Atlas of Essential Orthopaedic Procedures [1 ed.] 0892036346, 9780392036349

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, Evan Flatow. MD

Alexis Chiang Calvin. Editors

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Amman ACADEMY ml DRTHDPAEDIG SURGEDNE

Atlas of

Essential Orthopaedic Procedures

Atlas of

Essential Orthopaedic Procedures Edited by Evan Flatow, MD Chairman

Department of Orthopaedics Mount Sinai School ofMedicine New York, New York

Alexis Chiang Calvin, MD Assistant Profizssor Department of Orthopaedics Mount Sinai School ofMedicine New York, New York

AAOS

AMERICAN Acaosmr or ORTHOPAEDIC SURGEONS

American Academy of Ordlopaedic Surgeons Board of Directors, 2013-2014 Joshua J. Jacobs, MD President Frederick M. Azar, MD First Vice-President

David Teuscher Second Vice—President John R. Tongue, MD Past President

Andrew N. Pollak, MD "lieasnrer Annunciato Amendola, MD

William]. Best Joseph A. Bosco III, MD

Matthew B. Dobbs, MD Wilford K. Gibson, MD

The material presented in the Atlas of Essential Orthopaedic

Procedures has been made available by the American Academy of Orthopaedic Surgeons for educational purposes only. This

material is not intended to present the only, or necessarily best,

methods or procedures for the medical situations discussed, but rather is intended to represent an approach, View, statement, or

opinion of the authorts} or producer[_s}, which may be helpful to others who face similar situations.

Some drugs or medical devices demonstrated in Academy courses

or described in Academy print or electronic publications have not been cleared by the Food and Drug Administration (FDA) or have

been cleared for specific uses only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice.

Furthermore, any statements about commercial products are solely the opinion(s) of the author{s) and do not represent an

Academy endorsement or evaluation of these products. These statements may not be used in advertising or for any commercial

David Mansfield, MD

PUIPPPE-

John I. McGraw, MD

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any

Todd A. Milbrandt, MD David C. Templeman, MD

form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Karen L. Hackett, FACI-IE, CAB

ISBN 937'3-0-39203-634-9

Steven ELK. Ross, MD

(ex (wit-to)

Library of Congress Control Number: 2013933??? Printed in the DEA

Staff Constance M. Filling, CiriefEdncation Qflicer Hans Koelsch, PhD, Director, Department of Pairiications Jane Baque, Senior Manager, Publications Websites

Laurie Braun, Managing Editor Juliet Drellana, Copy Editor

Published 2013 by the

American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, IL 60018

Copyright 2013 by the American Academy of Orthopaedic Surgeons

Mary Steermann Bishop, Senior Manager, Production and Content Management

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(it 2013 American Academy of Drthopaedic Sat-gems

Acknowledgments Editorial Board Atlas of Essential Orthopaedic Procedures Editors Evan Hatow, MD Chairman Department of Orthopaedics

Mount Sinai School ofMedicine New York, New York

Alexis Chiang Calvin, MD

Assistant Professor

Department of Orthopaedics Mount Sinai School of Medicine New York, New York

Section Editors Eben A. Carroll, MD (Ttauma) Assistant Professor

Department of Orthopaedic Surgeryr Wake Forest ll’nioersityr Winston—Salem, North Carolina

Andrew C. Hecht, MD (Spine)

Chief, Spine Surgeryr Assistant Professor, Orthopaedics and Neurosurgery Mount Sinai Medical Center

New York, New York

Henry G. Chambers, MD (Pediatrics) Professor ofClinical Orthopaedic Surgeryr

William Macaulay, MD (Adult Reconstruction)

Alexis Chiang Calvin, MD {‘Sports Medicine) Assistant Professor Department of Orthopaedics Mount Sinai School of Medicine

Michael Pinznr, MD (Foot and Ankle) Professor of Orthopaedic Surgery Department of Orthopaedic Surgeryr loyola Llnioersityr Health System

Department of Orthopaedic Surgery linioersit},r of California, San Diego San Diego, Califirrnia

Chin; Dimision ofAdult Reconstruction of the Hip and Knee Department of Orthopaedics Columbia Unioersity Medical Center New York, New York

New York, New York

hrlaywood, Illinois

Edward Dian, MD (Hand and Wrist)

John W. Sperling, MD, MBA (Shoulder and Elbow)

Professor Emeritus ChefofHand Surgery

Califirrnia Pacific Medical Center

Consultant Department of Orthopedic Surgeryr hrlayo Clinic Rochester; Minnesota

Christopher D. Harrier, MD (Sports hiedicine)

Chairman

Chiefof Sports Medicine Department of Orthopaedic Surgery University of Pittsburgh Medical Centerfor Sports Medicine

Medical Center of Central Georgia Macon, Georgia

Lilnioersityr of Calrfilrnia, San Francisco

San Francisco, California

Professor

Pittsburgh, Pennsylvania

(El 2013 American Academy of Orthopaedic Surgeons

Lawrence X. Webb, MD (Trauma)

Georgia Orthopaedic Trauma Institute

Contributors Nicholas A. Abidi, MD

Director Department of Orthopaedic Surgery

Santa Cruz Orthopaedic Institute, Inc. Capitola, California

Samttam Bajai, BE Midwest Orthopaedics at Rush Rush University Medical Center Chwago, lllinois

Champ L. Baker 11], MD Julie E. Adams, MD, MS

Stafi Physician

Department ofOrthopaedic Surgery University of Minnesota

Columbus, Georgia

Assistant Professor

Minneapolis, Minnesota

John Mains, MD

Orthopaedic Surgeon Department ofOrthopaedic Surgery

The Hughston Clinic Champ L. Baker, Jr, MD

The Hughston Clinic Columbus. Georgia

Kelley Banagan, MD

Mountain View Specialty Clinic Mountain View, Arkansas

Assistant Professor, Spine Surgery Department of Orthopaedics University ofMaryland

David W. Altchek, MD

Baltimore, Maryland

Co—chief, Sports Medicine and Shoulder Service Sports Medicine and Shoulder Services Hospital for Special Surgery New York, New York

Anmmaiato Amendola, MD

Professor Department ofOrthopaedic Surgery and Rehabilitation

University in" town Hospitals and Clinics

ioura City, lowa

Howard An, MD

Professor and Director of Spine Surgery Department ofOrthopaedics Rush University Medical Center Chicago, lllinois Robert A. Arciero, MD

Professor of Orthopaedics

Alireza Behboucli, DD Orthopedic Surgeon Department of Orthopedic Surgery East listens Medical Center Tyler, Texas

Stephen Benirschke, MD

Department of Orthopaedics and Sports Medicine Harborview Medical Center Seattle, Washington Gregory C. Berlet, MD

Attending Physician Department of Orthopedic Foot and Ankle Surgery Orthopedic Foot 6‘ Ankle Center Columbus, Ohio

Department ofOrthopaedics

Louis U. Bigliani, MD Professor and Chairman

Pannington, Connecticut

Columbia University Medical Center

University of Connecticut Health Center Bernard R. Bach, Jr, MD The Claude N. Lambert, MD — Helen Susan Thomson Professor ofOrthopaedic Surgery

Director, Division ofSports Medicine Director, Sports Medicine Fellowship Rush University Medical Center

Department of Orthopaedics New York, New York

Randy Bindra, MD Orthopaedic Surgeon Department of Orthopaedic Surgery Loyola University Medical Center Mayavood, lllinois

Chicago, lllinois Michael V. Birman, MD Sermon Bader, MD

Hand and Microvascular Surgery Fellow

Geoffrey 5. Fact, MD, PhD

New York, New York

Walnut Creek, Califirrnia

Assistant Professor

Department ofOrthopedics and Rehabilitation

Division of Sports Medicine University of Wisconsin Madison, Wisconsin

D 2013 American Academy of Orthopaedic Surgeons

Department of Orthopaedic Surgery Columbia University Medical Center Scott D. Baden, MD

Director The Emory Spine Center

Emory University School ofMedicine Atlanta, Georgia

vii

Davide Eduardo Bonasia, MD

Thomas D. Cha, MD, MBA

I Clinics Ortopedica, AO CTO Hospital University of Torino Torino, Italy

Massachusetts General Hospital Boston, Massachusetts

Orthopaedic Surgeon

Christopher M. Bono, MD

Associate Professor of Orthopaedic Surgery Harvard Medical School Chief, Orthopaedic Spine Service Brigham and Women’s Hospital

Boston, Massachusetts

Robert B. Boume, MD, FRCSC

Professor of Surgery Division of Orthopaedic Surgery Western University

Spine Surgeon Department of Orthopaedic Surgery

Peter Chalmers, MD

Resident Department of Orthopaedic Surgery Rush Unitersity Medical Center

Chicago, lltinois

Henry (3. Chambers, MD Professor ofClinical Orthopaedic Surgery

Department of Orthopaedic Surgery University ofCalifornia, San Diego San Diego, California

tendon, Ontario, Canada

Paul D. Choi, MD

Karl F. Bowman, Jr; MD Fellow, Sports Medicine

Centerfor Sports Medicine Department ofOrthopaedic Surgery University of Pittsburgh

Pittsburgh, Pennsylvania

Assistant Professor of Clinical Orthopaedics Department of Orthopaedic Surgery

Children 's Hospital Los Angeles University of Southern California Los Angeles, California Loretta Chou, MD

James P. Bradley, MD

Clinical Professor

Burke 6r Bradley Orthopedics University of Pittsburgh Medical Center

Pittsburgh, Pennsylvania Jayeen Brown, BS

Clinical Manager Stanley Graves MDPC

Phoenix, Arizona

Professor Departrrrent of Orthopaedic Surgery Stanford University

Stanford, California

Michael P. Clare, MD Director ofFoot and Ankle Fellowship Education Florida Orthopaedic Institute Tampa, Florida

I. fluis Coetzee, 1WD, FRCSC LCDR Brandon Bryant, MD, USN

Assistant Professor ofOrthopaedic Surgery

Department ofOrthopaedic Surgery and Sports Medicine

Portsmouth Naval Medical Center Portsmouth, Virginia James B. Carr, MD ldeceased)

Roanoke, Virginia

Eben A. Carroll, MD

Assistant Professor Department ofOrthopaedic Surgery Wake Forest University

livin Cities Orthopedics Edina, Minnesota

Brian]. Cole, MD, MBA

Professor, Section Head Department of Orthopaedics, Anatomy and Cell Biology Cartilage Restoration Center

Rush University Medical Center Chicago, lllinois Alexis Chiang Calvin, MD Assistant Professor Department of Orthopaedics

Winston—Salem, North Carolina

Mount Sinai School ofMedicine New York, Nero York

Cordelia Carter, MD

Andrew]. Cosgarea, MD

Assistant Professor Department ofOrthopaedics and Rehabilitation Yale University

Professor and Director of Sports Medicine Department of Orthopaedic Surgery johns Hopkins University

New Haven, Connecticut

Baltimore, Maryland

Danielle Casagrande, MD

Michael]. Coughlin, MD

Department ofOrthopaedics University of Texas Medical Branch

Department of Orthopaedic Surgery Saint Alphonsus Regional Medical Center Boise, ldaho

Orthopaedic Resident Galveston, Texas

Chief. Coughlin Foot and Ankle Clinic

(D 2013 American Academy of Orthopaedic Surgeons

Jonathan R. Danoff, MD Postdoctoral Residency Fellow Department ofOrthopaedic Surgery

Associate Professor

New York PresbyterianfColum-lria University Medical Center New York, New York

Duke University Medical Center Durham, North Carolina

Michael R. Dayton, MD Assistant Professor Department ofOrthopaedics

T. Bradley Edwards, MD Attending Shoulder Surgeon Fondren Orthopedic Group

Samuel M. Davis, MD

John J. Elias, PhD

University of Colorado Denver Aurora, Colorado Assistant Pmfiassor

Mark E. Easley, MD

Department of Orthopaedic Surgery

Texas Orthopedic Hospital Houston, Texas

Senior Research Scientist

Department ofOrthopaedic Surgery Emory University

Atlanta, Georgia

Calhoun Research Laboratory Akron General Medical Center Akron, Ohio

Thomas M. Deflerardino, MD

Jesse James F. Exaltacion, MD

Department ofOrthopaedic Surgery

University of Connecticut Health Center

Centerfirr Orthopaedic Surgery The Methodist Hospital Houston, Texas

Gregory E“. Deirmengian, MD Assistant Professor ofOrthopaedic Surgery Rothman Institute Thomas Jefi‘erson Medical School

Chairnwn Department of Orthopaedics and Rehabilimtion

Philadelphia, Pennsylvania

San Antonio Military Medical Center Fort Sam Houston, Texas

Edward Diao, MD

Larry D. Field, MD

Associate Professor

Farmington, Connecticut

Professor Emeritus

Chiefof Hand Surgery University ofCalifirmia, San Francisco Caly‘irmia Pacific Medical Center San Francisco, Califirrnia

Gregory S. DiFelice, MD Orthopaedic Surgeon Department ofOrthopaedic Surgery

Hospital for Special Surgery New York, New York

Joshua S. Dines, MD Orthopedic Surgeon Sports Medicine and Shoulder Service Hospital for Special Surgery New York, New York

Henry J. Dolch, DD

Orthopaedic Trauma Surgeon

Orthopaedic Trauma Group

Charleston Area Medical Center Charleston, West Virginia

Fellow, Adult Reconstructive Surgery

COL James R. Fiche, MD

Director

Upper Extremity Service Mississippi Sports Medicine and Orthopaedic Center

Jackson, Mississippi

Steven J. Fineherg, MD Research Coordinator Department of Orthopaedic Surgery Rush University Medical Center Chicago, lllinois Jennifer FitzPatrick, MD

Orthopedic Surgeon Department of Orthopedics University ofColorado

Aurora, Colorado

John C.FL Floyd, MD Associate Professor

Mercer University School ofMedicine Associate Director Georgia Orthopaedic Trauma Institute Macon, Georgia

James C. Deeese, MD

John M. Flynn, MD

Department ofOrthopaedics

Professor ofOrthopaedic Surgery

Assistant Professor

University ofhrlaryland Baltimore, Maryland

Thomas R. Duqoin, MD

Assistant Professor Department ofOrthopaedic Surgery State University of New York, University at Bufilrlo Bufialo, New York

(D 2013 American Academy of Orthopaedic Surgeons

Associate Chief

University ofPennsylvania School ofMedicine Department of Pediatric Orthopaedics The Children '5 Hospital ofPhiladelphia Philadelphia, Pennsylvania

Brett A. Freedman, MD

James A. Goulet, MD

Department ofOrthopaedics and Rehabilitation

Department of Orthopaedic Surgery

Chief, Spine and Neurosurgery Service

Landstuhl Regional Medical Center Landstuhl, Germany Carol Frey, MD Orthopaedic Surgeon Assistant Professor

Clinical Orthopaedic Surgery University of Californ ia, Los Angeles

Los Angeles, Californtn

Freddie H. Fu, MD David Silver Professor and Chaim‘tart Department of Orthopaedic Surgery University of Pittsburgh

Pittsburgh, Pennsylvania

Bethany Gallagher, MD Assistant Professor Department ofOrthopaedics Vanderbilt University

Nashville, Tennessee

Lauren E. Geaneg. MD

Orthopaedic Resident Department ofOrthopaedic Surgery University of Connecticut

Pennington, Connecticut

Prry‘essor

University ofMichigan Ann Arbor, Michigan

Stanley C. Graves, MD Director

Stanley Graves MD PC Phoenix, Arizona

Steven B. Haas, MD

Chiefi Knee Service

Hospitalfor Specarl Surgery New York, New York

Marl: E. Hake, MD

Resident Department of Orthopaedic Surgery University ofMichigan Ann Arbor, Michigan

Jason I. Halvorson, MD

Chis;rResident Department of Orthopaedic Surgery Waite Forest University School ofMedicine Winston-Satan, North Carolina

Christopher D. Hamel; MD

sor

Chief of Sports Medicine

William B. Geissler, MD

Department of Orthopaedic Surgery

University ofMississippi Medical Center

Andrew C. Hecht, NID

Professor and Chief Division ofHand and Upper Extremity Surgery Department of Orthopaedic Surgery

lflflkfiflfl. MiSSiSSI'PPI'

Jeffrey A. Geller, MD

Associate Professor of Orthopaedic Surgery

Department ofOrthopaedic Surgery Nero York-Presbyterian HospitaIJCoiumbia University New York, New York Neil Ghodadra, MD Department ofOrthopedic Surgery and Sports Medicine Southern California Orthopedic Institute Van Nuys, California Filippos S. Giannoulis, MD Orthopaedic Surgeon

University ofPittsburgh Medical Centerfor Sports Medicine Pittsburgh. Pennsylvania

Chief. Spine Surgery

Assistant Professor, Orthopaedics and Neurvsurgery Mount Sinai Medical Center

New York, Nero York

john G. Heller, MD Baur Professor of Orthopaedic Surgery Depurimcnt of Orthopaedic Surgery Emory University School ofMedicine Atlanta, Georgia Christopher B. Himse, MD Orthopaedic Surgeon

The Coughlin Clinic Saint Alphonsas Regional Medical Center

Hand. Upper Extremity. and Micrvsurgery Department Athens UAT Hospital Athens, Greece

Boise, ldaho

Thomas V. Giel 11], MD

HPC Oldenburg

Orthopaedic Surgeon

Division of Sports Medicine UrihflMflflPlt-ifi

Reimer Hoffmam'l, MD Consultant Hand Surgeon

Oldenburg, Germany Donald W. Hohman, Jr, MD

Memphis, Tennessee

Orthopaedic Resident

Hilton Phillip Gottschalk, MD Pediatric Orthopaedic Surgeon Central Texas Pediatric Orthopedics Dell Children’s Hospital

State University :3m York, University at Bufaio Bufalo, New York

Department of Orthopaedic Surgery

Austin, Texas

or

(it 2013 American Academy of Orthopaedic Surgeons

Harish Hosalkan MD

James P. Kellam, BSc, MD, FRCSC, FACS, FRCSI

San Diego, California

Carolinas Medical Center Charlotte, North Camlina

Jonathan A. Hoskins, MD Research Associate Department ofOrthopaedic Surgery

Attending Physician Resurgens Orthopaedics

Attending Orthopedic Surgeon Department ofOrthopedics Rady Children ’5 Hospital

Director of Orthopaedic Trauma Program Department of Orthopaedic Surgery

Stephen Kim, MD

Rush University Medical Center

Kennestone Hospital Marietta, Georgia

William]. Hozack, MD

Mininder S. Kuchen, MD, MPH Associate Director

Chicago, litinois

Professor of Orthopaedic Surgery

Rothman Institute Thomas Igfi‘erson Medical School Philadelphia, Pennsylvania

Stephanie Hsu, MD .Fellow Centerfirr Shoulder, Elbow, and Sports Medicine

Division ofSports Medicine Boston Children's Hospital Boston, Massachusetts

Patricia Kramer, PhD

Research Associate Professor

Department ofAnthropology

New York, New York

University of Washington Seattle, Washington

Stephen J. Incavo, MD

Jonathan H. Lee, MD

Houston, Texas

Columbia University Medical Center New Park, New York

Peter Johnston, MD Southern Maryland Chthopaedics and Sports Medicine

Ronald A. Lehman, Jr, MD Chief, Pediatric and Adult Spine

Calumtria University

Section Head, Adult Reconstructive Surgery Department ofOrthopaedics The Methodist Hospital

Leonardtown, Maryland

Assistant Professor, Clinical Orthopaedic Surgery Department of Orthopaedics

Associate Prvfissor ofSurgery

Clifford B. Jones, MD, FACS

Walter Reed National Medical Center Bethesda, Maryland

Grand Rapids, Michigan

Associate Professor Department of Orthopedic Surgery

Jesse B. Jupiter; MD

IOklahoma City, Oklahoma

Clinical Professor Michigan State University College of Human Medicine Orthopaedic Associates of Michigan

Hansjorg Wyes A0 Profiessor

Department ofOrthopaedic Surgery

Massachusetts General Hospital Boston, Massachusetts

Jay V. Kalawadia, MD Resident Physician Department ofOrthopaedic Surgery Northwestern University

Chicago, lllinois

Daniel G. Kang, MD

Orthopaedic Surgery Resident Department ofOrthopaedic Surgery and Rehabilitation Walter Reed National Military Medical Center Bethesda, Maryland Christopher A. Keen, MD

Fellow Department ofOrthopaedic Surgery and Rehabilitation

University ofMississippi Health Care

Jackson, Mississippi

(D 2013 American Academy of Orthopaedic Surgeons

Thomas F. Lehman, PI}. MD

University of Oklahoma Health Sciences Center

lawrence G. Lenka, MD

Jerome I. tden Distinguished Professcrr of Orthopaedic Surgery Chiefof Spine Surgery Department of Orthopaedic Surgery Washington University School ofMedicine Saint Louis, Missouri

Albert Lin, MD

Assistant Professor

Department of Orthopaedics Division of Sports Medicine University ofPittsburgh Medical Center Pittsburgh, Pennsylvania

Sheldon S. Lin, MD

Associate Profiessor

Department of Orthopaedics University ofMedicine Er Dentistry ofNew Jersey New Jersey Medical School Newark, New Jersey

Randall T. Loder, MD Department ofOrthopaedic Surgery

Riley Children ’s Hospital Indianapolis, lndiana John D. Lubahn, MD

Hand, Microsurgery, and Reconstructive Orthopaedics, LLP Erie, Pennsylvania

Steven C. Ludwig, MD Associate Professor and Chiefof Spine Surgery Department of Orthopaedics University ofMaryland Baltimore, Maryland Jeffrey Macalena, MD

Assistant Profi-ssor

Department ofOrthopaedic Surgery University ofMinnesota

Anna N. Miller, MD Assistant Professor Department of Orthopaedic Surgery

Wake Forest School ofMedicine Winston-Salon, North Carolina

Bradley Moatz, MD Resident Physician Department of Orthopaedics Union Memorial Hospital

Baltimore, Maryland

Scott]. Mubarak, MD

Department of Orthopedics Pediatric Orthopedic and Scoliosis Center Rudy Children 's Hospital University ofCalifornia, San Diego San Diego, California

Minneapolis, Minnesota

Daniel I. NagIe, MD

William Macaulay, MD

Department of Orthopaedic Surgery Feinlrerg School ofMedicine Northwestern University

Chief, Division ofAdult Reconstruction of the Hip and Knee Department ofOrthopaedics

Columbia University Medical Center New York, New York Tahir Mahmud, BSclHons), MBBS, MRCSfEng}, FRCSl'Ii' & Orth} Fellow, Adult Lower Limb Reconstruction

Division of Orthopaedic Surgery

London Health Sciences Centre University Hospital London, Ontario, Canada Richard C. Mather 1]], MD

Assistant Professor Department of Orthopaedic Surgery Duke University Medical Center Durham, North Carolina Kristofer S. Matullo, MD

Head ofHand Surgery Orthopaedic Surgical Specfilists

Clinical Professor

Chicago, Illinois

Blaise Alexander Nemeth, MD, MS

Associate Professor, Clinical Health Science

Department of Orthopedics and Rehabilitation University of Wisconsin School ofMedicine and Public Health

Madison, Wisconsin

Gregory F. Nicholson, MD Associate Professor Department of Orthopaedic Surgery Rush University Medical Center Chicago, lllinois Kenneth Noonan, MD

Associate Profirssor

Department of Pediatric Orthopedics University of Wisconsin Health

Madison, Wisconsin

St. Luke’s University Hospital Bethlehem, Pennsylvania

Thomas Obermeyer, MD

Augustus D. Marrocca, MS, MD

Mount Sinai Medical Center New York, New York

Associate Professor of Orthopaedic Surgery Director of Resident Education Department ofOrthopaedics

University of Connecticut

Farmington, Connecticut

Michael David McKee, MD, FRCSC

Professor of Surgery Department ofSurgery

Division of Orthopaedics

St. Michael'5 Hospital University of Toronto Toronto, Ontario, Canada

Fellow, Shoulder and Elbow Surgery Department of Orthopaedic Surgery

Matthew Oglesby; BA

Research Coordinator Department of Orthopaedic Surgery Rush University Medical Center Chicago, illinois Nirav K. Pandya, MD

Attending Orthopaedic Surgeon Department of Pediatric Chihopaedics

Children 's Hospital and Research Center Oakland University ofCalifiarnia, San Francisco Oakland, California

Siddhant K. Mehta, MD

Postdoctoral Research Fellow Department ofOrthopaedic Surgery and Rehabilitation University ofMississippi Medical Center

Iackson, Mississippi

ro'i

Ct 2013 American Academy of Orthopaedic Surgeons

Wayne Paprosk}; MD

Matthew L. Ramsey, NID

Department ofOrthopaedic Surgery Adult Joint Reconstruction

Department of Orthopaedic Surgery Rothman institute

Professor

Rush University Medical Center Chicago, Illinois Andrew Park, MD

Department ofOrthopedic Surgery Methodist Hospitalfor Surgery Addison, Texas

Richard D. Parker; MD

Professor and Chairman

Department ofOrthopaedics Cleveland Clinic Foundation Cleveland, Ohio

Prty‘essor and VICE Chairman Thomas Iefirson University Philadelphia, Pennsylvania Anil S. Ranawat, MD

Orthopaedic Surgeon

Department of Sports Medicine and Joint Preservation Hospitalfor Special Surgery

New York, New York

Ghazi Rayan, MD

Clinical Professor Department of Orthopedics Oklahoma University Oklahoma City, Oklahoma

Bradford Parsons, MD

Assistant Professor of Orthopaedic Surgery

Brett Reba], BA

New York, New York

Department of Orthopaedics Columbia University Medical Center

Department ofOrthopaedic Surgery Mount Sinai School ofMedicine

Chirag S. Patel, MD Resident Department ofOrthopaedic Surgery Stanford University Redwood City, Caly‘ornrh Nee-raj M. Patel, MD, MPH, MBS Benjamin For Orthopaedic Research Fellow Division of Whopaedic Surgery

Research Fellow Medical Student

New York, New York

Keith R. Reinhardt, MD Fellow Department of Orthopedic Surgery Howard Brigham and Women’s Hospital Boston, Massachusetts

K. Daniel Riew, MD

Children ’s Hospital of Philadelphia Philadelphia, Pennsylvania

Mildred E. Simon Distinguished Professor Department of Orthopaedic Surgery

Steven L. Peterson, MD, DVM

St. Louis, Missouri

Operative Care Division Portland Veterans Administration Medical Center Portland, Oregon

David Ring, MD, PhD

Stay?"Hand Surgeon

Terrence NI. Philbin, DO

Attending Physician Department ofOrthopedic Surgery Orthopedic Foot and Ankle Center Columbus, Ohio

Maya Pring, MD

Associate Professor

Department ofOrthopaedic Surgery

University of California. San Diego San Diego, California Sheeraa Qnreshi, MD

Orthopaedic Spine Surgeon Department ofOrthopaedics

Mount Sinai Hospital New York, New York

Steven M. Raikin, MD

Director, Foot and Ankle Service

Professor. Orthopaedic Surgery

Rothman Institute

Philadelphia, Pennsylvania

(it 2013 American Academy of Orthopaedic Surgeons

Washington University School ofMedicine

Director ofResearch

Orthopaedic Hand and Upper Extrendty Service Massachusetts General Hospital Boston, Massachusetts Pascal Rippstein, MD

Medical Directorr’Chief Department ofPoot and Ankle Schulthess Clinic Zurich, Switzerland

Mark Wllliam Rodoslqc MD Chief, Division at Shoulder Surgery

Department of Orthopaedic Sports Medicine

University ofPittsburgh Pittshurgh, Pennsylvania

Arnaldo I. Rodriguez Santiago, MD ShoulderfEllrow Surgeon Department of Orthopedic Surgery HIMA San Pablo Cognac

Caguas, Puerto Rico

Anthony A. Romeo, MD

Profissor, Division of Orthopaedics

Director, Section ofShoulder and Elbow Surgery

Team Physician, Chicago White Sox Department of Orthopaedic Surgery Division of Sports Medicine

Giles R. Scutleri, MD Vice President, Orthopaedic Service Line

Department of Orthopaedics

North Shore Long island Jewish Health System Long island, New York

Rush University Medical Center Chicago, illinois

Scott Scuderi, BS Research Assistant

Melvin P. Rosenwasser, MD

New York, New York

Department ofOrthopaedic Surgery Columbia University

Ari D. Seiclenstein, MD Orthopaedic Surgeon Hartahand Centerfor Hip and Knee Replacement, LLC

Rotrert E. Carroll Professor of Orthopaedic Surgery New York, New York

Roberto Rossi, MD

Professor Department ofOrthopaedics University of Turin Turin, ltaly

Michael J. Salata, MD

Director, Joint Preservation and Cartilage Restoration Center Department ofOrthopaedic Surgery University Hospitals ofCleveland Cleveland, Ohio Paul M. Saluan, MD

Director, Pediatric and Adolescent Sports Medicine

Department ofOrthopaedic Surgery Cleveland Clinic Sports Health

Cleveland, Ohio

Felix H. Savoie III, MD

Professor Department ofOrthopaedic Surgery Tulane University New Orleans, iouisiana

Andrew]. Sehoenfeld, MD Assistant Professor

Department ofOrthopaedic Surgery Texas Tech University Health Sciences Center El Paso, Texas

Patrick Schottel, MD Resident Department ofOrthopaedic Surgery Hospital for Special Surgery

New York. New York

William C. Schro-eljr MD Research Director

lnsall Scott Kelly lnstitutefirr Orthopaedics and Sports Medicine

Hackensack University Medical Centerfl-loly Name Medical Center Paramus, New Jersey

Christopher L. Sherman, DD, MS

Department of Orthopaedic Surgery Riverside County Regional Medical Center Moreno Valley, California

Seth L. Sherman, MD

Assistant Professor

Department of Orthopaedic Surgery University ofMissouri Columbia, Missouri Alexander Y. Shin, MD

Professor of Orthopedic Surgery Department of Orthopedics

Mayo Clinic

Rochester, Minnesota

Benjamin ]. Shore, MD, FRCSC

instructor in Orthopaedic Surgery Department of Orthopaedic Surgery Boston Children 's Hospital Harvard Medical School Boston, Massachusetts Peter Silvers, MD

Orthopaedic Surgeon

Associates in Orthopaedic Surgery Jordan Valley Medical Center Salt Lake City, Utah Micah Sinclair, MD Hand Surgery Fellow

Department of Orthopaedics University of Utah Salt Lake City, Utah

St. Louis joint Replacement institute SSM DePaui Health Center St. Louis, Missouri

Kern Singh, MD Assistant Professor Department of Orthopaedic Surgery Rush University Medical Center

Alexandra Schwartz, MD

Chicago, illinois

Department ofOrthopaedic Surgery University of California, San Diego San Diego, California

