS AFTER AMPUTATION

RECONSTRUCTION AFTER AMPUTATION OF THE HAND

Hand amputation is an extremely disabling injury. In most patients, when replantation is not possible, prosthetic use is required. The field of prosthetics and orthotics is ever advancing. With new developments in 3D printing, myoelectric prosthetics, and groundbreaking operations, such as targeted muscle reinnervation or the starfish procedure, patients have shown significant improvements in use and function. For patients with bilateral hand amputations, advances in transplantation are continually being made. However, transplantation is not yet commonplace except at a few centers in the United States, and prosthetic use still remains the standard of care. In selected patients, the Krukenberg operation is helpful. It converts the forearm to forceps in which the radial ray acts against the ulnar ray. Swanson compared function of the reconstructed limb with the use of chopsticks. Normal sensibility between the tips of the rays is ensured by proper shifting of skin during closure of the wound. The operation is especially helpful in blind patients with bilateral amputations because it provides not only prehension but also sensibility at the terminal parts of the limb. It is also helpful in other patients with similar amputations, especially in surroundings where modern prosthetic services are unavailable. According to Swanson, children with bilateral congenital amputation find the reconstructed limb much more useful than a mechanical prosthesis; they transfer

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CHAPTER 19   AMPUTATIONS OF THE HAND dominance to this limb when a prosthesis is used on the opposite one. In children, the appearance of the limb after surgery has not been distressing, and the operation does not prevent the wearing of an ordinary prosthesis if desired.   

KRUKENBERG RECONSTRUCTION TECHNIQUE 19.14 (KRUKENBERG; SWANSON) Make a longitudinal incision on the flexor surface of the forearm slightly toward the radial side (Fig. 19.24A). Make

n 

a similar incision on the dorsal surface slightly toward the ulnar side, but on this surface elevate a V-shaped flap to form a web at the junction of the rays (Fig. 19.24B). n  Separate the forearm muscles into two groups (Fig. 19.24C, D): The radial side comprises the radial wrist flexors and extensors, the radial half of the flexor digitorum sublimis, the radial half of the extensor digitorum communis, the brachioradialis, the palmaris longus, and the pronator teres; the ulnar side comprises the ulnar wrist flexors and extensors, the ulnar half of the flexor digitorum sublimis, and the ulnar half of the extensor digitorum communis. If the stump is made too bulky or the wound hard to close, resect as necessary the pronator quadratus, the flexor digitorum profundus, the flexor pollicis longus,

Biceps m.

Triceps m. Brachialis m.

Brachioradialis m.

Pronator teres m. Supinator m. Palmaris longus m. Flexor carpi radialis m.

Flexor carpi ulnaris m. 1/2 Flexor digitorum sublimis m.

1/2 Flexor digitorum sublimis m. Radial

Ulnar

Ulnar

Volar

Radial

Radial

Dorsal

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Triceps m.

Ulnar Volar

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Brachioradialis m.

Anconeus m.

Extensor carpi radialis longus m.

Extensor carpi ulnaris m. Extensor carpi radialis brevis m.

Extensor digiti quinti proprius m.

1/2 Extensor digitorum communis m.

1/2 Extensor digitorum communis m. Ulnar

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Radial Dorsal

Radial

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Ulnar Volar

Ulnar

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Radial Dorsal

FIGURE 19.24 Krukenberg operation. A, Incision on flexor surface of forearm. B, Incision on dorsal surface (see text). C and D, Forearm muscles have been separated into two groups (see text). E, Closure of skin on flexor surface of forearm; the area yet to be closed indicates location of any needed split-thickness skin graft. F, Closure of skin on dorsal surface (see text). SEE TECHNIQUE 19.14.

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PART VI AMPUTATIONS the abductor pollicis longus, and the extensor pollicis brevis. Take care not to disturb the pronator teres. n  Incise the interosseous membrane throughout its length along its ulnar attachment, taking care not to damage the interosseous vessel and nerve. n  The radial and ulnar rays can be separated 6 to 12 cm at their tips depending on the size of the forearm; motion at their proximal ends occurs at the radiohumeral and proximal radioulnar joints. The opposing ends of the rays should touch; if not, osteotomize the radius or ulna as necessary. Now the adductors of the radial ray are the pronator teres, the supinator, the flexor carpi radialis, the radial half of the flexor digitorum sublimis, and the palmaris longus; the abductors of the radial ray are the brachioradialis, the extensor carpi radialis longus, the extensor carpi radialis brevis, the radial half of the extensor digitorum communis, and the biceps. The adductors of the ulnar ray are the flexor carpi ulnaris, the ulnar half of the flexor digitorum sublimis, the brachialis, and the anconeus; the abductors of the ulnar ray are the extensor carpi ulnaris, the ulnar half of the extensor digitorum communis, and the triceps. n  Remove the tourniquet, obtain hemostasis, and observe the circulation in the flaps. n  Excise any excess fat, rotate the skin around each ray, and close the skin over each so that the suture line is not on the opposing surface of either (Fig. 19.24E, F). n  Excise any scarred skin at the ends of the rays and, if necessary to permit closure, shorten the bones; in children, the skin usually is sufficient for closure, and the bones must not be shortened because growth at the distal epiphyses would still be incomplete. n  Preserve any remaining rudimentary digit. Next, suture the flap in place at the junction of the rays and apply any needed split-thickness graft. n  Insert small rubber drains and, with the tips of the rays separated 6 cm or more, apply a compression dressing.

POSTOPERATIVE CARE The limb is continuously elevated for 3 to 4 days. The sutures are removed at the usual time. After 2 to 3 weeks, rehabilitation is begun to develop abduction and adduction of the rays.   

RECONSTRUCTION AFTER AMPUTATION OF MULTIPLE DIGITS

Several reconstructive operations are useful after amputation of multiple digits at various levels. After soft-tissue stabilization is achieved, digital lengthening by callotasis is an option. Thumb pollicization may be required when transposition of remaining digits permits. Restoration of opposition by sensate opposable digits often necessitates a protracted reconstructive course that challenges the creativity of the surgeon and patience of the patient. 

however, several factors must be considered, including the length of any remaining part of the thumb, the condition of the rest of the hand, the occupational requirements and age of the patient, and the knowledge and experience of the surgeon. If the opposite thumb is normal, some surgeons question the need for reconstructing even a totally absent thumb. Function of the hand can be improved, however, by a carefully planned and skillfully executed operation, especially in a young patient. Usually the thumb should be reconstructed only when amputation has been at the metacarpophalangeal joint or at a more proximal level. When this joint and a useful segment of the proximal phalanx remain, the only surgery necessary, if any, is deepening of the thumb web by Z-plasty (see Chapter 64). When amputation has been through the interphalangeal joint, the distal phalanx, or the pulp of the thumb, only appropriate coverage by skin is necessary, unless sensibility in the area of pinch is grossly impaired. In this latter instance, a more elaborate coverage, such as by a neurovascular island transfer, may be indicated (see Chapter 68). A reconstructed thumb must meet five requirements. First and most important, sensibility, although not necessarily normal, should be painless and sufficient for recognition of objects held in the position of pinch. Second, the thumb should have sufficient stability so that pinch pressure does not cause the thumb joints to deviate or collapse or cause the skin pad to shift. Third, there should be sufficient mobility to enable the hand to flatten and the thumb to oppose for pinch. Fourth, the thumb should be of sufficient length to enable the opposing digital tips to touch it. Sometimes amputation or stiffness of the remaining digits may require greater than normal length of the thumb to accomplish prehension. Fifth, the thumb should be cosmetically acceptable because if it is not it may remain hidden and not be used. Several reconstructive procedures are possible, and the choice depends on the length of the stump remaining and the sensibility of the remaining thumb pad (Figs. 19.25 and 19.26). The thumb can be lengthened by a short bone graft or distraction osteoplasty. In the face of an adjacent mangled finger, an “on-top plasty” can be considered. Sensibility can be restored by skin rotation flaps, with the nonopposing surface skin grafted as in the Gillies-Millard “cocked hat” procedure. Another possibility is pollicizing a digit. A promising possibility is microvascular free transfer of a toe to the hand. Provide padding and sensibility No reconstruction needed for length Provide padded painless tip

a. Deepen web b. Add bone length when coverage with local sensitive skin possible or osteoplastic lengthening a. Pollicization or b. Toe transfer when indicated

RECONSTRUCTION OF THE THUMB

Traumatic or congenital absence of the thumb causes a severe deficiency in hand function; such an absence usually is considered to constitute a 40% disability of the hand as a whole. When the thumb is partially or totally absent, reconstructive surgery is appealing. Before any decision for surgery is made,

Pollicization when indicated FIGURE 19.25 Thumb reconstruction at various levels. Basic needs are sensibility, stability, mobility, and length.

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FIGURE 19.26 Moberg advancement flap. A, Thumb pulp defect with flap outlined. B, Flap raised on bilateral neurovascular pedicles. C, Flap advanced 1.5 cm. D, Flap sutured into position with hypothenar free full-thickness skin flap at flap base.

Pollicization also is a viable option for thumb reconstruction (Techniques 19.17 to 19.19). 

TABLE 19.1 Lister Classification GROUPS Group 1

AMPUTATION Acceptable length and poor soft-tissue coverage

Group 2

Subtotal amputation with questionable length

Group 3

Total amputation with preservation of basal joint

Group 4

Total amputation with absence of basal joint

RECONSTRUCTION OPTIONS Glabrous: Moberg advancement; V-Y advancement; NV island; free flap, free toe pulp transfer Nonglabrous: FDMA flap; distal free flap (PIA; RFF; groin flap) First web deepening; rotational flaps; ectopic banking or ectopic replantation, rigid or free flaps; distraction osteogenesis Toe transfer; metacarpal lengthening (distraction osteogenesis); osteoplastic reconstruction; pollicization Toe transfer; pollicization

 

LENGTHENING OF THE METACARPAL AND TRANSFER OF LOCAL FLAP When amputation of the thumb has been at the metacarpophalangeal joint or within the condylar area of the first metacarpal, the thenar muscles are able to stabilize the digit. In these instances, lengthening of the metacarpal by bone grafting and transfer of a local skin flap may be indicated. The technique as described by Gillies and Millard can be completed in one stage, and the time required for surgery and convalescence is less than in some other reconstructions. Disadvantages of this procedure include bone graft resorption and ray shortening and skin perforation after flap contraction. This procedure requires that there be minimal scarring of the amputated stump.

TECHNIQUE 19.15 (GILLIES AND MILLARD, MODIFIED) Make a curved incision around the dorsal, radial, and volar aspects of the base of the thumb (Fig. 19.27A). n  Undermine the skin distally, but stay superficial to the main veins to prevent congestion of the flap. Continue the undermining until a hollow flap has been elevated and slipped off the end of the stump; the blood supply to the flap is from a source around the base of the index finger in the thumb web. (If desired, complete elevation of the flap can be delayed.) n 

FDMA, First dorsal metacarpal artery; PIA, posterior interosseous flap; RFF, radial forearm flap.

In this procedure, sensory restoration is never normal. The osteoplastic technique with a bone graft and tube pedicle skin graft supplemented by a neurovascular pedicle is now rarely recommended. Lister’s classification is useful in selecting appropriate treatment (Table 19.1).

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FIGURE 19.27 Reconstruction of thumb by technique of Gillies and Millard, modified. A, Outline of curved incision around dorsal, radial, and volar aspects of base of thumb. B, Hollow flap has been undermined and elevated, iliac bone graft has been fixed (this time to base of proximal phalanx), and raw area at base of thumb has been covered by split-thickness skin graft. SEE TECHNIQUE 19.15.

Attach an iliac bone graft or a phalanx excised from a toe to the distal end of the metacarpal by tapering the graft and fitting it into a hole in the end of the metacarpal. n  Fix the graft to the bone by a Kirschner wire and place iliac chips around its base. Ensure that the graft is small enough that the flap can be placed easily over it. n  Cover the raw area at the base of the thumb by a splitthickness skin graft (Fig. 19.27B). n 

POSTOPERATIVE CARE  The newly constructed thumb is immobilized by a supportive dressing, and a volar plaster splint is applied to the palm and forearm. The Kirschner wire is removed when the graft has united with the metacarpal. Minor Z-plasties may be necessary later to relieve the volar and dorsal web formed by advancing the flap.      

OSTEOPLASTIC RECONSTRUCTION AND TRANSFER OF NEUROVASCULAR ISLAND GRAFT Verdan recommended osteoplastic reconstruction, especially when the first carpometacarpal joint has been spared and is functional. It is a useful method when the remaining part of the first metacarpal is short. As in the technique of Gillies and Millard, no finger is endangered, and all are spared to function against the reconstructed thumb. Transfer of a neurovascular island graft supplies discrete sensibility to the new thumb, but precise sensory reorientation is always lacking (Fig. 19.28).

TECHNIQUE 19.16 (VERDAN) Raise the subpectoral region, or some other appropriate area a tubed pedicle graft that contains only moderate subcutaneous fat, from the abdomen. n  Excise the skin and subcutaneous tissue over the distal end of the first metacarpal; make this area for implantation of the tubed graft a long oval and as large as possible so that the graft can include many vessels and nerves and will not constrict later. n  Insert into the end of the first metacarpal an iliac bone graft shaped like a palette to imitate the normal thumb. Do not place the graft in line with the first metacarpal, but rather place it at an obtuse angle in the direction of opposition. Ensure that the graft is not too long. Place the end of the tubed pedicle over the bone graft and suture it to its prepared bed on the thumb. n  Immobilize the hand and tubed pedicle to allow normal motion of the fingers and some motion of the shoulder and elbow. n  After 3 to 4 weeks, free the tubed pedicle. n  Close the skin over the distal end of the newly constructed thumb, or transfer a neurovascular island graft from an appropriate area to the volar aspect of the thumb to assist in closure and to improve sensation and circulation in the digit. n 

POSTOPERATIVE CARE A supportive dressing and a volar plaster splint are applied. The newly constructed thumb is protected for about 8 weeks to prevent or decrease

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B

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H

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FIGURE 19.28 Osteoplastic thumb reconstruction. A, A 32-year-old woman presented with traumatic thumb amputation 4 years previously with amputation level just distal to metacarpophalangeal joint and thumb-index web space contracture. B, Simple two-flap Z-plasty web space release allows access to ulnar shaft of thumb metacarpal. C, Lengthening frame applied percutaneously from radial side of thumb under fluoroscopic guidance before osteotomy. Note web contracture release after Z-plasty. D and E, Palmar and dorsal view of thumb soon after frame application. Lengthening begun at 1 week after surgery at a rate of 0.5 mm twice daily. F and G, Lateral radiograph at 2 weeks and 10 weeks after surgery. H, Lateral radiograph 5 months after surgery indicating solid union. No bone graft was required, and metacarpal manual osteoclasis was done after fixator removal to simulate metacarpophalangeal joint fusion. SEE TECHNIQUE 19.16.

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PART VI AMPUTATIONS resorption of the bone graft. If a neurovascular island graft was not included in the reconstruction, this transfer must be done later.   

POLLICIZATION

Pollicization (transposition of a finger to replace an absent thumb) may endanger the transposed finger; therefore, some surgeons recommend transposition only of an already shortened or otherwise damaged finger. When amputation has been traumatic, extensive scarring may require resurfacing by a pedicle skin graft before pollicization. In such instances, full function of the new thumb hardly can be expected; indeed full function cannot be expected even after successful transposition of a normal finger. However, in amputations near the carpometacarpal joint, especially in patients with significant bilateral thumb-level amputations, pollicization may be of benefit. In the hands of an experienced surgeon, pollicization is worthwhile, especially in pouce flottant (floating thumb) and congenital absence of a thumb, assuming that the digit to be pollicized is relatively normal. Pollicization is performed when the child is 9 to 12 months of age; however, when the thumb is congenitally absent, the age of pollicization is not as important as a cerebral cortex awareness of a radial opposition post. 

A

B

 

RIORDAN POLLICIZATION In the Riordan technique, the index ray is shortened by resection of its metacarpal shaft. To simulate the trapezium, the second metacarpal head is positioned palmar to the normal plane of the metacarpal bases, and the metacarpophalangeal joint acts as the carpometacarpal joint of the new thumb. The first dorsal interosseous is converted to an abductor pollicis brevis, and the first volar interosseous is converted to an adductor pollicis. The technique as described is for an immature hand with congenital absence of the thumb, including the greater multangular, but it can be modified appropriately for other hands.

TECHNIQUE 19.17 (RIORDAN) Beginning on the proximal phalanx of the index finger, make a circumferential oval incision (Fig. 19.29A, B) on the dorsal surface. n  Place the incision level with the middle of the phalanx and on the palmar surface level with the base of the phalanx. From the radiopalmar aspect of this oval, extend the incision proximally, radially, and dorsally to the radial side of the second metacarpal head, then palmarward and ulnarward to the radial side of the third metacarpal base in the middle of the palm, and finally again radially to end at the radial margin of the base of the palm. n 

C

D

E

FIGURE 19.29 Riordan pollicization for congenital absence of thumb, including greater trapezium, in an immature hand. A and B, Incision (see text). Skin of proximal phalanx (pink area in A) is elevated as full-thickness skin flap. C and D, Second metacarpal has been resected by dividing base proximally and by cutting through epiphysis distally, and finger has been relocated proximally and radially. Second metacarpal head has been anchored palmar to second metacarpal base and simulates greater trapezium (see text). E, Insertion of first dorsal interosseous has been anchored to radial lateral band of extensor mechanism of new thumb and origin to soft tissues at base of digit; insertion of first volar interosseous has been anchored to opposite lateral band and origin to soft tissues. SEE TECHNIQUE 19.17.

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CHAPTER 19   AMPUTATIONS OF THE HAND Dissect the skin from the proximal phalanx of the index finger, leaving the fat attached to the digit and creating a full-thickness skin flap. n  Isolate and free the insertion of the first dorsal interosseous and strip from the radial side of the second metacarpal shaft the origin of the muscle. n  Isolate and free the insertion of the first volar interosseous and strip from the ulnar side of the metacarpal shaft the origin of this muscle. Take care to preserve the nerve and blood supplies to the muscle in each instance. n  Separate the second metacarpal head from the metacarpal shaft by cutting through its epiphysis with a knife; preserve all of its soft-tissue attachments. n  Divide the second metacarpal at its base, leaving intact the insertions of the extensor carpi radialis longus and flexor carpi radialis; discard the metacarpal shaft. n  Carry the index finger proximally and radially and relocate the second metacarpal head palmar to the second metacarpal base so that it simulates a trapezium (Fig. 19.29C); take care to rotate and angulate it so that the new thumb is properly positioned. n  Anchor it in this position with a wire suture (Fig. 19.29D). Anchor the insertion of the first dorsal interosseous to the radial lateral band of the extensor mechanism of the new thumb and its origin to the soft tissues at the base of the digit; this muscle now functions as an abductor pollicis brevis (Fig. 19.29E). n  Anchor the insertion of the first volar interosseous to the opposite lateral band and its origin to the soft tissues; this muscle now functions as an adductor pollicis. n  Shorten the extensor indicis proprius by resecting a segment of its tendon; this muscle now functions as an extensor pollicis brevis. Also, shorten the extensor digitorum communis by resecting a segment of its tendon. n  Anchor the proximal segment of the tendon to the base of the proximal phalanx; this muscle now functions as an abductor pollicis longus. n  Trim the skin flaps appropriately; fashion the palmar flap so that when sutured it places sufficient tension on the new thumb to hold it in opposition. n  Suture the flaps, but avoid a circumferential closure at the base of the new thumb. n  Apply a pressure dressing of wet cotton and a plaster cast. n 

POSTOPERATIVE CARE At 3 weeks, the cast is removed and motion therapy is begun. The thumb is appropriately splinted.    

 

BUCK-GRAMCKO POLLICIZATION Buck-Gramcko reported experience with 100 operations for pollicization of the index finger in children with congenital absence or marked hypoplasia of the thumb. He emphasized a reduction in length of the pollicized digit trapezium. For best results, the index finger has to be rotated initially approximately 160 degrees during the operation so that it is opposite the pulp of the ring finger. This position changes

during the suturing of the muscles and the skin so that by the end of the operation there is rotation of approximately 120 degrees. In addition, the pollicized digit is angulated approximately 40 degrees into palmar abduction.

TECHNIQUE 19.18 (BUCK-GRAMCKO) Make an S-shaped incision down the radial side of the hand just onto the palmar surface. n  Begin the incision near the base of the index finger on the palmar aspect and end it just proximal to the wrist. Make a slightly curved transverse incision across the base of the index finger on the palmar surface, connecting at right angles to the distal end of the first incision. Connect both ends of the incision on the dorsum of the hand (Fig. 19.30A). Make a third incision on the dorsum of the proximal phalanx of the index finger from the proximal interphalangeal joint extending proximally to end at the incision around the base of the index finger (Fig. 19.30B). n  Through the palmar incision, free the neurovascular bundle between the index and middle fingers by ligating the artery to the radial side of the middle finger. n  Separate the common digital nerve carefully into its component parts for the two adjacent fingers so that no tension is present after the index finger is rotated. n  Sometimes an anomalous neural ring is found around the artery; split this ring carefully so that angulation of the artery after transposition of the finger does not occur. If the radial digital artery to the index finger is absent, it is possible to perform the pollicization on a vascular pedicle of only one artery. On the dorsal side, preserve at least one of the great veins. n  On the dorsum of the hand, sever the tendon of the extensor digitorum communis at the metacarpophalangeal level. n  Detach the interosseous muscles of the index finger from the proximal phalanx and the lateral bands of the dorsal aponeurosis. n  Partially subperiosteally strip the origins of the interosseous muscles from the second metacarpal, being careful to preserve the neurovascular structures. n  Osteotomize and resect the second metacarpal. If the phalanges of the index finger are of normal length, the whole metacarpal is resected with the exception of its head. When the phalanges are relatively short, the base of the metacarpal must be retained to obtain the proper length of the new thumb. n  When the entire metacarpal is resected except for the head, rotate the head as shown in and attach it by sutures to the joint capsule of the carpus and to the carpal bones (Fig. 19.30E), which in young children can be pierced with a sharp needle. n  Rotate the digit 160 degrees to allow opposition (Fig. 19.30F). n  Bony union is not essential, and fibrous fixation of the head is sufficient for good function. When the base of the metacarpal is retained, fix the metacarpal head to its base with one or two Kirschner wires in the previously described position. In attaching the metacarpal head, bring the proximal phalanx into complete hyperextension in relation to the metacarpal head for maximal stability of n 

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A

C

B

B C A

A´ A´

A

Dorsal

B

C

D

Palmar First DI (“APB”)

First PI (“AP”)

EIP (“EPL”) EDC (“APL”)

E

F

G

H

FIGURE 19.30 Pollicization of index finger. A and B, Palmar and dorsal skin incisions. C and D, Appearance after wound closure. E, Rotation of metacarpal head into flexion to prevent postoperative hyperextension. F, Index finger rotated about 160 degrees along long axis to place finger pulp into position of opposition. G, Final position of skeleton in about 40 degrees of palmar abduction with metacarpal head secured to metacarpal base or carpus. H, Reattachment of tendons to provide control of new thumb. First palmar interosseous (PI) functions as adductor pollicis (AP), first dorsal interosseous (DI) functions as abductor pollicis brevis (APB), extensor digitorum communis (EDC) functions as abductor pollicis longus (APL), and extensor indicis proprius (EIP) functions as extensor pollicis longus (EPL). SEE TECHNIQUE 19.18.

the joint. Unless this is done, hyperextension is likely at the new “carpometacarpal” joint (Fig. 19.30G). n  Suture the proximal end of the detached extensor digitorum communis tendon to the base of the former proximal phalanx (now acting as the first metacarpal) to become the new “abductor pollicis longus.” n  Section the extensor indicis proprius tendon, shorten it appropriately, and suture it by end-to-end anastomosis. n  Suture the tendinous insertions of the two interosseous muscles to the lateral bands of the dorsal aponeurosis by weaving the lateral bands through the distal part of the interosseous muscle and turning them back distally to form a loop that is sutured to itself. In this way, the first palmar interosseous becomes an “adductor pollicis” and the first dorsal interosseous becomes an “abductor brevis” (Fig. 19.30H). n  Close the wound by fashioning a dorsal skin flap to close the defect over the proximal phalanx and fashion the rest

of the flaps as necessary for skin closure as in Fig. 19.30C and D.

POSTOPERATIVE CARE  The hand is immobilized for 3 weeks, and then careful active motion is begun.    

 

FOUCHER POLLICIZATION Despite good sensibility, mobility, growth, and integration of pollicized digits, grip and pinch strength reduction (55% and 42% of the uninvolved side, respectively) have prompted technique modifications. Weakness in abduction and adduction as well as the slenderness and cleftlike appearance of the pollicized digit are corrected with the Foucher technique.

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CHAPTER 19   AMPUTATIONS OF THE HAND

TECHNIQUE 19.19 Outline the incisions on the index finger and palm (Fig. 19.31A). Line AB, as depicted in Fig. 19.31A, is situated on the midlateral line and crosses the proximal interphalangeal joint. Line DE is on the volar aspect of the indexmiddle web, and line EF is volar to the midlateral line elongating the web incision. Line F is more distal than line A. Line GHI is a longitudinal incision to the volar wrist crease. Begin the dissection volarly to allow refilling of the dorsal veins and simplify the dorsal dissection. Elevate the arteries and veins, noting absence or hypoplasia of the radial digital artery. Preserve the fat around the digital arteries to protect the small vena comitantes. Divide the

n 

radial digital artery to the middle finger and be aware of the Hartmann boutonniere deformity (nerve loop around artery). Divide the intermetacarpal ligament and resect the lumbrical. n  Dissect the first dorsal interosseous muscle from distal to proximal to avoid denervation. n  Begin the dorsal dissection over the proximal interphalangeal joint and preserve the veins and sensory branches. Expose the extensor mechanism. Longitudinally separate the extensor indicis proprius and extensor indicis communis and extensor digitorum communis tendons along the length of the proximal phalanx to form two separate bands that are sectioned at the proximal phalangeal base.

A

F B D

E G

C H

I

B

A

D Second volar interossei

First dorsal interossei

C

F

A H

EIP

C

B

I

EIC

D FIGURE 19.31 Foucher index pollicization. A, Proposed skin incisions providing a large dorsal flap and a distally based palmar flap, which provide a more weblike fold. B, Metacarpal head rotated into flexion and fixed into the metacarpal base with a bone anchor. C, New thumb balanced by tendon transfers; adduction is provided by the extensor indicis communis (EIC), second volar interosseous muscle (2nd VI), and adductor pollicis (not shown), and abduction is provided by extensor indicis proprius (EIP) and first dorsal interosseous muscle (1st DI). D, Sutured skin flaps showing weblike space between new thumb and middle finger and circular scar prevention by the radially based Z-plasty.

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E

F

G

H

FIGURE 19.31, cont’d E-H, New thumb at 3 months postoperatively. (E, From Foucher G, Medina J, Lorea P, Pivato G: Principalization of pollicization of the index finger in congenital absence of the thumb, Tech Hand Upper Extr Surg 9:96, 2005.) SEE TECHNIQUE 19.19.

Separate the metacarpal head from its shaft through the physis, which is destroyed by curettage to prevent overgrowth of the pollicized finger. Dissect the first palmar osseous muscle from the index metacarpal shaft and remove the shaft by sectioning the bone with a palmar slope at its base. Maintain 1 cm of bone at the metacarpal base to preserve the flexor carpi radialis and extensor carpi radialis longus insertions. If present, destroy the pseudoepiphysis at the metacarpal base and open the base like a flower to provide stability for the metacarpal head. Shift the metacarpal head onto the metacarpal base and avoid kinking of the vessels. Rotate the metacarpal head to allow

n 

opposition and fix in flexion to prevent hyperextension of the new carpometacarpal joint (Fig. 19.31B). A suture anchor may facilitate this fixation. n  Next, balance the thumb through tendon transfers (Fig. 19.31C). To provide adduction strength, attach the hypoplastic adductor pollicis, which is often present, to the extensor indicis communis and attach the second palmar interosseous muscles to the distal tendon ulnar slip. n  Abduction and pronation are achieved by transfer of the extensor indicis proprius (through a proximoradial fibrous sling of the first dorsal interosseous muscle) and the first dorsal interosseous muscle to the radial half of the distal

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CHAPTER 19   AMPUTATIONS OF THE HAND tendon slip over the proximal phalanx. The thumb should rest in 135 degrees of pronation and 45 degrees of palmar abduction. n  Suture the skin, maintaining some tension on the dorsal web fold from the dorsal flap. To prevent circular scarring, make a Z-plasty on the radial aspect of the thumb (Figs. 19.31D, E).

POSTOPERATIVE CARE  A fluffy dressing is placed in the new web space, and a drop of superglue maintains contact between the new thumb and middle finger. A dorsal plaster shell is applied, incorporating the elbow with two straps of Elastoplast to prevent escape. No therapy is used, and an opposition splint is used nightly for 2 months. Scar compression may be required if the pollicization is performed early because scar hypertrophy is more common in younger children. At 6 weeks if interphalangeal and metacarpophalangeal joint flexion are limited, a splint is worn for 1 h in the morning and evening until full active flexion is achieved (in 4 to 5 months).   

REFERENCES Barr JS, Chu MW, Thanik V, Sharma S: Pediatric thenar flaps: a modified design, case series and review of the literature, J Pediatr Surg 49:1433, 2014. Borrelli MR, Dupré S, Mediratta S, et  al.: Composite grafts for pediatric fingertip amputations: a retrospective case series of 100 patients, Plast Reconstr Surg Glob Open 6(6):e1843, 2018. Chen S-Y, Wang CH, Fu J-P, et al.: Composite grafting for traumatic fingertip amputation in adults: technique reinforcement and experience in 31 digits, J Trauma 20:30, 2010. Del Pinal F, Pennazzato D, Urrutia E: Primary thumb reconstruction in a mutilated hand, Hand Clin 32(4):519, 2016. Fakin RM, Biraima A, Klein H, et al.: Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap, J Hand Surg Eur 39:499, 2014. Gil JA, Goodman AD, Harris AP, et al.: Cost-effectiveness of initial revision digit amputation performed in the emergency department versus the operating room, Hand (NY). 1558944718790577, 2018. Huang Y-C, Liu Y, Chen T-H: Use of homodigital reverse island flaps for distal digital reconstruction, J Trauma 68:429, 2010. Hustedt JW, Chung A, Bohl DD, et al.: Evaluating the effect of comorbidities on the success, risk, and cost of digital replantation, J Hand Surg Am 41(12):1145, 2016. Jones NF, Clune JE: Thumb amputations in children: classification and reconstruction by microsurgical toe transfers, J Hand Surg Am pii:S03635023(17)32129-9, 2018. Krauss EM, Lalonde DH: Secondary healing of fingertip amputations: a review, Hand 9:282, 2014. Manske PR: Index pollicisation for thumb deficiency, Tech Hand Up Extrem Surg 14(22), 2010. Mahmoudi E, Huetteman HE, Chung KC: A population based study of replantation after traumatic thumb amputation 2007-2012, J Hand Surg Am 42(1):25, 2017.

Mattiassich G, Rittenschober F, Dorninger L, et al.: Long-term outcome following upper extremity replantation after major traumatic amputation, BMC Musculoskelet Disord 18(1):77, 2017. Miller AJ, Rivlin M, Kirkpatrick W, et al.: Fingertip amputation treatment: a survey study, Am J Orthop 44(9):E331, 2015. Morgan EN, Kyle Potter B, Souza JM, et al.: Targeted muscle reinnervation for transradial amputation: description of operative technique, Tech Hand Up Extrem Surg 20(4):166, 2016. Nakanishi A, Kawamura K, Omokawa S, et al.: Predictors of hand dexterity after single-digit replantation, J Reconstr Microsurg 2018. [Epub ahead of print]. O’Brien MS, Singh N: Surgical technique utilizing suture-button device for central metacarpal ray, J Hand Surg Am 41(8):3247, 2016. Paige DM, George JA, Kluger DT, et al.: Motor control and sensory feedback enhance prosthesis embodiment and reduce phantom pain after longterm hand amputation, Front Hum Neurosci 12:352, 2018. Panattoni JB, De Ona IR, Ahmed MM: Reconstruction of fingertip injuries: surgical tips and avoiding complications, J Hand Surg Am 40(5):1016, 2015. Pet MA, Morrison SD, Mack JS, et al.: Comparison of patient-reported outcomes after traumatic upper extremity amputation: replantation versus prosthetic rehabilitation, Injury 47(12):2783, 2016. Peterson SL, Peterson EL, Wheatley MJ: Management of fingertip amputations, J Hand Surg 39:2093, 2014. Pierrie SN, Gaston RG, Loeffler BJ: Current concepts in upper-extremity amputation, J Hand Surg Am 43(7):657–667, 2018. Rabarin F, Sain Cast Y, Jeudy J, et al.: Cross-finger flap for reconstruction of fingertip amputations: long-term results, Orthop Traumatol Surg Res 102(Suppl 4):S225, 2016. Salminger S, Roche AD, Sturma A, et al.: Hand transplantation versus hand prosthetics: pros and cons, Curr Surg Rep 4:8, 2016. Shaterian A, Rajaii R, Kanack M, et al.: Predictors of digit survival following replantation: quantitative review and meta-analysis, J Hand Microsurg 10(2):66, 2018. Sindhu K, DeFroda SF, Harris AP, Gil JA: Management of partial fingertip amputation in adults: operative and nonoperative treatment, Injury 48(12):2643, 2017. Solarz MK, Thoder JJ, Rehman S: Management of major traumatic upper extremity amputations, Orthop Clin North Am 47(1):127, 2016. Tatebe M, Urata S, Tanaka K, et al.: Survival rate of limb replantation in different age groups, J Hand Microsurg 9(2):92, 2017. Tessler O, Bartow, Tremblay-Champagne NP, et  al.: Long-term healthrelated quality of life outcomes in digital replantation versus revision amputation, J Reconstr Microsurg 33(6):446, 2017. Tosti R, Eberlin KR: Damage control hand surgery: evaluation and emergency management of the mangled hand, Hand Clin 34(1):17, 2018. Usama S, Kawahara S, Yamaguchi T, Hirase Y: Homodigital artery flap reconstruction for fingertip amputation: a comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap, J Hand Surg Eur 40:291, 2015. Wilkens SC, Claessen FM, Ogink PT, et  al.: Reoperation after combined injury of the index finger: repair versus immediate amputation, J Hand Surg Am 41(3):436, 2016. Yorlets RR, Busa K, Eberlin KR, et al.: Fingertip injuries in children: epidemiology, financial burden, and implications for prevention, Hand (NY) 12(4):342, 2017. Zhu X, Zhu H, Zhang C, Zheng X: Preoperative predictive factors for the survival of replanted digits, Int Orthop 41(8):1623, 2017.

The complete list of references is available online at Expert Consult.com.

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SUPPLEMENTAL REFERENCES Al-Qattan MM: De-epithelialized cross-finger flaps versus adipofascial turnover flaps for the reconstruction of small complex dorsal digital defects: a comparative analysis, J Hand Surg 30A:549, 2005. Aliu O, Netscher DT, Stains KB, et al.: 5-Year interval evaluation of function after pollicisation for congenital thumb aplasia using multiple outcome measures, Plast Reconstr Surg 122:198, 2008. Arata J, Ishikawa K, Soeda H, et al.: The palmar pocket method: an adjunct to the management of zone I and II fingertip amputations, J Hand Surg 26:945, 2001. Atasoy E: The cross thumb to index finger pedicle, J Hand Surg 5:572, 1980. Atasoy E, Ioakimidis E, Kasdan ML, et al.: Reconstruction of the amputated fingertip with a triangular volar flap: a new surgical procedure, J Bone Joint Surg 52A:921, 1970. Belcher HJ, Pandya AN: Centro-central union for the prevention of neuroma formation after finger amputation, J Hand Surg 25:154, 2000. Buck-Gramcko D: Pollicization of the index finger: method and results in aplasia and hypoplasia of the thumb, J Bone Joint Surg 53A:1605, 1971. Chang KD, Wang WH, Lai CS, et al.: Refinement of reverse digital arterial flap for finger defects: surgical technique, J Hand Surg 30A:558, 2005. Cook FW, Jakab E, Pollock MA: Local neurovascular island flap, J Hand Surg 15A:798, 1990. Finsen V, Russwurm H: Metacarpal lengthening after traumatic amputation of the thumb, J Bone Joint Surg 78B:133, 1996. Fisher RH: The Kutler method of repair of finger-tip amputation, J Bone Joint Surg 49A:317, 1967. Foucher G, Medina J, Lorea P, Pivato G: Principalization of pollicisation of the index finger in congenital absence of the thumb, Tech Hand Up Extrem Surg 9:96, 2005. Gilles HD, Millard R: The Principles and Art of Plastic Surgery, London, Butterworths, 1957, pp. 486-487. Goitz RJ, Westkaemper JG, Tomaino MM, et  al.: Soft-tissue defects of the digits: coverage considerations, Hand Clin 13:189, 1997. Hallock G: The simple cross-flap, technique and vascular anatomy, Orthop Rev 13:75, 1984. Heitmann C, Levin LS: Distraction lengthening of thumb metacarpal, J Hand Surg 29B:71, 2004. Henry M, Stutz C: Homodigital antegrade-flow neurovascular pedicle flaps for sensate reconstruction of fingertip amputation injuries, J Hand Surg 31A:1220, 2006. Houshian S, Ipsen T: Metacarpal and phalangeal lengthening by callus distraction, J Hand Surg 26B:13, 2001. Kay S, Werntz J, Wolff TW: Ring avulsion injuries: classification and prognosis, J Hand Surg [Am] 14(2 Pt 1):204, 1989. Keiter JE: Immediate pollicization of an amputated index finger, J Hand Surg 5:584, 1980. Krukenberg H: Über plastischen Umwertung von Amputationsstumpen, Stuttgart, 1917, Ferdinand Enk. Kutler W: A new method for fingertip amputation, JAMA 133:29, 1947. Laoulakos DH, Tsetsonis CH, Michail AA, et al.: The dorsal reverse adipofascial flap for fingertip reconstruction, Plast Reconstr Surg 114:1678, 2004. Lister G: The choice of procedure following thumb amputation, Clin Orthop Relat Res 195:45, 1985.

Littler JW: Subtotal reconstruction of thumb, Plast Reconstr Surg 10:215, 1952. Littler JW: Digital transposition. In Adams JP, editor: Current practice in orthopaedic surgery, (vol 3). St. Louis, 1966, CV Mosby. Littler JW: On making a thumb: one hundred years of surgical effort, J Hand Surg 1:35, 1976. Lobay GW, Moysa GL: Primary neurovascular bundle transfer in the management of avulsed thumbs, J Hand Surg 6:31, 1981. Lyall H, Elliot D: Total middle ray amputation, J Hand Surg 21B:675, 1996. Ma FY, Cheng CY, Chen Y, et  al.: Fingertip injuries: a prospective study on seven methods of treatment on 200 cases, Ann Acad Med Singapore 11:207, 1982. Moschella F, Cordova A: Reverse homodigital dorsal radial flap of the thumb, Plast Reconstr Surg 117:920, 2006. Murray JF, Carman W, MacKenzie JK: Transmetacarpal amputation of the index finger: a clinical assessment of hand strength and complications, J Hand Surg 2:471, 1977. Nuzumlali E, Orhun E, Ozturk K, et al.: Results of ray resection and amputation for ring avulsion injuries at the proximal interphalangeal joint, J Hand Surg 28:578, 2003. Omokawa S, Yajima H, Inada Y, et al.: A reverse ulnar hypothenar flap for finger reconstruction, Plast Reconstr Surg 106:828, 2000. Peacock Jr EE: Metacarpal transfer following amputation of a central digit, Plast Reconstr Surg 29:345, 1962. Peimer CA, Wheeler DR, Barrett A, et al.: Hand function following single ray amputation, J Hand Surg 24A:1245, 1999. Posner MA: Ray transposition for central digital loss, J Hand Surg 4:242, 1979. Rose EH, Norris NS, Kowalski TA, et al.: The “cap” technique: nonmicrosurgical reattachment of fingertip amputations, J Hand Surg 14:513, 1989. Rybka FJ, Pratt FE: Thumb reconstruction with a sensory flap from the dorsum of the index finger, Plast Reconstr Surg 64:141, 1979. Shibu MM, Tarabe MA, Graham K, et  al.: Fingertip reconstruction with a dorsal island homodigital flap, Br J Plast Surg 50:121, 1997. Stern PJ, Lister GD: Pollicization after traumatic amputation of the thumb, Clin Orthop Relat Res 155:85, 1981. Swanson AB: The Krukenberg procedure in the juvenile amputee, J Bone Joint Surg 46A:1540, 1964. Takeishi M, Shinoda A, Sugiyama A, Ui K: Innervated reverse dorsal digital island flap for fingertip reconstruction, J Hand Surg 31A:1094, 2006. Toh S, Narita S, Arai K, et al.: Distraction lengthening by callostasis in the hand, J Bone Joint Surg 84B:205, 2002. Tsai TM, Yuen JC: A neurovascular island flap for volar-oblique fingertip amputations, J Hand Surg 21B:94, 1996. Varitimidis SE, Dailiana ZH, Zibis AH, et  al.: Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip, J Hand Surg 30B:338, 2005. Verdan C: The reconstruction of the thumb, Surg Clin North Am 48:1033, 1968. Wilson ADH, Stone C: Reverse digital artery island flap in the elderly, Injury 35:507, 2004. Winspur I: Single-stage reconstruction of the subtotally amputated thumb: a synchronous neurovascular flap and Z-plasty, J Hand Surg 6A:70, 1981.

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20

GENERAL PRINCIPLES OF INFECTION Kevin B. Cleveland

ETIOLOGY Patient-dependent factors Nutritional status Glucose Rheumatoid arthritis Immunologic status Surgeon-dependent factors Skin preparation

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Operating room environment Prophylactic antibiotic therapy DIAGNOSIS Laboratory studies Imaging studies Culture studies TREATMENT

ETIOLOGY Bone and joint infections pose a formidable challenge to the orthopaedic surgeon. The high success rate obtained with antibiotic therapy in most bacterial diseases has not been obtained in bone and joint infections because of the physiologic and anatomic characteristics of bone. Approximately 80 million surgical cases are performed in the United States yearly, and with the rise in aging population, this will most likely increase. The overall surgical site infection (SSI) rate has been estimated by the U.S. Centers for Disease Control and Prevention (CDC) to be 2.8% in the United States. Approximately 300,000 SSIs occur each year in the United States, with affected patients requiring 6.5 more hospital days on average, which increases the cost of surgery two to five times. Although bacteremia is common (estimated to occur 25% of the time after simple tooth brushings), other etiologic factors must be present for an infection to occur. The mere presence of bacteria in bone, whether from bacteremia or from direct inoculation is insufficient to produce osteomyelitis. Illness, malnutrition, and inadequacy of the immune system can contribute to bone and joint infections. As in other parts of the body, bones and joints produce inflammatory and immune responses to infection. Osteomyelitis occurs when an adequate number of a sufficiently virulent organism overcomes the host’s natural defenses (inflammatory and immune responses) and establishes a focus of infection. Local skeletal factors also play a role in the development of infection. For example, the relative absence of phagocytic cells in the metaphysis of bones in children may explain why acute hematogenous osteomyelitis is more common in this location. The peculiarity of an abscess in bone is that it is contained within a firm structure with little chance of tissue expansion. As infection progresses, purulent material works its way through the Haversian system and Volkmann canals and lifts the periosteum off the surface of bone. The combination of pus in the medullary cavity and in the subperiosteal space causes necrosis of cortical bone. This necrotic cortical bone, known as a sequestrum, can continue to harbor bacteria despite antibiotic treatment. Antibiotics and inflammatory cells cannot adequately access this avascular area, resulting in failure of medical treatment of osteomyelitis.

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HUMAN IMMUNODEFICIENCY VIRUS AND HEPATITIS B 806 AND C 807 Diagnostic tests 807 Confirmatory tests Musculoskeletal syndromes in human immunodeficiency 807 virus–infected patients Risks and prevention 808

Recognizing these unique characteristics of bone infections, the best course of action is prevention. The orthopaedic surgeon should evaluate the risk of infection in each patient by considering patient-dependent and surgeon-dependent factors. Patient-dependent factors include nutrition, immunologic status, alcohol abuse, smoking, infection at a remote site, congestive heart failure, depression, and other comorbidities (Table 20.1). Surgeon-dependent factors include prophylactic antibiotics, skin and wound care, operating environment, surgical technique, and treatment of impending infections, such as in open fractures. Duration of hospital stay also has been directly correlated with an increased risk of SSI. Simply stated, it is much easier to prevent an infection than it is to treat it.

PATIENT-DEPENDENT FACTORS

It has been discovered that up to 80% of patients have at least one modifiable risk factor that, if corrected, could decrease the risk of SSI. Alcohol abuse, for instance, doubles the risk, and tobacco use more than triples the risk for infection. These substances should be discontinued 1 month before surgery is recommended. Intra-articular injections also should be discontinued 3 to 6 months before elective surgery, and any poor dentition issues should be treated.

NUTRITIONAL STATUS

A patient’s nutritional status and immunologic response are important. A body mass index greater than 40 is associated with an eight times greater risk for SSI. Despite their appearance, obese patients are frequently malnourished. In fact, over half of patients are noted to be malnourished. If a patient is malnourished or immunocompromised and cannot mount a response to an infection, the effects of any treatment are diminished. Malnutrition adversely affects humoral and cell-mediated immunity, impairs neutrophil chemotaxis, diminishes bacterial clearance, and depresses neutrophil bactericidal function, the delivery of inflammatory cells to infectious foci, and serum complement components. Basal energy requirements of a traumatized or infected patient increase from 30% to 55% of normal. Fever of just 1°F above normal increases the body’s metabolic rate by 13%. Nutritional status can be determined preoperatively by (1) anthropometric measurements (height, weight, triceps

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CHAPTER 20  GENERAL PRINCIPLES OF INFECTION

TABLE. 20.1

Summary of Risk Factors Associated With Development of Surgical Joint Infection/Prosthetic Joint Infection NONMODIFIABLE HOST FACTORS Age (≥75 years)—moderate Male sex—strong Black race—strong TKA vs. THA—strong

MODIFIABLE HOST FACTORS BMI—strong Smoking—strong High alcohol intake (alcohol abuse)—strong Low income—strong Malnutrition (low serum albumin)—strong History of DM—strong History of CVD—moderate History of CHF—strong History of cardiac arrhythmia—strong History of peripheral vascular disease—strong Chronic pulmonary disease—strong Chronic obstructive pulmonary disease History of renal disease—strong History of liver disease/cirrhosis—strong History of RA—strong History of cancer/malignancy—strong History of osteonecrosis—strong History of depression—strong History of psychosis—strong History of HIV/AIDS—strong Neurologic disease (hemiplegia, paraplegia)—moderate History of corticosteroid administration—strong History of intra-articular corticosteroid injection—moderate Previous joint surgery—strong Revision arthroplasty—strong Previous joint infection—moderate Frailty—moderate Preoperative anemia—strong American Society of Anesthesiologists grade >2—strong Charlson comorbidity index (high)—strong Preoperative hyperglycemia and high HbA1c—moderate Allogenic blood transfusion—strong Prophylaxis with warfarin or low-molecular weight heparin—moderate

FACTORS WITH LIMITED EVIDENCE OF ASSOCIATIONS WITH SSI/PJI Age—(as a continuous exposure)—limited Hispanic ethnicity—limited Native American and Eskimo ethnicity—limited Asian race—limited History of drug abuse—limited Rural location vs. nonrural location—limited Underweight—limited History of hypertension—limited History of osteoarthritis—limited History of posttraumatic arthritis—limited Low- or high-risk dental procedures—limited History of urinary tract infection—limited History of dementia—limited Hypercholesterolemia—limited Peptic ulcer disease—limited Valvular disease—limited Metastatic tumor—limited History of coagulopathy—limited History of venous thromboembolism—limited Pulmonary circulatory disorders—limited Hypothyroidism—limited Hepatitis (B or C)—limited Electrolyte imbalance—limited Autogenous blood transfusion—limited

BMI, Body mass index; CHF, congestive heart failure; CVD, cardiovascular disease; DM, diabetes mellitus; PJI, periprosthetic joint infection; RA, rheumatoid arthritis; SSI, surgical site infection; THA, total hip arthroplasty; TKA, total knee arthroplasty. From Zainul-Abidin S, Amanatullah DF, Anderson MB, et al: General assembly, prevention, host related general: proceedings of international consensus on orthopedic infections, J Arthroplasty 34(2S):S13–S35, 2019.

skinfold thickness, and arm muscle circumference), (2) measurement of serum proteins or cell types (lymphocytes), and (3) antibody reaction to certain antigens in skin testing. Nutritional support is recommended before elective surgery for patients with recent weight losses of more than 10 lb, serum albumin levels less than 3.5 g/dL, or lymphocyte counts of less than 1500 cells/mm3, which can be obtained

from a routine complete blood cell count and BMP-24. With the use of serum albumin and transferrin levels, the formula that follows can be used to screen for patients who may need nutritional support: [(1.2 × serum albumin) + (0.013 × serum transferrin)] − 6.43. If the sum is 0 or a negative number, the patient is nutritionally depleted and is at high risk for sepsis. If nutritional support is needed, enteral therapy should

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PART VII  INFECTIONS always be used when the gastrointestinal tract is functional; if not, hyperalimentation must be employed. Vitamin D deficiency also has been linked to an increase in SSIs. Vitamin D levels should be obtained preoperatively, and any deficiencies corrected at that time.

GLUCOSE

Glycemic control is a patient modifiable risk factor that can lead to a decrease in SSI. The optimal hemoglobin A1c (HbA1c) has yet to be determined. Some advocate 7%, whereas others believe 8% is the correct value for risk stratification. Fructosamine levels have been utilized to detect hyperglycemia especially in the 2 to 3 week period before surgery. A level greater than 292 mmol/L has been shown to be a better indicator of deep infection than HbA1c (>7%). Most agree that hyperglycemia, even in nondiabetic patients, is a risk factor for developing SSI. A glucose level greater than 200 mg/dL requires treatment before elective surgery. 

RHEUMATOID ARTHRITIS

The incidence of periprosthetic joint infection (PJI) is 1.6 times higher in patients with rheumatoid arthritis than with osteoarthritis. Most believe that this is associated with their use of disease-modifying antirheumatic drugs. To decrease the incidence of SSI in this population, it is recommended that these medications be discontinued according to their half-life and resumed 2 weeks postoperatively. 

IMMUNOLOGIC STATUS

To fight infection, the patient must mount inflammatory (white blood cell [WBC] count) and immune (antibody) responses that initially stop the spread of infection and then, ideally, destroy the infecting organisms. The body’s main cellular defense mechanisms are (1) neutrophil response, (2) humoral immunity, (3) cell-mediated immunity, and (4) reticuloendothelial cells. A deficiency in production or function of any of these predisposes the host to infection by specific groups of opportunistic pathogens. Deficiencies in the immune system may be acquired or may result from congenital abnormalities. Immunocompromised hosts are not susceptible to all opportunistic pathogens. The susceptibility to a microorganism depends on the specific defect in immunity. Abnormal neutrophils or humoral and cell-mediated immunities have been implicated in infections caused by encapsulated bacteria in infants and elderly patients, in the increased incidence of Pseudomonas infections in heroin addicts, and in Salmonella and Pneumococcus infections in patients with sickle cell anemia. Diabetes, alcoholism, hematologic malignancy, and cytotoxic therapy are common causes of neutrophil abnormalities. If the neutrophil count decreases to less than 55/mm3, infections caused by Staphylococcus aureus, gram-negative bacilli, Aspergillus organisms, and Candida organisms become a major threat. Immunoglobulins and complement factors are two plasma proteins that play crucial roles in humoral immunity. Patients with hypogammaglobulinemia or who have had a splenectomy are at increased risk of infection caused by encapsulated bacteria, such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria organisms. When a defect in a component of the complement cascade is present, S. aureus and gram-negative bacillus infections are

common. Septic arthritis caused by unusual organisms such as Mycoplasma pneumoniae and Ureaplasma urealyticum has been reported and should be suspected in patients with hypogammaglobulinemia and culture-negative septic arthritis. Cell-mediated immunity depends on an interaction between T lymphocytes and macrophages. Primary cellmediated deficiencies are rare, but secondary cell-mediated deficiencies are common. Corticosteroid therapy, malnutrition, lymphoma, systemic lupus erythematosus, immunodeficiency in elderly patients, and autoimmune deficiency syndrome all can cause a secondary cell-mediated deficiency, which predisposes the host to fungal and mycobacterial infections as well as infection with herpes virus and Pneumocystis jiroveci. Vaccinations also play a role in host response. The hepatitis B vaccine has dramatically reduced the incidence of hepatitis B virus (HBV), and the H. influenzae type B vaccine, that is given to children, has all but eliminated musculoskeletal infections caused by H. influenzae. 

SURGEON-DEPENDENT FACTORS SKIN PREPARATION

Wound contamination exists whenever the skin barrier is broken, but proper skin preparation decreases the contamination caused by bacteria present on the skin. Skin barriers also may decrease skin contamination during surgery. Although the skin can never be disinfected completely, the number of bacteria present can be reduced markedly before surgery. The skin and hair can be sterilized with alcohol, iodine, hexachlorophene, or chlorhexidine, but it is almost impossible to sterilize the hair follicles and sebaceous glands where bacteria normally reside and reproduce. Skin preparations have a limited effect on sebaceous glands and hair follicles because they do not penetrate an oily environment. Disinfectants that penetrate the oily environment are absorbed by the body and have potentially toxic side effects. Hexachlorophene has better penetration but also has neurotoxic side effects. Very few level I evidence-based studies discuss if preoperative skin antiseptics actually decrease SSI and, if so, the correct method of cleansing. Most agree that the patient should bathe the night before surgery with soap and water. Some advocate adding chlorhexidine wipes. A Cochrane Library systematic review concluded that 4% chlorhexidine in 70% alcohol had the most favorable results in reducing SSI. Most agree that some form of alcohol needs to be employed with whatever skin preparation is used, whether it be chlorhexidine or iodophor. We agree with the CDC guidelines for skin preparation with slight modifications: 1. The size of the area being prepared should be enough to include any additional exposure that may be required. 2. The solution should be applied in concentric circles from the incision site peripherally. 3. A dedicated instrument may be utilized that is removed from the operative field after preparation and before draping (i.e., sponge clamp). 4. Time should be allowed for the alcohol to dry because a fire risk exists. Hand washing is the single-most important procedure for prevention of nosocomial infections and should be performed before and after each patient encounter. Studies suggest that hand scrubbing for 2 minutes is as effective as traditional hand scrubbing for 5 minutes. The optimal duration of hand scrubbing has yet to be determined. Hand rubbing with an aqueous

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TABLE. 20.2

Antimicrobial Activity* and Summary of Properties of Antiseptics Used in Hand Hygiene ANTISEPTICS Alcohols Chloroxylenol Chlorhexidine Hexachlorophene† Iodophors Triclosan¶ Quaternary ammonium compounds§ ANTISEPTICS Alcohols Chloroxylenol Chlorhexidine Hexachlorophene† Iodophors Triclosan|| Quaternary ammonium compounds§

GRAM-POSITIVE BACTERIA +++ +++ +++ +++ +++ +++ ++

GRAM-NEGATIVE BACTERIA +++ + ++ + +++ ++ +

TYPICAL CONC. IN% 60%–70% 0.5%–4% 0.5%–4% 3% 0.5%–10% 0.1%–2%

VIRUSES ENVELOPED +++ + ++ ? ++ ? +

SPEED OF ACTION Fast Slow Intermediate Slow Intermediate Intermediate Slow

VIRUSES NONENVELOPED MYCOBACTERIA ++ +++ ± + + + ? + ++ ++ ? ± ? ± RESIDUAL ACTIVITY No Contradictory Yes Yes Contradictory Yes No

FUNGI +++ + + + ++ ±¶ ±

SPORES − − − − ±‡ − −

USE HR HW HR/HW HW, but not recommended HW HW; seldom HR, HW; Seldom; +alcohols

Good = +++, moderate = ++, poor = +, variable = ±, none = − *Activity varies with concentration. †Bacteriostatic. ‡In concentrations used in antiseptics, iodophors are not sporicidal. ||Mostly bacteriostatic. ¶Activity against Candida spp., but little activity against filamentous fungi. §Bacteriostatic, fungistatic, microbicidal at high concentrations. HR, Hand rubbing; HW, hand washing. From Pittet D, Allegranzi B, Boyce J, et al: The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infec Control Hosp Epidemiol 30:611–622, 2009.

alcohol solution that is preceded by a 1-minute nonantiseptic hand washing for the first case of the day was found by Parienti et al. to be just as effective in prevention of SSI as traditional hand scrubbing with antiseptic soap. The effectiveness of common antiseptics is summarized in Table 20.2. Hair removal at the operative site is not recommended unless done in the operating room with clippers. Shaving the operative site the night before surgery can cause local trauma that produces a favorable environment for bacterial reproduction. Prevention of infection transmission between the patient and the surgeon also includes proper surgical attire. Edlich et al. showed that a narrow glove gauntlet (cuff) significantly increased the security of the gown-glove interface. The U.S. Food and Drug Administration accepts there is a 2.5% failure rate of new unused sterile gloves. Glove perforation has been reported to occur in up to 48% of operations. Perforations usually occur approximately 40 minutes into the procedure, and as much as 83% of the time the surgeon is unaware of the perforation. Most frequently, the perforation occurs on the index finger of the nondominant hand. Double gloving reduces the exposure rate by as much as 87%. In addition, double gloving decreases the volume of blood on a solid needle (through a wipe-clean pass mechanism from the outer glove)

as much as 95%. A meta-analysis by Tanner and Parkinson found that double gloving decreased skin contamination, and the use of Biogel indicator gloves (Regent Medical, Norcross, GA) increased the awareness of glove perforation. A darker glove should be worn as the indicator glove. When both gloves were compromised, however, the indicator gloves did not increase the awareness of a perforation. As long as the indicator glove was intact, perforation of the outer glove was promptly detected in 90% of cases. Wearing an outer cloth glove over a latex glove significantly reduced the number of perforations to the innermost latex glove. When a liner glove was used between two latex gloves, the perforation rate of the innermost glove decreased. No reduction in perforations was seen when using an outer steel–weave glove. Double gloving does not provide reduction in perforations when tears occur as a result of geometry configurations such as bone or hollow-core needles. At a minimum, surgical gloves should be changed after draping, before handling implants, and then every 2 hours. No level I evidence exists currently that conclusively proves reduction of SSI with the use of surgical mask, caps, shoe covers, cloth versus disposable gowns, or operating room attire worn outside the hospital; however, experience dictates their usefulness. A very large number of patients will be required to sufficiently power future level I studies. 

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OPERATING ROOM ENVIRONMENT

Airborne bacteria are another source of wound contamination in the operating room. These bacteria usually are gram positive and originate almost exclusively from humans in the operating room; 5000 to 55,000 particles are shed per minute by each individual in the operating room. Conventional operating room air may contain 10 to 15 bacteria per cubic foot and 250,000 particles per cubic foot. The number of door openings and surgical personnel has been shown to increase the number of airborne particles and, therefore, should be kept to a minimum. Bouffant style hats allow significantly greater microbial shedding than disposable skull caps and perhaps should be avoided. In past research, airborne bacterial concentrations in the operating room were thought to be reduced by at least 80% with laminar-airflow systems and even more with personnel-isolator systems. Wound contamination rates have been reported to be reduced by 80% with the use of these systems, although an increased infection rate has been reported with the use of horizontal laminar flow after total knee arthroplasty, possibly from deposition of bacteria shed by scrubbed personnel who were not wearing personnel-isolator systems. However, most recent studies have shown that the use of laminar flow does not decrease SSI. At this time, laminar flow is no longer required. Ultraviolet light also has been noted to decrease the incidence of wound infection by reducing the number of airborne bacteria; however, the use of ultraviolet light rooms is not recommended by the Hospital Infection Control Practice Advisory Committee or the CDC because of the increased risk to surgical personnel of exposure to ultraviolet light. It can be employed as a method for terminal cleaning of the unoccupied operating room. No level I evidence exists that forced air warming increases SSI; however, a multicentered pooled data study by Augustine showed a 78% reduction in SSI after discontinuing forced air warming. Normothermia has shown to decrease SSI. Additional evidence exists for changing the scalpel after the first incision, changing the suction tip every hour, avoiding a back-table splash basin (the dirty pond), keeping operative time to less than 2.5 hours to decrease the occurrence of infection. Of note, low-pressure (bulb) lavage has been demonstrated to be equal to high-pressure (pulse) lavage. The addition of antibiotics to the irrigation fluid had no additional benefit and, therefore, is not recommended. Although little has changed in over 50 years in our use of surgical attire and little clinically based evidence exists for scrub masks, head coverings, iodine-impregnated plastic drapes, and many of our “standard sterile techniques,” we believe that the practices listed in Table 20.3 should be adhered to in an effort to minimize the risk of SSI. 

PROPHYLACTIC ANTIBIOTIC THERAPY

Many studies have shown the effectiveness of prophylactic antibiotics in reducing infection rates after orthopaedic procedures. During the first 24 hours, infection depends on the number of bacteria present. During the first 2 hours, the host defense mechanism works to decrease the overall number of bacteria. During the next 4 hours, the number of bacteria remains constant, with the bacteria that are multiplying and the bacteria that are being killed by the host defenses being about equal. These first 6 hours are called the “golden period,” after which the bacteria multiply exponentially. Antibiotics decrease bacterial growth geometrically and delay

the reproduction of the bacteria. The administration of prophylactic antibiotics expands the golden period. A prophylactic antibiotic should be safe, bactericidal, and effective against the most common organisms causing infections in orthopaedic surgery. Because the patient’s skin remains the major source of orthopaedic infection, prophylactic antibiotics should be directed against the organism most commonly found on the skin, which is S. aureus, although the frequency of Staphylococcus epidermidis is increasing. This increase in S. epidermidis is important because this organism has antibiotic resistance and often gives erroneous sensitivity data. Escherichia coli and Proteus organisms also should be covered by antibiotic prophylaxis. In the United States, firstgeneration cephalosporins (cefazolin weight adjusted, but a minimum of 2 g for patients weighing more than 70 kg and 3 g for patients weighing over 120 kg) have been favored for many reasons. They are relatively nontoxic, inexpensive, and effective against most potential pathogens in orthopaedic surgery. Cephalosporins are more effective against S. epidermidis than are semisynthetic penicillins. Clindamycin can be given if a patient has a history of anaphylaxis to penicillin. Routine use of vancomycin for prophylaxis should be avoided. If a patient has risk factors that predisposes to an infection, then weightadjusted vancomycin (15 mg/kg, 1 g over 1 hour to avoid red man syndrome) may be added to the preoperative antibiotic protocol. Antibiotic therapy should begin immediately before surgery (30 to 60 minutes before skin incision). A maximal dose of antibiotic (weight adjusted) should be given and can be repeated every 4 hours intraoperatively or whenever the blood loss exceeds 1000 to 1500 mL. Little is gained by extending antibiotic coverage over 24 hours, and the possibility of side effects, such as thrombophlebitis, allergic reactions, superinfections, or drug fever, is increased. Prophylactic antibiotics should not be extended past 24 hours even if drains and catheters are still in place. The current CDC recommends no additional antibiotics after skin closure. Namias et  al. found that antibiotic coverage for longer than 4 days led to increased bacteremia and intravenous line infections in patients in intensive care units. Evidence now shows that 24 hours of antibiotic administration is just as beneficial as 48 to 72 hours. Currently, antibiotic prophylaxis for patients undergoing colonoscopy, upper gastrointestinal endoscopy, or dental procedures (even in patients with total joint arthroplasty) is not recommended. For current prophylaxis please visit www.orthoguidelines.org/auc. If antibiotics are to be used see Table 20.4 for recommended antibiotics and dosing. Antibiotic irrigation has not found a definite role in orthopaedic surgery. Several studies have shown a decrease in colony counts in wounds and a decrease in infection rates with the use of antibiotic irrigation in general surgical procedures. When a topical antibiotic is used, it should have (1) a wide spectrum of antibacterial activity, (2) the ability to remain in contact with normal tissues without causing significant local irritation, (3) low systemic absorption and toxicity, (4) low allergenicity, (5) minimal potential to induce bacterial resistance, and (6) availability in a topical preparation that can be easily suspended in a physiologic solution. We have employed the recommendations of the CDC as well as the World Health Organization (WHO) in utilizing a dilute (sterile water not tap) povidone-iodine wound soak before closure to decrease SSI. We follow the recommendations of Brown et al., utilizing

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TABLE. 20.3

Methods for Reducing Surgical Site Infection PATIENT FACTORS Diabetes mellitus Rheumatoid arthritis

Obesity (BMI ≥30 kg/m2)

Smoking Carrier screening Oral hygiene

Aggressive glucose control; if HgbA1c >7%, recommend delaying elective surgery DMARDs and methotrexate should NOT be stopped Perioperative steroids are generally not required (stress dose steroids) Balance the risks and benefits of stopping anti-TNF at 3–5 half-lives preoperatively, restarting after wound healing and no evidence of infection Dietician input to encourage weight loss over long period before surgery without rapid weight loss preoperatively Adjust perioperative antibiotic doses appropriately In extremely obese, consider bariatric surgery before surgery Consider a smoking cessation program 4–6 weeks preoperatively MRSA and MSSA screening based on local guidelines, and decolonize before admission which may include mupirocin ointment to the area for 5 days and chlorhexidine betadine for 5 days Complete any dental treatment before elective surgery

PREOPERATIVE FACTORS Patient preparation

Antibiotics

NSAIDs

Shower on day of surgery If shaving required, use electric clippers on day of surgery Avoid oil-based skin moisturizers Prophylactic antibiotics should be given within 1 h before incision and continued for 24 h postoperatively (antibiotic type dependent on local guidelines) Administer antibiotics at a minimum of 5 min before tourniquet inflation If cementation is required, should be antibiotic-impregnated Those with short half-lives (including ibuprofen) stop a minimum of 48 h prior; those with long half-lives (naproxen) stop within 3–7 days prior

PERIOPERATIVE FACTORS Theater Personnel

Skin preparation Anesthetic

Drapes Blood transfusion

Keep theater door opening to a minimum Hand wash with antiseptic surgical solution, using a single-use brush or pic for the nails Before subsequent operations hands should be washed with either an alcoholic hand rub or an antiseptic surgical solution Double glove and change gloves regularly minimum at 2 h; change outer gloves when draping Use an alcohol prewash followed by a 2% chlorhexidine-alcohol scrub solution Maintain normothermia Maintain normovolemia A higher inspired oxygen concentration perioperatively and for 6 h postoperative may be of benefit Use of iodine-impregnated incise drapes may be of benefit (in patients without allergy) Optimize preoperative hemoglobin If possible, transfusion should be avoided intraoperatively and, if anticipated, should be given more than 48 h before surgery Antifibrinolytics may indirectly reduce SSI by reducing the need for transfusion

POSTOPERATIVE FACTORS Dental procedures

Insufficient evidence to recommend the use of prophylactic antibiotics for patients undergoing routine dental procedures following joint replacement

BMI, Body mass index; DMARDs, disease-modifying antirheumatic drugs; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-sensitive S. aureus; NSAIDs, nonsteroidal antiinflammatory drugs; SSI, surgical site infection; TNF, tumor necrosis factor. Modified from Johnson R, Jameson SS, Sanders RD, et al: Reducing surgical site infection in arthroplasty of the lower limb. A multi-disciplinary approach, Bone Joint Res 2(3):58–65, 2013.

17.5 mL of 10% povidone-iodine in 500 to 1000 mL sterile normal saline irrigation of the wound for 3 minutes. The wound is then irrigated with normal saline. This has led to a decrease in SSI from 0.97% to 0.15%. Although the numbers may appear small, the overall increase in surgeries (by 2030: TKA increase 673% and THA increase by 174%) will significantly reduce infections in individual patients. This solution should be avoided in patients who are allergic to iodine or

when cartilage-sparing procedures are performed (i.e., unicompartmental knee replacements). In addition, when liposomal bupivacaine is used, the povidone-iodine solution should be applied before the bupivacaine because it is toxic to liposomes. We no longer routinely add antibiotics to our irrigation solutions. The use of powdered vancomycin sprinkled locally into the wound remains controversial. Hydrogen peroxide also is no longer recommended for wound irrigation because

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TABLE. 20.4

Appropriate Prophylactic Antibiotics and Dosages SITUATION

AGENT

Oral Unable to take oral medication

Amoxicillin Ampicillin or ceftriaxone

Allergic to oral penicillins or ampicillin Allergic to penicillins or ampicillin and unable to take oral medication

Cephalexin†,‡ or azithromycin or clarithromycin Ceftriaxone,‡ azithromycin, clarithromycin

REGIMEN—SINGLE DOSE 30–60 MIN BEFORE DENTAL ­PROCEDURES Adults Children 2g 50 mg/kg 2 g IM or IV* 50 mg/kg IM or IV 1 g IM or IV 50 mg/kg IM or IV 2g 50 m/kg 500 mg 15 mg/kg 1 g IM or IV 50 mg/kg IM or IV Equivalent dose 500 mg IV Equivalent dose

*Intramuscular injections should be avoided in persons receiving anticoagulants. †Or other first-or second-generation oral cephalosporin in equivalent adult or pediatric dosage. ‡Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin. From, American Academy of Orthopaedic Surgeons Board of Directors and the American Dental Association Council on Scientific Affaris: Appropriate use criteria for the management of patients with orthopaedic implants undergoing dental procedures, 2016.

of its associated cytotoxicity, impaired wound healing, and oxygen embolic phenomenon. The importance of irrigation and debridement in the treatment of open fractures has been well documented. The principles of elimination of devitalized tissue and dead space, evacuation of hematomas, and soft-tissue coverage also can be applied to “clean” orthopaedic cases.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

The evolution of S. aureus into a multiple-drug–resistant pathogen, methicillin-resistant S. aureus (MRSA), has become a major health concern worldwide. Approximately 57% of S. aureus bacteria are methicillin resistant, and now vancomycin-resistant strains are being reported. This is probably one of the most worrisome problems in the fight against bacterial infections. Initially, MRSA was seen only in hospital settings and long-term care facilities; however, it is now becoming increasingly prevalent in young, healthy individuals in the community (Table 20.5; At-Risk Groups). It has been estimated that 4% of the population in the United States are carriers of MRSA. It is particularly virulent, with a mortality rate of approximately 20%. S. aureus infection in orthopaedic hospitalized patients generally is around 3%; however, over half of these patients have MRSA. Osteomyelitis caused by MRSA is an infrequent presentation, but treatment can be especially troublesome, and reports of subperiosteal abscess and necrotizing fasciitis also are increasing. Estimates of MRSA infection after total joint replacement range from 1% to 4%, and infection can occur up to 12 years after surgery. Kim et  al. prospectively studied the feasibility of bacterial prescreening before elective orthopaedic surgery. They found that 22.6% of 7019 patients were S. aureus carriers and 4.4% were MRSA carriers. MRSA carriers had a statistically significantly higher rate of SSIs than methicillin-sensitive S. aureus (MSSA) carriers (0.97% compared with 0.14%; P = 0.0162). Although not statistically significant, MSSA carriers, approximately 30% of the United States population, also had higher rates of SSIs. After screening was initiated, the institutional infection rate dropped from 0.45% to 0.19% (P



TABLE. 20.5

At-Risk Groups and Risk Factors for CommunityAcquired Methicillin-Resistant Staphylococcus aureus AT-RISK GROUPS Athletes in contact sports Children in day care Homeless persons Intravenous drug users Homosexual males Military recruits Alaskan natives, Native Americans, and Pacific Islanders Prison inmates

RISK FACTORS Antibiotic use within the preceding year Close, crowded living conditions Compromised skin integrity Contaminated surfaces Frequent skin-to-skin contact Shared items Suboptimal cleanliness

From Marcotte AL, Trzeciak MA: Community-acquired methicillin-resistant Staphylococcus aureus: an emerging pathogen in orthopaedics, J Am Acad Orthop Surg 16:98–106, 2008.

= 0.0093). The cost-effectiveness of such screening programs has not been determined, although with the increasing prevalence of MRSA, these costs may be justified. Approximately 3% of MRSA outbreaks have been attributed to asymptomatic colonized health care workers. Schwarzkopf et  al. prospectively studied the prevalence of S. aureus colonization in orthopaedic surgeons and their patients and found that among surgeons and residents there was a higher prevalence of MRSA compared with a high-risk group of patients. Junior residents had the same prevalence of MRSA colonization as institutionalized patients, most likely because of the substantial time spent in direct patient care. These researchers recommended hand hygiene for the prevention of MRSA. In addition, universal decolonization of patients with mupirocin was recommended before total joint and spine surgeries, although further study of this practice is indicated. Skramm et  al. proved that the S. aureus colonies that were isolated from operating personnel were indeed the

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CHAPTER 20  GENERAL PRINCIPLES OF INFECTION same strain found at the SSI up to 85% of the time. No true proof exists that decolonization of MRSA carriers decreases SSI incidence. There is no definitive recommendation on screening and preoperative treatment of MRSA carriers. However, some advocate povidone-iodine nasal ointment, which would also ease fears of emerging resistance to mupirocin use. Because of the prevalence of community-acquired (CA)MRSA, it is necessary to rapidly identify the organism, determine antibiotic sensitivity, and begin antibiotic therapy (for empirical coverage see Table 22.3). Polymerase chain reaction (PCR) can be used to detect Staphylococcus with results within 24 hours as opposed to conventional cultures that can take 3 days before results are available. Vancomycin or teicoplanin should be considered in patients with colonization of MRSA or when screening results before surgery are not available. For invasive infections, intravenous vancomycin is recommended or, alternatively, daptomycin, gentamicin, rifampin, and linezolid can be used. In cases of necrotizing fasciitis, clindamycin, gentamicin, rifampin, trimethoprimsulfamethoxazole, and vancomycin are effective. Rifampin should never be used alone as the single antibiotic. Until a sensitivity determination can be made, antimicrobial coverage specifically of CA-MRSA is recommended. For deep subperiosteal abscesses or superficial abscesses, irrigation and debridement are necessary to reduce bacterial counts. Overuse of quinolones may be driving the selection of MRSA over MSSA and should be avoided. Obtaining an infectious disease consult is highly recommended. In summary, despite few direct evidence-based studies, best current efforts at controlling SSI are described in Table 20.3. 

DIAGNOSIS The diagnosis of infection may be obvious or obscure. Signs and symptoms vary with the rate and extent of bone and joint involvement. Characteristic features of fever, chills, nausea, vomiting, malaise, erythema, swelling, and tenderness may or may not be present. The classic triad is fever, swelling, and tenderness (pain). Pain probably is the most common symptom. Fever is not always a consistent finding. Infection may also be as indolent as a progressive backache or a decrease in or loss of function of an extremity. No single test is able to serve as a definitive indicator of the presence of musculoskeletal infection.

LABORATORY STUDIES

normal approximately 3 weeks after treatment is begun. The ESR should very rarely be used alone in diagnosing infection. CRP synthesized by the liver in response to infection, is a better way to follow the response of infection to treatment. CRP increases within 6 hours of infection, reaches a peak elevation 2 days after infection, and returns to normal within 1 week after adequate treatment has begun. CRP can be misleading, however, in patients with chronic inflammatory conditions, neoplasms, and metabolic disease. D-dimer has been shown to better evaluate a patient for infection than ESR or CRP, with a specificity of 93% and a sensitivity of 89%. D-dimer can return to normal levels after 2 days postoperatively. However, if an infection exists it usually re-spikes at 2 weeks. Interleukin-6 (IL-6) also is a useful marker for infection. It provides a rapid diagnosis and returns to normal level 3 days after surgery. Alpha-defensin is another effective marker for infection. It is unaffected by antibiotic treatment, but it is expensive and has a high false-positive rate. Leukocyte esterase also has been employed as a marker for infection. It is inexpensive and can be measured quickly. Other tests, such as the S. aureus surface antigen or antibody test and counterimmunofluorescence studies of the urine, are promising, but their usefulness in clinical situations has not been proved. Material obtained from aspiration of joint fluid can be sent to the laboratory for a cell count and differential to distinguish acute septic arthritis from other causes of arthritis. In septic arthritis, the cell count usually is greater than 80,000/mm3, with more than 75% of the cells being neutrophils (Table 20.6). A Gram stain also should be obtained. Gram stains identify the types of organisms (gram-positive or gram-negative) in about a third of bone and joint aspirates. However, intraoperative Gram stain is not recommended in the face of PJI because it is unreliable. Intraoperative frozen sections also should be obtained in cases in which infection is suspected. A WBC count greater than 10 per high-power field is considered indicative of infection, whereas a count less than five per high-power field all but excludes infection. Combining these test results in a higher sensitivity and specificity. The future of serum biomarkers most likely lies with using genomics and proteomics to identify proteins associated with infections. 

IMAGING STUDIES

Radiographic studies are helpful but are not as useful in the diagnosis of acute bone and joint infections as they are in

A complete blood cell count, including differential and erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), should be obtained during initial evaluation of bone and joint infections. The WBC count is an unreliable indicator of infection and often is normal, even when infection is present. The differential shows an increase in neutrophils during acute infections. The ESR becomes elevated when infection is present, but this does not occur exclusively in the presence of infection. Fractures or other underlying diseases can cause elevation of the ESR. The ESR also is unreliable in neonates, patients with sickle cell disease, patients taking corticosteroids, and patients whose symptoms have been present for less than 48 hours. Peak elevation of the ESR occurs at 3 to 5 days after infection and returns to

TABLE. 20.6

Synovial Fluid Analysis Normal Traumatic Toxic synovitis Acute rheumatic fever Juvenile rheumatoid arthritis Septic arthritis

LEUKOCYTES 90 degrees). Arthrodesis of the shoulder may be indicated when the paralysis around the joint is extensive, provided that power in at least the serratus anterior and the trapezius is fair or better.

TENDON AND MUSCLE TRANSFERS FOR PARALYSIS OF THE DELTOID

Transfer of the insertion of the trapezius is the most satisfactory operation for complete paralysis of the deltoid. Resecting a part of the spine of the scapula and including it in the transfer permits fixation of the transfer with screws after the muscle is pulled like a hood over the head of the humerus (Fig. 34.20). In a technique modification, the superior and middle trapezius is completely mobilized laterally from its origin and the transfer is made 5 cm longer without endangering

its nerve or blood supply; this added length greatly increases leverage of the transfer on the humerus. The entire insertion of the trapezius is freed by resecting the lateral clavicle, the acromion, and the adjoining part of the scapular spine; these are anchored to the humerus by screws (Fig. 34.21). Saha developed a functional classification of the muscles around the joint and recommended careful assessment of their strength before surgery. 1.  Prime movers: the deltoid and clavicular head of the pectoralis major, which in lifting exert forces in three directions at the junction of the proximal and middle thirds of the humeral shaft axis. 2.  Steering group: the subscapularis, the supraspinatus, and the infraspinatus. These muscles exert forces at the junction of the axes of the humeral head and neck and humeral shaft. As the arm is elevated, the humeral head, by rolling and gliding movements, constantly changes its point of contact with the glenoid cavity. Although these muscles exert a little force in lifting the arm, their chief function is stabilizing the humeral head as it moves in the glenoid. 3.  Depressor group: the pectoralis major (sternal head), latissimus dorsi, teres major, and teres minor. These muscles are intermediately located and exert their forces on the proximal fourth of the humeral shaft axis. During elevation, they rotate the shaft, and in the last few degrees of this movement, they depress the humeral head. They exert only minimal steering action on the head. Absence of their power would cause no apparent disability except that performance of the limb in lifting weights above the head would be diminished. The classic methods of transferring a single muscle (or even several muscles to a common attachment) to restore abduction of the shoulder do not consider the functions of the steering muscles. When the steering muscles are paralyzed and a single muscle has been transferred to restore functions only of the deltoid, the arm cannot be elevated more than 90 degrees and scapulohumeral motion is significantly disturbed. For paralysis of the deltoid, the entire insertion of the trapezius can be transferred to the humerus to replace the anterior and middle parts of the muscle; however, the subscapularis, the supraspinatus, and the infraspinatus must be carefully evaluated. When any two are paralyzed, their functions also must be restored because otherwise the effectiveness of the transferred trapezius as an elevator of the shoulder would be greatly reduced. As already mentioned, for paralysis of the subscapularis, either the pectoralis minor or the superior two digitations of the serratus anterior can be transferred because either can be rerouted and anchored to the lesser tuberosity; as an alternative procedure, the latissimus dorsi or the teres major can be transferred posteriorly to a point exactly opposite the lesser tuberosity. For paralysis of the supraspinatus, the levator scapulae, sternocleidomastoid, scalenus anterior, scalenus medius, or scalenus capitis can be transferred to the greater tuberosity; of these, the levator scapulae is the best because of the direction and length of its fibers. When suitable transfers are unavailable, the insertion of the trapezius can be anchored more anteriorly or posteriorly on the humerus to restore internal or external rotation. Contractures of unopposed muscles around the shoulder rarely are severe enough to cause extreme disability; most can be corrected at the time of transfer or arthrodesis. 

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CHAPTER 34  PARALYTIC DISORDERS Line of division of deltoid muscle

Deltoid muscle detached

Trapezius muscle freed

A

B

Osteotomy of scapular spine

Lateral 1.2 cm of clavicle resected

Fixation in abduction

C

D

FIGURE 34.20 Bateman trapezius transfer for paralysis of deltoid. A, Skin incision. B, Spine of scapula is osteotomized near its base in obliquely distal and lateral plane. Broken line indicates division of deltoid. C, Atrophic deltoid has been split, deep surface of acromion and spine and corresponding area on lateral aspect of humerus have been roughened, and lateral end of clavicle has been resected. D, Acromion has been anchored to humerus as far distally as possible with two or three screws. SEE TECHNIQUE 34.21.

 

TRAPEZIUS TRANSFER FOR PARALYSIS OF DELTOID TECHNIQUE 34.21 (BATEMAN) With the patient prone, approach the shoulder through a T-shaped incision (Fig. 34.20A); extend the transverse part around the shoulder over the spine of the scapula and the acromion and end it just above the coracoid process; extend the longitudinal limb distally over the lateral aspect of the shoulder and upper arm for 6 cm. n  Mobilize the flaps, split the atrophic deltoid muscle, and expose the joint. n  Free the undersurface of the acromion and spine of the scapula of soft tissue and osteotomize the spine of the scapula near its base in an obliquely distal and lateral plane; thus, a broad cuff of the trapezius is freed but still attached to the spine and the acromion. n  Resect the lateral 2 cm of the clavicle, taking care to avoid damaging the coracoclavicular ligament. n  Roughen the deep surface of the acromion and spine, abduct the arm to 90 degrees, and at the appropriate n 

FIGURE 34.21 Saha trapezius transfer for paralysis of deltoid. Entire insertion of trapezius along with attached lateral end of clavicle, acromioclavicular joint, and acromion and adjoining part of scapular spine have been anchored to lateral aspect of humerus distal to tuberosities by two screws. SEE TECHNIQUE 34.22.

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN level on the lateral aspect of the humerus roughen a corresponding area. n  With firm traction, bring the muscular cuff laterally over the humeral head and anchor the acromion to the humerus as far distally as possible with two or three screws (Fig. 34.20D). Immobilize the arm in a shoulder spica cast with the shoulder abducted to 90 degrees.

POSTOPERATIVE CARE  Immobilization is continued for 8 weeks, but at 4 to 6 weeks the arm and shoulder part of the spica is bivalved to allow some movement. When the transplanted acromion has united with the humerus, the arm is placed on an abduction humeral splint and is gradually lowered to the side and the muscle is reeducated by exercises.    

With the shoulder in neutral rotation and 45 degrees of abduction, anchor the transfer by two screws passed through fragments of bone and into the proximal humerus (Fig. 34.21). n  When suitable transfers are unavailable to replace any paralyzed external or internal rotators, anchor the muscle a little more anteriorly or posteriorly. Transfers for paralysis of the subscapularis, supraspinatus, or infraspinatus are discussed later; when indicated, they should be performed at the time of trapezius transfer. n 

POSTOPERATIVE CARE  A spica cast is applied with the shoulder abducted 45 degrees, neutrally rotated, and flexed in the plane of the scapula. At 10 days, the sutures are removed and radiographs are made to be sure that the humeral head has not become dislocated inferiorly. At 6 to 8 weeks, the cast is removed and active exercises are started.    

 

TRAPEZIUS TRANSFER FOR PARALYSIS OF DELTOID

 

TRANSFER OF DELTOID ORIGIN FOR PARTIAL PARALYSIS

TECHNIQUE 34.22

TECHNIQUE 34.23

(SAHA) Make a saber-cut incision convex medially; begin it anteriorly a little superior to the inferior margin of the anterior axillary fold at about its middle, extend it superiorly, then posteriorly, and finally inferiorly, and end it slightly inferior to the base of the scapular spine and 2.5 cm lateral to the vertebral border of the scapula. n  Mobilize the skin flaps, and expose the trapezius medially to 2.5 cm medial to the vertebral border of the scapula; expose the acromion, the capsule of the acromioclavicular joint, the lateral third of the clavicle, and the entire origin of the paralyzed deltoid muscle. n  Detach and reflect laterally the origin of the deltoid, and locate the anterior border of the trapezius. n  Identify the coronoid ligament, and divide the clavicle just lateral to it. n  Palpate the scapular notch, identify the acromion and the adjoining part of the scapular spine, and with a Gigli saw and beveling posteriorly, resect the spine. n  Elevate the insertion of the trapezius along with the attached lateral end of the clavicle, the acromioclavicular joint, and the acromion and adjoining part of the scapular spine. Then free the trapezius from the superior border of the remaining part of the scapular spine medially to the base of the spine where the inferior fibers of the muscle glide over the triangular area of the scapula. Next free from the investing layer of deep cervical fascia the anterior border of the trapezius, and raise the muscle from its bed for rerouting. n  Denude the inferior surfaces of the bones attached to the freed trapezius insertion; with forceps, break these bones in several places but leave intact the periosteum on their superior surfaces. Denude also the area on the lateral aspect of the proximal humerus selected for attachment of the transfer. n 

(HARMON) Make a U-shaped incision 20 cm long extending from the middle third of the clavicle laterally and posteriorly around the shoulder just distal to the acromion to the middle of the spine of the scapula. n  Raise flaps of skin and subcutaneous tissue proximally and distally. n  Detach subperiosteally from its origin the active posterior part of the deltoid, and free it distally from the deep structures for about one half its length, being careful not to injure the axillary nerve and its branches. n  Expose subperiosteally the lateral third of the clavicle, transfer the muscle flap anteriorly, and anchor it against the clavicle with interrupted nonabsorbable sutures through the adjacent soft tissues (Fig. 34.22). n 

POSTOPERATIVE CARE  A shoulder spica cast is applied, holding the arm abducted 75 degrees. At 3 weeks, part of the cast is removed for massage and active exercise. At 6 weeks, the entire cast is removed and an abduction humeral splint is fitted to be worn for at least 4 months; supervised active exercises are continued during this time.   

TENDON AND MUSCLE TRANSFERS FOR PARALYSIS OF THE SUBSCAPULARIS, SUPRASCAPULARIS, SUPRASPINATUS, OR INFRASPINATUS

When two of these three muscles are paralyzed, their functions must be restored by suitable transfers; this is just as necessary as the trapezius transfer for paralysis of the deltoid. Without the function of these muscles or their substitutes the effectiveness of the transferred trapezius in elevating the

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CHAPTER 34  PARALYTIC DISORDERS  

Clavicle

TRANSFER OF LATISSIMUS DORSI OR TERES MAJOR OR BOTH FOR PARALYSIS OF SUBSCAPULARIS OR INFRASPINATUS

Scapula Atrophied portion of deltoid muscle

Head of humerus dislocated anteriorly

Contracting portion of deltoid muscle

A

Periosteal area of detachment of posterior part of deltoid muscle

Deltoid muscle implant over atrophied portion

TECHNIQUE 34.24 (SAHA) Elevate the arm about 130 degrees. Then make an incision in the posterior axillary fold beginning in the upper arm about 6.5 cm inferior to the crease of the axilla and extending to the inferior angle of the scapula, crossing the crease in a zigzag manner. n  Expose and free the insertion of the latissimus dorsi, and raise the muscle from its bed, taking care to preserve its nerve and blood supply. n  If the transfer is to be reinforced by the teres major, free and raise both muscles. n  Fold the freed insertion on itself and close its margins by interrupted sutures; place in its end a strong mattress suture. n  With a blunt instrument, open the interval between the deltoid and long head of the triceps. n  Identify the tubercle at the inferior end of the greater tuberosity, carry the end of the transfer to this tubercle, and while holding the limb in neutral rotation, anchor the transfer there by interrupted sutures.    n 

Humerus

ARTHRODESIS

B FIGURE 34.22 Harmon transfer of origin of deltoid for partial paralysis. A, Posterior part of deltoid is functioning; middle and anterior parts are paralyzed. B, Transferred posterior part of deltoid is overlying atrophic anterior part. When transfer contracts, it prevents anterior dislocation of shoulder and exerts more direct abduction force than in its previous posterior location. SEE TECHNIQUE 34.23.

shoulder would be markedly reduced. Muscles suitable for transfer are muscles whose distal ends can be carried to the tuberosities of the humerus and whose general directions of pull correspond to those of the muscles they are to replace. The transfers should be rerouted close to the end of the axis of the humeral head and neck, or the desired functions will not be restored. The nerve and blood supply to any transferred muscle must be protected. Currently, the most commonly performed transfers are transfer of the latissimus dorsi or teres major or both and posterior transfer of the pectoralis minor to the scapula. These transfers, when indicated, are done at the same time as the Saha trapezius transfer for paralysis of the deltoid. Consequently, in each instance, the sabercut incision would have been made, the lateral end of the clavicle and the acromion and adjoining part of the scapular spine would have been elevated, and the superior and middle trapezius would have been mobilized as already described. 

When paralysis around the shoulder is extensive, arthrodesis may be the procedure of choice, especially when there is a paralytic dislocation, the muscles of the forearm and hand are functional, and the serratus anterior and trapezius are strong. Motion of the scapula compensates for lack of motion in the joint. Normal function of the forearm and hand is a prerequisite. The position of the shoulder for arthrodesis is similar to that recommended for any shoulder fusion (see Chapter 13). The angle of abduction should be determined on the basis of the clinical presentation of the arm’s position in relation to the body. This angle traditionally is obtained by measuring the angle between the vertebral border of the scapula and the humerus; however, this frequently is difficult to determine on radiographs. The position of the arm in shoulder arthrodesis should be established with the arm at the side of the body, with enough abduction of the arm clinically determined from the side of the body to clear the axilla (15 to 20 degrees) and enough forward flexion (25 to 30 degrees) and internal rotation (40 to 50 degrees) to bring the hand to the midline of the body. An additional 10 degrees of abduction should be obtained in children with poliomyelitis when no internal fixation is used. When both shoulders must be fused, their positions should allow the patient to bring the hands together. A weak or flail shoulder should be fused in only slight abduction. A study of 11 patients (average age, 15 years) with 13 shoulder arthrodesis reported great variability in the position of fusion, but improved function in all patients. The authors concluded that the position of arthrodesis and the resulting

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ELBOW

Most operations for paralysis of the muscles acting across the elbow are designed to restore active flexion or extension of the joint. Operations to correct deformity or operations to stabilize the joint, such as posterior bone block or arthrodesis, rarely are necessary.

MUSCLE AND TENDON TRANSFERS TO RESTORE ELBOW FLEXION

Several methods of restoring active elbow flexion are available. Here, as elsewhere, the actual and the relative power of the remaining muscles must be accurately determined before a transfer procedure is chosen. Also, because the function of the hand is more important than flexion of the elbow, these operations should not be done when the muscles controlling the fingers are paralyzed, unless their function has been or can be restored by tendon transfers. Several methods of restoring elbow flexion have been described: (1) flexorplasty (Steindler), (2) anterior transfer of the triceps tendon (Bunnell and Carroll), (3) transfer of part of the pectoralis major muscle (Clark), (4) transfer of the sternocleidomastoid muscle (Bunnell), (5) transfer of the pectoralis minor muscle (Spira), (6) transfer of the pectoralis major tendon (Brooks and Seddon), and (7) transfer of the latissimus dorsi muscle (Hovnanian). 

 

TECHNIQUE 34.25 (BUNNELL) Make a curved longitudinal incision over the medial side of the elbow, beginning 7.5 cm proximal to the medial epicondyle and extending distally posterior to the medial condyle and thence anteriorly on the volar surface of the forearm along the course of the pronator teres muscle. n  Locate the ulnar nerve posterior to the medial epicondyle, and retract it posteriorly. n  Detach en bloc the common origin of the pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum sublimis, and flexor carpi ulnaris from the medial epicondyle close to the periosteum. Free these muscles distally for 4 cm and prolong the common muscle origin with a free graft of fascia lata. n  Advance this origin 5 cm up the lateral side rather than the medial side of the humerus (Fig. 34.23); this results in a moderate, although not complete, correction of the tendency of the transfer to pronate the forearm. n  Should a pronation deformity persist after this procedure, it can be corrected by transferring the tendon of the flexor carpi ulnaris around the ulnar margin of the forearm into the distal radius. n  Apply a cast with the elbow in acute flexion and the forearm midway between pronation and supination. n 

POSTOPERATIVE CARE  At 2 weeks the cast is replaced by a splint that holds the arm in this same position for at least 6 weeks; physical therapy and active exercises are then started and are gradually increased to strengthen the transferred muscles.    

FLEXORPLASTY Flexorplasty consists of transferring the common origin of the pronator teres, the flexor carpi radialis, the palmaris longus, the flexor digitorum sublimis, and the flexor carpi ulnaris muscles from the medial epicondylar region of the humerus proximally about 5 cm. Its chief disadvantage is the frequent development of a pronation deformity of the forearm. Flexorplasty is indicated when the biceps brachii and brachialis are paralyzed, and the group of muscles arising from the medial epicondyle are fair or better in strength. The best results are obtained when the elbow flexors are only partially paralyzed and the finger and wrist flexors are normal. The strength in active flexion and the range of motion of the elbow after surgery do not compare favorably with that of the normal elbow, but the usefulness of the arm is nonetheless increased. When only the flexor digitorum sublimis is active, the elbow can be flexed only if the fingers are strongly flexed; this interferes with the function of the hand, and another method should be used to restore elbow flexion. Unsuccessful results from this procedure usually are caused by overestimating the strength of the muscles to be transferred. A practical way to test them is to hold the patient’s arm at a right angle to the body, rotate it to eliminate the influence of gravity, and determine whether the muscles to be transferred can flex the elbow in this position; if not, this type of transfer would fail and another should be used.

Humerus

Pronator teres muscle

Pull-out wire

Ulna Flexor carpi ulnaris muscle Flexor digitorum sublimis muscle

FIGURE 34.23 Bunnell modification of Steindler flexorplasty. Common muscle origin is transferred laterally on humerus by means of fascial transplant. SEE TECHNIQUE 34.25.

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CHAPTER 34  PARALYTIC DISORDERS  

POSTOPERATIVE CARE  At 2 weeks the cast is replaced

ANTERIOR TRANSFER OF THE TRICEPS

by a splint that holds the arm in the same position for at least 6 weeks. The pull-out wire is removed at 4 weeks. Physical therapy and active exercises are begun at 6 weeks and are gradually increased.    

Anterior transfer of the triceps tendon can be done to regain active elbow flexion. One disadvantage of this transfer is that the triceps tendon would not reach the tuberosity of the radius; a short graft of fascia or a tendon graft must be used to complete the transfer.  

TECHNIQUE 34.26 (BUNNELL) Through a posterolateral incision expose the triceps tendon, and divide it at its insertion. n  Dissect it from the posterior aspect of the distal fourth of the humerus, and transfer it around the lateral aspect. n  Make an anterolateral curvilinear incision, and retract the brachioradialis and pronator teres muscles to expose the tuberosity of the radius. n  Prolong the triceps tendon by a graft of fascia lata that is 4 cm long and wide enough to make a tube. n  Attach it to the roughened tuberosity of the radius with a steel pull-out suture passed to the dorsum of the forearm via a hole drilled through the tuberosity and the neck of the radius (Fig. 34.24). n  Flex the elbow, gently pull the suture taut to snug the tendon against the bone, and tie the suture over a padded button. n  Apply a cast with the elbow in acute flexion and the forearm midway between pronation and supination. n  Carroll described a similar method of triceps transfer in which the tendon is passed superficial to the radial nerve and through a longitudinal slit in the biceps tendon and is sutured under tension with the elbow in flexion. n 

FIGURE 34.24 Bunnell anterior transfer of triceps for paralysis of biceps. Triceps tendon elongated by short graft of fascia or tendon, routed laterally, and inserted into tuberosity of radius by pull-out suture. SEE TECHNIQUE 34.26.

TRANSFER OF THE PECTORALIS MAJOR TENDON Brooks and Seddon described an operation to restore elbow flexion in which the entire pectoralis major muscle is used as the motor and its tendon is prolonged distally by means of the long head of the biceps brachii. This transfer is contraindicated unless the biceps is completely paralyzed; they recommended it when flexorplasty is not applicable, when the distal part of the pectoralis major is weak but the proximal part is strong, or when both parts of the muscle are so weak that the entire muscle is needed for transfer. To avoid undesirable movements of the shoulder during elbow flexion after this procedure, muscular control of the shoulder and scapula must be good, or an arthrodesis of the shoulder should be performed.

TECHNIQUE 34.27 (BROOKS AND SEDDON) Make an incision from the distal end of the deltopectoral groove distally to the junction of the proximal and middle thirds of the arm. n  Detach the tendon of insertion of the pectoralis major as close to bone as possible and by blunt dissection mobilize the muscle from the chest wall proximally toward the clavicle (Fig. 34.25A). n  Retract the deltoid laterally and superiorly, and expose the tendon of the long head of the biceps as it runs proximally into the shoulder joint; sever this tendon at the proximal end of the bicipital groove and withdraw it into the wound. n  By blunt and sharp dissection, free the belly of the long head of the biceps from that of the short head and ligate and divide all vessels entering it. n  Make an L-shaped incision at the elbow with its transverse limb in the flexor crease and its longitudinal limb extending proximally along the medial border of the biceps muscle. n  Mobilize the long head of the biceps by dividing its remaining neurovascular bundles so that the tendon and muscle are completely freed distally to the tuberosity of the radius; withdraw the tendon and muscle through the distal incision (Fig. 34.25B and C). (When the muscle belly is adherent to the overlying fascia, free it by sharp dissection.) n  Replace the long head of the biceps in its original position, and through the proximal incision pass its tendon and muscle belly through two slits in the tendon of the pectoralis major; loop the long head of the biceps on itself so that its proximal tendon is brought into the distal incision. n  Then, using nonabsorbable sutures, suture the end of the proximal tendon through a slit in the distal tendon n 

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A

D

B

C

E FIGURE 34.25 Brooks-Seddon transfer of pectoralis major tendon for paralysis of elbow flexors. A, Insertion of pectoralis major is detached as close to bone as possible. B, Tendon of long head of biceps is exposed and divided at proximal end of bicipital groove. C, Tendon and muscle of long head of biceps are completely mobilized distally to tuberosity of radius by dividing all vessels and nerves that enter muscle proximal to elbow. D, Long head of biceps is passed through two slits in pectoralis major, is looped on itself so that its proximal tendon is brought into distal incision, and is sutured through slit in its distal tendon. E, To avoid undesirable movements of shoulder during elbow flexion after this transfer, muscular control of shoulder and scapula must be good, or shoulder must be fused. Left shoulder shown is flail; right has been fused. When transfer on left contracts, some of its force is wasted because of lack of control of shoulder, but, on right, transfer moves only elbow. SEE TECHNIQUE 34.27.

(Fig. 34.25D) and suture the tendon of the pectoralis major to the long head of the biceps at their junction. n  Close the incisions, and apply a posterior plaster splint with the elbow in flexion.

POSTOPERATIVE CARE At 3 weeks, the splint is removed and muscle reeducation is started. Care must be taken to extend the elbow gradually so that active flexion of more than 90 degrees is preserved. It may be 2 or 3 months before full extension is possible.    

 

TRANSFER OF THE LATISSIMUS DORSI MUSCLE Hovnanian described a method of restoring active elbow flexion by transferring the origin and belly of the latissimus dorsi to the arm and anchoring the origin near the radial tuberosity. This transfer is possible because the neurovascular bundle of the muscle is long and easily mobilized (Fig. 34.26A); a similar transfer in which the origin is anchored to the olecranon to restore active extension also is possible.

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CHAPTER 34  PARALYTIC DISORDERS

Thoracodorsal artery Teres major muscle Thoracodorsal nerve Latissimus dorsi muscle

A

Subscapularis muscle

Transplanted latissimus dorsi Thoracodorsal artery muscle

Thoracodorsal nerve

B

C FIGURE 34.26 Hovnanian transfer of latissimus dorsi muscle for paralysis of biceps and brachialis muscles. A, Normal anatomy of axilla; note that thoracodorsal nerve and artery are long and can be easily mobilized. B, Skin incision. C, Origin and belly of latissimus dorsi have been transferred to arm, and origin has been sutured to biceps tendon and to other structures distal to elbow joint. SEE TECHNIQUE 34.28.

TECHNIQUE 34.28 (HOVNANIAN) Place the patient on his or her side with the affected extremity upward. Start the skin incision over the loin, and extend it superiorly along the lateral border of the latissimus dorsi to the posterior axillary fold, distally along the medial aspect of the arm, and finally laterally to end in the antecubital fossa (Fig. 34.26B). Carefully expose the dorsal and lateral aspects of the latissimus dorsi, leaving its investing fascia intact. n  Free the origin of the muscle by cutting across its musculofascial junction inferiorly and its muscle fibers superiorly. Then gradually free the muscle from the underlying abdominal and flank muscles. n  Divide the four slips of the muscle that arise from the inferior four ribs and the few arising from the angle of the scapula. n  Carefully protect the neurovascular bundle that enters the superior third of the muscle. To prevent injury of the n 

vessels to the latissimus dorsi, ligate their branches that anastomose with the lateral thoracic vessels. Identify and gently free the thoracodorsal nerve that supplies the muscle; its trunk is about 15 cm long and runs from the apex of the axilla along the deep surface of the muscle belly. n  Next prepare a bed in the anteromedial aspect of the arm to receive the transfer. n  Carefully swing the transfer into this bed without twisting its vessels or nerve. To prevent kinking of the vessels, divide the intercostobrachial nerve and the lateral cutaneous branches of the third and fourth intercostal nerves; also free as necessary any fascial bands. n  Now suture the aponeurotic origin of the muscle to the biceps tendon and the periosteal tissues about the radial tuberosity and then suture the remaining origin to the sheaths of the forearm muscles and to the lacertus fibrosus (Fig. 34.26C). n  Close the wound in layers and bandage the arm against the thorax with the elbow flexed and the forearm ­pronated.

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POSTOPERATIVE CARE  Exercises of the fingers are encouraged early. At 3 or 4 weeks, the bandage is removed and passive and active exercises of the elbow are started.   

MUSCLE TRANSFERS FOR PARALYSIS OF THE TRICEPS

Weakness or paralysis of the triceps muscle usually is considered of little importance because gravity would extend the elbow passively in most positions that the arm assumes. A good triceps is essential, however, to crutch walking or to shifting the body weight to the hands during such activities as moving from a bed to a wheelchair. A functioning triceps allows the patient to perform these activities by locking the elbow in extension. To place the hand on top of the head when the patient is erect, the triceps must be strong enough to extend the elbow against gravity; thrusting and pushing motions with the forearm also require a functional triceps. In other activities, strong active extension of the elbow is relatively unimportant compared with strong active flexion.

POSTERIOR DELTOID TRANSFER (MOBERG PROCEDURE)

Moberg described an operation to transfer the posterior third of the deltoid muscle to the triceps to restore active elbow extension in the quadriplegic patient. Patients with complete quadriplegia at the functioning level of C5 or C6 have active elbow flexion, shoulder flexion and abduction, and possibly wrist extension. Elbow extension is by gravity only, without triceps function (C7). Active extension is impossible. Ambulation is not a realistic goal in such patients. Rather, improved strength, mobility, and function and improved ability to reach overhead, to perform personal hygiene and grooming, to relieve ischial pressure from the wheelchair, to achieve driving ability and wheelchair use, and to eat and control eating utensils are sought. The Moberg procedure has been modified by the construction of tendinoperiosteal tongues proximally and distally instead of using the free tendon grafts from the foot. The posterior belly of the deltoid muscle is freed, along with the most distal insertion of the muscle and including a strip of periosteum 1.0 × 3.0 cm, continuous with the muscle and its insertion. A tongue of the triceps tendon 1.5 to 2.0 cm wide is developed by parallel incisions and including a continuous strip of periosteum similar to that for the deltoid, if possible. The length of the tendinoperiosteal tongues should be such that with the elbow extended and the arm adducted their deep surfaces should appose when the triceps tendon is folded over 180 degrees. The angle of tendinous reflection is reinforced by a narrow sheet of Dacron wrapped around the grafts and sutured to the tongues and to itself. 

FOREARM

Operations on the forearm after poliomyelitis consist of tenotomy, fasciotomy, and osteotomy to correct deformities and tendon transfers to restore function.

PRONATION CONTRACTURE

Deformities of the forearm seldom are disabling enough in themselves to warrant surgery; the most common exception is a fixed pronation contracture from imbalance between the

supinators and pronators. When the pronator teres is not strong enough to transfer to replace the paralyzed supinators, correcting the contracture alone is indicated, provided that there is active flexion of the elbow. When the pronators of the forearm and the flexors of the wrist are active, however, function can be improved not only by correcting the pronation contracture but also by transferring the flexor carpi ulnaris (see Chapter 72). Fixed supination deformity develops from muscle imbalance in which usually the pronators and finger flexors are weak and the biceps and wrist extensors are strong. The soft tissues, such as the interosseous membrane, contract; the bones become deformed, and eventually the radioulnar joints may dislocate. A fixed supination deformity combined with weak shoulder abduction markedly limits an otherwise functional hand. Recommended procedures for this deformity include rerouting of the biceps tendon (Zancolli) and manual osteoclasis of the middle thirds of the radius and ulna (Blount). The latter is recommended for children younger than 12 years old with insufficient muscle power for tendon transfer.   

REROUTING OF BICEPS TENDON FOR SUPINATION DEFORMITIES OF FOREARM TECHNIQUE 34.29 (ZANCOLLI) If full passive pronation is already possible before surgery, omit the first part of the operation. Otherwise, make a longitudinal incision on the dorsum of the forearm over the radial shaft (Fig. 34.27A, 1). n  By blunt dissection, expose the interosseous membrane and retract the dorsal muscles radialward to protect the posterior interosseous nerve (Fig. 34.27B). n  Divide the interosseous membrane throughout its length close to the ulna. If the dorsal ligaments of the distal radioulnar joint are contracted, extend the incision distally and perform a capsulotomy of this joint. n  If necessary, release the supinator muscle after identifying and protecting the posterior interosseous nerve in the proximal part of the incision. At this point in the operation full passive pronation of the forearm should be possible. n  Now make a second incision; begin it on the medial aspect of the arm proximal to the elbow and extend it distally to the flexion crease of the joint, then laterally across the joint in the crease, and then distally over the anterior aspect of the radial head (Fig. 34.27A, 2). n  Identify and retract the median nerve and brachial artery. n  Divide the lacertus fibrosus and expose the insertion of the biceps tendon on the radial tuberosity. n  Now divide the biceps tendon by a long Z-plasty (Fig. 34.27C). n  Reroute the distal segment of the tendon around the radial neck medially, then posteriorly, and then laterally so that traction on it will pronate the forearm (Fig. 34.27D). n  Place the ends of the biceps tendon side-by-side and suture them together under tension that will maintain full pronation and yet allow extension of the elbow. n 

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CHAPTER 34  PARALYTIC DISORDERS

2

1

a

A

B

b

a c

C

a

D FIGURE 34.27 Zancolli rerouting of biceps tendon for supination deformity of forearm. A, 1, Dorsal skin incision (dotted line) is extended distally to a when distal radioulnar joint requires capsulotomy. 2, Anterior incision to expose biceps tendon and radial head. B, Exposure of interosseous membrane by retracting dorsal muscles radially (see text). C, Line at b shows Z-plasty incision to be made in biceps tendon. Interosseous membrane has been divided at a. D, At c, biceps tendon has been divided by Z-plasty, distal segment has been rerouted around radial neck medially, and ends of tendon are being sutured together. Traction on tendon will now pronate forearm as indicated by arrow. SEE TECHNIQUE 34.29.

If the radial head is subluxated or is dislocated, reduce it if possible and hold it in place by capsulorrhaphy of the radiohumeral joint; if the radial head cannot be reduced, excise it and transfer the proximal segment of the biceps tendon to the brachialis tendon. n  Close the incisions and apply a cast with the elbow flexed 90 degrees and the forearm moderately pronated. n 

POSTOPERATIVE CARE  At about 3 weeks, the cast and sutures are removed and passive and active exercises are begun.   

WRIST AND HAND

The treatment of disabilities of the wrist and hand caused by paralysis is discussed in Chapter 71. 

MYELOMENINGOCELE EPIDEMIOLOGY

Myelomeningocele is a complex congenital malformation of the central nervous system. Advances in medicine, surgery, and allied health services have reduced the mortality rates in patients born with severe defects of the central nervous system. The challenge for orthopaedic surgeons is to assist these patients in attaining the best possible function within their anatomic and physiologic limitations. With advances in

technology such as gait analysis, as well as the use of evidencebased medicine and multispecialty care models, significant changes in the management of patients with myelomeningocele are occurring. Myelomeningocele is the most common of the spectrum of conditions described as spina bifida. Myelomeningocele is a severe form of spinal dysraphism that also includes meningocele, lipomeningocele, and caudal regression syndrome. Neural tube defect is a broader term that includes myelomeningocele, anencephaly, and encephalocele. A myelomeningocele is a sac-like structure containing cerebrospinal fluid and neural tissue (Fig. 34.28A). The herniation of the spinal cord and its meninges through a defect in the vertebral canal results in variable neurologic defects depending on the location and severity of the lesion. A meningocele is a cystic distention of the meninges through unfused vertebral arches, but the spinal cord remains in the vertebral canal. Most lesions are posterior, but rarely an anterior or lateral meningocele may occur. Neurologic deficits are not as common as in myelomeningocele. Spina bifida occulta is a term that refers to a defect in the posterior vertebral elements that includes the spinous process and often part of the lamina, most commonly of the fifth lumbar and first sacral vertebrae. Spina bifida occulta occurs in approximately 10% of asymptomatic adult spines and is often an incidental finding on plain radiographs that is rarely associated with neurologic involvement. The nervous system develops by the formation of a tubular structure (neurulation). Closure of this tube is completed

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN Neural plaque Cerebrospinal fluid Pia-arachnoid Dura Skin

A B

Vertebra

Neural plaque Pia-arachnoid Dura Skin

C

Vertebrae

Cerebrospinal fluid

Nerves

FIGURE 34.28 A, Infant with myelomeningocele. Lesion may be small extension (B) or large sessile protrusion (C).

by closure of the cranial and caudal neuropores between day 26 to 28 of gestation. Myelomeningocele and anencephaly occur because of abnormalities during this phase of closure of the neural tube. Conditions such as meningocele, lipomeningocele, and diastematomyelia occur from abnormalities during the canalization phase from day 28 to 48 of gestation and are referred to as postneurulation defects. The myelomeningocele is formed by the protrusion of dura and arachnoid through the defect in the vertebral arches. The spinal cord and nerve roots are carried out through this defect (Fig. 34.28B and C). These lesions can occur at any level along the spinal column but occur most commonly in the lower thoracic and lumbosacral regions. The skin over a myelomeningocele is almost always absent. The neural placode is covered by a thin membrane (arachnoid) that breaks down in a couple of days, leaving an ulcerated granulating surface. The superficial surface of the neural placode represents the everted interior of the neural tube. The ventral surface represents what should have been the outside of a closed neural tube. Because of this pathologic anatomy, the nerve roots arise from the ventral part of the neural placode. The pedicles are everted and lie almost horizontal in the coronal plane. The affected laminae are hypoplastic and everted, and the paraspinal muscles are everted with the pedicles and lie in an anterior position. These muscles act as flexors of the spine instead of functioning normally as extensors because of their anterior position. The incidence of myelomeningocele in the United States is 2.5 to 1.1 per 1000 births. The overall incidence of infants born with neural tube defects is decreasing, which is most likely related to better prenatal screening and the use of folic

acid supplementation before conception and during the first month of pregnancy; an estimated 23% of pregnancies with myelomeningocele are terminated. Testing for elevated levels of maternal serum α-fetoprotein between 16 and 18 weeks of gestation can detect 75% to 80% of affected pregnancies. If the maternal serum α-fetoprotein is found to be elevated, ultrasound examination, ultrafast MRI, and amniocentesis for α-fetoprotein and acetylcholinesterase may be needed to confirm a possible neural tube defect. Ultrasound is a sensitive and efficient test to determine the presence and location of a neural tube defect. If no abnormalities are found on ultrasound examination, an amniocentesis is recommended to evaluate for α-fetoprotein and acetylcholinesterase. With this prenatal screening program, there has been a reported decrease in birth prevalence of anencephaly from 100% to 80% and birth prevalence of myelomeningocele from 80% to 60%. Other studies have shown a 60% to 100% reduction in the risk of neural tube defects when adequate levels of folate are taken by pregnant women. The U.S. Food and Drug Administration recommends that all women of childbearing age receive 0.4 mg folate before conception and during early pregnancy. The CDC also recommends that women who are at high risk (i.e., women who have given birth to a prior affected child or who have a first-degree relative with a neural tube defect) receive 4 mg of folate daily. Genetic factors also play a role in myelomeningocele. There is a greater incidence of neural tube defects, including myelomeningocele, in siblings of affected children, in the range of 2% to 7%. There also is a higher frequency in twins than in single births. For a couple who has a child with myelomeningocele the chance that a subsequent child will

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CHAPTER 34  PARALYTIC DISORDERS be affected by a major malformation of the central nervous system is approximately 1 in 14. With over 100 known genes that affect neurulation and the low frequency of occurrence in the population, the determination of the exact molecular defect(s) remains difficult. 

ASSOCIATED CONDITIONS

The natural history of myelomeningocele has changed over the past several decades because of advances in medical treatment. Patients born with myelomeningocele often died of urinary tract infection, renal failure, meningitis, and sepsis. With early neurosurgical and urologic intervention, patients born with myelomeningocele are surviving into adult life, with about 65% having normal intelligence. Myelomeningocele was believed to be nonprogressive, but studies have shown progressive neurologic deterioration can occur, manifested by increasing levels of paralysis and decreasing upper extremity function. Hydrocephalus and associated hydrosyringomyelia, ArnoldChiari malformation, and tethered cord syndrome have been associated with progressive neurologic deterioration.

HYDROCEPHALUS

Hydrocephalus is a dilation of the ventricles of the brain from excessive cerebrospinal fluid. Before closure of the myelomeningocele defect, the ventricles are decompressed by their direct communication to the persistently open central canal of the cord. Of children with myelomeningocele, 80% to 90% have hydrocephalus that requires cerebrospinal shunting. Chakarborty et al. described new protocols aimed at reducing shunt placement rates in myelomeningocele patients. Using these protocols, the shunt rate in infants with myelomeningocele was decreased to 60%. The incidence of hydrocephalus is related to the neurologic level of the lesion, with patients with thoracic and upper lumbar lesions having a higher incidence than those with lower lumbar and sacral level lesions. Early treatment of hydrocephalus has improved the early mortality rate and, more importantly, improved the long-term intellectual development of these children. If the hydrocephalus is not treated, the increased fluid pressure results in atrophy of the brain, hydromyelia, and syringomyelia. Children who do not require shunting have a better prognosis for upper extremity function and trunk balance than children who require shunting. Shunt malfunctions, manifested by signs of acute hydrocephaly such as nausea, vomiting, and severe headaches, do occur. In older children, the diagnosis may be more difficult because the shunt malfunction may be associated with increased irritability, decreased perceptual motor function, short attention span, intermittent headaches, increasing scoliosis, and increased level of paralysis. 

HYDROSYRINGOMYELIA

Hydrosyringomyelia is an accumulation of fluid in the enlarged central canal of the spinal cord. This usually is the result of hydrocephalus or an alteration in the normal cerebrospinal fluid dynamics. Hydrosyringomyelia can cause three problems in patients with myelomeningocele: (1) an increasing level of paralysis of the lower extremities, often associated with an increase in spasticity of the lower extremity, (2) progressive scoliosis, and (3) weakness in the hands and upper extremities. This condition can be diagnosed with MRI; early treatment may reverse some of the neurologic loss and scoliosis. 

ARNOLD-CHIARI MALFORMATION

Arnold-Chiari malformation (caudal displacement of the posterior lobe of the cerebellum) is a consistent finding in patients with myelomeningocele. Type II Arnold-Chiari malformation is seen most often in children with myelomeningocele and is characterized by displacement of the medulla oblongata into the cervical neural canal through the foramen magnum. This malformation causes dysfunction of the lower cranial nerves, resulting in weakness or paralysis of vocal cords and difficulty in feeding, crying, and breathing. Sometimes, these symptoms are episodic, which makes diagnosis difficult. In childhood, symptoms may consist of nystagmus, stridor, swallowing difficulties, and a depressed cough reflex. Spastic weakness of the upper extremities also may be present. Placement of a ventriculoperitoneal shunt to control hydrocephalus often resolves brainstem symptoms, and surgical decompression of the Arnold-Chiari malformation is unnecessary unless the neurologic symptoms are not relieved by shunting. In these rare cases, the posterior fossa and upper cervical spine require surgical decompression. 

TETHERED SPINAL CORD

MRI shows signs of tethering of the spinal cord in most children with myelomeningocele, but only 20% to 30% have clinical manifestations. Clinical signs vary, but the most consistent are (1) loss of motor function, (2) development of spasticity in the lower extremities, primarily the medial hamstrings and ankle dorsiflexors and evertors, (3) development of scoliosis before age 6 years in the absence of congenital anomalies of the vertebral bodies, (4) back pain and increased lumbar lordosis in an older child, and (5) changes in urologic function. Deterioration in somatosensory evoked potentials of the posterior tibial nerve has been used to document deterioration of lower extremity function and a clinically significant tethered cord. MRI evaluation should be performed in any child suspected of having a tethered cord syndrome. Because dermal elements are left attached during initial closure, a dermal cyst often is seen in association with a tethered cord. If clinical signs are documented, surgical treatment is indicated to prevent further deterioration of the motor function and to diminish the progress of spasticity and scoliosis. It is important to make an early diagnosis and start treatment because surgical release of the tethered cord rarely provides complete return of lost function. 

OTHER SPINAL ABNORMALITIES

Vertebral bone anomalies, such as a defect in segmentation and failure of formation of vertebral bodies, may cause congenital scoliosis, kyphosis, and kyphoscoliosis. Other spinal anomalies the treating physician should be aware of are duplication of the spinal cord and diastematomyelia. Diastematomyelia may cause progressive loss of neurologic function. 

UROLOGIC DYSFUNCTION

Almost all children with myelomeningocele have some form of bladder dysfunction, with most having bladder paralysis. Chronic renal failure and sepsis from urinary tract infections were the most common causes of delayed mortality in patients with myelomeningocele before modern urologic treatment methods. The goal of urologic management is to achieve continence at an appropriate age, decompress the upper urinary tract to prevent renal failure, and prevent urinary tract infections. The mainstay of treatment is clean intermittent catheterization to

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN prevent hydronephrosis and maintain bladder compliance and capacity. Antibiotic prophylaxis and anticholinergic medication to reduce infection and vesicoureteral reflux may be beneficial. Screening examinations, consisting of voiding cystometrograms and renal sonograms, are routinely done every 6 to 12 months. Surgical options for patients in whom medical treatment is unsuccessful include vesicostomy, a diversion of the bladder to the lower abdominal wall to facilitate catheterization, and bladder augmentation in which a segment of the ileum is added to the bladder to increase capacity and reduce bladder pressure. The orthopaedist must be aware of the effects any orthopaedic surgery may have on the need for self-catheterization and any possible urinary diversion procedures. 

BOWEL DYSFUNCTION

Most patients with myelomeningocele have innervation of the bowel and anus that results in dysmotility, poor sphincter control, and often fecal incontinence. Constipation and fecal impaction resulting from decreased bowel motility can cause increased intraabdominal pressure that leads to ventriculoperitoneal shunt malfunction. Oral laxatives, suppositories, or enemas can be used to achieve continence and avoid fecal impaction by promoting regular fecal elimination. If these are unsuccessful, the Malone antegrade continence enema (MACE) procedure is an option: the appendix and cecum are used to create a stoma through which the colon can be irrigated. In one study evaluating the results of the MACE procedure in 108 patients with myelomeningocele, approximately 85% achieved continence. 

LATEX HYPERSENSITIVITY

Latex hypersensitivity has been noted in children with myelomeningocele, with a reported incidence of 3.8% to 38%. The hypersensitivity is a type 1 IgE-mediated response to residual free protein found in latex products. Tosi et al. reported a serologic prevalence of hypersensitivity in 38% of at-risk patients but a clinical prevalence of 10%. A detailed history is the most sensitive way to detect individuals at risk for latex reaction. It is recommended that all patients with myelomeningocele be treated “latex free” during surgery with avoidance of latex gloves and latex-containing accessories (catheters, adhesives, tourniquets, and anesthesia equipment) (Box 34.1). High-risk patients or those with known hypersensitivity reactions can be treated prophylactically with corticosteroids and/or antihistamines before medical procedures. 

MISCELLANEOUS MEDICAL ISSUES

Depending on the severity of involvement, children with myelomeningocele are at risk for depression, as well as cognitive dysfunction and learning difficulties. Obesity also is a problem for children with myelomeningocele both medically and functionally. This is especially true in nonambulatory children in whom it may be difficult to increase caloric expenditure. Small changes in body weight can have a dramatic impact on ambulation because of the increased demands placed on already weak muscles by the additional body weight. It is exceptionally rare for an obese nonambulatory child to lose weight and regain ambulation. 

CLASSIFICATION

The most commonly used classification of myelomeningocele is based on the neurologic level of the lesion (Fig. 34.29);



BOX 34.1

Steps to Ensure a Latex-Safe Office Visit or Surgical Procedure Prior to the Visit/Surgery n Assess the examination room or surgical suite for latexcontaining products. n Find suitable nonlatex alternatives for use during the procedure, or prepare for modifications that can make the products safe for use with latex-allergic patients. Be sure to include proper latex-free resuscitation equipment in the preparation for surgery for a latex-sensitive patient. n Schedule latex-sensitive patients for the first procedure of the day, which will decrease the risk of contamination from powdered latex surgical gloves used in other procedures. n Inform all staff of the patient’s allergy and the precautions that must be taken. n Label the room that will be used as a “Latex-Free Room.” n Label the patient’s chart with information on his or her latex allergy. n Sterilize equipment for the procedure in a latex-free load.  During the Visit/Surgery n Closely assess the patient before surgery, noting any skin rashes and documenting lung examination and blood ­pressure. n Place only nonlatex products (e.g., bouffant, mask) on the patient. n Monitor the patient closely during the procedure for changes in respiratory function, blood pressure, or new skin findings. From Accetta D, Kelly KH: Recognition and management of the latex-allergic patient in the ambulatory plastic surgical suite, Anesth Surg J 31:560, 2011.

however, there are several difficulties with this classification system, including performing isolated muscle testing in young children, differences in classification systems, and differences in the affected neurologic level compared with the anatomic defect. In addition, not all patients have these distinct levels of paralysis. Some patients may not have symmetric levels for each extremity, and some may be flaccid, whereas others may have some associated spasticity in the involved lower extremities. Despite these limitations, patients with myelomeningocele can be grouped into four distinct levels: thoracic level, upper lumbar level, lower lumbar level, and sacral level. This classification assists in predicting the patient’s natural history and expected deformities that may need intervention. Patients can be placed into one of four groups according to the level of the lesion and resultant muscle function. Patients with thoracic level lesions have no active hip flexion and no voluntary muscle control in the lower extremities. Patients with upper lumbar level lesions have variable power with hip flexion and adduction (L1-2) and quadriceps function (L3). Patients with lower lumbar level lesions have active knee flexion against gravity (hamstring power), anterior tibial function (L4), and extensor hallucis longus function (L5). Patients with sacral level lesions have weakness of the peroneals and intrinsic muscles of the foot but have some active toe flexor function and hip extensor and abductor power. The sensory level has been suggested to be a better way to define the level of paralysis because muscles that can

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CHAPTER 34  PARALYTIC DISORDERS L1

L2

L3

L4

L5

S1

S2

S3

Iliopsoas Sartorius Pectineus Gracilis Add. longus Add. brevis Adductor magnus Quadriceps Obt. ext. Tib. ant. Tib. post. Ten. fas. lata Glut. med. & min. Semimembranosus Semitendinosus Ext. hal.I. Ext. dig. I. Per. tert. Per. brevis Per. longus Lat. hip. rot. Gastrocn. Soleus & plant. Biceps femoris Gluteus max. Fl. hal. I. & b. Fl. dig. I. & b. Foot intrinsics FIGURE 34.29    Neurosegmental innervation of lower limb muscles.

communicate with the brain through sensory feedback are functional but muscles that cannot become flaccid or spastic, functioning only by reflex. A sensory level classification also may be more reproducible between different observers. The functional classification described by Swaroop and Dias is useful in determining a child’s prognosis for ambulation and bracing. Patients are divided into four groups based on lesion level and accompanying functional and ambulatory capacity (Table 34.1). The Functional Mobility Scale (FMS) also has been used to evaluate the functional ability of children with neuromuscular disorders. This scale is simple and fast, rating the child’s mobility on a scale of 1 to 6 (1 = wheelchair, 2 = walker, 3 = two crutches, 4 = one crutch, 5 = independent on level surfaces, 6 = independent on all surfaces) over three different distances: home (5 m), school (50 m), and community (500 m). Additional advantages of the FMS include the ability to systematically compare children affected with different neuromuscular diseases and the fact that this is more a true measure of the child’s functional abilities than isolated motor or sensory testing. Hoffer et al. also described a functional five-category classification of patients with myelomeningocele: normal ambulator, community ambulator, household ambulator, therapy ambulatory, and wheelchair ambulator. 

ORTHOPAEDIC EVALUATION

Orthopaedic evaluation of children with myelomeningocele should include the following: 1. Serial sensory and motor examinations: Evaluate the neurologic level of function; this may be difficult before 4 years of age.

2. Sitting balance: Indicates central nervous system function; if significant support is required for sitting, the probability of ambulation is significantly decreased. 3. Upper extremity function: Assesses ability to use assistive devices; decreased grip strength and atrophy of the thenar musculature are indications of hydromyelia. 4. Spine evaluation: Clinical evaluation and yearly radiographs are needed to detect development of scoliosis and/ or kyphosis and lumbar hyperlordosis. 5. Hip evaluation: Range of motion, stability, contractures, pelvic obliquity 6. Knee evaluation: Range of motion, alignment, contractures, and spasticity 7. Rotational evaluation: Including internal/external tibial torsion and femoral anteversion and retroversion 8. Ankle evaluation: Range of motion, valgus deformity 9. Foot evaluation: Foot deformities, skin breakdown 10. Mobility and bracing evaluation: Changes in mobility that have remained stable; braces fitting properly and in good condition 11. Miscellaneous: Depression, obesity, school performance 

GAIT EVALUATION

Advances in the quality and use of gait analysis have produced useful information about gait function and energy expenditure in patients with myelomeningocele. Most patients with myelomeningocele, especially those with higher level involvement, have multilevel three-dimensional deformities. These deformities can be difficult to assess on isolated clinical examination. Gait analysis allows assessment of the patient in real time during ambulation, which can be helpful diagnostically

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN

TABLE 34.1

Functional Classification of Myelomeningocele GROUP Thoracic/high lumbar

NEUROLOGIC LEVEL OF LESION L3 or above

PREVALENCE (%) 30

Low lumbar

L3-L5

30

High sacral

S1-S3

30

Low sacral

S3-S5

5-10

FUNCTIONAL CAPACITY No functional quadriceps (≤grade 2)

Quadriceps, medial hamstring ≥grade 3 No functional activity (≤grade 2) of gluteus medius and maximus, gastrocsoleus Quadriceps, gluteus medius ≥grade 3 No functional activity (≤grade 2) of gastrocsoleus Quadriceps, gluteus medius, gastrocsoleus ≥grade 3

FUNCTIONAL AMBULATORY CAPABILITY MOBILITY SCALE During childhood, require 1,1,1 bracing to level of pelvis for ambulation (RGO, HKAFO) 70%-99% require wheelchair for mobility in adulthood Require AFOs and crutches 3,3,1 for ambulation 80%-95% maintain community ambulation in adulthood Require AFOs for ambulation 94%-100% maintain community ambulation in adulthood Ambulate without braces or support 94%-100% maintain community ambulation in adulthood

6,6,6

6,6,6

AFO, Ankle-foot orthosis; HKAFO, hip-knee-ankle-foot orthosis; RGO, reciprocal gait orthosis. From Swaroop VT, Dias L: Myelomeningocele. In Weinstein SL, Flynn JM, editors: Lovell and winter’s pediatric orthopaedics, ed 7, Philadelphia, 2014, Wolters Kluwer.

and in planning treatment strategies. Gait analysis has shown that hip abductor strength is one of the most important determinants of ambulatory kinematics and ability; that pelvic obliquity, determined by hip abductor strength, has the strongest correlation to oxygen cost during gait; and that children tend to self-select both velocity and dynamics to maintain a comfortable level of exertion. Gait studies also have shown increased dynamic knee flexion in patients with myelomeningocele compared with static examination. Patients with low lumbar level lesions have a walking velocity that is 60% of normal, and patients with high sacral level lesions have a walking velocity approximately 70% of normal. 

PRINCIPLES OF ORTHOPAEDIC MANAGEMENT

Orthopaedic management should be tailored to meet specific goals during childhood, taking into account the expected function in adulthood. The goal for a child with myelomeningocele is to establish a pattern of development for the child that is as near normal as possible. Ambulation is not the goal for every child. Despite the best medical and surgical care, about 40% of children with myelomeningocele are unable to walk as adults. An evidence-based review found that neurosegmental level is the primary determinant of walking ability and physical function. Other factors believed to play a lesser role in the ability to ambulate in children with myelomeningocele include cognitive ability, physical therapy, compliant parents, clubfoot deformity, scoliosis, increased age, back pain, and lack of motivation. Often, the goal of orthopaedic treatment is a stable posture in braces or in a wheelchair. Surgery may be more detrimental than helpful, causing long-term disability. Before aggressive orthopaedic treatment is instituted, the

lifetime prognosis for the patient should be considered. Only 30% of all patients with myelomeningocele are functionally independent, and only 30% of adults with myelomeningocele are employed full time or part time. Almost all patients with L2 or higher-level lesions use a wheelchair, and more than two thirds of patients with lower-level lesions (L3-5) use a wheelchair at least part of the time. Most children achieve their maximal level of ambulation around age 4 to 6 years. If a child with myelomeningocele is not standing independently by about age 6 years, walking is unlikely. Prerequisites for walking include a spine balanced over the pelvis; absence of hip and knee contractures (or only mild contractures); and plantigrade, supple, braceable feet with the center of gravity centered over them. An extension posture at the hip and knee can be maintained with minimal support from leg and arm muscles, whereas a flexion posture tends to be a collapsing posture (Fig. 34.30). At least 80% of children with myelomeningocele have some impairment of their upper extremities; effective ambulation with low energy consumption and minimal bracing is possible in only about 50% of adult patients. If a child has functioning quadriceps and medial hamstring muscles, good sitting balance, and upper extremity function, all efforts should be made to achieve ambulation.

NONOPERATIVE MANAGEMENT

Almost all children with myelomeningocele except those with low sacral level lesions will require some type of orthotic device. Orthotic treatment goals include maintenance of motion, prevention of deformity, assistance with ambulation/mobility, and the protection of insensate skin. Bracing and splinting vary with the degree of motor deficit and trunk balance, and each child should be carefully evaluated using

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CHAPTER 34  PARALYTIC DISORDERS Carbon fiber ankle-foot orthoses have been shown to increase energy return and ankle plantarflexion motion, positive work, and stride length compared with standard materials. 

OPERATIVE MANAGEMENT

A

B

FIGURE 34.30 A, Extension posture with hips and knees extended, feet plantigrade; posture aimed for regardless of bracing necessary. B, Flexion posture at the hips imposes lumbar lordosis and patient uses both arms for weight bearing and loses other, more valuable function.

a team approach. Children 12 to 18 months old may benefit from the use of a standing frame for upright positioning, and for children older than 2 years, a parapodium that supports the spine and allows a swing-to or swing-through gait with crutches or a walker may be beneficial. An ankle-foot orthosis is used in children with low lumbar or sacral level lesions and fair quadriceps muscle function. The ankle-foot orthosis should be rigid enough to provide ankle and foot stabilization and to maintain the ankle at 90 degrees. A knee-anklefoot orthosis (KAFO) may be indicated for a child with a lumbar level lesion and weak quadriceps function to prevent abnormal valgus of the knee during the stance phase of gait. Children with high-level lesions often have excessive anterior pelvic tilt and lumbar lordosis and require a pelvic band, either a conventional HKAFO or a reciprocating gait orthosis. The reciprocating gait orthosis also can be used in patients with upper lumbar lesions, allowing them to be upright and assisting them in attempts at ambulation. This brace is started around the age of 2 and provides the ability to walk in a reciprocal fashion by dynamically coupling the flexion of one hip to the simultaneous extension of the contralateral hip. For the reciprocating orthosis to be effective, the patient should have good upper extremity strength, sitting (trunk) balance, and active hip flexion. Energy expenditure for children in reciprocal gait orthoses and traditional HKAFO are similar; however, children with HKAFO have a faster gait velocity. A child can be tapered from a reciprocal gait orthosis to a HKAFO if he or she develops enough upper body strength to use crutches safely. The use of materials such as carbon fiber may provide an alternative to patients who do not benefit from current braces.

Orthopaedic deformities in children with myelomeningocele are caused by (1) muscle imbalance resulting from the neurologic abnormality, (2) habitually assumed posture, and (3) associated congenital malformations. Surgical correction of deformities may be indicated. Most surgical procedures in patients with myelomeningocele are performed during the first 15 years of life. When surgical correction is indicated, the deformity should be completely and permanently corrected. Principles of orthopaedic management include: 1. Multiple procedures should be done simultaneously to minimize repeated anesthetic exposures. 2.  Cast immobilization, especially in recumbency, should be minimized owing to the risk of osteopenia and pathologic fracture. 3. The orthopaedic treatment program must be integrated with the total treatment program. 4.  The absence of sensation, osteopenia, and the increased risk of infection secondary to urinary tract problems must be constantly considered. 5. Hospitalization must be kept at a minimum. 6. The demands on the family in terms of time, effort, expense, and separation must be minimized. 

FOOT

Approximately 75% of children with myelomeningocele have foot deformities that can seriously limit function. These deformities can take many forms including clubfoot, acquired equinovarus, varus, metatarsus adductus, equinus, equinovalgus, vertical talus, talipes calcaneus, calcaneovalgus, calcaneovarus, calcaneocavus, cavus, cavovarus, supination, pes planovalgus, and toe deformities. The goal of orthopaedic treatment of foot deformities is a plantigrade, painless, mobile, braceable foot. Musclebalancing procedures that remove deforming muscular forces are more reliable than tendon transfer procedures. Often tendon excision is more reliable than tendon lengthening or transfer. Bone deformities should be corrected by appropriate osteotomies that preserve joint motion. Arthrodesis should be avoided if possible because most feet in patients with myelomeningocele are insensate, which can lead to neuropathic problems including joint destruction and pressure sores. Manipulation and casting should be used with caution in these patients to avoid pressure sores and iatrogenic fractures. Most foot deformities may eventually require surgical correction if correction of the deformity is needed to improve function. Despite surgical correction, there is a relatively high recurrence rate of the deformity because of the deforming neurologic forces present.

EQUINUS DEFORMITY

Equinus usually is an acquired deformity that may be prevented or delayed by bracing and splinting. Depending on the ambulatory function of the patient, an Achilles tendon lengthening, tenotomy, or resection can be performed. Equinus is seen more frequently in children with high lumbar or thoracic level lesions. For mild deformities, excision of 2 cm of the Achilles tendon through a vertical incision usually

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN is sufficient. Alternatively, a percutaneous Achilles tendon lengthening or tenotomy may be performed. Often the long toe flexors must be released to prevent persistent toe flexion deformities that can result in pressure sores. For more severe deformity, radical posterior release is required, including excision of all the tendons contributing to the equinus and extensive capsulotomies of the ankle and subtalar joints. In rare cases, salvage procedures such as osteotomy or talectomy may be required for a symptomatic deformity. 

CLUBFOOT

Clubfoot is present at birth in approximately 30% to 50% of children with myelomeningocele. The deformity usually is rigid and resembles that of arthrogryposis multiplex congenita and differs markedly from idiopathic clubfoot. It is characterized by severe rigidity, supination-varus deformity, rotational malalignment of the calcaneus and talus, subluxation of the calcaneocuboid and talonavicular joints, and often a cavus component. Internal tibial torsion often is present. With the increased use of the Ponseti clubfoot casting technique, infants with myelomeningocele are being treated with this method. Patients can be successfully treated with this technique, but the complication and recurrence rates are much higher than in idiopathic clubfoot. A 68% early relapse rate and a 33% surgical release rate have been reported in children with myelomeningocele treated with this method. In a series of 24 infants (48 feet), however, only 5 feet (10%) failed to show improvement. Even with adequate surgical correction, recurrence of the clubfoot deformity is frequent. Surgery can be done between 10 and 12 months of age. Radical posteromedial-lateral release through the Cincinnati incision (see Chapter 29) is recommended. If there is significant equinus, a variety of techniques have been described to help prevent posterior soft-tissue and incision breakdown including the use of medial and posterior incisions (Carroll), a modification of the Cincinnati incision that includes a complete circumferential skin release (Noonan et al.), and a modified V-Y plasty (Lubicky and Altiok) (Fig. 34.31). Another method to avoid undue tension on the incision posteriorly is to immobilize the foot postoperatively in an undercorrected position until the wound is healed. Two weeks later, when the incision has healed, the cast can be changed and the foot can be placed in a corrected position safely. Tenotomies instead of tendon lengthening should be done to minimize any recurrence with growth. If the anterior tibial tendon is active, simple tenotomy should be performed to prevent recurrent supination deformity. In older children, the imbalance between the medial and lateral columns of the foot may be so severe that it cannot be corrected by soft-tissue release alone. Closing wedge osteotomy of the cuboid (see Chapter 29), lateral wedge resection of the distal calcaneus (Lichtblau procedure; see Chapter 29), or calcaneocuboid arthrodesis (Dillwyn Evans procedure; Fig. 34.2) may be required to shorten the lateral column. Talectomy (see Chapter 29) is indicated as a salvage procedure for a severely deformed rigid clubfoot in an older child. The talus should be completely removed because any fragment left behind would resume its growth and cause recurrence of the deformity. The Achilles tendon may need to be resected after talectomy to prevent further equinus. Talectomy would correct the hindfoot deformity, but any adduction deformity should be corrected by shortening of the lateral column through the same

incision. Severe forefoot deformities require midtarsal or metatarsal osteotomies (see Chapter 29).   

V-O PROCEDURE Verebelyi and Ogston described a decancellation procedure to correct residual clubfoot deformity in patients with myelomeningocele. This procedure consists of removing as much cancellous bone as possible from the talus and the cuboid. This leaves a hollow shell of bone and more space for correction. The foot is manipulated into calcaneus and valgus, which, because of collapse of the talus and cuboid bone, would lead to correction of the residual deformity. In selected patients, this procedure may be preferable to talectomy for correction of severe rigid clubfoot deformity.

TECHNIQUE 34.30 Make an oblique incision on the dorsolateral aspect of the foot to expose the cuboid and the talus. n  Retract the peroneal tendons and sural nerve plantarly, and protect them while retracting the extensor digitorum brevis dorsally. n  Cut a square window in the cuboid with a ¼-inch osteotome and remove all cancellous bone with a curet. n  Along the lateral talus, cut a rectangular window with the longer dimension parallel to the long axis of the talus and curet the cancellous contents of the body, neck, and head. n  Confirm the removal of all cancellous bone, with fluoroscopy or radiography, especially at the posterior aspect of the talus. n  Obtain correction by collapsing the empty cartilaginous shells of the cuboid and talus. If satisfactory correction is not obtained, remove lateral wedges from the cuboid or the talar neck. n  If necessary, perform a percutaneous heel cord l­ engthening. n  Close the wounds routinely, and apply a short leg cast, monovalved for swelling. n 

POSTOPERATIVE CARE  After the swelling has subsided, the cast is reinforced and initially changed at 10 days, maintaining the foot in a neutral or slightly overcorrected position. At 4 weeks after surgery, at the time of the second cast change, a mold is made of the foot in a slightly overcorrected position for an ankle-foot orthosis. When the cast is removed at 6 weeks, the orthosis is worn usually until skeletal maturity.   

VARUS DEFORMITY

Isolated varus deformity of the hindfoot is rare; it is usually associated with adduction deformity of the forefoot, cavus deformity, or supination deformity. Imbalance between the invertors and evertors should be evaluated carefully. For isolated, rigid hindfoot varus deformity, a closing wedge osteotomy is indicated. After removal of the lateral wedge (Fig. 34.32), the calcaneus should be translated laterally, if needed to increase correction. 

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CHAPTER 34  PARALYTIC DISORDERS

A A

A

Lateral malleolus V–Y advancement flap

Rotational flap

B

Softtissue gap

C

Corrected Position FIGURE 34.31 Incisions used for clubfoot correction. A, Carroll two-incision technique. B, ­Modification of the Cincinnati incision by Noonan et al. C, V-Y advancement flap technique of Lubicky and Altiok.

CAVOVARUS DEFORMITY

Cavovarus deformities occur mainly in children with sacral level lesions. The cavus is the primary deformity that causes the hindfoot varus. The Coleman test (see Chapter 35) helps to determine the rigidity of the varus deformity. For a supple deformity, radical plantar release (see Chapter 35) is indicated to correct the cavus deformity, without hindfoot bone surgery. If the varus deformity is rigid despite plantar release with or without midtarsal osteotomy, a closing wedge osteotomy (see Chapter 87) is indicated. Any muscle balance must be corrected before the bony procedures or at the same time. Triple arthrodesis (see Technique 34.4) rarely is indicated as a salvage procedure and should be used with caution in myelomeningocele patients. 

SUPINATION DE0FORMITY

Supination deformity of the forefoot occurs most frequently in children with L5 to S1 level lesions and is caused by the unopposed action of the anterior tibial muscle when the peroneus brevis and peroneus longus are inactive. Adduction deformity also can be present. If the muscle imbalance is not corrected, the deformity becomes fixed. If the deformity is supple, simple tenotomy of the anterior tibial tendon is adequate. Simple tenotomy usually is the preferred treatment method for patients with myelomeningocele, but a tendon transfer may be indicated in selective situations. If there is some gastrocnemius-soleus activity and no spasticity, the anterior tibial tendon can be transferred to the midfoot in line with the third metatarsal. Split anterior tibial tendon transfer

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A FIGURE 34.32 Lateral closing wedge osteotomy of calcaneus for isolated varus deformity of hindfoot.

(see Technique 34.9) occasionally can be used, with the lateral half of the tendon inserted in the cuboid. Osteotomy of the first cuneiform or the base of the first metatarsal may be required for residual bone deformity. 

CALCANEAL DEFORMITY

Approximately one third of children with myelomeningocele have calcaneal deformities, most frequently children with L4 and L5 lesions. The most common form is a calcaneovalgus deformity caused by the active anterior leg muscles and inactive posterior muscles. Spasticity of the evertors and dorsiflexors may cause calcaneal deformity in children with highlevel lesions. Untreated calcaneal deformity produces a bulky, prominent heel that is prone to pressure sores and makes shoe wear difficult. Patients also lose toe-off power and develop an increased crouched gait. If the deformity is supple, as usually is the case, manipulation and splinting can bring the foot to a neutral position, but this rarely gives permanent correction. Muscle imbalance can be corrected early by simple tenotomy of all ankle dorsiflexors, as well as the peroneus brevis and peroneus longus. After anterolateral release in some patients, spasticity develops in the gastrocnemius-soleus muscle, causing an equinus deformity that requires tenotomy of the Achilles tendon or posterior release. Posterior transfer of the anterior tibial tendon has been reported to give good results. This often is combined with other soft-tissue and bony procedures to balance the foot. In older children with severe structural deformities, tendon transfers or tenotomies seldom achieve correction, and bone procedures are indicated.   

ANTEROLATERAL RELEASE TECHNIQUE 34.31 With the patient supine, apply and inflate a pneumatic tourniquet. n  Make a transverse incision about 2.5 cm long 2.0 to 3.0 cm above the ankle joint (Fig. 34.33A). Alternatively, an n 

B

C

FIGURE 34.33 Anterolateral release for calcaneal deformity (see text). A, Transverse and longitudinal incisions. B and C, Excision of portion of tendons and tendon sheaths. SEE TECHNIQUE 34.31.

anterior lazy-S incision may be made. With sharp dissection, divide the superficial fascia to expose the tendons of the extensor hallucis longus, extensor digitorum communis, and tibialis anterior. n  Divide each tendon, and excise at least 2.0 cm of each (Fig. 34.33B). n  Locate the peroneus tertius tendon in the lateralmost part of the wound, and divide it. n  Make a second longitudinal incision above the ankle joint lateral and posterior to the fibula (Fig. 34.33A). n  Identify and divide the peroneus brevis and longus tendons, and excise a section of each (Fig. 34.33C). Close the wounds, and apply a short leg walking cast.

POSTOPERATIVE CARE The cast is worn for 10 days, and then an ankle-foot orthosis is fabricated for night wear.    

 

TRANSFER OF THE ANTERIOR TIBIAL TENDON TO THE CALCANEUS TECHNIQUE 34.32 With the patient supine, make an incision in the dorsal aspect of the foot at the level of the insertion of the anterior tibial tendon at the base of the first metatarsal. n  Carefully detach the tendon from its insertion and free it as far proximally as possible. n  Make a second incision on the anterolateral aspect of the leg, just lateral to the tibial crest and 3 to 5 cm above the ankle joint. n  Free the tendon as far distally as possible and bring it up into the proximal wound (Fig. 34.34A). n  Expose the interosseous membrane and make a wide opening in it (Fig. 34.34B). n 

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CHAPTER 34  PARALYTIC DISORDERS

Interosseous window

Anterior tibial tendon

A

B

Achilles tendon Pull-out wire

Anterior tibial tendon Drill hole

C

D FIGURE 34.34 A, Anterior tibial tendon is divided distally and passed subcutaneously to the proximal incision. B, A 4 × 1.5 cm window is created in the interosseous membrane. C, The anterior tibial tendon is transferred posteriorly through the interosseous membrane. D, The transferred tendon is fixed to the calcaneus with a Bunnell suture or suture anchor. (Redrawn from Georgiadis GM, Aronson DD: Posterior transfer of the anterior tibial tendon in children who have a myelomeningocele, J Bone Joint Surg 72A:392, 1990.) SEE TECHNIQUE 34.32.

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN Make a third transverse incision posteriorly at the level of the insertion of the Achilles tendon into the calcaneus. n  Using a tendon passer, bring the anterior tibial tendon through the interosseous membrane, from anterior to posterior, down to the level of this incision (Fig. 34.34C). n  Drill a large hole in the calcaneus, starting posteriorly and medially and exiting laterally and plantarward. n  Pass a Bunnell suture through the tendon, and use a Keith needle to draw the tendon through the hole. A button suture is not recommended because of pressure sores. Suture the tendon to the surrounding soft tissues to the level of its entrance into the calcaneus and to the Achilles tendon (Fig. 34.34D). Alternatively, a suture anchor can be used to secure the transferred tendon. The length of tendon is often not enough to secure the transfer to the calcaneus. When this occurs, the transferred anterior tibial tendon can be sutured directly into the Achilles tendon. n  Close the wounds and apply a short leg cast.    n 

HINDFOOT VALGUS

Valgus deformity at the ankle joint and external rotation deformity of the tibia and fibula frequently can exacerbate a hindfoot valgus deformity. Initially, this can be controlled with a wellfitted orthosis, but as the child becomes taller and heavier, control of the deformity is more difficult, pressure sores develop over the medial malleolus and the head of the talus, and surgical treatment is indicated. Clinical and radiographic measurements of the hindfoot valgus should be obtained; more than 10 mm of “lateral shift” of the calcaneus is significant. The Grice extraarticular arthrodesis (see Technique 34.2) is the classic treatment for this problem, but frequently reported complications include resorption of the graft, nonunion, varus overcorrection, and residual valgus. A 19-year follow-up of 35 feet treated with the Grice arthrodesis found significant improvement in visual analog scale (VAS) satisfaction scores and, although there was some mild increase in ankle valgus, 83% of patients were satisfied with their outcome. Medial displacement osteotomy has been recommended for correction of hindfoot valgus so that arthrodesis of the subtalar joint can be avoided (see Chapter 11). Lateral column lengthening also can be done if there is significant midfoot breakdown associated with the hindfoot valgus. The combination of hindfoot and ankle valgus should be considered; if the ankle deformity is more than 10 to 15 degrees, closing wedge osteotomy or hemiepiphysiodesis of the distal tibial epiphysis is recommended in addition to the calcaneal osteotomy. 

VERTICAL TALUS

Vertical talus deformities occur in approximately 10% of children with myelomeningocele. The deformity is characterized by malalignment of the hindfoot and midfoot. The talus is almost vertical, the calcaneus is in equinus and valgus, the navicular is dislocated dorsally on the talus, and the cuboid may be subluxated dorsally in relation to the calcaneus. In congenital vertical talus, manipulation and serial casting may partially correct the soft-tissue contractures in preparation for a complete posteromedial-lateral release (see Chapter 29), which should be performed when the child is ready to stand in braces, usually between 12 and 18 months old. The anterior tibial tendon can be resected or transferred into the neck of

the talus. Occasionally, an extraarticular subtalar arthrodesis is needed to stabilize the subtalar joint. Dobbs et al. described a technique for correction of vertical talus in which serial manipulation and casting are followed by closed or open reduction of the talus and pin fixation. Percutaneous Achilles tenotomy is required to correct the equinus deformity. This method has been used successfully in children from birth to 4 years of age; the upper age limit at which this technique can be successful has not been defined. 

PES CAVUS DEFORMITY

Cavus deformity, alone or with clawing of the toes or varus of the hindfoot, occurs most often in children with sacral level lesions. It may cause painful callosities under the metatarsal heads and difficulty with shoe wear. Plantarflexion of the first ray must be corrected for successful correction of the deformity. Although several procedures have been recommended for this deformity, few have been reported in patients with myelomeningocele. For an isolated cavus deformity with no hindfoot varus, radical plantar release is indicated. When varus deformity is present, medial subtalar release (see Chapter 29) is indicated. After surgery, a short leg cast is applied, and 1 to 2 weeks later the deformity is gradually corrected by cast changes every week or every other week for 6 weeks. In older children with rigid cavus deformities, anterior first metatarsal closing wedge osteotomy (see Chapter 87) is indicated in addition to radical plantar release. Opening wedge midfoot osteotomies also can be performed to correct the cavus. For residual varus deformity, a Dwyer closing wedge osteotomy of the calcaneus (see Chapter 33) is recommended. 

TOE DEFORMITIES

Claw toe or hammer toe deformities occur more often in children with sacral level lesions and can cause problems with shoe and orthotic fitting. For flexible claw toe deformities, simple tenotomy of the flexors at the level of the proximal phalanx usually is sufficient. Rigid claw toe deformities can be treated with partial resection of the interphalangeal joint or arthrodesis. The Jones procedure (tendon suspension; see Chapter 87) is indicated when clawing of the great toe is associated with a cavus deformity. Arthrodesis of the proximal interphalangeal joint (see Chapter 87) or tenodesis of the distal stump of the extensor pollicis longus to the extensor pollicis brevis is recommended with the Jones procedure, although arthrodesis would hold up better than a tenodesis. The Hibbs transfer (see Chapter 35) can be performed to treat clawing of the lesser toes. 

ANKLE

Progressive valgus deformity at the ankle or in combination with hindfoot valgus occurs most frequently in children with low lumbar level lesions. The strength of the gastrocnemiussoleus muscle is diminished or absent, and excessive laxity of the Achilles tendon allows marked passive ankle dorsiflexion. The medial malleolus is bulky, the head of the talus is shifted medially, and pressure ulcerations in these areas are common. The calcaneovalgus deformity usually appears early, but problems with orthotic fitting do not arise until the child is about 6 years old. Fibular shortening is common in children with L4, L5, or higher-level lesions. In the paralytic limb, abnormal shortening of the fibula and lateral malleolus causes a valgus tilt of the talus, with subsequent valgus deformity at

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CHAPTER 34  PARALYTIC DISORDERS the ankle (Fig. 34.35). Shortening of the fibula alters the normal distribution of forces on the distal tibial articular surface and increases compression forces on the lateral portion of the tibial epiphysis, further inhibiting growth, whereas decreased compression on the medial portion of the tibial epiphysis accelerates growth. This imbalance causes the lateral wedging that produces a valgus inclination of the talus. The degree of lateral wedging of the tibial epiphysis correlates with the degree of fibular shortening. To evaluate valgus ankle deformity in children with myelomeningocele accurately, three factors must be determined: (1) the degree of fibular shortening, (2) the degree of valgus tilt of the talus in the ankle mortise, and (3) the amount of “lateral shift” of the calcaneus in relation to the weight-bearing axis of the tibia. Fibular shortening can be evaluated by measuring the distance between the distal fibular physis and the dome of the talus. In the normal ankle joint, the distal fibular physis is 2 to 3 mm proximal to the dome of the talus in children 4 years old (Fig. 34.36A). Between ages 4 and 8 years, the physis is at the same level as the talar dome (Fig. 34.36B), and in children older than 8 years, it is

A

HEMIEPIPHYSIODESIS OF THE DISTAL TIBIAL EPIPHYSIS

B

FIGURE 34.35 A, Posterior view of right foot of normal child with correct alignment of malleoli and hindfoot. B, In child with myelomeningocele, medial malleolus is prominent and lateral malleolus is shortened, causing valgus deformity of ankle.

A

2 to 3 mm distal to the talar dome (Fig. 34.36C). Differences of more than 10 mm from these values are considered significant. The valgus tilt of the talus can be measured accurately on anteroposterior, weight-bearing radiographs. The lateral shift of the calcaneus is more difficult to determine, and radiographic techniques have been developed for evaluating ankle valgus and hindfoot alignment. If the talar tilt exceeds 10 degrees, the x-ray tube should be tilted appropriately to obtain a true lateral weight-bearing view of the foot. On this view, the weight-bearing axis of the tibia is drawn and the distance from this line to the center of the calcaneus is measured. On an anteroposterior weight-bearing view, the beam should be directed horizontally to preserve the coronal relationship in both dimensions. The foot is positioned in slight dorsiflexion by placing a hard foam wedge under the plantar surface, but not under the calcaneus, and by positioning the cassette behind the foot and ankle. The normal lateral shift of the calcaneus is 5 to 10 mm (Fig. 34.37A); if the center of the calcaneus is more than 10 mm lateral to the weight-bearing line, excessive valgus is present (Fig. 34.37B). This technique is useful to determine before surgery if the valgus deformity is at the ankle or subtalar level. Operative treatment is indicated when the ankle valgus deformity causes problems with orthotic fitting and cannot be relieved with orthoses. Achilles tenodesis is indicated for valgus talar tilt between 10 and 25 degrees in patients 6 to 10 years old (Fig. 34.1). Other procedures to correct ankle valgus caused by bone deformities include hemiepiphysiodesis in children with remaining growth and supramalleolar derotation osteotomy for severe angular deformity. Medial sliding osteotomy of the calcaneus may be indicated if the valgus deformity is in the subtalar joint and calcaneus.

Hemiepiphysiodesis of the distal tibial epiphysis is indicated in young children with valgus deformities of less than 20 degrees and mild fibular shortening. Through a medial incision at the ankle, the medial aspect of the epiphysis is exposed and epiphysiodesis is performed by a percutaneous or an

B

C

FIGURE 34.36 Normal position of distal fibular physis. A, Proximal to dome of talus in children up to 4 years of age. B, Level with dome of talus in children between 4 and 8 years of age. C, Distal to dome of talus in children older than 8 years of age.

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A

B

FIGURE 34.37 Radiographic technique for evaluation of ankle valgus. A, Normal shift of calcaneus is 5 to 10 mm. B, Lateral shift of 15 to 18 mm indicates excessive valgus.

ankle valgus (median rate of correction of 0.59 degree per month). If the single screw is removed, growth can resume and the deformity may recur. This procedure is recommended in children older than 6 years (Fig. 34.39).

TECHNIQUE 34.33 Place the patient supine. Make a 3-mm stab wound over the medial malleolus. Use image intensification to properly position the incision. n  Insert a guide pin from the 4.5-mm cannulated screw set into the medial malleolus and advance it proximally and medially across the distal tibial physis. Confirm the position of the guide pin by image intensification. The guide pin should be as vertical as possible in the medial one fourth of the medial distal tibial physis in the anteroposterior plane. In the sagittal plane the guide pin should cross the physis through its middle third. n  Place a tap over the guide pin and tap the bone across the physis. Insert a fully threaded, cannulated screw over the guide pin until it is completely seated     n  n 

FIGURE 34.38 Radiopaque dye shows extent of medial hemiepiphysiodesis of distal tibial epiphysis.

open method (Fig. 34.38). The growth arrest of the medial physis combined with continued growth of the lateral side gradually corrects the lateral wedging of the tibial epiphysis. If overcorrection occurs, the epiphysiodesis should be completed laterally. This procedure does not correct any rotational component of the deformity, and derotation osteotomy of the distal tibia and fibula may be required.   

SCREW EPIPHYSIODESIS

 

SUPRAMALLEOLAR VARUS DEROTATION OSTEOTOMY Supramalleolar osteotomy is recommended for children older than 10 years of age with low lumbar level lesions, severe fibular shortening (>10 to 20 mm), valgus tilt of more than 20 degrees, and external tibial torsion.

TECHNIQUE 34.34

Good results have been obtained with screw epiphysiodesis for correction of ankle valgus, which involves placing a vertical 4.5-mm screw across the medial malleolar physis to slow medial growth, allowing gradual correction of

With the patient supine, make an anterior longitudinal incision at the distal third of the leg. Expose the distal tibia and identify the epiphysis.

n 

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CHAPTER 34  PARALYTIC DISORDERS Staples or Kirschner wires (Fig. 34.40C) or, in patients nearing skeletal maturity, a plate and screws (Fig. 34.40B) can be used for internal fixation. n  Close the wounds, and apply a long leg cast with the ankle and foot in neutral. n 

POSTOPERATIVE CARE Partial weight bearing with crutches is allowed immediately. At 3 weeks, the cast is changed to a below-knee cast and full weight-bearing is allowed. The Kirschner wires can be removed at 8 to 12 weeks.   

A

B

C

D

FIGURE 34.39 A, Preoperative standing anteroposterior radiographs of ankle in an 8-year, 6-month-old boy with symptomatic flexible pes planus. Note valgus alignment of tibiotalar axis (11 degrees valgus), increased fibular station (station 1), and distal tibial epiphyseal wedging (index 0.55). Standing anteroposterior (B) and lateral (C) radiographs 1 year, 3 months after placement of transphyseal medial malleolar screw. Tibiotalar axis is improved (3 degrees varus), whereas fibular station and epiphyseal wedging are unchanged. Note position of screw in both planes, subtle distal tibial metaphyseal deformity, and obliquity of physis created by screw. D, Standing anteroposterior radiograph of ankle 1 year, 4 months after screw removal. With release of medial tether and resumption of complete physeal growth, ankle valgus recurred (6 degrees valgus). (From Davids JR, Valadie AL, Ferguson RL, et al: Surgical management of ankle valgus in children: use of a transphyseal medial malleolar screw, J Pediatr Orthop 17:3, 1997.) SEE TECHNIQUE 34.33.

Make a second incision over the distal third of the fibula and perform an oblique osteotomy beginning laterally and extending distally and medially, depending on the degree of valgus to be corrected. n  Make the medial-based wedge osteotomy as distal on the tibia as possible (Fig. 34.40A). n  At the time of correction of the valgus, rotate the distal fragment internally to correct external tibial torsion. n  Use two Kirschner wires to temporarily hold the fragments in place, and obtain radiographs to evaluate correction of the valgus deformity. The talus should be horizontal and the lateral malleolus lower than the medial malleolus. n 

Rotational deformities of the lower extremity can cause functional problems in patients with myelomeningocele. Out-toeing can result either from an external rotation deformity of the hip or from external tibial torsion and can lead to abnormal knee stress, primarily valgus, as well as difficulties with brace fitting. Internal rotation osteotomies should be considered in children with 20 degrees or more of tibial torsion that interferes with gait. In-toeing can cause difficulties with foot clearance during swing phase of gait. In-toeing frequently occurs in patients with L4 or L5 lesions because of an imbalance between the medial and lateral hamstrings. The hamstrings tend to remain active during the stance phase of gait and, when the biceps femoris is paralyzed, the muscle imbalance produces an in-toeing gait. Another cause for intoeing is residual internal tibial torsion. Rotation deformity of the hip and external and internal tibial torsion can be corrected by derotation osteotomies. Dynamic in-toeing gait can be corrected by transferring the semitendinosus laterally to the biceps tendon.

KNEE

Knee deformities are common in patients with myelomeningocele and can cause significant difficulties in maintaining ambulatory function. Deformities of the knee in patients with myelomeningocele are of four types: (1) flexion contracture, (2) extension contracture, (3) valgus deformity, and (4) varus deformity.

FLEXION CONTRACTURE

Flexion contractures are more common than extension contractures. About half of children with thoracic or lumbar level lesions have knee flexion contractures. Contractures of 20 degrees are common at birth, but most correct spontaneously. Knee flexion contractures may become fixed because of (1) the typical position assumed when supine—hips in abduction, flexion, and external rotation; knees in flexion; and feet in equinus; (2) gradual contracture of the hamstring and biceps muscles, with contracture of the posterior knee capsule from quadriceps weakness and prolonged sitting; (3) spasticity of the hamstrings that may occur with the tethered cord syndrome; and (4) hip flexion contracture or calcaneal deformity in the ambulatory patient. Knee flexion contractures of more than 20 degrees can interfere with an effective bracing and standing program and ambulation in an ambulatory patient. Patients who are nonambulatory may tolerate larger degrees of flexion contractures as long as it does not interfere with transfers and sitting balance. Radical flexor release usually is required for contractures of 20 to 30 degrees, especially in children who walk with below-knee orthoses.

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A

B

C

FIGURE 34.40 Supramalleolar varus derotation osteotomy for severe ankle valgus deformity in adolescents. A, Removal of medial bone wedge from distal tibial metaphysis. B, Fixation of osteotomy with plate and screws. C, Fixation with crossed wires. SEE TECHNIQUE 34.34.

Supracondylar extension osteotomy of the femur (Fig. 34.11) generally is required for contractures of more than 30 to 45 degrees in older children who are community ambulators and in whom radical flexor release was unsuccessful. If a hip flexion contracture is present, hip and knee contractures should be corrected at the same time. Spiro et al. reported that anterior femoral epiphysiodesis by stapling is an effective and safe method for the treatment of fixed knee flexion deformity in growing children and adolescents with spina bifida. Guided growth with plate and screws also can be used to correct fixed flexion deformities. No surgical treatment is indicated in older children who are not community ambulators if the contracture does not interfere with mobility and sitting balance.   

Division of semitendinosus

Division of aponeurosis of semimembranosus

Division of gracilis

Division of aponeurosis of biceps

Femur

A Complete division of muscle and tendon of semimembranosus

Complete division of muscle and tendon of biceps femoris

RADICAL FLEXOR RELEASE TECHNIQUE 34.35 Make a medial and a lateral vertical incision just above the flexor crease. Alternatively, a vertical midline incision just above the flexor crease can be used. Z- or S-shaped incisions that cross the flexor crease should be avoided because of difficulty with skin closure after a radical flexor release. n  In a child with a high-level lesion, identify and divide the medial hamstring tendons (semitendinosus, semimembranosus, gracilis, and sartorius). n  Resect part of each tendon (Fig. 34.41A). n  Laterally, identify, divide, and resect the biceps tendon and the iliotibial band. n  In a child with a low lumbar level lesion, intramuscularly lengthen the biceps and semimembranosus to preserve some flexor power. n  Free the origin of the gastrocnemius from the medial and lateral condyles, exposing the posterior knee capsule, and perform an extensive capsulectomy (Fig. 34.41B). n  If full extension is not obtained, divide the medial and lateral collateral ligaments and the posterior cruciate ligament (Fig. 34.41C).

Femur

n 

Division of posterior fibers of iliotibial band

B Division of entire posterior capsule

Division of posterior fibers of lateral collateral ligament

Division of posterior fibers of medial collateral ligament Division of posterior cruciate ligament

C FIGURE 34.41 Release of flexor tendons for flexion contracture of knee. A, Minimal procedure. B, Additional optional procedures above joint level. C, Additional optional procedures at joint level. SEE TECHNIQUE 34.35.

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CHAPTER 34  PARALYTIC DISORDERS Close the wound over a suction drain and apply a long leg cast or brace with the knee in full extension. If the flexion contracture is greater than 45 degrees, because of the possibility of vascular problems the first cast should be applied with the knee in 20 to 30 degrees of flexion and gradually brought to full extension through serial cast changes.

n 

POSTOPERATIVE CARE  The cast is removed at 14 days, and a long leg splint is used at night. For children with low lumbar level lesions, intensive physical therapy for strengthening of the quadriceps mechanism is imperative after cast removal.   

EXTENSION CONTRACTURE

Knee extension contractures can occur in patients with myelomeningocele. Approximately two thirds have no useful muscle function in the lower extremities, one third of which are caused by unopposed quadriceps function from paralytic hamstring muscles. Extension contractures usually are bilateral and frequently are associated with other congenital anomalies, such as dislocation of the ipsilateral hip, external rotation contracture of the hip, equinovarus deformity of the foot, and occasionally valgus deformity of the knee. Knee extension contracture can impair ambulation and make wheelchair sitting and transfers difficult. Serial casting, attempting to flex the knee to at least 90 degrees, is successful in some patients. If this does not correct the contracture, lengthening of the quadriceps mechanism is indicated. The most common procedure to correct this deformity is a V-Y quadriceps lengthening, capsular release, and posterior displacement of the hamstring muscles (Fig. 34.42). This usually is done by 1 year of age. Other methods of lengthening have been described, including “anterior circumcision,” in which all of the structures in front and at the side of the knee are divided by subcutaneous tenotomy, subcutaneous release of quadriceps tendon, Z-plasty of the extensor mechanism combined with anterior capsulotomy, and subcutaneous release of the patellar ligament. 

VARUS OR VALGUS DEFORMITY

Varus or valgus deformity of the knee can occur in patients with myelomeningocele and can result from abnormal trunk mechanics that lead to abnormal knee mechanics or from malunion of a supracondylar fracture of the femur or proximal metaphyseal fracture of the tibia. In ambulatory patients, valgus knee instability is more common. This is caused by several reasons in ambulatory patients. Weak quadriceps, gastrocnemius-soleus muscles, and hip abductors cause the knee to go into valgus as the patient displaces the hemipelvis laterally during stance phase. The amount of knee valgus is proportional to the degree of neurologic impairment. This deformity also can be associated with excessive femoral anteversion or excessive external tibial torsion. Both increase the valgus or adductor stresses at the knee during the stance phase of gait (Fig. 34.43). This eventually leads to increased joint laxity and degenerative changes around the knee. Nonoperative treatment consists of the use of forearm crutches to decrease the Trendelenburg gait. A KAFO can be used to stabilize the knee, but often they are too bulky and not well accepted by an ambulatory patient. Deformities that

A

B

FIGURE 34.42 V-Y quadricepsplasty for hyperextension contracture of the knee. A, Detachment of rectus femoris tendon from muscle of rectus femoris, vastus medialis, and vastus lateralis muscles; vastus medialis and lateralis muscles are separated from iliotibial band, lateral hamstrings, medial hamstrings, and sartorius muscles. B, When knee is flexed, hamstring muscles and tensor fascia lata slip posterior to knee axis, restoring normal function. Quadriceps muscles are repaired in lengthened position.

interfere with bracing and mobility require supracondylar or tibial osteotomy with internal fixation to correct the deformity. Hemiepiphysiodesis, stapling, or guided growth with plate and screws also can be used for correction if the angular deformity is recognized early. 

HIP

Treatment recommendations for deformities and instability around the hip in children with myelomeningocele have changed owing, in part, to the use of gait analysis. Deformities or instability of the hip in children with myelomeningocele can be caused by muscle imbalance, congenital dysplasia, habitual posture, or a combination of these three. Nearly half of children with myelomeningocele have hip subluxation or dislocation, which correlates poorly with overall hip function and ambulatory potential. Many authors found that the presence of a concentric reduction did not lead to improvements in hip range of motion, ability to ambulate, and decreased pain. The goal of current treatment protocols is to maintain hip range of motion through contracture prevention and release rather than obtaining anatomic concentric reduction. Abduction or adduction contractures of the hip can cause infrapelvic obliquity that can interfere with ambulation and bracing. Hip flexion contractures with associated lumbar

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN the hip flexors (iliopsoas, sartorius, and rectus femoris), habitual posture from long periods of lying supine or sitting, and spasticity of the hip flexors. Hip flexion contractures must be distinguished from the physiologic flexion position, and the amount of hip flexion should be determined by the Thomas test. Because of a tendency to improve, hip flexion deformities rarely should be surgically treated before 24 months of age. A hip flexion contracture of 20 to 30 degrees usually can be accommodated. Increased lumbar lordosis and knee flexion often are associated with hip flexion contractures and may make a stable upright posture difficult. Surgical release is indicated for contractures that interfere with bracing, walking, or obtaining an upright posture when hip flexion contractures are greater than 30 degrees. Knee flexion contractures, which commonly occur with the hip contractures, should be corrected at the same time as the hip contracture. Anterior hip release involves release of the sartorius, rectus femoris, iliopsoas, and tensor fasciae latae muscles; the anterior hip capsule; and the iliopsoas tendon. This procedure should adequately correct flexion contractures of 60 degrees. If deformity remains after release, subtrochanteric extension osteotomy is indicated.   

A

ANTERIOR HIP RELEASE

B

FIGURE 34.43 A, Maximal coronal plane movement and posteromedial position of ground reaction force in relation to knee joint center. B, Close-up of ground reaction force during maximal coronal plane displacement of trunk. (From Gupta RT, Vankoski S, Novak RA, Dias LS: Trunk kinematics and the influence on valgus knee stress in persons with high sacral level myelomeningocele, J Pediatr Orthop 25:89, 2005.)

lordosis and knee flexion contracture may cause more disability than mobile dislocated hips. Because of the different levels of paralysis and the combination of mixed and flaccid paralysis, treatment must be individualized for each patient. An evidence-based review of hip surgery in patients with myelomeningocele found that there was no benefit to surgical treatment of dislocated hips and that walking ability was related to the degree of contracture present. The only subgroup that might benefit from surgery is children with myelomeningocele below L4 with a unilateral hip dislocation. Children in this group may have a worsened Trendelenburg gait secondary to leg-length discrepancy; however, this remains controversial. Gait analysis has shown that walking speed is unaffected by the presence of a hip dislocation in patients with low-level myelomeningocele, and gait symmetry more closely correlates to the absence of joint contractures or the presence of symmetric contractures rather than the status of the hip itself. In addition, the complication rate for surgical reduction of the hip in patients with myelomeningocele can be very high, ranging from 30% to 45%. Complications include loss of motion, pathologic fractures, worsening ambulatory function, and worsening neurologic deficits.

FLEXION CONTRACTURE

Flexion deformity of the hip occurs most frequently in children with high lumbar or thoracic level lesions. The proposed causes for a hip flexion contracture are unopposed action of

TECHNIQUE 34.36 Make a “bikini-line” skin incision slightly distal and parallel to the iliac crest, extending it obliquely along the inguinal crease. n  Identify and protect the neurovascular bundle medially. n  Identify the iliopsoas tendon as far distally as possible and divide it transversely. n  Detach the sartorius muscle from its origin on the superior iliac crest. n  Identify the rectus insertion in the anterior inferior iliac crest and detach it. n  Laterally, identify the tensor fasciae latae muscle, and, after carefully separating it from the fascia, divide the fascia transversely completely posterior to the anterior border of the gluteal muscles to expose the anterior hip capsule. n  If any residual flexion contracture remains, open the joint capsule transversely about 2 cm from the acetabular labrum. n  Place a suction drain in the wound, suture the subcutaneous tissue with interrupted sutures, and approximate the skin edges with subcuticular nylon sutures. n  Apply a hip spica cast or a total body splint with the hip in full extension, 10 degrees of abduction, and neutral rotation. n  In children with low lumbar level lesions this release greatly reduces hip flexor power and may impair mobility. A free tendon graft, using part of the tensor fasciae latae, can be used to reattach the sartorius to the anterior superior iliac crest, and the rectus tendon can be sutured distal to the sartorius muscle in the hip capsule. n 

POSTOPERATIVE CARE Early weight bearing for 2 to 3 hours a day is encouraged. The spica cast is removed at 4 to 6 weeks. If a splint is used, it can be removed for range-of-motion exercises after the wounds are healed.   

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CHAPTER 34  PARALYTIC DISORDERS

FLEXION-ABDUCTION–EXTERNAL ROTATION CONTRACTURE

Flexion-abduction–external rotation contractures are common in children with thoracic level lesions and complete paralysis of the muscles of the lower extremity. Continuous external rotation of the hip in the supine position causes contractures of the posterior hip capsule and short external rotator muscles; this occurrence may be decreased by the use of night splints (total body splints) and range-of-motion exercises. Complete hip release (see Technique 34.18) is indicated only when the deformity interferes with bracing. If both hips are contracted, as is often the case, both should be corrected at the same time. 

EXTERNAL ROTATION CONTRACTURE

Isolated external rotation contracture of the hip occasionally occurs in children with low lumbar level lesions. Initially, bracing and physical therapy help improve the external rotation contracture. If the external hip rotation persists after the child is 5 or 6 years old, a subtrochanteric medial rotation osteotomy (see Chapter 33) is indicated. 

ABDUCTION CONTRACTURE

Isolated unilateral abduction contracture is a common cause of pelvic obliquity, scoliosis, and difficulty in sitting and ambulation. It generally is caused by contracture of the tensor fasciae latae, but it may occur after iliopsoas transfer. It is common in children with high-level lesions, and early splinting and physical therapy may decrease the risk of its occurrence. Fascial release is indicated when the abduction contracture causes pelvic obliquity and scoliosis and interferes with function or bracing. 

is indicated when the contracture causes pelvic obliquity and interferes with sitting or walking. Adductor release may be combined with operative treatment of hip subluxation or dislocation.   

ADDUCTOR RELEASE TECHNIQUE 34.38 Make a transverse inguinal incision 2 to 3 cm long just distal to the inguinal crease over the adductor longus tendon. n  Open the superficial fascia to expose the adductor longus tendon. n  Using electrocautery, divide the tendon close to its insertion on the pubic ramus. n  If necessary, divide the muscle fibers of the gracilis proximally and completely divide the adductor brevis muscle fibers, taking care to protect the anterior branch of the obturator nerve. At least 45 degrees of abduction should be possible. n  Close the wound over a suction drain. n 

POSTOPERATIVE CARE  A brace or cast that holds the hip in 25 to 30 degrees of abduction can be used postoperatively. If a cast is used, it is removed at 2 weeks, and a splint is fitted with the hip in 25 degrees of abduction.   

HIP SUBLUXATION AND DISLOCATION

 

FASCIAL RELEASE TECHNIQUE 34.37 Incise the skin along the anterior one half or two thirds of the iliac crest to the anterior superior iliac spine. n  Divide all thigh fascial and tendinous structures around the anterolateral aspect of the hip: fascia lata, fascia over the gluteus medius and gluteus minimus, and tensor fasciae latae. n  Do not divide the muscle tissue, only the enveloping fascial structures. n  Fasciotomy of the fascia lata distally, as described by Yount (see Technique 34.18), also may be required. n  Close the wound over a suction drain, and apply a hip spica cast with the operated hip in neutral abduction and the opposite hip in 20 degrees of abduction, enough to permit perineal care. n 

POSTOPERATIVE CARE  The cast is removed at 2 weeks, and a total body splint is fitted.   

ADDUCTION CONTRACTURE

Adduction contractures are common with dislocation or subluxation of the hip in children with high-level lesions because of spasticity and contracture of the adductor muscles. Surgery

True developmental hip dislocation is rare in patients with myelomeningocele and occurs in children with sacral level lesions without significant muscle imbalance. Treatment should follow standard conservative methods (Pavlik harness, closed reduction, and spica cast immobilization). Teratologic dislocations usually occur in children with high-level lesions. Initial radiographs show a dysplastic acetabulum, with the head of the femur displaced proximally; these dislocations should not be treated initially. Paralytic subluxation or dislocation is the most common type, occurring in 50% to 70% of children with low-level (L3 or L4) lesions. Dislocation occurs most frequently during the first 3 years of life because of an imbalance between abduction and adduction forces. Dislocations in older children usually are caused by contractures or spasticity of the unopposed adductors and flexors associated with a tethered cord syndrome or hydromyelia. Reduction of hip dislocations in children with myelomeningocele is generally not recommended. Maintaining a level pelvis and flexible hips seems more important than reduction of the hip dislocation. The goal of treatment should be maximal function, rather than radiographic reduction. Soft-tissue release alone is indicated in patients without functional quadriceps muscles because only occasionally do they remain community ambulators as adults. Open reduction is appropriate only for rare children with sacral level involvement who have strong quadriceps muscles bilaterally, normal trunk balance, and normal upper extremity function. Bilateral or unilateral hip dislocation or subluxation in children with high-level

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN lesions does not require extensive surgical treatment, but softtissue contractures should be corrected. If treatment is undertaken for hip subluxation or dislocation in the rare patient who may benefit from it, the principles of paralytic hip surgery should be adhered to as follows: (1) obtain reduction of the hip into the acetabulum, (2) correct any residual bony deformity, and (3) balance the deforming muscle forces to prevent recurrence. The two most common procedures to balance the deforming muscle forces in an unstable hip in patients with myelomeningocele have been transfer of the iliopsoas muscle (Sharrad or Mustard procedure) and transfer of the external oblique muscle. Iliopsoas transfer with adductor release, capsulorrhaphy, and acetabuloplasty can be done in addition to open reduction. The Sharrad iliopsoas transfer through the posterolateral ilium (see Technique 34.21) is most often used. Iliopsoas transfer is controversial and is not routinely recommended; it has reported success rates ranging from 20% to 95%. Alternative procedures include transfer of the external oblique muscle to the greater trochanter (see Technique 34.19) in conjunction with femoral osteotomy and posterolateral transfer of the tensor fasciae latae with transfer of the adductor and external oblique muscles. This procedure also is controversial. Yildram et al. found no difference in functional improvement with external oblique transfer compared with surgery with internal oblique transfer.   

TRANSFER OF ADDUCTORS, EXTERNAL OBLIQUE, AND TENSOR FASCIAE LATAE TECHNIQUE 34.39 (PHILLIPS AND LINDSETH) Place the patient supine and expose the adductor muscles through a transverse incision beginning just anterior to the tendon of the adductor longus and extending posteriorly to the ischium. n  Incise the fascia longitudinally and detach the tendons of the gracilis, adductor longus and brevis, and the anterior third of the magnus from the pubis. n  Carry the dissection posteriorly to the ischial tuberosity and suture the detached origins of the adductor muscles to the ischium with nonabsorbable sutures. Take care not to disrupt the anterior branch of the obturator nerve that supplies the adductor muscles. n  Transfer the external abdominal oblique muscle to the gluteus medius tendon or preferably to the greater trochanter, as described by Thomas, Thompson, and Straub. n  Make an oblique skin incision extending from the posterior third of the iliac crest to the anterior superior iliac spine (Fig. 34.44A). n  Curve the incision distally and posteriorly to the junction of the proximal and middle third of the femur. n  With sharp and blunt dissection, raise skin flaps to expose the fascia of the leg from the lateral border of the sartorius to the level of the greater trochanter. n  Expose the external oblique similarly from the iliac crest to the posterior superior iliac spine and from its costal origin to the pubis (Fig. 34.44B). n 

Make two incisions approximately 1 cm apart in the aponeurosis of the external oblique parallel to the Poupart ligament and join them close to the pubis at the external ring. n  Extend the superior incision proximally along the medial border of the muscle belly until the costal margin is reached. n  Free the muscle from the underlying internal oblique by blunt dissection until the posterior aspect is reached in the Petit triangle. n  Elevate the muscle fibers from the iliac crest by cutting from posterior to anterior along the crest. n  Close the defect that remains in the aponeurosis of the external oblique beginning at the pubis and extending as far laterally as possible. n  Fold the cut edges of the muscle and aponeurosis over and suture with a single suture at the muscle-tendinous junction. n  Weave a heavy, nonabsorbable suture through the aponeurosis in preparation for transfer (Fig. 34.44C). n  Attention is then directed to the tensor fasciae latae. n  Detach the origin of the tensor fasciae latae from the ilium. n  Separate the muscle along its anterior border from the sartorius down to its insertion into the iliotibial band. n  Divide the iliotibial band transversely to the posterior part of the thigh. n  Carry the incision in the iliotibial band proximally to the insertion of the oblique fibers of the tensor fasciae latae and the tendon of the gluteus maximus. Take care to preserve the superior gluteal nerve and arteries beneath the gluteus medius muscle approximately 1 cm distal and posterior to the anterior superior iliac spine (Fig. 34.44D). n  Abduct the hip and fold the origin of the tensor fasciae latae back on itself to the limit allowed by the neurovascular bundle and then suture it to the ilium with nonabsorbable sutures so that its origin overlies the gluteus medius muscle. Do not attach the distal end to the gluteus maximus tendon until the end of the procedure. n  The hip, proximal femur, and ilium are now easily accessible for indicated corrective procedures such as open reduction of the hip, capsular plication, proximal femoral osteotomy, and acetabular augmentation. The origins of the rectus femoris and the psoas tendon are not routinely divided, although they can be released at this time if there is a hip flexion contracture. n  With the patient maximally relaxed or paralyzed, transfer the tendon of the external oblique to the greater trochanter. n  Drill a hole in the greater trochanter and pass the tendon of the external oblique from posterior to anterior and suture it back on itself. The muscle should reach the greater trochanter and should follow a straight line from the rib cage to the trochanter; if it does not, the borders of the muscle should be inspected to ensure that they are free from all attachments (Fig. 34.44D). n  Weave the distal end of the tensor fasciae latae through the tendon of the gluteus maximus while the hip is abducted approximately 20 degrees. n 

POSTOPERATIVE CARE  A hip spica cast is applied postoperatively with the hips in extension and abducted 20 degrees. The child is encouraged to stand in the cast to

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CHAPTER 34  PARALYTIC DISORDERS

A

B

C

D

FIGURE 34.44 Transfer of adductors, external oblique, and tensor fasciae latae. A, Skin incision. B, Skin flaps are elevated to expose fascia of leg and external oblique muscle. C, Cut edges of external oblique muscle and aponeurosis are folded over and sutured. Defect in aponeurosis is sutured. Origin of tensor fasciae latae on ilium is detached, with care being taken to preserve neurovascular bundle. Remainder of muscle is prepared for transfer. D, Tendon of external oblique is transferred to greater trochanter from posterior to anterior. Distal end of tensor fasciae latae is woven through tendon of gluteus maximus. SEE TECHNIQUE 34.39.

prevent osteopenia. The cast is removed 1 month after surgery, and physical therapy is started. The patient is returned to the braces used before the operation. Any modification in bracing is made as indicated on follow-up.   

For severe acetabular dysplasia, a shelf procedure or Chiari pelvic osteotomy (see Chapter 30) can be done at the same time as the transfer. If more than 20 to 30 degrees of abduction is necessary to maintain concentric reduction of the hip, a varus femoral osteotomy is indicated. Even with these procedures to correct acetabular dysplasia there is a high failure rate if muscle-balancing procedures are not included as part of the procedure. 

 

PROXIMAL FEMORAL RESECTION AND INTERPOSITION ARTHROPLASTY Severe joint stiffness is one of the most disabling results of hip surgery in patients with myelomeningocele. If the hip is stiff in extension, the child cannot sit; if it is stiff in flexion, the child cannot stand; if it is stiff “in between,” the child can neither sit nor stand. Resection of the femoral head and neck often is not effective. Proximal femoral resection and interposition arthroplasty are recommended in severely involved multiply handicapped children with dislocated hips and severe adduction contractures of the lower extremity.

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TECHNIQUE 34.40 (BAXTER AND D’ASTOUS) Position the patient with a sandbag beneath the affected hip. n  Make a straight lateral approach beginning 10 cm proximal to the greater trochanter and extending down to the proximal femur. n  Split the fascia lata. n  Detach the vastus lateralis and gluteus maximus from their insertions, and detach them from the greater trochanter. n  Identify the psoas tendon, and detach its distal insertion on the lesser trochanter to expose extraperiosteally the proximal femur. n  Incise the periosteum circumferentially just distal to the gluteus maximus insertion, and transect the bone at this level. n  Divide the short external rotators. Incise the capsule circumferentially at the level of the basal neck. n  Cut the ligamentous teres, remove the proximal femur, and test the range of motion of the hip. If necessary, perform a proximal hamstring tenotomy through the same incision after identifying the sciatic nerve. n  Adductor release also can be performed through a separate groin incision. n  Seal the acetabular cavity by oversewing the capsular edges. n  Cover the proximal end of the femur with the vastus lateralis and rectus femoris muscles. n  Interpose the gluteal muscles between the closed acetabulum and the covered end of the proximal femur to act as a further soft-tissue cushion. n  Close the wound in layers over a suction drain. n 

POSTOPERATIVE CARE  The operated lower extremity is placed in Russell traction in abduction until the soft tissues have healed, and then gentle range-of-motion ­exercises are begun. If traction is not tolerated, the patient can be placed in a cast or brace until the soft tissues have healed.   

PELVIC OBLIQUITY

Pelvic obliquity is common in patients with myelomeningocele. In addition to predisposing the hip to dislocation, it interferes with sitting, standing, and walking, and it can lead to ulceration under the prominent ischial tuberosity. Pelvic obliquity is an important determinant of ambulatory function, second only to neurologic level of involvement. Gait analysis has shown that pelvic obliquity has the strongest correlation with oxygen cost in ambulatory patients with myelomeningocele and that patients may self-select their walking speed to minimize the pelvic shift in the sagittal and coronal planes during gait. Mayer described three types of pelvic obliquity: (1) infrapelvic, caused by contracture of the abductor and tensor fasciae latae muscles of one hip and contracture of the adductors of the opposite hip; (2) suprapelvic, caused by uncompensated scoliosis resulting from bony deformity of the lumbosacral spine or severe paralytic scoliosis; and (3) pelvic, caused by bony deformity of the sacrum and sacroiliac joint, such as partial sacral agenesis, causing asymmetry of the pelvis. Incidence of infrapelvic obliquity can be decreased by splinting, range-of-motion exercises,

and positioning, but when hip contractures are well established, soft-tissue release is required. Occasionally, more severe deformities require proximal femoral osteotomy. Suprapelvic obliquity can be corrected by control of the scoliosis by orthoses or spinal fusion. If severe scoliosis cannot be completely corrected, bony pelvic obliquity becomes fixed. Obliquity of 20 degrees is sufficient to interfere with walking and to produce ischial decubitus ulcerations; Mayer recommended pelvic osteotomy in this instance. Before osteotomy, hip contractures should be released and the scoliosis should be corrected by spinal fusion. The degree of correction of pelvic obliquity is determined preoperatively from appropriate radiographs of the pelvis and spine (Fig. 34.45A). The maximal correction obtainable with bilateral iliac osteotomies is 40 degrees.   

PELVIC OSTEOTOMY TECHNIQUE 34.41 (LINDSETH) The approach is similar to that described by O’Phelan for iliac osteotomy to correct exstrophy of the bladder (see Chapter 30). n  With the child prone, make bilateral, inverted, L-shaped incisions beginning above the iliac crest, proceeding medially to the posterior superior iliac spine, and then curving downward along each side of the sacrum to the sciatic notch. n  Detach the iliac apophysis by splitting it longitudinally starting at the anterior superior iliac spine and proceeding posteriorly. n  Retract the paraspinal muscles, the quadratus lumborum muscle, and the iliac muscles medially along the inner half of the epiphysis and the inner periosteum of the ilium. n  After the sacral origin of the gluteus maximus has been detached from the sacrum, divide the outer periosteum of the ilium longitudinally just lateral to the posteromedial iliac border, extending from the posterior superior iliac spine down to the sciatic notch. n  Strip the outer periosteum along the gluteus muscles and the outer half of the epiphysis from the outer table of the ilium, taking care to avoid damaging the superior and inferior gluteal vessels and nerves. Retract the soft tissues down to the sciatic notch, and protect them by inserting malleable retractors. Next, make bilateral osteotomies approximately 2 cm lateral to each sacroiliac joint. The size of the wedge is determined by the amount of the correction desired and is limited to no more than one third of the iliac crest; the base of the wedge usually is about 2.5 cm long (Fig. 34.45B). n  After the wedge of bone has been removed, correct the deformity by pulling on the limb on the short side and pushing up on the limb on the long side (Fig. 34.45C). Usually this closes the osteotomy on the long side. If upper migration of the ilium onto the sacrum is severe, trim the excess iliac crest. n  Close the wedge osteotomy with two threaded pins or sutures through drill holes. n 

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CHAPTER 34  PARALYTIC DISORDERS

Angle of pelvic obliquity

A

Measure of spinal malalignment

B

C FIGURE 34.45 Pelvic osteotomy for pelvic obliquity, as described by Lindseth. A, Preoperative determination of size of iliac wedge to be removed and transferred. B, After bilateral osteotomies and removal of wedge from low side, deformity is corrected. C, Transferred iliac wedge is fixed with two Kirschner wires. SEE TECHNIQUE 34.41.

Then use a spreader to open the osteotomy on the ­opposite (short) side sufficiently to receive the graft. n  Use two Kirschner wires to hold the graft in place (Fig. 34.45C). n  Close the wound over suction-irrigation drains, and apply a double full-hip spica cast. n 

POSTOPERATIVE CARE  The cast is worn for 2 weeks. The Kirschner wires are removed when radiographs show sufficient healing of the osteotomy.   

SPINE

SCOLIOSIS

Paralytic spinal deformities have been reported in 90% of patients with myelomeningocele. Scoliosis is the most common deformity and usually is progressive. The incidence of scoliosis is related to the level of the bone defect and the level of paralysis: 100% with T12 lesions, 80% with L2 lesions, 70% with L3 lesions, 60% with L4 lesions, 25% with L5 lesions, and 5% with S1 lesions. Glard expanded on this concept by dividing patients into four neurosegmental groups based on the spinal deformities that occur within each group. Group 1 (L5 or

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN below) had no spinal deformity, group 2 (L3-L4) had variable deformities, group 3 (L1-L2) was predictive of spinal deformity, and group 4 (T12 and above) was predictive of kyphosis. The curves develop gradually until the child reaches age 10 years and may increase rapidly with the adolescent growth spurt. Raycroft and Curtis differentiated between developmental (no vertebral anomalies) and congenital (structural abnormalities of the vertebral bodies) scoliosis in patients with myelomeningocele. The two types were almost evenly divided in their patients. They suggested muscle imbalance and habitual posturing as causes of developmental scoliosis. Developmental curves occur later than congenital curves, are more flexible, and usually are in the lumbar area with compensatory curves above and below. Several authors have suggested that developmental scoliosis can be caused in some patients by hydromyelia or a tethered cord syndrome, and an early onset of scoliosis (30 years or 10–30 years

SMA II SMA III

SMA IV

Sitting

MOTOR ABILITY AND ADDITIONAL FEATURES Severe hypotonia; unable to sit or rollb Severe hypotonia; unable to sit or rollc

PROGNOSISa Respiratory insufficiency at birth; death within weeks Death/ventilation by 2 years

Survival into adulthood

Walking

Proximal weakness; unable to walk independently May lose ability to walk

Normal

Mild motor impairment

Normal life span

Normal life span

aPrognosis

varies with phenotype and supportive care interventions. for respiratory support at birth; contractures and birth; reduced fetal movements. cIa joint contractures present at birth; Ic may achieve head control. From Farrar MA, Park SB, Vucic S, et al: Emerging therapies and challenges in spinal muscular atrophy, Ann Neurol 81:335, 2017. bNeed

type I, 21 months for type II, and 50 months for type III. SMA should be considered in the differential diagnosis in children with any of the clinical characteristics associated with the disease (see Table 35.1), and these signs should prompt referral to a pediatric neurologist as well as for a SMN1 gene deletion test. In patients with SMA, the blood creatine kinase or aldolase value is normal or mildly elevated. Electromyography reveals muscle denervation. Nerve conduction velocities are normal. Genetic studies have shown the defective gene to be located on chromosome 5. In 98% of patients with SMA, deletions of either exon 7 or exon 8 have been identified in the SMN-1 gene. A second disease-modifying gene, SMN2, also plays a role in the severity of the disease. Advances in molecular biology have now made a test for these genes and their potential deletions commercially available. The five types of SMA seem to result from different mutations of the same gene. Clinical characteristics of SMA include severe weakness and hypotonia, areflexia, fine tremor of the fingers, fasciculation of the tongue, and normal sensation. Proximal muscles are affected more than distal ones, and the lower extremities are usually weaker than the upper extremities. In nonambulatory patients, variable improvement in motor function occurs up to 4 to 5 years of age, before functional ability (e.g., in upper limbs) declines between 5 and 15 years. After age 15, a relative stability in function develops with subsequent gradual decline over time. Evans, Drennan, and Russman proposed a functional classification to aid in planning long-term orthopaedic care: group I patients never develop the strength to sit independently and have poor head control; group II patients develop head control and can sit but are unable to walk; group III patients can pull themselves up and walk in a limited fashion, frequently with the use of orthoses; and group IV patients develop the ability to walk and run normally and to climb stairs before onset of the weakness. Recent advances in the medical management of SMA include the use of a compound known as nusinersen, which was released in 2016 by the FDA. It is an antisense

oligonucleotide administered intrathecally that modifies the splicing of SMN2 and increases the number of full-length protein molecules. It has been shown to improve motor function and motor milestone development in all types of SMA, with younger and asymptomatic patients, those who have not yet developed joint contractures or scoliosis, having better outcomes. Efforts are ongoing to improve drug delivery either by implantable pumps or by orally administered medications. Orthopaedic treatment is generally required for hip and spine problems. Fractures are frequent in these patients as well, especially nonambulators, with the femur, ankle, and humerus the most common sites. Joint contractures can also occur, especially in the upper extremities, and tend to worsen with age. Children with type I SMA are markedly hypotonic and generally die as a result of the disease early in life. In these patients, orthopaedic reconstruction is not warranted; however, patients with type I SMA may develop fractures that heal quickly with appropriate splinting. Many children with infantile SMA are never able to walk even with braces, but most patients with the juvenile form are able to walk for many years. Gentle passive range-of-motion exercises and positioning instructions can be beneficial initially. Surgical release of contractures is rarely required. Because of the absence of movement and weightbearing, coxa valga deformity of the hip is frequent and unilateral or bilateral hip subluxation may occur (Fig. 35.31). Because many of these children are sitters, a stable and comfortable sitting position is essential. Traditionally in nonambulatory patients, proximal femoral varus derotational osteotomy (Chapter 33) has been used to produce a more stable sitting base. Efforts to maintain the reduction of the hips for good sitting balance may prevent pain and pelvic obliquity. Observation instead of surgical intervention is generally recommended because of the small number of patients having symptoms or seating problems. Among children with SMA who survive childhood, scoliosis becomes the greatest threat during adolescence. The prevalence of scoliosis is nearly 100% in children with type II SMA and in children with type III muscular atrophy who become nonambulatory. Curves typically are long and

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN C-shaped and are most common in the thoracolumbar spine, occurring in up to 80% of patients. Scoliosis is usually progressive and severe and can limit daily function and cause cardiopulmonary problems. Bracing may be indicated during the growing years to slow curve progression, but spinal stabilization is ultimately required in almost all adolescent patients. Several authors have emphasized the importance of early surgery before the curve becomes severe and rigid. An inverse relationship between pulmonary function and scoliosis severity has been identified: for every 10 degree increase in Cobb angle, there is a 5% decrease in predicted vital capacity and a 3% decrease in peak flow. This limits the timeframe during which patients with SMA have sufficient lung capacity to successfully undergo spinal surgery without tracheostomy and mechanical ventilation. Growing rod constructs have been shown to improve spine height, space available for the lungs, and control of

FIGURE 35.31 Coxa valga deformity and subluxation in 12-yearold child with spinal muscular atrophy.

A

B

pelvic obliquity in young patients with progressive scoliosis who are too young for definitive spinal fusion. Chandran et al. and McElroy et al. reported improvement in Cobb angles, as well as in quality of life for patients and caregivers, with few complications with the use of growing rods in patients with SMA. Use of a vertical expandable prosthetic titanium rib (VEPTR; Synthes, Westchester, PA) has been reported in children with neuromuscular scoliosis, with varying results (Fig. 35.32). Livingstone et al. compared the use of growing rods (9 children) with VEPTR (11 children) in SMA and found that neither improved “parasol rib” deformity (collapse of the rib cage), although spinal deformity was better corrected with growing rods. At least one complication occurred in 83% of those with VEPTR, compared with 41% of those with growing rods. For most older patients, long posterior spinal fusion (PSF) to the pelvis is the treatment of choice. A 10-year follow-up of 11 patients with SMA who had PSF showed that PSF resulted in significant curve correction and an improvement in the rate of decline of forced vital capacity from 5.3%/ year preoperatively to 1.3%/year postoperatively. During PSF, it is important to leave a midline “window” centrally in the fusion mass, typically at L3-L4, to allow access for intrathecal injection or port placement for the administration of nusinersen (Fig. 35.33). Intraoperative and postoperative complications are frequent in these patients, and thorough preoperative evaluation is mandatory. Numerous studies have found the frequency of respiratory tract infections before surgery and the vital capacity of the lungs to be good indicators of the patient’s ability to tolerate surgery. Tracheostomy should be considered for any patient with frequent preoperative respiratory tract infections and a vital capacity of less than 35% of normal. Techniques of surgery for the treatment of neuromuscular scoliosis are described in Chapter 44.

C

D

FIGURE 35.32 A and B, Spinal deformity in a young child with spinal muscular atrophy. C and D, At the age of 5 years, 2.5 years after implantation of vertical expandable prosthetic titanium rib.

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CHAPTER 35  NEUROMUSCULAR DISORDERS

A

B FIGURE 35.33 “Skip construct” for posterior spinal fusion in a patients with SMA-2. Operative photograph (A) and radiographs (B) show rod passage under muscle flap with uninstrumented, unfused lumbar segments to allow intrathecal nusinersen injection. (Courtesy Michael G. Vitale MD.)

REFERENCES GENERAL Bengtsson NE, Seto JT, Hall JK, et al.: Progress and prospects of gene therapy clinical trials for the muscular dystrophies, Hum Mol Genet 15:R9, 2016. Brooks JT, Sponseller PD: What’s new in the management of neuromuscular scoliosis, J Pediatr Orthop 36:627, 2016. Cichos KH, Lehtonen EJ, McGwin Jr G, et  al.: Inhospital complications of patients with neuromuscular disorders undergoing total joint arthroplasty, J Am Acad Orthop Surg 27:e535, 2019. Conklin MJ, Pearson JM: The musculoskeletal aspects of obesity in neuromuscular conditions, Orthop Clin North Am 49:325, 2018. Jirka S, Aartsma-Rus A: An update on RNA-targeting therapies for neuromuscular disorders, Curr Opin Neurol 28:515, 2015. Lassche S, Janssen BH, IJzermans T, et al.: MRI-guided biopsy as a tool for diagnosis and research of muscle disorders, J Neuromuscul Dis 5:315, 2018. Mary P, Servais L, Vialle R: Neuromuscular diseases: diagnosis and management, Orthop Traumatol Surg Res 104(1S):S89, 2018. Mastrangelo M: Clinical approach to neurodegenerative disorders in childhood: an updated overview, Acta Neurol Belg, 2019 Jun 3, [Epub ahead of print]. Scoto M, Finkel R, Mercuri E, et al.: Genetic therapies for inherited neuromuscular disorders, Lancet Child Aoles Health 2:600, 2018. Smitaman E, Flores DV, Mejia Gómez C, et al.: MR imaging of atraumatic muscle disorders, Radiographics 38:500, 2018. Wagner S, Poirot I, Vuillerot C, Berard C: Tolerance and effectiveness on pain control of Pamidronate(r) intravenous infusions in children with neuromuscular disorders, Ann Phys Rehabil Med 54:348, 2011.

MUSCULAR DYSTROPHY—GENERAL Fishman FG, Goldstein EM, Peljovich AE: Surgical treatment of upper extremity contractures in Emery-Dreifuss muscular dystrophy, J Pediatr Orthop B 26:32, 2017.

Griffet J, Decrocq L, Rauscent H, et al.: Lower extremity surgery in muscular dystrophy, Orthop Traumatol Surg Res 97:634, 2011. Rahimov F, Kunkel LM: The cell biology of disease: cellular and molecular mechanisms underlying muscular dystrophy, J Cell Biol 201:499, 2013. Whitehead NP, Kim MJ, Bible KL, et al.: A new therapeutic effect of simvastatin revealed by functional improvement in muscular dystrophy, Proc Natl Acad Sci U S A 112:12864, 2015.

DUCHENNE MUSCULAR DYSTROPHY Abbs S, Tuffery-Giraud S, Bakker E, et al.: Best Practice Guidelines on molecular diagnosis in Duchenne/Becker muscular dystrophies, Neuromuscul Disord 20:422, 2010. Apkon SD, Alman B, Birnkrant DJ, et  al.: Orthopedic and surgical management of the patient with Duchenne muscular dystrophy, Pediatrics 142(Suppl 2):S82, 2018. Birnkrant DJ, Bushby K, Bann CM, et  al.: Diagnosis and management of Duchenne muscular dystrophy, part 2: respiratory, cardiac, bone health, and orthopaedic management, Lancet Neurol 17:347, 2018. Bos W, Westra AE, Pinxten W, et al.: Risks in a trial of an innovative treatment of Duchenne muscular dystrophy, Pediatrics 136:1173, 2015. Buckner JL, Bowden SA, Mahan JD: Optimizing bone health in Duchenne muscular dystrophy, Int J Endocrinol2015, 2015, 928385. Bushby K, Finkel R, Birnkrant DJ, et  al.: Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis and pharmacologic and psychosocial management, Lancet Neurology 9:77, 2010. Cheuk DK, Wong V, Wraige E, et al.: Surgery for scoliosis in Duchenne muscular dystrophy, Cochrane Database Syst Rev 10:CD005375, 2015. Choi YA, Chun SM, Kim Y, et al.: Lower extremity joint contracture according to ambulatory status in children with Duchenne muscular dystrophy, BMC Musculoskelet Disord 19:287, 2018. Crone M, Mah JK: Current and emerging therapies for Duchenne muscular dystrophy, Curr Treat Options Neurol 20:31, 2018.

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN Di Marco M, Joseph S, Horrocks I, et  al.: Fractures and bone health in Duchenne muscular dystrophy in Scotland, Neuromuscul Disord 29:342, 2019. Gordon KE, Dooley JM, Sheppard KM, et  al.: Impact of bisphosphonates on survival for patients with Duchenne muscular dystrophy, Pediatrics 127:e353, 2011. James KA, Cunniff C, Apkon SD, et al.: Risk factors for first fractures among males with Duchenne or Becker muscular dystrophy, J Pediatr Orthop 35:640, 2015. Kim S, Campbell KA, Fox DJ, et al.: Corticosteroid treatment in males with Duchenne muscular dystrophy: treatment duration and time to loss of ambulation, J Child Neurol 30:1275, 2015. Lebel DE, Corston JA, McAdam LC, et al.: Glucocorticoid treatment for the prevention of scoliosis in children with Duchenne muscular dystrophy: long-term follow-up, J Bone Joint Surg Am 95:1057, 2013. McAdam LC, Rastogi A, Macleod K, et al.: Fat embolism syndrome following minor trauma in Duchenne muscular dystrophy, Neuromuscul Disord 22:1035, 2012. McDonald CM, Mercuri E: Evidence-based care in Duchenne muscular dystrophy, Lancet Neurol 17:389, 2018. McMillan HJ: Intermittent glucocorticoid regimes for younger boys with Duchenne muscular dystrophy: balancing efficacy with side effects, Muscle Nerve 59:638, 2019. McMillan HJ, Gregas M, Darras BT, Kang PB: Serum transaminase levels in boys with Duchenne and Becker muscular dystrophy, Pediatrics 127:e132, 2011. Partridge TA: Impending therapies for Duchenne muscular dystrophy, Curr Opin Neurol 24:415, 2011. Sawnani H, Horn PS, Wong B, et al.: Comparison of pulmomary function decline in steroid-treated and steroid-naïve patients with Duchenne muscular dystrophy, J Pediatr, 2019 Apr 4, [Epub ahead of print]. Shieh PB: Duchenne muscular dystrophy: clinical trials and emerging tribulations, Curr Opin Neurol 28:542, 2015. Shieh PB: Emerging strategies in the treatment of Duchenne muscular dystrophy, Neurotherapeutics 15:840, 2018. Sienkiewicz D, Kulak W, Okurowska-Zawada B, et al.: Duchenne muscular dystrophy: current cell therapies, Ther Adv Neurol Disord 8:166, 2015. Suk KS, Lee BH, Lee HM, et al.: Functional outcomes in Duchenne muscular dystrophy scoliosis: comparison of the differences between surgical and nonsurgical treatment, J Bone Joint Surg Am 96:409, 2014. Takaso M, Nakazawa T, Imura T, et al.: Two-year results for scoliosis secondary to Duchenne muscular dystrophy fused to lumbar 5 with segmental pedicle screw instrumentation, J Orthop Sci 15:171, 2010. Verhaart IEC, Aartsma-Rus A: Therapeutic developments for Duchenne muscular dystrophy, Nat Rev Neurol, 2019 May 30, [Epub ahead of print]. Ward LM, Hadjiyannakis S, McMillan HJ, et al.: Bone health and osteoporosis management of the patient with Duchenne muscular dystrophy, Pediatrics 142(Suppl 2):S34, 2018. Wein N, Alfano L, Flanigan KM: Genetics and emerging treatments for Duchenne and Becker muscular dystrophy, Pediatr Clin North Am 62:723, 2015.

LIMB-GIRDLE DYSTROPHY Angelini C, Giaretta L, Marozzo R: An update on diagnostic options and considerations in limb-girdle dystrophies, Expert Rev Neurother 18:693, 2018. Chu ML, Moran E: The limb-girdle muscular dystrophies: is treatment on the horizon? Neurotherapeutics 15:849, 2018. Liewluck T, Milone M: Untangling the complexity of limb-girdle muscular dystrophies, Muscle Nerve 58:167, 2018. Taghizadeh E, Rezaee M, Barreto GE, et al.: Prevalence, pathological mechanisms, and genetic basis of limb-girdle muscular dystrophies: a review, J Cell Physiol, 2018 Dec 7, [Epub ahead of print]. Vissing J: Limb girdle muscular dystrophies: classification, clinical spectrum and emerging therapies, Curr Opin Neurol 29:635, 2016.

FACIOSCAPULOHUMERAL DYSTROPHY de Greef JC, Lemmers RJ, Camano P, et al.: Clinical features of facioscapulohumeral muscular dystrophy 2, Neurology 75:1548, 2010.

DeSimone AM, Pakula A, Lek A, et al.: Facioscapulohumeral muscular dystrophy, Compr Physiol 7:1229, 2017. DGerevini S, Scarlato M, Maggi L, et al.: Muscle MRI findings in facioscapulohumeral muscular dystrophy, Eur Radiol 26:693, 2016. Goselink RJM, Mul K, van Kernebeek CR, et al.: Early onset as a marker for disease severity on facioscapulohumeral muscular dystrophy, Neurology 92:e378, 2019. Goselink RJM, Schreuder THA, van Alfen N, et al.: Fascioscapulohumeral dystrophy in childhood: a nationwide natural history study, Ann Neurol 84:627, 2018. Hamel J, Tawil R: Fascioscapulohumeral muscular dystrophy: update on pathogenesis and future treatments, Neurotherapeutics 15:863, 2018. Karceski S: Diagnosis and treatment of facioscapulohumeral muscular dystrophy: 2015 guidelines, Neurology 85:e41, 2015. Mah JK, Chen YW: A pediatric review of facioscapulohumeral muscular dystrophy, J Pediatr Neurol 16:222, 2018. Steel D, Main M, Manzur A, et al.: Clinical features of facioscapulohumeral muscular dystrophy 1 in childhood, Dev Med Child Neurol, 2019 Jan 20, [Epub ahead of print]. Tawil R, Kissel JT, Heatwole C, et  al.: Evidence-based guideline summary: evaluation, diagnosis, and management of facioscapulohumeral muscular dystrophy: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the Practice Issues Review Panel of the American Association of Neuromuscular & Electrodiagnostic Medicine, Neurology 85:357, 2015. Van Tongel A, Atoun E, Narvani A, et  al.: Medium to long-term outcome of thoracoscapular arthrodesis with screw fixation for fascioscapulohumeral muscular dystrophy, J Bone Joint Surg Am 95:1404, 2013.

CONGENITAL DYSTROPHY Chakrabarty B, Sharma MC, Gulati S, et  al.: Skin biopsy for diagnosis of Ullrich congenital muscular dystrophy: an observational study, Child Neurol 32:1099, 2017. Ho G, Cardamone M, Farrar M: Congenital and childhood myotonic dystrophy: current aspect of disease and future directions, World J Clin Pediatr 4:66, 2015. Saade DN, Neuhaus SB, Foley AR, et al.: The use of muscle ultrasound in the diagnosis and differential diagnosis of congenital disorders of muscle in the age of next generation genetics, Semin Pediatr Neurol 29:44, 2019. Takaso M, Nakazawa T, Imura T, et al.: Surgical correction of spinal deformity in patients with congenital muscular dystrophy, J Orthop Sci 15:493, 2010. Theadom A, Rodrigues M, Poke G, et al.: A nationwide, population-based prevalence study of genetic muscle disorders, Neuroepidemiology 52:128, 2019.

MYOTONIC DYSTROPHY Gadalla SM, Pfeiffer RM, Kristinsson SY, et al.: Brain tumors in patients with myotonic dystrophy: a population-based study, Eur J Neurol 23:542, 2016. Johnson NE, Abbott D, Cannon-Albright LA: Relative risks for comorbidities associated with myotonic dystrophy: a population-based analysis, Muscle Nerve 52:659, 2015. Johnston NE, Ekstrom AB, Campbell C, et  al.: Parent-reported multinational study of the impact of congenital and childhood onset myotonic dystrophy, Dev Med Child Neurol 58:698, 2016. Schilling L, Forst R, Forst J, Fujak A: Orthopaedic disorders in myotonic dystrophy type 1: descriptive clinical study of 21 patients, BMC Musculoskelet Disord 14:338, 2013. Zapata-Aldana E, Ceballos-Sáenz D, Hicks R, et al.: Prenatal, neonatal, and early childhood features in congenital mytonic dystrophy, J Neuromuscul Dis 5:331, 2018.

CHARCOT-MARIE-TOOTH DISEASE Burns J, Ryan MM, Ouvrier RA: Quality of life in children with CharcotMarie-Tooth disease, J Child Neurol 25:343, 2010. Burns J, Scheinberg A, Ryan MM, et al.: Randomized trial of botulinum toxin to prevent pes cavus progression in pediatric Charcot-Marie-Tooth disease type 1A, Muscle Nerve 42:262, 2010. Cornett KMG, Menezes MP, Shy RR, et  al.: Natural history of CharcotMarie-Tooth disease during childhood, Ann Neurol 82:353, 2017.

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CHAPTER 35  NEUROMUSCULAR DISORDERS Cornett KMD, Wojciechowski E, Sman AD, et al.: Magnetic resonance imaging of the anterior compartment of the lower leg is a biomarker for weakness, disability, and impaired gait in childhood Charcot-Marie-Tooth disease, Muscle Nerve 59:213, 2019. Dreher T, Wolf SI, Heitzmann D, et al.: Tibialis posterior tendon transfer corrects the foot drop component of cavovarus foot deformity in CharcotMarie-Tooth disease, J Bone Joint Surg 96:456, 2014. Faldini C, Traina F, Nanni M, et  al.: Surgical treatment of cavus foot in Charcot-Marie-Tooth disease: a review of twenty-four cases: AAOS exhibit selection, J Bone Joint Surg 97:e30, 2015. Hoellwarth IS, Mahan ST, Spencer SA: Painful pes planovalgus: an uncommon pediatric orthopedic presentation of Charcot-Marie-Tooth disease, J Pediatr Orthop B 21:428, 2012. Karakis I, Greags M, Darras BT, et al.: Clinical correlates of Charcot-MarieTooth disease in patients with pes cavus deformities, Muscle Nerve 47:488, 2013. Kennedy RA, McGinley JL, Paterson KL, et al.: Gait and footwear in children and adolescents with Charcot-Marie-Tooth disease: a cross-sectional, case-controlled study, Gait Posture 62:262, 2018. Laurá M, Singh D, Ramdharry G, et  al.: Prevalence and orthopedic management of foot and ankle deformities in Charcot-Marie-Tooth disease, Muscle Nerve 57:255, 2018. Lin T, Gibbons P, Mudge AJ, et  al.: Surgical outcomes of cavovarus foot deformity in children with Charcot-Marie-Tooth disease, Neuromuscul Disord, 2019 Apr 29, [Epub ahead of print]. Louwerens JWK: Operative treatment algorithm for foot deformities in Charcot-Marie-Tooth disease, Oper Orthop Traumatol 30:130, 2018. Napiontek M, Pietrzak K: Joint preserving surgery versus arthrodesis in operative treatment of patients with neuromuscular polyneuropathy: questionnaire assessment, Eur J Orthop Surg Traumatol 25:391, 2015. Novais EN, Bixby SD, Rennick J, et  al.: Hip dysplasia is more severe in Charcot-Marie-Tooth disease than in developmental dysplasia of the hip, Clin Orthop Relat Res 472:665, 2014. Novais EN, Kim YJ, Carry PM, Millis MB: Periacetabular osteotomy redirects the acetabulum and improves pain in Charcot-Marie-Tooth hip dysplasia with higher complications compared with developmental dysplasia of the hip, J Pediatr Orthop 36:853, 2016. Pouwels S, de Boer A, Leufkens HG, et al.: Risk of fracture in patients with Charcot-Marie-Tooth disease, Muscle Nerve 50:919, 2014. Rose KJ, Raymond J, Regshauge K, et al.: Serial night casting increases ankle dorsiflexion range in children and young adults with Charcot-MarieTooth disease: a randomised trial, J Physiother 56:113, 2010. Saporta AS, Sottile SL, Miller LJ, et  al.: Charcot-Marie-Tooth disease subtypes and genetic testing strategies, Ann Neurol 69:22, 2011. Stover MD, Podeszwa DA, De La Rocha A, Sucato DJ: Early results of the Bernese periacetabular osteotomy for symptomatic dysplasia in CharcotMarie-Tooth disease, Hip Int 23(Suppl 9):S2, 2013. VanderHave KL, Hensinger RN, King BW: Flexible cavovarus foot in children and adolescents, Foot Ankle Clin 18:715, 2013. Yagerman SE, Cross MB, Green DW, Scher DM: Pediatric orthopedic conditions in Charcot-Marie-Tooth disease: a literature review, Curr Opin Pediatr 24:50, 2012.

FRIEDREICH ATAXIA Ashley CN, Hoang KD, Lynch DR, et al.: Childhood ataxia: clinical features, pathogenesis, key unanswered questions, and future directions, J Child Neurol 27:1095, 2012. Bodensteiner JB: Friedreich ataxia, Semin Pediatr Neurol 21:72, 2014. Cook A, Giunti P: Friedreich’s ataxia: clinical features, pathogenesis and management, Br Med Bull 124:19, 2017. Lynch DR, Seyer L: Friedreich ataxia: new findings, new challenges, Ann Neurol 76:487, 2014. Paulsen EK, Friedman LS, Myers LM, Lynch DR: Health-related quality of life in children with Friedreich ataxia, Pediatr Neurol 42:335, 2010. Sival DA, Pouwels ME, Van Brederode A, et al.: In children with Friedreich ataxia, muscle and ataxis parameters are associated, Dev Med Child Neurol 53:529, 2011. Tsirikos AI, Smith G: Scoliosis in patients with Friedreich’s ataxia, J Bone Joint Surg 94:684, 2012.

Tsou AY, Paulsen EK, Lagedrost SJ, et al.: Mortality in Friedreich ataxia, J Neurol Sci 307:46, 2011. Zhang S, Napierala M, Napierala JS: Therapeutic prospects for Friedreich’s ataxia, Trends Pharmacol Sci 40:229, 2019.

SPINAL MUSCULAR ATROPHY Cardenas J, Menier M, Heitzer MD, et al.: High healthcare resource use in hospitalized patients with a diagnosis of spinal muscular atrophy type 1 (SMA1): retrospective analysis of the Kids’ Inpatient Database (KID), Pharmaoecon Open 3:205, 2019. Chandran S, McCarthy J, Noonan K, et al.: Early treatment of scoliosis with growing rods in children with severe spinal muscular atrophy: a preliminary report, J Pediatr Orthop 31:450, 2011. Eckart M, Guenther UP, Idkowiak J, et al.: The natural course of infantile spinal muscular atrophy with respiratory distress type I (SMRD1), Pediatrics 129:e148, 2012. Fujak A, Kopschina C, Forst R, et al.: Fractures in proximal spinal muscular atrophy, Arch Orthop Trauma Surg 130:775, 2010. Fujak A, Raab W, Schuh A, et  al.: Natural course of scoliosis in proximal spinal muscular atrophy type II and IIIa: descriptive clinical study with retrospective data collection of 126 patients, BMC Musculoskelet Disord 14:283, 2013. Funk S, Lovejoy S, Mencio G, Martus J: Rigid instrumentation for neuromuscular scoliosis improves deformity correction without increasing complications, Spine 41:46, 2016. Glascock J, Sampson J, Haidet-Phillips A, et  al.: Treatment algorithm for infants diagnosed with spinal muscular atrophy through newborn screening, J Neuromuscul Dis 5:145, 2018. Goodkey K, Aslesh T, Maruyama Rm, et al.: Nusinersen in the treatment of spinal muscular atrophy, Methods Mol Biol 69:1828, 2018. Haaker G, Fujak A: Proximal spinal muscular atrophy: current orthopedic perspective, Appl Clin Genet 6:113, 2013. Halawi MJ, Lark RK, Fitch RD: Neuromuscular scoliosis: current concepts, Orthopedics 38:e452, 2015. Humphrey E, Fuller HR, Morris GE: Current research on SMN protein and treatment strategies for spinal muscular atrophy, Neuromuscul Disord 22:193, 2012. Humphrey E, Fuller HR, Morris GE: Current research on SMN protein and treatment strategies for spinal muscular atrophy, Neuromuscul Disord 22:193, 2012. Kolb SJ, Coffey CS, Yankey JW, et al.: Natural history of infantile-onset spinal muscular atrophy, Ann Neurol 82:883, 2017. Kolb SJ, Kissel JT: Spinal muscular atrophy, Neurol Clin 33:831, 2015. Lawton S, Hickerton C, Archibald AD, et al.: A mixed methods exploration of families’ experiences of the diagnosis of childhood spinal muscular atrophy, Eur J Hum Genet 23:575, 2015. Lin CW, Kalb SJ, Yeh WS: Delay in diagnosis of spinal muscular atrophy: a systematic literature review, Pediatr Neurol 53:293, 2015. Livingstone K, Zurakowski D, Snyder B: Growing Spine Study Group; Children’s Spine Study Group: Parasol rib deformity in hypotonic neuromuscular scoliosis: a new radiographical definition and a comparison of short-term treatment outcomes with VEPTR and growing rods, Spine 40:E780, 2015. McElroy MJ, Shaner AC, Crawford TO, et al.: Growing rods for scoliosis in spinal muscular atrophy: structural effects, complications, and hospital stays, Spine 36:1305, 2011. Mercuri E, Darras BT, Chiriboga CA, et al.: Nusinersen versus sham control in later-onset spinal muscular atrophy, N Engl J Med 378:625, 2018. Mesfin A, Sponseller PD, Leet AI: Spinal muscular atrophy: manifestations and management, J Am Acad Orthop Surg 20:393, 2012. Modi HN, Suh SW, Jong JY, et al.: Treatment and complications in flaccid neuromuscular scoliosis (Duchenne muscular dystrophy and spinal muscular atrophy) with posterior-only pedicle screw instrumentation, Eur J Spine 19:384, 2010. Strauss KA, Carson VJ, Brigatti KW, et al.: Preliminary safety and tolerability of a novel subcutaneous intrathecal catheter system for repeated outpatient dosing of nusinersen to children and adults with spinal muscular dystrophy, J Pediatr Orthop 38:e610, 2018.

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN Tisdale S, Pellizzoni L: Disease mechanisms and therapeutic approaches in spinal muscular atrophy, J Neurosci 35:8691, 2015. Tobert DG, Vitale MG: Strategies for treating scoliosis in children with spinal muscular atrophy, Am J Orthop 42:E99, 2013. Vai S, Bianchi ML, Moroni I, et al.: Bone and spinal muscular atrophy, Bone 79:116, 2015. Wadman RI, Bosboom WM, van den Berg LH, et al.: Drug treatment for spinal muscular atrophy type I, Cochrane Database Syst Rev (1)CD006281, 2011. Wadman RI, Bosboom WM, vanden Berg LH, et  al.: Drug treatment for spinal muscular atrophy types II and III, Cochrane Database Syst Rev (1)CD006282, 2011. White KK, Song KM, Frost N, et  al.: VEPTR growing rods for early-onset neuromuscular scoliosis: feasible and effective, Clin Orthop Relat Res 469:1335, 2011.

Winjngaarde CA, Brink RC, de Kort FAS, et  al.: Natural course of scoliosis and lifetime risk of scoliosis surgery in spinal muscular atrophy, Neurology, 2019 Jun 4, [Epub ahead of print]. Yuan P, Jiang L: Clinical characteristics of three subtypes of spinal muscular atrophy in children, Brain Dev 37:537, 2015. Wertz MH, Sahin M: Developing therapies for spinal muscular atrophy, Ann N Y Acad Sci 1366:5, 2016. Zebala LP, Bridwell KH, Baldus C, et  al.: Minimum 5-year radiographic results of long scoliosis fusion in juvenile spinal muscular atrophy patients: major curve progression after instrumented fusion, J Pediatr Orthop 31:480, 2011.

The complete list of references is available online at Expert Consult.com.

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SUPPLEMENTAL REFERENCES GENERAL Allen Jr BL, Ferguson RL: The Galveston technique of pelvic fixation with L-rod instrumentation of the spine, Spine 9:388, 1984. Bach JR: Letter to the editor, J Bone Joint Surg 77A:649, 1995. Bleck EE: Orthopaedic management of cerebral palsy, Philadelphia, 1979, Saunders. Botte MJ, Keenan MAE, Abrams RA: Heterotopic ossification in neuromuscular disorders, Orthopedics 20:335, 1997. Brumsen C, Neveen A, Hamdy T, et  al.: Long-term effects of bisphosphonates on the growing skeleton, Medicine 76:266, 1997. Canavese F, Sussman MD: Strategies of hip management in neuromuscular disorders: Duchenne muscular dystrophy, spinal muscular atrophy, Charcot-Marie-Tooth disease and arthrogryposis multiplex congenital, Hip Int 19(Suppl 6):S46, 2009. Clark MW: New developments in activity for young people with disabilities. Paper presented at Pediatric Orthopedic Society of North America, Boston, May 1986. Crawford AH, Jucharzyk D, Roy DR, et al.: Subtalar stabilization of the planovalgus foot by staple arthroereisis in young children who have neuromuscular problems, J Bone Joint Surg 72A:840, 1990. DiLiberti JH, D’Agnostino AN, Cole G: Needle muscle biopsy in infants and children, J Pediatr 103:566, 1983. Drennan JC: Orthopaedic management of neuromuscular disorders, Philadelphia, 1983, Lippincott. Drennan JC: Neuromuscular disorders. In ed 3, Morrissy RT, editor: Lovell and Winter’s pediatric orthopaedics, vol 2. Philadelphia, 1990, Lippincott. Gardner-Medwin D: Clinical features and classification of muscular dystrophies, Br Med Bull 36:109, 1980. Glorieux FH, Bishop NJ, Plotkin H, et  al.: Cyclic administration of pamidronate in children with severe osteogenesis imperfecta, N Engl J Med 339:947, 1998. Gower WR: Clinical lecture on pseudo-hypertrophic muscular paralysis, Lancet 2:1, 1879. Green NE: The orthopaedic care of children with muscular dystrophy, Instr Course Lect 36:267, 1987. Hageman G, Ippel EPF, Beemer FA, et  al.: The diagnostic management of newborns with congenital contractures: a nosologic study of 75 cases, Am J Med Genet 30:883, 1988. Inal-Ince D, Savci S, Arikan H, et al.: Effects of scoliosis on respiratory muscle strength in patients with neuromuscular disorders, Spine J 9:981, 2009. Ingram AJ: Paralytic disorders. In Crenshaw AH, editor: Campbell’s operative orthopaedics, ed 7, St. Louis, 1987, Mosby. Jablecki CK: Electromyography in infants and children, J Child Neurol 1:297, 1986. Kim H, Wenger DR: Location of acetabular deficiency and associated hip dislocation in neuromuscular hip dysplasia: three-dimensional computed tomographic analysis, J Pediatr Orthop 17:143, 1997. Koch SJ, Aergo DE, Bowser B: Outpatient rehabilitation for chronic neuromuscular diseases, Am J Phys Med Rehabil 65:245, 1986. Kunkel LM: The Welcome lecture, 1988. Muscular dystrophy: a time of hope, Proc R Soc Lond 237:1, 1989. Lonstein JE, Renshaw TS: Neuromuscular spine deformities, Instr Course Lect 36:285, 1987. Louis DS, Hensinger RN, Fraser BA, et  al.: Surgical management of the severely multiply handicapped individual, J Pediatr Orthop 9–15, 1989. Mercuri E, Pichiecchio A, Allsop J, et al.: Muscle MRI in inherited neuromuscular disorders: past, present, and future, J Magn Reson Imaging 25:433, 2007. Mubarak SJ, Chambers HG, Wenger DR: Percutaneous muscle biopsy in the diagnosis of neuromuscular disease, J Pediatr Orthop 12:191, 1992. O’Neill DL, Harris SR: Developing goals and objectives for handicapped children, Phys Ther 62:295, 1982. Rinsky LA, Gamble JG, Bleck EE: Segmental instrumentation without fusion in children with progressive scoliosis, J Pediatr Orthop 5:687, 1985. Sage FP: Inheritable progressive neuromuscular diseases. In Crenshaw AH, editor: Campbell’s operative orthopaedics, ed 7, St. Louis, 1987, Mosby.

Sanchez AA, Rathjen KE, Mubarak SJ: Subtalar staple arthroereisis for planovalgus foot deformity in children with neuromuscular disease, J Pediatr Orthop 19:34, 1999. Schwend RM, Drennan JC: Cavus foot deformity in children, J Am Acad Orthop Surg 11:201, 2003. Shapiro F, Bresnan MJ: Current concepts review: orthopaedic management of childhood neuromuscular disease, part II: diseases of muscle, J Bone Joint Surg 64A:1102, 1982. Shapiro F, Specht L: Current concepts review: the diagnosis and orthopaedic treatment of childhood spinal muscular atrophy, peripheral neuropathy, Friedreich ataxia, and arthrogryposis, J Bone Joint Surg 75A:1699, 1993. Shapiro F, Specht L: Current concepts review: the diagnosis and orthopaedic treatment of inherited muscular diseases of childhood, J Bone Joint Surg 75A:439, 1993. Shaw NJ, White CP, Fraser WD, et al.: Osteopenia in cerebral palsy, Arch Dis Child 71:235, 1994. Siegel IM: The clinical management of muscle disease: a practical manual of diagnosis and treatment, London, 1977, William Heinemann. Siegel IM: Diagnosis, management, and orthopaedic treatment of muscular dystrophy, Instr Course Lect 30:3, 1981. Tachdjian MO: Pediatric orthopedics, ed 2, Philadelphia, 1990, Saunders1990. Vedantam R, Capelli AM, Schoenecker PL: Subtalar arthroereisis for the correction of planovalgus foot in children with neuromuscular disorders, J Pediatr Orthop 18:294, 1998. Yazici M, Ahser MA, Hardacker JW: The safety and efficacy of IsolaGalveston instrumentation and arthrodesis in the treatment of neuromuscular spinal deformities, J Bone Joint Surg 82A:524, 2000.

MUSCULAR DYSTROPHY—GENERAL Angelini C: The role of corticosteroids in muscular dystrophy: a critical appraisal, Muscle Nerve 36:424, 2007. Bailey RO, Marzulo DC, Hans MB: Muscular dystrophy: infantile facioscapulohumeral muscular dystrophy—new observations, Acta Neurol Scand 74:51, 1986. Becker PE: Two new families of benign sex-linked recessive muscular dystrophy, Rev Can Biol 21:551, 1962. Berman AT, Garbarino JL, Rosenberg H, et al.: Muscle biopsy: proper surgical technique, Clin Orthop Relat Res 198:240, 1985. Bowen TR, Miller F, Mackenzie W: Comparison of oxygen consumption measurements in children with cerebral palsy to children with muscular dystrophy, J Pediatr Orthop 19:133, 1999. Brown RH, Phil D: Dystrophy-associated proteins and the muscular dystrophies, Annu Rev Med 48:457, 1997. Copeland SA, Levy O, Warner GC, et al.: The shoulder in patients with muscular dystrophy, Clin Orthop Relat Res 368:80, 1999. Gardner-Medwin D: Clinical features and classification of muscular dystrophies, Br Med Bull 36:109, 1980. Green NE: The orthopaedic care of children with muscular dystrophy, Instr Course Lect 36:267, 1987. Hsu JD, Hoffer MM: Posterior tibial tendon transfer anteriorly through the interosseous membrane, Clin Orthop Relat Res 131:202, 1978. Roy L, Gibson D: Pseudohypertrophic muscular dystrophy and its surgical management: review of 30 patients, Can J Surg 13:13, 1970. Shapiro F, Bresnan MJ: Current concepts review: orthopaedic management of childhood neuromuscular disease, part II: diseases of muscle, J Bone Joint Surg 64A:1102, 1982. Siegel IM: The clinical management of muscle disease: a practical manual of diagnosis and treatment, London, 1977, William Heinemann. Siegel IM: Diagnosis, management, and orthopaedic treatment of muscular dystrophy, Instr Course Lect 30:3, 1981. Wright JG, Smith PL, Owen JL, Fehlings D: Assessing functional outcomes of children with muscular dystrophy and scoliosis: the Muscular Dystrophy Spine Questionnaire, J Pediatr Orthop 28:840, 2008.

DUCHENNE MUSCULAR DYSTROPHY Alman BA: Duchenne muscular dystrophy and steroids: pharmacologic treatment in the absence of effective gene therapy, J Pediatr Orthop 25:554, 2005.

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN Alman BA, Kim HKW: Pelvic obliquity after fusion of the spine in Duchenne muscular dystrophy, J Bone Joint Surg 81B:821, 1999. Alman BA, Raza SN, Biggar WD: Steroid treatment and the development of scoliosis in males with Duchenne muscular dystrophy, J Bone Joint Surg 86A:519, 2004. Biggar WD, Gingras M, Fehlings DL, et  al.: Deflazacort treatment of Duchenne muscular dystrophy, J Pediatr 138:45, 2001. Bleck EE: Mobility of patients with Duchenne muscular dystrophy [letter], Dev Med Child Neurol 21:823, 1979. Bridwell KH, Baldus C, Iffrig TM, et al.: Process measures and patient/parent evaluation of surgical management of spinal deformities in patients with progressive flaccid neuromuscular scoliosis (Duchenne’s muscular dystrophy and spinal muscle atrophy), Spine 24:1300, 1999. Brook PD, Kennedy JD, Stern LM, et al.: Spinal fusion in Duchenne’s muscular dystrophy, J Pediatr Orthop 16:324, 1996. Brown JC: Muscular dystrophy, Practitioner, 226. 1982, p 1031. Brownell AKW, Paasuke RT, Elash A, et  al.: Malignant hyperthermia in Duchenne muscular dystrophy, Anesthesiology 58:180, 1983. Cambridge W, Drennan JC: Scoliosis associated with Duchenne muscular dystrophy, J Pediatr Orthop 7:436, 1987. Chamberlain JS: Gene therapy of muscular dystrophy, Hum Mol Genet 11:2355, 2002. Cheuk DK, Wong V, Wraige E, et al.: Surgery for scoliosis in Duchenne muscular dystrophy, Cochrane Database Syst Rev 1:CD005375, 2007. Connolly AM, Schierbecker J, Renna R, et al.: High-dose weekly oral prednisone improves strength in boys with Duchenne muscular dystrophy, Neuromuscul Disord 12:917, 2002. Cooper RR: Skeletal muscle and muscle disorders. In Cruess RL, Rennie WRJ, editors: Adult orthopaedics, vol 1. New York, 1984, Churchill Livingstone. Crisp DE, Ziter FA, Bray PF: Diagnostic delay in Duchenne’s muscular dystrophy, JAMA 247:478, 1982. DeSilva S, Drachman D: Prednisone treatment in Duchenne muscular dystrophy, Arch Neurol 44:818, 1987. Douglas R, Larson PF, Ambrosia RD, et  al.: The LSU reciprocation-gait orthosis, Orthopedics 6:834, 1983. Drennan JC, Bondurant M: Paralytic disorders. In American Academy of Orthopaedic Surgeons: Atlas of orthotics, ed 2, St. Louis, 1985, Mosby. Fenichel GM, Florence JM, Pestronk A, et al.: Long-term benefit from prednisone therapy in Duchenne muscular dystrophy, Neurology 41:1874, 1991. Firth M, Gardner-Medwin D, Hoskin G, et  al.: Interviews with parents of boys suffering from Duchenne muscular dystrophy, Dev Med Child Neurol 25:466, 1983. Fletcher R, Blennow G, Olsson AK, et al.: Malignant hyperthermia in a myopathic child: prolonged postoperative course requiring dantrolene, Acta Anaesth Scand 26:435, 1982. Fowler Jr WM: Rehabilitation management of muscular dystrophy and related disorders, part II: comprehensive care, Arch Phys Med Rehabil 63:322, 1982. Fowler Jr WM, Taylor M: Rehabilitation management of muscular dystrophy and related disorders, part I: the role of exercise, Arch Phys Med Rehabil 63:319, 1982. Galasko CSB, Delaney C, Morris P: Spinal stabilisation in Duchenne muscular dystrophy, J Bone Joint Surg 74B:210, 1992. Gardner-Medwin D, Johnston HM: Severe muscular dystrophy in girls, J Neurol Sci 64:79, 1984. Goertzen M, Baltzer A, Voit T: Clinical results of early orthopaedic management in Duchenne muscular dystrophy, Neuropediatrics 26:257, 1995. Granata C, Giannini S, Ballestrazzi L, et al.: Early surgery in Duchenne muscular dystrophy, Neuromuscul Disord 4:87, 1994. Green NE: The orthopaedic care of children with muscular dystrophy, Instr Course Lect 36:267, 1987. Greene W: Transfer versus lengthening of the posterior tibial tendon in Duchenne’s muscular dystrophy, Foot Ankle 13:526, 1992. Griggs RC, Moxley RT, Mendell JR, et al.: Duchenne dystrophy: randomized, controlled trial of prednisone (18 months) and azathioprine (12 months), Neurology 43:520, 2001.

Gussoni E: Dystrophin expressin in the mdx mouse restored by stem cell transplantation, Nature 401:390, 1999. Hahn A, Bach JR, Delaubier A, et al.: Clinical implications of maximal respiratory pressure determinations for individuals with Duchenne muscular dystropy, Arch Phys Med Rehabil 78:1, 1997. Hartigan-O’Connor D, Chamberlain J: Developments in gene therapy for muscular dystrophy, Microsc Res Tech 48:223, 2000. Heckmatt J, Rodillo E, Dubowitz V: Management of children: pharmacological and physical, Br Med Bull 45:788, 1987. Hoffman EP, Brown RH, Kunkel LM: Dystrophin: the protein product of Duchenne muscular dystrophy locus, Cell 51:919, 1987. Hoffman EP, Kunkel LM: Dystrophin abnormalities in Duchenne/Becker muscular dystrophy, Neuron 2:1019, 1989. Hsu JD: The natural history of spine curvature progression in the nonambulatory Duchenne muscular dystrophy patient, Spine 8:771, 1983. Hsu JD: Orthopedic approaches for the treatment of lower-extremity contractures in the Duchenne muscular dystrophy patient in the United States and Canada, Semin Neurol 15:6, 1995. Hsu JD, Hall VD, Swank S, et al.: Control of spine curvature in the Duchenne muscular dystrophy (DMD) patient. In Proceedings of the Scoliosis Research Society, Denver, 1982, Scoliosis Research Society. Hsu JD, Hsu CL: Motor unit disease. In Jahss MH, editor: Disorders of the foot, Philadelphia, 1982, Saunders. Hsu JD, Lewis JE: Challenges in the care of the retarded child with Duchenne muscular dystrophy, Orthop Clin North Am 12:73, 1981. Karol LA: Scoliosis in patients with Duchenne muscular dystrophy, J Bone Joint Surg 89A(Suppl 1):155, 2007. Kelfer HM, Singer WD, Reynolds RN: Malignant hyperthermia in a child with Duchenne muscular dystrophy, Pediatrics 71:118, 1983. Kennedy JD, Staples AJ, Brook PD, et  al.: Effect of spinal surgery on lung function in Duchenne muscular dystrophy, Thorax 50:1173, 1995. Kerr TP, Lin JP, Gresty MA, et al.: Spinal stability is improved by inducing a lumbar lordosis in boys with Duchenne muscular dystrophy: a pilot study, Gait Posture 28:108, 2008. King WM, Ruttencutter R, Nagaraja HN, et  al.: Orthopedic outcomes of long-term daily corticosteroid treatment in Duchenne muscular dystrophy, Neurology 68:1607, 2007. Kurz LT, Mubarak SJ, Schultz P, et al.: Correlation of scoliosis and pulmonary function in Duchenne muscular dystrophy, J Pediatr Orthop 3:347, 1983. Lane RJM, Robinow M, Roses AD: The genetic status of mothers of isolated cases of Duchenne muscular dystrophy, J Med Genet 20:1, 1983. LaPrade RF, Rowe DE: The operative treatment of scoliosis in Duchenne muscular dystrophy, Orthop Rev 21:39, 1992. Larson CM, Henderson RC: Bone mineral density and fractures in boys with Duchenne muscular dystrophy, J Pediatr Orthop 20:71, 2000. Leitch KK, Raza N, Biggar D, et al.: Should foot surgery be performed for children with Duchenne muscular dystrophy? J Pediatr Orthop 25:95, 2005. Lutter LD, Carlson M, Winner RB, et al: Spine curvatures in progressive muscular dystrophy. Paper presented at the Annual Meeting of the Pediatric Orthopaedic Society, Vancouver, 1984. Main M, Mercuri E, Haliloglu G, et  al.: Serial casting of the ankles in Duchenne muscular dystrophy: can it be an alternative to surgery? Neuromuscul Disord 17:277, 2007. Manzur AY, Hyde SA, Rodillo E, et al.: A randomized controlled trial of early surgery in Duchenne muscular dystrophy, Neuromuscul Disord 2:379, 1992. Manzur AY, Kuntzer T, Pike A, Swan A: Glucocorticoid corticosteroids for Duchenne muscular dystrophy, Cochrane Database Syst Rev 1:CD003725, 2008. Marchesi D, Arlet V, Stricker U, et  al.: Modification of the original Luque technique in the treatment of Duchenne’s neuromuscular scoliosis, J Pediatr Orthop 17:743, 1997. Marchildon MB: Malignant hyperthermia: current concepts, Arch Surg 117:349, 1982.

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CHAPTER 35  NEUROMUSCULAR DISORDERS McDonald CM, Abresch RT, Carter GT, et al.: Profiles of neuromuscular diseases: Duchenne muscular dystrophy, Am J Phys Med Rehabil 74(Suppl) :S70, 1995. Melkonian GJ, Cristofaro RL, Perry J, et al.: Dynamic gait electromyography study in Duchenne muscular dystrophy (DMD) patients, Foot Ankle 1:78, 1980. Mendell JR, Moxley RT, Griggs RC, et  al.: Randomized, double-blind sixmonth trial of prednisone in Duchenne’s muscular dystrophy, N Engl J Med 320:1592, 1989. Miller F, Moseley CF, Koreska J, et al.: Pulmonary function and scoliosis in Duchenne dystrophy, J Pediatr Orthop 8:133, 1988. Miller F, Moseley CF, Koreska J: Spinal fusion in Duchenne muscular dystrophy, Dev Med Child Neurol 34:775, 1992. Miller RG, Chalmers AC, Dao H, et al.: The effect of spine fusion on respiratory function in Duchenne muscular dystrophy, Neurology 41:38, 1991. Moser H: Duchenne muscular dystrophy: pathogenetic aspects and genetic prevention, Hum Genet 66:17, 1984. Mubarak SJ, Morin WD, Leach J: Spinal fusion in Duchenne muscular dystrophy—fixation and fusion to the sacropelvis? J Pediatr Orthop 13:7562, 1993. Ramirez N, Richards BS, Warren PD, et  al.: Complications after posterior spinal fusion in Duchenne’s muscular dystrophy, J Pediatr Orthop 17:109, 1997. Renshaw TS: Treatment of Duchenne’s muscular dystrophy, JAMA 248:922, 1982. Rideau Y, Duport G, Delaubier A, et al.: Early treatment to preserve quality of locomotion for children with Duchenne muscular dystrophy, Semin Neurol 15:9, 1995. Rochelle J, Bowen JR, Ray S: Pediatric foot deformities in progressive neuromuscular disease, Contemp Orthop 8:41, 1984. Scher DM, Mubarak SJ: Surgical prevention of foot deformity in patients with Duchenne muscular dystrophy, J Pediatr Orthop 22:384, 2002. Seeger BR, Caudrey DJ, Little JD: Progression of equinus deformity in Duchenne muscular dystrophy, Arch Phys Med Rehabil 66:286, 1985. Seeger BR, Sutherland AD, Clark MS: Orthotic management of scoliosis in Duchenne muscular dystrophy, Arch Phys Med Rehabil 65:83, 1984. Serrano C, Wall C, Moore SA, et al.: Gentamicin treatment for muscular dystrophy patients with stop codon mutation, Neurology 569(Suppl 3):A79, 2001. Shapiro F, Sethna N, Colan S, et al.: Spinal fusion in Duchenne muscular dystrophy: a multidisciplinary approach, Muscle Nerve 15:604, 1992. Siegel IM: Maintenance of ambulation in Duchenne muscular dystrophy: the role of the orthopedic surgeon, Clin Pediatr 19:383, 1980. Smith AD, Koreska J, Moseley CF: Progression of scoliosis in Duchenne muscular dystrophy, J Bone Joint Surg 71A:1066, 1989. Sussman MD: Duchenne muscular dystrophy, J Am Acad Orthop Surg 10:138, 2002. Sussman MD: Advantage of early spinal stabilization and fusion in patients with Duchenne muscular dystrophy, J Pediatr Orthop 4:531, 1984. Sutherland DH, Olshen R, Cooper L, et al.: The pathomechanics of gait in Duchenne muscular dystrophy, Dev Med Child Neurol 23:3, 1981. Swank SM, Brown JC, Perry RE: Spinal fusion in Duchenne’s muscular dystrophy, Spine 7:484, 1982. Velasco MV, Colin AA, Zurakowski D, et al.: Posterior spinal fusion for scoliosis in Duchenne muscular dystrophy diminishes the rate of respiratory decline, Spine (Phila Pa 1976) 32:459, 2007. Vignos PJ, Wagner MB, Kaplan JS, et al.: Predicting the success of reambulation in patients with Duchenne muscular dystrophy, J Bone Joint Surg 65A:719, 1983. Vignos PJ, Wagner MB, Karlinchak B, et  al.: Evaluation of a program for long-term treatment of Duchenne muscular dystrophy, J Bone Joint Surg 78A:1844, 1996. Wagner KR, Hamed S, Hadley DW, et al.: Gentamicin treatment of Duchenne and Becker muscular dystrophy due to nonsense mutations, Ann Neurol 49:706, 2001. Weimann RL, Gibson DA, Moseley CF, et  al.: Surgical stabilization of the spine in Duchenne muscular dystrophy, Spine 8:776, 1983.

Yasuma F, Sakai M: Scoliosis in Duchenne muscular dystrophy, Respiration 66:463, 1999.

BECKER MUSCULAR DYSTROPHY Becker PE, Kiener F: Eine neue x-chromosomale Muskeldystrophie, Arch Psychiatr Nervenkr 193:427, 1955. Brown III FR, Voigt R, Singh AK, et al.: Peroxisomal disorders: neurodevelopmental and biochemical aspects, Am J Dis Child 147:617, 1993. Emery AEH, Skinner R: Clinical studies in benign (Becker type) X-linked muscular dystrophy, Clin Genet 10:189, 1976. Fowler Jr WM: Rehabilitation management of muscular dystrophy and related disorders, part II: comprehensive care, Arch Phys Med Rehabil 63:322, 1982. Grimm T: Genetic counseling in Becker type X-linked muscular dystrophy, part I: theoretical considerations, Am J Med Genet 18:713, 1984. Grimm T: Genetic counseling in Becker type X-linked muscular dystrophy, part II: practical considerations, Am J Med Genet 18:719, 1984. Herrmann FH, Spiegler AWJ: Carrier detection in X-linked Becker muscular dystrophy by muscle provocation test (MPT), J Neurol Sci 62:141, 1983. Khan RH, MacNicol MF: Bilateral patellar subluxation secondary to Becker muscular dystrophy: a case report, J Bone Joint Surg 64A:777, 1982. Kloster R: Benign X-linked muscular dystrophy (Becker type): a kindred with very slow rate of progression, Acta Neurol Scand 68:344, 1983. McDonald CM, Abresch RT, Carter GT, et  al.: Profiles of neuromuscular diseases: Becker’s muscular dystrophy, Am J Phys Med Rehabil 74(Supp l):S93, 1995.

LIMB-GIRDLE DYSTROPHY Bönnermann CG: Limb-girdle muscular dystrophy in childhood, Pediatr Ann 34:569, 2005. Fowler Jr WM: Rehabilitation management of muscular dystrophy and related disorders, part II: comprehensive care, Arch Phys Med Rehabil 63:322, 1982. Fowler Jr WM, Nayak NN: Slowly progressive proximal weakness: limb-girdle syndromes, Arch Phys Med Rehabil 64:527, 1983. McDonald CM, Johnson ER, Abresch RT, et al.: Profiles of neuromuscular diseases: limb-girdle syndromes, Am J Phys Med Rehabil 74(Suppl):S117, 1995. Moore SA, Shilling CJ, Westra S, et al.: Limb-girdle muscular dystrophy in the United States, J Neuropathol Exp Neurol 65:995, 2006.

EMERY-DREIFUSS MUSCULAR DYSTROPHY Morrison P, Jago RH: Emery-Dreifuss muscular dystrophy, Anesthesia 46(33), 1991. Shapiro F, Specht L: Orthopedic deformities in Emery-Dreifuss muscular dystrophy, J Pediatr Orthop 11:336, 1991. Zacharias AS, Wagener ME, Warren ST, et al.: Emery-Dreifuss muscular dystrophy, Semin Neurol 19:67, 1999.

FACIOSCAPULOHUMERAL DYSTROPHY Berne D, Laude F, Laporte C, et al.: Scapulothoracic arthrodesis in facioscapulohumeral muscular dystrophy, Clin Orthop Relat Res 409:106, 2003. Diab M, Darras BT, Shapiro F: Scapulothoracic fusion for facioscapulohumeral dystrophy, J Bone Joint Surg 87A:2267, 2005. Fowler Jr WM: Rehabilitation management of muscular dystrophy, and related disorders, part II: comprehensive care, Arch Phys Med Rehabil 63:322, 1982. Jakab E, Gledhill RB: Simplified technique for scapulocostal fusion in the facioscapulohumeral dystrophy, J Pediatr Orthop 13:749, 1993. Kocialkowski A, Frostick SP, Wallace WA: One-stage bilateral thoracoscapular fusion using allografts, Clin Orthop Relat Res 273:264, 1991. Krishnan SG, Hawkins RJ, Michelotti JD, et al.: Scapulothoracic arthrodesis: indications, technique, and results, Clin Orthop Relat Res 435:126, 2005. Lee CS, Kang SJ, Hwang CJ, et al.: Early-onset facioscapulohumeral muscular dystrophy—significance of pelvic extensors in sagittal spinal imbalance, J Pediatr Orthop B 18:325, 2009.

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PART X  NERVOUS SYSTEM DISORDERS IN CHILDREN Letournel E, Fardeau M, Lytle JO, et  al.: Scapulothoracic arthrodesis for patients who have facioscapulohumeral muscular dystrophy, J Bone Joint Surg 72A:78, 1990. Mackenzie WG, Riddle EC, Earley JL, et al.: A neurovascular complication after scapulothoracic arthrodesis, Clin Orthop Relat Res 408:157, 2003. McGarry J, Garg B, Silbert S: Death in childhood due to facioscapulohumeral dystrophy, Acta Neurol Scand 68:61, 1983. Padberg G, Erikson AW, Volkers WS, et  al.: Linkage studies in autosomal dominant facioscapulohumeral muscular dystrophy, J Neurol Sci 65:261, 1984. Shapiro F, Specht L, Korf BR: Locomotor problems in infantile facioscapulohumeral muscular dystrophy, Acta Orthop Scand 62:367, 1991. Twyman RS, Harper GD: Thoracoscapular fusion in fascioscapulohumeral dystrophy: clinical review of a new surgical method, J Shoulder Elbow Surg 5(3):201, 1996.

CONGENITAL DYSTROPHY Cornelio F, Di Donato S: Myopathies due to enzyme deficiencies, J Neurol 232:329, 1985. Cunliffe M, Burrows FA: Anaesthetic implications of nemaline rod myopathy, Can Anaesth Soc J 32:543, 1985. Eeg-Olofsson O, Henriksson KG, Thornell LE, et  al.: Early infant death in nemaline (rod) myopathy, Brain Dev 5:53, 1983. Fowler Jr WM: Rehabilitation management of muscular dystrophy and related disorders, part II: comprehensive care, Arch Phys Med Rehabil 63:322, 1982. Jones R, Kahn R, Hughes S, et al.: Congenital muscular dystrophy: the importance of early diagnosis and orthopaedic management in the long-term prognosis, J Bone Joint Surg 61B:13, 1979. McMenamin JB, Becker LE, Murphy EG: Congenital muscular dystrophy: a clinicopathologic report of 24 cases, J Pediatr 100:692, 1982. McMenamin JB, Becker LE, Murphy EG: Fukuyama-type congenital muscular dystrophy, J Pediatr 100:580, 1982. Mercuri E, Longman C: Congenital muscular dystrophy, Pediatr Ann 34:560, 2005. Peat RA, Smith JM, Compton AG, et al.: Diagnosis and etiology of congenital muscular dystrophy, Neurology 71:312, 2008.

MYOTONIC DYSTROPHY Begin R, Bureau MA, Lupien L, et  al.: Pathogenesis of respiratory insufficiency in myotonic dystrophy: the mechanical factors, Am Rev Respir Dis 125:312, 1982. Canavese F, Sussman MD: Orthopaedic manifestations of congenital myotonic dystrophy during childhood and adolescence, J Pediatr Orthop 29:208, 2009. Hawley RJ, Gottdiener JS, Gay JA, et al.: Families with myotonic dystrophy with and without cardiac involvement, Arch Intern Med 143:2134, 1983. Johnson ER, Abresch RT, Carter GT, et al.: Profiles of neuromuscular diseases: myotonic dystrophy, Am J Phys Med Rehabil 74(Suppl):104, 1995. O’Brien TA, Harper PS: Course, prognosis and complications of childhoodonset myotonic dystrophy, Dev Med Child Neurol 26:62, 1984. Ray S, Bowen JR, Marks HG: Foot deformity in myotonic dystrophy, Foot Ankle 5:125, 1984.

CHARCOT-MARIE-TOOTH DISEASE Aktas S, Sussman MD: The radiological analysis of pes cavus deformity in Charcot Marie Tooth disease, J Pediatr Orthop 9:137, 2000. Alexander IJ, Johnson KA: Assessment and management of pes cavus in Charcot-Marie-Tooth disease, Clin Orthop Relat Res 246:273, 1989. Azmaipairashvili Z, Riddle EC, Scavina M, et  al.: Correction of cavovarus foot deformity in Charcot-Marie-Tooth disease, J Pediatr Orthop 25:360, 2005. Bamford NS, White KK, Robinett SA, et  al.: Neuromuscular hip dysplasia in Charcot-Marie-Tooth disease type 1A, Dev Med Child Neurol 51:408, 2009. Beals TC, Nickisch F: Charcot-Marie-Tooth disease and the cavovarus foot, Foot Ankle Clin 13:259, 2008.

Bradley GW, Coleman SS: Treatment of the calcaneocavus foot deformity, J Bone Joint Surg 63A:1159, 1981. Chan G, Bowen JR, Kumar SJ: Evaluation and treatment of hip dysplasia in Charcot-Marie-Tooth disease, Orthop Clin North Am 37:203, 2006. Charcot JM, Marie P: Sur une forme particuliere d’atrophie musculaire souvent familiale debutant par les pied et les jambes et atteignant plus tard les mains, Rev Med 96, 1886. Chung KW, Suh BC, Shy ME, et  al.: Different clinical and magnetic resonance imaging features between Charcot-Marie-Tooth disease type 1A and 2A, Neuromuscul Disord 18:6–10, 2008. Coleman SS: Complex foot deformities in children, Philadelphia, 1983, Lea & Febiger. Coleman SS, Chestnut WJ: A simple test for hind foot flexibility in the cavovarus foot, Clin Orthop Relat Res 123:60, 1977. Daher YH, Lonstein JE, Winter RB, et al.: Spinal deformities in patients with Charcot-Marie-Tooth disease: a review of 21 patients, Clin Orthop Relat Res 202–219, 1986. Dejerine J, Sottas J: Sur la neurité interstitielle hypertrophique et progressive de l’enfance, CR Soc Biol 45:63, 1893. Dwyer FC: The treatment of relapsed club foot by the insertion of a wedge into the calcaneum, J Bone Joint Surg 45B:67, 1963. Fuller JE, DeLuca PA: Acetabular dysplasia and Charcot-Marie-Tooth disease in a family, J Bone Joint Surg 77A:1087, 1995. Gould N: Surgery in advanced Charcot-Marie-Tooth disease, Foot Ankle 4:267, 1984. Guyton GP: Current concepts review: orthopaedic aspects of Charcot-MarieTooth disease, Foot Ankle Int 27:1003, 2006. Guyton GP, Mann RA: The pathogenesis and surgical management of foot deformity in Charcot-Marie-Tooth disease, Foot Ankle Clin 5:317, 2000. Hayasaka K, Himoro M, Sato W, et  al.: Charcot-Marie-Tooth neuropathy type 1B is associated with mutations of the myelin P0 gene, Nat Genet 5:31, 1993. Hensinger RN, MacEwen GD: Spinal deformity associated with heritable neurologic conditions: spinal muscular atrophy, Friedreich’s ataxia, familial dysautonomia, and Charcot-Marie-Tooth disease, J Bone Joint Surg 58A:13, 1976. Hibbs RA: An operation for “claw-foot, JAMA 73:1583, 1919. International Myotonic Dystrophy Consortium: New nomenclature and DNA testing guidelines for myotonic dystrophy type-1 (DM-1), Neurology 54:1218, 2000. Jansen GA, Ferdinandusse S, Skjeldal OH, et al.: Molecular basis of Refsum disease: identification of new mutations in the phytanoyl-CoA hydroxylase cDNA, J Inherit Metab Dis 21:228, 1998. Jones R: The soldier’s foot and the treatment of common deformities of the foot, part II: claw-foot, BMJ 1:749, 1916. Kaplan L, Margulies JY, Kadari A, et al.: Aspects of spinal deformity in familial dysautonomia (Riley-Day syndrome), Eur Spine J 6:33, 1997. Karol LA, Elerson E: Scoliosis in patients with Charcot-Marie-Tooth disease, J Bone Joint Surg 89A:150, 2007. Kirkpatrick JS, Goldner JL, Goldner RD: Revision arthrodesis for tibiotalar pseudarthrosis with fibular onlay-inlay graft and internal screw fixation, Clin Orthop Relat Res 268:29, 1991. Kumar SJ, Marks HG, Bowen JR, et  al.: Hip dysplasia associated with Charcot-Marie-Tooth disease in the older child and adolescent, J Pediatr Orthop 5:511, 1985. Lorenzetti D, Pareyson D, Sghirlanzoni A, et  al.: A 1.5-Mb deletion in 17p11.2-p12 is frequently observed in Italian families with hereditary neuropathy with liability to pressure palsies, Am J Hum Genet 56:91, 1995. Lupski JR, Chance PF, Garcia CA: Inherited primary peripheral neuropathies: molecular genetics and clinical implications of CMT1A and HNPP, JAMA 270:2326, 1993. Lupski JR, de-Oca-Luna RM, Slaugenhaupt S, et al.: DNA duplication associated with Charcot-Marie-Tooth disease type 1A, Cell 66:219, 1991. Mann RA: Missirian J: Pathophysiology of Charcot-Marie-Tooth disease, Clin Orthop Relat Res 234:221, 1988. McCluskey WP, Lovell WW, Cummings RJ: The cavovarus foot deformity: etiology and management, Clin Orthop Relat Res 247:27, 1989.

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CHAPTER 35  NEUROMUSCULAR DISORDERS Medhat MA, Krantz H: Neuropathic ankle joint in Charcot-Marie-Tooth disease after triple arthrodesis of the foot, Orthop Rev 17:873, 1988. Miller GM, Hsu JD, Hoffer MM, et  al.: Posterior tibial tendon transfer: a review of the literature and analysis of 74 procedures, J Pediatr Orthop 2:363, 1982. Mubarak SJ, Van Valin SE: Osteotomies of the foot for cavus deformities in children, J Pediatr Orthop 29(3):294, 2009. Patel PI, Roa BB, Welcher AA, et al.: The gene for the peripheral myelin protein PMP-22 is a candidate for Charcot-Marie-Tooth disease type 1A, Nat Genet 1:159, 1992. Paulos L, Coleman SS, Samuelson KM: Pes cavovarus: review of a surgical approach using selective soft-tissue procedures, J Bone Joint Surg 62A:942, 1980. Refsum S: Heredopathia atactica polyneuritiformis: a familial syndrome not hitherto described, Acta Psych Neurol Suppl 38:1, 1946. Roa BB, Garcia CA, Suter U, et  al.: Charcot-Marie-Tooth disease type 1A: association with a spontaneous point mutation in the PMP22 gene, N Engl J Med 329:96, 1993. Rochelle J, Bowen JR, Ray S: Pediatric foot deformities in progressive neuromuscular disease, Contemp Orthop 8:41, 1984. Roposch A, Wedge JH: An incomplete periacetabular osteotomy for treatment of neuromuscular hip dysplasia, Clin Orthop Relat Res 431:166, 2005. Roussy G, Levy G: Sept case d’une maladie familiale particulaire: troubles de la marche, pieds, bots et areflexie tendineuse generalisée, avec accesoirement, Rev Neurol 54:427, 1926. Sabir M, Lyttle D: Pathogenesis of Charcot-Marie-Tooth disease: gait analysis and electrophysiologic, genetic, histopathologic, and enzyme studies in a kinship, Clin Orthop Relat Res184–223, 1984. Samilson RL, Dillin W: Cavus, cavovarus, and calcaneocavus: an update, Clin Orthop Relat Res 177:125, 1983. Schonk D, Coerwinkel-Driessen M, van Dalen I, et  al.: Definition of subchromosomal intervals around the myotonic dystrophy gene region at 19q, Genomics 4:384, 1989. Sherman FC, Westin GW: Plantar release in the correction of deformities of the foot in childhood, J Bone Joint Surg 63A:1382, 1981. Siffert RS, del Torto U: “Beak” triple arthrodesis for severe cavus deformity, Clin Orthop Relat Res 181:64, 1983. Speer MC, Pericak-Vance MA, Yamaoka L, et al.: Presymptomatic and prenatal diagnosis in myotonic dystrophy by genetic linkage studies, Neurology 40:671, 1990. Sporer SM, Smith BG: Hip dislocation in patients with spinal muscular atrophy, J Pediatr Orthop 23:10, 2003. Steindler A: Stripping of the os calcis, J Orthop Surg 2:8, 1920. Timmerman V, Nellis E, Van Hul W, et al.: The peripheral myelin protein gene PMP-22 is contained within the Charcot-Marie-Tooth disease type 1A duplications, Nat Genet 1:171, 1992. Tooth HH: The peroneal type of progressive muscular atrophy, London, 1886, HK Lewis1886. Valentijn LJ, Bolhuis PA, Zorn A, et al.: The peripheral myelin gene PMP-22/ GAS-3 is duplicated in Charcot-Marie-Tooth disease type IA, Nat Genet 1:166, 1992. Walker JL, Nelson KR, Stevens DB, et al.: Spinal deformity in Charcot-MarieTooth disease, Spine 19:1044, 1994. Ward CM, Dolan LA, Bennett DL, et  al.: Long-term results of reconstruction for treatment of a flexible cavovarus foot in Charcot-Marie-Tooth disease, J Bone Joint Surg 90A:2631, 2008. Wetmore RS, Drennan JC: Long-term results of triple arthrodesis in CharcotMarie-Tooth disease, J Bone Joint Surg 71A:417, 1989. Wukich DK, Bowen JR: A long-term study of triple arthrodesis for correction of pes cavovarus in Charcot-Marie-Tooth disease, J Pediatr Orthop 9:433, 1989.

FRIEDREICH ATAXIA Cady RB, Bobechko WP: Incidence, natural history, and treatment of scoliosis in Friedreich’s ataxia, J Pediatr Orthop 4:673, 1984. Labelle H, Thome S, Duhaime M, et  al.: Natural history of scoliosis in Friedreich’s ataxia, J Bone Joint Surg 68A:564, 1986.

La Pean A, Jeffries N, Grow C, et  al.: Predictors of progression in patients with Friedreich ataxia, Mov Disord 23:2026, 2008. Levitt RL, Canale ST, Cooke AJ, et al.: The role of foot surgery in progressive neuromuscular disorders in children, J Bone Joint Surg 55A:1396, 1973. Paulos L, Coleman SS, Samuelson KM: Pes cavovarus: review of a surgical approach using selective soft-tissue procedures, J Bone Joint Surg 62A:942, 1980. Rochelle J, Bowen JR, Ray S: Pediatric foot deformities in progressive neuromuscular disease, Contemp Orthop 8:41, 1984. Rothschild H, Shoji H, McCormick D: Heel deformity in hereditary spastic paraplegia, Clin Orthop Relat Res 160:48, 1981. Shapiro F, Bresnan MJ: Current concepts review: orthopaedic management of childhood neuromuscular disease, part II: peripheral neuropathies, Friedreich’s ataxia, and arthrogryposis multiplex congenita, J Bone Joint Surg 64A:949, 1982. Tynan MC, Klenerman L, Helliwell MA, et al.: Investigation of muscle imbalance in the leg in symptomatic forefoot pes cavus: a multidisciplinary study, Foot Ankle 13:489, 1992.

SPINAL MUSCULAR ATROPHY Aprin H, Bowen JR, MacEwen GD: Spine fusion in patients with spinal muscular atrophy, J Bone Joint Surg 64A:1179, 1982. Bell DF, Moseley CF, Koreska J: Unit rod segmental spinal instrumentation in the management of patients with progressive neuromuscular spinal deformity, Spine 14:1301, 1989. Daher YH, Lonstein JE, Winter RB, et al.: Spinal surgery in spinal muscular atrophy, J Pediatr Orthop 5:391, 1985. Drennan JC: Skeletal deformities in spinal muscular atrophy. In Abstracts of Association of Bone and Joint Surgeons, Clin Orthop Relat Res 133:266, 1978. Evans GA, Drennan JC, Russman BS: Functional classification and orthopaedic management of spinal muscular atrophy, J Bone Joint Surg 63B:516, 1981. Ferguson RL, Allen BL: Segmental spinal instrumentation for routine scoliotic curve, Contemp Orthop 2:450, 1980. Granata C, Merlini L, Magni E, et al.: Spinal muscular atrophy: natural history and orthopaedic treatment of scoliosis, Spine 14:760, 1989. Hahnen E, Forkert R, Marke C, et al.: Molecular analysis of candidate genes on chromosome 5q13 in autosomal recessive spinal muscular atrophy: evidence of homozygous deletions of SMN gene in unaffected individuals, Hum Mol Genet 4:1995, 1927. Hensinger RN, MacEwen GD: Spinal deformity associated with heritable neurological conditions: spinal muscular atrophy, Friedreich’s ataxia, familial dysautonomia, and Charcot-Marie-Tooth disease, J Bone Joint Surg 58A:13, 1976. Hoffmann J: Ueber chronische spinale Muskelatrophie im Kindersalter, auf familiarer Basis, Dtsch Z Nervenheulkd 3:427, 1893. Hsu JD, Grollman T, Hoffer M, et al.: The orthopaedic management of spinal muscular atrophy, J Bone Joint Surg 55B 663, 1973. Kugelberg E, Welander L: Heredofamilial juvenile muscular atrophy simulating muscular dystrophy, Arch Neurol Psychiatry 75:500, 1956. Lefebvre S, Burglen L, Reboullet S, et al.: Identification and characterization of a spinal muscular atrophy-determining gene, Cell 80–155, 1995. Merlini L, Granata C, Bonfiglioli S, et al.: Scoliosis in spinal muscular atrophy: natural history and management, Dev Med Child Neurol 31:501, 1989. Phillips DP, Roye DP, Farcy JPC, et al.: Surgical treatment of scoliosis in a spinal muscular atrophy population, Spine 15:942, 1990. JO Piasecki, Mahinpour S, Levine DB: Long-term follow-up of spinal fusion in spinal muscular atrophy, Clin Orthop Relat Res 207:44, 1986. Shapiro F, Bresnan MJ: Current concepts review: orthopaedic management of childhood neuromuscular disease, part I: spinal muscular atrophy, J Bone Joint Surg 64A:785, 1982. Sucato DJ: Spine deformity in spinal muscular atrophy, J Bone Joint Surg 89A(Suppl 1):148, 2007. van der Steege G, Grootscholten PM, van der Vlies P, et al.: PCR-based DNA test to confirm clinical diagnosis of autosomal recessive spinal muscular atrophy, Lancet 345:985, 1995. Werdnig G: Die frühinfantile progressive spinale Amyotrophie, Arch Psychiatr Nervenkr 26:706, 1894.

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FRACTURES AND DISLOCATIONS IN CHILDREN Jeffrey R. Sawyer, David D. Spence GENERAL PRINCIPLES 1493 GROWTH PLATE INJURIES 1493 OPEN FRACTURES 1494 BIRTH FRACTURES 1494 NONACCIDENTAL TRAUMA 1495 1498 CLAVICLE STERNOCLAVICULAR FRACTURES AND 1498 DISLOCATIONS LATERAL (DISTAL) CLAVICULAR FRACTURES 1498 ACROMIOCLAVICULAR DISLOCATIONS 1498 SHOULDER DISLOCATIONS 1500 PROXIMAL HUMERAL FRACTURES 1500 1500 Closed treatment 1500 Operative treatment HUMERAL SHAFT 1502 FRACTURES SUPRACONDYLAR HUMERAL FRACTURES 1502 LATERAL CONDYLAR 1510 FRACTURES Complications after lateral condylar 1512 fracture MEDIAL CONDYLAR FRACTURES 1514 Complications after medial condylar 1515 fracture MEDIAL EPICONDYLAR FRACTURES 1516 Complications after medial epicondylar fracture 1517 Chronic medial epicondyle apophysitis (Little League elbow) 1518 DISTAL HUMERAL FRACTURES 1519 Treatment 1521 CAPITELLAR FRACTURES 1521 OLECRANON FRACTURES 1521 RADIAL HEAD AND NECK 1522 FRACTURES Complications after radial neck 1528 fracture CORONOID FRACTURES 1528 ELBOW DISLOCATIONS 1528 Complications after elbow dislocation 1529

RADIAL HEAD DISLOCATIONS (MONTEGGIA FRACTURE1529 DISLOCATIONS) 1535 GALEAZZI FRACTURES NURSEMAID’S ELBOW 1536 FOREARM FRACTURES 1537 Proximal third forearm fractures 1537 1537 Middle third forearm fractures Plastic deformation and greenstick fractures 1538 Distal third forearm fractures 1538 WRIST DISLOCATIONS 1541 SCAPHOID AND CARPAL 1541 FRACTURES METACARPAL FRACTURES 1541 1542 Thumb metacarpal fractures PHALANGEAL FRACTURES 1542 1544 Distal phalangeal fracture Complications of phalangeal fractures 1544 PEDIATRIC SPINE FRACTURES AND 1544 DISLOCATIONS Cervical Spine 1545 Atlantooccipital fractures and 1545 instability Upper cervical spine (C1–C2) injuries 1545 Rotatory subluxation 1546 Lower cervical spine (C3–C7) injuries 1548 1548 Thoracolumbar spine PELVIC FRACTURES 1549 Avulsion fractures 1553 1554 Acetabular fractures HIP FRACTURES 1555 Type I, transepiphyseal 1555 separations Type II, transcervical fractures 1556 Type III, cervicotrochanteric 1557 fractures Type IV, intertrochanteric fractures 1558 1558 complications TRAUMATIC HIP DISLOCATIONS 1565 SLIPPED CAPITAL FEMORAL EPIPHYSIS 1566 Treatment 1568 In situ pin or screw fixation 1569

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Contralateral slips Open techniques Complications Osteonecrosis Chondrolysis Femoral neck fracture Continued slipping Femoroacetabular impingement FEMORAL FRACTURES Femoral shaft fractures (diaphyseal femoral fractures) Spica casting External fixation Intramedullary nailing Plating Complications Fractures of the distal femoral physis Complications KNEE FRACTURES AND DISLOCATIONS Patellar dislocations Patellar fractures Fractures of the intercondylar eminence of the tibia Tibial tuberosity fractures Osteochondral fractures Floating knee injuries TIBIAL AND FIBULAR FRACTURES Proximal tibial physeal fractures Proximal tibial metaphyseal fractures Middle and distal tibial shaft fractures Distal tibial and fibular epiphyseal fractures Triplane fractures Tillaux fractures FOOT FRACTURES Talar Fractures Talar neck fractures Fractures of the dome and lateral process of the talus Osteochondral fractures of the talus Calcaneal fractures Tarsal fractures Metatarsal and phalangeal fractures

1571 1571 1579 1579 1579 1579 1579 1580 1580 1583 1584 1587 1588 1591 1592 1593 1596 1596 1596 1599 1601 1603 1607 1608 1609 1609 1610 1612 1615 1618 1618 1619 1619 1619 1621 1621 1626 1626 1629

CHAPTER 36  FRACTURES AND DISLOCATIONS IN CHILDREN

GENERAL PRINCIPLES

Type III fractures occur through the physis and epiphysis into the joint with joint incongruity when the fracture is displaced. n  Type IV fractures occur in the metaphysis and pass through the physis and epiphysis into the joint. Joint incongruity occurs with displaced fractures. n  Type V fractures, which are usually diagnosed only in retrospect, are compression or crush fractures of the physis, producing permanent damage and growth arrest. n  Type VI fractures are caused by a shearing injury to the peripheral aspect of the physis (perichondral ring). These fractures have been classically described in lawn mower accidents when the peripheral aspect of the physis is sheared off and have a high rate of angular deformity and growth arrest. Although not completely prognostic, in general, SalterHarris types III–VI fractures have a greater risk of complications than Salter-Harris types I and II injuries. An exception might be a completely displaced Salter-Harris type I fracture that has a greater potential for growth arrest than a nondisplaced Salter-Harris type IV fracture of the distal femur. Although many Salter-Harris types I and II fractures can be treated nonoperatively, Salter-Harris types III and IV fractures usually require operative intervention, most commonly open reduction and internal fixation because of the intraarticular nature of the fracture and the potential for posttraumatic arthritis with nonanatomic reduction. Implants crossing the physis should be avoided when possible and when used should be smooth and the smallest diameter possible, and should be removed as soon as the fracture is stable (Fig. 36.3). The treatment of specific fractures and the potential for growth arrest are discussed for each specific injury. Regardless of the injury type, parents need to be educated as to the possibility of growth disturbance and the need for long-term follow-up for any physeal fracture. When growth arrest occurs, it can result in a shortening or angular deformity or both of the limb, depending on the size and the location of the growth arrest. Growth arrest most commonly results from a bony bar that crosses the physis. Although spontaneous correction of the bar with growth resumption has been reported, it is very rare. Central bars tend to lead to shortening, and peripheral bars tend to lead to angular deformity, but in most cases there are components of each. Certain fractures, such as distal femoral and distal tibial physeal fractures, have a higher rate of growth arrest and deformity than others. Once a bony bar occurs, the size and location of the bar can be determined using threedimensional imaging such as computed tomography (CT) or volumetric magnetic resonance imaging (MRI). Physeal bar resection has been tried using a variety of direct and indirect methods, and the results have been unpredictable with unsuccessful outcomes occurring in 10% to 40% of patients. In general, younger patients with smaller (6 months after index procedure) are more common than acute deep wound infections and usually are caused by indolent skin flora organisms such as Propionibacterium acnes or Staphylococcus epidermidis. The rate of late infection may be decreasing due to the fact that the risk of delayed infection is higher with stainless steel implants than with other metals now in use. In these infections, implant removal usually is necessary to eradicate the infection. 

ILEUS

Ileus is a common complication after both anterior and posterior spinal fusion. Oral feedings are resumed slowly after surgery. A multimodal approach to decreasing the rate of gastrointestinal complications, including early mobilization, decreased narcotic usage, epidural catheters, and early

feeding, have been helpful. Malnutrition is uncommon in teenagers with idiopathic scoliosis, but patients requiring a two-stage corrective procedure may become malnourished as a result of the limited oral calorie intake and increased caloric requirements associated with closely spaced surgical procedures, and nutritional consultation and supplementation including parenteral nutrition should be considered. 

SUPERIOR MESENTERIC ARTERY SYNDROME

Superior mesenteric artery syndrome can present 1 to 2 weeks after surgery as abdominal pain and distention and vomiting. It is due to compression of the duodenum between the superior mesenteric artery and the aorta that can occur after spinal deformity correction (Fig. 44.90). Risk factors include thin habitus and spinal lengthening that occurs during scoliosis correction. Prompt recognition, bowel rest and intravenous hydration, and gradual post-pyloric feeding are essential for a good outcome, which can take several weeks. General surgical and nutritional consultation are helpful. 

ATELECTASIS

Atelectasis is a common cause of fever after scoliosis surgery. Frequent turning of the patient and the use of incentive spirometry and deep breathing and coughing usually

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DURAL TEAR

AP view

Inferior vena cava Ligament of Treitz

Aorta

Stomach

Jejunum Left renal vein

The syndrome of inappropriate antidiuretic hormone secretion develops in the immediate postoperative period in up to one third of patients undergoing spinal fusion. This causes a decline in urinary output and is maximal 36 hours after surgery. If the serum osmolality is diminished and the urine osmolality is elevated, this syndrome should be considered and fluid overload should be avoided. The urinary output gradually increases in the next 2 to 3 days after surgery. 

Superior mesenteric artery

Lateral view Aorta Superior mesenteric artery

VISION LOSS

Left renal vein Duodenum Fat pad Normal

Duodenal compression

FIGURE 44.90 Superior mesenteric artery syndrome. Relationship between superior mesenteric artery and duodenum. (From Lam, DJ, Lee JZ, Chua JH, et al: Superior mesenteric artery syndrome following surgery for adolescent idiopathic scoliosis: a case series, review of the literature, and algorithm for management, J Pediatr Orthop B 23:312, 2014.)

control or prevent serious atelectasis. Inhalation therapy with intermittent positive-pressure breathing may be beneficial in cooperative patients. With current emphasis on early patient rehabilitation, significant atelectasis has become less common. 

PNEUMOTHORAX

WRONG LEVELS

Care should be taken in the operating room to identify the correct vertebral levels as there are normal variants in the number of ribs and segmentation at the lumbosacral junction. In most instances, an intraoperative radiograph with use of a marker on the vertebra is the best way to accurately identify the appropriate spinal level. 

URINARY COMPLICATIONS

Duodenal compression Duodenum

If a dural tear occurs during removal of the ligamentum flavum or insertion of a hook or wire, repair should be attempted. The laminotomy often must be enlarged to allow access to the ends of the dural tear. If repair is not done, drainage of the cerebrospinal fluid through the wound can cause problems postoperatively. Larger or non-repairable tears can be managed with soft-tissue, usually muscle or fascia, patches. When large tears are repaired or patched, the patient should be left supine for 24 hours before gradual sitting to decrease intraspinal pressure. 

At the time of subperiosteal posterior spine exposure, the pleura may be entered inadvertently, most commonly between the transverse processes on the concave side of the scoliosis. If a thoracoplasty is done at the same time, a pneumothorax is more likely to occur. Observation of the pneumothorax is probably appropriate if it is less than 20%, but chest tube insertion is needed for larger pneumothoraces. A Valsalva maneuver in conjunction with the anesthesia team should be performed intraoperatively if a pneumothorax is suspected so that a chest tube can be placed. 

Postoperative loss of vision has an incidence of 0.02% to 0.2%. In a review of a nationwide database including over 40,000 patients under the age of 18 who had surgery for idiopathic scoliosis, De la Garza-Ramos et al. found that vision loss was reported in 0.16%. Prone positioning, particularly in the Trendelenburg position, has been noted to increase intraocular pressure. This is thought to be a risk factor for postoperative loss of vision as the result of decreased perfusion of the optic nerve. Other suggested risk factors include a younger age, a history of iron deficiency anemia, and long-segment fusions. The loss of vision manifests itself during the first 2 postoperative days. Most deficits are permanent. 

LATE COMPLICATIONS PSEUDARTHROSIS

In adolescents with idiopathic scoliosis, the pseudarthrosis rate is approximately 1%, which is lower than that in patients with neuromuscular scoliosis. The most common areas of pseudarthrosis are at the thoracolumbar junction and at the distally fused segment. With more rigid and stronger implants, the pseudarthrosis may not be apparent for years. In a review of cases of nonunion with segmental instrumentation, the average time to presentation of nonunion was 3.5 years. In 23% of patients with nonunion, implant failure was detected 5 to 10 years postoperatively. The diagnosis of pseudarthrosis usually is made by oblique radiographs, a broken implant, tomograms, CT, or bone scanning (Fig. 44.91). After successful posterior fusion, the disc height anteriorly should diminish as the vertebral body continues to grow at the expense of the disc space. A large disc space anteriorly may indicate a posterior pseudarthrosis. Often, however,

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

FIGURE 44.91 Pseudarthrosis with rod fracture (arrows) 4 years after posterior spinal fusion in 18-year-old male.

the pseudarthrosis cannot be confirmed even with the most sophisticated radiographic evaluation and can be detected only by surgical exploration. If a pseudarthrosis does not cause pain or loss of correction, surgery may not be necessary. Asymptomatic pseudarthrosis is more common in the distally fused segments. A pseudarthrosis at the thoracolumbar junction is more likely to cause loss of correction and pain. During surgical exploration, the cortex is smooth and firm over the mature and intact areas of the fusion mass and the soft tissues strip away easily. Conversely, at a pseudarthrosis, the soft tissues usually are adherent and continuous into the defect; however, a narrow pseudarthrosis may be difficult to locate, especially if motion is slight. In this instance, decortication of the fusion mass in suspicious areas is indicated and a search always should be made for several pseudarthroses. An extremely difficult type of pseudarthrosis to determine is a solid fusion mass posteriorly that is not well adherent to the underlying spine and lamina. Once the pseudarthrosis has been identified, it is cleared of fibrous tissue, and the curve is reinstrumented by the application of compression over the pseudarthrosis. If this is not done, kyphotic deformity may worsen because of incompetent spinal extensor muscles from the previous surgical exposure. The pseudarthroses are treated as ordinary joints to be fused: their edges are freshened and decorticated, and autogenous bone graft is applied in addition to the instrumentation. 

CRANKSHAFT PHENOMENON

If posterior fusion alone is done in patients with a significant amount of anterior growth remaining, a crankshaft phenomenon can occur (see section on treatment of juvenile idiopathic

scoliosis). Combined anterior and posterior arthrodesis with posterior wire and hook constructs were recommended to eliminate anterior growth. More recent reports in the literature indicate that the use of posterior segmental pedicle screw instrumentation with three-column fixation may obviate the need for combined fusions. A report of 46 patients with interval or continuous pedicle screw instrumentation found that none had experienced crankshaft phenomenon at 3-year follow-up. 

POSTERIOR THORACOPLASTY

Of all the deformities caused by idiopathic scoliosis, the posterior rib prominence generally is the patient’s main concern. With thoracic pedicle instrumentation and derotation techniques, we now rarely find it necessary to perform a thoracoplasty. Chen et al. found that posterior instrumentation in combination with thoracoplasty led to a significant decrease in pulmonary function at 3 months. Eventually, the function returned to normal at 1 year postoperatively. Approximately 75% of patients have a pleural effusion on chest radiograph. If necessary for cosmetic reasons, resection of the convex ribs can improve the postoperative cosmetic result of this surgery. With the advances in posterior correction techniques and convex rib resection at the time of spinal fusion, the use of delayed thoracoplasty has fallen out of favor. 

CONCAVE RIB OSTEOTOMIES

Concave rib osteotomies can be used to help increase flexibility for very stiff curves. Cadaver studies have shown an average increase in deflection of 53%. Flexibility increased most when five or six ribs were resected. The addition of concave rib osteotomies to instrumentation and fusion procedures increases the risk of pulmonary morbidity and should

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A

B

FIGURE 44.92 Rib osteotomy. A, Rib is exposed subperiosteally 1 cm lateral to transverse process. Osteotomy is completed with microsagittal saw. B, Overlap of lateral rib segment. SEE TECHNIQUE 44.22.

be used sparingly because of the increased power of modern instrumentation systems and high complication rate associated with their use. 

 

OSTEOTOMY OF THE RIBS TECHNIQUE 44.22 (MANN ET AL.) Approach the concave ribs through the midline incision used for the instrumentation and spinal fusion. n  Retract the paraspinous muscles lateral to the tips of the concave transverse processes. When needed, use electrocautery to incise overlying tissue along the rib axis. n  Incise the periosteum along the rib axis for 1.5 cm lateral to the transverse process and use small elevators to expose the rib periosteally. n  Protect the pleura with the elevators and use a rib cutter to section the rib approximately 1 cm lateral to the transverse process (Fig. 44.92A). n  Lift the lateral rib segment with a Kocher clamp and allow it to posteriorly overlap the medial segment (Fig. 44.92B). n  Rongeur any jagged ends and place a small piece of thrombin-soaked Gelfoam between the rib and pleura for protection and hemostasis. n  Make four to six osteotomies over the apical concave vertebrae. n  Approximate the paraspinous muscles with an absorbable suture. n  Complete the instrumentation and fusion and insert a chest tube.    n 

ANTERIOR INSTRUMENTATION FOR IDIOPATHIC SCOLIOSIS

Anterior instrumentation and fusion for idiopathic scoliosis is a well-accepted procedure for certain thoracolumbar and lumbar curves, although with newer segmental posterior instrumentation systems, the use of anterior arthrodesis and

instrumentation has declined dramatically. A Lenke type 4 curve pattern in which the thoracolumbar or lumbar curve is the structural component and the main thoracic or proximal thoracic curves are nonstructural is the ideal situation for this type of procedure. Anterior instrumentation can provide derotation and correction of the curve in the coronal plane. The child must be old enough for the vertebrae to be large enough to allow screw fixation, and caution is advised in using these systems in children younger than 9 years. In general, the lowest instrumented vertebra is the lower end vertebra of the Cobb measurement. The proximal level usually is the neutral vertebra. The fusion should not extend into the compensatory thoracic curve above. On the convex bending film, the disc below the lowest instrumented vertebra should open up on both sides. This indicates that the lower vertebra selected can be made horizontal with the anterior approach. The anterior approach for thoracolumbar and lumbar curves has several potential disadvantages: chylothorax; injury to the ureter, spleen, or great vessels; retroperitoneal fibrosis; and prominent instrumentation that must be carefully isolated from the great vessels. Without careful attention to detail, a kyphosing effect can occur even with solid-rod and dual-rod anterior instrumentation systems. The attachment to the spine is through relatively cancellous vertebral bodies, and proximal screw dislodgement also is a risk. Many orthopaedic surgeons require the assistance of a thoracic or general surgeon with anterior approaches. Anterior instrumentation and fusion can also be used in the treatment of thoracic curves but has generally been replaced by posterior techniques because of the potential disadvantages of this approach, including chest cage disruption, need for a chest tube, effects on pulmonary function, the need for the assistance of a thoracic surgeon, an increased risk of progressive kyphosis because of posterior spinal growth in skeletally immature patients (Risser grade 0), and smaller vertebrae and less secure fixation, especially of the proximal screw (Fig. 44.93). The aorta can be very close to the screw tips if bicortical fixation is achieved (Fig. 44.94). A comparison of curve correction by posterior spinal fusion and thoracic pedicle screws with anterior spinal fusion by single-rod instrumentation in Lenke type 1 curves found that posterior spinal fusion by thoracic pedicle screw instrumentation provided superior instrumented correction of the main thoracic

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

A

B

C

FIGURE 44.93 A, Standing posteroanterior radiograph of patient with idiopathic scoliosis. With posterior approach, this patient would require fusion well down into the lumbar spine. B and C, Postoperative posteroanterior and lateral radiographs after anterior instrumentation. Although some loss of fixation of proximal screw is noted, patient achieved satisfactory correction and well-balanced spine in both coronal and sagittal planes by instrumentation of only thoracic spine deformity.

curves and spontaneous correction of the thoracolumbar and lumbar curves, as well as improved correction of thoracic torsion and rotation. If the curve to be instrumented is a thoracolumbar curve, a thoracoabdominal approach is required. If the curve is purely lumbar, a lumbar extraperitoneal approach can be used. 

 

THORACOABDOMINAL APPROACH TECHNIQUE 44.23 Place the patient in the lateral decubitus position with the convex side of the curve elevated. n  Make a curvilinear incision along the rib that is one level higher than the most proximal level to be instrumented. This generally is the ninth rib in most thoracolumbar curves. Make the incision along the rib and extend it distally along the anterolateral abdominal wall just lateral to the rectus abdominis muscle. n  Expose and excise the rib. n  Enter the chest and retract the lung. n  Identify the diaphragm as a separate structure; it tends to closely approximate the wall of the thoracic cage. The diaphragm can be removed in two ways. We prefer to remove it from the chest cavity and then continue with retroperitoneal dissection distally. Alternatively, the retroperitoneum can be entered below the diaphragm, and then the diaphragm can be divided. To remove the diaphragm from the chest cavity, enter the chest cavity transpleurally through the bed of the rib. Then use elec n 

trocautery to divide the diaphragm close to the chest wall. Leave a small tag of diaphragm for reattachment. n  Once the diaphragm has been reflected, expose the retroperitoneal space. n  Dissect the peritoneal cavity from underneath the internal oblique muscle and the abdominal musculature. n  Split the internal oblique and the transverse abdominal muscles in line with the skin incisions and extend the exposure distally as far as necessary. n  Identify the vertebral bodies and carefully dissect the psoas muscle laterally off the vertebral disc spaces. The psoas origin usually is at about L1. n  Divide the prevertebral fascia in the direction of the spine. n  Identify the segmental arteries over the waist of each vertebral body and isolate and ligate them in the midline. n  Expose the bone extraperiosteally. n  The exposure from T10 to L2 or L3 with this approach is simple; but more distally the iliac vessels overlie the L4 and L5 vertebrae, and exposure in this area requires more meticulous dissection and displacement of these vessels.    

 

LUMBAR EXTRAPERITONEAL APPROACH TECHNIQUE 44.24 Place the patient in the lateral decubitus position with the convex side up.

n 

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PART XII  THE SPINE Divide the segmental arteries and veins as they cross the waist of the vertebra in the midline and ligate them to control hemorrhage. n  The skin incision must be placed carefully to ensure that the most cephalad vertebra to be instrumented can be easily seen.     n 

T5 Aorta

 

DISC EXCISION TECHNIQUE 44.25

A

Once the anterior portion of the spine has been exposed, the discs can be felt as soft, rounded, protuberant areas of the spine compared with the concave surface of the vertebral body. n  Divide the annulus sharply with a long-handled scalpel (Fig. 44.96) and remove it. n  Remove the nucleus pulposus with rongeurs and curets. It is not necessary to remove the anterior or posterior longitudinal ligaments. n  Once the disc excision has been completed, remove the cartilaginous endplates with use of either ring curets or an osteotome. The posterior aspects of the cartilaginous endplates often are more easily removed with angled curets. n  Obtain hemostasis with Gelfoam soaked in thrombin unless a cell saver is in use. n  Significant correction of the curve usually occurs during the discectomies, and it becomes more flexible and more easily correctable.     n 

Diaphragm Aorta

B

T12

FIGURE 44.94 A, CT image at T5 showing good screw position. B, With descending aorta at 2-o’clock position, 26% of distal screw was thought to be adjacent to aorta at 2 mm or less. (From Kuklo TR, Lehman RA Jr, Lenke LG: Structures at risk following anterior instrumented spinal fusion for thoracic adolescent idiopathic scoliosis, J Spinal Disord Tech 18:S58, 2005.)

 

Make a midflank incision from the midline anteriorly to the midline posteriorly (Fig. 44.95A). n  Divide the abdominal oblique muscles in line with the incision (Fig. 44.95B,C). n  As the dissection leads laterally, identify the latissimus dorsi muscle as it adds another layer: the transversalis fascia and the peritoneum. The transversalis fascia and the peritoneum diverge posteriorly as the transversalis fascia lines the trunk wall, and the peritoneum turns anteriorly to encase the viscera. Posterior dissection in this plane allows access to the spine without entering the abdominal cavity. n  Repair any inadvertent entry into the peritoneum immediately because it may not be identifiable later. n  Reflect all the fat-containing areolar tissue back to the transverse fascia and the lumbar fascia, reflecting the ureter along with the peritoneum (Fig. 44.95D). n  Locate the major vessels in the midline, divide the lumbar fascia, and carefully retract the great vessels. n 

ANTERIOR INSTRUMENTATION OF A THORACOLUMBAR CURVE TECHNIQUE 44.26 After exposure of the spine and removal of the discs, staples and screws are inserted into each vertebral body, beginning proximally and working distally. n  Place an appropriate-sized staple on the lateral aspect of the vertebral body, being sure to be posterior enough to allow placement of the anterior screw. Various staple lengths are available to accommodate different-sized patients. Normally, in the lower thoracic spine, the staple is placed just anterior to the rib head. n  Impact the staple into the vertebral body (Fig. 44.97A,B). Make a pilot hole with an awl in the vertebral body, which eliminates the need to tap the screws. n 

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

A

B

C

D

FIGURE 44.95 A, Skin incision for extraperitoneal approach to lumbar and lumbosacral spine. B, Incision of fibers of external oblique muscle. C, Incision into fibers of internal oblique muscle. D, Exposure of spine before ligation of segmental vessels. SEE TECHNIQUE 44.24.

FIGURE 44.96 Disc excision. Annulus is divided with longhandled scalpel and removed. SEE TECHNIQUE 44.25.

In the posterior hole, insert a screw of appropriate diameter and length angled approximately 10 degrees posterior to anterior, perpendicular to the base of the staple. Leave the screw slightly elevated off the staple surface until the anterior screw is fully seated to prevent tilting of the staple (Fig. 44.97C). n  Place the anterior screws in a neutral but slightly anterior to posterior angular position. Once again, the goal is to place the screw perpendicular to the base of the staple n 

(Fig. 44.97D). Bicortical purchase is required at the ends of the construct and is suggested in the intermediate levels as well. Figure 44.97E shows the staples and screws inserted from T11 to L3 before rod insertion. n  Decorticate the endplates before graft placement. n  Place intervertebral structural grafts beginning in the most caudal disc and working in a proximal direction. Structural grafts are placed in the anterior aspect of the disc to facilitate lordosis (Fig. 44.97F). Posteriorly, autogenous morselized rib graft is placed against the decorticated endplates. n  Perform appropriate biplanar bending of the posterior rod. n  Engage the posterior rod proximally and cantilever it into the distal screws. Capture the rod at each level with set screws (Fig. 44.97G). The orientation of the posterior rod is shown in Figure 44.97H prior to the rod rotation maneuver. n  Place the rod grippers onto the rod and rotate it 90 degrees from posterior to anterior. This will facilitate both scoliosis correction and the production of sagittal lordosis (Fig. 44.97I). n  Perform intervertebral compression across the posterior screws after locking the apical screw and compressing from the apex to both ends (Fig. 44.97J). n  Place the anterior rod sequentially into the screws and seat and lock it with mild compression forces. This is just a stabilizing rod, and no further correction is attempted. Correction in the coronal and sagittal planes can be determined on intraoperative anteroposterior radiographs.

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A

B

C

D

L3

L1

T12

T11

F

E

L3

G

L2

L2

L1

T12

T11

H FIGURE 44.97 A-Q, Anterior instrumentation of thoracolumbar curve with dual-rod instrumentation. See text for description. (Medtronic Sofamor Danek.) SEE TECHNIQUE 44.26.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

I

J

K

L

M

N

O

P

Q

FIGURE 44.97, cont’d

Once the final position is confirmed, break off the set screws with the counterforce device (Fig. 44.97K). n  Place one or two crosslink plates to create a rectangular construct, which increases rigidity of the system. Use the crosslink plate measuring tools to determine the required implant size (Fig. 44.97L) and then grasp the appropriatesized crosslink and place it on the rods (Fig. 44.97M and N). n  The lower profile of this anterior instrumentation (Fig. 44.97O,P) allows the closure of the pleura distally to the junction of the pleura and the diaphragm. n  Complete the closure procedure. Close the diaphragm, deep abdominal layers, chest wall (after chest tube placement), muscle layers, subcutaneous tissues, and skin. n 

POSTOPERATIVE CARE The patient is allowed up on the first postoperative day. The chest tube usually is left in place for 48 to 72 hours and is removed when the drainage decreases to less than 50 mL for two consecutive 8-hour periods. A TLSO can be used for immobilization, but if the screws have good purchase, no postoperative immobilization is used. A Foley catheter is necessary to monitor urine output because urinary retention is common. An ileus is to be expected after anterior surgery and usually lasts 2 to 3 days. Temperature elevation consistent with atelectasis is common and usually responds to pulmonary therapy and ambulation as soon as the patient is capable (Fig. 44.98).   

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A

B FIGURE 44.98 A, Preoperative clinical and radiographic views of 12-year-old, skeletally immature patient. B, Clinical and radiographic views after anterior spinal fusion and instrumentation from T11 to L3. (From Lenke LG: CD Horizon Legacy Spinal System anterior dual-rod surgical technique manual, Memphis, TN, 2002, Medtronic Sofamor Danek.) SEE TECHNIQUE 44.26.

COMPLICATIONS AND PITFALLS OF ANTERIOR INSTRUMENTATION

Pitfalls and complications may be related to poor patient selection, poor level selection, or instrument technical difficulties. A common technical problem is failure of the most proximal screw (see Fig. 44.93), which can be prevented by watching this screw carefully during the derotation maneuver. At any sign of screw loosening, the correction maneuver should be stopped. Another technical problem is encountered if the screw heads are not aligned properly and one screw head is offset from the others. If one screw is off just slightly, rod placement can be difficult. Variable-angle screws or polyaxial screws allow some adjustment to account for this offset. A number of studies have emphasized the potential complications associated with an anterior approach to the spine, including respiratory insufficiency requiring ventilatory support, pneumonia, atelectasis, pneumothorax, pleural effusion, urinary tract infection, prolonged ileus, hemothorax, splenic injury, retroperitoneal fibrosis, and partial sympathectomy. Neurologic injury can occur during discectomy or screw insertion. The screws should be placed parallel to the vertebral

endplates. When the segmental vessels are ligated, the anastomosis at the intervertebral foramina should be avoided to minimize the chance of injury to the vascular supply of the spinal cord. A scoliotic deformity is approached from the convex side of the curve, and because the great vessels are inevitably on the concave side of the curve, the risk of injury to them is low. To increase purchase of the screws, however, the opposite cortex of the vertebra should be engaged by the screw, and care must be taken to be certain that the screw is not too prominent on the concave side. 

VIDEO-ASSISTED THORACOSCOPY

Video-assisted thoracoscopic surgery in the treatment of pediatric spinal deformity can be used for anterior release and instrumentation; however, it rarely is used due to similar issues related to anterior arthrodesis, a steep learning curve, and advances in posterior arthrodesis and instrumentation. Advantages of thoracoscopic surgery over open thoracotomy, in addition to better illumination and magnification at the site of surgery, include less injury to the latissimus muscle and chest wall with less long-term pain, decreased blood loss,

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Monitor

Anesthesiologist Monitor

Assistant

Spine surgeon

First assistant surgeon

Spine surgeon

Monitor

Anesthesiologist

Co-surgeon Scrub nurse

Mayo stand Scrub nurse

A

Second assistant

B

Monitor

FIGURE 44.99 A, Conventional setup for video-assisted thoracoscopic spinal surgery. B, Setup with surgeon working away from spine. SEE TECHNIQUE 44.27.

better cosmesis, shorter recovery time, improved postoperative pulmonary function, and potentially shorter hospital stays. The primary disadvantages of thoracoscopy are related to a steep learning curve and the technical demands of the procedure. Specialized equipment is required for these procedures. A general, pediatric, or thoracic surgeon familiar with thoracoscopy and open thoracotomies should be present, and the anesthesiologist should be skilled in the use of doublelumen tubes and one-lung ventilation. With the introduction of vertebral body tethering and spinal growth modulation, there has been renewed interest in thoracoscopic spinal approaches, although the exact indications and expected outcomes for vertebral body tethering remain unknown; they are a topic of active investigation. Contraindications to the thoracoscopic spinal procedure include the inability to tolerate single-lung ventilation, severe or acute respiratory insufficiency, high airway pressures with positive-pressure ventilation, emphysema, and previous thoracotomy. 

 

VIDEO-ASSISTED THORACOSCOPIC DISCECTOMY Some surgeons prefer to work facing the patient with the patient in a lateral decubitus position (Fig. 44.99A), whereas others prefer to work from behind the patient, therefore working away from the spinal cord (Fig. 44.99B). Two monitors are positioned so that they can be seen from each side of the table. Because the traditional setup for most endoscopic procedures requires members of the surgical team to be on opposite sides of the patient, and because working opposite the camera image can lead to disorientation, Horton described turning the assistant’s monitor upside down. The monitor on the posterior aspect of the patient is inverted, and once the visualization port for the camera is established, the scope is inserted into the

camera and rotated 180 degrees on the scope mount so that the camera is upside down. The assistant holding the inverted camera views the inverted monitor, which projects a normal monitor image as would be seen in an open thoracotomy (Fig. 44.100).

TECHNIQUE 44.27 (CRAWFORD) After general anesthesia is obtained by either a doublelumen endotracheal tube or a bronchial blocker for single-lung ventilation, turn the patient into the lateral decubitus position. Prepare and drape the operative field as the anesthesiologist deflates the lung. About 20 minutes is required for complete resorption atelectasis to be obtained. n  Place the upper arm on a stand with the shoulder slightly abducted and flexed more than 90 degrees to allow placement of portals higher into the axilla. Use an axillary roll to take pressure off the axillary structures. n  Identify the scapular borders, 12th rib, and iliac crest, and outline them with a marker. n  Place the first portal at or around the T6 or T7 interspace in the posterior axillary line (Fig. 44.101A). n  Make a skin incision with a scalpel and then continue with electrocautery through the intercostal muscle to enter the chest cavity. To avoid damage to the intercostal vessels and nerves, make the incision over the top of the rib. Insert a finger to be sure the lung is deflated and that it is away from the chest wall so it will not be injured when the trocar is inserted. n  Insert flexible portals through the intercostal spaces with a trocar (Fig. 44.101B,C). n  Insert a 30-degree angled, 10-mm rigid thoracoscope. Prevent fogging of the endoscope by prewarming it with warm irrigation solution and wiping the lens with a sterile fog-reduction solution. Wipe the endoscope lens intermittently with this solution to optimize visibility. Some endoscopes have incorporated irrigating and n 

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Assistant’s monitor

R7

T7

R8

Surgeon’s monitor

Assistant’s monitor 180°

T8

R8

T8

R7

Monitor Spine surgeon

T7

180°

Monitor

Assistant

Spine surgeon

A

Assistant 180°

B FIGURE 44.100 A, Thoracoscopic traditional technique. B, Thoracoscopic inversion technique. SEE TECHNIQUE 44.27.

A

Posterior axillary line

Anterior axillary line

B

C

FIGURE 44.101 A, First portal for anterior thoracoscopic release of spine created along posterior axillary line between T6 and T8 intercostal spaces. Subsequent portals are created along anterior axillary line. B, Technique of portal insertion. Fifteen- to 20-mm incision is made parallel to superior surface of rib. Flexible portal is inserted with trocar. C, Trocar is removed, leaving flexible portal in place. SEE TECHNIQUE 44.27.

windshield-like cleaning mechanisms to further simplify the procedure. n  Evaluate the intrathoracic space to determine anatomy, as well as possible sites for other portals. The superior thoracic spine usually can be seen without retraction of the lung once the lung is completely deflated; however, some retraction usually is necessary below T9-T10 because the diaphragm blocks the view. n  Once the spinal anatomy has been identified, continue to identify levels. The first rib usually cannot be seen, and the first visually identifiable rib is the second rib. Count the ribs sequentially to identify the levels to be released. Insert a long, blunt-tipped needle into the disc space and obtain a radiograph to confirm the levels intraoperatively. n  Select other portal sites after viewing from within. View the trocars with the endoscope as they are inserted. Take care on inserting the inferior portal to avoid perforation

of the diaphragm. Use a fan retractor to retract the diaphragm, but take care not to lacerate the lung. n  Divide the parietal pleura with an endoscopic cautery hook. n  Place the hook in the parietal pleura in the region of the disc, midway between the head of the rib and the anterior spine. n  Pull the pleura up and cauterize in successive movements proximally and distally, avoiding the segmental vessels. n  Identify the intervertebral discs as elevations on the spinal column and the vertebral bodies as depressions. n  For a simple anterior release, do not ligate the segmental vessels because of the risk of tearing. Bleeding can be difficult to control endoscopically. Crawford recommended coagulation of any vessels that appear to be at risk for bleeding. n  Vertebral body tethering instrumentation can be placed at this time.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS The pleura can be closed or left open. Place a chest tube through the most posterior inferior portal. Use the endoscope to observe the chest tube as it is placed along the vertebral column. Connect the chest tube to a water seal. n  Once the anesthesiologist has inflated the lung to determine whether an air leak exists, close the portals in routine fashion.    n 

TECHNIQUE 44.28

n 

PITFALLS AND COMPLICATIONS

Bleeding can be difficult to control with endoscopic surgery. A radiopaque sponge with a heavy suture attached and loaded on a sponge stick should be available at all times to apply pressure. The suture allows later retrieval of the sponge. After application of direct pressure, electrocautery should be used for hemostasis. If necessary, endoscopic clip appliers or another hemostatic agent should be used. Instrumentation for open thoracotomy should be set up on a sterile back table to avoid delays or confusion if an immediate thoracotomy is needed to control bleeding. Lung tissue can be damaged during the procedure. If an air leak occurs, it can be repaired with an endoscopic stapler. Cloudy fluid in the intervertebral disc space after irrigation and suctioning may indicate a lymphatic injury, which can be closed with an endoscopic clip applier. The thoracic duct is especially vulnerable to injury at the level of the diaphragm. If a chylothorax is discovered after closure, it is treated with a low-fat diet. A dural tear can be recognized by leakage of clear cerebrospinal fluid from the disc space. Hemostatic agents can sometimes seal small cerebrospinal fluid leaks. If a dural tear continues to leak cerebrospinal fluid, a thoracotomy and vertebrectomy with dural repair may be required. The sympathetic nerve chain on the operative side often is transected. This causes little or no morbidity; however, the surgeon needs to inform the patient and family members of the possibility of temperature and skin color changes below the level of the surgery. Postoperative pulmonary problems often involve the downside lung, in which mucous plugs can form. The anesthesiologist should suction both lungs before extubation. 

ENDOSCOPIC ANTERIOR INSTRUMENTATION OF IDIOPATHIC SCOLIOSIS

As experience with video-assisted thoracoscopy has increased, techniques have been developed for anterior instrumentation of the thoracic spine through a thoracoscopic approach. While the initial goal was to allow thoracoscopic anterior discectomy, fusion, and instrumentation, the most common use is now for the placement of vertebral body tethers. 

 

THORACOSCOPIC VERTEBRAL BODY INSTRUMENTATION FOR VERTEBRAL BODY TETHER

(PICETTI) Obtain appropriate preoperative radiographs and determine the fusion levels by Cobb angles. n  After general anesthesia is obtained by a double-lumen intubation technique (children weighing less than 45 kg may require selective intubation of the ventilated lung) and one-lung ventilation has been achieved, place the patient into the direct lateral decubitus position, with the arms at 90/90 and the concave side of the curve down. It is imperative to have the lung completely collapsed in this procedure. If the patient’s oxygen saturation drops on placement into the lateral decubitus position, have the anesthesiologist readjust the tube. n  Tape the patient’s hips and the shoulders to the operating table. Have a general or thoracic surgeon assist in the first part of the procedure if necessary. n  With the use of C-arm intensification, identify the vertebral levels and portal sites. A straight metallic object is used as a marker to identify the vertebral levels and portal sites. The superior and inferior access incisions are the most critical because the vertebrae at these levels are at the greatest angle in relation to the apex of the curve. n  View the planes with a C-arm in the posteroanterior plane and make sure the endplates are parallel and well defined. Rotate the C-arm until it is parallel to the vertebral body endplates, not perpendicular to the table. n  Position the marker posterior to the patient and align with every other vertebral body. n  Obtain a C-arm image at each level. n  Once the marker is centered and parallel to the endplates, make a line on the patient at each portal site in line with the marker. Marks should be two interspaces apart to allow placement of portals above and below the rib at each level and to provide access to two levels through a single skin incision. Use three to five incisions, depending on the number of levels to be instrumented. n  Once marks are made at all portal sites, rotate the Carm to the lateral position. Place the marker end on each line and adjust the marker position until the C-arm image shows the end of the marker at the level of the rib head on the vertebrae. Place a cross mark on the previous line. This is the location of the center of the portals and will show the degree of rotation of the spine. n  The spine surgeon’s position at the patient’s back allows all of the instruments to be directed away from the spinal cord. n 

EXPOSURE AND DISCECTOMY Prepare and drape the patient, including the axilla and scapula. n  Check positioning to confirm that the patient has remained in the direct lateral decubitus position. This orientation provides a reference to gauge the anteroposterior and lateral direction of the guidewires and the screws. n  Make a modified thoracotomy incision at the central mark. The incision can be smaller because it is used only for the central discectomies, screw placement, and viewing. The other discectomies and screw placements are done through the access portals because they provide better alignment to the end disc spaces and vertebral bodies. n 

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PART XII  THE SPINE After the lung has been deflated completely, make the initial portal in the sixth or seventh interspace by use of the alignment marks made previously. Make sure that the portal is in line with the spine and positioned according to the amount of spinal rotation. Insertion of the first portal at this level will avoid injury to the diaphragm, which normally is more caudal. n  Once the portal is made, use a finger to confirm that the lung is deflated and make sure there are no adhesions. n  Place 10.5- to 12-mm access portals under direct observation at the predetermined positions. Count the ribs to ensure that the correct levels are identified on the basis of preoperative plans. n  Incise the pleura longitudinally along the entire length of the spine to be instrumented. n  Place a Bovie hook on the pleura over a disc and make an opening. Insert the hook under the pleura and elevate it and incise along the entire length. Use suction to evacuate the smoke from the chest cavity. n  Dissect the pleura off the vertebral bodies and discs. Continue pleural dissection anteriorly off the anterior longitudinal ligament and posteriorly off the rib heads by use of a peanut or endoscopic grasper. n  Place a Kirschner wire into the disc space and confirm the level with C-arm intensification. n  With electrocautery, incise the disc annulus. n  Remove the disc in standard fashion with use of various endoscopic curets and pituitary, Cobb, and Kerrison rongeurs. If necessary, use endoscopic shavers and rasps to assist in discectomy. n  Once the disc is completely removed, thin the anterior longitudinal ligament from within the disc space with a pituitary rongeur. Thin the ligament to a flexible remnant that is no longer structural but will contain the bone graft. n  Remove the disc and annulus posteriorly back to at least the rib head. Use a Kerrison rongeur to remove the annulus posterior to the rib heads. Leave the rib head intact at this point because it will be used to guide screw placement. n  Once the disc has been evacuated, remove the endplate completely and inspect the disc space directly with the scope. Pack the disc space with Surgicel to control endplate bleeding.  n 

GRAFT HARVEST (IF NECESSARY) Use an Army-Navy retractor to stabilize the rib. n  With a rib cutter, make two vertical cuts through the superior aspect of the rib and perpendicular to the rib extending halfway across it. Use an osteotome to connect the two cuts while the retractor supports the rib. n  Remove and morselize the rib section. n  Remove three or four other rib sections in a similar fashion until enough bone graft has been obtained. n  If a rib is removed through an access incision, retract the portal anteriorly as far as possible. Dissect the rib subperiosteally and carry posterior dissection as far as the portal can be retracted. This technique yields an adequate amount of graft and preserves the integrity of the rib, thus protecting the intercostal nerve and decreasing postoperative pain. n  If the patient has a large chest wall deformity, perform thoracoplasties and use rib sections for grafting. n 

Do not remove the rib heads at this time because they function as landmarks for screw placement. 

n 

SCREW PLACEMENT Position the C-arm at the most superior vertebral body to be instrumented. It is imperative to have the C-arm parallel to the spine to give an accurate image. n  The vessels are located in the depression or middle of the vertebral body and serve as an anatomic guide for screw placement. n  Grasp the segmental vessels and coagulate at the mid– vertebral body level with the electrocautery. Hemoclip and cut larger segmental vessels if necessary. n  Check positioning again to ensure that the patient is still in the direct lateral decubitus position. n  Place the Kirschner guidewire onto the vertebral body just anterior to the rib head. Check this position with the Carm to verify that the wire will be parallel to the endplates and in the center of the body. n  Check the inclination of the guide in the lateral plane by examining the chest wall and the rotation. The guide should be in a slight posterior to anterior inclination, directing the wire away from the canal. If there is any doubt or concern about the anterior inclination, obtain a lateral C-arm image to verify position. n  Once the correct alignment of the guide has been attained, insert the Kirschner wire into the cannula of the Kirschner guide that is positioned centrally on the vertebral body. n  Drill the guidewire to the opposite cortex, ensuring that it is parallel to the vertebral body. n  Confirm the position with the C-arm as the wire is inserted. Take care not to drill the wire through the opposite cortex because this can injure the segmental vessels and the lung on the opposite side. n  The most superior mark on the guidewire represents a length of 50 mm, and the etched lines are at 5-mm increments. The length of the Kirschner wire in the vertebral body can be determined by these marks. Start at the 50mm mark and subtract 5 mm for each additional mark that is showing. For example, if there are four marks in addition to the 50-mm mark, the length of the Kirschner wire would be 30 mm. n  Remove the guide and place the tap over the Kirschner wire onto the vertebral body. To maximize fixation strength, use the largest-diameter tap that will fit in the vertebral bodies, based on the preoperative radiographs. Grasp the distal end of the wire with a clamp and hold it as the tap is inserted so that the wire will not advance. This is important to avoid a pneumothorax in the opposite chest cavity. Tap only the near cortex. Use the C-arm to monitor tap depth and Kirschner wire position. n  Place the appropriate-sized screw, based on the Kirschner wire measurement and tap diameter, over the wire with the Eclipse screwdriver and advance it. To ensure bicortical fixation, select a screw that is 5 mm longer than the width of the vertebral body as measured with the Kirschner wire. Grasp the wire again to avoid advancement while the screw is inserted. n  Remove the wire when the screw is approximately halfway across the vertebral body. n 

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Check the screw direction with the C-arm as it is advanced and seated against the vertebral body. The screw should penetrate the opposite cortex for bicortical fixation. n  Instrument all Cobb levels. n  Use each rib head as a reference for subsequent screw placement to help ensure that the screws are in line and will produce proper spinal rotation when the rod is inserted. With the screws properly aligned, the screw heads form an arc that can be verified with a lateral image. n  Adjust the side walls of the screws (saddles) to be in line for insertion of the rod. If a screw is sunk more than a few millimeters deeper than the rest of the screws, reduction of the rod into the screw head may be difficult. The Carm image can confirm depth of screw placement as the screws are inserted. n  Once all the screws have been placed, remove the Surgicel and use the graft funnel and plunger to deliver the graft into the disc spaces. Fill each disc space all the way across to the opposite side.  n 

ROD MEASUREMENT AND PLACEMENT Determine the rod length with the rod length gauge. Place the fixed ball at the end of the measuring device into the saddle of the inferior screw. Then guide the ball at the end of the cable through all of the screws with a pituitary rongeur to the most superior screw and insert it into the saddle. Pull the wire tight and take a reading from the scale. The scale is in centimeters. n  Cut the 4.5-mm-diameter rod to length and insert it into the chest cavity through the thoracotomy. The rod has slight flexibility, so do not bend it before insertion. n  Apply anterior compression to obtain kyphosis in the thoracic spine. n  Do not cut the rod longer than measured because the total distance between the screws will be reduced with compression. n  Manipulate the rod into the inferior screw with the rod holder. The end of the rod should be flush with the saddle of the screw to prevent the rod from protruding and irritating or puncturing the diaphragm. n  Once the rod is in place, remove the portal and place the plug introduction guide over the screw to guide the plug and to hold the rod in position. n  Place the obturator in the tube to assist in the insertion through the incision if necessary. n  Load a plug onto the plug-capturing T25 driver. Insert the plug with the flat side and the laser etching up. n  Once the plug is placed on the driver, turn the sleeve clockwise to engage the plug with the sleeve. n  Place the plug through the plug introduction guide and insert it into the screw. Do not place the plug without using the introduction guide and the plug inserter. n  To ensure proper threading, turn the sleeve once counterclockwise before advancing the plug. n  Once the plug has been correctly started, hold the locking sleeve to prevent any further rotation. This will disengage the plug from the inserter as the plug is placed into the screw. n  Remove the driver and introduction guide and torque the screw with the torque-limiting wrench. This is the only plug that is tightened completely at this time. n 

Sequentially insert the rod into the remaining screws with use of the rod pusher. Place the rod pusher on the rod several screws above the screw into which the rod is being placed. n  Apply the plugs through the plug introduction guide as described. To allow compression, do not fully tighten the plugs at this time. n  Once the rod has been seated and all the plugs are inserted into the screws, apply compression between the screws.  n 

COMPRESSION: RACK AND PINION Insert the compressor through the thoracotomy incision. Once it is in the thoracic cavity, manipulate it by holding the ball-shaped attachment with the compressor holder. The rack and pinion compressor fits over two screw heads on the rod; turning the compressor driver clockwise compresses the two screws. Start compression at the inferior end of the construct with the most inferior screw’s plug fully tightened. n  Once satisfactory compression has been obtained on a level, tighten the superior plug with the plug driver through the plug introduction guide. n  Apply compression sequentially superiorly until all levels have been compressed, then torque each plug to 75 in-lb with the torque-limiting wrench. The construct is complete at this point.  n 

COMPRESSION: CABLE COMPRESSOR Insert each end of the cable through one of the distal holes on the side of the guide (not the larger central hole). The actuator should be in the position closest to the compressor body. n  Form a 3-inch loop at the end of the guide, with the two cable ends passing through the actuator body. n  Engage the lever arm by use of one of the plug drivers through the cam mechanism. n  Place the end of the compressor through the distal portal. With the portal removed, place a plug introduction guide through the adjacent incision, through the loop, and over the next screw to be compressed. n  Place the foot of the compressor over the rod and against the inferior side of the end screw. n  Fully tighten the plug in the end screw. Squeeze the handle of the compressor several times to compress. n  Once satisfactory compression has been obtained at a level, tighten the superior plug with the plug driver through the plug introduction guide. n  To disengage the compressor, tilt it toward the superior screw until the foot disengages from the inferior screw. n  Turn the actuator mechanism 90 degrees to disengage the ratchet. n  With the cable loop still around the plug introduction guide that is on the superior screw, pull the compressor until the actuator is next to the compressor body. n  Repeat the steps described on subsequent screws. Apply compression sequentially until all levels have been compressed and then torque each plug to 75 in-lb with the torque-limiting wrench. The construct is complete at this point. n  Place a 20-French chest tube through the inferior portal and close the incisions. Obtain anteroposterior and lateral n 

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PART XII  THE SPINE radiographs before the patient is transferred to the recovery room. 