Associate Profi'ssor

Laura E. Scordino, MD

New York, New York

Professor

Orthopaedic Surgery Resident Department ofOrthopaedic Surgery

Ernest L. Sink, MD

Department of Pediatric Orthopaedic Surgery Hospitaifor Spechrl Surgery

University of Connecticut Fannington, Connectimt

C1 2013 American Academy of Orthopaedic Surgeons

David L. Sic-eggs, MD

Professor and Chief of Orthopaedic Surgery Children ’s Orthopaedic Center

Children’s Hospital Los Angeles Los Angeles, California Nicholas R. Slenker, NID

Michael E. Torchia, MD

Consultant Department of Orthopedic Surgery

Mayo Clinic

Rochester, Minnesota

P. Justin Tortolani, MD

Orthopaedic Resident Rothman Institute Thomas Jefferson University Hospital

Director. Spine Education and Research Dermrtment of Orthopaedic Surgery

Dean G. Sotereanos, MD

Carola van Eek, MD, PhD

Hand and Upper Extremity Surgery Allegheny General Hospital Pittsburgh, Pennsylvania

Department of Orthopaedic Surgery University ofPittsburgh Medical Center Pittsburgh, Pennsylvania

Philadelphia, Pennsylvania

Professor

Scott Sporer, MD, MS

Medstar Union Memorial Hospital

Baltimore, Maryland

Orthopaedic Surgery Resident

Thomas F. Varecka, MD

Associate Professor

Assistant Professor

Chicago, lllinois

Department of Orthopaedic Surgery Hennepin County Medical Center Minneapolis, Minnesota

Department ofOrthopaedic Surgery Rush University Medical Center

Scott P. Steinmann, MD

Professor of Orthopedic Surgery Mayo Clinic Rochester; Minnesota

University ofMinnesota

Aaron I. Venouziou, MD

Fellow Division of Upper Extremity Surgery

MA] Daniel J. Stinner, MD

Allegheny General Hospital Pittsburgh, Pennsylvania

Department ofOrthopaedics and Rehabilitation San Antonio Military Mediml Center

Assistant Prmressor

Eric J. Strauss, MD

Denver, Colorado

ChiefResident, Orthopaedic Surgery Fort Sam Houston, Texas

Assistant Professor Department ofOrthopaedic Surgery

New York University Hospitalfor Joint Diseases New York, New l’orlc John M. Tahit, DO

Orthopaedic Traumatologist

Armando F. Vidal, MD Sports Medicine and Shoulder Service University ofColorado School ofMedicine Dharmesh Vyas, MD

Assistant Professor Department of Orthopaedic Surgery

University ofPittsburgh Medical Center Pittsburgh, Pennsylvania

The Orthopaedic Trauma Group Charleston Area Medical Center Charleston, West Virginia

EmilyT A. Wagstrom, MD

Miho J. Tanaka, MD

Iowa City, larva

Director, Women’s Sports Medicine Initiative

Regeneration Orthopedics Chesterfield, Missouri

Oliver O. Tannous, MD Resident

Department ofOrthopaedics University ofMaryland Medical Center

Resident Physician Department of Orthopaedics University oftowa Erie 1Wall, MD Professor

Department of Pediatric Orthopaedic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Arthur E. Walling, MD

Baltimore, Maryland

Foot and Ankle Surgery Fellowship Director

Nikki] A. Thakur, MD Assistant Professor

Tampa, Florida

Department ofOrthopaedics

State University of New York Upstate Medical University Syracuse. New York Matthew M. Tomaino, MD, MBA

llrmaino Orthopaedic Care

Rochester; New York

(D 2013 American Academy of Orthopaedic Surgeons

Florida Orthopaedic Institute

lawrence x. Webb, MD

Chairman

Georgia Orthopaedic Trauma institute Medical Center ofCen tral Georgia Macon, Georgia

Robin West, MD

Bryan Witt, DD

University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Columbus, Ohio

Orthopaedic Surgeon Associate Professor

Matthew]. White, MD Orthopaedic Surgeon Physicians’ Ciinic of Iowa Cedar Rapids, Iowa

Orthopaedic Surgery Resident Department of Orthopaedic Surgery Doctors Hospital

Brian FL Wolf, MD, MS

Congdon Professor ofOrthopaedic Surgery Department of Orthopaedics and Rehabilitation University ortoa Iowa City, Iowa

Neil J. White, MD, FRCSC Hand Surgeon Orth0paedic Trauma Surgeon

Adam B. Yanks, MD

Caigury, Aiberta, Canada

Chicago, Illinois

Department ofOrthopaedics University of Caigary Kevin W. Wilson, MD

Orthopaedic Surgery Resident Department ofOrthopaedios and Rehahiiitation

Waiter Reed National Military Medical Center Bethesda, Maryland

Resident

Department of Orthopaedic Surgery Rush University 1iial'nsl'Li Yelavarthi, BA Medicai Student Boston University School ofMedicine Boston, Massachusetts

Michael A. Wirth, MD

Professor and Charles A. Rockweod, Jr, MD, Chair Department of Orthopaedics University of Texas Health Science Center San Antonio, Texas

(D 2013 American Academy of Orthopaedic Sui-gems

Dedication Te uur families, far their lave and support; to our teachers, for their wisdom and tn our patients, fium Wham we learned the value of our craft.

(E1 2013 American Asmimy of Urthopsedic Surgeons

Preface Orthopaedic surgeons face an ever-growing body of information to be mastered, yet the demands on their time have never been greater. The Atlas of Essential Orthopaedic Procedures has been developed by the American Academy of Orthopaedic Surgeons (AAOS) to provide a concise yet comprehensive multimedia resource for the busy orthopaedic surgeon. Every specialty is represented, and each of the 107 procedures has been selected thoughtfully by experts in each specialty. The authors are surgeons who are recognized leaders in their field. The management of each condition is detailed in an easy-to-aooess format that begins with patient selection, takes the reader through a detailed, step-by-step description of the author’s procedure, and includes the author's surgical pearls. The 70 surgical videos complement the chapters and enhance the learning experience. The Atlas of Essential Orthopaedic Procedures is a highly visual, technique-oriented reference. The chapters are heavily illustrated with radiographs, intraoperative photographs, and line drawings. They contain few citations because the emphasis is on conveying the practical teclmiques of expert surgeons rather than on reviewing the literature. We expect fitis publication to be a one-stop destination for the surgeon who is confronted with a multitude of conditions requiring knowledge of these essential surgical techniques. The Atlas of Essential Orthopaedic Procedures would not have been possible without the support of the AAOS and the efforts of numerous individuals. First, the authors are owed a debt

of gratitude for providing the outstanding text, illustrations, and video that are certain to make this publication a standard reference for the orthopaedic surgeon. Second we are gra = to the section editors for their outstanding work 111 revi the text and video. These busy surgeons have devote -, man},r hours to this project over the course of se . in addition to the many other demands on their ti -

© 2013 American Academy of Orthopaedic Surgeons

gratitude goes to the following, listed in alphabetical order: Eben A. Carroll, MD (Ttauma); Henry G. Chambers, MD

(Pediatrics); Edward Diao, MD (Hand and Wrist); Christopher D. Harner, MD (Sports Medicine); Andrew C. Hecht, MD (Spine); William Macaulay, MD (Adult Reconstruction); Michael Pinzur, MD (Foot and Ankle); John W. Sperling, MD, MBA (Shoulder and Elbow); and Lawrence X. Webb, MD (Fatima). Also, we would be remiss if we failed to acknowledge the loss

to the orthopaedic community with the passing of one of our

authors, Dr. James Carr, who was a renowned orthopaedic surgeon and educator.

Finally, we thank the members of the AAOS Publications and

Electronic Media departments who were instrumental in the production of this groundbreaking multimedia reference. The project had the good fortune of benefiting from the leadership of two Directors of Publications: Marilyn Fox, PhD, whose vision and support made this possible and whose tenure ended rece . ‘ , d Hans Koelsch, PhD, her able successor. Jane Baqu , ‘ ' Manager, Publications Websites; Laurie Bra - 3 Editor, Textbooks; Rachel Winokur,Publ1cat15fi*5" tant; and Brian Moore, Manager,

Electronic i.) 71’ age: ,are all to be commended for their extra .~ “ i sin organizmg and editing the text and video ,the AAOS Production Department ‘3‘; n for their talent and professionalism'm . . i '- e presentation of a tremendously complex art * rising many hundreds of graphic elements was to high quality standards. you agree that these efforts have resulted in a ication that will improve patient care and should be a Vltfll part of every orthopaedic surgeon’s library. Evan Flatow, MD

Alexis Chiang Calvin, MD Editors

Table of Contents Q

Section 1: Sports Medicine Section Editors: Christopher D. Harner, MD; Alexis Chiang Colvin, MD 1 Arthroscopic Repair of Partial-Thiclmess Rotator Cuff Tears ........................................... 3 Matthew l. White, MD; Geofirey 5. Beer, MD, PhD

2 Arthroscopic and Open Bankart Repair ............................................................. 9 LCDR Brandon Bryant, MD, USN; Iames P. Bradley, MD

3 Arthroscopic Superior Labrum Anterior-to—Posterior Repair .......................................... 17' Iarnes C. Dreese, MD; Danielle Casagrunde, MD

4. Bioeps Tenotomjs,r and Tenoclesis................................................................... 25 Peter Chalmers. MD; Seth L. Sherman, MD; Neil Ghodadra, MD;

Richard C. Mather III, MD; Anthony A. Romeo, MD

5 Anatomic Acromioclavicular Joint Reconstruction ................................................... 31 Albert Lin, MD; Mark William Radosky, MD

6 Open Reduction and Internal Fixation of Clauicle Fractures........................................... 35 Laura E. Scordino, MD; Thomas M. DeBerardino, MD

r Open Treatment of Medial and Lateral Epicondylitis ................................................. 39 Champ L. Baker III, MD; John Akins, MD; Champ L. Baker, In MD

:1

8 Distal Biceps Repair ............................................................................. 43 lauren E. Geaney, MD; Robert A. Arciero. MD; Anthony A. Romeo, MD; Augustus D. Mazzocca, MS, MD

a a

o Ulnar Collateral Ligament Reconstruction .......................................................... 49 Joshua S. Dines, MD; David W. Altchek, MD

10

Arthroscopic Management of Femoroacetabular Impingement ........................................ 55 Alexis Chilling Coloin, MD

11 Meniscectomy .................................................................................. 59 Semen Baden MD; Paul M. Saiuan, MD; Richard B. Parker; MD

12 Meniscal Repair ................................................................................ 6'? Karl F. Bowman, Ir, MD; Christopher D. Harrier, MD

13 Medial Meniscal Root Repair ..................................................................... 73 Dharmesh Vyas, MD; Christopher D. Harrier; MD

14 Microfracture................................................................................... '39 Amanda F. Vidal, MD; Jennifer Fitzpatrick, MD

15 Surgical Treatment of Osteochondritis Dissecans lesions ............................................. 85 Sarnottam Baiaj, BE; Michael I. Salata, MD; Brian J. Cole, MD, MBA

16 Anterior Cruciate Ligament Reconstruction: Single-Bundle Transtibial Technique........................ 95 Eric I. Strauss, MD; Adorn B. Yanke, MD; Bernard R. Bach, Ir, MD

17

Anterior Cruciate Ligament Reconstruction: Two-Turmel Technique .................................. 1fl3 Dharmesh Vyas, MD; Christopher D. Harrier, MD

a

Is Anatomic Anterior Cruciate Ligament Doubloflundle Reconstruction ................................ 109

a

19 Pediatric Anterior Cruciate Ligament Reconstruction ............................................... 117'

E1

20

Infra}; Macalena, MD; Carola nan Eek, MD, PhD; Freddie H. Fu, MD

Davide Edvardo Bonasia, MD; Roberto Rossi. MD; Brian R. Welt MD, MS; Annunziato Amendola, MD

Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability ...................... 125

Andrew I. Cosgarea, MD; Miho I. Tanalca, MD; John I. Elias, PhD

21 Realignment for Patellofemoral Arthritis .......................................................... 131 Albert Lin, MD; Robin West, MD

(D 2013 American Academy of Drthopaedic Surgeons

H

22 Surgical Treatment of Traumatic Quadriceps and Fatellar Tendon Injuries of the Knee................... 13?. Patrick Schottel, MD; Keith R. Reinhardt, MD,- Gregory 5. DiFelice, MD; Anil S. Ranawai, MD

Section 2: Shoulder and Elbow Section Editor: John W. Sperling, MD, MBA 23 Arthroscopic Subacmmial Decompression and Distal Claricle Resection .............................. 149 Albert Lin, MD,- Mark William Rodosky, MD

a

24 Arthroscopic Management of Frozen Shoulder ..................................................... 153 Peter N. Chalmers, MD,- Sein L. Sheraton, MD,- Neii Ghodadra, MD,-

Gregory F. Nicholson, MD

25 Arthroscopic Rotator Cuff Repair ................................................................ 159 Thomas R. anin, MD; Donald W Holiman, Jr, MD

26 Percutaneous Firming of Proximal Humerus Fractures .............................................. 169 Bradford 0. Parsons, MD 27 Fixation of Proximal Humerus Fractures .......................................................... 125

Michael E. Tor-chin, MD; Thomas S. Diner-mayor, MD

28 Herniarthroplast}r for Proximal Humerus Fractures ................................................. 183

Arnaldo l. Rodriguez-Santiago, MD,- T. Bradley Edam-its, MD

29 Total Shoulder Arthroplasty for Osteoarthritis ..................................................... 191 Stephanie H. Hsn, MD,- Lonis Ll. Bigliani, MD

30 Reverse Total Shoulder Arthroplasty for Rotator Cuff Artl'lropathy ................................... 19? Peter Silosro, MD; Michael A. Wirtli, MD

a

31 .ikrthroscopyr of the Elbow ....................................................................... 263 Thomas ti Giel III, MD; Larryr D. Field, MD; Felix H. Saooie III, MD 32 Open Treatment of Radial Head Fractures and Olen-anon Fractures................................... 211 Julie E. Adams, MD, MS,- Scott R Steinmann, MD 33 Open Reduction and lntemal Fixation of Distal Humerus Fractures................................... 219 Michael Danni McKee, MD, FRCSC

34 Total Elbow Arthroplast}:r ....................................................................... 225 Peter Johnston, MD; Matthew L. Ramsey, MD Section 3: Hand and Wrist Section Editor: Edward Diao, MD 35 Carpal Tunnel Release .......................................................................... 235

Edward Diao, MD

E

36 Surgical Treatment of Cubital Tunnel Syndrome .................................................... 241

E1

3'." First Dorsal Extensor Compartment Release ....................................................... 24'? Aaron I. lenonaion, MD; Filippos S. Giannonlis, MD; Dean G. Sotereanos, MD

El

33 Trigger Finger Release .......................................................................... 253

Reimer Hofi‘mann, MD; John D. talm, MD

Randy Bindra, MD,- Micah Sinclair, MD

39 Open Reduction and lntemal Fixation of the Distal Radius With a Volar locking Plate .................. 259 Jesse B. Jh..:p-i.te.r, MD,- Daoid Ring, MD, PhD

+0 External Fixation of Distal Radius Fractures ....................................................... 263 Michael VI Birman, MD,- lonatlzan R. Danofi', MD; Neil J. Mite, MD; Melvin P. Rosenwasser, MD

#1 Open Reduction and hiternal Fixation of Scaphoid Fractures ........................................ 269 Kristofer S. Matallo, MD,- Alexander 1’. Shin, MD

42 Open Reduction and lntemal Fixation of Phalangeal Fractures ....................................... 2375 William B. Geissler, MD

xxii

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43 Surgical Fixation of Metacarpal Fractures ......................................................... 281 William B. Geissler, MD; Christopher A. Keen, MD

Excision of Ganglion Cysts of the Wrist and Hand .................................................. 23'? Daniel I. Nagle, MD; Jay V. Kaiawaa'ia, MD

45 Surgical Excision of Digital Mucous Cysts ......................................................... 293 Matthew M. Tomaino, MD, MBA

Surgical Treatment of Basal Joint Arthritis of the Thumb ............................................ 295 Edward Diao, MD 47 Partial Palmer I-lasciectorrnyr for Duq Disease ................................................. 305

Thomas P. lehman, PT, MD; Steven L. Peterson, MD, DVM; Ghazi Rayan, MD

E]

Section 4: Adult Reconstruction Section Editor: William Macaulay, MD as Hip Arthroplasty via Small-Incision Enhanced Posterior Soft-Tissue Repair ............................ 313 Ionathan H. Lee, MD; William Macaulay, MD; Brett Rebel, BA

49 Hip Arthroplastyr via a Direct lateral Approach .................................................... 319

a

Tahir Mahmud, BSc (Hons), MBBS, FRCS {Tr Err Drthl; Robert B. Bourne, MD, FRCSC

so Direct Anterior Approach for Hip Arthroplasty .................................................... 325 Gregory K. Deirmengian, MD; William I. Hoeack, MD

51 Revision Total Hip Arthroplasty via Extended Trochanteric Osteotomy................................ 333 Scott M. Sporer, MD, MS; Wayne G. Paproslcy, MD, PACS

52 Total Knee Arthroplasty via the Medial Parapatellar Approach ....................................... 341 Stephen J. lncaao, MD; Michael R. Dayton, MD; Jesse james F. Exaltacian, MD

53 Total Knee Arthroplasty via Small—Incision lvlidvastus Approach ..................................... 345 Steoen B. Haas, MD, MPH; Stephen Kim, MD

ca

54 Total Knee Arthroplasty via the Mini-Subvastus Approach .......................................... 351 William C. Schroer, MD

55 Revision Total Knee Arthroplasty via Quadriceps Snip .............................................. 359 Ari Seitienstein, MD; Scott Scaderi, BS; Giles R. Scaderi, MD

56

Revision Total Knee Artl‘IIOPlaStY via Tibial Tubercle DStEUtOmY ..................................... 363 Iefl‘rey A. Geller, MD

Section 5: Trauma Section Editors: lawrence X. Webb, MD; Eben A. Carroll, MD

a

57 General Principles of Surgical Debridement ....................................................... 369 lawrence X. Webb, MD; Henryr I. Dolch, DD SB

Fasciotomy for Compartment Syndrome of the Leg................................................. 371 Laanence X. Webb, MD; Alireea Behbomii, DD

59 Open Reduction and lntemal Fixation of Forearm Fractures ......................................... 3275 Thomas F. Wrecka, MD

a} .42)

so Open Reduction and Internal Fixation of Posterior Wall Acetabular Fractures .......................... 385 Lawrence X. Webb, MD

Open Reduction and Internal Fixation of Femoral Neck Fractures .................................... 393 61 iaaeence X. Webb, MD; john C.P. Floyd, MD 62

Intertrochanteric Fracture Fixation Using a Sliding Hip Screw or Cephalomedtfllary Nail................ 401 Alexandra K. Schwartz, MD; Christopher L. Sherman, DD, MS

63 lntrameclullary Nailing of Diaphyseal Femur Fractures ............................................. 40?

Anna N. Miller, MD

as Surgical Fixation of Fractures of the Distal Femur .................................................. 413 James E Kellarn, BSC, MD, FRCSC, l-HCS, FRCSI

(D 2013 American Academy of Orthopaedic Surgeons

Hm

65 Open Reduction and Internal Fixation of Tibial Plateau Fractures ..................................... 421 James A. Goulet, MD; Mark E. Hake, MD

H

66 Tibial Diaphyseal Intrarnedullar},ir Nailing ......................................................... 4:29 Clifl'ora B. Jones, MD, FACS

67 Open Reduction and Internal Fixation of the Tibial Platoncl .......................................... 43'? Stephen K. Benirschke, MD; Patricia Kramer, PhD

Q

63 Surgical Treatment of Ankle Fractures ............................................................ 443 Eben A. Carroll, MD,- Iason I. Haloorson, MD

Q

69 Surgical Management of Fractures of the Talus ..................................................... 451 john M. Tabit, DD; ianrrence X. Webb, MD

Q

70 Open Reduction and Internal Fixation of Calcaneal Fractures ........................................ 459 Michael P. Clare, MD

71 Open Reduction and Internal Fixation of Fracture-Dislocations of the Tarsometatarsal Joint .............. 467 Terrence M. Philliin, DD: Gmgflfy C. Berlet, MD

:3

12 Open Reduction and Internal Fixation of Proximal Fifth Metatarsal Fractures .......................... 4'73 Mark E. Easley, MD

Section 6: Foot and Ankle Section Editor: Michael Pinzur, MD a

T3 Ankle Arthroscopy: Diagnostics, Débridement, and Removal of Loose Bodies.......................... 485 Carol Frey, MD

74 Arthroscopic Treatment of Osteochondral lesions of the Talus ....................................... 491 Steven M. Railrin, MD,- Ntcholas R. Slenlcer, MD

?5 Augmented Lateral Ankle Ligament Reconstruction for Persistent Ankle Int-italoilit}r .................... 499 Nicholas A. Abidi, MD

16 Achilles Tendon Rupture Repair ................................................................. 505 Stanleyr C. Graoes, MD,- Iaycen Brown, ES

7? Trhiotalar Arthrodesis .......................................................................... 509 Siddhant K. Mehta, MD; Nicholas A. Ahtdt, MD; Sheldon 5. Lin, MD

3

78 Subtalar Arthrodesis ........................................................................... 515 James B. Carr, MD

7'9 Arthrodesis of the Tarsometatarsal Joint........................................................... 519 ]. Chris Coetzee, MD, PRCSC; Pascal Rippstein, MD

80 Surgical Treatment of Navicular Stress Fractures ................................................... 527r Bethany Gallagher, MD,- Arthur K. Walling, MD

81 Arthrodesis of the Hallux Metatarsophalangeal Joint ............................................... 531 Chirag S. Patel, MD; Loretta Chou, MD

E

82 Proximal and Distal First Metatarsal Osteotorru'es for Hallux Valgus .................................. 535

3 i2}

33 Chronic Exertional Compartment Syndrome and Release ........................................... 54] Emily A. Wagstront, MD; Annanaiato Antenaoia, MD; Brian E. Wolf, MD, MS

a

3+ Transtibial Amputation ......................................................................... 545

Christopher B. Himse, MD; Materiel I. Caughlin, MD

‘3’

cor James R. Fiche, MD; MA] Daniel 1. Stinner; MD

85 Midfoot Amputations .......................................................................... 551 Terrence M. Philbin, DO,- Bryan Witt, DD

rode

(it 2013 American Academy of Drthopaedic Sat-gems

Section 7: Spine

Section Editor: Andrew C. Hecht, MD 86 Anterior Cervical Diskectorn}.r and Fusion ......................................................... 559

1:]

Howard S. An, MD; Thomas D. Cha, MD, MBA

Q

[2} {2}

37 Anterior Cervical Corp-ectomyr and Fusion}r Instrumentation ......................................... 563 Daniel G. Kong, MD; Ronald A. Lehman, Jr, MD; K. Daniel Riew, MD

as Posterior Cervical Foraminotomy ................................................................ 5175 Kent Singh, MD; Steven I. Fineberg, MD; Matthew Dgiesby, BA;

Jonathan A. Hoskins, MD; Vamshi Yeiaoarthi, BA

a

so

Posterior Cervical Laminectomy and Fusion ....................................................... 579

9!}

Cervical Laminoplasty.......................................................................... 585

Sheeraa A. Qareshi, MD, MBA; Andrew C. Hecht, MD Niichil A. Thakor MD; Brett A. Freedman, MD; John G. Heller; MD

91 Placement of Thoracic Pedicle Screws............................................................. 591

Kevin W. Wilson, MD; Ronald A. Lehman, It; MD; Lawrence G. Lenka, MD

92 Lumbar Micro-diskectom}:r ....................................................................... 601 Bradley Moatz, MD; P. Instin Tortolani, MD

93 Lumbar lanfinectomy .......................................................................... 60’? Samuel M. Davis, MD; Scott D. Boden, MD El

{2}

94

Instrumented Lumbar Fusion .................................................................... 611 Andrew I. Schoenfiid, MD; Christopher M. Bono, MD

95 Transforaminal Lumbar Intertidal);r Fusion ......................................................... 6117‘'

Oliver 0. Tan-nous, MD; Keiley Banagan, MD; Steoen C. Ludwig, MD

96 Anterior Lumbar Interbody Fusion ............................................................... 625

Andrew Park, MD

Section 8: Pediatrics

Section Editor: Henryr G. Chambers, MD 97 Closed and Open Reduction of Supracondvlar Humerus Fractures ................................... 633 David L. Skaggs, MD; Paul D. Choi, MD; Cordelia Carter; MD 98 Reduction and Fixation of Lateral Condvle Fractures of the Distal Humerus ........................... 641

Ill

Neeraj M. Patel, MD, WH, MBS; John M. Flynn, MD

99 Intramedullary Fixation of Radial and Ulnar Shaft Fractures in Skeletally Immature Patients............. 647 Maya E. Pring, MD; Hilton FE Gottschalk, MD; Henry G. Chambers, MD

100 Incision and Drainage of the Septic Hip ........................................................... 653 Benjamin J. Shore, MD, FRCSC; Minimier S. Kocher, MD, MPH

101 Percutaneous in Situ Fixation of Slipped Capital Femoral Epiphysis .................................. 657 Randall T. Ioder, MD

102. Fixation of Pediatric Femur Fractures ..........................................' ................... 663 Ernest L. Sink, MD El

103 Femoral Derotation Dsteotomy in Adolescents and Young Adults .................................... 67"3

Harish S. Hosatkar, MD

104 Surgical Reduction and Fixation of Tibial Spine Fractures in Children .................................. 677 Eric Wall, MD .-

-\.

:.

105

Treatment of Clubfoot Using the Ponseti Method ................................................... 683 Biaise Alexander Nemeth, MD, MS; Kenneth J. Noonan, MD

106 Treatment of Tarsal Coalitions .................................................................... 639 Scott I. Mubarak, MD

107 Lower Extremity Surgeryr in Children With Cerebral Pals}r........................................... 695 Nirao K. Pandya, MD; Henry G. Chambers, MD

(D 2013 American Academy of Drthopaedic Surgeons

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xxv

Sports Medicine Section Editors

Christopher D. Harner, MD

Alexis Chiang Coluin, MD

-Arthroscopic Repair of Partial-Thickness Rotator Cuff Tears . . . . . Matthew J. White, MD; Gecflrey 5. Beer, MD, PhD _Arthroscopic and Open Bankart Repair ............... LCDR Brandon Bryant, MD, USN; Iatttes P. Bradley, MD

_Arthroscopic Superior Labrum Anterior-to-Posterior Repair . ....... James C. Dreese, MD,- Dattt'eile Casagrande, MD

-Biceps Tenotomy and Tenodesis . ............................... 25 Peter Chalmers, MD,- Seth L. Shaman, MD; Neil Ghodadra, MD;

-Anatomic Acromioclauicular Joint Reconstruction .....

-

Richard C. Mather III, MD; Anthony A. Romeo, MD

.....

Albert Lin, #11:};e William Rodoslcy, MD

-Open Reduction and Internal Fixation of Clatride Fractures . ......... 35 Laura E. Seordt'tto, MD; Thomas M. DeBerardttto, MD

-Dpen Treatment of Medial and Lateral Epicondylitis. ............... 39 Champ L. Baker III, MD,- Iolttt Aldus, MD,- Cltamp L. Baker, Ir, MD

_Distal Biceps Repair .................................. I ...... 43 [amen E. Geaney, MD; Robert A. Areiero, MD;

Anthony A. Romeo, MD; Augustus D. Mazzoeea, MS, MD

_Ulnar Collateral Ligament Reconstruction ...... ._..J ..... 49 Ioshua S. Dines, MD,- Datrid W. Altelteic, MD

_Arthroscopic Management of Femoroacetabular Impingement . ...... 55 Alexis Chiang Calvin, MD

—l's*|eniscectom}l ............................................. 59 Semen Batter; MD; Paul M. Bataan, MD; Richard D. Partner; MD

-Meniscal Repair . ................................... I I ...... Kari 1-". Bowman, Ir, MD; Christopher D. Harrier; MD

_ Medial Meniscal Root Repair ..................-..... Dharrnesh Vyas, MD; Christopher D. Harrier:r MD

-Microfracture ............................. - ..... 1' Armando E Vidal, MD; Iennifier FitzPatrick, MD

_Surgical Treatment of Osteochondritis Dissecans Lesions ........... 35 Sar'oottam Bafaj, BE; Michael I. Saiata, MD; Brian I. Cole, MD, .MHA

-Anterior Cruciate Ligament Reconstruction: Single-Bundle

Transtibial Technique ........................................ 95 Eric J. Strauss, MD; Adam B. Yanhe, MD; Bernard R. Bach, Ir, MD

-Anterior Cruciate Ligament Reconstruction: Two-Tunnel Technique . . . 103 Dharmesh Vyas, MD; Christopher D. Harrier, MD

-Anatomic Anterior Cruciate Ligament Double-Bundle Reconstruction . .......................................... 109 Iefi‘rey Maeaiena, MD; Carola oan Eek, MD, PhD; Freddie H. For, MD

—Pediatric Anterior Cruciate Ligament Reconstruction .............. 11? Davida aardo Bonasia, MD; Roberto Rossi, MD;

Brian R. Wotf, MD, MS; Annunaiato Amenaoia, MD

-Medial Patellofemoral Ligament Reconstruction for

-

Recurrent Patellar Instability . ................................ 125

Andrew I. Cosgarea, MD; Miho I. Tanaka, MD; John I. Elias, PhD

_Rea|ignment for Patellofemoral Arthritis . . . . .......... 'Il"""131 Albert Lin, MD; Robin West, MD

-Surgical Treatment of Traumatic Quadriceps and Patellar Tendon Injuries of the Knee ........................................ 137 Patrick Schottei, MD; Keith R. Reinhardt, MD; Gregory S. DiPeiice, MD;Anii S. Ranaanit, MD

Chapter 1 Arthroscopic Repair of Partial-Thickness

Rotator Cuff Tears

Matthew I. were, MD Geoficrey 5. Beer, MD, PhD Patient Selection

Rotator cuff surgery is one of the more common procedures performed by orthopaedic surgeons. As knowledge of the anatomy and function of the rotator cuff improves, more sophisticated meth— ods have been developed to repair this musculotendinous construct. Partialthickness articular-surface rotator cuff repair and transosseous—equivalent repair represent two techniques that expand the treatment options for rotator cuff damage.

Indications The indications for partial-thickness articular-surface rotator cuff repair and transosseous-equivalent repair are similar. The patient should have docu— mented clinical findings in the presence of radiographically confirmed rotator cuff injury and should have undergone a concerted attempt at nonsurgical modalities such as rest, activity modification, medication, and physical

therapy. Failure of nonsurgical treatment necessitates further treatment in the form of open or arthroscopic surgery. Subsequent decisions are based on the intraoperative findings. Fukuda et al1 demonstrated that partial-thickness rotator cuff tears have a poor healing capacity, which may limit the success

of nonsurgical treatment. These tears also have a tendency to progress when treated with acromioplasty alone.2 On the other hand, results of repair for these tears have been excellent, espe—

cially in the young patient?“ Acute full— thickness tears of the rotator cu ff should

be managed surgically. For both full- and

dered, the most common of which is MRI [Figure 1, A and B}. Magnetic resonance arthrography (MFA) is an additional

option. In a recent meta-analysis, MRA showed excellent diagnostic capabilities for both full— and partial—thickness rota— tor cuff tears.5 fine of the newer modalities for detecting shoulder pathology is

partial-mickness chronic tears, nonsurgical treatment should be used initially. In patients who report continued pain despite these nonsurgical measures, some authors recommend surgical re— pair of the tear regardless of size.‘

ultrasonography (Figure 1, C). Vlychou

Contraindications

Contraindications to the surgical repair of rotator cuff tears are limited to patients in poor medical health and patients who cannot perform the necessary postoperative rehabilitation.

slightly less sensitive. In addition, ultrasonography may not be available to all surgeons. Ultrasonography has the advantage of potentially being done at the same time as the office visit and can provide dynamic imaging.

Preoperative Imaging

Procedure

Each patient should have a shoulder series of plain radiographs. At our institution, we obtain AR Neer AI", outlet, and

axillary views of the affected shoulder. These views will demonstrate pos-

sible fracture, bony abnormality, acro-

mion type, or, in some cases, humeral

subluxationi’escape. If suspicion exists about a full— or partial—thickness rotator cuff tear, advanced imaging can be or-

et al" found ultrasonography to be almost equally as effective as MRI in detecting rotator cuff tears. Ultrasonography is a less expensive alternative to MRI for the diagnosis of rotator cuff tears, but it

is also highly operator-dependent and

ltoom SetupiPatient Positioning We prefer to perform shoulder arthroscopy with the patient in the lateral decubitus position. A standard arthroscopic pump is used for fluid control, and an arm holder is positioned at the distal portion of the operating table to keep the arm in approximately 20° of forward flexion and 20° to 40° of abduction with the assistance of a 5- to IU—lb weight.

Figure 1 Partial-thickness articular-surface rotator cuff tears. A, Coronal TE-weighted MRI demonstrates a partial-thickness articularsurface supraspinatus tear. B, Sagittal Tveighted MRI shows a tea r. C, Longitudinal ultrasound image demonstrates a partial-thickness supraspinatus tear.

Dr. Baer or an immediate family member serves as a board member, ortmer; qfl‘icer; or committee member of the Big Ten Fellowship Society. Neither Dr. White nor any immediatefamily member has received anything of minefrom or owns stock in a commercial company or institution related directly or indirectly to the subject of this chapter.

(fl) 2013 American Academy of Cirtiropaedic Surgeons

Suction 1: Sports Medicine

suture passed through and retrieved through the anterior portal in the gle-

nohumeral joint (Figure 2). This makes

Figure .1 Arthroscopic views demonstrate technique for locating a rotator cuff tear. A, Monofilament suture is placed into the glenohumeral joint percutaneotlsly to locate a partial-thickness rotator cuff tear. B, The monofilament suture indicates the location of the

tear. A standard shaver is used to perform a bursectomy.

Grade [Depth of Lesion)

A [articular surface)

1 {3?) and medial joint

space narrowing on long-cassette radiographs, and (3) diffuse international

Cartilage Repair Society grade 3 or 4 chondral changes in the femoral condyle or tibial plateau articular cartilage identi-

fied at the time of surgery.

Preoperative Imaging

Radiographs Diagnostic imaging begins with plain radiographs. These include 45" flexion weight-bearing PA views of both knees, a lateral view, and Merchant patella views

Figure 1

A 45° flexion weight-bearing FA view of both knees (A), a lateral view {B}, and a

Merchant patella view {C} demonstrate well-maintained joint spaces with mild early arthritic changes seen in the form of marginal osteophytes in all three compartments Slight patella baja is also seen.

Dr. Harrier or an immediatefamily member has received research or institutional support from DePuy and Smith 6* Nephew and serves as a board member, owner, q‘icer; or connnittee member of the American Board of Orthopaedic Surgery, the American Orthopaedic Association, the American Academy of Orthopaedic Surgeons, and the American Orthopaedic Societyfor Sports Medicine. Neither Dr. Vyas nor any immediate firmiiy member has received anything of oat-ire from or same stock in a comuremia!I company or institution reintea directly or indirectly to the subject of this chapter.

(it 2013 American Academy of Urflropaedic Surgeons

Section 1: Sports Medicine

is placed under the ipsilateral hip. and a

Iii-lb sandbag is taped to the table to sup-

port the knee at 90° of flexion (Figure 3). A lateral post is placed at the level of the midthigh to support the lower extremity. We do not use a tourniquet or a leg holder. Special Instrun'iarnts!Equipmeritir Implants The procedure calls for the following equipment:

* 30° and TO” arthroscopes 1' 4.5—mm full—radius resectors (straight and curved)

I ACL drill guide with guide pin Meniscal rasp TD” suture shuttle

Hewson suture passer B-mm clear cannula No. 2 nonabsorbable braided suture 6.5-rnm cancellous screw with washer Surgical Technique Examination Under Anesthesia An examination of both knees is performed after anesthesia is induced. Knee range of motion, the presence of an effusion, and ligamentous laxity are assessed

and documented. Prior to preparation

and draping of the limb, surface landFigure 2

Coronal (A and E) and sagittal (C and D} "ii-weighted Mitls demonstrate a medial

meniscal root tear (MMRT) (arrow). This is identified by increased signal intensity widrin the meniscal root that extends to the articular surface. Also. extrusion of the medial meniscus is noted. As a result of a complete radial tear, the two fragments are separated and take on the appearance of an empty meniscal space {C and D). An associated medial femoral condyle articular cartilage lesion can also be seen.

marks and incisions are drawn with a

skin marker. To aid in hemostasis, the

incisions are prepped with Betadine (povidone-iodine), and the skin is injected with l‘it. lidocaine with epinephrine

(1:IDD,UIJIJ). The extremity is then prepped

in its entirety with Betadine and draped.

Landmarks Key landmarks are the patella (inferior pole), the patellar tendon. the medial joint line, the Gerdy tubercle. and the tibial tubercle. Portals and lncisions

The landmarks, arthroscopic portal sites,

and skin incisions are marked on the skin (Figure 4). For the procedure, we use four

portals: anterolateral. anteromedial, su-

1}-

Lateralposi

--... v;

I

Its--‘1'.

'

Figure 3 Photograph shows the surgical setup for MMRT repair. The patient is positioned supine with a bump under the ipsilateral hip. A sandbag and a lateral post are used to keep the leg at 90° of flexion.

may be separated and take on the appearance of an empty meniscal space or an empty meniscus signil-m Associated bone bruises andfor ligamentous injuries can also be identified on MEL 74

Procedure

Room SetupiPatient Positioning The patient is placed supine on the oper— ating room table, and prophylactic antibiotics are administered. A soft gel bump

perolateral outflow, and posteromedial. A 5- to T—cm skin incision is made medial to the tibial tubercle, starting 1 cm proximal to the patellar tendon attachment and extending distally. A 3-crn oblique incision

is made on the anterolateral proximal tibia, distal to the Gerdy tubercle and proxi-

mal to the origin of the tibialis anterior muscle. Diagnostic Arthroscopy The diagnostic arthroscopy is performed

with the arthroscope in the anterolat-

o 2013 American Academy of flrthopacdic 51113130115

Chapter 13: Media] Meniscal Root Repair eral portal and a probe placed through

the anteromedial portal. After all three

compartments have been evaluated and

associated injuries ruled out, attention is

turned to the posterior root of the medial meniscus. In some cases, the root of the medial meniscus is difficult to inspect arthroscopically. To assist in visualization of the posteromedial joint space, the arthroscope is positioned along the lateral aspect of the medial femoral condyle and under the posteromedial bundle of the posterior cruciate ligament (Gillquist view). From this position, both the pos— terior horn of the medial meniscus and the medial meniscal root insertion are inspected. Under direct visualization and tactile probing, the root is confirmed to be repairable (adequate quality remaining tissue with minimal retraction of the meniscus). At this point, a posteromedial

Figure 4 Photograph shows the surface anatomy and skin incisions for arthroscopic MMRT repair. Surface landmarks are marked and include the inferior pole of the patella, the medial joint line, and the tibial tubercle. Three of the four portals are shown: anterolateral {AL},

visualization of the root.

anteromedial {AM}, and posterornedial (PM—provisionally marked; the final position is determined by direct arthroscopic visualization). Not shown is the superolateral outflow portal. The anterolateral tibial incision is also marked.

Posteromedial Portal The knee is maintained flexed at 90?, and the entry point is approximated at 10 mm proximal to the medial joint line and

cartilage from the posteroinferior aspect of the medial femoral condyle. The utility of the reverse notchplastj,r is for visu-

portal is created if necessary to improve

5 nun behind the posterior edge of the

femoral condyle. Under direct visualization from the Gillquist view, a spinal needle is inserted percutaneously to verify the entry point. When the entry point has

been confirmed, the needle is withdrawn,

and a vertical portal is made using a No.

11 blade (the incision is made through all soft-tissue layers, including the capsule). Using a switching stick, the arthroscope is then introduced into the posteromedial joint space through this portal. Video 13.1 Posterior Horn Medial Meniscal Root Repair.

Dhannesh Was, MD, PhD; Christopher D. Harner, MD (13 min}

Procedure Figure 5 illustrates steps in arthroscopic meniscal root repair. Exposure of the Root Tear

and insertion Site After establishing all the necessary portals, the first step in the root repair is to provide adequate exposure to visualise the meniscal root and its insertion on the posterior tibial plateau. This is done using a 4.5-mm full—radius resector (shaver) to perform a reverse notchplasty of synovium and 3 to 5 mm of articular

alization of the root and insertion, tunnel positioning, repair bed preparation, and

root fixation. Critical to the repair is preparation of a broad tibial insertion site down to bleeding bone. This is done with the arthroscope in the posteromedial portal and the curved shaver or meniscal map in the anterolateral portal. The surface is shaved until pinpoint bleeding sites or marrow fat globules are seen emanating from the prepared bed.

Suture Passage and i'uririeiI Preparation After the tibial bed has been adequately prepared, suture capture of the meniscal root is performed. To facilitate the passage and control of the suture, an fir—mm

clear cannula is used in the anterolateral portal. Visualized with the arthrosoope

in the anteromedial portal, the suture

shuttle device is introduced via the cannula, and the meniscal root is pierced in

a tibial—tofemoral surface direction. The monofilament loop is passed through the meniscal root, and the shuttle device is

removed from the joint The loop is then pulled out of the anterolateral portal, and

the free ends of the monofilament are held to prevent them from advancing into the

joint. Next, one end of the braided No. 2

suture is fed into the monofilament loop, and a braided loop is created by making the two ends eqml. The monofilament is

ifli 2013 American Academy of Unhopaedic Surgeons

used to shuttle the braided loop through the meniscus and out the anterolateral portal. Outside the joint, the free ends of the braided suture are then fed through its loop and advanced down onto the meniscus, creating a tight loop stitch. This step is repeated to capture the root with a second loop stitch for added security and force distribution to prevent suture

pull-out. Tunnel preparation for the passage of

the sutures begins with the arthroscope in the posteromedial portal. An ACL transtibial tip guide is inserted through the anterolateral portal, over the ACL,

and positioned at the native root insertion site. The entry point of the guidewire is estimated using the drilling sleeve, and an oblique incision is made over the anterolateral tibial skin. The dissection is carried down to the anterior compartment fascia and the periosteum. Two to 3 cm of anterior compartment soft tissue is

elevated off the tibia at a level just distal

to the Gordy tubercle. This is done to protect the soft tissue during drilling of the tunnel as well as placement of the screw;r

washer-post construct. Next, the ACL tip guide is repositioned on the root insertion, and the drill sleeve is placed onto the anterolateral aspect of the tibia. A 3f32-in (2.4-mm) guide pin is drilled to (but not through) the posterior cortex of the tibia by power. Perforation of the far cortex is completed manually

by tapping the guide pin with gentle mallet blows, thereby assuring steady control ?5

Section 1: Sports Medicine

Figure 5 lllustrations depict the lee}.r steps in an arthroscopic medial menisoal root repair in a left knee. A, The meniscal root is pierced from the tibial to the superior surface with the suture shuttle device, and the monofilament loop is passed through the root. E, Using the anterolateral portal, the loop is grasped and pulled through a clear cannula. C, A No. 2 nonabsorbable braided suture is looped through the monofilament loop. D, The braided suture loop is shuttled through the meniscal root and back out of the anterolateral portal. E, A loop is created in the braided suture. F, The loop is advanced down onto the root of the meniscus, creating a well—secured loop stitch. Steps A through F are repeated with a separate braided suture to create a second point of fixation on the meniscal root {second suture not shown here]. G, Both sutures are individually passed through the tibial tunnel and tied over a post {screw and washer). This final step results in reduction of the meniscal root to its native insertion site.

of the pin when in close proximity to the

popliteal neurovascular bundle.

Tear Fixation Having completed the tunnel, the guide pin is withdrawn and a Hewson suture passer is introduced in its place. Through

the anterolateral portal, arthroscopic

suture retrievers (ice tongs) are passed through the Hewson loop, and the braided suture is grasped and pulled out through the tunnel. To facilitate ease of passage, the ice tongs can be used as a

pulley to improve the angle of suture re-

trieval through the tunnel entrance. Depending on the size of the posterior horn as well as the extent of the tear, a second

suture may provide added fixation to the

root tear. In that case, both sets of sutures

can be retrieved through the same tunnel. Reduction of the root to its insertion 76

should be artl'rrosoopica113,.r verified by

pulling tension on the sutures after they have been retrieved out the anterior tibia.

As the final step in the fixation, the su-

tures are tied over a post on the antero— lateral aspect of the tibia using a 4.5-mm cancellous screw with a washer {Fig-

ure ti). This is accomplished with the knee in 30° of flerion to aid in proper

reduction of the meniscus. The anterior compartment soft tissue is reapproximated using No. [l 1Foficrvl l[Ethicon], and the skin is closed in the usual fashion.

Complications

Complications specific to meniscal root repair surgery can occur mostly from inadequate exposure of the repair bed (insufficient reverse notchplastv). This could result in an insufficient amount

of root tissue captured with the repair

stitch, iatrogenic damage to the ACL with

frequent and vigorous passage of the tip guide, or even damage to the neurovascular bundle in the posterior knee with a poorlyr visualized pin passage. Other complications generally associated with knee surgeryr include postoperative in-

fection, arthrofibrosis, deep venous thrombosis, and failure of meniscal root

healing despite an otherwise properly executed repair.

Postoperative Care and

Rehabilitation

Postoperatively, the patient is allowed

partial weight bearing for the first 6 weeks. Progressive weight bearing is then begun, with a goal of full weight hearing by 8 weeks after surgery. In the iMediate postoperative period, a continuous passive motion machine is used

(fl) 2013 American Academy of flrthopardic 51113130115

Chapter 13: Medial Meniscal Root Repair ] Bone Joint Surg Arn 2009;91tsupp1 2): 257-270. Koenig Il-I, Ranawat AS, Umans HR,

Difelice GS: Meniscal root tears: Diagnosis and treatment. Arthroscapy 2009;25(9}:1025-1032.

Rubinstein RA Ir, DeHaan A, Baldwin IL:

Posterior medial meniscus detachment: A unique type of medial meniscal hear. I Knee Snrg 2009;22(4):339-3-15. Allaire R, Muriuki M, Gilbertson L, Har-

ner CD: Biomechanical consequences of a tear of the posterior root of the medial meniscus: Similar to total meniscectomy. 1 Bone Joint Snrg Am 2003;90t9}:1922-1931. Ding C, Martel-Pelletier J, Pelletier IE

ct al: Knee meniscal extrusion in a largely non-osteoarthritic cohort: Association with greater loss of cartilage volume. Arthritis Res Ther 2007;9{2}:R21. Stilrke C, Kopf S, Griibel KH, Becker R:

Figure 6 Postoperative AP (A) and lateral {B} radiographs demonste the position of the screw-and-washer construct used as a post to tie the meniscal root fixation sutures. Note that this is not a 45° flexion weight-bearing view, so it projects slightly differently from the preoperative views in Figure l. for the first 4 weeks (set at 0° to 90”). In

the first month, physical therapy consists of straight-leg raises, quadriceps sets, heel

slides, and calf pumps. Formal, super-

vised physical therapy can be prescribed during the second and third months after surgery. In most patients, return to full activity can be achieved by 4 months. Bracing is optional; it may be useful for

the first week in the event of a regional

block or weak quadriceps strength.

l A reverse notchplasty should be per— formed. Compromised arthroscopic visualization of the insertion site will make bed preparation, suture passage, and fixation very difficult.

- Multiple passes of the suture shuttle device through the meniscal root should be avoided because this will result in irreparable fraying of already

injured tissue.

I If two sets of sutures are passed

around the meniscus, the surgeon

Pearls

I The majority of the procedure can be done with the knee at 90° of flexion and without the use of a tourniquet or

leg holder. t A posteromedial portal is often nec-

essary for added visualization of the root and its insertion.

should not try to pass all four strands through the tunnel at the same time.

References 1.

Harner CD, Mauro C5, Lesnialc BP, Romanowski IR: Biomechanical conse-

quences of a tear of the posterior root of the medial meniscus: Surgical technique.

(El 2013 American Academy of Drthopaedic Surgeons

The effect of a nonanatomic repair of the meniscal horn attachment on meniscal tension: A biomechanical study. Arthroscopy 2010;26t3):358-365. Lerer DB, Umans HR, Hu MK, Jones MB:

The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion. Sin-feta.I Radial 2004;33flfl}: SEQ-SM. Brody ]'M, Lin HM, Hulstyn MI, Tung GA: Lateral meniscus root tear and meniscus extrusion with anterior cruciate

ligament tear. Radiology ZDDEJEQG): 305-810. Cl'loi C], Choi Y]. Lee I], Choi CH: Magnetic resonance imaging evidence of meniscal extrusion in medial rueniscus posterior root tear. Arthroscapy 2010:26(12):1602-1606.

10. Lee SY, Jee WH, Kim 1M: Radial tear of the medial meniscal root: Reliability and accuracy of MRI for diagnosis. AIR An: I

Roentgenoi 2008;191{1}:31—85.

Chapter 14

Microfracture Amanda F. Vidal, MD Jennifer FitzPatricl‘c, MD

Introduction

Chondral lesions of the knee are frequent-

ly encountered during arthroscopic procedures and can commonly be a source of pain and recurrent effusions. In the young patient, the presence of chondral pathology can be complicated by insta-

bility, malalignment, and meniscal insufficiency. It has been known for decades

dicated for degenerative, bipolar lesions.

Femoral condylar lesions are ideal; however, microfracture can be performed on any articular surface. Generally, the results are less favorable for lesions in the patellofemoral compartment.5 Addi— tionally, the ability of these pluripoten-

tial cells to differentiate into cartilage is influenced by age. Several authors have

that articular cartilage has limited intrinsic healing capacity, therefore, various different cartilage repair strategies have been developed. Broadly, these strategies have included marrow-stimulating techniques Such as rnicrofracture, autologous

shown better results in younger patientsfii'j'i' The age cutoff has generally been accepted as younger than 40 years. It is also essential to determine by history and physical examination which lesions are symptomatic, as focal grade IV carti-

and autologous chondrocyte implantation. Marrow—stimulating techniques rely on perforation of the subchondral plate, which allows pluripotentia] mesenchy-

tomafic elite athletes.”

and allograft osteochondral transplants,

mal cells to fill the defect and create a hybrid fibrocartilage repair. Patient Selection

For many patients, the microfracture technique is the first-line treatment of full-thickness cartilage lesions (Outerbridge grade W} because of its success, relative ease, and cost effectiveness. In addition, when unsuccessful, it generally

does not preclude the use of other cartilage restoration techniques as subsequent treatment options. The selection criteria for a successful outcome are very specific, hDWEVEI‘.

lage defects have been found in asymp-

Contraindications Contraindications to microfracture include bipolar lesions, diffuse degenerative joint disease, uncorrected malalignment, significant loss of meniscal tissue, and

patients who will not be able to fulfill or comply with the required postoperative protocol. Bipolar lesions preclude the appropriate healing environment because

there are two incongruent surfaces in

contact with one another}l Lesions with subchondral bone loss and uncontained lesions are not amenable to microfracture for similar reasons. Uncorrected malalignment will cause abnormal me— chanics, which will place increased loads

Indications Clinically important parameters when considering the suitability of a patient for containment of the articular cartilage lesion; status of the meniscus; age of the

Preoperative Imaging The diagnostic imaging begins with

there is some controversy as to the maxi-

cludes four views: weight-bearing AR

patient: and body mass index. Although

mum siae of the lesion, many describe the "ideal" lesion as less than 2 cm2 and not

exceeding an area of 4 cm1.” Additionally, the lesion should be unipolar and

well contained. Microfracture is not in-

and a loose body consistent with an osteochondral fragment. When any cartilage repair technique is being considered, including microfracture, long—leg align— ment radiographs must also be obtained

to evaluate for any angular deformity

that may require concomitant treatment. Focal cartilage lesions that satisfy these criteria in the setting of varus malalignment can be treated successfully with combined microfracture and high tibial osteotomy.” MRI also has become a standard diagnostic imaging technique. Cartilage-specific MRI sequences can accurately diagnose cartilage injury" [Figure 1}. Sequences recommended by the International Cartilage Repair Society are proton density—weighted fast spin—echo imaging with or without fat saturation, T2weighted fast spin-echo imaging with or without fat saturation, and Tl-weighted

gradient—echo imaging with fat suppres— sion.“ In addition to the chondral injury, MRI will reveal any concomitant menis-

cal or ligamentous pathology that may need to be addressed.

Video 14.1 Microiracture: Ted'rnique and Pearls. Armando F. Vidal. MD [10 min}

on the microfractured surface.“| Longer

duration of preoperative symptoms and a body mass index greater than 30 kgfm2 may also have an association with poorer outcomes.”

microfracture include size, location, and

ture as a viable option. In an acute injury,

these four views may reveal a donor site

plain radiographs. A standard series in-

weight-bearing 45" PA, lateral, and Mer-

chant. In patients with chronic or degenerative conditions, these views can help

determine if the degree of arthrosis is too severe or diffuse to consider microfrac-

Dr. Vidal or an imnrerliatefirmily member is a member of a speakers“ bureau or has made paid presentations on behalf of the Musculoskeletal Transplant Foundation. Neither Dr. FitzPatrick nor any immediatefamily member has received anything ofvaluefrom or aunts stock in a com— mercial company or institution related directly or indirectly to the subject of this chapter:

re 2013 American Academy of Grtlropaedic Surgeons

Procedure

SetuplPatient Positioning Microfracture can be performed under general, spinal, or regional block anes— thesia. After anesthesia is administered,

the patient is placed in the supine posi-

tion, and the affected lower extremity is prepared for a standard knee arthroscopy based on the surgeon’s preference. An examination under anesthesia is important, as with any cartilage or ligamentous procedure. A valgus stress post or leg holder can be used to provide access to the intended compartment as long as full range of motion of the knee is allowed. A tourniquet is not typically necessary but can be used per surgeon preference. The pressure created by the arthroscopic fluid

is usually sufficient to tamponade bleed-

'39

Section 1: Sports Medicine ing during the procedure. A standard

diagnostic knee arthroscopy is then performed through anterolateral and antero-

medial portals. Meniscal, chondral, and

ligamentous pathologies are identified. Often, loose bodies are encountered with

full-thickness cartilage lesions; these should be addressed.

Surgical Technique

In general, other pathology (meniscal

tears, plica, loose bodies, etc) is addressed first, and the microfracture procedure

is reserved for the end. This sequence

is recommended because the bleeding caused by the microfrachu'e may obscure

visualization for the other parts of the procedure. However, it is recommended

Figure 1 Ca rtilage—specific MRI sequences. A, Transaxial proton—density fast spin—echo fat— saturation MRI demonstrates a posterior femoral condyle lesion. B, Coronal proton density— weighted fat-saturation MRI demonstrates a medial tibial plateau lesion.

that ligamentous pathology be addressed after the microfracture procedure. Generally. the chondral lesion is easier to access

before the ligament reconstruction; addi-

tionally, undue stress on the graft is avoided while accessing the chondral lesion. Once the chondral lesion is identified, unstable cartilage flaps are debrided,

and the factors mentioned earlier are assessed to determine if the lesion is amenable to microfracture treatment. If there is significant subchondral bone loss or an uncontainod lesion without clear

borders, then microfracture may not

be indicated because the results will be suboptimal. The arc of motion in which

the lesion is weight bearing is noted because this may have implications for the

postoperative rehabilitation course. The debridement and preparation of the lesion is performed with a combination of an arthroscopic shaver and a curet. The shaver is used. both on oscillate and on

forward and reverse to help define the

lesion and rid the joint of debris, which

may later lead to loose bodies. It is important to create perpendicular edges at the transition between the lesion and stable,

healthyr cartilage. This step enhances the lesion's ability to contain the "super clot." Our preference is to use a ring curet that produces a vertical and stable shoulder to the lesion. After débridement, the cal-

cified cartilage layer that remains must be debrided (Figure 2}. Animal studies

have shown this to be a critical step that enhances volume fill of the lesion and the

ability of the repair tissue to bond to the

underlying subchondral plate-J2 If a stable rim of healthy cartilage does not shoulder the lesion, achieving a stable clot may be more difficul .4!“ After debridement and preparation of the lesion, commercially available miBl]

Figure 2 r'irthroscopic views demonstrate dobridcmcnt and preparation of a chondral lesion before microfracture. A, Ring curet removes the calcified cartilage layer. E, King curet creates shoulders.

crofracture awls are used to create holes within the base of the lesion. The awls have conical-shaped tips and come in multiple angles to facilitate the creation of holes perpendicular to the subchondral plate (Figure 3}. Accessory portals may also be necessary to achieve this, particularly for very posterior femoral condyle or patellar lesions. Typically, the 45° awl is used first. The holes are cre— ated in a systematic fashion, starting at the periphery and working in toward the center of the lesion. It is imperative that

Figure 3 Photograph depicts microfracture awls of various angles.

the awl is perpendicular to the surface to

prevent skiving so that the holes do not become confluent with one another. It is also important to maintain adequate spacing (approximately 3 to 4 mm) when creating the holes to preserve the integ-

rity of the subchondral bone between the holes. This will help to prevent the "mac-

rofracture” complication, rather than the

microfracture that is intended. The awls allow for controlled depth of penetration, approximately 2 to 4 mm. Adequate access to marrow elements is then assessed with the visualization of fat droplets or

blood by clamping off the inflow or the negative pressure from the arthroscopic pump. An egress of blood and fat droplets from all holes confirms successful penetration with the awls. (The steps of

the microfracture technique are shown in

Figure 4.) It is important to perform this procedure without tourniquet control to assess the stimulation of blood from the subchondral plate. Bony debris created during the microfracture process is removed with a shaver.

(fl) 2013 American Acadmy of Drthopaedic Sui-gems

Chapter 14: Microfracturc

Figure 4 Arthroscopic views show a chondral lesion of the trochlea treated with the microfracture technique. A, Initial debridement of the lesion. B, A shaver is used to remove the calcified cartilage layer. C, Beginning at the periphery of the lesion, a microfracture awl is used to create holes perpendicular to the subchondral bone. D, The completed holes. E and F, Inflow has been clamped off, allowing visualization of blood emanating from the holes.

All arthroscopic instruments are then removed from the knee. Postoperative drains should not be used because they may dislodge or remove the mesenchy-

mal cells that are intended for the super

clot. A compressive wrap and cryotherapy cuff are applied to the knee to help with postoperative swelling and pain. A brace is typically not used for femoral condyle lesions. Knees treated for patellofemoral lesions are immobilized in a hinged knee brace locked in full extension

Complications

One of the advantages of the microfrac— ture procedure is that the associated com— plications are relatively feW. A joint effusion is typical for the first several weeks after surgery. A return of this effusion may occur at 6 to 8 weeks,

when the patient begins full weight hearing and is becoming more active on the extremity. This effusion is generally painless and should not be alarming to the surgeon or patient because it usually resolves in a few weeks without any intervention.

Dsseous overgrowth after microfracture has been noted on subsequent MRI stud— ies in 25% to 49% of patients.‘ The repair cartilage overlying these areas is thin-

ner, but it is unclear whether this plays a role in prognosis or patient outcome. Although the exact mechanism for easeous overgrowth has not been elucidated, excessive debridement of subchondral bone may be a contributing factor.“1 Although regenerative tissue following microfracture may be limited in terms of durability, intralesional bone formation and elevation of the subchondral bone plate seem to be characteristic problems of this technique. Additionally, although microfracture does not preclude other cartilage repair techniques in the future, the success of techniques such as autolo— gous chondrocyte implantation may be compromised if performed as a revision

procedure following microfracture rather

than as a primary procedure.“ Because of the rehabilitation restrictions required, patients will develop some quadriceps weakness and atrophy. This frequently leads to anterior knee pain as the postoperative course progresses and

patients begin to bear full weight and be-

come more active. This pain resolves as quadriceps strength returns. After the treatment of patellofemoral lesions, pa— tients may report mechanical symptoms during a range of motion. This also resolves as rehabilitation progresses.

o 2013 American Academy of firthopaedic Surgeons

Postoperative Care and

Rehabilitation

The rehabilitation program is considered a critical component of the success of a

microfracture procedure. Protocols are

tailored somewhat, depending on the location of the chondral lesion, but the same

basic principles apply to all microfracture patients: protected weight bearing and the use of a continuous passive motion

[CPM) machine. However, rehabilitation

protocols are mostly empirical because the effect of CPM and weight-bearing status has not been evaluated systematically? The initial 7' to 10 days are focused on controlling edema and pain. A com— pressive bandage and a cryotherapy device are used. CPM use is started on the clay of surgery. Patients are encouraged to avoid rigorous activity to allow the super clot to form and adhere. The goal is to provide the optimal environment for the mesenchymal cells of the super clot

to differentiate into cartilage repair cells (Figure 5).

For lesions involving a femoral condyle or the tibial plateau, patients are started on a CPM machine immediately in the recovery room. The initial range—of—motion setting varies slightly based on surgeon

preference, but frequently used protocols 31

Section 1: Sports Medicine

Figure 5 Arthroscopic images shmv a fenmral contiyle lesion before {fit} and after {[5] mict'ttfracture- C, Subsequent filling in of the lesion observed during a second-look arthroscopy.