POSTOPERATIVE CARE The chest tube is left in until drainage is less than 100 mL every 8 hours. Patients can be ambulatory after the first postoperative day, and they can be discharged from the hospital the day after the chest tube is removed. A brace should be worn for 3 months.    

NEUROMUSCULAR SCOLIOSIS The specific causes of neuromuscular scoliosis are unknown, but several contributing factors are well known. Loss of muscle strength or voluntary muscle control and loss of sensory abilities, such as proprioception, in the flexible and rapidly growing spinal column of a juvenile patient are believed to be factors in development of these curves. As the spine collapses, increased pressure on the concave side of the curve results in decreased growth of that side of the vertebral body and wedging of the vertebral body itself. The vertebrae also can be structurally compromised by malnutrition or disuse osteopenia. The SRS has established a classification for neuromuscular scoliosis (Box 44.5). Neuromuscular curves develop at a younger age than do idiopathic curves, and a larger percentage of neuromuscular curves are progressive. Unlike idiopathic curves, even small neuromuscular curves may continue to progress beyond skeletal maturity. Many neuromuscular curves are long, C-shaped curves that include the sacrum, and pelvic obliquity is common. Hip subluxation or dislocation often is associated with the pelvic obliquity. Patients with neuromuscular scoliosis also may have pelvic obliquity from other sources, such as hip joint and other lower extremity contractures, all of which can affect the lumbar spine. Progressing neurologic or muscular disease also can interfere with trunk stability. These patients generally are less tolerant of orthotic management than are patients with idiopathic scoliosis, and brace treatment often is ineffective in preventing curve progression. Spinal surgery in this group is associated with increased bleeding and less satisfactory bone stock; longer fusions, often to the pelvis, are needed. Many neuromuscular spinal deformities require operative intervention. The goal of treatment is to maintain a spine balanced in the coronal and sagittal planes over a level pelvis. The basic treatment methods are similar to those for idiopathic scoliosis: observation, orthotic treatment, and surgery.

NONOPERATIVE TREATMENT OBSERVATION

Not all neuromuscular spinal deformities require immediate treatment. Small curves of less than 20 to 25 degrees can be observed carefully for progression before treatment is begun. Similarly, large curves in severely involved patients in whom the curve is not causing any functional disability or hindering nursing care can be observed. If progression of a small curve is noted, orthotic management may be considered if the patient can tolerate this form of treatment. If the functional ability of severely impaired patients is compromised by increasing curvature, treatment may be instituted. 

BOX 44.5



Scoliosis Research Society Classification of Neuromuscular Spinal Deformity Primary neuropathies Upper motor neuron neuropathies Cerebral palsy Spinocerebellar degeneration Friedreich ataxia Roussy-Levy disease Spinocerebellar ataxia Syringomyelia Spinal cord tumor Spinal cord trauma n Lower motor neuron pathologies Poliomyelitis Other viral myelitides Traumatic Charcot-Marie-Tooth disease Spinal muscular atrophy Werdnig-Hoffmann disease (SMA type 1) Kugelberg-Welander disease (SMA type 3) Dysautonomia Riley-Day syndrome Combined upper and lower pathologies Amyotrophic lateral sclerosis Myelomeningocele Tethered cord n Primary myopathies Muscular dystrophy Duchenne muscular dystrophy Limb-girdle dystrophy Facioscapulohumeral dystrophy Arthrogryposis Congenital hypotonia Myotonia dystrophica n  n 

ORTHOTIC TREATMENT

Progressive neuromuscular scoliosis in a very young patient can be treated with an orthosis. The scoliosis often continues to progress despite orthotic treatment, but the rate of progression can be slowed, and further spinal growth can occur before definitive spinal fusion. The brace also can provide patients with trunk support, allowing the use of the upper extremities. A custom-molded TLSO usually is required for these children because their trunk contours do not accommodate standard braces. Most patients with neuromuscular scoliosis lack voluntary muscle control, normal righting reflexes, and the ability to cooperate with an active brace program; therefore, passive-type orthotics have been more successful in our experience in managing these neuromuscular curves. Patients with severe involvement and no head control frequently require custom-fabricated seating devices combined with orthoses or head-control devices. A more malleable type of spinal brace, the soft Boston orthosis, is fabricated from a soft material that is well tolerated by patients, yet it is strong enough to provide good trunk support. The major complaint with the use of this brace has been heat retention.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Because of problems with brace treatment of neuromuscular patients, growing rods and rib-based techniques have been successfully used to control progressive neuromuscular curves. Several authors have reported improvement in the Cobb angle and pelvic obliquity with these techniques, but a deep wound infection rate of 30% also has been reported. 

OPERATIVE TREATMENT

The goal of surgery in patients with neuromuscular scoliosis is to produce solid arthrodesis of the spine, balanced in both the coronal and sagittal planes and over a level pelvis. In doing so, the surgery should maximize function and improve the quality of life. To achieve this goal, a much longer fusion is necessary than usually is indicated for idiopathic scoliosis. Because of a tendency for cephalad progression of the deformity when fusion ends at or below the fourth thoracic vertebra, fusion should extend to T4 or above. The decision on the distal extent of the fusion generally is whether to fuse to the sacrum or to attempt to stop short of it. On occasion, the fusion can exclude the sacrum if the patient is an ambulator who requires lumbosacral motion, has no significant pelvic obliquity, and has a horizontal L5 vertebral body. Many of these patients, unfortunately, are nonambulators with a fixed spinopelvic obliquity. If the spinopelvic obliquity is fixed on bending or traction films (>10 to 15 degrees of L4 or L5 tilt relative to the interiliac crest line), the caudal extent of the fusion usually is the sacrum or the pelvis. Maintaining physiologic lordosis in the lumbar spine is important in insensate patients who require fusion to the pelvis. This permits body weight to be distributed more equally beneath the ischial tuberosities and the posterior region of the thigh, reducing the risk of pressure sores over the coccyx and ischium. Bonebank allograft usually is used to obtain a fusion.

PREOPERATIVE CONSIDERATIONS

Patients with neuromuscular scoliosis must have complete medical evaluations, including cardiac, pulmonary, and nutritional status. In a literature review, Legg et al. reported that the complication rate after scoliosis surgery in neuromuscular patients varied from 10% to as high as 70%, with a mortality rate between 2.18% and 19%; when only the most recent studies were included, the mortality rate was 5%. The respiratory complication rate ranged from 26% to 57% and the infection rate from 2.5% to 56%. McCarthy et al. cited an overall complication rate between 44% and 80%, a mortality rate between 0 and 7%, major pulmonary complication rate of 21%, and wound problem rate of 8.7%. They also noted significant gastrointestinal and instrument or pseudarthrosis problems. Watanabe et al. reported three intraoperative cardiac arrests in their series of 84 patients, highlighting the fragility of these patients. The treating surgeon also should assess hospital services and support services that are available during and after surgery. Toovey et al. reported that the mean ICU stay after neuromuscular scoliosis surgery was 4.4 days (range, 1.7 to 6.7) and mean hospital stay was 16.9 days (range, 8.7 to 24.5). To improve the complication rate to an acceptable rate less than 10%, ICU stay of less than 24 hours, and hospital stay less than 7 days, a care team is needed to assess risk factors and take steps to decrease them before any surgery, including discussions with the medical providers, treating surgeon, patient, and caregivers. Shrader et  al. reported decreased

complication rates, surgical time, and length of hospitalization if an experienced second surgeon was present during the surgery. Most patients with neuromuscular scoliosis, especially those with cerebral palsy, have diminished pulmonary function, and careful preoperative evaluation is essential. Nickel et al. found that patients with vital capacities of less than 30% of predicted normal required respiratory support postoperatively, and those with a similar decrease of vital capacity and without a voluntary cough reflex required tracheostomy. The pulmonary service should be actively involved in preoperative and postoperative care to minimize the risk of pulmonary complications. Khirani et al. reported that noninvasive pulmonary techniques and coaching before surgery decreased respiratory complications and decreased the need for prolonged intubation. Patients often are malnourished, and their nutritional status should be improved preoperatively. Jevsevar and Karlin found an increase in complications if albumin was less than 35 g/L and total blood lymphocyte count was less than 1.5 g/L. The endocrine service should be involved to ensure optimized bone health in patients who often have significantly decreased bone mineral because of non–weight bearing and poor nutritional support. Optimizing bone health preoperatively will allow better fixation of the implants used to correct scoliosis and potentially less implant failure. Many neurologic conditions, such as Duchenne muscular dystrophy and Friedreich ataxia, are associated with cardiac involvement, and the patient’s cardiac status should be evaluated. Gastrointestinal and general surgery consultation may be needed for possible gastrostomy-tube placement and management and evaluation of the need for a gastric fundoplication to prevent or decrease the risk of reflux and aspiration. Otolaryngology evaluation for management of excessive drooling also may decrease the risk of aspiration. Neurology specialists should be involved for seizure management. Valproic acid has been shown to increase bleeding times and interfere with clotting, and an alternative seizure medication may be needed before surgery. Having the assistance of a plastic surgeon to aid in wound closure has been shown to decrease wound complications. Ambulatory status should be evaluated carefully before surgery. Often a patient with marginal ambulation capabilities and progressive scoliosis may not walk again after spinal surgery. The patient and parents must understand this before surgery. Techniques to minimize blood loss intraoperatively should be available, including electrocautery, hypotensive anesthesia, hemodilution techniques, and a cell saver. Use of antifibrinolytics has been shown to decrease intraoperative blood loss during posterior spinal fusion and instrumentation in neuromuscular scoliosis surgery. Dhawale et al. reported that tranexamic acid was more effective than epsilon-aminocaproic acid in decreasing blood loss in neuromuscular patients. Most patients with neuromuscular disease have insufficient autogenous bone; allograft bone usually is used to obtain fusion and is an acceptable alternative. As in other types of scoliosis surgery, the fusion levels and instrumentation must be determined preoperatively. The source of pelvic obliquity must be determined (Fig. 44.102). Several methods have been described for radiographic measurement of pelvic obliquity, including those devised by Maloney (Fig. 44.103A), O’Brien (Fig. 44.103B), Osebold

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A

B

C

FIGURE 44.102 A, Pelvic obliquity. B, If pelvic obliquity is eliminated by abduction or adduction of hips, pelvic-femoral muscle contracture is cause. C, If obliquity persists despite abduction or adduction of hips, fixed spinal-pelvic deformity exists. (From Shook JE, Lubicky JP: Paralytic scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven.)

(Fig. 44.103C), Lindseth (Fig. 44.103D), and Allen and Ferguson (Fig. 44.103E). Shrader et  al. compared these measurement techniques and determined that the Maloney method was the most reliable method of measuring pelvic obliquity on a frontal view radiograph. Ko et  al. reported that more than half of cerebral palsy patients had more than 10 degrees of asymmetry in the transaxial plane between right and left sides of the pelvis. There was greater asymmetry in patients with windswept hips. Combined anterior and posterior arthrodeses may be required for severe pelvic obliquity. Other indications for a combined anterior and posterior approach include necessity for an anterior release for further correction of severe kyphosis, severe and rigid scoliosis that cannot be corrected by bending or traction to less than 60 degrees, and deficient posterior elements, such as those in patients with myelomeningocele. With the use of pedicle screws the need for anterior surgery has decreased. Most neuromuscular deformities can be treated with a posterior surgery with segmental instrumentation using pedicle screw fixation and supplemented with sublaminar cables as needed. Several authors have compared results of posterior-only surgery with those of anterior and posterior surgery and found similar correction, less surgical time, shorter hospitalizations, and fewer complications. Finally, the patient’s family should be clearly informed of the potential benefits and risks of any surgical procedure. With good preoperative planning and medical management, good results from scoliosis surgery in neuromuscular patients and improved quality of life for the patient with an acceptable risk of complications can be expected. 

OPERATIVE CONSIDERATIONS

The potential for intraoperative complications in patients with neuromuscular scoliosis is great. Death can result from anesthesia problems, although more frequently it occurs from

postoperative pulmonary deterioration. Relative hypothermia can easily occur in a lengthy spinal operation in which a large area of tissue is exposed and can cause myocardial depression and arrhythmias. Spinal surgery is associated with greater blood loss in patients with neuromuscular disease than in patients with idiopathic scoliosis. The anesthesiologist should be aware of both of these potential problems and should be prepared for them with an arterial line, a central venous pressure line, temperature probes, and careful management of urine output. Because the curves generally are larger, more rigid, and more difficult to instrument, neurologic complications can occur during surgery. Many patients with neuromuscular scoliosis are unable to cooperate with an intraoperative wake-up test. Spinal cord monitoring can be a valuable technique in these patients. Schwartz et al. and Salem et al. evaluated the safety of using transcranial motorevoked potentials in neuromuscular patients. There were no episodes of seizures in any neuromuscular patients, including those with a history of epilepsy. The decision to use neuromonitoring for patients with a history of seizures should be a joint decision between the surgeon and the neuromonitoring team. The surgical technique must include meticulous debridement of the soft tissue off the posterior elements of the spine. Ablation of the facet joints and a large amount of bone graft are necessary. The bone frequently is osteopenic, and appropriate stable segmental instrumentation should be used. Anterior release and fusion can be considered in patients with large curves with a fixed spinal pelvic obliquity or in patients with posterior element deficiencies. Anterior instrumentation in neuromuscular curves may be used if needed, but it is rarely used. A 29% failure rate has been reported with pelvic fixation in neuromuscular patients. Myung et  al. recommended placing bilateral pedicle screws at L5 and S1, in addition to two iliac screws, to decrease the failure rate of pelvic fixation in neuromuscular patients. Lee

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

–°

Horizontal reference line (HRL)

–x

Femoral horizontal reference line (FHRL)

Pelvic coronal reference line (PCRL)

+°

HRL PCRL

HRL –° PCRL

A

+x

FHRL

B

A

C

D

A

E B

FIGURE 44.103   Radiographic measurement of pelvic obliquity. A, Maloney method. B, O’Brien method. C, Osebold method. D, Lindseth method. E, Allen and Ferguson method.

et  al. and Shabtai et  al. reported better results with the use of sacral alar screws than with traditional iliac screws. 

POSTOPERATIVE CONSIDERATIONS

Pulmonary problems are the most likely complications in the immediate postoperative period, and the assistance of a pulmonary specialist is invaluable. Ventilatory support may be necessary, and such techniques as suctioning, spirometers, and intermittent positive-pressure breathing may be appropriate. Possibly the best measure to prevent postoperative

pulmonary problems is a spinal construct strong enough to allow early mobilization. Fluid balance must be monitored carefully. After spinal surgery, especially in patients with neuromuscular scoliosis, antidiuretic hormone levels may be increased, leading to oliguria. If fluids are increased to overcome the oliguria, fluid overload may occur. This is especially disastrous in patients with impaired renal function, pulmonary compromise, and cardiac difficulties. The necessity for postoperative orthotic support must be determined for each patient. If a complication, such as

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PART XII  THE SPINE extremely osteopenic bone, compromises spinal fixation, or if less than ideal instrumentation is used, the use of postoperative external support may be wise. Infection is a frequent problem in patients with neuromuscular scoliosis, probably because of the metabolically compromised host and the lengthy spinal fusions necessary. Patients with myelomeningocele and cerebral palsy have the highest infection rates. A major source of postoperative infection is the urinary tract. Spinal infection is treated in the same manner as in patients with idiopathic scoliosis (see section on complications of posterior scoliosis surgery). Pseudarthrosis with subsequent instrumentation failure is a potential late problem. If the pseudarthrosis causes pain or loss of correction, repair probably will be necessary, but asymptomatic pseudarthrosis without curve progression or pain can be observed. 

LUQUE ROD INSTRUMENTATION WITH SUBLAMINAR WIRING

Eduardo Luque is credited with popularizing the use of long L-shaped rods and sublaminar wires in the surgical treatment of spinal deformity. The rods can be contoured, and the spine is corrected as the wires are tightened. Wilber et al. noted neurologic changes in 17% of their patients with idiopathic scoliosis, but since surgeons have become more proficient with the technique, the incidence of neurologic injury has been much lower. The neurologic complications from sublaminar wires are of three types: cord injury, root injury, and dural tears. Root injuries are the most common and lead to hyperesthesia, but these generally resolve within 2 weeks. Although sublaminar wires or cables have potential risks, we have found that for neuromuscular curves, the advantages of this type of segmental instrumentation far outweigh the potential risks. The original Luque rods were L-shaped rods that were contoured to appropriate sagittal contours. Appropriately sized alloy rods are contoured to the appropriate sagittal contours and are connected proximally and distally with crosslinks. Originally, stainless-steel wires in diameters of 16- and 18-gauge were used. We now usually use sublaminar cables as opposed to the wire (see Technique 44.17).   

LUQUE ROD INSTRUMENTATION AND SUBLAMINAR WIRES WITHOUT PELVIC FIXATION TECHNIQUE 44.29 The spine is exposed posteriorly as described in Technique 44.6. n  Wires or cables are passed as described in Technique 44.14. n  Two rods are used for most scoliosis corrections, with the first rod applied either to the convex or concave side of the curve. Lumbar scoliosis generally is more easily corrected by the concave rod technique. And because most neuromuscular curves include the lumbar n 

spine and pelvis, the concave rod technique is most frequently used. n  Bend the appropriate amount of lordosis and kyphosis into the rods with the rod benders. n  Place the initial rod with its short limb passing transversely across the lamina of the lowermost vertebra to undergo instrumentation on the concave side. n  Pass it through the hole at the base of the spinous process if possible. n  Tighten the inferior double wire or cable on the concave side to supply firm fixation at the distal level. Now tighten the wires or cables to the lamina of the vertebra above the curve. n  Loosely attach the convex rod proximally after the short end has been placed loosely under the long limb of the concave rod. Once the concave rod has been completely tightened, it often is difficult to pass this short limb under the long limb of the concave rod. n  Reduce the spine to the rod by manual correction and a wire or cable tightener. An assistant can apply appropriate manual correction by pressure on the trunk as the wires or cables are tightened beneath the apex of the curvature (Fig. 44.104). n  As each wire or cable is tightened, more correction is obtained, and the twisting maneuver must be repeated two or three times on each wire to ensure a tight fit. n  Securely fasten the convex rod, tightening wires or cables from cephalad to caudad. n  Once in position, both rods usually can be brought into firm contact with the lamina by squeezing them together with the rod approximator. As this is done, the concave wires or cables will again loosen and must be tightened. n  Trim the wires to about ½ inch in length and bend them toward the midline. n  With the internal fixation device in place, very little bone is exposed for decortication and facet excision. We prefer to excise the facets if at all possible. n  A large volume of bone graft is necessary, and cancellous bone is harvested from the posterior iliac crest. Because the instrumentation often includes the iliac crest (see Technique 44.36), allograft bone usually is necessary. Place the graft lateral to the rods on both sides of the spine and out to the tips of the transverse processes. If possible, place bone graft between the wires, along the laminae.   

SACROPELVIC FIXATION

Many patients with neuromuscular problems require instrumentation and fusion to the sacrum. O’Brien described three fixation zones for sacropelvic fixation (Fig. 44.105). Examples of zone I fixation include S1 sacral screws and a McCarthy S-rod. Zone II fixation includes S2 screws and the Jackson intrasacral rod technique (see later section on combined anterior and posterior fusion for scoliosis in patients with myelomeningocele). Zone III fixation includes the Galveston L-rod technique and sacroiliac screws. If fixation to the pelvis is necessary, an S-rod technique as described by McCarthy et al. can be useful (Fig. 44.106). The two rods are crosslinked at the lumbosacral junction and then fixed with a combination of hooks, pedicle screws, and

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

Manual push

Pull Stabilize

A

B

FIGURE 44.104 A and B, Concave rod technique for correction of lumbar scoliosis. (From Segmental spinal fixation and correction using Richards’ L-rod instrumentation, Memphis, TN, Smith & Nephew Richards.) SEE TECHNIQUE 44.29.

is not a problem because the ilium is not violated as it is when the Galveston technique is used. Prebent S-rods are available; complex bends cannot be done effectively at the time of surgery. The rods can be further contoured with a rod bender at the time of surgery to accommodate the size of the sacrum and to provide the appropriate sagittal plane correction.  Zone 1 Zone 2  

Zone 3

SACROPELVIC FIXATION TECHNIQUE 44.30

FIGURE 44.105   Sacropelvic fixation zones.

(MCCARTHY) Expose the spine posteriorly as described in Technique 44.8. n  Perform careful dissection of the sacral ala, using a curet to clean the superior edge. Use finger dissection ventrally. n  The rods come in different sizes and contours. In most instances, a 5.5-mm rod provides satisfactory fit to the sacral ala. n  Contour the rods to appropriate sagittal contours. n  Place the S-rod over the sacral ala from posterior to anterior in a position adjacent to the anterior border of the n 

sublaminar wires or cables bilaterally throughout the lumbar and thoracic spine. The rods generally are crosslinked below the upper fixation to provide further stability against migration or rotation of the rods. We have found that if hooks or screws are not used at the upper end, wires alone provide no support against axial loading. The advantages of the S-rod are that firm fixation is provided around the sacral ala without crossing the sacroiliac joint and that harvesting of bone graft from the ilium

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A

B

C

FIGURE 44.106 A-C, S-rods are manufactured as a pair to fit over the right and left sacral alae for fixation to the sacrum without crossing the sacroiliac joint. They are available in 3⁄16-inch and ¼-inch rods.

sacroiliac joint. It lies posterior to the L5 nerve root and roughly parallel to it. n  Seat the S-portion of the rod firmly against the sacral ala by distraction between an L4-level hook or pedicle screw. The rods then can be used as a firm fixation point for translation or correction of scoliotic deformities or by placing the right and left rods simultaneously and crosslinking them, applying a strong cantilever corrective force for correction of pelvic obliquity. Crosslinking the two Srods provides stability and eliminates the increased time and difficulty of insertion of rods into the ilium. n  Elevate the medial aspect of the iliac apophysis and rotate it over the top of the S-rod on the sacral ala. n  Provide bone graft to encase the S-rod into the sacrum.    

 

GALVESTON SACROPELVIC FIXATION Another popular method for achieving sacropelvic fixation is the Galveston technique described by Allen and Ferguson in which the pelvis is stabilized by driving a segment of the L-rod into each ilium (Fig. 44.107). The rod is inserted into the posterior iliac crest and rests between the cortices above the sciatic notch. This fixation provides immediate firm stability and is biomechanically a stable construct. There are potential disadvantages, however, because the rod crosses the sacroiliac joint. It is postulated that motion in the sacroiliac joint is responsible for a “halo” that is often seen around the end of the Galveston rod in the iliac wing. Whether this radiographic phenomenon actually results in clinical problems is unknown.

TECHNIQUE 44.31 (ALLEN AND FERGUSON) Expose both iliac crests from the midline incision at the level of the posterior superior iliac spine. Expose the iliac crest to the sciatic notch. The area just proximal to the sciatic notch provides the most satisfactory fixation. n  Use a large, smooth Steinmann pin corresponding to the size of the rod diameter or a pedicle awl to create a tunnel n 

A

B

FIGURE 44.107 A and B, Stabilization of pelvis with Galveston technique. Segment of rod is driven into each ilium. SEE TECHNIQUE 44.31.

for the rod. The insertion site is just posterior to the sacroiliac joint at the level of the posterior inferior iliac spine, distal to the posterior superior iliac spine, along the transverse bar of the ilium. The area for insertion often is difficult to identify, and the rod may be inserted too superiorly. n  Carefully identify the area for insertion and use a rongeur to carefully remove soft tissue and bone to expose the inner and outer tables of the ilium. n  Drill the Steinmann pin to a depth of 6 to 9 cm. n  Asher et al. described use of a pedicle awl for pin insertion. This allows tactile perception to determine whether the awl is perforating the cortex of the ilium. n  Use a rongeur to remove enough cartilage and cortical bone to create a 1 × 1-cm entry site into the inferior portion of the posterior superior iliac spine. This exposes the intramedullary space. n  Introduce a blunt-tipped pedicle awl into the intracortical space and advance it by gentle oscillating pressure on the handle of the awl.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Direct the awl to 2 cm above the sciatic notch and advance it to the appropriate depth of the rod in the ilium (Fig. 44.108).

Now use a flexible ball-tipped pedicle probe to ensure that the hole made by the blunt-tipped probe is completely intracortical. Place the smooth Steinmann pin into the iliac hole.

n 

n 

ROD CONTOURING (ASHER) Preparation of the rod is made easier by the use of a variable-radius bender set. To prepare the rod for iliac (Galveston) placement, four measurements are needed: (1) the length of the intrailiac portion of the rod (Fig. 44.109A), (2) the transverse plane angle of the iliac fixation site to the midsagittal plane (Fig. 44.109B), (3) the medial-lateral distance from the iliac entry site to the intended line of longitudinal passage of the rod along the spine (Fig. 44.109C), and (4) the length of the rod needed from the sacrum to the most cephalad instrumentation site. n  Lay suture along the spine line from the sacrum to the facet above the last instrumented vertebra; its length plus 1 cm is the usual length for this portion of the rod. n 

FIGURE 44.108 Intracortical passage of pedicle probe in ilium. SEE TECHNIQUE 44.31.

Y

X

Z

A

B

Y

C

Y X

Z X

D

E

F

G

H

FIGURE 44.109 Technique of Asher. A, Length of intrailiac portion of rod. B, Transverse angle of iliac fixation site in midsagittal plane. C, Coronal plane distance from iliac entry site to intended line of longitudinal passage along spine. D, Right-angle bend. E, Iliosacral axial plane bend. F, Placement of long- and short-radius lordosis. G, Placement of long and short thoracic kyphosis. H, Sagittal plane iliac angle adjustment. (Redrawn from Boachie-Adjei O, Asher MA: Isola instrumentation for scoliosis. In McCarthy R, editor: Spinal instrumentation techniques, vol. 2, Rosemont, IL, 1998, Scoliosis Research Society.) SEE TECHNIQUE 44.31.

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PART XII  THE SPINE Add the first and third measurements. A right-angle bend is placed at this distance from one end (Fig. 44.109D); this is the iliosacral portion of the rod. n  The medial-lateral distance (measurement 3) minus approximately 3 mm to allow for the bend is from the middle of the right-angle bend. Mark this at the iliosacral portion of the rod. n  After the right-left orientation is verified, place an angle identical to that of the iliac fixation site to the midsagittal plane at this second mark (Fig. 44.109E). This separates the iliosacral portion of the rod into the iliac and sacral portions. n  Add sagittal plane bends, beginning at L5-S1, thus leaving a straight portion over the sacrum. Because lordosis is not uniform but is greater in the lower lumbar spine, two contours are necessary. The contour for the entire lumbar spine is a long radius, whereas that for the lower lumbar spine is shorter (Fig. 44.109F). n  Add thoracic kyphosis, again by use of the flat benders (Fig. 44.109G). n  Attempt a trial placement to check whether the sagittal plane bend of the sacroiliac bend is correct. This can be determined by measuring the distance from the rod to the spine at the cephalad and caudal levels of the rod. n  Make final sagittal plane iliac angle adjustments with flat bender posts and a tube bender (Fig. 44.109H). n  The Galveston technique can be combined with a multiple-hook or pedicle screw segmental system with crosslinks if desired.     n 

 

UNIT ROD INSTRUMENTATION WITH PELVIC FIXATION When two unlinked L-rods are used, the rods may translate with respect to one another and compromise control of pelvic obliquity. In addition, twisting within the laminar wires can result in rotation of one rod relative to another. The ¼-inch rods generally used in neuromuscular patients are difficult to bend so that they can conform to the complex three-dimensional curves of the spine. In response to these problems, Bell et al. developed the unit rod. The unit rod is a single, continuous ¼-inch stainless-steel rod with a U bend at the top and “bullet-ended” pelvic legs for implantation into the pelvis. The three-dimensional preshaped kyphosis, lordosis, and pelvic legs were devised from a database of patients without spinal deformity. Eight lengths of rod are available, increasing in 20-cm increments from 310 to 450 cm. Right and left iliac guides facilitate drilling into the posterior ilia and subsequent introduction of the pelvic legs. The length of the iliac legs decreases proportionally as the rod shortens. The unit rod attempts to normalize body alignment in both the sagittal and coronal planes by establishing normal lordosis and kyphosis and correcting pelvic obliquity. We have not found the unit rod satisfactory for extremely rigid curves unless an anterior release or osteotomies are done to reduce the spinal stiffness. If, however, the curves seem relatively flexible on

bending films or physical examination, correcting to less than 40 degrees, we have had excellent results with the use of the unit rod.

TECHNIQUE 44.32 Expose the spine as described in Technique 44.6. Expose both iliac crests to the posterior superior iliac spine and down to the sciatic notch. n  Mark a ¼-inch drill with a marking pen at 15 mm longer than the sciatic notch if the child weighs more than 45 kg and at 10 mm if the child weighs less than 45 kg. n  Place the appropriate right or left drill guide into the sciatic notch. Keep the lateral handle of the drill guide parallel to the pelvis (Fig. 44.110A) and the axial handle of the drill guide parallel to the body axis (Fig. 44.110B). n  Start the drill hole as far inferiorly on the posterior superior iliac crest as possible (Fig. 44.110C). n  Drill a hole in the ilium to the marked depth and check the hole with a wire to make certain the cortex has not been penetrated. n  Use a similar technique on the opposite iliac crest. n  Pass the sublaminar wires. n  Measure the length of the rod by placing the rod upside down, with the corner of the rod at the drilled hole on the elevated side of the pelvis. If kyphosis is severe, choose one length shorter because the kyphotic spine shortens as it corrects. If pelvic obliquity is severe, test the length from both the high and low sides and choose an intermediate length. If the rod is placed and turns out to be too long, it may be necessary to cut off the superior end; the upper end then can be connected with a crosslink. n  Cross the legs of the appropriate-length rod and insert them first into the hole on the low side of the pelvic obliquity (Fig. 44.111A). Cross the rod so that the leg going into the low side is underneath the other leg. n  Insert approximately one half to three fourths of the leg length into the hole. Then insert the next leg by holding it with a rod holder and guiding it into the correct direction of the hole. n  Use the impactor and drive the rod leg in by alternately impacting each leg (Fig. 44.111B). Be certain that each rod leg is impacted in the exact direction of the hole or the cortex may be penetrated. n  Once the rod is firmly seated, use the proximal end of the rod as a “rudder” to bring the distal end of the rod to the spine (Fig. 44.111C). n  Do not push the rod down completely into the wound in one move because this may pull the legs out of the pelvis or fracture the ilium. Instead, push the rod to line it up with the L5 lamina only and tie these wires down with a jet wire twister. n  Now push the rod to the L4 vertebra, twist the wires, and cut them off. n  Tighten the wires from caudad to cephalad one level at a time. Do not relax the push on the rod between the levels of the major curve or too much load may be applied to the end vertebra. Do not use the wires themselves to pull the rod down to the lamina or the wires will cut through the lamina. n  After all the wires have been tightened, go back and verify that all previously tightened wires are well seated. n 

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A

B

C

FIGURE 44.110 A and B, Unit rod for neuromuscular scoliosis developed by Bell, Moseley, and Koreska. Single, continuous ¼ -inch stainless steel rod has U-shaped bend at top and bullet-shaped ends for insertion into pelvis. SEE TECHNIQUE 44.32.

Cut the wires at 10- to 15-mm lengths. Bend all wires into the midline of the rod and direct them caudally (Fig. 44.111D). n  Apply bone graft. Bank bone usually is needed because the iliac crest is used for pelvic fixation.     n  n 

 

ILIAC FIXATION WITH ILIAC SCREWS Iliac screws provide secure and rigid pelvic fixation, which has the advantage of not having prefixed angles for pelvic fixation. The disadvantage is the need for a lateral connector for attachment to the rod.

TECHNIQUE 44.33 After the spine is exposed, dissect laterally underneath the spinal fascia to reach the medial aspect of the iliac wing at its very distal aspect. n  Identify the posterior superior iliac spine. The starting point for screw placement is 1 cm inferior to the posterior superior iliac spine and 1 cm proximal to the distal edge of the posterior superior iliac spine (Fig. 44.112A). If required, expose the lateral aspect of the iliac wing to help with the trajectory of the pathway down the iliac bone (Fig. 44.112B). n  With a 4-mm burr, create a medial cortical defect at the appropriate starting point. n 

By use of an iliac probe or pedicle probe with the tip facing medially and the trajectory 45 degrees caudal and lateral, tunnel down between the cortices of the ilium (Fig. 44.112C). It is more likely to exit laterally than medially. That is the reason for the probe to face medially. The ideal placement of the screw will be just cephalad to the superior gluteal notch, which is the thickest part of the ilium. n  Once the tunnel has been formed with the probe, use a flexible ball-tip sounding probe to palpate the intraosseous borders of the ilium to confirm intraosseous placement of the screw. Tap the tunnel if necessary. n  Various angles are available on the screw heads to allow easier placement of the connector rods. Screw trials are used to determine which type of screw best fits the patient’s anatomy. Select an appropriate-sized screw. n  Insert the screw with the screwdriver. If angled screw heads are used, each angle screw has its own screwdriver. Once the screw is placed snuggly into the ilium, it is important that the top of the screw head rest below the top of the posterior superior iliac spine (Fig. 44.112D). This ensures that the screw will not be prominent postoperatively. n  Position the screw head facing directly medial to allow the lateral connector to engage and thus keep the rod vertical in its orientation. n  Determine the length of the lateral connector after placing and aligning the more cephalad spinal instrumentation; the goal is a vertical rod with only sagittal plane and minimal coronal plane bending. n  Once the offset is determined, cut the lateral connector to length and insert it into the screw head and provisionally tighten the screw. n 

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A

C

B

FIGURE 44.111   Unit rod instrumentation. A, Lateral handle of drill guide is kept parallel to pelvis. B, Axial handle is kept parallel to body axis. C, Drill hole started inferiorly on posterior superior iliac crest. (C redrawn from Miller F, Dabney KW: Unit rod procedure for neuromuscular scoliosis. In McCarthy R, editor: Spinal instrumentation techniques, vol. 2, Rosemont, IL, 1998, Scoliosis Research Society.) SEE TECHNIQUE 44.32.

D

Insert the rod into the lateral connector and cantilever it down into the cephalad spinal instrumentation (Fig. 44.112E). n  Place the set screw for the lateral connector and provisionally tighten it. n  When all implants are securely in place, perform final tightening and break off the set screw head (Fig. 44.112F). n 

POSTOPERATIVE CARE Postoperative immobilization is not recommended after L-rod or unit-rod instrumentation. However, because neuromuscular curves frequently are associated with osteoporosis, spasticity, inability of the

patient to cooperate, and severe curves, postoperative immobilization in a TLSO for 3 to 6 months may be needed if there is any question about stability of the instrumentation construct.   

S2 ILIAC LUMBOPELVIC SCREW PLACEMENT

The screws in this technique do not require a separate skin or fascial incision, and average lengths of 70 to 100 mm are attainable. Additionally, this fixation does not interfere with aggressive iliac crest harvest. The advantages of

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

A

B

C

D

E

F

FIGURE 44.112 Unit rod instrumentation, continued. A, One leg of rod is placed into low side of pelvic obliquity first. B, Impactor is used to drive rod legs into pelvis. C, Once rod is firmly seated, proximal end can be used as rudder to bring distal end to spine. D, Wires are bent into midline of rod and directed caudally. SEE TECHNIQUE 44.32.

this technique are reduced implant prominence and placement of the iliac screw in line with other spinal anchors, thus avoiding acute bends in the rod to obtain pelvic fixation. Ramchandran et al. described the use of an alternate starting portal to the S2 alar iliac portal using an anatomic trajectory described by Vaccaro and Harrop et  al. This starting portal is on medial wall of the iliac crest (Fig. 44.113). 

S1 Screw

SAI

PSIS start

Anatomic portal

 

ILIAC AND LUMBOSACRAL FIXATION WITH SACRAL-ALAR-ILIAC SCREWS TECHNIQUE 44.34 Place the patient prone on a radiolucent table, ensuring that the pelvis is as neutral as possible with minimal rotation. n  Extend a midline skin incision to expose the dorsal foramina of the sacrum, specifically the S1 and S2 foramina. Additional lateral dissection to the iliac crest is not needed. n  Stand on the contralateral side of the patient to identify the starting point. Find the midpoint between the S1 and n 

FIGURE 44.113 Model of pelvis and sacrum showing entry points for various iliac fixation methods: traditional iliac PSIS entry; SAI (S2-alar-iliac) screw entry; S1 pedicle screw entry; and anatomic trajectory portal for iliac screw. (Redrawn from Ramchandran S, George S, Asghar J, et al: Anatomic trajectory for iliac screw placement in pediatric scoliosis and spondylolisthesis: an alternative to S2-alar-iliac portal, Spine Deform 7:286, 2019.)

S2 dorsal foramina and the lateral border of the foramen; the starting point is where these two lines intersect (Fig. 44.114A). This starting point should be in line with the S1 pedicle screw. n  Be aware that the entry point may vary with the local anatomy of the patient. If the pelvis is asymmetric in the

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A B

20–30º

40–50º

D C

E

F FIGURE 44.114 Iliac and lumbosacral fixation with sacral-alar-iliac screws. A, Starting point for screw insertion. B, Screw trajectory. C and D, Fluoroscopic confirmation of appropriate trajectory.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

G

H

I

J

K

FIGURE  44. 114, cont’d   E, With proper trajectory, iliac teardrop should be visible on anteroposterior image. F, Path of probe or drill within 20 mm of the greater sciatic notch and aimed toward the anterior inferior iliac spine. G, Guidewire placed through drilled hole. H-J, Fluoroscopic teardrop view to confirm screw placement. K, Final position of rods. (Courtesy DePuy Synthes Companies of Johnson & & Johnson.) SEE TECHNIQUE 44.34.

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PART XII  THE SPINE transverse plane, as is common in patients with genetic or neuromuscular disorders, the starting point may need to vary in the mediolateral plane. n  Determine the proper trajectory of the sacral-alar-iliac fixation. Aim for the anterior inferior iliac spine, which can be found by palpating the top of the greater trochanter (Fig. 44.114B). The trajectory should pass immediately above the sciatic notch. n  To use fluoroscopy to identify the appropriate trajectory, orient the C-arm in the intended trajectory and position it above the starting point. Then angle the C-arm 20 to 30 degrees caudal (Fig. 44.114C) and 40 to 50 degrees to the vertical plane (Fig. 44.114D), aiming for the anterior inferior iliac spine. With this trajectory, the iliac teardrop should be visible on the anteroposterior fluoroscopic image (Fig. 44.114E). n  Use an awl and probe or pelvic 2.5-mm drill bit to verify the correct trajectory. The path of the probe or drill should be within 20 mm of the greater sciatic notch and aiming toward the anterior inferior iliac spine (Fig. 44.114F). This trajectory may vary with pelvic obliquity and lumbar lordosis. n  If using a drill, feel for the bony end point after each advancement of the drill. Once the drill crosses the sacroiliac joint, use a 3.2-mm drill bit to avoid breaking the smaller bit in the ilium. Alternatively, an awl can be used in a dysplastic pelvis. n  Obtain a teardrop fluoroscopic image to ensure that the anterior-posterior trajectory is within the thickest part of the ilium, without a cortical breach. n  Use a ball-tipped probe to palpate the course of the screw and confirm the bony end point. Note the appropriate screw length as shown on the ball-tipped probe or on the tap. n  Place a guidewire through the probed or drilled hole to preserve the trajectory (Fig. 44.114G) and confirm its position with fluoroscopy. n  Tap the hole using the same-size pedicle tap as the intended screw diameter. Make sure that the guidewire does not advance during advancement of the tap. n  Insert the screw, aiming for the anterior inferior iliac spine with the trajectory within 20 mm above the greater sciatic notch. Before the screw is fully seated, remove the guidewire to prevent bending or breakage. n  Using the teardrop fluoroscopy view, confirm screw placement (Fig. 44.114H-J). n  Choose a rod length that will span the full length of the construct. Sagittally contour the rod before implanting it. n  Check to ensure that the sacral-alar-iliac screws are in line with the S1 screws and proximal screws in the construct. Rods can be inserted from caudal to cranial (most commonly) or from cranial to caudal in the case of severe proximal deformity. n  Insert the set screw to capture the rod. Tighten the rod to fix the rod to the distal screw and continue in a cephalad direction, capturing the rod with the rest of the screws in the construct (Fig. 44.115), and tighten the set screws.   

CEREBRAL PALSY

Neuromuscular spinal deformities are most common in patients with cerebral palsy, and their risk of developing scoliosis has been related to disease severity. Children with severe spasticity and quadriplegic limb involvement have the highest risk of developing scoliosis. The Gross Motor Function Classification System (GMFCS) has been helpful in assessing the risk of developing scoliosis in patients with cerebral palsy (see Chapter 33). GMFCS I and II levels have almost no risk of developing scoliosis, while GMFCS levels IV and V have a 50% risk of developing moderate to severe spine deformity. Patients with GMFCS level IV and V classifications often have significant comorbidities that can make surgical correction of their scoliosis challenging; however, surgical correction of scoliosis has been reported to improve the quality of life in these patients, and patients and caregivers report high satisfaction rates after surgical correction of scoliosis, despite high complication rates. Although quality of life is improved and patient/caregiver satisfaction is high, it is the responsibility of the treating surgeon to accurately access the risks and benefits of surgery. The greatest progression has been noted in patients who are unable to walk and have thoracolumbar or lumbar curves (average progression 0.8 degree per year in curves less than 50 and 1.4 degrees per year in curves more than 50 degrees). Scoliosis in patients with cerebral palsy is best managed by early recognition and control of the curve before the deformity becomes severe. If the scoliosis is left untreated, function may be lost. If the patient is ambulatory, the trunk may become so distorted that standing erect becomes impossible. Sitting may become more difficult with increasing pelvic obliquity. If supplemental support by the hands is needed to sit, the patient will lose the ability to perform activities that require use of the upper extremity. Bonnett et al. listed the following seven goals of scoliosis treatment in patients with cerebral palsy: •  Improvement in assisted sitting to make positioning and transfer easier for nursing attendants and family •  Relief of pain in the hips and back •  Increased independence because of a decreased need for assistance, both for the positioning required to relieve pain and to prevent pressure areas and for feeding •  Improvement in upper extremity function and table-top activities by eliminating the need to use the upper extremities for trunk support •  Reduction of the equipment needed, making possible the use of other equipment •  Placement of the patient in a different facility, one in which less care is provided •  Improved eating ability made possible by a change in position Each patient must be evaluated individually to determine the potential for achieving these rehabilitation goals.

CLASSIFICATION

Lonstein and Akbarnia classified cerebral palsy curves into two groups (Fig. 44.116). Group I curves—double curves with both thoracic and lumbar components—occurred in 40% of their patients. These curves, which are similar to curves of idiopathic scoliosis, occurred more commonly

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS home, and were more likely to have the classic form of cerebral palsy. 

NONOPERATIVE TREATMENT

If the curve is small, careful observation is indicated. If the curve progresses or is more than 30 degrees in a growing child who is an independent ambulator or sitter, treatment should be instituted. If a child is skeletally mature, bracing is not likely to be effective and surgery is indicated if the curve is 50 degrees or more. Most nonambulatory patients with cerebral palsy do not have head or neck control during the first years of life. Custom seating may be effective in providing these patients with a straight spine and a level pelvis. Custom seating also can effectively accommodate severe spinal deformities and allow an upright posture in severely involved individuals. If the curve is progressive, an orthotic device may be helpful as a temporizing device but will not provide permanent control of the curve. Orthoses generally are used for curve control during growth in a child who is ambulatory or who has independent sitting ability. The orthosis often provides enough trunk support to free the upper extremities for functional use. The orthosis of choice is a custom-molded totalcontact TLSO. 

A R

OPERATIVE TREATMENT

B FIGURE 44.115 NIQUE 44.35.

Alar-S2-iliac pedicle screw fixation. SEE TECH-

in patients who were ambulatory and lived at home. Group II curves were present in 58% of patients. These curves were more severe lumbar or thoracolumbar curves that extended into the sacrum, with marked pelvic obliquity. Patients with these curves usually were nonambulatory with spastic quadriplegia, generally were not cared for at

The operative treatment of scoliosis in cerebral palsy is complex. Determining which type of surgery is needed, and even whether any surgical procedure is warranted, is difficult. The surgical techniques available for scoliosis in patients with cerebral palsy have improved significantly. A pseudarthrosis rate of 20% has been reported in patients with posterior spinal fusion and Harrington instrumentation. Combined anterior and posterior procedures with anterior and posterior instrumentation result in adequate correction with a low incidence of pseudarthrosis. With pedicle screw instrumentation and posterior-only surgery, results are reported to be similar to those of anterior and posterior surgery. There probably is no one ideal technique for managing these complex curves. In general, we use pedicle screws, and pelvic fixation is preferred when possible. The rods can be crosslinked to increase stability. Our preference at this time for pelvic fixation is the iliac screw technique or S2 iliac screw technique (see Techniques 44.29 and 44.30). If the pelvis is too small to accept screw fixation, we use the McCarthy S-rod technique (see Technique 44.30) with crosslinking for pelvic fixation. The type of surgery also depends on the type of scoliosis. According to Lonstein and Akbarnia, patients with group I curves usually require only a posterior fusion, with fusion to the sacrum rarely needed. Group II curves usually require a long fusion to the sacrum because the sacrum is part of the curve and pelvic obliquity is present. Traction radiographs should be obtained. If a level pelvis and balanced spine can be obtained, a one-stage posterior approach is indicated. However, if the traction radiograph shows significant residual pelvic obliquity, or if the torso is not balanced over the pelvis, a two-stage approach may be indicated, although with

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A

B

C

D

FIGURE 44.116 A and B, Group I double curves with thoracic and lumbar component and little pelvic obliquity. C and D, Group II large lumbar or thoracolumbar curves with marked pelvic obliquity.

current segmental instrumentation with pedicle screws, anterior and posterior procedures usually are not needed. Jackson et  al. and LaMothe et  al. reported that the use of intraoperative traction may decrease the need for anterior surgery and allow adequate correction with a posterior-only procedure. Radiographic evaluation of patients with contractures around the hips can lead to erroneous conclusions. The radiograph often is made with the patient supine and the hips extended. If one hip has an adduction contracture and the opposite hip has an abduction contracture, it may appear that pelvic obliquity is present. An appropriate radiographic evaluation should include a supine view obtained with the hips in a relaxed position, whatever the contractures dictate. This allows the spine and pelvis to assume a neutral alignment without the influence of hip contractures. Kyphosis can be caused by tight hamstrings and should be evaluated carefully because if the hamstrings are not released, increased stress will be placed on the instrumentation. Several technical points should be considered in instrumentation of patients with cerebral palsy. The most proximal level of the fusion should be above T4 to prevent junctional kyphosis above the instrumentation. Only small portions of the ligamentum flavum on either side of the superior interspinous space to be instrumented should be removed. If possible, the supraspinous and interspinous ligaments at the superior level should be preserved to prevent an increase in kyphosis above instrumentation. Pedicle hooks or screws are used for fixation at the most proximal level to add axial load support to the system. With current instrumentation techniques, postoperative immobilization usually is not needed. If the bone is obviously osteopenic or instrumentation is less than ideal, postoperative external support may be necessary. 

COMPLICATIONS

Improved techniques of instrumentation and preoperative and postoperative management have decreased complications, but a much higher complication rate should be expected after surgery for this type of scoliosis than after that for idiopathic curves. Complications in patients with cerebral palsy have been reported in up to 81%, including infection in 15% to 19%. Patients with cerebral palsy are believed to be at an increased risk for infection. Deep infections can be treated by irrigation and debridement, administration of systemic antibiotics, and delayed primary closure or closure over a suction drain. Pulmonary complications often develop in these patients because they cannot cooperate in deep breathing and coughing exercises, and appropriate prophylactic pulmonary measures are needed. If the upper limit of the fusion is not selected carefully (above T4), kyphosis cephalad to the upper limit of the fusion can occur. Pseudarthrosis is less frequent with newer instrumentation systems, but it still occurs and often results in implant failure. Other possible complications are those inherent in any spinal operation, such as urinary tract infection, ileus, and blood loss. Although the complications can be significant in these patients, the functional improvement or prevention of deterioration of function may be worth the effort and the risks of surgery. Complications should be expected and planned for; prompt treatment will lessen their severity. 

FRIEDREICH ATAXIA

Friedreich ataxia is a recessively inherited condition characterized by spinocerebellar degeneration. The genetic cause has been found to be a flaw within the frataxin gene on chromosome 9q13. The clinical onset takes place between the ages of 6 and 20 years. Primary symptoms include

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS progressive ataxic gait, dysarthria, decreased proprioception or vibratory sense, muscle weakness, and lack of deep tendon reflexes. Secondary symptoms include pes cavus, scoliosis, and cardiomyopathy. Affected children frequently are wheelchair bound in the first or second decade of life. The cardiomyopathy often leads to death in the third or fourth decade of life. Labelle et  al. evaluated 56 patients with a diagnosis of Friedreich ataxia and found that all 56 patients had scoliosis. The most common pattern was double structural thoracic and lumbar curves (57%). The typical neuromuscular thoracolumbar curve with pelvic obliquity was found in only 14%. Milbrandt et  al. reported that 63% of their patients developed scoliosis. Because no significant correlation could be established between overall muscle weakness and curve progression, as would be expected in neuromuscular scoliosis, Cady and Bobechko postulated that the pathogenesis of scoliosis in patients with Friedreich ataxia may be a disturbance of equilibrium and postural reflexes rather than muscle weakness. Not all curves in patients with Friedreich ataxia are progressive (49% are progressive); the onset of the disease at an early age and the presence of scoliosis before puberty have been found to be major factors in progression. Scoliosis appearing in the late teens or early 20s is less likely to be progressive. Most authors have not found bracing to be useful for progressive curves in patients with Friedreich ataxia. The orthosis fails to control the curve, and by the time scoliosis develops, the patients often have a significant degree of ataxia and the restriction of a spinal orthosis makes ambulation more difficult. Curves of less than 40 degrees should be observed, curves of more than 60 degrees should be treated operatively, and curves of between 40 and 60 degrees should be observed or treated operatively, depending on the age of the patient, the onset of the disease, and such characteristics of the scoliosis as the patient’s age when it is recognized and evidence of progression of the curve. If the curve is observed too long, cardiomyopathy may have progressed to the point that surgery is risky, if not impossible; early surgical treatment is therefore recommended for progressive curves. Cardiology evaluation is mandatory before any surgery is considered in these patients. Prolonged bed rest postoperatively must be kept to a minimum, or weakness can increase rapidly. For these reasons, the ideal instrumentation for these patients is segmental spinal instrumentation with multiple fixation devices, such as hooks, sublaminar cables, or pedicle screws, that do not require external support postoperatively. In general, these patients require a long fusion with attention to sagittal contours to prevent later problems with thoracic kyphosis. Milbrandt recommended segmental instrumentation and fusion from T2 to the sacrum. The pelvis usually is not included in these fusions unless pelvic obliquity is significant. Spinal cord monitoring usually is not effective in these patients and plans for a wake-up test should be made preoperatively to evaluate the neurologic status after instrumentation and correction. 

CHARCOT-MARIE-TOOTH DISEASE

Classic Charcot-Marie-Tooth disease is a demyelinating neuropathy. The condition is dominantly inherited, with considerable variation in severity. The reported incidence of spinal deformity in Charcot-Marie-Tooth disease varies

from 10% to 26%. Some authors have found brace treatment to be well tolerated, whereas others have had little success, with curve progression reported in 71% and with 33% requiring instrumentation and fusion. The sagittal plane deformity accompanying this scoliosis most frequently is kyphosis, and fusion to the pelvis generally is not necessary unless pelvic obliquity exists. Intraoperative monitoring rarely is possible in patients with Charcot-Marie-Tooth disease; therefore, preoperative plans for intraoperative assessment of possible neurologic compromise with a wake-up test should be considered. 

SYRINGOMYELIA

Syringomyelia is a cystic, fluid-filled cavitation within the spinal cord. Scoliosis may be the first manifestation of a syringomyelia. Syringomyelia can exist with or without Chiari I malformations. The proposed cause of syringomyelia associated with Chiari I malformation is disturbed or obstructed cerebrospinal fluid flow. Syringomyelia without associated Chiari I malformation is described as a noncommunicating syrinx. Scoliosis has been reported in 63% to 73% of children with syringomyelia. Physical findings that may indicate syringomyelia include neurologic deficits and pain associated with the scoliosis, intrinsic muscle wasting of the hands, cavus deformity, asymmetric muscle bulk, occipital and upper cervical headaches, and loss of superficial abdominal reflexes. Radiographic features suggestive of syringomyelia include Charcot changes in joints and a left thoracic curvature. Patients with syringomyelia and scoliosis have been found to have thoracic kyphosis (>40 degrees) instead of thoracic hypokyphosis seen with idiopathic scoliosis. Cervical lordosis also is increased in this patient population. If the diagnosis of syringomyelia is suspected, MRI should be done (Fig. 44.117). In obtaining the MRI study, care must be taken to include the craniocervical junction to rule out the presence of an Arnold-Chiari malformation. The association of syringomyelia with scoliosis may have a significant influence on treatment. Paraplegia and rupture of a large cyst in the cord resulting in death have been reported in patients with syringomyelia who had instrumentation and fusion. Because of the possibility of these complications, surgery for scoliosis in patients with syringomyelia should be approached cautiously. The rate of progression of the neurologic deficit and the prognosis of the curve should be considered carefully before any extensive surgery is considered. Drainage of the cyst, followed by observation to determine if the subsequent curve stabilizes, has been recommended as initial treatment. In one study, improvement was noted in three of 15 patients, and progression did not occur in any patient. Another study showed that drainage of the syrinx delayed but did not prevent curve progression in immature patients; however, drainage of the syrinx did allow use of distraction-type instrumentation without complications. At our institution, the pediatric neurosurgeons believe that the syrinx usually is associated with Chiari I malformations. Their preferred management is decompression of the posterior fossa. If the curve continues to progress after posterior fossa decompression, surgery may be indicated. If instrumentation is necessary in these patients, distraction should be limited. This can be accomplished by either anterior instrumentation or posterior thoracic pedicle

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29

C7

L

R

A

L

12 months

B

R

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FIGURE 44.117 Progressive curve in patient with syringomyelia. A, Initial curve. B, One year later. C, MRI shows syrinx at C7 (arrow).

instrumentation with a direct vertebral rotation technique. Direct communication with the neurosurgeon always is indicated preoperatively in these patients to minimize the possibility of spinal cord injury. 

SPINAL CORD INJURY

Several series in the literature have reported an incidence of spinal deformity in 99% of children with spinal cord injuries before the adolescent growth spurt. Spinal deformity is much more common and the rate of curve progression much greater in preadolescents than in older patients. Increasing curvature with pelvic obliquity in a child with a spinal cord injury can lead to a loss of sitting balance that requires the use of the upper extremities for trunk support rather than for functional tasks. Pressure sores may occur on the downside of the ischium, and hip subluxation can occur on the high side of the pelvic obliquity.

ORTHOTIC TREATMENT

Although some authors believe that alteration of the natural progression of scoliosis in these patients is impossible with devices such as braces and corsets, other authors indicated that orthotic treatment does have a place in the management of scoliosis in preadolescent patients with spinal cord injuries. Orthotic treatment is difficult because of potential skin problems, but effective slowing of progression has been noted. The use of an orthosis may delay the need for surgery in preadolescent patients until longitudinal growth of the spine is more complete. Orthotic treatment requires close cooperation among the physician, the family, and the patient. A customfitted, well-padded, plastic total-contact TLSO generally is used. Close attention must be paid to any evidence of pressure changes on the skin. The brace can be removed at night and used only during sitting. 

OPERATIVE TREATMENT

Most preadolescent children with spinal cord injuries ultimately require surgical stabilization of their scoliosis (50% to 60%). If the curve progresses despite orthotic treatment, operative intervention is indicated. If the curve is more than 60 degrees when the child is first seen, surgery should be considered. Curves treated with an orthosis are considered for surgery if they progress beyond 40 degrees, and curves between 40 and 60 degrees are considered individually. In young children, growing constructs can be used to control the spinal deformity during growth. The prevalence of pseudarthrosis in these patients reported in the literature ranges from 27% to 53%. Dearolf et al. found pseudarthrosis in 26% of their patients, and they attributed the lower figure to the use of segmental fixation in recent years. Segmental instrumentation allows more rigid fixation, and postoperative immobilization can be avoided (Fig. 44.118). Complete urinary tract evaluation should be done before surgery because urinary tract infections are common in patients with spinal cord injuries. Rapidly progressive curves in patients with spinal cord injury should be evaluated with MRI for the possibility of a posttraumatic syrinx. If possible, surgery should be delayed until the patient weighs more than 100 lb. This allows the use of larger rods and more stable fixation. With the increased use of thoracic pedicle screws and lumbar pedicle screws, anterior release is becoming less necessary. For patients younger than 10 years with progressive curves of more than 50 degrees, growing rods can be used to control the curve during growth. If a definitive fusion is required in a young child at risk for future crankshaft problems, a first-stage anterior release and fusion should be considered, followed by posterior segmental spinal instrumentation and fusion. With the better correction in the coronal, sagittal, and axial planes provided by posterior

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A

B

C

FIGURE 44.118 Progressive paralytic scoliosis after gunshot wound. A, Initial curve of 30 degrees. B, Seven years later, curve is 110 degrees. C, After fusion and segmental instrumentation, correction to 53 degrees.

pedicle screw instrumentation, anterior fusion may not be necessary even in these young children. Dearolf et  al. reported pseudarthroses in 3 of 10 preadolescent patients and in 1 mature patient who had fusion to the sacrum. They believed that if there was little residual pelvic obliquity, fusion to L4 or L5 would be sufficient. If, on the other hand, the pelvis was significantly involved in the curve, fusion probably should include the sacrum with pelvic instrumentation. For patients who are ambulators and in whom adequate correction can be obtained without involving the pelvis, an effort should be made to end the instrumentation above the pelvis. In carefully selected patients, Shook and Lubicky used short anterior spinal fusion with instrumentation alone. They reported that this provided excellent curve correction over a short segment and allowed a number of open disc spaces below the fused segment (Fig. 44.119). If laminectomy was used to treat the initial spinal cord injury, an increased incidence of kyphosis can be expected. 

POLIOMYELITIS

Because the Salk and Sabin vaccines have made poliomyelitis in children rare in the United States, most recent experience in treating postpolio spinal deformities is in adult patients. The basic principles of treatment, however, are no different from those of treatment of spinal deformities resulting from other neuromuscular diseases. Bonnett et  al. outlined the indications for correction and posterior spine fusion in patients with poliomyelitis (Box 44.6). As in any other neuromuscular curve, the length of fusion is much greater in patients with poliomyelitis than in those with idiopathic scoliosis. Segmental instrumentation

is recommended. In evaluation of the distal extent of the fusion in a patient with poliomyelitis, it must be determined whether the pelvic obliquity is caused by the spinal curvature itself or by other factors, such as iliotibial band contractures. 

SPINAL MUSCULAR ATROPHY

Spinal muscular atrophy is an autosomal recessive condition in which the anterior horn cells of the spinal cord, and occasionally the bulbar nuclei, atrophy. Spinal muscular atrophy can be classified into four types based on the severity of disease and the age of the patient at the time of clinical onset. Type I, or acute infantile Werdnig-Hoffmann disease, is the most severe form and is usually diagnosed within the first 6 months of life. The course of the disease is progressive, with most of these children dying within the first 2 to 3 years of life. Children with type 2 spinal muscular atrophy (chronic or intermediate form) manage to achieve normal motor milestones until 6 to 8 months of age. They often are very weak but can usually sit without support. Patients usually survive into the third or fourth decade. Type III, or Kugelberg-Welander disease, usually is seen after 2 years of age. It is more slowly progressive, and most patients are able to ambulate independently. Type IV presents in adolescence or early adulthood. On clinical examination, children with spinal muscular atrophy have severe weakness of the trunk and limb muscles. Fasciculations of the tongue and tremors of the extremities are frequent. Reflexes are diminished. Most patients have normal intelligence, and the heart is unaffected by the disease process. Motor and sensory nerve conduction velocities are normal, but electromyography demonstrates denervation with fibrillation potentials. The cause of death usually

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FIGURE 44.119 Fourteen-year-old boy who was paraplegic as result of gunshot wound to spine. A and B, Anteroposterior and lateral sitting thoracolumbar spine views showing 45-degree right lumbar curve with minimal pelvic obliquity. Lateral view shows thoracolumbar junction to be fairly straight. Because patient wanted to continue walking with braces, preservation of as many mobile segments below fusion was thought advantageous. Because of behavior of lumbar curve on side bending, it was thought that anterior fusion alone with instrumentation would provide correction of scoliosis and maintain sagittal contour. C, Anteroposterior sitting thoracolumbar spine view postoperatively shows excellent correction of scoliosis and preservation of sagittal contour. Anterior procedure was done with subperiosteal stripping of spine, and fusion healed rapidly within a few months. (From Shook JE, Lubicky JP: Paralytic scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven.)



BOX 44.6

Indications for Correction and Posterior Spine Fusion in Patients with Poliomyelitis Collapsing spinal deformity because of marked paralysis Progressive spinal deformity that does not respond to nonoperative treatment n Reduction of cardiorespiratory function associated with progressive restrictive lung disease n Decreasing independence in functional activities because of spinal instability that necessitates use of the upper extremities for trunk support rather than for tabletop activities n Back pain and loss of sitting balance associated with pelvic obliquity, which frequently causes ischial pain and pressure necrosis on the downside of the gluteal region n  n 

is pulmonary insufficiency. Ninety percent of these patients have scoliosis, and it is the most severe problem in those who survive childhood. Once patients with spinal muscular atrophy are wheelchair bound, their scoliosis develops rapidly. Aprin et al. noted that scoliosis usually is diagnosed between 6 and 8 years of age, and the more severe the disease, the more likely the curve is to be progressive. The scoliosis is a typical neuromuscular spinal deformity with a long C-shaped curve pattern. Thoracolumbar curves are seen in

80% of patients, and thoracic curves are noted in only 20% of patients. Repeated injections of nusinersen have improved survival and motor development in infants with severe SMA. Nusinersen is administered intrathecally, so allowances must be made for continued injections if treatment of progressive scoliosis is planned.

ORTHOTIC TREATMENT

Bracing has been reported to slow progression of the curve and allows sitting for longer periods. However, patients treated in braces have been found to be less functional because of decreased flexibility of the spine and therefore tend to be noncompliant. When the scoliosis in a skeletally immature patient reaches 20 degrees in the sitting position, orthotic treatment can be considered, usually with a total-contact TLSO. This is used only during sitting to minimize progression of the curve and to provide an extremely weak child with a stable sitting support. Severe chest wall deformities can occur from bracing, and developing chest wall deformities are a contraindication to brace treatment. Although bracing may not eliminate the need for surgical stabilization, it may delay surgery until the child is closer to the end of growth. The use of a growing rod construct as an effective option in the treatment of scoliosis in patients with spinal muscular atrophy has been reported by several authors. This is the preferred option until a definitive posterior fusion can be done. 

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

OPERATIVE TREATMENT

Surgical treatment of the spinal deformity is posterior spinal fusion with posterior segmental instrumentation and adequate bone grafting. Because fusion to the sacrum is needed for many of these patients, fixation to the pelvis can be obtained by the Galveston, iliac screw, or S2 alar screw technique (see Techniques 44.31, 44.33, and 44.35). Augmentation of the fusion with bone-bank allograft bone usually is necessary. For a severe fixed lumbar curve with pelvic obliquity, anterior release and fusion may be needed in addition to posterior instrumentation. It should be understood, however, that anterior surgery in patients with severe pulmonary compromise carries a great risk, and this risk must be evaluated carefully before surgery. With posterior pedicle screw instrumentation, which provides better correction in the coronal, sagittal, and axial planes, anterior fusion usually is not necessary. Preoperative traction can offer an excellent method to improve the flexibility of the spine and also improves pulmonary function before posterior fusion and instrumentation. Complications should be expected in this group of patients (45%). Pseudarthrosis, atelectasis, pneumonitis, and death have been reported. Brown et  al. reduced their complication rate from 35% to 15% with the use of Luque segmental instrumentation and the elimination of postoperative immobilization. Frequent pulmonary complications in patients with spinal muscular atrophy require respiratory support for a longer than normal period after surgery and rapid mobilization when possible. Patients with spinal muscular atrophy may be especially sensitive to medications that depress the respiratory centers, and the use of these drugs in the postoperative period should be minimal. Lonstein and Renshaw found that patients with forced vital capacity of less than 20% of that predicted are at great risk for postoperative death. A vigorous preoperative and postoperative physical therapy program is mandatory. The patient and the family should be warned of the possibility of some loss of function after spinal instrumentation and fusion. A flexible spine allows a weak trunk to collapse forward to increase the reach of the upper extremity. Also, flexibility of the spine and extremities allows the center of gravity to be placed where weak muscles have the best mechanical advantage. Spinal fusion creates a longer lever arm that weak hip muscles are unable to control. Gross motor activities, such as transfers, rolling, bathing, dressing, and toileting, have been noted to decline after spinal fusion. This loss of function, however, must be weighed against the predicted functional loss and pulmonary compromise from severe, untreated spinal deformity. During the long, progressive course of this disease, the advantages of a stable trunk far outweigh the disadvantages. 

FAMILIAL DYSAUTONOMIA

Familial dysautonomia (Riley-Day syndrome), first described in 1949, is a rare autosomal recessive disorder found mostly in Jewish children of Eastern European extraction. Its clinical features include absence of overflow tears and sweating, vasomotor instability that often leads to hyperthermia, and relative indifference to pain. Other frequent findings include episodic hypertension, postural hypotension, transient blotching of the skin, hyperhidrosis, episodic vomiting,

disordered swallowing, dysarthria, and motor incoordination. Death is caused most often by pulmonary disease. Scoliosis is the major orthopaedic problem in patients with this disease. The scoliosis may be progressive and may be large enough to contribute to early death because of kyphoscoliotic cardiopulmonary decompensation. Kyphosis also is a frequent sagittal plane deformity in these patients. If surgery for the scoliosis is considered, however, features of the syndrome such as vasomotor and thermal instability can cause troublesome and sometimes fatal operative or postoperative complications. Brace treatment, although beneficial in some patients, often is complicated by the tendency for pressure ulcers to develop. Posterior spinal fusion with instrumentation was required in 13 of 51 patients in the Israeli series of Kaplan et al. All children undergoing surgery had severe pulmonary problems. Intraoperative and postoperative respiratory and dysautonomic complications were frequent. Because of osteopenic bone, only minor improvement of the spinal deformity was possible, and a small loss of correction was common; however, those surviving noted a marked decrease in the frequency of pneumonia and, for some reason, an improvement in the degree of ataxia. One technical problem in instrumenting these curves is the frequent occurrence of severe kyphosis combined with weak bone. Anterior procedures should be approached with caution because of the frequency of respiratory problems. Despite the significant dangers and high complication rates in patients with familial dysautonomia, surgery can be done successfully with proper precautions and can improve the quality of life. 

ARTHROGRYPOSIS MULTIPLEX CONGENITA

Arthrogryposis multiplex congenita is a syndrome of persistent joint contractures that are present at birth. A myopathic subtype is characterized by muscle changes similar to those found in progressive muscular dystrophy. In the neuropathic subtype, anterior horn cells are reduced or absent in the cervical, thoracic, and lumbosacral segments of the spinal cord. In the third subtype, joint fibrosis and contractures alone are the main problems. Scoliosis is common in patients with arthrogryposis multiplex congenita (20% to 66%). A single thoracolumbar curve is the predominant curve pattern. The scoliosis usually is detected at birth or within the first few years of life. Brace treatment rarely is successful and should be used only with small, flexible curves ( 10° –

*

*

< 1° – 1°

*

> 5° –

< 1° – 1.5°

*

*

*

*

FIGURE 44.129 Median yearly rate of deterioration without treatment for each type of single congenital scoliosis in each region of spine. Numbers on left in each column refer to patients seen before 10 years of age; numbers on right refer to patients seen at age 10 years or older.



BOX 44.8



BOX 44.9

Common Errors in Instrumentation in Patients with Congenital Scoliosis

Treatment of Congenital Scoliosis Prevention of future deformity In situ fusion n Correction of deformity—gradual Hemiepiphysiodesis and hemiarthrodesis Growing rod nonfusion Vertical expandable prosthetic titanium rib n Correction of deformity—acute Instrumentation and fusion Hemivertebra excision Vertebral column resection Osteotomy n 

Use of rods in small children in whom the bone structure is not strong enough to add any stability n Excessive distraction leading to paralysis n Failure to preoperatively evaluate for a tethered cord or other intraspinal abnormalities n Failure to do a wake-up test after rod insertion n Failure to perform adequate fusion because of reliance on internal stability n Failure to supplement the instrumentation with adequate external immobilization n 

COMBINED ANTERIOR AND POSTERIOR FUSIONS

The main indications for anterior and posterior fusions instead of isolated posterior fusion are to treat sagittal plane problems, to increase the flexibility of the scoliosis by discectomy, to eliminate the anterior physis to prevent bending or torsion of the fusion mass with further growth (crankshaft phenomenon), and to treat curves with a significant potential for progression. The anterior procedure consists of removal of the disc, cartilage endplates, and bony endplates. Bone graft in the form of bone chips is placed into the disc space for fusion. Anterior instrumentation usually is not used. The spine is exposed on the convex side, but the approach is dictated by the level of the curve. The anterior fusion can be done through an open anterior approach or thoracoscopically. After the anterior fusion, a posterior procedure is done, with or without instrumentation. The postoperative management

is the same as after posterior fusion with or without instrumentation. Dubousset et al. recommended anterior and posterior fusions in young patients who are fused at the lumbar level before Risser grade 0 and who have significant residual deformity of 30 and 10 degrees of rotation. For thoracic curves, the amount of crankshaft effect that can be tolerated is weighed against the risks of the thoracotomy necessary to perform the anterior epiphysiodesis.   

TRANSPEDICULAR CONVEX ANTERIOR HEMIEPIPHYSIODESIS AND POSTERIOR ARTHRODESIS King et al. described a technique of transpedicular convex anterior hemiepiphysiodesis combined with posterior

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS arthrodesis for treatment of progressive congenital scoliosis. In effect, a combined anterior and posterior fusion can be done through a single posterior approach. These authors reported arrest of curve progression in all nine of their patients after this procedure. The average age of patients at surgery was 9 years. Their technique is based on the work of Michel and Krueger, who described a transpedicular approach to the vertebral body, and Heinig, who described the “eggshell” procedure, so called because the vertebral body is hollowed out until it is eggshell thin before it is collapsed. King et al. found the pedicle dimensions to be adequate for this technique even in infants; however, they recommended preoperative CT through the center of each pedicle to be included in the epiphysiodesis.

TECHNIQUE 44.35 (KING) Position the patient prone on a radiolucent operating table, with a frame or chest rolls. After preparation and draping, obtain a radiograph over a skin marker to identify the appropriate level for the incision. n  Make a single midline posterior incision and retract the paraspinous muscles on both sides of the curve as far as the tips of the costotransverse processes in the thoracic spine and lateral to the facet joints in the lumbar spine. n  Remove the cortical bone in the area of the pedicle to be mined caudad to the facet joint and at the base of the costotransverse process in the thoracic spine. n  Use the curet to remove the cancellous bone. The medullary cavity of the pedicle can now be seen. The cortex medially indicates the boundary of the spinal canal, and caudally and cranially it indicates the margins of the intervertebral neural foramina. Use progressively larger curets until only the cortical rim of the pedicle remains (Fig. 44.130A). The pedicle margins then expand into the vertebral body. n  Remove cancellous bone, creating a hole in the lateral half of the vertebral body, and use curved curets to remove cancellous bone from the vertebral body in the cephalad and caudal directions until the endplate bone, the physis, and the intervertebral disc are encountered. Brisk bleeding may occur, and the surgeon should be prepared for it. n  For a single hemivertebra, mine the pedicle of the hemivertebra itself, along with that of the adjacent vertebrae in the cephalad and caudal directions (Fig. 44.130B). Communication with each pedicle hole across the physis and disc space is readily achieved (Fig. 44.130C). n  Pack autogenous bone from the iliac crest down the pedicles and across the vertebral endplates and discs. n  Posteriorly, excise the convex and concave facet joints and pack with cancellous bone. Carry out decortication bilaterally. n  Use autologous iliac crest bone graft or allograft bone graft. n  If internal fixation is needed, a wire, compression device, or pedicle screw device can be used. n 

POSTOPERATIVE CARE  The patient is placed in a TLSO for 4 to 6 months. After that, no further immobilization is used.   

COMBINED ANTERIOR AND POSTERIOR CONVEX HEMIEPIPHYSIODESIS (GROWTH ARREST)

Gradual correction of congenital scoliosis may be obtained through the use of a convex hemiepiphysiodesis. This technique is used for curves that are the result of failure of formation. There is no role for this technique in failures of segmentation. Correction of deformity relies on the future growth of the spine on the concave side. In deformities caused by failure of segmentation, there is really no growth potential on the concave side. This technique is best for treating a single hemivertebra that has not resulted in a large curve at the time of surgery. This technique is appropriate in children younger than 5 years who meet certain criteria: a documented progressive curve, a curve of less than 50 degrees, a curve of six segments or fewer, concave growth potential, and no pathologic congenital kyphosis or lordosis. Even if the concave side ceases to grow, the anterior and posterior fusions obtain a good result as far as stabilizing the curve. Epiphysiodesis of the entire curve, not merely the apical segment, should be done. Rigid spinal immobilization is used until the fusions are solid, usually at least 6 months after surgery. Preoperative planning is important. Each vertebra should be considered a cube divided into four quadrants, with each quadrant growing symmetrically around the spinal canal (Fig. 44.131). When growth is unbalanced, the zones that must be fused to reestablish balanced growth are determined preoperatively. King et al. noted a true epiphysiodesis effect after transpedicular convex anterior hemiepiphysiodesis (see Technique 44.37) in four of their nine patients, all four of whom had a single hemivertebra. On the basis of these results, they recommended transpedicular hemiepiphysiodesis with posterior hemiarthrodesis in selected patients with a single hemivertebra. Demirkiran et al. reported that a convex growth arrest could be obtained with a posterior fusion and pedicle screw instrumentation at each involved level, with results similar to those of an anteroposterior convex hemiepiphysiodesis.   

CONVEX ANTERIOR AND POSTERIOR HEMIEPIPHYSIODESES AND FUSION TECHNIQUE 44.36 (WINTER) Place the patient in a straight lateral position with the convexity of the curve upward. Prepare and drape the back and side in the same field. The anterior approach technique varies according to the level to be fused (see Techniques 44.23 and 44.24). The posterior approach is a standard subperiosteal exposure (see Technique 44.6) but is always only on the convex side of the curve. n  Once the curve has been exposed, insert needles or other markers both anteriorly and posteriorly so that both are visible on one cross-table radiograph. Failure to place the fusion precisely in the proper area can lead to a poor result. n 

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FIGURE 44.130 A, How pedicles are curetted. B, Anterior view of bone removed during “eggshell” procedure. C, Bone is almost completely hollowed out, and endplates and discs have been removed. SEE TECHNIQUE 44.35.

Once the proper area has been identified, incise the periosteum of the anterior vertebral bodies and peel it forward to the lateral edge of the anterior longitudinal ligament and backward to the base of the pedicle (Fig. 44.132A). n  Incise the annulus of the disc at its superior and inferior margins and remove the superficial portion of the nucleus pulposus. n  Carefully remove the cartilaginous endplates, which are thick in children, taking at least one third of the physes but never more than half. n  Once the cartilaginous endplates have been removed, remove the cortical bony endplate with a curet. n  Make a trough in the lateral side of the vertebral bodies (Fig. 44.132B) and lay the autogenous rib graft in the trough. Use cancellous bone to augment the autogenous rib graft. If autogenous rib is not available, use iliac or bone-bank bone. n  The posterior procedure consists of a standard, unilateral, subperiosteal exposure of the area to be fused (Fig. 44.132C). n  Excise the facet joints, remove any facet cartilage, decorticate the entire area, and apply a bone graft. n  Apply a corrective Risser cast while the child is still under anesthesia to avoid having to use a second anesthetic. n 

AL

PL

AR

PR

A

D

B

E

C

F

FIGURE 44.131 A, Vertebral growth on horizontal plane, four segments: AL, Anterior left; AR, anterior right; PL, posterior left; and PR, posterior right. B, Congenital posterior bar involving PL and PR; level of epiphysiodesis must be AL and AR. C, Anterior defect involving AL and AR; epiphysiodesis must involve PL and PR. D, Anterior excess of growth potential involving both AR and AL; epiphysiodesis must involve both AR and AL above and below. E, Congenital posterolateral bar involving PL only; epiphysiodesis must involve only AR. F, Excess (hemivertebra) growth involving only AR and part of PR; hemiepiphysiodesis must involve AR and PR. (Modified from Dubousset J, Katti E, Seringe R: Epiphysiodesis of spine in young children for congenital spinal deformation, J Pediatr Orthop B 1:23, 1992.)

POSTOPERATIVE CARE Casting is continued for 6 months, and the cast is changed as frequently as necessary. Follow-up must be continued until the end of growth. Results may appear excellent for years but can deteriorate during the adolescent growth spurt.   

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FIGURE 44.132 Combined anterior and posterior convex hemiepiphysiodesis. A, Periosteum of anterior vertebral bodies incised and peeled forward and backward. B, Trough created in lateral side of vertebral bodies. Autogenous rib graft placed in trough. C, Area to be fused exposed through standard, unilateral, subperiosteal exposure. Area is decorticated, and bone graft is applied. SEE TECHNIQUE 44.36.

Growing rods and VEPTR instrumentations that have been used to treat early-onset scoliosis also have been used for gradual correction and stabilization of progressive congenital curves. Several authors have reported good results with these techniques, with acceptable complication rates. The growing rod technique is suggested for patients with primary vertebral anomalies (Fig. 44.133); patients with rib fusion or associated thoracic insufficiency syndrome with congenital scoliosis usually are treated with a VEPTR.

HEMIVERTEBRA EXCISION

Hemivertebra excision can produce immediate correction of a congenital spine deformity. This technique will remove the cause of and prevent further worsening of the deformity. Hemivertebra excision usually is reserved for patients with pelvic obliquity or with fixed, lateral translation of the thorax that cannot be corrected by other means. At the lumbosacral area, excision of the hemivertebra can improve trunk imbalance. The L3, L4, or lumbosacral level, below the level of the

C

conus medullaris, is the safest level at which to excise a hemivertebra. Hemivertebra excision in the thoracic area has more risk because this area of the spinal canal is the narrowest and has the least blood supply, but with spinal cord monitoring (somatosensory-evoked potentials and motor-evoked potentials) the excision can still be performed. The curves best managed by hemivertebra excision are angular curves in which the hemivertebra is the apex. This technique has been reported mostly in lumbosacral hemivertebrae that produce lateral spinal decompensation in patients for whom curve-stabilizing techniques cannot achieve adequate alignment. Hemivertebra resection can be done at any age, but the optimal indication of hemivertebra resection is a patient younger than 5 years with a thoracolumbar, lumbar, or lumbosacral hemivertebra that is associated with truncal imbalance or a progressive curve. Chang et al. recommended early resection before structural changes occur above and below the hemivertebra. They also found that if resection was done before 6 years of age, the patients had significantly better

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FIGURE 44.133 A, Eight-year-old boy with congenital scoliosis. B, After correction and insertion of MAGEC growing rods. SEE TECHNIQUE 44.36.

deformity correction and did not have any negative effects on the growth of the vertebral body or spinal canal compared with patients treated after 6 years of age. Yaszay et al. found that while hemivertebra resection had a higher complication rate than either hemiepiphysiodesis/in situ fusion or instrumented fusion without resection, posterior hemivertebra resection in younger patients resulted in a better percentage of correction than the other two techniques. Hemivertebra excision should be considered a convex osteotomy at the apex of the curve. The entire curve front and back must be fused. Neurologic risk is inherent in hemivertebra excision because the spinal canal is entered both anteriorly and posteriorly. Leatherman and Dickson recommended a two-stage procedure in which the vertebral body is removed through an anterior exposure; then, in a second stage, the posterior elements are removed and fusion is done. Other authors have reported acceptable results with one-stage anterior and posterior hemivertebra resection. The hemivertebra can be excised from a posterior-only technique as described by Ruf and Harms or through a costotransversectomy as described by Smith. In general, postoperative cast or brace immobilization is prescribed for 6 months. The use of instrumentation will give adequate fixation and may permit a brace to be worn rather than a cast, but the bone stock must be adequate to accept the instrumentation or a postoperative cast will be needed. Heinig described a decancellation procedure done with curets through the pedicle. Lubicky recommended both internal fixation and external immobilization with this technique. He found that the amount of immediate correction from this technique was unpredictable, but it did generally lead to a hemiepiphysiodesis when it was combined with a convex posterior fusion at the same level. He recommended that the technique be done with C-arm control (Figs. 44.134A, B). Heinig and Lubicky advised leaving the hemilamina in place until the vertebral body resection is complete to protect the neural

tube while the curet is used. This technique can be useful if the hemivertebra is located posteriorly next to the spinal canal, where seeing the hemivertebra from anteriorly can be difficult. Hedequist, Emans, and Proctor described hemivertebra excision through a posterior approach (see Technique 44.6). With a discrete hemivertebra, the spinal cord or lumbar nerve roots are toward the concavity of the curve, while the hemivertebra is toward the convexity, placing the majority of the operation at a distance from the neural elements. Pedicle screw fixation may be tenuous in the thoracic spine of young children, and standard lumbar hooks should be placed on the rib above and below the excised hemivertebra, just lateral to the transverse process. These hooks are then attached with a rod and compressed across the ribs to achieve closure of the osteotomy while avoiding any compromise of the pedicle screws. The final rod can then be placed across the pedicle screws, and the temporary rib-to-rib rod removed. 

 

HEMIVERTEBRA EXCISION: ANTEROPOSTERIOR APPROACH TECHNIQUE 44.37 (HEDEQUIST AND EMANS) Place the patient in the lateral decubitus position for the simultaneous anteroposterior approach. The anterior approach is on the convex side and should be marked before surgery (Fig. 44.135A). n  For the anterior procedure, approach the spine through a standard transthoracic, transthoracic-retroperitoneal, or retroperitoneal approach, depending on the location n 

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A

B

FIGURE 44.134 A, Congenital scoliosis in a 7-year-old boy. B, After hemivertebra excision and fusion with short-segment rods and pedicle screws.

of the hemivertebra. The only exposure needed is of the hemivertebra and the discs above and below it. n  For the posterior approach, make a standard posterior midline incision and carry the dissection out to the tips of the transverse process, taking care when dissecting over the areas of laminar deficiency. n  After the dissection is complete, obtain a spot radiograph or fluoroscopic view to confirm the appropriate level. HEMIVERTEBRA EXCISION Begin the excision by dissecting over the edge of the transverse process and down the lateral wall of the body with a Cobb elevator and a curve-tipped device. Place a curved retractor. If the hemivertebra is in the thoracic region, resect the rib head first to obtain access. n  Resect the cartilaginous surfaces of the concave facet to encourage fusion. n  With a Kerrison rongeur, begin resection in the midline with the ligamentum flavum followed by resection of the hemilamina (Fig. 44.135B). Extend the resection over to the facet, protecting the nerve roots above and below the hemivertebra. Resect the transverse process and cortical bone over the pedicle until cancellous bone of the pedicle and cortical outlines of its walls are seen. Once again, take care to avoid nerve roots. Gelfoam and cottonoids can be used to protect the dura during resection. n  Develop the subperiosteal plane down the lateral wall of the pedicle and body with the use of a Cobb elevator to facilitate retraction and protection. The dural contents can be protected with a nerve root retractor. Blood loss can be controlled by bipolar sealing of the epidural vessels. Use a diamond-tipped burr to continue resection to the pedicle and into the hemivertebral body to protect against unwanted injury to the soft tissues. Work stepwise within the walls of the pedicle and confines of the body to make removal of the cortical shells easier n 

(Fig. 44.135C). Resect the walls of the pedicle and the remaining walls of the hemivertebral body. Generally, the dorsal cortex of the vertebral body is removed last. The resection is wedge shaped and includes the discs above and below, as well as the concave area of the disc. n  While protecting the dura and its contents, remove the disc material with a pituitary rongeur and curet. Do not remove the disc material above or below or correction will be limited. Proceed with wedge closure and deformity correction.  CLOSURE OF WEDGE RESECTION Place resected vertebral cancellous bone and allograft chips into the wedge resection site anteriorly. n  Closure of the wedge resection is achieved with the use of laminar hooks and external three-point pressure on the body. n  Place a downgoing supralaminar hook at the superior level and an upgoing infralaminar hook on the inferior level. n  To close the resection site, insert the rod, using compression to obtain correction. Using the rod avoids having to place large compression forces across the pedicle screws and allows the screws to maintain correction without plowing of the screws into the immature bone. The compression should be slow and controlled. Observe the dura to make sure it does not get caught in the closure of the posterior elements (Fig. 44.135D). If insufficient correction is obtained, resect further along the edges of the laminae. n  Place two additional rods on either side of the spine connected to the corresponding screws. Apply a crosslink if possible. n  Decorticate the spine and place vertebral corticocancellous allograft.  n 

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Nerve root extractor

Burr Cobb elevator

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Posterior cortex of hemivertebra Far side annulus

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Pedicle

FIGURE 44.135 Hemivertebra excision. A, Patient positioning for anteroposterior excision. B and C, Resection of posterior hemilamina with Kerrison rongeur. D, Compression of laminar hooks with closure of excision site. E, Anterior resection. F, Resection carried back to pedicle. (From Hedequist DJ, Emans JB: Hemivertebra excision. In Wiesel SW, editor: Operative techniques in orthopaedic surgery, Philadelphia, 2011, Wolters Kluwer/Lippincott Williams & Wilkins, p 1466.) SEE TECHNIQUE 44.37.

ANTEROPOSTERIOR EXCISION n  If anteroposterior excision is performed, place the posterior implant anchors before resection. Once complete exposure has been performed, place the posterior screws. n  Create a full-thickness subperiosteal flap over the hemivertebra after localization is confirmed (Fig. 44.135E). n  Starting at the inferior endplate of the adjacent superior body and the superior endplate of the adjacent inferior

body, create longitudinal full-thickness cuts in the periosteum, working anteriorly to the contralateral side. Then move posteriorly until the hemivertebral pedicle is seen. n  Resect the discs above and below the hemivertebra all the way posterior to the posterior longitudinal ligament. n  Resect the hemivertebral body back to the posterior cortical wall of the body with rongeurs and a diamond-tipped burr. The posterior wall can be resected off the posterior longitudinal ligament starting at the level of the disc re-

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FIGURE 44.136 Lateral-posterior approach for hemivertebra resection. (Redrawn from Li X, Luo Z, Li X, et al: Hemivertebra resection for the treatment of congenital lumbar spinal scoliosis with lateral-posterior approach, Spine 33:2001, 2008.) SEE TECHNIQUE 44.38.

sections. The part of the pedicle that can be seen can be resected. n  For posterior resection, start with the hemilamina and proceed to the pedicle (Fig. 44.135F). With both incisions open and fields exposed, the pedicle can be resected though both incisions. n  Once the hemivertebra has been resected, wedge closure and correction of the deformity can proceed as described earlier. 

POSTOPERATIVE CARE  Postoperative care is similar to that for other spinal correction procedures. If fixation is adequate, patients can be placed in a custom-molded TLSO for 3 months. In children younger than 2 years or if fixation is not adequate, a Risser type cast is recommended for 2 months followed by brace wear for 6 months. It may be necessary to remove the implants after a year if prominence is a problem.    

 

HEMIVERTEBRA EXCISION: LATERALPOSTERIOR APPROACH

one segment cephalad to one segment caudad to the hemivertebra, and then turn to the lateral. n  Carry the dissection down to the lumbodorsal fascia and retract the skin and subcutaneous tissue on either side. n  Make a fascial incision and pull the sacrospinal muscle medially. n  Expose the lumbar transverse processes, facet joints, lamina, and spinous process subperiosteally. n  After pulling the psoas major laterally, proceed with dissection directly anteriorly on the pedicle to the vertebral body. n  After segmental vessels have been ligated, the hemivertebra and the appendage, which have been identified radiographically, are exposed (Fig. 44.137B). n  Remove the lamina of the hemivertebra with its attached transverse process, facet joint, and the remaining portion of the pedicle and spinous process. n  Completely excise the disc material on both sides of the hemivertebra. n  Remove the vertebral physes. n  Remove the hemivertebra, starting dissection from the convex aspect to the concave aspect. If the dura has been exposed, place a Gelfoam sponge over it. n  Cut the removed hemivertebral body into morsels and carefully lay it as a graft in the gap that was created by the resection. n  Carry out compression and stabilization on the convex side with short-segmental instrumentation (Cotrel-Dubousset Horizon, Medtronic Sofamor Danek, Memphis, TN), including vertebrae cephalad and caudad to the hemivertebra to correct the scoliosis deformity (Fig. 44.137D). n  Decorticate the facets and the laminae cephalad and caudad to the hemivertebra on the convex side of the curve. n  Cut any bone that is removed during the laminectomy into morsels and place it as graft material through the area extending from one vertebra cephalad to one vertebra caudad to the hemivertebra (Fig. 44.137E). n  Control bleeding with thrombin-soaked Gelfoam and place thrombin-soaked Gelfoam over the dural sac. Close the wound in a routine manner. n  Obtain radiographs to confirm curve correction.

POSTOPERATIVE CARE  A rigid brace is worn full time or part time for an average of 4 months, depending on when the fusion appears solid on radiographs.    

Li et al. described a lateral-posterior approach for hemivertebra resection that gave a safe and stable resection through a single incision (Fig. 44.136).

TECHNIQUE 44.38

 

(LI ET AL.) After administration of general anesthesia, place the patient in a lateral decubitus position, with the convex side of the curve up. Prepare and drape the flank in routine fashion. n  Use an L-shaped lateral-posterior approach to expose the hemivertebra (Fig. 44.137A). Make a straight longitudinal incision about 3.5 cm lateral to the spinous process from n 

HEMIVERTEBRA EXCISION: POSTERIOR APPROACH TECHNIQUE 44.39 (HEDEQUIST, EMANS, PROCTOR) Place the patient prone with good fluoroscopic imaging of the hemivertebra verified.

n 

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A

B

C

D

FIGURE 44.137 Hemivertebra excision through lateralposterior approach. A, Patient positioning. B, Exposure of hemivertebra. C, Resection of hemivertebra. D, Compression and stabilization. E, Fusion. (Redrawn from Li X, Luo Z, Li X, et al: Hemivertebra resection for the treatment of congenital lumbar spinal scoliosis with lateral-posterior approach, Spine 33:2001, 2008.) SEE TECHNIQUE 44.38.

E

Remove the hemilamina and surrounding ligamentum flavum. n  Place pedicle screws in the vertebrae above and below the hemivertebra that is to be removed. Enter the pedicle with a pedicle probe and expand this track with a series of enlarging curets (Fig. 44.138A). n  In the thoracic region, remove about 4 cm of the attached rib and remove the transverse process. The rib head can n 

be removed or left in place and later pushed out laterally during closure of the osteotomy. n  Using a series of straight and downgoing curets, remove the cancellous portion of the vertebral body in its entirety. Frequent use of bone wax on cancellous bone limits bleeding and improves visualization. n  In young children, a layer of cartilage and/or periosteum remains intact and separates the excised vertebra from struc-

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS tures anterior and lateral to the vertebral body. Take care to leave the medial wall of the pedicle and the posterior wall of the vertebra intact (Fig. 44.138B). This is key from a safety standpoint: as long as the medial pedicle wall and posterior vertebral cortex are intact, the neural structures are protected. n  Remove the discs above and below the isolated hemivertebra, including the physes. n  If needed to maximize correction, remove bone above and below the vertebra (Fig. 44.138C). At this stage, it is not unusual to encounter threads of the pedicle screw in the inferior vertebral body, confirming that more than enough tissue has been removed. n  The challenge at this point usually is to dissect sufficiently medially across the midline of the spine; fluoroscopy with the curet in place may help confirm the medial extent of dissection. Remove tissue up to, but not including, the concave annulus. n  During this part of the dissection, the lateral wall of the pedicle usually breaks open, allowing the curet to be directed more medially and providing a good view into the cavity with a headlamp. n  With a pituitary rongeur or curet, remove the medial wall of the pedicle, while gently retracting nerve root and dura from this area. Bipolar cautery is helpful to separate the dural sac from the bone to be removed. n  Push the thinned-out posterior cortex of the vertebral body anteriorly to complete hemivertebra excision. n  Close the opening wedge, making certain that no bone or tissue buckle into the spinal canal. n  Fill any gaps with bone graft.

POSTOPERATIVE CARE  If fixation is secure, a TLSO can be used for 3 months. If there is trunk imbalance or a substantial curve above or below the resection, bracing should be extended for as long as needed until the spine seems balanced.    

 

TRANSPEDICULAR EGGSHELL OSTEOTOMIES WITH FRAMELESS STEREOTACTIC GUIDANCE Mikles et al. described a technique for transpedicular eggshell osteotomies for congenital scoliosis with frameless stereotactic guidance. This technique is recommended in older patients who have congenital scoliosis with multiplanar spinal abnormalities. The guidance system was used to locate the pedicles intraoperatively for accurate screw placement. They thought that screw placement was difficult because of the abnormal anatomy, and they found the use of the guidance system to be helpful in obtaining screw placement proximally and distally and, therefore, a rigid instrumentation construct.

TECHNIQUE 44.40 (MIKLES ET AL.) Obtain an operative CT scan with 1-mm cuts from one level above to one level below the spinal deformity, with use of the appropriate protocol for the frameless stereo-

n 

tactic guidance system. Three-dimensional reconstructions are assimilated. With newer fluoroscopic image guidance systems, CT may not be necessary. n  Determine the level of the osteotomy before surgery. This usually corresponds with an eggshell osteotomy of the hemivertebra but is individualized for each patient. n  Monitor spinal cord and cauda equina function by somatosensory-evoked potentials. n  Position the patient prone on a Jackson spinal table. Carefully pad bony prominences. n  Make a midline posterior incision and subperiosteally dissect to the deformity. n  Confirm the location and identification of the vertebral elements by plain radiographs. n  Place an appropriate reference arc on the upper thoracic spinous processes. n  Register numerous skeletal sites by paired-point and surface-matching techniques. Registration points are determined for only two levels above and below the osteotomy site. n  By use of the guidance system, locate the pedicles with the digitized probe, a digitized drill guide, or a digitized pedicle tap. n  Probe the pedicle with a pedicle probe to the appropriate depth and angle. Insert a digitized ball-tipped probe into the pedicle hole to check the length of the hole and to verify the intrapedicular position. n  Place the screws approximately two levels above and below the chosen osteotomy site. n  After screw placement, identify the transverse processes at the osteotomy level bilaterally; identify the foramina above and below the pedicle and check with fluoroscopy. n  Trim the midline region down carefully with a burr until a thin layer of lamina is left. n  Perform a central laminectomy at the chosen level, including any overhanging lamina from the levels above or below. n  Start the posterior decancellation osteotomy on the side of the most accurately detailed anatomy. Identify the pedicle circumferentially and remove it with its transverse process while visual protection of the nerve root is maintained. n  Identify the pedicle opposite the proposed osteotomy and perform a similar exposure. n  After pedicle removal, expose the vertebral body and inferior floor of the spinal canal. n  Elevate the dura off the posterior wall of the vertebral body and begin the decancellation of the body through the pedicle remnants. Use angled curets to remove the cancellous bone from the vertebral body. Remove the disc spaces if necessary. Push the floor of the canal into the created space with reverse curets and subsequently remove it. Complete vertebrectomy is attempted but not always achieved. This allows the best correction of the curve. n  After completion of the osteotomy, apply gentle pressure to the posterior spine with extension of the hips to close the osteotomy site. Spinal cord monitoring is followed carefully during this time. The dura and nerve roots are continuously viewed to prevent entrapment. Titanium instrumentation is used. Some additional coronal correction is obtained with compression and distraction of the

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A FIGURE 44.138 Hemivertebra excision. A, Pedicle is entered with standard pedicle probe and expanded with series of increasing sized curets; this often creates a hole large enough to see into. B, Cross-section of hemivertebra. Medial wall of pedicle (black arrow) is second-to-last thing to be removed. Posterior wall of vertebral body is last thing to be removed by pushing anteriorly, away from neural elements (white arrow). In this case, not only are inferior disc and endplate removed, but also some of vertebral body is removed to maximize correction. (From Hedequist DJ, Emans JB: Hemivertebra excision. In Rhee J, Wiesel SW, Boden SD, et al, editors: Operative techniques in spine surgery, Philadelphia, 2013, Lippincott Williams & Wilkins, pp 367-375.) SEE TECHNIQUE 44.39.

osteotomy site. Additional lordosis can be obtained with in situ contouring. n  Place two crosslinks and local autogenous bone graft, which was harvested from the vertebral body, laterally along the decorticated transverse processes of the instrumented segment. n  Close the deep fascial layer and place a suction drain subcutaneously. n  Perform a Stagnara wake-up test in the operating room.

POSTOPERATIVE CARE  The patient is fitted with a wellmolded TLSO, which is worn for 12 weeks, starting on the second postoperative day.   

THORACIC INSUFFICIENCY SYNDROME

Growing rod techniques can be used to treat congenital deformities involving long sections of the spine or deformities with large compensatory curves in normally segmented regions above and below a congenital deformity. Thoracic insufficiency syndrome may be associated with congenital scoliosis and fused ribs. When this occurs, it is best managed during growth by expansion thoracostomy and insertion of expandable VEPTR devices. Campbell defined thoracic insufficiency syndrome as the inability of the thorax to support normal respiration or lung growth. This condition occurs in patients with hypoplastic thorax syndromes, such as Jeune and Jarcho-Levin syndromes, progressive infantile scoliosis with reductive distortion of the thoracic volume from spinal rotation, and congenital scoliosis associated with fused ribs on the concave side

C

B

D

FIGURE 44.139 A, Birth radiograph of girl with 50-degree congenital scoliosis due to multiple vertebral anomalies. B, Curve had increased to 83 degrees by age 3 years. She underwent anterior convex spinal fusion and developed respiratory insufficiency 6 months after surgery, requiring supplemental nasal oxygen. C, “False” lateral decubitus view, better showing changes in dimensions of thorax in addition to spinal curvature. D, CT scan shows extreme hypoplasia of chest and underlying lungs. (From Campbell RM: Congenital scoliosis due to multiple vertebral anomalies associated with thoracic insufficiency syndrome, Spine: State of the Art Reviews 14:210, 2000.)

of the curve. In a hypoplastic thorax associated with congenital scoliosis, “extrinsic” restrictive lung disease can be caused by volume restriction of the underlying growing lungs and motion restriction of the ribs with reduction of the secondary breathing mechanism, as well as altered diaphragmatic mechanics. Thoracic and, therefore, lung volume increases to 30% of adult size by the age of 5 and to 50% of adult size by the age of 10. Lung growth is limited to the anatomic boundaries of the thorax, so any spine or rib cage malformation that reduces the thoracic volume early in life may adversely affect the size of the lungs at skeletal maturity (Fig. 44.139). Maximizing thoracic height and volume is especially important in very young patients because lung growth between birth and the age of 8 years is related to increases in alveolar number and size and because growth of the lung between 8 years and maturity is primarily a result of increases in alveolar size. Patients with early-onset scoliosis have been shown to have a higher mortality rate from respiratory failure than those with adolescent idiopathic scoliosis. A review of the literature found that young patients treated with thoracic fusions had a high rate of revision surgery (24% to 39%) and

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FIGURE 44.140 A, Multiple congenital anomalies of thoracic spine, including hemivertebra on convex side of curve and long unilateral unsegmented bar on concave side (arrows), in 2½-year-old girl with 87-degree scoliosis. B, At 6-year follow-up, curve is corrected to 65 degrees. Length of large central, unilateral segmented bar from T5 to T11 on concave side of curve (arrows) compared preoperatively and postoperatively suggests growth on concave side of curve. (From Campbell RM: Congenital scoliosis due to multiple vertebral anomalies associated with thoracic insufficiency syndrome, Spine: State of the Art Reviews 14:210, 2000.)

restrictive lung disease (43% to 64%), with those patients having upper thoracic fusions being at the highest risk. Long thoracic fusions by limiting thoracic and lung growth in young patients should be avoided to prevent the development of iatrogenic thoracic insufficiency. Because of the inability of traditional spinal correction techniques to increase the dimensions of the thorax, Campbell developed a technique to directly treat chest wall deformity with indirect correction of the congenital scoliosis. This procedure treats the total global deformity of the thorax, allowing the spine to grow undisturbed by surgical intervention, with increased height of the thoracic spine and the thorax. Gruca described a technique of operative compression of the ribs to obtain correction of idiopathic scoliosis on the convex side of the curve; however, concerns exist about this limiting thoracic and therefore lung growth. Campbell developed rib distraction instrumentation techniques for treatment of primary hemithorax constriction in severe spinal deformity in young children. He postulated that indirect correction of scoliosis could be obtained by surgical expansion of the chest through rib distraction on the concave side of the curve. He compared this technique with an opening wedge osteotomy of a malunion of a long bone. In this technique, the thoracic deformity is corrected by an “opening wedge thoracostomy” in the center of the deformity of the concave constricted hemithorax. Once the constricted hemithorax is lengthened, the thorax is equilibrated, with indirect correction of the scoliosis. Correction is maintained with an expandable titanium rib prosthesis. A substantial correction of the hemithorax deformity, an average curve correction of approximately 20 degrees, and the continued growth of the spine were noted as well. Elongation of unilateral unsegmented bars over time in patients treated with chest wall distraction techniques also

has been noted (Fig. 44.140). The advantages of this technique are that it directly treats the anatomic causes of thoracic insufficiency syndrome and does not interfere with any subsequent spinal procedures that may be needed later in life. Campbell treated 34 patients who had progressive congenital scoliosis associated with fused ribs of the concave hemithorax with expansion thoracoplasty and a titanium rib prosthesis. He recommended consideration of spinal growthsparing techniques, such as growth rods and expansion thoracoplasty, for patients with multiple levels of malformation in the thoracic spine (jumbled spine) with associated areas of either rib deletion or fusion (jumbled thorax). Patients treated with rib-based distraction have been shown to have improvement in their coronal and sagittal spine deformities, pulmonary status, hemoglobin levels, and nutritional status. Although Cobb angle correction with this technique is well described, it has been shown to correlate poorly with pulmonary function and so the exact method(s) of physiologic improvement remain unknown. Since the initial reports, rib-based distraction has now been used in the treatment of thoracic insufficiency and scoliosis in other conditions such as neuromuscular scoliosis and myelomeningocele. Because this is a posteriorbased distraction technique, there is a potential for the development of increased kyphosis, especially in patients with increased preoperative kyphosis. Increased kyphosis may also play a role in proximal rib anchor failure. Longer constructs from the pelvis to ribs have been used to prevent excessive kyphosis; however, these should be avoided in ambulatory patients because of the increased incidence of postoperative crouch gait caused by changes in the lumbosacral mechanics. Intraoperative neuromonitoring is recommended for all initial insertions and in lengthening in which patients have neurologic changes at the time of their

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PART XII  THE SPINE initial insertion. The role of its use in routine lengthenings in neurologically normal patients remains controversial. A large multicenter study found a rate of eight neurologic injuries in 1736 consecutive procedures (0.5%) of which five were at the time of initial implantation. When used, it should include monitoring of the upper extremities because the upper extremity was involved in six of eight cases, which may have been related to brachial plexus injury. 

 

EXPANSION THORACOPLASTY The VEPTR device comes in two forms. The device with a radius of 220 mm is most commonly used in the treatment of fused ribs and scoliosis. The titanium alloy permits the use of MRI postoperatively. There are three anchors available: rib, spine, and pelvis. The rib anchor consists of two C-shaped clamps that, when locked, form a loose encirclement around the rib to avoid vascular compromise of the underlying rib. Lateral stability is provided by the surrounding soft tissues. The spine anchor consists of a low-profile closed laminar hook. The pelvic anchor consists of an S-shaped modified McCarthy hook that is placed over the iliac crest. The central portion of the device consists of two sliding rib sleeves. The superior sleeve is attached to the cranial anchor, which is usually a rib, and the inferior sleeve is attached to the caudal anchor, which can be a rib, the spine, or the pelvis. The device is locked inferiorly by a peg-type lock through one of two holes, 5 mm apart in the distal rib sleeve, into partial-thickness holes in the inferior rib cradle post. This provides variable expandability for the device in increments of 5 mm. It is important to insert the device with the sleeves completely overlapped to maximize the excursion of the construct before revision is necessary (Fig. 44.141).

TECHNIQUE 44.41 (CAMPBELL) Place the patient in a lateral decubitus position with the concave side of the hemithorax upward. A small padded bolster can be placed at the apex of the curve to help with correction. n  Intraoperative spinal monitoring of both upper and lower extremities is used. Begin prophylactic intravenous antibiotics. n  Make a thoracotomy incision around the tip of the scapula and carry it anteriorly. Often in patients with fused ribs, the scapula is both hypoplastic and elevated proximally. In these patients, the skin incision may need to be brought more distal as it courses around the scapula. n  If a hybrid device is to be used, make a second incision 1 cm lateral to the midline over the proximal lumbar spine (Fig. 44.142A). n  Through the thoracotomy incision, elevate the muscle flaps and proximally identify the middle scalene muscle. Place devices on the second rib posterior to the scalene muscle. Anterior to the middle scalene muscle device, attachment is not done proximally because of the risk of impingement on the neurovascular bundle (Fig. 44.142B). n 

FIGURE 44.141 Expandable prosthetic rib device. (Redrawn from Campbell RM, personal communication.) SEE TECHNIQUE 44.41.

Once exposure has been completed, identify the central rib fusion mass by the absence of intercostal muscles. This is the center of the apex of thoracic deformity where the concave hemithorax is most tightly constricted by rib fusion and is best seen on preoperative bending radiographs. n  Before the opening wedge thoracostomy is performed, prepare the rib prosthesis cradle sites proximally and distally. Make 1-cm incisions by use of an electrocautery in the intercostal muscles under the second rib, with a second 5-mm incision above it in the muscle. n  Use an elevator to carefully strip off only the anterior portion of the rib periosteum without violating the pleura (Fig. 44.142C). n  Insert a second elevator into the proximal intercostal muscle incision to encircle the rib. n  Prepare the inferior rib cradle site in the same fashion. n  Insert the rib cradle cap into the proximal intercostal muscle incision sideways and then turn it distally to encircle the rib, similar to insertion of a spinal laminar hook. n  Pass the superior rib cradle into the inferior intercostal muscle incision (Fig. 44.142D), mate it with the cradle cap, and lock it into place with pliers (Fig. 44.142E). n  The sites for the cradles should be just lateral to the transverse processes of the spine. The superior cradle site should be at the top of the area of the constricted hemithorax. If that site does not allow enough distance between the cradle sites for a device of sufficient length to have reasonable expansion capability, the site can be moved superiorly. In very flexible spines, however, care must be taken not to induce a large compensatory curve in the spine above the primary hemithorax constriction by placing the rib cradle too far superiorly. The inferior cradle site should be in a stable base of the area of the n 

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E

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F FIGURE 44.142 A–J, Campbell technique of expansion thoracoplasty. See text for description. (Redrawn from Campbell RM, personal communication, 2000.) SEE TECHNIQUE 44.41.

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J FIGURE 44.142, cont’d

constricted hemithorax, below the line of the opening wedge thoracostomy, and usually encircling two fused ribs. n  Select the inferior rib cradle site by picking a rib of attachment that is clinically stable, as horizontal as possible, and at the inferior edge of the thoracic constriction. Avoid unstable rib attachments distally (vestigial rib) because of the high loads placed on the device in the expansion of a fused chest wall. n  Insert the superior cradle before the opening wedge thoracostomy is made. The inferior cradle is not placed at this point because the size of the device required to hold acute hemithorax correction is not known until the hemithorax is lengthened by the opening wedge thoracostomy. n  The deformity of the concave hemithorax is corrected by an opening wedge thoracostomy (Fig. 44.142F). This corrects the “angulated thorax,” similar to the use of an

opening wedge osteotomy to correct malunion of a long bone. n  Place the thoracostomy in the apex of the thoracic constriction where it can best correct the concave hemithorax, lengthen the constricted segment, and flare out the superior ribs laterally to increase thoracic volume. In most patients, this line of correction passes not through the apex of the scoliosis but above it. n  To confirm the correct position, place metal markers on the chest wall and verify the location with C-arm radiographs and then compare with the preoperative plan. n  The line of cleavage for the primary opening wedge thoracostomy may be through a mass of fused ribs, an area of fibrous adhesions between two ribs, or vestigial intercostal muscle. If the chosen interval is osseous, use a rongeur and Kerrison punches to make the thoracostomy. Be careful not to reflect periosteum from the rib incision

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS site, which will devascularize the rib. Strip away the underlying periosteum with a No. 4 Penfield elevator. The line of the thoracostomy extends from the sternum, along the contours of the ribs, to the transverse processes of the spine posteriorly. n  Reflect the paraspinous muscles from lateral to medial. Take care not to expose the spine to minimize the risk of inadvertent fusion. n  Once exposure is completed, gently spread the thoracostomy interval apart with two vein retractors to allow a lamina spreader to be inserted between the ribs in the midaxillary line of the thorax. Then complete the opening wedge thoracostomy by gradually widening the lamina spreader about 5 mm every 3 minutes (Fig. 44.142G) until the thoracic interval is widened to approximately 1 cm. n  If the ribs are easily distracted and there is at least 0.5 cm of soft tissue between the ribs as they articulate with the spine medially, no further resection is necessary. n  If rib distraction is difficult, additional rib fusion mass probably requires resection medially. If further resection is needed, cut a 1-cm wide channel medially at the posterior apex of the opening wedge thoracostomy, resecting the remaining fused rib anterior to the transverse process and following it down to the vertebral body for complete removal. n  Expose the bone to be removed a few millimeters at a time by subperiosteal dissection with a Freer elevator. n  Use a rongeur to remove the exposed bone. Take care to resect only visible bone, avoiding the spinal canal posteriorly and the esophagus and great vessels anteriorly. Preserve anomalous segmental vessels. n  Disarticulate the last 5 mm of fused rib from the spine with an angled curet, avoiding the neuroforamen, until the cartilage articular disc is visible. n  Secure hemostasis with bipolar cautery. n  Place bone wax over any raw bone surfaces. n  If the maximal thoracostomy interval distraction is 2 cm or less, the underlying pleura generally stretches and remains intact. If distraction is more than 2 cm, the pleura may begin to tear. Small tears in the pleura require no treatment, but substantial defects are treated with a Gore-Tex sheet (WL Gore and Assoc., Newark, DE) sutured to the edges of the intact pleura. Avoid attaching it to rib, muscle, or periosteum because it will become a tether. A Gore-Tex sheet of 0.6-mm thickness is used for small defects, and a 2-mm sheet is used for larger defects. The Gore-Tex sheet usually is placed after the device has been implanted to allow accurate sizing of the sheet needed for maximal thoracic volume. The surface of the sheet is brought outward to maximize volume. n  After the chest is expanded by the lamina spreader, measure the distance between the superior and inferior cradle sites to determine the size of the device needed. The inferior rib cradle and the rib sleeve should be of compatible sizes. An inferior rib cradle that is substantially shorter than the rib sleeve will reduce the device’s ability for later expansion and require more frequent change-outs. n  Assess the orientation of the device and cradle after acute thoracostomy expansion so that they conform best to the corrected anatomy. n  After the device is sized and the orientation for the inferior cradle is chosen, relax the lamina spreader to ease access to the cradle sites.

Insert the cradle cap inferiorly, implant the inferior cradle, and lock the components together with a cradle lock. n  If a hybrid device is used to span down to the lumbar spine, place this in a supralaminar position by resecting the intraspinous ligament and ligamentum flavum using a Kerrison rongeur. n  Place a bone graft on the lamina down to the hook to further stabilize a construct with a one-level fusion. Alternatively, a two-level claw construct can be used to increase stability, especially in older patients. n  If the superior cradle has not been previously inserted, implant it now. n  Reinsert the lamina spreader between medial ribs at the apex of the opening wedge thoracostomy. Reexpand the interval, expanding the thorax by bringing the device components out to length. n  Assemble the device by threading the rib sleeve over the inferior cradle and levering the rib sleeve in line with the superior rib cradle by the device wrenches. The acute correction obtained by the opening wedge thoracostomy is now stabilized by the rib device (Fig. 44.142H). n  For primary thoracic scoliosis in children younger than 18 months, only a single thoracic device is placed posteriorly, adjacent to the transverse processes of the spine. If a patient is older than 18 months and has adequate lumbar canal size and laminae, more support of the thoracostomy can be provided by a hybrid device and a second thoracic prosthesis added posterolaterally. n  Place the thoracic prosthesis in the posterior axillary line to further expand the constricted hemithorax, with proximal attachment just posterior to the middle scalene muscle with at least 0.5 cm between the superior rib cradles. n  Once assembled, tension both devices by expanding them 0.5 cm to fit snugly without excessive distraction pressure and then place two distraction locks on the rib sleeve. n  If the chest wall defect created by the opening wedge thoracostomy is larger than 2 cm, potential chest wall instability will need to be considered. A chest wall defect up to 3 cm wide is well tolerated proximally because of the splinting effect of the scapula posteriorly and the pectoralis muscle anteriorly. A distal chest wall defect of more than 2 cm and a proximal defect of more than 3 cm may need augmentation to provide chest wall stability by centralization of surgically created “pseudoribs” in the defect, addition of more devices, or implantation of a Gore-Tex sheet (2 mm thick) over the defect. n  In the first technique, called transport centralization, separate a single rib or pseudorib of two or three fused ribs away from the superior border of the opening wedge thoracostomy and rotate it downward, like a “bucket handle,” to lie centrally in the chest wall defect. The goal of this technique is to divide the chest wall defect into a series of smaller defects, none larger than 2 cm. If the defect is too large for a single rib, separate another rib or pseudorib from the inferior border of the open wedge thoracostomy and bring it into the defect, dividing the larger defect into three smaller ones. Take care to preserve all soft-tissue attachments to avoid devascularization of the rib. n  The second method of augmentation is to add additional devices if transport centralization is not feasible or bone stock is inadequate. This method is practical only in larger n 

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PART XII  THE SPINE patients with adequate soft tissue for device coverage, and usually three devices are the maximum that can be used safely. n  Finally, a 2-mm Gore-Tex sheet can be used to supplement either of the other two methods. When the scoliosis extends from the thorax into the lumbar spine, use a lumbar hybrid rod extension. This lumbar extension can be used only in patients with adequate lumbar spinal canal size for hook placement, and generally the patient should be at least 18 months of age. Preoperatively assess the width of the canal by CT. The usual site of distal insertion is at either L1 or L2; but if the scoliosis extends well distally into the lumbar spine, L3 can be used. Avoid more distal insertion sites on the spine if possible. n  Spinal dysraphism of the proximal lumbar spine may require that the laminar hook be placed in the distal lumbar spine or that a modified McCarthy hook for the pelvis be coupled to the hybrid lumbar extension. n  Through a separate skin incision over the lumbar spine, insert the hybrid distraction device and pass it percutaneously from proximal to distal through the paraspinal muscles. Because of the kyphosis of the thorax, if the device is passed in a proximal direction, it may inadvertently penetrate the chest. Size the device similar to the all-thoracic technique and complete the opening wedge thoracostomy. n  Implant the superior cradle with an empty rib sleeve sized to extend to the inferior border of the thorax at the 12th rib. n  Size a hybrid rod lumbar extension to match the rib sleeve and select for implantation. n  Insert the inferior hook sublaminar. Size a hybrid rod lumbar extension to match the rib sleeve. n  With a lamina spreader in place to maintain the correction obtained with the opening wedge thoracostomy, use in situ benders to bend the hybrid rod into a slight kyphosis proximally and slight valgus and lordosis distally to best fit the lamina hook. The length of the rod should allow it to extend 1 cm distal to the hook. n  With a Kelly clamp, create a tunnel from the proximal incision through the paraspinal muscles, moving proximally to distally, with a finger in the lumbar incision to palpate the tip of the clamp as it exits the muscle. Use the Kelly clamp to grasp a small chest tube and pull it into the proximal incision. n  Attach the hybrid device to the tube and, by use of the tube, thread it proximally to engage the rib cradle and then into the hook. n  Distract the rib and tighten the hook. n  Place bone graft over the laminae. n  A large amount of correction may push the anterior portion of the proximal fused ribs proximally into the brachial plexus. To check for acute thoracic outlet syndrome, bring the scapula back into position while the anesthesiologist monitors pulses and ulnar nerve function is monitored by somatosensory potentials. If both are normal, close the muscle flaps with absorbable suture and close the skin in standard fashion with absorbable subcutaneous sutures. n  If either the pulse or ulnar nerve function is abnormal, retract the scapula and subperiosteally resect 2 cm of the proximal two ribs that are anterior under the brachial plexus.

Bring the scapula back into position and check somatosensory potentials again. If they are normal, close the incision.

n 

POSTOPERATIVE CARE  The patient is placed in the intensive care unit until extubation, which will depend on the severity of the preoperative pulmonary compromise. In general, we leave our uncomplicated thoracostomy patients intubated overnight and wean respiratory support as tolerated. No bracing is used postoperatively to avoid constriction of chest wall growth. At intervals of approximately 6 months after the initial implantation, the device is expanded in an outpatient procedure. Prophylactic intravenous antibiotics are administered, and the distal end of the device is exposed with an incision through the thoracostomy incision if possible. Once the underlying muscle is exposed, it is split along its fibers or cut vertically either on the medial or lateral side of the device to form a thick muscle flap. Incisions directly over the device(s) should be avoided owing to the potential for skin breakdown and implant infection. The distraction lock over the device is removed, and distractor pliers are inserted to lengthen the device (Fig. 44.142I,J). The prosthesis is lengthened slowly, approximately 2 mm every 3 minutes, to avoid fracture. Once maximal reactive pressure is reached, the device is locked in place with a new distraction lock. Lengthening usually is a minimum of 0.5 cm and up to 1.5 cm. Once the device has exhausted its expandability, a change-out operative procedure is done through small proximal and distal transverse incisions. The sleeves are removed and replaced with larger components (implants). Devices that extend well under the scapula may be difficult to exchange and often require opening of a large portion of the old thoracotomy incision to change the components.    

KYPHOSIS In the sagittal plane, the normal spine has four balanced curves: the cervical spine is lordotic; the thoracic spine is kyphotic (20 to 50 degrees), with the curve extending from T2 or T3 to T12; the lumbar region is lordotic (31 to 79 degrees); and the sacral curve is kyphotic. On standing, the thoracic kyphosis and lumbar lordosis are balanced. Normal sagittal balance is defined as a plumb line dropped from C7 and intersecting the posterosuperior corner of the S1 vertebra (Fig. 44.143). Positive sagittal balance occurs when the plumb line falls in front of the sacrum, and negative sagittal balance occurs when the plumb line falls behind the sacrum. In the upright position, the spine is subjected to the forces of gravity, and several structures maintain its stability: the disc complex (nucleus pulposus and annulus), the ligaments (anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, apophyseal joint ligaments, and intraspinous ligament), and the muscles (the long spinal muscles, short intrinsic spinal muscles, and abdominal muscles). Kyphosis of 50 degrees or more in the thoracic spine usually is considered abnormal. Kyphotic deformity may occur if the anterior spinal column is unable to withstand compression, causing shortening of the anterior column. Disruption of the

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

C7

1 2 3 4 5 6 7 8 9 10 11 12

Positive balance

1 2

Negative balance

3 4 5 S1

FIGURE 44.143 Plumb line is dropped from middle of C7 vertebral body to posterosuperior corner of S1 vertebral body. (Redrawn from Bernhardt M: Normal spinal anatomy: normal sagittal plane alignment. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven.)

posterior column and inability to resist tension can lead to relative lengthening of the posterior column and kyphosis (Fig. 44.144). 

SCHEUERMANN DISEASE Scheuermann originally described a rigid juvenile kyphosis in 1920. Scheuermann disease is a structural kyphosis of the thoracic or thoracolumbar spine that occurs in 0.4% to 8.3% of the general population. It occurs slightly more often in males. The age at onset usually is during the prepubertal growth spurt, between 10 and 12 years of age.

CLASSIFICATION

Scheuermann disease is divided into two distinct groups: a typical form and an atypical form. These two types are determined by the location and natural history of the kyphosis, including symptoms occurring during adolescence and after growth is completed. Typical Scheuermann disease usually involves the thoracic spine. This classic form of Scheuermann kyphosis has three or more consecutive vertebrae, each wedged 5 degrees or more, producing a structural kyphosis. In contrast, atypical Scheuermann disease usually is located in the thoracolumbar junction or the lumbar spine. It is characterized by vertebral endplate changes, disc space narrowing, and anterior Schmorl nodes but does not necessarily have three consecutively wedged vertebrae of 5 degrees. Thoracic Scheuermann disease is the most common form. 

FIGURE 44.144 Forces that contribute to kyphotic deformity of thoracic spine. Anterior vertebral bodies are in compression, and posterior vertebral elements are in tension.

ETIOLOGY

The cause of Scheuermann disease is probably multifactorial. Scheuermann thought that the kyphosis resulted from osteonecrosis of the ring apophysis of the vertebral body. However, the ring apophysis lies outside the true cartilaginous physis and contributes nothing to the longitudinal growth of the body; therefore, a disturbance in the ring apophysis should not affect growth of the vertebra or cause vertebral wedging. In 1930, Schmorl suggested that the vertebral wedging is caused by herniation of disc material into the vertebral body; these herniations now are known as Schmorl nodes. Schmorl theorized that as the disc material is extruded into the vertebral body the height of the intervertebral disc is diminished, which causes increased pressure anteriorly and disturbances of enchondral growth of the vertebral body and subsequent wedging. However, Schmorl nodes are relatively common and frequently occur in patients with no evidence of Scheuermann disease. Ferguson implicated the persistence of anterior vascular grooves in the vertebral bodies during preadolescence and adolescence. He suggested that these vascular defects create a point of structural weakness in the vertebral body, which leads to wedging and kyphosis. Bradford and Moe and Lopez et al. found that osteoporosis may be responsible for the development of Scheuermann disease. However, a study of bone density in a group of trauma patients and teenagers with Scheuermann disease, as well as a cadaver study, found no evidence of osteoporosis in the vertebrae. Mechanical factors are a likely cause of Scheuermann disease. Lambrinudi and others suggested that the upright posture and the tightness of the anterior longitudinal ligament of the spine contribute to the deformity. Scheuermann kyphosis is more common in patients who do heavy lifting or manual labor. The fact that some correction of the kyphosis can

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PART XII  THE SPINE be obtained by bracing that relieves pressure on the anterior vertebral regions also indicates that mechanical factors are important. The kyphosis probably increases pressure on the vertebral endplates anteriorly, causing uneven growth of the vertebral bodies as a response to the law of Wolff. A biochemical abnormality of the collagen and matrix of the vertebral endplate cartilage also has been suggested as an important factor in the cause. Abnormal collagen fibers and a decrease in the ratio between collagen and proteoglycan have been found in the matrix of the endplate cartilage in patients with Scheuermann disease. Several authors have found support for a genetic basis for Scheuermann disease. A high familial predilection has been noted in several studies. The disease may be inherited in an autosomal dominant fashion. Additional support for a genetic basis is provided by Carr et  al. in a report of Scheuermann disease occurring in identical twins. In summary, many causes have been suggested but none has been proved. Further research is required to better investigate the ultimate causes of Scheuermann disease. 

A

CLINICAL FINDINGS

Scheuermann disease usually appears around the adolescent growth spurt. The presenting complaint is either pain in the middle or lower back or concern about posture. Frequently, the parents believe that the kyphosis is postural, so diagnosis and treatment are delayed. Pain usually is located in the area of the deformity or in the lower back, is made worse by activity, and typically improves with the cessation of growth. If pain is present in the lumbar area and the deformity is in the thoracic region, the possibility of spondylolysis should be considered. Physical examination shows an angular thoracic or thoracolumbar kyphosis with compensatory hyperlordosis of the lumbar spine. The kyphosis is sharply angular and does not correct with the prone extension test (Fig. 44.145). The lumbar lordosis below the kyphosis usually is flexible and corrects with forward bending. Tight hamstrings and pectoral muscles are common. On forward bending, a small structural scoliosis may be present in as many as 30% of patients. Physical findings in patients with atypical (lumbar) Scheuermann disease may differ from those in patients with thoracic deformity. These patients usually have low back pain, but, unlike patients with the more common form of Scheuermann disease, they may not have as noticeable a deformity. Pain with spinal movement is the primary symptom. The condition is especially common in males involved in competitive athletics and in farm laborers, suggesting that it represents an injury to the vertebral physes from repeated trauma rather than true Scheuermann disease. Abnormal neurologic findings have been reported in 9% to 15% of patients with Scheuermann kyphosis; such findings emphasize the importance of a detailed neurologic examination. Spinal cord compression from kyphosis, thoracic disc herniation, epidural cysts, and epidural lipomatosis have been reported. If lower extremity weakness, hyperreflexia, sensory changes, or other neurologic findings are detected, MRI of the kyphotic area should be done. 

RADIOGRAPHIC FINDINGS

Standing anteroposterior and lateral radiographs of the spine should be obtained. The amount of kyphosis is determined

B FIGURE 44.145 A, Scheuermann kyphosis. B, Postural kyphosis. (From Warner WC: Kyphosis. In Morrissy RT, Weinstein SL, editors: Lovell and Winters pediatric orthopaedics, ed 6, Philadelphia, 2006, Lippincott Williams & Wilkins, p 797.)

by the Cobb method on a lateral radiograph of the spine. The cranial and most caudal tilted vertebrae in the kyphotic deformity are selected. A line is drawn along the superior endplate of the cranial vertebra and the inferior endplate of the most caudal vertebra. Lines are drawn perpendicular to the line along the endplates, and the angle they form is the degree of kyphosis. The criteria for the diagnosis of typical Scheuermann disease are more than 5 degrees of wedging of at least three adjacent vertebrae at the apex of the kyphosis and vertebral endplate irregularities with a thoracic kyphosis of more than 50 degrees (Fig. 44.146). Bradford suggested that three wedged vertebrae are not necessary for the diagnosis but rather an abnormal, rigid kyphosis is indicative of Scheuermann disease. Flexibility and the structural nature of the deformity are determined by taking a lateral radiograph with the patient lying over a bolster placed at the apex of the deformity to hyperextend the spine. On a lateral radiograph, most patients will be in negative sagittal balance measured by dropping a plumb line from the center of the C7 vertebral body and measuring the distance from this line to the posterosuperior corner of the S1 vertebra. Scoliosis is evident on posteroanterior radiographs in approximately a third of patients. A lateral radiograph should be made with the patient in the hyperextended position over a bolster to determine the structural nature of the deformity. Atypical Scheuermann disease of the lumbar spine is characterized by irregularity of the vertebral endplates, the presence of Schmorl nodes, and narrowing of the intervertebral discs, without wedging of the vertebral bodies or kyphosis. 

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Lumbar Scheuermann disease, which usually is associated with strenuous physical activity, generally becomes asymptomatic within several months after restriction of activities. 

ASSOCIATED CONDITIONS

FIGURE 44.146 Scheuermann kyphosis. Kyphotic deformity of 81 degrees and Schmorl nodes.

NATURAL HISTORY

In most cases, Scheuermann disease results in minimal deformity and few symptoms. The kyphotic deformity can progress rapidly during the adolescent growth spurt. Back pain and fatigue are common complaints during adolescence but usually disappear with skeletal maturity. Factors that contribute to the risk of continued progression of kyphosis include the number of years of growth remaining and the number of wedged vertebrae. Neurologic symptoms have occasionally been reported in adolescents because of herniation of a thoracic disc, an epidural cyst, or the severe kyphotic deformity alone with subsequent compression of the cord. The true natural history of untreated Scheuermann disease in adulthood is not well established. Travaglini and Conte found that the kyphosis increased during adulthood in 80% of their patients, although few developed severe deformity. During middle age, degenerative spondylosis is common, but radiographic findings do not always correlate with the presence or absence of back pain. If the kyphosis is less than 60 degrees, these changes usually do not occur in adulthood. Patients with Scheuermann kyphosis were found in one study to have more intense back pain, jobs that tend to have lower requirements for activity, loss of extension of the trunk, and different localization of pain. However, the level of education, number of days absent from work because of back pain, pain that interfered with activities of daily living, self-esteem, social limitations, use of medication for back pain, or level of recreational activities were not significantly different from those without Scheuermann disease. Most patients reported little preoccupation with their physical appearances. Normal or above-normal averages of pulmonary function were found in patients in whom the kyphosis was less than 100 degrees. Patients who have Scheuermann kyphosis may have some functional limitation, but it does not significantly affect their lives. Patients who have not had surgery for the kyphosis adapt reasonably well to their condition.

Mild-to-moderate scoliosis is present in about one third of patients with Scheuermann disease, but the curves tend to be small (10 to 20 degrees). Scoliosis associated with Scheuermann disease usually has a benign natural history. Deacon et al. divided scoliotic curves in patients with Scheuermann disease into two types on the basis of the location of the curve and the rotation of the vertebrae into or away from the concavity of the scoliotic curve. In the first type of curve, the apices of the scoliosis and kyphosis are the same and the curve is rotated toward the convexity. The rotation of the scoliotic curve is opposite to that normally seen in idiopathic scoliosis. They suggested that the difference in direction of rotation is caused by scoliosis occurring in a kyphotic spine, instead of the hypokyphotic or lordotic spine that is common in idiopathic scoliosis. In the second type of curve, the apex of the scoliosis is above or below the apex of the kyphosis and the scoliotic curve is rotated into the concavity of the scoliosis, more like idiopathic scoliosis. This type of scoliosis seen with Scheuermann kyphosis is the more common, and it rarely progresses or requires treatment. Lumbar spondylolysis is frequently found in patients with Scheuermann kyphosis (Fig. 44.147). The suggested reason for the increased incidence of spondylolysis (50% to 54%) is that increased stress is placed on the pars interarticularis because of the associated compensatory hyperlordosis of the lumbar spine. This increased stress causes a fatigue fracture at the pars interarticularis, resulting in spondylolysis. Other conditions reported in patients with Scheuermann disease include endocrine abnormalities, hypovitaminosis, inflammatory disorders, and dural cysts. 

DIFFERENTIAL DIAGNOSIS

The most common entity to be differentiated from Scheuermann disease is postural round-back deformity. This deformity characteristically produces a slight increase in thoracic kyphosis, which is mobile clinically and is easily correctable on the prone extension test. Radiographs show normal vertebral body contours without vertebral wedging. The kyphosis is more gradual than the angular kyphosis commonly seen in Scheuermann disease. A normal radiograph, however, may not rule out Scheuermann disease because radiographic changes may not be apparent until a child is 10 to 12 years of age. If pain is a presenting symptom, infectious spondylitis must be considered. This usually can be excluded, however, by clinical and laboratory studies and by MRI, CT, or bone scan of the spine. On occasion, traumatic injuries can confuse the differential diagnosis, but usually the wedging caused by a compression fracture involves only a single vertebra rather than the three or more vertebrae involved in true Scheuermann kyphosis. Osteochondrodystrophies, such as Morquio and Hurler syndromes, as well as tumors and congenital deformities, especially congenital kyphosis, also must be considered. In young men, ankylosing spondylitis must be ruled out, and this may require an HLA-B27 blood test. 

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B

A FIGURE 44.147   Spondylolisthesis with kyphosis.

TREATMENT

The indications for treatment of patients with Scheuermann kyphosis can be grouped into five general categories: pain, progression of deformity, neurologic compromise, cardiopulmonary compromise, and cosmesis. Treatment options include observation, conservative methods, and surgery.

NONOPERATIVE TREATMENT OBSERVATION

Adolescents with mildly increased kyphosis of less than 50 degrees without evidence of progression can be evaluated with repeated standing lateral radiographs every 4 to 6 months. Exercises alone have not been shown to provide any correction of the deformity in patients with Scheuermann disease. An exercise program, however, can help maintain flexibility, correct lumbar lordosis, and strengthen the extensor muscles of the spine and may improve any postural component of the deformity. Stretching exercises should be prescribed for patients with associated tightness of the hamstring or pectoralis muscles. Patients with lumbar Scheuermann disease and back pain should avoid heavy lifting and should be prescribed an exercise program for the lower back. 

ORTHOTIC TREATMENT

The Milwaukee brace has been recommended for the treatment of Scheuermann disease but has been replaced with more low-profile braces. The brace acts as a dynamic threepoint orthosis that promotes extension of the thoracic spine. Indications for brace treatment are at least 1 year of growth remaining in the spine, some flexibility of curve (40% to 50%), and kyphosis of more than 50 degrees. The brace is worn full time for the first 12 to 18 months. If the curve has stabilized and no progression is noted, then a part-time brace

program can be used until skeletal maturity. An improvement in lumbar lordosis of 35% and in thoracic kyphosis of 49% has been reported in teenagers with Scheuermann kyphosis treated in this manner. Overall, at long-term follow-up, some loss of correction had occurred, but 69% of patients had improvement from the initial kyphosis. Others have reported less correction (30% initially), with the final kyphosis correction averaging only 10%. Although the Milwaukee brace has been shown to effectively prevent kyphosis progression and offers some modest permanent correction, full-time brace wear often is resisted by adolescents. Gutowski and Renshaw found that the Boston lumbar kyphosis orthosis was satisfactory for correction of curves of less than 70 degrees and had better compliance. They recommended the Boston lumbar orthosis as an acceptable alternative to the Milwaukee brace in patients with flexible kyphotic curves of less than 70 degrees and in whom compliance may be a problem. The rationale for the Boston lumbar orthosis is that reduction of the lumbar lordosis will cause the patient to dynamically straighten the thoracic kyphosis to maintain an upright posture. This presupposes a flexible kyphosis, a normal neurovestibular axis, and the absence of hip flexion contractures. Lowe used a modified underarm TLSO with padded anterior, infraclavicular outriggers for patients with thoracolumbar-pattern Scheuermann disease (apex T9 and below) and found that it was as effective as the Milwaukee brace and was cosmetically more acceptable to patients. This is now the more popular bracing method. Hyperextension casting has been used with excellent results in Europe, but this method is associated with frequent problems with the skin, restrictions of physical activity, and the need for frequent cast changes. 

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

A

B FIGURE 44.148

OPERATIVE TREATMENT

C

D

A and B, Scheuermann kyphosis. C and D, After correction and posterior fusion.

The indications for surgery in patients with Scheuermann kyphosis are a progressive kyphosis of more than 70 degrees and significant kyphosis associated with pain that is not alleviated by conservative treatment methods. The biomechanical principles of correction of kyphosis include lengthening the anterior column (anterior release), providing anterior support (interbody fusion), and shortening and stabilizing the posterior column (compression instrumentation and arthrodesis). Surgical correction can be achieved by a posterior approach, an anterior approach, or a combined anterior and posterior approach. The combined anterior and posterior approach has been the most frequently recommended, but with the development of pedicle screw fixation and posterior spinal osteotomy techniques, such as the Ponte procedure, posterior-only surgery has become the preferred approach. A posterior procedure without osteotomy can be considered if the kyphosis is flexible and can be corrected to, and maintained at, less than 50 degrees while a posterior fusion occurs (Fig. 44.148). Historically, the use of Harrington compression rods was common, but these have been replaced by segmental hook and pedicle screw instrumentation. When a combined anterior and posterior procedure is used for Scheuermann disease, the anterior release and fusion are done first. The anterior release can be done through an open anterior procedure or by thoracoscopy. Herrera-Soto et al. showed good sagittal correction, with no loss of correction or junctional kyphosis, with a thoracoscopic technique. Interbody cages have been used in an effort to improve sagittal correction; however, Arun et al. found no difference in outcomes between patients with anterior fusion using interbody cages and those with anterior fusion using autogenous rib grafting. The posterior fusion and instrumentation can be done on the same day as the anterior release and fusion or as a staged procedure. Segmental instrumentation systems using multiple hooks or pedicle screws are used for the posterior spinal fusion.

Other instrumentation techniques have been used for correction of Scheuermann kyphosis. Sturm, Dobson, and Armstrong reported good results with posterior fusion alone by use of large, threaded Harrington compression rods rather than small ones. The use of posterior spinal osteotomies such as the Ponte osteotomy allows for relative shortening of the posterior column and greater correction of the kyphosis. Several studies have shown similar sagittal correction with combined anterior and posterior procedures and posterioronly procedures with Ponte osteotomies. Posterior fusion and instrumentation should include the proximal vertebra in the measured kyphotic deformity and the first lordotic disc distally. If the fusion and instrumentation end in the kyphotic deformity, a junctional kyphosis at the end of the instrumentation may occur. Cho et al. reported the occurrence of distal junctional kyphosis despite inclusion of the first lordotic disc. They recommended inclusion of the lumbar vertebral body bisected by a vertical line drawn from the posterosuperior corner of the sacrum to prevent distal junctional kyphosis. Junctional decompensation has been reported to occur in as many as 30% of patients. Overcorrection of the deformity should be avoided to prevent junctional kyphosis. No more than 50% of the preoperative kyphosis should be corrected, and the final kyphosis should not be less than 40 degrees. Lowe found that patients with Scheuermann disease tend to be in negative sagittal balance and become further negatively balanced after surgery, which may predispose them to develop a junctional kyphosis. Lonner et  al. found that the pelvic incidence may be related to the amount of proximal junctional kyphosis and that distal junctional kyphosis was related to fusion that ended cranial to the neutral sagittal vertebra. Denis et  al. suggested that the incidence of proximal junctional kyphosis can be minimized by the appropriate selection of the upper end vertebra and avoiding disruption

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PART XII  THE SPINE of the junctional ligamentum flavum. They also recommended incorporation of the first lordotic disc into the fusion construct. 

 

ANTERIOR RELEASE AND FUSION TECHNIQUE 44.42 The levels of the anterior release are those with the most wedging and the least flexibility on hyperextension lateral views. This region generally includes seven or eight interspaces centered on the apex of the kyphosis. n  Select the appropriate anterior approach for the levels to be fused. If there is no associated scoliosis, make the approach through the left side. If there is a concomitant scoliosis, approach the spine on the convexity of the scoliosis. n  Release the anterior longitudinal ligament and excise the entire disc and cartilaginous endplate, leaving only the posterior portion of the annulus and the posterior longitudinal ligament. n  Curet the bony endplates but do not remove them completely. n  Use a laminar spreader to loosen or to mobilize each joint. n  Pack each disc space temporarily with Gelfoam or Surgicel to minimize blood loss. n  Perform an interbody fusion with use of the morselized rib graft. n  Anterior instrumentation can be used to aid in correction of the deformity and stabilization until a solid fusion occurs.     n 

A

B

FIGURE 44.149 Reduction of kyphosis, standard method. A, Insertion of hooks. Note three sets of pedicle-transverse claws above apex of kyphosis. B, Rod passed through hooks of proximal segment and distal end of rod pushed to lower spine with rod pusher. Note that lower tip bend in rod facilitates hook insertion under distal lamina. SEE TECHNIQUE 44.43.

also can be used. These two techniques often are combined with a posterior column shortening procedure, allowing gradual correction of the kyphosis. Rigid posterior instrumentation systems can be combined with posterior column shortening (Ponte osteotomies) to correct the kyphosis without the need for anterior release and fusion.

TECHNIQUE 44.43 (CRANDALL)

 

Place the patient prone on a Jackson frame. The spine is approached posteriorly. The instrumentation frequently extends proximally to T2 to T3. n  Determine the apex of the kyphosis on preoperative radiographs. n  Use at least two sets of pedicular-transverse process claws or thoracic pedicle screws above the apex if the curve is flexible. In very large patients with rigid curves, extra fixation sites may be needed. A third set of fixation points may be used. Below the apex, reduction pedicle screws are used. At least three sets of screws are recommended. n  Debride the facet joints at each level to allow posterior column compression and to provide a bony surface for fusion. n  Perform osteotomies if necessary. n  Bend both rods above the kyphosis to approximate the normal spinal contour. Proper rod contouring is important. Leave the distal rods uncontoured. n  Insert the upper end of both rods into the proximal points. If hooks are being used, compress each claw construct to ensure that each hook claw remains seated. Tighten the threaded plugs to hold the upper hooks or pedicle screws securely in the rod. n 

POSTERIOR MULTIPLE HOOK AND SCREW SEGMENTAL INSTRUMENTATION With multiple hook and screw segmental instrumentation systems, several techniques are available for reduction of kyphosis. The cantilever method (Fig. 44.149) consists of inserting the precontoured rod into the pedicle–transverse process claws or thoracic pedicle screws above the apex of the kyphosis. With the apex of the deformity as a fulcrum, the distal end of the rod is pushed into the lower hood or pedicle screws at the caudal end of the deformity by a cantilever maneuver. The disadvantage of this method is that the correction is a three-point cantilever maneuver and the correction is therefore somewhat abrupt and forces are concentrated at the ends of the construct. Reduction pedicle screws and instruments can be used to make this reduction maneuver more gradual. Another method for correction is an apical compression technique using multisegmental hooks or pedicle screw constructs on either side of the apex. A combination of the cantilever and compression techniques

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

A

B

FIGURE 44.150 Posterior multiple-hook and screw segmental instrumentation. A, Reduction crimps are attached. B, Incremental reduction. C, Distal end of rod cut to appropriate length. SEE TECHNIQUE 44.43.

After all the rods are in the proximal fixation points, place a crosslink plate on the rods. Attach the distal ends of both rods into the reduction screws (Fig. 44.150A). n  Begin the incremental reduction process with all reduction screws to pull the spine up to the rod (Fig. 44.150B). n  Cut the distal ends of the rods to the appropriate length (Fig. 44.150C). n  As the intermediate points of fixation come in contact with the rod, lock them to the rod and compress them to the proximal points of fixation. Gradual, repeated n 

C

tightening, a few turns at a time with “two-finger” force on the driver, will bring the spine up in a safe and controlled fashion (Fig. 44.151). The spine is directly translated to the rod from any direction, achieving simultaneous correction in both the coronal and sagittal plane. Importantly, this correction should not proceed too quickly. A gradual reduction allows the spine to stretch the soft-tissue structures contracted in the kyphosis and allows the least amount of stress on the construct and spinal cord.

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A

B

C

FIGURE 44.151 A, Beginning of correction, 70 degrees of kyphosis. B, Midpoint of correction, 47 degrees of kyphosis. C, Final construct, 40 degrees of kyphosis. SEE TECHNIQUE 44.43.

After full kyphosis correction, fully compress the posterior column and lock it into position. Place a crosslink plate distally and proximally (Fig. 44.152). n  During tightening of the reduction crimps (every 3 to 5 minutes), harvest bone graft and decorticate the spine and facets. n  At the completion of the instrumentation, add abundant autogenous bone graft. n 

POSTOPERATIVE CARE  Unless the bone quality is poor and fixation is tenuous, postoperative bracing is not required. If there is any concern about fixation, an extension orthosis, such as a Jewett brace, can be used until the fusion begins to consolidate, usually in 3 to 6 months. Ambulation is started as soon as possible. All patients start isometric and isotonic back exercise programs when the fusion appears solid. In adolescents, the fusion generally is solid in approximately 6 months. The patient generally is allowed to sit up on the second or third day postoperatively.    

 

POSTERIOR COLUMN SHORTENING PROCEDURE FOR SCHEUERMANN KYPHOSIS Ponte, Gebbia, and Eliseo described a posterior column shortening technique for the correction of Scheuermann kyphosis. The potential advantages of this technique include that it is a single-stage posterior procedure; the posterior spine is shortened rather than the anterior spine lengthened, thereby increasing safety; a gradual correction is obtained; there are no complications from a thoracotomy or thoracoscopy; and there is no surgical interference with anterior blood supply to the spinal cord.

TECHNIQUE 44.44 (PONTE ET AL.) A posterior midline approach is performed.

n 

Expose the spine subperiosteally to include one vertebra above and one vertebra below the fusion levels. The proximal extent of the fusion may need to include T1 to minimize the risk of cranial junctional kyphosis. The caudal limit must always be included and is determined by the first lordotic disc (open anteriorly) on lateral standing films. n  Resect the spinous processes and perform wide facetectomies and partial laminectomies of both the inferior and superior laminar borders at every intersegmental level of the fusion area. Ideally, gaps of 4 to 6 mm should be obtained (Fig. 44.153A). A generous resection of the facet joints as far as the pedicles is an essential step of this technique. n  Remove the ligamentum flavum entirely at all levels. The gaps extend uniformly over the entire width of the posterior spine (Fig. 44.153B-D). n  Insert the rods into the supralaminar hooks. If closed hooks are used, preload the hooks onto the rod and insert it as a unit. Pass the rod through the hooks just proximal to the apex. If open hooks are used, use appropriate set screws to hold the rod in the hooks or screws above the apex of the kyphosis. n  Leave the apical vertebra uninstrumented (Fig. 44.153D-I). n  Apply minimal compression force to keep the hooks in place. Any corrective tightening at this point would narrow the gaps and make placement of the hooks for the second rod difficult. n  Repeat the same sequence for the second rod. Apply compressive forces, beginning with the two opposing hooks facing the apex and then continuing sequentially to the cranial and caudal ends (see Fig. 44.153G). n  Repeat these maneuvers alternately on both sides and several times, always beginning at the apex. As compression proceeds, the rods will gradually straighten out and the intersegmental gaps will close. Creating small notches for the hook blades will prevent their interference with the closure of the gaps. n  Obtain an intraoperative radiograph to assess the magnitude of the correction. Fine-tuning is performed as needed to obtain a harmonious distribution of intersegmental correction. n  Secure two transverse connectors if they are needed for additional stability. n 

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

A

B

C

D

E

F

G

H

FIGURE 44.152 A-C, Preoperative radiographs of patient with Scheuermann kyphosis. D, Preoperative clinical photograph. E-G, Postoperative radiographs. H, Postoperative photograph. SEE TECHNIQUE 44.43.

Perform decortication and add morselized bone graft. The same principle, with Ponte osteotomies, can be used with different instrumentation, including pedicle screws. Pedicle screws provide secure fixation without the problem of multiple hooks within the spinal canal and without the problem of the hooks potentially blocking the closure of the osteotomies. Gradual reduction-type pedicle screws can be used distally to allow a more gradual correction of the kyphosis.

n  n 

POSTOPERATIVE CARE  The patient is allowed to sit out of bed on the first postoperative day. There is no need for external support, such as bracing. Physical activities, such as sports or lifting of more than 5 or 10 lb, are restricted for 3 to 6 months. Radiographic assessment of the fusion at 6 months is performed, and if the fusion appears solid, gradual return to full activities is then allowed. Patients with an osteopenic spine or who are overweight or noncompliant may require a brace until the fusion is solid.   

COMPLICATIONS

Complications are more frequent after the operative treatment of Scheuermann kyphosis than adolescent idiopathic scoliosis; in the case of major complications, Lonner et al. reported that they were four times more likely in Scheuermann kyphosis. Proximal junctional kyphosis has been reported to be present in as many as 30% and distal junctional kyphosis in 12% of surgically treated patients. To decrease the risk of junctional kyphosis, Denis et  al. suggested that the fusion should include all vertebrae involved in the kyphosis, disruption of the ligamentous complex at the ends of the fusion should be avoided, and the fusion should extend distally to include the vertebra below the first lordotic disc. Distal and proximal implant failure is caused by the increased stresses placed on the instrumentation. 

CONGENITAL KYPHOSIS Congenital kyphosis is an uncommon deformity, but neurologic deficits resulting from this deformity are frequent. Congenital kyphosis occurs because of abnormal

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T9 Pedicle

Spinal cord

T10

Pedicle T10

Sites after complete resection

T11

T11

T12

Resections for caudal most hooks

T12

L1

L1

L2

A

B T7 Spinous processes partially removed T8

T9

C

D C7 T1 T2

C7

C7

C7

T1

T1

T1

T2

T2

T2

T8 T8

T8

T12

T12

L1

L1

T8

T12

T12

L1

L1

E

F

G

H

FIGURE 44.153 Posterior column shortening for Scheuermann kyphosis. A, Broad posterior resection (shaded parts) at every intersegmental level of entire area of fusion and instrumentation. B, Posterior view showing levels of completed resections. C, Lateral view showing gaps from osteotomies. Correction is achieved by closing gaps. D, Oblique view showing three apical vertebrae after completion of bone resections. Apical vertebra is left uninstrumented. E-H, Schematic representation of reduction of kyphosis. (Redrawn from Ponte A: Posterior column shortening for Scheuermann’s kyphosis. An innovative one-stage technique. In Haher TR, Merola AA, editors: Surgical techniques for the spine, New York, 2003, Thieme.) SEE TECHNIQUE 44.44.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

A FIGURE 44.154 shown.)

Effects of Vertebral Body Segmentation Partial

B

C

Classification of congenital kyphosis. A and B, Type I. C, Type II. (Type III is not

Defects of Vertebral Body Formation Anterior and unilateral aplasia

Mixed Anomalies

Anterior and median aplasia

Anterior unsegmented bar

Posterolateral quadrant vertebra

Butterfly vertebra

Complete

Anterior aplasia

Anterior hypoplasia

Block vertebra

Posterior hemivertebra

Wedged vertebra

Anterolateral bar and contralateral quadrant vertebra

FIGURE 44.155 Different types of vertebral anomalies that produce congenital kyphosis or kyphoscoliosis. (From McMaster MJ, Singh H: Natural history of congenital kyphosis in kyphoscoliosis: a study of 112 patients, J Bone Joint Surg 81A:1367, 1999.)

development of the vertebrae consisting of a failure of formation or failure of segmentation of the developing segments. The spine may be either stable or unstable, or it may become unstable with growth. Spinal deformity in congenital kyphosis usually will progress with growth, and the amount of progression is directly proportional to the number of vertebrae involved, the type of involvement, and the amount of remaining normal growth in the affected vertebrae. Winter et  al. described 130 patients with congenital kyphosis of three types. Type I is congenital failure of vertebral body formation. Type II is failure of vertebral body segmentation (Fig. 44.154). Type III is a combination of both of these conditions. McMaster and Singh further subdivided type I congenital kyphosis into posterolateral quadrant vertebrae, posterior hemivertebrae, butterfly (sagittal cleft) vertebrae, and anterior or anterolateral wedged vertebrae (Fig. 44.155). This

classification is important in predicting the natural history of these congenital kyphotic deformities. Dubousset and Zeller et al. added a rotatory dislocation of the spine, and Shapiro and Herring further divided type III displacement into type A (sagittal plane only) and type B (rotatory, transverse, and sagittal planes). Any classification can be further subdivided into deformities with or without neurologic compromise. The natural history of congenital kyphosis is well known and based on the type of kyphosis. Type I deformities are more common than type II deformities and occur more commonly in the thoracic spine and at the thoracolumbar junction. They are extremely rare in the cervical spine. In the series of McMaster and Singh, progression was most rapid in type III kyphosis, followed by type I. Kyphosis caused by two adjacent type I vertebral anomalies progressed more rapidly and produced a more severe deformity than did a single

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PART XII  THE SPINE anomaly. Approximately 25% of patients with type I deformities had neurologic deficits, and deformities in the upper thoracic spine were more likely to be associated with neurologic problems. No patient in whom the apex of the kyphosis was at or caudad to the 12th thoracic vertebra had neurologic abnormalities. However, type I kyphosis progressed relentlessly during growth and usually accelerated during the adolescent growth spurt before stabilizing at skeletal maturity. An anterior failure of vertebral body formation produces a sharply angular kyphosis that is much more deforming and potentially dangerous neurologically than a curve with a similar Cobb measurement, owing to an anterior failure of segmentation that affects several adjacent vertebrae and produces a smooth, less obvious deformity. Type II deformities (failure of segmentation) are less common. An absence of physes and discs anteriorly in one or more vertebrae results in the development of an anterior unsegmented bar. The amount of kyphosis produced is proportional to the discrepancy between the amounts of growth in the anterior and posterior portions of the defective vertebral segments. Mayfield et al. reported that these deformities progress at an average rate of 5 degrees a year and are not as severe as type I deformities. Paraplegia usually is not reported in patients with type II kyphosis; however, low back pain and cosmetic deformities are significant and early treatment is warranted.

CLINICAL AND RADIOGRAPHIC EVALUATION

The diagnosis of a congenital spine problem usually is made by a pediatrician before the patient is seen by an orthopaedist. The deformity may be detected before birth on a prenatal ultrasound examination or noted as a clinical deformity in a neonate. If the deformity is mild, congenital kyphosis can be overlooked until a rapid growth spurt makes the condition more obvious. Some mild deformities are found by chance on radiographs that are obtained for other reasons. Clinical deformities seen in the neonate tend to have a worse prognosis than those discovered as an incidental finding on plain radiographs. Physical examination usually reveals a kyphotic deformity at the thoracolumbar junction or in the lower thoracic spine. A detailed neurologic examination should be done to look for any subtle signs of neurologic compromise. Associated musculoskeletal and nonmusculoskeletal anomalies should be sought on physical examination. High-quality, detailed anteroposterior and lateral radiographs provide the most information in the evaluation of congenital kyphosis (Fig. 44.156). Failure of segmentation and the true extent of failure of formation may be difficult to detect on early films because of incomplete ossification. Flexion and extension lateral radiographs are helpful in determining the rigidity of the kyphosis and possible instability of the spine. CT with three-dimensional reconstructions can identify the amount of vertebral body involvement and can determine whether more kyphosis or scoliosis might be expected (Fig. 44.157). CT can only identify the nature of the bony deformity and the size of the cartilage anlage; it does not show the amount of growth potential in the cartilage anlage and therefore only estimates the possible progression. An MRI study should be obtained in most patients because of the significant incidence of intraspinal abnormalities. In addition, the location of the

FIGURE 44.156 Two-year-old child with type I congenital kyphosis measuring 40 degrees. Radiograph shows failure of formation of anterior portion of first lumbar vertebra. (From Warner WC: Kyphosis. In Morrissy RT, Weinstein SL, editors: Lovell and Winter’s pediatric orthopaedics, ed 6, Philadelphia, 2006, Lippincott Williams & Wilkins.)

spinal cord and any areas of spinal cord compression caused by the kyphosis can be seen on MRI. The cartilage anlage will be well defined by MRI in patients with failure of formation (Fig. 44.158). Genitourinary abnormalities, cardiac abnormalities, Klippel-Feil syndrome, and intraspinal abnormalities are frequent in these patients. Cardiac evaluation and renal ultrasonography should be done. Myelograms have been used for documenting spinal cord compression but generally have been replaced by MRI. 

OPERATIVE TREATMENT

The natural history of this condition usually is one of continued progression and an increased risk of neurologic compromise. Therefore surgery is the preferred method of treatment. If the diagnosis is uncertain or the deformity is mild, close observation may be an option. Unless compensatory curves are being treated above or below the congenital kyphosis, bracing has no role in the treatment of congenital kyphosis because it neither corrects the deformity nor stops the progression of kyphosis. Surgery is recommended for congenital kyphosis. The type of surgery depends on the type and size of the deformity, the age of the patient, and the presence of neurologic deficits. Procedures include posterior fusion, anterior fusion, combined anterior and posterior fusion, anterior osteotomy with posterior fusion, posterior column shortening and fusion, and vertebral body resection. Fusion can be done with or without instrumentation.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

A

D

B

C

E FIGURE 44.157 Congenital kyphosis. A and B, Anteroposterior and lateral radiographs. Note inadequate detail of kyphosis on lateral radiograph of spine. C-E, CT three-dimensional reconstruction views that clearly show bony anatomy of congenital kyphosis. (From Warner WC: Kyphosis. In Morrissy RT, Weinstein SL, editors: Lovell and Winter’s pediatric orthopaedics, ed 6, Philadelphia, 2006, Lippincott Williams & Wilkins.)

TREATMENT OF TYPE I DEFORMITY

The treatment of type I deformity depends on the stage of the disease. For type I deformity, the best treatment is early posterior fusion. In a patient younger than 5 years old with a deformity of less than 50 or 55 degrees, posterior fusion alone, extending from one level above the kyphotic deformity to one level below, is recommended. This allows for some improvement because growth continues anteriorly from the anterior endplates of the vertebrae one level above and below the kyphotic vertebrae that are included in the posterior fusion. Although McMaster and Singh reported 15 degrees of correction in most patients treated with this technique, Kim et al. reported that correction of kyphosis occurred with growth only in patients younger than 3 years of age with type II and type III deformities. In curves of more than 60 degrees, anterior and posterior spinal fusions at least one level above and one level below the kyphosis are indicated. This halts the

progression of the kyphotic deformity, but because the anterior physes are ablated, there is no possibility of correction with growth. Posterior fusion alone may be successful if the kyphosis is less than 50 to 55 degrees in older patients with type I kyphotic deformity. If the deformity is more than 55 degrees, anterior and posterior fusion produces more reliable results. Anterior fusion alone will not correct the deformity, and anterior strut grafting with temporary distraction and posterior fusion, with or without posterior compression instrumentation, is necessary for deformity correction (Fig. 44.159). Posterior instrumentation may allow for some correction of the kyphosis but should be regarded more as an internal stabilizer than as a correction device. Although instrumentation has been reported to decrease the occurrence of pseudarthrosis, it should be used with caution in rigid, angular curves because of the high incidence of neurologic complications.

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A

B

FIGURE 44.160 Effect of traction on rigid congenital kyphosis. A, Apical area does not change with traction, but adjacent spine is lengthened. B, As spine lengthens, so does spinal cord, producing increased tension in cord and aggravating existing neurologic deficits.

FIGURE 44.158 MRI of type I congenital kyphosis. Failure of formation of anterior vertebral body is shown, but growth potential of involved vertebra cannot be determined. Note pressure on dural sac. (From Warner WC: Kyphosis. In Morrissy RT, Weinstein SL, editors: Lovell and Winter’s pediatric orthopaedics, ed 6, Philadelphia, 2006, Lippincott Williams & Wilkins.)

A

If anterior strut grafting is done, the strut graft should be placed anteriorly under compression. If the goal of surgery is to stop the progression of deformity without correction, an anterior interbody fusion with a posterior fusion can be done. Simultaneous anterior and posterior approaches through a costotransversectomy that allows resection of the posterior hemivertebra and correction of the kyphosis with posterior compression instrumentation have been described. After removal of the hemivertebra, correction can be obtained safely and the thecal sac observed during correction. Use of skeletal traction (halo-pelvic, halo-femoral, or halo-gravity) to correct the deformity is tempting but is not recommended because there is a risk of paraplegia (Fig. 44.160). Traction pulls the spinal cord against the apex of the rigid kyphosis, which can lead to neurologic compromise in a patient with a rigid gibbus deformity. Late treatment of a severe congenital kyphotic deformity that is accompanied by spinal cord compression is difficult; laminectomy has no role in the treatment of this condition. If there is an associated scoliosis, the anterior approach for decompression may need to be on the concavity of the scoliosis to allow the spinal cord to move both forward and into the midline after decompression. After adequate decompression, the involved vertebrae are fused with an anterior strut graft. Posterior fusion, with or without posterior stabilizing instrumentation, is then performed. Postoperative support using a cast, brace, or halo cast may be required. Posterior vertebral column resection or decompression and subtraction osteotomy, followed by stabilizing instrumentation, also can be used. Chang et al. described circumferential decompression and cantilever bending correction with posterior instrumentation. 

TREATMENT OF TYPE II DEFORMITY

B FIGURE 44.159 A, Preparation of tunnels for strut grafts. B, Insertion of strut grafts into prepared tunnels with cancellous bone graft in disc spaces.

If a type II kyphosis is mild (55 degrees) and progression of the deformity. Restoration of spinopelvic balance is important in the treatment of spondylolisthesis. Hresko et  al. described two patterns of deformity in patients with a high-grade spondylolisthesis, based on the alignment of the sacrum and pelvis. The first group was classified as balanced, and the sacral slope

Treatment of acquired spondylolysis from a stress fracture in children and adolescents depends on whether the spondylolysis is acute or chronic. Micheli, Jackson et al., and Rabushka et  al. described children and adolescents in whom acute spondylolytic defects healed with cast or brace immobilization. Typically, these children have an acute onset of symptoms and the episode of injury is clearly documented. Often they are participating in a sport, such as gymnastics, that causes repetitive hyperextension of the spine. A SPECT scan or MRI can be helpful in determining whether the process is acute or chronic. If the SPECT scan detects an abnormality or MRI shows edema in the pedicle, a CT scan of the suspected area can be obtained to distinguish between a stress reaction and an acute stress fracture. CT scanning is the most helpful radiographic technique for determining the presence or absence of healing. Nonoperative treatment will return most adolescents to normal activities. The spectrum of nonoperative treatment recommendations ranges from rest and restriction of activities to bracing and a structured rehabilitation program. Treatment begins with rest and restriction of activities; however, El Rassi et  al. found that there was only a 42% compliance rate with restriction of activities. This finding highlights the need for participation by the patient, parents, and coaches in the treatment plan. Brace treatment has been controversial because of the inability of a standard TLSO to completely immobilize the lumbosacral junction. A brace will give some global restriction of

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS patients may require 4 to 5 months of rehabilitation before they are ready to return to sports. Children and adolescents in whom the spondylolysis is of long duration are treated with routine nonoperative measures. Activities are restricted, and back, abdominal, and core-strengthening exercises are prescribed. If the symptoms are more severe, a brief period of brace immobilization may be required. Once the pain has improved and the hamstring tightness has lessened, the child is allowed progressive activities. Yearly examinations with standing spot lateral radiographs of the lumbosacral spine are advised to rule out the development of spondylolisthesis. If the patient remains asymptomatic, limitation of activities or contact sports is not necessary. Most children with spondylolysis have excellent relief of symptoms or only minimal discomfort at longterm follow-up. If a child does not respond to conservative measures, other causes of back pain, such as infection, tumor, osteoid osteoma, and herniated disc, should be ruled out. Special attention should be paid to children whose symptoms do not respond to bed rest or who have objective neurologic findings. A very small percentage of children with spondylolysis who do not respond to conservative measures and in whom the other possible causes of back pain have been eliminated may require operative treatment.

A

REPAIR OF SPONDYLOLYTIC DEFECT

B FIGURE 44.174 Schematic representation of slip angle or kyphotic malalignment of lumbosacral junction present in highgrade isthmic dysplastic spondylolisthesis. A, Standard method of measurement. B, Method used when inferior L5 endplate is irregularly shaped.

motion of the lumbar spine but is probably most effective in forcing restriction of activities. Electrical stimulation has been used with varied results in attempts to heal an acute pars fracture. A structured rehabilitation program is essential to return the patient to sports. This program has four phases: (1) acute, (2) subacute, (3) pre-sport, and (4) sport-conditioning. The acute phase focuses on relief of pain and inflammation and rehabilitation of the lumbopelvic stabilizers. The subacute phase emphasizes core strengthening and restoration of trunk range of motion. Nonimpact cardio activities can be begun during this stage. The therapist initiates sports-simulated movements to increase the patient’s strength and endurance during the pre-sport phase. In the final sports-conditioning phase, sport-specific drills and impact cardio training are begun with the goal of returning the patient to his or her desired sport. The nonoperative treatment and structured rehabilitation program usually requires 12 weeks to complete. Patients with a stress reaction may progress faster, but some

The primary indication for operative treatment of spondylolysis is failure of a 6-month conservative treatment program. The principles of pseudarthrosis repair are the same as for any long bone: debridement, grafting of the site with autogenous bone graft, and compression across the fracture. The type of surgery is based on the location of the spondylolysis and any associated disc pathology or associated vertebral dysplasia. The surgical treatment of spondylolysis can be either an intervertebral fusion or a repair of the pars defect. When the lesion is at L5, direct repair of the pars defect and an L5 to S1 fusion will give similar results. If there is associated disc pathology at L5 or S1 or any associated dysplasia, fusion is the preferred treatment. When the pars lesion is at L4 or L3, direct repair is recommended. Four repair techniques have been described: (1) Scott wiring, (2) Buck screw, (3) pedicle screw and hook, and (4) V-rod or U-rod technique. With all techniques, the rate of return to sports is reported to be 80% to 90%. The Scott technique places wires around the transverse process on each side and through the spinous process to compress the pars defect. This is the least rigid of all the fixation methods, but it nonetheless has a healing rate of nearly 80%. Direct intralaminar screw fixation of a pars defect, described by Buck in 1970 with good outcomes in 93%, offers a minimally invasive and motion-preserving technique. The use of pedicle screws and infralaminar hoods attached to a short rod allows compression of the pars defect along the rod to stabilize the defect. This is the most rigid construct. A similar technique uses a U-shaped rod placed inferior to the spinous process for stabilization and compression of the pars defect. Sairyo et  al. described restoration of disc stresses to normal at the cranial and caudal levels of the pars defect after direct intralaminar screw fixation using the Buck technique. Several other studies also have shown a superior biomechanical advantage of the Buck technique relative to other common fixation techniques; however, according to a biomechanical study of the four different techniques, all of which restored

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Balanced pelvis

Unbalanced pelvis

FIGURE 44.175 Sagittal view of spinopelvic alignment in high-grade spondylolisthesis. (From Hresko MT, LaBelle H, Roussouly P, Berthonnaud E: Classification of high-grade spondylolistheses based on pelvic version and spine balance, Spine 32:2208, 2007.)

normal intervertebral rotation, the Scott and Buck constructs were found to be less stable than the screw-hook or U-rod constructs. Mihara et al. found that the Buck screw technique restored more normal motion at the involved level and adjacent level. Kakiuchi reported successful union of pars defects with the use of a pedicle screw, laminar hook, and rod system. A pedicle screw is placed in the pedicle above the pars defect. The pars defect is bone grafted. A rod is placed in the pedicle screw and then into the caudal laminar hook, and compression is applied. This gives a more stable construct than that afforded by wire techniques. A second surgery for removal of prominent implants after healing may be necessary. 

 

SPONDYLOLYSIS REPAIR TECHNIQUE 44.50 (KAKIUCHI) Place the patient prone on a Hall frame. Expose the involved vertebra, including the defect of the pars interarticularis, through a midline posterior incision. Remove the fibrous tissue in and behind the defect with a Cobb elevator, rongeur, or curet. To maintain the length of the pars interarticularis, do not remove the sclerotic bone on both sides of the defect. n  Clean the lateral aspect of the inferior half of the superior articular process and the medial third of the posterior aspect of the transverse process of soft tissue without interfering with the capsule of the facet. n  n 

Decorticate the posterior aspect of the pars interarticularis and adjoining portion of the lamina with use of a small chisel (Fig. 44.176A). Do not decorticate the lateral and inferior aspects of the superior articular process to maintain the strength of the osseous structures for pedicle screw placement. n  If nerve root decompression is indicated, remove the bone spurs over the nerve root with an osteotome (Fig. 44.176B). Bury free fat tissue in the defect created above the nerve root to prevent bone graft from falling onto the nerve root. n  To achieve a wider area for bone grafting, make the starting point for the insertion of the pedicle screw is near the intersection of a vertical line through the center axis of the pedicle and a horizontal line at the superior border of the pedicle (Fig. 44.176C). n  Direct the screw slightly caudally so that it enters the vertebral body at the center axis of the pedicle. n  After insertion of the pedicle screw, take strips of cancellous bone from the posterior aspect of the ilium through the same incision in the skin. n  Pack the cancellous bone as an onlay graft from the medial third of the transverse process to the decorticated portion of the lamina to form a sheet of bone about 1 cm thick (see Fig. 44.176C). n  If the multifidus muscle is too tight for pedicle screw insertion through this midline approach (which is more common at L5 than more cephalad levels), the starting point for insertion of the pedicle screw on the superior articular process should be exposed through the paraspinal approach over the pedicle through the same midline incision in the skin and additional small fascial incisions made 2 to 3 cm lateral to the midline (Fig. 44.176D). Insert a finger through the natural cleavage plane between the multifidus and longissimus muscles to the insertion point over the pedicle. n 

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Area of soft-tissue removal without decortication

Location of pedicle

Spondylolytic defect

Area of decortication

A

Head of variableangle screw

Area of excision of posterior elements

Nerve root before decompression

Ligamentum flavum not to be excised

B Multifidus

Starting point of screw insertion Longissimus

Rod

Paraspinal fascial incision

Area of bone graft

C

Midline fascial incision

D

Laminar hook

E

FIGURE 44.176 A, Recipient bed prepared for autogenous cancellous bone graft. B, Posterior elements overlying affected nerve root are excised. C, Variable-angle pedicle screw and bone graft inserted. D, Paraspinal approach can be used when the multifidus muscle is too tight for pedicle screw insertion through the midline. E, Rod attached to head of screw with variable-angle eyebolt. Laminar hook attached to rod. (From Kakiuci M: Repair of the defect in spondylolysis, J Bone Joint Surg 79A:818, 1997.) SEE TECHNIQUE 44.50.

Cut the rod to the appropriate length and attach it to the head of the variable-angle screw. Insert a laminar hook to the inferior edge of the lamina and attach it to the rod (Fig. 44.176E). n  To reduce the size of the defect of the pars interarticularis, apply a mild compression force between the hook and the head of the screw with the hook compressor before tightening the locknut in the eyebolt. n  Repeat the procedure on the contralateral side.  n 

POSTOPERATIVE CARE  Usually patients are allowed to stand and walk on the second or third postoperative day. A hard lumbosacral corset is worn for 2 months, but its use should be determined on an individual basis. Patients are allowed unrestricted activity after 6 months.      

MODIFIED SCOTT REPAIR TECHNIQUE Van Dam reported success in 16 patients with a modification of the Scott repair technique. In 26 direct pars repairs, union was achieved in 22.

TECHNIQUE 44.51 (VAN DAM) Approach the lumbar spine posteriorly.

Identify and debride the area of the pars pseudarthrosis. n  Place a 6.5-mm cancellous screw approximately two thirds of the way into the ipsilateral pedicle. n  Loop an 18-gauge wire around the screw head and pass the wire through a hole at the base of the spinous process. n  Pass the ends of the wire through a metal button and tighten the wire loop around the screw head. n  Twist the wire ends tightly against the metal button and cut the excess wire away. n  Place autogenous cancellous bone in and around the debrided pars defect. n  Fully seat the screw to accomplish final tightening of the wire (Fig. 44.177). n  Taddonio described the use of pedicle screws attached to Cotrel-Dubousset rods and offset laminar hooks to accomplish the same mechanical stability as in the Buck technique and Bradford technique. Roca et al. described the use of a titanium variable-angle pedicular-laminar hook-screw especially designed for direct spondylolysis repair. n 

POSTOPERATIVE CARE  The patient should use a lumbosacral orthosis for a minimum of 3 months and up to 6 months after surgery. Healing of the pars is ascertained by follow-up CT scan.    

n 

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FIGURE 44.177 Scott wiring technique. (Redrawn from Rechtine G II: Spondylolysis repair. In Vaccaro A, Albert TJ, editors: Spine surgery tricks of the trade, New York, 2003, Thieme.) SEE TECHNIQUE 44.51.

SPONDYLOLYSIS REPAIR WITH U-ROD OR V-ROD TECHNIQUE 44.53 (SUMITA ET AL.) With the patient prone, make a midline incision and elevate the paraspinal musculature laterally to expose the lamina, pars, and base of the transverse process. Take care not to injure the capsule of the facet joint. n  Expose the defect in the pars and use a curet to remove the fibrocartilage. n  Use a burr to decorticate the defect and the corresponding lamina and transverse process. n  Using anatomic landmarks and fluoroscopy, determine the starting point for the pedicle screw. n  Create the starting hole with a burr and use a pedicle finder to enter the pedicle. n  Assess the walls and floor with a ball-tipped probe and tap the hole for a 5-mm pedicle screw. n  Harvest bone graft from the iliac crest, place it in the defect, and impact it before insertion of the screw. n  After the screws are placed, contour a rod into a U shape or V shape (Fig. 44.179) and place it just caudal to the interspinous ligament of the affected level; attach the rod to each pedicle screw, and tighten the screws to compress the defect. n  Confirm correct placement of the screw and rod with fluoroscopic imaging. n 

FIGURE 44.178 Technique of Buck screw fixation of pars defect. SEE TECHNIQUE 44.52.

 

INTRALAMINAR SCREW FIXATION OF PARS DEFECT (BUCK SCREW TECHNIQUE) TECHNIQUE 44.52 PARS SCREW FIXATION With the patient prone in a position to minimize lordosis, use fluoroscopy to localize the level of the defect. n  Make a midline incision approximately 5 cm long lateral to the corresponding spinous process to expose the lamina and the defect. n  Use a curet to clean the defect. n  Under fluoroscopy, and alternating between anteroposterior and lateral views, make a percutaneous stab wound with a 4.5-mm cannulated screw guidewire. n  Drill the wire through the caudal laminar surface, bisecting the pedicle to the superior cortex of the pedicle and traversing the pars defect (Fig. 44.178). n  Use a 3.2-mm cannulated drill to drill over the guidewire. n 

POSTOPERATIVE CARE  Intravenous antibiotics are administered until the wound is dry. The patient is mobilized without a brace.   

POSTEROLATERAL FUSION

Posterolateral fusion is the conventional operative treatment of symptomatic spondylolysis at L5 unresponsive to conservative treatment. Pedicle instrumentation and fusion often are done to avoid the necessity of postoperative bracing. If no internal fixation is used, the patient is immobilized in a TLSO. A pantaloon cast or a TLSO with a thigh extension also may be used for greater immobilization. Fusion rates of approximately 90% have been reported with similar percentages of

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FIGURE 44.179 Sagittal (A) and axial (B) position of the pedicle screw instrumentation for V-rod fixation. SEE TECHNIQUE 44.53.

relief of symptoms after fusion of L5 to the sacrum. Extension of the fusion to L4 is not necessary. The Gill procedure or a wide laminectomy in a child is not necessary. 

TREATMENT OF DEVELOPMENTAL SPONDYLOLISTHESIS NONOPERATIVE TREATMENT

Surgery is not always necessary for spondylolisthesis. Restriction of the patient’s activities, muscle rehabilitation (spinal, abdominal, and trunk), and other nonoperative measures, including the intermittent use of a rigid back brace, often are sufficient if the symptoms are minimal and the slippage is mild. If symptoms improve, progressive increases in activity are permitted. Activity restrictions are unnecessary for patients with mild degrees of spondylolisthesis. For symptom-free patients with slips of more than 25% but less than 50%, contact sports and activities that carry a high probability of back injury should be avoided. Standing spot lateral radiographs of the lumbosacral junction are made every 6 to 12 months until the completion of growth. 

OPERATIVE TREATMENT

Indications for surgery include persistent symptoms despite conservative treatment for 6 months to 1 year, persistent tight hamstrings, abnormal gait, and pelvic-trunk deformity. Development of a neurologic deficit is an indication for operative intervention, as is progression of the slip, which is indicative of a severe dysplasia. Early surgery may prevent more difficult or risky surgeries at a later time. If a patient is asymptomatic and has a slip of more than 50%, severe dysplasia (high dysplastic spondylolisthesis) is likely and surgery is indicated. A posterolateral fusion between L5 and the sacrum is recommended for slips of less than 50% in children and adolescents whose symptoms persist despite conservative treatment. This degree of slippage has a mild dysplasia (low dysplastic type), usually without a significant slip angle. These patients usually do well with a posterolateral fusion in situ or with a partial reduction. Unless there is significant lumbosacral kyphosis, there is no need for anatomic reduction. Instrumentation with pedicle screw fixation will avoid the need for postoperative immobilization. Extremely tight hamstrings, decreased Achilles tendon reflexes, and even footdrop may improve after a solid arthrodesis. Laminectomy as

an isolated technique in a growing child is contraindicated because further slipping will occur. 

TREATMENT OF SEVERE (HIGH DYSPLASTIC) SPONDYLOLISTHESIS

Operative treatment of high dysplastic spondylolisthesis is more controversial. Most authors agree that slippage of more than 50% requires fusion. The operative options, however, are many and may include posterior fusion with or without reduction and instrumentation, with or without decompression, and with or without anterior interbody fusion. For patients with a grade V spondyloptosis, Gaines and Nichols described an L5 spondylectomy with fusion of L4 to the sacrum. Lenke et al. found that 21% of 56 in situ bilateral transverse process fusions for spondylolisthesis were definitely not fused, but despite this low fusion rate, overall clinical improvement was noted in more than 80% of patients. Other authors recommended combined anterior fusion and reduction with posterior spinal instrumentation for high dysplastic slips because of problems with the healing of a posterior arthrodesis alone. In addition to improving the appearance, the reduction of spondylolisthesis with instrumentation improves the chance of fusion (Fig. 44.180). Johnson and Kirwan and Wiltse et  al. reported excellent results in patients with slips of more than 50% treated with bilateral lateral fusions. Freeman and Donati found similar results after in situ fusion in patients observed for an average of 12 years (Fig. 44.181). Poussa et  al. compared the results of in situ fusion of spondylolisthesis of more than 50% with results of reduction by a transpedicular system and found no differences between the groups in functional improvement or pain relief. In situ fusion gave a satisfactory cosmetic appearance; reduction procedures were associated with increased operative time, complications, and reoperations. Other reports have recorded an increased rate of nonunion and delayed neurologic complications when posterolateral fusion in situ has been performed in high-grade slips. Instrumentation with pedicle screws has been used in an attempt to prevent further deterioration of the spondylolisthesis with in situ fusion. The goal of surgical treatment in patients with a high-grade spondylolisthesis is to restore the global sagittal balance of the spinopelvic complex. The degree of reduction of the translatory displacement in high-grade

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FIGURE 44.180 A, Severe spondylolisthesis. B, MR image shows slip. C, After anterior and posterior reduction and fusion with posterior instrumentation.

A

B FIGURE 44.181

C

A, Severe spondylolisthesis. B and C, After in situ fusion.

slips is less important than improving the lumbosacral kyphosis and restoring sagittal imbalance. In severe cases, the fusion may need to be extended to L4. The advantages of reduction of high-grade spondylolisthesis include reduction of the slip angle (lumbosacral kyphosis), which improves the sagittal lumbosacral orientation and places the fusion mass in more compression, and improves the global sagittal balance and the cosmetic appearance. Direct neural decompression also is allowed with this procedure. Disadvantages are that more extensive surgery is required, an additional anterior procedure often is needed, and there is an increased risk for neurologic injury. Cauda equina injuries may occur after in situ fusions. In severe spondylolisthesis, the sacral roots are stretched over the back of the body of S1 and are sensitive to any movement of L5 on S1. It has been postulated that muscle relaxation after general anesthesia and the surgical dissection may lead to additional slippage that further stretches these sacral roots. Patients most at risk have an initial slip angle of more than 45 degrees. Thorough neurologic evaluation before and after in situ arthrodesis is recommended in all patients with grade III or grade IV spondylolisthesis. Examination should include clinical assessment of perineal sensation, function of the bladder, and rectal tone. If a patient has a detectable neurologic deficit preoperatively, decompression of the

cauda equina at the time of the arthrodesis with removal of the posterior superior lip of the sacrum (Fig. 44.182) can be done. Because this decompression causes additional instability, segmental instrumentation with pedicle screws is required. Alternatively, decompression of the cauda equina can be combined with reduction of the forward slip with posterior pedicle segmental instrumentation. If injury to the cauda equina is evident after an otherwise uneventful in situ arthrodesis, prompt decompression with removal of the posterior aspect of S1 is recommended. In situ pedicle segmental instrumentation should be considered to further stabilize the area. There are no definite guidelines regarding the appropriate surgical treatment of children and adolescents with high dysplastic spondylolisthesis. Intuitively, it seems that the more dysplastic and unstable the spine is, the more justifiable is some type of reduction and instrumentation. Boachie-Adjei et al. proposed a technique of partial reduction of the lumbosacral kyphosis, decompression of the nerve roots, posterolateral fusion, and pedicle screw transvertebral fixation of the lumbosacral junction. This technique has the advantage of providing three-column fixation by the lumbosacral transfixation, yet it is performed through a single posterior approach. It also allows interbody grafting to be done if necessary without a formal anterior procedure. Lenke and Bridwell also

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FIGURE 44.182 A, Severe spondylolisthesis. B, Increase that may occur intraoperatively. C, Operative decompression of cauda equina with sacroplasty. D, Appearance of sacrum after excision of posterior superior aspect.

found that this approach provided the best fusion rates and clinical outcomes with acceptable complication rates. 

 

POSTEROLATERAL FUSION AND PEDICLE SCREW FIXATION TECHNIQUE 44.54

If an adequate anterior spinal fusion could not be performed posteriorly, the patient is brought back 5 to 7 days later for an anterior procedure. n  Depending on the degree of reduction obtained, a formal discectomy with structural grafts or metallic cages is used with the anterior iliac crest graft for fusion. n  If the slip angle and translation correction have not been enough to allow access to the L5 disc anteriorly, ream over a Kirschner wire that is placed from the midportion of the L5 through the L5-S1 disc and into the proximal sacrum and insert the fibular allograft.  n 

POSTOPERATIVE CARE  Depending on the security of

(LENKE AND BRIDWELL) Place the patient prone on a radiolucent table. Initially, the patient can be positioned with the knees and hips flexed to facilitate decompression. n  Approach the spine through a standard posterior midline lumbosacral incision. n  Perform a Gill laminectomy and bilateral L5 and S1 nerve root decompressions. It is extremely important to decompress the L5 nerve roots widely past the tips of the L5 transverse processes. n  Place pedicle screws at L5 and S1. For additional sacropelvic fixation points, use bilateral distal iliac wing screws. In high-grade slips, instrumentation to L4 may be needed. n  Apply mild distraction to the L5-S1 segment and perform a sacroplasty to shorten the sacrum and decrease the stretch of the L5 nerve roots. n  At this point, if the hips and knees are flexed, extend them to flex the pelvis to meet the L5 segment. n  Attempt to access the L5-S1 disc space from the posterior approach. If this can be done, remove the disc and use morselized bone graft or place structural cages in the L5 disc. n  Contour the rod and place it into the distal fixation segment; flex the sacrum with the rod to meet the L5 segment. n  Place the graft anterior just before locking the instrumentation into place. n  Review the intraoperative anteroposterior and lateral radiographs. n  Perform a formal wake-up test to assess bilateral foot and ankle movement. n  Place iliac crest bone graft harvested proximal to the iliac screw site over the decorticated transverse process and sacral ala bilaterally (Fig. 44.183).

the fixation obtained, a single pantaloon brace or TLSO may be needed. The brace can be discontinued when it appears that the fusion is solid enough to safely do so, usually at 3 to 4 months postoperatively.    

n 

 

INSTRUMENTED REDUCTION In high dysplastic spondylolisthesis, reduction and fusion with internal fixation and a sagittally aligned spine can eliminate the complication of progression of the deformity that can occur after in situ fusion. Lumbar root pain or deficit may require decompression of the L5 symptomatic roots and internal fixation. Internal fixation makes it possible to decompress these roots fully without fear of residual instability or progressive slipping (Fig. 44.184). Sacral radiculopathy caused by stretching of the sacral roots over the posterosuperior corner of the sacrum theoretically can be relieved by restoring the lumbar spine to its proper position over the sacrum. This relieves the anterior pressure from the sacral roots, shortens their course, and relaxes the cauda equina. Correction of the slip angle (kyphosis) greatly reduces the bending moment and tensile stress that works against the posterior lumbosacral graft. When normal biomechanics are restored by correction of the deformity, it may be possible to fuse fewer lumbosacral segments. Theoretically, restoring body posture and mechanics to normal may lessen future problems in the proximal areas of the spine. Physical appearance is a concern of adoles-

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D FIGURE 44.183 Radiographs of 12-year-old girl with high-grade IV isthmic dysplastic spondylolisthesis. Patient has small amount of sciatic scoliosis on coronal view (A and B). Sacrum is vertical on sagittal radiograph (C), and she is positioned with her trunk anterior to her pelvis, showing anterior sagittal imbalance. Patient had posterior decompression, partial reduction, sacral dome osteotomy, and posterolateral fusion with instrumentation from L5 to sacrum. One week later, she had anterior fibular dowel graft placement from L5 to sacrum. Radiographs D to F show improved position of L5 on sacrum and excellent alignment in overall coronal (D) and sagittal (E) radiographs. F, Arrow points to anterior edge of fibular graft. (From Lenke LG, Bridwell KH: Evaluation and surgical treatment of high-grade isthmic dysplastic spondylolisthesis, Instr Course Lect 52:525, 2003.) SEE TECHNIQUE 44.54.

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D FIGURE 44.184 In high dysplastic spondylolisthesis (A and B), lumbar root pain or deficit may require decompression of the L5 symptomatic roots and internal fixation. C and D, Internal fixation makes it possible to decompress these roots fully without fear of residual instability or progressive slipping.

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PART XII  THE SPINE cents with high-grade spondylolisthesis, and this can be improved with reduction of the deformity. These advantages, however, should be weighed against the potential risks of the surgery. These procedures are technically demanding and carry with them a significant risk of nerve root injury. As techniques are evolving, these risks are decreasing but are still present. Numerous techniques to obtain complete reduction of high-grade dysplastic spondylolisthesis have been described. The following technique is just one of those described.

TECHNIQUE 44.55 (CRANDALL) After general anesthesia is obtained, place the patient prone on a radiolucent table. n  Use a routine midline approach to the lumbosacral spine. n  Perform a full L5 laminectomy, inferior facetectomy, and nerve root decompression. A discectomy at L5-S1 will also make L5 more mobile for reduction. n  Prepare and tap the pedicles at L5-S1 and insert long post screws bilaterally at L5. n  Screws also should be placed bilaterally at S1. n  For high-grade spondylolisthesis, a distal point of fixation is needed to form a strong and stable base from which L5 can be pulled into position. Options include iliac screws (Fig. 44.185A) and S2 alar screws (Fig. 44.185B,C). n  Aim the S2 multiaxial screws laterally into the beak of the sacral ala. n  After all screws are placed, select a rod of the appropriate length and diameter, along with the corresponding threedimensional connectors, and preassemble the construct. n  Place screw extenders on the post of the S1 screws to ease insertion. n  Slide the preassembled construct down the screw extenders at S1 and the threaded post of the long post screw at L5 and into the multiaxial screw heads at S2. n  Repeat the same process on the contralateral side of the spine. n  Once the connectors are in place, temporarily secure them at S1 with a lock screw. When the construct is in place, each rod creates a “diving board” over L5 (Fig. 44.185D). n  Place a low-profile crosslink plate between the S1 and S2 levels of the construct. If iliac screws are used, this is not necessary. n  Place the provisional reduction crimps on both the long post three-dimensional screws at L5 (Fig. 44.185E). Place the crimp driver on the threaded posts of the screws. Advance the driver down the threaded post to the provisional reduction crimp. Sequentially tighten the driver by rotating clockwise and pushing down on the reduction crimps (Fig. 44.185F). By use of the provisional reduction crimps, the spine is brought into its correct anatomic position in a gradual and highly controlled way (Fig. 44.185G,H). n  If the L5 connector “bottoms out” onto the screw head before full reduction is achieved (Fig. 44.185I), there are two options for getting the last few millimeters of correction. n  Contour the rod with more lordosis at L5 to increase the reduction distance for L5 to be pulled back (Fig. 44.185J), n 

or place the connector at S1 at the very top of the post, which creates more reduction distance (Fig. 44.185K). n  Once the spondylolisthesis is fully corrected, compress L5 to S1 with the compressor to make the alignment as stable as possible. The correction is more likely to be maintained if bone or a small cage is placed into the disc space through a posterior lumbar interbody fusion or transforaminal lumbar interbody fusion before L5 is compressed to S1. n  Place lock screws in the three-dimensional connectors at L5 and S1 (Fig. 44.185L) and tighten all four lock screws. As the tightening occurs, the break-off portion of the set screw will shear off and remain in the sleeve of the driver. n  Use a “cutter” to cut the long post flush with the assembly (Fig. 44.185M,N).    

 

REDUCTION AND INTERBODY FUSION Satisfactory results have been reported with reduction and posterior interbody fusion for the management of highgrade spondylolisthesis in pediatric and adult patients. Reduction can be augmented with an anterior fusion using morselized bone graft or a structural cage in the L5 disc. Placement of a transsacral fibular graft or direct placement of sacral screws across the L5 disc into the L5 vertebral body also can be used to augment a partial reduction and fusion, as described by Smith et al.

TECHNIQUE 44.56 (SMITH ET AL.) Place the patient prone on a four-poster frame. Neuromonitoring is strongly recommended for this technique, including an intraoperative wake-up test in adult patients. n  Perform standard subperiosteal dissection of the posterior elements from L2 to the sacrum. Perform decompression and sacral laminectomies of S1 and S2. n  Place a temporary distracting rod from the inferior aspect of the lamina of L2 to the sacral ala, allowing distraction with concomitant extension moment applied by extension of the thighs. If distraction prevents reduction of the slip angle, the primary reduction maneuver is extension of the hip joints. n  If the sacral dome is thought to cause significant anterior impingement of the dural sac, perform partial sacral dome resection to decompress the neural elements further. n  Sweep the dural sac toward the midline in the vicinity of the S1-S2 disc. n  While protecting the neural elements under fluoroscopic control, advance a guidewire through the body of S1, across the L5-S1 disc space, and up to the anterior cortex of L5. n  Overream the guidewire under fluoroscopic guidance, beginning at 6 mm and increasing by 2 mm increments, usually up to 12 mm. n 

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E FIGURE 44.185 A-N, Reduction and fusion in high dysplastic spondylolisthesis with internal fixation. See text for description. (Redrawn from Crandall D: TSRH-3D Plus MPA spinal instrumentationdeformity and degenerative, surgical technique manual, Memphis, TN, 2005, Medtronic Sofamor Danek.) SEE TECHNIQUE 44.55.

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J FIGURE 44.185, cont’d

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N FIGURE 44.185, cont’d

Measure a single fibular allograft. Cut it and impact it into position. Remove the temporary distraction rod. n  To augment the transsacral fibula, place pedicle screw fixation in L4 and transsacral pedicle screws capturing L5. Direct the sacral screws along the same sagittal trajectory as the fibula to capture L5 with subsequent placement of rods connecting the pedicle screws (Fig. 44.186). n  Perform a posterolateral fusion from L4 to the sacral ala after harvest of iliac crest bone graft. n 

POSTOPERATIVE CARE  Postoperative care is the same as that after the one-stage decompression and posterolateral interbody fusion.    

 

ONE-STAGE DECOMPRESSION AND POSTEROLATERAL INTERBODY FUSION TECHNIQUE 44.57 (BOHLMAN AND COOK) Place the patient prone, with the right leg draped free as the graft donor site. n  Approach the spine through a standard midline incision from the third lumbar level to the second sacral level. Subperiosteally strip muscle to the tip of the transverse process and sacral ala on each side. n 

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FIGURE 44.186 To augment the transsacral fibula, place pedicle screw fixation in L4 and transsacral pedicle screws capturing L5. Direct the sacral screws along the same sagittal trajectory as the fibula to capture L5 with subsequent placement of rods connecting the pedicle screws.

Remove the posterior elements of the fifth lumbar and first sacral vertebrae (and fourth lumbar vertebra if necessary). n  Perform a wide foraminotomy to decompress the fifth lumbar and first sacral nerve roots. n  Gently free the dura from the posterosuperior prominence of the first sacral vertebral body with a Penfield elevator. Osteotomize the sacral prominence with a curved osteotome to create a ventral trough for the dura and to eliminate all pressure on the dura (Fig. 44.187A). n  Introduce a guide pin between the fifth lumbar and first sacral nerve roots on each side. Each pin is approximately 1 cm lateral to the midline and is directed through the first sacral vertebral body anteriorly. Confirm the proper position of each guidewire with radiographs. n  Drill a 3⁄8-inch epiphysiodesis bit over each guide pin to the appropriate depth, being careful not to violate the anterior cortex of the fifth lumbar vertebra (≈5 cm). n  Obtain a fibular graft from the right leg and divide it longitudinally. Insert one half of the graft into each hole and n 

countersink it 2 mm so as not to impinge on the dura (Fig. 44.187B). n  Perform a standard bilateral, posterolateral transverse process fusion from the third or fourth lumbar vertebra to the sacral ala using iliac crest grafts (Fig. 44.187B,C). n  Close the wound over a drain.

POSTOPERATIVE CARE  The patient is kept at bed rest for 7 to 10 days and then is mobilized in a lumbosacral orthosis. The drain is removed in 48 hours.      

UNINSTRUMENTED CIRCUMFERENTIAL IN SITU FUSION Circumferential in situ fusion has been used for the treatment of high-grade spondylolisthesis in chil-

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FIGURE 44.187 A, Amount of first sacral vertebral body resected to decompress dura (blue line). B, Insertion of interbody fibular graft and posterior decompression. C, After posterior decompression and fusion. Colored area represents posterolateral fusions. Ends of two fibular grafts are shown just above first sacral nerve roots. (From Bohlman HH, Cook SS: One-stage decompression and posterolateral and interbody fusion for lumbosacral spondyloptosis through a posterior approach, J Bone Joint Surg 64A:415, 1982.) SEE TECHNIQUE 44.57.

dren with better long-term results reported than after posterolateral or anterior fusion alone. The SRS recommends that if reduction is performed, circumferential fusion with instrumentation should be done at the time of reduction.

TECHNIQUE 44.58 (HELENIUS ET AL.) Place the patient prone on a four-poster Relton frame. Make a posterior midline skin incision and develop the space bilaterally through the erector spinae muscles, 3 cm from the midline. Identify the L5 transverse process, the L5-S1 facet joint, and the sacral ala. n  Expose the posterior iliac wing through the same incision and obtain corticocancellous bone graft material. n  Open the L5-S1 facet joint with an osteotome and decorticate and curet the L5 transverse process and sacral ala. Place autogenous graft over the decorticated bone and impact it into the L5-S1 facet joint space. n  Close the fasciae on both sides as well as the subcutaneous tissues and skin with running absorbable suture. n  Place the patient supine, with both hips extended and the lower extremities spread apart. Place a small bolster under the lumbar spine to obtain lumbar lordosis. A Trendelenburg position of the table helps to keep the abdominal contents cephalad to the operating area. n  Make a longitudinal midline incision from just caudal to the umbilicus to just cephalad to the symphysis pubis. n  Open the fascia over the rectus abdominis muscle and develop the internervous plane between the abdominal muscles. n  After opening the peritoneum, extend the approach cephalad by cutting through the linea alba and packing the abdominal contents superiorly. Take care not to enter the dome of the bladder caudally. n  n 

Open the posterior peritoneum (Fig. 44.188A) and assess the anatomy of the iliac vessels. Usually, the presacral intervertebral disc can be approached between the great vessels. Protect the left iliac vein across the L5 vertebral body and caudal to the aortic bifurcation. n  With forceps, use blunt dissection to expose the L5-S1 disc. n  Identify the anterior longitudinal ligament and ligate the middle sacral artery. To help retract the iliac vessels, two Steinmann pins can be inserted on either side of the L5 vertebral body. Try to preserve all the parasympathetic nerve fibers in this area by approaching the disc space in the midline. n  Open the anterior longitudinal ligament horizontally, just cephalad to the L5-S1 disc space (Fig. 44.188B). The lower anterior lip of the L5 vertebra can be resected along the anterior longitudinal ligament to better expose the disc space. n  Carefully remove all intervertebral disc material up to the posterior longitudinal ligament, as well as the ring apophysis on both sides. Prepare the endplates with curettage. n  Obtain two to three tricortical wedge-shaped bone grafts (15 mm anterior and 10 mm posterior dimension) from either anterior iliac wing. The length of this graft is approximately 20 mm but may vary some. The grafts must fit into the disc space as prepared (Fig. 44.188C). A moderate increase in disc height and proper patient positioning reduce the spondylolisthesis and lumbosacral kyphosis. Using three structural autogenous grafts provides the best stability. n  In slips of nearly 100%, it may be necessary to increase the area for anterior spinal fusion. In these cases, an osteotomy of the sacrum may be necessary. Continue the release of the anterior ligament inferiorly, producing an osteoperiosteal flap over the S1 vertebral body. Apply corticocancellous bone grafts beneath this flap to increase the area for anterior intervertebral fusion. n 

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FIGURE 44.188 A, Posterior peritoneum opened and middle sacral artery ligated. B, Anterior longitudinal ligament opened, and small piece of bone removed from lower lip of L5. C, After discectomy, structural autogenous grafts placed. D, Anterior longitudinal ligament reattached through osseous channels and posterior peritoneal and laparotomy incisions are subsequently closed. (From Helenius I, Remes V, Poussa M: Uninstrumented in situ fusion for high-grade childhood and adolescent isthmic spondylolisthesis: long-term outcome, J Bone Joint Surg 90A:145, 2008.) SEE TECHNIQUE 44.58.

Reattach the anterior longitudinal ligament with absorbable sutures through osseous channels in the L5 vertebra. n  Close the posterior peritoneal and laparotomy incision (Fig. 44.188D). n 

POSTOPERATIVE CARE A postoperative custom-molded TLSO is worn, and the patient is allowed to mobilize 2 to 3 days after surgery. Bending, lifting, and sports are restricted for 3 to 6 months or until a solid fusion is obtained.   

popularized a two-stage L5 vertebrectomy procedure for this difficult problem (Fig. 44.189). The objective is to restore sagittal plane balance to avoid nerve root damage from cauda equina and nerve root stretching during reduction. This is a challenging procedure and should be done only by surgeons experienced in the surgical treatment of patients with high-grade isthmic dysplastic spondylolisthesis.

TECHNIQUE 44.59 (GAINES)

TREATMENT OF SPONDYLOPTOSIS

This technique is performed in two stages, during either a single anesthetic or two separate anesthetic procedures. n  In the first stage, perform an L5 vertebrectomy and totally remove the L4-L5 and L5-S1 discs through a transverse abdominal incision (Fig. 44.190A). n 

 

L5 VERTEBRECTOMY Spondyloptosis exists when the entire body of L5 on a lateral standing radiograph is totally below the top of S1. Gaines

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

4 4

4 5

1

A

1

1

B

C

FIGURE 44.189 A-C, Diagram of two-stage L5 vertebrectomy for spondyloptosis. SEE TECHNIQUE 44.59. L1 L2 Common iliac artery and vein

L3 L4 L5

Internal iliac artery and vein External iliac artery and vein

A

B

C FIGURE 44.190 A, Anterior approach for resection of L4-L5 disc, vertebral body of L5, and L5-S1 disc is made through incision extending transversely across both rectus abdominis muscles. Great vessels are mobilized laterally after being carefully identified, and structures to be resected are seen between bifurcation of vena cava and aorta. B, Preoperative and postoperative lateral radiograph. C, Radiographs of same patient 7 years later. Solid intertransverse fusion and interbody fusion are shown. Reconstructed L4-S1 intervertebral foramen is wide open on lateral radiograph. (A redrawn from and B and C from Gaines RW Jr: The L5 vertebrectomy approach for the treatment of spondyloptosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven.) SEE TECHNIQUE 44.59.

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A

B

C

D

FIGURE 44.191 A and B, Scoliosis in patient with myelomeningocele; note C-shaped curve. C and D, After posterior fusion and instrumentation.

Excise the L5 body back to the base of the pedicles and control epidural bleeding with Gelfoam. n  Do not attempt reduction of the deformity at this time. n  Remove the caudal cartilage endplate of L4 after the L5 vertebrectomy is completed. n  For the second stage, place the patient prone. n  Through a posterior approach, remove the L5 pedicles, facets, and laminar arch bilaterally. n  Place the pedicle screws into L4 and S1. n  Clean the upper surface of the sacrum of the cartilage endplate but preserve the cortical endplate for docking with the inferior endplate of L4. Bone from the vertebrectomy is left between the L4 and S1 screws posterolaterally (Fig. 44.190B,C). L4 must touch S1 directly after the reduction, and the L5 and S1 nerve roots must both be free. Direct exposure of the L5 nerve roots and dural tube is the most important way to avoid serious iatrogenic injury to the cauda equina.     n 

KYPHOSCOLIOSIS MYELOMENINGOCELE

Treatment of patients with myelomeningocele spinal deformities is the most challenging in spine surgery. It requires a team effort, with cooperation of consultants in several subspecialties. These children often have multiple system dysfunctions that influence the treatment of their spinal deformity.

INCIDENCE AND NATURAL HISTORY

Scoliosis and kyphosis with secondary adaptive changes are common in patients with myelomeningocele. Spinal deformity may be the result of developmental deformities that are acquired and related to the level of paralysis or congenital deformities that are the result of vertebral malformation. Developmental and congenital forms of spinal deformity may exist concurrently in patients with myelomeningocele. These deformities often are progressive and can lead to significant disabilities. The incidence of scoliosis increases with increasing age and neurologic level. Trivedi et al. found the

prevalence of scoliosis to be 93%, 72%, 43%, and less than 1%, respectively, in patients with thoracic, upper lumbar, lower lumbar, and sacral motor levels. Congenital scoliosis in myelomeningocele is associated with structural disorganization of the vertebrae with asymmetric growth and includes all of the congenital anomalies associated with scoliosis: hemivertebrae, unilateral unsegmented bars, and various combinations of the two. Congenital scoliosis occurs in 15% to 20% of patients with myelomeningocele, and most curves in myelomeningocele patients are paralytic. In these patients, the spine is straight at birth and gradually develops a progressive curvature because of the neuromuscular problems. These generally are long, C-shaped curves with the apex in the thoracolumbar or lumbar spine (Fig. 44.191). These paralytic curves often extend into the lumbosacral junction and often are associated with pelvic obliquity. In these children, spinal curvatures often develop at a younger age than in children with idiopathic scoliosis, beginning at 3 to 4 years of age, and can become severe before the patient is 10 years old. Future trunk growth and final trunk height are considerations in treatment, although Lindseth noted that children with myelomeningocele have slow growth because of growth hormone deficiency and mature earlier than usual, often by 9 to 10 years in girls and 11 to 12 years in boys. 

CLINICAL EVALUATION

Thorough evaluation is critical for determining the appropriate management of patients with myelomeningocele and spinal deformity. The following areas are closely investigated: presence of hydrocephalus, any operative procedures for shunting, bowel and bladder function, frequency of urinary tract infections, use of an indwelling catheter or intermittent catheterization, possible latex allergies, current medications, mental status, method of ambulation, level of the defect, any noticeable progression of the curve, and any lower extremity contractures. The spine is examined to determine the type and flexibility of the deformity and to detect any evidence of pressure sores or lack of sitting balance. In patients with progressive paralytic scoliosis, hydromyelia, disturbed ventricular shunts, syringomyelia, tethered cord, or compression from an Arnold-Chiari syndrome may contribute to the

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS progression of scoliosis. Most patients with myelomeningocele have radiographic tethering of the spinal cord at the site of the sac closure, but the mere presence of radiographic tethering does not necessarily imply traction on the cord. Other clinical signs and symptoms of cord tethering should be observed, including back pain, new or increased spasticity, changes in muscle strength, difficulty with gait, changes in bowel or bladder function, and the appearance of lower extremity deformities. Careful evaluation of any pelvic obliquity is necessary. Because patients with myelomeningocele are prone to development of contractures around the hips, careful physical examination of the hip adductors, extensors, and flexors is important in evaluating the cause of pelvic obliquity. Lubicky noted a difficult but unusual problem in some patients with myelomeningocele and extension contractures of the hips. In these patients, flexion through the thoracolumbar spine was needed for them to sit upright. Spinal fusion would make sitting impossible and would place significant mechanical stresses on the instrumentation. Physiologic hip flexion should be restored in these patients before spinal instrumentation and fusion are undertaken. 

RADIOGRAPHIC FINDINGS

Radiographs should be taken with the patient upright and supine. If the patient can ambulate, standing films should be made. If the patient is nonambulatory, sitting films should be made. The upright films allow better evaluation of the actual deformity of the spine and will demonstrate the contribution of the paralytic component to the spine deformity. Supine films show better detail of various associated spinal deformities. The flexibility of the curves is determined with traction or bending films. Radiographic evaluation of the pelvic obliquity should include a supine view obtained with the hips in the “relaxed” position. In this view, the hips are flexed and abducted or adducted as dictated by the contractures. Alternatively, radiographs can be made with the patient prone and the hips off the edge of the radiographic table and placed in abduction or adduction. Various specialized radiographs are helpful. Myelography and MRI are useful for evaluating such conditions as hydromyelia, tethered cord (Fig. 44.192), diastematomyelia, and Arnold-Chiari malformation. CT with reconstruction views will give better bone detail for associated congenital spine anomalies. Renal ultrasound or intravenous pyelography should be done at regular intervals, according to the urologist’s recommendation. 

SCOLIOSIS AND LORDOSIS IN MYELOMENINGOCELE ORTHOTIC TREATMENT

Although the natural history of paralytic curves in patients with myelomeningocele is not changed by orthotic treatment, bracing may be useful to delay spinal fusion until adequate spinal growth has occurred. Bracing may accomplish this in paralytic curves but does not affect congenital curves. The brace also can improve sitting balance and free the hands for other activities. Custom-fitted braces are used but require close and frequent observation by the parents. The skin must be examined frequently for pressure areas; any sign of pressure requires immediate brace adjustment. Bracing usually is

3

FIGURE 44.192 kyphoscoliosis.

MRI shows tethered cord at L3 in patient with

not instituted until the curve is beginning to cause clinical problems, and generally it is worn only when the patient is upright. If the curve fails to respond to bracing or if bracing becomes impossible because of pressure sores or noncompliance, surgery is indicated. The patient and the parents need to understand that the brace is not the definitive treatment of these curves. Flynn et  al. reported that VEPTR is a reasonable treatment option for spinal deformity in immature, nonambulatory myelomeningocele patients for correcting spinal deformity, allowing spinal growth, and maintaining adequate respiratory function until definitive fusion is needed. 

OPERATIVE TREATMENT

Several authors have indicated that surgery on the myelomeningocele spine is accompanied by potentially serious complications. Although the operative procedures varied considerably in these reports, some observations could be made. Because of densely scarred and adherent soft tissue, spinal exposure often is lengthy and hemorrhagic. The deformity often is rigid, and correction may be limited. The quality of the bone often provides poor fixation for instrumentation systems, and the inadequacy of the posterior bone mass provides a poor bed for bone grafting. The lack of normal posterior vertebral elements makes instrumentation and achieving a solid fusion difficult. The abnormal placement of the paraspinal muscles results in the lack of usual soft-tissue coverage of the spine and instrumentation systems. Newer techniques of surgery and instrumentation, bank bone, and prophylactic antibiotics have lessened but not eliminated these problems. The parents must be aware of these potential problems before surgery and must accept these as inherent in the operative treatment. Emans et  al. called attention to the problem of latex allergy in patients with myelomeningocele. Repeated exposures to latex during daily catheterization and multiple operations most likely accounts for sensitization of these patients to natural latex. The allergy is to the residual plant proteins in natural latex products and is an immunoglobulin E–mediated, immediate type of hypersensitivity. Anaphylaxis may

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PART XII  THE SPINE occur intraoperatively and easily can be confused with other intraoperative emergencies. Patients with myelomeningocele should be closely questioned about any preoperative reactions to latex. Latex allergy testing can now be performed. We routinely treat all patients with myelomeningocele as if they have a latex allergy. Congenital abnormalities that cause scoliosis in patients with myelomeningocele are treated in the same manner as in other patients with congenital scoliosis with early operative intervention. Paralytic scoliosis is more common than congenital scoliosis, and lordoscoliosis is the most common type. The combined anterior and posterior fusion method provides the best chance to achieve a durable fusion. Stella et al. also reported that the best correction was obtained in patients who had instrumented anterior and posterior fusions. High pseudarthrosis rates have been reported in patients with myelomeningocele and are related to the surgical approach, type, and presence of instrumentation or the use of a posterior-only approach. The reported pseudarthrosis rates are 0% to 50% for anterior fusion, 26% to 76% for isolated posterior fusion, and 5% to 23% for combined anterior and posterior fusions. Infection rates have approached 43% and are highest when surgery is performed with concurrent urinary tract infections. Preoperative urinary cultures are mandatory, as is treatment with antibiotics preoperatively and postoperatively. Prophylactic antibiotic use has reduced the infection rate to 8%. Selection of Fusion Levels.  The levels of fusion depend on the age of the child, location of the curve, level of paralysis, ambulatory status, and presence or absence of pelvic obliquity. Spinal fusion generally should extend from neutral vertebra to neutral vertebra, with the end vertebra of the scoliotic curve located within the stable zone. Paralytic curves often tend to be fused too short, especially proximally. In deciding whether to stop the fusion short or long, the longer fusion usually is safer. In the past, instrumentation was extended to the pelvis because deficient posterior elements of the lumbar spine made adequate fixation impossible. With pedicle screw fixation, fusion and instrumentation sometimes can be stopped short of the pelvis. Mazur et al. and Müller et al. showed that spinal fusion to the pelvis in ambulatory patients diminished their ambulatory status. They therefore recommended fusion short of the pelvis, if possible, in ambulatory patients. Ending the fusion above the pelvis eliminates the stresses on the instrumentation and fusion areas at the lumbosacral junction and allows some motion for adjustment of lordosis in those who have mild hip flexion contractures. In nonambulatory patients, unless the lumbar curve can be corrected to less than 20 degrees and the pelvic obliquity to less than 10 to 15 degrees, the scoliosis will continue to progress if the lumbosacral junction is not fused. Attention to the sagittal contour is extremely important. Even in a nonambulatory patient, maintenance of lumbar lordosis is important. If the lumbar lordosis is flattened, the pelvis rotates and much of the sitting weight is placed directly on the ischial tuberosities; this can result in the development of pressure sores.  Anterior-Only Fusion.  Sponseller et  al. recommended anterior fusion and instrumentation alone in selected patients with myelomeningocele and paralytic scoliosis. Their indications for this procedure include thoracolumbar curves of less than 75 degrees, compensatory proximal curves of less than

40 degrees, no significant kyphosis in the primary curve, and no evidence of syrinx. Fourteen patients were treated with this technique. A rod and vertebral body screw construct was used most frequently anteriorly. 

 

POSTERIOR INSTRUMENTATION AND FUSION Posterior instrumentation and fusion alone has been reserved for flexible curves with most of the posterior elements intact so that adequate fixation can be obtained with pedicle screws. However, the curve must be flexible and correction must allow almost normal coronal and sagittal balance. Posterior-only instrumentation and fusion has been associated with the highest pseudarthrosis rates.

TECHNIQUE 44.60 Place the patient prone on a radiolucent frame. Prepare and drape the back in a sterile manner. n  Make a midline incision from the area of the superior vertebra to be instrumented down to the sacrum. n  In the area of the normal spine, carry out subperiosteal dissection. An inverted-Y incision has been described to prevent exposure of the sac in the midline, but we have had difficulty with skin necrosis with use of this technique and have had better results with a midline incision that follows the scarred area of the skin posteriorly and careful dissection around the sac in the midline area. n  Make the skin incision carefully because the dural sac is just beneath the skin. If a dural leak is noted, repair it immediately. n  Carry the dissection laterally over the convex and concave facet areas and down to the ala of the sacrum to expose the area of normal spine to be fused and the bony elements in the region of the abnormal sac area. n  Hooks, pedicle screws, or sublaminar wires can be used to instrument the normal vertebra above the sac area. n  In the area of the defect, attempt to achieve segmental fixation. Pass a wire around a pedicle and twist it on itself to secure fixation. Pass wires on both the concave and the convex sides of the curve. Because these pedicles often are osteoporotic, take care in tightening the wires so that they do not “cut through.” n  On the concave side of the curve, distraction can help correct pelvic obliquity. n  If the iliac wing is large enough to accept the Galveston fixation, make a Galveston bend in short rods and insert the short rods in the iliac crests. Alternatively, an iliac screw and/or an S2 alar screw can be used. n  An iliac screw with connectors can be used. n  Connect two longer rods to the spine with the segmental wires and connect the long rods to the Galveston-type rods with domino-type crosslinks (see Technique 44.31). n  Alternatively, if the iliac wings are too small, use the McCarthy technique (see Technique 44.30). Take care to preserve normal lumbar lordosis and secure the rods in place by tightening the segmental wires. n  n 

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Normal pedicle

Myelopedicle FIGURE 44.194 Diagram shows alteration in anatomic relationship of pedicle-transverse process. FIGURE 44.193 CT scan shows abnormal pedicle orientation in dysraphic vertebra. (From Rodgers WB, Frim DM, Emans JB: Surgery of the spine in myelodysplasia: an overview, Clin Orthop Relat Res 338:19, 1997.)

Apply copious bone-bank allograft to any areas of bony structures posteriorly. n  It is important to link the two rods with a crosslink system.    n 

COMBINED ANTERIOR AND POSTERIOR FUSION

The most commonly required procedure for progressive scoliosis in patients with myelomeningocele combines anterior and posterior fusions with posterior instrumentation. Posterior instrumentation consists of a standard rod with hooks, pedicle screws, sublaminar wires, or cables, or a combination of these in the areas of normal posterior elements. The hooks and pedicle screws allow distraction or compressive forces to be applied, and the wires or cables allow a translational force to be applied. The absence of posterior elements in the dysraphic portion of the spine makes fixation more of a problem, so various instrumentation systems need to be available (Fig. 44.193). Rodgers et al. noted that pedicle screws greatly improved fixation and correction of the dysraphic portion of the spine. In widely dysraphic vertebrae, the orientation and landmarks of the pedicle are altered (Fig. 44.194), and direct viewing of the pedicle is necessary to insert pedicle screws in these areas. The pedicle is exposed either by resection of a sufficient amount of facet or by dissection along the medial wall of the spinal canal and retraction of the meningocele sac to identify the medial wall of the pedicle. During probing of the pedicle, remaining within the cortices of the pedicle is imperative. The pedicle screws do not necessarily need to penetrate the anterior vertebral cortex. In the dysraphic spine, the pedicle screws often have to be inserted at an angle from lateral to medial (Fig. 44.195). This requires special attention to rod contouring to attach the rod to the screw because of the lateral position of the screw head. The small vertebral bodies and osteopenic bone often make the purchase of pedicle screws questionable. Two other techniques for fixation of the dysraphic spine can be used. Drummond spinous process button wires can be passed through laminar remnants (Fig. 44.196), or segmental wires can be looped around each pedicle. When Drummond

FIGURE 44.195

Pedicle screw insertion.

FIGURE 44.196 Diagram of Wisconsin button wire fixation of dysraphic vertebra.

button wires are used, the dysraphic laminae are exposed and dissection is done between the sac and the adjacent laminae while the sac is carefully retracted medially. A hole is placed through the strongest available portion of the laminar remnant, and the wire is passed from medial to lateral, leaving the button on the inner surface of the lamina. Segmental wires can be looped around each pedicle by passing from one foramen around the pedicle and other posterior remnants medial to the pedicle and then back through the next foramen and back to the original wire. The passage of these wires usually is blind. The wires then attach to the rod. The wire also can be looped around a pedicle bone screw if it is difficult to contour the rod to easily fit in the screw.

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A

B

FIGURE 44.197 A, Correct passage of sacral bar through body of sacrum, posterior to great vessels and anterior to spinal canal. B, Connection between sacral bar and vertical rods.

Instrumentation to the pelvis frequently is necessary to correct associated pelvic obliquity in nonambulatory children. Fixation to the pelvis and sacrum is especially difficult in children with myelomeningocele because the bone often is osteoporotic and the pelvis is small, making secure instrumentation difficult. The stresses placed on distal fixation in scoliosis tend to displace sacral or sacropelvic instrumentation laterally. If there is associated kyphosis, these forces tend to displace sacral or pelvic instrumentation dorsally. Several techniques have been described for extending fixation to the pelvis, including Galveston, Dunn-McCarthy, Jackson, Fackler, sacral bar, and pedicle screws. Our preferred technique for pelvic fixation in patients with paralytic scoliosis is the Galveston technique (see Technique 44.31). We believe this provides the most secure pelvic fixation for scoliotic curves. However, many patients with myelomeningocele have hypoplastic iliac crests, and in these patients, rods are fixed to the sacrum with the technique described by McCarthy (see Technique 44.30). This technique does not restrict lateral displacement as well as the Galveston intrapelvic fixation does, but crosslinking of the two rods may help decrease lateral displacement. Once the two rods are crosslinked, pelvic obliquity can be corrected by cantilevering the crosslinked rods. The Jackson intrasacral rod technique consists of inserting the rods through the lateral sacral mass and into the sacrum. The rod then penetrates the anterolateral cortex and usually is attached to a sacral screw, providing fixation in flexion and extension. The anatomy of the sacrum in patients with myelomeningocele makes this technique quite difficult. Widmann et al. described a technique using a sacral bar connected to standard Cotrel-Dubousset–like rods in 10 patients and found it to be effective (Fig. 44.197). Pelvic fixation by sacral pedicle screws is not reliable in these small osteopenic patients. In patients who are treated with combined anterior and posterior fusion, the necessity for anterior instrumentation is controversial. One study found no statistical differences in fusion rate, curve correction, or change in pelvic obliquity with anterior and posterior instrumentation and fusion compared with anterior arthrodesis with only posterior instrumentation and fusion. However, other studies have reported better correction and a decrease in the rate of implant failure and postoperative loss of correction with instrumented anterior and posterior fusions. If anterior instrumentation is used,

care must be taken to not cause a kyphotic deformity in the instrumented spine. 

KYPHOSIS IN MYELOMENINGOCELE INCIDENCE AND NATURAL HISTORY

Kyphosis in patients with myelomeningocele may be either developmental or congenital. Developmental kyphosis is not present at birth and progresses slowly. It is a paralytic kyphosis that is aggravated by the lack of posterior stability. Congenital kyphosis, which is a much more difficult problem, usually measures 80 degrees or more at birth. The level of the lesion usually is T12 with total paraplegia. The kyphosis is rigid and progresses rapidly during infancy. Children with severe kyphosis are unable to wear braces and often have difficulty sitting in wheelchairs because the center of gravity is displaced forward. An ulceration may develop over the prominent kyphosis and make skin coverage difficult. Progression of the kyphosis may lead to respiratory difficulty because of incompetence of the inspiratory muscles, crowding of the abdominal contents, and upward pressure on the diaphragm. Increased flexion of the trunk can interfere with urinary drainage and also may cause problems if urinary diversion or ileostomy becomes necessary. Hoppenfeld described the anatomy of this condition and noted that the pedicles are widely spread and the rudimentary laminae actually are everted. The anterior longitudinal ligament is short and thick. The paraspinal muscles are present but are displaced far anterolaterally (Fig. 44.198); thus, all muscles act anterior to the axis of rotation, which tends to worsen the kyphosis. 

OPERATIVE TREATMENT

Apical vertebral ostectomy, as proposed by Sharrard, makes closure of the skin easier in neonates but provides only shortterm improvement, and the kyphotic deformity invariably recurs. Crawford et al. reported kyphectomies performed at the time of dural sac closure in the neonate. They found this to be a safe procedure with excellent initial correction. Eventual recurrence is expected despite the procedure. The recurrence, however, is a longer, more rounded deformity that is technically less demanding to correct. Lindseth and Selzer reported vertebral excision for kyphosis in children with myelomeningocele. Their most consistent results were obtained with partial resection of the apical vertebra and the proximal lordotic

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Diaphragm

L1

A

instrumentation to the pelvis. He recommended intervening early while the gibbus was still flexible and before skin breakdown over the deformity. This technique effectively improved the gibbus deformity and avoided early vertebral column resection and fusion. 

Crura of diaphragm

Psoas

 

Iliac crest

VERTEBRAL EXCISION AND REDUCTION OF KYPHOSIS TECHNIQUE 44.61

L5

(LINDSETH AND SELZER)

Dura

Use a midline posterior incision (Fig. 44.199A), which can be varied somewhat, depending on local skin conditions. n  Expose subperiosteally the more normal vertebrae superiorly and the area of the abnormality, continuing the exposure past the lateral bony ridges. n  At this point, remove the sac. n  Dissect inside the lamina until the foramina are exposed on each side of the spine. n  Expose, divide, and coagulate the nerve, artery, and vein within each foramen, exposing the sac distally where it is scarred down and thin. n  At its distal level, cross-clamp the sac with Kelly clamps and divide it between the clamps (Fig. 44.199B). n  Close the scarred ends with a running stitch. Dissect the sac proximally. n  As this proximal dissection is done, large venous channels connecting the sac to the posterior vertebral body will be encountered; control the bleeding from the bone with bone wax and from the soft tissue with electrocautery. n  Dissect the sac up to the level of the dura that appears more normal (Fig. 44.199C). n  The sac can be transected at this point. If this is done, close the dura with a purse-string suture. Do not suture the cord itself shut but leave it open so that the spinal fluid can escape from the central canal of the cord into the arachnoid space. n  If the sac is not removed, it can be used at the completion of the procedure to further cover the area of the resected vertebra. n  Once the sac has been reflected proximally, continue dissection around the vertebral bodies, exposing only the area to be removed. If the entire kyphotic area of the spine is exposed subperiosteally, osteonecrosis of these vertebral bodies may occur. n  Remove the vertebrae between the apex of the lordosis and the apex of the kyphosis (Fig. 44.199D). Remove the vertebra at the apex of the kyphosis first by removing the intervertebral disc with a Cobb elevator and curets. Take care to leave the anterior longitudinal ligament intact to act as a stabilizing hinge. n  Once this vertebra has been removed, temporarily correct the spine to determine how many cephalad vertebrae should be removed. Remove enough vertebrae to correct the kyphosis as much as possible but not so many that approximation is impossible (Fig. 44.199E). n 

Cauda equina

Quad lumborum

Pedicle Transverse process

Sacrospinalis Lumbodorsal fascia

B

Nerve root Anterior layer Posterior layer

Psoas

FIGURE 44.198 A, Sagittal diagram showing deforming effect of psoas muscle on kyphosis. B, Transverse section of lumbar spine and attached muscles in region of kyphosis. Pedicles and laminae of vertebrae are splayed laterally; erector spinae muscles enclosed in thoracolumbar fascia lie lateral to vertebral bodies and act as flexors.

curve. Others have found that the Warner and Fackler type of sacral anchoring (see Fig. 44.200) provides a rigid construct, good correction, and low-profile instrumentation. That has also been our experience and is our preferred method of sacral anchoring in kyphectomies. Other techniques using a Dunn-McCarthy technique, intrasacral fixation, and pedicle screws also have been described. Although all severe congenital kyphoses in patients with myelomeningocele progress, not all patients require surgery. Kyphectomy is indicated to improve sitting balance or when skin problems occur over the apex. The trend is to delay surgery until the patient is 7 or 8 years of age, if possible. The surgery should be done before skeletal maturity, however. Delaying the surgery allows more secure internal fixation with less postoperative loss of correction. Sarwark reported a subtraction osteotomy of multiple vertebrae at the apex, which creates lordosing osteotomies at each level. The vertebral body is entered and subtracted via the pedicles with a curet, distal to proximal. A closing osteotomy is done posteriorly to obtain correction. The spine is instrumented from the midthoracic level to the sacrum. The reported advantages include less blood loss, decreased morbidity, no need for cordotomy, and continued growth because the endplates are not violated. Smith reported good results in the management of congenital gibbus deformity in the growing child with myelomeningocele using bilateral rib-based distraction

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A

B

D

C

E

F

FIGURE 44.199 Technique of vertebral excision (Lindseth and Selzer). A, Patient positioning. B, Exposure of area of kyphosis and dural sac. C, Sac is divided distally and dissected proximally. D, Vertebrae between apex of lordosis and apex of kyphosis are removed. E, Kyphosis is reduced. F, Reduction is maintained with stable internal fixation (in this instance, with Luque rods and segmental wires). SEE TECHNIQUE 44.61.

Morselization of these vertebral bodies provides additional bone graft. n  Many techniques have been described for fixation of the kyphotic deformity, but L-rod instrumentation to the pelvis with segmental wires is our preferred method (Fig. 44.199F). The distal end of the rod can be contoured. We prefer to use a prebent, right-angled rod and pass the bend through the S1 foramen rather than around the ala of the sacrum. This is the method of Warner and Fackler (Fig. 44.200). n  Move the distal segment to the proximal segment and tighten the segmental wires. n 

POSTOPERATIVE CARE  If fixation is secure, the patient can be mobilized in a wheelchair as tolerated. Some patients in whom the bone is too osteoporotic and the stability of internal fixation is in doubt may be kept at bed rest or may require postoperative custom bracing. The fusion usually is solid in 6 to 9 months.

The postoperative care of these patients requires close observation by all subspecialty consultants involved. Postoperative infections, urinary tract problems, skin problems, and pseudarthrosis are frequent. The improved function, however, and the prevention of progression of the kyphosis make surgery worth the risks.   

Paralytic kyphosis is treated with more standard techniques. When surgery becomes necessary, anterior fusion over the area of the apex and all levels of deficient posterior elements is done. This is followed by posterior fusion and instrumentation.

SACRAL AGENESIS

Sacral agenesis is a rare lesion that often is associated with maternal diabetes mellitus. Renshaw postulated that the condition is teratogenically induced or is a spontaneous genetic

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A

B

C

D

FIGURE 44.200 A-D, Anterior fixation of kyphotic deformity in patients with myelomeningocele. (From Warner WC Jr, Fackler CD: Comparison of two instrumentation techniques in treatment of lumbar kyphosis in myelodysplasia, J Pediatr Orthop 13:704, 1993.) SEE TECHNIQUE 44.61.

mutation that predisposes to or causes failure of embryonic induction of the caudal notochord sheath and ventral spinal cord. The dorsal ganglia and the dorsal (sensory) portion of the spinal cord continue to develop. The vertebrae and motor nerves are not subsequently induced, and the sacral agenesis results. Sensation remains relatively intact because the dorsal ganglia and the dorsal portion of the spinal cord have been derived from the neural crest tissue. This disturbance in the normal sequence of development explains the observation that the lowest vertebral body with pedicles corresponds

closely to the motor level, whereas the sensory level is distal to the motor level. Renshaw proposed the following classification: type I, either total or partial unilateral sacral agenesis (Fig. 44.201A); type II, partial sacral agenesis with partial but bilaterally symmetric defects and a stable articulation between the ilia and a normal or hypoplastic S1 vertebra (Fig. 44.201B); type III, variable lumbar and total sacral agenesis with the ilia articulating with the sides of the lowest vertebra present (Fig. 44.201C); and type IV, variable lumbar and total

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D

FIGURE 44.201 Types of sacral agenesis. A, Type I, total or partial unilateral sacral agenesis. B, Type II, partial sacral agenesis with partial, bilateral symmetric defects in stable articulation between ilia and normal or hypoplastic S1 vertebra. C, Type III, variable lumbar and total sacral agenesis; ilia articulate with lowest vertebra. D, Type IV, variable lumbar and total sacral agenesis; caudal endplate of lowest vertebra rests above fused ilia or iliac amphiarthrosis.

sacral agenesis with the caudal endplate of the lowest vertebra resting above either fused ilia or an iliac amphiarthrosis (Fig. 44.201D). Type II defects are most common, and type I are least common. Types I and II usually have a stable vertebral-pelvic articulation, whereas types III and IV produce instability and possibly a progressive kyphosis. The clinical appearance of a child with sacral agenesis ranges from one of severe deformities of the pelvis and lower extremities to no deformity or weakness whatsoever. Those with partial sacral or coccygeal agenesis may have no symptoms. Those with lumbar or complete sacral agenesis may be severely deformed, with multiple musculoskeletal abnormalities, including foot deformities, knee flexion contractures with popliteal webbing, hip flexion contractures, dislocated hips, spinal-pelvic instability, and scoliosis. The posture of the lower extremities has been compared with a “sitting Buddha” (Fig. 44.202). Anomalies of the viscera, especially in the genitourinary system and the rectal area, are common. Inspection of the back reveals a bone prominence representing the last vertebral segment, often with gross motion between this vertebral prominence and the pelvis. Flexion and extension may occur at the junction of the spine and pelvis rather than at the hips. Neurologic examination usually reveals intact motor power down to the level of the lowest vertebral body that has pedicles. Sensation, however, is present down to more caudal levels. Even patients with the most severe involvement may have sensation to the knees and spotty hypesthesia distally. Bladder and bowel control often is impaired.

TREATMENT

Phillips et al. reviewed the orthopaedic management of lumbosacral agenesis and concluded that patients with partial absence of the sacrum only (types I and II) have an excellent chance of becoming community ambulators. Management of more severe deformities (types III and IV) is more controversial. Scoliosis is the most common spinal anomaly associated with sacral agenesis. No correlation has been found between the type of defect and the likelihood of scoliosis. Scoliosis may be associated with congenital anomalies, such as hemivertebra, or with no obvious spinal abnormality above the level of the vertebral agenesis. Progressive scoliosis or kyphosis requires operative stabilization as for similar scoliosis without sacral agenesis. The treatment of spinal-pelvic instability is more controversial. Perry et al. noted that the key to rehabilitation of a patient with an unstable spinal-pelvic junction is establishment of a stable vertebral-pelvic complex around which lower extremity contractures can be stretched or operatively released. Renshaw also emphasized that patients with type III or type IV defects must be observed closely for signs of progressive kyphosis. If progressive deformity is noted, he recommended lumbopelvic arthrodesis as early as is consistent with successful fusion. In his series, fusion was done in patients 4 years of age or older. Ferland et al. reported successful spinopelvic fusion using vascularized rib grafts, with good outcomes in their patients. Phillips et al., however, found that spinal-pelvic instability was not a problem in 18 of the 20 surviving patients at long-term

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FIGURE 44.202 Severe knee flexion contractures with popliteal wedging and hip flexion deformities or contractures in children with lumbosacral agenesis result in the “sitting Buddha” position.

follow-up. Others noted an actual decrease in the ability to sit after stabilization of the lumbopelvic area. Proper care of patients with sacral agenesis is best provided by a treatment team, including an orthopaedic surgeon, urologist, neurosurgeon, pediatrician, physical therapist, and orthotist-prosthetist. 

UNUSUAL CAUSES OF SCOLIOSIS NEUROFIBROMATOSIS

Neurofibromatosis is a hereditary hamartomatous disorder of neural crest derivation. These hamartomatous tissues may appear in any organ system of the body. The most widely described clinical forms of neurofibromatosis are the peripheral (NF1) and central (NF2) types. The classic neurofibromatosis (NF1) described by von Recklinghausen is an autosomal dominant disorder that affects approximately 1 in 4000 people. Patients with NF1 develop Schwann cell tumors and pigmentation abnormalities. Orthopaedic problems are frequent in patients with this type of neurofibromatosis, with spinal deformity being the most common. Central neurofibromatosis (NF2) also is an autosomal dominant disorder; however, it is much less common. It is characterized by bilateral acoustic neuromas. NF2 usually does not have any bone involvement or orthopaedic manifestations. The diagnosis of NF1 is based on clinical criteria (Box 44.13). Scoliosis is the most common osseous defect associated with neurofibromatosis. Studies have reported spinal disorders in 10% to 60% of patients with neurofibromatosis. The spinal deformities of neurofibromatosis are of two basic forms: nondystrophic and dystrophic. Nondystrophic deformities mimic idiopathic scoliosis and behave accordingly; the neurofibromatosis seems to have little influence on the curve or its treatment. Scoliosis may also develop due to a leg-length discrepancy resulting from lower extremity hypertrophy or dysplasia of the long bones. Dystrophic scoliosis characteristically is a short-segment, sharply angulated curve with wedging of the vertebral bodies, rotation of the vertebrae, scalloping of the vertebral bodies, spindling of the



BOX 44.13

Clinical Criteria for Diagnosis of Neurofibromatosis For the diagnosis of neurofibromatosis to be made, two of the following features are necessary: n A minimum of six café au lait spots larger than 1.5 cm in diameter in a postpubertal patient and larger than 5 mm in diameter in prepubertal patients n Two or more neurofibromas of any type or one plexiform neurofibroma n Freckling in the inguinal or axillary regions n Optic glioma n Two or more iris Lisch nodules by slit-lamp examination n A distinctive osseous lesion n A first-degree relative with a definitive diagnosis of neurofibromatosis

transverse processes, foraminal enlargement, and rotation of the ribs 90 degrees in the anteroposterior direction that makes them appear abnormally thin. Rib penetration into the spinal canal has even been reported. Curves with significant sagittal plane deformity are common in dystrophic scoliosis. Dystrophic curves usually progress without treatment in patients with neurofibromatosis. Lykissas et al. found that the presence of three or more dystrophic features was highly predictive of curve progression and the need for operative stabilization (Fig. 44.203). Neurofibromatosis kyphoscoliosis is characterized by acute angulation in the sagittal plane and striking deformity of the vertebral bodies near the apex. Paraplegia has been reported in patients with this type of kyphoscoliosis. Severe thoracic lordoscoliosis also has been described in patients with neurofibromatosis.

MANAGEMENT OF NONDYSTROPHIC CURVES

Nondystrophic curves have the same prognosis and evolution as do idiopathic curves, except for a higher risk of pseudarthrosis after operative fusion. Dystrophic vertebral body changes may develop over time in nondystrophic curves. A spinal deformity that develops before 7 years of age should

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FIGURE 44.203 A and B, Dystrophic scoliosis. C and D, After posterior thoracic fusion and instrumentation.

be observed closely for potential evolving dystrophic features (modulation). If the curve then acquires either three penciled ribs or a combination of three dystrophic features, clinical progression is almost a certainty. The general guidelines for treating nondystrophic curves are the same as for idiopathic curves other than monitoring closely for any signs of modulation. Curves of less than 20 to 25 degrees are observed; if no dystrophic changes occur, a brace is prescribed when the deformity progresses to 30 degrees. If the deformity exceeds 40 to 45 degrees, a posterior spinal fusion with segmental instrumentation will produce results similar to those obtained in patients with idiopathic scoliosis. Also common in these patients are spinal canal neurofibromas, which may grow and cause pressure-induced dysplasia of the canal. MRI should be done before surgery to rule out the presence of any intraspinal canal neurofibroma. 

MANAGEMENT OF DYSTROPHIC SCOLIOSIS

Brace treatment is probably not indicated for the typical dystrophic curve of neurofibromatosis. Appropriate operative treatment is determined by the presence or absence of a kyphotic deformity and by the presence or absence of neurologic deficits. Before operative treatment of dystrophic curves in patients with neurofibromatosis, the presence of an intraspinal lesion, such as pseudomeningocele, dural ectasia, or intraspinal neurofibroma (dumbbell tumor), should be ruled out. Impingement of these lesions against the spinal cord has been reported to cause paraplegia after instrumentation of these curves. Routine neural axis MRI evaluation in patients with NF1 and spinal deformity should be performed, particularly if surgical intervention is planned. 

SCOLIOSIS WITHOUT KYPHOSIS

Patients with dystrophic scoliosis without kyphosis should be observed at 6-month intervals if the curve is less than 20 degrees. As soon as the progression of the curve is noted, a posterior spinal fusion should be done. If this fusion is done before the curve becomes too large, anterior fusion may not be necessary. Traditionally, combined anterior and posterior fusion has been recommended unless there are contraindications to the anterior approach (e.g., patients with anterior neurofibromas, excessive venous channels, poor medical

condition, or thrombocytopenia caused by splenic obstruction by a fibroma or peculiar anatomic configurations). However, more recent studies have suggested that posterior fusion alone can stabilize curves less than 90 degrees. Curves with kyphosis or with the apex below T8 should be considered for combined anterior and posterior fusion to decrease the rate of pseudarthrosis and curve progression. Segmental hook or screw instrumentation systems provide correction and permit ambulation with or without postoperative bracing. Sublaminar wires can be used to augment the instrumentation, particularly at the proximal end of the construction and across the apex of the curve. The fusion mass must be followed carefully. If there is any question as to the status of the fusion mass, the surgical area is explored 6 to 12 months after surgery and additional autogenous bone grafting is done. Similarly, if progression of more than 10 degrees occurs, the fusion mass is explored and reinforced. In younger patients, growing rods can be used to control the curve until definitive instrumentation and fusion can be done. 

KYPHOSCOLIOSIS

Patients with dystrophic scoliosis and angular kyphosis have been shown to respond poorly to posterior fusion alone. Good results are obtained by combined anterior and posterior fusion. Reasons for fusion failure may include too little bone and too limited an area for fusion; therefore, the entire structural area of the deformity should be fused anteriorly. Ideally, all anterior grafts should be in contact throughout with other grafts or with the spine. Grafts surrounded by soft tissue tend to be resorbed in the midportion. Early diagnosis and treatment by combined anterior and posterior fusion with internal fixation, if possible, is recommended. If anterior fusion is necessary for kyphoscoliotic deformities, vascularized rib graft augmentation as described by Bradford (Fig. 44.204) may be considered. However, some authors have questioned the necessity of an anterior approach in all dystrophic kyphoscoliotic curves. For smaller dystrophic scoliosis with kyphosis of less than 40 degrees, posterior spinal instrumentation with arthrodesis is considered as soon as possible. The fusion mass should be explored at 6 to 12 months after surgery or sooner if progression of more than 10 degrees occurs. 

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A

B

FIGURE 44.204 A and B, After anterior fusion with vascularized rib graft in patient with dystrophic kyphoscoliosis.

KYPHOSCOLIOSIS WITH SPINAL CORD COMPRESSION

Spinal cord or cauda equina compression caused by spinal angulation, rib penetration, or tumor has been described. Cord compression caused by an intraspinal lesion must be distinguished from kyphotic angular cord compression by MRI. Patients with severe scoliosis without significant kyphosis and with evidence of paraplegia should be assumed to have an intraspinal lesion until proved otherwise. If cord compression is caused by kyphoscoliotic deformity, laminectomy is contraindicated. Removal of the posterior elements adds to the kyphosis and also removes valuable bone surface for a posterior fusion. If spinal cord compression is minor and no intraspinal tumor is present, halo-gravity traction can be used. The patient’s neurologic status must be monitored carefully even if the kyphosis is mobile. As the alignment of the spinal canal improves and the compression is eliminated, anterior and posterior fusions can be done without direct observation of the cord. However, significant cord compression in patients with severe structural kyphoscoliosis requires anterior cord decompression. If a tumor causes spinal cord compression anteriorly, anterior excision, spinal cord decompression, and fusion are indicated. If the lesion is posterior, a hemilaminectomy with tumor excision may be necessary. Instrumentation and fusion should be done at the time of decompression to prevent a rapidly increasing kyphotic deformity and neurologic injury. 

POSTOPERATIVE MANAGEMENT

Patients with nondystrophic curves are managed the same as those with idiopathic curves. If, however, the instrumentation is tenuous, casting or bracing is used. However, patients with dystrophic scoliosis should be considered for immobilization in a cast or brace until fusion is evident on anteroposterior,

lateral, and oblique radiographs. Exploration of the fusion mass at 6 to 12 months after surgery may be necessary in dystrophic curves, and prolonged immobilization often is needed. Even after the fusion is solid, the patient should be observed annually to be certain that no erosion of the fusion mass is occurring. 

COMPLICATIONS OF SURGERY

In addition to the complications inherent in any major spinal surgery, several complications are related to the neurofibromatosis. Plexiform venous anomalies can be present in the soft tissues surrounding the spine and can impede the operative approach to the vertebral bodies, leading to excessive bleeding. The increased vascularity of the neurofibromatous tissue itself also may increase blood loss. The apical bodies may have subluxed into bayonet apposition or be so rotated that they no longer are in alignment with the rest of the spine. Anterior strut grafts are no longer commonly used. Pheochromocytoma, a tumor arising from chromaffin cells, can be associated with neurofibromatosis and can create an anesthetic challenge. Patients with neurofibromatosis have a general tendency for decreased bone mineral density and osteopenia, possibly increasing the challenge of obtaining stable implant fixation to the spine. Many patients with neurofibromatosis and scoliosis have cervical spine abnormalities (Fig. 44.205). Deformities of the cervical spine that cause cord compression and paraplegia have been reported in patients with neurofibromatosis. Cervical lesions associated with scoliosis or kyphoscoliosis have been classified into two groups: abnormalities of bone structure and abnormalities of vertebral alignment. Cervical anomalies are most common in patients with short kyphotic curves or thoracic or lumbar curves that measure more than 65 degrees. These patients are more likely to require anesthesia,

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B FIGURE 44.205

A and B, Cervical spine deformity in patient with neurofibromatosis.

traction, and operative stabilization of the spine. Routine radiographic evaluation of the cervical spine is recommended in all patients with neurofibromatosis before anesthesia for any reason and before traction for treatment of the scoliosis. High-grade spondylolisthesis of the lower lumbar spine also has been reported in association with neurofibromatosis. The entire spinal column must be carefully assessed for cervical and lumbosacral abnormalities. Postoperative paralysis caused by contusion of the spinal cord by the periosteal elevator during exposure has been reported in two patients with unsuspected areas of laminar erosion because of dural ectasia. A total-spine MRI study can alert the surgeon to this before surgery. The most dangerous situation for neurologically intact patients with neurofibromatosis is instrumentation and distraction of the spine in the presence of unrecognized intraspinal lesions. 

MARFAN SYNDROME

Marfan syndrome is a disorder of connective tissue inherited as an autosomal dominant trait. It occurs in 1 to 2 per 10,000 persons and affects males and females equally. Sporadic occurrences reportedly account for 25% of patients. In most cases, a mutation in the fibrillin-1 (FBN1) gene has been implicated, resulting in abnormalities in a protein essential to proper formatting of elastic fibers found in connective tissue.

DIAGNOSIS

In addition to genetic testing, the diagnosis of Marfan syndrome relies on physical findings, which have traditionally been divided into two categories: major and minor signs. Major signs include ectopia lentis, aortic dilation, severe kyphoscoliosis, and pectus deformity. Minor signs include myopia, tall stature, mitral valve prolapse, ligamentous laxity, and arachnodactyly. Newer diagnostic criteria place greater weight on cardiovascular manifestations; therefore, in the absence of a family history, the presence of both aortic root aneurysm and ectopia lentis is sufficient for the unequivocal diagnosis of Marfan syndrome. Screening tests for the Marfan phenotype in the orthopaedic examination include the thumb sign (the thumb extends well beyond the ulnar border of the hand when it is overlapped by the fingers) and the

wrist sign (the thumb overlaps the fifth finger as the patient grasps the opposite wrist). The diagnosis of Marfan syndrome frequently is delayed because cardiovascular involvement is a major diagnostic criterion and may not be evident until adolescence or adulthood. Scoliosis is reported to occur in 40% to 60% of patients with Marfan syndrome. These curves develop in patients with multiple major signs (definite diagnosis of Marfan), as well as those with only minor signs (Marfan phenotype). Marfan curves of less than 40 degrees in adults tend not to progress, whereas curves of more than 40 degrees progress (an average of 2.8 degrees a year in a study by Sponseller et al.); the curve patterns of scoliosis in Marfan syndrome are similar to those in idiopathic scoliosis. Double major curves are more frequent, and the scoliosis progresses more frequently in younger patients. Disabling back pain is more frequently a presenting complaint in patients with scoliosis associated with Marfan syndrome than in patients with idiopathic scoliosis. Sagittal plane deformities are common (Fig. 44.206). A thoracolumbar kyphosis can be found in patients with Marfan syndrome (Fig. 44.207). Characteristic vertebral anomalies also are found in these patients, including narrow pedicles, wide transverse processes, and vertebral scalloping. Spondylolisthesis associated with Marfan syndrome also has been reported in one study. Cervical spine abnormalities also are common in patients with Marfan syndrome, but clinical problems from these abnormalities are rare. Basilar impression and focal cervical kyphosis are the most commonly reported cervical spine abnormalities. The focal cervical kyphosis usually is associated with a lordotic thoracic spine. 

NONOPERATIVE TREATMENT OBSERVATION

For young patients with small curves of less than 25 degrees, observation every 3 to 4 months is indicated. The family should be made aware, however, that many of these curves progress. 

ORTHOTIC TREATMENT

Brace treatment is less successful in patients with Marfan syndrome than in those with idiopathic scoliosis. Sponseller et al.

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A

B FIGURE 44.206

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A and B, Thoracic lordosis in patient with Marfan syndrome.

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FIGURE 44.207 A and B, Lateral radiographs of 17-year-old child with Marfan syndrome and 40-degree progressive thoracolumbar kyphosis. C, Lateral radiograph of same patient 3 years later shows that thoracolumbar kyphosis has progressed to 110 degrees. (From Warner WC: Kyphosis. In Morrissy RT, Weinstein SL, editors: Lovell and Winter’s pediatric orthopaedics, ed 6, Philadelphia, 2006, Lippincott Williams & Wilkins.)

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OPERATIVE TREATMENT

If progression occurs despite bracing or if the curve exceeds 40 degrees, spinal fusion is recommended. If nonoperative treatment is continued too long, cardiovascular involvement may progress to the point of making surgery dangerous, if not impossible. Before operative intervention is considered, a complete cardiovascular evaluation is mandatory. Aortic dilation can develop in these patients at any time from childhood to late adolescence or adulthood. Echocardiography is recommended to evaluate for aortic root dilation. Any evidence of aortic dilation should be treated medically or operatively before treatment of the spinal deformity. Scoliosis in patients with Marfan syndrome can be corrected similar to the way it is corrected in idiopathic scoliosis, and solid fusion and maintenance of correction can be anticipated; however, Jones et al. and Gjolaj et al. found that the number of surgical complications was higher in patients with Marfan syndrome. Complications included increased blood loss, pseudarthroses (10%), dural tears (8%), infection (10%), and failure of fixation (21%). The development of scoliosis or kyphosis at the upper or lower fusion levels (adding on) can occur after surgery. Jones et al. found this complication to occur in the coronal plane in 8% of their patients and in the sagittal plane in 21%. Large bone grafts, secure segmental internal fixation, and careful postoperative observation for pseudarthrosis are required in these patients. In general, the technique of instrumentation and selection of hook or screw levels are the same as for idiopathic scoliosis, but selection of the lowest instrumented vertebrae is ideally the neutral and stable vertebra in both the coronal and sagittal planes. Jones et  al. recommended that any curve of more than 30 degrees should be included in the arthrodesis. As with all scoliotic deformity correction, care must be taken in determining the distal extent of the fusion to avoid junctional kyphosis. Thoracic lordosis is relatively common in patients with Marfan syndrome and spinal deformity, and sagittal plane balance must be obtained in addition to improvement of the coronal plane deformity. Segmental instrumentation systems using hooks and pedicle screws or all pedicle screws are effective in correcting this problem. Surgical treatment should provide a more normal anteroposterior diameter of the chest, because this frequently is narrow. Growing rod constructs have been used with success for patients with Marfan syndrome with early-onset scoliosis for which definitive spinal fusion is not possible because of skeletal immaturity. Dual rod constructs are recommended. Because these children will require multiple lengthening procedures, careful monitoring of the cardiovascular manifestations of Marfan syndrome is essential. Severe spondylolisthesis associated with Marfan syndrome has been reported. It has been postulated that the spondylolisthesis may be more likely to progress because of poor musculoligamentous tissues. 

VERTEBRAL COLUMN TUMORS

Because of their variable presentation, tumors of the vertebral column often present diagnostic problems. A team composed of a surgeon, a diagnostic radiologist, a pathologist, and often a medical oncologist and radiotherapist is necessary for treatment of the spectrum of tumors that involve the spine. The discussion in this section is on the most common primary tumors of the vertebral column in children.

CLINICAL FINDINGS

A complete history is the first step in the evaluation of any patient with a tumor. The initial complaint of patients with tumors involving the spine generally is pain. The exact type and distribution of pain vary with the anatomic location of the pathologic process. In general, pain caused by a neoplasm is not relieved by rest and often is worse at night. On occasion, constitutional symptoms such as anorexia, weight loss, and fever may be present. The age and sex of the patient may be important in the differential diagnosis. Physical examination should include a general evaluation in addition to careful examination of the spine. The tumor may produce local tenderness, muscle spasm, scoliosis, and limited spine motion. Painful scoliosis can be the result of a spinal tumor. In such cases, the tumor is usually located at the concavity of the curve. Spine deformity also may be secondary to vertebral collapse or muscular spasms caused by pain. More than 50% of patients with malignant tumors of the spine present with neurologic symptoms. A careful neurologic examination is essential. Laboratory studies should include a complete blood cell count, urinalysis, and sedimentation rate, as well as determination of serum calcium, phosphorus, and alkaline phosphatase concentrations. Alkaline phosphatase may be elevated two to three times normal in patients with osteosarcoma. Lactate dehydrogenase is a reliable indicator of the tumor burden in patients with Ewing sarcoma. An elevated white blood cell count with thrombocytopenia is characteristic of leukemia. Further laboratory studies may be indicated based on the clinical course. 

RADIOGRAPHIC EVALUATION AND TREATMENT

Radiographs of the spine should be made in at least two planes at 90-degree angles. The radiographs should be evaluated for the presence of scoliosis, kyphosis, loss of lumbar lordosis, destruction of pedicles, congenital vertebral anomalies, lytic lesions, altered size of neural foramina, abnormal calcifications, and soft-tissue masses. If a scoliotic curve is present, the curve usually shows significant coronal decompensation. There is an absence of the usual compensatory balancing curve above or below the curve containing the lesion. The scoliosis lacks the usual structural characteristics associated with idiopathic scoliosis, such as vertebral rotation and wedging. Curves with these characteristics should raise the index of suspicion for an underlying cause of the scoliosis. Bone scanning is helpful in certain tumors of the spine, especially osteoid osteoma. CT has greatly improved evaluation of the extent of the lesion and the presence of any spinal canal compromise; sagittal and coronal reformatted images are necessary to define the exact anatomic location and extent of the lesion. MRI is useful in evaluating the extent of softtissue involvement of the tumor and for determining the level

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Left Spinous process

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FIGURE 44.208 A, Weinstein-Boriani-Biagini tumor classification system. Vertebra is divided into 12 radiating zones that are numbered clockwise, beginning at one half of spinous process. Concentric layers are lettered sequentially from extraosseous soft tissues to intradural space. B, The Spine Oncology Study Group modified classification by numbering radial zones in counterclockwise fashion, beginning at left half of spinous process to allow for more anatomic orientation of diagram for ease of use. Circled letters: A, extraosseous soft tissues; B, intraosseous (superficial); C, intraosseous (deep); D, extraosseous (extradural); E, extraosseous (intradural). (A redrawn from Boriani S, Weinstein JN, Biagini R: Primary bone tumors of the spine: terminology and surgical staging, Spine 22:1036, 1997. B redrawn from Chan P, Boriani S, Fourney DR, et al: An assessment of the reliability of the Enneking and Weinstein-Boriani-Biagini classifications for staging of primary spinal tumors by the Spine Oncology Study Group, Spine 34:384, 2009.)

and extent of neurologic compromise in patients with a neurologic deficit. Arteriography may be indicated to evaluate the extent of the tumor and to localize major feeder vessels. Surgical staging classification systems specific to spine tumors have been designed to guide treatment and aid in defining the prognosis. The surgical staging systems proposed by Boriani et al. and Tomita et al. were devised to aid in surgical planning and are used to delineate the margins of the tumor. The Weinstein-Boriani-Biagini (WBB) classification is an alphanumeric system that can be used to evaluate the extent of a lesion in the axial plane by dividing the vertebrae into 12 radial zones and five concentric layers with a designation for the presence of metastasis (Fig. 44.208). The Spine Oncology Study Group modified this system by orienting the diagram to correspond to the orientation of the vertebrae on axial tomograms. The tumor is reported according to the spinal level or levels affected in the cephalocaudal dimension. The method of surgical excision is based on the zone or zones that the tumor occupies. Tomita et al. classified tumors based on their anatomic location in the axial and sagittal planes using a numeric system that reflects the most common progression of tumor growth (Figs. 44.209 and 44.210); this classification is used to guide surgical management. 

BIOPSY

Certain tumors, such as osteochondroma and osteoid osteoma, generally can be diagnosed by their clinical presentation and radiographic appearance. Other benign tumors, such as osteoblastoma, aneurysmal bone cyst, and giant cell tumors, often are difficult to diagnose preoperatively. Biopsy is the ultimate diagnostic technique for evaluating neoplasms. The

biopsy may be incisional (removal of a small portion of the tumor) or excisional (removal of the entire tumor). Percutaneous CT-guided needle biopsy is an excellent diagnostic tool. Ghelman et  al. obtained histologic diagnoses in 85% of 76 biopsy specimens, and Kattapuram, Khurana, and Rosenthal obtained accurate diagnoses in 92%. Metastatic diseases were most often diagnosed accurately (95%), and benign primary tumors were diagnosed least often (82%). Fine-needle cytologic aspirates are satisfactory for diagnosis of metastatic disease and most infections, but large-core biopsy specimens are preferable for primary bone tumors. 

 

OPEN BIOPSY OF THORACIC VERTEBRA If the needle biopsy is not diagnostic, an open biopsy or transpedicular biopsy will yield more tissue. Care must be taken that the open biopsy does not interfere with the definitive surgery if total resection is anticipated.

TECHNIQUE 44.62 (MICHELE AND KRUEGER) With the patient prone, make an incision over the side of the spinous process of the involved vertebra. n  Retract the muscles and expose the transverse process. n  Perform an osteotomy at the base of the transverse process at its junction with the lamina (Fig. 44.211A). n 

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PART XII  THE SPINE By depressing or retracting the transverse process, expose the isthmus of the vertebra, revealing the cancellous nature of its bone structure. Radiographic verification of the level is important. n  Insert a 3/16-inch trephine with ¼-inch markings through the fenestra and guide it downward with slight pressure so that a mere twisting action leads the trephine into the pedicle and finally into the body (Fig. 44.211B). Remove the trephine repeatedly and in each instance check that the contents consist of cancellous bone, which indicates that the trephine is in the medullary substance of the pedicle and has created a channel from the posterior elements directly into the vertebral body. n 

3

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BENIGN TUMORS OF THE VERTEBRAL COLUMN

The most common benign tumors of the vertebral column in children are osteoid osteoma, osteoblastoma, aneurysmal bone cyst, eosinophilic granuloma, and hemangioma.

OSTEOID OSTEOMA

5

4

Remove the pathologic tissue with a small blunt curet. Alternatively, after the osteotomy of the base of the transverse process, expose the vertebral body by retracting the transverse process and depressing the adjacent rib to expose the junction of the pedicle and the body. n  Use the trephine to penetrate this junction at an angle of 45 degrees toward the midline and remove the material with a curet (Fig. 44.211C).    n 

4

B

FIGURE 44.209 Axial (A) and lateral (B) illustrations of Tomita anatomic classification of primary spinal malignant tumors. Lesions are classified by their location on vertebra using numeric scheme that reflects most common progression of tumor growth: 1, vertebral body; 2, pedicle; 3, lamina and transverse and spinous processes; 4, spinal canal and epidural space; and 5, paravertebral space. (Redrawn from Tomita K, Kewahara N, Baba H, et al: Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors, Spine 22:324, 1997.)

Intracompartmental

Osteoid osteoma is a benign growth that consists of a discrete osteoid nidus and reactive sclerotic bone thickening around the nidus. No malignant change of these tumors has ever been documented. The lesion occurs more frequently in males than in females. Spinal lesions occur predominantly in the posterior elements of the spine, especially the lamina and the pedicles. Osteoid osteoma of the vertebral body has been reported but is rare. The lumbar spine is the most frequently involved area. Typically, patients with spinal osteoid osteoma have pain that is worse at night and relieved by aspirin. The pain increases with activity and often is localized to the site of the lesion. Radicular symptoms are especially common with lesions of the lumbar spine. Lesions in the cervical spine can produce radicular-type symptoms in the shoulders and arms, but the results of the neurologic examination usually are normal. Physical examination reveals muscle spasm in the involved area of the spine. The patient’s gait may be abnormal

Extracompartmental

Type 1 Vertebral body

Type 4 Epidural extension

Type 2 Pedicle extension

Type 5 Paravertebral extension

Type 3 Body-lamina extension

Type 6 2–3 vertebrae

Multiple

Type 7

FIGURE 44.210 Tomita surgical classification of spinal tumors. Tumor types are categorized based on the number of vertebral areas affected. (Redrawn from Tomita K, Kewahara N, Baba H, et al: Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors, Spine 22:324, 1997.)

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS because of pain, and localized tenderness over the tumor may be moderate to severe. Osteoid osteoma is the most common cause of painful scoliosis in adolescents. The scoliosis associated with osteoid osteoma usually is described as a C-shaped curve, but only 23% to 33% of patients have this classic curve pattern. The

A

B

osteoid osteoma usually is located on the concave side of the curve and in the area of the apical vertebra. When the osteoid osteoma is visible on plain radiographs, its appearance is diagnostic—a central radiolucency with a surrounding sclerotic bony reaction; however, the lesion often is not visible on plain films. Technetium bone scanning should be considered in any adolescent with painful scoliosis (Fig. 44.212A). False-negative bone scans have not been reported in patients with osteoid osteoma of the spine. MRI scans will show increased signal changes. CT with very narrow cuts will precisely define the location of the tumor and the extent of the osseous involvement (Fig. 44.212B). Patients with spinal tumors and scoliosis reach a critical point after which the continuation of a painful stimulus results in structural changes in the spine. Pettine and Klassen found that 15 months is the critical duration of symptoms if antalgic scoliosis is to undergo spontaneous correction after excision of the tumor. Although the natural course of many osteoid osteomas is spontaneous remission, spinal lesions in children or adolescents should be removed when they are diagnosed to prevent the development of structural scoliosis. The operative treatment of an osteoid osteoma is complete removal; recurrence is likely after incomplete removal. If pain and deformity persist after removal of the lesion, incomplete removal or perhaps a multifocal lesion should be suspected. Exact localization of the tumor is imperative. The O-arm or intraoperative navigation will allow intraoperative localization of the lesion. Excision of these lesions usually does not require spinal fusion, but if removal of a significant portion of the facet joints and pedicles makes the spine unstable, spinal fusion can be done at the time of tumor removal. Surgical navigation systems such as the O-arm can be used intraoperatively to evaluate the adequacy of resection. This is the preferred method if it is available in the treating institution. Radiofrequency ablation of osteoid osteoma of the spine is not recommended. 

OSTEOBLASTOMA

C FIGURE 44.211 A, Transverse osteotomy at base of thoracic transverse process. B, Trephine through fenestra of isthmus, into pedicle and body. C, Trephine inserted into body at junction of pedicle. SEE TECHNIQUE 44.62.

A FIGURE 44.212

Most authors believe that osteoid osteoma and osteoblastoma are variant manifestations of a benign osteoblastic process, resulting in an osteoid nidus surrounded by sclerotic bone. The lesions are histologically similar. The primary difference is the tendency of the osteoblastoma to form a less sclerotic

B Bone scan (A) and CT scan (B) of patient with spinal osteoid osteoma.

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ANEURYSMAL BONE CYSTS

An aneurysmal bone cyst is a nonneoplastic, vasocystic tumor originating on either a previously normal bone or a preexisting lesion. It is most common in children and young adults, and vertebral involvement is common. Its radiographic appearance is characteristic—an expansile lesion confined by a thin rim of reactive bone. The lesion can occur in the vertebral body but is more commonly seen in the posterior elements of the spine. An aneurysmal bone cyst is the only benign tumor that can cross the disc and involve more than one spinal level. Pain is the most common symptom, and radicular symptoms may be caused by cord compression. Treatment is operative excision whenever possible. The tumors can be quite vascular, and if operative resection is contemplated, preoperative embolization should be considered. Embolization should be done in addition to the operative excision, and vessels supplying important segments of the spinal cord or brain should not be embolized. The indications for embolization are benign vascular tumors in central locations. In one study, three of the four tumors that were embolized were aneurysmal bone cysts. Contraindications include avascular tumors and tumors supplied by vessels that also supply important segments of the spinal cord because embolization of these vessels may infarct the spinal cord. Good clinical results have been reported after arterial embolization; however, the major disadvantage is the need for repeated procedures and repeated CT scans and angiography. Radiation

A

B FIGURE 44.213 Radiograph (A) and CT scan (B) of patient with osteoblastoma on right side of spine that caused left thoracic curve.

therapy should be used only in those lesions that cannot be operatively excised. Many patients with aneurysmal bone cysts of the vertebral column have neurologic symptoms (30%), including complete or incomplete paraplegia or root signs or symptoms. When these neurologic symptoms occur, complete excision of the aneurysmal bone cyst with decompression of the spinal canal is indicated. The approach, whether anterior, posterior, or combined anterior and posterior, is dictated by the location of the lesion. 

EOSINOPHILIC GRANULOMA

Eosinophilic granuloma in childhood usually is a solitary lesion. The cause of this lesion, which may not represent a true neoplasm, is unknown. Approximately 10% involve the spine. Eosinophilic granuloma may produce varying degrees of vertebral collapse, including the classic picture of a vertebra plana (Fig. 44.214). Considerable collapse of the vertebral body may occur without neurologic compromise, and significant reconstitution in height may occur after treatment (Fig. 44.215). Bone scan may show increased uptake. A lytic radiographic image without vertebra plana with normal bone scan uptake probably is a benign lesion, but biopsy must still be done. The differential diagnoses include aneurysmal bone cyst, acute leukemia, metastatic neuroblastoma, Ewing

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FIGURE 44.214 Eosinophilic granuloma in a 10-year-old child resulting in vertebra plana at T4. A and B, Radiographic appearance. C, Appearance on sagittal MRI.

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FIGURE 44.215 A, Eosinophilic granuloma of spine in 3½-year-old patient. B, Sudden collapse of T12 3 weeks later, in addition to vertebra plana at L2. C, Collapse of T12 and L2. D and E, Considerable reconstitution of the vertebral height of T12 and L2 16 months later. (From Seiman LP: Eosinophilic granuloma of the spine, J Pediatr Orthop 1:371, 1981.)

sarcoma, or multifocal osteomyelitis. MRI can be helpful in distinguishing eosinophilic granuloma from a malignant neoplasm. Eosinophilic granuloma will most often not have a prominent soft-tissue mass associated with the vertebral collapse. A malignant tumor, such as Ewing sarcoma, often has extensive soft-tissue involvement. The treatment of vertebra plana generally focuses on relief of symptoms. The usual result is spontaneous healing. Spinal deformity may be minimized by the use of an appropriate orthosis. Other reported treatment alternatives include curettage and bone grafting, radiotherapy, and interlesional instillation of corticosteroids, but they rarely are needed. 

HEMANGIOMA

Hemangioma is the most common benign vascular tumor of bone. Most hemangiomas involve the vertebral bodies or skull, and involvement of other bones is rare. Vertebral involvement usually is an incidental finding and requires surgery only when neurologic function is compromised (Fig. 44.215C). Hemangioma has been reported in as many

as 12% of spines studied by autopsy. The lesion usually produces a characteristic, vertical, striated appearance (Fig. 44.216A,B). Laredo et al. divided vertebral hemangiomas into three subcategories. The most common is the asymptomatic vertebral hemangioma; the second is a compressive vertebral hemangioma that compresses the cord or cauda equina; and the third is the rare vertebral hemangioma that causes clinical symptoms (symptomatic vertebral hemangioma). Six radiographic criteria were noted that were indicative of vertebral hemangioma leading to compressive problems: thoracic location (from T3 to T9), entire vertebral body involvement, neural arch (particularly pedicles) involvement, irregular honeycomb appearance, expanded and poorly defined cortex, and swelling of the soft tissue. It was suggested in patients with vertebral hemangioma and back pain of uncertain origin that the presence of three or more of these signs may indicate a potentially symptomatic vertebral hemangioma. Laredo et  al. also compared MRI findings in asymptomatic and symptomatic vertebral hemangiomas. They found that vertebral hemangiomas with low-signal intensity on T1-weighted

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FIGURE 44.216 Radiograph (A), CT scan (B), and MRI (C) of patient with spinal hemangioma with canal compromise.

images had a significant vascular component, which might have been a major contributing factor to the patient’s symptoms. Most vertebral hemangiomas contained predominant fat attenuation values on CT and showed high-signal intensity on T1-weighted imaging, indicating a predominantly fatty content. These researchers emphasized, however, as has been our experience, that most vertebral hemangiomas are not symptomatic and are an incidental finding. If neurologic dysfunction and anterior collapse occur, operative excision of the lesion, perhaps with adjuvant embolization as described by Dick et al., is recommended. 

PRIMARY MALIGNANT TUMORS OF THE VERTEBRAL COLUMN

Primary malignant tumors of the vertebral column are uncommon. In children, the most common are Ewing sarcoma and osteogenic sarcoma.

EWING SARCOMA

Ewing sarcoma is a relatively rare, primary malignant tumor of bone. The tumor occurs most frequently in males in the second decade of life. All bones, including the spine, may be affected. The tumor most commonly begins in the pelvis or long bones and rapidly metastasizes to other skeletal sites, including the spine, especially the vertebral bodies and pedicles. The currently recommended treatment of Ewing sarcoma is radiotherapy and adjuvant chemotherapy. On occasion, surgery may be necessary to stabilize the spine because of compression of the neural elements and bony instability. If decompression of the neural elements is necessary, stabilization usually is needed at the same time. 

OSTEOGENIC SARCOMA

Osteogenic sarcoma is the most common primary malignant bone tumor, excluding multiple myeloma, but less than 2% originate in the spine. It is a malignant tumor of bone in which tumor cells form neoplastic osteoid or bone, or both. Classic osteogenic sarcoma is more common in boys 10 to 15 years of age. This is a rapidly progressive malignant neoplasm, and multiple metastatic lesions to the vertebral column are more common than primary involvement (Fig. 44.217). The role of surgery for vertebral involvement is based on whether the spinal lesion is solitary, primary, or metastatic. If decompression of the spinal cord becomes necessary, or if structural

A

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FIGURE 44.217 A, Osteogenic sarcoma in a 14-year-old child. B, After tumor resection and stabilization.

integrity of the vertebral column is compromised, stabilizing procedures usually are required. If aggressive operative debridement is required, the neural structures limit the margin of the resection, making it impossible to achieve as wide a margin of resection as in the extremities. 

POSTIRRADIATION SPINAL DEFORMITY

Perthes in 1903 first described inhibition of osseous development by irradiation. Later studies indicated that the physis is particularly sensitive to radiation. A physis exposed to 600 rad or more showed some growth retardation, and complete inhibition of growth was produced by doses of more than 1200 rad. The longitudinal growth of a vertebral body takes place by means of true physeal cartilage, similar to the longitudinal growth of the metaphysis of the long bones. The three most common solid tumors of childhood for which radiation therapy is part of the treatment regimen and in which the vertebral column is included in the radiation fields are neuroblastoma, Wilms tumor, and medulloblastoma.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS

INCIDENCE

Mayfield et  al. studied spinal deformity in children treated for neuroblastoma, and Riseborough et  al. studied spinal deformity in children treated for Wilms tumor. Several principles can be summarized from these studies. A direct relationship seems to exist between the amount of radiation and the severity of the spinal deformity. In general, a dose of less than 2000 rad is not associated with significant deformity, a dose between 2000 and 3000 rad is associated with mild scoliosis, and a dose of more than 3000 rad is associated with more severe scoliosis. Irradiation in younger children, especially those 2 years of age or younger, produces the most serious disturbance in vertebral growth. Radiation treatment in children older than 4 years is less frequently associated with spinal deformity. Asymmetric irradiation is associated with significant spinal deformity. Progression usually occurs during the adolescent growth spurt. Scoliosis is a common deformity, and the direction of the curve usually is concave toward the side of the irradiation. Kyphosis may occur in association with the scoliosis, or kyphosis alone may be present, most frequently at the thoracolumbar junction. Children who require a laminectomy because of epidural spread of tumor are especially prone to the development of moderateto-severe spinal deformity. Similarly, those children whose disease causes paraplegia also are prone to rapid progression of the deformity. Without these two complicating features, most radiation-induced scoliotic deformities remain small and do not require treatment. Because progression of these curves generally occurs during the adolescent growth spurt, any child undergoing radiation therapy to the spine should have orthopaedic consultation and regular follow-up until skeletal maturity. 

FIGURE 44.218 “Bone-in-bone” appearance of irradiated spine, equivalent of growth arrest line in long bone. (From Katzman H, Waugh T, Berdon W: Skeletal changes following irradiation of childhood tumors, J Bone Joint Surg 51A:825, 1969.)

RADIOGRAPHIC FINDINGS

Neuhauser et al. described the radiographic changes in previously irradiated spines, and Riseborough et al. divided the radiographic findings into four groups. The earliest noted changes were alterations in the vertebral bodies within the irradiated section of the spine, which are expressions of irradiation impairment of physeal enchondral growth at the vertebral endplates. The most obvious features of these lesions were growth arrest lines that subsequently led to the bone-inbone picture (28%) (Fig. 44.218). Endplate irregularity with an altered trabecular pattern and decreased vertebral body height were seen most frequently (83% of patients). Contour abnormalities, causing anterior narrowing and beaking of the vertebral bodies, such as those seen in Morquio disease (Fig. 44.219), were present in 20% of patients. Asymmetric or symmetric failure of vertebral body development was apparent on the anteroposterior radiographs of all 81 patients studied. The second group of radiographic changes included alterations in spinal alignment. Scoliosis was present in 70% of patients and kyphosis in 25%. The third group of radiographic findings included skeletal alterations in bones other than the vertebral column, the most common of which were iliac wing hypoplasia (68%) and osteochondroma (6%). The fourth group consisted of patients with no evidence of deformity of the axial skeleton (27%). 

TREATMENT

Most studies indicate that the curves usually remain slight until the adolescent growth spurt, when progression can be severe and rapid. Orthoses for treatment of postirradiation

FIGURE 44.219 Contour abnormalities of vertebral bodies after radiotherapy for Wilms tumor in 8-month-old patient. (From Katzman H, Waugh T, Berdon W: Skeletal changes following irradiation of childhood tumors, J Bone Joint Surg 51A:825, 1969.)

spinal deformity may or may not (50%) improve or stop progression of the deformity, especially if severe changes in the architecture of the vertebrae and excessive soft-tissue scarring are present. The indications for operative treatment are a scoliosis of more than 40 degrees and a thoracolumbar kyphosis of more than 50 degrees. Patients with progression despite brace treatment also are considered candidates for operative intervention. Riseborough et al. outlined the difficulties in obtaining adequate correction and fusion of these curves,

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PART XII  THE SPINE which frequently are rigid. Extensive soft-tissue scarring may further complicate the surgery. Many patients requiring operative treatment have a kyphoscoliotic deformity, and many also have had previous laminectomies, which will inhibit solid fusion. Healing can be prolonged, and pseudarthrosis is common. Combined anterior and posterior fusions with an anterior strut graft or anterior interbody fusion and posterior instrumentation should be considered for patients with kyphotic deformities of more than 40 degrees. Because of the unpredictable nature of the irradiated anterior bone stock, anterior instrumentation may not be possible. Segmental hook or screw instrumentation systems, with their ability to apply both compression and distraction, are ideal for posterior instrumentation in these patients. If irradiation was for a tumorous process, consideration should be given to titanium implants, which would allow better follow-up MRI, if necessary. The fusion area is selected by the same criteria as for idiopathic curves (see earlier section on fusion levels and hook site placement). A large quantity of bone from the nonirradiated iliac crest should be used. Ogilvie suggested exploration of the fusion 6 months after surgery for repeated bone grafting of any developing pseudarthrosis. Because of problems with bone stock, postoperative immobilization in a TLSO often is indicated until complete fusion is obtained. 

COMPLICATIONS AND PITFALLS

Pseudarthrosis, infection, and neurologic injury are more frequent after spinal fusion for radiation-induced deformity than for other spinal deformities. The increase in pseudarthrosis is attributed to poor bone quality, decreased bone vascularity, kyphotic deformity, and absence of posterior bone elements after laminectomy. Poor vascularity and skin quality have been associated with an increased infection rate. Severe scarring sometimes is present in the retroperitoneal space, making the anterior exposure more difficult. Because viscera can be damaged by radiation, bowel obstruction, perforation, and fistula formation may occur after spinal fusion. This can be difficult to differentiate from postoperative cast syndrome. Paraplegia also has been reported in patients who had radiation treatment for neuroblastoma and surgical correction. It is believed that they had a subclinical form of radiation myelopathy and that spinal correction compromised what little vascular supply there was to the cord. The surgeon should be aware of this possibility and avoid overcorrection of these kyphotic deformities. 

OSTEOCHONDRODYSTROPHY DIASTROPHIC DWARFISM

Diastrophic dwarfism is inherited as an autosomal recessive disease. The diagnosis usually can be made at birth on the basis of clinical features and, for families at risk, before birth by ultrasound examination and molecular genetic testing. Clinical and radiographic findings are short limbs, short stature, multiple joint contractures, and early degeneration of joints. Spinal deformities, including cervical kyphosis, scoliosis, and exaggerated lumbar lordosis, often are seen. Remes et  al. found scoliosis in 88% of patients with diastrophic dwarfism. They subdivided the scoliotic curves into three subtypes: early progressive, idiopathic-like, and mild nonprogressive. The early progressive type resembled the progressive form of infantile idiopathic scoliosis, with early onset,

rapid progression, and severe outcome. Patients with the idiopathic-like scoliosis had features similar to patients with adolescent idiopathic scoliosis. The indications for treatment of scoliosis in diastrophic dwarfism have not been fully established. Patients with diastrophic dwarfism already have many abnormalities in their appearance. The benefits of surgical treatment should therefore be evaluated critically. Brace treatment has been found to be useful only for small curves in these patients. If the curve cannot be braced successfully, the spinal deformity can progress to a severe scoliosis causing imbalance of the trunk. This can lead to difficulties in gait and a reduction in the already short standing height. The most important factors to be considered are the rate of progression and the time at onset: the earlier the time at onset, the more rapid and severe the progression and curve type. The early progressive type of scoliosis virtually always develops into a severe deformity unless surgery is performed. In very young children, growth rod–type instrumentation can be considered. However, because growth is limited, repeated surgeries to lengthen the rods are done at 15- to 18-month intervals instead of the usual 4- to 6-month interval. If a significantly progressive curve is noted in a very young child not appropriate for growing rods, combined anterior and posterior fusion should be considered. If a growth rod can be successfully used, by the age of 10 years, most of the spinal growth in a diastrophic dysplastic patient is complete and definitive fusion is then done. Cervical kyphosis occurs commonly, and although it usually resolves with age, it can cause quadriplegia. Radiographic evaluation of the cervical spine is mandatory in these patients. If the cervical kyphosis worsens, surgical treatment is necessary. If the kyphosis is mild, posterior fusion alone, combined with a halo brace, should be considered. In an older child with a more severe kyphosis, combined anterior and posterior fusion should be considered. If the kyphosis is causing neurologic problems, decompression anteriorly at the apex of the kyphosis is needed along with anterior and posterior fusion. 

SPONDYLOEPIPHYSEAL DYSPLASIA

Orthopaedic aspects of spondyloepiphyseal dysplasia are discussed in Chapter 32. The spinal problems most commonly associated with this condition are scoliosis, kyphoscoliosis, and odontoid hypoplasia with atlantoaxial instability (Fig. 44.220). If the scoliosis and kyphoscoliosis are progressive, orthotic treatment sometimes is useful for delaying the fusion until the patient is older. Kopits found a 30% to 40% incidence of atlantoaxial instability in patients with spondyloepiphyseal dysplasia. In children with this condition who are not walking by 2 to 3 years of age, the most likely explanation is spinal cord compression at the upper cervical region. Flexion-extension lateral cervical spine radiographs should be obtained. If ossification delay in vertebral bodies makes accurate determination of movement at this level impossible, a flexion-extension lateral MRI study is indicated. Once the instability is diagnosed, the treatment is surgical fusion. If the scoliotic curve continues to progress despite bracing, surgical fusion is considered. Unlike in achondroplasia, spinal stenosis generally is not present in patients with spondyloepiphyseal dysplasia. 

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS had a 93% prevalence of severe scoliosis (curve larger than 50 degrees). Patients with fewer than six biconcave vertebrae were not at risk to develop severe scoliosis. The age at which a child achieves motor milestones is associated with later development of spinal deformities. Bisphosphonate therapy has been shown to reduce and prevent vertebral deformity, but its effect on scoliosis and curve progression remains unclear. Bisphosphonates should be stopped 6 months before spinal fusion and not resumed until 6 months following surgery. The natural history of scoliosis in patients with osteogenesis imperfecta is continued progression. Scoliosis present at a young age almost always is progressive, and progression may continue into adulthood. Severe and disabling spinal deformities have been found in many adults with osteogenesis imperfecta.

ANESTHESIA PROBLEMS

FIGURE 44.220 Spinal deformity in patient with spondyloepiphyseal dysplasia.

OSTEOGENESIS IMPERFECTA

Patients with osteogenesis imperfecta have abnormal collagen production that results in defective bone and connective tissue. Other orthopaedic aspects of osteogenesis imperfecta are described in Chapter 32. The reported incidence of spinal deformity in patients with osteogenesis imperfecta ranges from 40% to 90%. Hanscom et al. developed a classification system based on the degree of bone involvement and the likelihood of development of a spinal deformity. Patients with type A disease have mild bony abnormalities with normal vertebral contours. Patients with type B disease have bowed long bones and wide cortices with biconcave vertebral bodies and a normal pelvic contour. Patients with type C disease have thin, bowed long bones and protrusio acetabuli, which develop around the age of 10 years. Patients with type D disease have deformities similar to type C, with the addition of cystic changes around the knee by the age of 5 years. Patients with type E disease are totally dependent functionally. Scoliosis occurred in 46% of their patients with type A disease and in all patients with types C and D. Benson et  al., in a review of 100 patients with osteogenesis imperfecta, also concluded that the severity of the disease correlates with the risk of development and the severity of the scoliosis. Anissipour et al. reviewed 157 patients with osteogenesis imperfecta and scoliosis. Using the modified Sillence classification, they were able to follow patients having mild (type I), intermediate (type IV), and severe (type III) disease. There were high rates of scoliosis progression in types II and IV osteogenesis imperfecta, with a benign course in type I patients. Ishikawa et  al. described biconcave vertebrae as a predictive factor for development of future scoliotic deformity. Patients with 6 or more biconcave vertebral fractures

There are several areas of concern in the administration of anesthesia for a patient with osteogenesis imperfecta. The primary concern is the risk of fractures. Extreme care must be taken in handling these patients, including positioning on the operating table with adequate padding and care in transfer. Care also should be taken in establishment of the intravenous line or application of a blood pressure cuff because both can result in fracture. Intubation and airway control also can be problematic because these patients have large heads and short necks, as well as tongues that often are disproportionately large. Extension of the head to facilitate intubation could cause a cervical spine fracture or a mandibular fracture. Because many patients with osteogenesis imperfecta have thoracic deformities, poor respiratory function should be expected. A tendency for hyperthermia to develop in patients with osteogenesis imperfecta also has been noted. This does not appear to be a malignant type, however, and it may be related to elevated thyroid hormone levels, which are found in at least half of the patients with osteogenesis imperfecta. Hyperthermia can be induced by various anesthetic agents, as well as by atropine, and atropine should be avoided in these patients. If hyperthermia occurs, it is controlled with cooling, supplemental oxygen, sodium bicarbonate, cardiovascular stimulants, and dantrolene sodium. Libman suggested preoperative treatment with dantrolene sodium to perhaps prevent hyperthermia. He also recommended minimizing fasciculations associated with succinylcholine chloride. If possible, other agents should be used. If succinylcholine chloride is necessary, the fasciculations may be minimized by prior administration of a nondepolarizing muscle relaxant. 

ORTHOTIC TREATMENT

Most authors agree that bracing does not control progressive scoliosis in patients with severe osteogenesis imperfecta. Brace treatment has been found to be ineffective in stopping progression of scoliosis in patients with osteogenesis imperfecta even if the curves are small, although Hanscom et  al. suggested that orthotic treatment under carefully controlled circumstances may be a reasonable alternative to operative intervention in patients with type A or type B osteogenesis imperfecta. It is doubtful whether any effective forces from an orthosis can be transmitted to the spine of a patient with preexisting deformity of the chest wall, fragile ribs, and deformed vertebral bodies. 

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FIGURE 44.221 A and B, Spinal deformity in patient with osteogenesis imperfecta. C and D, Postoperative radiographs after posterior fusion and instrumentation.

OPERATIVE TREATMENT

Spinal fusion is recommended for curves of more than 50 degrees in patients with osteogenesis imperfecta, regardless of the age of the patient, provided there are no medical contraindications (Fig. 44.221). The decision to fuse the spine should depend on the extent of the curvature and the presence of progression rather than on the age of the patient. The upper instrumented level usually is T2 to reduce the risk of proximal junctional kyphosis. The lower instrumented level usually is between L3 and L5, with the goal of leveling the inferior endplate to the pelvis. Segmental hook or screw instrumentation systems can be considered in patients with type A osteogenesis imperfecta. Patients with the milder form of the disease can be treated in the same manner as patients with idiopathic scoliosis, although significant correction of the curve should not be attempted. Bone graft should be obtained from the iliac crest, but often the amount of bone available is inadequate and allograft is required for a supplement. If the patient is small, pediatric instrumentation may be needed. The rod must be bent carefully to conform to the contours of the spine in both the coronal and sagittal planes to prevent excessive pull-out forces on the hooks. In patients with more severe disease (type C or type D), segmental instrumentation with hooks and screws can be used. Segmental wires also can be used for fixation. Great care in tightening these wires should be taken to prevent a wire from pulling through the lamina posteriorly. An alternative is to use Mersilene tapes. Cement augmentation for pedicle screw fixation has been described by Yilmaz et al., who used cement augmentation at the 3 to 4 vertebral levels at the cranial and caudal ends of the spine to establish strong foundations at either end of the construct. For severe deformity, preoperative halo traction can be used to obtain preoperative correction instead of relying on fixation in poor quality bone. Anterior procedures should not be necessary if spinal deformities are stabilized before they become too severe. Because of poor bone quality, immobilization in a twopiece TLSO often is necessary for 6 to 9 months after surgery until the fusion is solid. 

UNUSUAL CAUSES OF KYPHOSIS POSTLAMINECTOMY SPINAL DEFORMITY

Laminectomies most often are done in children for the diagnosis and treatment of spinal cord tumors, although they also

may be needed in other conditions, such as neurofibromatosis and syringomyelia. Several authors reported the frequency of spinal deformities after laminectomy in children. The incidence of spinal deformity ranged from 33% to 100%. Kyphosis is the most common deformity that occurs after multiple-level laminectomies (Fig. 44.222). Spinal deformity after laminectomy has been found to be more frequent in children younger than 15 years; also noted was the higher the level of the laminectomy, the greater the likelihood of spinal deformity or instability. All cervical or cervicothoracic laminectomies were followed by deformity in two studies. Lonstein et al. described two basic types of kyphosis, depending on the status of the facet joints posteriorly: sharp and angular or long and gradually rounding. Scoliosis also may occur after laminectomy and generally is in the area of the laminectomy and associated with the kyphotic deformity. Scoliosis may occur at levels below the laminectomy, but this is usually caused by the paralysis from the cord tumor or its treatment rather than by the laminectomy. The causes of instability of the spine after multiple laminectomies include skeletal and ligamentous deficiencies, neuromuscular imbalance, progressive osseous deformity, and radiation therapy. Increased wedging or excessive motion has been noted in children rather than subluxation as occurs in adults, possibly because, after laminectomy, pressure is increased on the cartilaginous endplates of the vertebral bodies anteriorly and, with time, cartilage growth is decreased and vertebral wedging occurs (Fig. 44.223). Panjabi et  al. showed that the loss of posterior stability caused by removal of interspinous ligaments, spinous processes, and laminae allows the normal flexion forces to produce a kyphosis. Lonstein et al. emphasized the importance of the facet joints posteriorly in these deformities. They showed that when the facet joints are completely removed at one level, gross instability results, with maximal angulation at that level causing a sharp, angular kyphos, enlargement of the intervertebral foramen, and opening of the disc space posteriorly (Fig. 44.224). If complete removal is on one side only, the angular kyphosis is accompanied by a sharp scoliosis with the apex at the same level. If all the facets are preserved, a gradual rounding kyphos results in the area of the laminectomy. Many authors have

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FIGURE 44.222 Postlaminectomy kyphosis. A and B, Clinical appearance. C and D, Radiographic appearance. E and F, After posterior fusion with pedicle screw instrumentation.

reported extremely high incidences of spinal deformity in children younger than 10 years with complete paralysis. Children with extensive laminectomies and paralysis as a result of spinal cord tumors or their treatment are likely to have increasing spinal deformities. Radiation therapy, used to treat many spinal tumors, has been associated with injury to the vertebral physis and subsequent spinal deformity (see Postirradiation Spinal Deformity, earlier). The cause of postlaminectomy spinal deformity is therefore multifactorial.

TREATMENT

The treatment of postlaminectomy kyphosis is difficult, and, if at all possible, it is best to prevent the deformity from

occurring. When laminectomy is necessary, the facet joints should be preserved whenever possible. Localized fusion at the time of facetectomy or laminectomy may help prevent progression of the deformity, but because of the loss of bone mass posteriorly, localized fusion may not produce a large enough fusion mass to prevent kyphosis. The surgical technique of laminoplasty to expose the spinal cord may lessen the chance of progressive deformity. This approach involves suturing the laminae back into place after removal or removing just one side of the laminae and allowing them to hinge open like a book to expose the spinal cord and then suturing that side of the lamina back in place. This procedure may provide a fibrous tether connecting the laminae to the spine, and Mimatsu has shown a decreased incidence

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FIGURE 44.223 Drawings of thoracic spine before and after repeated laminectomy show effects on growth of vertebral bodies. A, Before laminectomy, anterior vertebral bodies are rectangular in configuration. B, Spine that has had multiple laminectomies will have increased compression anteriorly because of loss of posterior supporting structures. This compression results in less growth in anterior portion of vertebral body than in posterior portion. In time, this will result in wedging of vertebral bodies, causing kyphotic deformity.

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of postlaminectomy kyphosis when it has been used. After surgery in which the laminae have been removed, the child should be examined regularly by an orthopaedic surgeon. If a spinal deformity is detected, brace treatment can be considered. The patient’s long-term prognosis, however, should be considered before definitive treatment plans are made. If the prognosis for survival is poor, spinal fusion may not be appropriate. With modern treatment protocols and improved survival rates for tumors, fusion usually is indicated for progressive deformity. Most authors recommend combined anterior and posterior fusions for this condition because of the small amount of bone surface posteriorly after a wide laminectomy. Also, many of these deformities have a kyphotic component and anterior spinal fusion is more successful biomechanically than posterior fusion. Anteriorly, the fusion mass is under compression rather than distraction forces. Of 45 patients treated for postlaminectomy scoliosis, Lonstein reported pseudarthroses in 33% with posterior fusion alone, in 22% with anterior fusion alone, and in 9.5% with combined anterior and posterior fusion. At the first stage, anterior fusion is done by removal of all of the disc material, taking special care to remove the entire disc back to the posterior longitudinal ligament to prevent growth in the posterior aspect of the vertebral endplate with increasing kyphotic deformity. Additional bone obtained locally from the vertebral bodies or ilium or remaining rib should be packed into the open disc spaces. Posterior fusion and instrumentation

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FIGURE 44.224 A, Lateral radiograph of 16-yearold with postlaminectomy kyphosis secondary to treatment of spinal cord tumor. B, Lateral radiograph shows progression of postlaminectomy kyphosis. C, Lateral radiograph after anterior and posterior spine fusion and instrumentation.

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FIGURE 44.225   Kyphosis in infant with achondroplasia.

are done either immediately or a week after the anterior fusion. Because of the absence of the posterior elements, instrumentation of the involved spine is desirable but not always possible. Pedicle screw fixation has been helpful in allowing the use of posterior instrumentation for postlaminectomy kyphosis and scoliosis. This procedure provides secure fixation while the spinal fusion is maturing. The use of titanium rod instrumentation has been recommended at the time of laminectomy. The instrumentation provides stability postoperatively, and the titanium rods allow postoperative MRI to evaluate spinal cord tumors. Often, the extent of the deformity and the absence of the posterior elements make instrumentation impossible, and a halo cast or vest may be necessary in these patients after surgery. 

SKELETAL DYSPLASIAS ACHONDROPLASIA

Achondroplasia, the most common of the bony dysplasias, is caused by a mutation of fibroblast growth factor receptor 3. The most frequent spinal deformity associated with this condition is thoracolumbar kyphosis that is present at birth (Fig. 44.225). The frequency of kyphosis in achondroplasia is 87% from age 1 to 2 years, 39% from age 2 to 5 years, and 11% from age 5 to 10 years. As muscle tone develops and walking begins, the kyphotic deformity usually resolves, although persistent kyphosis has been reported and can become severe in some patients. This kyphosis is poorly tolerated by the patient with achondroplasia because of the decreased size of the spinal canal related to a marked decrease in the interpedicular distance in the lower lumbar region and to shortened pedicles, which cause a reduction in the anteroposterior dimensions of the spinal canal.

It is important to be aware of the possibility of persistent or progressive thoracolumbar kyphosis in these patients. Early bracing to prevent progression and correction of any associated hip flexion contractures to prevent hyperlordosis below the kyphosis are recommended. Pauli et  al. showed the efficacy of early prohibition of unsupported sitting and bracing in a series of 66 infants with achondroplasia. The parents were advised to prevent unsupported sitting and to keep young children from sitting up more than 60 degrees even with support. If the kyphosis developed and became greater than 30 degrees (as measured on prone lateral radiographs), TLSO bracing was begun and continued until the child was walking independently and there was evidence of improvement in vertebral body wedging and kyphosis. With this form of early intervention, they reported no recurrences of progressive kyphosis. If the kyphosis progresses despite conservative treatment, operative stabilization is indicated. The indications for surgery include a documented progression of a kyphotic deformity, kyphosis of more than 50 degrees, and neurologic deficits relating to the spinal deformity. Unless the kyphosis is rapidly progressive or there are neurologic deficits, surgery is delayed until 4 years of age. Neurologic deficits can occur as a direct result of the kyphotic deformity and also as a result of the lumbar stenosis. Neurologic deficits in infants with achondroplasia may indicate narrowing of the foramen magnum and basilar impression. Evaluation of neurologic deficits therefore should include appropriate imaging studies of the foramen magnum and the occipitocervical junction. A thorough physical examination and diagnostic study, including a CT scan or MRI, may be necessary to determine the source of neurologic deficits. Patients with progressive thoracolumbar kyphosis require combined anterior and posterior fusion. The traditional approach has been to avoid posterior instrumentation because of the small canal, but if pedicle screws can be placed and the kyphosis is flexible, then posterior instrumentation and fusion can be used to treat progressive kyphosis. Ain and Browne recommended an anterior approach when the pedicle was too small to accommodate screw instrumentation. Corpectomy to relieve anterior impingement was needed when hyperextension over a bolster failed to correct the kyphosis to less than 50 degrees. Patients in whom no instrumentation was used posteriorly had repeated posterior bone grafting 4 months after the original procedure. If pedicle screw instrumentation was used, the pedicle screws were placed under fluoroscopic guidance. In patients with achondroplasia, the pedicles are directed cranially at all levels, and the average pedicle length is nearly 10 mm shorter than in individuals without achondroplasia. In Ain and Browne’s patients, all kyphotic segments were included in the fusion. If a concomitant decompression was done, the fusion was ended at least one level cephalad to the most superior level of laminectomy to avoid development of junctional kyphosis (Fig. 44.226). They found that pedicle instrumentation of the pediatric achondroplastic spine did not cause intraoperative neurologic monitoring difficulties or lead to postoperative neurologic deficits. Posterior column shortening with pedicle screws and posterior instrumentation also has been used to successfully treat neurologic deficits secondary to thoracolumbar kyphosis.

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PART XII  THE SPINE Symptomatic spinal stenosis usually does not occur until the third or fourth decade of life, but it may develop before adolescence. The reported incidence of symptomatic spinal stenosis ranges from 37% to 89%. The interpedicular distance typically decreases from L1 to L5 and the pedicle diameter increases in the same direction, resulting in a 40% reduction in size of the sagittal and coronal diameter of the spinal canal. Approximately one fourth of all patients with achondroplasia will require surgery for spinal stenosis. Surgical indications are progressive symptoms, urinary retention, severe claudication (symptoms after walking less than two city blocks), and neurologic symptoms at rest. Surgical management of spinal stenosis is a decompressive laminectomy. Laminectomy alone is not always sufficient for decompression, and the nerve root recesses on both sides should be explored because lateral stenosis usually is present. Because of the high risk of developing a postlaminectomy kyphosis, concurrent posterior instrumentation and fusion are recommended. 

MUCOPOLYSACCHARIDOSES

Of the many types of mucopolysaccharidoses, Morquio, Hurler, and Maroteaux-Lamy syndromes are the types most commonly associated with structural changes of the spine. The spinal deformity commonly seen in children with these conditions is kyphosis, usually in the thoracolumbar junction (Figs. 44.227 and 44.228). The vertebral bodies of these patients are deficient anteriorly and are flattened, beaked, or notched. The intervertebral discs are thick and bulging, often larger than the bodies. Thus, in time, the thoracolumbar spine collapses into kyphosis. The kyphosis is flexible in childhood but with progression becomes increasingly rigid. Treatment of the condition depends on the degree of the deformity, as well as the child’s prognosis (Fig. 44.229). Morquio syndrome is the most common of the mucopolysaccharidoses. Children with this condition may

well live into adult life and have normal mentality. Many authors, including Blaw and Langer, Kopits, Langer, and Lipson, have emphasized the frequent occurrence of atlantoaxial instability in patients with Morquio syndrome. The most common presenting symptom is reduced exercise tolerance, followed by progressive upper motor neuron deficits. Blaw and Langer stated that neurologic problems in the first two decades of life usually are related to odontoid abnormalities or atlantoaxial instability; later, symptoms primarily are caused by the kyphosis or gibbus. Posterior fusion of C1 to C2 is the recommended treatment of atlantoaxial instability as soon as any signs of a myelopathy are identified. Blaw and Langer recommended that the developing gibbus during childhood be treated with an appropriate spinal orthosis to prevent neurologic deficits. Dalvie et  al. described the use of anterior discectomy and anterior instrumentation to correct the thoracolumbar gibbus in these patients. The advantages of this technique are the opportunity for anterior decompression by excision of the bulging disc before correction of the kyphosis; the number of levels included in the fusion is less than required posteriorly; the posterior elements in these children are not strong enough to hold instrumentation, and, furthermore, associated canal stenosis, because of soft-tissue deposition, makes intracanal instrumentation unsafe; the interbody fusion obtained is of excellent quality; and anterior surgery can be performed, dissecting fewer muscle planes. The primary difficulty with this technique is technical in nature. The vertebral bodies are very small, and great care must be taken to ensure central placement of the screws. If the correction maneuver places excess stress on the implants, they may cut through the bone. The corrective maneuver must therefore include an external corrective force. Good correction of the kyphosis was obtained and maintained throughout the follow-up period (Fig. 44.230).

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FIGURE 44.226 Spinal arthrodesis with instrumentation in pediatric achondroplasia. A, Preoperative lateral radiograph. B, Postoperative anteroposterior radiograph. C, Postoperative lateral radiograph. (From Ain MC, Browne JA: Spinal arthrodesis with instrumentation for thoracolumbar kyphosis in pediatric achondroplasia, Spine 29:2075, 2004.)

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FIGURE 44.227 Spinal deformity in Morquio syndrome. A, Hook-shaped bodies in young child. B, Further anterior ossification in older child. C, Flattened, rectangular vertebral bodies in adult. (From Langer LO, Carey LS: The radiographic features of the KS mucopolysaccharidosis of Morquio, Am J Roentgenol 97:1, 1966.)

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D FIGURE 44.228 Kyphotic deformity in patient with mucopolysaccharidosis. A, Clinical appearance. B and C, Radiographic appearance. D, MRI.

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FIGURE 44.229 Kyphosis at thoracolumbar junction in patient with Hurler syndrome.

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B C FIGURE 44.230 Anterior fusion for thoracolumbar kyphosis in mucopolysaccharidosis. A, Preoperative radiograph. B, Anteroposterior radiograph showing instrumentation in place. C, Radiograph at 3 years shows correction of gibbus with instrumentation and solid bony fusion. (From Dalvie SS, Noordeen MH, Vellodi A: Anterior instrumented fusion for thoracolumbar kyphosis in mucopolysaccharidosis, Spine 26:E539, 2001.)

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REFERENCES INFANTILE AND JUVENILE IDIOPATHIC SCOLIOSIS Akbarnia BA: Management themes in early onset scoliosis, J Bone Joint Surg 89A:42, 2007. Bess S, Akbarnia BA, Thompson GH, et al.: Complications of growing-rod treatment for early-onset scoliosis: analysis of one hundred and forty patients, J Bone Joint Surg 92A:2533, 2010. Cahill PJ, Marvil S, Cuddihy L, et  al.: Autofusion in the immature spine treated with growing rods, Spine 35:E1199, 2010. Corona J, Sanders JO, Luhmann SJ, et al.: Reliability of radiographic measures for infantile idiopathic scoliosis, J Bone Joint Surg 94A:e86, 2012. Crawford 3rd CH, Lenke LG: Growth modulation by means of anterior tethering resulting in progressive correction of juvenile idiopathic scoliosis: a case report, J Bone Joint Surg 92A:202, 2010. Dede O, Demirkiran G, Bekmez S, et al.: Utilizing the “stable-to-be vertebra” saves motion segments in growing rods treatment for early-onset scoliosis, J Pediatr Orthop 36:336, 2016. Flynn JM, Tomlinson LA, Pawelek J, et al.: Growing-rod graduates: lessons learned from ninety-nine patients who completed lengthening, J Bone Joint Surg 95A:1745, 2013. Jain V, Lykissas M, Trobisch P, et al.: Surgical aspects of spinal growth modulation in scoliosis correction, Instr Course Lect 63:335, 2014. Khoshbin A, Caspi L, Law PW, et al.: Outcomes of bracing in juvenile idiopathic scoliosis until skeletal maturity or surgery, Spine 40:50, 2015. Lavelle WF, Samdani AF, Cahill PJ, Betz RR: Clinical outcomes of nitinol staples for preventing curve progression in idiopathic scoliosis, J Pediatr Orthop 31:S107, 2011. McCarthy RE, Luhmann S, Lenke L, McCullough FL: The Shilla growth guidance technique for early-onset spinal deformities at 2-year follow-up: a preliminary report, J Pediatr Orthop 34:1, 2014. McCarthy RE, McCullough FL: Shilla growth guidance for early-onset scoliosis: results after a minimum of five years of follow-up, J Bone Joint Surg 97A:1578, 2015. Murray E, Tung R, Sherman A, et al.: Continued vertebral body growth in patients with juvenile idiopathic scoliosis following vertebral body stapling, Spine Deform 8:221, 2020. Samdani AF, Ames RJ, Kimball JS, et al.: Anterior vertebral body tethering for idiopathic scoliosis: two-year results, Spine 39:1688, 2014. Sankar WN, Skaggs DL, Yazici M, et al.: Lengthening of dual growing rods and the law of diminishing returns, Spine 36:806, 2011. Schulz JF, Smith J, Cahill PJ, et al.: The role of the vertical expandable titanium rib in the treatment of infantile idiopathic scoliosis: early results from a single institution, J Pediatr Orthop 30:659, 2010. Sucato DJ: Management of severe spinal deformity: scoliosis and kyphosis, Spine 35:2186, 2010. Talmadge MS, Nielson SN, Heflin JA, et al.: Prevalance of hip dysplasia and associated conditions in children treated for idiopathic early-onset scoliosis—don’t just look at the spine, J Pediatr Orthop 40:e49, 2020. Yang JS, McElroy MJ, Akbarnia BA, et al.: Growing rods for spinal deformity: characterizing consensus and variation in current use, J Pediatr Orthop 30:264, 2010.

NATURAL HISTORY OF ADOLESCENT IDIOPATHIC SCOLIOSIS Coillard C, Circo AB, Rivard CH: A prospective randomized controlled trial of the natural history of idiopathic scoliosis versus treatment with the SpineCor brace: sosort award 2011 winner, Eur J Phys Rehabil Med 50:479, 2014. Grothaus O, Molina D, Jacobs C, et  al.: Is is growth or natural history? Increasing spinal deformity after Sanders stage 7 in females with AIS, J Pediatr Orthop 40:e176, 2020. Kruse LM, Buchan JG, Gurnett CA, Dobbs MB: Polygenic threshold model with sex dimorphism in adolescent idiopathic scoliosis: the Carter effect, J Bone Joint Surg 94A:1485, 2012. Larson AN, Baky F, Ashraf A, et  al.: Minimum of 20-year health-related quality of life and surgical rates after the treatment of adolescent idiopathic scoliosis, Spine Deform 7:417, 2019.

Ogilvie JW: Update on prognostic genetic testing in adolescent idiopathic scoliosis (AIS), J Pediatr Orthop 31(Suppl 1):S46, 2011. Sitoula P, Verma K, Holmes Jr L, et al.: Prediction of curve progression in idiopathic scoliosis: validation of the Sanders Skeletal Maturity Staging System, Spine 40:1006, 2015. Verma K, Errico T, Diefenbach C, et al.: The relative efficacy of antifibrinolytics in adolescent idiopathic scoliosis: a prospective randomized trial, J Bone Joint Surg 96A:e80, 2014. Wang WJ, Yeung HY, Chu WC, et al.: Top theories for the etiopathogenesis of adolescent idiopathic scoliosis, J Pediatr Orthop 31(Suppl 1):S14, 2011. Weinstein SL: The natural history of adolescent idiopathic scoliosis, J Pediatr Orthop 39(6 Suppl 1):S44, 2019.

PATIENT EVALUATION IN ADOLESCENT IDIOPATHIC SCOLIOSIS Chen ZQ, Wang CF, Bai YS, et al.: Using precisely controlled bidirectional orthopedic forces to assess flexibility in adolescent idiopathic scoliosis: comparisons between push-traction film supine side bending suspension, and fulcrum bending films, Spine 36:1679, 2011. Duchaussoy T, Lacoste M, Norberciak L, et al.: Preoperative assessment of idiopathic scoliosis in adolescent and young adult with three-dimensional T2-weighted spin-echo MRI, Diagn Interv Imaging 100:371, 2019. Ilharreborde B, Steffen JS, Nectoux E, et al.: Angle measurement reproducibility using EOS three-dimensional reconstructions in adolescent idiopathic scoliosis treated by posterior instrumentation, Spine 36:E1306, 2011. Johnston CE, Richards BS, Sucato DJ, et  al.: Correlation of preoperative deformity magnitude and pulmonary function test in adolescent idiopathic scoliosis, Spine 36:1096, 2011. Luk KD, Cheung WY, Wong Y, et al.: The predictive value of the fulcrum bending radiographs in spontaneous apical vertebral derotation in adolescent idiopathic scoliosis, Spine 37:E922, 2012. Nault ML, Parent S, Phan P, et al.: A modified Risser grading system predicts the curve acceleration phase of female adolescent idiopathic scoliosis, J Bone Joint Surg 92A:1073, 2010.

NONOPERATIVE MANAGEMENT OF IDIOPATHIC SCOLIOSIS Cheung JPY, Cheung PWH, Luk KDK: When should we wean bracing for adolescent idiopathic scoliosis? Clin Orthop Relat Res 477:2145, 2019. Gammon SR, Mehlman CT, Chan W, et al.: A comparison of thoracolumbar orthoses and SpineCor treatment of adolescent idiopathic scoliosis patients using the Scoliosis Research Society standardized criteria, J Pediatr Orthop 30:531, 2010. Guo J, Lam TP, Wong MS, et al.: A prospective randomized controlled study on the treatment outcome of SpineCor brace versus rigid brace for adolescent idiopathic scoliosis with follow-up according to the SRS standardized criteria, Eur Spine J 23:2650, 2014. Gutman G, Benoit M, Joncas J, et al.: The effectiveness of the SpineCor brace for the conservative treatment of adolescent idiopathic scoliosis: comparison with the Boston brace, Spine J 16:626, 2016. Harfouch BF, Weinstein SL: Intraoperative push-prone test: a useful technique to determine the lowest instrumented vertebra in adolescent idiopathic scoliosis, J Spinal Disord Tech 27:237, 2014. Hawary RE, Zaaroor-Regev D, Floman Y, et al.: Brace treatment in adolescent idiopathic scoliosis: risk factors for failure—a literature review, Spine J 19:1917, 2019. Katz DE, Herring JA, Browne RH, et al.: Brace wear control of curve progression in adolescent idiopathic scoliosis, J Bone Joint Surg 92A:1343, 2010. Ohashi M, Watanabe K, Hirano T, et al.: Long-term impacts of brace treatment for adolescent idiopathic scoliosis on body composition, paraspinal muscle morphology, and bone mineral density, Spine (Phila Pa 1976) 44:E1075, 2019. Ohrt-Nissen S, Hallager DW, Gehrchen M, Dahl B: Flexibility predicts curve progression in Providence nighttime bracing of patients with adolescent idiopathic scoliosis, Spine (Phil Pa 1976 41:1724, 2016. Pellios S, Kenanidis E, Potoupnis M, et al.: Curve progression 25 years after bracing for adolescent idiopathic scoliosis: long term comparative results

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS between two matched groups of 18 versus 23 hours daily bracing, Scoliosis Spinal Disord 11:3, 2016. Sponseller PD: Bracing for adolescent idiopathic scoliosis in practice today, J Pediatr Orthop 31(Suppl 1):S53, 2011. Sponseller PD, Takenaga R: The use of traction in treating large scoliotic curves in idiopathic scoliosis. In Newton PO, O’Brien MF, Shufflebarger HL, et al, editors: Idiopathic scoliosis: the Harms Study Group treatment guide, New York, 2010, Thieme. Watanabe K, Ohashi M, Hirano T, et al.: Health-related quality of life in nonoperated patients with adolescent idiopathic scoliosis in the middle years: a mean 25-year follow-up study, Spine (Phila Pa 1976) 2019, [Epub ahead of print]. Weinstein SL, Dolan LA, Wright JG, Dobbs MB: Effects of bracing in adolescents with idiopathic scoliosis, N Engl J Med 369:1512, 2013.

OPERATIVE TREATMENT OF IDIOPATHIC SCOLIOSIS Alzakri A, Vergari C, Van den Abbeele M, et al.: Global sagittal alignment and proximal junctional kyphosis in adolescent idiopathic scoliosis, Spine Deform 7:236, 2019. Betz RR, Ranade A, Samdani AF, et al.: Vertebral body stapling: a fusionless treatment option for a growing child with moderate idiopathic scoliosis, Spine 35:169, 2010. Baky FJ, Milbrandt T, Echternacht S, et al.: Intraoperative computed tomography-guided navigation for pediatric spine patients reduced return to operating room for screw malposition compared with freehand/fluoroscopic techniques, Spine Deform 7:577, 2019. Bogunovic L, Lenke LG, Bridwell KH, et al.: Preoperative halo-gravity traction for severe pediatric spinal deformity: complications, radiographic correction and changes in pulmonary function, Spine Deform 1:33, 2013. Buckland AJ, Moon JY, Betz RR, et al.: Ponte osteotomies increase the risk of neuromonitoring alerts in adolescent idiopathic scoliosis correction surgery, Spine (Phila Pa 1976) 44:E175, 2019. Burton DC, Carlson BB, Place HM, et al.: Results of the scoliosis research society morbidity and mortality database 2009-2012: a report from the morbidity and mortality committee, Spine Deform 4:338, 2016. Cahill PJ, Marvil SC, Cuddihy L, et al.: Autofusion of the skeletally immature spine treated with growing rod instrumentation, Spine 35:E1199, 2010. Carlson BC, Milbrandt TA, Larson AN: Quality, safety and value in pediatric spine surgery, Orthop Clin North America 49:491, 2018. de Kleuver M, Lewis SJ, Germscheid NM, et  al.: Optimal surgical care for adolescent idiopathic scoliosis: an international consensus, Eur Spine J 23:2603, 2014. de Mendonca RG, Sawyer JR, Kelly DM: Complications after surgical treatment of adolescent idiopathic scoliosis, Orthop Clin North Am 47:395, 2016. Diab MG, Franzone JM, Vitale MG: The role of posterior spinal osteotomies in pediatric spinal deformity surgery: indications and operative treatment, J Pediatr Orthop 31:S88, 2011. Diab M, Landman Z, Lubicky J, et al.: Use and outcome of MRI in the surgical treatment of adolescent idiopathic scoliosis, Spine 36:667, 2011. Direito-Santos B, Queirós CM, Serrano P, et  al.: Long-term follow-up of anterior spinal fusion for thoracolumbar/lumbar curves in adolescent idiopathic scoliosis, Spine (Phila Pa 1976) 44:1137, 2019. Fletcher ND, Andras LM, Lazarus DE, et al.: Use of a novel pathway for early discharge was associated with a 48% shorter length of stay after posterior spinal fusion for adolescent idiopathic scoliosis, J Pediatr Orthop 37:92, 2017. Fletcher ND, Shourbaji N, Mitchell PM, et al.: Clinical and economic implications of early discharge following posterior spinal fusion for adolescent idiopathic scoliosis, J Child Orthop 8:257, 2014. Glotzbecker M, Troy M, Miller P, et  al.: Implementing a multidisciplinary clinical pathway can reduce the deep surgical site infection rate after posterior spinal fusion in high-risk patients, Spine Deform 7:33, 2019. Glotzbecker MP, Gomez JA, Miller PE, et al.: Management of spinal implants in acute pediatric surgical site infections: a multicenter study, Spine Deform 4:277, 2016. Glotzbecker MP, St Hilaire TA, Pawelek JB, et al.: Best practice guidelines for surgical site infection prevention with surgical treatment of early onset scoliosis, J Pediatr Orthop 39, 2019:e602.