Figure 6 Arthroscopic views show microfracture- A, A small, well-contained femoral condyle lesion with robust shoulders. B, The same lesion after debridement and microfracture. C, Confirmation of penetration of the subcltondral plate and bleeding from the microfracture holes.

With small, well—shouldered lesions such as this, earlier weight bearing can be considered.

start at U” to 60° or 30° to 70° at a rate of

exercises within the arc of motion that

for E- to 3 hours per day for 6 to 8 weeks. Range of motion is advanced in 10° increments as tolerated by the patient until full passive range of motion is achieved. For those patients who cannot tolerate the

lesion. Progressive active strengthening begins at 8 weeks. Running is allowed at

1 cyclefmin. The CPM machine is used

CPM machine, a program of passive flex-

ion and extension, mm 500 repetitions three times a day, has been employed.15 Protected weight bearing is maintained for 6 to 3 weeks depending on the size

safely avoids compressive forces on the 3 to 4 months, but activities that involve

any cutting or pivoting are restricted un— til 4 to 6 months after surgery.“ The rehabilitation guidelines for patel-

lofemoral lesions differ slightly, but the

prefer non—weight bearing with crutch

same principles apply. To protect against compressive and shear forces on the super clot, a hinged knee brace is employed. Patients may weight-bear fully on the earn-emit}r with the knee brace locked in

weight-bearing protocoL With either protocol, the patient must understand the importance of protected weight bearing to avoid compressive forces that could jeopardize and dislodge the super

patella from engaging the trochlea while weight bearing. The CPM machine is begun immediately, and passive range of motion is allowed without the knee brace

of the lesion (Figure 6). Some authors

assistance; others employ a touchdown

clot. After the protected weight-bearing

phase, patients are progressed to full weight bearing. Strength training in the form of isometric quadriceps and hamstring strengthening can begin immediately. At 2 weeks, the patient can begin riding a stationary bike without resistance and commence 32

full extension for all weight-bearing activities? The brace settings prevent the

on. As with femoral condyle or tibial

plateau lesions, early isometric strengthening is allowed. However, progressive strength training is limited to the arc of motion (noted at the time of surgery) in which the lesion is not subjected to com— pressive forces in the patellofemoral compartment.

Pearls - The lesion should be defined with well-shouldered borders.

0 The calcified cartilage layer that re-

mains must be débrided. I The lesion should be measured after débridement.

- Microfracture awls are used in systemafic fashion, starting at the periphery and working centrally. I Sharp microfracture awls should be used to avoid coalescence of the holes.

I The subchondral bone is perforated 2 to 4 mm apart and 2 to 4 mm deep. I All holes should be checked for bleed-

ing at the conclusion of the case. It is common for some of the microfracture holes to become impacted with bone,

and preventing the marrow elements from emanating. All holes that do not

actively bleed should be revised.

References

1. Asik M, Ciftci F, Sen C, Erdil M, Atalar A: The microfracture technique for the treatment of full-thickness articular cartilage

lesions of the knee: Midterm results. Arthroscopy assessment—1220.

(it 2013 American Acadmy of flrthopaedic Surgetms

Chapter 14: Microfracture

CD

. Knutsen G, Drogset JO, Engebretsen L,

et al: A randomized trial comparing autologous chondrocyte implantation with microfracture: Findings at five years.

I Bone Joint Sarg Ant 2W;39(10]:2105-2112. H:-

. Mithoefer K, Williams R] III, Warren RF.

et al: The microfracture technique for the treatment of articular cartilage lesions in the knee: A prospective cohort study 1 Bone Joint Sarg An: 2015;B?(9):1911-192tl. 5. Kreua PC, Steinwachs MR, Erggelet C,

et al: Results after microfracture of fullthickness chondral defects in different compartments in the knee. Osteoarthritis Cartilage 2006;14t11}:1119—1125. En. Kreuz PC, Erggelet C, Steinwadts MR,

et: al: Is microfracture of dtondral defects in the knee associated with different results in patients aged 40 years or younger? Arthroscopy 2006;22{11):1130-1136.

1?. Mithoefer K, McAdams T, Williams R], Kreuz PC, Mandelbaurn BR: Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: An evidence-based systematic analysis. Am I Sports Med Ztltltl:3?{ltll:2053-2063. . Kaplan LEI, Schurhoff MR, Selesnick H,r Thorpe M, Uribe 1W: Magnetic resonance imaging of the knee in asymptomatic professional basketball players. Arthroscopy EDDS;21{5):55?-55L . Steadman IR. Rodkey WE, Rodrigo I]: Microfracture: Surgical technique and rehabilitation to treat chondral defects. Clin Orthop Reiat Res EWIflQlfsuppl): 5352-5359. 10. Sterett WI, Steadman JR, Huang M], Matheny Lit-IL Briggs KK: Chondral resurfacing and high tibial osteotomy in the varus knee: Survivorship analysis. Am I Sports Med 2D1fl;33{?}:142[l-1424. 11. Shindle MK, Foo LP, Kelly ET, et al: Magnetic resonance imaging of cartilage in the athlete: Current techniques and spectrum of disease. I Bone Joint Surg Am 2006;88{suppl oar-cs. 02-

ment of full thickness chondrat lesions of the knee with microfracture in a group of athletes. Knee Snrg Sports Walnuts! Arthrosc 2005:13(3):213—221.

SD

2. Gobbi A, Nunag P, Malinowski K: Treat-

(it 2013 American Academy of firthopaedic Surgeons

12. Frisbie DD, Morisset S, Ho CPL Rod key WG, Steadrnan IR, Mcllwraith CW:

Effects of calcified cartilage on healing of chondral defects treated with microfracture in horses. An: I Sports Med

2006:34f11]:1824~1331. 13. Mithoefer K, Williams R] IIL Warren RF, et al: Chandra] resurfacing of articular cartilage defects in the knee with the microfracture technique: Surgical technique. I Bone Joint Sing An: 2006; 33(suppl 1, pt 2}:294-3{l4. 14. Minas T, Gomoll AH, Rosenberger R,

Royce RU, Bryant T: Increased failure rate of autologous chondrocyte implantation after previous treatment with marrow stimulation techniques. Am I Sports Med 2009;3Ff5):902—908.

15. Hurst IM, Steadman JR, IO'Brien L, Rodkey WC, Briggs KK: Rehabilitation following microfracture for chondral injury in the knee. Cfin Sports Med 2010;29f2}:257-2&5, viii.

Chapter 15 Surgical Treatment of Osteochondritis

Dissecans Lesions Sarapttam Bajaj, BE

Michael I. Salata, MD

Introduction

Dsteochondritis dissecans [0CD] is a pathologic joint disorder that affects the subchondral bone and the overlying articular cartilage.1 The disease results in subchondral bone loss and destabiliza— tion of the overlying articular cartilage,

leading to separation and increased susceptibility to stress and shear of the

resultant fragment.2 The true etiologyr is unknown, but this condition may be re-

.lated to repetitive microtrauma, a single acute traumatic incident, ischemia, or

endocrine and genetic predisposition.3L Regardless of the etiology, the end result is fragmentation of both cartilage and bone that can progress to early degenerative changes and loss of function in the affected compartment. In its final stages, bipolar osteoarthritis can develop, leading to the need for arthroplasty in some instances. The prevalence of (JED is estimated at 15 to 3D per lflDJJDIi, with most lesions

occurring in the knee. Nearly 30% of the cases involve the medial femoral condyle (MFC), 15% involve the lateral femoral

condyle, and 5% involve the patellofeIn-

oral region. More than 70% of all 0CD lesions are found in the ”classic" area of the lateral aspect of the lvlFC intersecting the intercondylar notch near the femoral footprint of the posterior cruciate ligament (PCL)."

In the case of a stable lesion and a short duration of symptoms, nonsurgical management can be successful. In the past,

these lesions have been treated with immobilization and weight—bearing limita— tions. However, published studies have

shown that prolonged immobilization can be detrimental to the health of the knee joint: thus, currently employed non-

surgical management should focus on a hiatus from sporting and high—impact

Brian I. Cole, MD, MBA

activities for E to 3 weeks with allowance

is often achieved through fragment re-

patient. Asking a patient to participate in "rela-

mediate term. Although intuitively it is reasonable always to try to retain a viable fragment and provide rigid fixation to promote biologic union of any osteo— chondral fragment, the fact that many patients can clinically tolerate a concave,

for normal weight bearing in a compliant

tive rest," much like the treatment rec— ommendations for stress fractures, can

maintain the health of the joint without compromising the healing potential of a

symptomatic DIED lesion. The length of

time required to render a patient asymptomatic and safe to return to high-level activities is highly variable and is a consideration when deciding to intervene with surgery. In the case of failed nonsurgical management or in the setting of an unstable fragment, surgical intervention includes fragment removal, drilling [antegrade or retrograde], internal fixation,2 marrow

stimulation,

autologous

chondrocyte

moval, at least in the short and inter-

well-defined osteochondral defect is pro-

vocative to the extent that benign neglect following fragment removal remains a treatment option in some instances. The resultant paucity of symptoms following fragment removal is explicable by the typical geometry and the relatively load-sparing location of these lesions, which allow the defect bed to become clinically silent simply because the sur— rounding osteoarticular environment can "shiel " the lesion, rendering it less

or osteochondral

clinically relevant. The debate that re-

repair the lesion or supplement the area of cartilage loss. As a last resort, joint arthroplasty may be the only feasible solu— tion in advanced cases.

with cartilage restoration procedures when initial fragment excision renders a patient clinically normal. Because no cartilage restoration procedure has been demonstrated to last "forever" nor been

implantation {AC1},

autograftlallograft transplantation to

Subtleties in Decision Making

Unique to 0CD is the fact that patients with this pathology can have very little in the way of symptoms until the fragment becomes destabilized based on the endogenous natural history of that lesion or through acute or repetitive trauma. It is appropriate to consider symptomatic 0CD with fragment instability as an intra-articular atrophic fracture nonunion. This concept is important to recognize because it relates to treatment decisions and the technical steps requisite to successful defect healing. Because

the natural history of the isolated OED lesion is not clarified in the body of ex-

isting literature nor in our contemporary experience, successful clinical treatment

Dr. Salata or an immediate family member serves as a paid consultant to or is an employee of

linuatec, Mimi, and Smith a Nephew. Dr. Cole or an immediate family member has received royalties from Arthrex, DI Orthopaedics, Lippincott, and Elseuier; is a member of a speak-

ers' bureau or has made paid presentations on behalf of Genryme; serves as a paid consul-

tant to or is an employee oimmer, Arthrer, Carticept, Biomimetic, Allosource, and DePay;

and has received research or institutional support from Regentis, Arthrex, Smith Sr Nephew, DI Orthopaedics, Zimmer, and DePay. Neither Mr. Bafaj nor any immediate family member has reached anything of oaluefmm or has stuck or stock options held in a commercial company

or institution related directly or indirectly to the subject of this chapter. (El 2013 American Academy of Grthopaedic Surgeons

mains is when to treat these lesions early

demonstrated to definitively prevent pro-

gression of osteoarthritis over time, deci-

sion making remains challenging for the patient presenting with the asymptomatic defect following fragment removal. This is especially true for the high-level

competitive athlete who places a premi-

um on the short- and intermediate-term maintenance of functional activity.

Patient Selection

A thorough history is mandatory and should elicit any inciting events, any un— derlying metabolic or systemic conditions

that may have contributed to the OED, the duration of symptoms, and previous

attempts at treatment (both nonsurgical and surgical). The typical presentation of 0CD in the knee includes pain and swelling related to activity.” Instability is usually not reported, although mechani-

cal symptoms such as catching or locking

can occur if the fragment has become completely detached and is acting as a loose body. On physical examination, patients typically have tenderness localized over the compartment where the ECU

lesion is located.‘ The patient may walk 85

Section 1: Sports Medicine

with an antalgic gait or with the leg ex-

mmally rotated (Wilson sign) to decrease

pressure over the lesion. With external rotation, a lesion located on the MJFC will

not impinge with the medial tibial eminence, which decreases the pain associ— ated with motion at the lesion interface. Joint effusion, decreased range of motion,

loose-body symptoms, and quadriceps

atrophy are variably present, depending on the extent of the lesion and the duration of symptoms.

When contemplating surgical interven-

tion, it is important to consider the site of

the lesion. Certain sites, such as the classic location on the MFC, have a spontaneous resolution rate of less than Sfl‘i'a, whereas

nonclassic locations are much more likely to heal in the adolescent population, with 88% to 100% healing rates reported with nonsurgical management“ The ideal candidate for primary repair is an unstable lesion in an active,

symptomatic patient. The ideal patient

is willing to comply with the postopera-

tive weight-bearing limitations and ac-

tivity restrictions and understands the potential need for a second procedure for implant removal. Patients with open physes on radiographs and in whom nonsurgical therapy for a stable fragment fails to achieve symptomatic and

radiographic improvement should be

considered for retrograde or antegrade drilling. Arthroscopically stable, symptomatic lesions might benefit from bio— absorbable screw fixation, with the screw

heads buried just below the level of the

subchondral plate as an adjunct to drill-

ing through an extra-articular or periarticular location. Primary surgical fixation is not recommended if the lesion is freefloating as a loose body and the underlying subchondral bone is compromised. An initial strategy in this patient population should include loose body removal and possible chondrocyte biopsy for subsequent ACI if the patient demonstrates persistent symptoms attributable to the resultant chondral defect. In such cases,

primary marrow stimulation can also be considered on a case-by-case basis Should these initial treatments fail to

resolve symptoms, definitive cartilage

restoration (osteochondral auhagrafting, osteochondral allograft transplantation, or ACI} can be considered.

Figure 1 Radiographic appearance of an osteochondritis dissecans {GED} lesion. A, Weightb-earing AP radiograph of a left knee depicts an 0CD lesion on the medial femoral condyle (MFC). B, Lateral view at 45“ flexion. C, Merchant view. The area of lucency on the MFC can be best appreciated on the AP and lateral views.

Preoperative Imaging Because the physical findings of (ICU are

often vague and nonspecific, a physical examination cannot be used in isolation to diagnose this type of pathology. Imaging is crucial in the evaluation of patients

Figure 2 M RI appearance of an osteochondritis dissecans [DClili lesion. A,'l"1-weighted sagittal view. B, T2-weighted sagittal view. C, T2weighted coronal view of an 0CD lesion presenting concomitantly with compromised subchondral bone. An area of high signal intensity between the OED lesion and the subchondral bone suggests instability.

86

(El 2013 American Acadmy of Drtltopaedic Sui-gems

Chapter 15: Surgical Treatment for Dsteochondritis Dissecans Lesions presenting with these symptoms and

should include a plain radiographic se-

ries and often a subsequent MRI. Preliminary radiographs should be standard and include AP weight-bearing knee, weight—bearing 45° flexion PA, lat— eral, and Merchant views?1 (Figure 1). The

flexion weight-bearing PA view should be obtained in addition to standard AP because it allows for better visualization of lesions along the posterolateral aspect of the MFC. Open physes are a positive predictor for healing of an 0CD lesion and should be noted on the plain radiographs. MRI is often required in the diagnosis of 0CD lesions because it is the most informative imaging modality. Specifically, an evaluation for the presence of bone edema, subchondral separation, cartilage breakdown, lesion size, and location can be assessed using MRI before treatment}The MRI scans are assessed based on the criteria presented below, in which meet-

ing one of the four criteria offers up to 97% sensitivity and 100% specificity in predicting lesion stability2 (Figure 2): 1. A thin, ill-defined, or well-

demarcated line of high signal intensity, measuring 5 mm or more in length at the interface between the lesion and the underlying subchondral bone

2. A discrete, rounded area of homoge-

neous high signal intensity

3. A focal defect with a width of 5 mm or more in the articular surface of the lesion

4. A high signal intensity line traversing the articular cartilage and subchondral bone plate into the lesion

Procedure

Most adult 0CD cases arise from estab— lished but untreated or asymptomatic juvenile 0CD. Spontaneous healing has

been reported in such cases with non-

surgical treatment options. However, for lesions presenting in the classic location of the lateral aspect of the MFC or lesions that persist after adequate nonsurgical treatment, an array of surgical options is available.

The overall goal of surgical intervention

is to enhance the healing potential of the subchondral bone, fix the unstable frag-

ment, or replace the abnormal cartilage and bone with implantable tissue.1 The type and extent of surgery necessary for 0CD depends on myriad factors,

Figure 3 Surgical treatment algorithm for osteochondritis dissecans. The surgical goals should always incorporate an attempt to reestablish the joint surface using the least invasive procedure first. DA graft = osteodiondral allograft, OATS = osteo-chondral autograft transfer system, AC1 = autologous chondrocyte implantation.

including patient age, lesion characteris— tics (the quality of the articular cartilage; the size of the associated subchondral bone; and the shape, thickness, and location of the lesion}, lesion stability, and surgeon preference [Figure 3). Room Setupl‘Patient Positioning A supine position, with the affected leg placed within a leg holder allowing full flexion, allows complete access to femoral condyle lesions that might require hyperfleition or a figure-of—4 position to optimize arthroscopic lesion preparation and fixation. The contralateral extremity is positioned in an obstetric-type well leg holder with adequate padding around the common peroneal nerve. The affected joint is draped to the proximal thigh, and a well-padded nonsterile pneumafic tourniquet is applied before draping. An examination under anesthesia is per— formed to assess range of motion and ligamentous stability. Depending on the

(fl) 2013 American Academy of Grthopaedic Surgeons

lesion site and size, an arthroscopic or

a mini—open technique is used. Lesions on the condyles are often easily accessed

with the use of arthroscopic techniques

and through satellite portal placement wherever needed. Patellofemoral and tibial lesions can be more difficult to access arthroscopically and may require an arthrotomy or mini-arthrotomy for adequate visualization and treatment. Surgical Technique A complete arthroscopic evaluation of each compartment and its structure is performed to determine all intraarticular sources of pain. A standard

arthroscopic probe is used to assess the

boundaries and the stability of the lesion

(Figure 4). In the case of a lesion with intact articular cartilage, the lesion will be ballottable, and a ”trampoline" effect will

be appreciated when the lesion is probed. This clinical scenario is more common in very young patients who present with

8'?

Section 1: Sports Medicine

Figure 5 Arthroscopic view shows osteocl-iondritis dissecans (0CD) lesion fi ration using a bioabsorbable screw. This is used for intact 0CD lesions that are neither hallottable nor displaceable at the time of surgical intervention.

Figure 4 Arthroscopic views of an osteochund ritis dissecans (0CD) lesion. A, Large 0CD lesion with fibrillation and fissuring dcmarcating the lesion border. B, Arthroscopic assessment of lesion stability performed using a standard probe. C, Detached DCD lesion with demarcated border. D, Subchondral base of the detached 0CD lesion, which will be de’brided

using a shaver or burr.

activity-related pain without effusions and with fluid behind the lesion on lll.

However, in many cases, there are fis-

sures or fibrillations that mark a distinct transition from a firm to a soft segment of cartilage that can be appreciated as one

moves the elbow of a probe from normal

cartilage to the overlying cartilage of an 0CD lesion. Often, for classic 0CD of the

MFC, access can occur at the leading edge of the femoral origin of the PCL using an electrocautery device and elevator to ex-

pose a fissure that enters the intercondy— lar notch in this area.

With the lesion identified and classified,

the following surgical techniques can be used to alleviate a patient's symptoms.

Heparative Procedures The goal of a reparafive procedure is to restore the integrity of the subchondral bone and preserve the overlying articular cartilage. This generally is a primary reduction and fixation of the fragment. It is often accompanied by a removal of

fibrocartilaginous scar at the interface between the lesion and underlying sub-

chondral bone, coupled with restoration

of blood flow to the lesion by microfracture or drilling of the host tissue bed. In the presence of cystic changes or attritional bone loss, local bone graft procedures that harvest cancellous bone from 88

the Gerdy tubercle or the distal femur using a small-diameter osteochondral autograft harvesting tube are effective. Drilling

In the setting of a stable lesion with intact articular cartilage that remains symptomatic despite appropriate nonsurgical management, retrograde or antegrade drilling can restore blood supply to the fragment. This technique serves to create vascular channels that can provide ade-

quate blood flow to the affected region, al-

lowing for l'iealing.5L This technique is less likely to be successful with true fragment instability. Understanding that these lesions often hurt because of micromotion due to ”fracture nonunion" principles can help surgeons avoid implementation

of subtherapeutic treatment that might inevitably lead to repeated surgical intervention if the lesions become macroscopically unstable. Antegrade drilling has been described as being performed from within the joint

through the articular cartilage and into

the subchondral bone. Lesions of the MFC can be drilled through an antero-

lateral or anteromedial portal, whereas

lesions of the lateral femoral condyle are usually accessible through the anterolat— eral portal. If the lesion is not accessible via standard portals, accessory portals

are created to obtain an orthogonal drilling angle. Holes are drilled uniformly using a Kirschner wire {K-wire], and blood and fat droplets from the drilled region are used to confirm the depth of the penetration? Anterograde drilling violates the articular cartilage surface, with the resultant gap filled in with fibrocartilage, tissue similar to the cartilage created

with a microfracture. We prefer to avoid

direct penetration of intact healthy articular cartilage overlying the fragment and drill just behind the lesion through the intercondylar notch or through the juxtaarticular osseous surfaces, which is more

analogous to retrograde drilling. In addi-

tion. consideration should be given to the use of third-generation small-diameter bioabsorbable, variably pitched screws (Bio£ompmssion Screw, Arthrex) placed directly through the lesion, which will essentially provide a combined approach of antegrade drilling with fracture fixation, even if the fragment is only ”microscopically" unstable [Figure 5). Surgeons must consider that, despite being bioabsorbable, these devices will remain intact for up to several years; therefore, their

heads must be advanced to or bed the

subchondral plate to avoid inadvertent damage to opposing articular surfaces either primarily or following potential fragment subsidence over time. Theargumentsupportingextra-articular or retrograde drilling is to avoid fibrocar-

tilage formation at the fragment site and

damage to intact, healthy cartilage in

general. In this procedure, the drill enters proximal to the lesion and penetrates the sclerotic proximal border of the lesion without violating the overlying articular cartilage. Fluoroscopic guidance is extremely helpful when performing ret-

(fl) 2013 American Academy of flrfhopaedic Surgemrs

Chapter 15: Surgical Treatment for mteochondritis Dissecans Lesions-

Figure 6 lntcrnal fixation of an osteochondritis dissecans {KID} lesion. fit, rt large L'I'CD lesion is arthroscopically probed to determine stability. B, Guidewires are placed to control rotation during fixation. C, DEE} lesion affixed using a nonabsorbable, cannulated, headless

va riable-pitch compression screw. D, Removal of the cannulated, headless compression screw. A hemostat is used to prevent loss of the screw in the joint, fat pad, or extra-articular soft tissue. E, Assessing lesion stability after removal of fixation.

rograde drilling. A definitive "plunge" is felt when passing the K—wire through the sclerotic border, which can be used to

confirm that this border has been appropriately perforated. Overall outcomes of 0CD drilling are generallyr favorable in the younger population. Donaldson and lwlni’ojtys‘r compared outcomes of juvenile 0CD to adult 0CD, reporting a higher level of radiographic healing and favorable relief of symptoms in the younger population. As noted previously, drilling should be used only when the defect is categorically stable to palpation. When possible, drill-

ing should be performed through the intercondylar notch (ie, adjacent to the PCL

femoral origin for 0CD of the MFC) or along the lateral nonarticulating border of the distal femur using a 4.5-mm K—wirefi Occasionally, in the setting of larger le-

sions, we augment the treatment of these lesions by using one or two bioabsorbable

compression screws that are buried deep to the level of the subchondral plate in an effort to stimulate biologic healing and stabilize the osteochondral fragment. internal Fixation

0CD lesions that have detached from the subchondral bone may present with articular cartilage flaps or loose bodies. If the lesion has sufficient subchondral bone to provide biologic and mechanical support for fixation, every attempt

to perform a reduction {arthroscopic or

open} and fixation should be made.2 With

all types of fixation, the bed of the defect

should be prepared to optimize healing.“ In the setting of a flap, the fragment can be hinged open, and the bed can be cleared of fibrocartilaginous scar using a curet and microfractured to restore vascular channels. Internal fixation can be achieved using a variety of fixative devices, such as cannulated screws, metal pins-wires,

and bioabsorbable pins and screws.“ The method of fixation is largely based on surgeon preference. Some surgeons bury the head of these screws to prevent subsequent damage to the opposing tibial surfaces; however, when repairing grossly unstable osteochondral fragments that are mobile and hinged open during defect preparation, we prefer to use a can-

nulated variable-pitched metal screw

placed deep to the level of the subchon— dral cortical bone. A second surgical procedure is planned 3 weeks after the first operation to assess for healing and for hardware removal (Figure 6].

Bioabsorbable screws have been recommended by some to avoid removal, but the degree of compression provided by these devices is probably inferior to tra-

ditional metal screws, and the long-term

effects of this implant material require consideration by the surgeon before use? In addition, these devices must be con-

o 2013 American Academy of Grthopaedic Surgeons

sidered prolonged absorbable and will remain intact for at least 12 months; thus, they can still become noxious mechanical devices and lead to opposing surface damage if implanted incorrectly or fol— lowing fragment subsidence. Dnce the sclerotic bed is prepared appropriately (using a curet, a shaver, and a microfracture awl), a guidewire is drilled through the fragment into the femoral condyle to provide provisional fixation. It is often necessary to trim the edges of the fragment because the borders often become rounded and may

hypertrophy, making an anatomic reduction difficult:g As mentioned previously,

cystic changes or cumulative bone loss within the bed can be grafted first by arthroscopically harvesting and mor— cellizing small~diameter osteochondral autograft plugs from the intercondylar

notch, the trochlear ridge, or the Gerdy

tubercle before stabilization. flnce the guidewires are placed, they are exchanged for a compression screw. In general, at least two fixation points are used to ensure compression and rota-

tional stability. Screws are tightened until the fragment is compressed, but over-

tightening should be avoided to prevent fragment fracture or implant failure.2 All devices with a prominent head should be recessed beneath the articular cartilage to avoid further injury to the articulat-

ing surface of the tibia. As mentioned

39

Section 1: Sports Medicine

Figure 27

h-licrofracture of an osteochondritis dissecans {0CD} lesion. A, Arthroscopic view of an unstable 0CD lesion. B, Defect site is

prepared with vertical wall formation. A surgical awl is used to penetrate the subchondral bone. C, Completed microfracture; the holes are about 3 to 4 mm apart. Microfracture holes are started at the periphery, adjacent to the stable cartilage rim.

previously, nonabsorbahle screws often

require a second procedure for hardware removal; however, an advantage of this is

that it allows a second look at the lesion site to verify healing. Although screw removal obviously requires a subsequent

procedure, it offers the opportunity to

remove any fragments that fail to unite and can help the surgeon determine the source of persistent symptoms following fragment fixation once patients are al— lowed to return to higher level activities. Following any 0CD procedure treated with internal fixation, the knee should

be ranged to ensure that the screw head does not abrade the opposing articular surface.2 Patients are made heel-touch weight bearing and use continuous passive motion (CPM) for 5 hours per day for up to 6 weeks.

Despite the screws being "headless," we

sion, pain, and reduced range of motion or if the fragment at the time of the index procedure is determined to be unsuitable for primary reduction and fixation.2 Multiple restorative techniques can be employed for the treatment of 0CD; however, the treatment algorithm should start with the least invasive and progress to the most invasive options Practically speaking, although not necessarily appropriate, the decision to repair an 0CD lesion or perform microfracture is rarely associated with a decision to simultaneously address concomitant pathology, such as meniscal deficiency or malalignment. In contrast, higher-level procedures, such as

AC] or osteochondral grafting for 0CD lesions, are often undertaken simultane-

ously with meniscal allograft transplantation and osteotomy when appropriate.

This distinction must be kept in mind

prefer to remove them to prevent them from becoming proud with settling of the fragment and to determine which part of the fragments may not have healed entirely. Following screw removal, patients are asked to avoid high-impact activities for at least an additional 8 weeks. Bioabsorbable screws are also an option, especially when only one screw is needed for adequate stabilization. In this case, a second-look arthroscopy is generally not performed, but the screw must be

when using the literature to make decisions for patients being treated surgically because there is considerable treatment bias inherent in the specific options being offered.

With strict postoperative rehabilitation,

formation of fibrocartilage.1 The decision

Marrow Stimulation (Mirrofracture)

Microfracture involves perforation of the subchondral bone, allowing for an egress of pluripotent stem cells from the mar— row (Figure ir']. This influx results in the

recessed completely within bone.

formation of a super clot and allows for subsequent cell differentiation and the

favorable outcomes have been reported after internal fixation of 0CD fragments using absorbable and nonabsorbable screws?I

of when to perform microfracture in a patient with 0CD is complex and takes into consideration multiple variables. Despite the fact that most microfractu re proce-

Restorative Procedures Restorative procedures attempt to replace the damaged articular cartilage with hyaline or hyaline-like tissuef' These techniques should be considered if the reparative options have failed and the

at the time the fragment is removed or as a primary revision treatment of the empty defect without consideration for relevant comorbidities [meniscal deficiency and malalignment}, good results follow— ing microfracture of DCD lesions have been reported. The real challenge in deci-

patient presents with recurrent joint effu90

dures performed for 0CD are conducted

sion making for treatment of the patient in whom a fragment must be removed is whether the literature and our experience is sufficient to help us decide if a concave defect with associated bone loss will behave any differently clinically with or

without microfracture after the fragment

is removed, which is often all that is re-

quired to render a patient initially less symptomatic or asymptomatic. Postoperative rehabilitation requires 6 weeks of protected weight bearing with the use of CPM for 6 hours a day. In a randomized clinical trial, Knutsen et al1“ randomized femoral condyle (28% with 0CD lesions)

cartilage defects to treatment with microfracture or ACL Both groups demon— strated satisfactory results in ?T% of the patients at 5 years, with younger patients reporting better outcomes.“ Overall, microfracture should be considered as a first-line treatment, especially in the setting of fragment removal in small, shallow defects. Because microfracture is often entertained as a first-line treatment of the defect bed at the time of fragment removal or considered as an option if the empty defect becomes symptomatic later, sev-

eral concepts must be considered during the decision—making process before recommendn a microfracture procedure. Implicit in this decision making is a de-

sire to reduce symptoms in the "here and

now" versus a desire to change the natural history of what might otherwise remain an asymptomatic lesion. If the patient's symptoms are acute on a chronic, previously asymptomatic, never-treated 0CD

lesion, then fragment removal might lead

to complete and prolonged symptom resolution. There is no formal guidance on the long-term benefits of performing microfracture in these patients because only low levels of research evidence exists in this regard. Thus, a decision to perform

microfracture in the patient undergoing

(fl) 2013 American Acodmy of flrtltopaedic Str-tgemts

Chapter 15: Surgical Treatment for @teochondritis Dissecans Lesions fragment removal is highly individualized, with considerations of defect location, defect containment, the condition of the bone, and the size and depth of the

lesion. Given the rehabilitation required following microfracture, the decision is not taken lightly. Even beyond the initial period of protected weight bearing and CPM, if the surgeon truly follows the existing recommendations about return to sport for these patients, they would not be allowed to return to high—level activi— ties for at least ti to 3 months. Thus, it can

be challenging to hold active patients back when all that might have been required was fragment removal to render them symptom free. A weight-bearing, shallow, small, con—

tained defect with a healthy subchondral (ie, nonsclerotic) bed represents the ideal

defect for microfracture. Alternatively. a

deep. sclerotic, uncontained defect pres-

ents a challenging mechanical and biologic environment where microfracture

may have little to no benefit. Thus, we

microfracture the bed (of a recently re— moved fragment) only if it includes the ideal defect characteristics, assuming the

patient understands and consents to the postoperative program. Although this decision making is somewhat intuitive,

it is not supported by any literature that demonstrates that with this exact clinical scenario the symptoms will be reduced

further than fragment removal alone,

that symptom onset will be prevented or delayed, or that the natural history of the

defect will be altered in any way.

In conclusion, it must be remembered

that the decision to perform microfractore may have no bearing on the future progression of the defect—either structurally or clinically—because neither the literature not our experience offers us guidance in this regard. Osteochondrat Autograft 'n'ansfer System

Scenarios in which the underlying sub-

chonclral bone integrity has been significantly compromised do not perform well

with a marrow stimulation technique and require restorative procedures to address both the underlying structural support of the subchondral plate and the articular surface to be successful. The osteochon-

dral autograft transfer system (OATS)

involves transplantation of osteochondral autograft tissue from a non—weightbearing region of the joint to the defect site8 (Figure 8}. A single autograft plug is preferred for defects smaller than 1 cm1;

however, some clinicians perform a mo-

Figure B IIJsteocl'iondral autograft for an osteochondritis dissecans (0CD) lesion. A, Arthroscopic view of an unstable 0CD lesion. B, Using the osteochondral autograft transfer system {OATS} transfer tool, the defect site is prepared to an appropriate depth. C, Arthroscopic view of the recipient site. D, Implantation of a donor osteochondral plug into the recipient site.

saicplasty with multiple smaller plugs for

repair, debridement, or microfracture are

to small lesions because of a limited supply of donor tissue and donor—site mor— bidity. Typically, restorative treatment of 0CD using OATS has limited utility because of the size and the geometry of

ited for the treatment of this pathology, other than the approach described using an osteochondral plug as a biologic splint.11

larger defects. In general. DATE is limited

most lesions. A novel technique of using

an osteochondral autograft plug as a biologic splint has been reported by Miniaci and T1},i'therleigh-Strong11 and remains a consideration for a defect that has an in— tact, relatively stable fragment within the defect bed. Postoperative rehabilitation consists of immediate CPM with protected weight bearing for 4 to 6 weeks. Return to normal activities of daily living and sport activity is considered at 8 to 12 months. Good clinical outcomes have been re-

ported for GATE techniques, with Min-

iaci and Tytherleigh—Strong“ reporting normal postoperative knee scores at 13 months for all 2|] {JED patients. Osteochondral plugs taken from the ipsilateral lateral patella to treat patients with large osteochondral defects allowed 31% of the cohort to return to a high level of function.11 However, as stated earlier, OATS is

limited to small lesions because of limited donor tissue supply and donor—site morbidity. In general, most GED lesions that re-

quire further treatment beyond initial

(fl) 2013 American Acadoay of Grrhopeedfc Surgeons

relatively large, deep, and uncontained. Thus, the use of DATE is relatively lim-

Autologous Chondrocyte Implantation For large, isolated osteochondral defects

measuring up to 10 cm2, we employ the ACI technique. This two-step procedure involves an initial healthy chondrocyte biopsy, performed arthroscopically with tissue extracted from the non-weightbearing intercondylar notch region? or, in the setting of an irreparable 0CD, the biopsy can be taken from the excised loose body as long as the fragment is grossly healthy. Extracted cells are dedifferenfiated in vitro over 4 to 6 weeks and reimplanted at the lesion site. At the time of implantation, defect preparation involves preservation of the calcified cartilage layer and creation of a vertically walled defect to act as a reservoir for the

implanted cells and better distribute force at the edges of the lesion.1l2 Either perios-

teum or a synthetic collagen patch (offlabel usage) is attached to the perimeter of the healthy articular cartilage using 6-0 Vicryl sutures {Ethicon).“ The edges are sealed using fibrin glue, and the cul-

tured cells are injected beneath the pa

‘1

91

Suction 1: Sports Medicine

—. a — .xrmg

i. Figure 9 Autologous chond rocyte implantation {AC1} for an osteochondritis dissecans lesion. A, Patellar defect. B, The defect site after vertical wall formation, ready for suturing of the type Lr’lll collagen patch. The patch is sutured with 6-D Vicryl. C, The lesion following injection of the dedifferentiated cultured chondrocytes and suturing and gluing of the collagen patch. The patch is sutured and then glued over the defect using a fibrin glue.

(Figure 9). Similar to a microfracture,

6 weeks of postoperative non—weight bearing and CPM are indicated for both DATE and AC1. Defects deeper than S to 10 mm can still be treated with ACI; however, a concomi-

tant or staged bone grafting is recom— mended. Prior to bone grafting, drilling through the subchondral bed following debridement allows appropriate blood

flow into the defect site, optimizing the

incorporation of the bone graft into the defect site. When bone grafting is performed as a primary procedure in an ef— fort to stage for definitive treatment with AC1, it is customary to wait a minimum of 6 months to allow bone graft incorpo-

ration before implantatlon of the cultured

a large patient population undergoing AC] for [ED lesions. Similarly, Knutsen

et a1m reported Wit: satisfactory results in patients with femoral conde lesions treated with ACI. Postoperatively, patients who undergo AC] for femoral condyle lesions require protected weight bearing with CPM for up to 6 weeks. Following AC1 for a patellofemoral lesion, patients are permitted to fully weight-bear with the knee in extension as long as a tibial tuberosity osteotomy was not performed, which would require some degree of weight—bearing protection to prevent a postoperative tibia fracture. Patients whose initial treatment fails,

ACI can be implemented in a deep lesion that requires bone grafting. A bilayer col-

who remain symptomafic or become symptomatic over time, and who are young with relatively shallow contained 0CD lesions, especially of the patellafemoral joint, represent some of the best candidates for AC1. The challenges in

technique) can be employed without the

cavitating, are cystic, andfor have a scle-

chondrocytes. Because this is a long interval for patients to endure, an alternative method of

lagen membrane {periosteal "sandwich"

need to stage the AC]. A layer of collagen membrane is used to seal the bone graft and is fixed using a 6—0 Vicryl suture. A second layer is placed on top of the first

and is similarly sewn, followed by injec-

tion of the cultured cell in between the

two layers. However, limited experience

exists with this technique.” Results following ACI for 0CD lesions have been well described in the literature, with Bentley et a1" reporting good to excellent outcomes in 88% of the cohort from 92

decision making include defects that are

rotic base that presents a difficult biologic environment for AC1 to successfully integrate. These patients may be better candidates for osteochondral allograft transplantation because the bone represents a greater clinical and biomechanical challenge than the cartilage surface. Osteochondraf Affograft

Large 0CD lesions may be treated with osteochondral allograft transplantation. This is a salvage procedure that should

Video 15.1 Fresh Osteod'lendral Allografting to the Knee

for osteodiondritis Dissecans. Joseph Yu, MD: William

Bugbee, MD {3 min)

rarely be used as the first-line treatment2 because this technique requires further violation of the subchondral architecture,

limiting future treatment options should

the procedure prove unsuccessful. An advantage of the osteochondral allograft is that this technique has the ability to resurface larger and deeper defects with mature hyaline cartilage while concomi-

tantly addressing the underlying subchondral bone deficiency. Commercially

available systems convert the host defect to a cylindrical socket. A prolonged fresh allograft is then shaped into a plug that matches the diameter and depth of the

resultant socket. Ideally, the allograft tis-

sue should be implanted before 23 days of donor asystole to maximize the viability of the donor articular cartilage.15 At the time of implantation, minimal force

should be used to place the donor plug because the donor chondrocytes can be adversely affected by increased levels of force.1t To ensure proper fixation, a bioabsorbable compression screw is implanted in the center of the graft with the head advanced to the level of the subchondral bone“ (Figure 10}. This osteochondral allograft technique can be seen on the video supplement.

(El 2013 American Acadmy of Drthopaedfc Eur-gems

Chapter 15: Surgical Treatment for Dsteochondritis Dissecans Lesions Fresh osteochondral allograft transplantation has demonstrated good to excel-

lent clinical outcomes with long-term

follow-up. For a group of 0CD lesions presenting on the femoral condyle, Garrett” reported successful outcomes at a mean follow-up of 3 years in 94% of the patients. In a larger study of 66 0CD lesions in 64 patients, treatment with fresh osteochondral allograft yielded good to excellent results in 3% of patients.“l Postoperative rehabilitation is similar to that used with the DATE or AC1 procedures. After rehabilitation, significant improvements are observed in the majority of patients, with approximately 38% of them showing excellent graft incorporation on radiographic examination."3| Patients whose initial treatment has failed and who have deeper, cavitating lesions with poor quality subchondral bone

represent ideal candidates for osteochon-

dral allograft treatment. While engaging in a treatment strategy that "burns no bridges,” our experience suggests that osteochondral allografts rarely fail; when

they do, it is typically a clinical failure (ie, symptoms persist) despite graft incorporation and maintenance of the articular surface. Revising a failed osteochondral allograft with another osteochondral allograft should it fail to integrate repre— sents a reasonable treatment option as well, but typically failure results from the extent of subchondral bone involvement, which can initially be addressed with restoration using autograft bone grafting, allowing a minimum of 6 to 8 months to incorporate before definitive treatment with an osteochondral allograft. Because of the complex and variable geometry of the patellofemoral joint, in addition to the fact that most 0CD lesions at this location tend to be relatively shallow, we reserve

large osteochondral allografting for revisions of failed AC1 procedures. Notably; this decision making is not universal among surgeons who perform cartilage

restoration procedures. Comorbidities

Combined pathologies such as meniscal injury or deficiency, malalignment, and ligamentous instability are frequently encountered when treating articular

cartilage defects. These pathologies are

notoriously known to contribute to the development of articular lesions, and a

correcting surgical intervention is crucial for an effective and durable cartilage repair. Studies have reported that surgically addressing these combined patholo-

Figure 10 Ostcochondral allogra Fting for an osteochondritis dissccans (0CD) lesion. A, Arthrotomy reveals the chondral defect. B, The defect site is prepared to receive a donor cartilage plug. A counterbore is used to drill to a depth of 6 to 8 mm or until a bleeding bone is established. C, A donor cartilage plug is procured from a donor condyle that has been sized and contour matched to the recipient site. D, The donor plug is press—fit into place, and a bioabsorbable compression screw is used to ensure fixation.

gies ensures the integrity of the primary cartilage repair without affecting the pa— tient’s ability to return to day-to-day ac— tivities. It is also advantageous to address

these combined pathologies at the time

of primary cartilage repair to avoid prolonged rehabilitation.

Pearls

l Early recognition is important, and treatment should be initiated once the

diagnosis of a symptomatic 0CD le-

sion is rendered. II Advanced imaging, including IVER], is helpful in making the diagnosis and determining the relative stability of the lesion. - In skeletally immature patients, initial

nonsurgical therapy can be employed

with some success, but persistently

painful lesions may still require surgical fixation despite skeletal imma— turity. *- In the case of an unstable lesion that

is favorable for repair, every effort should be made to preserve the frag-

ment; the treatment concepts are

somewhat analogous to treating an atrophic fracture nonunion. :- If the fragment is irreparable, the initial step should be removal of the fragment with or without a concomi-

(fl) 2013 American Academy of Unhopaedic Surgeons

tant microfracture procedure and ultimately considering a trial of return to activities to allow the patient to determine a persistent or recurrent problem. An AC1 biopsy can be per-

formed at the time of the fragment

removal. i The condition of the subchondral bone and the size of the lesion should be used to select the appropriate cartilage augmentation or restoration prooedure. - Comorbidities such as malalignment,

meniscal deficiency, or ligament deficiency should be addressed with the same decision making as any cartilage repair procedure.

References

1. Bedi a, Feeley er, Williams s] 111:

Management of articular cartilage defects of the knee. I Bone Joint Surg Ant

monogram—1009.

2. McCarty LP III: Primary repair of osteo— chondritis dissecans in the knee, in Cole B], Sekiya IK, eds: Surgical Techniques of the Shoulder, Elbow, and Knee in Sports Medicine. Philadelphia, PA, Saunders Elsevier, 2008, pp 51?-526. 3. Aichroth P: Osteochondritis dissecans of the knee: A clinical survey. I Bone joint Surg Br 1W1;53{3}:440-442

93

Section 1: Sports Medicine 4 . Steinhsgen J, Bruns J, Deuretzbacher G,

Ruether W, Fuerst M, Niggemeyer 0: Treatment of osteochond ritis dissecans of the femoral condyle with autologous bone grafts and matri rat-supported autologous chondrocytes. int Orthep 2010;34(6}:

819-325.

5. Adachi N, Deie M, Nakamae A, Ishikawa

P‘

M, Motoyama M, Ochi M: Functional and radiographic outcome of stable juvenile osteochondritis dissecans of the knee treated with retroarticular drilling without bone grafting. Arthroscopy 2009;25f2}:145-152. Cole B], Pascual-Garrido C, Grumet RC:

Surgical management of articular cartilage defects in the knee. I Bone [0i Surg Am 2009;91(7):1??S-1?QD.

Donaldson LD, Wojqrs EM: Extraarticular drilling for stable osteochondritis dissecans in the skeletally immature knee. I Pediatr Orthop 2008:23(8}:831—335. Magnussen RA, Carey IL, Spindler ICF: Does operative fixation of an osteochondritis dissecans loose body result in healing and long-term maintenance of knee function? Am I Sports Med 2009;3?(4I: 554-759. . Pascual-Garrido C, Friel NA, Kirk 55, et a1: Midterm results of surgical treatment for adult osteochondritis dissecans of the knee. Am I Sports Med 2110?; 3?{suppl 1}:1155—13il‘3.

10. Knutsen G, Drogset IE}, Engehretsen L, et al: A randomized trial comparing autologous chondrocyte implantation with microfracture: Findings at five years. I Bone Ioiat Surg Am 200?:39f1tl}: 2105-2112. 11. Miniaci A, Tytherleigh-Strong G: Fixation of unstable osteochondritis dissecans lesions of the knee using arthroscopic autogenous osteochondral grafting [mosaicplasty}. Artfnoseopy MESH]:

345-351. 12. Day IB, Gillogly SD: Autologous chondrocyte implantation in the knee, in Cole B], Sekiya JK, eds: Surgical Techniques ofthe Shoulder. Elbow, and Knee in Sports Medicine. Philadelphia, PA, Saunders Elsevier,

2003, pp 559—555. 13. Bartlett W, Gooding CR, Carrington KW, Skinner IA, Briggs TW, Bentley C: Antologous chondrocyte implantation at the knee using a bflayer collagen membrane with bone graft: A preliminary report. I Home Ioirlt Surg Br 21105;S?{3):330-332. 14. Bentley '3, Biant LC, Carrington RW, et al:

A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. I Bone Ioiril Surg Br

loosesrnossssu.

. Willian‘ts Hui, Virdi AS, Pylawka TK, Edwards EB l]I, Markel MD, Cole B]:

Prolonged—fresh preservation of intact

whole canine femoral oondyles for the potential use as osteochondral allografbs. I Oriflop Res 2005:23114):831-33E 16. Kang RW, Friel NA, Williams IM, Cole B], Wimmer MA: Effect of impaction sequence on osteochondral graft damage: The role of repeated and varying loads. Am I Sports Med 2010;33{1):105-113. 1?. Garrett JC: Fresh osteochondral allografts for treatment of articular defects in osteochondritis dissecans of the lateral femoral condyle in adults. Clin Orthop Rclci Res 1994;303:3367“. 13. Kang KW, Gomoll AH, Cole B]: Debenchondral allografting in the knee, in Cole B], Selciya 1K, eds: Surgical Techniques ofthe Shoulder, Elbow, and Knee in Sports Medicine. Philadelphia, PA, Saunders

Elsiever, 2008, pp 549-552 19. McCulloch PC, Kang RW, Sobhy MH, Hayden IK, Cole B]: Prospective evaluation of prolonged fresh osteochondral allograft transplantation of the femoral condyle: Minimum 2-year follow-up. Am I Sports Med 200?;35(3):411-420.

Video Reference 15.1

Yu J, Bugbee W: DVDVideo: Fresh Deteochondral Allografiing lo the Kneefiar Deteochondritis Dissecens. Rosemont,

IL, American Academy of Elrthopaedic Surgeons, 21105.

(fl) 2013 American Academy of Drtlropaedic Sui-gems

Chapter 16 Anterior Cruciate Ligament Reconstruction: Single-Bundle Transtibial Technique Eric I. Strauss, MD

Adam B. Yanks, MD

Introduction

Injuries to the anterior cruciate ligament

(ACL) are common, typically occurring

in association with participation in athletic activities. For active patients, surgi— cal reconstruction of the ACL following injury is recommended in an effort to

restore stability and normal knee kine-

matics that will lead to an improvement in function and a return to an active lifestyle. Various reconstruction techniques and graft options are available for ACL reconstruction, including autograft (bone-patellar tendon-bone [BPTB],

quadriceps tendon, and hamstring) and

Bernard R. Bach, ir, MD

ply with the required rigorous postopera-

strumented side-to-side differences, concomitant meniscal pathology, the failure of nonsurgical care, and the ability to

tive rehabilitation pmtocoL

physical therapy program. in our practice, approximately 15% of patients are over 40 years of age, and for these patients,

During the initial evaluation of patients with ACL injuries, radiographs are ob tained to assess the quality of the joint

ommended, preferably patellar tendon allograft. Surgical intervention is delayed until the patient’s postinjury effusion has fully resolved, full knee range of motion has been regained, quadriceps control is

notch architecture. The four-view series includes a weight-bearing AP view in full extension, a weight-bearing PA 45" flexion view, a non—weight—bearing

participate in a structured postoperative

different graft sources are generally rec-

achieved, and personal and professional

Preoperative Imaging

space, the bony alignment, and the

45° flexion lateral view, and a Merchant

view of the patellofemoral joint. Plain

radiographs may identify a Segond frac-

tendon) tissue}2 For the past 25 years, patellar tendon autograft reconstruction has been the most commonly used technique secondary to its biomechanical

issues are ”under contro " so that the patient is physically and psychologically prepared for surgery. In our practice, if patients have normal or nearly normal motion recovery before surgery, the in— cidence of reoperation for symptomatic scar tissueiarthrofibrosis has averaged

harvest, bone-to-bone healing, rigid initial interference screw fixation, and its

don disease, should have no patellar ma-

value, we have used the KT-lilflfl arthrometer in our practice since 1936. It gives

or prolonged kneeling secondary to the

differences exceeding 3 mm are highly

allograft (BP'I'B, hamstring, anterior and

posterior tibialis tendons, and Achilles

strength, accessibility and ease of graft

track record of clinical success.” This chapter describes the surgical technique for endoscopic ACL reconstruction with BPTB autograft using a single-bundle transtibial approach. This endoscopic technique can be used with patellar tendon autograft tissue, enabling the creation of a femoral tunnel that replicates a portion of both the posterolateral and anteromedial bundles, thereby eliminating both the abnormal Lachman test results and, more importantly, the pivot-shift phenomenon.

Patient Selection

Indications The ideal patient for ACL reconstruction using a BPTB autograft is young (6.40 years) with an active, athletic lifestyle. lEither considerations include the

specific type of sports involvement, the hours of sports involvement weekly, KT-lflflfl arthrometer (MEDmetric) in-

1% to 2% since 1936. Ideally, the patient

should have no evidence of patellar ten-

lalignment or antecedent patellofemoral symptoms, and should not be employed in a profession that requires repetitive

ture consistent with a lateral capsular avulsion, a tibial spine fracture, a "lat-

eral notc ” sign, or loose bodies present within the joint. Although the FIT-1000 arthrometer does not measure rotational translations and for this reason some authors question its valuable information both preoperatively and postoperatively. Anterior translations greater than 10 mm or side-to-side

BPTB autograft reconstruction is contraindicated in patients with open physes and those with symptomafic preoperative patellar tendon disease. In adolescents, we use a variety of factors—onset

suggestive of an ACL injury. MRI is used as an adjunct to the patient’s history and physical examination to support the diagnosis of an ACL tear. However, our experience suggests that it is extremely unusual to require MRI to establish the diagnosis of an ACL injury. It is critical to emphasize that the physical history and physical examination, along with a KT—IDIJIJ arthrometer measure—

as determined by a PA radiograph of

injury in over 93% of our patients. Never-

potential incidence of postoperative anterior knee pain or kneeling pain following graft harvest.

Contraindications

of menses in females, skeletal bone age the hand, parent height, and Tanner

ment, establishes the diagnosis of ACL theless, MRI has been demonstrated to be

characteristics—to guide the recommendation for ACL surgery and graft choice. Relative contraindications include radiographic evidence of degenerative joint

both sensitive and specific for ACL inju-

and an unwillingness or inability to com-

ligament, lateral collateral ligament, and chonclral surfaces. Bone bruises associated with ACL injury are often readily identifiable on 1v1, typically presenting in the midportion of the lateral femoral condyle and in the posterior aspect of the lateral tibial plateau. A careful review of the preoperative MRI can alert the treating orthopaedic surgeon to concomitant

disease, a sedentary or inactive lifestyle,

Dr. Bach or an immediatefirmily member has received nonincome support (such as equipment or services), commercially derived honoraria, or other non—researcir—reiated funding (such as paid travel) from Ariirrex, Smith 6-“ Nephew, Conmed Linvatec, and {issue Neither of thefoi— touring authors nor anyr immediote family member has received anything of value from or has stock or stock options held in a commercial company or institution minted directly or indirectly to the subject of this chapter: Dr. Strauss and Dr. Yanks.

(fl) 2013 American Academy of Cirtiropoedic Surgeons

ries in addition to providing information about the status of other infra-articular structures, such as the menisci, posterior cruciate ligament, medial collateral

95

Section 1: Sports Medicine

M-

Figure 1 Photograph shows positioning of a left lower extremity for anterior cruciate ligament reconstruction. With the foot of the operating room table flexed completely, the surgical knee is capable of at least 110“ of

flexion.

Video 16.1 Anterior Crudate Ligament Reconstruction:

Single-Bu ndle Transtibial Technique. Eric J. Strauss, MD; Adam Yanks, MD; Bernard R. Bach, Jr, MD (19 min)

injuries that may need to be addressed during the ACL reconstruction.

Procedure

Room Setup! Patient Positioning

Following the induction of anesthesia, the

patient is positioned supine on the operating room table. The waist of the operating table is flexed to reduce the amount of lumbar extension and, subsequent to the examination under anesthesia, the op-

posite leg is placed in a gynecological leg holder to protect the femoral and peroneal nerves. The surgical knee is carefully examined under anesthesia, evaluating the amount of translation present with the anterior and posterior drawer tests and the Lachman test, knee stability with

applied varus and valgus stress, and whether a pivot-shift phenomenon is

present. The status of the posterolateral

corner is assessed for asymmetric external rotation at both 30° and 90° of knee flexion, with comparison made to the

contralateral side. If a pivot-shift is noted during the examination under anesthe-

sia, the BPTB graft harvest can proceed before diagnostic arthroscopy.

A tourniquet is then placed on the thigh, and the surgical lower extremity is placed in an arthroscopic leg holder. Although some surgeons routinely use a tourni— quet, we rare inflate it during the procedure. The foot of the operating room table 96

Figure 2 Photograph shows the incision for autologous bone—patellar tendon-bone anterior cruciate ligament reconstruction. The incision extends from the distal aspect of the patella to 2 cm distal to the tibial tubercle just medial to the midline.

Figure 3 Photograph shows a central-third bone—patellar tendon—bone autograft harvest using a No. Ill scalpel blade starting on the patella and continuing into the patellar tendon.

is flexed completely, allowing the surgical knee to flex to at least 1113“ {Figure 1).

The leg is then prepped and draped, and a preoperative dose of a first—generation cephalosporin is administered.

aspect of the patella, the tibial tubercle, and the borders of the patellar tendon,

Special lnstrumentlquipmentl Implants The single-bundle transtibial BPTB autograft ACL reconstruction is performed using a standard arthroscopy setup and instruments, including arthroscopic scie

through an B-cm incision extending from the distal patellar pole to the tibial tubercle region, paralleling the medial edge

sore and a basket For the graft harvest,

a No. It] scalpel, forceps with teeth, two Senn retractors, an Army-Navy retractor, a metal ruler, 3,!“3— and lie—in curved osteotomes, a mallet, and Metzenbaum

scissors are required. The bone plugs are created using an oscillating saw with a

ltl-mm—wide blade (No. 233 blade). For

graft preparation, a rongeur, 1t]- and

11-mm sizing tubes, a Kirschner—wire (BI-wire) driver with flflffl-in smooth 1(wires, and two No. 5 sutures are needed.

A tibial aiming device [we prefer the elbow aimer to the tip aimer] for the tibial tunnel and a F—mm offset airner are required for drilling the femoral tunnel, using 11-min and ill-mm acorn reamers,

respectively. A chamfer reamer and a hand rasp are used to aid in tibial tun-

nel preparation. a large shaver, a “lie-in

{if-mm) curved osteotome, and a large

spherical burr are needed for clearing and preparing the intercondylar notch. A satellite pusher is used to aid in graft passage, and for graft fixation, a file—in hyperflex nitinol wire and F x 25-mm metal interference screw are used for the femoral tunnel, and a 9 x Eli-mm screw is used for the tibial tunnel. Surgical Technique Graft Harvest Prior to making the surgical incision, anatomic landmarks, including the distal

are marked using a surgical marking

pen. The BPTB autograft is harvested

of the patellar tendon (Figure 2). This in-

cision allows for both graft harvest and tibial tunnel drilling through the same

approach. The incision is taken down to the transverse fibers of the patellar ten-

don paratenon. At this level, medial and

lateral skin flaps are created. A No. 15 scalpel is then used to make a midline,

longitudinal incision in the paratenon,

which is extended both proximally and

distally with Metzenbaum scissors. The Metzenbaum scissors are then used to elevate the paratenon off the patellar tendon both medially and laterally, fully exposing the patellar tendon. The tendon width is measured and recorded in the surgical report.

The ideal BPTB autograft is 1|] mm wide

with 1D x 25-mm bone plugs. The center of the inferior pole of the patella and the center of the distal patellar tendon at the tibial tubercle are marked with a surgical marking pen, and a curved BIS-in osteotome (which is nonghly 1D mm in width) is used as a cutting

guide for the central third of the patellar tendon. With the Army—Navy retractor placed proximally, parallel longitudinal incisions are made using a No. 10 scalpel,

starting on the patella and continuing

into the patellar tendon. Once the midpoint of the patellar tendon is reached, the Army-Navy retractor is switched to the inferior aspect of the wound to protect the skin as the incision is extended distally 2.5 cm past the tendo-osseous junction on the tibial tubercle (Figure 3).

(El 2013 American Academy of flrtlropaedfc Surgetms

Chapter 16: Anterior Cruciate Ligament Reconstruction: Single-Bundle Transtibial Technique

Figure 4 Intraoperative photographs show bone cuts made using an oscillating saw with a Ill-mm (No. 233) blade. Cuts on the right side are made with the saw in the surgeon's right hand (A) and those on the left are made with the saw in the surgeon‘s left hand {E}.

Figure 5 lntraoperative photograph shows the patellar bone plug being freed from its osseous bed with an osteotome.

Figure 6 Illustrations demonstrate the preparation of the harvested bone—patellar tendon—bone autograft. A, The first step is measurement of the overall graft length, the length of its tendinous portion, and then the length of each bone plug. B, Fine tuning of the bone plugs is performed using a rongeur, ensuring that each bone plug fits in the Ill—mm sizing tube. (2, Two drill holes are made in the tibial bone plug using a smooth flflfiZ—in K-wire with a No. 5 suture passed through each hole.

This process is repeated on the other side, creating a lfl-mm—wide graft. Bone cuts are then made using an oscillating saw with a 10-mm (No. 238)

blade, starting on the tibial side. Cuts on

the right side of the graft are made with the saw in the surgeon’s right hand and those on the left with the saw in the sur— geon’s left hand (Figure 4). With the saw supported by the surgeon's thumb and the graft protected with the index finger, the oscillating saw is used to first score the cortex, starting at the tendo-osseous

junction, followed by angling of the saw to create a plug with an equilateral tri— angle profile. The transverse bony cut is then made with the saw angled 45", us-

ing the corner of the blade on each side

of the graft to avoid the creation of stress risers. The patellar bone plug is then cut in similar fashion, angling the saw dur— ing the longitudinal cuts to create a plug that is trapezoidal in shape. The saw

blade should not penetrate deeper than 6 to 7 mm, to avoid injury to the patel-

lar articular surface. The transverse bonyr cut is similarly made with the saw angled 45°. The tibial bone plug is then carefufly freed from its osseous bed using BIB— and lid—in osteotomes, without levering.

A lap sponge is then placed around the

freed tibial plug to apply traction on the graft as Metzenbaurn scissors are used to remove any remaining connections to

bone plug. A surgical marking pen is then used to mark the tendo-osseous junction on the femoral side of the graft to aid in

plug is then similarly freed from its os-

the femoral tunnel, and the distal cortical edge of the tibial plug is marked to assist in graft orientation. The prepared BPTB graft is then wrapped in a moist sponge and safely set aside in a kidney basin. It is critical that all operating room staff know

the underlying fat pad. The patellar bone

seous bed (Figure 5}, and the harvested

graft is wrapped in a moist sponge and walked to the back table by the operating surgeon.

Graft Preparation

The first assistant prepares the BPTB au-

tograft, fashioning the grafts bone plugs to 10 x 25-min dimensions. The first step is the measurement and documentation of the overall graft length, the length of its tendinous portion, and the length of each bone plug {Figure ti, A}. Fine tuning

of the bone plugs is performed using a rongeur to allow for passage through the iii-mm sizing tube [Figure ti, B}. Excess bone removed during the preparation process should be saved for later bone grafting of the harvest sites. Once appro-

priately sized, two drill holes are made

in the tibial bone plug using a smooth 0.062411 K—wire, parallel to its cortex (Figure 6, C}. A No. 5 suture is then placed

through each hole. Because we prefer to use a push-in technique for graft passage, no drill holes are created in the femoral

(fl) 2013 American Academy of Cirthopaedic Surgeons

assessing the full seating of the graft in

where the graft has been placed so it is not inadvertently passed off the field.