Helenius L, Diarbakerli E, Grauers A, et al.: Back pain and quality of life after surgicala treatment for adolescent idiopathic scoliosis at 5-year followup: comparison with healthy controls and patients with untreated idiopathic scoliosis, J Bone Joint Surg Am 101:1460, 2019. Jain V, Kykissas M, Trobisch P, et al.: Surgical aspects of spinal growth modulation in scoliosis correction, Instr Course Lect 63:335, 2014. Karol LA: Early definitive spinal fusion in young children: what we have learned, Clin Orthop Relat Res 469:1323, 2011. Lam DJ, Lee JZ, Chua JH, et al.: Superior mesenteric artery syndrome following surgery for adolescent idiopathic scoliosis: a case series, review of the literature, and algorithm for management, J Pediatr Orthop B 23:312, 2014. Larson AN, Polly Jr DW, Diamond B, et  al.: Does higher anchor density result in increased curve correction and improved clinical outcomes in adolescent idiopathic scoliosis (AIS)? Spine (Phila Pa 1976) 39:571, 2014. Letko L, Jensen RG, Harms J: The treatment of rigid idiopathic scoliosis: releases, osteotomies, and apical vertebral column resection. In Newton PO, O’Brien MF, Shufflebarger HL, et al, editors: Idiopathic scoliosis: the harms study group treatment guide, New York, 2010, Thieme. Lonner BS, Ren Y, Asghar J, et  al.: Antifibrinolytic therapy in surgery for adolescent idiopathic scoliosis: does Level 1 evidence translate into practice? Bull Hosp Jt Dis 76:165, 2013. Lonner BS, Ren Y, Newton PO, et  al.: Risk factors of proximal junctional kyphosis in adolescent idiopathic scoliosis-the pelvis and other considerations, Spine Deform 5:181, 2017. Lonner BS, Toombs C, Parent S, et al.: Is anterior release obsolete or does it play a role in contemporary adolescent idiopathic scoliosis surgery? A matched pair analysis, Pediatr Orthop, 2019, [Epub ahead of print]. Marks MC, Newton PO, Bastrom TP, et al.: Surgical site infection in adolescent idiopathic scoliosis surgery, Spine Deform 1:352, 2013. McCarthy KP, Chafetz RS, Mulcahey MJ, et al.: Clinical efficacy of the vertebral wedge osteotomy for the fusionless treatment of paralytic scoliosis, Spine 35:403, 2010. McCarthy RE, Sucato D, Turner JL, et al.: Shilla growing rods in a caprine animal model: a pilot study, Clin Orthop Relat Res 468:705, 2010. McNichol ED, Tzortzopoulou A, Schumann R, et al.: Antifibrinolytic agents in reducing blood loss in scoliosis surgery in children, Cochrane Database Syst Rev 19(9):CD006883, 2016. Newton PO, Bastrom TP, Yaszay B: Patient-specific risk adjustment improves comparison of infection rates following posterior fusion for adolescent idiopathic scoliosis, J Bone Joint J Am 99:1846, 2017. Newton PO, Upasani VV: Surgical treatment of the right thoracic curve pattern. In Newton PO, O’Brien MF, Shufflebarger HL, et  al, editors: Idiopathic scoliosis: the harms study group treatment guide, New York, 2010, Thieme. Powers AK, O’Shaughnessy BA, Lemke LG: Posterior thoracic vertebral column resection. In Wang JC, editor: advanced reconstruction: spine, Rosemont, IL, 2011, American Academy of Orthopaedic Surgeons, p 265. Pugely AJ, Martin CT, Gao Y, et al.: The incidence and risk factors for shortterm morbidity and mortality in pediatric deformity spinal surgery: an analysis of the NSQIP pediatric database, Spine (Phila Pa 1976) 39:1225, 2014. Ramo B, Tran DP, Reddy A, et al.: Delay to surgery greater than 6 months leads to substantial deformity progression and increased intervention in immature adolescent idiopathic scoliosis (AIS) patients: a retrospective cohort study, Spine Deform 7:428, 2019. Ramo BA, Richards BS: Repeat surgical interventions following “definitive” instrumentation and fusion for idiopathic scoliosis: five-year update on a previously published cohort, Spine (Phila Pa 1976) 37:1211, 2012. Samdani AF, Belin EJ, Bennett JT, et al.: Unplanned return to the operating room in patients with adolescent idiopathic scoliosis: are we doing better with pedicle screws? Spine (Phila Pa 1976) 38:1842, 2013. Sankar WN, Skaggs DL: Rib anchors in distraction-based growing spine implants. In Wang JC, editor: Advanced reconstruction: spine, Rosemont, IL, 2011, American Academy of Orthopaedic Surgeons. Schulz JF, Smith J, Cahill P, et al.: The role of the vertical expandable titanium rib in the treatment of infantile idiopathic scoliosis: early results from a single institution, J Pediatr Orthop 30:659, 2010.

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PART XII  THE SPINE Smith JT: Bilateral rib-to-pelvis technique for managing early-onset scoliosis, Clin Orthop Relat Res 469:1349, 2011. Sponseller PD, Jain A, Newton PO, et al.: Posterior spinal fusion with pedicle screws in patients with idiopathic scoliosis and open triradiate cartilage: does deformity progression occur? J Pediatr Orthop 36:695, 2016. Sui WY, Ye F, Yang JL: Efficacy of tranexamic acid in reducing allogeneic blood products in adolescent idiopathic scoliosis surgery, BMC Musculoskelet Disord 17:187, 2016. Tao F, Zhao Y, Wu Y, et al.: The effect of differing spinal fusion instrumentation on the occurrence of postoperative crankshaft phenomenon in adolescent idiopathic scoliosis, J Spinal Disord Tech 23:e75, 2010. Trobisch PD, Ducoffe AR, Lonner BS, Errico TJ: Choosing fusion levels in adolescent idiopathic scoliosis, J Am Acad Orthop Surg 21:519, 2013. Vitale MG, Moore DW, Matsumoto H, et al.: Risk factors for spinal cord injury during surgery for spinal deformity, J Bone Joint Surg Am 92:64, 2010. White KK, Song KM, Frost N, Daines BK: VEPTR™ growing rods for earlyonset neuromuscular scoliosis: feasible and effective, Clin Orthop Relat Res 469:1335, 2011.

NEUROMUSCULAR SCOLIOSIS (GENERAL) Blumstein GW, Andras LM, Seehausen DA, et  al.: Fever is common postoperatively following posterior spinal fusion: infection is an uncommon cause, J Pediatr 166:751, 2015. Brooks JT: Sponseller PD: What’s new in the management of neuromuscular scoliosis, J Pediatr Orthop 36:627, 2016. Funk S, Lovejoy S, Mencio G, Martus J: Rigid instrumentation for neuromuscular scoliosis improves deformity correction without increasing complications, Spine 41:46, 2016. Khirani S, Bersanini C, Aubertin G, et  al.: Non-invasive positive pressure ventilation to facilitate the postoperative respiratory outcome of spine surgery in neuromuscular children, Eur Spine J 23(Suppl 4):S406, 2014. LaMothe JM, Al Sayegh S, Parsons DL, et al.: The use of intraoperative traction in pediatric scoliosis surgery: a systematic review, Spine Deform 3:45, 2015. Myung KS, Lee C, Skaggs DL: Early pelvic fixation failure in neuromuscular scoliosis, J Pediatr Orthop 35:258, 2015. Patel J, Shapiro F: Simultaneous progression patterns of scoliosis, pelvic obliquity, and hip subluxation/dislocation in non-ambulatory neuromuscular patients: an approach to deformity documentation, J Child Orthop 9:345, 2015. Salem KM, Goodger L, Bowyer K, et al.: Does transcranial stimulation for motor evoked potentials (TcMEP) worsen seizures in epileptic patients following spinal deformity surgery? Eur Spine J 25:3044, 2016. Schwartz DM, Sestokas AK, Dormans JP, et al.: Transcranial electric motor evoked potential monitoring during spine surgery: is it safe? Spine 36:1046, 2011. Shao ZX, Fang X, Lv QB, et al.: Comparison of combined anterior-posterior approach versus posterior-only approach in neuromuscular scoliosis: a systematic review and meta-analysis, Eur Spine J 27:2213, 2018. Shirley E, Bejarano C, Clay C, et al.: Helping families make difficult choices: creation and implementation of a decision aid for neuromuscular scoliosis surgery, J Pediatr Orthop 35:831, 2015. Sponseller PD, Zimmerman RM, Ko PS, et  al.: Low-profile pelvic fixation with the sacral alar iliac technique in the pediatric population improves results at two-year minimum follow-up, Spine 35:1887, 2010. Ward JP, Feldman DS, Paul J, et al.: Wound closure in nonidiopathic scoliosis: Does closure matter? J Pediatr Orthop 37:166, 2017. White KK, Song KM, Frost N, Daines BK: VEPTR growing rods for earlyonset neuromuscular scoliosis: feasible and effective, Clin Orthop Relat Res 469:1335, 2011.

CEREBRAL PALSY Beckmann K, Lange T, Gosheger G, et al.: Surgical correction of scoliosis in patients with severe cerebral palsy, Eur Spine J 25:506, 2016. Chong HS, Padua MR, Kim JS, et  al.: Usefulness of noninvasive positivepressure ventilation during surgery of flaccid neuromuscular scoliosis, J Spinal Disord Tech 28:298, 2015. Crawford L, Herrera-Soto J, Ruder JA, et al.: The fate of the neuromuscular hip after spinal fusion, J Pediatr Orthop 37:403, 2017. Dhawale AA, Shah SA, Sponseller PD, et al.: Are antifibrinolytics helpful in decreasing blood loss and transfusions during spinal fusion surgey in children with cerebral palsy scoliosis? Spine 37:E549, 2012.

Funk S, Lovejoy S, Mencio G, et al.: Rigid Instrumentation for neuromuscular scoliosis improves deformity correction without increasing complications, Spine (Phila Pa 1976) 41:46, 2016. Hollenbeck SM, Yaszay B, Sponseller PD, et al.: The pros and cons of operating early versus late in the progression of cerebral palsy scoliosis, Spine Deform 7:489, 2019. Jackson TJ, Yaszay B, Pahys JM, et al.: Intraoperative traction may be a viable alternative to anterior surgery in cerebral palsy scoliosis >/=100 degrees, J Pediatr Orthop 38:e278, 2018. Ko PS, Jameson 2nd PG, Chang TL, Sponseller PD: Transverse-plane pelvic asymmetry in patients with cerebral palsy and scoliosis, J Pediatr Orthop 31:277, 2011. McElroy MJ, Sponseller PD, Dattilo JR, et al.: Growing rods for the treatment of scoliosis in children with cerebral palsy: a critical assessment, Spine 37:E1504, 2012. Miller DJ, Flynn JJM, Pasha S, et al.: Improving health-related quality of life for patients With nonambulatory cerebral palsy: who stands to gain from scoliosis surgery?, J Pediatr Orthop, 2019, [Epub ahead of print]. Ramchandran S, George S, Asghar J, et al.: Anatomic trajectory for iliac screw placement in pediatric scoliosis and spondylolisthesis: an alternative to S2-alar iliac portal, Spine Deform 7:286, 2019. Shabtai L, Andras LM, Portman M, et al.: Sacral alar iliac (SAI) screws fail 75% less frequently than iliac screws in neuromuscular scoliosis, J Pediatr Orthop 37, 2017:e470. Shrader MW, Andrisevic EM, Belthur MV, et al.: Inter- and intraobserver reliability of pelvic obliquity measurement methods in patients with cerebral palsy, Spine Deform 6:257, 2018. Takaso M, Nakazawa T, Imura T, et al.: Segmental pedicle screw instrumentation and fusion only to L5 in the surgical treatment of flaccid neuromuscular scoliosis, Spine (Phila Pa 1976) 43:331, 2018. Toovey R, Harvey A, Johnson M, et al.: Outcomes after scoliosis surgery for children with cerebral palsy: a systematic review, Dev Med Child Neurol 59:690, 2017. Yousef MAA, Dranginis D, Rosenfeld S: Incidence and diagnostic evaluation of postoperative fever in pediatric patients with neuromuscular disorders, J Pediatr Orthop 38:e104, 2018.

INHERITABLE NEUROLOGIC DISORDERS— NEUROFIBROMATOSIS Abdulian MH, Liu RW, Son-Hing JP, et al.: Double rib penetration of the spinal canal in a patients with neurofibromatosis, J Pediatr Orthop 31:6, 2011. Carbone M, Vittoria F, Del Sal A: Treatment of early-onset scoliosis with growing rods in patients with neurofibromatosis-1, J Pediatr Orthop B 28:278, 2019. Deng A, Zhang HQ, Tang MX, Liu SH, et al.: Posterior-only surgical correction of dystrophic scoliosis in 31 patients with neurofibromatosis Type 1 using the multiple anchor point method, J Neurosurg Pediatr 19:96, 2017. Feldman DS, Jordan C, Fonesca L: Orthopaedic manifestation of neurofibromatosis type I, J Am Acad Orthop Surg 18:346, 2010. Heflin JA, Cleveland A, Ford SD, et al.: Use of rib-based distraction in the treatment of early-onset scoliosis associated with neurofibromatosis type 1 in the young child, Spine Deform 3:239, 2015. Jain VV, Berry CA, Crawford AH, et al.: Growing rods are an effective fusionless method of controlling early-onset scoliosis associated with neurofibromatosis type 1 (NF1): a multicenter retrospective case series, J Pediatr Orthop 37, 2017:e612. Lykissas MG, Schorry EK, Crawford AH, et al.: Does the presence of dystrophic features in patients with type 1 neurofibromatosis and spine deformities increase the risk of surgery? Spine 38:1595, 2013. Mao S, Shi B, Wang S, et al.: Migration of the penetrated rib head following deformity correction surgery without rib head excision in dystrophic scoliosis secondary to type 1 neurofibromatosis, Eur Spine J 24:1502, 2015. Tauchi R, Kawakami N, Castro MA, et al.: Long-term surgical outcomes after early defnitive spinal fusion for early-onset scoliosis with neurofibromatosis type 1 at a mean follow-up of 14 years, J Pediatr Orthop 40:42, 2020. Tsirikos AL, Smith G: Scoliosis in patients with Friedreich’s ataxia, J Bone Joint Surg 94B:684, 2012. Xu E, Gao R, Jiang H, et al.: Combined halo gravity traction and dual rod technique for the treatment of early onset dystrophic scoliosis in neurofibromatosis type 1, World Neurosurg 126:e173, 2019.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Yao Z, Li H, Zhang X, et al.: Incidence and risk factors for instrumentationrelated complications after scoliosis surgery in pediatric patients with NF-1, Spine (Phila Pa 1976) 43:1719, 2018.

SPINAL MUSCULAR ATROPHY Bekmez S, Dede O, Yataganbaba A, et al.: Early results of a management algorithm for collapsing spine deformity in young children (below 10-year old) with spinal muscular atrophy type II, J Pediatr Orthop, 2019, [Epub ahead of print]. Holt JB, Dolan LA, Weinstein SL: Outcomes of primary posterior spinal fusion for scoliosis in spinal muscular atrophy: clinical, radiographic, and pulmonary outcomes and complications, J Pediatr Orthop 37:e505, 2017. Labianca L, Weinstein S: Scoliosis and spinal muscular atrophy in the new world of medical therapy: providing lumbar access for intrathecal treatment in patients previously treated or undergoing spinal instrumentation and fusion, J Pediatr Orthop B 28:393, 2019. Lenhart RL, Youlo S, Schroth MK, et al.: Radiographic and respiratory effects of growing rods in children with spinal muscular atrophy, J Pediatr Orthop 37, 2017:e500. Lorenz HM, Badwan B, Hecker MM, et al.: Magnetically controlled devices parallel to the spine in children with spinal muscular atrophy, JB JS Open Access 2:e0036, 2017. McElroy MJ, Shaner AC, Crawford TO, et al.: Growing rods for scoliosis in spinal muscular atrophy: structural effects, complications, and hospital stays, Spine 36:1305, 2011. Rosenfeld S, Schlechter J, Smith B: Achievement of guided growth in children with low-tone neuromuscular early-onset scoliosis using a segmental sublaminar instrumentation technique, Spine Deform 6:607, 2018. Strauss KA, Carson VJ, Brigatti KW, et al.: Preliminary safety and tolerability of a novel subcutaneous intrathecal catheter system for repeated outpatient dosing of nusinersen to children and adults with spinal muscular atrophy, J Pediatr Orthop 38, 2018:e610. Wijngaarde CA, Brink RC, de Kort FAS, et al.: Natural course of scoliosis and lifetime risk of scoliosis surgery in spinal muscular atrophy, Neurology 93:e149, 2019.

SYRINGOMYELIA Godzik J, Holekamp TF, Limbrick DD, et al.: Risks and outcomes of spinal deformity surgery in Chiari malformation, type 1, with syringomyelia versus adolescent idiopathic scoliosis, Spine J 15:2015, 2002. Li Z, Lei F, Xiu P, et  al.: Surgical treatment for severe and rigid scoliosis: a case-matched study between idiopathic scoliosis and syringomyeliaassociated scoliosis, Spine J 19:87, 2019. Sha S, Qiu Y, Sun W, et al.: Does surgical correction of right thoracic scoliosis in syringomyelia produce outcomes similar to those in adolescent idiopathic scoliosis? J Bone Joint Surg 98A:295, 2016. Shen J, Tan H, Chen C, et al.: Comparison of radiological features and clinical characteristics in scoliosis patients with Chiari I malformation and idiopathic syringomyelia: a matched study, Spine (Phila Pa 1976) 44:1653, 2019. Strahle J, Smith BW, Martinez M, et al.: The association between Chiari malformation type I, spinal syrinx, and scoliosis, J Neurosurg Pediatr 15:607, 2015. Zebala LP, Bridwell KH, Baldus C, et  al.: Minimum 5-year radiographic results of long scoliosis fusion in juvenile spinal muscular atrophy patients: major curve progression after instrumented fusion, J Pediatr Orthop 31:480, 2011. Zhang ZX, Feng DX, Li P, et  al.: Surgical treatment of scoliosis associated with syringomyelia with no or minor neurologic symptoms, Eur Spine J 24:1555, 2015.

ARTHROGRYPOSIS MULTIPLEX CONGENITA Astur N, Flynn JM, Flynn JM, et al.: The efficacy of rib-based distraction with VEPTR in the treatment of early-onset scoliosis in patients with arthrogryposis, J Pediatr Orthop 34:8, 2014. Greggo T, Martikos K, Pipitone E, et al.: Surgical treatment of scoliosis in a rare disease: arthrogryposis, Scoliosis 5:24, 2010.

Komolkin I, Ulrich EV, Agranovice OE, et al.: Treatment of scoliosis associated with arthrogryposis multiplex congenital, J Pediatr Orthop 37(Suppl 1):S24, 2017. Li Y, Sheng F, Xia C, et al.: Risk factors of impaired pulmonary function in arthrogryposis multiplex congenital patients with concomitant scoliosis: a comparison with adolescent idiopathic scoliosis, Spine (Phila Pa 1976) 43:E456, 2018. Xu L, Chen Z, Qui Y, et  al.: Case-matched comparative analysis of spinal deformity correction in arthrogryposis multiplex congenital versus adolescent idiopathic scoliosis, J Neurosurg Pediatr 23:22, 2018.

DUCHENNE MUSCULAR DYSTROPHY Archer JE, Gardner AC, Roper HP, et al.: Duchenne muscular dystrophy: the management of scoliosis, J Spine Surg 2:185, 2019. Cheuk DK, Wong V, Wraige E, et al.: Surgery for scoliosis in Duchenne muscular dystrophy, Cochrane Database Syst Rev (10):CD005375, 2015. Choi YA, Shin HI, Shin HI: Scoliosis in Duchenne muscular dystrophy children is fully reducible in the initial stage, and becomes structural over time, BMC Musculoskelet Disord 20:277, 2019. Chua K, Tan CY, Chen Z, et al.: Long-term follow-up of pulmonary function and scoliosis in patients with Duchenne’s muscular dystrophy and spinal muscular atrophy, J Pediatr Orthop 36:63, 2016. Garg S: Management of scoliosis in patients with Duchenne muscular dystrophy and spinal muscular atrophy: a literature review, J Pediatr Rehabil Med 9:23, 2016. Lebel DE, Corston JA, McAdam LC, et al.: Glucocorticoid treatment for the prevention of scoliosis in children with Duchenne muscular dystrophy: long-term follow-up, J Bone Joint Surg 95A:1057, 2013. Lee MC, Jarvis C, Solomito MJ, et al.: Comparison of S2-Alar and traditional iliac screw pelvic fixation for pediatric neuromuscular deformity, Spine J 18:648, 2018. Raudenbush BL, Thirukumaran CP, Li Y, et  al.: Impact of a comparative study on the management of scoliosis in Duchenne muscular dystrophy: are corticosteroids decreasing the rate of scoliosis surgery in the United States? Spine 41:E1030, 2016. Scannell BP, Yaszay B, Bartley CE, et  al.: Surgical correction of scoliosis in patients with Duchenne muscular dystrophy: 30-year experience, J Pediatr Orthop 37:e469, 2017. Suk KS, Lee BH, Lee HM, et al.: Functional outcomes in Duchenne muscular dystrophy scoliosis: comparison of the differences between surgical and nonsurgical treatment, J Bone Joint Surg 96A:409, 2014.

CONGENITAL SCOLIOSIS Ayvaz M, Akalan N, Yazici M, et al.: Is it necessary to operate all split cord malformations before corrective surgery for patients with congenital spinal deformities? Spine (Phila Pa 1976) 34:2413, 2009. Chang DG, Kim JH, Ha KY, et  al.: Posterior hemivertebra resection and short segment fusion with pedicle screw fixation for congenital scoliosis in children younger than 10 years: greater than 7-year follow-up, Spine 40:484, 2015. Chang DG, Suk SI, Kim JH, et al.: Surgical outcomes by the age at the time of surgery in the treatment of congenital scoliosis in children under age 10 years, Spine J 15:1783, 2015. Demirkiran HG, Bekmez S, Celilov R, et al.: Serial derotational casting in congenital scoliosis as a time-buying strategy, J Pediatr Orthop 35:43, 2015. Feng F, Shen J, Zhang J, et al.: Characteristics and clinical relevance of the osseous spur in patients with congenital scoliosis and split spinal cord malformation, J Bone Joint Surg Am 98:2096, 2016. Flynn JM, Emans JB, Smith JT, et al.: VEPTR to treat nonsyndromic congenital scoliosis: a multicenter, mid-term follow-up study, J Pediatr Orthop 33:679, 2013. Furdock R, Brouillet K, Luhmann SJ: Organ system anomalies associated with congenital scoliosis: a retrospective study of 305 patients, J Pediatr Orthop 39, 2019:e190. Imrie MN: A “simple” option in the surgical treatment of congenital scoliosis, Spine J 11:119, 2011. Jalanko T, Rintala R, Puisto V, Helenius I: Hemivertebra resection for congenital scoliosis in young children, Spine 36:41, 2011. Karaarslan UC, Gurel IE, Yucekul A, et  al.: Team approach: contemporary treatment of congenital scoliosis, JBJS Rev 7:e5, 2019.

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PART XII  THE SPINE Li XF, Liu ZD, Hu GY, et al.: Posterior unilateral pedicle subtraction osteotomy of hemivertebra for correction of the adolescent congenital spinal deformity, Spine J 11:111, 2011. Lonstein JE: Long-term outcome of early fusions for congenital scoliosis, Spine Deform 6:552, 2018. Louis ML, Gennari JM, Loundou AD, et al.: Congenital scoliosis: a frontal plane evaluation of 251 operated patients 14 years old or older at followup, Orthop Traumatol Surg Res 96:741, 2010. McMaster MJ, McMaster ME: Prognosis for congenital scoliosis due to a unilateral failure of vertebral segmentation, J Bone Joint Surg 95A:972, 2013. Murphy RF, Moisan A, Kelly DM, et al.: Use of vertical expandable prosthetic titanium rib (VEPTR) in the treatment of congenital scoliosis without fused ribs, J Pediatr Orthop 36:329, 2016. Pahys JM, Guille JT: What’s new in congenital scoliosis? J Pediatr Orthop 38:e172, 2018. Passias PG, Poorman GW, Jalai CM, et  al.: Incidence of congenital spinal abnormalities among pediatric patients and their association with scoliosis and systemic anomalies, J Pediatr Orthop 39:e608, 2019. Shen J, Wang Z, Liu J, et al.: Abnormalities associated with congenital scoliosis: a retrospective study of 226 Chinese surgical cases, Spine 38:814, 2013. Shen J, Zhang J, Feng F, et  al.: Corrective surgery for congenital scoliosis associated with split cord malformation: It may be safe to leave diastematomyelia untreated in patients with intact or stable neurological status, J Bone Joint Surg Am 98:926, 2016. Wang S, Zhang J, Qiu G, et al.: Dual growing rods technique for congential scoliosis: more than 2 years outcomes: preliminary results of a single center, Spine 37:E1639, 2012. Yaszay B, O’Brien M, Shufflebarger HL, et al.: Efficacy of hemivertebra resection for congenital scoliosis: a multicenter retrospective comparison of three surgical techniques, Spine 36:2052, 2011.

KYPHOSIS SCHEUERMANN DISEASE Abul-Kasim K, Schlenzka D, Selariu E, Ohlin A: Spinal epidural lipomatosis: a common imaging feature in Scheuermann disease, J Spinal Disord Tech 25:356, 2012. Cho W, Lenke LG, Bridwell KH, et al.: The prevalence of abnormal preoperative neurological examination in Scheuermann kyphosis: correlation with X-ray, magnetic resonance imaging, and surgical outcome, Spine 39:1771, 2014. Makurthou AA, Oei L, El Saddy S, et al.: Scheuermann disease: evaluation of radiological criteria and population prevalence, Spine 38:1690, 2013. Polly Jr DW, Ledonio CGT, Diamond B, et al.: What are the indications for spinal fusion surgery in Scheuermann kyphosis, J Pediatr Orthop 39:217, 2019. Toombs C, Lonner B, Shah S, et al.: Quality of life improvement following surgery in adolescent spinal deformity patients: a comparison between Scheuermann kyphosis and adolescent idiopathic scoliosis, Spine Deform 6:676, 2018. Tsirikos AI, Jain AK: Scheuermann’s kyphosis: current controversies, J Bone Joint Surg 93B:857, 2011. Wood KB, Melikian R, Villamil F: Adult Scheuermann kyphosis: evaluation, management, and new developments, J Am Acad Orthop Surg 20:113, 2012. Zeng Y, Chen Z, Qi Q, et al.: The posterior surgical correction of congenital kyphosis and kyphoscoliosis: 23 cases with minimum 2 years follow-up, Eur Spine J 22:372, 2013.

CONGENITAL KYPHOSIS Alyvaz M, Olgun ZD, Demirkiran HG, et  al.: Posterior all-pedicle screw instrumentation combined with multiple chevron and concave rib osteotomies in the treatment of adolescent congenital kyphoscoliosis, Spine J 14:11, 2014. Atici Y, Sököcü S, Uzümcügil O, et  al.: The results of closing wedge osteotomy with posterior instrumented fusion for the surgical treatment of congenital kyphosis, Eur Spine J 22:1368, 2013. Demirkiran G, Dede O, Karadeniz E, et  al.: Anterior and posterior vertebral column resection versus posterior-only technique: a comparison of

clinical outcomes and complications in congenital kyphoscoliosis, Clin Spine Surg 30:285, 2017. Hansen-Algenstaedt N, Gessler R, Goepfert M, Knight R: Percutaneous three column osteotomy for kyphotic deformity correction in congenital kyphosis, Eur Spine J 22:2139, 2013. Helgeson MD, Shah SA, Newton PO, et al.: Evaluation of proximal junctional kyphosis in adolescent idiopathic scoliosis following pedicle screw, hook, or hybrid instrumentation, Spine 35:177, 2010. McMaster MJ: Congenital kyphosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 3, Philadelphia, 2011, Wolters Kluwer/ Lippincott-Raven. Reinker K, Simmons JW, Patil V, Stinson Z: Can VEPTR® control progression of early-onset kyphoscoliosis? A cohort study of VEPTR® patients with severe kyphoscoliosis, Clin Orthop Relat Res 469:1342, 2011. Spiro AS, Rupprecht M, Stenger P, et al.: Surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach, Bone Joint J 95:1527, 2013. Tsirikos AI, McMaster MJ: Infantile developmental thoracolumbar kyphosis with segmental subluxation of the spine, J Bone Joint Surg 92B:40, 2010. Zeng Y, Chen Z, Qi Q, et al.: The posterior surgical correction of congenital kyphosis and kyphoscoliosis: 23 cases with minimum 2 years follow-up, Eur Spine J 22:372, 2013.

PROGRESSIVE ANTERIOR VERTEBRAL FUSION Bollini G, Guillaume JM, Launay F, et al.: Progressive anterior vertebral bars: a study of 16 cases, Spine 36:E423, 2011.

SPONDYLOLYSIS AND SPONDYLOLISTHESIS Altaf F, Osei NA, Garrido E, et al.: Repair of spondylolysis using compression with a modular link and screws, J Bone Joint Surg 93B:73, 2011. Beck NA, Miller R, Baldwin K, et al.: Do oblique views add value in the diagnosis of spondylolysis in adolescents? J Bone Joint Surg 95A:e65, 2013. Bourassa-Moreau E, Mac-Thiong JM, Joncas J, et al.: Quality of life of patients with high-grade spondylolisthesis: minimum 2-year follow-up after surgical and nonsurgical treatments, Spine J 13:770, 2013. Crawford 3rd CH, Larson AN, Gates M, et al.: Current evidence regarding the treatment of pediatric lumbar spondylolisthesis: a report from the Scoliosis Research Society Evidence Based Medicine Committee, Spine Deform 5:284, 2017. El Rassi G, Takemitsu M, Glutting J, Shah SA: Effect of sports modification on clinical outcome in children and adolescent athletes with symptomatic lumbar spondylolysis, Am J Phys Med Rehabil 92:1070, 2013. Fadell MF, Gralla J, Bercha I, et al.: CT outperforms radiographs at a comparable radiation dose in the assessment for spondylolysis, Pediatr Radiol 45:1026, 2015. Fan J, Yu GR, Liu F, et  al.: A biomechanical study on the direct repair of spondylolysis by different techniques of fixation, Orthop Surg 2:46, 2010. Ghobrial GM, Crandall KM, Lau A, et  al.: Minimally invasive direct pars repair with cannulated screws and recombinant human bone morphogenetic protein: case series and review of the literature, Neurosurg Focus 43:E6, 2017. Ledonio CG, Burton DC, Crawford 3rd CH, et al.: Current evidence regarding diagnostic imaging methods for pediatric lumbar spondylolysis: a report from the Scoliosis Research Society Evidence-Based Medicine Committee, Spine Deform 5:97, 2017. Leone A, Cianfoni A, Cerase A, et  al.: Lumbar spondylolysis: a review, Skeletal Radiol 40:683, 2011. Mac-Thiong JM, Duong L, Parent S, et al.: Reliability of the SDSG classification of lumbosacral spondylolisthesis, Spine 37:E95, 2012. Mac-Thiong JM, Parent S, Joncas J, et al.: The importance of proximal femoral angle on sagittal balance and quality of life in children and adolescents with high-grade lumbosacral spondylolisthesis, Eur Spine J 27:2038, 2018. Menga EN, Jain A, Kebaish KM, et al.: Anatomic parameters: direct intralaminar screw repair of spondylolysis, Spine 39:E153, 2014. Menga EN, Kebaish KM, Jain A, et al.: Clinical results and functional outcomes after direct intralaminar screw repair of spondylolysis, Spine 39:104, 2014.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Nitta A, Sakai T, Goda Y, et al.: Prevalence of symptomatic lumbar spondylolysis in pediatric patients, Orthopedics 39:e434, 2016. Rush JK, Astur N, Scott S, et al.: Use of magnetic resonance imaging in the evaluation of spondylolysis, J Pediatr Orthop 35:271, 2015. Sakai T, Goda Y, Tezuka F, et al.: Characteristics of lumbar spondylolysis in elementary school age children, Eur Spine J 25:602, 2016. Sakai T, Sairyo K, Mima S, Yasui N: Significance of magnetic resonance imaging signal change in the pedicle in the management of pediatric lumbar spondylolysis, Spine 35:E641, 2010. Sakai T, Tezuka F, Yamashita K, et al.: Conservative treatment for bony healing in pediatric lumbar spondylolysis, Spine (Phila Pa 1976) 42:E716, 2017. Selhorst M, Fischer A, MacDonald J: Prevalence of spondylolysis in symptomatic adolescent athletes: an assessment of sport risk in nonelite athletes, Clin J Sport Med 29:421, 2019. Snyder LA, Shufflebarger H, O’Brien MF, et  al.: Spondylolysis outcomes in adolescents after direct screw repair of the pars interarticularis, J Neurosurg Spine 21:329, 2014. Sumita T, Sairyo K, Shibuya I, et al.: V-rod technique for direct repair surgery of pediatric lumbar spondylolysis combined with posterior apophyseal ring fracture, Asian Spine J 7:115, 2013. Tanguay F, Labelle H, Wang Z, et  al.: Clinical significance of lumbosacral kyphosis in adolescent spondylolisthesis, Spine 37:304, 2012. Tofte JN, CarlLee TL, Holte AJ, et al.: Imaging pediatric spondylolysis: a systematic review, Spine (Phila Pa 1976) 42:777, 2017. Tsirikos AI, Garrido EG: Spondylolysis and spondylolisthesis in children and adolescents, J Bone Joint Surg 92B:751, 2010. Tsirikos AI, Sud A, McGurk SM: Radiographic and functional outcome of posterolateral lumbosacral fusion for low grade isthmic spondylolisthesis in children and adolescents, Bone Joint J 98:88, 2016.

Sponseller PD, Erkula G, Skolasky RL, et al.: Improving clinical recognition of Marfan syndrome, J Bone Joint Surg 92A:1868, 2010. Zenner J, Hitzl W, Meier O, et al.: Surgical outcomes of scoliosis surgery in Marfan syndrome, J Spinal Disord Tech 27:48, 2014.

VERTEBRAL COLUMN TUMORS Chunguang Z, Limin L, Rigao C, et  al.: Surgical treatment of kyphosis in children in healed stages of spinal tuberculosis, J Pediatr Orthop 30:271, 2010. Galgano MA, Goulart CR, Iwenofu H, et al.: Osteoblastomas of the spine: a comprehensive review, Neurosurg Focus 41:E4, 2016. Hersh DS, Iyer RR, Garzon-Muvdi T, et al.: Instrumented fusion for spinal deformity after laminectomy or laminoplasty for resection of intramedullary spinal cord tumors in pediatric patients, Neurosurg Focus 43:E1 2, 2017. Kim HJ, McLawhorn AS, Goldstein MJ, Boland PJ: Malignant osseous tumors of the pediatric spine, J Am Acad Orthop Surg 20:646, 2012. Maheshwari AV, Cheng EY: Ewing sarcoma family of tumors, J Am Acad Orthop Surg 18:94, 2010. Moon MS, Kim SS, Lee BJ, et al.: Surgical management of severe rigid tuberculous kyphosis of the lumbar spine, Int Orthop 35:75, 2011. Rajasekaran S, Vijay K, Shetty AP: Single-stage closing-opening wedge osteotomy of spine to correct severe post-tubercular kyphotic deformities of the spine: a 3-year follow-up of 17 patients, Eur Spine J 19:583, 2010. Ravindra VM, Eli IM, Schmidt MH, et al.: Primary osseous tumors of the pediatric spinal column: review of pathology and surgical decision making, Neurosurg Focus 41:E3, 2016. Zhang HQ, Wang YX, Guo CF, et al.: One-stage posterior approach and combined interbody and posterior fusion for thoracolumbar spinal tuberculosis with kyphosis in children. , Available at orthosupersite.com.

KYPHOSCOLIOSIS IN MYELOMENINGOCELE

OSTEOCHONDRODYSTROPHY

Altiok H, Finlayson C, Hassani S, Sturm P: Kyphectomy in children with myelomeningocele, Clin Orthop Relat Res 469:1272, 2011. Ferland CE, Sardar ZM, Abuljabbar F, et al.: Bilateral vascularized rib grafts to promote spino-pelvic fixation in patients with sacral agenesis and spino-pelvic dissociation: a new surgical technique, Spine J 15:2583, 2015. Flynn JM, Ramirez N, Emans JB, et al.: Is the vertebral expandable prosthetic titanium rib a surgical alternative in patients with spina bifida? Clin Orthop Relat Res 469:1291, 2011. Ollesch B, Brazell C, Carry PM, et al.: Complications, results, and risk factors of spinal fusion in patients with myelomeningocele, Spine Deform 6:460, 2018. Samagh SP, Cheng I, Elzik M, et al.: Kyphectomy in the treatment of patients with myelomeningocele, Spine J 11:E5, 2011. Smith JT: Bilateral rib-based distraction to the pelvis for the management of congenital gibbus deformity in the growing child with myelodysplasia, Spine Deform 4:70, 2016. Smith JT, Novais E: Treatment of the gibbus deformity associated with myelomeningocele in the young child with the use of the vertical expandable prosthetic titanium rib (VEPTR): a case report, J Bone Joint Surg 92A:2211, 2010.

Absousmra O, Shah SA, Heydemann JA, et  al: Sagittal spinopelvic parameters in children with achondroplasia, Spine Defor 7163, 2019. Anissipour AK, Hammerberg KW, Caudill A, et  al.: Behavior of scoliosis during growth in children with osteogenesis imperfecta, J Bone Joint Surg 96A:237, 2014. O’Donnell C, Bloch N, Michael N, et al.: Management of scoliosis in children with osteogenesis imperfecta, JBJS Rev 5:e8, 2017. Piantoni L, Noel MA, Francheri Wilson IA, et  al.: Surgical treatment with pedicle screws of scoliosis associated with osteogenesis imperfecta in children, Spine Deform 5:360, 2017. Wallace MJ, Kruse RW, Shah SA: The spine in patients with osteogenesis imperfecta, J Am Acad Orthop Surg 25:100, 2017. Yilmaz G, Hwang S, Oto M, et al.: Surgical treatment of scoliosis in osteogenesis imperfecta with cement-augmented pedicle screw instrumentation, J Spinal Disord Tech 27:174, 2014.

UNUSUAL CAUSES OF SCOLIOSIS MARFAN SYNDROME Gjolaj JP, Sponseller PD, Shah SA, et  al.: Spinal deformity correction in Marfan syndrome versus adolescent idiopathic scoliosis: learning from the differences, Spine 37:1558, 2012. Haller G, Alvarado DM, Willing MC, et al.: Genetic risk for aortic aneurysm in adolescent idiopathic scoliosis, J Bone Joint Surg Am 97:1411, 2015. Jiang D, Liu Z, Yan H, et  al.: Correction of scoliosis with large thoracic curves in Marfan syndrome: does the high-density pedicle screwe construct contribute to better surgical outcomes, Med Sci Monit 25:9658, 2019. Kurucan E, Bernstein DN, Ying M, et al.: Trends in spinal deformity surgery in Marfan syndrome, Spine J 19:1934, 2019. Qiao J, Xu L, Liu Z, et al.: Surgical treatment of scoliosis in Marfan syndrome: outcomes and complications, Eur Spine J 25:3288, 2016.

SACRAL AGENESIS Balioglu MB, Akman YE, Ucpunar H, et  al.: Sacral agenesis: evaluation of accompanying pathologies in 38 cases, with analysis of long-term outcomes, Childs Nerv Syst 32:1693, 2016. Ferland CE, Sardar ZM, Abduljabbar F, et al.: Bilateral vascularized rib grafts to promote spinopelvic fixation in patients with sacral agenesis and spinopelvic dissociation: a new surgical technique, Spine J 15:2583, 2015.

UNUSUAL CAUSES OF KYPHOSIS MUCOPOLYSACCHARIDOSIS Remondino RG, Tello CA, Noel M, et al.: Clinical manifestations and surgical management of spinal lesions in patients with mucopolysaccharidosis: a report of 52 cases, Spine Deform 7:298, 2019. Roberts SB, Dryden R, Tsirikos AI: Thoracolumbar kyphosis in patients with mucopolysaccharidoses: clinical outcomes and predictive radiographic factors for progression of deformity, Bone Joint J 98-B:229, 2016. Williams N, Challoumas D, Eastwood DM: Does orthopaedic surgery improve quality of life and function in patients with mucopolysaccharidoses? J Child Orthop 11:289, 2017.

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PART XII  THE SPINE SKELETAL DYSPLASIA

POSTLAMINECTOMY SPINAL DEFORMITY

Bauer JM, Ditro CP, Mackenzie WG: The management of kyphosis in metatropic dysplasia, Spine Deform 7:494, 2019. Khab BI, Yost MT, Badkoobehi A, et al.: Prevalence of scoliosis and thoracolumbar kyphosis in patients with achondroplalsia, Spine Deform 4:145, 2016. Margalit A, McKean G, Lawing C, et al.: Walking out of the curve: thoracolumbar kyphosis in achodroplasia, J Pediatr Orthop 38:491, 2018. Weiner DS, Guirguis J, Makowski M, et al.: Orthopaedic manifestations of pseudoachondroplasia, J Child Orthop 13:409, 2019. White KK, Bompadre V, Shah SA, et  al.: Early-onset spinal deformity in skeletal dysplasias: a multicenter study of growth-friendly systems, Spine Deform 6:478, 2018. Xu L, Li Y, Sheng F, et al.: The efficacy of brace treatment for thoracolumbar kyphosis in patients with achondroplasia, Spine (Phila Pa 1976) 43:1133, 2018.

Kennamer BT, Arginteanu MS, Moore FM, et al.: Complications of poor cervical alignment in patients undergoing posterior cervicothoracic laminectomy and fusion, World Neurosurg 122:e408, 2019. Nori S, Shiraishi T, Aoyama R, et al.: Upper cervical lordosis compensates lower cervical kyphosis to maintain whole cervical lordosis after selective laminectomy, J Clin Neurosci 58:64, 2018. Yang X, He S, Yang J, et  al.: One-stage wedge osteotomy through posterolateral approach for cervical postlaminectomy kyphosis with anterior fusion, World Neurosurg 119:45, 2018. The complete list of references is available online at Expert Consult. com.Muscioctur quam dem tem me publis, praverem atus, nocum maio, que factatique actodium restilici terus, dius et facerev ignotem sa vit, quem inculin Itatum tem ia cris, C. Obserrius, et? Guliciente in telum,

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SUPPLEMENTAL REFERENCES INFANTILE AND JUVENILE IDIOPATHIC SCOLIOSIS Akbarnia BA, Marks DS, Boachie-Adjei O, et  al.: Dual growing rod technique for the treatment of progressive early-onset scoliosis: a multicenter study, Spine 30(Suppl 17):S46, 2003. Branthwaite MA: Cardiorespiratory consequences of unfused idiopathic scoliosis, Br J Dis Chest 80:360, 1986. Brown JK, Bell E, Fulford GE: Mechanism of deformity in children with cerebral palsy with special reference to postural deformity, Pädiatr Fortbild Praxis 53:78, 1982. Ceballos T, Ferrer-Torrelles M, Costillo F, et al.: Prognosis in infantile idiopathic scoliosis, J Bone Joint Surg 62A:863, 1980. Charles YP, Daures JP, de Rosa V, Dimeglio A: Progression risk of idiopathic juvenile scoliosis during pubertal growth, Spine 31:1933, 2006. Conner AN: Early onset scoliosis: a call for awareness, BMJ 289:962, 1994. Davies G, Reid L: Effect of scoliosis on growth of alveoli, pulmonary arteries, and the right ventricle, Arch Dis Child 46:623, 1971. Dickson RA: The etiology of spinal deformities, Lancet 1:1151, 1988. Dickson RA, Lawton JO, Archer IA, et  al.: The pathogenesis of idiopathic scoliosis: biplanar spinal asymmetry, J Bone Joint Surg 66B:8, 1984. Dimeglio A: Growth of the spine before 5 years, J Pediatr Orthop 1B: 102, 1993. Dobbs MB, Lenke LG, Bridwell KH: Curve patterns in infantile and juvenile idiopathic scoliosis. Presented as a poster exhibit at the 38th Annual Meeting of the Scoliosis Research society, Quebec City, Canada, September 10-13, 2003. Dobbs MB, Lenke LG, Szymanski DA, et al.: Prevalence of neural axis abnormalities in patients with infantile idiopathic scoliosis, J Bone Joint Surg 84A:2230, 2002. Dubousset J, Herring JA, Shufflebarger H: The crankshaft phenomenon, J Pediatr Orthop 9:541, 1989. Evans SC, Edgar MA, Hall-Craggs MA, et al.: MRI of “idiopathic” juvenile scoliosis, J Bone Joint Surg 78B:314, 1996. Figueiredo UM, James JIP: Juvenile idiopathic scoliosis, J Bone Joint Surg 63B:61, 1981. Gupta P, Lenke LG, Bridwell KH: Incidence of neural axis abnormalities in infantile and juvenile patients with spinal deformity: is a magnetic resonance image screening necessary? Spine 23:206, 1998. Hefti FL, McMaster MJ: The effect of the adolescent growth spurt on early posterior spinal fusion in infantile and juvenile idiopathic scoliosis, J Bone Joint Surg 65B:247, 1983. James JIP: Infantile idiopathic scoliosis, Clin Orthop 21:106, 1961. James JIP: The management of infants with scoliosis, J Bone Joint Surg 57B:422, 1975. James JIP, Lloyd-Roberts GC, Pilcher MF: Infantile structural scoliosis, J Bone Joint Surg 41B:719, 1959. Jarvis J, Garbedian S, Swamy G: Juvenile idiopathic scoliosis: the effectiveness of part-time bracing, Spine 33:1074, 2008. Kager AN, Marks M, Bastrom T, et al.: Morbidity of iliac crest bone graft harvesting in adolescent deformity surgery, J Pediatr Orthop 26:132, 2006. Kahanovitz N, Levine DB, Lardone J: The part-time Milwaukee brace treatment of juvenile idiopathic scoliosis: long-term follow-up, Clin Orthop Relat Res 167:145, 1982. Karol LA, Johnston C, Mladenov K, et al.: Pulmonary function following early thoracic fusion in non-neuromuscular scoliosis, J Bone Joint Surg 90A:1272, 2008. Koop SE: Infantile and juvenile idiopathic scoliosis, Orthop Clin North Am 19:331, 1988. Krismundsdottir F, Burwell RG, James JIP: The rib-vertebra angles on the convexity and concavity of the spinal curve in infantile idiopathic scoliosis, Clin Orthop Relat Res 205:201, 1985. Lascombes P: CD Horizon Legacy Spinal System-deformity, surgical technique manual, 2005, Memphis, TN. Lenke LG, Dobbs MB: Management of juvenile idiopathic scoliosis, J Bone Joint Surg 89A:55, 2007. Lewonowski K, King JD, Nelson MD: Routine use of magnetic resonance imaging in idiopathic scoliosis patients less than 11 years of age, Spine 17(Suppl):510, 1992.

Lloyd-Roberts GC, Pilcher MF: Structural idiopathic scoliosis in infancy, J Bone Joint Surg 47B:520, 1965. Lonstein JE, Carlson JM: The prediction of curve progression in untreated idiopathic scoliosis during growth, J Bone Joint Surg 66A:1061, 1984. Lowe TG, Peters JD: Anterior spinal fusion with Zielke instrumentation for idiopathic scoliosis: a frontal and sagittal curve analysis in 36 patients, Spine 18:423, 1993. Luhmann SJ, Lenke LG, Kim YJ, et al.: Thoracic adolescent idiopathic scoliosis curves between 70 degrees and 100 degrees: is anterior release necessary? Spine 30:2061, 2005. Maenza RA: Juvenile and adolescent idiopathic scoliosis: magnetic resonance imaging evaluation and clinical indications, J Pediatr Orthop B 12:295, 2003. Mannherz RE, Betz RR, Clancy M, et  al.: Juvenile idiopathic scoliosis followed to skeletal maturity, Spine 13:1087, 1988. Mardjetko SM: Infantile and juvenile scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Mardjetko SM, Hammerberg KW, Lubicky JP, et al.: The Luque trolley revisited: review of 9 cases requiring revision, Spine 17:582, 1992. Mau H: Etiology of idiopathic scoliosis, Reconstr Surg Traumatol 13:184, 1972. McCarthy RE, McCullough FL: Growing instrumentation for scoliosis. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. McMaster MJ: Infantile idiopathic scoliosis: can it be prevented? J Bone Joint Surg 65B:612, 1983. McMaster MJ, Macnicol MF: The management of progressive infantile idiopathic scoliosis, J Bone Joint Surg 61B:36, 1979. Mehta MH: Growth as a corrective force in the early treatment of progressive infantile scoliosis, J Bone Joint Surg 87B:1237, 2005. Mehta MH: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis, J Bone Joint Surg 54B:230, 1972. Moe JH, Kharrat K, Winter RB, et al.: Harrington instrumentation without fusion plus external orthotic support for the treatment of difficult curvature problems in young children, Clin Orthop Relat Res 185:35, 1984. Morin MR: Pediatric Cotrel-Dubousset instrumentation system. In Bridwell KH, DeWald RL, editors: Spinal surgery, Philadelphia, 1991, JB Lippincott. Pahys JM, Samdani AF, Betz RR: Intraspinal anomalies in infantile idiopathic scoliosis: prevalence and role of magnetic resonance imaging, Spine 34:E434, 2009. Parent S, Labelle H, Skalli W, et al.: Thoracic pedicle morphometry in vertebrae from scoliotic spines, Spine 29:239, 2004. Patterson JF, Webb JK, Burwell RG: The operative treatment of progressive early onset scoliosis: a preliminary report, Spine 15:809, 1990. Pehrsson K, Nachemson A, Olofson J, et al.: Respiratory failure in scoliosis and other thoracic deformities, Spine 17:714, 1992. Redding G, Song K, Inscore S, et al.: Lung function asymmetry in children with congenital and infantile scoliosis, Spine J 8:639, 2008. Rinsky LA, Gamble JG, Bleck EE: Segmental instrumentation without fusion in children with progressive scoliosis, J Pediatr Orthop 5:687, 1985. Roberts S, Menage J, Eisenstein SM: The cartilage end-plate and intervertebral disc in scoliosis: calcification and other sequelae, J Orthop Res 11:747, 1993. Robinson CM, McMaster MJ: Juvenile idiopathic scoliosis: curve patterns and prognosis in one hundred and nine patients, J Bone Joint Surg 78A:1140, 1996. Sanders JO, D’Astous J, Fitzgerald M, et al.: Derotational casting for progressive infantile scoliosis, J Pediatr Orthop 29:581, 2009. Sanders JO, Herring JA, Browne RH: Posterior arthrodesis and instrumentation in the immature (Risser-grade-0) spine in idiopathic scoliosis, J Bone Joint Surg 77A:39, 1995. Shufflebarger HL, Clark CE: Prevention of the crankshaft phenomenon, Spine 16:S409, 1991. Sarlak AY, Atmaca H, Buluc L, et  al.: Juvenile idiopathic scoliosis treated with posterior arthrodesis and segmental pedicle screw instrumentation before the age of 9 years: a 5-year follow-up, Scoliosis 4:1, 2009.

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PART XII  THE SPINE Thompson GH, Akbarnia BA, Campbell Jr RM: Growing rod techniques in early-onset scoliosis, J Pediatr Orthop 27:354, 2007. Thompson GH, Lenke LG, Akbarnia BA, et al.: Early onset scoliosis: future directions, J Bone Joint Surg 89A:163, 2007. Thompson SK, Bentley G: Prognosis in infantile idiopathic scoliosis, J Bone Joint Surg 62B:151, 1980. Tolo VT, Gillespie R: The characteristics of juvenile idiopathic scoliosis and results of its treatment, J Bone Joint Surg 60B:181, 1978. Vanlommel E, Fabry G, Urlus M, et al.: Harrington instrumentation without fusion for the treatment of scoliosis in young children, J Pediatr Orthop 11:116, 1992. Winter RW: Scoliosis and spinal growth, Orthop Rev 7:17, 1977. Winter SL, Kriel RL, Novacheck TF, et al.: Perioperative blood loss: the effect of valproate, Pediatr Neurol 15:19, 1996. Wynne-Davies R: Infantile idiopathic scoliosis: causative factors, particularly in the first six months of life, J Bone Joint Surg 57B:138, 1975.

NATURAL HISTORY OF ADOLESCENT IDIOPATHIC SCOLIOSIS Aaro S, Ohlund C: Scoliosis and pulmonary function, Spine 9:220, 1984. Apter A, Morein G, Munitz H, et  al.: The psychosocial sequelae of the Milwaukee brace in adolescent girls, Clin Orthop Relat Res 131:156, 1978. Arai S, Ohtsuka Y, Moriya H, et al.: Scoliosis associated with syringomyelia, Spine 18:1591, 1993. Archer IA, Dickson RA: Stature and idiopathic scoliosis: a prospective study, J Bone Joint Surg 67B:185, 1985. Ascani E, Bartolozzi P, Logroscino CA, et al.: Natural history of untreated idiopathic scoliosis after skeletal maturity, Spine 11:787, 1986. Bagnall KM, Raso VJ, Hill DL, et al.: Melatonin levels in idiopathic scoliosis: diurnal and nocturnal serum melatonin levels in girls with adolescent idiopathic scoliosis, Spine 21:1974, 1996. Beals RK: Nosologic and genetic aspects of scoliosis, Clin Orthop Relat Res 93:23, 1973. Berman AT, Cohen DL, Schwentker EP: The effects of pregnancy on idiopathic scoliosis: a preliminary report on eight cases and review of the literature, Spine 7:76, 1982. Betz RR, Bunnell WP, Lambrecht-Mulier E, et al.: Scoliosis and pregnancy, J Bone Joint Surg 69A:90, 1987. Biondi J, Weiner DS, Bethem D, et al.: Correlation of Risser sign and bone age determination in adolescent idiopathic scoliosis, J Pediatr Orthop 5:697, 1985. Bjerkreim I, Hassan I: Progression in untreated idiopathic scoliosis after end of growth, Acta Orthop Scand 53:897, 1982. Bjure J, Nachemson A: Nontreated scoliosis, Clin Orthop Relat Res 93:44, 1973. Blount WP, Mellencamp DD: The effect of pregnancy on idiopathic scoliosis, J Bone Joint Surg 62A:1083, 1980. Branthwaite MA: Cardiorespiratory consequence of unfused idiopathic scoliosis patients, Br J Dis Chest 80:360, 1986. Bremberg S, Nilsson-Berggren B: School screening for adolescent idiopathic scoliosis, J Pediatr Orthop 6:564, 1986. Buchowsky JM, Skaggs DL, Sponseller PD: Temporary internal distraction as an aid to correction of severe scoliosis: surgical technique, J Bone Joint Surg 89A(Suppl 2):297, 2007. Bunnell WP: A study of the natural history of idiopathic scoliosis. Paper presented at the 19th annual meeting of the Scoliosis Research Society, Orlando, FL, 1984. Bunnell WP: The natural history of idiopathic scoliosis before skeletal maturity, Spine 11:773, 1986. Bunnell WP: The natural history of idiopathic scoliosis, Clin Orthop Relat Res 229:20, 1988. Burwell RG, James JN, Johnson F, et al.: The rib hump score: a guide to referral and prognosis? J Bone Joint Surg 64B:248, 1982. Burwell RG, James NH, Johnson F, et  al.: Standardized trunk asymmetry scores: a study of back contours in healthy school children, J Bone Joint Surg 65B:453, 1983. Byl NN, Gray JM: Complex balance reactions in different sensory conditions: adolescents with and without idiopathic scoliosis, J Orthop Res 11:215, 1993.

Bylund P, Jansson E, Dahlberg E, et al.: Muscle fiber types in thoracic erector spinae muscles: fiber types in idiopathic and other forms of scoliosis, Clin Orthop Relat Res 274:305, 1992. Carpintero P, Mesa M, Garcia J, et al.: Scoliosis induced by asymmetric lordosis and rotation: an experimental study, Spine 22:2202, 1987. Carr AJ, Jefferson RJ, Turner-Smith AR: Family stature in idiopathic scoliosis, Spine 18:20, 1993. Carr AJ, Ogilvie DJ, Wordsworth BP, et al.: Segregation of structural collagen genes in adolescent idiopathic scoliosis, Clin Orthop Relat Res 247:305, 1992. Cil A, Yazici M, Uzumcugil A, et  al.: The evolution of sagittal segmental alignment of the spine during childhood, Spine 30:93, 2004. Clayson D, Luz-Alterman S, Cataletto MM, et al.: Long-term psychological sequelae of surgically versus nonsurgically treated scoliosis, Spine 12:983, 1987. Collis DK, Ponseti IV: Long-term follow-up of patients with idiopathic scoliosis, J Bone Joint Surg 51A:425, 1969. Cowell HR, Hall JN, MacEwen GD: Genetic aspects of idiopathic scoliosis, Clin Orthop Relat Res 86:121, 1972. Cruickshank JL, Koike M, Dickson RA: Curve patterns in idiopathic scoliosis, J Bone Joint Surg 71B:259, 1989. Cummings RJ, Loveless EA, Campbell J, et al.: Interobserver reliability and intraobserver reproducibility of the system of King et al. for the classification of adolescent idiopathic scoliosis, J Bone Joint Surg 81A:743, 1999. Czeizel A, Bellyei A, Barta O, et al.: Genetics of adolescent idiopathic scoliosis, J Med Genet 15:424, 1978. Davids JR, Chamberlin E, Blackhurst DW: Indications for magnetic resonance imaging in presumed adolescent idiopathic scoliosis, J Bone Joint Surg 86A:2187, 2004. Davies G, Reid L: Effect of scoliosis on growth of alveoli and pulmonary arteries and on right ventricle, Arch Dis Child 46:623, 1971. Deacon P, Archer IA, Dickson RA: The anatomy of spinal deformity: a biomechanical analysis, Orthopedics 10:897, 1987. Deacon P, Flood BM, Dickson RA: Idiopathic scoliosis in three dimensions: a radiographic and morphometric analysis, J Bone Joint Surg 66B:509, 1984. DeGeorge FV, Fisher RL: Idiopathic scoliosis: genetic and environmental aspects, J Med Genet 4:251, 1967. Dickson RA: Scoliosis in the community, BMJ 286:615, 1983. Dickson RA: The etiology and pathogenesis of idiopathic scoliosis, Acta Orthop Belg 58(Suppl):21, 1992. Dickson R, Deacon P: Spinal growth, J Bone Joint Surg 69B:690, 1987. Dickson RA, Lawton JO, Archer IA, et  al.: The pathogenesis of idiopathic scoliosis: biplanar spinal asymmetry, J Bone Joint Surg 66B:8, 1984. Dickson JH, Mirkovic S, Noble MS, et al.: Results of operative treatment of idiopathic scoliosis in adults, J Bone Joint Surg 77A:513, 1995. Dickson RA, Stamper P, Sharp AM, et  al.: School screening for scoliosis: cohort study of clinical course, BMJ 281:265, 1980. Dobbs MB, Lenke LG, Szymanski DA, et al.: Prevalence of neural axis abnormalities in patients with infantile idiopathic scoliosis, J Bone Joint Surg 84A:2230, 2002. Dobbs MB, Lenke LG, Walton T, et al.: Can we predict the ultimate lumbar curve in adolescent idiopathic scoliosis patients undergoing a selective fusion with undercorrection of the thoracic curve? Spine 29:277, 2004. Dubousset J, Machida M: Melatonin: a possible role in the pathogenesis of human idiopathic scoliosis [abstract 3.19]. In Proceedings of the tenth international philip zorab symposium on scoliosis, Oxford, 1998, Oxford University Press. Duval-Beaupere G: Rib hump and supine angle as prognostic factors for mild scoliosis, Spine 17:103, 1992. Duval-Beaupere G, Lamireau TH: Scoliosis of less than 30 degrees: properties of the evolutivity (risk of progression), Spine 10:421, 1985. Echenne B, Barneon G, Pages M, et al.: Skin elastic fiber pathology and idiopathic scoliosis, J Pediatr Orthop 8:522, 1988. Edgar MA: The natural history of unfused scoliosis, Orthopedics 10:931, 1987. Edgar MA, Mehta M: Long-term follow-up of fused and unfused idiopathic scoliosis, J Bone Joint Surg 70B: 712, 1988.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Eliason JM, Richman LC: Psychological effects of idiopathic adolescent scoliosis, Dev Behav Pediatr 5:169, 1984. Fallstrom K, Nachemson AL, Cochran TP: Psychologic effect of treatment for adolescent idiopathic scoliosis, Orthop Trans 8:150, 1984. Ford DM, Bagnall KM, Clements CA, et  al.: Muscle spindles in the paraspinal musculature of patients with adolescent idiopathic scoliosis, Spine 13:461, 1988. Gazioglu K, Goldstein LA, Femi-Pearse D, et  al.: Pulmonary function in idiopathic scoliosis: comparative evaluation before and after orthopaedic correction, J Bone Joint Surg 50A:1391, 1968. Gibson JN, McMaster MJ, Scrimgeour CM, et  al.: Rates of muscle protein synthesis in paraspinal muscles: literal disparity in children with idiopathic scoliosis, Clin Sci 75:79, 1988. Goldberg CJ, Dowling FE, Fogarty EE: Adolescent idiopathic scoliosis—early menarche, normal growth, Spine 18:529, 1993. Goldberg MS, Mayo NE, Poitras B, et  al.: The Ste-Justine adolescent idiopathic scoliosis cohort study, part II. Perception of health, self, and body image and participation in physical activities, Spine 19:1562, 1994. Hadley-Miller N, Mims B, Milewicz DM: The potential role of the elastic fiber system in adolescent idiopathic scoliosis, J Bone Joint Surg 76A:1193, 1994. Hamanishi C, Tanaka S, Kasahara Y, et al.: Progressive scoliosis associated with lateral gaze palsy, Spine 18:2545, 1993. Harrington PR: The etiology of idiopathic scoliosis, Clin Orthop Relat Res 126:17, 1977. Hassan I, Bjerkreim I: Progression in idiopathic scoliosis after conservative treatment, Acta Orthop Scand 54:88, 1983. Henderson MH, Rieger MA, Miller F, et  al.: Influence of parental age on degree of curvature in idiopathic scoliosis, J Bone Joint Surg 72A:910, 1990. Herman R, Mixon J, Fisher A, et al.: Idiopathic scoliosis and the central nervous system: a motor control problem, Spine 10:1, 1985. Horacek O, Mazanec R, Morris CE, Kobesova A: Spinal deformities in hereditary motor and sensory neuropathy: a retrospective qualitative, quantitative, genotypical, and familial analysis of 175 patients, Spine 32:2502, 2007. Howell FR, Mahood JK, Dickson RA: Growth beyond skeletal maturity, Spine 17:437, 1992. Jackson RP, McManus AC: Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size: a prospective, controlled clinical study, Spine 19:611, 1994. James JIP: Idiopathic scoliosis: the prognosis, diagnosis, and operative indications related to curve pattern and age at onset, J Bone Joint Surg 36B:36, 1954. Keessen W, Crowe A, Hearn M: Proprioceptive accuracy in idiopathic scoliosis, Spine 17:149, 1992. Kesling KL, Reinker KA: Scoliosis in twins: a meta-analysis of the literature and report of six cases, Spine 22:1997, 2009. Kindsfater K, Lowe T, Lawellin D, et al.: Levels of platelet calmodulin for the prediction of progression and severity of adolescent idiopathic scoliosis, J Bone Joint Surg 76A:1186, 1994. Kolind-Sörensen V: A follow-up study of patients with idiopathic scoliosis, Acta Orthop Scand 44:98, 1973. Kostuik JP, Bentivoglio J: The incidence of low-back pain in adult scoliosis, Spine 6:268, 1981. Lenke LG, Betz RR, Bridwell KH, et al: Intraobserver and interobserver reliability of the classification of thoracic adolescent idiopathic scoliosis, J Bone Joint Surg 80A:1097, 1998. Little DG, Song KM, Katz D, Herring JA: Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls, J Bone Joint Surg 82A:685, 2000. Little DG, Sussman MD: The Risser sign: a critical analysis, J Pediatr Orthop 14:569, 1994. Lonstein JE: Natural history and school screening for scoliosis, Orthop Clin North Am 19:227, 1988. Lonstein JE, Bjorklund S, Wanninger MH, et al.: Voluntary school screening for scoliosis in Minnesota, J Bone Joint Surg 64A:481, 1982.

Lonstein JE, Carlson JM: The prediction of curve progression in untreated idiopathic scoliosis during growth, J Bone Joint Surg 66A:1061, 1984. Low WD, Chew EC, Kung LS, et  al.: Ultrastructures of nerve fibers and muscle spindles in adolescent idiopathic scoliosis, Clin Orthop Relat Res 174:217, 1983. Machida M, Dubousset J, Imamura Y, et  al.: Pathogenesis of idiopathic scoliosis: SEPs in chicken with experimentally induced scoliosis and in patients with idiopathic scoliosis, J Pediatr Orthop 14:329, 1994. Maguire J, Madigan R, Wallace S, et  al.: Intraoperative long-latency reflex activity in idiopathic scoliosis demonstrates abnormal central processing: a possible cause for idiopathic scoliosis, Spine 18:1621, 1993. Maisenbacher MK, O’Brien M, Tracy MR, et  al.: Molecular analysis of congenital scoliosis: a candidate gene approach, Hum Genet 116:416, 2005. Makley JT, Herndon CH, Inkley S, et al.: Pulmonary function in paralytic and nonparalytic scoliosis before and after treatment: a study of sixtythree cases, J Bone Joint Surg 50A:1379, 1968. Mankin HJ, Graham JJ, Schack J: Cardiopulmonary function in mild and moderate idiopathic scoliosis, J Bone Joint Surg 46A:53, 1964. Mayo NE, Goldberg MS, Poitras B, et  al.: The Ste-Justine adolescent idiopathic scoliosis cohort study, part III: back pain, Spine 19:1573, 1994. McInnes E, Hill DL, Raso VJ, et al.: Vibratory response in adolescents who have idiopathic scoliosis, J Bone Joint Surg 73A:1208, 1991. Mehta MH: Growth as a corrective force in the early treatment of progressive infantile scoliosis, J Bone Joint Surg 87B:1237, 2005. Miller NH: Cause and natural history of adolescent idiopathic scoliosis, Orthop Clin North Am 30:343, 1999. Miller NH, Mims B, Child A, et al.: Genetic analysis of structural elastic fiber and collagen genes in familial adolescent idiopathic scoliosis, J Orthop Res 14:994, 1996. Montgomery F, Willner S: A natural history of idiopathic scoliosis: a study of the incidence of treatment, Spine 13:401, 1988. Muhlrad A, Yarom R: Contractile protein on platelets from patients with idiopathic scoliosis, Haemostasis 11:154, 1982. Muirhead A, Conner AN: The assessment of lung function in children with scoliosis, J Bone Joint Surg 67B:699, 1985. Nachemson A: A long-term follow-up study of nontreated scoliosis, Acta Orthop Scand 39:466, 1968. Nachemson A: A long-term follow-up study of nontreated scoliosis, J Bone Joint Surg 50A:203, 1969. Nachemson A: Adult scoliosis and back pain, Spine 4:513, 1979. Nash Jr CL, Lorig RA, Schatzinger LA, et al.: Spinal cord monitoring during operative treatment of the spine, Clin Orthop Relat Res 126:100, 1977. Nathan SW: Body image of scoliotic female adolescents before and after surgery, Matern Child Nurs J 6:139, 1977. Nilsonne U, Lundgren KD: Long-term prognosis in idiopathic scoliosis, Acta Orthop Scand 39:456, 1968. O’Beirne J, Goldberg C, Dowling FE, et al.: Equilibrial dysfunction in scoliosis: cause or effect? J Spinal Disord 2:184, 1989. Oegema Jr TR, Bradford DS, Cooper KM, et al.: Comparison of biochemistry of proteoglycans isolated from normal, idiopathic scoliotic and cerebral palsy spine, Spine 8:378, 1983. Ogilvie JW, Schendel MJ: Calculated thoracic volume as related to parameters of scoliosis correction, Spine 13:39, 1988. Pedrini VA, Ponseti IV, Dohrman SC: Glycosaminoglycans of intervertebral disc in idiopathic scoliosis, J Lab Clin Med 82:938, 1973. Pehrsson K, Bake B, Larsson S, et al.: Lung function in adult idiopathic scoliosis: a 20-year follow-up, Thorax 46:474, 1991. Pehrsson K, Larsson S, Oden A, et al.: Long-term follow-up of patients with untreated scoliosis: a study of mortality, causes of death, and symptoms, Spine 17:191, 1992. Perdriolle R, Vidal J: Thoracic idiopathic scoliosis curve evolution and prognosis, Spine 10:785, 1985. Picault C, deMauroy JC, Mouilleseaux B: Natural history of idiopathic scoliosis in girls and boys, Spine 11:777, 1986. Poitras B, Mayo NE, Goldberg MS, et  al.: The Ste-Justine adolescent idiopathic scoliosis cohort study, part IV: surgical correction and back pain, Spine 19:1582, 1994.

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PART XII  THE SPINE Ponseti IV, Friedman B: Prognosis in idiopathic scoliosis, J Bone Joint Surg 32A:381, 1950. Renshaw TS: Screening school children for scoliosis, Clin Orthop Relat Res 229:26, 1988. Riseborough EJ, Wynne-Davies R: A genetic survey of idiopathic scoliosis in Boston, Massachusetts, J Bone Joint Surg 55A:974, 1973. Robin GC, Span Y, Steinberg R, et al.: Scoliosis in the elderly: a follow-up study, Spine 7:355, 1982. Sanders JO, Khoury JG, Kishan S, et al.: Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence, J Bone Joint Surg 90A:540, 2008. Saunders JO, Little DG, Richard S: Prediction of the crankshaft phenomenon by peak height velocities, Spine 22:1352, 1997. Scoles PV, Salvagno R, Villalba K, et al.: Relationship of iliac crest maturation to skeletal and chronologic age, J Pediatr Orthop 8:639, 1988. Shands AR, Eisberg HBL: The incidence of scoliosis in the state of Delaware: a study of 50,000 minifilms of the chest made during a survey for tuberculosis, J Bone Joint Surg 37A:1243, 1955. Shannon DC, Roseborough EJ, Valenca LM, et al.: The distribution of abnormal lung function in kyphoscoliosis, J Bone Joint Surg 52A:131, 1979. Shuren N, Kasser JR, Emans JB, et al.: Reevaluation of the use of the Risser sign in idiopathic scoliosis, Spine 17:359, 1992. Smyrnis T, Antoniou D, Valavanis J, et al.: Idiopathic scoliosis: characteristics and epidemiology, Clin Orthop Relat Res 10:921, 1987. Sponseller PD, Cohen MS, Nachemson AL, et al.: Results of surgical treatment of adults with scoliosis, J Bone Joint Surg 69A:667, 1987. Stagnara P: Examen du scoliotique. In Deviations laterales du rachis: scolioses, excyclopedic mediocochirurgicale (vol 7). Paris, 1974, Appareil Locomoteur. Suh PB, MacEwen GD: Idiopathic scoliosis in males: a natural history study, Spine 13:1091, 1988. Suk SI, Song HS, Lee CK: Scoliosis induced by anterior and poster rhizotomy, Spine 14:692, 1989. Taylor TKF, Ghosh P, Bushnell GR: The contribution of the intervertebral disk to the scoliotic deformity, Clin Orthop Relat Res 156:79, 1981. Torell G, Nordwall A, Nachemson A: The changing pattern of scoliosis treatment due to effective screening, J Bone Joint Surg 63A:337, 1981. Veraart BEEMJ, Jansen BJ: Changes in lung function associated with idiopathic thoracic scoliosis, Acta Orthop Scand 61:235, 1990. Visscher W, Lonstein JE, Hoffman DA, et al.: Reproductive outcomes in scoliosis patients, Spine 13:1096, 1988. Walick KS, Kragh Jr JE, Ward JA, Crawford JJ: Changes in intraocular pressure due to surgical positioning: studying potential risk for postoperative vision loss, Spine 32:2591, 2007. Weinstein SL: Idiopathic scoliosis: natural history, Spine 11:780, 1986. Weinstein SL: The natural history of scoliosis in the skeletally mature patient. In Dickson JH, editor: Spinal deformities, vol 1, no. 2. Spine: State of the Art Reviews, Philadelphia, 1987, Hanley & Belfus. Weinstein SL: Adolescent idiopathic scoliosis: prevalence and natural history, Instr Course Lect 38:115, 1989. Weinstein SL, Dolan LA, Spratt KF, et al: Natural history of adolescent idiopathic scoliosis: back pain at 50 years. Paper presented at the annual meeting of the Scoliosis Research Society, New York, September 1998. Weinstein SL, Ponseti IV: Curve progression in idiopathic scoliosis, J Bone Joint Surg 65A:447, 1983. Weinstein SL, Zavala DC, Ponseti IV: Idiopathic scoliosis: long-term followup and prognosis in untreated patients, J Bone Joint Surg 63A:702, 1981. Willner S: Prospective prevalence study of scoliosis in southern Sweden, Acta Orthop Scand 53:233, 1982. Willner S: Prevalence study of trunk asymmetries and structural scoliosis in 10-year-old school children, Spine 9:644, 1984. Wynne-Davies R: Familial (idiopathic) scoliosis: a family survey, J Bone Joint Surg 50B:24, 1968. Wynne-Davies R: Genetic aspects of idiopathic scoliosis, Dev Med Child Neurol 15:809, 1973. Xiong B, Sevastik J, Hedlund R, et al.: Sagittal configuration of the spine and growth of the posterior elements in early scoliosis, J Orthop Res 12:113, 1994.

Yamauchi Y, Yamaguchi T, Asaka Y: Prediction of curve progression in idiopathic scoliosis based on initial roentgenograms: a proposal of an equation, Spine 13:1258, 1988. Yarom R, Blatt J, Gorodetsky R, et al.: Microanalysis and x-ray fluorescence spectrometry of platelets in diseases with elevated muscle calcium, Eur J Clin Invest 10:143, 1980. Yarom R, Robin GC: Studies on spinal and peripheral muscles from patients with scoliosis, Spine 4:12, 1979. Yekutiel M, Robin GC, Yarom R: Proprioceptive function in children with adolescent idiopathic scoliosis, Spine 6:560, 1981.

PATIENT EVALUATION IN ADOLESCENT IDIOPATHIC SCOLIOSIS Aaro S, Dahlborn M: Vertebral rotation: estimation of vertebral rotation and spinal and rib cage deformity in scoliosis by computerized tomography, Spine 6:460, 1981. Asher MA: Scoliosis evaluation, Orthop Clin North Am 19:805, 1988. Barsanti CM, deBari A, Covino BM: The torsion meter: a critical review, J Pediatr Orthop 10:527, 1990. Bernhardt M: Normal spinal anatomy: normal sagittal plane alignment. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Bernhardt M, Bridwell KH: Segmental analysis of the sagittal plane alignment of the normal thoracic lumbar spines and thoracolumbar junction, Spine 14:717, 1989. Bunnell WP: Vertebral rotation: a simple method of measurement in routine radiographs, Orthop Trans 9:114, 1985. Carman DL, Browne RH, Birch JG: Measurement of scoliosis and kyphosis radiographs: intraobserver and interobserver variation, J Bone Joint Surg 72A:328, 1990. Charles YP, Diméglio A, Canavese F, Daures JP: Skeletal age assessment from the olecranon for idiopathic scoliosis at Risser grade 0, J Bone Joint Surg 89A:2737, 2007. Cheung KM, Luk KD: Prediction of correction of scoliosis with use of the fulcrum bending radiograph, J Bone Joint Surg 79A:1144, 1997. Cobb JR: Outline for the study of scoliosis, AAOS Instruct Course Lect 5:261, 1948. Deacon P, Flood BM, Dickson RA: Idiopathic scoliosis in three dimensions: a radiographic and morphometric analysis, J Bone Joint Surg 66B:509, 1984. DeSmet A, Fritz SL, Asher MA: A method for minimizing the radiation exposure from scoliosis radiographs, J Bone Joint Surg 63A:156, 1981. DeSmet A, Goin JE, Asher MA, et  al.: A clinical study of the differences between the scoliotic angles measured on the PA versus the AP radiographs, J Bone Joint Surg 64A:489, 1982. Diméglio A, Charles YP, Daures JP, et  al.: Accuracy of the Sauvegrain method in determining skeletal age during puberty, J Bone Joint Surg 87A:1689, 2005. Drummond D, Ranallo F, Lonstein J, et al.: Radiation hazards and scoliosis management, Spine 8:741, 1983. Edwards 2nd CC, Lenke LG, Peelte M, et  al.: Selective thoracic fusion for adolescent idiopathic scoliosis with C modifier lumbar curves: 2- to 16-year radiographic and clinical results, Spine 29:536, 2004. Escalada F, Marco E, Duate E, et al.: Assessment of angle velocity in girls with adolescent idiopathic scoliosis, Scoliosis 4:20, 2009. Farren J: Routine radiographic assessment of the scoliotic spine, Radiography 47:92, 1981. Ferguson AB: Roentgen interpretations and decisions in scoliosis, AAOS Instruct Course Lect 7:160, 1950. Gelb DE, Lenke LG, Bridwell KH, et al.: An analysis of sagittal spinal alignment in 100 asymptomatic middle and older age volunteers, Spine 20:1351, 1995. Gille O, Champain N, Benchikh-El-Fegoun A, et al.: Reliability of 3D reconstruction of the spine of mild scoliotic patients, Spine 32:568, 2007. Gray JE, Hoffman AE, Peterson HA: Reduction of radiation exposure during radiography for scoliosis, J Bone Joint Surg 65A:5, 1983. Gunzburg R, Gunzburg J, Wagner J, et al.: Radiologic interpretation of lumbar vertebral rotation, Spine 16:660, 1991.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Hans SD, Sanders JO, Cooperman DR: Using the Sauvegrain method to predict peak height velocity in boys and girls, J Pediatr Orthop 28:836, 2008. Herring JA, editor: Tachdjian’s pediatric orthopaedics, ed 4, Philadelphia, 2008, Elsevier Saunders. Hopkins R, Grundy M, Sherr-Mehl M: X-ray filters in scoliosis x-rays, Orthop Trans 8:148, 1984. Hung VW, Quin L, Cheung CS, et al.: Osteopenia: a new prognostic factor of curve progression in adolescent idiopathic scoliosis, J Bone Joint Surg 87A:2709, 2005. King HA, Moe JH, Bradford DS, et al.: The selection of the fusion levels in thoracic idiopathic scoliosis, J Bone Joint Surg 65A:1302, 1983. Kleinman RE, Csongradi JJ, Rinsky LA, et al.: A radiographic assessment of spinal flexibility in scoliosis, Clin Orthop Relat Res 162:47, 1982. Klepps SJ, Lenke LG, Bridwell KH, et  al.: Prospective comparison of flexibility radiographs in adolescent idiopathic scoliosis, Spine 26:E74, 2001. Kuklo TR, Potter BK, Lenke LG: Vertebral rotation and thoracic torsion in adolescent idiopathic scoliosis: what is the best radiographic correlate? J Spinal Disord Tech 18:139, 2005. Lenke LG, Edwards 2nd CC, Bridwell KH: The Lenke classification of adolescent idiopathic scoliosis: how it organizes curve patterns as a template to perform selective fusions of the spine, Spine 28:S199, 2003. Lenke LG, Linville DA, Bridwell KH: Sagittal balance considerations in adults. In Margulies JY, Aebi M, Farcy JPC, editors: Revision spine surgery, St. Louis, 1999, Mosby. Leuonowaski K, King JD, Nelson MD: Routine use of magnetic resonance imaging in idiopathic scoliosis patients less than 11 years of age, Spine 17:S109, 1992. Little DG, Song KM, Katz D, Herring JA: Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls, J Bone Joint Surg 82A:685, 2000. Lonstein JE, Carlson JM: The prediction of curve progression in untreated idiopathic scoliosis during growth, J Bone Joint Surg 66A:1061, 1984. Lu KD, Cheung KM, Lu DS, Leong JC: Assessment of scoliosis in relation to flexibility using the fulcrum bending correction index, Spine 23:2303, 1998. Maenza RA: Juvenile and adolescent idiopathic scoliosis: magnetic resonance imaging evaluation and clinical indications, J Pediatr Orthop 12B:295, 2003. Mehta MH: Radiographic estimation of vertebral rotation in scoliosis, J Bone Joint Surg 55B 513, 1973. Morrissy RT, Goldsmith GS, Hall EC, et al.: Measurement of the Cobb angle on radiographs of patients who have scoliosis: evaluation of intrinsic error, J Bone Joint Surg 72A:320, 1990. Nash C, Moe J: A study of vertebral rotation, J Bone Joint Surg 51A:223, 1969. Newton PO, Faro FD, Gollogly S, et al.: Results of preoperative pulmonary function testing of adolescents with idiopathic scoliosis: a study of six hundred and thirty-one patients, J Bone Joint Surg 87A:2005, 1937. Perdriolle R, Vidal J: Morphology of scoliosis: three-dimension evolution, Orthopedics 10:909, 1987. Polly Jr DW, Sturm PF: Traction versus supine side bending: which technique best determines curve flexibility? Spine 23:804, 1998. Ponseti IV, Friedman B: Prognosis in idiopathic scoliosis, J Bone Joint Surg 32A:381, 1950. Probst-Proctor SL, Bleck EE: Radiographic determination of lordosis and kyphosis in normal and scoliotic children, J Pediatr Orthop 3:344, 1983. Pun WK, Lak KDK, Lee W, et al.: A simple method to estimate the rib hump in scoliosis, Spine 12:342, 1987. Richards BS: Measurement error in assessment of vertebral rotation using the Perdriolle torsiometer, Spine 17:513, 1992. Risser JC: Important practical facts in the treatment of scoliosis, AAOS Instruct Course Lect 5:248, 1948. Risser JC: The iliac apophysis: an invaluable sign in the management of scoliosis, Clin Orthop 11:111, 1958. Russell GG, Raso VJ, Hill D, et al.: A comparison of four computerized methods of measuring vertebral rotation, Spine 15:24, 1990. Sahlstrand T: The clinical value of moiré topography in the management of scoliosis, Spine 11:409, 1986.

Sanders JO, Herring JA, Brown RH: Behavior of the immature Risser 0 (spine) in idiopathic scoliosis following posterior spinal instrumentation and fusion. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. Sanders JO, Khoury JG, Kishan S, et al.: Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence, J Bone Joint Surg 90A:540, 2008. Song KM, Little DG: Peak height velocity as a maturity indicator for males with idiopathic scoliosis, J Pediatr Orthop 20:286, 2000. Stagnara P: Examen du scoliotique. In Deviations laterales du rachis: scolioses, encyclopedie mediocochirurgicale (vol 7). Paris, 1974, Appareil Locomoteur. Stokes IAF, Moreland MS: Measurement of the shape of the surface of the back in patients with scoliosis: the standing and forward-bending positions, J Bone Joint Surg 69A:203, 1987. Stokes IAF, Shuma-Hartswick D, Moreland MS: Spine and back-shape changes in scoliosis, Acta Orthop Scand 59:128, 1988. Takahashi S, Passuti N, Delecrin J: Interpretation and utility of traction radiography in scoliosis surgery: analysis of patients treated with CotrelDubousset instrumentation, Spine 22:2542, 1997. Vaughan JJ, Winter RB, Lonstein JE: Comparison of the use of supine bending and traction radiographs in the selection of the fusion area in adolescent idiopathic scoliosis, Spine 21:2469, 1996. Vedantam R, Lenke LG, Bridwell KH, Linville DL: Comparison of the pushprone and lateral-bending radiographs for predicting postoperative coronal alignment in thoracolumbar and lumbar scoliotic curves, Spine 25:76, 2000. Vedantam R, Lenke LG, Keeney JA, et al.: Comparison of standing sagittal alignment in asymptomatic adolescents versus adults, Spine 23:211, 1998. Wamboldt A, Spencer DL: A segmental analysis of the distribution of lumbar lordosis in the normal spine, Orthop Trans 11:92, 1987. Weisz I, Jefferson RJ, Turner-Smith AR, et al.: ISIS scanning: a useful assessment to technique in the management of scoliosis, Spine 13:405, 1988.

NONOPERATIVE MANAGEMENT OF IDIOPATHIC SCOLIOSIS Aaro S, Burstrom R, Dahlborn M: The derotating effect of the Boston brace: a comparison between computer tomography and a conventional method, Spine 6:477, 1981. Andrews G, MacEwen GD: Idiopathic scoliosis: an 11-year follow-up study of the role of the Milwaukee brace in curve control and trunco-pelvic alignment, Orthopedics 12:809, 1989. Apter A, Morein G, Munitz H, et  al.: The psychological sequelae of the Milwaukee brace in adolescent girls, Clin Orthop Relat Res 131:156, 1978. Axelgaard J, Brown JC: Lateral electrode surface stimulation for the treatment of progressive idiopathic scoliosis, Spine 8:242, 1983. Bancel P, Kaelin A, Hall J, et al.: The Boston brace: results of a clinical and radiologic study of 401 patients, Orthop Trans 8:33, 1984. Bassett GS, Bunnell WP: Effect of a thoracolumbar orthosis on lateral trunk shift in idiopathic scoliosis, J Pediatr Orthop 6:182, 1986. Benson DR, Wolf AW, Shoji H: Can the Milwaukee patient participate in competitive athletics? Am J Sports Med 5:7, 1977. Bjerkreim I, Carlsen B, Korsell E: Preoperative Cotrel traction in idiopathic scoliosis, Acta Orthop Scand 53:901, 1982. Bradford DS, Tanguy A, Vanselow J: Surface electrical stimulation in the treatment of idiopathic scoliosis: preliminary results in 30 patients, Spine 8:757, 1983. Bunnell WP: Treatment of idiopathic scoliosis, Orthop Clin North Am 10:813, 1979. Bunnell WP: Nonoperative treatment of spinal deformity: the case for observation, Instr Course Lect 34:106, 1985. Bylund P, Aaro S, Gottfries B: Is lateral electric surface stimulation an effective treatment for scoliosis? J Pediatr Orthop 7:298, 1987. Carr WA, Moe JH, Winter RB, et al.: Treatment of idiopathic scoliosis in the Milwaukee brace, J Bone Joint Surg 62A:599, 1980. Clayson D, Luz-Alterman S, Cataletto MM, et al.: Long-term psychological sequelae of surgically versus nonsurgically treated scoliosis, Spine 12:983, 1987.

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PART XII  THE SPINE Cochran T, Nachemson A: Long-term anatomic and functional changes in patients with adolescent idiopathic scoliosis treated with the Milwaukee brace, Spine 10:27, 1985. Danielsson AJ, Nachemson AL: Back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis: a case-control study, part I, Spine 28:2078, 2003. Dickson RA: Spinal deformity: adolescent idiopathic scoliosis: nonoperative treatment, Spine 24:2601, 1999. DiRaimondo CV: Green NE: Brace-wear compliance in patients with adolescent idiopathic scoliosis, J Pediatr Orthop 8:143, 1988. Dove J, Hsu LC, Yau AC: The cervical spine after halo-pelvic traction: an analysis of the complications of 83 patients, J Bone Joint Surg 62B:158, 1980. Durham JW, Moskowitz A, Whitney J: Surface electrical stimulation versus brace in treatment of idiopathic scoliosis, Spine 15:888, 1990. Edgar MA, Chapman RH, Glasgow MM: Preoperative correction in adolescent idiopathic scoliosis, J Bone Joint Surg 64A:530, 1982. Edmonson AS, Morris JT: Follow-up study of Milwaukee brace treatment in patients with idiopathic scoliosis, Clin Orthop Relat Res 126:58, 1977. Edmonson AS, Smith GR: Long-term follow-up study of Milwaukee brace treatment in patients with idiopathic scoliosis, Proceedings of the Scoliosis Research Society, Denver, September 22, 1982. Emans JB, Kaelin A, Bancel P, et al.: The Boston bracing system for idiopathic scoliosis: follow-up results of 295 patients, Spine 11:792, 1986. Fallstrom K, Cochran T, Nachemson A: Long-term effects on personality development in patients with adolescent idiopathic scoliosis: influence of type of treatment, Spine 11:756, 1986. Federico DJ, Renshaw TS: Results of treatment of idiopathic scoliosis with the Charleston bending orthosis, Spine 15:886, 1990. Focarile FA, Bonaldi A, Giarolo M, et al.: Effectiveness of nonsurgical treatment for idiopathic scoliosis: overview of available evidence, Spine 16:395, 1991. Goldberg C, Poitras B, Mayo NE: Electro-spinal stimulation in children with adolescent and juvenile scoliosis, Spine 13:482, 1988. Goldberg CJ, Dowling FE, Hall JE, et al.: A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls, Spine 18:902, 1993. Green NE: Part-time bracing of idiopathic scoliosis, J Bone Joint Surg 68A:738, 1986. Hanks GA, Zimmer B, Nogi J: TLSO treatment of idiopathic scoliosis: an analysis of the Wilmington jacket, Spine 13:626, 1988. Hassan J, Bjerkreim I: Progression in idiopathic scoliosis after conservative treatment, Acta Orthop Scand 54:88, 1983. Humbyrd DE, Latimer FR, Lonstein JE, et al.: Brain abscess as a complication of halo traction, Spine 6:364, 1981. Jonassen-Rajala E, Josefsson E, Lundberg B, et al.: Boston thoracic brace in the treatment of idiopathic scoliosis, Clin Orthop Relat Res 183:37, 1984. Kahanovitz N, Levine DB, Lardone J: The part-time Milwaukee brace treatment of juvenile idiopathic scoliosis: long-term follow-up, Clin Orthop Relat Res 167:145, 1982. Kahanovitz N, Weiser S: Lateral electrical surface stimulation (LESS) compliance in adolescent female scoliosis patients. Proceedings of the Scoliosis Research Society, Coronado, CA, September 1985. Kahanovitz N, Weiser S: The psychological impact of idiopathic scoliosis on the adolescent female, Spine 14:483, 1989. Katz DE, Richards S, Browne RH, et al.: A comparison between the Boston brace and the Charleston bending brace in adolescent idiopathic scoliosis, Spine 22:1302, 1997. Kehl OK, Morrissy RT: Brace treatment in adolescent idiopathic scoliosis: an update on concepts and technique, Clin Orthop Relat Res 229:34, 1988. Keller RB: Nonoperative treatment of adolescent idiopathic scoliosis, Instr Course Lect 38:129, 1989. Laurnen EL, Tupper JW, Mullen MP: The Boston brace in thoracic scoliosis: a preliminary report, Spine 8:388, 1983. Leslie IJ, Dorgan JC, Bentley G, et  al.: A prospective study of deep vein thrombosis of the leg in children on halo-femoral traction, J Bone Joint Surg 63B:168, 1981. Lindh M: The effect of sagittal curve changes on brace correction of idiopathic scoliosis, Spine 5:26, 1980.

Lonstein JE: Cast techniques. In Bradford DS, Ogilvie JW, et al, editors: Moe’s textbook of scoliosis and other spinal deformities, ed 2, Philadelphia, 1987, WB Sanders. Lonstein JE, Winter RB: Adolescent idiopathic scoliosis: nonoperative treatment, Orthop Clin North Am 19:239, 1988. Lonstein JE, Winter RB: The Milwaukee brace for the treatment of adolescent idiopathic scoliosis: review of 1020 patients, J Bone Joint Surg 76A:1207, 1994. MacLean WE, Green NE, Pierre CB, et al.: Stress and coping with scoliosis: psychological effects on adolescents and their families, J Pediatr Orthop 9:257, 1989. McCollough III NC: Nonoperative treatment of idiopathic scoliosis using surface electrical stimulation, Spine 11:802, 1986. McCollough NC, Schultz M, Javech N, et al.: Miami TLSO in the management of scoliosis: preliminary results from 100 cases, J Pediatr Orthop 1:141, 1981. Meade KP, Bunch WH, Vanderby Jr R, et  al.: Progression of unsupported curves in adolescent idiopathic scoliosis, Spine 12:520, 1987. Miller JAA, Nachemson AL, Schultz AB: Effectiveness of braces in mild idiopathic scoliosis, Spine 9:632, 1984. Moe JH: Methods of correction and surgical techniques in scoliosis, Orthop Clin North Am 3:17, 1972. Montgomery F, Willner S: Prognosis of brace-treated scoliosis: comparison of the Boston and Milwaukee methods in 244 girls, Acta Orthop Scand 60:383, 1989. Montgomery F, Willner S, Appelgren G: Long-term follow-up of patients with adolescent idiopathic scoliosis treated conservatively: an analysis of the clinical value of progression, J Pediatr Orthop 10:48, 1990. Mubarak SJ, Camp JF, Valetich W, et  al.: Halo application in the infant, J Pediatr Orthop 9:612, 1989. Nachemson AL, Cochran TP, Fällström K, et al.: Somatic, social, and psychologic effects of treatment for idiopathic scoliosis, Orthop Trans 7:508, 1983. Nachemson AL, Nordwall A: Effectiveness of preoperative Cotrel traction for idiopathic scoliosis, J Bone Joint Surg 59A:504, 1977. Nachemson AL, Peterson L: Scoliosis Research Society brace study report, part I: effectiveness of brace treatment in moderate adolescent idiopathic scoliosis. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. Nash CL: Current concepts review: scoliosis bracing, J Bone Joint Surg 62A:848, 1980. Nickel VL, Perry J, Garrett A, et al.: The halo: a spinal skeletal traction fixation device, J Bone Joint Surg 50A:1400, 1968. O’Brien JP, Yau AC, Hodgson AR: Halo-pelvic traction: a technic for severe spinal deformities, Clin Orthop Relat Res 93:179, 1973. O’Brien JP, Yau ACMC, Smith TK, et al.: Halo-pelvic traction: a preliminary report on a method of external skeletal fixation for correcting deformities and maintaining fixation of the spine, J Bone Joint Surg 53B:217, 1971. Perry J: The halo in spinal abnormalities: practical factors and avoidance of complications, Orthop Clin North Am 3:69, 1972. Piazza MR, Bassett GS: Curve progression after treatment with the Wilmington brace for idiopathic scoliosis, J Pediatr Orthop 10:39, 1990. Price CT, Scott DS, Reed Jr FE, et al.: Nighttime bracing for idiopathic scoliosis with the Charleston bending brace: preliminary report, Spine 16:1294, 1990. Refsum HE, Naess-Andreson CF, Lange JE: Pulmonary function and gas exchange at rest and exercise in adolescent girls with mild idiopathic scoliosis during treatment with Boston thoracic brace, Spine 15:420, 1990. Renshaw TS: Orthotic treatment of idiopathic scoliosis and kyphosis, Instr Course Lect 34:110, 1985. Richards BS, Bernstein RM, D’Amato CR, Thompson GH: Standardization of criteria for adolescent idiopathic scoliosis brace studies, Spine 30:2068, 2005. Risser JC: Plaster body-jackets, Am J Orthop 3(19), 1961. Risser JC, Norquist DM, Lauder Jr CH, et  al.: Three types of body casts, AAOS Instruct Course Lect 10:131, 1953. Rowe DE, Berstein SM, Riddick MF, et al.: A meta-analysis of the efficacy of nonoperative treatments for idiopathic scoliosis, J Bone Joint Surg 79A:664, 1997.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Rudicel S, Renshaw TS: The effect of the Milwaukee brace on spinal decompensation in idiopathic scoliosis, Spine 8:385, 1983. Sanders JO, D’Astous J, Fitzgerald M, et al.: Derotational casting for progressive infantile scoliosis, J Pediatr Orthop 29:581, 2009. Schultz A, Haderspeck K, Takashima S: Correction of scoliosis by muscle stimulation: biomechanical analyses, Spine 6:468, 1981. Shufflebarger HL, Kaiser RP: Nonoperative treatment of idiopathic scoliosis: a 10-year study, Orthop Trans 7:11, 1983. Sullivan JA, Davidson R, Renshaw TS, et  al.: Further evaluation of the Scolitron treatment of idiopathic adolescent scoliosis, Spine 11:903, 1986. Swank SM, Brown JC, Jennings MV, et al.: Lateral electrical surface stimulation in idiopathic scoliosis: experience in two private practices, Spine 14:1293, 1989. Swank SM, Winter RB, Moe JH: Scoliosis and cor pulmonale, Spine 7:343, 1982. Toledo LC, Toledo CH, MacEwen GD: Halo traction with the Circolectric bed in the treatment of severe spinal deformities: a preliminary report, J Pediatr Orthop 2:554, 1982. Tolo VT: Treatment follow-up or discharge, Spine 13:1189, 1988. Uden A, Willner S: The effect of lumbar flexion and Boston thoracic brace on the curves in idiopathic scoliosis, Spine 8:846, 1983. Wiley JW, Thomson JD, Mitchell TM, et al.: The effectiveness of the Boston brace in treatment of large curves in adolescent idiopathic scoliosis, Spine 25:2326, 2000. Willers U, Mormelli H, Aaro S, et al.: Long-term results of Boston brace treatment on vertebral rotation in idiopathic scoliosis, Spine 18:432, 1993. Willner S: Effect of the Boston thoracic brace on the frontal and sagittal curves of the spine, Acta Orthop Scand 55:457, 1984. Winter RB, Lonstein JE: Brace or not to brace: the true value of school screening [editorial], Spine 22:1283, 1997. Winter RB, Lonstein JE, Drogt J, et  al.: The effectiveness of bracing in the nonoperative treatment of idiopathic scoliosis, Spine 11:790, 1986. Wynarsky GT, Schultz AB: Trunk muscle activities in braced scoliosis patients, Spine 14:1283, 1989. Ylikoski M, Peltonen J, Poussa M: Biological factors and predictability of bracing in adolescent idiopathic scoliosis, J Pediatr Orthop 9:680, 1989.

OPERATIVE TREATMENT OF IDIOPATHIC SCOLIOSIS Aaro S, Ohlen G: The effect of Harrington instrumentation on the sagittal configuration and mobility of the spine in scoliosis, Spine 8:570, 1983. Akbarnia BA: Selection of methodology in surgical treatment of adolescent idiopathic scoliosis, Orthop Clin North Am 19:319, 1988. Akbarnia BA, Marks DS, Boachie-Adjei O, et  al.: Dual growing rod technique for the treatment of progressive early-onset scoliosis: a multicenter study, Spine 30:S46, 2005. Akbarnia BA, McCarthy RE: Pediatric Isola instrumentation without fusion for the treatment of progressive early-onset scoliosis. In McCarthy R, editor: Spinal instrumentation techniques, Chicago, 1998, Scoliosis Research Society. Albanese SA, Bobechko WP: Spine deformity in familial dysautonomia (Riley-Day syndrome), J Pediatr Orthop 7:179, 1987. Altiok H, Lubicky JP, DeWald CJ, Herman JE: The superior mesenteric artery syndrome in patients with spinal deformity, Spine 30:2164, 2005. Apel DM, Marrero G, King J, et al.: Avoiding paraplegia during anterior spinal surgery: the role of somatosensory-evoked potential monitoring with temporary occlusion of segmental spinal arteries, Spine 16:365, 1991. Aprin H, Bowen JR, MacEwen GD, et al.: Spine fusion in patients with spinal muscle atrophy, J Bone Joint Surg 64A:1179, 1982. Asher M, Heinig C, Carson W, et al.: ISOLA spinal implant system: principles, design, and applications. In An HS, Cotler JM, editors: Spinal instrumentation, Baltimore, 1992, Williams & Wilkins. Asher MA, Strippgen WE, Heinig CF, et  al.: ISOLA spine implant system: principles and practice, Cleveland, 1991, AcroMed. Ashman RB, Herring JA, Johnston II CE: Texas Scottish Rite Hospital (TSRH) instrumentation system. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Aurori BF, Weierman RJ, Lowell HA, et al.: Pseudarthrosis after spinal fusion for scoliosis: a comparison of autogenic and allogenic bone grafts, Clin Orthop Relat Res 199:153, 1985.

Bailey TE, Mahoney OM: The use of banked autologous blood in patients undergoing surgery for spinal deformity, J Bone Joint Surg 69A:329, 1987. Balderston RA: Cotrel-Dubousset instrumentation. In An HS, Cotler JM, editors: Spinal instrumentation, Baltimore, 1992, Williams & Wilkins. Banta CJ, King AG, Dabezies EG, et  al.: Measurement of effective pedicle diameter in the human spine, Orthopedics 12:939, 1989. Barr SJ, Scutte AM, Emans JB: Screws versus hooks: results in double-major curves in adolescent idiopathic scoliosis, Spine 22:1369, 1997. Bell GR, Gurd AR, Orlowski JP, et al.: The syndrome of inappropriate antidiuretic-hormone secretion following spinal fusion, J Bone Joint Surg 68A:720, 1986. Ben-David B: Spinal cord monitoring, Orthop Clin North Am 19:427, 1988. Benson L, Ibrahim K, Goldberg B: Coronal balance in Cotrel-Dubousset instrumentation: compensation versus decompensation. Paper presented at the annual meeting of the Scoliosis Research Society, Honolulu, September 1990. Bergoin M, Bollini G, Hornung H: Is the Cotrel-Dubousset really universal in the surgical treatment of idiopathic scoliosis? J Pediatr Orthop 8:45, 1988. Bernhardt M, Bridwell KH: Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction, Spine 14:717, 1989. Berry JL, Moran JM, Berg WS, et al.: A morphometric study of human lumbar and selected thoracic vertebrae, Spine 12:362, 1987. Beschetti GD, Moore JS, Smith JG, et al.: Techniques for exposure of the anterior thoracic and lumbar spine, Spine 12:599, 1998. Bess RS, Lenke LG, Bridwell KH, et al.: Wasting of preoperatively donated autologous blood in the surgical treatment of adolescent idiopathic scoliosis, Spine 31:2375, 2006. Betz RR, D’Andrea L: ProteusTM shape memory alloy staple surgical technique. In Medtronic technique manual, Memphis, TN, 2006, Medtronic Sofamor Danek. Betz RR, D’Andrea LP, Mulcahey MJ, Chaftz RS: Vertebral body stapling procedure for the treatment of scoliosis in the growing child, Clin Orthop Relat Res 434:55, 2005. Betz RR, Harms J, Clements DH, et al.: Comparison of anterior and posterior instrumentation for correction of adolescent thoracic idiopathic scoliosis, Spine 24:225, 1999. Betz RR, Kim J, D’Andrea LP, et  al.: An innovative technique of vertebral body stapling for the treatment of patients with adolescent idiopathic scoliosis: a feasibility, safety, and utility study, Spine 28:S255, 2003. Bieber E, Tolo V, Uematsu S: Spinal cord monitoring during posterior spinal instrumentation and fusion, Clin Orthop Relat Res 229:121, 1988. Birch JG, Herring JA, Roach JW, et al.: Cotrel-Dubousset instrumentation in idiopathic scoliosis: a preliminary report, Clin Orthop Relat Res 227:24, 1988. Blackman R: Multiple level anterior thoracic diskectomy using an endoscopic exposure. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 18–23, 1993. Blackman RG, Picetti G, O’Neal K: Endoscopic thoracic spine surgery. In White AH, Schofferman JA, editors: Spine care: operative treatment, vol 2. St. Louis, 1995, Mosby. Bollini G, Docquier PL, Viehweger E, et al.: Lumbar hemivertebra resection, J Bone Joint Surg 88A:1043, 2006. Bradford DS: Techniques of surgery. In Bradford DS, Ogilvie JW, et  al, editors: Moe’s textbook of scoliosis and other spinal deformities, ed 2, Philadelphia, 1987, WB Saunders. Bradshaw K, Webb JK, Fraser AM: Clinical evaluation of spinal cord monitoring in scoliosis surgery, Spine 9:636, 1984. Bridwell KH: Idiopathic scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Bridwell KH, Betz RR, Capelli AM, et al.: Sagittal plane analysis in idiopathic scoliosis patients treated with Cotrel-Dubousset instrumentation, Spine 15:921, 1990. Bridwell KH, McCallister JW, Betz RR, et al.: Coronal decompensation produced by Cotrel-Dubousset “derotation” maneuver for idiopathic right thoracic scoliosis, Spine 16:769, 1991. Brinker MR, Willis JK, Cook SD, et al.: Neurologic testing with somatosensory-evoked potentials in idiopathic scoliosis, Spine 17:277, 1992.

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PART XII  THE SPINE Brodsky JW, Dickson JH, Erwin WD, et al.: Hypotensive anesthesia for scoliosis surgery in Jehovah’s Witnesses, Spine 16:304, 1991. Broome G, Simpson AHRW, Catalan J, et al.: The modified Schollner costoplasty, J Bone Joint Surg 72B:894, 1990. Brown JC, Zelter JS, Swank SM, et al.: Surgical and functional results of spine fusion in spinal muscle atrophy, Spine 14:763, 1989. Brown RH, Nash Jr CL: Current status of spinal cord monitoring, Spine 4:466, 1979. Bullmann V, Fallenberg EM, Meier N, et al.: Anterior dual rod instrumentation in idiopathic thoracic scoliosis: a computed tomography analysis of screw placement relative to the aorta and the spinal canal, Spine 30:2078, 2005. Bullmann V, Halm HF, Niemeyer T, et al.: Dual-rod correction and instrumentation of idiopathic scoliosis with the Halm-Zielke instrumentation, Spine 15:1306, 2003. Bungard TJ, Kale-Pradhan PB: Prokinetic agents for the treatment of postoperative ileus in adults: a review of the literature, Pharmacotherapy 19:416, 1999. Casey MP, Asher MA, Jacobs RR, et al.: The effect of Harrington rod contouring on lumbar lordosis, Spine 12:750, 1987. Caubet JF, Emans JB, Smith VT, et  al.: Increased hemoglobin levels in patients with early onset scoliosis: prevalence and effect of a treatment with vertical expandable prosthetic titanium rib (VEPTR), Spine 34:2534, 2009. Chen SH, Huang TJ, Lee YY, et al.: Pulmonary function after thoracoplasty in adolescent idiopathic scoliosis, Clin Orthop Relat Res 399:152, 2002. Cheng I, Kim Y, Gupta MC, et al.: Apical sublaminar wires versus pedicle screws: which provides better results for surgical correction of adolescent idiopathic scoliosis? Spine 30:2104, 2005. Chopin D, Morin C: Cotrel-Dubousset instrumentation (CDI) for adolescent and pediatric scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Clark CE, Shufflebarger HL: Cotrel-Dubousset instrumentation for Scheuermann’s kyphosis. Paper presented at the annual meeting of the American Academy of Orthopaedie Surgeons, New Orleans, February, 1990. Cobb JR: The treatment of scoliosis, Conn Med J 7:467, 1943. Cobb JR: Technique, after-treatment, and results of spine fusion for scoliosis, AAOS Instruct Course Lect 9:62, 1952. Cobb JR: The problem of the primary curve, J Bone Joint Surg 42A:1413, 1960. Cochran T, Irstam L, Nachemson A: Long-term anatomic and function changes in patients with adolescent idiopathic scoliosis treated by Harrington rod fusions, Spine 8:576, 1983. Coe JD, Warden KE, Herzig MA, McAfee PC: Influence of bone mineral density on the fixation of thoracolumbar implants: a comparative study of transpedicular screws, laminar hooks, and spinous process wires, Spine 21:1759, 2007. Corovessis PG, Zielke K: Does the combined ventral derotation system (VDS) followed by Harrington instrumentation improve the vital capacity in patients with idiopathic double major curve pattern scoliosis? Clin Orthop Relat Res 283:130, 1992. Cotrel Y, Dubousset J: New segmental posterior instrumentation of the spine, Orthop Trans 9:118, 1985. Cotrel Y, Dubousset J, Guillaumat M: New universal instrumentation and spinal surgery, Clin Orthop Relat Res 227:10, 1988. Coventry MB, Tapper EM: Pelvic instability: a consequence of removing iliac bone for grafting, J Bone Joint Surg 54A:83, 1972. Crawford AH: Video-assisted thoracoscopy: minimally invasive spine surgery, Spine 11:341, 1997. Crawford AH, Wall EJ, Wolf R: Video-assisted thoracoscopy, Orthop Clin North Am 30:367, 1999. Crawford AH, Wolf RK, Wall EJ, et al.: Pediatric spinal deformity. In Regan JJ, McAfee PC, Mack MF, editors: Atlas of endoscopic spine surgery, St. Louis, 1995, Quality Medical Publishing. Crowther MA, Webb PJ, Eyre-Brook IA: Superior mesenteric artery syndrome following surgery for scoliosis, Spine 27:E528, 2002. Cundy PJ, Paterson DC, Hillier TM, et al.: Cotrel-Dubousset instrumentation and vertebral rotation in adolescent idiopathic scoliosis, J Bone Joint Surg 72B:670, 1990.

Cunningham BW, Kotani Y, McNulty PS, et al.: Video-assisted thoracoscopic surgery versus open thoracotomy for anterior thoracic spinal fusion: a comparative radiographic, biomechanical, and histologic analysis in a sheep model, Spine 23:1333, 1998. Daher YH, Lonstein JE, Winter RB, et  al.: Spinal surgery in spinal muscle atrophy, J Pediatr Orthop 5:391, 1985. Daher YH, Winter RB, Lonstein JE, et al.: Spinal deformities in patients with Friedrich’s ataxia: a review of 19 patients, J Pediatr Orthop 5:553, 1985. Daher YH, Winter RB, Lonstein JE, et al.: Spinal deformities in patients with Charcot-Marie-Tooth: a review of 12 patients, Clin Orthop Relat Res 202:219, 1986. D’Andrea LP, Betz RR, Lenke LG, et  al.: The effect of continued posterior spinal growth on sagittal contour in patients treated by anterior instrumentation for idiopathic scoliosis, Spine 25:813, 2000. Danielsson AJ, Nachemson AL: Back pain and function 23 years after fusion for adolescent idiopathic scoliosis: a case-control study, part II, Spine 28:E373, 2003. Dawson EG, Sherman JE, Kanim LEA, et al.: Spinal cord monitoring: results of the Scoliosis Research Society and the European Spinal Society survey, Spine 16:S361, 1991. Denis F: Cotrel-Dubousset instrumentation in the treatment of idiopathic scoliosis, Orthop Clin North Am 19:291, 1988. Devlin VJ, Schwartz DM: Intraoperative neurophysiologic monitoring during spinal surgery, J Am Acad Orthop Surg 15:549, 2007. Diab M, Smith AR, Kuklo TR: Spinal Deformity Study Group: neural complications in the surgical treatment of adolescent idiopathic scoliosis, Spine 32:2759, 2007. Dickman CA, Mican C: Thoracoscopic approaches for the treatment of anterior thoracic spinal pathology, Barrow Neurol Inst Q 12:4, 1996. Dickman CA, Rosenthal D, Karahalios DG, et  al.: Thoracic vertebrectomy and reconstruction using a microsurgical thoracoscopic approach, Neurosurgery 38:279, 1996. Dickson JH, Erwin WD, Rossi D: Harrington instrumentation and arthrodesis for idiopathic scoliosis: a 21-year follow-up, J Bone Joint Surg 72A:678, 1990. Dodd CAF, Fergusson CM, Freedman L, et  al.: Allograft versus autograft bone in scoliosis surgery, J Bone Joint Surg 70B:431, 1988. Dove J, Lin YT, Shen YS, et al.: Aortic aneurysm complicating spinal fixation with Dwyer’s apparatus: report of a case, Spine 6:524, 1981. Dowell JK, Powell JM, Webb PJ, et al.: Factors influencing the result of posterior spinal fusion in the treatment of adolescent idiopathic scoliosis, Spine 15:803, 1990. Dubousset J, Katti E, Seringe R: Epiphysiodesis of the spine in young children for congenital spinal deformations, J Pediatr Orthop 1:123, 1993. Dunn HK: Spinal instrumentation, part I: principles of posterior and anterior instrumentation, Instr Course Lect 32:192, 1983. Dwyer AF, Newton NC, Sherwood AA: An anterior approach to scoliosis: a preliminary report, Clin Orthop Relat Res 62:192, 1969. Dwyer AP, O’Brien JP, Seal PP, et al.: The late complications after the Dwyer anterior spinal instrumentation for scoliosis, J Bone Joint Surg 59B:117, 1977. Edgar MA, Mehta MH: Long-term follow-up of fused and unfused idiopathic scoliosis, J Bone Joint Surg 70B:712, 1988. Edmonds HL, Paloheimo MP, Backman MH, et al.: Transcranial magnetic motor evoked potentials (tcMMEP) for functional monitoring of motor pathways during scoliosis surgery, Spine 14:683, 1989. Edwards 2nd CC, Lenke LG, Peelle M, et  al.: Selective thoracic fusion for adolescent idiopathic scoliosis with C modifier lumbar curves: 2- to 16-year radiographic and clinical results, Spine 29:536, 2004. Eker ML, Betz RR, Trent PS, et  al.: Computer tomography evaluation of Cotrel-Dubousset instrumentation in idiopathic scoliosis, Spine 13:1141, 1988. Emans JB, Caubet JF, Ordonez CL, et al.: The treatment of spine and chest wall deformities with fused ribs by expansion thoracostomy and insertion of vertical expandable prosthetic titanium rib: growth of thoracic spine and improvement of lung volumes, Spine 1:S58, 2005. Engler G: Preoperative and intraoperative considerations in adolescent idiopathic scoliosis, Instr Course Lect 38:137, 1989.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Engler GL, Spielholz NI, Bernhard WN, et al.: Somatosensory-evoked potentials during Harrington instrumentation for scoliosis, J Bone Joint Surg 60A:528, 1978. Fabry G, Melkebeek JV, Bockx E: Back pain after Harrington rod instrumentation for idiopathic scoliosis, Spine 14:620, 1989. Farcy J, Weidenbaum M, Roye Jr DP: Correction of thoracic scoliosis using the Cotrel-Dubousset technique, Surg Rounds Orthop 1:11, 1987. Fernyhough JC, Schimandle JJ, Weigel MC, et al.: Chronic donor site pain complicating bone graft harvesting from the posterior iliac crest for spinal fusion, Spine 17:1474, 1992. Fitch RD, Turi M, Bowman BE, et al.: Comparison of Cotrel-Dubousset and Harrington rod instrumentations in idiopathic scoliosis, J Pediatr Orthop 10:44, 1990. Flinchum D: Rib resection in the treatment of scoliosis, South Med J 56:1378, 1963. Flinchum D: Scoliosis trouble, J Med Assoc Ga 52:67, 1963. Fraser RD: A wide muscle-splitting approach to the lumbosacral spine, J Bone Joint Surg 64B:44, 1982. Fraser RD, Gogan WJ: A modified muscle-splitting approach to the lumbosacral spine, Spine 17:943, 1992. Freeman BL, Betz RR: The pediatric spine. In Canale ST, Beaty JH, editors: Operative pediatric orthopaedics, St. Louis, 1995, Mosby. Gaines Jr RW, York DH, Watts C: Identification of spinal cord pathways responsible for the peroneal-evoked response in the dog, Spine 9:810, 1984. Gertzbein SD, Robbins SE: Accuracy of pedicular screw placement in vivo, Spine 15:11, 1990. Giehl JP, Zielke K: Zielke procedures in scoliosis correction. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Goldstein LA: Concave rib resection and ligament release for correction of idiopathic scoliosis. In American academy of orthopaedic surgeons: symposium on the spine, St. Louis, 1969, Mosby. Gollehon D, Kahanovitz N, Happel LT: Temperature effects on the feline cortical and spinal evoked potentials, Spine 8:443, 1983. Goodnough LT, Marcus RE: Effect of autologous blood donation in patients undergoing elective spine surgery, Spine 17:172, 1992. Graham EJ, Lenke LG, Lowe TG, et al.: Prospective pulmonary function evaluation following open thoracotomy for anterior spinal fusion in adolescent idiopathic scoliosis, Spine 25:2319, 2000. Granata C, Merlini L, Magni E, et al.: Spinal muscle atrophy: natural history and orthopaedic treatment of scoliosis, Spine 14:760, 1989. Gray JM, Smith BW, Ashley RK, et  al.: Derotational analysis of CotrelDubousset instrumentation in idiopathic scoliosis, Spine 16:S391, 1991. Guidera KJ, Hoote J, Weatherly W, et al.: Cotrel-Dubousset instrumentation: results in 52 patients, Spine 18:427, 1993. Hales DD, Dawson EG, Delamarter R: Late neurological complications of Harrington-rod instrumentation, J Bone Joint Surg 71A:1053, 1989. Hall JE: The anterior approach to spinal deformities, Orthop Clin North Am 3:81, 1972. Hall JE: Preoperative assessment of the patient with a spinal deformity, Instr Course Lect 34:127, 1985. Hall JE, Millis MB, Snyder BD: Short segment anterior instrumentation for thoracolumbar scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Halsall AP, James DF, Kostuik JP, et al.: An experimental evaluation of spinal flexibility with respect to scoliosis surgery, Spine 8:482, 1983. Hamill CL, Lenke LG, Bridwell KH: Use of pedicle screw fixation to improve correction in the lumbar spine in patients with idiopathic scoliosis. Is it warranted? Spine 21:1241, 1996. Hammerberg KW, Rodts MF, DeWald RL: Zielke instrumentation, Orthopedics 11:1365, 1988. Harms J: Surgical treatment of spondylolisthesis: the Harms technique. In Bridwell KH, DeWald RL, editors: Spinal surgery, Philadelphia, 1991, JB Lippincott. Harms J, Jaczienski D, Biel B: Ventral correction of thoracic scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven.

Harrington PR: Surgical instrumentation for management of scoliosis, J Bone Joint Surg 42A:1448, 1960. Harrington PR: Treatment of scoliosis: correction and internal fixation by spine instrumentation, J Bone Joint Surg 44A:591, 1962. Harrington PR, Dickson JH: An eleven-year clinical investigation of Harrington instrumentation: a preliminary report of 578 cases, Clin Orthop Relat Res 93:113, 1973. Harvey CJ, Betz RR, Huss GK, et  al: Are there indications for partial rib resection in adolescent patients treated with Cotrel-Dubousset instrumentation? Paper presented at annual meeting of the Scoliosis Research Society, Kansas City, MO, Sept 1992. Hayes MA, Tompkins SF, Herndon WA, et al.: Clinical and radiological evaluation of lumbosacral motion below fusion levels in idiopathic scoliosis, Spine 13:1161, 1988. Hedequist DJ, Hall JE, Emans JB: Hemivertebra excision in children via simultaneous anterior and posterior exposures, J Pediatr Orthop 25:60, 2005. Herron LD, Newman MH: The failure of ethylene oxide gas-sterilized freezedried bone graft for thoracic and lumbar spinal fusion, Spine 14:496, 1989. Hibbs RA: An operation for progressive spinal deformities, N Y Med J 93:1013, 1911. Hibbs RA: A report of 59 cases of scoliosis treated by the fusion operation, J Bone Joint Surg 6:3, 1924. Ho C, Skaggs DL, Weiss JM, Tolo VT: Management of infection after instrumented posterior spine fusion in pediatric scoliosis, Spine 32:2739, 2007. Hodgson AR, Stock FE: Anterior spine fusion, Br J Surg 44:266, 1956. Holcomb 3rd GW, Menzio GA: Green NE: Video-assisted thoracoscopic diskectomy and fusion, J Pediatr Surg 32:1120, 1997. Horton WC: Eliminating the reversed orientation in endoscopic spinal surgery: the technique of camera-monitor inversion. Paper presented at Endoscopic Approaches to the Spine, Memphis, TN, February 5, 2000. Horton WC, Hoh RT, Johnson JR, et al.: Zielke instrumentation in idiopathic scoliosis: late effects and minimizing complications, Spine 13:1145, 1988. Hsu LCS, Zucherman J, Tang SC, et al.: Dwyer instrumentation in the treatment of adolescent idiopathic scoliosis, J Bone Joint Surg 64B:536, 1982. Huang TJ, Hsu RW, Sum CW, et al.: Complications in thoracoscopic spinal surgery: a study of 90 consecutive patients, Surg Endosc 13:346, 1999. Huang TJ, Hsu RW, Sum CW, et al.: Video-assisted thoracoscopic surgery to the upper thoracic spine, Surg Endosc 13:123, 1999. Hur S, Huizenga BA, Major M: Acute normovolemic hemodilution combined with hypotensive anesthesia and other techniques to avoid homologous transfusion in spinal fusion surgery, Spine 17:867, 1992. Hutchinson DT, Bassett GS: Superior mesenteric artery syndrome in pediatric orthopaedic patients, Clin Orthop Relat Res 250:250, 1990. Jefferson RJ, Weisz I, Turner-Smith AR, et al.: Scoliosis and its effect on back shape, J Bone Joint Surg 70B:261, 1988. Johnson RM, McGuire EJ: Urogenital complications of anterior approaches to the lumbar spine, Clin Orthop Relat Res 154:114, 1981. Johnston II CE, Ashman RB, Baird AM, et al.: Effect of construct stiffness on early fusion mass incorporation: experimental study, Spine 15:908, 1990. Johnston II CE, Herring JA, Ashman RB: Texas Scottish Rite Hospital (TSRH) universal spinal instrumentation system. In An HS, Cotler JM, editors: Spinal instrumentation, Baltimore, 1992, Williams & Wilkins. Jones SJ, Edgar MA, Ransford AO, et al.: A system for the electrophysiological monitoring of the spinal cord during operations for scoliosis, J Bone Joint Surg 65B:134, 1983. Kaiser LR, Bavaria JE: Complications of thoracoscopy, Ann Thorac Surg 56:796, 1993. Kalen V, Conklin M: The behavior of the unfused lumbar curve following selective thoracic fusion for idiopathic scoliosis, Spine 15:271, 1990. Kaneda K, Fujiya N, Satoh S: Results with Zielke instrumentation for idiopathic thoracolumbar and lumbar scoliosis, Clin Orthop Relat Res 195:205, 1986. Kaneda K, Shona Y, Situ S, et  al.: Anterior correction of thoracic scoliosis with Kaneda anterior spinal system, a preliminary report, Spine 22:1358, 1997.

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PART XII  THE SPINE Karol LA, Johnston C, Mladenov K, et  al.: Pulmonary function following early thoracic fusion in non-neuromuscular scoliosis, J Bone Joint Surg 90A:1272, 2008. Kepes ER, Martinez LR, Andrews IC, et al.: Anesthetic problems and hereditary muscular abnormalities, NY State J Med 72:1051, 1972. Kim YJ, Bridwell KH, Lenke LG, et al.: Pseudarthrosis in adult spinal deformity following multisegmental instrumentation and arthrodesis, J Bone Joint Surg 88A:721, 2006. Kim YJ, Bridwell KH, Lenke LG, et al.: Proximal junctional kyphosis in adolescent idiopathic scoliosis following segmental posterior spinal instrumentation and fusion: minimum 5-year follow-up, Spine 30:2045, 2005. Kim YJ, Lenke LG, Bridwell KH, et al.: Free hand pedicle screw placement in the thoracic spine: is it safe? Spine 29:333, 2004. Kim YJ, Lenke LG, Bridwell KH, et  al.: Pulmonary function in adolescent idiopathic scoliosis relative to the surgical procedure, J Bone Joint Surg 87A:1534, 2005. Kim YJ, Lenke LG, Cheh G, et al.: Evaluation of pedicle screw placement in the deformed spine using intraoperative plain radiographs: a comparison with computerized tomography, Spine 30:2084, 2005. Kim YJ, Lenke LG, Cho SK, et al.: Comparative analysis of pedicle screw versus hook instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis, Spine 29:2040, 2004. King HA: Selection of fusion levels for posterior instrumentation and fusion in idiopathic scoliosis, Orthop Clin North Am 19:247, 1988. King HA, Moe JH, Bradford DS, et al.: The selection of the fusion levels in thoracic idiopathic scoliosis, J Bone Joint Surg 65A:1302, 1983. King AG, Mills TE, Loe WA, et al.: Video-assisted thoracoscopic surgery in the prone position, Spine 25:2403, 2000. Knapp DR, Jones ET: Use of cortical allograft for posterior spinal fusion, Clin Orthop Relat Res 229:99, 1988. Knapp Jr DR, Jones ET, Blanco JS, et al.: Allograft bone in spinal fusion for adolescent idiopathic scoliosis, J Spinal Disord Tech 18:S73, 2005. Knapp Jr DR, Price CT, Jones ET, et al.: Choosing fusion levels in progressive thoracic idiopathic scoliosis, Spine 17:1159, 1992. Kohler R, Galland O, Mechin H, et al.: The Dwyer procedure in the treatment of idiopathic scoliosis: a 10-year follow-up review of 21 patients, Spine 15:75, 1990. Korovessis P: Combined VDS and Harrington instrumentation for treatment of idiopathic double major curves, Spine 12:244, 1987. Kostuik JP: Recent advances in the treatment of painful adult scoliosis, Clin Orthop Relat Res 147:238, 1980. Krag MH: Biomechanics of thoracolumbar spinal fixation: a review, Spine 16(Suppl):S84, 1991. Krag MH, Van Hal ME, Beynnon BD: Placement of transpedicular vertebral screws close to anterior vertebral cortex: description of methods, Spine 14:879, 1989. Krag MH, Weaver DL, Beynnon BD, et al.: Morphometry of the thoracic and lumbar spine related to transpedicular screw placement for surgical spine fixation, Spine 13:27, 1988. Krasna MJ, Mack MJ, editors: Atlas of thoracoscopic surgery, St. Louis, 1994, Quality Medical Publishing. Krismer M, Bauer R, Sterzinger W: Scoliosis correction by Cotrel-Dubousset instrumentation: the effect of derotation and three-dimensional correction, Spine 17:S263, 1992. Kuklo TR, Lehman Jr RA, Lenke LG: Structures at risk following anterior instrumented spinal fusion for thoracic adolescent idiopathic scoliosis, J Spinal Disord Tech 18:S58, 2005. Kuklo TR, Lenke LG, Graham EG, et al.: Correlation of radiographic, clinical, and patient assessment of shoulder balance following fusion versus nonfusion of the proximal thoracic curve in adolescent idiopathic scoliosis, Spine 27:2013, 2002. Kuklo TR, Potter BK, Polly Jr DW, et al.: Monaxial versus multiaxial thoracic pedicle screws in the correction of adolescent idiopathic scoliosis, Spine 30:2113, 2005. Kurz LT, Garfin SR, Booth Jr RE: Harvesting autogenous iliac bone grafts: a review of complications and techniques, Spine 14:1324, 1989. Lagrone MO: Loss of lumbar lordosis: a complication of spinal fusion for scoliosis, Orthop Clin North Am 19:383, 1988.

Lagrone MO, Bradford DS, Moe JH, et al.: Treatment of symptomatic flatback after spinal fusion, J Bone Joint Surg 70A:569, 1988. Landin P, Nachemson A: Transfusion-related non-a, non-b hepatitis in elective spine deformity surgery patients in Gothenburg, Sweden, Spine 14:1033, 1989. Landreneau RJ, Mack MJ, Hazelrig SR, et al.: Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies, Ann Thorac Surg 54:800, 1992. Larson SJ, Walsh PR, Sances A, et  al.: Evoked potentials in experimental myelopathy, Spine 5:299, 1980. Lascombes P: CD Horizon Legacy Spinal System-deformity, surgical technique manual, Memphis, TN, 2005, Medtronic Sofamor Danek. Lee SM, Suk SI, Chung ER: Direct vertebral rotation: a new technique of three-dimensional deformity correction with segmental pedicle screw fixation in adolescent idiopathic scoliosis, Spine 29:343, 2004. Lenke LG: Basic techniques of posterior segmental spine internal fixation. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Lenke LG, Betz RR, Bridwell KH, et al.: Spontaneous lumbar curve coronal correction after selective anterior or posterior thoracic fusion in adolescent idiopathic scoliosis, Spine 24:1663, 1999. Lenke LG, Bridwell KH, Baldus C, et al.: Analysis of pulmonary function and axis rotation in adolescent and young adult idiopathic scoliosis patients treated with Cotrel-Dubousset instrumentation, J Spinal Disord 5:16, 1992. Lenke LG, Bridwell KH, Baldus C, et al.: Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis, J Bone Joint Surg 74A:1056, 1992. Lenke LG, Bridwell KH, Baldus C, et al.: Preventing decompensation in King type II curves treated with Cotrel-Dubousset instrumentation: strict guidelines for selective thoracic fusion, Spine 17:S274, 1992. Lenke LG, King AG: CD Horizon Legacy iliac fixation spinal system guide, Memphis, TN, 2004, Medtronic Sofamor Danek. Levy Jr WJ: Clinical experience with motor and cerebellar-evoked potential monitoring, Neurosurgery 20:169, 1987. Lichtblau S: Dislocation of the sacroiliac joint: a complication of bone grafting, J Bone Joint Surg 44A:193, 1962. Liljenqvist UR, Halm HFH, Link TM: Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosis, Spine 22:2239, 1997. Longley MCH, Lonstein JE: Spinal decompensation after Cotrel-Dubousset instrumentation, Orthop Consult 13:1, 1992. Lonstein JE, Renshaw TS: Neuromuscular spine deformities, Instr Course Lect 36:285, 1987. Lowe TG: Morbidity and mortality committee report. Paper presented at 22nd annual meeting of the Scoliosis Research Society, Vancouver, September 1987. Lowe TG, Peters JD: Anterior spinal fusion with Zielke instrumentation for idiopathic scoliosis: a frontal and sagittal curve analysis in 36 patients, Spine 18:423, 1993. Lueders H, Gurd A, Hahn J, et al.: A new technique for intraoperative monitoring of spinal cord function: multichannel recording of spinal cord and subcortical-evoked potentials, Spine 7:110, 1982. Luhmann SJ, Lenke LG, Kim YJ, et al.: Thoracic adolescent idiopathic scoliosis curves between 70 degrees and 100 degrees: is anterior release necessary? Spine 30:2061, 2005. Luk KDK, Lee FB, Leong JCY, et al.: The effect on the lumbosacral spine of long spinal fusion for idiopathic scoliosis: a minimum ten-year followup, Spine 12:996, 1987. MacEwen GD, Bennett E, Guille JT: Autologous blood transfusions in children and young adults with low body weight undergoing spinal surgery, J Pediatr Orthop 10:750, 1990. Machida M, Weinstein SL, Yamada T, et  al.: Spinal cord monitoring: electrophysiological measures of sensory and motor function during spinal surgery, Spine 10:407, 1985. Mack MJ, Regan JJ, McAfee PC, et al.: Video-assisted thoracic surgery for the anterior approach to the thoracic spine, Ann Thorac Surg 59:1100, 1995. Madigan RR, Linton BS, Wallace SL, et al.: A new technique to improve cortical-evoked potentials in spinal cord monitoring, Spine 12:330, 1987.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Majd ME, Castro FE, Holt RT: Anterior fusion for idiopathic scoliosis, Spine 25:696, 2000. Mann DC, Nash CL, Wilham MR, et al.: Evaluation of the role of concave rib osteotomies in the correction of thoracic scoliosis, Spine 14:491, 1989. Mann DC, Wilham MR, Brower EM, et al.: Decreasing homologous blood transfusion in spinal surgery by use of the cell saver and predeposited blood, Spine 14:1296, 1989. Mardjetko SM, Hammerberg KW, Lubicky JP, Fister JS: The Luque trolley revisited: review of nine cases requiring revision, Spine 17:582, 1992. Marsicano JG, Lenke LG, Bridwell KH, et  al.: The lordotic effect of the OSI frame on operative adolescent idiopathic scoliosis patients, Spine 23:1341, 1998. Mason DE, Crango P: Spinal decompensation in Cotrel-Dubousset instrumentation, Spine 16:S394, 1991. Mason RJ, Betz RR, Orlowski JP, et al.: The syndrome of inappropriate antidiuretic hormone secretion and its effect on blood indices following spinal fusion, Spine 14:722, 1989. McAfee P, Regan J, Zdeblick T, et  al.: The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery, Spine 20:1624, 1995. McCall RE, Bronson W: Criteria for selective fusion in idiopathic scoliosis using Cotrel-Dubousset instrumentation, J Pediatr Orthop 12:475, 1992. McCarthy RE, Peek RD, Morrissy RT, et al.: Allograft bone and spinal fusion for paralytic scoliosis, J Bone Joint Surg 68A:370, 1986. Mehlman CT, Al-Sayyad MJ, Crawford AH: Effectiveness of spinal release and halo-femoral traction in the management of severe spinal deformity, J Pediatr Orthop 24:667, 2004. Mehlman CT, Crawford AH: Video-assisted thoracoscopic surgery: pediatric orthopaedic applications. In Zdeblick T, editor: Anterior approaches in spine surgery, St. Louis, 1995, Quality Medical Publishing. Mehlman CT, Crawford AH, Wolf RK: Video-assisted thoracic surgery: endoscopic thoracoplasty technique, Spine 22:2178, 1997. Michel CR, Lalain JJ: Late results of Harrington’s operation: long-term evolution of the lumbar spine below the fused segments, Spine 10:414, 1985. Mirkovic S, Abitbol JJ, Steinman J, et al.: Anatomic considerations for sacral screw placement, Spine 16(Suppl):289, 1991. Moe JH: A critical analysis of methods of fusion for scoliosis: an evaluation in 266 patients, J Bone Joint Surg 40A:529, 1958. Moe JH: Methods of correction and surgical techniques in scoliosis, Orthop Clin North Am 3:17, 1972. Moe JH, Purcel GA, Bradford DS: Zielke instrumentation (VDS) for the correction of spinal curvature, Clin Orthop Relat Res 180:133, 1983. Moore MR, Baynham GC, Brown CW, et al.: Analysis of factors related to truncal decompensation following Cotrel-Dubousset instrumentation, J Spinal Disord 4:188, 1991. Moore SV: Segmental spinal instrumentation: complications, correction, and indications, Orthop Trans 7:413, 1983. Moskowitz A, Moe JH, Winter RB, et al.: Long-term follow-up of scoliosis fusion, J Bone Joint Surg 62A:364, 1980. Mubarak SJ, Wenger DR, Leach J: Evaluation of Cotrel-Dubousset instrumentation for treatment of idiopathic scoliosis, Update Spinal Disord 2(3), 1987. Naito M, Owen JH, Bridwell KH, et al.: Effects of distraction on physiologic integrity of the spinal cord, spinal cord bloodflow, and clinical status, Spine 17:1154, 1992. Nakamura H, Matsuda H, Konishi S, et al.: Single-stage excision of hemivertebrae via the posterior approach alone for congenital spine deformity: follow-up period longer than ten years, Spine 27:110, 2002. Nasca RJ, Lemons JE, Montgomery R: Evaluation of cryopreserved bone and synthetic biomaterials in promoting spinal fusion, Spine 16:S330, 1991. Nash C, Moe J: A study of vertebral rotation, J Bone Joint Surg 51A:223, 1969. Newton PO, Cardelia JM, Farnsworth CL, et al.: Biomechanical comparison of open and thoracoscopic anterior spinal release in a goat model, Spine 23:530, 1998. Newton PO, Shea KG, Granlund KF: Defining the pediatric spinal thoracoscopy learning curve, 65 consecutive cases, Spine 25:1028, 2000. Newton PO, Wenger DR, Mubarak SJ, et al.: Anterior release and fusion in pediatric spinal deformity: a comparison of early outcome and cost of thoracoscopic and open thoracotomy approaches, Spine 22:1398, 1997.

Nickel VL, Perry J, Affeldt JE, et al.: Elective surgery on patients with respiratory paralysis, J Bone Joint Surg 39A:989, 1957. O’Brien MF, Lenke LG, Bridwell KH, et al: Recognition and treatment of the proximal thoracic curve in adolescent idiopathic scoliosis treated with Cotrel-Dubousset instrumentation. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. Oga M, Ikuta H, Sugioka Y: The use of autologous blood and the surgical treatment of spinal disorders, Spine 17:1381, 1992. Ogiela DM, Chan PK: Ventral derotation spondylodesis: a review of 22 cases, Spine 11:18, 1986. Ogilvie JW: Anterior spine fusion with Zielke instrumentation for idiopathic scoliosis in adolescents, Orthop Clin North Am 19:313, 1988. Olsewski JM, Simmons EH, Kallen FC, et al.: Morphometry of the lumbar spine: anatomical perspectives related to transpedicular fixation, J Bone Joint Surg 72A:541, 1990. Owen JH, Laschinger J, Bridwell K, et  al.: Sensitivity and specificity of somatosensory- and neurogenic motor-evoked potentials in animals and humans, Spine 13:1111, 1988. Owen R, Turner DA, Bamforth JS, et al.: Costectomy as the first stage of surgery for scoliosis, J Bone Joint Surg 68B:91, 1986. Passuti N, Daculsi G, Rogez JM, et  al.: Macroporous calcium phosphate ceramic performance in human spine fusion, Clin Orthop Relat Res 248:169, 1989. Phillips WA, Hensinger RN: Control of blood loss during scoliosis surgery, Clin Orthop Relat Res 229:88, 1988. Picetti III GD: CD Horizon Eclipse Spinal System surgical technique manual, Memphis, TN, 1999, Medtronic Sofamor Danek. Pinto MR: Complications of pedicle screw fixation, Spine 6:45, 1992. Polly Jr DW: Material presented at spinal deformity: challenges and solutions of surgical treatment, Puerto Rico 12–13, 2000. Ponseti IV, Friedman B: Changes in the scoliotic spine after fusion, J Bone Joint Surg 32A:751, 1950. Potter BK, Kuklo TR, Lenke LG: Radiographic outcomes of anterior spinal fusion versus posterior spinal fusion with thoracic pedicle screws for treatment of Lenke type I adolescent idiopathic scoliosis curves, Spine 30:1859, 2005. Pullock FE, Pollock Jr FE: Idiopathic scoliosis: correction of lateral and rotational deformities using the Cotrel-Dubousset spinal instrumentation system, South Med J 83:161, 1990. Puno RM, Grossfeld SL, Johnson JR, et al.: Cotrel-Dubousset instrumentation in idiopathic scoliosis, Spine 17:S258, 1992. Puno RM, Johnson JR, Ostermann PA, et al.: Analysis of the primary and compensatory curvatures following Zielke instrumentation for idiopathic scoliosis, Spine 14:738, 1989. Rappaport M, Hall K, Hopkins K, et al.: Effects of corrective scoliosis surgery on somatosensory-evoked potentials, Spine 7:404, 1982. Regan JJ, Mack MJ, Picetti MG: Comparison of VAT to open thoracotomy in thoracic spinal surgery, Orthop Trans 18:112, 1994. Regan JJ, Mack MJ, Picetti GD: A technical report on video-assisted thoracoscopy in thoracic spinal surgery, Spine 20:831, 1995. Regan JJ, McAfee PC: Thoracoscopy and laparoscopy of the spine. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Relton JES, Hall JE: An operation frame for spinal fusion: a new apparatus designed to reduce haemorrhage during operation, J Bone Joint Surg 49B:327, 1967. Richards BS: Lumbar curve response in type II idiopathic scoliosis after posterior instrumentation of the thoracic curve, Spine 17:S282, 1992. Richards BS, Birch JG, Herring JA, et  al.: Frontal plane and sagittal plane balance following Cotrel-Dubousset instrumentation for idiopathic scoliosis, Spine 14:733, 1989. Richards BS, Johnston II CE: Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis, Orthopedics 10:649, 1987. Riddick M, Winter RB, Lutter L: Spinal deformities in patients with spinal muscle atrophy, Spine 8:476, 1982. Rinella A, Lenke L, Whitaker C, et al.: Perioperative halo-gravity traction in the treatment of severe scoliosis and kyphosis, Spine 30:475, 2005. Riseborough EJ: The anterior approach to the spine for the correction of deformities of the axial skeleton, Clin Orthop Relat Res 93:207, 1973.

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PART XII  THE SPINE Roaf R: The treatment of progressive scoliosis by unilateral growth arrest, J Bone Joint Surg 45B:637, 1963. Roth A, Rosenthal A, Hall JE, et al.: Scoliosis and congenital heart disease, Clin Orthop Relat Res 93:95, 1973. Roye Jr DP, Farcy JP, Rickert JB, et al.: Results of spinal instrumentation of adolescent idiopathic scoliosis by King type, Spine 17:S270, 1992. Ruf M, Harms J: Pedicle screws in 1- and 2-year-old children: technique, complications, and effect on further growth, Spine 27:E460, 2002. Ryan TP, Britt RH: Spinal and cortical somatosensory-evoked potential monitoring during corrective spinal surgery with 108 patients, Spine 11:352, 1986. Sariak AY, Atmaca H, Buluc L, et  al.: Juvenile idiopathic scoliosis treated with posterior arthrodesis and segmental pedicle screw instrumentation before the age of 9 years: a 5-year follow-up study, Scoliosis 4:1, 2009. Schram RA, Allen Jr BL, Ferguson RL: Rib regeneration area as an indicator of fusion area in adolescent idiopathic scoliosis, Spine 12:346, 1987. Shono Y, Abumi K, Kaneda K: One-stage posterior hemivertebra resection and correction using segmental posterior instrumentation, Spine 26:752, 2001. Shono Y, Kaneda K, Yamamoto I: A biomechanical analysis of Zielke, Kanada, and Cotrel-Dubousset instrumentations in thoracolumbar scoliosis: a calf spine model, Spine 16:1305, 1991. Shufflebarger HL: Clinical issue: rod rotation in scoliosis surgery, Warsaw, IN, 1994, DePuy Motech. Shufflebarger HL: The theory of the segmental approach to spinal instrumentation: a definitive method of planning spinal instrumentation for every spinal pathology, Warsaw, IN, 1994, DePuy Motech. Shufflebarger HL: Thoracoplasty anterior technique. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Shufflebarger HL, Clark CE: Cotrel-Dubousset instrumentation, Orthopedics 11:1435, 1988. Shufflebarger HL, Clark CE: Fusion levels and hook patterns in thoracic scoliosis with Cotrel-Dubousset instrumentation, Spine 15:916, 1990. Shufflebarger HL, Geck MJ, Clark CE: The posterior approach for lumbar and thoracolumbar adolescent idiopathic scoliosis: posterior shortening and pedicle screws, Spine 29:269, 2004. Shufflebarger HL, Harms J: Moss Miami three-dimensional spinal instrumentation: surgical technique, Warsaw, IN, 1994, DePuy Motech. Shufflebarger HL, Harms J: Moss Miami three-dimensional spinal instrumentation: taking spinal instrumentation to a new dimension, Warsaw, IN, 1994, DePuy Motech. Skaggs DL, Choi PD, Rice C, et al.: Efficacy of intraoperative neurologic monitoring in surgery involving a vertical expandable prosthetic titanium rib for early-onset spinal deformity, J Bone Joint Surg 91A:1657, 2009. Skaggs DL, Sankar WN, Albrekston J, et al.: Weight gain following vertical expandable prosthetic titanium ribs surgery in children with thoracic insufficiency syndrome, Spine 34:2530, 2009. Smith AD, von Lackum WH, Wylie R: An operation for stapling vertebral bodies in congenital scoliosis, J Bone Joint Surg 36A:342, 1954. Smith RM, Pool RO, Butt WP, et al.: The transverse plane deformity of structural scoliosis, Spine 16:1126, 1991. Sorenson J, Asher M: Six degrees freedom of motion analysis of biplanar radiographs: comparison of two instrumentation techniques for treatment of thoracolumbar/lumbar adolescent idiopathic scoliosis. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. Steel HH: Rib resection and spine fusion and correction of convex deformity in scoliosis, J Bone Joint Surg 65A:920, 1983. Sucato DJ, Elerson E: A comparison between the prone and lateral position for performing a thoracoscopic anterior release and fusion for pediatric spinal deformity, Spine 28:2176, 2003. Suk SI, Kim JH, Kim WJ, et  al.: Posterior vertebral column resection for severe spinal deformities, Spine 27:2374, 2002. Suk SI, Kim WJ, Kim JH, et  al.: Restoration of thoracic kyphosis in the hypokyphotic spine: a comparison between multiple-hook and segmental pedicle screw fixation in adolescent idiopathic scoliosis, J Spinal Disord 12:489, 1999.

Suk SI, Lee CK, Kim JH, et al.: Segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis, Spine 20:1399, 1995. Swank SM, Mauri TM, Brown JC: The lumbar lordosis below Harrington instrumentation for scoliosis, Spine 15:181, 1990. Szalay EA, Carollo JJ, Roach JW: Sensitivity of spinal cord monitoring to intraoperative events, J Pediatr Orthop 6:437, 1986. Tate DE, Friedman RJ: Blood conservation in spinal surgery: review of current techniques, Spine 17:1450, 1992. Thompson GH, Akbarnia BA, Campbell Jr RM: Growing rod techniques in early-onset scoliosis, J Pediatr Orthop 27:354, 2007. Thompson GH, Akbarnia BA, Kostial P, et al.: Comparison of single and dual growing rod techniques followed through definitive surgery: a preliminary study, Spine 30:2039, 2005. Thompson JD, Callaghan JJ, Savory CG, et al.: Prior deposition of autologous blood in elective orthopaedic surgery, J Bone Joint Surg 69A:320, 1987. Thompson JP, Transfeldt EE, Bradford DS, et  al.: Decompensation after Cotrel-Dubousset instrumentation of idiopathic scoliosis, Spine 15:927, 1990. Tolo VT: Surgical treatment of adolescent idiopathic scoliosis, Instr Course Lect 38:143, 1989. Trammell TR, Benedict F, Reed D: Anterior spine fusion using Zielke instrumentation for adult thoracolumbar and lumbar scoliosis, Spine 16:307, 1991. Tredwell SJ, Sawatzky B: The use of fibrin sealant to reduce blood loss during Cotrel-Dubousset instrumentation for idiopathic scoliosis, Spine 15:913, 1990. Turi M, Johnston CE, Richards BS: Anterior correction of idiopathic scoliosis using TSRH instrumentation, Spine 18:417, 1993. Vauzelle C, Stagnara P, Jouvinroux P: Functional monitoring of spinal cord activity during spinal surgery, Clin Orthop Relat Res 93:173, 1973. Vedantam R, Lenke LG, Bridwell KH, et al.: A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis relative to the surgical approach used for spinal arthrodesis, Spine 25:82, 2000. Violas P, Chapuis M, Bracq H: Local autograft bone in the surgical management of adolescent idiopathic scoliosis, Spine 29:189, 2004. Waisman M, Saute M: Thoracoscopy spine release before posterior instrumentation and scoliosis, Clin Orthop Relat Res 336:130, 1997. Wall EJ, Bylski-Austrow DI, Shelton FS, et  al.: Endoscopic discectomy increases thoracic spine flexibility as effectively as open discectomy: a mechanical study in a porcine model, Spine 23:9, 1998. Weatherly CR, Draycott V, O’Brien JF, et  al.: The rib deformity in adolescent idiopathic scoliosis: a prospective study to evaluate changes after Harrington distraction and posterior fusion, J Bone Joint Surg 69B:179, 1987. Weinstein JN, Rydevik BL, Rauschning W, et  al.: Anatomic and technical considerations of pedicle screw fixation, Clin Orthop Relat Res 284:34, 1992. Weinstein JN, Spratt KF, Spengler D, et al.: Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement, Spine 13:1012, 1988. Weis JC, Betz RR, Clements DH: The prevalence of perioperative complications following anterior spinal fusion in patients with idiopathic scoliosis. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. Wenger DR, Mubarak SJ, Leach J: Managing complications of posterior spinal instrumentation and fusion, Clin Orthop Relat Res 284:24, 1992. Westfall SH, Akbarnia BA, Merenda JT, et al.: Exposure of the anterior spine: technique, complications, and results in 85 patients, Am J Surg 154:700, 1987. Willers U, Hedlund R, Aaro S, et al.: Long-term results of Harrington instrumentation in idiopathic scoliosis, Spine 18:713, 1993. Winter RB: Posterior spinal fusion in scoliosis: indications, techniques, and results, Orthop Clin North Am 10:787, 1979. Winter RB: The idiopathic double thoracic curve pattern: its recognition and surgical management, Spine 14:1287, 1989. Winter RB, Lovell WW, Moe JH: Excessive thoracic lordosis and loss of pulmonary function in patients with idiopathic scoliosis, J Bone Joint Surg 57A:972, 1974.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Wojcik AS, Webb JK, Burwell RG: An analysis of the effect of the Zielke operation on S-shaped curves in idiopathic scoliosis, Spine 14:625, 1989. Wojcik AS, Webb JK, Burwell RG: An analysis of the effect of the Zielke operation on S-shaped curves in idiopathic scoliosis: a follow-up study revealing some skeletal and soft tissue factors involved in curve progression, Spine 15:816, 1990. Wojcik AS, Webb JK, Burwell RG: Harrington-Luque and Cotrel-Dubousset instrumentation for idiopathic scoliosis: a postoperative comparison using segmental radiologic analysis, Spine 15:424, 1990. Wood KB, Dekutoski MB, Schendel MJ: Rotational changes of the vertebralpelvic axis following Isola sublaminar instrumentation. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. Wood KB, Olsewski JM, Schendel MJ, et al.: Rotational changes of vertebral pelvic access after sublaminar instrumentation in adolescent idiopathic scoliosis, Spine 22:51, 1997. Wood KB, Transfeldt EE, Ogilvie JW, et al.: Rotational changes of the vertebral-pelvic axis following Cotrel-Dubousset instrumentation, Spine 16:S404, 1991. Woodson ST, Marsh JS, Tanner JB: Transfusion of previously deposited autologous blood for patients undergoing hip-replacement surgery, J Bone Joint Surg 69A:325, 1987. Wu Z: Posterior vertebral instrumentation for correction of scoliosis, Clin Orthop Relat Res 215:40, 1987. York DH, Cabot RJ, Gaines RW: Response variability of somatosensoryevoked potentials during scoliosis surgery, Spine 12:864, 1987. Yoslow W, Becker MH, Bartels J, et al.: Orthopaedic defects in familial dysautonomia: a review of 65 cases, J Bone Joint Surg 53A:1541, 1971. Zagra A, Lamartina C, Pace A, et al.: Posterior spinal fusion in scoliosis: computer-assisted tomography and biomechanics of the fusion mass, Spine 13:155, 1988. Zhu ZZ, Qiu Y: Superior mesenteric artery syndrome following scoliosis surgery: its risk indicators and treatment strategy, World J Gastroenterol 11:3307, 2005. Zielke K: Derotation and fusion: anterior spinal instrumentation, Orthop Trans 2:270, 1978. Zielke K, Berthet A: Ventral derotation spondylodesis: preliminary report on 58 cases, Beitr Orthop Traumatol 25:85, 1978. Zindrick MR: Clinical pedicle anatomy, Spine 6:11, 1992. Zindrick MR, Wiltse LL, Doornik A, et  al.: Analysis of the morphometric characteristics of the thoracic and lumbar pedicles, Spine 12:160, 1987.

NEUROMUSCULAR SCOLIOSIS (GENERAL) Allen Jr BL: The place for segmental instrumentation in the treatment of spine deformity, Orthop Trans 6:21, 1982. Allen Jr BL: Segmental spinal instrumentation with L-rods, Instr Course Lect 32:202, 1983. Allen BL, Ferguson RL: The Galveston technique for L-rod instrumentation of the scoliotic spine, Spine 7:119, 1982. Allen BL, Ferguson RL: L-rod instrumentation (LRI) for scoliosis in cerebral palsy, J Pediatr Orthop 2:87, 1982. Allen Jr BL, Ferguson RL: Neurologic injuries with the Galveston technique of L-rod instrumentation for scoliosis, Spine 11:14, 1986. Allen Jr BL, Ferguson RL: A 1988 perspective on the Galveston technique of pelvic fixation, Orthop Clin North Am 19:409, 1988. Allen Jr BL, Ferguson RL: The Galveston experience with L-rod instrumentation for adolescent idiopathic scoliosis, Clin Orthop Relat Res 229:59, 1988. Bell DF, Moseley CF, Koreska J: Unit rod segmental spinal instrumentation in the management of patients with progressive neuromuscular spinal deformity, Spine 14:1301, 1989. Bernard TN, Johnson II CE: Late complications due to wire breakage in segmental spinal instrumentation, J Bone Joint Surg 65A:1339, 1983. Boachie-Adjei O, Asher M: ISOLA instrumentation. In McCarthy R, editor: Spinal instrumentation techniques, Chicago, 1998, Scoliosis Research Society. Boachie-Adjei O, Lonstein JE, Winter RB, et al.: Luque segmental instrumentation in management of neuromuscular spinal deformities, J Bone Joint Surg 71A:548, 1989.

Bonnett C, Brown JC, Perry J, et al.: The evolution of treatment of paralytic scoliosis at Rancho Los Amigos Hospital, J Bone Joint Surg 57A:206, 1975. Broadstone T: Consider postoperative immobilization of double L-rod SSI patients, Orthop Trans 8:171, 1984. Brook PD, Kennedy JD, Stern LM, et al.: Spinal fusion in Duchenne’s muscular dystrophy, J Pediatr Orthop 16:324, 1996. Broom MJ, Banta JV, Renshaw TS: Spinal fusion augmented by Luque-rod segmental instrumentation for neuromuscular scoliosis, J Bone Joint Surg 71A:32, 1989. Brown JC, Swank SM, Matta J, et al.: Late spinal deformity in quadriplegic children and adolescents, J Pediatr Orthop 4:456, 1984. Camp JF, Caudle R, Ashman RD, et al.: Immediate complications of CotrelDubousset instrumentation to the sacropelvis: a clinical and biomechanical study, Spine 15:932, 1990. DeWald RL, Faut MM: Anterior and posterior spinal fusion for paralytic scoliosis, Spine 4:401, 1979. Eberle CF: Failure of fixation after segmental spinal instrumentation without arthrodesis in the management of paralytic scoliosis, J Bone Joint Surg 70A:696, 1988. Farcy JC, Rawlins BA, Glassman SD: Technique and results of fixation to the sacrum with iliosacral screws, Spine 17:S190, 1992. Ferguson RL, Allen Jr BL: Segmental spinal instrumentation for routine scoliotic curve, Contemp Orthop 2:450, 1980. Ferguson RL, Allen BL: Staged correction of neuromuscular scoliosis, J Pediatr Orthop 3:555, 1983. Gaines Jr RW, Abernathie DL: Mersilene tapes as a substitute for wire in segmental spinal instrumentation for children, Spine 11:907, 1986. Goll SR, Balderston RA, Stambough JL, et al.: Depth of intraspinal wire penetration during passage of sublaminar wires, Spine 13:503, 1988. Greene WB, Miles JD: A modified technique for insertion of unit rod into the pelvis, Am J Orthop 29:401, 2000. Herndon WA, Sullivan JA, Yngve DA, et al.: Segmental spinal instrumentation with sublaminar wires: a critical appraisal, J Bone Joint Surg 69A:851, 1987. Herring JA, Wenger DR: Early complications of segmental spinal instrumentation, Orthop Trans 6:22, 1982. Herring JA, Wenger DR: Segmental spinal instrumentation: a preliminary report of 40 consecutive cases, Spine 7:285, 1982. Johnston CE, Ashman RB, Sherman MC: Mechanical consequences of rod contouring and residual scoliosis in sublaminar pelvic SSI, Orthop Trans 10:5, 1986. Johnston CE, Happel LT, Randall N, et al.: Delayed paraplegia complicating sublaminar segmental spinal instrumentation, J Bone Joint Surg 68A:556, 1986. Kepes ER, Martinez LR, Andrews IC, et al.: Anesthetic problems in hereditary muscular abnormalities, N Y State J Med 72:1051, 1972. Letts M, Rathbone D, Yamashita T, et al.: Soft Boston orthosis in management of neuromuscular scoliosis: a preliminary report, J Pediatr Orthop 12:470, 1992. Lieponis JV, Bunch WH, Lonser RE, et al.: Spinal cord injury during segmental sublamina spinal instrumentation: an animal model, Orthop Trans 8:173, 1984. Lonstein JE, Renshaw TS: Neuromuscular spine deformities, Instr Course Lect 36:285, 1987. Luque ER: Segmental spinal instrumentation: a method of rigid internal fixation of the spine to induce arthrodesis, Orthop Trans 4:391, 1980. Luque ER: Paralytic scoliosis in growing children, Clin Orthop Relat Res 163:202, 1982. Luque ER: Segmental spinal instrumentation for correction of scoliosis, Clin Orthop Relat Res 163:192, 1982. Luque ER: The anatomic basis and development of segmental spinal instrumentation, Spine 7:256, 1982. Luque ER, Cardoso A: Segmental correction of scoliosis with rigid internal fixation, Orthop Trans 1:136, 1977. Maloney WJ, Rinsky LA, Gamble JG: Simultaneous correction of pelvis obliquity, frontal plane, and sagittal plane deformities and neuromuscular scoliosis using a unit rod with segmental sublaminar wires: a preliminary report, J Pediatr Orthop 10:742, 1990.

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PART XII  THE SPINE McCall RE, Hayes B: Long-term outcome in neuromuscular scoliosis fused only to lumbar 5, Spine 30:2056, 2005. McCarthy RE: Neuromuscular scoliosis: the tide mark for surgery. Material presented at Spinal Deformity: Challenges and Solutions of Surgical Treatment, Puerto Rico, May 12–13, 2000. McCarthy RE, Dunn H, McCullough FL: Luque fixation to the sacral ala using the Dunn-McCarthy modification, Spine 14:281, 1989. McCarthy RE, Peek RD, Morrissy RT, et al.: Allograft bone in spinal fusion for paralytic scoliosis, J Bone Joint Surg 68A:370, 1986. McCarthy RE, Saer 3rd EH: The treatment of flaccid neuromuscular scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. McCord DH, Cunningham BN, Shono Y, et  al.: Biomechanical analysis of lumbosacral fixation, Spine 17:S235, 1992. Miller F, Dabney KW: Unit rod segmental instrumentation. In McCarthy RE, editor: Spinal instrumentation techniques, Chicago, 1998, Scoliosis Research Society. Moe JH: The management of paralytic scoliosis, South Med J 50:67, 1957. Nasca RJ: Segmental spinal instrumentation, South Med J 78:303, 1985. Nash CL: Current concepts review: scoliosis bracing, J Bone Joint Surg 62A:848, 1980. Neustadt JB, Shufflebarger HL, Cammisa FP: Spinal fusions to the pelvis augmented by Cotrel-Dubousset instrumentation for neuromuscular scoliosis, J Pediatr Orthop 12:465, 1992. Nicastro JF, Traina J, Lancaster M, et al.: Sublaminar segmental wire fixation: anatomic pathways during their removal, Orthop Trans 8:172, 1984. Nickel VL, Perry J, Affeldt JE, et al.: Elective surgery on patient with respiratory paralysis, J Bone Joint Surg 39A:989, 1957. O’Brien MF: Sacropelvic fixation in spinal deformity. Material presented at Spinal Deformity: Challenges and Solutions of Surgical Treatment, Puerto Rico, May 12–13, 2000. O’Brien JP, Yau AC: Anterior and posterior correction and fusion for paralytic scoliosis, Clin Orthop Relat Res 86:151, 1972. Ogilvie JW, Millar EA: Comparison of segmental spinal instrumentation devices in the correction of scoliosis, Spine 8:416, 1983. Olson SA, Gaines RW: Removal of sublaminar wires after spinal fusion, J Bone Joint Surg 69A:1419, 1987. Osebold WR, Yamamoto SK, Hurley JH: Variability of response of scoliotic spines to segmental spinal instrumentation, Spine 17:1174, 1992. Pampliega T, Beguiristain JL, Artieda J: Neurologic complications after sublaminar wiring: an experimental study in lambs, Spine 17:441, 1992. Renshaw TS: Spinal fusion with segmental instrumentation, Contemp Orthop 4:413, 1982. Sanders JO, Evert M, Stanley EA, et al.: Mechanisms of curve progression following sublaminar (Luque) spinal instrumentation, Spine 17:781, 1992. Schrader WC, Bethem D, Scerbin V: The chronic local effects of sublaminar wires: an animal model, Spine 13:499, 1988. Shook JE, Lubicky JP: Paralytic scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Shufflebarger HL, Kahn 3rd A, Rinsky LA, et  al.: Segmental spinal instrumentation in idiopathic scoliosis: a retrospective analysis of 234 cases, Orthop Trans 9:124, 1985. Songer MN, Spencer DL, Meyer PR, et al.: The use of sublaminar cables to replace Luque wires, Spine 16:S418, 1991. Stevens DB, Beard C: Segmental spinal instrumentation for neuromuscular spinal deformity, Clin Orthop Relat Res 242:164, 1989. Sullivan JA, Conner SB: Comparison of Harrington instrumentation and segmental spinal instrumentation in the management of neuromuscular spinal deformity, Spine 7:299, 1982. Taddonio RF: Segmental spinal instrumentation in the management of neuromuscular spinal deformity, Spine 7:305, 1982. Taddonio RF, Weller K, Appel M: A comparison of patients with idiopathic scoliosis managed with and without postoperative immobilization following segmental spinal instrumentation with Luque rods, Orthop Trans 8:172, 1984. Thompson GH, Wilber G, Shaffer JW, et al.: Segmental spinal instrumentation in idiopathic scoliosis: a preliminary report, Spine 10:623, 1985. Weiler PJ, McNeice GM, Medley JB: An experimental study of the buckling behavior of L-rod implants used in the surgical treatment of scoliosis, Spine 11:992, 1986.

Weiler PJ, Medley JB, McNeice GN: Numeric analysis of the load capacity of the human spine fitted with L-rod instrumentation, Spine 15:1285, 1990. Wenger DR, Carollo JJ, Wilkerson JA: Biomechanics of scoliosis correction by segmental spinal instrumentation, Spine 7:260, 1982. Wenger DR, Carollo JJ, Wilkerson JA, et al.: Laboratory testing of segmental spinal instrumentation versus traditional Harrington instrumentation for scoliosis treatment, Spine 7:265, 1982. Wenger DR, Miller S, Wilkerson J: Evaluation of fixation sites for segmental instrumentation of the human vertebra, Orthop Trans 6:23, 1982. Wilber RG, Thompson GH, Shaffer JW, et  al.: Postoperative neurologic deficits and segmental spinal instrumentation: a study using spinal cord monitoring, J Bone Joint Surg 66A:1178, 1984. Winter RB: Posterior spinal arthrodesis with instrumentation and sublaminar wire: 100 consecutive cases, Orthop Trans 9:124, 1985. Winter RB, Carlson JM: Modern orthotics for spinal deformities, Clin Orthop Relat Res 23:74, 1977. Winter RB, Pinto WC: Pelvic obliquity: its causes and its treatment, Spine 11:225, 1986.

CEREBRAL PALSY Allen BL, Ferguson RL: L-rod instrumentation for scoliosis in cerebral palsy, J Pediatr Orthop 2:87, 1982. Auerbach JD, Spiegel DA, Zgonis MH, et al.: The correction of pelvic obliquity in patients with cerebral palsy and neuromuscular scoliosis: is there a benefit of anterior release prior to posterior spinal arthrodesis? Spine 34:E766, 2009. Balmer GA, MacEwen GD: The incidence and treatment of scoliosis in cerebral palsy, J Bone Joint Surg 52B:134, 1970. Bleck EE: Orthopaedic management in cerebral palsy. In Clinics in developmental medicine, Philadelphia, 1987, JB Lippincott. Bonnett C, Brown J, Brooks HL: Anterior spine fusion with Dwyer instrumentation for lumbar scoliosis in cerebral palsy, J Bone Joint Surg 55A:425, 1973. Bonnett CA, Brown JC, Grow T: Thoracolumbar scoliosis in cerebral palsy: results of surgical treatment, J Bone Joint Surg 58A:328, 1976. Brown JC, Swank SM, Specht L: Combined anterior and posterior spine fusion in cerebral palsy, Spine 7:570, 1982. Bunnell WP, MacEwen GD: Nonoperative treatment in scoliosis in cerebral palsy: preliminary report on the use of a plastic jacket, Dev Med Child Neurol 19:45, 1977. Carney BT, Minter CL: Is operative blood loss associated with valproic acid? Analysis of bilateral femoral osteotomy in children with total involvement cerebral palsy, J Pediatr Orthop 25:283, 2005. Ferguson RL, Allen BL: Considerations in the treatment of cerebral palsy patients with spinal deformities, Orthop Clin North Am 19:419, 1988. Gersoff WK, Renshaw JS: The treatment of scoliosis in cerebral palsy by posterior spinal fusion with Luque-rod segmented instrumentation, J Bone Joint Surg 70A:41, 1988. Hennrikus WL, Rosenthal RK, Kasser JR: Incidence of spondylolisthesis in ambulatory cerebral palsy patients, J Pediatr Orthop 13:37, 1993. Jevsevar DS, Karlin LI: The relationship between preoperative nutritional status and complications after an operation for scoliosis in patients who have cerebral palsy, J Bone Joint Surg Am 75:880, 1993. Kalen V, Conklin MM, Shermann FC: Untreated scoliosis in severe cerebral palsy, J Pediatr Orthop 12:337, 1992. Lonstein JE, Akbarnia BA: Operative treatment of spinal deformities in patients with cerebral palsy or mental retardation: an analysis of 107 cases, J Bone Joint Surg 65A:43, 1983. MacEwen GD: Operative treatment of scoliosis in cerebral palsy, Reconstr Surg Traumatol 13:58, 1972. Madigan RR, Wallace SL: Scoliosis in the institutionalized cerebral palsy population, Spine 6:583, 1981. Modi HN, Hong JY, Mehta SS, et  al.: Surgical correction and fusion using posterior-only pedicle screw construct for neuropathic scoliosis in patients with cerebral palsy: a three-year follow-up study, Spine 34:1167, 2009. Neustadt JB, Shufflebarger HL, Cammisa FP: Spinal fusions to the pelvis augmented by Cotrel-Dubousset instrumentation for neuromuscular scoliosis, J Pediatr Orthop 12:465, 1992.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Rinsky LA: Surgery of spinal deformity in cerebral palsy: twelve years in the evolution of scoliosis management, Clin Orthop Relat Res 253:100, 1990. Samilson RL: Orthopedic surgery of the hips and spine in retarded cerebral palsy, Orthop Clin North Am 12:83, 1981. Sponseller PD, Whiffen JR, Drummond DS: Interspinous process segmental spinal instrumentation for scoliosis in cerebral palsy, J Pediatr Orthop 6:559, 1986. Stanitski CL, Micheli LJ, Hall JE, et al.: Surgical correction of spinal deformity in cerebral palsy, Spine 7:563, 1982. Swank SM, Cohen DS, Brown JC: Spine fusion in cerebral palsy with L-rod segmental spinal instrumentation: a comparison of single and two-stage combined approach with Zielke instrumentation, Spine 14:750, 1989. Taddonio RF: Segmental spinal instrumentation and the management of neuromuscular spinal deformity, Spine 7:305, 1982. Thometz JG, Simon SR: Progression of scoliosis after skeletal maturity in institutionalized adults who have cerebral palsy, J Bone Joint Surg 70A:1290, 1988. Winter RB, Carlson JM: Modern orthotics for spinal deformities, Clin Orthop Relat Res 126:74, 1977. Winter RB, Pinto WC: Pelvic obliquity: its causes and its treatment, Spine 11:225, 1986.

INHERITABLE NEUROLOGIC DISORDERS Albanese SA, Bobechko WP: Spine deformity in familial dysautonomia (Riley-Day syndrome), J Pediatr Orthop 7:179, 1987. Aprin H, Bowen JR, MacEwen GD, et al.: Spine fusion in patients with spinal muscle atrophy, J Bone Joint Surg 64A:1179, 1982. Axelrod FB, Iyer K, Fish I: Progressive sensory loss and familial dysautonomia, Pediatrics 67:517, 1981. Brown JC, Zeller JS, Swank SM, et al.: Surgical and functional results of spine fusion in spinal muscle atrophy, Spine 14:763, 1989. Cady RB, Bobechko WP: Incidence, natural history, and treatment of scoliosis in Friedreich’s ataxia, J Pediatr Orthop 4:673, 1984. Daher YH, Lonstein JE, Winter RB, et  al.: Spinal surgery in spinal muscle atrophy, J Pediatr Orthop 5:391, 1985. Daher YH, Winter RB, Lonstein JE, et al.: Spinal deformities in patients with Friedreich’s ataxia: a review of 19 patients, J Pediatr Orthop 5:553, 1985. Daher YH, Winter RB, Lonstein JE, et al.: Spinal deformities in patients with Charcot-Marie-Tooth: a review of 12 patients, Clin Orthop Relat Res 202:219, 1986. Evans GA, Drennan JC, Russman BS: Functional classification and orthopaedic management of spinal muscle atrophy, J Bone Joint Surg 63B:516, 1981. Furumasu J, Swank SM, Brown JC: Functional activities in spinal muscular atrophy patients after spinal fusion, Spine 14:771, 1989. Geoffrey G, Barbeau A, Breton G, et al.: Clinical description and roentgenologic evaluation of patients with Friedreich’s ataxia, Can J Neurol Sci 3:279, 1976. Goldstein LA, Fuller J, Haake P, et al.: Surgical treatment of thoracic scoliosis in patients with familial dysautonomia, J Bone Joint Surg 51A:205, 1969. Granata C, Merlini L, Magni E, et al.: Spinal muscle atrophy: natural history and orthopaedic treatment of scoliosis, Spine 14:760, 1989. Hensinger RN, MacEwen GD: Spinal deformity associated with heritable neurologic conditions: spinal muscle atrophy, Friedreich’s ataxia, familial dysautonomia, and Charcot-Marie-Tooth disease, J Bone Joint Surg 58A:13, 1976. Hsu JD, Grollman T, Hoffer M, et al.: The orthopaedic management of spinal muscular atrophy, J Bone Joint Surg 55B:663, 1973. Kaplan L, Margulies JY, Kadari A, et al: Spinal deformity in familial dysautonomia: the Israeli experience. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. Karol LA, Elerson E: Scoliosis in patients with Charcot-Marie-Tooth disease, J Bone Joint Surg 89A:1504, 2007. Kepes ER, Martinez LR, Andrews IC, et al.: Anesthetic problems and hereditary muscular abnormalities, N Y State J Med 72:1051, 1972. Kugelberg E, Welander L: Heredofamilial juvenile muscular atrophy simulating muscular dystrophy, Arch Neurol 75:500, 1956. Labelle H, Thome S, Duhaine M, et  al.: Natural history in scoliosis in Friedreich’s ataxia, J Bone Joint Surg 68A:564, 1986.

Merlini L, Granata C, Bonfiglioli S, et al.: Scoliosis in spinal muscular atrophy: natural history and management, Dev Med Child Neurol 31:501, 1989. Milbrandt TA, Kunes JR, Karol LA: Friedreich’s ataxia and scoliosis: the experience at two institutions, J Pediatr Orthop 28:234, 2008. Miller F: Spinal deformity secondary to impaired neurologic control, J Bone Joint Surg 89A:143, 2007. Phillips DP, Roye Jr DP, Farcy JC, et al.: Surgical treatment of scoliosis in a spinal muscle atrophy population, Spine 15:942, 1990. JO Piasecki, Mahinpour S, Levine DB: Long-term follow-up for spinal fusion in spinal muscular atrophy, Clin Orthop Relat Res 207:44, 1986. Riddick M, Winter RB, Lutter L: Spinal deformities in patients with spinal muscle atrophy, Spine 8:476, 1982. Riley CM, Day RL, Greeley DM, et al.: Central autonomic dysfunction with defective lachrymation: report of five cases, Pediatrics 3:468, 1949. Robin GC: Scoliosis in familial dysautonomia, Bull Hosp Jt Dis Orthop Inst 44:16, 1984. Schwentker EP, Gibson DA: The orthopaedic aspects of spinal muscle atrophy, J Bone Joint Surg 58A:32, 1976. Shapiro F, Bresnan MJ: Current concepts reviewed: management of childhood neuromuscular disease, part I: spinal muscle atrophy, J Bone Joint Surg 64A:785, 1982. Shapiro F, Bresnan MJ: Current concepts reviewed: orthopaedic management of childhood neuromuscular disease, part II: peripheral neuropathies, Friedreich’s ataxia, and arthrogryposis multiplex congenita, J Bone Joint Surg 64A:949, 1982. Stenqvist O, Sigurdson J: The anaesthetic management of a patient with familial dysautonomia, Anaesthesia 37:929, 1982. Yoslow W, Becker MH, Bartels J, et al.: Orthopaedic defects in familial dysautonomia: a review of 65 cases, J Bone Joint Surg 53A:1541, 1971.

SYRINGOMYELIA Akhtar OH, Rowe DE: Syringomyelia-associated scoliosis with and without the Chiari I malformation, J Am Acad Orthop Surg 16:407, 2008. Baker AS, Dove J: Progressive scoliosis as the first presenting sign of syringomyelia: report of a case, J Bone Joint Surg 65B:472, 1983. Bertrand SL, Drvaric DM, Roberts JM: Scoliosis in syringomyelia, Orthopedics 12:335, 1989. Bradford DS: Neuromuscular spinal deformity. In Bradford DS, et al, editors: Moe’s textbook of scoliosis and other spinal deformities, ed 2, Philadelphia, 1987, WB Saunders. Flynn JM, Sodha S, Lou JE, et al.: Predictors of progression of scoliosis after decompression of an Arnold Chiari I malformation, Spine 29:286, 2004. Gurr KR, Taylor TKF, Stobo P: Syringomyelia in scoliosis in childhood and adolescents, J Bone Joint Surg 70B:159, 1988. Huebert HT, MacKinnon WB: Syringomyelia and scoliosis, J Bone Joint Surg 51B:338, 1969. Loder RT, Stasikelis P, Farley FA: Sagittal profiles of the spine in scoliosis associated with an Arnold-Chiari malformation with or without syringomyelia, J Pediatr Orthop 2:483, 2002. Nordwall A, Wikkelso C: A late neurologic complication of scoliosis surgery in connection with syringomyelia, Acta Orthop Scand 50:407, 1979. Ozerdemoglu RA, Transfeldt EE, Denis F: Value of treating primary causes of syrinx in scoliosis associated with syringomyelia, Spine 28:806, 2003. Philips WA, Hensinger RN, Kling TF: Management of scoliosis due to syringomyelia in childhood and adolescents, J Pediatr Orthop 10:351, 1990. Shook JE, Lubicky JP: Paralytic scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Williams B: Orthopaedic features in the presentation of syringomyelia, J Bone Joint Surg 61B:314, 1979.

SPINAL CORD INJURIES Bonnett CA: The cord-injured child. In Lovell WW, Winter RB, editors: Children’s orthopaedics, Philadelphia, 1978, JB Lippincott. Brown HP, Bonnett CC: Spine deformity subsequent to spinal cord injury. In Proceedings of the Scoliosis Research Society, J Bone Joint Surg 55A:441, 1973. Campbell J, Bonnett C: Spinal cord injury in children, Clin Orthop Relat Res 112:114, 1975.

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PART XII  THE SPINE Dearolf WW, Betz RR, Vogel LC, et al.: Scoliosis in pediatric spinal cord– injured patients, J Pediatr Orthop 10:214, 1990. Johnston II CE, Hakaka MW, Rosenberger R: Paralytic spine deformity: orthotic treatment in spinal discontinuity syndromes, J Pediatr Orthop 2:233, 1982. Lancourt JC, Dickson JH, Carter RE: Paralytic spinal deformity following traumatic spinal cord injury in children and adolescents, J Bone Joint Surg 63A:47, 1981. Luque ER: Paralytic scoliosis in growing children, Clin Orthop Relat Res 163:202, 1982. Mayfield JK, Erkkila JD, Winter RB: Spine deformity subsequent to acquired childhood spinal cord injury, J Bone Joint Surg 63A:1401, 1981. Shook JE, Lubicky JP: Paralytic scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven.

POLIOMYELITIS Bonnett C, Brown J, Perry J, et al.: The evolution of treatment of paralytic scoliosis at Rancho Los Amigos Hospital, J Bone Joint Surg 57A:206, 1975. Colonna PC, Vom Saal F: A study of paralytic scoliosis based on 500 cases of poliomyelitis, J Bone Joint Surg 23:335, 1941. Garrett AL, Perry J, Nickel VL: Paralytic scoliosis, Clin Orthop Relat Res 21:117, 1961. Garrett AL, Perry J, Nickel VL: Stabilization of the collapsing spine, J Bone Joint Surg 43A:474, 1961. Gucker T: Experience in poliomyelitis scoliosis after correction and fusion, J Bone Joint Surg 38A:1281, 1956. Irwin CE: The iliotibial band: its role in producing deformity in poliomyelitis, J Bone Joint Surg 31A:141, 1949. James JIP: Paralytic scoliosis, J Bone Joint Surg 38B:660, 1956. Leong JCY, Wilding K, Mok CD, et al.: Surgical treatment of scoliosis following poliomyelitis: a review of 100 cases, J Bone Joint Surg 63A:726, 1981. Mayer L: Further studies of fixed paralytic pelvic obliquity, J Bone Joint Surg 18:87, 1936. Mayer PJ, Dove J, Ditmanson M, et  al.: Postpoliomyelitis paralytic scoliosis, Spine 6:573, 1981. O’Brien JP, Dwyer AP, Hodgson AR: Paralytic pelvic obliquity: its prognosis and management and the development of a technique for full correction of the deformity, J Bone Joint Surg 57A:626, 1975. O’Brien JP, Yau AC, Gertzbern S, et al.: Combined staged, anterior and posterior correction and fusion of the spine in scoliosis following poliomyelitis, Clin Orthop Relat Res 110:81, 1975. Yount CC: Role of the tensor fascia femoris in certain deformities of the lower extremities, J Bone Joint Surg 8:171, 1926.

ARTHROGRYPOSIS MULTIPLEX CONGENITA Brown LM, Robson MJ: The pathophysiology of arthrogryposis multiplex congenita neurologica, J Bone Joint Surg 62B:291, 1980. Campbell Jr RM: Spine deformities in rare congenital syndromes: clinical issues, Spine 34:1815, 2009. Daher YH, Lonstein JE, Winter RB, et al.: Spinal deformities in patients with arthrogryposis: a review of 16 patients, Spine 10:609, 1985. Drummond D, Mackenzie DA: Scoliosis in arthrogryposis multiplex congenita, Spine 3:146, 1978. Herron LD, Westin GW, Dawson EG: Scoliosis in arthrogryposis multiplex congenita, J Bone Joint Surg 60A:293, 1978. Karol LA: Scoliosis in patients with Duchenne muscular atrophy, J Bone Joint Surg 89A:155, 2007. Shapiro F, Bresnan MJ: Current concepts review: orthopaedic management of childhood neuromuscular disease, part II: peripheral neuropathies, Friedreich’s ataxia, and arthrogryposis multiplex congenita, J Bone Joint Surg 64A:949, 1982.

DUCHENNE MUSCULAR DYSTROPHY Alman BA, Raza SN, Biggar WD: Steroid treatment and the development of scoliosis in males with Duchenne muscular dystrophy, J Bone Joint Surg 86A:519, 2004.

Aprin H, Bowen JR, McEwen JD, et al.: Spine fusion in patients with spinal muscle atrophy, J Bone Joint Surg 64A:1179, 1982. Balaban B, Matthews DJ, Clayton GH, Carry T: Corticosteroid treatment and functional improvement in Duchenne muscular dystrophy: long-term effect, Am J Phys Med Rehabil 84:843, 2005. Biggar WD, Klamut HJ, Demacio PC, et al.: Duchenne muscular dystrophy: current knowledge, treatment, and future prospects, Clin Orthop Relat Res 401:88, 2002. Bronson W, Drummond DS, Setal L, et  al: Treatment of scoliosis patients with Duchenne muscular dystrophy. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. Cambridge W, Drennan JC: Scoliosis associated with Duchenne muscular dystrophy, J Pediatr Orthop 7:436, 1987. Colbert AP, Clifford C: Scoliosis management in Duchenne muscular dystrophy: prospective study of modified Jewett hyperextension brace, Arch Phys Med Rehabil 60A:302, 1987. Daher YH, Lonstein JE, Winter RB: Spinal deformities in patients with muscular dystrophy other than Duchenne: review of 11 patients having surgical treatment, Spine 10:614, 1984. Daher YH, Lonstein JE, Winter RE, et  al.: Spinal surgery in spinal muscle atrophy, J Pediatr Orthop 5:391, 1985. Galasko CSB, Delaney C, Morris P: Spinal stabilization in Duchenne muscular dystrophy, J Bone Joint Surg 74B:210, 1992. Gibson DA, Koreska J, Robertson D, et al.: The management of spinal deformity in Duchenne’s muscular dystrophy, Orthop Clin North Am 9:437, 1978. Granata C, Merlina L, Magne E, et al.: Spinal muscle atrophy, natural history in orthopaedic treatment of scoliosis, Spine 14:760, 1989. Green NE: The orthopaedic care of children with muscular dystrophy, Instr Course Lect 36:267, 1987. Hsu JD: The natural history of spine curvature progression in the nonambulatory Duchenne muscular dystrophy patient, Spine 8:771, 1983. Jenkins JG, Bohn D, Edmonds JF, et al.: Evaluation of pulmonary function in muscular dystrophy patients requiring spinal surgery, Crit Care Med 10:645, 1982. Karol LA: Scoliosis in patients with Duchenne muscular atrophy, J Bone Joint Surg 89A:155, 2007. Kurz LT, Mubarak SJ, Schultz P, et al.: Correlation of scoliosis and pulmonary function in Duchenne muscular dystrophy, J Pediatr Orthop 3:347, 1983. LaPrade RF, Rowe DE: The operative treatment of scoliosis in Duchenne muscular dystrophy, Orthop Rev 21:39, 1992. Lonstein JE, Renshaw TS: Neuromuscular spine deformities, Instr Course Lect 36:285, 1987. Lord J, Behrman B, Varzos N, et al.: Scoliosis associated with Duchenne muscular dystrophy, Arch Phys Med Rehabil 71:13, 1990. Luque ER: Segmental spinal instrumentation for correction of scoliosis, Clin Orthop Relat Res 163:192, 1982. Miller F, Moseley CF, Koreska J, et al.: Pulmonary function and scoliosis in Duchenne dystrophy, J Pediatr Orthop 8:133, 1988. Miller F, Moseley CF, Koreska J: Spinal fusion in Duchenne muscular dystrophy, Dev Med Child Neurol 34:775, 1992. Milne B, Rosales JK: Anesthetic considerations in patients with muscular dystrophy undergoing spinal fusion and Harrington rod insertion, Can Anaesth Soc J 29:250, 1982. Mubarak SJ, Morin WD, Leach J: Spinal fusion in Duchenne muscular dystrophy—fixation and fusion to the sacropelvis? J Pediatr Orthop 13:756, 1993. Rideau Y, Glorion B, Delaubier A, et  al.: The treatment of scoliosis in Duchenne muscular dystrophy, Muscle Nerve 7:281, 1984. Rideau Y, Jankowski LW, Grellet J: Respiratory function in muscular dystrophies, Muscle Nerve 4:155, 1981. Seeger BR, Sutherland AD, Clark MS: Orthotic management of scoliosis in Duchenne muscular dystrophy, Arch Phys Med Rehabil 65:83, 1984. Shapiro F, Bresnan MJ: Orthopaedic management of childhood neuromuscular disease, part III: diseases of muscle, J Bone Joint Surg 64A:1102, 1982.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Shapiro F, Navil S, Colan S, et al.: Spinal fusion in Duchenne muscular dystrophy: a multidisciplinary approach, Muscle Nerve 15:604, 1992. Shapiro F, Specht L: Current concepts review: the diagnosis and orthopaedic treatment of inherited muscular diseases in childhood, J Bone Joint Surg 75A:439, 1993. Siegel IM: Scoliosis in muscular dystrophy, Clin Orthop Relat Res 93:235, 1973. Siegel IM: Spinal stabilization in Duchenne muscular dystrophy: rationale and method, Muscle Nerve 5:417, 1982. Smith AD, Koreska J, Moseley CF: Progression of scoliosis in Duchenne muscular dystrophy, J Bone Joint Surg 71A:1066, 1989. Smith PE, Calverley PM, Edwards RH, et al.: Practical problems in the respiratory care of patients with muscular dystrophy, N Engl J Med 316:1197, 1987. Sucato DJ: Spine deformity in spinal muscular atrophy, J Bone Joint Surg 89A:148, 2007. Sullivan JA, Conner SB: Comparison of Harrington instrumentation and segmental spinal instrumentation in the management of neuromuscular spinal deformity, Spine 7:299, 1982. Sussman MD: Advantage of early spinal stabilization and fusion in patients with Duchenne muscular dystrophy, J Pediatr Orthop 4:532, 1984. Swank SM, Brown JC, Perry RE: Spinal fusion in Duchenne’s muscular dystrophy, Spine 7:484, 1982. Taddonio RF: Segmental spinal instrumentation in the management of neuromuscular spinal deformity, Spine 7:305, 1982. Weimann RL, Gibson DA, Moseley CF, et  al.: Surgical stabilization of the spine in Duchenne muscular dystrophy, Spine 8:776, 1983. Yingsakmongkol W, Kumar SJ: Scoliosis in arthrogryposis multiplex congenita: results after nonsurgical and surgical treatment, J Pediatr Orthop 20:656, 2000.

CONGENITAL SCOLIOSIS Akbarnia BA, Heydarian K, Ganjavian MS: Concordant congenital spine deformity in monozygotic twins, J Pediatr Orthop 3:502, 1983. Albanese SA, Coren AB, Weinstein MP, et al.: Ultrasonography for urinary tract evaluation in patients with congenital spine anomalies, Clin Orthop Relat Res 22A:302, 1988. Andrew T, Piggott H: Growth arrest for progressive scoliosis: combined anterior and posterior fusion of the convexity, J Bone Joint Surg 67B:193, 1985. Bergoin M, Bollini G, Gennari JM: One-stage hemivertebral excision and arthrodesis on congenital oblique take-off in children aged less than 5 years, J Pediatr Orthop 1:108, 1993. Bernard Jr TN, Burke SW, Johnston 3rd CE, et al.: Congenital spine deformities: a review of 47 cases, Orthopedics 8:777, 1985. Bernhardt M: Normal spinal anatomy: normal sagittal plane alignment. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Bollini G, Bergoin M, Labriet C, et al.: Hemivertebrae excision and fusion in children aged less than five years, J Pediatr Orthop 1B:95, 1993. Bowen RE, Scaduto AA, Banuelos S: Does early thoracic fusion exacerbate preexisting restrictive lung disease in congenital scoliosis patients? J Pediatr Orthop 28:506, 2008. Bradford DS: Partial epiphyseal arrest and supplemental fixation for progressive correction of congenital spine deformity, J Bone Joint Surg 64A:610, 1982. Bradford DS, Boachie-Adjei O: One-stage anterior and posterior hemivertebral resection and arthrodesis for congenital scoliosis, J Bone Joint Surg 72A:536, 1990. Bradford DS, Tribus CB: Current concepts in management of patients with fixed decompensated spinal deformity, Clin Orthop Relat Res 306:64, 1994. Campbell RM: Congenital scoliosis due to multiple vertebral anomalies associated with thoracic insufficiency syndrome, Spine 14:209, 2000. Campbell Jr RM, Hell-Vocke AK: Growth of the thoracic spine in congenital scoliosis after expansion thoracoplasty, J Bone Joint Surg 85A:409, 2003. Campbell Jr RM, Smith MD, Mayes TC, et al.: The characteristics of thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis, J Bone Joint Surg 85A:399, 2003.

Campbell Jr RM, Smith MD, Mayes TC, et al.: The effect of opening wedge thoracostomy on thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis, J Bone Joint Surg 86A:1659, 2004. Danisa OA, Turner D, Richardson WJ: Surgical correction of lumbar kyphotic deformity: posterior reduction “eggshell” osteotomy, J Neurosurg 92(Suppl):50, 2000. Dimeglio A: Growth of the spine before age 5 years, J Pediatr Orthop 1:102, 1993. Drvaric DM, Ruderman RJ, Conrad RW, et al.: Congenital scoliosis and urinary tract abnormalities: are intravenous pyelograms necessary? J Pediatr Orthop 7:441, 1987. Dubousset J, Katti E, Seringe R: Epiphysiodesis of the spine in young children for congenital spinal deformations, J Pediatr Orthop 1:123, 1993. Freedman L, Leong J, Luk K, et al.: One-stage combined anterior and posterior excision of hemivertebrae in the lower lumbar spine, J Bone Joint Surg 69B:854, 1987. Gillespie R, Faithful D, Roth A, et al.: Intraspinal anomalies and congenital scoliosis, Clin Orthop Relat Res 93:103, 1973. Goldberg C, Fenlon G, Blacke NS: Diastematomyelia: a critical review of the natural history and treatment, Spine 9:367, 1984. Gruca A: On the pathology and treatment of “idiopathic” scoliosis, Acta Med Pol 15:139, 1974. Hall JE, Herndon WA, Levine CR: Surgical treatment of congenital scoliosis with or without Harrington instrumentation, J Bone Joint Surg 63A:608, 1981. Hedequist D, Hall JE, Emans JB: The safety and efficacy of spinal instrumentation in children with congenital spine deformities, Spine 29:2081, 2004. Hedden D: Management themes in congenital scoliosis, J Bone Joint Surg 89A:72, 2007. Hedequist D, Emans J: Congenital scoliosis: a review and update, J Pediatr Orthop 27:107, 2007. Heinig CF: The eggshell procedure. In Luque ER, editor: Segmental spinal instrumentation, Thorofare, NJ, 1984, Slack. Hell AK, Campbell RM, Hefti F: The vertical expandable prosthetic titanium rib implant for the treatment of thoracic insufficiency syndrome associated with congenital and neuromuscular scoliosis in young children, J Pediatr Orthop 14B:287, 2005. Hensinger RN: Congenital scoliosis: etiology and associations, Spine 34:1745, 2009. Holte DC, Winter RB, Lonstein JE, Denis F: Excision of hemivertebrae and wedge resection in the treatment of congenital scoliosis, J Bone Joint Surg 77A:159, 1995. Hood RW, Riseborough E, Nehme A, et al.: Diastematomyelia and structural spinal deformities, J Bone Joint Surg 62A:520, 1980. Kawakami N, Tsuji T, Imagama S, et al.: Classification of congenital scoliosis and kyphosis: a new approach to the three-dimensional classification for progressive vertebral anomalies requiring operative treatment, Spine 34:1756, 2009. Kesling KL, Lonstein JE, Denis F, et al.: The crankshaft phenomenon after posterior spinal arthrodesis for congenital scoliosis: a review of 54 patients, Spine 28:267, 2003. King AG, MacEwen GD, Bose WJ: Transpedicular convex anterior hemiepiphysiodesis and posterior arthrodesis for progressive congenital scoliosis, Spine 17(Suppl):291, 1992. King JD, Lowery GL: Results of lumbar hemivertebral excision for congenital scoliosis, Spine 16:778, 1991. Leatherman KD, Dickson RA: Two-stage corrective surgery for congenital deformities of the spine, J Bone Joint Surg 61B:324, 1979. Letts RM, Hollenberg C: Delayed paresis following spinal fusion with Harrington instrumentation, Clin Orthop Relat Res 125:45, 1977. Lhowe D, Ehrlich MG, Chapman PH, et  al.: Congenital intraspinal lipomas: clinical presentation and response to treatment, J Pediatr Orthop 7:531, 1987. Li X, Luo Z, Li X, et al.: Hemivertebra resection for the treatment of congenital lumbar spinal scoliosis with lateral-posterior approach, Spine 33:2001, 2008. Loder RT, Hernandez MJ, Lerner AL, et al.: The induction of congenital spinal deformities in mice by maternal carbon monoxide exposure, J Pediatr Orthop 20:662, 2000.

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PART XII  THE SPINE Lonstein JE, Winter RB, Moe JH, et al.: Neurologic deficit secondary to spinal deformity: a review of the literature and report of 43 cases, Spine 5:331, 1980. Lubicky JP: Congenital scoliosis. In Bridwell KH, Dewald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. MacEwen GD, Winter RB, Hardy JH: Evaluation of kidney anomalies in congenital scoliosis, J Bone Joint Surg 54A:1341, 1972. Marks DS, Qaimkhani SA: The natural history of congenital scoliosis and kyphosis, Spine 34:1751, 2009. McCarthy RE, Campbell Jr RM, Hall JE: Infantile and juvenile idiopathic scoliosis, Spine 14:163, 2000. McMaster MJ: Occult intraspinal anomalies and congenital scoliosis, J Bone Joint Surg 66A:588, 1984. McMaster MJ: Congenital scoliosis caused by a unilateral failure of vertebral segmentation with contralateral hemivertebrae, Spine 23:998, 1998. McMaster MJ, David CV: Hemivertebra as a cause of scoliosis: a study of 104 patients, J Bone Joint Surg 68B:588, 1986. McMaster MJ, Ohtsuka K: The natural history of congenital scoliosis: a study of 251 patients, J Bone Joint Surg 64A:1128, 1982. Michel A, Krueger FJ: A surgical approach to the vertebral body, J Bone Joint Surg 31A:873, 1949. Mik G, Drummond DS, Hosalkar HS, et  al.: Diminished spinal cord size associated with congenital scoliosis of the thoracic spine, J Bone Joint Surg 91A:1698, 2009. Mikles MR, Graziano GP, Hensinger AR: Transpedicular eggshell osteotomies for congenital scoliosis using frameless stereotactic guidance, Spine 26:2289, 2001. Nasca RJ, Stelling FH, Steel HH: Progression of congenital scoliosis due to hemivertebrae and hemivertebrae with bars, J Bone Joint Surg 57A:456, 1975. Onimus M, Manzone P, Michel F, et al.: Early operation and congenital scoliosis, J Pediatr Orthop 1:119, 1993. Prahinski JR, Polly Jr DW, McHale KA, et al.: Occult intraspinal anomalies in congenital scoliosis, J Pediatr Orthop 20:59, 2000. Roaf R: The treatment of progressive scoliosis by unilateral growth arrest, J Bone Joint Surg 45B:637, 1963. Shapiro F, Eyre D: Congenital scolioses: a histopathologic study, Spine 6:107, 1981. Slabaugh P, Lonstein J, Winter RB, et al.: Lumbosacral hemivertebra: a review of 24 patients with resection in eight, Spine 5:234, 1980. Smith AD, von Lackum WH, Wylie R: An operation for stapling vertebral bodies in congenital scoliosis, J Bone Joint Surg 36A:342, 1954. Stoll J, Bunch W: Segmental spinal instrumentation for congenital scoliosis: a report of two cases, Spine 8:43, 1983. Thompson GH, Akbarnia BA, Kostial P, et al.: Comparison of single and dual growing rod techniques followed through definitive surgery: a preliminary study, Spine 30:2039, 2005. Ulrich EV, Moushkin AY: Surgical treatment of scoliosis and kyphoscoliosis caused by hemivertebrae in infants, J Pediatr Orthop 1:113, 1993. Vitale MG, Matsumoto H, Bye MR, et al.: A retrospective cohort study of pulmonary function, radiographic measures, and quality of life in children with congenital scoliosis: an evaluation of patient outcomes after early spinal fusion, Spine 33:1242, 2008. Whitecloud III TS, Brinker MR, Barrack RL, et  al.: Vibratory response in congenital scoliosis, J Pediatr Orthop 9:422, 1989. Winter RB: Congenital scoliosis, Clin Orthop Relat Res 93:75, 1973. Winter Rb, Haven JJ, Moe JH, et al.: Diastematomyelia and congenital spine deformities, J Bone Joint Surg Am 56:27, 1974. Winter RB: Scoliosis and spinal growth, Orthop Rev 6:17, 1977. Winter RB: Convex anterior and posterior hemiarthrodesis and epiphysiodesis in young children with progressive congenital scoliosis, J Pediatr Orthop 1:361, 1981. Winter RB: Congenital deformities of the spine, New York, 1983, Thieme-Stratton1983. Winter RB: Posterior spinal arthrodesis with instrumentation and sublaminar wire: 100 consecutive cases, Orthop Trans 9:124, 1985. Winter RB: Congenital spine deformity. In Bradford DS, et al, editors: Moe’s textbook of scoliosis and other spinal anomalies, ed 2, Philadelphia, 1987, WB Saunders. Winter RB: Congenital scoliosis, Orthop Clin North Am 19:395, 1988.

Winter RB: Congenital spine deformity: what’s the latest and what’s the best? Spine 14:1406, 1989. Winter RB, Lonstein JE, Denis F, et al.: Convex growth arrest for progressive congenital scoliosis due to hemivertebrae, J Pediatr Orthop 8:633, 1988. Winter RB, Moe JH: The results of spinal arthrodesis for congenital spine deformity in patients younger than 5 years old, J Bone Joint Surg 64A:419, 1982. Winter RB, Moe JH, Bradford DS: Congenital thoracic lordosis, J Bone Joint Surg 60A:806, 1978. Winter RB, Moe JH, Eilers VE: Congenital scoliosis: a study of 234 patients treated and untreated, J Bone Joint Surg 50A:1, 1968. Winter RB, Moe JH, Lonstein JE: Posterior spinal arthrodesis for congenital scoliosis: an analysis of the cases of 290 patients, 5 to 19 years old, J Bone Joint Surg 66A:1188, 1984. Winter RB, Moe JH, Lonstein JE: The incidence of Klippel-Feil syndrome in patients with congenital scoliosis and kyphosis, Spine 9:363, 1984. Winter RB, Moe JH, MacEwen D, et al.: The Milwaukee brace and the nonoperative treatment of congenital scoliosis, Spine 1:85, 1976. Wynne-Davies R: Congenital vertebral anomalies: aetiology and relationship to spina bifida cystica, J Med Genet 12:280, 1975. Yazici M, Emans J: Fusionless instrumentation systems for congenital scoliosis: expandable spinal rods and vertical expandable prosthetic titanium rib in the management of congenital spine deformities in the growing child, Spine 34:1800, 2009.

SCHEUERMANN DISEASE Arun R, Mehdian SMH, Freeman BJC, et  al.: Do anterior interbody cages have a potential value in comparison to autogenous rib graft in the surgical management of Scheuermann’s kyphosis? Spine J 6:413, 2006. Ascani E, Ippolito E, Montanaro A: Scheuermann’s kyphosis: histological, histochemical, and ultrastructural studies, Orthop Trans 7:28, 1982. Asher M, Heinig C, Carson W, et al.: ISOLA spinal implant system: principles, design, and applications. In An HS, Cotler JM, editors: Spinal instrumentation, Baltimore, 1992, Williams & Wilkins. Asher MA, Strippgen WE, Heinig CF, et  al.: ISOLA spine implant system: principles and practice, Cleveland, 1991, AcroMed. Aufdermaur M: Juvenile kyphosis (Scheuermann’s disease): radiography, histology, and pathogenesis, Clin Orthop Relat Res 154:166, 1981. Aufdermaur M, Spycher M: Pathogenesis of osteochondrosis juvenilis Scheuermann, J Orthop Res 4:452, 1986. Bick EM, Copel JW: Longitudinal growth of the human vertebra: contribution to human osteogeny, J Bone Joint Surg 33A:783, 1951. Blumenthal SL, Roach J, Herring JA: Lumbar Scheuermann’s: a clinical series in classification, Spine 12:929, 1987. Bradford DS: Neurological complications in Scheuermann’s disease, J Bone Joint Surg 51A 657, 1969. Bradford DS: Juvenile kyphosis, Clin Orthop Relat Res 128:45, 1977. Bradford DS: Juvenile kyphosis. In Bradford DS, et  al, editors: Moe’s textbook of scoliosis and other spinal deformities, ed 4, Philadelphia, 1987, WB Saunders. Bradford DS, Ahmed KB, Moe JH, et  al.: The surgical management of patients with Scheuermann’s disease: a review of 24 cases managed by combined anterior and posterior spine fusion, J Bone Joint Surg 62A:705, 1980. Bradford DS, Brown DM, Moe JH, et al.: Scheuermann’s kyphosis: a form of juvenile osteoporosis? Clin Orthop Relat Res 118:10, 1976. Bradford DS, Moe JH: Scheuermann’s juvenile kyphosis: a histologic study, Clin Orthop Relat Res 110:45, 1975. Bradford DS, Moe JH, Montalvo FJ, et  al.: Scheuermann’s kyphosis and roundback deformity: results of Milwaukee brace treatment, J Bone Joint Surg 56A:749, 1974. Bradford DS, Moe JH, Montalvo FJ, et al.: Scheuermann’s kyphosis: results of surgical treatment in 22 patients, J Bone Joint Surg 57A:439, 1975. Bradford DS, Moe JH, Winter RB: Kyphosis and postural roundback deformity in children and adolescents, Minn Med 56:114, 1973. Bradford DS, Winter RB, Lonstein JE, et al.: Techniques of anterior spine surgery for the management of kyphosis, Clin Orthop Relat Res 128:129, 1977. Carr AJ: Idiopathic thoracic kyphosis in identical twins, J Bone Joint Surg 72B:144, 1990.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Carr AJ, Jefferson RJ, Turner-Smith AR, et al.: Surface stereophotogrammetry of thoracic kyphosis, Acta Orthop Scand 60:177, 1989. Clark CE, Shufflebarger HL: Cotrel-Dubousset instrumentation for Scheuermann’s kyphosis. Paper presented at the annual meeting of the American Academy of Orthopaedic Surgeons, New Orleans, February 1990. Coe JD, Smith JS, Berven S, et  al.: Complications of spinal fusion for Scheuermann kyphosis: a report of the Scoliosis Research Society Morbidity and Mortality Committee, Spine 35:99, 2009. Coscia MF, Bradford DS, Ogilvie JW: Scheuermann’s kyphosis: treatment with Luque instrumentation—a review of 19 patients. Paper presented at the 55th annual meeting of the American Academy of Orthopaedic Surgeons, Atlanta, February 4–9, 1988. Damborg F, Engell V, Andersen M, et al.: Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins, J Bone Joint Surg 88A:2133, 2006. Deacon P, Berkin C, Dickson R: Combined idiopathic kyphosis and scoliosis: an analysis of the lateral spinal curvature associated with Scheuermann’s disease, J Bone Joint Surg 67B:189, 1985. Denis F, Sun EC, Winter RB: Incidence and risk factors for proximal and distal junctional kyphosis following surgical treatment for Scheuermann kyphosis, Spine 34:E729, 2009. Digiovanni BF, Scoles PV, Latimer BH: Anterior extension of the thoracic vertebral bodies in Scheuermann’s kyphosis: an anatomic study, Spine 14:712, 1989. Ferguson Jr AB: Etiology of preadolescent kyphosis, J Bone Joint Surg 38A:149, 1956. Fon GT, Pitt MJ, Thies AC: Thoracic kyphosis: range in normal subjects, AJR Am J Roentgenol 134:979, 1980. Fotiadis E, Kenanidis E, Samoladas E, et al.: Scheuermann’s disease: focus on weight and height role, Eur Spine J 17:673, 2008. Geck MJ, Macagno A, Ponte A, Shufflebarger HL: The Ponte procedure: posterior only treatment of Scheuermann’s kyphosis using segmental posterior shortening and pedicle screw instrumentation, J Spinal Disord Tech 20:586, 2007. Gilsanz V, Gibbens DT, Carlson M, et  al.: Vertebral bone density in Scheuermann disease, J Bone Joint Surg 71A:894, 1989. Gutowski WT, Renshaw TS: Orthotic results in adolescent kyphosis, Spine 13:485, 1988. Halal F, Gledhill RB, Fraser FC: Dominant inheritance of Scheuermann’s juvenile kyphosis, Am J Dis Child 132:1105, 1978. Hammerberg KW, Rodts MF, Dewald RL: Zielke instrumentation, Orthopedics 11:1365, 1988. Hensinger RN, Greene TL, Hunter LY: Back pain and vertebral changes simulating Scheuermann’s kyphosis, Spine 6:341, 1982. Herndon WA, Emans JB, Micheli LJ, et al.: Combined anterior and posterior fusion for Scheuermann’s kyphosis, Spine 6:125, 1981. Herrera-Soto JA, Parikh SN, Al-Sayyad MJ, et al.: Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann’s kyphosis, Spine 30:2176, 2005. Ippolito E, Ponseti I: Juvenile kyphosis: histological and histochemical studies, J Bone Joint Surg 63A:175, 1981. Jansen RC, van Rhijn LW, van Ooij A: Predictable correction of the unfused lumbar lordosis after thoracic correction and fusion in Scheuermann kyphosis, Spine 31:1227, 2006. Johnston CE, Elerson E, Dagher G: Correction of adolescent hyperkyphosis with posterior-only threaded rod compression instrumentation: is anterior spinal fusion still necessary? Spine 13:1528, 2005. Kehl D, Lovell WW, MacEwen GD: Scheuermann’s disease of the lumbar spine, Orthop Trans 6:342, 1982. Koptan WMT, El Miligui YH, El Sebaie HB: All pedicle screw instrumentation for Scheuermann’s kyphosis correction: is it worth it? Spine J 9:296, 2009. Kostuik J, Lorenz M: Long-term follow-up of surgical management in adult Scheuermann’s kyphosis, Orthop Trans 7:28, 1983. Lambrinudi L: Adolescent and senile kyphosis, BMJ 2:800, 1934. Lee SS, Lenke LG, Kuklo TR, et al.: Comparison of Scheuermann kyphosis correction by posterior-only thoracic pedicle screw fixation versus combined anterior/posterior fusion, Spine 31:2316, 2006.

Lonner BS, Newton P, Betz R, et al.: Operative management of Scheuermann’s kyphosis in 78 patients: radiographic outcomes, complications, and technique, Spine 32:2644, 2007. Lonner BS, Toombs CS, Guss M, et  al.: Complications in operative Scheuermann kyphosis: do the pitfalls differ from operative adolescent idiopathic scoliosis? Spine 40:305, 2015. Lopez RA, Burke SW, Levine DB, et al.: Osteoporosis in Scheuermann’s disease, Spine 13:1099, 1988. Lowe TG: Double L-rod instrumentation in the treatment of severe kyphosis, secondary to Scheuermann disease, Spine 12:336, 1987. Lowe TG: Combined anterior-posterior fusion with Cotrel-Dubousset instrumentation for severe Scheuermann’s kyphosis. Paper presented at the annual meeting of the American Academy of Orthopaedic Surgeons, New Orleans, February 1990. Lowe TG: Scheuermann disease, J Bone Joint Surg 72A:940, 1990. Lowe TG, Line BG: Evidence based medicine: analysis of Scheuermann kyphosis, Spine 32:S115, 2007. McKenzie L, Sillence D: Familial Scheuermann disese: a genetic and linkage study, J Med Genet 29:41, 1992. Moe JH: Treatment of adolescent kyphosis by nonoperative and operative methods, Manitoba Med Rev 45:481, 1965. Montgomery SP, Erwin WE: Scheuermann’s kyphosis: long-term results of Milwaukee brace treatment, Spine 6:5, 1978. Murray PM, Weinstein SL, Spratt KF: The natural history and long-term follow-up of Scheuermann kyphosis, J Bone Joint Surg 75A:236, 1993. Neithard FV: Scheuermann’s disease and spondylolysis, Orthop Trans 7:103, 1983. Ogilvie JW, Sherman J: Spondylolysis in Scheuermann’s disease, Spine 12:251, 1987. Otsuka NY, Hall JE, Mah JY: Posterior fusion for Scheuermann’s kyphosis, Clin Orthop Relat Res 251:134, 1990. Ponseti IV, Friedman B: Changes in the scoliotic spine after fusion, J Bone Joint Surg 32A:751, 1950. Ponte A, Gebbia F, Eliseo F: Nonoperative treatment of adolescent hyperkyphosis, Orthop Trans 9:108, 1985. Ruf M, Harms J: Posterior hemivertebra resection with transpedicular instrumentation: early correction in children aged 1 to 6 years, Spine 28:2132, 2003. Ryan MD, Taylor TKF: Acute spinal cord compression in Scheuermann’s disease, J Bone Joint Surg 64B:409, 1982. Sachs BL, Bradford DS, Winter RB, et al.: Scheuermann’s kyphosis: follow-up of Milwaukee-brace treatment, J Bone Joint Surg 69A:50, 1987. Scheuermann H: Kyphosis dorsalis juvenile, Ztschr Orthop Chir 41:305, 1921. Schmorl G: Die Pathogenese der juvenilen Kyphose, Fortschr Geb Rontgenstr Nuklearmed 41:359, 1930. Scoles PV, Latimer BM, Digiovanni BF: Vertebral alterations in Scheuermann’s kyphosis, Spine 16:509, 1991. Shufflebarger HL: Clinical issue: rod rotation in scoliosis surgery, Warsaw, IN, 1994, DePuy Motech. Shufflebarger HL: The theory of the segmental approach to spinal instrumentation: a definitive method of planning spinal instrumentation for every spinal pathology, Warsaw, IN, 1994, DePuy Motech. Shufflebarger HL, Harms J: Moss Miami three-dimensional spinal instrumentation: surgical technique, Warsaw, IN, 1994, DePuy Motech. Shufflebarger HL, Harms J: Moss Miami three-dimensional spinal instrumentation: taking spinal instrumentation to a new dimension, Warsaw, IN, 1994, DePuy Motech. Singh M, Nagrath AR, Maini PS: Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis, J Bone Joint Surg 52A:457, 1970. Sorensen KH: Scheuermann’s juvenile kyphosis: clinical appearances, radiography, aetiology, and prognosis, Copenhagen, 1964, Munksgaard. Speck GR, Chopin DC: The surgical treatment of Scheuermann’s kyphosis, J Bone Joint Surg 68B:189, 1986. Stoddard A, Osborn JF: Scheuermann’s disease or spinal osteochondrosis: its frequency and relationship with spondylosis, J Bone Joint Surg 61B:56, 1979. Sturm PF, Dobson JC, Armstrong GWD: The surgical management of Scheuermann’s disease. Paper presented at the 55th annual meeting of

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PART XII  THE SPINE The American Academy of Orthopaedic Surgeons, Atlanta, February 4–9, 1988. Sturm PF, Dobson JC, Armstrong GWD: The surgical management of Scheuermann’s disease, Spine 18:685, 1993. Travaglini F, Conte M: Untreated kyphosis: 25 years later. In Gaggi A, editor: Kyphosis, Bologna, Italian Scoliosis Research Group, 1984. Voutsinas SA, MacEwen GD: Sagittal profiles of the spine, Clin Orthop Relat Res 210:235, 1986. Winter RB: Congenital scoliosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Yablon JS, Kasdon DL, Levine H: Thoracic cord compression in Scheuermann’s disease, Spine 13:896, 1988.

CONGENITAL KYPHOSIS Bernard TN, Burke SW, Johnston III CE, et al.: Congenital spine deformities: a review of 47 cases, Orthopedics 8:777, 1985. Betz RR: Kyphosis of the thoracic and thoracolumbar spine in the pediatric patient: normal sagittal parameters and scope of the problem, Instr Course Lect 53:479, 2004. Bjekreim I, Magnaes B, Semb G: Surgical treatment of severe angular kyphosis, Acta Orthop Scand 53:913, 1982. Bradford DS: Anterior vascular pedicle bone grafting for the treatment of kyphosis, Spine 5:318, 1980. Bradford DS, Ganjavian S, Antonious D, et  al.: Anterior strut-grafting for the treatment of kyphosis: a review of experience with 48 patients, J Bone Joint Surg 64A:680, 1982. Campos MA, Fernandes P, Dolan L, Weinstein SL: Infantile thoracolumbar kyphosis secondary to lumbar hypoplasia, J Bone Joint Surg 90A:1726, 2008. Cheh G, Lenke LG, Padberg AM, et al.: Loss of spinal cord monitoring signals in children during thoracic kyphosis correction with spinal osteotomy, Spine 33:1093, 2008. Giglio CA, Volpon JB: Development and evaluation of thoracic kyphosis and lumbar lordosis during growth, J Child Orthop 1:187, 2007. Guille JT, Forlin E, Bowen JR: Congenital kyphosis, Orthop Rev 22:235, 1993. James JIP: Paraplegia in congenital kyphoscoliosis, J Bone Joint Surg 57B:261, 1975. Hamzaoglu A, Ozturk C, Tezer M, et al.: Simultaneous surgical treatment in congenital scoliosis and/or kyphosis associated with intraspinal abnormalities, Spine 32:2880, 2007. Kim YJ, Otsuka NY, Flynn JM, et al.: Surgical treatment of congenital kyphosis, Spine 26:2251, 2001. Lonstein JE, Winter RB, Moe JH, et al.: Neurologic deficit secondary to spinal deformity: a review of the literature and report of 43 cases, Spine 5:331, 1980. Lowe TG: Kyphosis of the thoracic and thoracolumbar spine in the pediatric patient: surgical treatment, Instr Course Lect 53:501, 2004. Mayfield JK, Winter RB, Bradford DS, et  al.: Congenital kyphosis due to defects of anterior segmentation, J Bone Joint Surg 62A:1291, 1980. McMaster MJ, Glasby MA, Singh H, Cunningham S: Lung function in congenital kyphosis and kyphoscoliosis, J Spinal Disord Tech 20:203, 2007. McMaster MJ, Ohtsuk AK: The natural history of congenital scoliosis: a study of two hundred an fifty-one patients, J Bone Joint Surg 64A:1128, 1982. McMaster MJ, Singh H: The surgical management of congenital kyphosis and kyphoscoliosis, Spine 26:2146, 2001. McMaster MJ, Singh H: Natural history of congenital kyphosis in kyphoscoliosis: a study of 112 patients, J Bone Joint Surg 81A:1367, 1999. Montgomery SP, Hall JE: Congenital kyphosis, Spine 7:360, 1982. Mooney IIIJF: Identical type I congenital kyphosis in male twins: a brief report, J Surg Orthop Adv 14:99, 2005. Morrin B, Poitras B, Duhaime M, et al.: Congenital kyphosis by segmentation defect: etiologic and pathogenic studies, J Pediatr Orthop 5:309, 1985. Noordeen MHH, Garrido E, Tucker SK, Elsebaie HB: The surgical treatment of congenital kyphosis, Spine 34:1808, 2009. Rose GK, Owen R, Sanderson JM: Transposition of rib with blood supply for the stabilization of spinal kyphosis, J Bone Joint Surg 57B:112, 1975. Shaffer JW, Bradford DS: The use of and techniques for vascularized rib pedicle grafts. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven.

Shapiro J, Herring J: Congenital vertebral displacement, J Bone Joint Surg 75A:656, 1993. Shimode M, Kojima T, Sowa K: Spinal wedge osteotomy by a single posterior approach for correction of severe and rigid kyphosis or kyphoscoliosis, Spine 27:2260, 2002. Singh M, Nagrath AR, Maini PS: Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis, J Bone Joint Surg 52A:457, 1970. Smith JT, Gollogly S, Dunn HK: Simultaneous anterior-posterior approach through a costotransversectomy for the treatment of congenital kyphosis and acquired kyphoscoliotic deformities, J Bone Joint Surg 87A:2281, 2005. White III AA, Panjabi MM: Practical biomechanics of scoliosis and kyphosis. In White AA, Panjabi AA, editors: Clinical biomechanics of the spine, Philadelphia, 1990, JB Lippincott. Winter RB: Congenital kyphoscoliosis with paralysis following hemivertebra excision, Clin Orthop Relat Res 119:116, 1976. Winter RB: Congenital spinal deformity: what’s the latest and what’s the best? Spine 14:1406, 1989. Winter RB, Lonstein JE, Denis F: Sagittal spinal alignment: the true measurement, norms, and description of correction for thoracic kyphosis, J Spinal Disord Tech 22:311, 2009. Winter RB, Moe JH: The results of spinal arthrodesis for congenital spinal deformity in patients younger than 5 years old, J Bone Joint Surg 64A:419, 1982. Winter RB, Moe JH, Lonstein JE: The surgical treatment of congenital kyphosis: a review of 94 patients age 5 years or older with 2 years or more follow-up in 77 patients, Spine 10:224, 1985. Winter RB, Moe JH, Wang JF: Congenital kyphosis, J Bone Joint Surg 55A:223, 1973. Winter RB, Moe JH, Wang JF: Congenital kyphosis: its natural history and treatment as observed in a study of one hundred and thirty patients, J Bone Joint Surg 55A:223, 1973. Zeller RD, Dubousset J: Progressive rotational dislocation in kyphoscoliotic deformities: presentation and treatment, Spine 25:1092, 2000.

PROGRESSIVE ANTERIOR VERTEBRAL FUSION Andersen J, Rostgaard-Christensen E: Progressive non-infectious anterior vertebral fusion, J Bone Joint Surg 73B:859, 1991. Bollini G, Jowe JL, Zell R: Progressive spontaneous anterior fusion of the spine. A study of seventeen patients. Presented at the 15th Meeting of the European Pediatric Orthopaedic Society, Prague, 1996. Knutsson F: Fusion of vertebrae following non-infectious disturbance in the zone of growth, Acta Radiol 32:404, 1949. Kharrat K, Dubousset J: Progressive anterior vertebral fusion in children, Rev Chir Orthop Reparatrice Appar Mot 66:485, 1980 (in French). Rivard CH, Marbaitz R, Uhthoff HK: Congenital vertebral malformations: time of induction in human and mouse embryo, Orthop Rev 8:135, 1979. Smith R: Idiopathic juvenile osteoporosis: experience of twenty-one patients, Br J Rheumatol 34:68, 1995. Van Buskirk CS, Zeller RD, Dubousset JF: Progressive anterior vertebral fusion: a frequently missed diagnosis, New York, 1998, Presented at Scoliosis Research Society.

SPONDYLOLYSIS AND SPONDYLOLISTHESIS Ani N, Keppler L, Biscup RS, et  al.: Reduction of high-grade slips (grades III through V) with VSP instrumentation: report of a series of 41 cases, Spine 16:302, 1991. Askar Z, Wardlaw D, Koti M: Scott wiring for direct repair of lumbar spondylolysis, Spine 28:354, 2003. Balderston RA, Bradford DS: Technique for achievement and maintenance of reduction for severe spondylolisthesis using spinous process traction wiring and external fixation of the pelvis, Spine 10:376, 1985. Bhatia NN, Chow G, Timon SJ, Watts HG: Diagnostic modalities for the evaluation of pediatric back pain: a prospective study, J Pediatr Orthop 28:230, 2008. Bell DF, Ehrlich MG, Zaleske DJ: Brace treatment for symptomatic spondylolisthesis, Clin Orthop Relat Res 236:192, 1988.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Beutler WJ, Fredrickson BE, Murtland A, et al.: The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation, Spine 28:1027, 2003. Boachie-Adjei O, Do T, Rawlins BA: Partial lumbosacral kyphosis reduction, decompression, and posterior lumbosacral transfixation in highgrade isthmic spondylolisthesis: clinical and radiographic results in six patients, Spine 27:E161, 2002. Bohlman HH, Cook SS: One-stage decompression and posterolateral and interbody fusion for lumbosacral spondyloptosis through a posterior approach: report of two cases, J Bone Joint Surg 64A:415, 1982. Boxall D, Bradford DS, Winter RB, et al.: Management of severe spondylolisthesis in children and adolescents, J Bone Joint Surg 61A:479, 1979. Bradford DS: Spondylolysis and spondylolisthesis, Curr Pract Orthop Surg 8:12, 1979. Bradford DS: Treatment of severe spondylolisthesis: a combined approach for reduction and stabilization, Spine 4:423, 1979. Bradford DS: Repair of spondylolysis or minimal degrees of spondylolisthesis by segmental wire fixation and bone grafting, Orthop Trans 6:1, 1982. Bradford DS: Management of spondylolysis and spondylolisthesis, Instr Course Lect 32:151, 1983. Bradford DS: Closed reduction of spondylolisthesis: an experience in 22 patients, Spine 13:580, 1988. Bradford DS, Boachie-Adjei O: Treatment of severe spondylolisthesis by anterior and posterior reduction and stabilization, J Bone Joint Surg 72A:1060, 1990. Bradford DS, Iza J: Repair of the defect in spondylolysis or minimal degrees of spondylolisthesis by segmental wire fixation and bone grafting, Spine 10:673, 1985. Buck JE: Direct repair of the defect in spondylolisthesis. Preliminary report, J Bone Joint Surg 52B:432, 1970. Buck JE: Direct repair of the defect in spondylolisthesis, J Bone Joint Surg 61A:479, 1979. Burkus JK, Lonstein JE, Winter RB, et al.: Long-term evaluation of adolescents treated operatively for spondylolisthesis: a comparison for in situ arthrodesis and reduction followed by immobilization in a cast, J Bone Joint Surg 74A:693, 1992. Callahan RA, Johnson RM, Margolis RN, et  al.: Cervical facet fusion for control of instability following laminectomy, J Bone Joint Surg 59A:991, 1977. Cavalier R, Herman MJ, Cheung EV, Pizzutillo PD: Spondylolysis and spondylolisthesis in children and adolescents, part I. Diagnosis, natural history, and nonsurgical management, J Am Acad Orthop Surg 14:417, 2006. Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD: Spondylolysis and spondylolisthesis in children and adolescents, part II. Surgical management, J Am Acad Orthop Surg 14:488, 2006. Cloward RB: Spondylolisthesis: treatment by laminectomy and posterior interbody fusion: review of 100 cases, Clin Orthop Relat Res 154:74, 1981. Cohen E, Stuecker RD: Magnetic resonance imaging in diagnosis and followup of impending spondylolysis in children and adolescents: early treatment may prevent pars defects, J Pediatr Orthop B 14:63, 2005. Crandall DG, Morrison MM, Baker D: Correcting scoliosis, kyphosis, and spondylolisthesis by direct vertebral translation using the new TSRH-3D multiplanar adjusting (MPA) screw: surgical techniques, biomechanical testing, and 2-year clinical results, Memphis, TN, 2005, Medtronic Sofamor Danek. Cyron BM, Hutton C: Variations in the amount and distribution of cortical bone across the pars interarticularis of L5: a predisposing factor in spondylolysis? Spine 4:163, 1979. Cyron BM, Hutton WC: The fatigue strength of the lumbar neural arch in spondylolysis, J Bone Joint Surg 60B:234, 1978. Danielson BI, Frennered AK, Irstam LKH: Radiologic progression of isthmic lumbar spondylolisthesis in young patients, Spine 16:422, 1991. Dawson EG, Lotysch 3rd M, Urist MR: Intertransverse process lumbar arthrodesis with autogenous bone graft, Clin Orthop Relat Res 154:90, 1981. DeWald RL: Spondylolisthesis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven.

DeWald RL, Faut M, Taddonio RF, et  al.: Severe lumbosacral spondylolisthesis in adolescents and children: reduction and staged circumferential fusion, J Bone Joint Surg 63A:619, 1981. Dick WT, Schnebel B: Severe spondylolisthesis: reduction in internal fixation, Clin Orthop Relat Res 232:70, 1988. Dietrich M, Kurowski P: The importance of mechanical factors in the etiology of spondylolysis: a modern analysis of loads and stresses in human lumbar spine, Spine 10:532, 1985. Ebraheim NA, Lu J, Hao Y, et  al.: Anatomic considerations of the lumbar isthmus, Spine 22:941, 1997. Edwards CC: Reduction of spondylolisthesis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 22, Philadelphia, 1997, Lippincott-Raven. Fredrickson BE, Baker D, Yuan H, et al.: The natural history of spondylolysis and spondylolisthesis, J Bone Joint Surg 66A:699, 1984. Freeman BL, Donati NL: Spinal arthrodesis for severe spondylolisthesis in children and adolescents: a long-term follow-up study, J Bone Joint Surg 71A:594, 1989. Frennered AK, Danielson BI, Nachemson AL: Midterm follow-up of young patients fused in situ for spondylolisthesis, Spine 16:409, 1991. Gaines RW: L5 vertebrectomy for the surgical treatment of spondyloptosis: thirty cases in 25 years, Spine 30:S66, 2005. Gaines RW, Nichols WK: Treatment of spondyloptosis by two-stage L5 vertebrectomy and reduction of L4 onto S1, Spine 10:680, 1985. Gaines Jr RW: The L5 vertebrectomy approach for the treatment of spondyloptosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Garfin SR, Amundson GM: Spondylolisthesis, Update Spinal Dis 1:3, 1986. Gelfand MJ, Strife JL, Kereiakes SG: Radionuclide bone imaging in spondylolysis of the lumbar spine in children, Radiology 140:191, 1981. Gill GG, Manning JG, White HL: Surgical treatment of spondylolisthesis without spine fusion, J Bone Joint Surg 37A:493, 1955. Gill GG, White HL: Surgical treatment of spondylolisthesis without spine fusion: a long-term follow-up of operated cases. Paper presented at the Western Orthopaedic Association, San Francisco, November 1962. Goldberg MJ: Gymnastic injuries, Orthop Clin North Am 11:717, 1980. Grzegorzewski A, Kumar SJ: In situ posterolateral spine arthrodesis for grades III, IV, and V spondylolisthesis in children and adolescents, J Pediatr Orthop 20:506, 2000. Hambly M, Lee CK, Gutteling E, et al.: Tension band wiring-bone grafting for spondylolysis and spondylolisthesis: a clinical and biomechanical study, Spine 14:455, 1989. Haraldsson S, Willner S: A comparative study of spondylolisthesis in operations on adolescents and adults, Arch Orthop Trauma Surg 101:101, 1983. Harms J, Jeszenszky D, Stoltze D, et al.: True spondylolisthesis reduction and monosegmental fusion in spondylolisthesis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Harrington PR, Dickson JH: Spinal instrumentation in the treatment of severe progressive spondylolisthesis, Clin Orthop Relat Res 117:157, 1976. Harrington PR, Tullos HS: Spondylolisthesis in children: observations and surgical treatment, Clin Orthop Relat Res 79:75, 1971. Harris IE, Weinstein SL: Long-term follow-up of patients with grade III and IV spondylolisthesis: treatment with and without fusion, J Bone Joint Surg 69A:960, 1987. Helenius I, Lamberg T, Osterman K, et al.: Scoliosis Research Society outcome instrument in evaluation of long-term surgical results in spondylolysis and low-grade isthmic spondylolisthesis in young patients, Spine 30:336, 2005. Helenius I, Remes V, Lamberg T, et al.: Long-term health-related quality of life after surgery for adolescent idiopathic scoliosis and spondylolisthesis, J Bone Joint Surg 90A:1231, 2008. Helenius I, Remes V, Poussa M: Uninstrumented in situ fusion for highgrade childhood and adolescent isthmic spondylolisthesis: long-term outcome: surgical technique, J Bone Joint Surg 90A:145, 2008. Hensinger RN: Spondylolysis and spondylolisthesis in children, Instr Course Lect 32:132, 1983.

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PART XII  THE SPINE Hensinger RN: Spondylolysis and spondylolisthesis in children and adolescents, J Bone Joint Surg 71A:1098, 1989. Hensinger RN, Lang JR, MacEwen GD: Surgical management of the spondylolisthesis in children and adolescents, Spine 1:207, 1976. Herbiniaux G: Traite sur divers accouchemens laborieux et sur les polypes de la matrice, Braxelles, 1782, JL DeBoubers. Herman MJ, Pizzutillo PD: spondylolysis and spondylolisthesis in the child and adolescent, Clin Orthop Relat Res 434:46, 2005. Hollenberg GM, Beattie PF, Meyers SP, et al.: Stress reactions of the lumbar pars interarticularis: the development of a new MRI classification system, Spine 27:181, 2002. Hu SS, Bradford DS, Transfeldt EE, Cohen M: Reduction of high-grade spondylolisthesis using Edwards instrumentation, Spine 21:367, 1996. Hresko MT, Hirschfeld R, Buerk AA, Zurakowski D: The effect of reduction and instrumentation of the spondylolisthesis on spinopelvic sagittal alignment, J Pediatr Orthop 29:157, 2009. Hresko MT, Labelle H, Roussouly P, Berthonnaud E: Classification of highgrade spondylolistheses based on pelvic version and spine balance: possible rationale for reduction, Spine 32:2208, 2007. Huizenga BA: Reduction of spondyloptosis with two-stage vertebrectomy, Orthop Trans 7:21, 1983. Ivanic GM, Pink TP, Achatz W, et al.: Direct stabilization of lumbar spondylolysis with a hook screw: mean 11-year follow-up period for 113 patients, Spine 28:255, 2003. Jackson DW, Wiltse LL, Cirincione RJ: Spondylolysis in the female gymnast, Clin Orthop Relat Res 117:68, 1976. Jackson DW, Wiltse LL, Dingerman RD, Hayes M: Stress reactions involving the pars interarticularis in young athletes, Am J Sports Med 9:304, 1981. Johnson GV, Thompson AG: The Scott wiring technique for direct repair of lumbar spondylolysis, J Bone Joint Surg 74B:426, 1992. Johnson JR, Kirwan EOG: The long-term results of fusion in situ for severe spondylolisthesis, J Bone Joint Surg 65B:43, 1983. Johnson LP, Nasca RJ, Dunham WK, et al.: Surgical management of isthmic spondylolisthesis, Spine 13:93, 1988. Kakiuchi M: Repair of the defect in spondylolysis: durable fixation with pedicled screws and laminar hooks, J Bone Joint Surg 79A:818, 1997. Kaneda K, Satoh S, Nohara Y, et al.: Distraction rod instrumentation with posterolateral fusion in isthmic spondylolisthesis: 53 cases followed for 18 to 89 months, Spine 10:383, 1985. Kilian HF: Schilderungen neuer Eckenformen und ihres Verhaltens in Leven, Mannheim, 1854, Verlag von Bassermann & Mathy. Kiviluoto O, Santavirta S, Salenius P, et al.: Posterolateral spine fusion: a 1- to 4-year follow-up of 80 consecutive patients, Acta Orthop Scand 56:152, 1985. Klein G, Mehlman CT, McCarty M: Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies, J Pediatr Orthop 29:146, 2009. Klinghoffer L, Murdock MG: Spondylolysis following trauma: a case report and review of the literature, Clin Orthop Relat Res 166:72, 1982. Kohles SS, Kohles DA, Karp AP, et al.: Time-dependent surgical outcomes following cauda equina syndrome diagnosis: comments on a meta-analysis, Spine 25:1515, 2004. Lamberg T, Remes V, Helenius I, et al.: Uninstrumented in situ fusion for high-grade childhood and adolescent isthmic spondylolisthesis: longterm outcome, J Bone Joint Surg 89A:512, 2007. Lenke LG, Bridwell KH: Evaluation and surgical treatment of high-grade isthmic dysplastic spondylolisthesis, Instr Course Lect 52:525, 2003. Lenke LG, Bridwell KH, Bullis D, et al.: Results of in situ fusion for isthmic spondylolisthesis, J Spinal Disord 5:433, 1992. Letts M, Smallmon T, Afanasiev R, et al.: Fracture of the pars interarticularis in adolescent athletes: a clinical biomechanical analysis, J Pediatr Orthop 6:40, 1986. Lindholm TS, Ragni P, Ylikoski M, et al.: Lumbar isthmic spondylolisthesis in children and adolescents: radiologic evaluation and results of operative treatment, Spine 15:1350, 1990. Lowe RW, Hayes TD, Kaye J, et al.: Standing roentgenograms in spondylolisthesis, Clin Orthop Relat Res 117:80, 1976.

Mac-Thiong JM, Labelle H: A proposal for a surgical classification of pediatric lumbosacral spondylolisthesis based on current literature, Eur Spine J 15:1425, 2006. Mac-Thiong JM, Wang Z, de Guide JA, Labelle H: Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis, Spine 33:2316, 2008. Marchetti PG, Bartolozzi P: Classification of spondylolisthesis as a guideline for treatment. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Mardjetko S, Albert T, Andersson G, et al.: Spine/SRS spondylolisthesis summary statement, Spine 30(6S):S3, 2005. Martin G, Boden S, Marone M: Posterolateral intertransverse process spinal arthrodesis with rhBMP-2 in a nonhuman primate: important lessons learned regarding dose, carrier and safety, J Spinal Disord 12:179, 1999. Matthiass HH, Heine J: The surgical reduction of spondylolisthesis, Clin Orthop Relat Res 203:34, 1986. Maurice HD, Morley TR: Cauda equina lesions following fusion in situ and decompressive laminectomy for severe spondylolisthesis: four case reports, Spine 14:214, 1989. McCarroll JR, Miller JM, Ritter MA: Lumbar spondylolysis and spondylolisthesis in college football players: a prospective study, Am J Sports Med 14:404, 1986. McCarty ME, Mehlman CT, Tamai J, et al.: Spondylolisthesis: intraobserver and interobserver reliability with regard to the measurement of slip percentage, J Pediatr Orthop 29:755, 2009. McPhee IB, O’Brien JP: Scoliosis in symptomatic spondylolisthesis, J Bone Joint Surg 62B:155, 1980. Meyerding HW: Spondylolisthesis, Surg Gynecol Obstet 54:371, 1932. Micheli LJ: Low back pain in the adolescent: differential diagnosis, Am J Sports Med 7:361, 1979. Mihara H, Onari K, Cheng BC, et al.: The biomechanical effects of spondyloysis and its treatment, Spine 28:235, 2003. Miller SF, Congeni J, Swanson K: Long-term functional and anatomical followup of early detected spondylolysis in young athletes, Am J Sports Med 32:928, 2004. Mimatsu K: New laminoplasty after thoracic and lumbar laminectomy, J Spinal Disord 10:20, 1997. Molinari RW, Bridwell KH, Lenke LG, et  al.: Anterior column support in surgery for high-grade, isthmic spondylolisthesis, Clin Orthop Relat Res 394:109, 2002. Morita T, Ikata T, Katoh S, Miyake R: Lumbar spondylolysis in children and adolescents, J Bone Joint Surg 77B:620, 1995. Murray PM, Weinstein SL, Spratt KF: The natural history and long-term follow-up of Scheurermann kyphosis, J Bone Joint Surg 75A:236, 1993. Nachemson A: Repair of the spondylolisthetic defect and intertransverse fusion for young patients, Clin Orthop Relat Res 117:101, 1976. Neugebauer FL: A new contribution to the history and etiology of spondylolisthesis, New Sydenham Society Selected Monographs 121:1, 1988. Newman PH: A clinical syndrome associated with severe lumbosacral subluxation, J Bone Joint Surg 47B:472, 1965. Newman PH: Stenosis of the lumbar spine in spondylolisthesis, Clin Orthop Relat Res 115:116, 1976. Newton PO, Johnston 2nd CE: Analysis and treatment of poor outcomes following in situ arthrodesis in adolescent spondylolisthesis, J Pediatr Orthop 17:754, 1997. Nicol RO, Scott JHS: Lytic spondylolysis: repair by wiring, Spine 11:1027, 1986. Nozawa S, Simizu K, Miyamoto K, et al.: Repair of pars interarticularis defect by segmental wire fixation in young athletes with spondylolysis, Am J Sports Med 31:359, 2003. Ogilvie JW: Complications in spondylolisthesis surgery, Spine 30(6S):S97, 2005. Ohki I, Inoue S, Murata T, et al.: Reduction and fusion of severe spondylolisthesis using halo-pelvic traction with a wire reduction device, Int Orthop 4:107, 1980. Osterman K, Snellman O, Poussa M, et al.: Treatment of lumbar lytic spondylolisthesis using osteoperiosteal transplants in young patients, J Pediatr Orthop 1:289, 1981.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Pedersen AK, Hagen R: Spondylolysis and spondylolisthesis: treatment by internal fixation and bone grafting of the defect, J Bone Joint Surg 70A:15, 1988. Pennell RG, Maurer AH, Bonakdarpour A: Stress injuries of the pars interarciularis: radiographic classification and indications for scintigraphy, AJR Am J Roentgenol 145:763, 1985. Petraco DM, Spivac JM, Cappadona JG, et al.: An anatomic evaluation of L5 nerve stretch in spondylolisthesis reduction, Spine 21:1133, 1996. Pizzutillo PD, Hummer III CD: Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis, J Pediatr Orthop 9:538, 1989. Pizzutillo PD, Mirenda W, MacEwen GD: Posterolateral fusion for spondylolisthesis in adolescence, J Pediatr Orthop 6:311, 1986. Poussa M, Remes V, Lambert T, et al.: Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ: long-term clinical, radiologic, and functional outcome, Spine 31:583, 2006. Poussa M, Schlenzka S, Seitsalo M, et al.: Surgical treatment of severe isthmic spondylolisthesis in adolescents: reduction of fusion in situ, Spine 18:894, 1993. Rabushka SE, Apfelbach H, Love L: Spontaneous healing of spondylolysis of the fifth lumbar vertebra: a case report, Clin Orthop Relat Res 93:259, 1973. Riley P, Gillespie R: Severe spondylolisthesis: results of posterolateral fusion, Orthop Trans 9:119, 1985. Roca J, Iborra M, Cavanilles-Walker JM, et al.: Direct repair of spondylolysis using a new pedicle screw hook fixation: clinical and CT-assessed study: an analysis of 19 patients, J Spinal Disord Tech 18(Suppl):S82, 2005. Roca J, Moretta D, Fuster S, et al.: Direct repair of spondylolysis, Clin Orthop Relat Res 246:86, 1989. Rombold C: Treatment of spondylolisthesis by posterolateral fusion, resection of the pars interarticularis, and prompt mobilization of the patient: an end-result study of seventy-three patients, J Bone Joint Surg 48A:1282, 1966. Rosenberg NJ, Bargar WL, Friedman B: The incidence of spondylolysis and spondylolisthesis in nonambulatory patients, Spine 6:35, 1981. Rosomoff HL: Lumbar spondylolisthesis: etiology of radiculopathy and role of the neurosurgeon, Clin Neurosurg 27:577, 1980. Saifuddin A, Burnett SJD: The value of lumbar spine MRI in assessment of the pars interarticularis, Clin Radiol 52:666, 1997. Sairyo K, Goel VK, Faizan A, et al.: Buck’s direct repair of lumbar spondylolysis restores disc stresses at the involved and adjacent levels, Clin Biomech (Bristol, Avon) 21:1020, 2006. Sairyo K, Katoh S, Takata Y, et al.: MRI signal changes of the pedicle as an indicator for early diagnosis of spondylolysis in children and adolescents: a clinical and biomechanical study, Spine 31:206, 2006. Salib RM, Pettine KA: Modified repair of a defect in spondylolysis or minimal spondylolisthesis by pedicle screw, segmental wire fixation, and bone grafting, Spine 18:440, 1993. Saraste H: Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis, J Pediatr Orthop 7:631, 1987. Scaglietti O, Frontino G, Bartolozzi P: Technique of anatomical reduction of lumbar spondylolisthesis and its surgical stabilization, Clin Orthop Relat Res 117:164, 1976. Schlegel K, Pon MA: The biomechanics of posterior lumbar interbody fusion (PLIF) in spondylolisthesis, Clin Orthop Relat Res 193:115, 1985. Schoenecker PL: Developmental spondylolisthesis without lysis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Schoenecker PL, Cole HO, Herring JA, et al.: Cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction, J Bone Joint Surg 72A:369, 1990. Seitsalo S: Operative and conservative treatment of moderate spondylolisthesis in young patients, J Bone Joint Surg 72B:908, 1990. Seitsalo S, Osterman K, Hyvarinen H, et al.: Severe spondylolisthesis in children and adolescents: a long-term review of fusion in situ, J Bone Joint Surg 72B:259, 1990. Seitsalo S, Osterman K, Hyvarinen H, et al.: Progression of spondylolisthesis in children and adolescents: a long-term follow-up of 272 patients, Spine 16:417, 1991.

Seitsalo S, Osterman K, Poussa M: Scoliosis associated with lumbar spondylolisthesis: a clinical survey of 190 young patients, Spine 13:899, 1988. Seitsalo S, Osterman K, Poussa M, et al.: Spondylolisthesis in children under 12 years of age: long-term results of 56 patients treated conservatively or operatively, J Pediatr Orthop 8:516, 1988. Sevastikoglou JA, Spangfort E, Aaro S: Operative treatment of spondylolisthesis in children and adolescents with tight hamstrings syndrome, Clin Orthop Relat Res 147:192, 1980. Sherman FC, Rosenthal RK, Hall JE: Spine fusion for spondylolysis and spondylolisthesis in children, Spine 4:59, 1979. Shufflebarger HL, Geck MJ: High-grade isthmic dysplastic spondylolisthesis: monosegmental surgical treatment, Spine 30:S42, 2005. Sijbrandij S: A new technique for the reduction and stabilisation of severe spondylolisthesis: a report of two cases, J Bone Joint Surg 63B:266, 1981. Sijbrandij S: Reduction and stabilisation of severe spondylolisthesis: a report of three cases, J Bone Joint Surg 65B:40, 1983. Smith JA, Deviren V, Berven S, et al.: Clinical outcome of trans-sacral interbody fusion after partial reduction for high-grade L5-S1 spondylolisthesis, Spine 26:2227, 2001. Soler T, Calderon C: The prevalence of spondylolysis in the Spanish elite athlete, Am J Sports Med 28:57, 2000. Stanton RP, Meehan P, Lovell WW: Surgical fusion in childhood spondylolisthesis, J Pediatr Orthop 5:411, 1985. Steffee AD, Sitkowski DJ: Reduction and stabilization of grade IV spondylolisthesis, Clin Orthop Relat Res 227:82, 1988. Sys J, Michielsen J, Bracke P, et al.: Nonoperative treatment of active spondylolysis in elite athletes with normal x-ray findings: literature review and results of conservative treatment, Eur Spine J 10:498, 2001. Szappanos L, Szepesi K, Thomazy V: Spondylolysis in osteopetrosis, J Bone Joint Surg 70B:428, 1988. Taddonio RF: Isthmic spondylolisthesis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Takeda M: A newly devised “three-one” method for the surgical treatment of spondylolysis and spondylolisthesis, Clin Orthop Relat Res 147:228, 1980. Timon SJ, Gardner MJ, Wanach T, et al.: Not all spondylolisthesis grading instruments are reliable, Clin Orthop Relat Res 434:157, 2005. Tower SS, Prat WB: Spondylolysis and associated spondylolisthesis in Eskimo and Athabascan populations, Clin Orthop Relat Res 250:171, 1990. Transfelt EE, Dendrinos GK, Bradford DS: Paresis of proximal lumbar roots after reduction of L5-S1 spondylolisthesis, Spine 14:884, 1988. Troup JD: The etiology of spondylolysis, Orthop Clin North Am 8:57, 1977. Troup JD: Mechanical factors in spondylolisthesis and spondylolysis, Clin Orthop Relat Res 117:59, 1976. Turner RH, Bianco Jr AJ: Spondylolysis and spondylolisthesis in children and teen-agers, J Bone Joint Surg 53A:1298, 1971. van Dam DE: Nonoperative treatment and surgical repair of lumbar spondylolysis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. van den Oever M, Merrick MV, Scott JHS: Bone scintigraphy in symptomatic spondylolysis, J Bone Joint Surg 69B:453, 1987. Velikas EP, Blackburne JS: Surgical treatment of spondylolisthesis in children and adolescents, J Bone Joint Surg 63B:67, 1981. Vidal J, Fassio B, Buscauret C, et al.: Surgical reduction of spondylolisthesis using a posterior approach, Clin Orthop Relat Res 154:156, 1981. Wang Z, Parent S, Mac-Thiong JM, et al.: Influence of sacral morphology in developmental spondylolisthesis, Spine 33:2185, 2008. Ward CV, Latimer B: Human evolution and the development of spondylolysis, Spine 30:1808, 2005. Warner WC: Kyphosis. In Morrissy RT, Weinstein SL, editors: Lovell and Winter’s pediatric orthopaedics, ed 6, Philadelphia, 2006, Lippincott Williams & Wilkins. Weiner BK, Walker M, Wiley W, McCulloch JA: The lateral buttress: an anatomic feature of the lumbar pars interarticularis, Spine 27:E3857, 2002. Wertzberger KL, Peterson HA: Acquired spondylolysis and spondylolisthesis in the young child, Spine 5:437, 1980. Wiltse LL, Bateman JG, Hutchinson RH, et al.: The paraspinal sacrospinalissplitting approach to the lumbar spine, J Bone Joint Surg 50A:919, 1968.

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PART XII  THE SPINE Wiltse LL, Jackson DW: Treatment of spondylolisthesis and spondylolysis in children, Clin Orthop Relat Res 117:92, 1976. Wiltse LL, Newman PH, Macnab I: Classification of spondylolysis and spondylolisthesis, Clin Orthop Relat Res 117:23, 1976. Wimberly RL, Lauerman WC: Spondylolisthesis in the athlete, Clin Sports Med 21:133, 2002. Yamane T, Yoshida T, Mimatsu K: Early diagnosis of lumbar spondylolysis by MRI, J Bone Joint Surg 75B:764, 1993.

KYPHOSCOLIOSIS IN MYELOMENINGOCELE Akbar M, Bremer R, Thomsen M, et al.: Kyphectomy in children with myelodysplasia: results 1994-2004, Spine 31:1007, 2006. Allen B, Ferguson R: Operative treatment of myelomeningocele spinal deformities, Orthop Clin North Am 10:845, 1979. Archibeck MJ, Smith JT, Carol KL, et  al.: Surgical release of the tethered spinal cord: survivorship analysis and orthopaedic outcome, J Pediatr Orthop 17:773, 1997. Banta JV: Combined anterior and posterior fusion for spinal deformity in myelomeningocele, Spine 15:946, 1990. Banta JV, Park SM: Improvement in pulmonary function in patients having combined anterior and posterior spine fusion for myelomeningocele scoliosis, Spine 8:766, 1983. Banta JV, Whiteman S, Dyck PM, et al.: Fifteen-year review of myelodysplasia, J Bone Joint Surg 58A:726, 1976. Benson ER, Thomson JD, Smith BG, et al.: Results and morbidity in a consecutive series of patients undergoing spinal fusion for neuromuscular scoliosis, Spine 23:2308, 1998. Bodel JG, Stephane JP: Luque rods in the treatment of kyphosis in myelomeningocele, J Bone Joint Surg 65B:98, 1983. Christofersen MR, Brooks AL: Excision and wire fixation of rigid myelomeningocele kyphosis, J Pediatr Orthop 5:691, 1985. Crawford AH, Strub WM, Lewis R, et al.: Neonatal kyphectomy in the patient with myelomeningocele, Spine 28:260, 2003. D’Astous J, Drouin MA: Rhine E: Intraoperative anaphylaxis secondary to allergy to latex in children who have spina bifida: report of two cases, J Bone Joint Surg 74A:1084, 1992. Drennan JC, Banta JV, Bunch WH, et al.: Symposium, current concepts in the management of myelomeningocele, Contemp Orthop 19:63, 1989. Drummond DS, Morear M, Cruess RL: The results and complications of surgery for the paralytic hip and spine in myelomeningocele, J Bone Joint Surg 62B:49, 1980. Dunn HK: Kyphosis of myelodysplasia: operative treatment based on pathophysiology, Orthop Trans 7:19, 1983. Dunn HK, Bender NK: The management of kyphosis of myelodysplasia. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993. Emans JB: Allergy to latex in patients who have myelodysplasia, J Bone Joint Surg 74A:1103, 1992. Feiwell E: Selection of appropriate treatment for patients with myelomeningocele, Orthop Clin North Am 12:101, 1981. Geiger F, Parsch D, Carstens C: Complications of scoliosis surgery in children with myelomeningocele, Eur Spine J 8:22, 1999. Gillespie R, Torode I, van Olm Jr RS: Myelomeningocele kyphosis fixed by kyphectomy and segmental spinal instrumentation, Orthop Trans 8:162, 1984. Guille JT, Sarwark JF, Sherk HH, Kumar SJ: Congenital and developmental deformities of the spine in children with myelomeningocele, J Am Acad Orthop Surg 14:294, 2006. Heydemann JS, Gillespie R: Management of myelomeningocele kyphosis in the older child by kyphectomy and segmental spinal instrumentation, Spine 12:37, 1987. Hoppenfeld S: Congenital kyphosis in myelomeningocele, J Bone Joint Surg 49B:276, 1967. Hull WJ, Moe JH, Winter RB: Spinal deformity in myelomeningocele: natural history, evaluation, and treatment, J Bone Joint Surg 56A:1767, 1974. Johnston CE, Hakala MW, Rosenberg R: Paralytic spinal deformity: orthotic treatment in spinal discontinuity syndromes, J Pediatr Orthop 2:233, 1982. Jones ET: Kyphectomy in myelodysplasia, Orthop Trans 7:432, 1983.

Kahanovitz N, Duncan JW: The role of scoliosis and pelvic obliquity on functional disability in myelomeningocele, Spine 6:494, 1981. Kilfoyle RM, Foley JJ, Norton PL: Spine and pelvic deformity in childhood and adolescent paraplegia: a study of 104 cases, J Bone Joint Surg 47A:659, 1976. Ko AL, Song K, Ellenbogen RG, Avellino AM: Retrospective review of multilevel spinal fusion combined with spinal cord transection for treatment of kyphoscoliosis in pediatric myelomeningocele patients, Spine 32:2493, 2007. Kocaoglu B, Erol B, Akgülle H, et al.: Combination of Luque instrumentation with polyaxial screws in the treatment of myelomeningocele kyphosis, J Spinal Disord Tech 21:199, 2008. Leatherman KD, Dickson RA: Congenital kyphosis in myelomeningocele: vertebral body resection and posterior spinal fusion, Spine 3:222, 1978. Lindseth RE: Myelomeningocele spine. In Weinstein SL, editor: The pediatric spine, New York, 1994, Raven Press. Lindseth RE, Selzer L: Vertebral excision of kyphosis in myelomeningocele, J Bone Joint Surg 61A:699, 1979. Lubicky JP: The myelomeningocele spine. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Lubicky JP: Spinal deformity in myelomeningocele. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Mackel JL, Lindseth RE: Scoliosis in myelodysplasia, J Bone Joint Surg 57A:131, 1975. Mayfield JK: Severe spine deformity and myelodysplasia and sacral agenesis: an aggressive surgical approach, Spine 6:498, 1981. Mazur J, Menelaus MB, Dickens DRV, et al.: Efficacy of surgical management for scoliosis in myelomeningocele: correction of deformity and alteration of functional status, J Pediatr Orthop 6:568, 1986. McCarthy RE, Peak RD, Morissy RT, et al.: Allograft bone and spinal fusion for paralytic scoliosis, J Bone Joint Surg 68A:370, 1986. McIvor J, Kraibech JI, Hoffman H: Orthopaedic complications of lumboperitoneal shunts, J Pediatr Orthop 8:687, 1988. McLaughlin TP, Banta JV, Gahm NH, et al.: Intraspinal rhizotomy and distal cordectomy in patients with myelomeningocele, J Bone Joint Surg 68A:88, 1986. McMaster MJ: Anterior and posterior instrumentation and fusion of thoracolumbar scoliosis due to myelomeningocele, J Bone Joint Surg 69B:20, 1987. McMaster MJ: The long-term results of kyphectomy and spinal stabilization in children with myelomeningocele, Spine 13:417, 1988. Meehan PL, Galina MP, Daftari T: Intraoperative anaphylaxis due to allergy to latex: report of two cases, J Bone Joint Surg 74A:1087, 1992. Mintz LJ, Sarwark JF, Dias LS, et al.: The natural history of congenital kyphosis in myelomeningocele: a review of 51 children, Spine 16:S348, 1991. Müller EB, Nordwall A: Brace treatment of scoliosis in children with myelomeningocele, Spine 19:151, 1994. Müller EB, Nordwall A, Oden A: Progression of scoliosis in children with myelomeningocele, Spine 19:144, 1994. Niall DM, Dowling FE, Fogarty EE, et  al.: Kyphectomy in children with myelomeningocele: a long-term outcome study, J Pediatr Orthop 24:37, 2004. Nolden MT, Sarwark JF, Vora A, et  al.: A kyphectomy technique with reduced perioperative morbidity for myelomeningocele kyphosis, Spine 27:1807, 2002. Osebold W, Mayfield JK, Winter RB, et al.: Surgical treatment of paralytic scoliosis in myelomeningocele, J Bone Joint Surg 64A:841, 1982. Poitras B, Rivard C, Duhaime M, et al.: Correction of the kyphosis in myelomeningocele patients by both anterior and posterior stabilization procedure, Orthop Trans 7:432, 1983. Raycroft JF, Curtis BH: Spinal curvature in myelomeningocele. In The American Academy of Orthopaedic Surgeons: Symposium on myelomeningocele, St. Louis, 1972, Mosby. Rodgers WB, Frim DM, Emans JB: Surgery of the spine in myelodysplasia: an overview, Clin Orthop Relat Res 338:19, 1997. Rodgers WB, Williams MS, Schwend RM, et al.: Spinal deformity in myelodysplasia: correction with posterior pedicle screw instrumentation, Spine 22:2435, 1997.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Samuelsson L, Eklof O: Scoliosis in myelomeningocele, Acta Orthop Scand 59:122, 1988. Sarwark JF: Kyphosis deformity in myelomeningocele, Orthop Clin North Am 30:451, 1990. Sharrard WJW: Spinal osteotomy for congenital kyphosis in myelomeningocele, J Bone Joint Surg 50B 466, 1968. Sharrard WJW, Drennan JC: Osteoexcision of the spine for lumbar kyphosis in older children with myelomeningocele, J Bone Joint Surg 54B:50, 1972. Smith RM, Emans JB: Sitting balance in spinal deformity, Spine 17:1103, 1992. Sponseller PD, Young AT, Sarwark JF, et al.: Anterior-only fusion for scoliosis in patients with myelomeningocele, Clin Orthop Relat Res 364:117, 1999. Sriram K, Bobechko WP, Hall JE: Surgical management of spinal deformities in spina bifida, J Bone Joint Surg 54A:666, 1972. Stark A, Saraste H: Anterior fusion insufficient for scoliosis in myelomeningocele: eight children, 2 to 6 years after the Zielke operation, Acta Orthop Scand 64:22, 1993. Stella G, Ascani E, Cervellati S, et al.: Surgical treatment of scoliosis associated with myelomeningocele, Eur J Pediatr Surg 8(Suppl 1):22, 1998. Szalay EA, Roach JW, Smith H, et al.: Magnetic resonance imaging of the spinal cord and spinal dysraphisms, J Pediatr Orthop 7:541, 1987. Trivedi J, Thomson JD, Slakey JB, et  al.: Clinical and radiographic predictors of scoliosis in patients with myelomeningocele, J Bone Joint Surg 84A:1389, 2002. Vogel LC, Schrader T, Lubicky JT: Latex allergy in children and adolescents with spinal cord injuries, J Pediatr Orthop 15:517, 1995. Ward WT, Wenger DR, Roach JW: Surgical correction of myelomeningocele scoliosis: critical appraisal of various spinal instrumentation systems, J Pediatr Orthop 9:262, 1989. Warner Jr WC, Fackler CD: Comparison of two instrumentation techniques in treatment of lumbar kyphosis in myelodysplasia, J Pediatr Orthop 13:704, 1993. Widmann RF, Hresko MT, Hall JE: Lumbosacral fusion in children and adolescents using the modified sacral bar technique, Clin Orthop Relat Res 364:85, 1999. Winston K, Hall JE, Johnson D, et al.: Acute elevation of intracranial pressure following transection of nonfunctional spinal cord, Clin Orthop Relat Res 128:41, 1977. Winter RB, Carlson JM: Modern orthotics for spinal deformities, Clin Orthop Relat Res 126:74, 1977. Winter RB, Pinto WC: Pelvic obliquity: its causes and treatment, Spine 11:225, 1986. Yamane T, Shinoto A, Kamegaya M, et  al.: Spinal dysraphism: a study of patients over the age of 10 years, Spine 16:1295, 1991.

SACRAL AGENESIS Abraham E: Lumbosacral coccygeal agenesis: autopsy case report, J Bone Joint Surg 58A:1169, 1976. Abraham E: Sacral agenesis with associated anomalies (caudal regression syndrome): autopsy case report, Clin Orthop Relat Res 145:168, 1979. Andrish J, Kalamchi A, MacEwen GD: Sacral agenesis: a clinical evaluation of its management, heredity, and associated anomalies, Clin Orthop Relat Res 139:52, 1979. Blumel J, Evans ER, GWN Eggers: Partial and complete agenesis or malformation of the sacrum with associated anomalies: etiologic and clinical study with special reference to heredity. A preliminary report, J Bone Joint Surg 41:497, 1959. Dumont C, Dansin J, Forin V, et  al.: Lumbosacral agenesis: three cases of reconstruction using Cotrel-Dubousset or L-rod instrumentation, Spine 18:1229, 1993. Elting JJ, Allen JC: Management of the young child with bilateral anomalous and functionless lower extremities, J Bone Joint Surg 54A:1523, 1972. Faciszewski T, Winter RB, Lonstein JE: Segmental spinal dysgenesis: a disorder different from spinal agenesis, J Bone Joint Surg 77A:530, 1995. Flynn JM, Otsuka NY, Emans JB, et al.: Segmental spinal dysgenesis: early neurologic deterioration and treatment, J Pediatr Orthop 17:100, 1997.

Hughes LO, McCarthy RE, Glasier CM: Segmental spinal dysgenesis: a report of three cases, J Pediatr Orthop 18:227, 1998. Ignelzi RJ, Lehman RAW: Lumbosacral agenesis: management and embryological implications, J Neurol Neurosurg Psychiatry 37:1273, 1974. Marsh HO, Tejano NA: Four cases of lumbosacral and sacral agenesis, Clin Orthop Relat Res 92:214, 1973. Mongeau M, LeClaire R: Complete agenesis of the lumbosacral spine: a case report, J Bone Joint Surg 54A:161, 1972. Nicol WJ: Lumbosacral agenesis in a 60-year-old man, Br J Surg 59:577, 1972. Pang D: Sacral agenesis and caudal spinal cord malformations, Neurosurgery 32:755, 1993. Perry J, Bonnett CA, Hoffer MM: Vertebral pelvic fusions in the rehabilitation of patients with sacral agenesis, J Bone Joint Surg 52A:288, 1970. Phillips WA, Cooperman DR, Lindquist TC, et  al.: Orthopaedic management of lumbosacral agenesis: long-term follow-up, J Bone Joint Surg 64A:1282, 1982. Renshaw TS: Sacral agenesis: a classification in review of 23 cases, J Bone Joint Surg 60A:373, 1978. Rieger MA, Hall JE, Dalury DF: Spinal fusion in a patient with lumbosacral agenesis, Spine 12:1382, 1990. Rusnak SL, Driscoll SG: Congenital spinal anomalies in infants of diabetic mothers, Pediatrics 35:989, 1965. Stanley JK, Owen R, Koff S: Congenital sacral anomalies, J Bone Joint Surg 61B:401, 1979. White RI, Klauber GT: Sacral agenesis: analysis of 22 cases, Urology 8:521, 1976.

NEUROFIBROMATOSIS Akbarnia BA, Gabriel KR, Beckman E, et al.: Prevalence of scoliosis in neurofibromatosis, Spine 17:S244, 1992. Betz RR, Iorio R, Lombardi AV, et al.: Scoliosis surgery in neurofibromatosis, Clin Orthop Relat Res 245:53, 1989. Bradford DS: Anterior vascular pedicle bone grafting for the treatment of kyphosis, Spine 5:318, 1980. Brown CW: Spinal deformities in neurofibromatosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Calvert PT, Edgar MA, Webb PJ: Scoliosis in neurofibromatosis: the natural history with and without operation, J Bone Joint Surg 71B:246, 1989. Chee CP: Lateral thoracic meningocele associated with neurofibromatosis: total excision by posterolateral extradural approach: a case report, Spine 14:129, 1989. Crawford AH: Pitfalls of spinal deformities associated with neurofibromatosis in children, Clin Orthop Relat Res 245:29, 1989. Crawford Jr AH, Bagamery N: Osseous manifestations of neurofibromatosis in childhood, J Pediatr Orthop 6:72, 1986. Crawford AH, Gabriel KR: Dysplastic scoliosis: neurofibromatosis. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Curtis B, Fisher R, Butterfield W, et al.: Neurofibromatosis with paraplegia, J Bone Joint Surg 51A:843, 1969. DiSimone RE, Berman AT, Schwentker EP: The orthopaedic manifestation of neurofibromatosis: a clinical experience and review of the literature, Clin Orthop Relat Res 230:277, 1988. Durrani AA, Crawford AH, Chouhdry SN, et al.: Modulation of spinal deformities in patients with neurofibromatosis type 1, Spine 25:69, 2000. Flood BM, Butt WP, Dickson RA: Rib penetration of the intervertebral foraminae in neurofibromatosis, Spine 11:172, 1986. Hensinger R: Kyphosis secondary to skeletal dysplasias and metabolic disease, Clin Orthop Relat Res 128:113, 1977. Holt RT, Johnson JR: Cotrel-Dubousset instrumentation in neurofibromatosis spine curves: a preliminary report, Clin Orthop Relat Res 245:19, 1989. Hsu L, Lee P, Leong J: Dystrophic spinal deformities in neurofibromatosis, J Bone Joint Surg 66B:495, 1984. Lonstein J, Winter RB, Moe JH, et al.: Neurologic deficits secondary to spinal deformity, Spine 5:331, 1980. McCarroll H: Clinical manifestations of congenital neurofibromatosis, J Bone Joint Surg 32A:601, 1950.

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PART XII  THE SPINE Miller A: Neurofibromatosis: with reference to skeletal changes, compression myelitis, and malignant degeneration, Arch Surg 32:109, 1936. Ramachandran M, Tsirikos AI, Lee J, Saifuddin A: Whole-spine magnetic resonance imaging in neurofibromatosis type I and spinal deformity, J Spinal Disord Tech 17:483, 2004. Riccardi V: Von Recklinghausen neurofibromatosis, N Engl J Med 305:1617, 1981. Savini R, Parisini P, Cervellati S, et al.: Surgical treatment of vertebral deformities in neurofibromatosis, Ital J Orthop Traumatol 9:13, 1983. Shufflebarger HL: Cotrel-Dubousset instrumentation in neurofibromatosis spinal problem, Clin Orthop Relat Res 245:24, 1989. Stone JW, Bridwell KH, Shackelford GD, et al.: Dural ectasia associated with spontaneous dislocation of the upper part of the thoracic spine in neurofibromatosis: a case report and review of the literature, J Bone Joint Surg 69A:1079, 1987. Tolo VT: Spinal deformity in skeletal dysplasia conditions. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. von Recklinghausen F: Über die multiplen Fibrome der Haut und ihre Beziehung zu den multiplen Neuromen, Festschrift für Rudolph Virchow, Berlin, 1882, August, Hirschwald. Winter RB: Thoracic lordoscoliosis in neurofibromatosis: treatment by Harrington rod with sublaminar wiring: report of two cases, J Bone Joint Surg 62A:1102, 1984. Winter RB, Edwards W: Neurofibromatosis with lumbosacral spondylolisthesis, J Pediatr Orthop 1:91, 1981. Winter RB, Lonstein JE, Anderson M: Neurofibromatosis hyperkyphosis: a review of 33 patients with kyphosis of 80 degrees or greater, J Spinal Disord 1:39, 1988. Winter RB, Lonstein JE, Anderson M: Neurofibromatosis kyphosis. Paper presented at the 55th annual meeting of the American Academy of Orthopaedic Surgeons, Atlanta, February 4–9, 1988. Winter RB, Moe J, Bradford D, et al.: Spine deformity in neurofibromatosis, J Bone Joint Surg 61A:677, 1979. Yong-Hing K, Kalamchi A, MacEwen GD: Cervical spine abnormalities in neurofibromatosis, J Bone Joint Surg 61A:695, 1979.

MARFAN SYNDROME Amis J, Herring J: Iatrogenic kyphosis: complication of Harrington instrumentation in Marfan’s syndrome, J Bone Joint Surg 66A:460, 1984. Birch JG, Herring JA: Spinal deformity in Marfan’s syndrome, J Pediatr Orthop 7:546, 1987. Boucek RJ, Noble NL, Gunya-Smith Z, et al.: The Marfan’s syndrome: a deficiency in chemically stable collagen cross links, N Engl J Med 305:988, 1981. Donaldson DH: Spinal deformity associated with Marfan’s syndrome. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Donaldson DH, Brown CW: Marfan’s spinal pathology. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Jones KB, Erkula G, Sponseller PD, Dormans JP: Spine deformity correction in Marfan syndrome, Spine 27:2002, 2003. Joseph KN, Kane HA, Milner RS, et al.: Orthopaedic aspects of the Marfan phenotype, Clin Orthop Relat Res 277:251, 1992. Pyeritz RE, McKusick VA: Basic defects in the Marfan syndrome, N Engl J Med 305:1011, 1981. Robins PR, Moe JH, Winter RB: Scoliosis in Marfan syndrome: its characteristics and results of treatment in 35 patients, J Bone Joint Surg 57A:358, 1975. Savini R, Cerrellati S, Beroaldo E: Spinal deformities in Marfan’s syndrome, Ital J Orthop Traumatol 6:19, 1980. Shirley ED: Sponseller PD: Marfan syndrome, J Am Acad Orthop Surg 17:572, 2009. Sponseller PD, Bhimani M, Solacoff D, et al.: Results of brace treatment of scoliosis in Marfan syndrome, Spine 25:2350, 2000. Sponseller PD, Hobbs W, Riley LH III, et  al: Spinal deformity and Marfan syndrome: prevalence and natural history. Paper presented at the 28th annual meeting of the Scoliosis Research Society, Dublin, September 1993.

Sponseller PD, Thompson GH, Akbarnia BA, et al.: Growing rods for infantile scoliosis in Marfan syndrome, Spine 34:1711, 2009. Taylor LJ: Severe spondylolisthesis and scoliosis in association with Marfan’s syndrome: case report and review of the literature, Clin Orthop Relat Res 221:207, 1987. Waters P, Welch K, Micheli LJ, et al.: Scoliosis in children with pectus excavatum and pectus carinatum, J Pediatr Orthop 9:551, 1989. Winter RB: Severe spondylolisthesis in Marfan’s syndrome: report of two cases, J Pediatr Orthop 2:51, 1982. Winter RB: Thoracic lordoscoliosis in Marfan’s syndrome: report of two patients with surgical correction using rods and sublaminar wires, Spine 15:233, 1990.

VERTEBRAL COLUMN TUMORS Akbarnia BA, Bradford DS, Winter RB: Osteoid osteoma of the spine: an analysis of 14 patients, Orthop Trans 6:4, 1982. Akbarnia BA, Rooholamini SA: Scoliosis caused by benign osteoblastoma of the thoracic or lumbar spine, J Bone Joint Surg 63A:1146, 1981. Allison DJ: Therapeutic embolization, J Bone Joint Surg 64B:151, 1982. Barwick KW, Huvos AG, Smith J: Primary osteogenic sarcoma of the vertebral column, Cancer 46:595, 1980. Boriani S, Weinstein JN, Biagini R: Primary bone tumors of the spine: terminology and surgical staging, Spine 22:1036, 1997. Chan P, Boriani S, Fourney DR, et  al.: An assessment of the reliability of the Enneking and Weinstein-Boriani-Biagini classifications for staging of primary spinal tumors by the Spine Oncology Study Group, Spine 34:384, 2009. De Cristofaro R, Biagini R, Boriani S, et al.: Selective arterial embolization in the treatment of aneurysmal bone cyst in angioma of bone, Skeletal Radiol 21:523, 1992. Dick HM, LU Bigliani, Michelsen WJ, et al.: Adjuvant arterial embolization in the treatment of benign primary bone tumors in children, Clin Orthop Relat Res 139:133, 1979. Dunn HK: Tumors of the thoracic and lumbar spine. In Evarts CM, editor: Surgery of the musculoskeletal system, New York, 1983, Churchill Livingstone. Garg S, Dormans JP: Tumors and tumor-like conditions of the spine in children, J Am Acad Orthop Surg 13:372, 2005. Gelb DE, Bridwell KH: Benign tumors of the spine. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Ghelman B, Lospinuso MF, Levine DB, et  al.: Percutaneous computed tomography–guided biopsy of the thoracic and lumbar spine, Spine 16:736, 1991. Hay MC, Paterson D, Taylor TKF: Aneurysmal bone cysts of the spine, J Bone Joint Surg 60B:406, 1978. Israeli A, Zwas ST, Horoszowski H, et al.: Use of radionuclide method in preoperative and intraoperative diagnosis of osteoid osteoma of the spine: case report, Clin Orthop Relat Res 175:194, 1983. Jelsma RK, Kirsch PT: The treatment of malignancy of a vertebral body, Surg Neurol 13:189, 1980. Kalra KP, Dhar SB, Shetty G, Dhariwal Q: Pedicle subtraction osteotomy for rigid posttuberculous kyphosis, J Bone Joint Surg 88B:925, 2006. Kattapuram SV, Khurana JS, Rosenthal DI: Percutaneous needle biopsy of the spine, Spine 17:561, 1992. Keim HA, Reina EG: Osteoid osteoma as a cause of scoliosis, J Bone Joint Surg 57A:159, 1975. Kelly SP, Ashford RJ, Rao AS, Dickson RA: Primary bone tumours of the spine: a 42-year survey from the Leeds Regional Bone Tumour Registry, Eur Spine J 16:405, 2007. Laredo J, Assouline E, Gelbert F, et al.: Vertebral hemangiomas: fat content as a sign of aggressiveness, Radiology 177:467, 1990. Laredo J, Reizine D, Bard M, et al.: Vertebral hemangiomas: radiologic evaluation, Radiology 161:183, 1986. Marsh BW, Bonfiglio M, Brady LP, et  al.: Benign osteoblastoma: range of manifestations, J Bone Joint Surg 57A:1, 1975. McLeod RA, Dahlin DC, Beabout JW: The spectrum of osteoblastoma, AJR Am J Roentgenol 126:321, 1976. Mehta MH: Pain-provoked scoliosis: observations on the evolution of the deformity, Clin Orthop Relat Res 135:58, 1978.

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CHAPTER 44  SCOLIOSIS AND KYPHOSIS Mehta MH, Murray RO: Scoliosis provoked by painful vertebral lesions, Skeletal Radiol 1:223, 1977. Merryweather R, Middlemiss JH, Sanerkin NG: Malignant transformation of osteoblastoma, J Bone Joint Surg 62B:381, 1980. Michele A, Krueger FJ: A surgical approach to the vertebral body, J Bone Joint Surg 31A:873, 1949. Moon KL, Genant HK, Holmes CA: Muscular skeletal applications of nuclear magnetic resonance imaging, Radiology 147:161, 1983. Nelson OA, Greer 3rd RB: Localization of osteoid osteoma of the spine using computerized tomography, J Bone Joint Surg 65A:263, 1983. Nemoto O, Moser RP, Van Dam BE, et  al.: Osteoblastoma of the spine: a report of 75 cases, Spine 15:1272, 1990. Peterson HA: Iatrogenic spinal deformities. In Weinstein SL, editor: The pediatric spine: principles and practice, New York, 1994, Raven. Pettine KA, Klassen RA: Osteoid osteoma and osteoblastoma of the spine, J Bone Joint Surg 68A:354, 1986. Ransford AO, Pozo JL, Hutton PAN, et al.: The behavior pattern of the scoliosis associated with osteoid osteoma or osteoblastoma of the spine, J Bone Joint Surg 66B:16, 1984. Richardson FL: A report of 16 tumors of the spinal cord in children: the importance of spinal rigidity as an early sign of disease, J Pediatr 57:42, 1960. Rinsky LA, Goris M, Bleck EE, et al.: Intraoperative skeletal scintigraphy for localization of osteoid-osteoma in the spine, J Bone Joint Surg 62A:143, 1980. Schacked I, Tarudor R, Wolpin G, et al.: Aneurysmal bone cyst of a vertebral body with acute paraplegia, Paraplegia 19:294, 1981. Seiman LP: Eosinophilic granuloma of the spine, J Pediatr Orthop 1:371, 1981. Sinigaglia R, Gigante C, Bisinella G, et al.: Musculoskeletal manifestations in pediatric acute leukemia, J Pediatr Orthop 28:20, 2008. Tomita K, Kawahara N, Baba H, et al.: Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors, Spine 22:324, 1997. Villas C, Martinez-Peric R, Barrios RH, et al.: Eosinophilic granuloma of the spine with and without vertebra plana: long-term follow-up of six cases, J Spinal Disord 6:260, 1993. Warner WC: Kyphosis. In Morrissy RT, Weinstein SL, editors: Lovell and Winter’s pediatric orthopaedics, ed 6, Philadelphia, 2006, Lippincott Williams & Wilkins. Wedge JH, Tchang S, MacFadyen DJ: Computed tomography and localization of spinal osteoid osteoma, Spine 6:423, 1981. Yu L, Kasser JR, O’Rourke E: Chronic recurrent multifocal osteomyelitis: association with vertebra plana, J Bone Joint Surg 71A:105, 1989.

POSTIRRADIATION SPINAL DEFORMITY Arkin AM, Pack GT, Ransohoff NS, et al.: Radiation-induced scoliosis: a case report, J Bone Joint Surg 32A:401, 1950. Barr JS, Lingley JR, Gall EA: The effect of roentgen irradiation on epiphyseal growth, AJR Am J Roentgenol 49:104, 1943. Bick EM, Copel JW: Longitudinal growth of the human vertebra: a contribution to human osteogeny, J Bone Joint Surg 32A:803, 1950. Donaldson DH: Scoliosis secondary to radiation. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Engel D: Experiments on the production of spinal deformities by radium, AJR Am J Roentgenol 42:217, 1950. Hinkel CL: The effect of roentgen rays upon the growing long bones of albino rats, part II: histopathological changes involving enchondral growth centers, AJR Am J Roentgenol 49:321, 1943. Katzman H, Waugh T, Berdon W: Skeletal changes following irradiation of childhood tumors, J Bone Joint Surg 51A:825, 1969. King J, Stowe S: Results of spinal fusion for radiation scoliosis, Spine 7:574, 1982. Mayfield JK: Postirradiation spinal deformity, Orthop Clin North Am 10:829, 1979. Mayfield JK, Riseborough EJ, Jaffe N, et  al.: Spinal deformity in children treated for neuroblastoma, J Bone Joint Surg 63A:183, 1981. Neuhauser EBD, Wittenborg MH, Berman CZ, et  al.: Radiation effects of roentgen therapy on the growing spine, Radiology 59:637, 1952.

Ogilvie JW: Spinal deformity following radiation. In Bradford DS, et  al.: Moe’s textbook of scoliosis and other spinal deformities, ed 2, Philadelphia, 1987, WB Saunders. Reidy JA, Lingley JR, Gall EA, et  al.: The effect of roentgen irradiation on epiphyseal growth, J Bone Joint Surg 29:853, 1947. Riseborough EJ: Irradiation-induced kyphosis, Clin Orthop Relat Res 128:101, 1977. Riseborough EJ, Grabias SL, Burton RI, et al.: Skeletal alterations following irradiation for Wilms’ tumor, J Bone Joint Surg 58A:526, 1976.

OSTEOCHONDRODYSTROPHY Bethem D, Winter RB, Lutter L: Spinal disorders of dwarfism: review of the literature and report of 80 cases, J Bone Joint Surg 63A:1412, 1981. Borkhuu B, Nagaraju DK, Holems L, Mackenzie WG: Factors related to progression of thoracolumbar kyphosis in children with achondroplasia: a retrospective cohort study of forty-eight children treated in a comprehensive orthopaedic center, Spine 34:1699, 2009. Kopits SE: Thoracolumbar kyphosis and lumbosacral hyperlordosis in achondroplastic children, Basic Life Sci 48:241, 1988. Qi X, Matsumoto M, Ishii K, et  al.: Posterior osteotomy and instrumentation for thoracolumbar kyphosis in patients with achondroplasia, Spine 17:E606, 2006. Remes V, Poussa M, Peltonen J: Scoliosis in patients with diastrophic dysplasia: a new classification, Spine 26:1689, 2001. Shirley ED: Ain MC: Achondroplasia: manifestations and treatment, J Am Acad Orthop Surg 17:231, 2009.

OSTEOGENESIS IMPERFECTA Albright JA: Management overview of osteogenesis imperfecta, Clin Orthop Relat Res 159:80, 1981. Benson DR, Newman DC: The spine and surgical treatment in osteogenesis imperfecta, Clin Orthop Relat Res 159:147, 1981. Bradford DS: Osteogenesis imperfecta. In Bradford DS, et al.: Moe’s textbook of scoliosis and other spinal deformities, ed 2, Philadelphia, 1987, WB Saunders. Donaldson DH: Spinal deformity associated with osteogenesis imperfecta. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, Philadelphia, 1991, JB Lippincott. Gitelis S, Whiffen J, DeWald RL: The treatment of severe scoliosis in osteogenesis imperfecta, Clin Orthop Relat Res 175:56, 1983. Hanscom DA, Bloom BA: The spine in osteogenesis imperfecta, Orthop Clin North Am 19:449, 1988. Hanscom DA, Winter RB, Lutter L, et  al.: Osteogenesis imperfecta: radiographic classification, natural history, and treatment of spinal deformities, J Bone Joint Surg 74A:598, 1992. Ishikawa S, Kumar SJ, Takahashi HE, et al.: Vertebral body shape as a predictor of spinal deformity in osteogenesis imperfecta, J Bone Joint Surg Am 78:212, 1996. King JD, Bobechko WP: Osteogenesis imperfecta, J Bone Joint Surg 53B:72, 1971. Libman RH: Anesthetic considerations for the patient with osteogenesis imperfecta, Clin Orthop Relat Res 159:123, 1981. Lubicky JP: The spine and osteogenesis imperfecta. In Bridwell KH, DeWald RL, editors: The textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven. Moorefield WG, Miller GR: Aftermath of osteogenesis imperfecta: the disease of adulthood, J Bone Joint Surg 62A:113, 1980. Norimatsu H, Mayuzumi T, Takahashi T: The development of the spinal deformities in osteogenesis imperfecta, Clin Orthop Relat Res 162:20, 1982. Versfeld GA: Costovertebral anomalies in osteogenesis imperfecta, J Bone Joint Surg 67B:602, 1985. Yong-Hing K, MacEwen GD: Scoliosis associated with osteogenesis imperfecta: results of treatment, J Bone Joint Surg 64B:36, 1982. Ziv I, Rang M, Hoffman JH: Paraplegia in osteogenesis imperfecta: a case report, J Bone Joint Surg 65B:184, 1983.

POSTLAMINECTOMY SPINAL DEFORMITY Ain MC, Shirley ED, Pirouzmanesh A, et al.: Postlaminectomy kyphosis in the skeletally immature achondroplast, Spine 31:197, 2006.

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PART XII  THE SPINE Albert TJ, Vacarro A: Postlaminectomy kyphosis, Spine 23:2738, 1998. Brown HP, Bonnett CC: Spine deformity subsequent to spinal cord injury, J Bone Joint Surg 55A:441, 1973. Cattell HS, Clark Jr GL: Cervical kyphosis and instability following multiple laminectomies in children, J Bone Joint Surg 49A:713, 1967. Fraser RD, Patterson DC, Simpson DA: Orthopaedic aspects of spinal tumors in children, J Bone Joint Surg 59B:143, 1977. Haft H, Ransohoff J, Carter S: Spinal cord tumors in children, Pediatrics 23:1152, 1959. Johnston II CE: Postlaminectomy kyphoscoliosis following surgical treatment for spinal cord astrocytoma, Orthopedics 9:587, 1986. Katsumi Y, Honma T, Nakamura T: Analysis of cervical instability resulting from laminectomies for removal of spinal cord tumor, Spine 14:1171, 1989. Kilfoyle RM, Foley JJ, Norton PL: Spine and pelvic deformity in childhood and adolescent paraplegia: a study of 104 cases, J Bone Joint Surg 47A:659, 1965. Lonstein JE: Postlaminectomy kyphosis, Clin Orthop Relat Res 128:93, 1977. Lonstein JE, Winter RB, Bradford DS, et al.: Postlaminectomy spine deformity, J Bone Joint Surg 58A:727, 1976. McLaughlin MR, Wahlig JB, Pollack IF: Incidence of postlaminectomy kyphosis after Chiari decompression, Spine 22:613, 1997. Mimatsu K: New laminoplasty after thoracic and lumbar laminectomy, J Spinal Disord 10:20, 1997. Panjabi MM, White AA, Johnson RM: Cervical spine mechanics as a function of transection on components, J Biomech 8:327, 1975. Simon SL, Auerbach JD, Garg S, et al.: Efficacy of spinal instrumentation and fusion in the prevention of postlaminectomy spinal deformity in children with intramedullary spinal cord tumors, J Pediatr Orthop 28:244, 2008. Tachdjian MO, Matson DD: Orthopaedic aspects of intraspinal tumors in infants and children, J Bone Joint Surg 47A:223, 1965. Torpey BM, Dormans JP, Drummond DS: The use of MRI-compatible titanium segmental spinal instrumentation in pediatric patients with intraspinal tumor, J Spinal Disord 8:76, 1995. Winter RB, McBride GG: Severe postlaminectomy kyphosis: treatment by total vertebrectomy (plus late recurrence of childhood spinal cord astrocytoma), Spine 9:690, 1984. Yasuoka S, Peterson H, Laws Jr ER, et  al.: Pathogenesis and prophylaxis of postlaminectomy deformity of the spine after multiple level laminectomy: difference between children and adults, Neurosurgery 9:145, 1981. Yasuoka S, Peterson HA, MacCarty CS: Incidence of spinal column deformity after multilevel laminectomy in children and adults, J Neurosurg 57:441, 1982.

SKELETAL DYSPLASIAS Ain MC, Browne JA: Spinal arthrodesis with instrumentation for thoracolumbar kyphosis in pediatric achondroplasia, Spine 29:2075, 2004. Ain MC, Shirley ED: Spinal fusion for kyphosis in achondroplasia, J Pediatr Orthop 24:541, 2004. Bailey JA: Orthopaedic aspects of achondroplasia, J Bone Joint Surg 52A:1285, 1970.

Beals RK: Hypochondroplasia, J Bone Joint Surg 51A:728, 1969. Beighton P: Orthopaedic problems in dwarfism, J Bone Joint Surg 62B:116, 1980. Bethem D, Winter RB, Lutter L: Disorders of the spine in diastrophic dwarfism: a discussion of nine patients and review of the literature, J Bone Joint Surg 62A:529, 1980. Bethem D, Winter RB, Lutter L: Spinal disorders of dwarfism: review of the literature and report of 80 cases, J Bone Joint Surg 63A:1412, 1981. Blaw MD, Langer LO: Spinal cord compression in Morquio-Brailsford disease, J Pediatr 74:593, 1969. Dalvie SS, Noordeen MH, Vellodi A: Anterior instrumented fusion for thoracolumbar kyphosis in mucopolysaccharidosis, Spine 26:E539, 2001. Eulert J: Scoliosis and kyphosis in dwarfing conditions, Arch Orthop Trauma Surg 102:45, 1983. Hensinger RN: Kyphosis secondary to skeletal dysplasias and metabolic disease, Clin Orthop Relat Res 128:113, 1977. Herring JA, Winter RB: Kyphosis in an achondroplastic dwarf, J Pediatr Orthop 3:250, 1983. Hurler G: Über einen Typ multipler Abartungen, vorwiegend am Skelettsystem, Z Kinderheilk 24:220, 1919. Johnston II CE: Scoliosis in metatrophic dwarfism, Orthopedics 6:491, 1983. Kahanovitz N, Rimoin DL, Sillence DO: The clinical spectrum of lumbar spine disease in achondroplasia, Spine 7:137, 1982. Kopits SE: Orthopaedic complications of dwarfism, Clin Orthop Relat Res 114:153, 1976. Kopits SE: Cervical myelopathy and dwarfism, Orthop Trans 3:119, 1979. Kozlowski K, Beighton P: Radiographic features of spondyloepimetaphyseal dysplasia with joint laxity and progressive kyphoscoliosis, Rofo 141:337, 1984. Lamy M, Maroteaux P: Le nanisme diastrophique, Presse Med 68:1960, 1977. Langer LO, Carey LS: The radiographic features of the KS mucopolysaccharidosis of Morquio, AJR Am J Roentgenol 97:1, 1966. Lipson SJ: Dysplasia of the odontoid process in Morquio’s syndrome causing quadriparesis, J Bone Joint Surg 59A:340, 1977. Morgan DF, Young RF: Spinal neurologica complications of achondroplasia: results of surgical treatment, J Neurosurg 52:463, 1980. Morquio L: Sur une forme de dystrophie osseuse familiale, Arch Med Enf 32:129, 1929. Pauli RM, Breed A, Horton VK, et al.: Prevention of fixed, angular kyphosis in achondroplasia, J Pediatr Orthop 17:726, 1997. Ponseti IV: Skeletal growth in achondroplasia, J Bone Joint Surg 52A:701, 1970. Remes V, Poussa M, Peltonen J: Scoliosis in patients with diastrophic dysplasia: a new classification, Spine 26:1689, 2001. Stanescu V, Stanescu R, Maroteaux P: Pathogenic mechanisms in osteochondrodysplasias, J Bone Joint Surg 66A:817, 1984. Tolo VT: Surgical treatment of thoracolumbar kyphosis in achondroplasia. Paper presented at the 55th annual meeting of the American Academy of Orthopaedic Surgeons, Atlanta, February 4–9, 1988. Yamada H, Nakamura S, Tajima M, et  al.: Neurological manifestations of pediatric achondroplasia, J Neurosurg 54:49, 1981.

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45

KNEE INJURIES Robert H. Miller III, Frederick M. Azar

ANATOMY 2199 Osseous structures 2199 Extraarticular tendinous structures 2199 Extraarticular ligamentous 2201 structures 2202 Medial side anatomy Posteromedial corner 2202 2204 Lateral side anatomy 2209 Intraarticular structures 2210 MECHANICS MENISCI 2211 2211 Function and anatomy 2214 Meniscal healing and repair 2215 Mechanism of tear Classification of meniscal tears 2215 Diagnosis 2216 Diagnostic tests 2217 2218 Imaging studies 2218 Arthroscopy 2218 Nonoperative management Operative management 2219 Other conditions of menisci 2225 2225 Cysts of menisci 2227 Discoid meniscus ACUTE TRAUMATIC LESIONS 2228 OF LIGAMENTS General considerations 2228 Etiology 2228 2228 Mechanism Ligament healing 2229 2229 Classification 2229 Diagnosis History and physical examination 2229 Radiographic examination 2238 2239 Classification of knee instability One-plane instability 2240 2241 Rotary instability 2241 Combined instabilities Treatment considerations 2241 2241 Nonoperative treatment 2243 Operative treatment Medial compartment (collateral) disruptions 2244 Repair 2244 Reconstruction 2252 Reconstruction with allograft tendons 2258

Lateral compartment (collateral) 2259 disruptions Reconstruction of lateral 2267 compartment Posterolateral rotary instability 2267 Posterolateral Instability with varus knee 2279 Anterolateral rotary instability 2282 ANTERIOR CRUCIATE LIGAMENT INJURIES 2282 2282 Incidence 2282 Anatomy Biomechanics 2283 2283 History and physical examination 2284 Natural History Treatment 2286 Reconstruction for anterior cruciate ligament insufficiency 2288 Rehabilitation after anterior cruciate ligament reconstruction 2305 Results of anterior cruciate 2306 ligament reconstruction Complications of anterior cruciate 2308 ligament surgery Revision anterior cruciate ligament surgery 2309 2310 Graft selection 2311 Technical considerations POSTERIOR CRUCIATE LIGAMENT 2312 Anatomy 2312 Biomechanics 2313 2313 Physical examination 2313 Natural history Treatment 2314 Nonoperative treatment 2314 Operative treatment 2315 Arthroscopically aided posterior cruciate ligament reconstruction 2327 Complications of posterior cruciate ligament reconstruction 2328 TRAUMATIC 2328 DISLOCATIONS Classification 2328 Examination and radiographic evaluation 2329 Vascular and nerve injuries 2330

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2330 Vascular injuries 2331 Nerve damage Other associated injuries 2331 treatment 2331 Outcome of operative treatment of knee dislocations 2334 2335 SYNOVIAL PLICAE ARTICULAR CARTILAGE INJURIES 2336 Treatment 2337 Arthroscopic debridement 2337 Abrasion chondroplasty, 2337 microfracture Osteochondral autograft transplant, osteochondral allografting, autologous chondrocyte 2338 implantation Autologous chondrocyte 2339 implantation 2343 Emerging technologies OSTEOCHONDRITIS DISSECANS 2343 Etiology 2344 Clinical and radiographic findings 2344 2345 treatment 2346 Excision of loose bodies Outcomes of treatment of osteochondritis dissecans 2347 of the knee 2347 Complications DISORDERS OF THE PATELLA 2347 Osteochondritis dissecans 2347 of the patella Dorsal defect of the patella 2347 Bipartite patella 2348 2349 Chondromalacia of the patella Classification and etiology 2350 2350 Clinical findings 2351 Treatment Extraarticular ankylosis of the knee 2353 Extraarticular ankylosis in extension 2353 2356 Extraarticular ankylosis in flexion OPEN WOUNDS OF THE KNEE JOINT 2357

CHAPTER 45  KNEE INJURIES

ANATOMY The knee is one of the most frequently injured joints because of its anatomic structure, its exposure to external forces, and the functional demands placed on it. Basic to an understanding of knee injuries is an understanding of the normal knee anatomy. Although much emphasis has been placed on the ligaments of the knee, without the supporting action of the associated muscles and tendons, the ligaments are not enough to maintain knee stability. The structures around the knee have been classified into three broad categories: osseous structures, extraarticular structures, and intraarticular structures.

OSSEOUS STRUCTURES

The osseous structures of the knee consist of three components: the patella, the distal femoral condyles, and the proximal tibial plateaus, or condyles. The knee is called a hinge joint, but actually it is more complicated than that, because in addition to flexion and extension its motion has a rotary component. The femoral condyles are two rounded prominences that are eccentrically curved. Anteriorly, the condyles are somewhat flattened, which creates a larger surface for contact and weight transmission. The condyles project very little in front of the femoral shaft but markedly so behind. The groove found anteriorly between the condyles is the patellofemoral groove, or trochlea. Posteriorly, the condyles are separated by the intercondylar notch. The articular surface of the medial condyle is longer than that of the lateral condyle, but the lateral condyle is wider. The long axis of the lateral condyle is oriented essentially along the sagittal plane, whereas the medial condyle usually is at about a 22-degree angle to the sagittal plane. The expanded proximal end of the tibia forms two rather flat surfaces, condyles or plateaus, that articulate with the femoral condyles. They are separated in the midline by the intercondylar eminence with its medial and lateral intercondylar tubercles. Anterior and posterior to the intercondylar eminence are the areas that serve as attachment sites for the cruciate ligaments and menisci. The posterior lip of the lateral tibial condyle is rounded off where the lateral meniscus slides posteriorly during flexion of the knee. The articular surfaces of the knee are not congruent. On the medial side, the femur meets the tibia like a wheel on a flat surface, whereas on the lateral side, it is like a wheel on a dome. Only the ligaments acting in concert with the other soft-tissue structures provide the knee with the necessary stability. The patella is a somewhat triangular sesamoid bone that is wider at the proximal pole than at the distal pole. The articular surface of the patella is divided by a vertical ridge, resulting in a smaller medial and a larger lateral articular facet, or surface. With the knee in extension, the patella rides above the superior articular margin of the femoral groove. In extension, the distal portion of the lateral patellar facet articulates with the lateral femoral condyle, but the medial patellar facet barely articulates with the medial femoral condyle until complete flexion is approached. At 45 degrees of flexion, contact moves proximally to the midportion of the articular surfaces. In complete flexion, the proximal portions of both facets are in contact with the femur; and during flexion and extension, the patella moves 7 to 8 cm in relation to the femoral condyles. With complete flexion, more pressure is applied to the medial facet.

Trauma that affects these osseous structures and their relationship with each other frequently causes derangement of the joint. Restoration of these structures is essential to restoration of the function of the knee. 

EXTRAARTICULAR TENDINOUS STRUCTURES

The important extraarticular structures supporting and influencing the function of this joint are the synovium, capsule, collateral ligaments, and musculotendinous units that span the joint. The musculotendinous units are principally the quadriceps mechanism, the gastrocnemius, the medial and lateral hamstring groups, the popliteus, and the iliotibial band. The four components of the quadriceps mechanism form a three-layered quadriceps tendon that inserts into the patella. The tendon of the rectus femoris flattens immediately above the patella and becomes the anterior layer, which inserts at the anterior edge of the proximal pole. The tendon of the vastus intermedius continues downward as the deepest layer of the quadriceps tendon and inserts into the posterior edge of the proximal pole. The middle lamina is formed by the confluent edges of the vastus lateralis and vastus medialis. The fibers of the medial retinaculum formed from the aponeurosis of the vastus medialis insert directly into the side of the patella to help prevent lateral displacement of the patella during flexion. The patellar tendon takes its origin from the apex or distal pole of the patella and inserts distally into the tibial tuberosity. The gastrocnemius, the most powerful calf muscle, spans the posterior aspect of the knee in intimate relationship with the posterior capsule to insert on the posterior aspect of the medial and lateral femoral condyles. Pes anserinus is the term for the conjoined insertion of the sartorius, gracilis, and semitendinosus muscles along the proximal medial aspect to the tibia. These primary flexors of the knee have a secondary internal rotational influence on the tibia and help protect the knee against rotary and valgus stress. Their counterpart on the lateral side of the knee is the strong biceps femoris insertion into the fibular head, lateral tibia, and posterolateral capsular structures. This muscle is a strong flexor of the knee that also produces simultaneous strong external rotation of the tibia. It provides rotary stability by preventing forward dislocation of the tibia on the femur during flexion. Its contributions to the arcuate ligament complex at the posterolateral corner of the knee also provide varus and rotary stability. The iliotibial tract, the posterior third of the iliotibial band, inserts proximally into the lateral epicondyle of the femur and distally into the lateral tibial tubercle (Gerdy’s tubercle). It thus forms an additional ligament that is contiguous anteriorly with the vastus lateralis and posteriorly with the biceps. The iliotibial band moves forward in extension and backward in flexion but is tense in both positions. During flexion, the iliotibial band, the popliteal tendon, and the lateral collateral ligament (LCL) cross each other, whereas the iliotibial band and biceps tendon remain parallel to each other as in extension, all serving to enhance lateral stability (Fig. 45.1). The popliteus muscle has three origins, the strongest of which is from the lateral femoral condyle. Other important origins are from the fibula (popliteofibular ligament) and from the posterior horn of the lateral meniscus. The femoral

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PART XIII  SPORTS MEDICINE Biceps femoris (cut)

Iliotibial tract

Vastus lateralis

Superior medial collateral ligament (cut)

Posterior third medial capsular ligament (posterior oblique ligament)

Superior lateral genicular artery Rectus femoris

Common peroneal nerve Plantaris

Arcuate ligament

Popliteus tendon

Lateral collateral ligament Biceps femoris tendon Lateral gastrocnemius Lateral sural cutaneous nerve Superficial peroneal nerve Soleus

1

2

Inferior lateral genicular artery

Patellar ligament Anterior tibial recurrent artery Deep peroneal nerve Anterior tibial artery

FIGURE 45.1 Tendinous and neurovascular structures of lateral side of knee.

A

C B

FIGURE 45.2 Popliteus muscle with its tripartite origin. Main tendon attached to lateral condyle of femur (A). Attachment to posterior horn of lateral meniscus (B). Attachment to fibular head (C).

and fibular origins form the arms of an oblique Y-shaped ligament, the arcuate. The arms are joined together by the capsule and meniscal origin. The arcuate ligament is not a separate ligament but is a condensation of the fibers of the origin of the popliteus (Fig. 45.2). With electromyographic studies, Basmajian and Lovejoy found that the popliteus muscle is a prime medial rotator of the tibia during the initial stages of

Anterior third medial capsular ligament Pes anserine (cut)

3 4

5

Semimembranosus

Middle third medial capsular ligament (deep tibial collateral ligament) Superior tibial collateral ligament (cut)

FIGURE 45.3 Medial supporting structures of knee. 1, Oblique popliteal ligament; 2, posterior capsule and posterior horn of medial meniscus; 3, anterior or medial tendon of semimembranosus; 4, direct head of semimembranosus; 5, distal portion of semimembranosus tendon (see text).

flexion and also acts to withdraw the meniscus during flexion. In addition, it supplies rotary stability to the femur on the tibia and aids the posterior cruciate ligament (PCL) in preventing forward dislocation of the femur on the tibia. The semimembranosus muscle is especially important as a stabilizing structure around the posterior and posteromedial aspects of the knee. It has five distal expansions (Fig. 45.3). The first is the oblique popliteal ligament (OPL), which passes from the insertion of the semimembranosus on the posteromedial aspect of the tibia obliquely and laterally upward toward the insertion of the lateral gastrocnemius head (Fig. 45.4A). It acts as an important stabilizing structure on the posterior aspect of the knee. The semimembranosus helps tighten this ligament with contraction (Fig. 45.4B). When the OPL is pulled medially and forward, it tightens the posterior capsule of the knee. This maneuver can be used to tighten the posterior capsule in the posteromedial corner of the knee in surgical repair. A second tendinous attachment is to the posterior capsule and posterior horn of the medial meniscus. This tendinous slip helps tighten the posterior capsule and pulls the medial meniscus posteriorly during knee flexion. The anterior or deep head continues medially along the flare of the tibial condyle and inserts beneath the superficial medial collateral ligament (MCL) just distal to the joint line. The direct head of the semimembranosus attaches to the tubercle on the posterior aspect of the medial condyle of the tibia just below the joint line. This tendinous attachment provides a firm point in which sutures can be anchored for posteromedial capsular repair. The distal portion of the semimembranosus tendon continues distally to form a fibrous expansion over the popliteus and fuses with the periosteum of the medial tibia. The semimembranosus, through its muscle contraction, tenses the posterior capsule and posteromedial capsular structures, providing significant stability. Functionally, it acts as a flexor of the knee and internal rotator of the tibia.

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CHAPTER 45  KNEE INJURIES

AT

PL

LG

MG

MG Fa Sm

OPL

POL

LCL PT AL

MCL

LG

Sm Medial collateral ligament (deep)

OPL AL

Medial collateral ligament (superficial)

Po

Fabellofibular ligament (ligament of Vallois) Po

A

B

FIGURE 45.4 A, Triangular arrangement of passive elements in posterior capsule of knee crucial for rotary stability. B, Posterior view of knee showing ligamentous reinforcement of posterior capsule. Oblique popliteal ligament is dynamically stabilized by semimembranosus muscle and arcuate ligament by popliteus muscle. AL, Arcuate ligament; AT, anterior tibial; Fa, fabella; LCL, lateral collateral ligament; LG, lateral gastrocnemius muscle; MCL, medial collateral ligament; MG, medial gastrocnemius muscle; OPL, oblique popliteal ligament; PL, plantaris longus muscle; Po, popliteus muscle; POL, posterior oblique collateral ligament; PT, popliteal tendon; Sm, semimembranosus.

The medial extensor expansion, or medial retinaculum, is a distal expansion of the vastus medialis aponeurosis. It attaches along the medial border of the patella and patellar tendon and distally inserts into the tibia. It functions as the medial tracking support of the patella in the patellofemoral groove. It covers and may blend into the anteromedial capsular ligament. Contraction of the vastus medialis helps tighten the anterior portion of the medial capsular ligament. The lateral extensor expansion, or lateral retinaculum, is an extension of the vastus lateralis attaching to the iliotibial band, which helps tense this band as the knee extends and the iliotibial band moves forward. Imbalance between the lateral and medial retinacular structures often is present in patellar subluxations and dislocations. In addition to these musculotendinous units that directly span the knee, abnormalities in the orientation and alignment of the foot, as well as deficiencies in the hip flexors and abductors, can influence the alignment and function of the knee and must be considered in evaluation and rehabilitation of this joint. 

EXTRAARTICULAR LIGAMENTOUS STRUCTURES

The joint capsule and the collateral ligaments are the principal extraarticular static stabilizing structures. The capsule is a sleeve of fibrous tissue extending from the patella and patellar tendon anteriorly to the medial, lateral, and posterior expanses of the joint. The menisci are attached firmly at the periphery to this capsule, especially so medially and less so laterally. Laterally, the passage of the popliteal tendon

through the popliteal hiatus to its origin on the femoral condyle produces a less secure meniscal attachment than is present medially. The medial capsule is more distinct and well defined than its lateral counterpart. The capsular structures, along with the medial and lateral extensor expansions of the powerful quadriceps musculature, are the principal stabilizing structures anterior to the transverse axis of the joint. The capsule is especially reinforced by the collateral ligaments and the medial and lateral hamstring muscles, as well as by the popliteus muscle and the iliotibial band posterior to the transverse axis. The anteromedial and anterolateral portions of the capsule are relatively thin structures but are reinforced by the medial and lateral patellar retinacular expansions and also laterally by the iliotibial band and medially by reinforcing bands extending from the patella as the medial patellofemoral ligament and the medial patellotibial ligament. The medial patellofemoral ligament is more important for patellar stability and runs from the patella near the junction of the middle and superior thirds to the medial femoral epicondyle. Laterally, there are corresponding lateral patellofemoral and lateral patellotibial ligaments supporting the tracking of the patella. The anteromedial and anterolateral portions of the capsule are significant in protecting the anteromedial and anterolateral aspects of the knee against subluxation and rotational excesses. In their classic study of knee anatomy, Warren and Marshall divided the knee into three layers. Layer I includes the deep fascia or crural fascia; layer II is composed of the

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B

B

C

Medial meniscus

C 90° flexion

Posterior fibers relaxed Displacement of ligament in flexion

A

B

A

FIGURE 45.5 Joint stripped to reveal medial collateral ligament. A, Anterior, posterosuperior, and posteroinferior portions of ligament are tense with joint in extension. B, On flexion and extension, ligament glides backward and forward on tibia; in flexion, posterior oblique portions are relaxed. Note that ligament attaches 4 to 5 cm distal to joint.

superficial MCL, various structures anterior to this ligament, and the ligaments of the posteromedial corner; and layer III is made up of the capsule of the knee joint and the deep MCL.

MEDIAL SIDE ANATOMY

Robinson et al. performed a cadaver study of the medial side of the knee, dividing the anatomy into thirds extending circumferentially from the medial edge of the patellar tendon to the medial edge of the medial head of the gastrocnemius posteriorly. They identified three distinct ligamentous components that cross the joint line: the superficial MCL, the deep MCL, and the posteromedial capsule. The anterior third reaches from the medial edge of the patella tendon to the anterior edge of the superficial MCL. The superficial MCL composes the middle third. The posterior third extends from the posterior edge of the superficial MCL to the medial head of the gastrocnemius and makes up the posterior medial corner.

MEDIAL COLLATERAL LIGAMENT

A

The MCL is a long, rather narrow, well-delineated structure lying superficial to the medial capsule and capsular ligaments, originating on the medial epicondyle and inserting 7 to 10 cm below the joint line on the posterior half of the medial surface of the tibial metaphysis deep to the pes anserinus tendons. It has been referred to as the superficial tibial collateral ligament or the superficial portion of the MCL. Biomechanical studies have shown that it provides the principal stability to valgus stresses. It glides forward over the side of the femoral condyle in extension and posteriorly in flexion (Fig. 45.5). The long fibers of the MCL are the primary stabilizers of the medial side of the knee against valgus and external rotary stress. The anterior fibers of the ligament tighten as the knee flexes, with fibers more posteriorly becoming slack (Fig. 45.6). 

A

B

FIGURE 45.6 A and B, Fibers of medial collateral ligament. Points A and B are at anterior border of long fibers. C is 5 mm posterior to B (see text).

MIDMEDIAL CAPSULE

The midmedial capsule is reinforced and thickened by vertically oriented fibers and has often been referred to as the deep layer of the MCL. It originates from the femoral condyle and epicondyle and inserts just below the tibial articular margin. It is divided into a meniscofemoral portion, extending from the meniscal attachment to the femoral origin, and the meniscotibial portion, extending as the coronary ligament of the meniscus to its tibial insertion. The meniscofemoral portion is the much longer and stronger of these two divisions. The midmedial capsule resists valgus and rotary stresses. 

POSTEROMEDIAL CORNER

The posteromedial corner of the knee has five major components: the posterior oblique ligament (POL), the semimembranosus tendon and its expansions, the OPL, the posteromedial joint capsule, and the posterior horn of the medial meniscus. Hughston described this POL as a thickening of the medial capsular ligament attached proximally to the adductor tubercle of the femur and distally to the tibia and posterior aspect of the capsule. The distal attachment is composed of three arms: (1) the prominent central, or tibial, arm, which attaches to the edge of the posterior surface of the tibia close to the margin of the articular surface and central to the upper edge of the semimembranosus tendon; (2) the superior, or capsular, arm, which is continuous with the posterior capsule and the proximal part of the OPL; and (3) the poorly defined inferior, or distal, arm, which attaches distally both to the sheath covering the semimembranosus tendon and to the tibia just distal to the direct insertion of the semimembranosus tendon (Figs. 45.7 to 45.10). The central portion is the thickest and probably the most important arm of the ligament, originating in the region of the adductor tubercle (the origin has also been described as being posterior and distal to the adductor tubercle) and coursing posteriorly and obliquely to insert at the posteromedial corner of the tibia near the insertion of the direct head of

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CHAPTER 45  KNEE INJURIES

J

G

AT ME POL

SP S ST OP PA

A B C MCL

AT A MM MCL MTL POL B

FIGURE 45.7 Posteromedial corner of the knee. A, Superior or capsular arm of posterior oblique ligament (POL); AT, Adductor tubercle; B, central or tibial arm of posterior oblique ligament; C, superficial arm of posterior oblique ligament; G, gastrocnemius muscle; J, common ligament of origin of posterior oblique ligament; MCL, medial collateral ligament; ME, medial epicondyle; OP, oblique popliteal ligament; PA, pes anserinus; S, common tendon of semimembranosus; SP, portion of semimembranosus tendon that becomes oblique popliteal ligament; ST, portion of semimembranosus tendon that goes to posteromedial corner of tibia.

FIGURE 45.9 Posteromedial aspect of knee. Femoral attachment of posterior oblique ligament is divided and ligament is retracted posteriorly. Capsular arm (A) forms portion of posterior capsule (see text and previous illustrations).

AT B H AT P Q

ST

A MM B

FIGURE 45.8 Common origin of posterior oblique ligament has been dissected from adductor tubercle (AT). Capsular arm (A) is retracted posteriorly and tibial arm (B) distalward. P, Intraarticular portion of femoral condyle; Q, attachment of tibial arm of posterior oblique ligament to posteromedial corner of medial meniscus (MM).

the semimembranosus tendon. The superior, or more proximal, arm of the POL passes posteriorly, blending with the posterior capsule and the OPL as it separates from the semimembranosus tendon. The inferior and distal groups of fibers pass superficially over the insertion of the semimembranosus tendon, attach to the tibia and fascia inferiorly, and probably have little functional importance. As previously described, the semimembranosus tendon has five expansions: (1) the direct arm, (2) the anterior or deep arm, (3) the arm to the POL or capsular arm, (4) the

FIGURE 45.10 By pulling central or tibial arm (B) of posterior oblique ligament proximally toward its insertion on adductor tubercle (AT) while tibial arm of semimembranosus tendon (ST) is retracted posteriorly and inferiorly, firm broad attachment (H) of central arm of posterior oblique ligament to tibia is visible beneath and deep to semimembranosus tendon (see text and previous illustrations).

arm to the OPL, and (5) the expansion to the popliteus aponeurosis or the inferior arm. The OPL is a broad fascial band originating from the capsular arm of the POL and the lateral expansion of the semimembranosus to cross the posterior aspect of the knee. It passes laterally and proximally toward the lateral femoral condyle. Laterally it attaches to the meniscofemoral portion of the posterior capsule and to the fabella. The posteromedial capsule begins posterior to the superficial and deep MCL. Posteriorly, the deep MCL blends with and becomes inseparable from the central arm of the POL. The central arm forms a thick fascial reinforcement of both

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PART XIII  SPORTS MEDICINE the meniscofemoral and meniscotibial portions of the posteromedial capsule with an additional attachment to the medial meniscus. The posterior horn of the medial meniscus is the last component of the posteromedial corner. It is linked to the posteromedial capsule, the deep MCL, the POL, and the semimembranosus expansion. The contributions to knee stability are well known, serving as a chock block on the tibial plateau. Absence of the posterior horn increases instability in both anterior cruciate ligament (ACL) and PCL deficient knees. The posteromedial portion of the medial capsular ligamentous complex is especially important for valgus and rotational stability to the knee. The posteromedial capsule and POL become progressively relaxed as the knee flexes; however, with active contraction of the semimembranosus muscle, each of the three arms of the POL is tense. Therefore, both kinetic and static stabilizing effects are obtained from this portion of the medial capsular ligament, even with the knee flexed. In knee ligament reconstruction, this important part of the posteromedial complex is as essential as any other structures requiring attention if stability is to be restored. A precise understanding of anatomy and function is required for repair or reconstruction of this posteromedial complex. The central arm of the POL must be tightened in surgical repair or reconstruction, or passive stability cannot be attained regardless of any other surgical procedures.

LATERAL COLLATERAL LIGAMENT

The LCL attaches to the lateral femoral epicondyle proximally and to the fibular head distally. The LCL has an average femoral attachment slightly proximal (1.4 mm) and posterior (3.1 mm) to the lateral epicondyle. In a cadaver study, Kamath et al. identified the origin of the LCL as 58% across the width of the condyle and 2.3 mm distal to the Blumensaat line, with less than 5 mm variance from the mean in all specimens. Distally, it is attached 8.2 mm posterior to the anterior aspect of the fibular head. It is more of a tendinous structure than a wide ligamentous band. It is of prime importance in stabilizing the knee against varus stress with the knee in extension. As the knee goes into flexion, the LCL becomes less influential as a varus-stabilizing structure. 

ILIOTIBIAL BAND

In addition to the lateral ligaments and lateral capsular structures, stability depends on the iliotibial band, the biceps tendon, and the popliteal tendon. The iliotibial band inserts into the lateral epicondyle of the femur and then passes in its broad expansion between the lateral aspect of the patella and the more posterior location of the biceps femoris to insert into the lateral tibial (Gerdy’s) tubercle. Thus it acts as a supplemental ligament across the lateral aspect of the joint. This band moves anteriorly as the knee extends and slides posteriorly as the knee flexes but remains tense in all knee positions. With flexion, the iliotibial band, the popliteal tendon, and the LCL cross each other, thereby greatly enhancing lateral stability. The biceps tendon functions as a lateral stabilizer by contributing to the arcuate complex and by being a powerful flexor and external rotator of the tibia on the femur. The popliteal tendon courses from the posterior aspect of the tibia through the popliteal hiatus and attaches deep to, and somewhat anterior to, the femoral insertion of the LCL. 

Popliteus tendon Popliteofibular ligament

FIGURE 45.11 Popliteofibular ligament arises from posterior part of fibula to join popliteal tendon just above musculotendinous junction.

POPLITEAL TENDON

Warren et al. identified a strong direct attachment of the popliteal tendon to the fibula, which has been called the popliteal fibular fascicle and the fibular origin of the popliteus muscle. These researchers called this structure the popliteofibular ligament because it connects the fibula to the femur through the popliteal tendon (Fig. 45.11). This ligament is located deep to the lateral limb of the arcuate ligament; it originates from the posterior part of the fibula and posterior to the biceps insertion and joins the popliteal tendon just proximal to its musculotendinous junction. Thus the popliteus muscle-tendon unit is a Y-shaped structure with a muscle origin from the posterior part of the tibia, a ligamentous origin from the fibula, and a united insertion on the femur. The popliteal tendon has a constant, broad-based femoral attachment at the most proximal and anterior fifth of the popliteal sulcus. The popliteal tendon attachment on the femur is always anterior to the LCL. The average distance between the femoral attachments of the popliteal tendon and the LCL is 18.5 mm. The popliteofibular ligament has two divisions, anterior and posterior. The average attachment of the posterior division is 1.6 mm distal to the posteromedial aspect of the tip of the fibular styloid process, and the anterior division attaches 2.8 mm distal to the anteromedial aspect of the tip of the fibular styloid process. Selective cutting studies confirmed that the popliteal tendon attachments to the tibia and the popliteofibular ligament are important in resisting posterior translation, varus rotation, and external rotation. 

LATERAL SIDE ANATOMY

Seebacher, Inglis, Marshall, and Warren defined three distinct layers of the lateral structures of the knee. The most superficial layer, or layer I, has two parts: (1) the iliotibial tract and its expansion anteriorly and (2) the superficial portion of the

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CHAPTER 45  KNEE INJURIES Prepatellar bursa (I)

I—first layer II—second later III—third layer

Patella Fat pad

Iliotibial tract (I) Lateral meniscus Patellar retinaculum (II) Joint capsule (III) Anterior cruciate ligament Posterior cruciate ligament Ligament of Wrisberg Oblique popliteal ligament Popliteus

Popliteus tendon (entering joint through hiatus) Lateral collateral ligament (II) in superior lamina Biceps tendon (I) Fabellofibular ligament (III) Lateral inferior geniculate artery Arcuate ligament (III) in deep lamina Fibular head

Common peroneal nerve

FIGURE 45.12 View of right knee joint from above after removal of right femur. Note three layers of lateral side and division of posterolateral part of capsule (layer III) into deep and superficial laminae, which are separated by lateral inferior genicular vessels.

Accessory vastus lateralis arising from lateral intermuscular septum

Rectus femoris Vastus lateralis

Lateral intermuscular septum Lateral superior genicular artery

Biceps Long head Short head

Plantaris

Femur

Fabella and lateral head of gastrocnemius

Suprapatellar pouch Patella Patellar retinaculum with attachments to: Accessory vastus Lateral intermuscular septum Fabella Iliotibial tract Lateral meniscus Lateral tubercle of tibia

Iliotibial tract Lateral head of gastrocnemius

Lateral meniscus (through window) Patellar ligament Lateral tubercle of tibia

Fat pad

A

Joint capsule

B

FIGURE 45.13 Layers I and II of structures of lateral side of knee. A, Major constituents of layer I: iliotibial tract and superficial portion of expansion of biceps. B, Layer I has been incised and peeled back from lateral margin of patella, showing layer II. Layer II includes vastus lateralis and its expansions, as well as patellofemoral and patellomeniscal ligaments.

biceps femoris and its expansion posteriorly (Figs. 45.12 and 45.13). The peroneal nerve lies on the deep side of layer I, just posterior to the biceps tendon. Layer II is formed by the retinaculum of the quadriceps, most of which descends anterolaterally and adjacent to the patella.