Diagnostic Arthroscopy and Notch Preparation A superomedial outflow portal is created proximally, and the standard inferolateral and inferomedial portals are created within the graft harvest site. A diagnostic arthroscopy is performed to assess the patellofemoral joint, the lateral and medial gutters, and the medial and

lateral compartments, assessing for asso-

ciated meniscal injury, loose bodies, and

articular cartilage injury. In the absence of associated pathology that requires surgical management, attention is turned to the intercondylar notch. Once in the notch, the status of the posterior cruciate

ligament can be evaluated and the nature of the ACL injury can be documented. 9?

Section 1: Sports Medicine

Figure '3" Arthroscopic view demonstrates debridement of the remnant of the torn anterior cruciate ligament.

The interval between the remnant ACL and the posterior cruciate ligament is developed and any remaining ACL tissue is removed using a combination of

arthroscopic scissors, an arthroscopic

basket, and a large motorized shaver (Figure 7). The lateral wall of the notch is cleared of soft tissue using the shaver or a curet. Any fat pad or ligamentum mu— cosum that is impeding visualization can also be removed from the intercondylar notch. Notchplasty is performed if necessary to improve visualization of the "overthe—top” position posteriorly and limit the possibility of graft impingement, especially with the knee in the extended position. A 1f4-in curved osteotome is

inserted through the medial portal and

used to begin the notchplasty at the level of the articular surface of the lateral wall,

with the fragments removed with an arthroscopic grasper. These fragments are saved for later use as graft for the distal

patellar and tibial tubercle defects. Next, a 5.5-mm spherical burr is used to wid-

en the notch in an anterior-to-posterior direction, working toward the over-thetop position (Figure 8). The adequacy of the notchplasty is checked with an ar— throscopic probe, ensuring that the probe

can be hooked around the sharp edge of the posterior wall of the notch.

Tibial Tunnel Placement

To create the tibial tunnel, a variable—

angle tibial aimer is used, with the angle selected dependent on the length of the soft-tissue component of the BPTB graft (Figure 9). Generally, we use an "N +

1D” rule for setting the angle of the tibial aimer (45 mm of tendon length equates to a 55° setting on the aimer). However, we do not use less than 55° for shorter tendon lengths. The major criticism of 98

Figure B Arthroscopic view demonstrates notchplasty. a 5.5—mm spherical burr is used to widen the notch in an anterior-to-posterior direction, working toward the over-the-top position.

the transtibial technique is that surgeons do not create enough obliquity with the tibial tunnel, leading to a femoral tunnel

that is drilled with an orientation that is too vertical. A vertically oriented femoral tunnel is the most common technical error we have encountered in failed endoscopic reconstructions. Some authors have advocated drilling through an accessory portal to create a femoral tunnel along the lateral intercondylar wall?" Other authors have maintained that a two-incision technique with independent tunnel creation will obviate the potential for a vertically oriented femoral tunnel.“"3 Still other authors have advocated the use of a double—bundle technique to more anatomically replicate the antero— medial and posterolateral ACL femoral

bundles?” We have developed an alternative approach, whereby an accessory

incision is placed through the patellar tendon rent, 1 cm distal and 1 cm lateral to the standard inferomedial portal. This portal allows easier rotation of the tibial aimer and a more distal starting point on

the tibia, which reduces the likelihood of

graft tunnel mismatch and allows for the creation of a tibial tunnel that is obliquely oriented such that the subsequent femo~ ral tunnel can be created to replicate portions of both the posterolateral and anteromedial bundles of the ACL. The

tip of the tibial aimer is inserted through

this accessory midpatellar portal, created following spinal needle localization. An ideal guide—pin placement is just lateral to the medial tibial spine at the level of the posterior aspect of the anterior horn of the lateral meniscus andfor 5' m an-

Figure 9 Illustration shows a variable-angle tibial aimer used for the creation of the tibial tunnel.

terior to the posterior cruciate ligament. We use the posterior edge of the anterior horn of the lateral meniscus as a coro— nal plane landmark for placement of the pin within the midregion of the former

ACL insertion. Once the tip of the tibial

aimer is appropriately localized intraarticularly, the cannulated portion of the aimer is rotated into position using the upper border of the pes anserine and the anterior edge of the superficial edge of the medial collateral ligament as ana-

tomic landmarks. Provisional guide-pin

placement is performed using a 3/32-in smooth Steinmann pin (Figure 10). Once the pin is advanced into the joint, its position is checked arthroscopically, ensuring that no impingement on the superior notch occurs with knee extension; the pin should be posterior to the apex of the intercondylar notch with the knee in complete extension. With the knee returned to the flexed position, the guide pin is advanced with a mallet until it reaches the lateral wall of the intercondylar notch, to

stabilize it during the reaming process. Next, the appropriately sized cannulated acorn reamer is used over the guide pin. We typically ream the tibial tunnel with an 11—mm reamer for a Ill—mm bone plug to ease the process of graft passage and reduce the likelihood of graft delam-

ination. During the reaming process, the

arthroscopic pump is turned off, and a cannulated bone chip collector is placed over the tibial reamer, allowing bone

chips from reaming to be collected for later grafting of the harvest sites. After the reamer is advanced into the joint, the

pump is turned back on, and additional

(fl) 2013 American Acadmy of flrthopaedic 51113130115

Chapter 16: Anterior Cruciate Ligament Reconstruction: Single-Bundle Transfibial Technique

Figure 1|] Arthroscopic view shows provisional guide pin placement performed using a BEBE-in smooth Steinmann pin.

bone from the reaming process is collected using fine-mesh burn gauze. Once the tibial tunnel has been created, its pos-

terior edge is smoothed with a chamfer

reamer and finished with an arthroscopic

hand rasp (Figure 11]. Any overhanging soft tissue can be removed with a large shaver. Femoral Tunnel Placement For the femoral tunnel, a ?—mrn offset

aimer is inserted through the tibial tun-

nel into the intercondylar notch, with the

knee flexed to approximately fit)” to 90“. The tip of the aimer is hooked around the posterior wall of the over-the-top position and rotated laterally to allow

for guide-pin placement lower on the

lateral wall of the notch (Figure 12). A smooth 3/32-in Steinmann pin is drilled

into the lateral wall to a depth of 3 cm. With the arthroscopic pump turned off, the guide pin is then overreamed using a 10-min reamer, initially advanced 1 cm

and then backed off to allow for visual confirmation of maintamed posterior wall integrity (Figure 13). Ideally, I to 2 mm of posterior cortex should remain. Roaming of the femoral tunnel is then completed to a depth of 30 to 35 mm. The arthroscopic pump is then turned back

on, so that reamings can once again be

collected using fine-mesh burn gauze. The overall integrity of the femoral tunnel can be visually inspected by insert— ing the arthroscope retrograde through the tibial tunnel into the femoral tunnel.

This is important to make certain that an intratunnel perforation has not occurred. Graft Passage and

Interference Screw Fixation

Following intercondylar notch prepara— tion, notchplasty, and tibial and fernoral tunnel creation, attention is directed to

Figure 11 After the tibial tunnel is reamed using an ll-mm acorn reamer, a chamfer reamer is used to smooth the posterolateral edge of the tunnel.

graft passage and fixation. The BPTB autograft is advanced into the joint using a push-in technique. With this technique, the graft is inserted into the tibial tun-

Figure 12 Arthroscopic view shows a T—mm offset aimer inserted through the tibial tunnel into the intercondylar notch, with its tip hooked around the back wall and rotated laterally, to allow for guide-pin placement

low on the lateral wall at the anatomic

femoral footprint of the anterior cruciate ligament.

nel with a two-pronged pusher placed

checked by the surgeon by placing a

or a tunnel-notching device. The nitinol

tension held on the tibial bone-plug sutures. As the knee is extended from 90" to full extension, 1 to 2 mm of graft shorten— ing is typically noted during the terminal 20° of extension. The graft is then cycled, and attention is turned to tibial boneplug fixation. With the knee in full extension and an axial load applied, a hemostat is used to externally rotate the tibial bone plug 180", such that the cortical surface of the plug is facing anteriorly. The nitinol wire is inserted anterior to the tibial bone

at the base of the femoral bone plug. A hemostat is inserted through the medial portal, grasping the femoral bone plug at the junction of the proximal and middle thirds, guiding the plug into the femoral tunnel with the cortical surface of the plug facing posteriorly {Figure 14). The fEmoral bone plug is seated into the funnel approximately Ffi'iii, leaving room for placement of the 14—inch hyperflex nitinol wire. A small pilot hole for wire placement can be created using a hemostat wire is then inserted at the l-o’clock (left

knee} or 11-o’clock [right knee} position of the graft, the knee is further flexed, and

the wire is advanced into the depth of the tunnel. With the nitinol wire in posi— tion, the femoral bone plug can then be

advanced and fully seated using a satel-

lite pusher. Prior to interference screw placement, the tibial bone plug should be evaluated for any graft-tunnel mismatch that may be present. If mismatch is present, the femoral bone plug can be further recessed with the satellite pusher. With the femoral bone plug in its final position, the knee is hyperflexed to lflfl“ to 115°,

and the F x 25-mm metal interference screw is advanced over the nitinol wire. Care should be taken to remove the wire once the screw has been inserted halfway {Figure 15}.

With the femoral bone plug secured,

tension is held on the tibial bone plug sutures and the ”rock test" is performed. Enough tension is placed on the graft to rock the patient on the operating table, confirming stable fixation of the femoral bone plug. Gross isometry is then

(El 2013 American Academy of firthopaedic Surgeons

thumb at the tibial tunnel aperture, with

plug, and a 9 x 20-min metal interference

screw is inserted while tension is held on the tibial bone-plug sutures. The screw is advanced until it is seated just below the cortical surface of the tibia. Following tibial-side fixation, the arthroscope is placed back into the lateral portal to visually inspect and probe the graft to ensure proper graft tension (Figure 16). A Lachman test and pivot-shift test are performed to confirm knee stability. Closure

The wound is copiously irrigated, and

the patellar tendon is reapproximated using three or four interrupted No. 1 Vicryl

sutures (Ethicon) with the knee in flexion

to avoid excessive shortening. Bone graft that was collected from the reaming pro-

cess and graft preparation are placed into the patellar and tibial bony defects. The

patellar tendon paratenon is closed with a running 2-D Vicryl suture. Skin closure is then performed with subcutaneous 2—D Vicryl sutures followed by a running 3—0 Prolene pullout stitch (Ethicon). The su-

peromeclial outflOw arthroscopic portal 99

Section 1: Sports Medicine

Figure 13

Arthroscopic views show overreamlng of the guide pin. A 10—mm rea mer is

initiallyr advanced 1 cm (A) and then backed off to allowr for visual confirmation of maintained

posterior wall integrity ([1).

Figure 14 Arthoscopic view demonstrates the push-in technique for femoral bone plug insertion. A hemostat inserted through the medial portal guides the plug into the femoral tunnel, with the cortical surface of

the plug facing posteriorly.

Figure 15

A, The ,7 x ES—I‘nm metal screw is advanced over a nitinul wire for interference

screw fixation. Cince the screw is advanced halfway, the wire is removed because removal is more difficult once the screw is fully seated. Care should be taken to avoid fraying of the soft— tissue component. B, With the driver and wire removed, the screw is slightly recessed, and

there is no evidence of graft damage during insertion.

is closed with a simple 3-0 Prolene suture. The surgical incision is injected with 0.5% bupivacaine and covered with adhesive skin closure strips and sterile dressings. A cryotherapy device is placed over a gauze bandage and overwrapped with a compressive elastic wrap. Finally, the leg is placed in a hinged knee brace locked in

extension but allowing full range of motion as tolerated.

Complications

rate for symptomatic knee flexion con-

Figure 16 Arthroscopic view shows the final anterior cruciate ligament reconstruction.

Postoperative Care and

Rehabilitation

tractures or arthrofibrosis has averaged

Following ACL reconstruction using a

(B.R.B's) overall. personal revision rate

protocol, including dosed-chain exercises,

1% to 2% since 1966. The senior author’s

has been 13% based on 1,809 primary ACL reconstructions performed between July 1986 and March 2012. Two thirds of these were autografts, and one third were

allograft BPTB reconstructions. No differences were noted in the personal re-

vision rates of autograft versus allograft BPTB (1.6% vs. 2.0%], and no differences

BPTB autograft, we employ an accelerated

with the goal of regaining full active knee range of motion while maintaining stability and avoiding symptoms related to the patellofemoral joint. In the immediate postoperative period, patients are allowed to fully weight-bear with the hinged knee brace locked in extension. The brace is used specifically to protect the donor site should the patient slip or fall. It is removed for motion activities. Supervised physical therapy is started at 1 week postoperative-

Potential postoperative complications fol— lowing ACL reconstruction using EPTB autograft include arthrofibrosis, infection, patellar fracture. anterior knee pain,

were noted between nonirradiated al—

BP'IB allograft. However, the mean age for primary autograft ACL reconstruc-

ly, at which point quadriceps sets, straight-

gional pain syndrome, and compartment syndrome. In a literature review of ACL reconstructions using BPTB autografts, Nedeff and Bach” reported an overall reoperation rate of 13% following the pro-

for primary allograft was 36 years. Dur personal revision rate between 2002 and 2009 was as follows: four fellowshiptrained surgeons performed 1,944 ACL reconstructions and personally revised 28 patients (1.4%). In previous studies, we reported patellofemoral pain symptoms ranging from 12% to 13%, with the majority of patients reporting minimal to mild pain. In previously reported studies, approximately 95% of patients were either

performed with the knee in extension. We emphasize regaining complete extension or hyperextension within the first 10 days postoperatively; a secondary goal is to have 80” to 90° of knee flexion. From weeks 2 through 4, closed-diam extension exercises are initiated along with hamstring curls and the use of a stationary bicycle. From weeks 4 through 6, the goal of knee flexion to 120‘“ is usually ob— tained, and patients are advanced to using

deep venous thrombosis. complex re-

cedure, with reported mean incidences

of arthrofibrosis and infection of 7% and 0.4%, respectively. Specifically, the incidence of intraoperative or postoperative patellar fracture is approximately 1 in 300; patellar tendon rupture, 1 in 1,000;

and infection, 1 in 300. Our reoperation

100

lograft

versus

low~dose

{LS-mRad)

tion was 26 years, whereas the mean age

completely or mostly satisfiedfiilm

leg raises, and patellar mobilizations are

a stair climber for continued quadriceps

(El 2013 American Acadmy of flrtltopaedic Surgemts

Chapter 16: Anterior Cruciate Ligament Reconstruction: Single-Bundle Transtibial Technique strengthenmg. At 8 to 10 weeks postoperatively, patients are advanced to light jogging and outdoor biking while continuing to perform dosed-chain strengthening exercises. Sport-specific exercises and a gradual return to play are allowed at 4 to 6 months postoperatively. Open-chain exercises and isokinetic strengthening are

not used in our postoperative rehabilitation program.

Patients are seen at 10 days postoperatively for suture removal and evaluation of range of motion. If they have achieved full extension and flexion to 90“ at this visit, patients are seen again at 6 weeks postoperatively. If their range of motion is short of this goal, patients are seen week-

ly until motion recovery is acceptable. Starting at the 6-week time point, patients are seen at 6-week intervals until the 6-month postoperative visit, with KT-IOOO

tibial tunnel and into the femoral tunnel allows visual confirmation of the integrity of the posterior wall throughout its length. - With the femoral plug seated in the femoral tunnel, the tibial bone plug should be checked for evidence of graft-tunnel mismatch; if present, recession of the femoral bone plug can be performed to improve tibial plug position. i The tibial bone plug should be externally rotated such that the corti-

cal surface is facing anteriorly; this allows for anterior placement of the tibial interference screw, which keeps

arthrometer testing performed at each

the graft posterior, avoiding potential impingement in extension. l The patellar tendon is reapproximated with the knee in flexion to avoid excessive shortening.

Pearls

1. Miller 5L, Gladstone IN: lGraft selection in anterior cruciate ligament reconstruction. Orthop Clin North Am 2002;33f4}:6?5-6&3.

visit. Patients are then seen at 9 months and 1 year postoperatively, at which point they are discharged from care.

References

- The patient should be positioned so

2.

room table is dropped, the knee is able to flex to 110“; this will avoid difficulty

3.

- The surgical incision should be 8 cm long, extending from the distal aspect of the patella to 2 cm distal to the tibial tubercle, just medial to the midline, so

Each BR Ir, Levy ME, ochuk I, Tradon—

struction of the anterior cruciate ligament with an ipsilateral patellar tendon autograft: A prospective longitudinal five-year study. I Bone Ioint Surg Br 20m:82(?}:934-991.

10 mm wide) can be used as a tem-

5.

left hand); this improves visualization

ME, Bush-Ioseph CA, Khan NH: Arthroscopicall},r assisted anterior cruciate ligament reconstruction using patellar tendon autograft: Five- to nine-year follow-up evaluation. An: I Sports Med 19932612113029. :5. Fox IA, Nedeff DD, Each BR Ir, Spindler KP: Anterior cruciate ligament reconstruction with patellar autograft tendon.

during the harvest process.

guide, an accessory midpatellar portal can improve the surgeon’s effort to improve the obliquity of the tibial tunnel. i Roaming the tibial tunnel with an 11-mm reamer for a 10-mm bone plug

can make graft passage easier.

Klinger HM, Schultz W, Fu FH: The

double-bundle technique for anterior cruciate ligament reconstruction: A systematic overview. Scond‘ I Med Sci Sports 200?;1?{2I:99—103.

15. Che PS, Brucker PU, West RV, et al: Ar— throscopic double—bundle anterior cruciate ligament reconstruction: An anatomic approach. Arthroscopy 2005;21(10}:12?5. . Nedeff DD, Bach BR Ir: Arthroscopic

anterior cruciate ligament reconstruction using patellar tendon autografts: A comprehensive review of contemporary literature. An: I Knee Surg 2001:14{4): 243-253.

A, Pinczewski LA: Endoscopic recon-

- During the graft harvest, a curved BIB-in osteotome [which is effectively

1' For placement of the tibial aiming

tunnel. Arthroscopy 2008;24(1I:113—115.

11. Garofalo R, Moretti B, Kombot C, Moretti L, Mouhsine E: Femoral tunnel placement in anterior cruciate ligament reconstruction: Rationale of the two incision technique. I Orthop Surg Res 200?;2:10. 12. Gill TI, Steadman IR: Anterior cruciate ligament reconstruction the twoincision technique. Orthop Clin Norfl: Ant 2002;33(4}:72?—?35, vii. 13. Harner CD, Marks PH, Pu FI-I, Irrgang II, Silby MB, Mengato R: Anterior cruciate ligament reconstruction: Endoscopic versus two-incision technique. Arthroscopy 1994;10t5):502-512. 14. Stecl-zel H, Starman IS, Baums MH,

West RV; Harner CD: Graft selection in

sky 5, Bush—Joseph CA, Khan NH: Single— incision endoscopic anterior cruciate ligament reconsh‘uction using patellar tendon autograft: Minimum two-year follow-up evaluation. An: I Sports Med 1993:26flIt30-40. 4. Deeban DI, Salmon LI, Webb VI, Davies

that both graft harvest and tibial tun— nel drilling can be performed through the same approach.

plate for the central third of the patellar tendon. - The surgeon should use both hands when making the bone cuts during the graft harvest (cuts on the right side of the graft are made with the saw in the surgeon’s right hand and those on the left with the saw in the surgeon's

10. Harner CD, Honkamp NI, Ranawat AS: Anteromedial portal technique for creating the anterior cruciate ligament femoral

anterior cruciate ligament reconstruction. I An: Acari Drtirop Snrg 2005:13{3}:19?—20?.

that once the foot of the operating

with drilling of the femoral tunnel and placement of the femoral interference screw.

tion: An anatomic and biomechanical evaluation of surgical technique. Arthroscopy 2011:27(3):330-390. Silva A, Sampaio R, Pinto E: ACL reconstruction: Comparison between transtibis] and anterornedial portal techniques. Knee Snrg Sports Tmnnratol Arthrosc 2012;20(5}:396-903.

:- Placing the arthroscope through the

Bach BR Ir, Tradonsky S, Bojchuk I, Lavy

Clin Orthop Relat Res sweetness-as.

F.

8.

Novak PI, Each BR Ir, Hager CA: lClinical and functional outcome of anterior cruciate ligament reconstruction in the recreational athlete over the age of 35. Am I Knee 5mg 1996;9{3}:111-11ti.

1?. Bach BR Ir, Jones GT, Sweet FA. Hagar CA: Arthroscopy—assisted anterior cruciate ligament reconstruction using patellar tendon substitution: Two- to fouryear follow-up results. An: I Sports Med 1994;22(6}:753-?6E 18. Bach BR Ir, Aadalen KI, Dennis M, et al: Primary anterior cruciate ligament reconstruction using fresh-frozen nonirradiated patellar tendon allograft: Minimm 2-year follow-up. An: I Sports Med 2005;32t2}:234—292.

1Video Reference 16.1

Strauss E], Yanks A, Each BR Ir:

Hedi A, Musahl V, Steuber V, et a1: Trans-

Anterior Cruciate Ligament Reconstruction: SingleBundle Transtibial Technique, in Fu PH, Howell SM, eds: Video: Arthroscopic Surgical Techniques: Anterior Cruciate Ligament Reconstruc—

tibial versus anteromedial portal reaming in anterior cruciate ligament reconstruc-

of Orthopaedic Surgeons, 21010.

(fl) 2013 American Academy of firthopaedic Surgeons

tion. Rosemont, IL, American Academy

101

Chapter 17 Anterior Cruciate Ligament Reconstruction: Two-Tunnel Technique Dharmesh Vyas, MD

Christopher D. Harrier, MD

Introduction

The anterior cruciate ligament (ACL) has

been shown to play a critical role in the maintenance of knee stability. Leaving an ACL—deficient knee untreated can result in recurrent instability, meniscal pathol— ogy, and articular cartilage damage.‘ De—

Figure 1 Photographs depict autograft options.

A, Bone—patellar tendon—

bone: femoral side with EndoButton CL ETE (Smith Er Nephew Endoscopy) and tibial side with Ethibond

spite the fact that ACL injury has become one of the most popular topics of study in orthopaedic sports medicine, significant

(Ethicon) lead sutures.

disagreement exists on the appropriate management of this injury.”M Despite adherence to strict surgical principles, the inability to predict long-term articular

The first blue mark is at the bone-tendon junction, and the second marks the amount of graft needed in the femoral tunnel for the EndoButton to engage the lateral femoral cortex. B, Quadrupled hamstring: semitendinosus and gracilis. C, Quadriceps with patellar bone block.

cartilage degeneration after ACL recon-

struction (ACLR) has raised questions

about the choice of surgical technique,

graft choices, fixation, and rehabilita-

tion. In this chapter, we present our

preference for ACLR, which is based on

a single-bundle reconstruction primari111,r using a bone—patellar tendon—bone

(BTB) autograft. The procedure takes ad-

vantage of the medial portal technique {versus transtibial) for femoral tunnel

placement}!5 Unique to this technique is its versatility, being appropriate for all

autograft and allograft types as well as

fixation methods:1

Patient Selection

The decision to proceed with an ACLR begins with a comprehensive history and physical examination. This includes a demonstration of ACL insufficiency and an assessment of the patient’s expectations, activity level, and comorbidities.

Surgical indications are founded on three major criteria: the degree of perceived in— stability, associated knee injuries (meniscus or multiligament}, and chronicity of the ligament insufficiency. Prior to surgical intervention, the patient

is enrolled in physical therapy, emphasizing the achievement of full range of motion, symmetric quadriceps strength, and decreased effusion. Generally, most

patients meet these criteria within 3 to 4 weeks. In the context of an associated

medial collateral ligament MEL) injury amenable to nonsurgical management, we delay surgery for up to a weeks to allow time for the MCL to heal. Contraindications to ACLR include {1) partial tears with minimal reported instabilit)ir and no joint laxity on examination; (2) elderly, low—demand patients with minimal instability; and {3] comorbidi-

ties that make surgical intervention un-

safe for the patient.

Graft Choice

Graft options are individualised for each patient and are contingent on age, activity level, the grade of injury (partial versus complete}, associated injuries, and the return-to-playr timeline. in most cases, autografts are recommended for patients younger than 35 years, and allografts are reserved for older patients.ii This is based on the notion that younger patients generally have more active lifestyles.

Dr: Harner or an immediatefirmity member has received research or institutional supportfrom DePuy and Smith 6* Nephew and serves as a board member, oumer, qflicer, or committee mem-

ber of the American Board of Orthopaedic Surgery, the American Orthopaedic Association, the American Academy of Orthopaedic Surgeons, and the American Orthopaedic Society for Sports Medicine. Neither Dr. Vyas nor any immediatefamily monher has received anything of oaluefiom or owns stock in a commercial company or institution related directly or indirectly to the subject of this chapter:

(it 2013 American Academy of Orthopaedic Surgeons

We prefer to use BTB in younger, active

athletes, especially if they are involved in cutting sports (eg, football, soccer, basketball), and in larger patients? (Fig ure 1). Hamstring grafts are used in patients who require single-bundle augmentation, those with contraindications to BTB, and females with donorsite incisional cosmesis concerns (unless the ac-

tivity level dictates otherwise). In select revision cases, we use quadriceps tendon graft.

Preoperative Imaging

Radiography Diagnostic imaging begins with plain radiographs. These include 45" flexion weight—bearing PA views of both knees, a lateral view, and Merchant patella views.

These radiographs are used to identify associated fractures (avulsion, plateau,

or subchondral impaction), gauge the amount of joint-space narrowing in the three compartments, and assess patellar height (lateral view), tilt, and subluxation

[Merchant View). Determination of patella alta versus patella baja is critical for medial portal ACLR because it influences the correct position of the portals. Furthermore, radiographs are a prerequisite in pediatric patients to assess the status of the growth plate. In these patients,

hand and wrist radiographs are often 103

Section 1: Sports Medicine Knee range of motion. presence of an

effusion, and ligamentous laxity are assessed and documented. The Lachman, anterior drawer, and pivot shift tests are

documented, as is any ligamentous laxity in the coronal plane. Prior to preparation and draping of the limb, surface landmarks and incisions are drawn with a skin marker. To aid in hemostasis. the skin

is injected with 0.25% brupivacaine hydrochloride with epinephrine (1100000). The extremity is then prepped in its e11— tirety with povidone—iodine and draped. Landmarks

Key landmarks are the patella (inferior

pole), the medial and lateral joint lines (assess for patella alta or baja), the tibial tubercle, the medial parapatellar skin in-

cision for BTB autograft harvest, and the

anteromedial tibial skin incision (appro-

Figure 2 Photograph shows surgical setup for anterior cruciate ligament reconstruction. The patient is positioned supine with a bump under the ipsi lateral hip. a sandbag {black arrow} and a lateral post (white arrow} are used to keep the leg at 90° of flexion for most of the case.

obtained to assist in the determination of

skeletal age.“

Magnetic Resonance Imaging Based on the patient’s history and physi-

cal examination, if an ACL tear is suspected, then a noncontrast MRI scan of

the knee is obtained in most cases. Discontinuity of the ACL in the coronal and sagittal planes on either the T1 or T? image sequences is a reliable indication of an ACL tear. Importantly, MRI helps the clinician identify associated injuries of the knee, such as meniscal tears, chon— dral damage including bone bruises, and associated ligament injuries. This is especially important in the patient with an acute knee injury when the physical examination for associated injuries can be limited by pain and swelling.

extremity is positioned in neutral rotation with the use of a soft gel bump under the ipsflateral hip. A 10-11:: sandbag is taped to the table to support the knee at 90“ of flexion [Figure 2}. A lateral post is placed at the level of the midthigh to support the lower extremity. We do not use a tourniquet or a leg holder. The nonoperative side is well padded to prevent pres-

sure points and nerve palsies.

Special lnstrumentsiEquipmenti Implants The procedure calls for the following equipment: - 30° arthroscope I 30" Steadman awl II ACL drill guide with 3f32-in Kirschner wire [ii-wire} guide pin 0 EndoButton CL BTB (Smith ti: Neph—

EW)

Procedure

- 3.3mm EndoButton cannulated drill

{in the clay of surgery, laterality is marked

I

Room Setup! Patient Positioning

and consent is reviewed with the patient in the preoperative holding area. A combined femoral and sciatic nerve block is administered for postoperative pain control. The sciatic block is maintained for 3 days postoperatively with an indwelling catheter. The procedure is performed under either monitored or general anesthesia as determined by the anesthesiologist The patient is placed supine on the operating room table, and prophylactic antibiotics are administered. The lower 104

I Cannulated compaction reamer

Tunnel dilators (round, 0.5-mm incremerits)

l Heath pin - 4.5—mm cortical screw with washer ' 0.25% bupivacaine hydrochloride with 1200.000 epinephrine {subcutaneous injection for local anesthesia and hemostasis]

Surgical Technique Examination Under Anesthesia An

examination

of

both

knees

is

performed after anesthesia is induced.

imately 3 cm below the joint line for ham-

string tendon harvest). The meniscal repair landmarks are: medial, medial joint line. and posterior bor-

der of superficial MCL; and lateral, lateral

joint line, and fibular head.

Portals and Incisions The landmarks and arthroscopic potrtal sites and skin incisions are marked on the skirt (Figure 3}.