ANTEROLATERAL LIGAMENT

Although Segond identified the anterolateral ligament (ALL) in 1879, it was believed to be a variant of the LCL and of little importance. More recently, however, a number of cadaver, radiographic, and biomechanical studies have established it

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PART XIII  SPORTS MEDICINE as a distinct ligament important to knee stability. One study identified a network of peripheral nerves, suggesting a proprioception function of the ALL. Claes et al., in 2013, identified the ALL in 40 of 41 cadaver knees, finding that the ligament had consistent origin and insertion sites in 97% of specimens. Despite the number of studies devoted to investigation of the ALL, its exact structure and function are not clearly defined. Although most studies agree on the location of the ALL tibial insertion halfway between Gerdy’s tubercle (average 18 to 25 mm posterior to it) and the fibular head (average 17 to 24 mm anterior to it), the femoral insertion site is not firmly established. Two anatomic variations have been described: posterior and proximal to the insertion of the LCL and anterior and distal to it. The position of the ALL relative to the popliteus tendon also is controversial. Claes et al. and Cavaignac et  al. described the ALL origin as proximal and posterior to the popliteus tendon; Vincent et al. described it as being anterior to the tendon. In a systematic review of the literature, Van der Watt et  al. concluded that the ALL is an extraarticular structure with a clear course from the lateral femoral epicondylar region, running anteroinferiorly to the proximal tibia at a site midway between Gerdy’s tubercle and the head of the fibula (Table 45.1 and Fig. 45.14). The mean width of the ALL at the lateral joint was found to be 6.7 mm, with a thickness of about 2 mm. The location and appearance of the ALL have been delineated on radiographs (Fig. 45.15), MRI (Fig. 45.16), and ultrasound, as well as intraoperative observation. Reported sensitivity of MRI ranges from 51% to 98%. In their cadaver ultrasound study, Cavaignac et al. found that the entire ALL was visible from its proximal insertion to its distal insertion, with excellent agreement between ultrasound and anatomic findings. Several studies have suggested that the primary function of the ALL is to provide anterolateral stability, preventing the proximal-lateral tibia from subluxation anteriorly relative to the distal femur, with the stabilizing force most significant at 30 and 90 degrees of knee flexion. It also has been implicated in lateral meniscal tears and Segond fractures. In numerous articles detailing the anatomy of the lateral side of the knee, LaPrade and co-investigators described the structures from superficial to deep. The first structure encountered is the iliotibial band, a thick fascial sheath inserting on the anterolateral aspect of the lateral tibial plateau at Gerdy’s tubercle. The iliotibial band has three layers. The superficial layer appears first and, after splitting this layer, deeper fibers adhere to the lateral supracondylar tubercle of the femur and blend into the lateral intramuscular septum. These layers are called the deep and capsule-osseous layers or “Kaplan fibers.” An anterior band, the iliopatellar band, curves anteriorly and inserts onto the lateral aspect of the patella. The deep layer begins 6 cm proximal to the lateral femoral epicondyle, at the termination of the lateral intermuscular septum, and connects the medial border of the superficial iliotibial layer to the distal termination of the lateral intermuscular septum of the distal femur. Medial and distal to the deep layer, the capsule-osseous layer originates from the region of the lateral intermuscular septum and the fascia over the lateral gastrocnemius and plantaris muscles, creating a sling over the lateral femoral condyle. This structure blends with the short head of the biceps femoris in a region known as the confluence of the short head of the biceps femoris and

the capsule-osseous layer. Distally, it inserts onto the lateral tibial tuberosity, just posterior and proximal to Gerdy’s tubercle. This lateral sling is the structure most surgeons attempt to reconstruct in extraarticular ACL reconstructions. The biceps femoris has two insertions: the long and short heads. The long head has five major insertions at the knee, two tendinous and three fascial. The tendinous components are the direct arm, which inserts onto the lateral aspect of the fibula styloid, and the anterior arm, which courses lateral to the lateral collateral ligament (LCL) and inserts onto the lateral tibial plateau. A small biceps femoris bursa separates this arm from the LCL. The three fascial components are the reflected arm and the anterior and lateral aponeurotic expansions. The latter connects the long and short heads of the biceps femoris to the posterolateral aspect of the LCL. The short head divides into six components consisting of direct, capsular, and anterior tendinous arms and three nontendinous attachments. The three tendinous arms are the most important. The direct arm attaches to the posterolateral aspect of the fibular styloid. The capsular arm attaches to the posterolateral aspect of the capsule and just lateral to the tip of the fibular styloid, providing a stout attachment between the posterolateral capsule, the lateral gastrocnemius tendon, and the capsule-osseous layer of the iliotibial band. The most distal edge of the capsular arm is the fabellofibular ligament, which spans from the lateral edge of the fabella, distally and laterally, to attach to the fibular head just posterior to the posterior division of the popliteofibular ligament. The anterior arm passes medial to the LCL and inserts with the meniscotibial portion of the midthird lateral capsular ligament onto the proximal-lateral tibia. This insertion site is the location of the Segond fracture seen in association with ACL injuries. The surgeon should be mindful that the peroneal nerve lies deep and posterior to the biceps femoris tendon, passing 1.5 to 2 cm distal to the fibular styloid as it travels along the lateral aspect of the fibular head. The LCL is the primary static stabilizer to varus stress of the knee between 0 and 30 degrees of flexion. It also provides resistance to external rotation of the tibia, primarily near extension. The femoral attachment is extracapsular and lies 1.4 mm proximal and 3.1 mm posterior to the lateral epicondyle. The LCL is approximately 70 mm long and inserts on the lateral aspect of the fibular head 8.2 mm posterior to the anterior border of the fibula and 28.4 mm antero-inferior to the proximal tip of the fibular styloid. At surgery, the LCL can be identified by making an incision parallel to the fibers of the long head of the biceps tendon superficial to the proximal aspect of the fibular head exposing the biceps bursa which encompasses the LCL. 

POPLITEUS MUSCLE AND LIGAMENT

The popliteus muscle is obliquely oriented, originating from the posteromedial aspect of the proximal tibia. The tendon passes proximally through the popliteal hiatus in the coronary ligament where it becomes intraarticular and inserts into the popliteal sulcus of the lateral femoral condyle. It is usually found in the most anterior one fifth and proximal half of the sulcus. It has also been located 18.5 mm distal and anterior to the femoral insertion of the LCL and 15.8 mm distal and anterior to the lateral femoral epicondyle. The popliteus has multiple other insertion sites. The ligamentous insertion on the fibula is composed of the anterior and posterior

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CHAPTER 45  KNEE INJURIES

TABLE 45.1

Structure of Anterolateral Ligament STUDY Claes et al.

ORIGIN Lateral femoral epicondyle

Helito et al.

1.9 ± 1.4 mm anterior and 4.1 ± 1.1 mm distal to LCL Lateral radiograph: 47% from anterior condyle and 3.7 mm inferior to Blumensaat line AP radiograph: 15.8 mm from posterior bicondylar line Lateral femoral condyle, immediately anterior to LCL

Helito et al.

COURSE Depth of lateral tibial synovial recess measured 6.5 ± 1.5 mm

INSERTION Anterolateral proximal tibia Gerdy’s tubercle to ALL: 22 mm Fibular head to ALL: 21.3 mm Not stated 4.4 ± 0.8 mm distal to anterolateral proximal tibia, at a point 42% of the way from the fibular head to Gerdy’s tubercle Lateral radiograph: 53% from anterior tibial plateau AP radiograph: 7.0 mm from tibial joint line Anteroinferior, superfi- 7.0 mm distal to lateral cial to popliteal tendon tibial plateau Bifurcation 3.0 mm proximal to lateral meniscus Not stated 24.7 mm from Gerdy’s tubercle and 11.5 mm distal to lateral tibial plateau, at a point between a line along the posterior tibial cortex and a parallel line from the apex of the tibial spine, intersecting a perpendicular line from the apex of the posterior tibial condyles Midway between head of Obliquely within capfibula and Gerdy’s tubercle sule to insert on tibia. Deep attachment to lateral meniscus

Rezansoff et al.

Near lateral femoral epicondyle, at a point on a line drawn from the posterior femoral cortical line and just inferior to the Blumensaat line

Caterine et al.

Two variations: (1) proximal and posterior to lateral epicondyle and (2) anterior and distal to lateral epicondyle 8 mm proximal and 4.3 Superficial to LCL and mm posterior to lateral capsule with branchfemoral epicondyle ing attachments to meniscus Not stated Over lateral meniscus, traveling obliquely and parallel to ITT

Dodds et al.

Cianca et al.

CHARACTERISTICS Gerdy’s tubercle to Segond fracture: 22.4 mm Insertion width: 11.3 mm

Not stated

Thin linear structure with thickness between 1 and 3 mm

Not stated

Intracapsular ligamentous thickening of anterolateral capsule

Midway between head of Extracapsular ligamentous fibula and Gerdy’s tubercle structure

Inferior to proximal lateral edge of tibia, posterior and proximal to Gerdy’s tubercle

Helito et al.

2.2 ± 1.5 mm anterior and 3.5 ± 2.1 mm distal to LCL

Bifurcation present at 52.5% of its length (proximal to distal), attaching to lateral meniscus

4.4 ± 1.1 mm distal to lateral tibial plateau, at a point 38% of way from fibular head to Gerdy’s tubercle

Claes et al.

Lateral femoral epicondyle, anterior to LCL, proximal and posterior to insertion of popliteus

Oblique anteroinferior to proximal tibia Attachment to meniscus

In middle of a line connecting Gerdy’s tubercle and tip of fibular head

Easiest to identify with 90 degrees of flexion and internal rotation of knee, resulting in ligament being taut Length: 37.3 ± 4.0 mm Width: 7.4 ± 1.7 mm Thickness: 2.7 ± 0.6 mm Histology: dense connective tissue with arranged fibers and little cellular material Length: 41.5 mm (flexion), 38.5 mm (extension) Width: 8.3 mm (origin), 6.7 mm (joint line), 11.2 mm (insertion) Thickness: 1.3 mm (joint line) Continued

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TABLE 45.1

Structure of Anterolateral Ligament—cont’d STUDY Vincent et al.

ORIGIN Lateral femoral epicondyle

COURSE Obliquely anteroinferiorly toward lateral meniscus and tibial plateau

INSERTION Proximal anterolateral tibia, 5 mm from articular cartilage, posterior to Gerdy’s tubercle

Vieira et al.

Lateral supraepicondylar region bordering lateral edge of lateral epicondyle 1.5 cm anterior and superior to lateral epicondyle Lateral femoral epicondyle

Oblique course toward proximal tibia

Laterally to Gerdy’s tubercle

Oblique anteroinferior course

1.5 cm posteriorly to Gerdy’s tubercle

Oblique anteroinferior course

Lateral midportion of proximal tibia

Irvine et al.

Not stated

Not stated

Midway between Gerdy’s tubercle and head of fibula

Terry et al.

Near lateral epicondyle

Oblique course toward proximal tibia

Dietz et al.

Not stated

Not stated

Just posterior to Gerdy’s tubercle on lateral tibial tuberosity A point between Gerdy’s tubercle and fibular head

Fulkerson and Gossling

Lateral epicondyle, just anterior to origin of gastrocnemius Lateral femoral epicondyle Lateral femoral epicondyle

Anteroinferior course

Patella et al.

Campos et al.

Johnson Hughston et al.

CHARACTERISTICS Collagenous fibers with dense core and parallel orientation Width: 8.2 mm Thickness: 2 to 3 mm Length: 34.1 mm Well-defined ligamentous structure

Ligamentous structure composed of a superficial and deep bundle Thick band of tissue between ITT and LCL at level of lateral tibial plateau Ligamentous structure, strong enough to cause avulsion fracture off proximal tibia Distinct ligamentous structure

Can cause avulsion off tibial condyle (optimal radiograph is straight AP radiograph) Proximal tibia immediately Not stated anterior to fibular head

Not stated

Proximal tibia

Not stated

Tibial joint margin

Strong ligamentous structure Technically strong ligament

ALL, Anterolateral ligament; AP, anteroposterior; LCL, lateral collateral ligament; ITT, iliotibial tract. From Van der Watt L, Khan M, Rothrauff BB, et al: The structure and function of the anterolateral ligament of the knee: a systematic review, Arthroscopy 31:569, 2015.

popliteofibular ligaments, which arise from the popliteus tendon at its musculotendinous junction, forming a “Y” configuration also known as the arcuate ligament. These ligaments provide a strong connection between the popliteus tendon and the fibula. The more important posterior division (and the one typically reconstructed in posterolateral corner injuries) inserts 1.6 mm distal to the tip of the fibular styloid process on its posterior medial downslope. The anterior division inserts anterior to the posterior arm and medial to the FCL typically 2.8 mm distal to the anteromedial aspect of the fibular styloid process. The popliteus also has attachments to the lateral meniscus known as the three popliteomeniscal fascicles, which contribute to the dynamic stability of the lateral meniscus. The popliteus is a dynamic internal rotator of the tibia and provides dynamic and static stability to the knee primarily in response to external tibial rotation. The popliteofibular ligament is a static stabilizer of the lateral and posterolateral knee resisting varus, external rotation, and posterior tibial

translation. The popliteus and popliteofibular ligament are vital components of any posterolateral reconstruction. The deepest layer is the joint capsule, which is divided into superficial and deep laminae. The superficial layer is the original capsule embryologically; it encompasses the LCL and ends posteriorly at the fabellofibular ligament. The deep capsular layer is phylogenetically younger and results from the fibula receding from the lateral femur during early embryonic development. It extends posterolaterally and forms the coronary ligament and the hiatus for the popliteus tendon. It travels along the lateral meniscus and spans from the junction of the popliteus muscle and tendon to its termination at the popliteofibular ligament. The capsule can be divided into three sections: anterior, lateral, and posterior. The anterior section extends from the patellar tendon to the anterior border of the popliteus tendon insertion on the femur. The lateral capsule extends from the anterior border of the popliteus tendon to the lateral gastrocnemius attachment. The posterior capsule attaches to the femur

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CHAPTER 45  KNEE INJURIES ALL femoral attachment LCL femoral attachment Biceps femoris

LE Popliteus tendon ALL tibial attachment

Lateral gastrocnemius

Gerdy’s tubercle Anterior arm of biceps femoris LCL attachment to fibular head

FIGURE 45.14 Lateral view, right knee: osseous landmarks and attachment sites of main structures of lateral knee (iliotibial band and non-anterolateral-ligament related capsule removed). Femoral attachment of anterolateral ligament is located posterior and proximal to lateral collateral ligament; it courses anterodistally to its anterolateral tibial attachment approximately midway between center of Gerdy’s tubercle and the anterior margin of fibular head. ALL, Anterolateral ligament; LCL, lateral collateral ligament; LE, lateral epicondyle. (Redrawn from Kennedy MI, Claes S, Fuso FA, et al: The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis, Am J Sports Med 43:1606, 2015.)

A C B

*

D A

*

CD

B

25.4 mm

*

G

E C’ F

E

C’

A

F

25.4 mm

* G

B

FIGURE 45.15 Anteroposterior (A) and lateral (B) radiographs illustrating relationship of femoral and tibial anterolateral ligament attachments (*) to lateral gastrocnemius tendon (A), popliteus tendon (B), femoral attachment of the lateral collateral ligament (C) and lateral epicondyle (D), anterior arm of short head of biceps femoris (E), anterior margin of fibular head (F), and Gerdy’s tubercle (G). (From Kennedy MI, Claes S, Fuso FA, et al: The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis, Am J Sports Med 43:1606, 2015.)

proximal to the articular margin of the lateral femoral condyle. It is covered by the muscular origins of the plantaris and lateral gastrocnemius muscle and tendon. Distally, it blends with the musculotendinous junction of the popliteus and the posterior division of the popliteofibular ligament. The midthird capsular ligament is a thickening of the lateral capsule of the knee and is divided into the meniscofemoral and meniscotibial components similar to the deep MCL on the medial side of the knee. It is thought to be an important secondary stabilizer to varus instability, and the meniscotibial portion helps stabilize the lateral meniscus anterior to the popliteal hiatus. 

INTRAARTICULAR STRUCTURES

The principal intraarticular structures of importance are the medial and lateral menisci and the anterior and PCLs. Numerous functions have been assigned to the menisci, some known and some hypothetical. Among these functions are distribution of joint fluid, nutrition, shock absorption, deepening of the joint, stabilization of the joint, and a load-bearing or weight-bearing function. The cruciate ligaments function as stabilizers of the joint and axes around which rotary motion, both normal and abnormal, occurs. They restrict the backward and forward motion of the tibia on the femur and assist in the control of both medial and lateral rotation of the

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PART XIII  SPORTS MEDICINE tibia on the femur. External rotation of the tibia produces an unwinding of the ligaments, and internal rotation produces a winding up of the cruciate ligaments (Fig. 45.17). Further discussion of their specific functions is presented in the section on cruciate ligament injuries. 

ALL LCL

FIGURE 45.16 Coronal magnetic resonance images of right knee demonstrating the anatomic location of lateral collateral ligament (LCL) on left and anterolateral ligament (ALL) on right, located more anteriorly to lateral collateral ligament. (From Van der Watt L, Khan M, Routhrauff BB, et al: The structure and function of the anterolateral ligament of the knee: a systematic review, Arthroscopy 31:569, 2015.)

MECHANICS Both menisci are displaced slightly forward in full extension and move backward as flexion proceeds. The anchorage of the medial meniscus permits less mobility than of the lateral meniscus, possibly explaining why injuries are more common to the medial meniscus than to the lateral meniscus. The action of the popliteus muscle laterally and the semimembranosus muscle medially retracting the menisci posteriorly also helps prevent the menisci from becoming entrapped during movements of the knee. The menisci are described as moving with the femoral condyles with flexion and extension but moving with the tibia with rotary movements. The mechanical axis of the femur does not coincide with its anatomic axis because a line traversing the center of the hip joint and the center of the knee forms an angle of 6 to 9 degrees with the axis of the shaft of the femur. The mechanical axis generally passes near the center of the normal knee joint. Significant deviations from this mechanical axis may be present with genu varum or genu valgum deformity. The medial and lateral femoral condyles have different configurations. The lateral condyle is broader in the anteroposterior and the transverse planes than the medial condyle, and the medial condyle projects distally to a level slightly lower than the lateral condyle. This distal projection helps compensate for the inclination of the mechanical axis in the erect position so that the transverse axis lies near the horizontal. Since the medial femoral condyle articular surface is smaller than the lateral, during rotary movements it describes a smaller arc than the lateral condyle, thereby producing

PCL

ACL

LCL

MCL

A

External rotation

B

Neutral rotation

C

Internal rotation

FIGURE 45.17 In addition to their synergistic functions, cruciate and collateral ligaments exercise basic antagonistic function during rotation. A, In external rotation, it is collateral ligaments that tighten and inhibit excessive rotation by becoming crossed in space. B, In neutral rotation, none of four ligaments is under unusual tension. C, In internal rotation, collateral ligaments become more vertical and are more lax, whereas cruciate ligaments become coiled around each other and come under strong tension. ACL, Anterior cruciate ligament; LCL, lateral collateral ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.

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CHAPTER 45  KNEE INJURIES Anterior meniscofemoral ligament

Anterior meniscofemoral ligament Posterior horn of lateral meniscus

Posterior cruciate ligament

Popliteal tendon

Popliteal tendon

Posterior cruciate ligament Posterior meniscofemoral ligament

Attaching fibers of popliteus muscle Posterior horn of lateral meniscus

Popliteus muscle

Attaching fibers of popliteus muscle

Popliteus muscle

Posterior meniscofemoral ligament

FIGURE 45.18 Superior view of tibial condyles after removal of femur. Lateral meniscus is smaller in diameter, thicker around its periphery, wider in body, and more mobile; posteriorly, it is attached to medial femoral condyle by either anterior or posterior meniscofemoral ligament, depending on which is present, and to popliteus muscle.

two types of motion during flexion and extension. The knee thus possesses features characteristic of both a ginglymus (hinge joint) and a trochoid (pivot joint) articulation. The joint permits flexion and extension in the sagittal plane and some degree of internal and external rotation when the joint is flexed. No rotation is possible when the knee is in full extension. The complex flexion-extension motion is a combination of rocking and gliding. The rocking motion is demonstrable in the first 20 degrees of flexion, after which the motion becomes predominantly of the gliding type. This transition from one form of motion to the other is gradual but progressive. The rocking motion in the first 20 degrees of flexion better meets the requirements for stability of the knee in the relatively extended position, whereas the gliding motion as the joint unwinds permits more freedom for rotation. The articular surface of the medial condyle is prolonged anteriorly, and as the knee comes into the fully extended position, the femur internally rotates until the remaining articular surface on the medial condyle is in contact. The posterior portion of the lateral condyle rotates forward laterally, thus producing a “screwing home” movement, locking the knee in the fully extended position. When flexion is initiated, unscrewing of the joint occurs by external rotation of the femur on the tibia. As previously mentioned, the rotary movement responsible for screwing and unscrewing of the knee joint occurs around an axis that passes near the medial condyle of the femur and is greatly influenced by the PCL. Normal flexion and extension are from 0 to 140 degrees, but 5 to 10 degrees of hyperextension is often possible. With the knee flexed to 90 degrees, passive rotation of the tibia on the femur can be demonstrated up to 25 or 30 degrees; this passive rotation varies with each individual. The extent of internal rotation always exceeds that of external rotation, and no rotation is possible with the knee fully extended. Sagittal displacement of the tibia on the fixed femur is detectable in

FIGURE 45.19 Posterior view of knee after removal of femur. Posteriorly, lateral meniscus is attached to either anterior or posterior meniscofemoral ligament, depending on which is present, and to popliteus muscle.

both the anterior and posterior directions when the knee is flexed. Under normal conditions, the extent of the excursion should not exceed 3 to 5 mm. When the knee is extended, lateral (abduction–adduction) motion at the knee joint occurs to a limited extent; this motion varies with individual characteristics but should not exceed 6 to 8 degrees. In the hyperextended position, no lateral motion is present. In the flexed position, more lateral motion is possible but should never exceed 15 degrees. 

MENISCI FUNCTION AND ANATOMY

Meniscal function is essential to the normal function of the knee joint. As stated in the previous section on anatomy, various functions have been attributed to the menisci, some of which are known or proved and others that are theorized. The menisci act as a joint filler, compensating for gross incongruity between femoral and tibial articulating surfaces (Figs. 45.18 and 45.19). So located, the menisci prevent capsular and synovial impingement during flexion-extension movements. The menisci are believed to have a joint lubrication function, helping to distribute synovial fluid throughout the joint and aiding the nutrition of the articular cartilage. They contribute to stability in all planes but are especially important rotary stabilizers and are probably essential for the smooth transition from a pure hinge to a gliding or rotary motion as the knee moves from flexion to extension. Radiographic changes, as described by Fairbank, appear after meniscectomy and include narrowing of the joint space, flattening of the femoral condyle, and formation of osteophytes. Narrowing of the joint space initially is caused by removal of the spacer effect of the meniscus (approximately 1 mm); it is further narrowed by a reduction in the contact area in the absence of the meniscus. When the medial meniscus is removed, the contact area is reduced by approximately 40%; in other words, the contact area is 2.5 times greater when the meniscus is present. The larger contact area provided by the

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B Circumferential fibers A

Radial fibers

C Vessels

Middle perforating fibers

Chondrocytes

FIGURE 45.22 Cross section of meniscus showing direction of longitudinal tear. Note that direction of tear usually is oblique rather than vertical. FIGURE 45.20 Pattern of collagen fibers within meniscus. Radial fibers (A). Circumferential fibers (B). Perforating fibers (C).

Circumferential fibers Radial fibers Vessels

Chondrocytes FIGURE 45.21 cleavage split.

Cross section of meniscus showing horizontal

meniscus reduces the average contact stress acting between the bones. The menisci are thus important in reducing the stress on the articular cartilage; they prevent mechanical damage to both the chondrocytes and the extracellular matrix. Increased contact stress resulting from decreased contact area may produce bone remodeling, producing a flattened femoral condyle. Softening of the joint cartilage also results in increased joint space narrowing and osteophyte formation. The menisci have long been assumed to have shock- or energy-absorbing functions. Significant weight-bearing or load-transmitting forces are carried by the menisci, from 40% to 60% of the superimposed weight in the standing position. Thus, if normal and intact menisci spare the articular cartilage from compressive loads, then perhaps this partly explains the high incidence of osteoarthritis after removal of the meniscus. The effects of meniscectomy on joint laxity have been studied for anteroposterior and varus-valgus motions and rotation. These studies indicated that the effect on joint laxity depends on whether the ligaments of the knee are intact and whether the joint is bearing weight. In the presence of intact ligamentous structures, excision of the menisci produces small increases in joint laxity. When combined with

ligamentous insufficiency, these increased instabilities caused by meniscectomy are greatly exaggerated. In an ACL-deficient knee, medial meniscectomy has been shown to increase tibial translation by 58% at 90 degrees, whereas primary anterior and posterior translations were not affected by lateral meniscectomy. Anatomically, the capsular components that attach the lateral meniscus to the tibia do not affix the lateral meniscus as firmly as they do the medial meniscus. These results indicate that in contrast to the medial meniscus, the lateral meniscus does not act as an efficient posterior wedge to resist anterior translation of the tibia on the femur. Therefore, in knees that lack an ACL, the lateral meniscus is subjected to forces different from those that occur on the medial side; forces in the medial meniscus increase significantly in response to an anterior tibial load after transection of the ACL. This may account for the different patterns of injury of the lateral and medial menisci in knees with ACL deficiency. Biomechanical studies have shown that under loads of up to 150 kg, the lateral meniscus appears to carry 70% of the load on that side of the joint; whereas on the medial side, the load is shared approximately equally by the meniscus and the exposed articular cartilage. Medial meniscectomy decreases contact area by 50% to 70% and increases contact stress by 100%. Lateral meniscectomy decreases contact area by 40% to 50% but dramatically increases contact stress by 200% to 300% because of the relative convex surface of the lateral tibial plateau. The menisci are crescents, roughly triangular in cross section, that cover one half to two thirds of the articular surface of the corresponding tibial plateau. They are composed of dense, tightly woven collagen fibers arranged in a pattern providing great elasticity and ability to withstand compression. The major orientation of collagen fibers in the meniscus is circumferential; radial fibers and perforating fibers also are present. The arrangement of these collagen fibers determines to some extent the characteristic patterns of meniscal tears (Figs. 45.20 to 45.22). When meniscal samples are tested by application of a force perpendicular to the fiber direction, the strength is decreased to less than 10% because collagen fibers function primarily to resist tensile forces along the direction of the fibers. The circumferential fibers act in much the same way as metal hoops placed around a pressurized

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CHAPTER 45  KNEE INJURIES

Joint load

Joint load

FIGURE 45.23 Role of hoop tension in menisci. Hoop tension developed in menisci acts to keep them between bones.

wooden barrel. The tension in the hoops keeps the wooden staves in place (Figs. 45.23 and 45.24). The compression of the menisci by the tibia and the femur generates outward forces that push the menisci out from between the bones. The circumferential tension in the menisci counteracts this outward or radial force. These hoop forces are transmitted to the tibia through the strong anterior and posterior attachments of the menisci. Hoop tension is lost when a single radial cut or tear extends to the capsular margin; in terms of load bearing, a single radial cut through the meniscus may be equivalent to meniscectomy. The peripheral edges of the menisci are convex, fixed, and attached to the inner surface of the knee joint capsule, except where the popliteus is interposed laterally; these peripheral edges also are attached loosely to the borders of the tibial plateaus by the coronary ligaments. The inner edges are concave, thin, and unattached. The menisci are largely avascular except near their peripheral attachment to the coronary ligaments. The inferior surface of each meniscus is flat, whereas the superior surface is concave, corresponding to the contour of the underlying tibial plateau and superimposed femoral condyle. The medial meniscus is a C-shaped structure larger in radius than the lateral meniscus, with the posterior horn being wider than the anterior. The anterior horn is attached firmly to the tibia anterior to the intercondylar eminence and to the ACL. Most of the weight is borne on the posterior portion of the meniscus. The posterior horn is anchored immediately in front of the attachments of the PCL posterior to the intercondylar eminence. Its entire peripheral border is firmly attached to the medial capsule and through the coronary ligament to the upper border of the tibia. The lateral meniscus is more circular in form, covering up to two thirds of the articular surface of the underlying tibial plateau. The anterior horn is attached to the tibia medially in front of the intercondylar eminence, whereas the posterior horn inserts into the posterior aspect of the intercondylar eminence and in front of the posterior attachment of the medial meniscus. The posterior horn often receives anchorage also to the femur by the ligament of Wrisberg and the ligament of Humphry and from fascia covering the popliteus muscle and the arcuate complex at the posterolateral corner of the knee. The inner border, like that of the medial meniscus, is thin, concave, and free. The tendon of the popliteus muscle separates the posterolateral periphery of the lateral meniscus from the joint capsule and the FCL. The tendon of the popliteus is enveloped in a synovial membrane and forms an oblique groove on the lateral border of the meniscus.

FIGURE 45.24 Role of hoop tension in menisci. Single cut to radial edge eliminates hoop tension and allows menisci to move out from between bones.

The lateral meniscus is smaller in diameter, thicker in periphery, wider in body, and more mobile than the medial meniscus. It is attached to both cruciate ligaments and posteriorly to the medial femoral condyle by either the ligament of Humphry or the ligament of Wrisberg, depending on which is present; it is also attached posteriorly to the popliteus muscle (see Figs. 45.18 and 45.19). It is separated from the LCL by the popliteal tendon. In contrast, the medial meniscus is much larger in diameter, is thinner in its periphery and narrower in body, and does not attach to either cruciate ligament. It is loosely attached to the medial capsular ligaments. The menisci follow the tibial condyles during flexion and extension, but during rotation they follow the femur and move on the tibia; consequently, the medial meniscus becomes distorted. Its anterior and posterior attachments follow the tibia, but its intervening part follows the femur; thus it is likely to be injured during rotation. However, the lateral meniscus, because it is firmly attached to the popliteus muscle and to the ligament of Wrisberg or of Humphry, follows the lateral femoral condyle during rotation and therefore is less likely to be injured. In addition, when the tibia is rotated internally and the knee flexed, the popliteus muscle, by way of the arcuate ligament, draws the posterior segment of the lateral meniscus backward, thereby preventing the meniscus from being caught between the condyle of the femur and the plateau of the tibia. The vascular supply to the medial and lateral menisci originates predominantly from the lateral and medial geniculate vessels (both inferior and superior). Branches from these vessels give rise to a perimeniscal capillary plexus within the synovial and capsular tissue. The plexus is an arboroid network of vessels that supplies the peripheral border of the meniscus throughout its attachment to the joint capsule (Fig. 45.25). These vessels are oriented in a predominantly circumferential pattern with radial branches directed toward the center of the joint (Fig. 45.26). Microinjection techniques have shown that the depth of peripheral vascular penetration is 10% to 30% of the width of the medial meniscus and 10% to 25% of the width of the lateral meniscus. The medial and lateral geniculate arteries, along with their branches, supply vessels to the menisci through the vascular synovial covering of the anterior and posterior horn attachments. A small reflection of vascular synovial tissue also is present throughout the periphery of the menisci at both the femoral and tibial attachments and extends for a short distance (1 to 3 mm). The meniscus is a relatively acellular structure with predominately fibroblast-like cells in the peripheral vascular zone and chondrocyte-like cells in the avascular zone. Knees

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A

B

FIGURE 45.25 Superior aspect of medial (A) and lateral (B) menisci after vascular perfusion with India ink and tissue clearing by modified Spalteholz technique. Note vascularity at periphery of meniscus, as well as at anterior and posterior horn attachments. Absence of peripheral vasculature at posterolateral corner of lateral meniscus (arrow) represents area of passage of popliteal tendon.

1 PCP

F 2 3

R R

R W

W W

T FIGURE 45.26 Frontal section of medial compartment of knee. Branching radial vessels from perimeniscal capillary plexus (PCP) can be seen penetrating peripheral border of medial meniscus. F, Femur; T, tibia. Three zones of meniscal vascularity are shown: 1 RR, red-red is fully within vascular area; 2 RW, red-white is at border of vascular area; and 3 WW, white-white is within avascular area. (From Arnoczky SP, Warren RF: Microvasculature of the human meniscus, Am J Sports Med 10:90, 1982.)

with traumatic or degenerative meniscal tears have synovial fluid that contains degradative enzymes, including metalloproteinases and aggrecanases, which contribute to meniscal degeneration through proteoglycan and collagen degradation. Biologic augmentation strategies are designed to promote a healing environment and disrupt the degradative cascade. 

MENISCAL HEALING AND REPAIR

The vascular supply to the meniscus determines its potential for repair. The peripheral meniscal blood supply is capable of producing a reparative response similar to that observed in other connective tissues because of a perimeniscal capillary plexus that supplies the peripheral 10% to 25% of the menisci. Meniscal tears have been classified on the basis of

their location in three zones of vascularity—red (fully within the vascular area), red-white (at the border of the vascular area), and white (within the avascular area)—and this classification indicates the potential for healing after repair (see Fig. 45.21 and section on surgical repair of torn menisci). After injury within the peripheral vascular zone, a fibrin clot that is rich in inflammatory cells forms. Vessels from the perimeniscal capillary plexus proliferate throughout this fibrin scaffold and are accompanied by the proliferations of differentiated mesenchymal cells. The lesion is eventually filled with cellular fibrovascular scar tissue that glues the wound edges together and appears continuous with the adjacent normal meniscal fibrocartilage. Vessels from the perimeniscal capillary plexus as well as the proliferative vascular pannus from the synovial fringe penetrate the fibrous scar to provide a marked inflammatory response. Experimental studies in animals have shown that complete radial lesions of the meniscus are completely healed with a young fibrocartilaginous scar by 10 weeks, although several months are required for maturation to fibrocartilage that appears normal. Several reports described excellent results after primary repair of lesions at the periphery of the meniscus; because results of repair of tears in partially vascular or avascular areas are not as predictable, techniques have been developed to improve vascularity in meniscal repair. Techniques for open suture of peripheral tears of the meniscus are presented in this chapter, and those for arthroscopic suture are described in Chapter 51. Controversy exists about the ability of a meniscus or a meniscus-like tissue to regenerate after meniscectomy. It is now generally accepted that for a meniscus to regenerate to any extent, the entire structure must be resected to expose the vascular synovial tissue; or, in subtotal meniscectomy, the excision must extend to the peripheral vasculature of the meniscus. Subtotal excisions of the meniscus within the avascular central half of the meniscus do not show any regeneration potential. The frequency and degree of regeneration of the meniscus have

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CHAPTER 45  KNEE INJURIES predispose to either degeneration or traumatic laceration. Likewise, areas of degeneration that develop as a result of aging cannot withstand as much trauma as healthy fibrocartilage. Abnormal mechanical axes in a joint with incongruities or ligamentous disruptions expose the menisci to abnormal mechanics and thus can lead to a greater incidence of injury. Congenitally relaxed joints and those with inadequate musculature, especially the quadriceps, probably are at significantly greater risk of meniscal injuries, as well as other internal derangements. 

CLASSIFICATION OF MENISCAL TEARS

FIGURE 45.27 Two tears of medial meniscus: classic buckethandle tear and tear of posterior peripheral part.

not been determined precisely. Many surgeons believe that only the peripheral rim regenerates after total meniscectomy and that the quality of regenerated meniscus does not compare with that of original meniscus (see discussion of regeneration of menisci after excision).

MECHANISM OF TEAR

Traumatic lesions of the menisci are produced most commonly by rotation as the flexed knee moves toward an extended position. The medial meniscus, being far less mobile on the tibia, can become entrapped between the condyles, and injury can result. The most common location for injury is the posterior horn of the meniscus, and longitudinal tears are the most common type of injury. During vigorous internal rotation of the femur on the tibia with the knee in flexion, the femur tends to force the medial meniscus posteriorly and toward the center of the joint. A strong peripheral attachment posteriorly may prevent the meniscus from being injured, but if this attachment stretches or tears, the posterior part of the meniscus is forced toward the center of the joint, is caught between the femur and the tibia, and is torn longitudinally when the joint is suddenly extended. The length, depth, and position of the tear depend on the position of the posterior horn in relation to the femoral and tibial condyles at the time of injury. If this longitudinal tear extends anteriorly beyond the MCL, the inner segment of the meniscus is caught in the intercondylar notch and cannot return to its former position; thus a classic bucket-handle tear with locking of the joint is produced (Fig. 45.27). The same mechanism can produce a posterior peripheral or a longitudinal tear of the lateral meniscus; the lateral femoral condyle forces the anterior half of the meniscus anteriorly and toward the center of the joint, and this strain in turn may tear the posterior half of the meniscus from its peripheral attachment. When the joint is extended, a longitudinal tear results. Because of its mobility and structure, the lateral meniscus is not as susceptible to bucket-handle tears; however, because it is more sharply curved and is neither attached to, nor controlled by, the LCL, the lateral meniscus sustains incomplete transverse tears more often than does the medial meniscus. Menisci with peripheral cystic formation or menisci that have been rendered less mobile from previous injury or disease may sustain tears from less trauma. Congenital anomalies of the menisci, especially discoid lateral meniscus, may

Numerous classifications of tears of the menisci have been proposed on the basis of location or type of tear, etiology, and other factors; most of the commonly used classifications are based on the type of tear found at surgery. These are (1) longitudinal tears, (2) radial and oblique tears, (3) horizontal cleavage tears, (4) complex tears which are a combination of longitudinal and cleavage tears, (5) tears associated with cystic menisci, and (6) tears associated with discoid menisci. More recently, investigators have focused on two versions of the previously described tear patterns: the posterior root tear, which is a type of radial tear at the posterior root attachment of the meniscus, and the ramp lesion, which is a form of longitudinal tear at the menisco-capsular junction or the menisco-tibial attachment of the meniscus. Both tear types are thought to lead to increased anterior instability in ACLdeficient knees, as well as increased contact forces and early arthritis with posterior root tears. The most common type of tear is the longitudinal tear, usually involving the posterior segment of either the medial or the lateral meniscus. Before the extensive use of arthroscopy for diagnosis and treatment of meniscal injuries, tears of the medial meniscus in most series were approximately five to seven times more common than those of the lateral meniscus. However, as use of the arthroscope has increased, allowing more thorough inspection of both menisci, more lateral meniscal tears have been diagnosed. The two types are believed to occur with almost equal frequency. Tears within the meniscus itself can be complete or incomplete. Most involve the inferior rather than the superior surface of the meniscus. Small tears limited to the posterior horn are not capable of producing locking but will cause pain, recurrent swelling, and a feeling of instability in the joint. Extensive longitudinal tears can cause mechanical locking if the central portion of the meniscus is displaced into the intercondylar notch. A pedunculated fragment may result if either the posterior or anterior attachment of the bucket-handle fragment becomes detached. Transverse, radial, or oblique tears can occur in either meniscus but more commonly involve the lateral meniscus. These usually are located at the junction of the anterior and middle thirds and, as previously pointed out, tend to occur when forces separate the anterior and posterior segments of the meniscus, stretching the inner concave border and resulting in a transverse tear. Because the lateral meniscus is more of a circle and has a shorter radius, the inner free edge is more easily torn radially than its medial counterpart. Radial tears also can result from degenerative changes within the meniscus itself or from injury or conditions such as cystic changes at the periphery that render the meniscus less mobile. Both radial and longitudinal complex tears may be found and may follow degeneration or repeated traumatic episodes.

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PART XIII  SPORTS MEDICINE Cysts of the menisci are frequently associated with tears and are nine times more common on the lateral than on the medial side. The most common cause is trauma that produces degeneration and secondary mucinous and cystic changes in the periphery of the meniscus; when inflammatory changes follow, the meniscus may become less mobile during flexion, extension, and rotary motions and thus more susceptible to additional longitudinal or radial tearing. Discoid menisci are abnormal and, because of hypermobility and the bulk of the tissue between the articular surfaces, they are vulnerable to compression and rotary stresses. Degeneration within the discoid meniscus, as well as tears, may develop. The diagnosis often is made incidentally on MRI and occasionally at the time of arthroscopy, since the discoid meniscus may not produce significant symptoms until some derangement of the meniscus occurs. 

DIAGNOSIS

The diagnosis of a meniscal tear can be difficult even for an experienced orthopaedic surgeon. Use of a careful history and physical examination and supplementation of standard radiographs in specific instances with special imaging techniques and arthroscopy can keep errors in diagnosis of tears of the menisci to less than 5%. When a meniscus has been injured, capsular and ligamentous structures and the articular surfaces also often have been injured. For simplicity, tears of the menisci are discussed here as though they always are isolated injuries, but evidence of other injuries always must be sought. Disorders that can produce symptoms similar to those of a torn meniscus must be kept in mind and, to avoid error, a detailed, careful, systemic history and physical examination supplemented with appropriate imaging studies are indicated, especially if symptoms and findings are not quite typical of a torn meniscus. A history of specific injury may not be obtained, especially when tears of abnormal or degenerative menisci have occurred. This scenario is noted most often in a middle-aged person who sustains a weight-bearing twist on the knee or who has pain after squatting. Occasionally, an overweight middle-aged patient with mild-to-moderate knee arthritis describes a painful pop in the back of the knee when loading the knee, such as stepping up. In this scenario, the pop represents failure of the posterior root of the meniscus. Tears of normal menisci usually are associated with more significant trauma or injury but are produced by a similar mechanism: the meniscus is entrapped between the femoral and tibial condyles in flexion, tearing as the knee is extended. Patients with tears in degenerative menisci may recall symptoms of mild catching, snapping, or clicking, as well as occasional pain and mild swelling in the joint. Once the tear in the meniscus becomes of significant size, more obvious symptoms of giving way and locking may develop. The syndromes caused by tears of the menisci can be divided into two groups: those in which there is locking and the diagnosis is clear and those in which locking is absent and the diagnosis is more difficult. The first group requires little discussion because the symptoms and findings have been described many times elsewhere. However, locking may not be recognized unless the injured knee is compared with the opposite knee, which should exhibit the 5 to 10 degrees of recurvatum that normally is present. The injured knee can be locked and still extend to neutral position. This presentation may be seen with a chronic bucket-handle tear when the tear has elongated sufficiently to

allow the meniscal fragment to displace far enough into the notch so that knee extension is no longer impaired. Locking usually occurs only with longitudinal tears and is much more common with bucket-handle tears, usually of the medial meniscus. A very peripheral tear of the lateral meniscus may cause locking, even though the MRI appears normal. The patient will describe an episode when the knee locks in more flexion (sometimes approaching 70 degrees) and is associated with lateral-side knee pain. Often this is preceded by the patient having placed the knee in a highly flexed position, such as sitting on the knee, sitting tailor fashion, kneeling, or squatting. When the patient is able to unlock the knee, it usually occurs with an audible clunk and a visible jerk to the knee. The pain will lessen but soreness along the lateral joint line persists. When the MRI appears normal, the history may be the only clue to the diagnosis. Locking of the knee must not be considered pathognomonic of a bucket-handle tear of a meniscus; an intraarticular tumor, an osteocartilaginous loose body, and other conditions can cause locking. Regardless of its cause, locking that is unrelieved after aspiration of the hemarthrosis and a period of conservative treatment may require surgical treatment. A serious error is failure to distinguish locking from false locking. False locking occurs most often soon after an injury in which hemorrhage around the posterior part of the capsule or a collateral ligament with associated hamstring spasm prevents complete extension of the knee. Aspiration and a short period of rest until the reaction has partially subsided usually differentiates locking from false locking of the joint. If a patient does not have locking, the diagnosis of a torn meniscus is more difficult even for the most astute surgeon. Degenerative tears often present in this fashion. These tears result from repetitive physiologic forces leading to gradual wear of the meniscus, commonly resulting in horizontal cleavage or complex tears accompanied by osteoarthritic changes of the joint. A patient typically gives a history of several episodes of trouble referable to the knee, often resulting in effusion and a brief period of disability but no definite locking. A sensation of “giving way” or snaps, clicks, catches, or jerks in the knee may be described, or the history may be even more indefinite, with recurrent episodes of pain and mild effusion in the knee and tenderness along the joint line after excessive activity. The clinician should also be mindful that mechanical symptoms may result from osteoarthritis when rough, incongruous surfaces catch on each other instead of gliding smoothly. When they are well understood, the following clues can be important in the differential diagnosis in this second group: a sensation of giving way, effusion, atrophy of the quadriceps, tenderness over the joint line (or the meniscus), and reproduction of a click by manipulative maneuvers during the physical examination. A sensation of giving way is in itself of little help in diagnosis because it can occur in other disturbances of the knee, especially loose bodies, chondromalacia of the patella, instability of the joint resulting from injury to the ligaments or from weakness of the supporting musculature, especially the quadriceps, or any painful stimulus. When this symptom results from a tear in the posterior part of a meniscus, the patient usually notices this on rotary movements of the knee and often associates it with a feeling of subluxation or “the joint jumping out of place.” When giving way is a result of other causes, such as quadriceps weakness, it usually is noticeable during simple flexion of the knee against resistance, such as in walking down stairs. Effusion indicates that something is irritating the synovium; therefore, it has limited specific diagnostic value.

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CHAPTER 45  KNEE INJURIES

A

B

FIGURE 45.29 A and B, Apley grinding test for meniscal injury (see text). (From Tria AJ Jr: Clinical examination of the knee. In Scott WN, editor: Insall & Scott surgery of the knee, ed 4, Philadelphia, 2006, Churchill Livingstone.)

FIGURE 45.28 McMurray test for meniscal injury (see text). (From Tria AJ Jr: Clinical examination of the knee. In Scott WN, editor: Insall & Scott surgery of the knee, ed 4, Philadelphia, 2006, Churchill Livingstone Elsevier.)

The sudden onset of effusion after an injury usually denotes a hemarthrosis, and it can occur when the vascularized periphery of a meniscus is torn. Tears occurring within the body of a meniscus or in degenerative areas may not produce a hemarthrosis. Repeated displacement of a pedunculated or torn portion of a meniscus can cause sufficient synovial irritation to produce a chronic synovitis with an effusion of a nonbloody nature. Thus, the time at onset and the characteristics of the effusion are of value in assessing the knee, but the absence of an effusion or hemarthrosis does not rule out a tear of the meniscus. Atrophy of the musculature around the knee, especially of the vastus medialis component of the quadriceps mechanism, suggests a recurring disability of the knee but does not indicate its cause. Probably the most important physical finding is localized tenderness along the medial or lateral joint line or over the periphery of the meniscus. This most often is located posteromedially or posterolaterally, because most meniscal tears are in the posterior horn areas. The meniscus itself is without nerve fibers except at its periphery; therefore, the tenderness or pain is related to synovitis in the adjacent capsular and synovial tissues. 

DIAGNOSTIC TESTS

Clicks, snaps, or catches, either audible or detected by palpation during flexion, extension, and rotary motions of the joint, can be valuable diagnostically, and efforts should be made to reproduce and accurately locate them. If these noises are localized to the joint line, the meniscus most likely contains a tear. Similar noises originating from the patella, the quadriceps mechanism, the patellofemoral groove, or arthritic joint surfaces must be differentiated. Numerous manipulative tests have been described, but the McMurray test and the Apley

grinding test probably are most commonly used. All basically involve attempts to locate and to reproduce crepitation that results as the knee is manipulated. The McMurray test (Fig. 45.28) is probably best known and is carried out as follows. With the patient supine and the knee acutely and forcibly flexed, the examiner can check the medial meniscus by palpating the posteromedial margin of the joint with one hand while grasping the foot with the other hand. Keeping the knee completely flexed, the leg is externally rotated as far as possible and then the knee is slowly extended. As the femur passes over a tear in the meniscus, a click may be heard or felt. The lateral meniscus is checked by palpating the posterolateral margin of the joint, internally rotating the leg as far as possible, and slowly extending the knee while listening and feeling for a click. A click produced by the McMurray test usually is caused by a posterior peripheral tear of the meniscus and occurs between complete flexion of the knee and 90 degrees. Popping, which occurs with greater degrees of extension when it is definitely localized to the joint line, suggests a tear of the middle and anterior portions of the meniscus. The position of the knee when the click occurs thus may help locate the lesion. A McMurray click localized to the joint line is additional evidence that the meniscus is torn; a negative result of the McMurray test does not rule out a tear. The grinding test, as described by Apley, is carried out as follows. With the patient prone, the knee is flexed to 90 degrees and the anterior thigh is fixed against the examining table. The foot and leg are then pulled upward to distract the joint and rotated to place rotational strain on the ligaments (Fig. 45.29A); when ligaments have been torn, this part of the test usually is painful. Next, with the knee in the same position, the foot and leg are pressed downward and rotated as the joint is slowly flexed and extended (Fig. 45.29B); when a meniscus has been torn, popping and pain localized to the joint line may be noted. Although the McMurray, Apley, and other tests cannot be considered diagnostic, they are useful enough to be included in the routine examination of the knee. Tears of one meniscus can produce pain in the opposite compartment of the knee. This is most commonly seen with posterior tears of the lateral meniscus. This phenomenon is not understood. The use of MRI has minimized initial exploration of the wrong compartment.

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IMAGING STUDIES RADIOGRAPHY

Anteroposterior, lateral, and intercondylar notch views with a tangential view of the inferior surface of the patella should be routine. Ordinary radiographs will not confirm the diagnosis of a torn meniscus but are essential to exclude osteocartilaginous loose bodies, osteochondritis dissecans, and other pathologic processes that can mimic a torn meniscus. Occasionally, a relatively widened lateral joint space may suggest the presence of a discoid lateral meniscus. 

ARTHROGRAPHY

The usefulness of arthrography in diagnosis of pathologic conditions of the meniscus usually is directly proportional to the interest and experience of the arthrographer (Fig. 45.30). To never use arthrography is to eliminate an extremely valuable diagnostic procedure, but to use it routinely on every injured knee is just as unfortunate. With the improvements in CT and MRI scanning, we rarely use arthrography for knee examination. 

OTHER DIAGNOSTIC STUDIES

FIGURE 45.30

Arthrogram of knee showing tear of meniscus.

Another useful test, the squat test, consists of several repetitions of a full squat with the feet and legs alternately fully internally and externally rotated as the squat is performed. Pain usually is produced on either the medial or lateral side of the knee, corresponding to the side of the torn meniscus. Pain in the internally rotated position suggests injury to the lateral meniscus, whereas pain in the external rotation suggests injury to the medial meniscus. However, the localization of the pain to either the medial joint line or the lateral joint line is a much more dependable localizing sign than the position of rotation. Karachalios et  al. described a test for early detection of meniscal tears (Thessaly test) for which they reported diagnostic accuracy rates of 94% in detecting tears of the medial meniscus and 96% in the detection of tears of the lateral meniscus. The examiner supports the patient by holding his or her outstretched hands while the patient stands flatfooted on the floor on just the affected leg. The patient then rotates his or her knee and body, internally and externally, three times with the knee in slight flexion (5 degrees). The same procedure is carried out with the knee flexed 20 degrees. Patients with suspected meniscal tears experience medial or lateral joint-line discomfort and may have a sense of locking or catching. The test is always done on the normal knee first to teach the patient how to keep the knee in 5 and 20 degrees of flexion and how to recognize a possible positive result in the symptomatic knee. The Thessaly test at 20 degrees of knee flexion was suggested to be effective as a first-line clinical screening test for meniscal tears. Two meta-analyses of the literature attempted to determine the relative accuracy of these clinical tests, but both found problems with methodology of studies and small sample sizes, as well as with differences in how the tests were defined, performed, and interpreted. One analysis determined that joint line tenderness is the best “common” test, while the other found sensitivities and specificities similar among the three tests: McMurray, 70% and 71%; Apley, 60% and 70%; and joint line tenderness, 63% and 77%. Combined testing will improve the accuracy. 

Other diagnostic studies, such as ultrasonography, bone scanning, CT, and MRI, have been shown to improve diagnostic accuracy in many knee disorders (see Chapter 2). Their principal attractiveness over arthrography or arthroscopy is that they are noninvasive procedures. Compared with arthroscopy, MRI has been shown to have 98% accuracy for medial meniscal tears and 90% for lateral meniscal tears. Others have reported that MRI had a positive predictive value of 75%, a negative predictive value of 90%, a sensitivity of 83%, and a specificity of 84% for pathologic changes in the menisci. More recently, a study of acute and chronic meniscal tears in 122 young adults found a sensitivity of 67%, specificity of 93%, and diagnostic accuracy of 88% in the detection of acute tears; sensitivity was 64%, specificity was 91%, and diagnostic accuracy was 86% for chronic tears. Menisco-capsular tears such as ramp lesions are not as easily detected by MRI and therefore should be evaluated at the time of arthroscopy. Although MRI appears to be efficient in detecting meniscal tears, it has not been shown to be effective in predicting the reparability of such tears. Motamedi reported that two experienced musculoskeletal radiologists, using established arthroscopic criteria to grade 119 meniscal tears, agreed on reparable or not reparable classifications 74% of the time but came to identical scores only 38% of the time. High-resolution CT has been reported to have a sensitivity of 96%, specificity of 81%, and accuracy of 91%. We most often use CT for examining the patellofemoral joint because it allows evaluation of the normal and abnormal relation of the articulation at various degrees of knee flexion, with and without quadriceps contraction. CT arthrography is used when MRI is contra-indicated as in patients with pacemakers or other similar implants. It also is useful for delineating synovial cysts and other soft-tissue tumors around the knee. 

ARTHROSCOPY

Details about equipment, principles, and diagnostic and surgical arthroscopic techniques are presented in Chapter 51. 

NONOPERATIVE MANAGEMENT

Arthroscopy has made the diagnosis of acute meniscal injuries more precise, which aids in the treatment planning. Incomplete

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CHAPTER 45  KNEE INJURIES tears or small peripheral tears (displaced .05) by 12%, 18%, and 10% at 0, 30, and 90 degrees of flexion, respectively. PMJC repair reduced (P < .05) ACL strain by 40%, 39%, 43%, and 31% at 0, 30, 60, and 90 degrees of flexion, respectively. In a biomechanical study using 12 matched pairs of human cadaver knees, DePhillipo et al. evaluated the effects of meniscocapsular and meniscotibial lesions of the posterior medial meniscus in ACL-deficient and ACL-reconstructed knees and the effect of the repair of ramp lesions. Cutting the meniscocapsular and meniscotibial attachments of the posterior horn of the medial meniscus significantly increased anterior tibial translation in ACL-deficient knees at 30 degrees (P < .020) and 90 degrees (P < .005). Cutting both the meniscocapsular and meniscotibial attachments increased tibial internal (all P > .004) and external (all P < .001) rotation at all flexion angles in ACL-reconstructed knees. Reconstruction of the ACL in the presence of meniscocapsular and meniscotibial tears restored anterior tibial translation (P > 0.053) but did not restore internal rotation (P < .002), external rotation (P < .002), or the pivot shift (P < .05). To restore the pivot shift, an ACL reconstruction and a concurrent repair of the meniscocapsular and meniscotibial lesions were both necessary. Repairing the meniscocapsular and meniscotibial lesions after ACL reconstruction did not restore internal rotation and external rotation at angles of more than 30 degrees. Research and understanding of meniscal root injuries have evolved since 2010. In cadaver studies, root tears of the medial meniscus have been shown to increase translational and rotational instability in both ACL-intact and ACLdeficient knees. Lateral root injury was found to reduce the stability of the ACL-deficient knee in rotational loading. Tang et al. studied 13 cadaver knees with a robotic testing system. In the ACL-reconstructed knee, a tear of the lateral meniscal posterior root significantly increased knee laxity under loading by as much as 1 mm. The transosseous pullout suture root repair improved knee stability under anterior tibial and simulated pivot shift loading. Root repair improved ACL graft force closer to that of the native ACL under anterior tibial loading. Another study by Allaire et al. analyzed loading and kinematics in intact knees, knees with a posterior root tear of the medial meniscus, knees with a repaired posterior root tear, and knees with a total meniscectomy. They found that a root tear resulted in increased tibiofemoral contact pressure equal to that following a total meniscectomy, whereas repair restored contact pressure to that of the uninjured knee. Repairs are recommended for active patients (typically younger than 50 years) following acute or chronic injury with no significant osteoarthritis (Outerbridge grade 3 or 4), jointspace narrowing, or malalignment. Repairs usually are done either by transtibial pullout or suture anchor and the results are reported to be equivalent. Reports of repair are somewhat controversial, with some showing inability to restore ultimate failure loads or prevent displacement of the root attachment, while others demonstrated improvements in clinical outcome

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PART XIII  SPORTS MEDICINE scores compared to the preoperative baseline values. Lee et al. evaluated 56 patients who had pullout sutures for medial meniscal root repair using the Lysholm score, Hospital for Special Surgery score, IKDC subjective score, medial joint space height, and Kellgren-Lawrence grade. Thirty-three patients had second-look arthroscopy and were divided into a “stable healed group” (23 patients, 69.7%) and an “unhealed group” (10 patients, 30.3%). Medial joint space became significantly narrower (P < .001), and 23 patients showed progression of their Kellgren-Lawrence grade. All other clinical outcomes improved. The stable-healed group had higher HSS scores, IKDC subjective scores, and less progression of medial joint space narrowing. Two studies by Cho and Song and Seo et  al. reported second-look arthroscopy in 24 patients; four were completely healed, nine healed in a lax position, eight healed with scar tissue, and three failed to heal. In spite of the controversy, given the known poor results of posterior root meniscal tears treated nonoperatively, an attempt at repair should be considered in appropriate patients. Tears of the menisci can be sutured by open or arthroscopic techniques, which are described in Chapter 51. Open suturing of the meniscus has been successful in stable knees. In unstable knees, the sutured meniscus can tear again unless reconstruction stabilizes the knee or the patient alters physical activities. A cadaver study showed that anterior knee laxity significantly increased gapping of repaired and unrepaired posterior horn medial meniscal tears. If the meniscal tear involves the periphery of the posterior horn, exposure through a posteromedial or posterolateral arthrotomy is relatively easy, the latter being more difficult. In such tears, the meniscal rim and the synoviocapsular junction can be prepared, and multiple sutures can be accurately placed. Because of the collagen arrangement within the meniscus, vertically oriented sutures can be used. We still prefer to repair posterior horn peripheral tears by open arthrotomy if posteromedial or posterolateral capsular reconstructions are being done concurrently. Arthroscopic techniques of suturing are necessary for tears at or near the junction of the vascular and avascular zones. A long tear at or near this junction is almost impossible to expose and to suture through a posteromedial or posterolateral arthrotomy. Medial tears that extend deep to the collateral ligament are difficult to expose by open techniques without risking injury to the ligament. Tears of the posterior horn of the lateral meniscus are difficult to expose and to suture because the posterolateral capsule is not nearly as well defined. These can be more easily repaired by arthroscopic techniques. Meniscal repair sutures can approximate tissue and provide vascular access channels for ingrowth of healing tissue. The ideal suture material has not been determined. Most early reports of meniscal repair advocated the use of an absorbable suture, such as polyglycolic acid (Dexon), polyglactin-910 (Vicryl), or polydioxanone (PDS). The mechanical effects of normal joint motion probably cause failure of even nonabsorbable sutures over time. Because the human meniscus requires several months to heal completely, the suture selected for meniscal repair should be capable of providing adequate support for this period. Significant instability adds tension to the meniscal repair, and the chance of another tear is greatly increased. We have repaired the meniscus without ligamentous stabilization but only when a patient is willing to seriously curtail activities and

is fully aware that a second tear is more likely in an unstable joint. For younger, active patients, ligamentous stabilization should accompany meniscal suture because of the decreased likelihood of healing and increased risk of re-rupture in a knee with ligamentous laxity. 

 

OPEN MENISCAL REPAIR

TECHNIQUE 45.1

Systematically examine the entire knee arthroscopically to rule out additional pathologic conditions. The technique for repair is essentially the same for medial and lateral meniscal tears. n  Medial meniscal tears most commonly extend for 2 to 3 cm along the posterior horn anteriorly to the posterior edge of the MCL. The tear sometimes extends farther anteriorly, or a bucket-handle displacement occurs. Some bucket-handle tears and longitudinal tears in the outer third of the meniscus can be sutured. n  If the medial meniscus is torn, position the knee in 60 degrees of flexion. n  Then make a vertical posteromedial arthrotomy incision from the medial epicondylar area of the femur distally toward the semimembranosus tendon in line with the fibers of the POL. n  Use a right-angle retractor to retract the posterior capsule posteriorly and then explore the extent of the tear. Such tears usually are 2 to 3 mm from the periphery of the meniscus, well within the vascular zone. If the tear is 5 mm or more from the peripheral attachment, it can be difficult to see and to repair through the arthrotomy approach. n  Debride the edges of the tear with a small curet or scalpel. As a rule, do not remove any intact peripheral meniscal tissue. Removal of this tissue and pulling of the meniscal rim to the capsule with sutures narrow the meniscus and reduce its weight-bearing function. n  With a small rasp, abrade the debrided edges of the tear and also the parameniscal synovial tissue to evoke an increased inflammatory healing response. n  Once the tear has been prepared for suturing, identify the interval between the posterior capsule and the medial head of the gastrocnemius and retract the latter posteriorly. n  Free the posterior capsule from the overlying gastrocnemius head along the entire length of the meniscal tear to make accurate suture placement easier. n  Place interrupted sutures of Mersilene or other nonabsorbable surgical suture material every 3 to 4 mm. Beginning outside the posterior capsule, pass the sutures through the capsule, then vertically from inferior to superior through the meniscus, and then back out through the capsule, but do not tie them (Fig. 45.32). Each suture should be oriented vertically rather than horizontally to achieve maximal purchase on the meniscus. n  Before the arthrotomy incision is closed, gather the ends of the meniscal sutures and exert tension on them. Check to see that the approximation of the meniscal tear is accurate. n 

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CHAPTER 45  KNEE INJURIES

A

B

C

FIGURE 45.32 A, Through posteromedial arthrotomy, multiple interrupted sutures placed vertically through periphery of meniscus are spaced every few millimeters and tied outside joint capsule. B, Looking down on top of longitudinal tear of meniscus with multiple approximating sutures. C, Sutures tied outside capsule, approximating capsule or peripheral meniscal rim to body of meniscus. SEE TECHNIQUE 45.1.

Maintain tension on the sutures, watch the tear, and slowly extend the knee to be sure the approximation is not pulled apart as the knee extends. If the sutures are placed too far superiorly in the posterior capsule, the edges of the tear will part as the knee extends. If the approximation involves a meniscal rim fragment, the fragment orients the proper placement of the sutures. If repair is of a peripheral attachment, pull the meniscus back to as near the original meniscocapsular junction as possible. n  If the medial meniscal tear extends anteriorly deep to the MCL and thus makes inspection and repair through the posteromedial arthrotomy difficult, the sutures are best placed with arthroscopic techniques (see Chapter 51). If one is not skilled in arthroscopic techniques, careful longitudinal incisions through the MCL and capsule may permit inspection and repair. Great care must be taken to avoid injury to the collateral ligament. n  If the arthrotomy has extended through the coronary ligament, be sure it is accurately approximated to restore peripheral stability. With the knee in 45 degrees of flexion, close the arthrotomy with multiple interrupted, nonabsorbable sutures, advancing and tightening the POL. n  Once the arthrotomy has been closed, tie the meniscal sutures individually, beginning with the most lateral suture and progressing to the most medial. Tears of the lateral meniscus are treated by techniques similar to those described for medial meniscal tears, but lateral meniscal tears are more difficult to repair. The posterior horn of the lateral meniscus is exposed through a posterolateral capsular incision above the popliteal tendon, as described by Henderson (see Chapter 1). The coursing of the popliteal tendon through a hiatus in the periphery of the lateral meniscus adds to the difficulty. Because of this more difficult exposure and suturing, we prefer to repair all lateral meniscal tears by arthroscopic techniques. n 

POSTOPERATIVE CARE Postoperative care is determined by the size or extent of the tear, whether it is stable (not displaceable into the joint) or unstable (displaceable

into the joint), and whether the repair is combined with a ligament reconstruction or other procedure. If the repair is not combined with another procedure and the tear is small and stable, the knee is placed in a hinged brace and immediate range of motion from 0 to 90 degrees is permitted. Touch-down weight bearing is permitted immediately, and full weight bearing is permitted at 6 weeks when the brace and crutches are discarded. No sports are allowed for 3 months. If the repair is not combined with other procedures but the tear is sufficiently large to allow displacement into the joint, the knee is placed in a hinged brace that is locked in full extension for 3 to 4 weeks. Only touch-down weight bearing with crutches is permitted. At 4 weeks, the hinge mechanism of the brace is adjusted and motion from 0 to 90 degrees is begun. The brace is worn for 6 weeks and then removed. Weight bearing to 50% is reached at this point. Crutches can be discontinued at 8 weeks. No sports are allowed for 6 months, depending on the success of rehabilitation. If the meniscal repair is combined with a reconstructive procedure, such as reconstruction of the ACL, motion, brace wear, and weight bearing are determined by the postoperative care required for the reconstructive procedure.   

MENISCAL AUTOGRAFTS AND ALLOGRAFTS

Despite the best of efforts, not all meniscal tears can be repaired and arthritic changes may develop in the involved knee compartment. Perhaps one of the greatest dilemmas facing orthopaedists is the treatment of a young, active, healthy individual with an arthritic knee who is not a candidate for a total knee replacement. In response to this problem, investigators have studied the use of meniscal allografts, autograft fascial material, and synthetic menisci scaffolds. Reported results of meniscal allografts are mixed, and most studies report only short-term and mediumterm follow-up (Fig. 45.33). Success usually is defined by pain relief, improved function, lack of meniscal symptoms, lack of rejection, and peripheral healing of the graft. True success will be

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FIGURE 45.33

Meniscal allograft.

determined by the prevention of arthritis, which will be proved only with long-term follow-up. A systematic review of the literature found that meniscal extrusion was present in most patients with meniscal allografts but was not associated with clinical or radiographic outcomes. The authors concluded that there is some evidence to suggest that meniscal allograft transplantation reduces the progression of osteoarthritis; however, the quality of the studies was low, with a high risk for bias. A few studies have examined the histology and biochemistry of transplants, but this research needs further investigation. Long-term success requires that the meniscal allografts be histologically, biochemically, and biomechanically similar to the native meniscus. Because of the difficulty in locating, harvesting, and distributing fresh donor allografts to a size-matched recipient, as well as the possibility of disease transmission, fresh menisci suitable for allograft implantation have given way to bankpreserved meniscal allografts. Currently, meniscal allografts are preserved in one of four ways: fresh, fresh frozen (deepfreezing), freeze-dried (lyophilization), and cryopreserved. Of these four methods, only cryopreservation has been shown to reproducibly maintain a substantially viable cell population (10% to 40%). The necessity of preserving viable cells in the allograft has been questioned because of animal studies showing that allograft is repopulated with host cells. Preservation techniques also affect the immunogenicity of the allograft meniscus. Deep-freezing or freeze-drying of meniscal tissue tends to decrease immunogenicity. Cryopreservation maintains the content of donor human leukocyte antigen– encoded antigens and is more sensitizing to the host. Studies have demonstrated an immunologic response of the host to the transplant, but the clinical significance of this is unknown. The potential for disease transmission also is affected by preservation techniques. Cryopreservation is not considered a process through which sterilization can be ensured, but freeze-drying and gamma irradiation have been shown to effectively eliminate the risk of viral transmission. Unfortunately, these techniques appear to have the deleterious effect of graft shrinkage. To eliminate human immunodeficiency virus DNA, allograft tissue must be irradiated with more than 3 Mrad of gamma irradiation, but exposure to more than 2.5 Mrad of irradiation negatively affects the mechanical

properties of collagen-containing tissues. Consequently, secondary sterilization with gamma irradiation is not currently recommended. The appropriate candidate for meniscal allograft transplantation should be skeletally mature but too young for TKA and have significant knee pain and limited function. All other options for medical management of pain, including a thorough trial of conservative therapy and bracing techniques, should be exhausted. The cause of meniscal damage must be mechanical, not degenerative, and the meniscal damage must not be caused by synovial disease. If a nonmechanical disease state exists, the allograft will fail. The ideal candidate is a patient younger than 40 years with an absent or nonfunctioning meniscus. On occasion, patients up to 50 years old may benefit from transplantation if they are highly active with only limited arthritis and are not good candidates for arthroplasty. The pain should be localized to the affected compartment with activities of daily living or sports. In addition, the patient should have normal mechanical alignment, a stable knee, and only Outerbridge grade I or grade II articular cartilage changes. Contraindications include knee instability or varusvalgus malalignment, unless these can be corrected. Varusvalgus malalignment is defined as asymmetry of 2 to 4 degrees or more compared with the contralateral knee. Malalignment also exists if the weight-bearing line on long-leg alignment radiographs falls into the affected meniscus-deficient compartment. ACL reconstructions and osteotomies can be performed simultaneously or as staged procedures. Most investigators believe that advanced osteoarthritis is an absolute contraindication because of questionable graft survival. Poorer results have been reported when meniscal allografts have been used in association with osteochondral allograft transplantations, ACL reconstructions, and realignment procedures. Because mostly short-term and medium-term results of transplantation of meniscal allografts are available, questions remain about their survivorship and function. In one study the beneficial effects of pain relief and improved function remained in approximately 70% of the patients at 10 years after surgery; another study with follow-up of 14 years found deterioration of clinical results during follow-up. Bin et al. reported a meta-analysis that assessed survival rates in patients who had medial or lateral meniscal allograft transplantation with more than 5 years of follow-up. They found that 85.8% of medial and 89.2% of lateral meniscal allograft transplants survived at midterm (5 to 10 years), while 52.6% of medial and 56.6% of lateral transplants survived long term (>10 years). Patients with lateral meniscal allograft transplantation demonstrated greater pain relief and functional improvement than patients with medial transplantation. A more recent meta-analysis found that, regardless of the follow-up period and the scoring system used, patients showed continuous clinical improvement, and a systematic review of the literature reported patient satisfaction ranging from 62% to 100% at follow-ups ranging from 3 to almost 12 years. Extrusion of the meniscal transplant has been a concern, but Lee et al. found no significant differences in clinical outcomes in 45 medial and lateral meniscal transplants at a minimum of 8 years of follow-up. They divided the patients into two groups: extrusion (≥3 mm) and nonextrusion (20 mm, >15 mm with dysplasia Contraindicated with proximal/medial facet arthritis Long healing time, increased risk of proximal tibial fracture with sports

HIGH RISK—HIGH REWARD* Rotational high tibial osteotomy Distal femoral osteotomy Trochleoplasty

Grooveplasty 3-in-1 procedure—extensor mechanism realignment + VMO advancement + transfer of the medial third of the patellar tendon to the MCL

Indicated for instability + severe rotational deformity More normalized gait compared with distal realignment Indicated for dysplastic trochlea Low recurrence rate Increased risk for osteonecrosis, DJD, arthrofibrosis Lateral condyle: increased pressure; increased DJD of lateral facet Increased DJD Good results with less risk reported with MPFL reconstruction Recurrent instability, TT-TG >20 mm Open physes Not as effective as MQTFL reconstruction avoiding physis

*Indicated in special circumstances when risk/benefit ratio is acceptable. DJD, Degenerative joint disease; MCL, medial collateral ligament; MPFL, medial patellofemoral ligament; TT-TG, tibial tubercle–trochlear groove; VMO, vastus medialis oblique.

prevent the patella from relocating. Routine lateral release should not be done because it may create more instability.   

RECONSTRUCTION OF THE MEDIAL PATELLOFEMORAL LIGAMENT The MPFL can be repaired by making a 3-cm incision over the site of injury as shown by MRI. An incompetent ligament with damage limited to the femoral attachment can be repaired and reinforced by use of the adductor magnus tendon (Fig. 47.7). Chronic instability with a Q angle of less than 20 degrees or an extensively damaged MPFL should be treated using a semitendinosus hamstring tendon graft technique. Nelitz et al. reported no growth abnormalities or recurrences in 21 skeletally immature patients treated

with MPFL reconstruction. Two patients with severe dysplasia had persistence of apprehension. In their systematic review, Vavken et al. also found no growth abnormalities or recurrences in the 425 patients (456 knees) reported. Hopper et al. found that severe dysplasia reduced satisfactory results from 83% to 57%. Numerous techniques have been described for MPFL reconstruction, most using autogenous doubled semitendinosus-hamstring grafts placed in a physiometric position confirmed by palpation of landmarks and imaging, and tested for isometry. The technique we have been using for over a decade involves appropriate placement of a strong, physiologically tensioned graft through the quadriceps tendon, thus reproducing the MQTFL. This technique has resulted in low recurrence rates, no risk of patellar fracture, and minimal risk of loss of motion.     

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Patellofemoral ligament

Patellofemoral ligament

Adductor magnus

Adductor magnus

Patellotibial ligament Medial collateral ligament

A

B

C

FIGURE 47.7 A, Medial patellofemoral ligament detached from medial femoral epicondyle after acute patellar dislocation. B, Medial patellofemoral ligament with firm edge of vastus medialis obliquus muscle reinserted to periosteum of medial femoral epicondyle, and adductor magnus tendon harvested. C, Adductor magnus tendon fixed near medial border of patella, and retinaculum duplicated.

 

MEDIAL QUADRICEPS TENDON-FEMORAL LIGAMENT RECONSTRUCTION

Make a second 1-cm vertical incision 1.5 cm lateral to the first incision through the quadriceps at its insertion into the patella. Use a Kelly clamp to spread the soft tissues and pass a looped no. 2 suture to use as a shuttle for the graft. n  Use blunt dissection to spread between layers 2 and 3 (between the MPFL and the capsular layer), staying extrasynovial and developing the plane with a curved Kelly clamp directed toward the medial epicondyle, spreading between the layers to create a soft-tissue tunnel. Use the Kelly clamp to pass a looped suture to use as a shuttle for the tunnel thus created (Fig. 47.8B). n  Shuttle one tail of the graft through the slit in the quadriceps, and then shuttle both tails through the MPFL tunnel to the femoral insertion site. n  Select the site for the femoral tunnel approximately 4 mm distal and 2 mm anterior to the adductor tubercle, in the “saddle” region between the tubercle and the medial epicondyle. Confirm correct position with imaging (Figs. 47.8C and 47.9). n  Place a Beath-tip guidewire at the chosen spot, and pass two suture tails from the graft around the wire. Mark the sutures so that pistoning of the graft can be identified with range of motion of the knee. n  Move the knee through a range of motion and observe the sutures, which should have minimal motion between 0 and 70 degrees of flexion and slight laxity above 70 degrees. If tension increases with flexion, the femoral tunnel site is too far proximal (most commonly) or possibly too far anterior. If the sutures tighten excessively in extension, the tunnel is too far distal or too far posterior. If necessary, correct the guidewire position and repeat the evaluation. n 

TECHNIQUE 47.1 (PHILLIPS)

With the patient supine, place a tourniquet on the upper thigh. Use a lateral post on the operating table to assist with arthroscopic examination. n  After sterile preparation and draping, arthroscopically examine the knee through standard medial and lateral portals to evaluate patellar tracking and look for intraarticular damage. This evaluation is essential for determining appropriate treatment. n  Make a 3-cm incision 3 cm medial to the inferior portion of the patellar tuberosity and harvest the semitendinosus tendon in standard fashion. Size the folded graft so that the appropriately sized tunnel can be reamed later. Place a 0 Vicryl Krakow suture in each tail of the semitendinosus graft (Fig. 47.8A). n  Make two 2-cm incisions, the first just medial to the superior border of the patella and the second starting at the adductor tubercle and extending just distal to the medial epicondyle of the femur, to expose the patellofemoral ligament. n  Dissect subcutaneously to expose the proximal medial retinaculum at its insertion into the proximal portion of the patella. Make a 1.5-cm incision in the retinaculum adjacent to the quadriceps insertion. n 

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CHAPTER 47  RECURRENT DISLOCATIONS

A

C

B

E

D

F FIGURE 47.8 Phillips reconstruction of the medial patellofemoral ligament. A, Semitendinosus tendon graft. B, Creation of soft-tissue tunnel. C, Correct position confirmed radiographically. D, Whip stitch placed in each end of graft. E, Graft tails passed through soft-tissue tunnel. F, Closure. SEE TECHNIQUE 47.1.

At the selected femoral tunnel site, ream a 30-mm tunnel the diameter of the doubled tendon. n  Pull the graft taut, and stress the patella so as to allow for one to two quadrants of lateral passive glide. When the physiologic amount of tension on the graft is determined, make a mark on the graft, which will correspond to the aperture of the femoral tunnel (Fig. 47.8D). n  Cut the graft 20 mm distal to this mark to allow 20 mm of graft to be placed into the tunnel. n  Place absorbable whip sutures into the tails of the graft (see Fig. 47.8D), place them into the tip of a Beath pin, and pull them out laterally (Fig. 47.8E). n  Before fixation with a biocomposite screw, move the knee through a range of motion, once again making sure that the tendons do not become taut in flexion and that the tendon length is appropriate to allow one to two quadrants of passive glide at 30 degrees of flexion so as not to overconstrain the patella. n  With the knee held in 60 degrees of flexion, maintain this graft length while it is secured with a biocomposite screw equal to the tunnel size chosen. Again, move the knee through a range of motion to make sure motion is not inhibited. n 

Proximal Line 2 Line 3

Point 1

Point 2

Distal

FIGURE 47.9 Schöttle and colleagues’ radiographic landmark for femoral tunnel placement in medial patellofemoral ligament reconstruction. Two perpendicular lines to line 1 are drawn, intersecting the contact point of the medial condyle and posterior cortex (point 1, line 2) and intersecting the most posterior point of the Blumensaat line (point 2, line 3). For determination of vertical position, distance between line 2 and the lead ball center is measured as is the distance between line 2 and line 3. SEE TECHNIQUE 47.1.

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n 

If tracking is acceptable and the transferred tubercle fits flush with the underlying tibia, fix it with one or two AO 4-mm cancellous lag screws. Use a 2.7-mm bit to drill through the tubercle and tibia. Angle the drill toward the joint and advance it until the posterior cortex is felt. Angling the drill proximally allows fixation to be placed in cancellous bone near the proximal tibia. Bicortical fixation is not used, and the screw should be long enough (usually 40-50 mm) to come near, but not penetrate, the posterior cortex.

n 

POSTOPERATIVE CARE The knee joint is immobilized in extension with a simple knee brace for 3 days after surgery. Range-of-motion exercises and gait with weight bearing on two crutches are started and gradually progressed. Weight bearing is allowed as tolerated immediately after surgery. Walking with full weight bearing is usually possible 2 or 3 weeks after surgery. Achieving at least 90 degrees knee flexion by the end of postoperative week 3 is encouraged. Jogging is allowed after 3 months, and participation in the original sporting activity is allowed 4 to 6 months after surgery, depending on the patient’s rehabilitation progress.    

POSTOPERATIVE CARE Weight bearing is allowed to tolerance using a straight-leg splint for ambulation for the first 6 weeks after surgery. At 1 week after surgery, closed chain kinetic strengthening is begun, with a goal of achieving 70% strength by 6 weeks. A functional progression program that allows the patient to return to unrestricted sports is begun 12 weeks after surgery. Most athletes can return to sport at 6 to 9 months.    

   

DISTAL REALIGNMENT Indications for distal realignment include patellar instability secondary to malalignment indicated by a Q angle of more than 20 degrees and anterior TT-TG distance of more than 20 mm. When trochlear dysplasia is present, less malalignment is tolerated, and a TT-TG distance of as little as 15 mm may require realignment procedures. If chondral damage is present distal and lateral on the patella, an oblique osteotomy helps unload these areas and transfer weight bearing proximal and medial. Bony distal realignment procedures are contraindicated in skeletally immature patients. We recommend the Trillat procedure for dislocations due to malalignment with an Insall index of less than 1:3 and grade 2 or less chondromalacia noted at arthroscopy. We have found the modification described by Shelbourne, Porter, and Rozzi to be an effective technique.



TECHNIQUE 47.2 (MODIFIED BY SHELBOURNE, PORTER, AND ROZZI)

Make a 6-cm lateral parapatellar incision approximately 1 cm lateral to the patellar tendon. n  Perform a lateral release from the tibial tubercle to the level of the insertion of the vastus lateralis tendon on the proximal patella. The release is considered adequate when the patellar articular surface can be everted 90 degrees laterally. n  Approach the tibial tubercle through the same parapatellar incision, and identify the patellar tendon insertion. Using a 2.5-cm flat osteotome, raise a flat, 6-cm long, 7-mm thick osteoperiosteal flap, tapering anteriorly and hinged distally with periosteum. Do not violate the soft tissues. n  Rotate the bone flap medially, cracking the cortex distally, and hold it in place with a Kirschner wire while the knee is moved through a full passive range of motion to evaluate patellar tracking. n 

OBLIQUE OSTEOTOMY OF THE TUBEROSITY We generally prefer a slightly oblique osteotomy of the tuberosity, such as that described by Fulkerson and by Brown et al. that transfers the tuberosity anteriorly and medially. This procedure is indicated when grade 3 or 4 chondromalacia is associated with recurrent dislocations. A guide can be used to cut a flat osteotomy surface that angled from anteromedial just deep to the anterior crest of the tibia in a posterolateral direction. Increased obliquity of the cut increases anterior translation; however, the more superficial cut avoids a stress riser effect and reduces the risk of later fracture through the osteotomy. It is important to taper the osteotomy distally to prevent a stress riser. Although this technique has been reported to produce 86% good to excellent results, complications have included stress risers and stress fractures through the area months after clinical and radiographic healing are present. Mechanical testing showed that a flat (Elmslie-Trillat) osteotomy had significantly higher mean load-to-failure and total energy-to-failure rates than the oblique osteotomy technique. In general, this procedure is not indicated for athletes and should be reserved for patients with patellofemoral degenerative changes. For recurrent patellar dislocation and significant patella alta with an Insall index of more than 1.3, medial and distal transfer of the tuberosity occasionally is indicated. Preoperative radiographs are used to determine the amount of distal transfer necessary and to ensure the inferior pole of the patella is not placed distal to the Blumensaat line, creating patella baja. The tuberosity is detached distally, and 5 to 10 mm of bone is resected from the distal tip of the tuberosity to allow distal transfer before secure fixation. Because loss of flexion or loss of fixation may occur, distalization is not routinely done.     

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CHAPTER 47  RECURRENT DISLOCATIONS  

POSTOPERATIVE CARE Weight bearing is allowed as

FULKERSON OSTEOTOMY

tolerated after surgery. Immobilization is continued 4 to 6 weeks, at which time range-of-motion and strengthening exercises are instituted. Return to sports usually is allowed at 6 to 9 months after surgery. In our opinion, there is some long-term risk for fracture after this procedure if an osteotomy of more than 30 degrees is done.    

TECHNIQUE 47.3

Make a 9-cm lateral parapatellar incision extending from the inferior pole of the patella distally. Exposure is similar to the Elmslie-Trillat procedure, with the difference being in the oblique osteotomy of the tuberosity. n  Extend the cut distally about 6 cm with the medial tip of the cut being more superficial. n  Drill holes to perforate the cortex distally so that the fragment can be hinged. n  Using an osteotome, complete the osteotomy deep and just proximal to the insertion of the patellar tendon and pry the tuberosity medially so that the Q angle is corrected to between 10 and 15 degrees. This usually requires moving the tuberosity anteriorly 8 to 10 mm. Obliquity of the osteotomy determines the amount of anterior displacement. A 30-degree osteotomy produces 1 mm of anteriorization for each 2 mm of medialization, whereas a 45-degree cut produces a 1 mm to 1 mm translation. n  Secure the transferred tuberosity by placing a drill bit proximally through the tuberosity and tibia with the knee in 90 degrees of flexion to decrease risk to neurovascular structures. n  Move the knee through a range of motion, and evaluate patellar tracking. n  If tracking is satisfactory, secure the tuberosity with two countersunk, low-profile, cancellous screws (Fig. 47.10) or bicortical screws. n  Close the medial retinaculum in a pants-over-vest fashion, plicating the medial side. Do not close the lateral retinaculum. n 

A

For severe rotational deformities, a distal femoral rotational osteotomy or proximal tibial osteotomy rarely may be indicated. Epiphysiodesis can be done for severe coronal malalignment deformities in immature patients. Most recurrent instability problems in skeletally immature patients are treated with MQTFL procedures, with the femoral fixation looped around the adductor tendon insertion or in a carefully placed tunnel distal to the physis.  

TROCHLEOPLASTY Sulcus-deepening trochleoplasty is a technically demanding procedure with precise indications: high-grade trochlear dysplasia with patellar instability and/or abnormal tracking. The primary goal is to improve patellar tracking by decreasing the prominence of the trochlea and creating a new groove with normal depth. Associated abnormalities should be evaluated and corrected (Box 47.1).



TECHNIQUE 47.4 After administration of regional anesthesia, supplemented with patient sedation, position the patient supine and prepare and drape the extremity.

n 

B

C

FIGURE 47.10 Fulkerson procedure. A, Preoperative lateral radiograph. B, Postoperative lateral radiograph. C, Anteroposterior radiograph. SEE TECHNIQUE 47.3.

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PART XIII  SPORTS MEDICINE With the knee flexed to 90 degrees, make a straight midline skin incision from the superior patellar margin to the tibiofemoral articulation. n  Move the knee into extension and develop a medial fullthickness skin flap. n  Make a modified midvastus approach with sharp dissection of the medial retinaculum starting over the 1 to 2 n 

BOX 47.1



Associated Abnormalities That May Require Correction in Addition to Trochleoplasty Tibial tubercle-trochlear groove (TT-TG) >20 mm: tibial tuberosity medializing osteotomy to obtain TT-TG distance between 10 and 15 mm. n Patella alta (Canton-Deschamps index >1.2): distalization osteotomy to obtain normal patellar index of 1.0. n Lateral patellar tilt >20 degrees: VMO plasty or reconstruction of the MPFL with a double-looped gracilis tendon graft. n 

MPFL, Medial patellofemoral ligament; VMO, vastus medialis obliquus.

cm medial border of the patella and blunt dissection of the vastus medialis oblique (VMO) fibers starting distally at the patellar superomedial pole and extending approximately 4 cm into the muscle belly. n  Evert the patella for inspection and treatment of chondral injuries if needed, and then retract it laterally. n  Expose the trochlea by incising the peritrochlear synovium and periosteum along their osteochondral junction and reflecting them from the field with a periosteal elevator. The anterior femoral cortex should be visible to orientate the amount of deepening. Changing the degree of flexion/extension allows a better view of the complete operative field and avoids extending the incision. n  Once the trochlea is fully exposed, draw the new trochlear limits with a sterile pen. Use the intercondylar notch as a starting point to draw the new trochlear groove. From there, draw a straight line directed proximally and 3 to 6 degrees laterally; the superior limit is the osteochondral edge. Draw two divergent lines, starting at the notch and passing proximally through the condyle-trochlear grooves, representing lateral and medial facet limits; these lines should not enter the tibiofemoral joint (Fig. 47.11A). n  To access the undersurface of the femoral trochlea, remove a thin strip of cortical bone from the osteochondral

A

C

B

D FIGURE 47.11 DeJour sulcus-deepening trochleoplasty. A, Drawing of the new trochlear limits. B, Removal of subchondral bone under the trochlea to correct the prominence and reshape the groove. C, Shape of the trochlea before (above) and after (below) sulcus-deepening trochleoplasty. D, Fixation of new trochlea with two staples after restoration of trochlear sulcus and more “anatomic” shape. (From DeJour D, Saggin P: The sulcus deepening trochleoplasty—the Lyon’s procedure, Int Orthop 34:311–316, 2010.) SEE TECHNIQUE 47.4.

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CHAPTER 47  RECURRENT DISLOCATIONS edge. The width of the strip is similar to the prominence of the trochlea from the anterior femoral cortex (the bump). Gently tap with a sharp osteotome and then use a rongeur to remove the bone. n  To remove cancellous bone from the undersurface of the trochlea, use a drill with a depth guide set at 5 mm to ensure uniform thickness of the osteochondral flap and maintain an adequate amount of bone attached to the cartilage (Fig. 47.11B). The guide also avoids injuring the cartilage or getting too close to it and causing thermal injury. The shell produced must be sufficiently compliant to allow modeling without being fractured. n  Extend cancellous bone removal up to the notch; remove more bone from the central portion where the new trochlear groove will lie (Fig. 47.11C). n  Use light pressure to mold the flap to the underlying cancellous bone bed in the distal femur. If needed, cut the bottom of the groove and the external margin of the lateral facet to allow further modeling by gently tapping over a scalpel. n  If the correction obtained is satisfactory, fix the new trochlea with two staples, one in each side of the groove, with one arm in the cartilaginous upper part of each facet and the other arm in the anterior femoral cortex (Fig. 47.11D). n  Test patellar tracking. Suture the periosteum and synovial tissue to the osteochondral edge and anchor them in the staples.

POSTOPERATIVE CARE Immediate weight bearing is permitted, and no limitation is placed on range of motion. Continuous passive motion is indicated to model the trochlea and patella, and frequent knee movement is encouraged to help ensure cartilage nutrition and further molding of the trochlea by the tracking patella. Because trochleoplasty is rarely done as an isolated procedure, postoperative care must consider associated procedures. Radiographs, including anteroposterior and lateral views and an axial view in 30 degrees of flexion, are reviewed at 6 weeks. At 6 months, a CT scan is obtained to document correction.   

IATROGENIC MEDIAL PATELLAR INSTABILITY

Iatrogenic medial patellar instability is diagnosed when manual medial subluxation re-creates a patient’s symptoms. Treatment consists of repairing the vastus lateralis if previously released and revising a distal realignment to a more lateral position. If the initial procedure was proximal and inadequate tissues remain, repair or reconstruction using the lateral portion of the patellar tendon is done (Fig. 47.12). 

HIP With the evolution of hip arthroscopy and MR arthrography of the hip, the diagnosis and treatment of hip instability have greatly improved. The diagnosis is indicated by recurrent “giving way,” pain, or popping with hip extension and external rotation during activities, such as getting out of a car or kicking or pivoting maneuvers during sports. The physical examination should include evaluation for generalized ligamentous

Lateral one-quarter strip patellar tendon

A

B FIGURE 47.12 Reconstruction using patellar tendon. A, Lateral one-quarter strip of patellar tendon is developed. B, Strip is attached at lateral tibial tubercle by suture to periosteum or through bony tunnel.

laxity, as well as examination of the uninvolved hip for comparison. Tests that may indicate pathologic laxity include the dial test, passive external rotation of the more than 45 degrees, particularly if symptoms are reproduced. Other tests to reproduce symptoms of instability are the Ganz test, in which hip extension and external rotation produce anterior capsular pain. Finally, direct axial traction may produce apprehension. Moving the hip from flexion, abduction, and external rotation into extension, adduction, and internal rotation may re-create catching or popping associated with labral pathology. Plain anteroposterior and lateral radiographs are helpful in evaluating acetabular dysplasia and impingement. A center-edge (CE) angle of less than 20 degrees, a crossover sign, and a Sharp angle of more than 42 degrees also are indicative of dysplasia (see Chapter 6). MR arthrography is used to evaluate for labral tears or capsular redundancy that may be related to recurrent instability. Hip instability may be categorized as loss of bony acetabular containment, disruption of the capsulolabral complex, or a combination of the two. Recurrent trauma from stress at extremes of motion may result in capsulolabral deficiency and instability. Bony development problems can cause containment issues resulting in impingement or straight-forward instability. Finally, hyperlax joints from collagen deficiencies, Ehlers-Danlos and Marfan syndromes, and generalized joint laxity can result in symptomatic hip instability. Treatment of these conditions must be tailored to the pathology, as in any other joint. Many of these procedures are now done arthroscopically and are described in Chapter 51. 

STERNOCLAVICULAR JOINT Most recurrent dislocations of the sternoclavicular joint are anterior and require only conservative treatment; posterior dislocations, although uncommon, require reduction because

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PART XIII  SPORTS MEDICINE of the proximity and potential compromise of the subclavian vessels, esophagus, and trachea. A complete discussion of acute dislocations and their treatment is presented in Chapter 60. Recurrent atraumatic anterior subluxation of the sternoclavicular joint with shoulder abduction and extension usually occurs in young girls. Often it is associated with laxity of other joints and generally is a self-limiting condition. Most patients with recurrent anterior sternoclavicular joint dislocation should be treated with a generalized upper extremity strengthening program and avoidance of activities that produce stress on the sternoclavicular joint. Surgery is recommended only if severe symptoms limit activities of daily living. The surgical procedures, which include open repair of the sternoclavicular capsule, reconstruction of the sternoclavicular joint, and resection of the medial end of the clavicle and securing of the clavicle to the first rib, all are fraught with potentially severe complications, including injury to major vessels, persistent pain, unsightly scar formation, and recurrence of dislocation. A strong semitendinosus graft is recommended for reconstruction of the joint. A figure-of-eight configuration through drill holes in the manubrium and midclavicle produces a strong, stable configuration that was shown in mechanical testing to restore native joint stiffness better than resection arthroplasty (Fig. 47.13). The reconstruction should be reinforced with local tissue repair, in particular the important posterior capsular tissue. It is wise to have a thoracic surgeon available for the procedure because of the potential complications associated with the procedure. Because of the possibility of pin migration and potentially severe complications, pins or wires should not be placed across the joint. After reconstruction, the shoulder is immobilized in a sling for 6 weeks. On the second day, the patient is allowed to perform gentle pendulum exercises but is cautioned against active flexion or abduction of the shoulder above 90 degrees. Pushing, pulling, and lifting are avoided for 3 months. Strengthening exercises are started at 8 to 12 weeks. The patient is restricted from returning to strenuous manual labor for a minimum of 3 months. 

SHOULDER The shoulder, by virtue of its anatomy and biomechanics, is one of the most unstable and frequently dislocated joints in the body, accounting for nearly 50% of all dislocations, with a 2% incidence in the general population. Factors that influence the probability of recurrent dislocations are age, return to contact or collision sports, hyperlaxity, and the presence of a significant bony defect in the glenoid or humeral head. In a study of 101 acute dislocations, recurrence developed in 90% of the patients younger than 20 years old, in 60% of patients 20 to 40 years old, and in only 10% of patients older than 40 years old. Contact and collision sports increase the recurrence rate to near 100% in skeletally immature athletes. The duration of immobilization also does not seem to affect stability; a recent meta-analysis determined that there is no benefit for conventional sling immobilization longer than 1 week for primary anterior dislocation. Immobilization in external rotation is thought to decrease recurrence rates, but this has not been proven; meta-analyses found a recurrence risk of 36% with immobilization in internal rotation compared with 25% with external rotation bracing, but the numbers were small and the difference was not significant. Burkhart and DeBeer, Sugaya

A

B

C FIGURE 47.13 Semitendinosus figure-of-eight reconstruction. A, Drill holes passed anterior to posterior through medial part of clavicle and manubrium. B, Free semitendinosus tendon graft woven through drill holes so tendon strands are parallel to each other posterior to the joint and cross each other anterior to the joint. C, Tendon tied in square knot and secured with suture.

et al., and Itoi et al. have shown that glenoid bone loss of more than 20% results in bony instability and increased recurrence rates. This is because the “safe arc” that the glenoid provides for humeral rotation is diminished, resulting in instability when the deficient edge is loaded at extremes of motion (Fig. 47.14).

NORMAL FUNCTIONAL ANATOMY

An understanding of the normal functional anatomy of the shoulder is necessary to understand the factors influencing the stability of the joint. The bony anatomy of the shoulder joint does not provide inherent stability. The glenoid fossa is a flattened, dish-like structure. Only one fourth of the large humeral head articulates with the glenoid at any given time. This small, flat glenoid does not provide the inherent stability for the humeral head that the acetabulum does for the hip. The glenoid is deepened by 50% by the presence of the

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CHAPTER 47  RECURRENT DISLOCATIONS glenoid labrum. The labrum increases the humeral contact to 75%. Integral to the glenoid labrum is the insertion of the tendon of the long head of the biceps, which inserts on the superior aspect of the joint and blends to become indistinguishable from the posterior glenoid labrum. Matsen et  al. suggested that the labrum may serve as a “chock block” to

φ1

φ2

Normal glenoid

Bone-deficient glenoid

FIGURE 47.14 Glenoid bone loss shortens “safe arc” through which glenoid can resist axial forces. Φ2 (bone-deficient condition) is less than Φ1.

prevent excessive humeral head rollback. The shoulder joint capsule is lax and thin and, by itself, offers little resistance or stability. Anteriorly, the capsule is reinforced by three capsular thickenings or ligaments that are intimately fused with the labral attachment to the glenoid rim. The superior glenohumeral ligament attaches to the glenoid rim near the apex of the labrum conjoined with the long head of the biceps (Fig. 47.15). On the humerus, it is attached to the anterior aspect of the anatomic neck of the humerus (Fig. 47.16). The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction and is the primary stabilizer to anterior and posterior stress at 0 degrees of abduction. Tightening of the rotator interval (which includes the superior glenohumeral ligament) decreases posterior and inferior translation; external rotation also may be decreased. The middle glenohumeral ligament has a wide attachment extending from the superior glenohumeral ligament along the anterior margin of the glenoid down as far as the junction of the middle and inferior thirds of the glenoid rim. On the humerus, it also is attached to the anterior aspect of the anatomic neck. The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction. The inferior glenohumeral ligament attaches to the glenoid margin from the 2- to 3-o’clock positions anteriorly to the 8- to 9-o’clock positions posteriorly. The humeral attachment is below the level of the horizontally oriented physis into the inferior aspect of the anatomic and surgical neck of the humerus. The anterosuperior edge of this ligament usually is quite thickened. There is a less distinct posterior thickening, a hammock-type model consisting of thickened anterior and posterior bands and a thinner axillary pouch. With external rotation, the hammock

Long head of biceps Coracoacromial ligament

Acromion process

Coracohumeral ligament

Supraspinatus

Coracoid process Superior glenohumeral ligament

Infraspinatus

Middle glenohumeral ligament Posterior band of glenohumeral ligament

Subscapularis

Anterior band of the inferior glenohumeral ligament

Teres minor

Long head of the triceps

FIGURE 47.15

Glenoid and surrounding capsule, ligaments, and tendons.

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PART XIII  SPORTS MEDICINE Superior glenohumeral ligament Greater tuberosity

Middle glenohumeral ligament

Lesser tuberosity Insertion of subscapularis Intertubercular groove

Superior band of inferior glenohumeral ligament

A

Articular margin

Axillary pouch

B

FIGURE 47.16 Upper part of left humerus showing attachments of glenohumeral ligaments on anterior (A) and medial (B) aspects of surgical and anatomic neck.

slides anteriorly and superiorly. The anterior band tightens, and the posterior band fans out. With internal rotation, the opposite occurs. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more. The ligament provides a restraint at the extremes of motion and assists in the rollback of the humeral head in the glenoid. The muscles around the shoulder also contribute significantly to its stability. The action of the deltoid (the principal extrinsic muscle) produces primarily vertical shear forces, tending to displace the humeral head superiorly. The intrinsic muscle forces from the rotator cuff provide compressive or stabilizing forces. Concavity compression is produced by dynamic rotator cuff muscular stabilization of the humeral head when the concavity of the glenoid and labral complex is intact. Loss of the labrum can reduce this stabilizing effect by 20%. In the concavity of the glenoid-labral complex, synchronous eccentric deceleration, and concentric contraction of the rotator cuff and biceps tendon are necessary for humeral stability during midranges of humeral motion. Asynchronous fatigue of the rotator cuff from overuse or incompetent ligamentous support can result in further damage to the static and dynamic supports. MRI studies have shown fatty infiltration and thinning of the subscapularis tendon in recurrent anterior instability. Several authors have noted the importance of synchronous mobility of the scapula and glenoid to shoulder stability and emphasized the importance of this dynamic balance to appropriate positioning of the glenoid articular surface so that the joint reaction force produced is a compressive rather than a shear force. With normal synchronous function of the scapular stabilizers, the scapula and the glenoid articular structures are maintained in the most stable functional position. Strengthening rehabilitation of the scapular stabilizers (serratus anterior, trapezius, latissimus dorsi, rhomboids, and levator scapulae) is especially important in patients who participate in upper extremity-dominant sports. Although the glenoid is small, it has the mobility to remain in the most stable position in relation to the humeral head with movement. Rowe compared this with a seal balancing a ball on its nose. The glenoid also has the ability to “recoil” when a sudden force is applied to the shoulder joint, such as in a fall on the outstretched hand. This ability to “recoil” lessens the impact on the shoulder as the scapula slides along the chest wall.

Scapular dyskinesis is an alteration of the normal position or motion of the scapula during coupled scapulohumeral movements and can occur after overuse of and repeated injuries to the shoulder joint. A particular overuse muscle fatigue syndrome has been designated the SICK scapula: scapular malposition, inferior medial border prominence, coracoid pain and malposition, and dyskinesis of scapular movement. The demonstration of Ruffini end organs and Pacinian corpuscles in the shoulder capsule helps solidify the concept of proprioceptive neuromuscular training as an important part of shoulder stabilization. Another force that has a lesser effect on glenohumeral stability is glenoid version. Glenoid version probably is not a significant contributor to instability except in a severely deformed shoulder. Cohesion produced by joint fluid and the vacuum effect produced by negative intraarticular pressure in normal shoulders play lesser roles in joint stability. 

PATHOLOGIC ANATOMY

No essential pathologic lesion is responsible for every recurrent subluxation or dislocation of the shoulder. In 1906, Perthes considered detachment of the labrum from the anterior rim of the glenoid cavity to be the “essential” lesion in recurrent dislocations and described an operation to correct it. In 1938, Bankart published his classic paper in which he recognized two types of acute dislocations. In the first type, the humeral head is forced through the capsule where it is the weakest, generally anteriorly and inferiorly in the interval between the lower border of the subscapularis and the long head of the triceps muscle. In the second type, the humeral head is forced anteriorly out of the glenoid cavity and tears not only the fibrocartilaginous labrum from almost the entire anterior half of the rim of the glenoid cavity but also the capsule and periosteum from the anterior surface of the neck of the scapula. This traumatic detachment of the glenoid labrum has been called the Bankart lesion. Most authors agree that the Bankart lesion is the most commonly observed pathologic lesion in recurrent subluxation or dislocation of the shoulder, but it is not the “essential” lesion. Excessive laxity of the shoulder capsule also causes instability of the shoulder joint. Excessive laxity can be caused by a congenital collagen deficiency, shown by hyperlaxity of other joints, or by plastic deformation of the capsuloligamentous complex from a single macrotraumatic event or repetitive

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CHAPTER 47  RECURRENT DISLOCATIONS microtraumatic events. Hyperlaxity has been implicated as a cause of failure in surgical correction of chronic shoulder instability. An arthroscopic study of anterior shoulder dislocations found that 38% of the acute injuries were intrasubstance ligamentous failures, and 62% were disruptions of the capsuloligamentous insertion into the glenoid neck. The “circle concept” of structural damage to the capsular structures was suggested by cadaver studies that showed that humeral dislocation does not occur unless the posterior capsular structures are disrupted, in addition to the anterior capsular structures. Posterior capsulolabral changes associated with recurrent anterior instability often are identified by arthroscopy. A humeral head impaction fracture can be produced as the shoulder is dislocated, and the humeral head is impacted against the rim of the glenoid at the time of dislocation. This Hill-Sachs lesion is a defect in the posterolateral aspect of the humeral head. Instability results when the defect engages the glenoid rim in the functional arc of motion at 90 degrees abduction and external rotation. In a cadaver model, humeral head defects of 35% to 40% were shown to decrease stability, whereas glenoid defects of as little as 13% were found to decrease stability. Glenoid rim fractures or attrition also can occur with an anterior or posterior dislocation. If these lesions involve more than 20% to 25% of the glenoid, they can result in recurrent instability despite having an excellent soft-tissue repair. These lesions are difficult to see on plain radiographs; if a defect is visible in an acute dislocation or one is evaluating recurrent instability, (3D) CT is the best method for evaluating the extent of the defect (Fig. 47.17). It seems that no single “essential” lesion is responsible for all recurrent dislocations of the shoulder. Stability of this inherently unstable joint depends on a continuing balance between the static and dynamic mechanisms influencing motion and stability. In addition to the various possible primary deficiencies influencing instability, secondary deficiencies can be caused by repeated dislocations. Erosion of the anterior glenoid rim, stretching of the anterior capsule and subscapularis tendon, and fraying and degeneration of the glenoid labrum all can occur with repeated dislocation. The primary deficiency and the secondary deficiencies need to be considered at the time of surgery and in postoperative rehabilitation to correct the instability. Because no single deficiency is responsible for all recurrent dislocations of the shoulder, no single operative procedure can be applied to every patient. The surgeon must search carefully for and identify the deficiencies present to choose the proper procedure. 

CLASSIFICATION

Successful treatment of shoulder instability is based on a thorough understanding of the various posttraumatic lesions that can be associated with a deficient capsulolabral complex and on correct classification of the patient’s primary and secondary lesions. Classification and treatment of shoulder instability are based on the direction, degree, and duration of symptoms; the trauma that resulted in instability; and the patient’s age, mental set, and associated conditions, such as seizures, neuromuscular disorders, collagen deficiencies, and congenital disorders. The direction of instability should be categorized as unidirectional, bidirectional, or multidirectional. Anterior dislocations account for 90% to 95% of recurrent dislocations, and posterior dislocations account for approximately 5% to 10%.

A

B FIGURE 47.17 A, Three-dimensional CT showing large Hill-Sachs lesion and deficient glenoid. B, Three-dimensional CT with humeral head subtracted showing loss of anterior glenoid surface.

Despite increased understanding of shoulder instability, 50% of posterior shoulder dislocations can be missed unless an adequate examination and appropriate radiographs are done. Inferior and superior dislocations are rare. Superior instability generally arises secondary to severe rotator cuff insufficiency. Instability is categorized as subluxation with partial separation of the humeral head from the glenoid or dislocation with complete separation of the humeral head from the glenoid concavity. The duration of the symptoms should be recorded as acute, subacute, chronic, or recurrent. The dislocation is classified as chronic if the humeral head has remained dislocated longer than 6 weeks. The type of trauma associated with the dislocation is important in determining whether conservative or operative treatment is appropriate. Instability should be categorized as macrotraumatic, in which a single traumatic event results in dislocation, or microtraumatic (acquired), in which repetitive trauma at the extremes of motion results in plastic deformation of the capsulolabral complex. Secondary trauma to the rotator cuff and biceps tendon may cause asynchronous rotator cuff function. These injuries most commonly occur in pitchers, batters, gymnasts, weightlifters, tennis players and others who play racquet sports, and swimmers, especially with the backstroke or butterfly stroke. The flexibility that allows an athlete to compete at a high level may be attributed to a generalized ligamentous laxity, which also predisposes the athlete to injury. Trauma may cause decompensation of

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PART XIII  SPORTS MEDICINE a previously stable capsuloligamentous complex. A thorough history of the initial traumatic event, symptoms, and family history and a thorough examination of the injured shoulder, contralateral shoulder, and other joints are necessary. Age also is important in predicting pathologic lesions and outcomes, with recurrence rates of more than 90% reported in patients younger than 20 years old compared with a recurrence rate of about 10% to 20% in patients older than 40 years old. In most studies, the recurrence rate for adolescents treated with surgical stabilization was higher than that for patients in other age groups. These differences can be explained by the greater elasticity in adolescent ligaments that results in greater plastic deformation before failure of the system. This deformation must be considered in surgical treatment approaches. Although recurrence of the dislocation is uncommon in patients 40 years old or older, associated rotator cuff tears are present in 30%, and such tears are present in more than 80% of patients older than 60 years. Fractures of the greater tuberosity also are more prevalent in patients older than 40 years old; some series report an incidence of 42%. In this age group, surgical treatment of rotator cuff tears or fractures of the greater tuberosity generally takes precedence over treatment of the capsular injury. The mental set of the patient must be evaluated before treatment is started. Some patients with posterior instability learn to dislocate their shoulder through selective muscular contractions. Although voluntary dislocation does not indicate pathologic overlay, some of these patients have learned to use voluntary dislocation for secondary gain, and in these patients surgical treatment is doomed to failure. In patients with primary neuromuscular disorders or syndromes and recurrent dislocation, conservative, nonoperative treatment should be the initial approach. If instability remains after appropriate medical treatment, surgery may be necessary in conjunction with continued nonoperative treatment. Patients with primary collagen disorders, EhlersDanlos syndrome, or Marfan syndrome should be treated with extensive supervised conservative treatment. If surgical intervention becomes necessary, the possibility of the abnormal tissue stretching out and allowing dislocation to recur should be stressed to the patient and family. When severe dysplastic or traumatic glenohumeral deformity is present, capsular and bony procedures may be necessary. Reformatted 3D CT images are beneficial in determining the need for osteotomy or bone grafting procedures in these patients. Matsen’s simplified classification system is useful for categorizing instability patterns: TUBS (traumatic, unidirectional Bankart surgery) and AMBRII (atraumatic, multidirectional, bilateral, rehabilitation, inferior capsular shift, and internal closure). Microtraumatic or developmental lesions fall between the extremes of macrotraumatic and atraumatic lesions and can overlap these extreme lesions (Fig. 47.18). Classification of 168 shoulders according to four systems used for describing shoulder instability revealed variations in

Macrotraumatic

FIGURE 47.18

Microtraumatic

Atraumatic

Matsen’s classification system.

the criteria that resulted in marked variations in the number of patients diagnosed with multidirectional instability. 

HISTORY

The history is important in recurrent instability of the shoulder joint. The amount of initial trauma, if any, should be determined. High-energy traumatic collision sports and motor vehicle accidents are associated with an increased risk of glenoid or humeral bone defects. Recurrence with minimal trauma in the midrange of motion often is associated with bony lesions, which must be treated. The position in which the dislocation or subluxation occurs should be elicited. In complete dislocations, the ease with which the shoulder is relocated is determined. Dislocations that occur during sleep or with the arm in an overhead position often are associated with a significant glenoid defect that requires surgical treatment. Dislocations that are reduced by the patient often are subluxations or dislocations associated with generalized ligamentous laxity. The signs and symptoms of any nerve injury should be elicited. Most important, the physical limitations caused by this instability should be documented. Recurrent subluxation of the shoulder is commonly overlooked by physicians because the symptoms are vague and there is no history of actual dislocation. The patient may complain of a sensation of the shoulder sliding in and out of place, or he or she may not be aware of any shoulder instability. The patient may complain of having a “dead arm” as a result of stretching of the axillary nerve or of secondary rotator cuff symptoms. It is important to differentiate primary from secondary rotator cuff impingement. Rotator cuff symptoms develop secondary to ligamentous dysfunction. Internal impingement of the undersurface of the posterior rotator cuff against the posterior glenoid and labrum is caused by anterior humeral subluxation with the shoulder externally rotated. This secondary impingement is more common than primary impingement in patients younger than 35 years old who are involved in upper extremity–dominant sports. Posterior shoulder instability may present as posterior pain or fatigue with repeated activity (e.g., blocking in football, swimming, bench press, rowing, and sports requiring overhead arm movement). 

PHYSICAL EXAMINATION

The physical examination of a patient with instability begins by asking the patient which arm position creates the instability, what direction the shoulder subluxes, and if he or she can safely demonstrate the subluxation. Both shoulders should be thoroughly examined, with the normal shoulder used as a reference. The examination includes evaluation of the shoulders for atrophy or asymmetry, followed by palpation to determine the amount of tenderness present in the anterior or posterior capsule, the rotator cuff, and the acromioclavicular joint. Active and passive ranges of motion are evaluated with the patient upright and supine to record accurately the motion in all planes. The strengths of the deltoid, rotator cuff, and scapular stabilizers are evaluated, recorded, and graded from 0 to 5, with 5 being normal. Scapular winging or dysfunction should be noted during active range of motion and during strength examination. Winging may indicate scapular weakness and can be evaluated by having the patient do a press-up from the examination table or an incline type of push-up off the wall. Stability is evaluated with the patient upright. A “shiftand-load” test is done by placing one hand along the edge of

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CHAPTER 47  RECURRENT DISLOCATIONS the scapula to stabilize it and grasping the humeral head with the other hand and applying a slight compressive force. The amount of anterior and posterior translation of the humeral head in the glenoid is observed with the arm abducted 0 degrees. Easy subluxation of the shoulder indicates loss of the glenoid concavity, which must be surgically treated. The sulcus test is done with the arm in 0 degrees and 45 degrees of abduction. This test is done by pulling distally on the extremity and observing for a sulcus or dimple between the humeral head and the acromion that does not reduce with 45 degrees of external rotation. The distance between the humeral head and acromion should be graded from 0 to 3 with the arm in 0 degrees and 45 degrees of abduction, with 1+ indicating subluxation of less than 1 cm, 2+ indicating 1 to 2 cm of subluxation, and 3+ indicating more than 2 cm of inferior subluxation that does not reduce with external rotation. Subluxation at 0 degrees of abduction is more indicative of laxity at the rotator interval, and subluxation at 45 degrees indicates laxity of the inferior glenohumeral ligament complex. Anterior apprehension is evaluated with the shoulder in 90 degrees of abduction and the elbow in 90 degrees of flexion, with a slight external rotation force applied to the extremity as anterior stress is applied to the humerus. This generally produces an apprehension reaction in a patient who has anterior instability. Control of the proximal humerus should be maintained during any of the apprehension or stress tests to prevent dislocation during these procedures. Posterior instability can be evaluated with a Kim test or a posterior clunk test, in which the 90-degree abducted extremity is brought to a forward flexed, internally rotated position while posterior stress is applied to the elbow. The clunk is felt as the humeral head subluxes posteriorly, producing pain or a feeling of subluxation in an unstable shoulder. The shoulder anterior drawer test should be performed with the patient supine and the extremity in various degrees of abduction and external rotation in the plane of the scapula. When examining the patient’s right shoulder, the examiner’s left hand is used to grasp the proximal humerus while the right hand is used to hold the elbow lightly. Anterior stress is applied to the proximal humerus using the left hand, and the amount of translation and the end point are evaluated. In performing this and other anterior or posterior instability tests, the amount of instability is graded from 0 to 3. Grade 1 means that the humeral head slips up to the rim of the glenoid, and grade 2 means that it slips over the labrum but then spontaneously relocates. Grade 3 indicates dislocation. A grade 3 instability should not be exhibited in an awake patient. Anterior stress is applied with the shoulder in various degrees of abduction and external rotation, and posterior stress is applied to evaluate for posterior instability with the arm in 90 degrees of abduction and various degrees of flexion. When examining the patient’s right shoulder, posterior stress is applied with the examiner’s right hand, starting at 0 degrees of forward flexion and internal rotation and proceeding to 110 degrees. The examiner’s left hand stabilizes the scapula and palpates the posterior part of the glenohumeral joint with the palm. It also can be used as a buttress to ensure that posterior dislocation does not occur during this procedure. Apprehension is evaluated with anterior and posterior stress during these procedures. The Jobe relocation test can be used for evaluating instability in athletes involved in sports requiring overhead motion (Fig. 47.19). This test is done with the patient supine and the

FIGURE 47.19 Jobe’s relocation test (see text). A positive relocation test and a positive apprehension test are highly predictive of recurrent instability.

shoulder in 90 degrees of abduction and external rotation. Various degrees of abduction are evaluated while anterior stress is applied by the examiner’s hand to the posterior part of the humerus. If this produces pain or apprehension, posteriorly directed force is applied to the humerus to relocate the humeral head in the glenohumeral joint while the shoulder is placed in abduction and external rotation. The posteriorly directed stress used to relocate the humerus is released. A feeling of apprehension or subluxation on the part of the patient indicates anterior instability. Bony deformity of the glenoid or humerus is indicated by apprehension or instability at low ranges of motion (25% Erosional bone loss >40%

Laterjet procedure Eden-Hybinette procedure

BONE LOSS—HUMERAL HEAD 20% + glenoid defect 25% (6 mm deep) 40%

Jobe capsular reconstruction + capsular shift + remplissage Remplissage Laterjet to increase glenoid rotational arc

BONE LOSS—ANTERIOR HUMERAL HEAD >30% Capsular deficiency

McLaughlin Achilles allograft capsular reinforcement

HAGL, Humeral avulsion glenohumeral ligament.

A

B

FIGURE 47.26 Division of subscapularis tendon. A, Lower fourth of subscapularis tendon is left intact to protect anterior humeral circumflex artery and axillary nerve. B, Subscapularis muscle is split horizontally and retracted superiorly and inferiorly to expose underlying capsule.

scapular neck, (2) restoring glenoid concavity, (3) securing anatomic capsular fixation at the edge of the glenoid articular surface, (4) re-creating physiologic capsular tension by superior and inferior capsular advancement and imbrication, and (5) performing supervised goal-oriented rehabilitation.    

MODIFIED BANKART REPAIR

TECHNIQUE 47.5 (MONTGOMERY AND JOBE)

Make an incision along the Langer lines, beginning 2 cm distal and lateral to the coracoid process and going inferiorly to the anterior axillary crease. n  Develop the deltopectoral interval, retracting the deltoid and cephalic vein laterally and the pectoralis major muscle medially. Leave the conjoined tendon intact, and retract it medially. n  Split the subscapularis tendon transversely in line with its fibers at the junction of the upper two thirds and lower one third of the tendon, and carefully dissect it from the underlying anterior capsule. Maintain the subscapularis tendon interval with a modified Gelpi retractor (Anspach, Inc., Lake Park, FL), and place a three-pronged retractor medially on the glenoid neck. n  Make a horizontal anterior capsulotomy in line with the split in the subscapularis tendon from the humeral insertion laterally to the anterior glenoid neck medially (Fig. 47.27A). Place stay sutures in the superior and inferior capsular flaps at the glenoid margin. n  Insert a narrow humeral head retractor, and retract the head laterally. Elevate the capsule on the anterior neck subperiosteally. Leave the labrum intact if it is still attached. Decorticate the anterior neck to bleeding bone with a rongeur. n  Drill holes near the glenoid rim at approximately the 3-, 4-, and 5:30-o’clock positions, keeping the drill bit parallel to the glenoid surface (Fig. 47.27B). n  Place suture anchors in each hole and check for security of the anchors (Fig. 47.27C). During this portion of the procedure, maintain the shoulder in approximately 90 degrees of abduction and 60 degrees of external rotation for throwing athletes. Maintain the shoulder in 60 degrees abduction and 30 to 45 degrees external rotation in nonthrowing athletes and other patients. n  Tie the inferior flap down in mattress fashion, shifting the capsule superiorly but not medially (Fig. 47.27D). The stay sutures help prevent medialization of the capsule. Shift the superior flap interiorly, overlapping and reinforcing the inferior flap (Fig. 47.27E). n  Loosely close the remaining gap in the capsule (Fig. 47.27F). The reconstruction has two layers of reinforced capsule outside the joint. n 

POSTOPERATIVE CARE Postoperative rehabilitation is carried out as described in Box 47.2.   

Humeral avulsion of the glenohumeral ligament should always be evaluated with MRI or, better, an MRA. Anterior lesions are best treated open with a lower-third scapularis split and suture anchors placed in the anatomic footprint on the humerus. These lesions can be bipolar, involving detachment from the humerus and the glenoid, and should be carefully examined to produce a stable repair. 

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A

B

C

D

E

F FIGURE 47.27 Montgomery and Jobe technique. A, Capsular incision made at center (3-o’clock position) of glenoid. Incision is extended medially over neck of glenoid. Stay suture is placed in capsule to mark glenoid attachment site. B, Suture anchor drill holes are started in scapular neck adjacent to glenoid articular surface and directed medially away from joint surface. For exposure of neck, sharp Hohmann retractor is placed along superior and inferior neck for capsular retraction (not pictured). C, Suture anchors are placed in each prepared drill hole. Sutures are pulled to set anchor. Each individual suture is pulled to ensure suture slides in anchor. D, Approximation of capsule to freshened neck. Two or three suture anchors are used to secure inferior capsule firmly to scapular neck. An Allis clamp is used by assistant to advance capsule superiorly against neck while sutures are placed. E, Superior and middle suture anchors are used to secure and advance superior flap in inferior direction. F, Final imbrication of capsule is done with interrupted nonabsorbable sutures. Extremity is maintained in 45 degrees abduction and 45 degrees external rotation during closure to prevent overconstraint. Technical note: Suture anchors should be at edge of glenoid articular surface and aimed medially 20 degrees. SEE TECHNIQUE 47.5.

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BOX 47.2



Rehabilitation Program After Anterior Capsulolabral Reconstruction Postoperative Period (0-3 Weeks) Abduction pillow Passive/active ROM: abduction (90 degrees), flexion (90 degrees), and external rotation (45 degrees); no extension Isometric abduction, horizontal adduction, and external rotation Elbow ROM Ball squeeze Ice  Phase I (3-6 Weeks) Discontinue brace/pillow Modalities as needed Progressive passive and active ROM, protecting anterior capsule Active internal rotation (full) and external rotation (neutral) using tubing and free weights Prone extension (not posterior to trunk) Shoulder shrugs and active abduction Supraspinatus strengthening Ice  Phase II (6 Weeks to 3 Months) Continue ROM, gradually increasing external rotation (goal is full ROM by 2 months) Continue strengthening exercises, with emphasis on rotator cuff and parascapular muscles Add shoulder flexion and horizontal adduction exercises Joint mobilization Begin upper body ergometer for endurance at low resistance Ice  Phase III (3-6 Months) Continue capsular stretching and strengthening and ergometer May include isokinetic strengthening and endurance exercises for internal and external rotation Add push-ups (begin with wall push-up with body always posterior to elbows) Start chin-ups at 4-5 months Total body conditioning Advance to throwing program or skill-specific training as tolerated Ice ROM, Range of motion. From Montgomery WH, Jobe FW: Functional outcomes in athletes after modified anterior capsulolabral reconstruction, Am J Sports Med 22:352–358, 1994.



TECHNIQUE 47.6 (WALCH AND BOILEAU)

With the patient secured in a beach-chair position and after induction of general endotracheal anesthesia, place a small pillow behind the scapula to position the glenoid surface perpendicular to the operative table. Sterilize and drape free the neck, chest, axilla, and entire arm. n  Make a 4 to 7-cm skin incision beginning under the tip of the coracoid process (Fig. 47.29A). Open the deltopectoral interval and retract the cephalic vein laterally with the deltoid. Place a self-retaining retractor into the deltopectoral interval and a Hohmann retractor on the top of the coracoid process. n 

HARVESTING AND PREPARATION OF THE BONE BLOCK  Position the patient’s arm in 90 degrees of abduction and external rotation, and section the coracoacromial ligament 1 cm from the coracoid. n  Adduct and internally rotate the arm to release the pectoralis minor insertion from the coracoid, and expose the base of the coracoid with a periosteal elevator to allow observation of the “knee” of the coracoid process. Use an osteotome or small angulated saw to osteotomize the coracoid process from medial to lateral at the junction of the horizontal-vertical parts (Fig. 47.29B). n  Bring the arm back into abduction and external rotation and release the coracohumeral ligament from the lateral part of the coracoid. n  Grasp the bone graft firmly with forceps and carefully release it from its deep attachments. Dissect the lateral part of the conjoined tendon, avoiding the medial aspect and potential damage to the musculocutaneous nerve. n  Evert the bone graft and decorticate its deep surface with a cutting rongeur or saw. n  With a 3.2-mm drill, drill two parallel holes in the deep surface of the bone graft. n  Measure the thickness of the bone graft with a caliper and place the graft under the pectoralis major for subsequent use; hold it in place with the self-retaining retractor, which keeps the deltopectoral interval open.  n 

DIVISION OF THE SUBSCAPULARIS, ­CAPSULOTOMY, AND EXPOSURE  With the upper limb in full external rotation, identify the inferior and superior margins of the subscapularis tendon. Use electrocautery and then Mayo scissors to divide the muscle at the superior two thirds or inferior one third junction in line with its fibers, carefully obtaining hemostasis at each step. n  Carefully carry division down to the white capsule, and then extend it medially by inserting a 4 × 4-inch sponge into the cleavage plane, thus exposing the subscapular fossa. Extend the division laterally as far as the lesser tuberosity. Place a Hohmann retractor in the subscapular fossa. n 

 

ANTERIOR STABILIZATION WITH ASSOCIATED GLENOID DEFICIENCY (LATERJET PROCEDURE) In patients who have an inverted pear-shaped glenoid and an engaging Hill-Sachs lesion, we have found that the Laterjet procedure alone usually is adequate to treat this combined bone deficiency. The bone graft corrects the glenoid deficiency so that it can resist axial forces across an

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CHAPTER 47  RECURRENT DISLOCATIONS

A

B

D

C

FIGURE 47.28 A, Preoperative sagittal MRI of shoulder with multiple loose bodies and loss of 35% of glenoid articular surface. Anteroposterior (B) and lateral (C) views after Laterjet procedure with parallel screw fixation. D, Arthroscopic view showing healed Laterjet procedure.

Place the upper limb in neutral rotation to provide full exposure of the capsule, and make a 1.5-cm vertical capsulotomy at the level of the anteroinferior margin of the glenoid. n  Move the arm into full internal rotation to allow insertion of a humeral head retractor, which rests on the posterior margin of the glenoid. n  Retract the superior two thirds of the subscapularis superiorly with a Steinmann pin impacted at the superior part of the scapular neck; retract the inferior part inferiorly with a Hohmann retractor pushed under the neck of the scapula between the capsule and the subscapularis. n  With the anteroinferior rim of the scapula exposed, inspect the labrum, cartilage, and insertion site of the glenohumer n 

al ligaments. Resect the medial capsular flap along with damaged portions of the labrum or fracture fragments. n  Use a scalpel to expose the anteroinferior margin of the glenoid and decorticate it with a curet or osteotome (Fig. 47.29C). 

FIXATION OF THE BONE BLOCK  Insert the bone block through the soft tissues and position it flush to the anteroinferior margin of the glenoid. Check the position of the bone block with the arm in internal rotation, taking care to avoid any lateral overhang; a slight medial position (no more than 1 to 2 mm) is acceptable. Never accept a lateral overhang of the coracoid in the joint; it can lead to rapid degenerative joint disease.

n 

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A

B

C

D FIGURE 47.29 Laterjet-Bristow procedure (Walch and Boileau). A, Vertical incision under tip of coracoid process. B, Harvest of bone block corresponding to horizontal part of coracoid process, retaining conjoined coracobrachialis tendon and coracoacromial ligament. C, Division of subscapularis horizontally. Anteroinferior glenoid rim is decorticated. D, Bicortical fixation of bone block. Outer capsular flap is sutured to remainder of coracoacromial ligament. SEE TECHNIQUE 47.6.

Insert a 3.2-mm drill through the inferior hole in the bone graft and into the glenoid neck in an anteroposterior and superior direction. Check the orientation of the articular surface and direct the drill parallel to this plane. Temporarily reflect the bone block to allow measurement of the drilling depth with a depth gauge. n  Place an AO malleolar screw into the posterior cortex to secure the bone block to the glenoid. Tighten this screw loosely to allow easy rotation and proper positioning of the superior part of the bone block. When positioning is correct, insert a second AO malleolar screw through the superior hole in the bone block and tighten both screws firmly (Fig. 47.29D). To avoid impingement with the humeral head, do not use washers with the screws.  n 

CLOSURE  With the arm in external rotation, repair the remnant of the coracoacromial ligament to the lateral capsular flap with two interrupted absorbable sutures. n  Remove the sponge placed earlier in the subscapular fossa, and move the arm through all ranges of motion to evaluate mobility. n  Coat the cut surface of the coracoid with bone wax, place a suction drain, and close the superficial soft-tissue layers.  n 

POSTOPERATIVE CARE  Patients require immobilization in a sling or shoulder immobilizer for 2 weeks after surgery. Forward flexion is begun thereafter, and external rotation is begun at 6 weeks. Strengthening exercises are started 8 weeks after surgery.    

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CHAPTER 47  RECURRENT DISLOCATIONS  

RECONSTRUCTION OF ANTERIOR GLENOID USING ILIAC CREST BONE AUTOGRAFT The Eden-Hybbinette procedure was originally described using an iliac crest autograft to reconstruct the anterior glenoid. Glenoid bone loss approaching 40% of the anterior glenoid or posterior bone loss of 25% with recurrent posterior dislocation should be reconstructed with an autogenous iliac crest bone graft, or, occasionally for posterior lesions, the medial aspect of the acromion can be used as a graft. Provencher et al. described using allograft from the lateral aspect of a distal tibia for reconstruction. At present, however, an iliac crest autograft is recommended because of its availability, greater healing potential, and less potential for resorption than an allograft.



TECHNIQUE 47.7 (WARNER ET AL.)

Harvest a tricortical iliac crest autograft 2 cm wide and 3 cm long and contour it to make a smooth continuation of the glenoid arc. n  Drill two holes in the graft and use these to align the graft to form a smooth articular arc. n  Drill holes in the glenoid neck and mark them with electrocautery for ease in finding. n  Place sutures in the capsule and pass them around the screw shaft between the glenoid and graft sutures. Secure the graft extracapsularly. n  Appropriate graft position is vertical before closure of the lateral extent of the capsular incision. n  Decorticate the glenoid neck and secure the graft with two 4.0-mm cannulated bicortical screws. n  Anteriorly, place the graft intracapsularly, securing the capsule around the screwheads. n  Posteriorly, perform a medial-based plication. n 

POSTOPERATIVE CARE Postoperative care is as described for Technique 47.6.   

UNSUCCESSFUL SURGICAL REPAIRS FOR ANTERIOR INSTABILITY

Failure of stabilization may occur because of failure to correct the pathology, failure to heal, or poor patient compliance. All potential causes of failure must be fully evaluated and should include a 3D CT evaluation for bony deficiency of the glenoid and humeral head and, on occasion, an arthrogram to identify the site of capsular failure. If failure of stabilization is determined to be caused by failure to heal, the procedure may be revised arthroscopically with the option of open repair if it is thought to be advantageous. Bony deficiency of the humeral head usually is corrected with an arthroscopic remplissage procedure. Deficiency of the glenoid more than 25% should be approached with an open Latarjet procedure (see Table 47.6). Loss of as little as 13.5% of the glenoid bone may give a sense of instability.

Recent studies have reported complication rates of up to 25% and return to previous level of sport of about 50% in patients with glenoid deformities treated with Latarjet procedures. Stability is increased with Latarjet procedures, but a meta-analysis showed arthroscopic soft-tissue procedures to have the lowest complication rates (1%) compared with arthroscopic Latarjet procedures (13.6%). Reported complications of recurrent instability or loss of motion, neurovascular problems, infection, and postoperative degenerative changes can be reduced significantly with appropriate planning preoperatively, intraoperatively, and postoperatively. The patient’s expectations and any secondary gains must be realized. Secure repair of the pathologic lesion is necessary to restore stability and preserve motion. Excessive loss of motion and injury to the glenohumeral joint from hardware have been indicated as causes of degenerative changes. Excessive loss of motion can be treated with an arthroscopic capsular release (see Chapter 52). If severe restriction of rotation (i.e., 30 mm Hg

Medial

Posterior

< 30 mm Hg

Continuous compar tmental pressure monitoring and serial clinical evaluation < 30 mm Hg Clinical diagnosis made

> 30 mm Hg

Fasciotomy FIGURE 48.4 Algorithm for diagnosis and treatment of acute compartment syndrome of lower leg after tibial fracture. (From Bourne RB, Rorabeck CH: Compartment syndromes of the lower leg, Clin Orthop Relat Res 240:97, 1989.)

sensitivity of 77% and specificity of 93%. Infrared imaging also has been used in trauma patients to determine temperature differences between the proximal and distal skin surfaces to help make the diagnosis of compartment syndrome. Schmidt et al. determined that near-infrared spectroscopy data were not collected reliably, calling into question its utility for monitoring oxygenation in patients at risk for acute compartment syndrome. Currently, neither of these methods has been shown to be as accurate or easily available as the invasive methods. 

TREATMENT

Significant controversy exists regarding appropriate compartmental pressures for performing fasciotomies. At our institution, if compartmental pressures are greater than 30 mm Hg in the presence of clinical findings, immediate fasciotomy is indicated. Equivocal readings require continuous monitoring and serial clinical examinations. In patients with major disruption of the arterial circulation or circumferential fullthickness burns, fasciotomy should be performed at the time of initial surgery. An algorithm for patients with tibial fractures has been developed to determine the roles of tissue pressure measurement and clinical findings (Fig. 48.4). In isolated limb injuries, splitting of the cast and underlying padding can decrease compartment pressure by as much as 50% to 85%. Any circular constrictive bandages also should be released. Positioning of the limb is important; placing the limb at the level of the heart produces the highest arteriovenous gradient. On the other hand, elevation of the

FIGURE 48.5 Three compartments of the thigh: anterior, medial, and posterior.

limb decreases arterial inflow without significantly increasing venous outflow, thus increasing local ischemia. If symptoms do not resolve within 30 to 60 minutes after appropriate treatment, pressure measurement should be repeated and, if results are equivocal, fasciotomy is indicated without delay. Although an exact timeframe has not been firmly established by evidence-based research in humans, fasciotomy after 12 hours has been associated with adverse outcomes. 

ACUTE COMPARTMENT SYNDROME OF THIGH

Compartment syndrome of the thigh is much less frequent than that of the forearm or lower leg, but it is associated with a high level of morbidity. In one study of 23 patients with acute thigh compartment syndrome, four patients (17%) required amputations, whereas in another study of 18 patients more than half did not recover full thigh-muscle strength and had long-term functional deficits. Factors associated with an increased likelihood of functional deficits were high injury severity scores, ipsilateral femoral fracture, prolonged intervals to decompression, the presence of myonecrosis at the time of fasciotomy, and an age older than 30 years. The most common causes of thigh compartment syndrome are blunt trauma (with or without fracture) and vascular injury; other cited causes of acute compartment syndrome of the thigh include polytrauma, arterial ischemia, burns, limb compression secondary to drug abuse, tourniquet use for lower leg surgery, use of military antishock trousers, muscle overuse, penetrating gunshot wounds, quadriceps tendon rupture and contusion or strain, other thigh muscle strains, and heterotopic ossification. Acute compartment syndrome of the thigh has been described mostly in case reports, and most often in young, active males participating in a contact sport (e.g., soccer, rugby). “Idiopathic” thigh compartment syndrome also has been described. The myofascial compartments of the thigh have a considerably larger volume and potential capacity than those of the lower leg or forearm, accounting for the relative infrequency of thigh compartment syndrome. The thigh is divided into three distinct compartments (anterior, medial, and posterior) by intermuscular fascial extensions (Fig. 48.5); collectively, the compartments are encased by the fascia lata. Within the anterior compartment are the quadriceps muscle group

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TABLE 48.1

Compartment-Specific Diagnostic Criteria of Acute Compartment Syndrome of the Thigh Pain with passive stretch Motor deficit

Sensory deficit

ANTERIOR COMPARTMENT Passive knee flexion with hip in extension Knee extension

Passive hip abduction with knee in extension

POSTERIOR COMPARTMENT Passive knee extension with hip in flexion Knee flexion, plantar flexion (sciatic tibial branch), dorsiflexion, great toe extension (peroneal branch) Hip adduction

MEDIAL COMPARTMENT Passive hip abduction with knee in extension Hip adduction

Proximal-medial thigh (obturator nerve cutaneous branch)

Modified from Mithoefer K, Lhowe DW, Vrahas MS, et al: Functional outcome after acute compartment syndrome of the thigh, J Bone Joint Surg 88A:729, 2006.

and the sartorius muscle, the femoral nerve and its sensory branch, the saphenous nerve, and the femoral artery and vein. The medial compartment contains the adductor muscle group and its neurovascular supply, the profunda femoris and obturator arteries, and the obturator nerve. In the posterior compartment are the biceps femoris, semimembranosus and semitendinosus muscles, arterial branches of the profunda femoris, and the sciatic nerve. Most reported compartment syndromes of the thigh involve the anterior compartment because it is surrounded by the stiffest walls laterally and medially (fascia lata and iliotibial tract) and is the most vulnerable to trauma. The diagnosis of acute compartment syndrome of the thigh is based on the criteria described earlier for acute compartment syndrome. The most common signs of thigh compartment syndrome are pain and increased thigh circumference compared with the opposite side. Weakness of the involved thigh muscles and sensory or motor deficits in the anatomic distribution of the nerves contained in specific compartments can help determine which compartments are involved (Table 48.1). Marmor et  al., in a cadaver model of elevated muscle compartment pressures, used ultrasound to measure the width of the anterior compartment and the amount of pressure needed to flatten the bulging superficial compartment fascia, both of which showed strong correlation to compartment pressures, suggesting a clinical use for this modality in the future. Although conservative management has been advocated for young patients with isolated anterior compartment syndrome of the thigh, most often immediate surgical decompression is indicated. A retrospective review of 29 patients with thigh compartment syndromes found that the frequency of complications correlated with the time to fasciotomy: delay of more than 12 hours was associated with a poor outcome in one study, and in another study patients who had decompression within 8 hours had significantly better outcomes than those with later surgery. High pressures in the thigh compartments have been found to cause long-term functional deficits even with shorter pressure durations, suggesting that the pressure level affects the time window until irreversible neuromuscular damage occurs. Some have suggested that fasciotomy should not be done when surgery is delayed for more than 12 hours because of the risk of infection in the ischemic muscle tissue, recommending that patients be treated medically (rapid fluid resuscitation) in an intensive care setting to manage rhabdomyolysis and avoid acute renal failure. When

the condition of the involved muscles is unknown, a small incision has been recommended to allow access for testing of muscle viability before the extensive fasciotomy incision is made.   

FASCIOTOMY FOR ACUTE COMPARTMENT SYNDROME OF THE THIGH

TECHNIQUE 48.1 (TARLOW ET AL.)

Prepare and drape the thigh in a sterile fashion, exposing the limb from the iliac crest to the knee joint. n  Make a lateral incision beginning just distal to the intertrochanteric line and extending to the lateral epicondyle (Fig. 48.6A). n  Use subcutaneous dissection to expose the iliotibial band and then make a straight incision in line with the skin incision through the iliotibial band (Fig. 48.6B). n  Carefully reflect the vastus lateralis off the lateral intermuscular septum, making sure to coagulate all perforating vessels as they are encountered. n  Make a 1.5-cm incision in the lateral intermuscular septum and, using Metzenbaum scissors, extend it proximally and distally the length of the incision (Fig. 48.6C). n  After the anterior and posterior compartments have been released, measure the pressure of the medial compartment. If the pressure is elevated, make a separate medial incision to release the adductor compartment. n  Pack the wound open and apply a large, bulky dressing. See also Video 48.1. n 

POSTOPERATIVE CARE  At 48 to 72 hours the patient is returned to the operating room for debridement of any necrotic material. Intravenous fluorescein and a Wood light can be helpful in evaluating muscle viability. If there is no evidence of muscle necrosis, the skin is loosely closed. Alternatively, a negative pressure wound device can be used. If closure is not accomplished, the debridement is repeated after another 48- to 72-hour interval, after which skin closure or skin grafting can be done.   

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CHAPTER 48  TRAUMATIC DISORDERS

Anterior compartment Medial intermuscular septum

Skin incision

A

Anterior compartment Medial compartment

Posterior intermuscular septum

B

C

Posterior compartment

Posterior compartment

Lateral intermuscular septum

FIGURE 48.6 Decompression of thigh compartments. A, Incision from intertrochanteric line to lateral epicondyle. B, Anterior compartment is opened by incising fascia lata, and vastus lateralis is retracted medially to expose lateral intermuscular septum, which is then incised to decompress posterior compartment. C, Drawing of thigh compartments and appropriate incisions. SEE TECHNIQUE 48.1.

ACUTE COMPARTMENT SYNDROME OF LOWER LEG

Most acute compartment syndromes of the lower leg (approximately 36%) are associated with tibial fractures; the second most common cause is blunt soft-tissue injury. During a 10-year period at a large trauma center, 288 (2.8%) of 10,315 patients with extremity trauma required fasciotomy for compartment syndrome. The need for fasciotomy varied widely according to mechanism of injury (12 weeks

Posterior slab/splint; non–weight bearing with crutches (immediately postoperative or after injury) Aircast walking boot with 2-cm heel lift* Protected weight bearing with crutches. Active plantar flexion and dorsiflexion to neutral, inversion/eversion below neutral, modalities to control swelling Incision mobilization modalities† (e.g., friction, ultrasound, stretching) Knee/hip exercises with no ankle involvement (e.g., leg lifts from sitting, prone, or side-lying position) Non–weight-bearing fitness/cardiovascular exercises (e.g., bicycling with one leg, deep-water running) Hydrotherapy (within motion and weight-bearing limitations) Weight bearing as tolerated* Continue activities as above Remove heel lift from boot Weight bearing as tolerated *Dorsiflexion stretching, slowly graduated resistance exercises (open and closed kinetic chain, functional activities) Proprioceptive and gait training Modalities, including ice, heat, and ultrasound as indicated Incision mobilization †Fitness/cardiovascular exercises, including weight bearing as tolerated (e.g., bicycling, elliptical machine, walking and/or running on treadmill, StairMaster) Hydrotherapy Wean off boot Return to crutches and/or cane as necessary and gradually wean off Continue to progress range of motion, strength, proprioception Continue to progress range of motion, strength, proprioception Retrain strength, power, endurance Increase dynamic weight-bearing exercise, include plyometric training Sport-specific training

*Patients are required to wear the boot while sleeping; may be removed for bathing and dressing but weight-bearing restrictions must be observed. †If deemed necessary by the physical therapist (scar tight or not moving well). Modified from Willits K, Amendola A, Bryant D, et al: Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation, J Bone Joint Surg 92A:2767, 2010.

ACUTE RUPTURE

A variety of techniques and modifications have been described for repair of acute Achilles tendon ruptures, including open repair, with or without augmentation (tendon transfer, local fascial turndown, allograft), and percutaneous or minimally invasive repair, with or without intraoperative ultrasound or endoscopy. In addition, numerous suture materials and configurations have been used for repair, including single and double Bunnell, Kessler, and Krackow (locking-loop) techniques and various modifications of these. Although proponents have suggested benefits for varied modifications, none has been firmly proved to be superior. A cadaver study found no difference in strength between Krackow, Bunnell, and Kessler sutures when all were done with a double-suture technique. One long-term follow-up study (12 years) reported that fibrin glue produced functional results equal to those obtained with sutures, with fewer complications. Repairs of acute Achilles tendon ruptures have been augmented with “turn-down” flap of fascia, the plantaris and peroneus brevis tendons, and biologic or synthetic scaffolds. Two large studies found no benefit of turn-down flaps over simple end-to-end repair, noting that the augmentation required a longer incision and a longer operating time. Extracellular matrix xenografts have been reported to decrease gapping and increase load to failure immediately after surgery in

cadaver models of Achilles rupture, as well as in animal studies; however, these benefits have not been clinically proven. Another “biologic” treatment approach involves the use of platelet-rich plasma (PRP) injected into the area of tendon rupture to theoretically recruit platelet growth factors to promote rapid tendon healing. Animal studies have shown that local application of PRP stimulates tendon repair, and cell culture studies have shown that PRP can stimulate processes associated with tendon healing. A clinical study on the use of PRP in open repair of acute Achilles tendon injuries reported faster recovery of motion and quicker return to sports with PRP; however, others reached the opposite conclusion, reporting no effect on function and suggesting that PRP may actually have a negative effect on tendon healing. Until preparation and delivery methods, as well as patient selection, are more standardized, it is difficult to determine the effect of PRP on tendon healing. Animal studies using mesenchymal stem cells for tendon healing also have shown promise.

OPEN REPAIR TECHNIQUES FOR ACHILLES TENDON RUPTURE

Open repair of acute Achilles tendon ruptures remains the “gold standard” of operative treatment, especially for athletic individuals, because of the historically low rate of reruptures,

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Plantaris tendon

FIGURE 48.15

Technique of repair of Achilles tendon. SEE TECHNIQUE 48.7.

high rate of return to sports, and decreased complication rate with newer techniques. Of 62 professional athletes with acute Achilles tendon ruptures repaired operatively, 31% were unable to return to play. Athletes who did return played in fewer games, had less playing time, and performed at a lower level than their preinjury status. However, these functional deficits were seen at only 1 year after surgery compared to matched controls, suggesting that those who return to play can expect to perform at a level similar to that of uninjured controls 2 years after surgery. Advocates of open repair argue that Achilles tendon injuries often result in complex obliquely oriented tears that cannot be adequately apposed and repaired with percutaneous or minimally invasive techniques. Complications of open Achilles tendon surgery have been well documented, with major complications reported in up to 10% of patients. The most frequently reported complications include wound infection, rerupture, and sural nerve injury. Traditionally, Achilles tendon repair has been done with the patient prone, which itself is associated with a number of complication risks. Marcel et  al. described an alternative technique in which the surgery is done through a posteromedial incision with the patient supine. They suggest that supine positioning can avoid risks associated with prone positioning and markedly reduce operating room time without increasing complications. None of their 45 patients in whom supine positioning was used had infections, sural nerve injuries, or reruptures. Delayed time to surgery has been cited as a prognostic factor in outcomes after open repair of acute Achilles tendon ruptures. Svedman et al., in a study of 228 patients with acute Achilles tendon rupture who were treated with uniform anesthetic and surgical techniques within 10 days of injury, found that those who had surgery within 48 hours of injury had better outcomes and fewer adverse events than those treated after 72 hours. 

 

OPEN REPAIR OF ACUTE ACHILLES TENDON RUPTURE TECHNIQUE 48.7

Figure 48.15

With the patient prone, make a posteromedial longitudinal incision 8 to 10 cm long; make it about 1 cm medial to the tendon, and end it just proximal to where the shoe counter strikes the heel. The skin incision should be off center to prevent later irritation by shoes directly over the tendon in the midline. n  Carry the incision sharply through the skin, subcutaneous tissues, and tendon sheath. n  Reflect the tendon sheath with the subcutaneous tissue, minimizing subcutaneous dissection. n  Approximate the ruptured ends of the tendon with No. 5 nonabsorbable tension suture, using a modified Kessler stitch through the stump 2.5 cm from the rupture. Plantar flex the foot 0 to 5 degrees, flex the knee 15 degrees, and approximate the ends of the tendon by tying the tension suture. n  Use a tendon stripper and harvest the plantaris tendon, releasing it proximally. Lay it aside in a moist sponge. n  Place the frayed ends of the tendon in as nearly normal position as possible and repair the rupture with multiple 2-0 absorbable sutures anteriorly and posteriorly. n  Place the previously harvested plantaris tendon in a fascial needle and pass it circumferentially, first through the posterior and then through the anterior part of the tendon 2 cm from the rupture. n  Use multiple 2-0 absorbable sutures to tack the plantaris tendon to the Achilles tendon. The distal tendon usually is long enough to be fanned out and tacked over the repair, as described by Lynn (see Technique 48.10). n 

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FIGURE 48.16 Krackow suture technique for Achilles tendon rupture. SEE TECHNIQUE 48.8. FIGURE 48.17 Lindholm technique for repairing ruptures of Achilles tendon. SEE TECHNIQUE 48.9.

Close the fascial sheath and subcutaneous tissues with 2-0 absorbable sutures. n  Close the skin and apply a sterile dressing. n  Apply a short leg cast with the foot in gravity equinus.     n 

 

OPEN REPAIR OF ACHILLES TENDON RUPTURE—LINDHOLM TECHNIQUE 48.9 With the patient prone, make a posterior curvilinear incision extending from the midcalf to the calcaneus. n  Incise the deep fascia in the midline and expose the tendon rupture. n  Debride the ragged ends of the tendon and appose them with a box type of mattress suture of heavy nonabsorbable suture material or wire; also use fine interrupted sutures (Fig. 48.17). n  Fashion two flaps from the proximal tendon and gastrocnemius aponeurosis, each approximately 1 cm wide and 7 to 8 cm long. Leave these flaps attached at a point 3 cm proximal to the site of rupture. n  Twist each flap 180 degrees on itself so that its smooth external surface lies next to the subcutaneous tissue as it is turned distally over the rupture. n  Suture each flap to the distal stump of the tendon and to one another so that they cover the site of rupture completely. n  Close the wound, being careful to approximate the tendon sheath over the site of repair.     n 

OPEN REPAIR OF ACHILLES TENDON RUPTURE—KRACKOW ET AL. TECHNIQUE 48.8 With the patient prone, make a posteromedial incision approximately 10 cm long about 1 cm medial to the tendon and ending proximal to where the shoe counter strikes the heel. n  Sharply dissect through the skin, subcutaneous tissues, and tendon sheath. Reflect the tendon sheath with the subcutaneous tissue to minimize subcutaneous dissection. n  Approximate the ruptured ends of the tendon with a 2-0 nonabsorbable suture (Fig. 48.16). n  Check the repair for stability after the sutures are tied. n  Close the peritenon and subcutaneous tissues with 4-0 absorbable sutures. n  Close the skin and apply a sterile dressing and a posterior splint or short leg cast with the foot in gravity equinus.     n 

 

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CHAPTER 48  TRAUMATIC DISORDERS Open the tendon sheath in the midline and, with the foot held in 20 degrees of plantar flexion and without excising the irregular edges, sew the ends of the Achilles tendon together with 2-0 absorbable sutures. n  If the plantaris tendon is intact (Fig. 48.18A), divide its insertion on the calcaneus; then, using forceps and beginning distally, fan out the tendon to form a membrane. n  Place this membrane over the repair of the Achilles tendon and suture it in place with interrupted sutures (Fig. 48.18B). When possible, cover the Achilles tendon for 2.5 cm both proximal and distal to the repair. n  If the plantaris tendon also is ruptured, dissect it free from the Achilles tendon for several centimeters and divide it proximally, using a tendon stripper. n  Then pull the tendon distally into the incision, fan it out as a free graft, and cover the repair as already described. n  Close the sheath of the Achilles tendon as far distally as possible without tension and close the wound. n 

A

POSTOPERATIVE CARE  Postoperative care is the same as that used after treatment of acute rupture of the Achilles tendon (see Technique 48.11).    

 

DYNAMIC LOOP SUTURE TECHNIQUE FOR ACUTE ACHILLES TENDON RUPTURE TECHNIQUE 48.11

B FIGURE 48.18 Lynn technique for repairing fresh rupture of Achilles tendon. A, Ruptured Achilles tendon has been sutured, and plantaris tendon has been divided distally and is being fanned out to form membrane. B, Fanned-out plantaris tendon has been placed over repair of Achilles tendon and sutured in place. SEE TECHNIQUES 48.10 AND 48.16.

 

REPAIR OF ACUTE ACHILLES TENDON RUPTURE USING PLANTARIS TENDON Lynn described a method of repairing ruptures of the Achilles tendon in which the plantaris tendon is fanned out to make a membrane 2.5 cm or wider for reinforcing the repair. The method is useful for injuries less than 10 days old; later the plantaris tendon becomes incorporated in the scar tissue and cannot be identified easily.

TECHNIQUE 48.10 (LYNN) Make an incision 12.5 to 17.5 cm long parallel to the medial border of the Achilles tendon.

n 

(TEUFFER) Expose the Achilles tendon and the tuberosity of the calcaneus through a posterolateral longitudinal incision. n  Identify and retract the sural nerve in the proximal part of the wound. n  Detach the peroneus brevis tendon from its insertion through a small incision at the base of the fifth metatarsal. n  Excise the aponeurotic septum, separating the lateral and posterior compartments, and deliver the freed peroneus brevis into the first incision. n  Dissect the tuberosity of the calcaneus and drill a hole large enough for passage of the tendon through the transverse diameter of the bone. n  Pass the peroneus brevis tendon through this hole and back proximally beside the Achilles tendon, reinforcing the site of rupture, and suture it to the peroneus brevis itself, producing a dynamic loop (Fig. 48.19). Turco and Spinella described a modification in which the peroneus brevis is passed through a midcoronal slit in the distal stump of the Achilles tendon. The graft is sutured medially and laterally to the stump and proximally to the tendon with multiple interrupted sutures to prevent splitting of the distal tendon stump (Fig. 48.20). This modification can be beneficial if a long distal stump is present. n 

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Achilles tendon

Achilles tendon

Peroneus brevis

FIGURE 48.19 Dynamic loop suture of peroneus brevis to itself when end-to-end suture is not possible. SEE TECHNIQUE 48.11.

POSTOPERATIVE CARE  The cast is removed at 2 weeks, the wound is inspected, and the staples or sutures are removed unless subcuticular sutures were used for wound closure. Occasionally, another week is required for proper wound healing before sutures are removed. Another short leg cast with the foot in gravity equinus is worn for an additional 2 weeks. At 4 weeks, the cast is changed again and the foot is gradually brought to the plantigrade position over the next 2 weeks. Walking is gradually resumed with partial weight bearing on crutches during a 2-week period. At 6 to 8 weeks, a short leg walking cast is applied with the foot in the plantigrade position and full weight bearing is allowed. Alternatively, a removable brace allowing only plantar flexion can be used as early as 4 to 6 weeks after surgery. Gentle active rangeof-motion exercises for 20 minutes twice a day are begun. Isometric ankle exercises along with a knee-strengthening and hip-strengthening program can be instituted. Toe raises, progressive resistance exercises, and proprioceptive exercises, in combination with a general strengthening program, constitute the third stage of rehabilitation. In reliable, well-supervised patients with good tissue repair, this program can be accelerated, with earlier use of dorsiflexion-stop orthoses and active range-of-motion exercises. Return to full unrestricted activity usually requires at least 6 months and often more.    

 

MINIMALLY INVASIVE AND PERCUTANEOUS REPAIR OF ACUTE ACHILLES TENDON RUPTURE A number of techniques have been developed to allow repair through smaller incisions to speed recovery and minimize complications, especially infection and sural nerve damage. Because of the risk of sural nerve injuries with

Peroneus brevis

FIGURE 48.20 Turco and Spinella modification. Peroneus brevis is passed through midcoronal slit in distal stump of Achilles tendon and sutured to stump and to tendon. SEE TECHNIQUE 48.11.

“blind” suturing of the tendon, some of these techniques use multiple incisions (e.g., three-incision technique), endoscopy, or specially designed devices. Comparisons of open repairs with minimally invasive or percutaneous techniques have shown functional results comparable to those obtained with open repair, with fewer complications, no apparent increased risk of rerupture, and better cosmetic results. A recent systematic review involving 182 patients found a significantly decreased risk of postoperative complications, especially wound infection, in acute Achilles tendon ruptures treated with minimally invasive surgery compared with open surgery. In their systematic review and meta-analysis of 2060 patients treated with six commonly used surgery and rehabilitation protocols, Wu et al. determined that minimally invasive surgery with accelerated rehabilitation had the lowest risk of DVT, deep infection, and rerupture. Cited disadvantages of minimally invasive techniques include risk of sural nerve injury, failure to appose tendon ends or malalignment of tendon ends, and a lower strength of the repair. In a study of 211 patients with minimally invasive repairs, sural nerve injury occurred in 41 (19%) and reruptures in 17 (8%). Keller et al. described a mini-open Achilles tendon rupture technique that does not open the paratenon and avoids the sural nerve. In their 100 patients with this procedure, there were no infections, wound dehiscence, scar adherence, or sural nerve damage; 98% of patients were satisfied with their results, and 80 returned to their previous sport activity at the same or higher level. The technique requires the use of custom-made suture retrievers. In a later description of the technique, Wagner and Wagner listed important tips for performing the procedure: (1) operate within 10 days of the rupture to avoid scar formation at the rupture site; (2) plan the procedure according to the level of the rupture to ensure that the suture passers are long enough to span the rupture site from the proximal incision up to the calcaneus; (3) ensure that the bone anchors are placed in the middle of the total height of the calcaneus, avoiding the enthesis, and align the anchors

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1

2

3

4

5

6

7

8

Equinus

9

FIGURE 48.21 Ma and Griffith technique for percutaneous repair of acute rupture of Achilles tendon. SEE TECHNIQUE 48.12.

to be perpendicular to the axis of the calcaneus; (4) follow the proximal suturing technique to obtain the best resistance of the repair; and (5) taking care to not overtighten consecutive sutures, restore the appropriate level of physiologic equinus. A percutaneous technique using a device (percutaneous Achilles repair system, PARS, Arthrex) has been developed to improve recovery and reduce postoperative complications. Hsu et al. compared the PARS technique in 101 patients to open repair in 169 patients and found that the percutaneous group had shorter surgical times and more patients who returned to baseline physical activities by 5 months compared to the open repair group. The overall postoperative complication rate was 5% in the percutaneous group and 11% in the open group. As noted by Lichti et al., the PARS technique requires that the surgeon be familiar with the instrumentation and suture management must be meticulous to avoid entanglement of the sutures.

POSTOPERATIVE CARE The short leg cast is worn with non–weight bearing for 4 weeks, at which time a weight-bearing, low-heeled, short leg equinus cast is applied. At 8 weeks, the cast is removed and a therapy program of toe-heel raising and gastrocnemius-soleus exercises is begun. The patient gradually restores the foot to a neutral position during a 4-week period. Then the patient begins heel cord stretching exercises for an additional 4 weeks.    

 

PERCUTANEOUS ACHILLES TENDON REPAIR TECHNIQUE 48.13

TECHNIQUE 48.12

(HSU, BERLET, ANDERSON)

(MA AND GRIFFITH) In the operating room with the patient under local, regional, or general anesthesia, and with the extremity prepared as for open surgery, palpate the tendon defect

n 

and make small stab wounds on each side of the Achilles tendon 2.5 cm proximal to the rupture defect. n  Use a small hemostat to free the underlying tendon sheath from the subcutaneous tissue; pass a No. 0 or a No. 1 nonabsorbable suture threaded on a straight needle from the lateral stab wound through the body of the tendon and exit in the medial stab wound (Fig. 48.21, step 1). n  With a straight needle on each end of the inserted suture, crisscross the needles within the body of the tendon and puncture the skin just distal to the site of tendon rupture; enlarge the sites of needle puncture with a scalpel (Fig. 48.21, step 2) and pull the suture completely through the stab wounds; snug the suture within the proximal portion of the ruptured tendon. n  With the lateral suture now threaded on a curved cutting needle, pass the suture back through the last stab wound to exit at about the midportion of the distal stump of the ruptured tendon on the lateral side (Fig. 48.21, step 3). Enlarge the hole with a scalpel before pulling the suture through. n  Use a hemostat to free the subcutaneous tissue from the underlying tendon sheath (Fig. 48.21, step 4). n  Using a straight needle, pass the lateral suture through the body of the distal stump of the tendon; enlarge the puncture wound in the skin as before (Fig. 48.21, steps 5 and 6). n  Using a curved cutting needle, pass the suture from this distalmost stab wound on the medial side and exit at the middle stab wound on the medial side of the ruptured tendon (Fig. 48.21, step 7). n  With the ankle maintained in equinus position, apply tension to the suture in a crisscross manner and bring the tendon ends together; tie the suture in this position and, with a small hemostat, bury the knot in the depths of the wound (Fig. 48.21, steps 8 and 9). n  Suturing the skin is unnecessary. Apply a sterile dressing to the stab wounds, and apply a short leg cast in gravity equinus position.

Position the patient prone and apply a thigh tourniquet. Place the feet slightly hanging off the end of the bed with a bump beneath the operative side ankle to adjust

n 

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A

C

B

D FIGURE 48.22 A, Proximal jig insertion. B, Passage of sutures creating locking sutures in either side of the tendon. C, Distal jig insertion. D, Completed repair. (From Hsu AR, Jones CP, Cohen BE: Clinical outcomes and complications of percutaneous Achilles repair system versus open technique for acute Achilles tendon ruptures, Foot Ankle Int 36:1279, 2015.) SEE TECHNIQUE 48.13.

plantar flexion and Achilles tension and avoid interference with the contralateral leg. The operative leg should be in neutral rotation to allow subsequent central positioning of the PARS jig. n  After preparation and draping, exsanguinate the extremity and inflate the tourniquet. n  Palpate the defect in the Achilles tendon and make a 2-cm transverse or vertical incision just proximal to the defect in the center of the tendon. Placing the incision just proximal to the rupture site ensures proper visualization and control of the proximal Achilles tendon stump, which can be retracted proximally into the calf. The distal stump can be brought into the incision by plantar flexing the ankle. A transverse incision follows the natural skin creases in the back of the ankle and allows for percutaneous jig insertion with minimal paratenon disruption. A vertical incision can be used and extended in cases of tendinosis, calcifications, or delayed presentation, but it requires increased paratenon and soft-tissue disruption. n  Incise the skin and soft tissues using a “no-touch” technique without pickups. Carefully carry dissection down to the paratenon and sharply incise it. Preservation of the paratenon helps minimize disruption to the vascular supply of the tendon and allows repair at the end of the procedure. n  The sural nerve is not typically seen in the operative field, but if it is, dissect it out and retract it out of the way with a vessel loop. n  Use an index finger or Freer elevator within the wound to confirm that the center of the rupture has been located.

Insert an Allis clamp into the wound, secure the proximal tendon stump, and pull it through the wound 1 to 2 cm. Run a Freer elevator along the dorsal aspect of the proximal tendon to release potential adhesions that may limit distal excursion. Avoid dissection along the ventral aspect of the tendon to preserve native tendon blood supply.

n 

PROXIMAL JIG INSERTION  Insert the proximal jig into the wound with the inner prongs in the narrowest position possible while gently placing traction on the proximal tendon stump with a clamp (Fig. 48.22A). n  Use the center turn wheel to widen the inner prongs so that they slide along the sides of the tendon in the paratenon. Proper jig placement should allow the jig to slide along the tendon with minimal resistance. n  Palpate the proximal tendon under the skin to check that the tendon is centered within the prongs of the jig. The most common error is to insert the jig too deep, which causes subsequent needles and sutures to miss the tendon and pull through. n  Once it is properly located, keep the jig centered and stabilized so that it does not veer medially or laterally. n  During suture passing, first use all the needles (1.6 mm) with Nitinol loops that are not loaded with suture. n  Insert the first two needles into their respective numbered holes through the tendon and then through the opposite side of the jig. Check each needle to make sure it does not pass outside the jig. The placement of two needles within the jig and tendon at all times during suture passing helps n 

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CHAPTER 48  TRAUMATIC DISORDERS stabilize the jig and avoids adjacent suture piercing with the subsequent needle. n  Pass a #2 FiberWire suture or SutureTape suture through the jig with the needle suture passer, making them of equal length on both sides. SutureTape has a broader, flatter surface to increase contact surface area between the suture and tendon and reduce any suture cutting through frayed tendon. n  The colors of the sutures are not as important as the order in which they are placed. An assistant can write down the colors and order of the sutures passed, as needed. The two central sutures—#3 and #4—have one looped end and one end with a tail. They are passed in an oblique, crossing pattern. These sutures create locking sutures on either side of the tendon (Fig. 48.22B). Holes #6 and #7 can be used if a second locking suture is needed.

JIG REMOVAL, SUTURE MANAGEMENT After all sutures are passed, use the turn wheel to narrow the inner prongs while applying controlled tension to the jig to remove it. Remove all sutures from both sides of the tendon from the wound. Before the jig is completely removed, use a hemostat through each loop of sutures to guide them out of the wound. Test both pairs of sutures by pulling them distally to ensure that adequate proximal fixation has been obtained. n  If any or all of the sutures pull out of the tendon, this indicates that the tendon was not centered in the jig or the jig was placed too deep or not proximal enough along the tendon during suture passing. If this occurs, remove the sutures and repeat the previous steps paying attention to tendon positioning within the jig. n  Do not extend the incision longitudinally on either end of a transverse incision as this may lead to wound healing complications. n  Once proximal fixation is achieved, neatly spread apart the sutures on each side of the tendon in the following order from proximal to distal: first suture, second suture, looped, green striped suture (third), tail of the green striped suture (fourth), and fifth suture. Loop the second suture on both sides around the two green striped sutures and back proximally through the looped end of the green striped suture. n  Pull the green striped suture tail through the tendon onto the opposite side to create a locking suture on both sides of the tendon. In the end, there are two nonlocking sutures and one locking suture on either side of the tendon. Pull each pair of sutures individually distally to confirm fixation and remove creep from the sutures. Place a hemostat on each group of three sutures to keep these out of the way during distal tendon preparation. n  For distal tendon preparation using this technique, repeat the above steps. Secure the distal tendon stump with an Allis clamp and deliver it out of the wound while inserting the jig (Fig. 48.22C). Insert the jig as distal as possible to the Achilles insertion to ensure that all sutures are passed through the tendon. Suture passing, jig removal, and creation of locking sutures follow the previously outlined steps. Test and pull on each pair of sutures to ensure that adequate distal tendon fixation was achieved.

n 











n Place and hold the ankle in maximal plantar flexion during suture tying for a secure repair. We have never found the Achilles tendon repair to be too tight when using the percutaneous technique. The tendon will always gradually stretch out during weight bearing and physical therapy. n When tying nonlocking sutures, have an assistant hold tension on the opposite side as the suture will continue to slide through the tendon with increasing force applied to the suture during knot tying. During tying, pull out any remaining slack from the sutures before securing them with five or six knots. After each suture is tied, cut it above the knot and away from the other sutures to avoid tangling. n  After the sutures are tied, the ankle should be plantar flexed with improved resting tension. After wound irrigation, ensure the suture knots are tucked ventrally into the wound and do not protrude into the subcutaneous tissue. Sharply debride residual strands of tendon and tuck them within the wound for adequate paratenon closure (Fig. 48.22D). Use absorbable sutures to close the paratenon and subcutaneous tissues and nylon sutures for skin closure.    

CHRONIC RUPTURE

The definition of a “chronic” rupture has ranged from those diagnosed and treated more than 48 hours after injury to those diagnosed and treated up to 2 months after injury. There appears to be some consensus that a rupture diagnosed 4 to 6 weeks after injury should be considered a chronic rupture and that these are more difficult to treat than acute injuries. At about 1 week after rupture of the Achilles tendon, any space between the tendon ends fills with scar tissue. If left untreated, the tendon heals elongated, leaving the patient unable to push off on the affected side. Running, jumping, and activities such as ascending or descending stairs are severely compromised. Calf atrophy usually is present, the Achilles tendon often loses its normal contour, and a visible tendon defect may be present. MRI can be helpful to estimate the gap between the ruptured ends of the tendon (Fig. 48.23). Chronic ruptures appear as an area of low-intensity signal on T1-weighted images and alteration in T2-weighted signal. If posterior heel pain, swelling, or functional impairment is disabling, delayed repair or reconstruction is indicated. In most active adults, repair is preferable but often is not possible. For ruptures more than 3 months old, treatment depends on the patient’s physiologic age, activity level, and amount of functional impairment. A number of techniques have been described for reconstruction of a neglected Achilles tendon rupture (Box 48.4). If the tendon defect is less than 3 cm after debridement and the injury is less than 3 months old, direct repair often is possible. If, however, the tendon gap is more than 3 cm (more common), additional techniques must be used, such as local tissue transfer, tissue augmentation, synthetics, and allografts. V-Y quadricepsplasty (see Technique 48.18) and gastrocnemius-soleus fascia turn-down graft (see Technique 48.17) techniques can be used for augmentation, and local tendon transfers (flexor hallucis longus, flexor digitorum longus, peroneus brevis and longus, plantaris) can be used to bridge larger defects (Table 48.3). Minimally invasive and endoscopically assisted techniques have been described for tendon transfers, but there are few reports of the long-term outcomes of these procedures. Maffulli et al. described a “less-invasive” technique

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FIGURE 48.23

MRI appearance of chronic Achilles tendon rupture.

 

BOX 48.4



Techniques for Reconstruction of Chronic Achilles Tendon Ruptures Primary repair (uncommon) Augmentation n  Free fascia tendon graft Fascia lata Donor tendons (semitendinosus, peroneal, gracilis, patellar tendon) n  Fascia advancement V-Y quadriceps plasty Gastrocnemius-soleus fascia turn-down graft n  Local tendon transfer Flexor hallucis longus Flexor digitorum longus Peroneus brevis Peroneus longus Plantaris Posterior tibial n Synthetic or allograft augmentation n  Polyglycol threads n  Marlex mesh n  Dacron vascular graft n  Carbon fiber n  Allograft tendon n 

TRANSFER OF THE PERONEUS BREVIS TENDON FOR NEGLECTED ACHILLES TENDON RUPTURES

n 

Modified from Coughlin MJ, Schon LC: Disorders of tendons. In Coughlin MJ, Mann RA, Saltzman CL, editors: Surgery of the foot and ankle, ed 8, Philadelphia, 2007, Elsevier.

for transfer of the peroneus brevis through two paramidline incisions and recommended this technique for tendon gaps of less than 6 cm. In a later report, he and his colleagues compared outcomes of three less invasive tendon transfer procedures: free ipsilateral semitendinosus graft (gaps of more than 6 cm), ipsilateral peroneus brevis transfer (smaller gaps), and ipsilateral flexor hallucis longus transfer. All three techniques produced significant functional improvement, and return to sports was possible in most patients; no clear advantage of one technique over the others was demonstrated. 

TECHNIQUE 48.14 (MAFFULLI ET AL.) Make a 5-cm longitudinal incision 2 cm proximal and just medial to the palpable end of the proximal stump. n  Make a second longitudinal incision, 3 cm long, 2 cm distal, and just lateral to the lateral margin of the distal stump (Fig. 48.24A). Take care to avoid sural nerve injury by making this incision as close as possible to the anterior aspect of the lateral border of the Achilles tendon (posterior to the sural nerve). n  Make a 2-cm longitudinal incision at the base of the fifth metatarsal. n  Mobilize the distal Achilles tendon stump, freeing it of all peritendinous adhesions, particularly on its lateral aspect. Resect the ruptured tendon end back to healthy tendon and place a locking suture (No. 1 Vicryl) along the free tendon edge to prevent separation of the bundles. n  Mobilize the proximal tendon stump through the proximal incision, divide any adhesions, and release the soft tissues anterior to the soleus and gastrocnemius muscle to allow maximal excursion and minimize the gap between the tendon stumps. n  Plantar flex the ankle and measure the gap between the two tendon ends. If less than 6 cm, the peroneus brevis tendon can be used to bridge the gap. n  Identify the peroneus brevis tendon through the incision on the lateral border of the foot. Expose the tendon and place a locking suture in the tendon end before releasing it from the metatarsal base. n  Through the distal incision over the Achilles tendon, incise the deep fascia overlying the peroneal muscle compartment and identify the peroneus brevis tendon at the base n 

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TABLE 48.3

Comparison of Tendons for Tendon Transfer in Treatment of Chronic Achilles Tendon Rupture TENDON Peroneus brevis

STRENGTH RELATIVE TO GSC 18 times weaker

ADVANTAGES In phase with GSC during normal gait Shared role as plantar flexor of ankle Relatively close proximity to Achilles tendon but in separate muscle compartment

CONCERNS Loss of eversion strength Lateral-to-medial pull after transfer to calcaneus, which does not reproduce inversion normally created by Achilles tendon Sural nerve damage during harvest

Flexor digitorum longus

27 times weaker

In phase with GSC during normal gait Shared role as plantar flexor of ankle Relatively close proximity to Achilles tendon

Weakened flexion of toes Lesser toe deformities Nerve or artery injury during harvest

Flexor hallucis longus

13 times weaker

In phase with GSC during normal gait Shared role as plantar flexor of ankle Closest proximity to Achilles tendon

Loss of push-off strength during gait Clawed hallux deformity Transfer metatarsalgia Nerve or artery injury during harvest

GSC, Gastrocnemius-soleus.

5 cm

3 cm

A

B

FIGURE 48.24 Peroneus brevis transfer for chronic Achilles tendon rupture. A, Longitudinal incisions.B, Completed transfer. SEE TECHNIQUE 48.14.

of the incision. Withdraw the peroneus brevis tendon through the distal incision; tendinous strands between the two peroneal tendons distally may require strong force to withdraw the tendon. n  Mobilize the muscular portion of the peroneus brevis proximally to increase its excursion. n  Make a longitudinal tenotomy parallel to the tendon fibers in both tendon stumps. n  Use a clamp to develop the plane, from lateral to medial, in the distal Achilles tendon stump, and pass the peroneus brevis graft through the tenotomy.

With the ankle in maximal plantar flexion, suture the peroneus brevis to both sides of the distal stump. n  Pass the peroneus brevis tendon beneath the intact skin bridge into the proximal incision, then from medial to lateral through the transverse tenotomy in the proximal stump, and secure it with sutures. n  Suture the peroneus brevis tendon back onto itself on the lateral side of the proximal incision (Fig. 48.24B). n  Close the incisions in standard fashion and apply a previously prepared removable fiberglass cast support with the foot in maximal equinus. n 

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PART XIII  SPORTS MEDICINE Resect most of the scar tissue and proceed with repair as described for acute ruptures, using tension sutures and reinforcement with the plantaris tendon. n  Keep the knee flexed and the foot in equinus during the repair to relieve tension. n 

POSTOPERATIVE CARE Postoperative care is as described for after repair of an acute rupture of the Achilles tendon (see Technique 48.11).     Plantaris tendon

Achilles tendon

Peroneus brevis

A

 

REPAIR OF NEGLECTED ACHILLES TENDON RUPTURES USING PERONEUS BREVIS AND PLANTARIS TENDONS

B

FIGURE 48.25 Technique for chronic rupture of Achilles tendon. A, Exposure of Achilles tendon and tuberosity through posterolateral incision. Peroneus brevis is passed through hole drilled in tuberosity and sutured to Achilles tendon. B, Plantaris tendon is passed through ruptured ends of tendon. SEE TECHNIQUE 48.16.

Repair of significant tendon defects in active patients may be best accomplished using a modification of local tendon transfer described by White and Kraynick and Teuffer.

TECHNIQUE 48.16 (WHITE AND KRAYNICK; TEUFFER, MODIFIED) Expose the Achilles tendon and the tuberosity of the calcaneus through a posterolateral incision; identify and retract the sural nerve in the proximal part of the wound. n  Through a small second incision, detach the peroneus brevis from the base of the fifth metatarsal. n  Incise the lateral septum and draw the peroneus brevis tendon through the first incision. n  Make an incision through the sheath of the Achilles tendon to expose the ruptured ends. n  Resect the scarred tissue and dissect proximally to free the gastrocnemius-soleus. n  Identify the plantaris tendon and release it with a tendon stripper. n  Take the peroneus brevis tendon from lateral to medial through a hole drilled in the calcaneal tuberosity and suture it to the Achilles tendon with multiple interrupted nonabsorbable sutures to form a dynamic loop (Fig. 48.25A). n  Place the harvested plantaris tendon on a fascial needle and pass it in a figure-of-eight manner from posterior to anterior through the ruptured ends of the tendon (Fig. 48.25B). n  Leave enough of the tendon to be fanned over the distal part of the tendon and tack it over the repair for a smoother closure of the tendon graft (see Fig. 48.18). n  Close the tendon sheath and subcutaneous tissues with nonabsorbable sutures. n  Close the skin and apply a sterile dressing and a short leg cast in gravity equinus. n 

POSTOPERATIVE CARE Weight bearing to tolerance on the metatarsal heads is allowed with the use of elbow crutches. Active flexion and extension of the hallux and lesser toes are encouraged, as are isometric exercises of the calf muscles and toes. At 2 weeks, the back shell of the cast is removed and physical therapy focusing on proprioception, plantar flexion, inversion, and eversion is begun with the front shell in place to prevent ankle dorsiflexion. Full weight bearing is allowed with the front shell of the cast in place, but this rarely is possible because of balance difficulties, and most patients still require the assistance of a single elbow crutch. The front shell of the cast is removed at 6 weeks and physical therapy is continued. Patients normally regain a plantigrade ankle over the next 2 to 3 weeks.    

 

DIRECT REPAIR OF NEGLECTED ACHILLES TENDON RUPTURES TECHNIQUE 48.15 Make a curvilinear, posteromedial incision, extending proximally as far as necessary for mobilization of the tendon. n  Free the gastrocnemius and soleus muscles individually in the proximal leg with combinations of sharp and blunt dissection to provide additional mobilization. n 

POSTOPERATIVE CARE  Postoperative care is the same as described after repair of an acute rupture of the Achilles tendon (see Technique 48.11).    

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CHAPTER 48  TRAUMATIC DISORDERS

A FIGURE 48.26 48.17.

B

C

Bosworth technique for repairing old ruptures of Achilles tendon. SEE TECHNIQUE

 

 

REPAIR OF NEGLECTED ACHILLES TENDON RUPTURES USING GASTROCNEMIUS-SOLEUS TURNDOWN GRAFT

V-Y REPAIR OF NEGLECTED ACHILLES TENDON RUPTURES

TECHNIQUE 48.17 (BOSWORTH) Make a posterior longitudinal midline incision, extending from the calcaneus to the proximal one third of the calf. n  Expose the ruptured tendon and, using sharp dissection, excise the scar tissue from between the ends. n  Free from the median raphe of the gastrocnemius muscle a strip of tendon 1.5 cm wide and 17.5 to 22.5 cm long and leave it attached just proximal to the site of rupture. n  Turn the strip distally, pass it transversely through the proximal tendon (Fig. 48.26A), and anchor it there with absorbable suture. n  Pass the strip distally and then transversely through the distal end of the tendon; pass it again through this end from anterior to posterior. n  While holding the knee at 90 degrees and the ankle in plantar flexion, draw the fascial strip tight and anchor it with chromic catgut sutures. n  Bring the strip proximally and pass it transversely through the proximal end of the tendon; carry it distally and suture it on itself (Fig. 48.26B,C). n  Close the wound and apply a long leg cast, holding the knee in flexion and the foot in plantar flexion.

Abraham and Pankovich described a V-Y tendinous flap for repair of chronic ruptures of the Achilles tendon. V-Y advancement may be required if more than 80% of the tendon width is involved. It also is useful when 1 to 3 cm of tendon must be resected.

TECHNIQUE 48.18

n 

POSTOPERATIVE CARE Postoperative care is as described for after repair of an acute rupture of the Achilles tendon (see Technique 48.11).    

(ABRAHAM AND PANKOVICH) With the patient prone and under tourniquet control, make a lazy “S” incision from the lateral aspect of the Achilles tendon insertion to the midpart of the calf (Fig. 48.27A). n  Identify and retract the sural nerve. n  Incise the deep fascia in line with the skin incision. n  Resect the scar tissue from the tendon ends. n  Measure the length of the tendon defect with the knee in 30 degrees of flexion and the ankle in 20 degrees of plantar flexion. n  Make an inverted-V incision through the aponeurosis with the apex over its central part. Make the arms of the incision at least one and a half times longer than the tendon defect to allow approximation in a Y configuration (Fig. 48.27B). n  Pull the flap distally and approximate the ends of the ruptured tendon with interrupted nonabsorbable sutures. n  Close the proximal part of the incision in a Y configuration (Fig. 48.27C). n  Suture the peritenon with interrupted nonabsorbable sutures. n  Close the deep fascia and subcutaneous tissue in a routine manner and apply a long leg cast with the knee in 30 degrees of flexion and the ankle in 20 degrees of plantar flexion. n 

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Sural nerve

A

B

C

FIGURE 48.27 V-Y repair of neglected rupture of Achilles tendon. A, Incision. B, Design of V flap. C, Y repair and end-to-end anastomosis. SEE TECHNIQUE 48.18.

POSTOPERATIVE CARE  At 6 to 8 weeks, the long leg cast is removed, a short leg cast is applied and worn for 1 month, and weight bearing is allowed. After cast removal, a 3- to 5-cm heel lift is used for 1 month and progressive stretching exercises are begun immediately.    

 

REPAIR OF NEGLECTED ACHILLES TENDON RUPTURES USING FLEXOR HALLUCIS LONGUS TENDON TRANSFER TECHNIQUE 48.19 (WAPNER ET AL.) Place the patient supine and apply a tourniquet. Make a longitudinal incision on the medial border of the foot just above the abductor muscle, extending from the head of the first metatarsal to the navicular (Fig. 48.28A). n  Carry the dissection sharply through the subcutaneous tissue to the fascia of the abductor. n  Reflect the abductor with the flexor hallucis brevis plantarward. n  Identify the flexor hallucis longus and the flexor digitorum longus tendons and divide the flexor hallucis longus as far distally as possible, allowing an adequate distal stump for repair to the flexor digitorum longus. n  n 

Place a tag suture into the divided proximal end of the flexor hallucis longus. n  Suture the distal end of the flexor hallucis longus into the flexor digitorum longus with the toes in neutral position. n  Make a posteromedial incision about 1 cm medial to the Achilles tendon from its musculotendinous junction proximally to approximately 2.5 cm below its calcaneal insertion (Fig. 48.28A). n  Carry the incision sharply through the skin, subcutaneous tissues, and tendon sheath, minimizing subcutaneous dissection. Inspect the substance of the tendon. n  Carry the dissection deep to the paratenon, creating fullthickness flaps to avoid skin slough. n  Incise the deep fascia longitudinally over the posterior compartment and expose the flexor hallucis longus. Retract the flexor hallucis tendon from the midfoot into the posterior wound. n  Drill a transverse hole just distal to the insertion of the Achilles tendon halfway from medial to lateral (Fig. 48.28B). n  Drill a second hole vertically just deep to the insertion of the Achilles tendon to join the first drill hole. Enlarge the tunnel with a large towel clip. n  Pull the tag suture through the tunnel from proximal to distal using a suture passer. n  Pass the flexor hallucis longus tendon through the tunnel and weave from distal to proximal through the Achilles tendon using a tendon weaver until the full length of the harvested tendon is used (Fig. 48.28C). n  Secure the weave with multiple 1-0 Dacron sutures. n  If desired, the repair can be supplemented using the plantaris tendon or a central slip of the Achilles tendon as previously described. n  Close the paratenon using absorbable suture. Close the subcutaneous tissues and skin of both incisions. n 

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CHAPTER 48  TRAUMATIC DISORDERS

A

B

C

FIGURE 48.28 Repair of chronic Achilles tendon rupture with flexor hallucis longus. A, Two incisions are made. Medial midline incision on midfoot is used to harvest flexor tendon. Posteromedial incision anterior to Achilles tendon is used to expose tendon. B, Hole is drilled just deep to Achilles tendon insertion and is directed plantarward. Second drill hole is made from medial to lateral to intersect first drill hole midway through posterior body of calcaneus. C, Flexor hallucis longus is woven through remaining portion of Achilles tendon for secure fixation and supplementation of tendon. SEE TECHNIQUE 48.19.

Apply sterile bandages and place the leg in a posterior plaster, non–weight-bearing cast in 15 degrees of plantar flexion.

n 

POSTOPERATIVE CARE  The cast is changed at 4 weeks to a short leg walking cast or a removable cast brace with the ankle in neutral; the cast brace is worn for an additional 4 weeks. A rehabilitation program is begun with strengthening and range-of-motion exercises at 8 weeks. The removable brace remains in place until grade 4 to 5 strength and 10 degrees of dorsiflexion are obtained. Athletic activity is restricted for 6 months.   

COMPLICATIONS

Wong et  al. and Kocher et  al. classified complications after open repair of Achilles tendon ruptures as minor, moderate, or major (Box 48.5). The most common complication appears to be rerupture. Reported rerupture rates after operative treatment are approximately 3%, with higher rates reported after nonoperative treatment. MRI is helpful to delineate the length of the tendon defect, evaluate the morphology of the tendon ends, and identify any pathologic processes. Sural nerve damage has been reported in 3% to 40% of percutaneous repairs and 0% to 20% of open repairs. Wound healing problems can occur after operative treatment of Achilles tendon ruptures, ranging from adhesions to deep infection associated with wound breakdown and tendon necrosis. Patients with deep infection typically are older, have received corticosteroid medication more often, sustained the tendon injury during everyday activities, and had a longer delay before treatment. Major wound breakdown, skin loss, and tendon necrosis may require complex reconstructive procedures, including local pedicle flaps and free flaps. 

RUPTURE OF GASTROCNEMIUS MUSCLE

Musculotendinous rupture of the gastrocnemius muscle usually occurs at the insertion of the medial head into the soleus aponeurosis. It is most common in middle-aged, male athletes during eccentric overload with the knee extended and the ankle dorsiflexed, as may occur in tennis or jogging. This condition, although rarely confused with rupture of the Achilles tendon, may be confused with rupture of the plantaris tendon, or more important, with thrombophlebitis. Patients may be mistakenly treated for thrombophlebitis with anticoagulants, which can cause other complications, as well as an increase in bleeding in the torn gastrocnemius muscle. Patients may report hearing an audible pop or a feeling of being struck in the back of the leg when the injury occurred. Swelling and bruising in the leg may extend to the foot and ankle. A defect in the medial gastrocnemius muscle may be visible or palpable. If the diagnosis is uncertain, MRI shows the area of disruption better than CT or ultrasonography. Only conservative management is required to treat ruptures of the gastrocnemius muscle. Initial management includes relative rest, ice, compression, elevation (RICE) and early weight bearing as tolerated. Ankle or foot bracing that holds the ankle in a position of slight plantarflexion may be helpful, and some studies have shown an increased rate of healing with the use of bracing. Physical therapy progresses until the patient is pain free and has full, symmetric range of motion and strength; sport-specific exercises can then be initiated. Depending on the severity of the rupture, return to play may require from 1 to 12 weeks of rehabilitation. 

TENDINOSIS OF EXTENSOR MECHANISM OF KNEE (JUMPER’S KNEE)

Tendinosis of the extensor mechanism (“jumper’s knee”) is most common in elite athletes in jumping sports but can affect athletes in other sports. The prevalence of jumper’s knee has been estimated to range from 40% to 50% in high-level volleyball players and from 35% to 40% in elite basketball players.

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Classification of Complications After Open Repair of Achilles Tendon Rupture Classification of Wong et al. Minor Wound n  Superficial infection n  Wound hematoma n  Delayed wound healing n  Adhesion of scar n  Suture granuloma n  Skin necrosis n General n  Pain n  Disturbances in sensibility n  Suture rupture  n 

FIGURE 48.29 Elongation of lower pole of patella in tennis player with long history of patellar tendinitis. (From Roels J, Martins M, Mulior JC, Burssens A: Patellar tendinitis [jumper’s knee], Am J Sports Med 6:362, 1978.)

Major Wound n  Deep infection n  Chronic fistula n General n  Deep venous thrombosis n  Tendon lengthening n  Death  n 



TABLE 48.4

Classification of Jumper’s Knee According to Symptoms STAGE 0 1

Classification of Kocher et al.

2

Major n Death n Pulmonary embolism n Deep venous thrombosis n Pneumonia n Skin slough n Sinus formation n Fistula n Tendon lengthening n Second operation 

3 4 5

SYMPTOMS No pain Pain only after intense sports activity; no undue functional impairment Pain at the beginning and after sports activity; still able to perform at a satisfactory level Pain during sports activity; increasing difficulty in performing at a satisfactory level Pain during sports activity; unable to participate in sport at a satisfactory level Pain during daily activity; unable to participate in sport at any level

Modified from Ferretti A, Conteduca F, Camerucci E, et al: Patellar tendinosis: a follow-up study of surgical treatment, J Bone Joint Surg 84A:2179, 2002.

Moderate Delayed healing n Granuloma n Medical infection n Nerve injury  n 

Minor Adhesion

n 

Tendinosis of the extensor mechanism (“jumper’s knee”) usually occurs at the tendo-osseous junction at the inferior pole of the patella and is caused by repetitive traction or overload injury during sports. Prolonged, repetitive microtrauma causes focal mucoid degeneration, fraying, and microtearing of the collagen fibrils. Occasionally, a single episode of eccentric overload or a direct blow to the tendon may cause onset of symptoms. Physical examination usually reveals tenderness at the inferior pole of the patella and often associated abnormalities of patellar tracking, chondromalacia, Osgood-Schlatter disease, or mechanical malalignment of the leg. The tenderness usually is worse with extension than with flexion. Anteroposterior, lateral, and tangential views of

the patella may show radiolucency of the involved pole early in the process. With prolonged symptoms, the involved pole may become elongated (Fig. 48.29). Periosteal reaction of the anterior patellar surface (“tooth sign”) and tendon calcification may be evident, and in long-standing disease stress fracture or disruption of the extensor mechanism may occur. Blazina et  al. described three stages of jumper’s knee based on symptoms: phase 1, pain only after activity; phase 2, pain during and after activity but no significant functional impairment; and phase 3, pain during and after activities with progressive difficulty in satisfactory performance. Phase 4, end-stage disease with stress fracture through the patella or disruption of the extensor mechanism, was later added. Ferretti et  al. classified jumper’s knee symptoms into six stages (Table 48.4) based on the system of Blazina et al. MRI demonstrated medial focal thickening in almost all 11 knees, and all demonstrated a focus of abnormal signal intensity in the proximal third of the patellar tendon. MRI findings correlated with intraoperative findings of degenerative pathologic changes consistent with angiofibroblastic tendinosis. The medial thickening was thought to represent the greater

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CHAPTER 48  TRAUMATIC DISORDERS stresses across the medial portion of the extensor mechanism. Advances in ultrasonography have provided more options for diagnosis and conservative treatment of patellar tendinitis. Patients with symptoms of phase 1 or 2 usually respond well to conservative treatment with activity modification, rest, and antiinflammatory medication. Jumping and eccentric exercises are discouraged, although some now recommend eccentric exercise for treatment of jumper’s knee. Functional, pain-free physical therapy is begun after symptoms resolve, with a gradual return to activity. Cortisone injections should not be used because they may increase the risk of tendon rupture. The same nonoperative protocol, with a longer rest period, can be tried initially in patients with symptoms of phase 3 involvement, but operative treatment is indicated if symptoms persist. Patients with “end-stage” or phase 4 symptoms generally require operative treatment. Several studies have indicated that delays in operative treatment result in worse outcomes, whereas others have found no such correlation. As early as 2 weeks but more commonly at 4 to 8 weeks after patellar tendon rupture, muscle retraction of up to 5 cm may be present, necessitating quadriceps lengthening, tendon or muscle transfer, or a combination of these techniques. For endstage disruption of the extensor mechanism (phase four), repair is as described for acute rupture of the quadriceps (see Technique 48.26) or patellar (see Techniques 48.21 or 48.22) tendon.

CHRONIC PATELLAR TENDINOSIS

Suggested alternatives to open patellar tenotomy of chronic jumper’s knee include eccentric exercise, sclerosing injections targeting the area of neovessels and nerves on the dorsal side of the patellar tendon, injections of PRP, arthroscopic shaving of the same area, and extracorporeal shockwave therapy. Studies of the effectiveness of eccentric training have had conflicting results, with one randomized controlled study reporting results comparable to surgery and another reporting no effect of a 12-week eccentric training program. A systematic review and meta-analysis of 2530 patients found that eccentric exercise therapies obtained the best results at short-term, but multiple injections of PRP obtained the best results at long-term follow-up. A randomized controlled trial comparing ultrasound-guided injection of autologous skinderived tendon-like cells and injection of autologous plasma alone found faster response and greater improvements in pain and function with cell therapy. Satisfactory results were obtained in 74% of 83 knees treated with extracorporeal shockwave therapy, with athletes returning to participation in their sport in an average of 6 weeks. Two studies, however, compared extracorporeal shockwave therapy with PRP injection and found that PRP had significantly better results at 6 and 12 months. Mesenchymal stem cells also may have therapeutic utility in the future. 

 

TENOTOMY AND REPAIR FOR CHRONIC PATELLAR TENDINOSIS TECHNIQUE 48.20

POSTOPERATIVE CARE The knee immobilizer is worn for 3 to 4 weeks, and crutches are used for partial weight bearing. Stage 1 of rehabilitation should emphasize range of motion and isometric strengthening. Closed-chain kinetics are started in stage 2 when swelling and tenderness have resolved. Stage 3 should consist of activity-specific exercises, avoiding eccentric overload. Return to full activities can be allowed when 85% to 90% of strength and full range of motion are achieved.   

STRESS FRACTURE THROUGH THE PATELLA

The same repetitive loading that can cause patellar tendinosis or even patellar tendon rupture can result in a stress fracture of the patella, usually in a young athlete. Initially a stress reaction may produce low-grade symptoms, which if recognized and treated with activity restriction may resolve. If activities are continued, a stress fracture may develop. The most common site of stress fracture is at the junction of the middle and distal thirds of the patella where the fibers of the distal quadriceps and proximal patellar tendons merge and insert. 

 

FIXATION OF PATELLAR STRESS FRACTURE TECHNIQUE 48.21 For stress fracture through the inferior pole of the patella (Fig. 48.30), make a longitudinal midline or curvilinear transverse incision to expose the fracture. n  If the fracture is several weeks old, freshen the fracture surface and insert parallel, vertical 4.0 cancellous screws through the inferior pole. If needed, this can be augmented with nonabsorbable sutures passed circumferentially through the screw holes. n  As an optional step, use an oscillating saw to take a slot graft 10 mm wide × 15 mm long and slide it distally across the fracture site. n  Close the wound in routine fashion and apply a cylinder cast. n 

POSTOPERATIVE CARE  The cast is worn for 6 weeks,

Incise the tendon sheath longitudinally and identify and excise the area of degeneration using longitudinal incisions in the tendon.

n 

The inferior pole of the patella can be curetted or drilled to incite a healing response. n  Suture the defect in the tendon with side-to-side interrupted 2-0 Vicryl sutures. n  Close the peritenon with interrupted absorbable sutures and close the skin and subcutaneous tissue in routine fashion. n  Apply a knee immobilizer. n 

after which active range-of-motion and strengthening exercises are begun. Return to full activity usually is possible at 10 to 16 weeks.   

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Slot graft

B

A

C

D

FIGURE 48.30 Stress fracture of inferior pole of patella. Fracture is secured with parallel screws; corticocancellous slot graft is placed distally across fracture. SEE TECHNIQUE 48.21.

RUPTURE OF EXTENSOR MECHANISM OF KNEE

Disruption of the extensor mechanism of the knee most commonly is caused by fracture of the patella. Disruption of the quadriceps mechanism and disruption of the patellar tendon are the next most common causes. The mechanism of injury usually is an eccentric overload to the extensor mechanism with the foot planted and the knee partially flexed. Patellar tendon rupture or avulsion is more common in patients younger than 40 years old, especially athletes. Quadriceps rupture is more common in older patients and in patients with systemic disease or degenerative changes. Systemic diseases, such as lupus erythematosus, diabetes, gout, hyperparathyroidism, uremia, and obesity, have been associated with disruption of the quadriceps mechanism. A relationship between prior steroid injection, as well as use of corticosteroids or fluoroquinolone antibiotics, and tendon rupture has been documented.

ANATOMY AND PATHOPHYSIOLOGY

Many studies have indicated that degenerative tendinopathy is present before tendon rupture; however, a more recent histologic analysis of 22 ruptured quadriceps tendons

found degenerative changes in only 64%, with the frequency of degenerative changes increasing with age. Numerous authors have documented a history of pain before rupture. Occasionally, as may be the case in an athlete, no history of pain is reported. This is consistent with a subclinical process. Degenerative spurring (“tooth sign”), as seen on a tangential view of the patella, may indicate significant changes in the quadriceps mechanism (Fig. 48.31). 

CLINICAL EVALUATION

Diagnosis of a disrupted extensor mechanism can be difficult, and often diagnosis is delayed, especially in patients with large lower extremities. Extensor mechanism disruption should be suspected in middle-aged or elderly patients with swelling, pain, and dysfunction of the knee, especially if a history of jumping, squatting, or stumbling is reported. An audible pop may be heard. Physical examination usually reveals a palpable gap in the quadriceps tendon, and the patella can be displaced inferiorly. Swelling and ecchymosis may be present. Straightleg raising reveals a significant extension lag. This may be less evident with an intact extensor mechanism. Disruption of the patellar tendon causes similar findings, in addition to a superiorly displaced patella. A lateral radiograph may reveal a

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CHAPTER 48  TRAUMATIC DISORDERS

FIGURE 48.31 Degenerative spurring (tooth sign) on tangential view of patella indicates significant changes in quadriceps mechanism.

Trough in inferior pole

A

B

FIGURE 48.32 Anteroposterior (A) and lateral (B) radiographs of patellar tendon rupture.

superiorly displaced patella, especially if the knee is flexed. If the diagnosis is in doubt, ultrasound or MRI can be helpful. 

TREATMENT OF ACUTE RUPTURE OF PATELLAR TENDON

Rupture of the patellar tendon usually occurs at the inferior pole of the patella; the patella is a part of the proximal segment of the tendon and may be retracted 3 to 5 cm proximal to its normal position by contracture of the quadriceps muscle (Fig. 48.32). Fresh ruptures should be repaired if skin conditions are optimal. It is important to pay close attention to the position of the patella in the sagittal plane to prevent excessive baja or alta. Tensioning of the suture to allow 90 to 100 degrees of passive flexion has been recommended. 

FIGURE 48.33 Technique of repair of fresh rupture of patellar tendon. SEE TECHNIQUE 48.22.  

SUTURE REPAIR OF PATELLAR TENDON RUPTURE TECHNIQUE 48.22

Figure 48.33

With the patient supine and a tourniquet around the upper thigh, make a longitudinal incision centered over the defect. n  With careful subcutaneous dissection, expose the area of the rupture. Identify the infrapatellar branch of the saphenous nerve and retract it during the procedure; the patient n 

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A

B

FIGURE 48.34 Mersilene loop tendon repair. A, Route of burr channels. B, Suturing of ruptured tendon. SEE TECHNIQUE 48.22.

should be informed before surgery that there will likely be a permanent anesthetic area lateral to the incision. n  Use sharp dissection to open the peritenon longitudinally in the midline proximally and distally from the defect. n  Carefully realign the tear, which is most commonly at the tendon-bone junction, replacing the tendon in its anatomic position to allow normal patellar tracking. n  With a rongeur, make a small horizontal trough at the inferior pole of the patella, place three horizontal No. 5 nonabsorbable mattress sutures through the patellar tendon stump and bring the tendon through holes drilled in the patella, drawing the tendon securely to the inferior pole of the patella. This can be accomplished with a suture passer or Beath pin. n  Flex the knee to 45 degrees and place a hemostat parallel to the roof of the intercondylar notch to ensure that patella baja has not been produced. The inferior pole of the patella should be at or just slightly above the hemostat. n  Bury the nonabsorbable suture knots superior to the patella deep to the quadriceps tendon and hold them there during closing of the two vertical windows in the quadriceps with No. 0 absorbable sutures. n  The tendon should be repaired adjacent to the articular surface and not to the anterior surface of the patella. Failure to do this causes tilting of the patella and an increase in patellofemoral forces. n  Identify the full extent of the retinacular tear and repair it with No. 0 absorbable sutures or No. 2 nonabsorbable sutures. n  If the patellar tendon is extensively frayed, two running interlocking No. 5 nonabsorbable sutures can be used to secure the tendon, as described subsequently. Use a suture retriever or Beath pin to thread the suture strands through 3-mm drill tunnels, one horizontally into the tibial tubercle and two vertically into the patella (Fig. 48.34). If secure fixation cannot be obtained with this method, augment the repair with the semitendinosus or gracilis tendon.

FIGURE 48.35 Technique of repair of fresh rupture of patellar tendon. Interlocking sutures are secured through parallel vertical holes drilled in patella and transverse hole drilled in tibial tuberosity. SEE TECHNIQUE 48.22.

Ruptures through the substance of the tendon can be repaired with running interlocking sutures placed in the proximally and distally based bundles and secured through parallel vertical holes drilled in the patella and a transverse hole drilled in the tibial tuberosity (Fig. 48.35). Repair the individual bundles side-to-side after appropriate tendon length is determined. n  If needed after completion of the repair, place a circumferential tension suture of No. 5 nonabsorbable box wire. n 

POSTOPERATIVE CARE  A cylinder cast with the knee in extension or a hinged brace locked in extension is applied, and weight bearing to tolerance is allowed. Straight-leg raising exercises are begun at 3 weeks. At 6 weeks, the cast is removed and a controlled motion brace with a range of motion 0 to 45 degrees is fitted. Motion is increased 10 to 15 degrees each week. Crutches are used for ambulation in the brace until sufficient strength and motion have been regained. If a tension wire was used for protection, it can be removed electively at 10 to 12 weeks under local anesthesia.    

 

SUTURE ANCHOR REPAIR OF PATELLAR TENDON RUPTURE TECHNIQUE 48.23 (DEBERARDINO AND OWENS) Through a midline longitudinal incision over the patellar tendon, incise the peritenon longitudinally and dissect it away from the underlying tendon.

n 

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CHAPTER 48  TRAUMATIC DISORDERS

A

B

FIGURE 48.36 Repair of patellar tendon avulsion with suture anchors (see text). A, For proximal avulsions, three suture anchors are placed in anatomic tendon footprint. B, For distal avulsions, suture anchors are placed in the tibial tubercle. SEE TECHNIQUE 48.23.

Debride or resect any grossly pathologic tendon tissue. For ruptures in the midsubstance of the tendon, expose the full length of the tendon and place two Krackow locking stitches in each tendon stump with No. 2 or No. 5 nonabsorbable suture. Repair the retinaculum with absorbable sutures. With the knee fully extended, tie the four proximal core sutures to the distal ones. n  For proximal avulsion of the tendon from the patella, expose the inferior patellar pole and place three suture anchors equidistant along the anatomic tendon footprint. Pull the suture through the anchor eyelet to produce long and short suture arms. Pass the long suture arm down and back of the tendon stump in a locking Krackow fashion, and use the short arm to reduce the tendon to the patella (Fig. 48.36A). Tie each suture repair securely. n  For distal avulsion of the tendon, the same procedure is used but the suture anchors are placed in the tibial tubercle and the tendon is repaired to the tubercle (Fig. 48.36B). n  Flex the knee to check for gap formation. Close the peritenon with absorbable sutures. n  n 

POSTOPERATIVE CARE  Weight bearing is allowed with the knee braced in full extension. The stability of the tendon repair determines the amount of early flexion allowed with active-assisted range of motion. Motion is progressed as tolerated, with the goal of 90 degrees of flexion by 4 to 6 weeks and full motion by 10 to 12 weeks. Isometric quadriceps contractions can be done immediately after surgery, progressing to straight-leg raises at 6 weeks. Full return to activities is not allowed for 6 months.   

TREATMENT OF CHRONIC RUPTURE OF PATELLAR TENDON

When a rupture of the patellar tendon is more than 6 weeks old, the patella is retracted proximally and may require extensive surgical release to draw it distally to the appropriate level.

Although preoperative traction through a Kirschner wire placed transversely in the patella has been recommended, we now believe better results can be obtained with proximal release of scar tissue and a modified Thompson quadricepsplasty (see Chapter 45), if necessary. Before surgery, lateral radiographs of the uninvolved extremity should be obtained with the knee flexed to 45 degrees to evaluate patellar height; these are compared with radiographs of the involved knee during surgery to determine the appropriate tendon length. Various methods of reconstruction of the patellar tendon have been described. If sufficient patellar tendon is left for repair, augmentation with the semitendinosus or gracilis tendon may be indicated. If the rupture is several months old, an allograft can be used, and an Achilles tendon allograft has been used with some success in this situation. 

 

ACHILLES TENDON ALLOGRAFT FOR CHRONIC PATELLAR TENDON RUPTURE TECHNIQUE 48.24 Make a longitudinal incision beginning 3 to 4 cm above the superior pole of the patella and extending just distal to the tibial tuberosity. n  With sharp subcutaneous dissection, expose the extensor mechanism medially and laterally through the plane of the prepatellar bursa. Medially protect the infrapatellar branch of the saphenous nerve if possible. n  Make a sharp longitudinal incision through the tendon sheath and scar tissue in the midportion of the patellar tendon and expose the remains of the tendon. If sufficient tissue is present to add structural strength to the n 

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PART XIII  SPORTS MEDICINE repair, freshen the ends of the tendon to be used later as described for hamstring augmentation. n  Perform a lateral retinacular release and use blunt and sharp dissection to free the medial and lateral gutters in the suprapatellar pouch. n  If further mobilization is necessary, use a periosteal elevator to dissect the vastus intermedius muscle proximally off the femur. Rarely, a medial release may be required to complete the quadricepsplasty as described by Thompson, but this should be avoided, if possible, to decrease the likelihood of avascular changes in the patella. The lateral incision allows inspection of the intraarticular structures and the patellofemoral articulation. n  If an allograft is necessary, we have had good results using the Achilles tendon, as well as the tibialis and hamstring tendons. Place the allograft over the tibial tuberosity about 4 cm distal to the joint line to estimate the proper length of the trough to be made in this area. n  Use an oscillating saw to make the trough 2.5 to 3.0 cm long, 1.5 to 2.0 cm wide, and 1.5 cm deep. n  Contour the corticocancellous bone attached to the Achilles tendon to fit flush in the trough (Fig. 48.37A). After ensuring proper alignment, secure it in this position with two staggered 4-mm cancellous screws using a lag screw technique or two 6.5-mm partially threaded cancellous screws. n  Identify the attachment of the patellar tendon in the central area of the inferior pole of the patella and place a Kirschner wire through this area, exiting superiorly 3 mm posterior to the central part of the quadriceps tendon. n  Pass an 8- or 9-mm reamer over the Kirschner wire and use a rasp to contour the tunnel edges. n  Fashion the Achilles tendon graft into three branches, the central third consisting of the thick half to two thirds of the tendon. This central branch should be 8 to 9 mm in diameter and should be freed distally far enough to allow

the graft to be pulled up to the inferior pole of the patella without hindering the two lateral branches. n  Place a whipstitch of No. 2 nonabsorbable suture in the central branch and pass it from inferior to superior through the tunnel, exiting through a slit in the quadriceps tendon just superior to the patellar insertion (Fig. 48.37B). A ligament passer may be helpful. n  Tack the tendon in place with multiple interrupted nonabsorbable sutures through the graft in the soft tissue of the inferior pole of the patella and at the edges of the quadriceps tendon just superior to the superior pole of the patella (Fig. 48.37C). n  The appropriate graft length is determined by ensuring the knee flexes to 90 degrees, evaluating Insall’s index, and measuring the alignment of the inferior pole of the patella and ensuring that it is parallel to the roof of the intercondylar notch with the knee at 45 degrees. With the knee extended, there should be about 1.5 cm of slack in the patellar tendon. Obtain a lateral radiograph to confirm correct patellar height compared with the uninvolved extremity. n  When the appropriate patellar level has been determined, use multiple interrupted sutures to tack the patellar tendon stump to the graft, which was passed through the midline slit in the patellar stump. n  Close the lateral release with the knee flexed 30 degrees and carefully check patellar tracking and the quadriceps angle. n  Tack the medial and lateral branches of the graft to the medial and lateral retinaculum using No. 0 nonabsorbable sutures. n  Close the tendon sheath with interrupted 2-0 absorbable sutures, close the subcutaneous tissue with 2-0 absorbable sutures, and close the skin in the usual fashion. n  Alternatively, place suture anchors in the distal pole of the patella and the anterior cortex of the patella and use

Slit in quadriceps tendon Patellar tunnel 8 to 9 mm wide

Trough in tibial tubercle

A

Contour bone to fit in trough

Cancellous screws

B

C

FIGURE 48.37 Technique of reconstruction of chronic rupture of patellar tendon using Achilles tendon allograft. A, Slot measuring 3.0 cm long, 2.0 cm wide, and 1.5 cm deep is cut in tuberosity; graft is contoured to fit. B, Central arm of graft is placed through 9 mm longitudinal tunnel and then through vertical slit in quadriceps tendon. Tunnel is placed centrally to avoid penetration of articular cartilage. C, Graft is secured with multiple sutures. SEE TECHNIQUE 48.24.

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CHAPTER 48  TRAUMATIC DISORDERS these to secure the allograft tendon to the patella. Drape the allograft tendon over the quadriceps tendon and muscle fascia and secure it with nonabsorbable sutures. n  If augmentation of the repair is necessary, use No. 5 nonabsorbable suture placed in a box-stitch fashion through holes drilled in the patella and tibial tubercle. Steel wire or cerclage cables also can be used. n  Apply a cylinder cast or knee immobilizer locked in extension.

POSTOPERATIVE CARE At 10 to 14 days, the cast is removed for wound evaluation and removal of sutures or staples if needed. A cylinder cast or locked brace is worn for 4 to 6 weeks. Active and passive range-of-motion exercises are begun at 4 to 6 weeks. Weight bearing to tolerance with crutches is allowed until sufficient motion and strength allow unassisted ambulation. A progressive strengthening and range-of-motion exercise program is essential to regain function. The timing of rehabilitation can be adjusted depending on the intraoperative findings.    

 

HAMSTRING (SEMITENDINOSUS AND GRACILIS) AUTOGRAFT AUGMENTATION FOR CHRONIC PATELLAR TENDON RUPTURE We have in the past advocated the use of autogenous hamstring tendon grafts in a two-stage procedure in which the quadriceps mechanism is freed and traction is applied through the patella with a Kirschner wire as the first stage.

The second stage is reconstruction of the patellar tendon with the semitendinosus tendon. We now believe a onestage procedure is preferable and that use of both the gracilis and semitendinosus is necessary for augmentation. The semitendinosus is a suitable graft because it is strong native tissue, does not require an additional surgery for removal, and allows immediate postoperative mobilization; harvesting the hamstrings has been shown to cause little functional deficit. A biomechanical study showed that augmentation of the patellar tendon repair decreased gap formation at the repair site after cyclic loading.

TECHNIQUE 48.25 (ECKER, LOTKE, AND GLAZER) Make an incision beginning just proximal and lateral to the patella, extending distally, crossing the midline of the limb inferior to the patella, and ending along the medial flare of the tibia. Expose the patella, quadriceps tendon, and tibial tuberosity. n  Place a Steinmann pin transversely through the midportion of the patella for distal traction (Fig. 48.38A). n  Remove all scar tissue from the remnants of the patellar tendon. n  Now flex the knee and expose the insertions of the gracilis and semitendinosus tendons into the pes anserinus. n  Use a tendon stripper to release the tendons from their proximal musculotendinous junctions and bring the tendons into the primary incision. n  Pass the semitendinosus tendon through an oblique hole drilled in the tibial tuberosity and through one of two transverse holes drilled through the distal part of the patella. n  Then pass the gracilis tendon through the other hole in the patella (Fig. 48.38B). n 

Steinmann pin in patella Divide

Gracilis

Gracilis

Semitendinosus

Fixation wire Twisted fixation wire

A

B

C

FIGURE 48.38 Technique for one-stage delayed reconstruction of patellar tendon. A, Steinmann pin through transverse hole in patella is used for distal traction. B, Proximally divided semitendinosus and gracilis tendons are placed through holes and fixation wire is inserted. C, With patella in normal position, fixation wire is secured and gracilis and semitendinosus tendons are sutured to each other. SEE TECHNIQUE 48.25.

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PART XIII  SPORTS MEDICINE Pass a wire through the patella and the tibial tuberosity and tighten it to maintain a distance between the patella and the tibial tuberosity equal to the length of the patella. n  Suture the semitendinosus and gracilis tendons under tension (Fig. 48.38C). n  Remove the transverse traction pin, close the wound, and apply a cylinder cast.  n 

POSTOPERATIVE CARE At 2 weeks, the cast is removed for wound evaluation and a new cylinder cast or locked brace is applied. At 6 weeks, vigorous straightleg raising with weights and active flexion exercises are instituted.    

 

HAMSTRING AUTOGRAFT AUGMENTATION FOR CHRONIC PATELLAR TENDON RUPTURE TECHNIQUE 48.26 (MANDELBAUM ET AL.) Make a midline approach to the patellar tendon. Make a medial arthrotomy for inspection of the joint and lysis of adhesions as necessary. n  Make a Z-lengthening incision in the quadriceps tendon and a Z-shortening incision through the patellar tendon, using careful dissection to preserve the vascular pedicle in the proximal and the distal flaps (Fig. 48.39A). n  Place sutures in the tendon (Fig. 48.39B) and obtain an anteroposterior radiograph; compare it with the preoperative film of the uninvolved extremity to determine appropriate patellar height. n  When a satisfactory position is obtained, place multiple absorbable sutures in the quadriceps and patellar tendons to secure the repair. n  Expose the distal insertion of the pes anserinus and with a tendon stripper harvest the semitendinosus and gracilis tendons (Fig. 48.39C). n  Suture the tendons together with multiple interrupted absorbable sutures. n  Pass the tendons through a transverse hole in the midportion of the patella and through a transverse hole in the tibial tuberosity in a figure-of-eight fashion. n  Use running interlocking sutures, as described by Krackow, Thomas, and Jones, to suture the tendon to itself (Fig. 48.39D). n  Tack the tendons to the underlying patellar tendon (Fig. 48.39E) and close the wound in the usual fashion. n 

POSTOPERATIVE CARE  Postoperative care is the same as after reconstruction of a neglected rupture of the patellar tendon (see Technique 48.23).   

RUPTURE OF TENDON OF QUADRICEPS FEMORIS MUSCLE ACUTE RUPTURE

Acute ruptures of the quadriceps tendon generally result from eccentric contraction of the extensor mechanism against a sudden load of body weight with the foot planted and the knee flexed. The quadriceps tendon usually ruptures transversely at the osteotendinous junction in older patients and at the midtendon or musculotendinous area in younger patients. A cadaver study identified a hypovascular zone in the quadriceps tendon 1 to 2 cm from the superior pole of the patella, corresponding to the site of spontaneous ruptures reported in the literature. The rupture often extends through the vastus intermedius tendon, slightly proximal to the rupture of the rectus femoris tendon. Incomplete ruptures usually can be treated nonoperatively, depending on the extent of the tear and the patient’s occupation or sports activity, with immobilization of the knee in full extension for 6 weeks, followed by protected range-of-motion and strengthening exercises. When good quadriceps muscle control is regained, and the patient can perform a straight-leg raise without discomfort, the immobilizer is progressively discontinued. For complete ruptures, operative repair should be done as soon as possible. Delays in operative repair can complicate the repair process and lead to unsatisfactory results. Without its distal tendinous insertion intact, the quadriceps apparatus begins to retract in the first few days after injury. After days or weeks, retraction can make apposition of the torn tendon ends difficult and can increase tension on the suture line. Although various techniques have been described for repair of quadriceps tendon ruptures, none has been proved to be the most reliable and effective. Most techniques involve repair of the tendon with sutures passed through holes drilled in the patella, although suture anchors have been used instead. If a local flap technique is to be used for reinforcement, the tendon proximal to the rupture should be evaluated carefully to avoid formation of an additional weakened area. The repair can be protected by a circumferential wire or strong nonabsorbable sutures or by a Bunnell pull-out wire through the medial and lateral retinaculum. PRP injection may aid in the reparative process, although more studies are needed.   

REPAIR OF ACUTE RUPTURE OF THE TENDON OF THE QUADRICEPS FEMORIS MUSCLE TECHNIQUE 48.27

Figure 48.40

Make a midline longitudinal incision 15 to 20 cm long to expose the rupture. n  Irrigate the hematoma and freshen the tendon ends. n  If sufficient tendon is left distally, make an end-to-end repair using multiple No. 2 or No. 5 nonabsorbable mattress sutures through the tendon and No. 0 absorbable sutures to repair the retinaculum. Carefully align the tendon and evaluate patellar tracking and position. Use a circumferential wire or suture for protection of the repair. n 

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CHAPTER 48  TRAUMATIC DISORDERS

Vascularized, attenuated, scarred patellar tendon

A

B

Gracilis muscle tendon Semitendinosus muscle tendon

C

D

E

FIGURE 48.39 Technique of reconstruction of neglected ruptures of patellar tendon. A, Z-shortening of patellar tendon and Z-lengthening of quadriceps tendon. B, Tack sutures are placed in tendons. C, Semitendinosus and gracilis tendons are harvested with tendon stripper and sutured together. D, Tendons are passed through transverse hole in patella and sutured together with Krackow technique. E, Tendons are tacked to underlying patellar tendon. SEE TECHNIQUE 48.26.

In ruptures at the osteotendinous junction, an 8- to 10mm stump of vastus intermedius often is left attached to the patella. Place No. 0 nonabsorbable sutures through the stump and lay them aside for later use. n  With a rongeur, make a small trough in the superior pole of the patella. n  Drill three longitudinal holes about 1 cm apart centered over the anticipated area of attachment of the quadriceps tendon. n  Pass a No. 5 nonabsorbable suture proximally through the quadriceps tendon, using a running interlocking suture, for a distance of about 2.5 cm, until normal-appearing tendon is reached. Pass the suture distally in a similar manner, ending just lateral to the midline of the ruptured tendon. n 

Pass similar sutures along the medial side of the tendon and distally as previously described. n  Pass the suture distally with a suture retriever or Beath pin, place a single throw in the suture, and secure it with a hemostat. n  Move the knee through a range of motion to check patellar tracking and position. n  If placement is satisfactory, bring the sutures in the vastus intermedius stump anteriorly and secure them through the quadriceps tendon while maintaining anatomic position. n  Tie the sutures distally, drawing the tendon into the bony trough. n  Repair the retinaculum with interrupted absorbable sutures and close the skin and subcutaneous tissue in a rou n 

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PART XIII  SPORTS MEDICINE tine manner. Apply a cylinder cast or locked brace with the knee in extension.

POSTOPERATIVE CARE The cylinder cast or locked brace is worn for 6 weeks. Weight bearing with crutches is allowed at 3 weeks. Cast removal and a dial-locked brace is fitted, allowing a range of knee motion from 0 to 60 degrees; the range is increased 10 to 15 degrees each week. An aggressive strengthening program is essential for good functional recovery.   

CHRONIC RUPTURE

When a rupture of the quadriceps tendon is not treated for months or years, its repair is difficult. A defect of 2.5 to 5.0 cm

or more may be present between the ends of the tendon and must be repaired with fascia lata. If the ends can be apposed, the repair is done as described for fresh rupture of the tendon of the quadriceps femoris muscle. If shortening makes apposing the ends of the tendon impossible, tendon lengthening can be helpful. An inverted V is cut through the full thickness of the proximal segment of the quadriceps tendon, with the inferior ends of the V ending 1.5 to 2.0 cm proximal to the rupture (Fig. 48.41). The triangular flap thus fashioned is split into an anterior part of one third of its thickness and a posterior part of two thirds. The tendon ends are apposed with interrupted sutures, and the anterior part of the flap is turned distally and is sutured. The open upper part of the V is closed with interrupted sutures. Pull-out wire sutures can be used to protect the repair but typically are not necessary. 

COMPLICATIONS

Suture in stump of vastus intermedius

Loss of motion, especially flexion, is a common complication after rupture of the quadriceps tendon. Extensor mechanism weakness, manifested by quadriceps atrophy and extensor lag, may occur, although this can be corrected with time and proper rehabilitation. Infection and wound problems may occur with subcutaneous placement of nonabsorbable sutures or wires and with an incision directly over the tibial tubercle. Occasionally, these sutures or wires require removal, especially when wire breakage has occurred. Patella alta or baja can be avoided by paying close attention to the position of the patella within the sagittal plane during surgery. Malalignment can lead to degenerative changes at the patellofemoral joint by increasing joint reactive forces. Rerupture that requires repeat repair also is a potential complication. 

Trough in superior pole of patella

RUPTURE OF ADDUCTOR LONGUS MUSCLE

A

B

FIGURE 48.40 Technique for repair of fresh rupture of quadriceps femoris muscle. A, Two parallel interlocking sutures are placed in quadriceps tendon. Small trough is made in anterior aspect of superior pole of patella. Horizontal mattress sutures are placed in vastus intermedius stump. B, Sutures in vastus intermedius are pulled anteriorly through rectus and are tied while tendon is held in anatomic position, using sutures placed distally through drill holes; sutures are then tied distally. SEE TECHNIQUE 48.27.

FIGURE 48.41

Rupture of the adductor longus muscle is characterized by the sudden or gradual appearance of swelling on the medial aspect of the upper third of the thigh with an inconsistent history of trauma. Soccer, ice hockey, and football players seem prone to this condition, and the mechanism of injury may be a combination of wide abduction of the thighs with flexion of one hip and internal rotation of the other. The palpable mass becomes more prominent during contraction of the adductor longus muscle. In 19 NFL players with adductor ruptures, nearly half (9) reported prior abdominal or groin pain.

Codivilla tendon lengthening and repair of quadriceps tendon.

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CHAPTER 48  TRAUMATIC DISORDERS We have found repair of adductor longus ruptures difficult when they occur at the musculotendinous junction. Conservative therapy consisting of ice, thigh compression using a thigh sleeve, and relative rest using crutches if necessary generally is successful. When the acute inflammatory response has subsided, stretching and strengthening exercises are begun for rehabilitation of the hip and thigh musculature, concentrating on the adductors. Minimal functional deficit can be expected with this treatment. Nonoperative treatment was reported to result in a significantly faster return to play (6 weeks) in 14 NFL players compared with operative repair in five players (12 weeks). 

RUPTURE OF GLUTEUS MEDIUS AND MINIMUS TENDONS

Often misdiagnosed as greater trochanteric pain syndrome or trochanteric bursitis, avulsion or rupture of the gluteus medius or minimus tendons (“rotator cuff of the hip”) can cause prolonged lateral hip pain. The cause of tendinosis and rupture of these tendons is uncertain but may be related to local mechanical trauma or predisposing systemic conditions. The incidence of gluteal ruptures is unknown, but gluteal medius or minimus tears have been reported in 4% to 20% of patients undergoing total hip replacement and in approximately 25% of patients with femoral neck fractures. Most reported gluteus medius ruptures have been in women older than age 50 years. The two most reliable signs of a gluteus medius rupture are a Trendelenburg gait and pain on resisted hip abduction, both of which are reported to have a more than 70% specificity and sensitivity. In patients with chronic tears, plain radiographs usually are unremarkable but may show sclerosis, an irregular border, or osteophytes at the anterior edge of the greater trochanter. MRI (91% accuracy) and ultrasound can be used for confirmation of the diagnosis. If diagnosed early, gluteus tendon ruptures can be treated conservatively by unloading the involved hip with crutches or a cane, NSAIDs, and physical therapy once acute symptoms subside. If symptoms persist, operative treatment may involve conjoined tendon debridement, transosseous fixation, and possibly augmentation with a soft-tissue graft. Transosseous

fixation can be obtained with suture fixation through drill holes or suture anchors in the greater trochanteric footprint of the tendons. Open repair has been reported to successfully relieve pain in 90% to 95% of patients. Techniques for endoscopic repair of the gluteus tendon also have been described. 

HAMSTRING TENDON INJURIES

Although hamstring tendon injuries are among the most common musculoskeletal injuries in athletes, there is little information in the literature concerning their diagnosis, treatment, and outcomes. Proximal hamstring avulsions can cause considerable morbidity. A variety of forms of damage exist, including inflammation, degeneration, partial tearing, complete tearing, and a combination of these pathologies. Injuries can range from mild strains of the muscles or myotendinous junction to complete avulsions from the ischial tuberosity with tendon retraction. Complete proximal rupture of the hamstring tendons represents the most severe and uncommon form of hamstring injuries with a prevalence of 9%. A complete rupture is defined as the tearing of all three tendons (biceps femoris, semitendinosus, and semimembranosus) from the ischial tuberosity. The clinical diagnosis can be made when several physical examination findings are present, including absence of palpable tension in the distal part of the hamstrings with the patient prone and the knee flexed to 90 degrees (positive bowstring sign) (Fig. 48.42). Ecchymosis of the posterior aspect of the thigh, a palpable defect of the proximal part of the hamstrings, and weakness in prone knee flexion are also indicative of a proximal avulsion. The diagnosis of a three-tendon avulsion can be confirmed with noncontrast MRI, with use of a combination of fat-suppressed inversion recovery and proton density-weighted fast-spin-echo sequences in multiple orthogonal planes (Fig. 48.43).

Ischial tuberosity

Retracted tendon

F FIGURE 48.42 Positive bowstring sign: absence of palpable hamstring tendons distally. (From Birmingham P, Muller M, Wickiewicz T, et al: Functional outcome after repair of proximal hamstring avulsions, J Bone Joint Surg Am 93:1819, 2011.)

FIGURE 48.43 Fat-suppressed inversion-recovery MRI in the coronal plane, showing retracted tear of proximal hamstrings with surrounding edema. (From Birmingham P, Muller M, Wickiewicz T, et al: Functional outcome after repair of proximal hamstring avulsions, J Bone Joint Surg Am 93:1819, 2011.)

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PART XIII  SPORTS MEDICINE Benazzo et al. and Lempainen et al. detailed specific tendon involvement seen on MRI: 33% of patients had semitendinosus and biceps tendon involvement, and 48% had semimembranosus and three-tendon involvement. Of those with single-tendon involvement, 8% had only semimembranosus involvement, 11% had only biceps femoris involvement, and 1.5% had only semitendinosus involvement. The central or paramuscular tendons of the hamstrings may be the site of chronic and recurrent hamstring injuries. These central tendon tears are mainly located 10 to 20 cm distally from the origin of the hamstrings, and they often are difficult to diagnose because they can mimic a simple muscle strain injury. The central tendons of the hamstrings run from the ischial tuberosity to different insertion sites medially (the semimembranosus and semitendinosus muscles) and laterally (the biceps femoris muscle) around the knee joint. Studies have mainly reported the benefits of surgical treatment of proximal and distal ruptures of the hamstring tendon. Information on central hamstring tendon injuries and the outcome of operative treatment is limited. 

TREATMENT

NONOPERATIVE TREATMENT

In the treatment of chronic proximal hamstring tendinosis and partial tearing of the proximal hamstring origin, a trial of conservative measures is typically completed before surgical intervention. Nonoperative treatment has been recommended for single-tendon tears with or without retraction, although more recent studies have associated nonoperative treatment of hamstring (as low as 71%), and less patient satisfaction when compared with those treated surgically. Consequently, both acute and chronic repairs of complete and partial proximal hamstring ruptures have become more popular in recent years. Nonoperative treatment often results in sciatica, posterior thigh pain, and muscle weakness, leaving patients with poor function and more extensive rehabilitation. Zissen et al. showed fair results with ultrasound-guided injection of corticosteroid in 38 patients, 29 of whom reported immediate relief of symptoms. Half experienced improvement of symptoms for at least 1 month, and a third reported prolonged resolution of symptoms. No complications were identified. 

OPERATIVE TREATMENT

Operative treatment of proximal hamstring tears has been suggested for osseous avulsions with 2 cm or more displacement, for partial tears for which nonoperative treatment is unsuccessful, and for complete three-tendon tears with or without displacement. The literature supports consideration of operative treatment primarily for competitive athletes, but a case-by-case decision is recommended. Operative repair has variable outcomes. Multiple studies have demonstrated improved strength and endurance, with a low risk of reruptures. Functionally, 76% to 100% of patients eventually return to sports, 55% to 100% return to their preinjury activity level, and 88% to 100% of patients are satisfied with surgical outcomes. In their systematic review, Startzman et al. determined that of 266 patients involved, 99% returned to strenuous activities and sports after surgery. Multiple series have shown that surgically repaired proximal hamstring avulsions yield better functional results and patient-reported outcome scores and a higher rate of return

to preinjury activities than patients treated nonoperatively. Bodendorfer et  al. found that satisfaction was much higher among patients treated operatively (93%) compared to those treated nonoperatively (53%), with higher strength in the surgical group compared with the contralateral extremity. In their series of 58 patients with hamstring repairs, Bowman et al. reported an overall satisfaction rate of 94%. At a mean of 7 months, 88% of patients were able to return to their usual sports or recreational activities, with 72% returning at the same level. Birmingham et al. reported that 21 of 23 patients returned to activity at an average of 95% of their preinjury activity level at an average of 9.8 months after repair of proximal hamstring tendon ruptures. Some studies have suggested that delayed repair is associated with poorer results and reduced hamstring strength and endurance, while other studies showed no difference. Sarimo et al. reported that 29 of their 41 patients had good or excellent results, while 12 patients had moderate or poor results. The good or excellent group had an average delay of 2.4 months from the time of injury to the time of surgery, while the moderate or poor group had an average delay of 11.7 months, and the difference was significant. Rust et  al., in their series of 72 patients who had either direct tendon repair with suture anchors or Achilles allograft tendon reconstruction, found that acute repair was superior to surgery for chronic tears with regard to return to sports. Neither Birmingham et  al. nor Klingele and Sallay, however, found a difference in postoperative isokinetic testing between acute (repair less than 4 weeks after injury) and chronic (repair more than 4 weeks after injury) repairs. In their systematic review involving 387 participants, van der Made et al. found no to minimal difference in outcome between acute and delayed repair in terms of return to sports, patient satisfaction, hamstring strength, or pain.   

REPAIR OF PROXIMAL HAMSTRING AVULSION TECHNIQUE 48.28 (BIRMINGHAM ET AL.) With the patient prone, make a longitudinal incision at the edge of the gluteus maximus muscle. A longitudinal incision minimizes excessive traction on the gluteus maximus muscle and the inferior gluteal nerve and allows adequate mobilization of displaced soft-tissue tears. n  Retract the gluteus muscle proximally; identify the fascia distal to the transverse gluteus maximus fibers and open it, taking care to protect the posterior femoral cutaneous nerve and the inferior cluneal nerve. n  Identify the tendons and avulsion site. There usually is a large hematoma present in acute injuries. n  Place traction sutures in the tendon and debride the tuberosity avulsion site. n  The sciatic nerve lies lateral and anterior on the surface of the semimembranosus and semitendinosus. The sciatic nerve dissection is more difficult to perform after 4 weeks have passed since the occurrence of the injury, as scar n 

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CHAPTER 48  TRAUMATIC DISORDERS  

Cephalad

Hamstring tendons

OPEN REPAIR OF PROXIMAL HAMSTRING AVULSION TECHNIQUE 48.29 (BOWMAN ET AL.) With the patient prone, make an 8-cm horizontal incision in the gluteal crease. Carry out cautious subcutaneous dissection to identify and protect the posterior femoral cutaneous nerve. n  Identify the inferior gluteus maximus musculature and retract it superiorly and laterally. n  Identify the sciatic nerve, neurolyse it, and protect it throughout the procedure. n  Identify the hamstring sheath and incise it longitudinally to expose the invested hamstring tendons. n  Define the ischial tuberosity, perform bursectomy, and roughen the bone with a Cobb elevator and a rongeur. n  Place a double-loaded 2.3-mm Iconix (Stryker) or 4.5-mm PEEK Corkscrew (Arthrex) suture anchor in the oblique lateral facet of the ischial tuberosity. n  Insert a modified Krackow suture in the proximal hamstring tendons and use a tension-slide technique to bring the tendon down to the bone. n  Evaluate the adequacy of the repair and insert a second or third anchor as needed. n  Place the suture ends through a 4.75-mm SwiveLock (Arthrex) and set them proximally to complete double-row repair.     n 

Distal hamstring muscle FIGURE 48.44 Mobilized proximal hamstring tendons with Krackow stitches in place and exiting proximally. (From Birmingham P, Muller M, Wickiewicz T, et al: Functional outcome after repair of proximal hamstring avulsions, J Bone Joint Surg Am 93:1819, 2011.) SEE TECHNIQUE 48.28.

tissue can begin to encase the nerve, making it difficult to mobilize the nerve safely; thus the dissection is best performed by someone experienced in nerve dissection. n  With use of two Orthocord sutures (DePuy Mitek, Raynham, MA), place two sets of Krackow stitches in the tendon, exiting proximally (Fig. 48.44). n  Debride the tuberosity to bone and place two UltraFix RC anchors (ConMed Linvatec, Utica, NY) in the tuberosity approximately 1 inch (2.54 cm) apart. n  Repair the tendons back to the lateral aspect of the ischial tuberosity. n  If the semimembranosus tendon is distinguishable, place it more lateral than the semitendinosus and the biceps femoris tendons in their anatomic locations. n  Pull one limb of the Krackow suture through the anchor, pulling the tendon to bone, and tie it in place. Use a minimum of two anchors to recreate a tendon footprint on the tuberosity, which creates more surface area for tendon-to-bone healing. This can usually be done with minimal knee flexion if done early (30 □  Smoking □  Chronic systemic disease □  □ 

in the crater and stabilized. Displaced loose bodies with viable cartilage and some attached subchondral bone have been successfully reattached and have healed in more than 90% of patients in a study by Magnussen et al. The fragments were trimmed and cancellous bone graft added when necessary to fill the crater. When the fragment is not acceptable, the crater may be treated by microfracture or autogenous osteochondral transfer. Osteochondritis dissecans of the patella may occur on the medial or lateral facet and the central ridge or the medial or lateral aspect of the trochlea. In the case of localized lesions, the first line of treatment is debridement and microfracture. For persistent mechanical symptoms with swelling and pain that does not respond to conservative treatment or microfracture, a second line of treatment in a mature individual with these lesions would be anterior medialization of the tibial tuberosity and autogenous osteochondral transplant as an open procedure if indicated (see Chapter 45). It is important to note that the condition of the surrounding cartilage, viability of the meniscus, stability of the knee, and alignment of the extremity weighs greatly on the long-term results of these lesions. Smoking and obesity negatively affect results as does age older than 30 to 45 years (Box 51.5). 

POSTOPERATIVE CARE Postoperative management consists of immobilization in a restricted motion brace, with the arc of motion controlled to prevent contact of the tibial articular surface with the lesion. Use of crutches with partial weight bearing is encouraged until early healing is noted radiographically. Four to 6 weeks of immobilization for young patients is common, whereas older patients with larger lesions should continue the immobilization and avoid weight bearing until definite radiographic evidence of healing is noted. Range-of-motion exercises should be performed for 15 to 20 minutes two to three times daily.    

 

 

ARTHROSCOPIC DRILLING OF AN INTACT LESION OF THE FEMORAL CONDYLE TECHNIQUE 51.13 Perform a complete and systematic diagnostic arthroscopy with the 30-degree viewing arthroscope in the anterolateral portal. n  Inspect carefully the articular surface of the medial femoral condyle, varying the degree of flexion of the knee between 20 and 90 degrees to view the posterior extent of the lesion. The articular surfaces appear smooth except for a slightly raised irregularity at the borders of the lesion. n  Insert a probe through the anteromedial portal and carefully probe this irregular line to ensure there is no break n 

in the continuity of the articular surface overlying the subchondral bone lesion. n  If the lesion is intact, perforate it with multiple holes using a 0.045-inch Kirschner wire. Position the Kirschner wire perpendicular to the articular surface, with the soft tissues protected by a sleeve or cannula over the wire (Fig. 51.38). Access for drilling inferocentral lesions of the medial femoral condyle usually is through the anteromedial portal; laterocentral lesions may be approached better by bringing the Kirschner wire through the anterolateral portal while viewing through the anteromedial portal. If the patient is not fully skeletally mature and the physis is open, take care not to penetrate too deeply and injure the physis. A radiographic image can be used to pass a 0.045-inch Kirschner wire starting distal to the physis and ending just proximal to the articular surface, thus preserving the cartilage. Passing one wire through the cartilage to exit laterally can act as a guide for the wires to be passed from proximal to the lesion. n  Thoroughly lavage and suction the joint and remove the instruments.

ARTHROSCOPIC SCREW FIXATION FOR OSTEOCHONDRITIS DISSECANS LESIONS IN THE MEDIAL FEMORAL CONDYLE We generally prefer the use of an absorbable screw fixation technique for unstable fragments. For unstable fragments, metal screws provide greater security but must be removed. Bioabsorbable screws have less secure fixation, have variable absorption, and sometimes cause synovitis; however, removal may not be necessary.

TECHNIQUE 51.14 Evaluate the defect and determine the best method of fixation. Displaced lesions that require contouring probably are best treated open through a parapatellar incision.

n 

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PART XIV ARTHROSCOPY For relatively stable lesions, debride the base and secure the lesion with cannulated bioabsorbable screws placed perpendicular to the lesion. n  If the defect is large, use cancellous bone obtained from the proximal tibia to fill the cavity. n  Secure the lesion with small 1.5- to 2.7-mm metal screws. n 

POSTOPERATIVE CARE  Immediate range of motion is encouraged. Non–weight bearing with crutches for 12 weeks is necessary for healing and to protect the joint surfaces until the metal screws are removed arthroscopically if necessary.   

OSTEOCHONDRITIC LOOSE BODIES Osteochondritic loose bodies that are already completely detached and floating free within the joint usually are not suitable for reduction and fixation or bone grafting. Only a recently detached loose body with viable cartilage and bone and a fresh crater base is suitable for replacement and fixation. More often the loose body or bodies become rounded off and cannot be made to fit congruously back within the crater by either open or closed methods. In these instances, the loose bodies should be extracted from the joint, the base of the crater cleared of fibrous debris, the underlying eburnated and sclerotic bone perforated with multiple drill holes or abraded to bleeding cancellous bone, and the edges and walls of the crater contoured and smoothed without removing additional healthy articular cartilage. Postoperatively, immediate motion and weight bearing are allowed. Prolonged protection in these circumstances does not seem to improve coverage of the base of the crater with fibrocartilaginous tissue. Constant passive motion for 6 weeks has proved effective. Larger defects (1.0 to 2.5 cm) in a weight-bearing portion with a wall of intact cartilage surrounding the defect are preferably treated by use of an osteochondral autograft transfer (OATS) type of graft to plug the defect. 

OSTEOCHONDRAL AUTOGRAFTS

The first reports of osteochondral autograft transfer were by Yamashita et al. in 1985 followed by Fabbriciani et al. in 1992. The osteochondral transfer method for autogenous material has developed into two similar procedures. One method involves the use of individual donor cores 5 to 10 mm in size, whereas the other uses smaller plugs, ranging from 2.7 to 8.5 mm, which are believed to cause less trauma to the donor site and can be plugged into the recipient site to restore an area about 2 cm in diameter. The larger graft, which proponents believe fills the recipient site with more cartilage, can be used in defects ranging from 1.0 to 2.5 cm. Many researchers think that the most advantageous size graft is 4.5 to 6.5 mm. When multiple grafts are used (mosaicplasty), an open technique is preferable to enable ideal restoration of the articular cartilage surface (see Chapter 45). When multiple grafts are taken, the defect is thought to fill with 60% to 80% of hyaline cartilage. To maximize cartilage transfer, a cartilage bone paste can be used to fill the small defects between the cartilage surfaces. Osteochondral autograft transfer is indicated for patients who are younger than age 45 years and have a sharply defined defect with normal-appearing hyaline cartilage surrounding the borders of the defect. Lesions should be unipolar

and generally no more than 2.0 to 2.5 cm. Relative contraindications to the procedure are patients older than 45 years of age and obvious chondromalacia of the articular cartilage surrounding the defect. For best long-term results, normal mechanical alignment and a stable knee are necessary. 

 

OSTEOCHONDRAL AUTOGRAFT TRANSFER TECHNIQUE 51.15 Inspect the osteochondral defect arthroscopically and measure the size of the lesion. Use a set of OATS sizer/tamps with heads of 5 to 10 mm to determine precisely the diameter of the defect. The color-coded tamps correspond in size with the diameter of the tube harvesters (Fig. 51.39A). n  Assemble the tube harvester driver/extractor. n  Load the donor tube harvester with the collared pin into the base of the driver and tighten the chuck. Screw a cartilage protector cap onto the back of the driver. When seated, the collared pin protrudes a few millimeters past the sharp cutting tip of the harvester to protect articular surfaces (Fig. 51.39B). n  When an acceptable position is established, drive the donor harvester with a mallet into subchondral bone or to a depth of approximately 15 mm. Avoid rotating the harvester during impaction. n  Remove the harvester and bone core by axially loading the harvester and rotating the driver 90 degrees clockwise and then 90 degrees counterclockwise (Fig. 51.39C). n  Fully insert the recipient harvester into the driver and insert the protector caps in a similar fashion. During socket creation, maintain a 90-degree angle to the articular surface to end up with a flush transfer. Rotate the harvester so that the depth markings are seen. Maintain a constant knee flexion angle during harvesting (Fig. 51.39D). n  After using a mallet to drive the tube harvester into subchondral bone to a depth of approximately 13 mm (2 mm less than the length of the donor core), extract the recipient bone core in the same manner as the donor bone core, and measure and record the depth of the core (Fig. 51.39E). n  Use the calibrated OATS alignment stick of the appropriate diameter to measure the recipient socket depth and align the angle of the recipient socket correctly in relation to the position of the insertion portal when using an arthroscopic approach (Fig. 51.39F). n  Reinsert the donor harvester, collared pin, and autograft core into the driver. Unscrew the cap and remove the Thandled midsection. This exposes the end of the collared pin that is used to advance the bone into the recipient socket. n  Insert the pin calibrator over the guide pin and press into the open back of the driver (Fig. 51.39G). Insert the donor tube harvester’s beveled edge fully into the recipient socket. Stabilize the harvester during autograft impaction. Use a mallet to tap the end of the collared pin lightly and drive the bone core into the recipient socket (Fig. 51.39H). n 

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY

BONE GRAFTING

Cancellous bone grafts can be packed into the base of the crater in partially detached lesions before reduction and fixation to obliterate step-off. A cancellous graft can be obtained from the proximal tibia, using a trephine coring needle or similar device to obtain the harvest. This is placed arthroscopically or by open technique behind the osteochondritis dissecans lesion, packing it to a smooth surface before fixation with a cannulated screw. Autogenous chondrocyte implantation of the osteochondritis dissecans lesions should be contained and should have a depth of bone loss of less than 8 mm. Bone loss of more than 8 mm should be bone grafted, and a staged procedure should be performed 6 to 12 months later. These techniques are discussed further in Chapter 45. Osteochondral defects larger than 2.5 cm are treated with allograft transfer or an autogenous chondrocyte implantation sandwich technique (Fig. 51.40). Osteochondritis dissecans treated with stacked “snowman” plugs have a reported shortterm failure rate of 33%, and this procedure should not be routinely performed.  FIGURE 51.38 Technique for drilling intact lesion of osteochondritis dissecans. Multiple perforations of lesion of medial femoral condyle are made using Kirschner wire through anteromedial portal. SEE TECHNIQUE 51.13.

Maintain a stable knee flexion angle and position of the harvester during this step. Carefully advance the collared pin until the end of the pin is flush with the pin calibrator on the back of the driver/extractor. This provides exact mechanical control to ensure proper bone core insertion depth. The predetermined length of the collared pin is designed to advance the bone core so that 1 mm of graft is exposed from the recipient socket when the pin is driven flush with the end of the pin calibrator. One can see the core insertion as it is occurring by viewing the core and the collared pin advancement through the slots in the side of the harvester. n  Alternatively, the core extruder is an option to using the mallet to insert the bone core into the recipient socket. Place the donor harvester into the chuck of the fully assembled tube harvester driver/extractor. As described previously, insert the beveled edge of the donor tube harvester into the recipient socket. While keeping the donor tube harvester firmly in position, slowly screw the core extruder into the rear of the fully assembled driver/extractor. Advance the core extruder by turning it in a clockwise motion, forcing the bone core from the donor tube harvester into the recipient socket. When the core extruder is fully seated, the bone core should remain slightly proud. n  Remove the donor tube harvester and position a sizer tamp, measuring at least 1 mm in diameter larger than the diameter of the bone core, over the bone core. Final seating of the bone core flush with surrounding cartilage is achieved by tapping the tamp lightly with the mallet (Fig. 51.39I). n  When multiple cores of various diameters are elected to be harvested and transferred into specific quadrants of the defect, each core transfer should be completed before proceeding with further recipient socket creation. This prevents potential recipient tunnel wall fracture and allows subsequent cores to be placed directly adjacent to previously inserted bone cores (Fig. 51.39J).    n 

CRUCIATE LIGAMENT RECONSTRUCTION

The selection of grafts depends on the surgeon’s preference and the tissues available. Among the autogenous tissues currently available, the most commonly used are central one third patellar tendon, quadrupled hamstrings of 8 mm or more, and, less commonly, quadriceps tendon grafts. Each of these grafts has been shown to have sufficient load-to-failure strength and stiffness to replace the cruciate ligament (Table 51.2). Another important consideration in selecting an appropriate graft is graft creep or stress relaxation of the graft over time, the occurrence of which may be more frequent with hamstring tendons than with ligaments, such as the patellar or quadriceps ligament. Fixation strength, including pull-out strength, graft slippage, and bony ingrowth, also is important. Fixation with interference screws, if performed properly, provides sufficient strength with bone­–patellar tendon–bone grafts. Use of the BioScrew for fixation of soft-tissue grafts is enhanced by tunnel compaction and secondary fixation. The time of graft incorporation into bone varies considerably from study to study, ranging from 3 weeks for bone plugs to more than 3 months for soft tissues. Generally, bone plug graft incorporation into the tunnel occurs at around 6 weeks, with soft-tissue grafts taking 2 to 3 weeks longer. Aperture tunnel widening occurs to various degrees during the first 6 weeks and continues until 12 weeks, after which the tunnels begin to narrow somewhat. Successful cruciate ligament reconstruction is best accomplished by secure anatomic graft placement and physiologic repair or reconstruction of all secondary stabilizers, including menisci. Failure rates for anterior cruciate ligament reconstruction have been shown to be significantly increased when preoperative 3+ pivot shift or hyperextension of more than 5 degrees is present. Anterior cruciate ligament plus anterolateral ligament reconstruction results in a less than 3% failure rate, 2.5 times lower than isolated anterior cruciate ligament reconstruction with bone–patellar tendon–bone graft, and 3.1 times lower than reconstruction with hamstring grafts. Failure of medial meniscal repair is 2 times lower with anterior cruciate and anterolateral ligament reconstructions combined. Abnormal varus alignment or tibial slope causes an increase in graft stress and failure. Double-bundle anterior cruciate or posterior

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Donor 90°

A

Donor

C

B

Alignment stick

Recipient

D

E

F

FIGURE 51.39 Osteochondral autograft transfer. A, Size of defect determined. B, Harvester driver extractor assembled with tube harvester and collared pin loaded. C, Harvester driven into subchondral bone. D and E, Harvesting of graft. F, Calibrated osteochondral allograft transplantation system (OATS) alignment stick of appropriate diameter used to measure recipient socket depth and align angle of recipient socket correctly to position of insertion portal.

cruciate ligament reconstruction has not shown clinically significant functional improvement. Likewise for posterior cruciate ligament reconstruction, no clinically significant improvements in functional results are obtained using inlay compared to transtibial or allograft compared to autografts. There is a clear difference in autograft superiority in anterior cruciate ligament reconstruction in young athletes and should be routinely used. Finally, snug suspension fixation allows more graft-to-bone contact and more complete healing for soft-tissue grafts. Donor morbidity and cosmesis also must be considered when choosing a graft. Bone–patellar tendon–bone harvest is associated with increased risk for patellar tendinitis, especially if larger grafts are harvested. Acute and delayed stress fractures of the patella resulting from taking too deep of a

graft also have been reported. Properly harvested tendon and rehabilitation show no significant difference in arthritis. The weakness from harvesting two hamstrings approaches 20%. Injury to the saphenous nerve from graft harvest can be detrimental. The ideal graft and graft fixation techniques are still being developed. Currently, patellar tendon and hamstring grafts, when fixed at the joint line with secondary fixation on the tibia, have almost equal reported results, slightly favoring the patellar tendon for stability and lower failure rate. The ultimate goals of anterior cruciate ligament surgery are a graft with low morbidity; excellent cosmesis, strength, and stiffness; and secure early fixation and incorporation near the joint line. At this time, there are over 100,000 anterior cruciate ligament reconstructions done yearly, with the number

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY

G

H

I

J

FIGURE 51.39, cont’d G, Donor harvester, collared pin, and autograft core reinserted into driver. H, Donor tube harvester inserted into recipient socket. I, Sizer tamp, measuring 1 mm in diameter larger than bone core, positioned over bone core. J, Harvested and transferred cores. SEE TECHNIQUE 51.15.

increasing. Also, the number of allografts being used for primary and revision procedures is increasing. The advantages of using allografts are decreased postoperative morbidity, improved cosmesis, decreased operating time, and preservation of the extensor mechanism, which may eliminate some postoperative symptoms of tendinitis or chondromalacia. Arguments against using allografts are that the length of time for allograft maturation and the percentage of incorporation of the graft into the ligamentous structure vary. Studies have shown failure rates in athletes to be as much as two to four times that of autograft. The potential for infection is low, including bacterial infection and hepatitis. The possibility of AIDS transmission is approximately 1 in 1.5 million.

The cost and availability of good, young allografts of appropriate length also is an issue. The increased use of allografts in primary procedures is making it more difficult to obtain these for revision or for multiple ligament procedures. The use of allografts in our opinion is best reserved for revision surgery in patients who do not wish to have the patellar tendon harvested from the contralateral leg and for patients with multiple ligamentous injuries in whom morbidity may be increased from harvesting a graft in an already severely injured knee. Allografts also may be useful in athletes who are negatively affected by harvest site symptoms. In revision surgery, reported failure rates range from 27% to 46%. The best results are obtained with the use of autografts. The first

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A

8mm bur

B

Fibrin glue

Cells

Membranes

C

FIGURE 51.40 Technique for “sandwich” implantation of autologous chondrocytes. A, Osteochondral defect and bone defect are similar. B, High-speed burr, usually 8 mm in diameter, is used to remove all subchondral sclerotic bone back to healthy-appearing spongy bone. Base is drilled multiple times with a Kirschner wire to enhance the blood supply to the grafting site. A 3-mm burr is used to undermine the subchondral bone to secure the membrane when it is glued to graft with gentle pressure and covered by a neutral patty as the tourniquet is released and knee is brought into full extension. Neutral patty is removed, defect is separated and dry from underlying marrow space and bone graft. C, Second membrane is sutured to surface and sealed with fibrin glue. Cultured chondrocytes are then injected or “sandwiched” between two membranes. (Redrawn from Minas T, Oguar T, Headrick J, et al: Autologous chondrocyte implantation “sandwich” technique compared with autologous bone grafting for deep osteochondral lesions in the knee, Am J Sports Med 46:322, 2018.)



ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

TABLE 51.2

Ultimate Load to Failure and Stiffness of Current Graft Selections in Cruciate Ligament Surgery

GRAFT SELECTION Native ACL (Woo et al.) Native PCL (Race, Amis) Patellar tendon (Cooper et al.) Quadruple hamstring tendon (semitendinosus and gracilis) (Hamner et al.) Quadriceps tendon (Stäubli et al.)

ULTIMATE STRENGTH TO FAILURE (N) 2160 1867 2977 4140

STIFFNESS (N/MM) 242 — 455 807

2353

326

ACL, Anterior cruciate ligament; PCL, posterior cruciate ligament. From Brand J, Weiler A, Caborn DNM, et al: Graft fixation in cruciate ligament reconstruction, Am J Sports Med 28:761, 2000.

attempt at anterior cruciate ligament reconstruction should be the best attempt. The keys to surgical success are ample mental preparation, knowledge of recent literature, and proper patient evaluation, including assessment of potential stresses, ligamentous deficiencies (including the anterolateral ligament), and ultimate goals of the patient. This evaluation should help to determine what to correct and how and when to proceed with surgery. Finally, prioritizing the surgical approach is necessary as far as alignment, instability, articulation, and the meniscus are concerned. Preparation also includes knowledge of potential complications and the ability to recognize and resolve them (Figs. 51.41 and 51.42).

For pathologic laxity of the anterior cruciate ligament in an active, healthy individual who wishes to remain active, our preferred treatment is endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft or a quadrupled hamstring graft of 8 mm or more. Surgery is performed as an outpatient or 23-hour admission after the acute inflammatory reaction has resolved. We use physical therapy to regain muscle tone and motion before the surgical procedure, which usually takes 10 to 21 days before surgery. 

 

ANATOMIC SINGLE-BUNDLE ENDOSCOPIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING BONE–PATELLAR TENDON–BONE GRAFT TECHNIQUE 51.16 Place the patient supine on the operating table. After general endotracheal anesthesia has been administered, examine the uninjured knee to obtain a reference examination for ligamentous laxity. Examine the injured knee and record Lachman and pivot shift instability.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Screw divergence < 15° minimum (15-mm fixation) Ingrowth (maximize contact) (minimize motion) Bone mineral index (dilation) helpful

Graft–tunnel length mismatch

Untreated instabilities (posterolateral corner)

Slippage Soft-tissue grafts Fixation

Impingement

Autograft

Allograft

Harvest morbidity Tendinitis Patellar fracture Neuropathy Strength Stiffness Creep (pretension) FIGURE 51.41

Unrestricted rehabilitation

Delayed maturation

Location

Resistant organisms

Surgical limitations

(Postoperative infection)

Chondral/meniscal damage Graft rejection Healing response Arthrofibrosis Complex regional pain syndrome

Immune response

Causes of complications of anterior cruciate ligament reconstruction.

Performance • Knowledge and skill • Adherence to details • Avoidance, recognition and early intervention in complications

Evaluation • Honest assessment of surgical results • Radiographs, examination, KT-1000

FIGURE 51.42

Keys to surgical success.

of tourniquet time is anticipated for completion of the procedure, arthroscopy portals should be made for joint evaluation and notch debridement before inflating the tourniquet and making the skin incision for harvest of the patellar tendon. n  Inject the portals with lidocaine and epinephrine to help control bleeding and maintain hypotensive anesthesia. An arthroscopy pump can be used to maintain proper joint distention and to reduce bone bleeding. n  Unless contraindicated, administer antibiotics and ketorolac (Toradol) before tourniquet inflation (30 mg intravenously in patients younger than 65 years; 15 mg in patients older than 65 years or in those weighing less than 50 kg). Two additional doses can be given postoperatively, not to exceed 120 mg or 60 mg, respectively.  GRAFT HARVEST With the knee held in 90 degrees of flexion, make a 4- to 6-cm medial parapatellar incision starting inferior to the patella and extending distally medial to the tibial tuberosity. The length of this incision depends on the size of the patient. n  Expose the patella and tendon by subcutaneous dissection. n  Make a straight midline incision through the peritenon and dissect the peritenon from the patellar tendon, taking the flaps medially and laterally. n  With the knee held flexed to maintain some tension on the patellar tendon, measure the width of the tendon. n  Harvest a 10-mm-wide graft or one third of the tendon, whichever is smaller, from the central portion of the tendon, extending distally from the palpable inferior tip of n 

Apply a tourniquet around the upper thigh and use a well-padded lateral post. Secure a 5-L intravenous saline bag to the table to act as a stop to maintain 90 degrees of knee flexion (Fig. 51.43A). n  Prepare and drape the extremity with standard arthroscopy drapes and use an Esmarch wrap for exsanguination. Inflate the tourniquet to 100 mm Hg above the patient’s systolic pressure. n  If preoperative examination revealed significant laxity, proceed with patellar tendon harvesting. n  Arthroscopic joint portals can be made through this initial skin incision. If the status of the anterior cruciate ligament is in question (Fig. 51.44), or if more than 90 minutes n 

Excessive graft stress

Nonanatomic placement

Preparation • Analyze (patients, literature, failures) • Simplify • Prioritize

Implementation • Correct and refine techniques • If it isn’t working, fix it

Malalignment

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30°

3 cm 5 cm

A

50°

B

1–2 mm posterior wall

Slope of medial tibial spine

35°

A B

C

Edge of lateral meniscus

D

F

E

H

G

FIGURE 51.43 Anatomic single-bundle anterior cruciate ligament reconstruction. A, Saline arthroscopy bag is secured to table to assist in maintaining knee flexion. B, Increase in tibial guide angle. Length of tunnel can be increased. C, Tibial tunnel using inner edge of lateral meniscus and medial tibial spine as reference points. Tibial tunnel should be reamed into edge of medial spine and should be centered just slightly anterior to inner edge of lateral meniscus. D, Three reference points—inner edge of lateral meniscus, base of medial spine, and posterior cruciate ligament—are used for tibial guidewire. E, Tibial tunnel should be posterior to roof of altered intercondylar notch to prevent graft impingement in knee extension. F, Note position of femoral tunnel, about 4 to 5 mm off articular surface and 2 to 3 mm anterior to over-the-top spot. G, With knee flexed more than 100 degrees, guidewire is placed up femoral tunnel through middle cannula. Interference screw is passed, ensuring that guidewire and traction suture is straight line and ensuring minimal divergence between screw and bone plug. H, Use of sheath to protect graft and to assist in placing screw parallel to graft. SEE TECHNIQUE 51.16.

the patella. Maintain straight, single-fiber plane incisions while harvesting the tendon. The size of the graft is individualized. For a large football lineman, an 11-mm graft or double-bundle graft may be indicated. For a small patient, a 9-mm or possibly an 8-mm graft and tunnels may be indicated.

Use an oscillating saw with a 1-cm-wide blade to make the bone cuts. Run the saw blade 15 degrees oblique to a line perpendicular to the anterior cortex of the patella, keeping 2 mm of the saw blade visible, to make a cut 8 mm in depth. This cut should be about 10 mm wide × 17 mm long measured from the bony tip of the patella.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Make 25-mm-long cuts distally and free the tibial graft with a curved osteotome. n  Flip the plug and place it back into the harvest site. Drill a 2-mm hole, 3 mm from the distal tip of the plug, and pass a no. 5 Tevdek suture (Deknatel OSP, Fall River, MA). An assistant should hold this at all times to ensure that the graft is not contaminated. n  Complete the patellar cut with the saw placed at the inferior pole of the patella, 7 to 8 mm deep and parallel to the anterior cortex. 

Reflect the flap medially with a periosteal elevator to expose the proximal tibia for later placement of the tibial tunnel. n  Make standard anteromedial and anterolateral arthroscopy portals, taking care not to damage the remaining portion of the patellar tendon. n  Systematically examine the knee and evaluate and treat any associated intraarticular pathologic condition. n  Perform meniscal suturing before securing the anterior cruciate ligament graft. n  With the arthroscope in the anterolateral portal and a 5.5mm full-radius resector in the anteromedial portal, release the ligamentum mucosum and partially resect the fat pad to allow full exposure of the joint during the procedure. n  Resect the soft tissue from the intercondylar notch and from the tibial stump by sliding the resector between the remaining stump of the anterior cruciate ligament and the posterior cruciate ligament. The opening of the blade should always be pointed superiorly or laterally to avoid damage to the posterior cruciate ligament. n  Leave the outline of the tibial and femoral footprint intact as a reference guide (Figs. 51.45 and 51.46). Visualize the lateral intercondylar ridge, the lateral bifurcate ridge, and the extent of the footprint that covers the lower third of the notch wall. Use an awl to make a hole in the posterosuperior part of the footprint so that the tunnel will have a 2-mm posterior wall and be about 5 mm superior to the articular cartilage in the posterosuperior aspect of the footprint just below the intercondylar ridge. After properly marking the footprint while visualizing from the anteromedial portal, the scope can be changed to the anterolateral portal and a small internal notchplasty can be performed to aid with graft placement. n  With the knee in 30 degrees of flexion to expose the opening of the notch, evaluate the available space between the posterior cruciate ligament and lateral wall and the architecture of the roof. Use a 5.5-mm burr to enlarge the notch as indicated. The notch should be opened to look like an inverted U. Do not extend the notchplasty

n 

n 

GRAFT PREPARATION Secure the graft to the top drape on a previously prepared table that holds appropriate-sized bone plug trials, rongeurs, a 2-mm drill bit, a Silastic block, a skin marker, no. 5 Tevdek sutures on Keith needles, and an 18-gauge steel wire. n  Commercially available graft preparation boards make tensioning and graft preparation much easier. n  Contour the graft with the rongeurs so that it fits through the 10-mm trial, ensuring that the complete graft would pass through the trial. n  Drill a single hole in the patellar plug about 3 mm from the end. n  Bullet the end of the bone plug to make passage easier. n  Drill a hole in the tibial bone plug. This plug should be 20 mm. n  Place a no. 5 nonabsorbable suture through the better bone plug to be placed into the femoral tunnel and an 18-gauge wire through the other plug, which is placed into the tibial tunnel. The use of a wire prevents cut-out before firm fixation is obtained. n  Mark the bone-tendon junction on the cancellous side of the graft at both ends with a methylene blue pencil and measure the total graft length. Wrap it in a sterile salinesoaked sponge and place it in a safe holding location. n  Use electrocautery to make an inverted L-shaped flap through the tibial periosteum, starting about 2.5 cm distal to the joint line and extending distally 1 cm medial to the tibial tuberosity. n 

A

B

FIGURE 51.44 A, Calcified stump of anterior cruciate ligament after chronic tear. B, Empty lateral wall sign indicating anterior cruciate ligament-deficient knee; anterior cruciate ligament can be attached to posterior cruciate ligament, giving false indication of functional ligament. SEE TECHNIQUE 51.16.

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A

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C

D FIGURE 51.45 A, View of anterior cruciate ligament footprint using a 30-degree scope through a lateral parapatellar portal. Note proximity of anterior cruciate ligament footprint to articular surface of femoral condyle. B, Same footprint from medial parapatellar portal. Entire extent of footprint can be visualized more adequately through this view. C, Femoral footprint just posterior to center of anterior cruciate ligament footprint is marked with awl to use as reference point for reaming of femoral tunnel. D, Reamer. SEE TECHNIQUE 51.16.

A

B

FIGURE 51.46 A, Flat-blade reamer for femoral tunnel preparation. B, Completion of tunnel preparation. SEE TECHNIQUE 51.16.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY too far medially or superiorly, which would interfere with the patellofemoral articulation. Often, the opening needs to be enlarged only 2 to 3 mm superiorly and laterally. The burr can be placed in reverse to remove the articular fringe and smooth the initial notchplasty. n  As the notchplasty proceeds posteriorly, flex the knee from 45 to 60 degrees; when the notchplasty is complete, the knee should be at 90 degrees of flexion. Use controlled strokes with the burr from posterior to anterior. Posteriorly, open the notch enough to accommodate the 10-mm endoscopic reamer. Smooth the edges of the tunnel by placing the burr in reverse or by using an arthroscopic rasp. 

TIBIAL TUNNEL PREPARATION AND DETERMINING APPROPRIATE LENGTH If transosseous drilling of the femoral tunnel is planned, the tibial tunnel will need to be placed at a 45-degree sagittal angle, starting just lateral to the medial collateral ligament. More acute angles tend to undercut the tibial articular suture and result in an oblique nonanatomic aperture. This does allow for a longer tibial tunnel, and the anatomic femoral footprint can be successfully reamed about 60% of the time through the tibial tunnel. A low medial portal may be preferable to independently ream the femur in the posterosuperior aspect of the direct fibers of the anterior cruciate ligament stump. n  When placing the tibial guide intraarticularly, be aware of the intended tunnel length and direction so that the graft can be secured in an anatomic, impingement-free position. Proper length and direction of the tunnel require a starting point approximately 1 cm proximal to the pes anserinus and about 1.5 cm medial to the tibial tuberosity to form a 30- to 40-degree angle with the shaft of the tibia. One should see this wire being directed to approach the femoral pilot hole (see Fig. 51.43B). Intraarticular reference points that can serve as guides include the anterior cruciate ligament stump, the inner edge of the anterior horn of the lateral meniscus, the medial tibial spine, and the posterior cruciate ligament (see Fig. 51.43C and D). n  When evaluating pin placement in a two-dimensional picture, in the anteroposterior plane, ensure that the guidewire exits just anterior to a reference line extended medially from the inner edge of the lateral meniscus. This point should be approximately 7 mm anterior to the posterior cruciate ligament and 2 to 3 mm anterior to the peak of the medial spine at the center of the anterior cruciate ligament footprint. In the mediolateral plane, ensure that the wire enters at the base of the medial spine or just slightly medial to the center of the anterior cruciate ligament footprint (see Fig. 51.43D). n  The unaltered roof of the intercondylar notch normally forms an angle of 35 to 40 degrees with the long axis of the femur (see Fig. 51.43E). To prevent impingement, an internal notchplasty, as previously described, may be necessary, as is appropriate tunnel placement. Use the tibial and femoral landmarks described earlier and place the guide at 55 to 60 degrees to the tibial plateau surface to obtain sufficient tunnel length and an angle that allows the graft angle to approximate that of the original. Measure the tibial tunnel length directly off the guide n 

calibrations and approximate the length of the tendinous portion of the graft. The tunnel length should be sufficient to allow at least 20 mm of bone to be secured in the tibial tunnel for stable fixation. n  If the tendinous portion of the graft is 50 mm long or less, increase the guide angle to produce a longer tibial tunnel. The tunnel can be easily increased to 45 to 50 mm long to accommodate the longer graft. n  Using the guide, advance the wire approximately 10 mm into the knee while observing through the arthroscope. n  Place a clamp over the intraarticular end of the Kirschner wire to prevent advancement. Ream over the wire with a reamer 2 mm smaller than the intended final tunnel. n  Leave the protruding end of the reamer in the tunnel and examine the tunnel for appropriate impingement-free position as the knee is moved through a full range of motion. n  Make necessary adjustments with the 8-mm reamer. n  Prevent bowstringing of the anterior cruciate ligament graft over the posterior cruciate ligament by leaving a 2-mm posterior wall between the tibial tunnel and the posterior cruciate ligament. By directing the tunnel just lateral to the posterior cruciate ligament, the graft lies on the posterior cruciate ligament without bowing around the ligament. n  Ream the tunnel with a reamer the size of the graft and use the full-radius resector to contour the edges of the tunnel and resect any remaining soft tissue that might block extension. n  Place a rasp through the tunnel to complete contouring and ensure that the external portion of the tunnel is free of soft tissue. 

FEMORAL TUNNEL PREPARATION Visualize from a high anteromedial portal just medial to the tip of the patella. n  Use a spinal needle to identify the best position for a low medial portal about 2.5 cm medial to the patellar tendon and just above the meniscus. A guide is placed to ensure that the tunnel is just anterior to the anteromedial bundle; that is, leaving a 2-mm posterior wall and about 5 mm from the femoral articular surface (see Fig. 51.43F). Flex the knee 120 degrees and use a flat-blade reamer to avoid articular damage and to allow optimal visualization of tunnel placement (see Fig. 51.44). Advance the reamer 1 mm and recheck the tunnel location. If it is in the desired location, ream a 30-mm tunnel if possible. n  Carefully retract the reamer and remove it from the joint, being careful not to enlarge the tunnel and ream out the posterior wall of the femur. n  Smooth the edges of the femoral tunnel with a full-radius resector. n  Use the tunnel notcher to make a 25-mm-long slot per the guidewire.  n 

GRAFT PASSAGE Use the eyelet guidewire to pass a suture loop with tails through the femoral tunnel and out through the lateral thigh. Retrieve the loop through the femoral tunnel. Use this loop to pass the graft up through the tibial tunnel and then guide it into the femoral tunnel using a probe. The

n 

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PART XIV ARTHROSCOPY cancellous surface of the femoral bone plug is positioned to face anteriorly. n  When the graft is in the femoral tunnel, pass a flexible guidewire through the medial portal, and with the wire parallel to the graft, advance both up into the tunnel. Ensure that at least 2 cm of bone plug remains in the tibial tunnel for later fixation; if necessary, recess the graft into the femoral tunnel and choose a longer interference screw to fix the graft at the femoral aperture. 

GRAFT FIXATION Secure the graft with an interference screw with a sheath passed through the low medial portal to form a straight line with the tunnel (see Fig. 51.43G and H). The screw should firmly engage the bone and be flush with the femoral aperture. Visualization is aided by placing the scope into the top of the notch and looking down on the tunnel. n  Move the knee through a range of motion while holding tension distally on the graft to ensure that there is no impingement or pistoning of the graft. If the graft tightens more than 2 mm with knee flexion, remove the graft and move the femoral tunnel, or both tunnels, slightly posterior using a convex arthroscopic rasp. Slight tightening during knee extension is normal. n  Rotate the tibial bone plug counterclockwise (right knee) so that the cancellous plug faces laterally, thus replicating the anterior cruciate ligament fiber orientation. n  If no graft pistoning or impingement is evident, hold the tension on the graft for approximately 3 minutes while cycling the knee to allow for collagen fiber stress relaxation. If the graft tends to impinge in one direction, use the screw to push the bone graft in the opposite direction. n  Tension the graft with 8 to 10 lb of pull. Overtensioning of the graft can cause failure because of joint capture or graft necrosis. n  Secure the graft with a screw equal to the gap size plus 5 mm with the knee in full extension. n  If the tendon is so long that the bone plug is completely out of the tibial tunnel, as may be the case with an allograft mismatch, then a biocomposite or noncutting screw 1 mm smaller than the tunnel can be used for softtissue fixation of the patellar tendon and bone construct. n  Move the knee through a full range of motion and ensure there is no evidence of capture of the knee joint. Observe and probe the graft arthroscopically to ensure that it is taut. The graft should be slightly tighter than a normal anterior cruciate ligament. Also ensure that there is no impingement and that no bone or screw protrudes into the joint from the tibial or femoral tunnel. n  Check the stability of the knee by Lachman and pivot shift maneuvers. The knee should be just slightly tighter than the uninjured knee. n  If fixation is secure, remove the 18-gauge wire and the tension sutures.  n 

CLOSURE Loosely approximate the patellar tendon with simple interrupted absorbable sutures through the anterior portion of the fiber of the tendon. n  Place bone saved from contouring of the bone plugs into the patellar defect and close the peritenon. n 

Remove the sutures from the thigh proximally (femoral bone plug) and from the tibial bone plug distally. n  Remove any protruding bone, leaving a smooth surface distally. n  Close the periosteal flap back over the tunnel. n  Close the subcutaneous tissues with interrupted 2-0 Vicryl suture and approximate the skin with a running subcuticular 4-0 Monocryl suture. n  Apply adhesive strips loosely over the closure and apply a sterile dressing, a cooling sleeve, and an elastic wrap. n 

POSTOPERATIVE CARE For the anterior cruciate ligament rehabilitation protocol, see Box 51.6.    

 

TWO-INCISION TECHNIQUE FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING BONE– PATELLAR TENDON–BONE GRAFT The two-incision technique can be used for revisions, for recovery of a posterior wall blowout, and for pediatric patients.

TECHNIQUE 51.17 The basics for the two-incision technique are as described for the endoscopic technique except a lateral exposure is necessary.

n 

LATERAL EXPOSURE  Make a 4-cm lateral incision starting 1.5 cm proximal to the flare of the lateral condyle and centered directly over the iliotibial band. Carry the dissection down to the iliotibial band and expose it with wide subcutaneous dissection. n  Divide the iliotibial band in its midline and extend it proximally and distally from the skin incision. The lower edge of the distal portion of the vastus lateralis can be felt by sweeping a finger along the intermuscular septum. n  Slide a periosteal elevator under the edge of the vastus lateralis and lift the muscle anteriorly over the lateral part of the femur without injuring the muscle belly. n  Place a Z-retractor over the femur to hold the vastus lateralis superiorly. n  Use electrocautery to make a longitudinal incision through the periosteum just proximal to the flare of the condyle and extend it proximally for about 2.5 cm. Use a periosteal elevator to expose the bone and the over-the-top spot where the flare of the condyle and the metaphysis of the femur meet. Coagulate the lateral genicular vessels in this area. n 

   

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY BOX 51.6



Anterior Cruciate Ligament Rehabilitation Protocol Stage I: 0-2 Weeks Patellar mobilizations (emphasize superior/inferior glides) n MCB 0-90 degrees n Quadriceps sets/SLR all planes (emphasize SLR without extension lag) n Prone/standing hamstring curls n Passive extension (emphasize full extension) n Prone hangs n Pillow under heel n Passive, active, and active-assisted ROM knee flexion n Wall slides n Sitting slides n Prone towel pulls n Edema control—compression pump n Electrical stimulation for muscle re-education if poor QS n PWB 50%-75% with crutches or WBTT without crutches if MCB locked in full extension n Sleep in brace locked in extension n 

Goals Full knee extension ROM n 90-Degree knee flexion ROM n Good QS n Emphasize normal gait pattern  n 

Goals n ROM 0-120 degrees n FWB without crutches, no limp 

Stage II: 8-10 Weeks Progress above-listed exercises n Slow-form running with sport cord (forward and backward) n Isokinetic quadriceps work at different speeds (60, 90, 120 degrees per second) n Begin lunges n At 10 weeks, begin Fitter, slide board  n 

Stage III: 12-16 Weeks Full-range isotonics on Kin-Com dynamometer (begin moving antishear pad down) n Knee extension machine with low weight/high repetitions n Lateral sport cord drills (slow, controlled) n Kin-Com dynamometer test hamstrings, discontinue isokinetic hamstrings if 90% n Progress isokinetic quadriceps to full extension by 16 weeks  n 

Stage II: 2-4 Weeks MCB full ROM n Progress ROM to 120 degrees by week 4 n Progress SLR and prone/standing hamstring curls with weights n Bike for ROM, begin low-resistance program when ROM adequate n Stool scoots n FWB with crutches; discontinue crutches when ambulating without limp n Begin double-leg BAPS, progress to single leg n Begin double-leg press with light weight/high repetitions n Wall sits at 45-degree angle with tibia vertical, progress time n Lateral step-ups (4 inches) when able to perform single-leg quarter squat n Hip machine and hamstring machine when able to perform SLR with 10 lb n Treadmill (forward and backward) with emphasis on normal gait n Knee extension 90-60 degrees (submaximal) with manual resistance by therapist n 

Stage II: 4-6 Weeks Progress to full ROM by 6 weeks n Begin Kin-Com isokinetic hamstring progression (isotonic/ isokinetic) n Begin Kin-Com dynamometer quadriceps work 90-40 degrees isotonics with antishear pad n Stairmaster (forward and backward) n Progress closed chain exercises n At 6 weeks, begin Kin-Com dynamometer quadriceps work 90-40 degrees isokinetics (start with higher speed and work on endurance) n Aquatic exercises  n 

Stage IV: 16-20 Weeks n Kin-Com dynamometer test for quadriceps, retest hamstrings if necessary n Begin plyometric program with shuttle, minitrampoline, jump rope if quadriceps strength 65%, no effusion, full ROM, stable knee n Begin jogging program if quadriceps strength is 65%  Stage V: 20-36 Weeks Agility training n Sport-specific drills (e.g., carioca, 45 cutting, figure-of-eight) n Retest quadriceps if necessary  n 

Stage VI: Agility Testing 36 Weeks Return to sport if: n Motion > 130 degrees n Hamstrings > 90% n Quadriceps > 85% n Sport-specific agility training completed and testing passed n Maintenance exercises two to three times per week n 

BAPS, Biomechanical Ankle Platform System; FWB, full weight bearing; MCB, motion control brace; PWB, partial weight bearing; QS, quadriceps setting; ROM, range of motion; SLR, straight-leg raises; WBTT, weight bearing to tolerance.

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Incision

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B

C

D FIGURE 51.47 Endoscopic quadruple hamstring graft. A, A 3-cm incision is made over the pes anserinus tendon. B, Inferior retraction of the sartorius tendon, exposing the gracilis and semitendinosus tendons. C, Placement of Penrose drain around the hamstring tendon to be harvested. D, Two running, interlocking (Krackow) sutures. SEE TECHNIQUE 51.18.

 

ENDOSCOPIC QUADRUPLE HAMSTRING GRAFT TECHNIQUE 51.18 GRAFT HARVEST  Make a 4-cm incision anteromedially on the tibia starting approximately 4 cm distal to the joint line and 3 cm medial to the tibial tuberosity (Fig. 51.47A). n  Expose the pes anserinus insertion with subcutaneous dissection. n  Palpate the upper and lower borders of the sartorius tendon and identify the palpable gracilis and semitendinosus tendons 3 cm to 4 cm medial to the tendinous insertion (Fig. 51.47B). n  Make a short incision in line with the upper border of the gracilis tendon and carry the incision just through the first layer, taking care not to injure the underlying medial collateral ligament. n  With Metzenbaum scissors, carry the dissection proximally up the thigh. Stay in the same plane and maintain adequate exposure by using properly placed retractors. Careful observation of structures is necessary to avoid injuring the n 

saphenous vein or nerve by straying from the plane of dissection. n  With a curved hemostat, dissect the gracilis and semitendinosus tendons from the surrounding soft tissues about 3 cm medial to their insertion onto the tibia. n  After carefully identifying each tendon, use a right-angle vascular clamp to pass a Penrose drain around the gracilis tendon and release its fibrous extensions to the gastrocnemius and semimembranosus muscles (Fig. 51.47C). These fibrous extensions come off the hamstring tendons at 6 cm to 7 cm proximal to their distal attachment. Subperiosteally dissect the tendons medially to the insertion and release them sharply. Do not damage or release the sartorius tendon. Place a nonabsorbable Krackow stitch on the tendon ends using different colored sutures to differentiate the two tendons (Fig. 51.47D). Use a tendon tube sizer to accurately measure the give of the quadrupled tendon. n  Palpate all sides of the tendon to ensure there are no fibrous extensions before releasing it with an open-end tendon stripper. If firm resistance is felt, redissect around the tendons with a periosteal elevator and Metzenbaum scissors. Release the tendon proximally by controlled tension on the tendon, while advancing the stripper proximally. The muscle should slide off the tendon as the stripper is advanced proximally.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Use the same procedure to release the semitendinosus tendon. n  At a separate table, separate the muscle from the tendon with a no. 10 blade. n  Place a Krackow-type whipstitch in both ends of each tendon with no. 2 nonabsorbable sutures. Fold both tendons in half to form four strands of tendon. n  Perform a limited notchplasty and tunnel placement as described for the endoscopic bone–tendon–bone technique (see Technique 51.16). n  Ream the tibial tunnel at 50 degrees to the tibial articular surface. The tunnel is reamed 2 mm smaller than the graft size and serially dilated to produce a snug fit. Dilation of the tibial tunnel has been shown to significantly increase the pull-out strength. The tunnel length should be 30 to 35 mm to allow fixation near the articular surface. n  A low anteromedial portal is used for reaming the femoral tunnel. Use an EndoButton (Smith & Nephew, Memphis, TN) or similar type device to secure 20 to 25 mm of tendon in the femoral tunnel. After tensioning the graft for 3 minutes while cycling the knee, use a composite screw 1 mm smaller than the tunnel for tibial fixation and use secondary suture and post fixation. A screw sheath, softtissue fixation device may also be used to secure the tibial end of the graft.  n 

POSTOPERATIVE CARE See Box 51.6 for postoperative anterior cruciate ligament rehabilitation. We generally proceed more slowly with rehabilitation when a hamstring graft has been used. The patient generally is allowed to return to full activity at around 9 to 12 months.    

 

ALL-INSIDE QUADRUPLE HAMSTRING GRAFT ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION A quadriceps graft can be harvested through a 4-cm vertical incision extending proximally from the superior patella. Instrumentation is available to simplify the harvest for primary or revision procedures.

TECHNIQUE 51.19 After graft harvest, prepare the graft by folding it appropriately and then, using a “buried knot” technique, start from the inside of the graft and place the needle around two limbs. Wrap the suture around the graft, then place the needle through the second set of graft limbs from outside-in. Tension the suture and tie a knot to secure the stitch. Repeat on the other end of the graft for a total of two stitches in each end (Fig. 51.48A). n  Assuming a maximal intraarticular length of 30 mm, there will be approximately 20 mm of graft in the femoral and tibial n 

socket. Drill the femur 20 mm deep and the tibia approximately 30 mm deep to allow an extra 10 mm for tensioning.

FEMORAL SOCKET PREPARATION  For medial portal drilling, use the TightRope Drill Pin, transportal ACL guides, and low profile reamers. Note the intraosseous length from the TightRope Drill Pin. n  After socket drilling, pass a suture with the TightRope Drill Pin for later graft passing (Fig. 51.48B). n  Using the FlipCutter drill, place the guide into the joint and push the drill sleeve down to bone and note the measurement where the drill sleeve meets the guide (Fig. 51.48C, inset). n  Drill the FlipCutter into the joint, remove the guide, and tap the stepped drill sleeve into bone. Flip the blade on the FlipCutter and ream until the desired socket depth is reached. n  Flip the FlipCutter blade straight and remove it from the joint while keeping the drill sleeve in place. Pass a FiberStick suture through the stepped drill sleeve and dock for later graft passage.  n 

TIBIAL SOCKET PREPARATION Drill the FlipCutter reamer into the joint. Remove the marking hook and tap the stepped drill sleeve into the bone (Fig. 51.49A). n  Flip the blade and lock into cutting position. Drill on forward, with distal traction, to cut the socket. Use the rubber ring and 5-mm markings on the cutter to measure socket depth (Fig. 51.49B). n 

GRAFT PASSAGE  Straighten the FlipCutter blade and remove from the joint. Pass a TigerStick suture into the joint and retrieve both the tibial TigerStick and the femoral FiberStick sutures out the medial portal together with a Suture Retriever (Fig. 51.50A). Retrieving both sutures at the same time helps avoid tissue interposition that can complicate graft passage. n  Pass the blue button suture and the white shortening strands through the femur. Remove slack from sutures and ensure equal tension. Clamp or hold both blue and white sutures and pull them together to advance the button out of the femur. Pull back on the graft to confirm that the button is seated (Fig. 51.50B). n  While holding slight tension on the graft, pull the shortening strands proximally, one at a time, to advance the graft. Pull on each strand in 2-cm increments (Fig. 51.50C). The graft can be fully seated into the femur or left partially inserted until tibial passing is complete, which allows fine tuning of graft depth in each socket. n  Cinch a suture around the end of the TightRope ABS loop to use for passing (Fig. 51.50D, inset). Load the cinch suture and the whipstitch tails from the graft into the tibial passing suture. Pull distally on the tibial passing suture to deliver both the TightRope ABS loop and the whipstitch sutures out of the tibial distally (Fig. 51.50D). n  Advance the graft into the tibia by pulling on the inside of the ABS loop and whipstitch sutures (Fig. 51.50E). n  Load the TightRope ABS button onto the loop. Pull on the white shortening strands to advance the button to bone and tension the graft (Fig. 51.50F). Ensure that the button has a clear path to bone so that no soft tissue is trapped underneath it. n 

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A

B

C FIGURE 51.48 All-inside quadruple hamstring graft anterior cruciate ligament reconstruction. A, Graft preparation. B and C, Femoral socket drilling. Inset, Guide is placed into joint and drill sleeve is pushed down to bone. SEE TECHNIQUE 51.19.

Load the whipstitch sutures into the button and tie a knot for backup fixation (Fig. 51.50G). Alternatively, backup sutures can be fixed to the tibia using the Swivel Lock.    

n 

 

ANATOMIC DOUBLE-BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION Anatomic double-bundle anterior cruciate ligament reconstruction places the femoral graft into the femoral footprint

of the native anterior cruciate ligament, which has been shown to result in closer knee joint kinematics than the original isometric femoral position. A three-portal technique adds an accessory medial portal to create the femoral tunnel.

TECHNIQUE 51.20 (KARLSSON ET AL.) A three-portal approach, using standard anterolateral and central medial portals and an accessory anteromedial portal, allows for a complete view of the entire ante-

n 

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B

A

FIGURE 51.49 Tibial socket preparation. A, After reaming, stepped drill sleeve is tapped into bone. B, Measure socket depth using rubber ring and 5-mm markings on cutter. SEE TECHNIQUE 51.19.

rior cruciate ligament and its femoral and tibial insertion sites. n  Using a spinal needle, create the central portal while viewing through the lateral portal. The spinal needle should be in the center of the notch in a proximal to distal direction. n  Create the accessory anteromedial portal superior to the medial joint line, approximately 2 cm medial to the medial border of the patellar tendon. The femoral tunnels can be drilled through the accessory medial portal. n  Locate the ideal anterior cruciate ligament insertion sites for anatomic tunnel placement. Anterior cruciate ligament remnants can be used to determine this site. On the femoral side, the bony landmarks, such as the lateral intercondylar ridge and lateral bifurcate ridge, can be used, as well as posterior cartilage border. With the knee flexed 90 degrees, the femoral insertion site encompasses the lower 30% to 35% of the notch wall (Fig. 51.51). n  Mark the tibial and femoral insertion sites of the anterior cruciate ligament and measure to determine the tunnel location and size. If the insertion site is smaller than 14 mm in diameter, a double-bundle reconstruction may become challenging. The width of the notch entrance and

its shape will determine if a double-bundle technique can be used, but generally a notch width no smaller than 12 mm is the minimal size required. n  Create the femoral posterolateral tunnel first, through the accessory anteromedial portal, followed by the tibial anteromedial and posterolateral tunnels. Place the anteromedial and posterolateral tunnels in the center of the native anteromedial and posterolateral tibial and femoral insertion sites. n  Drill the femoral anteromedial tunnel through the accessory medial portal or through the tibial anteromedial or posterolateral tunnel if this allows for the native femoral insertion site to be reached. n  In determining the size of the tunnels, aim to restore as much of the native insertion site as possible while maintaining an approximately 2-mm bony bridge between the bundles. n  After the tunnels have been drilled, prepare the grafts. The graft size should be equal to the tunnel diameter. Tension the anteromedial and posterolateral grafts separately, with the anteromedial graft in approximately 45 degrees of knee flexion and the posterolateral graft in full knee extension. n  For fixation, use suspensory fixation on the femoral side to avoid disruption of the insertion site, which can occur

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C

A

E

B

D

F

G

FIGURE 51.50 Graft passage. A, Femoral sutures are retrieved out medial portal. B, Blue and white sutures are passed through the femur and pulled together to advance the button out of femur. C, With slight tension on graft, the shortening strands are pulled proximally to advance graft; each strand is pulled in 2-cm increments. D and inset, Suture is cinched around end of TightRope ABS loop to use for passing. Tibial passing suture is used to deliver TightRope ABS loop and whipstitch sutures out of distal distally. E, Graft is advanced into tibia. F, Button is advanced to bone and graft is tensioned. G, Whipstitch sutures are loaded into button and a knot is tied for backup fixation. SEE TECHNIQUE 51.19.

with aperture interference screw fixation. Use interference screw fixation on the cortical tibial side.   

Quadriceps Tendon Graft.  Use of a 10-mm-wide quadriceps tendon with an attached piece of patellar bone for anterior cruciate ligament reconstruction has been described. We have rarely used this as a revision technique, but it is an attractive alternative.  Anterior Cruciate Ligament Injuries in Skeletally Immature Individuals.  With athletic activities becoming more competitive at a younger age, the incidence of anterior cruciate ligament injuries in skeletally immature individuals has rapidly increased over the past decades. These injuries present a particularly perplexing problem with the potential for physeal injury with reaming of tunnels that is

counterbalanced by the potential for meniscal damage from recurrent giving way in these individuals. Two principles must be followed: (1) preserve menisci if possible, and (2) prevent recurrent giving way. In some less active individuals with mild-to-moderate instability, reduction of activity level may be all that is necessary until they have had an appropriate growth spurt and maturing of the physes. In active, young boys, sometimes this is quite hard to accomplish. In these children when there is a meniscal tear or recurrent giving way, a physeal-preserving, soft-tissue graft procedure is best. A small central tunnel made in the tibia just above the physis with preservation of the physis in the femur seems to be a safe procedure. The benefit of stabilizing the knee seems to outweigh the small potential for growth disturbance if these procedures are done correctly. It is necessary to use a softtissue graft to avoid bone or fixation across the physis. The

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY

BOX 51.7

Pitfalls of Transepiphyseal Replacement of the Anterior Cruciate Ligament Using Quadruple Hamstring Grafts in Skeletally Immature Patients

Upper 60% to 65% of notch wall

Suboptimal Graft Placement n Optimal graft placement is essential to restore normal knee kinematics and avoid physeal injuries. n Avoid placing the femoral or tibial drill hole anterior; correct positioning of the drill hole is crucial in preventing graft impingement. n Surgery should not proceed without clearly seeing the physes on anteroposterior and lateral planes using C-arm. n Guidewires should be inserted under real-time C-arm viewing. n Confirm arthroscopically that the guidewires enter the joint in the center of the footprint of the anterior cruciate ligament on the femur and in the posterior footprint of the anterior cruciate ligament on the tibia. 

Lateral intercondylar ridge

Lateral bifurcate ridge

90° FIGURE 51.51 Right knee in 90 degrees of flexion showing whole lateral wall of notch. Femoral anterior cruciate ligament (ACL) insertion site is clearly demarcated by lateral intercondylar ridge and lateral bifurcate ridge. It can be seen that anterior cruciate ligament attaches to lower 30% to 35% of lateral notch wall area when the knee is in operating position. (From Karlsson J, Irrgang JJ, van Eck, et al: Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2, Am J Sports Med 39:2016, 2011.) SEE TECHNIQUE 51.20.

Incorrect Diameter of Transepiphyseal Drill Holes n A drill bit corresponding to the smallest size through which tendon would easily pass should be used to make transepiphyseal holes. n A small-diameter drill bit is less likely to damage the physes, and a snug fit promotes healing of the graft to bone. n Graft passage can be eased by chamfering the femoral hole and pushing the graft into the hole using a blunt instrument through an anteromedial portal while pulling a no. 5 FiberWire suture tied to an EndoButton. 

tunnel and the tibia can be drilled above the physis, or a small central tunnel through the physis probably is acceptable, particularly in Tanner stages II, III, and IV patients. In younger patients, a procedure going around the physis or an over-thetop procedure as described by Anderson and Kocher, Garg, and Micheli is recommended. 

Failure of Fixation n Load to failure in this technique exceeds normal tensile loads on the anterior cruciate ligament. n In the early phase of healing, failure can lead to instability. n Check the femoral side fixation with C-arm to confirm that EndoButton washer is flush on lateral femoral condyle. 

 

TRANSEPIPHYSEAL REPLACEMENT OF ANTERIOR CRUCIATE LIGAMENT USING QUADRUPLE HAMSTRING GRAFTS The transepiphyseal replacement of anterior cruciate ligament using quadruple hamstring grafts procedure is indicated in patients in Tanner stage I, II, or III of development. The procedure is contraindicated in patients in Tanner stage IV of development, who can have conventional anterior cruciate ligament reconstruction. Pitfalls of this procedure are summarized in Box 51.7.

TECHNIQUE 51.21 (ANDERSON) Place the injured lower limb in an arthroscopic leg holder with the hip flexed to 20 degrees to facilitate C-arm fluoroscopic viewing of the knee in the lateral plane. n  Position the C-arm on the side of the table opposite the injured knee and place the monitor at the head of the table. View the tibial and femoral physes in the anteroposterior and lateral planes before the limb is prepared n 

Graft Slippage Associated With Suture Post Fixation n Minimize slippage by meticulous placement of whipstitches in tendon ends with tight loops placed in close proximity. n Pretension graft using Graftmaster (Smith & Nephew Endoscopy, Andover, MA) n When tendon graft extends through the tibial hole, augment the tibial fixation by suturing the tendons through the periosteum. Data from Anderson AF: Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients, J Bone Joint Surg 86A:201, 2004.

and draped. When the distal part of the femur is viewed, adjust the C-arm so that the medial and lateral femoral condyles line up perfectly with the lateral plane. Rotate the C-arm to see the extension of the tibial physis into the tibial tubercle on the lateral view of the tibia. n  Make an oblique 4-cm incision over the semitendinosus and gracilis tendons. Dissect these tendons free and transect at the musculotendinous junction with use of a standard tendon stripper and detach distally. n  Double the tendons and place a no. 5 FiberWire suture (Arthrex, Naples, FL) in the ends of the tendons with a whipstitch.

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B

A

D

C

E

F

G

FIGURE 51.52 Anderson transepiphyseal replacement of anterior cruciate ligament using quadruple hamstring grafts. A, Graphically enhanced lateral view from C-arm after drilling of femoral hole. B, Lateral radiograph of tibia, showing correct position of tibial guidewire. Although guidewire appears to enter tibial tubercle in this view, it actually enters epiphysis medial to tibial tubercle. C, EndoButton continuous loop passed around middle of double tendons and looped on itself. D, Semitendinosus and gracilis tendons pulled up through tibia and out of lateral femoral condyle with use of no. 5 suture in EndoButton. E, EndoButton washer is placed over EndoButton, and washer is pulled back to surface of lateral femoral condyle. F, Quadruple hamstring grafts secured distally by tying no. 5 FiberWire sutures over tibial screw and post. G, Radiograph 4 months after surgery, showing properly placed transepiphyseal tibial and femoral holes. SEE TECHNIQUE 51.21.

Place the doubled tendons under 4.5 kg (10 lb) of tension on the back table with the use of the Graftmaster device (Smith & Nephew Endoscopy, Andover, MA). n  Insert the arthroscope into the anterolateral portal and insert a probe through the anteromedial portal. n  Perform intraarticular examination in the usual manner. n  Remove debris in the intercondylar notch and perform a notchplasty to see the anatomic footprint of the anterior cruciate ligament on the femur. n  Repair any substantial meniscal tears found. n  With the C-arm in the lateral position, adjust the limb to show a perfect lateral view. n 

Place the point of the guidewire over the lateral femoral condyle, corresponding with the location of the footprint of the anterior cruciate ligament on the femur. This point is approximately one fourth of the distance from posterior to anterior along the Blumensaat line and one fourth of the distance down from the Blumensaat line (Fig. 51.52A). Make a 2-cm lateral incision at this point. n  Incise the iliotibial tract longitudinally and strip the periosteum from a small area of the lateral femoral condyle. n  Use the C-arm to view the entry point of the guidewire in the anteroposterior and the lateral planes. With the Carm in the lateral plane and with the use of a free-hand n 

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY technique, introduce the point of the guidewire 2 to 3 mm into the femoral epiphysis. Do not angulate the pin anteriorly or posteriorly, but rather keep it perpendicular to the femur in the coronal plane. Rotate the C-arm to the anteroposterior plane to ensure that the guidewire is not angulated superiorly or inferiorly. n  Drive the guidewire across the femoral epiphysis, perpendicular to the femur and distal to the physis (see Fig. 51.52A). Through the arthroscope, view the entrance of the guidewire into the intercondylar notch. The guidewire should enter the joint 1 mm posterior and superior to the center of the anatomic footprint of the anterior cruciate ligament on the femur. n  Leave the femoral guidewire in place and insert a second guidewire into the anteromedial aspect of the tibia, through the epiphysis, with the aid of a tibial drill guide. From the direct lateral position, rotate the C-arm externally approximately 30 degrees to show the physis clearly extending into the tibial tubercle. Drill the guidewire into the tibial epiphysis under real-time fluoroscopic imaging (Fig. 51.52B). The handle of the drill guide must be lifted for the wire to clear the anterior part of the tibial physis. The wire should enter the joint at the level of the free edge of the lateral meniscus and in the posterior footprint of the anterior cruciate ligament on the tibia. n  Arthroscopically confirm the appropriate position of both guidewires at this point. n  Use tendon sizers to measure the diameter of the quadruple tendon graft (which typically is 6 to 8 mm). A tight fit is important; consequently, use the smallest appropriate drill to ream over both guidewires. n  Chamfer the edge of the femoral hole intraarticularly and measure the width of the lateral femoral condyle. Choose the appropriate EndoButton continuous loop (2 to 3 cm) so that approximately 2 cm of the quadruple hamstring tendon graft remains within the lateral femoral condyle. n  Pass the EndoButton continuous loop around the middle of the double tendons and loop inside of itself to secure the tendons proximally (Fig. 51.52C). Alternatively, the tendons can be placed through the continuous loop before the tendon ends are sutured together. That requires drilling and measuring the length of the femoral hole before graft preparation, however. Otherwise, it is difficult to determine the appropriate length of the EndoButton continuous loop necessary to leave 2 cm of the tendon graft within the lateral femoral condyle. n  Place a no. 5 FiberWire suture in one end of the EndoButton and pass a suture passer from anterior to posterior through the tibia and out the lateral femoral condyle (Fig. 51.52D). Pull the EndoButton and tendons up through the tibia and out the femoral hole with the use of the no. 5 suture. n  Place an EndoButton washer, 3 to 4 mm larger than the femoral hole, over the EndoButton. Apply tension to the tendons distally, pulling the EndoButton and washer to the surface of the lateral femoral condyle (Fig. 51.52E). The washer is necessary to anchor the graft proximally because the hole in the femoral condyle is larger than the EndoButton. n  Place the graft under tension and extend the knee to determine arthroscopically if there is impingement of the graft on the intercondylar notch. n  An anterior notchplasty usually is unnecessary when this technique is used; however, if the anterior outlet of the in-

tercondylar notch touches or indents the graft in terminal extension, remove a small portion of the anterior outlet. n  With the knee in 10 degrees of flexion, secure the quadruple hamstring graft distally by tying the no. 5 FiberWire sutures over a tibial screw and post that is placed medial to the tibial tubercle apophysis and distal to the proximal tibial physis (Fig. 51.52F and G). n  If the tendon graft extends through the tibial drill hole, secure it to the periosteum of the anterior tibia with multiple no. 1 Ethibond sutures with use of figure-of-eight stitches (see Fig. 51.52F). Close the subcutaneous tissue and skin in a routine fashion and apply a hinged brace.    

 

PHYSEAL-SPARING RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT The procedure of Kocher, Garg, and Micheli consists of arthroscopically assisted, physeal-sparing, combined intraarticular and extraarticular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft. It is a modification of the combined intraarticular and extraarticular reconstruction described by MacIntosh and Darby. Modifications include application in skeletally immature patients, arthroscopic assistance, graft fixation, and accelerated rehabilitation. Rehabilitation must be geared to the age of the young patient.

TECHNIQUE 51.22

Figure 51.53

(KOCHER, GARG, AND MICHELI) The procedure is done with the patient under general anesthesia as an overnight observation procedure. n  Position the child supine on the operating table with a pneumatic tourniquet around the proximal aspect of the thigh. n  With the patient under anesthesia, confirm anterior cruciate ligament insufficiency. n  Make an incision of approximately 6 cm obliquely from the lateral joint line to the superior border of the iliotibial band. Separate the iliotibial band proximally from the subcutaneous tissue with the use of a periosteal elevator under the skin of the lateral part of the thigh. n  Incise the anterior and posterior borders of the iliotibial band and carry the incisions proximally under the skin with the use of a curved meniscotome. n  Detach the iliotibial band proximally under the skin with the use of a curved meniscotome or an open tendon stripper. n  Leave the iliotibial band attached distally at Gerdy’s tubercle. n  Dissect distally to separate the iliotibial band from the joint capsule and from the lateral patellar retinaculum. n  Tubularize the free proximal end of the iliotibial band with a whipstitch using a no. 5 Ethibond suture (Ethicon, Johnson & Johnson, Somerville, NJ). n 

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PART XIV ARTHROSCOPY Make a trough in the proximal medial tibial metaphyseal cortex and suture the graft to the periosteum at the rough margins with mattress sutures.

n 

POSTOPERATIVE CARE Postoperatively, the patient is permitted touch-down weight bearing for 6 weeks. Immediate mobilization from 0 to 90 degrees is allowed for the first 2 weeks, followed by progression to full range of motion. Continuous passive motion from 0 to 90 degrees is used for the first 2 weeks postoperatively to initiate motion and overcome the anxiety associated with postoperative movement in young children. A protective hinged knee brace is used for 6 weeks after surgery with motion limits of 0 to 90 degrees for the first 2 weeks. Progressive rehabilitation consists of range-of-motion exercises, patellar mobilization, electrical stimulation, pool therapy (if available), proprioception exercises, and closed chain strengthening exercises during the first 3 months postoperatively followed by straight-line jogging, plyometric exercises, sport cord exercises, and sport-specific exercises. Return to full activity, including sports that involve cutting, usually is allowed 6 months postoperatively. A custommade knee brace is used routinely during cutting and pivoting activities for the first 2 years after return to sports.   

FIGURE 51.53 Technique of physeal-sparing, combined intraarticular and extraarticular reconstruction of anterior cruciate ligament. (Redrawn from Kocher MS, Garg S, Micheli LJ: Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents, J Bone Joint Surg 87A:2371, 2005.) SEE TECHNIQUE 51.22.

Examine the knee with the arthroscope through standard anterolateral and anteromedial portals, treat any meniscal injury or chondral injury, and excise the anterior cruciate ligament remnant. n  Identify the over-the-top position on the femur and the over-the-front position under the intermeniscal ligament. n  Perform a minimal notchplasty to avoid iatrogenic injury to the perichondrial ring of the distal femoral physis, which is in close proximity to the over-the-top position. n  Bring the free end of the iliotibial band graft through the over-the-top position with the use of a full-length clamp or a two-incision, rear-entry guide and out through the anteromedial portal. n  Make a second incision of approximately 4.5 cm over the proximal medial aspect of the tibia in the region of the pes anserinus. Carry the dissection through the subcutaneous tissue to the periosteum. n  Place a curved clamp from this incision into the joint under the intermeniscal ligament. n  Make a small groove in the anteromedial aspect of the proximal tibial epiphysis under the intermeniscal ligament with the use of a curved rat-tail rasp to bring the tibial graft placement more posterior. n  Bring the free end of the graft through the joint, under the intermeniscal ligament in the anteromedial epiphyseal groove, and out through the medial tibial incision. n  Place the knee in 90 degrees of flexion and 15 degrees of external rotation. For extraarticular reconstruction, fix the graft on the femoral side through the lateral incision using mattress sutures on the lateral femoral condyle at the insertion of the lateral intermuscular septum. n  Fix the tibial side through the medial incision with the knee flexed 20 degrees and tension applied to the graft. n  Make a periosteal incision distal to the proximal tibial physis as confirmed fluoroscopically. n 

Azar and Miller developed a surgical technique of arthroscopic-assisted ACL reconstruction using a quadruplelooped hamstring graft with a synthetic graft extender and a distal femoral physeal-sparing technique. The graft extender allows a consistent quadrupled hamstring graft, allows the optimal portion of the graft to be delivered to the intraarticular position, and provides sufficient length for proximal and distal fixation. They reported that all 17 patients with this procedure had a stable Lachman test and were able to return to sporting activities. 

 

PARTIAL TRANSEPIPHYSEAL ACL RECONSTRUCTION IN SKELETALLY IMMATURE ATHLETES TECHNIQUE 51.23 (AZAR AND MILLER)

GRAFT HARVEST  After induction of general anesthesia, confirm clinical instability of the knee with Lachman and pivot shift tests. n  Inflate a pneumatic tourniquet and perform diagnostic arthroscopy, with repair of any additional pathology as needed. n  Make a 3-cm longitudinal incision 6 cm below the anteromedial tibial plateau and 3-cm medial to the tibial tubercle and identify the gracilis and semitendinosus tendons. n 

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Carry dissection down to the sartorial fascia and elevate it off the superficial medial collateral ligament in an inverted-L fashion. n  Identify the hamstring tendons and use a right-angle clamp to separate the gracilis from the semitendinosus. n  Use a sharp No. 15 blade to peel the semitendinosus and gracilis off the sartorius at their insertion point and place a clamp on the end of the gracilis tendon. n  Clear attachments from the gracilis and use a tendon stripper to extract the tendon. Extract the semitendinosus in a similar manner. n  Repair the sartorial fascia.  n 

GRAFT PREPARATION  Place a whipstitch into the opposite ends of the tendons with a No. 2 nonabsorbable braided suture (Fig. 51.54A). Fold the tendons over a No. 10 French red rubber catheter that has been cut to 3 cm in length. n  Feed a braided nonabsorbable tape suture through the catheter to act as a graft extender (Fig. 51.54B). n  Trim and size the graft as necessary (Fig. 51.54C) and set it aside under a moistened sponge. n  Mark the optimal 3.5 cm of the graft with a blue marking pen to designate it as the intraarticular portion of the graft.  n 

position around the back portion of the lateral femoral and out to the lateral cortex. n  Under direct fluoroscopic guidance, determine an entry point for a 6.5-mm fully threaded cancellous screw with washer on the distal femur proximal to the physis. Tie the nonabsorbable braided tape previously placed through the red rubber catheter over the 6.5-mm screw post (Fig. 51.54D). n  On the tibial side, place a second 6.5-mm fully threaded cancellous screw with a non-spiked washer distal to the tibial physis (Fig. 51.54E). n  Tension the graft with the leg in extension to avoid overtightening due to the over-the-top position and then tie it over the post (Fig. 51.54F). Assess stability with a Lachman maneuver. n  Reinsert the arthroscope to confirm appropriate graft placement and close the incision in standard fashion. 

POSTOPERATIVE MANAGEMENT  Patients are placed into a hinged knee brace locked in extension and are kept non–weight bearing on the involved extremity. Physical therapy begins within 1 week after surgery. At 3 weeks the knee brace is unlocked from 0 to 90 degrees. Weight bearing is advanced to partial weight bearing at 6 weeks when the brace is unlocked completely. At 6 weeks full weight bearing is allowed. At 4 months jogging and unrestricted strength training are allowed. Biodex dynamometer testing is obtained at 6 months’ follow-up and as needed until release to full activity, which usually is between 9 and 12 months.    

GRAFT FIXATION  Use a motorized shaver to remove the remnant ACL and tissue from the intercondylar notch posterolaterally, taking care to protect the PCL. n  Place a tibial guide set at 60 degrees off the medial eminence and at the level of the posterior portion of the anterior horn of the lateral meniscus, just in front of the PCL insertion. n  Place a guide pin and drill a transtibial, transphyseal tunnel; ream the tunnel up to the graft size. n  Position the guide pin approximately 2.5 cm medial to the tibial tubercle apophysis to avoid damaging it. For patients younger than 10 years of age, we also typically avoid drilling the proximal tibial physis and instead groove the physis. n  Use a No. 11 blade to make an incision in the distal lateral thigh down to the fascial layer; incise the fascia and identify the iliotibial band. n  Palpate the posterior aspect of the iliotibial band and just anterior to this make a longitudinal incision with a No. 15 blade. Identify the lateral intermuscular septum. n  Use a periosteal elevator to elevate soft tissue, taking care to avoid the distal femoral physis. n  Pass an arthroscopic gaff through the lateral portal and around the lateral femoral condyle, taking care not to loop around the PCL in the intercondylar notch. n  Place the arthroscope into the medial portal, and place the gaff in the anterolateral portal and retrieve it in the lateral aspect of the femur in the area of the previous incision. n  Under direct observation, pass a No. 5 nonabsorbable braided suture through the end of the gaff and back into the joint. Then pass this suture out through the tibial tunnel for graft passage. n  Retrieve the prepared graft and use the suture-shuttle to pass it through the tibial tunnel and in an over-the-top n 

 

ANTERIOR CRUCIATE AND ANTEROLATERAL LIGAMENT RECONSTRUCTION (BOX 51.8) TECHNIQUE 51.24 (PHILLIPS) Harvest the semitendinosus through the inferior portion of a medial parapatellar tendon incision or use a hamstring allograft. n  Make 1-cm incisions over the femoral and tibial insertions of the anterolateral ligament (ALL) as verified by imaging. n  Make a nick in the iliotibial band proximally and use Kelly forceps to spread the tissues, forming a tunnel between the iliotibial band and the underlying capsule. n  Secure the tendon graft distally with a 5.5-mm swivel lock (Fig. 51.55A). n  Pass the graft under the iliotibial band proximally to the insertion site (Fig. 51.55B). n  Place a femoral guidewire and verify its position with imaging, 5 mm proximal and posterior to the epicondyle. n  Taking care to prevent injury to the lateral collateral ligament or popliteus tendon, direct the wire proximally and anterior to avoid the femoral tunnel. n 

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PART XIV ARTHROSCOPY Mark the graft and move the knee through a range of motion to evaluate isometry. n  Ream a 22-mm × 5-mm tunnel. n  Shorten the graft and place a Vicryl Krackow suture in the graft so as to seat 15 to 20 mm of the graft in the tunnel. n  Pull the guidewire out medially, seating the graft. n  Move the knee through a range of motion to check isometry. n  With the knee in 25 to 30 degrees of flexion, secure the graft with a polyetheretherketone (PEEK) interference screw equal to the tunnel size (Fig. 51.55C).    n 

COMPLICATIONS OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Five-year follow-up studies of anterior cruciate ligament reconstruction using autograft bone–patellar tendon–bone grafts and hamstring grafts show similar results as far as stability and failure rates are concerned. Stiffness and strength tend to be slightly better with bone–patellar tendon–bone grafts, but overall results are comparable. Allograft studies at 5- and 7-year follow-up are similar to those with autograft, especially because the incidence of effusions and apparent graft rejection has decreased and graft procurement and

A

C

D

B

E

F

FIGURE 51.54 Technique for partial transphyseal anterior cruciate ligament reconstruction in skeletally immature athletes. A, Graft measurements. B, Graft with synthetic extender. C, Sizing of graft. D, Fixation of graft on the femoral side (blue lines represent physes). E, Fixation of graft on the tibial side. F, Final position of the graft. (From Bettin CC, Throckmorton TW, Miller RH, Azar FM: Technique for partial transphyseal ACL reconstruction in skeletally immature athletes: preliminary results, Curr Orthop Prac 30:19, 2019.) SEE TECHNIQUE 51.23.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY sterilization techniques have improved. Failure rates seem to have stabilized at 7% to 8% at 5-year follow-up when graft failure is the cause of the poor outcome. Other studies measure failure by KT-1000 testing, giving way of the knee, or failure of the patient to return to a previous sporting activity. If these parameters are used to measure surgical failure, the percentage ranges from 5% to 52%. Although the failure rate has stabilized, the number of revision surgeries continues to increase, probably because of better follow-up protocols; higher patient demands, expectations, and activity levels; and the earlier age at which these procedures are being performed. Economically, the cost of failure can be high. Additional procedures and rehabilitation, loss of work for the patient, and the potential loss of a college scholarship for a high school athlete can be financially burdensome. Anterior cruciate ligament failure also may take an emotional toll on the patient. Psychologic trauma from additional surgery, frustration over prolonged rehabilitation, loss of motivation, and displaced anger may result. Physiologic consequences include additional surgical trauma from harvesting the graft, possible articular damage, and additional chondral or meniscal damage from chronic instability because many

BOX 51.8

Preferred Techniques for Anterior Cruciate Ligament Reconstruction in Athletes Primary reconstruction Male—10-mm BPTB n  Female—9-mm BPTB n Chronic, revision, or 3+ pivot shift n  BPTB + ALL reconstruction using semitendinosus harvested through same incision or Lemaire lateral extraarticular tenodesis n 

n 

ALL, Anterolateral ligament; BPTB, bone–patellar tendon–bone.

A

patients wait some time before revision surgery. Meniscal damage has been shown to occur in approximately 40% at 1 year, 60% at 5 years, and approximately 80% at 10 years, which is the same incidence as degenerative joint disease seen at 10 years. The causes of anterior cruciate ligament reconstruction complications can be outlined by the failures as depicted in Figure 51.41. Most failures can be prevented by careful surgical planning and preparation, adherence to technique, attention to detail, and careful postoperative follow-up with early recognition and intervention for complications. Surgeons should be knowledgeable about the current literature and potential complications. If one is to advance on a surgical learning curve and decrease the number of complications, assessment of surgical results, radiographic evaluation of tunnels and screw placements, and careful, unbiased physical and KT-1000 examinations are necessary. Complications can be divided into preoperative, intraoperative, and postoperative categories. Preoperative radiographic evaluation can eliminate most problems of excessive patellar tendon length, tuberosity ossicles, or aberrancy of the patella. Intraoperative complications can result from graft, fixation, or tunnel problems and are avoidable by attention to details. Methods for avoiding these complications are discussed subsequently. Less common or significant problems are noted in Figure 51.41. Surgical failure can be caused by nonphysiometric tunnel placement, graft impingement, a weak graft, or weak graft fixation. Careful observation of the landmarks and correct placement of tunnels are essential to prevent excessive graft stress or impingement. We generally like to ream the tunnels initially with a reamer that is approximately 2 mm smaller than the definitive tunnel so that minor adjustments can be made easily. Use of a rasp or eccentric reaming to move a tunnel to an appropriate place is easily accomplished. Stress on the patella can be decreased greatly by carefully harvesting the patellar tendon graft. It is important to make straight cuts in line with the fibers and to ensure that the bone cuts are

B

C

FIGURE 51.55 Reconstruction of the anterior cruciate and anterolateral ligaments. A, Graft is secured distally with a swivel lock. B, Graft is passed under the iliotibial band proximal to the insertion site. C, Graft is secured with a polyetheretherketone (PEEK) interference screw. SEE TECHNIQUE 51.24.

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PART XIV ARTHROSCOPY not too deep, especially in the patella, and that the length of the cut is 20 to 23 mm. Cuts should be slightly angled, and the patella should be bone grafted on completion to avoid late stress fractures. At the time of the procedure, an internal notchplasty and careful viewing of the guidewire to ensure that it does not impinge on the roof or the wall of the tunnel with flexion and extension is essential. Also, one should ensure that it is not too far posterior, where it would impinge on the PCL. After placement and alterations have been made, the graft should be fully observed again, particularly in knee extension. Postoperative problems include arthrofibrosis, which should be treated with nonsteroidal antiinflammatory drugs and supervised therapy. Therapy to rebuild muscular tone initially should be attempted to try to regain full knee extension. Supervised therapy is instituted three times a week with the patient working on range of motion three times daily, stressing prone hangs to regain full extension. If motion fails to progress over 4 to 6 weeks of therapy, and the patient has less than 90 degrees flexion after 6 weeks of supervised physical therapy, gentle manipulation and possibly arthroscopic evaluation should be considered. Postoperative radiographs are reviewed to ensure that the tunnels are correctly placed and that an obvious impingement is not demonstrable. Loss of full extension, persistent effusion, anterior knee pain, or clicking or popping in the anterior part of the knee that is painful with terminal extension may indicate impingement. A lateral radiograph should be obtained with the knee in extension to ensure the tibial tunnel is posterior to the foot of the intercondylar notch and that screw placement in the femur is in the posterior aspect of the intercondylar notch. Postoperative infections are uncommon with arthroscopic anterior cruciate ligament reconstructions, but persistence or recurrence of fever 5 to 6 days after the procedure with increased pain, loss of knee motion, and heat or erythema at the knee site may indicate early infection and must be treated appropriately and aggressively. If a knee aspiration shows a white blood cell count to be elevated (often ≥ 20,000/μL), arthroscopic irrigation and evaluation of the graft should be performed. If the graft is still intact and in good condition, it should be left in place, but the joint should be thoroughly irrigated, and repeat irrigation and debridement should be done at 48 to 72 hours if symptoms are not drastically improving. A combination of antibiotics intravenously for 2 to 3 weeks followed by oral antibiotics to complete a 6-week course of organism-specific antibiotic treatment is necessary. In any postoperative infection, finding the source is crucial to prevent additional infections. Equipment sterilization procedures, preparation and draping techniques, handling of the graft by operating room personnel, and surgical techniques should be evaluated carefully. The surgical site of arthroscopy should always be prepared with a waterproof antibiotic solution and draped and sealed proximal and distal to the site of surgery. The chance of deep venous thrombosis (DVT) is increased with smoking, obesity, and metabolic and hypercoagulable abnormalities. There is a 50% chance of DVT, 11% proximal, before arthroscopy in patients with high-energy trauma. Presurgery screening is indicated in these patients. Smoking

increases the failure rates of anterior cruciate ligament and meniscal repairs. 

POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

The PCL consists of three components: an anterolateral band, a posteromedial band, and the meniscofemoral ligaments. The larger anterolateral band is approximately 150% the strength and stiffness of the posteromedial band and tightens slightly with knee flexion. Structural properties of the two bundles are the same other than size, and they have co-functionality. The entire ligament has 1.5 to 2 times the strength of the anterior cruciate ligament, and the broadness of its femoral footprint is approximately 3 cm2. The large insertion site of the dual ligaments makes physiometric reconstruction difficult. Many PCL injuries have an associated ligamentous injury, most commonly the posterolateral corner. Hyperflexion is the most common cause for PCL injuries in athletes. Sometimes a partial PCL injury, with 1+ to 2+ posterior laxity, occurs. Shelbourne and Muthukaruppan reported good clinical outcomes when these injuries were treated conservatively initially, consisting of knee extension and a protective rehabilitation program with no active hamstring strengthening. Long-term results did not correlate with the initial degree of instability in isolated injuries. Subjective scores did not deteriorate with time. PCL injuries in active, healthy athletes should be assessed with kneeling stress radiographs and MRI to evaluate associated injuries. Injuries of the posterolateral or medial corner should be repaired and augmented or reconstructed. PCL injuries with 3+ laxity (≥ 8 mm on stress radiographs) and symptomatic PCL injuries are reconstructed. Double-bundle reconstructions have gained favor with many, but anatomic single-bundle techniques have good results, similar to those for transtibial and inlay techniques. The two-tunnel technique has been shown in clinical studies to have increased stability and to better fill the large PCL footprint. The single-tunnel technique, which we use mostly for reconstruction of multiple knee ligaments in knee dislocations, is described subsequently. The two-tunnel technique is used primarily in isolated PCL reconstruction. An Achilles tendon allograft is our preferred graft source for PCL reconstruction. Comparable results have been reported with allografts and autografts. An all-arthroscopic inlay procedure, using a retrocutting reamer and a closed-ended tibial tunnel with suture fixation anteriorly, has been described by several authors; this, like aperture screw fixation, produces a shorter, stiffer graft construct and removes the “killer curve” that sometimes occurs in the transtibial technique, although a killer curve still remains on the femoral side. Comparative studies show that anatomic single-tunnel and inlay procedures produce equal function and stability. Double-bundle techniques have been shown to be slightly better (2.5 mm of posterior displacement compared with 3.2 mm), with better IKDC scores, in most studies. The most important factors for long-term success are correction of associated instabilities and meniscal preservation. Slow, protected rehabilitation also increases the likelihood of knee stability and should emphasize early maintenance of knee

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY extension, delayed weight bearing, and delayed return to sports. For multiligament instability, a simple single-tunnel procedure usually is effective; an isolated PCL double-tunnel procedure may be indicated. LaPrade et  al. showed that a decreased posterior tibial slope puts athletes at some increased risk of PCL injuries, but with double-bundle reconstruction there is no increased failure rate based on tibial slope. 

 

SINGLE-TUNNEL POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION TECHNIQUE 51.25 (PHILLIPS) Place the patient supine and apply a tourniquet high around the thigh. Use a padded lateral post to assist with valgus stress. Tape a 3-L saline bag to the table before draping to use as a foot bolster to help maintain 80 to 90 degrees of knee flexion during the procedure. n  Perform a routine systematic arthroscopic examination of the knee and repair any associated intraarticular abnormalities as necessary. If a meniscal repair is performed, the sutures should be tied after the ligament reconstruction is completed. n  Using standard anterolateral and anteromedial portals, debride the soft tissue and remaining cruciate ligament from the intercondylar notch. n  Perform an internal bony notchplasty as necessary. n  Viewing of the tibial attachment site of the posterior cruciate ligament (Fig. 51.56A) is improved by using a 70-degree viewing arthroscope in the anterolateral portal or by placing the 30-degree viewing arthroscope through a posteromedial portal. n  Using a full-radius resector, remove the remaining stump of the posterior cruciate ligament. Specially designed back-cutting knives, curets, and rasps also are available to assist in removing the remnants. n  Elevate the posterior capsule from its attachment to the posterior flat spot on the tibia using a curved curet or periosteal elevator passed through the intercondylar notch or the posteromedial portal. n  Contour an Achilles tendon allograft to make a bone plug 11 mm wide × 20 mm long. n  Place the tendinous part of the graft under tension and roll the graft with a running Vicryl suture. Place a no. 5 tension suture in the distal 5 cm of the graft, using a running interlocking suture. Place the graft on a graft tension board, maintained with 10 lb of tension for 15 minutes. n  If an autogenous patellar tendon is chosen as a graft, make a 7-cm midline incision, starting at the inferior patella and extending distally over the tibial tuberosity. n  Harvest the central third of the patellar tendon—10 to 11 mm wide and 25 mm long—with 8-mm-thick bone plugs. n  Contour the graft to pass through a 10- or 11-mm trial. The bone plug to be secured in the femoral tunnel should n 

be shortened to approximately 20 mm to make intraarticular passage easier. n  For making the tibial tunnel, we prefer to use the Arthrex drill guide system. With the 70-degree arthroscope in the anterolateral portal, insert the guide through the anteromedial portal and pass it through the notch. n  Place the guide tip 10 to 12 mm below the joint line in the posterior cruciate ligament facet. n  Orient the drill guide approximately 60 degrees to the articular surface of the tibia, starting just inferior and medial to the tibial tuberosity (Fig. 51.57A). A more perpendicular angle would create too much of an acute angle at the posterior tibia that may abrade the graft. A tibial tunnel that is started too distally may ream out the posterior tibial shelf. The simultaneous use of image intensification and arthroscopy aids in proper positioning of the drill guide before and during drilling. Calibrations on the tibial guide accurately measure the distance from the anterior tibial cortex to the tip of the guide. n  Adjust the guide pin so that it is protruding from the tip of the drill 1 cm less than the distance measured on the guide system to help prevent overdrilling (see Fig. 51.57A). n  The guide pin should exit posteriorly at the physeal scar area. n  Tap the pin in the final 1 cm to help prevent penetration. While tapping the pin in, place a curet through the posteromedial portal to protect the neurovascular structures from pin penetration during advancement and reaming. If adequate soft-tissue debridement has been performed, the guide pin can be observed arthroscopically as it exits the tibia. An image intensifier is used to confirm appropriate guidewire placement. n  The femoral physiometric point is 8 mm proximal to the articular cartilage at the 1-o’clock position on the right knee and at the 11-o’clock position on the left knee (Fig. 51.57B). Place the tip of the posterior cruciate ligament femoral guide through the anteromedial portal while viewing with the arthroscope in the anterolateral portal. n  Expose the femoral cortex through the 3-cm longitudinal incision and elevate the vastus medialis obliquus superiorly. n  Insert the guide pin midway between the articular margin of the medial femoral condyle and the medial epicondyle. n  Use the appropriate size reamer for the available graft, leaving 1 to 2 mm of distal bone at the articular margin. n  Pass a Gore smoother through the tibial tunnel into the joint and pull it through the central fat pad portal (Fig. 51.57C). The smoother is used to smooth and remove the posterior soft-tissue remnants. Do not enlarge the tibial tunnel excessively. n  When the smoother passes without undue resistance, attach the graft to the end of the smoother and pull the graft sutures and bone plug into the joint. n  Extreme flexion of the knee sometimes aids passage of the patellar bone plug from the posterior tibial aperture into the joint. Placing a switching stick through the posteromedial portal allows the guide sutures to be redirected over the stick to assist in passing the graft. n  Place a grasper through the femoral tunnel to grab the sutures. Use a probe or Allis clamp to assist the graft into the femoral tunnel.

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PART XIV ARTHROSCOPY Popliteus m. Champagne-glass drop-off (CGD)

Posterior capsule

Medial groove

PMB Lateral cartilage point

PCL ALB Medial meniscus

Lateral meniscus

Shiny white fiber point

A Trochlear point

Medial arch point

Sulcus terminalis ALB Medial intercondylar ridge

PMB

aMFL pMFL

Posterior point

B FIGURE 51.56 Arthroscopic view of the tibial attachment (A) and femoral attachment (B) of the posterior cruciate ligament (PCL) in a right knee, demonstrating pertinent landmarks. ALB, anterolateral bundle; aMFL, anterior meniscofemoral ligament; PMB, posteromedial bundle; pMFL, posterior meniscofemoral ligament. (Redrawn from Anderson CJ, Ziegler CG, Wijdicks CA, et al: Arthroscopically pertinent anatomy of the anterolateral and posteromedial bundles of the posterior cruciate ligament, J Bone Joint Surg 94:1936, 2012.) SEE TECHNIQUE 51.56

Place the cancellous portion of the bone plug posteriorly to reduce graft abrasion. n  Before tibial fixation, ensure that the femoral bone plug would fit appropriately at the aperture of the femoral tunnel. n  Put the knee through a range of motion and ensure there is no more than 3 mm of graft pistoning through range n 

of motion from 0 to 100 degrees. If excessive pistoning is encountered, rasp the femoral tunnel proximal wall. n  Secure the femoral bone plug with a metal interference screw. n  Maintain graft tension and put the knee through a range of motion for 20 cycles to allow stress relaxation of the graft.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY

A

B

C

FIGURE 51.57 Posterior ligament reconstruction. A, Arthrex Popliteal Drill Stop prevents advancement of guide pin past the tip of the marking hook during drilling. B, Millimeter markings on Arthrex PCL Femoral Marking Hook allow determination of the distance of the femoral tunnel from the margin of the articular cartilage. C, Arthrex “Worm” Curving Suture Passer facilitates passing of graft sutures through tibial tunnel into intercondylar notch. SEE TECHNIQUE 51.25.

Secure the graft with an interference screw. If a soft-tissue graft is used, backup fixation over a post is indicated.

n 

POSTOPERATIVE CARE Rehabilitation depends on the graft material selected, the size of the patient, and any other surgery done. After isolated posterior cruciate ligament reconstruction, the knee can be immobilized in extension in a removable knee immobilizer for 4 weeks. Early range-of-motion and quadriceps exercises are encouraged, but flexion is limited to 90 degrees for the first 4 weeks. Hamstring strengthening is begun at 3 months. During motion and strengthening therapy, care is taken to prevent posterior tibial stress. Return to sports is allowed at 9 months.    

 

DOUBLE-TUNNEL POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION TECHNIQUE 51.26 (LAPRADE ET AL.) Prepare the anterolateral bundle graft from an Achilles tendon allograft with an 11-mm diameter and 20-mm

n 

long calcaneal bone graft; tubularize the distal soft-tissue aspect of the graft. n  Prepare the posteromedial bundle graft from a 7-mm diameter soft-tissue anterior tibial allograft by tubularizing each end of the graft. n  Create standard anterolateral and anteromedial arthroscopic portals and identify the femoral attachments of the anterolateral and posteromedial bundles. n  Outline the anterolateral bundle attachment between the trochlear point and medial arch point, adjoining the edge of the articular cartilage. n  Mark the posteromedial bundle attachment approximately 5.8 mm proximal to the edge of the articular cartilage of the medial femoral condyle and slightly posterior to the anterolateral bundle tunnel. n  Ream an 11-mm diameter closed socket tunnel to a depth of 25 mm for the anterolateral bundle and place a 7-mm reamer against the outlined posteromedial bundle to create the second tunnel of the same depth. Maintain a 2-mm bone bridge between the femoral tunnels (Fig. 51.58A-C). n  Create a posteromedial portal to facilitate identification and preparation of the PCL attachment site. Drill a tibial guide pin, entering the anteromedial aspect of the tibial approximately 6 cm distal to the joint line and exiting posteriorly at the center of the PCL tibial attachment along the PCL bundle ridge (Fig. 51.59A, B ). n  Use a 12-mm acorn reamer to overream the tibial guide pin under direct posterior arthroscopic observation (Fig. 51.59C). n  Insert a large smoother (Gore Smoother Crucial Tool, Smith & Nephew) up the tibial tunnel to facilitate graft

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PART XIV ARTHROSCOPY Trochlear point Guide pin

ALB

ALB

Medial arch point

PMB Guide pin

A

B

C

FIGURE 51.58 Medial aspect of femoral notch in right knee demonstrating sequence of doublebundle posterior cruciate ligament reconstruction. A, Guide pin is inserted (through an 11-mm reamer between trochlear point and medial arch point, adjacent to cartilage) to re-create anterolateral bundle (ALB). B, An 11-mm diameter closed socket tunnel is reamed to depth of 24 mm for ALB. Posteromedial bundle (PMB) attachment is reproduced next, approximately 5 mm posterior to edge of articular cartilage of medial femoral condyle and distal to medial arch point (also with help of 7-mm reamer placed in medial wall to assess for final position). C, Closed socket tunnel is reamed to depth of 25 mm for second tunnel (PMB). Of note, bone bridge of 2 mm should always be present between tunnels. (From LaPrade RF, Cinque ME, Dornan GJ, et al: Double-bundle posterior cruciate reconstruction in 100 patients at mean 3 years’ follow-up. Outcomes were comparable to anterior cruciate ligament reconstructions, Am H Sports Med 46:1809, 2018.) SEE TECHNIQUE 51.26.

Lateral meniscus

Lateral cartilage point

Posterior capsule

Champagne glass dropoff Bundle ridge Small white fibers

Posterior cruciate ligament

Medial meniscus

B

7 mm

12 mm

Guide pin

A

C

FIGURE 51.59 Tibial attachment of the posterior cruciate ligament (PCL) for double-bundle reconstruction. A, Guide pin is drilled, entering anteromedial aspect of tibia approximately 6 cm distal to joint line and exiting at center of the PCL tibial attachment along PCL bundle ridge. Positioning of guide pin should be assessed with fluoroscopy (7 mm anterior to the posterior cortex on lateral view and medial to lateral eminence on anteroposterior view.) B, Arthroscopically, pin should exit at center of bundle ridge, posterior to shiny white fibers and medial to lateral cartilage point. C, A 12-mm acorn reamer is used to overream tibial guide pin under direct posterior arthroscopic observation. CGD, champagne glass drop-off; LM, lateral meniscus; MM, medial meniscus. (From LaPrade RF, Cinque ME, Dornan GJ, et al: Double-bundle posterior cruciate reconstruction in 100 patients at mean 3 years’ follow-up. Outcomes were comparable to anterior cruciate ligament reconstructions, Am H Sports Med 46:1809, 2018.) SEE TECHNIQUE 51.26.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Popliteus tendon Fibular collateral ligament

Fibular collateral ligament

Anterolateral bundle Posteromedial bundle

Posterior meniscofemoral ligament

Anterior cruciate ligament

Popliteus tendon Popliteofibular ligament Champagne glass drop-off

A

Screw and spiked washer

B

FIGURE 51.60 Anterior (A) and posterior (B) views of anatomic double-bundle PCL reconstruction. Reconstructed ALB and PMB are shown, as well as size, shape, and location of their femoral and tibial tunnels. PMB enters the tibial tunnel posteromedial to ALB. PMB is posterior in transtibial tunnel, exits deep to ALB, and is fixed medially and distally to ALB. Femoral fixation of both bundles and champagne glass drop-off also are displayed. ACL, anterior cruciate ligament; FCL, fibular collateral ligament; PFL, popliteofibular ligament; PLT, popliteus tendon; pMFL, posterior meniscofemoral ligament (ligament of Wrisberg). (From LaPrade RF, Cinque ME, Dornan GJ, et al: Double-bundle posterior cruciate reconstruction in 100 patients at mean 3 years’ follow-up. Outcomes were comparable to anterior cruciate ligament reconstructions, Am H Sports Med 46:1809, 2018.) SEE TECHNIQUE 51.26.

passage; pass the end of the smoother out the anterolateral arthroscopic portal. n  Fix the posteromedial bundle graft in the femoral tunnel with a 7- × 23-mm bioabsorbable interference screw and the anterolateral bundle graft with a 7- × 20-mm titanium interference screw. n  After the grafts are fixed in the femoral tunnels, pass the sutures in the ends of both grafts through the loop tip of the smoother and pull the smoother and the graft sutures in its eyelet tip distally down the tibial tunnel and out the anteromedial aspect of the tibia. n  Cycle the grafts and secure them individually with 6.5mm cancellous bicortical screws and 18-mm spiked washers (Fig. 51.60). Suture the anterolateral bundle graft first at 90 degrees with an anterior drawer force to reproduce the normal tibiofemoral step off and then secure the posteromedial bundle graft at 0 degrees.

POSTOPERATIVE CARE Postoperatively, all patients remain non–weight bearing for 6 weeks. For the first 6 months, a dynamic posterior cruciate ligament brace is worn at all times except during bathing and dressing. Range of motion and edema control are begun the day after surgery. Prone knee flexion is limited to 90 degrees for the first 2 weeks; thereafter, knee motion is increased as tolerated. Weight bearing is initiated at 6 weeks with

low-resistance cycling on a stationary bike and leg presses performed to a maximum of 70 degrees of knee flexion. Progressive advancement into low-impact knee exercises is allowed as tolerated starting at 12 weeks. Six months after surgery, patients are evaluated clinically and with kneeling posterior stress radiographs. Discontinuation of the brace for daily use is allowed if the side-to-side difference in kneeing stress radiographs was less than 2 mm, and jogging, side-to-side activities, and proprioceptive exercises are allowed. Functional testing (e.g., the Vail Sports Test) is done between 9 and 12 months after surgery to determine the patient’s ability to return to full activity. A dynamic PCL brace is worn for sporting activities for the first year of athletic competition.   

Inlay Technique.  This technique, which allows direct fixation of a tibial bone plug to a tibial trough in the anatomic insertion of the PCL along the posterior tibia, has the advantages of eliminating acute graft angle changes and allows secure direct fixation to the posterior tibia, thus making a shorter, stiffer graft. The approach allows safe exposure of this area. The disadvantage of this technique is that access to the anterior and the posterior knee is necessary during the surgical procedure. The patient can be placed in the lateral decubitus position with the injured side up. The hip can be

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PART XIV ARTHROSCOPY externally rotated for the arthroscopic part of the procedure, and then the knee can be straightened and placed on a padded Mayo stand for the posterior exposure. Conversely, an easier method for posterior exposure is made possible by placing a bump under the unaffected side and placing the affected side in a figure-of-four position. The surgeon starts on the opposite side of the table (i.e., the unaffected side). Tilting the table toward or away from the surgeon allows for better visualization during different parts of the procedure. Femoral tunnels are reamed at 1 o’clock and at 3 o’clock, 1 mm and 3 mm, respectively, off the articular surfaces before posterior exposure. 

+15°

CHONDROMALACIA OF THE PATELLA SYNDROME

Chondromalacia, which means softening of the articular cartilage, has multiple causes. Cartilage changes can be classified from an arthroscopic standpoint based on the modified Outerbridge (Insall) classification: grade I, softening and swelling of the cartilage; grade II, fragmentation and fissuring in an area 0.5 inch or less in diameter; grade III, more severe fragmentation and fissuring involving an area of more than 0.5 inch in diameter; and grade IV, erosion of cartilage down to bone. Chondromalacia can be treated conservatively in most patients with an emphasis on maximizing flexibility of the musculature and strengthening the vastus medialis obliquus muscle. Closed chain exercises are recommended, and some studies showed that taping and bracing were advantageous. Carefully evaluating lower extremity alignment, particularly for hyperpronation that can be corrected with orthotics, also can decrease patellofemoral stress. If prolonged, conservative treatment fails, then surgical intervention may be necessary. Careful evaluation of the individual, including alignment, associated articular changes, ligamentous laxity, future goals, and rehabilitation potential, is necessary to obtain a good surgical result. In the case of chondromalacia with no significant malalignment and grade II or early grade III changes, arthroscopic debridement of the patellofemoral joint and reevaluation of the exercise program may be all that is necessary. Arthroscopic debridement of the articular surface can be done safely with mechanical instrumentation. For full-thickness chondral defects, realignment and cartilage cell transfer can give moderate to good relief. Lateral release is indicated for excessive lateral pressure syndrome unresponsive to therapy and for lateral facet arthritis in combination with excision of a painful lateral facet osteophyte. Isolated lateral release for patellar instability has not been shown to be effective and may compound the problem caused by persistent quadriceps weakness. The most predictable criterion for success of a lateral release is a negative passive patellar tilt, a medial and lateral patellar glide of two quadrants or less, and a normal tubercle-sulcus angle with the knee at 90 degrees of flexion. The passive patellar tilt test is performed with the patient supine, the knee extended, and the quadriceps relaxed. The examiner lifts the lateral edge of the patella from the lateral femoral condyle. The patella should remain in the trochlea. An excessively tight lateral restraint is shown by a neutral or negative angle to the horizontal (Fig. 51.61A). The patellar glide test determines medial or lateral retinacular tightness (Fig. 51.61B). This test is performed with the knee flexed 20 to 30 degrees and the quadriceps relaxed. This position can be accomplished by placing a small pillow beneath

b

a

A

B FIGURE 51.61 A, Passive patellar tilt test. Lateral edge of patella is lifted from lateral femoral condyle (b). Patella should remain in trochlea and not be allowed lateral subluxation. Excessively tight lateral restraint is shown by neutral or negative angle to horizontal (a). B, Patellar glide test in 30 degrees of flexion.

the knee. The patella is divided into longitudinal quadrants, and an attempt is made to displace the patella medially and laterally. A lateral patellar glide of three quadrants or more suggests an incompetent medial restraint. A medial glide of one quadrant is consistent with a tight lateral restraint, and a glide of three or more quadrants suggests a hypermobile patella. The tuberosity-sulcus angle is determined by measuring the Q angle with the knee at 90 degrees of flexion. The angle is formed by a line drawn from the center of the patella to the center of the tibial tuberosity and a line drawn from the center of the patella and passing perpendicular to the transepicondylar axis. This angle should be 0 degrees, and more than 10 degrees is definitely abnormal. The traditional Q angle measured from the tibial tuberosity to the center of the patella and extending to the anterior superior iliac spine likewise is a valuable measurement that should be evaluated when contemplating surgical procedures for the patella. Anteroposterior, 45-degree lateral, and 45-degree Merchant view radiographs are helpful in determining patellar tilt, subluxation, and Insall ratio,

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY

FIGURE 51.63 Patellofemoral joint viewed from superolateral portal; lateral subluxation of patella is evident. SEE TECHNIQUE 51.27.

FIGURE 51.62

Trochlear dysplasia. SEE TECHNIQUE 51.27.

as described in Chapter 45. Lateral release should extend only to the vastus lateralis and not include this structure.   

LATERAL RETINACULAR RELEASE TECHNIQUE 51.27 View the patellofemoral joint with a 30-degree viewing arthroscope in the inferior or superior portal; either is adequate. With the arthroscope in the standard anterolateral portal and advanced into the patellofemoral joint, rotate the lens upward and downward alternately to view the articular surfaces of the patella and the trochlear groove of the distal femur (Fig. 51.62). n  Manually manipulate the patella with the thumb and index finger for complete viewing of the entire surface of the patella. The tracking of the patella and the dynamics of the patella and the patellofemoral joint can be viewed better from a superior portal (Fig. 51.63). The patella naturally rides laterally with the knee in extension, and observation of it in this position does not confirm that the patella is subluxable or riding laterally. As the knee is moved from full extension into 30 to 40 degrees of flexion, the patella enters the trochlear groove and should become congruous and centered at this degree of flexion. Persistent lateral tilt or overhang of the lateral facet over the edge of the lateral femoral condyle with the knee in this position suggests a lateral tracking phenomenon. Note the various degrees of chondromalacia of the patellar and trochlear articular surfaces and record them (Fig. 51.64). n  Before performing the lateral retinacular release, carry out a complete and systematic examination of the knee for other pathologic entities and trim and shave severe patellar articular surface chondromalacic changes where appropriate. Extensive shaving of chondromalacic areas on the patellar or trochlear surface probably has only n 

FIGURE 51.64 Grade III chondromalacia of patella involving central ridge and lateral facet. SEE TECHNIQUE 51.27.

short-term effects; shaving should be kept to a minimum, emphasizing removal of only degenerative fibrillated material. The objective is restoration of the proper dynamics of the extensor mechanism. n  When a complete arthroscopic examination has been done and any chondroplastic areas have been shaved, remove the arthroscopic instruments from the joint and evacuate the irrigating fluids. n  Attempt to palpate the inferior edge of the vastus lateralis tendon and mark this junction at its insertion into the patella with an 18-gauge spinal needle at the superior pole of the patella. If the edge of the tendon cannot be palpated, simply insert the needle at the superolateral corner of the patella. n  Insert the arthroscope through the superolateral or the anteromedial portal. Initially, insert the electrocautery into the anterolateral portal. n  Under arthroscopic guidance, divide the synovium and lateral retinaculum from the superolateral corner of the patella marked by the spinal needle to the inferior extent of the lateral border of the patellar tendon. Occasionally, the electrocautery must be placed in a superomedial or superolateral portal to complete the most inferior portion of the release. The release can

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PART XIV ARTHROSCOPY be extended proximally along the lateral border of the vastus lateralis tendon. n  Place a thick sponge pad over the superolateral aspect of the distal thigh just proximal to the patellar tendon to serve as a pressure pad over the cut superolateral geniculate vessels. This has reduced the incidence of troublesome hemarthrosis after release. n  A drain can be placed intraarticularly and removed after several hours.

POSTOPERATIVE CARE  The knee is maintained in an immobile, extended position for 48 hours, and then gentle range-of-motion exercises are begun. Immobilization of the knee in extension for longer than 72 hours may allow the edges of the lateral retinacular release to adhere and become ineffective. Early range of motion tends to spread the release. Quadriceps isometric and stiff-leg exercises are encouraged. Weight bearing is allowed as tolerated.   

ARTHROSCOPIC MEDIAL PARAPATELLAR PLICATION

Arthroscopic plication of the medial retinaculum has been described for patellar instability. The all-inside technique uses a 17-gauge Tuohy epidural needle to pass a no. 1 polydioxanone suture near the medial edge of the patella. The edge of the suture is retrieved out of a superolateral portal. The needle is backed up slightly to remain under the subcutaneous tissue and advanced posteriorly about 2 cm. The needle is passed back through the retinaculum, and the resulting loop of the suture is pulled out superiorly, taking both tails out superiorly. After passage of four to five sutures, they are tied arthroscopically through the anteromedial portal. An arthroscopic lateral release is performed. We do not do this procedure and believe that the same technique can be performed more adequately with nonabsorbable sutures and better imbrication through a small medial parapatellar incision. 

SYNOVECTOMY Arthroscopic synovectomy in rheumatoid disease and other chronic inflammatory conditions and in hemophilia has been reported to produce less morbidity, shorter hospitalization, and more rapid return of function to the joint.

TECHNIQUE 51.28 Four or five portals, including the posteromedial and posterolateral portals, are used routinely. Approach the posterior compartment with a 70-degree viewing arthroscope placed through the intercondylar notch and place a full-radius resector through the corresponding posteromedial or posterolateral portal. n  Preserving the menisci, resect the synovial proliferation inferior to the menisci and around the cruciate ligaments, preserving the underlying structures. n  Carefully strip the synovial proliferation in the medial and lateral aspects of the knee off the junction of the synovium and the articular cartilage. Frequent repositioning of the arthroscope and motorized shavers is necessary to avoid damage to the articular cartilage and to reach all synovial recesses. n 

After synovectomy, insert a drain in the knee and connect it to suction. Place the knee in a modified Jones dressing.

n 

POSTOPERATIVE CARE Before discharge, the drain is removed. Weight bearing to tolerance with crutches is allowed, and range-of-motion and quadriceps-strengthening exercises are begun immediately.    

DRAINAGE AND DEBRIDEMENT IN PYARTHROSIS Arthroscopic debridement and lavage in pyarthrosis offer the advantages of reduced morbidity and shortened hospitalization. With the arthroscope, the knee can be lavaged with large volumes of fluid and any fibrinoid material and infected debris can be removed. With the advent of more resistant organisms, the use of appropriate cultures and initial use of broad-spectrum antibiotic coverage, including coverage for methicillin-resistant Staphylococcus aureus, are indicated. When the cultures are complete, antibiotics specific to the organism should be used.

TECHNIQUE 51.29 The standard arthroscopic setup is used for arthroscopic debridement. Do not exsanguinate the extremity. Use a large-bore cannula or arthroscopic pump for irrigation. n  Make anteromedial and anterolateral portals to examine and debride fibrinoid exudate as indicated. Take appropriate bacterial cultures. n  Thoroughly lavage all compartments (anterior, posterior, and suprapatellar) and the medial and lateral gutters, using 9 to 10 L of fluid. n  Place suction drain tubes in the medial and lateral gutters through the arthroscopic cannula and then withdraw the cannula over the drain. Loosely approximate the portals with absorbable sutures. n 

POSTOPERATIVE CARE  A Jones-type dressing is applied to immobilize the knee for 36 to 48 hours while appropriate antibiotics are administered. At 48 hours, the drains are removed and range of motion is begun. If the infection fails to respond to treatment, repeat debridement is considered at 72 hours.    

OTHER APPLICATIONS OF ARTHROSCOPY OF THE KNEE

The following are additional, less frequent, applications for arthroscopy of the knee. Several are refinements of principles and techniques previously described in this chapter, and most should be attempted only by surgeons with considerable arthroscopic experience. Many of these techniques have not been sufficiently evaluated to determine the long-term results and are not described in detail.

ARTHROSCOPY IN FRACTURES AROUND THE KNEE

Arthroscopic techniques have been used to evaluate fractures of the anterior intercondylar eminence of the tibia, to

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY reduce such fractures, and, after reduction, to fix the eminence with percutaneously inserted internal fixation. In addition, arthroscopy has been advocated to assess the degree of articular surface depression and the adequacy of reduction after tibial plateau fractures. Good results have been reported with arthroscopically assisted fracture reduction and percutaneous fixation. Fracture patterns that are appropriate for arthroscopic management are those that can be internally fixed with a cancellous screw and do not require a major reduction or use of a buttress plate. Better fracture evaluation, reduced operative time and morbidity, shorter hospitalization, and quicker recovery have been cited as advantages to the arthroscopically assisted technique. 

 

ARTHROSCOPICALLY ASSISTED FRACTURE REDUCTION AND PERCUTANEOUS FIXATION TECHNIQUE 51.30 (CASPARI ET AL.) Make a small transverse incision in the skin 3 cm to 4 cm below the joint line and drill holes through the anterior cortex. n  With the use of an image intensifier and under arthroscopic guidance, insert a 0.25-inch osteotome through the cortical window and drive it under the fracture to elevate the fragments. By manipulating the osteotome and using the anterior cortex as a fulcrum, elevate the fragments under arthroscopic guidance. Caspari et al. termed this “indirect triangulation.” They recommended over-elevation of the fragments. n  Remove the stress from the knee and move it through a range of motion. The femoral condyle serves to mold the surface of the tibial plateau back into its anatomic configuration. If necessary, insert a bone graft under the fracture through the cortical window. n  Obtain internal fixation by percutaneous or open technique. n  Use of an arthroscopic anterior cruciate ligament guide to place a guidewire into the fracture site also has been described. A reamer is used to make the cortical window and a tamp to elevate the fragments. A 15-mm Arthrex “coring” reamer can preserve local bone graft. Image intensification is used to place percutaneous cannulated screws. n 

release. If extensive infrapatellar contracture syndrome develops, as evidenced by peripatellar induration, restricted patellar mobility, and loss of knee motion, conservative means should be used to reduce inflammation and regain muscle tone and knee extension. An open technique, including lateral release and excision of the fat pad, may be necessary after the acute reaction has subsided. 

 

ARTHROSCOPIC LYSIS AND EXCISION OF ADHESIONS TECHNIQUE 51.31 (SPRAGUE) Insert an arthroscopic sheath and blunt trocar through standard anterolateral and anteromedial portals. n  Pass the blunt trocar carefully beneath the patella and into the suprapatellar pouch. Use the trocar to disrupt bluntly any adhesions in the suprapatellar pouch and in the medial and lateral gutters. n  Insert the arthroscope and inspect the joint in a routine manner. If the adhesions are dense, the patellofemoral joint usually is spared. n  Begin the debridement in the peripatellar region and extend it outward. n  When the suprapatellar pouch has been restored, insert an inflow cannula through a superior portal. n  Continue the dissection down into the medial and lateral gutters and compartments and finally into the intercondylar area. Avoid damage to the cruciate ligaments. n  Occasionally, proliferation of fibrous tissue is present within the intercondylar notch and anterior regions; this should be removed because it may limit extension. Some investigators recommend a lateral retinacular release as part of the procedure if patellar mobility is restricted after the arthroscopic release. Avoid iatrogenic fracture caused by excessive manipulation. n  After the systematic lysis of adhesions, perform a gentle manipulation. If any further adhesions are disrupted, debride these further arthroscopically. n  Thoroughly irrigate the joint, insert a suction drain, and apply a bulky compressive dressing. n 

POSTOPERATIVE CARE We have found it helpful to

tailored to the specific injury and the adequacy of reduction and fixation. If the fracture is stable, with rigid internal fixation, early controlled range of motion is begun.

perform this procedure with the patient under continuous epidural anesthesia, which is maintained for 2 to 3 days after surgery. The patient is placed in a continuous passive motion machine immediately after surgery, and the suction drain is removed at 2 days.

  

  

POSTOPERATIVE CARE  Postoperative management is

ARTHROFIBROSIS

Arthroscopic techniques for lysis and excision of postoperative adhesions have been described. The arthroscopic procedure usually is combined with a gentle manipulation after the

COMPLICATIONS ASSOCIATED WITH KNEE ARTHROSCOPY

Large series on complications associated with knee arthroscopy published in the late 1980s reported overall complication

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PART XIV ARTHROSCOPY rates for knee arthroscopy of less than 2%. More recent reports generally cite overall complication rates of less than 1%. Four large series with a combined total of 191,584 arthroscopic knee procedures reported complications in 1175 (0.6%), with the most common being infection and DVT or pulmonary embolism (PE). Data from the American Board of Orthopaedic Surgery from 2003 to 2009, however, showed an overall complication rate of almost 5%, with a range of 2.5% for meniscectomy to 20% for PCL reconstruction. Infection was the most common complication overall. Complications increase with the difficulty of the case, and saphenous and peroneal nerve injuries are still being reported with arthroscopic repairs; however, with all-inside techniques the frequency of these injuries has decreased dramatically. The incidence of arthrofibrosis associated with anterior cruciate ligament reconstruction is increased when meniscal repair is performed. Likewise, the incidence of infection associated with anterior cruciate ligament reconstructions is slightly increased when the reconstruction is performed in conjunction with meniscal repair. Additional exposure, surgical time, and potential for joint contamination during the passing and retrieving of needles are probably the reasons. Surgical complications related to ligamentous reconstruction are associated with multiple factors that have been reported (see Figs. 51.41 and 51.42). DVT is a real concern with long, complicated procedures, particularly in patients who are overweight, have a history of DVT, are taking birth control pills, or have been inactive as a result of injury. In patients with high-energy knee injuries in whom treatment is delayed for more than 2 weeks, preoperative ultrasound examination of the lower extremities usually should be done. When limited postoperative weight bearing is indicated in these patients, DVT prophylaxis with at least 81 mg of aspirin twice a day probably is warranted. The use of a sequential compression device (SCD) may be indicated for high-risk patients. Most of these causes of failures have been discussed in the technique section. Careful attention to detail during surgery, including proper sterilization techniques, handling of the graft, and appropriate preparation and draping, can help to prevent postoperative infections. If a graft is contaminated by dropping it on the floor, the surgeon has two choices: change graft sources (i.e., a different autogenous graft source) or attempt sterilization of the dropped graft. Molina et  al. reported the results of sterilization of dropped grafts in three solutions: (1) a 1-mL vial containing 40 mg of neomycin and polymyxin in 1000 mL of sterile saline, (2) 10% povidoneiodine solution, or (3) 4% chlorhexidine gluconate solution. Their results after a 90-second soak showed that one of 50 of the contaminated grafts that were soaked in chlorhexidine remained positive, three of 50 soaked in antibiotic remained positive, and 12 of 50 soaked in the povidone-iodine solution remained positive. Several more recent reports have confirmed the efficacy of 4% chlorhexidine for sterilizing contaminated grafts, including laboratory studies that included 495 graft samples. Bacitracin alone also was found effective (97%), as was a combination of neomycin and polymyxin B. With this in mind, it should be reasonable to retrieve the graft immediately from the floor, rinse it using sterile technique with a large volume of sterile saline, soak it in 4% chlorhexidine gluconate solution for at least 90 seconds (we recommend 10 minutes) and then in the neomycin

and polymyxin B solution for at least another 90 seconds (we recommend 10 minutes), and finally rinse it thoroughly. In a survey by Izquierdo et al., 196 sports-trained surgeons responded to a questionnaire on anterior cruciate ligament graft contamination (from a variety of sources). Forty-nine surgeons had experienced a total of 57 contaminations, 75% of which were treated with graft cleansing and proceeding with the reconstruction. In 18% of contaminations, the surgeon harvested a different graft, and in 7% an allograft was used. There were no reported infections. Sixty-five of the 147 surgeons with no graft contaminations responded with hypothetical treatments: 58% would cleanse the graft, 34% would harvest a different graft, and 8% would use an allograft. When postoperative knee infections occur, early, thorough arthroscopic irrigation and debridement are indicated with repeat irrigation and debridement at 48 to 72 hours if the symptoms have not resolved. Anterior cruciate ligament grafts can be left in place, provided that no extensive deterioration of the graft is present at the time of initial irrigation. The appropriate intravenous antibiotics if susceptible generally are prescribed for 2 to 3 weeks, followed by oral antibiotics to complete a 6-week course of antibiotic treatment. A recent meta-analysis determined that approximately 85% of grafts could be salvaged with arthroscopic debridement and antibiotic therapy. Abnormal healing reactions, arthrofibrosis, complex regional pain syndrome, and failure of graft incorporation fall under the category of surgical limitations, as do chondral or meniscal injuries. Surgical control over these conditions often is limited, but sometimes skill in surgical planning and timing can have an effect. Early surgical intervention for ligamentous injuries before regaining muscular tone and motion is associated with arthrofibrosis, as are surgical procedures such as medial collateral ligament repair on the femoral side and meniscal repair. Allowing motion and allowing the knee to calm before surgery has been shown to greatly decrease postoperative stiffness and arthrofibrosis. Complex regional pain syndrome is a poorly understood condition that possibly could be decreased by better patient selection, decreased operating time, and early physical therapy. Early reports stated that overtightening of the anterior cruciate ligament graft might result in failure of graft maturation, but other studies have not supported this conclusion. 

HIP Arthroscopy of the hip continues to evolve and become more common with expanding indications. The number of hip arthroscopic procedures has grown significantly, increasing 600% between 2006 and 2010, as reported through the ABOS database. A recent database review showed the number of arthroscopic procedures in the hip increasing almost fivefold between 2008 and 2013, with the most common procedures being femoroplasty, labral repair, and acetabuloplasty. Arthroscopy of the hip is a technically demanding procedure because of the sphericity of the femoral head and the dense capsule and musculature that surround the joint. Several papers have described a learning curve for hip

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY arthroscopy, which may be as high as 60 cases before there is a decrease in major complications. Arthroscopy of the hip gives the surgeon access to the central compartment and peripheral compartments of the hip. The central compartment includes the articular surfaces of the femoral head and acetabulum, the labrum, and the ligamentum teres. The peripheral compartment includes the femoral neck and the surrounding capsule and synovium. Numerous procedures involving the peritrochanteric space also have been described.

INDICATIONS/CONTRAINDICATIONS

The indications for hip arthroscopy continue to expand. Current indications include labral tears, removal of loose bodies, femoroacetabular impingement (FAI), chondral lesions, synovial disorders, ligamentum teres pathology, septic arthritis, psoas tendon disorders, extraarticular impingement (subspine and ischiofemoral), external snapping hip, greater trochanteric pain syndrome, proximal hamstring injuries, and sciatic nerve disorders. In addition, hip arthroscopy is used frequently in the setting of trauma. A systematic review by Niroopan et al. demonstrated good outcomes using hip arthroscopy for bullet extraction, loose body removal, femoral head fixation, acetabular fracture fixation, treatment of labral injuries, and debridement of ligamentum teres injuries. However, care must be taken in patients with acute trauma because the soft-tissue envelope of the hip may be disrupted, which can lead to excessive fluid extravasation into the abdomen and subsequent compartment syndrome. Relative contraindications are obesity, hip dysplasia, and inability to distract the hip joint. Instrumentation may not be long enough to access the hip joint in obese patients. Hip arthroscopy may lead to chronic instability in patients with dysplasia; however, several authors have shown improvement in symptoms following hip arthroscopy in these patients. Domb et  al. reported improvement of patient symptoms and no conversions to total hip arthroplasty in a 5-year follow-up of patients with borderline dysplasia treated arthroscopically. In the evaluation of patients for hip arthroscopy, care needs to be taken to determine the radiographic level of osteoarthritis in the affected hip. Numerous studies have shown worse results in patients with preexisting osteoarthritis of the hip. Larson et  al. found less symptomatic improvement after FAI correction in patients with osteoarthritis and no improvement in patients with advanced osteoarthritis compared to patients without radiographic signs of osteoarthritis. Chandrasekaran et  al. showed a significantly higher rate of conversion to total hip arthroplasty in patients with Tönnis grade 2 arthritis (small cysts, moderate joint space narrowing, and moderate loss of femoral head sphericity). 

GENERAL SETUP

Arthroscopy of the hip has been described with the patient supine or in the lateral position. Both positions offer some advantages, but the choice is surgeon dependent. The supine position offers ease of patient positioning, surgeon familiarity, and the ability to use a fracture table. The lateral position is often easier in obese patients. The lateral position does require distraction devices for the operating table.

Both techniques require the affected leg to be placed in traction for access to the joint, as well as for procedures involving the intraarticular portion or central compartment of the hip. Some commercially available distractors are available, but a regular fracture table can be used (Fig. 51.65A). Ten to 12 mm of distraction is needed for placement of 4.5or 5.5-mm cannulas. With devices that have tensiometers, approximately 50 lb of force is needed. Traction time should be limited to less than 2 hours to decrease the chance of traction neurapraxias. A well-padded, often oversized perineal post is used. The post should be placed laterally. This improves the vector of the traction force and decreases the risk of neu­ rapraxia (Fig. 51.65B). Often less traction is needed after the joint has been accessed, relieving the negative pressure. In both positions, image intensification is used extensively for portal placement. After completion of the central compartment procedure, the leg is removed from traction and the hip is flexed, typically to 45 degrees. This relaxes the capsule and gives greater access to the peripheral compartment. Both 30- and 70-degree arthroscopes are used for adequate visualization. The 70-degree arthroscopy is used for most central compartment procedures. Commercially available hip arthroscopy instruments are available. The instruments typically are longer than standard arthroscopy equipment. Various dilators and slotted cannulas are helpful for portal placement and exchanging instruments within portals, as well as minimizing soft-tissue trauma. 

PORTALS

Supine position arthroscopy uses three standard portals: the anterolateral, anterior, and posterolateral (Figs. 51.66 and 51.67). The anterolateral portal typically is placed first with the aid of fluoroscopy. This portal is made approximately 1 cm superior and anterior to the anterior edge of the greater trochanter. The posterolateral portal is made 1 cm posterior and superior to the greater trochanter. The location of the anterior portal is determined by the intersection of a line drawn from the tip of the greater trochanter and a line extending inferiorly from the anterior superior iliac spine. The posterolateral and anterior portals are made under direct observation with the camera in the anterolateral portal. After establishing the additional portals, the camera is placed in the anterior portal to assess the placement of the anterolateral portal. Because the anterolateral portal is made without direct visualization, this portal needs to be inspected to be sure there has not been inadvertent penetration of the labrum. Numerous additional accessory portals can be placed under direct visualization depending on the procedure (Fig. 51.68). The anterolateral portal pierces the gluteus medius muscle and then the hip capsule (Fig. 51.69A). The nearest neurovascular structures are the superior gluteal nerve and the sciatic nerve. The anterior portal passes through the sartorius and the rectus femoris muscles and then the hip capsule. This portal passes close to the lateral femoral cutaneous nerve and ascending branch of the lateral femoral circumflex artery (Fig. 51.69B). The posterolateral portal passes through the gluteus medius and minimus muscles. The closest neurovascular structure is the sciatic nerve (see Fig. 51.69C). A cadaver study determined the distances of the arthroscopic portals to neurovascular structures: the anterolateral portal is 6 cm from the superior gluteal nerve and 4 cm from the

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PART XIV ARTHROSCOPY sciatic nerve, the posterolateral portal lies 2.2 cm from the sciatic nerve, and the anterior portal is 1.5 cm from the lateral femoral cutaneous nerve, although several branches of this nerve may be closer. 

 

SUPINE POSITION ARTHROSCOPY TECHNIQUE 51.32 (BYRD) Place the patient supine on the fracture table or on a regular operating table with a distraction device. n  Place a heavily padded perineal post, lateralizing it against the medial thigh of the operative leg (see Fig. 51.65B). n  Position the operative hip in neutral, slight abduction, and neutral rotation. Slight flexion may relax the capsule and facilitate distraction but can place more traction on the sciatic nerve and draw it closer to the joint, making it more vulnerable to injury. n  Apply traction to the operative extremity, and confirm distraction of the joint fluoroscopically. n  Three standard portals are used for this procedure: anterior, anterolateral, and posterolateral (Fig. 51.70A and B). n 

Establish the anterolateral portal first, using a 6-inch, 17-gauge needle under fluoroscopy. The portal is in the safe zone. n  Take care that the labrum is not penetrated when establishing all arthroscopic portals. If excessive resistance is met during needle placement, redirect it under fluoroscopic control, aiming slightly more parallel to the femoral head and away from the edge of the acetabulum. Distend the joint with saline, pass the guidewire through the needle, and withdraw the needle. Pass the cannula operator assembly over the guidewire into the joint. Do not injure the articular surface of the head or penetrate the labrum when introducing the cannula. n  To make the anterior portal and the posterolateral portal, pass the spinal needle into the joint, observing the needle and its position with a 70-degree arthroscope. Verify correct placement with fluoroscopy. n  Place the anterior portal at the intersection of a line drawn from the anterior superior iliac spine and a transverse line drawn from the superior margin of the greater trochanter (see Fig. 51.67). The anterior portal penetrates the sartorius and rectus femoris before entering the anterior capsule (see Fig. 51.69). To avoid the lateral femoral cutaneous nerve, make the incision only through the skin. n  Rotate the 70-degree scope posteriorly, and make the posterolateral portal under arthroscopic and fluoroscopic control just superior to the margin of the greater trochan n 

A

Pressure

Traction

B

Perineal post Distraction vector

FIGURE 51.65 A, Commercially available distraction device. B, Perineal post for hip positioning of the operative leg. SEE TECHNIQUE 51.29.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY ter at its posterior border. The portal should be directed slightly cephalad and anteriorly, converging toward the anterolateral portal. It is important to have the hip in neutral rotation while making this portal to ensure that the sciatic nerve is not at risk. n  After establishing the three portals, place the outflow in the posterolateral portal. n  To view the acetabulum, labrum, and femoral head from each of the three portals, alternate the 70-degree scope and 30-degree scope between the anterolateral and anterior portals. Rotate the lens, and internally and externally rotate the hip. The 70-degree scope is best for viewing the labrum and the periphery of the acetabulum and femoral head, and the 30-degree scope is used for viewing of the central portion of the acetabulum, femoral head, and superior portion of the acetabular fossa (Fig. 51.71). n  Pass an arthroscopic knife through the cannula, and slightly incise the surrounding capsule transversely to allow greater maneuverability of the instruments (Fig. 51.72A and B). n  Use interchangeable, flexible cannulas with curved shaver blades to reach the greatest portion of the head and acetabulum and extra-length instrumentation for removal of labral or loose body fragments. n  Remove larger loose bodies piecemeal, carefully observing the retraction through the cannulas. n  After completing arthroscopy of the central compartment, the operative leg is released from traction and flexed 45 degrees. This allows relaxation of the capsule in order to proceed with examination of the peripheral compartment. n  The original anterior and anterolateral portals may be redirected onto the femoral neck. Alternatively, an ancillary portal may be established 4 to 5 cm distal to the anterolateral portal (Fig. 51.73). Fluoroscopy is used to guide placement onto the femoral neck.    

FIGURE 51.66 Landmarks outlined: femoral artery, vein, and nerve; greater trochanter; and anterosuperior iliac spine.

30° 45° Anterior portal Anterolateral portal

Posterolateral portal FIGURE 51.67 Three standard portals: anterior, anterolateral, and posterolateral. SEE TECHNIQUE 51.29.

Anterior superior iliac spine

AP MAP PSP

PMAP PALA AL 1 cm

Greater trochanter FIGURE 51.68 Additional accessory portals. AL, Anterolateral; AP, anterior; MAP, midanterior portal; PMAP, proximal midanterior portal; PALA, proximal accessory anterolateral portal; PSP, peritrochanteric space portal. (From Robertson WJ, Kelly BT: The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement, Arthroscopy 24:1019, 2008.)

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PART XIV ARTHROSCOPY Portal pathway

Gluteus medius muscle

Portal pathway Superior gluteal nerve

Sartorius muscle Rectus femoris muscle

Lateral femoral cutaneous nerve Ascending branch, lateral circumflex femoral artery

Anterolateral portal

A

Anterior portal

B

Gluteus minimus muscle Gluteus medius muscle Piriformis tendon

Portal pathway

Piriformis tendon Sciatic nerve

C

Posterolateral portal

FIGURE 51.69 Standard portals: anterolateral (A), anterior (B), and posterolateral (C). SEE TECHNIQUE 51.32.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Lateral femoral cutaneous nerve

Sartorius muscle

Rectus femoris muscle

Lateral femoral cutaneous nerve

Femoral artery and nerve

Sciatic nerve

A

Superior gluteal nerve

Cannula Arthroscope

Sciatic nerve

B FIGURE 51.70 A and B, Diagrams of arthroscopic incisions around hip joint and their relationship to nerves in vicinity. SEE TECHNIQUE 51.32.

 

LATERAL POSITION ARTHROSCOPY The lateral decubitus position for hip arthroscopy may be more familiar to surgeons who perform total hip arthroplasty with the patient in this position. In addition, in obese patients, the fat around the hip tends to fall away from the surgical site. In patients with large anterolateral bone spurs, the joint can be easily entered through the posterior peritrochanteric portal.

TECHNIQUE 51.33 (GLICK ET AL.) Place the anesthetized patient in the lateral decubitus position with the affected hip superior. A fracture table or a specialized distraction device may be used. A well-padded perineal post is placed. The post should be placed as lateral as possible on the surgical leg to protect the pudendal nerve and to improve the traction vector on the hip. The foot of the affected leg is placed in the foot holder to apply traction. n  Abduct the hip between 20 and 45 degrees, and extend it. The hip is placed in mild abduction, flexion, and external rotation. Use an image intensifier to evaluate traction and to guide instruments. Apply sufficient traction to create a space large enough to accommodate a 5-mm arthroscope and instruments. n  Prepare and drape the hip in a routine sterile manner to allow access as far anteriorly as the femoral artery and slightly past the posterior aspect of the greater trochanter. n  Place the affected leg in traction, and obtain a fluoroscopic image to ensure distraction of the joint 8 to 10 mm. If excessive force is required to distract the joint, a needle may be inserted into the joint under imaging. A small amount of air is then introduced into the joint, thereby breaking the vacuum seal of the hip. The required force needed for distraction will be reduced. n  Mark the anatomical landmarks, including the femoral artery anteriorly, the anterosuperior iliac spine, and the inguinal ligament, and outline the anterior, posterior, and superior portions of the greater trochanter. n 

FIGURE 51.71 Arthroscopic view of the acetabular fossa. SEE TECHNIQUE 51.32.

The lateral approach uses an anterior peritrochanteric, a posterior peritrochanteric, and a direct anterior portal. Additional portals can be made depending on the procedure. n  The anterior peritrochanteric portal is typically established first. Insert a 6-inch, 18-gauge spinal needle into the hip joint, under image intensifier guidance, starting just anterior to the anterior edge of the greater trochanter. Be sure not to penetrate the labrum. n  Air or fluid may then be injected into the joint for distention. A nitinol wire is then introduced through the spinal needle and into the hip joint. Image intensification is used to ensure placement. n  Make a skin incision at the needle site. The scope cannula is then placed over the wire and introduced into the joint. Again, an image intensifier is used. Avoid bending or breaking the nitinol wire. n  Establish an anterior portal for inflow. The anterior portal also is necessary for viewing of the anterior corners of the hip joint. n  Insert a spinal needle at a point where a sagittal line through the anterior iliac spine meets a horizontal line from the proximal tip of the greater trochanter. Angle the needle 45 degrees in the cephalad direction and 20 n 

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B

A

FIGURE 51.72 Capsulotomy. A, Anterolateral and anterior portals. B, View from anterior portal. SEE TECHNIQUE 51.32.

Spinal needle

FIGURE 51.73

Establishing an ancillary portal. SEE TECHNIQUE 51.32.

degrees medially, using the image intensifier and the arthroscope for guidance. The needle should enter the joint under direct visualization to ensure protection of the labrum and articular cartilage. n  Make a small skin incision at the needle site, and insert a 5.25-inch inflow cannula. Branches of the lateral femoral cutaneous nerve are close to this portal; avoid them by incising only the skin and by bluntly dissecting through the subcutaneous tissues. The sheath and trocar push the nerve to the side as they are directed through the tissues. n  Establish the posterior peritrochanteric portal in a similar fashion beginning at the posterior tip on the greater trochanter.

Make capsulotomies where each of the portals penetrate the capsule. This allows maneuverability and visualization by alternating the camera between the portals depending on the procedure being performed.   

n 

HIP CAPSULE

The capsule of the hip joint is composed of three ligaments: the iliofemoral, the ischiofemoral, and the pubofemoral ligaments. All of these ligaments are thickenings of the capsule and perform specific functions that contribute to hip stability. The iliofemoral ligament resists external rotation of the hip.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Groove in articular capsule for tendon of obturator externus

Iliofemoral ligament

Ischiofemoral ligament

Pubofemoral ligament

Greater trochanter Obturator membrane

Greater trochanter Obturator externus muscle

Lesser trochanter

Intertrochanteric line

A

Intertrochanteric crest

B FIGURE 51.74 A, Anteroposterior view of the hip showing iliofemoral and pubofemoral ligaments. Note capsular insertion distally to intertrochanteric line. B, Posterior view of hip showing ischiofemoral ligament and relation to obturator externus tendon. (Redrawn from Bedi A, Galano G, Walsh C, Kelly BT: Capsular management during hip arthroscopy: from femoroacetabular impingement to instability, Arthroscopy 27:1720, 2011.)

The ischiofemoral ligament is a restraint to internal rotation. The pubofemoral ligament also helps to control external rotation (Fig. 51.74A and B). During hip arthroscopy, the typical portals transverse the iliofemoral ligament. Because of the thickness of this ligament, various capsulotomies have been described to allow increased maneuverability and increased visualization of certain pathologies (Fig. 51.75A-C). Typically, for central compartment arthroscopy, an intraportal capsulotomy is made that connects the anterolateral and the anterior (or midanterior) portals (Fig. 51.75B). This capsulotomy runs parallel to the acetabulum. In cases of femoroacetabular impingement, this capsulotomy may not be adequate to visualize the full extent of the pathology. A T-shaped capsulotomy can be added to allow full visualization of the femoral neck (Fig. 51.75C). Controversy exists in the repair of these capsulotomies. Some surgeons repair the entire capsulotomy, and others repair only the T-limb (vertical limb) of the capsulotomy (Fig. 51.75D and E). If instability is a concern, repair of the entire capsulotomy is recommended. Some studies show an increase in external rotation after capsulotomy, which returns to normal with repair. Another study showed improved patient outcomes when the entire T-capsulotomy was repaired compared to partial repair with only the vertical limb repaired. Domb et al. reported 5-year patient reported outcomes in repaired and unrepaired capsulotomies. Patients in both groups showed improvements, but the unrepaired group demonstrated a decrease in hip scores at 2- and 5-year follow-up and a higher conversion rate to arthroplasty. A recent systematic review of capsular management concluded that, based on current literature, there are not enough data to

support the suggestion that routine capsular closure provides better functional outcomes. 

ARTHROSCOPIC MANAGEMENT OF LABRAL TEARS

The acetabular labrum is a fibrocartilaginous structure that surrounds the periphery of the acetabulum and inserts on the transverse acetabular ligament. Blood supply to the acetabulum is primarily through the obturator artery, superior gluteal artery, and inferior gluteal artery. The periphery of the labrum is more vascularized than the articular region. The labrum functions to increase the stability of the hip joint and to seal the hip joint and prevent escape of fluid. In the presence of a labral tear, this latter function is lost and may lead to increased contact pressure, which is thought to have a role in the development of degenerative disease of the hip. In a study of 436 patients, 73% of those with labral tears or fraying had articular damage, with most of the damage located in the same zone as the labral damage. Also, the severity of chondral damage was greater in patients with labral tears than in patients who had an intact labrum. Seldes et  al. described two types of labral injuries: a separation of the labrum from its articular attachment and tears in various planes within the substance of the labrum. A morphologic classification based on arthroscopic findings includes radial flap tears, radial fibrillated tears, longitudinal peripheral tears, and unstable tears. More recently, the majority of labral tears have been suggested to be related to abnormal joint morphology and function. Certain tears are seen with particular hip pathologies. Labral-chondral separation is more commonly seen with cam type impingement than with

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A

B

C

D

E

F

FIGURE 51.75 Capsulotomy and capsular repair techniques. A, Hip joint. B. Interportal capsulotomy. C, T-capsulotomy. D, Repaired interportal capsulotomy. E, T-capsulotomy with partial repair. F, T-capsulotomy with complete repair. (From Ekhtiari S, de Sa D, Haldane CE, et al: Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review, Knee Surg Sports Traumatol Arthrosc 25:9, 2017.)

femoroacetabular impingement, while intrasubstance tears are more typical of pincer impingement. Patients with labral tears typically present with pain (usually groin pain) and mechanical symptoms. Byrd described the C-sign: when asked to localize the pain patients cup their hand, forming a C over the greater trochanter (Fig. 51.76). Pain may be positional, with symptoms increasing with sitting, driving, putting on shoes, or crossing the legs. Pain may be minimal with level walking. Evaluation should include radiographs of the pelvis and hip and advanced imaging when indicated. Associated conditions should be noted and treated at the time of surgery. CT scan offers greater detail in assessing bony architecture, while MRI and MRI-arthrogram are useful for identifying labral tears. Initial treatment is typically nonoperative, with rest, antiinflammatory agents, and physical therapy. Unresolved pain after nonoperative treatment is treated with labral debridement or repair. In 2009, Byrd and Jones reported 10-year follow-up of patients with labral lesions treated with debridement. Hips that did not show any signs of arthritis had a significant increase in Harris Hip Scores, an improvement that remained

significant throughout the 10-year period. However, seven of eight patients with associated arthritis required total hip arthroplasty. Larson and Giveans compared the outcomes of labral debridement and labral repair in patients with femoral acetabular impingement and found that improvement in Harris Hip scores was greater in the labral refixation group. Two main suture configurations are used when repairing labral tears. The suture can be looped around the entirety of the labrum for a circumferential repair. Alternatively, it can be passed through the substance of the labrum creating a labral base repair. The decision of which suture configuration to use is based on the quality of the labral tissue remaining. In patients with robust labral tissue, a labral base repair is typically used. When the labrum is significantly frayed, a circumferential repair is chosen to avoid the suture lacerating the remaining labrum. In either type of repair, it is essential to maintain the labral contact with the femoral head, reestablishing the suction seal. Anchors placed too far from the acetabular rim or sutures that are overtightened may evert the labral edge. Jackson et  al. showed no difference in outcomes between the suture patterns in a retrospective study. 

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Right hip arthroscopy

FIGURE 51.76

FIGURE 51.77

Labral tear. SEE TECHNIQUE 51.34.

FIGURE 51.78 NIQUE 51.34.

Placement of anchor in labral repair. SEE TECH-

The “C” sign, which is indicative of a labral tear.

 

ARTHROSCOPIC REPAIR OF LABRAL TEARS TECHNIQUE 51.34 (KELLY ET AL.) Establish anterior, anterolateral, and posterolateral portals in typical fashion, with the patient supine or in the lateral decubitus position. Often, a midanterior portal is established. This portal is helpful because it creates an easier angle to place anchors in the acetabular rim without penetrating the joint surface. n  Debride all torn tissue, leaving as much healthy labrum intact as possible (Fig. 51.77). n  When a labral tear is well identified, define the margins with a flexible probe. Controlled use of monopolar radiofrequency energy through the same flexible probe can contract the torn portion of the labrum and better define the edges. n  Use a flexible ligament chisel to detach the torn part of the labrum from the intact labrum, leaving only a small portion attached. n  Complete the débridement and remove the torn portion of the labrum with a motorized shaver. n  If the labrum is detached from the bone, stabilize the fibrocartilaginous tissue back to the rim of the acetabulum with a bioabsorbable suture anchor. Typically, the anchor should be placed on the acetabular rim, more on the capsular side than the articular side of the labrum, to achieve an appropriate angle that will not result in penetration of the anchor n 

into the joint. Ensure appropriate placement using fluoroscopy. Anchors can be placed through any portal (Fig. 51.78). n  After the sleeve for the anchor is placed in the appropriate position, tap the anchor while viewing the articular surface of the acetabulum to avoid iatrogenic chondral injury. n  When the anchor is placed, use a suture passer to deliver a limb of suture through a small portion of the substance of the labrum. Retrieve the suture and pass it through the labrum a second time, creating a vertical mattress suture. Pull the cannula back slightly to an extraarticular position and tie the suture down using standard arthroscopic knot-tying techniques. n  An intrasubstance split in the labrum can be repaired if it is well fixed to the acetabulum and has a stable outer rim. Fully define and débride the cleavage plane in the labrum of frayed, nonviable tissue. n  Use a spectrum to deliver a looped monofilament suture between the junction of the articular cartilage and the fibrocartilage labrum. Pull the working cannula back to the capsule and deliver a bird beak through the outer edge of the labrum peripheral to the tear. n  Grasp the loop and bring it out through the working cannula. Pass a bioabsorbable suture around the labral split using the looped monofilament as a suture lasso. Using tactile sensation, tie the knot in an extraarticular position

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FEMOROACETABULAR IMPINGEMENT

Femoroacetabular impingement is abnormal contact between the proximal femur and the acetabulum during terminal motion. This abnormal contact leads to damage of the acetabular labrum and articular cartilage and may lead to what was previously thought of as idiopathic osteoarthritis of the hip. Based on 600 surgical dislocations, Ganz et al. described two types of femoroacetabular impingement and the mechanisms by which this might lead to osteoarthritis: cam impingement, most common in young males, and pincer impingement, most common in middle-aged women. Cam impingement results from an abnormally shaped, nonspherical femoral head, with decreased head-neck offset, abutting against the acetabulum. The impingement typically occurs in flexion and results in a shearing of the articular surface and avulsion of the labrum (Fig. 51.79). Pincer impingement is abnormal contact between the acetabular rim and the femoral head-neck junction caused by acetabular overcoverage, which may be global, as in coxa profunda, or more focal in the anterosuperior acetabulum, as in acetabular retroversion (Fig. 51.80). This contact causes intrasubstance tears of the labrum. As pincer impingement worsens, the femoral head can be levered from the socket causing chondral damage in the posteroinferior acetabulum (contrecoup injury) (Figs. 51.81 and 51.82). In most cases, cam and pincer impingement exist together. Patients with femoroacetabular impingement typically complain of pain in the groin with an insidious onset. Pain usually is exacerbated by exercise and may be positional. Patients may complain of pain with sitting, driving, or putting on socks and shoes. Examination begins with observation of posture and gait. Palpation of the hip typically does not reproduce tenderness. Ranges of motion of both hips are checked, and asymmetrical range of motion is noted. The affected hip usually has decreased internal rotation. An impingement test may reproduce the patient’s pain: with the patient supine and the hip flexed to 90 degrees, the hip is adducted and internally rotated (Fig. 51.83). A FABER (flexion, abduction, external rotation) test may show increased knee-to-table distance on the affected side in patients with femoroacetabular impingement. Imaging evaluation begins with plain radiographs, which may include anteroposterior pelvic, false profile, cross-table lateral, frog-leg lateral, and Dunn views of the hip. The anteroposterior pelvic view should be well centered, with the tip of the coccyx pointing to the symphysis pubis. The distance between the coccyx and symphysis, on a well-centered view, should be 1 to 2 cm. The acetabulum is assessed for coxa profunda, acetabular protrusion, or acetabular retroversion. Coxa profunda is indicated when the acetabular teardrop lies medial to the ilioischial line. If the femoral head lies medial to the ilioischial line, acetabular protrusion is indicated. With

A

Cam impingement

Acetabular cartilage

B

Labrum

FIGURE 51.79 A, Cam impingement. B, With hip flexion, cam lesion glides under labrum, engaging edge of articular cartilage causing failure over time.

Normal

A

Pincer impingement

Labrum

B FIGURE 51.80 A, Pincer impingement from anterior acetabular prominence. B, Labrum is pushed against neck of femur causing failure over time.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Right hip arthroscopy

FIGURE 51.81 ulum.

Articular cartilage is sheared from the acetabFIGURE 51.84 “Crossover sign” (left) is created when anterior wall crosses lateral to posterior wall in acetabular retropulsion. Center edge angle is created with line drawn perpendicular to horizontal axis of pelvis through center of femoral head and second line drawn to edge of sourcil.

FIGURE 51.82

Labral tear.

FIGURE 51.83 Impingement test is performed by provoking pain with flexion, adduction, and internal rotation of symptomatic hip.

acetabular retroversion, the anterior wall crosses lateral to the posterior wall, creating a “crossover sign” (Fig. 51.84). Certain measurements can be used to assess acetabular coverage. The center-edge angle is the angle formed between a line that is perpendicular to the transverse axis of the pelvis that passes through the center of the femoral head and a second line from the center of the femoral head to the lateral edge of the acetabular sourcil (see Fig. 51.84). Values of less than 20 to 25 degrees may indicate acetabular undercoverage. Any preoperative osteoarthritic changes of the hip are noted. On all views, femoral head sphericity and femoral head-neck offset are evaluated. The alpha angle is determined on the lateral radiographs. This angle is formed by a line through the center of the femoral head and neck and a second line from the center of the femoral head to the point where the femoral head radius exits a concentric circle drawn around the femoral head. An alpha angle of more than 50 degrees is typical in hips with loss of sphericity (Fig. 51.85). CT may help further define bony anatomy. MRI is used to assess labral and chondral injuries. There is evidence to show that femoroacetabular impingement exists in asymptomatic patients. A review by Frank et al. documented a 37% occurrence of radiographic femoroacetabular impingement in asymptomatic individuals. The prevalence is even higher in the athletic population. There is no indication for operative treatment in asymptomatic individuals. These patients should be followed if symptoms do arise. Treatment is initially nonoperative and includes activity modification, nonsteroidal antiinflammatory drugs, and physical therapy. Patients who do not respond to conservative treatment may be candidates for arthroscopic treatment. The goal of arthroscopic treatment is to treat labral pathology as well as chondral damage and to remove sites of bony impingement and reestablish the femoral head-neck offset. In a cadaver study, Mardones et al. showed that up to 30% of the femoral head-neck junction can be resected without producing a significant increase in the risk of femoral neck fracture.

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FIGURE 51.85

portal and take down the labrum at the labral-chondral junction in the area of the lesion. n  Place a burr in the midanterior portal and position it on the anterior wall at the level of the acetabular overcoverage. Confirm with fluoroscopy that the burr is just distal to the crossover sign, resect the rim to the appropriate level, and confirm resection of the crossover with fluoroscopy. The camera can be switched to the anterior portal and the burr to the anterolateral portal to complete the more superior rim resection. n  Refix the labrum to the rim with suture anchors. Place the first anchor superiorly through the anterolateral portal, using fluoroscopy and direct observation to ensure that the joint is not penetrated. Pass one suture limb into the joint between the labrum and rim (Fig. 51.86C). n  Pass a bird beak or other penetrating grasper through the labrum, retrieve the suture, and tie it (Fig. 51.86D). Alternatively, loop the suture around the labrum instead of piercing the tissue. n  With the camera in the anterolateral portal, place the remaining anchors through the midanterior portal in a similar fashion. n  Remove traction from the leg, and move the hip through a range of motion to ensure there is no residual impingement.

Alpha angle.

Mid-term results after femoroacetabular impingement correction continue to show improvement in pain and function. Menge et al. published survivorship and outcomes at 10 years after femoroacetabular impingement correction that included labral debridement or labral repair: 34% of patients had total hip arthroplasty within the 10-year period. Older age, less than 2 mm of joint space, and acetabular microfracture were more prominent in the group requiring total hip arthroplasty. Patients who did not require total hip arthroplasty had significant improvements in patient-reported outcomes and satisfaction, regardless of whether treatment was labral repair or debridement. Perets et al. showed statistically significant improvement in modified Harris Hip score and other hip scores at 5-year follow-up. In addition, 80% of patients returned to sports, with 71% returning to the same or higher level of ability compared to preoperative function. A systematic review showed that 87% of patients were able to return to sports. Reports of femoroacetabular impingement correction in professional athletes demonstrate return-toplay in basketball, hockey, and other sports.   

ARTHROSCOPIC TREATMENT OF PINCER IMPINGEMENT TECHNIQUE 51.35 (LARSON) Establish standard arthroscopic portals and examine the hip to confirm pincer impingement. A midanterior portal can be used to aid in anchor placement. n  If the pincer lesion can be seen (Fig. 51.86A), leave the labral-chondral junction intact and use a burr to resect the bony prominence (Fig. 51.86B). n  If exposure of the acetabular rim is needed to access the pincer lesion, place a banana blade through the anterior n 

   

 

ARTHROSCOPIC TREATMENT OF CAM IMPINGEMENT TECHNIQUE 51.36 (MAURO ET AL.) After standard arthroscopic portal placement and examination, complete any needed central compartment procedures. n  Remove the leg from traction, and flex the hip approximately 45 degrees. n  With the camera in the midanterior portal, introduce an arthroscopic blade through a distal accessory anterolateral portal and make a T-shaped capsulotomy to allow inspection of the cam lesion. Flexion and external rotation will help expose inferior medial lesions, and extension and internal rotation will help expose superolateral lesions. Take care to avoid the retinacular vessels when treating lesions on the superolateral neck. n  Introduce a burr and resect the cam lesion to re-create a spherical femoral head. Use fluoroscopy to assist and confirm resection. n  Perform dynamic assessment of the hip. The hip is flexed and internally and externally rotated to ensure there is no residual impingement. n  Repair the limb of the capsulotomy that extends down the femoral neck in side-to-side fashion. n 

POSTOPERATIVE CARE Physical therapy and range of motion are begun in the first 24 to 48 hours. A stationary

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY

A

B

C

D

FIGURE 51.86 A, Pincer lesion. B, Pincer resection. C, Suture limb passed into joint between labrum and rim. D, Suture retrieved with bird beak grasper and tied. SEE TECHNIQUE 51.35.

bike may be used immediately. Patients are limited to touchdown weight bearing for 2 weeks. Extremes of motion are avoided for several weeks, particularly extension and external rotation. Some surgeons recommend bracing for the first few weeks. Impact activities are not recommended for 2 to 3 months. Return to sports may take 4 to 6 months.   

LABRAL RECONSTRUCTION

The acetabular labrum provides several important protective roles in the hip. There are cases in which the labrum is too damaged to repair or may be absent. This may be seen in a primary or a revision setting. In young, active patients reconstruction of the labrum may help provide some protection to the joint. Several graft choices have been described, including IT band, gracilis, and ligamentum teres. The technique involves side-to-side repair with the native labrum and repair of the graft to the acetabular rim with anchors placed 1 cm apart. In a cadaver study, Lee et al. demonstrated an increase in joint contact forces with decreased contact areas after resection of the labrum. Reconstructing the labrum did produce a reversal of some of these changes. Shortterm results have shown increased patient satisfaction and improved hip scores. Boykin et al. reported an average rate of return to sports of 85% after labral reconstruction in elite athletes. Improvements were seen in modified Harris Hip score and

patient satisfaction. In a 2-year follow-up, Domb et al. compared labral resection to labral reconstruction in similarly matched groups. Both groups showed improvement; however, in a few categories, patient-reported outcomes in the reconstruction group were significantly improved over the resection group. Perets et  al. compared 2-year follow-up in patients requiring revision labral reconstruction to those with revision labral repair. Patients requiring labral reconstruction had lower preoperative patient-reported outcomes, but at follow-up both groups had similar increases in patient-reported outcomes, satisfaction, and VAS (visual analog scale) scores. There were no significant differences in the number of reoperation or major complications. 

 

ARTHROSCOPIC LABRAL RECONSTRUCTION TECHNIQUE 51.37 (MATSUDA) With the patient supine, confirm indications for labral reconstruction.

n 

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L

AR

FH

A

B

*

FH

Gr Gr

2

L

3 FH

C

1

*

L

D

E

FIGURE 51.87 A, Supine arthroscopic view of right hip with 70-degree scope in anterolateral portal showing anterosuperior acetabulum after rim trimming and predrilling of suture anchor sites (black arrows). Red arrow indicates location of anterior suture anchor drill hole, which is hidden by stable labral margin (L); posterosuperior drill hole is not visible in field of view (AR, acetabular rim; FH, femoral head). B, Gracilis autograft after suture placement. Note simple midsubstance sutures and whip stitches at terminal ends of graft. C, Supine arthroscopic view of right hip during partial insertion of leading end of gracilis graft (Gr) into first suture anchor drill site with intimate contact and intentional overlap with labral margin (L). Arrow shows direction of suture anchor (asterisk) placement into acetabular rim (FH, femoral head). D, Supine arthroscopic view of right hip showing terminal end of gracilis autograft (Gr) being seated into final suture anchor site in overlapped position with posterosuperior labral remnant (L) permitting graft tensioning just before deployment of suture anchor (FH, femoral head). E, Image of right hip showing key steps of graft fixation to acetabular rim: 1, seating and fixation of leading autograft end into anterior suture anchor site; 2, labral graft fixation in intercalary section to anterosuperior rim; and 3, seating of “tail” end of graft into final suture anchor site in direction of black arrow with resultant tensioning of graft (red arrow) before final knotless suture anchor fixation to facilitate fluid seal. Yellow asterisk shows region of intentional overlap at labrum-graft junction. (From Matsuda DK: Labral reconstruction with gracilis autograft, Arthrosc Tech 1:e15, 2012.) SEE TECHNIQUE 51.36.

Establish a modified midanterior portal (MMAP), 3 cm anterior and 4.5 mm distal to the anterolateral portal. n  Debride the labrum to be reconstructed back to a stable rim. n  Drill the suture anchor sites on the acetabulum for later use with knotless anchors (Fig. 51.87A). Four or five anchors typically are used, spaced about 8 mm apart; the number of anchors used varies depending on the size of the labral defect. n  Remove the hip from traction, and flex the hip and knee (figure-of-four position). n  Harvest the ipsilateral gracilis tendon through a 2-cm vertical incision just medial and distal to the tibial tuberosity. n 

Prepare the harvested tendon. Prepare the graft 2 cm longer than the defect to be grafted. Place a whipstitch in each end with No. 2 nonabsorbable suture. Place 2 or 3 simple midsubstance sutures (Fig. 51.87B). n  Pass the graft through the MMAP with an 8.25-mm cannula. n  Place the leading end of the graft partially in the most anterior drill hole, and fix it with the first anchor, achieving an interference fit (Fig. 51.87C). n  Fix the midsubstance sutures along the acetabular rim into the previously drilled holes, proceeding from anterior to posterior. n 

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Partially insert the end of the graft into the last drill hole, and fix it there (Figs. 51.87D and E).   

n 

ABDUCTOR TENDON TEARS

Lateral hip pain, or greater trochanteric pain syndrome, is a common complaint. Causes of greater trochanteric pain syndrome range from bursitis to partial or full-thickness tears of the abductor tendon. In patients with abductor tendon pathology, weakness may also be present. Initial treatment includes activity modification, physical therapy, nonsteroidal antiinflammatory medication, and trochanteric steroidal injections. In patients who do not respond, an MRI can determine the integrity of the abductor tendon. If pain and weakness persist, endoscopic tendon repair may be indicated. Short-term followup studies demonstrate improvement in symptoms, strength, and patient satisfaction. A systematic review showed similar results to open repair with fewer wound complications. Endoscopic repair can be done with the patient supine or in the lateral position. If indicated, central and peripheral compartment arthroscopy are completed first. Perets et al. reported 5-year outcomes in patients with endoscopic gluteus medius repairs with concomitant arthroscopy for labral tears. There was significant improvement in all measured hip scores, and no patients had clinical failure of the gluteus medius repair.   

REPAIR OF THE ADDUCTOR TENDON

 

TREATMENT OF EXTERNAL SNAPPING HIP

TECHNIQUE 51.38 (BYRD) Position the leg in slight extension and abduction; do not apply traction. n  Establish a distal anterior portal, anterior and distal to the vastus ridge, and insert a 30-degree arthroscope. n  Establish a proximal anterior portal under direct observation. Both portals should be aimed toward the vastus ridge, deep to the iliotibial band. n  Excise bursal tissue to expose the insertion of the abductor tendon, the vastus ridge, and the origin of the vastus lateralis. n  Establish a posterior portal at the posterior border of the vastus ridge. n  Mobilize the torn tendon edges, and use a burr to prepare the bony footprint. n  Place anchors in the footprint perpendicular to the cortical surface. n  Use mattress sutures to approximate the tendon edges to the prepared bed.    n 

SNAPPING HIPS

occurs when the iliotibial band snaps over the greater trochanter while the hip moves between flexion and extension. Patients often can reproduce this snapping, which can even be seen. In some patients, the snapping may be painless and no treatment is needed. Internal snapping hip occurs when the psoas tendon snaps over the iliopectineal eminence, femoral head, or a prominent acetabular component after total hip arthroplasty. Internal snapping is typically reproduced when the flexed, externally rotated hip is brought into extension and internal rotation. For painful external or internal snapping hips, treatment typically is nonsurgical and consists of physical therapy, antiinflammatory medication, and steroid injection. For patients who do not respond to conservative management, surgical release may be indicated. For external snapping hips, an endoscopic release on the iliotibial band is performed by creating a diamond-shaped defect overlying the greater trochanter. Surgical treatment of internal snapping hips involves release of the psoas tendon at the lesser trochanter or at the level of the hip joint. At the level of the hip joint, the psoas tendon can be released through the central compartment with the leg in traction or through the peripheral compartment with the leg flexed. The psoas tendon typically is released at the end of the surgical procedure to prevent fluid extravasation into the retroperitoneal space. In a recent review, there were fewer complications and less postoperative pain associated with arthroscopic release compared to open procedures. 

There are a variety of causes of snapping hips. Intraarticular pathology such as labral tears, femoroacetabular impingement, or loose bodies may cause a sensation of snapping or popping in the hip. These causes are treated during hip arthroscopy when indicated. External snapping hip

TECHNIQUE 51.39 (ILIZALITURRI ET AL) Position the patient lateral, but do not place the leg in traction. The leg should have free range of motion in order to reproduce the snapping. n  Inject 40 to 50 mL of saline under the iliotibial band. n  Mark the location of the greater trochanter, and establish two portals in line with the femur, one proximal and one distal to the trochanter. n  Make the distal portal first and place a 30-degree arthroscope superficial to the iliotibial band. n  Make the proximal portal under direct observation and place a shaver through this portal. n  Use the shaver to create a plane superficial to the iliotibial band to expose the tendon. n  Place a radiofrequency probe in the proximal portal, and make a vertical cut in the iliotibial band starting at the level of the distal portal and extending proximally 4 to 6 cm. n  At the midportion of the vertical cut, make a 2-cm horizontal cut anteriorly and extend a similar cut posteriorly. n  Create the anterior and posterior flaps and resect them to create a diamond-shaped defect. n  Move the leg through a range of motion to ensure there is no residual snapping.     n 

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PART XIV ARTHROSCOPY postoperative outcome scores, but these scores were lower than in the primary group. Patients with more than two revisions have lower outcome scores. 

 

PSOAS RELEASE AT THE LESSER TROCHANTER

COMPLICATIONS OF HIP ARTHROSCOPY

TECHNIQUE 51.40 If indicated, complete a routine arthroscopic examination of the hip. n  Remove traction from the operative leg, flex the hip 15 to 20 degrees, and externally rotate it. n  Using fluoroscopic guidance, create a portal distal to the anterolateral portal in line with the lesser trochanter and insert a 30-degree arthroscope. n  Create a second, more distal portal for instrumentation. n  Identify the fibers of the psoas tendon within the psoas bursa. If needed for exposure, clear the bursa with a shaver. n  Use a radiofrequency device to divide the tendon.     n 

 

PSOAS RELEASE AT THE JOINT LEVEL TECHNIQUE 51.41 (WETTSTEIN ET AL.) After completion of central compartment hip arthroscopy, remove the hip from traction and flex it 30 degrees. n  Establish anterior and anterolateral portals. Insert a 30-degree arthroscope directed toward the anterior femoral neck through the anterolateral portal. n  Identify the medial synovial fold, zona orbicularis, and anterior hip capsule. n  Introduce a radiofrequency probe through the anterior portal and make an incision in the anterior capsule anterior to the medial synovial fold and proximal to the zona orbicularis. The psoas tendon lies directly anterior to the capsule at this level. n  Release the tendon.    n 

REVISION HIP ARTHROSCOPY

As the number of arthroscopic hip procedures increases, so does the number of revision hip arthroscopies. The most common reason for revision hip arthroscopy is residual impingement, which may result from untreated or undertreated impingement at the initial procedure. Gwathmey, Jones, and Byrd reported that, in 190 consecutive revision hip arthroscopies, residual impingement was the most common finding at surgery. In most of the revision patients, there was no attempt at bony correction at the initial procedure. At a minimum of 2-years’ follow-up after revision, 84.5% of patients had improvement in symptoms. Newman et al. compared 246 patients with revision hip arthroscopic surgeries to a matched control group with primary arthroscopy patients and found that revision patients did have significant improvements in

Reported complication rates for hip arthroscopy generally are low. A systematic review of 36,761 hip arthroscopies demonstrated a 3.3% complication rate. Traction neurapraxia affecting the femoral, sciatic, pudendal, or lateral femoral cutaneous nerves is the most commonly reported complication; these typically resolve spontaneously. Neurapraxia usually is caused by prolonged length of time the leg is placed in traction or excessive pressure from the perineal post. The lateral femoral cutaneous nerve also may be damaged if the anterior portal is placed too far medially. Excessive traction may also cause pressure damage to the perineal areas. Scuffing of the articular surfaces may occur, and this may be underreported. Iatrogenic damage to the labrum may occur during placement of the initial anterolateral portal, as this portal is not placed under direct visualization. Other rare complications have been reported after hip arthroscopy, including abdominal compartment syndrome and hip instability. Abdominal compartment syndrome results from fluid extravasation into the retroperitoneal space. Fluid extravasation may track through the psoas tendon sheath; therefore a psoas release, if indicated, should be completed at the end of the procedure. In trauma patients, careful monitoring of the abdomen is required because of disruption of the soft-tissue envelope of the hip. Hip instability is a rare but serious complication of hip arthroscopy that may present as repetitive microinstability or a hip dislocation. A systematic review by Duplantier et al. looked at potential causes for instability and concluded that preoperative conditions such as dysplasia or ligamentous laxity may play a role. Postoperative conditions that may lead to instability include overresection of the acetabular rim, psoas tenotomy, unrepaired capsulotomy, and ligamentum teres debridement. Arthroscopic treatment of femoroacetabular impingement may lead to complications because of bony overresection or underresection. Underresection of pincer or cam deformities can lead to incomplete relief and a need for further surgery. Overresection of a femoral neck cam lesion places the femoral neck at risk for fracture. As with open hip surgery, there is a risk of heterotopic ossification after hip arthroscopy. A report of 300 cases had a 1.6% rate of heterotopic ossification, all of which occurred in a control group of 15 patients who did not receive prophylaxis. None of 285 patients who received nonsteroidal antiinflammatory drugs for 3 weeks developed heterotopic ossification.

REFERENCES KNEE

General. Balato G, Di Donato SL, Ascione T, et al.: Knee septic arthritis after arthroscopy: incidence, risk factors, functional outcome, and infection eradication rate, Joints 5:107, 2017. Behery OA, Suchman KI, Paoli AR, et  al.: What are the prevalence and risk factors for repeat ipsilateral knee arthroscopy?, Knee Surg Sports Traumatol Arthrosc, 2019 Jan 17, https://doi.org/10.1007/s00167-01905348-y, [Epub ahead of print]. Bohensky MA, Ademi Z, deSteiger R, et  al.: Quantifying the excess cost and resource utilisation for patients with complications associated with

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY elective knee arthroscopy: a retrospective cohort study, Knee 21:491, 2014. Bohensky MA, deSteiger R, Kondogiannis C, et al.: Adverse outcomes associated with elective knee arthroscopy: a population-based cohort study, Arthroscopy 29:716, 2013. Burkhart SS, Miller MD, Sanders TG, et al.: MRI-arthroscopy correlations of the shoulder, elbow, hip and knee: a case-based approach, San Diego, CA, February 2011, AAOS Instructional Course Lecture, Annual Meeting of the American Academy of Orthopaedic Surgeons. Hagino T, Ochiai S, Watanabe Y, et  al.: Complications after arthroscopic knee surgery, Arch Orthop Trauma Surg 134:1561, 2014. Hoshino Y, Rothrauff BB, Hensler D, et al.: Arthroscopic image distortionpart I: the effect of lens and viewing angles in a 2-dimensional in vitro model, Knee Surg Sports Traumatol Arthrosc 24:2065, 2016. Karargyris O, Mandalia V: Arthroscopic treatment of patellar tendinopathy: use of 70° arthroscope and superolateral portal, Arthrosc Tech 5:e1083,2016. Kaye ID, Patel DN, Strauss EJ, et al.: Prevention of venous thromboembolism after arthroscopic knee surgery in a low-risk population with the use of aspirin. A randomized trial, Bull Hosp Jt Dis 73:243, 2015. Lee DY, Park YJ, Song SY, et al.: Which technique is better for treating patellar dislocation? A systematic review and meta-analysis, Arthroscopy, 2018 Oct 6, pii: S0749-8063(18)30569-3, https://doi.org/10.1016/j. arthro.2018.06.052, [Epub ahead of print]. Martin CT, Pugely AJ, Gao Y, Wolf BR: Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database, J Bone Joint Surg 95A:e98, 2013. Matsushita T, Araki D, Hoshino Y, et al.: Analysis of graft length change patterns in medial patellofemoral ligament reconstruction via a fluoroscopic guidance method, Am J Sports Med 46:1150, 2018. Nelson JD, Hogan MV, Miller MD: What’s new in sports medicine, J Bone Joint Surg 92A:250, 2010. Rong Z, Yao Y, Chen D, et  al.: The incidence of deep venous thrombosis before arthroscopy among patients suffering from high-energy knee trauma, Knee Surg Sports Traumatol Arthrosc 24:1717, 2016. Salzler MJ, Lin A, Miller CD, et al.: Complications after arthroscopic knee surgery, Am J Sports Med 42:292, 2014. Sanchis-Alfonso V, Baydal-Bertomeu JM, Castelli A, et al.: Laboratory evaluation of the pivot-shift phenomenon with the use of kinetic analysis: a preliminary study, J Bone Joint Surg 93A:1256, 2011. Thompson SR: Diagnostic knee arthroscopy and partial meniscectomy, JBJS Essent Surg Tech 6:e7, 2016. Werner BC, Cancienne JM, Miller MD, Gwathmey FW: Incidence of manipulation under anesthesia or lysis of adhesions after arthroscopic knee surgery, Am J Sports Med 43:1656, 2015. Westermann RW, Pugely AJ, Teis Z, et al.: Causes and predictors of 30-day readmission after shoulder and knee arthroscopy: an analysis of 15, 167 cases, Arthroscopy 31:1035, 2015. Wyatt RWB, Maletis GB, Lyon LL, et al.: Efficacy of prophylactic antibiotics in simple knee arthroscopy, Arthroscopy 33:157, 2017.

MENISCUS Bedi A, Kelly NH, Baad M, et al.: Dynamic contact mechanics of the medial meniscus as a function of radial tear, repair, and partial meniscectomy, J Bone Joint Surg 92A:1398, 2010. Bhatia S, LaPrade CM, Ellman MB, et al.: Meniscal root tears. Significance, diagnosis, and treatment, Am J Sports Med 42:3016, 2014. Blackwell R, Schmitt LC, Flanigan DC, Magnussen RA: Smoking increases the risk of early meniscus repair failure, Knee Surg Sports Traumatol 24:1540, 2016. Brelin AM, Rue JP: Return to play following meniscus surgery, Clin Sports Med 35:669, 2016. Bryceland JK, Powell AJ, Nunn T: Knee menisci, Cartilage 8:99, 2016. Bin SI, Nha KW, Cheong JY, et al.: Midterm and long-term results of medial versus lateral meniscal allograft transplantation. A meta-analysis, Am J Sports Med 46:1243, 2018. Chung KS, Ha JK, Ra HJ, et al.: A meta-analysis of clinical and radiographic outcomes of posterior horn medial meniscus root repairs, Knee Surg Sports Traumatol Arthrosc 24:1455, 2016.

Chung KS, Ha JK, Ra HJ, et  al.: Prognostic factors in the midterm results of pullout fixation for posterior root tears of the medial meniscus, Arthroscopy 32:1319, 2016. Ellis HB: Can a meniscus really regenerate so easily? A Level-I study says it can but not for everyone: Commentary on an article by Vangsness et al: Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: a randomized, double-blind, controlled study, J Bone Joint Surg 96:e14, 2014. Eun SS, Lee SH, Sabal LA: Arthroscopic repair of the posterior root of the medial meniscus using knotless suture anchor: a technical note, Knee 23:740, 2016. Faucett SC, Geisler BP, Chahla J, et  al.: Meniscus root repair vs meniscectomy or nonoperative management to prevent knee osteoarthritis after medial meniscus root tears: clinical and economic effectiveness, Am J Sports Med, 2018 Mar 1:363546518755754, https:// doi.org/10.1177/0363546518755754, [Epub ahead of print]. Feucht MJ, Grande E, Brunhuber J, et al.: Biomechanical evaluation of different suture techniques for arthroscopic transtibial pull-out repair of posterior medial meniscus root tears, Am J Sports Med 41:2784, 2013. Fillingham YA, Riboh JC, Erickson BJ, et  al.: Inside-out versus all-inside repair of isolated meniscal tears: an updated systematic review, Am J Sports Med 45:234, 2016. Freymann U, Metzlaff S, Krüger JP, et al.: Effect of human serum and 2 different types of platelet concentrates on human meniscus cell migration, proliferation, and matrix formation, Arthroscopy 32:1106, 2016. Hannon MG, Ryan MK, Strauss EJ: Meniscal allograft transplantation: a comprehensive historical and current review, Bull Hosp Jt Dis 73:100, 2015. Harston A, Nyland J, Brand E, et al.: Collagen meniscus implantation: a systematic review including rehabilitation and return to sports activity, Knee Surg Sports Traumatol Arthrosc 20:135, 2011. Haskel JD, Uppstrom TJ, Dare DM, et al.: Decline in clinical scores at longterm follow-up of arthroscopically treated discoid lateral meniscus in children, Knee Surg Sports Traumatol Arthrosc 26:2906, 2018. Hendrix ST, Kwapisz A, Wyland DJ: All-inside arthroscopic meniscal repair technique using a midbody accessory portal, Arthroscopy Tech 6: e1885,2017. Herbort M, Siam S, Lenschow S, et  al.: Strategies for repair of radial tears close to the meniscal rim—biomechanical analysis with a cyclic loading protocol, Am J Sports Med 38:2281, 2010. Jacquet C, Erivan R, Argenson JN, et  al.: Effect of 3 preservation methods (freezing, cryopreservation, and freezing + irradiation) on human menisci ultrastructure: an ex vivo comparative study with fresh tissue as a gold standard, Am J Sports Med 46:2899, 2018. Jung YH, Choi NH, Oh JS, Victoroff BN: All-inside repair for a root tear of the medial meniscus using a suture anchor, Am J Sports Med 40:1406, 2012. Keyhani S, Ahn JH, Verdonk R, et al.: Arthroscopic all-inside ramp lesion repair using the posterolateral transseptal portal view, Knee Surg Sports Traumatol Arthrosc 25:454, 2017. Kim NK, Bin SI, Kim JM, Lee CR: Does medial meniscal allograft transplantation with the bone-plug technique restore the anatomic location of the native medial meniscus? Am J Sports Med 43:3045, 2015. Konan S, McNicholas M, Vedonk P, et  al.: Meniscal injuries: management and outcome. In Kerkhoffs GMMJ, Haddad F, Hirschman MT, et  al, editors: ESSKA Instructional Course Lecture Book, Glasgow 2018, 2018. Berlin, Germany, 2018, Springer, pp 33–44. Krych AJ, Pitts RT, Dajani KA, et al.: Surgical repair of meniscal tears with concomitant anterior cruciate ligament reconstruction in patients 18 years and younger, Am J Sports Med 38:976, 2010. LaPrade CM, James EW, Cran TR, et al.: Meniscal root tears. A classification system based on tear morphology, Am J Sports Med 43:363, 2014. LaPrade RF, LaPrade CM, James EW: Recent advances in posterior meniscal root repair techniques, J Am Acad Orthop Surg 23:71, 2015. Lavender CD, Hanzlik SR, Caldwell 3rd PE, et  al.: Transosseous medial meniscal root repair using a modified Mason-Allen suture configuration, Arthrosc Tech 4:e78, 2015. Lind M, Nielsen T, Faunø P, et al.: Free rehabilitation is safe after isolated meniscus repair: a prospective randomized trial comparing free with restricted rehabilitation regimens, Am J Sports Med 41:2753, 2013.

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PART XIV ARTHROSCOPY McCulloch PC, Jones HL, Lue J, et al.: What is the optimal minimum penetration depth for “all-inside” meniscal repairs? Arthroscopy 32:1624, 2016. Miller MD, Rodeo SL, Sgaglione NA, Noyes FR: Meniscus repair and transplantation: update on surgical techniques and clinical outcomes, AAOS Instructional Course Lecture, San Diego, California, February, 2011, Annual Meeting of the AAOS. Moatshe G, Chahla J, Slette E, et al.: Posterior meniscal root injuries, Acta Orthop 87:452, 2016. Moatshe G, Cinque ME, Godin JA, et al.: Comparable outcomes after buckethandle meniscal repair and vertical meniscal repair can be achieved at a minimum 2 years’ follow-up, Am J Sports Med 45:3104, 2017. Moulton SG, Bhatia S, Civitarese DM, et  al.: Surgical techniques and outcomes of repairing meniscal radial tears: a systematic review, Arthroscopy 32:1919, 2016. Noyes FR, Barber-Westin SD: Repair of complex and avascular meniscal tears and meniscal transplantation, J Bone Joint Surg 92A:1012, 2010. Rao AJ, Erickson BJ, Cvetanovich GL, et  al.: The meniscus-deficient knee, Orthop J Sports Med 44:1724, 2016. Rongen JJ, Govers TM, Buma P, et al.: Societal and economic effect of meniscus scaffold procedures for irreparable meniscus injuries, Am J Sports Med 44:1724, 2016. Shieh AK, Edmonds EW, Pennock AT: Revision meniscal surgery in children and adolescents: risk factors and mechanisms for failure and subsequent management, Am J Sports Med 44:838, 2016. Sihvonen R, Paavola M, Malmivaara A, et al.: Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear, N Engl J Med 369:2515, 2013. Sommerfeldt MF, Magnussen RA, Randall KL, et  al.: The relationship between body mass index and risk of failure following meniscus repair, J Knee Surg 29:645, 2016. Spencer SJ, Saitha A, Carmont MR, et al.: Meniscal scaffolds: early experience and review of the literature, Knee 19:760, 2012. Steiner SR, Feeley SM, Ruland JR, et al.: Outside-in repair technique for a complete radial tear of the lateral meniscus, Arthroscopy Tech 7:e285, 2018. Strauss EJ, Day MS, Ryan M, et  al.: Evaluation, treatment, and outcomes of meniscal root tears: a critical analysis review, JBJS Rev 4, 2016, pii: 01874474-201608000-00004. Thaunat M, Fayard JM, Guimaraes TM, et  al.: Classification and surgical repair of ramp lesions of the medial meniscus, Arthrosc Tech 5, 2016:e871. Thaunat M, Jan N, Fayard JM, et al.: Repair of meniscal ramp lesions through a posteromedial portal during anterior cruciate ligament reconstruction: outcome study with a minimum 2-year follow-up, Arthroscopy 32:2269, 2016. Vangsness Jr CT, Farr 2nd J, Boyd J, et al.: Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: a randomized, double-blind, controlled study, J Bone Joint Surg Am 96:90, 2014. Van Steyn MO, Mariscalco MW, Pedroza AD, et al.: The hypermobile lateral meniscus: a retrospective review of presentation, imaging, treatment, and results, Knee Surg Sports Traumatol Arthrosc 24:1555, 2016. Verdonk R, Verdonk K, Huysse W, et al.: Tissue ingrowth after implantation of a novel, biodegradeable polyurethane scaffold for treatment of partial meniscal lesions, Am J Sports Med 39:774, 2011. Vundelinckx B, Bellemans J, Vanlauwe J: Arthroscopically assisted meniscal allograft transplantation in the knee: a medium-term subjective, clinical, and radiograhical outcome evaluation, Am J Sports Med 38:2240, 2010.

OSTEOCHONDRAL DEFECTS Bedi A, Feeley BT, Williams RJ: Current Concepts Review. Management of articular cartilage defects of the knee, J Bone Joint Surg 92A:994, 2010. Boughanem J, Riaz R, Patel RM, Sarwark JF: Functional and radiographic outcomes of juvenile osteochondritis dissecans of the knee treated with extra-articular retrograde drilling, Am J Sports Med 39:2212, 2011. Carey JL, Wall EJ, Grimm NL, et  al.: Novel arthroscopic classification of osteochondritis dissecans of the knee: a multicentere reliability study, Am J Sports Med 44:1694, 2016. Cotter EJ, Hannon CP, Christian DR, et al.: Clinical outcomes of multifocal osteochondral allograft transplantation of the knee: an analysis of overlapping grafts and multifocal lesions, Am J Sports Med 46:2884, 2018.

Gudas R, Gudaite A, Mickevicius T, et  al.: Comparison of osteochondral autologous transplantation, microfracture, or debridement techniques in articular cartilage lesions associated with anterior cruciate ligament injury: a prospective study with a 3-year follow-up, Arthroscopy 29:89, 2013. Harris JD, Siston RA, Pan X, Flanigan DC: Autologous chondrocyte implantation, J Bone Joint Surg 92A:2220, 2010. Heir S, Nerhus TK, Rotterud JH, et  al.: Focal cartilage defects in the knee impair quality of life as much as severe osteoarthritis: a comparison of knee injury and osteoarthritis outcome score in 4 patient categories scheduled for knee surgery, Am J Sports Med 38:231, 2010. Jones MH, Williams AM: Osteochondritis dissecans of the knee: a practical guide for surgeons, Bone Joint J 98-B:723, 2016. Kramer DE, Kalish LA, Abola MV, et al.: The effects of medial synovial plica excision with and with lateral retinacular release on adolescents with anterior knee pain, J Child Orthop 10:155, 2016. Krych AJ, Robertson CM, Williams 3rd RJ, et al.: Return to athletic activity after osteochondral allograft transplantation in the knee, Am J Sports Med 40:1053, 2012. Liu H, Zhao Z, Clarke RB, et al.: Enhanced tissue regeneration potential of juvenile articular cartilage, Am J Sports Med 41:2658, 2013. Millington KL, Shah JP, Dahm DL, et al.: Bioabsorbable fixation of unstable osteochondritis dissecans lesions, Am J Sports Med 38:2065, 2010. Minas T, Oguar T, Headrick J, et al.: Autologous chondrocyte implantation “sandwich” technique compared with autologous bone grafting for deep osteochondral lesions in the knee, Am J Sports Med 46:322, 2018. Moseley JB, Anderson AF, Browne JE, et al.: Long-term durability of autologous chondrocyte implantation: a multicenter, observations study in US patients, Am J Sports Med 38:238, 2010. Murphy RT, Pennock AT, Bugbee WD: Osteochondral allograft transplantation of the knee in the pediatric and adolescent population, Am J Sports Med 42:635, 2014. Nishizawa Y, Matsumoto T, Araki D, et al.: Matching articular surfaces of selected donor and recipient sites for cylindrical osteochondral grafts of the femur: quantitative evaluation using a 3-dimensional laser scanner, Am J Sports Med 42:658, 2014. Peterson L, Vasiliadis HS, Brittberg M, Lindahl A: Autologous chondrocyte implantation: a long-term follow-up, Am J Sports Med 38:1117, 2010. Richmond J, Hunter D, Irrgang J, et al.: The treatment of osteoarthritis (OA) of the knee, J Bone Joint Surg 92A:990, 2010. Safran MR, Seiber K: The evidence for surgical repair of articular cartilage in the knee, J Am Acad Orthop Surg 18:259, 2010. Shaha JS, Cook JB, Rowles DJ, et al.: Return to an athletic lifestyle after osteochondral allograft transplantation of the knee, Am J Sports Med 41:2083, 2013. Tompkins M, Hamann JC, Diduch DR, et al.: Preliminary results of a novel single-stage cartilage restoration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella, Arthroscopy 29:1662, 2013. Wong CC, Chen CH, Chan WP, et  al.: Single-stage cartilage repair using platelet-rich fibrin scaffolds with autologous cartilaginous grafts, Am J Sports Med 45:3128, 2017.

ANTERIOR CRUCIATE LIGAMENT Aboulijoud MM, Everhart JS, Sigman BO, et  al.: Risk of retear following anterior cruciate ligament reconstruction using hybrid graft of autograft augmented with allograft tissue: a systematic review and meta-analysis, Arthroscopy 34:2927, 2018. Aga C, Riseberg MA, Fagerland MW, et  al.: No difference in the KOOS Quality of Life subscore between anatomic double-bundle and anatomic single-bundle anterior cruciate ligament reconstruction of the knee: a prospective randomized controlled trial with 2 years’ follow-up, Am J Sports Med 46:2341, 2018. Akpinar B, Thorhauer E, Irrgang JJ, et al.: Alteration of knee kinematics after anatomic anterior cruciate ligament reconstruction is dependent on associated meniscal injury, Am J Sports Med 46:1158, 2018. Anderson CN, Anderson AF: Management of the anterior cruciate ligamentinjured knee in the skeletally immature athletes, Clin Sports Med 36:35, 2017.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Bettin CC, Throckmorton TW, Miller RH, Azar FM: Technique for partial transphyseal ACL reconstruction in skeletally immature athletes: preliminary results, Curr Orthop Prac 30:19, 2019. Boden BP, Sheehan FT, Torg JS, Hewett TE: Noncontact anterior cruciate ligament injuries: mechanisms and risk factors, J Am Acad Orthop Surg 18:520, 2010. Cancienne JM, Gwathmey FW, Miller MD, Werner BC: Tobacco use is associated with increased complications after anterior cruciate ligament reconstruction, Am J Sports Med 44:99, 2016. Chen H, Chen B, Tie K, et al.: Single-bundle versus double-bundle autologous anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials at 5-year minimum follow-up, J Orthop Surg Res 13:50, 2018. Chen T, Zhang P, Chen J, et  al.: Long-term outcomes of anterior cruciate ligament reconstruction using either synthetics with remnant preservation or hamstring autografts: a 10-year longitudinal study, Am J Sports Med 45:2739, 2017. Colombet P, Saffarini M, Bouguennec N: Clinical and functional outcomes of anterior cruciate ligament reconstruction at a minimum of 2 years using adjustable suspensory fixation in both the femur and tibia: a prospective study, Orthop J Sports Med 6:232596711, 2018. Delaloye JR, Murar J, Gonzalez M, et al.: Clinical outcomes after combined anterior cruciate ligament and anterolateral ligament reconstruction, Tech Orthop 33:225, 2018. Desai VS, Anderson GR, Wu IT, et  al.: Anterior cruciate ligament reconstruction with hamstring autograft: a matched cohort comparison of the all-inside and complete tibial tunnel techniques, Orthop J Sports Med 7: 2325967118820297, 2019. Dhawan A, Gallo RA, Lynch SA: Anatomic tunnel placement in anterior cruciate ligament reconstruction, J Am Acad Orthop Surg 24:443, 2016. El-Sherief FAH, Aldahshan WA, Wahd YE, et  al.: Double-bundle anterior cruciate ligament reconstruction is better than single-bundle reconstruction in terms of objective assessment but no in terms of subjective score, Knee Surg Sports Traumatol Arthrosc 26:2395, 2018. Forsythe B, Kopf S, Wong A, et al.: The location of femoral and tibial tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional computed tomography models, J Bone Joint Surg 92A:1418, 2010. Guenther D, Irarrázaval S, Bell KM, et al.: The role of extra-articular tenodesis in combined ACL and anterolateral capsular injury, J Bone Joint Surg Am 99:1654, 2017. Häner M, Bierke S, Petersen W: Anterior cruciate ligament revision surgery: ipsilateral quadriceps versus contralateral semitendinosus-gracilis autografts, Arthroscopy 32:2308, 2016. Iriuchishima T, Tajima G, Ingham SJN, et al.: Impingement pressure in the anatomical and nonanatomical anterior cruciate ligament reconstruction, Am J Sports Med 38:1611, 2010. Joyce CD, Randall KL, Mariscalco MW, et  al.: Bone-patellar tendon-bone versus soft-tissue allograft for anterior cruciate ligament reconstruction: a systematic review, Arthroscopy 32:394, 2016. Karlsson J, Irrgang JJ, van Eck CF, et al.: Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2, Am J Sports Med 39:2016, 2011. Khan M, Rothrauff BB, Merali F, et  al.: Management of the contaminated anterior cruciate ligament graft, Arthroscopy 30:236, 2014. Kocher MS, Heyworth BE, Fabricant PD, et al.: Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children, J Bone Joint Surg Am 100:1087, 2018. Kopf S, Forsythe B, Wong AK, et al.: Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography, J Bone Joint Surg 92A:1427, 2010. Kopf S, Martin DE, Tashman S, Fu F: Effect of tibial drill angles on bone tunnel aperture during anterior cruciate ligament reconstruction, J Bone Joint Surg 92A:871, 2010. Kursumovic K, Charalambous CP: Graft salvage following infected anterior cruciate ligament reconstruction: a systematic review and meta-analysis, Bone Joint J 98B:608, 2016.

Lecoq FA, Parienti JJ, Murison J, et  al.: Graft choice and the incidence of osteoarthritis after anterior cruciate ligament reconstruction: a causal analysis from a cohort of 541 patients, Am J Sports Med 46:2842, 2018. Leo BM, Krill M, Barksdale L, et  al.: Failure rate and clinical outcomes of anterior cruciate ligament reconstruction using autograft hamstring versus a hybrid graft, Arthroscopy 32:2357, 2016. Magnussen RA, Reinke eK, Huston LJ, et al.: Effect of high-grade preoperative knee laxity on 6-year anterior cruciate ligament reconstruction outcomes, Am J Sports Med 46:2865, 2018. Marchant BG, Noyes FR, Barber-Westin SD, Fleckenstein C: Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions, Am J Sports Med 38:2010, 1987. MARS group, Cooper DE, Dunn WR, et  al.: Physiologic preoperative knee hyperextension is a predictor of failure in an anterior cruciate ligament revision cohort: a report from the MARS group, Am J Sports Med 46:2836, 2018. Mayr HO, Bruder S, Hube R, et  al.: Single-bundle versus double-bundle anterior cruciate ligament reconstruction—5-year results, Arthroscopy 34:2647, 2018. Nawai DH, Tucker S, Schafer KA, et al.: ACL fibers near the lateral intercondylar ridge are the most load bearing during stability examinations and isometric through passive flexion, Am J Sports Med 44:2563, 2016. Noyes FR, Huser LE, Levy MS: The effect of an ACL reconstruction in controlling rotational knee stability in knees with intact and physiologic laxity of secondary restraints as defined by tibiofemoral compartment translations and graft forces, J Bone Joint Surg Am 100:586, 2018. Paci JM, Schweizer SK, Wilbur DM, et al.: Results of laboratory evaluation of acute knee effusion after anterior cruciate ligament reconstruction, Am J Sports Med 38:2267, 2010. Pathare NP, Nicholas SJ, Colbrunn R, McHugh MP: Kinematic analysis of the indirect femoral insertion of the anterior cruciate ligament: implications for anatomic femoral tunnel placement, Arthroscopy 30:1430, 2014. Pearle AD, McAllister D, Howell SM: Rationale for strategic graft placement in anterior cruciate ligament reconstruction: I.D.E.A.L. femoral tunnel position, Am J Orthop (Belle Mead NJ) 44:253, 2015. Pfeiffer TR, Burnham JM, Hughes JD, et  al.: An increased lateral femoral condyle ratio is a risk factor for anterior cruciate ligament injury, J Bone Joint Surg Am 100:857, 2018. Plante MJ, Li X, Scully G, et al.: Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction, Knee Surg Sports Traumatol Arthrosc 21:696, 2013. Sasaki N, Ishibashi Y, Tsuda E, et al.: The femoral insertion of the anterior cruciate ligament: discrepancy between macroscopic and histological observations, Arthroscopy 28:1135, 2012. Sernert N, Hansson E: Similar cost-utility for double- and single-bundle techniques in ACL reconstruction, Knee Surg Sports Traumatol Arthrosc 26:634, 2018. Shimodaira H, Tensho K, Akaoka Y, et al.: Remnant-preserving tibial tunnel positioning using anatomic landmarks in double-bundle anterior cruciate ligament reconstruction, Arthroscopy 32:1822, 2016. Sonnery-Cottet B, Saithna A, Cavalier M, et al.: Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group, Am J Sports Med 45:1547, 2017. Southam BR, Colosimo AJ, Grawe B: Underappreciated factors to consider in revision anterior cruciate ligament reconstruction: a current concepts review, Orthop J Sports Med 6:1, 2018. Tang X, Marshall B, Wang JH: Lateral meniscal posterior root repair with anterior cruciate ligament reconstruction better restores knee stability, Am J Sports Med Nov 19: 363546518808004. [Epub ahead of print] Weber AE, Delos D, Oltean HN, et  al.: Tibial and femoral tunnel changes after ACL reconstruction: a prospective 2-year longitudinal MRI study, Am J Sports Med 43:1147, 2015. Webster KE, Feller JA, Kimp AJ, et al.: Revision anterior cruciate ligament reconstruction outcomes in younger patients: medial meniscal pathology and high rates of return to sport are associated with third ACL injuries, Am J Sports Med 46:1137, 2018. Wiggins AJ, Grandhi RK, Schneider DK, et al.: Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis, Am J Sports Med 44:1861, 2016.

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PART XIV ARTHROSCOPY Yamamoto Y, Tsuda E, Maeda S, et al.: Greater laxity in the anterior cruciate ligament-injured knee carries a higher risk of postreconstruction pivot shift: intraoperative measurements with a navigation system, Am J Sports Med 46:2859, 2018. Yoon KH, Kim JS, Park SY, et al.: One-stage revision anterior cruciate ligament reconstruction: results according to preoperative bone tunnel diameter: five to fifteen-year follow-up, J Bone Joint Surg Am 100:993, 2018. Zhang Y, Huang W, Yao Z, et  al.: Anterior cruciate ligament injuries alter the kinematics of knees with or without meniscal deficiency, Am J Sports Med 44:3132, 2016.

ANTEROLATERAL LIGAMENT Chahla J, Menge TJ, Mitchell JJ, et al.: Anterolateral ligament reconstruction technique: an anatomic-based approach, Arthrosc Tech 5:e453, 2016. DePhillipo NN, Cinque ME, Chahla J, et al.: Anterolateral ligament reconstruction techniques, biomechanics, and clinical outcomes: a systematic review, Arthroscopy 33:1575, 2017. Geeslin AG, Moatsche G, Chahla J, et al.: Anterolateral knee extra-articular stabilizers: a robotic study comparing anterolateral ligament reconstruction and modified Lemaire lateral extra-articular tenodesis, Am J Sports Med 46:607, 2018. Kraeutler MJ, Welton L, Chahla J, et al.: Current concepts of the anterolateral ligament of the knee: anatomy, biomechanics, and reconstruction, Am J Sports Med 46:1235, 2018. Schon JM, Moatshe G, Brady AW, et  al.: Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle, Am J Sports Med 44:2546, 2016. Smeets K, Bellemans J, Lamers G, et  al.: High risk of tunnel convergence during combined anterior cruciate ligament and anterolateral ligament reconstruction, Knee Surg Sports Traumatol Arthrosc, 2018 Oct 8, https:// doi.org/10.1007/s00167-018-5200-3, [Epub ahead of print].

POSTERIOR CRUCIATE LIGAMENT Anderson CJ, Ziegler CG, Wijdicks CA, et al: Arthroscopically pertinent anatomy of the anterolateral and posteromedial bundles of the posterior cruciate ligament, J Bone Joint Surg 94:1936, 2012. Bedi A, Musahl V, Cowan JB: Management of posterior cruciate ligament injuries: an evidence-based review, J Am Acad Orthop Surg 24:277, 2016. Belk JW, Kraeutler MJ, Purcell JM, et al.: Autograft versus allograft for posterior cruciate ligament reconstruction: an updated systematic review and meta-analysis, Am J Sports Med 46:1752, 2018. Bernhardson A, DePhillipo NN, Daney BT, et al.: Posterior tibial slope and risk of posterior cruciate ligament inury, Am J Sports Med, 2019 Jan 14 :363546518819176, https://doi.org/10.1177/0363546518819176, [Epub ahead of print]. Bernhardson AS, DePhillipo NN, Aman ZS, et al: Decreased posterior tibial slope does not affect postoperative posterior knee laxity after double-bundle posterior cruciate ligament reconstruction, Am J Sports Med Jan 18:363546518819786, https://doi.org/10.1177/0363546518819786. [Epub ahead of print] Jang KM, Park SC, Lee DH: Graft bending angle at the intra-articular femoral tunnel aperture after single-bundle posterior cruciate ligament reconstruction: inside-out versus outside in techniques, Am J Sports Med 44:1269, 2016. LaPrade RF, Cinque ME, Dornan GJ, et al.: Double-bundle posterior cruciate ligament reconstruction in 100 patients at a mean 3 years’ follow-up: outcomes were comparable to anterior cruciate ligament reconstructions, Am J Sports Med 46:1809, 2018. Lee DY, Kim DH, Kim HJ, et al.: Biomechanical comparison of single-bundle and double-bundle posterior cruciate ligament reconstruction: a systematic review and meta-analysis, JBJS Rev 5:e6, 2017. Lee DY, Kim DH, Kim HJ, et al.: Posterior cruciate ligament reconstruction with transtibial and tibial inlay techniques: a meta-analysis of biomechanical and clinical outcomes, Am J Sports Med 46: 27898, 2018. Novaretti JV, Sheean AJ, Lian J, et al.: The role of osteotomy for the treatment of PCL injuries, Curr Rev Musculoskelet Med 11:298, 2018. Pache S, Aman ZS, Kennedy M, et al.: Posterior cruciate ligament: current concepts review, Arch Bone Jt Surg 6:8, 2018. Schuster P, Geßlein M, Mayer P, et al.: Septic arthritis after arthroscopic posterior cruciate ligament and multi-ligament reconstructions is rare and can be

successfully treated with arthroscopic irrigation and debridement: analysis of 866 reconstructions, Knee Surg Sports Traumatol Arthrosc 26:3029, 2018. Shin YS, Kim HJ, Lee DH: No clinically important difference in knee scores or instability between transtibial and inlay techniques for PCL reconstruction: a systematic review, Clin Orthop Relat Res 475:1239, 2017. Spiridonov SI, Slinkard NJ, LaPrade RF: Isolated and combined grade III posterior cruciate ligament tears treated with double-bundle reconstruction with use of endoscopically placed femoral tunnels and grafts: operative technique and clinical outcomes, J Bone Joint Surg 93A:1773, 2011. Wright JO, Skelley NW, Schur RP, et al.: Comparison of the anterolateral and posteromedial bundles, J Bone Joint Surg 98:1656, 2016.

OTHER ARTHROSCOPIC PROCEDURES OF THE KNEE Bodendorfer BM, Kotler JA, Zelenty WD, et al.: Outcomes and predictors of success for arthroscopic lysis of adhesions for the stiff total knee arthroplasty, Orthopedics 40:e1062, 2017. Cerciello S, Cote M, Lustig S, et al.: Arthroscopically assisted fixation is a reliable option for patellar fractures: a literature review, Orthop Traumatol Surg Res 103:1087, 2017. Kampa J, Dunlay R, Sikka R, et al.: Arthroscopic-assisted fixation of tibial plateau fractures: patient-reported postoperative activity levels, Orthopedics 39:e486, 2016. Le Baron M, Cermolacce M, Flecher X, et al.: Tibial plateau fracture management: ARIF versus ORIF—clinical and radiological comparison, Orthop Traumatol Surg Res 105:101, 2019. Li J, Yu Y, Liu C, et al.: Arthroscopic fixation of tibial eminence fractures: a biomechanical comparative study of screw, suture, and suture anchor, Arthroscopy 34:1608, 2018. Lipina M, Makarov M, Mukhanov V, et al.: Arthroscopic synovectomy of the knee joint for rheumatoid arthritis, Int Orthop, 2018 Oct 3, https://doi. org/10.1007/s00264-018-4160-z, [Epub ahead of print]. Liu TH: Complete arthroscopic synovectomy in management of recalcitrant septic arthritis of the knee joint, Arthrosc Tech 6:e475, 2017. Song JG, Nha KW, Lee SW: Open posterior approach versus arthroscopic suture fixation for displaced posterior cruciate ligament avulsion fractures: systematic review, Knee Surg Relat Res 30:275, 2018. Stiefel EC, McIntyre L: Arthroscopic lysis of adhesions for treatment of posttraumatic arthrofibrosis of the knee joint, Arthrosc Tech 6:e939, 2017. Strauss EJ, Kaplan DJ, Weinbeg ME, et al.: Arthroscopic management of tibial spine avulsion fractures: principles and techniques, J Am Acad Orthop Surg 26:360, 2018. Wang Z, Tang Z, Liu C, et al.: Comparison of outcome of ARIF and ORIF in the treatment of tibial plateau fractures, Knee Surg Sports Traumatol Arthrosc 25:578, 2017.

HIP Abrams GD, Hart MA, Takami K, et al.: Biomechanical evaluation of capsulotomy, capsulectomy, and capsular repair on hip rotation, Arthroscopy 31:1511, 2015. Adib F, Johnson AJ, Hennrikus WL, et  al.: Iliopsoas tendonitis after hip arthroscopy: prevalence, risk factors and treatment algorithm, J Hip Preserv Surg 5:362, 2018. Adler KL, Giordano BD: The utility of hip arthroscopy in the setting of acetabular dysplasia: a systematic review, Arthroscopy 35:237, 2019. Alpaugh K, Chilelli BJ, Xu S, Martin DS: Outcomes after primary open or endoscopic abductor tendon repair in the hip: a systematic review of the literature, Arthroscopy 31:530, 2015. Anthony CA, Pagely AJ, Gao Y, et  al.: Complications and risk factors for morbidity in elective hip arthroscopy: a review of 1325 cases, Am J Orthop (Belle Mead NJ) 46:E1, 2017. Ayeni OR, Alradwan H, de Sa D, Philippon MJ: The hip labrum reconstruction: indications and outcomes—a systematic review, Knee Surg Sports Traumatol Arthrosc 22:737, 2014. Bayne CO, Stanley R, Simon P, et al.: Effect of capsulotomy on hip stability—a consideration during hip arthroscopy, Am J Orthop (Belle Mead NJ) 43:160, 2014. Beckamnn JT, Wylie JD, Potter MQ, et al.: Effect of naproxen prophylaxis on heterotopic ossification following hip arthroscopy: a double-blind randomized placebo-controlled trial, J Bone Joint Surg 97A:2032, 2015.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Bedi A, Galano G, Walsh C, Kelly BT: Capsular management during hip arthroscopy: from femoroacetabular impingement to instability, Arthroscopy 27:1720, 2011. Bedi A, Ross JR, Kelly BT, Larson CM: Avoiding complications and treating failures of arthroscopic femoroacetabular impingement correction, Instr Course Lect 64:197, 2015. Begly JP, Buckley PS, Utsunomiya H, et al.: Femoroacertabular impingement in professional basketball players: return to play, career length, and performance after hip arthroscopy, Am J Sports Med 46:3090, 2018. Begly JP, Robins B, Youm T: Arthroscopic treatment of traumatic hip dislocation, J Am Acad Orthop Surg 34:309, 2016. Boden RA, Wall AP, Fehily MJ: Results of the learning curve for interventional hip arthroscopy: a prospective study, Acta Orthop Belg 80:39, 2014. Botser IB, Smith Jr TW, Nasser R, Domb BG: Open surgical dislocation versus arthroscopy for femoroacetabular impingement and comparison of clinical outcomes, Arthroscopy 27:270, 2011. Boykin RE, Patterson D, Briggs KK, et  al.: Results of arthroscopic labral reconstruction of the hip in elite athletes, Am J Sports Med 41:2296, 2013. Brandenburg JB, Kapron AL, Wylie JD, et  al.: The functional and structural outcomes of arthroscopic iliopsoas release, Am J Sports Med 44:1286, 2016. Byrd JW, Jones KS, Gwathmey FW: Arthroscopic management of femoroacetabular impingement in adolescents, Arthroscopy 32:1800, 2016. Casartelli NC, Leunig M, Maffiuletti NA, Bizzini M: Return to sports after hip surgery for femoroacetabular impingement: a systematic review, Br J Sports Med 49:819, 2015. Chahla J, Mikula JD, Schon JM, et al.: Hip capsular closure: a biomechanical analysis of failure torque, Am J Sports Med 45:434, 2017. Chandrasekaran S, Darwish N, Gui C, et al.: Outcomes of hip arthroscopy in patients with Tönnis grade-2 osteoarthritis at a mean 2-year followup: evaluation using a matched-pair analysis with Tönnis grade-0 and grade-1 cohorts, J Bone Joint Surg 98A:973, 2016. Chandrasekaran S, Lodhia P, Gui C, et al.: Outcomes of open versus endoscopic repair of abductor muscle tears of the hip: a systematic review, Arthroscopy 31:2057, 2015. Chen WH, Lin CM, Huang CF, et al.: Functional recovery in osteoarthritic chondrocytes through hyaluronic acid and platelet-rich plasma-inhibited infrapatellar fat pad adipocytes, Am J Sports Med 44:2696, 2016. Colvin AC, Harrast J, Harner C: Trends in hip arthroscopy, J Bone Joint Surg 94A:e23, 2012. Cunningham DJ, Lewis BD, Hutyra CA, et  al.: Early recovery after hip arthroscopy for femoroacetabular impingement syndrome: a prospective, observational study, J Hip Preserv Surg 4:299, 2017. Cvetanovich GL, Weber AE, Kuhns BD, et al.: Hip arthroscopic surgery for femoroacetabular impingement with capsular management: factors associated with achieving clinically significant outcomes, Am J Sports Med 46:288, 2018. Degen RM, Pan TJ, Chang B, et al.: Risk of failure of primary hip arthroscopy—a population-based study, J Hip Preserv Surg 4:214, 2017. de Sa D, Cargnelli S, Catapano M, et  al.: Femoroacetabular impingement in skeletally immature patients: a systematic review examining indications, outcomes, and complications of open and arthroscopic treatment, Arthroscopy 31:373, 2015. Domb BG, El Bitar YF, Stake CE, et al.: Arthroscopic labral reconstruction is superior to segmental resection for irreparable labral tears in the hip: a matched-pair controlled study with minimum 2-year follow-up, Am J Sports Med 42:122, 2014. Domb BG, Chaharbakhshi EO, Perets I, et al.: Hip arthroscopic surgery with labral preservation and capsular plication in patients with borderline hip dysplasia: minimum 5-year patient-reported outcomes, Am J Sports Med 46:305, 2018. Domb BG, Gui C, Lodhia P: How much arthritis is too much for hip arthroscopy: a systematic review, Arthroscopy 31:510, 2015. Domb BG, Philippon MJ, Giordano BD: Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: relation to atraumatic instability, Arthroscopy 29:162, 2013. Domb BG, Rybalko D, Mu B, et al.: Acetabular microfracture in hip arthroscopy: clinical outcomes with minimum 5-year follow-up, Hip Int 28:649, 2018. Domb BG, Stake CE, Botser IB, Jackson TJ: Surgical dislocation of the hip versus arthroscopic treatment of femoroacetabular impingement: a prospective matched-pair study with average 2-year follow-up, Arthroscopy 29:1506, 2013.

Domb BG, Yuen LC, Ortiz-Declet V, et al.: Arthroscopic labral base repair in the hip: 5-year minimum clinical outcomes, Am J Sports Med 45:2882, 2017. Duplantier NL, McCulloch PC, Nho SJ, et al.: Hip dislocation or subluxation after hip arthroscopy: a systematic review, Arthroscopy 32(7):1428, 2016. Ekhtiari S, de Sa D, Haldane CE, et al.: Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review, Knee Surg Sports Traumatol Arthrosc 25:9, 2017. Fowler J, Owens BD: Abdominal compartment syndrome after hip arthroscopy, Arthroscopy 26:128, 2010. Frank JM, Harris JD, Erickson BJ, et  al.: Prevalence of femoroacetabular impingement imaging findings in asymptomatic volunteers: a systematic review, Arthroscopy 31:1199, 2015. Frank RM, Lee S, Bush-Joseph CA, et  al.: Improved outcomes after hip arthroscopic surgery in patients undergoining T-capsulotomy with complete repair versus partial repair for femoroacetabular impingement: a comparative matched-pair analysis, Am J Sports Med 42:2634, 2014. Frank RM, Lee S, Bush-Joseph CA, et  al.: Outcomes for hip arthroscopy according to sex and age: a comparative matched-group analysis, J Bone Joint Surg 98A:797, 2016. Geyer MR, Philippon MJ, Fagrelius TS, Briggs KK: Acetabular labral reconstruction with an iliotibial band autograft: outcomes and survivorship analysis at minimum 3-year follow-up, Am J Sports Med 41:1750, 2013. Glick JM: Hip arthroscopy by the lateral approach, Instr Course Lect 55:317, 2006. Gupta A, Redmond JM, Stake CE, et al.: Does primary hip arthroscopy result in improved clinical outcomes? 2-year clinical follow-up on a mixed group of 738 consecutive primary hip arthroscopies performed at a highvolume referral center, Am J Sports Med 44:74, 2016. Gwathmey FW, Jones KS, Thomas Byrd JW: Revision hip arthroscopy: findings and outcomes, J Hip Preserv Surg 4:318, 2017. Habib A, Haldane CE, Ekhtiari S, et al.: Pudendal nerve injury is a relatively common but transient complication of hip arthroscopy, Knee Surg Sports Traumatol Arthrosc 26:969, 2018. Hanypsiak BT, Stoll MA, Gerhardt MB, DeLong JM: Intra-articular psoas tendon release alters fluid flow during hip arthroscopy, Hip Int 22:668, 2012. Harris JD, McCormick FM, Abrams GD, et al.: Complications and reoperations during and after hip arthroscopy: a systematic review of 92 studies and more than 6,000 patients, Arthroscopy 29:589, 2013. Hoppe D, de Sa D, Simunovic N, et al.: The learning curve for hip arthroscopy: a systematic review, Arthroscopy 30:389, 2014. Horisberger M, Brunner A, Herzog RF: Arthroscopic treatment of femoral acetabular impingement in patients with preoperative generalized degenerative changes, Arthroscopy 26:623, 2010. Ilizaliturri Jr VM, Camacho-Galindo J: Endoscopic treatment of snapping hips, iliotibial band, and iliopsoas tendon, Sports Med Arthrosc 18:120, 2010. Jackson TJ, Hammarstedt JE, Vemula SP, Domb BG: Acetabular labral base repair versus circumferential suture repair: a matched-paired comparison of clinical outcomes, Arthroscopy 31:1716, 2015. Javed A, O’Donnell JM: Arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement in patients over 60 years of age, J Bone Joint Surg 93B:326, 2011. Kemp JL, MacDonald D, Collins NJ, et al.: Hip arthroscopy in the setting of hip osteoarthritis: systematic review of ourcomes and progression to hip arthroplasty, Clin Orthop Relat Res 473:1055, 2015. Khan M, Adamich J, Simunovic N, et  al.: Surgical management of internal snapping hip syndrome: a systematic review evaluating open and arthroscopic approaches, Arthroscopy 29:942, 2013. Larson CM: Arthroscopic management of pincer-type impingement, Sports Med Arthrosc 18:100, 2010. Larson CM, Clohisy JC, Beaulé PE, et al.: Intraoperative and early postoperative complications after hip arthroscopic surgery: a prospective multicenter trial utilizing a validated grading scheme, Am J Sports Med 44:2292, 2016. Larson CM, Giveans MR, Taylor M: Does arthroscopic FAI correction improve function with radiographic arthritis? Clin Orthop Relat Res 469:1667, 2011. Lee S, Kuhn A, Draovitch P, et al.: Return to play following hip arthroscopy, Clin Sports Med 35:637, 2016. Leunig M, Ganz R: The evolution and concepts of joint-preserving surgery of the hip, Bone Joint J 96B:5, 2014. Locks R, Chahla J, Frank JM, et  al.: Arthroscopic hip labral augmentation technique with iliotibial band graft, Arthrosc Tech 6:e351, 2017.

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PART XIV ARTHROSCOPY Malviya A, Raza A, Jameson S, et al.: Complications and survival analyses of hip arthroscopies performed in the National Health Service in England: a review of 6,395 cases, Arthroscopy 31:836, 2015. Márquez Arabia WH, Gómez-Hoyos J, Llano Serna JF, et al.: Regrowth of the psoas tendon after arthroscopic tenotomy: a magnetic resonance imaging study, Arthroscopy 29:1308, 2013. Marquez-Lara A, Mannava S, Howse EA, et al.: Arthroscopic management of hip chondral defects: a systematic review of the literature, Arthroscopy 32:1435, 2016. Matsuda DK: Labral reconstruction with gracilis autograft, Arthrosc Tech 1:e15, 2012. Martin D, Tashman S: The biomechanics of femoroacetabular impingement, Op Tech Orthop 20:248, 2010. Matsuda DK, Burchette RJ: Arthroscopic hip labral reconstruction with a gracilis autograft versus labral refixation: 2-year minimum outcomes, Am J Sports Med 41:980, 2013. Mauro CS, Voos JE, Kelly BT: Femoroacetabular impingement surgical techniques, Op Tech Orthop 20:223, 2010. McCormick F, Alpuagh K, Nwachukwu BU, et al.: Endoscopic repair of fullthickness abductor tendon tears: surgical technique and outcome at minimum of 1-year follow-up, Arthroscopy 29:1941, 2013. McCormick F, Nwachukwu BU, Alpaugh K, Martin SD: Predictors of hip arthroscopy outcomes for labral tears at minimum 2-year follow-up: the influence of age and arthritis, Arthroscopy 28:1359, 2012. Menge TJ, Briggs KK, Philippon MJ: Predictors of length of career after hip arthroscopy for femoroacetabular impingement in professional hockey players, Am J Sports Med 44:2286, 2016. Menge TJ, Chacla J, Soares E, et al.: The Quebec City slider: a technique for capsular closure and plication in hip arthroscopy, Arthroscopy 32:2513, 2016. Minkara AA, Westermann RW, Rosneck J, et  al.: Systematic review and meta-analysis of outcomes after hip arthroscopy in femoroacetabular impingement, Am J Sports Med, 2018 Jan 1: 363546517749475, https:// doi.org/10.1177/0363546517749475, [Epub ahead of print]. Mitchell JJ, Chahla J, Vap AR, et  al.: Endoscopic trochanteric bursectomy and iliotibial band release for persistent trochanteric bursitis, Arthrosc Tech 5:e1185, 2016. Murata Y, Uchida S, Utsunomiya H, et al.: A comparison of clinical outcomes between athletes and nonathletes undergoing hip arthroscopy for femoroacetabular impingement, Clin J Sport Med 27:349, 2017. Nakano N, Lisenda L, Jones TL, et al.: Complications following arthroscopic surgey of the hip: a systematic review of 36 761 cases, Bone Joint J 99B:1577, 2017. Nepple JJ, Byrd JW, Siebenrock KA, et al.: Overview of treatment options, clinical results, and controversies in the management of femoroacetabular impingement, J Am Acad Orthop Surg 21(Suppl 1):S53, 2013. Newman JT, Briggs KK, McNamara SC, et  al.: Revision hip arthroscopy: a matched-cohort study comparing revision to primary arthroscopy patients, Am J Sports Med 44:2499, 2016. Nho SJ, Magennis EM, Singh CK, Kelly BT: Outcomes of the arthroscopic treatment of femoroacetabular impingement in a mixed group of highlevel athletes, Am J Sports Med 39(Suppl):14S, 2011. Nielsen TG, Miller LL, Lund B, et al.: Outcome of arthroscopic treatment for symptomatic femoroacetabular impingement, BMC Musculoskelet Disord 15:394, 2014. Niroopan G, de Sa D, MacDonald A, et  al.: Hip arthroscopy in trauma: a systematic review of indications, efficacy, and complications, Arthroscopy 32:692, 2016. O’Connor M, Minkara AA, Westermann RW, et al.: Return to play after hip arthroscopy: a systematic review and meta-analysis, Am J Sports Med 46:2780, 2018. Pennock AT, Philippon MJ, Briggs KK: Acetabular labral preservation: surgical techniques, indications, and early outcomes, Op Tech Orthop 20:217, 2010. Perets I, Craig MJ, Mu BH, et al.: Midterm outcomes and return to sports among athletes underling hip arthroscopy, Am J Sports Med 46:1661, 2019. Perets I, Rybalko D, Mu BH, et al.: In revision hip arthroplasty, labral reconstruction can address a deficient labrum, but labral repair retains its

role for the reparable labrum: a matched control study, Am J Sports Med 46:3437, 2018. Philippon MJ, Briggs KK, Carlisle JC, Patterson DC: Joint space predicts THA after hip arthroscopy in patients 50 years and older, Clin Orthop Relat Res 471:2492, 2013. Philippon MJ, Ejnisman L, Ellis HB, Briggs KK: Outcomes 2 to 5 years following hip arthroscopy for femoroacetabular impingement in the patient aged 11 to 16 years, Arthroscopy 28:1255, 2012. Philippon MJ, Schroder e Souza BG, Briggs KK: Hip arthroscopy for femoroacetabular impingement in patients aged 50 years or older, Arthroscopy 28:59, 2012. Philippon MJ, Schroder e Souza BG, Briggs KK: Labrum: resection, repair and reconstruction sports medicine and arthroscopy review, Sports Med Arthrosc 18:76, 2010. Philippon MJ, Weiss DR, Kuppersmith DA, et al.: Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players, Am J Sports Med 38:99, 2010. Piuzzi NS, Slullitel PA, Bertona A, et al.: hip arthroscopy in osteoarthritis: a systematic review of the literature, Hip Int 26:8, 2016. Randelli F, Pierannunzil L, Banci L, et  al.: Heterotopic ossifications after arthroscopic management of femoroacetabular impingement: the role of NSAID prophylaxis, J Orthop Traumatol 11:245, 2010. Redmond JM, Gupta A, Dunne K, et al.: What factors predict conversion to THA after arthroscopy? Clin Orthop Relat Res 475:2538, 2017. Rhee SM, Kang SY, Jang EC, et al.: Clinical outcomes after arthroscopic acetabular labral repair using knot-tying or knotless suture technique, Arch Orthop Trauma Surg 136:1411, 2016. Riff SJ, Kunze KN, Movassaghi K, et al.: Systematic review of hip arthroscopy for femoroacetabular impingement: the importance of labral repair and capsular closure, Arthroscopy 35:646, 2019. Ross JR, Larson CM, Bedi A: Indications for hip arthroscopy, Sports Health 9:402, 2017. Scher DL, Belmont Jr PJ, Owens BD: Case report: osteonecrosis of the femoral head after hip arthroscopy, Clin Orthop Relat Res 468:3121, 2010. Schüttler KF, Schramm R, El-Zayat BF, et al.: The effect of surgeon’s learning curve: complications and outcome after hip arthroscopy, Arch Orthop Trauma Surg 138:1415, 2018. Shin JJ, de Sa DL, Burnham JM, et al.: Refractory pain following hip arthroscopy: evaluation and management, J Hip Preserv Surg 5:3, 2018. Shin JJ, McCrum CL, Mauro CS, et al.: Pain management after hip arthroscopy: systematic review of randomized controlled trials and cohort studies, Am J Sports Med 46:3288, 2018. Shindle MK, Voos JE, Heyworth BE, Kelly BT: Arthroscopic management of labral tears in the hip, J Bone Joint Surg 90A(Suppl 4):2, 2008. Skendzel JG, Philppon MJ, Briggs MJ, Goljan P: The effect of joint space on midterm outcomes after arthroscopic hip surgery for femoroacetabular impingement, Am J Sports Med 42:1127, 2014. Spiker AM, Degen RM, Camp CL, et al.: Arthroscopic psoas management: techniques for psoas preservation and psoas tenotomy, Arthrosc Tech 5: e1487, 2016. Stevens MS, Legray DA, Glazebrook MA, Amirault D: The evidence for hip arthroscopy: grading the current indications, Arthroscopy 26:1370, 2010. Vaughn ZD, Safran MR: Arthroscopic femoral osteoplasty—cheilectomy for cam-type femoroacetabular impingement in the athlete, Sports Med Arthrosc 18:90, 2010. Walters BL, Cooper JH, Rodriguez JA: New findings in hip capsular anatomy: dimensions of capsular thickness and pericapsular contributions, Arthroscopy 30:1235, 2014. Watson JN, Bohnenkamp F, El-Bitar Y, et al.: Variability in locations of hip neurovascular structures and their proximity to hip arthroscopic portals, Arthroscopy 30:462, 2014. Weber AE, Harris JD, Nho SJ: Complications in hip arthroscopy: a systematic review and strategies for prevention, Sports Med Arthrosc 23:187, 2015. White BJ, Patterson J, Herzog MM: Revision arthroscopic acetabular labral treatment: repair or reconstruct? Arthroscopy 32:2513, 2016. The complete list of references is available online at expertconsult.inkling.com.

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SUPPLEMENTAL REFERENCES KNEE Adachi N, Ochi M, Uchio Y, et  al.: Torn discoid lateral meniscus treated using partial central meniscectomy and suture of the peripheral tear, Arthroscopy 20:536, 2004. Aglietti P, Pisaneschi A, Buzzi R, et al.: Arthroscopic lateral release for patellar pain or instability, Arthroscopy 5:176, 1989. Ahn JH, Ha CW: Posterior trans-septal portal for arthroscopy surgery of the knee joint, Arthroscopy 16:774, 2000. Ahn JH, Oh I: Arthroscopic partial meniscectomy of a medial meniscus bucket-handle tear using the posteromedial portal, Arthroscopy 20:e75, 2004. Ahn JH, Yang HS, Jeong WK, et al.: Arthroscopic transtibial posterior cruciate ligament reconstruction with preservation of posterior cruciate ligament fibers: clinical results of minimum 2-year followup, Am J Sports Med 34:194, 2006. Albertsson M, Gillquist J: Discoid lateral menisci: a report of 29 cases, Arthroscopy 4:211, 1988. Alford JW, Cole BJ: Cartilage restoration, part 2: techniques, outcomes, and future directions, Am J Sports Med 33:443, 2005. Anderson AF: Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients, J Bone Joint Surg 86A:201, 2004. Anderson DR, Gershuni DH, Nakhostine M, et  al.: The effects of nonweight-bearing and limited motion on tensile properties of the meniscus, Arthroscopy 9:440, 1993. Anderson K, Marx RG, Hannafin J, et al.: Chondral injury following meniscal repair with a biodegradable implant, Arthroscopy 16:749, 2000. Anderson-Molina H, Karlsson H, Rockborn P: Arthroscopic partial and total meniscectomy: a long-term follow-up study with matched controls, Arthroscopy 18:183, 2002. Arnoczky SP: The blood supply of the meniscus and its role in healing and repair. In American Academy of Orthopaedic Surgeons: Symposium on sports medicine: the knee, St. Louis, 1985, Mosby. Arnoczky SP, McDevitt CA: The meniscus: structure, function, repair, and replacement. In Buckwalter JA, Einhorn TA, Simon SR, editors: Orthopaedic basic science, Rosemont, 2000, American Academy of Orthopaedic Surgeons. Arnoczky SP, Warren RF: Microvasculature of the human meniscus, Am J Sports Med 10:90, 1982. Arnoczky SP, Warren RF: The microvasculature of the meniscus and its response to injury: an experimental study in the dog, Am J Sports Med 11:131, 1983. Arnoczky SP, Warren RF, Kaplan N: Meniscal remodeling following partial meniscectomy: an experimental study in the dog, Arthroscopy 1:247, 1985. Arnoczky SP, Warren RF, Spivak JM: Meniscal repair using an exogenous fibrin clot: an experimental study in dogs, J Bone Joint Surg 70A:1209, 1988. Augé WK, Yifan K: A technique for resolution of graft-tunnel length mismatch in central third bone-patellar tendon-bone anterior cruciate ligament reconstruction, Arthroscopy 15:877, 1999. Bach BR, Bush-Joseph C: The surgical approach to lateral meniscal repair, Arthroscopy 8:269, 1992. Baratz ME, Fu FH, Mengato RL: The effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee, Am J Sports Med 14:270, 1986. Barber FA: Flipped patellar tendon autograft anterior cruciate ligament reconstruction, Arthroscopy 16:483, 2000. Barber FA, Fanelli GC, Matthews LS, et al.: The treatment of complete posterior cruciate ligament tears, Arthroscopy 16:725, 2000. Barber FA, Herbert MA: Meniscal repair devices, Arthroscopy 16:613, 2000. Barber FA, Herbert MA, Richards DP: Load to failure testing of new meniscal repair devices, Arthroscopy 20:45, 2004. Barber FA, Spruill B, Sheluga M: The effect of outlet fixation on tunnel widening, Arthroscopy 19:485, 2003.

Beaver RJ, Mahomed M, Backstein D, et al.: Fresh osteochondral allografts for post-traumatic defects in the knee: a survivorship analysis, J Bone Joint Surg 74B:105, 1992. Bellier G, Dupont JY, Larrain M, et al.: Lateral discoid menisci in children, Arthroscopy 5:52, 1989. Bentley G, Biant LC, Carrington RW, et  al.: A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee, J Bone Joint Surg 85B:223, 2003. Berg EE: Posterior cruciate ligament tibial inlay reconstruction, Arthroscopy 11:69, 1995. Bergfeld JA, Graham SM, Parker RD: A biomechanical comparisons of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay technique, Am J Sports Med 33:976, 2005. Bergstrom R, Hamberg P, Lysholm J, et al.: Comparison of open and endoscopic meniscectomy, Clin Orthop Relat Res 184:133, 1984. Berns GS, Howell SM: Roofplasty requirements in  vitro for different tibial hole placements in anterior cruciate ligament reconstruction, Am J Sports Med 21:292, 1993. Biau DJ, Katsahian S, Kartus J, et al.: Patellar tendon versus hamstring tendon autografts for reconstructing the anterior cruciate ligament: a metaanalysis based on individual patient data, Am J Sports Med 37:2470, 2009. Bionx implants for osteochondral fragments from trauma or OCD lesions using the SmartNail: Surgical technique manual, Blue Bell, Bionx Implants, Inc, 2001. Bobic V, Morgan CD: Osteochondral autograft transfer: surgical technique manual, Naples, 2000, Arthrex. Bolano LE, Grana WA: Isolated arthroscopic partial meniscectomy, Am J Sports Med 21:432, 1993. Borchers JR, Pedroza A, Kaeding C: Activity level and graft type as risk factors for anterior cruciate ligament graft failure: a case-control study, Am J Sports Med 37:2362, 2009. Brand JC, Pienkowski D, Steenlage E, et  al.: Interference screw fixation strength of a quadrupled hamstring graft is directly related to bone mineral density and insertion torque, Am J Sports Med 28:705, 2000. Brand JC, Weiler A, Caborn DNM, et al.: Graft fixation in cruciate ligament reconstruction, Am J Sports Med 28:761, 2000. Bronstein RD, Sebastianelli WJ, DeHaven KE: Case report: localized pigmented villonodular synovitis presenting as a loose body in the knee, Arthroscopy 9:596, 1993. Brophy RH, Wright RW, Matava MJ: Cost analysis of converting from singlebundle to double-bundle anterior cruciate ligament reconstruction, Am J Sports Med 37:683, 2009. Burks RT, Schaffer JJ: A simplified approach to tibial attachment of the posterior cruciate ligament, Clin Orthop Relat Res 254:216, 1990. Butler JC, Branch TP, Hutton WC: Optimal graft fixation: the effect of gap size and screw size on bone plug fixation in anterior cruciate ligament reconstruction, Paper presented at the sixty-second annual meeting of the American Academy of Orthopaedic Surgeons, Orlando, FL, February 1995. Cabaud HE, Rodkey WG, Fitzwater JE: Medial meniscus repairs: an experimental and morphologic study, Am J Sports Med 9:129, 1981. Cahill BR: Osteochondritis dissecans of the knee: treatment of juvenile and adult forms, J Am Acad Orthop Surg 3:237, 1995. Cain EL, Phillips BB, Azar FM: Biomechanical study of the effect of tunnel dilation on pull-out strength of soft tissue grafts, Paper presented at the annual meeting of the American Academy of Orthopedic Surgeons. Travers City, MI, 1996. Caldwell GL, Allen AA, Fu FH: Functional anatomy and biomechanics of the meniscus, Op Tech Sports Med 2:152, 1994. Cameron JC, Saha S: Meniscal Allograft transplantation for unicompartmental arthritis of the knee, Clin Orthop Relat Res 337:164, 1997. Cannon WD: Arthroscopic meniscal repair as related to ligamentous instability, San Francisco, October 1984, Paper presented at American College of Surgeons meeting. Cannon WD, editor: Arthroscopic meniscal repair, Rosemont, American Academy of Orthopaedic Surgeons, 1999.

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PART XIV ARTHROSCOPY Cannon WD, Morgan CD: Meniscal repair, part II: arthroscopic repair techniques, J Bone Joint Surg 76A:294, 1994. Carruthers CC, Kennedy M: Knee arthroscopy: a follow-up of patients initially not recommended for further surgery, Clin Orthop Relat Res 147:275, 1980. Caspari RB, Hutton PM, Whipple TL: The role of arthroscopy in the management of tibial plateau fractures, Arthroscopy 1:76, 1985. Casscells SW: Arthroscopy of the knee joint: a review of 150 cases, J Bone Joint Surg 53A:287, 1971. Casscells SW: The arthroscope in the diagnosis of disorders of the patellofemoral joint, Clin Orthop Relat Res 144:45, 1979. Casscells SW: The place of arthroscopy in the diagnosis and treatment of internal derangement of the knee: an analysis of 1000 cases, Clin Orthop Relat Res 151:135, 1980. Cassidy RE, Shaffer AJ: Repairs of peripheral meniscus tears: a preliminary report, Am J Sports Med 9:209, 1981. Chatain F, Robinson AH, Adeleine P, et al.: The natural history of the knee following arthroscopic medial meniscectomy, Knee Surg Sports Traumatol Arthrosc 9:15, 2001. Chen CH, Chen WJ, Shih CH: Arthroscopic reconstruction of the posterior cruciate ligament: a comparison of quadriceps tendon autograft and quadruple hamstring tendon graft, Arthroscopy 18:603, 2002. Christian CA, Indelicato PA: Allograft anterior cruciate ligament reconstruction with patellar tendon: an endoscopic technique, Op Tech Sports Med 1:50, 1993. Clancy WG, Bisson LJ: Double tunnel technique for reconstruction of the posterior cruciate ligament, Op Tech Sports Med 7:110, 1999. Clancy Jr WG, Graf BK: Arthroscopic meniscal repair, Orthopedics 6:1125, 1983. Cohen B, Khan TH, Dandy DJ: Case report: arthroscopic resection of chondroblastoma of the knee, Arthroscopy 8:370, 1992. Cohen SB, Fu FH: Three-portal technique for anterior cruciate ligament reconstruction: use of a central medial portal, Arthroscopy 23:325, 2007. Cole BJ, Carter TR, Rodeo SA: Allograft meniscal transplantation: background, techniques, and results, J Bone Joint Surg 84A:1235, 2002. Cole BJ, Pascual-Garrido C, Grumet RC: Surgical management of articular cartilage defects in the knee, J Bone Joint Surg 91A:1778, 2009. Cooper DE: Meniscal repair: open and arthroscopic outside-in techniques, Op Tech Orthop 5:46, 1995. Cooper DE, Arnoczky SP, Warren RF: Arthroscopic meniscal repair, Clin Sports Med 9:589, 1990. Cooper DE, Deng XH, Burstein AL, et al.: The strength of the central third patellar tendon graft: a biomechanical study, Am J Sports Med 21:818, 1993. Cooper DE, Stewart D: Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2- to 10-year follow-up, Am J Sports Med 232:346, 2004. Covall DJ, Wasilewski SA: Roentgenographic changes after arthroscopic meniscectomy: five-year follow-up in patients more than 45 years old, Arthroscopy 8:242, 1992. Cugat R, Garcia M, Cusco X, et al.: Osteochondritis dissecans: a historical review and its treatment with cannulated screws, Arthroscopy 9:675, 1993. Curran Jr WP, Woodward EP: Arthroscopy: its role in diagnosis and treatment of athletic knee injuries, Am J Sports Med 8:415, 1980. Dandy DJ: The bucket handle meniscal tear: a technique detaching the posterior segment first, Orthop Clin North Am 13:369, 1982. Dandy DJ, Flanagan JP, Steenmeyer V: Arthroscopy and the management of the ruptured anterior cruciate ligament, Clin Orthop Relat Res 167:43, 1982. Dandy DJ, O’Carroll PF: Arthroscopic surgery of the knee, Br Med J (Clin Res Ed) 285:1256, 1982. Dandy DJ, O’Carroll PF: The removal of loose bodies from the knee under arthroscopic control, J Bone Joint Surg 64B:473, 1982. Daniel D, Daniels E, Aronson D: The diagnosis of meniscus pathology, Clin Orthop Relat Res 163:218, 1982. Daniel DM, Stone ML, Dobson BE, et al.: Fate of the ACL-injured patient: a prospective outcome study, Am J Sports Med 22:632, 1994.

DeHaven KE: Diagnosis of acute knee injuries with hemarthrosis, Am J Sports Med 8:9, 1980. DeHaven KE: Meniscus repair: open versus arthroscopic, Arthroscopy 1:173, 1985. DeHaven KE, Arnoczky SP: Meniscal repair, part I: basic science, indications for repair, and open repair, J Bone Joint Surg 76A:140, 1994. Delay BS, Smolinski RJ, Wind WM, et  al.: Current practices and opinions in ACL reconstruction and rehabilitation: results of a survey of the American Orthopaedic Society for Sports Medicine, Am J Knee Surg 14:85, 2001. Dickason JM, Del Pizzo W, Blazina ME, et al.: A series of ten discoid medial menisci, Clin Orthop Relat Res 168:75, 1982. Dickhaut SC, DeLee JC: The discoid lateral meniscus syndrome, J Bone Joint Surg 64A:1068, 1982. DiNubile NA, Joyce III JJ: Arthroscopy of the postmeniscectomy knee, Orthopedics 6:1301, 1983. DiStefano VJ, Bizzle P: A technique of arthroscopic meniscoplasty, Orthopedics 6:1135, 1983. Dodds JA, Arnoczky SP: Anatomy of the anterior cruciate ligament: a blueprint for repair and reconstruction, Arthroscopy 10:132, 1994. Dorfmann H, Orengo P, Amarenco G: Pathology of the synovial folds of the knee: value of arthroscopy, Rev Rhum Mal Osteoartic 49:67, 1982. Dowdy PA, Miniaci A, Arnoczky SP, et al.: Effect of immobilization on meniscal healing: an experimental study in the dog, Orlando, FL, Feb 1995, Paper presented at the sixty-second annual meeting of the American Academy of Orthopaedic Surgeons. Drez D, Guhl JF, Gollehon DL: Ankle arthroscopy: technique and indications, Foot Ankle 2:138, 1981. Eriksson E, Sebik A: A comparison between the transpatellar tendon and the lateral approach to the knee joint during arthroscopy: a cadaver study, Am J Sports Med 8:103, 1980. Ewing JW, Voto SJ: Arthroscopic surgical management of osteochondritis dissecans of the knee, Arthroscopy 4:37, 1988. Fabbriciani C, Panni AS, Delcogliano A, et al.: Osteochondral autograft in the treatment of osteochondritis dissecans of the knee, Orthop Trans 16:42, 1992. Fairbank TJ: Knee joint changes after meniscectomy, J Bone Joint Surg 30B:664, 1948. Fanelli GC, Giannotti BF, Edson CJ: Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction, Arthroscopy 12:521, 1996. Ferkel RD, Davis JR, Friedman MJ, et al.: Arthroscopic partial medial meniscectomy: analysis of unsatisfactory results, Arthroscopy 1:44, 1985. Ficat RP, Hungerford DS: Disorders of the patellofemoral joint, Baltimore, 1977, Williams & Wilkins. Fineberg MS, Zarins B, Shermann OH: Practical considerations in anterior cruciate ligament replacement surgery, Arthroscopy 16:715, 2000. Fleming BC, Spindler KP, Palmer MP, et  al.: Collagen-platelet composites improve the biomechanical properties of healing anterior cruciate ligament grafts in a porcine model, Am J Sports Med 37:1554, 2009. Flynn NRM, Kelly JP: Local excision of cystic lateral meniscus of the knee without recurrence, J Bone Joint Surg 64B:88, 1982. Forsythe B, Harner C, Martins CAQ, et al.: Topography of the femoral attachment of the posterior cruciate ligament, J Bone Joint Surg 91A:89, 2009. Fowble CD, Zimmer JW, Schepsis AA: The role of arthroscopy in the assessment and treatment of tibial plateau fractures, Arthroscopy 9:584, 1993. Fowler PJ, Messieh PJ: Isolated posterior cruciate ligament injuries in athletes, Am J Sports Med 15:553, 1987. Fox JM, Sherman OH, Markolf K: Arthroscopic anterior cruciate ligament repair: preliminary results and instrumented testing for anterior instability, Arthroscopy 1:175, 1985. Fu FH, Bennett CH, Lattermann C, et al.: Current trends in anterior cruciate ligament reconstruction, part 1: biology and biomechanics of reconstruction, Am J Sports Med 27:821, 1999. Fu FH, Bennett CH, Ma B, et al.: Current trends in anterior cruciate ligament reconstruction, part II: operative procedures and clinical correlations, Am J Sports Med 28:124, 2000.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Fulkerson JP, Langeland R: An alternative cruciate reconstruction graft: the central quadriceps tendon, Arthroscopy 11:252, 1995. Fuss FH, Jordan SS: The lateral intercondylar ridge—a key to anatomic anterior cruciate ligament reconstruction, J Bone Joint Surg 89A:2103, 2007. Gadikota HR, Seon JK, Kozanek M, et al.: Biomechanical comparison of single-tunnel-double-bundle and single-bundle anterior cruciate ligament reconstructions, Am J Sports Med 37:962, 2009. Garino JP, Lotke PA, Sapega AA, et  al.: Case report: osteonecrosis of the knee following laser-assisted arthroscopic surgery: a report of six cases, Arthroscopy 11:467, 1995. Garrett JC: Treatment of osteochondral defects of the distal femur with fresh osteochondral allografts: a preliminary report, Arthroscopy 2:222, 1986. Geib TM, Shelton WR, Phelps RA, Clark L: Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome, Arthroscopy 25:1408, 2009. Gillquist J, Hagberg G: A new modification of the technique of arthroscopy of the knee joint, Acta Chir Scand 142:123, 1976. Gillquist J, Hagberg G, Oretorp N: Arthroscopy in acute injuries of the knee joint, Acta Orthop Scand 48:190, 1977. Gillquist J, Hagberg G, Oretorp N: Arthroscopic visualization of the posteromedial compartment of the knee joint, Orthop Clin North Am 10:545, 1979. Gillquist J, Oretorp N: The technique of endoscopic total meniscectomy, Orthop Clin North Am 13:363, 1982. Glasgow MM, Allen PW, Blakeway C: Arthroscopic treatment of cysts of the lateral meniscus, J Bone Joint Surg 75B:299, 1993. Glinz W: Indications for arthroscopy after injuries of the knee joint, Z Unfallmed Berufskr 75:133, 1982. Gold DL, Schaner PJ, Sapega AA: The posteromedial portal in knee arthroscopy: an analysis of diagnostic and surgical utility, Arthroscopy 11:139, 1995. Grana WA, Connor S, Hollingsworth S: Partial arthroscopic meniscectomy: a preliminary report, Clin Orthop Relat Res 164:78, 1982. Guanche CA, Maekman AW: Arthroscopic management of tibial plateau fractures, Arthroscopy 9:467, 1993. Guhl JF: Arthroscopic treatment of osteochondritis dissecans: preliminary report, Orthop Clin North Am 10:671, 1979. Guhl JF: Arthroscopic treatment of osteochondritis dissecans, Clin Orthop Relat Res 167:65, 1982. Guhl JF: Excision of flap tears, Orthop Clin North Am 13:387, 1982. Gupte CM, Bull AMJ, Thomas RD, et al.: A review of the function and biomechanics of the meniscofemoral ligaments, Arthroscopy 19:161, 2003. Haklar U, Kocaoglu B, Nalbantoglu U, et al.: Arthroscopic repair of radial lateral meniscus [corrected] tear by double horizontal sutures with insideoutside technique, Knee 15:355, 2008. Halbrecht JL: Arthroscopic patella realignment: an all-inside technique, Arthroscopy 17:940, 2001. Hamada M, Shino K, Horibe S, et al.: Single versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with EndoButton femoral fixation: a prospective study, Arthroscopy 17:801, 2001. Hamberg P, Gillquist J, Lysholm J: Suture of new and old peripheral meniscus tears, J Bone Joint Surg 65A:193, 1983. Hamberg P, Gillquist J, Lysholm J: A comparison between arthroscopic meniscectomy and modified open meniscectomy: a prospective randomised study with emphasis on postoperative rehabilitation, J Bone Joint Surg 66B:189, 1984. Hamberg P, Gillquist J, Lysholm J, et al.: The effect of diagnostic and operative arthroscopy and open meniscectomy on muscle strength in the thigh, Am J Sports Med 11:289, 1983. Hamner DL, Brown Jr CH, Steinder ME, et al.: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: biomechanical evaluation of the use of multiple strands and tensioning techniques, J Bone Joint Surg 81A:549, 1999. Hangody L, Kish G, Karpati Z, et al.: Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects: a preliminary report, Knee Surg Sports Traumatol Arthrosc 5:262, 1997.

Hara K, Mochizuki T, Sekiya I, et al.: Anatomy of normal human anterior cruciate ligament attachments evaluated by divided small bundles, Am J Sports Med 37:2386, 2009. Harner CD, Janaushek MA, Kanamori A, et al.: Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction, Am J Sports Med 28:144, 2000. Harner CD, Vogrin TM, Hoher J, et al.: Biomechanical analysis of a posterior cruciate ligament reconstruction: deficiency of the posterolateral structures as a cause of graft failure, Am J Sports Med 28:32, 2000. Hayhurst J: Meniscal repair using the T-Fix. Technique manual, Mansfield, Acufex Microsurgical. Hazel WA, Rand JA, Morrey BF: Results of meniscectomy in the knee with anterior cruciate ligament deficiency, Clin Orthop Relat Res 292:232, 1993. Henning CE: Arthroscopic repair of meniscus tears, Orthopedics 6:1130, 1983. Hershman EB, Nisonson B: Arthroscopic meniscectomy: a follow-up report, Am J Sports Med 11:253, 1983. Higuchi H, Kimura M, Shirakura K, et al.: Factors affecting long-term results after arthroscopic partial meniscectomy, Clin Orthop Relat Res 377:161, 2000. Hinkin DT: Arthroscopic partial meniscectomy, Op Tech Orthop 5:28, 1995. Hoser C, Fink C, Brown C, et al.: Long-term results of arthroscopic partial lateral meniscectomy in knees without associated damage, J Bone Joint Surg 83B:513, 2001. Hotchkiss RN, Tew WP, Hungerford DS: Cartilaginous debris in the injured human knee: correlation with arthroscopic findings, Clin Orthop Relat Res 168:133, 1982. Howell SM: Arthroscopic roofplasty: a method for correcting an extension deficit caused by roof impingement of an anterior cruciate ligament graft, Arthroscopy 8:375, 1992. Hulstyn M, Fadale PD, Abate J, et  al.: Biomechanical evaluation of interference screw fixation in a bovine patellar bone-tendon-bone autograft complex for anterior cruciate ligament reconstruction, Arthroscopy 9:417, 1993. Hunter RE: Meniscectomy is “OK” in many settings, Salida, CO, 2009, Boston University Sports Medicine Course. Hunter RE: Osteochondritis dissecans: evaluation and treatment, Salida, CO, 2009, Boston University Sports Medicine Update Course. Iino S: Normal arthroscopic findings of the knee joint in adults, J Jpn Orthop Assoc 14:467, 1939. Ikeuchi H: Arthroscopic treatment of the discoid lateral meniscus: technique and long-term results, Clin Orthop Relat Res 167:19, 1982. Ikeuchi H: Trial and error in the development of instruments for endoscopic knee surgery, Orthop Clin North Am 13:255, 1982. Ireland J, Trickey EL, Stoker DJ: Arthroscopy and arthrography of the knee: a critical review, J Bone Joint Surg 62B:3, 1980. Itokazu M, Matsunaga T: Arthroscopic restoration of depressed tibial plateau fractures using bone and hydroxyapatite grafts, Arthroscopy 9:103, 1993. Ivey FM, Blazina ME, Fox JM, et al.: Arthroscopy of the knee under general anesthesia: an aid to the determination of ligamentous instability, Am J Sports Med 8:235, 1980. Izquierdo Jr R, Cadet ER, Bauer R, et al.: A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts, Arthroscopy 21:1348, 2005. Jackson RW: Current concepts review: arthroscopic surgery, J Bone Joint Surg 65A:416, 1983. Jackson RW: The septic knee, arthroscopic treatment, Arthroscopy 1:194, 1985. Jackson RW, Marshall DJ, Fujisawa Y: The pathological medial shelf, Orthop Clin North Am 13:307, 1982. Jackson RW, Rouse DW: The results of partial arthroscopic meniscectomy in patients over 40 years of age, J Bone Joint Surg 64B:481, 1982. Jaureguito JW, Elliot JS, Lietner T, et al.: The effects of arthroscopic partial lateral meniscectomy in an otherwise normal knee: a retrospective review of functional, clinical, and radiographic results, Arthroscopy 11:29, 1995.

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PART XIV ARTHROSCOPY Jennings JE: Arthroscopic management of tibial plateau fractures, Arthroscopy 1:160, 1985. Johnson DH, Fanelli GC, Miller MD: PCL 2002: indications, double-bundle versus inlay technique and revision surgery, Arthroscopy 18:40, 2002. Johnson DL, Swenson TM, Irrgang JJ, et al.: Revision anterior cruciate ligament surgery: experience from Pittsburgh, Clin Orthop Relat Res 325:100, 1996. Johnson JJ: The science of rehabilitation in ACL surgery, February 1995, Paper presented at the Arthroscopy Association of North America Specialty Day. Orlando, FL. Johnson LL: Comprehensive arthroscopic examination of the knee, St. Louis, 1977, Mosby. Johnson LL: Diagnostic and surgical arthroscopy: the knee and other joints, 2nd ed, St. Louis, 1981, Mosby. Johnson LL, van Dyle GA: Autogenous bone grafting of large defects of the knee joint: osteochondritis dissecans and osteonecrosis, San Francisco, 1993, Paper presented at the American Orthopaedic Association meeting. Johnson RE, Simmons EH: Discoid medial meniscus, Clin Orthop Relat Res 167:176, 1982. Johnson TC, Evans JA, Gilley JA, et  al.: Osteonecrosis of the knee after arthroscopic surgery for meniscal tears and chondral lesions, Arthroscopy 16:254, 2000. Jomha NM, Pinczewski LA, Clingeleffer A, et al.: Arthroscopic reconstruction of the anterior cruciate ligament with patellar-tendon autograft and interference screw fixation: the results at seven years, J Bone Joint Surg 81B:775, 1999. Jung YB, Jung HJ, Tae SK, et  al.: Reconstruction of the posterior cruciate ligament with a mid-third patellar tendon graft with use of a modified tibial inlay method: surgical technique, J Bone Joint Surg 86A:2005, 1878. Kawamura S, Lotito K, Rodeo SA: Biomechanics and healing response of the meniscus, Op Tech Sports Med 11:68, 2003. Kim SJ, Kim HJ: High portal: practical philosophy for positioning portals in knee arthroscopy, Arthroscopy 17:333, 2001. Kim HK, Moran ME, Salter RB: The potential for regeneration of articular cartilage defects created by chondral shaving and subchondral abrasion, J Bone Joint Surg 73A:1301, 1991. Kimura M, Shirakura K, Hasegawa A, et al.: Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus, part 1: arthroscopic and anatomical investigation, Arthroscopy 8:419, 1992. King D: The healing of semilunar cartilages, J Bone Joint Surg 18:333, 1936. Kitamura N, Yasuda K, Tohyama H, et al.: Primary stability of three posterior cruciate ligament reconstruction procedures: a biomechanical in  vitro study, Arthroscopy 21:970, 2005. Kitamura N, Yasuda K, Yamanaka M, et al.: Biomechanical comparisons of three posterior cruciate ligament reconstruction procedures with loadcontrolled and displacement-controlled cyclic tests, Am J Sports Med 31:907, 2003. Knutsen G, Engebretsen L, Ludvigsen TC, et  al.: Autologous chondrocyte implantation compared with microfracture in the knee: a randomized trial, J Bone Joint Surg 86A:455, 2004. Kocher MS, Garg S, Micheli LJ: Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents, J Bone Joint Surg 87A:2371, 2005. Kohn D: Current concepts: meniscus repair/removal, Orlando, FL, February 1995, Paper presented at the Arthroscopy Association of North America Specialty Day. Kohn D, Siebert W: Meniscus suture techniques: a comparative biomechanical cadaver study, Arthroscopy 5:324, 1989. Kolowich PA, Paulos LE, Rosenberg TD, et al.: Lateral release of the patella: indications and contraindications, Am J Sports Med 18:359, 1990. Kurosaka M, Yoshiya S, Yamada M, et al.: Lateral synovial plica syndrome: a case report, Am J Sports Med 20:92, 1992. Lee JH, Lim YJ, Kim KB, et al.: Arthroscopic pullout suture repair of posterior root tear of the medial meniscus: radiographic and clinical results with a 2-year follow-up, Arthroscopy 25:951, 2009. Lexer E: Die Verwendung der freien Knochenplastik nebst Versuchen uber Glenkversteifung und Gelenktransplantation, Arch Klin Chir 86:939, 1908.

Lindenbaum BL: Complications of knee joint arthroscopy, Clin Orthop Relat Res 160:158, 1981. Logan M, Watts M, Owen J: Meniscal repair in the elite athlete: results of 45 repairs with a minimum 5-year follow-up, Am J Sports Med 37:1131, 2009. Lopes Jr OV, Ferretti M, Shen W, Ekdahl M: Topography of the femoral attachment of the posterior cruciate ligament, J Bone Joint Surg 90A: 249, 2008. Lopez RA: Arthroscopic management of cysts of the lateral meniscus, Arthroscopy 6:156, 1990. Losse GM, Howard ME, Cawley PW: Bone-patellar tendon-bone grafts for anterior cruciate ligament reconstruction: the effects of pretensioning, Orlando, FL, February 1995, Paper presented at the sixty-second annual meeting of the American Academy of Orthopaedic Surgeons. Lynch MA, Herring CE, Glick Jr KR: Knee joint surface changes: long-term follow-up: meniscus tear treatment in stable anterior cruciate ligament reconstruction, Clin Orthop Relat Res 172:148, 1983. Lysholm J, Gillquist J: Arthroscopic examination of the posterior cruciate ligament, J Bone Joint Surg 63A:363, 1981. Lysholm J, Gillquist J, Liljedahl SD: Arthroscopy in the early diagnosis of injuries to the knee joint, Acta Orthop Scand 52:111, 1981. MacIntosh DL, Darby TA: Lateral substitution reconstruction, J Bone Joint Surg 58B:142, 1976. Magnussen RA, Carey JL, Spindler KP: Does operative fixation of an osteochondritis dissecans loose body result in healing and long-term maintenance of knee function? Am J Sports Med 37:754, 2009. Mannor DA, Shearn JT, Grood ES, et al.: Two-bundle posterior cruciate ligament reconstruction, Am J Sports Med 28:833, 2000. Margheritini F, Mancini L, Mauro CS, et al.: Stress radiography for quantifying posterior cruciate ligament deficiency, Arthroscopy 19:706, 2003. Margheritini F, Rihn JA, Mauro CS, et al.: Biomechanics of initial tibial fixation in posterior cruciate ligament reconstruction, Arthroscopy 21:1164, 2005. Markolf K, Davies M, Zoric B, et al.: Effects of bone block position and orientation within the tibial tunnel posterior cruciate ligament graft reconstructions: a cyclic loading study of bone-patellar tendon-bone allografts, Am J Sports Med 31:673, 2003. Markolf KL, Feeley BT, Jackson SR, et al.: Where should the femoral tunnel of a posterior cruciate ligament reconstruction be placed to best restore anteroposterior laxity and ligament forces, Am J Sports Med 10:1, 2005. Marshall S, Levas MG, Harrah A: Simple arthroscopic partial meniscectomy associated with anterior cruciate-deficient knees, Arthroscopy 1:22, 1985. Martin JA, McCabe D, Walter M, et al.: N-acetylcysteine inhibits post-impact chondrocyte death in osteochondral explants, J Bone Joint Surg 91A:1890, 2009. Martins CAQ, Kropf EJ, Shen W, et al.: The concept of anatomic anterior cruciate ligament reconstruction, Oper Tech Sports Med 16:104, 2008. Marymont JV, Henning CE, Andrish JT, et al.: Rasp abrasion of the handle (inner) fragment: effect on meniscal healing in repairs of single longitudinal tears associated with anterior cruciate reconstruction, February 1995, Paper presented at the sixty-second annual meeting of the American Academy of Orthopaedic Surgeons. Orlando, FL. McCarty EC, Marx RG, DeHaven KE: Meniscus repair: considerations in treatment and update of clinical results, Clin Orthop Relat Res 402:122, 2002. McConville OR, Kipnis JM, Richmond JC, et al.: The effect of meniscal status on knee stability and function after anterior cruciate ligament reconstruction, Arthroscopy 9:431, 1993. McDermott AG, Langer F, Pritzker KP, et al.: Fresh small-fragment osteochondral allografts: long-term follow-up study on first 100 cases, Clin Orthop Relat Res 197:96, 1985. McLennan JG: The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia, J Bone Joint Surg 64B:477, 1982. Merchan ECR, Galindo E: Arthroscope-guided surgery versus nonoperative treatment for limited degenerative osteoarthritis of the femorotibial joint in patients over 50 years of age: a prospective comparative study, Arthroscopy 9:663, 1993.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Metcalf RW: An arthroscopic method for lateral release of the subluxating or dislocating patella, Clin Orthop Relat Res 167:9, 1982. Metcalf RW, Coward DC, Rosenberg TD: Arthroscopic partial meniscectomy: a five-year follow-up, Orthop Trans 7:504, 1983. Miller GK, Maylahn DJ, Drennan DB: The treatment of idiopathic osteonecrosis of the medial femoral condyle with arthroscopic debridement, Arthroscopy 2:21, 1986. Miller MD, Bergfeld JA, Fowler PJ, et al.: The posterior cruciate ligamentinjured knee: principles of evaluation and treatment, Instr Course Lect 48:199, 1999. Miller MD, Blessey PB, Chhabra A, et al.: Meniscal repair with the Rapid Loc device: a cadaver study, J Knee Surg 16:79, 2003. Miller MD, Hart JA: All-inside meniscal repair, Instr Course Lect 54:337, 2005. Molina ME, Nonweiller DE, Evans JA, et al.: Contaminated anterior cruciate ligament grafts: the efficacy of three sterilization agents, Arthroscopy 16:373, 2000. Morgan CD: Technical note: the “all-inside” meniscus repair, Op Tech Sports Med 2:201, 1994. Morgan CD, Casscells W: Arthroscopic meniscus repair: a safe approach to the posterior horns, Arthroscopy 2:3, 1986. Morrissy RT, Eubanks RG, Park JP, et al.: Arthroscopy of the knee in children, Clin Orthop Relat Res 162:103, 1982. Moseley JB, O’Malley K, Petersen NJ, et al.: A controlled trial of arthroscopic surgery for osteoarthritis of the knee, N Engl J Med 347:81, 2002. Müezzinoglu ÜS, Güner G, Gürfidan E: Arthroscopically assisted tibial plateau fracture management: a modified method, Arthroscopy 11:506, 1995. Muneta T, Sekiya I, Yagishita K, et al.: Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with EndoButtons: operative technique and preliminary results, Arthroscopy 15:618, 1999. Muse GL, Grana WA, Hollingsworth S: Arthroscopic treatment of medial shelf syndrome, Arthroscopy 1:63, 1985. Neuschwander DC: Discoid meniscus, Op Tech Orthop 5:78, 1995. Neuschwander DC, Drez D, Finney TP: Lateral meniscal variant with absence of the posterior coronary ligament, J Bone Joint Surg 74A:1186, 1992. Newman AP, Daniels AU, Burks RT: Principles and decision making in meniscal surgery, Arthroscopy 9:33, 1993. Ngo IU, Hamilton WG, Wichern WA, et al.: Local anesthesia with sedation for arthroscopic surgery of the knee, Arthroscopy 1:237, 1985. Nole R, Munson NM, Fulkerson JP: Bupivacaine and saline effects on articular cartilage, Arthroscopy 1:123, 1985. Northmore-Ball MD, Dandy DJ: Long-term results of arthroscopic partial meniscectomy, Clin Orthop Relat Res 167:34, 1982. Northmore-Ball MD, Dandy DJ, Jackson RW: Arthroscopic, open partial, and total meniscectomy: a comparative study, J Bone Joint Surg 65B:400, 1983. Novak PJ, Bach BR: Selection criteria for knee arthroscopy in the osteoarthritic patient, Orthop Rev 7:798, 1993. Noyes FR, Barber-Westin SD: Irradiated meniscus allografts in the human knee: a two- to five-year follow-up study, February 1995, Paper presented at the Arthroscopy Association of North America Specialty Day, Orlando, FL. Noyes FR, Barber-Westin SD: Revision anterior cruciate ligament surgery: experience from Cincinnati, Clin Orthop Relat Res 325:116, 1996. Noyes FR, Barber-Westin SD, Butler DL, et al.: The role of allografts in repair and reconstruction of knee joint ligaments and menisci, Instr Course Lect 47:379, 1998. Noyes FR, Barber-Westin S: Posterior cruciate ligament replacement with a two-strand quadriceps tendon-patellar bone autograft and a tibial inlay technique, J Bone Joint Surg 87A:1241, 2005. Noyes FR, Barber-Westin SD: Posterior cruciate ligament revision reconstruction, part 1: causes of surgical failure in 52 consecutive operations, Am J Sports Med 33:646, 2005. Noyes FR, Barber-Westin SD: Posterior cruciate ligament revision reconstruction, part 2: results of revision using a 2-strand quadriceps tendonpatellar bone autograft, Am J Sports Med 33:655, 2005. Noyes FR, Barber-Westin SD, Rankin M: Meniscal transplantation in symptomatic patients less than fifty years old, J Bone Joint Surg 86A:1392, 2004.

Noyes FR, Bassett RW, Grood ES, et al.: Arthroscopy in acute traumatic hemarthrosis of the knee: incidence of anterior cruciate tears and other injuries, J Bone Joint Surg 62A:687, 1980. Noyes FR, Spievack ES: Extraarticular fluid dissection in tissues during arthroscopy: a report of clinical cases and a study of intraarticular and thigh pressures in cadavers, Am J Sports Med 10:346, 1982. O’Connor RL: Arthroscopy in the diagnosis and treatment of acute ligament injuries of the knee, J Bone Joint Surg 56A:333, 1974. O’Connor RL: Arthroscopy of the knee, Surg Annu 9:265, 1977. Ogilvie-Harris DJ, Basinski A: Arthroscopic synovectomy of the knee for rheumatoid arthritis, Arthroscopy 7:91, 1991. Ogilvie-Harris DJ, Biggs DJ, Mackay M, et  al.: Posterior portals for arthroscopic surgery of the knee, Arthroscopy 10:608, 1994. Ogilvie-Harris DJ: Giddens J: Hoffa’s disease: arthroscopic resection of the infrapatellar fat pad, Arthroscopy 10:184, 1994. Ogilvie-Harris DJ, Weisleder L: Arthroscopic synovectomy of the knee: is it helpful? Arthroscopy 11:91, 1995. Ohkoshi Y, Takeuchi T, Inoue C, et al.: Arthroscopic studies of variants of the anterior horn of the medial meniscus, Arthroscopy 13:725, 1997. O’Neill DB, Micheli LJ, Warner JP: Patellofemoral stress: a prospective analysis of exercise treatment in adolescents and adults, Am J Sports Med 20:151, 1992. Outerbridge HK, Outerbridge AR, Outerbridge RE: The use of a lateral patellar autologous graft for the repair of a large osteochondral defect in the knee, J Bone Joint Surg 77A:65, 1995. Patel D: Proximal approaches to arthroscopic surgery of the knee, Am J Sports Med 9:296, 1981. Patel D: Superior lateral-medial approach to arthroscopic meniscectomy, Orthop Clin North Am 13:299, 1982. Patil S, Butcher W, D’Lima DD, et al.: Effect of osteochondral graft insertion forces on chondrocyte viability, Am J Sports Med 36:1726, 2008. Paulos L, Swanson SC, Stoddard GJ, Barber-Westin S: Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques, Am J Sports Med 37:1288, 2009. Paulos LE, Wnorowski C, Greenwald AE: Infrapatellar contracture syndrome: diagnosis, treatment, and long-term follow-up, Am J Sports Med 22:440, 1994. Pellacci F, Montanari G, Prosperi P, et al.: Lateral discoid meniscus: treatment and results, Arthroscopy 8:526, 1992. Peters TA, McLean ID: Osteochondritis dissecans of the patellofemoral joint, Am J Sports Med 28:63, 2000. Peterson L, Minas T, Brittberg M, et  al.: Two- to nine-year outcome after autologous chondrocyte transplantation of the knee, Clin Orthop Relat Res 374:212, 2000. Petersen W, Lenschow S, Weimann A, et al.: Importance of femoral tunnel placement in double-bundle posterior cruciate ligament reconstruction, Am J Sports Med 34:456, 2006. Pettrone FA: Meniscectomy: arthrotomy versus arthroscopy, Am J Sports Med 10:355, 1982. Phillips BB, Cain LE, Dlabach JA: Correlation of interference screw insertion torque with depth of placement in tibial tunnel using quadrupled hamstring graft, Paper presented at the Southern Orthopaedic annual meeting, S. Hamilton, Bermuda. 1998. Port J, Simon TM, Jackson DW: Preparation of an exogenous fibrin clot, Arthroscopy 11:332, 1995. Purnell ML, Larson AI, Clancy W: Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography, Am J Sports Med 36:2083, 2008. Race A, Amis AA: The mechanical properties of the two bundles of the human posterior cruciate ligaments, J Biomech 27:13, 1994. Rath E, Richmond JC, Yassir W, et  al.: Meniscal allograft transplantation: two- to eight-year results, Am J Sports Med 29:410, 2001. Rodeo SA: Arthroscopic meniscal repair with use of the outside-in technique, Instr Course Lect 49:195, 2000. Rodeo SA, Seneviratne A, Suzuki K, et  al.: Histological analysis of human meniscal allografts: a preliminary report, J Bone Joint Surg 82A:1071, 2000.

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PART XIV ARTHROSCOPY Rodeo SA, Warren RF: Meniscal repair using the outside-to-inside technique, Clin Sports Med 15:469, 1996. Rodkey WG, DeHaven KE, Montgomery 3rd WH, et al.: Comparison of the collagen meniscus implant with partial meniscectomy. A prospective randomized trial, J Bone Joint Surg Am 90:1413, 2008. Rokito AS, Kvitne RS, Lee MR, et  al.: Long-term results following meniscal repair, February 1995, Paper presented at the Arthroscopy Association of North America Specialty Day, Orlando, FL. Rosenberg TD: Technique for rear entry ACL guide, Miami, 1988, Acufex Microsurgical. Rosenberg TD: Techniques for endoscope method of ACL reconstruction, Miami, 1989, Acufex Microsurgical. Rosenberg TD: Revision of failed ACL reconstruction with semitendinosus autograft, Paper presented at the Arthroscopy Association of North America Specialty Day, Orlando, FL. February 1995. Rosenberg TD, Graf B: Techniques for ACL reconstruction with Multi-Track drill guide, Miami, 1994, Acufex Microsurgical. Rosenberg TD, Scott SM, Coward DB, et al.: Arthroscopic meniscal repair evaluated with repeat arthroscopy, Arthroscopy 2:14, 1986. Rosenberg TD, Scott S, Paulos L: Arthroscopic surgery: repair of peripheral detachment of the meniscus, Contemp Orthop 10:43, 1985. Rosenberg TD, Wong HC: Arthroscopic knee surgery in a freestanding outpatient surgery center, Orthop Clin North Am 13:277, 1982. Rubman MH, Noyes FR, Barber-Westin SD: Arthroscopic repair of meniscal tears that extend into the avascular zone: a review of 198 single and complex tears, Am J Sports Med 26:87, 1998. Ryu KN, Kim IS, Kim EJ, et al.: MR imaging of tears of discoid lateral menisci, AJR Am J Roentgenol 171:963, 1998. Sagastibelza J, Zuniga JJR, Blasco JJL, et al.: Case report: osteochondritis dissecans of the anterior tibial spine, Arthroscopy 9:695, 1993. Samuelsson K, Andersson D, Karlsson J: Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials, Arthroscopy 25:1139, 2009. Scheller G, Sobau C, JU Bulow: Arthroscopic partial lateral meniscectomy in an otherwise normal knee: clinical, functional, and radiographic results of a long-term follow-up study, Arthroscopy 17:946, 2001. Schimmer RC, Brulhart KB, Duff C, et  al.: Arthroscopic partial meniscectomy: a 12-year follow-up and two-step evaluation of the long-term course, Arthroscopy 14:136, 1998. Schonholtz GJ: Arthroscopy and arthroscopic surgery, Md State Med J 30:56, 1981. Schonholtz GJ, Zahn MG, Magee CM: Lateral retinacular release of the patella, Arthroscopy 3:269, 1987. Schwarz C, Blazina ME, Sisto DJ, Hirsh LC: The results of operative treatment of osteochondritis dissecans of the patella, Am J Sports Med 16:522, 1988. Scott GA, Jolly BL, Henning CE: Combined posterior incision and arthroscopic intra-articular repair of the meniscus, J Bone Joint Surg 68A:847, 1986. Seger BM, Woods WG: Arthroscopic management of lateral meniscal cysts, Am J Sports Med 14:105, 1986. Sekiya JK, Haemmerle MJ, Stabile KJ, et al.: Biomechanical analysis of a combined double-bundle posterior cruciate ligament and posterolateral corner reconstruction, Am J Sports Med 33:360, 2005. Sekiya JK, Whiddon DR, Zehms CT, Miller MD: A clinically relevant assessment of posterior cruciate ligament and posterolateral corner injuries: evaluation of isolated and combined deficiency, J Bone Joint Surg 90A:1621, 2008. Sgaglione NA: Articular cartilage repair 2000: indications, techniques, and results, Paper presented at Specialty Day, American Academy of Orthopaedic Surgeons annual meeting, Orlando, FL. 2000. Sgaglione NA, Steadman JR, Shaffer B, et al.: Current concepts in meniscus surgery: resection to replacement, Arthroscopy 19:161, 2003. Shapiro MS, Safran MR, Crockett H, et al.: Local anesthesia for knee arthroscopy: efficacy and cost benefits, Am J Sports Med 23:50, 1995. Shearn JT, Grood ES, Noyes FR, et al.: Two-bundle posterior cruciate ligament reconstruction: how bundle tension depends on femoral placement, J Bone Joint Surg 86A:1262, 2004.

Shelbourne KD, Carr DR: Meniscal repair compared with meniscectomy for bucket-handle medial meniscal tears in anterior cruciate ligament-reconstruction knees, Am J Sports Med 31:718, 2003. Shelbourne KD, Davis TJ, Patel DV: The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries, Am J Sports Med 27:276, 1999. Shelbourne KD, Dersam MD: Comparison of partial meniscectomy versus meniscus repair for bucket-handle lateral meniscus tears in anterior cruciate ligament reconstructed knees, Arthroscopy 20:581, 2004. Shelbourne KD, Heinrich J: The long-term evaluation of lateral meniscus tears left in situ at the time of anterior cruciate ligament reconstruction, Arthroscopy 20:346, 2004. Shelbourne KD, Muthukaruppan Y: Subjective results of nonoperatively treated, acute, isolated posterior cruciate ligament injuries, Arthroscopy 21:457, 2005. Shelbourne KD, Patel DV, Martini DJ: Classification and management of arthrofibrosis of the knee after anterior cruciate ligament reconstruction, Am J Sports Med 24:857, 1996. Shellock FG, Shields CL: Radiofrequency energy-induced heating of bovine articular cartilage using a bipolar radiofrequency electrode, Am J Sports Med 28:720, 2000. Shelton WR: Meniscal allotransplantation: an arthroscopically assisted technique, Arthroscopy 9:361, 1993. Shen W, Forsythe B, Ingham SM, et  al.: Application of the anatomic double-bundle reconstruction concept to revision and augmentation anterior cruciate ligament surgeries, J Bone Joint Surg 90A(Suppl 4):20, 2008. Sherman O, Fox J, Sperling H, et al.: Patellar instability: arthroscopic treatment by electrosurgical subcutaneous lateral release, Arthroscopy 3:152, 1987. Shneider DA: Arthroscopy and arthroscopic surgery in patellar problems, Orthop Clin North Am 13:407, 1982. Siegel MG, Roberts CS: Meniscal allografts, Clin Sports Med 12:59, 1993. Sim FH: Complications and late results of meniscectomy. In American Academy of Orthopaedic Surgeons: Symposium on the athlete’s knee: surgical repair and reconstruction, St. Louis, 1980, Mosby. Simonian PT, Levine RE, Wright TM: Response of hamstring and patellar tendon grafts for anterior cruciate ligament reconstruction during cyclic tensile loading, Am J Knee Surg 13:8, 2000. Small NC: Complications in arthroscopy: the knee and other joints, Arthroscopy 4:253, 1986. Small NC: Complications in arthroscopic surgery performed by experienced arthroscopist, Arthroscopy 4:215, 1988. Smiley P, Wasilewski SA: Arthroscopic synovectomy, Arthroscopy 6:18, 1990. Smith CF, Van-Dyk GE, Jurgutis J, et  al.: Cautious surgery for discoid menisci, Am J Knee Surg 12:25, 1999. Smith M: Arthroscopic treatment of the septic knee, Arthroscopy 2:30, 1986. Sommer C, Friederich NF, Muller W: Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results, Knee Surg Sports Traumatol Arthrosc 8:207, 2008. Song EK, Oh LS, Gill TJ, et al.: Prospective comparative study of anterior cruciate ligament reconstruction using the double-bundle and single-bundle techniques, Am J Sports Med 37:1705, 2009. Sprague III NF: Arthroscopic debridement for degenerative knee joint disease, Clin Orthop Relat Res 160:118, 1981. Sprague III NF: The bucket handle meniscal tear: a technique using two incisions, Orthop Clin North Am 13:337, 1982. Sprague III NF, O’Connor RL, Fox JM: Arthroscopic treatment of postoperative knee fibroarthrosis, Clin Orthop Relat Res 166:165, 1982. Stähelin AC, Südkamp NP, Weiler A: Anatomic double-bundle posterior cruciate ligament reconstruction using hamstring tendons, Arthroscopy 17:88, 2001. Stäubli HU, Schatzmann L, Brunner P, et al.: Quadriceps tendon and patellar ligament: cryosectional anatomy and structural properties in young adults, Knee Surg Sports Traumatol Arthrosc 4:100, 1996. Steadmen JR, Rodkey WJ, Briggs KK: Microfracture to treat full-thickness chondral defects: surgical technique, rehabilitation, and outcomes, J Knee Surg 15:170, 2002.

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CHAPTER 51  ARTHROSCOPY OF THE LOWER EXTREMITY Steiner ME, Hecker AT, Brown CH, et al.: Anterior cruciate ligament graft fixation: comparison of hamstring and patellar tendon grafts, Am J Sports Med 22:240, 1994. Stetson WB, Templin K: Two- versus three-portal technique for routine knee arthroscopy, Am J Sports Med 30:108, 2002. Stollsteimer GT, Shelton WR, Dukes A, et al.: Meniscal allograft transplantation: a 1- to 5-year follow-up of 22 patients, Arthroscopy 16:343, 2000. Stone RG, Miller GA: A technique of arthroscopic suture of torn menisci, Arthroscopy 1:226, 1985. Strickland JP, Fester EW, Noyes FR: Lateral, posterior, and cruciate knee anatomy. In Noyes FR, editor: Noyes knee disorders surgery, rehabilitation, clinical outcomes, Philadelphia, 2009, Saunders. Tajima G, Nozaki M, Iriuchishima T, et al.: Morphology of the tibial insertion of the posterior cruciate ligament, J Bone Joint Surg 91A:859, 2009. Talley MC, Grana WA: Treatment of partial meniscal tears identified during anterior cruciate ligament reconstruction with limited synovial abrasion, Arthroscopy 16:6, 2000. Tippett JW: Arthroscopy and the Maquet proximal tibial osteotomy, Orthopedics 6:1145, 1983. Triantafyllou SJ, Hanks GA, Handal JA, et al.: Open and arthroscopic synovectomy in hemophilic arthropathy of the knee, Clin Orthop Relat Res 283:196, 1992. Tucker JB, Corsett J, Gregg JR: Arthroscopically assisted proximal quadricepsplasty for patellar instability, Clin Sports Med 12:81, 1993. Uribe JW, Hechtman KS, Zvijac JE, et al.: Revision anterior cruciate ligament surgery: experience from Miami, Clin Orthop Relat Res 325:91, 1996. Van Arkel ER, de Boer HH: Survival analysis of human meniscal transplantations, J Bone Joint Surg Br 84:227, 2002. Vandermeer RD, Cunningham FK: Arthroscopic treatment of the discoid lateral meniscus: results of long-term follow-up, Arthroscopy 5:101, 1989. Van Trommel MF, Simonian PT, Potter HG, Wickiewicz TL: Arthroscopic meniscal repair with fibrin clot of complete radial tears of the lateral meniscus in the avascular zone, Arthroscopy 14:360, 1998. Verdonk PC, Demurie A, Almqvist KF, et  al.: Transplantation of viable meniscal allograft: survivorship analysis and clinical outcome of one hundred cases, J Bone Joint Surg 87A:715, 2005. Verdonk R, Vandendriessche G, DeSmet L, et al.: Free patellar tendon graft for reconstruction of old posterior cruciate ligament ruptures, Acta Orthop Belg 52:554, 1986. Viola R, Marzano N, Vianello R: An unusual epidemic of Staphylococcusnegative infections involving anterior cruciate ligament reconstruction with salvage of the graft and function, Arthroscopy 16:173, 2000. Wagner M, Kaab MJ, Schallock J, et al.: Hamstring tendon versus patellar tendon anterior cruciate ligament reconstruction using biodegradable fit fixation: a prospective matched-group analysis, Am J Sports Med 33:1327, 2005. Walcott D, Shelton W, Bomboy L: ACL reconstruction: a comparison of patellar tendon autograft and quadriceps tendon autograft at 2-year follow-up, Arthroscopy 16:411, 2000. Wantanabe M, Takada S, Ikeuchi H: Atlas of arthroscopy, Tokyo, 1979, Igaku Shoin. Warren RF: Arthroscopic meniscus repair, Arthroscopy 1:170, 1985. Washington III ER, Root L, Liener UC: Discoid lateral meniscus in children: long-term follow-up after excision, J Bone Joint Surg 77A:1357, 1995. Weiss CB, Lundberg M, Hamberg P: Non-operative treatment of meniscal tears, J Bone Joint Surg 71A:811, 1989. Whiddon DR, Zehms CT, Miller MD, et  al.: Double- compared with single-bundle open inlay posterior cruciate ligament reconstruction in a cadaver model, J Bone Joint Surg 90A:1820, 2008. Whipple TL: Posterior peripheral detachment of the lateral meniscus: pathogenesis with respect to the popliteus tendon, Contemp Orthop 4:533, 1982. Whitelaw GP, DeMuth KA, Demos HA, et al.: The use of the Cryo/Cuff versus ice and elastic wrap in the postoperative care of knee arthroscopy patients, Am J Knee Surg 8:28, 1995. Wind WM, Bergfeld JA, Parker RD: Evaluation and treatment of posterior cruciate ligament injuries, Am J Sports Med 32:1765, 2004. Wirth CJ, Peters G, Milachowski KA, et al.: Long-term results of meniscal allograft transplantation, Am J Sports Med 30:174, 2002.

Woo SLY, Hollis JM, Adams DJ, et  al.: Tensile properties of the human femur-anterior cruciate ligament-tibia complex: the effects of specimen age and orientation, Am J Sports Med 19:217, 1991. Woo SL, Kanamori A, Zeminski J, et al.: The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon: a cadaver study comparing anterior tibial and rotation loads, J Bone Joint Surg 84A:907, 2002. Yagi M, Wong EK, Kanamori A, et al.: Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction, Am J Sports Med 30:660, 2002. Yamamoto T, Bullough PG: Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture, J Bone Joint Surg 82A:858, 2000. Yamashita F, Sakakida K, Suzu F, et al.: The transplantation of an autogeneic osteochondral fragment for osteochondritis dissecans of the knee, Clin Orthop Relat Res 43:201, 1985. Yoldas EA, Sekiya JK, Irrgang JJ, et  al.: Arthroscopically assisted meniscal allograft transplantation with and without combined anterior cruciate ligament reconstruction, Knee Surg Sports Traumatol Arthrosc 11:173, 2003. Yoshiya S, Kuroda R, Mizuno K, et al.: Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases, Am J Sports Med 33:1380, 2005. Zabinski SJ, Wiciewicz TL: Osteochondritis dissecans of the knee: current concepts, J Bone Joint Dis Index Rev 4:1, 1995. Zantop T, Diermann N, Schumacher T, et al.: Anatomical and nonanatomical double-bundle anterior cruciate ligament reconstruction: importance of femoral tunnel location on knee kinematics, Am J Sports Med 36:678, 2008. Zarins B: Knee arthroscopy: basic technique, Contemp Orthop 6:63, 1983. Zarins B: Technique of arthroscopic medial meniscectomy, Contemp Orthop 6:19, 1983. Zijl JA, Kleipool AE, Willems WJ: Comparison of tibial tunnel enlargement after anterior cruciate ligament reconstruction using patellar tendon autograft or allograft, Am J Sports Med 28:547, 2000. Zuniga JJR, Sagastibelza J, Blasco JJL, et al.: Arthroscopic use of the Herbert screw in osteochondritis dissecans of the knee, Arthroscopy 9:668, 1993.

HIP Awan N, Murray P: Role of hip arthroscopy in the diagnosis and treatment of hip joint pathology, Arthroscopy 22:215, 2006. Bond JL, Knutson ZA, Ebert A, Guanche CA: The 23-point arthroscopic examination of the hip: basic setup, portal placement, and surgical technique, Arthroscopy 25:416, 2009. Byrd JW: Peritrochanteric access and gluteus medius repair, Arthrosc Tech 2:e243, 2013. Byrd JW: Hip arthroscopy, J Am Acad Orthop Surg 14:433, 2006. Byrd JW: Hip arthroscopy by the supine approach, Instr Course Lect 55:325, 2006. Byrd JW: Hip arthroscopy: surgical indications, Arthroscopy 22:1260, 2006. Byrd JW: Indications for hip arthroscopy, San Francisco, 2001, Presented at the annual meeting of the American Academy of Orthopaedic Surgeons. Byrd JW, Jones KS: Hip arthroscopy for labral pathology: prospective analysis with 10-year follow-up, Arthroscopy 25:365, 2009. Clarke MT, Arora A, Villar RN: Hip arthroscopy: complications in 1054 cases, Clin Orthop Relat Res 406:84, 2003. Clohisy JC, Carlisle JC, Beaulé PE, et al.: A systematic approach to the plain radiographic evaluation of the young adult hip, J Bone Joint Surg 90(Suppl 4):47, 2008. Domb BG, Brooks AG, Byrd JW: Clinical examination of the hip joint in athletes, J Sports Rehabil 18:3, 2009. Ganz R, Parvizi J, Beck M, et al.: Femoroacetabular impingement: a cause for osteoarthritis of the hip, Clin Orthop Relat Res 417:112, 2003. Ilizaliturri Jr VM, Byrd JW, Sampson TG, et al.: A geographic zone method to describe intra-articular pathology in hip arthroscopy: cadaveric study and preliminary report, Arthroscopy 24:54, 2008. Kamath AF, Componovo R, Baldwi K, et al.: Hip arthroscopy for labral tears: review of clinical outcomes with 4.8-year mean follow-up, Am J Sports Med 37:1721, 2009.

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PART XIV ARTHROSCOPY Kelly BT, Weiland DE, Schenker ML, Philippon MJ: Arthroscopic labral repair in the hip: surgical technique and review of the literature, Arthroscopy 21:496, 2005. Kelly BT, Weiland DE, Schenker ML, et al.: Current concepts: arthroscopic labral repair in the hip: surgical technique and review of the literature, Arthroscopy 21:1496, 2005. Kelly BT, Williams RJ, Philippon MJ: Hip arthroscopy: current indications, treatment options, and management issues, Am J Sports Med 31:1020, 2003. Khanduja V, Villar RN: Arthroscopic surgery of the hip: current concepts and recent advances, J Bone Joint Surg 88B:1557, 2006. Kim KC, Hwang DS, Lee CH, Kwon ST: Influence of femoroacetabular impingement on results of hip arthroscopy in patients with early osteoarthritis, Clin Orthop Relat Res 456:128, 2007. Lage LA, Patel JV, Villar RN: The acetabular labral tear: an arthroscopic classification, Arthroscopy 12:269, 1996. Larson CM, Giveans MR: Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement, Arthroscopy 25:369, 2009. Mardones RM, Gonzalez C, Chen Q, et al.: Surgical treatment of femoroacetabular impingement: evaluation of the effect of the size of the resection, J Bone Joint Surg 87A:273, 2005. McCarthy JC, Lee JA: Hip arthroscopy: indications, outcomes, and complications, J Bone Joint Surg 87A:1138, 2005. McCarthy JC, Lee JA: Hip arthroscopy: indications, outcomes and complications, Instr Course Lect 55:301, 2006. McCarthy JC, Noble PC, Schuck MR, et al.: The Otto E Aufranc Award: the role of labral lesions to development of early degenerative hip disease, Clin Orthop Relat Res 393:25, 2001.

McCarthy MR, Wright J, Lee J: The watershed labral lesions: its relationship to early arthritis of the hip, J Arthroplasty 16:81, 2001. O’Leary JA, Berend K, Vail TP: The relationship between diagnosis and outcome in arthroscopy of the hip, Arthroscopy 17:181, 2001. Parvizi J, Leunig M, Ganz R: Femoroacetabular impingement, J Am Acad Orthop Surg 15:561, 2007. Philippon MJ, Schenker ML: Arthroscopy for the treatment of femoroacetabular impingement in the athlete, Clin Sports Med 25:299, 2006. Philippon MJ, Yen YM, Briggs KK, et al.: Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report, J Pediatr Orthop 28:705, 2008. Robertson WJ, Kelly BT: The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement, Arthroscopy 24:1019, 2008. Roy DR: Arthroscopy of the hip in children and adolescents, J Child Orthop 3:89, 2009. Seldes RM, Tan V, Hunt J, et al.: Anatomy, histologic features, and vascularity of the adult acetabular labrum, Clin Orthop Relat Res 382:232, 2001. Shindle MK, Voos JE, Heyworth BE, et al.: Hip arthroscopy in the athletic patient: current techniques and spectrum of disease, J Bone Joint Surg 89A:29, 2007. Smart LR, Oetgen M, Noonan B, Medvecky M: Beginning hip arthroscopy: indications, positioning, portals, basic techniques, and complications, Arthroscopy 23:1348, 2007. Wettstein M, Jung J, Dienst M: Arthroscopic psoas tenotomy, Arthroscopy 22:907, 2006.

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ARTHROSCOPY OF THE UPPER EXTREMITY Barry B. Phillips, Tyler J. Brolin

SHOULDER Indications Patient positioning and anesthesia Lateral decubitus position Beach-chair position Control of bleeding during arthroscopy Fluid extravasation Portal placement Posterior portal Posteroinferior seven-o’clock portal Anterior portal Anteroinferior five-o’clock portal (used with caution) Superior portal Suprascapular nerve portal as described by Lafosse Lateral, posterolateral, and anterolateral portals Portal of Wilmington Diagnostic arthroscopy and arthroscopic anatomy Loose bodies Synovectomy Drainage and debridement Labral tears Biceps tendon lesions Subpectoral biceps tenodesis

2663 2664 2664 2664 2664 2665 2665 2665 2666 2667 2667 2668 2668 2669 2669 2669 2669 2671 2672 2672 2672 2678 2682

Anterior instability 2682 Arthroscopic Bankart-Bristow-Latarjet 2690 technique Posterior instability 2690 2694 Multidirectional instability Humeral and/or glenoid avulsion of the inferior glenohumeral ligament 2694 2695 Hill-Sachs lesion Bony Bankart lesions and glenoid fractures 2697 Latarjet procedure 2700 Subacromial impingement syndrome 2700 Partial-thickness rotator cuff tears 2702 Full-thickness rotator cuff tears 2710 Massive contracted rotator cuff tears 2716 2717 Superior capsule reconstruction 2719 Subscapularis tendon tears Acromioclavicular joint osteoarthritis 2724 Acromioclavicular joint separation 2726 Calcific tendinitis of the rotator cuff 2727 Osteoarthritis 2729 Posterior ossification of the 2729 shoulder (Bennett lesion) Spinoglenoid cyst 2729 2729 Shoulder contractures 2731 Suprascapular nerve entrapment

Diagnostic and surgical arthroscopy of the upper extremity has become much more common as surgeons have developed proficiency with the arthroscope and appropriate instrumentation has been developed. A thorough knowledge of the anatomy, disorders, arthroscopic variations, and pathologic findings of each joint is essential to perform the procedures successfully and to minimize complications. This chapter discusses indications for arthroscopic treatment, patient preparation, portal anatomy, specific arthroscopic techniques, and complications after arthroscopy of the shoulder, acromioclavicular, and elbow joints.

SHOULDER Painful syndromes, altered function, and signs and symptoms of instability and internal derangement are frequent in the shoulder. The causes of such dysfunctions can be difficult to prove. The underlying cause often can be established by a careful history and physical examination combined with appropriate radiographic evaluation of the shoulder girdle, cervical spine, and thoracic cavity. Further workup

Complications ELBOW Indications Patient positioning and anesthesia Supine position Prone position Lateral decubitus position Portal placement Evaluation of the elbow Loose bodies Panner disease and osteochondritis dissecans Throwing injuries Evaluation of ulnar collateral ligament function Posterior elbow impingement Posterolateral synovial plica syndrome Radial head resection Arthrofibrosis Osteoarthritis Synovectomy Tennis elbow Olecranon bursitis Arthroscopic-assisted intraarticular fracture care Pyarthrosis Complications WRIST

2733 2735 2735 2735 2735 2736 2736 2736 2739 2741 2741 2745 2745 2745 2746 2747 2747 2748 2748 2749 2750 2750 2750 2750 2751

may include other diagnostic studies, including stress radiographs, CT with or without intraarticular contrast dye, MRI with or without intraarticular contrast dye, ultrasound, and electromyographic studies/nerve conduction studies. Appropriate radiographs should be obtained and include anteroposterior view with arm in external rotation, true anteroposterior view (Grashey view) with arm in internal rotation, scapular outlet view, and axillary lateral view. In an adolescent athlete, with dominant-side pain during sports requiring overhead motion, anteroposterior views with the shoulder in internal and external rotation help to evaluate for physeal injury. Young adults with symptoms of instability may require further radiographs, including West Point, Bergeneau, and Stryker notch views, to evaluate for potential glenoid and humeral head bony defects. MRI is useful to evaluate the soft-tissue structures surrounding the shoulder and is most useful in identifying rotator cuff pathology. Magnetic resonance arthrography (MRA) is most commonly used to identify capsulolabral pathology which can be difficult to visualize with standard MRI. In acute instability, hemarthrosis provides good contrast medium;

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PART XIV ARTHROSCOPY thus MRA may not be necessary. MRA is especially helpful in evaluation of biceps labral complex or superior labral anterior to posterior (SLAP) tears and better delineates humeral avulsion of the glenohumeral ligament. For chronic instability or if radiographs indicate bony defects from instability, threedimensional CT is the best means of quantifying bone loss in deciding whether an arthroscopic or open reconstruction is warranted. Careful thorough preoperative planning is essential for all arthroscopic surgical procedures. The surgeon also should consider potential unexpected findings and mentally prepare for an open procedure when necessary to obtain the best results.

INDICATIONS

For developmental, traumatic, degenerative, or inflammatory conditions of the shoulder resulting in pain, instability, or disability that cannot be controlled by conservative measures, arthroscopic treatment performed by a skilled surgeon results in a low-risk, high-reward reproducible procedure. Contraindications to shoulder arthroscopy include local skin conditions, remote infections that might spread to the joint, and increased medical risks. Surgeons considering arthroscopic procedures should adhere to appropriate indications for the technique and should advise patients about the possibility of an open procedure if arthroscopic findings warrant it. 

PATIENT POSITIONING AND ANESTHESIA

Two basic positions for shoulder arthroscopy have been described: the lateral decubitus and the “beach-chair” positions. Both positions have potential advantages and disadvantages, and the decision between the two is largely dependent on the surgeon’s training and comfort with each position. Advantages of the lateral decubitus position include better ability to apply traction to the arm, better access to the posterior shoulder, and ease and safety of position. Advantages of the beach-chair position include more anatomic orientation, greater ease of manipulating the arm with an arm positioner, less risk of traction neuropraxia, and ability to easily convert to an open procedure. There remain concerns over cerebral perfusion with the beach-chair position because complications of stroke and death have been reported from hypotensive episodes. Blood pressure at the brachium is lower than that in the cerebrum and potentially significantly lower if carotid artery disease is present. Because blood pressure measured in the calf of a patient in the beach-chair position can be easily 40 mm Hg higher than the accurate cerebral perfusion pressure, pressure should be monitored on the opposite brachium or with cerebral perfusion monitors when possible. Recent studies, however, have demonstrated safety with shoulder arthroscopy in the beach-chair position with no cognitive deficits and much lower frequency of clinical deoxy­genation events.

LATERAL DECUBITUS POSITION

The patient is placed in the lateral decubitus position with the affected shoulder exposed and is supported by a vacuum beanbag and kidney rest. A chest strap is used for additional support. The patient’s head is supported by a foam rest, and care is taken to protect the eyes and the downside ear. An axillary roll often is requested by anesthesiologists to improve ventilation.

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5

FIGURE 52.1 Traction for distraction of glenohumeral joint with minimal inferior subluxation. Wide 4-inch sling should be used; amount of traction and length of procedure should be monitored.

Peripheral pulses and pulse oximeter readings should be evaluated to ensure axillary structures are not compromised. All pressure points are padded, with a pillow beneath the down leg protecting the peroneal nerve and lateral malleolus and one or more pillows between the knees and ankles. This straight lateral decubitus position can be modified by tilting the patient 20 degrees posteriorly, so that the glenoid surface is placed parallel to the floor. Using a commercially available sterile arm traction device, 10 to 13 lb of traction is applied. Overdistraction with excessive weight should be avoided. The principle is more one of balanced suspension. Only the amount of traction required for clear viewing should be used. Most arthroscopists use 30 to 60 degrees of abduction and 20 to 30 degrees of forward flexion and pay more attention to the amount of traction and the length of the procedure (Fig. 52.1). A small, soft bolster can be placed in the axillary area to provide lateral displacement of the humeral head. The arm position for arthroscopy of the subacromial space and acromioclavicular joint is slightly different. The arm is brought down to 20 to 45 degrees of abduction and 0 degrees of flexion. This position permits mild inferior subluxation of the humeral head, opening up the subacromial space. 

BEACH-CHAIR POSITION

The patient is placed supine on the operating room table with a commercially available beach-chair attachment. Pillows or commercially available pads are placed under the knees to take tension off the sciatic nerve. The patient’s head is securely fastened to the headrest with a foam facemask. Eye protection is ensured, and the endotracheal tube is placed to exit from the contralateral side of the mouth. The patient is carefully inclined so that the undersurface of the acromion is roughly parallel with the floor, generally 70 to 80 degrees of inclination after satisfactory blood pressure is obtained. If concerns over blood pressure are present the patient can be inclined halfway and repeat blood pressure measurement obtained. Once in position, special attention is paid to the alignment of the cervical spine to avoid cervical extension. The patient is secured to the bed with straps over the waist and lower extremity as well as kidney rests (Fig. 52.2). Commercially available arm positioners with sterile attachments are valuable in allowing the surgeon to easily position the upper extremity during the surgical procedure

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CHAPTER 52  ARTHROSCOPY OF THE UPPER EXTREMITY and freeing up a surgical assistant who now does not have to hold the arm. 

CONTROL OF BLEEDING DURING ARTHROSCOPY

Hemostasis is paramount during shoulder arthroscopy. Bleeding during shoulder arthroscopy decreases visualization and lengthens the surgical procedure. One method of controlling bleeding is to add 1 mL of 1:1000 epinephrine to each 3000-mL bag of irrigant, if the patient has a stable pressure and no cardiac contraindications. We have not experienced any anesthetic problems with this mixture. Another technique, and perhaps the most effective, is to use hypotensive anesthesia, with a systolic blood pressure of 90 to 100 mm Hg. A systolic-to-pump pressure gradient of approximately 40 mm Hg should be maintained when possible. Elevation of the fluid bags 3 feet above the level produces a similar pressure

gradient of 66 mm fluid flow pressure. The surgeon also should be aware of locations that have a tendency to bleed, including the areas around the scapular spine, coracoacromial ligament, and coracoid base. 

FLUID EXTRAVASATION

Fluid extravasation also is more of a problem during shoulder arthroscopy than during knee arthroscopy. The increased depth of tissue traversed makes reinsertion of cannulas difficult. Tissue is traumatized, or “new” portals are created with subsequent passes, and fluid extravasation is worsened. Established portals should be maintained by an interchangeable cannula system or by cannulas with rubber diaphragms that close while instruments are being exchanged. Procedures such as subacromial decompression are extraarticular, and fluid extravasation can be pronounced. Lo and Burkhart evaluated 53 patients immediately after shoulder arthroscopy and found an average fluid weight gain of 8.7 lb. Keeping arthroscopy portals with a tight fit, avoiding violation of the deltoid fascia, and increasing pump pressure only when necessary can help avoid fluid extravasation. 

PORTAL PLACEMENT

FIGURE 52.2 stabilization.

Beach-chair position for arthroscopic shoulder

The number of described arthroscopic portals for the shoulder has greatly increased as shoulder surgical procedures have become more complex. The nomenclature for various portals often is confusing because authors have used the same descriptive terms for anatomically different portal sites. Before making arthroscopic portals, a thorough understanding of the local anatomy is necessary to prevent damage to neurovascular structures (Fig. 52.3). The portal that passes closest to a neurovascular structure is the low anterior portal approximately 1 cm from the cephalic vein. Awareness of the axillary nerve is important in portal placement anteriorly, posteriorly, and laterally. Posteriorly, the suprascapular nerve and circumflex scapular artery are approximately 2 cm from the portal site. Later portals, which are used to work on the glenohumeral space, should be directed to enter medial to the rotator cable (Table 52.1).

Suprascapular nerve Cephalic vein

Axillary nerve

A

B FIGURE 52.3 A, Bony landmarks outlined on skin. B, Anterior neurovascular structures. (B redrawn from Hulstyn MJ, Fadale PD: Arthroscopic anatomy of the shoulder, Orthop Clin North Am 26:597, 1995.)

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TABLE 52.1

Description of Portals ANTERIOR

5-o’clock portal (Davidson)

The leading edge of the inferior glenohumeral ligament at the 5-o’clock position of the glenoid rim (right shoulder)

Anterior inferior (Wolf)

The arthroscope slides off the inferior edge of the coracoid tip

Anterior central (Matthews)

Skin point lateral to the coracoid

Anterior superior (Wolf) Superolateral (Laurencin)

Mid distance between the coracoid and the acromion Lateral to the acromion on a line drawn from the acromion to the coracoid 2 cm below the lateral edge of the acromion in the prolongation of its anterior edge 1.5 cm inferior and 2 cm medial to the posterolateral corner of the acromion 2 cm medial and 3 cm inferior to the posterolateral corner of the acromion 2 cm below the lateral edge of the acromion in the prolongation of its posterior edge 3–4 cm inferior and approximately 1 cm lateral to the posterolateral acromial edge 1 cm anterior and 1 cm lateral to the posterolateral corner of the acromion 1 cm posterior and 2 cm lateral to the anterolateral corner of the acromion Superior “soft spot” surrounded by the clavicle anteriorly, the medial edge of the acromion 1 cm medially, and the spine of the scapula posteriorly Percutaneous, approximately 7 cm medial to lateral border of acromion, approximately 2 cm medial to Neviaser portal. Approach to suprascapular notch.

Anterolateral (Ellman) POSTERIOR

Soft point Central posterior (Wolf) Posterolateral (Ellman) 7-o’clock portal (Davidson)

LATERAL

SUPERIOR

Portal of Wilmington Transrotator cuff (O’Brien) Neviaser portal

Superior suprascapular nerve portal (Lafosse)

POSTERIOR PORTAL

The posterior portal is the primary entry portal for shoulder arthroscopy. It allows examination of most of the joint and assists in the placement of subsequent portals. Thus, before making the posterior portal, its purpose and functions

The arthroscope is placed through the posterior “soft point” portal, withdrawn, and replaced by a Wissinger rod, which is passed through the anterior capsule while the humerus is maximally adducted. Better with spinal needle outside-in technique. Percutaneous for better localization and angle to the glenoid. Percutaneous localization approximately 1 cm inferior and just lateral to coracoid 1 cm from cephalic vein entering joint just superior to the inferior glenohumeral ligament through junction of mid third and inferior third of subscapular tendon The arthroscope placed through the posterior “soft point” portal is withdrawn and replaced by a Wissinger rod, which is passed through the anterior capsule The space limited by the humeral head lateral, the glenoid rim medially, the long head of the biceps tendon superiorly, the subscapularis tendon inferiorly Enters the joint just anterior to the long head of the biceps tendon Enters the joint obliquely directly above the biceps tendon, where it pierces the rotator interval tissue Medially to the subacromial bursa

To the coracoid To the coracoid Medially to the subacromial bursa, just medial to the ledge of the acromion

45-degree approach angle to the posterosuperior glenoid labrum To the 11-o’clock position in the glenoid labrum (right shoulder) medial to the rotator arch Down at 30 degrees laterally and slightly posteriorly into the glenohumeral joint

should be known (Fig. 52.4). For visualization, the “soft spot” portal works well. This portal is located 1.5 to 3 cm inferior and 1 cm medial to the posterolateral tip of the acromion. Thus, the location attempts to pass through the posterior soft spot between the infraspinatus and teres minor muscles.

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CHAPTER 52  ARTHROSCOPY OF THE UPPER EXTREMITY Suprascapular nerve

Axillary nerve

FIGURE 52.4 Posterior shoulder portal risks injury to suprascapular nerve if too medial and to axillary nerve if too inferior or lateral.

By placing the portal 1 cm medial to the posterolateral acromion, the portal can be made approximately parallel to the glenoid articular surface, making for easier passage of the arthroscopic instrumentation to the anterior part of the joint. To locate this spot, one places a hand on the top of the shoulder and palpates the coracoid process with the index or long finger and the posterior soft spot with the thumb. By rotating the humerus with the opposite hand, the posterior glenohumeral joint line often can be located with the thumb. If a posterior stabilization procedure is contemplated, or if two posterior portals are necessary, the portal is made 1.5 to 2 cm inferiorly in line with the acromial edge. For subacromial procedures, a portal 15 cm inferior and in line with the acromion works nicely. A second posterior portal can subsequently be made under direct vision. When a posterior procedure is the main focus, an anterior portal should be made first and then the posterior portals under direct vision.   

ESTABLISHING A POSTERIOR PORTAL

TECHNIQUE 52.1

Establish a posterior portal by inserting an 18-gauge spinal needle through the posterior soft spot into the joint. Place the index or long finger on the coracoid tip to direct the needle anteromedially toward the coracoid. The needle should meet little resistance entering the joint, but sometimes it abuts the humeral head. n  After the capsule has been entered, inject 30 to 40 mL of saline into the joint; far less fluid may be accepted if adhesive capsulitis is significant. There should be free flow into the joint and free backflow. Preinsufflation of the joint produces some distraction of the humeral head from the glenoid and makes entry into the joint with the cannulas easier. If the needle is extraarticular, however, the n 

initial fluid bolus is injected into the soft tissues, distorting the anatomy. Some authors prefer using a blunt trocar to enter the joint before joint distention because the glenoid neck and humeral head are more easily palpable without distention. The blunt trocar is used to palpate the neck and head area before entering into the triangle just superior to the glenohumeral articulation. n  After the skin site for the posterior portal is selected, inject this area and other planned arthroscopic portal areas with local anesthetic and epinephrine to decrease bleeding. n  Incise the superficial skin layer with a No. 11 knife blade. Avoid deeper penetration because it may precipitate excessive bleeding. n  Insert a cannula and blunt trocar along the path of the needle, anteriorly and medially toward the anterior joint line. Palpate the bony scapular neck and glenoid with the blunt tip of the trocar to determine the midpoint in a superoinferior direction. Slide the trocar laterally to locate the rim of the glenoid as a small ridge. Immediately lateral to this ridge is the entry site for the joint capsule. This position ensures that the entry site is as far medial as possible and that it passes through the muscular portions of the rotator cuff instead of damaging the tendinous portions.   

POSTEROINFERIOR SEVEN-O’CLOCK PORTAL

Davidson and Rivenburgh described a 7-o’clock accessory posterior working portal for shoulder arthroscopy that allows direct access to the inferior glenohumeral capsule and avoids damage to the nearby structures. The inside-to-outside portal is created by using a switching stick passed through the 3-o’clock portal and directed posteroinferiorly. The switching stick is brought through a small skin incision and left in place. The outside-to-inside 7-o’clock portal is established by making a small skin incision 2 to 3 cm inferior and 1 cm anterior to the posterior acromial edge. A blunt-tipped rod is then inserted into the glenohumeral joint under direct vision. 

ANTERIOR PORTAL

Multiple anterior portals have been described for diagnostic and surgical stabilization techniques. For complete diagnostic examination of the shoulder, an anterior portal is essential to allow observation of the posterior capsule and the rotator cuff and for an anterior view of the glenohumeral ligaments and the subscapularis tendon. The most commonly described anterior portal is made slightly lateral to a point halfway between the anterolateral tip of the acromion and the coracoid process. Other described portals are superior or inferior to this portal and lateral to a line drawn from the coracoid toward the anterolateral aspect of the acromion. The anteroinferior portal is made just lateral and slightly superior to the palpable coracoid process. The anterolateral portal is made approximately 1 cm lateral to the anterolateral tip of the acromion and enters the glenohumeral joint through the rotator interval. If this portal is made, a large inflow sheath should not be used to prevent damage to the rotator cuff musculature. When anterior stabilization procedures are contemplated, the anterior portals should be separated as much as is safely possible to allow easy placement of instruments without overcrowding and disrupting vision.

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PART XIV ARTHROSCOPY For repair of superior labral pathologic conditions, an accessory anterosuperior portal just anterior to the acromioclavicular joint may be needed. The anterior portal is established after the posterior portal, and the posteriorly placed arthroscope is used to assist visually with its establishment. Two basic methods are used to establish the anterior portal: antegrade (outside-in) and retrograde (inside-out). With both methods, the cannula passes through the anterior soft spot, which corresponds to an intraarticular triangle bounded by the intraarticular portion of the biceps tendon superiorly, the superior intraarticular portion of the subscapularis tendon inferiorly, and the anterior edge of the glenoid at the base. Accessory portals are made by using a spinal needle to confirm appropriate placement of the portal that allows access to the pathologic process. The portal is made using an outside-in (antegrade) technique.   

ANTEGRADE METHOD TECHNIQUE 52.2 Before joint distention, when anatomic landmarks can be palpated, mark on the skin the approximate sites for arthroscopic anterior portal placement. n  Push the arthroscope, which is already in the posterior portal, up into the anterior soft spot triangle formed by the glenoid articular surface, the biceps tendon, and the subscapularis tendon. Push the arthroscope up against the area of the joint capsule and, with the overhead lights off, transilluminate the area of intended portal placement. n  Back the arthroscope slightly away from this area and palpate externally from the intended portal site while observing arthroscopically the soft spot area. Pass a spinal needle from this spot into the joint. Manipulate the spinal needle within the joint to ensure ease of instrumentation. n  Withdraw the needle and, with a No. 11 blade, make a portal in this chosen spot. n  Pass a cannula with a blunt trocar into the joint capsule. Before penetrating the capsule, move the arthroscope superiorly so that the lens is not damaged as the trocar enters into the joint. Maintain careful control of the trocar to prevent damage to articular structures or to the arthroscope. n  If an accessory anterior portal is necessary, the decision about its location should be made before making the initial anterior portal. The accessory anterior portals should be separated by at least 2 to 3 cm. The appropriate position of an accessory portal also can be confirmed with a spinal needle.     n 

Pass a Wissinger rod or large blunted Steinmann pin into the cannula and advance it through the anterior capsular structures until the anterior skin is tented. n  Make a skin incision over the tip of the rod and advance the rod past the skin. Pass a cannula sheath over the Wissinger rod and advance it retrograde into the joint. Remove the rod to establish the anterior portal. This method is easier with larger shoulder joints but affords less flexibility in positioning. n  The anterior portal traverses the clavicular portion of the deltoid muscle and enters the rotator cuff interval of the anterior capsule. The structures at risk include the cephalic vein laterally and the musculocutaneous nerve, brachial plexus, and axillary artery and vein anteromedially. Generally, the musculocutaneous nerve passes 3 to 5 cm inferior to the tip of the coracoid, but several anatomic variations have been described, and staying lateral to the coracoid process is safer. Remaining superior to the leading edge of the subscapularis tendon avoids injury to the brachial plexus and vascular structures.    n 

ANTEROINFERIOR FIVE-O’CLOCK PORTAL (USED WITH CAUTION)

The intraarticular starting point for establishing the retrograde anteroinferior portal is along the leading edge of the inferior glenohumeral ligament at the 5-o’clock position along the glenoid rim. The portal travels through the subscapularis and lateral to the conjoined tendon. Both the cephalic vein and the anterior humeral circumflex artery are in the path of this portal, but a blunt passer rod or cannula can effectively push these aside. The portal passes lateral to the musculocutaneous nerve and superolateral to the axillary nerve and approximately 1 cm from the cephalic vein. The distances between the portal and the musculocutaneous and axillary nerves have been measured at 22.9 + 4 mm (mean + SD) and 24.4 + 5.7 mm, respectively. The convexity of the humeral head should be moved away from the starting site, not only for visualization but also so that a Wissinger rod can be directed laterally. When the arm is unweighted, removed from traction, and placed alongside the body, the humeral head convexity moves superiorly. This allows appropriate access to the leading edge of the inferior glenohumeral ligament. Placing an object such as a rolled towel in the axilla distracts the joint and allows visualization of the starting site for the 5-o’clock portal. Conversely, using the outside-in 5-o’clock portal allows the portal to be created from a point lateral and inferior to the coracoid using spinal needle localization for best access to the inferior glenoid. 

SUPERIOR PORTAL

 

RETROGRADE METHOD TECHNIQUE 52.3 “Drive” the arthroscope, which is in the posterior portal, directly into the soft spot. Then remove the arthroscope from its sheath, keeping the sheath against the anterior capsule.

n 

Neviaser is credited with the description of the superior portal (supraclavicular or suprascapular portal). This portal is most useful for passage of suture retrieval devices for rotator cuff repair. It is bound anteriorly by the clavicle, laterally by the acromion, posteriorly by the base of the acromion and the scapular spine, and inferiorly by the posterosuperior rim of the glenoid. This portal penetrates the trapezius muscle and passes through the supraspinatus muscle belly. The suprascapular nerve and artery lie approximately 3 cm medial to the superior portal at its closest point. 

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CHAPTER 52  ARTHROSCOPY OF THE UPPER EXTREMITY when placing this portal so as not to damage the rotator cuff near its attachment to the greater tuberosity. 

 

ESTABLISHING THE SUPERIOR PORTAL

DIAGNOSTIC ARTHROSCOPY AND ARTHROSCOPIC ANATOMY

TECHNIQUE 52.4 (NEVIASER) The entry site is easily palpable as a soft spot. Introduce an 18-gauge spinal needle 1 cm medial to the medial acromion at an angle of 30 to 45 degrees to the skin and 10 degrees posteriorly to enter the joint at the superior margin of the glenoid just posterior to the attachment of the long head of the biceps tendon. n  Observe passage of the needle arthroscopically to confirm proper position before making a small skin incision.    n 

SUPRASCAPULAR NERVE PORTAL AS DESCRIBED BY LAFOSSE

The suprascapular nerve portal is positioned between the clavicle and the scapular spine approximately 7 cm medial to the lateral border of the acromion. This portal is approximately 2 cm medial to the Neviaser portal. 

LATERAL, POSTEROLATERAL, AND ANTEROLATERAL PORTALS

The lateral portal is the primary operative portal for the subacromial space. It is located 3 cm lateral to the lateral border of the acromion and passes through the deltoid muscle. One must ensure that instrumentation can be used and not be hindered by impingement on the lateral acromial edge. When advancing the cannula, it is initially directed downward and toward the tuberosity to enter the lateral extent of the bursa, allowing for a full view and ease of instrumentation. Accessory portals can be spaced anteriorly or posteriorly as necessary. The axillary nerve lies approximately 5 cm distal to the lateral border of the acromion. Arthroscopy of the subacromial space usually can be accomplished through the initial posterior portal and the central anterior portal. The cannulas are easily redirected up into the bursa from the same skin incisions, after passing through the deltoid muscle. When passing the anterior cannula, gentle palpation with the cannula tip can reveal the extent of the coracoacromial ligament, allowing redirection of the cannula just lateral to the ligament. In a very muscular individual or if the posterior portal has been placed too far inferiorly, a new portal, 1.5 cm inferior to the posterior acromion, may be required. Burkhart described two lateral portals for repair of SLAP lesions. Depending on the site of disruption, he used an anterolateral portal, 1 cm lateral and posterior to the anterolateral corner of the acromion, or a posterolateral portal, 1 cm anterior and lateral to the posterolateral corner of the acromion. 

PORTAL OF WILMINGTON

This posterolateral accessory portal is used to approach posterior type II SLAP lesions, providing access to the glenoid and superior labrum. The location is 1 cm anterior and 1 cm lateral to the posterior acromial angle. Care should be taken

As with arthroscopy of other joints, a thorough knowledge of the major anatomic structures around the shoulder is necessary. The surgeon must be familiar with the normal anatomy to identify abnormal or pathologic processes. The examination begins with identification of the soft spot between the biceps and subscapularis tendons (Fig. 52.5). The subscapularis is evaluated by having an assistant rotate and then lever the humerus posteriorly by placing a posterior force on the proximal humerus while pushing anteriorly at the elbow. The subscapularis recess is inspected for loose bodies. The examination consists of arthroscopically circling the joint, viewing the labral attachment at the biceps, and following the labral attachment to the glenoid and the capsular attachment to the humerus circumferentially around the shoulder back to the biceps superiorly. Capsular laxity is demonstrated by a drive-through sign and a rotator interval of more than 1.5 cm. A large sublabral hole or Buford complex variant where the middle glenohumeral ligament inserts at the base of the biceps must be distinguished from a true Bankart lesion, which extends inferiorly from the glenoid equator. Inferior glenohumeral ligament injuries may be off the glenoid, midsubstance, or off the humerus (humeral avulsion of the glenohumeral ligament [HAGL] lesions) or bipolar lesions and, when identified, should later be reexamined through an anterosuperior portal. The biceps attachment to the superior labrum is thoroughly evaluated by applying traction to the biceps with a probe and by taking the arm out of traction to check for peelback due to a SLAP lesion. The biceps tendon is followed to the bicipital arch while one evaluates for fraying, inflammation, instability, and chondromalacia where the tendon rubs against the humeral head. Using the scope and looking superiorly, a circumferential examination in the reverse direction, starting at the biceps and progressing posteriorly, is undertaken to evaluate the rotator cuff insertion. The anterior footprint insertion of the rotator arch is just posterior to the biceps and is the key component of the supraspinatus insertion. The cuff is followed posteriorly; a healthy cuff attaches just off the articular surface of the humeral head. The posterior attachment of the rotator arch marks the overlap of the attachments of the supraspinatus and infraspinatus onto the humeral head and the start of the bare area. This area is evaluated for chondromalacia or a Hill-Sachs lesion. If a HillSachs lesion is noted, the Hill-Sachs interval is measured from the posterior cuff insertion to the medial edge of the lesion. This loss of humeral articulation, as well as the amount of loss of anterior glenoid articulation (determined by using the glenoid bare area to measure the posterior radius compared with the anterior radius), is used to identify on-track or off-track lesions resulting from shoulder instability (described later). The arthroscope is now moved to the anterosuperior portal, and the posterior portal can be used for probing. The arthroscope is inserted anteriorly to view the posterior articular surface, posterior labrum, posterior pouch, and posterior capsule for redundancy, synovitis, fraying from instability, or inflammatory processes (Fig. 52.5I). Although not as prevalent as the anterior band of the inferior glenohumeral ligament, the posterior band may be visible with internal rotation as it

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M FIGURE 52.5 Patient is in lateral decubitus position, and glenoid is oriented horizontally. A, Superior part of shoulder joint with biceps tendon inserting into superior labrum. Humeral head is superior right, and glenoid is inferior. B, Superior glenohumeral ligament and subscapularis tendon on right with middle glenohumeral ligament inferiorly. C, Normal sublabral hole. D, Buford complex showing insertion of middle glenohumeral ligament directly into biceps anchor (see text). E, Middle cord variant of glenohumeral ligament crossing subscapularis tendon. F, Inferior pouch. Glenohumeral ligaments and labrum are seen. G, Capsular attachment to humeral head observed through inferior pouch. H, Rotator cuff evaluated for fraying, partial tears, or calcification. Supraspinatus tendon is seen superiorly with biceps tendon in center of picture. I, Posterior articular surface, posterior labrum, posterior pouch, and posterior capsule observed with arthroscope inserted anteriorly. J, Posterior band of inferior glenohumeral ligament. K, Anterior band of inferior glenohumeral ligament observed from anterior portal. Humeral insertion of ligament is superior. L, Capsulolabral attachment to glenoid observed through anterior portal. M, View of subacromial space with cuff below and acromion above.

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CHAPTER 52  ARTHROSCOPY OF THE UPPER EXTREMITY approaches its insertion at the 7-o’clock to 9-o’clock positions posteriorly (Fig. 52.5J). After examination of the bare area in the humeral articular cartilage, the arthroscope is moved anteriorly to evaluate the rotator cuff by looking superiorly and the biceps-labral complex by looking inferiorly toward the glenoid. As the arthroscope is moved more anteriorly and directed back toward the inferior pouch, the glenohumeral ligaments can be seen from their humeral insertion down to the glenoid insertion. Careful observation for the ligamentous insertion to the humerus is indicated to rule out humeral avulsion of the glenohumeral ligament (HAGL). Figure 52.5K shows a normal glenohumeral ligament. By turning the arthroscope more inferiorly, the attachment of the anteroinferior glenohumeral ligament and the capsulolabral attachment can be seen (Fig. 52.5L). The middle glenohumeral ligament and subscapularis tendon and the subscapularis recess also can be observed, and the arthroscope can be moved inferiorly into the subscapular recess for evaluation of the subscapularis tendon and muscle. Loose bodies and loose implants in previously operated shoulders may be found in the subscapular recess. Glenoid bone loss is best evaluated by measuring the posterior radius of the bare area and comparing it with the radius of the anterior bare area through the anterosuperior portal. To complete diagnostic arthroscopy of the shoulder for impingement, rotator cuff calcification, and inflammatory conditions, the subacromial bursa should be examined. The bursa extends from at least 2 cm anterior to the anterior edge of the acromion to approximately the midacromion posteriorly. To enter this space, all distention from the glenohumeral joint should be removed before removing any cannulas. The posterior cannula can be used to enter the subacromial space. The cannula is withdrawn from its previous placement and redirected so that the blunt edge of the trocar abuts the posterior edge of the acromion just medial to the posterolateral edge. It is redirected slightly inferior to the acromion so as to slide up under the acromion without probing into the soft tissue under the bone. At the tip of the acromion, the cannula is directed toward the surgeon’s finger, which is placed at the anterolateral edge of the acromion. The cannula should not be aimed toward the acromioclavicular joint. The subacromial space can be increased, and the approach can be made easier by placing the arm in approximately 30 degrees of abduction. When the tip of the cannula is felt up under the anterolateral edge of the acromion, it is gently swept back and forth to free the area in the bursa. The arthroscope is placed in the subacromial bursa, and contiguous structures are examined carefully. If the view is limited at this time, attempts can be made to reinsert the cannula or to sweep the cannula back and forth to open the bursa further. During this portion of the procedure, as in all arthroscopic shoulder procedures, maintaining a systolic blood pressure of no more than 30 mm Hg above the pump pressure is helpful. Initially, viewing superiorly, the undersurface of the acromion can be seen and evaluated for roughening or fraying, with an associated kissing lesion on the rotator cuff indicating impingement. The shoulder is rotated internally and externally, and increased abduction can be applied to evaluate the area for impingement. The arthroscope is turned to view medially the area of the acromioclavicular joint and the coracoacromial ligament as it ascends under the acromion. If the shoulder has impingement or inflammation, vision may be limited, and an anterolateral portal can be

made using an outside-in technique. A shaver is placed into the bursa under direct vision, and bursectomy is performed to allow better exposure of the rotator cuff. The rotator cuff and bursa should be cleaned from the area of the insertion to the tuberosity, which is the usual area of attrition, impingement, or calcification (Fig. 52.5M). After rotation of the arm to evaluate the cuff through the posterior portal, the arthroscope can be placed in the lateral portal and directed toward the posterior bursal wall. The same procedure can be used to view directly the acromion superiorly and the clavicle for evidence of bony prominence or fraying indicating impingement. The subacromial space should be examined thoroughly, which may require partial or subtotal bursectomy to see the rotator cuff and the undersurface of the acromion clearly. Any bony prominences of the acromion or the acromioclavicular joint should be evaluated and resected. The rotator cuff itself should be palpated for roughness, fraying, or calcifications. Although calcifications may be difficult to delineate, generally they can be palpated, or a slight bulge or vascular blush of the tendon can be seen. The internal extent of the bursa is approximately 4 cm from the acromial edge with the axillary nerve always lateral to the bursa, on average 0.8 cm. The lateral extent of the bursa should not be violated arthroscopically. If an open repair technique is used, the palpable internal extent of the bursa can be used as the limit of safely splitting the deltoid. General evaluation of the acromioclavicular joint can be accomplished through the subacromial portal. If an acromioclavicular spur is present, electrocautery and a shaver should be used to resect the soft tissue from the undersurface of the acromion; inferiorly directed pressure places the clavicle into the joint for better vision. The acromioclavicular joint also can be seen directly through the anterosuperior and posterosuperior portals by placing the spinal needles at approximately a 45-degree angle into the acromioclavicular joint from just anterior and posterior to the joint. 

LOOSE BODIES

Loose bodies occasionally are encountered during shoulder arthroscopy. Small ones sometimes can be removed from the joint with suction applied to a large-caliber outflow cannula. Often by increasing the rate of inflow, the joint can be vacuumed without applying suction to the outflow.   

ARTHROSCOPIC REMOVAL OF LOOSE BODY TECHNIQUE 52.5 Remove larger loose bodies with grasping forceps and triangulation techniques. Loose bodies tend to bob like apples, and turning off the inflow or outflow to decrease turbulence makes it easier to grasp the loose body. When securely grasped, extract the loose body with a slow, twisting movement to minimize the chance of its slipping from the jaws of the grasper. If necessary, enlarge the portal by spreading the joint capsule and soft tissues with

n 

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PART XIV ARTHROSCOPY the grasper or hemostat tips to prevent pulling the loose body from the jaws of the grasper. n  Extremely large loose bodies may have to be broken into smaller fragments by cutting them with a burr before they can be extracted through the portals. Keep the loose bodies contained to a localized accessible space when breaking the larger fragments. If the loose body floats away, insert a suction tip or apply suction to the outflow cannula to pull the loose body to the tip and stabilize it. Insert a grasping instrument to grasp it. n  Loose bodies tend to gravitate into the axillary pouch of the shoulder or occasionally into the subscapular recess. Loose implants likewise may be found in these areas. Other hiding places include the posterior recess behind the glenoid, the synovial folds behind the biceps tendon insertion on the glenoid, and at the site where the biceps tendon exits the joint. If a loose body is seen on a radiograph, but is not readily visible arthroscopically and is hidden within the subscapularis bursa, “milk” the loose body from the bursa by palpating in the subcoracoid area. From an anterior portal, drive the arthroscope into the subscapular bursa to examine this area fully. n  In addition to removing the loose body, determine its source because the underlying abnormality may need correction. Loose bodies may form from Hill-Sachs lesions or glenoid rim fractures in patients who have sustained dislocations. They also may be produced in shoulders with advanced arthritis or osteonecrosis where portions of the lesion have broken free.   

SYNOVECTOMY

The arthroscope allows almost complete inspection of the shoulder joint and can be used successfully for selective biopsy of the synovium. A near-total synovectomy is possible using the arthroscope without the debilitating disruption of the deltoid or rotator cuff. The lateral decubitus position with the affected arm suspended in skin traction is preferred, and the three-portal (anterior, posterior, and superior) technique usually allows complete access. The superior and anterior portions of the joint are reached with operative instruments placed through the anterior portal and the arthroscope in the posterior or superior portal. The posterior and superior portions of the joint are reached with the operative instruments in the posterior portal and the arthroscope in the anterior or superior portal. For involvement of the inferior recess, accessory posterior and inferior operating portals may be necessary. Motorized synovial resectors are required for adequate arthroscopic synovectomy. Large-diameter (>5 mm) blades allow for more efficient resection of synovial tissue. Maintaining a systolic-to-joint distention pressure of 30 mm Hg or less and adding one ampule of epinephrine to the 3-L arthroscopy bag helps maintain clear vision. 

for postoperative scarring and stiffness that occur after formal arthrotomies; and (4) can be done several times if necessary. A contraindication to arthroscopic debridement is an adjacent soft-tissue abscess. 

LABRAL TEARS

The glenoid labrum consists of dense fibrocartilaginous tissues and some elastic fibers. On the inner side, the labrum is continuous with the hyaline cartilage of the glenoid, and on the outer side, it is continuous with the fibrous tissue of the capsule. The capsule and ligaments of the shoulder, including the biceps tendon, are attached to and become part of the glenoid labrum, which attaches to the glenoid. The labrum encircles the glenoid, increasing its depth around the humeral head, and provides increased stability. Saha has shown that adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% in the horizontal direction. Karzel et  al., in biomechanical testing of cadaver shoulder specimens, showed that the labrum affects the distribution of contact stresses when a compressive load is applied to the shoulder at 90 degrees of abduction. The most common mechanisms of injury to the superior labrum (i.e., SLAP lesions) are extrinsic secondary to traction on the upper extremity and intrinsic during the throwing motion, which likewise produces traction on the biceps anchor. A second proposed mechanism of injury is torsional peel-back of the posterior superior labrum during the cocking phase of throwing. Compression, shear, and degenerative changes associated with decreased peripheral vascularity and age increase the likelihood of labral tears and decrease the likelihood of a successful repair. To aid in localizing the site of labral injury, the glenoid labrum has been divided into six areas: (1) the superior labrum, (2) the anterior labrum above the midglenoid notch, (3) the anterior labrum below the midglenoid notch, (4) the inferior labrum, (5) the posteroinferior labrum, and (6) the posterosuperior labrum (Fig. 52.6). Lesions located above the equator of the glenoid (a line drawn between the 3-o’clock and 9-o’clock positions on the glenoid) often are associated with rotator cuff or biceps disease. Lesions located below the equator are highly suggestive of shoulder instability. Superior Biceps

I Posterior

VI

II

V

Anterior III

IV

DRAINAGE AND DEBRIDEMENT

As in the knee, the arthroscope has been recommended for drainage and debridement of a septic shoulder joint; however, few clinical studies have been reported. Arthroscopic debridement (1) improves inspection, irrigation, and debridement compared with multiple needle aspirations; (2) allows breaking up of intraarticular loculations; (3) decreases the potential

Inferior FIGURE 52.6

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Glenoid labrum can be divided into six areas.

CHAPTER 52  ARTHROSCOPY OF THE UPPER EXTREMITY

A

B

FIGURE 52.7 Labral tears. A, Type II. B, Type IV SLAP lesion with displaced labral fragment and tear extending into base of biceps. Biceps anchor was stable, and labrum was excised.

Snyder further classified superior labral anterior to posterior lesions and coined the term SLAP lesions. He categorized them into four basic varieties and a complex variety that involves a combination of two or more of the other SLAP lesions. These descriptive categorizations are used to determine treatment alternatives and to predict long-term results. Type I lesions, which can be treated with simple debridement, are described as fraying of the superior labrum with a solid biceps tendon anchor attachment. Type II lesions involve pathologic detachments of the labrum and biceps anchor from the superior part of the glenoid (Fig. 52.7A). These lesions most commonly progress posterior to the biceps but may progress anterior to or both anterior and posterior to the biceps attachment at the supraglenoid tubercle. Bicepslabral instability is evidenced by labral displacement of 5 mm or more with traction on the biceps tendon, hemorrhage, or fibrous granulation tissue at the insertion with long-standing lesions and superior articular cartilage changes. The peelback test as described by Burkhart is used to evaluate for posterior extension of the lesion by removing the arm from traction and placing it in 90 degrees of abduction. The labrum is observed to displace medially on the scapular neck as the shoulder is externally rotated to 90 degrees. Type III lesions, which occur with the meniscoid-type labrum, are vertical tears within the labrum that produce bucket-handle fragments. These can be excised, provided that the biceps anchor is securely fixed to the supraglenoid tubercle. Type IV lesions are bucket-handle type tears that extend up into the biceps tendon (Fig. 52.7B). These lesions also can be excised if less than 30% of the thickness of the biceps tendon is involved. Snyder suggested that if approximately one third of the biceps tendon is involved, suture repair of the segment should be considered. In older patients, if more than a third of the tendon is involved, he suggested performing biceps tenodesis or tenotomy after resection of the labral tear. Complex tears involving a combination of two or more of the previously described lesions should be treated with repair of the type II portion if present and resection of the other lesions, provided that there is a stable biceps anchor. With multiple authors showing poor results with SLAP repairs in older individuals, the current thinking is that it is best to perform SLAP repairs in symptomatic athletes who do not respond to conservative therapy. Age is a determining factor: In general, for patients 40 years of age or younger, SLAP

repair is recommended; 40 to 60 years, tenodesis; and over 60 years of age, tenodesis or tenotomy, depending on patient preference. Repairs must have low-profile knots or knotless constructs to prevent knot impingement. If a tenodesis is chosen and a component of shoulder instability is present, repair of the superior labrum probably is warranted.   

ARTHROSCOPIC FIXATION OF TYPE II SLAP LESIONS TECHNIQUE 52.6 (MODIFIED FROM BURKHART, MORGAN, AND KIBLER) Place the patient in the lateral decubitus position and place the arm in 30 to 45 degrees of abduction and 20 degrees of forward flexion with 5 to 10 lb of balanced suspension. Administer general anesthesia and place a warming blanket to prevent hypothermia. Use an arthroscopic pump to maintain intraarticular pressure at 50 to 60 mm Hg. Use serial compression devices on the lower extremities. n  Establish a viewing portal 2 cm below the posterolateral acromion and an anterior central working portal for routine diagnostic arthroscopy. Findings such as a superior sulcus of more than 5 mm in depth, a displaceable biceps root, a positive drive-through sign, and a positive peelback sign are indicative of a SLAP lesion (Fig. 52.8). n  Use an arthroscopic probe to test the stability of the biceps-superior labral attachments to the glenoid. A normal superior sublabral sulcus covered with articular cartilage can be seen 5 mm medially beneath the labrum. If the sublabral sulcus is deeper than 5 mm, or if the labral attachments at the medial limit of the sulcus are tenuous, a SLAP lesion may be present. n  Assess whether the biceps root is easily displaceable with a probe. An unstable biceps root and superior labrum are easily displaced medially on the glenoid neck. Occasionally, the biceps root is unstable to probing, yet tenuous superior labral attachments are present. Such cases represent interstitial disruption of medially located attachments n 

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1 cm

FIGURE 52.8    Type II SLAP lesion. SEE TECHNIQUE 52.6.

Humeral head

FIGURE 52.10 Anterosuperior portal to access superior glenoid for suture anchor placement, suture passing, and knot tying. Portal is typically located 1 cm off anterolateral tip of acromion. Anterosuperior portal provides 45-degree angle of approach to corner of superior glenoid. SEE TECHNIQUE 52.6.

Biceps

Peelback FIGURE 52.9    Dynamic peel-back test. SEE TECHNIQUE 52.6.

and require completion of the lesions, bone bed preparation, and repair. n  Sweep the arthroscope from superior to inferior between the glenoid and humeral head to see if the arthroscope can be easily “driven through” the joint. Although a positive drive-through sign indicates instability, “pseudolaxity” associated with SLAP lesions also may be the cause. n  The positive peel-back sign is diagnostic for a posterior SLAP lesion; however, isolated anterior SLAP lesions often have a negative peel-back test, but other arthroscopic signs, as described earlier, usually are positive. To perform the peel-back test, remove the arm from traction and observe the superior labrum arthroscopically as an assistant brings the arm to 90 degrees of abduction and 90 degrees of external rotation (Fig. 52.9). Performing this dynamic peel-back maneuver in a shoulder with a posterior SLAP lesion causes the entire biceps–superior labrum complex to drop medially over the edge of the glenoid. n  When the diagnosis of a SLAP lesion is made, repair the lesion immediately because swelling may occur that ­obliterates

FIGURE 52.11 Preparation of bone bed on superior neck of glenoid. SEE TECHNIQUE 52.6.

the supralabral recess and obscures exposure. For the SLAP lesion repair, make three portals: a standard posterior viewing portal, an anterior portal located just above the lateral border of the subscapularis tendon, and an anterosuperior portal. The anterosuperior portal is located just lateral to the anterolateral corner of the acromion (Fig. 52.10). Use a spinal needle to locate this portal precisely so that it provides a 45-degree angle of approach to the anterosuperior corner of the glenoid for proper placement of the suture anchor. Alternatively, use a percutaneous shuttle through the superomedial (Neviaser) portal. n  Through the anterior portal, prepare the bone bed on the superior neck of the glenoid, beneath the detached labrum, using a motorized shaver (Fig. 52.11). Debride

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CHAPTER 52  ARTHROSCOPY OF THE UPPER EXTREMITY

A

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G

FIGURE 52.12 A and B, Anchor placement at base of biceps. C and D, Sutures passed through biceps anchor complex and retrieved posterior to biceps tendon. E, Suture retrieved anterior to biceps tendon. F, Humeral head erosion secondary to knot impingement. G, Knotless repair. H, Passage of suture shuttle at base of biceps. SEE TECHNIQUE 52.6.

the soft tissues carefully down to a bleeding base of bone, but do not remove bone. n  For fixation of SLAP lesions, use small-size suture anchors and simple translabral loop sutures, preferably small PEEK suture anchors (Fig. 52.12A). The most critical element to resisting peel-back forces in a mechanically effective

­ anner is to position a tight suture loop just posterior to m the root of the biceps, with the loop attached to a suture anchor placed beneath the root of the biceps (Fig. 52.12B). n  To prevent suture or knot impingement, a vertical suture through the labrum or horizontal suture behind the biceps can be helpful in some cases (Fig. 52.12C to E). The strength

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1 cm 1 cm

FIGURE 52.13 Posterolateral portal (portal of Wilmington) used to place suture anchor in posterosuperior quadrant of glenoid. Portal located 1 cm lateral and 1 cm anterior to posterior acromial angle. SEE TECHNIQUE 52.6.

of the different suture configurations is similar in laboratory studies. Using knotless suture anchors is now our preferred technique for helping to prevent knot impingement on the cuff or humeral head (Fig. 52.12F and G). n  For superior labral lesions that extend posteriorly to overlie the posterosuperior quadrant, place a second anchor through a posterolateral portal (Fig. 52.13). n  Pass a Spear guide (Arthrex, Naples, FL) through the rotator cuff near the musculotendinous junction of the infraspinatus by this approach. Because the diameter of the Spear guide is only 3.5 mm, it is preferred over a standard 7-mm arthroscopy cannula for delivery of the suture anchor through the posterolateral portal. To minimize damage to the rotator cuff from portal placement, place only the 3.5-mm Spear guide through the posterolateral portal. This posterolateral portal is used for anchor placement only; suture passage and knot-tying for the posterior anchor are accomplished through the anterosuperior portal. n  Use the BirdBeak suture passers (Arthrex, Naples, FL) to pass the suture through the labrum. The 45-degree BirdBeak is ideal for passing sutures posterior to the biceps through the anterosuperior cannula, and the 22-degree BirdBeak is best for passing sutures anterior to the biceps through the anterior cannula. Penetrate the labrum with the BirdBeak from superior to inferior and grasp the suture; withdraw the BirdBeak to pull the suture out of the anterosuperior cannula. If the SLAP lesion extends anteriorly beyond the 1-o’clock position, place a separate suture anchor in that position for fixation of that portion of the labrum. A suture shuttle device through an anterior or a percutaneous Neviaser portal allows for less trauma and more accurate placement and is necessary for knotless anchors (Fig. 52.12H). The shuttle suture is placed before drilling to prevent inadvertent damage to the permanent sutures.

FIGURE 52.14

Completed SLAP repair. SEE TECHNIQUE 52.6.

After the repair, perform the peel-back and drive-through test again to be sure that they are negative, indicating that the pathologic process has been corrected (Fig. 52.14). If the drive-through sign remains positive, consider adjunctive measures for capsular tightening.

n 

POSTOPERATIVE CARE  The operated arm is placed at the side in a sling with a small pillow. Passive external rotation of the shoulder with the arm at the side (not in abduction) and flexion and extension of the elbow are emphasized immediately. Patients who require posteroinferior capsulotomy are started on posteroinferior capsular stretches (sleeper stretches) on the first postoperative day. The sling is discontinued after 3 weeks, and passive elevation is initiated. From weeks 3 to 6, progressive passive motion as tolerated is permitted in all planes, and sleeper stretches are begun in patients who did not have posteroinferior capsulotomy. From weeks 6 to 16, stretching and flexibility exercises are continued. Passive posteroinferior capsular stretching is continued, as is external rotation stretching in abduction. Strengthening exercises for the rotator cuff, scapular stabilizers, and deltoid are initiated at 6 weeks. Biceps strengthening is begun 8 weeks postoperatively. At 4 months, athletes begin an interval throwing program on a level surface. They continue a stretching and strengthening program, with particular emphasis on posteroinferior capsular stretching. At 6 months, pitchers may begin throwing at full speed, and at 7 months they are allowed full-velocity throwing from the mound. All throwing athletes are instructed to continue posteroinferior capsular stretching indefinitely. A tight posteroinferior capsule probably initiates the pathologic cascade to a SLAP lesion, and recurrence of the tightness can be expected to place the repair at risk in a throwing athlete (Table 52.2).   

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TABLE 52.2

Rehabilitation Protocol for Superior Labral Anterior-Posterior Lesion PHASE I—IMMEDIATE POSTSURGICAL WEEKS 0–2 POSTOPERATIVE (TYPE II AND IV) GOALS (BY END OF 2 WK) 1. P/AAROM with following restrictions 1. Independent with HEP FL 5 lb 5. Progress rhythmic stabilization/PNF diagonals 6. Progress closed-chain exercises (especially wall push-ups) WEEKS 10–11 POSTOPERATIVE GOALS (BY END OF 11 WK) 1. Progress above exercises as tolerated 1. MMT elbow FL 4/5 2. TheraBand ER/IR 45 to 90 degrees increase speed/ 2. MMT shoulder FL 4/5 intensity (must be pain-free and demonstrate correct 3. MMT shoulder ABD 4/5 mechanics) 4. MMT shoulder ER 4/5 3. Closed-chain scapular stability exercises (quadruped, 5. MMT shoulder IR 4/5 tripod, side lying) 6. Able to lift 3 lb into overhead cabinet 4. Progress proprioceptive training to include progres 7. Maintain scapulohumeral rhythm with strengthening and sive weight-bearing exercises on unstable surfaces functional activities 8. Able to tuck shirt and fasten bra Precaution No unilateral lifting overhead >5 lb Continued

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TABLE 52.2

Rehabilitation Protocol for Superior Labral Anterior-Posterior Lesion—cont’d PHASE III—ADVANCED STRENGTHENING FOR RETURN TO SPORT WEEKS 12–15 POSTOPERATIVE GOALS (BY END OF 15  WK) 1. Progress isotonics increasing resistance/repetitions 1. MMT shoulder musculature 5/5 (exercises, throwing, lunges) 2. Able to place ≥10 lb in overhead cabinet 2. Plyoball exercises if appropriate Chest pass Overhead throw Sideway throw One-handed ball on wall 3. Progress shoulder strengthening (lateral pull-downs, rows) 4. Isokinetic strengthening as needed WEEKS 16 TO 24 POSTOPERATIVE GOALS (BY END OF 6 MO) 1. Initiate interval throwing (per physician input) 1. Return to sport/activity of choice 2. Initiate sport-specific/functional training 2. Independent with exercise progression 3. Isokinetic testing if requested Protocol was developed for patients after SLAP lesion repair. Surgery and rehabilitation differ depending on type of lesion. Types I and III usually are treated with debridement. The biceps tendon is stable, so postoperative rehabilitation usually can progress as tolerated. Types II and IV indicate an unstable biceps tendon requiring repair. This protocol addresses range-of-motion limitations and limited active biceps work necessary for type II/IV repairs. This is a guideline and may be adjusted to the clinical presentation and physician’s guidance. ABD, Abduction; ADD, adduction; AROM, active range of motion; ER, external rotation; EXT, extension; HEP, home exercise programs; FL, flexion; IR, internal rotation; MMT, manual muscle testing; P/AAROM, passive or active-assisted range of motion; PNF, proprioceptive neuromuscular facilitation; PROM, passive range of motion; ROM, range of motion; UBE, upper body exercises; WNL, within normal limits.

BICEPS TENDON LESIONS

Biceps tendon lesions may be inflammatory, degenerative, or traumatic as a result of repetitive microtrauma or macrotrauma. The injury site or sites may include the attachment to the supraglenoid tubercle, SLAP, the tendon (intraarticular or extraarticular), and the bicipital arch. The bicipital arch consists of the conglomerate of the superior glenohumeral ligament and the coracohumeral ligament attachment at the superior bicipital groove. The ligaments are reinforced anteriorly by the subscapular tendon attachment and posteriorly by the supraspinatus attachment. In a study of 200 consecutive patients undergoing arthroscopic cuff repair, Lafosse et al. found 45% to have anterior, posterior, or both anterior and posterior biceps instability. Larger tears correlated with a higher incidence and degree of biceps instability. The researchers suggested internal and external rotation of the humerus in 0 to 30 degrees of abduction for dynamic evaluation of the biceps followed by probing to evaluate for static stability. Boileau et  al. described an hourglass-shaped biceps deformity that is associated with inflammation and triggering through the proximal pulley. Persistence of the triggering can result in pulley instability. The treatment is arthroscopic tendon debulking or tenodesis. In patients who have chronic impingement and persistent biceps tendinitis with more than 50% of the biceps tendon disrupted, or with biceps tendon subluxation as described by Lafosse et al., Habermeyer et al., and Bennett, an arthroscopic or mini–open tenodesis can be used (Fig. 52.15). Tenodesis is favored over tenotomy in active patients for cosmesis and prevention of biceps cramping. Multiple articles support various fixation techniques, including interference screws, suture anchors, and soft-tissue fixation (percutaneous

intraarticular transtendon [PITT] procedure). The method of fixation seems to be less important than the quality of the tissue fixed. Subpectoral tenodesis has been recommended to prevent the groove pain reported in some series. The potential for plexus and musculocutaneous nerve injury or humeral diaphyseal stress fractures has been reported with these techniques and must be considered. Biceps tenodesis to treat type 2 SLAP tears has been reported to be successful in approximately two thirds of athletes, comparable to primary SLAP repair. Pitchers treated with tenodesis tend to have persistence of some anterior shoulder pain, as reported by Smith et al.   

BICEPS TENDON RELEASE TECHNIQUE 52.7 Perform arthroscopy of the shoulder through standard anterior and posterior portals. n  Release the biceps tendon at its glenoid attachment with an arthroscopic electrode or arthroscopic scissors to allow for a thickened biceps tip, which should hang up in the bicipital sling, thus preventing a severe “Popeye” deformity. n  Debride any attached stump with a shaver. n 

POSTOPERATIVE CARE Patients are given a sling to wear for 3 to 5 days for comfort; a full range of motion is allowed. No resisted elbow flexion is allowed for 1 month.    

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B

C

E

F

cut 20 mm

D

G

15 mm

H FIGURE 52.15 Mazzocca et al. subpectoral mini-open biceps tenodesis. A, Skin incision. B, Location of biceps tendon made by dissecting through superficial fascia using blunt dissection to palpate tendon. C, Probe is used to withdraw tendon from joint and out of incision. D, To ensure appropriate tensioning, 20 mm of diseased portion of tendon is excised. E, Guidewire is placed in center of bicipital groove, usually at junction of middle and distal thirds of intertubercular groove between lesser and greater tuberosities. A 7- or 8-mm acorn reamer is placed over this and reamed to 15 to 20 mm. F, Suture is placed through Arthrex Bio-Tenodesis driver, and one suture is left out. G, Bio-Tenodesis screw inserted into bone tunnel, and suture that was left out of driver is tied to suture that is in cannulated portion of tenodesis screw. H, Musculotendinous junction rests in its anatomic location underneath inferior border of pectoralis major tendon.

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Sequentially tie the sutures using standard arthroscopic knot-tying techniques or pass them through a swivel-lock device and secure them to the proximal groove. n  Remove all fluid and debris and close portals in the standard fashion. Dress the wound and place the shoulder in a sling. n 

ARTHROSCOPIC BICEPS TENODESIS: PERCUTANEOUS INTRAARTICULAR TRANSTENDON TECHNIQUE Sekiya et al. described a technique that should be used in middle-aged patients who are not participating in highlevel sports or heavy lifting. Indications are as for other biceps tendon problems with chronic bicipital tendinitis and an associated tear, medial subluxation, or bicipital pain with an associated SLAP tear.

POSTOPERATIVE CARE If an isolated arthroscopic biceps tenodesis was done, the patient is immediately started on passive pendulum exercises and active wrist and hand range-of-motion exercises. At 1 week after surgery, gentle passive elbow and shoulder range of motion is begun in all planes under the guidance of a physical therapist. The sling is used for 3 to 4 weeks. Active motion and gentle strengthening of the shoulder and elbow can begin 8 weeks after surgery. By 12 to 16 weeks after surgery, the patient is “weaned” from physical therapy to a home exercise program. Unrestricted use of the extremity is allowed 4 to 6 months after surgery.    

TECHNIQUE 52.8 (SEKIYA ET AL.) Place the patient in a beach-chair or lateral decubitus ­position. n  Insert a spinal needle from the anterior aspect of the shoulder into the bicipital groove and through the transverse humeral ligament and the lateral aspect of the internal capsule. n  Under direct view, pierce the biceps tendon with the spinal needle. Thread a No. 1 PDS (Ethicon, Somerville, NJ) through the spinal needle and pull it through the anterior portal with a grasper. n  Insert a second spinal needle through the transverse humeral ligament from the anterior shoulder and pierce the biceps tendon near the first suture. Thread a second No. 1 PDS through the spinal needle and pull it out of the anterior portal. n  These two sutures are used to pull a No. 2 braided, nonabsorbable suture through the biceps tendon. Tie the No. 2 suture to one strand of the PDS and pull it from the puncture wound in the anterior aspect of the shoulder through the biceps tendon and out of the anterior cannula. Tie the end of the suture that was pulled through the anterior cannula to the other PDS and pull it back through the anterior cannula, through the biceps tendon, and out of the anterior shoulder puncture wound. This creates a mattress suture, which secures the biceps tendon to the transverse humeral ligament in the bicipital groove. n  Repeat these steps to create a second mattress suture to secure the biceps tendon. Sutures of different colors can be used to simplify suture management. n  After the biceps tendon is adequately secured, use an arthroscopic scissors or biter to transect the biceps tendon proximal to the suture. n  Debride the stump of the biceps anchor down to a smooth, stable rim on the superior labrum. n  At this point, direct the arthroscope into the subacromial space. Establish a lateral portal and perform any concomitant procedures, such as a subacromial decompression or rotator cuff repair. Avoid transection of the previously passed sutures. We prefer to perform a subacromial bursectomy before passing tenodesis sutures. n  Locate the sutures securing the biceps tendon to the transverse humeral ligament in the bicipital groove in the subacromial space and pull through the lateral ­portal. n 

 

ARTHROSCOPIC “LOOP ‘N’ TACK” TENODESIS A suture “loop ‘n’ tack” tenodesis, performed by passing a FiberSnare (Arthrex) around and through the proximal biceps, is a quick and effective method for tenodesis. We have had good success with this technique.

TECHNIQUE 52.9 (DUERR ET AL.) With the patient in the beach-chair or lateral position, perform diagnostic arthroscopy through a standard posterior portal. n  After pathology of the long head of the biceps is identified, use an 18-gauge spinal needle to localize the anterior portal within the rotator interval directly over the biceps tendon; place a cannula for suture passing. n  Pass a looped nonabsorbable FiberSnare suture (Arthrex) around the biceps tendon (Fig. 52.16A); pass the free tail end through the looped end, and pull the tail to cinch the loop over the biceps tendon near its insertion at the superior labrum (Fig. 52.16B). n  Pass a tissue penetrator through the center of the biceps tendon, distal to the cinched loop, and grasp the free end and pull it through the tendon (Fig. 52.16C), tacking the loop in place (Fig. 52.16D). n  Cut the biceps tendon at its insertion. n  Load the free end of the suture into a PushLock suture anchor (Arthrex). n  Drill a pilot hole at the most distally visualized portion of the intraarticular bicipital groove, just above the subscapularis tendon. n  Seat the anchor with all slack taken out of the suture, allowing the tendon to translate distally with the bicipital groove, “tacking” the biceps in place. n 

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BT

H

BT

H

G G

A

H BT

H

BT

G

G

B

C

H H

BT BT

G G

D

FIGURE 52.16 Loop ‘n’ tack tenodesis, as described by Duerr et  al. Left shoulder in lateral decubitus position with a 30-degree arthroscope from the posterior portal (same orientation and position for all figures). A (left image). End of a looped suture is passed around biceps tendon (BT) from superior labrum to BT. Right image, suture is then pulled from inferior to BT to complete passage around it (G, glenoid; H, humerus). B, Free end of suture has been passed through looped end and is cinched to BT close to its insertion at superior labrum. C, Free end of suture is passed into the joint with excess slack. D, Tissue penetrator can be passed through the BT in a more distal position to secure the tendon without distalizing it. (From Duerr RA, Nye D, Paci JM, et  al. Clinical evaluation of an arthroscopic knotless suprapectoral biceps tenodesis technique: loop ‘n’ tack tenodesis. Orthop J Sports Med 6:2325967118779786, 2018.) SEE TECHNIQUE 52.9.

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POSTOPERATIVE CARE  After isolated biceps tenodesis, patients are allowed immediate shoulder and elbow range of motion. A sling is worn for comfort for a week. When this procedure is combined with another procedure (e.g., rotator cuff repair), the other procedure typically dictates the rehabilitation protocol.    

 

BICEPS TENODESIS: ARTHROSCOPIC OR MINI-OPEN TECHNIQUE WITH SCREW FIXATION Tenodesis can be done with a PEEK tenodesis screw, with two suture anchors, or with the use of a FiberSnare. The resistance to cyclic loading is comparable in both techniques, whereas the ultimate pull-out strength of the biotenodesis screw is stronger than the suture anchors. Whether done arthroscopically or through a mini-open approach with a small anterior incision or a small subpectoral incision, long-term results are comparable, and the technique should be chosen based on the skills and experience of the operating surgeon.

TECHNIQUE 52.10 (ROMEO ET AL. MODIFIED) Place the patient in the lateral decubitus position, with the shoulder abducted 30 to 40 degrees and forward flexed 30 degrees. n  Pass an 18-gauge needle from the anterolateral corner of the acromion through the rotator cuff interval and into the biceps tendon. n  Pass a No. 1 monofilament suture through the 18-gauge needle, capture it with a grabber from the anterior portal and then extract it. n  Use a No. 11 blade along the same plane as the spinal needle to make a vertical incision in the lower portion of the visible biceps tendon sheath to aid in finding the tendon later in the subacromial space. n  After the tendon is marked with a suture, use an arthroscopic basket to release the tendon from its origin just lateral to the superior labrum. This completes the preparation for the biceps tenodesis during the glenohumeral joint arthroscopy. n  Make an anterolateral portal 2 to 3 cm below the palpable edge of the anterior acromion in the center of the anterior third of the acromion. Visualization is maintained through the lateral portal or with a 70-degree scope through the posterior portal; the anterior portal is the working portal. n  Place an arthroscopic shaver in the anterior portal and remove all adventitial tissue. Anatomic landmarks and the monofilament suture are used for localizing the tendon in the groove. The falciform ligament of the pectoralis tendon is a reproducible landmark. The biceps tendon is directly under this structure. n  Using an arthroscopic basket, identify the sheath and open it. Use electrocautery to clean surrounding tissues and use a probe to free the tendon. Extend the ­dissection n 

proximally to the lateral aspect of the rotator interval. Avoid proceeding too far medially. Otherwise, the dissection to expose the biceps tendon from the biceps sheath may lead to a partial displacement of the superficial attachment of the subscapularis tendon. n  Debride soft tissues to expose the bicipital groove. n  Pull the tendon directly out through the skin incision of the anterolateral portal. n  Place a hemostat on the tendon at the level of the skin to prevent it from retracting underneath the skin. n  The placement and tension of the tenodesis are important for anatomic repair. To approximate the intraarticular distance, remove 20 mm of tendon and place a Krackow stitch of No. 2 FiberWire. n  Allow the sutures to fall back into the subacromial space. n  Place cannulas into the anterior and anterolateral portals and shuttle the sutures into the anterior portal so that they are out of the way for the bone tunnel preparation. n  Use a lateral portal for exposure and identify the bicipital groove. n  For instrumentation, use an 8.25-mm clear cannula in the anterior portal to enhance exposure and minimize softtissue distention. Through the anterolateral portal, insert a tenodesis reamer into the center of the bicipital groove, 10 to 15 mm below the insertion of the supraspinatus lateral to the subscapularis insertion at the level of the transverse humeral ligament. The depth of insertion is 20 mm. For most men, an 8-mm reamer is used, and for most women, a 7-mm reamer. The tendon can be contoured slightly to make sure it fits easily. Ream to a depth of 25 mm. n  Retrieve the sutures out of the anterolateral portal and slide an 8-mm cannula over the sutures to align them over the tunnel. n  Pull the sutures through a swivel-lock tip and hold tension on the construct to push the biceps into the base of the tunnel. n  Insert the tenodesis screw flush with the cortex. n  Check for stability by rotating the humerus.

POSTOPERATIVE CARE  Postoperative management depends largely on the types of procedures that were performed in conjunction with the biceps tenodesis. If only a biceps tenodesis was done, the postoperative procedure is the same as for arthroscopic acromioplasty (see Technique 52.17). Strengthening activities related to elbow flexion or forward elevation of the arm with the elbow extended should be restricted until 6 weeks after the biceps ­tenodesis.   

SUBPECTORAL BICEPS TENODESIS

Successful arthroscopic subpectoral tenodesis has been described by several authors. Currently, mini-open or open subpectoral tenodesis with a small nonabsorbable screw is indicated in patients who are not athletes participating in contact sports or overhead throwing (see Fig. 52.15). 

ANTERIOR INSTABILITY

Since Detrisac and Johnson first introduced the staple capsulorrhaphy in the 1970s, arthroscopic shoulder stabilization

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A2

83%-d

d

83%

B2

A

B

FIGURE 52.17 Off-track Hill-Sachs lesion. A, Three-dimensional CT showing glenoid face with bone loss of width d. In this case, the glenoid track is 83% of normal glenoid width minus d. A2-B2 is the long axis of glenoid. B, Relation of glenohumeral joint in abduction and external rotation. Note loss of contact of intact humeral articular surface with glenoid articular surface because of anteroinferior glenoid bone loss. Large Hill-Sachs interval (distance from posterior rotator cuff attachments to medial margin of Hill-Sachs lesion) is wider than glenoid track width of which has been reduced by glenoid bone loss. (From DiGiacomo G, Itoi E, Burkhart SS: Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion, Arthroscopy 30:90, 2014.)

procedures have evolved with continued development of technology and procedure modifications. Arthroscopic suture anchors, capsular plication, and interval closure repair techniques were developed, with a recurrence rate in appropriately selected patients being comparable to that of open techniques. As the technique evolved, so did the indications and contraindications. In a study of 190 patients, Burkhart and DeBeer noted an increased recurrence rate (from 6.5% to 89%) in contact athletes when a 25% glenoid defect or an engaging Hill-Sachs lesion alone or in combination was present. Di Giacomo et  al. developed the concept of “on-track” and “off-track” lesions based on evaluation of bipolar bone loss at the glenoid and humeral head (Fig. 52.17 and Box 52.1). Glenoid lesions involving more than 25% are treated with a Bankart-Bristow-Latarjet procedure. Glenoid lesions that involve less than 25% but are nonetheless off track are treated with an arthroscopic Bankart procedure with the addition of a remplissage procedure. This is especially important in contact athletes and has been shown to significantly decrease recurrence rates. Balg and Boileau developed an injury severity index (Table 52.3) and found a recurrence rate of 75% with glenoid bone loss and hyperlaxity. Shaha et  al. showed that in the active military population, bone loss of 13.5% resulted in a significant decrease in functional outcomes. Likewise, Neviaser noted inferior results when treating anterior periosteal sleeve avulsions in young patients. At this time, we believe that the arthroscopic procedure with plication and interval closure as indicated and repair of the capsulolabral defects produces comparable results to an open procedure. Surgeons should evaluate their skills and technical expertise and choose between an open and arthroscopic procedure based on the best procedure for their level of expertise and the pathologic process present. Indications for shoulder stabilization procedures include primary dislocation in high-risk patients involved in contact or collision sports near the season’s end or dislocation of the dominant shoulder in an athlete who uses an overhead



BOX 52.1

Determining If a Hill-Sachs Lesion Is “On Track” or “Off Track” 1. Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from a three-dimensional CT scan or three-dimensional MRI. 2. Determine the width of the anterior glenoid bone loss (d). 3. Calculate the width of the glenoid track (GT) by following the formula: GT = 0.83 D – d. 4. Calculate the width of the HSI, which is the width of the Hill-Sachs lesion (HS) plus the width of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the Hill-Sachs lesion: HSI = HS + BB. 5. If HSI > GT, the HS is off track, or engaging. If HSI < GT, the HS is on track, or nonengaging. From DiGiacomo G, Itoi E, Burkhart SS: Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/ off-track” lesion, Arthroscopy 30:90, 2014.

motion. In-season instability treated aggressively with rehabilitation allows 75% of athletes to return to competition, though two thirds of those returning have additional instability episodes. Instability episodes produce bone loss and chondral damage of the glenoid and humeral head, as well as further soft-tissue damage. Long-term sequelae should be discussed with the patient. Recurrence of instability despite conservative treatment also is an indication for shoulder stabilization (Box 52.2). Contraindications include an uncooperative or medically unstable patient. Relative contraindications include glenoid bone loss of 25% (≈6 mm) and an off-track Hill-Sachs lesion and an anterior HAGL lesion. The HAGL lesion was originally described by Nicola in 1942 and subsequently by Bach, Wolf, and Baker et al. Wolf described the HAGL lesion in 9.3% of patients with shoulder

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TABLE 52.3

Instability Severity Index Score PROGNOSTIC FACTORS Age at surgery (yr)   ≤ 20  >20 Degree of sport participation (preoperative)  Competitive   Recreational or none Type of sport (preoperative)   Contact or forced overhead  Other Shoulder hyperlaxity   Shoulder hyperlaxity (anterior or inferior)   Normal laxity Hill-Sachs on anteroposterior radiograph   Visible in external rotation   Not visible in external rotation Glenoid loss of contour on anteroposterior radiograph   Loss of contour   No lesion Total (points)

POINTS 2 0 2 0 1 0 1 0 2 0

2 0 10

From Balg F, Boileau P: The instability severity index score, J Bone Joint Surg 89B:1470, 2007. Copyright British Editorial Society of Bone and Joint Surgery.



Pertinent technical points for the success of arthroscopic Bankart repair include the following: Realistic patient goals and time frames Careful evaluation and identification of all significant pathologic conditions, including preoperative MRI or a threedimensional CT scan to evaluate significant bone defects associated with recurrent instability. An arthroscopic examination through an anterosuperior portal is performed to evaluate glenoid bone loss forming the socalled inverted-pear defect. Release of the capsular ligamentous complex to approximately the 6-o’clock position so that the underlying subscapularis muscle can be clearly seen to allow appropriate superior advancement of the capsule Abrasion of the glenoid neck to promote bony bleeding for a well-vascularized bed for optimal capsular healing Superior advancement of the glenohumeral complex to restore physiologic tension and eliminate any potential drive-through sign; an injury to the posterior inferior glenohumeral ligament is often present and should be repaired to restore normal tension; any appreciable HillSachs lesion in a collision athlete is repaired with a remplissage procedure, except for a lesion of the dominant shoulder in a throwing athlete; secure anatomic fixation 1 to 2 mm over the articular surface with a minimum of three suture anchors and secure loop and knot fixation to compress the capsuloligamentous complex to the bone surface and provide adequate fixation during the early healing stage; placement of knots or knotless anchors to avoid impingement. Repair of significant rotator interval, labral, and cuff defects Supervised, goal-oriented rehabilitation 

BOX 52.2

Indications for Shoulder Stabilization Modifiers Bone loss >25% (6 mm) of glenoid—Latarjet procedure Humeral head >6 mm deep or 18 mm wide—Consider remplissage for collision athletes Soft-tissue multidirectional instability—Arthroscopic capsular shift ALPSA—Restore anatomy anteriorly; consider plication Anterior HAGL—Mini-open or arthroscopic repair Posterior HAGL—Arthroscopic repair SLAP lesion—Concomitant repair Cuff lesion—Concomitant repair ALPSA, Anterior labroligamentous periosteal sleeve avulsion; HAGL, humeral avulsion of glenohumeral ligament; SLAP, superior labral tear anterior to posterior.

instability. Both anterior and posterior humeral avulsions with and without a piece of bone and a floating inferior glenohumeral ligament both anteriorly and posteriorly have been reported. Preoperative MRI in the acute setting or MRA in the subacute setting as well as thorough arthroscopic examination are needed to identify and treat all points of damage (Fig. 52.18). Open and arthroscopic repairs of HAGL lesions have been described, and at this time most authors believe that an open procedure is the easiest and most reproducible way to repair anterior lesions.

 

ARTHROSCOPIC BANKART REPAIR TECHNIQUE TECHNIQUE 52.11 Place the patient on the operating table in the lateral decubitus position with a beanbag and kidney rest. Carefully protect all bony prominences as well as the axillary area. Apply a heating blanket and serial compression devices around the lower extremities. Prepare and drape the patient so that there is wide exposure to the anterior, posterior, and superior aspects of the shoulder. Place the arm in 45 to 60 degrees of abduction and 20 degrees of forward flexion using 12 to 14 lb of traction. n  Outline the bony landmarks and mark the potential portals on the skin. n  Place the posterior portal 2 cm inferior and just medial to the posterolateral edge of the acromion. n  Before making additional portals, thoroughly examine the shoulder through the posterior portal to identify the most appropriate sites for placement of the anterior portals and for any additional posterior portals that may be necessary. Carefully visualize the entire labrum, 360 degrees of the shoulder joint, and the attachment of the glenohumeral ligament to the humerus from anterior to posterior. n 

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B

A

C FIGURE 52.18 A, Humeral avulsion of glenohumeral ligament with exposure of posterior cuff. B, Posterior glenoid avulsion of glenohumeral ligament same patient. C, Repaired floating humeral avulsion of glenohumeral ligament.

Thoroughly evaluate the glenohumeral joint for bony loss of the glenoid or humeral head. Defects of the humeral head measured from the cuff to the medial edge of the lesion should be repaired by remplissage if the defect is more than 80% of the glenoid articular surface as measured anterior to posterior using a calibrated probe (see Technique 52.16). Glenoid bone loss greater than 6 mm should be restored with a Latarjet procedure. Proper preoperative planning eliminates surprises. n  After identifying the quadrant or quadrants of injury to the labrum, create the planned portals using spinal needle localization according to the quadrant approach as shown in Figure 52.19. n  Make an anterosuperior portal with the cannula entering the shoulder just posterior to the biceps tendon and anterior to the leading edge of the supraspinatus tendon. It is the best portal to visualize the full extent of the capsular ligamentous damage and bone loss (Fig. 52.20).

Make an anterior central portal to place an 8.25-mm clear cannula just above the superior edge of the subscapularis tendon at an angle of approximately 45 degrees to the glenoid articular surface. This is used for placement of anchors and for instrumentation using a suture shuttle. n  If the lesion extends posterior, make a 7-o’clock portal posteriorly using spinal needle localization. Enter the joint at an appropriate angle for placement of a suture anchor in the inferior part of the glenoid if necessary or for placement of a shuttle for passing sutures along the capsular ligamentous complex. n  While viewing from the anterosuperior portal, use an elevator to free up the capsule down to the subscapularis muscle, which should be visible. Abrade the glenoid neck to stimulate healing (see Fig. 52.22A). n  While viewing from the anterosuperior portal if necessary, perform a capsular plication procedure posteriorly, extending along to the attachment of the posterior band of n 

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ASL PW

AP

AP

5-o'clock portal

A

B

5-o'clock portal 7-o'clock portal

7-o'clock portal

C

D FIGURE 52.19 Four-quadrant approach by Seroyer et al. A, In superior quadrant, SLAP tears between 2 and 10 o’clock are accessible through anterior portal (AP), anterosuperior lateral (ASL), and portal of Wilmington (PW). B, In anterior quadrant, anteroinferior labral tears are accessible through anterior portal (AP) and 5-o’clock portal. C, In anteroinferior quadrant, anteroinferior capsulolabral tears are accessible through 5- and 7-o’clock portals. D, In posteroinferior quadrant, posterior labral tears can be accessed through 7-o’clock portal. SEE TECHNIQUE 52.11.

the inferior glenohumeral ligament. Using a rasp, freshen the soft tissue and the intended area of plication to incite some inflammation without damaging the tissue. n  Use a suture shuttle to pass PDS sutures, starting at about the 6-o’clock position and taking a bite of approximately 1 cm of capsule in a pinch-tuck technique, making sure that the needle comes out through the capsule and passes up under the labrum in its appropriate position. The

sutures can be tied at the time they are passed, but it may be easier to pass multiple sutures first, store them outside the cannula, and tie them later. Generally, three sutures are passed, with the upper extent being at the attachment of the posterior band of the inferior glenohumeral ligament. n  Now perform the anterior part of the Bankart procedure. Abrade the anterior neck and free up the capsule

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A

B

C

D

E

F FIGURE 52.20 A, Bankart lesion. B, Bony Bankart lesion. C, Anterior labral periosteal sleeve avulsion. D, Glenoid avulsion of glenohumeral ligament. E, Glenoid labral articular disruption. F, Juvenile glenoid avulsion of the glenohumeral ligament. SEE TECHNIQUE 52.11.

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A

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C

D FIGURE 52.21 Bankart repair. A, Capsule and labral complex freed. B, Anchor inserted on articular edge. C, A 1-cm capsular bite taken with Spectrum suture passed distal to anchor. D, Knots tied recreating soft-tissue bumper. SEE TECHNIQUE 52.11.

and labral complex so it can be advanced superiorly (Fig. 52.21A). Plan the position of the suture anchors, trying to get three or four anchors placed below the 3-o’clock position. n  The most inferior anchor often is best placed using a 5-o’clock percutaneous portal made with the help of a spinal needle for localization. Place the spinal needle at a 45-degree angle to the articular surface. The Spear point guide can be placed at the 5:30 position on the neck, 1 to 2 mm on the articular surface for reaming and placement of the suture anchor. Note the exact position of the drill hole, observe the anchor as it is placed in the hole, use a mallet to tap the anchor down, and then check security by tugging on the sutures. To obtain the best area of bone for drilling at a lower level, an angled reamer and anchor inserter can be placed percutaneously. This provides excellent fixation in this position (Fig. 52.21B). n  The second and third anchors may be either single-loaded or double-loaded anchors and usually are PEEK doubleloaded anchors. Recently, we have used knotless anchors to provide secure fixation without the risk of knot

i­mpingement. When knots are used, use the cannula to direct the knot away from the articular surface as it is being seated. With this technique, take the most inferior suture out the posteroinferior cannula using a suture grasper. Obtain a good bite of the capsule and labrum just distal to the intended site of the anchor (Fig. 52.21C). Take the shuttle out of the posterior inferior cannula and secure it around the inferior suture limb of the anchor, and then retrieve it out the anterior cannula. Grasp the two sutures not involved in the first knot with a suture retrieval device from the posterior cannula, take them out the posterior cannula, and store them for later tying. The arthroscopic knot is then tied. n  Firmly secure the first suture that was passed through the labrum to the capsule and labrum up to the edge of the glenoid, creating an anterior bumper. Pass the superior of the two suture limbs that were passed out the posterior cannula back through the anterior cannula. Use the shuttle to pass the shuttle loop through the capsule and labrum. Carry this shuttle out the posterior cannula and shuttle the second suture through the capsule and out the

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CHAPTER 52  ARTHROSCOPY OF THE UPPER EXTREMITY

A

B

C FIGURE 52.22 A, Abrasion of glenoid neck and capsular release to allow advancement of capsulolabral complex superiorly and laterally to restore anatomy and physiologic tension. Arthroscope is in anterosuperior portal. B and C, Restored anterior labral bumper. SEE TECHNIQUE 52.11.

anterior cannula. Use the cannula to direct the knot away from the joint surface as it is secured. n  Place a third anchor either single-loaded or double-loaded using the same technique. Sometimes, some of the lower sutures can be used in either a single simple repair or as a mattress suture, depending on the type of tear and tissue involved. This is determined at the time of surgery. Place three or four anchors, each separated by 5 to 7 mm. Tie the knots securely, re-creating a soft-tissue bumper (Figs. 52.21D and 52.22). At this time, if the plication sutures have not been tied, they should be tied posteriorly from the posterior cannula and secured. In our practice, we generally tie these earlier in the procedure when they are placed, but some authors prefer to tie them later. n  If the patient had hyperlaxity and significant sulcus associated with the Bankart lesion, perform a rotator interval closure at this time by withdrawing the anterior central cannula to just outside the capsule. Pass a crescent spectrum needle through the middle glenohumeral ligament several millimeters into the ligament and out into the joint. Maintain one limb outside the capsule while the limb in the joint is retrieved using a penetrator device through the anterior central cannula. Grasp the ­intraarticular limb

of the suture at the level of the superior glenohumeral ligament and retrieve it out of the cannula for extracapsular tying using an SMC (Samsung Medical Center, Seoul, South Korea)–type knot (see Fig. 52.57). Generally, two sutures are passed in securing the rotator interval if it is thought that the slight loss of external rotation is offset by the added stability of these additional sutures (Figs. 52.23 and 52.24). n  Upon completion, close the portals with subcuticular poliglecaprone 25 (Monocryl). Apply a sterile dressing and an UltraSling (DJO Global, Vista, CA).

POSTOPERATIVE CARE  The sling is applied after surgery and worn for 4 to 6 weeks. Physical therapy is started 2 to 3 weeks after surgery. Active-assisted range of motion is performed from weeks 2 to 8, and isometric strengthening is performed from weeks 8 to 12. The athlete is allowed to return to preinjury conditioning programs and weight training at 12 weeks, and at 6 months he or she is allowed to participate in contact sports based on rangeof-motion and strength guidelines dictated by the contralateral shoulder (Table 52.4).    

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ARTHROSCOPIC BANKART-BRISTOWLATARJET TECHNIQUE

Boileau, Mercier, and Olds proposed the combined technique as an alternative to capsulolabral repair in patients with anterior instability and significant glenoid bone loss. They reported a high rate of return to sports and a low rate of instability. Tasaki et al. reported 40 rugby players who had anterior dislocations treated with this procedure. All players returned to competitive rugby with no recurrent anterior dislocations at 2-year follow-up.

POSTERIOR INSTABILITY

FIGURE 52.23 Completed Bankart repair with three anchors and capsule plicated inferiorly. Rotator interval is closed. SEE TECHNIQUE 52.11.

Arthroscopic posterior shoulder stabilization has rapidly gained favor in recent years, with the results of open procedures having been less than adequate. Arthroscopic repairs have been shown to be effective in athletic and nonathletic patients. In a study by Bradley et al. reviewing 100 shoulder procedures for posterior recurrent shoulder instability, the American Shoulder and Elbow Surgeons score improved from 50.36 to 85.66 at a mean follow-up of 27 months. Overall, 89% of their patients were able to return to sports and 67% were able to return to the same level of sports

A B

C FIGURE 52.24 A, Repaired glenoid avulsion of glenohumeral ligament. B, Repaired juvenile glenoid avulsion. C, Completed bony Bankart repair. SEE TECHNIQUE 52.11.

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CHAPTER 52  ARTHROSCOPY OF THE UPPER EXTREMITY

TABLE 52.4

Bankart Repair Rehabilitation Protocol PREOPERATIVE GOALS . Independent with postoperative exercise program 1 2. Independent with preoperative strengthening with isometrics and isotonics in pain-free, stable range PHASE I WEEKS 1–2 POSTOPERATIVE 1. Pendulum exercises 2. Elbow, forearm, wrist AROM 3. Wrist isotonics and grip exercises 4. Sling at all times WEEKS 3–4 POSTOPERATIVE (PT QIW-TIW) 1. Initiate PT approximately 15 d postoperatively 2. PROM with the following restrictions FL 2 mm of displacement), more severe arthrosis can be expected. In a series of 37 AO type B3 and C3 fractures treated with external fixation and delayed internal fixation of the articular surface, Dickson, Montgomery, and Field identified a subset of patients with “ground-glass” comminution, which was defined as more than three pieces of articular surface less than 2 mm in size seen on CT scan. Posttraumatic arthritis developed in 10 (38%) of the 26 ankles with ground-glass comminution and in none of the ankles without it. Overall, 17% of anatomically reduced fractures (5 of 29) developed arthritis, whereas five of seven nonanatomically reduced fractures developed arthritis. In recent years, there has been a greater emphasis on functional outcome. Although there is no disagreement that anatomic reduction is desirable, the impact of anatomic reduction on overall outcome is less clear. An analysis of the effect of severity of injury and fracture reduction on clinical outcome found no correlation with clinical ankle score. In addition, no correlation has been found between radiographic arthrosis and clinical results. Williams et al. found that although radiographic arthrosis was related to injury severity and quality of reduction, there was no significant relationship between these variables and the 36-Item Short Form Health Survey (SF36) score, clinical ankle score, or return to work. Functional outcome was more closely related to socioeconomic factors. Patients with a higher level of education were more likely to return to work and had higher ankle scores. The predictors of

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY clinical outcome seem to be multifactorial and are not fully understood. Other studies have found pilon fractures to have a negative long-term effect on general health as measured by the SF-36. Stiffness, swelling, persistent pain, and the use of an ambulatory aid were some of the reasons. Forty-three percent of previously employed patients were no longer employed, and of this subgroup, 68% attributed their inability to work to the pilon fracture. Poorer results were correlated with having two or more comorbidities and treatment with external fixation. Fractures treated with external fixation had more impairment of range of motion and worse pain scores than fractures treated with ORIF. External fixation tended to be used in more severe injuries (AO type C). Factors to consider in the formulation of a treatment plan include the fracture pattern, soft-tissue injury, patient comorbidities, fixation resources, and surgical experience. The degree of articular comminution, talar damage, and soft-tissue injury is dictated by the injury; however, the surgeon does have some influence over other prognostic factors. The goal should be to obtain the best possible articular reduction and axial alignment while respecting the soft tissues. If the articular surface does not reduce by ligamentotaxis, some form of open reduction usually is indicated after the soft tissues have recovered. Fracture union can be enhanced by bone grafting areas of impaction, bone loss, or extensive metaphyseal comminution. The frequency of wound healing problems and infection can be decreased by recognizing open and closed soft-tissue injury and not operating through compromised soft tissue. In some cases, the surgeon must achieve a balance between the goals of anatomic reduction and prevention of wound complications. Anatomic reduction often is more difficult to achieve after a delay of 2 to 3 weeks; however, surgical incisions through swollen, contused soft tissues can lead to disastrous results, which may require free tissue transfer or even amputation. Nondisplaced fractures, such as AO types A1, B1, and C1, have been treated successfully with operative and nonoperative methods. These are the only fracture types in which cast immobilization alone may be suitable. If casting is chosen, the patient should be observed closely for displacement, and weight bearing should be restricted for at least 8 to 12 weeks if the joint is nonarthritic. Calcaneal traction alone often is helpful in temporarily stabilizing severe fractures associated with soft-tissue swelling, but it seldom is used for definitive treatment. External fixation accomplishes the same goal of fracture reduction through ligamentotaxis and allows the patient to be mobilized. Limited fixation with 3.5- or 4.0-mm screws, inserted after either percutaneous or limited open reduction, combined with external fixation or minimally invasive plating techniques may be adequate treatment for AO types B1, B2, and stable C1 fractures.

OPEN REDUCTION AND PLATE FIXATION

For displaced fractures, operative treatment has been found to be superior to nonoperative treatment. Rüedi and Allgöwer popularized the technique of ORIF with plates and screws for tibial pilon fractures in the 1960s. This technique follows the AO principles of anatomic reduction, rigid stabilization, and early motion. The fibula is reduced first and stabilized with a plate. Then the articular surface of the tibia is reduced and provisionally fixed with Kirschner wires through an

anteromedial incision. Metaphyseal defects are filled with bone graft, and the fracture is stabilized with a medial buttress plate. Rüedi and Allgöwer reported 70 good or excellent results in 75 fractures treated with this method. Only three fractures were open, and almost half were low-energy, sportrelated injuries. In the 1980s to the mid-1990s, series involving larger percentages of open and high-energy injuries reported far fewer successful results and a high incidence of complications with this technique, especially in Rüedi and Allgöwer type III (AO type C3) fractures. When complications occur, they can be devastating. Free tissue transfer often is necessary to salvage the extremity, and the final result in some cases is amputation. Satisfactory results in Rüedi and Allgöwer types I and II fractures have been reported to be between 60% and 82% and 37% and 40% in type III fractures treated with ORIF, respectively. Infection rates after type III fractures have been reported to be 12.5% to 37%. Plate and screw fixation has been associated with more frequent wound breakdown and infection than in similar fractures treated with external fixation. Watson et  al. reported more excellent and good results at 5-year follow-up with external fixation (81%) than with open plating (75%) in 94 pilon fractures. They based their treatment choices on the severity of the soft-tissue injury: Tscherne grade 0 and grade I were treated with plating, and grade II and grade III and open fractures were treated with external fixation. 

TWO-STAGE DELAYED OPEN REDUCTION AND INTERNAL FIXATION

The high incidence of wound complications after ORIF of pilon fractures reported in the 1980s and in the early to mid1990s is attributable to operating through a poor soft-tissue envelope. In an effort to improve overall results, protocols for staged ORIF were developed, and these have decreased the frequency of wound complications and infections associated with plating of pilon fractures. Initially, the fibula is plated and an external fixator is placed, spanning the ankle. Preoperatively, the proposed incision for tibial reduction is planned and the fibular incision is placed so that the skin bridge between the two incisions is at least 7 cm, although smaller soft-tissue bridges have been shown to be tolerable. If the soft tissue overlying the fibula is compromised, fibular plating should be delayed. External fixation pins should be placed well away from planned incisions and out of the zone of injury and potential plate fixation. Watson et al. described a two-pin “traveling traction” type of external fixator that is useful in this situation. An AO delta frame spanning the ankle or a medial half-pin fixator consisting of one half-pin in the talus, one half-pin in the calcaneus, and two half-pins in the tibial shaft have been recommended; however, the use of a talar pin may compromise certain surgical approaches. Tibial pilon open reduction is done after the soft tissues have improved and swelling has decreased (usually between 10 and 21 days). Skin wrinkling and healing of fracture blisters are clinical indicators of improved soft-tissue condition. Careful soft-tissue handling and low-profile plates are recommended. When the soft-tissue swelling has significantly diminished, anatomic reduction and internal fixation can be done with fewer wound complications than with early ORIF.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Several authors have recommended staged protocols for treatment of complex pilon fractures with severe soft-tissue injuries. Patterson and Cole described immediate fibular fixation and placement of a medial spanning external fixator, followed at an average 24 days later by removal of the fixator and ORIF. Of 22 type C3 pilon fractures, 21 healed within an average of 4.2 months with no infections or soft-tissue complications. These authors cited as advantages of this protocol (1) better soft-tissue management, because the first stage aims to obtain anatomic fibular realignment and restore anatomic length of the distal tibia with little disruption of the soft tissues, and (2) the ability to obtain anatomic realignment of the articular surface under direct vision in the second stage. Disadvantages include the need for a large soft-tissue dissection initially and the difficulty of reduction techniques and maneuvers in a fracture 3 weeks or more after injury. Patterson and Cole also cautioned against creating large softtissue dissections and bone stripping. Blauth et al. compared three different treatment methods in 51 patients with predominantly AO type C pilon fractures. They found no significant difference among the methods in regard to soft-tissue infection. There was no statistical correlation between arthritis and soft-tissue injury or treatment group. There was a trend toward better range of motion, less pain, more frequent return to previous occupation, and increased ability to return to leisure activities in the staged treatment group; however, it was not statistically significant. Based on these results, the authors stated a preference for the staged procedure in patients with severe soft-tissue compromise that involved limited screw fixation of the articular surface through stab incisions and spanning external fixation followed by a less invasive plating technique after soft-tissue healing. Most pilon injuries are treated in staged fashion owing to the reported decrease in associated complications. However, investigation continues to further our understanding of these difficult fractures in an effort to minimize soft-tissue complications and maximize treatment results. Graves et al. revealed that the larger soft-tissue envelope associated with obesity resulted in a trend toward increased wound complications. White et al. evaluated 95 OTA 43.C-type tibial pilon fractures, 88% of which were managed within 48 hours of injury, and found results comparable to those previously reported for other treatment modalities. The lateral approach has been advocated for treating certain fracture patterns in a staged fashion, as have combined posteromedial and posterolateral approaches. Boraiah et al. reported outcomes of open pilon fractures treated with ORIF in a staged fashion. Despite a 3% and 5% deep and superficial infection rate, respectively, functional outcome scoring for most patients was poor. Harris et al. determined that patients sustaining a type C3 fracture developed more complications, required secondary interventions, and had worse functional scoring at a mean follow-up of 98 months.

PLATING TECHNIQUE

Open anatomic reduction and rigid fixation with plate and screw devices can be used effectively to treat tibial pilon fractures if strict attention is paid to fracture reduction and softtissue management. This technique is suitable for low-energy fractures with large displaced fragments, little comminution, and no diaphyseal extension (Fig. 54.15). An extremity with

minimal swelling and a good soft-tissue envelope is of paramount importance if complications are to be prevented. Skin wrinkling is a good indication that edema has subsided. Softtissue handling must be meticulous, and strict “no-touch” techniques have been advocated. The most prudent course is temporization with placement of an external fixator until the soft tissues can be definitively treated. Formal open plating techniques should be used cautiously in open fractures and Rüedi and Allgöwer type III fractures (AO type C3) because of the high reported incidences of poor results and complications. 

MINIMALLY INVASIVE PLATING

In an effort to decrease the wound complications associated with traditional open plating techniques, less invasive methods of plating have been developed. The fracture is primarily reduced by ligamentotaxis, and further reduction and plating are performed through limited incisions. Open medial plating has been found to disrupt the blood supply of the distal tibia to a greater extent than percutaneous plating, which might predispose to delayed union or nonunion. Borens et al. reported their results in 17 patients treated with minimally invasive plating of selected tibial pilon fractures with a low-profile medial plate. All fractures healed. Results were rated as excellent in eight patients (47%), fair in seven patients (41%), and poor in two patients (12%). The authors concluded that this technique was effective and reduced soft-tissue complications associated with open plating of pilon fractures. They advocated the use of this technique in a staged protocol. Minimally invasive plating techniques have been further enhanced with the widespread development of precontoured locking-plate technology, particularly those with outriggers to target proximal fixation. We do not routinely perform open reduction of the fibular component during the initial setting and prefer to maintain length through application of an external fixator alone, particularly if the fibular fracture is highly comminuted. Alternatively, a small anterolateral surgical approach can be used for articular reduction and then fixation can be done in submuscular fashion and proximal fixation percutaneously positioned. This can be done with a medially based large distractor for facilitation of reduction. The anterolateral approach is described in Chapter 1. Care must be taken to ensure adequate soft-tissue bridging if a separate incision is necessary to treat the fibula. When the anterolateral approach is used, a separate incision occasionally is needed to place a percutaneous small medial plate if the fracture pattern demands. Understanding the typical morphology of tibial pilon fractures is paramount to devising an appropriate reduction strategy, whether the fibula is fixed acutely or not. Mapping of tibial pilon fractures has revealed characteristic fracture fragments that can be identified in most fractures. These consist of anterolateral, medial, and posterolateral fragments, with a central component that may be significantly comminuted. As with many ankle fractures, reduction of the fibular component can improve the reduction of the posterior fragment. These fragments must be recognized whether a formal open or a limited technique is used. With open approaches, the reduction sequence (after fixation of the fibula in many cases) begins posteriorly and then progresses medially, followed by central reduction, and finally the anterolateral fragment. 

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY

FIGURE 54.15

Plate and screw fixation of distal tibial and fibular fractures.

 

STAGED MINIMALLY INVASIVE OPEN REDUCTION AND INTERNAL FIXATION TECHNIQUE 54.7 Stage 1 Place the patient supine on a radiolucent operating table and place a tourniquet. n  For ORIF, make a standard posterolateral incision. n  Reduce the fracture, and fix the fibula with a one third tubular plate. n  Close the wound with 3-0 nylon. n  Place a triangular external fixator spanning the ankle joint. n  Place two pins proximally in the anteromedial aspect of the tibia and place one threaded pin through the calcaneus. n  Using ligamentotaxis and the reestablished lateral column, the pilon fracture is temporarily reduced and secured (Fig. 54.16).  Stage 2 n  Definitive reconstruction can be done as soon as healing of the soft tissues permits, typically as judged by the return of skin wrinkling. n  Place the patient supine on a radiolucent table with a tourniquet. If preoperative planning has shown that percutaneous plating is impossible, reduce articular surfaces through a limited anterior arthrotomy, chosen by the location of primary fracture lines, which can also allow bone grafting or application of a small anterior plate or both. n  If percutaneous plating is possible, estimate the length of the plate based on preoperative films. Place the plate on the skin while checking the position with fluoroscopy. n 

Contour the plate to fit on the anteromedial aspect of the distal tibia. After bending and twisting the plate using plate benders, check the anticipated position using fluoroscopy. n  Make one anteromedial incision at the proximal end of the anticipated plate position and one at the distal end. n  Make a tunnel connecting these two incisions in an extraperiosteal fashion by advancing a clamp from distal to proximal or from proximal to distal. n  Tie a strong suture (e.g., Ethibond No. 5) through the first hole in the plate. Use the Kelly clamp to help pull the plate through the subcutaneous tunnel under radiographic control. Through small stab incisions, fix the plate with 3.5mm cortical low-profile screws. Locking screws may be used if a bridge plate construct is deemed necessary. n  If necessary, place a cortical screw through the midportion of the plate. Because the plate is flexible, good boneplate contact can be achieved (Fig. 54.17). n  When final radiographic control shows adequate reduction and fixation, remove the external fixator. n  Deflate the tourniquet and obtain hemostasis. Close the wound over drains in standard layered fashion. n  Place a bulky cotton dressing with a posterior plaster splint to maintain the ankle in neutral position.  n 

POSTOPERATIVE CARE  Postoperatively, the limb is immobilized with the use of a splint. Closed suction drains are typically removed on postoperative day 1 or 2. Depending on the rigidity of fixation, splint immobilization is discontinued as wound healing permits. Passive and active range-of-motion exercises are then initiated. Sutures are removed between 2 and 3 weeks postoperatively. Full weight bearing is not permitted until full bony healing is confirmed radiographically, usually by 12 weeks.   

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS other approaches. They recommended this surgical approach only for pilon fractures in which the articular displacement and comminution are predominantly located posteriorly or when an anterior approach is not recommended because of the condition of the soft tissues. The posterolateral approach is rarely indicated as the sole approach for management of pilon injuries. Instead, it can be a component of an overall strategy to treat these injuries. Some have advocated its use early in the treatment of the fibula and posterior fragment. Definitive ORIF of the plafond from a staged anterior-based approach has the benefit of a stable posterior column to serve as the base for reconstruction. 

A

 

B

FIGURE 54.16 A, Comminuted pilon fracture with fibular fracture. B, Fibular length is restored and secured with six-hole plate as first step in reconstruction of pilon fracture. (From deSouza LJ: Fractures and dislocations about the ankle. In Gustilo RB, Kyle RF, Templeman DC, editors: Fractures and dislocations, St. Louis, 1993, Mosby.) SEE TECHNIQUE 54.7.

POSTEROLATERAL APPROACH TO PILON FRACTURES TECHNIQUE 54.8 With the patient under general anesthesia, remove the temporary external fixator that was previously placed. Administer antibiotics preoperatively. n  Place the patient prone and exsanguinate the extremity and inflate the tourniquet. n  Make a posterolateral incision into the distal tibia between the peroneal tendons and flexor hallucis longus, adjacent to the Achilles tendon. The approach can be carried proximally if needed. n  Identify and protect the sural nerve. n  Apply a femoral distractor if necessary to gain length or view the joint. Apply the distractor through new pins in the tibia to the calcaneus (Fig. 54.18). n  If necessary, plate the fibula through the same incision and fix with a 3.5-mm one third tubular plate. n  Obtain articular reduction by direct manipulation of the fracture fragments through the fracture sites under direct exposure. Confirm reduction with fluoroscopy. n  Fix the articular fragments with 3.5-mm lag screws or 4.0mm cancellous screws. n  For the metaphyseal component of the injury, apply an appropriate plate for the injury type. C-type injuries typically require a 3.5-mm plate. B-type injuries can be treated with lower-profile implants placed in an antiglide fashion. n  For large bone defects caused by comminution, consider using iliac crest bone grafting or appropriate bone graft substitutes. n  Perform wound closure in standard layered fashion and consider insertion of a subfascial closed suction drain.  n 

If minimally invasive techniques are not deemed appropriate for the fracture pattern, open techniques should be used. Similar to the technique above, once the soft-tissue envelope is appropriate after staged external fixation, the surgeon can embark on definitive fixation. The selected surgical approach should take into account the primary fracture lines or “lines of access” to effect the reduction with the most direct access to minimize soft-tissue undermining. This may consist of multiple smaller surgical incisions. Multiple surgical approaches have been described for definitive fixation, the most common being anterolateral and anteromedial.

POSTEROLATERAL APPROACH TO PILON FRACTURES Alternatives to the traditional anteromedial approach for ORIF of pilon fractures have been advocated in an attempt to reduce the incidence of soft-tissue complications. The interval is between the peroneal tendons and the flexor hallucis longus. A thicker soft-tissue envelope overlying the plate (flexor hallucis longus muscle) was thought to potentially decrease problems with wound healing and deep infection. A disadvantage of this approach is poor exposure of the ankle joint, which limits its utility in fractures with anterior comminution. Some authors suggest the posterolateral approach should be considered as an alternative surgical approach in fractures that can be effectively reduced posteriorly. Bhattacharyya examined the complications associated with the use of the posterolateral approach for pilon fractures in 19 patients. Complications occurred in nine of the 19 patients. Six patients (31%) had wound problems (three superficial infections, three deep infections). Four patients (21%) had nonunions (two aseptic, two infected), three patients required ankle arthrodesis, and one patient had a 3-mm step-off. The authors concluded that the posterolateral approach did not reduce the incidence of wound complications compared with

POSTOPERATIVE CARE  The leg is splinted and elevated for 48 hours. We routinely place a closed suction drain postoperatively for posterolateral approaches. Early ankle motion is encouraged with physical therapy once the wound permits and sutures have been removed. Weight bearing begins at 12 weeks when radiographs permit.   

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY

B

A D C

E

F

G

FIGURE 54.17 A, Closed, comminuted fracture involving tibial pilon and fibula. B and C, Application of uniplanar external fixation and fibular ORIF facilitates indirect reduction of distal tibial comminution. D-G, After healing of soft tissues, patient returned for definitive fixation with limited open reduction and minimally invasive plate osteosynthesis. SEE TECHNIQUE 54.7.

COMBINED INTERNAL AND EXTERNAL FIXATION In response to reports of unacceptable results with plating of high-energy tibial pilon fractures with traditional techniques, external fixation combined with limited internal fixation of the fibula and articular surface of the tibia has been advocated as an alternative approach. Reports of external fixation combined with limited internal fixation for tibial pilon fractures have shown a decreased incidence of infection compared with similar fractures treated with plate and screw devices. However, a 20% incidence of pin complications and wound healing problems over the fibular incision were noted in one study.

In a long-term follow-up study (5 to 12 years) by Marsh et al., of 35 pilon fractures treated with monolateral spanning external fixation, reduction was rated as good in 14, fair in 15, and poor in 6. Osteoarthrosis was grade 0 in 3, grade 1 in 6, grade 2 in 20, and grade 3 in 6. Arthrosis was correlated with severity of injury and quality of reduction but did not correlate with clinical result (15 excellent, 10 good, and 7 poor). Fifteen patients rated their outcome as excellent, 10 as good, 7 as fair, and 1 as poor. Most patients (27 of 31) were unable to run. Another study by Dickson et al. of 37 high-energy tibial pilon fractures (AO B3 and C3) treated by spanning external fixation and a second-stage open reduction of the articular surface at 10 to 21 days reported 81% good and excellent

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FIGURE 54.18 Posterior approach. Femoral distractor has been applied, and sural nerve is dissected free. SEE TECHNIQUE 54.8.

results. Complications included infection in 8%, loss of reduction in 11%, secondary arthrosis in 8%, and one (3%) amputation in a diabetic patient with a failed arthrodesis. Studies have shown good to excellent results with the use of hybrid external fixation in 67% to 69% of intraarticular or Rüedi-Allgöwer type II fractures and 75% to 97% good results. Complications have been reported in 23% to 66% of patients and include deep and superficial infections and malunion. 

EXTERNAL FIXATION AND FIBULAR PLATING

Although an integral part of the AO principles for ORIF of tibial pilon fractures, the role of fibular plating is controversial when external fixation is used as the definitive treatment. Potential advantages of fibular plating include increasing mechanical stability, assisting in reduction of the anterolateral articular fragment, and restoring the length and alignment of the tibia. Potential disadvantages include increased operative time, possible wound complications, and potential malreduction resulting in inability to accurately reduce the plafond. In addition, fibular plating restricts the ability of the fixator to be dynamized and may lead to delayed union or varus malunion if metaphyseal defects are not bone grafted. Fibular reduction may be difficult in some fractures, and malreduction impairs the ability to reduce the tibia. In a study by Williams et al. of patients treated with fibular plating, complications included fibular wound infections (23%), fibular nonunions (9%), and angular malalignment (4.5%). Complications in patients without fibular plating

included angular malunions (19%) and tibial wound infection (3%). An increased frequency of delayed union or varus malunion in the fractures with fibular plating was not found; however, the authors concluded that plating of the fibula in tibial pilon fractures treated with external fixation spanning the ankle is associated with significant complications and that good results can be obtained without fibular fixation. Limitations of the study included the small number of patients. Watson et  al. analyzed 39 tibial pilon fractures that were treated with a variety of external fixation devices and were considered treatment failures. They found that 64% of the failures consisted of malunion or nonunion of the diaphyseal-metaphyseal junction in fractures with plated or intact fibulas and unrecognized bone loss or comminution of the tibia that was never bone grafted. The authors contended that this complication may be avoided by early recognition and bone grafting of tibial bone loss or comminution before frame dynamization. Alternatively, bone grafting potentially can be avoided by not plating the fibula and by using a screw or wire to maintain fibular reduction at the ankle mortise. There currently is no definitive evidence to support or condemn fibular fixation in tibial pilon fractures treated with external fixation. The risks and benefits of fibular fixation must be weighed for each individual fracture. We do not routinely stabilize the fibular fracture at the time of initial external fixator application, particularly if the definitive management will be with external fixation. However, we do in select patients treat the fibular fracture early if a posterolateral approach is used to treat a posterior plafond fragment and then return in a staged fashion once the soft-tissue envelope allows for fixation of the remaining components of the injury. Although external fixation techniques have been shown to reduce the incidence of wound complications and deep infection compared with open reduction and plating, malunions and pin site infections remain problematic. Comparative series have shown that articular reduction was better in the open reduction group than in the external fixation group, although external fixation was used more commonly for more severe fractures.

SPANNING EXTERNAL FIXATION

Traditional half-pin external fixation that spans the ankle joint has the advantages of requiring less soft-tissue dissection and of leaving no large implants in a subcutaneous position, which theoretically should lead to fewer wound complications and infections, especially in open fractures or fractures with severe closed soft-tissue injury. Limited open reduction may be necessary, however, if the fracture does not reduce by ligamentotaxis. External fixation can be used to stabilize almost any fracture of the distal tibia, regardless of comminution, and is especially useful in fractures with diaphyseal extension. Half-pin external fixators are relatively easy to apply, and most surgeons are familiar with this technique. Potential disadvantages include pin track infection and pin loosening, which are common with any type of external fixator; loss of reduction, which can occur if the fixation is removed before the fracture heals; and ankle stiffness, which may occur because half-pin fixators span the ankle and subtalar joints. At least one halfpin usually is inserted into the calcaneus, which makes this technique more difficult if an ipsilateral calcaneal fracture is involved. Half-pins in the hindfoot loosen with time, and bone grafting may be needed in comminuted fractures to promote fracture union before fixator removal.

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A

B

D

E

C

FIGURE 54.19 A and B, Severe fracture-dislocation of distal tibia and fibula. C, CT scan shows fracture pattern. D and E, After fixation with plate and screws in fibula, lag screws in tibia, and articulated fixator to maintain reduction.

The articulated half-pin fixator, with a hinge to allow ankle motion, was developed to prevent immobilization of the tibiotalar joint. The axis of the hinge is aligned as closely as possible to the true axis of the ankle, and the articulated hinge can be loosened to allow ankle motion. It has not been proved, however, that the articulating feature improves overall functional results. Marsh et  al. compared 19 patients with pilon fractures treated in a spanning external fixator without ankle motion with 22 patients treated with an articulated spanning external fixator and early ankle range of motion (within 2 weeks of surgery). Patients were placed in a short leg cast or walking boot for 4 to 6 weeks after fixator removal. The authors found no significant differences between the groups in range of motion, pain, or functional scores. The authors cautioned that follow-up was short and that numbers may have been too small to detect differences. Half-pins are placed in the calcaneus and talus and connected to half-pins in the diaphysis. The fracture is reduced by distraction and ligamentotaxis. The fibula can be plated if the overlying soft tissues have not been damaged. The articular surface is reduced further percutaneously, under fluoroscopic

guidance, or through limited incisions made directly over fracture lines. The articular reduction is fixed with 3.5- or 4.0-mm screws (Fig. 54.19). Bone grafting of metaphyseal defects is necessary in 25% to 60% of fractures; it can be done acutely if soft-tissue coverage is good, or it can be delayed 4 to 6 weeks until the soft tissues have healed.   

SPANNING EXTERNAL FIXATION OF TIBIAL PILON FRACTURE TECHNIQUE 54.9 (BONAR AND MARSH) Fix a hinged, articulated fixator to two screws distally, one in the calcaneus and one in the talus, and to two screws proximally in the tibia. Insert all screws after predrilling. To protect the soft tissues, perform all drilling and screw insertion through sleeves.

n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Place the calcaneal and talar screws as indicated in Fig. 54.20A to straddle the neurovascular bundle. n  Using fluoroscopy, place the talar screw first without using the fixator template. Locate the starting point of the talar screw on the distal medial neck of the talus (see Fig. 54.20A); place the screw parallel to the dome of the talus, as seen fluoroscopically on an anteroposterior view of the ankle (Fig. 54.20B), and roughly perpendicular to the long axis of the foot (Fig. 54.20C). The placement and direction of this screw are important because they align the template used to insert the rest of the screws. n  Ensure bicortical purchase by making sure that two threads penetrate the lateral neck of the talus on an anteroposterior fluoroscopic view. n  Place the calcaneal and tibial screws through the template based on the talar screw. The calcaneal screw can be placed high or low in the tuberosity of the calcaneus by rotating the articulated hinge. The high position allows more postoperative dorsiflexion and is recommended. n  Confirm bicortical purchase of the calcaneal screw on an axial fluoroscopic view of the hindfoot. The center of the hinge of the articulated fixator should be near the middle of the talus. n  After the screws have been placed, remove the template, apply the fixator, and lock the proximal ball joint. Use a compression distraction apparatus to distract the ankle joint and evaluate the reduction fluoroscopically. n  Based on preoperative planning and the intraoperative appearance after distraction, make limited incisions to aid in exact reduction of the articular surface and obtain fixation with small fragment screws. Choose incision locations that coincide directly with the major fracture lines to provide a view of the articular surface, using the fracture as a window. Large tenaculum reduction forceps may help reduce the major fragments. n  Use screw fixation for the articular fragments only; do not attempt to obtain screw fixation across the metaphyseal fracture. Tibial plates are not used. Use cannulated screws for percutaneous insertion and keep periosteal stripping to a minimum. n  Apply bone graft to the metaphyseal defect through the same incision or through a separate incision if needed.  n 

POSTOPERATIVE CARE  The limb is kept elevated until softtissue healing allows mobilization. Most patients are kept non–weight bearing and are not allowed to bear more than 20 kg of weight during the first 6 weeks. The external fixator is dynamized (the locking nut is released to allow sliding of the telescoping body) at 4 to 12 weeks, at which time weight bearing is increased. The fixator is removed when healing of the fracture is evident on radiographs and the patient can walk without pain when the fixator body is removed. Ankle joint motion is begun when soft-tissue conditions permit, usually at 1 to 2 weeks. An Orthoplast (Johnson & Johnson, New Brunswick, NJ) splint is worn to maintain the ankle in neutral except during range-of-motion exercises.   

HYBRID EXTERNAL FIXATION

Hybrid external fixators consist of tensioned wires in the epiphyseal fragment of the tibia connected to half-pins placed in the diaphysis. Similar to half-pin fixators, these devices

provide greater preservation of the soft tissues and greater ease in spanning diaphyseal fracture lines than do plating devices. The tensioned wires, which can be used in a manner similar to lag screws, can aid in the reduction and fixation of articular fragments. Confining the fixation to above the ankle joint has potential advantages and disadvantages. The tibiotalar and subtalar joints are not immobilized, which theoretically should diminish stiffness in these areas. The surgeon must be familiar with the biomechanics of these fixators to ensure a stable construct. In a biomechanical study, Yang et  al. found that a bar-ring hybrid fixator consisting of a unilateral fixator body connected to a ring/wire assembly was too flexible. The addition of diagonally placed struts significantly improved the stability of this construct. A two-ring hybrid fixator seemed to have the best mechanical performance. In fractures with extreme articular comminution, the wires may not provide adequate fixation, however. Fixation wires may need to be placed intracapsularly for adequate fixation, and although septic arthritis caused by pin track infection is a potential complication, this has not been a problem in the ankle as it has been in the knee. Neurologic, vascular, or tendinous impalement can occur if safe corridors for wire placement are not recognized. Fractures associated with tibiotalar instability also are not adequately stabilized with this method. Many surgeons do not have experience with tensioned wire techniques. Hybrid fixators are most appropriate for AO type A, type C1, and type C2 fractures. Early ligamentotaxis reduction is important to close large fracture gaps and to reduce fracture hemorrhage and tension on the tenuous soft-tissue envelope. A delay of more than a few days may make it impossible to disimpact the metaphyseal fragments and makes realignment of any shaft extension and comminution difficult; it also makes indirect reduction difficult and may require a larger or more extensile incision. Calcaneal traction can be applied immediately after evaluation in the emergency department or, for open fractures, in the operating room during emergency irrigation and debridement. Watson et al. described the use of a “traveling traction” device consisting of a 6-mm, centrally threaded Steinmann pin through the calcaneal tuberosity and a similar pin through the proximal tibia at the level of the fibular head. A simple quadrilateral external fixator frame is constructed by applying medial and lateral radiolucent external fixation bars, and manual distraction is done to obtain a ligamentotaxis reduction. A CT scan of the extremity in traction allows formulation of an operative plan. If ligamentotaxis has obtained a relative reduction, percutaneous olive wires can be used, with or without cannulated screws. If the joint is not reduced, a limited open approach is indicated. Based on review of more than 150 CT scans of these injuries, Watson developed a four-quadrant approach to wire insertion (Fig. 54.21). Incisions are made to correspond with the anatomically “safe” corridors for transfixation wire placement to stabilize the metaphyseal fragments. The only region inaccessible to tension wire fixation is a fracture line that is exactly transverse in the coronal plane. Because of anatomic restraints, olive wires cannot be placed from directly anterior to posterior, and fracture lines in this orientation are best stabilized with small cannulated screws. 