For the procedure, we use three portals:

anterolateral (AL; viewing]. (AM; work-

ing), and superolateral {outflow}. An accessory medial portal is not required

with this technique. The AL and AM portals are made with the knee in 90° of flexion and in line with their respective joint lines and approximately 1 cm from the patellar tendon edges. The medial portal is made under direct arthroscopic visualization. using a spinal needle to identify the appropriate location. This is done not only to avoid damaging the medial meniscus, but also to allow ad-

equate clearance from the medial femoral condyle {important to avoid articular

cartilage damage during passage of the

reamer for femoral tunnel drilling}. Furthermore, oorrect positioning of the medial portal will allow a proper trajectory for the reamer into the anatomic location on the wall of the lateral femoral condyle. The superolateml portal is made with the knee in extension and 2 cm proximal to the superior pole of the patella and lateral to the quadriceps tendon. Incisions for the BTB or hamstring auto— graft harvest sites are marked and shown in Figure 1. The tibial tunnel is drilled

using these incisions. If using allograft, a

is) 2013 American Academy of flrthopoedic Sa-rgemts

Chapter 17: Anterior Cmciate Ligament Reconstruction: Two-Tunnel Technique BTB graft? however, in select cases, we

use hamstring or quadriceps tendon au-

tografts. All three grafts are harvested in the standard fashion, but only the BTB

will be described here. For the BTB harvest, a 5- to 6—cm skin incision is made just medial to the midline. Full-thickness flaps are developed and limited by the medial and lateral borders

of the patellar tendon. Next, a midline vertical incision is made in the paratenon,

and it is meticulously lifted off the ten— don. This layer is preserved and closed after the tendon is harvested. A ill-mm— wide middle-third tendon segment is harvested with Ill-mm bone plugs. The plugs are designed to be trapezoidal in shape (not triangular), and the leading plug is tapered to facilitate graft passage. Two 1.5»mm holes are drilled in the tibial bone plug and a No. 5 braided nonabsorbable suture is threaded through the holes. These will be used to secure final plug fixation over a post. On the femoral bone plug, an EndoButton CL BTB is at— tached via a 1.5—mm drill hole in the plug. The EndoButton loop size necessary to allow the entirety of the plug to reside in the femoral tunnel is not determined until after the tunnel has been drilled and measured. After the bone plugs have been sized, any extra trimmed bone is re—

placed into the patella bone harvest site, and the paratmon is closed in its entire Figure 3 Photographs show surface anatomy and skin incisions marked on skin for anterior cruciate ligament reconstruction procedures. A, BTB autograft. Marked are the inferior pole of the patella, the tibial tubercle, the graft harvest incision, the medial and lateral joint lines,

the lateral portal, and the provisional position of the medial portal. This portal is made through the BTB incision and only after identification of the appropriate location with a spinal needle. B, Hamsh-ing autograft. C, Medial meniscus inside-out repair {as needed}. D, Lateral

meniscus inside~out repair {as needed). Markings include the lateral joint line, the fibular head

and neck, and the position of the peroneal nerve.

3-cm vertical incision is made later in the procedure, with its position estimated by provisional placement of the tibial tunnel ACL guide. Diagnostic Arthroscopy Priorto graft harvest,a diagnostic arthroscopy is performed with the arthroscope in the AL portal. All three compartments are inspected for articular cartilage damage, medial andfor lateral meniscal tears,

thereby preventing repair failure during hyperflexion of the knee for the femoral tunnel drilling. Focal articular cartilage injuries are treated with microfracture if indicated.

after the ACL tear has been confirmed do we proceed with the graft harvest. If a

repairable meniscus tear is encountered,

an inside—out technique is most frequent— ly used. The sutures are passed but not tied until after the ACLR is completed,

Insertion Site Preparation

With the arthroscope in the AL portal and working instruments in the AM portal, the ACL tear pattern is evaluated. The fat pad is left intact to prevent postoperative scarring, patellar entrapment, and pain. In the context of a partial tear with a preserved AM or posterolateral bundle, we may choose to augment the deficient bundle if indicated. On the femoral side,

and using the location of the torn ACL

remnant as a guide, we mark the center

of the anatomic ACL insertion site with

Medial Portal Technique. Dharmesh 1v'vas, MD, PhD;

nant is removed and the wall of the lateral femoral conde is exposed using a com-

Christopher D. Harner, MD {16 min] Graft Harvest and Preparation

Autograft harvest is performed after an ACL tear is continued during the diag-

nostic arthroscopy. Our preference is a

(fl) 2013 American Academy of Unhopaedic Surgeons

Femoral and Tibial

Video 1?.1 Anterior Cruci-

ate Ligament Reconstruction:

and verification of the ACL injury. Only

length with a No. 0 Vicryl suture {Ethi-

con) in a running fashion.

a 30° Steadman awl. Next, the ACL rem-

bination of a shaver and an arthroscopic burner. In contrast, on the tibial side, a

significant portion of the ACL stump is preserved to enhance proprioceptive and vascular properties.“ We do not routinely perform a notchplasty unless needed for better visualization (1 to 2 mm)I or to al-

loviate graft impingement.

105

Section 1: Sports Medicine flexed maximally (2420”), and through

the medial portal a guide pin is malleted

into the position marked by the awl. A 0.5- to 1-cm undersized cannulated acorn reamer is drilled over the guidewire, and

special care is taken not to damage the cartilage of the medial femoral condyle during insertion into the joint. By hand, a shallow provisional footprint of the reamer is made on the medial wall and evaluated to ensure accurate position and safe distance away from the posterior wall (to prevent posterior femoral wall compromise). If acceptable. the reamer is connected to power and drilled to a predetermined depth for the fixation technique of choice. In [1.5-mm increments and using the round dilators, the tunnel

is then sequentially dilated to a size 1 mm larger than the bone block diameter. Fi-

nally, a 3.2-mm EndoButton drill is used to breach the lateral femoral cortex.

Tibial Tunnel Anatomic tibial tunnel positioning is also accomplished using a combination of vi— sual arthroscopic landmarks and fluoroscopic imaging [Figure 4, B through D).

An ACL tip-guide is set at 50° to 55° and

Figure 4 lntraopcrativc fluoroscopy used to verify tunnel positions before drilling. A, Position of the femoral tunnel as marked using the Steadman awl through the medial portal. The awl is used to mark the center of the anterior cruciate ligament footprint. with the goal being anatomic positioning of the tunnel. B, AP view of the knee shows correct guidewire placement in the coronal plane. This corresponds to the midpoint between the tibial spines. C, Lateral image of the knee shows correct position of the tibial guidewire for bone— patella: tendon-bone grafts. The proper placement is parallel and in line with the Blumensaat

line. D, Lateral view of the knee shows the correct position of the tibial guidewire for softtissue grafts. Proper placement is parallel and 2 to 4 mm posterior to the Blumensaat line.

Femoral and Tibial Tunnel Placement We strongly recommend that all tunnel positions be confirmed by intraoperative fluoroscopy before drillingll (Figure 4).

As described previously. the femoral insertion of the ACL is marked using an awl before debridement of the lat-

Femoral mane! We aim for anatomic placement of the femoral and tibial tunnels. The femoral tunnel placement is done via the medial portal. allowing placement of its position independent of the tibial tunnel (transtibial technique). This technique may be used in all cases of primary ACLR (single- or double-bundle, or augmentation) or revision ACLR and is not dependent

generally 4 to ti mm anterior to the posterior femoral cortex with the knee at 90°

on the choice of graft, instrumentation,

or final fixation. lmportantly, placement of the femoral tunnel through the medial portal has been shown to decrease tun— nel widening and minimize divergence

when using interference screw fixation.12 106

eral notch. The native ACL footprint, although variable in each individual, is

of flexion. Thorough debridement of the

wall of overlying periosteum allows adequate visualization of the posterior cortex ("back wall”) and confirms, proper placement of the femoral tunnel. 1f necessary, and for additional perspective. the provisional tunnel mark can be visualized with the arthroscope temporarily placed in the medial portal. Appropriate tunnel position is further confirmed via intraoperative fluoroscopy by taking a lateral image of the knee (90" flexion and overlapping condyles) with the awl

left in position [Figure 4, A). The knee is

positioned at the intersection between the free edge of the anterior horn of the lateral meniscus and the midline between the tibial spines. The usual tunnel length is 3i} to 45 mm; however. in cases of patella

alta [longer BTE tendinous portion), a longer tunnel is required. The guidewire

is inserted at a point approximately 3 cm below the medial joint line and 1.5 to 2 cm medial to the tibial tubercle. A 3132in K—wire is advanced until the tip is visible in the joint under direct arthroscopic visualization. The wire (and subsequent

tunnel) placement can be accomplished

through the previous BTB or hamstring harvest incisions. If allograft is used, a 4— to 5—cm incision is made in the corre— sponding area. Anatomic placement of the K—wire is

verified both arthroscopically and with

fluoroscopy. The knee is then brought into full extension to check for guide pin impingement on the notch. Next, AP and lateral images of the knee are taken. In the AP view. the wire should be placed

directly between the two tibial spines.

0n the lateral view, the authors aim for placement of the pin within the anterior 20% to 40% of the tibial plateau and parallel to the Blumensaat line (in line for

BTB grafts, 2 to 4 mm posterior for hamstring or quadriceps soft-tissue grafts) (Figure 4, C and D}. If minor adjustments

(El 2013 American Academy of flrtltopasdic 51113130115

Chapter 1?: Anterior Cruciate Ligament Reconstruction: Two-Tunnel Technique are needed in any plane, a 3- or 5-mm off-

set K—wire guide is used for corrections.

Following satisfactory placement of the tibial guide pin, a cannulated compaction reamer (0.5 to 1 cm smaller than the

final graft size) is used to drill. the tunnel. In {LS-mm increments, the tunnel is dilated to a final size 0.5 mm larger than

the bone block. At this point, a Beath pin

with attached suture loop is passed from the medial portal into the femoral tunnel and out the skin on the lateral thigh. The suture loop is pulled through the tibial tunnel using an arthroscopic grasper. Graft Passage ancl Fixation Using the looped Beath pin, the passing sutures from the femoral side of the graft are pulled out through the lateral side of the thigh. The graft is advanced up the tibial tunnel, and the tendinous portion of

the BTB graft is maintained in the poste-

rior aspect of both tunnels. After clearing the lateral femoral cortex with the EndoButton, the device is engaged and seated on the cortex, preventing antegrade pas— sage back into the tunnel. Tension is ap-

Figure 5 Postoperative rill:I {A} and lateral (B) radiographs demonstrate femoral and tibial fixation and tunnel positions.

is cycled to minimize graft creep. Graft impingement and isometry are checked as the final step before tibial fixation. The tibial fixation for graft choices is ty— ing over a post (4.5-mm AD fully threaded cortical screw over a washer, bicortical

failure of graft healing despite an other-

(especially the medial tibial spine). Also included are postoperative infection, arthrofibrosis, deep venous thrombosis, or

The majority of the procedure can be

purchase}. The screw is placed 1 to 2 cm

wise properly executed reconstruction. It is our philosophy to use enoxaparin as prophylaxis against deep venous throm— bosis in patients who smoke or have a personal or family history of blood clots, or in females patients.

We do not use a tourniquet or leg holder. Positioning of the BTB vertical incision just medial to the midline minimizes scar-induced anterior knee pain during kneeling.

knee in full extension. Range-of-motion,

Postoperative Care and Rehabilitation

patellar tendon helps restore normal anatomic fascial planes. The medial portal is made under direct arthroscopic visualization with a spinal needle. This provides three

plied to the tibial sutures, and the knee

below the tunnel, and the sutures are individually tied around the post with the

Lachman, and pivot-shift testing are performed to confirm restoration of normal knee laxity. If a meniscal repair is per-

formed, it is at this point in the surgery

that the inside-out sutures are tied over the capsule. Closure of the incisions is performed in the standard fashion.

Complications

Complications specific to the medial por-

tal technique for ACLR can occur secondary to incorrect placement of the medial

portal and resultant damage to the medial femoral condyle. This is usually the result of inadequate clearance from the medial femoral condyle for safe passage of the guide pins and drill bits. The use of half acorn reamers (introduced into the joint with the nonfluted side facing the condyle} has significantly helped avoid this complication. Other complications generally associated with arthroscopic ACLR include iatrogenic injury to the menisci, articular cartilage, and tibial spines

Postoperatively for the first week, the patients are asked to bear weight with crutches and with their brace locked in full extension.” Basic home exercises include quadriceps sets, straight-leg raises, calf pumps, and heel slides. The goal is protection of the graft while regaining quadriceps strength and knee extension. At the first postoperative visit (1 week), the incisions are checked, radiographs

are obtained {Figure 5}, and formal physical therapy is started with the brace un-

locked. The patient is allowed to wean off crutches at 1 month and begin rurming at 6 months. The expected return to full activity is projected at 9 to 12 months postoperatively. This time is extended in the context of allograft use.

Pearls

- The medial portal technique is uni— versal to all autograft and allograft choices. An accessory medial portal is not necessary.

(El 2013 American Academy of Grthopaedic Surgeons

done with the knee at 90° of flexion;

final fixation on the tibia is accom-

plished with thekneeinfull extension.

Closure of the paratenon over the

benefits: avoidance of iatrogenic damage to the medial meniscus; adequate

clearance of the medial femoral condyle articular cartilage, prevention of damage during the passage of reamers; and facilitation of the proper angle for direct access to the anatomic

positioning of the graft on the lateral

femoral condyle. Use of half acorn reamers also helps to minimize the chances of iatrogenic damage to the medial femoral condyle during passage of the drill bits. Use of intraoperative fluoroscopy ensures precise and reproducible positioning of the femoral and tibial tunnels. Minor adjustments to the tibial guide— wire positioning can be made quickly and easi using a 3- or 5-mm offset drill guide. If}?

Section 1: Sports Medicine *- Intraoperative fluoroscopy is criti—

cal to verify that the EndoButton has seated and engaged the lateral femo-

ral cortex. The tibial and femoral tunnels are dilated 0.5 mm larger than the BTB bone block size to facilitate easy passage of the graft. Meniscal repair sutures are passed before the ACLR is undertaken but are not tied until after the graft is passed and secured. This avoids tearing of the repair sutures during hyperflex— ion of the knee for the fernoral tunnel drilling. References

1. Maletius W, Messner K: Eighteen- to twenty-four-year follow-up after complete rupture of the anterior cruciate ligament.

Am I Sports Med l?99;2?(6):?ll-?12

.

McCulloch PC, Lattermann C. Boland

AL, Each BR It: An illustrated hishary of

anterior cruciate ligament surgery. I Knee Surg 200?;20(2}:95-104.

.

Marx RG. Jones EC, Angel M, Wickiewicz TL, Warren RF: Beliefs and attitudes of

. Harner CD. Honkamp N]. Ranawat AS: Anteromedial portal technique for creat— ing the anterior cruciate ligament femoral tunnel. Arthroscopy Eflflfifiifl]:113-115. Hedi A, Musahl if. Steuber V, et a1: Trans-

tibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: An anatomic and hiomechanical evaluation of surgical technique. Arthros— capy ZHIIEFBJflEEFBEID. Harner CD, Lo MY: Future of allografts in sports medicine. Clin Sports Med 2009;23(2}:32?-3-lfl, ix. Greis PE. Burks RT} Bachus K. [ulcer MG: The influence of tendon length and fit on the strength of a tendon—hone tunnel

complex: A biomedtanical and histo-

logic study in the dog. Am I Sports Med 2001;29{4}:493-49E . Greulich WW. Pyle SI: Radiogmpftic Atlas of Skeletal Detetopment attire Hand and Wrist. Stanford. CA. Stanford University Press. 1959. Nedeff DD, Each BF. Jr: Arthroscopic anterior cruciate ligament reconstruction using patellar tendon autografls. Orthopedics 2002;25t3}:343-359.

1i]. lee BL Min KD. Choi HS. Kim IE. Kim ST: Arthroscopic anterior cruciate ligament reconstruction with the tibial-remnant preserving technique using a hamstring graft. Arthroscopy 2006;22{3):e1-e2 11. Singh AP, Singh BK: The use of intraoperative image intensifier control for the ACL surgeon. Knee 2011;18f6}:379-331. 12. Chhabra A. Kline A]. Nilles KM. Harner

CD: Tunnel expansion after anterior cruciate ligament reconstruction with autogenous hamstrings: A comparison of the medial portal and transtibial techniques. Arthroscopy flittiflfllflhllW-llll 13. Harner CD. Sandoval CM: Anterior

cruciate ligament injuries: Evaluation and management. Dper Tech Sports Med nonsense-as.

members of the American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate ligament injury. Arthroscopy roos;1s{7):rse-rro.

103

(it 2013 American Academy of Drthopaedic Sui-gems

Chapter 18 Anatomic Anterior Cruciate Ligament Double-Bundle Reconstruction Jeffrey Macaiena, MD

Carola van Eek, MD, PhD

Introduction Injury to the anterior cruciate ligament {ACL} is common. Each year, more than IDUflDD ACL reconstructions are done in the United States alone.1 Traditionally,

only one of the two native bundles of the

ACL is reconstructed. These traditional

"sirrgle-bund1e” reconstructions place the

AC1. outside the native insertion site area,

in a nonanatomic position.” They have

been shown to return the knee to normal International Knee Documentation Committee (IKDC) scores in only 61% to 67%

of Izaatients.i Anatomic double-bundle re-

construction better re-creates the native knee kinematics and function.5J5 Further,

we believe that performing anatomic reconstruction and respecting the native anatomy will improve the long-term health of the knee and decrease the risk of degenerative arthritis.

Patient Selection

Ruptures to the ACL are diagnosed based on the patient’s history and physical examination. A detailed history is of utmost importance to the diagnosis of ACL injuries. Most ACL ruptures are secondary to noncontact trauma to the knee sustained during cutting or pivoting sports. Athletes frequently report hearing a pop and noticing an immediate effusion. The physical examination is also important to the workup of athletes with an injured knee. Attention to Lachman and pivot-shift testing is very important. Isolated injuries to the posterolateral (PL) bundle are suggested by the presence of a positive pivot-shift test with an intact

end point on Lachman testing. Isolated injuries to the anteromedial (Altai) bun-

dle are indicated by increased anterior translation without a firm end point on Lachman testing and a negative pivot—

Freddie H. Pu, MD

shift examination. KT-lflflfl and [CT-2000 arthrometer testing fllDmetric) can be

used to further objectify the physical ex—

amination.

Indications

The indications for anatomic ACL double-bundle reconstruction are an ACL-deficient knee with symptomatic instability or in a patient who desires to return to cutting and pivoting sports. For decision making on the course of treatment of individual patients, the anatomic single- and double-bundle ACL reconstruction algorithm can be followed {Figure 1}.“5

Contraindications

Relative contra indications to anatomic ACL double-bundle reconstruction include the following: II A small femoral or tibial insertion site. Tibial insertion sites smaller than

14 mm will not support the bone tunnels necessary for anatomic double-

bundle reconstruction. This can be

determined on MRI preoperatively,

but the ultimate decision is made at

the time of surgery by arthroscopic

measurement of the ACL insertion site. When the insertion site is small— er than 14 mm, an anatomic single-

I

bundle reconstruction is performed.

Notch size of less than 12 mm in the medial-to-lateral dimension”? Small notch widths do not allow for the placement of both tunnels, and an an—

atomic single—bundle reconstruction is preferred.

As with all surgical procedures, ab-

solute contraindications to ACL reconstruction exist. Active infection is an absolute contraindication to ACL recon— struction, as is malalignment in the set-

ting of a chronic ACL-deficient knee. In knees with a chronic ACL deficiency, any malalignment needs to be corrected be— fore proceeding with ACL reconstruc— tion. Malalignment is best judged on

standing pelvis-to-ankle radiographs

on a Sui-in cassette. Instability to varus or valgus stress also needs to be evaluated and corrected if present. ACL reconstructions performed in the setting of incompetencyr of the posterior cruciate ligament, the posterolateral corner, or

the medial collateral ligament complex

will increase the rate of failure. Meniscal tears should be treated with either repair or partial menisoectomy as clinically indicated. Osteochondritis dissecans le— sions should be evaluated and treated accordingly.

Preoperative Imaging

Plain radiographs are evaluated for fractures and dislocations, as well as the

presence of a Segond fracture. A Segond fracture is an avulsion injury to the lateral meniscotibial ligament and is pathognomonic for an ACL injury. MRI is used to evaluate for concomitant ligament injury as well as associated meniscal or chendral pathology. MRI can be used for preoperative planning. Using special planes, such as the oblique sagittal and oblique

coronal planes,18 both the AM and the PL

bundles of the ACL can be adequately

evaluated. In addition, measurements of

the ACL femoral and tibial insertion sites can be performed. If IvLRI of the contra—

lateral knee is available, the native ACL

inclination angle can be measured (Figure 2}. MRI can also be used to determine autogratt length and the diameter of the quadriceps and bone—patellar tendon— bone graft.

Dr. Fu or an immediatefamily member has receioed royalties from Arthrocare; seroes as a paid.

consultant to or is an employee qtryker; has stock or stock options held in Strylcer; and serves

as a board member, oumer, officer, or committee member of the American r'lcademyr of Drthopaedic Surgeons; the American Orthopaedic Societyr for Sports Medicine; the International Society ofArthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; and the Orthopaedic Research and Education Foundation. Neither ofthefollowing authors nor anyr immediatefamily member has received anything of oataefrom or owns stock in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. distortions and Dr. can Eek.

(it 2013 American Academy of Cirthopaedic Surgeons

Video 18.1 Anatomic Singleand Double-Bundle Anterior Cruciate Ligament Reconstruc-

tion. Jeffrey Macalena, MD; Carola van Eck, MD, PhD; Freddie H. Fu, MD (11 mini

109

Section 1: Sports Medicine

(meant with norm Preoperative i Detailed history to assess injury mechanism.

physical errantinaiiort to assess knee irritability + Radio-graph to evaluate bony morphology and

pathology: high-quality MRI to evaluate ACL rupture pattern and measure native insertion site size. Surgery 1

I

Repeat physical examination [under anesthesia} it iilsttallze and probe femoral and tibial remnants of native iltCL anti determine mptnre patient. Hote:AM portal offers supee view of

I

femoral remnants.

lndlvidualize surgery for each patient. Follow

‘ remnants of nativeAEL to identify trial and femoral hsertion sitesnte inserfiort sitter visible?

Yes

|

No

Mark tibial insertion site wing tibial plateau an Iationshb of tibial spine. anterior horn lateral menl

ark tibial insertion site and measure ltto detennlne tlllllEI siae. 4

aid PCL with ACI.) and measure to detenn‘ne tunnel site.

1ltl'isualize whole lateral wall of notdt. Identify bony landmarks {lateral intercondylar and bifuroate ridge). Mark femoral ACL insertion site and measure to

l

If Iaterd intacondylar ridge is visible. use it to malt

determine tunnel sire. Note: 30“ artitroscope offers

superior view of bony ridges Pedorming notchplasty

femoral lrtsertiort site and rneaarre it to determine imnel sire.

acctrate to indicate location of ferroral insertion site.

i

riSnpts native ACI. insertion site. o'clock reference is not it

. . . . . . Is tibial trrsenton srte smaler than 14 mm I1

lsfemoralireieriion silesmallerti'fl'l 14min I

length ordoespatiertt haves nanownotd't?

b lergthordoespatierrthaveananow

Yes {14 mm]I

Wider anatomic sirrglebunde reconstruction.

‘I'ES (2 mm) at the fracture site. Convergently placed pins should be avoided. (Reproduced with permission from Skaggs DL, Cluck l'v, Mostoli A, Hynn JM, Kay RM: Lateral—entry pin fixation in the management of supracondylar fractures in children. I Bone joint Surg Am 2004;36[4]:702—70?.]

636

deemed acceptable, the shoulder is exter-

(El 2013 American Acadmy of Drthopaedic Sargerms

Chapter 95’: Closed and Open Reduction of Supracondylar Humerus Fractures adequate fixation in the distal fragment

on this view. Of note, having a slightly

anterior-to-posterior trajectory of the pins as they are advanced across the proximal fragment may maximize bony purchase by going through the capitellum (Figure 3).

Following pin placement, the stability

of the fracture should be evaluated by

performing dynamic fluoroscopic stress views of the elbow in both the sagittal {flexion—extension stress) and coronal

{varus—valgus stress} planes. If there is any uncertainty about the stability of

the construct, an additional pin should

be placed. lDnce construct stability is confirmed, final fluoroscopic images should be taken, including AP (with the elbow in extension), lateral, and internal

and external oblique views. One helpful technique is to save the image showing fracture reduction at its worst. to aid in evaluating films performed at follow-up

visits, should there be there concern over

loss of reduction.

Dressing and Casting Once adequate reduction and fixation have been achieved, the pins are bent to

an angle of 90°, 1 cm from their entry into

the skin; the pins are then cut to a length of 1 to 1.5 cm. Sterile dressings should then be applied in a way that protects the skin from the pins and accommodates

Figure B Intraoperative AP {A} and lateral {B} fluoroscopic views show a typical type II supracondylar humerus fracture. Intraoperative AP (C) and lateral (D) fluroscopic views show pin placement following fracture reduction and fixation. Note the slight anterior-to-posterior trajecmry of the pins on the lateral view. [Courtesy of lIEIhildren’s Orthopaedic Center, Los Angeles, CA.)

by making a slit in a square of sterile felt and placing it beneath the pins. Strips of 0.5—in—thick sterile foam may then be placed over the dorsal and volar aspects

nerve palsy in this patient population, they found a 4.9% rate of injury to the ulnar nerve that was associated in every case with the placement of a medial—entry pin. In this patient series, even exposure of the medial-entry pin site through a

the significant soft-tissue swelling that is often present. This can be achieved

of the arm and overwrapped loosely with

sterile cotton undercast padding; no circumferential dressings should be placed underneath the foam. This allows room for postoperative swelling and obviates the need to split the cast. Finally, a long— arm cast is loosely applied with the arm held in 60° to PD” of flexion and the fore-

arm neutrally positioned, after ensuring

that the radial pulse is present in this position (Figure 9).

Lateral-Entry Versus Medial-Entry Pins There is good evidence in the literature to support the use of lateral-entry-onlyr pin constructs. In 2001, Skaggs et a1“ reported retrospectively on 281 displaced (Gartland type I] and III) supracondylar humerus fractures treated with either lateral-entry—only pin fixation or a crossed-pin construct. When the authors looked specifically at iatrogenic ulnar

small incision before pin placement did

not infallibly prevent ulnar nerve injury. In a subsequent study, Skaggs et al12 reviewed 124 consecutive supracondylar fractures treated with lateral—entry pin fixation alone. In this patient population,

they reported no clinical loss of elbow

motion, loss of fracture reduction, iat-

rogenic nerve palsy, need for additional surgery, or cubitus varus deformity. The authors concluded that for even the most unstable supracondylar humerus frac-

tures, adequate fracture stability can be achieved using only lateral-entry pins,

thus decreasing the risk of iatrogenic ulnar nerve palsy. Although lateral-entry constructs have become increasingly popular, medial— entry pins may also be used for fixation— especiallyr in cases with excessive lateral

(fl) 2013 American Academy of Grthopaedic Surgeons

comminution or extremely distal fracture lines, where adequate purchase laterally in the distal fragment is not easily ob— tained. If placement of a medial pin is underta ken, it should be placed after the first lateral-entry pin so that the elbow can be extended without displacing the fracture; positioning the arm in relative extension prevents the ulnar nerve from subluxating anteriorly over the medial epicondyle and being speared by an advancing Kwire. The authors use medial pins in less than 1% of fractures. Special Situations FIexion-Type Fractures An uncommon variant of the supracondylar humerus fracture, the flexion-type fracture, must be recognized and appropriately treated in a timely fashion. Mahan et a1“ recently published their 10-year experience with flexion-type supracondylar fractures using a cohort of patients with extension—type injuries treated at the same institution during the same time period as a control group. 63?

Section 8: Pediatric Orthopaedics

_ a..._.-..l_ It.

a.

Figure 9 Photographs show dressing and casting for supraconclylar fractures of the humerus. A, Sterile felt squares may be used to protect the skin. Petrolatum gauze mesh strips or sterile gauze may also be used for this purpose. B, In cases of significant swelling, strips of sterile foam may be placed volarly and dorsally on the skin and then overwrapped loosely with sterile cotton undercast padding. C, A long-arm cast is loosely applied, with the elbow in roughly 70“ of flexion. [Reproduced with permission from Skaggs D: Closed reduction and pinning of supracondylar humerus fractures, in Tolo VT. Skaggs DL. eds: Master Techniques in Orthopaedic Surgery: Pediatrics. Philadelphia. PA, Lippincott

Williams 51: Wilkins, 2008, p 12.)

They found that the 58 patients with flexion-type fractures differed from the control group in several ways. Patients with flexion-type injuries were significantly older (17.5 years versus 5.3 years, on average), were significantly more likely to have preoperative ulnar nerve symptoms requiring decompression, and were significantly more likely to require an open reduction of the fracture than their extension—type counterparts by a factor of three. Despite these findings, closed reduction is still possible in most cases. In terms of the surgical approach to fracture

reduction and fixation, the flexion-type fracture differs from the extension-type fracture in one significant aspect: reduction is performed with the elbow posi— tioned in relative extension.

Type IV Fractures

For fractures that are multidirectionally

unstable (Gartland type IV), the recom-

mended reduction maneuver is slightly different. As described by Leitch et al,3

the fracture is first confirmed to be multi— directionally unstable by demonstrating both flexion and extension of the distal fragment on lateral fluoroscopic views.

Unlike stable fractures, which are treated by immediate fracture reduction, for mul-

of the fracture fragments to correct varus

and valgus malalignment as well as any major rotational deformity is employed with the elbow held in relative extension. AP views of the elbow are obtained in this position. lEl‘nce adequate alignment in the coronal plane is established, the C-arm is rotated 9D” to a lateral position, and the deformity in the sagittal plane is addressed by passive flexion or extension of the elbow; direct anterior—posterior

translation of the fracture fragments may also be useful. Manual pressure on the

medial andior lateral humeral condyles

the anterior cubital fossa, at the level of

the natural flexion crease. The incision begins just medial to the palpable biceps tendon and is extended laterally. A No. 15 blade is used to go through the skin, followed by blunt dissection of the

subcutaneous tissue beneath. Care is tak-

en to dissect well lateral to the biceps ten-

the pins may be advanced across the fracture site—in an anterior-to-posterior direction as described previously for type [I and II] fractures—and the C-arm is again rotated to provide an AP view. One or more additional pins are frequently placed to ensure adequate stability of the

run just medial to it—the brachial vein, brachial artery, and median nerve—are

firmed on the lateral fluoroscopic view;

construct.

flpen Fractures

Open reduction of a pediatric supracon-

dylar humerus fracture is at times necessary. Indications for open reduction

include open fracture, neurovascular

injury warranting exploration, failure to achieve or maintain a closed reduction secondary to interposed soft tissues at the

ture reduction and then using AP and lateral fluoroscopic imaging to confirm adequate pin placement and anticipated pin trajectory Fracture reduction is attentpted initially in the coronal plane. Direct manipulation

and loss of previously present neurologic or vascular function following closed re— duction. Although various approaches to the elbow have been described for

633

prefer the anterior approach)” After positioning and draping in the previously described fashion, a sterile tourniquet is placed as high on the arm as possible without immediate inflation. A 3-cm incision is made transversely in

is used to correct residual rotational deformity. After fracture reduction is con-

tidirectionally unstable fractures these authors recommend first placing two {1.062-in K—wires into the lateral aspect of

the distal fracture fragment before frac-

terior, and combined approaches), we

fracture site or severe soft-tissue swelling,

the open treatment of supracondylar humerus fractures fag, lateral, medial. pos-

don and its distal aponeurosis to ensure that the neurovascular structures that not damaged. The median nerve and

brachial artery may be tightly tented

over the proximal fracture fragment. Not infrequently, the proximal fracture fragment is buttonholed anteriorly through the brachialis muscle, and this rent in

the soft-tissue envelope may be exploited to provide direct access to the fracture site. Fracture hematoma is evacuated with a combination of suction and saline lavage. The fracture site, once cleaned, is in-

spected for interposed soft tissues. The placement of retractors into the surgical wound while examining the fracture site should be done with care to prevent direct or indirect injury to nearby neurovascular structures. Interposed tissues may include joint capsule, periosteum, muscle fibers (brachialis, common flexor,

and triceps muscle interposition have all been described), and neurovascular

is) 2013 American Academy of flrfhopaedic Surgemts

Chapter 95': Closed and Open Reduction of Supracondylar Humerus Fractures structures, including the radial nerve, the

adhering to the concepts described previ-

site as necessary. Of note, soft-tissue in-

Postoperative Care and Rehabilitation

median nerve, and the brachial artery. These are gently freed from the fracture

terposition is fairly common and should be considered a primary cause of irre— ducibility in the supracondylar humerus fracture. In their report of 61 children

with Gartland type ill fractures treated

with open reduction and percutaneous fixation through an anterior approach, Ay et a1“ noted that the proximal fracture fragment was buttonholed through the brachialis muscle in 46% of cases, and the

anterior joint capsule was interposed in the fracture fragments in 33% of cases.