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C FIGURE 54.20 A, Placement of calcaneal and talar screws to avoid neurovascular bundle and subtalar joint. B, Talar screw is parallel to talar dome on anteroposterior view (dashed lines indicate inaccurate screw placement). C, Screw is perpendicular to long axis of foot, and two threads should protrude through far cortex of talus. SEE TECHNIQUE 54.9.  

DEFINITIVE RING EXTERNAL FIXATION OF TIBIAL PILON FRACTURES TECHNIQUE 54.10 (WATSON) Place the patient on a radiolucent table on a beanbag patient-positioning device. Bolster the beanbag to elevate the entire lower extremity and to allow placement of a circular fixator without its impinging on the table. Maintain

n 

calcaneal traction through a table extension with a sterile traction bow. If a two-pin external fixator is in place, use it to maintain traction. n  Stabilize the fibula first. If the condition of the soft tissues allows, use a limited open reduction technique to apply a four-hole or six-hole plate. If the soft tissues along the lateral aspect of the fibula are compromised, use percutaneous tenaculum forceps to pull the fibula out to length and pin it temporarily to the lateral tibia with a percutaneous Kirschner wire, which later is replaced with a tensioned olive wire. n  The external fixation frame usually consists of three or four rings. Begin the frame with a distally based ring located at the level of the ankle joint. Locate the second ring just proximal to any shaft extension. If there is a wide zone of diaphyseal-metaphyseal extension, an additional middle ring is necessary. Connect the proximal two or three rings above the fracture by long, threaded rods. Leave the distal ring free. n  Open the proximal ring construct in a “clamshell” fashion and place it over the tibial shaft. Place a transverse reference wire parallel to the knee joint and level with the fibular head, and attach the proximal ring to this wire. Obtain appropriate soft-tissue clearance and position the proximal ring on the limb to ensure that it is parallel to the knee joint and collinear with the intact proximal shaft of the tibia. n  Place a Schanz pin into the proximal tibial shaft and attach it to the most proximal ring. At this point, the proximal ring construct is firmly attached to the tibia above the fracture. Place additional transfixation wires or Schanz pins on the additional proximal rings to obtain two levels of fixation on each ring of the intact proximal shaft. Do not yet place olive wires through any area of comminution. n  Articular fixation is performed next. If ligamentotaxis was successful, stabilize the fracture by placing percutaneous olive wires across the major fragments in accordance with the preoperative CT data (Fig. 54.22A). This approach differs from techniques in which a standardized pattern of transfixation wire placement is used; in this technique, the transfixation wires are placed where the fracture patterns dictate. For coronal plane fractures, use cannulated screws to facilitate fixation of the wires. n  If ligamentotaxis was unsuccessful, an open approach is indicated. n  Based on the CT data, select an appropriate corridor and make a 4- to 6-cm incision, avoiding undermining any large cutaneous flaps. If the placement of the incision has been selected carefully, it should lead directly to the major fracture line. n  Minimal periosteal stripping is necessary, and the fracture line is opened like a book to reveal the joint. The impacted articular fragments also are visible because the joint is distracted. n  Use a small elevator to disimpact the articular surface and reduce it under direct vision. n  Use Kirschner wires to hold the fragments temporarily and apply any bone graft necessary to maintain the segment in position and fill any cancellous defects. Reduce the metaphyseal fragments and hold them with temporary Kirschner wire fixation. Use screws for de-

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C

B

D

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D

Tension the opposing olive wires symmetrically using two-wire tensioners. Perform this tensioning under fluoroscopic control to prevent asymmetric compression of the fracture lines. n  Attach the distal ring to the proximal rings with threaded rods with conical washers, allowing some variability in reducing and maintaining the overall mechanical axis. n  Use the ring at the level of proximal shaft extension to reduce proximal shaft comminution. Use olive or smooth wires to manipulate and maintain shaft alignment and to reduce any large fracture lines in this area. Attach these wires to the mid-distal ring and tension them under fluoroscopy so that the reduction can be observed. n  For AO type C injuries with extensive joint involvement and large areas of metaphyseal comminution, it is helpful to preconstruct a four-ring frame with an attached foot frame to maintain distraction at the ankle joint. The distraction construct can be as simple as a calcaneal pin or wire attached to a distal calcaneal ring or as extensive as a full foot frame attached to the distal tibial ring. n  Use a distraction frame similar to that described earlier and attach the proximal tibial rings first, providing appropriate soft-tissue clearance. n  Attach the foot frame or calcaneal pin and perform distraction ligamentotaxis across the ankle joint by adjusting the threaded rods. n  If ligamentotaxis reduction is inadequate, do an open procedure as described previously. n  When reduction is satisfactory, position the distal tibial ring at the level of the fracture; pass the fixation wires across the fracture fragments, attach them to the ring, and tension them as described earlier. The only difference in this technique is that the distal tibial ring is already attached to the frame and it is not necessary to “clamshell” the ring to place it around the wires.  n 

B

A

FIGURE 54.21 Fracture patterns found on CT scans of pilon fracture: anterolateral, posterolateral, anteromedial, or posteromedial fragments with central impaction or compression. Based on anatomically safe corridors, wires can be passed obliquely through safe zones A and D or B and C; wires cannot be passed safely directly from anterior to posterior. Safe zones A, B, C, and D correspond to incisions. (Redrawn from Watson JT: Tibial pilon fractures, Tech Orthop 11:150, 1996.)

finitive articular fixation of any coronal fracture lines. Alternatively, for most fracture lines, place olive wires percutaneously or directly through the incision to fix the fragments. n  At least three or four olive wires are necessary to obtain adequate fixation of the articular surfaces. If the distal tibial-fibular joint has been disrupted, use an olive wire to reduce the diastasis by passing the wire from the fibula across the tibia. If the fibula has not been plated, ensure that it is pulled out to its full length and that appropriate rotation is maintained before placing the tibia-fibula transfixation wire. Place the final wire, a transverse reference wire, just anterior to the fibula. Pass the wire only through the tibia to ensure that it is parallel to the joint, approximately 1 cm proximal to the ankle joint. Then “clamshell” the distal ring and place it around the wires, positioning the ring on the reference wire (Fig. 54.22B). This ensures that the knee and ankle joints are parallel when the distal and proximal rings have been connected. n  Attach the remainder of the wires to the free ring. Because the wires may not lie directly in apposition to the ring, build up to the ring by using various posts of different heights (Fig. 54.22C).

POSTOPERATIVE CARE In fractures with significant periarticular comminution or fragments with minimal soft-tissue attachment, Watson recommended maintaining distraction across the ankle for 6 weeks. When tentative healing has occurred at the joint line, the foot frame or calcaneal pin is removed in an outpatient procedure. Physical therapy is begun to increase range of motion and general strength. Total non–weight bearing is maintained in patients with severely comminuted (AO type C3) fractures. In fractures with shaft extension, tentative weight bearing is begun when early callus and some signs of healing are seen on radiographs, usually at 8 to 10 weeks. Progressive weight bearing is begun, and by 12 to 14 weeks the patient usually is ambulatory with the aid of one crutch or a cane.   

PRIMARY ARTHRODESIS

Primary arthrodesis has been suggested as a method of treating severely comminuted tibial pilon fractures. Several investigators have noted, however, that severe skeletal injury and

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B

C FIGURE 54.22 A, Fracture lines are reduced and compressed with multiple olive wires, based on preoperative CT data. B, Distal ring is “clam-shelled” and placed parallel to ankle joint. C, Posts of various heights are used to attach wires to ring. (From Watson JT: Tibial pilon fractures, Tech Orthop 11:150, 1996.) SEE TECHNIQUE 54.10.

nonanatomic reduction do not preclude a satisfactory clinical result. We recommend stabilization of these fractures with an external fixator to maintain alignment and allow bony consolidation. Arthrodesis can be done later if the patient is sufficiently symptomatic. Primary arthrodesis may be considered for severe open injuries with extensive loss of cartilage from the tibial and talar articular surfaces (Fig. 54.23). The wound is debrided, and the remaining cartilage is removed from the talus and tibia. An external fixator can be used to stabilize the fracture. Bone grafting may be necessary when the soft tissues have healed. 

FRACTURES OF THE TIBIAL SHAFT Fractures of the shaft of the tibia cannot be treated by following a simple set of rules. Because of its location, the tibia is exposed to frequent injury; it is the most commonly fractured long bone. Because one third of the tibial surface is subcutaneous throughout most of its length, open fractures are more common in the tibia than in any other major long bone. The blood supply to the tibia is more precarious than that of bones enclosed by heavy muscles. High-energy tibial fractures may be associated with compartment syndrome or neural or vascular injury. The presence of hinge joints at the knee and the

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Cross-table

A

B FIGURE 54.23 A, Comminuted fracture of tibial pilon after a fall from height. Patient had previous talar fracture resulting in posttraumatic arthritis of tibiotalar and subtalar articulations. B, Definitive management with primary tibiotalocalcaneal arthrodesis with retrograde intramedullary implant secondary to preexisting arthrosis.

ankle allows no adjustment for rotary deformity after fracture, and special care is necessary during reduction to correct such deformity. Delayed union, nonunion, and infection are relatively common complications of tibial shaft fractures. Evaluation of tibial fractures should include a detailed history and physical examination. The limb is inspected for open wounds and soft-tissue crush or contusion, and a thorough neurovascular examination is performed. A pulse deficit or neurologic deficit may be a sign of compartment syndrome or vascular injury, which must be identified and treated immediately. The ipsilateral femur, knee, ankle, and foot also must be examined. When the examination is completed, the limb is realigned gently and splinted. Appropriate tetanus and antibiotic prophylaxes are administered. Plain anteroposterior and lateral radiographs that include the knee and ankle are obtained. Oblique radiographic views at 45 degrees sometimes are required to detect a nondisplaced spiral fracture. Radiographs of the contralateral tibia sometimes are necessary to evaluate length in fractures with severe comminution or bone loss. The indications for operative and nonoperative treatment of tibial shaft fractures continue to be refined. Although commonly advocated in the past, nonoperative treatment now is generally reserved for closed, stable, isolated, minimally displaced fractures caused by low-energy trauma and some stable low-velocity gunshot fractures. Operative treatment is indicated for most tibial fractures caused by high-energy trauma. These fractures usually are unstable, comminuted, and associated with varying degrees of soft-tissue trauma. Operative treatment allows early motion, provides soft-tissue access, and avoids complications associated with immobilization. The goals of treatment are to obtain a healed, wellaligned fracture; pain-free weight bearing; and functional range of motion of the knee and ankle joints. The optimal

treatment method should assist in meeting these goals while minimizing complications, especially infection. These goals may not be attainable in severely injured limbs. Sarmiento, Nicoll, and others found that closed treatment with casting or functional bracing is an effective method of treatment for many tibial shaft fractures that avoids the potential complications of surgical intervention. For closed treatment to succeed, the cast or brace must maintain acceptable fracture alignment and the fracture pattern must allow early weight bearing to prevent delayed union or nonunion. Repeated attempts at manipulation should be avoided. If the fracture cannot be well aligned, an alternative method of treatment should be chosen. Axial or rotational malalignment and shortening cause cosmetic deformities and alter the loading characteristics in adjacent joints, which may hasten the development of posttraumatic arthritis. The amount of malalignment and shortening considered acceptable also is controversial. Distal tibial malalignment may be more poorly tolerated than more proximal malalignment. The recommendations in the literature vary widely: 4 to 10 degrees of varus-valgus malalignment, 5 to 20 degrees of anteroposterior malalignment, 5 to 20 degrees of rotatory malalignment, and 10 to 20 mm of shortening. In general, we strive to achieve less than 5 degrees of varus-valgus angulation, less than 10 degrees of anteroposterior angulation, less than 10 degrees of rotation, and less than 15 mm of shortening. Maintaining fracture alignment is difficult in certain fracture types, and if repeated attempts at realignment have been unsuccessful, operative fixation is indicated. The important factors in prognosis are (1) the amount of initial displacement, (2) the degree of comminution, (3) whether infection has developed, and (4) the severity of the soft-tissue injury excluding infection. Torsional fractures with or without simple comminution have been found to

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY have a better prognosis than high-energy patterns, such as short oblique or transverse fractures, with or without comminution. Torsional fractures tend to create a longitudinal tear of the periosteum and may not disrupt endosteal vessels, whereas transverse fractures usually tear the periosteum circumferentially and completely disrupt the endosteal circulation. Reduction is difficult in displaced spiral fractures of the distal third of the tibia. Hoaglund and States classified fractures of the tibia as being caused by either high-energy or low-energy trauma and found this classification useful in prognosis. Fractures in the high-energy group resulted from accidents such as motor vehicle collisions and crush injuries. This group included more than half the total fractures and 90% of the open fractures; fractures in this group healed in an average of 6 months. Fractures in the low-energy group resulted from accidents such as falls on ice and while skiing; these healed in an average of about 4 months. These researchers found that the level of fracture was not significant in the prognosis but that the amount of bony contact was. Fractures in which contact between the fragments after reduction was 50% to 90% of normal healed significantly faster than fractures in which contact was less. Displacement of more than 50% of the width of the tibia at the fracture site has been noted to be a significant cause of delayed union or nonunion. Fractures with more than 50% comminution are considered unstable and usually are associated with high-energy trauma and significant open or closed soft-tissue injury. The presence or absence of a fibular fracture does not influence the prognosis, although inhibited fracture healing of closed tibial fractures associated with intact fibulas treated with cast immobilization has been reported. Patient characteristics also can influence the success of closed treatment of tibial shaft fractures. Alignment can be difficult to maintain with casts or braces in patients with edematous or obese extremities. Loss of reduction may occur in noncompliant patients with closed treatment, whereas delayed union and nonunion are common in patients in whom weight bearing must be restricted for a prolonged time. An individual’s functional demands also must be considered when planning treatment. In comparative studies of intramedullary nailing and casting for the treatment of isolated closed tibial shaft fractures, intramedullary nailing has been found to achieve higher union rates and better functional scores. Although these studies show the superiority of intramedullary nailing over casting for closed unstable tibial shaft fractures, further comparative studies are necessary to confirm these results and establish more rigid treatment guidelines. Nicoll, an advocate of closed treatment, listed the following indications for internal fixation: (1) open fracture requiring complicated plastic surgery, (2) associated fracture of the femur and other major injuries, (3) paraplegia with sensory loss, (4) segmental fracture with displaced central fragments, and (5) gaps resulting from missing bone fragments. Internal fixation has been recommended for unstable, comminuted, or segmental fractures; bilateral tibial fractures; and ipsilateral femoral fractures. Operative treatment also currently is favored for open fractures, fractures with severe closed softtissue injury, fractures associated with compartment syndrome, fractures involving vascular injury, and fractures in patients with multiple trauma.

Fractures in which closed treatment is inappropriate can be treated with plate and screw fixation, intramedullary fixation (interlocking intramedullary nails), and external fixation. Locked intramedullary nailing currently is the preferred treatment for most tibial shaft fractures requiring operative fixation. Plating is used primarily for fractures at or proximal to the metaphyseal-diaphyseal junction. External fixation is useful for fractures with periarticular extension and for severe open fractures. In severely mangled extremities, amputation should be considered. For open high-energy tibial fractures, results of treatment have improved significantly because of important contributions made by large trauma services. Several factors are important for a good outcome in these fractures. Aggressive and repeated debridements of all devitalized tissue, including large fragments of bone, are essential. Because vascular soft tissue and bone are essential for resisting infection and providing a bed for reconstruction, Gustilo and others stressed the importance of leaving the wound open and repeating debridement every 24 to 48 hours until closure at 5 to 7 days by delayed primary closure, skin grafting, or skin flaps. Our protocol is repeat debridement and irrigation at 48 to 72 hours if there is evidence of continuing demarcation of the zone of injury. All Gustilo type III fractures routinely have repeat debridement. Antibiotics should be used routinely with open fractures. Aminoglycosides are added to cephalosporins for type III open fractures, and penicillin is included for fractures with severe contamination. Soft-tissue coverage by 5 to 7 days should be obtained by delayed closure, skin grafting, or flap coverage. Although there is no dispute that soft-tissue management is the most important factor in determining the outcome of open tibial fractures, the optimal method of fixation is debated. Sufficient stability of the fracture fragments and soft tissues usually can be obtained only by locked intramedullary nails or external fixation. Plate fixation has been associated with an unacceptably high incidence of infection. For Gustilo type I, type II, and type IIIA open fractures, most orthopaedic traumatologists prefer intramedullary nailing. Studies comparing unreamed nailing with external fixation have shown that tibial fractures treated with unreamed nailing required fewer additional operations and achieved better functional outcomes with fewer superficial infections than fractures treated with external fixation. Comparisons of reamed with unreamed nailing (two studies with 132 patients) have shown a reduced risk of reoperation with a reamed technique. Type IIIB open tibial fractures have been associated with a relatively high incidence of infection when treated with external fixation and with unreamed nailing. There are, however, specific open fractures for which acute intramedullary nailing is almost certainly not the best treatment option. Open fractures secondary to war injuries; fractures with severe contamination, especially involving the medullary canal; and type IIIC open tibial fractures, especially those in which limb salvage is questionable, all are potentially better treated with external fixation. The time to debridement for open tibial fractures has not been found to be predictive of infection; however, fracture severity has. Negative-pressure wound therapy is being used more frequently for open wound management, although similar infection and nonunion rates with negative-pressure

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS wound therapy compared with historical controls have been reported. We prefer intramedullary nailing for most open tibial fractures. Our protocol (Fig. 54.24) includes planning of postoperative management to decrease the frequency of delayed union and implant failure. With this protocol, union was obtained in 48 (96%) of 50 open tibial fractures. Additional procedures to promote union were done in 18 patients at an average of 4 months after injury. Mangled extremities are severe open fractures often associated with vascular injury or nerve disruption. Surgeons treating these injuries face the difficult decision of whether to attempt limb salvage or perform early amputation. Salvage often is technically possible but may result in disastrous medical, social, psychologic, and financial consequences for the patient. Complete anatomic disruption of the tibial nerve in adults and crush injuries with a warm ischemia time of more than 6 hours have been suggested as absolute indications for primary amputation; suggested relative indications include serious associated polytrauma, severe ipsilateral foot trauma, and a projected long course to full recovery. Other factors are the patient’s age, occupation, and medical condition; the mechanism of injury; fracture comminution; bone loss; the extent and location of neurologic and vascular injury; and the severity and duration of shock. Various authors have attempted to formulate scores predicting the likelihood of

salvage or amputation, but none has proved entirely accurate. In a long-term study of functional results and quality of life in patients with severe open tibial fractures treated with either salvage or amputation, recovery time and long-term disability were reduced with early below-knee amputation, while another study reported a high rate of preservation of a functional weight-bearing limb in patients with type IIIB open tibial fractures treated with aggressive wound management and early soft-tissue coverage. In an effort to resolve questions about the indications for limb salvage or amputation in a mangled extremity, the Lower Extremity Assessment Project (LEAP) study group was formed. In a multicenter, prospective, longitudinal study, the investigators identified risk factors that predisposed patients to poor outcomes in the salvage and amputee groups. Poor prognostic indicators were attributable to low educational level, income below poverty level, nonwhite racial background, lack of insurance, poor social support network, smoking, and pending legal action. Patients with salvaged limbs without risk factors for poor outcomes had results equivalent to the results of amputees at 2 and 7 years but required more surgical procedures and more rehospitalizations. Patients with tibial nerve injury and insensate feet had substantial impairment at 12 and 24 months; however, outcomes were no different in patients with amputated or salvaged limbs. The LEAP study group also found that muscle injury, absence of sensation, arterial injury, and vein injury

Initial fracture 50% comminution

50% comminution

Diaphyseal

Metaphyseal

Dynamic lock

Static lock

50% bone loss Static lock

Static lock

6 weeks, bone graft If ununited at 4-6 months, exchange nailing

3-4 months*

Minimal callus

Progressing to union

Diaphyseal

Observe

Metaphyseal Exchange nailing

6 months United

Axially stable

6 months Ununited

Not axially stable Exchange nailing

Exchange nailing

If static locked, dynamize

Ununited

Ununited Bone graft

Exchange nailing

FIGURE 54.24 Protocol for initial unreamed nailing and postoperative treatment of open tibial fractures. *Bone graft may be indicated at 6 weeks in type IIIB open fractures. (From Whittle AP: Clinical results of unreamed nailing of tibial and femoral fractures, Tech Orthop 11:67, 1996.)

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Ununited Bone graft

United United

United

If dynamic locked, exchange nailing

CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY were factors that had the greatest impact on the surgeon’s decision to amputate or salvage the extremity. However, the group of patients with insensate limbs recovered intact sensation in 67%, questioning insensibility as an absolute indication for amputation.

TREATMENT

CAST BRACING

The use of a short cast or functional brace for treatment of a tibial shaft fracture resulted in a 97% union rate in a study by Sarmiento et al. The incidence of nonunion ranged from 0% to 13%. Sarmiento narrowed his indications for bracing to closed fractures and low-energy open fractures. Other studies all resulted in recommendations for some type of closed treatment. Although good functional results without deformity have been reported in more than 95% of patients, the immobilization required with closed treatment may adversely affect ankle motion. Ankle stiffness has been reported in 20% to 30% of patients who had closed treatment. Angular deformity of more than 5 degrees occurs in 10% to 55% of fractures treated with a cast or brace, and shortening of at least 12 to 14 mm occurs in 5% to 27% of patients. Sarmiento’s series of carefully selected fractures had the best results, whereas series with more unstable fractures reported poorer results. Loss of reduction requiring operative treatment has been reported in 2.4% to 9.3% of patients in several larger series. Anatomic reduction and rigid immobilization are highly advantageous to the healing of a fracture, but not at the risk of infection and delayed union. The closed, early weight-bearing method of treatment often concedes minor complications in favor of a predictably high union rate and no major complications. It is a method applicable to many types of tibial shaft fractures, but it requires a good deal of patience and time from the physician and a cooperative patient. We prefer casting for minimally displaced, stable, low-energy tibial fractures. 

PLATE AND SCREW FIXATION

Plate fixation has been recommended for treatment of tibial fractures that are unsuitable for nonoperative management historically. Open reduction and plating provide stable fixation, allow early motion of the knee and ankle, and maintain length and alignment. The greatest disadvantage of plating is that it requires soft-tissue stripping, which can lead to wound complications and infection. Before the 1960s, plating of open and closed tibial fractures often was complicated by delayed union, nonunion, implant failure, soft-tissue sloughing, and infection, especially if performed within the first week after injury. The AO group subsequently developed compression plating techniques and implants that remain in use today. Good functional results were reported in 98% of closed fractures with a 6% complication rate, and 90% good results in open fractures; these had, however, a 30% complication rate. A significant increase in complications was noted in progressively higher-energy fractures that were treated by ORIF, and complications increased from 9.5% for torsional fractures to 48.3% for comminuted fractures. Likewise, increased infection rates from 2.1% for torsional fractures to 10.3% for comminuted fractures were noted. Also, nonunion was twice as common and infection five times more likely when open fractures were treated with plating.

Other investigators also have reported increased complications when plating open tibial fractures (infections 1.9% in closed fractures and 7.1% in open fractures; implant failure 0.6% in closed fractures and 10.3% in open fractures). Most authors now recommend plating for tibial shaft fractures associated with displaced intraarticular fractures of the knee and ankle. Refinements in plating and indirect reduction should be used when plating extended shaft fractures, and soft-tissue handling should be meticulous. In an effort to decrease the frequency of delayed union, nonunion, and infection after tibial shaft fractures, “percutaneous” plating was developed to obtain stable fixation while preserving the fracture environment. This technique involves plating of any associated fibular fracture, prebending a 3.5-mm dynamic compression plate to match the tibial anatomy, and placing the plate and screws through small incisions. Current indications for percutaneous plating are (1) a tibial shaft fracture with periarticular metaphyseal comminution that precludes locked intramedullary nailing and (2) a tibial fracture that cannot be treated with intramedullary fixation because of a preexisting implant, such as a tibial base plate from a total knee arthroplasty. Percutaneous plating is technically challenging, and malalignment is more frequent than with other methods of fixation. 

TRANSFIXATION BY SCREWS

Lag screws can be used for fixation of long oblique (more than three shaft diameters) or spiral fractures that extend into the metaphysis, although these fractures more commonly are treated using other methods. These evenly placed lag screws are oriented perpendicular to the fracture and are placed away from narrow fracture ends. This technique may be useful to supplement external fixation in open fractures by stabilizing large butterfly fragments to one of the principal fragments. Furthermore, we have found this technique useful for open fractures with short periarticular segments that are difficult to control with external fixation alone before definitive fixation (Fig. 54.25). 

INTRAMEDULLARY FIXATION

Locked intramedullary nailing currently is considered the treatment of choice for most type I, type II, and type IIIA open and closed tibial shaft fractures (Fig. 54.26) and is especially useful for segmental and bilateral tibial fractures. Busse et al. polled orthopaedic trauma surgeons with regard to management of tibial fractures. Eighty percent preferred operative treatment for closed fractures. Intramedullary nailing preserves the soft-tissue sleeve around the fracture site and allows early motion of the adjacent joints. The ability to lock the nails proximally and distally provides control of length, alignment, and rotation in unstable fractures and permits stabilization of fractures located below the tibial tubercle or 3 to 4 cm proximal to the ankle joint. Nailing is not recommended in patients with open physes, anatomic deformity, or burns or wounds over the entry portal. Küntscher developed his V-shaped and cloverleaf nails in the 1930s, but it was not until nearly 50 years later that rigid intramedullary nailing became a widely accepted treatment for tibial shaft fractures, with 98% good results in closed fractures and in 97.5% of open fractures treated with unreamed straight Küntscher nails. Herzog modified the straight Küntscher nail to accommodate the eccentric proximal portal. Some authors proposed reaming of the medullary canal

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A

C

B

FIGURE 54.25 A, Patient with medially open extraarticular distal tibia and fibular fractures. B and C, At time of uniplanar external fixation application, coronal plane stability was difficult to control and resulted in continued soft-tissue endangerment from displaced underlying tibial metaphyseal spike. Anatomic reduction of tibia and interfragmentary lag screw fixation as temporizing measure to provide stability as adjunct to external fixator.

rate; 2.2% complication rate), especially in closed fractures, but some authors have cautioned against their use in the dynamic or simple unlocked mode, noting that most complications in their series occurred with dynamic locked nails; they also did not recommend routine dynamization.

REAMED VERSUS UNREAMED NAILING

FIGURE 54.26 lary nail.

Open tibial fracture stabilized with intramedul-

to improve the fit of the nail and to increase its rotational control and strength. Biomechanical data suggest substantial improvement in fracture site mobility when increasing to a larger diameter implant. In the 1970s, Grosse and Kempf and Klemm and Schellmann developed nails with interlocking screws, which expanded the indications for nailing to include more proximal, distal, and unstable fractures. Reports of interlocking nails inserted with reaming showed good results (97% union

Studies published in the 1970s and 1980s reported unacceptably high infection rates (13.6% to 33%) in small series of open tibial fractures treated with reamed nailing. These reports led to the conclusion that medullary reaming is contraindicated in open tibial fractures, especially Gustilo type II and type III. Studies of open tibial fractures treated with unreamed Ender pins and Lottes nails during the same time period reported infection rates of 6% to 7%. Animal experiments showed that insertion of reamed nails disturbs cortical blood flow to a greater extent than insertion of unreamed nails, possibly increasing susceptibility to infection. These factors led to the development of interlocking intramedullary nails suitable for unreamed insertion. In our series of 50 unreamed tibial nailings of three type I, 13 type II, and 34 type III (11 type IIIA and six type IIIB) open fractures, there were four infections, all in type III fractures. Two infections occurred in type IIIB fractures after failure of initial rotational or free flaps. One infection in a type IIIA open fracture developed at 10 months, immediately after bone grafting of a bone defect. All infections resolved with no chronic osteomyelitis. This series and subsequent studies reported union in 96% to 100% of fractures, infection in 2% to 13%, nail failure in 0% to 6%, screw failure in 6% to 41%, and secondary surgery to achieve union in 35% to 48%. Implant failure most often is associated with smaller (8 mm) nails, axially unstable fractures, metaphyseal fractures, delayed union or nonunion, open fracture, and severe

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY comminution. Nail failure may require additional surgery. In one study, failure occurred most often at the transverse proximal locking screw when a single screw was used. Fractures in the distal third of the tibia had the highest frequency of nail breakage. Problems with delayed union and implant failure with the smaller implants used in unreamed nailing have led some investigators to return to the use of reamed nailing in open tibial fractures. Using perioperative antibiotics and modern techniques of wound closure, infection rates have been reported to be 1.8% of type I, 3.8% of type II, and 9.5% of type III open tibial fractures (5.15% in type IIIA and 12.5% in type IIIB) treated with reamed nailing. These results are similar to the results obtained with unreamed locked tibial nails. A randomized, prospective study comparing reamed with unreamed locked nailing of open tibial fractures found no statistically significant difference in the results of treatment of open tibial fractures with reamed nailing and with unreamed nailing except for the higher incidence of screw failure in the unreamed nailings. Other investigators still caution against reamed nailing in open tibial fractures, especially high-grade open fractures, reporting a 21% occurrence of deep infection in type I and type II fractures treated with reamed nailing. The severity of soft-tissue injury and adequacy of debridement and soft-tissue coverage are more important in the prevention of infection than is the type of implant used. Currently, most orthopaedic traumatologists in North America accept the use of reamed nails in type I and type II open fractures; however, the use of reamed nailing in type III open fractures is controversial. The successful use of unreamed nailing in patients with open tibial fractures has led some investigators to recommend this technique for closed fractures as well. Potential advantages of unreamed nailing over the reamed technique include shorter operative time, less blood loss, and less disruption of the endosteal blood supply in patients with severe closed soft-tissue injuries. No significant differences have been found in outcomes and complications between reamed and unreamed nailing of closed tibial shaft fractures. However, a trend toward improved union has been noted with reamed nailing. In one study, significantly more screws failed in unreamed than reamed nails. These and other studies seem to indicate that fracture and softtissue characteristics are more important in determining fracture outcome than the choice of treatment, and reamed nailing is recommended for most closed unstable tibial shaft fractures. A meta-analysis showed a decreased nonunion rate with reamed intramedullary nailings for closed injuries. Furthermore, the results of the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) illustrate a possible benefit to reaming when compared with unreamed devices. In addition, it also found that delaying reoperation until at least 6 months may decrease the need for secondary interventions for fractures of the tibia. Lefaivre et  al. evaluated long-term (median 14 years) functional outcomes after intramedullary tibial nailing. They found outcome measures comparable to the normal population, but with some insignificant sequelae still present. 

INTRAMEDULLARY NAILING OF FRACTURES OF THE PROXIMAL THIRD OF THE TIBIAL SHAFT

The enthusiasm for locked nailing of tibial shaft fractures has led some surgeons to expand the indications to include

A

B

FIGURE 54.27 A and B, Proximal tibial fracture treated with intramedullary nailing and lateral plate.

more proximal and distal fractures. Malalignment is a common problem in proximal-third fractures treated with locked nails because of the large discrepancy in size between the tibial nail and the wide tibial metaphysis. Valgus angulation and anterior displacement of the proximal fragment are the most common deformities. Valgus deformity can be caused by a portal that starts too far medially and is directed laterally. A medial parapatellar incision and impingement from the patella may cause a portal to be directed in this manner. A biomechanical study found that medial to lateral screws in one plane can allow the nail to slide on the screws. Apex anterior angulation or anterior displacement can be caused by a portal that starts too distally or is directed too posteriorly. A proximal bend that is at or below the fracture site can cause anterior translation of the proximal fragment when the nail wedges against the cortex. Locking the nail proximally with the knee flexed causes extension of the proximal fragment owing to the pull of the patellar tendon. Refinements in technique, including more precise placement of the entry portal and the use of some form of supplemental fixation such as blocking screws, unicortical plates (Fig. 54.27), and two-pin medial external fixation, have greatly reduced the frequency of this complication. Some proximal-third tibial fractures can best be treated by other methods. Bono et al. developed an algorithm that is helpful in treatment decision-making (Fig. 54.28). Tornetta et  al. described a technique of nailing with the knee in a semiextended position with a medial parapatellar arthrotomy to mitigate against extension deformity of the proximal fragment. The technique was later revised to include a smaller superomedial incision, which is facilitated by newly available instrumentation permitting this application in a more percutaneous manner. Investigations are ongoing with regard to this technique’s effect on the patellofemoral articulation. A 22% trochlear articular damage rate has been reported

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Proximal tibia fracture

Minimal soft-tissue injury

Stable fracture

Severe soft-tissue injury

Unstable fracture

Longleg cast

Short proximal fragment

Long proximal fragment

Loss of reduction

External fixation (preferred) or plate fixation

Intramedullary nailing (preferred) or external fixation or plate fixation

Open fracture, compartment syndrome, vascular repair

Closed fracture, no limb-threatening condition

Emergency stabilization

Emergency stabilization

Short proximal fragment

Long proximal fragment

Short proximal fragment

Spanning external fixator

If nail portal intact, external fixation or immediate intramedullary nailing

Bulky dressing, splint, and observation or spanning external fixator (for very unstable fractures)

Soft tissue healed, bone covered

External fixation or unilateral plate fixation or composite fixation

Swelling decreased, blisters resolved

FIGURE 54.28 Treatment algorithm for proximal tibial fractures with minimal or severe softtissue injury. (From Bono CM, Levine RG, Rao JP, Behrens FF: Nonarticular proximal tibia fractures: treatment options and decision making, J Am Acad Orthop Surg 9:176, 2001.)

in one study after the semiextended nailing; however, these patients were early in the series and results were attributed to errors in technique. In a recent cadaver investigation, patellofemoral contact pressures were examined and found to be higher in the suprapatellar portal compared with traditional approaches. The authors thought the pressure exerted was below that necessary for cartilage damage and therefore concluded that the surgical approach is viable. Further investigation is necessary to determine the long-term functional implications for the patellofemoral joint. Data continue to emerge regarding this technique. Sanders et  al. recently reported a series of 55 patients who underwent tibial nailing through a semiextended approach with a suprapatellar portal. Radiographic and clinical follow-up were performed at a minimum of 12 months postoperatively including follow-up arthroscopy and MRI. The authors concluded that this technique results in no significant differences in pain, disability, or knee range of motion after 12 months of follow-up when compared to infrapatellar nailing. A recent meta-analysis found no superiority of the semi-extended technique compared to the intra-patellar technique with regard to functional and knee pain outcomes.

Currently, we use this technique for most difficult proximal third fractures. The technique has several advantages beyond reduction of proximal tibial fractures. It likely lessens the need for supplementary reduction aids, such as blocking screws, and the intraoperative radiographs are significantly easier to obtain. 

INTRAMEDULLARY NAILING OF FRACTURES OF THE DISTAL TIBIAL SHAFT

Intramedullary nailing of more distal fractures is possible, but the ability to maintain a mechanically stable reduction becomes more difficult the farther the fracture extends distally. Two distinct fracture patterns have been identified. Direct bending forces produce simple transverse and oblique tibial fractures with same-level fibular fractures and no intraarticular extension, but soft-tissue injury is more severe. Torsional forces cause spiral fractures, usually with differentlevel fibular fracture and frequent intraarticular involvement of either the medial or the posterior malleolus. One must also be cognizant of the potential for distal fracture extension to the tibial plafond or associated ankle pathology. Stuermer and Stuermer identified that in the presence of certain injury

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY markers, namely, pronation-eversion mechanisms, spiral fractures, proximal fibular fractures, or an intact fibula, associated ankle injuries were diagnosed in 20.1% of patients. We typically recommend a CT scan for distal fractures with radiographic evidence or concern about distal intraarticular extension. Two distal locking screws are required to prevent recurvatum deformity from rotation around a single distal locking screw. Cancellous lag screws can be used to stabilize medial and posterior malleolar fractures. Open reduction is done if there is intraarticular displacement. The fibula is plated if necessary for the stability of the ankle joint or if it is severely displaced. Distal fibular fixation can be useful in very distal fractures to facilitate alignment of the tibia. Although not advocated by Robinson et al., some investigators believe that plating same-level fibular fractures helps prevent malalignment in distal tibial fractures treated with intramedullary nailing. We analyzed the influence of fibular fractures on maintaining alignment in 40 distalfourth tibial fractures treated with locked intramedullary nailing. The five tibial fractures with intact fibulas and four fractures with fibular fixation all healed in anatomic alignment. All 11 unfixed fibular fractures located at levels different from the tibial fracture were in anatomic alignment, whereas 12 (60%) of 20 unfixed fibular fractures occurring at the same level as the tibial fracture were malaligned. This study suggests that internal fixation of some fibular fractures improves stability in distal-fourth tibial fractures treated with intramedullary nailing. For transverse fractures of the fibula, we prefer a medullary device if fixation is deemed necessary. Overall union rates of 96% have been reported after reamed nailing of distal tibial fractures. A biomechanical study determined that the fixation strength achieved in fractures 4 cm from the tibiotalar joint with a shortened nail (1 cm removed) was comparable with that of standard intramedullary nailing of fractures 5 cm from the joint. They cautioned, however, in neither construct was fixation strong enough to resist moderate compression-bending loads and that patients with distal tibial fractures treated with intramedullary nailing must follow weight-bearing restrictions until significant fracture healing occurs to prevent coronal plane malalignment. It is clear that intramedullary nail fixation of distal tibial fractures is challenging. Newer implant designs with tighter distal screw clusters have facilitated treatment of these injuries without need for implant modification. Vallier et al. investigated the factors influencing outcomes after distal tibial shaft fractures in 104 patients. Functional testing identified residual dysfunction when compared with the uninjured population. Mild pain was noted but was not typically limiting. No patients reported unemployment as a result of their fracture. The same investigators reported a prospective comparison of plate with intramedullary nail fixation for distal tibial fractures. In their series, intramedullary nailing was associated with more malalignment. 

ANTERIOR KNEE PAIN AFTER INTRAMEDULLARY NAILING

Anterior knee pain is the most commonly reported complication after intramedullary nailing of the tibia. Historically, 56% of patients have some degree of chronic knee pain and have difficulty kneeling. The cause of this knee pain is still unclear.

Suggested contributing factors include younger, more active patients, nail prominence above the proximal tibial cortex, meniscal tear, unrecognized articular injury, increased contact pressure in the patellofemoral articulation, damage to the infrapatellar nerve, and surgically induced scar formation. Some authors have suggested that a transpatellar approach is associated with more frequent anterior knee pain than is a medial paratendinous approach, although others disagree. Investigations have shown no difference in anterior knee pain whether a transtendinous or paratendinous surgical approach was used. Anterior knee pain improves with time, yet quadriceps weakness and lower functional knee scores correlated with knee pain in the long term. In an effort to circumvent this issue, semiextended nailing techniques have been advocated, but have yet to demonstrate clear benefit with regard to anterior knee pain. 

INTRAMEDULLARY INTERLOCKING NAILS

Currently, a variety of interlocking tibial nails are available. Most can be inserted using a reamed or unreamed technique. There are differences in nail composition (stainless steel, titanium) and location of the proximal bend. Some nails have medially to laterally directed locking screws, and others have additional proximal oblique screw holes and anteroposterior distal screw holes. Nails with more distally placed distal locking screws improve the ability to treat very distal tibial fractures. The surgeon should be familiar with the strengths and limitations of the various nailing systems to choose the appropriate implant for a specific fracture. All unstable fractures should be locked with two screws distally and two proximally to maintain length and prevent rotation. We routinely statically lock most fractures. A proximal drill guide allows accurate nail insertion and placement of the proximal screws, whereas distal fixation is typically performed free-hand. 

PREOPERATIVE PLANNING

Preoperative radiographs of the uninjured tibia can be used to establish the proper nail diameter, the expected amount of reaming, and the final nail length for severely comminuted fractures. (Radiographic templates are available for preoperative planning.) The nail length should permit the proximal end to be countersunk with the distal end centered in the distal epiphysis. Diaphyseal fractures must be slightly distracted with traction before closed antegrade medullary nailing. Further impaction occasionally occurs when severely comminuted fractures are later dynamized. This risk should be considered during the selection of nail length to prevent later nail migration into the ankle or nail protrusion out of the proximal tibia. Measurement is especially important for very tall or very short patients who may require a nail either longer or shorter than is commonly kept in inventory. Colen and Prieskorn found that the most accurate method for determining correct nail length of four methods tested (full-length scanograms, “spotograms,” acrylic template overlays, and tibial tubercle-medial malleolar distance [TMD]) was the TMD. The TMD is determined by measuring the length between the highest (most prominent) points on the medial malleolus and the tibial tubercle. Eleven of 14 nails selected by scanograms were incorrect, 6 of 14 selected by spotograms were incorrect, and 14 of 14 selected by templates were too small. TMD correctly selected 10 of 14 nail lengths. The

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS authors suggested that the TMD is an easy, inexpensive, and accurate method of preoperative determination of correct nail length. The diameter of the nail is assessed by measuring the tibia at its narrowest point, which is best appreciated on lateral radiographs. The decision to insert the nail with or without reaming should be made preoperatively. “Reamed” and “unreamed” refer to technique, rather than implants. Unreamed nail insertion usually requires nails with diameters ranging from 8 to 10 mm, depending on canal diameter, and cannot be used in patients with medullary canals narrower than 8 mm. Reaming allows insertion of stronger implants with larger diameters. We recommend reamed nail insertion for fractures, open or closed, with minor soft-tissue injury and only consider the unreamed nail technique for fractures with more extensive soft-tissue injury. Nailing can be done using either a fracture table or a standard radiolucent operating table. A fracture table may be preferable if a skilled assistant is unavailable or if the fracture is not nailed acutely. Disadvantages of a fracture table include the longer time required for patient positioning, increased risk of nerve injury from traction or pressure on the posterior thigh from the crossbar, and the possibility of elevation of compartment pressures with prolonged traction. Multiple injuries are more easily treated on a standard operating table. Other advantages of the standard operating table include lower risk of iatrogenic nerve injury and greater flexibility in manipulating the fracture site and changing position of the extremity as needed. Without skeletal traction, however, fracture reduction is more difficult to maintain, and an assistant is needed to help stabilize the limb. We prefer a standard radiolucent table with the limb positioned over a bolster. 

 

INTRAMEDULLARY NAILING OF TIBIAL SHAFT FRACTURES TECHNIQUE 54.11 Fracture Table If a fracture table is used, place a calcaneal traction pin before positioning. Place the patient supine with the hip flexed 45 degrees and the knee flexed 90 degrees (Fig. 54.29). n  Place a well-padded crossbar proximal to the popliteal fossa to support the thigh in the flexed position. Adequate padding should reduce the risk of compression neuropathy. n  Attach the calcaneal pin to the traction apparatus on the fracture table, apply traction, and reduce the fracture under fluoroscopic guidance. n  To decrease the risk of traction injury to neurologic structures, release the traction after the ability to reduce the fracture has been confirmed. n  Prepare and drape the limb, allowing full exposure of the knee to above the patella and enough access to the distal tibia for locking screw placement. Reapply traction after the entry portal is made.  n 

FIGURE 54.29 Patient is positioned supine, and traction is applied through calcaneal traction pin or special foot holder. SEE TECHNIQUE 54.11.

Standard Operating Table If a standard operating table is used, place the patient supine with the thigh supported in a flexed position over a padded bolster. n  A skilled assistant is needed to assist with fracture reduction and help support the limb during the procedure. n  A femoral distractor or two-pin external fixator can be used to help maintain reduction. Place a Schanz pin 1 cm distal to the knee joint and place a second pin 1 cm proximal to the ankle joint. The proximal pin must be placed in the posterior portion of the tibial condyle to avoid the path of the nail.  n 

Measurement of Rotation Before nailing, measure rotation by the method described by Clementz. Measure the amount of tibial torsion in the uninjured extremity with the knee fully extended and a C-arm image intensifier placed in the lateral position with the beam parallel to the floor. n  Rotate the leg until a perfect lateral view of the distal femur is obtained with the condyles superimposed exactly. Hold the knee and foot in this position while the C-arm is brought into the anteroposterior position with the beam perpendicular to the floor to image the ankle. n  Rotate the C-arm until a tangential image of the inner surface of the medial malleolus is seen. This is the reference line at the ankle. n  Tilt the beam cranially 5 degrees to obtain a better image of the ankle. Center the structures to be imaged in the radiographic field. n  The amount of tibial torsion is equal to the difference between the reference line at the ankle and a line perpendicular to the floor. If the tangential view of the medial malleolus is obtained with the C-arm rotated laterally 10 degrees from perpendicular, tibial torsion is 10 degrees. n  Alternatively, obtain rotational alignment by aligning the iliac crest, patella, and second ray of the foot. n  Close attention to operative technique can greatly decrease the risk of complications after tibial nailing.  n 

Nail Placement Begin the entry portal by making a 3-cm incision along the medial border of the patellar tendon, extending from the tibial tubercle in a proximal direction. It may be necessary to extend the incision farther proximally through skin and subcutaneous tissue only to protect the soft tissues around the knee during reaming and nail insertion. n  Insert a threaded tip guidewire through the metaphysis anteriorly to gain access to the medullary canal (Fig. 54.30). With the appropriate soft-tissue sleeve, advance n 

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY the guidewire into the correct starting portal as noted on multiplanar imaging. This typically is located along the medial slope of the lateral tibial eminence on the anteroposterior view and just anterior to the articular margin on lateral imaging. n  Confirm the proper position on anteroposterior and lateral fluoroscopic views before guidewire insertion. Obtain a true anteroposterior view of the tibia when assessing the placement of the guidewire. If the limb is externally rotated, the portal may be placed too medially and violate the tibial plateau and injure the intermeniscal ligament. A portal placed too distally may damage the insertion of the patellar tendon or cause the nail to enter the tibia at too steep of an angle, which may cause the tibia to split or cause the nail to penetrate the posterior cortex. Check the process of insertion on lateral fluoroscopic views. The safe zone for tibial nail placement is just medial to the lateral tibial spine on the anteroposterior view and immediately adjacent and anterior to the articular surface on the lateral view. n  Direct the guidewire to a position nearly parallel to the shaft as it is inserted more deeply to prevent violation of the posterior cortex. Once appropriate provisional guidewire trajectory is achieved, create the entry portal with the cannulated entry reamer with matching soft-tissue protection sleeve. Alternatively, the starting portal can be created with a cannulated curved awl. n  Insert a ball-tipped guidewire through the entry portal into the tibial canal and pass it across the fracture site into the tibia under fluoroscopic guidance (Fig. 54.31). The guide rod should be centered and slightly lateral within the distal fragment on anteroposterior and central lateral views and advanced to within 1.0 to 0.5 cm of the ankle joint. n  If a reamed technique is chosen, ream the canal in 0.5mm increments, starting with a reamer smaller than the measured diameter of the tibial canal (Fig. 54.32). Ream with the knee in flexion to avoid excessive reaming of the anterior cortex. Hold the fracture reduced during reaming to decrease the risk of iatrogenic comminution. Prevent the guide rod from being partially withdrawn during reaming. We prefer “minimal” reaming, with no more than 2 mm of reaming after cortical contact (“chatter”) is first initiated. Newer larger diameter end-cutting reamers simplify the medullary preparation. It is advised to ream with the tourniquet deflated because its use may lead to thermal necrosis of bone and soft tissue. n  Choose a nail diameter that is 1.0 to 1.5 mm smaller than the last reamer used. Ream the entry site large enough to accept the proximal diameter of the chosen nail. n  Do not undersize the nail because a loose-fitting nail would be less stable and the smaller implants are not as strong and may be more prone to implant failure. In general, the largest implant suitable for a given patient should be used. n  When reaming is completed, determine the length of the nail by using the system-specific depth gauge to accurately determine the necessary implant length. Alternatively, place the tip of a guidewire of the same length at the most distal edge of the entry portal. Subtract the length of the overlapped portions of the guide rods from the full length of the guide rod to determine the length of the

nail, making sure the fracture is held out to length during this measurement. Comminuted fractures may require preoperative radiographic measurement of the contralateral tibia to assess length properly. n  Attach the insertion device and proximal locking screw guide to the nail. Direct the apex of the proximal bend in the nail posteriorly. Some nail systems use oblique proximal locking screws, which are directed anteromedial to posterolateral and anterolateral to posteromedial. Insert the nail with the knee in flexion (except in some proximal third fractures) to avoid impingement on the patella. Evaluate rotational alignment by aligning the iliac crest, patella, and second ray of the foot. This is imperative for not only fracture alignment but also the rotation of the implant in relation to the limb. This ensures that the interlocking holes remain in their intended orientation and that the sagittal bend of the nail does not induce deformity. Tremendous force should not be necessary to insert the nail. Moderate manual pressure with a gentle backand-forth twisting motion usually is sufficient for nail insertion. If a mallet is used, the nail should advance with each blow. If the nail does not advance, withdraw the nail and perform further reaming or insert a smaller diameter nail. It is important to keep the fracture well aligned during nail insertion to prevent iatrogenic comminution and malalignment. n  When the nail has passed well into the distal fragment, remove the guidewire to avoid incarceration; and during final seating of the nail, release traction to allow impaction of the fracture. Do not shorten fractures excessively with segmental comminution. When the nail is fully inserted, the proximal end should lie 0.5 to 1.0 cm below the cortical opening of the entry portal. This position is best seen on a lateral fluoroscopic view. If the nail protrudes too far proximally, knee pain and difficulty with kneeling may result. Excessive countersinking also should be avoided because it makes nail removal more difficult. The distal tip of the nail should lie 0.5 to 2.0 cm from the subchondral bone of the ankle joint. Distal fractures require nail insertion near the more distal end of this range. If compression of the fracture is planned, the nail should be appropriately countersunk to prevent prominence once the fracture is compressed. n  Insert proximal locking screws using the jig attached to the nail insertion device. Place the drill sleeve through a small incision down to bone. Measure the length of the screw from calibrations on the drill bit. The number of interlocking screws is dependent on fracture characteristics. Tighten all connections between the insertion device, drill guide, and nail before screw insertion. n  Perform distal locking by using a freehand technique after “perfect circles” are obtained by fluoroscopy. In the lateral position, adjust the fluoroscopic beam until it is directed straight through the distal screw holes and the holes appear perfectly round. n  Place a drill bit through a small incision overlying the hole and center the tip in the hole. Taking care not to move the location of the tip, bring the drill bit in line with the fluoroscopic beam and drill through the near (medial) cortex. Detach the drill from the bit and check the position of the drill bit with fluoroscopy to ensure that it is passing through the screw hole. When proper position is confirmed, drive the drill bit through the far (lateral) cortex.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Measure the screw length using drill sleeves and calibrated bits or check the anteroposterior view on the fluoroscopy screen, using the known diameter of the nail as a reference for length, or a system-specific depth gauge. n  After screw insertion, obtain a lateral image to ensure the screws have been inserted through the screw holes. Two distal locking screws are used in most fractures. n  Some nail systems have the option of placing an anteroposterior distal locking screw. “Perfect circles” are obtained in the anteroposterior fluoroscopic view. Do not injure the anterior tibial tendon or extensor hallucis longus or nearby neurovascular structures. Meticulous attention to technique can minimize complications from anteroposterior distal interlocking. Careful soft-tissue protection and retraction both during drilling and screw insertion are critical to prevent soft-tissue injury or tethering as the screw head engages anterior tibial cortex. A drill sleeve can be valuable for protection of the associated soft tissues during this portion of the procedure. n  Before interlocking, inspect the fracture site for possible distraction. If the fracture is distracted, place the distal locking screws first. Some intramedullary implants now have the capability to provide axial compression, for properly selected fracture patterns, during the process of interlocking. n  After distal locking is complete, impact the fracture by carefully driving the nail backward while watching the fracture site under fluoroscopy. Keep the knee flexed until the nail insertion instruments are removed to avoid damage to the soft tissues around the patella. n  Most nails are statically locked. Minimally comminuted transverse diaphyseal fractures can be dynamically locked; however, comminuted or metaphyseal fractures should be statically locked. If there is any question about stability, perform static locking. Because the nail may not prevent malalignment of unstable fractures before it is locked, it is crucial to maintain accurate reduction until proximal and distal locking is complete. n  Modifications in technique have decreased the incidence of malalignment in proximal-third fractures. The reduction can be manipulated more freely if nailing is not done on a fracture table. n  To prevent valgus, start the entry portal in line with the lateral intercondylar eminence and center it on the medullary canal on the anteroposterior fluoroscopic image. An incision lateral to the patellar tendon can be used. n  To prevent anterior angulation and displacement, move the portal more proximally and posteriorly and direct it more vertically in a line more parallel with the anterior tibial cortex. Interlocking the nail proximally with the knee extended relaxes the pull of the patellar tendon and prevents anterior angulation. Many nail systems require removal of the insertion jig, however, to extend the knee to avoid impingement on soft tissues. n  Tornetta et al. recommended nailing proximal-third tibial fractures in a semiextended position (15 degrees of flexion) using two thirds of a medial parapatellar arthrotomy to retract the patella laterally. This technique prevents the patella from causing the portal to be angled from medial to lateral and allows proximal interlocking to be performed with the knee extended. Using a nail with a more proximally located bend decreases the risk of ante n 

FIGURE 54.30 Opening of medullary canal with curved awl. SEE TECHNIQUE 54.11.

FIGURE 54.31 Reduction of fracture with guide rod. SEE TECHNIQUE 54.11.

FIGURE 54.32 Reaming of tibia in 0.5-mm increments, using cannulated reamers over guide rod. SEE TECHNIQUE 54.11.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY rior displacement of the proximal fragment. A nail with proximal locking screws oriented obliquely at 90 degrees to each other provides more resistance to varus-valgus angulation than one-plane, medial-to-lateral screws. Semiextended nailing through a suprapatellar portal also has been described and is gaining in popularity. In this technique, a midline incision is created approximately two fingerbreadths proximal to the superior pole of the patella. The quadriceps mechanism is divided sharply in line with its fibers. It is critical to use suprapatellar specific instrumentation to provide protection to the patellofemoral joint. The cannula and trocar are inserted atraumatically in a retropatellar fashion, allowing the femoral trochlea to act as a guide to positioning the instrumentation in line with the medullary canal. The guide pin placement, medullary reaming, and nail insertion can then proceed as previously described. n  In contrast to diaphyseal fractures, the nail does not “automatically” reduce the fracture because it is inserted through the wide tibial metaphysis. Accurate fracture reduction before nail insertion helps to decrease the risk of malalignment. Reduction can be accomplished by using an AO distractor medially or by limited open reduction and application of a unicortical plate as described by Benirschke et al. This technique can be particularly useful in open fractures. n  Malalignment also can be prevented by using blocking screws as described by Krettek et al. Overcorrect the deformity and insert blocking screws anteriorly to posteriorly on the concave side of the deformity. The screws effectively reduce the diameter of the metaphysis and physically block the nail by creating an artificial “cortex,” thus preventing angulation by increasing stability. Use of blocking screws to prevent malalignment in distal metaphyseal fractures also can be valuable (Fig. 54.33). 

POSTOPERATIVE CARE  The patient initially is placed in a removable splint or orthosis and early range-of-motion exercises are begun. Noncompliant patients or patients with unstable fracture fixation are placed in a patellar tendon-bearing brace or orthosis until enough healing occurs to ensure stability. Unrestricted weight bearing is permitted in axial stable patterns (i.e., transverse diaphyseal). Weight bearing is restricted until early callus occurs (4 to 6 weeks) and then is progressed as tolerated in fractures without axial stability and those at the proximal or distal metadiaphyseal junction. Nail removal is not routinely necessary but may be needed to relieve pain in patients with prominent implants. Nail removal usually is delayed until at least 12 to 18 months after injury, when all fracture lines are obliterated and there is full cortical remodeling. Conversely, removal of interlocking screws for symptomatic implants is not uncommon and can be done once sufficient healing and fracture stability are achieved.   

EXTERNAL FIXATION

External fixation is a useful and versatile tool in the treatment of tibial fractures, both as a temporizing and definitive treatment. Three distinct types of fixators are

FIGURE 54.33 Malalignment after intramedullary nailing can be prevented by use of blocking screws in addition to standard locking screws. SEE TECHNIQUE 54.11.

commonly used: half-pin fixators, wire and ring fixators, and hybrid fixators that combine half-pins and tensioned wires. Although commonly used in the past, transfixion pins currently are used mainly in the calcaneus or as part of a two-pin “traveling traction” fixator. These devices can be used to stabilize almost any fracture, whether open or closed, throughout the length of the tibia. External fixation provides stable fixation, preserves soft tissues and bone vascularity, leaves wounds accessible, and causes little blood loss. Frame designs provide uniplanar or multiplanar fixation and can be modified to allow axial compression with weight bearing, which stimulates fracture union. External fixators that use tensioned wires for fixation extend the indications for external fixation to include periarticular fractures (Fig. 54.34). Pin site infection, malunion, joint stiffness, patient acceptance, and delayed union remain the greatest problems, however, associated with external fixation. External fixation as definitive management usually is indicated for severe open fractures (type IIIB and type C), especially fractures with gross contamination of the tibial canal or if the adequacy of the initial debridement (shotgun wound, crush injuries) is a concern. External fixation also can be used in the delayed management of fractures with bone loss, either by providing stabilization for autogenous bone grafting or by creating regenerated bone with circular wire fixators. External fixators also are preferable in patients with very small medullary canals, fractures associated with burns or wounds over the tibial nail entry portal, open fractures receiving delayed treatment (>24 hours), severely contaminated fractures, fractures with vascular injury in which

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A

B

C

D FIGURE 54.34 A and B, Clinical photograph and initial radiograph of pedestrian struck by vehicle at high speed. Presented with Gustilo 3B open proximal fibular and tibial fractures. Note large bone defect. C and D, Fracture managed with multiplanar ring external fixator secondary to overlying soft-tissue injury requiring skin grafting. Osseous defect managed with bulk autogenous bone grafting and acute compression/shortening of fracture in wire frame after removal of large antibiotic spacer.

salvage may be questionable, war injuries, and in some patients with multiple-system trauma in whom blood loss must be kept to a minimum.

External fixation may be indicated for patients with unstable closed fractures, fractures complicated by compartment syndrome, diaphyseal fractures with periarticular extension,

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY segmental fractures with a periarticular component, and head injury or impaired sensation. Initial healing of a fracture, especially a comminuted open fracture, depends on the blood supply from surrounding soft tissues. Fracture and soft-tissue stability must be maintained to allow continued capillary ingrowth into the injured areas. If external fixation is used for open tibial fractures, temporary fixation of the foot to eliminate ankle and soft-tissue motion at the fracture site should be considered. If fixation of the foot is not important for fracture stability, it is removed when the soft tissues have healed, and ankle motion is encouraged. The amount of stiffness that provides the most favorable environment for fracture healing in an external fixator is unknown. More rigid frames are preferred initially during the phase of soft-tissue healing and usually have fewer pin site problems. Fractures with more inherent instability require stiffer frames than more stable fracture patterns. There is evidence that gradually destabilizing the frame to permit more weight bearing by the bone stimulates fracture healing. Destabilization usually includes converting the frame from a static to a dynamic construct by loosening the pin-tobar clamps on one side of the fracture. Axial compression is allowed while maintaining angular and rotational alignment. Frames also can be made less rigid by increasing the distance between the bar and the bone and removing the outer bar in a double-bar frame. The fracture should be stable enough to resist excessive shortening or angulation before fracture destabilization. Although external fixation long has been proposed for provisional soft-tissue care, a growing number of reports advocate it for definitive fracture care, especially for highenergy fractures with significant diastasis or dissociation of the tibia and fibula and little intrinsic stability. These reports cite high complication rates, especially of malunion, with conversion of high-energy fractures from external fixation to casts. External fixators now usually are retained until fracture union. External fixation also provides stability for fractures that require subsequent bone grafting. Although open fractures with bone loss clearly require bone grafting or bone transport with ring fixators, open fractures with periosteal stripping (type IIIB) also frequently require autogenous bone grafting for union. These especially difficult fractures have led some authors to recommend early bone grafting in all such injuries. To avoid intrinsic problems of delayed union, nonunion, pin loosening, and pin track infection, conversion to internal fixation after soft tissues and all pin sites have healed (8 to 12 weeks) has been suggested as the ideal time for such conversion, while others have cautioned against early removal of the fixator in high-energy fractures with disruption of the interosseous membrane, comminution, or bone loss. In a prospective evaluation of 78 patients, Bråten et al. demonstrated that time to union and full weight bearing were similar between intramedullary nails and external fixation. However, the cohort receiving a nail achieved unprotected weight bearing sooner. External fixation resulted in more reoperations, whereas 64% of the patients with intramedullary nails had anterior knee pain at 1 year. Others have evaluated the factors that influence fracture healing with external fixation and found significant disparities of

healing associated with lack of supplemental fixation techniques and pin track infections.

HALF-PIN FIXATORS

Numerous brands of external fixators are available. The fixator chosen should provide adequate stability, permit progressive weight bearing, and allow dynamization and destabilization as the fracture heals. Fixator systems that accommodate pin placement in more than one plane and have the ability to include the foot are most useful. Lighter weight, lower cost, and less interference with visualization of the bone on radiographs also are desirable attributes if they do not compromise the stability and versatility of the system. Single-unit fixators with large universal joints readily permit adjustments to fracture reduction after the frame is applied. These fixators tend to be less stable because they do not allow wide pin spacing, and it is more difficult to add a second plane of fixation. Modular fixators allow greater freedom in placement but are more difficult to adjust when the frame is completed. Pin removal and replacement may be necessary to improve reduction. Newer pin clamp designs with ball joint or pivoting mechanisms increase the adjustability of these constructs to some extent. 

PREOPERATIVE PLANNING

The initial frame should be rigid enough to minimize motion at the fracture site. Stability can be increased in several ways, as follows: increasing pin diameter, increasing the distance between the pins, increasing the number of pins, increasing the number of stabilizing bars, decreasing the distance from the bar to the limb, and adding a second plane of fixation. Tibial fixators use pins ranging from 4.5 to 6.0 mm in diameter. The pin should be less than one third the diameter of the bone to prevent fracture. Uncomminuted fractures require a minimum of two pins for each major fragment (including large segmental fragments). A uniplanar construct usually provides sufficient stability for many tibial fractures. The addition of a third pin to a fragment significantly increases rigidity, especially if it is in another plane. A fourth pin in a single fragment provides minimal additional stability and usually is unnecessary. Comminuted fractures may benefit from three pins per major fragment, and two-plane fixation is preferred. Two-plane fixation can be achieved by connecting pins in different planes to a single bar. Alternatively, the pins placed in a second plane can be attached to a second bar, and the bars can be connected with bar-to-bar clamps. Rigidity can be increased in a uniplanar construct by connecting the pins to the two bars stacked on top of each other. Widely spaced pins in each fragment provide stability in the plane of fixation and in the plane perpendicular to it. Short fragments do not allow wide pin spread, however. Two pins placed in the same plane in a short fragment provide stability in the plane of the pins but are less stable in the plane perpendicular to the pins. Adding a pin in a different plane enhances stability. Because the major bending moments in the tibia occur in the sagittal plane, fixation in this plane is more stable. Tibial fractures associated with unstable ipsilateral ankle injuries or with severe soft-tissue wounds of the

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EXTERNAL FIXATION FOR TIBIAL SHAFT FRACTURES At our institution, this technique is most applicable for provisional stabilization of open tibial fractures or in the setting of multiple trauma for fractures that will typically be managed definitively by other means.

TECHNIQUE 54.12 Before fixator application, review cross-sectional anatomy to confirm the “safe zones” for pin placement and to minimize the risk of neurologic, vascular, or tendinous injury. n  Place pins through either the anterior or the anteromedial cortex along the subcutaneous border of the tibia to avoid soft-tissue tethering. Direct the pins perpendicular to the long axis of the bone and parallel to the joint surfaces and insert them through small longitudinal incisions. n  Bluntly dissect soft tissues to bone. n  Place a drill sleeve against the bone and predrill the pin hole with an appropriate-size bit. Predrilling lowers the risk of thermal necrosis and pin loosening. n  Insert a pin with the correct thread length through the sleeve by power drill and into the bone. Bicortical purchase is necessary to prevent loosening. Threads should not protrude through the skin at the insertion site because this can cause pin site irritation. Some pins have conical rather than cylindrical threaded portions to create a radial preload with tightening. These pins cannot be backed out after insertion without causing loosening. Do not insert them too deeply. n  Some systems have different thread designs for cortical and cancellous bone, which use different drill bits. The following is a technique for the application of a generic modular fixator. n  Pins should be nearly perpendicular to the long axis of the tibia and parallel to the knee and ankle joints. If the length of the segments allow, place the most proximal and distal pins at the metaphyseal-diaphyseal junction, where the bone is thicker and better pin purchase is obtained than in the cancellous bone of the metaphysis. Proximally, place the pin at least 15 mm from the joint to avoid penetration of the joint capsule and avoid the pes tendons and patellar tendon. n  Place the inner pin in each fragment at least 1 cm from the fracture site, avoiding undisplaced areas of comminution. The fracture site could become secondarily infected from a pin site infection if the pin is too close. If the length of the segment allows, place inner pins 2 to 3 cm from the fracture site. Keep in mind that wide pin spread enhances stability. n  Apply multiple pin-to-bar connections and connect the bars positioned. n 

Perform reduction. If the injury is open, the traumatic wound provides an excellent opportunity to effect reduction under direct vision or with provisional clamps. n  Securely tighten all connections. Assess fracture reduction with fluoroscopy and adjust as needed. n  Additional bars can increase construct stability. n  If stability warrants, expand the external fixation to include the foot. To include the foot, insert 4-mm or 3-mm pins through the subcutaneous border of either the first or the fifth metatarsal respectively or, if necessary, place larger half-pins or transfixation pins in the posterior tuberosity of the calcaneus. Avoid equinus, inversion, and eversion of the foot. n  Connect the foot pins to the tibial frame using either specialized pin clamps or additional bars and bar-to-bar clamps. n  Combining external fixation with lag screw fixation of the diaphysis is discouraged.  n 

POSTOPERATIVE CARE Pin site care is started after the initial postoperative dressing has been removed. Pin sites are cleaned daily using a diluted hydrogen peroxide solution or antibacterial soap and water. Pin sites are inspected to ensure that the pins are tight. A removable splint is used to prevent equinus, with definitive fixation performed later.   

COMPLICATIONS

When the soft-tissue techniques previously described are used and the safe zones of the tibia are observed, especially with half-pin fixation in the subcutaneous tibial border, immediate complications are rare. Vascular injury more often is the result of late erosion of a vessel than of direct injury; however, direct injury is possible, especially with transfixation pins in bilateral uniplanar frames. Persistent bleeding at the time of surgery or late spontaneous bleeding must be investigated to rule out direct injury, late erosion, or pseudoaneurysm of a major vessel. We have seen persistent bleeding around the pins from small periosteal arteries in children. Pin track irritation is common and requires daily pin site care with soap and water cleansing and gentle pressure dressings. Oral antibiotics may be required for secondary cellulitis. Removal of the external fixator and application of a cast before union in high-energy tibial fractures may result in malunion or nonunion. Intramedullary nailing after external fixation, especially with a history of a pin track infection, results in a high rate of infection, although a low rate of malunion or nonunion. In our experience, with an average delay in nailing of 7 weeks after fixator removal, intramedullary nailing of delayed union or nonunion of the tibia has been extremely successful. Gustilo recommended delaying any reconstructive surgery for severe open tibial fractures, including bone grafting and delayed nailing, until all wounds are reepithelialized. 

ILIZAROV EXTERNAL FIXATION DEVICE

The tensioned wire external fixator has proved valuable in the acute and subacute care of tibial fractures. It has

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY been used more frequently for difficult fractures, especially metaphyseal fractures with significant shaft extension. Difficult nonunions with bone loss, deformity, or infection also have been managed effectively with this type of fixation (Fig. 54.35). Preoperative planning and frame construction, early mobilization of the patient, daily cleansing of skin and frame, and close follow-up minimize complications. Our experience with the Ilizarov external fixator has been primarily with tibial fractures. Stabilization of short periarticular fragments is possible with this appliance. Four 1.8-mm diameter wires used to stabilize a bicondylar tibial plateau fracture provide the effective cross section of fixation of 7.2 mm. Four wires also provide eight cortical interfaces and, because of the multiplanar orientation, virtually eliminate any late displacement of fragments. Because the wires are highly tensioned and supported circumferentially, a trampoline of fixation is provided (Fig. 54.36). Spanning the knee or ankle for 4 to 6 weeks occasionally is necessary, especially after elevation of a joint surface and bone grafting. The Taylor spatial frame (Smith & Nephew, Memphis, TN) is a unique ring-and-wire fixator consisting of two rings connected by six oblique struts (Fig. 54.37). Its application is similar to that of the Ilizarov except that FastFx struts are used, and reduction is performed manually under image intensification until the best possible reduction is obtained in the anteroposterior and lateral planes. The struts are then locked in place. Additional rings can be added as necessary, and the foot can be incorporated. With the aid of a computer software-generated prescription, the struts can be adjusted as a procedure in the outpatient setting to effect anatomic reduction at the fracture site. Radiographic parameters are entered into a computer. Length, rotation, translation, and coronal and sagittal alignment all can be corrected by changing the lengths of the six struts as dictated by the computer program. We have used this fixator primarily to correct malunions, but it can be useful in treating acute fractures as well. Open fractures with extensive bone loss are another indication for the Ilizarov method. The unstable fracture, soft-tissue defect, and bone loss all are managed successfully with one device and method. The first step in the management of complex fractures is to determine if the limb is salvageable, however. Occasionally, these injuries are managed best by early amputation, especially in the presence of major arterial or nerve injury. A dysvascular, insensate terminal limb does not function better than a prosthetic limb. The number of operations, the length of treatment, and the psychologic factors associated with salvage of a severely injured limb must be considered. Other relative indications for the Ilizarov fixator in acute trauma are open fractures, unstable closed fractures, and compartment syndrome. Up to 100% union rates have been reported after this technique. We examined 40 unstable tibial fractures treated with the Ilizarov external fixator, 37.5% of which were open fractures; 12 of the 15 open fractures were Gustilo grade III fractures. Nineteen fractures were bicondylar tibial plateau fractures with extensive shaft extension. Four autogenous bone grafts were required for open fractures with bone loss. One fracture failed to unite and required

A

B

FIGURE 54.35 A, Infection after open tibial fracture was treated with bone resection and Ilizarov bone transplant, with bone graft at docking site. B, After removal of fixator.

FIGURE 54.36 Ilizarov external fixation provides trampoline effect because of highly tensioned wires that are supported circumferentially.

reapplication of a frame, after which union was obtained. The average active range of motion of the knee after fracture healing was 110 degrees. Time to union probably is related to the quality of reduction and restoration of normal alignment. We prefer accurate apposition and alignment at the initial application of a simpler trauma frame rather than the use of articulated frames and subsequent reduction. Our preference for tibial fractures for which definitive external fixation has been selected is multiplanar ring external fixation as opposed to a modular halfpin fixator. 

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B

A Free movement

Locking sleeve “on”

Locking sleeve released Adjusting nut

C FIGURE 54.37 A, Taylor spatial frame is applied before fracture reduction. B, FastFx struts allow reduction under direct vision or C-arm control. If reduction is satisfactory, no adjustments are necessary; if not, gradual adjustments can be made using the deformity correction computer program. C, FastFx struts have dual actions. With the locking sleeve released, strut lengths can be changed to effect fracture reduction. (Courtesy Smith & Nephew, Memphis, TN.)

ILIZAROV METHOD IN OPEN FRACTURES

In open fractures with bone loss, the Ilizarov external fixator should be strongly considered as the primary treatment. Conventional treatment consists of debridement and delayed coverage with a rotation or free flap, followed by autogenous bone grafting. The tensioned wire fixator allows serial debridement of all necrotic tissue. If bone is not exposed, a split-thickness skin graft can be placed onto the remaining muscle. Later, a corticotomy is performed with transport of bone into the gap. The tendency of soft tissue is to move with the transported bone and the normal tendency of split-thickness grafts to contract and fill the soft-tissue and bony defects, eliminating the need for more difficult rotation or free flaps. If an insignificant length of vascular exposed bone is present after debridement, further shortening of fragment ends should be considered to avoid the necessity of flap coverage. Then a simple skin graft can be used as just described. Alternatively, the Taylor Spatial Frame can be used. It permits soft-tissue closure followed

by gradual correction of osseous alignment for injuries that would otherwise require more involved soft-tissue coverage procedures. If a significant amount of vascular bone remains uncovered after debridement, a free flap or rotation flap should be used (Fig. 54.38A). At flap coverage, a corticotomy is made and a fragment is prepared for transport into the bony defect (Fig. 54.38B and C). Ilizarov recommended a metaphyseal corticotomy for bone transport. 

RECONSTRUCTIVE PROCEDURES

Reconstructive soft-tissue procedures are possible with circular tensioned wire fixators. Typical fracture frames are composed of four threaded rods linking four complete rings. Temporary removal of one rod allows 180-degree access to the leg for bone grafting of delayed unions or for free flap grafts. Removal of the anterolateral rod allows access to a dorsalis pedis donor, and removal of the posteromedial rod allows access to the posterior tibial artery. 

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A

B

C FIGURE 54.38 A, Free flap or rotation flap. B and C, Corticotomy and preparation of fragment for transport into bony defect.

second level of fixation in each segment improves frame stiffness to anteroposterior bending and torsion. Two rings are used on large fragments, and a ring and drop post are used for smaller fragments. The midfemur is the most proximal level to accommodate a complete ring comfortably. Fixation to the proximal femur usually is accomplished with hybrid frames and halfpins. The entire lower extremity can be treated with a simple cylindrical frame from midfemur to the ankle. The thigh dictates ring size, usually one or two sizes larger than that normally used for the tibia. The frame should be situated parallel to the tibia on anteroposterior and lateral views. The femur is centered at the level of the patella and inclined in anatomic valgus with respect to the frame. An open section ring can be used as the distal femoral ring to allow full flexion at the knee (Fig. 54.40). This ring can be attached to a complete ring with heavyweight sockets to make it more resistant to deformity when tensioned wires are applied to the open section ring. Likewise, the most proximal ring in a tibial mounting can be an open section ring attached to a complete ring, allowing maximal flexion and providing two levels of fixation (see Fig. 54.39). In open tibial fractures, the foot can be included in the frame to prevent soft-tissue motion at the fracture. Pilon fractures also may require foot fixation for fracture stability. The foot frame is removed after the soft tissues have healed, unless it is required for fracture stability. If the peroneal nerve or anterior or lateral compartment is injured, at least temporary incorporation of the foot should be considered to prevent contracture. The foot may be included in a tibial lengthening or bone transport to prevent equinus. A stable foot mounting consists of two half-rings joined by plates threaded on one end (Fig. 54.41). These special plates prevent distortion of the foot frame when wires are tensioned. Half-rings of the same size used for the tibial frame usually are used for the foot frame. Swelling and dependent edema create late changes in extremity dimensions and must be anticipated. More clearance is needed posteriorly for the lower extremity, and the thigh requires more room for swelling than the leg. 

 

ILIZAROV EXTERNAL FIXATION FOR TIBIAL SHAFT FRACTURES FIGURE 54.39 Open section ring used for most proximal ring in tibial mounting and attached to complete ring.

PREOPERATIVE PLANNING

TECHNIQUE 54.13 Place the patient on a radiolucent table extension, using the external fixator for traction and subsequent reduction. Longitudinal traction reduces most fractures to within 10 to 15 degrees of anatomic alignment. In our experience, the addition of hinges to the trauma frame has been unnecessary. Excessive or prolonged traction should be avoided to prevent neurologic or vascular injury. n  After preparing and draping the extremity, disconnect the ring connection bolts on one side of the preassembled frame and open the frame. n 

Preparation is essential to success with the Ilizarov fixator. We modify the standard Ilizarov method by assembling the frames preoperatively, which greatly reduces intraoperative time. Radiographs are used to determine correct ring positions, and ring size is determined by the uninjured extremity. Two fingerbreadths of clearance are necessary for tibial mountings (Fig. 54.39). Rings that are too large do not support the transfixing wires adequately, and osteogenesis is impaired. Because of the anatomic constraints of safe wire placement, 90-degree divergence generally is unobtainable. A

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FIGURE 54.40

Open section distal femoral ring.

FIGURE 54.42 Frame reassembled around tibia and aligned parallel to crest of tibia in anteroposterior plane. SEE TECHNIQUE 54.13.

After adequate correction is obtained in this plane, secure the wire to the frame on the olive side. If further correction is needed in the sagittal plane, connect this olive wire in an arched fashion (Fig. 54.43H) and tension the wire to obtain final correction (Fig. 54.43I and J). Eliminate any residual distraction (Fig. 54.44). n  In rare cases, two olive wires inserted from opposite sides perpendicular to the fracture plane can effect reduction and apply compression to the fracture (Fig. 54.45). This pattern of wire placement may not always be safe, however. These fractures should be fixed with one or more lag screws followed by external fixator placement (Fig. 54.46). Preoperative axial CT scans help determine the appropriate method of fixation. Interfragmentary screws or wires in the diaphyseal region usually should be avoided because they negate the axial flexibility of the Ilizarov external fixator, which ideally promotes secondary fracture healing. n  Handle skin and other soft tissues with care. In general, 1.5-mm and 1.8-mm wires need no incision or drill sheath. If desired, use a sheath and incision for insertion of the larger 2-mm wires. Glove paper can facilitate grasping the wire close to the insertion site for increased control. n  Use a small skin incision for olive wires. Predrilling is not required for wire insertion. Use a low-speed power drill with frequent pauses or a hand drill to drill the wires through bone. n  After determining the safe angle for the transfixation wires at a given level, stab the wire through the skin and muscle to bone. (Several references for safe transfixation using cross-sectional anatomy are available.) n  Use a low-speed drill to insert the wire across both cortices of the bone. When the wire emerges from the far cortex, tap it through the remaining soft tissues to reduce the risk of neurovascular injury. Avoid undue pressure or tension on the pin-skin interface. n  Attach the wires to the rings without bending them to meet the frame; this may require small spacers to build the connecting bolts off the frame.    n 

FIGURE 54.41 Stable foot mounting consisting of two halfrings joined by plates.

Place the frame around the extremity, reassemble it with adequate soft-tissue clearance, and align it with coupling bolts parallel to the crest of the tibia in the anteroposterior and lateral planes (Fig. 54.42). n  If used to treat the fracture shown in Fig. 54.43A, hold the frame in this position with proximal and distal transverse reference wires placed parallel to the knee and ankle (Fig. 54.43B). As the wires are secured to the frame (Fig. 54.43C) and tension is applied, further correction of the fracture in the coronal plane is achieved (Fig. 54.43D). n  Alternatively, suspend the frame with ordinary suction tubing placed around the extremity and secured to the frame with towel clips. Tilt eccentrically the proximal and distal rings until they are parallel to the knee and ankle joints. After secure fixation with at least two wires to the proximal and distal rings, bring these two rings parallel to their counterparts in the center of the frame for further fracture reduction. n  Use arched olive wires for final fracture reduction (Fig. 54.43E). For final coronal plane correction of the residual displacement (Fig. 54.43F), place an olive wire in a transverse fashion (if safe) (Fig. 54.43G) and apply tension, without securing it tightly to the frame, to pull the fragment toward the tensioner. Use image intensification to ensure adequate reduction. n 

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY 1

2

A

B

F

C

G

D

E

H

Tension wire

Tension wire Tighten nut

I

Tighten nut

J FIGURE 54.43 A-J, Fractures of tibial and fibular shafts treated with Ilizarov fixator. See text for steps in application. SEE TECHNIQUE 54.13.

FIGURE 54.44

Residual distraction eliminated. SEE TECHNIQUE 54.13.

COMPLICATIONS

With careful determination of safe zones by level of fixation, acute neurovascular injury with transfixation wires is rare. In the immediate postoperative period, an unusually painful wire should be suspected of passing through a larger nerve and should be removed. Late neurovascular injury is exceedingly rare, unless bone transport or relative motion of

fragments exists, and usually occurs during a reconstructive procedure rather than during simple fracture immobilization. Flexion contractures of the knee and ankle occur less frequently with fracture treatment than with lengthening and can be prevented by active exercises and weight bearing in the frame. Pin irritation is common, although serious pin track infection is unusual. Wire-skin interfaces should be cleaned daily with soap and water. After wounds have healed, showers are encouraged and swimming in chlorinated pools is allowed with a clear water rinse afterward. Gentle pressure dressings prevent pin and skin motion. A loose wire must be suspected at the first signs of pain and inflammation. Suspect wires should be retensioned. Generalized cellulitis should be managed by assessment of all pin sites and administration of oral antibiotics until it resolves. Pin track infection that fails to respond to these measures should be treated by wire exchange. Patients with head injuries may have excessive dependent edema because they rarely are moved enough to change the dependency or to help lymphatic pumping. If skin impinges on the frame toward the end of treatment (Fig. 54.47A), thin cardboard can be slotted to accommodate any wires and slipped between the skin and the frame to prevent pressure necrosis (Fig. 54.47B). If skin impinges on the frame early in the treatment, the frame must be modified. When problems

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2

A 1

3

B FIGURE 54.47 A, Impingement of skin on frame. B, Thin cardboard used to prevent pressure necrosis.

FIGURE 54.45 Insertion of two olive wires from opposite sides perpendicular to fracture plane. SEE TECHNIQUE 54.13.

1

Alternatively, a saw can be used to remove a segment of a ring if sufficient stability remains. Major problems with circumferential impingement at several levels can be solved by constructing a larger frame around the first frame. The rings of this larger frame are positioned at exactly the same levels. Curled wire ends are straightened, and the wires are attached to the outer frame at both ends. Finally, wire fixation bolts on the smaller frame are loosened and the smaller frame is disassembled. Cannulated wire fixation bolts from the smaller frame may be taped against the new frame. This modification can be made without loosening wires or losing reduction. 

TREATMENT OF DELAYED UNION OR NONUNION

2

3

FIGURE 54.46 Fixation with one or more lag screws and application of external fixator. SEE TECHNIQUE 54.13.

exist at short-arc segments of several rings, the frame may be shifted toward the impingement by reattaching all wire fixation bolts in new holes away from the impingement. If the skin impinges on a single ring, that ring can be modified by introducing two short plates between the ends of the half-rings to create an ellipse with its major axis toward the impingement.

Delayed union after unreamed nailing can be treated by nail exchange or by removal of the nail and insertion of a larger nail using a reamed technique. This technique is indicated for delayed unions in fractures with small (8 mm) or loose implants, axially unstable fractures, and perimetaphyseal fractures. The technique is unsuccessful in fractures with bone loss of more than one third to one half of the cortical circumference and may precipitate infection in type IIIB open fractures. Percutaneous bone grafting, the time-tested method for delayed union and nonunion of the tibia, is used most frequently for type IIIB open fractures and fractures with significant bone loss and after other methods have failed. Other methods for treatment of delayed union are external bone stimulation and historically dynamization of the nail to allow axial impaction of the fracture and to stimulate healing, provided that the fibula has not healed. Loss of reduction has been reported to occur in 16% of proximal and distal fractures after dynamization. 

FIXATION OF THE FIBULA FOR TIBIAL FRACTURE

Internal fixation of the fibula is unnecessary in treating fibular shaft fractures but may be useful in stabilizing other structures. Fixation of a fibular fracture by a plate and screws or by an intramedullary nail inserted through the lateral malleolus partially stabilizes comminuted fractures of the distal

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY tibial shaft or metaphysis when damage of the soft tissues or contamination of the wound makes internal fixation of the tibia inadvisable. Furthermore, internal fixation of the fibula may be considered as an adjuvant in very distal tibial fractures treated with intramedullary fixation to prevent valgus deformity. 

DEFORMITIES OF THE FOOT AND TOES AFTER TIBIAL FRACTURE

A checkrein deformity of the great toe can occur after fracture of the distal third of the tibia. The flexor hallucis longus muscle adheres to callus at the fracture, with its tendon forming a bowstring between this point and the site of insertion of the tendon into the great toe. When the ankle is dorsiflexed, the great toe is sharply flexed, but when the ankle is plantarflexed, the interphalangeal joint extends completely. The pressure of the plantar surface of the great toe against the sole of the shoe on dorsiflexion of the ankle produces a painful callus. If it is impossible to free the muscle in the distal third of the leg after the fracture has united, the tendon is lengthened in the foot. Clawfoot or cavus deformity has been reported after fractures of the tibial shaft and are believed to be the result of fibrous contracture of the muscles of the deep compartment from muscle trauma and ischemia in the deep posterior compartment of the leg. This deformity may be misinterpreted as an inward malrotation of the tibial fracture. 

TIBIAL PLATEAU FRACTURE Proximal tibial articular fractures caused by high-energy mechanisms may be associated with neurologic and vascular injury, compartment syndrome, deep vein thrombosis, contusion, crush injury to the soft tissues, or open wounds. Tscherne and Lobenhoffer emphasized the importance of distinguishing between the “pure” plateau fracture pattern and the fracture-dislocation pattern. In their review of 190 proximal tibial articular fractures, 67% of meniscal injuries occurred in plateau fracture patterns, whereas 96% of cruciate injuries and 85% of medial collateral ligament injuries occurred in fracture-dislocation patterns. Peroneal nerve injury was twice as common in fracture-dislocation patterns. These authors also introduced the term complex knee trauma to describe injuries associated with significant damage to two or more of the following compartments: the soft-tissue envelope of the knee, the ligamentous stabilizers, and the bony structures of the distal femur and proximal tibia. Complex fractures involving the femoral and tibial articular surfaces had a 25% incidence of vascular injury and 25% incidence of compartment syndrome. In 19 complex fractures with severe soft-tissue injury, vascular injury occurred in 31%, compartment syndrome in 31%, and peroneal nerve injury in 23%. Accurate determination of fracture pattern and soft-tissue injury is necessary when developing a treatment plan. Proximal tibial articular fractures can be caused by motor vehicle accidents or bumper strike injuries; however, sports injuries, falls, and other less violent trauma frequently produce them, especially in elderly patients with osteopenia. The frequency of the type of fracture produced has been shown to be related to the frequency of collateral ligament injury to the type and mechanism of forces applied to the knee (Fig. 54.48). Considering the “pure” fracture patterns, ligamentous injuries occur more frequently in minimally displaced,

local compression, and split compression fractures, and it is wise to obtain stress radiographs of the knee to evaluate these structures. The classification of intraarticular proximal tibial fractures originally proposed by Hohl and later modified by Moore and Hohl is commonly used to describe tibial plateau fractures (Fig. 54.49). The classification distinguishes between five primary fracture patterns and five fracture-dislocation patterns, with fracture-dislocations occurring one seventh as frequently as fractures. Tibial plateau fracture patterns according to Hohl and Moore include type 1, minimally displaced; type 2, local compression; type 3, split compression; type 4, total condyle; and type 5, bicondylar. (Fracture-dislocation patterns are described in a later section.) Hohl observed that this classification may be an intermediate step in the evolution of a classification that separates the myriad ligamentous and soft-tissue injuries that, along with the bony injury, determine outcome. Our involvement with a level I trauma center has shown several fractures that defy conventional classification and treatment methods. These extremely high-energy fractures, frequently open, usually include bicondylar comminution and extensive shaft comminution with dissociation of the metaphysis and the diaphysis, as in Schatzker type VI. The Schatzker classification closely corresponds to the fracture patterns of Hohl and Moore with the addition of type VI, metaphyseal-diaphyseal dissociation. Schatzker, McBroom, and Bruce, in a review of 94 tibial condylar fractures, proposed the following classification and treatment methods when the fracture is significantly displaced or when significant joint instability is present.

FRACTURE CLASSIFICATION

Fracture patterns as classified by Schatzker: Type I—pure cleavage (Fig. 54.50A). A typical wedge-shaped uncomminuted fragment is split off and displaced laterally and downward. This fracture is common in younger patients without osteoporotic bone. If displaced, it can be fixed with two transverse screws, or the addition of a lowprofile condylar plate. Type II—cleavage combined with depression (Fig. 54.50B). A lateral wedge is split off, but in addition the articular surface is depressed down into the metaphysis. This tends to occur in older individuals, and, if the depression is more than 5 to 8 mm or instability is present, most should be treated by open reduction, elevation of the depressed plateau “en masse.” Then bone grafting of the metaphysis, fixation of the fracture with screws, and buttress plating of the lateral cortex are performed. Type III—pure central depression (Fig. 54.50C). The articular surface is driven into the plateau. The lateral cortex is intact. These tend to occur in osteoporotic bone. If the depression is severe, or if instability can be shown on stress, the articular fragments should be elevated and bone grafted and the reduced articular injury is supported with subchondral rafting fixation, with or without plate augmentation. Type IV—fractures of medial condyle (Fig. 54.50D). These may be split off as a single wedge or may be comminuted and depressed. The tibial spines often are involved. These fractures tend to angulate into varus and should be treated by open reduction and fixation with a medial buttress plate and screws.

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Split

Further valgus force TCL intact

“Ultimate fracture by valgus”

Often

Valgus force

Local depression

Compression force

Compression force often in extension

Mixed Valgus force

Often

Often

Compression valgus force

Total depression

Compression force

Compression force

Compression force

Bicondylar

FIGURE 54.48 Relationship of force to tibial condylar fractures. Tibial collateral ligament injuries commonly occur in split and mixed fractures of lateral plateau. In mixed fractures, fibula is often fractured. In total depression fractures, proximal fibular fracture or proximal tibiofibular diastasis occurs.

Type V—bicondylar fractures (Fig. 54.50E). Both tibial plateaus are split off. The distinguishing feature is that the metaphysis and diaphysis retain continuity. Both condyles can be fixed with buttress plates and cancellous screws, to avoid stabilizing condyles with large bulky implants. The less involved condyle can be stabilized with a small antiglide plate placed at the apex of the fracture with minimal soft-tissue dissection, our preferred method. Type VI—plateau fracture with dissociation of metaphysis and diaphysis (Fig. 54.50F). A transverse or oblique fracture of the proximal tibia is present in addition to a fracture of one or both tibial condyles and articular surfaces. The dissociation of the diaphysis and metaphysis makes this fracture unsuitable for treatment in traction, and most should be treated with buttress plates and screws, one on either side if both condyles are fractured. Pin and wire fixators also have been advocated for fixation of these difficult fractures. 

FRACTURE-DISLOCATION CLASSIFICATION

The fracture-dislocation patterns classified by Hohl and Moore (Fig. 54.51), in addition to occurring with a higher incidence of associated ligamentous injuries, occur with more frequent meniscal injuries, and a much higher incidence of neurovascular injury, increasing from 2% for type I to 50% for type V, with an overall average of 15%, approximately that of classic dislocation of the knee. Type I—coronal split fracture. These fractures account for 37% of tibial plateau fracture-dislocations. The fracture involves the medial side, is apparent on the lateral view, and has a fracture line running at 45 degrees to the medial plateau in an oblique coronal-transverse plane. The fracture may extend to the lateral side, and avulsion fractures of the fibular styloid, insertion of the cruciates, and Gerdy’s tubercle are common. Half of these fracturedislocations are stable on stress views, and although they conceivably could be managed in a cast in extension or traction with limited range of motion, we frequently

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY 1

2

Minimally displaced

3

Local compression

4

Split compression

5

Total condyle

Bicondylar

FIGURE 54.49 Classification of tibial plateau fractures as described by Hohl and Moore: type 1, minimally displaced; type 2, local compression; type 3, split compression; type 4, total condyle; and type 5, bicondylar.

use closed reduction and percutaneous screw fixation to improve reduction and allow early range of motion in a cast brace; protected weight bearing is continued for 8 to 10 weeks. If open reduction is required, the fragment usually reduces in extension and can be fixed with interfragmentary screws. Associated ligamentous injuries can be repaired along with the invariable capsular disruption. Type II—entire condyle fracture. This fracture-dislocation may involve the medial or lateral plateau and is distinguished from the type IV fracture by a fracture line extending into the opposite compartment beneath the intercondylar eminence (Fig. 54.52). The opposite collateral ligament is involved in half of fractures, resulting in fracture or dislocation of the proximal fibula. This type constitutes 25% of all fracture-dislocations, and 12% result in neurovascular injuries. Stress testing is necessary to determine occult ligament injury. Stable fractures can be managed by cast bracing, frequent follow-up, and delayed weight bearing. Unstable or poorly reduced fractures can be fixed with interfragmentary screws after closed or open reduction and repair of any ligament injury, cast bracing, and delayed weight bearing. Type III—rim avulsion fracture. Constituting 16% of fracture-dislocations, this type involves almost exclusively the lateral plateau, with avulsion fragments of the capsular attachment, Gerdy’s tubercle, or the plateau. Disruption of either or both cruciate ligaments is common. Although meniscal injury is rare, neurovascular injuries occur in 30% of fractures and nearly all type III fractures are unstable. A lateral approach allows screw fixation of the articular rim and repair of avulsed iliotibial band and collateral ligaments. Cruciate ligament repair or augmentation may be necessary. Type IV—rim compression fracture. This injury accounts for 12% of all fracture-dislocations. It is almost always unstable. The opposite collateral ligament complex and usually (75% of patients) the cruciate ligaments are avulsed or torn, allowing the tibia to sublux to the extent that the femoral condyle compresses a portion of the anterior, posterior, or “middle” articular rim. Stable injuries can

be treated by casting until the ligaments heal. If surgery is necessary, a parapatellar approach allows debridement of small fragments, elevation and stabilization of larger fragments, and repair of cruciate and opposite collateral ligaments. Postoperative mobilization is largely dictated by the nature of the ligamentous injury and repair. Type V—four-part fracture. Constituting 10% of all fracture-dislocations, this injury is nearly always unstable. Neurovascular injury occurs in 50% of fractures; the popliteal artery and the peroneal nerve are injured in more than one third. Both collateral ligament complexes are disrupted with the bicondylar fracture, and the stabilization provided by the cruciates is lost because the intercondylar eminence is a separate fragment. Although a bicondylar approach has been recommended, others have been more cautious, recommending plating of the more comminuted plateau and lag screw fixation of the more intact condyle. Realizing the high incidence of infection and dehiscence with bicondylar plating and the extensive exposure necessary, a method of lateral plateau plating with temporary medial external fixation was described by Mast. We have used limited open reduction techniques combined with multiplanar external fixation. As with Schatzker type V bicondylar fractures, extreme care must be taken with soft tissues. Motion is not allowed until the skin has healed. Weight bearing is delayed according to the method of fixation; with Ilizarov fixation, early weight bearing is allowed to tolerance. 

EVALUATION

A thorough history should be obtained, including determination of the mechanism of injury and the patient’s overall medical status, age, and functional and economic demands. A detailed physical examination is necessary to detect concomitant ligamentous injuries, neurovascular injuries, compartment syndrome, additional fractures, and other injuries. Compartmental pressures should be measured with an accurate method if clinical suspicion of compartment syndrome exists in patients unable to provide a reliable clinical examination. Ankle-brachial indices should be obtained, and

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Type II

B

A Type III

Type IV

D

C Type V

Type VI

E

F FIGURE 54.50 A, Type I, pure cleavage fracture. B, Type II, cleavage combined with depression. Reduction requires elevation of fragments with bone grafting of resultant hole in metaphysis. Lateral wedge is lagged on lateral cortex, protected with buttress plate. C, Type III, pure central depression. There is no lateral wedge. Depression also can be anterior or posterior or involve whole plateau. After elevation of depression and bone grafting, lateral cortex is best protected with buttress plate. D, Type IV. Medial condyle is split off as wedge (type A) as illustrated, or it can be crumbled and depressed (type B), which is characteristic of older patients with osteoporosis (not illustrated). E, Type V. Note continuity of metaphysis and diaphysis. In internal fixation, both sides must be protected with buttress plates. F, Type VI. Essence of this fracture is fracture line that dissociates metaphysis from diaphysis. Fracture pattern of condyles varies, and all types can occur. If both condyles are involved, proximal tibia should be buttressed on both sides.

further vascular studies should be obtained in patients with suspected vascular injury. Patients with obvious vascular injuries should be taken promptly to the operating room for vascular exploration and revascularization. Provisional stabilization with external fixation may be required. Anteroposterior, lateral, and oblique radiographs and CT scans are necessary to evaluate these fractures. Assessment of the degree and the size of depressed articular fragments may be possible only with CT. Often the classification of the fracture made from standard radiographs is changed to another type after the CT scans are evaluated. The upper tibial articular surface normally is inclined posteriorly 10 to 15 degrees, and an anteroposterior radiograph with the beam angled caudally 10 to 15 degrees provides better views of the tibial plateaus. Stress radiographs for collateral ligament injury have been mentioned previously. Analysis of MRI findings in 29 tibial plateau fractures found tibial collateral injuries

in 55%, lateral meniscal tears in 45%, fibular collateral ligament injuries in 34%, anterior cruciate ligament injuries in 41%, posterior cruciate ligament injuries in 28%, and medial meniscal tears in 21%. Mustonen et al. demonstrated a 42% incidence of abnormal meniscal findings on MRI in patients who sustained tibial plateau fractures, and 88% of patients with meniscal tears had unstable injuries. The exact role of MRI in evaluating patients with tibial plateau fractures is still evolving. MRI is probably most appropriate in the evaluation of fracture-dislocation patterns when there is a high suspicion for injury to the associated soft-tissue stabilizers. Radiographic predictors for fractures with an increased incidence of compartment syndrome include tibial widening and femoral displacement. Ruffolo et  al. reported complication rates after ORIF of bicondylar injuries treated through dual incisions. Nonunion and deep infection occurred commonly after staged ORIF of

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY I

II

Split

III

Entire condyle

IV

Rim avulsion

V

Rim compression

Four part

FIGURE 54.51 Hohl and Moore classification of proximal tibial fracture-dislocations. (Redrawn from Hohl M, Moore TM: Articular fractures of the proximal tibia. In Evarts CM, editor: Surgery of the musculoskeletal system, ed 2, New York, 1990, Churchill Livingstone.)

FIGURE 54.52

Type II fracture-dislocation of tibial plateau fixed with plate and screws.

high-energy tibial plateau fractures. Open fractures and open fasciotomy wounds at the time of internal fixation are associated with higher infection rates, 43.8% and 50.0%, respectively. Ahearn et  al. noted poor patient-reported outcome measures after complex bicondylar tibial plateau fractures and similar clinical and radiographic outcomes with internal fixation and Taylor Spatial Frame. Whatever the injury, the damage to the joint usually is more extensive than the radiographs indicate. The bony attachments

of one or both cruciate ligaments may be avulsed and lie as free fragments in the joint. Comminuted fragments of the articular surface often lie at angles to their normal plane and may be upside down. The meniscus often is torn at its periphery, and a part or all of it may lie between the comminuted fragments. 

TREATMENT

Goals of treatment of proximal tibial articular fractures include restoration of articular congruity, axial alignment,

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS joint stability, and functional motion. If operative treatment is chosen, fixation must be stable enough to allow early motion and the technique should minimize wound complications. Surgical treatment is usually recommended for fractures associated with instability, ligamentous injury, and significant articular displacement; open fractures; and fractures associated with compartment syndrome. Ligamentous instability must be distinguished from osseous instability. After the articular surfaces of a joint have been fractured, joint function usually is proportionate to the accuracy of reduction. For displaced fractures, most authors point out that the most significant factor influencing long-term results, and hence treatment approach, is the degree of displacement and depression. The degree of acceptable articular displacement is controversial. Some authors recommend surgical reduction for an articular stepoff of more than 2 mm, whereas others advocate surgical reduction for 5 mm or more of joint depression or displacement of more than 5 degrees axial alignment. Still others have reported similar clinical results with operative and nonoperative treatment of fractures with 8 mm of depression. Most authors agree that if depression or displacement exceeds 10 mm, surgery to elevate and restore the joint surface is indicated. If the depression is less than 5 mm in stable fractures, nonoperative treatment consisting of early motion in a hinged knee brace and delayed weight bearing usually is satisfactory. If the depression is 5 to 8 mm, the decision for nonoperative or operative treatment depends to a great degree on the patient’s age, activity demands on the knee, and coronal plane stability. If a patient is elderly and sedentary, nonoperative treatment usually is suitable. If a patient is young or active, attempts at surgical reconstruction of the joint surface are justified. Long-term follow-up studies have shown that posttraumatic arthritis is associated with residual instability or axial malalignment and not the degree of articular depression. Instability is another indication for operative treatment. Instability may result from ligamentous disruption, osseous depression of the articular surface, or translational displacement of a fracture fragment. Ligament injuries occur in 10% to 33% of tibial plateau fractures. The major indication for surgery is not the measure of depression of the fragment or articular surface but the presence of varus or valgus instability of 10 degrees or more with the knee flexed less than 20 degrees. Treatment methods proposed for fractures of the tibial condyles include extensile exposure with arthrotomy and reconstruction of the joint surface with plate and screw fixation (Fig. 54.53), arthroscopy or limited arthrotomy and percutaneous screw fixation or external fixation with pin or wire fixators, and nonoperative management with a cast brace for selected patients. Newer plating techniques are capable of fixation with less iatrogenic soft-tissue elevation and use minimally invasive approaches. If more than one incision is used, a large soft-tissue bridge is left between them. No method can be used routinely for all fractures, and each patient must be evaluated individually. Extensive surgery on a severely comminuted fracture may result in less than optimal internal fixation and a need for postoperative immobilization, often resulting in the joint being neither stable nor freely movable.

In undisplaced fractures, after the integrity of the collateral ligaments is established, treatment should consist of a few days of splinting followed by early active knee motion. Weight bearing should be delayed until fracture healing is evident, generally at 8 to 10 weeks. Eighty-nine percent good results have been reported in fractures treated with closed reduction and cast bracing with little correlation between the late radiographic appearance and the functional result. Reduction and alignment were lost most often in medial condylar and bicondylar fractures. Sarmiento et  al. found that often the condition of the fibula, whether fractured or intact, determines the angular behavior of these fractures under weight-bearing and functional conditions. Isolated fractures of the lateral condyle with an intact fibula did not collapse further because of the support of the fibula. Conversely, fractures of the lateral condyle with associated fibular fractures had a tendency to collapse into valgus because of the loss of fibular support. Fractures of both condyles did not collapse further or angulate when the proximal fibula was fractured and displaced. If the fibula was intact, however, the medial condyle usually collapsed, creating a varus deformity. Lateral split fractures can be reduced open or percutaneously using traction and reduction forceps under arthroscopic or fluoroscopic control. If the displaced rim of the condyle cannot be reduced into a supporting position under the femoral condyle using closed manipulation, open reduction is required. Arthroscopic evaluation of all Schatzker type I fractures that are treated operatively has been recommended to ensure that the lateral meniscus is not trapped within the fracture site. Many lateral split fractures can be stabilized adequately by percutaneously placed large cancellous screws. If the lateral condylar fracture is associated with a fibular head fracture, a lateral buttress plate provides additional stability. Depressed articular segments cannot be reduced by ligamentotaxis alone and require elevation through a cortical window, bone grafting, and fixation with either subchondral screws or a buttress plate. Patil et  al. reported biomechanical data suggesting that four 3.5-mm screws were superior to two 6.5-mm screws in axial compression. Traditionally, the reduction has been observed through an arthrotomy and submeniscal incision; however, investigators have successfully used fluoroscopic or arthroscopically assisted reduction, bone graft or bone graft substitute, and percutaneous screw fixation to treat tibial plateau fractures with articular depression (Schatzker type II and type III). Displaced fractures of the medial condyle (Schatzker type IV) often are quite unstable and generally are best treated with open reduction and fixation with a medial buttress plate, which is biomechanically the most sound. The treatment of severe or “complex” tibial plateau fractures can be quite difficult. Severe or complex tibial plateau fractures include bicondylar fractures (Schatzker type V), tibial plateau fractures with metaphyseal-diaphyseal discontinuity (Schatzker type VI), and fractures with open wounds, severe closed soft-tissue abrasions, contusions or crush injuries (Tscherne type II or III), compartment syndrome, or vascular injury. Closed methods of treatment with traction or cast bracing usually are unsuccessful in maintaining articular reduction and axial alignment. Traditional methods of open reduction and plating require extensive exposure, which may

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY

FIGURE 54.53 Lateral split depression tibial plateau fractures can be managed with anatomic reduction of articular injury and subchondral rafting screws to support articular elevation. Lateral condyle supported with buttress plate construct. With lateral peripheral rim comminution, subchondral rafter screws can be coupled with plate to act as washer.

compromise soft tissue further and devascularize bone fragments, leading to infection. Attempts have been made to reduce the incidence of complications in these fractures by using less extensile exposures and indirect reduction techniques and by supplementing lateral buttress plate fixation with a small antiglide plate rather than a second bulky medial buttress plate. Mills and Nork suggested that dual plating could be achieved with minimal soft-tissue dissection by using a more anterior skin incision and limiting subperiosteal dissection to fracture margins and to the area of anticipated plate application. The use of small-fragment (3.5-mm screws) AO/ASIF T-plates has been reported for fixation of tibial plateau fractures. Anatomic or nearly anatomic reductions were obtained in 86.7% without infections or soft-tissue complications. The smaller diameter and increased malleability of the small fragment T-plate is thought to have provided better buttressing of the osteochondral fragments than the larger precontoured AO/ASIF T-plates and L-plates (6.5-mm screws). Others have obtained good results without infection in grade II and grade III open complex (Schatzker types V and VI) tibial plateau fractures treated by experienced surgeons with a standard protocol of thorough debridement, immediate rigid internal fixation, and delayed closure at 5 days. Temporarily spanning the knee with an external fixator has been recommended in patients with severe soft-tissue injury. Internal fixation can be done after swelling has decreased, much akin to the current strategies for management of pilon injuries.

External fixation using either half-pin fixators or ringand-wire fixators also has been advocated as definitive fixation for complex tibial plateau fractures. Cannulated screws can be used as accessory fixation of the articular surface. An external fixator placed below the knee can maintain articular reduction and axial alignment and allow early motion (Fig. 54.54). Minimal soft-tissue dissection is required for application of an external fixator, which theoretically should reduce wound complications. Not all fractures reduce with ligamentotaxis alone, and a limited open reduction sometimes is necessary with bone grafting. One potential disadvantage of external fixation is the risk of pin site infection. Pin site infections usually are minor and can be treated with oral antibiotics. Septic arthritis has been reported to develop, however, as a result of infection around periarticular pins and wires. Anatomic studies have shown that pins or wires placed within 14 mm of the knee joint may be intracapsular. To prevent septic arthritis, intracapsular placement of pins and wires should be avoided. Clinical studies have shown that ring-and-wire fixation is an acceptable method of treatment for complex tibial plateau fractures (87% to 88% good or excellent results with 6.5% to 12% superficial infections). A four-wire construct has been shown to provide stability comparable to that obtained with dual plating. We frequently use ring-and-wire fixation for the treatment of complex tibial plateau fractures (Fig. 54.55). In 57 patients with Schatzker type VI tibial plateau fractures treated with Ilizarov fixation, four fractures became infected

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A

B

C

D

FIGURE 54.54 A, CT scan of open fracture of tibial plateau. B and C, Fixation with hybrid external fixator. D, After fixator removal.

A

B

C

D

FIGURE 54.55 A and B, Fracture of tibial plateau. C, Stabilization with Ilizarov circular external fixator. D, After fixator removal.

(7%), including two with septic arthritis. Twenty-two fractures (38%) were open. In 45 fractures (84%) with acceptable reductions, knee range of motion averaged 115 degrees. In nine patients (16%) with poor reductions, knee motion averaged 79 degrees. Monolateral half-pin external fixation placed below the knee is another technique that has been used to treat complex tibial plateau fractures. Accessory cancellous screws are used to maintain the articular reduction. This is technically easier for surgeons unfamiliar with ring-and-wire fixation techniques; however, half-pins may not achieve as secure fixation as small tensioned wires in comminuted metaphyseal bone.

Occasionally, a tibial plateau fracture is so comminuted or the soft-tissue injury so severe that accurate reduction and stable fixation are impossible in the acute setting. In this situation, the knee can be spanned by a half-pin external fixator as temporary or definitive fixation. This technique allows the patient to be mobilized while maintaining axial alignment of the limb. Immobilization of the knee for 6 weeks does not seem to affect adversely the ultimate knee range of motion.

FRACTURE OF THE LATERAL CONDYLE

An understanding of the mechanism producing fractures of the lateral tibial condyle is necessary for intelligent treatment. This fracture usually is produced by a valgus strain on

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY the knee, with the ligaments and muscles on the medial side resisting separation of the tibial and femoral condyles. The lateral femoral condyle is driven downward into the weightbearing surface of the lateral tibial condyle, depressing the central portion of the articular surface into the cancellous metaphysis well below its normal level. In addition, the lateral margin of the articular surface of the tibia bursts laterally and one or more fractures extend longitudinally down into the metaphysis of the tibia, producing a lateral fragment. This fragment usually is fairly large and, when seen from the lateral side, often is triangular, with the base of the triangle proximal. Usually the fragment is held at joint level by the intact fibula. Less often, the lateral condyle fractures the fibula at its neck and may be displaced as one large fragment with only slight central depression and comminution. Open treatment of tibial plateau fractures is made easier by the use of the AO large distractor. For lateral plateau fractures, one bicortical pin is inserted just anterior to the lateral femoral epicondyle, parallel to the joint. The second pin is inserted into the lateral tibial cortex, distal to the site of proposed fixation, in the midcoronal plane, perpendicular to the tibia. As the distractor is lengthened, much of the reduction is attained by ligamentotaxis. The use of this device also permits improved intraarticular visualization for reduction. Because the femoral pin is located near the center of rotation of the femoral condyle, the fracture is minimally disturbed by flexion and extension of the knee in attempts to locate the fracture lines and fix the plateau. 

 

OPEN REDUCTION AND FIXATION OF A LATERAL TIBIAL PLATEAU FRACTURE TECHNIQUE 54.14 The procedure typically is done under tourniquet control. For fractures of the lateral condyle, make a straight or slightly curvilinear anterolateral incision, starting 3 to 5 cm above the joint line proximally and extending distally below the inferior margin of the fracture site from just anterior to the lateral femoral epicondyle to Gerdy’s tubercle. This incision provides good exposure while avoiding skin complications. n  Make the fascial incision in line with the skin incision. Do not undermine soft-tissue flaps more than necessary. Reflect the iliotibial band from its insertion on Gerdy’s tubercle both anteriorly and posteriorly. Gain intraarticular exposure by incising the coronary or inframeniscotibial ligament by submeniscal arthrotomy and retract the meniscus superiorly after placement of nonabsorbable meniscocapsular tagging sutures. n  Inspect and debride or repair any meniscal tears to preserve as much of the meniscus as possible. n  To expose the longitudinal fracture of the lateral condyle, elevate the origin of the extensor muscles from the anterolateral aspect of the condyle in an extraperiosteal n  n 

fashion. Reflect the muscle origin laterally until the fracture line is exposed. n  Retract the lateral fragment to gain access to the central part of the tibial condyle. This lateral fragment often hinges open like a book, exposing the depressed articular surface and cancellous bone of the central depression. n  Alternatively, make a cortical window below the area of depression to allow reduction of this fragment. This approach generally requires less soft-tissue dissection than hinging open the lateral condylar fragment. n  Insert a periosteal elevator or osteotome well beneath the depressed articular fragments, and by slow and meticulous pressure elevate the articular fragments and compressed cancellous bone in one large mass (Fig. 54.56). Take as much cancellous bone as possible. This produces a large cavity in the metaphysis that must be filled with bone graft or substitute. Unless this is done, redisplacement and settling can occur. Various types of grafts have been proposed, from transverse cortical supports to full-thickness iliac grafts. We prefer injectable bone substitutes or allograft for metaphyseal subchondral defect management after elevation of depressed articular segments. Recent data support the use of structural allograft to reduce the risk of articular subsidence with satisfactory clinical outcomes. n  The standard lateral approach gives only a limited view of the posterolateral plateau and provides no access to the posterior wall of the lateral tibial plateau. Certain fractures located in the posterolateral plateau require a more extensile approach. In this situation, the fascial incision follows the insertion of the extensor muscles and continues over the subcapital fibula. The entire layer is stripped distally as required. Expose the peroneal nerve and cut the fibular neck with an oscillating saw. This allows retraction of the upper segment to the back or rotation of the fibular head upward, exposing the posterolateral plateau and the lateral and posterior flare of the proximal tibia. n  If displacement of the peripheral rim is slight and central depression of the condyle is the main deformity, remove an anterior cortical window with its proximal edge distal to the articular surface. n  Insert a curved bone tamp through the cortical window or fracture line into the cancellous subchondral bone, and elevate to the normal level the depressed fragments of the articular surface as seen through the submeniscal arthrotomy. As the fragments are elevated and reduced, temporarily fix them with multiple small Kirschner wires. Stabilize with subchondral raft screw fixation. The Kirschner wires can be advanced through the soft-tissue envelope medially and then extracted from the medial side until flush with the lateral cortex. n  Apply a buttress plate to the anterolateral proximal tibia. Precontoured periarticular plates designed for tibial plateau fractures are readily available, typically in either a 3.5- or 4.5-mm dimension. Depending on the fit of the implant, one may choose to place separate raft screws before affixing the plate to ensure subchondral support of newly elevated articular segments. Typically, for simple lateral condylar fractures alone, nonlocking 3.5-mm implants are sufficient. n  Augment the defect with cancellous bone or bone graft substitute.

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FIGURE 54.56 Periosteal elevator or similar instrument is introduced below level of depressed tibial plateau fragment. With careful and gentle upward pressure, articular fragments are elevated. SEE TECHNIQUE 54.14.

bony tunnels or with a small fragment screw if the eminence fragment is large enough. Midsubstance tears of the anterior cruciate ligament should be reconstructed later if significant laxity remains after fracture healing. Acute midsubstance tears of the medial collateral ligament usually heal satisfactorily with nonoperative treatment. Because the increased surgical exposure necessary to repair the ligament and postoperative immobilization that is required can lead to increased knee stiffness, acute repair of the medial collateral ligament is infrequently indicated. Collateral ligament injuries should be protected with a hinged knee brace. If the medial collateral ligament is repaired, a separate medial incision is required as described for the repair of the medial collateral ligament. Although early motion after fixation of tibial condylar fractures is desirable, motion may be delayed if repair of an acute collateral ligament injury also is involved. 

ARTHROSCOPICALLY ASSISTED REDUCTION AND FIXATION OF TIBIAL PLATEAU FRACTURES

The meniscocapsular tagging sutures can then be incorporated in the repair, either through the plate or the iliotibial band. 

n 

POSTOPERATIVE CARE The knee is placed into a removable knee immobilizer. At 1 to 2 days postoperatively, physical therapy is initiated with quadriceps exercises and gentle active-assisted exercises are begun, or a passive motion machine can be used. Crutch walking is begun, but no weight bearing is permitted for 10 to 12 weeks.   

LIGAMENT INJURY WITH CONDYLAR FRACTURE

Collateral and cruciate ligament injuries occurring with tibial condylar fractures are much more common than previously realized and, if untreated, may be responsible for instability and a poor late result, despite a well-healed condylar fracture. An increased incidence of posttraumatic arthritis has been found after tibial plateau fractures with concomitant ligamentous injury. Ligamentous injuries have been reported in 4% to 33% of tibial plateau fractures and 60% of fracture-dislocations. The medial collateral ligament is most commonly injured, usually with undisplaced or local depression fractures of the lateral tibial condyle. Stress radiographs are helpful in making this diagnosis. A prospective study of 30 tibial plateau fractures with operative repair, found a 56% incidence of additional soft-tissue injury; 20% of fractures were associated with meniscal tears, 20% had medial collateral ligament injury, 10% had anterior cruciate ligament injury, 3% had lateral collateral ligament injury, and 3% had peroneal nerve injury. Medial collateral ligament injury occurred most often with Schatzker type II fractures, whereas meniscal injury occurred most often with Schatzker type IV fractures. Preoperative and postoperative stress examination of the knee is recommended to detect ligamentous injury. Residual laxity after anatomic reduction of the tibial plateau indicates ligamentous injury. If the intercondylar eminences of the tibia are fractured and displaced, these should be replaced and secured at the time of open reduction of the condyle. Fixation can be done with sutures passed through

Arthroscopic techniques require minimal soft-tissue dissection, afford excellent exposure of the articular surface, and can be used to diagnose and treat concomitant meniscal injury. Buchko and Johnson described an arthroscopic technique in which the affected extremity is placed in a thigh holder, a tourniquet is inflated, and an anterolateral arthroscopic portal is placed approximately 2 cm above the joint line to enable the surgeon to look downward on the tibial plateau. A complete diagnostic assessment is performed. A low-pressure arthroscopic pump can be used but is not mandatory, although it improves exposure and facilitates joint lavage. If the pump is used for extracapsular fractures, the metaphyseal portion of the fracture site should be exposed to prevent extravasation of irrigation fluid into the soft tissues. This incision can be used later to create a bony window for reduction and bone grafting. Schatzker type III fractures usually are intraarticular, and extravasation is less of a concern. The joint should be thoroughly lavaged to evacuate the hemarthrosis and remove loose bony and chondral fragments. When the diagnostic evaluation has been completed, the reduction can be performed with the pump off or as a dry arthroscopic technique. If the lateral meniscus is entrapped in the fracture site, it can be lifted out with a hook. Meniscal tears usually can be repaired and should be treated accordingly. Depressed fragments can be elevated through a small cortical window. The depressed fragment can be localized by using an anterior cruciate ligament tibial guide to place a Kirschner wire into the displaced fragment. The fragment can be elevated using a cannulated impactor. The reduction can be evaluated accurately through the arthroscope, and the resulting defect can be filled with autogenous bone graft or appropriate bone graft substitute. Fixation is achieved with percutaneously placed 3.5-mm cortical screws. Because buttress plating may be necessary in patients with osteoporotic bone, arthroscopically assisted reduction is less suitable for this patient population. Small clinical series using arthroscopically assisted reduction and fixation techniques in predominantly Schatzker type I, type II, and type III tibial plateau fractures have shown good or excellent results in 80% to 100% of patients. 

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY

FRACTURE OF THE MEDIAL CONDYLE

The location of the distal extent of the medial condyle on CT aids in determining the ideal location for the surgical incision. n  The goal of internal fixation application should be a stable buttress construct. To achieve this goal, internal fixation should be positioned over the apex of the fracture distally. n  Most medial and posteromedial condyle fractures can be fixed through a posteromedial surgical approach, otherwise a posterior approach should be considered. n  Mark the proposed skin incision with surgical indelible ink just posterior and parallel to the posteromedial tibial border. n  Divide the skin and subcutaneous tissues sharply and mobilize the inferior border or the pes anserinus tendons, and then use the interval created with the medial head of the gastrocnemius. n  At times, mobilization of the superior border of the pes anserinus tendons may be necessary for fracture fixation. Alternatively, if a more extensile exposure is necessary, the pes anserinus tendons can be released and subsequently repaired. n  Perform reduction and internal fixation using a 3.5-mm small fragment plate centered over the apex of the distal fracture extension. This approach can be used in conjunction with lateral condylar fixation through an anterolateral approach to treat bicondylar injuries. n  The incision can be placed farther anteriorly if the fracture pattern dictates. Although infrequently necessary, extensile medial approaches have been advocated through anterior midline incisions for medial condyle fractures of the proximal tibia.    n 

If open reduction, elevation, and internal fixation of the medial tibial condyle are required, a technique similar to that previously described for the lateral tibial condyle is done. The fracture can be approached through a straight anterior, anteromedial, or posteromedial incision. For split compression and total depression fractures of the medial tibial condyle, in addition to elevating the depressed fragment and packing bone beneath it, a medial buttressing plate should be applied. This can be bent to an accurate contour to fit the tibial metaphysis and the tibial condyle, and the fracture can be secured with cancellous or cortical locking screws in the proximal portion of the plate and standard cortical screws in the distal portion (Fig. 54.57). More complex fractures of the medial plateau may require a more extensile exposure. Alternatively, for isolated medial injuries with joint impaction, an anterior parapatellar approach can be used to permit visualization of the articular reduction. 

 

POSTEROMEDIAL EXPOSURE TECHNIQUE 54.15 Critically evaluate the preoperative imaging and the patient’s soft-tissue envelope to ensure satisfactory edema resolution before proceeding.

n 

A

B

FIGURE 54.57 A, Medial tibial plateau fracture-dislocation injury. B, Reduction and stabilization of displaced medial tibial condyle through posteromedial approach allowing buttress plate fixation.

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COMMINUTED PROXIMAL FRACTURES

In the past, anatomic reduction through extensive exposures and rigid fixation with multiple large fragment plates have been advocated for the treatment of bicondylar tibial plateau fractures. The unacceptable incidence of wound and infectious complications often associated with these techniques has led to the development of alternative treatment strategies. Currently accepted techniques include indirect reduction, less extensive surgical exposures, buttress plate fixation of the most comminuted condyle, and fixation of the less involved condyle with smaller implants, such as cannulated screws, and antiglide plates. Ring-and-wire fixators with or without limited open reduction are also being used to treat these difficult fractures. Preoperative CT scans are essential in planning a strategy for treatment. ORIF is delayed for 7 to 10 days (sometimes longer) until edema and soft-tissue injury have subsided. If surgery is delayed, temporary uniplanar external fixation spanning the knee is a valuable technique for both skeletal and soft-tissue stabilization until definitive fixation can occur. 

between the medial and lateral condyles. Subchondral rafting screws can then be positioned. The ability to use these screws is somewhat dependent on the “fit” of the lateral plate, given the variable proximal tibial anatomy. If the plate seems to fit more distally, then proceed with placement of subchondral rafting interfragmentary lag screws independent of the plate. Otherwise, the proximalmost screws of the plate can serve this function. n  Perform definitive anterolateral fixation with a precontoured proximal tibial plate, whose proximal fixation allows capture of the medial condylar segment. n  Any residual cancellous void from elevation of articular depression can then be treated as previously described. (see Technique 54.14) 

POSTOPERATIVE CARE  Active and active-assisted exercises, including controlled passive motion, are instituted. Weight bearing is not permitted for 10 to 12 weeks postoperatively. Any associated soft-tissue issues may delay initiation of aggressive motion, as do certain fracture patterns such as those involving the tibial tubercle.    

 

OPEN REDUCTION AND INTERNAL FIXATION OF BICONDYLAR INJURIES The surgical approach to complex tibial plateau fractures must be individualized on the basis of particular fracture configuration. The following is a general approach applicable to many of these fractures.

TECHNIQUE 54.17 Position the patient on a fracture table or radiolucent operating table. n  Apply calcaneal or distal tibial pin traction. Ensure that sufficient clearance exists around the limb for placement of appropriately sized circular rings. Fixator rings should allow 1.5 cm of clearance over the anterior crest of the tibia and 3 to 4 cm of clearance around the posterior calf. n  When the patient is positioned, apply traction and obtain reduction using ligamentotaxis. n  Achieve further closed manipulation by using large reduction forceps. n  If any articular depression is not reduced by ligamentotaxis alone, use a limited approach through a CT-directed incision to ensure minimal soft-tissue dissection and reduction of the articular surface (Fig. 54.58A). n  Perform bone grafting. n  After reduction of the condyles, use olive wires (1.8-mm Kirschner wires with a 4-mm bead located eccentrically on the wire) to achieve interfragmentary compression of the condylar surface (Fig. 54.58B). Place counteropposed olive wires through the fragments, coming from opposite sides of the major condylar fracture lines to maintain condylar reduction. Cannulated screws can be substituted for olive wires if fragments are not extensively comminuted. Use fluoroscopy for placement and direction of the periarticular olive wires and for tensioning of the wires. Three or four olive wires usually are required for stabilization of the condylar and metaphyseal fragments. n 

Place the patient supine on the fluoroscopic table. Based on imaging studies, as well as careful preoperative planning, mark the proposed surgical incisions, both medially and laterally, which aids in confirming that a sufficient soft-tissue bridge will be present to minimize the potential for soft-tissue complications. n  Typically, the posteromedial approach is performed as described earlier. This permits reduction and stabilization of the medial condylar segment of the injury, thus effectively converting the injury to a unicondylar fracture. Small fragment plates (3.5-mm; one third tubular, reconstruction, or T-plates) are commonly used. Fortunately, medial condylar impaction is rare. Medial condylar fixation can be applied as a true antiglide buttress plate, without proximal screw fixation, particularly when comminution is absent. When apical comminution is present, proximal fixation may be necessary to maintain reduction. We have found temporary unicortical locking screws to be of benefit. This technique prevents longer screws from interfering with the lateral reduction. Once the lateral reduction and fixation are complete, these unicortical screws can be exchanged for longer implants if necessary. n  Expose the lateral condylar component as described earlier, through an anterolateral approach, with meticulous soft-tissue handling as also described earlier. Correct articular comminution or depression and any meniscal pathologic process and stabilize the fracture provisionally. Large periarticular clamps often are used to effect compression n 

CIRCULAR EXTERNAL FIXATION

(WATSON)

TECHNIQUE 54.16 n 

 

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY bearing is instituted. When radiographic consolidation has occurred, the external fixation frame can be removed. The patient is placed in a hinged knee brace to aid in rehabilitation.    

PATELLA

B

A

FIGURE 54.58 A, Elevation of depressed plateau. B, Placement of opposing olive wires and cannulated screw after bone grafting. SEE TECHNIQUE 54.17.

Open the frame by removing the anterior connecting bolts of each ring and place the frame over the leg. n  Reattach the anterior connecting bolts. n  Temporarily place the proximal ring below the level of condylar involvement. After condylar reduction, it is slid proximally on the threaded rods to the level of the fibular head, and eventually all the proximal wires are attached to this fixation ring. Position the middle ring just distal to any shaft fracture component and place the distal ring at the level of the ankle joint. If extensive shaft comminution is present, apply an additional ring to the midportion of the shaft to complete a four-ring frame. Attach the proximal ring to the proximal wires, taking care that the proximal ring is parallel to the joint. Pass a distal transfixion wire at the level of the distal tibia and parallel to the ankle joint. When this wire is attached and tensioned to the distal ring, ensure appropriate alignment of the mechanical axis by forcing the proximal and distal rings to become parallel to each other; the joints also are parallel. n  It also is possible to use the fibular head as a buttress plate. By placing an olive wire through the fibular head obliquely into the lateral condyle and tensioning this olive wire, the fibular head is compressed onto the lateral condyle.  n 

POSTOPERATIVE CARE  Weight bearing is delayed for 10 to 12 weeks to allow all intraarticular fracture lines and bone grafts to consolidate, and progressive weight

Fractures of the patella constitute almost 1% of all skeletal injuries, resulting from either direct or indirect trauma. The anterior subcutaneous location of the patella makes it vulnerable to direct trauma, such as the knee striking the dashboard of a motor vehicle or from a fall on the anterior knee. These injuries often are comminuted or displaced and may include chondral injury to the distal femur or patella. Fractures caused by indirect mechanisms result from a violent contraction of the quadriceps with the knee flexed. These fractures usually are transverse and may be associated with tears of the medial and lateral retinacular expansions. Most patellar fractures are caused by a combination of direct and indirect forces. The most significant effects of fracture of the patella are loss of continuity of the extensor mechanism of the knee and potential incongruity of the patellofemoral articulation. Fractures of the patella can be classified as undisplaced or displaced and subclassified further according to fracture configuration (Fig. 54.59). Transverse fractures usually involve the central third of the patella but can involve the proximal (apical) or distal (basal) poles. A variable amount of comminution of the poles may be present. Most fractures in reported series are transverse. Vertical fractures usually involve the middle and lateral thirds of the patella. If only the medial or lateral edge of the patella is affected, the fracture is called marginal. Vertical fractures are seen best on axial radiographs of the patella; displacement and retinacular disruption rarely occur in vertical fractures. Another common fracture pattern is the comminuted or stellate patellar fracture, which is associated with a variable amount of displacement. Patellar fractures generally are associated with a hemarthrosis and localized tenderness. In fractures that are displaced or have concomitant retinacular tears, a palpable defect may be present. Inability of the patient to extend the affected knee actively usually indicates a disruption of the extensor mechanism and a torn retinaculum, which require surgical treatment. Occasionally, if active knee extension is limited by pain, the hemarthrosis can be aspirated under sterile conditions and followed by intraarticular injection of local anesthetic. In patients without significant impairment of the extensor mechanism, active knee extension should be restored. An open wound in the vicinity of a patellar fracture may be a sign of an open fracture, which requires urgent surgical treatment. If uncertainty exists as to whether the open wound communicates with the joint, the saline load test can be used. This test may not be 100% reliable in open fractures with very small traumatic arthrotomies. Patellar fractures should be radiographically evaluated with anteroposterior, lateral, and axial (Merchant) views. Transverse fractures usually are best seen on a lateral view, whereas vertical fractures, osteochondral fractures, and articular incongruity are best evaluated on axial views. A comparison view of the opposite knee sometimes is necessary to differentiate an acute fracture from a bipartite patella, which

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Undisplaced

Transverse

Comminuted displaced

Lower or upper pole

Vertical

Comminuted undisplaced

Osteochondral

FIGURE 54.59 Classification of patellar fractures. (Redrawn from Wiss DA, Watson JT, Johnson EE: Fractures of the knee. In Rockwood CA Jr, Green DP, Bucholz RW, et al. editors: Rockwood and Green’s fractures in adults, ed 4, Philadelphia, 1996, Lippincott-Raven.)

is a failure of fusion of the superolateral portion of the patella and which usually is bilateral.

TREATMENT

The initial treatment of acute patellar fractures should consist of splinting the extremity in extension and applying ice to the knee. To prevent soft-tissue damage, the ice should not be applied directly to the skin. Closed fractures with minimal displacement, minimal articular incongruity, and an intact extensor retinaculum can be successfully treated nonoperatively. Nonoperative treatment consists of immobilizing the knee in extension in a cylinder cast or orthosis from ankle to groin for 4 to 6 weeks, with weight bearing allowed as tolerated. Boström considered 3 to 4 mm of fragment separation and 2 to 3 mm of articular incongruity to be acceptable for nonoperative treatment; if either separation or articular incongruity is greater, operative treatment is indicated. In his long-term follow-up study, fractures treated nonoperatively had the best overall results. Fractures associated with retinacular tears, open fractures, and fractures with more than 2 to 3 mm of displacement or incongruity are best treated operatively. The goal is restoration of articular congruity and repair of the extensor mechanism with fixation secure enough to allow early motion. When the skin is normal, the operation should be done as soon as is practical. Delay retards convalescence and to some extent unfavorably affects the result. If contusion or laceration of the skin is present, it usually is best to perform the indicated operation immediately on admission to the hospital or very soon thereafter. When lacerations or abrasions become superficially infected, surgery must be delayed 7 to 10 days until the danger of contaminating the operative wound is minimal. Opinions differ as to the optimal treatment of patellar fractures. Accepted methods include a variety of wiring techniques, screw fixation, partial patellectomy, and total patellectomy. Open fractures of the patella are a surgical urgency and should be treated with immediate debridement and irrigation. Early soft-tissue coverage (within 5 days) should reduce the incidence of infection. The same surgical techniques used to treat closed patellar fractures can be used successfully for

open fractures. Two series reported 77% good or excellent results after operative treatment of open patellar fractures. In open fractures, soft-tissue stripping should be kept to the minimum necessary to stabilize the fracture adequately. Torchia and Lewellen discouraged the use of cerclage wires in open fractures because of the potential adverse effects on vascularity. Wiring techniques are used most often for transverse fractures. They also can be used in comminuted fractures if the fragments are large enough to lag together with screws, converting it to a transverse fracture. Many different wiring techniques have been described, including cerclage wiring, alone or in combination; tension band wiring, alone or modified with longitudinal Kirschner wires or screws; Magnusson wiring; and Lotke longitudinal anterior band wiring (Fig. 54.60). In experimental studies, the most secure fixation was obtained with modified tension band wiring. This is especially useful in osteopenic and comminuted fractures. Anchoring the fixation wiring directly in bone rather than threading it through the soft tissue around the patella has been recommended if early motion is to be initiated. Also, a second tension band wire through tendon has been shown to provide improved fixation. Two screws alone provide adequate fixation in fractures with good bone stock; however, displacement of fragments is slightly greater with screws alone without tension band wiring. A cadaver study found that specimens fixed with the tension band through cannulated screws failed at the highest load. Good-to-excellent results have been described after fixation of displaced transverse patellar fractures with figure-ofeight wiring through parallel cannulated compression screws. Suggested advantages of this technique included a low-profile construct that caused less implant irritation of local soft-tissue structures, the possibility of early restricted motion, and its use as a salvage method after failure of traditional tension band wiring. We currently prefer a tension band modified with Kirschner wires or screws for transverse fractures with large fragments. If comminution is present, a cerclage wire can be added. The results of tension band wiring techniques generally are good (81%), but 2 mm of displacement has been reported in 22% of fractures treated with tension band fixation and early motion. Noncompliance and technical errors have been cited as reasons for displacement. Braided polyester and braided cable have been used and seem to provide fixation similar to stainless steel wire. Arthroscopically assisted percutaneous screw fixation also has been described for fixation of displaced transverse patellar fractures with good results. If the amount of comminution and the articular damage preclude salvage of the entire patella, partial or total patellectomy may be indicated. Although Brooke proposed in 1937 that the patella is not a functional organ, later studies refuted this claim. Haxton studied patients with and without patellae and showed that the power of extension of the knee increases as the joint extends; that is, the power of extension is greater with the knee at 30 degrees of flexion than at 60, 90, or 120 degrees. Kaufer compared intact and patellectomized cadaver knees and found that 15% to 30% more quadriceps force was required to fully extend patellectomized knees than intact knees. The effect of patellectomy was eliminated by elevation of the tibial tubercle 1.5 cm. Because extension is the

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY

A

B

C

FIGURE 54.60 Types of patellar fixation. A, Modified tension band. B, Lotke longitudinal anterior band (LAB) wiring. C, Magnusson wiring. SEE TECHNIQUE 54.20.

most important function of the knee, it must be concluded that patellectomy definitely impairs the efficiency of the quadriceps mechanism. This may not be enough to interfere with ordinary activities, and we have not found tibial tubercle elevation after patellectomy to be necessary. Two separate series with longterm follow-up reported reduction in quadriceps strength of 33% and 44%, respectively, after patellectomy. Comparison of anterior tension band fixation with patellectomy found 80% excellent results after osteosynthesis compared with 50% excellent results after patellectomy. In an effort to maintain the length of the patella and allow earlier motion, techniques have been developed to preserve rather than excise the inferior pole of the patella in comminuted fractures. Yang and Byun reported good functional results and no implant failure, infections, delayed unions, or nonunions in 25 patients treated with a separate vertical wiring technique for comminuted fractures of the inferior pole of the patella. The vertical wire technique also proved to be stronger than a partial patellectomy and pull-out sutures in biomechanical testing on cadavers. Matejcic et al. described the use of a basket plate for fixation of comminuted inferior pole patellar fractures. In 51 patients, results were excellent in 30, good in 16, and satisfactory in five. There were no poor results. Because of the objections to patellectomy, we try to save all of the patella or at least the proximal or distal third if practical. If the distal or proximal pole of the patella is comminuted, the small fragments are removed but the largest fragment is preserved. When comminution is extensive and reconstruction of the articular surface is impossible, complete patellectomy is performed. Despite the frequent occurrence of quadriceps weakness and atrophy, good or excellent results are noted after patellectomy in 78% of patients at long-term follow-up. A recent comparison of ORIF with partial patellectomy for patellar fractures found persistent functional impairment and equal range of motion, functional scores, and complication rates between the two modalities. When partial patellectomy is chosen, as much of the patella as possible should be salvaged. Larger pieces can be secured together with interfragmentary screws to increase the size of the patellar remnant. The comminuted fragments are removed, and the extensor mechanism is reattached to the patella through drill holes. The size of the patellar fragment worth salvaging is controversial. Measurement of patellofemoral contact areas and patellofemoral pressures in cadaver knees before and after partial patellectomy found marked alterations in patellofemoral contact area in specimens after 60% patellectomy with a contact area less than 50% of controls. Saltzman et  al. found that the area of the salvaged

fragment averaged 11.8 cm2 and that only one specimen was less than 4.1 cm2. At an average 8-year follow-up, 78% of patients had good or excellent results, range of motion averaged 94% of normal, and average strength was 85% of normal. Patellofemoral arthritis developed in 53%. The size of the retained fragment did not correlate with the result. The proper site of insertion of the patellar tendon into the patellar remnant after partial patellectomy also has been controversial. Reinserting the patellar tendon anteriorly on the patella has been shown to cause excessive tilting of the lower pole of the patella toward the femoral articular surface and lead to patellofemoral arthritis, and reattachment of the patellar tendon near the articular edge of the patella has been recommended. However, posterior attachment of the patellar tendon near the articular surface was found to cause tilting of the proximal pole of the patella toward the femoral articular surface and that anterior reattachment of the patellar tendon restored a more normal pattern of patellofemoral contact. In a cadaver model, the forces required to extend the knee were significantly higher when the patellar tendon was reattached near the articular surface, but forces were increased when the tendon was reattached to the anterior cortex. Whatever site of reattachment is chosen, intraoperative radiographs should be evaluated carefully to ensure that the extensor mechanism is not excessively shortened and that the remaining patella is not tilted. Comparison of the results of simple patellectomy with the results of patellectomy with advancement of the vastus medialis obliquus at a minimum 3-year follow-up determined that results were significantly better in patients with vastus medialis obliquus advancement. Open reduction and external fixation using superior and inferior pins placed transversely, adjacent to the proximal and distal poles, and connected externally to compressive clamps has been used successfully to treat transverse and comminuted fractures. Others have advocated application of circular external fixation under arthroscopic control and plating techniques. Recent series have advocated the use of minifragment augmentation to tension band fixation and locked mesh-plate fixation for comminuted fractures of the patella. Lazaro et al. reported a series of 36 patients. They demonstrated 37% removal of implants, patella baja in 57%, and anterior knee pain in 80% during activities of daily living. Improvement was noted over the first 6 months; however, functional impairments persisted at 1-year follow-up, noting deficits in strength, power, and endurance. Bonnaig et al. reported 73 patients with functional outcome data at 1 year, noting that functional impairment persisted at 1-year minimum follow-up, and ORIF scored similarly to partial

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS patellectomy for range of motion, functional scores, and complications. Lazaro et al. reported outcomes after operative fixation of complete articular patellar fractures. Functional impairment was noted with a decrease in extensor mechanism strength, power, and endurance. In this series, 37% underwent removal of symptomatic implants, and 80% had anterior knee pain during activities of daily living. LeBrun et al. also noted persistent symptoms at a mean of 6.5-year follow-up. Removal of symptomatic implants occurred in 52%. 

achieved, so a delay of 3 to 4 weeks in starting knee motion is necessary if this technique is used. It has largely been replaced by more rigid fixation techniques to permit early motion of the joint, although it can be used in conjunction with other techniques for fixation of comminuted fractures. We frequently use a variation of this technique for augmentation of a repair with nonabsorbable suture.

TECHNIQUE 54.19 (MARTIN)

 

COMMON APPROACH AND TECHNIQUE FOR PATELLAR FRACTURES

Begin threading a No. 18 stainless steel wire at the superolateral border of the patella, passing it transversely immediately next to the superior pole of the patella through the quadriceps tendon. n  Pass the wire through the tissue using a large Gallie needle, or thread it through a large Intracath needle inserted with the sharp point exiting at the site where the next suture is desired. n  Fit the No. 18 wire into the sharp end of the Intracath needle, and as the needle is withdrawn, pass the No. 18 wire along its path within the needle. This usually is easier than using the large Gallie needle because of the stiffness of the No. 18 wire. n  Pass the medial end of the wire in a similar manner along the medial border of both fragments midway between the anterior and posterior surfaces. n  Pass the medial end of the wire transversely through the patellar tendon from the medial to the lateral side around the distal border of the patella and then proximally along the lateral side of the patella to the superolateral border. The wire must be placed close to the patella, especially above and below; if it is inserted through the tendons away from the fragments, fixation is insecure because the wire cuts through the soft tissues when under tension and allows separation of the fragments. Centering the wire midway between the anterior and posterior surfaces keeps the fracture line from opening anteriorly or posteriorly as the circumferential wire is tightened. n  Approximate the fragments and hold them in position with a towel clip or bone-holding forceps; draw both ends of the wire until they are tight and twist them together. n  Confirm the position of the fragments, especially the relationship of the articular surfaces, by radiographs of the knee in the anteroposterior and the lateral planes and by direct inspection and palpation before the capsular tears are repaired. n  Cut off the redundant wire and depress the twisted ends into the quadriceps tendon. n  Repair the capsular tears with interrupted suture. n  A pretwisted wire that is tightened by twists at two points opposite each other supplies more even pressure and fixation across the fracture site. Placing the first twist in the wire before beginning its insertion allows for this extra site for tightening.  n 

TECHNIQUE 54.18 Make a longitudinal midline incision, our preference. Alternatively, a transverse curved incision can be made approximately 12.5 cm long with the apex of the curve on the distal fragment, which gives enough exposure for reduction of the fracture and repair of the ruptured extensor expansion and synovium. If an area of skin is severely contused, attempt to avoid it or elect to excise a small area because skin closure produces no significant difficulty. n  Reflect the skin and subcutaneous tissue proximally and distally to expose the entire anterior surface of the patella and the quadriceps and patellar tendons. If the fracture fragments are significantly separated, tears in the extensor expansion are presumed, and these must be carefully explored medially and laterally. n  Remove all small, detached fragments of bone and inspect the interior of the joint and especially the patellofemoral groove for an osteochondral fracture. n  Thoroughly irrigate the interior of the joint to remove blood clots and small particles of bone. n  Anatomically reduce the fracture fragments using large towel clips or appropriate bone-holding forceps and fix the fragments internally by the method preferred by the surgeon. Inspect the articular surface after fixation to ensure that the reduction is anatomic. n  Carefully repair with interrupted sutures the synovium, ruptured capsule, and extensor mechanism from their outer ends toward the midline of the joint.     n 

 

CIRCUMFERENTIAL WIRE LOOP FIXATION Circumferential wire loop fixation was formerly the most popular technique. With the loop threaded through the soft tissues around the patella, rigid fixation is not

POSTOPERATIVE CARE  A posterior splint from groin to ankle provides sufficient immobilization during the early

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY postoperative period. The patient is encouraged to perform quadriceps-setting exercises and within a few days should be lifting the leg off the bed. At 10 to 14 days, the sutures are removed and a cylinder cast or knee immobilizer is applied with the knee in extension. The patient is allowed to be ambulatory, using crutches when active muscular control of the leg has been obtained. As muscle power returns, the crutches are discarded, usually at 6 to 8 weeks. After fracture union, the wire can be removed; if not, it eventually may break, become painful, and be difficult to remove. The twisted ends usually can be located through a small stab incision; the wire is cut near the ends and is withdrawn with little difficulty. We have used heavy synthetic sutures instead of wire, and some data suggest comparable performance with potentially less soft-tissue irritation compared to traditional wire.    

 

TENSION BAND WIRING FIXATION The AO group has used and recommended a tension band wiring principle for fixation of fractures of the patella. By proper placement of the wires, the distracting or shear forces tending to separate the fragments are converted into compressive forces across the fracture site (see Fig. 54.60), resulting in earlier union and allowing immediate motion and exercise of the knee. Generally, two sets of wire are used. One is passed transversely through the insertion of the quadriceps tendon immediately adjacent to the bone of the superior pole and then passed anteriorly over the superficial surface of the patella and in a similar way through the insertion of the patellar tendon. This wire is tightened until the fracture is slightly overcorrected or opened on the articular surface. The second wire is passed through transverse holes drilled in the superior and inferior poles of the anterior patellar surface and tightened. The capsular tears are repaired in the usual manner. The knee is immobilized in flexion, and early active flexion produces compressive forces to keep the edges of the articular surface of the patella compressed together. Early active flexion exercises are essential for the tension band principle to work. Schauwecker described a similar technique in which the wire is crossed in a figure-of-eight over the anterior surface of the patella (Fig. 54.61). Supplemental lag screws or Kirschner wires can be used to increase fixation in comminuted fractures (Fig. 54.62). Our preference is to use cannulated screws with a figure-of-eight tension band wire for those fractures that can be anatomically reduced.

TECHNIQUE 54.20 Approach the patellar fracture in the usual fashion. Carefully clean the fracture surfaces of blood clot and small fragments. n  Explore the extent of the retinacular tears and inspect the trochlear groove of the femur for damage. n  Thoroughly lavage the joint. n  n 

FIGURE 54.61 Schauwecker technique of tension band wiring of patella. SEE TECHNIQUE 54.20.

If the major proximal and distal fragments are large, reduce them accurately, with special attention to restoring a smooth articular surface. n  With the fracture reduced and held firmly with clamps, drill two 2-mm Kirschner wires from inferior to superior through each fragment. Place these wires about 5 mm deep to the anterior surface of the patella along lines dividing the patella into medial, central, and lateral thirds. Insert the wires as parallel as possible. In some cases, it is easier to insert the wires through the fracture site into the proximal fragment in a retrograde manner before reduction. This is made easier by tilting the fracture anteriorly about 90 degrees. n  Withdraw the wires until they are flush with the fracture site, accurately reduce the fracture and hold it with clamps, and drive the wires through the distal fragment. Leave the ends of the wires long, protruding beyond the patella and quadriceps tendon attachments to the inferior and superior fragments. n  Pass a strand of 18-gauge wire transversely through the quadriceps tendon attachment, as close to the bone as possible, deep to the protruding Kirschner wires, over the anterior surface of the reduced patella, transversely through the patellar tendon attachment on the inferior fragment and deep to the protruding Kirschner wires, and back over the anterior patellar surface; tighten it at the upper end. Alternatively, place the wire in a figure-ofeight fashion. n  Check the reduction by palpating the undersurface of the patella with the knee extended. If necessary, make a small longitudinal incision in the retinaculum to allow insertion of the finger. n  Bend the upper ends of the two Kirschner wires acutely anteriorly and cut them short. n  When they are cut, rotate the Kirschner wires 180 degrees; with an impactor, embed the bent ends into the superior margin of the patella posterior to the wire loops. Cut the protruding ends of the Kirschner wires short inferiorly. n  Repair the retinacular tears with multiple interrupted sutures. n  Alternatively, 4.0-mm partially threaded cannulated screws can be used instead of Kirschner wires (Fig. 54.63). Minifragment lag screws also can be placed horizontally to join comminuted fracture fragments, converting a comminuted fracture to a transverse fracture pattern. A n 

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A

B

C

FIGURE 54.62 A-C, Schauwecker method of compression wiring of patella using supplemental screws for comminuted fracture (C). Comminuted fragments (A) are transformed with screws into bifragmental fracture (B). SEE TECHNIQUE 54.20.

B

A

FIGURE 54.63 A and B, Displaced transverse fracture of patella fixed with tension band wires using two anterior wire loops and two longitudinally directed screws. SEE TECHNIQUE 54.20.

modified anterior tension band technique can be used. If the anterior cortex is split from the articular surface in the coronal plane, the fragment often can be secured with the anterior tension band wire. If this is unsuccessful, the fragment can be excised. As with all patellar repairs, a gravity flexion test is performed intraoperatively to determine stability, and range of motion can be initiated early in the postoperative course. 

POSTOPERATIVE CARE  The limb is placed in extension in a posterior plaster splint or removable knee brace. The patient is allowed to ambulate while bearing weight as tolerated on the first postoperative day. Isometric and stiff-leg exercises are encouraged, beginning on the first postoperative day. The extent of active motion permitted in the immediate postoperative period is determined intraoperatively based on the fracture repair stability. Active range-of-motion exercises can be performed when the wound has healed, at 2 to 3 weeks. Progressive resistance exercises can be begun and

the brace discontinued at 6 to 8 weeks if healing is evident on radiograph. Unrestricted activity can be resumed when full quadriceps strength has returned, at 18 to 24 weeks. In patients with less stable fixation or extensive retinacular tears, active motion should be delayed until fracture healing has occurred. Initiating range-of-motion exercises by the sixth postoperative week is desirable but not always possible. A controlled motion knee brace can be used, allowing full extension and flexion to the degree permitted by the fixation as determined intraoperatively. If fixation is lost and the fragments separate 3 to 4 mm, or 2 to 3 mm of articular incongruity is present, revision surgery may be required. If the reduction improves with the knee in full extension, the patient can be treated by 6 weeks of splinting or casting with the knee in full extension. If the reduction does not improve, revision fixation or partial patellectomy should be considered. The implant can be removed after healing of the fracture if it causes symptoms.   

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY

A

B

C

FIGURE 54.64 Partial patellectomy (see text). A, Retained fragment is approximated to tendon with large, nonabsorbable sutures. B, Drill holes are oriented to reattach tendon close to articular surface. C, Quadriceps expansions are completely repaired. SEE TECHNIQUE 54.21.

COMMINUTED PATELLAR FRACTURES

Often, only the distal pole of the patella is fragmented, leaving a substantial and relatively normal proximal fragment. This fragment is an important part of the extensor mechanism and should be preserved. The details of suture of the patellar tendon to the fragment should be observed carefully to prevent a tilt of the fragment, which can cause erosion of the trochlear groove. 

 

PARTIAL PATELLECTOMY

With the knee slightly hyperextended, tie the sutures securely over the superior pole of the patella. The patellar tendon should evaginate and lie against the raw fractured surface of the patellar remnant near the articular surface. This prevents tilting of the fragment and contact of the raw surface with the femur. n  Occasionally, the proximal pole of the patella is comminuted, leaving a single distal fragment consisting of half or more of the bone. This fragment, provided that it contains a smooth articular surface, also should be preserved by applying the principles outlined in the technique just described. Much of the lower pole at its inferior limits is uncovered by articular cartilage.     n 

TECHNIQUE 54.21 Expose the fracture as previously described. If at least one third of the proximal third of the patella is intact, preserve it. n  Clear the joint of loose fragments of bone and cartilage. Trim away the edges of the capsule and tendon. Excise the comminuted fragments. Small flecks of bone can be left within the patellar tendon to make anchorage easier. n  Trim the articular edge of the proximal fragment and smooth it with a rasp. n  Beginning on the fracture surface of the proximal fragment just anterior to the articular cartilage, use a 2-mm Kirschner wire or 2.5-mm drill bit to drill three parallel holes in a proximal direction (one hole in the center and one each in the medial and lateral thirds). Alternatively, we routinely use a Beathe pin to create the bone tunnels and pass the suture simultaneously. n  Weave two heavy nonabsorbable sutures through the patellar tendon, one through the medial and one through the lateral half of the tendon (Fig. 54.64). Use a suture passer to pass the free proximal ends of the sutures through the holes in the patella. Place one suture end each through the medial and lateral holes and two through the central hole. n 

 

PARTIAL PATELLECTOMY USING FIGURE-OF-EIGHT LOAD-SHARING WIRE OR CABLE Because of the powerful forces generated by the quadriceps mechanism, protection of the repair often is necessary. This can be accomplished by a figure-of-eight, load-sharing wire or cable, as described by Perry et al. The cable protects the patellar tendon repair by transmitting tensile loads directly from the quadriceps tendon or proximal pole of the patella to the tibial tubercle. This technique also can be used to protect tenuous internal fixation of patellar fractures, and it allows more aggressive rehabilitation. We frequently augment an extensor mechanism repair with a nonabsorbable suture in this fashion, thus facilitating earlier range of motion.

TECHNIQUE 54.22 (PERRY ET AL.) After internal fixation or partial patellectomy with extensor mechanism repair has been done, drill a 2-mm

n 

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TECHNIQUE 54.23 Excise all the fragments, preserving as much of the patellar and quadriceps tendons as possible. n  Clear the joint of bone chips and debris by thorough irrigation. n  Place a heavy, nonabsorbable suture with a grasping technique through the margins of the patellar and quadriceps tendons and through the medial and lateral capsular expansions in a purse-string manner. n  Pull the suture taut and evaginate the tendon ends completely outside the joint. When the suture has been tightened until it makes a circle about 2 mm in diameter, tie it securely. n  Although small, this rosette of tendon may give the appearance of a small patella. Use supplemental interrupted sutures to repair the capsular rupture and to appose the quadriceps and patellar tendon ends further. The pursestring suture shortens the quadriceps mechanism and helps prevent extensor lag, which is common after patellectomy. n  A quadriceps tie-down technique can be used if insufficient tendon is available to suture the quadriceps and patellar tendons primarily. One such technique is an inverted V-plasty of the quadriceps tendon.     n 

FIGURE 54.65 After reduction and internal fixation of patellar fracture, two cables are inserted through transverse holes drilled in tibial tubercle and proximal pole of patella; they are crossed anteriorly to patellar ligament to form figure-of-eight and are crimped to each other. SEE TECHNIQUE 54.22.

hole transversely across the proximal pole of the patella and drill a second hole transversely across the tibial tubercle. n  Hyperextend the knee to relax the patellar tendon. n  Pass a heavy braided suture or a 16-gauge stainless steel wire through each of the two drill holes (Fig. 54.65). Alternatively, pass the wire or cable through the quadriceps insertion adjacent to the patella proximally, rather than through the proximal pole of the patella. n  Cross the sutures or wires anterior to the patellar tendon and tighten and crimp them to each other to form a figure of eight. As the wires are tightened, the patella tracks distally; the patellar tendon should be completely lax during this step. Avoid patella baja. n  Gently flex the knee to 90 degrees to confirm that displacement of the fracture does not occur. It is important to cross the wires anteriorly over the patellar tendon; otherwise, flexion of the knee causes the wire to displace posteriorly, which prevents it from sharing the load across the fracture site. The wire can be removed as an outpatient procedure in about 3 months or after healing of the fracture has occurred.    

 

TOTAL PATELLECTOMY In fractures in which comminution is so severe that no sizable fragments are salvageable, a total patellectomy may be indicated.

DISTAL FEMUR Supracondylar and intercondylar fractures of the distal femur historically have been difficult to treat. These fractures often are unstable and comminuted and tend to have a bimodal distribution, occurring in elderly or younger multiple-injured patients. Because of the proximity of these fractures to the knee joint, regaining full knee motion and function may be difficult. The incidences of malunion, nonunion, and infection are relatively high in many reported series. In older patients, treatment may be complicated by previous joint arthroplasty. The classification of distal femoral fractures described by Müller et  al. and expanded in the AO/OTA classification is useful in determining treatment and prognosis. It is based on the location and pattern of the fracture and considers all fractures within the transepicondylar width of the knee (Fig. 54.66). Type A fractures involve the distal shaft only with varying degrees of comminution. Type B fractures are condylar fractures; type B1 is a sagittal split of the lateral condyle, type B2 is a sagittal split of the medial condyle, and type B3 is a coronal plane fracture. Type C fractures are T-condylar and Y-condylar fractures; type C1 fractures have no comminution, type C2 fractures have a comminuted shaft fracture with two principal articular fragments, and type C3 fractures have intraarticular comminution. In the 1960s, nonoperative treatment methods, such as traction and cast bracing, produced better results than operative treatment because of the lack of adequate internal fixation devices. With the development of improved internal fixation devices by the AO group, treatment recommendations began to change and operative treatment produced better results than nonoperative treatment, especially for intercondylar and extraarticular fractures.

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A

A1

A2

A3

B

B1

B2

B3

C

C1

C2

C3

FIGURE 54.66 Classification of fractures of distal femur described by Müller et al. (Redrawn from Müller ME, Nazarian J, Koch P, Schatzker J: The comprehensive classification of fractures of long bones, Berlin, 1990, Springer-Verlag.)

all fractures of the distal femur in the appropriate patient, with the exception of simple, nondisplaced fractures. Early mobilization of the knee is important in obtaining a good result.

PLATE AND SCREW FIXATION

FIGURE 54.67 Patient with displaced comminuted supracondylar fracture of femur internally fixed with AO supracondylar blade plate and multiple screws.

Advances in implant technology, technical execution of surgical fixation, rehabilitation, and surgeon understanding have largely contributed to the shift toward operative intervention for these injuries. Operative treatment is recommended for

The blade plate designed by the AO group in Switzerland was one of the first plate-and-screw devices to gain wide acceptance for treatment of fractures of the distal femur. Although it provides stable fixation of most fractures (Fig. 54.67), the technique is technically demanding; early problems included infection and inadequate fixation in osteoporotic bone and refracture after plate removal. As experience with AO plating techniques increased and the use of perioperative antibiotics became routine, the results reported with these devices improved. In 1989, Siliski, Mahring, and Hofer reported good or excellent results in 81% of fractures, with infection occurring in 7.7%, unintentional shortening in 7.6%, and malalignment in 5.8%. Results were better in type C1 fractures (92% good or excellent results) than in type C2 and type C3 fractures (77% good or excellent results). More biologic techniques of plating have been advocated using indirect reduction techniques, minimal soft-tissue stripping, and gentle retraction. Femoral distractors or

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FIGURE 54.68 Fixation of medial condylar fracture with dynamic condylar screw.

external fixators are used to regain length and alignment of the fracture, and metaphyseal comminution is left in situ with no attempt made to reduce comminuted fragments anatomically. Because the soft tissues are left relatively undisturbed, bone grafting is less often necessary (see Video 54.1). 

DYNAMIC CONDYLAR SCREW FIXATION

A less technically demanding alternative to the blade plate is the dynamic condylar screw (Fig. 54.68). The blade plate requires accurate insertion in three planes simultaneously, whereas the dynamic condylar screw allows freedom in the flexionextension plane. A minimum of 4 cm of uncomminuted bone in the femoral condyles above the intercondylar notch is necessary for successful fixation. The main disadvantage of the dynamic condylar screw is that insertion of the condylar lag screw requires removal of a large amount of bone, which makes revision surgery, should it be necessary, more difficult. Reported results of distal femoral fractures treated with the dynamic condylar screw were similar to results obtained with blade plates with 87% excellent or satisfactory results. Nonunion occurred in 0% to 5.7%, infection in 0% to 5.3%, and malunion in 5.3% to 11%. Bone grafting was used in about one third of the fractures. In one study, all poor results occurred in elderly, osteopenic patients with comminuted intraarticular fractures. This technique may be unsuitable for patients with osteoporosis. Blade plates and condylar screws are unsuitable for use in fractures with less than 3 to 4 cm of intact femoral condylar bone and in fractures with a large amount of articular comminution. For these fractures, the condylar buttress plate is the most commonly used implant. The multiple holes in the distal

end of the plate allow multiple screws to be directed into comminuted fragments. Fractures with a comminuted medial buttress, segmental bone loss, or very low transcondylar fractures may angulate into varus because of movement at the screw-plate interface. Devices developed to lock the screws into the plate increase the stability of the construct to prevent varus deformation. Some authors have used methyl methacrylate to improve screw purchase in osteopenic bone. Traditionally, if medial instability is present after application of a lateral buttress plate, the addition of a medial plate is recommended. An inverted large fragment T-plate inserted through a separate medial subvastus incision, double plating with bone grafting, and a locked dual plating technique all have been recommended. Bolhofner et al. advocated percutaneous plating. They treated 57 supracondylar femoral fractures with open reduction and plating using indirect methods, and all fractures healed. Using the Schatzker scoring method, they reported good results in 84% but admitted that surgical skill was a factor. We agree that this is a good technique for bridging a highly comminuted fracture. Condylar plates with screws that are locked to the plate have been used (Fig. 54.69). These plates provide stability similar to the dynamic condylar screw and mitigate the varus angulation that can occur with a medial femoral defect. This fixation may eliminate the need for a medial femoral plate. The less invasive stabilization system (LISS) plate, which uses locked screws and percutaneous fixation, was developed to circumvent the problems with previous fixation methods. The biomechanical properties of this fixation device have been compared with the properties of the dynamic condylar screw and condylar buttress plate. The LISS allowed higher elastic deformation than the other systems, placing it between rigid fixation and intramedullary nailing. Our experience with this method has been satisfactory, but our implant preference is locking condylar plating systems. Locking implants with polyaxial capability also are available, which provide utility for certain fractures, particularly periprosthetic injuries. 

INTRAMEDULLARY NAILING

Intramedullary nailing has received increased attention for the treatment of distal femoral fractures. These devices obtain more “biologic” fixation than plates because they are load-sharing, rather than load-sparing, implants. They offer greater softtissue preservation, and bone grafting is required less often. The major disadvantage of nail fixation is that it provides less rigid stabilization of distal femoral fractures than plate fixation in biomechanical testing. Implant failure has been reported in 15% of distal-third femoral fractures treated with antegrade interlocking nailing using slotted designs. The frequency of implant failure increases if the fracture is within 5 cm of the most proximal screw hole. It has been suggested that implant failure can be prevented by driving the nail to subchondral bone, delaying full weight bearing, and increasing the wall thickness of the nail. By using these principles, intramedullary nailing has been used successfully to treat fractures of the distal femur. When antegrade interlocked intramedullary nailing is done with the patient in the lateral decubitus position, the weight of the leg can cause valgus angulation. When the patient is supine, however, the pull of the gastrocnemius muscles cause posterior angulation. Smooth Steinmann pins in the distal femur, medial and lateral to the patella, can be used to manipulate the fragment and maintain proper alignment. A traction pin also can be placed anteriorly in the distal femur

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A

B

C FIGURE 54.69 A, Comminuted fracture of distal femur with intraarticular extension. B and C, Open reduction and internal fixation through lateral parapatellar arthrotomy to view anatomic reduction of articular component, and submuscular plate is then positioned percutaneously.

to prevent posterior angulation when the supine position is used. Overall, excellent or good results have been reported in 95% after antegrade nailing. We evaluated the results of 57 supracondylar and intercondylar fractures of the femur treated with antegrade interlocking

nailing at our institution. These included eight AO type A2, 13 type A3, eight type C1, 25 type C2, and three type C3 fractures; 44% of the fractures were open. All fractures united, and 3.5% required bone graft. Malunion occurred in 7% of fractures, and two type IIIB open fractures (3.5%) became infected. One nail

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS (1.7%) failed but did not require reoperation. Range of motion averaged 115 degrees. Poor results occurred in all three AO type C3 fractures, one caused by infection and two by malreduction of unrecognized coronal fracture lines. If nailing is considered for treatment of an intercondylar femoral fracture, preoperative radiographs and CT scans must be scrutinized carefully for the presence of coronal fracture lines. AO type C3 fractures generally are best treated with plating techniques, whereas retrograde nailing probably is preferable for distal femoral fractures with extensive shaft extension. Anteroposterior medial and lateral blocking screws can increase the primary stability of these fractures. Retrograde femoral nails inserted through the intercondylar notch have become a popular method of treating supracondylar fractures. Similar to antegrade nails, these nails have the theoretical advantages of being load-sharing devices, requiring little soft-tissue dissection and infrequently needing bone grafting. Retrograde nailing of distal femoral fractures is preferable to antegrade nailing in the vast majority of situations involving the distal femur. Retrograde nailing is technically easier than antegrade nailing in obese patients. Distal femoral fractures below hip implants or above total knee implants with an open notch design also can be treated effectively with retrograde nailing. Retrograde nailing also can be used to stabilize distal femoral fractures associated with ipsilateral hip fractures, allowing the hip fracture to be stabilized with a separate device. In mechanical testing comparing antegrade nailing with retrograde nailing in femoral shaft fractures with and without bony contact, no difference was found in the nails when used for stable fracture configurations, but in unstable fracture configurations, the nail size (larger), not the method of insertion, determined stability. Reports of retrograde supracondylar nailing have shown acceptable results (90% to 100% union; knee range of motion 100 to 116 degrees). Reported complications have included infection in 0% to 4%; malunion in 0% to 8%; implant failure in 4% to 10%; nail fracture in 0% to 8%; and nail impingement on the patella in 0% to 12%, which can be avoided by properly countersinking the nail. Flexible intramedullary implants, such as the Zickel supracondylar device, Ender rods, and Rush rods, also have been used with some success to treat distal femoral fractures; however, since the development of more rigid plate and screw devices and interlocking intramedullary nails, the indications for their use are limited. Newer implant designs with minimally invasive insertion techniques have antiquated the use of flexible devices. Successful use of retrograde intramedullary nail fixation as an adjuvant to distal femoral plating has been reported, particularly in elderly patients. 

EXTERNAL FIXATION

If a patient is placed in a spanning external fixator and is not medically ready for intramedullary nailing or plating, a period of skeletal traction can be instituted during a pin site holiday in preparation for definitive fixation if the initial fixator has been in place longer than 14 days or the pin sites are of concern. 

CONDYLAR FRACTURES OF THE FEMUR UNICONDYLAR FRACTURES OF THE FEMUR

Unicondylar fractures (AO type B) occur less frequently than supracondylar or intercondylar femoral fractures. Concomitant injuries to the ipsilateral extremity are present in about one third of patients. Careful radiographic evaluation, including anteroposterior, lateral, and tunnel views, is necessary to diagnose accurately associated injuries to the knee and coronal fractures of the posterior condyle (AO type B3 or Hoffa fractures). A CT scan is necessary to describe the fracture more accurately. Nondisplaced fractures can be treated nonoperatively but must be followed closely for loss of reduction. Displaced unicondylar fractures require surgical fixation to prevent the complications of axial malalignment, posttraumatic arthritis, knee stiffness, and instability frequently reported after nonoperative treatment. Some minimally displaced fractures can be treated with percutaneous reduction and fixation, but open reduction usually is necessary to obtain an anatomic articular reconstruction. Cancellous lag screws or a small-fragment buttress plate provide sufficient fixation to allow movement after a few days. In patients with osteoporotic bone, a buttress plate may be necessary to prevent cephalad migration of the condyle. 

 

FRACTURE FIXATION OF THE MEDIAL CONDYLE If only one condyle is fractured, the operation is relatively simple, and because the shaft is not involved, internal fixation usually is secure enough to allow movement early in the postoperative course. Often condylar fractures can be reduced with traction on a fracture table or flat-topped radiolucent table and provisionally maintained with various periarticular clamps. The fracture can then be secured with a percutaneous lag screw, a conical, headless compression screw, or placement of a buttress plate. However, we recommend open reduction to ensure anatomic articular reconstruction.

TECHNIQUE 54.24

External fixation can be used as either temporary or definitive fixation in severe open distal femoral fractures, especially fractures associated with vascular injury. If the fracture has significant comminution with shortening, consideration should be given to application of an external fixator. Because of the potential for pin track infection and knee stiffness, this technique should be reserved for the most severe open fractures. We use this technique to provide local traction while allowing mobility for patients with multiple trauma. This technique also allows better CT evaluation of the distal femoral fracture. Early conversion from a spanning external fixator to an intramedullary nail is safe in patients with multiple injuries.

On the anteromedial aspect of the knee, begin a longitudinal incision 10 cm proximal to the joint line and extend it distally to below the level of the joint. Incise the capsule and synovium at the joint level in line with the skin incision, and extend the incision proximally along the lateral edge of the vastus medialis muscle at its junction with the quadriceps tendon. Extend this incision proximally enough to expose the medial femoral condyle, the patellofemoral groove, and the intercondylar area. n  Insert a Steinmann pin into the large fragment so that it can be used as a lever during reduction. n 

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY desired. Gentle active and active-assisted exercises are begun when swelling subsides. Ambulation with a walker or crutches is started on postoperative day 2 or 3, allowing only non–weight bearing. Range-of-motion exercises and quadriceps and hamstring exercises are increased gradually. If the fracture is healing satisfactorily, partial weight bearing can be allowed at 8 to 10 weeks. By 12 to 14 weeks, the patient usually has gradually progressed to full weight bearing. The residual disability after isolated fractures of the medial femoral condyle usually is minor, and good range of motion can be regained when reduction and fixation are satisfactory and joint motion is begun early.    

 

FIGURE 54.70 Fracture of medial condyle fixed with 6.5-mm cancellous screws. SEE TECHNIQUE 54.24.

Clear the joint of all debris, thoroughly irrigate and reduce the fracture under direct vision using the pin as a lever. A periarticular reduction clamp can be inserted percutaneously on the lateral femoral condyle to effect interfragmentary compression after articular reduction. n  Multiple Kirschner wires can be inserted across the fracture fragments into the intact lateral femoral condyle for provisional fixation. n  Place two cancellous screws perpendicular to the fracture site to fix the medial femoral condylar fragment to the intact lateral femoral condyle (Fig. 54.70). The size of the implant depends on the fragment size but can range from 3.5- to 6.5-mm screws. If the bone is osteoporotic, a washer under the head of the screw prevents the head from sinking through the cortex. n  Remove the multiple Kirschner wires used for temporary fixation, and confirm the reduction with radiographs made in two planes. Ensure that the ends of the pins or cancellous screws penetrate the lateral femoral cortex because osteoporotic bone within the condyle does not afford good purchase. The lag screw effect of the cancellous screws should produce good fixation and interfragmentary compression. n  In some patients with osteoporotic bone, fixation with screws alone may be inadequate; therefore, a buttress plate is contoured to fit the medial condyle. n  An alternative is the use of small fragment fixation, in which interfragmentary compression can be achieved with 3.5-mm interfragmentary screws and further stabilized with the addition of a small-fragment buttress plate, which is our preference in most cases. n  Whichever internal fixation construct is selected, the key principle remains anatomic articular reduction.  n 

POSTOPERATIVE CARE The patient is placed in a removable long-leg splint or a bulky soft dressing with light compression wrap and knee immobilizer. Continuous passive motion can be initiated immediately after surgery if

FRACTURE FIXATION OF THE POSTERIOR PART OF THE MEDIAL CONDYLE If the posterior part of the medial femoral condyle is sheared off, ORIF with lag screws is recommended. Although this fracture looks harmless on the radiographs, it may produce a marked disability. Initially undisplaced fractures frequently displace if treated conservatively. As seen on the lateral view, the loose fragment consists of approximately the posterior half of the condyle. The fragment has minimal soft-tissue attachments and may be devoid of blood supply. Almost its entire surface is covered with articular cartilage. The amount of displacement may be minimal. If the fragment is not reduced properly, roughening of the articular surface and osteonecrosis occur. Ordinarily, the fragment should not be removed because it is an important part of the articular surface when the knee is flexed at 90 degrees. Treatment consists of fixation of the fracture in proper position.

TECHNIQUE 54.25 Adequate exposure can require anteromedial and posteromedial incisions. Anatomic reduction of the articular surface is of paramount importance. n  Replace the posterior portion of the medial femoral condyle using a posteromedial Henderson incision (see Chapter 1) and fix it temporarily with multiple Kirschner wires. n  Depending on the size of the fragment, insert two 3.5mm or 4.5-mm appropriately countersunk interfragmentary lag screws from the anterior to posterior. We also have used cannulated differential thread headless compression screw fixation. Place the screws medial to the patellofemoral articulation, if possible, and direct them perpendicular to the fracture site. n  Countersink all screws that are placed through the articular surface. Inspect to see that the screw does not penetrate the articular surface posteriorly. n  Remove the transfixing Kirschner wires. Occasionally, a portion of the medial head of the gastrocnemius may require reflection for adequate exposure. n  After the screws have been inserted, check the reduction and position of the screw by radiographs and close the wound.  n 

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POSTOPERATIVE CARE  Postoperative care is the same as that recommended after fixation of the medial femoral condyle (see Technique 54.24).   

INTERCONDYLAR FRACTURES OF THE FEMUR

ORIF of comminuted intercondylar and supracondylar fractures of the femur demands experience and surgical skill. A complete set of instruments and familiarity with their use are required for this method of fixation. Strict adherence to basic principles and technique is required to prevent unsatisfactory results. ORIF of these difficult fractures is justified only if (1) the joint surfaces can be restored anatomically, (2) fixation is sufficiently rigid that external immobilization is not required, (3) rigidity of fixation is sufficient to allow early and active motion of the knee joint, and (4) the skin and soft tissues are satisfactory for a major operation. Historically, insertion of a 95-degree condylar blade plate is technically difficult and unforgiving. The broad surface area of the plate provides excellent fixation and resistance to bending and torsional forces. If the blade is inserted correctly into the condyles, anatomic alignment of the femur can be obtained by fixing the plate to the shaft of the femur. If the blade is inserted incorrectly, malalignment occurs. Difficulty in application and design advancements have largely eliminated the use of blade plates and dynamic condylar screws as first-line fixation devices. Evolution of fracture fixation devices for the distal femur has led to most extramedullary implants being condylar plates with the capability for locking screws, at times polyaxial, and typically with some form of targeting instrumentation that has allowed for considerably less soft-tissue dissection. Refer to earlier editions of this text for detailed techniques on distal femoral blade plate or dynamic condylar screw implant insertion. Fracture morphology will dictate the required surgical approach for appropriate reduction and fracture stabilization. The need for significant proximal extensile exposure is rare, particularly with modern targeting instrumentation. Supracondylar fractures or simple intercondylar fractures often can be treated through direct lateral surgical approaches distally. Those with more extensive articular involvement necessitate direct exposure to ensure anatomic reduction. This is most frequently accomplished through an anterior approach with lateral parapatellar arthrotomy. In fracture-specific cases, a small accessory medial incision may be required for fracture manipulation or screw placement. Most frequently, we use the distal aspect of the approach described next (swashbuckler approach) or a more lateral parapatellar approach for those in need of anatomic reduction of comminuted articular injuries. The most distal extent of the approach is necessary for direct articular reduction and implant insertion. Care should be taken to avoid dissection or manipulation of the metaphyseal region in an effort to retain the fracture biology and lessen the chance for healing difficulties. To provide better exposure of the distal articular surface of the femur, Starr, Jones, and Reinert used a modified anterior approach they called the “swashbuckler approach.” Cited advantages to this approach, in addition to improved exposure, are sparing of the quadriceps muscle bellies and a surgical scar that does not interfere with subsequent total knee arthroplasty. 

 

SWASHBUCKLER APPROACH TO THE DISTAL FEMUR TECHNIQUE 54.26 (STARR ET AL.) Place the patient supine, preferably on a radiolucent table. n  Use a sterile tourniquet only if necessary to avoid medial retraction of the quadriceps. n  Place a roll or triangle under the knee. Make a midline incision from above the fracture laterally to across the patella (Fig. 54.71A). n  Extend the incision directly down to the fascia of the quadriceps. Incise the quadriceps fascia in line with the skin incision. Sharply dissect the quadriceps fascia off the vastus lateralis muscle laterally to its inclusion with the iliotibial band. n  Retract the iliotibial band and fascia laterally, continuing the dissection down to the linea aspera. n  Incise the lateral parapatellar retinaculum, separating it from the vastus lateralis (Fig. 54.71B). n  Make a lateral parapatellar arthrotomy to expose the femoral condyles. n  Place a retractor under the vastus lateralis and medialis, exposing the distal femur and displacing the patella medially (Fig. 54.71C). n  Ligate the perforating vessels and elevate the vastus lateralis, exposing the entire distal femur. n  Proceed with the internal fixation as needed. n  Close the wound by suturing the fascia back in place.    n 

LOCKING CONDYLAR PLATE FIXATION

Locking condylar plate fixation is indicated for intraarticular and extraarticular condylar fractures, bridging of highly comminuted distal femoral fractures, and treatment of distal femoral malunions. Current implants offer the stability of fixed angle devices with the ability to be placed in a biologically appropriate manner and therefore are our current choice for most AO/ OTA Type A and C fractures requiring plate osteosynthesis. Authors have attempted to identify factors contributing to nonunion and failures in these difficult fractures. Obesity, open fractures, infection, and stainless steel implants have been identified as risk factors for development of nonunion. Ricci et  al. evaluated risk factors for reoperation. In their series, 19% required reoperation to achieve union. Diabetes and open fracture were independent risk factors for deep infection and delayed union. Factors associated with implant failure included open fractures, smoking, increased body mass index, and shorter plate length. Barei et  al. evaluated their series of open distal femoral fracture. They concluded that despite metaphyseal bone loss, locking plates obviate the need for routine bone grafting of some open distal femoral fractures. Fractures demonstrating posterior cortical contact were strongly correlated with primary union. Because of the inconsistent callus these injuries exhibit through comminuted metaphyseal regions, alterations of the fixation strategy

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Quadriceps retracted medially

Quadriceps tendon Vastus lateralis

Vastus lateralis

Lateral retinaculum

Lateral parapatellar arthrotomy

A

Perforating vessels Quadriceps tendon

B

Patella medially everted

C

FIGURE 54.71 Swashbuckler technique. A, Fascia overlying quadriceps is incised longitudinally and lifted laterally off underlying muscle. B, Farther laterally, fascia over quadriceps becomes confluent with iliotibial band. Lateral parapatellar arthrotomy is performed. Proximally, arthrotomy incision is made between vastus lateralis muscle and lateral retinaculum of knee. C, Proximal release of vastus lateralis fibers from lateral intermuscular septum allows further mobilization of quadriceps. Perforating vessels can be controlled with cautery. SEE TECHNIQUE 54.26.

have been proposed. Dynamic locking or far cortical locking, as a method to increase micromotion on the lateral cortex to increase the callus response, has been advocated. 

 

SUBMUSCULAR MINIMALLY INVASIVE LOCKING CONDYLAR PLATE APPLICATION TECHNIQUE 54.27 Position the patient supine on a radiolucent table. Place a well-padded bump under the ipsilateral hip to maintain the femur in neutral rotation. Prepare and drape the limb in normal fashion. Position the limb on a sterile bump or triangular bolster. Contralateral rotation films can be helpful to gauge rotation reduction and for intraoperative referencing. n  Expose the distal femur as previously described (see Technique 54.26). Typically, only the distal extent of the approach is necessary with lateral parapatellar arthrotomy for articular reduction. Alternatively, a direct lateral approach may be used in extraarticular fractures or those with simple articular components (Fig. 54.72). n  Reduce the condylar fragments with Kirschner wires and reduction forceps. n  Place the condylar plate guide on the lateral cortex to determine the proper position for the placement of interfragmentary lag screws to maintain the condylar reduction without interfering with the plate. n  Using anatomic landmarks and C-arm imaging, place the plate in a submuscular fashion on the reconstructed condyles with or without attempting to reduce the proximal fragments, and insert a 2.5-mm guidewire through the wire guide central hole parallel to the femorotibial joint line. Obtain an image to confirm placement parallel to the joint line. For this portion of the procedure, wire placement is critical because it “sets” the distal position n 

of the plate in the coronal plane. Nonparallel positioning of this initial reference wire can inadvertently induce a varus or valgus coronal plane malalignment. Beware of anatomic variances, such as a hypoplastic lateral condyle, which can make reconstruction and implant positioning quite difficult. Close scrutiny of contralateral knee films can facilitate identification of anatomic nuances when preoperative templating is performed. n  On the lateral fluoroscopic plane, confirm that the distal positioning of the plate parallels the posterior cortex of the distal femur to ensure appropriate coronal plane flexion and extension. Once appropriate positioning is noted, place additional guidewires through the locking guides to secure the plate on the distal segment. n  Longitudinal traction can be applied and the targeting instrumentation used to permit placement of a provisional guidewire in the most proximal hole of the plate chosen. It is critical that the length and rotational reduction be noted before this step. Additionally, in particularly comminuted fractures of the distal femoral metaphysis, a single proximal wire may not provide sufficient length maintenance alone. n  Once the length and rotational alignment are “set,” place a small bolster under the metaphyseal portion of the fracture to determine flexion and extension. n  Many periarticular plates do not fit every patient’s anatomy, and consequently there can be variable offset of the plate from the femoral shaft. As a result, failure to recognize this can induce varus or valgus malalignment when threaded reduction instrumentation or nonlocking cortical screws are used to seat the plate on bone. When offset is identified, the plate should be applied as an “internal-external fixator,” with locking screw fixation to maintain anatomic coronal plane reduction. The reduction is more important than plate to bone contact. n  Locking screws can be inserted in any order, but we usually prefer to insert the central screw first, followed by the surrounding screws in the distal segment. Proximal fixation is achieved with placement of 4.5-mm cortical screws or 5.0-mm locking cortical screws through the targeting instrumentation. A minimum of eight cortices should be used proximally.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS the design of many locking condylar plates allows for plate reduction techniques, the LISS relies on the reduction being achieved before implant positioning. Furthermore, it truly is an “internalexternal fixator,” and therefore fixation with locking screws near and far from the fracture provides the greatest stability. This is better tolerated with the LISS as compared with locking condylar plates because of the increased flexibility in LISS. In addition, the screw fixation is solely unicortical.   

DOUBLE PLATE FIXATION Very low distal femoral fractures with extensive articular and metaphyseal comminution may not be stabilized adequately by lateral plating alone. Application of an additional medial plate may be necessary. A separate medial incision is preferred to reduce the amount of soft-tissue stripping required for plate application.

TECHNIQUE 54.28 (CHAPMAN AND HENLEY) After lateral fixation, assess whether the fracture stabilization is sufficient to permit early functional range of motion. If not, proceed with application of medial fixation through a separate longitudinal medial approach. n  Alternatively, very distal fractures may require an accessory medial approach for reduction purposes in addition to lateral intervention and before definitive fixation. n  Make an anteromedial incision from the anterior margin of the pes anserinus, following the adductor canal (Fig. 54.74A). The deep dissection follows the subvastus (Southern) approach. Incise the fascial envelope surrounding the vastus medialis along the posterior margin of the muscle. n  Use blunt dissection to elevate the muscle off the periosteum and the intermuscular septum from the adductor tubercle to the intact proximal femoral shaft. n  Distally, sharply incise the 2- to 3-cm wide tendinous insertion of the vastus medialis into the medial capsule. n  Expose the joint through a medial parapatellar arthrotomy. This approach does not require formal dissection of the superficial femoral artery because the artery is retracted posteriorly with the sartorius muscle. n  Protect the descending genicular artery and saphenous nerve by bluntly dissecting the posterior margin of the vastus medialis and retracting the artery and nerve anteriorly. Leave the superficial and deep fibers of the medial collateral ligament attached to the femoral condyle. n  If a posterior medial condylar fragment is present, make an additional arthrotomy just posterior to the medial collateral ligament to allow access to this portion of the articular surface. Flexion of the knee and posterior retraction of the sartorius and adductor longus make this easier. n  Inspect the medial compartment, including the meniscus, and remove any loose fragments from the joint. n  Continue posterior exposure until the intact medial femoral shaft is visible, minimizing soft-tissue stripping during dissection and retraction. n  Reduce and provisionally stabilize each of the femoral condyles as described for application of a locking condylar n 

FIGURE 54.72 Minimally invasive plate insertion for fixation of supracondylar or intercondylar distal femoral fractures using specially designed outriggers for targeting proximal fixation. This permits accurate fixation while minimizing further biologic insult to comminuted metaphyseal zones. Note proximal tibial traction pin and bow used for greater control of axial length and rotational alignment. SEE TECHNIQUE 54.27.

Take care when placing proximal fixation into the shaft. Consider filling the most proximal hole in the construct with a unicortical locking screw or a bicortical nonlocking screw to minimize stress riser formation. n  Ideally, long plate constructs with well-spaced fixation is sought. Locking screw fixation in close proximity to metaphyseal comminution can result in a very rigid construct that may contribute to inconsistent callus formation and should be avoided if possible. n  Securely tighten all screws again before wound closure. n  Perform fascial and skin closure in the standard fashion.  n 

POSTOPERATIVE CARE  Early passive motion with some active motion is begun as tolerated. Focus also is placed on passive extension exercises to minimize contracture formation. Weight bearing is avoided for 10 to 12 weeks. Active and passive range of motion should be encouraged during this time.   

LESS INVASIVE STABILIZATION SYSTEM

The technique for use of the LISS system is in many respects very similar to application of the locking condylar plate in a minimally invasive fashion (Fig. 54.73). One can refer to the previous technique. However, several key differences should be mentioned. The LISS system is constructed of titanium and, therefore, its modulus of elasticity is different than many available locking condylar plating systems and permits more flexibility. Whereas

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY

Lateral View C

A

5

4

3

2

1

B

G

D E

A F

B

Incision

Incision

10°

C

D

E FIGURE 54.73 Less invasive stabilization system (LISS) plate technique. A, Letters are used to identify distal plate holes; numbers are used to identify diaphyseal plate holes. B, Lateral incision. C, In complex intraarticular fracture, lateral parapatellar approach is necessary. D, Insertion guide has tendency to tilt toward floor. When positioned properly on lateral condyle, insertion guide is internally rotated approximately 10 degrees to femoral shaft. Plate position is adjusted if necessary. E, Kirschner wire inserted through stabilization bolt. (Redrawn from Less Invasive Stabilization Technique (LISS): technique guide, Paoli, PA, 2001, Synthes.)

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS plate and reduce and fix the medial and lateral femoral condyles to each other, incorporating any intercalary fragments. n  Use Kirschner wires, pointed reduction tenaculums, or large periarticular clamps for temporary stabilization. n  Reduce the reconstructed distal articular block and provisionally fix it to the femoral shaft. Position a lateral plate and temporarily fix it to the distal femur. n  When reduction is satisfactory, secure it with two to four proximal and distal screws inserted with image intensification guidance. n  Bend the medial buttress plate to match exactly the contour of the medial femur. We prefer small-fragment fixation, typically. n  Place the transverse portion of the plate distally so that the screw holes allow placement of screws into the anterior and posterior portions of the femoral condyles. The anterior screw should permit bicondylar-transcondylar fixation (Fig. 54.74B). n  For the proximal end of the medial plate, use at least four cortices of fixation (Fig. 54.75). n  After screws are placed, consider filling bone defects with autologous cancellous grafts in closed injuries. Otherwise, antibiotic cement spacers may be advisable in open injuries and in preparation for future grafting. Repair the arthrotomy and close the medial approach in routine fashion. 

POSTOPERATIVE CARE  Postoperative care is the same as after that for locking condylar plate fixation, with initiating motion based on stability of fracture repair.   

SUPRACONDYLAR FRACTURES OF THE FEMUR

Most supracondylar fractures of the femur can be treated with interlocking intramedullary nailing or plate-andscrew devices. Even those with simple intraarticular fracture components often can be treated with intramedullary nail fixation. Distal screw configurations vary and are often the determinants in whether a supracondylar femoral fracture can be adequately stabilized with an intramedullary device. In patients who are poor operative risks, nonoperative treatment with acute skeletal traction followed by cast bracing is an option. Historically, flexible intramedullary implants with supplemental bracing have been used in some low-demand elderly patients; however, current minimally invasive nailing and plating techniques have the advantages of minimizing surgical trauma and providing stable fixation, which typically requires no adjuvant bracing. Refer to techniques for retrograde intramedullary nail fixation and minimally invasive locking condylar plate insertion. 

SHAFT OF THE FEMUR Fractures of the shaft of the femur are among the most common fractures encountered in orthopaedic practice. Because the femur is the largest bone of the body and one of the principal load-bearing bones in the lower extremity, fractures can cause prolonged morbidity and extensive disability unless treatment is appropriate. Fractures of the femoral shaft often

are the result of high-energy trauma and may be associated with multiple system injuries. Several techniques are now available for their treatment, and the orthopaedic surgeon must be aware of the advantages, disadvantages, and limitations of each to select the proper treatment for each patient. The type and location of the fracture, the degree of comminution, the age of the patient, the patient’s social and economic demands, and other factors may influence the method of treatment. Possible treatment methods for fractures of the femoral shaft include the following: n  Closed reduction and spica cast immobilization n  Skeletal traction n  Femoral cast bracing n  External fixation n  Internal fixation n  Intramedullary nailing with open or closed technique n  Antegrade interlocking intramedullary nailing with or without reaming n  Retrograde interlocking intramedullary nailing n  Plate fixation Locked intramedullary nailing is currently considered to be the treatment of choice for most femoral shaft fractures. Regardless of the treatment method chosen, the following principles are agreed on: (1) restoration of alignment, rotation, and length, (2) preservation of the blood supply to aid union and prevent infection, and (3) rehabilitation of the extremity and the patient.

TRACTION AND CAST IMMOBILIZATION

Skeletal traction methods most often are a preliminary phase to other definitive methods of femoral shaft fracture management, for instance, before plating or closed intramedullary nailing. Rarely are balanced skeletal or roller traction methods used as definitive treatment in adults. These are mentioned for historical reasons only. The length of confinement to bed, with its potential for complications, and the economic consequences of several weeks or months in the hospital make this an impractical method when used alone. 

EXTERNAL FIXATION

Although we recommend immediate debridement, irrigation, and interlocking intramedullary nailing for most open femoral shaft fractures, half-pin fixators have proved effective, especially for massively contaminated fractures and fractures requiring rapid stabilization for vascular repair. Infections have occurred in some of our patients after nailing of fractures previously treated with external fixation, as has been reported by other authors. After wound coverage, early conversion (2 weeks) of external fixation to intramedullary fixation may decrease the incidence of infection. Temporary rapid external fixation of femoral fractures can be used in unstable, severely injured polytraumatized patients, especially if further blood loss is a major concern. External fixation can be maintained until union, but this is rare. Most commonly, a uniplanar external fixator is applied anteriorly or anterolaterally in polytraumatized patients or in patients with massive contaminated wounds as a means of temporary skeletal stabilization for later definitive management. For diaphyseal fractures, the knee joint rarely is immobilized; however, more distal fractures of the supracondylar or intercondylar variety most frequently require fixation to the tibia. 

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Medial collateral ligament Vastus medialis

A

B

Medial

FIGURE 54.74 Double plating of distal femoral fracture. A, Subvastus (Southern) approach (see text). B, Application of large fragment T-plate. SEE TECHNIQUE 54.28.

A

B

FIGURE 54.75 A, Highly comminuted distal femoral fracture in pedestrian struck by a high-speed vehicle. Note very low fracture involvement of medial femoral condyle. Lateral-based constructs would not typically provide adequate fixation into this fragment. B, Small fragment fixation of medial femoral condyle through subvastus approach, as adjuvant to more typical lateral-based fixation construct. SEE TECHNIQUE 54.28.

FIXATION WITH PLATES AND SCREWS

Since the 1960s, the AO surgeons in Switzerland have used either intramedullary fixation or compression plate fixation for almost all femoral shaft fractures. Their methods have many proponents. The most accurate reduction of comminuted fractures of the femoral shaft can be obtained with interfragmentary compression and plate and screw fixation. This treatment allows early motion and good function, but the risk of infection (2% to 5%), failure of fixation (6% to

10%), and delayed union (up to 19%) have been reported at unacceptable levels. However, if rigid internal fixation with interfragmentary compression is achieved successfully, complications are few. Several reports have recommended the routine application of a bone graft medially in all comminuted fractures fixed with AO plates, or if rigid fixation is not obtained. Plating of femoral shaft fractures requires experience and judgment. Misuse of this method produces more poor results than any other.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Excellent results have been obtained with plating of comminuted shaft fractures without medial bone grafting when indirect reduction of intermediate fragments, preservation of soft-tissue attachments to bone especially medially, and final compression have been obtained. Femoral plating in patients with blunt polytrauma has been recommended, especially patients with ipsilateral femoral neck and shaft fractures, arterial injuries, or unstable spinal injuries. The technique involves indirect reduction, posterolateral plate application, and medial bone graft. Plating does not require the fracture table or fluoroscopic image intensifier that is necessary for closed femoral nailing. Plating preserves the endosteal blood supply; however, the cortex underlying the plate is devitalized. Low-contact dynamic compression plates with scalloped recesses permit less iatrogenic insult to the periosteal blood supply (Fig. 54.76). Seligson et  al. reviewed the results of femoral plating in 15 patients with multiple trauma. They noted a reduced postoperative morbidity from adult respiratory distress syndrome after plating as compared to that reported after intramedullary nailing. Complications of fracture healing were significantly greater (30%) after plating, however, than after intramedullary nailing (12%). If plate and screw fixation is indicated, we prefer the 4.5mm dynamic compression plate. In general, the broad plate should be used with approximately eight cortices (four holes) of screw purchase on either side of a transverse fracture. If plates and screws are used for internal fixation of femoral shaft fractures, weight bearing and unprotected ambulation usually are not possible as soon as after intramedullary nailing. A lateral approach (see Chapter 1) is used for fractures of the femoral shaft when plates and screws are used for fixation. It is essential that the plate be sufficiently long so that at least four screws are proximal and distal to the limits of the fracture. Cancellous screws at the distal end of the femur improve purchase, especially if the bone is osteoporotic. Plates can be removed 2 to 3 years after injury, provided that union is complete; however, plate removal is not routinely necessary. Cortical bone beneath a rigid AO plate remodels more like cancellous bone. For the cortex to return to its normal strength and structure, stress has to be gradually reapplied after removal of the plate. When two plates at 90 degrees to each other have been used, both plates should not be removed at the same time because the bone is doubly weak, and thus refracture is likely. The second plate can be removed 6 months after the first. The bone should be protected from excessive stress for at least 6 weeks after plate removal. 

INTRAMEDULLARY FIXATION

Internal fixation of fractures of the femoral shaft became popular after World War II, when open intramedullary nailing was introduced. In a young adult patient with an uncomminuted fracture through the narrowest portion of the medullary canal, an intramedullary nail, barring complications, provides the ultimate treatment for femoral shaft fractures. Successful intramedullary nailing results in a short hospital stay, a rapid return of motion in all joints, prompt return to walking, and a relatively short total disability time. With current implant designs, fractures in the proximal or distal thirds of the shaft or fractures with severe comminution are also suitable for this form of internal fixation.

FIGURE 54.76 Polytraumatized patient with extensive pulmonary injuries and femoral diaphyseal fracture treated with ORIF using large fragment compression plating.

Although Küntscher introduced closed intramedullary nailing in the 1940s, it did not gain popularity in North America until the 1970s. With improvements in technique and especially the availability of image intensifiers, closed nailings have replaced the open technique. Historical improvements in design have expanded the indications for nailing of proximal and distal fractures. A variety of intramedullary devices are available; the most commonly used today are interlocking intramedullary nails, through which transverse or oblique transfixing screws can be inserted to control the major proximal and distal fragments, providing length and rotational stability. The nail can be inserted in either an antegrade or retrograde fashion.

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Type I comminuted

Proximal transverse

Type II comminuted

Proximal oblique

Type III comminuted

Type IV comminuted

Proximal comminuted

Segmental transverse

Distal transverse

Segmental oblique and comminuted

Distal oblique

Spiral

Distal comminuted

FIGURE 54.77 Winquist-Hansen classification of comminution (see text). (Redrawn from Winquist RA, Hansen RT, Clawson DK: Closed intramedullary nailing of femoral fractures: a report of five hundred and twenty cases, J Bone Joint Surg 66A:529, 1984.)

Historically, plating of femoral fractures has had higher rates of infection and nonunion than closed intramedullary nailing. Because there was some concern that interlocking nails might promote healing difficulties, the Winquist-Hansen classification of comminution (Fig. 54.77) was routinely used to determine whether static locking was necessary. Winquist and Hansen classified fractures into the following categories: (1) type I fracture, a comminuted fracture in which a small piece of bone has broken off, not affecting fracture stability; (2) type II fracture, in which at least 50% contact of the abutting cortices remains to prevent shortening and help control rotation, and in which sufficient proximal and distal cortical contact of the nail is possible to prevent translation and shortening; (3) type III comminuted fracture, which has less than 50% cortical contact or in which purchase of the nail would be poor in either the proximal or the distal fragment, allowing rotation, translation, and shortening; and (4) type IV comminuted fracture, in which the circumferential buttress of bone has been lost and no fixed contact exists between the major proximal and distal fragments to prevent shortening. The optimal time for intramedullary nailing of closed and open fractures has been an area of controversy, particularly in the presence of multisystem trauma; however, current

data support early (within 24 hours) nailing for most femoral fractures. Authors have demonstrated significant decreases in patient morbidity with stabilization of femoral fractures within 24 hours compared with delayed fixation after 48 hours, especially in patients with multiple injuries. Another series suggested that delayed femoral fixation beyond 12 hours in polytrauma patients can result in mortality reduction of approximately 50%. Pape et al. suggested that immediate reamed femoral nailing may precipitate adult respiratory distress syndrome in patients with blunt thoracic trauma. In follow-up clinical studies, patients were subclassified to assess the risk for complications after reamed femoral nailing. Those identified as “borderline” patients, or those with multiple injuries who were at risk for complications after early reamed intramedullary femoral nailing, were found to have a higher incidence of pulmonary complications with early definitive intervention. The authors advocated that in the presence of multiple injuries, the preoperative condition should be considered when deciding on treatment modalities for femoral shaft fractures to minimize complications. Other studies have not confirmed the findings of Pape et  al. Controversy remains regarding the impact of reamed intramedullary nail fixation of femoral fractures in patients

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS with multisystem trauma. The current consensus seems to be that immediate fixation of femoral fractures with reamed intramedullary nailing does not increase the risk of clinically significant pulmonary complications in most patients. However, those who are identified as being “borderline” or at very high risk for complications may be best served with an approach using “damage control orthopaedics” to provide necessary stabilization while minimizing early surgical insult. At our institution, most femoral shaft fractures that can be treated with intramedullary nail fixation are treated with early total care. Patients identified to be at risk, primarily based on concomitant multisystem injuries and physiologic parameters, are temporized with either external fixation or skeletal traction, both of which have been demonstrated to be efficient as early measures. Winquist and others have shown that elevation in intramedullary pressures and thermal damage caused by reaming can be decreased by using sharp reamers with deep cutting flutes and narrow shafts and by using minimal force during reamer insertion. In addition to causing marrow embolization, reaming also damages the endosteum and decreases the torsion strength of the femoral fragments. Because of the possible effects of medullary reaming, unreamed nailing has received increased attention. Interlocked intramedullary nailing without reaming requires smaller implants capable of not only sustaining the loads of weight bearing but also withstanding the prolonged healing time generally required for severe open fractures. RussellTaylor Delta nails (Smith and Nephew, Memphis, TN) have functioned well in this situation. Our first 100 Delta femoral nailings of acute fractures included all grades and 35 open fractures. In a population that formerly would have been treated with nails averaging 13.5 mm in diameter, 62 10-mm nails and 38 11-mm nails were used. No infections developed in the 100 fractures. One screw broke in a patient with a delayed union, and thus renailing was required before union. One other delayed union also required renailing before union. Studies have found similar results between reamed and unreamed nailing with no differences in operative time, transfusion requirements, or pulmonary complications. Although there was no overall difference in time to union, delayed unions have been reported more often after unreamed than reamed nailing. When distal fractures were analyzed separately, fractures with reamed nailing were found to heal more quickly. No advantage to unreamed nail insertion has been demonstrated. In contrast to the tibia, the femur is surrounded by vascular soft tissue and infection of femoral fractures is less of a concern. Although the incidence of infection with open nailing of closed fractures is nearly 10% in some series, the incidence in closed nailing of closed fractures generally is less than 1%. The incidence of infection after closed reamed nailing of open femoral fractures is 2% to 5%. In the past, delayed nailing was recommended to prevent infection; however, more recent reports indicate that immediate nailing of open femoral fractures does not significantly increase the risk of infection. In our early use of locked intramedullary nails for segmentally comminuted fractures, we attempted to delay definitive intramedullary fixation for 2 to 3 weeks until soft tissues had theoretically stabilized and the granulation tissue around the fracture would serve as a better recipient bed for reaming. In our first 100 fractures treated with the Russell-Taylor

nail (1985-1986), including 23 open fractures of all grades, we were forced to intervene earlier, however, to prevent further deterioration of patients with multiple injuries, and the average delay to nailing of open fractures was only 8.4 days. Two of the three infections after nailing of open femoral fractures in our series occurred in patients with persistent initial wounds (20 and 24 days after injury) who had delayed reamed nailing. In our first 125 open femoral fractures treated with the Russell-Taylor nail, with immediate or delayed fixation, with or without reaming, the overall infection rate was 4%. Currently, we strive to operatively treat all open fractures within 8 hours of injury. Open femoral fractures are treated with initiating immediate intravenous antibiotic coverage depending on the wound type, followed by urgent debridement and irrigation. The femur is stabilized with a statically locked reamed intramedullary nail. The isthmus diameter is approximated radiographically as part of preoperative templating. The traumatic wound is closed, if surgically clean, over closed suction drains in lower-grade open injuries. Massive open wounds or those that are grossly contaminated are left open or covered with vacuum-assisted wound closure dressings. Repeat debridements are performed every 24 to 48 hours, depending on the characteristics of the wound environment, until delayed primary closure can be safely obtained. Otherwise, we aim to obtain wound closure by 2 to 7 days using skin grafting or, rarely, flap coverage. We also have found locked intramedullary nailing to be a safe and effective treatment for femoral fractures with vascular injury. Although repair of the popliteal artery can withstand 18 kg of traction, we prefer to fix the femoral fracture at the time of vascular repair if possible because little additional surgical exposure is required for closed nailing. Early fixation allows the benefits of early mobilization. We also have found that intramedullary nailing is easier to perform early because usually less traction is required and the fragments are easier to reduce. In a review of femoral fractures with vascular injuries treated at our institution between 1986 and 1994, 17 fractures treated with either immediate or delayed intramedullary nailing all were successfully salvaged. Gunshot wounds caused most injuries, and only one fracture was nailed before vascular repair. A patient with a femoral fracture and suspected vascular injury ideally should be taken to the operating room for arteriography after sufficient imaging to accurately assess the fracture morphology for preoperative planning purposes, and, of course, to identify any other limb or life-threatening injuries. Time is critical in these injuries. Close coordination with the general trauma and vascular surgical services is a prerequisite, and rapid external fixation can be applied to provide a stable skeletal environment for vascular repair. Alternatively, a temporary vascular shunt can be placed while skeletal fixation is performed, which thus permits vascular repair without the potential impedance that an external fixator may impose. In our experience, an anterolateral external fixator orientation is preferred because it does not interfere with medial access and does not place pin tracks in line with any potential lateral approach or interlocking incisions. Retrograde intramedullary nailing has been advocated for patients with morbid obesity, ipsilateral femoral neck and shaft fractures, ipsilateral femoral and tibial fractures (floating knee injuries), pregnancy, and multiple trauma. Current techniques recommend using a portal in the intercondylar notch. Retrograde and antegrade femoral nailing in femoral

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY shaft fractures have been compared. Healing, delayed union, and malunion were nearly identical in both groups. Patients in the antegrade group reported more hip pain (9%) at follow-up, and patients in the retrograde group reported more knee pain (36%). Retrograde nailing also is a viable option for open femoral fractures. The incidence of associated knee sepsis was 1.1% in a series by O’Toole et al. Closed nailing of acute femoral fractures using either a femoral distractor or manual traction without a fracture table has been advocated. We continue to use a fracture table routinely. The newer fracture tables allow total body imaging without moving the patient, decreasing the risk to the patient and minimizing setup time. We recommend early static locked nailing, with reaming, of open and closed femoral fractures as soon as possible. Relative contraindications to nailing include the presence of previously inserted fixation device, preexisting deformity, massive contaminated open wounds, or borderline patient parameters. Absolute but correctable contraindications to femoral nailing are hypovolemia, hypothermia, and coagulopathy. Most femoral shaft fractures at our institution are treated with the patient supine on a fracture table. Lateral positioning typically is reserved for proximal subtrochanteric fractures for which lateral positioning is much more conducive to fracture reduction as opposed to the supine position. Distal interlocking is performed using a freehand “perfect circle” technique. This technique can be performed rapidly; we routinely use two locking screws distally, primarily in comminuted fractures that require not only rotational but also length stability. Although some studies have found no difference when one or two screws were used for locking, we believe that weight bearing can potentially begin earlier when two distal locking screws are used rather than one. We do not routinely perform dynamization for those fractures that demonstrate healing difficulties. For delayed union at 6 to 8 months in Winquist-Hansen grade 3 or grade 4 comminuted fractures, we prefer bone grafting in situ or closed reamed exchange nailing. Small and moderate bone defects usually fill in spontaneously.

PREOPERATIVE PLANNING

After deciding that the fracture is suitable for intramedullary nailing, careful planning before surgery is necessary. There is no correlation between the length of the bone and size or contour of its canal. Young athletes with strong bones usually have a small medullary canal at the isthmus where the thick cortices encroach on the canal. In contrast, elderly patients usually have large canals; even a 15-mm nail may not be large enough. In an average patient, the smallest diameter of the canal is in the distal part of the proximal third of the shaft. The canal gradually enlarges proximally and distally. Fractures through an expanded part of the canal are less securely fixed by a standard intramedullary nail than fractures through the narrowest part. The proper length of the nail should be determined preoperatively; this is best done by radiography to ensure the appropriate array of sizes are available intraoperatively. Even with this information, the proper diameter of the nail is best determined at the time of surgery because of inherent measurement errors that may be present in electronic imaging software if no calibration tool is used. Regardless of its diameter, the canal in an adult should be prepared to 1.0 to 1.5 mm greater in diameter than the anticipated nail diameter.

Insertion instrumentation for closed nailing procedures is commonplace, with the general concepts being standard. Different manufacturers may have a variety of features permitting, for example, variable interlocking options. Therefore, familiarity with the available implant systems translates directly into the surgeon’s understanding of their utility in special or unexpected circumstances intraoperatively. Ensuring the availability and presence of the implants and instrumentation is one of the most important preoperative planning steps for a successful procedure. One must also consider the advantages and disadvantages of the use of a fracture table in treating these injuries. Fracture tables can be time-consuming to set up, continuous traction generated by a fracture table can lead to postoperative nerve palsies, and fracture tables pose difficulties for other surgeons who may need to operate on associated injuries. Their primary indications for this technique were an ipsilateral acetabular or vertical shear pelvic fracture, associated unstable spinal injuries, and bilateral extremity injuries. McFerran and Johnson initially excluded obese or very muscular patients, very small or skeletally immature patients, and patients with ipsilateral neck and shaft fractures; however, as they gained experience, only patients with ipsilateral neck and shaft fractures and fractures more than 24 hours old were excluded. McFerran and Johnson recommended preoperative scanograms of the uninvolved femur in the emergency department to evaluate length. Because of their success in performing femoral nailings with a femoral distractor, their technique evolved to femoral nailing without a fracture table using manual traction only. This technique saves the time that is necessary to place the femoral distractor. A skilled assistant is necessary to perform this technique. Reduction of uncomminuted fractures can be difficult. Reduction of comminuted fractures is easier, but it is more difficult to judge length and rotation. There has been debate as to the ideal entry portal for antegrade closed femoral nailing. Stannard et al. reported their prospective randomized comparison of piriformis fossa and greater trochanteric starting portals. There was no difference in hip function at 1-year follow-up. Intraoperative parameters favored a trochanteric entry portal, primarily because of less operative and fluoroscopy time. A recent meta-analysis did not identify functional superiority when comparing trochanteric and piriformis entry points or antegrade and retrograde starting portals. In our institution, most acute fractures are treated with the use of a fracture table for antegrade intramedullary nailing procedures through a trochanteric entry portal. Lateral piriformis entry tends to be reserved for select subtrochanteric femoral fractures where trochanteric entry can potentiate deformity of the proximal segment. We have not found the added time of patient positioning or table setup to be excessive and have found the ease of imaging to outweigh the disadvantages of the table.   

ANTEGRADE FEMORAL NAILING TECHNIQUE 54.29 Patient Positioning and Preparation Based on preoperative templating and surgical plan, decide on a radiolucent flat-topped or fracture table and patient position. We prefer the use of a fracture table.

n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS We have used the lateral and supine positions extensively, and each has its relative indications (Fig. 54.78). The supine position is more universal. It provides easier access for the anesthesiologist, especially in severely injured patients. The circulating and scrub nurses and the radiographic technicians also are more comfortable with the patient in this position. It is most useful for bilateral femoral fractures, fractures of the distal third of the femur, and femoral fractures with contralateral acetabular fractures. Gaining the correct entry portal to the proximal femur usually is only somewhat more difficult with the patient supine, primarily in obese patients. n  If the patient is supine, adduct the trunk and affected extremity. Flex the affected hip 15 to 30 degrees. n  Apply traction through a skeletal pin or to the foot with a well-padded traction boot. A well-padded perineal post is positioned, and the uninjured extremity is placed in a well-padded traction boot. The legs are positioned in a scissor configuration. n  Estimate correct rotational alignment with respect to the normal anteversion of the hip as determined with the image intensifier. This can be accomplished by taking fluoroscopic views of the uninjured knee and hip at the same rotation of the image intensifier and saving these for later reference. Therefore, comparable anteroposterior fluoroscopic views of the injured limb, both knee and hip, can then allow for rotational correction based on the profile of the lesser trochanter. Similarly, the angle difference between a radiographic true lateral of the knee and hip will represent hip anteversion. n  Rotate the foot and distal fragment of the femur to match the proximal fragment by observing the image C-arm. By taking successive views with the C-arm, it is possible to obtain a lateral view of the proximal femur in which the femoral neck and shaft are parallel but offset about 1 cm. The angle of the C-arm necessary to obtain this “true lateral” usually can be read directly off the C-arm. Taking into account the normal femoral anteversion of 15 to 20 degrees, it is possible to determine exactly the angle at which to place the foot. For example, if the femoral neck and shaft were superimposed when the C-arm was angled 40 degrees from the horizontal, assuming a femoral anteversion of 20 degrees, it would be necessary to externally rotate the foot 20 degrees to match proximal and distal fragments. n  If the patient is in the lateral decubitus position with the perineal post, ensure that most of the trunk weight is on the trochanteric rest of the unaffected hip. n  Place the fractured side in 15 to 30 degrees of hip flexion. The normal side is in neutral to slight hip extension. Use the image intensifier to view the entire femur in the anteroposterior and lateral projections from the knee to the hip. n  Prepare the patient in the standard manner. Drape the buttocks and lateral thigh to the popliteal crease. Cover the image intensifier arm with a sterile isolation drape.  n 

Preparation of Femur Make a short oblique skin incision starting 2 to 3 cm from the proximal tip of the greater trochanter and continue it

n 

proximally and medially. A longer incision may be necessary in obese patients. n  Incise the fascia of the gluteus maximus in line with its fibers. n  Identify the subfascial plane of the gluteus maximus and palpate the piriformis fossa or trochanteric portal. n  Advance the threaded tip guidewire to the approximate level of the piriformis fossa. If a trochanteric antegrade technique is used, the entry point is along the medial slope of the greater trochanter (Fig. 54.79). n  Image the trochanteric region to adjust the position of the guidewire such that the trajectory will permit placement into the center of the medullary canal distally. n  Check the pin position with anteroposterior and lateral imaging. If the pin is not central in the femoral canal, but appropriate on one image plane, then the softtissue guide with multiple-pin “honeycomb” insert may be used. This device permits fine tuning of the starting guidewire to the proper position by the addition of a second pin. n  When the pin is properly placed, advance it to below the lesser trochanter.  Proximal Entry Portal Preparation Remove the honeycomb insert, leaving the guidewire and the entry portal tool in the wound. If the insert was not needed, place the soft-tissue sleeve before creating the entry portal to protect the abductor muscular insertion. n  Place the entry reamer assembly, consisting of a 14-mm channel reamer, entry reamer connector, and entry reamer (Fig. 54.80), into the entry portal tool and over the guidewire. n  Ream the assembly into the femur until it bottoms out on the entry portal tool. n  Check the position of the reamer during the insertion with anteroposterior and lateral imaging. n  Remove the entry reamer and guidewire, leaving the entry portal tube and the channel reamer in place. n  Alternatively, the channel reamer may not be used. The cannulated entry reamer may be positioned over the starting guidewire. For simple diaphyseal fractures the channel reamer generally is not necessary. The device’s advantages become clearly evident with more proximal fractures as a means of externally controlling the characteristic deformity often seen in subtrochanteric fracture patterns.  n 

Reduction and Guidewire Insertion Place the reduction tool consisting of the reducer and a T-handle into the channel reamer and connector in the femur (Fig. 54.81). n  Advance the reduction tool to the fracture site. Use the tool to manipulate the proximal fragment and engage the distal fragment with the tool’s tip. Alternatively, if the intramedullary reduction tool is not used, percutaneous unicortical reduction “joysticks” can be employed for facilitating reduction or external reduction devices also are available. n  When the distal fragment is reached and engaged, advance the 3.0-mm ball-tipped guidewire across the fracture. Use the vice-grip device to advance the guidewire (see Fig. 54.81). n  Confirm the reduction and position of the guidewire with anteroposterior and lateral images at multiple lev n 

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A

B FIGURE 54.78 Russell-Taylor interlocking nail technique. A, Patient in supine position. B, Patient in lateral decubitus position. SEE TECHNIQUE 54.29.

FIGURE 54.79 Trochanteric starting portal for antegrade intramedullary nailing procedures of femur. SEE TECHNIQUE 54.29.

FIGURE 54.80 Insertion of the channel reamer into proximal femoral metaphysis for creating a starting portal for antegrade nailing. SEE TECHNIQUE 54.29.

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FIGURE 54.81 Antegrade femoral nailing. When reducer is in medullary canal and has captured distal fragment, ball-tipped guide rod is inserted through it with use of gripper into distal femur in region of old epiphyseal scar. (Redrawn from Femoral antegrade nailing: technique manual, Memphis, TN, 2001, Smith & Nephew Richards.) SEE TECHNIQUE 54.29.

els. The goal should be concentric central placement of the wire distally to the level of the epiphyseal scar (Fig. 54.82). n  Remove the reduction tool with the T-handle if used.  Canal Preparation Remove the reducer and ream the canal sequentially at 0.5-mm intervals until there is moderate “chatter” or until the reaming exceeds the selected nail diameter by 1.0 to 1.5 mm. The channel reamer must be removed for reamers larger than 12.5 mm (Fig. 54.83). An obturator is used to prevent inadvertent removal of the ball-tipped wire from the proper position within the distal segment of the femur. This must be done during withdrawal of the reamer with each pass. If the wire is withdrawn, re-

n 

position and confirm the location on fluoroscopy before further reaming. n  Confirm the proper nail length by positioning the guidewire at the point of desired distal position, usually between the superior pole of the patella and the level of the distal epiphyseal scar on the anteroposterior image. n  The proper nail length can be determined by either of several methods. n  Using the guidewire method, with the distal end of the rod between the proximal pole of the patella and the distal femoral epiphyseal scar, overlap a second guide rod on the portion of the reduction guide rod extending proximally from the femoral entry portal. The difference in length of the two guidewires is the desired length of the nail.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Make a stab wound at that point and spread the tissue to the bone. n  Insert the gold drill sleeve with the silver inner liner and use the long pilot drill to go to the inner cortex but not through it. n  Measure the length on the calibrated drill bit at the silver guide top. Then penetrate the far cortex. Remove the drill and silver sleeve. n  Insert the screw of the proper length and advance it manually until seated. n  Check the position with an anteroposterior image. n  Evaluate that satisfactory length and rotational alignment has been restored before proceeding with distal interlocking.  n 

Freehand Technique for Distal Targeting Place the image intensifier in the lateral position and scan the distal femoral metaphysis. A true lateral image should be sought. This is confirmed with visualization of the distal interlocking screw holes appearing as perfect, clear circles. If the holes appear oblong or to have double density, then the proper image has not been obtained. Note that this represents a true lateral image of the nail and not necessarily the distal femur. n  When the holes are completely circular, center a ring forceps or the tip of a scalpel over the chosen interlocking hole on the lateral side of the leg. Make a longitudinal stab incision through the skin, subcutaneous tissue, and iliotibial band centered over the interlocking hole in the nail. n  Place a trocar-tip drill bit over the screw hole, angled approximately 45 degrees to permit viewing under fluoroscopy (Fig. 54.84). Make appropriate adjustments until the tip is centered over the desired hole; each adjustment should be accompanied by a fluoroscopic image until the proper position is obtained. n  Bring the drill parallel and in line with the fluoroscopic beam. Take care to maintain constant pressure to avoid movement of the drill tip. n  Penetrate the lateral cortex. Remove the drill bit from the driver and confirm on the lateral image the drill bit placed within the interlocking hole. If it is not, make appropriate adjustments in alignment. Then reattach the driver and penetrate the medial cortex. n  Calibrated drill bits are used for this portion of the procedure and it greatly increases the ease of determining screw length. Alternatively, a standard depth gauge can be used. Place the appropriate length interlocking bolt by hand, confirming satisfactory purchase. n  Repeat if additional distal interlocking screws are desired. n  Anteroposterior and lateral imaging should confirm appropriate screw position and length. n  Irrigate and close the wounds in a standard layered fashion.  n 

FIGURE 54.82 Intramedullary bead-tipped guidewire inserted concentrically to distal femur at level of distal femoral physeal scar or midportion of patella. SEE TECHNIQUE 54.29.

FIGURE 54.83 Reaming of femoral canal over 3.2-mm guide rod. SEE TECHNIQUE 54.29.

Alternatively, most nail systems now supply cannulated depth gauges designed to be placed over the 3.0-mm wire, permitting length determination. This is the preferred method. n  Insert the ruler over the guidewire and place it at the level of the femoral insertion. n  Check this with the anteroposterior image. Read the measurement off the measurement device.  n 

Nail Insertion Attach the drill guide assembly to the selected nail. n  Remove the entry portal tube and channel reamer, leaving the guidewire in place. n  Place the nail into the femur and advance it manually. The nail may require gentle impaction to fully seat. n  If there is significant resistance, remove the nail and ream the canal 0.5 mm larger. n  Seat the nail completely as confirmed on multiplanar image intensification.  n 

Interlocking of Nail For proximal and distal interlocking, use the 5-mm locking screws. Depending on the chosen implant’s configuration, proximal and distal locking options may vary. Standard static locking with this implant is from the greater trochanter directed obliquely to the lesser trochanter. n  Place the gold drill sleeve into the proximal guide and dimple the skin. n 

Final Evaluation Before leaving the operative suite, several key elements must be evaluated. n  First, if the nail has been locked in standard fashion, evaluate the femoral neck with multiplanar fluoroscopic imaging to ensure that no occult femoral neck fracture is identified. Dynamic stress fluoroscopy has been shown to n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Examine the ligaments of the ipsilateral knee. A postoperative anteroposterior pelvis radiograph with both hips internally rotated provides the optimal profile view of the femoral neck as a further check for occult femoral neck fractures and should be obtained and reviewed before anesthesia is discontinued. 

n  n 

POSTOPERATIVE CARE  Weight bearing depends on the stability of the fracture fixation. Weight bearing to tolerance is allowed immediately regardless of the nail size if satisfactory cortical contact is achieved. In the rare circumstance that an adolescent nail is used in an adult, protected weight bearing should be initiated until early radiographic healing is noted. Touch-down or partial weight bearing is allowed in comminuted injuries. Hip and knee range of motion are encouraged. Quadriceps-setting and straight-leg raising exercises are begun before hospital discharge. Hip abduction exercises are begun after wound healing. Weight bearing is progressed as callus formation occurs. Ambulatory aids such as crutches or a walker are used for the first 6 weeks. Hip and knee range-of-motion and strengthening exercises are recommended during this time. Unassisted ambulation is permitted as strength recovery and radiographic healing progress.   

A

B

C

RETROGRADE NAILING OF THE FEMUR

D FIGURE 54.84 Freehand technique. A, Awl is placed over proximal screw hole with its handle angled 45 degrees. B-D, Awl is adjusted under image intensification until point is centered in screw hole and then is swung perpendicular to axis of bone (C) and driven to lateral side of rod (D). SEE TECHNIQUE 54.29.

be superior to static imaging for identifying occult fractures intraoperatively. n  Next, confirm the length and rotational reductions and compare with the uninjured limb to ensure symmetry. This can prove to be challenging with significantly comminuted fractures and is best performed with a combination of methods. Comparison to the contralateral uninjured femur has been questioned from an accuracy standpoint, given inherent side-to-side differences in individuals. The fracture rotation also can be estimated based on the inherent anteversion of the cephalomedullary nail intraoperatively. Length can be assessed with measurement of the contralateral uninjured femur radiographically, clinical assessment, or use of postoperative CT scanogram scout imaging. n  Evaluate the thigh compartments, and if clinical concern exists, then obtain objective compartment measurements.

Retrograde femoral nailing may be beneficial in the following clinical situations: (1) obese patients, in whom it is difficult to obtain an antegrade entry portal; (2) patients with ipsilateral femoral neck and shaft fractures, to allow the use of separate fixation devices for the shaft and neck fractures; (3) patients with floating knee injuries, to allow fixation of the femoral and tibial fractures through the same anterior longitudinal incision; (4) multiply-injured trauma patients, to decrease operative time by not using a fracture table, which allows multiple injuries to be treated by preparing and draping simultaneously; and (5) pregnant patients, such that intraoperative fluoroscopy is minimized around the pelvis. An intercondylar portal is favored for insertion. It is important to remember that retrograde nailing is more reliable in controlling distal shaft fractures, whereas antegrade nailing provides better control of proximal shaft fractures. Satisfactory results were reported by Moed and Watson and Herscovici and Whiteman in early trials of this technique and have been reported in more recent series. Supracondylar fractures have lower union rates (80% to 84%) with this technique than femoral shaft fractures (85% to 100%). Retrograde nailing of the femur is not without frequent complications, however, including knee pain (13% to 60%) and secondary surgery (12% to 35%). The infection rate is acceptable (0% to 14%). Varusvalgus malunion, common with the initial extraarticular entry site (12% to 29%), is less common with the current intercondylar entry site. Nonetheless, retrograde intramedullary nail stabilization provides significant benefits in certain clinical circumstances and has an acceptable risk profile compared with antegrade procedures. 

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY  

RETROGRADE FEMORAL NAILING TECHNIQUE 54.30 Place the patient on a radiolucent flattop operating room table. A small bolster can be positioned under the ipsilateral hip to prevent external rotation of the proximal femur. Surgical preparation and draping must include the hip girdle and lower flank. n  Position the leg over a sterile bump or triangle. Tibial traction may be used and affixed to the traction bow holder. Alternatively, a tibial traction pin and traction bow can be used as a “handle” for more exacting control of the distal segment when manual traction is used. n  Make an incision through the lateral parapatellar, medial parapatellar, or transpatellar tendon based on surgeon preference. The retropatellar fat pad must be incised and an arthrotomy performed. Insert a guidewire into the intercondylar notch. Position the pin directed centrally into the medullary canal on anteroposterior imaging. Confirm its position and trajectory on lateral imaging; the pin placement should be in line with the medullary canal at the anterior extent of Blumensaat’s line (Fig. 54.85). n  Advance the guidewire into the distal femoral metaphysis. Place the soft-tissue protection sleeve over the guidewire for protection of the articular surfaces and patellar tendon. n  Similar to the antegrade technique, a multiple-pin “honeycomb” insert can aid in perfecting the guidepin placement. If this is used, remove the honeycomb insert and place the cannulated entry reamer over the initial guidewire. n  Advance into the femur until the reamer is within the distal femur, taking special care to maintain the soft-tissue protection sleeve in place to avoid iatrogenic intraarticular injury. (Do not use the channel reamer and entry reamer connector for this procedure.) n  Take care to ensure appropriate trajectory of the pin in the distal segment, particularly with fractures involving the distal femoral metaphysis. Otherwise, coronal and sagittal plane malalignments can result secondary to nailcanal mismatch. Blocking screws may be indicated to maintain alignment. n  Remove the reamer and guidewire and insert a 3-mm bead-tipped guidewire into the distal fragment. n  Reduce the fracture and advance the guidewire into the proximal segment to the level of the lesser trochanter. A cannulated reduction tool or external devices, such as a large distractor, can be used for reduction maneuvers in combination with axial traction. Small bumps or bolsters can be placed along the posterior surface of the thigh as determined by fluoroscopy to aid in sagittal plane reduction. n  Prepare the medullary canal by introducing cannulated reamers over the guidewire to a diameter 1.0 to 1.5 mm larger than the nail to be used. n  Recheck the position of the guidewire to confirm its position at the lesser trochanter. n  Apply traction to the leg to ensure proper length. Measure for the appropriate length of the nail with a ruler n 

A

B FIGURE 54.85 Retrograde femoral nailing (see text). A, Anteroposterior view of guide pin being passed 10 cm into medullary canal through intercondylar notch. B, On lateral view, medullary canal tapers distally (arrows) to form V; guide pin is placed at apex of canal. (From Herscovici D, Whiteman KW: Retrograde nailing of the femur using an intercondylar approach, Clin Orthop Relat Res 332:98, 1996.) SEE TECHNIQUE 54.30.

placed over the guidewire. Check to ensure the ruler is countersunk. This is most easily performed on the lateral image plane. n  Remove the entry portal tool and insert the nail attached to the targeting guide, seating it to the level of the lesser trochanter (Fig. 54.86). n  Maintain traction on the leg to avoid shortening. n  Check the lateral image to ensure the nail is properly inset. n  When the nail is at the proper level, remove the guidewire. n  Proceed with distal locking of the nail using the guide. n  Insert the drill sleeve and trocar through the targeting guide and dimple the skin. n  Make a stab wound at the site and enlarge the hole with blunt dissection to bone. n  Reinsert the drill guide to bone. Advance the drill until the far cortex is encountered and read the measurement off the drill bit calibrations for length approximation. Complete the penetration of the cortex. n  Insert the screw by hand until fully seated. n  Check the length and position of the screws with anteroposterior and lateral imaging.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS tures with less secure fixation may require hinged bracing. Initial weight bearing depends on fracture stability after fixation. Patients with intercondylar fractures or supracondylar fractures require protected weight bearing until radiographic progression permits advancement of weight bearing (usually between 10 and 12 weeks).   

ERRORS AND COMPLICATIONS OF INTRAMEDULLARY FIXATION

FIGURE 54.86 Nail is seated at level of distal trochanter. (From Herscovici D, Whiteman KW: Retrograde nailing of the femur using an intercondylar approach, Clin Orthop Relat Res 332:98, 1996.) SEE TECHNIQUE 54.30.

Repeat this procedure until the desired number of interlocking screws have been positioned. n  Recheck the alignment and length of the femur using a Bovie cord from the anterior superior iliac crest, middle of the femoral head, middle of the knee, and middle of the tibial plafond. Check the lateral reduction. n  When the final reduction and length are acceptable, move to the proximal locking hole, which should be placed in the anteroposterior plane at the level of the lesser trochanter to avoid nerve and vessel injury. Identify the hole by the perfect circle technique. n  Using the image intensifier, localize the interlocking holes proximally because this will assist in placement of the incision. Make a longitudinal skin incision, sharply dividing the subcutaneous tissue and deep fascia, and bluntly dissect to bone. Avoid damage to the branches of the femoral nerve. n  Drill into the femur when the position is acceptable by the perfect circle technique. n  Use the same technique to determine the screw length as described previously. n  Place the interlocking screw using the captured screwdriver. n  Recheck the alignment and reduction with multiple anteroposterior and lateral views. n  Image the hip in full fluoroscopic mode with internal and external rotation and push-pull to check for an occult femoral neck fracture. n  Close the wounds in a standard layered fashion and apply a dressing. n  Perform the same series of checks as described for antegrade nail procedures.  n 

POSTOPERATIVE CARE  Postoperative rehabilitation depends on the stability of fixation, and the fracture pattern and must be individualized for each patient. All patients are initially placed in a knee immobilizer. Patients with stable fixation can be started on a continuous passive motion program in the first 24 to 48 hours after surgery. Frac-

Given the correct indications for intramedullary nailing, the necessary equipment and assistance, and adequate training, the following are the most common difficulties in interlocking nailing. Although locked femoral nailing generally is considered to yield good functional results, many patients report symptoms related to their fracture and fixation more than 1 year after injury, including pain related to changes in weather, limping, difficulty with walking, climbing, or standing, and trochanteric pain or thigh pain. A significant decrease in hip abductor strength also has been noted. The presence of heterotopic ossification, femoral shortening, or proximal nail prominence has not been shown to correlate with this loss of abductor strength. It has been hypothesized that postoperative abductor weakness is caused by injury to the gluteus medius and minimus muscles or to the superior gluteal nerve during portal creation or by inadequate postoperative rehabilitation. Retracting the gluteus medius and minimus anteriorly when exposing the nail insertion site has been suggested to prevent injury to these muscles and their nerve supply. Patients should be counseled about their expected postoperative recovery.

PATIENT POSITIONING AND TRACTION

Femoral nailing with the patient supine on a fracture table is our preferred method when an antegrade approach is used. In this technique, the hip is adducted to improve access to the piriformis fossa or trochanteric entry portal and intraoperative traction is used. Hip adduction has been found to increase pressure on the pudendal nerve, resulting in pudendal nerve palsy. Traction should be minimized to avoid this complication. Use of a well-padded perineal post and minimizing operative and traction time have been recommended. We recommend the following technique modifications to limit intraoperative hip adduction and traction when using a fracture table. The patient is placed on the fracture table, and traction is applied with the hip in neutral position to confirm the ability to reduce the fracture. Traction is released during preparation and draping of the extremity and during creation of the entry portal. The hip is adducted to gain access to the nail insertion site but is brought back to neutral position when the entry portal has been created. Traction is reapplied for fracture reduction. We have identified two patterns of injury in which excessive traction may be required for fracture reduction, leading to a higher incidence of pudendal and peroneal nerve palsies: segmental femoral fractures and floating knee injuries (which necessitate antegrade femoral nailing). Because of the soft-tissue stripping that often occurs with segmental femoral fractures, the segmental fragment may not reduce with the application of even large amounts of traction. In these rare cases, we prefer a limited open reduction or percutaneous

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY joystick manipulation to the use of excessive traction. For floating knee injuries, we prefer to nail the femur first, applying traction through a pin inserted in either the distal femur or the proximal tibia, flexing the knee, and supporting the tibial fracture with a splint to reduce tension on the peroneal nerve. Early nailings are technically easier than delayed nailings. Less traction force is required, and fragment reduction is easier. If nailing is delayed more than 12 hours, the femur should be stabilized with traction, which can facilitate length maintenance in anticipation of definitive fixation. Compartment syndrome and peroneal nerve palsy as a result of elevation in a calf-supporting, well-leg holder have been described. We recommend placing the unoperated leg, regardless of injury, in the extended supine position on the fracture table. 

ERRORS IN NAIL INSERTION

We recommend the supine position for many reasons. True lateral views of the hip and proximal femur are easily obtained, and it is imperative that the starting portal be directly in line with the center of the shaft on both views. This usually is in the piriformis fossa close to the medial wall of the greater trochanter, sometimes slightly within the greater trochanter. Determining the correct starting portal is worth extra time and effort. An eccentric portal can cause comminution and loss of fixation. If difficulty exists in passage of the reamer guidewire, several techniques can be used. A cannulated intramedullary reduction tool can be invaluable in effecting a difficult reduction in a closed manner. If one is not available, the proximal segment can be reamed to accommodate a small intramedullary nail that can then be placed in lieu of a reduction tool to accomplish the same goal. The proximal fragment usually must be extended and, depending on the level of the fracture with respect to the perineal post, either adducted or abducted. The containment of the guidewire must be confirmed on orthogonal views. If a guidewire is inadvertently partially withdrawn with the reamer, its position should be immediately evaluated fluoroscopically. The passage of the nail across the fracture must be seen on orthogonal views to prevent impingement on the cortex. Complications of reaming are eliminated by the unreamed technique. Closed section nails can be driven over the initial guidewire. Short distal fragments should be supported as the nail is being driven to prevent extension at the fracture. The guidewire must enter the distal fragment well centered and must stay centered to the intercondylar notch for very short distal fragments to prevent varus or valgus malalignment. All fractures should be locked statically (proximal and distal screws), and blocking screws may be indicated to provide an artificial “cortex” for containment of nails when metaphyseal canal-nail mismatch exists. A nail that is larger than the medullary canal may become firmly incarcerated and resist all efforts to drive it farther or to extract it. To remove the nail, a small incision is made laterally at the level of incarceration, two 5- to 6-mm holes are drilled in the lateral cortex 3 to 4 cm apart, and they are connected with an osteotome or sagittal saw. The nail can then be withdrawn. If the starting portal is correct, a smaller nail should be used or the constricting

FIGURE 54.87 Bending of femoral intramedullary nail after repeated secondary trauma.

section of the canal should be reamed to a larger diameter. Careful preoperative templating and canal preparation should virtually eliminate the complication of nail incarceration. 

BENT OR BROKEN NAILS

The femoral nails in common use today have a smooth, bullet-shaped leading tip to make insertion easier and are slightly bowed anteriorly. This preformed anterior bow should be directed anteriorly when the nail is inserted. Improper selection (inserting a “right” nail in a left femur) results in improper alignment of the proximal interlocking screw hole. A bent nail usually indicates an injudicious act on the part of the patient or a nail that was too small (Fig. 54.87). A bent nail is not an indication for manipulation; it only succeeds in further weakening the nail. Instead, the bent nail should be removed and a new one should be inserted. When bending of the nail has occurred, it is wishful thinking to expect that union will occur before further bending or breaking of the nail, a far more complicated situation. Just before a bent nail is extracted, the leg should be manipulated into as nearly normal alignment as possible. A broken nail almost always can be extracted through the buttock incision, using an assortment of extraction hooks to engage the distal tip and deliver both halves. If a hook is unsuccessful, the proximal half is removed by its normal driver extractor. Next, a ball-tip guidewire is placed through the distal half of the nail and jammed into position with other guidewires. The initial guidewire is withdrawn with the distal segment of nail. 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Insert the pin into the nail. Remove the heterotopic bone with curets or a reamer. n  Remove the guide pin, and insert a hooked guidewire and advance it to the tip of the broken nail. n  Wedge the hooked guidewire with multiple smaller guidewires. This should align the broken ends to make the broken nail more like one piece and avoid catching the sides of the femur. Manipulation of the femur may be necessary if deformity is present to allow for “linear” removal. n  Grasp the multiple guidewires with locking (vice-grip) pliers attached to a universal sliding extractor. n  Carefully extract the nail with gentle mallet blows. If unsuccessful, an open approach may be necessary.   

 

n 

EXTRACTION OF AN UNBROKEN ANTEGRADE FEMORAL NAIL

n 

TECHNIQUE 54.31 Place the patient in the straight lateral position using a beanbag or other positioning device on a radiolucent operating table. n  Prepare the entire leg, lateral buttock, and torso to the ribs. Drape the leg to allow full hip and knee motion for positioning. n  Flex the hip to almost 90 degrees. n  Remove the proximal and distal locking screws in the standard fashion. n  Lay a guidewire on the thigh and obtain a fluoroscopic image of the proximal hip. Adjust the wire to coincide with the femoral nail on the lateral view. Draw a line along the wire, extending it onto the buttock. Externally rotate the thigh and, using fluoroscopic imaging, mark a line in a similar fashion to determine the anteroposterior nail position. The intersection of the two lines indicates the site of the incision for placement of the extractor. The incision may be different than what was used initially to insert the device, particularly if it was originally placed with the patient supine. n  If heterotopic bone is to be removed, the incision will need to be made larger. n  Insert a guidewire along the scissors until it touches the nail. n  Adjust the guide pin until it advances into the nail. n  Obtain anteroposterior and lateral images of the hip to confirm placement of the guidewire into the nail. n  Insert the cone-shaped femoral extractor on the extraction bar into the wound over the guide pin. Screw the extractor into the nail. If there is overgrown bone, use a soft-tissue protection sleeve and place a cannulated entry reamer over the guidewire to remove the osseous cap before insertion of the nail extractor. The first pass may not engage the nail fully, but it removes much of the interposed soft tissue. n  Reinsert the extractor over the guide pin or wire and tighten it onto the nail with force sufficient to require the use of the wrenches. n  Use the slotted mallet to hammer the nail out. Irrigate and close the wound in the standard fashion.     n 

 

EXTRACTION OF A BROKEN FEMORAL ANTEGRADE NAIL TECHNIQUE 54.32 Position the patient as described previously. Remove all locking screws. n  Approach the proximal femur as described previously with the long 3.2-mm guide pin. n  n 

INFECTIONS

A deep infection after either open or closed intramedullary fixation is a serious complication. The literature reports infection rates of 1.5% to 10% after open reduction and intramedullary fixation; after closed reduction and nailing, most authors report less than a 1% deep infection rate. This in and of itself is justification for mastering the closed nailing technique. If a deep infection occurs after intramedullary nailing, the involved site (usually the fracture site) should be surgically opened and widely drained. All devitalized tissue, small bone fragments, granulation tissue, and hematoma should be removed, and the surgical site may require multiple debridements, depending on the virulence of the organism. The intramedullary nail can be left in place, however, if it is providing fixation because removal of the nail usually results in an infected nonunion. At times, infections that are difficult to control may require early deep implant removal and temporary antibiotic cement nail insertion before definitive fixation in an effort to eradicate the infection. Cultures should be obtained, and appropriate antibiotics should be begun. We usually give the patient intravenous antibiotics for 6 weeks after this surgery. The patient is then given an oral suppressive antibiotic, often until union if the implant is retained. The patient’s progress is monitored by repeated measuring of erythrocyte sedimentation rate and C-reactive protein. The infection usually remains localized to the fracture site, and although drainage may continue indefinitely and a medullary sequestrum may form, the nail should be left in place if possible. Involucrum and callus form despite infection if the fixation remains fairly rigid. The nail should not be removed until the healing is strong enough to support the fracture. At this time, a sequestrectomy is performed and the nail is removed. Rarely, infection extends from one end of the medullary canal to the other and may follow the nailing of an open fracture of the femur. This complication is serious and usually results in drainage for a long time, with exacerbations and remissions. The nail is left in place despite the infection until the fracture unites, provided that fixation is reasonably firm. If the fracture is infected and the nail is broken or providing little stability, it can be removed at the time of the open drainage procedure and a larger nail can be inserted or an external fixator applied. With either choice, the fragments

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY

A

C

B

D

FIGURE 54.88 A and B, Femoral fracture in patient with Paget disease was fixed with double plates. C and D, Fracture occurred below plates; plates were removed, and femur was stabilized with intramedullary nail.

must be immobilized; the wound may be left open, and an appropriate antibiotic regimen is begun. In our experience, infection occurs after closed nailing of closed fractures in about 0.5% of patients. Of the femoral fractures we treat, 25% are open and infection occurs after closed nailing of open fractures in 2% to 3% of patients. To date, in more than 2500 femoral nailings, all infections were controlled with debridement and antibiotics during fracture healing. After healing of the fracture, the nails were removed and the medullary canals underwent debridement and irrigation. No evidence of infection returned after nail removal. 

INTRAMEDULLARY FIXATION IN PATHOLOGIC FRACTURES

For pathologic fractures resulting from metastatic tumors, intramedullary fixation is usually rigid enough to allow the patient to be up and about in relative comfort for the remaining months of life. If the metastatic deposit is discovered before fracture, closed prophylactic intramedullary nailing is justified if a pathologic fracture is impending. If a fracture occurs through a large metastatic tumor, a large intramedullary nail supplemented by methyl methacrylate may afford good fixation. Union may even occur. The theoretical disadvantage that the passage of an intramedullary nail through the tumor may dislodge tumor cells and accelerate metastatic spread does not justify condemnation of the method. In these fractures, because the bone is often severely osteoporotic, fixation usually is more secure after intramedullary nailing than after the application of plates and screws. Local radiation therapy can be given after nailing without ill effect. Grundy reported 63 fractures of the femur in patients with Paget disease. The most common site of fracture was the subtrochanteric area, with the upper shaft the next most common (Fig. 54.88). He recommended treatment of shaft fractures with traction followed by cast immobilization. In subtrochanteric fractures, he suggested using a short

intramedullary nail, pointing out that there is usually bowing and that a long nail would become incarcerated or would cut out because of the deformity. The short nail fixation did allow the fractures to heal and prevented the progressive varus deformity that tends to result with nonoperative treatment of subtrochanteric fractures in Paget disease. Metastatic lesions frequently are in the subtrochanteric region and may be multicentric. They are slow to heal because of bone loss, tumor extension, and radiation therapy. Therefore intramedullary implants are well suited for treatment of pathologic processes because they allow immediate weight bearing. Furthermore, modern cephalomedullary nails provide rigid fixation of the entire femur from the femoral neck to the intercondylar notch, and rotation and length are maintained by the proximal and distal locking screws. In a multicenter prospective study, 25 metastatic femoral lesions in 22 patients were treated with the Russell-Taylor reconstruction nail. Pathologic fractures had occurred in 15 femurs, and 10 had impending pathologic fractures. Twenty-four of the 25 lesions produced incapacitating pain, and pain relief was evident immediately after surgery in all. At an average 1-year follow-up, fixation had not been lost in any patient, and of the 22 patients, 16 were still alive. 

FRACTURE OF THE FEMORAL SHAFT WITH DISLOCATION OF THE HIP

It was previously believed that the same mechanism that produces a fracture of the neck of the femur with a fracture of the shaft also may produce a dislocated hip. In a cadaver study, the combination of dislocation of the hip and fracture of the shaft could be produced only by two separate forces. The hip is dislocated by a force applied in line with the shaft while the knee and hip are flexed 90 degrees and the hip is adducted; the femoral shaft is fractured by another force applied to the lateral aspect of the thigh. The fact that in this injury the shaft fracture usually is transverse supports these

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A

B FIGURE 54.89 A, Polytraumatized patient with left femoral diaphyseal fracture and associated femoroacetabular dislocation. Also note concomitant complex pelvic ring and left-sided acetabular injury. B, Proximal femur was reduced using percutaneous positioned Schanz pin at time of patient’s exploratory laparotomy. Pin was then incorporated into uniplanar external fixator for temporary stabilization of femoral fracture secondary to patient’s overall condition on presentation.

findings. Adduction of the proximal fragment as seen in the radiographs of the femur is strong evidence that the hip is dislocated; in most fractures of the femoral shaft without dislocation of the hip, the proximal fragment is abducted. This illustrates and supports the importance of a thorough systematic radiographic evaluation in the setting of high-energy trauma to include at a minimum orthogonal imaging of joints adjacent to the anatomic area of primary injury. In this combined injury, the dislocation of the hip is an emergency and must be reduced promptly to prevent osteonecrosis of the femoral head (Fig. 54.89). We prefer to treat the femoral shaft fracture definitively, in the same setting, if the patient’s condition permits early total care. Rarely will the femoracetabular dislocation reduce closed, and percutaneous instruments are necessary for a successful reduction.

REFERENCES ANKLE (PILON FRACTURES) Alexandropoulos C, Tsourvakas S, Papchristos J, et al.: Ankle fracture classification: an evaluation of three classification systems: Lauge-Hansen, A.O. and Broos-Bisschop, Acta Orthop Belg 76:521, 2010. Amorosa LF, Brown GD, Greisberg J: A surgical approach to posterior pilon fractures, J Orthop Trauma 24:188, 2010. Bava E, Charlton T, Thorderson D: Ankle fracture syndesmosis fixation and management: the current practice of orthopaedic surgeons, Am J Orthop 39:242, 2010. Boraiah S, Kemp TJ, Erwteman A, et al.: Outcome following open reduction and internal fixation of open pilon fractures, J Bone Joint Surg 92A:346, 2010. Briceno J, Wusu T, Kaiser P, et al.: Effect of syndesmotic implant removal on dorsiflexion, Foot Ankle Int 40:499, 2019. Cannada LK: The no-touch approach for operative treatment of pilon fractures to minimize soft tissue complications, Orthopedics 33:734, 2010. Choi Y, Kwon SS, Chung CY, et al.: Preoperative radiographic and CT findings predicting syndesmotic injuries in supination-external rotation-type ankle fractures, J Bone Joint Surg 96A:1161, 2014.

Egol KA, Pahk B, Walsh M, et  al.: Outcome after unstable ankle fracture: effect of syndesmotic stabilization, J Orthop Trauma 24:7, 2010. Gougoulia N, Knanna A, Sakellariou A, Maffulli N: Supination-external rotation ankle fractures: stability a key issue, Clin Orthop Relat Res 468:243, 2010. Grassi A, Samuelsson K, D’Hooghe P, et al.: Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: a meta-analysis of randomized controlled trials, Am J Sports Med 48:1000, 2020. Graves ML, Porter SE, Fagan BC, et al.: Is obesity protective against wound healing complications in pilon surgery? Soft tissue envelope and pilon fractures in the obese, Orthopedics 11:33, 2010. Ketz J, Sanders R: Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures, J Orthop Trauma 26:341, 2012. Little MM, Berkes MB, Schottel PC, et  al.: Anatomic fixation of the supination external rotation type IV equivalent ankle fractures, J Orthop Trauma 29:250, 2015. Liu JW, Ahn J, Raspovic KM, et  al.: Increased rates of readmission, reoperation, and mortality following open reduction and internal fixation of ankle fractures are associated with diabetes mellitus, J Foot Ankle Surg 58:470, 2019. Peterson KS, Chapman WD, Hyer CF, Berlet GC: Maintenance of reduction with suture button fixation devices for ankle syndesmotic repair, Foot Ankle Int 36:679, 2015. Pollard JD, Deyhim A, Rigby RB, et  al.: Comparison of pullout strength between 3.5 mm fully threaded bicortical screws and 4.0 mm partially threaded, cancellous screws in the fixation of medial malleolar fractures, J Foot Ankle Surg 49:248, 2010. Raeder BW, Figved W, Madsen JE, et al.: Better outcome for suture button compared with single syndesmotic screw for syndesmosis injury: fiveyear results of a randomized controlled trial, Bone Joint Lett J 102-B:212, 2020. Sanders DW, Tieszer C, Corbett B: Operative versus nonoperative treatment of unstable lateral malleolar fractures: a randomized multicenter trial, J Orthop Trauma 26:129, 2012. Shimozono Y, Hurley ET, Myerson CL, et al.: Suture button versus syndesmotic screw for syndesmosis injuries: a meta-analysis of randomized controlled trials, Am J Sports Med 47:2764, 2019.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Tantigate D, Ho G, Kirschenbaum J, et al.: Functional outcomes after fracture-dislocation of the ankle, Foot Ankle Spec 13:18, 2020. Wake J, Martin JD: Syndesmosis injury from diagnosis to repair: physical examination, diagnosis, and arthroscopic-assisted reduction, J Am Acad Orthop Surg, 2020, [Epub ahead of print]. Wawrose RA, Grossman LS, Tagliaferro M, et  al.: Temporizing external fixation vs splinting following ankle fracture dislocation, Foot Ankle Int 41:177, 2020. White TO, Guy P, Cooke CJ, et al.: The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures: a cohort study, J Orthop Trauma 24:757, 2010.

TIBIAL SHAFT Cain ME, Hendrickx LAM, Bleeker NJ, et  al.: Prevalence of rotational malalignment after intramedullary nailing of tibial shaft fractures: can we reliably use the contralateral uninjured side as the reference standard? J Bone Joint Surg Am 102:582, 2020. Chan DS, Serrano-Riera R, Griffing R, et al.: Suprapatellar versus infrapatellar tibial nail insertion: a prospective randomized control pilot study, J Orthop Trauma 30:130, 2016. Connelly CL, Bucknall V, Jenkins PJ, et al: Outcome at 12 to 22 years of 1502 tibial shaft fractures, Bone Joint J 96B:1370, 2014. Foote CJ, Guyatt GH, Vignesh KN, et al.: Which surgical treatment for open tibial shaft fractures results in the fewest reoperations? A network metaanalysis, Clin Orthop Relat Res 473:2179, 2015. Frihagen F, Madsen JE, Sundfeldt M, et al.: Taylor Spatial Frame™ or reamed intramedullary nailing for closed fractures of the tibial shaft. A randomized controlled trial, J Orthop Trauma, 2020, [Epub ahead of print.]. Hendrickx LAM, Virgin J, van den Bekerom MPJ, et al.: Complications and subsequent surgery after intra-medullary nailing for tibial shaft fractures: review of 8110 patients, Injury, 2020, [Epub ahead of print.]. Ibrahim I, Johnson A, Rodriguez EK: Improved outcomes with semiextended nailing of tibial fractures? a systematic review, J Orthop Trauma 33:155, 2019. Lack WD, Starman JS, Seymour R, et al.: Any cortical bridging predicts healing of tibial shaft fractures, J Bone Joint Surg 96:1066, 2014. Lam SW, Teraa M, Leenen LP, van der Heijden GJ: Systematic review shows lowered risk of non-union after reamed nailing in patients with closed tibial shaft fractures, Injury 41:671, 2010. Vallier HA, Cureton BA, Patterson BM: Randomised, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures, J Orthop Trauma 25:736, 2011. Zamorano DP, Robicheaux GW, Law J, Mercer J: Semiextended nailing: is the patellofemoral joint safe? Paper #58, presented at the annual meeting of the Orthopaedic Trauma Association, 2010.

Ruffolo MR, Gettys FK, Montijo HE, et  al.: Complications of high energy bicondylar tibial plateau fractures treated with dual plating through 2 incisions, J Orthop Trauma 29:85, 2015. Sanders R, DiPasquale TG, Jordan CJ, et al.: Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up, J Orthop Trauma 28:245, 2014. Stewart CC, O’Hara NN, Mascarenhas D, et al.: Predictors of symptomatic implant removal after open reduction and internal fixation of tibial plateau fractures: a retrospective case-control study, Orthopedics 43:161, 2020. Zeng ZM, Luo CF, Putnis S, Zeng BF: Biomechanical analysis of posteromedial tibial plateau split fracture fixation, Knee 18:51, 2011. Ziran BH, Becher SJ: Radiographic predictors of compartment syndrome in tibial plateau fractures, J Orthop Trauma 27:612, 2013.

PATELLA Bonnaig NS, Casstevens C, Archdeacon MT, et al.: Fix it or discard it? A retrospective analysis of functional outcomes after surgically treated patella fractures comparing ORIF with partial patellectomy, J Orthop Trauma 29:80, 2015. Busel G, Barrick B, Auston D, et al.: Patella fractures treated with cannulated lag screws and Fiberwire® have a high union rate and low rate of implant removal, Injury 51:473, 2020. Camarda L, La Gutta A, Butera M, et al.: FiberWire tension band for patellar fractures, J Orthop Traumatol 17:75, 2016. Cho JW, Kent WT, Cho WT, et al.: Miniplate augmented tension-band wiring for comminuted patella fractures, J Orthop Trauma 33:e143, 2019. Lazaro LE, Wellman DS, Sauro G, et al.: Outcomes after operative fixation of complete articular patellar fractures: assessment of functional impairment, J Bone Joint Surg 95A(e96):1–8, 2013. LeBrun CT, Langford JR, Sagi HC: Functional outcomes after operatively treated patella fractures, J Orthop Trauma 26:422, 2012. Lorich DG, Fabricant PD, Sauro G, et al.: Superior outcomes after operative fixation of patella fractures using a novel plating technique: a prospective cohort study, J Orthop Trauma 31:241, 2017. Sillander M, Koueiter DM, Gandhi S, et  al.: Outcomes following lowprofile mesh plate osteosynthesis of patella fractures, J Knee Surg 31:919, 2018. Taylor BC, Mehta S, Castaneda J, et al.: Plating of patella fractures: techniques and outcomes, J Orthop Trauma 28:e231, 2014. Wagner FC, Neumann MV, Wolf S, et  al.: Biomechanical comparison of a 3.5 mm anterior locking plate to cannulated screws with anterior tension band wiring in comminuted patellar fractures, Injury, 2020, [Epub ahead of print.].

TIBIAL CONDYLE AND TIBIAL PLATEAU

FEMUR

Ahearn N, Oppy A, Halliday R, et al.: The outcome following fixation of bicondylar tibial plateau fractures, Bone Joint Lett J 96B(95):6–62, 2014. Berkes MB, Little MT, Schottel PC, et  al.: Outcomes of Schatzker II tibial plateau fracture open reduction internal fixation using structural bone allograft, J Orthop Trauma 28:97–102, 2014. Colman M, Wright A, Gruen G, et  al.: Prolonged operative time increases infection rate in tibial plateau fractures, Injury 44:249, 2013. Evangelopoulos D, Chalikias S, Michalos M, et al.: Medium-term results after surgical treatment of high-energy tibial plateau fractures, J Knee Surg 33:394, 2020. Haller JM, Holt DC, McFadden ML, et al.: Arthrofibrosis of the knee following a fracture of the tibial plateau, Bone Joint Lett J 97B:109, 2015. Haller JM, McFadden M, Kubiak EN, Higgins TF: Inflammatory cytokine response following acute tibial plateau fracture, J Bone Joint Surg 97A:478, 2015. Hap DXF, Kwek EBK: Functional outcomes after surgical treatment of tibial plateau fractures, J Clin Orthop Trauma 11(Suppl 1):S11, 2020. Hong G, Huang X, Lv T, et al.: An analysis on the effect of the three-incision combined approach for complex fracture of tibial plateau involving the posterolateral tibial plateau, J Orthop Surg Res 15:43, 2020.

Adams Jr JD, Tanner SL, Jeray KJ: Far cortical locking screws in distal femur fractures, Orthopedics 38:e153, 2015. Avilucea FR, Joyce D, Mir HR: Dynamic stress fluoroscopy for evaluation of the femoral neck after intramedullary nails: improved sensitivity for identifying occult fractures, J Orthop Trauma 33:88, 2019. Barei DP, Beingessner DM: Open distal femur fractures treated with lateral locked implants: union, secondary bone grafting, and predictive parameters, Orthopedics 35:e843, 2012. Becher S, Ziran B: Retrograde intramedullary nailing of open femoral shaft fractures: a retrospective case series, J Trauma Acute Care Surg 72:696, 2012. Bottlang M, Fitzpatrick DC, Sheerin D, et  al.: Dynamic fixation of distal femur fractures using far cortical locking screws: a prospective observational study, J Orthop Trauma 28:181, 2014. Brewster J, Grenier G, Taylor BC, et al.: Long-term comparison of retrograde and antegrade femoral nailing, Orthopedics 20:1, 2020. Croom WP, Lorenzana DJ, Auran RL, et  al.: Is contralateral templating reliable for establishing rotational alignment during intramedullary stabilization of femoral shaft fractures? A study of individual bilateral differences in femoral version, J Orthop Trauma 32:61, 2018.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Even JL, Richards JE, Crosby CG, et al.: Preoperative skeletal versus cutaneous traction for femoral shaft fractures treated within 24 hours, J Orthop Trauma 26:e177, 2012. Gheraibeh P, Vaidya R, Hudson I, et al.: Minimizing leg length discrepancy after intramedullary nailing of comminuted femoral shaft fractures: a quality improvement initiative using the scout computed tomography scanogram, J Orthop Trauma 32:256, 2018. Harvin WH, Oladeji LO, Della GJ, et  al.: Working length and proximal screw constructs in plate osteosynthesis of distal femur fractures, Injury 48:2597, 2017. Hussain N, Hussai FN, Sermer C, et al.: Antegrade versus retrograde nailing techniques and trochanteric versus piriformis intramedullary nailing entry points for femoral shaft fractures: a systematic review and metaanalysis, Can J Surg 60:19, 2017. Karahan G, Yamak K, Kocoglu T, et al.: The effect of implant choice on varus angulation and clinical results in the management of subtrochanteric fractures, J Orthop 20:46, 2020. Linn MS, McAndrew CM, Prusaczyk B, et  al.: Dynamic locked plating of distal femur fractures, J Orthop Trauma 29:447, 2015. Liporace FA, Yoon RS: Nail plate combination technique for native and periprosthetic distal femur fractures, J Orthop Trauma 33:e64, 2019. O’Toole RV, Riche K, Cannada LK, et al.: Analysis of postoperative knee sepsis after retrograde nail insertion of open femoral shaft fractures, J Orthop Trauma 24:677, 2010. Patterson JT, Ishii K, Tornetta 3rd P, et al.: Open reduction is associated with greater hazard of early reoperation after internal fixation of displaced femoral neck fractures in adults 18-65 years, J Orthop Trauma 34:294, 2020.

Ricci WM, Streubel PN, Morshed S, et al.: Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases, J Orthop Trauma 28:83, 2014. Ries Z, Hansen K, Bottlang M, et al.: Healing results of periprosthetic distal femurs fractures treated with far cortical locking technology: a preliminary retrospective study, Iowa Orthop J 33:7–11, 2013. Rodriquez EK, Boulton C, Weaver MJ, et al.: Predictive factors of distal femoral fracture nonunion after lateral locked plating: a retrospective multicenter case-control study of 283 fractures, Injury 45:554, 2014. Rogers NB, Hartline BE, Achor TS, et al.: Improving the diagnosis of ipsilateral femoral neck and shaft fractures: a new imaging protocol, J Bone Joint Surg Am 102:309, 2020. Scannell BP, Waldrop NE, Sasser HC, et al.: Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients, J Trauma 68:633, 2010. Stannard JP, Bankston L, Futch LA, et  al.: Functional outcome following intramedullary nailing of the femur: a prospective randomized comparison of piriformis fossa and greater trochanteric entry portals, J Bone Joint Surg 93A:1385, 2011. Steinberg EL, Elis J, Steinberg Y, et al.: A double-plating approach to distal femur fracture: a clinical study, Injury 48:2260, 2017. Vaidya R, Dimoyski R, Cizmic Z, et  al.: Use of inherent anteversion of an intramedullary nail to avoid malrotation in comminuted femur fractures: a prospective case- control study, J Orthop Trauma 32:623, 2018. The complete list of references is available online at ExpertConsult.com.

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SUPPLEMENTAL REFERENCES GENERAL

Gustilo RB, Gruninger RP, Davis T: Classification of type III (severe) open fractures relative to treatment and results, Orthopedics 10:1781, 1987. Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures, J Trauma 24:742, 1984. Hardin GT: Timing of fracture fixation: a review, Orthop Rev 19:861, 1990. Swiontkowski MF, MacKenzie EJ, Bosse MJ, et  al.: Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma, J Trauma 52:641, 2002.

ANKLE (PILON FRACTURES) Ahl T, Dalen N, Selvik G: Ankle fractures: a clinical and roentgenographic stereophotogrammetric study, Clin Orthop Relat Res 245:246, 1989. Amendola A: Controversies in diagnosis and management of syndesmosis injuries of the ankle, Foot Ankle 13:44, 1992. Anderson JG, Hansen ST: Fracture-dislocation of the ankle with posterior tibial tendon entrapment within the tibiofibular interosseous space: a case report of a late diagnosis, Foot Ankle Int 17:114, 1996. Anglen JO: Early outcome of hybrid external fixation for fracture of the distal tibia, J Orthop Trauma 13:92, 1999. Ayeni JP: Pilon fractures of the tibia: a study based on 19 cases, Injury 19:109, 1988. Ayoub MA: Ankle fractures in diabetic neuropathic arthropathy: can tibiotalar arthrodesis salvage the limb? J Bone Joint Surg 90B:906, 2008. Barbieri R, Schenk R, Koval K, et  al.: Hybrid external fixation in the treatment of tibial plafond fractures, Clin Orthop Relat Res 332:16, 1996. Bauer M, Jonsson K, Nilsson B: Thirty-year follow-up of ankle fractures, Acta Orthop Scand 56:103, 1985. Beauchamp CG, Clay NR, Thexton PW: Displaced ankle fractures in patients over 50 years of age, J Bone Joint Surg 65B:329, 1983. Bhattacharyya T: Case controversy. Position: open reduction and internal fixation, J Orthop Trauma 20:512, 2006. Bhattacharyya T, Crichlow R, Gobezie R, et  al.: Complications associated with the posterolateral approach for pilon fractures, J Orthop Trauma 20:104, 2006. Blauth M, Bastian L, Krettek C, et al.: Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques, J Orthop Trauma 15:153, 2001. Blotter RH, Connolly E, Wasan A, et al.: Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus, Foot Ankle Int 20:687, 1999. Boden SD, Labropoulos PA, McCowin P, et al.: Mechanical considerations for the syndesmosis screw, J Bone Joint Surg 71A:1548, 1989. Boden BP, Osbahr DC: High-risk stress fractures: evaluation and treatment, J Am Acad Orthop Surg 8:344, 2000. Bonar SK, Marsh JL: Unilateral external fixation for severe pilon fractures, Foot Ankle 14:57, 1993. Bone LB: Fractures of the tibial plafond: the pilon fracture, Orthop Clin North Am 18:95, 1987. Borens O, Kloen P, Richmond J, et al.: Minimally invasive treatment of pilon fractures with a low profile plate: preliminary results in 17 cases, Arch Orthop Trauma Surg 129:649, 2009. Borrelli Jr J, Ellis E: Pilon fractures: assessment and treatment, Orthop Clin North Am 33:231, 2002. Borrelli J, Prickett W, Song E, et al.: Extraosseous blood supply of the tibia and effects of different plating techniques: a human cadaver study, J Orthop Trauma 16:691, 2002. Böstman OM: Displaced malleolar fractures associated with spiral fractures of the tibial shaft, Clin Orthop Relat Res 228:202, 1988. Böstman OM: Intense granulomatous inflammatory lesions associated with absorbable internal fixation devices made of polyglycolide in ankle fractures, Clin Orthop Relat Res 278:193, 1992.

Böstman OM, Hirvensalo E, Vainionpaa S, et  al.: Ankle fractures treated using biodegradable internal fixation, Clin Orthop Relat Res 238:195, 1989. Böstman OM, Pihlajamake HK: Adverse tissue reactions to bioabsorbable fixation devices, Clin Orthop Relat Res 371:216, 2000. Bosworth DM: Fracture-dislocation of the ankle with fixed displacement of the fibula behind the tibia, J Bone Joint Surg 29:130, 1947. Bourne RB, Rorabeck CH, Macnab J: Intraarticular fractures of the distal tibia: the pilon fracture, J Trauma 23:591, 1983. Bray TJ, Endicott M, Capra SE: Treatment of open ankle fractures: immediate internal fixation versus closed immobilization and delayed fixation, Clin Orthop Relat Res 240:47, 1989. Brodie IAOD, Denham RA: The treatment of unstable ankle fractures, J Bone Joint Surg 56B:256, 1974. Brown OL, Dirschl DR, Obremskey WT: Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures, J Orthop Trauma 15:271, 2001. Brown TD, Hurlbut PT, Hale JE, et al.: Effects of imposed hindfoot constraint on contact mechanics of displaced lateral malleolar fractures, Trans Orthop Res Soc 40:257, 1994. Bucholz RW, Henry S, Henley MB: Fixation with bioabsorbable screws for the treatment of fractures of the ankle, J Bone Joint Surg 76A:325, 1994. Burns II WC, Prakash K, Adelaar R, et al.: Tibiotalar joint dynamics: indications for the syndesmotic screw—a cadaver study, Foot Ankle 14:153, 1993. Burwell HN, Charnley AD: The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement, J Bone Joint Surg 47B:634, 1965. Candal-Couto JJ, Burrow D, Bromage S, et al.: Instability of the tibio-fibular syndesmosis: have we been pulling in the wrong direction? Injury Int J Care 35:814, 2004. Carothers CO, Crenshaw AH: Clinical significance of a classification of epiphyseal injuries at the ankle, Am J Surg 89:879, 1955. Casey D, McConnell T, Parekh S, et al.: Percutaneous pin placement in the medial calcaneus: is anywhere safe? J Orthop Trauma 16:26, 2002. Chen PY, Wang TG, Wang CL: Ultrasonographic examination of the deltoid ligament in bimalleolar equivalent fractures, Foot Ankle Int 29:883, 2008. Childress HM: Vertical transarticular pin fixation for unstable ankle fractures, J Bone Joint Surg 47A:1323, 1965. Cole PA, Benirschke SK: Minimally invasive surgery for the pilon fracture: the percutaneous-submuscular plating technique, Tech Orthop 14:201, 1999. Collinge CA, Sanders RW: Percutaneous plating in the lower extremity, J Am Acad Orthop Surg 8:211, 2000. Coonrad RW, Bugg Jr EL: Trapping of the posterior tibial tendon and interposition of soft tissue in severe fractures about the ankle joint, J Bone Joint Surg 36A:744, 1954. Costigan W, Thordarson DB, Debnath UK: Operative management of ankle fractures in patients with diabetes mellitus, Foot Ankle Int 28:32, 2007. Court-Brown CM, Walker C, Garg A, et al.: Half-ring external fixation in the management of tibial plafond fractures, J Orthop Trauma 13:200, 1999. Cotton FJ: Fractures and joint dislocations, Philadelphia, 1910, WB Saunders, p 549. Crenshaw AH: Injuries of the distal tibial epiphysis, Clin Orthop Relat Res 41:98, 1965. Curry EE, O’Brien TS, Johnson JE: Fibular nonunion and equinovarus deformity secondary to posterior tibial tendon incarceration in the syndesmosis: a case report after a bimalleolar fracture-dislocation, Foot Ankle Int 20:527, 1999. Dabezies E, D’Ambrosia RD, Shoji H: Classification and treatment of ankle fractures, Orthopedics 1:365, 1978. Dahners LE: The pathogenesis and treatment of bimalleolar ankle fractures, Instr Course Lect 39:85, 1990. DeAngelis NA, Eskander MS, French BG: Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? J Orthop Trauma 21:244, 2007.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS DeCoster TA, Willis MC, Marsh JL, et al.: Rank order analysis of tibial plafond fractures: does injury or reduction predict outcome? Foot Ankle Int 20:44, 1999. Dickson KF, Montgomery S, Field J: High energy plafond fractures treated by a spanning external fixator initially and followed by a second stage open reduction internal fixation of the articular surface-preliminary report, Injury 32(Suppl D):92, 2001. Donatto KC: Ankle fractures and syndesmosis injuries, Orthop Clin North Am 32:79, 2001. Dumigan RM, Bronson DG, Early JS: Analysis of fixation methods for vertical shear fractures of the medial malleolus, J Orthop Trauma 20:687, 2006. Dunbar RP, Barei DP, Kubiak EN, et  al.: Early limited internal fixation of diaphyseal extensions in select pilon fractures: upgrading AO/OTA type C fractures to AO/OTA type B, J Orthop Trauma 22:426, 2008. Ebraheim NA, Mekhail AO, Haman SP: External rotation-lateral view of the ankle in the assessment of the posterior malleolus, Foot Ankle Int 20:379, 1999. Egol KA, Weisz R, Hiebert R, et  al.: Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures? J Orthop Trauma 20:94, 2006. Egol KA, Wolinsky P, Koval KJ: Open reduction and internal fixation of tibial pilon fractures, Foot Ankle Clin 5:873, 2000. El-Shazly M, Dalbyu Ball J, Burton M, et al.: The use of transarticular and extraarticular external fixation for management of distal tibial intraarticular fractures, Injury 32(Suppl 4):99, 2001. Etter C, Ganz R: Long-term results of tibial plafond fractures treated with open reduction and internal fixation, Arch Orthop Trauma Surg 11:227, 1991. Finsen V, Saetermo R, Kibsgaard L, et al.: Early postoperative weight-bearing and muscle activity in patients who have a fracture of the ankle, J Bone Joint Surg 71A:23, 1989. Franklin JL, Johnson KD, Hansen Jr ST: Immediate internal fixation of open ankle fractures: report of thirty-eight cases treated with a standard protocol, J Bone Joint Surg 66A:1349, 1984. French B, Tornetta III P: Hybrid external fixation of tibial pilon fractures, Foot Ankle Clin 5:853, 2000. Frokjaer J, Möller BN: Biodegradable fixation of ankle fractures: complications in a prospective study of 25 cases, Acta Orthop Scand 63:434, 1992. Gardner MJ, Brodsky A, Briggs SM, et  al.: Fixation of posterior malleolar fractures provides greater syndesmotic stability, Clin Orthop Relat Res 447:165, 2006. Gardner MJ, Demetrakopoulos D, Briggs SM, et al.: The ability of the LaugeHansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study, J Orthop Trauma 20:267, 2006. Gardner MJ, Demetrakopoulos D, Briggs SM, et al.: Malreduction of the tibiofibular syndesmosis in ankle fractures, Foot Ankle Int 27:788, 2006. Gaston S, McLaughlin HL: Complex fractures of the lateral malleolus, J Trauma 1:69, 1961. Gatellier J: The juxtaretroperoneal route in the operative treatment of fracture of the malleolus with posterior marginal fragment, Surg Gynecol Obstet 52:67, 1931. Gatellier J, Chastang B: Access to fractured malleolus with piece chipped off at back, J Chir 24:513, 1924. Giachino AA, Hammond DI: The relationship between oblique fractures of the medial malleolus and concomitant fractures of the anterolateral aspect of the tibial plafond, J Bone Joint Surg 69A:381, 1987. Grantham SA: Trimalleolar ankle fractures and open ankle fractures, Instr Course Lect 39:105, 1990. Grose A, Gardner MJ, Hettrich C, et al.: Open reduction and internal fixation of tibial pilon fractures using a lateral approach, J Orthop Trauma 21:530, 2007. Guo JJ, Yang H, Xu Y, et  al.: Results after immediate operations of closed ankle fractures in patients with preoperatively neglected type 2 diabetes, Injury 40:894, 2009. Hamid N, Loeffler BJ, Braddy W, et al.: Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw, J Bone Joint Surg 91B:1069, 2009.

Harper MC, Hardin G: Posterior malleolar fractures of the ankle associated with external rotation-abduction injuries: results with and without internal fixation, J Bone Joint Surg 70A: 1348, 1988. Harris AM, Patterson BM, Sontich JK, Vallier HA: Results and outcomes after operative treatment of high-energy tibial plafond fractures, Foot Ankle Int 27:256, 2006. Hayes AG, Nadkarni JB: Extensile posterior approach to the ankle, J Bone Joint Surg 78B:468, 1996. Helfet DL, Shonnard PY, Levine D, et al.: Minimally invasive plate osteosynthesis of distal fractures of the tibia, Injury 28:42, 1997. Helfet DL, Sorkin AT, Levine DS, et al.: Minimally invasive plate osteosynthesis of distal tibial fractures, Tech Orthop 14:191, 1999. Herscovici D, Sanders RW, Infante A: Böhler incision: an extensile anterolateral approach to the foot and ankle, J Orthop Trauma 13:586, 1999. Herscovici Jr D, Scaduto JM, Infante A: Conservative treatment of isolated fractures of the medial malleolus, J Bone Joint Surg 89B:89, 2007. Hirvensalo E: Fracture fixation with biodegradable rods: forty-one cases of severe ankle fractures, Acta Orthop Scand 60:601, 1989. Ho JY, Ren Y, Kelikian A, et al.: Mid-diaphyseal fibular fractures with syndesmotic disruption: should we plate the fibula? Foot Ankle Int 29:587, 2008. Hovis WD, Bucholz RW: Polyglycolide bioabsorbable screws in the treatment of ankle fractures, Foot Ankle Int 18:128, 1997. Hovis WD, Kaiser BW, Watson JT, et al.: Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation, J Bone Joint Surg 84A:26, 2002. Hughes JL, Weber H, Willenegger H, et  al.: Evaluation of ankle fractures: nonoperative and operative treatment, Clin Orthop Relat Res 138:111, 1979. Johnson DP, Hill J: Fracture-dislocation of the ankle with rupture of the deltoid ligament, Injury 19:59, 1988. Johnson EE, Davlin LB: Open ankle fractures: the indications for immediate open reduction and internal fixation, Clin Orthop Relat Res 292:118, 1993. Jones KB, Maiers-Yelden KA, March JL, et  al.: Ankle fractures in patients with diabetes mellitus, J Bone Joint Surg 87B:489, 2005. Joy G, Patzakis MJ, Harvey Jr JP: Precise evaluation of the reduction of severe ankle fractures: technique and correlation with end results, J Bone Joint Surg 56A:979, 1974. Kao KF, Huang PJ, Chen YW, et al.: Postero-medio-anterior approach of the ankle for the pilon fracture, Injury 31:71, 2000. Kaukonen JP, Lamberg T, Korkala O, Pajarinen J: Fixation of syndesmotic ruptures in 38 patients with a malleolar fracture: a randomized study comparing a metallic and a bioabsorbable screw, J Orthop Trauma 19B:392, 2005. Kaye RA: Stabilization of ankle syndesmosis injuries with a syndesmosis screw, Foot Ankle 9:290, 1989. Kellam JF, Waddell JP: Fractures of the distal tibial metaphysis with intraarticular extension—the distal tibial explosion fracture, J Trauma 19:593, 1979. Kennedy JG, Soffe KE, Dalla Vedova P, et al.: Evaluation of the syndesmotic screw in low Weber C ankle fractures, J Orthop Trauma 14:359, 2000. Ketenjian AY, Shelton ML: Primary internal fixation of open fractures: a retrospective study of the use of metallic internal fixation in fresh open fractures, J Trauma 12:756, 1972. Kim SK, Oh JK: One or two lag screws for fixation of Danis-Weber type B fractures of the ankle, J Trauma 46:1039, 1999. Konrath GA, Hopkins II G: Posterolateral approach for tibial pilon fractures: a report of two cases, J Orthop Trauma 13:586, 1999. Konvath G, Karges D, Watson JT, et  al.: Early versus delayed treatment of severe ankle fracture: a comparison of results, J Orthop Trauma 9:377, 1995. Koval KJ, Egol KA, Cheung Y, et al.: Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report, J Orthop Trauma 21:449, 2007. Koval KJ, Petraco DM, Kummer FJ, et al.: A new technique for complex fibula fracture fixation in the elderly: a clinical and biomechanical evaluation, J Orthop Trauma 11:28, 1997.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Kristensen KD, Hansen T: Closed treatment of ankle fractures: stage II supination-eversion fractures followed for 20 years, Acta Orthop Scand 56:107, 1985. Laskin RS: Steinmann pin fixation in the treatment of unstable fractures of the ankle, J Bone Joint Surg 56A:549, 1974. Lauge-Hansen N: Fractures of the ankle, part II: combined experimentalsurgical and experimental-roentgenologic investigations, Arch Surg 60:957, 1950. Lauge-Hansen N: Fractures of the ankle, part V: pronation-dorsiflexion fracture, Arch Surg 67:813, 1953. Leach RE: Ankle fractures: internal fixation, part III: fractures of the tibial plafond, Instr Course Lect 28:88, 1979. Lee HG, Horan TB: Internal fixation in injuries of the ankle, Surg Gynecol Obstet 76:593, 1943. Loren GJ, Ferkel RD: Arthroscopic assessment of occult intraarticular injury in acute ankle fractures, Arthroscopy 18:412, 2002. Lynn MD: The triplane distal tibial epiphyseal fracture, Clin Orthop Relat Res 86:187, 1972. Maale G, Seligson D: Fractures through the weight-bearing surface of the distal tibia, Orthopedics 3:517, 1980. Makwana NK, Bhowal B, Harper WM, et al.: Conservative versus operative treatment for displaced ankle fracture in patients over 55 years of age: a prospective, randomized study, J Bone Joint Surg 83B:525, 2001. Malek IA, Machani B, Mecha AM, Hyder NH: Inter-observer reliability and intra-observer reproducibility of the Weber classification of ankle fractures, J Bone Joint Surg 88B:1204, 2006. Marmor L: An unusual fracture of the tibial epiphysis, Clin Orthop Relat Res 73:132, 1970. Marsh JL: Current controversies in orthopaedic trauma: external fixation is the treatment of choice for fractures of the tibial plafond, J Orthop Trauma 13:583, 1999. Marsh JL, Bonar S, Nepola JV, et al.: Use of an articulated external fixator for fractures of the tibial plafond, J Bone Joint Surg 77A:1995, 1498. Marsh JL, Muehling V, Dirschl D, et al.: Tibial plafond fractures treated by articulated external fixation: a randomized trial of postoperative motion versus nonmotion, J Orthop Trauma 20:536, 2006. Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: how do these ankles function over time? J Bone Joint Surg 85A:287, 2003. Mast JW: Reduction techniques in fractures of the distal tibial articular surface, Tech Orthop 2:29, 1987. Mast JW, Spiegel PG, Pappas JN: Fractures of the tibial pilon, Clin Orthop Relat Res 230:68, 1988. McCormack RG, Leith JM: Ankle fractures in diabetics: complications of surgical management, J Bone Joint Surg 80B: 689, 1998. McDade WC: Diagnosis and treatment of ankle injuries, Instr Course Lect 24:251, 1975. McFerran MA, Smith SW, Boulas HJ, Schwartz HS: Complications encountered in the treatment of pilon fractures, J Orthop Trauma 6:195, 1992. McKenna PB, O’Shea K, Burke T: Less is more: lag screw only fixation of lateral malleolar fractures, Int Orthop 31:497, 2007. McLennan JG, Ungersma J: Evaluation of the treatment of ankle fractures with the Inyo nail, J Orthop Trauma 2:272, 1989. Meyers MH: Fracture about the ankle joint with fixed displacement of the proximal fragment of the fibula behind the tibia, Clin Orthop Relat Res 42:67, 1965. Michelson JD: Current concepts review: fractures about the ankle, J Bone Joint Surg 77A:142, 1995. Michelson JD, Helgemo SL, Ahn UM: Dynamic biomechanics of the normal and fractured ankle, Trans Orthop Res Soc 40:253, 1994. Miller AN, Carroll EA, Parker RJ, et al.: Direct visualization for syndesmotic stabilization of ankle fractures, Foot Ankle Int 30:419, 2009. Molinari M, Bertoldi L, De March L: Fracture dislocation of the ankle with the fibula trapped behind the tibia: a case report, Acta Orthop Scand 61:471, 1990. Müller ME, Allgöwer M, Schneider R, et  al.: Manual of internal fixation: techniques recommended by the AO group, ed 2, New York, 1979, Springer-Verlag.

Myerson MS, Edwards WHB: Management of neuropathic fractures in the foot and ankle, J Am Acad Orthop Surg 7:8, 1999. Namba RS, Kabo JM, Dorey FJ, et  al.: Continuous passive motion versus immobilization: the effect on posttraumatic joint stiffness, Clin Orthop Relat Res 267:218, 1991. Needleman RL, Skrade DA, Stiehl JB: Effect of the syndesmotic screw on ankle motion, Foot Ankle 10:17, 1989. Ngcelwane MV: Management of open fractures of the ankle joint, Injury 21:93, 1990. Nielsen JO, Dons-Jensen H, Sorensen HT: Lauge-Hansen classification of malleolar fractures: an assessment of the reproducibility in 118 cases, Acta Orthop Scand 61:385, 1990. Okcu G, Aktuglu K: Intra-articular fractures of the tibial plafond: a comparison of the results using articulated and ring external fixators, J Bone Joint Surg 86B:868, 2004. O’Leary C, Ward FJ: A unique closed abduction-external rotation ankle fracture, J Trauma 29:119, 1989. Olerud S, Johansson H: The lateral malleolus, Ann Dig Foreign Orthop Lit 3rd qtr 29, 1970. Orava S, Karpakka J, Taimela S, et al.: Stress fracture of medial malleolus, J Bone Joint Surg 77A:362, 1995. Ostrum RF: Posterior plating of displaced Weber B fibula fractures, J Orthop Trauma 10:199, 1996. Ovadia DN, Beals RK: Fractures of the tibial plafond, J Bone Joint Surg 68A:543, 1986. Pankovich AM: Fractures of the fibula at the distal tibiofibular syndesmosis, Clin Orthop Relat Res 143:138, 1979. Pankovich AM, Shivaram MS: Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament, part I: anatomical studies; part II: clinical studies, Acta Orthop Scand 50:217, 1979. Park JW, Kim SK, Hong JS, et  al.: Anterior tibiofibular ligament avulsion fracture in Weber type B lateral malleolar fracture, J Trauma 52:655, 2002. Park SS, Kubiak EN, Egol KA, et al.: Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements, J Orthop Trauma 20:11, 2006. Parrish TF: Fracture dislocation of the ankle—an unusual cause of failure of reduction: a case report, J Bone Joint Surg 41A:749, 1959. Patterson MJ, Cole JD: Two-staged delayed open reduction and internal fixation of severe pilon fractures, J Orthop Trauma 13:85, 1999. Peter RE, Harrington RM, Henley MB, et al.: Biomechanical effects of internal fixation of the distal tibiofibular syndesmotic joint: comparison of two fixation techniques, J Orthop Trauma 8:215, 1994. Petrisor BA, Poolman R, Koval K, et al.: Management of displaced ankle fractures, J Orthop Trauma 20:515, 2006. Pettrone FA, Gail M, Pee D, et al.: Quantitative criteria for prediction of the results after displaced fracture of the ankle, J Bone Joint Surg 65A:66, 1983. Phillips WA, Schwartz HS, Keller CS, et al.: A prospective, randomized study of the management of severe ankle fractures, J Bone Joint Surg 67A:67, 1985. Phillips WA, Spiegel PG: Evaluation of ankle fractures: nonoperative vs operative [editorial], Clin Orthop Relat Res 138:17, 1979. Pierce Jr RO, Heinrich JH: Comminuted intraarticular fractures of the distal tibia, J Trauma 19:828, 1979. Pollak AN, McCarthy ML, Bess RS, et al.: Outcomes after treatment of highenergy tibial plafond fractures, J Bone Joint Surg 85A:2003, 1893. Pugh KJ, Wolinsky PR, McAndrew MP, et al.: Tibial pilon fractures: a comparison of treatment methods, J Trauma 47:937, 1999. Ramsey PL, Hamilton W: Changes in tibiotalar area of contact caused by lateral talar shift, J Bone Joint Surg 58A:356, 1976. Roberts RS: Surgical treatment of displaced ankle fractures, Clin Orthop Relat Res 172:164, 1983. Rokkanen PU, Böstman O, Hirvensalo E, et  al.: Bioabsorbable fixation in orthopaedic surgery and traumatology, Biomaterials 21:2607, 2000. Rüedi T: Fractures of the lower end of the tibia into the ankle joint: results 9 years after open reduction and internal fixation, Injury 5:130, 1973. Rüedi T, Allgöwer M: Fractures of the lower end of the tibia into the ankle joint, Injury 1:92, 1969.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Rüedi T, Allgöwer M: Fractures of the lower end of the tibia into the ankle joint: results 9 years after open reduction and internal fixation, Injury 5:130, 1973. Rüedi TP, Allgöwer M: The operative treatment of intraarticular fractures of the lower end of the tibia, Clin Orthop Relat Res 138:105, 1979. Salter RB: Injuries of the ankle in children, Orthop Clin North Am 5:147, 1974. Salter RB, Simmonds DF, Malcolm BW, et al.: The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage: an experimental investigation in the rabbit, J Bone Joint Surg 62A:1232, 1980. Sarkisian JS, Cody SW: Closed treatment of ankle fractures: a new criterion for evaluation: a review of 250 cases, J Trauma 16:323, 1976. Segal D: Ankle fractures: internal fixation, part II: displaced ankle fractures treated surgically and postoperative management, Instr Course Lect 28:79, 1979. Shariff SS, Nathwani DK: Lauge-Hansen classification—a literature review, Injury 37:888, 2006. Shelbourne KD, Fisher DA, Rettig AC, et al.: Stress fractures of the medial malleolus, Am J Sports Med 16:60, 1988. Sirkin M, Sanders R: The treatment of pilon fractures, Orthop Clin North Am 32:91, 2001. Sirkin M, Sanders R, DiPasquale T, et  al.: A staged protocol for soft tissue management in the treatment of complex pilon fractures, J Orthop Trauma 13:78, 1999. Stark E, Tornetta 3rd P, Creevy WR: Syndesmotic instability in Weber B ankle fractures: a clinical evaluation, J Orthop Trauma 21:643, 2007. Stiehl JB: Ankle fractures with diastasis, Instr Course Lect 39:95, 1990. Stiehl JB: Complex ankle fracture dislocations with syndesmotic diastasis, Orthop Rev 19:499, 1990. Stiehl JB: Open fractures of the ankle joint, Instr Course Lect 39:113, 1990. Stufkens SA, Knupp M, Lampert C, et  al.: Long-term outcome after supination external rotation type-4 fractures of the ankle, J Bone Joint Surg 91B:1607, 2009. Svend-Hansen H, Bremerskov V, Baekgaard N: Ankle fractures treated by fixation of the medial malleolus alone: late results in 29 patients, Acta Orthop Scand 49:211, 1978. Teeny SM, Wiss DA: Open reduction and internal fixation of tibial plafond fractures, Clin Orthop Relat Res 292:108, 1993. Tejwani NC, McLaurin TM, Walsh M, et  al.: Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury, J Bone Joint Surg 89A:1438, 2007. Thompson MC, Gesink D, Hamson K: Biomechanical evaluation of syndesmosis fixation with 3.5- and 4.5-millimeter stainless steel screws, Charlotte, NC, 1999, Paper presented at the annual meeting of the Orthopaedic Trauma Association. Tile ON: Fractures of the ankle. In Schatzker J, Tile ON, editors: The rationale of operative fracture care, New York, 1987, Springer-Verlag. Topliss CJ, Jackson M, Atkins RM: Anatomy of pilon fractures of the distal tibia, J Bone Joint Surg 87B:692, 2005. Torg JS, Ruggiero RA: Comminuted epiphyseal fracture of the distal tibia: a case report and review of the literature, Clin Orthop Relat Res 110:215, 1975. Tornetta P, Gorup J: Axial computed tomography of pilon fractures, Clin Orthop Relat Res 232:273, 1996. Tornetta P, Nguyen S, Scott C: Lag screw fixation of the lateral malleolus, Vancouver, British Columbia, 1998, Paper presented at the annual meeting of the Orthopaedic Trauma Association. Tornetta P, Reynolds F, Spoo J, et al.: Overtightening of the syndesmosis: is it really possible?, Charlotte, NC, 1999, Paper presented at the annual meeting of the Orthopaedic Trauma Association. Vander Griend R, Michelson JD, Bone LB: Fractures of the ankle and the distal part of the tibia, J Bone Joint Surg 78A:1772, 1996. Vives MJ, Abidi NA, Ishikawa SN, et al.: Soft tissue injuries with the use of safe corridors for transfixion wire placement during external fixation of distal tibia fractures: an anatomical study, J Orthop Trauma 15:555, 2001. Vives P, Hourlier H, DeLestang M, et al.: Articular fractures of the lower end of the tibia: an attempt at classification, Rev Chir Orthop 70:129, 1984.

Warner WC, Farber LA: Trimalleolar fractures, South Med J 58:1292, 1965. Watson JT: Tibial pilon fractures, Tech Orthop 11:150, 1996. Watson JT, Karges DE, Cramer KE, et al.: Analysis of failure of hybrid external fixation techniques for the treatment of distal tibial pilon fractures, San Antonio, TX, 2000, Paper presented at the annual meeting of the Orthopaedic Trauma Association. Watson JT, Moed BR, Karges DE, et al.: Pilon fractures: treatment protocol based on severity of soft tissue injury, Clin Orthop Relat Res 375:78, 2000. Weber BG: Die Verletzungen des Oberen sprunggelenkes, ed 2, Bern, 1972, Hans Huber. Weber M, Krause F: Peroneal tendon lesions caused by antiglide plates used for fixation of lateral malleolar fractures: the effect of plate and screw position, Foot Ankle Int 26:281, 2005. Whitelaw GP, Sawka MW, Wetzler M, et  al.: Unrecognized injuries of the lateral ligaments associated with lateral malleolar fractures of the ankle, J Bone Joint Surg 71A:1396, 1989. Williams TM, Marsh JL, Nepola JV, et al.: External fixation of the tibial plafond fractures: is routine plating of the fibula necessary? J Orthop Trauma 12:16, 1998. Williams TM, Nepola JV, DeCoster TA, et al.: Factors affecting outcome in tibial plafond fractures, Clin Orthop Relat Res 423:93, 2004. Wilson FC: The pathogenesis and treatment of ankle fractures: classification, Instr Course Lect 39:79, 1990. Wilson FC: The pathogenesis and treatment of ankle fractures: historical studies, Instr Course Lect 39:73, 1990. Wilson Jr FC, Skilbred LA: Long-term results in the treatment of displaced bimalleolar fractures, J Bone Joint Surg 48A:1065, 1966. Wiss DA, Gilbert P, Merritt PO, et al.: Immediate internal fixation of open ankle fractures, J Orthop Trauma 2:265, 1988. Wyrsch B, McFerran MA, McAndrew M, et al.: Operative treatment of fractures of the tibial plafond: a randomized, prospective study, J Bone Joint Surg 78A:1646, 1996. Xenos JS, Hopkinson WJ, Mulligan ME, et al.: The tibiofibular syndesmosis, J Bone Joint Surg 77A:847, 1995. Yablon IG: Ankle fractures: internal fixation, part I: reduction of displaced bimalleolar ankle fractures, Instr Course Lect 28:72, 1979. Yablon IG, Heller FG, Shouse L: The key role of the lateral malleolus in displaced fractures of the ankle, J Bone Joint Surg 59A:169, 1977. Yang L, Nayagam S, Saleh M: Stiffness characteristics and inter-fragmentary displacements with different hybrid external fixators, Clin Biomech (Bristol, Avon) 18:166, 2002. Yde J, Kristensen KD: Ankle fractures: supination-eversion fractures of stage II—primary and late results of operative and nonoperative treatment, Acta Orthop Scand 51:695, 1980. Yde J, Kristensen KD: Ankle fractures: supination-eversion fractures of stage IV—primary and late results of operative and nonoperative treatment, Acta Orthop Scand 51:981, 1980. Zadik FR: Primary internal fixation of compound fractures: proceedings of the British Orthopaedic Association, J Bone Joint Surg 35B:146, 1953.

TIBIAL SHAFT Alemdaroglu KB, Tiftikci U, Iltar S, et al.: Factors affecting the fracture healing in treatment of tibial shaft fractures with circular external fixator, Injury 40:1151, 2009. Anderson LD, Hutchins WC: Fractures of the tibia and fibula treated with casts and transfixing pins, South Med J 59:1026, 1966. Anderson LD, Hutchins WC, Wright PE, et  al.: Fractures of the tibia and fibula treated by casts and transfixing pins, Clin Orthop Relat Res 105:179, 1974. Archdeacon MT, Wyrick JD: Reduction plating for provisional fracture fixation, J Orthop Trauma 20:206, 2006. Austin RT: The Sarmiento tibial plaster: a prospective study of 145 fractures, Injury 13:10, 1981. Bach AW, Hansen Jr ST: Plates versus external fixation in severe open tibial shaft fractures: a randomized trial, Clin Orthop Relat Res 241:89, 1989. Bauer GCH, Edwards P: Fracture of the shaft of the tibia: incidence of complications as a function of age and sex, Acta Orthop Scand 36:95, 1965-1966.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Bayne LG, Morris H, Wickstrom J: Evaluation of intermedullary fixation of the tibia with the Lottes nail, South Med J 53:1429, 1960. Behrens F: Current concepts of external fixation of fractures, Berlin, 1982, Springer-Verlag. Behrens F, Comfort TH, Searls K, et al.: Unilateral external fixation for severe open tibial fractures: preliminary report of a prospective study, Clin Orthop Relat Res 178:111, 1983. Behrens F, Searles K: External fixation of the tibia: basic concepts and prospective evaluation, J Bone Joint Surg 68B:246, 1986. Berkin CR, Marshall DV: Three-sided plate fixation for fractures of the tibial and femoral shafts: a follow-up note, J Bone Joint Surg 54A:1105, 1972. Bhandari M, Adii A, Leone J, et al.: Early versus delayed operative management of closed tibial fractures, Clin Orthop Relat Res 368:230, 1999. Bhandari M, Guyatt GH, Swiontkowski MF, et al.: Treatment of open fractures of the shaft of the tibia: a systematic overview and meta-analysis, J Bone Joint Surg 83B:62, 2001. Bhandari M, Guyatt G, Tornetta 3rd P, et  al.: Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures, J Bone Joint Surg 90A:2567, 2008. Bhandari M, Zlowodzki M, Tornetta P, et  al.: Intramedullary nailing following external fixation in femoral and tibial shaft fractures, J Orthop Trauma 19:140, 2005. Bilat C, Leutenegger A, Rüedi T: Osteosynthesis of 245 tibial shaft fractures: early and late complications, Injury 25:349, 1994. Blachut PA, O’Brien PJ, Meek RN, et al.: Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft, J Bone Joint Surg 79A:640, 1997. Böhler J: Behandlung der Kniescheibenbruche: Osteosythese, Teilexstirpation, Exstirpation, Dtsch Med Wochenschr 86:1209, 1961. Bone LB, Johnson KD: Treatment of tibial fractures by reaming and intramedullary nailing, J Bone Joint Surg 68A:877, 1986. Bone LB, Kassman S, Stegemann P, et al.: Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails, J Orthop Trauma 8:45, 1994. Bono CM, Levine RG, Rao JP, Behrens FF: Nonarticular proximal tibia fractures: treatment options and decision making, J Am Acad Orthop Surg 9:176, 2001. Bosse MJ, MacKenzie EJ, Kellam JF, et al.: An analysis of outcomes of reconstruction or amputation after leg threatening injuries, N Engl J Med 347:1924, 2002. Böstman OM: Spiral fractures of the shaft of the tibia: initial displacement and stability of reduction, J Bone Joint Surg 68:462, 1986. Boyd HB, Lipinski SW, Wiley JH: Observations on nonunion of the shafts of the long bones, with a statistical analysis of 842 patients, J Bone Joint Surg 43A:159, 1961. Bråten M, Helland P, Grontvedt T, et  al.: External fixation versus locked intramedullary nailing in tibial shaft fractures: a prospective, randomised study of 78 patients, Arch Orthop Trauma Surg 125:21, 2005. Burgess A, Poka A, Brumback RJ, et al.: Pedestrian tibial injuries, J Trauma 27:596, 1987. Burgess AR, Poka A, Brumback RJ, et  al.: Management of open grade III tibial fractures, Orthop Clin North Am 18:85, 1987. Burwell HN: Plate fixation of tibial shaft fractures: a survey of 181 injuries, J Bone Joint Surg 53B:258, 1971. Busse JW, Morton E, Lachetti C, et al.: Current management of tibial fractures: a survey of 450 Canadian orthopaedic trauma surgeons, Acta Orthop 79:689, 2008. Byrd HS, Spicer T, Cierney G: Management of open tibial fractures, Plast Reconstr Surg 76:719, 1985. Cannada LK, Jones AL: Demographic, social and economic variables that affect lower extremity injury outcomes, Injury 37:1109, 2006. Carrell WB: Transplantation of fibula in the same leg, J Bone Joint Surg 20:627, 1938. Caudle RJ, Stern PJ: Severe open fractures of the tibia, J Bone Joint Surg 69A:801, 1987. Clark RP: Quoted in: tibial plateau fractures reparable arthroscopically, Orthop Today 10:24, 1990.

Clawson DK: Claw toes following tibial fracture, Clin Orthop Relat Res 103:47, 1974. Clementz BC: Assessment of tibial torsion and rotational deformity with a new fluoroscopic technique, Clin Orthop Relat Res 245:199, 1989. Clough JR: Segmental fractures of the shaft of the tibia, J Bone Joint Surg 55B:9, 1973. Colen RP, Prieskorn DW: Tibial tubercle-medial malleolar distance in determining tibial nail length, J Orthop Trauma 14:345, 2000. Collinge C, Sanders RW: Percutaneous plating in the lower extremity, J Am Acad Orthop Surg 8:211, 2000. Collinge C, Sanders RW, DePasquale T: Treatment of complex tibial periarticular fractures using percutaneous techniques, Clin Orthop Relat Res 375:69, 2000. Court-Brown CM, Gustilo T, Shaw AD: Knee pain after intramedullary tibial nailing: its incidence, etiology, and outcome, J Orthop Trauma 11:103, 1997. Court-Brown CM, Keating JF, McQueen MM: Infection after intramedullary nailing of the tibia: incidence and protocol for management, J Bone Joint Surg 74B:770, 1992. Court-Brown CM, Will E, Christie J, et al.: Reamed or unreamed nailing for closed tibial fractures: a prospective study in Tscherne C1 fractures, J Bone Joint Surg 78B:580, 1996. d’Aubigne RM, Maurer P, Zucman J, et al.: Blind intramedullary nailing for tibial fractures, Clin Orthop Relat Res 105:267, 1974. Dedmond BT, Kortesis B, Punger K, et  al.: The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft tissue injuries associated with high energy open tibial shaft fractures, J Orthop Trauma 21:11, 2007. Dehne E: Ambulatory treatment of the fractured tibia, Clin Orthop Relat Res 105:192, 1974. Dehne E, Deffer PA, Hall RM, et al.: The natural history of the fractured tibia, Surg Clin North Am 41:1495, 1961. Digby JM, Holloway GMN, Webb JK: A study of function after tibial cast bracing, Injury 14:432, 1983. Dobozi WR, Saltzman M, Brash R: Ender nailing of problem tibial shaft fractures, Orthopedics 5:1162, 1982. Dogra AS, Ruiz AL, Thompson NS, et al.: Dia-metaphyseal distal tibial fractures—treatment with a shortened intramedullary nail: a review of 15 cases, Injury 31:799, 2000. Drosos G, Karnezis IA, Bishay M, et al.: Initial rotational stability of distal tibial fractures nailed without proximal locking: the importance of fracture type and degree of cortical contact, Injury 32:137, 2001. Duwelius PJ, Schmidt AH, Rubenstein RA, et  al.: Nonreamed interlocked intramedullary tibial nailing: one community’s experience, Clin Orthop Relat Res 315:104, 1995. Edwards CC: Current concepts of external fixation of fractures, Berlin, 1982, Springer-Verlag. Edwards CC: Staged reconstruction of complex open tibial fractures using Hoffmann external fixation: clinical decisions and dilemmas, Clin Orthop Relat Res 178:130, 1983. Edwards CC, Jaworski MF, Solana J, et al.: Management of compound tibial fractures using external fixation, Am Surg 45:190, 1979. Edwards P: Fracture of the shaft of the tibia: 492 consecutive cases in adults: importance of the soft tissue injury, Acta Orthop Scand Suppl 76:1, 1965. Edwards P, Baver G, Widmark PH: The time of disability following fracture of the shaft of the tibia, Acta Orthop Scand 40:501, 1969. Eijer H, Hauke C, Arens S, et  al.: PC-Fix and local infection resistance— influence of implant design on postoperative infections development, clinical and experimental results, Injury 32(Suppl B):38, 2001. Ekeland A, Thoresen BO, Alho A, et al.: Interlocking intramedullary nailing in the treatment of tibial fractures: a report of 45 cases, Clin Orthop Relat Res 231:205, 1988. Finkemeier CG, Schmidt AH, Kyle RF, et  al.: A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft, J Orthop Trauma 14:187, 2000. Fischer MD, Gustilo RB: Timing of flap coverage: bone grafting and intramedullary nailing of tibial shaft fractures with extensive soft tissue injury,

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Anaheim, CA, 1991, Paper presented at the annual meeting of the American Academy of Orthopaedic Surgeons. Freedman EL, Johnson EE: Radiographic analysis of tibial fracture malalignment following intramedullary nailing, Clin Orthop Relat Res 315:25, 1995. French B, Tornetta III P: High-energy tibial shaft fractures, Orthop Clin North Am 33:211, 2002. Georgiadis GM, Behrens FF, Joyce MJ, et al.: Open tibial fractures with severe soft tissue loss: limb salvage compared with below-the-knee amputation, J Bone Joint Surg 75A:1431, 1993. Georgiadis GM, Minster GJ, Moed BR: Effects of dynamization after interlocking tibial nailing: an experimental study in dogs, J Orthop Trauma 4:323, 1990. Gershuni DH, Halma G: The AO external skeletal fixator in the treatment of severe tibia fractures, J Trauma 23:986, 1983. Gorczyca JT, McKale J, Pugh K, et al.: Modified tibial nails for treating distal tibia fractures, J Orthop Trauma 16:18, 2002. Gregory P, Sanders R: The treatment of closed, unstable tibial shaft fractures with unreamed interlocking nails, Clin Orthop Relat Res 315:48, 1995. Grosse A, Kempf I, Lafforgued D: Le traitement des fracas, pertes de substance osseuse et pseudoarthroses du fémur et du tibia par l’enclouage verrouillé (a propos de 40 case), Rev Chir Orthop 64(Suppl 2):33, 1978. Hamza KN, Dunkerley GE, Murray CMM: Fractures of the tibia: a report on fifty patients treated by intramedullary nailing, J Bone Joint Surg 53B:696, 1971. Harvey Jr JP: Management of open tibial fractures, Clin Orthop Relat Res 105:154, 1974. Hasenhuttl K: The treatment of unstable fractures of the tibia and fibula with flexible medullary wires: a review of two hundred and thirty-five fractures, J Bone Joint Surg 63A:921, 1981. Henley MB: Intramedullary devices for tibial fracture stabilization, Clin Orthop Relat Res 240:87, 1989. Henley MB, Mayo K, Benirschke S: Prospective comparison of unreamed interlocking IM nails and half-pin external fixation for grade II or III open tibia fractures: preliminary results, Philadelphia, 1989, Paper presented at the annual meeting of the Orthopaedic Trauma Association. Henley MB, Meier M, Tencer AE: Influences of some design parameters and the biomechanics of unreamed tibial intramedullary nails, J Orthop Trauma 7:311, 1993. Heppenstall RB, Brighton CT, Esterhai Jr JL, et al.: Prognostic factors in nonunion of the tibia: an evaluation of 185 cases treated with constant direct current, J Trauma 24:790, 1984. Herzog K: Marknagelung von tibiafrakturen mit dem oberschenkelnagel, Zentralbl Chir 76:903, 1951. Hoaglund FT, States JD: Factors influencing the rate of healing in tibial shaft fractures, Surg Gynecol Obstet 124:71, 1967. Holbrook JL, Swiontkowski MF, Sanders R: Treatment of open fractures of the tibial shaft: ender nailing versus external fixation, J Bone Joint Surg 71A:1231, 1989. Hooper GJ, Keddell RG, Penny ID: Conservative management or closed nailing for tibial shaft fractures: a randomised prospective trial, J Bone Joint Surg 73B:83, 1991. Hou Z, Zhang Q, Zhang Y, et al.: Occult and regular combination injury: the posterior malleolar fracture associated with spiral tibial shaft fracture, J Trauma 66:1385, 2009. Hutson JJ, Zych GA, Cole JD, et al.: Mechanical failures of intramedullary tibial nails applied without reaming, Clin Orthop Relat Res 315:129, 1995. Jackson DW, Cozen L: Genu valgum as a complication of proximal tibial metaphyseal fractures in children, J Bone Joint Surg 53A:1571, 1971. Johner R, Wruhs O: Classification of tibial shaft fractures and correlation with results after rigid internal fixation, Clin Orthop Relat Res 178:7, 1983. Karlström G, Lönnerholm T, Olerud S: Cavus deformity of the foot after fracture of the tibial shaft, J Bone Joint Surg 57A:893, 1975. Karlström G, Olerud S: Fractures of the tibial shaft: a critical evaluation of treatment alternatives, Clin Orthop Relat Res 105:82, 1974. Karlström G, Olerud S: Percutaneous pin fixation of open tibial fractures: double-frame anchorage using the Vidal-Adrey method, J Bone Joint Surg 57A:915, 1975.

Karlström G, Olerud S: Stable external fixation of open tibial fractures: a report of five years of experience with the Vidal-Adrey double-frame method, Orthop Rev 6:25, 1977. Keating JF, O’Brien BJ, Blachut PA, et  al.: Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft, J Bone Joint Surg 79A:334, 1997. Keating JF, Orflay R, O’Brien PJ: Knee pain after tibial nailing, J Orthop Trauma 11:10, 1997. Khatod M, Botte M, Hoyt DB, et al.: Outcomes in open tibia fractures: relationship between delay in treatment and infection, J Trauma 55:949, 2003. Kimmel RB: Results of treatment using the Hoffmann external fixator for fractures of the tibial diaphysis, J Trauma 22:960, 1982. Klein MPM, Rahn BA, Frigg R, et al.: Reaming versus nonreaming in medullary nailing: interference with cortical circulation of the canine tibia, Arch Orthop Trauma Surg 109:314, 1990. Klemm KW, Borner M: Interlocking nailing of complex fractures of the femur and tibia, Clin Orthop Relat Res 212:89, 1986. Klemm K, Schellman WD: Dynamische und Statische Verrigelung des Marknagels, Mschr Unfallheilk 75:568, 1972. Knight RA: Treatment of fractures of the tibial condyles, South Med J 38:246, 1945. Krettek C, Schandelmaier P, Tsherne H: Nonreamed interlocking nailing of closed tibial fractures with severe soft tissue injury, Clin Orthop Relat Res 315:34, 1995. Lam SF: Fractures of the neck of the femur in children, J Bone Joint Surg 53A:1165, 1971. Lang GJ, Cohen BE, Bosse MJ, et  al.: Proximal third tibial shaft fractures: should they be nailed? Clin Orthop Relat Res 315:64, 1995. Lange RH, Bach AW, Hansen ST, et al.: Open tibial fractures with associated vascular injuries: prognosis for limb salvage, J Trauma 25:203, 1985. Lawyer RB, Lubbers LM: Use of the Hoffmann apparatus in the treatment of unstable tibial fractures, J Bone Joint Surg 62A:1264, 1980. Lefaivre KA, Guy P, Chan H, Blachut PA: Long-term follow-up of tibial shaft fractures treated with intramedullary nailing, J Orthop Trauma 22:525, 2008. Leunig M, Hertel R: Thermal necrosis after tibial reaming for intramedullary nail fixation: a report of three cases, J Bone Joint Surg 78B:584, 1996. Lindsey RW, Blair SR: Closed tibial shaft fractures: which ones benefit from surgical treatment? J Am Assoc Orthop Surg 4:35, 1996. Lottes JO: Blind nailing technique for insertion of the triflange medullary nail, JAMA 155:1039, 1954. Lottes JO: Intramedullary nailing of the tibia, Instr Course Lect 15:65, 1958. Lottes JO: Medullary nailing of the tibia with the triflange nail, Clin Orthop Relat Res 105:253, 1974. Lottes JO, Hill LJ, Key JA: Closed reduction, plate fixation and medullary nailing of fractures of both bones of the leg, J Bone Joint Surg 34A:861, 1952. MacKenzie EJ, Bosse MJ, Kellam JF, et al.: Characterization of patients with high-energy lower extremity trauma, J Orthop Trauma 14:455, 2000. MacKenzie EJ, Bosse MJ, Pollak AN, et al.: Long-term persistence of disability following severe lower-limb trauma: results of a seven year follow-up, J Bone Joint Surg 87A:1801, 2005. Mast J: Reduction techniques in fractures of the distal tibial articular surface, Tech Orthop 2:29, 1987. McConnell T, Tornetta III P, Tilzey J, et  al.: Tibial portal placement: the radiographic correlate of the anatomical safe zone, J Orthop Trauma 15:207, 2001. McKee MD, DiPasquale DJ, Wild LM, et al.: The effect of smoking on clinical outcome and complication rates following Ilizarov reconstruction, J Orthop Trauma 17:663, 2003. McKeever FM: Unpublished data, 1953. Melis GC, Sotigiu F, Lepori M, et  al.: Intramedullary nailing in segmental tibial fractures, J Bone Joint Surg 63A:1310, 1981. Merriam WF, Porter KM: Hindfoot disability after a tibial shaft fracture treated by internal fixation, J Bone Joint Surg 65B:326, 1983. Miller WE: Fractures of the hip in children from birth to adolescence, Clin Orthop Relat Res 92:155, 1973.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Moed BR, Watson JT: Intramedullary nailing of the tibial without a fracture table: the transfixion pin distractor technique, J Orthop Trauma 8:195, 1994. Moore JR: The closed fracture of long bones, J Bone Joint Surg 42A:869, 1960. Moore TM: Fracture-dislocation of the knee, Clin Orthop Relat Res 156:128, 1981. Moscato M, Sabetta E, Tigani D, et al.: Grosse-Kempf nailing in fractures of the tibia, Ital J Orthop Traumatol 17:313, 1991. Müller ME, Allgöwer M, Willenegger H: Technique of internal fixation of fractures, New York, 1965, Springer-Verlag. Müller ME, Nazarian S, Koch P: Classification AO des fractures des os longs, Berlin, 1988, Springer Verlag. Nassif JM, Gorczyca JT, Cole JK, et  al.: Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft fractures: a randomized prospective study, J Orthop Trauma 14:554, 2000. Nicoll EA: Fractures of the tibial shaft: a survey of 705 cases, J Bone Joint Surg 46B:373, 1964. Nicoll EA: Closed and open management of tibial fractures, Clin Orthop Relat Res 105:144, 1974. Olerud S: Treatment of fractures by the Vidal-Adrey method, Acta Orthop Scand 44:516, 1973. Olerud S, Karlström G: Tibial fractures treated by AO compression osteosynthesis: experiences from a five year material, Acta Orthop Scand Suppl 140:1, 1972. Oni OOA, Hui A, Gregg PJ: the healing of closed tibial shaft fractures, J Bone Joint Surg 70B:787, 1988. Oni OOA, Stafford H, Gregg PJ: An experimental study of the patterns of periosteal and endosteal damage in tibial shaft fractures using a rabbit trauma model, J Orthop Trauma 3:142, 1989. Orfaly R, Keating JE, O’Brien PJ: Knee pain after tibial nailing: does the entry point matter? J Bone Joint Surg 77B:976, 1995. Pankovich AM: Letters to the, Arthroscopy 2:132, 1986. Pankovich AM, Tarabishy IE, Yelda S: Flexible intramedullary nailing of tibial-shaft fractures, Clin Orthop Relat Res 160:185, 1981. Penzkofer R, Maier M, Nolte A, et al.: Influence of intramedullary nail diameter and locking mode on the stability of tibial shaft fracture fixation, Arch Orthop Trauma Surg 129:525, 2009. Puno RM, Teynor JT, Nagano J, et al.: Critical analysis of results of treatment of 201 tibial shaft fractures, Clin Orthop Relat Res 212:113, 1986. Puno RM, Vaughan JJ, Stetten ML, et al.: Long-term effects of tibial angular malunion on the knee and ankle joints, J Orthop Trauma 5:247, 1991. Ratliff AHC: Fractures of the neck of the femur in children, Orthop Clin North Am 5:903, 1974. Reuss BL, Cole JD: Effect of delayed treatment on open tibial shaft fractures, Am J Orthop 36:215, 2007. Ricci WM, O’Boyle M, Borrelli J, et  al.: Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws, J Orthop Trauma 15:264, 2001. Riemer BL, DiChristina DG, Cooper A, et al.: Nonreamed nailing of tibial diaphyseal fractures in blunt polytrauma patients, J Orthop Trauma 9:66, 1995. Robinson CM, McLaughlan GJ, McLean IP, et al.: Distal metaphyseal fractures of the tibia with minimal involvement of the ankle: classification and treatment by locked intramedullary nailing, J Bone Joint Surg 77B:781, 1995. Rommens P, Gielen J, Broos P, et  al.: Intrinsic problems with the external fixation device of Hoffmann-Vidal-Adrey: a critical evaluation of 117 patients with complex tibial shaft fractures, J Trauma 29:630, 1989. Rommens P, Schmit-Neuerberg KP: Ten years of experience with the operative management of tibial shaft fractures, J Trauma 27:917, 1987. Rowntree M, Getty CJM: The knee after midshaft femoral fracture treatment: a comparison of three methods, Injury 13:125, 1981. Rüedi T, Webb JK, Allgöwer M: Experience with the dynamic compression plate (DCP) in 418 recent fractures of the tibial shaft, Injury 7:252, 1976. Ruiz AL, Kealey WDC, McCoy GF: Implant failure in tibial nailing, Injury 31:359, 2000.

Samuelson MA, McPherson EJ, Norris L: Anatomical assessment of the proper insertion site for a tibial intramedullary nail, J Orthop Trauma 16:23, 2002. Sanders R, Jersinovich I, Anglen J, et al.: The treatment of open tibial shaft fractures using an interlocked intramedullary nail without reaming, J Orthop Trauma 8:503, 1994. Santoro VM, Benirschke K, Henley B, et  al.: Prospective comparison of unreamed interlocking intramedullary nail vs half-pin external fixation in open tibial fractures [abstract], Orthop Trans 15:808, 1991. Sarmiento A: A functional below-the-knee cast for tibial fractures, J Bone Joint Surg 49A:855, 1967. Sarmiento A: A functional below-the-knee brace for tibial fractures: a report on its use in one hundred thirty-five cases, J Bone Joint Surg 52A:295, 1970. Sarmiento A: Functional bracing of tibial fractures, Clin Orthop Relat Res 105:202, 1974. Sarmiento A, Kinman PB, Latta LL: Fractures of the proximal tibia and tibial condyles: a clinical and laboratory comparative study, Clin Orthop Relat Res 145:136, 1979. Sarmiento A, Sharpe FE, Ebramzadeh E, et al.: Factors influencing the outcome of closed tibial fractures treated with functional bracing, Clin Orthop Relat Res 315:8, 1995. Sarmiento A, Sobol PA, Sewhoy AL, et al.: Prefabricated functional braces for the treatment of fractures of the tibial diaphysis, J Bone Joint Surg 66A:1328, 1984. Schatzker J: Compression in surgical treatment of fractures of the tibia, Clin Orthop Relat Res 105:220, 1974. Schemitsch EH, Kowalski MJ, Swiontkowski MF, et al.: Cortical bone blood flow in reamed and unreamed locked intramedullary nailing: a fractured tibial model in sheep, J Orthop Trauma 8:373, 1994. Scudese VA, Birotte A, Gialanella J: Tibial shaft fractures: percutaneous multiple pin fixation, short leg cast and immediate weight-bearing, Clin Orthop Relat Res 72:271, 1970. Sedlin ED, Zitner DT: The Lottes nail in the closed treatment of tibia fractures, Clin Orthop Relat Res 192:185, 1985. Shakespeare DT, Henderson NJ: Compartmental pressure changes during calcaneal traction in tibial fractures, J Bone Joint Surg 64B:498, 1982. Shannon FJ, Mullett H, O’Rourke K: Unreamed intramedullary nail versus external fixation in grade III open tibial fractures, J Trauma 52:650, 2002. Singer RW, Kellam JF: Open tibial diaphyseal fractures: results of unreamed locked intramedullary nailing, Clin Orthop Relat Res 315:114, 1995. Slatis P, Rokkanen P: Closed intramedullary nailing of tibial shaft fractures, Acta Orthop Scand 38:88, 1967. Smith JEM: Results of early and delayed internal fixation for tibial shaft fractures: a review of 470 fractures, J Bone Joint Surg 56B:469, 1974. Solheim K, Bø O: Intramedullary nailing of tibial shaft fractures, Acta Orthop Scand 44:323, 1973. Stegemann P, Lorio M, Soriano R, et al.: Management protocol for unreamed interlocking tibial nails for open tibial fractures, J Orthop Trauma 9:117, 1995. Stuermer EK, Stuermer KM: Tibial shaft fracture and ankle joint injury, J Orthop Trauma 22:107, 2008. Suman RK: The management of tibial shaft fractures by early weight-bearing in a patellar tendon-bearing cast: a comparative study, J Trauma 17:97, 1977. Swanson TV, Sutherland TB, Spiegel JD, et  al.: Prospective comparative study of the Lottes nail versus external fixation in open tibia fractures, New Orleans, 1990, Paper presented at the 57th annual meeting of the American Academy of Orthopaedic Surgeons. Tarr RR, Resnick CT, Wagner KS, et al.: Changes in tibiotalar joint contact areas following experimentally induced tibial angular deformities, Clin Orthop Relat Res 199:72, 1985. Tayton K, Bradley J: How stiff should semi-rigid fixation of the human tibia be? A clue to the answer, J Bone Joint Surg 65B:312, 1983. Teitz CC, Carter DR, Frankel VH: Problems associated with tibial fractures with intact fibulae, J Bone Joint Surg 62A:770, 1980. Templeman D, Thomas M, Varecka T, et al.: Exchange reamed intramedullary nailing for delayed union and nonunion of the tibia, Clin Orthop Relat Res 315:169, 1995.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Thunold J, Varhaug JE, Bjerkeset T: Tibial shaft fractures treated by rigid internal fixation: the early results in a 4-year series, Injury 7:125, 1975. Toivanen JA, Väistö O, Kannus P, et al.: Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: a prospective, randomized study comparing two different nail-insertion techniques, J Bone Joint Surg 84A:580, 2002. Tornetta 3rd P, Collins E: Semiextended position of intramedullary nailing of the proximal tibia, Clin Orthop Relat Res 328:185, 1996. Tornetta III P, Bergman M, Watnik N, et al.: Treatment of grade IIIB open tibial fractures, J Bone Joint Surg 76B:13, 1994. Tornetta 3rd P, Ryan S: Tibial metaphyseal fractures: nailing in extension, Denver, Colorado, 2008, Paper presented at 24th annual meeting of the Orthopaedic Trauma Association. Trabulsy PP, Kerley SM, Hoffman WY: A prospective study of early soft tissue coverage of grade IIIB tibial fractures, J Trauma 36:661, 1994. Trafton PG: Closed unstable fractures of the tibia, Clin Orthop Relat Res 230:58, 1988. Tripuraneni K, Ganga S, Quinn R, Gehlert R: The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate, Orthopedics 31:12, 2008. Tu YK, Lin CH, Su JI, et al.: Unreamed interlocking nail versus external fixator for open type III tibia fractures, J Trauma 39:361, 1995. Tucker H: Management of unstable tibial fractures using the method of Ilizarov, Fla Orthop Soc J 2:36, 1989. Väistö O, Toivanen J, Kannus P, Järvinen M: Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight year follow-up of a prospective, randomized study comparing two different nail-insertion techniques, J Trauma 64:1511, 2008. Väistö O, Toivanen J, Kannus P, Järvinen M: Anterior knee pain and thigh muscle strength after intramedullary nailing of tibial shaft fractures: an 8-year follow-up of 28 consecutive cases, J Orthop Trauma 21:165, 2007. Vallier HA, Le TT, Bedi A: Radiographic and clinical comparisons of distal tibia shaft fractures (4 to 11 cm proximal to plafond): plating versus intramedullary nailing, J Orthop Trauma 22:307, 2008. Velazco A, Whitesides Jr TE, Fleming LL: Fractures of the tibia treated with Lottes nail fixation, South Med J 74:427, 1981. Velazco A, Whitesides Jr TE, Fleming LL: Open fractures of the tibia treated with the Lottes nail, J Bone Joint Surg 65A:879, 1983. Waddell JP, Reardon GP: Complications of tibial shaft fractures, Clin Orthop Relat Res 178:173, 1983. Watson-Jones R: Fractures and joint injuries, ed 4, Baltimore, 1952 (vol 1) and 1955 (vol 2). Williams & Wilkins. W-Dahl A, Toksvig-Larsen S, Lindstrand A: No difference between daily and weekly pin site care: a randomized study of 50 patients with external fixation, Acta Orthop Scand 74:704, 2003. Weissman SL, Herold HZ, Engelberg M: Fractures of the middle two-thirds of the tibial shaft: results of treatment without internal fixation in one hundred and forty consecutive cases, J Bone Joint Surg 48A:257, 1966. Whittle AP: Clinical results of unreamed nailing of tibial and femoral fractures, Tech Orthop 11:67, 1996. Whittle AP, Russell TA, Taylor JC, et al.: Treatment of open fracture of the tibial shaft with the use of interlocking nails without reaming, J Bone Joint Surg 74A:1162, 1992. Whittle AP, Wester W, Russell TA: Fatigue failure in small diameter tibial nails, Clin Orthop Relat Res 315:119, 1995. Wiss DA: Flexible medullary nailing of the acute tibial shaft fractures, Clin Orthop Relat Res 212:122, 1986. Wiss DA, Stetson WB: Unstable fractures of the tibia treated with a reamed intramedullary interlocking nail, Clin Orthop Relat Res 315:56, 1995. Xenos JS, Hopkinson WJ, Mulligan ME, et al.: The tibiofibular syndesmosis, J Bone Joint Surg 77A:847, 1995. Yang EC, Weiner L, Strauss E, et al.: Metaphyseal dissociation fractures of the proximal tibia: an analysis of treatment and complications, Am J Orthop 24:695, 1995. Zucman J, Maurer P: Two-level fractures of the tibia, J Bone Joint Surg 51B:686, 1969.

TIBIAL CONDYLE AND TIBIAL PLATEAU Ali AM, Saleh M, Bolongar S, et al.: The strength of different fixation techniques for bicondylar tibial plateau fractures—a biomechanical study, Clin Biomech (Bristol, Avon) 18:864, 2003. Ali AM, Yand L, Hashmi M, et al.: Bicondylar tibial plateau fractures managed with the Sheffield Hybrid Fixator: biomechanical study and operative technique, Injury 32(Suppl D):86, 2001. Apley AG: Fractures of the lateral tibial condyle treated by skeletal traction and early mobilisation: a review of sixty cases with special reference to the long-term results, J Bone Joint Surg 38B:699, 1956. Apley AG: Fractures of the tibial plateau, Orthop Clin North Am 10:61, 1979. Bakalim G, Wilppula E: Fractures of the tibial condyles, Acta Orthop Scand 44:311, 1973. Ballmer FT, Hertel R, Nötzli HP: Treatment of tibial plateau fractures with small fragment internal fixation: a preliminary report, J Orthop Trauma 14:467, 2000. Barei DP, Nork SE, Mills WJ, et al.: Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates, J Bone Joint Surg 88A:1713, 2006. Barbieri R, Schenk R, Koval K, et  al.: Hybrid external fixation in the treatment of tibial plafond fractures, Clin Orthop Relat Res 332:16, 1996. Barei DP, Nork SE, Mills WJ, et al.: Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a twoincision technique, J Orthop Trauma 18:649, 2004. Benirschke SK, Agnew S, Mayo KA, et  al.: Immediate internal fixation of open, complex tibial plateau fractures: treatment by a standard protocol, J Orthop Trauma 6:78, 1992. Bennett WF, Browner B: Tibial plateau fractures: a study of associated soft tissue injury, J Orthop Trauma 8:183, 1994. Berkson EM, Virkus WW: High-energy tibial plateau fractures, J Am Acad Orthop Surg 14:20, 2006. Bhattacharyya T, McCarty LP, Harris MB, et al.: The posterior shearing tibial plateau fracture: treatment and results, J Orthop Trauma 19:305, 2005. Blokker CP, Rorabeck CH, Bourne RB: Tibial plateau fractures: an analysis of the results of treatment in 60 patients, Clin Orthop Relat Res 182:193, 1984. Bowes DN, Hohl M: Tibial condylar fractures: evaluation of treatment and outcome, Clin Orthop Relat Res 171:104, 1982. Brown TD, Anderson DD, Nepola JV, et al.: Contact stress aberrations following imprecise reduction of simple tibial plateau fractures, J Orthop Res 6:851, 1988. Buchko GM, Johnson DH: Arthroscopy assisted operative management of tibial plateau fractures, Clin Orthop Relat Res 332:29, 1996. Burri C, Bartzke G, Coldewey J, et  al.: Fractures of the tibial plateau, Clin Orthop Relat Res 138:84, 1979. Caspari RB, Hutton PMJ, Whipple TL, et al.: The role of arthroscopy in the management of tibial plateau fractures, Arthroscopy 1:76, 1985. Cole PA, Zlowodzki M, Kregor PJ: Less invasive stabilization systems (LISS) for fractures of the proximal tibia: indications, surgical technique and preliminary results of the UMC clinical trial, Injury Int J Care Injured 34:S–A16, 2003. Cole PA, Zlowodzki M, Kregor PJ: Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures, J Orthop Trauma 18:528, 2004. Colletti P, Greenberg H, Terk MR: MR findings in patients with acute tibial plateau fractures, Comput Med Imaging Graph 20:389, 1996. Delamarter R, Hohl M: The cast brace and tibial plateau fractures, Clin Orthop Relat Res 242:26, 1989. Delamarter R, Hohl M, Hopp Jr E: Ligament injuries associated with tibial plateau fractures, Clin Orthop Relat Res 250:226, 1990. Dias JJ, Stirling AJ, Finlay DBL, et al.: Computerised axial tomography for tibial plateau fractures, J Bone Joint Surg 69B:84, 1987. Dovey H, Heerfordt J: Tibial condyle fractures: a follow-up of 200 cases, Acta Chir Scand 137:521, 1971. Drennan DB, Locher FG, Maylahn DJ: Fractures of the tibial plateau: treatment by closed reduction and spica cast, J Bone Joint Surg 61A:989, 1979.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Duwelius PJ, Connolly JF: Closed reduction of tibial plateau fractures: a comparison of functional and roentgenographic end results, Clin Orthop Relat Res 230:116, 1988. Egol KA, Su E, Tejwani NC, et al.: Treatment of complex tibial plateau fractures using the less invasive stabilization system plate: clinical experience and a laboratory comparison with double plating, J Trauma 57:340, 2004. Egol KA, Tejwani NC, Capla EL, et al.: Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol, J Orthop Trauma 19:448, 2005. Elstrom J, Pankovich AM, Sassoon H, et al.: The use of tomography in the assessment of fractures of the tibial plateau, J Bone Joint Surg 58A:551, 1976. French B, Tornetta P: High-energy tibial shaft fractures, Orthop Clin North Am 33:211, 2002. Gausewitz S, Hohl M: The significance of early motion in the treatment of tibial plateau fractures, Clin Orthop Relat Res 202:135, 1986. Georgiadis GM: Combined anterior and posterior approaches for complex tibial plateau fractures, J Bone Joint Surg 76B:285, 1994. Gossling HR, Peterson CA: A new surgical approach in the treatment of depressed lateral condylar fractures of the tibia, Clin Orthop Relat Res 140:96, 1979. Hand WL, Hand CR, Dunn AW: Avulsion fractures of the tibial tubercle, J Bone Joint Surg 53A:1579, 1971. Handelberg F, Casteleyn P, DeRoeck P: Arthroscopic assessment and treatment of tibial plateau fractures, Arthroscopy 7:318, 1991. Hohl M: Tibial condylar fractures: an instructional course lecture. The American Academy of Orthopaedic Surgeons, J Bone Joint Surg 49A:1455, 1967. Hohl M: Treatment methods in tibial condylar fractures, South Med J 68:985, 1975. Hohl M, Luck JV: Fractures of the tibial condyle: a clinical and experimental study, J Bone Joint Surg 38A:1001, 1956. Hohl M, Moore TM: Articular fractures of the proximal tibia. In Ewarts CM, editor: Surgery of the musculoskeletal system, ed 2, New York, 1990, Churchill-Livingstone. Holzach P, Matter P, Minter J: Arthroscopically assisted treatment of lateral tibial plateau fractures in skiers: use of a cannulated reduction system, J Orthop Trauma 8:273, 1994. Honkonen SE: Degenerative arthritis after tibial plateau fractures, J Orthop Trauma 9:273, 1995. Horwitz DS, Bachus KN, Craig MA, et al.: A biomechanical analysis of internal fixation of complex tibial plateau fractures, J Orthop Trauma 13:545, 1999. Itokazu M, Matsunaga T: Arthroscopic restoration of depressed tibial plateau fractures using bone and hydroxyapatite grafts, Arthroscopy 9:103, 1993. Jackson DW: The use of autologous fibula for a prop graft in depressed lateral tibial plateau fractures, Clin Orthop Relat Res 87:110, 1972. Jackson DW, Jennings LD, Maywood RM, et al.: Magnetic resonance imaging of the knee, Am J Sports Med 16:29, 1988. Jacobs JE: Patellar graft for severely depressed comminuted fractures of the lateral tibial condyle, J Bone Joint Surg 47A:842, 1965. Jennings JE: Arthroscopic management of tibial plateau fractures, Arthroscopy 1:160, 1985. Jennings JE: Letters to the, Arthroscopy 2:133, 1986. Jensen DB, Rude C, Duus B, et al.: Tibial plateau fractures: a comparison of conservative and surgical treatment, J Bone Joint Surg 72B:49, 1990. Kennedy JC, Bailey WH: Experimental tibial-plateau fractures: studies of the mechanism and a classification, J Bone Joint Surg 50A:1522, 1968. Kennedy JC, Grainger RW: McGraw RW: Osteochondral fractures of the femoral condyles, J Bone Joint Surg 48B:436, 1966. Kettlekamp DB, Hillberry BM, Murrish DE, et al.: Degenerative arthritis of the knee secondary to fracture malunion, Clin Orthop Relat Res 234:159, 1988. Knight RA: Treatment of fractures of the tibial condyles, South Med J 38:246, 1945. Kregor PJ: Distal femur fractures with complex articular involvement: management by articular exposure and submuscular fixation, Orthop Clin North Am 33:153, 2002.

Kumar A, Russell TA, Davidson RL, et  al.: Fibular head autograft-salvage technique for severely comminuted lateral fractures of the tibial plateau: report of five cases, Am J Orthop 25:766, 1996. Lachiewicz PF, Funcik T: Factors influencing the results of open reduction and internal fixation of tibial plateau fractures, Clin Orthop Relat Res 259:210, 1990. Lansinger O, Bergman B, Korner L, et al.: Tibial condylar fractures: a twentyyear follow-up, J Bone Joint Surg 68A:13, 1986. Lee HG: Osteoplastic reconstruction in severe fractures of the tibial condyles: utilization of the anterior superior iliac spine, Am J Surg 94:940, 1957. Lemon RA, Bartlett DH: Arthroscopic assisted internal fixation of certain fractures about the knee, J Trauma 25:355, 1985. Lobenhoffer P, Schulze M, Gerich T, et al.: Closed reduction/percutaneous fixation of tibial plateau fractures: arthroscopic versus fluoroscopic control of reduction, J Orthop Trauma 13:426, 1999. Lucht U, Pilgaard S: Fractures of the tibial condyles, Acta Orthop Scand 42:366, 1971. Marmor L: Fracture as a complication of osteonecrosis of the tibial plateau: case report, J Bone Joint Surg 70A:454, 1988. Marsh JL, Smith ST, Do TT: External fixation and limited internal fixation for complex fractures of the tibial plateau, J Bone Joint Surg 77A:661, 1995. Martin AF: The pathomechanics of the knee joint, part I: the medial collateral ligament and lateral tibial plateau fractures, J Bone Joint Surg 42A:13, 1960. McConkey JP, Meeuwisse W: Tibial plateau fractures in alpine skiing, Am J Sports Med 16:159, 1988. McDonnell MF, Butler III JE: Osteochondral fracture of the tibial plateau in a ballerina, Am J Sports Med 16:417, 1988. Meyers MH, Harvey JP: Traumatic dislocation of the knee joint, J Bone Joint Surg 53A:16, 1971. Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia, J Bone Joint Surg 52A:1677, 1970. Meyers MH, Moore TM, Harvey JP: Traumatic dislocation of the knee joint, J Bone Joint Surg 57A:430, 1975. Mills WJ, Nork SE: Open reduction and internal fixation of high-energy tibial plateau fractures, Orthop Clin North Am 33:177, 2002. Moore TM, Harvey Jr JP: Roentgenographic measurement of tibial-plateau depression due to fracture, J Bone Joint Surg 56A:155, 1974. Moore TM, Meyers MH, Harvey JP: Collateral ligamentous laxity of the knee: a long-term comparison between plateau fractures and normal, J Bone Joint Surg 59A:594, 1976. Moore TM, Patzakis MJ, Harvey JP: Tibial plateau fractures: definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction, J Orthop Trauma 1:97, 1987. Morandi M, Pearse MF: Management of complex tibial plateau fractures with the Ilizarov external fixator, Tech Orthop 11:125, 1996. Mueller CA, Eingartner C, Schreitmueller E, et al.: Primary stability of various forms of osteosynthesis in the treatment of fractures of the proximal tibia, J Bone Joint Surg 87B:426, 2005. Mueller KL, Karunakar MA, Frankenburg EP, et al.: Bicondylar tibial plateau fractures: a biomechanical study, Clin Orthop Relat Res 412:189, 2003. Mustonen AO, Koivikko MP, Lindahl J, Koskinen SK: MRI of acute meniscal injury associated with tibial plateau fractures: prevalence, type and location, AJR Am J Roentgenol 191:1002, 2008. Nork SE, Barei DP, Schildhauer TA, et al.: Intramedullary nailing of proximal quarter tibial fractures, J Orthop Trauma 20:523, 2006. Patil S, Mahon A, Green S, et al.: A biomechanical study comparing a raft of 3.5 mm cortical screws with 6.5 mm cancellous screws in depressed tibial plateau fractures, Knee 13:231, 2006. Peindl RD, Zura RD, Vincent A, et  al.: Unstable proximal extraarticular tibia fractures: a biomechanical evaluation of four methods of fixation, J Orthop Trauma 18:540, 2004. Perry CR, Evans LG, Rice S, et al.: A new surgical approach to fractures of the lateral tibial plateau, J Bone Joint Surg 66A:1236, 1984. Rafii M, Lamont JG, Firooznia H: Tibial plateau fractures: CT evaluation and classification, Crit Rev Diagn Imaging 27:91, 1987.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Rasmussen PS: Tibial condylar fractures as a cause of degenerative arthritis, Acta Orthop Scand 43:566, 1972. Rasmussen PS: Tibial condylar fractures: impairment of knee joint stability as an indication for surgical treatment, J Bone Joint Surg 55A:1331, 1973. Reibel DB, Wade PA: Fractures of the tibial plateau, J Trauma 2:337, 1962. Reiner MJ: The arthroscope in tibial plateau fractures: its use in evaluation of soft tissue and bony injury, J Am Osteopath Assoc 81:704, 1982. Ricci WM, Rudzki JR, Borrelli J: Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system, J Orthop Trauma 18:521, 2004. Rich C, Dabezies EJ: Tibial plateau fractures, Orthopedics 10:1455, 1987. Ries MD, Meinhard BP: Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures: a report of eight cases associated with severe soft tissue injury, Clin Orthop Relat Res 256:215, 1990. Roberts JM: Fractures of the condyles of the tibia: an anatomical and clinical end-result study of one hundred cases, J Bone Joint Surg 50A: 1505, 1968. Sarmiento A, Kinman PB, Latta LL: Fractures of the proximal tibia and tibial condyles: a clinical and laboratory comparative study, Clin Orthop Relat Res 145:136, 1999. Savoie FH, Vander Griend RA, Ward EF, et  al.: Tibial plateau fractures: a review of operative treatment using AO technique, Orthopedics 10:745, 1987. Schatzker J, McBroom R, Bruce D: The tibial plateau fracture: the Toronto experience 1968-1975, Clin Orthop Relat Res 138(94):1979. Schulak DJ, Gunn DR: Fractures of the tibial plateaus: a review of the literature, Clin Orthop Relat Res 109:166, 1975. Shybut GT, Spiegel PG: Tibial plateau fractures [editorial], Clin Orthop Relat Res 138:12, 1979. Sirkin MS, Bono CM, Reilly MC, et al.: Percutaneous methods of tibial plateau fixation, Clin Orthop Relat Res 375:60, 2000. Sommer C, Müller M, Hanson BD: Locking compression plate loosening and plate breakage: a report of four cases, J Orthop Trauma 18:572, 2004. Stamer DT, Schenk R, Staggies B, et al.: Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study, J Orthop Trauma 8:455, 1994. Tscherne H, Lobenhoffer P: Tibial plateau fractures: management and expected results, Clin Orthop Relat Res 292:87, 1993. Volpin G, Dowd GSE, Stein H, et al.: Degenerative arthritis after intra-articular fractures of the knee: long-term results, J Bone Joint Surg 72B:634, 1990. Waddell JP, Johnston DWC, Neidre A: Fractures of the tibial plateau: a review of ninety-five patients and comparison of treatment methods, J Trauma 21:376, 1981. Waldrop JI, Macey TI, Trettin JC, et al.: Fractures of the posterolateral tibial plateau, Am J Sports Med 16:492, 1988. Watson JT: High energy fractures of the tibial plateau, Orthop Clin North Am 25:723, 1994. Watson JT, Ripple S, Hoshaw SJ, et al.: Hybrid external fixation for tibial plateau fractures: clinical and biomechanical correlation, Orthop Clin North Am 33:199, 2002. Weigel DP, Marsh JL: High-energy fractures of the tibial plateau, J Bone Joint Surg 84A:1541, 2002. Weiner LS, Kelley M, Yang E, et al.: The use of combination internal fixation and hybrid external fixation in severe proximal tibia fractures, J Orthop Trauma 9:244, 1995. Wilppula E, Bakalim G: Ligamentous tear concomitant with tibial condylar fracture, Acta Orthop Scand 43:292, 1972. Wilson WJ, Jacobs JE: Patellar graft for severely depressed comminuted fractures of the lateral tibial condyle, J Bone Joint Surg 34A:436, 1952. Young MJ, Barrak RL: Complications in internal fixation of tibial plateau fractures, Orthop Rev 149, 1994.

PATELLA Ahstrom Jr JP: Osteochondral fracture in the knee joint associated with hypermobility and dislocation of the patella: report of eighteen cases, J Bone Joint Surg 47A:1491, 1965.

Andrews JR, Hughston JC: Treatment of patellar fractures by partial patellectomy, South Med J 70:809, 1977. Benjamin J, Bried J, Dohm M, et  al.: Biomechanical evaluation of various forms of fixation of transverse patellar fractures, J Orthop Trauma 1:219, 1987. Berg EE: Open reduction internal fixation of displaced transverse patella fractures with figure-eight wiring through parallel cannulated compression screws, J Orthop Trauma 11:573, 1997. Bickel WH, Johnson KA: Z-plasty patellectomy, Surg Gynecol Obstet 132:985, 1971. Böstman O, Kiviluoto O, Nirhamo J: Comminuted displaced fractures of the patella, Injury 13:196, 1981. Boström A: Fracture of the patella: a study of 422 patellar fractures, Acta Orthop Scand Suppl 143:1, 1972. Brooke R: The treatment of fractured patella by excision: a study of morphology and function, Br J Surg 24:733, 1936-1937. Burton VW, Thomas HM: Results of excision of the patella, Surg Gynecol Obstet 135:753, 1972. Burvant JG, Thomas KA, Alexander R, et  al.: Evaluation of methods of internal fixation of transverse patella fractures: a biomechanical study, J Orthop Trauma 8:147, 1994. Carpenter JE, Kasman R, Matthews LS: Fractures of the patella, J Bone Joint Surg 75A:1550, 1993. Catalano JB, Iannacone WM, Marczyk S, et al.: Open fractures of the patella: long-term functional outcome, J Trauma 39:439, 1995. Chang MA, Rand JA, Trousdale RT: Patellectomy after total knee arthroplasty, Clin Orthop Relat Res 440:175, 2005. Chen A, Hou C, Bao J, et al.: Comparison of biodegradable and metallic tension-band fixation for patella fractures: 38 patients followed for 2 years, Acta Orthop Scand 69:39, 1998. Codavilla A: Sur tendinei nella practica ortopedica, Orch Ortop 16:225, 1899. Convery FR, Akeson WH, Keown GH: The repair of large osteochondral defects: an experimental study in horses, Clin Orthop Relat Res 82:253, 1972. Crenshaw AH, Wilson FD: The surgical treatment of fractures of the patella, South Med J 47:716, 1954. Curtis MJ: Internal fixation for fractures of the patella: a comparison of two methods, J Bone Joint Surg 72B:280, 1990. Devas MB: Stress fractures of the patella, J Bone Joint Surg 42B:71, 1960. Duthie HL, Hutchinson JR: The results of partial and total excision of the patella, J Bone Joint Surg 40B:75, 1958. Edwards B, Johnell O, Redlund-Johnell I: Patellar fractures: a 30-year followup, Acta Orthop Scand 60:712, 1989. Einola S, Aho AJ, Kallio P: Patellectomy after fracture: long-term follow-up results with special reference to functional disability, Acta Orthop Scand 47:441, 1976. Foppen GM, Kramer WL, Bultman H: Treatment of medial tangential osteochondral fractures of the patella, with resorbable materials: case report, Eur J Surg 160:649, 1994. Frandsen PA, Kristensen H: Osteochondral fracture associated with dislocation of the patella: another mechanism of injury, J Trauma 19:195, 1979. Freiberger RH, Kotzen LM: Fracture of the medial margin of the patella, a finding diagnostic of lateral dislocation, Radiology 88:902, 1967. Gosal HS, Singh P, Field RE: Clinical experience of patellar fracture fixation using metal wire or non-absorbable polyester—a study of 37 cases, Injury 32:129, 2001. Griswold AS: Fractures of the patella, Clin Orthop Relat Res 4:44, 1954. Günal I, Karatosun V: Patellectomy: an overview with reconstructive procedures, Clin Orthop Relat Res 389:74, 2001. Günal I, Taymaz A, Kose N, et al.: Patellectomy with vastus medialis obliquus advancement for comminuted patellar fractures: a prospective randomized trial, J Bone Joint Surg 79B:13, 1997. Haxton HA: The function of the patella and the effects of its excision, Surg Gynecol Obstet 80:389, 1945. Heckman JD, Alkire CC: Distal patellar pole fractures: a proposed common mechanism of injury, Am J Sports Med 12:424, 1984.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Ho TK, Fang D: Posterior cruciate avulsion fracture associated with a large inverted medial tibial osteochondral fragment, J Trauma 38:653, 1995. Hoffer MM, Schechter DE: Results of seventy-five patellectomies in seventy patients, Am J Surg 111:645, 1966. Houghton GR, Ackroyd CE: Sleeve fractures of the patella in children: a report of three cases, J Bone Joint Surg 61B:165, 1979. Hung LK, Chan KM, Chow YN, et al.: Fractured patella: operative treatment using the tension band principle, Injury 16:343, 1985. Jacobsen J, Christensen KS, Rasmussen OS: Patellectomy—a 20-year followup, Acta Orthop Scand 56:430, 1985. Kaufer H: Mechanical function of the patella, J Bone Joint Surg 53A:1551, 1971. Kennedy JC, Grainger RW: McGraw RW: Osteochondral fractures of the femoral condyles, J Bone Joint Surg 48B:436, 1966. Leung PC, Mak KH, Lee SY: Percutaneous tension band wiring: a new method of internal fixation for mildly displaced patella fracture, J Trauma 23:62, 1983. Levitt RL: A long-term evaluation of patellar prostheses, Clin Orthop Relat Res 97:153, 1973. Liang QY, Wu JW: Fracture of the patella treated by open reduction and external compressive skeletal fixation, J Bone Joint Surg 69A:83, 1987. Ma YZ, Zhang YF, Qu KF, et al.: Treatment of fractures of the patella with percutaneous suture, Clin Orthop Relat Res 191:235, 1984. Makino A, Aponte-Tinao L, Muscolo DL, et al.: Arthroscopic-assisted surgical technique for treating patella fractures, Arthroscopy 18:671, 2002. Marder RA, Swanson TV, Sharkey NA, et al.: Effects of partial patellectomy and reattachment of the patellar tendon on patellofemoral contact areas and pressures, J Bone Joint Surg 75A:35, 1993. Marya SKS, Bhan S, Dave PK: Comparative study of knee function after patellectomy and osteosynthesis with a tension band wire following patellar fractures, Int Surg 72:211, 1987. Matejcic A, Smiljanic B, Bekavac-Beslin M, et  al.: The basket plate in the osteosynthesis of comminuted fractures of distal pole of the patella, Injury 37:525, 2006. Matthewson MH, Dandy DJ: Osteochondral fractures of the lateral femoral condyle: a result of indirect violence to the knee, J Bone Joint Surg 60B: 199, 1978. Mayer G, Seidlein H: Chondral and osteochondral fractures of the knee joint-treatment and results, Arch Orthop Trauma Surg 107:154, 1988. McGreal G, Reidy D, Joy A, et al.: The biomechanical evaluation of polyester as a tension band for the internal fixation of patellar fractures, J Med Eng Technol 23:53, 1999. Milgram JE: Tangential osteochondral fracture of the patella, J Bone Joint Surg 25:271, 1943. Mishra US: Late results of patellectomy in fractured patella, Acta Orthop Scand 43:256, 1972. O’Donoghue DH: Facetectomy, South Med J 65:645, 1972. Patel VR, Parks BG, Wang Y, et al.: Fixation of patella fractures with braided polyester suture: a biomechanical study, Injury 31:1, 2000. Peeples RE, Margo MK: Function after patellectomy, Clin Orthop Relat Res 132:180, 1978. Perry CR, McCarthy JA, Kain CC, et  al.: Patellar fixation protected with a load-sharing cable: a mechanical and clinical study, J Orthop Trauma 2:234, 1988. Peterson L, Stener B: Distal disinsertion of the patellar ligament combined with avulsion fractures at the medial and lateral margins of the patella: a case of report and an experimental study, Acta Orthop Scand 47:680, 1976. Plaga BR, Royster RM, Donigian AM, et al.: Fixation of osteochondral fractures in rabbit knees: a comparison of Kirschner wires, fibrin sealant, and polydioxanone pins, J Bone Joint Surg 74B:292, 1992. Pritsch M, Velkes S, Levy O, et al.: Suture fixation of osteochondral fractures of the patella, J Bone Joint Surg 77B:154, 1995. Rae PS, Khasawneh ZM: Herbert screw fixation of osteochondral fractures of the patella, Injury 19:116, 1988.

Rorabeck CH, Bobechko WP: Acute dislocation of the patella with osteochondral fracture: review of eighteen cases, J Bone Joint Surg 58B:237, 1976. Rosenberg MJ: Osteochondral fractures of the lateral femoral condyle, J Bone Joint Surg 46A:1013, 1964. Saltzman CL, Goulet JA, McClellan T, et al.: Results of treatment of displaced patellar fractures by partial patellectomy, J Bone Joint Surg 72A:1279, 1990. Schauwecker F: The practice of osteosynthesis, Stuttgart, 1974, Georg Theime Verlag. Scilaris TA, Grantham JL, Prayson MJ, et al.: Biomechanical comparison of fixation methods in transverse patella fractures, J Orthop Trauma 12:356, 1998. Shorbe HB, Dobson CH: Patellectomy: repair of the extensor mechanism, J Bone Joint Surg 40A:1281, 1958. fpeeples ST, Cramer KE, Karges DE, et al.: Early complications in the operative treatment of patella fractures, J Orthop Trauma 11:183, 1997. Taitsman LA, Frank JB, Mills WT, et al.: Osteochondral fracture of the distal lateral femoral condyle: a report of two cases, J Orthop Trauma 20:358, 2006. Tandogan RN, Demirors H, Tuncay CI, et al.: Arthroscopic-assisted percutaneous screw fixation of select patellar fractures, Arthroscopy 18:156, 2002. Thompson WJ, Schweigel JF: Patellectomy: a 21-year follow-up, Can J Surg 11:173, 1968. Torchia ME, Lewellen DG: Open fractures of the patella, J Orthop Trauma 10:403, 1996. Turgut A, Gunal I, Acar S, et al.: Arthroscopic-assisted percutaneous stabilization of patellar fractures, Clin Orthop Relat Res 389:57, 2001. Weber MJ, Janecki CJ, McLeod P, et al.: Efficacy of various forms of fixation of transverse fractures of the patella, J Bone Joint Surg 62A:215, 1980. West FE: End results of patellectomy, J Bone Joint Surg 44A:1089, 1962. Yang KH, Byun YS: Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella, J Bone Joint Surg 85B:1155, 2003. Yanmis I, Oguz E, Atesalp AS, et al.: Application of circular external fixator under arthroscopic control in comminuted patella fractures: technique and early results, J Trauma 60:659, 2006. Zhao J, Wu X, Peng X: Biomechanical experiment and clinical report of modified patellectomy for polar fracture of the patella, Clin J Traumatol 2:122, 1999.

FEMUR Ali F, Saleh M: Treatment of isolated complex distal femoral fractures by external fixation, Injury 31:139, 2000. Anderson RL: Conservative treatment of fractures of the femur, J Bone Joint Surg 49A:1371, 1967. Arazi M, Memik R, Ogun TC, Yel M: Ilizarov external fixation for severely comminuted supracondylar fractures of the distal femur, J Bone Joint Surg 83B:663, 2001. Bain GI, Zacest AC, Paterson DC, et al.: Abduction strength following intramedullary nailing of the femur, J Orthop Trauma 11:93, 1997. Baixauli Sr F, Baixauli EJ, Sanchez-Alepuz E, et al.: Interlocked intramedullary nailing for treatment of open femoral shaft fractures, Clin Orthop Relat Res 350:67, 1998. Barazi M, Memik R, Ogun TC, et al.: Ilizarov external fixation for severely comminuted supracondylar and intercondylar fractures of the distal femur, J Bone Joint Surg 83B:663, 2001. Barquet A, Fernandez A, Leon H: Simultaneous ipsilateral trochanteric and femoral shaft fracture, Acta Orthop Scand 56:36, 1985. Barquet A, Mussio A: Fracture dislocation of the femoral head with associated ipsilateral trochanteric and shaft fracture of the femur, Arch Orthop Trauma Surg 102:61, 1983. Bassett III FH, Goldner JL: Fractures involving the distal femoral epiphyseal growth line, South Med J 55:545, 1962. Behrman SW, Fabian TC, Kudsk KA, et al.: Improved outcome with femur fractures: early vs. delayed fixation, J Trauma 30:792, 1990.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Bellabarba C, Ricci WM, Bolhofner BR: Indirect reduction and plating of distal femoral nonunions, J Orthop Trauma 16:287, 2002. Benirschke SK, Melder I, Henley MB, et al.: Closed interlocking nailing of femoral shaft fractures: assessment of technical complications and functional outcomes by comparison of a prospective database with retrospective review, J Orthop Trauma 7:118, 1993. Benum P: The use of bone cement as an adjunct to internal fixation of supracondylar fractures of osteoporotic femurs, Acta Orthop Scand 48:52, 1977. Bergman GD, Winquist RA, Mayo KA, et al.: Subtrochanteric fracture of the femur, J Bone Joint Surg 69A:1032, 1987. Bernstein SM: Fractures of the femoral shaft and associated ipsilateral fractures of the hip, Orthop Clin North Am 5:799, 1974. Blake R, McBryde Jr A: The floating knee: ipsilateral fractures of the femur and tibia, South Med J 68:13, 1975. Böhler J: Behandlung der Kniescheibenbruche: Osteosythese, Teilexstirpation, Extirpation, Dtsch Med Wochenschr 86:1209, 1961. Bolhofner BR, Carmen B, Clifford P: The results of open reduction and internal fixation of distal femur fractures using a biologic (indirect) reduction technique, J Orthop Trauma 10:372, 1996. Bone LB, Babikian G, Stegemann PM: Femoral canal reaming in the polytrauma patient with chest injury: a clinical perspective, Clin Orthop Relat Res 318:91, 1995. Bone LB, Johnson KD, Weige J, et al.: Early versus delayed stabilization of femoral fractures: a randomized study, J Bone Joint Surg 71A:336, 1989. Borgen D, Sprague BL: Treatment of distal femoral fractures with early weight-bearing: a preliminary report, Clin Orthop Relat Res 111:156, 1975. Bosse MJ, MacKenzie EJ, Riemer BL, et al.: Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate: a comparative study, J Bone Joint Surg 79A:799, 1997. Bosse MJ, Sims S, Kellam JF: External fixation of supracondylar femur fractures in the multiple-trauma patient, Tech Orthop 9:221, 1994. Böstman OM: Refractures after removal of a condylar plate from the distal third of the femur, J Bone Joint Surg 72A:1013, 1990. Böstman OM, Yarjonen L, Vainionpää S, et al.: Incidence of local complications after intramedullary nailing and after plate fixation of femoral shaft fractures, J Trauma 29:639, 1989. Boyer MI, Ribeiro E, Hu R, et al.: Small versus large diameter closed-section femoral nails for the treatment of femoral shaft fractures: is there a difference? J Trauma 41:279, 1996. Browner BD: The Grosse-Kempf locking nail, Contemp Orthop 8:17, 1984. Brumback RJ, Ellison TS, Molligan H, et al.: Pudendal nerve palsy complicating intramedullary nailing of the femur, J Bone Joint Surg 74A:1450, 1992. Brumback RJ, Ellison Jr PS, Poka A, et  al.: Intramedullary nailing of open fractures of the femoral shaft, J Bone Joint Surg 71A:1324, 1989. Brumback RJ, Ellison TS, Poka A, et al.: Intramedullary nailing of femoral shaft fractures, part III: long-term effects of static interlocking fixation, J Bone Joint Surg 74A:106, 1992. Brumback RJ, Toal Jr TR, Murphy-Zane MS, et al.: Immediate weight-bearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail, J Bone Joint Surg 81A:1538, 1999. Brumback RJ, Virkus WW: Intramedullary nailing of the femur: reamed versus nonreamed, J Am Acad Orthop Surg 8:83, 2000. Brumback RJ, Wells DJ, Lakatos R, et al.: Heterotopic ossification about the hip after intramedullary nailing for fractures of the femur, J Bone Joint Surg 72A:1067, 1990. Bucholz R, Rathjen K: Concomitant ipsilateral fractures of the hip and femur treated with interlocking nails, Orthopedics 8:1402, 1985. Bucholz RW, Ross SE, Lawrence KL: Fatigue fracture of the interlocking nail in the treatment of fractures of the distal part of the femoral shaft, J Bone Joint Surg 69A:1391, 1987. Butler MS, Brumback RJ, Ellison TS, et al.: Interlocking intramedullary nailing for ipsilateral fractures of the femoral shaft and distal part of the femur, J Bone Joint Surg 73A:1492, 1991. Carlson DA, Dobozi WR, Rabin S: Peroneal nerve palsy and compartment syndrome in bilateral femoral fractures, Clin Orthop Relat Res 320:115, 1995.

Casey JM, Chapman MW: Ipsilateral concomitant fractures of the hip and femoral shaft, J Bone Joint Surg 61A:503, 1979. Catagni MA, Mendlick RM: Femoral fractures, Tech Orthop 11:160, 1996. Chapman JR, Henley MB: Double plating of distal femur fractures: indications and techniques, Tech Orthop 9:210, 1994. Chapman MW: Closed intramedullary bone-grafting and nailing of segmental defects of the femur: a report of three cases, J Bone Joint Surg 62A:1004, 1980. Chapman MW: Closed intramedullary nailing of femoral-shaft fractures: technique and rationale, Contemp Orthop 4:213, 1982. Charash WE, Fabian TC, Croce MA: Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma, J Trauma 37:667, 1994. Cheng JCY, Tse PYT, Chow YYN: The place of the dynamic compression plate in femoral shaft fractures, Injury 16:529, 1985. Chiron HS, Tremoulet J, Casey P, et al.: Fractures of the distal third of the femur treated by internal fixation, Clin Orthop Relat Res 100:160, 1974. Clawson DK, Smith RF, Hansen ST: Closed intramedullary nailing of the femur, J Bone Joint Surg 53A:681, 1971. Codavilla A: Sur tendinei nella practica ortopedica, Orch Ortop 16:225, 1899. Connolly JF, Dehne E, Lafollette B: Closed reduction and early cast-brace ambulation in the treatment of femoral fractures, part II: results in one hundred and forty-three fractures, J Bone Joint Surg 55A:1581, 1973. Connolly JF, King P: Closed reduction and early cast-brace ambulation in the treatment of femoral fractures, part I: an in vivo quantitative analysis of immobilization in skeletal traction and a cast-brace, J Bone Joint Surg 55A:1559, 1973. Cope AR, McGlone R, Sloan JP: Do we need to cross-match blood in closed fractures of the shaft of the femur? Injury 20:27, 1989. Dabezies EJ, D’Ambrosia RD, Shoji H, et al.: Fractures of the femoral shaft treated by external fixation with the Wagner device, J Bone Joint Surg 66A:360, 1984. Danziger MB, Caucci D, Zecher SB, et al.: Treatment of intercondylar and supracondylar distal femur fractures using the GSH supracondylar nail, Am J Orthop 24:684, 1995. David SM, Harrow ME, Peindl RD, et al.: Comparative biomechanical analysis of supracondylar femur fracture fixation: locked intramedullary nail versus 95-degree angled plate, J Orthop Trauma 11:344, 1997. De Campos J, Vangsness T, Merritt PO, et  al.: Ipsilateral knee injury with femoral fracture: examination under anesthesia and arthroscopic evaluation, Clin Orthop Relat Res 300:178, 1994. Dedrick DK, Mackenzie JR, Burney ER: Complications of femoral neck fracture in young adults, J Trauma 26:932, 1986. Deep K, Sharp I, Hay SM: Femoral neck fracture complicating intramedullary nailing of femoral shaft, Injury 30:445, 1999. Delaney WM, Street DM: Fracture of the femoral shaft with fracture of neck of same femur, J Int Coll Surg 19:303, 1953. DeLee JC: Ipsilateral fracture of the femur and tibia treated in a quadrilateral cast brace, Clin Orthop Relat Res 142:115, 1979. Dencker H: Shaft fractures of the femur: a comparative study of the results of various methods of treatment in 1003 cases, Acta Chir Scand 130:173, 1965. Dencker H: Technical problems of medullary nailing: a study of 435 nailed shaft fractures of the femur, Acta Chir Scand 130:185, 1965. Dennis MG, Simon JA, Kummer FJ, et al.: Fixation of periprosthetic femoral shaft fractures: a biomechanical comparison of two techniques, J Orthop Trauma 15:177, 2001. DiCicco III JD, Jenkins M, Ostrum RF: Retrograde nailing for subtrochanteric femur fractures, Am J Orthop 29(Suppl 9):4, 2000. Dominguez I, Moro-Rodriguez E, De Pedro Moro JA, et al.: Antegrade nailing for fractures of the distal femur, Clin Orthop Relat Res 350:74, 1998. Duwelius PJ, Huckfeldt R, Mullins RJ, et al.: The effects of femoral intramedullary reaming on pulmonary function in a sheep lung model, J Bone Joint Surg 79A:194, 1997. Eiskjaer S, Schmidt SA, Søjbjerg JO, et al.: Alternatives in the treatment of ipsilateral fractures of the hip and femur, Orthopedics 12:397, 1989. Elliott RB: Fractures of the femoral condyles: experiences with a new design femoral condyle blade plate, South Med J 52:80, 1959.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Ender HG: Treatment of peritrochanteric and subtrochanteric fractures of the femur with Ender pins. In The hip, St. Louis, 1978, Mosby. Eriksson E, Lovelius L: Ender nailing in fractures of the diaphysis of the femur, J Bone Joint Surg 61A:1175, 1979. Eriksson E, Wallin C: Immediate or delayed Küntscher-rodding of femoral shaft fractures, Orthopedics 9:201, 1986. Esser MP, Cloke JH, Hart JAL: Closed Küntscher nailing: a critical review after 20 years, Injury 13:455, 1982. Farrar MJ, Binns MS: Percutaneous reduction for closed nailing of femoral shaft fractures, J R Coll Surg Edinb 41:267, 1996. Fielding JW, Cochran GV, Zickel RE: Biochemical characteristics and surgical management of subtrochanteric fractures, Orthop Clin North Am 5:629, 1974. Fielding JW, Magliato HJ: Subtrochanteric fractures, Surg Gynecol Obstet 122:555, 1966. Firoozbakhsh K, Behzadi K, DeCoster TA, et  al.: Mechanics of retrograde nail versus plate fixation for supracondylar femur fractures, J Orthop Trauma 9:152, 1995. Frankle M, Cordey J, Sanders RW, et al.: A biomechanical comparison of the antegrade-inserted universal femoral nail with the retrograde-inserted universal tibial nail for use in femoral shaft fractures, Injury 30(Suppl 1):40, 1999. Frederick D, Seligson D: Developments in locked femoral nailing, Orthopedics 13:1141, 1990. Froimson AI: Treatment of comminuted subtrochanteric fractures of the femur, Surg Gynecol Obstet 131:465, 1980. Gallagher JC, Melton LJ, Riggs BL: Examination of prevalence rates of possible risk factors in a population with a fracture of the proximal femur, Clin Orthop Relat Res 153:158, 1980. Gallagher JC, Melton LJ, Riggs BL, et al.: Epidemiology of fractures of the proximal femur in Rochester, Minn, Clin Orthop Relat Res 150:163, 1980. Geist RW, Laros GS: Femoral shaft fractures: editorial comment and comparative results, Clin Orthop Relat Res 138:5, 1979. Gellman RE, Paiment GD, Green HD, et  al.: Treatment of supracondylar femoral fractures with a retrograde intramedullary nail, Clin Orthop Relat Res 332:90, 1996. Giachino AA, Cheng M: Irradiation of the surgeon during pinning of femoral fractures, J Bone Joint Surg 62B:227, 1980. Giles JB, DeLee JC, Heckman JD, et  al.: Supracondylar-intercondylar fractures of the femur treated with a supracondylar plate and lag screw, J Bone Joint Surg 64A:864, 1982. Gill SS, Nagi ON, Dhillon MS: Ipsilateral fractures of femoral neck and shaft, J Orthop Trauma 4:293, 1990. Grana WA, Gruel J, Wedro B, et al.: Complications of ipsilateral femur and tibia fractures, Orthopedics 7:825, 1984. Green A, Trafton PG: Early complications in the management of open femur fractures: a retrospective study, J Orthop Trauma 5:51, 1991. Gregory P, DiCiccio J, Karpik K, et al.: Ipsilateral fractures of the femur and tibia: treatment with retrograde femoral nailing and unreamed tibial nailing, J Orthop Trauma 10:309, 1996. Gregory P, Sanders R: The treatment of supracondylar-intracondylar fractures of the femur using the dynamic condylar screw, Tech Orthop 9:195, 1995. Grosse A: Manual for osteosynthesis for femoral and tibial shaft fractures, Kiel, Germany, 1981, Howmedica International. Grosse A, Kempf I, Lafforgued D: Le traitement des fracas, pertes de substance osseuse et pseudoarthroses du fémur et du tibia par l’enclouage verrouillé (a propos de 40 case), Rev Chir Orthop 64(Suppl 2):33, 1978. Grover J, Wiss DA: A prospective study of fractures of the femoral shaft treated with a static, intramedullary, interlocking nail comparing one versus two distal screws, Orthop Clin North Am 26:139, 1995. Grundy M: Fractures of the femur in Paget’s disease of bone: their etiology and treatment, J Bone Joint Surg 52B:252, 1970. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones, J Bone Joint Surg 58A:453, 1976. Gynning JB, Hansen D: Treatment of distal femoral fractures with intramedullary supracondylar nails in elderly patients, Injury 30:43, 1999.

Hall RM: Freehand technique, Smith & Nephew technique manual for RussellTaylor Nail System, Memphis, TN, 1997, Smith & Nephew. Halpenny J, Rorabeck CH: Supracondylar fractures of the femur: results of treatment of 61 patients, Can J Surg 27:606, 1984. Hammacher ER, van Meeteren MC, van der Werken C: Improved results in treatment of femoral shaft fractures with the unreamed femoral nail? A multicenter experience, J Trauma 45:517, 1998. Hanks GA, Foster WC, Cardea JA: Treatment of femoral shaft fractures with the Brooker-Wills interlocking intramedullary nail, Clin Orthop Relat Res 226:206, 1988. Hansen ST, Winquist RA: Closed intramedullary nailing of fractures of the femoral shaft, part II: technical considerations, Instr Course Lect 27:90, 1978. Hansen ST, Winquist RA: Closed intramedullary nailing of the femur: Küntscher technique with reaming, Clin Orthop Relat Res 138:56, 1979. Hansson LI, Cedar L, Svensson K, et al.: Incidence of fractures of the distal radius and proximal femur: comparison of patients in a mental hospital and the general population, Acta Orthop Scand 53:721, 1982. Harder Y, Martinet O, Barraud GE, et al.: The mechanics of internal fixation of fractures of the distal femur: a comparison of the condylar screw (CS) with the condylar plate (CP), Injury 30:A31, 1999. Hardy AE: The treatment of femoral fractures by cast-brace application and early ambulation, J Bone Joint Surg 65A:56, 1983. Harris LJ: Condylocephalic nailing of proximal femoral fractures, Instr Course Lect 32:292, 1983. Harryman II DT, Kurth LA, Davis CM: Ipsilateral femoral neck and shaft fractures: report of two cases using an alternate technique, Clin Orthop Relat Res 213:183, 1986. Healy WL, Brooker Jr AF: Distal femoral fractures: comparison of open and closed methods of treatment, Clin Orthop Relat Res 174:166, 1983. Helal B, Skevis X: Unrecognized dislocation of the hip in fractures of the femoral shaft, J Bone Joint Surg 49B:293, 1967. Hemple D: Interlocking nail osteosynthesis. In Hemple D, editor: Intramedullary nailing, New York, 1982, Thieme, Stratton. Henry SL, Booth Jr RE: Management of supracondylar fractures above total knee prostheses, Tech Orthop 9:243, 1994. Henry SL, Seligson D: Management of supracondylar fractures of the femur with the GHS supracondylar nail: the percutaneous technique, Tech Orthop 9:189, 1995. Herscovici D, Whiteman KW: Retrograde nailing of the femur using an intercondylar approach, Clin Orthop Relat Res 332:98, 1996. Hershman EB, Lombardo J, Bergfeld JA: Femoral shaft stress fractures in athletes, Clin Sports Med 9:111, 1990. Hossam E, Morsey A, Eid E: Ipsilateral fracture of the femoral neck and shaft, treated by reconstruction interlocking nail, Arch Orthop Trauma Surg 121:71, 2001. Hutson Jr JJ: Reconstruction of distal intercondylar femoral fractures with limited internal fixation and Ilizarov tensioned-wire external fixation, Tech Orthop 11:182, 1996. Hutson Jr JJ, Zych GA: Treatment of comminuted intraarticular distal femur fractures with limited internal and external tensioned wire fixation, J Orthop Trauma 14:405, 2000. Iannacone WM, Bennett FS, DeLong Jr WG, et al.: Initial experience with treatment of supracondylar femoral fractures using the supracondylar intramedullary nail: a preliminary report, J Orthop Trauma 8:322, 1994. Ingram AJ, Turner TC: Bilateral traumatic posterior dislocation of the hip complicated by bilateral fracture of the femoral shaft: report of a case, J Bone Joint Surg 36A:1249, 1954. Ito K: Grass R, Zwipp H: Internal fixation of supracondylar femoral fractures: comparative biomechanical performance of the 95-degree blade plate and two retrograde nails, J Orthop Trauma 12:259, 1998. Jaarsma RL, Pakvis DFM, Verdonschot N, et  al.: Rotational malalignment after intramedullary nailing of femoral fractures, J Orthop Trauma 18:403, 2004. Jakobsen J, Christensen KS, Rasmussen OS: Patellectomy—a 20-year followup, Acta Orthop Scand 56:430, 1985. Janzing HM, Vaes F, Van Damme G, et al.: Treatment of distal femoral fractures in the elderly: results with the retrograde intramedullary supracondylar nail, Unfallchir 24:55, 1998.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Jazrawi LM, Kummer FJ, Simon JA, et al.: New technique for treatment of unstable distal femur fractures by locked double-plating: case report and biomechanical evaluation, J Trauma 48:87, 2000. Johnson KD, Johnston DWC, Parker B: Comminuted femoral-shaft fractures: treatment by roller traction, cerclage wires and an intramedullary nail, or an interlocking intramedullary nail, J Bone Joint Surg 66A:1222, 1984. Kääb MJ, Frenk A, Schmeling A, et al.: Locked internal fixator: sensitivity of screw/plate stability to the correct insertion angle of the screw, J Orthop Trauma 18:483, 2004. Kao JT, Burton D, Cornstock C, et al.: Pudendal nerve palsy after femoral intramedullary nailing, J Orthop Trauma 7:58, 1993. Karlström G, Olerud S: Ipsilateral fracture of the femur and tibia, J Bone Joint Surg 59A:240, 1977. Karpos PAG, McFerran MA, Johnson KD: Intramedullary nailing of acute femoral shaft fractures using manual traction without a fracture table, Orthop Trauma 9:57, 1995. Kellam JF: Early results of the Sunnybrook experience with locked intramedullary nailing, Orthopedics 8:1387, 1985. Kempf I, Grosse A, Lafforgued L: L’enclouage avec blocage de la rotation on “clou blogue” principles, technique, indications et premiers resultants, Sofcot, 1976, Communication à la journée d’hiver. Ker MB, Maempel FZ, Paton DF: Bone cement as an adjunct to medullary nailing in fractures of the distal third of the femur in elderly patients, Injury 16:102, 1984. Khan FA, Ikram MS, Badr AA, al-Khawashki H: Femoral neck fracture: a complication of femoral nailing, Injury 26:319, 1995. Kimbrough EE: Concomitant unilateral hip and femoral-shaft fractures—a too frequently unrecognized syndrome: report of five cases, J Bone Joint Surg 43A:443, 1961. King KF, Rush J: Closed intramedullary nailing of femoral shaft fractures: a review of one hundred and twelve cases treated by the Küntscher technique, J Bone Joint Surg 63A:1319, 1981. Klemm K, Schellmann WD: [Dynamic and static locking of the intramedullary nail], Monatsschr Unfallheilkd Versicher Versorg Verkehrsmed 75:568, 1972, In German. Kohlhaas AR, Howard R: Radiation protection during interlocking Küntscher nailing, Orthop Rev 11:83, 1982. Koldenhoven GA, Burke JS, Pierron R: Ipsilateral femoral neck and shaft fractures, South Med J 90:288, 1997. Kolmert L, Persson BM, Romanus B: An experimental study of device for internal fixation of distal femoral fractures, Clin Orthop Relat Res 171:290, 1982. Koval KJ, Kummar FJ, Bharan S, et al.: Distal femoral fixation: a laboratory comparison of the 95 degrees plate, antegrade and retrograde inserted reamed intramedullary nail, J Orthop Trauma 10:378, 1996. Krettek C, Rudolf J, Schandelmaier P, et al.: Unreamed intramedullary nailing of femoral shaft fractures: operative technique and early clinical experience with the standard locking option, Injury 27:233, 1996. Kröpfl A, Berger U, Neureiter H, et  al.: Intramedullary pressure and bone marrow fat intravasation in unreamed femoral nailing, J Trauma 42:946, 1997. Kröpfl A, Naglik H, Primavesi C, et al.: Unreamed intramedullary nailing of femoral fractures, J Trauma 38:717, 1995. Krupp RJ, Malkani AL, Goodin RA, et al.: Optimal entry point for retrograde femoral nailing, J Orthop Trauma 17:100, 2003. Kumar A, Jasani V, Butt MS: Management of distal femoral fractures in elderly patients using retrograde titanium supracondylar nails, Injury 31:169, 2000. Küntscher G: Die Marknagelung von Knochenbrüchen: Tierexperimenteller Teil, Klin Wochenschr 19:6, 1940. Küntscher G: The Küntscher method of intramedullary fixation, J Bone Joint Surg 40A:17, 1958. Küntscher G: Intramedullary surgical technique and its place in orthopaedic surgery: my present concept, J Bone Joint Surg 47A:809, 1965. Lam SJ: The place of delayed internal fixation in the treatment of fractures of the long bones, J Bone Joint Surg 46B:393, 1964.

Lanfranco G, Alberton G, Gnemmi G, et al.: The use of the computer in a long-term review of 315 fractures of the proximal end of the femur, Ital J Orthop Traumatol 16:103, 1990. Laros GS: Supracondylar fractures of the femur: editorial comment and comparative results, Clin Orthop Relat Res 138:9, 1979. Laros GS, Spiegel PG: Rigid internal fixation of fractures [editorial], Clin Orthop Relat Res 138:2, 1979. Leggon RE, Feldman DD: Retrograde femoral nailing: a focus on the knee, Am J Knee Surg 14:109, 2001. Leung KS, Shen WY, So WS, et al.: Interlocking intramedullary nailing for supracondylar and intercondylar fractures of the distal part of the femur, J Bone Joint Surg 73A:332, 1991. Leung PC, Mak KH, Lee SY: Percutaneous tension band wiring: a new method of internal fixation for mildly displaced patella fracture, J Trauma 23:62, 1983. Lewert AH, Modny MT: Transfixion rod in condylar and intercondylar fractures of femur, Orthop Rev 16:310, 1987. Lhowe DW, Hansen Jr ST: Immediate nailing of open fractures of the femoral shaft, J Bone Joint Surg 70A:812, 1988. Lindsey RW, Blair SR: Closed tibial shaft fractures: which ones benefit from surgical treatment? J Am Assoc Orthop Surg 4:35, 1996. Locking Condylar Plate: technique guide, Paoli, PA, 2001, Synthes. Lotke PA, Ecker ML: Transverse fractures of the patella, Clin Orthop Relat Res 158:180, 1981. Lottes JO, Key JA: Complications and errors in technic in medullary nailing for fractures of the femur, Clin Orthop Relat Res 2:38, 1953. Lund B, Sørensen OH, Lund B, et al.: Vitamin D metabolism and osteomalacia in patients with fractures of the proximal femur, Acta Orthop Scand 53:251, 1982. MacAusland Jr WR, Eaton RG: The management of sepsis following intramedullary fixation for fractures of the femur, J Bone Joint Surg 45A:1643, 1963. MacNamee PB, Bunker TD, Scott TD: The Herbert screw for osteochondral fractures: brief report, J Bone Joint Surg 70B:145, 1988. Maffulli N, Yip KM, Cowman JE, et al.: Ender nailing for ipsilateral femoral shaft fractures after Austin-Moore hemiarthroplasty, J Trauma 42:20, 1997. Magerl F, Wyss A, Brunner C, et  al.: Plate osteosynthesis of femoral shaft fractures in adults: a follow-up study, Clin Orthop Relat Res 138:62, 1979. Malkani AL, Helfet DL: Blade-plate fixation of supracondylar femur fractures, Tech Orthop 9:203, 1995. Mariani EM, Rand JA: Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation: results of second attempt to gain union, Clin Orthop Relat Res 218:81, 1987. Markmiller M, Konrad G, Südkamp N: Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications, Clin Orthop Relat Res 426:252, 2004. Marsh JL, Smith ST, Do TT: External fixation and limited internal fixation for complex fractures of the tibial plateau, J Bone Joint Surg 77A:661, 1995. Marti A, Fankhauser C, Frenk A, et al.: Biomechanical evaluation of the less invasive stabilization system for the internal fixation of distal femur fractures, J Orthop Trauma 15:482, 2001. Martinet O, Cordey J, Harder Y, et al.: The epidemiology of fractures of the distal femur, Injury 31:C62, 2000. McClelland SJ, Bauman PA, Medley Jr CF, et al.: Obturator hip dislocation with ipsilateral fractures of the femoral head and femoral neck: a case report, Clin Orthop Relat Res 224:164, 1987. McFerran MA, Johnson KD: Intramedullary nailing of acute femoral shaft fractures without a fracture table: technique of using a femoral distractor, J Orthop Trauma 6:271, 1992. McMaster WC, Prietto C, Rovner R: Closed treatment of femoral fractures with the fluted Sampson intramedullary rod, Orthop Clin North Am 11:593, 1980. Meggitt BF, Juett DA, Smith JD: Cast-bracing for fractures of the femoral shaft: a biomechanical and clinical study, J Bone Joint Surg 63B:12, 1981. Mela G, Melis GC, Tolu S, et al.: The surgical treatment of supra-intercondylar fractures of the femur, Ital J Orthop Traumatol 15:445, 1989.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Merchan ECR, Maestu PR, Blanco RP: Blade-plating of closed displaced supracondylar fractures of the distal femur with the AO system, J Trauma 32:174, 1992. Mize RD: Surgical management of complex fractures of the distal femur, Clin Orthop Relat Res 249:77, 1989. Mize RD, Bucholz RW, Grogan DP: Surgical treatment of displaced, comminuted fractures of the distal end of the femur: an extensile approach, J Bone Joint Surg 64A:871, 1982. Moed BR, Watson JT: Retrograde intramedullary nailing without reaming of fractures of the femoral shaft in multiply injured patients, J Bone Joint Surg 77A:1520, 1995. Moehring HD: Flexible intramedullary fixation of femoral fractures, Clin Orthop Relat Res 227:190, 1988. Mohr VD, Eickhoff U, Haaker R, et  al.: External fixation of open femoral shaft fractures, J Trauma 38:648, 1995. Mollica Q, Gangitano R, Longo G: Elastic intramedullary nailing in shaft fractures of the femur and tibia, Orthopedics 9:1065, 1986. Montgomery SP, Mooney V: Femur fractures: treatment with roller traction and early ambulation, Clin Orthop Relat Res 156:196, 1981. Mooney V, Nickel VL, Harvey Jr JP, et al.: Cast-brace treatment for fractures of the distal part of the femur: a prospective controlled study of one hundred and fifty patients, J Bone Joint Surg 52A:1563, 1970. Moore TJ, Watson T, Green SA, et  al.: Complications of surgically treated supracondylar fractures of the femur, J Trauma 27:402, 1987. Morshed S, Miclau 3rd T, Bembom O, et  al.: Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma, J Bone Joint Surg 91A:3, 2009. Muller KH, Strosche H, Scheuer I: Plate osteosynthesis in posttraumatic deformities of the femoral shaft, Arch Orthop Trauma Surg 103:303, 1984. Murti GS, Ring PA: Closed medullary nailing of fractures of the femoral shaft using the AO method, Injury 14:318, 1983. Nasr AM, McLeod I, Sabboubeh A, et al.: Conservative or surgical management of distal femoral fractures: a retrospective study with a minimum 5-year follow-up, Acta Orthop Belg 66:477, 2000. Neer II CS, Grantham SA, Shelton ML: Supracondylar fracture of the adult femur: a study of one hundred and ten cases, J Bone Joint Surg 49A:591, 1967. Nicoll EA: Fractures of the tibial shaft: a survey of 705 cases, J Bone Joint Surg 46B:373, 1964. Norbeck Jr DE, Asselmeier M, Pinzur MS: Torsional malunion of a femur fracture: diagnosis and treatment, Orthop Rev 19:625, 1990. Norris BL, Patton WC, Rudd Jr JN, et al.: Pulmonary dysfunction in patients with femoral shaft fracture treated with intramedullary nailing, J Bone Joint Surg 83A:1162, 2001. Noumi T, Yokoyama K, Ohtsuka H, et al.: Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis, Injury Int J Care Injured 36:1085, 2005. Nowotarski PJ, Turen CH, Brumback RJ, et al.: Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients, J Bone Joint Surg 82A:781, 2000. O’Beirne J, O’Connell RJ, White JM, et  al.: Fractures of the femur treated by femoral plating using the anterolateral approach, Injury 17:387, 1986. O’Brien PJ, Meek RN, Powell JN, et  al.: Primary intramedullary nailing of open femoral shaft fractures, J Trauma 31:113, 1991. Olerud S: Operative treatment of supracondylar-condylar fractures of the femur: technique and results in fifteen cases, J Bone Joint Surg 54A:1015, 1972. Omer Jr GE, Moll JH, Bacon WL: Combined fractures of the femur and tibia in a single extremity: analytical study of cases at Brooke General Hospital from 1961 to 1967, J Trauma 8:1026, 1968. Ostermann PAW, Neumann K, Ekkenkamp A, et al.: Results of unicondylar fractures of the femur, J Orthop Trauma 8:142, 1994. Ostrum RF, Agarwal A, Lakatos R, et al.: Prospective comparison of retrograde and antegrade femoral intramedullary nailing, J Orthop Trauma 14:496, 2000.

Ostrum RF, Geel C: Indirect reduction and internal fixation of supracondylar femur fractures without bone graft, J Orthop Trauma 9:278, 1995. Pankovich AM: Adjunctive fixation in flexible intramedullary nailing of femoral fractures: a study of twenty-six cases, Clin Orthop Relat Res 157:301, 1981. Pankovich AM, Goldflies ML, Pearson RL: Closed Ender nailing of femoralshaft fractures, J Bone Joint Surg 61A:222, 1979. Papagiannopoulos G, Clement DA: Treatment of fractures of the distal third of the femur: a prospective trial of the Derby intramedullary nail, J Bone Joint Surg 69B:67, 1987. Papadokostakis G, Papakostidis C, Dimitriou R, et al.: The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature, Injury Int J Care Injured 36:813, 2005. Pape HC, Dwenger A, Regel G, et al.: Pulmonary damage after intramedullary femoral nailing in traumatized sheep—is there an effect from different nailing methods? J Trauma 33:574, 1992. Pape HC, Hildebrand F, Pertschy S, et  al.: Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery, J Trauma 53:452, 2002. Pape HC, Regel G, Dwenger A, et al.: Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma, J Trauma 35:709, 1993. Pape HC, Rixen K, Morely J, et al.: Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients), Ann Surg 246:491, 2007, discussion 499–501. Ricci WM, Loftus T, Cox C, et al.: Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty, J Orthop Trauma 20:190, 2006. Ricci WM, Schwappach J, Tucker M, et  al.: Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures, J Orthop Trauma 20:663, 2006. The Canadian Orthopedic Trauma Society: Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients, J Orthop Trauma 20:384, 2006. Parrish TF, Jones JR: Fracture of the femur following prosthetic arthroplasty of the hip: report of nine cases, J Bone Joint Surg 46A:241, 1964. Patterson BM, Benirschke SK, Mayo KA, et  al.: Comminuted, intraarticular fractures of the distal femur: a study of outcome [abstract], J Orthop Trauma 7:170, 1993. Pearlman HS, Patel M, Sclafani SJ, et al.: Fractures of the femoral shaft: treatment with solitary plate compression, Orthop Rev 10:109, 1981. Peljovich AE, Patterson BM: Ipsilateral femoral neck and shaft fractures, J Am Acad Orthop Surg 6:106, 1998. Pollack AN, Battistella F, Pettey J, et al.: Reamed femoral nailing in patients with multiple injuries: adverse effects of tourniquet use, Clin Orthop Relat Res 339:41, 1997. Pratt DJ, Papagiannopoulos G, Rees PH, et al.: The effects of the medullary reaming on the torsional strength of the femur, Injury 18:177, 1987. Pritchett JW: Supracondylar fractures of the femur, Clin Orthop Relat Res 184:173, 1984. Pryor GA, Doran A: Fractures of the distal femur: the role of the Zickle supracondylar fixation device, Injury 19:410, 1988. Randelli P, Landi S, Fanton F, et al.: Treatment of ipsilateral femoral neck and shaft fractures with the Russell-Taylor reconstructive nail, Orthopedics 22:673, 1999. Rascher JJ, Nahigian SH, Macys JR, et  al.: Closed nailing of femoral-shaft fractures, J Bone Joint Surg 54A:534, 1972. Reynders P, Broos P: Unreamed intramedullary nailing of acute femoral shaft fractures using a traction device without fracture table, Acta Orthop Belg 64:175, 1998. Rhinelander FW, Nelson CL: The vascular and histologic response of diaphyseal cortex to experimental medullary nailing and reaming, J Bone Joint Surg 55A:1767, 1973.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Ricci WM, Bellabarba C, Evanoff B, et al.: Retrograde versus antegrade nailing of femoral shaft fractures, J Orthop Trauma 15:161, 2001. Ricci WM, Bellabara C, Lewis R, et al.: Angular malalignment after intramedullary nailing of femoral shaft fractures, J Orthop Trauma 15:90, 2001. Ricci WM, Devinney S, Haidukewych G, et al.: Trochanteric nail insertion for the treatment of femoral shaft fractures, J Orthop Trauma 19:511, 2005. Richards RR, Waddell JP, Sullivan TR, et al.: Infra-isthmal fractures of the femur: a review of 82 cases, J Trauma 24:735, 1984. Riemer BL, Foglesong ME, Miranda MA: Femoral plating, Orthop Clin North Am 25:625, 1994. Riggins RS, Garrick JG, Lipscomb PR: Supracondylar fractures of the femur: a survey of treatment, Clin Orthop Relat Res 82:32, 1972. Rinaldi E, Marenghi P: Plate and screw fixation by autogenous corticocancellous grafts in comminuted fractures of the femur, Ital J Orthop Traumatol 10:349, 1984. Rosenberg NJ: Osteochondral fractures of the lateral femoral condyle, J Bone Joint Surg 46A:1013, 1964. Rüedi TP, Lüscher JN: Results after internal fixation of comminuted fractures of the femoral shaft with DC plates, Clin Orthop Relat Res 138:74, 1979. Russell GV, Kregor PJ, Jarrett CA, Zlowodzki M: Complicated femoral shaft fractures, Orthop Clin North Am 33:127, 2002. Russell Jr GV, Smith DG: Minimally invasive treatment of distal femur fractures: report of a technique, J Trauma 47:799, 1999. Sage FP: The second decade of experience with the Küntscher medullary nail in the femur, Clin Orthop Relat Res 60:77, 1968. Salminen ST, Philajamaki HK, Avikainen VJ, et al.: Population based epidemiologic and morphologic study of femoral shaft fractures, Clin Orthop Relat Res 372:241, 2000. Sanders R, Koval KJ, DiPasquale T, et al.: Retrograde reamed femoral nailing, J Orthop Trauma 7:293, 1993. Sanders R, Regazzoni P, Rüedi TP: Treatment of supracondylar-intracondylar fractures of the femur using the dynamic condylar screw, J Orthop Trauma 3:214, 1989. Sarmiento A: Functional bracing of tibial and femoral shaft fractures, Clin Orthop Relat Res 81:2, 1972. Sarmiento A: Unstable intertrochanteric fractures of the femur, Clin Orthop Relat Res 92:77, 1973. Schandelmaier P, Krettek C, Rudolf J, et al.: Outcome of tibial shaft fractures with severe soft tissue injury treated by unreamed nailing versus external fixation, J Trauma 39:707, 1995. Schatzker J: Open intramedullary nailing of the femur, Orthop Clin North Am 11:623, 1980. Schatzker J, Home G, Waddell J: The Toronto experience with the supracondylar fracture of the femur, Injury 6(113):1974, 1966-72. Schatzker J, Lambert DC: Supracondylar fractures of the femur, Clin Orthop Relat Res 138:77, 1979. Schatzker J, Mahomed N, Schiffman K, et  al.: Dynamic condylar screw: a new device: a preliminary report, J Orthop Trauma 3:124, 1989. Schauwecker F: The practice of osteosynthesis, Stuttgart, 1974, Georg Thieme Verlag. Schemitsch EH, Jain R, Turchin DC, et al.: Pulmonary effects of fixation of a fracture with a plate compared with intramedullary nailing: a canine model of fat embolism and fracture fixation, J Bone Joint Surg 79A:984, 1997. Schmidt AH, Kyle RF: Periprosthetic fractures of the femur, Orthop Clin North Am 33:143, 2002. Schneider M: Intramedullary nailing of long-bone fractures—current concepts, part III: closed intramedullary nailing of shaft fractures using Küntscher’s method, Instr Course Lect 22:188, 1973. Scott RD, Turner RH, Leitzes SM, et  al.: Femoral fractures in conjunction with total hip replacement, J Bone Joint Surg 57A:494, 1975. Scudese VA: Femoral shaft fractures: percutaneous multiple pin fixation, thigh cylinder plaster cast and early weight-bearing, Clin Orthop Relat Res 77:164, 1971. Seinsheimer F: Subtrochanteric fractures of the femur, J Bone Joint Surg 60A:300, 1978.

Seinsheimer III F: Fractures of the distal femur, Clin Orthop Relat Res 153:169, 1980. Seligson D, Henry SL, Green SA: Intramedullary supracondylar nail: technique manual, Memphis, TN, Smith & Nephew. Seligson D, Mulier T, Keirsbilck S, et al.: Plating of femoral shaft fractures: a review of 15 cases, Acta Orthop Belg 67:24, 2001. Shelbourne KD, Brueckmann FR: Rush-pin fixation of supracondylar and intercondylar fractures of the femur, J Bone Joint Surg 64A:161, 1982. Shelton ML, Grantham SA, Neer II CS, et al.: A new fixation device for supracondylar and low femoral shaft fractures, J Trauma 14:821, 1974. Shelton ML, Neer II CS, Grantham SA: Occult knee ligament ruptures associated with fractures, J Trauma 11:853, 1971. Siliski JM, Mahring M, Hofer HP: Supracondylar-intercondylar fractures of the femur, J Bone Joint Surg 71A:95, 1989. Sims SH: Subtrochanteric femoral fractures, Orthop Clin North Am 33:113, 2002. Sirkin MS, Behrens F, McCracken K, et al.: Femoral nailing without a fracture table, Clin Orthop Relat Res 332:119, 1996. Slatis P, Ryöppy S, Huittinen V: AO osteosynthesis of fractures of the distal third of the femur, Acta Orthop Scand 42:162, 1971. Smith H: Introduction (medullary fixation of the femur symposium), Instr Course Lect 8:1, 1951. Smith H: Medullary fixation of the femur, Radiology 61:194, 1953. Soto-Hall R, McCloy NP: Cause and treatment of angulation of femoral intramedullary nails, Clin Orthop 2:66, 1953. Spray P: Treatment of fractures of the femoral shaft with Rush pins, Contemp Orthop 6:39, 1983. Sprenger TR: Fractures of the shaft of the femur treated with a single AO plate, South Med J 76:471, 1983. Starr AJ, Jones AL, Reinert CM: The “swashbuckler”: a modified approach for fractures of the distal femur, J Orthop Trauma 13:138, 1999. Stewart MJ, Sisk TD, Wallace SL: Fractures of the distal third of the femur: a comparison of methods of treatment, J Bone Joint Surg 48A:784, 1966. Stewart MJ, Wallace SL: Fracture of the distal third of the femur, J Bone Joint Surg 40A:235, 1958. Street D: One hundred fractures of the femur treated by means of the diamond-shaped medullary nail, J Bone Joint Surg 33A:659, 1951. Swiontkowski MF: Ipsilateral femoral shaft and hip fractures, Orthop Clin North Am 18:73, 1987. Taylor JC: Treatment of distal femoral fractures with the Russell-Taylor nail, Tech Orthop 9:225, 1994. Thomas TL, Meggitt BF: A comparative study of methods for treating fractures of the distal half of the femur, J Bone Joint Surg 63B, 1981, 3. Thompson F, O’Beirne J, Gallagher J, et  al.: Fractures of the femoral shaft treated by plating, Injury 16:535, 1985. Thorensen BO, Alho A, Ekel A, et  al.: Interlocking intramedullary nailing in femoral shaft fractures: a report of forty-eight cases, J Bone Joint Surg 67A:1313, 1985. Titanium Elastic Nail System: technique guide, Paoli, PA, 1998, Synthes. Toolan BC, Koval KJ, Kummer FJ, et al.: Effects of supine positioning and fracture post placement on the perineal countertraction force in awake volunteers, J Orthop Trauma 9:164, 1995. Tornetta III P, Tiburzi D: Anterograde interlocked nailing of distal femoral fractures after gunshot wounds, J Orthop Trauma 8:220, 1994. Tornetta III P, Tiburzi D: The treatment of femoral shaft fractures using intramedullary interlocked nails with and without intramedullary reaming: a preliminary report, J Orthop Trauma 11:89, 1997. van der Made WJ, Smit EJ, van Luyt PA, et al.: Intramedullary femoral osteosynthesis: an additional cause of ARDS in multiply injured patients? Injury 27:391, 1996. Veith RG, Hansen Jr ST: Closed intramedullary nailing of femoral-shaft fractures following reaming: technique and rationale, Contemp Orthop 4:41, 1982. Veith RG, Winquist RA, Hansen Jr ST: Ipsilateral fractures of the femur and tibia: a report of fifty-seven consecutive cases, J Bone Joint Surg 66A:991, 1984.

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CHAPTER 54  FRACTURES OF THE LOWER EXTREMITY Waldrop JI, Macey TI, Trettin JC, et al.: Fractures of the posterolateral tibial plateau, Am J Sports Med 16:492, 1988. Walling AK, Seradge H, Spiegel PG: Injuries to the knee ligaments with fractures of the femur, J Bone Joint Surg 64A:1324, 1982. Wardlaw D, McLauchlan J, Pratt DJ, et al.: A biomechanical study of castbrace treatment of femoral shaft fractures, J Bone Joint Surg 63B, 1981, 7. Watson HK, Campbell Jr RD, Wade PA: Classification, treatment, and complications of the adult subtrochanteric fracture, J Trauma 4:457, 1964. Wenda K, Runkel M, Degreif J, et al.: Pathogenesis and clinical relevance of bone marrow embolism in medullary nailing demonstrated by intraoperative echocardiography, Injury 24:73, 1993. White GM, Healy WL, Brumbeck RJ, et al.: The treatment of fractures of the femoral shaft with the Brooker-Willis distal locking intramedullary nail, J Bone Joint Surg 68A:865, 1986. Whittaker RP, Heppenstall B, Menkowitz E, et al.: Comparison of open vs closed rodding femurs utilizing a Sampson rod, J Trauma 22:461, 1982. Whittle APW, Russell TA, Taylor JC, et al.: Treatment of supracondylar and intercondylar fractures of the femur with antegrade interlocking intramedullary nails [abstract], Orthop Trans 18:10323, 1994/1995. Wickstrom J, Corban MS: Intramedullary fixation for fractures of the femoral shaft: a study of complications in 298 operations, J Trauma 7:551, 1967. Wieck JA, Russell TA, Taylor JC, et  al.: Results of treatment of 100 femoral fractures with the 10 and 11 millimeter Russell-Taylor delta femoral intramedullary nails, Nashville, 1990, Paper presented at the Tennessee Orthopaedic Society. Williams MM, Askins V, Hinkes EW, et al.: Primary reamed intramedullary nailing of open femoral shaft fractures, Clin Orthop Relat Res 318:182, 1995. Winquist RA, Hansen Jr ST: Comminuted fractures of the femoral shaft treated by intramedullary nailing, Orthop Clin North Am 11:633, 1980. Winters C, Dabezies EJ: Supracondylar fractures of the femur, Orthopedics 7:1051, 1984. Wiss DA, Brien WW, Stetson WB: Interlocked nailing for treatment of segmental fractures of the femur, J Bone Joint Surg 72A:724, 1990. Wiss DA, Fleming CA, Matta JM, et al.: Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail, Clin Orthop Relat Res 212:35, 1986.

Wood EG, Savoie FH, Vander Griend RA: Treatment of ipsilateral fractures of the distal femur and femoral shaft, J Orthop Trauma 111:232, 1992. Yang KH, Han DY, Park HW, et al.: Fracture of the ipsilateral neck of the femur in shaft nailing: the role of CT in diagnosis, J Bone Joint Surg 80:673, 1998. Yang R, Liu H, Lui T: Supracondylar fractures of the femur, J Trauma 30:315, 1990. Zehntner MK, Marchesi DG, Burch H, et al.: Alignment of supracondylar/ intercondylar fractures of the femur after internal fixation by AO/ASIF technique, J Orthop Trauma 6:318, 1992. Zettas JP, Zettas P: Ipsilateral fractures of the femoral neck and shaft, Clin Orthop Relat Res 160:63, 1981. Zickel RE: A new fixation device for subtrochanteric fractures of the femur: a preliminary report, Clin Orthop Relat Res 54:115, 1967. Zickel RE: An intramedullary fixation device for the proximal part of the femur: nine year’s experience, J Bone Joint Surg 58A:866, 1976. Zickel RE: Fractures of the adult femur excluding the femoral head and neck: a review and evaluation of current therapy, Clin Orthop Relat Res 147:93, 1980. Zickel RE: Zickel supracondylar nail, Tech Orthop 9:217, 1994. Zickel RE, Bercik MJ, Licciardi LM: A continuing study on the use of the Zickel intramedullary appliance in fractures and lesions of the proximal femur. The hip, St. Louis, 1978, Mosby. Zickel RE, Hobeika P, Robbins DS: Zickel supracondylar nails for fractures of the distal end of the femur, Clin Orthop Relat Res 212:77, 1986. Zickel RE, Mouradian WH: Intramedullary fixation of pathological fractures and lesions of the subtrochanteric region of the femur, J Bone Joint Surg 58A:1061, 1976. Zimmerman AJ: Intraarticular fractures of the distal femur, Orthop Clin North Am 10:75, 1979. Zlowodzki M, Williamson S, Cole P, et  al.: Biomechanical evaluation of the less invasive stabilization system, angled blade plate, and retrograde intramedullary nail for the internal fixation of distal femur fractures, J Orthop Trauma 18:494, 2004.

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55

FRACTURES AND DISLOCATIONS OF THE HIP John C. Weinlein

FEMORAL NECK FRACTURES Classification Diagnosis Treatment Operative treatment Outcomes and complications Failure of fixation Nonunion and osteonecrosis Arthroplasty Basicervical femoral neck fractures INTERTROCHANTERIC FEMORAL FRACTURES

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Classification Treatment Treatment with screw–side plate devices Treatment with intramedullary nails Plate fixation compared with intramedullary nail fixation SUBTROCHANTERIC FEMORAL FRACTURES Classification Treatment

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Intramedullary nailing Plate fixation HIP DISLOCATIONS AND FEMORAL HEAD FRACTURES Reduction maneuvers for posterior hip dislocation Reduction maneuver for anterior hip dislocation FRACTURES OF THE IPSILATERAL FEMORAL NECK AND SHAFT

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As the number of hip fractures continues to increase in the United States (with an estimated 458,000 to 1,037,000 hip fractures per year by 2050 in patients 45 years old or older), orthopaedic surgeons will be called on to help deal with this impending public health crisis. Although most hip fractures occur in the geriatric population, more and more young patients are surviving motor vehicle accidents and presenting with high-energy injuries about the hip. Hip fractures in these two populations can be very different, and an understanding of these differences will help determine the appropriate treatment to minimize morbidity and mortality and restore the patient to his or her preinjury functional status.

FEMORAL NECK FRACTURES Fractures of the neck of the femur occur predominantly in the elderly, typically resulting from low-energy falls, and may be associated with osteoporosis. Fractures of the femoral neck in the young are a very different injury and are treated in very different ways. Femoral neck fractures in young patients typically are the result of a high-energy mechanism, and associated injuries are common. Most fractures of the femoral neck are intracapsular and may compromise the tenuous blood supply to the femoral head (Fig. 55.1).This blood supply must also be understood for approaches to the proximal femur as well as implant placement. While the superior retinacular artery has been well described as being the main provider of perfusion to the femoral head, the inferior retinacular artery has more recently been shown to also provide significant perfusion and the anatomic course has been demonstrated to be consistent.

CLASSIFICATION

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Femoral neck fractures can be classified by the location of the fracture line (subcapital, transcervical, or basicervical [Fig. 55.2]), the Garden classification, or Pauwels classification. The Garden classification (Fig. 55.3) is the most commonly

used classification system and is based on the degree of displacement: Stage I: incomplete fracture line (valgus impacted) Stage II: complete fracture line; nondisplaced Stage III: complete fracture line; partially displaced Stage IV: complete fracture line; completely displaced Stages III and IV can be differentiated radiographically by carefully scrutinizing the trabecular patterns of the femoral head and acetabulum. Stage III femoral neck fractures maintain contact between the femoral neck and femoral head, and the trabecular patterns between the head and acetabulum are no longer aligned. Stage IV fractures do not maintain contact between the femoral neck and femoral head, and the trabecular patterns between the head and acetabulum have realigned. Interobserver reliability between stages is low; however, most surgeons are able to differentiate between nondisplaced femoral neck fractures (stages I and II) and displaced femoral neck fractures (stages III and IV). A shortcoming of the Garden classification is that angulation and displacement in the sagittal plane are not considered. The Pauwels classification (Fig. 55.4) was initially described in 1935 in the German literature and was thought to describe the major forces present at the fracture site. The classification has been misquoted in the literature over the years, causing some confusion, but the basic premise remains: increasing verticality of the femoral neck fracture line is associated with increased presence of shear at the fracture site. The classification is based on the angle the fracture line makes in reference to the horizontal. The fracture line in a Pauwels type I fracture is between 0 and 30 degrees in reference to the horizontal, type II is between 30 and 50 degrees, and type III is more than 50 degrees (Fig. 55.5). More recently, Collinge et  al. reported significant comminution in 96% of femoral neck fractures with high Pauwels angles. The Pauwels classification is relevant because optimal treatment may vary with the Pauwels angle. 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Lateral epiphyseal arterial group Subsynovial intracapsular arterial ring Ascending cervical arteries

Medial femoral circumflex artery

FIGURE 55.1

Extracapsular arterial ring

Stage I

Blood supply to the femoral head.

Subcapital Transcervical Basicervical

Stage III FIGURE 55.3

FIGURE 55.2 Classification of femoral neck fractures by location: subcapital, transcervical, basicervical.

The diagnosis of a femoral neck fracture is based on history, physical examination, and radiographs. Most patients with femoral neck fractures give a history of a traumatic event, with the exception of patients who have stress fractures of the femoral neck. Also, many young patients with high-energy femoral neck fractures have associated injuries, including head injuries, and may not be able to give a history. The index of suspicion for a femoral neck fracture must be extremely high because the consequences of a missed femoral neck fracture can be disastrous. The physical examination typically reveals an extremity that is shortened and externally rotated. Standard anteroposterior pelvic and cross-table lateral views of the hip are necessary, and a traction internal rotation view often is helpful. The cross-table lateral view, while often difficult to obtain, is probably essential in enabling prediction of failure with fixation in Garden I and II femoral neck fractures. The entire femur should be imaged. MRI has become the imaging study of choice to evaluate occult femoral neck

Stage IV Garden classification of femoral neck fractures.

fractures. CT scans to evaluate femoral neck fractures, often available as part of the trauma work up (CT scan of the chest, abdomen, and pelvis), can yield useful information including degree of comminution. 

TREATMENT

DIAGNOSIS

Stage II

A satisfactory reduction is paramount in minimizing the complications associated with treatment of femoral neck fractures, including nonunion and osteonecrosis. “Radiographic” or “visual” reduction continues to be debated; however. studies that have associated reduction quality with outcomes are generally based on radiographs. A closed reduction can be attempted in every patient for whom internal fixation is planned. The Whitman technique involves applying traction to the abducted, extended, externally rotated hip with subsequent internal rotation. Reduction attempts should not be forceful and should not be repeated more than two or three times. Once reduction has been attempted, the angulation and alignment must be critically evaluated. The Garden alignment index (Fig. 55.6) can be used to evaluate femoral neck angulation and alignment. The trabecular alignment pattern (Fig. 55.7) is evaluated with both anteroposterior and lateral radiographs or fluoroscopy. On the anteroposterior image, the angle between the medial shaft and the central axis of the medial compressive trabeculae should measure between 160 and 180 degrees. An angle of less than 160 degrees indicates varus, whereas an angle of more than 180 degrees indicates excessive valgus. On the lateral image, angulation should be approximately 180 degrees and deviation of more than 20 degrees indicates excessive anteversion or retroversion. Interestingly, Liporace et  al. reported a high percentage of retroversion of the femoral neck (approximately 20% of Caucasians in their series), and this relatively high

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CHAPTER 55  FRACTURES AND DISLOCATIONS OF THE HIP < 30°

Type I

30 – 50°

> 50°

Type II

Type III

FIGURE 55.4    Pauwels classification of femoral neck fractures.

A

B

C

D

FIGURE 55.5 Radiograph (A), CT scans (B and C), and clinical photograph (D) of high Pauwels angle femoral neck fracture.

frequency of retroversion must be considered in the care of not just femoral neck fractures but other fractures of the proximal femur and femoral shaft. Lowell et al. described the radiographic or fluoroscopic appearance of an anatomically reduced femoral neck as “shallow-S– or reverse-S–shaped curves” (Fig. 55.8); these “curves” may be more useful than the Garden alignment index for intraoperative evaluation of

alignment. We find using the fluoroscopic appearance of the contralateral uninjured hip useful intraoperatively as a reference for these “curves” as well as varus/valgus angulation.

OPERATIVE TREATMENT

Most femoral neck fractures require operative treatment. Possible exceptions include stress fractures on the

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS compression side of the femoral neck and femoral neck fractures in patients who are nonambulatory and comfortable or are too infirm for operative treatment.

IMPLANT CHOICE

The choice of implant and operation is largely dependent on the patient’s physiologic age. Patients with displaced femoral neck fractures who are physiologically older are best treated with arthroplasty. Younger patients are treated with internal fixation. With hemiarthroplasty, controversy exists to some degree over the use of cemented or cementless stems, as well as unipolar or bipolar prostheses. Data from several studies indicate that many community ambulators may be better treated with THA than with hemiarthroplasty. A major concern with THA for femoral neck fracture is dislocation, which has led to an increased interest in using an anterior or anterolateral approach (see Chapter 1, Techniques 1.63 and 1.65) when THA is done for treatment of a femoral neck fracture. 

 

FIXATION OF FEMORAL NECK FRACTURE WITH CANNULATED SCREWS

TECHNIQUE 55.1 Place the patient supine on a fracture table. Attempt closed reduction with the Whitman or other reduction technique. We typically scissor the lower extremities (unaffected hip extended relative to the injured side), but a well-leg holder also can be used.

n 

Fluoroscopically assess the quality of the reduction. If reduction is satisfactory, proceed with fixation. n  We typically use three partially threaded screws (6.5, 7.0, or 7.3 mm) in an inverted triangle configuration (Fig. 55.9A and B). n  Use fluoroscopy in both planes to localize placement of the inferocentral wire. Make a skin incision extending 2 to 3 cm proximally. Split the fascia in line with the skin incision, and use a Cobb elevator to gently split the fibers of the vastus lateralis muscle longitudinally. n  Place the inferocentral wire in perfect position on both views. Placing a guidewire along the anterior femoral neck can be helpful in determining appropriate anteversion. Make sure not to begin below the lesser trochanter and to continue proximally along the calcar. We use smooth or drill-tipped guidewires to optimize tactile feel and minimize cortical extrusion. n  Once the first guide pin is in place, use a parallel guide to place the posterosuperior and then anterosuperior pins to obtain posterior and anterior cortical support in the femoral neck. The posterosuperior guidewire should not be above the equator on the anteroposterior view. The anterosuperior guidewire should be above the equator on the anteroposterior view. Advance the guide pins just short of the articular surface. Be very careful not to violate the articular surface. n  To determine appropriate screw length, measure the length of the guide pin and subtract 5 mm. Self-drilling, self-tapping screws generally are used, but sometimes predrilling of the outer cortex is necessary in patients with dense bone. Washers are used where space permits. n  A fourth screw (diamond configuration) may be used in patients with significant posterior comminution (Fig. 55.9C). Use extreme care if a fourth screw is used because of the possibility of being extraosseous if the screw is placed posteriorly.    n 

180°

160°

FIGURE 55.6    Garden alignment index.

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150°

CHAPTER 55  FRACTURES AND DISLOCATIONS OF THE HIP configuration. They reported a 70% screw extrusion rate (Fig. 55.11) for posterosuperior screw (6.5 mm) placement using fluoroscopy in a cadaver model. Care must be taken in the starting of guide pins on the lateral cortex because inaccurate passage of the pins (multiple attempts or attempts below the level of the lesser trochanter) has been associated with subtrochanteric femoral fractures. In a biomechanical model, screw configuration was shown to influence the occurrence of subtrochanteric femoral fracture. Femoral neck fractures fixed with an apex-distal configuration exhibited a greater load to failure (before subtrochanteric femoral fracture) than those fixed with an apex-proximal configuration. The concern of subtrochanteric femoral fracture, as well as the increased possibility of nonunion, was reported in a recent clinical study as well. Although a randomized trial suggested no difference between long (32 mm) and short (16 mm) threaded screws for femoral neck fractures, we attempt to maximize thread length proximal to the fracture line, but not crossing the fracture line, when compressing femoral neck fractures. Interestingly, Liu et al. suggested a redesign of screw thread length (26 mm) to accomplish this goal. Washers are used whenever possible because their use has been suggested to reduce the risk of failure, likely because of increased compressive forces generated when they are used. Cannulated screw fixation can be done only after satisfactory reduction has been obtained. If satisfactory closed reduction cannot be obtained, open reduction, or arthroplasty in an elderly patient, is indicated. An inadequate closed reduction must not be accepted. An open reduction can be done through either a Watson Jones-approach (see Technique 1.67) or a modified Smith-Petersen approach (see Technique 55.2). Subcapital or transcervical femoral neck fractures can be better seen and more easily reduced through a modified Smith-Petersen approach; however, this approach does require a second incision for placement of fixation. A recent cadaver study supports increased anatomic exposure with the modified Smith-Petersen approach

Guide pins should be placed with the goal of obtaining femoral neck cortical support for screws. The femoral neck is not circular; it is more of an anterior-leaning ellipse. Zhang et al. warned of a cortical perforation risk of almost 20% in a two-dimensional 6.5-mm screw placement simulation (Fig. 55.10). The risk of perforation was 6.7% posterosuperiorly and 10.7% anteroinferiorly, and the authors illustrated “risk zones” for screw placement. Concerns about cortical perforation have also been noted, specifically in regard to the posterosuperior screw placement in an inverted triangle

FIGURE 55.7 Anteroposterior radiograph shows angle between medial trabecular stream in femoral head and medial cortex of femoral shaft. (From Garden RS: Reduction and fixation of subcapital fractures of the femur, Orthop Clin North Am 5:683, 1974.)

A

B FIGURE 55.8 A, Concave outline of femoral neck meets convex outline of femoral head in “S” or reversed-“S” curve superiorly, inferiorly, anteriorly, and posteriorly. B, Failure of restoration of these “S” signs is indicative of nonanatomic alignment. (Redrawn from Lowell JD: Results and complications of femoral neck fractures, Clin Orthop Relat Res 152:162, 1980.)

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Incise the fascia of the tensor fascia latae and develop the interval between the tensor fascia latae and the sartorius muscle. Cauterize ascending branches of the lateral femoral circumflex artery as they are encountered. n  Identify and tag the direct head of the rectus femoris and then release it off the anterior inferior iliac spine if desired. Repair it at the conclusion of the procedure either directly (if stump has been left) or with a suture anchor. n  Reflect the indirect head of the rectus femoris muscle from the capsule, along with the iliocapsularis muscle if present. n  Perform a capsulotomy in the shape of a T, inverted-T, Z, or H. We most often use a T-shaped capsulotomy; however, a Z-shaped capsulotomy also is reasonable. The vascular anatomy of the proximal femur must be considered, and portions of the capsulotomy must be carefully extended (e.g., if a capsulotomy in the shape of an inverted T or H is made, posterior extension of the transverse limb at the base of the femoral neck should be avoided to prevent injury to the blood supply to the femoral head). Hohmann retractors can be placed within the capsule and used for gentle retraction, always being cognizant of femoral head perfusion. n  Place a 5.0-mm Schanz pin in the proximal femoral diaphysis to control the distal segment and place a T-handle on the Schanz pin to aid in manipulation. n  Insert two 2.0-mm threaded Kirschner wires into the head segment and use them as joysticks to reduce the fracture. We also have used a reduction clamp (Farabeuf) to gain compression across the fracture of the femoral neck, as described by Molnar and Routt (Fig. 55.12). n  Once satisfactory reduction is confirmed both visually and radiographically, insert cannulated screws (see Technique 55.1), screw–side plate (SSP) device with derotational screw, or proximal femoral plate. n 

A

B

C

FIGURE 55.9 For fixation of femoral neck fractures, three partially threaded screws can be inserted in an inverted triangle configuration (A and B). Four screws can be placed in a diamond configuration when significant comminution is present (C). SEE TECHNIQUE 55.1.

Superior 2.5%

AS

PS

Anterior

Posterior

SZ

AI

PI

10.7%

6.7%

3.8%

Inferior FIGURE 55.10 SZ indicates the safe zone. (From Zhang YQ, Chang SM, Huang YG, et al: The femoral neck safe zone: a radiographic simulation study to prevent cortical perforation with multiple screw insertion, J Orthop Trauma 29:e178, 2014.)

(with or without a rectus tenotomy) versus the WatsonJones approach.   

OPEN REDUCTION AND INTERNAL FIXATION TECHNIQUE 55.2 (MODIFIED SMITH-PETERSEN) Position the patient supine on a flat-topped or fracture table. A fracture table makes lateral fluoroscopy easier. n  Make a longitudinal incision beginning at the anterior superior iliac spine and extending approximately 10 cm distally toward the lateral aspect of the patella. n 

POSTOPERATIVE CARE  Patients with high-energy femoral neck fractures are kept at touch-down (weight of leg) weight bearing for 10 to 12 weeks. Older patients are allowed protected weight bearing with a walker if their balance and other medical comorbidities allow. Patients who cannot safely ambulate are encouraged to mobilize to a chair to minimize pulmonary complications.   

Controversy exists about the best method of fixation for displaced subcapital and transcervical femoral neck fractures, and there are strong advocates of both cannulated screws (Fig. 55.13) and compression hip screws. The recent FAITH (Fixation using Alternative Implants for the Treatment of Hip Fractures) randomized controlled trial showed no difference in reoperation rates between cancellous screws and SSP in the treatment of low-energy femoral neck fractures in patients older than 50 years. Subgroup analysis did suggest a potential advantage of SSP devices in displaced fractures, basicervical fractures, and in smokers, although there was a higher rate of osteonecrosis in patients treated with SSP devices (9% vs. 5%). Based on study protocol, none of the patients treated with SSP devices had supplemental fixation such as a derotational screw. Biomechanical studies suggest that a compression hip screw coupled with a derotational screw (Fig. 55.14) is

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CHAPTER 55  FRACTURES AND DISLOCATIONS OF THE HIP

65916 RIGHT

65916 RIGHT

65835 LEFT

65835 LEFT

A

B FIGURE 55.11 A, Anteroposterior and lateral fluoroscopic images showing contained screw. B, Stripped cadaver specimen with posterior-cranial screw breach with thread extrusion. (From Hoffmann JC, Kellam J, Kumaravel M, et al: Is the cranial and posterior screw of the “inverted triangle” configuration for femoral neck fractures safe? J Orthop Trauma 33:331, 2019.)

A

B FIGURE 55.12 Reduction (Farabeuf) clamp can be used to gain compression across femoral neck fracture. A, Displaced fracture. B, Reduced fracture. SEE TECHNIQUE 55.2.

stronger than three cannulated screws in the treatment of unstable basicervical femoral neck fractures. A retrospective clinical study comparing fixation devices for Pauwels type III femoral neck fractures found no definitive evidence indicating the optimal fixation device. There was a higher nonunion rate with cannulated screws than with fixed angle devices (dynamic hip screw, cephalomedullary nail, dynamic condylar screw); however, this difference was not statistically significant. Biomechanical data suggest that a proximal femoral locking plate may be superior to both cannulated screws and a compression hip screw in

a Pauwels type III femoral neck model, but clinical studies have not been encouraging. Berkes et  al. reported a high incidence of catastrophic failure with proximal femoral locking plates. A different design of plate has shown improved results compared with cannulated screws; this design allows some controlled shortening. We typically reserve use of proximal femoral locking plates for fractures with significant femoral neck comminution (Figs. 55.15 and 55.16). The Targon dynamic proximal femoral locking plate (Aesculap AG, Tuttlingen, Germany) (Fig. 55.17A), which has been used in Europe for more than a decade

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS with generally favorable results, is currently not available in United States. The Conquest dynamic proximal femoral locking plate (Smith & Nephew, Memphis, TN) (Fig. 55.17B) is a similar option; however, clinical data currently are lacking. Other options include a trochanteric lag screw and medial buttress plating. A trochanteric lag screw for high Pauwels angle femoral neck fractures is supported by biomechanical data; however, a recent clinical series specifically using this technique did not have favorable results.

FIGURE 55.13 Cannulated screw fixation of displaced femoral neck fracture after open reduction.

A

The technique for placement of a compression hip screw is described in the section on intertrochanteric femoral fractures (see Technique 55.4). Care must be taken with placement of a large diameter lag screw in patients with nonosteoporotic bone, and consideration should be given to routinely using a tap as well as placing a derotational screw. Femoral neck shortening (Fig. 55.18) appears to be common after fixation of femoral neck fractures. Shortening of more than 1 cm was reported to occur after 42% of Garden I fractures and 63% of Garden II fractures fixed with cannulated screws. The importance of femoral neck length in influencing functional outcome has been emphasized in several reports. Femoral neck shortening was associated with pain and decreased mobility in a study of over 500 patients with femoral neck fractures treated with the Targon dynamic femoral locking plate. The mean age of patients in this study was 76.1 years. Zlowodzki et  al. retrospectively evaluated the effect of femoral neck shortening on functional outcome in 70 patients with healed femoral neck fractures, 64% of which were nondisplaced intracapsular fractures. All patients were treated with screw fixation, and 69 of 70 had acceptable reductions according to the Garden alignment index. Interestingly, 46 (66%) of the 70 patients healed with shortening of more than 5 mm and 27 (39%) had more than 5 degrees of varus. The primary outcome measure, the SF-36 physical functioning score, correlated with the degree of femoral neck shortening, suggesting that femoral neck shortening negatively impacts functional outcome. Similarly, Slobogean et al. reported decreased functional outcomes (Harris Hip Score, Timed Up and Go, SF-36 Physical Component Summary) in patients younger than 55 years of age (mean, 43.7 years) who had shortening of 10 mm or more after treatment of a femoral neck fracture with multiple cancellous screws. Boraiah et al. reported treatment of 54 intracapsular femoral neck fractures with anatomic reduction, intraoperative

B FIGURE 55.14 Displaced femoral neck fracture (A), in this case ipsilateral to femoral shaft fracture, fixed with compression hip screw and derotational screw (B).

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CHAPTER 55  FRACTURES AND DISLOCATIONS OF THE HIP compression across the fracture site. Once adequate compression is achieved, the cannulated screws are replaced one by one with fully threaded screws with washers. If a compression hip screw is to be used, such as for a high Pauwels angle femoral neck fracture, a guide pin is placed perpendicular to the fracture line, and a partially threaded cannulated screw is inserted, followed by the SSP device. The partially threaded screw is then changed to a fully threaded screw (Fig. 55.19). Two fully threaded screws also can be used if patient’s femoral neck anatomy will allow. As previously noted, large series demonstrating the effectiveness of these techniques are lacking in the literature. Femoral neck shortening also may lead to prominent implant placement. Implant removal was the most frequent reoperation (24%) reported in 796 young patients after treatment of femoral neck fractures. Zielinski et  al. reported a similar rate of reoperation for implant removal (23%), but implant removal generally had a positive impact on patients’ quality of life. Surgeons and patients should be aware of the possibility of femoral neck fracture after implant removal.

OUTCOMES AND COMPLICATIONS FIGURE 55.15 Axial CT scan of femoral neck fracture with significant posterior femoral neck comminution.

compression, and length-stable implants. Various open reduction techniques were used depending on fracture pattern and physiologic age. Intraoperative compression was achieved before placement of a dynamic hip screw (or dynamic helical hip screw) and fully threaded screws. The overall union rate was 94%, with an average shortening of the femoral neck of 1.7 mm. The average 36-Item Short Form Health Survey (SF-36) physical functioning score was 42, and the Harris Hip Score was 87. The Bodily Pain subscore of the SF-36 correlated with the “abductor lever arm” (distance from the center of the femoral head to a tangential line along the greater trochanter). Patients with greater differences in the abductor lever arm between the fractured and unaffected sides had lower Bodily Pain subscores. Weil et al. reported a small series demonstrating minimal shortening after the treatment of femoral neck fractures with fully threaded screws; 23 of 24 fractures were classified as Garden I or II. There was no statistically significant difference in complication or reoperation rates when compared to a historical control treated with partially threaded screws. Larger series supporting this technique currently are lacking in the literature, and at least one study reported high complication rates. Only slight changes in technique are necessary to stabilize femoral neck fractures at length. Obviously, the reduction is paramount. Using length-stable implants in fractures that are not well reduced may result in nonunion. Potentially, the goals of union and maintenance of femoral neck length can both be achieved. Closed reduction of displaced fractures can be attempted, followed by open reduction through either a Smith-Petersen or Watson-Jones approach if closed reduction fails to obtain an anatomic reduction. In older patients and fractures with less displacement, more limited open reductions can be done if needed with the use of ballspike pushers, Cobb elevators, and Kirschner wires to obtain anatomic reductions. After reduction has been obtained, partially threaded cannulated screws can be placed for

FAILURE OF FIXATION

Internal fixation may fail because of many factors, including inadequate reduction, poor implant selection or position, nonunion, osteonecrosis, and infection. Determining the cause of fixation failure is extremely important in planning revision surgery. In young patients, early recognition of inadequate reduction or poor implant selection or position can be treated with revision open reduction and internal fixation (Fig. 55.20) and femoral neck nonunions or malunions can be treated with valgus intertrochanteric osteotomy. Femoral neck nonunion, malunion, and osteonecrosis in elderly patients can be treated with THA. Infection after the treatment of femoral neck fractures can be quite problematic. The goal is to suppress the infection with debridement and culture-specific antibiotics, maintaining the hardware until union at which time it is removed. Hardware failure with infection requires hardware removal and possibly resection arthroplasty. Occasionally, total hip arthroplasty can be done after implant failure with infection but only in a staged fashion and after infection has been eradicated. 

NONUNION AND OSTEONECROSIS

Nonunion (Fig. 55.21) and osteonecrosis (Fig. 55.22) are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures. In a meta-analysis of 18 studies involving younger patients (ages 15 to 50 years) with femoral neck fractures, the overall incidence of osteonecrosis was 23% and the incidence of nonunion was 9%. The 564 patients in these studies included those with both displaced and nondisplaced intracapsular femoral neck fractures. In a series of 73 femoral neck fractures in patients between the ages of 15 and 50 years treated at a single institution, Haidukewych et al. found an overall frequency of osteonecrosis of 23% and nonunion of 8%. Osteonecrosis developed in 27% of displaced fractures and 14% of nondisplaced fractures. Thirteen patients (18%) had conversion to arthroplasty; 11 of these arthroplasties were done purely for osteonecrosis. Initial fracture displacement and the quality of radiographic reduction were found to affect results. In another series including 62 Pauwels type III femoral neck fractures, osteonecrosis developed in

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A

B

C

D

FIGURE 55.16 Preoperative radiograph (A) and axial (B) and coronal (C) CT scans of a femoral neck fracture with posterior femoral neck comminution with extension into the greater trochanter. D, United fracture after fixation.

11% and nonunion in 16%. The average age of patients in this series was 42 years (range 19 to 64 years). The higher nonunion rate in this study is likely a result of the difficulty of treating higher Pauwels angle femoral neck fractures. Osteonecrosis continues to be a problem after femoral neck fractures, even nondisplaced fractures. In fact, higher intracapsular pressures have been demonstrated with nondisplaced femoral neck fractures than with displaced fractures. Routine capsulotomy is controversial. Capsulotomy probably is most effective in Garden types I and II fractures in which the capsule may not be torn or completely torn and tamponade may be a major cause in the development of osteonecrosis. We usually perform capsulotomies in young patients with nondisplaced femoral neck fractures and only occasionally do so in the geriatric population. Although there is no conclusive study proving that

capsulotomy decreases the frequency of osteonecrosis, it can be done quickly and safely and may reduce the risk of osteonecrosis.   

FLUOROSCOPICALLY GUIDED CAPSULOTOMY OF THE HIP TECHNIQUE 55.3 After fixation of the femoral neck fracture, prepare a no. 10 scalpel blade by placing an approximately 2-cm strip of Ioban around the blade/handle junction to decrease the

n 

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CHAPTER 55  FRACTURES AND DISLOCATIONS OF THE HIP

A

B

FIGURE 55.17 Dynamic locking constructs for proximal femoral fractures. A, Targon FN (Aesculap B. Braun Medical Inc, Tuttlingen, Germany). B, CONQUEST FN (Smith & Nephew, Memphis, TN).

A

B

FIGURE 55.18 Significant femoral neck shortening after treatment of minimally displaced femoral neck fracture with partially threaded cannulated screws. A, Intraoperative fluoroscopic anteroposterior view. B, Anteroposterior radiograph revealing significant femoral neck shortening.

likelihood of dissociation of the blade from handle within the body. n  Through the lateral incision made for fixation with cannulated screws, compression hip screw, or proximal femoral locking plate, using tactile feel and fluoroscopic guidance, advance the scalpel along the anterior femoral neck with the blade directed inferiorly. n  Once the femoral head is encountered, rotate the blade 90 degrees and withdraw the scalpel with a posterior directed force to complete the capsulotomy.   

Christal et al. showed in a cadaver series that fluoroscopically guided capsulotomy is safe and effective at decreasing intracapsular pressure. Dissections of the cadavers after capsulotomy found that the average distances from the femoral artery and lateral most branch of the femoral nerve were 40.3 and 19.5 mm, respectively. The minimal distances in individual cadavers were 36 mm from the femoral artery and 15 mm from the lateral most branch of the femoral nerve. Intracapsular pressure was substantially decreased after capsulotomy. A meta-analysis of 106 reports of displaced femoral neck fractures in older patients (65 years or older) reported overall

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A

B

C

FIGURE 55.19 In an attempt to minimize femoral neck shortening, partially threaded screw used for compression is changed to fully threaded screw. A, Radiograph at time of injury. B and C, After operative reduction and fixation.

rates of osteonecrosis and nonunion of 16% and 33%, respectively. The rate of reoperation within 2 years ranged from 20% to 36% after internal fixation, which was higher than after hemiarthroplasty. Interestingly, a recent randomized controlled trial revealed a 20% major reoperation rate for nondisplaced femoral neck fractures treated with screws in patients 70 years of age or older. Although there was no difference in Harris Hip Scores between those treated with screws and those with hemiarthroplasty, patients with hemiarthroplasty were more mobile and had a lower rate of major reoperations.

ARTHROPLASTY

The decision to proceed with fixation or arthroplasty depends on fracture characteristics and physiologic patient age. Displaced femoral neck fractures in physiologic younger patients (3 fragments) n Segmental fractures n Open fractures n Impending open fractures with soft-tissue compromise n Obvious clinical deformity (usually associated with displacement and shortening) n Scapular malposition and winging at initial examination  Associated Injuries n Vascular injury requiring repair n Progressive neurologic deficit n Ipsilateral upper extremity injuries/fractures n Multiple ipsilateral upper rib fractures n “Floating shoulder” n Bilateral clavicular fractures  Patient Factors n Polytrauma with requirement for early upper extremity weight bearing/arm use n Patient motivation for rapid return of function (e.g., elite sports or self-employed professional) From McKee MD: Clavicle fractures. In Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P 3rd, editors: Rockwood and Green’s fractures in adults, 7th ed, Philadelphia, 2010, Lippincott Williams & Wilkins.

TABLE 57.4

“Ready Reckoner” for Estimating the Risk of Nonunion OVERALL DISPLACEMENT (MM) 10 15 20 25 30 40

NONCOMMINUTED FRACTURE IN NONSMOKER 2 3 7 14 26 62

COMMINUTED FRACTURE IN NONSMOKER 3 6 12 23 39 74

NONCOMMINUTED FRACTURE IN SMOKER 6 12 23 39 57 86

COMMINUTED FRACTURE IN SMOKER 10 19 34 52 70 92

From Murray IR, Foster CJ, Eros A, Robinson CM: Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures of the clavicle, J Bone Joint Surg Am 95:1153, 2013.

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Release the lateral platysma and identify the supraclavicular nerve traversing the anterior aspect of the clavicle. n  Incise the clavipectoral fascia along its attachment to the anterior clavicle and carefully elevate it inferiorly. n  Dissect first along the medial fragment, which usually has flexed up away from the vital infraclavicular structures. For acute fractures, only minimal soft-tissue dissection is needed. n  Reduce the fracture and hold it with bone clamps. n  Use a lag screw if possible for provisional fixation; as an alternative, consider using a mini-fragment screw as provisional fixation to allow perfect contouring of the plate. n  Contour a 3.5-mm plate to fit along the anteroinferior edge of the clavicle. Typically, an eight-hole plate fits well when contoured into an S-shape as viewed on edge (Fig. 57.4B). n  Aim the screws for plate fixation posteriorly and superiorly (Fig. 57.4C). If an oblique fracture is present, a lag screw can be placed either through the plate or directly into the bone at roughly a 90-degree angle to the fracture line.  n 

OPEN REDUCTION AND INTERNAL FIXATION OF CLAVICULAR FRACTURES

TECHNIQUE 57.1 (COLLINGE ET AL., MODIFIED) 

ANTEROINFERIOR PLATE AND SCREW FIXATION Place the patient supine with a large “bump” placed between the scapulae, allowing the injured shoulder girdle to fall posteriorly, which helps to restore length and increase exposure of the clavicle. n  Make an incision centered over the fracture from the sternal notch to the anterior edge of the acromion (Fig. 57.4A). n 

B

A FIGURE 57.1

Clavicular fracture (A) fixed with superior plate (B). SEE TECHNIQUE 57.1.

B

A FIGURE 57.2

Clavicular fracture (A) fixed with anteroinferior plate (B).

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM SUPERIOR FIXATION For superior fixation, contour the plate to fit the superior edge of the clavicle (see Fig. 57.1). Insert the screws from superior to inferior, taking care to avoid injury to the neurovascular structures.

n 

See also Video 57.1.

POSTOPERATIVE CARE The operated extremity is placed in a sling for comfort. Pendulum and Codman exercises are taught, and the patient is encouraged to use the arm but to avoid heavy lifting, pushing, or pulling. Full return of activities is allowed when fracture healing is present, usually at 2 to 3 months.   

INTRAMEDULLARY FIXATION

Intramedullary nailing of clavicular fractures has been done for over 50 years, with a variety of devices, including Rockwood pins, Kirschner wires, Küntscher nails, and Rush nails (Fig. 57.5). Suggested advantages of intramedullary fixation include small skin incision, less periosteal stripping, and relative stability to allow callus formation. Frequent complications, such as intrathoracic migration, pin breakage, and damage to underlying structures, however, have limited the use of this technique. A biomechanical study comparing fixation of clavicular osteotomies with 3.5-mm compression plates and 3.8- or 4.5-mm intramedullary pins also showed that plated constructs were superior in resisting displacement. More recently, titanium elastic intramedullary nails have been used, with good results reported in a number of studies. However, reported complication rates have ranged from 9% to 78% with these devices, mainly medial or lateral migration and perforations. Frigg et al. reported a reduction in complications from 60% to 17% with the use of an end cap, converting to open reduction after two failed attempts at closed reduction, using careful manual passage of the nail, obtaining intraoperative oblique radiographs to rule out lateral perforation, and limiting postoperative range of motion to 90 degrees for 6 weeks. 

RIGHT

A R

B FIGURE 57.3

Dual mini-fragment plate.

Acr

SN 18 mm

A

C

B

FIGURE 57.4 Open reduction and internal fixation of clavicular fracture. A, Incision. B, Plate prebent to match normal clavicular anatomy. C, Screw placement posteriorly and superiorly. Acr, acromion; SN, sternal notch. SEE TECHNIQUE 57.1.

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B

A FIGURE 57.5

Clavicular fracture (A) treated with intramedullary fixation (B).

 

INTRAMEDULLARY FIXATION WITH A HEADED, DISTALLY THREADED PIN (ROCKWOOD CLAVICLE PIN)

TECHNIQUE 57.2

Place the patient in a semi-sitting position on a radiolucent table with an image intensifier on the ipsilateral side. By rotating the image 45 degrees caudal and cephalad, orthogonal views of the clavicle can be obtained. n  Make a 2- to 3-cm incision over the posterolateral corner of the clavicle 2 to 3 cm medial to the acromioclavicular joint. Little subcutaneous fat is in this region, so take care to prevent injury to the underlying platysma muscle. n  Use scissors to free the platysma muscle from the overlying skin; split its fibers in line with the muscle. Take care to prevent injury to the middle branch of the supraclavicular nerve, which usually is found directly beneath the platysma muscle near the midclavicle. Identify and retract the nerve. n  Use a towel clip to elevate the proximal end of the medial clavicle through the incision (Fig. 57.6A). n  Taking care not to penetrate the anterior cortex, attach the appropriate-sized drill to the ratchet T-handle and drill the medullary canal (Fig. 57.6B). n  Remove the drill from the medial fragment, attach the appropriate-sized tap to the T-handle, and tap the medullary canal to the anterior cortex (Fig. 57.6C). Hand tapping is recommended, especially for small patients and smaller-diameter clavicle pins. n  Elevate the lateral fragment through the incision; externally rotating the arm and shoulder helps improve exposure. n  Attach the same-sized drill used in the medial fragment to the ratchet T-handle and drill the medullary canal (Fig. 57.6D). n  Under C-arm guidance, pass the drill out through the posterolateral cortex of the clavicle (Fig. 57.6E). The drill position should be posterior and medial to the acromioclavicular joint, around the level of the coracoid. Allow the n 

drill to exit no higher than the equator of the posterolateral clavicle. n  Remove the drill from the lateral fragment, attach the appropriate-sized tap to the T-handle, and tap the medullary canal so that the large threads are advanced fully into the canal (Fig. 57.6F). If the tap is a tight fit, consider redrilling with the next larger drill size. Again, hand tapping is recommended. n  While holding the distal fragment with a bone clamp, remove the nuts from the pin assembly and pass the trocar end of the pin into the medullary canal of the distal fragment. The pin should exit through the previously drilled hole in the posterolateral cortex. n  Once the pin exits the clavicle, its tip can be felt subcutaneously. Make a small incision over the palpable tip and spread the subcutaneous tissue with a hemostat (Fig. 57.6G). Place the tip of the hemostat under the tip of the clavicle pin to facilitate its passage through the incision. Then drill the pin out laterally until the large, medial threads start to engage the cortex. n  Attach the Jacobs chuck and T-handle to the end of the pin protruding laterally (take care not to place the chuck over the machined threads, both lateral and medial) and carefully retract the pin into the lateral fragment (Fig. 57.6H). Ensure that the pin is inserted correctly. n  Reduce the fracture and pass the pin into the medial fragment. Advance the pin until all medial threads are across the fracture site. Because the weight of the arm usually pulls the arm down, lifting the shoulder will facilitate pin passage into the medial fragment. n  Place the medial nut on the pin, followed by the smaller lateral nut. Cold weld the two nuts together by grasping the medial nut with a needle driver or needle-nose pliers and tightening the lateral nut against the medial nut with the lateral nut wrench. Use the T-handle and wrench on the lateral nut to medially advance the pin down into the medial fragment until it contacts the anterior cortex. Confirm position with fluoroscopy. n  Break the cold weld between the nuts by grasping the medial nut with a needle driver or pliers and quickly turn-

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

A

B

C

D

E

F FIGURE 57.6 Intramedullary fixation of clavicular fracture. A, Elevation of proximal end of medial clavicle. B, Drilling of medullary canal. C, Tapping of medullary canal. D, Drilling of medullary canal. E, Passage of drill out through posterolateral cortex. F, Tapping of medullary canal.

ing the lateral nut counterclockwise with the insertion wrench. Advance the medial nut until it against the lateral cortex of the clavicle. Tighten the lateral nut until it engages the medial nut (Fig. 57.6I). n  Use the medial wrench to back out the pin 1 cm or more to expose the nuts from the soft tissue. Ensure that the clavicle threads are still engaged in the cortical bone of the medial fragment. n  Use a side-cutting pin cutter to cut the pin as close to the lateral nut as possible. Readvance the clavicle pin using the lateral nut wrench.

POSTOPERATIVE CARE  The arm is placed in a standard sling for comfort, and gentle pendulum exercises are allowed. At 10 to 14 days, sutures are removed and, if healing is seen on radiographs, the sling is discontinued; unrestricted range-of-motion exercises, but no strengthening, resisted exercises, or sports activities are allowed. If radiographs at 6 weeks show union, resisted and strengthening activities are begun. Contact sports (e.g., football, hockey) should be avoided for 12 weeks after surgery. If the fracture is healed at 12 weeks, the pin can be removed.   

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G

Retract pin laterally

Lateral nut wrench

H

I

FIGURE 57.6, cont’d G, Incision over tip of intramedullary pin. H, Retraction of pin into lateral fragment. I, Final position of intramedullary pin. (Redrawn from Lippert S: Rockwood clavicle pin surgical technique, Warsaw IN, DePuy.) SEE TECHNIQUE 57.2.

LATERAL CLAVICULAR FRACTURES

Neer described five types of lateral clavicular fractures (Table 57.5 and Fig. 57.7). Types I and II are lateral to the coracoclavicular ligaments and are inherently stable. Type II fractures occur just medial to the coracoacromial ligaments (type IIa) or occur with rupture of the ligaments (type IIb). The trapezius can be a deforming force and cause displacement of type II fractures. Treatment is still controversial, with good results reported with both operative and nonoperative treatment, even with malunions. The challenge is to obtain secure fixation in the lateral segments. Anatomic locking plates have improved fixation in the distal segment (Fig. 57.8) Other strategies include plating over to the acromion to gain greater fixation, supplementing fixation with sutures from the clavicle to the coracoid (Fig. 57.9), and using subacromial hook-plates (Figs. 57.10 and 57.11). High rates of union (95% or higher) and good shoulder function have been reported with the use of hook-plates, but patient discomfort and acromial osteolysis generally require plate removal as soon as union occurs. The author uses hook plates only in rare circumstances and recommends judicious use.



TABLE 57.5

Neer Classification of Lateral Clavicular Fractures TYPE I II

IIa IIb III

DESCRIPTION Coracoclavicular ligaments intact, attached to medial segment Coracoclavicular ligaments detached from medial segment, but trapezoid intact to distal segment Both conoid and trapezoid attached to distal segment Conoid is torn Intraarticular extension into acromioclavicular joint

Recently, Yagnik et al. reported a combination of cortical button fixation with coracoclavicular ligament reconstruction for distal clavicular fracture repair. Fractures united in all patients with low complication rates (Fig. 57.12). 

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

Type I Intact ligaments hold fragments in place

FIGURE 57.7

Type IIa Conoid and trapezoid ligaments are on distal segment; proximal segment, with no ligamentous attachments, is displaced

Type IIb Conoid ligament ruptured, trapezoid ligament remains attached to distal segment; proximal fragment is displaced

Neer classification of lateral clavicular fractures.

 

DISTAL CLAVICULAR FRACTURE REPAIR WITH CORACOCLAVICULAR LIGAMENT RECONSTRUCTION AND CORTICAL BUTTON FIXATION

L

TECHNIQUE 57.3 (YAGNIK ET AL.)

After administration of a regional interscalene block and general anesthesia, place the patient in a modified beachchair position. n  Make a 5-cm vertical incision 2 to 3 cm medial to the acromioclavicular joint, with the base of the incision at the proximal aspect of the coracoid. Carefully incise the deltotrapezial fascia in line with the clavicle to facilitate closure over the implants at the end of the procedure. n  Bluntly dissect the medial and lateral soft tissues adjacent to the coracoid for later passage of the sutures and graft around the coracoid. n  Prepare a 7 × 240-mm semitendinosus allograft, tapering the ends of the graft using a whip stitch (No. 2 nonabsorbable suture). Both ends of the graft should easily pass through the 6-mm tunnel. n  Using a coracoid passer, shuttle a strong passing suture through the instrument and under the coracoid and then shuttle two different-colored suture tapes and allograft around the coracoid. n  Using a 2.4-mm drill, create a bicortical hole for the suture tape as close to the fracture site as possible, preserving 5 mm of bone laterally to prevent iatrogenic fracture through this drill hole. n  Create a second tunnel for the graft with a 6.0-mm cannulated reamer over a 2.4-mm guide wire at least 15 mm medial to the first tunnel. n  Shuttle the two suture tapes through the lateral tunnel before the graft so that they lie posterior to the graft. n 

A

L

B FIGURE 57.8

Anatomic locking plate.

Pass both ends of the graft through the 6-mm tunnel using a second shuttle suture (Fig. 57.13A). n  Pass four limbs of the colored suture tape through a cortical button and tie, reducing the medial fragment to the lateral fragment. n  Tension the graft and insert a 5.5 × 10-mm PEEK interference screw, then cut the ends of the graft (Fig. 57.13B). n  Pass the free ends of the suture tape through the anterior deltotrapezial fascia in a horizontal mattress fashion n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Tie the sutures, repair the deltotrapezial fascia to the clavicle, bury the knots to minimize soft-tissue irritation, and close the incision in the standard fashion.

n 

POSTOPERATIVE CARE  The arm is placed in a sling to minimize tension on the repair for 4 to 6 weeks. Passive range of motion is started immediately after surgery. After 4 to 6 weeks, patients begin active and active-assisted range of motion exercises, with strengthening exercises at 8 weeks. Patients may return to full activity and sports around 4 months.    

FRACTURES AROUND THE SHOULDER FRACTURES OF THE SCAPULA

Fractures of the scapula account for 3% to 5% of all fractures about the shoulder, are most often caused by high-energy trauma, and are frequently associated with multiple trauma

(approximately 90% of patients with scapular fractures have associated injuries). Treatment of scapular fractures has traditionally been described as “benign neglect” and, like clavicular fractures, most scapular fractures do well with conservative management. Although outcomes are generally good, not all scapular fractures heal uneventfully and there has been a resurgence of interest in determining which patients would benefit from operative treatment. In their systematic review of the literature concerning scapular fractures, Zlowodzki et  al. found that of the total 520 fractures reported, 82% had good-to-excellent functional results. Almost all scapular body fractures were treated nonoperatively, with 86% good-to-excellent results; scapular neck and isolated glenoid fractures were most often treated operatively (83%), with good-to-excellent results in 76% and 82%, respectively. Although the numbers of specific fractures were small, the overall results after operative treatment were better than those after nonoperative treatment in all types (Table 57.6). Lantry et  al. also reported a systematic review of operative treatment of scapular fractures in which good-to-excellent functional results were found in approximately 85% of patients. In contrast, in their comparison of 31 displaced scapular fractures treated operatively to 31 treated nonoperatively (matched by age, occupation, and sex), Jones and Sietsema found that all fractures healed with no differences in return to work, pain, or complications. Dienstknecht et al. reported that a meta-analysis of the literature indicated that operatively treated scapular fractures had better radiographic results and more pain-free results, whereas nonoperatively treated patients had significantly better range of motion. Although the literature is still lacking in sufficient evidence to formulate concrete treatment guidelines, these two reviews emphasize that most scapular fractures do well, but criteria for deciding which fractures are at risk for poor outcomes are still evolving. Recent reports by Schroder et al. and Tatro et al. continue to support operative treatment in widely displaced scapular fractures with high functional outcomes and low complication rates.

TREATMENT OPTIONS

FIGURE 57.9 Supplemental suture fixation from clavicle to coracoid over the acromion for lateral clavicular fracture.

Almost all scapular body and neck fractures are still treated nonoperatively. We immobilize the shoulder for 2 to 3 weeks and begin an active-assisted range-of-motion protocol when pain permits. An active range-of-motion program is then

B

A FIGURE 57.10

Clavicular fracture (A) fixed with hook plate (B).

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM begun, and strengthening exercises are allowed when fracture healing is confirmed clinically and radiographically. The mobility of the shoulder is predictive of function in many patients with a scapular fracture; however, there is still a small group of patients in whom ORIF probably is indicated. The goal of treatment is to preserve shoulder function by avoiding malalignment, arthrosis, scapulothoracic dyskinesis, and impingement pain (Table 57.7). 

returned to preinjury levels of work or activity after operative treatment. The operative approach of choice is the Judet or modified Judet (see Technique 1.94). Additional anterior approaches occasionally are needed. 

GLENOID FRACTURES

Glenoid fractures should be treated as all other intraarticular fractures, and reduced and stabilized when significant (>4 mm) displacement exists through the articular surface that leads to joint subluxation or incongruency. Anavian et  al. reported that, of 33 patients with complex and displaced intraarticular glenoid fractures, 87% were pain free and 90%

FIGURE 57.11

Healed clavicular fracture after plate removal.

FIGURE 57.12 Distal clavicle repair using combination of cortical button fixation and coracoclavicular ligament reconstruction. (Redrawn from Yagnik GP, Jordan CJ, Narvel RR, Hassan RJ, Porter DA: Distal clavicle fracture repair: clinical outcomes of a surgical technique utilizing a combination of cortical button fixation and coracoclavicular ligament reconstruction, Orthop J Sports Med 7(9):2325967119867920, 2019.)

Dog bone

Tensioned graft

Lateral Lateral

Medial Medial

* A

Reduced fracture Inferior

B

Inferior

FIGURE 57.13 A, Distal clavicular fracture with suture tapes passed through laterally based tunnel and allograft passed through medial tunnel. Asterisk indicates coracoid process. B, Final construct demonstrates reduction with suture tapes tied over cortical button and graft tensioned with interference screw. Graft is passed anterior to suture tapes. (From Yagnik GP, Jordan CJ, Narvel RR, Hassan RJ, Porter DA: Distal clavicle fracture repair: clinical outcomes of a surgical technique utilizing a combination of cortical button fixation and coracoclavicular ligament reconstruction, Orthop J Sports Med 7(9):2325967119867920, 2019.). SEE TECHNIQUE 57.3.

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TABLE 57.6

Results of Operative and Nonoperative Treatment of Scapular Fractures FRACTURE TYPE Glenoid only Neck with or without other associated scapular fractures (excluding glenoid) Acromion and/or coracoid (with/without associated scapular fractures) Body only (including spine)

OPERATIVE: EXCELLENT/GOOD 82% (45/55) 92% (23/25)

NONOPERATIVE: EXCELLENT/GOOD 67% (6/9) 79% (110/140)

88% (7/8)

77% (80/104)

100% (2/2)

86% (6/7)

Data from Zlowodzki M, Bhandari M, Zelle BA, et al: Treatment of scapula fractures: systematic review of 520 fractures in 22 case series, J Orthop Trauma 20:230, 2006.



TABLE 57.7

Indications for Surgical Treatment of a Scapular Fracture INDICATION INTRAARTICULAR FRACTURE Articular step-off Percentage of glenoid affected Glenohumeral articulation EXTRAARTICULAR Glenopolar angle Lateral border offset Angulation Translation

Scapular body fracture with injury to the clavicle or clavicle-acromion complex. These decision-making criteria have not yet been shown to produce improved outcomes; the surgeon’s skill level and patient issues should contribute to the decision for operative treatment. We generally favor conservative treatment, but this is an active treatment decision and not “benign neglect” (Fig. 57.15).  n 

CRITERION ≥4-5 mm ≥20% Unstable despite closed reduction ≤20° ≥20 mm ≥45° ≥100%

From Furey MJ, McKee MD: Fractures of the clavicle and scapula, AAOS OKU: Trauma 5:241, 2016.

SCAPULAR BODY OR NECK FRACTURES

Fractures of the scapular body or neck that are so significantly displaced that malunion and pain are of concern should be considered for operative treatment. Medialization of the glenoid has been questioned by Zuckerman et al., who recommended evaluation of lateralization of the scapular border. CT evaluation also found that in patients with glenoid neck fractures, pure medial translation of the glenoid relative to the axial skeleton was rare; instead, there was typically a component of shortening of the scapular width combined with lateralization of the scapular body. Treatment decisions should be based on the amount of displacement. Some authors use the glenopolar angle as a criterion for determining treatment. This angle is formed by a line drawn from the inferior pole of the glenoid fossa up to the superior pole and a second line drawn from the superior pole of the glenoid fossa down through the inferiormost angle of the scapular body (Fig. 57.14). The normal glenopolar angle ranges from 30 to 45 degrees. Anavian et al. suggested that three-dimensional CT is more reliable than plain radiography in the evaluation of extraarticular scapular fracture displacement. Cole et al. listed several criteria for operative treatment of scapular fractures: n A 15 to 20 mm lateral border offset (lateralization) n Forty degrees of scapular body angulation, as measured on a scapular-Y view n Glenopolar angle of 20 degrees or less and greater than 60 degrees.

PROXIMAL HUMERAL FRACTURES Use adequate radiograms to understand the traumatic lesion, be careful denying older patients effective treatment, use a safe and simple surgical approach, know the options for internal fixation, recognize the value of prosthetic replacement, avoid technical pitfalls, and thoughtfully supervise the postoperative patient care.— R.H. Cofield (1988)

Cofield’s summary of treatment of proximal humeral fractures is an indication of the difficulty of treating these injuries—from first evaluation to final outcome. Much controversy and confusion still exist, and no single treatment protocol or algorithm has been proved to be universally effective. As indicated by Cofield, areas still in question include radiographic diagnosis, operative or nonoperative treatment, consideration of patient age in treatment decision making, surgical approach, fracture fixation or hemiarthroplasty, type of internal fixation, and rehabilitation protocol. Numerous authors have suggested that nonoperative treatment may be preferable for two-, three-, and four-part proximal humeral fractures in elderly patients, but pain and loss of function have been reported in high percentages of patients after this treatment approach. Several more recent reports, however, have indicated that the functional results of operative treatment are not significantly better than the results of nonoperative treatment in elderly patients, although radiograph results may be superior. Court-Brown et  al. reported good or excellent results in 81% of impacted valgus fractures in elderly patients treated nonoperatively, and in a comparison of operative and nonoperative treatment of displaced twopart fractures, these authors found similar results in the two treatment groups. In one of the largest studies to date (PROFHER), with 231 patients, the authors were unable to show superiority of operative or nonoperative treatment using the Oxford Shoulder Score as the primary outcome. A 5-year follow-up study of the PROHFER study again was unable to show any advantage of operative treatment over nonoperative treatment. Although there are many

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b

a

A

b

a

B

FIGURE 57.14 Normal (A) and abnormal (B) glenopolar angle. Angle is measured between line connecting most cranial with most caudal point of glenoid cavity (a) and line connecting most cranial point of glenoid cavity with most caudal point of scapular body (b). Normal glenopolar angle ranges from 30 to 45 degrees.

limitations of the PROHFER studies, it certainly demonstrates some of the difficulty in treatment of patients with proximal humeral fractures. A meta-analysis by Beks et  al. confirmed the PROHFER finding of no difference between operative and nonoperative treatment. In a study of the geographic incidence and treatment variation of common fractures in elderly patients, Sporer et  al. found large variations in the percentage of proximal humeral fractures treated operatively, ranging from 6.4% to 60%; in eight regions of the United States, at least 40% were treated operatively, whereas in 35 regions, fewer than 20% were treated operatively. The fact that 10 different fixation techniques were evaluated for a single fracture type (fractures of the surgical neck of the humerus) is further indication of the complexity of treating proximal humeral fractures. Interestingly, one study showed a higher rate of operative treatment of proximal humeral fractures among upper extremity surgeons compared with trauma surgeons. In another study by LaMartina et  al., experienced shoulder surgeons agreed on treatment plans only 63% of the time, demonstrating the difficulty in devising and evaluating treatment plans.

CLASSIFICATION

The most commonly used classification system for proximal humeral fractures is that of Neer (Fig. 57.16). Although limited reliability, reproducibility among observers, and consistency by the same observer at different times have been cited as limitations of the Neer system, it remains useful in guiding treatment. Classification is based on the four-part anatomy of the proximal humerus: the humeral head, the lesser and greater tuberosities, and the proximal humeral shaft. The criterion for displacement is more than 1 cm of separation of a part or angulation of 45 degrees. Displaced three-part and four-part fractures markedly alter the articular congruity of the glenohumeral joint and have the highest likelihood of disrupting the major blood supply to the proximal humerus (Fig. 57.17). Osteonecrosis is most likely after displaced fourpart fractures. 

RADIOGRAPHIC EVALUATION

An anteroposterior view of the shoulder in the plane of the scapula, a lateral view of the scapula (Y view) (Fig. 57.18), and a supine axillary view (Fig. 57.19) are necessary in all patients initially to evaluate a proximal humeral fracture. If the amount of displacement of the humeral head or tuberosity fragments is unclear on radiographs, an axial CT scan with 2-mm sections is indicated (Fig. 57.20). 

NONOPERATIVE TREATMENT

Nonoperative treatment can obtain a functional, painless extremity in most proximal humeral fractures. The range of motion of the shoulder joint accommodates moderate angular deformity without significant functional loss. Neer described acceptable angulation as less than 45 degrees and less than 1 cm of displacement. Although these criteria are not absolute, they do provide a guide. An elderly, infirm patient can tolerate functional loss better than a young, active patient. The first step in treatment decision-making is to determine if displacement (5 mm) greater tuberosity fractures, displaced three-part fractures, and displaced four-part fractures in young patients. The type of fixation (transosseous suture fixation, percutaneous pinning, intramedullary nailing, or plate fixation) used depends on the patient’s age, activity level, and bone quality; the

fracture type and associated fractures; and the surgeon’s technical ability (Table 57.8). Age alone has been shown both to be predictive of failure and to have no association with failure. In their series of 154 fractures with proximal humeral fractures treated with plating, Boesmueller et al. found that the risk of screw cut-out was four times higher in patients over the age of 60 years and the overall risk for complications was three times higher than in younger patients. Before surgery is considered, it is important to determine if the blood supply and bone quality are adequate. The Hertel radiographic criteria for perfusion of the humeral head (Fig. 57.21) can be used to predict ischemia: metaphyseal extension of the humeral head of less than 8 mm and medial hinge disruption of more than 2 mm are predictive of ischemia. The combination of metaphyseal extension of the humeral head, medial hinge disruption of more than 2 mm, and an anatomic neck fracture pattern has a 97% positive predictive value for humeral head ischemia. According

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3-part

2-part

4-part

Anatomic neck

Surgical neck

B A

C

Greater tuberosity

Lesser tuberosity

Articular surface Fracturedislocation Anterior Posterior

FIGURE 57.16 Neer’s terminology of four-segment classification of displaced fractures and fracture-dislocations relates pattern of displacement (two-part, three-part, or four-part) and key segment displaced. In each two-part pattern, segment named is one displaced. Two-part surgical neck fractures are impacted (A), unimpacted (B), and comminuted (C). All three-part patterns have displacement of shaft segment, and displaced tuberosity identifies type of three-part fracture. In four-part pattern, all segments are displaced. Fracture-dislocations are identified by anterior or posterior position of articular segment. Large articular surface defects require separate recognition.

Vessels from rotator cuff Posterior humeral circumflex artery Anterior humeral circumflex artery

Arcuate artery Axillary artery

FIGURE 57.17

Blood supply of proximal humerus.

to the AO/ASIF classification system, extraarticular type A fractures have an intact vascular supply, whereas type B fractures have a possible injury to the vascular supply and type C articular fractures have a high probability of osteonecrosis. The cortical thickness of the humeral diaphysis has been suggested to be a reliable and reproducible predictor of bone mineral density and the success of internal fixation. The combined cortical thickness is the average of the medial and lateral cortical thickness at two levels (Fig. 57.22). Generally, a cortical thickness of less than 4 mm precludes internal fixation because adequate screw purchase cannot be obtained; sling immobilization, transosseous suture, or hemiarthroplasty may be better options. Spross et  al. and Newton et al. also demonstrated that the quality of the bone was associated with late cut-out.

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35°

A

B FIGURE 57.18 Special radiographic view perpendicular to plane of scapula to show glenohumeral joint in profile (A) and parallel to plane of scapula to show anterior and posterior displacement (B).

FIGURE 57.20 FIGURE 57.19 Method of obtaining axillary view of glenohumeral joint. This exposure can be obtained with patient prone, supine, or standing. Minimal abduction of injured arm is required to determine anteroposterior relationships.

Transosseous suture fixation techniques are well defined in the orthopaedic literature. Park et al. reported 78% excellent results in patients with two-part and three-part proximal humeral fractures treated with suture fixation. The use of strong nonabsorbable suture provides the advantage of incorporating the rotator cuff insertion to increase fixation in patients with poor bone quality (Fig. 57.23). The level of soft-tissue dissection is not extensive, and relatively low rates of osteonecrosis have been reported with this technique. Concerns include the ability of the patient to move the shoulder joint and loss of reduction secondary to a nonrigid construct. More recently, Dimakopoulos et  al. reported good results in 188 displaced proximal humeral fractures treated

CT scan of humeral head-splitting fracture.

with transosseous fixation (Fig. 57.24). They suggested as advantages of this technique less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants. Percutaneous pinning has the advantage of avoiding further damage to the soft-tissue envelope and the blood supply to the humeral head (Figs. 57.25 and 57.26). It also is a relatively inexpensive technique, and several series have reported good results in two-part, three-part, and valgusimpacted four-part fractures. The procedure is technically challenging and requires a satisfactory closed reduction, adequate bone stock, minimal comminution (particularly of the tuberosities), an intact medial calcar, and a compliant patient. In their series of 74 older patients (average age, 71 years), Calvo et  al. demonstrated that reduction was associated with satisfactory outcome. However, if satisfactory closed reduction cannot be obtained, another form

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TABLE 57.8

Advantages and Disadvantages of Techniques Used to Treat Displaced Fractures of the Proximal Humerus TECHNIQUE Nonoperative treatment

Minimally invasive techniques

ADVANTAGES Function as good as operative treatment for many fractures Low risk of infection and other operative complications Reduced injury to soft-tissue envelope Lower risk of infection

Intramedullary nailing

More stable fixation technique in osteoporotic bone Minimal dissection required for insertion

Open reduction and plate fixation

Anatomic fracture reduction possible n  Improved functional outcome n  Later revision easier Most stable fixation in multipart fractures n  Rigid implants n  Adjuvant bone grafting possible Risk of nonunion, osteonecrosis, symptomatic malunion avoided Low reoperation rate

Hemiarthroplasty

DISADVANTAGES Malunion inevitable: n  Cuff dysfunction/stiffness more likely n  Later salvage surgery more difficult Risk of nonunion increased Steep learning curve Risk of axillary nerve/vascular injury Less stable fixation Rotator cuff dysfunction after anterograde insertion Poor results in multipart fractures High rate of late implant removal Open surgical approach required: n Increased risk of infection n Increased risk of osteonecrosis

Poor functional outcome Late arthroplasty complications difficult to treat in elderly patients

From Robinson CM: Proximal humerus fractures. In Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P 3rd, editors: Rockwood and Green’s fracture in adults, ed 7, Philadelphia, 2010, Lippincott Williams & Wilkins.

Greater tuberosity

A

Humeral head Humeral head (>9 mm) Metaphyseal extension

B

Metaphyseal extension (minimal)

Greater tuberosity Humeral head

Medial hinge (displaced) Medial hinge (undisplaced)

C

D

FIGURE 57.21 Hertel radiographic criteria for perfusion of humeral head. A, Metaphyseal extension of humeral head of more than 9 mm. B, Metaphyseal extension of humeral head less than 8 mm. C, Undisplaced medial hinge. D, Medial hinge of more than 2-mm displacement.

of reduction and fixation should be used. Loss of fixation, pin track infections, and axillary nerve injuries are common complications. Terminally threaded Schanz pins and bicortical pins inserted from the greater tuberosity to the medial humeral shaft add stability to the overall construct.

Percutaneous pinning is contraindicated for fractures with metaphyseal comminution. Intramedullary nailing (see Technique 57.4) provides more stable fixation than percutaneous pinning, although less than locked plate fixation. The Polarus nail (Accumed,

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Level 1

Level 2

B

A

FIGURE 57.22 Two levels used to measure cortical thickness of humeral diaphysis. Level 1, most proximal aspect of humeral diaphysis, is at level in which endosteal borders of medial and lateral cortices are parallel. Level 2 is 20 mm distal to level 1. Examples of patients with low bone mineral density (A) and high bone mineral density (B). (From Tingart MS, Apprelexa M, von Stechow D, et al: The cortical thickness of the proximal humeral diaphysis predicts bone mineral density of the proximal humerus, J Bone Joint Surg 85B:611, 2003. Copyright British Editorial Society of Bone and Joint Surgery.)

FIGURE 57.23 Transosseous nonabsorbable sutures incorporate rotator cuff to increase fixation and help control tuberosity fragments.

Portland, OR) has been shown to provide more biomechanical stability than pin fixation, and good clinical outcomes have been reported with this device. Newer nail designs with polyaxial screws have more stability than earlier designs, and

the addition of polyethylene bushings may increase stability and prevent screw back-out (Fig. 57.27). Insertion of an intramedullary nail into the proximal humerus violates the rotator cuff, which can lead to postoperative shoulder pain. The advantages of the technique include preservation of the soft tissues and the theoretical biomechanical properties of intramedullary nails. A comminuted lateral cortex fracture or fractures involving the tuberosities may be a contraindication to intramedullary nailing. A recent randomized controlled trial demonstrated that complications were fewer with a straight nail design compared with a curvilinear design. A systematic review by Wong et al. reported satisfactory results in displaced two- and three-part proximal humeral fracture treatment with intramedullary nails. Sun et  al. compared locking plates with intramedullary nails in displaced proximal humeral fractures in a systematic review and metaanalysis and demonstrated similar performance between the two fixation types. Plate-and-screw constructs provide the most stable fixation of the three fixation methods (Fig. 57.28). Locked plates add stability, especially in osteoporotic bone. An open reduction and rigid fixation allow accurate reduction and stabilization of the tuberosities, which is important because malunion of the tuberosities is poorly tolerated and is associated with poor outcomes in posttraumatic reconstructive shoulder arthroplasty. A prospective randomized trial by Zhu et  al. found that at 1-year follow-up patients treated with locking plates had better outcomes than those treated with locked

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HH GT HD LT

A

B

C FIGURE 57.24 Transosseous fixation of displaced proximal humeral fracture. A, Sutures placed through drill holes in medial and lateral aspects of humeral diaphysis (HD). Black arrows (just below HD) indicate drill holes in diaphysis. GT, Greater tuberosity; LT, lesser tuberosity; HH, humeral head. B, Just before tying of knots there is adequate reduction and balance of involved rotator cuff tendons. Fracture site has been closed, and both tuberosities have been placed below articular margin of humeral head. Note cruciate configuration of sutures. C, Final suture configuration. (From Dimakopoulos P, Panagopoulos A, Kasimatis G: Transosseous suture fixation of proximal humeral fractures: surgical technique, J Bone Joint Surg 91A[Suppl 2, pt 1]:8, 2009.)

intramedullary nailing, but at 3-year follow-up outcomes were equal. The locking nail group had a significantly lower complication rate (4%) than the locking plate group (13%). Konrad et  al. also reported similar outcomes in three-part proximal humeral fractures treated with intramedullary nailing (58 fractures) or plate fixation (153 fractures). Historically, plate fixation of the proximal humerus has been fraught with complications, with malunion and nonunion caused by poor fixation in the humeral head (Fig. 57.29). In addition, extensive soft-tissue dissection increases the possibility of osteonecrosis of the humeral head, leading to a painful and functionally limited shoulder joint. The development of locked proximal humeral plates was expected

to improve treatment of these complex injuries greatly. The advantage of ORIF with a locked plate is an ability to reduce the fracture fragments into an anatomic position and stabilize them rigidly to allow early motion. Numerous outcome studies are now available because the locked proximal humeral plate has been widely used for more than 10 years; however, as was pointed out in a Cochrane review, there is little level I or II evidence. A recent randomized controlled trial comparing locked plating with conservative treatment of three-part and four-part fractures in elderly patients found no difference in outcomes at 1-year follow-up. Despite the lack of a large body of supporting literature, the locked proximal humeral plate is considered by most fracture surgeons to be a great

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a a b

FIGURE 57.25 Placement of percutaneous pins for fracture fixation. Two are passed through lateral aspect of shaft, just above deltoid insertion (a), and one is placed through anterior cortex (b); if greater tuberosity is fractured and displaced, two pins are inserted retrograde (c) to reduce and repair this fracture component.

FIGURE 57.26 Two-part proximal humeral fracture stabilized with percutaneous pins.

improvement in the management of proximal humeral fractures, and it has become the implant of choice for these fractures. Schnetzke et al. reported 98 patients treated with locked plating and concluded that anatomic reduction significantly improved outcomes.

FIGURE 57.27 Fixation of segmental proximal humeral fracture with locked intramedullary nail.

Much attention has been focused on the medial side of the metaphyseal injury. Gardner et al. called attention to this by documenting the importance of the inferior screw behaving as a medial calcar substitution. Biomechanical studies have confirmed this importance, and Jung et  al. confirmed it clinically by identifying medial comminution and insufficient medial support (no cortical or screw support) as independent risk factors for loss of reduction in 17 (7%) of 252 proximal humeral fractures. As an alternative to medial calcar screws, fracture site impaction adds stability by impacting the humeral head onto the humeral shaft. As modified by Torchia, valgus impaction osteotomy (Fig. 57.30A-D) appears promising, although no large series have been reported. In a biomechanical study, Weeks et al. found that fracture impaction increased the ability of the locking plate to withstand repetitive varus loading and was biomechanically superior to locking plate fixation alone. Gardner et  al. described the use of a fibular strut graft to provide medial column support. Although promising, the technique also is demanding, and further randomized trials are needed to confirm its efficacy. Kim et al. noted improvement using a fibular strut graft versus inferomedial screws in conjunction with locking plates in four-part fractures, but there was no advantage noted in three-part fractures. In a systematic review, Saltzman et  al. found satisfactory results when fibular strut grafts were used for augmentation. Some issues with open reduction and locked plating include the extensive exposure required for plate application that carries a risk of damage to neurovascular structures, especially the ascending branch of the lateral circumflex artery. The complication and reoperation rates do remain high with this technique. Screw perforation through the humeral head

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A

B

C

FIGURE 57.28 A, Displaced two-part surgical neck fracture with extension between greater and lesser tuberosities. B and C, After locking plate fixation. Note screw in inferior head because of medial comminution. SEE TECHNIQUE 57.5.

nonunion, osteonecrosis, infection, and hardware failure. Poor outcomes are associated with initial varus displacement of three- and four-part fractures. In an attempt to decrease complications with plate fixation, Gardner et  al. used an anterolateral acromial (Mackenzie) approach in which the axillary nerve is identified and protected, anterior dissection near the critical blood supply is avoided, substantial muscle retraction is minimized, and the lateral plating zone is directly accessed (see Technique 57.6). Laflamme et al. reported no axillary nerve injuries and no loss of reduction in fractures treated with percutaneous humeral plating through two minimal incisions (a lateral deltoid split and a more distal shaft incision). As our understanding of the anatomy of the proximal humerus and our instruments improve, less invasive techniques appear promising. Electrophysiologic findings in a study by Westphal et al., however, revealed a 10% axillary nerve injury rate.

FIXATION OF SPECIFIC FRACTURE TYPES

Two-part greater tuberosity fractures have historically been treated operatively when displacement is greater than 1 cm; however, Rath et  al. reported satisfactory outcomes after nonoperative treatment of 69 fractures with less than 3 mm of displacement. Many authors have suggested that the shoulder has little tolerance for displacement of the tuberosities and have advocated operative treatment for displacement of more than 5 mm because of functional loss and complications secondary to impingement. Usually these fractures are stabilized with transosseous sutures (Fig. 57.31; see also Fig. 57.23) or occasionally with screws in larger fragments. The rotator interval also must be repaired. n Two-part surgical neck fractures with displacement do poorly with nonoperative treatment. Closed reduction and percutaneous pinning have been reported to be successful n 

FIGURE 57.29 Micro-CT study of cancellous trabecular bone in humeral head shows marked porosity in greater tuberosity region and densest bone just underneath humeral head. (From Meyer DC, Fucentese SF, Koller B, et al: Association of osteopenia of the humeral head with full-thickness rotator cuff tears, J Shoulder Elbow Surg 13:333, 2004.)

is the most frequently reported complication. Perforation can occur as cutout from fracture settlement or from poor initial technique. Calcium phosphate cement augmentation has been shown to decrease this complication. Other complications include arthrofibrosis, impingement, malunion,

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A

B

C

D

FIGURE 57.30 Fixation of proximal humeral fracture after valgus impaction osteotomy. A, Long Steinmann pin is placed from shaft into head segment. B, Traction sutures are tensioned and tied to pin. Tensioning sutures pulls head segment out of varus. C, Lateral view of proximal humerus after provisional fixation; note that position of pin and sutures allows unobstructed access for definitive fixation with precontoured locking plate (D). (Redrawn from Torchia ME: Technical tips for fixation of proximal humeral fractures in elderly patients, Instr Course Lect 59:553, 2010, with permission from the Mayo Foundation of Medical Education and Research, Rochester, MN.)

in fractures that are reducible and are not comminuted. Complications such as loss of fixation, pin migration, infection, and malunion have made rigid intramedullary nailing our preferred technique, however, for fractures that can be reduced closed and for segmental fractures (see Fig. 57.27). The violation of the rotator cuff is offset by the advantages of decreased soft-tissue violation and decreased blood loss compared with ORIF. Widely displaced fractures, fractures with comminution, and irreducible fractures are stabilized with a locked-plate construct (see Fig. 57.28). Improved proximal fixation of these systems has increased stability so

that immediate postoperative range of motion is allowed. For extremely osteopenic patients, Banco et al. described a “parachute” technique, which included a valgus impaction osteotomy and tension-band fixation incorporating transosseous sutures (Fig. 57.32). Union was obtained in all 14 elderly patients, and patient satisfaction and function were excellent. n Three-part proximal humeral fractures in elderly patients with osteopenic bone may require hemiarthroplasty, but for most of these fractures plate fixation is the preferred procedure. Realignment of the head and shaft, combined with reduction of the tuberosity, gives the best chance

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A

B

C FIGURE 57.31 sutures.

A to C, Greater tuberosity fracture reduced and repaired with transosseous

for a good outcome. The rigid fixation provided by locking plates allows early range of motion, one of the goals of operative treatment. n Four-part proximal humeral fractures treated nonoperatively generally have poor outcomes; however, poor bone quality makes fixation difficult, and the vascular insult to the articular surface increases the risk of osteonecrosis of the humeral head. Osteonecrosis alone does not lead to a poor outcome if the anatomic relationships of the humeral head, tuberosities, and shaft are reestablished. Wijgman et al. reported osteonecrosis in 22 (37%) of 60 patients with three-part and four-part proximal humeral fractures treated with T-plates or cerclage wires, but 17 of the 22 patients had good or excellent functional outcomes. In young, active patients, open reduction and plate fixation usually are successful if soft-tissue stripping is kept to a minimum to avoid further damage to the humeral head blood supply. Rigid fixation with locking plates currently is our procedure of choice for fourpart proximal humeral fractures in young, active patients. Initial varus displacement has been shown to be associated with poor outcomes, as have varus malreductions.

Successful closed reduction and percutaneous pinning have been reported, but we have no experience with this technique for four-part fractures. Hemiarthroplasty (see Chapter 12) is a viable option in elderly patients with low functional demands. 

 

INTRAMEDULLARY NAILING OF A PROXIMAL HUMERAL FRACTURE

TECHNIQUE 57.4 Position the patient on a radiolucent table with the thorax “bumped” 30 to 40 degrees. Place the image intensifier unit on the opposite side of the table from the surgeon; rolling the unit back allows an adequate anteroposterior view (Fig. 57.33A,B), and rolling it forward allows an adequate lateral view of the shoulder and humerus (Fig. 57.33C,D).

n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Repair the rotator cuff with full-thickness sutures under direct observation (Fig. 57.37). n  Confirm reduction and screw placement and length on anteroposterior and lateral fluoroscopy images. n  Early rehabilitation is begun with active-assisted range-ofmotion exercises.     n 

 

OPEN REDUCTION AND INTERNAL FIXATION OF PROXIMAL HUMERAL FRACTURES

TECHNIQUE 57.5

Position the patient on a radiolucent table with a beanbag “bump” holding the shoulder and thorax 30 to 40 degrees off the table. Place the C-arm on the opposite side of the table from the surgeon; rolling the unit back allows an adequate anteroposterior view (see Fig. 57.33A,B), and rolling it forward allows an adequate lateral view of the shoulder and humerus (see Fig. 57.33C,D). n  Make a deltopectoral approach (see Chapter 1) to the proximal humerus. n  Release the anterior portion of the deltoid to expose the fracture site. n  If necessary, use a threaded pin as a joystick in the posterior humeral head to derotate the head into a reduced position (see Fig. 57.35). Sutures placed through the rotator cuff tendon (supraspinatus) also can be helpful for mobilization (see Fig. 57.23). n  For three-part or four-part fractures, place sutures into the rotator cuff tendons attached to the displaced tuberosity to aid in reduction (Fig. 57.38). n  For simpler fracture patterns, reduce the fracture and provisionally fix it with Kirschner wires; confirm reduction with fluoroscopy. If medial comminution is present, check to ensure that a varus malreduction has not occurred. n  Place the plate onto the greater tuberosity, posterior to the biceps tendon, and provisionally fix it in place with Kirschner wires; confirm correct plate position with fluoroscopy. A plate placed too far proximally may cause impingement, and a plate placed too close to the biceps tendon may damage the anterior humeral circumflex artery. n  Place two locking screws through the plate holes into the humeral head segment and one or two screws into the shaft. Confirm subchondral placement of the proximal screws and the quality of the reduction with fluoroscopy; this is easier with the fluoroscopy unit on the opposite side of the table from the surgeon. n  When accurate reduction is confirmed, insert remaining screws under direct fluoroscopic guidance. n  For fractures with medial comminution, fix the plate to the proximal segment with screws and reduce the shaft n 

FIGURE 57.32 Parachute technique using valgus impaction osteotomy and tension-band fixation incorporating transosseous sutures.

Make an incision diagonally from the anterolateral corner of the acromion, splitting the deltoid in line with its fibers in the raphe between the anterior and middle thirds of the deltoid (Fig. 57.34). To protect the axillary nerve, avoid splitting the deltoid more than 5 cm distal to the acromion. n  Under direct observation, incise the rotator cuff in line with its fibers. Use full-thickness sutures to protect the cuff from damage during reaming of the humeral canal. n  Use a threaded pin as a “joystick” in the posterior humeral head to derotate the head into a reduced position (Fig. 57.35A,B). n  Place the initial guidewire posterior to the biceps tendon and advance it under fluoroscopic guidance into the appropriate position as shown on anteroposterior and lateral views (Fig. 57.35C). n  Carefully advance the proximal reamer, protecting the rotator cuff. n  Use the reduction device to reduce the fracture and pass the bead-tipped guidewire. n  With sequentially larger reamers, ream the humerus to the predetermined diameter, usually 1.0 to 1.5 mm larger than the nail diameter. n  When reaming is completed, pass the nail down the humeral canal, avoiding distraction of the fracture (Fig. 57.36); ensure that the nail is below the articular surface of the humeral head. n  With the use of the outrigger device, insert the proximal locking bolts (see Fig. 57.35D). Carefully spread the soft tissues to avoid injury to the axillary nerve. n 

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A

B

C

D FIGURE 57.33 Placement of image intensifier for intramedullary nailing of proximal humeral fracture (A and C). Rolling unit back (A) allows anteroposterior view (B), whereas rolling it forward (C) allows lateral view (D) of shoulder and humerus. SEE TECHNIQUES 57.4, 57.5, AND 57.9.

segment to the plate. This helps avoid varus malposition, which is associated with higher failure rates. Screw fixation into the inferomedial humeral head also adds stability for fractures with medial comminution (see Fig. 57.28B). n  In three-part or four-part fractures, sutures inserted into the supraspinatus and subscapularis tendons aid in controlling the fracture fragments (see Fig. 57.38). n  Reduce the tuberosities to the articular surface and to each other with pins or sutures or both (Fig. 57.39); Observation or palpation through the rotator interval may aid in reduction of the lesser tuberosity to the humeral head. Often there is a small segment of articular surface with the lesser tuberosity that is a key to reduction. Fluoroscopy is helpful during difficult proximal humeral reconstruction. n  Fix the plate in the same manner as for a two-part fracture. Rotator cuff sutures can be incorporated into the plate for added stability. n  Confirm reduction and screw placement on anteroposterior and lateral fluoroscopy images.

POSTOPERATIVE CARE  An early rehabilitation program is begun with active-assisted range-of-motion exercises.    

 

ANTEROLATERAL ACROMIAL APPROACH FOR INTERNAL FIXATION OF PROXIMAL HUMERAL FRACTURE

TECHNIQUE 57.6 (GARDNER ET AL.; MACKENZIE) Position the patient in either the beach chair or supine semilateral position.

n 

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Incision

A

C

B

FIGURE 57.34 Entry portal for intramedullary nailing of proximal humeral fracture. A, Diagonal incision from anterolateral corner of acromion splits deltoid in line with its fibers in raphe between anterior and middle thirds. B, Location of incision. C, Establishment of portal. SEE TECHNIQUES 57.4 AND 57.9.

A

B

C

D

FIGURE 57.35 Intramedullary nailing of proximal humeral fracture. A, Two-part surgical neck fracture. B, Threaded pin used as “joystick” to reduce fracture. C, Placement of initial guidewire. D, After nail insertion and placement of locking screws. SEE TECHNIQUES 57.4 AND 57.5.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

FIGURE 57.36 Antegrade insertion of humeral nail for fixation of proximal humeral fracture. SEE TECHNIQUE 57.4.

FIGURE 57.38 Open reduction and internal fixation of proximal humeral shaft fracture. Sutures placed in rotator cuff can be used to assist reduction of tuberosities. SEE TECHNIQUE 57.5.

FIGURE 57.37 TECHNIQUE 57.4.

Repair of rotator cuff after nail insertion. SEE

lary nerve to a level where the axillary nerve overlies the junction of the head and shaft of the plate (Fig. 57.40B). While positioning the plate, be sure to stay on the “bare spot” on the lateral cortex posterior to the bicipital groove (Fig. 57.40C) to avoid the humeral head penetrating vessels. n  Secure the plate to the humeral shaft through the lower soft-tissue window distal to the axillary nerve. n  After thorough irrigation, close the raphe and deltoid fascial layers with absorbable sutures. Place a suction drain and close the subcutaneous tissue in layers.

POSTOPERATIVE CARE  Postoperative care is the same as that after Technique 57.5.   

Make a 10-cm skin incision from the palpable anterolateral edge of the acromion distally in line with the fibers of the deltoid. n  Identify the deltoid fascia and anterior deltoid raphe between the anterior middle heads of the deltoid (Fig. 57.40A) and split the raphe in line with its fibers for several centimeters. For maximal exposure, split the deltoid up to the margin of the acromion but do not split it distally more than 5 cm from its origin to avoid damage to the axillary nerve. To prevent damage to the axillary nerve from too-distal dissection, place a stay suture at the inferior border of the deltoid raphe. n  If the nerve is in proximity to a fracture line, gently explore it. If it is tethered or incarcerated in the fracture, gently free it. n  Reduce the fracture fragments with indirect reduction techniques, working within the tuberosity fracture lines if present. If extension of the subdeltoid interval anteriorly is necessary, take care to handle the soft tissues carefully. n  With the fracture reduced and the axillary nerve protected, slide the plate from proximal to distal under the axil n 

COMPLICATIONS

The most common complication of proximal humeral fractures is loss of motion (stiffness). Early physical therapy is associated with improved motion, but many patients do not recover full motion even with early physical therapy. Impingement from high-riding tuberosities or subacromial scarring also can limit motion. Nonunion also is fairly common, but nonunion rates have been decreasing with the use of new technologies such as locking plates and improved intramedullary nails. Malunion can result from unstable or delayed fracture fixation, patient factors, and poor surgical technique. In older patients with limited functional demands, malunion generally is well tolerated, but it may be debilitating in younger patients because of poor shoulder function, impingement, or rotator cuff tears. Osteonecrosis is relatively uncommon after nondisplaced or unoperated two-part and three-part fractures; functional outcome is improved if the proximal humeral anatomy has been restored. The presence of osteonecrosis does not always result in a poor outcome; osteonecrosis

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B

A

FIGURE 57.39 Open reduction and internal fixation of proximal humeral shaft fracture (see text). A and B, Sutures used for reduction and fixation of tuberosity fragments. SEE TECHNIQUE 57.5. Superior

Superior

1cm

Bare spot

Axillary nerve Anterior deltoid raphe Axillary nerve

A

C

B

FIGURE 57.40 Internal fixation of proximal humeral fracture through anterolateral acromial approach. A, Raphe between anterior and middle head of deltoid is developed. B, With axillary nerve protected, plate is slid deep to nerve. C, “Bare spot” on lateral humerus posterior to bicipital groove; plate position here avoids humeral head penetrating vessels. (From Gardner MJ, Voos JE, Wanich T, et al. Vascular implications of minimally invasive plating of proximal humerus fractures. J Orthop Trauma 2006;20:602-607). SEE TECHNIQUE 57.6.

may be evident radiographically but cause minimal symptoms. Because late hemiarthroplasty has poorer results than early hemiarthroplasty, it is important to be sure that ORIF can adequately stabilize four-part fractures and restore humeral anatomy before this option is chosen. 

FRACTURES OF THE HUMERAL SHAFT Fractures of the humeral shaft account for approximately 3% of all fractures; most can be treated nonoperatively. Charnley stated, “It is perhaps the easiest of the major

long bones to treat by conservative methods.” The range of motion afforded by the shoulder and elbow joints, coupled with a tolerance for small amounts of shortening, allow radiographic imperfections that cause minimal functional deficit and are well tolerated by the patient. Historically, methods of conservative treatment have included skeletal traction, abduction casting and splinting, Velpeau dressing, and hanging arm cast, each with its own advantages and disadvantages. Functional bracing has essentially replaced all other conservative methods and has become the “gold standard” for nonoperative treatment because of its ease of application, adjustability, allowance of shoulder and elbow

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM motion, relatively low cost, and reproducible results. Initially popularized by Sarmiento in 1977, the functional brace works on the principles of the hydraulic effect of the brace, active contraction of the muscles, and beneficial effect of gravity. Union rates of 77% to 100% have been reported with this technique (Papasoulis et al. 2010). In a randomized controlled trial comparing minimally invasive plate osteosynthesis and functional bracing, Matsunaga et al. reported a 15% nonunion rate with functional bracing. Driesman et al. reported 84 consecutive patients with diaphyseal humeral fractures managed nonoperatively. Within 6 months 87% of fractures healed. They noted that a mobile humeral shaft fracture at the 6-week follow-up visit was a predictor of nonunion with 82% sensitivity and 99% specificity. This author counsels patients appropriately as to risk of developing a nonunion if fracture site variability exists at 6 weeks. We currently use a coaptation splint or hanging arm cast for the first 7 to 10 days to allow pain to subside and then convert to a prefabricated functional brace. The use of a sling is discouraged to avoid varus and internal rotation deformities. Pendulum exercises are started early, and use of the extremity is encouraged as tolerated, avoiding active shoulder abduction. The brace is worn until the patient is pain free and there is radiographic evidence of union. Skin maceration is a concern, so daily hygiene is stressed. Morbid obesity may increase the risk of varus deformities; however, these deformities are more of a cosmetic issue than a functional issue and often are not evident in an obese arm. Shields et al. showed no correlation between residual deformity and functional outcome scores. A nonrandomized study by Jawa et al. compared outcomes in 21 distal-third diaphyseal fractures treated with functional bracing to those of 19 treated with plate-and-screw fixation. Operative treatment resulted in more predictable alignment and faster healing but was associated with more complications, such as iatrogenic nerve injury, loss of fixation, and infection. Plate-and-screw fixation was done in two patients initially treated with bracing because of concerns about alignment. Complications associated with bracing included skin breakdown and malunion. The advantages, disadvantages, and risks of both nonoperative and operative treatment should be discussed with the patient before a decision is made. We reserve the use of a hanging arm cast for patients in whom compliance or finances preclude the use of a functional brace. Guidelines for acceptable reduction include less than 3 cm of shortening, angulation of less than 20 degrees, and rotation of less than 30 degrees. In a series of 32 patients with humeral shaft fractures treated nonoperatively, Shields et  al. found that residual angular deformity ranging from 0 to 18 degrees in the sagittal plane and from 2 to 27 degrees in the coronal plane had no correlation with patient-reported outcomes.

INDICATIONS FOR OPERATIVE TREATMENT

The choice of operative treatment for a humeral shaft fracture depends on multiple factors. McKee divided the indications for operative treatment into three categories: (1) fracture indications, (2) associated injuries, and (3) patient indications (Box 57.2). Some indications are more absolute than others. Failure of conservative treatment, pathologic fracture, displaced intraarticular extension, vascular injury, and brachial



BOX 57.2

Indications for Primary Operative Treatment of Humeral Shaft Fractures Fracture Indications n Failure to obtain and maintain adequate closed reduction Shortening >3 cm Rotation >30 degrees Angulation >20 degrees n Segmental fracture n Pathologic fracture n Intraarticular extension (shoulder joint, elbow joint)  Associated Injuries n Open wound n Vascular injury n Brachial plexus injury n Ipsilateral forearm fracture n Ipsilateral shoulder or elbow fracture n Bilateral humeral fractures n Lower extremity fracture requiring upper extremity weight bearing n Burns n High-velocity gunshot injury n Chronic associated joint stiffness of elbow or shoulder  Patient Indications n Multiple injuries, polytrauma n Head injury (Glasgow Coma Scale score = 8) n Chest trauma n Poor patient tolerance, compliance n Unfavorable body habitus (morbid obesity, large breasts) From McKee MD: Fractures of the shaft of the humerus. In Bucholz RW, Heckman JD, Court-Brown CM, editors: Rockwood and Green’s fractures in adults, ed 6, Philadelphia, 2006, Lippincott Williams & Wilkins.

plexus injury almost always require surgery. Other conditions, such as minimally displaced segmental fractures and obesity, are only relative indications. Our most common indication for operative treatment is early mobilization of patients with polytrauma. Treatment decisions must take all factors into consideration, tailoring the treatment to the specific patient. The goal of operative treatment of humeral shaft fractures is to reestablish length, alignment, and rotation with stable fixation that allows early motion and ideally early weight bearing on the fractured extremity. Options for fixation include plate osteosynthesis, intramedullary nailing, and external fixation. External fixation generally is reserved for high-energy gunshot wounds, fractures with significant soft-tissue injuries, and fractures with massive contamination. Suzuki et al. suggested that immediate external fixation with planned conversion to plate fixation within 2 weeks is a safe and effective strategy for treatment of humeral shaft fractures in selected patients with multiple injuries or severe soft-tissue injuries that preclude early plate fixation; however, two of their 17 patients, both with open fractures, developed deep infections after conversion from external fixation to plating. 

PLATE OSTEOSYNTHESIS

Plate osteosynthesis remains the gold standard of fixation for humeral shaft fractures. Plating can be used for fractures with

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS proximal and distal extension and for open fractures. It provides enough stability to allow early upper extremity weight bearing in polytrauma patients and produces minimal shoulder or elbow morbidity, as shown by Tingstad et al. Numerous reports in the literature cite high union rates, low complication rates, and rapid return to function after plate fixation of humeral shaft fractures. Five large series (Foster et al., McKee et  al., Vander Griend et  al., Bell et  al., and Tingstad et  al.) including 361 fractures had an average union rate of 96.7%. A prospective, randomized comparison of plate fixation and intramedullary nail fixation of humeral shaft fractures found no significant differences in the function of the shoulder and elbow, but shoulder impingement occurred more often with intramedullary nailing, and a second surgical procedure was required in more patients with intramedullary nails than with a plate. Another study comparing antegrade intramedullary nailing with plating found that although patients had slightly more shoulder pain after intramedullary nailing than after plating, there was no difference in shoulder joint function except for flexion, which was better in patients with plating. A metaanalysis of the literature that included 155 patients found that reoperation and shoulder impingement were significantly more common after intramedullary nailing than after compression plating. In their updated meta-analysis, Heineman et al. concluded that the data were insufficient to show superiority of either technique. Gottschalk et al., however, noted that although complication rates in regard to infection and nerve palsies were significantly lower in intramedullary nailing compared with ORIF with plates (3.1% compared with 7.8%, and 1.5% compared with 3.0%, respectively), mortality was higher with intramedullary nailing (4.9% vs. 0.7%, respectively), and intramedullary nailing had significantly more pathologic fractures than open reduction with plate fixation (26.8% compared with 1.5%, respectively).

FIGURE 57.41 Anterior plating of humeral shaft fracture with limited-contact dynamic compression plate in neutralization mode with lag screw.

IMPLANT CHOICE

The most commonly used plate for fixation of humeral shaft fractures is the broad, 4.5-mm, limited-contact dynamic compression plate (Fig. 57.41); occasionally, a narrow, 4.5- or 3.5-mm, limited-contact dynamic compression plate is used for smaller bones. The distal metaphyseal-diaphyseal transition zone may require dual 3.5-mm, limited-contact dynamic compression plates (Fig. 57.42) or newer plates designed specifically for the metaphysis. For spiral or oblique fractures, the ideal construct consists of a lag screw with a neutralization plate, whereas transverse fractures are ideally suited for a compression plating technique. In these fractures, attaining provisional reduction with a lag screw, Kirschner wire, or mini-fragment plate (Eglseder technique) allows direct observation of the reduction and a relatively simple plate application on the reduced humeral shaft (Fig. 57.43); we believe this also limits periosteal stripping by clamps. Comminuted fractures may require a bridge plating technique. Anatomic reduction of each fracture fragment is unnecessary. Attaining correct alignment, rotation, and length without disrupting the soft-tissue attachments to the comminuted fragments often leads to successful healing. Livani et  al. reported 15 patients with bridge plating done through two small incisions proximal and distal to

FIGURE 57.42 Dual plating of distal metaphyseal-diaphyseal humeral shaft fracture.

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B

A

FIGURE 57.43 A, Displaced humeral shaft fracture. B, After fixation with mini-fragment plate (Eglseder technique) and compression plating.

the fracture; all fractures united within 12 weeks except for a grade III open fracture with an associated brachial plexus injury. In patients with poor bone quality, longer implants should be used to improve stability (Fig. 57.44). Locking plates and screw augmentation with methyl methacrylate have been reported to add more stability to the construct. Generally, at least eight cortices (four screws) above and below the fracture are necessary to avoid screw pullout. The length of the plate is as important as the number of screws. More screws and longer plates for a greater working length of the implant may be needed for instability caused by poor bone quality or fracture comminution. We reserve the use of locking screws for poor bone quality and short segments. 

APPROACH

Numerous approaches can be used for plate fixation of the humerus. Fractures of the middle or proximal third usually are best approached through an anterolateral approach (brachialis-splitting approach). A posterior approach (triceps-splitting or modified posterior approach) is best for fractures that are midshaft or extend into the distal third of the humerus (Fig. 57.45). Gerwin, Hotchkiss, and Weiland described a modified posterior approach in which the triceps is reflected medially off the lateral intermuscular septum (see Technique 57.7). This approach exposes an average 10 cm more of the humeral shaft than the standard posterior approach. Less frequently, a direct lateral or anteromedial approach may be appropriate. A recent study using this approach showed high union rates and low complications. 

POSTOPERATIVE CARE

Postoperatively, range of motion of the shoulder and elbow is begun within the first week and weight bearing usually is allowed if fixation is stable. A biomechanical study found that both large (4.5-mm) and small (3.5-mm) plate constructs would experience plastic deformation during bilateral crutch weight bearing in patients weighing 50 kg (∼110 lb) or more. The large construct was not predicted to fail with loads of 90 kg (almost 200 lb) or less, whereas the small-fragment construct was predicted to fail in patients weighing 70 kg (approximately 150 lb) or more. 

COMPLICATIONS

The most frequently reported complication after plate fixation of humeral shaft fractures is radial nerve palsy. Primary radial nerve injury ranges from 4% to 22%; iatrogenic or secondary injury has been reported to be 0 to 10% (Chang and Ilyas et  al.) and is more common in ORIF techniques. Gausden et al.’s report on a single series of a triceps-reflecting approach for ORIF demonstrated a 4% secondary nerve injury rate in a single experienced trauma surgeon’s practice. When using an anterolateral (brachialis-splitting) approach, it is essential to ensure that the nerve is not under the implant during plate application to avoid iatrogenic radial nerve injury. Posteriorly, soft-tissue tethers on the radial nerve can lead to iatrogenic injury in posterior approaches. This can be remedied by adequate soft-tissue release off the radial nerve. Infection is reported to occur after 1% to 2% of closed humeral fractures and 5% of open fractures. Refractures occur in approximately 1% of patients. Nonunion of humeral shaft fractures is infrequent. Treatment of nonunion is discussed in Chapter 59. 

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B

A

C

FIGURE 57.44 A, Segmental shaft fracture with extension into proximal humerus. B and C, Long plate used to obtain secure fixation.  

OPEN REDUCTION AND INTERNAL FIXATION OF THE HUMERAL SHAFT THROUGH A MODIFIED POSTERIOR APPROACH (TRICEPS-REFLECTING)

TECHNIQUE 57.7

Place the patient in a lateral decubitus position. Use a wide proximal preparation and drape to allow for the use of a sterile tourniquet. n  Make an incision from the tourniquet to the tip of the olecranon in line with the humerus (Fig. 57.46A). n  Carry dissection down to the triceps fascia, incise the fascia, and carry the dissection laterally to the intermuscular septum (Fig. 57.46B). n  Identify the lower lateral brachial cutaneous nerve and follow it proximally where it meets the radial nerve as it pierces the septum (Fig. 57.46C). This usually is at the level of the tourniquet. Release the tourniquet. n  Identify the radial nerve. n  Dissect the triceps muscle proximally off the intermuscular septum. n  Free the radial nerve proximally, distally, anteriorly, and posteriorly, including incision of the lateral intermuscular septum for 3 cm to allow mobilization of the nerve (Fig. 57.46D). n  Incise the triceps off the periosteum to expose the humerus; preserve as much of the periosteum as possible. n  Proximally, reflect the posterior border of the deltoid anteriorly if needed for exposure. n  n 

A

B

FIGURE 57.45 A, Fracture of distal third of humeral shaft. B, After plate fixation through posterior triceps-splitting approach.

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A

C

D

E

F

G

FIGURE 57.46 Open reduction and internal fixation of humeral shaft fracture through modified (triceps-reflecting) posterior approach. A, Incision. B, Incision of fascia to expose intramuscular septum. C, Identification of lateral brachial cutaneous nerve. D, Mobilization of radial nerve. E, Bone clamp used to control fragments. F, After debridement, fixation with lag screw. G, After plate application. SEE TECHNIQUE 57.7.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Place a single bone clamp in the proximal and distal fragments, far away from the fracture, to control the fragments and reflect the triceps (Fig. 57.46E). Avoid circumferential stripping of the soft tissues with the clamp. n  After debridement of the fracture site, insert a lag screw for provisional fixation (Fig. 57.46F). Alternatively, for transverse fractures where lag screw fixation is difficult, a compression plating technique can be used, or a minifragment plate (Eglseder technique) can be used for provisional fixation, followed by plate fixation. n  Perform large-fragment plating in neutralization, compression, or bridge-plating mode (Fig. 57.46G). n  Confirm alignment of the humerus and reduction of the fragments with fluoroscopy. n  Perform routine skin closure over a drain.     n 

BOX 57.3



Basic Minimally Invasive Plate Osteosynthesis Principles . Thorough knowledge of upper extremity anatomy 1 2. Awareness of at-risk structures, notably the radial nerve 3. Skilled at indirect reduction techniques 4. Understanding of a functional reduction: length, alignment, and rotation 5. Techniques of plate provisional fixation that allows assessment of reduction and plate placement 6. A good understanding of relative stability and secondary bone healing

Begin the distal incision 1 to 2 cm proximal to the antecubital crease and extend it proximally for 4- to 5-cm in the midline (see Fig. 57.47C). n  Identify the interval between the biceps and brachialis laterally and retract the biceps medially. Protect the lateral antebrachial cutaneous nerve beneath (Fig. 57.47E). n  Split the brachialis longitudinally by blunt dissection to bone. Keep the forearm supinated to protect the radial nerve in the distal portion of the approach. n  Obtain provisional fracture reduction under fluoroscopic control and develop a submuscular extraperiosteal tunnel, connecting the two incisions (see Fig. 57.47C). n  Insert a locking compression plate (Fig. 57.47F). If the patient depends on the operated limb for ambulation (polytraumatized patient with lower extremity fractures that limit mobilization), a narrow 4.5-mm plate is used. Align the proximal segment of the plate and use a single unlocked screw to reduce the plate to the anterior humeral cortex. The plate can be precontoured to achieve the most anatomic reduction (Fig. 57.47G and H). n  Augment fixation with two additional locked screws, using the plate to assist with reduction. Then align the distal segment of the plate, checking fracture reduction with fluoroscopy. Correct any malalignment at this time; rotation may be the most difficult to judge correctly. n  Manually compress the fracture site to limit distraction that may result in delayed union. n  After provisional fixation, assess rotation by directly comparing rotational excursion with the opposite limb. n  Reduce the plate to the distal humerus with a single unlocked cortical screw and augment with two additional locked screws. n 

 

MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS Minimally invasive plate osteosynthesis has been shown to be a successful technique in other anatomic areas of the body, particularly the femur and tibia. The theoretical advantages in the upper extremity are (1) less soft-tissue damage, (2) avoidance of shoulder pain as seen with intramedullary nailing, and (3) secondary bone healing. Case reports of minimally invasive plate osteosynthesis of the humeral shaft was first described by Fernández Dell’Oca in 2002, but the first small series was described by Livani and Belangero. They reported 14 of 15 successful unions with this technique. Since then numerous case series, comparative studies, randomized controlled trials, systematic reviews, and meta-analyses have been reported. The data suggest that minimally invasive plate osteosynthesis of the humeral shaft has low nonunion rates, low complication rates, and minimal shoulder problems. On the other hand, this technique is technically challenging and is subject to a learning curve. Surgeons skilled at minimally invasive plate osteosynthesis in other long bones should be able to adopt the technique swiftly. However, surgeons with minimal skills in minimally invasive techniques need to be careful, and should consider a gradual transition from full open to minimally invasive plate osteosynthesis. Box 57.3 outlines basic minimally invasive plate osteosynthesis principles. Tetsworth et al. have written an excellent state-of-the-art review paper on this subject.



TECHNIQUE 57.8

POSTOPERATIVE CARE  A sling is used for comfort for

(APIVATTHAKAKUL ET AL.; TETSWORTH ET AL.) Place the patient supine on a radiolucent table, with the elbow in mild flexion to relax the biceps and mark the incisions (Fig. 57.47A,B). n  Through a deltopectoral approach, make a proximal incision inferiorly, using the biceps groove and pectoralis tendon as landmarks, and expose the proximal diaphysis immediately lateral to the biceps tendon (Fig. 57.47C,D). n 

the first 2 weeks postoperatively. Range of motion of the shoulder and elbow (active and assisted) is encouraged immediately without restrictions and gradually increased with emphasis placed on full elbow extension. Minor functional limitations are placed on the arm until solid bridging is noted radiographically, and patients can return to unrestricted activity at 4 to 6 months (Fig. 57.48).   

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A

B

C

D

E

F

G

H

FIGURE 57.47 A, Closed midshaft right humeral shaft fracture. B, Planned incision for 14-hole plate. C, Two incisions on anterior arm connected by a submuscular extraperiosteal tunnel. D, Proximal 4- to 5-cm incision at level of pectoralis major insertion, with cephalic vein preserved. E, Distal 4- to 5-cm incision proximal to antecubital crease; lateral antebrachial cutaneous nerve identified beneath biceps. F, Provisional reduction and alignment after plate insertion. G, Plate contoured to match normal anterior humeral cortical surface. H, Plate internally rotated 15 to 20 degrees through its midportion, consistent with normal anatomy. (From Tetsworth K, Hohmann E, Glatt V: Minimally invasive plate osteosynthesis of humeral shaft fractures: current state of the art, J Am Acad Orthop Surg 26:252, 2018.) SEE TECHNIQUE 57.8.

INTRAMEDULLARY FIXATION

The success of intramedullary nailing in the lower extremities led to an initial enthusiasm for intramedullary nailing of the humeral shaft. Although there are many reports in the literature of good results with nailing techniques, problems with insertion site morbidity and union rates have dampened the original enthusiasm for this mode of treatment. Shoulder pain has been reported after antegrade intramedullary nailing in

16% to 37% of patients in more recent studies, and Bhandari et al. found that reoperation and shoulder impingement were significantly more common after intramedullary nailing than after plate fixation. A systematic review by Zhao et al. found no differences in union rate, infections, or iatrogenic injury to the radial nerve. The risk of shoulder complications, however, was higher. Confounding variables, such as flexible or rigid nails;

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A

B

FIGURE 57.49 Humeral shaft fracture treated by closed intramedullary nailing with multiple flexible intramedullary (Ender) nails.

C

D

FIGURE 57.48 A and B, Eight weeks postoperatively demonstrating early callus formation with minor varus alignment. C and D, One year postoperatively demonstrating mature bridging callus. (From Tetsworth K, Hohmann E, Glatt V: Minimally invasive plate osteosynthesis of humeral shaft fractures: current state of the art, J Am Acad Orthop Surg 26:252, 2018.) SEE TECHNIQUE 57.8.

antegrade or retrograde insertion; and lateral, anterolateral, or extraarticular portal for antegrade insertion, make conclusions difficult to interpret. A large well-controlled trial is needed. Early flexible nails, such as Rush and Enders, provided little axial or rotational stability and required additional forms of stabilization (cerclage wiring or prolonged immobilization) in comminuted or unstable fractures (Fig. 57.49). Even with additional stabilization, the resulting construct generally was not stable enough to allow early motion or weight bearing in multiply injured patients with concomitant lower extremity injuries. The development of locking nails improved stability and rotational control but results still did not reach the successful outcomes obtained in lower extremity fractures.

Because nail sizes were limited, reaming was required for insertion of most locked nails, and fracture distraction was a problem, especially in small medullary canals. Newer nails come in smaller sizes (7, 8, or 9 mm) to fit smaller bones and can be inserted with or without reaming. An antegrade approach is most commonly used for intramedullary nail fixation of humeral shaft fractures in adults. The specific portal placement is controversial, however. Traditionally, a midacromial lateral incision was used, which tends to place the nail through the posterior humeral head. In addition, the incision through the rotator cuff is not in line with the fibers of the tendon (see Fig. 57.34). An anterolateral starting portal is in line with the humeral medullary canal, and the incision is in line with the fibers of the rotator cuff. Several authors have postulated that shoulder pain after antegrade nailing is caused by the transverse incision through the rotator cuff. Alternatives to antegrade humeral nailing (e.g., plate osteosynthesis) should be considered in patients who have preexisting shoulder pathology or who require upper extremity weight bearing for ambulation (paraplegic or amputee patients). Because of the frequency of shoulder pain after antegrade insertion, retrograde insertion has been advocated to avoid this complication; however, retrograde insertion has been associated with distal humeral fracture propagation. The traditional starting point for retrograde humeral nailing is in the midline, 2 cm above the olecranon fossa. More recently, insertion through the superior aspect of the olecranon fossa has

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM been recommended. Proposed advantages of the olecranon fossa site include an increase in the effective working length of the distal fracture segment and straight alignment with the medullary canal; however, biomechanical studies have shown less resistance to torque and a reduction in load-to-failure with this approach compared with the more superior portal. Although flexible humeral nails have been successful in obtaining fracture union, insertion site morbidity and their suitability for only the most stable fracture patterns have limited their use. A cadaver study found that the axillary nerve is at significant risk during insertion of the interlocking and tension screws of a titanium flexible humeral nail; blunt dissection through the deltoid, direct observation of the humeral cortex, and use of a soft-tissue sleeve during predrilling and placement of the screws can help prevent this complication. Newer self-locking expandable nails are reported to be easier to insert, while providing bending and torsional stiffness equal to that of locked nails. Few clinical studies are available to allow evaluation of these nails. Franck et al. described the use of an expandable nail (Fixion; Disc-o-Tech, Herzliya, Israel) for fixation of 25 unstable humeral shaft fractures in elderly patients with osteoporotic bone; all fractures healed without complications. Stannard et  al. used a flexible locking nail (Synthes, Paoli, PA) inserted through an extraarticular antegrade or retrograde portal for fixation of 42 humeral shaft fractures, with healing in 39; 86% had full range of motion, and 90% had no pain. Five complications occurred in four patients: two nonunions, two hardware failures, and one wound infection. All complications occurred in patients whose fractures were fixed with 7.5-mm nails, and the authors recommended that flexible nails should be used with caution in medullary canals with a diameter of 8 mm or less. The technique is technically demanding. Currently, we prefer rigid, locked nails inserted through an antegrade approach when intramedullary nailing is indicated, such as for segmental fractures (see Fig. 57.27), for proximal-to-middle third junction fractures, for pathologic fractures, for fractures with poor soft-tissue coverage, for fractures in obese patients, and for fractures in certain patients with polytrauma (Fig. 57.50A-C). We use an anterolateral incision with direct inspection and repair of the rotator cuff. Iatrogenic radial nerve injury has been reported, and care must be taken during fracture reduction, reaming, nail insertion, and locking screw placement. Intramedullary nailing is contraindicated in patients with very narrow medullary canals. 

Position the patient on a radiolucent table with the thorax “bumped” 30 to 40 degrees. Place the image intensifier unit on the opposite side of the table from the surgeon (see Fig. 57.33); rolling the unit back allows an adequate anteroposterior view, and rolling it forward allows an adequate lateral view of the shoulder and humerus. n  Make an incision diagonally from the anterolateral corner of the acromion, splitting the deltoid in line with its fibers in the raphe between the anterior and middle thirds of the deltoid (see Fig. 57.34). To protect the axillary nerve, avoid splitting the deltoid more than 5 cm distal to the acromion. n  Under direct observation, incise the rotator cuff in line with its fibers (see Fig. 57.34). Use full-thickness sutures to protect the cuff from damage during reaming of the humeral canal. n  Place the initial guidewire posterior to the biceps tendon and advance it under fluoroscopic guidance into the appropriate position as shown on anteroposterior and lateral views (see Fig. 57.33). n  Carefully advance the proximal reamer, protecting the rotator cuff. n  Use the reduction device to reduce the fracture and pass the bead-tipped guidewire (Fig. 57.50E and F). With sequentially larger reamers, ream the humerus to the predetermined diameter, usually 1.0 to 1.5 mm larger than the nail diameter (Fig. 57.50G). With fractures of the middle third of the shaft, a small incision can be made at the fracture site to ensure manually that the radial nerve is not entrapped in the fracture before reduction and reaming. n  When reaming is complete, pass the nail down the humeral canal, avoiding distraction of the fracture; ensure that the nail is below the articular surface of the humeral head. n  With the use of the outrigger device, insert the proximal locking bolts (Fig. 57.50H). Carefully spread the soft tissues to avoid injury to the axillary nerve. n  Place the distal interlocking screws in an anterior-to-posterior direction to avoid the radial nerve. Make a 4- to 5-cm incision anteriorly to expose the biceps musculature; bluntly split the muscle to avoid iatrogenic damage to the brachial artery. n  Repair the rotator cuff with full-thickness sutures. n  Confirm reduction and screw length on anteroposterior and lateral fluoroscopy images (Fig. 57.50I). n  Begin an early rehabilitation program with active-assisted range-of-motion exercises.     n 

 

ANTEGRADE INTRAMEDULLARY NAILING OF HUMERAL SHAFT FRACTURES

TECHNIQUE 57.9 Carefully evaluate preoperative radiographs (Fig. 57.50D) to ensure that the diaphyseal diameter is adequate to accommodate the intramedullary nail; if the diameter is too small, plate fixation is indicated.

n 

FRACTURES OF THE HUMERAL SHAFT WITH RADIAL NERVE PALSY The radial nerve is the nerve most frequently injured with fractures of the humeral shaft because of its spiral course across the back of the midshaft of the bone and its relatively fixed position in the distal arm as it penetrates the lateral intermuscular septum anteriorly (Fig. 57.51). Usually the radial nerve injury is a neurapraxia, with recovery rates of 100% in low-energy injuries and up to 71% in high-energy

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B

A

D

E

C

F

G

FIGURE 57.50 Intramedullary nailing of humeral shaft fracture (see text). A, Segmental shaft fracture in patient with multiple trauma. B and C, After fixation with intramedullary nail. D, Transverse shaft fracture. E and F, Reduction device is used to reduce fracture. G, Reaming is done to 1.0 to 1.5 mm larger than nail diameter.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

H

I FIGURE  57.50, CONT’D H, Outrigger device is used for insertion of proximal locking bolts.I, Reduction and screw placement confirmed with fluoroscopy. (D-I courtesy Thomas A. Russell, MD, Memphis, TN.) SEE TECHNIQUE 57.9.

Right anterior view

Humerus Fascia of posterior compartment Lateral intermuscular septum

Fascia of anterior compartment

Radial nerve

Radius

A

Ulna

B

FIGURE 57.51 Entrapment of radial nerve between fragments in spiral fracture of distal third of humerus. A, Nerve is least mobile as it passes through lateral intermuscular septum in distal third of arm. B, Oblique fracture is typically angulated laterally, and distal fragment is displaced proximally. Radial nerve, fixed to proximal fragment by lateral intermuscular septum, is trapped between fragments when closed reduction is attempted.

open injuries; Bumbasirevic et  al. reported recovery in 94% of 16 open fractures. Although it is possible for the nerve to be severed by the sharp edge of a bone fragment, this rarely occurs. We treat the fractured humeral shaft in the usual nonoperative manner, support the wrist and fingers with a dynamic splint, and reserve exploration of the nerve for instances when function has not returned in 3 to 4 months and the fracture has healed. Because the nerve usually is only bruised or stretched, function can be expected to return spontaneously. Routine exploration of the nerve would subject many patients to an unnecessary operation and might increase the frequency of complications. Early exploration and repair of a severed nerve have not been proved to produce any better results than repair at a later date. If radial nerve palsy occurs with an open fracture of the humeral shaft, the nerve should be explored at the time of the irrigation and debridement of the wound. If it is found intact, only watchful waiting is required while the fracture heals. Early exploration is required if evidence suggests that the radial nerve is impaled on a bone fragment or is caught between the fragments. Advances in ultrasonography have been useful in diagnosing entrapped and lacerated radial nerves. If this diagnostic tool proved to be reproducible in large numbers of patients, the indications for nerve exploration would be more specifically defined. In patients with radial nerve palsy for whom operative treatment of a humeral shaft fracture is indicated, the nerve should be explored at the time of fracture fixation. Shao et  al. reviewed 21 scientific articles that included 4517 humeral shaft fractures and found an overall prevalence of radial nerve palsy of almost 12% (n = 532). Radial nerve palsy was most frequent with fractures of the middle and middle-distal humeral shaft and was more common

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Closed injury

Open injury

Multiple injuries Segmental fracture Floating elbow Major vascular injury Coma

Nerve exploration

Fracture immobilization Vascular repair, etc.

Observe

Ultrasound within 3 weeks, if possible

Intact contused

Entrapped

Observe

Extrication

Severed Partially severed

Surgical repair

Calculated waiting time interval

Improved

Unimproved

No surgical exploration

EMG, NAP, NCV before exploration

Injury extent indistinguishable

Surgical repair impossible

Mark the nerve Second exploration in 2 to 3 months Tendon transfer after fracture healed

FIGURE 57.52 Treatment algorithm for radial nerve palsy associated with humeral shaft fracture. EMG, Electromyogram; NAP, nerve axonal physiology; NCV, nerve conduction velocity. (From Shao YC, Harwood P, Grotz MR, et al: Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review, J Bone Joint Surg 87B:1647, 2005.)

with transverse and spiral fractures than with oblique or comminuted fractures. Overall, recovery occurred in 88%. Complete transection of the radial nerve usually occurs with open fractures of the humerus and requires nerve repair or grafting; most nerve palsies that occur with a closed fracture recover without treatment. Based on their review, Shao et  al. developed an algorithm for the treatment of radial nerve palsy associated with humeral shaft fractures (Fig. 57.52).

PERIPROSTHETIC HUMERAL SHAFT FRACTURES

Periprosthetic humeral shaft fractures after shoulder or elbow arthroplasty are rare but can be difficult to treat. Poor bone stock from osteoporosis, osteomalacia, or rheumatoid arthritis is the major contributing factor, and a variety of fracture patterns can result from low-energy direct blows, minor twisting injuries, “same level” falls, or intraoperative technical errors. Fractures around humeral arthroplasties may occur at the tuberosity level, the metaphysis, or the upper diaphysis around the stem or distal to the stem tip. Fractures around the humeral component of total elbow arthroplasties also can occur at any level from the medial or lateral column to proximal to the stem tip. Stable postoperative fractures without component loosening can be treated conservatively with immobilization.

Stable fractures with component loosening require revision immediately or after fracture healing if still painful. Unstable fractures with or without component loosening require operative fixation with or without component revision. If revision is necessary, the general principles of revision arthroplasty should be followed (see Chapter 12). Bone quality determines the need for supplemental allograft, strut grafts, methyl methacrylate cement, or autogenous bone grafts. Most patients requiring either hemiarthroplasty or total shoulder arthroplasty or elbow arthroplasty have agerelated osteoporosis. When treating unstable periprosthetic humeral shaft fractures with well-fixed components, we have found the following guidelines helpful as outlined by Cameron and Iannotti: (1) displaced tuberosity fractures should be repaired with wire or heavy suture, and associated rotator cuff tears should be treated; and (2) unstable diaphyseal fractures around or below the prosthesis require ORIF. Cerclage wire or limited screw fixation is unsatisfactory. A heavy plate with proximal cerclage wires and distal screws is preferred. At least four proximal cables and four distal screws, engaging eight cortices, are necessary. We recommend using 2-mm cables instead of the usual 1.6-mm cables. An anatomic reduction is necessary for union, and bone grafting the fracture site should be considered.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM When poor bone quality is present, fixation can be supplemented with methyl methacrylate cement. Cement should be kept out of the fracture site. If severe osteopenia is present, we recommend adding a full-thickness cortical allograft strut applied with additional cables 90 degrees to the plate-cablescrew construct. Autograft bone should be applied to the fracture site. We do not believe that a well-fixed, good functional shoulder or elbow arthroplasty should be revised to a long-stem implant just to repair a postoperative shaft fracture. Results with revision shoulder and elbow arthroplasty are not as satisfactory as primary arthroplasty. Instead, we believe every effort should be made to achieve primary fracture union. Intraoperative fractures during shoulder arthroplasty can be avoided by careful attention to detail and respect for osteopenic bone. Intraoperative fractures should be repaired at the time of surgery by internal fixation or revision to a longer stem implant. The general treatment principles of periprosthetic humeral fractures around the humeral component of total elbow arthroplasties are as just outlined. Fractures of the medial or lateral column with a firmly seated implant can be treated with immobilization. Union of a column fracture is unnecessary for a good functional outcome. 

A

High T

B

Low T

C

Y

D

H

E

Medial Lambda

F

Lateral Lambda

DISTAL HUMERAL FRACTURES

Fractures of the distal humerus remain a challenging problem despite advances in technique and implants. These injuries often involve articular comminution, and many occur in older patients with osteoporotic bone. Joint function often is compromised because of stiffness, pain, and weakness. Rarely is a “normal” elbow the outcome after these fractures, but outcomes have been improved with advances in implant technology, surgical approaches, and rehabilitation protocols, with good to excellent results reported in approximately 87% of patients. Most distal humeral fractures in adults must be treated operatively, in contrast to fractures of the proximal humerus or humeral shaft. Nonoperative treatment with the “bag of bones” technique may be reasonable in an elderly patient with significant medical comorbidities. Desloges et al. reported good to excellent subjective outcomes with this technique in 13 of 19 low-demand elderly patients. Alternatively, Shannon et  al. have reported the shock-trauma experience of treating elderly patients with comminuted distal humeral fracture with ORIF. Fractures united in all 16 patients in their series, with only an 18% reoperation rate. Both ORIF and total elbow arthroplasty have been reported to obtain good outcomes in lower-demand patients. In their meta-analysis, Githens et al. found that total elbow arthroplasty and ORIF produced similar functional scores, although there was an insignificant trend toward more complications and reoperations after open reduction. The many variables that must be considered in choosing treatment include fracture patterns, comminution, bone quality, surgeon experience (with total elbow arthroplasty and/or ORIF), underlying arthrosis, and patient comorbidities, making it imperative to individualize treatment according to patient and fracture characteristics. The complexity of distal humeral fractures in adults is reflected in the attempts at classifying the variety of

FIGURE 57.53 A to F, Mehne and Matta classification of distal humeral fractures.

injuries possible in this location. The AO/OTA classification, if all subgroup classifications are used, defines 61 types, although the three kinds of articular involvement are the most commonly used designations: A, extraarticular; B, partially articular; and C, completely articular. A more recent classification system suggested by Jupiter and Mehne is simpler: it describes only 25 types. This classification system is based on the “two-column” and “tie-arch” concepts of elbow stability. Mehne and Matta described complex bicolumnar distal humeral fractures according to the configuration formed by the fracture lines (Fig. 57.53): high or low T-fractures, Y-fractures, H-fractures, and medial and lateral L-fractures. We generally prefer to use the Jupiter classification system because it has been useful for preoperative planning. The goal of treatment is anatomic restoration of the joint surface with stable internal fixation that allows early motion. Lateral or medial column fractures (AO/ OTA type B) (Fig. 57.54) usually can be reduced through a direct approach and fixed with simple buttress plating. Intraarticular fractures (AO/OTA type C) vary greatly. Generally, the lower the transverse component, the more difficult is attaining stable fixation. Likewise, the greater the comminution, the more difficult is attaining an anatomic reduction.

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A

B

FIGURE 57.54 A and B, Isolated lateral condylar fracture fixed with lag screw and minifragment buttress plate.

A

B FIGURE 57.55

A and B, Plate application through triceps-reflecting approach.

A variety of approaches have been described for reduction and fixation of distal humeral fractures (Table 57.9). Most commonly, a posterior approach with an olecranon osteotomy has been used (see Technique 57.10), but concerns about healing and symptomatic implants have led to more frequent use of a triceps-reflecting (Bryan-Morrey [Fig. 57.55] or triceps-reflecting anconeus pedicle [Fig. 57.56]) approach, as advocated by Bryan and Morrey and O’Driscoll, or a triceps-splitting (Campbell [Fig. 57.57]) approach, as advocated by McKee et al. The best fracture exposure is provided by an olecranon osteotomy approach. As more familiarity is gained with fracture patterns and reduction techniques, a tricepsreflecting or triceps-splitting approach may be selected to reduce complications. Sharma et al. reported in a systematic

review that functional outcomes did not differ based on the approach used. With all posterior approaches, the ulnar nerve must be carefully dissected without excessive stripping and can be transposed anterior to the medial epicondyle at the end of the procedure. More recent reports have questioned the benefit of nerve transposition, noting that the frequency of ulnar neuritis in patients with ulnar nerve transposition was almost four times that in patients without transposition. Wiggers et  al. found ulnar neuropathy in 17 (16%) of 107 patients, 16 of whom had columnar fractures. Only one patient with a capitellar or trochlear fracture developed ulnar neuropathy. These authors suggested that it was not the ulnar nerve transposition alone that placed the ulnar nerve at risk, but rather it was the additional handling of the ulnar nerve

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

TABLE 57.9

Surgical Approaches Used for Treatment of Fractures of the Distal Humerus SURGICAL APPROACH POSTERIOR Olecranon osteotomy

INDICATIONS ORIF for fractures involving columns and articular surface

CONTRAINDICATIONS TER

ADVANTAGES Good access to posterior articular surfaces for reconstruction

Triceps-splitting

ORIF/TER for fractures involving columns and articular surface

Avoids complications associated with olecranon osteotomy

Tricepsreflecting

Fractures requiring TER

Tricepsdetaching

ORIF/TER for fractures involving columns and articular surface

Previous olecranon osteotomy approach Patients at increased risk for healing problems ORIF Previous olecranon osteotomy approach Patients at risk for healing problems Previous olecranon osteotomy approach Patients at risk for healing problems

Avoids complications associated with olecranon osteotomy

Poor access to articular surfaces for internal fixation Risk of triceps detachment Lateral column inaccessible

Suspected more complex articular surface fracture

Radial nerve protected

Medial column inaccessible

MEDIAL

Koher

LATERAL

Koeber

Jupiter ANTERIOR

Medial epicondylar fractures Medial column fractures Lateral column fractures Lateral epicondylar fractures Capitellar fractures

Avoids complications associated with olecranon osteotomy

Henry

Complex articular surface fractures Vascular injury

Significant involvement of the columns Requirement for Good access to braplate fixation of chial artery columns or articular surface reconstruction

DISADVANTAGES Nonunion and failure of fixation of osteotomy Poor anterior access to capitellum Poor access to articular surface for internal fixation Risk of triceps detachment Risk of triceps detachment

Risk of injury to radial nerve Medial column inaccessible Medial column inaccessible Limited access to columns

ORIF, Open reduction and internal fixation; TER, total elbow replacement. Modified from Robinson CM: Fractures of the distal humerus. In: Bucholz RW, Heckman JD, Court-Brown CM, editors: Rockwood and Green’s fractures in adults, ed 6, Philadelphia, 2006, Lippincott Williams & Wilkins.

during reduction of a columnar fracture and application of a medial plate. The standard plating technique calls for plates to be placed at orthogonal angles (90-90 plating) (Fig. 57.58). Studies have shown that direct medial and lateral plating is biomechanically sound (Fig. 57.59), and clinical reports have confirmed stable fixation and high rates of union with parallel (180-degree) plating. Sanchez-Sotelo et  al. listed several principles for distal humeral fracture fixation that we have incorporated into our treatment protocol (Box 57.4). Small osteochondral fragments can be fixed with headless screws, countersunk mini-fragment screws, or absorbable screws (Fig. 57.60). In a recent meta-analysis,

Shih et  al. concluded that parallel plating may provide improved axial stiffness. These authors suggested that either orthogonal or parallel plating performed well will almost always lead to successful union. However, many confounding variables, such as locked versus nonlocked plating, screw size, or hybrid plates that are placed posterior but incorporate a lateral “tub” make a direct inference from the data difficult. Reconstruction of the distal humerus can be done according to two strategies: (1) reduction and fixation of the articular surfaces followed by attachment to the humeral shaft; or (2) reduction and fixation of the medial or lateral condyle to the shaft, then reconstruction of the

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Flexion

Anconeus

Modified Kocher Triceps reflecting Triceps

A

B FIGURE 57.56 Triceps-reflecting anconeus pedicle approach. A, Modified Kocher lateral approach is combined with medial triceps-reflecting approach. B, Access to distal humerus is similar to that provided by olecranon osteotomy.

A

B

FIGURE 57.57 Triceps-splitting approach to distal humerus. A, Triceps split. B, Split extended to transcutaneous border of ulna. (From Frankle MA: Triceps split technique for total elbow arthroplasty, Tech Shoulder Elbow Surg 3:23, 2002.)

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

B

A

C

FIGURE 57.58 A, Supracondylar fracture with intraarticular extension. B, Fixation with 90-90 locked plates through olecranon osteotomy approach. C, After removal of symptomatic implants.

A A

B

FIGURE 57.59 A, Distal humeral fracture with intraarticular extension. B, After direct medial and lateral plate fixation.

articular surface (advantageous when the articular surface is comminuted), followed by reduction and fixation of the contralateral condyle. Care must be taken not to narrow the trochlea with a lag screw when there is bone loss because this would not allow the arm to sit properly. Because the area for screws is limited in the distal segment, provisional fixation can be used at the joint, with definitive

B

FIGURE 57.60 A, Fixation of small osteochondral fragment with absorbable screw. B, Very distal intercondylar fracture fixed with headless screws and minifragment buttress plating through olecranon osteotomy approach.

fixation screws passing through the plate to ensure that the screws in the distal segment contribute to the overall stability of the construct (see Fig. 57.60). Newer plates that are precontoured or 3.5-mm compression plates are preferable to one third tubular and 3.5-mm reconstruction

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Technical Objectives for Fixation of Distal Humeral Fractures Every screw should pass through a plate. Each screw should engage a fragment on the opposite side that is also fixed to a plate. n As many screws as possible should be placed in the distal fragments. n Each screw should be as long as possible. n Each screw should engage as many articular fragments as possible. n Plates should be applied such that compression is achieved at the supracondylar level for both columns. n Plates used must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level. n  n 

From Sanchez-Sotelo J, Torchia ME, O’Driscoll SW: Principle-based internal fixation of distal humerus fractures, Tech Hand Upper Extremity Surg 5:179, 2001.

plates because of fatigue failure in the latter group in fractures with metaphyseal comminution. For low-type fractures, additional mini-fragment plates may provide added fixation (see Fig. 57.60). Locking plates have been shown to provide added stability and may allow earlier rehabilitation. Poly-axial screws have been demonstrated to have a biomechanical advantage over locking screws in poor bone stock. If the goal of stable fixation that allows early motion is met, rehabilitation can begin within 3 days of surgery. Waddell et al. showed that disabling stiffness develops if the elbow is immobilized for more than 3 weeks. Supervised physical therapy sessions are scheduled three times a week, along with a daily home exercise program. Dynamic flexion and extension splinting is prescribed when early motion goals are not obtained. Tunali et  al. noted that increased fracture severity and delay to surgery were predictors of postoperative arthrofibrosis. Union rates for distal humeral fractures have improved significantly over the years. The most frequent complication is stiffness, which often requires a second procedure. McKee et al. reported an average motion arc of 108 degrees, 74% strength compared with the opposite side, and a mean DASH (Disability of the Arm, Shoulder, and Hand) score of 20 (0 = perfect and 100 = complete disability) in 25 patients at an average 3 years after medial and lateral plate fixation of intraarticular distal humeral fractures. Other complications include ulnar neuropathy, posttraumatic arthritis, osteonecrosis, and symptomatic implants (see Fig. 57.58). Wound complications are more frequent with open fractures and fractures in which a plate was used for olecranon fixation. It has been estimated that one in eight patients with operative fixation of a distal humeral fracture eventually requires a second procedure. Many complications can be avoided by the appropriate choice of procedure and meticulous attention to technical details. 

FIGURE 57.61 Arm holder (Elbow LOC, Symmetry Medical, Warsaw, IN) helps with arm positioning during surgery. SEE TECHNIQUE 57.10.  

OPEN REDUCTION AND INTERNAL FIXATION OF THE DISTAL HUMERUS WITH OLECRANON OSTEOTOMY TECHNIQUE 57.10 Position the patient in the lateral decubitus position. A prone or supine position also can be used. An advantage of the supine position is improved anterior exposure of the joint, which is helpful with very low fractures and fractures with anterior comminution. Fixation of the fracture with extension into the shaft can be difficult to reduce with the patient supine. When the supine position is chosen, we use an arm holder (Elbow LOC, Symmetry Medical Inc., Warsaw, IN) to assist with arm positioning (Fig. 57.61). n  Prepare and drape the entire forequarter to allow placement of a sterile tourniquet on the proximal arm. n  Make a midline incision, with or without a curve over the tip of the olecranon, and develop full-thickness flaps medially and laterally. n  Dissect the ulnar nerve free from the medial edge of the triceps and from the medial epicondyle. Preserve the vascular structures that supply the ulnar nerve (Fig. 57.62A). n  Laterally, dissect the triceps off the lateral intermuscular septum. Incise the interval between the triceps and anconeus muscles to expose the joint. Alternatively, preserve the anconeus innervation by using the interval between n 

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

Triceps Olecranon Ulnar n.

Olecranon

Olecranon

Trochlea

Chevron Ulna

A

Ulna

Ulna

B

C

FIGURE 57.62 Olecranon osteotomy approach. A, Olecranon osteotomy is marked in shape of shallow V or chevron. B, Thin-blade oscillating saw is used to start osteotomy. C, Osteotomized proximal olecranon fragment is elevated proximally; ulnar nerve is isolated, mobilized, and protected. SEE TECHNIQUE 57.10.

the anconeus and the extensor carpi radialis brevis and elevating the anconeus with the triceps. n  Ensure that the medial and lateral olecranon articular surface can be seen. n  Predrill the holes for olecranon fixation before making the osteotomy. We routinely use plate fixation. n  Make a distally oriented chevron osteotomy with an oscillating saw directed toward the sulcus of the articular surface of the olecranon (Fig. 57.62B). Use an osteotome to complete the osteotomy carefully. If the osteotomy is forcefully wedged open with the osteotome, a large cartilaginous flap can be created inadvertently. n  Raise the triceps with the proximal olecranon and direct the triceps musculature off the humerus, preserving the periosteum (Fig. 57.62C). n  Debride the fracture edges to clean surfaces. n  Use threaded Kirschner wires as joysticks to manipulate the medial and lateral condyles. n  If the articular fracture is simple, reduce the fracture with the joysticks and a Weber clamp and insert Kirschner wires for provisional fixation (Fig. 57.63A). n  Plate the column with the better key to reduction first, then the opposite column (Fig. 57.63B). n  If the articular fracture is complex and either the medial or lateral condyle has a good key to reduction with the shaft, reduce the condyle to the shaft. A countersunk mini-fragment (2-mm or 2.4-mm) lag screw can be used for provisional fixation because its low profile does not interfere with plate positioning. Alternatively, a plate can be placed along the column with provisional unicortical screws distally. n  Reconstruct the articular surface “around the clock,” provisionally fix the reconstructed fragments, and reduce the remaining condyle to the shaft and apply plate fixation. n  Use headless screws, mini-fragment screws, or absorbable screws for fixation of articular comminution (see Fig. 57.63B). n  Either 90-90 or medial and lateral plates are acceptable (Fig. 57.63C). n  Evaluate every screw to ensure that it does not cross the articular surface.

Repair the olecranon osteotomy, consider transposing the ulnar nerve, and close the incision in layers over closed suction drainage.

n 

POSTOPERATIVE CARE The elbow is splinted in extension. The drain is removed 2 days after surgery, and range of motion is begun 3 days after surgery. No bracing is used.    

FRACTURES, DISLOCATIONS, AND FRACTURE-DISLOCATIONS OF THE ELBOW FRACTURES OF THE RADIAL HEAD

Radial head fractures can occur in isolation or as part of a more complex elbow dislocation (see “terrible triad” section, later) or Essex-Lopresti injury. When confirmed that the fracture is in isolation, the goal of treatment is a pain-free, stable arc of motion in flexion-extension and pronation-supination. The Mason classification system is widely used to describe these fractures (Fig. 57.64). Most radial head fractures are treated conservatively (Mason types I and II). However, Motisi et  al. noted an increase in the rate of radial head fixation. Nonunion and fracture displacement are rare. Stiffness, however, can be a complication. If the patient has no block to range of motion, a sling and immediate use (as pain allows) predictably yields good results. Lindenhovius et  al. reported that results of operative treatment at long-term (22-year) follow-up demonstrated no appreciable advantage over the reported long-term results of nonoperative treatment. Of 49 patients with Mason type II fractures (2 to 5 mm of displacement), Akesson et al. reported that 80% were pain free and had ranges of motion similar to the noninjured extremity after primary nonoperative treatment. Those with poor results improved with delayed radial head resection. More recently, Duckworth et  al. reported excellent

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A

B

C FIGURE 57.63 Open reduction and internal fixation of distal humerus through olecranon osteotomy approach. A, Threaded Kirschner wires used as joysticks for fracture reduction. B, After plate application. C, After plate fixation of olecranon osteotomy. SEE TECHNIQUE 57.10.

results with nonoperative treatment of 100 Mason types I and II fractures. Overall elbow stability must be confirmed before treating Mason type III fractures conservatively; careful evaluation may reveal a Mason type IV fracture. Egol et  al. reported that nondisplaced or minimally displaced radial head and neck fractures do not need formal physical therapy and good outcomes can be achieved with a home exercise program. Critical to making the decision about operative treatment is determining that (1) the injury is isolated and not part of a complex dislocation and (2) there is no block to flexion-extension or pronation-supination.

OPERATIVE TREATMENT

Displaced Mason types II and III fractures that are part of an elbow dislocation pattern (Mason type IV) or have a limitation to motion require operative treatment.

TREATMENT OF MASON TYPE II FRACTURES

ORIF is the usual form of treatment for these injuries when surgery is indicated. The use of mini-fragment screws, with or without a buttress plate placed in the “safe zone” (area of radial head that does not articulate with the ulna [Fig. 57.65]), has had good results. Also partial resection of the radial head has been shown to provide satisfactory results. If the remaining

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FIGURE 57.64

Type I

Type II

Type III

Type IV

Mason classification of radial head and neck fractures.

fixation and the tripod technique, have shown good promise (Fig. 57.66). 

TREATMENT OF MASON TYPE III FRACTURES

Articular cartilage

Pronated

Supinated FIGURE 57.65 “Safe zone” (area of radial head that does not articulate with ulna) for placement of fixation. SEE TECHNIQUE 57.11.

articular surface is small, resection with radial head replacement is necessary as a primary stabilizer of the elbow in a complex fracture-dislocation. If the elbow is stable, resection without replacement has shown good results. Newer techniques with headless compression screws, such as cross-screw

These fractures often are part of a more severe injury and may occur with elbow dislocation and other injuries about the elbow. They are less frequently appropriate for ORIF than are type II fractures. Radial head resection may be a good option for isolated fractures in elderly patients, but it has been associated with variable results in younger patients. Undiagnosed concomitant injuries likely play a role in long-term outcome. Long-term arthrosis, valgus elbow instability, and longitudinal forearm instability have led many to avoid radial resection in younger patients. In one group of five patients, however, satisfactory results were reported at 16- to 21-year follow-up, and Faldini et al. described good results in 36 of 42 patients an average of 18 years after radial head excision. Before resection of the radial head, elbow and forearm instability must be ruled out. Lópiz et  al. also concluded that resection had fewer complications than radial head replacement in fractures with instability. ORIF can be done with good results in selected patients; Ikeda et al. reported greater strength and better function in 15 patients with ORIF than in 13 patients with radial head resection for Mason type III fractures. The ideal fracture for ORIF has three or fewer fragments, each of which is large enough to accept a screw for fixation, with minimal metaphyseal bone loss. Otherwise, excision or replacement should be considered. Prosthetic replacement with metallic implants has provided good results at short-term follow-up. Sun, Duan, and Li, in a meta-analysis that included 138 patients with ORIF and 181 with radial head arthroplasty, found a significantly higher satisfaction rate, better elbow scores, shorter operation time, and lower incidence of nonunion at short- and medium-term follow-up in those with prosthetic replacement. However, in a cohort of military patients, Kusnezov et al. found a higher rate of implant failure. The surgical technique can be challenging, with the main complication being overstuffing of the radiocapitellar

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A

B

C

E

D

F FIGURE 57.66 A and B, Anteroposterior and lateral radiographs of right elbow demonstrating initial transverse metaphyseal radial head fracture with posterior displacement and rotation of fragment. C and D, Anteroposterior and lateral views intraoperatively under image fluoroscopy after tripod fixation of fracture and lateral collateral ligament repair. E and F, Anteroposterior and lateral radiographs 5 months after surgery, demonstrating well-healed fracture without implant complications. (From Lipman MD, Gause TM, Teran VA, Chhabra AB, Deal DN: Radial head fracture fixation using tripod technique with headless compression screws, J Hand Surg Am 43(6):575.e1-e6, 2018.)

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

A

B

C

D

FIGURE 57.67 Open reduction and internal fixation of radial head fractures. A, Mason type II fracture stabilized with two small screws. B to D, Mason type III fracture stabilized with plate and screws. SEE TECHNIQUE 57.11.

joint, leading to erosion, pain, and decreased motion (see Chapter 12). The primary advantage of prosthetic replacement is maintenance of the radiocapitellar relationship for elbow stability and longitudinal radioulnar stability. The Kocher approach has long been the mainstay for surgical approaches to the radial head. Many surgeons, including the author, now use the Kaplan approach. Barnes et al. concluded that the Kaplan approach affords significantly greater visibility compared with the Kocher approach. 

 

OPEN REDUCTION AND INTERNAL FIXATION OF RADIAL HEAD FRACTURE TECHNIQUE 57.11 Expose the radial head and neck with a Kocher or Kaplan approach (see Chapter 1).

n 

Take care to preserve the lateral collateral ligament. In “terrible triad” injuries, the ligament will be reattached at the end of the procedure. 

n 

MASON TYPE II FRACTURE Reduce the partial fracture, taking care not to disrupt the periosteum; tamps, dental picks, or Freer elevators can be used as needed. n  Stabilize the reduction with one or two small screws (Fig. 57.67A). Occasionally, a buttress plate can be useful if the apex of the fracture is comminuted and a large defect remains under the articular segment. n  If reliable fixation cannot be obtained (as with fracturedislocations), consider radial head replacement.  n 

MASON TYPE III FRACTURES If needed for improved exposure, release the origin of the lateral collateral ligament; this will be repaired at the end of the procedure. n  Reduce and provisionally fix the articular surface with Kirschner wires. Occasionally, removing the fragments and assembling them on the back table may facilitate reduction. n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Protect the posterior interosseous nerve by pronating the forearm. n  Apply a small plate along the lateral surface of the proximal radius with the wrist in neutral (safe zone) (see Fig. 57.65) and secure it with lag screws as needed (Fig. 57.67B-D). n  Bone graft the defect if needed. n  Check pronation and supination of the forearm.  n 

POSTOPERATIVE CARE The arm is placed in a molded posterior plaster splint at 90 degrees. At 3 to 7 days, the splint is removed and the arm is supported in a sling. At about that time, active and activeassisted exercises are begun. The patient should discontinue the sling at 3 weeks, gradually increasing the exercises as tolerated. Forceful manipulation of the elbow is never permitted.   

FRACTURES OF THE CORONOID

Coronoid fractures occur in 10% to 15% of elbow dislocations. They historically were classified into three types, as described by Regan and Morrey: type I, fracture of the intraarticular tip of the coronoid (no long-term instability); type II, fracture

involving half or less of the coronoid (may significantly affect ulnohumeral stability); and type III, fracture involving more than half of the coronoid process (often associated with posterior instability) (Fig. 57.68). More recently, the classification system developed by O’Driscoll et  al. (Table 57.10 and Fig. 57.69) has been shown to more reliably predict associated injuries and guide treatment decisions (Fig. 57.70). Because a coronoid fracture fragment may appear small on a lateral radiograph or may be confused with a radial fracture, CT is recommended when a coronoid fracture is suspected. Displaced coronoid fractures should be reduced and stabilized with fixation. Careful assessment is mandatory to ensure that the coronoid fracture is not part of a more serious injury (see later section on “terrible triad” injuries). Sutures can be used for fixation of small coronoid fracture fragments (Fig. 57.71A) and lag screws can be used for larger fragments (Fig. 57.71B). In a cadaver study, Huh et al. demonstrated more extensive exposure of the anteromedial coronoid and proximal ulna with a flexor carpi ulnaris-splitting approach compared with an over-the-top approach. A distinct type of coronoid fracture, fracture of the anteromedial facet (Fig. 57.72), occurs from a varus force to the elbow and, if left untreated, can result in posteromedial rotary instability. Repair of the lateral collateral ligament and ORIF of the coronoid are recommended (Fig. 57.73). Chan et al. reported functional and radiographic outcomes of select patients with anteromedial coronoid fractures treated nonoperatively. All 10 patients in their study achieved bony union without radiographic arthrosis and no recurrent instability. They noted that nonoperative treatment is feasible in small, minimally

I II III

A

FIGURE 57.68 Regan and Morrey classification of fractures of coronoid process.



B

C

FIGURE 57.69 Classification of coronoid fracture based on fragmentation pattern (O’Driscoll et al.). A, Type 1, transverse fracture at tip of coronoid process. B, Type 2, fracture of anteromedial facet of coronoid process. C, Type 3, fracture of the base of coronoid process.

TABLE 57.10

Coronoid Fracture Classification (O’Driscoll et al.) FRACTURE Type I: Tip Type II: Anteromedial

Type III: Basal

SUBTYPE 1 2 1 2 3 1 2

DESCRIPTION ≤2 mm coronoid bony height (i.e., flake fracture) >2 mm coronoid height Anteromedial rim Anteromedial rim + tip Anteromedial rim + sublime tubercle (± tip) Coronoid body and base Transolecranon basal coronoid fracture

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM displaced fractures with no evidence of elbow subluxation; the elbow joint must be congruent and demonstrate a stable range of motion to a minimum 30 degrees of extension. 

SIMPLE ELBOW DISLOCATIONS

Simple elbow dislocations are dislocations of the ulnohumeral radiocapitellar joints. They are termed “simple” because there is no associated fracture. Treatment is almost always conservative, with a closed reduction after a thorough neurovascular examination. The propensity to redislocate is evaluated after reduction and noted. Radiographs should confirm a concentric reduction. Initially the elbow is splinted in 90 degrees of flexion, and range of motion is begun at 5 to 10 days after injury if the elbow is stable after reduction. More unstable injuries may require splinting for up to 2 or 3 weeks with a protected range-of-motion program or ligamentous repair. In their series of nearly 5000 simple elbow dislocations, Modi et  al. found that 2.3% required stabilization surgery at a median of 1 month and 1.2% required soft-tissue release at a median of 9 months after injury (Fig. 57.74) 

FRACTURE-DISLOCATIONS OF THE ELBOW

Fracture-dislocations of the elbow usually result from a fall on the outstretched hand with a shearing component to the injury, and fractures of the radial head, radial neck, or coronoid process, or combinations of these, occur as the proximal ulnarradial complex is driven posteriorly. Valgus-directed stress can result in avulsion of the medial epicondyle, which is much more common in adolescents. The medial collateral ligament and lateral collateral ligamentous complex are invariably torn. Posterior fracture-dislocations of the elbow in adults usually are treated surgically because the fracture and ligamentous components of the injury make most of these dislocations unstable. Fracture of the coronoid process or radial head or both can render the elbow significantly unstable after reduction (Fig. 57.75). Untreated injury to the collateral ligamentous complex and medial collateral ligament after repair of the osseous component of the injury can leave residual instability. Lengthy immobilization greatly increases stiffness, and open reduction and stable fixation should be done to allow early motion.

Coronoid fracture pattern

O’Driscoll Type I

O’Driscoll Type II

Valgus posterolateral rotatory instability

Varus posteromedial rotatory instability

“Terrible triad”

Planned radial head replacement

Anteromedial facet fracture, subluxation/dislocation, LCL disruption Planned radial head ORIF Posterior approach

Lateral approach

Deep to superficial repair 1. coronoid, 2. radial head, 3. LCL

Smaller fragment

Larger fragment

Capsular repair

Screw fixation

Single posterior or separate medial and lateral approaches

Medial approach or medial window of posterior approach for coronoid

Larger fragment

Lateral approach or lateral window of posterior approach for radial head + LCL

Smaller fragment

Capsular repair

Medial window for coronoid

Lateral window for LCL

Smaller fragment

Larger fragment

Capsular repair? Consider nonoperative treatment

Anteromedial buttress plate

FIGURE 57.70 Algorithm for management of O’Driscoll types I and II coronoid fractures and associated injuries. ORIF, Open reduction internal fixation; LCL, lateral collateral ligament. (From Manidakis N, Sperelakis I, Hackney R, Kontakis G: Fractures of the ulnar coronoid process, Injury 43:989, 2012.)

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TREATMENT

Closed reduction should be done as soon as possible. Radiographs often are necessary after reduction to define the osseous injury completely. Three-dimensional CT may be necessary to identify all of the components of this injury. The elbow should be carefully moved through a flexion-extension arc of motion. Subluxation or impending dislocation at 30 degrees or more from full extension indicates instability, and surgical stabilization is required. In the rare situation of a stable, concentric reduction, the patient can be started on early active exercises at 2 to 3 weeks, with close follow-up; if subluxation or spontaneous redislocation occurs, the elbow is surgically stabilized. 

“TERRIBLE TRIAD” INJURIES OF THE ELBOW

Originally described by Hotchkiss, the “terrible triad” consists of an elbow dislocation in conjunction with fractures of the radial head and coronoid. Historically, poor outcomes led to the designation of this combination of injuries as “terrible.” The essential lesion is disruption of the lateral collateral ligament with progression to the medial structures (Fig. 57.76). The lateral collateral ligament injury occurs as an avulsion of its origin, along with a variable amount of common extensor musculature, from the lateral distal humerus, leaving the typical bare-spot appearance of the distal humerus (Fig. 57.77B). The injuries to the radial head and coronoid vary in fragment size and complexity. Early studies reporting elbow dislocations and fracturedislocations indicated that triad injuries have uniformly poor outcomes, with Ring et al. reporting fair and poor results in four of their eight patients. However, excellent or good results were reported in 70% of 105 patients in four studies (Pugh et  al., Egol et  al., Forthman et  al., and Lindenhovius et  al.). McKee et al. reported good-to-excellent results in 78% of 36 “terrible triad” injuries treated with a standardized surgical protocol (Box 57.5), and Lindenhovius et al. reported goodto-excellent results in 15 (83%) of 18 patients. Mathew et al. also developed a surgical management algorithm for “terrible triad” fractures (Fig. 57.78). More recent reports by Fitzgibbons et al. and Gupta et al. continue to confirm excellent results after these injuries.

TREATMENT

A number of surgical approaches to the elbow have been described, and the best approach for treatment of “terrible triad” injuries remains controversial. The choice of approach depends primarily fracture pattern, type of instability, soft-tissue injury, and surgeon experience. A direct lateral approach or a midline incision with subcutaneous flaps to the Kocher interval usually is used; the latter allows a second interval medially if necessary. The fixation strategy usually is from deep to superficial as seen from the lateral approach (coronoid to anterior capsule to radial head to lateral collateral ligament to common extensor origin). Regardless of the approach selected, every effort should be made to operate through the traumatized planes and minimize surgical dissection. Coronoid fixation depends on the size of the fragment. Small tip avulsions usually are reduced and fixed with sutures through holes drilled in the posterior olecranon. This effectively anchors the anterior capsule to the coronoid. Larger fragments are stabilized with lag screws from the posterior olecranon. Coronoid fixation is more

easily observed when the radial head injury necessitates excision and replacement. The need for coronoid fixation has been questioned lately, first in a biomechanical study by Beingessner et al. and then in a clinical study by Papatheodorou et al. who noted excellent outcomes without coronoid fixation in triad injuries in which (1) the radial head was repaired or replaced, (2) the lateral ulnar collateral ligament was repaired, and (3) intraoperative fluoroscopic confirmed a concentric stable elbow. Management of the radial head fracture is determined by the ability to obtain a reduction and whether the quality of the bone allows the reduction to be maintained. If the fracture cannot be reduced and stabilized adequately, replacement with a metal prosthesis is indicated. Although this decision is made early in the treatment process, we generally place the radial head prosthesis after fixation of the coronoid fracture because removal of the radial head provides good exposure of the coronoid fragment. After coronoid and radial head stabilization or replacement, the lateral collateral ligament is reattached to its origin, as is the common extensor origin. Reestablishment of the soft-tissue restraints adds greatly to the overall stability in the elbow joint. If residual instability exists after fracture fixation and collateral ligament repair, a hinged external fixator can be used to maintain stability. However, it becomes more challenging after fracture of the radial head. For this reason, the author usually repairs or stabilizes the coronoid fragment. Orbay et  al. reported a technique utilizing a new device known as internal joint stabilizer. Essentially, the device functions as an internal, low-profile, hinged fixator that allows for elbow motion while maintaining elbow stability. A more recent multicenter series by Orbay et  al. reported outcomes of 24 elbows that had recurrent instability with elbow fracture or dislocation, or both, treated with an internal joint stabilizer. Stability was maintained in 23 of 24, with the only loss of concentric reduction in a coronoid-deficient elbow. We have used internal joint stabilizers with success at our institution and always have one available when treating these injuries. In an assessment of risk of subluxation or dislocation, Zhang et al. advised that “terrible triad” injuries treated after 2 weeks might benefit from ancillary fixation to limit subluxation (i.e., cross-pinning, external fixation, or internal joint stabilizer).   

STABILIZATION OF “TERRIBLE TRIAD” ELBOW FRACTURE-DISLOCATION TECHNIQUE 57.12 (MCKEE ET AL.) Place the patient supine with the arm on a hand table and make a direct lateral approach to the elbow (see Fig. 57.77A). Alternatively, if a posterior approach is chosen, place the patient in the lateral position with the affected side up and arm lying over a bolster, draped free. This position also is used if placement of a hinged external fixator or a separate medial approach is anticipated.

n 

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

A

B FIGURE 57.71 A, Small coronoid fracture fragments can be fixed with sutures. B, Lag screws can be used for larger fragments.

FIGURE 57.73 Plate fixation of anteromedial coronoid fracture. (From Steinmann SP: Coronoid process fractures, J Am Acad Orthop Surg 16:519, 2008.)

Lateral elbow instability

Acute simple elbow dislocation

Closed reduction under general anesthesia

FIGURE 57.72 Three-dimensional CT scan of anteromedial coronoid fracture; arrow indicates fracture fragment. (From Steinmann SP: Coronoid process fractures, J Am Acad Orthop Surg 16:519, 2008.)

Stable?

Unstable (before 30 degrees of extension)?

Rehabilitation with possible dynamic brace (6 weeks)

LCL ligament repair

FIGURE 57.74 Algorithm for management of acute simple elbow dislocations and chronic lateral ligament injuries. LCL, Lateral collateral ligament. (From Tashjian RZ, Wolf BR, van Riet RP, Steinmann SCP: The unstable elbow: current concepts in diagnosis and treatment, AAOS Instr Course Lect 65:55, 2016.)

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Identify the “bare spot” left by stripping of the lateral collateral ligament complex from the posterolateral aspect of the lateral condyle. Take care to work through any soft-tissue disruption created by the trauma (with proximal and distal surgical extension as required), preserving intact structures as much as possible. n  Tag the detached lateral ligament complex for repair. Also tag the common extensor origin if it is disrupted. n  Inspect the coronoid to determine fracture pattern and severity; view of the coronoid is enhanced by removing an irreparably damaged radial head (which occurs in 60% of these injuries). n  If a large fragment (type II or III coronoid fracture) is found, reduce it and place one or two small-fragment (3.0- or 3.5-mm) lag screws from the posterior surface of the ulna. Insert a guidewire from the dorsal surface of the ulna and check its exit point from the coronoid process visually; reduce the fragment under direct vision. n  Larger coronoid fragments can be fixed with plates designed specifically for the coronoid (Fig. 57.79), but this requires a direct medial approach to the coronoid. n  For comminuted fractures, attempt to fix the largest fragment possible (typically the articular portion) to restore the anterior buttress of the coronoid and prevent posterior subluxation of the elbow joint. n  Type I coronoid fracture fragments are too small to be fixed with screws. Repair them by placing lasso-type sutures around the fragment and the attached anterior capsule and tying the sutures to the base of the coronoid through drill holes made with an eyed Kirschner wire (Fig. 57.77B). n  Evaluate the radial fracture. If there are one or two fragments, reduce them and hold the reduction with small reduction forceps while inserting small Kirschner wires for temporary fixation. Insert small fragment screws (e.g., Herbert screws) and countersink them below the articular surface (Fig. 57.77C). n  If fracture comminution (three or more fragments), impaction, cartilage damage, or an associated radial neck fracture indicates that a stable anatomic reduction is not feasible, excise the radial head. n  Insert the trial components from a metal modular radial prosthesis and move the elbow through a range of motion to determine the size that best restores joint stability, then insert the definitive components. n  Once fracture fixation is completed, repair the detached lateral ligament complex with nonabsorbable sutures placed either through drill holes in the bone or with suture anchors (Fig. 57.77D). n  Before closure, examine the elbow for stability and confirm concentric reduction with no observed posterior or posterolateral subluxation or dislocation through an arc of flexion-extension from 20 to 130 degrees. n  If residual posterior or posterolateral instability is evident, check the quality of the reduction and fixation of the coronoid fracture and radial head and placement of the lateral ligament repair sutures. If these appear satisfactory, options are to repair any disrupted medial structures (medial collateral ligament and flexor pronator mass) or apply a hinged external fixator or an internal joint stabilizer (Fig. 57.80). n  Close the skin and subcutaneous tissue in standard fashion and apply a well-padded posterior splint with the elbow in the most stable position, typically at 90 degrees of flexion and full pronation. n 

A

B FIGURE 57.75 Fracture-dislocation of elbow. A, Posterior fracture-dislocation with irreparable radial head and neck fractures. Type II coronoid fracture is not apparent. This patient’s injuries were bilateral and almost identical. B, One elbow has redislocated in posterior splint at 90 degrees of elbow flexion. Large radial head fragment and coronoid fracture are readily apparent. Coronoid fracture had to be repaired to provide stability before radial head could be excised. (From Crenshaw AH: Adult fractures and complex joint injuries of the elbow. In Stanley D, Kay NRM, editors: Surgery of the elbow: practical and scientific aspects, London, 1998, Arnold.)

POSTOPERATIVE CARE  The splint is left in place for 1 to 10 days, depending on the stability obtained and other associated injuries. In most patients, range-of-motion exercises are started on the first postoperative day. Active and active-assisted exercises are allowed for recruitment of muscle groups that act as dynamic stabilizers (flexorpronator mass and common extensor origin). Full forearm rotation is allowed with the elbow flexed 90 degrees. Unrestricted shoulder and wrist exercises are encouraged. Typically, patients should avoid the terminal 30 degrees of extension (the most unstable position) for 4 weeks.    

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A

B

E

C

D

F

FIGURE 57.76 A, “Terrible triad” elbow injury. There is characteristic stripping of lateral collateral ligament complex from distal humerus. Portion of common extensor origin/lateral ligament complex is hanging down from bare lateral condyle. Coronoid fragment is trapped in joint (arrowhead). Defect in radial head can be seen behind coronoid fragment. B and C, Radiographic images of “terrible triad” injury. D, After radial head resection, instability was still present. E, After coronoid suture repair, minor subluxation was still present. F, Stability was obtained with repair of coronoid and lateral collateral ligament. (A from Pugh DM, Wild LM, Schemitsch EH, et  al: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures, J Bone Joint Surg 86A:1122, 2004.)

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B

A

D C FIGURE 57.77 Treatment of “terrible triad” elbow injury. A, Lateral approach. B, Anterior capsule captured by nonabsorbable sutures and secured through drill holes in fracture bed of coronoid. C, Reduction and fixation with two countersunk screws. D, Avulsed lateral ligamentous complex repaired to lateral condyle. (From McKee MD, Pugh DM, Wild LM, et al: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures, J Bone Joint Surg 87A(Suppl 1, Pt 1):22, 2005.) SEE TECHNIQUE 57.12.  

INTERNAL JOINT STABILIZATION FOR ELBOW INSTABILITY Orbay et al. described the use of a low-profile elbow joint stabilizer to prevent redislocation while bone and other structures are healing in patients with difficult elbow instability (Fig. 57.80A). Notable distal humeral or proximal ulnar bone loss may be a contraindication. The joint stabilizer can typically be removed in 3 to 4 months.

TECHNIQUE 57.13 (ORBAY ET AL.) The approach and incision depend on the individual case (Fig. 57.80B). n  Approach the extensor carpi radialis brevis and extensor digitorum communis (Kaplan interval), which splits the common extensors 50:50. n  Elevate the origin of the extensor carpi radialis longus, brachialis, and anterior capsule from the anterior humerus to improve access to the elbow. The avulsed origin of the lateral collateral ligament and the common extensors will be reattached at the end of the procedure. n 

Treat any fractures of the coronoid, radial head, olecranon, and distal humerus. n  To apply the internal elbow joint stabilizer, find the axis of ulno-humeral rotation. Two points in the line define this axis: the lateral point and the medial point. Locate visually the lateral point first at the geometric center of the dome of the capitellum or the center of a circle that fits the curvature of the articular surface as seen from the lateral view. Mark this point on the bone surface (Fig. 57.80C). To locate the medial point on the axis, use a centering guide that consists of a metallic arc of 240 degrees that is inserted over the waist of the trochlea and pushed medially until it self-aligns on the medial trochlear expansion (Fig. 57.80D, E). Apply varus stress to the elbow to see the trochlea during placement. n  Under fluoroscopy and using the centering guide insert a 1.5-mm guidewire toward the medial cortex. Avoid drilling through the medial cortex to avoid ulnar nerve injury. Use of an oscillating drill increases safety. n  After measuring the length of the axis pin, drill over the Kirschner wire using a 2.7-mm cannulated drill to create the axis pin track. Confirm that the Kirschner wire is not in contact with the lateral aspect of the capitellum before drilling because this can displace the axis guide and lead to incorrect placement of the axis pin. n 

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM Position the base plate at the most proximal aspect of the ulna, taking care to avoid placing screws into the articular surface. The base plate has a sliding slot that can be used to adjust positioning under fluoroscopic imaging. n  After securing the baseplate, connect the boom to the axis pin, with the head of the locking screw near the axis pin eyelet facing proximally. Secure the boom arm with a counter-torque device while tightening the axis pin to prevent deformation. It is easier to assemble the axis pin to the boom before its insertion onto the humerus. n  Insert the connecting boom and axis pin into the humerus and into the base plate clamp simultaneously to facilitate the internal joint stabilization assembly. n  Before tightening the two locking screws on the boom arm, ensure that the elbow is reduced concentrically by placing the hand over the head of the patient. This removes torsional stresses across the elbow joint by placing the shoulder in the position of neutral resting tension of the humeral rotators (Fig. 57.80F). n  Apply a reducing compressive force on the proximal ulna in line with the humeral shaft and inspect the reduction visually before locking the reduction by tightening both the gold boom locking screw and the purple base plate locking screw (Fig. 57.80G). n 



n 

Confirm that reduction is maintained through full range of motion using fluoroscopic imaging (Fig. 57.80H).

  

BOX 57.5

Principles of Operative Treatment of “Terrible Triad” Fracture-Dislocations of the Elbow Restore coronoid stability through fracture fixation (type II or III) or through anterior capsular repair (type I). n Restore radial head stability through fracture fixation or replacement with a metal prosthesis. n Restore lateral stability through repair of the lateral collateral ligament complex and associated so-called secondary constraints such as the common extensor origin and/or the posterolateral capsule. n Repair the medial collateral ligament in patients with residual posterior instability. n Apply a hinged external fixator when conventional repair does not establish sufficient joint stability to allow early motion. n 

From Pugh DMW, Wild LM, Schemitsch EH, et al: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures, J Bone Joint Surg 86A:1122, 2004.

Posterior skin incision Deep lateral approach Radial head fracture fixable?

Yes

No

Radial neck osteotomy Coronoid fracture fixable from lateral approach Yes

No

Fix coronoid fracture Fix or replace radial head Repair lateral collateral ligament

Fix coronoid from deep medial approach Fix or replace radial head Repair medial and lateral collateral ligaments

Elbow stable?

Yes

No

Done

Repair medial collateral ligament

Elbow stable?

Yes

No

Done

Apply external fixator

FIGURE 57.78 Algorithm for surgical management of terrible triad injuries. (From Tashjian RZ, Wolf BR, van Riet RP, Steinmann SCP: The unstable elbow: current concepts in diagnosis and treatment, AAOS Instr Course Lect 65:55, 2016.)

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Fracture line

FIGURE 57.79 57.12.

Plate fixation of coronoid process. SEE TECHNIQUE

COMPLICATIONS

Complications of elbow fracture-dislocations include infection, synostosis, arthrofibrosis, symptomatic hardware, and residual instability. Anatomic reduction of intraarticular fractures is necessary to prevent arthritic changes. Loss of extension to some degree is expected. Ectopic calcification is relatively common, including calcium deposition in the collateral ligaments and capsule; most reports indicate an occurrence of less than 20%. Shukla et al., however, found a 43% rate of heterotopic ossification in operatively treated fracture-dislocations, with about half of these requiring surgical intervention, and Foruria et  al. reported that in 20% of 130 elbows heterotopic ossification was associated with clinically relevant motion deficits. Heterotopic ossification can cause almost complete ankylosis of the elbow if severe enough (Fig. 57.81). It is common after fracture-dislocations and can be seen on radiographs 3 to 4 weeks after injury. Its severity seems to be associated with the magnitude of the injury and the length of immobilization, as well as to a longer time to surgical treatment. 

RADIAL HEAD AND NECK FRACTURES ASSOCIATED WITH ELBOW DISLOCATION

Treatment of radial head and neck fractures associated with elbow dislocations is controversial. The radial head, similar to the coronoid process, is an important stabilizer of the elbow joint. ORIF of radial head fractures is preferable to excision if the radial head is salvageable. If the radial head cannot be preserved, use of a metallic radial head implant after excision of the radial head is controversial but should be used in most “terrible triad” injuries if instability is still present after the medial and lateral collateral ligaments and flexor-pronator mass have been repaired. Complications include loosening and revision. Watters et al. reported good short-term results with radial head replacement. The goal of surgical intervention is a stable elbow, and, if necessary, all structures should be repaired to achieve this. 

FRACTURES AND FRACTUREDISLOCATIONS OF THE OLECRANON FRACTURES

Fractures of the olecranon can be caused either by direct trauma, such as falling on the tip of the elbow, or by indirect trauma, such as falling on a partially flexed elbow with indirect forces generated by the triceps muscle avulsing the

olecranon. These fractures were classified by Schatzker based on fracture pattern and mechanical considerations as to the type of internal fixation required for repair (Fig. 57.82). The goal of treatment of olecranon fractures is restoration of function without pain. With displaced fractures, loss of active extension is common. Anatomic reduction and stable internal fixation are vital for both function and prevention of arthrosis. Implementation of an early range-of-motion program will decrease the chances of posttraumatic arthrofibrosis making stable internal fixation that will tolerate motion mandatory. Nondisplaced or minimally displaced fractures with maintenance of active extension can be treated nonoperatively. The elbow is splinted in 90 degrees of flexion for 3 to 4 weeks, followed by gentle passive motion with progression to active-assisted and then active motion. Complications stem from the subcutaneous border of the olecranon in the form of wound complications and symptomatic implants. In addition, the distraction forces across the fracture from flexion or active extension may contribute to nonunion. Most olecranon fractures are displaced and require surgery. As in all surgically treated fractures, an appropriate preoperative evaluation and plan are necessary. The correct treatment must be chosen for each fracture to ensure a successful outcome. Critical to management is recognition of concurrent elbow injuries and dislocations.

TREATMENT

Excision of the olecranon and triceps advancement are not often necessary because reduction and internal fixation usually are achievable. Excision of the proximal fragment with suture fixation of the triceps into the distal olecranon has been reported to be successful in low-demand and infirm patients, patients with severe nonreconstructable proximal comminution, or for revision after failed fixation. Recent biomechanical data suggest that posterior rather than anterior attachment of the triceps on the olecranon leads to greater triceps strength. Nonoperative treatment also is a reasonable option in our elderly population. Duckworth et al. reported a randomized trial of operative versus nonoperative treatment of olecranon fractures in the elderly. The overall low number of patients in their study makes the results difficult to interpret. This was secondary to the study being aborted because of an unacceptably high rate of complications in the operative arm. Challenges in this population include poor bone quality and questionable soft-tissue envelope, as well as difficulty in participating in a rehabilitation protocol. The author has had satisfactory results with nonoperative treatment. The tension-band wiring technique has been purported to create compression at the articular end of an olecranon fracture when the dorsal cortex is tensioned under flexion of the elbow; however, biomechanical studies have not been able to demonstrate the conversion of tensile forces to compression forces. Tension-band wiring has been proved to be a useful technique in simple transverse olecranon fractures without comminution. It is contraindicated in fractures that are oblique, comminuted, or distal to the sigmoid notch. The procedure is fraught with complications, most commonly symptomatic implants that require removal, which is required in up to 80% of patients in some reports. Poorer outcomes have been noted in patients with elbow instability and fractures of the coronoid and radial head. Kirschner wires have historically been used to anchor the tension band. Risks of this technique include injury to the neurovascular structures in the forearm. Use of an

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A

C

F

B

D

E

G

H FIGURE 57.80 A, Internal elbow joint stabilizer. B, Terrible triad injury with coronoid deficiency and overstuffed radial head. C, Locating point where axis of elbow flexion-extension exits capitellum using guide. D and E, Using centering guide along curvature of medial trochlear axis of ulnohumeral rotation is identified. Centering guide is pushed against medial trochlear expansion to locate center point (E). Kirschner wire is inserted through guide and advanced into humerus, stopping short of medial cortex (D). F, For optimal congruent reduction, humerus placed in vertical position. With elbow in 90 degrees of flexion, ulna is pressed against humerus. Rotational stress is eliminated by placing hand over mouth. G, Tightening of connecting joints. H, Repaired terrible triad, with elbow full reduced and supported by internal joint stabilizer. Fixation of coronoid graft with compression screws and replacement of overstuffed radial head. (Courtesy Dr. Jorge Orbay, MD.)

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS intramedullary screw in conjunction with the tension band has been recommended, and transcortical rather than intramedullary placement of the Kirschner wires has been reported to increase stability and decrease complications. We infrequently use the tension-band technique for displaced olecranon fractures because of the high complication and reoperation rates compared with other techniques. Its main advantages are low cost and minimal space occupation in patients with poor soft tissues. Plate fixation has the advantage of maintaining fixation in fractures with comminution, distal fractures, and complex fracture-dislocations. Typically used in neutralization mode, the plating technique allows lag screw fixation of the olecranon and/or coronoid to anatomically reconstruct the proximal ulna (Figs. 57.83 to 57.85). The plate then provides the overall stability needed to obtain union and initiate an early range-of-motion program to promote maximal function. The most frequently cited disadvantage of plate fixation has been symptomatic hardware problems. More recent reports, however, refute this. Newer precontoured plates are lower in profile, provide more screw options for the proximal segment, have locking screw capabilities, and

can contain a bend to match the proximal ulnar anatomy for extended fractures (Fig. 57.86). These plates have produced favorable results in up to 80% of patients, and biomechanical testing found that they provide significantly greater compression than tension bands in the treatment of transverse olecranon fractures. Reconstruction plates and one third tubular plates have been used with some success, but we do not recommend them. De Giacomo et  al. evaluated the use of precontoured locked plates. Their results showed 100% union, but a third of patients had symptomatic implants, with 10% choosing implant removal. Wound complications are the biggest concern with plate fixation because the proximal ulna has a compromised soft-tissue envelope in addition to being placed in tension with elbow flexion. Duckworth et al. performed a prospective randomized trial comparing plate versus tension-band wiring. Functional outcomes were similar at 1 year, with the tension-band group experiencing a significantly higher hardware removal rate. They warned that deep infection occurred almost exclusively in the plate fixation group. Their study did not use locked plates. Of interest, Wellman et  al. reported successful biomechanical testing of mini-fragment plates for olecranon fractures. The lower-profile nature of these implants may help with soft-tissue complications. 

FRACTURE-DISLOCATIONS

FIGURE 57.81 Extensive heterotopic ossification after fracturedislocation of elbow and radial head excision.

Olecranon fracture-dislocations typically occur as anterior or posterior dislocations. In anterior dislocation the distal humerus implodes through the olecranon (transolecranon fracture-dislocation). There is an ulnohumeral dislocation, whereas the proximal radioulnar joint is preserved, as are the collateral ligaments. Varying in complexity, comminution can be extensive and the coronoid can be involved. We routinely treat these injuries with anatomic reconstruction of the articular surface and plate fixation. The coronoid is reduced and stabilized with lag screws, followed by articular reduction with provisional fixation and/or lag screw fixation and then plate fixation spanning the entire injury (Figs. 57.87 and 57.88). Posterior dislocations are ulnohumeral and radioulnar and can be considered variants of Bado type II Monteggia fracture-dislocations. Coronoid fractures, radial head fractures, and lateral collateral ligament injuries are common, and these injuries are similar to “terrible triad” injuries. These challenging injuries require accurate diagnosis, an understanding of the multiple injuries present, and a sound treatment plan for a successful outcome. Beingessner et al. reported good outcomes in 16 patients with a fragmentspecific surgical protocol: (1) repair or replacement of the

Transverse

Transverse-impacted

Oblique

Comminuted

Oblique-distal

Fracture-dislocation

FIGURE 57.82

Schatzker classification of olecranon fractures.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

FIGURE 57.83

Olecranon fracture-dislocation.

FIGURE 57.85 Fixation of olecranon fracture-dislocation with lag screw and plate.

SIMPLE FRACTURES Inspect the articular surface and reduce the fracture with pointed tenaculums (Fig. 57.89A). n  Insert Kirschner wire provisional fixation, out of the plane where the plate will sit; consider lag screw fixation if possible (Fig. 57.89B). n  Position the plate (ideally precontoured for the olecranon) over the proximal fragment on top of the triceps insertion. n  Place the proximal screw in intramedullary fashion to cross the fracture site if possible. n  Use an adequate number of screws proximally and distally. n  Confirm reduction and screw passage with fluoroscopy. n  Close the wound in layers and splint the elbow in extension with an anterior plaster slab.  n 

FIGURE 57.84 Fixation of olecranon fracture-dislocation with lag screw and plate.

radial head; (2) reduction of the ulnar shaft, including the anterior oblique cortical fragment if present; (3) reduction and stabilization of the coronoid process with either screws or transosseous sutures; (4) reduction and fixation of the olecranon process to the ulnar shaft and definitive fixation of the ulnar shaft component; (5) repair of osseous ulnar insertion of the medial collateral ligament and/ or lateral collateral ligament; and (6) repair of the humeral origin of the lateral collateral ligament.   

OPEN REDUCTION AND INTERNAL FIXATION OF OLECRANON FRACTURE TECHNIQUE 57.14 Position the patient supine or in the lateral decubitus position. n  Make a posterior skin incision from the tip of the olecranon to an adequate distance distally to secure fixation. n  Dissect out and protect the ulnar nerve if necessary in more complex injuries. n  Carefully debride the fracture edges, making sure to preserve the periosteum and soft-tissue attachments to comminuted fragments.  n 

COMMINUTED OR COMPLEX FRACTURES Sequentially reduce and stabilize with small lag screws one fracture fragment at a time. If a large anterior oblique fragment is present, stabilize it to the shaft. This will help stabilize the elbow joint and facilitate sequential reduction. n  Where use of lag screws is not possible, use provisional Kirschner wires. n  Reduce impacted subchondral segments and stabilize them with Kirschner wires, with or without supporting bone graft. n  Reduce the proximal segment and provisionally fix it with Kirschner wires. n  Apply the plate. If fixation is questionable because of the size or quality of the bone, consider using locked screws. n  Confirm reductions and screw placement on fluoroscopy. n 

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A

B FIGURE 57.86

C

A, Olecranon fracture-dislocation, B and C, Fixation with low-profile plate.

Close the wound in layers and apply a splint with the elbow in extension.

n 

POSTOPERATIVE CARE The splint is worn for 2 to 5 days; if the elbow is stable, protected range-of-motion exercises are begun and advanced as tolerated.   

FRACTURES OF THE RADIAL HEAD OR NECK WITH DISLOCATION OF THE DISTAL RADIOULNAR JOINT (ESSEX-LOPRESTI FRACTURE-DISLOCATION)

A hard fall on the outstretched hand can result in a fracture of the radial head or neck, disruption of the distal radioulnar joint, and tearing of the interosseous membrane for a considerable distance proximally (Fig. 57.90). The tethering effect of the proximal radial-oriented fibers of the interosseous membrane is lost; if the radial head is resected, rapid proximal migration of the radius can occur, resulting in wrist pain from ulnar carpal impingement and elbow pain from radiocapitellar impingement. Disruption of the distal radioulnar joint must be recognized early, before radial migration occurs. When migration has occurred, late reconstruction often is unsatisfactory (Fig. 57.91). Schnetzke et al. reported “deteriorated” outcomes with late diagnosis. Pain in the distal radioulnar joint with a displaced fracture of the radial head or neck should alert the surgeon to the possibility of this injury combination. ORIF of the proximal radial fracture and pinning of the distal radioulnar joint should be performed; the pin is left in place for 6 weeks. Edwards and Jupiter advised replacement of the radial head if the radial head fracture cannot be repaired. Pinning of the

FIGURE 57.87

Olecranon fracture-dislocation.

distal radioulnar joint is still needed to allow healing of the interosseous membrane. 

FRACTURES OF THE PROXIMAL THIRD OF THE ULNA WITH DISLOCATION OF THE RADIAL HEAD (MONTEGGIA FRACTUREDISLOCATION)

The combination of injuries known as a Monteggia fracture-dislocation is an often treacherous condition to treat. According to Watson-Jones, “No fracture presents so many problems, no injury is beset with greater difficulty, no treatment is characterized by more general failure.” This combination of fracture of the ulna with dislocation of the proximal end of the radius with or without fracture of the radius

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

A

C

B FIGURE 57.88

A-C, Fixation with lag screws and plate spanning entire injury. Radial migration

A Interosseous membrane rupture

B FIGURE 57.89 Open reduction and internal fixation of olecranon fracture. A, Reduction with bone tenaculum. B, Kirschner wires for provisional fixation. SEE TECHNIQUE 57.14. Displaced radial head fracture

usually can be treated conservatively in children but routinely requires open reduction in adults. Bado suggested classification into four types (Fig. 57.92): type 1, fracture of the middle or proximal third of the ulna with anterior dislocation of the radial head and characteristic apex anterior angulation of the ulna; type 2, fracture of the middle or proximal third of the ulna (the apex usually is posteriorly angulated) with posterior dislocation of the radial head and often a fracture of the radial head; type 3, fracture of the ulna just distal to the coronoid process with lateral dislocation of the radial head; and type 4, fracture of the proximal or middle third of the ulna, anterior dislocation of the radial head, and fracture of the proximal third of the radius below the bicipital tuberosity. In all series, type 1 far exceeds all others in frequency, although children’s injuries are included in most series. Several mechanisms of injury probably exist,

FIGURE 57.90

Essex-Lopresti fracture-dislocation (see text).

including direct blows to the ulnar aspect of the forearm and a fall with hyperpronation or hyperextension, with the strong supinating force of the biceps pulling the radial head anteriorly as the fracture of the ulna is produced by the compression forces of the fall. Historically, treatment of this injury, especially of the dislocation of the radial head, has been controversial. Early reports stated that all Monteggia fracture-dislocations could be treated nonoperatively, whereas later investigations determined that the best results were obtained when open reduction of the radial head with repair or reconstruction of the annular ligament was done with internal fixation of the ulna. A report by

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D

B

C

E

F

FIGURE 57.91 A to D, Essex-Lopresti fracture-dislocation. E, After external fixation, radial shortening is evident. F, Revision with radial head prosthesis restored radial length.

Boyd and Boals of 159 Monteggia-type injuries recommended rigid internal fixation of the fractured ulna with either a compression plate or a medullary nail and closed reduction of the radial head. Good results in approximately 80% of patients were reported with this treatment protocol. A better understanding of the injury and an awareness of the necessity of treating associated pathologic processes have led to better outcomes. Ring and Jupiter reported 83% good and excellent results with open reduction and stable fixation. Poor results are most frequent in Bado type 2 fractures, which are more complex injuries with elbow dislocations and fractures of the coronoid and radial head and greater soft-tissue compromise. Monteggia fracture-dislocations with associated radial head fracture can pose a difficult problem. Reynders et al. recognized early resection of the radial head as contributing to delayed union or nonunion of the ulnar fracture by allowing increased angular forces on the ulnar fracture fixation. They recommended that radial head fractures be repaired, replaced

with an implant, or left in place until union of the ulnar fracture. Ring and Jupiter recommended radial head replacement for comminuted radial head fractures. Although closed treatment is usual in children, Monteggia injuries in adults require surgical intervention. Anatomic ORIF of the ulna with stable fixation almost always (90%) allows closed reduction of the radial head dislocation. Continued radiocapitellar instability most frequently is caused by malreduction of the ulna. Comminution of the ulnar fracture can make anatomic reduction difficult. An apex-dorsal malreduction can force the radial head posteriorly. Jupiter and Kellam recommended a dorsal plate in this situation. We also have noted that with more proximal fractures, plate contouring must match the proximal ulnar bow. A straight (uncontoured) plate will malreduce the fracture and prevent the radial head from remaining reduced. When continued radial head subluxation or dislocation persists despite anatomic reduction of the ulnar fracture,

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM the radiocapitellar joint must be exposed and inspected. Often the annular ligament, capsule, and soft tissue (even the posterior interosseous nerve) is interposed and must be removed. Hamaker et al. from the Maryland Shock-Trauma unit reported a series of 121 adult Monteggia fractures. They noted that in 17% of patients the radial head was not reducible and that annular ligament entrapment was the cause, necessitating an open reduction. The radiocapitellar joint can be exposed by extending the approach to a Boyd-Thompson approach or using a Kocher approach (see Chapter 1). Reconstruction of the annular ligament rarely is necessary. We routinely use 3.5-mm limited-contact dynamic compression plates for ulnar fixation. If comminution is present, we attempt to reduce and fix the fracture with small-diameter screws in all fragments possible, with the goal of obtaining an anatomic reduction that will produce a stable radiocapitellar joint. For more proximal injuries, we find that precontoured olecranon plates facilitate stable fixation. A thorough fluoroscopic evaluation of the radiocapitellar joint is critical after ulnar fixation. Any subluxation noted should prompt reevaluation of the ulnar reduction or consideration of exploration of the radiocapitellar joint for tissue interposition. Complications of Monteggia fractures include arthrofibrosis, synostosis, nonunion, malunion, infection, and neurologic injury. In 20 patients with Monteggia variant injuries, Egol et al. found that nine had fair or poor outcomes at 2-year follow-up; overall, 7 had heterotopic ossification, 14 had arthritic changes on radiographs, and 8 had required revision surgery. 

FRACTURES OF THE SHAFTS OF THE RADIUS AND ULNA The relationship between the radius and ulna in the forearm is critical for function, especially pronation and supination. This relationship is so critical that the forearm has been called a “functional joint.” Malunited fractures can impair this functional joint, with resulting impairment of pronation and supination. Abe et al. recently evaluated malunions of the forearm with three-dimensional CT scans to further understand the pathoanatomy and plan the appropriate reconstruction. It is important to reestablish length, alignment, and rotation for the forearm to maintain its dynamic function. Operative treatment is indicated for almost all both-bone forearm fractures in adults. The goal is to reestablish the anatomic relationship between the radius and ulna with rigid fixation. There is almost no role for closed treatment except in the most infirm patients, and, although intramedullary nailing of the forearm has its indications, the most common form of stabilization is plate-and-screw fixation. Anderson’s landmark report in 1975 from this clinic reported excellent or satisfactory results in 86% of patients, with union rates of 98% and 96% of the radius and ulna, respectively. Chapman et al. reported similar results with 3.5-mm plates. These and other reports in the literature establish that ORIF of the radius and ulna predictably leads to bony union and good results. We routinely use plate fixation for both-bone forearm fractures in adults (Fig. 57.93). The volar approach of Henry (see Chapter 1) is used in all but the most proximal fractures of the radius, in which a dorsal Thompson approach is used. Limited-contact dynamic compression 3.5-mm plates are most commonly used. If a butterfly fragment is present, lag

screw fixation (with 2.4- or 2.7-mm screws) is used to obtain anatomic reduction, followed by application of a neutralization plate. For transverse or short oblique fractures, a compression plating technique is used. For distal ulnar fractures or proximal radial fractures where a 3.5-mm plate may be too large, 2.7-mm plates and locking screws can be used to lower the profile of the fixation while providing rigid stabilization. Open fractures with relatively minimal contamination are treated with thorough debridement, irrigation, and immediate ORIF. With grossly contaminated injuries, after thorough debridement and irrigation, splinting or temporary external fixation is used, with repeat debridement and irrigation followed by ORIF if the appearance of the tissue bed is satisfactory. The use of antibiotic-impregnated polymethylmethacrylate beads is considered for grossly contaminated fractures. If the soft-tissue wounds preclude the use of internal fixation, intramedullary nails are used to minimize the zone of injury and exposure to metallic implants. Auld et al. noted that the risk of compartment syndrome increased with the higher-energy variants of the AO/OTA classification, with group C fractures having a 33% compartment syndrome rate. Isolated ulnar fractures can pose a treatment dilemma in deciding between operative and nonoperative treatment. Although most heal uneventfully without surgery, Coulibaly et  al. recommended operative treatment of proximal-third fractures because of progressive displacement; they also recommended surgery if 50% displacement and more than 8 degrees of angulation were present, as both are markers of stability. Historically, intramedullary nailing of forearm fractures has had poor outcomes with earlier devices such as Kirschner wires and Rush rods. The Sage nail addressed the issue of radial bow, allowing improved motion and a decreasing the rate of nonunion. The ForeSight nail (Smith and Nephew, Memphis, TN), an interlocking nail that can be contoured to recreate the radial bow, has had satisfactory results in many studies. Despite the satisfactory outcomes with modern intramedullary nailing, the outcomes of open reduction and plate fixation remain superior. We reserve the use of intramedullary nails for injuries in which the soft-tissue envelope is so traumatized that safe plate application is not possible. The risks of decreased range of motion and decreased union rates are offset by the risk to limb salvage. Often, an intramedullary nail can be used for one bone (usually the ulna) with plate fixation of the other (usually the radius) to limit soft-tissue complications. We also use this technique for segmental ulnar fractures. For intramedullary nailing of forearm fractures see Video 57.2. 

 

OPEN REDUCTION AND INTERNAL FIXATION OF BOTH-BONE FOREARM FRACTURES TECHNIQUE 57.15 After evaluation of the radiographs, plan the sequence of fixation:

n 

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A

C

B

D

FIGURE 57.92 Monteggia fracture-dislocations classification (Bado). A, Type 1. B, Type 2. C, Type 3. D, Type 4.

If anatomic reduction is possible, begin with fixation of the radius. If both fractures are extensively comminuted, begin with fixation of the radius. If the radius is comminuted and the ulnar fracture is simpler, reduce and stabilize the ulna first. n  For most fractures, make a volar Henry approach to the distal radius (Fig. 57.94A). If a fracture requires fixation proximal to the biceps tuberosity, make a dorsal Thompson approach (see Technique 1.117). n  Preserve the periosteum along the proximal and distal segments (Fig. 57.94B, C). n  Debride the fracture edges of hematoma and debris. n  Assess the necessity for lengthening; options for attaining length include chemical paralysis, distraction using a screw in the radial shaft and a lamina spreader, and soft-tissue releases if the fracture has been in a shortened position for an extended period of time. n  For transverse fractures, apply a 3.5-mm limited-contact compression plate. If there is a butterfly fragment, stabilize it with 2.0- or 2.4-mm lag screws before plate application (Figs. 57.95 and 57.96). n  For oblique fractures, reduce the fracture and stabilize it with a 2.0-, 2.4-, or 2.7-mm lag screw, followed by a 3.5-mm limited-contact neutralization plate. n  For extensively comminuted fractures, use a bridge plate at the appropriate length. If the span of the plate is longer than 6 or 7 holes, adding a lateral contour to the plate will help match the radial bow. n  After fixation of the radial fracture, approach the ulna through the interval between the flexor carpi ulnaris and the extensor carpi ulnaris (Fig. 57.94D, E). The plating strategies used for the radius are applicable to the ulnar fracture. We attempt to avoid direct ulnar placement of the plate because of prominent hardware irritation.

The volar or distal aspect of the ulna is chosen for dissection based on which aspect of the ulna has more traumatic dissection. Take care to preserve the periosteum. n  After both the radius and ulna are stabilized, confirm adequate reduction and fixation with fluoroscopy (Fig. 57.97). n  Close the wounds in standard fashion. n 

POSTOPERATIVE CARE Typically, only a soft dressing is necessary. Splinting is used if the elbow or wrist joint is involved or if fixation is questionable. Range-of-motion exercises are begun 3 to 7 days after surgery; heavy lifting is avoided until fracture healing is evident.   

FRACTURES OF THE DISTAL THIRD OF THE RADIUS WITH DISLOCATION OF THE DISTAL RADIOULNAR JOINT (GALEAZZI FRACTURE-DISLOCATION)

The combination of fracture of the distal or middle third of the shaft of the radius and dislocation of the distal radioulnar joint was called “the fracture of necessity” by Campbell. Similar to Monteggia fracture-dislocations, Galeazzi fracture-dislocations often go unrecognized. Isolated fractures of the radial shaft are rare; more often there is some involvement of the distal radioulnar joint. Dislocation of the distal radioulnar joint at the time of injury should be suspected with a displaced fracture of the distal third of the shaft of the radius. Radiographic findings that suggest a distal radioulnar joint injury include (1) fracture at the base of the ulnar styloid; (2) widening of the distal radioulnar joint on the anteroposterior view; (3) dislocation of the ulna relative to the radius on a true lateral view of the wrist; and (4) more than 5 mm of shortening of the radius relative to the ulna when compared with the contralateral wrist.

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A

C

B FIGURE 57.93

D

A and B, Both-bone forearm fracture. C and D, Fixation with plates and screws.

Galeazzi fracture-dislocations have been classified based on the direction of radial displacement (Fig. 57.98). Treatment with closed reduction and cast immobilization has a high rate of unsatisfactory results. Open reduction of the radial shaft fracture through an anterior Henry approach (see Technique 1.114) and internal fixation with a 3.5-mm AO dynamic compression plate is the treatment of choice in adults (Figs. 57.99 and 57.100). Rigid anatomic fixation of the radial shaft fracture generally reduces the distal radioulnar joint dislocation. The forearm should then be splinted in the position of greatest stability, usually supination, for 6 weeks, although recent reports have indicated that immobilization in neutral for 2 weeks is just as effective. If this joint is still unstable, it should be temporarily transfixed with two Kirschner wires (four cortices to allow for removal in case of breakage) with the forearm in supination (Fig. 57.101). The Kirschner wires are removed after 6 weeks, and active forearm rotation is begun. Alternatively, the ulnar styloid can be fixed or the soft tissue of the triangular fibrocartilage complex can be repaired (Fig. 57.102). The radial shaft fracture usually is too distal to allow fixation with an intramedullary device. An irreducible distal radioulnar joint usually indicates soft-tissue interposition and requires open treatment. In a 7-year follow-up of 40 patients with distal radioulnar joint instability after radial shaft fracture fixation, Korompilias et al. found that instability was significantly more frequent with type I fractures than with type II or III fractures. They suggested that the location of the radial fracture can serve as a predictor of instability after fracture fixation. 

FRACTURES OF THE DISTAL RADIUS . . . will at some remote period again enjoy perfect freedom in all of its motions and be completely exempt from pain. Abraham Colles, 1814

The management of distal radial fractures has changed significantly since Colles’s proclamation in 1814. Although

distal radial fractures account for up to 20% of all fractures treated in emergency departments, many are not “completely exempt from pain” after treatment. More than 1000 peer-reviewed studies have been published on the subject, yet there is no consensus on which treatment is superior or firm guidelines for treatment decisions. Many confounding variables exist, all of which are somewhat controversial: the level to which the anatomy is restored, the quality of the bone, the emergence of new techniques and devices, the experience and ability of the surgeon, and outcomes in older populations. The desire for anatomic restoration of the distal radial joint often is the rationale for operative treatment. Many studies have associated as little as 1 mm of incongruity of the articular surface with worse outcomes, whereas other reports have found no association between radiographic arthrosis and outcomes. Complicating matters further is the fact of a bimodal distribution of patients: do the young and the elderly fare differently? Multiple reports indicate that older, low-demand patients tend to tolerate incongruity, deformity, and malunion well; however, Madhok et  al. noted that in elderly patients treated nonoperatively 26% reported functional impairment. Essentially, we know that elderly patients will tolerate more displacement (and closed treatment) than younger patients, but some still have poor outcomes. What is unknown is who would benefit from operative anatomic restoration. High-demand patients represent only a small percentage in most series and, although most patients do well, restoration of the distal radial anatomy is believed to be essential to minimize the complications of arthrosis and functional impairment in these patients. Bone quality also is a confounding variable in trying to determine the best treatment for a particular patient. Bone quality is directly related to the ability to obtain and maintain reduction. In patients with poor bone quality, low-energy trauma may produce significant displacement and communition, indicating that osteoporosis should be included in classification systems for distal radial fractures.

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Superficial branch of radial nerve

Supinator Radius

Brachioradialis

Periosteal incision

B

Biceps tendon

Radial artery Pronator teres

Flexor carpi radialis

A

Ulna

C

Flexor carpi ulnaris

Periosteum

Extensor carpi ulnaris Anconeus

E

D FIGURE 57.94 Open reduction and internal fixation of both-bone forearm fractures. A, Volar approach. B and C, Deep dissection. D and E, Approach to ulna. SEE TECHNIQUE 57.15.

One constant in the recent literature is that the specific technique is not as important as attaining anatomic reduction. Both clinical outcome and biomechanical studies demonstrate that maintenance of palmar tilt (normally 11 degrees), of ulnar variance (normally −2 mm), and of radial height (normally 12 mm) is the most important factor in obtaining good results. Numerous techniques are available (e.g., closed reduction and percutaneous pinning, external fixation, dorsal plating, volar locked plating, intramedullary nailing), each with its specific complications and learning curve (Table 57.11). Because of the unanswered questions concerning the treatment of distal radial fractures in a heterogeneous group

of patients, treatment must be individualized for each patient based on expectations, demand level, age, bone quality, fracture characteristics, and surgeon experience and ability.

CLASSIFICATION

More than 20 classification systems have been proposed for distal radial fractures. As with most fracture classifications, the intraobserver and interobserver agreement rates usually are only moderate at best. These classifications can, however, help in understanding the fracture and conceptualizing some of the challenges in treatment. Gartland and Werley’s system emphasized metaphyseal comminution, intraarticular extension, and fragment displacement. Frykman added

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

FIGURE 57.95 57.15.

Both-bone forearm fracture. SEE TECHNIQUE

FIGURE 57.97 Reduction and plate placement confirmed on fluoroscopy. SEE TECHNIQUE 57.15.

involvement of the radioulnar and radiocarpal joints to assessment of intraarticular and extraarticular involvement, and Melone evaluated the four major fracture components. Fernandez based his classification system on mechanism of injury (Table 57.12). 

ASSESSMENT OF STABILITY

FIGURE 57.96 Fixation of both-bone forearm fracture with lag screws and plate. SEE TECHNIQUE 57.15.

Most distal radial fractures are treated with immobilization after closed reduction; unfortunately, many of these fractures lose reduction or the initial reduction was not acceptable and outcomes are poor. LaFontaine et al. identified five factors indicative of instability: (1) initial dorsal angulation of more than 20 degrees (volar tilt); (2) dorsal metaphyseal comminution; (3) intraarticular involvement; (4) an associated ulnar fracture; and (5) patient age older than 60 years. Other suggested indicators of instability include volar tilt, dorsal angulation, comminution, and initial shortening. Goldwyn et al. suggested that traction radiographs can aid in treatment decision-making. There are no definitive criteria or guidelines to guide treatment decision making, and a number of factors must be considered in developing a treatment plan, including initial injury characteristics, alignment after reduction, patient age, bone quality, patient demand, and expected outcome. If closed treatment is chosen for a fracture with questionable stability, close monitoring is advised. It is important to note any change in the reduction over a series of radiographs that indicate instability or displacement and to change treatment when necessary. Fractures that are considered to be potentially unstable should be evaluated with serial radiographs until fracture healing results in stability. 

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A

B

FIGURE 57.98 Classification of Galeazzi fracture based on direction of radial displacement. A, Type I, apex volar, fractures are caused by axial loading of forearm in supination, which results in dorsal displacement of radius and volar dislocation of distal ulna. B, Type II, apex dorsal, fractures are caused by axial loading of forearm in pronation, resulting in anterior displacement of radius and dorsal dislocation of distal ulna.

A

B

C

FIGURE 57.99 A, Galeazzi fracture-dislocation. B and C, After fixation with 3.5-mm AO dynamic compression plate and screws. Temporary stabilization of distal radioulnar joint with transverse Kirschner wire was unnecessary.

TREATMENT OPTIONS CLOSED TREATMENT

Stable fractures can be successfully treated with closed reduction and immobilization, initially with a splint followed by a cast, and weekly radiographic evaluation for 3 weeks. Significant changes in radial length, palmar tilt, or radial inclination should prompt consideration of operative treatment. In infirm and low-demand patients, closed treatment often is appropriate even with factors that are indications for operative

treatment in more active patients. In a prospective randomized trial comparing nonoperative treatment with volar locking plate fixation in 73 patients aged 65 years or older, Arora et al. found no differences in range of motion or level of pain at 1-year follow-up; although grip strength was better in those treated operatively, anatomic reconstruction did not improve patients’ ability to perform daily living activities. Egol et  al. also found that minor limitations in wrist range of motion and diminished grip strength after nonoperative treatment

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM Galeazzi fracture

ORIF with plating of the radius

Intraoperative assessment of the DRUJ

Reduced, stable

Large ulnar styloid fragment

ORIF of the ulnar styloid

Reduced, unstable

Irreducible

No ulnar styloid fragment

Exploration of the DRUJ

TFCC exploration and repair Kirschner wire fixation of ulna to radius

Protective splint with early motion

Release interposition and reassess DRUJ

Unstable

Stable

Immobilization in supination in an above-elbow cast for 4 to 6 wk

FIGURE 57.100 Treatment algorithm for Galeazzi fractures in adults. ORIF, Open reduction internal fixation; DRUJ, distal radioulnar joint; TFCC, triangular fibrocartilage complex.

did not limit functional recovery in 90 patients older than the age of 65 years. In their systematic review and meta-analysis, Chen et al. determined that although operative management resulted in better radiographic outcomes and grip strength, there was no significant difference in pain, function, or range of motion, and major complications were significantly more frequent in those treated operatively.

PERCUTANEOUS PINNING

are better. Splint or cast immobilization usually is necessary after percutaneous pinning. Some complications related to the technique of percutaneous pinning include tendon tethering, injury, or rupture; pin migration; nerve injury; and pin site infections. 

 

Percutaneous pinning after closed reduction is useful for distal radial fractures with metaphyseal instability or simpler intraarticular displacement. An anatomic reduction must be obtained first, and then stability is provided by the Kirschner wires. Usually the first pins are placed from the radial styloid across to the medial radial metaphysis and diaphysis. We generally use at least two pins and confirm adequate reduction on anteroposterior and lateral views. The lunate facet can then pinned into position if needed. Intrafocal pins (Kapandji technique) can be added to provide a dorsal buttress. A number of studies have reported success with this technique. Glickel et  al. reported good long-term outcomes with closed reduction and percutaneous pinning of all but the most complex injuries. Three recent randomized controlled trials comparing volar locking plates and closed reduction with percutaneous pinning of distal radial fractures failed to show an advantage to the use of volar locking plates. Percutaneous pinning tends to work better when placed in subchondral bone, where bone quality and density usually

CLOSED REDUCTION AND PERCUTANEOUS PINNING OF DISTAL RADIAL FRACTURE TECHNIQUE 57.16 (GLICKEL ET AL.) After sterile preparation and draping, place the thumb and index fingers in finger traps for longitudinal traction (typically 10 lb). Manipulate and reduce the fracture (Fig. 57.103A). n  Evaluate the reduction fluoroscopically; if adequate, proceed with percutaneous pinning. If the reduction is not anatomic, or if there is severe comminution, alternative techniques such as ORIF may be indicated. n  Make a 1.5-cm incision longitudinally, beginning at the radial styloid and proceeding distally (Fig. 57.103B). n 

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Tension band

A

B

C

FIGURE 57.102 Open reduction and internal fixation of ulnar styloid fracture with lag screw (A), pins (B), and tension band technique (C). (Adapted from Katolik LI, Trumble T: Distal radioulnar joint dysfunction, J Am Soc Surg Hand 5:8, 2005.)

Place one 1.6-mm Kirschner wire percutaneously 90 degrees orthogonally to these wires, starting at the dorsal rim of the distal radius just distal to the Lister tubercle. Confirm the correct starting point with fluoroscopy and drive the wire in a proximal and volar direction across the fracture site to engage the volar cortex of the radius proximal to the fracture (Fig. 57.103C). n  If there is marked dorsal comminution, a second dorsal pin can be placed either into the dorsal rim of the distal radius or used as an intrafocal pin. If there is marked radial comminution and prereduction radial translation, an additional buttress pin can be placed into the radial aspect of the fracture and driven into the proximal ulnar cortex of the radius. A crossed-pin configuration, in which the pins are placed from the distal ulnar radial cortex and passed to engage the intact cortex radially, also may be helpful (Fig. 57.103D). n  Place additional wires as necessary to secure additional fracture fragments. n  Bend and cut the wires, leaving them superficial to the skin. Close the radial styloid incision with interrupted absorbable sutures. Apply a sugar-tong splint. n 

A

B

POSTOPERATIVE CARE  The splint is worn for 2 weeks

C

D

FIGURE 57.101 A and B, Galeazzi fracture-dislocation. C and D, Fixation of radius with dynamic compression plate; fixation of distal radioulnar joint with Kirschner wires.

Identify the branches of the superficial radial nerve, mobilize them with blunt dissection, and retract them. n  Identify the first extensor compartment and place two 1.6-mm (0.062-inches) Kirschner wires in succession from the radial styloid across the fracture site to engage the ulnar cortex of the radius proximal to the fracture. Place these wires either dorsal or volar to the first extensor compartment, depending on fracture pattern and anatomic variations.

to control rotation and minimize irritation at the pin sites, and then a soft arm cast is applied. The cast and pins are removed at between 5 and 6 weeks depending on the fracture pattern, the patient’s age and bone quality, and the extent of healing seen on radiographs. When healing is confirmed by lack of tenderness over the fracture and radiographic evidence of bridging callus across the fracture, supervised hand therapy is begun, including wound care and 1 to 2 weeks of splinting. As edema and pain decrease, soft-tissue and joint mobilization protocols are instituted and active and active-assisted range-of-motion exercises are begun. Functional use and activities are strongly encouraged by 8 to 10 weeks after surgery.   

n 

EXTERNAL FIXATION

External fixation can be useful as primary or adjunctive treatment in certain distal radial fractures. The external fixator neutralizes the axial load placed on the distal radius by physiologic activity of the forearm musculature. It can be placed in a bridging or nonbridging (does not cross the wrist joint) technique, with or without supplemental stabilization. Linear traction typically does not

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM TABLE 57.11



Radiographic Criteria for Acceptable Reduction of Distal Radial Fracture CRITERION Ulnar variance (radial length) Radial height Palmar (lateral) tilt Radial inclination Intraarticular step or gap

NORMAL ±2 mm comparing level of lunate facet to ulnar head 12 mm 11 degrees of volar tilt 20 degrees as measured from lunate facet to radial styloid None

fully restore volar tilt; however, neutral tilt is acceptable, and Wei et al. reported good results with external fixation when satisfactory reduction is obtained. Because external fixation alone can allow shortening and loss of reduction over time, supplemental fixation with percutaneous Kirschner wires is often used. The fixator is then used to neutralize the Kirschner wires. We rarely apply definitive external fixation without the use of supplemental Kirschner wires. The addition of a graft also can be useful with external fixation. External fixation has been reported by several authors to obtain good results in distal radial fractures. In a comparison to cast treatment in 46 patients 65 years of age or older, Aktekin et al. found that wrist extension, ulnar deviation, palmar tilt, and radial height were better in those treated with external fixation. In a similar comparison to ORIF, better grip strength and range of motion, as well as fewer malunions, were found with internal fixation. A meta-analysis of comparative clinical trials concluded that ORIF yields significantly better functional outcomes, forearm supination, and restoration of volar tilt while external fixation results in better grip strength and wrist flexion. The quality of the reduction appears to be the determining factor in outcome. Two studies comparing volar locking plates to external fixation by Grewal et al. and Williksen et al. did not show conclusively that volar locking plates obtained superior results. Nonbridging external fixation consists of a distal pin cluster inserted into the distal fragment without crossing the wrist joint. McQueen has reported on this technique for fractures that demonstrate enough distal bone to accept the external fixator pins. In extraarticular fractures, the results have been excellent. Despite the number of reports of its successful use, external fixation has not become an often used technique for distal radial fracture fixation. There are a variety of spanning and nonspanning external fixation devices available, and the techniques of application differ slightly according to the specific device chosen. 

ACCEPTABLE No more than 2 mm of shortening relative to ulnar head ???? Neutral No less than 10 degrees Less than 2 mm of either

quet to the arm. Reduce the fracture manually or with the aid of sterile finger traps or traction device (see Fig. 57.103A). n  Make a 2- to 3-cm incision over the dorsoradial aspect of the index metacarpal base and use blunt dissection with scissors to expose the metacarpal. Take care to preserve and reflect the branches of the dorsal radial sensory nerve. n  Place a soft-tissue protector on the metacarpal and insert 3-mm self-tapping half-pins at a 30- to 45-degree angle dorsal to the frontal plane of the hand and forearm. Confirm pin position and length with fluoroscopy. n  Make a 4-cm skin incision 8 to 10 cm proximal to the wrist joint and just dorsal to the midline. n  With blunt dissection, expose the superficial branches of the lateral antebrachial cutaneous nerve and the radial sensory nerve, the latter of which exits in the midforearm from the investing fascia between the brachioradialis and extensor carpi radialis longus (Fig. 57.104A). n  Insert two 3-mm half-pins, 1.5 cm apart, through a softtissue protector between the radial wrist extensors at a 30-degree angle dorsal to the frontal plane of the forearm (Fig. 57.104B). The pins should just perforate the medial cortex of the radius. Confirm pin position and length with fluoroscopy. n  Irrigate and close both incisions with 4-0 nylon sutures. n  Apply the selected external fixation frame according to the manufacturer’s instructions. For relatively stable fractures and when using Kirschner wires for augmentation of the fixation, a simple single-bar frame usually is sufficient (Fig. 57.105); more complex fixators allow independent palmar carpal translation to adjust volar tilt. 

NONSPANNING EXTERNAL FIXATION  If nonspanning external fixation is chosen for a minimally comminuted extraarticular or simple articular fracture in a patient with good bone stock, insert the proximal pins as described earlier. n  Insert the distal pins into the distal fragment. Place a radial-sided pin through a small dorsal radial incision between the wrist extensors in the radial half of the distal fragment. Direct the pin dorsal palmar, parallel to the joint surface in the sagittal plane. n  Insert a second pin in the ulnar aspect of the distal fragment through a limited incision between the fourth and fifth extensor compartments. Also direct this pin dorsal n 

 

EXTERNAL FIXATION OF FRACTURE OF THE DISTAL RADIUS TECHNIQUE 57.17 SPANNING EXTERNAL FIXATION  With the use of brachial block or general anesthesia, prepare and drape the upper extremity and apply a tourni-

n 

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TABLE 57.12

Classification of Distal Radial Fractures GARTLAND AND WERLEY (1951) Group 1 Group 2 Group 3

Simple Colles fracture Comminuted Colles fracture, undisplaced intraarticular fragment Comminuted Colles fracture, displaced intraarticular fragment

FRYKMAN (1967) Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8

Extraarticular without fracture of the distal ulna Extraarticular with fracture of the distal ulna Intraarticular involving the radiocarpal joint without fracture of the distal ulna Intraarticular involving the radiocarpal joint with fracture of the distal ulna Intraarticular involving the distal radioulnar joint without fracture of the distal ulna Intraarticular involving the distal radioulnar joint with fracture of the distal ulna Intraarticular involving both radiocarpal and distal radioulnar joints without fracture of the distal ulna Intraarticular involving both radiocarpal and distal radioulnar joints with fracture of the distal ulna

MELONE (1986) Type 1 Type 2 Type 3 Type 4

Undisplaced, minimal comminution, stable Unstable, displacement of medial complex, moderate-to-severe comminution Displacement of medial complex as a unit plus an anterior spike Wide separation or rotation of the dorsal fragment and palmar fragment rotation

FERNANDEZ (1987) Type 1 Type 2 Type 3 Type 4 Type 5

Bending: One cortex of the metaphysis fails because of tensile stress; opposite cortex with some comminution Shearing: Fracture of the joint surface Compression: Fracture of the joint surface with impaction of subchondral and metaphyseal bone, intraarticular comminution Avulsion: Fracture of the ligament attachments of the ulnar and radial styloid process, radiocarpal fracture-dislocation Combination: High-velocity injuries

COONEY (1990) UNIVERSAL CLASSIFICATION Type I Type 2 Type 3 Type 4

Extraarticular, undisplaced Extraarticular, displaced Intraarticular, undisplaced Intraarticular, displaced

MODIFIED AO Type A Type B

Type C

Extraarticular Partial articular B1–radial styloid fracture B2–dorsal rim fracture B3–volar rim fracture B4–die-punch fracture Complete articular

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

A

B

D

C

FIGURE 57.103 Closed reduction and percutaneous fixation of distal radial fractures. A, Fracture reduction. Suspension from finger allows disimpaction of the fracture, followed by pressure applied with thumb over distal fragment. B, Longitudinal incision. C, Percutaneous pinning confirmed fluoroscopically. D, Crossed pin configuration. (From Wolfe SW: Distal radius fractures. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, editors: Green’s operative hand surgery, ed 6, Philadelphia, 2011, Elsevier.) SEE TECHNIQUES 57.16 AND 57.17.

palmar, but aim it slightly obliquely from the ulnar to radial side to engage the palmar ulnar cortex of the distal fragment. n  Use the distal pins as “joysticks” to reduce the fracture and restore volar tilt. n  Assemble the pins with separate clamps and rods to create a triangular frame. 

AUGMENTED EXTERNAL FIXATION  For all but minimally comminuted extraarticular fractures, augmentation of the external fixation is recommended to provide additional support to individual fracture fragments and increase stability. n  For unstable fractures without depressed articular fragments, introduce 0.045- or 0.0625-inch Kirschner wires into the fracture fragments; a crossed configuration can be used to increase stability (Fig. 57.106A,B). Drive one or two pins through the radial styloid fragment and one through the dorsal ulnar fragment into the radial shaft to produce maximal stability. Pins should pierce the ulnar cortex of the radius but not penetrate into the ulnar shaft. n 

Cut off the pins 1 cm external to the skin margin and bend them at an acute angle. n  Apply the external fixator according to manufacturer’s instructions (Fig. 57.106C,D). Some fixators have components to accommodate the Kirschner wires.  n 

POSTOPERATIVE CARE  The wrist remains immobilized in a supinated position with a sugar-tong splint for 10 days until pain and swelling have subsided. This promotes stability of the distal radioulnar joint and facilitates resumption of full supination. The external fixator frame usually is removed at 6 weeks; any supplemental pins are kept in place for 8 weeks. Active and passive finger motion is begun as soon as the anesthesia wears off and is encouraged the entire time the frame is in place. Supination and pronation of the forearm are begun at the first postoperative visit. Supervised hand therapy is recommended for patients who are unwilling or unable to mobilize their fingers and forearm independently.   

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BR Radial sensory nerve ECRB ECRL

A

B

FIGURE 57.104 A, Two 3-mm half-pins introduced into base or second metacarpal and two into distal radius. BR, brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus. B, Single-bar frame for external fixation of distal radial fracture. (From Wolfe SW: Distal radius fractures. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, editors: Green’s operative hand surgery, ed 6, Philadelphia, 2011,Elsevier.) SEE TECHNIQUE 57.17.

OPEN REDUCTION AND PLATE FIXATION DORSAL PLATING

Most distal radial fractures result in an apex-volar angulation with dorsal cortical comminution. First-generation dorsal plate designs were a logical solution but were fraught with complications secondary to tendon dysfunction and rupture, which prompted a move to fixed-angle volar plating techniques after the development of angle-stable screws. There is still a role for dorsal plating, and newer lower-profile designs may decrease complications. In certain situations, such as dorsal die-punch fractures or fractures with displaced dorsal lunate facet fragments, a dorsal approach with a low-profile fragment-specific plate appears to work well. At this time, most of our dorsal plating is done with a fragment-specific technique, often in conjunction with other forms of fixation. 

VOLAR PLATING

The popularity of locked volar distal radial plate fixation continues to prompt development of new devices. Capo et  al. demonstrated the biomechanical superiority of volar plating over dorsal and radioulnar dual-column plating, and several clinical studies have reported better functional results with volar plating than with dorsal plating, external fixation, and percutaneous pinning; however, a complication rate of approximately 15% also has been reported with volar plating, primarily problems with tendon ruptures and tenosynovitis from prominent screws. Screw penetration of the radiocarpal joint occurred in 11 of 40 patients described by Knight et al. A low-profile volar plate produced no tendon ruptures in 95 patients reported by Soong et al. Precise volar plate placement on the metaphyseal area of the

distal radius may lessen the problems of flexor tendon irritation and eventual rupture (Fig. 57.107). In their series of 122 patients with distal radial fractures treated with volar locking plates, Roh et al. identified an increase in age and a decrease in bone mineral density as important risk factors for delayed functional recovery up to 12 months after surgery; fracture severity and high-energy trauma were associated with decreased functional outcomes up to 6 months after surgery. Wadsten et al., in a multicenter cohort study, showed that volar and dorsal comminution predicted later displacement. Volar comminution was the strongest predictor of displacement. 

 

VOLAR PLATE FIXATION OF FRACTURE OF THE DISTAL RADIUS TECHNIQUE 57.18 (CHUNG et al.) Make an 8-cm incision over the forearm between the radial artery and the flexor carpi radialis. Extension of the incision distally at the wrist crease in a V-shape may provide wider exposure of the fracture and help prevent scar contracture. The distal incision does not need to cross into the palm (Fig. 57.108A). n  Carry the incision to the sheath of the flexor carpi radialis (Fig. 57.108B). Open the sheath and incise the forearm deep fascia to expose the flexor pollicis longus. n 

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A

B

FIGURE 57.105 A, Fracture of distal radius. B, External fixation with supplemental percutaneous Kirschner wire fixation. SEE TECHNIQUE 57.17.

Place an index finger into the wound and gently sweep the flexor pollicis longus ulnarly. Partially detach the flexor pollicis longus muscle belly from the radius to gain full exposure of the pronator quadratus (Fig. 57.108C). n  Make an L-shaped incision over the radial styloid along the radial border of the radius to expose the pronator quadratus and use a Freer elevator to elevate it from the radius (Fig. 57.108D). The entire fracture line across the distal radius is now fully exposed (Fig. 57.108E). n  Insert a Freer elevator or small osteotome into the fracture line to serve as a lever to reduce the fracture. Insert the elevator or osteotome across the fracture line all the way to the dorsal cortex to allow disimpaction and reduction of the distal fragment. Apply finger pressure to the dorsal cortex to reduce the dorsal fragments. n  With a displaced radial styloid fracture, the brachioradialis may prevent reduction by pulling on the radial styloid. To relieve the deforming force, the brachioradialis can be transacted or detached from the distal radius. n  If necessary, use a Kirschner wire to temporarily fix the distal fragment to the proximal fragment. This usually is not necessary because distal traction should maintain reduction while the volar plate is placed. n  Disimpact and reduce the fracture through capsuloligamentotaxis achieved by an assistant through finger traction. After successful fracture reduction, position the volar plate under fluoroscopic guidance and insert a screw into the oblong or gliding hole first to allow proximaldistal adjustment (Fig. 57.108F). Use a 2.5-mm drill bit to drill into the center of the oblong hole and insert a self-tapping 3.5-mm screw. n  Confirm proper placement of the volar plate with mini-Carm fluoroscopy. If necessary, shift the plate proximally or distally to provide the best placement for the distal screws. n  Use a 2.0-mm drill bit to drill the distal holes. Measure the holes for screw length and insert smooth locking screws. Use a screw that is 2 mm shorter than the measured length to avoid having a prominent distal screw perfo n 

rate the dorsal cortex; typically, 20- to 22-mm screws are optimal, except for screws directed into the radial styloid, which are significantly shorter. Threaded screws may gain better bone dorsally; however, pegs may be sufficient when bone quality is poor. n  Once the first screw is inserted, distal traction on the fingers can be released because the fracture usually is appropriately reduced and fixed (Fig. 57.108G). n  Because of the fixed-angle design, the screws may perforate into the radiocarpal joint if the plate is placed too far distally. Obtain fluoroscopic views tangential to the subchondral bone in both the coronal and sagittal planes to assess for intraarticular penetration. Adjust the plate or screws, or both as indicated. n  After placement of the distal screws, place the remaining proximal screws (Fig. 57.108H). n  Reattach the pronator quadratus with braided absorbable sutures. Note that the pronator will not be able to cover the entire plate; the distal portion should be covered when possible to reduce flexor tendon-plate contact. For better purchase, the pronator quadratus can be sutured to the edge of the brachioradialis (Fig. 57.108I). n  If the ulnar styloid is fractured and displaced, making the distal radioulnar joint unstable, fix the styloid with one or two percutaneous Kirschner wires (Fig. 57.109). A volar approach may be helpful to obtain ulnar styloid reduction. Smaller fragments usually do not require surgical management; however, if the distal radioulnar joint is unstable after fixation of the radial fracture, styloid fragments can be excised and the peripheral rim of the triangular fibrocartilage complex anchored to the ulnar styloid base with nonabsorbable braided suture through drill holes or a bone anchor. n  Close the wound in layers and apply a splint.

POSTOPERATIVE CARE At 1 week, the sutures are removed and active wrist motion is begun when there is confidence in fracture stability. A removable Orthoplast (Northcoast Medical, Gilroy, CA) splint is worn for 6 weeks. Most

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B

A C

D FIGURE 57.106 A and B, Crossed-pin augmentation with external fixation (C and D) of distal radial fracture. (From Wolfe SW: Distal radius fractures. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, editors: Green’s operative hand surgery, ed 6, Philadelphia, 2011, Elsevier.) SEE TECHNIQUE 57.17.

A

FIGURE 57.107

B

C

A to C, Volar plate fixation of distal radial fracture.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM patients are given a home therapy program, but elderly patients may require twice-a-week supervised home therapy. Brehmer and Husband found in a prospective randomized controlled study that an accelerated rehabilitation protocol, which emphasizes motion immediately postoperatively and initiates strengthening at 2 weeks after volar open reduction and internal fixation, results in an earlier return to function than a standard rehabilitation protocol.    

 

DISTRACTION PLATE FIXATION As an alternative to external fixation of highly comminuted fractures of the distal radius, Burke and Singer described the use of a distraction plate as an internal fixator. The plate is applied to the dorsal surface of the hand, wrist, and distal forearm using three small incisions. External fixation pin site problems are avoided, and the plate can remain in place as long as necessary for union. Secondary bone grafting procedures also are done more easily without an overlying external fixator. Ruch et al. reported good-to-excellent outcomes in 90% of 22 patients using this technique, and Richard et al. reported good results in 33 patients over the age of 60 years.

TECHNIQUE 57.19 (BURKE AND SINGER AS MODIFIED BY RUCH ET AL.) Make a 4-cm longitudinal incision over the dorsal aspect of the long finger metacarpal shaft. Expose the bone by retracting the long finger extensor tendon. n  Make a second 4-cm dorsal incision at least 4 cm above the comminuted segment of the radius and expose the bone. n  Make a third 2-cm dorsal incision over the Lister tubercle, exposing the extensor pollicis longus tendon. n  Pass a 12- to 16-hole, 3.5-mm plate from the distal incision in a proximal direction using the plane between the extensor tendons (fourth dorsal compartment) and the joint capsule and periosteum. Mobilize the extensor tendons if necessary. n  Secure the plate to the long finger metacarpal shaft with three bicortical 3.5-mm screws. n  Under fluoroscopic guidance, apply distal traction to obtain normal radial length. With the hand in 60 degrees of supination, secure the plate to the radius with a bone clamp. n  Confirm that full rotation of the forearm is possible and then secure the plate with three bicortical 3- to 5-mm screws (Fig. 57.110). n  Reduce and fix diaphyseal fragments to the shaft with interfragmentary screws if possible. n  Elevate the lunate fossa through the middle incision. n  Insert a 3.5-mm screw through the plate and under the elevated lunate fossa to serve as a buttress. n  Percutaneously pin other fragments to stabilize the articular surface using Kirschner wires. n 

Place bone graft into the defects through the middle incision using autograft, allograft, or bone graft substitute. n  Assess the stability of the distal radioulnar joint. If it is unstable, immobilize the wrist in a sugar-tong splint. n 

POSTOPERATIVE CARE Finger and other joint upper extremity exercises are begun immediately. If a splint was applied, it should be removed at 3 weeks. Percutaneous Kirschner wires should be removed at 6 weeks. Activities of daily living are allowed, but lifting should be restricted to 5 lb. When union is achieved, the distraction plate is removed and range-of-motion exercises are begun.   

FRAGMENT-SPECIFIC OPEN REDUCTION AND INTERNAL FIXATION OF COMMINUTED DISTAL RADIAL FRACTURES

Recognizing the pitfalls of Kirschner wire fixation and plate and screw fixation when used alone for repair of comminuted intraarticular distal radial fractures, Medoff developed a wrist fixation system that combines both methods for stable reconstruction of the distal radius. Five potential fracture fragments are possible, especially in osteopenic bone: radial column, dorsal cortical wall, dorsal ulnar split, volar rim, and the central intraarticular fragment (Fig. 57.111). Radial styloid Kirschner wire fixation does not prevent settling or radial drift of the distal radial fracture fragments (Fig. 57.112). Thin metaphyseal cortical bone, especially in osteopenic bone, does not hold screws well, and conventional plates cannot be applied easily on the dorsal aspect of the distal radius because of plate thickness, potential irritation, and eventual rupture of the dorsal wrist tendons. The addition of a small buttress plate to a radial styloid pin prevents collapse and radial migration of the distal radius (Fig. 57.113). The radial styloid pin now has two fixation points—the first through the distal end of the plate and the second through the intact medial radial cortex. The dorsal ulnar fragment is stabilized with an ulnar pinplate of a similar design. This pin-plate maintains the length of the ulnar column and reduction of the distal radioulnar joint (Fig. 57.114). Wire-form implants are used to stabilize the dorsal cortical wall, the intraarticular fragment, and any structural bone graft used to support the articular fragment. Three different wire-form implants are used, depending on the fracture fragments present (Fig. 57.115). The volar rim–lunate facet fragment is secured with a low-profile buttress plate similar to that used for repair of volar Barton fractures (Fig. 57.116). Medoff reported 20 good-to-excellent results in 21 patients with intraarticular comminuted distal radial fractures treated with the TriMed system (TriMed Inc., Valencia, CA). We have had similar good results (Fig. 57.117). 

COMPLICATIONS

The type and frequency of complications of the distal radius vary greatly among reported series. In their literature review, McKay et al. found overall complication rates ranging from 6% to 80% and rates of posttraumatic arthritis that ranged from 7% to 65% (Table 57.13). Jupiter and Fernandez identified malunion with an intraarticular or extraarticular deformity as the most frequent complication. The reported incidence of distal radial malunion is approximately 17%. It is

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A

B

C

D

E

F

G

H

I FIGURE 57.108 Volar plate fixation of distal radial fracture. A, Skin incision. B, Incision carried to flexor carpi radialis sheath. C, Flexor pollicis longus muscle belly is partially detached from radius to expose pronator quadratus. D, Freer elevator is used to elevate pronator quadratus from radius. E, Fracture line is exposed. F, Volar plate positioned, insertion of first screw. G, Insertion of second screw after release of distal traction on fingers. H, Remaining proximal screws are placed. I, Pronator quadratus sutured to edge of brachioradialis. SEE TECHNIQUE 57.18.

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A

B

C

FIGURE 57.109 A to C, Distal radial fracture.

more common after nonoperative than operative treatment. The most common deformity after extraarticular distal radial fracture is shortening, rotation of the distal fragment, loss of volar tilt, and loss of ulnar inclination. Osteotomies and other operative procedures for the treatment of wrist problems after distal radial fracture are discussed in Chapter 69. Other less frequently reported complications include nonunion, implant complications, tendon rupture or scarring, and neurologic injuries. Nonunion of distal radial fractures is uncommon, occurring in less than 1% of patients, and is more frequent after operative treatment than nonoperative treatment. Factors suggested to predispose to nonunion include open comminuted fractures, infections, pathologic lesions, soft-tissue interposition, inadequate fixation, excessive distraction with an external fixator, and a concomitant fracture of the distal ulna. Tendon complications are most frequent after locked volar plating when the plate is placed too distal or off the bone or when screws that are too long are used, resulting in impingement on the traversing flexor tendons. Prominence of the volar plate at the watershed line, where the flexor tendons lie closest to the bone and plate, also has been implicated as a cause of flexor tendon rupture from abrasion. Flexor tendon ruptures have been reported in up to 12% of patients with locked volar plating. In a series of 96 distal radial fractures treated with volar plating, complications were identified in 23%; the frequency of complications decreased with increased surgeon experience. A systematic literature review of unstable distal radial fractures in elderly patients (60 years or older) identified rupture or adhesion of the flexor pollicis longus tendon, extensor pollicis longus, or both as the most common major complication requiring surgery after volar locked plating. In a comparison of younger (20 to 40 years of age) and older (60 years or older) patients treated with volar locking plates, Chung et al. found no increase in complication rates in older patients. Hanel et al. reported 16 complications (12%) in 144 fractures treated with dorsal distraction plates, noting that patients whose plates were left in place for longer than 16 weeks had an overall complication rate of 21%,

compared with a complication rate of 8.5% in those plates that were removed earlier. Rhee et al. listed several measures to avoid tendon injuries, including placement of volar plates proximal to the watershed line, closure of the pronator quadratus over a volar plate, and use of shorter unicortical screws or smooth pegs with volar plates. A dorsal tangential view of the wrist is helpful to detect screw penetration to the dorsal cortex during volar plating. Compartment syndrome associated with distal radial fractures is rare, occurring in approximately 1% of patients, primarily younger patients with high-energy injuries. Complex regional pain syndrome (CRPS) occurs most commonly in elderly patients and those with psychological or psychiatric conditions and has been reported in 8% to 35% of patients with distal radial fractures. A randomized, controlled, multicenter study involving 416 patients with 427 distal radial fractures determined that vitamin C (500 mg daily) can reduce the prevalence of CRPS, and this was listed as having “adequate evidence to support a moderately strong endorsement” in the recent AAOS clinical practice guidelines for distal radial fractures. The median nerve is the most frequently injured (0% to 17%), followed by the radial and ulnar nerves, primarily because of its close proximity to the fracture and its confinement within the carpal canal. Mild carpal tunnel syndromes occur in up to 20% of patients, but most resolve without treatment. Acute carpal tunnel syndrome requiring immediate release is most likely after high-energy, severely comminuted fractures. Late median neuropathy may be associated with malunion, residual palmar displacement, nerve impingement by callus formation, or prolonged immobilization with the wrist in flexion and ulnar deviation. Injury to the radial and ulnar nerves is less common (0% to 10%). Immobilization with the wrist in excessive flexion (more than 20 degrees) and ulnar deviation should be avoided because this increases carpal tunnel pressure. Regardless of the management strategy chosen for distal radial fractures, complications can occur even when appropriate care is delivered. The sequelae of specific complications may be lessened by prompt and problem-specific intervention.

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D

E

F

G

H

I

FIGURE 57.109, cont’d D and E, Reduction and placement of Kirschner wires for provisional fixation. F and G, Plate application. H and I, Plate in place after removal of Kirschner wires. SEE TECHNIQUE 57.18.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

FIGURE 57.113 Radial pin-plate provides transstyloid Kirschner wires with two-point fixation, enhancing stability. Plate adds radial buttress to radial column and helps resist dorsal torque on radial column fracture. (Redrawn from Dr. R. Medoff.)

B

A

C

FIGURE 57.110 A to C, Distraction plate internal fixator. (From Ruch DS, Ginn TA, Yang CC, et al: Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution, J Bone Joint Surg 87A:945, 2005.) SEE TECHNIQUE 57.19. Intraarticular

Radial column

Dorsal ulnar split

Dorsal wall

Intraarticular Dorsal wall

Volar rim FIGURE 57.111

Distal radial fracture elements.

Radial column

FIGURE 57.114 Ulnar pin-plate. Application of ulnar pinplate for stabilization of dorsal ulnar split fragment. By proper contouring, plate can close gaps in sagittal plane.

Bending

2

1

Angulation

A

1

1

B

FIGURE 57.112 A, Transstyloid Kirschner wire has only single point of fixation. Minor bending of wire or angulation at site of purchase may result in significant loss of position of radial column fracture. B, By adding second point of constraint, pin-plate greatly enhances Kirschner wire fixation. In addition, pin-plate adds buttress to radial column fragment.

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A

B

C

FIGURE 57.115 A, Small fragment clamp. Dorsal cortical wall fragment stabilized by small fragment clamp that provides pinch-type grip with extraosseous and endosteal wire form. B, Buttress pin. Intraarticular fragments are stabilized by providing peripheral cortical reconstruction around fragment and adding endosteal buttress, as shown here. C, Small fragment clamp/buttress pin combines function of small fragment clamp and buttress pin into single device to provide simultaneously stabilization of dorsal wall fragment and intraarticular component.

FIGURE 57.116 L-plate provides volar buttress to volar rim of lunate facet, yet allows fixation to subcutaneous radial side of proximal fragment.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM

A

B

C

FIGURE 57.117



D

A and B, Distal radial fracture. C and D, Fragment-specific fixation.

TABLE 57.13

Complications After Fracture of Distal Radius COMPLICATION Arthritis/arthrosis Loss of motion Implant complications Nerve compression/neuritis Osteomyelitis Dupuytren contracture Persistent pain/pain syndromes (CRPS) Tendon (rupture, lag, trigger, tenosynovitis) Delayed union/nonunion Radioulnar (synostosis, disturbance)

INCIDENCE (%) 7-65 0-31 1.4-26 0-17 4-9 2-9 0.3-8 0-5 0.7-4 0-1.3

NO. OF STUDIES* 4 10 14 11 2 4 11 3 4 2

*Number of studies from which frequencies were determined to calculate incidence. CRPS, Complex regional pain syndrome. Data from McKay SC, MacDermid JC, Roth JH, Richards RS: Assessment of complications of distal radius fractures and development of a complication checklist, J Hand Surg 26A:916, 2001.

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REFERENCES CLAVICLE AND SCAPULA Ahmed AF, Salameh M, Al Khatib N, et  al.: Open reduction and internal fixation versus nonsurgical treatment in displaced midshaft clavicle fractures: a metaanalysis, J Orthop Trauma 32:e276, 2018. Ahrens PM, Garlick NI, Barber J, Tims EM: The Clavicle Trial Collaborative Group: the clavicle trial. A multicenter randomized controlled trial comparing operative with nonoperative treatment of displaced midshaft clavicle fractures, J Bone Joint Surg Am 99:1345, 2017. Anavian J, Conflitti JM, Khanna G, et al.: A reliable radiographic measurement technique for extra-articular scapular fractures, Clin Orthop Relat Res 469:3371, 2011. Anavian J, Gauger EM, Schroder LK, et al.: Surgical and functional outcomes after operative management of complex and displaced intra-articular glenoid fractures, J Bone Joint Surg 94:645, 2012. Anavian J, Khanna G, Plocher EK, et al.: Progressive displacement of scapula fractures, J Trauma 69:156, 2010. Assobhi JEH: Reconstruction plate versus minimal invasive retrograde titanium elastic nail fixation for displaced midclavicular fractures, J Orthop Traumatol 12:185, 2011. Bachoura A, Deane AS, Kamineni S: Clavicle anatomy and the applicability of intramedullary midshaft fracture fixation, J Shoulder Elbow Surg 21:1384, 2012. Bachoura A, Deane AS, Wise JN, Kamineni S: Clavicle morphometry revisited: a 3-dimensional study with relevance to operative fixation, J Shoulder Elbow Surg 22:e15, 2013. Banerjee R, Waterman B, Padalecki J, Robertson W: Management of distal clavicle fractures, J Am Acad Orthop Surg 19:392, 2011. Bartonicek J, Fric V: Scapular body fractures: results of operative treatment, Int Orthop 35:747, 2011. Cole PA, Gauger EM, Herrera DA, et al.: Radiographic follow-up of 82 operatively treated scapula neck and body fractures, Injury 43:327, 2012. Cole PA, Gauger EM, Schroder LK: Management of scapular fractures, J Am Acad Orthop Surg 20:130, 2012. Cole PA, Dugarte AJ: Posterior scapula approaches: extensile and modified Judet, J Orthop Trauma 32(8):s10, 2018. Cole PA, Gilbertson JA, Cole PA: Functional outcomes of operative management of scapula fractures in a geriatric cohort, J Orthop Trauma 31:e1, 2017. Czajka CM, Kay A, Gary JL, et  al.: Symptomatic implant removal following dual mini-fragment plating for clavicular shaft fractures, J Orthop Trauma 31:236, 2017. Dienstknecht T, Horst K, Pishnamaz M, et al.: A meta-analysis of operative versus nonoperative treatment in 463 scapular neck fractures, Scand J Surg 102:69, 2013. Dimitroulias A, Molinero KG, Krenk DE, et  al.: Outcomes of nonoperatively treated displaced scapular body fractures, Clin Orthop Relat Res 469:1459, 2011. Duan X, Zhong G, Cen S, et al.: Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: a meta-analysis of randomized controlled trials, J Shoulder Elbow Surg 20:1008, 2011. Ferran NA, Hodgson P, Vannet N, et al.: Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial, J Shoulder Elbow Surg 19:783, 2010. Fox HM, Ramsey DC, Thompson AR, et al.: Neer type-II distal clavicle fractures: a cost-effectiveness analysis of fixation techniques, J Bone Joint Surg Am, 2019. https://doi.org/10.2106/JBJS.19.00590. Frigg A, Rillmann P, Perren T, et  al.: Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications, Am J Sports Med 37:352, 2009. Frigg A, Rillmann P, Ryf C, et al.: Can complications of titanium elastic nailing with end cap for clavicular fractures be reduced? Clin Orthop Relat Res 469:3356, 2011. Fuglesang HF, Flugsrud GB, Randsborg PH, et al.: Radiological and functional outcomes 2.7 years following conservatively treated completely displaced midshaft clavicle fractures, Arch Orthop Trauma Surg 136(1):17, 2016. Furey MJ, McKee MD: Fractures of the clavicle and scapula, AAOS orthopaedic knowledge update, Trauma 5:244, 2016.

Gauger EM, Cole PA: Surgical technique: a minimally invasive approach to scapula neck and body fractures, Clin Orthop Relat Res 469:3390, 2011. Good DW, Lui DF, Leonard M, et al.: Clavicle hook plate fixation for displaced lateral-third clavicle fractures (Neer type II): a functional outcome study, J Shoulder Elbow Surg 21:1045, 2012. Goudie EB, Clement ND, Murray IR, et al.: The influence of shortening on clinical outcome in healed displaced midshaft clavicular fractures after nonoperative treatment, J Bone Joint Surg Am 99:1166, 2017. Harvey E, Audigé L, Herscovici Jr D, et  al.: Development and validation of the new international classification for scapula fractures, J Orthop Trauma 26:364, 2012. Hill BW, Jacobson AR, Anavian J, Cole PA: Surgical management of coracoid fractures: technical tricks and clinical experience, J Orthop Trauma 28:e114, 2014. Houwert RM, Wijdicks FJ, Steins Bisschop C, et al.: Plate fixation verus intramedullary fixation for displaced mid-shaft clavicle fractures: a systematic review, Int Orthop 36:579, 2012. Jain S, Altman GT: Lateral clavicle fractures, J Hand Surg Am 36A:1213, 2011. Jarvis NE, Halliday L, Sinnott M, et al.: Surgery for the fractured clavicle: factors predicting nonunion, J Shoulder Elbow Surg 27:e155, 2018. Jeray KJ, Cole PA: Clavicle and scapula fracture problems: functional assessment and current treatment strategies, Instr Course Lect 60:51, 2011. Hsu KH, Tzeng YH, Chang MC, Hiang CC: Comparing the coracoclavicular loop technique with a hook plate for the treatment of distal clavicle fractures, J Shoulder Elbow Surg 27(2):224, 2018. Hulsmans MH, van Heijl M, Houwert RM, et al.: Surgical fixation of midshaft clavicle fractures: a systematic review of biomechanical studies, Injury Int J Care Injured 49:753, 2018. Jones CB, Sietsema DL: Analysis of operative versus nonoperative treatment of displaced scapular fractures, Clin Orthop Relat Res 469:3379, 2011. Kleweno CP, Jawa A, Wells JH, et  al.: Midshaft clavicular fractures: comparison of intramedullary pin and plate fixation, J Shoulder Elbow Surg 20:1114, 2011. Lambotte A: Chirurgie operatoire des fractures, Paris, 1913, Masson & Cie. Lewis S, Argintar E, Jahn R, et  al.: Intra-articular scapular fractures: outcomes after internal fixation, J Orthop 10:188, 2013. Liu HH, Chang CH, Chia WT, et  al.: Comparison of plates versus intramedullary nails for fixation of displaced midshaft clavicular fractures, J Trauma 69:E82, 2010. McKee MD: Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? Orthop Clin North Am 41:225, 2010. McKnight B, Heckmann N, Hill JR, et al.: Surgical management of midshaft clavicle nonunions is associated with a higher rate of short-term complications compared with acute fractures, J Shoulder Elbow Surg 25:1412, 2016. Millett PJ, Hurst JM, Horan MP, Hawkins RJ: Complications of clavicle fractures treated with intramedullary fixation, J Shoulder Elbow Surg 20:86, 2011. Mudd CD, Quigley KJ, Gross LB: Excessive complications of open intramedullary nailing of midshaft clavicle fractures with the Rockwood Clavicle Pin, Clin Orthop Relat Res 469:3364, 2011. Murray LR, Eros A, Robinson CM: Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures of the clavicle, J Bone Joint Surg 95:1153, 2013. Noguchi T, Mautner JF, Duncan SFM: Dorsal plate fixation of scapular fracture, J Hand Surg Am 42(10):843, 2017. Nourian A, Dhaliwal S, Vangala S, Vezeridis PS: Midshaft fractures of the clavicle: a meta-analysis comparing surgical fixation using anteroinferior plating versus superior plating, J Orthop Trauma 31(9):461, 2017. Oh JH, Kim SH, Lee JH, et al.: Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures, Arch Orthop Trauma Surg 131:525, 2011. Patterson JM, Galatz L, Streubel PN, et al.: CT evaluation of extra-articular glenoid neck fractures: does the glenoid medialize or does the scapula lateralize? J Orthop Trauma 26:360, 2012. Payne DE, Wray WH, Ruch DS, et al.: Outcome of intramedullary fixation of clavicular fractures, Am J Orthop (Belle Mead NJ) 40:E99, 2011. Pizanis A, Tosounidis G, Braun C, et al.: The posterior two-portal approach for reconstruction of scapula fractures: results of 39 patients, Injury 44:1630, 2013.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM Pulos N, Yoon RS, Shetye S, et  al.: Anteroinferior 2.7-mm versus 3.5-mm plating of the clavicle: a biomechanical study, Injury 47(8):1642, 2016. Rijal L, Sagar G, Joshi A, Joshi KN: Modified tension band for displaced type 2 lateral end clavicle fractures, Int Orthop 36:1417, 2012. Schroder LK, Gauger EM, Gilbertson JA, Cole PA: Functional outcomes after operative management of extra-articular glenoid neck and scapular body fractures, J Bone Joint Surg Am 98:1623, 2016. Serrano R, Borade A, Mir H, et al.: Anterior-inferior plating results in fewer secondary interventions compared to superior plating for acute displaced midshaft clavicle fractures, J Orthop Trauma 31:468, 2017. Seyhan M, Kocaoglu B, Kiyak G, et al.: Anatomic locking plate and coracoclavicular stabilization with suture endo-button technique is superior in the treatment of Neer type II distal clavicle fractures, Eur J Orthop Surg Traumatol 25(5):827, 2015. Shin SJ, Ko YW, Lee J, Park MG: Use of plate fixation without coracoclavicular ligament augmentation for unstable distal clavicle fractures, J Shoulder Elbow Surg 25(6):942, 2016. Smekal V, Irenberger A, Attal RE, et al.: Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: results in 60 patients, Injury 42:324, 2011. Tatro JM, Gilbertson JA, Schroder LK, Cole PA: Five to ten-year outcomes of operatively treated scapular fractures, J Bone Joint Surg Am 100:871, 2018. Tiren D, van Bemmel AJ, Swank DJ, van der Linden FM: Hook plate fixation of acute displaced lateral clavicle fractures: mid-term results and a brief literature overview, J Orthop Surg Res 7(2), 2012. Woltz S, Krijnen P, Schipper IB: Mid-term patient satisfaction and residual symptoms after plate fixation for nonoperative treatment for displaced midshaft clavicular fractures, J Orthop Trauma 32:e435, 2018. Woltz S, Krijnen P, Schipper IB: Plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures, J Bone Joint Surg Am 99:1051, 2017. Woltz S, Stegeman SA, Krijnen P, et al.: Plate fixation compared with nonoperative treatment for displaced midshaft clavicular fractures. A multicenter randomized controlled trial, J Bone Joint Surg Am 99:106, 2017. Wu K, Chang CH, Yang RS: Comparing hook plates and Kirschner tension band wiring for unstable lateral clavicle fractures, Orthopedics 34, 2011:e718. Zuckerman SL, Song Y, Obremskey WT: Understanding the concept of medialization in scapula fractures, J Orthop Trauma 26:350, 2012. Yagnik GP, Brady PC, Zimmerman JP, et al.: A biomechanical comparison of new techniques for distal clavicular fracture repair versus locked plating, J Shoulder Elbow Surg 28(5):982, 2019. Yagnik GP, Jordan CJ, Narvel RR, et al.: Distal clavicle fracture repair: clinical outcomes of a surgical technique utilizing a combination of cortical button fixation and coracoclavicular ligament reconstruction, Orthop J Sports Med 7(9):2325967119867920, 2019.

PROXIMAL HUMERUS Bae JH, Oh JK, Chon CS, et  al.: The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus, J Bone Joint Surg 93:937, 2011. Bahrs C, Kühle L, Blumenstock G, et al.: Which parameters affect medium- to long-term results after angular stable plate fixation for proximal humeral fractures? J Shoulder Elbow Surg 24:727, 2015. Bai L, Fu Z, An S, et al.: Effect of calcar screw use in surgical neck fractures of the proximal humerus with unstable medial support: a biomechanical study, J Orthop Trauma 28:452, 2014. Beks RB, Ochen Y, Frima H, et al.: Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials, J Shoulder Elbow Surg 27:1526, 2018. Bell JE, Leung BC, Spratt KF, et al.: Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly, J Bone Joint Surg 93A:121, 2011. Boesmueller S, Wech M, Gregori M, et  al.: Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures, Injury 47:350, 2016.

Boileau P, Pennington SD, Alami G: Proximal humeral fractures in younger patients: fixation techniques and arthroplasty, J Shoulder Elbow Surg 20(Suppl 2):S47, 2011. Brorson S, Frich LH, Winther A, Hrobjartsson A: Locking plate osteosynthesis in displaced 4-part fractures of the proximal humerus: a systematic review of benefits and harms, Acta Orthop 82:475, 2011. Cadet ER, Ahmad CS: Hemiarthroplasty for three- and four-part proximal humerus fractures, J Am Acad Orthop Surg 20:17, 2012. Capriccioso CE, Zuckerman JD, Egol KA: Initial varus displacement of proximal humerus fractures results in similar function but higher complication rates, Injury 47:909, 2016. Castoldi F, Bonasia DE, Blonna D, et al.: The stability of percutaneous fixation of proximal humeral fractures, J Bone Joint Surg 92A(Suppl 2):90, 2010. Catalano 3rd L, Dowling R: Valgus impacted fracture of the proximal humerus, J Hand Surg Am 36A:1843, 2011. Chow RM, Begum F, Beaupre LA, et  al.: Proximal humeral fracture fixation: locking plate construct ± intramedullary fibular allograft, J Shoulder Elbow Surg 21:894, 2012. Clavert P, Adam P, Bevort A, et al.: Pitfalls and complications with locking plate for proximal humerus fractures, J Shoulder Elbow Surg 19:489, 2010. Clement ND, Duckworth AD, McQueen MM, Court-Brown CM: The outcome of proximal humeral fractures in the elderly: predictors of mortality and function, Bone Joint Lett J 96B:870, 2014. Corbacho B, Duarte A, Keding A, et al.: Cost effectiveness of surgical versus non-surgical treatment of adults with displaced fractures of the proximal humerus: economic evaluation alongside the PROFHER trial, Bone Joint Lett J 98B:152, 2016. Dilisio MF, Nowinski RJ, Hatzidakis AM, Fehringer EV: Intramedullary nailing of the proximal humerus: evolution, technique, and results, J Shoulder Elbow Surg 25, 2016:e130. Egol KA, Sugi MT, Ong CC, et al.: Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures, J Shoulder Elbow Surg 21:741, 2012. Euler SA, Petri M, Venderley MB, et al.: Biomechanical evaluation of straight antegrade nailing in proximal humeral fractures: the rationale of the “proximal anchoring point”, Int Orthop 41(9):1715, 2017. Farmer KW, Wright TW: Three- and four-part proximal humerus fractures: open reduction and internal fixation versus arthroplasty, J Hand Surg Am 35A:2010, 1881. Fjalestad T, Hole MØ, Hovden IA, et al.: Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial, J Orthop Trauma 26:98, 2012. Foruria AM, de Gracia MM, Larson DR, et al.: The pattern of the fracture and displacement of the fragments predict the outcome in proximal humeral fractures, J Bone Joint Surg 93B:378, 2011. Foruria AM, Marti M, Sanchez-Sotelo J: Proximal humeral fractures treated conservatively settle during fracture healing, J Orthop Trauma 29:e24, 2014. Gavaskar AS, Chordary N, Abraham S: Complex proximal humeral fractures treated with locked plating utilizing an extended deltoid split approach and a shoulder strap incision, J Orthop Trauma 27:73, 2013. Gavaskar AS, Tummala NC: Locked plate osteosynthesis of humeral headsplitting fractures in young adults, J Shoulder Elbow Surg 24:908, 2015. Grawe B, Le T, Lee T, Wyrick J: Open reduction and internal fixation (ORIF) of complex 3- and 4-part fractures of the proximal humerus: does age really matter? Geriatr Orthop Surg Rehabil 3:27, 2012. Haasters F, Siebenbürger G, Helfen T: Complications of locked plating for proximal humeral fractures – are we getting any better? J Shoulder Elbow Surg 25:3296, 2016. Hagerman MG, Jayakumar P, King JD, et  al.: The factors influencing the decision making of operative treatment for proximal humeral fractures, J Shoulder Elbow Surg 24:e21, 2015. Handoll HH, Keding A, Corbacho B, et  al.: Five-year follow-up results of PROFHER trial comparing operative and non-operative treatment of adults with as displaced fracture of the proximal humerus, Bone Joint Lett 99B:383, 2017. Handoll HH, Ollivere BJ, Rollins KE: Interventions for treating proximal humeral fractures in adults, Cochrane Database Syst Rev 12:CD000434, 2012.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Hardeman F, Bollars P, Donnelly M, et al.: Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus, Injury 43:153, 2012. Harmer LS, Crickard CV, Phelps KD, et al.: Surgical approaches to the proximal humerus: a quantitative comparison of the deltopectoral approach and the anterolateral acromial approach, J Am Acad Orthop Surg 2(6):e017, 2018. Hatzidakis AM, Shevlin MJ, Fenton DL, et al.: Angular-stable locked intramedullary nailing of two-part surgical neck fractures of the proximal part of the humerus: a multicenter retrospective observational study, J Bone Joint Surg 93A:L2172, 2011. Hauschild O, Konrad G, Audige L, et  al.: Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus, Arch Orthop Trauma Surg 133:1385, 2013. Hinds RM, Garner MR, Tran WH, et al.: Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation, J Shoulder Elbow Surg 24:889, 2015. Hirschmann MT, Fallegger B, Amsler F, et al.: Clinical longer-term results after internal fixation of proximal humerus fractures with a locking compression plate (PHILOS), J Orthop Trauma 25:286, 2011. Inauen C, Platz A, Meier C, et al.: Quality of life after osteosynthesis of fractures of the proximal humerus, J Orthop Trauma 27:e74, 2013. Iyengar JJ, Devcic Z, Sproul RC, Feeley BT: Nonoperative treatment of proximal humerus fractures: a systematic review, J Orthop Trauma 25:612, 2011. Jung SW, Shim SB, Kim HM, et  al.: Factors that influence reduction loss in proximal humerus fracture surgery, J Orthop Trauma 29:276, 2015. Katthagen JC, Schwarze M, Meyer-Kobbe J, et al.: Biomechanical effects of calcar screws and bone block augmentation on medial support in locked plating of proximal humeral fractures, Clin Biomech (Bristol, Avon) 29:735, 2014. Kennedy J, Feerick E, McGarry P, et  al.: Effect of calcium triphosphate cement on proximal humeral fracture osteosynthesis: a finite element analysis, J Orthop Surg (Hong Kong) 21:167, 2013. Kennedy J, Molony D, Burke NG, et  al.: Effect of calcium triphosphate cement on proximal humeral fracture osteosynthesis: a cadaveric biomechanical study, J Orthop Surg 21:173, 2013. Kim DS, Lee DH, Chun YM, Shin SJ: Which additional augmented fixation procedure decreases surgical failure after proximal humeral fracture with medial comminution: fibular allograft or inferomedial screws? J Shoulder Elbow Surg 27:1852, 2018. Klement MR, Nickel BT, Bala A, et al.: Glenohumeral arthritis as a risk factor for proximal humerus nonunion, Injury 47(Suppl):S36, 2016, 7. Königshausen M, Kübler L, Godry H, et al.: Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures: a reliable system? Injury 43:223, 2012. Konrad G, Audigé L, Lambert S, et al.: Similar outcomes for nail versus plate fixation of three-part proximal humeral fractures, Clin Orthop Relat Res 470:602, 2012. Konrad G, Bayer J, Hepp P, et al.: Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate: surgical technique, J Bone Joint Surg 92A(Suppl 1 Pt ) :85, 2010. Kralinger F, Blauth M, Goldhahn J, et al.: The influence of local bone density on the outcome of one hundred and fifty proximal humeral fractures treated with a locking plate, J Bone Joint Surg 96:1026, 2014. Krappinger D, Bizzotto N, Riedmann S, et al.: Predicting failure after surgical fixation of proximal humerus fractures, Injury 42:1283, 2011. LaMartina J, Christmas KN, Simon P, et al.: Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes, J Shoulder Elbow Surg 27:470, 2018. Lopiz Y, Garcia-Coiradas J, Garcia-Fernandez C, Marco F: Proximal humerus nailing: a randomized clinical trial between curvilinear and straight nails, J Shoulder Elbow Surg 23:369, 2014. Lange M, Brandt D, Mittlmeier T, Gradl G: Proximal humeral fractures: nonoperative treatment versus intramedullary nailing in 2-,3- and 4-part fractures, Injury 47(Suppl 7):S14, 2016.

Maier D, Jaeger M, Izadpanah K, et al.: Current concepts review. Proximal humeral fracture treatment in adults, J Bone Joint Surg 96:251, 2014. Matassi F, Angeloni R, Carulli C, et al.: Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus, Injury 43:1939, 2012. Menendez ME, Ring D: does the timing of surgery for proximal humeral fracture affect inpatient outcomes? J Shoulder Elbow Surg 23:1257, 2014. Murray IR, Amin AK, White TO, Robinson CM: Proximal humeral fractures: current concepts in classification, treatment and outcomes, J Bone Joint Surg 93B:1, 2011. Neuhaus V, Bot AG, Swellengrebel CH, et al.: Treatment choice affects inpatient ad verse events and mortality in older aged in patients with an isolated fracture of the proximal humerus, J Shoulder Elbow Surg 23:800, 2014. Neviaser AS, Hettrich CM, Beamer BS, et  al.: Endosteal strut augment reduces complications associated with proximal humeral locking plates, Clin Orthop Relat Res 469:3300, 2011. Neviaser AS, Hettrich CM, Dines JS, Lorich DG: Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant, Arch Orthop Trauma Surg 131:1617, 2011. Newton AW, Selvaratnam V, Pydah SK, Nixon MF: Simple radiographic assessment of bone quality is associated with loss of surgical fixation in patients with proximal humeral fractures, Injury 47(4):904, 2016. Nolan BM, Kippe MA, Wiater JM, Nowinski GP: Surgical treatment of displaced proximal humeral fractures with a short intramedullary nail, J Shoulder Elbow Surg 20:1241, 2011. Obert L, Saadnia R, Tournier C, et  al.: Four-part fractures treated with a reversed total shoulder prosthesis: prospective and retrospective multicenter study. Results and complications, Orthop Traumatol Surg Res 102:279, 2016. Ockert B, Siebenbürger G, Kettler M, et al.: Long-term functional outcomes (median 10 years) after locked plating for displaced fractures of the proximal humerus, J Shoulder Elbow Surg 23:1223, 2014. Ogawa K, Kobayashi S, Ikegami H: Retrograde intramedullary multiple pinning through the deltoid “V” for valgus-impacted four-part fractures of the proximal humerus, J Trauma 71:238, 2011. Okike K, Lee OC, Makanji H, et al.: Factors associated with the decision for operative versus no-operative treatment of displaced proximal humerus fractures in the elderly, Injury 44:448, 2013. Olerud P, Ahrengart L, Ponzer S, et al.: Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial, J Shoulder Elbow Surg 20:1025, 2011. Olerud P, Ahrengart L, Ponzer S, et  al.: Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial, J Shoulder Elbow Surg 20:747, 2011. Olerud P, Ahrengart L, Söderqvist A, et  al.: Quality of life and functional outcome after a 2-part proximal humeral fracture: a prospective cohort study on 50 patients treated with a locking plate, J Shoulder Elbow Surg 19:814, 2010. Osterhoff G, Hoch A, Wanner GA, et al.: Calcar comminution as prognostic factor of clinical outcome after locking plate fixation of proximal humeral fractures, Injury 43:1651, 2012. Petrigliano FA, Bezrukov N, Gamardt SC, SooHoo NE: Factors predicting complication and reoperation rates following surgical fixation of proximal humeral fractures, J Bone Joint Surg 96:1544, 2014. Ponce BA, Thompson KJ, Raghava P, et al.: The role of medial comminution and calcar restoration in varus collapse of proximal humeral fractures treated with locking plates, J Bone Joint Surg 95:e113, 2013. Rangan A, Handoll H, Brealey S, et al.: Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial, J Am Med Assoc 313:1037, 2015. Rath E, Alkrinawi N, Levy O, et  al.: Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment, J Shoulder Elbow Surg 22:e8, 2013. Reitman RD, Kerzhner E: Reverse shoulder arthroplasty as treatment for comminuted proximal humeral fractures in elderly patients, Am J Orthop (Belle Mead NJ) 40:458, 2011.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM Robertson TA, Granade CM, Hunt Q, et  al.: Nonoperative management versus reverse shoulder arthroplasty for treatment of 3- and 4-part proximal humeral fractures in older adults, J Shoulder Elbow Surg 26(6):1017, 2017. Robinson CM, Amin AK, Godley KC, et al.: Modern perspectives of open reduction and plate fixation of proximal humerus fractures, J Orthop Trauma 25:618, 2011. Robinson CM, Wylie JR, Ray AG, et al.: Proximal humeral fractures with a severe varus deformity treated by fixation with a locking plate, J Bone Joint Surg 92B:672, 2010. Röderer G, Erhardt J, Graf M, et al.: Clinical results for minimally invasive locked plating of proximal humerus fractures, J Orthop Trauma 24:400, 2010. Röderer G, Erhardt J, Kuster M, et al.: Second generation locking plating of proximal humerus fractures—a prospective multicentre observational study, Int Orthop 35:425, 2011. Ruchholtz S, Hauk C, Lewan U, et  al.: Minimally invasive polyaxial locking plate fixation of proximal humerus fractures: a prospective study, J Trauma 71:1737, 2011. Saltzman BM, Erickson BJ, Harris JD, et al.: Fibular strut graft augmentation for open reduction and internal fixation of proximal humerus fracture, Orthop J Sports Med 4(7):2325967116656829, 2016. Sanders RJ, Thissen LG, Teepen JC, et al.: Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment, J Shoulder Elbow Surg 20:1118, 2011. Schnetzke M, Bockmeyer J, Porschke F, et  al.: Quality of reduction influences outcome after locked-plate fixation of proximal humeral type-C fractures, J Bone Joint Surg Am 98:1777, 2016. Schulte LM, Matteini LE, Neviaser RJ: Proximal periarticular locking plates in proximal humeral fractures: functional outcomes, J Shoulder Elbow Surg 20:1234, 2011. Shields E, Sundem L, Childs S, et al.: The impact of residual angulation on patient reported functional outcome scores after nonoperative treatment for humeral shaft fractures, Injury 47:914, 2016, compared with. Soliman OA, Koptan WM: Four-part fracture dislocations of the proximal humerus in young adults: results of fixation, Injury 44:442, 2013. Sosef N, van Leerdam R, Ott P, et al.: Minimal invasive fixation of proximal humeral fractures with an intramedullary nail: good results in elderly patients, Arch Orthop Trauma Surg 130:605, 2010. Spross C, Zeledon R, Zdravkovic V, Jost B: How bone quality may influence intraoperative and early postoperative problems after angular stable open reduction-internal fixation of proximal humeral fractures, J Shoulder Elbow Surg 26:1566, 2017. Sproul RC, Iyengar JJ, Devcic Z, Feeley BT: A systematic review of locking plate fixation of proximal humerus fractures, Injury 42:408, 2011. Sun Q, Ge W, Li G, et  al.: Locking plates versus intramedullary nails in the management of displaced proximal humeral fractures: a systematic review and meta-analysis, Int Orthop 42(3):641, 2018. Theopold J, Weihs K, Marqua ß, et al.: Detection of primary screw perforation in locking plate osteosynthesis of proximal humerus fracture by intraoperative 3D fluoroscopy, Arch Orthop Trauma Surg 137:1491, 2017. Torchia ME: Technical tips for fixation of proximal humeral fractures in elderly patients, Instr Course Lect 59:553, 2010. Torrens C, Corrales M, Vila G, et al.: Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively, J Orthop Trauma 25:581, 2011. Visser CPJ, Tavy DLJ, Coene LNJEM: Letter to the editor regarding Westphal T et al: “Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings” J Shoulder Elbow Surg 26:e364, 2017. Wallace MJ, Bledsoe G, Moed BR, et al.: Relationship of cortical thickness of the proximal humerus and pullout strength of a locked plate and screw construct, J Orthop Trauma 26:222, 2012. Weeks CA, Begum E, Beaupre LA, et al.: Locking plate fixation of proximal humeral fractures with impaction of the fracture site to restore medial column support: a biomechanical study, J Shoulder Elbow Surg 22:1552, 2013.

Werner BC, Griffin JW, Yang S, et al.: Obesity is associated with increased postoperative complications after operative management of proximal humerus fractures, J Shoulder Elbow Surg 24:593, 2015. Westphal T, Woischnik S, Adolf D, et al.: Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings, J Shoulder Elbow Surg 26:464, 2017. Wild JR, DeMers A, French R, et al.: Functional outcomes for surgically treated 3- and 4-part proximal humerus fractures, Orthopedics 34:e629, 2011. Wong J, Newman JM, Gruson KI: Outcomes of intramedullary nailing for acute proximal humerus fractures: a systematic review, J Orthop Traumatol 17(2):113, 2016. Wu CH, Ma CH, Yeh JJ, et al.: Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches, J Trauma 71:1364, 2011. Yang H, Li Z, Zhou F, et al.: A prospective clinical study of proximal humerus fractures treated with a locking proximal humerus plate, J Orthop Trauma 25:11, 2011. Yüksel HY, Yilmaz S, Aksahin E, et  al.: The results of nonoperative treatment for three- and four-part fractures of the proximal humerus in lowdemand patients, J Orthop Trauma 25:588, 2011. Zhu Y, Lu Y, Shen J, et al.: Locking intramedullary nails and locking plates in the treatment of two-part proximal humeral surgical neck fractures: a prospective randomized trial with a minimum of three years of followup, J Bone Joint Surg 93A:159, 2011.

HUMERAL SHAFT An Z, He X, Jiang C, Zhang C: Treatment of middle third humeral shaft fractures: minimal invasive plate osteosynthesis versus expandable nailing, Eur J Orthop Surg Traumatol 22:193, 2012. An Z, Zeng B, He X, et al.: Plating osteosynthesis of mid-distal humeral shaft fractures: minimally invasive versus conventional open reduction technique, Int Orthop 34:131, 2010. Bumbasirevic M, Lesic A, Bumbasirevic V, et  al.: The management of humeral shaft fractures with associated radial nerve palsy: a review of 117 cases, Arch Orthop Trauma Surg 130:519, 2010. Chang G, Ilyas AM: Radial nerve palsy after humeral shaft fractures. The case for early exploration and a new classification to guide treatment and prognosis, Hand Clin 34:105, 2018. Davies G, Yeo G, Meta M, et al.: Case-match controlled comparison of minimally invasive plate osteosynthesis and intramedullary nailing for the stabilization of humeral shaft fractures, J Orthop Trauma 30:612, 2016. Driesman AS, Fisher N, Karia R, et  al.: Fracture site mobility at 6 weeks after humeral shaft fracture predicts nonunion without surgery, J Orthop Trauma 31(12):657, 2017. Esmailiejah AA, Abbasian MR, Safdari F, Ashoori K: Treatment of humeral shaft fractures: minimally invasive plate osteosynthesis versus open reduction and internal fixation, Trauma Mon 20:e26271, 2015 Gausden EB, Christ AB, Warner SJ, et al.: The triceps-sparing posterior approach to plating humeral shaft fractures results in a high rate of union and low incidence of complications, Arch Orthop Trauma Surg 136:1683, 2016. Gosler MW, Testroote M, Morrenhof JW, Janzing HM: Surgical versus nonsurgical interventions for treating humeral shaft fractures in adults, Cochrane Database Syst Rev (1)CD008832, 2012. Gottschalk MB, Carpenter W, Hiza E, et al.: Humeral shaft fracture fixation. Incidence rates and complications as reported by American Board of Orthopaedic Surgery Part II Candidates, J Bone Joint Surg Am 98:e71, 2016. Heineman D, Poolman RW, Nork SE, et  al.: Plate fixation or intramedullary fixation of humeral shaft fractures: an updated meta-analysis, Acta Orthop 81:216, 2010. Hohmann E, Glatt V, Tetsworth K: Minimally invasive plating versus either open reduction and plate fixation or intramedullary nailing of humeral shaft fractures: a systematic review and meta-analysis of randomized controlled trials, J Shoulder Elbow Surg 25:1634, 2016. Hollister AM, Saulsbery C, Odom JL, et al.: New technique for humerus shaft fracture retrograde intramedullary nailing, Tech Hand Up Extrem Surg 15:138, 2011.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Idoine JD, French BG, Opalek JM, DeMott L: Plating of acute humeral diaphyseal fractures through an anterior approach in multiple trauma patients, J Orthop Trauma 26:9 2012. Kim JW, Oh CW, Byun YS, et al.: A prospective randomized study of operative treatment for noncomminuted humeral shaft fractures: conventional open plating versus minimal invasive plate osteosynthesis, J Orthop Trauma 29:189, 2015. Kobayashi M, Watanabe Y, Matsushita T: Early full range of shoulder and elbow motion is possible after minimally invasive plate osteosynthesis for humeral shaft fractures, J Orthop Trauma 24:212, 2010. Liang K, Wang L, Lin D, Chen Z: Minimally invasive plating osteosynthesis for mid distal third humeral shaft fractures, Orthopedics 36:e1025, 2013 López-Arévalo R, de Llano-Temboury AQ, Serrano-Montilla J, et  al.: Treatment of diaphyseal humeral fractures with the minimally invasive percutaneous plate (MIPPO) technique: a cadaveric study and clinical results, J Orthop Trauma 25:294, 2011. Matsunaga FT, Tamaoki MJS, Matsumoto MH, et  al.: Minimally invasive osteosynthesis with a bridge plate versus a functional brace for humeral shaft fractures. A randomized controlled trial, J Bone Joint Surg Am 99:583, 2017. Nachef N, Bariatinsky V, Sulimovic S, et al.: Predictors of radial nerve palsy recovery in humeral shaft fractures: a retrospective review of 17 patients, Orthop Traumatol Surg Res 103:177, 2017. Oh CW, Byun YS, Oh JK, et al.: Plating of humeral shaft fractures: comparison of standard conventional plating versus minimally invasive plating, Orthop Traumatol Surg Res 98:54, 2012. Papasoulis E, Drosos GI, Ververidis AN, Verettas DA: Functional bracing of humeral shaft fractures, A review of clinical studies, Injury, 41:e21, 2010. Patel R, Neu CP, Curtiss S, et  al.: Crutch weightbearing on comminuted humeral shaft fractures: a biomechanical comparison of large versus small fragment fixation for humeral shaft fractures, J Orthop Trauma 25:300, 2011. Qiu H, Wei Z, Liu Y, et al.: A Bayesian network meta-analysis of three different surgical procedures for the treatment of humeral shaft fractures, Medicine (Baltim) 95:e5454, 2016 Scolaro JA, Voleti P, Makani A, et  al.: Surgical fixation of extra-articular distal humerus fractures with a posterolateral plate through a tricepsreflecting technique, J Shoulder Elbow Surg 23:251, 2014. Shields E, Sundem L, Childs S, et al.: The impact of residual angulation on patient-reported functional outcome scores after nonoperative treatment for humeral shaft fractures, Injury 47:914, 2016. Shin SJ, Sohn HS, Do NH: Minimally invasive plate osteosynthesis of humeral shaft fractures: a technique to aid fracture reduction and minimize complications, J Orthop Trauma 26:585, 2012. Suzuki T, Hak DJ, Stahel PF, et al.: Safety and efficiency of conversion from external fixation to plate fixation in humeral shaft fractures, J Orthop Trauma 24:414, 2010. Tetsworth K, Hohmann E, Glatt V: Minimally invasive plate osteosynthesis of humeral shaft fractures: current state of the art, J Am Acad Orthop Surg 26:652, 2018. Updegrove GF, Mourad W, Abboud JA: Humeral shaft fractures, J Shoulder Elbow Surg 27:e87, 2018. Wang C, Li J, Li Y, et  al.: Is minimally invasive plating osteosynthesis for humeral shaft fracture advantageous compared with the conventional open technique? J Shoulder Elbow Surg 24:1741, 2015. Yu BF, Liu LL, Yang GJ, et al.: Comparison of minimally invasive plate osteosynthesis and conventional plate osteosynthesis for humeral shaft fracture: a meta-analysis, Medicine (Baltim) 95:e4955, 2016 Zhao JG, Wang J, Wang C, Kan SL: Intramedullary nail versus plate fixation for humeral shaft fractures, Medicine (Baltim) 94:e599, 2015. Ziran BH, Kinney RC, Smith WR, Preacher G: Sub-muscular plating of the humerus: an emerging technique, Injury 41:1047, 2010.

DISTAL HUMERUS Antuna SA, Laakso RB, Barrera JL, et al.: Linked total elbow as treatment of distal humerus fractures, Acta Orthop Belg 78:465, 2012. Burg A, Berenstein M, Engel J, et  al.: Fractures of the distal humerus in elderly patients treated with a ring fixator, Int Orthop 35:101, 2011.

Burkhart KJ, Nijs S, Mattyasovszky SG, et al.: Distal humerus hemiarthroplasty of the elbow for comminuted distal humeral fractures in the elderly patient, J Trauma 71:635, 2011. Chen G, Liao Q, Luo W, et al.: Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus, Injury 42:366, 2011. Chen RC, Harris DJ, Leduc S, et al.: Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures? J Orthop Trauma 24:391, 2010. Desloges W, Faber KJ, King GJW, Athwal GS: Functional outcomes of distal humeral fractures managed nonoperatively in medically unwell and lower-demand elderly patients, J Shoulder Elbow Surg 24:1187, 2015. Egol KA, Tsai P, Vazquez O, Tejwani NC: Comparison of functional outcomes of total elbow arthroplasty vs plate fixation for distal humerus fractures in osteoporotic elbow, Am J Orthop 40:67, 2011. Erpelding JM, Mallander A, High R, et  al.: Outcomes following distal humeral fracture fixation with an extensor mechanism-on approach, J Bone Joint Surg 94A:548, 2012. Foruria AM, Lawrence TM, Augustin S, et al.: Heterotopic ossification after surgery for distal humeral fractures, Bone Joint Lett J 96B:1681, 2014. Frattini M, Soncini G, Corradi M, et al.: Mid-term results of complex distal humeral fractures, Musculoskelet Surg 95:205, 2011. Galano GJ, Ahmad CS, Levine WN: Current treatment strategies for bicolumnar distal humerus fractures, J Am Acad Orthop Surg 18:20, 2010. Githens M, Yao J, Sox AH: Bishop J: open reduction and internal fixation versus total elbow arthroplasty for the treatment of geriatric distal humerus fractures: a systematic review and meta-analysis, J Orthop Trauma 28:481, 2014. Got C, Shuck J, Biercevicz A, et  al.: Biomechanical comparison of parallel versus 90-90 plating of bicolumn distal humerus fractures with intraarticular comminution, J Hand Surg Am 37:2512, 2012. Huang JI, Paczas M, Hoyen HA, Vallier HA: Functional outcome after open reduction internal fixation of intra-articular fractures of the distal humerus in the elderly, J Orthop Trauma 25:259, 2011. Hungerer S, Wipf F, von Oldenburg G, et al.: Complex distal humerus fractures—comparison of polyaxial locking and nonlocking screw configurations—a preliminary biomechanical study, J Orthop Trauma 28:130, 2014. Kaiser T, Brunner A, Hohendorff B, et  al.: Treatment of supra- and intraarticular fractures of the distal humerus with the LCP distal humerus plate: a 2-year follow-up, J Shoulder Elbow Surg 20:206, 2011. Kudo T, Hara A, Iwase H, et al.: Biomechanical properties of orthogonal plate configuration versus parallel plate configuration using the same locking plate system for intra-articular distal humeral fractures under radial or ulnar column axial load, Injury 47(10):2071, 2016. Lawrence TM, Ahmadi S, Morrey BF, Sánchez-Sotelo J: Wound complications after distal humerus fracture fixation: incidence, risk factors, and outcome, J Shoulder Elbow Surg 23:258, 2014. Manst P, Nouaille Degorce H, Bonnevialle N, et al.: Total elbow arthroplasty for acute distal humeral fractures in patients over 65 years old—results of multicenter study in 87 patients, Orthop Traumatol Surg Res 99:779, 2013. Min W, Ding BC, Tejwani NC: Comparative functional outcome of AO/OTA type C distal humerus fractures: open injuries do worse than closed fractures, J Trauma Acute Care Surg 72:E27, 2012. Min W, Ding BC, Tejwani NC: Staged versus acute definitive management of open distal humerus fractures, J Trauma 71:944, 2011. Muhldofer-Fodor M, Bekler H, Wolfe VM, et al.: Paratricipital-triceps splitting “two-window” approach for distal humerus fractures, Tech Hand Up Extrem Surg 15:156, 2011. Nauth A, McKee MD, Ristevski B, et al.: Distal humeral fractures in adults, J Bone Joint Surg 93A:686, 2011. Paryavi E, O’Toole RV, Frisch HM, et al.: Use of 2 column screws to treat transcondylar distal humeral fractures in geriatric patients, Tech Hand Up Extrem Surg 14:209, 2010. Popovic D, King GJ: Fragility fractures of the distal humerus: what is the optimal treatment? J Bone Joint Surg 94B:16, 2012. Prasarn ML, Ahn J, Paul O, et al.: Dual plating for fractures of the distal third of the humeral shaft, J Orthop Trauma 25:57 2011.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM Puchwein P, Wildburger R, Archan S, et al.: Outcome of type C (AO) distal humeral fractures: follow-up of 22 patients with bicolumnar plating osteosynthesis, J Shoulder Elbow Surg 20:631, 2011. Sela Y, Baratz ME: Distal humerus fractures in the elderly population, J Hand Surg Am 40:599, 2015. Shannon SF, Wagner ER, Houdek MT, et  al.: Osteosynthesis of AO/OTA 13-C3 distal humeral fractures in patients older than 70 years, J Shoulder Elbow Surg 27:291, 2018. Sharma S, John R, Dhillon MS, Kishore K: Surgical approaches for open reduction and internal fixation of intra-articular distal humerus fractures in adults: a systematic review and meta-analysis, Injury 49:1381, 2018. Shih CA, Su WR, Lin WC, T TW: Parallel versus orthogonal plate osteosynthesis of adult distal humerus fractures: a meta-analysis of biomechanical studies, Int Orthop 43:449, 2019. Swellengrebel HJC, Saper D, Yi P, et al.: Nonoperative treatment of closed extra-articular distal humeral shaft fractures in adults: a comparison of functional bracing and above-elbow casting, Am J Orthop (Belle Mead NJ) 47(5), 2018. https://doi:12788/ajo.2018.0031. Tunali O, Erşen A, Pehlivanoğlu T, et al.: Evaluation of risk factors for stiffness after distal humerus plating, Int Orthop 42(4):92, 2018. Varecka TF, Myeroff C: Distal humerus fractures in the elderly population, J Am Acad Orthop Surg 25:673, 2017. Vazquez O, Rutgers M, Ring DC, et al.: Fate of the ulnar nerve after operative fixation of distal humerus fractures, J Orthop Trauma 24:395, 2010. Wiggers JK, Brouwer KM, Helmerhorst GT, Ring D: Predictors of diagnosis of ulnar neuropathy after surgically treated distal humerus fractures, J Hand Surg Am 37:1168, 2012. Woods BI, Rosario BL, Siska PA, et  al.: Determining the efficacy of screw and washer fixation as a method for securing olecranon osteotomies used in the surgical management of intraarticular distal humerus fractures, J Orthop Trauma 29:44, 2015. Zalavras CG, Vercillo VT, Jun BJ, et al.: Biomechanical evaluation of parallel versus orthogonal plate fixation of intra-articular distal humerus fractures, J Shoulder Elbow Surg 20:12, 2011. Zhang C, Zhong B, Luo CF: Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients: six years clinical experience with both the triceps-sparing approach and olecranon osteotomy, Arch Orthop Trauma Surg 134:803, 2014. Zumstein MA, Raniga S, Flueckiger R, et al.: Triceps-sparing extra-articular step-cut olecranon osteotomy for distal humeral fractures: an anatomic study, J Shoulder Elbow Surg 26:1620, 2017.

ELBOW DISLOCATION; FOREARM FRACTURE; RADIAL HEAD, CORONOID, OLECRANON FRACTURE Antuna SA, Sanchez-Marquez JM, Barco R: Long-term results of radial head resection following isolated radial head fracture in patients younger than forty years old, J Bone Joint Surg 92A:558, 2010. Atesok KI, Jupiter JB, Weiss AP: Galeazzi fracture, J Am Acad Orthop Surg 19:623, 2011. Barnes LF, Lombardi J, Gardner TR, et al.: Comparison of exposure in the Kaplan versus the Kocher approach in the treatment of radial head fractures, Hand (N Y) 14(2):253, 2019. Bauer AS, Lawson BK, Bliss RL, Dyer GSM: Risk factors for posttraumatic heterotopic ossification of the elbow: case-control study, J Hand Surg Am 37A:1422, 2012. Behnke NMK, Redjal HR, Nguyen VT, Zinar DM: Internal fixation of diaphyseal fractures of the forearm: a retrospective comparison of hybrid fixation versus dual plating, J Orthop Trauma 26:611, 2012. Beingessner DM, Nork SE, Agel J, Viskontas D: A fragment-specific approach to type IID Monteggia elbow fracture-dislocations, J Orthop Trauma 25:414, 2011. Beutel BG: Monteggia fractures in pediatric and adult populations, Orthopedics 35:138, 2012. Bot AGJ, Dornberg JN, Lindenhovius ALC, et  al.: Long-term outcomes of fractures of both bones of the forearm, J Bone Joint Surg 93A:527, 2011. Chan K, Faber KJ, King GJW, Athwal GS: Selected anteromedial coronoid fractures can be treated nonoperatively, J Shoulder Elbow Surg 25:1251, 2016.

Coulibaly MO, Jones CB, Sietsema DL, Schildhauer TA: Results of 70 consecutive ulnar nightstick fractures, Injury 46:1359, 2015. De Giacomo AF, Tornetta P, Sinicrope BJ, et al.: Outcomes after plating of olecranon fractures: a multicenter evaluation, Injury 47:1466, 2016. Della Rocca GJ, Beuerlein MJ: Fractures and dislocations of the elbow. In Schmidt AH, Teague DC, editors: Orthopaedic knowledge update: trauma 4, Rosemont, IL, 2010, American Academy of Orthopaedic Surgeons. Ditsios K, Boutsiadis A, Papadopoulos P, et  al.: Floating elbow injuries in adults: prognostic factors affecting clinical outcomes, J Shoulder Elbow Surg 22:74, 2013. Duckworth AD, Clement ND, McEachan JE, et al.: Prospective randomized trial of non-operative versus operative management of olecranon fractures in the elderly, Bone Joint Lett J 99-B:964, 2017. Duckworth AD, Clement ND, White TO, et  al.: Plate versus tension-band wire fixation for olecranon fractures. A prospective randomized trial, J Bone Joint Surg Am 99:1261, 2017. Duckworth AD, Wickramasinghe NR, Clement ND, et al.: Long-term outcomes of isolated stable radial head fractures, J Bone Joint Surg 96:1716, 2014. Duckworth AD, Wickramasinghe NR, Clement ND, et  al.: Radial head replacement for acute complex fractures. What are the rate and risk factors for revision or removal? Clin Orthop Relat Res 472:2136, 2014. Edwards SG, Argintar E, Lamb J: Management of comminuted proximal ulna fracture-dislocations using a multiplanar locking intramedullary nail, Tech Hand Up Extrem Surg 15:106, 2011. Egol KA, Haglin JM, Lott A, et al.: Minimally displaced, isolated radial head and neck fractures do not require forma physical therapy, J Bone Joint Surg 100:648, 2018. Faldini C, Nanni M, Leonetti D, et al.: Early radial head excision for displaced and comminuted radial head fractures: considerations and concerns at long-term follow-up, J Orthop Trauma 26:236, 2012. Fantry A, Sobel A, Capito N, et al.: Biomechanical assessment of locking plate fixation of comminuted proximal olecranon fractures, J Orthop Trauma 32:e445, 2018. Fitzgibbons PG, Louie D, Dyer GSM, et al.: Functional outcomes after fixation of “terrible triad” elbow fracture dislocation, Orthopedics 37:e373, 2014. Foruria AM, Augustin S, Morrey BF, Sánchez-Sotelo J: Heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna, J Bone Joint Surg 95:e66, 2013. Garrigues GE, Wray 3rd WH, Lindenhovius AL, et al.: Fixation of the coronoid process in elbow fracture-dislocations, J Bone Joint Surg 93A:1873, 2011. Giannicola G, Polimanti D, Bullitta G, et al.: Critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability: prospective study on 76 patients, Injury 45:540, 2014. Giannoulis FS, Sotereanos DG: Galeazzi fractures and dislocations, Hand Clin 23:153, 2007. Grassman JP, Hakimi M, Gehrmann SV, et al.: The treatment of the acute Essex-Lopresti injury, Bone Joint Lett J 96B:1385, 2014. Gupta A, Barei D, Khwaja A, Beingessner D: Single-staged treatment using a standard protocol results in functional motion in the majority of patients with a terrible triad elbow injury, Clin Orthop Relat Res 472:2075, 2014. Hamaker M, Zheng A, Eglseder WA, Pensy RA: The adult Monteggia fracture: patterns and incidence of annular ligament incarceration among 121 cases at a single institution over 19 years, J Hand Surg Am 43(1):85. e1-85.e6, 2018 Hopf JC, Berger V, Krieglstein CF, et al.: Treatment of unstable elbow dislocations with hinged elbow fixation—subjective and objective results, J Shoulder Elbow Surg 24:250, 2015. Huh J, Krueger CA, Medvecky MJ, Hsu JR: Medial elbow exposure for coronoid fractures: FCU-split versus over-the-top, J Orthop Trauma 27:730, 2013. Iannuzzi NP, Paez AG, Parks BG, Murphy MS: Fixation of Regan-Morrey type II coronoid fractures: a comparison of screws and suture lasso technique for resistance to displacement, J Hand Surg Am 42(1):e11, 2017.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Iordens GIT, Den Hartog D, Van Lieshout EMM, et  al.: Good functional recovery of complex elbow dislocations treated with hinged external fixation: a multicenter prospective study, Clin Orthop Relat Res 473:1451, 2015. Jeon IH, Sanchez-Sotelo J, Zhao K, et al.: The contribution of the coronoid and radial head to the stability of the elbow, J Bone Joint Surg 94:86, 2012. Klug A, Gramlich Y, Buckup J, et al.: Excellent results and low complication rate for anatomic polyaxial locking plates in comminuted proximal ulna fractures, J Shoulder Elbow Surg 27:2198, 2018. Korompilias AV, Lykissas MG, Kostas-Agnantis IP, et al.: Distal radioulnar joint instability (Galeazzi type injury) after internal fixation in relation to the radius fracture pattern, J Hand Surg Am 36A:847, 2011. Kupperman ES, Kupperman AI, Mitchell SA: Treatment of radial head fractures and need for revision procedures at 1 and 2 years, J Hand Surg Am 43:241, 2018. Kusnezov N, Eisenstein E, Dunn JC, et al.: Operative management of unstable radial head fractures in a young active population, Hand 13(4):473, 2018. Lanting BA, Ferreira LM, Johnson JA, et al.: The effect of radial head implant length on radiocapitellar articular properties and load transfer within the forearm, J Orthop Trauma 28:348, 2014. Leigh WB, Ball CM: Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow, J Shoulder Elbow Surg 21:1336, 2012. Li SL, Lu Y, Wang MY: Is cross-screw fixation superior to plate for radial neck fractures? Bone Joint Lett J 97-B(6):830, 2015. Lipman MD, Gause TM, Teran VA, et al.: Radial head fracture fixation using tripod technique with headless compression screws, J Hand Surg Am 43:575.3e1, 2018. Lópiz Y, González A, García-Fernández C, et al.: Comminuted fractures of the radial head: resection or prosthesis? Injury 47S3:S29, 2016. Lovy AJ, Levy I, Keswani A, et al.: Outcomes of displaced olecranon fractures treated with olecranon sled, J Shoulder Elbow Surg 27:393, 2018. Marmor M, Amano K, Yamamoto A, et al.: Acute shortening versus bridging plate for highly comminuted olecranon fractures, Am J Orthop Sept/ Oct E330, 2017. Marsh JP, Grewal R, Faber KJ, et al.: Radial head fractures treated with modular metallic radial head replacement, J Bone Joint Surg 98:527, 2016. Modi CS, Wasserstein D, Mayne IP, et  al.: The frequency and risk factors for subsequent surgery after a simple elbow dislocation, Injury 46:1156, 2015. Motisi M, Kurowicki J, Berlund DD, et al.: Trends in management of radial head and olecranon fractures, Open Orthop J 11:239, 2017. Neumann M, Nyffeler R, Beck M: Comminuted fractures of the radial head and neck: is fixation to the shaft necessary? J Bone Joint Surg 93B:223, 2011. Nijs S, Graeler H, Bellemans J: Fixing simple olecranon fractures with olecranon osteotomy nail (OleON), Oper Orthop Traumatol 23:438, 2011. Obly N, Reid J: Tripod fixation of radial neck fractures, J Bone Joint Surg Br 93-B(Suppl II):187, 2011. Orbay JL, Mijares MR: The management of elbow instability using an internal joint stabilizer: preliminary results, Clin Orthop Relat Res 472:2049, 2014. Orbay JL, Ring D, Kachooei AR, et al.: Multicenter trial of an internal joint stabilizer for the elbow, J Shoulder Elbow Surg 26(1):125, 2017. Papatheodorou LK, Rubright JH, Heim KA, et al.: Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Clin Orthop Relat Res 472:2084, 2014. Park SM, Lee JS, Jung JY, et  al.: How should anteromedial coronoid facet fracture be managed? A surgical strategy based on O’Driscoll classification and ligament injury, J Shoulder Elbow Surg 24:74, 2015. Park MJ, Pappas N, Steinberg DR, Bozentka DJ: Immobilization in supination versus neutral following surgical treatment of Galeazzi fracture-dislocations in adults: case series, J Hand Surg Am 37A:528, 2012. Paschos NK, Mitsionis GI, Vasilladis HS, Georgoulis AD: Comparison of early mobilization protocols in radial head fractures, J Orthop Trauma 27:134, 2013.

Potini VC, Ogunro S, Henry PDG, et  al.: Complications associated with hinged external fixation for chronic elbow dislocations, J Hand Surg Am 40:730, 2015. Rhyou IH, Kim KC, Lee JH, Kim SY: Strategic approach to O’Driscoll type 2 anteromedial coronoid facet fracture, J Shoulder Elbow Surg 23:924, 2014. Ring D, Bruinsma WE, Jupiter J: Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability, Clin Orthop Relat Res 472:2044, 2014. Schnetzke M, Porschke F, Hoppe K, et al.: Outcome of early and late diagnosed Essex-Lopresti injury, J Bone Joint Surg Am 99:1043, 2017. Schulte LM, Meals CG, Neviaser RJ: Management of adult diaphyseal bothbone forearm fractures, J Am Acad Orthop Surg 22:437, 2014. Shimura H, Nimura A, Nasu H, et al.: Joint capsule attachment to the coronoid process of the ulna: an anatomic study with implications regarding the type 1 fractures of the coronoid process of the O’Driscoll classification, J Shoulder Elbow Surg 25:1517, 2016. Shukla DR, Pillai G, McAnany S, et al.: Heterotopic ossification formation after fracture-dislocations of the elbow, J Shoulder Elbow Surg 24:333, 2015. Sun H, Duan J, Li F: Comparison between radial head arthroplasty and open reduction and internal fixation in patients with radial head fractures (modified Mason type III and IV): a meta-analysis, Eur J Orthop Surg Traumatol 26:283, 2016, compared with. Tashjian RZ, Wolf BR, van Riet RP, Steinmann SP: The unstable elbow: current concepts in diagnosis and treatment, AAOS Instr Course Lect 65:55, 2016. Van Riet RP: Assessment and decision-making in the unstable elbow: management of simple dislocations, Shoulder Elbow 9(2):136, 2017. Venouziou AI, Papatheodorou LK, Weiser RW, Sotereanos DG: Chronic Essex-Lopresti injuries: an alternative treatment method, J Shoulder Elbow Surg 23:861, 2014. Watters TS, Garrigues GE, Ring D, Ruch DS: Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clin Orthop Relat Res 472:2128, 2014. Wellman DS, Tucker SM, Baxter JR, et al.: Comminuted olecranon fractures: biomechanical testing of locked versus minifragment non-locked plate fixation, Arch Orthop Trauma Surg 137:1173, 2017. Yoon A, King GJ, Grewal R: Is ORIF superior to nonoperative treatment in isolated displaced partial articular fractures of the radial head? Clin Orthop Relat Res 472:2105, 2014. Yoon RS, Tyagi V, Cantlon MB, et al.: Complex coronoid and proximal ulna fractures are we getting better at fixing these? Injury 47:2053, 2016. Zhang D, Tarabochia M, Janssen S, et  al.: Risk of subluxation or dislocation after operative treatment of terrible triad injuries, J Orthop Trauma 30:660, 2016.

DISTAL RADIAL FRACTURE Abe S, Murase T, Oka K, et al.: In vivo three-dimensional analysis of malunited forearm diaphyseal fractures with forearm rotational restriction, J Bone Joint Surg Am 100:e113, 2018. Aktekin CN, Altay M, Gursoy C, et al.: Comparison between external fixation and cast treatment in the management of distal radius fractures in patients aged 65 years and older, J Hand Surg Am 35:86, 2010. Arora R, Lutz M, Deml C, et  al.: A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five year of age and older, J Bone Joint Surg 93A:2146, 2011. Auld TS, Hwang JS, Stekas N, et al.: The correlation between the OTA/AO classification system and compartment syndrome in both bone forearm fractures, J Orthop Trauma 31:606, 2017. Bales JG, Stern PJ: Treatment strategies of distal radius fractures, Hand Clin 28:177, 2012. Beumer A, Lindau TR, Adlercreutz C: Early prognostic factors in distal radius fractures in a younger than osteoporotic age group: a multivariate analysis of trauma radiographs, BMC Musculoskelet Disord 14:170, 2013. Brehmer JL, Husband JB: Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM reduction and internal fixation. A prospective, randomized, controlled study, J Bone Joint Surg 96:1621, 2014. Chan YH, Foo TL, Yeo CJ, Chew WY: Comparison between cast immobilization versus volar locking plate fixation of distal radius fractures in active elderly patients, the Asian prospective, Hand Surg 19:19, 2014. Chappuis J, Bouté P, Putz P: Dorsally displaced extra-articular distal radius fractures fixation: dorsal IM nailing versus volar plating. A randomized controlled trial, Orthop Traumatol Surg Res 97:471, 2011. Chen Y, Chen X, Li Z, et al.: Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients: a systematic review and meta-analysis, J Hand Surg Am 41:404, 2016. Cherubino P, Bini A, Marcolli D: Management of distal radius fractures: treatment protocol and functional results, Injury 41:1120, 2010. Chou YC, Chen AC, Chen CY, et al.: Dorsal and volar 2.4-mm titanium locking plate fixation for AO type C3 dorsally comminuted distal radius fractures, J Hand Surg Am 36A:974, 2011. Costa ML, Achten J, Parsons NR, et al.: Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial, BMJ 349:g4807, 2014. Cui Z, Pan J, Yu B, et al.: Internal versus external fixation for unstable distal radius fractures: an up-to-date meta-analysis, Int Orthop 35:1333, 2011. Daneshvar P, Chan R, MacDermid J, Grewal R: The effects of ulnar styloid fractures on patients sustaining distal radius fractures, J Hand Surg Am 39:1915, 2014. Diaz-Garcia RJ, Chung KC: Common myths and evidence in the management of distal radius fractures, Hand Clin 28:127, 2012. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC: A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly, J Hand Surg Am 36A:824, 2011. Dzaja I, MacDermid JC, Roth J, Grewal R: Functional outcomes and cost estimation for extra-articular and simple intra-articular distal radius fractures treated with open reduction and internal fixation versus closed reduction and percutaneous Kirschner wire fixation, Can J Surg 56:378, 2013. Egol KA, Walsh M, Romo-Cardoso S, et  al.: Distal radial fractures in the elderly: operative compared with nonoperative treatment, J Bone Joint Surg 92A:1851, 2010. Eichenbaum MD, Shn EK: Nonbridging external fixation of distal radius fractures, Hand Clin 26:381, 2010. Ekrol I, Duckworth AD, Ralston SH, et al.: The influence of vitamin C on the outcome of distal radial fractures: a double-blind, randomized controlled trial, J Bone Joint Surg 96:1451, 2014. Fujitani R, Omokawa S, Akahane M, et  al.: Predictors of distal radioulnar joint instability in distal radius fractures, J Hand Surg Am 36A:2011, 1919. Gofton W, Liew A: Distal radius fractures: nonoperative and percutaneous pinning treatment options, Hand Clin 26:43, 2010. Goldwyn E, Pensy R, O’Toole RV, et al.: Do traction radiographs of distal radial fractures influence fracture characterization and treatment? J Bone Joint Surg 94:2055, 2012. Grewal R, MacDermid JC, King GJ, Faber KJ: Open reduction and internal fixation versus percutaneous pinning with external fixation of distal radius fractures: a prospective, randomized clinical trial, J Hand Surg Am 36A:1899, 2011 Gyuricza C, Carlson MG, Weiland AJ, et al.: Removal of locked volar plates after distal radius fractures, J Hand Surg Am 36A:982, 2011. Hakimi M, Jungbluth P, Windolf J, Wild M: Functional results and complications following locking palmar plating on the distal radius: a retrospective study, J Hand Surg Eur 35:283, 2010. Hanel DP, Ruhlman SD, Katolik LI, Allan CH: Complications associated with distraction plate fixation of wrist fractures, Hand Clin 26:237, 2010. Hull P, Baraza N, Gohil M, et al.: Volar locking plates versus K-wire fixation of dorsally displaced distal radius fractures—a functional outcome study, J Trauma 70:E125, 2011. Hussain A, Nema SK, Sharma D, et al.: Does operative fixation of isolated fractures of ulna shaft results in different outcomes than non-operative management by long arm cast? J Clin Orthop Trauma 9S:S86, 2018.

Ilyas AM, Jupiter JB: Distal radius fractures—classification of treatment and indications for surgery, Hand Clin 26:37, 2010. Jeudy J, Steiger V, Boyer P, et al.: Treatment of complex fractures of the distal radius: a prospective randomized comparison of external fixation versus locked volar plating, Injury 43:174, 2012. Jupiter JB, Marent Huber M, LCP Study Group: Operative management of distal radial fractures with 2.4-millimeter locking plates: a multicenter prospective case series. Surgical technique, J Bone Joint Surg 92A(Suppl 1 Pt 1):96, 2010. Karantana A, Downing ND, Forward DP, et al.: Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods. A randomized controlled trial, J Bone Joint Surg 95:1737, 2013. Kitay A, Swanstrom M, Schreiber JJ, et  al.: Volar plate position and flexor tendon rupture following distal radius fracture fixation, J Hand Surg Am 38:1091, 2013. Knight D, Hajducka C, Will E, McQueen M: Locked volar plating for unstable distal radial fractures: clinical and radiological outcomes, Injury 41:184, 2010. Kodama N, Imai S, Matsusue Y: A simple method for choosing treatment of distal radius fractures, J Hand Surg Am 38:1896, 2013. Kural C, Sungu I, Kaya I, et al.: Evaluation of the reliability of classification systems used for distal radius fractures, Orthopedics 33:801, 2010. Landgren M, Jerrhag D, Tägil M, et al.: External or internal fixation in the treatment of non-reducible distal radial fractures, Acta Orthop 82:610, 2011. Lattmann T, Meier C, Dietrich M, et al.: Results of volar locking plate osteosynthesis for distal radial fractures, J Trauma 70:1510, 2011. Lee YS, Wei TY, Cheng YC, et al.: A comparative study of Colles’ fractures in patients between fifty and seventy years of age: percutaneous K-wiring versus volar locking plating, Int Orthop 36:789, 2012. Lichtman DM, Bindra RR, Boyer MI, et al.: Treatment of distal radius fractures, J Am Acad Orthop Surg 18:180, 2010. Lichtman DM, Bindra RR, Boyer MI, et  al.: American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of distal radius fractures, J Bone Joint Surg 93A:775, 2011. Lutz K, Yeoh KM, MacDermid JC, et al.: Complications associated with operative versus nonsurgical treatment of distal radius fractures in patients aged 65 years and older, J Hand Surg Am 39:1280, 2014. Martineau PA, Berry GK, Harvey EJ: Plating for distal radius fractures, Hand Clin 26:61, 2010. Matschke S, Marent-Huber M, Audigé L, et  al.: The surgical treatment of unstable distal radius fractures by angle stable implants: a multicenter prospective study, J Orthop Trauma 25:312, 2011. Matschke S, Wentzensen A, Ring D, et al.: Comparison of angle stable plate fixation approaches for distal radius fractures, Injury 42:385, 2011. Meyer C, Chang J, Stern PJ, et al.: Complications of distal radial and scaphoid fracture treatment, Instr Course Lect 63:113, 2014. Moriya K, Saito H, Takahashi Y, Ohi H: Locking palmar plate fixation for dorsally displaced fractures of the distal radius: a preliminary report, Hand Surg 16:263, 2011. Neidenbach P, Audigé L, Wilhelmi-Mock M, et  al.: The efficacy of closed reduction in displaced distal radius fractures, Injury 41:592, 2010. Nishiwaki M, Tazaki K, Shimizu H, Ilyas AM: Prospective study of distal radial fractures treated with an intramedullary nail, J Bone Joint Surg 93A:1436, 2011. Ozer K, Toker S: Dorsal tangential view of the wrist to detect screw penetration to the dorsal cortex of the distal radius after volar fixed-angle plating, Hand (N Y) 6:190, 2011. Patel VP, Paksima N: Complications of distal radius fracture fixation, Bull NYU Hosp Jt Dis 68:112, 2010. Payandeh JB, McKee MD: External fixation of distal radius fractures, Hand Clin 26:55, 2010. Rampoldi M, Paolmbi D, Tagliente D: Distal radius fractures with diaphyseal involvement: fixation with fixed angle volar plate, J Orthop Traumatol 12:137, 2011. Rhee PC, Dennison DG, Kakar S: Avoiding and treating perioperative complications of distal radius fractures, Hand Clin 28:185, 2012.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Rhee SH, Kim J, Lee YH, et al.: Factors affecting late displacement following volar locking plate fixation for distal radial fractures in elderly female patients, Bone Joint Lett J 95B:396, 2013. Richard MJ, Katolik LI, Hanel DP, et al.: Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients, J Hand Surg Am 37A:948, 2012. Richard MJ, Wartinbee DA, Riboh J, et al.: Analysis of the complications of palmar plating versus external fixation for fractures of the distal radius, J Hand Surg Am 36A:1614, 2011. Riddick AP, Hickey B, White SP: Accuracy of the skyline view for detecting dorsal cortical penetration during volar distal radius fixation, J Hand Surg Eur 37:407, 2012. Roh YH, Lee BK, Noh JH, et al.: Factors delaying recovery after volar plate fixation of distal radius fractures, J Hand Surg Am 39:1465, 2014. Roth KM, Blazar PE, Earp BE, et al.: Incidence of displacement after nondisplaced distal radial fractures in adults, J Bone Joint Surg 95:1398, 2013. Ruckenstuhl P, Brnhardt GA, Sadoghi P, et  al.: Quality of life after volar locked plating: a 10-year follow-up study of patients with intra-articular distal radius fractures, BMC Musculoskelet Disord 15:250, 2014. Schwarz AM, Hohenberger GM, Weiglein AH, et al.: Avoiding radial nerve palsy in proximal radius shaft plating – a cadaver study, Injury 48S5:A23, 2017. Soong M, Earp BE, Bishop G, et al.: Volar locking plate implant prominence and flexor tendon rupture, J Bone Joint Surg 93A:328, 2011. Soong M, van Leerdam R, Guitton TG, et al.: Fracture of the distal radius: risk factors for complications after locked volar plate fixation, J Hand Surg Am 36A:3, 2011. Souer JS, Ring D, Jupiter J, et al.: Comparison of intra-articular simple compression and extra-articular distal radial fractures, J Bone Joint Surg 93A:2093, 2011. Tan V, Bratchenk W, Nourbakhsh A, Capo J: Comparative analysis of intramedullary nail fixation versus casting for treatment of distal radius fractures, J Hand Surg Am 37A:460, 2012.

Tarallo L, Mugnai R, Zambianchi F, et al.: Volar plate fixation for the treatment of distal radius fractures: analysis of adverse events, J Orthop Trauma 27:740, 2013. Turner RG, Faber KJ, Athwal GS: Complications of distal radius fractures, Hand Clin 26:85, 2010. Wadsten MA, Sayed-Noor AS, Englund E, et al.: Cortical comminution in distal radial fractures can predict the radiological outcome. A cohort multicenter study, Bone Joint Lett J 96B:978, 2014. Ward CM, Kuhl TL, Adams BD: Early complications of volar plating of distal radius fractures and their relationship to surgeon experience, Hand 6:185, 2011. Wei DH, Poolman RW, Bhandari M, et al.: External fixation versus internal fixation for unstable distal radius fractures: a systematic review and metaanalysis of comparative clinical trials, J Orthop Trauma 26:386, 2012. Weinberg DS, Park RJ, Boden KA, et  al.: Anatomic investigation of commonly used landmarks for evaluating rotation during forearm fracture reduction, J Bone Joint Surg 98:1103, 2016. White BD, Nydick JA, Karsky D, et  al.: Incidence and clinical outcomes of tendon rupture following distal radius fractures, J Hand Surg Am 37:2035, 2012. Williksen JH, Frihagen F, Hellund JC, et al.: Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled study, J Hand Surg Am 38:1469, 2013. Yu YR, Makhni MC, Tabrizi S, et al.: Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study, J Hand Surg Am 36A:1135, 2011. The complete list of references is available online at ExpertConsult.com.

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SUPPLEMENTAL REFERENCES CLAVICLE AND SCAPULA Anavian J, Wijdicks CA, Schroder LK, et al.: Surgery for scapula process fractures: good outcome in 26 patients, Acta Orthop 80:344, 2009. Anderson K: Evaluation and treatment of distal clavicle fractures, Clin Sports Med 22:319, 2003. Armitage BM, Wijdicks CA, Tarkin IS, et  al.: Mapping of scapular fractures with three-dimensional computed tomography, J Bone Joint Surg 91A:2222, 2009. Badhe SP, Lawrence TM, Clark DI: Tension band suturing for the treatment of displaced type 2 lateral end clavicle fractures, Arch Orthop Trauma Surg 127:25 2007. Bozkurt M, Can F, Kridemir V, et  al.: Conservative treatment of scapular neck fracture: the effect of stabililty and glenopolar angle on clinical outcome, Injury 36:1176, 2005. Cameron B, Iannotti JP: Periprosthetic fractures of the humerus and scapula, Orthop Clin North Am 30:305, 1999. Canadian Orthopaedic Trauma Society: Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter, randomized clinical trial, J Bone Joint Surg 89A:1, 2007. Collinge C, Devinney S, Herscovici D, et al.: Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle, J Orthop Trauma 20:680, 2006. DeFranco MJ, Patterson BM: The floating shoulder, J Am Acad Orthop Surg 14:499, 2006. Denard PJ, Koval KJ, Cantu RV, Weinstein JN: Management of midshaft clavicle fractures in adults, Am J Orthop (Belle Mead NJ) 34:527, 2005. Edwards SC, Whittle AP, Wood GW: Nonoperative treatment of ipsilateral fractures of the scapula and clavicle, J Bone Joint Surg 82A:774, 2000. Flinkkilä T, Ristiniemi J, Hyvönen P, et  al.: Surgical treatment of unstable fractures of the distal clavicle: a comparative study of Kirschner wire and clavicular hook plate fixation, Acta Orthop Scand 73:50, 2002. Flinkkilä T, Ristiniemi J, Lakovaara M, et al.: Hook-plate fixation of unstable lateral clavicle fractures: a report on 63 patients, Acta Orthop 77:644, 2006. Gosens T, Speigner B, Minekus J: Fracture of the scapular body: functional outcome after conservative treatment, J Shoulder Elbow Surg 18:443, 2009. Grassi FA, Tajana MS, D’Angelo F: Management of midclavicular fractures: comparison between nonoperative treatment and open intramedullary fixation in 80 patients, J Trauma 50:1096, 2001. Haidar SG, Krishnan KM, Deshmukh SC: Hook plate fixation for type II fractures of the lateral end of the clavicle, J Shoulder Elbow Surg 15:419, 2006. Herrera DA, Anavian J, Tarkin IS, et al.: Delayed operative management of fractures of the scapula, J Bone Joint Surg Br 91:619, 2009. Herscovici Jr D, Fiennes AGT, Allgöwer M, et  al.: The floating shoulder: ipsilateral clavicle and scapular neck fractures, J Bone Joint Surg 74B:362, 1992. Hill JM, McGuire MH, Crosby LA: Closed treatment of displaced middlethird fractures of the clavicle gives poor results, J Bone Joint Surg 79B:537, 1997. Jubel A, Andemahr J, Bergmann H, et al.: Elastic stable intramedullary nailing of midclavicular fractures in athletes, Br J Sports Med 37:480, 2003. Jeray KJ: Acute midshaft clavicular fracture, J Am Acad Orthop Surg 15:239, 2007. Jones CB, Cornelius JP, Sietsema DL, et  al.: Modified Judet approach and minifragment fixation of scapular body and glenoid neck fractures, J Orthop Trauma 23:558, 2009. Jubel A, Andemahr J, Schiffer G, et  al.: Elastic stable intramedullary nailing of midclavicular fractures with a titanium nail, Clin Orthop Relat Res 408:279, 2003. Judd DB, Pallis MP, Smith E, Bottoni CR: Acute operative stabilization versus nonoperative management of clavicle fractures, Am J Orthop (Belle Mead NJ) 38:341, 2009. Khalil A: Intramedullary screw fixation for midshaft fractures of the clavicle, Int Orthop 33:1421, 2009.

Khan LA, Bradnock TJ, Scott C, Robinson CM: Fractures of the clavicle, J Bone Joint Surg 91A:447, 2009. Lambotte A: Chirurgie operatoire des fractures, Paris, 1913, Masson & Cie. Lantry JM, Roberts CS, Giannoudis PV: Operative treatment of scapular fractures: a systematic review, Injury 39:271, 2008. Lapner PC, Uhthoff HK, Papp S: scapula fractures, Orthop Clin North Am 39:459, 2008. McGahan JP, Rab GT, Dublin A: Fractures of the scapula, J Trauma 20:880, 1980. McKeever DC: Principles and ideals of intramedullary internal fixation, Clin Orthop Relat Res 2:12, 1953. Meda PV, Machani B, Sinopidis C, et al.: Clavicular hook plate for lateral end fractures: a prospective study, Injury 37:277, 2006. Meier C, Grueninger P, Platz A: Elastic stable intramedullary nailing for midclavicular fractures in athletes: indications, technical pitfalls and early results, Acta Orthop Belg 72:269, 2006. Mueller M, Rangger C, Striepens N, Burger C: Minimally invasive intramedullary nailing of midshaft clavicular fractures using titanium elastic nails, J Trauma 64:1528, 2008. Neer II CS: Nonunion of the clavicle, J Am Med Assoc 172:1006, 1960. Neer II CS: Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults, J Trauma 3:99 1963. Ngarmukos C, Parkpian V, Patradul A: Fixation of fractures of the midshaft of the clavicle with Kirschner wires, J Bone Joint Surg 80B:106, 1998. Nork SE, Barei DP, Gardner MJ, et  al.: Surgical exposure and fixation of displaced type IV, V, and VI glenoid fractures, J Orthop Trauma 22:487, 2008. Nowak J, Holgersson M, Sarsson S: Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up, J Shoulder Elbow Surg 13:479, 2004. Obremskey WT, Lyman JR: A modified Judet approach to the scapula, J Orthop Trauma 18:696, 2004. Renger RJ, Roukema GR, Reurings JC, et al.: The clavicle hook plate for Neer type II lateral clavicle fractures, J Orthop Trauma 23:570, 2009. Robinson CM, Cairns DA: Primary nonoperative treatment of displaced lateral fractures of the clavicle, J Bone Joint Surg 86A:778, 2004. Rowe CR: An atlas of anatomy and treatment of midclavicular fractures, Clin Orthop Relat Res 58:29 1968. Schandelmaier P, Blauth M, Schneider C, et  al.: Fractures of the glenoid treated by operation. A 5- to 23-year follow-up of 22 cases, J Bone Joint Surg Br 84:173, 2002. Schofer MD, Sehrt AC, Timmesfeld N, et al.: Fractures of the scapula: longterm results after conservative treatment, Arch Orthop Trauma Surg 129:1511, 2009. Schuind F, Pay-Pay E, Andrianni Y, et al.: External fixation of the clavicle for fracture or non-union in adults, J Bone Joint Surg 70A:692, 1988. Smekal V, Irenberger A, Struve P, et al.: Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures—a randomized, controlled, clinical trial, J Orthop Trauma 23:106, 2009. Stanley D, Trowbridge EA, Norris SH: The mechanism of clavicular fracture: a clinical and biomechanical analysis, J Bone Joint Surg 70B:461, 1988. Strauss EJ, Egol KA, France MA, et  al.: Complications of intramedullary Hagie pin fixation for acute midshaft clavicle fractures, J Shoulder Elbow Surg 16:280, 2007. Tadros AM, Lunsjo K, Czechowski J, Abu-Zidan FM: Causes of delayed diagnosis of scapular fractures, Injury 39:314, 2008. Tambe AD, Motkur P, Qamar A, et al.: Fractures of the distal third of the clavicle treated by hook plating, Int Orthop 30:7 2006. van Noort A, van Kampen A: Fractures of the scapula surgical neck: outcome after conservative treatment in 13 cases, Arch Orthop Trauma Surg 125:696, 2005. Zenni Jr EJ, Krieg JK, Rosen MJ: Open reduction and internal fixation of clavicular fractures, J Bone Joint Surg 63A:147, 1981. Zlowodzki M, Bhandari M, Zelle BA, et al.: Treatment of scapula fractures: systematic review of 520 fractures in 22 case series, J Orthop Trauma 20:230, 2006.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS PROXIMAL HUMERUS Adedapo AO, Ikpeme JO: The results of internal fixation of three- and fourpart proximal humeral fractures with the Polarus nail, Injury 32:115, 2001. Agel J, Jones CB, Sanzone AG, et al.: Treatment of proximal humeral fractures with Polarus nail fixation, J Shoulder Elbow Surg 13:191, 2003. Agudelo JF, Schürmann M, Stahel P, et al.: Analysis of efficacy and failure in proximal humerus fractures treated with locking plates, J Orthop Trauma 21:676, 2007. Anglen J, Kyle RF, Marsh JL, et al.: Locking plates for extremity fractures, J Am Acad Orthop Surg 17:465, 2009. Badman BL, Mighell M: Fixed-angle locked plating of two-, three-, and fourpart proximal humerus fractures, J Am Acad Orthop Surg 16:294, 2008. Banco SP, Andrisani D, Ramsey M, et al.: The parachute technique: valgus impaction osteotomy for two-part fractures of the surgical neck of the humerus, J Bone Joint Surg 83A(Suppl 2 Pt 1):38, 2001. Bhatia DN, van Rooyen KS, du Toit DF, et al.: Surgical treatment of comminuted, displaced fractures of the greater tuberosity of the proximal humerus: a new technique of double-row suture-anchor fixation and long-term results, Injury 37:946, 2006. Bogner R, Hübner C, Matis N, et al.: Minimally-invasive treatment of threeand four-part fractures of the proximal humerus in elderly patients, J Bone Joint Surg 90B:1602, 2008. Bono CM, Renard R, Levine RG, et al.: Effect of displacement of fractures of the greater tuberosity on the mechanics of the shoulder, J Bone Joint Surg 83B:1056, 2001. Brems JJ: Rehabilitation following total shoulder arthroplasty, Clin Orthop Relat Res 307:70, 1994. Brunner F, Sommer C, Bahrs C, et al.: Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis, J Orthop Trauma 23:163, 2009. Calvo E, de Miguel I, de la Cruz JJ, López-Martin N: Percutaneous fixation of displaced proximal humeral fractures: indications based on the correlation between clinical and radiographic results, J Shoulder Elbow Surg 16:774, 2007. Clinton J, Franta A, Polissar NL, et al.: Proximal humeral fracture as a risk factor for subsequent hip fractures, J Bone Joint Surg 91A:503, 2009. Cofield RH: Comminuted fractures of the proximal humerus, Clin Orthop Relat Res 230:49, 1988. Compito CA, Self EB, Bigliani LU: Arthroplasty and acute shoulder trauma: reasons for success and failure, Clin Orthop Relat Res 307:27, 1994. Connor PM, Boatright JR, D’Alessandro DF: Posterior fracture-dislocation of the shoulder: treatment with acute osteochondral grafting, J Shoulder Elbow Surg 6:480, 1997. Court-Brown CM, Cattermole H, McQueen MM: Impacted valgus fractures (B1.1) of the proximal humerus: the results of non-operative treatment, J Bone Joint Surg 84B:504, 2002. Court-Brown CM, Garg A, McQueen MM: The translated two-part fracture of the proximal humerus: epidemiology and outcome in the older patient, J Bone Joint Surg 83B:799, 2001. Cuomo F, Zuckerman JD: Open reduction and internal fixation of two- and three-part proximal humerus fractures, Tech Orthop 9:141, 1994. Darder A, Darder Jr A, Sanchis V, et  al.: Four-part displaced proximal humeral fractures: operative treatment using Kirschner wires and a tension band, J Orthop Trauma 7:497, 1993. DeFranco MJ, Brems JJ, Williams Jr GR, et al.: Evaluation and management of valgus impacted four-part proximal humerus fractures, Clin Orthop Relat Res 442:109, 2006. Dimakopoulos P, Panagopoulos A, Kasimatis G: Transosseous suture fixation of proximal humeral fractures: surgical technique, J Bone Joint Surg 91A(Suppl 2 Pt 1):8, 2009. Edwards SL, Wilson NA, Zhang LW, et al.: Two-part surgical neck fractures of the proximal part of the humerus: a biomechanical evaluation of two fixation technique, J Bone Joint Surg 88A:2258, 2006. Egol KA, Ong CC, Walsh M, et al.: Early complications in proximal humerus fractures (OTA types 11) treated with locked plates, J Orthop Trauma 22:159, 2008. Esser RD: Open reduction and internal fixation of three- and four-part fractures of the proximal humerus, Clin Orthop Relat Res 299:244, 1994.

Esser RD: Treatment of three- and four-part fractures of the proximal humerus with a modified cloverleaf plate, J Orthop Trauma 8:15 1994. Fankhauser F, Boldin C, Schippinger G, et al.: A new locking plate for unstable fractures of the proximal humerus, Clin Orthop Relat Res 430:176, 2005. Fenichel I, Oran A, Burstein G, et al.: Percutaneous pinning using threaded pins as a treatment option for unstable two- and three-part fractures of the proximal humerus: a retrospective study, Int Orthop 30:153, 2006. Fenlin JM, Ramsey ML, Allardyce TJ, et al.: Modular total shoulder replacement: design rationale, indications, and results, Clin Orthop Relat Res 307:37, 1994. Flatow EL: Technique of prosthetic replacement for proximal humeral fractures, Tech Orthop 9:154, 1994. Flatow EL, Cuomo F, Maday MG, et al.: Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus, J Bone Joint Surg 73A:1213, 1991. Gallo RA, Hughes T, Altman G: Percutaneous plate fixation of two- and three-part proximal humerus fractures, Orthopedics 31:237, 2008. Gallo RA, Sciulli R, Daffner RH, et  al.: Defining the relationship between rotator cuff injury and proximal humerus fractures, Clin Orthop Relat Res 458:70, 2007. Gardner MJ, Boraiah S, Helfet DL, Lorich DG: The anterolateral acromial approach for fractures of the proximal humerus, J Orthop Trauma 22:132, 2008. Gardner MJ, Boraiah S, Helfet DL, Lorich DG: Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant, J Orthop Trauma 22:195, 2008. Gardner MJ, Griffith MH, Demetrakopoulos D, et  al.: Hybrid locked plating of osteoporotic fractures of the humerus, J Bone Joint Surg 88A:2006, 1962. Gardner MJ, Griffith MH, Dines JS, et  al.: A minimally invasive approach for plate fixation of the proximal humerus, Bull Hosp Jt Dis 62:18, 2004. Gardner MJ, Griffith MH, Dines JS, et al.: The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus, Clin Orthop Relat Res 434:123, 2005. Gardner MJ, Voos JE, Wanich T, et al.: Vascular implications of minimally invasive plating of proximal humerus fractures, J Orthop Trauma 20:602, 2006. Gardner MJ, Weil Y, Barker JU, et al.: The importance of medial support in locked plating of proximal humerus fractures, J Orthop Trauma 21:185, 2007. Gerber C, Werner CML, Vienne P: Internal fixation of complex fractures of the proximal humerus, J Bone Joint Surg 86B:848, 2004. Gibson JNA, Handoll HHG, Madhok R: Interventions for treatment of proximal humeral fractures in adults, Cochrane Database Syst Rev (4):CD000434, 2003. Goss TP: Proximal humeral fractures revisited, Orthop Rev 16:805, 1987. Hägg O, Lundberg BJ: Aspects of prognostic factors in comminuted and dislocated proximal humerus fractures. In Bateman JE, Welsh RP, editors: Surgery of the shoulder, Philadelphia, 1984, Decker. Hanson B, Neidenbach P, de Boer P, Stengel D: Functional outcomes after nonoperative management of fractures of the proximal humerus, J Shoulder Elbow Surg 18:612, 2009. Hawkins RJ, Kiefer GN: Internal fixation techniques for proximal humeral fractures, Clin Orthop Relat Res 223:77, 1987. Hawkins RJ, Switlyk P: Acute prosthetic replacement for severe fractures of the proximal humerus, Clin Orthop Relat Res 289:156, 1993. Hersche O, Gerber C: Iatrogenic displacement of fracture-dislocations of the shoulder: a report of seven cases, J Bone Joint Surg 76B:30, 1994. Hertel R, Hempfing A, Stiehler M, et al.: Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus, J Shoulder Elbow Surg 13:427, 2004. Jaberg H, Warner JJP, Jakob RP: Percutaneous stabilization of unstable fractures of the humerus, J Bone Joint Surg 74A:508, 1992. Jakob RP, Kristiansen T, Mayo K, et al.: Classification and aspects of treatment of fractures of the proximal humerus. In Bateman JE, Welsh RP, editors: Surgery of the shoulder, Philadelphia, 1984, Decker. Jakob RP, Miniaci A, Anson PS, et al.: Four-part valgus impacted fractures of the proximal humerus, J Bone Joint Surg 73B:295, 1991.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM Keener JD, Parsons BO, Flatow EL, et  al.: Outcomes after percutaneous reduction and fixation of proximal humeral fractures, J Shoulder Elbow Surg 16:330, 2007. Koukakis A, Apostolou CDM, Taneja T, et al.: Fixation of proximal humerus fractures using the PHILOS plate: early experience, Clin Orthop Relat Res 442:115, 2006. Kristiansen B: External fixation of proximal humerus fracture: clinical and cadaver study of pinning technique, Acta Orthop Scand 58:645, 1987. Kristiansen B, Kofoed H: External fixation of displaced fractures of the proximal humerus: technique and preliminary results, J Bone Joint Surg 69B:643, 1987. Kristiansen B, Kofoed H: Transcutaneous reduction and external fixation of displaced fractures of the proximal humerus: a controlled clinical trial, J Bone Joint Surg 70B:821, 1988. Kyle RF, Conner TN: External fixation of the proximal humerus, Orthopedics 11:163, 1988. Laflamme GY, Rouleau DM, Berry GK, et al.: Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial, J Orthop Trauma 22:153, 2008. Lanting B, MacDermid J, Drosdowech D, Faber KJ: Proximal humeral fractures: a systematic review of treatment modalities, J Shoulder Elbow Surg 17:42, 2008. Lau TW, Leung F, Chan CF, Chow SP: Minimally invasive plate osteosynthesis in the treatment of proximal humeral fracture, Int Orthop 31:657, 2006. Lefevre-Colau MM, Babinet A, Fayad F, et al.: Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture: a randomized controlled trial, J Bone Joint Surg 89A:2582, 2007. Levy J, Frankle M, Mighell M, et al.: The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture, J Bone Joint Surg 89A:292, 2007. Magovern B, Ramsey ML: Percutaneous fixation of proximal humerus fractures, Orthop Clin North Am 39:405, 2008. Martin C, Guillen M, Lopez G: Treatment of 2- and 3-part fractures of the proximal humerus using external fixation: a retrospective evaluation of 62 patients, Acta Orthop 77:275, 2006. McLaughlin HL: Posterior dislocation of the shoulder, J Bone Joint Surg 34A:584, 1952. Meier RA, Messmer P, Regazzoni P, et  al.: Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate, J Orthop Trauma 20:253, 2006. Muldoon MP, Cofield RH: Complications of humeral head replacement for proximal humeral fractures, Instr Course Lect 46:15, 1997. Neer II CS: Displaced proximal humeral fractures, I: classification and evaluation, J Bone Joint Surg 52A:1077, 1970. Neer II CS: Displaced proximal humeral fractures, II: treatment of three-part and four-part displacement, J Bone Joint Surg 52A:1090, 1970. Neer II CS: Four-segment classification of displaced proximal humeral fractures, Instr Course Lect 24:160, 1975. Neer II CS: Fractures and dislocations of the shoulder. In Rockwood Jr CA, Green DP, editors: Fractures in adults, Philadelphia, 1984, Lippincott. Neer II CS, Horowitz BS: Fractures of the proximal humeral epiphyseal plate, Clin Orthop Relat Res 41:24, 1965. Neer II CS, McIlveen SJ: Replacement de la tete humerale avec reconstruction des tuberosities et de la coiffe dans les fractures desplacees a 4 fragments: resultats actuals et techniques, Rev Chir Orthop Reparatrice Appar Mot 74(Suppl):31, 1988. Nho SJ, Brophy RH, Barker JU, et al.: Innovations in the management of displaced proximal humerus fractures, J Am Acad Orthop Surg 15:12, 2007. Owsley KC, Gorczyca JT: Displacement/screw cutout after open reduction and locked plate fixation of humeral fractures, J Bone Joint Surg 90A:233, 2008. Park MC, Murthi AM, Roth NS, et  al.: Two-part and three-part fractures of the proximal humerus treated with suture fixation, J Orthop Trauma 17:319, 2003. Post M: Fractures of the upper humerus, Orthop Clin North Am 11:239, 1980.

Resch H, Hübner C, Schwaiger R: Minimally invasive reduction and osteosynthesis of articular fractures of the humeral head, Injury 32(Suppl 1):SA25, 2001. Resch H, Povacz P, Fröhlich R, et  al.: Percutaneous fixation of three- and four-part fractures of the proximal humerus, J Bone Joint Surg 79B:295, 1997. Rockwood Jr CA: Injuries to the sternoclavicular joint. In Rockwood Jr CA, Green DP, Bucholz RW, editors: Rockwood and Green’s fractures in adults (vol 1), ed 3,Philadelphia, 1991, JB Lippincott, pp 1253–1307. Schlegel TF, Hawkins RJ: Displaced proximal humeral fractures: evaluation and treatment, J Am Acad Orthop Surg 2:54, 1994. Sehr JR, Szabo RM: Semitubular blade plate for fixation in the proximal humerus, J Orthop Trauma 2:327, 1989. Sidor ML, Zuckerman JD, Lyon T, et al.: The Neer classification system for proximal humeral fractures: an assessment of interobserver reliability and intraobserver reproducibility, J Bone Joint Surg 75A:1745, 1993. Siffri PC, Peindl RD, Coley ER, et al.: Biomechanical analysis of blade plate versus locking plate fixation for a proximal humerus fracture: comparison using cadaver and synthetic humeri, J Orthop Trauma 20:547, 2006. Sjöden GOJ, Movin T, Aspelin P, et  al.: Three-dimensional radiographic analysis does not improve the Neer and AO classifications of proximal humeral fractures, Acta Orthop Scand 70:325, 1999. Smith AM, Sperling JW, Cofield RH: Complications of operative fixation of proximal humeral fractures in patients with rheumatoid arthritis, J Shoulder Elbow Surg 14:559, 2005. Solberg BD, Moon CN, Franco DP, Paiement GD: Locking plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome, J Orthop Trauma 23:113, 2009. Solberg BD, Moon CN, Franco DP, Paiement GD: Surgical treatment of three and four-part proximal humeral fractures, J Bone Joint Surg 91A:1689, 2009. Sporer SM, Weinstein JN, Koval KJ: The geographic incidence and treatment variation of common fractures of elderly patients, J Am Acad Orthop Surg 14:246, 2006. Strohm PC, Kostler W, Sudkamp NP: Locking plate fixation of proximal humerus fractures, Tech Shoulder Elbow Surg 6:8 2005. Südkamp N, Bayer J, Hepp P, et al.: Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate: results of a prospective, multicenter, observational study, J Bone Joint Surg 91A:1320, 2009. Szyszkowitz R, Seggl W, Schleifer P, et al.: Proximal humeral fractures: management techniques and expected results, Clin Orthop Relat Res 292:13, 1993. Thanasas C, Kontakis G, Angoules A, et al.: Treatment of proximal humeral fractures with locking plates: a systematic review, J Shoulder Elbow Surg 18:837, 2009. Tingart MJ, Apreleva M, von Stechow D, et al.: The cortical thickness of the proximal humeral diaphysis predicts bone mineral density of the proximal humerus, J Bone Joint Surg 85B:611, 2003. Vallier HA: Treatment of proximal humerus fractures, J Orthop Trauma 21:469, 2007. van den Broek CM, van den Besselaar M, Coenen JM, Vegt PA: Displaced proximal humeral fractures: intramedullary nailing versus conservative treatment, Arch Orthop Trauma Surg 127:459, 2007. Wheeler DL, Colville MR: Biomechanical comparison of intramedullary and percutaneous pin fixation for proximal humeral fracture fixation, J Orthop Trauma 11:363, 1997. Wijgman AJ, Roolker W, Patt TW, et al.: Open reduction and internal fixation of three- and four-part fractures of the proximal part of the humerus, J Bone Joint Surg 84A:1919, 2002. Wirth MA, Rockwood CA: Complications of shoulder arthroplasty, Clin Orthop Relat Res 307:47, 1994. Young AA, Hughes JS: Locked intramedullary nailing for treatment of displaced proximal humerus fractures, Orthop Clin North Am 39:417, 2008. Zhiquan A, Bingfang Z, Yeming W, et al.: Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures, J Orthop Trauma 21:628, 2007. Zlotolow DA, Catalano III LE, Barron OA, et al.: Surgical exposures of the humerus, J Am Acad Orthop Surg 14:754, 2006.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Zyto K, Kronberg M, Broström LA: Shoulder function after displaced fractures of the proximal humerus, J Shoulder Elbow Surg 4:331, 1995. Zyto K, Wallace A, Frostick SP, et  al.: Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus, J Shoulder Elbow Surg 7:85, 1998.

HUMERAL SHAFT Albritton MJ, Barnes CJ, Basamania CJ, et  al.: Relationship of the axillary nerve to the proximal screws of a flexible humeral nail system: an anatomic study, J Orthop Trauma 17:411, 2003. Apivatthakakul T, Arpornchayanon O, Bavornratanavech S: Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture: is it possible? A cadaver study and preliminary report, Injury 36:530, 2005. Apivatthakakul T, Phornphutkul C, Laohapoonrungsee A, Sirirungruangsarn Y: Less invasive plate osteosynthesis in humeral shaft fractures, Orthop Traumatol 21:602, 2009. Bell MJ, Beauchamp CG, Kellam JK, et  al.: The results of plating humeral shaft fractures in patients with multiple injuries: the Sunnybrook experience, J Bone Joint Surg 67B:293, 1985. Bhandari M, Devereaux PJ, McKee MD, et al.: Compression plating versus intramedullary nailing of humeral shaft fractures—a meta-analysis, Acta Orthop 77:279, 2006. Bishop J, Ring D: Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model, J Hand Surg Am 34A:991, 2009. Bodner G, Buchberger W, Schoke M, et  al.: Radial nerve palsy associated with humeral shaft fracture: evaluation with US—initial experience, Radiology 219:811, 2001. Chapman JR, Henley B, Agel J, et  al.: Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates, J Orthop Trauma 14:162, 2000. Cox MA, Dolan M, Synnott K, et al.: Closed interlocking nailing of humeral shaft fractures with the Russell-Taylor nail, J Orthop Trauma 14:349, 2000. Dabezies EJ, Banta II CJ, Murphy CP, et  al.: Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries, J Orthop Trauma 6:10, 1992. Dijkstra S, Stapert J, Boxma H, et al.: Treatment of pathological fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone cement, Eur J Surg Oncol 22:621, 1996. Ekholm R, Adami J, Tidermark J, et al.: Fractures of the shaft of the humerus: an epidemiological study of 401 fractures, J Bone Joint Surg 88B:1469, 2006. Ekholm R, Ponzer S, Törnkvist H, et al.: Primary radial nerve palsy in patients with acute humeral shaft fractures, J Orthop Trauma 22:408, 2008. Ekholm R, Tidermark J, Törnkvist H, et al.: Outcome after closed functional treatment of humeral shaft fractures, J Orthop Trauma 20:591, 2006. Farragos AF, Schemitsch EH, McKee MD: Complications of intramedullary nailing for fractures of the humeral shaft: a review, J Orthop Trauma 13:258, 1999. Fernández Dell’Oca AA: The principle of helical implants: unusual ideas worth considering, Case studies, Injury 33(Suppl 1):SA29, 2002. Fernandez FF, Matschke S, Hülsenbeck A, et al.: Five years’ clinical experience with the unreamed humeral nail in the treatment of humeral shaft fractures, Injury 35:264, 2004. Fjalestad T, Stromsoe K, Salvesen P, et  al.: Functional results of braced humeral diaphyseal fractures: why do 38% lose external rotation of the shoulder? Arch Orthop Trauma Surg 120:281, 2000. Flinkkilä T, Hyvönen P, Siira P, et al.: Recovery of shoulder joint function after humeral shaft fracture: a comparative study between antegrade intramedullary nailing and plate fixation, Arch Orthop Trauma Surg 124:537, 2004. Foster RJ, Dixon Jr GL, Bach AW, et al.: Internal fixation of fractures and non-unions of the humeral shaft. Indications and results in a multi-center study, J Bone Joint Surg 67A:857, 1985. Franck WM, Olivieri M, Jannasch O, et al.: Expandable nail system for osteoporotic humeral shaft fractures: preliminary results, J Trauma 54:1152, 2003.

Gerber C, Schneeberger AG, Vinh TS: The arterial vascularization of the humeral head: an anatomical study, J Bone Joint Surg 72A:1486, 1990. Gerwin M, Hotchkiss RN, Weiland SJ: Alternative operative exposures of the posterior aspect of the humeral diaphysis, with reference to the radial nerve, J Bone Joint Surg 78A:1690, 1996. Gustilo RB: Current concepts in the management of open fractures, Instr Course Lect 36:359, 1987. Henley MB, Chapman JR, Claudi BF: Closed retrograde Hackethal nail stabilization of humeral shaft fractures, J Orthop Trauma 6:18, 1992. Holstein A, Lewis GB: Fractures of the humerus with radial-nerve paralysis, J Bone Joint Surg 45A:1382, 1963. Jaberg H, Warner JJP, Jakob RP: Percutaneous stabilization of unstable fractures of the humerus, J Bone Joint Surg 74A:508, 1992. Jawa A, McCarty P, Doornberg J, et al.: Extra-articular distal-third diaphyseal fractures of the humerus: a comparison of functional bracing and plate fixation, J Bone Joint Surg 88A:2343, 2006. Koch PP, Gross DFL, Gerber C: The results of functional (Sarmiento) bracing of humeral shaft fractures, J Shoulder Elbow Surg 11:143, 2002. Lin J: Treatment of humeral shaft fractures with humeral locked nail and comparison with plate fixation, J Trauma 44:859, 1998. Lin J, Shen PW, Hou SM: Complications of locked nailing in humeral shaft fractures, J Trauma 54:943, 2003. Livani B, Belangero WD: Bridging plate osteosynthesis of humeral shaft fractures, Injury 35(6):587, 2004. Livani B, Belangero WD, Castro de Medeiros R: Fractures of the distal third of the humerus with palsy of the radial nerve: management using minimally-invasive percutaneous plate osteosynthesis, J Bone Joint Surg 88B:1625, 2006. Lorich DG, Geller DS, Yacoubian SV, et  al.: Intramedullary fixation of humeral shaft fractures using an inflatable nail, Orthopedics 26:1011, 2003. McCormack RG, Brien D, Buckley RE, et al.: Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomized trial, J Bone Joint Surg 82B:336, 2000. McKee MD: Fractures of the shaft of the humerus. In Bucholz RW, Heckman JD, Court-Brown CM, editors: Rockwood and Green’s fractures in adults, Philadelphia, 2006, Lippincott Williams & Wilkins. McKee MD, Seiler J, Jupiter JB: The application of the limited contact dynamic compression plate in the upper extremity: an analysis of 114 cases, Injury 26:661, 1995. Mills WJ, Chapman JR, Robinson LR, et al.: Somatosensory evoked potential monitoring during closed humeral nailing: a preliminary report, J Orthop Trauma 14:167, 2000. Ogawa K, Ui M: Humeral shaft fracture sustained during arm wrestling: report on 30 cases and review of the literature, J Trauma 42:243, 1997. Pehlivan O: Functional treatment of the distal third humeral shaft fractures, Arch Orthop Trauma Surg 122:390, 2002. Pospula W, Abu Noor T: Percutaneous fixation of comminuted fractures of the humerus: initial experience at Al Razi hospital, Kuwait, Med Princ Pract 15:423, 2006. Ring D, Chin K, Jupiter JB: Radial nerve palsy associated with high-energy humeral shaft fractures, J Hand Surg Am 29:144, 2004. Robinson CM, Bell KM, Court-Brown CM, et al.: Locked nailing of humeral shaft fractures: experience in Edinburgh over a 2-year period, J Bone Joint Surg 74B:558, 1992. Ruland WO: Is there a place for external fixation in humeral shaft fractures? Injury 31:27, 2000. Russell TA, Taylor JC, Powell JN, et al: Surgical technique manual: RussellTaylor humeral interlocking nail system, Memphis, Tenn, Smith & Nephew. Rutgers M, Ring D: treatment of diaphyseal fractures of the humerus using a functional brace, J Orthop Trauma 20:597, 2006. Sanzana ES, Dümmer RE, Castro JP, et al.: Intramedullary nailing of humeral shaft fractures, Int Orthop 26:211, 2002. Sarmiento A, Horowitch A, Aboulafia A, et al.: Functional bracing for comminuted extra-articular fractures of the distal third of the humerus, J Bone Joint Surg 72B:283, 1990.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM Sarmiento A, Kinman PB, Galvin EG, et al.: Functional bracing of fractures of the shaft of the humerus, J Bone Joint Surg 59A:596, 1977. Sarmiento A, Zagorski JB, Zych GA, et al.: Functional bracing for the treatment of fractures of the humeral diaphysis, J Bone Joint Surg 82A:478, 2000. Schoots IG, Simons MP, Nork SE, et al.: Antegrade locked nailing of open humeral shaft fractures, Orthopedics 30:49, 2007. Schwarz N, Windish M, Mayr B: Minimally invasive osteosynthesis in humeral shaft fractures, Eur J Trauma Emerg Surg 35:271, 2009. Shao YC, Harwood P, Grotz MR, et al.: Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review, J Bone Joint Surg 87B:1647, 2005. Stannard JP, Harris HW, McGwin Jr G, et  al.: Intramedullary nailing of humeral shaft fractures with a locking flexible nail, J Bone Joint Surg 85A:2103, 2003. Strothman D, Templeman DC, Varecka T, et  al.: Retrograde nailing of humeral shaft fractures: a biomechanical study of its effects on the strength of the distal humerus, J Orthop Trauma 14:101, 2000. Tingstad EM, Wolinsky PR, Shyr Y, et al.: Effect of immediate weightbearing on plated fractures of the humeral shaft, J Trauma 49:2778, 2000. Toivanen JAK, Nieminen J, Laine HJ, et al.: Functional treatment of closed humeral shaft fractures, Int Orthop 29:10, 2005. Vander Griend RA, Tomasin J, Ward EF: Open reduction and internal fixation of humeral shaft fractures: results using AO plating techniques, J Bone Joint Surg 68A:430, 1986. Zhiquan A, Bingfang Z, Yeming W, et al.: Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures, J Orthop Trauma 21:628, 2007. Zlotolow DA, Catalano 3rd LW, Barron OA, Glickel SZ: Surgical exposures of othe humerus, J Am Acad Orthop Surg 14:754, 2006.

DISTAL HUMERUS Archdeacon MT: Combined olecranon osteotomy and posterior triceps splitting approach for complex fractures of the distal humerus, J Orthop Trauma 17:368, 2003. Armstrong AD, Yamaguchi K: Total elbow arthroplasty and distal humerus elbow fractures, Hand Clin 20:475, 2004. Arnander MWT, Reeves A, MacLeod IAR, et al.: A biomechanical comparison of plate configuration in distal humerus fractures, J Orthop Trauma 22:332, 2008. Aslam N, Willett K: Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C), Acta Orthop Belg 70:118, 2004. Athwal GS, Hoxie SC, Rispoli DM, Steinmann SP: Precontoured parallel plate fixation of AO/OTA type C distal humerus fractures, J Orthop Trauma 23:575, 2009. Bolano LE: Ilizarov hinge/distraction external fixation of the elbow: an adjunct to posttraumatic reconstruction, New Orleans, 1994, Paper presented at 61st Annual Meeting of the American Academy of Orthopaedic Surgeons. Broberg MA, Morrey BF: Results of treatment of fracture-dislocations of the elbow, Clin Orthop Relat Res 216:109, 1987. Bryan RS: Fractures about the elbow in adults, Instr Course Lect 30:200, 1981. Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: a tricepssparing approach, Clin Orthop Relat Res 166:188, 1982. Buxton SJD: Ossification in the ligaments of the elbow joint, J Bone Joint Surg 20:709, 1938. Ciullo JV, Melonakos AE: Hinged external fixation of the elbow: a salvage procedure, New Orleans, 1994, Paper presented at 61st Annual Meeting of the American Academy of Orthopaedic Surgeons. Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humerus fractures in elderly patients, J Bone Joint Surg 79A:826, 1997. Coles CP, Barei DP, Nork SE, et  al.: The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus, J Orthop Trauma 20:164, 2006. Coventry MB, Scanlon PW: The use of radiation to discourage ectopic bone: a nine-year study in surgery about the hip, J Bone Joint Surg 63A:201, 1981.

Crenshaw AH: Adult fractures and complex joint injuries of the elbow. In Stanley D, Kay NRM, editors: Surgery of the elbow: practical and scientific aspects, London, 1998, Arnold. Dalal S, Gibson RJ: Pathological fracture of the distal humerus treated with Nancy nails, Injury 35:327, 2004. Dijkstra S, Stapert J, Boxma H, et al.: Treatment of pathological fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone cement, Eur J Surg Oncol 22:621, 1996. Doornberg J, Lindenhovius A, Kloen P, et al.: Two- and three-dimensional computed tomography for the classification and management of distal humeral fractures: evaluation of reliability and diagnostic accuracy, J Bone Joint Surg 88A:1795, 2006. Doornberg JN, van Duijin PJ, Linzel D, et  al.: Surgical treatment of intraarticular fractures of the distal part of the humerus: functional outcome after twelve to thirty years, J Bone Joint Surg 89A:1524, 2007. Fabre KJ: Coronal shear fractures of the distal humerus: the capitellum and trochlea, Hand Clin 20:455, 2004. Frankle MA: Triceps split technique for total elbow arthroplasty, Tech Shoulder Elbow Surg 3:23, 2002. Frankle MA, Herscovici Jr D, DiPasquale TG, et al.: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65, J Orthop Trauma 17:473, 2003. Gabel GT, Hanson G, Bennett JB, et al.: Intraarticular fractures of the distal humerus in the adult, Clin Orthop Relat Res 216:99, 1987. Garcia JA, Mykula R, Stanley D: Complex fractures of the distal humerus in the elderly: the role of total elbow replacement as primary treatment, J Bone Joint Surg 84B:812, 2002. Gofton WT, Macdermid JC, Patterson SD, et al.: Functional outcome of AO type C distal humeral fractures, J Hand Surg Am 28A:294, 2003. Grantham SA, Norris TR, Bush DC: Isolated fracture of the humeral capitellum, Clin Orthop Relat Res 161:262, 1981. Greiner S, Haas NP, Bail HJ: Outcome after open reduction and angular stable internal fixation for supra-intercondylar fractures of the distal humerus: preliminary results with the LCP distal humerus system, Arch Orthop Trauma Surg 128:723, 2008. Gustilo RB: Current concepts in the management of open fractures, Instr Course Lect 36:359, 1987. Hackethal KH: Die Bündel-Nagelung, Berlin, 1961, Springer. Hall Jr RF, Pankovich AM: Ender nailing of acute fractures of the humerus: a study of closed fixation by intramedullary nails without reaming, J Bone Joint Surg 69A:558, 1987. Harrington IJ, Sekyi-Out A, Barrington TW, et al.: The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review, J Trauma 50:46, 2001. Hausman M, Panozzo A: Treatment of distal humerus fractures in the elderly, Clin Orthop Relat Res 425:55, 2004. Helfet DL, Schmeling GJ: Bicondylar intraarticular fractures of the distal humerus in adults, Clin Orthop Relat Res 292:26, 1993. Henley MB: Intra-articular distal humeral fractures in adults, Orthop Clin North Am 18:11, 1987. Henley MB, Chapman JR, Claudi BF: Closed retrograde Hackethal nail stabilization of humeral shaft fractures, J Orthop Trauma 6:18 1992. Hewsin EA, Gofton WT, Dubberly J, et al.: Plate fixation of olecranon osteotomies, J Orthop Trauma 21:58, 2007. Holstein A, Lewis GB: Fractures of the humerus with radial-nerve paralysis, J Bone Joint Surg 45A:1382, 1963. Horne G: Supracondylar fractures of the humerus in adults, J Trauma 20:71, 1980. Horne JB, Tanzer TL: Olecranon fractures: a review of 100 cases, J Trauma 21:469, 1981. Houben PFJ, Bongers KJ, von den Wildenberg FAJM: Double tension band osteosynthesis in supra- and transcondylar humeral fractures, Injury 25:305, 1994. Howard AC, Cooper JC, Welsh CL: Transection of the brachial artery complicating closed posterior dislocation of the elbow, Injury 22:240, 1991.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Huang TL, Chiu FY, Chuang TY, et  al.: Surgical treatment of acute displaced fractures of adult distal humerus with reconstruction plate, Injury 35:1143, 2004. Hutchinson DT, Horwitz D, Ha G, et al.: Cyclic loading of olecranon fracture fixation constructs, J Bone Joint Surg 85A:831, 2003. Jakob R, Fowles JV, Rang M, et al.: Observations concerning fractures of the lateral humeral condyle in children, J Bone Joint Surg 57B:430, 1975. Jawa A, McCarty P, Doornberg J, et al.: Extra-articular distal-third diaphyseal fractures of the humerus: a comparison of functional bracing and plate fixation, J Bone Joint Surg 88A:2343, 2006. Josefsson PO, Gentz CF, Johnell O, et  al.: Dislocations of the elbow and intraarticular fractures, Clin Orthop Relat Res 246:126, 1989. Jupiter JB, Mehne DK: Fractures of the distal humerus, Orthopedics 15:825, 1992. Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement, J Bone Joint Surg 86A:940, 2004. Korner J, Lill H, Muller LP, et al.: The LCP-concept in the operative treatment of distal humerus fractures—biological, biomechanical and surgical aspects, Injury 34(Suppl 2):B20, 2003. Korner J, Lill H, Muller LP, et al.: Distal humerus fractures in elderly patients: results after open reduction and internal fixation, Osteoporos Int 16(Suppl 2):S73, 2005. Lansinger O: Mare K: fracture of the capitellum humeri, Acta Orthop Scand 52:39 1981. Laporte C, Thiongo M, Jegou D: Posteromedial approach to the distal humerus for fracture fixation, Acta Orthop Belg 72:395, 2006. Letsch R, Schmit-Neuerburg KP, Stürmer KM, et al.: Intraarticular fractures of the distal humerus: surgical treatment and results, Clin Orthop Relat Res 241:238, 1989. Lewicky YM, Sheppard JE, Ruth JT: The combined olecranon osteotomy, lateral paratricipital sparing, deltoid insertion splitting approach for concomitant distal intra-articular and humeral shaft fractures, J Orthop Trauma 21:133, 2007. McArthur RA: Herbert screw fixation of fracture of the head of the radius, Clin Orthop Relat Res 224:79, 1987. McKee MD, Pugh DM, Wild LM, et al.: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures: surgical technique, J Bone Joint Surg 87A(Suppl 1 Pt 1):22, 2005. McKee MD, Veillette CJ, Hall JA, et al.: A multicenter, prospective, randomized, controlled trial of open reduction-internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients, J Shoulder Elbow Surg 18:3, 2009. McKee MD, Wilson TL, Winston L, et al.: Functional outcome following surgical treatment of intraarticular distal humeral fractures through a posterior approach, J Bone Joint Surg 82A:1701, 2000. McLaren AC: Prophylaxis with indomethacin for heterotopic bone after open reduction of fractures of the acetabulum, J Bone Joint Surg 72A:245, 1990. Mehne DK, Matta J: Bicolumn fractures of the adult humerus. Paper presented at the 53rd annual meeting of the American Academy of orthopaedic surgeons, 1986, New Orleans. Miller GK, Drennan DB, Maylahn DJ: Treatment of displaced segmental radial-head fractures: long-term follow-up, J Bone Joint Surg 63A:712, 1981. Neer II CS: Articular replacement for the humeral head, J Bone Joint Surg 25A:1607, 1964. Netz P, Strömberg L: Non-sliding pins in traction absorbing wiring of fractures: a modified technique, Acta Orthop Scand 53:355, 1982. Newell RLM: Olecranon fractures in children, Injury 7:33 1975. O’Driscoll SW: Parallel plate fixation of bicolumn distal humeral fractures, Instr Course Lect 58:521, 2009. O’Driscoll SW: The triceps-reflecting anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions, Orthop Clin North Am 31:91, 2000. O’Driscoll SW, Jupiter JB, Cohen MS, et al.: Difficult elbow fractures: pearls and pitfalls, Instr Course Lect 52:113, 2003. Pollock FH, Drake D, Bovill EG, et al.: Treatment of radial neuropathy associated with fractures of the humerus, J Bone Joint Surg 63A:239, 1981. Post M: Fractures of the upper humerus, Orthop Clin North Am 11:239, 1980.

Ring D, Gulotta L, Chin K, et al.: Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus, J Orthop Trauma 18:446, 2004. Ring D, Jupiter JB: Fractures of the distal humerus, Orthop Clin North Am 31:103, 2000. Ring D, Jupiter JB, Gulotta L: Articular fractures of the distal part of the humerus, J Bone Joint Surg 85A:232, 2003. Riseborough EJ, Radin EL: Intercondylar T fractures of the humerus in the adult: a comparison of operative and nonoperative treatment in twentynine cases, J Bone Joint Surg 51A:130, 1969. Sanchez-Sotelo J, Torchia ME, O’Driscoll SW: Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique, J Bone Joint Surg 89A:961, 2007. Sanchez-Sotelo J, Torchia ME, O’Driscoll SW: Principle-based internal fixation of distal humerus fractures, Tech Hand Up Extrem Surg 5:179, 2001. Sarmiento A, Zagorski JB, Zych GA, et al.: Functional bracing for the treatment of fractures of the humeral diaphysis, J Bone Joint Surg 82A:478, 2000. Schatzker J: Fractures of the olecranon. In Schatzker J, Tile M, editors: The rationale of operative fracture care, Berlin, 1987, Springer-Verlag. Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus, J Orthop Trauma 8:468, 1994. Schuster I, Korner J, Arzdorf M, et al.: Mechanical comparison in cadaver specimens of three different 90-degree double-plate osteosyntheses for simulated C2-type distal humerus fractures with varying bone densities, J Orthop Trauma 22:113, 2008. Seidel H: Humeral locking nail: a preliminary report, Orthopedics 12:219, 1989. Self J, Viegas SF, Buford WL, et al.: A comparison of double-plate fixation methods for complex distal humerus fractures, J Shoulder Elbow Surg 4:11 1995. Simpson LA, Richards RR: The fixation of capitellar fractures with Herbert screws, Tech Orthop 1:51, 1986. Smith L: Deformity following supracondylar fractures of the humerus, J Bone Joint Surg 42A:235, 1960. Smith L: Supracondylar fractures of the humerus treated by direct observation, Clin Orthop Relat Res 50:37, 1967. Speed JS: An operation for unreduced posterior dislocation of the elbow, South Med J 18:193, 1925. Speed JS: Surgical treatment of condylar fractures of the humerus, Instr Course Lect 7:187, 1950. Speed JS, Boyd HB: Fractures about the elbow, Am J Surg 38:727, 1937. Speed JS, Macey HB: Fractures of the humeral condyles in children, J Bone Joint Surg 15:903, 1953. Spetzler B, Heck CC, Kamell WM: Complex elbow fractures, Orthop Rev 11:67, 1982. Stamatis E, Paxinos O: The treatment and functional outcome of type IV coronal shear fractures of the distal humerus: a retrospective review of five cases, J Orthop Trauma 17:279, 2003. Strauss EJ, Alaia M, Egol KA: Management of distal humeral fractures in the elderly, Injury 38(Suppl 3):S10, 2007. Throckmorton TW, Zarkadas PC, Steinmann SP: Distal humerus fractures, Hand Clin 23:457, 2007. Tyllianakis M, Panagopoulos A, Papadopoulos AX, et  al.: Functional evaluation of comminuted intra-articular fractures of the distal humerus (AO type C): long-term results in twenty-six patients, Acta Orthop Belg 70:123, 2004. Waddell JP, Hatch J, Richards R: Supracondylar fractures of the humerus— results of surgical treatment, J Trauma 28:1615, 1988. Zalavras CG, McAllister ET, Singh A, Itamura JM: Operative treatment of intra-articular distal humerus fractures, Am J Orthop (Belle Mead NJ) 36(12 (Suppl 2):8, 2007.

ELBOW DISLOCATION; FOREARM FRACTURE; CORONOID, OLECRANON FRACTURE Adams JE, Hoskin TL, Morrey BF, Steinmann SP: Management and outcome of 103 acute fractures of the coronoid process of the ulna, J Bone Joint Surg 91B:632, 2009.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM Akesson T, Herbertsson P, Josefsson PO, et al.: Primary nonoperative treatment of moderately displaced two-part fractures of the radial head, J Bone Joint Surg 88A:2006, 1909. Anderson LD, Bacastow DW: Treatment of forearm shaft fractures with compression plates, Contemp Orthop 8:17 1984. Anderson LD, Sisk TD, Tooms RE, et al.: Compression-plate fixation in acute diaphyseal fractures of the radius and ulna, J Bone Joint Surg 57A:287, 1975. Andrianne Y, Donkerwolcke M, Hinsenkamp M, et al.: Hoffmann external fixation of fractures of the radius and ulna: a prospective study of fiftythree patients, Orthopedics 7:845, 1984. Atesok KI, Jupiter JB, Weiss AP: Galeazzi fracture, J Am Acad Orthop Surg 19:623, 2011. Bado JL: The Monteggia lesion, Clin Orthop Relat Res 50:71, 1967. Barford B: As cited by Colton CL: fractures of the olecranon in adults: classification and management, Injury 5:121, 1973. Bednar DA, Grandwilewski W: Complications of forearm-plate removal, Can J Surg 35:428, 1992. Böhler L: The treatment of fractures, translated by Tretter H, et  al.)., ed 5, New York, 1956-1958, Grune & Stratton. Boyd HB, Boals JC: The Monteggia lesion: a review of 159 cases, Clin Orthop Relat Res 66:94, 1969. Burwell HN, Charnley AD: Treatment of forearm fractures in adults with particular reference to plate fixation, J Bone Joint Surg 25B:404, 1964. Capo JT, Kinchelow T, Brooks K, et al.: Biomechanical stability of four fixation constructs for distal radius fractures, Hand (N Y) 4:272, 2009. Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna, J Bone Joint Surg 71A:159, 1989. Chung KC, Sauitieri L, Kim HM: Comparative outcomes study using the volar locking plating system for distal radius fractures in both young adults and adults older than 60 years, J Hand Surg Am 33A:809, 2008. Cole DJ: SST small bone locking nail: surgical technique, Warsaw, 1993, Biomet. Coleman DA, Blair WF, Shurr D: Resection of the radial head for fracture of the radial head: long-term follow-up of seventeen cases, J Bone Joint Surg 69A:385, 1987. Colton CL: Fractures of the olecranon in adults: classification and management, Injury 5:121, 1973. Cooney WP, Dobyns JH, Linscheid RL: External pin fixation for unstable Colles’ fractures, J Bone Joint Surg 61A:840, 1979. Crenshaw Jr AH: Surgical technique manual: foreSight nail system, Memphis, 1997, Smith & Nephew. Crenshaw Jr AH, Staton K: Intramedullary nailing of forearm fractures, Orlando, Fla, 2000, Paper presented at the American Academy of Orthopaedic Surgeons, Instructional Course Lectures. Crenshaw AH, Zinar DM, Pickering RM: Intramedullary nailing of forearm fractures, Instr Course Lect 51:279, 2002. Doornberg JB, Parisien R, van Duijn PJ: Ring D: radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability, J Bone Joint Surg 89A:1075, 2007. Doornberg JB, Ring DC: Fracture of the anteromedial facet of the coronoid process, J Bone Joint Surg 88A:2216, 2006. Droll KP, Perna P, Potter J, et al.: Outcomes following plate fixation of fractures of both bones of the forearm in adults, J Bone Joint Surg 89A:2619, 2007. Duncan R, Geissler W, Freeland AE, et al.: Immediate internal fixation of open fractures of the diaphysis of the forearm, J Orthop Trauma 6:25, 1992. Ebraheim NA, Skie MC, Zeiss J, et al.: Internal fixation of radial neck fracture in a fracture-dislocation of the elbow: a case report, Clin Orthop Relat Res 276:187, 1992. Edwards GS, Jupiter JB: Radial head fractures with acute distal radioulnar dislocation: Essex-Lopresti revisited, Clin Orthop Relat Res 234:61, 1988. Eggers GWN: The internal fixation of fractures of the shafts of long bones. In Carter BN, editor: Monographs on surgery, Baltimore, 1952, Williams & Wilkins. Egol KA, Tejwani NC, Bazzi J, et al.: Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study, Clin Orthop Relat Res 438:233, 2005.

Essex-Lopresti P: Fractures of the radial head with distal radio-ulnar dislocation, J Bone Joint Surg 33B:244, 1951. Forthman C, Henket M, Ring DC: Elbow dislocation with intraarticular fracture: the results of operative treatment without repair of the medial collateral ligament, J Hand Surg Am 33A:809, 2008. Furry KL, Clinkscales CM: Comminuted fractures of the radial head: arthroplasty versus internal fixation, Clin Orthop Relat Res 353:40, 1998. Gartland JJ, Werley CW: Evaluation of healed Colles’ fractures, J Bone Joint Surg 33:895, 1951. Gartsman GM, Sculco TP, Otis JC: Operative treatment of olecranon fractures: excision or open reduction with internal fixation, J Bone Joint Surg 63A:718, 1981. Geel CW, Palmer AK: Radial head fractures and their effect on the distal radioulnar joint, Clin Orthop Relat Res 275:79, 1992. Grace TG, Eversmann Jr WW: Forearm fractures: treatment by rigid fixation with early motion, J Bone Joint Surg 62A:433, 1980. Grace TG, Eversmann Jr WW: The management of segmental bone loss associated with forearm fractures, J Bone Joint Surg 62A:1150, 1980. Graham TJ: Surgical correction of malunited fractures of the distal radius, J Am Acad Orthop Surg 5:270, 1997. Grechenig W, Clement H, Pichler W, et  al.: The influence of lateral and anterior angulation of the proximal ulna on the treatment of a Monteggia fracture: an anatomical cadaver study, J Bone Joint Surg 89B:836, 2007. Grewal R, MacDermid JC, Faber KJ, et al.: Comminuted radial head fractures treated with a modular metallic radial head arthroplasty: study of outcomes, J Bone Joint Surg 88A:2192, 2006. Guitton TG, Ring D, Kloen P: Long-term evaluation of surgically treated anterior Monteggia fractures in skeletally mature patients, J Hand Surg Am 34A:1618, 2009. Hadden WA, Reschauer R, Seggl W: Results of AO plate fixation of forearm shaft fractures in adults, Injury 15:44, 1983. Harrington IJ, Sekyi-Out A, Barrington TW, et al.: The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review, J Trauma 50:46, 2001. Helm RH, Hornby R, Miller SWM: The complications of surgical treatment of displaced fractures of the olecranon, Injury 18:48, 1987. Herbertsson P, Josefsson PO, Hasserius R, et al.: Fractures of the radial head and neck treated with radial head excision, J Bone Joint Surg Am 86:1925, 2004. Hidaka S, Gustilo RB: Refracture of bones of the forearm after plate removal, J Bone Joint Surg 66A:1241, 1984. Hoël G, Kapandji AI: Osteosynthesis using intra-focal pins of anteriorly dislocated fractures of the inferior radial epiphysis, Ann Chir Main Memb Super 14:142 1995. (in French). Hong G, Cong-Feng L, Chang-Qing Z, et al.: Internal fixation of diaphyseal fractures of the forearm by interlocking intramedullary nail. Short-term results in eighteen patients, J Orthop Trauma 19:384, 2005. Horne JB, Tanzer TL: Olecranon fractures: a review of 100 cases, J Trauma 21:469, 1981. Hume MC, Wiss DA: Olecranon fractures: a clinical and radiographic comparison of tension band wiring and plate fixation, Clin Orthop Relat Res 285:229, 1992. Ikeda M, Sugiyama K, Kang C, et  al.: Comminuted fractures of the radial head: comparison of resection and internal fixation, J Bone Joint Surg Am 87:76, 2005. Jinkins Jr WJ, Lockhart LD, Eggers GWN: Fractures of the forearm in adults, South Med J 53:669, 1960. Jones DJ, Henley MB, Schemitsch EH, et al.: A biomechanical comparison of two methods of fixation of fractures of the forearm, J Orthop Trauma 9:198, 1995. Jones ERL, Esah M: Displaced fractures of the neck of the radius in children, J Bone Joint Surg 53B:429, 1971. Jones JA: Immediate internal fixation of high-energy open forearm fractures, J Orthop Trauma 5:272, 1991. Judet T, DeLoubresse CG, Piriou P, et al.: A floating prosthesis for radialhead fractures, J Bone Joint Surg 78B:244, 1996.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Jupiter JB, Kellam JF: Diaphyseal fractures of the forearm. In Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction. Philadelphia PA, WB Saunders, 2008. Karlsson MK, Herbertsson P, Nordqvist A, et  al.: Long-term outcome of displaced radial neck fractures in adulthood: 16-21 year follow-up of 5 patients treated with radial head excision, Acta Orthop 80:368, 2009. Kellam JF, Jupiter JB: Diaphyseal fractures of the forearm. In Browner BD, Jupiter JB, Levine AM, editors: Skeletal trauma, Philadelphia, 1992, Saunders. Kettler M, Kuhn V, Schieker M, Melone CP: Do we need to include osteoporosis in today’s classification of distal radius fractures? J Orthop Trauma 22:S79, 2008. Knight DJ, Rymaszewski LA, Amis AA, et al.: Primary replacement of the fractured radial head with a metal prosthesis, J Bone Joint Surg 75B:572, 1993. Knight RA, Purvis GD: Fractures of both bones of the forearm in adults, J Bone Joint Surg 31A:755, 1949. Konrad GG, Kundel K, Kreuz PC, et al.: Monteggia fractures in adults: longterm results and prognostic factors, J Bone Joint Surg 89B:354, 2007. Küntscher G: Die marknagelung von Knochenbrüchen: Tierexperimenteller Teil, Wien Klin Wochenschr 19:6, 1940. Lafontaine M, Hardy D, Delince P: Stability assessment of distal radius fractures, Injury 20:208, 1989. Larsen E, Lyndrup P: Netz or Kirschner pins in the treatment of olecranon fractures? J Trauma 27:664, 1987. Lee YH, Lee SK, Chung MS, et  al.: Interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults, J Bone Joint Surg 90A:1891, 2008. Lindenhovius AL, Felsch Q, Doornberg JN, et al.: Open reduction and internal fixation compared with excision for unstable displaced fractures of the radial head, J Hand Surg Am 32A:630, 2007. Lindenhovius AL, Felsch Q, Ring D, Kloen P: The long-term outcome of open reduction and internal fixation of stable displaced isolated partial articular fractures of the radial head, J Trauma 67:143, 2009. Lindenhovius AL, Jupiter JB, Ring D: Comparison of acute versus subacute treatment of terrible triad injuries of the elbow, J Hand Surg Am 33A:920, 2008. Llusa Perez M, Lamas C, Martinez Jr ET I Monteggia fractures in adults: review of 54 cases, J Orthop Trauma 16:438, 2002. MacAusland Jr WR, Wyman, Jr ET:Fractures of the adult elbow, Instr Course Lect 24:169, 1975. Madhok R, Green S: Longer term functional outcome and societal implications of upper limb fractures in the elderly, J R Soc Health 113:179, 1993. Mason ML: Some observations on fractures of the head of the radius with a review of one hundred cases, Br J Surg 42:123, 1954. Mathew PK, Athwal Gs, King GJW: Terrible triad injury of the elbow: current concepts, J Am Acad Orthop Surg 7:137, 2009. McKee MD, Pugh DMW, Wild LM, et al.: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique, J Bone Joint Surg Am 87(Suppl 1 Pt 1):22, 2005. McKeever FM, Buck RM: Fracture of the olecranon process of the ulna: treatment by excision of fragment and repair of triceps tendon, J Am Med Assoc 135:1 1947. McLaren AC, Hedley A, Magee F: The effect of intramedullary rod stiffness on fracture healing, Toronto, 1990, Paper presented at 60th Annual Meeting of OTA. Melone Jr CP: Articular fractures of the distal radius, Orthop Clin North Am 15:217, 1984. Mih AD, Cooney WP, Idler RS, et al.: Long-term follow-up of forearm bone diaphyseal plating, Clin Orthop Relat Res 299:256, 1994. Milliner S, Nunley JA: Treatment of isolated fractures of the shaft of the ulna, Orthopedics 5:1604, 1982. Moed BR, Ede DE, Brown TD: Fractures of the olecranon: an in vitro study of elbow joint stresses after tension-band wire fixation versus proximal fracture fragment excision, J Trauma 53:1088, 2002. Moro JK, Werier J, MacDermid JC, et al.: Arthroplasty with a metal radial head for unreconstructible fractures of the radial head, J Bone Joint Surg Am 83:1201, 2001. Morrey BF: General deep approaches to the elbow: posterior approaches, Tech Shoulder Elbow Surg 3:6 2002. Morrey BF, Askew L, Chao EY: Silastic prosthesis replacement of the radial head, J Bone Joint Surg 63A:454, 1981.

Morrey BF, Chao EY, Hui FC: Biomechanical study of the elbow following excision of the radial head, J Bone Joint Surg 61A:63, 1979. Murphy DF, Greene WB, Dameron Jr TB: Displaced olecranon fractures in adults: clinical evaluation, Clin Orthop Relat Res 224:215, 1987. Murphy DF, Greene WB, Gilbert JA, et al.: Displaced olecranon fractures in adults: biomechanical analysis of fixation methods, Clin Orthop Relat Res 224:210, 1987. Newell RLM: Olecranon fractures in children, Injury 7:33 1975. O’Driscoll SW, Jupiter JB, King GJW, et al.: The unstable elbow, J Bone Joint Surg Am 82:724, 2000. Pollock FH, Pankovich AM, Prieto JJ, et al.: The isolated fracture of the ulnar shaft, J Bone Joint Surg 65A:339, 1983. Popovic N, Gillet PH, Rodriguez A, et al.: Fracture of the radial head with associated elbow dislocation: results of treatment using a floating radial head prosthesis, J Orthop Trauma 14:171, 2000. Pugh DMW, Wild LM, Schemitsch EH, et al.: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures, J Bone Joint Surg 86A:1122, 2004. Regan W, Morrey B: Fractures of the coronoid process of the ulna, J Bone Joint Surg 71A:1348, 1989. Rettig AC, Waugh TR, Evanski PM: Fracture of the olecranon: a problem of management, J Trauma 19:23, 1979. Reynders P, De Groote W, Rondia J, et  al.: Monteggia lesions in adults: a multicenter BOTA study, Acta Orthop Belg 62:78, 1996. Riggs Jr SA, Cooney III WP: External fixation of complex hand and wrist fractures, J Trauma 23:332, 1983. Richard MJ, Ruch DS, Aldridge 3rd JM: Malunions and nonunions of the forearm, Hand Clin 23:235, 2007. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid, J Bone Joint Surg 84A:547, 2002. Ring D, Quintero J, Jupiter JB: Open reduction and internal fixation of fractures of the radial head, J Bone Joint Surg 84A:1811, 2002. Ring D, Tavakolian J, Kloen P, et al.: Loss of alignment after surgical treatment of posterior Monteggia fractures: salvage with dorsal contoured plating, J Hand Surg Am 29A:694, 2004. Rodriguez EK, Eglseder A: A technique for low-profile intramedullary fixation of intraarticular proximal ulnar fractures, J Surg Orthop Adv 17:252, 2008. Rush LV, Rush HL: A technic for longitudinal pin fixation of certain fractures of the ulna and of the femur, J Bone Joint Surg 21:619, 1939. Sage FP: Medullary fixation of fractures of the forearm: a study of the medullary canal of the radius and a report of fifty fractures of the radius treated with a prebent triangular nail, J Bone Joint Surg 41A:1489, 1959. Sage FP: Fractures of the shaft of the radius and ulna in the adult. In Adams JP, editor: Current practice in orthopaedic surgery (vol 1). St Louis, 1963, Mosby. Sage FP: Fractures of the shafts and distal ends of the radius and ulna, Instr Course Lect 20:91, 1971. Sanchez-Sotelo J, O’Driscoll SW, Morrey BF: Medial oblique compression fracture of the coronoid process of the ulna, J Shoulder Elbow Surg 14:60, 2005. Schemitsch EH, Richards RR: The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults, J Bone Joint Surg 74A:1068, 1992. Simpson NS, Goodman LA, Jupiter JB: Contoured LCDC plating of the proximal ulna, Injury 27:411, 1996. Sisk TD: Compression-plate fixation for fractures of the radius and ulna, Strat Orthop 2:1 1982. Smith AM, Morrey BF, Steinmann SP: Low profile fixation of radial head and neck fractures: surgical technique and clinical experience, J Orthop Trauma 21:718, 2007. Sotereanos DB, Darlis NA, Wright TW, et al.: Unstable fracture-dislocations of the elbow, Instr Course Lect 56:369, 2007. Speed JS, Boyd HB: Treatment of fractures of the ulna with dislocation of head of radius (Monteggia fracture), J Am Med Assoc 115:1900, 1940. Steinmann SP: Coronoid process fracture, J Am Acad Orthop Surg 16:519, 2008.

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CHAPTER 57  FRACTURES OF THE SHOULDER, ARM, AND FOREARM Steinmann SP: Coronoid process fracture, J Am Acad Orthop Surg 16:519, 2008. Street DM: Medullary fixation in multiple injuries, Orthop Clin North Am 1:169, 1970. Swanson AB, Jaeger SH, La Rochelle D: Comminuted fractures of the radial head, J Bone Joint Surg 63A:1039, 1981. Taylor TKF, O’Connor BT: The effect upon the inferior radio-ulnar joint of excision of the head of the radius in adults, J Bone Joint Surg 25B:83, 1964. Weber BG, Vasey H: Osteosynthese bei olecranon fraktur, Rev Accid Trav Mal Prot 56:90, 1963. Weckbach A, Blattert TR, Weisser CH: Interlocking nailing of forearm fractures, Arch Orthop Trauma Surg 126:309, 2006. Wei SY, Born CT, Abene A, et al.: Diaphyseal forearm fractures treated with and without bone graft, J Trauma 46:1045, 1999. Weseley MS, Barenfeld PA, Eisenstein AL: Closed treatment of isolated radial head fractures, J Trauma 23:36, 1983. Whiteside LA, Lesker PA: The effects of extraperiosteal and subperiosteal dissection, I: on blood flow in muscle, J Bone Joint Surg 60A:23, 1978. Wolfgang G, Burke F, Bush D, et al.: Surgical treatment of displaced olecranon fractures by tension band wiring technique, Clin Orthop Relat Res 224:192, 1987. Zinar DM, Street D, Wolgin M: Intramedullary nailing of the forearm. In Browner BD, editor: The science and practice of intramedullary nailing, ed 2, Baltimore, 1996, Williams & Wilkins. Zych GA, Latta LL, Zaborski JB: Treatment of isolated ulnar shaft fractures with prefabricated functional fracture braces, Clin Orthop Relat Res 219:194, 1987.

DISTAL RADIAL FRACTURE Azzopardi T, Ehrendorfer S, Coulton T, et al.: Unstable extra-articular fractures of the distal radius: a prospective, randomized study of immobilization in a cast versus supplementary percutaneous pinning, J Bone Joint Surg 87B:837, 2005. Bronstein AJ, Trumble TE, Tencer AF: The effects of distal radius fracture malalignment on forearm rotation: a cadaver study, J Hand Surg Am 22A:258, 1997. Burke EF, Singer RM: Treatment of comminuted distal radius with the use of an internal distraction plate, Tech Hand Up Extrem Surg 2:248, 1998. Chappuis J, Bouté P, Putz P: Dorsally displaced extra-articular distal radius fractures fixation: dorsal IM nailing versus volar plating. A randomized controlled trial, Orthop Traumatol Surg Res 97:471, 2011. Cole JM, Obletz BE: Comminuted fractures of the distal end of the radius treated by skeletal transfixion in plaster cast: an end-result study of thirty-three cases, J Bone Joint Surg 48A:931, 1966. Cooney WP: External fixation of distal radial fractures, Clin Orthop Relat Res 180:44, 1983. Ellis J: Smith’s and Barton’s fractures: a method of treatment, J Bone Joint Surg 47B:724, 1965. Fernandez DL: Fractures of the distal radius: operative treatment, Instr Course Lect 42:73, 1993. Frykman G: Fracture of the distal radius including sequelae—shoulderhand-finger syndrome, disturbance in the distal radio-ulnar joint, and impairment of nerve function: a clinical and experimental study, Acta Orthop Scand 108(Suppl):1, 1967. Fuller DJ: The Ellis plate operation for Smith’s fracture, J Bone Joint Surg 55B:173, 1973. Glickel SZ, Catalano LW, Raia FJ, et  al.: Long-term outcomes of closed reduction and percutaneous pinning for the treatment of distal radius fractures, J Hand Surg Am 33A:1700, 2008. Green DP: Pins and plaster treatment of comminuted fractures of the distal end of the radius, J Bone Joint Surg 57A:304, 1975.

Grewal R, MacDermid JC: The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients, J Hand Surg Am 32A:962, 2007. Hughston JC: Fracture of the distal radial shaft: mistakes in management, J Bone Joint Surg 39A:249, 1957. Jupiter JB, Fernandez DL: Complications following distal radial fractures, J Bone Joint Surg Am 83:1244, 2001. Jupiter JB, Lipton H: The operative treatment of intraarticular fractures of the distal radius, Clin Orthop Relat Res 292:48, 1993. Koenig KM, Davis GC, Grove MR, et al.: Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures? J Bone Joint Surg 91A:2086, 2009. McKay SD, MacDermid JC, Roth JH, Richards RS: Assessment of complications of distal radius fractures and development of a complication checklist, J Hand Surg Am 26:916, 2001. McQueen MM: Metaphyseal external fixation of the distal radius, Bull Hosp Jt Dis 58:9, 1999. McQueen MM: Redisplaced unstable fractures of the distal radius. A randomized, prospective study of bridging versus non-bridging external fixation, J Bone Joint Surg Br 80:665, 1998. McQueen MM, Hajducka C, Court-Brown CM: Redisplaced unstable fractures of the distal radius: a prospective randomized comparison of four methods of treatment, J Bone Joint Surg Br 78:404, 1996. McQueen MM, Michie M, Court-Brown CM: Hand and wrist function after external fixation of unstable distal radial fractures, Clin Orthop Relat Res 285:200, 1992. McQeen MM, Wakefield A: Sital radial osteotomy for malunion using nonbridging external fixation: good results in 23 patients, Acta Orthop 79(3):390, 2008. Medoff RJ: Immediate internal fixation and motion of comminuted distal radius fractures using a new fragment-specific fixation system, Minneapolis, 1998, Paper presented at American Society for Surgery of the Hand. Medoff RJ, Kopylov P: Open reduction and immediate motion of intraarticular distal radius fractures with a fragment specific system, Arch Am Acad Orthop Surg 2:53 1999. Mehta JA, Bain GI, Heptinstall RJ: Anatomical reduction of intraarticular fractures of the distal radius, J Bone Joint Surg 82B:79, 2000. Nana AD, Joshi A, Lichtman DM: Plating of the distal radius, J Am Acad Orthop Surg 13:159, 2005. Nesbitt KS, Failla JM, Les C: Assessment of instability factors in adult distal radius fractures, J Hand Surg Am 29:1128, 2004. Orbay JL, Fernandez DL: Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report, J Hand Surg Am 27A:205, 2002. Orbay JL, Fernandez DL: Volar fixed-angle plate fixation for unstable radius fractures in the elderly patient, J Hand Surg Am 29A:96, 2004. Ruch DS, Ginn TA, Yang CC, et al.: Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution, J Bone Joint Surg 87A:945, 2005. Szabo RM, Weber SC: Comminuted intraarticular fractures of the distal radius, Clin Orthop Relat Res 230:39, 1988. Trumble TE, Schmitt SR, Vedder NB: Factors affecting functional outcome of displaced intra-articular distal radius fractures, J Hand Surg Am 19A:325, 1994. Young BT, Rayan GM: Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years, J Hand Surg Am 25A:19, 2000. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW: Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study, J Bone Joint Surg 89A:1424, 2007.

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58

MALUNITED FRACTURES A. Paige Whittle

FOOT Phalanges of the toes Metatarsals Tarsals Talus Malunion of the talar neck Malunion of the talar body Calcaneus ANKLE Arthrodesis for malunited fractures of the ankle TIBIA Shafts of the tibia and fibula condyles of the tibia Inverted-Y fractures of the tibial condyles Fracture of the intercondylar eminence of the tibia PATELLA FEMUR AND HIP Condyles of the femur Lateral femoral condyle  Medial femoral condyle Both femoral condyles Supracondylar femur Femoral shaft

3128 3128 3128 3129 3129 3129 3130 3130 3137 3140 3140 3140 3148 3150 3150 3150 3150 3150 3150 3151 3151 3151 3151

Femoral malunion in children 3154 Trochanteric region of the femur 3156 Subtrochanteric osteotomy for coxa vara and rotational deformities 3157 Cervicotrochanteric region of the femur 3157 3158 ACETABULUM PELVIS 3158 Three-stage reconstruction for 3159 pelvic malunions SCAPULA 3159 3161 CLAVICLE Midshaft malunions of the clavicle  3161 3165 HUMERUS Proximal humerus 3165 Evaluation 3166 Treatment 3166 Humeral shaft 3168 3169 Middle third 3169 Distal humerus 3169 FOREARM Proximal third of the radius and ulna 3169 3169 Radial head Radial neck 3170 Olecranon 3170

A malunited fracture is one that has healed with the fragments in a nonanatomic position. Whether the deformity is unsightly or not it can impair function in several ways: (1) an abnormal joint surface can cause irregular weight transfer and arthritis of the joint, especially in the lower extremities; (2) rotation or angulation of the fragments can interfere with proper balance or gait in the lower extremities or positioning of the upper extremities; (3) overriding of fragments or bone loss can result in perceptible shortening; and (4) the movements of neighboring joints can be blocked. Malunions, by strict definition, commonly are the rule in the closed treatment of fractures; however, they frequently are compatible with function. A malunited fracture becomes surgically significant only when it impairs function. Malunions generally are caused by either inaccurate reduction or ineffective immobilization during healing. Most malunions could be prevented by skillful treatment of fresh fractures; however, malunion sometimes occurs despite the most expert treatment. Malunion may develop in patients with multiple trauma in whom treatment of more life-threatening injuries takes precedence. Especially in patients with head injuries, displacement can occur later and result in deformity and disability after the patient regains mobility.

Proximal third of the ulna with anterior dislocation of the radial head 3170 (Monteggia fracture) Synostosis between the radius and the ulna 3171 Shafts of the radius and ulna 3172 in adults Forearm malunions with distal radioulnar joint instability 3174 3175 Shaft of the ulna DISTAL RADIUS 3175 3175 Clinical evaluation Radiographic evaluation 3176 Operative treatment 3176 Extraarticular malunion with dorsal angulation 3178 Osteotomy and grafting of the 3178 radius Extraarticular malunion with volar angulation 3180 3184 Intraarticular malunions 3185 Salvage procedures Distal radioulnar joint incongruity and arthrosis 3186 3189 CARPUS HAND 3189

When treating malunions, the following facts must be considered. Of the four characteristics that determine the acceptability of fracture reduction, the first in importance is alignment, the second is rotation, the third is restoration of normal length, and the fourth and least important is the actual position of the fragments. A slight deformity can be seriously disabling when a malunion involves a joint or is near one. If malunion causes only slight disability, function sometimes cannot be improved enough to justify surgery; however, a rotational deformity can be so disabling that surgery is required. Deformity of axial alignment in children younger than 9 years old may correct spontaneously with growth, especially if it is near a joint and in the plane of its motion. An offset in an epiphysis usually also corrects itself spontaneously in a child if the physis has not been injured. Analysis of the deformity should take into consideration that most deformities can be resolved into one plane with regard to anteroposterior and varus or valgus deformity. Ries and O’Neill developed a trigonometric analysis of deformity and designed a graph to determine the true maximal deformity on the basis of the true anteroposterior and lateral radiographic views (Fig. 58.1). Other trigonometric analyses of angulation osteotomies also have been reported.

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AP

Y

C LAT

AP

D

LAT E

B

θ LAT

A

θ AP θT

X

Z

A

B

FIGURE 58.1 Ries and O’Neill method for determining bony deformity from anteroposterior and lateral radiographs. A, Tibial fracture angulated in plane between anteroposterior (AP) and lateral (LAT) planes. B, Angles formed by tibial fracture. CAD is the angle shown on anteroposterior view, CAB is the angle shown on lateral view, and CAE is the angle in the true plane (T) of deformity. (Redrawn from Ries M, O’Neill D: A method to determine the true angulation of long bone deformity, Clin Orthop Relat Res 218:191, 1987.)

The objective of surgery for malunion is to restore function. Although improving the appearance of the part may be equally important to the patient, surgery rarely is justified for cosmetic reasons alone. Operative treatment of malunion of most fractures should not be considered until 6 to 12 months after the fracture has occurred. In intraarticular fractures, surgery may be required sooner if satisfactory function is to be restored. When considering surgery, the degree of osteoporosis and soft-tissue atrophy must be evaluated, and a decision must be made whether early surgery would be preferable to active rehabilitation of the part followed by the surgery. Corrective surgery at the site of malunion is not always feasible. In some instances, a compensatory procedure may be necessary to restore function; in others, pain may be the predominant symptom and may require fusion of a joint. Ilizarov pioneered work on intercalary limb regeneration with the use of circular external fixation techniques and various hinged constructs. These developments make possible the simultaneous restoration of alignment, rotation, and length. These techniques require a thorough understanding of frame design and construction, intensive patient counseling, and intensive physical therapy. Impressive results have been reported in some of the most challenging situations, especially infected nonunions and bone loss problems. Circular fixation techniques have a definite role in malunion surgery for the restoration of length and when previous infection has made conventional

open reduction techniques inappropriate. Detailed instruction and experience with these techniques are necessary, however, before they can be used for reconstruction of complex malunions. Three-dimensional modeling can be useful in preoperative planning for various bone and joint malunions.

FOOT PHALANGES OF THE TOES

Malunion of fractures of the phalanges of the toes rarely causes enough disability to justify surgery. A deformity that causes pain can be corrected easily, however, through a lateral or dorsal incision that does not injure the tendons. Osteotomy and alignment of the fragments may be sufficient. For complete correction, however, wide resection may be required; this can be done with impunity because skillful movements of the toes are not needed. 

METATARSALS

If malunion of the neck or shaft of a metatarsal is disabling, the fragments almost always are angulated toward the plantar surface of the foot, producing an osseous mass on the sole; if the fracture was severely comminuted, the mass may simulate a tumor. Surgery should not aim to restore perfect apposition and alignment but only to correct angulation so that weight bearing does not cause painful pressure on the sole of the foot. 

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CHAPTER 58  MALUNITED FRACTURES  

CORRECTION OF METATARSAL ANGULATION

TECHNIQUE 58.1

Make an incision on the dorsum of the forefoot parallel with the shaft of the affected bones; often one skin incision provides access to two bones. n  Expose the old fractures and divide them with a small osteotome. In some instances, a wedge of bone must be removed to permit elevation of the fragments, but resection must not be extensive enough to result in nonunion. n  Raise the fragments into a slightly overcorrected position by pressing from below and forcibly flexing the toes. n  Fix the fragments with an intramedullary pin as described for fresh fractures (see Chapter 89). n 

POSTOPERATIVE CARE  A cast is applied from the tibial tuberosity to the toes; the bottom of the cast should be well molded to maintain the overcorrected position. At 3 weeks, any intramedullary pin or pins and the cast are removed and a walking boot cast is applied; a felt pad is inserted beneath the fractures to hold the toes in plantarflexion. At 6 weeks, the cast is replaced by a sturdy shoe fitted with an arch support and metatarsal pad.   

TARSALS

Malunion of the tarsals except the talus and calcaneus can be discussed together. Because most fractures in this region are caused by violent trauma, several bones may be involved and perhaps severely comminuted and one or more of the tarsal joints may be dislocated. The distal fragment or fragments usually are displaced dorsalward, and sometimes the bones overlap slightly; in these instances, the distal fragment produces a prominence on the dorsum of the foot and the proximal fragment beneath forms a mass on the sole. Occasionally, lateral movements of the foot can be preserved to some extent by osteotomy through the old fracture and reduction of the fragments. Even when resection of the articular surfaces is unnecessary, however, lateral movements usually are lost. Partial or total resection and arthrodesis of one or more of the tarsal joints frequently are required, not only to correct the position of the bones but also to relieve pain and prevent traumatic arthritis. Because lateral movements often are already partially or completely lost, arthrodesis that entirely eliminates lateral motion does not add much to the disability, especially in young people. When the subtalar joint is not involved, its motion should be preserved by fusing only the midtarsal joints. Unless deformity and pain are severe, operations for malunion in this area are not advisable until weight bearing has been tried for 6 to 12 months.   

CORRECTION OF TARSAL MALUNION TECHNIQUE 58.2 Make an incision either lateral to the extensor tendons on the dorsum of the foot or middorsally in line with the

n 

third metatarsal; reflect the periosteum and expose the old fracture. n  If the injury is only a few months old, divide the bones with an osteotome at the fracture; if the fragments overlap excessively, remove a small section from each. n  Using a bone skid or periosteal elevator, lever the fragments into position. n  The reduction usually is stable; if desired, however, bone staples or crossed Kirschner wires can be used to maintain apposition. n  If malunion has been present for several months or years, the tarsus may be completely fused and the old fracture line may be invisible; in these instances, osteotomize the bones without regard to joints or to the possible site of the old fracture. If the deformity is severe, reduction is impossible without wide resection of the bones. n  If the malunion has caused tenosynovitis of the extensor tendons and dorsal contracture of the toes, the deformities can be corrected later by an operation for claw toes (see Chapter 87).

POSTOPERATIVE CARE  With the foot at a right angle to the leg, a plaster cast is applied from the toes to just below the knee. After 1 week, radiographs are made through the cast to confirm the position. At 2 weeks, the cast and sutures are removed, the foot is inspected, and, if necessary, any residual deformity is corrected with the patient under general anesthesia. A short leg cast is applied and is worn for 1 month. Impressions for arch supports are made, and a walking boot cast is applied; the cast is well molded beneath the metatarsal necks and the longitudinal arch and is worn for 4 weeks. The cast is removed, and the patient is instructed in foot and toe exercises; the arch supports are worn for 4 to 6 months.   

TALUS Malunion of a fracture of the talus is always seriously disabling. The neck, body, or both may be involved in the malunion and can produce an irregularity of the ankle joint or the subtalar or talonavicular joint.

MALUNION OF THE TALAR NECK

Malunited fractures of the neck of the talus are analogous to intracapsular fractures of the neck of the femur in that they often impair circulation and can cause degeneration or even osteonecrosis of the talar head or body and consequent irregularity of one or more of the articular surfaces. Union may occur with the distal fragment in rotation or in lateral or medial deviation, producing a varus or valgus deformity. Treatment of varus malunion of the talar neck has been limited to triple arthrodesis, with unpredictable results. Shortening of the lateral column or lengthening of the medial column to correct forefoot rotation also has been suggested. A talar neck osteotomy at the apex of the deformity with a rhomboid-shaped autogenous tricortical iliac crest bone graft impacted into the osteotomy to maintain correction can be performed; however, care must be taken to preserve the extraosseous blood supply to the talus to prevent osteonecrosis. When the body of the talus is avascular, treatment is as described in Chapter 85. A triple arthrodesis with resection

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS of suitable wedges of bone may be necessary to correct heel inversion and forefoot varus (see Chapter 85). A malunited fracture of the base of the neck or of the anterior part of the body, with dorsal displacement of the distal fragment, may painfully block the ankle joint anteriorly. Excision of the protruding part of the bone may restore ankle motion, although traumatic arthritis may develop eventually. If symptoms of traumatic arthritis are incapacitating, ankle arthrodesis is indicated. 

MALUNION OF THE TALAR BODY

Fractures of the body of the talus, although rare, often unite in malposition. Disability is extreme when the fracture involves the subtalar or ankle joint or both. Arthrodesis or talectomy is the preferred treatment. If an articular surface of the talus is grossly distorted, and the bone is viable and is not infected, arthrodesis is the procedure of choice. When the superior and inferior articular surfaces of the talus are irregular, posterior arthrodesis of the ankle (see Chapter 11), including the subtalar joint, is preferable. When the body is nonviable, calcaneotibial arthrodesis (see Chapter 89) is indicated because motion in the midtarsal joints can be preserved. Traumatic arthritis may be limited to the ankle joint or to the subtalar joint. In these instances, ankle arthrodesis (see Chapter 11) or subtalar fusion may be indicated. Good results have followed subtalar fusion without arthrodesis of the midtarsal joints. Occasionally, a malunited comminuted fracture of the body or neck of the talus can be treated by pantalar arthro­ desis. Pantalar and calcaneotibial arthrodeses are difficult and extensive operations. For open fractures complicated by infection and draining sinuses and sequestration of the talus, talectomy has been recommended in the past. The technique of excision of the talus is similar to that described for tuberculosis of this bone (see Chapter 23). To preserve limb length, we have used Ilizarov circular fixation techniques and bone segment transport after corticotomy of the distal tibia to facilitate calcaneotibial arthrodesis, especially after loss of the talar body from open fractures or sepsis. This technique requires a compliant patient, radical debridement of the infected bone, and appropriate antibiotic therapy. 

CALCANEUS

Pain and disability often persist after fractures of the calcaneus even though the original injury was treated skillfully; this is especially likely if the patient’s occupation requires walking over rough ground. Deformities associated with nonoperative management of calcaneal fractures include heel widening, subtalar incongruity, loss of calcaneal height (decreased Böhler angle), and varus alignment. Heel widening can lead to subfibular impingement and dysfunction of the peroneal tendons. Decreased calcaneal height results in a more horizontally oriented talus, which causes anterior tibiotalar impingement, decreased dorsiflexion, and decreased push-off strength. Impaired calcaneal cuboid motion can occur from overhang of the anterolateral calcaneal wall. Varus deformity leads to excessive stress on the lateral foot, whereas subtalar incongruity causes posttraumatic arthrosis. Because pain after calcaneal fractures may improve for 1 to 2 years after injury, surgical treatment usually is deferred

I

II

III

FIGURE 58.2 Three types of calcaneal malunions: I, large lateral wall exostosis, no subtalar arthritis; II, large lateral wall exostosis, significant subtalar arthritis; and III, lateral exostosis, significant subtalar arthritis, calcaneal body malalignment of more than 10 degrees of hindfoot varus.

as long as the patient is making progress in rehabilitation. If a patient’s function fails to progress during this time, however, surgical intervention is warranted. Preoperative evaluation should include analysis of the location of the pain. Lateral pain usually is caused by lateral wall impingement or peroneal tendinitis, whereas more circumferential pain likely is caused by subtalar arthrosis. Anterior ankle pain may be caused by impingement. Posterior ankle pain may be caused by a posterior calcaneal bone spike behind the facet. An injection of 1% lidocaine into the subtalar joint may be helpful in differentiating the origin of the pain. Operative treatment may consist of osteotomy, arthrodesis, or resection of a prominence of the calcaneus laterally to free the peroneal tendons, or a combination of these techniques. A laterally based opening wedge osteotomy for extraarticular malunited fractures has been reported with good results for patients with a symptomatic heel valgus before the onset of subtalar arthritis. If arthrodesis is considered, having the patient wear a limited motion, double upright brace or prefabricated walking boot for 8 weeks can be useful in predicting the success of the procedure. Although smoking is not an absolute contraindication to surgical management, smoking increases the incidence of nonunion after subtalar arthrodesis and the likelihood of wound complications. Smokers should be encouraged to quit preoperatively and be counseled about potential complications. Radiographic evaluation includes standard lateral and lateral weight-bearing radiographs and views of the calcaneus. A Broden view can provide information about the subtalar joint; however, a CT scan most accurately shows alignment and subtalar congruity. CT scans are obtained in the transverse and coronal planes. Stephens and Sanders used CT to identify three types of calcaneal malunions (Fig. 58.2) and to develop treatment guidelines (Table 58.1). Using these guidelines in 26 malunions, they obtained 18 excellent, five good, and three fair results. Although outcomes deteriorated as the complexity of the malunions increased, significant clinical improvement was obtained in even the most severe deformities. In a follow-up study, Clare et  al. reported that the extensile lateral approach allowed adequate decompression of the peroneal tendons, bone block arthrodesis, and calcaneal osteotomy all through the same incision, which is not possible with other proposed approaches (Gallie, Ollier). Ninety-three percent of the arthrodeses united, all feet were plantigrade, and 93% were in neutral or valgus alignment. Twenty-four percent

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CHAPTER 58  MALUNITED FRACTURES TABLE 58.1

Guidelines for Treatment of Calcaneal Malunions Type I Type II Type III

Lateral exostectomy through extensile L-shaped lateral incision Lateral exostectomy plus subtalar arthrodesis using resected exostosis as graft Lateral exostectomy plus subtalar arthrodesis plus calcaneal osteotomy

A

Adapted from Stephens HM, Sanders R: Calcaneal malunions: results of prognostic computed tomography classification system, Foot Ankle Int 17:395, 1996.

had delayed healing, but only one deep infection occurred, and no free-tissue transfers were necessary. A nonsignificant trend toward increased nonunion and wound problems was noted in smokers, and mild residual pain was present in 64% of patients, usually lateral in location. There were no implant failures, which the authors attributed to using large (7.3 or 8.0 mm) titanium screws placed with a lag technique. Flemister et al. found that outcomes were similar regardless of the reconstructive procedure—lateral calcaneal closing wedge osteotomy, bone block arthrodesis, in situ fusion—but malunion and nonunion were more frequent after bone block procedures (15%) than after in situ fusions (5%). They recommended in situ fusion, unless anterior ankle impingement requires a more complicated bone block fusion. If the subtalar joint alone is involved, enough bone is resected to correct the weight-bearing alignment and the joint is arthrodesed. If the midtarsal joints also are involved, a triple arthrodesis (subtalar, talonavicular, and calcaneocuboid) is advisable. Romash described a reconstructive osteotomy of the calcaneus with subtalar arthrodesis for malunited calcaneal fractures with satisfactory results. According to him, the reconstructive osteotomy, which re-creates the primary fracture, allows repositioning of the tuberosity to narrow the heel, alleviates impingement, and returns height to the heel; the subtalar arthrodesis alleviates the symptoms of posttraumatic arthritis. Good or excellent results also have been reported with subtalar distraction realignment arthrodesis using lateral decompression, medial subtalar capsulotomy, and distraction and realignment of the subtalar joint with a tapered wedge bone graft (Fig. 58.3). The lateral approach has several advantages over the Gallie-type posterolateral approach, including less soft-tissue dissection, good view of the subtalar joint, easier access to the medial subtalar capsule and sustentaculum tali, and decreased risk of damage to the sural nerve. Several bone block fusion techniques to restore heel height and improve talar inclination have been described with union rates of 80% to 100% with no varus malunions. However, one study reported good results in only seven of 14 patients, and another study reported varus malunions of the arthrodesis in four of 15 patients. Trnka et al. reported 29 complications after subtalar bone block arthrodesis. Four of the five nonunions in their series were in patients in whom allografts were used, and they cautioned against allograft use. Bone block fusion rather than in situ fusion has been recommended for patients with loss of heel height; however, satisfactory results have been reported even with loss of heel height using subtalar arthrodesis without interpositional bone grafting. Distraction arthrodesis should

B FIGURE 58.3 Subtalar distraction realignment arthrodesis for calcaneal malunions. A, Subtalar distraction with lamina spreader. B, Subtalar distraction arthrodesis with anterior wedge bone graft and cannulated screw.

be considered only for patients with less than 10 degrees of ankle dorsiflexion and disabling pain. For a severe crushing fracture of the calcaneus, either fresh or malunited, triple arthrodesis has been recommended because there is not only derangement of the subtalar joint but also a subluxation of the calcaneocuboid and talonavicular joints caused by depression of the sustentaculum tali. With subtalar fusion alone, the head and neck of the talus are left projecting forward without support and form a constant lever in weight bearing that interferes with fusion. According to Conn, triple arthrodesis is preferable to subtalar fusion because the talonavicular, calcaneocuboid, and subtalar joints have a reciprocal action and because triple arthrodesis does not add to the disability since little midtarsal motion remains after the original injury. Others, however, believe that triple arthrodesis has no advantage in most patients with calcaneal malunions. We believe that unless the midtarsal joints are involved, arthrodesis should be limited to the subtalar joint; motion in the midtarsal joints may increase with activity and should be preserved.   

POSTERIOR SUBTALAR ARTHRODESIS Gallie advised arthrodesis of the subtalar joint from the posterior aspect because the procedure is simpler than the one usually employed (Fig. 58.4); however, it does not allow correction of varus or valgus position of the calcaneus or of any other deformity of the foot. According to Gallie, a mild valgus position of the heel usually can be disregarded. His operation is not suitable if the primary deformity is one of varus because excessive weight would be borne on the head of the fifth metatarsal and cause a painful callus.

TECHNIQUE 58.3 (GALLIE) With the patient prone, make a longitudinal incision along the lateral border of the Achilles tendon for 6 to

n 

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Mortise removed from subtalar joint Incision placed lateral to tendo calcaneus

A

Bone graft removed from anteromedial surface of tibia

Through to transverse sinus

B

C

Graft divided in two

E

Graft placed in mortise

D

F

G

FIGURE 58.4 Gallie subtalar fusion for malunited fracture of calcaneus. A, Line of skin incision. B and C, Mortise removed from subtalar joint, extending from posterior surface to transverse sinus. D–G, Tibial grafts inserted to fill mortise.

8 cm and incise transversely the posterior capsule of the ankle and of the subtalar joint. n  Locate the subtalar joint by medial and lateral motions of the calcaneus. n  Probe the subtalar joint to determine its general direction and cut a mortise in the calcaneus and talus approximately 1.3 cm wide, 0.6 cm deep, and as far distally as the sinus tarsi. n  Flex the knee and remove a graft 6.2 cm long × 1.3 cm wide from the anteromedial surface of the proximal tibia. Divide the graft into two parts and bevel one end of each. n  Pack cancellous bone into the depth of the mortise. With their cortical surfaces apposed, drive the two grafts into the mortise. If the grafts are of the proper size, their cancellous surfaces press snugly against the lateral walls of the mortise. Strips of cancellous bone from the ilium probably are preferable to the tibial grafts used by Gallie; they are packed tightly into the cavity. n  Close only the subcutaneous and skin layers over a suction drain. n  Apply a bulky dressing followed by a short leg cast.    

 

DISTRACTION ARTHRODESIS TECHNIQUE 58.4 (CARR ET AL.) Place the patient in the lateral decubitus position with the affected side up. Prepare and drape the posterior iliac crest. n  Under tourniquet control, make a longitudinal posterolateral Gallie-type approach to the subtalar joint. There should be no horizontal extension of this incision to avoid undue tension on the wound. n  Expose the lateral calcaneal wall subperiosteally and excise it to a more normal width (lateral wall decompression). This step should ensure peroneal and fibular decompression. n  Identify the subtalar joint and apply a femoral distractor with half-pins in the medial subcutaneous tibia and medial calcaneus. The medial application helps to correct hindfoot varus. n 

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B FIGURE 58.5 A and B, Distraction arthrodesis. (From Robinson JF, Murphy GA: Arthrodesis as salvage for calcaneal malunions, Foot Ankle Clin 7:107, 2002.) SEE TECHNIQUE 58.4.

Apply distraction and denude the posterior subtalar joint to subchondral bone. Use a lamina spreader to aid in subtalar joint exposure. n  Correct any heel varus or valgus by manipulation. n  Obtain intraoperative radiographs to ensure correction of the lateral talocalcaneal angle (normally 25 to 45 degrees). A weight-bearing view of the opposite foot obtained preoperatively is helpful in confirming a normal talocalcaneal angle. n  Measure the subtalar joint gap and harvest an appropriately sized tricortical posterior iliac crest bone graft. A block 2.5 cm in height may be required for severe deformity. Two separate pieces may be required to fill the gap completely and help prevent late collapse into varus or valgus. n  After inserting the graft, release the distraction forces. n  Insert two fully threaded, 6.5-mm AO cancellous screws through stab incisions in the heel to fix the calcaneus and the talus firmly. Two screws provide rigid fixation and help prevent rotatory movements around the axis of subtalar motion. Fully threaded screws are used to help prevent late collapse (Fig. 58.5). n  Obtain final radiographs to confirm position before wound closure.

the arthrodesis are obtained at 6 and 12 weeks. Usually a leather lace-up shoe with a rigid shank can be worn after 12 weeks, in conjunction with a leather lace-up ankle corset to control edema for another 4 to 6 weeks. The patient should be informed preoperatively that swelling around the hindfoot may persist for 6 to 9 months after surgery.    

n 

POSTOPERATIVE CARE The drain is removed at 24 hours. The foot is elevated for 72 hours, and the cast is not bivalved if the neurovascular status remains satisfactory. Crutch walking without weight bearing is allowed. At 2 weeks, the cast and sutures are removed and a well-molded short leg nonwalking cast is applied and worn 4 weeks. Active toe exercises are encouraged during this time. During the first 6 weeks, if patient compliance concerning weight bearing is questionable, a long leg cast with the knee bent is applied. At 6 weeks, a short leg walking cast is applied and weight bearing to tolerance is allowed. Radiographs of

 

RESECTION OF LATERAL PROMINENCE OF CALCANEUS According to Kashiwagi, pain in malunited fractures of the calcaneus sometimes is caused by changes around the peroneal tendons. The tendons may be buried in callus, caught by bony fragments, affected by adhesions, or displaced superiorly by a bony prominence. Kashiwagi recommended peroneal tomography to show changes around the tendons and their sheaths (Fig. 58.6). If pain is caused by such changes, he advised freeing the tendons and sheaths, resecting the bony prominence laterally, and, if necessary, subtalar arthrodesis.

TECHNIQUE 58.5 (KASHIWAGI, MODIFIED) Make a Kocher incision, but extend its distal half one fingerbreadth superior to the sole of the foot and end it at the base of the fifth metatarsal. n  Identify the peroneus longus and brevis tendons, and, without opening their sheaths, deepen the incisions to the lateral surface of the calcaneus 0.6 cm inferior to the peroneus longus tendon. Extend the dissection superiorly next to the bone and deep to the tendons, separating the peroneal retinaculum from the bone. n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Place a thigh tourniquet. Prepare and drape the leg and exsanguinate the extremity with the use of an Esmarch bandage. Inflate the tourniquet to 350 mm Hg. n  Make a lateral extensile incision over the calcaneus and raise a full-thickness subperiosteal flap. The vertical limb of the incision should be just anterior to the Achilles tendon and posterior to the sural nerve, allowing the nerve to be elevated with the full-thickness flap posteriorly. Avoid violation of the nerve at the terminal portion of the horizontal limb of the incision. n  Place three 1.6-mm Kirschner wires, one in the distal fibula, one in the talar neck, and the third in the cuboid, for retraction of the peroneal tendons and the subperiosteal flap. n  Carefully free the lateral wall of the calcaneus of all adjacent soft tissue as far distally as the calcaneocuboid articulation. In all three types of calcaneal malunions, the lateral wall exostosis must be resected. n  Place a Hohmann retractor on the plantar aspect of the calcaneus and one on the anterior process of the calcaneus, and perform an exostectomy using a thin-bladed AO osteotomy saw (Synthes USA, Paoli, PA). Starting posterior, angle the saw blade slightly medially relative to the longitudinal axis of the calcaneus, leaving more residual bone plantarly and providing decompression of the area of impingement in the subfibular region (Fig. 58.7A). Do not violate the talofibular joint. n  Continue the exostectomy to the level of the calcaneocuboid joint because the residual overhang of the lateral wall often results in an osseous block to motion of this joint. Remove the overhang and the lateral fourth of the distal aspect of the calcaneus because articulation of this lateral portion with the cuboid is almost always arthritic. n  Complete the exostectomy distally with an osteotome to avoid saw blade damage to the cuboid and remove the fragment en bloc (Fig. 58.7B). The excised lateral wall fragment should be maintained as a single fragment, if possible, for later use as a bone block autograft in type II and type III malunions. n  In type II and type III calcaneal malunions, attention is directed to the subtalar joint. If it is arthritic, perform a subtalar arthrodesis. Place a lamina spreader within the joint and debride the remaining articular surface using a sharp periosteal elevator or osteotome. n  Prepare the inferior talar and superior calcaneal osseous surfaces with a 2.5-mm drill bit, creating multiple perforations within the subchondral bone for vascular ingrowth. n  With the lamina spreader fully expanded within the subtalar joint posteriorly, verify by fluoroscopy how much height needs to be obtained. The talar head should align anatomically with the navicular, indicating restoration of the medial column, the normal angle of talar declination, and the talocalcaneal angle. n  When alignment is confirmed radiographically, measure the dimensions of the defect with a ruler, allowing the autograft bone block to be contoured to match the defect. If the joint is excessively tight medially, place lamina spreaders in the sinus tarsi and the posterior facet of the subtalar joint. A femoral distractor placed medially is not used because it is cumbersome and not as effec n 

FIGURE 58.6 Peroneal tenogram in acute fracture of calcaneus. Peroneal sheaths fail to fill with contrast medium opposite laterally displaced fragment of calcaneus. (Courtesy Daiji Kashiwagi, MD.)

Retract the tendons superiorly over the tip of the lateral malleolus. Free the origin of the extensor digiti brevis from the calcaneus and retract it superiorly also. The lateral surface of the calcaneus is exposed, including the lateral aspect of the subtalar and calcaneocuboid joints. n  With a wide osteotome, make a sagittal osteotomy through the calcaneus extending from the calcaneocuboid joint anteriorly to the tuberosity of the bone posteriorly and from the subtalar joint superiorly to the plantar surface inferiorly. n  Discard the bone resected. The lateral side of the calcaneus should now consist of a vertical wall, all excessive bone lateral to the subtalar joint and inferior to the lateral malleolus having been removed. n  The lateral aspects of the subtalar and calcaneocuboid joints are now exposed; if necessary, arthrodese these joints. n  Replace the peroneal tendons and sheaths inferior to the lateral malleolus and suture the peroneal retinaculum to the plantar fascia. n  Close the wound. n  With the knee flexed 30 degrees, apply a long leg cast. n 

POSTOPERATIVE CARE  At 10 to 14 days, the cast and sutures are removed. If the operation includes an arthrodesis, a short leg walking cast is applied and the postoperative care is the same as for triple arthrodesis (see Chapter 85).      

CORRECTION OF CALCANEAL MALUNION THROUGH EXTENSILE LATERAL APPROACH TECHNIQUE 58.6 (CLARE ET AL.) Place the patient in the lateral decubitus position on a beanbag, with the normal leg down and in front of the injured extremity.

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A

B

D

C FIGURE 58.7 Extensile lateral approach to calcaneus. A, Excision of lateral wall exostosis. B, En bloc removal of lateral wall exostosis. C, CT scan showing excised lateral wall used as autograft bone block. D, Completion of Dwyer-type calcaneal osteotomy for type III calcaneal malunion with severe varus malalignment of hindfoot. (From Clare MP, Lee WE, Sanders R: Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions, J Bone Joint Surg Am 87A:963, 2005.) SEE TECHNIQUE 58.6.

tive as direct intraarticular distraction. Avoid incising the deltoid ligament from inside the subtalar joint because this renders the joint unstable and overdistraction of the graft may result. n  Place the previously excised lateral wall fragment within the joint as an autograft bone block (Fig. 58.7C). This bone can be folded over on itself to obtain more height

if needed, but it should fill the subtalar joint because the height of the lateral calcaneus (and the graft) usually is equal to the width of the posterior facet. Additional cancellous allograft chips may be placed in the debrided sinus tarsi to assist fusion. n  If a subtalar arthrodesis alone is needed (type II malunion), place fixation at this point. With the subtalar joint held

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS in neutral to slight valgus alignment, place two terminally threaded 3.2-mm guide pins percutaneously from the posterior plantar edge of the calcaneus, and advance across the subtalar joint perpendicular to the plane of the posterior facet and into the talar dome. Angle the guide pin in a divergent fashion into the talar dome for increased stability. Avoid placing a pin in the lateral aspect of the ankle joint. n  Obtain fluoroscopic anteroposterior and mortise images of the ankle and obtain an axial radiograph of the calcaneus to verify correct pin placement and hindfoot alignment. n  If more stable fixation is required, place a third guide pin from the plantar margin of the anterior process of the calcaneus into the distal aspect of the talar neck and head for more stable fixation. Avoid violating the talonavicular joint. n  Place large fragment, partially threaded (7.3 or 8 mm) cannulated screws in lag mode for definitive fixation. n  In patients with a type III malunion, correction of axial mal­alignment also is necessary. Because rotation of the midfoot in the coronal plane around an anteroposterior axis (pronation-supination) would not correct a malpositioned calcaneal tuberosity healed in varus or valgus, a calcaneal osteotomy is performed before placement of the fixation for subtalar arthrodesis. For varus malalignment, perform a Dwyer lateral closing wedge osteotomy posterior to the posterior facet (Fig. 58.7D). Use a medial displacement calcaneal osteotomy with rotation for valgus malalignment. n  When the osteotomy is completed, insert the guide pins in the manner described earlier. In this way, the osteotomy and the fusion can be compressed simultaneously. If bone is removed during the closing wedge osteotomy, it can be used as graft material as well. n  Remove the Kirschner wires and examine the tendons for dislocation. In many ankles with obvious preoperative tendon subluxation, removal of the exostosis allows the tendons to fall back behind the fibula and no further treatment is needed. The peroneal tendon sheath should be entered distally with a Freer elevator, however, to evaluate sheath stenosis proximally. n  If stenosis is found, incise the sheath over a length of 2 to 3 cm along the undersurface of the subperiosteal flap so that a tenolysis can be performed. n  If a peroneal tendon dislocation is identified, reconstruct the superior peroneal retinaculum through a small separate incision in the flap. n  Place a deep drain exiting at the proximal tip of the vertical limb of the incision and close the subperiosteal flap in a layered fashion. n  Pass interrupted 0 Vicryl sutures in the deep layers of the subperiosteal flap, angling such that the flap is advanced to the apex of the incision. n  Clamp the sutures until all deep sutures have been placed. When completed, hand-tie the sutures sequentially, starting at the proximal and distal ends and working toward the apex of the incision. n  Close the subcuticular layer in a similar fashion with interrupted 2-0 Vicryl. Close the skin with 3-0 nylon suture, starting at the ends and progressing toward the apex. If height restoration prevents wound closure, the vertical

limb of the incision can be extended proximally to allow the flap to shift and rotate downward, with the proximal wound being left open to granulate.

POSTOPERATIVE CARE  Patients with type I malunions are kept non–weight bearing until the incision has healed, and physical therapy with early range-of-motion activities and gait training with full weight bearing is initiated thereafter, usually by 3 weeks. Patients with type II and type III malunions are kept non–weight bearing with the leg in a cast for 12 weeks (with cast changes every 4 to 6 weeks). This is followed by progression of weight bearing and the initiation of physical therapy after radiographic evidence of union of the subtalar fusion mass is confirmed.    

 

CORRECTION OF VALGUS MALUNION OF EXTRAARTICULAR CALCANEAL FRACTURE For malunited extraarticular fractures, Aly described a laterally based opening wedge osteotomy for symptomatic valgus calcaneal deformity in 34 patients. He obtained good or excellent results in 91% and poor results in 9% at a mean follow-up of 56.2 months. The mean AOFAS hindfoot and ankle score improved from 57 preoperatively to 90 postoperatively. In the patients with poor results, bilateral fractures and subtalar arthritis contributed to their gait abnormality and restricted hindfoot motion.

TECHNIQUE 58.7 (ALY) Approach the calcaneus through an oblique lateral incision. Protect and retract the superficial branches of the peroneal nerve. n  Identify the sustentaculum tali by probing over the dorsum of the exposed calcaneus. n  Shave the lateral border of the widened calcaneus. Incise the periosteum in line with the planned osteotomy, starting laterally approximately 2.5 cm proximal to the calcaneocuboid joint in the interval between the middle and posterior facets of the subtalar joint. n  Make a lateral to medial oblique osteotomy. The osteotomy line should be made slightly oblique from proximal-lateral to distal-medial. The required depth of the osteotomy should be estimated from the preoperative calcaneal axial radiographs. n  Open the osteotomy with a large osteotome. Preserve the periosteum of the medial calcaneus to prevent medial displacement of the posterior fragment. n  Take a suitable tricortical bone graft from the posterior iliac crest and place it into the osteotomy site and add the bone shavings. n  Through a posterior approach, place one cannulated screw through the long axis of the calcaneus. n 

POSTOPERATIVE CARE Postoperatively, the patient is kept non–weight bearing in a cast for 6 weeks and then

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FIGURE 58.8 A and B, Malunion of bimalleolar ankle fracture fixed with interfragmentary screws in elderly patient. C and D, Revision fixation with one third tubular buttress plate and hydroxyapatite grafting of medial malleolus and tension band fixation of lateral malleolus.

placed in a walking cast for an additional 6 weeks. Thereafter, the patient may wear normal shoes.    

ANKLE Occasionally, malunion occurs after the most accurate reduction of closed ankle fractures or more commonly after “stable” injuries that displace with widening of the mortise because of syndesmotic disruption. Malunion also can develop if fixation of the fibula is inadequate and the fibula is allowed to shorten and rotate. Disability from a malunited ankle fracture can be so extreme that relief can be obtained only by surgery. Even a minor varus or valgus deformity of the joint produces an abnormal weight-bearing alignment and posttraumatic arthritis. Although one cadaver study suggested that factors other than the magnitude of normal contact stresses are of greater importance in the pathogenesis of posttraumatic

arthritis, another cadaver study found that 2 mm or more of shortening or lateral displacement and 5 degrees or more of external rotation increase contact pressures significantly in the posterolateral and midlateral quadrants of the talar dome, and a corresponding decrease in the contact pressures was noted in the medial quadrants of the talar dome. Anatomic reduction of pronation-lateral rotation fractures of the lateral malleolus was recommended to diminish the risk of posttraumatic arthritis. Osteotomies to correct uncomplicated deformities caused by recently malunited fractures of the ankle usually are satisfactory, but displacement of the talus within the ankle mortise for more than 3 months may result in pathologic changes in the articular cartilage, with a diminished potential for satisfactory outcome with osteotomy. Some authors, however, have reported improvement in patients with adequate surgery after displacement of more than 3 months. Nevertheless, all agree that when the deformity has been of short duration and has been corrected with minimal trauma to the articular surfaces, good function usually can be obtained if the normal weight-bearing alignment of the lower extremity and the normal relationships between the articular surfaces of the tibia, the fibula, and the talus are restored (Fig. 58.8). Displacement and residual tilt of the talus have been associated with poor results, as have inaccurate reduction and poor surgical technique. Osteotomies have been less successful in treating bimalleolar malunions associated with moderate-to-severe arthritis. An osteotomy can restore weight-bearing alignment of the ankle, but pain and swelling can persist because of arthritic deterioration. Some authors recommend realignment osteotomies as the initial treatment of all symptomatic ankle malunions, regardless of the age of the patient, time from initial injury, severity of malunion, or presence of arthritic changes. However, although arthritis is not a contraindication to osteotomy, chondral damage has been found to be indicative of a poor result. Ankle arthrodesis or ankle arthroplasty should be considered in patients with severe arthritic changes and severely impaired function or in patients who remain significantly symptomatic after osteotomy. It is important to remember that walking on rough ground is difficult after arthrodesis, especially if the subtalar joint is secondarily fibrosed or ankylosed. Complications as high as 30% have been reported after ankle arthrodesis, including nonunion and malunion. Paley et al. treated malunion after ankle arthrodesis with Ilizarov reconstruction. They concluded that the Ilizarov apparatus can simultaneously treat the foot deformity, length discrepancy, and infection, achieving a solid union and plantigrade foot. However, 20 major complications that required surgery occurred during treatment and seven occurred after frame removal, four of which required additional surgery. There are three requirements for the anatomic restoration of the ankle joint: (1) a perfectly equidistant and parallel joint space; (2) a fibular spike in its normal position pointing exactly to the level of the distal tibial subchondral bone, indicating that the length of the fibula is correct; and (3) a normal contour at the lateral part of the articular surface of the talus in continuity as an unbroken curve to the recess of the distal fibula where the peroneal tendons lie. Up to 78% good results have been reported with fibular osteotomy and lengthening for ankle malunion. The criteria for osteotomy include radiographic confirmation

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS of malunion (Fig. 58.9), a demonstrable joint space on anteroposterior and mortise views, and remaining articular cartilage covering the tibial plafond and the talus. Contraindications include ankylosis, loss of bone stock, and severe degenerative arthritis. Operations to correct malunited ankle fractures are (1) osteotomy of the fractured fibula or medial malleolus or both with restoration of fibular length and internal fixation of the osteotomies, (2) supramalleolar osteotomy when only realignment of the lower extremity is required, and (3) arthrodesis of the ankle with or without supramalleolar osteotomy. Although a variety of malunions can occur, the procedures described here can be modified to treat most malunions. 

FIGURE 58.9 CT scan of occult malunion. Right ankle (left) is normal; left ankle (right) shows widening of distal tibiofibular joint, indicating fibular shortening and external rotation of lateral malleolus. (From Yablon IG, Leach RE: Reconstruction of malunited fractures of the lateral malleolus, J Bone Joint Surg Am 71A:521, 1989.)

A

 

OSTEOTOMY FOR BIMALLEOLAR FRACTURE TECHNIQUE 58.8 Make a longitudinal lateral incision over the old fibular fracture, curving slightly anteriorly at its distal end. n  With an osteotome or oscillating saw, make either a transverse or an oblique osteotomy of the fibula at the area of the old fracture. n  Excise scar tissue between the fibula and tibia to allow correct positioning of the fibula in the notch. Length and rotation of the fibula can be restored with the technique described by Weber. n  Attach a five-hole or six-hole, 3.5-mm dynamic compression plate to the distal fibular fragment with two screws (Fig. 58.10A). Before plate application, make a small recess in the distal fibula so that the plate is not prominent. Place the plate slightly posterior on the distal fragment to allow internal rotation of the fragment. Correct the rotation of the distal fragment by internally rotating it 10 degrees. n  Attach the articulated tensioning device from an AO small fragment system to the proximal end of the plate (Fig. 58.10B). Apply distraction until the distal fibula is reduced anatomically to its articulations with the tibia and talus. n  Confirm the reduction with radiographs or fluoroscopy. n  If a transverse osteotomy has been made, fill the gap created by distraction with a small wafer of corticocancellous bone from the medial tibial metaphysis above the medial malleolus (Fig. 58.10C). n 

B

C

FIGURE 58.10 Technique of fibular lengthening (see text). A, Five-hole plate is secured to fibula with two distal screws, and osteotomy is made. B, Lengthening is obtained with distraction device. C, Corticocancellous graft from tibia is placed in osteotomy, and compression is applied; remaining screws are inserted to attach plate to fibula. SEE TECHNIQUE 58.8.

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CHAPTER 58  MALUNITED FRACTURES Change the AO tensioning device to the compression mode and apply compression to the osteotomy site. Attach the plate to the proximal fibula using three 3.5-mm cortical screws. Yablon and Leach recommended the addition of a syndesmosis screw if the interosseous membrane is detached during the fibular dissection. In very distal fractures, it may be necessary to stabilize the fibula with transfixing Kirschner wires. n  Alternatively, Ward et al. described the use of the small AO distractor to restore fibular length and rotation. Expose the fibula, resect scar tissue, and osteotomize the fibula as previously described. n  Insert two 2.5-mm partially threaded pins in the anterior distal fibular fragment in 10 degrees of external rotation. n  Correct rotation of the distal fragment and insert two 2.5-mm pins into the proximal fibula in the same plane. n  Attach the small AO distractor and distract the fibula until it is anatomically aligned. n  Fill the gap with bone graft and apply compression with the distractor. n  Apply a one third tubular plate to stabilize the fibula.     n 

a small fragment one third tubular plate as a buttress if necessary. n  Obtain intraoperative radiographs to confirm anatomic reduction of the ankle.

POSTOPERATIVE CARE  A cast is applied over padding from the tibial tuberosity to the toes with the foot in neutral position. The cast is changed in 2 weeks, the sutures are removed, and a cast is reapplied and worn for 10 to 12 weeks. If stable fixation is obtained in a compliant patient, a removable cast brace that does not allow rotation can be substituted to allow controlled physical therapy. An ankle brace with a medial T-strap and an arch support may be necessary for an additional 10 to 12 weeks and can be worn for 3 to 6 months after difficult reconstructions. Physical therapy should be used to restore the soft tissues and encourage strengthening of the bone.    

 

SUPRAMALLEOLAR OSTEOTOMY  

CORRECTION OF DIASTASIS OF THE TIBIA AND FIBULA Operations for diastasis of the tibia and fibula should allow a shift of the talus medially and repositioning of the lateral malleolus. Yablon and Leach reported that a more extensive dissection usually is necessary to restore anatomic alignment in fibular malunion associated with lateral shift of the talus.

TECHNIQUE 58.9 Make a fibular osteotomy and rotate it distally 180 degrees to allow removal of an adequate amount of scar from the area of syndesmosis. n  Make a second incision over the anterior aspect of the medial malleolus and excise scar tissue between the medial malleolus and talus. n  Reduce the talus and place a Steinmann pin from the tibia into the talus to hold the reduction temporarily while the fibula is reduced and plated, as described for bimalleolar malunions. n  If the medial malleolus also has united in a poor position, make a second longitudinal incision just proximal to its base and drive an osteotome from above through four fifths of the diameter of the medial malleolus distally and laterally. Make this osteotomy through the medial part of the tibia just above the old fracture to obtain a broader bony surface. Refracture the bone by forcefully adducting the foot. n  Stabilize the medial malleolus with parallel small fragment lag screws and Kirschner wires as necessary. n  If a gap has been created by reduction of the medial malleolus, insert bone graft to prevent future collapse. Use n 

Occasionally, a malunion of the distal tibia and fibula occurs in which the normal tibiotalar relationships are retained but the ankle is in valgus or varus. A supramalleolar osteotomy is recommended for this malunion. Opening wedge, closing wedge, or dome osteotomies can be used. Because dome osteotomies do not sacrifice length to gain correction of the deformity, they may be preferred in malunions associated with shortening. Dome osteotomies are more effective, however, in correcting deformity in the frontal (varus-valgus) plane than in the sagittal (flexion-extension) plane. A properly positioned wedge osteotomy can be used to correct multiplanar deformities. Closing wedge osteotomies provide broad bony surfaces for healing but cause some shortening of the extremity. Opening wedge osteotomies maintain length, but bone grafting is required to fill the gap created. The Ilizarov method of gradual deformity correction with distraction osteogenesis also can be used.

TECHNIQUE 58.10 To create a dome osteotomy, expose the distal tibia through an anterolateral Henry approach (see Chapter 1). n  Use a 3.2-mm drill bit to create a series of holes in the distal tibial metaphysis in the shape of an arc, convex superiorly. The medial and lateral edges of the arc should be 1.0 to 1.5 cm proximal to the ankle joint, and the height of the arc should be 1.0 to 1.5 cm (Fig. 58.11A). n  Through the same incision or a separate lateral incision, expose the fibula and make an osteotomy at the same level as the tibial osteotomy. If the fracture has healed in varus, resect 1 to 3 cm of the fibula to correct the deformity. If the fracture has healed in valgus, make an oblique osteotomy of the fibula. Use an oscillating saw to connect the holes drilled anteriorly, medially, and laterally in the tibia. n  With fluoroscopic control, insert a 4- or 5-mm threaded pin transversely from medial to lateral into the distal tibial n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS If the fractures have healed in varus position, a closing wedge osteotomy of the tibia can be made in a similar fashion or internal fixation with a plate and screws can be used in conjunction with autogenous iliac bone grafts. n  Close the wound in layers and apply a bulky dressing if an external fixator has been used. n  If not, apply a cast from the tibial tuberosity to the toes. n 

POSTOPERATIVE CARE If casting was used, the cast and the sutures are removed at 2 weeks and then a new cast is reapplied. Weight bearing is not permitted for 6 weeks. If external fixation was used, it is removed at 6 to 8 weeks, and a short leg walking cast is applied. Weight bearing is progressed as tolerated, and the cast is removed when the osteotomies have healed (12 to 16 weeks after surgery). Rehabilitation of the lower extremity is begun by physical therapy.   

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ARTHRODESIS FOR MALUNITED FRACTURES OF THE ANKLE

B

FIGURE 58.11 Supramalleolar osteotomy. A, Dome osteotomy is created 1.0 to 1.5 cm proximal to ankle joint. Threaded pins are inserted parallel to ankle and knee joint lines. B, Osteotomy is completed, and pins are brought parallel to correct varus or valgus deformity. SEE TECHNIQUE 58.10.

fragment parallel to the joint line. Keep the pin out of the joint, the osteotomy site, and the neurovascular bundle. n  Insert a second 4-mm or 5-mm bicortical threaded pin 6 to 10 cm proximal to the osteotomy and parallel to the knee joint. n  With an osteotome, complete the tibial osteotomy through the posterior cortex. Correct varus or valgus deformity by making the pins parallel (Fig. 58.11B). n  If complete reduction is not obtained, it may be necessary to resect more of the fibula or to release more soft tissue, including the interosseous membrane. n  When the reduction is acceptable, connect the pins with an external fixator bar and apply compression. Additional external fixation pins can be placed in the tibia and talus. n  Alternatively, if the soft-tissue coverage is adequate, stabilize the osteotomy with a 3.5-mm dynamic compression plate and remove the two external fixation pins. The fibula also can be stabilized with a one third tubular plate if desired. Bone grafting is left to the surgeon’s discretion. n  An opening or closing wedge osteotomy can be made in the following manner. Through a lateral longitudinal incision, expose and osteotomize the fibula as previously described to correct either varus or valgus deformity. n  Through the same incision, expose the lateral surface of the tibia 1.3 cm proximal to the joint line and drive a wide osteotome transversely almost through the bone; carry out a manual osteoclasis. Insert cancellous iliac bone, or use a wedge-shaped graft taken from the shaft of the tibia into the lateral side of the osteotomy to pack it open. n  Stabilize the osteotomy with an external fixator applied in the standard fashion with pins through the tibia and talus.

Arthrodesis is indicated as a primary procedure in the following types of malunited fractures of the ankle:   1. Malunited bimalleolar fractures, with or without significant deformity, in which radiographs show definite traumatic arthritic changes to be the cause of persistent pain and disability (Fig. 58.12)   2. Malunited trimalleolar fractures of long duration with posterior and proximal dislocation of the talus   3. Malunited fractures in which the deformity cannot be completely corrected by conservative reconstruction or in which such extensive surgery is required for correction that arthritic changes in the ankle are inevitable When malalignment is marked, it should always be corrected by osteotomy at the time of arthrodesis; otherwise, a foot strain can be severely disabling later. This additional procedure does not materially complicate the operation or delay recovery. See Chapter 11 for techniques of arthrodesis of the ankle. 

TIBIA SHAFTS OF THE TIBIA AND FIBULA

In malunions of the shafts of the tibia and fibula, the degree of deformity that requires surgery is not clearly defined. It is widely believed that angular deformities of the tibial shaft cause alterations in the contact pressures of the knee and ankle joints and predispose them to the development of osteoarthritis. Clinical series with long-term follow-up have not always supported this hypothesis, however. One study found that the ankle joint is more affected than the knee and that the location of the fracture is significant. Poorer functional ankle scores were correlated with the degree of malalignment and the proximity of the deformity to the ankle joint. Varus deformities were more poorly tolerated than were valgus deformities. A later study found just the opposite, that symptoms at the knee were correlated with arthritic changes, whereas symptoms at the ankle were not. In addition, no relationship was shown between the location of the fracture and development of osteoarthritis of the knee or ankle. Rotational deformity also was not associated with arthritic changes.

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FIGURE 58.12 A, Malunion of bimalleolar ankle fracture with preexisting malunion of distal tibia. B, Correction of malunion was achieved; however, arthritis developed, causing pain and disability. C and D, Tibiotalar arthrodesis was performed using compression clamps. Ankle is now painless and stable.

Milner et al. determined that fracture malunion did not cause a higher incidence of ankle and subtalar arthritis ipsilateral to the fracture. There was a trend toward a higher prevalence of medial compartment osteoarthritis of the knee in patients with varus malalignment of the limb, and shortening of 10 mm or more correlated with subjective complaints of knee pain. Although osteoarthritis occurred more frequently on the side of the fracture, factors other than malalignment were believed to contribute more to the development of osteoarthritis. The degree of acceptable deformity noted by various authors is extremely variable. Surgery has been recommended for valgus deformity of more than 12 degrees, varus deformity of more than 6 degrees, external rotation deformity of more than 15 degrees, or internal rotation deformity of more than 10 degrees. Shortening of 2 cm or less usually is well tolerated with shoe modifications, but more than 2.5 cm of shortening can cause significant disability.

When surgery is considered for correction of a tibial malunion, the degree of the deformity, the patient’s symptoms, the condition of the injured extremity, and the functional demands of the patient all must be taken into account. Disability from malunion of the tibial shaft is produced mainly by rotational deformity, lateral and posterior bowing, and usually some degree of shortening. Often a resulting contracture of the Achilles tendon causes an equinus deformity of the foot. Symptoms may include ankle, knee, or back pain; gait disturbances; and a cosmetically unacceptable deformity. The limb must be evaluated for a history of neurologic or vascular injury, adequacy of soft-tissue coverage, and presence of infection. With a history of vascular injury, preoperative arteriograms can be helpful in determining the operative approach. If soft tissues in the area of the planned operative site are poor, a simultaneous rotation or vascularized free tissue transfer flap may be necessary to promote bone healing and prevent wound complications. In a patient with a previous infection, preoperative indium-labeled white blood cell scans, gallium scans, or technetium scans can help to determine the activity of the infection. It is generally desirable to treat the infection before osteotomy for malunion. Equinus contractures should be corrected by lengthening the Achilles tendon. When planning an osteotomy, the amount of angular and rotational deformity, leg-length discrepancy, and translation must be determined. Simple opening wedge, closing wedge, or dome-shaped osteotomies can be used to correct relatively small degrees of malunion; however, closing wedge osteotomies can create additional shortening and opening wedge osteotomies often require bone grafting. Oblique osteotomies can be used to correct multiplanar deformities. These osteotomies provide broad surface areas for healing, and lengthening can be obtained by sliding the osteotomy distally. Angular deformities in the frontal (varus-valgus) and sagittal (flexion-extension) planes can be resolved into a uniplanar deformity in an oblique plane (Fig. 58.13). The degree of maximal deformity is greater than the angular measurements on either anteroposterior or lateral radiographs. The plane of maximal deformity can be found by rotating the leg under fluoroscopy until the maximal degree of deformity is seen. A radiograph taken at 90 degrees to this plane should show no deformity. The oblique osteotomy should be made perpendicular to the plane of maximal deformity. Rotational deformity can be evaluated with CT or clinically by measuring the intermalleolar angle. Preoperative planning should include drawings of the injured and uninjured extremities, the site and configuration of the planned osteotomy, and the type of internal fixation device to be used. To prevent neurologic complications, somatosensory evoked potentials should be used during correction of a severe deformity, especially if lengthening is involved. Although the osteotomy usually is performed at the site of the old fracture, a supramalleolar osteotomy (see Technique 58.10) may be preferable if the previous fracture has been slow to heal, is covered with poor soft tissue, or contains extremely dense sclerotic bone. Russell et al. described a clamshell osteotomy for treatment of complex nonunions of the tibial or femoral diaphysis and noted that it is especially helpful in malunions that have a long malaligned segment. Satisfactory alignment after osteotomy is difficult to maintain without some type of internal fixation, such as a compression plate or intramedullary nail or external

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A

especially if associated with pin track infection, also is a relative contraindication to intramedullary nailing because of an increased risk of infection. Oblique tibial osteotomies stabilized with dynamic compression plates and lag screws have been advocated for the treatment of multiplanar tibial deformities with good results (Fig. 58.14). Sanders et al. recommended this technique for tibial shaft deformities that require less than 2.5 cm of lengthening. Contraindications to this procedure include inadequate soft-tissue coverage and active infection. The inability to restore full length, delayed union, plate failure, infection, vascular injury, and wound dehiscence are possible complications. Osteotomies for infected tibial malunions and malunions associated with a poor soft-tissue envelope may be best treated by the Ilizarov technique of corticotomy and gradual correction of deformity with a ring and wire fixator to correct tibial malunions. This technique is described in Chapter 54. 

B

 

OBLIQUE TIBIAL OSTEOTOMY TECHNIQUE 58.11 (SANDERS ET AL.) Place a tourniquet on the proximal part of the thigh. Prepare and drape both legs so that they can be compared after correction. n  If axial lengthening is planned, place electrodes for measurement of somatosensory evoked potentials. n  Under fluoroscopic control, insert a 6-mm Schanz pin in the proximal tibial metaphysis absolutely parallel to the proximal tibial articular surface (Fig. 58.15A). Similarly, place a 6-mm Schanz pin in the distal tibial metaphysis absolutely parallel to the tibial plafond. n  If lengthening is planned, or if the fibula interferes with correction of the tibia, make an oblique fibular osteotomy, ideally at the level of the proposed site of the tibial osteotomy. n  Exsanguinate the leg with a pressure bandage, inflate the tourniquet to 300 mm Hg (39.99 kPa), and remove the pressure bandage. n  Make a standard anterior extensile incision to expose the tibia. n  Identify the area of malunion and subperiosteally dissect all soft tissue from the area. Place Hohmann retractors to protect the neurovascular structures. n  Sculpt the bone to remove excess callus while the tibia is still intact; save the bone that is removed to be used later as a local graft. n  Place a femoral distractor (Synthes USA, Paoli, PA) on the Schanz pins, with the universal joint locked, leaving the rotational joint open (Fig. 58.15B). Make the tibial osteotomy with a single cut perpendicular to the plane of maximal deformity (see Fig. 58.15B). If lengthening is not needed, hold the saw at an angle of 30 to 45 degrees in the coronal plane to allow enough bone on either side of the cut to overlap and be lagged together. n 

C

D

E

FIGURE 58.13 A and B, Varus malunion of distal tibia. C, Osteotomy of tibia and fibula with reduction maintained by external fixator. D and E, Tibial union obtained with normal alignment; asymptomatic nonunion of fibular osteotomy persists.

fixation. If an intramedullary nail is used, the medullary canal must be opened at both ends of the old fracture, and any gaps created by the osteotomy should be filled with cancellous bone. Reamed, locked intramedullary nailing has been recommended for stabilization of osteotomies made to correct tibial malunions. We prefer to use statically locked nails to increase the stability of the osteotomy. The limited incisions used for the osteotomy are closed after opening of the medullary canals in both fragments and passing of the reaming guidewire but before reaming and nail insertion. Static locking can be converted to dynamic locking in several weeks if needed to promote healing. If a large amount of soft-tissue stripping is necessary to correct the deformity, fixation methods other than intramedullary nailing are preferable because intramedullary reaming often devascularizes the exposed bone segment further. A history of previous external fixation,

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FIGURE 58.14 A, Multiplane osteotomy of tibia for diaphyseal malunion. B, Severe deformity: 45 degrees of varus, 50 degrees of anterior bowing, 15 degrees of internal rotation, 1.4 cm of shortening, and distal tibiofibular synostosis. C–E, After osteotomy, correction of deformity. Lateral view shows minimal overcorrection in sagittal plane. (From Johnson EE: Multiplane correctional osteotomy of the tibia for diaphyseal malunion, Clin Orthop Relat Res 215:223, 1987.)

If more lengthening is needed, the exact amount, in millimeters, to be obtained from axial lengthening already has been determined by preoperative planning. Obtain this length by decreasing the angle between the osteotomy and the axis of the tibia in the coronal plane so that the bones can slide apart lengthwise at the cut while remaining in contact. The angle of the cut in the coronal

n 

plane is determined preoperatively and is marked on the bone with a marking pen and angle templates from the angled blade plate instrument set (Synthes USA, Paoli, PA). Rotate the saw to this angle in the coronal plane and make the tibial cut accordingly. Cuts made at angles of less than 20 degrees to the coronal axis are impossible to perform.

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Schanz pin parallel to joint

Locked

c Angular correction

Proposed osteotomy

Area of proposed osteotomy Fibular osteotomy

b Osteotomy

Schanz pin parallel to joint

A

B

b Leglengthening

C

a Rotational nut open

a Angular correction achieved: tighten nut

Lengthened 1.3 cm

Shaft screw as lag

D

FIGURE 58.15 Oblique osteotomy for tibial malunion (see text). A, Anterior and lateral views showing placement of Schanz pins parallel to planes of proximal and distal joints and to site of proposed osteotomy. B, Anterior view (left) after femoral distractor has been applied; rotational joint (a) is left open to allow lateral angular correction. Oblique osteotomy (b) is made to correct varus angulation and procurvatum; axial correction occurs as nut (c) is turned to lengthen distractor. Lateral view (right). Markings on distractor indicate angular correction has not been obtained. C, After angular correction is obtained, rotational joint is locked and further lengthening of distractor results in pure axial lengthening. Markings (right) now indicate that angular correction has been obtained. D, Anterior and lateral views after correction; lag screw has been inserted perpendicular to osteotomy.

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CHAPTER 58  MALUNITED FRACTURES Contour a narrow 4.5-mm dynamic compression plate and place it as a neutralization plate (Fig. 58.15E). n  Shave the bone and place the bone shavings as grafts around the osteotomy as needed. n  If an equinus contracture developed as the bone was lengthened, perform a Z-lengthening of the Achilles tendon. n  Remove the distractor, close the wound over a drain, and apply a bulky dressing and a below-knee posterior splint. n 

Exostosis removed

POSTOPERATIVE CARE  Range of motion of 0 to 90 degrees is begun immediately after surgery in a continuous passive motion machine. The patient is allowed out of bed on the first postoperative day. The drain is removed when less than 10 mL of drainage occurs in an 8-hour period, usually by the second day after surgery. The dressing is removed at 3 days, and if the wound appears satisfactory, a below-knee non–weight-bearing fiberglass cast is applied and touch-down weight bearing is allowed. The sutures are removed at 10 to 14 days, and the cast is changed. At 10 to 12 weeks, the cast is removed and a removable tibial brace is fitted. If bridging trabeculae across the osteotomy are visible on anteroposterior and lateral radiographs, partial weight bearing is allowed and is progressed as tolerated. Gait-training, range-of-motion, and strengthening exercises are begun. At the end of 16 weeks, if the tibial osteotomy seems to be healed clinically and radiographically, the brace is discontinued and activities of daily living and full weight bearing are encouraged. The patient is examined every 6 months for 2 years. The plate is removed if requested by the patient because of pain but not before 12 months after surgery.    

9–hole LC/DCP placed in neutral

E FIGURE 58.15, cont’d E, Final result with neutralization plate in place. (From Sanders R, Anglen JO, Mark JB: Oblique osteotomy for the correction of tibial malunion, J Bone Joint Surg 77A:240, 1995.) SEE TECHNIQUE 58.11.

As the femoral distractor is lengthened, the lengthening translates into angular correction. Leaving the rotational joint open (see Fig. 58.15B) allows simultaneous correction of the multiplanar deformity by rotating the two tibial segments around an axis perpendicular to the cut surface. Continue this correction until the two Schanz pins are parallel (Fig. 58.15C). n  If the cut is not perfect, additional bone can be shaved from the cut surfaces to correct alignment. n  If axial lengthening is not required, place a lag screw perpendicular to the cut surface and tighten it. If axial lengthening is required, use a clamp (bone reduction forceps with pointed tips) to hold the two cut surfaces together until the angular correction has been obtained and then lock the rotational joint of the distractor. Additional lengthening of the distractor now lengthens the tibia axially. Gently loosen the bone clamp, but hold it in place to allow sliding in the axial plane while preventing translation and loss of angular correction. If somatosensory evoked potentials change before axial lengthening is completed, stop the lengthening and reverse it until the potentials return to baseline. n  When lengthening is completed, tighten the clamp, lock the distractor joints, and obtain anteroposterior and lateral radiographs. Superimpose these radiographs on the preoperative drawings and on the radiograph of the normal leg and make modifications as needed. n  When the alignment and length are satisfactory, place a lag screw perpendicularly across the osteotomy (Fig. 58.15D). n 

 

CLAMSHELL OSTEOTOMY Russell et al. described a clamshell osteotomy in 10 patients for treatment of complex femoral and tibial diaphyseal malunions, in which the malunited segment is transected perpendicular to the normal diaphysis proximally and distally and the transected segment is wedged open by osteotomy much like opening a clamshell. An intramedullary rod is used to anatomically align the proximal and distal segments of the diaphysis. Pires et al. expanded the use of the clamshell osteotomy to facilitate intramedullary nailing in acute fractures of long bones with preexisting deformity. Contraindications for this technique include an unsuitable soft-tissue sleeve for open exposure, a metaphyseal malunion, intramedullary osteomyelitis, absent medullary canal, morbid obesity, open physes, and lengthening of the tibia by more than 3 cm. We have not used this technique.

TECHNIQUE 58.12 (RUSSELL ET AL.) Position the patient supine with both lower extremities included in the operative field. A tourniquet is not used.

n 

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A

B FIGURE 58.16 Clamshell osteotomy as described by Russell et al. A, Kirschner wire placed proximal to malunion. B, Plane of longitudinal portion of the clamshell osteotomy for tibia. Plane is approximately parallel to medial face of tibia. SEE TECHNIQUE 58.12.

Make a lateral incision along the fibular shaft at the planned level of the proximal transverse component of the tibial osteotomy. Perform a fibular oblique osteotomy to obtain complete freedom in repositioning the tibia after the osteotomy. n  Use a transpatellar or medial parapatellar tendon entrance to the previously defined safe zone for the tibial rod starting point. Take care to ensure an appropriate entrance angle into the proximal tibial segment. Open the proximal tibial segment with a threaded wire over which an opening reamer is passed. No attempt is made to ream the proximal tibia at this time. n  To expose the osteotomy site, make a longitudinal incision over the anterior compartment one fingerbreadth lateral to the tibial crest along the proposed longitudinal osteotomy site. n  Translate the anterior compartment musculature posteriorly to allow for an extraperiosteal exposure of the lateral aspect of the malunited segment. Only the anterolateral portion of the tibia is exposed. n  With radiographic guidance, localize the positions of the proximal and distal transverse osteotomies and place a Kirschner wire perpendicular to the anatomic axis to guide the osteotomies (Fig. 58.16A). n  Create the clamshell component of the osteotomy parallel to the medial tibial face, beginning just posterior to the anterolateral subcutaneous prominence of the tibia and aiming in a posteromedial direction (Fig. 58.16B). n 

Use a 3.5-mm drill bit to create the path for the longitudinal osteotomy with the goal of creating a bicortical uniform plane of stress risers (Fig. 58.17). Only osteotomy of the near cortex is accomplished with an osteotome using the drill holes as a guide. Use a sagittal saw to create the transverse proximal and distal osteotomies. n  Split the far cortex of the osteotomized segment parallel to the medial face with the use of an osteotome and laminar spreader. Separate the longitudinal osteotomy of the intercalary segment with a laminar spreader; the posterior cortex is hinged on the periosteal sleeve. If the posteromedial cortex does not open easily, then use an osteotome to cut the posteromedial cortex and then the laminar spreader to open the osteotomy. n  Place the limb over a radiolucent triangle and pass the guidewire from the proximal tibial segment through the osteotomized segment into the distal segment with the aid of fluoroscopic guidance. Measure the length of the guidewire. Make sure the entrance angle and the ending point in the distal segment are in the center of the tibia on both the anteroposterior and lateral fluoroscopic images. n  Before reaming, the anterior muscular compartment is allowed to drape over the cortex to preserve the bone fragments produced by subsequent reaming at the osteotomy sites. Ream the proximal and distal segments until cortical n 

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C

A

B

D

E FIGURE 58.17 Clamshell osteotomy as described by Russell et al. A, Anteroposterior standing radiograph of lower extremity, showing shortened tibia with medially translated distal tibial segment and varus malunion at inferior end of intercalary segment. B, Lateral radiograph demonstrating marked deformity of tibia highlighted by marked posterior translation and apex posterior angulation at superior end of intercalary segment. C, Tibial clamshell osteotomy with soft tissues included. Anterolateral muscular sleeve is being retracted posteriorly, exposing lateral aspect of tibia. Osteotomy is initiated 3 to 5 cm posterior to anterolateral tibial prominence and angled posteromedially and parallel to subcutaneous surface of tibia. D, Surgical exposure for tibial osteotomy. Anterolateral muscular envelope retracted posteriorly. Transverse osteotomies are denoted by blue lines, and circles represent drill holes. E, Lateral view showing osteotomy parallel to anteromedial surface of tibia. (A to D from Russell GV, Graves ML, Archdeacon MT, et al: The clamshell osteotomy: a new technique to correct complex diaphyseal malunions: surgical technique, J Bone Joint Surg Am 92A[Suppl 1 pt 2]:158, 2010; E redrawn from Pires RE, Gausden EB, Sanchez GT, et al: Clamshell osteotomy for acute fractures in the malunion setting: a technical note, J Orthop Trauma 32(10):e415, 2018.) SEE TECHNIQUE 58.12.

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B FIGURE 58.18 A, Deformity correction in coronal plane. B, Sagittal plane. (Redrawn from Russell GV, Graves ML, Archdeacon MT, et al: The clamshell osteotomy: a new technique to correct complex diaphyseal malunions: surgical technique, J Bone Joint Surg 92A[Suppl 1 pt 2]:158, 2010.) SEE TECHNIQUE 58.12.

chatter is noted. The reaming should result in a deposit of bone fragments at the osteotomy gap sites. n  Push the reamer through the clamshell segment to protect the neurovascular structures and to avoid binding against the osteotomized fragments. Continue reaming in 0.5-mm increments until cortical chatter is obtained. A tibial rod measuring 1 mm less in diameter than the final reamer is selected. n  Pass the rod and accomplish proximal interlocking. Remove the jig from the proximal aspect of the tibial nail and remove the limb from the triangle and place it flat on the operating table. n  The sagittal and coronal plane corrections have been accomplished at this point and only length and rotation need to be corrected (Fig. 58.18). Have an assistant apply manual traction or use a femoral distractor or an external fixator to correct length and rotation. Place the distal interlocking bolts with the use of fluoroscopic guidance. n  Retract the anterior compartment posteriorly from the lateral part of the tibia to inspect the osteotomy site. Fill the gaps with the bone fragments left from reaming. For gaps of more than 1 cm, demineralized bone matrix or autogenous bone graft can be used. Make sure that there is no space left between the osteotomy fragments and the intact proximal or distal parts of the tibia. n  Loosely approximate the fascia over the anterior compartment. However, if there is concern that excessive swelling may cause a compartment syndrome, do not close the anterior compartment. n  Close the extensile approach with the use of the Allgöwer modification of the Donati technique with careful softtissue handling.

POSTOPERATIVE CARE Monitor the patient for signs of compartment syndrome. Intravenous cephazolin is ad-

ministered for 24 hours postoperatively. The patient may begin touch-toe weight bearing on the first postoperative day using crutches. Russell et al. recommended prophylactic heparin until the patient is discharged from the hospital. Weight bearing is advanced as the osteotomy healing progresses with full weight bearing allowed by 12 weeks (Fig. 58.19).   

CONDYLES OF THE TIBIA

If a fracture of a tibial condyle heals with moderate-to-severe displacement, the change in position of its weight-bearing surface produces an increase in the joint space, a relaxation of some of the knee ligaments, a valgus or varus weight-bearing alignment, and frequently some rotational deformity. Any such displacement must be corrected if a severe disability from traumatic arthritis is to be avoided. The procedure of choice for this type of malunion varies with the kind of fracture and the exact source of the disability. Before surgery, the lateral instability might seem to indicate that a ligament should be repaired; yet after correction of the bony deformity, the joint usually is stable. If the disability is caused mainly by axial malalignment after depression of a condyle, the weight-bearing surfaces of the tibia usually do not need to be disturbed. Rather, a transverse subcondylar osteotomy combined with the insertion of a graft and internal fixation is indicated; this procedure is especially appropriate when the patient is of middle age, the malunion is of long duration, and the lateral displacement is not severe. In other instances, an oblique osteotomy through the old fracture is possible; the depressed condyle is elevated and fixed with a buttress plate and screws, and the defect is filled with bone grafts. This procedure is applicable to young patients after a fairly recent fracture. Sometimes the

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CHAPTER 58  MALUNITED FRACTURES Fill the wedge-shaped or cuneiform space created by the osteotomy with bone grafts. Make an anterior incision 7.5 cm long and 5 cm distal to the first incision and expose the shaft of the tibia; remove a free cortical graft to serve as a wedge (usually 1.9 cm wide and about 3.8 cm long). Set the graft on edge and, using an inlay, drive it tightly into the space beneath the lateral condyle. Insert around this graft cancellous bone from the opening in the tibia and a few shavings from the surface of the bone. No undue lateral motion should be possible after the procedure. A fullthickness iliac graft provides more stability, but removal of such a graft increases the complexity of the operation. n  Stabilize the osteotomy as for a fresh fracture with a Tplate as a buttress. n  Confirm the reduction with intraoperative radiographs. n  A similar procedure can be used for malunited fractures of the medial condyle. n  If the weight-bearing surface was comminuted at the time of fracture, elevation of only the depressed fragments produces a refracture through its articular surface and the fragments can be difficult to hold in position; even attempts to pry them into position usually lead only to crushing rather than to correction of the deformity. n 

A

POSTOPERATIVE CARE The knee is held in extension

B

and immobilized in a cast from the toes to the groin. At 2 weeks, the cast is removed and radiographs are obtained. If satisfactory stability of the osteotomy is obtained by internal fixation, range-of-motion exercises are begun. A cast brace can be worn if further protection is needed until the osteotomy has united. Union may be solid at 8 weeks, but direct weight bearing should not yet be allowed, lest the depression recur. Walking is permitted with crutches, and weight bearing is increased as tolerated, but the crutches must not be discarded for 1 month. Weight bearing and undue strain must be prevented until union of the grafted area is absolutely solid.    

FIGURE 58.19 Anteroposterior (A) and lateral (B) radiographs 1 year after surgery, demonstrating healed osteotomy with restoration of tibial length and alignment. (From Russell GV, Graves ML, Archdeacon MT, et al: The clamshell osteotomy: a new technique to correct complex diaphyseal malunions: surgical technique, J Bone Joint Surg 92A[Suppl 1 pt 2]:158, 2010.) SEE TECHNIQUE 58.12.

deformity of the condyle and the degeneration of the articular cartilage are so severe that reconstruction is impractical; an arthrodesis or arthroplasty is then usually indicated.   

SUBCONDYLAR OSTEOTOMY AND WEDGE GRAFT FOR MALUNION OF LATERAL CONDYLE

 

OSTEOTOMY AND INTERNAL FIXATION OF THE LATERAL CONDYLE

TECHNIQUE 58.13

TECHNIQUE 58.14

Begin an incision over the anterolateral aspect of the knee 2.5 cm proximal to the joint and extend it distally parallel with the shaft of the tibia for 7.5 cm. n  Make an inverted-L–shaped incision across the lateral condyle and down the crest of the tibia; detach the origin of the extensor muscles and dissect the muscles subperiosteally from the bone. n  Completely divide the bone by a transverse osteotomy at a point immediately distal to the tibial tuberosity. n  Using a broad osteotome as a lever, tilt the upper fragment proximally and angulate the distal shaft medially; the normal transverse plane of the tibial condyles and the normal alignment of the extremity are largely restored.

n 

n 

Expose the operative field as just described except that the incision must extend proximally far enough to expose the knee joint. n  Examine the lateral meniscus, and if it is torn, treat it as described in Chapter 45. n  Dissect all scar tissue from between the tibia and the condylar fragment and denude their surfaces as far distally as possible. n  Refracture the fragment at its base by inserting an osteotome in a proximal and medial direction. n  Sever the soft-tissue attachments only at the line of fracture or as necessary to mobilize the fragment. n  Drill a Knowles pin or Schanz screw into the fragment to use first as a lever to aid in reduction.

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POSTOPERATIVE CARE  With the knee extended, a plaster cast is applied from the toes to the groin. If satisfactory stability has been achieved at 2 weeks, the cast is removed and a cast brace is substituted to begin controlled range-of-motion exercises. Walking also is permitted with crutches and a cast brace. If consolidation of bone is sufficient 12 weeks after surgery, the crutches and cast brace can be discarded.   

INVERTED-Y FRACTURES OF THE TIBIAL CONDYLES

Malunited Y-shaped fractures or malunited fractures of both condyles are approached from both sides and are corrected by the method of osteotomy and internal fixation for malunion of a single condyle described previously. The operation is extensive and usually should be chosen only as a preliminary procedure to restore the contour of the condyles for a future arthroplasty. Practical function rarely can be expected, unless the deformity is corrected within a few months after injury; even then, osteoporosis may make replacement of the fragments difficult. 

FRACTURE OF THE INTERCONDYLAR EMINENCE OF THE TIBIA

Malunion of displaced fractures of the intercondylar eminence of the tibia can severely restrict knee extension because of impingement of the malunited fragment on the femoral intercondylar notch. Arthroscopic or open removal of the fragment, debridement, and open anatomic reduction and fixation have been recommended for treatment of this malunion. In patients with functionally stable anterior cruciate ligaments, arthroscopic notchplasty, in which the femoral notch is enlarged with a power burr until it can accommodate the prominent intercondylar eminence and allow full knee extension, can be performed. Panni et al. recommended as sparing a notchplasty as possible to achieve full extension. Arthroscopic notchplasty is described in Chapter 51. 

PATELLA The symptoms of a malunited fracture of the patella are similar to those of advanced chondromalacia. Disability is proportionate to the amount of irregularity of the articular surface of the patella and of the roughening of the contiguous surface of the femur. For even a relatively recent malunion, patellectomy usually is the procedure of choice (see Chapter 54). 

FEMUR AND HIP CONDYLES OF THE FEMUR

Malunion of one or both femoral condyles, as of the tibial condyles, distorts the articular surface of the knee; frequently, however, it produces a much more severe disability than does

one of a tibial condyle. Malunion of the lateral femoral condyle can produce external rotation, flexion, and valgus deformities of the knee; malunion of the medial condyle produces internal rotation, flexion, and varus deformities.

LATERAL FEMORAL CONDYLE   

OPEN REDUCTION AND INTERNAL FIXATION TECHNIQUE 58.15 Approach the joint through a lateral incision beginning 10 cm proximal to the knee and extending distally to 2.5 cm distal and slightly anterior to the head of the fibula. n  Incise the iliotibial band, but avoid the peroneal nerve that passes over the head of the fibula. n  Incise the vastus lateralis muscle and retract it anteriorly to expose the old fracture. n  Open the capsule and synovial membrane so that the interior of the joint can be seen during reduction of the fracture. n  Divide the bone as near the plane of the old fracture as possible, but protect the peroneal nerve. n  Grasp the condyle with bone-holding forceps and place it in its normal position; drill two Kirschner wires through the fragment into the medial condyle, the wires crossing each other at an angle of 30 degrees. The wires should protrude through the opposite cortex. n  Make two-plane radiographs to verify the position of the wires and of the fragment, then fix the fragment with AO cancellous screws. n  To expose a malunited fracture of the posterior part of the lateral condyle, use the same lateral incision but carry the dissection posteriorly. n  Expose the biceps tendon and peroneal nerve and retract them laterally and posteriorly. n  Incise the posterolateral part of the capsule and expose the malunited fragment. The fragment always is displaced proximally and usually can be refractured from above downward. n  After the fragment is freed, place it in position with a towel clip and fix it securely with two AO cancellous screws. If fixation is not sufficiently rigid, a buttress plate can be added. n  Close the incision in routine fashion and apply a plaster cast from the toes to the groin with the knee in extension. n 

POSTOPERATIVE CARE At 2 weeks, the cast is removed, a cast brace is applied, and active and passive exercises and physical therapy are begun; if fixation is firm, exercises can be done with overhead pulleys. An elevated shoe is fitted on the opposite side, and walking with crutches is permitted; however, weight bearing is not allowed until union is complete, usually at 8 weeks or more after surgery. Free motion of the knee in the brace is allowed at 10 to 12 weeks. The reduction can be partially lost unless every precaution is taken to preserve it.   

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MEDIAL FEMORAL CONDYLE

Malunion of fractures of the medial femoral condyle can be corrected by the same procedure described for malunion of the lateral condyle. The exposure is as described previously. When the distal femoral physis is involved in a child, growth of the distal femur can be disturbed. Sasidharan et al. described an osteotomy to treat a malunited medial Hoffa fracture (coronal intraarticular fracture of the posterior femoral condyle). In their technique, the fracture was approached through a medial parapatellar arthrotomy, with the leg in a lazy figure-of-four position. A Hohmann retractor was placed adjacent to the posterior aspect of the medial femoral condyle at the junction to the femoral shaft. The authors emphasized meticulous dissection on the posterior surface of the medial femoral condyle to avoid injury to the superior medial genicular artery, which is its primary blood supply, as this can lead to osteonecrosis of the medial femoral condyle. They also stressed preserving the femoral attachment of the medial collateral ligament and posterior oblique ligament when making the intraarticular osteotomy, as well as maintaining an awareness of the origin of the posterior cruciate ligament. The authors noted that posterior capsular contracture increases the difficulty of the procedure. In their patient, two Steinmann pins were placed on the medial aspect of the medial femoral condyle and used as joysticks to aid in reduction. The reduced condyle was stabilized with two partially threaded 4.0-mm screws placed in an anterior to posterior direction, with countersinking of the screw heads (headless screws of a similar size is another option). The authors advised immobilization in a cylinder cast for 2 weeks postoperatively followed by motion. The patient was kept non–weight bearing for 2 months. At 3-month followup, the patient was full weight bearing with a congruous articular surface on CT scan. Knee range of motion had improved from 20 to 80 degrees preoperatively to 5 to 110 degrees postoperatively. At latest follow-up, he had pain at the extreme of flexion. 

BOTH FEMORAL CONDYLES

Malunion of fractures of both condyles with marked displacement rarely should be corrected by open reduction of each condyle as just described, unless it is of short duration and is in a young patient. When there is a varus or valgus deformity, the extremity should be realigned by an osteotomy through the metaphysis. When the contour of the joint is irregular enough to impair function and cause pain (Figs. 58.20 and 58.21), arthroplasty or arthrodesis may be indicated (see Chapters 7 and 8, respectively). 

SUPRACONDYLAR FEMUR

Supracondylar femoral malunions are infrequently reported. If a malunion is associated with an angular deformity of the medial condyle and shortening, treatment may become challenging. Wu described a one-stage surgery using antegrade intramedullary nailing in 19 patients with supracondylar femoral fracture malunion associated with varus deformity and shortening of the medial condyle. Sixteen fractures healed without additional surgery at a median period of 4.5 months. Complications included nonunion in one patient and deep infection in one patient. No malunions or neurovascular injuries occurred, and the amount of lengthening obtained was 2.0 to 3.5 cm. 

FIGURE 58.20 Malunited comminuted fracture of both condyles of femur 1 year after injury. Knee motion was markedly limited and painful.

FEMORAL SHAFT

Malunions of femoral shaft fractures are much less common with the increased popularity of interlocking intramedullary nailing procedures. Malunions after closed treatment are the rule, but become significant only if they result in shortening of more than 2.5 cm, are angulated more than 10 degrees, or are internally or externally rotated to the point that the knee cannot be aligned with forward motion during gait. Although many authors define rotational malunion as 10 degrees or more of axial malalignment, many of these do not produce symptoms (0% in < 10 degrees; 12% in 10 to 15 degrees; and up to 38% in >15 degrees). Malunions of the femur can cause disturbances in gait and posture, which can cause abnormal stresses on the knee and spine. Whether femoral shaft fracture malunion leads to the development of knee osteoarthritis has not been well established. Phillips et al., in a study of 62 patients with femoral shaft fractures, found no significant association between malunion, the WOMAC scores, and the presence of clinical or radiographic osteoarthritis at 22 years’ follow-up. When corrective surgery is planned, the patient’s overall medical condition, functional demands, and severity of symptoms should be considered. The extent of angular deformity and shortening, degree of bony consolidation, and condition of the neurovascular structures and soft tissues also must be determined. Preoperative evaluation should include long, weight-bearing radiographs of the involved and uninvolved extremities for comparison. Femoral osteotomies in adults, especially osteotomies that involve acute lengthening, are associated with numerous complications, including infection, nerve palsies, hardware failure, and nonunion. Detailed preoperative planning is essential to select the optimal operative procedure and to avoid complications. Cancellous bone grafting usually is necessary to improve healing. Malunions of the femoral shaft from the lesser trochanter to within 5 cm of the intercondylar notch of the femur at the knee can be treated by several methods. In adults with aseptic malunions and good soft tissues, osteotomy, fixation with an interlocking intramedullary nail, and autogenous iliac bone grafting result in a high percentage of unions and offer the advantage of early mobilization with weight bearing

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FIGURE 58.21 Same patient as in Fig. 58.20, 3.5 months after compression arthrodesis. Knee is painless.

without the need for external immobilization (Fig. 58.22). This approach requires sophisticated instrumentation, image intensification equipment, an appropriate fracture table, and skill in the use of interlocking intramedullary nails. In children, for whom nonoperative treatment of femoral fractures is the standard of care, osteotomy combined with traction and casting can yield satisfactory results. The femur can be divided through the plane of the malunion with a reciprocating or oscillating saw, or the plane of malunion can be outlined with holes drilled close together and division of the bone completed with a small chisel. For patients who do not fulfill the aforementioned criteria, the options are open reduction and internal fixation with broad dynamic compression plates and screws with autogenous iliac bone grafting or external fixation with the Ilizarov technique. Malunions of the femoral shaft with angulation and rotation but with end-to-end apposition of the fragments often are the result of bearing weight before union has become completely solid (Fig. 58.23). If the malunion is of short duration and has occurred after nonoperative treatment, it can be broken up manually, and the overlapping and angulation can be corrected by skeletal traction or graduated distraction with an external fixation assembly; in these instances, care must be taken not to produce paralysis of the sciatic nerve or one of its branches with the traction. Most malunions of the femoral shaft that require surgery should be fixed internally at the time of such surgery and should be grafted when securing apposition has required extensive periosteal stripping. For malunion of the proximal third of the femoral shaft, especially of the subtrochanteric region, a cephalomedullary interlocking nail (reconstruction nail), a conventional interlocking nail, or compression hip screws suitable for fixing a subtrochanteric fracture can be used (Fig. 58.24). Distal femoral malunions also can be stabilized with a conventional interlocking intramedullary nail, a dynamic condylar compression plate, or a blade plate. Various osteotomies can be used depending on the deformity. Opening or closing wedge osteotomies can be used for axial corrections and transverse osteotomy to correct rotational deformity. A one-stage femoral lengthening using a Z-step osteotomy stabilized with an intramedullary nail has been reported (Fig. 58.25) with good results in selected patients. The defects

were filled with corticocancellous bone. Reported complications have included femoral nerve palsies, infection, nonunion, and loss of length. Extensive scarring and a history of infection, nerve injury, or previous bone graft are considered contraindications to this procedure. The successful use of oblique osteotomy with intramedullary nailing and autogenous bone grafting also has been reported as has oblique osteotomy using plate osteosynthesis and autogenous bone grafting. Complications with the use of plates included infection; persistent deformity; plate avulsion, loosening, or fracture; and nonunion. Chiodo et al. used an oblique osteotomy combined with closing wedges to correct coronal, transverse, and sagittal plane deformities in six femoral malunions. All six femurs had varus (average 22 degrees) and antecurvatum (average 23 degrees) deformities, and two had internal rotation deformities (10 degrees and 15 degrees). All that had at least 10 degrees of varus had medial knee pain. Limb-length discrepancy averaged 1.8 cm. Fixation was performed with 4.5-mm lag screws and 4.5-mm plates in five malunions and a 95-degree blade plate in one. All patients improved clinically, and all osteotomies healed. Average postoperative limb-length discrepancy was within 0.5 cm, and axial limb alignment was within 10 degrees of the contralateral side. The authors stated that plate fixation of femoral osteotomies for malunion may be preferred in cases in which the femoral canal is distorted or the fracture is in the distal part of the femur. Any operation for a malunited femoral fracture in an adult is easier with the patient on a fracture table. The affected extremity should be draped into the sterile field, and the footpiece should be covered with sterile drapes. Although the old fracture can be seen clearly in the radiographs, the ends of the fragments may be covered with so much callus that even after extensive stripping of soft tissues the exact plane of fracture can be difficult to recognize at surgery. To aid in identifying the fracture and in placing the osteotomy properly, a Kirschner wire or small pin can be drilled through the bone in what appears to be the plane of fracture, and the relative positions of the wire and the fracture are checked by radiographs or image intensifier. Alternatively, the thickened part of the bone can be divided by a long oblique osteotomy, producing a larger area for apposition of the fragments after length and alignment have been restored. Occasionally, internal fixation devices are fractured and deformed when the patient experiences a new injury. This situation frequently is difficult because the deformed internal fixation device must be removed first before the new fracture can be definitively fixed. If not corrected acutely, malalignments can cause pain and joint deformity.   

OSTEOTOMY FOR FEMORAL MALUNION TECHNIQUE 58.16 After determining preoperatively the site of osteotomy, expose the area of malunion through an appropriate anterolateral or lateral incision (see Chapter 1). n  Incise the periosteum longitudinally for a distance of 6 to 8 cm if interlocking nail techniques are to be used over the area of maximal deformity. n 

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A

B

C FIGURE 58.22 A, Rotational malunion of femur after unlocked intramedullary nailing. B, Correction of malunion with proximal femoral derotational osteotomy and locked nailing. C, Healed osteotomy.

Divide the bone transversely with a reciprocating motor saw, or, if preferable, drill several holes transversely through the bone and divide it in the plane of the holes with an osteotome to form broad, even surfaces for maximal apposition. Drilling the holes not only ensures that the osteotomy is transverse but also, because the femur is often exceedingly dense, saves time and decreases the effort required of the surgeon. n  Correct the deformity by manual force. n  Open the medullary canal of both fragments. n  In adults, the reduction is unstable, especially in the proximal half of the femur, and end-to-end apposition and proper alignment of the fragments can be maintained with certainty only by internal fixation. Use an interlocking intramedullary nail within the levels ordinarily indi n 

cated for intramedullary nailing of fresh fractures of the femoral shaft (see Chapter 54). n  Alternatively, the fragments can be fixed with a compression plate. With either type of fixation, cancellous grafts should be placed at the osteotomy. For a severe deformity of long duration, an operation in two stages may be necessary. In the first stage, union is broken up in an oblique plane by osteotomy; length is restored after surgery by skeletal traction or by external fixation distraction. In the second stage, satisfactory apposition and alignment are obtained, the fragments are fixed internally with an intramedullary nail or a large compression plate, and bone grafts are placed around the osteotomy medially and posteriorly.   

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A

B

C

FIGURE 58.23 A, Distal femoral fracture with 30-degree varus malunion. B, External fixation was used to correct deformity before plating. C, After osteotomy and plating.

A

B

C

D

FIGURE 58.24 A and B, Malunion of subtrochanteric fracture with severe internal rotational deformity. C and D, Corrective osteotomy, implant removal, and fixation with proximal interlocking Grosse-Kempf medullary nail.

When alignment is satisfactory but overlapping is excessive, experience and mature judgment are required to determine which malunions should be treated surgically, but the following general principles usually can be applied. In young children, overlapping that results in final shortening of more than 3.8 cm usually should be corrected. In young adults, surgery usually is indicated when the overlap is more than 3.8 cm, but the operation is difficult, union may be delayed after surgery, and impairment of function of the knee and of the vascular and nerve supplies of the extremity is possible. When osteoporosis is marked, the patient should bear weight before surgery until it has at least partially disappeared and pain and swelling have ceased.

FEMORAL MALUNION IN CHILDREN

Angular deformity has been reported to occur in 40% of children with femoral shaft fractures, although it usually remodels with growth. In children younger than 13 years, malunion of 25 degrees in any plane remodels enough to give normal alignment of joint surfaces. If significant angular deformity is present after fracture union, corrective osteotomy should be delayed for at least 1 year, unless the deformity is severe enough to impair function. The ideal osteotomy corrects the deformity at the site of fracture. In juvenile patients, metaphyseal osteotomy of the proximal or distal femur may be preferable, however. In adolescents with midshaft deformities, diaphyseal osteotomy and fixation with an interlocking intramedullary nail are preferable. Although rotational deformity

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FIGURE 58.25 One-stage femoral lengthening: reaming, Z-shaped osteotomy, lengthening, static locked medullary nailing, transverse screws, and bone grafts.

does not remodel significantly, it usually is well tolerated and rarely requires treatment. Complications of femoral shaft fractures in children, including malunion, are discussed in Chapter 36. Osteotomies for correction of varus and valgus deformities and leg-length discrepancy are described in Chapters 29 and 36. 

 

OSTEOTOMY FOR FEMORAL MALUNION IN CHILDREN TECHNIQUE 58.17 Expose the malunion through an appropriate lateral or anterolateral incision (see Chapter 1). n  Inspect the old fracture carefully and compare it with the radiograph so that the osteotomy can be placed as near to the fracture as possible. Usually the proximal fragment is located lateral and anterior to the distal one, and it can be identified easily if the malunion is of only 6 to 12 months’ duration. n  Incise the periosteum and strip it from the lateral, anterior, and posterior surfaces of the proximal fragment. n  Use a reciprocating motor saw to separate the fragments through the plane of union, or, if desired, outline the plane of union with a motor-driven drill and divide the bone with a narrow osteotome by connecting the holes. With either method of osteotomy, proceed cautiously to avoid injuring important nerves and vessels on the medial side of the femur. If union is far advanced, an oblique osteotomy can be made without regard to the plane of fracture. n 

Resect 0.6 to 1.3 cm of bone from each fragment with a saw. This resection is made for several reasons: (1) the ends of the fragments usually are sclerotic and should be resected back to comparatively normal bone; (2) the surfaces formed permit more stable and accurate apposition; and (3) apposing the fragments is less difficult and recurrence of deformity is less likely when the malunion has been of long duration and the soft tissues otherwise would be under too much tension. n  Apposing and firmly interlocking the fragments may be possible; apply a plate for fixation. If the deformity is severe, apposing the fragments may be impossible without too much stripping of soft tissues and without resection of too much bone from the ends of the fragments. In this instance, external fixation may be preferable. In older children and adolescents, an intramedullary nail usually is preferred for fixation.    n 

If adequate radiography or equipment for interlocking intramedullary nailing techniques or internal fixation is unavailable or cannot be used, older techniques can provide good results (Fig. 58.26). Malunions of the femoral shaft with angulation but little, if any, rotation can be treated by osteotomy and osteoclasis. Ferguson et al. described a twostage osteotomy that can be used in the femur, tibia (Fig. 58.27), or other long bone. A rectangular segment consisting of one half the width of the bone is removed from the concave side of the deformity; this segment is cut into small chips and is packed back into the defect. About 3 weeks later, the osteotomy is completed on the convex side of the deformity by removing a wedge opposite the middle of the first defect. The second stage is not done until sufficient callus has formed at the first defect; if necessary, additional

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FIGURE 58.26 A, Malunited fracture of femur with overlapping of fragments in 11-year-old boy. B, Five months after open reduction, insertion of Kirschner wire through distal femur and application of spica cast incorporating wire. Length of limb and function of knee were regained.

can be used for joints ankylosed in a position of deformity, genu valgum or varum, coxa vara, cubitus varus, and other deformities. Malunions that occur in patients with fibrous dysplasia are complicated by poor fixation with plates and screws in the pathologic bone. We have found that reconstruction with an intramedullary nail is helpful in this situation because it effectively splints the entire femur, avoiding delayed angulation and stress fractures at the ends of the implant.

TROCHANTERIC REGION OF THE FEMUR

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FIGURE 58.27 Ferguson, Thompson, and King two-stage osteotomy. A, Segment of bone resected from medial half of tibia (blue lines) and cut into chips for grafting. B, Grafts placed in defect to complete first stage. Second stage is delayed until sufficient callus has formed across defect. Varus deformity is corrected by resecting wedge of bone laterally (blue lines). C, Deformity has been corrected, and union is solid.

grafts are placed over the first defect before the osteotomy is completed. Moore described a method of correcting deformity of a long bone (including malunited fractures) in which about three fourths of the circumference of the bone is divided with an osteotome at the level of maximal deformity; the rest of the bone is broken by manual osteoclasis (Fig. 58.28). Irwin used a similar method for trochanteric osteotomy that also

Varus malunion is the most common deformity after intertrochanteric fracture and leads to limb shortening; abductor muscle imbalance; limp; and hip, back, and knee pain. Malunited fractures in the trochanteric region can be divided into two types: (1) malunions with internal or external rotation, coxa vara, and shortening of about 2.5 cm and (2) malunions with internal or external rotation, severe coxa vara, and shortening of 5 cm or more. In malunions of the first type, rotation and coxa vara are corrected by a subtrochanteric osteotomy and no attempt is made to reduce the shortening other than by angulating the bone at the osteotomy. Malunions of the second type are treated by a procedure similar to that described subsequently for malunited cervicotrochanteric fractures with extreme overriding. Bartonicek et  al. reported their results with a valgus intertrochanteric osteotomy by removal of a lateral wedge, lateral displacement of the femoral shaft, and fixation with a 120-degree blade plate. Fourteen of 15 osteotomies healed uneventfully, and there were no infections, osteonecrosis, or osteoarthritis at an average follow-up of 5.5 years. All patients were satisfied with the result, and Harris hip scores improved from an average of 73 preoperatively to 92 postoperatively. Indications for surgery were greater than 2 cm of shortening, a limp, gluteal muscle imbalance, and pain in the hip and lumbar spine.

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CHAPTER 58  MALUNITED FRACTURES

Excised wedge of bone reduced to chips and returned to defect

90° 90° 1

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Periosteum carefully approximated

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Circular segment of cast removed

C FIGURE 58.28 Moore osteotomy-osteoclasis. A, 1, Wedge has been resected from normal bone distal to malunion, leaving cortex on concave side of deformity intact; proximal cut is perpendicular to long axis of proximal fragment, and distal cut is perpendicular to that of distal fragment. 2, Grafts have become consolidated with early callus. 3, Deformity has been corrected by manual osteoclasis. B, Detail of technique. Wedge of bone is removed and is cut into chips that are placed back into defect; periosteum is carefully sutured. C, At 3 to 4 weeks after surgery, section of cast is removed and deformity is corrected manually. Cast is repaired with plaster.

SUBTROCHANTERIC OSTEOTOMY FOR COXA VARA AND ROTATIONAL DEFORMITIES

The routine technique for this procedure, useful in treating many conditions, is described in Chapter 30. Variations are described under the discussions of compensatory trochanteric osteotomy for malunited slipped proximal femoral epiphysis (see Chapter 36) and congenital coxa vara (see Chapter 36). 

CERVICOTROCHANTERIC REGION OF THE FEMUR

Cervicotrochanteric fractures occur at the junction of the trochanter and femoral neck. Posteriorly, the fracture is always outside the capsule of the hip because the posterior part of the capsule does not cover the distal third of the neck; anteriorly, the fracture can be just inside the capsule or can extend a short distance within it. Unless fractures in this region are treated properly, malunion is inevitable; usually coxa vara of 90 degrees, external rotation of the distal fragment, and about 5 cm of shortening are the deformities. In children, the shortening may be slight at the time of union but increase with growth and ultimately may be 7.5 cm, even though the physis is not affected; this increase in discrepancy seems to be caused by the partial disability of the extremity that results in insufficient stimulation of the physes by normal activity. After the deformity has been corrected, maintaining the position is especially difficult in children; the likelihood of maintaining satisfactory alignment and securing normal function is much more favorable in young adults. In the elderly, subtrochanteric

osteotomy alone (see Chapter 22) is used to correct the deformity; even though length is only partially restored, function is improved.   

CORRECTION OF CERVICOTROCHANTERIC MALUNION TECHNIQUE 58.18 Expose the malunion, the trochanters, and the proximal 5 cm of the femoral shaft through a curved lateral incision between the tensor fasciae latae and gluteus medius muscles (see Chapter 1). n  Because of the external rotation, the fractured surface of the greater trochanter faces anteromedially. A wedgeshaped space with its base anterior is present between the fragments and usually is filled with fibrous tissue. Excise this fibrous tissue down to normal bone and divide the osseous union posteriorly with an osteotome. n  Appose the bone surfaces and correct the deformity by abducting and internally rotating the distal fragment while marked traction is applied to the leg. n  Tenotomize the adductors (see Chapter 33) if necessary to obtain enough abduction of the distal fragment. n  Apply traction through the fracture table or a femoral distractor and confirm reduction of the neck-shaft angle n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS with image intensification or anteroposterior radiographs of the hip. n  If the normal angle between the shaft and the neck has been restored, fix the fracture with a compression screw or some other type of nail by a technique similar to that described for trochanteric fractures (see Chapter 55). For children, a pediatric compression hip screw (see Chapter 36) is preferable because it is much easier to insert into the hard bone of the femoral neck and head. The capital femoral physis should be avoided if possible.

POSTOPERATIVE CARE  If complete correction has been secured, and the fracture was fixed internally in a child, a cast should be applied and worn for at least 8 weeks; even with the most careful treatment after surgery, decrease in the angle between the neck and femoral shaft is fairly common even after union seems to be solid. In children, the results of this operation usually are disappointing because only moderate improvement in position may be secured; efficient treatment of fresh cervicotrochanteric fractures is crucial. In young adults, function is much improved but rarely, if ever, is the angle between the neck and shaft or the length of the limb restored completely.   

Fractures of the femoral head occur infrequently, and malunion has rarely been reported. Yoon et al. described three femoral head malunions after posterior hip dislocation with Pipkin type I fracture of the femoral head that had been treated with closed reduction and traction. Symptoms included limp and limited hip motion. All patients were treated with resection of the protruding bony prominence inferiorly followed by immediate full weight bearing and range-of-motion exercises. Results were excellent in all patients, with nearly full range of motion achieved postoperatively without pain. The authors stated that malunion should be suspected in patients with limited hip motion after femoral head fractures. Sontich and Cannada reported a femoral head avulsion fracture (Pipkin type I) that was malunited to the acetabulum. An excellent result was obtained after surgical debridement. 

ACETABULUM Usually, malunions of the pelvis in which correction is justified are those involving the acetabulum. Even with modern methods of treatment, malunion of fractures of the acetabulum with central dislocation of the femoral head still occurs; also, traumatic arthritis usually develops after comminuted fractures of the acetabulum. The treatment of either of these conditions varies with the severity of the injury, the deformity, the disability, and the age and health of the patient. When hip motion is limited and painful, and depending on the patient’s occupation, arthrodesis (see Chapter 5) or total hip arthroplasty (see Chapter 3) may be indicated. The treatment of fractures of the acetabular rim with dislocation of the hip is similar to that described in Chapter 56. The following elements should be considered before attempting acetabular reconstruction: (1) the location and condition of the different segments of the acetabular articular surface and of the bony columns supporting them, (2) the amount of wear of the femoral head, (3) the degree of

osteoarthritis, and (4) the existence of osteonecrosis. This type of surgery should be attempted only by surgeons experienced in the surgical treatment of acute acetabular and pelvic fractures. 

PELVIS A pelvic nonunion does not always cause pain, but pain occurs frequently with severe malunions, most commonly from malunion of the sacroiliac complex. Symptoms also can be caused by an internal rotational deformity or leg-length discrepancy. Impingement on the bladder by a displaced superior pubic ramus can cause urinary frequency. Late correction of a pelvic deformity is more difficult, less successful, and associated with a higher incidence of complications than management of acute pelvic fractures. Therefore, initial reduction and stabilization of pelvic injuries is of utmost importance to prevent malunion and nonunion. Indications for surgical treatment of pelvic malunions include pain, instability, sitting imbalance, limb shortening, and vaginal wall impingement. Pelvic tilt fractures that cause erosion into the perineum from a displaced fracture of the superior pubic ramus and severely shortened and internally rotated pelvic malunions also justify surgical correction. Cosmetic deformities secondary to limb shortening and malrotation also may be present. Cranial displacement of the hemipelvis of 1 cm or more may lead to leg-length discrepancy, sitting imbalance, a characteristic cosmetic deformity, and sacral prominence that can cause pain while sitting or lying supine. Patients with leg-length discrepancy but no other symptoms related to the pelvis can be treated with standard methods of limb-length equalization (see Chapter 29). In addition to pelvic osteotomy and fixation, several operations for leg-length equalization exist. For severe shortening and internal rotation, a two-stage correction, with a period of skeletal traction after the osteotomy to minimize neurologic complications has been reported. For chronic sacroiliac pain not relieved by conservative treatment, arthrodesis is the treatment of choice. Patient selection is important. Patients must have realistic expectations, accept known risks (loss of reduction, nerve or vascular injury, persistent nonunion, and significant blood loss), and be compliant with 3 to 5 months of restricted weight bearing. Anatomic reduction of the pelvic deformity frequently is impossible. Posterior pelvic pain usually is caused by nonunion, instability, or malreduction, and correction of these problems provides pain relief in most patients. Posterior pelvic pain of uncertain etiology or pain caused by old neurologic injury is less likely to be improved by surgery. Posterior pelvic pain also may be caused by concomitant lumbar injuries, which should be evaluated if present. In a study of 437 malunions, Kanakaris et al. reported that treatment in most patients is effective, with union rates averaging 86%, pain relief 93%, and patient satisfaction 79%. However, the return to a preinjury level of activity was reported in only 50%. Pelvic malunions are assessed radiographically with anteroposterior, 45-degree internal and external oblique, and 40-degree caudal and cephalad views. A pelvic CT scan also should be obtained, and three-dimensional CT reconstruction is helpful if it is available. Right and left single-leg standing anteroposterior pelvic radiographs are useful for detecting instability. Limb shortening is evaluated on the

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CHAPTER 58  MALUNITED FRACTURES anteroposterior pelvic views by comparing the cranial displacement of the acetabular roof with the contralateral side. A line perpendicular to the midline of the sacrum is used to make the comparative measurements. Radiographic evaluation provides information about the extent of fracture union and the nature of the deformity. Deformities often are complex and involve multiple planes. Operative correction of pelvic deformity is difficult and should be undertaken only by surgeons experienced in pelvic surgery. Each pelvic malunion is unique and requires individualized plans and techniques for operative reduction and stabilization. Nonunions without significant deformity can be treated with a one-stage or two-stage procedure with risks similar to those of acute fracture surgery. A three-stage procedure is recommended for malunited or malaligned fractures to provide the maximal amount of deformity correction. Anterior structures are approached with the patient supine, whereas posterior deformities are corrected with the patient prone.

THREE-STAGE RECONSTRUCTION FOR PELVIC MALUNIONS

Patients are placed on a radiolucent operating table, and fluoroscopy is used to guide osteotomy, reduction, and fixation. A Judet traction table is useful in some cases. In the first stage, the deformed anterior pelvic structures are osteotomized and anterior nonunions are mobilized. The patient is repositioned prone for the second stage. Posterior pelvic deformities are osteotomized or mobilized, the pelvis is reduced, and posterior structures are internally fixed. Wounds are closed between each stage. In the third stage, the patient is returned to a supine position, the initial wound is reopened, the anterior reduction is completed, and internal fixation is applied. The procedure also can be done in the opposite order: (1) mobilizing the posterior pelvis first; (2) mobilizing, reducing, and internally fixing the anterior pelvis; and (3) completion of reduction and fixation of the posterior pelvis. Osteotomies should be made at the old injury sites when possible. Correction of cranial displacement is made easier by dividing the attachment of the sacrospinous and sacrotuberous ligaments to the sacrum. External fixators can be used intraoperatively to aid in reduction. Anterior structures are stabilized by plate fixation, and plates or large iliosacral screws or both are used for posterior fixation. Old deformities often are resistant to correction and may require stronger fixation than is commonly used in acute fractures to prevent loss of reduction. In one study, 36 of 37 patients had stable unions of the pelvic ring. The overall incidence of complications was 19% (persistent nonunion, loss of reduction, neurologic injury, vascular injury, and persistent pain), and no infections were reported. Rousseau et al. reported a prone-supine, two-stage procedure in eight patients with 10-months’ follow-up. The surgery consisted of opening the sacroiliac joint and cutting the sacrotuberous and sacrospinous ligaments through a posterior approach; in a second stage, the pubic symphysis and the anterior aspect of the sacroiliac joint were released through an ilioinguinal approach to achieve reduction and then osteosynthesis of the pubic symphysis and sacroiliac joint, including bone graft harvesting and grafting. Anatomic reduction was achieved in six of eight patients. In the two patients without anatomic reduction, mechanical problems from leg-length inequality persisted. Complications included one bladder injury, one nosocomial

infection in the postoperative period, three motor deficits with footdrop, and a possible nonunion. 

SCAPULA With few exceptions, fractures of the scapular body and neck continue to be treated nonoperatively. In a review of 520 scapular fractures by Zlowodzki et  al., 82% had good or excellent functional results. Although most patients do well, there recently has been increased interest in identifying which fractures are likely to develop a symptomatic malunion. Parameters that have been evaluated include the degree of medial and lateral displacement of the glenoid on the anteroposterior radiograph, angulation of the scapular body as measured on the scapular Y radiograph, and the glenopolar angle as measured on the anteroposterior scapular view (normal 30 to 45 degrees). The degree of angular deformity and displacement causing functional impairment has not been precisely defined. In an analysis of 113 scapular fractures, Ada and Miller noted subacromial pain, decreased range of motion, and weakness with overhead activities in patients with displaced scapular neck fractures. They recommended surgical reduction and stabilization of scapular fractures, with more than 9 mm of glenoid medialization, or 40 degrees of angulation. Romero et  al. reported that patients with fractures having significant rotational deformity of the glenoid neck (quantified as a glenopolar angle of less than 20 degrees) had poor functional results. Operative criteria developed by Cole et al. include medial and lateral displacement of 2 cm or more, scapular body angulation of 45 degrees, and glenopolar angle of 22 degrees or less. Despite these recommendations, there are currently no studies confirming the superiority of operative treatment in this subset of scapular fractures. There have been a few reports describing surgical management of symptomatic scapular malunions. Moreover, favorable outcomes have been achieved. Success depends on appropriate patient selection and the surgeon’s familiarity with the anatomy and surgical techniques. Cole et  al. evaluated the functional outcome in five patients with extraarticular malunions of the scapular neck or body treated with osteotomy, reduction, plate osteosynthesis, and bone graft performed through a posterior Judet approach. One ipsilateral clavicular malunion also was repaired. Preoperatively, all patients complained of chronic pain, decreased range of motion, weakness, and unsatisfactory cosmetic deformity of the involved shoulder. All patients had marked deformity of the scapula on radiographs. None were able to perform their usual occupation. Radiographic deformity was a mean of 3.0 cm (range 1.7 cm to 4.2 cm) of medial or lateral displacement, 25 degrees of angulation (range 10 to 40 degrees) on scapular Y view, and a glenopolar angle of 25 degrees (range 19 to 29 degrees). Preoperative evaluation included a true anteroposterior scapular radiograph, scapular Y, and axillary lateral views, anteroposterior radiograph of the uninvolved shoulder, and CT scan with 3D reconstruction. The mean time from injury to surgery was 15 months (range 8 to 41 months). There were no intraoperative complications. The mean estimated blood loss was 569 mL (range 350 to 1125 mL). The mean follow-up was 39 months (range 18 to 101 months). All osteotomies united. All patients were pain free and highly satisfied with the result. Four of the five returned to their preinjury occupation and activities. Patients had statistically significant increases in forward flexion and abduction shoulder range

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FIGURE 58.29 Cole osteotomy and reorientation of scapular neck. A, Posterior Judet approach and surgical exposure of scapular nonunion. Note scapular deformity (solid arrow). Dashed arrow shows neurovascular bundle at spinoglenoid notch. B, Small external fixator used to maintain desired reduction at lateral border of scapula. Solid arrow shows superomedial angle. C, After corrective osteotomy and anatomic reduction, a 3.5-mm dynamic compression plate and a 2.7-mm reconstruction plate with conventional or locking screws are used for fixation. Solid arrow points out superomedial angle and dashed arrow the spinoglenoid notch. D, Thirty-two-month postoperative anteroposterior radiograph showing complete scapular healing in anatomic alignment with no evidence of hardware loosening. SEE TECHNIQUE 58.19. (From Cole PA, Talbot M, Schroder LK, Anavian J: Extra-articular malunions of the scapula: a comparison of functional outcome before and after reconstruction, J Orthop Trauma 25:649, 2011.) SEE TECHNIQUE 58.19.

of motion, and improved Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form (SF)-36 scores. One patient developed asymptomatic heterotopic ossification.   

OSTEOTOMY AND REORIENTATION OF SCAPULAR NECK TECHNIQUE 58.19 (COLE ET AL.) Place the patient in the lateral decubitus position, leaning slightly prone on a beanbag. Position the arm on an

n 

arm board abducted and in 90 degrees forward flexion. Prepare the shoulder, neck, and posterior hemithorax allowing access and manipulation of the shoulder. n  Through a posterior Judet approach, elevate the infraspinatus and teres minor muscles off the vertebral scapular border and retract the neurovascular pedicle that courses through the spinoglenoid notch. Take care to protect these structures. Using a large Deaver and Hohmann retractor, expose the scapular neck and body taking care not to damage the nerve or vessel (Fig. 58.29A). n  Carry out osteotomies along the original fracture pattern with a sagittal saw or an osteotome through multiple drill holes. Remove any ectopic bone encountered and store in saline solution for later use as bone graft. Use a laminar spreader to complete the osteotomies.

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CHAPTER 58  MALUNITED FRACTURES Once the primary fracture patterns are recreated, further debride the osteotomy sites to better delineate the true fracture lines, thereby allowing anatomic realignment of the fragments. Reduce the fragments by placing a 4-cm Schanz pin into the glenoid neck and another in the lateral border distal to the osteotomy. A small external fixator with the aid of multiple reduction clamps may be necessary to obtain anatomic alignment and compression at the fracture sites (Fig. 58.29B). n  Apply a 3.5-mm dynamic compression plate spanning the osteotomy site at the inferior glenoid neck or lateral border and fix with conventional or locking screws. Supplement this lateral fixation by applying a second 2.7-mm reconstruction plate at the angle formed by the medial extent of the acromial spine and the medial border (Fig. 58.29C) and secure with conventional or locking screws. If the fracture extends down into the inferior angle of the scapular body, an additional reconstruction plate may be necessary. n  Mix the ectopic bone extracted from the malunion site during the osteotomies with other autogenous bone and with 20 to 30 mL platelet-rich plasma. Use this to fill large defects in the scapula. n  Close the wound over a suction drain. Manipulate the shoulder to break apart longstanding adhesions and scar tissue. n 

POSTOPERATIVE CARE Patients are placed in a sling for comfort. Early physical therapy is initiated after the first postoperative visit, with passive and active-assisted range-of-motion exercises for a period of 1 month followed by active range-of-motion and repetition exercises for 1 month. Resistance and strengthening exercises with 3- to 5-lb weights are begun at 2 months, and all restrictions can be removed at 3 months (Fig. 58.29D).    

CLAVICLE Most fractures of the clavicle are treated nonoperatively and frequently heal with some degree of deformity. It is generally believed that clavicular malunions are tolerated well in most patients and cause no significant functional limitations. In some patients, however, malunion of the clavicle is painful or results in functional deficits. Shortening of 15 mm or more has been shown to cause discomfort and dysfunction of the shoulder girdle, and 20 mm of shortening after closed treatment of displaced middle-third clavicular fractures has been associated with poor results. A cadaver study showed that shortening combined with caudal displacement leads to functional deficits in abduction, particularly overhead motion. A vector model was devised to calculate the position of the glenoid fossa in relation to the position of the clavicle, which could be used for planning open reduction and fixation. Symptoms include rapid fatigability, thoracic outlet syndrome, difficulty wearing over-the-shoulder straps, weakness, pain, and cosmetic deformity of a droopy, “driven-in,” or ptotic shoulder. The malunions that usually are disabling are malunions of the medial or lateral third of the bone. Angular deformity and shortening can alter the position of the glenoid fossa, which may affect glenohumeral mobility and scapular rotation.

In some patients with thoracic outlet syndrome after clavicular malunion, excising the bony prominence that is compressing the brachial plexus relieves symptoms. Several investigators have recommended osteotomy and plate fixation for symptomatic clavicular nonunions. McKee et al. reported 15 patients with malunions of the clavicle after nonoperative management who actively sought treatment for persistent complaints. Indications for surgery were chronic pain, weakness, and thoracic outlet syndrome not responsive to conservative management for at least 1 year after injury. No osteotomies were performed for cosmesis alone. Preoperative shortening averaged 2.9 cm (range 1.6 to 4.0 cm). Functional scores improved in all patients. In 12 patients with preoperative pain and weakness, symptoms resolved in eight and improved in four patients. In 11 patients with preoperative neurologic complaints, symptoms resolved in seven, improved in three, and were unchanged in one. Of 13 patients who regarded the cosmetic appearance of their shoulder as unacceptable preoperatively, 12 were satisfied with postoperative cosmesis. There was one hypertrophic scar. Complications included one loss of fixation that resulted in nonunion. There were no cases of infections, neurovascular injury, or wound breakdowns. Two plates were removed electively. Overall, 14 of 15 patients were satisfied after surgery. No intercalary bone grafts were used in this series. The authors’ current radiographic criteria for osteotomy and plating for symptomatic clavicular malunions include malunions with substantial shortening (15 degrees) and high functional demands, O’Driscoll et  al. recommended osteotomy combined with ligament reconstruction. 

FOREARM PROXIMAL THIRD OF THE RADIUS AND ULNA

Malunions of the proximal third of the radius and ulna can be classified as follows: (1) malunions of the radial head, (2) malunions of the radial neck, (3) malunions of the olecranon, (4) malunions of the proximal third of the ulna with anterior dislocation of the proximal radius (Monteggia fracture), and (5) malunions with synostosis between the radius and ulna.

RADIAL HEAD

Malunion of the radial head with only mild deformity may not be disabling. If symptoms are caused by a small abnormal prominence of bone, resecting the prominence may relieve them. Severe deformity can cause pain and limit pronation and supination; occasionally, it also can limit flexion or extension of the elbow. It should be treated by excising the radial

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS head as described for fresh fractures (see Chapter 57). All loose fragments of bone, any excess bone, the scar tissue, the periosteum, and the remnants of the annular ligament should be excised carefully to help prevent the formation of new bone in the region. Use of the extremity is begun gradually as soon as the wound has healed. In a few patients, excising the radial head results in complete restoration of function; the result frequently is disappointing, however, and the patient should be informed in advance of this possibility. Reported complications of radial excision include loss of grip strength, wrist pain, distal radial ulnar joint instability, and valgus instability of the elbow. Rosenblatt et  al. reported five intraarticular osteotomies of the head of the radius in patients with symptomatic healed displaced articular fractures. The average Mayo Elbow Performance Index Score improved significantly from 74 before to 88 after osteotomy, with four patients having a good or excellent result. Prosthetic radial head replacement should be considered for patients with radial head malunions associated with distal radioulnar joint pain or instability or laxity of the medial collateral complex of the elbow (see Chapter 12). 

RADIAL NECK

Most radial neck fractures can be treated successfully with nonoperative methods; however, symptomatic malunions occasionally occur. A malunited radial neck fracture can cause pain, crepitance, elbow laxity, limitation of elbow flexion and extension, and limitation of forearm pronation and supination. It is desirable to maintain radial length and restore the congruity of the radiocapitellar articulation if the articular cartilage remains in good condition because of the potential for adverse sequelae after radial head excision. Corrective osteotomy of the radial neck should be considered for symptomatic malunions.   

CORRECTION OF RADIAL NECK MALUNION TECHNIQUE 58.24

POSTOPERATIVE CARE The elbow is immobilized in midflexion and midsupination for 2 weeks, after which a removable splint or functional orthosis is applied and progressive active range-of-motion exercises are begun. External support can be discontinued when healing of the osteotomy is secure.   

OLECRANON

In malunion of the olecranon, osteotomy and realignment of the fragments should not be attempted because the operation almost always increases the disability, but function of the elbow can be improved considerably by excising the deformed part of the bone. It has been repeatedly shown that a large part of the olecranon can be excised without causing much disability of the elbow. The part that can be excised is determined as follows. A lateral radiograph of the elbow is made with the joint flexed to 90 degrees. A line is drawn through the center of the longitudinal axis of the humerus and across the joint. At least 0.3 cm of olecranon should project posterior to this line; this much of the olecranon is enough to prevent anterior subluxation of the proximal ulna. The rest of the olecranon can be excised, and the triceps muscle is reattached accurately and firmly to the proximal ulna. 

PROXIMAL THIRD OF THE ULNA WITH ANTERIOR DISLOCATION OF THE RADIAL HEAD (MONTEGGIA FRACTURE)

If a Monteggia fracture unites in poor position, the deformity often is so disabling that almost any reconstruction is worth a trial. At 1 year or more after injury, the joint will have become so damaged that it may be impossible to restore elbow function to near normal.   

(INHOFE AND MONEIM, MODIFIED) Expose the proximal radius and radiocapitellar joint through a posterolateral approach (see Chapter 1). n  Debride the joint of inflamed synovium. Inspect the articular cartilage of the capitellum and proximal radius. n  If the extent of arthritic changes does not preclude a good result, make an osteotomy in the proximal radius approximately 1.5 cm from the articular surface using a small motorized oscillating saw, while protecting the soft tissues. n  Alternatively, an osteotome can be used to divide the bone. n  Realign the proximal radius, restoring the congruity of the radiocapitellar joint, and fix the osteotomy with two Herbert screws directed from proximal to distal. Kirschner wires or minifragment lag screws (2 or 2.7 mm) are alternative methods of fixation. If hardware is placed through the articular surface of the proximal radius, recess the screw head below the surface of the cartilage. n 

Place bone graft at the osteotomy site. Bone graft can be obtained from the lateral epicondyle of the humerus. n  Repair the annular ligament and lateral collateral ligament at the time of wound closure. n 

OSTEOTOMY AND FIXATION OF MONTEGGIA FRACTURE MALUNION TECHNIQUE 58.25 Expose the radial head and the malunion of the ulna through a single incision (see Chapter 1), or make two incisions as follows. n  Make a posterolateral incision (see Chapter 1) 5 cm long, and free the dislocated radial head from all of its attachments. n  Divide the neck of the radius just proximal to the bicipital tuberosity. n  Drill several holes transversely through the bone at the level of the anticipated osteotomy, complete the division of the bone with double-action bone cutting forceps while rotating the radial shaft, and smooth the end of the bone with a small rongeur. n 

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A

B

FIGURE 58.34 A, Malunited fracture of shaft of ulna and dislocation of proximal radius (Monteggia fracture). B, Four months after removal of medullary nail, osteotomy of ulna, and application of compression plate; radial head was excised, fragmented, and used for grafting ulna. Motion of elbow and forearm is excellent. SEE TECHNIQUE 58.25.

Make a second incision 7.5 cm long over the posterior aspect of the ulna and divide the bone as near the old fracture as possible. n  Align the fragments properly and fix them with a compression plate (Fig. 58.34); place autogenous cancellous bone around the osteotomy. n  Apply a long arm cast with the elbow at 90 degrees and the forearm in neutral rotation. n 

POSTOPERATIVE CARE A cast is worn until union is solid, usually at about 12 weeks, and active exercises are then begun.   

We have had satisfactory results in children with malunited Monteggia fractures treated by osteotomy of the ulna, reduction of the radial head, and fixation with Kirschner wires to maintain the reduction until the bone and soft tissues have healed.

SYNOSTOSIS BETWEEN THE RADIUS AND THE ULNA

Synostosis between the radius and the ulna may develop at the proximal radioulnar joint after severely comminuted fractures in this region. Jupiter and Ring classified proximal radioulnar synostosis into three types: A, synostosis at or distal to the bicipital tuberosity; B, synostosis involving the radial head and the proximal radioulnar joint; and C, synostosis contiguous with bone extending across the elbow to the distal aspect of the humerus. In their 17 patients (18 synostoses), operative resection of the synostosis gave good results in 16 patients (17 limbs). The only recurrence of synostosis was in a patient with a closed head injury. They found that the ultimate range of motion was not affected by any of the variables generally cited as contributing factors—size and location of the synostosis, severity of initial trauma, use of a free nonvascularized fat graft, and especially time between injury

and excision. Excision 6 to 12 months after initial injury did not increase the risk of recurrence, and although not statistically significant, patients with earlier resections had better motion than patients treated later. Although historically a delay in operative treatment for 6 to 12 months after injury has been recommended, Jupiter and Ring suggested that early resection is preferable because of its potential ability to limit the degree of soft-tissue contracture and the overall period of severe disability. No adjunctive radiotherapy or nonsteroidal antiinflammatory drugs were used in their patients, and they questioned the need for these prophylactic measures and the necessity of using interpositional fat to prevent recurrence. Other authors also have observed better results with fewer complications after early excision of the synostosis mass with or without interposition material. Although the most common and most direct treatment of proximal radioulnar synostosis is resection of the synostosis, creation of a pseudarthrosis of the radius distal to the synostosis has been used to restore forearm rotation. Kamineni et al. reported that resection of a 1-cm thick section of the proximal part of the radial shaft provided a safe and reliable method of improving forearm rotation in six of their seven patients. At almost 7-year follow-up, forearm rotation had improved from an average fixed pronation of 5 degrees to an average arc of motion of 98 degrees and re-ankylosis had occurred in only one patient, who also was the only patient in whom resection was done proximal to the bicipital tuberosity. Kamineni et al. noted that the single technical factor that seemed to influence results positively was the application of bone wax at the resection site. They recommended this procedure as a simple, safe alternative to synostosis resection in patients who have a proximal radioulnar synostosis that (1) is too extensive to allow a safe and discrete resection, (2) involves the articular surface, and (3) is associated with an anatomic deformity. They also emphasized that this technique should not be considered an alternative to removal of the synostosis when it is technically possible to excise a discrete bridge of bone. 

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RESECTION OF PROXIMAL PART OF RADIAL SHAFT TECHNIQUE 58.26 (KAMINENI ET AL.) With the patient supine and under general anesthesia, apply and inflate a tourniquet. n  Bring the affected arm across the patient’s chest and have an assistant stabilize it in this position. n  Make a Kocher approach to the proximal radius (see Chapter 1). n  When the interval between the anconeus and the extensor carpi ulnaris is entered, direct the dissection toward the ulnar shaft and the synostosis; follow the synostosis to its distal margin by elevating the supinator from the radius. n  With a power saw, resect a 1-cm section of the radial shaft either proximal or distal to the bicipital tuberosity as dictated by the extent of the synostosis. n  Examine the range of motion of the forearm and, if needed, gently manipulate the forearm. n  Cover the transected bone ends with bone wax and bridge the interval between bone ends with absorbable gelatin sponge (Gelfoam; Upjohn, Kalamazoo, MI). n  Release the tourniquet, secure hemostasis, and close the exposure in layers over a single suction drain. n 

POSTOPERATIVE CARE Continuous passive motion therapy can be used for 48 hours after surgery if desired. The postoperative rehabilitation program used by Kamineni et al. involves a two-component splint to achieve static pronation-supination splinting. The first component spans from the arm to the forearm, and the second component consists of an inner shell that wraps the distal part of the forearm and wrist like a gauntlet. A Velcro strap is used to rotate the forearm and wrist alternatively to the maximal attainable amounts of pronation and supination. For the first 3 weeks, the program proceeds as follows: full supination at night, active and passive motion for 1 hour on rising in the morning, full pronation until noon, removal of the splint for 1 hour at lunch, full supination until dinner, removal of the splint for 1 hour at dinner, full pronation during the evening, and removal of the splint for 1 hour until bedtime. After 3 weeks, the periods in which the splint is not worn are progressively increased. Patients are evaluated every 3 weeks, and the program is modified as needed. If motion is not maximal at 3 months, the splint is worn at night in the position in which it is most needed until no further progress is being made. The specific regimen varies from patient to patient.   

SHAFTS OF THE RADIUS AND ULNA IN ADULTS

Malunion of both-bone fractures of the forearm occasionally causes functional deficits severe enough to warrant surgical correction. Malrotation, angulation with encroachment on the interosseous space between the radius and ulna, and loss

of the radial bow all have been associated with loss of motion and compromised functional outcomes. Malunited forearm fractures may lead to disturbances of the distal radioulnar joint, and arthritis of the proximal radioulnar joint has been reported after long-standing (>20 years) malunions. Cadaver studies have shown insignificant reduction in forearm rotation with a 10-degree angular deformity, whereas a 20-degree angulation has been shown to result in loss of pronation and supination. With 15 degrees of total deformity, forearm motion was reduced by more than 27% except in distal-third fractures. Failure to restore the proper magnitude and location of the radial bow has been correlated with reduced forearm rotation and grip strength. The decision to operate on a forearm malunion should be based on an individual’s functional limitations and physical demands, rather than on the degree of radiographic deformity. Indications for surgery are loss of motion, distal radioulnar joint instability, and unacceptable cosmetic appearance. Restoring proper skeletal alignment in the forearm may not improve functional deficits caused by soft-tissue injury or prolonged immobilization; these factors also must be considered. In addition, the patient should be aware of potential complications, such as delayed union and nonunion, infection, loss of motion, radial nerve paresthesias, wrist pain, and instability of the distal radioulnar joint. Malunions are corrected by osteotomies of one or both bones of the forearm, correction of the deformity in all planes, compression plating, and bone grafting (Fig. 58.35). Operative treatment of forearm malunions is more likely to improve forearm motion significantly if done within the first year after injury. After 1 year, the soft-tissue contractures and scarring may limit the amount of motion that can be obtained. Trousdale and Linscheid retrospectively reviewed the results of osteotomy and plating in 27 patients with forearm malunions treated at the Mayo Clinic over a 15-year period. Most of the initial injuries occurred from falls during childhood and adolescence and originally were treated by closed methods. The average age at the time of correction of the deformity was 19 years. Of these 27 patients, 19 patients sustained fractures of both bones of the forearm, and eight patients sustained isolated fractures of the radius. Twenty patients had corrective osteotomies of the radius, two patients had corrective osteotomies of the ulna, and five patients required corrective osteotomies of the radius and ulna. Indications for surgery included loss of motion, instability of the distal radioulnar joint, and cosmesis. No information about the magnitude of the deformities was reported. Patients treated for loss of motion within 12 months of the original injury gained an average of 79 degrees of rotation (range 20 to 160 degrees), and those treated more than 12 months after injury gained an average of only 30 degrees additional rotation (range, 25 to 95 degrees). The results of the patients treated for distal radioulnar joint instability are discussed later in this chapter. Complications occurred in 48% of patients treated more than 1 year after surgery and included loss of motion (three patients), heterotopic ossification along the interosseous membrane (one patient), delayed union (one patient), subluxation of the ulnar head (one patient), and refracture after plate removal (one patient). Complications in the group treated earlier were mild wrist pain (two patients), a single postoperative infection, and a retained drain. Nagy et  al. reported 17 patients who were operated on for

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A

B

FIGURE 58.35 A, Malunion of shaft of radius and nonunion of shaft of ulna. B, Solid union and normal alignment 6 months after osteotomy of radius, fixation of both bones by compression plates, and application of iliac grafts.

symptomatic malunion. They found improvement in range of motion in all patients, but the overall improvement range was much better in patients with a supination deficit than a pronation deficit.   

OSTEOTOMY AND PLATING FOR FOREARM MALUNION TECHNIQUE 58.27 (TROUSDALE AND LINSCHEID, MODIFIED) Preoperatively, record the amount of forearm pronation and supination and elbow flexion and extension. n  Evaluate the stability of the distal and proximal radioulnar joints by manual stress palmarly and dorsally. n  Obtain full-length anteroposterior, lateral, and pronation and supination radiographs of the involved forearm and the contralateral forearm for comparison. n  Assess the relative lengths of the radius and ulna and identify the site and magnitude of the deformity. n  CT with both forearms in maximal pronation and supination is useful for evaluating rotational deformities. Cross-sectional cuts proximal and distal to the fracture are compared with the uninjured side. The proximal fragment usually is supinated relative to the distal fragment because of the insertion of the supinator and biceps proximally and the insertion of the pronator teres and pronator quadratus distally. n  Determine whether one or both bones of the forearm are significantly malaligned. If only one bone is malunited, osteotomy of only the involved bone is done. n 

If both bones are malaligned, osteotomy, realignment, and stabilization of the more severely deformed bone are done first. If the radius is more severely malaligned than the ulna and realignment of the radius produces smooth forearm rotation with passive manipulation, the ulna does not require osteotomy. If both bones are equally malaligned, it is preferable to osteotomize and correct the ulna first to establish proper forearm alignment and then osteotomize the radius to conform to the ulna. In some patients, osteotomy of both bones may be required to allow proper realignment of the forearm. n  Expose the radius through a 10- to 15-cm longitudinal anterior Henry approach (see Chapter 1) centered over the malunion site. n  Expose the ulna (if necessary) through a 10- to 15-cm longitudinal subcutaneous approach between the extensor carpi ulnaris and flexor carpi ulnaris. Minimize dissection in the interosseous space between the radius and ulna to decrease the risk of heterotopic ossification and synostosis. n  Determine the type of osteotomy required to restore alignment in all three planes. If the deformity is in one plane, a uniplanar osteotomy is sufficient. If the deformity is complex as determined on preoperative radiographs, a multiplanar osteotomy is necessary. n  Make the osteotomy according to preoperative plans at the apex of the deformity by dividing the bone with a small motorized oscillating saw. n  Alternatively, the plane of the osteotomy can be outlined with drill holes and the bone can be divided with an osteotome. Use a drill or hand reamer to reestablish the medullary canal in both fragments if this can be accomplished without excessive soft-tissue stripping. n  After the osteotomy is made, correct rotation and angulation and clamp a plate to each fragment. n 

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Assess the reduction clinically and radiographically and make adjustments as necessary. n  Additional contouring of the plate often is necessary, especially to restore the radial bow. A 3.5-mm dynamic compression plate long enough to provide six cortices of fixation proximal and distal to the osteotomy is preferred. If there is a short proximal radial fragment, it may be impossible to obtain more than four cortices of fixation without risking injury to the radial nerve. n  After alignment of the bone and contouring of the plate are satisfactory, provisionally fix the plate to the bone with screws on both sides of the osteotomy. n  Reassess the reduction radiographically and evaluate flexion and extension of the elbow and pronation and supination of the forearm to ensure that correction of the malunion has improved passive range of motion. n  If alignment seems satisfactory and significant motion has been restored, place the remaining screws through the plate, ideally with at least six cortices of fixation proximal and distal to the osteotomy. n  If the ulna has been osteotomized and realigned first, but the radius remains significantly deformed, restricting motion, correct radial alignment with the same procedure as described for the ulna. Sometimes osteotomies of both bones are required before either can be realigned properly. n  After realignment, close bony apposition at the osteotomy is not always possible. Place autogenous cancellous bone grafts in any bone gaps and in patients with any risk factors for delayed union or nonunion. n 

 

CORRECTION OF FOREARM MALUNION WITH DISTAL RADIOULNAR JOINT INSTABILITY TECHNIQUE 58.28 (TROUSDALE AND LINSCHEID, MODIFIED) Preoperative planning, osteotomy, realignment, and fixation of the malaligned forearm bones are done as described in Technique 58.27. n  After the plate is applied, evaluate the stability of the distal radioulnar joint using palmar and dorsal stress of the ulna. If instability is present, imbricate the palmar capsule of the distal radioulnar joint with 3-0 or 4-0 nonabsorbable sutures placed in a horizontal mattress fashion to shorten and tighten this structure. n  With the forearm supinated, stabilize the distal radioulnar joint with one or two 0.062-inch Kirschner wires inserted through the ulna and radius just proximal to the distal radioulnar joint. n 

POSTOPERATIVE CARE After skin closure, an aboveelbow splint is applied with the forearm in supination. Sutures are removed at approximately 2 weeks, and a second above-elbow cast or splint is applied with the forearm in supination. At 6 weeks, the cast or splint is removed, Kirschner wires are removed if they have been used, and range-of-motion exercises are begun.    

POSTOPERATIVE CARE  A posterior splint is applied after surgery. The splint usually is removed in 3 or 4 days if fixation is secure, and active and active-assisted rangeof-motion exercises of the hand, wrist, forearm, elbow, and shoulder are begun as tolerated. In some patients, temporary use of a removable orthosis is required. Normal activities can be resumed after healing of the osteotomies is solid (usually 4 months); plates are not routinely removed in adults.   

FOREARM MALUNIONS WITH DISTAL RADIOULNAR JOINT INSTABILITY

Malunions of fractures of the radial shaft or both bones of the forearm can cause instability in the distal radioulnar joint. This problem occurs most frequently with fractures located in the distal third of the forearm. A corrective osteotomy of the deformed bone is sometimes all that is necessary to restore stability to the distal radioulnar joint. In other cases, capsular imbrication and temporary transfixion of the distal radioulnar joint may be required. Trousdale and Linscheid treated six patients with forearm malunions and associated instability of the distal radioulnar joint. In three patients, stability of the distal radioulnar joint was obtained by osteotomy and plating of the bony deformity alone, and the other three patients required additional reconstruction of the distal radioulnar joint. A stable wrist was obtained in five of the six patients, but four lost some forearm motion (range 25-degree loss to 25-degree gain). Three patients had complications: one, mild instability of the ulna; one, mild wrist pain; and one, pain in the radial nerve distribution. 

 

DRILL OSTEOCLASIS Blackburn et al. reported good results using drill osteoclasis in 10 of 12 patients, and they recommended this as an alternative to open osteotomy in children. They cited as advantages the lack of a second operation to remove the plate and screws and the elimination of the possibility of refracture through screw holes.

TECHNIQUE 58.29 (BLACKBURN ET AL.) After administration of a general anesthetic, prepare and drape the extremity. n  Make a 0.5-cm stab incision at the site of the malunion. n  Insert a 3.2-mm drill guide to the bone and drill several holes in the radius; repeat the same steps for the ulna. n  Perform a manual osteoclasis. n  Apply a long arm, above-elbow cast. n 

POSTOPERATIVE CARE The cast is worn for 3 to 6 weeks. The progress of union is monitored radiographically at weekly intervals until callus is seen. The cast is removed when union is apparent clinically and radiographically.   

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SHAFT OF THE ULNA

TABLE 58.3

An operation for malunion of the ulna alone rarely is necessary; if it is necessary, the principles described for malunion of the radial shaft can be followed. 

Radiographic Criteria for Acceptable Healing of Distal Radial Fractures

DISTAL RADIUS

CRITERION Radioulnar length

Despite improvements in treatment since the early 1980s, malunion remains a common cause of residual disability after distal radial fractures. Modern investigators have not confirmed Colles’ observation in 1814 that the deformity will persist, but that the wrist eventually will “enjoy perfect freedom in all its motions and be completely exempt from pain.” Not all distal radial malunions are symptomatic, especially malunions in elderly patients with low functional demands. In such patients, no further treatment is indicated. Posttraumatic wrist deformities in younger, active patients may be sufficiently disabling, however, to warrant surgical correction. In one study malunion was found to be associated with higher arm-related disability regardless of age. Fracture characteristics and initial treatment contribute to the development of a malunion. Malunion can be caused by failure to achieve or maintain an accurate reduction or by inadequate duration or type of immobilization. Reduction is most difficult to obtain and maintain in fractures with marked comminution (especially fractures involving the articular surface), severe osteoporosis, or disruption of the distal radioulnar ligaments. Age also may be a factor in the development of malunion. In a study of 200 patients comparing distal radial fractures in patients at different ages, Hollevoet found that older patients had more malunions. The mean age of patients with malunions was 60 years, whereas the mean age of patients without malunions was 51 years. Efforts have been made to reduce the incidence of malunion by refining the indications and techniques for surgical management of acute distal radial fractures (see Chapter 57). Malunions of the distal radius may be associated with extraarticular deformities, intraarticular malalignment, distal radioulnar joint incongruity or instability, or a combination of these features. Extraarticular deformities include shortening and excessive dorsal or volar tilt of the distal radial articular surface. Radiographic measurement of alignment of an intact distal radius shows an average of 22 to 23 degrees of radial inclination, 11 to 12 mm of radial height, 11 to 12 degrees of volar tilt, and ± 2 mm of ulnar variance. No absolute radiographic criteria define a significant distal radial malunion; however, several investigators have identified parameters that are likely to be associated with a poor functional outcome, including intraarticular incongruity in the radiocarpal joint of more than 2 mm, a 1- to 2-mm step-off at the distal radioulnar joint, dorsal angulation of more than 20 degrees and radial inclination of less than 10 degrees, and the loss of sagittal tilt of 20 to 30 degrees. More than 10 degrees of dorsal tilt leads to decreased wrist flexion, and 6 mm of radial shortening causes dysfunction of the distal radioulnar joint. Fernandez observed that fractures with more than 25 or 30 degrees of angulation in the frontal or sagittal plane or 6 mm or more of radial shortening were likely to become

ACCEPTABLE MEASUREMENT Radial shortening of < 5 mm at distal radioulnar joint compared with contralateral wrist Radial inclination Inclination on posteroanterior film ≥ 15 degrees Radial tilt Sagittal tilt on lateral projection between 15-degree dorsal tilt and 20-degree volar tilt Articular incongruity Incongruity of intraarticular fracture ≤ 2 mm at radiocarpal joint

Modified from Graham TJ: Surgical correction of malunited fractures of the distal radius, J Acad Orthop Surg 5:270, 1997.

symptomatic. He also noted that patients with constitutional joint laxity may develop midcarpal instability with a dorsal tilt of only 10 to 15 degrees. One study reported significant changes to distal radioulnar joint mechanics as well as ligament lengthening with malunion of the distal radius, which may contribute to the dysfunction associated with these injuries. Laboratory studies showed that 20 to 30 degrees of dorsal tilt altered the force distribution across the radiocarpal joint, and this degree of deformity should be considered a prearthritic condition. Based on clinical and laboratory studies, Graham developed radiographic criteria for the acceptable healing of distal radial fractures (Table 58.3). These criteria should be used only as guidelines because of individual variations in preinjury anatomy and because some patients tolerate a greater degree of deformity than others. Significant articular incongruity and radial shortening are more consistently correlated with the development of symptoms than are other measurements.

CLINICAL EVALUATION

Pain, stiffness, weakness, and cosmetic deformity are common complaints in patients with distal radial malunions. Pain may be localized to the radiocarpal joint or distal radioulnar joint or both. Carpal instability patterns causing midcarpal pain may occur after dorsally tilted malunions (Fig. 58.36) (dorsal intercalated segment instability patterns) or diepunch fractures of the lunate facet (Fig. 58.37) (volar intercalated segment instability patterns). Decreased wrist flexion is typical of dorsally tilted malunions, and extension is limited with volarly tilted malunions. Loss of radial inclination can cause impaired ulnar deviation. Malunited Smith fractures and incongruity at the distal radioulnar joint lead to decreased pronation and supination, with supination affected more. Grip strength is impaired because of a combination of pain and altered wrist mechanics. Symptoms of median nerve compression may result from a dorsally tilted malunion that increases pressure within the carpal tunnel. Attritional ruptures of extensor tendons (most commonly the extensor pollicis longus) and, less frequently, of flexor tendons also have been reported.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Normal

A

Malunion

B

FIGURE 58.36 A, Normal radiocarpal and intercarpal alignment in sagittal plane. B, Dorsal tilting of radius may produce carpal collapse pattern similar to that in dorsal intercalated segment instability but without interosseous ligament disruption or secondary midcarpal instability. (From Graham TJ: Surgical correction of malunited fractures of the distal radius, J Acad Orthop Surg 5:270, 1997.)

Evaluation of distal radial malunions should include a detailed history and physical examination. The site of the pain (radiocarpal joint, distal radioulnar joint, midcarpal joint), intensity of the pain, and precipitating factors all should be noted. Mechanical symptoms should be distinguished from dystrophic pain. Range of motion in flexion, extension, radial and ulnar deviation, and pronation and supination should be measured. The stability of the distal radioulnar joint is assessed. Grip strength measurements of the affected and the uninjured wrists are helpful to determine the degree of weakness and can be used to assess functional recovery after surgery. The integrity of the soft tissues and degree of scar formation also should be noted. 

RADIOGRAPHIC EVALUATION

Plain anteroposterior and lateral radiographs of both wrists in neutral rotation are obtained to determine the nature and degree of deformity, to detect carpal subluxation and instability patterns, and to evaluate the quality of the bone. The uninjured wrist can be used as a template for surgical reconstruction if an osteotomy is chosen. The degree of correction necessary in the sagittal, coronal, and axial planes and the size and shape of the bone graft necessary to obtain the desired correction can be determined. CT is helpful to evaluate the potential for congruity of the distal radioulnar joint (axial views) and the condition of the articular surface. Malunions of the ulnar styloid also are well delineated by CT. MRI or arthrography can be used to evaluate the integrity of the triangular fibrocartilage complex and intercarpal ligaments. 

OPERATIVE TREATMENT

Indications for surgical intervention in a distal radial malunion include pain and functional deficits severe enough to interfere significantly with daily activities. Deformity of the

FIGURE 58.37 Die-punch fracture of lunate facet may produce volarly tilted malunion similar to volar intercalated segment instability.

distal radius, distal radioulnar joint, or both, or arthrosis of the radiocarpal joint or distal radioulnar joint also should be identified on radiographic studies. Operative treatment seldom is indicated for minimally symptomatic patients despite radiographic or cosmetic deformity. One possible exception is a young, active patient ( 2 mm, carpal instability, >20 to 30 degrees of dorsal angulation, incongruent distal radioulnar joint). Surgery is contraindicated in patients with active reflex sympathetic dystrophy syndrome. Reflex sympathetic dystrophy syndrome, also known as complex regional pain syndrome, is a distressing complication that often occurs after fractures around the wrist. In its early stages, this condition is characterized by extreme swelling of the soft tissues, exquisite tenderness to pressure, and pain on motion. Later, definite circulatory changes occur in the soft tissues and bone; the skin gradually becomes purplish and cold and perspires excessively. Even later, the joints of the fingers and wrist become increasingly stiff; even the shoulder and elbow can be affected secondarily from voluntary immobilization of the extremity in one position. Radiographs may show mottled decalcification or osteoporosis of the bones in late stages, but 30% of patients have no radiographic abnormalities. Three-phase delayed image bone scanning has been reported to be helpful in the diagnosis of reflex sympathetic dystrophy syndrome. Kozin et al. suggested that an abnormal bone scan in any of the three phases correlated with reflex sympathetic dystrophy syndrome, whereas Mackinnon and Holder indicated that only abnormalities in the third phase (regular bone scan) correlated with it. Reflex sympathetic dystrophy syndrome must be treated before surgery for malunion. No treatment is entirely satisfactory; treatment consisting of minimal immobilization with active and passive exercises, sympathetic blocks, and occupational and physical therapy seems to be as effective as any other treatment. Until symptoms and findings are relatively static or definite improvement is apparent, surgery usually should be delayed.

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TABLE 58.4

Guidelines for Treatment of Distal Radioulnar Joint in Radial Malunions RADIUS PARAMETERS INDICATED Unacceptable Acceptable Unacceptable

RADIOULNAR LENGTH Unacceptable Unacceptable Unacceptable

DRUJ REDUCIBLE BY RADIAL OSTEOTOMY Yes Yes No

POTENTIAL FOR DRUJ CONGRUITY Yes Yes Yes

Unacceptable

Unacceptable

No

No

RECONSTRUCTION DRO US DRO plus US or twostage reconstruction DRO plus DRUJ ablation

DRO, Distal radial osteotomy; DRUJ, distal radioulnar joint; US, ulnar shortening. Modified from Graham TJ: Surgical correction of malunited fractures of the distal radius, J Acad Orthop Surg 5:270, 1997.

Procedures used to treat malunions of the distal radius fall into three general categories: (1) procedures that correct the deformity of the distal radius (intraarticular and extraarticular osteotomies), (2) procedures that treat the pathologic process of the distal radioulnar joint (ulnar shortening, hemiresection arthroplasty, Sauvé-Kapandji procedure, Darrach resection of the distal ulna), and (3) salvage procedures (limited or total wrist arthrodesis, arthroplasty, proximal row carpectomy). These procedures can be used alone or in combination, depending on the specific deformity, functional demands, and degree of arthritic changes present in a particular patient (Table 58.4). Distal radial osteotomy and bone grafting are most often indicated in young, active patients with a significant radial deformity, good bone quality, good soft tissues, and minimal arthritic changes. Distal radial osteotomy alone often corrects distal radioulnar joint incongruence. In patients with remaining incongruity, an ulnar shortening osteotomy also is indicated. Lengthening of the distal radius more than 6 mm usually is impossible with distal radial osteotomy alone, and a concomitant ulnar shortening osteotomy often is needed in patients with more than 6 mm of radial shortening. If the distal radioulnar joint is arthritic or irreducible, a Bowers hemiresection arthroplasty or Sauvé-Kapandji distal radioulnar arthrodesis with pseudarthrosis should be done. Longterm results after osteotomy have shown that wrist alignment is maintained; however, some instability or symptomatic wrist arthritis may occur. An ulnar shortening osteotomy alone can be used to correct incongruence of the distal radioulnar joint if the radial deformity is minor. Resection of the distal ulna is another relatively simple technique that is useful in providing pain relief and improving motion in many patients with distal radial malunions. The technique is technically easier than radial osteotomy and bone grafting and does not have the danger of nonunion or recurrence of deformity. The distal radial deformity is not corrected, however, and radiocarpal symptoms may persist. Other potential complications include instability of the distal ulna and loss of grip strength. The primary indications for resection of the distal ulna are malunions in older patients with a significant ulnar variance, arthritis of the distal radioulnar joint, or as a salvage procedure after failed reconstruction of the distal radioulnar joint. Salvage procedures (wrist fusions) are indicated for symptomatic fractures with marked intraarticular comminution

or severe radiocarpal or intercarpal degenerative changes for which conservative treatment has failed. Carpal tunnel release sometimes is indicated either alone or in combination with other procedures. Dorsally displaced malunions decrease the space within the carpal tunnel, which can impair the excursion of the flexor tendons of the fingers or compress the median nerve. Division of the deep transverse carpal ligament in this situation improves function in the hand and wrist. Several types of fixation methods have been evaluated in the literature with comparable results. Fixed-angle volar plating with bone grafting provides stable fixation after corrective osteotomy and allows early mobilization. Tarng et al. used a 2.4-mm locking palmar plate without autologous bone grafting and noted that there was sufficient stability without the need for cast immobilization. Range of motion of the wrist was restored early. Intramedullary nailing has been reported to reliably correct deformity and produce good functional outcomes. A benefit of using an intramedullary nail is its percutaneous insertion, minimizing soft-tissue irritation. Distraction osteogenesis with the use of external fixation is an alternative to plating and has the benefit of not requiring plate removal and a second surgical procedure. Lubahn et al. reported that 17 of 20 patients healed uneventfully with this technique. Complications have included pin track infection and extensor pollicis longus rupture. Sammer et al., in a prospective study of five patients, found that although distraction osteogenesis was useful in improving the anatomy and function in distal radial malunions that required correction in multiple planes, a substantial amount of residual impairment remained in all domains of the Michigan Hand Outcomes Questionnaire, including activities of daily living; function cannot be expected to return to baseline. The use of bone graft also has been an area of study in the literature. Ozer et al. found no significant differences in clinical or statistical outcomes between patients who had locked volar plating without bone grafting and those who had locked volar plating with allograft bone. Abramo et al. used bone graft substitute with a buttress pin and plate system and reported minor loss of correction. They thought that a more rigid fixation system might be necessary with this type of bone graft substitute. Other authors have investigated whether precise preoperative planning of the size and shape of the corticocancellous bone graft restores alignment better than other grafting techniques, but they found no differences. Viegas described a modification that would

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22°

Trapezoidal graft

a = Radial inclination Osteotomy site

Graft harvest site

Graft harvest site

A

B

e = dorsal tilt

11° Osteotomy site

Dorsal

Palmar

C

Dorsal

Palmar

D

FIGURE 58.38 Trapezoidal osteotomy of distal radius. A, Preoperative posteroanterior view with decreased radial inclination; osteotomy and trapezoidal graft site are outlined. B, Postoperative posteroanterior view shows normal radial tilt and single “caging” pin. C, Abnormal dorsal tilt of radial articular surface reverses all loads across carpals and does not tolerate loading in active patients. D, Postoperative lateral view shows restoration of 11 degrees of palmar tilt before insertion of graft.

minimize or eliminate the need for bone grafting. The technique uses a volar and dorsal approach for an angled step-cut osteotomy, release of the extensor retinaculum, and volar plating. The dorsally extruded fracture fragments are mobilized and used as a dorsal strut graft to span the opening wedge osteotomy. Obert et al. used a costal cartilage graft harvested from the eighth rib to be placed in the epiphyseal-metaphyseal defect. Although costal cartilage grafts have been used in maxillofacial surgery, this was the first report of their use in intraarticular malunion. They reported results comparable to other grafts. 

EXTRAARTICULAR MALUNION WITH DORSAL ANGULATION

OSTEOTOMY AND GRAFTING OF THE RADIUS

Osteotomy and grafting most commonly are indicated for malunited Colles fractures in patients younger than 45 years old. Age should not be used as an absolute criterion, however. Older patients with good bone quality and high functional demands also may be considered for an osteotomy. Fernandez obtained satisfactory results with an opening wedge metaphyseal osteotomy combined with reinsertion of a graft and internal fixation with a plate and screws when no degenerative changes were present in the radiocarpal and intercarpal joints and when the preoperative range of motion of the wrist was adequate. Some patients benefited from the addition of a Bowers arthroplasty to the radial osteotomy. The evaluation

and treatment of distal radioulnar joint incongruity are discussed in more detail in the section on distal radioulnar joint arthrosis. Watson and Castle reported success with an osteotomy technique using a trapezoidal graft obtained from the dorsal radius (Fig. 58.38). Contraindications to radial osteotomy include active reflex sympathetic dystrophy, acceptable function despite deformity, poor soft-tissue envelope, severe osteopenia, and advanced radiocarpal or intercarpal arthritis. The role of timing of osteotomy for distal radial malunions has received attention more recently. It is well recognized that some patients regain adequate function despite residual deformity. Traditionally, osteotomy has not been done unless a patient has persistent pain and functional limitations after fracture healing and rehabilitation. Delaying corrective surgery until a patient is proved to be symptomatic may adversely affect the overall result. Prolonged angular deformity and shortening can produce altered loading of the articular surface, maladaptation of the soft tissues (capsule, ligaments), and dysfunction of the distal radioulnar joint. One comparison study showed no differences in outcomes between an early treatment group and a late treatment group; however, the overall time of disability was significantly shorter in the early group and the procedures were technically easier. Fracture lines were more easily identified, congruity of the distal radioulnar joint was more easily restored, and soft-tissue contractures were easier to correct. Although early intervention may lead to unnecessary surgery in some patients,

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FIGURE 58.39 Fernandez technique of osteotomy and grafting of distal radius. A and B, Site of osteotomy is marked. C, Osteotomy is opened dorsally, and graft is prepared. D and E, Graft is inserted and plate applied. SEE TECHNIQUE 58.30.

early reconstruction of distal radial malunions should be considered in young patients with high functional demands who have unfavorable radiographic parameters. Wada et al. reviewed opening and closing wedge osteotomy techniques in 42 patients with extraarticular distal radial malunions and found that radial closing wedge osteotomy and ulnar shortening without bone grafting produced better results in terms of restoration of ulnar variance, the extension-flexion arc of wrist motion, and the Mayo wrist score, although complications were similar to those observed with opening wedge osteotomy. Flinkkilä et al. did not recommend performing distal radial osteotomy for treatment of malunion in patients with mild symptoms. They examined their results in 45 patients with an average follow-up of 5.7 years and found that restoration of normal anatomy did not correlate with subjectively good results. Most patients received a dorsal opening wedge osteotomy and iliac crest bone graft stabilized with a plate. Good or satisfactory results were achieved in 33 of 45 patients. Seven patients had grade 2 osteoarthritis preoperatively. The distal radioulnar joint was not treated at the initial surgery. Overall, 12 patients required 19 additional surgeries; six were for distal radioulnar joint instability, and four were for osteoarthritis. Loss of supination and ulnar deviation correlated with an unsatisfactory result.   

OPENING WEDGE METAPHYSEAL OSTEOTOMY WITH BONE GRAFTING AND INTERNAL FIXATION WITH PLATE AND SCREWS TECHNIQUE 58.30 (FERNANDEZ) For a malunited Colles fracture, make a straight distal radial incision parallel to the long axis of the radius, begin-

n 

ning 2 cm distal to Lister’s tubercle and extending 8 cm proximally into the forearm. n  Expose the radius between the extensor carpi radialis brevis and extensor digitorum communis after mobilizing and protecting the extensor pollicis longus tendon. Subperiosteally, expose the radius to allow adequate seating of the buttress plate. n  Mark the site of osteotomy approximately 2.5 cm proximal to the wrist joint with an osteotome (Fig. 58.39A and B). n  Insert a Kirschner wire 4 cm proximal to the osteotomy site and perpendicular to the long axis of the radius. n  Insert a second Kirschner wire into the distal portion of the radius so that the angle subtended by it and the first Kirschner wire is equal to the angle of deformity in the sagittal plane. n  Confirm that the cut in the sagittal plane is parallel to the joint surface. n  Make the osteotomy and open it dorsally until the two Kirschner wires are parallel to restore the normal volar tilt of 5 to 10 degrees to the distal radial articular surface. Restoration of radial length is accomplished by opening the osteotomy on the radial side until the gap corresponds to the distance measured on the preoperative drawing (Fig. 58.39B to D). n  Stabilize the fragments with an oblique Kirschner wire. n  Obtain a bone graft from the ilium and trim it to fit the dorsal radial bone defect. Insert the bone graft and tamp it into place. Any pronation or supination of the distal fragment should be corrected before introducing the graft by rotating it around the long axis of the radius. n  Contour a small T-plate to fit the radius perfectly and stabilize it with two screws in each fragment (Fig. 58.39D and E). This should offer enough stability to allow motion soon after surgery. n  If the fixation is unstable, increase the number of screws in each fragment or add an additional oblique lag screw in the radial styloid across the osteotomy and into the cortex of the proximal radial fragment.

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS fractures has been advocated. The procedure is similar to the dorsal osteotomy described by Fernandez for dorsally angulated fractures. Additional procedures on the ulnar side of the wrist sometimes are necessary to correct distal radioulnar joint dysfunction. Indications for osteotomy are pain or functional deficits, rather than the extent of the deformity. Goals of the procedure are to reduce pain, improve motion, and correct deformity. Contraindications to the procedure are the same as the contraindications for the dorsal osteotomy. Shea et  al. reported 72% satisfactory results with this technique at short-term follow-up with improvement in radiographic parameters, wrist extension, forearm supination, and grip strength. Persistent pain in the distal radioulnar joint and restricted motion were noted in 6%. 

 

VOLAR OSTEOTOMY TECHNIQUE 58.31 FIGURE 58.40 Bowers arthroplasty with “anchovy” interposition of extensor carpi ulnaris. SEE TECHNIQUE 58.30.

If the distal radioulnar joint is arthritic, a Bowers arthroplasty is added using a graft from the extensor carpi ulnaris (Fig. 58.40); if it is not arthritic but remains incongruent, an ulnar shortening osteotomy is done (see Technique 58.36). n  Close the wound in layers and apply a sugar-tong splint. n 

POSTOPERATIVE CARE The wrist is immobilized in a volar plaster splint until the soft tissues heal. At 2 weeks, range-of-motion exercises are begun under the supervision of a physical therapist. No lifting work is allowed until the osteotomy has healed radiographically.   

EXTRAARTICULAR MALUNION WITH VOLAR ANGULATION

Fractures of the distal radius that unite with excessive volar inclination (Smith fractures) are less common than dorsally displaced malunions. Frequent sequelae of these malunions include decreased grip strength, decreased wrist extension, and cosmetic deformity owing to increased volar inclination, decreased radioulnar inclination, and the resultant ulnar deviation of the wrist. In addition, radial shortening and the characteristic pronation of the distal fragment cause incongruence and instability of the distal radioulnar joint. As a result, forearm rotation (especially supination) is limited and the distal ulna may impinge on the ulnar portion of the carpus. These deformities can cause pain and eventually arthrosis of the radiocarpal and particularly the distal radioulnar joint. Most researchers reported that volarly angulated malunions that were symptomatic initially were treated either nonoperatively or with internal fixation. Volar opening wedge osteotomy of the distal radius, with bone grafting and plating for symptomatic malunited Smith

(SHEA ET AL.) Obtain anteroposterior and lateral radiographs of the contralateral wrist to determine normal degrees of radioulnar and volar inclination. The goals are to restore the articular alignment of the distal radius to within 5 degrees of that on the contralateral side in the frontal and sagittal planes and to restore the articular congruity of the distal radioulnar joint. n  Plan the osteotomy so that it is transverse in the frontal plane and oblique in the sagittal plane. Locate the osteotomy as close as possible to the apex of the deformity. The shape of the corticocancellous graft is trapezoidal in the frontal plane and wider on the radial side to restore radioulnar inclination (Fig. 58.41A). The planned graft is triangular in the sagittal plane with the apex placed dorsally. n  Position the patient supine. n  Prepare and drape the involved arm and contralateral iliac crest after general endotracheal anesthesia has been induced. n  Use a volar approach between the tendon of the flexor carpi radialis and the radial artery, using the distal extent of the Henry approach (see Chapter 1). n  Use a pneumatic tourniquet to reduce bleeding. n  Elevate the pronator quadratus from the radial aspect of the distal radius and protect surrounding soft tissue with small Hohmann retractors. n  Drill a smooth 0.062- or 0.045-inch Kirschner wire into the radial shaft proximal to the site of the osteotomy and perpendicular to the long axis of the radius (Fig. 58.41B). Control the degree of planned correction in the sagittal plane by drilling a 0.062-inch Kirschner wire into the distal fragment in the predetermined angle of the deformity. Use these wires to help evaluate the correction of the deformity after the osteotomy. n  Use a small external fixator frame with one pin placed in the radial diaphysis to maintain the corrected alignment before placement of the bone graft, plate, and screws (Fig. 58.41C). n 

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E FIGURE 58.41 Volar osteotomy for malunited distal radial fracture (see text). A, Preoperative planning. B, Kirschner wire drilled into radial shaft proximal to osteotomy site. C, Small external fixator used to maintain corrected alignment. D, Osteotomy wedged open with lamina spreader. E, Iliac graft inserted and osteotomy stabilized with T-plate. (From Fernandez DL: Malunion of the distal radius: current approach to management, Instr Course Lect 42:99, 1993.) SEE TECHNIQUE 58.31.

Create the osteotomy with a sagittal saw, preferably at the site of the original fracture. n  Wedge open the osteotomy with a small lamina spreader clamp (Fig. 58.41D). Preserve the dorsal periosteum. This type of osteotomy corrects 10 mm of radial shortening. n  If lengthening of more than 10 mm is necessary, perform a Z-lengthening of the brachioradialis tendon and transect the dorsal periosteal sleeve. In this situation, the graft needed is trapezoidal in the frontal and sagittal planes. The resulting construct is less stable than if the dorsal periosteum is left intact. n 

Obtain and contour the corticocancellous iliac crest graft with the dimensions determined according to the preoperative plan. n  Insert the graft and stabilize the osteotomy with a 3.5mm angled T-shaped plate (Fig. 58.41E). n  The pronation deformity of the distal radial fragment tends to be corrected when the flat surface of the plate used to secure the osteotomy is applied to the volar aspect of the radius. n  Assess the distal radioulnar joint reduction. n  Perform an ulnar shortening osteotomy if normal ulnar variance cannot be restored with the distal radial n 

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FIGURE 58.42 A, Intramedullary nail implant. B, In vivo. (From Ilyas AM, Reish MW, Beg TM, Thoder JJ: Treatment of distal radius malunions with an intramedullary nail, Tech Hand Up Extr Surg 13:30, 2009.)

osteotomy and interposition of corticocancellous iliac crest graft. n  Perform an arthroplasty of the distal radioulnar joint if there is residual articular incongruity of that joint despite a more normal alignment and length of the distal radial fragment or if there is residual loss of passive rotation of the forearm intraoperatively after stable fixation of the osteotomy.

POSTOPERATIVE CARE The wrist is supported with a volar splint for 2 weeks, unless lengthening of 10 mm or more is necessary, in which case a below-elbow cast is worn for 6 weeks. Exercises and activities of daily living are encouraged after the external support has been removed. Activities against resistance and manual labor are not permitted until union has been confirmed radiographically, rarely before 8 weeks. The plate and screws are removed only if requested by the patient.      

INTRAMEDULLARY FIXATION Ilyas et al. reported a technique of intramedullary fixation after corrective osteotomies for treatment of extraarticular distal radial malunions. The implant (MICRONAIL; Wright Medical, Memphis, TN) (Fig. 58.42) is low profile and sits completely within the medullary canal of the distal radius. Unlike a locking plate that can be used for reduction, the distal radius requires reduction before insertion of the intramedullary nail. Three interlocking nails are placed through the distal implant in a divergent pattern. Two 2.7-mm bicortical interlocking screws are placed in a dorsal to volar

direction, locking in the length and rotation. The indication for this procedure includes a distal radial deformity of more than 15 degrees radial inclination, 4 mm loss of radial length, 4 mm ulnar variance, and 15 degrees dorsal or 20 degrees volar lateral tilt. The intramedullary nail should not be used in intraarticular fractures or in patients with active infections. Ilyas et al. used this fixation in more than 10 patients without any soft-tissue or hardware complications. We have not used this technology.

TECHNIQUE 58.32 Prepare the arm in a standard fashion. Use a hand table, tourniquet, and image intensifier. n  Make a 3-cm dorsal longitudinal incision extending from Lister’s tubercle proximally to over the radial shaft. Carry sharp dissection through the skin only. Perform blunt dissection to the level of the extensor retinaculum. Identify and release the extensor pollicis longus tendon and transpose it radially. Develop the interval between the pollicis longus tendon and the extensor digitorum communis, exposing the malunion site. Debride the overlying hypertrophied tissue. n  Perform the osteotomy at the malunion site using an oscillating saw or osteotome. For dorsally malunited fractures, use an osteotome to free the distal radius and hinge the dorsally malunited fracture on the intact volar cortex with a laminar spreader. If the cortex is not intact or if there is shortening of the distal radius with overlap of the volar cortices, take the osteotomy through both the dorsal and volar cortices circumferentially. Maximize mobilization of the distal radial fragment and release the surrounding soft tissue, in particular the brachioradialis. n 

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CHAPTER 58  MALUNITED FRACTURES After the distal radial fragment is freed, restore the radial length, radial inclination, and lateral tilt. Fix the provisional reduction with a 0.062-inch Kirschner wire placed dorsally along the ulnar column and then assess reduction. Volar tilt cannot be further corrected with the intramedullary nail, so it must be corrected and provisionally fixed before insertion of the nail. After insertion of the intramedullary nail, further height and inclination can be obtained. n  For nail insertion, make a 3-cm incision over the radial styloid, and with blunt dissection develop the interval between the first and second dorsal compartments. Identify and protect the branches of the radial sensory nerves. Place an additional 0.062-inch Kirschner wire into the radial styloid in the bare spot between the first and second dorsal compartments. Place a cannulated reamer over the Kirschner wire. Do not violate the articular surface of the radiocarpal joint or distal radial ulnar joint. Enter the distal radius with a starting awl and a broach and sequentially ream with the osteotomy held reduced. n  When selecting the actual implant, downsizing the nail proximally allows for further manipulation and reduction of the radius. Attach the implant to the aiming jig and place it into the broached path through the radial styloid. Place three divergent locking screws through the aiming jig directed into the subchondral bone of the distal radius. Remain subchondral to optimize purchase and avoid penetration of the articular surface or injury to the superficial radial sensory nerve. n  If necessary, the final position can be optimized by manipulation through the handle of the aiming jig that is still attached to the intramedullary nail within the distal radial fragment. n  Place bone graft into the dorsal defect. n  Place the proximal locking screws using the locking jig over the dorsum of the distal radius through the first incision, fixing the position of the osteotomy. n  Close the wound in the standard fashion and apply a plaster volar splint with the metacarpophalangeal joints and fingers left free. n 

POSTOPERATIVE CARE  The splint is left in place for 10 to 14 days. The sutures are removed, and a removable splint is applied. Gentle range of motion is started.    

 

EXTERNAL FIXATION Plate and screw fixation of distal radial malunions may be complicated by prominent hardware, late extensor tendon rupture, and need for subsequent hardware removal. To avoid these potential complications, Melendez advocated a technique of opening wedge osteotomy, bone grafting, and external fixation for symptomatic extraarticular distal radial malunions. The external fixator used does not span the wrist and allows early motion. Melendez reported his results in seven patients, all of

whom had significant radiographic deformities and pain associated with lifting or axial loading of the wrist and forearm rotation. A Darrach procedure also was done in two patients with radial shortening of 8 mm. All osteotomies healed at an average 7.5 weeks. Pain was reduced, mobility was increased, and radiographic parameters were significantly improved in all patients. Postoperative motion was an average of 88% of that of the contralateral wrist. Five complications occurred in three patients. Two patients with pin site infections were treated with local irrigation and cephalosporin. One patient developed a wound dehiscence at the distal pin site that required early fixator removal at 5 weeks and cast placement. One patient required remanipulation of the osteotomy, and one patient developed a transient radial nerve paresthesia. Contraindications to this technique include osteoporosis, more than 8 mm of radial shortening, intraarticular malunions, and malunions associated with radiocarpal or midcarpal arthritis.

TECHNIQUE 58.33 (MELENDEZ) Approach the wrist through a longitudinal radial incision. Incise the retinaculum over the first dorsal compartment and retract the tendons dorsally. n  Insert small guiding needles into the subcutaneous tissue to help view the direction in which the pins should be drilled. Use an image intensifier to guide pin placement. Drill the first pin into the distal radius in a radial-to-ulnar direction, parallel to the articular surface, starting in the groove of the first dorsal compartment. Insert the second pin dorsal to the tendons of the first dorsal compartment, aiming radially to ulnarly and paralleling the articular surface. The extensor tendons of the first dorsal compartment and sensory branch of the radial nerve lie between the two pins. n  Open the osteotomy site using traction or a lamina spreader. n  Using the Orthofix (Orthofix SRL, Verona, Italy) minifixator as a template, insert the two proximal pins into the proximal radius. n  Adjust the position of the osteotomy using the ball joint and distraction mechanism. n  Use image intensification to ensure proper position. n  Harvest a block of corticocancellous iliac crest bone graft, fashion it to fit the osteotomy gap, and place it into the osteotomy site. n  Close the skin. Make relaxing incisions around the pin sites. n  Apply a removable wrist splint. n  n 

POSTOPERATIVE CARE  Active finger motion is encouraged, and pin site care instructions are given. Patients are seen weekly for the first 2 weeks. After suture removal, active range of motion of the wrist is encouraged. A removable wrist splint is used between exercise sessions. After 2 weeks, patients are evaluated clinically and radiographically until the osteotomy has healed and the external fixator is removed in the office.   

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PART XV  FRACTURES AND DISLOCATIONS IN ADULTS Shin and Jones reported using provisional stabilization of the osteotomy with the Agee WristJack external fixation device (Hand Biomechanics Laboratory, Sacramento, CA) to facilitate plate application with minimal interference from the distal pins. They cite several benefits over other small external fixation devices in that its gear mechanism confers stable distraction of the distal radius and facilitates positioning of the distal fragment. Bone graft can be shaped to precisely fit the defect. The fixator also can be maintained after surgery to supplement internal fixation.

INTRAARTICULAR MALUNIONS

Intraarticular malunions of the distal radius frequently lead to functional disability. Intraarticular incongruity of 2 mm or more was associated with poor results and a likelihood of posttraumatic arthritis. It is preferable to prevent malunions through aggressive initial management of intraarticular distal radial fractures. Surgical treatment of intraarticular distal radial malunions can be broadly grouped into procedures aimed at preventing posttraumatic arthritis (intraarticular osteotomies) and salvage procedures (limited carpal arthrodesis, total wrist arthrodesis, proximal row carpectomy, wrist denervation, and wrist arthroplasty). Intraarticular osteotomies are indicated in young, active patients with high functional demands, more than 2 mm of articular step-off, and no evidence of posttraumatic arthritis. An additional indication is volar or dorsal subluxation of the radiocarpal joint. Because these procedures are technically demanding, they are recommended only for malunions with simple intraarticular fracture patterns, such as radial styloid fractures, Barton fractures, and dorsal die-punch fractures. Contraindications to intraarticular osteotomy include advanced osteoarthritis, massive articular comminution, poor bone quality, low functional demands, poor soft-tissue coverage, and reflex sympathetic dystrophy. Preoperative evaluation should include tomography or CT with 1-mm cuts to characterize the malunion more precisely. Three-dimensional reconstruction, when available, also can be useful. If the condition of the articular cartilage is uncertain, wrist arthroscopy can be done. Optimally, intraarticular osteotomies are done within 6 weeks after injury, when fracture lines are more easily identified. With large articular step-offs, arthritis may develop within the first year, and the wrist may become unsalvageable if osteotomy is delayed too long. Intraarticular malunions frequently are associated with other pathologic conditions (extraarticular malunions, distal radioulnar joint dysfunction, scapholunate ligament injury), which also should be treated at the time of surgery. There are few reports in the literature concerning the results of intraarticular osteotomy for intraarticular distal radial malunions, and long-term outcome is uncertain. Twoand 3-year outcomes in small series report good or excellent results in most patients. Ruch et al. noted that early intraarticular osteotomy significantly improved grip strength and range of motion of the wrist. Marx and Axelrod reported excellent results in one patient and good results in three patients, and all were satisfied with the result. In a multicenter study, Ring et al. reported 23 intraarticular distal radial malunions treated with corrective osteotomy, with an average follow-up of 38 months. The indication in 14 patients was dorsal or volar subluxation of the radiocarpal joint, and 17 patients had at least 2 mm of

articular incongruity. Six patients had combined intraarticular and extraarticular malunions. Malunions were corrected an average of 6 months after the initial injury. Fixation was performed with screws alone in seven patients, Kirschner wire fixation alone in two patients, and plate and screw fixation in 14 patients. Seventeen patients required autogenous bone grafting. All osteotomies healed with an average postoperative incongruity of 0.4 mm, and there was no osteonecrosis. Six patients had grade I arthrosis preoperatively, and 10 had postoperative arthrosis (eight grade I, two grade II). Dorsal implants were removed in seven patients, whereas no volar implants were removed. Five patients required other procedures at a later date (one partial wrist arthrodesis, three procedures for distal radioulnar joint dysfunction, and one tendon transfer for extensor pollicis longus rupture). Using the Fernandez and the Gartland and Werley criteria, 83% had good or excellent results. Grip strength averaged 83% of the opposite side, flexion averaged 56 degrees, and extension averaged 56 degrees. The authors asserted that this procedure cannot restore a normal wrist but can improve wrist function and delay arthritis in a healthy, active patient.   

OSTEOTOMY FOR INTRAARTICULAR MALUNION TECHNIQUE 58.34 (MARX AND AXELROD) If the articular malunion is located dorsally, approach the distal radius through a longitudinal incision between the third and fourth extensor compartments. Continue the dissection through the third compartment and reflect the extensor tendons ulnarly without violating the fourth compartment. Continue the exposure distally into the dorsal wrist capsule. n  Expose the distal radial articular surface with a T-shaped incision. If the intraarticular malunion is located volarly (malunited volar Barton fracture), approach the distal radius through a palmar incision in the interval between the flexor carpi radialis and the radial artery. The articular surface is seen through the fracture site, preserving the volar radiocarpal ligaments. n  Use a dull instrument to distinguish between hyaline cartilage and fibrocartilage; fibrocartilage feels softer. n  Carefully remove the fibrocartilage to appreciate the articular step. n  Identify the metaphyseal scar to re-create the primary extraarticular fracture. n  Pass two or three small (0.062-inch) Kirschner wires along the plane of the fracture, beginning at the extraarticular component and exiting within the joint to ensure that the correct plane is identified. n  Confirm Kirschner wire placement radiographically. n  Make the osteotomy through the old fracture site into the joint using a 3- or 4-mm wide osteotome. Monitor reduction with direct vision and radiographs. Intraoperative fluoroscopy is useful. n 

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CHAPTER 58  MALUNITED FRACTURES Provisionally stabilize the osteotomy with Kirschner wires. Use lag screws or a dorsal buttress plate for definitive fixation. The small 2.0- and 2.7-mm plate designs may be useful. n  If the osteotomy creates a large metaphyseal defect, fill the void with autogenous iliac crest bone graft. n  Extraarticular malunions, if present, are corrected before definitive fixation. If