In the same report, Ay et a1“ noted a 5% to 10% rate of traumatic nerve palsy preoperatively; in each case of traumatic neurovascular injury, the affected nerve at the time of open surgery was found

to be tethered anteriorly (AIN palsy] or

kinked anterolaterally {radial nerve palsy}. Surgical release of the incarcerated nerve from the fracture site was reliably associated with full neurologic recovery within 3 months of surgery. Vascular compromise is not infrequently associated with displaced supracondylar humerus fractures, with an estimated

ltl'iii to 20% of children presenting with

a pulseless limb. Often, fracture reduc— tion results in return of the radial pulse,

although a small subset of patients will require open exploration of the vessels. If there is any doubt regarding the integrity of the neurovascular structures surrounding the elbow, they may be formally explored by extending the transverse incision in a lazy-S fashion for approximately 5 cm both proximally (along the medial aspect of the biceps brachii) and distally (along the medial border of the brachioradialis).

Once the approach to the humerus is suocessfully made and the fracture frag—

ments are mobilized, attention is turned

to fracture reduction. This is typically

achieved through direct manipulation

of the fracture fragments and often consists of pressure applied posteriorly to the proximal fracture fragment with the dis— tal fragment stabilized. Palpable cortical step-offs medially and laterally are indicative of residual rotational malalignment and should be reduced if possible. However, once the soft tissues are removed from the fracture site, the reduction is often less stable than when reduced closed;

the surgeon should expect some “fiddling" and be patient. Fracture reduction

is followed by percutaneous pin fixation,

ously.

A minority of children with minimal swelling and minimal risk for compartment syndrome may be discharged to home with appropriate parental education on elevation and early warning signs requiring a return to the emergency clepartment. Most children will be admitted to the hospital for observation and serial neurovascular checks. Dnce the surgeon is certain that an evolving compartment syndrome is not present and the neurovascular examination is stable, the child

may be discharged home, with routine follow-up scheduled for 1 week after surgery. At this visit, AP and lateral views of the elbow in cast are obtained, and care is taken to ensure that the neurovascular examination is stable and that signs of pin-site infection, such as worsening pain, malodorous drainage, and fevers,

are not present. Cast immobilization is continued, and the next routine follow-

up generally is scheduled for the third postoperative week. At this visit, new

radiographs are obtained out of the cast,

and the pins are removed in the office. Generally, a return to regular activities of daily living is expected at this visit, with restrictions placed on activities that

would place the patient at risk for a fall

and refracture through the healing bone. Physical therapy is not routinely ordered because parents are trained to perform gentle range-of—motion exercises. Patients return for a range-of-motion check at 6 to 3 weeks postoperatively and are generally allowed to return to full activities at that time. Repeat radiographs are not typically obtained once healing has been demonstrated unless there is a concern about a loss of elbow motion or persistent elbow pain.

Pearls '- Some authors recommend using the

C—arm itself as the operating table; however, this setup is inadequate for obtaining lateral views by rotation of the machine {useful for unstable

type Iv fractures} and inadequate for

fractures that require open reduction. I To achieve and maintain adequate re— duction: o Consider using a sterile elastic bandage to hold the reduction with the elbow hyperflexed while pins are placed.

o 2013 American Academy of Cirrhopaedic Surgeons

o Check internal and external oblique views to evaluate medial and lateral columns. o Remember that the two most important criteria for assessing reduction are a Baumann angle Hi)" and the anterior humeral line intersecting the capitellum. o Save the worst fluoroscopic view

mtraoperatively to be used as a

comparison later in the office. o Recognize that if a gap remains at the fracture site after reduc— tion, or there is a rubbery feel,

interposition of neurovascular structures may be present, and

the surgeon should proceed

with open reduction. - Technical errors in pin placement can be avoided by o Engaging medial and lateral columns just proximal to the fracture. o Achieving bicortical fixation with each pin. o Maximizing pin spread at the fracture site. o Ensuring bony purchase in the distal fragment (by not starting

too posteriorly or too near the lateral edge).

o Avoiding pins crossing at the fracture site because they func— tion essentially as one pin. - Persistent instability or inadequate

fixation can be recognized by performing stress views of the fracture in

both the AP and lateral planes. i For medial-entry pins, neurovascular structures are protected by extending the elbow during pin placement to prevent anterior subluxation of the ulnar nerve and iatrogenic injury. *- Careful attention must be paid to the soft tissues and the neurovascular status of the arm by o Avoiding tight circumferential dressings. o Considering the use of sterile

foam to allow for swelling in

the cast. o Avoiding elbow flexion >m° in the postoperative cast. o Rechecking the radial pulse after fracture reduction.

References

1. Houshian S, Mahdi B, Larsen MS: The

epidemiology of elbow fracture in children: Analysis of 355 fractures, with special reference to supracondylar humerus fractures. J Orthop Sci 2001;6(4]:312-315.

639

Section 8: Pediatric Orthopaedics

JH, Kasser IR, eds: Rockwaod and Wilkins' Fractures in Children. Philadelphia, PA,

DJ

Lippincott Williams 8: Wilkins, 2006, pp 543-539. . Leitch KK, Kay RM, Femino ID, Tolo VT, Storer SK. Skaggs DL: Treatment of multidirectionally unstable supracondylar humeral fractures in children: A. modified Gartland type-IV fracture. I Bone Joint Snrg Am meanness-935.

m

ph-

. Babel JC, Mehlrnan CT, Klein (3: Nerve injuries associated with pediatric supraoondylar humeral fractures: A meta-analysis. I Psdiotr Drtfrop 2010;30f3):253-263. 5. Mapes RC, Hennrikus WL: The effect of elbow position on the radial pulse measured by Doppler ultrasonography after surgical treatment of supracondylar elbow fractures in children. I Pedrhtr Drthop 1998;18(4):441—444. . Battaglia TC, Armstrong DG, Sclmend RM: Factors affecting forearm compartment pressures in children with supracondylar fractures of the humerus.

jPodiotr Orthop numerator-439.

'3'. Skaggs DL, Sankar WM, Albrektson I,

Vaishnav S, Choi PD, Kay RM: How safe is the operative treatment of Gartland type 2 supracondylar humerus fractures in children? I Pediatr Orthop 2006:23f2]:139-141. . Omid R, Choi PD. Skaggs DL: Supracondylar humeral fractures in children.

0:-

fractures of the distal humerus. in Beaty

I Bone Joint Snrg Am 2003;90f5]:1121—1132.

. Peters CL. Scott SliI'I, Stovens PM: Closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children: Description of a new closed reduction technique for fractures with hrachialis muscle entrapment.

'Ivfl-

2. Kasser JR, Beaty IH: Supracondylar

Ifl'rtfrop Trauma 1sss;a{s):43o-eao.

10. Sanhar WN, Hehela NM, Skaggs DL,

Flynn IM: Loss of pin fixation in displaced supracondylar humeral fractures in children: Causes and prevention I Bone Joint Surg Asn 20D?;EE|{4}:?13-?1?. 11. Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo W: flperative treatment of supracondylar fractures of the humerus in children: The consequences of pin placement. I Bone joint Surg Am 2001;33f5}:?35—?4fl.

12. Skaggs DL, Cluck MW. Mostofi A, Flynn IM, Kay RM: Lateral-entry pin fixation in the management of supracondylar fractures in children. I Bone Joint Surg Am 2004;36(4):702—70?.

13. Mahan ST, May CD, Kocher MS: Operative management of displaced flexion supracondylar humerus fractures in children. I Pediatr Orthop 2W;27(5}:551—556. 14. fly 5, Akinci M, Kamiloglu S, Ercetin 0: Open reduction of displaoed pediatric supracondylar hunteral fractures through the anterior cubital approach. I Pediatr Orthop 2005;25f2}:149-153. 15. Koudstaal M], De Kidder VA, De Lange 5, Ulrich C: Pediatric supracondylar humerus fractures: The anterior approach. I Orflrop Trauma 2002;16(6):4D'9-412.

(El 2013 American Academy of Drthopaedfc Sui-gems

Chapter 98

Reduction and Fixation of Lateral Condyle Fractures of the Distal Humerus

Neeraj M. Patel, MD, MPH, MES

John M. Flynn, MD

Patient Selection

Fractures of the lateral comdyle of the hu-

merus typically occur as a result of a fall,

either on an outstretched hand or from a height. Classically, these injuries are categorized as Milch type I fractures if they pass through the ossific nucleus of

the capitellum or Milch type II fractures

if they pass medial to the capitalism and into the trochlear groove.1 Treatment depends more on the extent of displacement than on location, however2 (Figure l).

Nonsurgical treatment with a long-arm cast is adequate for nondisplaced or minimally displaced fractures (9lJ" arc of motion}. This is similar to most ante-

rior cruciate ligament [ACL] reconstruction preoperative protocols (”preha "}. During this waiting period, the patient

may be fully weight bearing and should

arthroscopic reduction and fixation with similarly good outcomes.“ Fixation of a cadaver-simulated tibial spine fracture with three reinforced No. 2 sutures was found to be stronger than a single 4—mm cannulated screw.1r In a bovine knee, fixa-

wean out of a bracer‘immobilizer and undergo physical therapy before surgery. Surgical delay of 2 to 3 weeks improves arthroscopic visualization because the hemarthrosis will have largely resolved. The fracture does not heal during this

showed more motion than a metal or bioabsorbable screw.“ Screw and suture fixation can be placed entirely within the epiphysis, which minimizes the risk of growth disturbance.” Suture fixation is less likely to cause notch impingement or require removal than screw fixation.

ular location.

tion with suture or bioabsorbable pins

waiting period because of its intra-artic— Preoperative Imaging

Plain radiographs, especially the lateral

view, should be scrutinized to assess

fracture displacement and fracture comminuu'on, which is less suitable for screw

Dr. Wall or an immediate family member serves as a paid consultant to or is an employee of OrthoPedialrics; serves as an unpaid consultant to SpineForm and Stryicer; has received non— income support (such as equipment or services), commercially derioed honoraria, or other non— research-relatedfunding (such as paid travel) from Spinal-"arm; ana‘ seroes as a board member, oumer, officer, or committee member of the Pediatric Orthopaedrb Society (3." North. America.

(El 2013 American Academy of Cirrhopaedic Surgeons

fixation (Figure 1). Meniscal entrapment and meniscal tears can be identified preoperatively on MRI to help plan the procedure and estimate surgical time, and a CT scan or MRI can show true fracture displacement and any comminution of the epiphyseal bed into which the fracture will be fixed. The lateral radiograph (Figure 2, A) does not show the significant epiphyseal comminution that is apparent on an MRI {Figure 2, B). In this case, screw purchase restricted to the

tibial epiphysis would be tenuous. Screw purchase across the growth plate into the metaphysis would be preferred.

Procedure

Room SetuplPatient Positioning It is essential to position the patient’s knee on the table so that a clear intraoperative lateral radiograph can be obtained. For suture fixation, the knee can be po-

sitioned in about 20” of flexion on top of the table by elevating the knee holder under the thigh. Cannulatecl screw fixation is facilitated with the knee at 60‘“ to 90° of flexion, usually off the end of the

table. The opposite leg can be placed in a well-padded hemilithotomy holder (wellleg holder}, or the leg can be padded and abducted off the opposite lateral side of 6??

Secfion 8: Pediatric firthopaedics ically to avoid impingement.1 2'” The anterior portion of the spine fracture is drawn in an anterior, medial, and distal direction until the wellvisualized medial compartment fracture line is anatomic (Figure 3, C}.

8. If the medial meniscus is entrapped, I pull the meniscus forward out of the fracture with an arthroscopic probe during final reduction. Reduction should be confirmed with lateral view arthroscopy and fluoroscopy.

Suture Fixation The following seven steps apply only to suture fixation. Figure 4 shows an AP and lateral view of a fragmented tibial Figure 2 Images show a displaced type 111 tibial spine fracture in a 13—year-old boy; this fracture is amenable to screw fixation. A, Lateral radiograph. B, MRI shows that the displaced tibial spine fragment is large enough to fix with a screw and washer, but the rest of the tibial epiphysis has multiple fracture lines. In this case, epiphyseal screw fixation would be tenuous, and metaphyseal fixation is needed for secure screw purchase, which will allow early postoperative knee motion.

the table. It is helpful if the fluoroscopy C—arm can give an unobstructed view of the knee during fixation to document ad-

equacy of reduction and the fixation device position.

Special lnstrumentlquipmenti Implants

For suture fixation, the following instru-

ments and equipment should be on hand:

No. 2 reinforced braided nonabsorbable suture, a suture lasso, an ACL tibial drill

guide and guide pin, a microfracture

pick, an arthroscopic curet, a Hewson su— ture passer, a standard fracture set with 3.5-mm drill guide, 30° and 70° arthro-

scopes, and an arthroscopy shaver. Screw fixation will require a 4.0- or

4.5-mm

cannulated

screwfwasher,

a

curet, an arthroscopy shaver, a microfracture pick, a Kirschner wire (K—wire) set, and nonabsorbable suture to tag the washer.

Surgical Technique The following eight steps apply to both arthroscopic suture fixation and screw fixation:

1. The tourniquet is inflated to improve visualization during a potentially bloody procedure.

2. Arthroscopy starts with irrigation

of any remaining hemarthrosis. The

knee joint should be rinsed with saline several times through the arthroscope cannula before placing the

673

arthroscope. An accessory outflow portal can be used if necessary. 3. The clot is shaved and curetted from the fracture crater that usually traverses the medial compartment. A portion of the anterior fat pad is resected to provide unobstructed visualization of the anterior fracture line (Figure 3, A].

spine fracture that is well suited to suture fixation and would be difficult to secure

firmly with a screw.

1. Using an ACL tibial guide, the first tibial guide pin is started just medial to the patellar tendon in the tibial epiphysis. The pin is aimed so that it hits the anterolateral crater rim (Figure 5]. The second guide pin is

placed more medially up through

the epiphysis to hit the crater on its anterior medial rim. This will create two all—epiphyseal bone turmels, as depicted in Figure ti, A and B. A 10-mm-long horizontal skin incision

is made between the two pins down

to the tibial epiphysis, being care-

4. The anterior horn of the medial meniscus is identified, as well as its transition into the transverse inter-

meniscal ligament, which can be

entrapped beneath the tibial spine fracture.11

5. The lateral compartments are inspected for a meniscal tear. The lateral fracture line is usually not visible in the lateral compartment and may be covered by the anterior horn of the lateral meniscus. 6. The anterior tibial spine is elevated and the clot is shaved from beneath the spine [Figure 3, E]. This is the longest portion of the procedure. it At this point, I reduce the tibial spine fracture, which is usually hinged

posterolaterally. The anterior horn of the lateral meniscus is frequently attached to the tibial spine fracture fragment, and it covers the lateral fracture line, which is usually impossible to visualize after reduction. The tibial spine and the attached lateral meniscus need to be reduced anatom-

ful not to disturb the proximal tibial growth plate.

2. A standard fracture drill guide is

placed over the guide pin; the pin is then withdrawn and exchanged with a Hewson suture passer in each tibial drill hole (Figure 6, C).

3. Using a suture lasso, a reinforced No. 2 suture is passed through the first Hewson suture passer, then through the most distal ACL where it inserts into the spine fracture fragment, and finally through the second

Hewson passer on the other side of

the fracture (Figure 5, D). This is

repeated with the second reinforced suture. 4. The reinforced sutures are drawn down through the tibial epiphysis with each Hewson passer {Figure 6, E).

5. With the knee at about 30‘3 of flexion, the fracture is reduced with a microfracture pick, and the four ends of

the two reinforced sutures are pulled fight. The sutures are tied and knot—

(El 2013 American Acadmy of flrthopaedic Surgerms

Chapter 104: Surgical Reduction and Fixation of Tibial Spine Fractures in Children

Figure 3 Arthroscopic views of a knee with a displaced type 1” tibial spine fracture {same patient as depicted in Figure 1) show the match and the medial compartment. A, The fracture fragment is displaced in a lateral and proximal direction. The crater extends into the medial compartment. B, The fracture fragment is displaced superiorly into the notch to allow clot removal from the fracture. C, An arthroscopic probe is seen reducing the fracture Fragment in feriorly and medially into the crater.

Figure 5 lntraoperative fluoroscopic image shows a tibial tunnel anterior cruciate ligament guide used to place a guidewire

Figure 4

AP (A) and lateral (B) views of a com minuted tibial spine fracture.

ted on the anterior tibial epiphyseal surface (Figure 6, F). The surgeon

mayr need to pull the entrapped medial meniscus or the transverse menis-

cal ligament anteriorly from under the fracture with an arthoscopic probe during the final reduction maneuver. 6. Knee stability is tested, and the fracture fixation strength is tested

though a full range of motion. Ideally,

fixation should be secure enough to allow immediate range of motion of the knee. Figure 7' shows the fracture depicted in Figure l, B anatomically

reduced into a position that remains stable after stress testing.

'7. Adhesive skin closure strips are placed over the arthroscopic portals, and the tibial suture tunnel incision is sutured closed.

Cannulated Screw Fixation Cannulated screw fixation is best suited for tibial spine fractures that have a large bon}F spine fragment attached to the ACL, as viewed on a lateral radiograph (Figure 2, A), a CT scan, or an MRI {Fig-

ure 2, B). The following five steps apply

only to screw fixation:

1. Art accessory portal for screw insertion is made directly medial to the equator of the patella with the knee at 60“ to 90°. 2. A guide pin for a 4.fl- or 45-min cannulated screw is placed through the medial parapatellar portal down into the fracture fragment. Care must be taken to ensure that the guidewire is not touching the femoral condyle because subsequent drilling and screw

(fl) 2013 American Acadmy of firthopaedic Surgeons

into the anterior rim of the fracture crater

without passing through the growth plate (all-epiphyseal).

placement will scuff the condylar cartilage. The fracture is reduced with a microfracture awl, and the guide

pin is advanced into the fragment. The guide pin is placed about 5 mm posterior to the anteromedial edge of the fracture fragment. If the bone is

solid. the fracture fragment (only) is

predrilled over the guide pin before placing the screw with a 3.2-mm cannulated drill. It may be helpful to temporarily hold the fracture in the reduced position with a 0.062-in K-wire placed in a position that will not interfere with the guide pin or the cannulated screw. 3. A cannulated depth gauge is used to expand the soft tissue around the

guide pin and measure screw length,

which is usually 22 mm if it is not

6??

Section 8: Pediatric Orthopaedics

Figure 6 AP (A) and lateral (B) radiographs show two epiphyseal tunnels drilled percutaneously with an anterior cruciate ligament (ACL) guide and a guide pin anteromedial and anterolateral to the fracture. Tunnels are placed only in the epiphysis, with both tunnels medial to the patellar tendon. B, Lateral view that shows the same two epiphyseal bone tunnels from a different angle. (2, Hewson suture passers are placed up through the tibial tunnels using a drill guide so the tunnel is not lost in the soft tissue during the guide pin—to-Hewson passer exchange. D, Reinforced suture is placed with a 90° suture passer through both Hewson suture passers and the ACL at its insertion into the tibial fracture fragment. E, Reinforced suture is drawn down into the tunnels with the Hewson passers and exits at the tibial skin incision. F, Sutures are tied

securely over a bone bridge in the epiphysis.

crossing the growth plate. A long

thread or fully threaded screw with a washer is used. lfbone purchase is

weak, a larger diameter screw should be used, or the screw should be placed

across the growth plate into the tibial metaphysis {Figure 8). Care should be taken to ensure that the screw or

guide pin does not overpenetrate the posterior wall of the proximal tibia, which can put the popliteal vessels at risk. Lateral view fluoroscop)ir can underestimate the protrusion of the screw or guide pin. As the cortex is

approached, the knee is rotated 3t]a

EEG

internally and externally to make

aids in identifying and removing the

relative to the tibial posterior cortex is caught. Any screw that crosses the open proximal tibia growth plate must be removed approximately 3 weeks later to avoid growth arrest. The screw head can also cause notch

Cally at a later date. Parilch“ has described an alternative technique for arthroscopic washer removal.

sure the true position of the device tip

impingement, and a small notchplasty may be necessary. Proper screw placement is continued with arthroscopy (Figure 9) and fluoroscopy.

4. Tying a nonabsorbable suture around

the washer and leaving a Z-cm tail

screw and the washer arthroscopi-

5. Adhesive skin closure strips are placed over the arthroscopic portals, and the accessory midpatellar portal, which is slightly larger, is sutured. Open Surgical Fixation l[)pen fixation of tibial spine fractures may be necessary if the fracture fails to

reduce with arthroscopic treatment. The

(fl) 2013 American Academy of flrthopaedic Surgemts

Chapter 104: Surgical Reduction and Fixation of Tibial Spine Fractures in Children

Figure 7 Postoperative lateral radiograph shows the tibial spine reduced into position after the placement of two reinforced sutures.

Figure ti Postoperative fluoroscopic image shows anatomic reduction of the fracture with secure fixation to the posterior metaphyseal cortex. Notice that the guide pin starts just medial to the patella at its equator. Caution must be exercised to avoid overpenetrating the posterior metaphyseal cortex with the guide pin or the screw, which could cause serious neurovascular injury.

best approach is usually through a me— dial parapatellar incision because the fracture is usually most displaced on its

blunt joker elevator can be used to initially open up a space within the joint in

tight working area, the use of a headlight is strongly recommended. Army—Navy or Langenbeck retractors are used for tissue retraction. Visualization is improved by partially removing the the fat pad and

the adhesions from the articular surface,

anteromedial aspect. Because of the deep,

the synovium that overlies the fracture.

The fragment is usually much deeper than expected. Care must be taken not to injure the medial meniscus during the deep incision into the capsule. Fixation should be similar to that described for the

arthoscopic suture and screw techniques.

Complications

Knee stiffness secondary to arthrofibrosis is a rare and perilous complication of arthroscopic treatment of tibial spine fractures. This risk may be minimized

by delaying surgical fixation until the

patient regains motion and the effusion resolves, similar to arthofibrosis preven-

tion with ACL tear surgery. Patients who do not regain 5" to 9113" motion by 3 to 4 weeks after surgery should undergo a very gentle manipulation under anesthesia. If any significant resistanoe to motion is present, an arthroscopic lysis of adhesions is performed before manipulation. This should minimize the risk of distal femur growth plate fracture, which is a pitfall. Adhesions within the joint can become adherent to the joint surface. A

which to place the arthroscope. A rotary

shaver is then used to carefully remove allowing gentle manipulation. An epi—

dural, continuous passive motion, and

aggressive physical therapy can be used to maintain and improve motion after the lysis of adhesions and manipulation under anesthesia. Loss of full extension and joint laxity can be asymptomafic complications of surgical treatmentlim

Postoperative Care and Rehabilitation

Every effort should be made to obtain secure fixation of the fracture with either two No. 2 reinforced sutures or with a 4.0—{4.5—mm cannulated screw and

washer. To avoid postoperative stiffness, the patient should move the knee after

3 days of rest. I have the patient start

physical therapy on postoperative day 3 with toe-touch weight hearing. I do not restrict active or passive motion. I have patients wean out of the brace within 1 week. I allow full weight bearing at about postoperative week 6.

Pearls *-

Due to the risk of arthrofibrosis, surgi-

cal treatment should be delayed until the hemarthrosis has resolved and the patient has regained most knee mo— tion (3:90“ arc of motion). If the patient

tfli 2013 American Academy of firthopaedic Surgeons

Figure '9 Al'tl'lrt‘ifit‘i‘ipit‘. viEw shows an anatomically reduced and securely fixed tibial spine fracture with screw. With secure fixation, the patient may start immediate range-of-motion exercises to avoid stiffness

and arthrofibrosis.

has not achieved 90" of knee flexion or more than 5° of knee extension by 3 to 4 weeks postoperafively, consider arthroscopic lysis of adhesions followed by a knee manipulation under anesthesia. Knee manipulation alone may cause a distal femur growth plate fracture. - In the suture fixation technique. during the step when the ACL tibial guide pin is exchanged for the Hewson suture passer, a fracture drill guide is placed over the guide pin before the exchange to maintain the alignment of the bone tunnel to ease passage of

the suture passer into the tibial bone

tunnels. '- For screw fixation, it may be helpful to hold the fracture in the reduced position with a 0.062-in K—wire placed in a position that will not interfere with the guide pin or the cannulated screw. - If the meniscus or the intra-meniscal ligament is entrapped in the fracture, it should be pulled anteriorly out of the fracture with an arthroscopic probe during the final reduction step of the procedure. - Care must be taken to ensure that the guidewire is not touching the femoral condyle because subsequent drilling and screw placement will scuff the cartilage. ' In my experience, approximately 50%

of the time the epiphysis alone will not

support screw fixation, and the screw must cross the growth plate and gain purchase in the tibial metaphysis. I Both screw and suture fixation need to be very secure to allow early motion exercises, which may minimize

the risk of arthrofibrosis and stiff631

Section 8: Pediatric Orthopaedics

References

1. Wilfinger C, Castellani C, Faith 1,. Pi]hatsch A, Hiillwarth ME, 1tr'tieinberg AM: Nonoperative treatment of tibial spine fractures in children: 38 patients with a minimum follow-up of 1 year. J Orthop Trauma 2009;23t7):519—524.

hi

. Willis RB. Blokker C, Stoll TM, Paterson

DC, l(Salpisn RD: Long-term follow-up of anterior tibial eminence fractures. I Pediair OrthOp 1993333561664. to

. Vargas B, Lutz N, Dutoit M, Zambelli PY:

Nonunion after fracture of the anterior tibial spine: Case report and review of the literature. I Pedfafr Drfhop B 2009;13{2): t“-

90-92. Tudisco C, Giovanuscio R, Febo A,

Savarese E, Bilcchia S: Intercondflar

U1

pin or the screw must be avoided; this could cause serious neurovascular injury. Multiple lateral fluoroscopic views should be obtained in slightly different degrees of rotation to confirm that the pin and screw are not too long on an},r view. Placing a nonabsorbable reinforced suture around the washer aids in its arthroscopic retrieval at a later date.

eminence avulsion fracture in children: Long-term follow-up of 14 cases at the end of skeletal growth. I Pediatr Orthop B 2010;19t5}:403-403. . Rademakers NW. Kerkhoffs GM, Kager I, Goslings JC. Marti RK, Raayrmalcers EL: Tibial spine fractures: A long-term followup stud}:r of open reduction and internal fixation. I Drifter: Trauma 2009336):

203-2132 . Perugia D. Basiglini L, tiadala A, Fer-

I31

ness. Overpenetrating the posterior

metaphyseal cortex with the guide

retti A: Clinical and radiological results of arthroscoplicallfgr treated tibial spine fractures in childhood. lrrf Drflrop 2009;33f1]:243-243. Bong MR, Romero A, Kubiak E, et al:

Suture versus screw fixation of displaced tibial eminence fractures: A biomechanical comparison. Arthroscopy 2005;21(1tl):11?2-11?fi. . Mahar AT, Duncan D, Dita R, Lowry A,

Gillingham E, Chambers H: Biomechanical comparison of four different fixation techniques for pediatric tibial eminence avulsion fractures. j Pediatr Drifter:

measures-152.

. Vega JR, Irribarra LA, Baar AK, Ifiiguez M, Salgado M, Gena N: Arthroscopic

fixation of displaced tibial eminence fractures: A new growth plate-sparing method. Arffrroscopy EDflSfi-tfllj: 1239—1113.

10. Vander Have KL, Gr.tnlt=.~},r T], Kocher MS, Price CT. Herrera-Soto IA: Arthrofibrosis

after surgical fixation of tibial eminence fractures in children and adolescents. Am I Sports Med 2010:38(2):293-301.

11. Siparskyr PN, Kocher MS: Current concepts in pediatric and adolescent arthroscopy. Arthroscopy 2009;25(12):1453-1469. 12. Ahn 1H,. You IC: Clinical outcome of arthroscopic reduction and suture for displaced acute and chronic tibial spine fractures. Knee Sarg Sports Ttaamatnl Arthrosc 2005;13(2):116-121. 13. Lowe I, Iiiihaimsltyr G, Freedman A, Zion L Howard C: The anatomy of tibial eminence fractures: Arthroscopic observations following failed closed reduction. J Bone Joint Surg Am 20m;84(11}:1933-1933. 14. Parikh 5N: Arthroscopic removal of a cannulated screw and washer from the knee joint. Orthopedics 2Dlfl;33(9}:675. 15. Park H], Urabe K, Naruse K, Aikawa I, Fujita M, Itoman M: Arthroscopic evaluation after surgical repair of intercondylar eminence fractures. Arch Orthop Trauma Surg 200?;12?{9):?53—?52 16. Kocher MS, Foreman ES, Micheli L]: Lastitjyr and functional outcome after arthroscopic reduction and internal fixation of displaced tibial spine fractures in children. Arthroscopy 2fl03;19{lfl}:1085—109ll

(it 2013 American Acadmy of Drfhopaedic Eur-gems

Chapter 105 Treatment of Clubfoot Using the Ponseti Method Eloise Alexander Noneth, MD, MS

Kenneth I. Noonan, MD

Patient Selection

Indications

The Ponseti method is appropriate for treating all types of clubfoot. Ponseti casting may be used even in patients with teratologic clubfoot caused by spina bifi— da, arthrogryposis, or other syndromes.”

Furthermore, children older than 2 years and those with a history of surgically

heated clubfoot may be treated with Ponseti casting to minimize the extent of surgery or even prevent further surgery.“

Contraindications

There are no absolute contraindications to attempting Ponseti casting, although the benefit of casting to an individual patient must be considered. Delaying casting until the patient’s condition improves may be prudent in premature infants; in infants with certain medical conditions, such as neonatal jaundice or poor feedingfgrowth; or in patients with unstable

cardiorespiratory status.

Evaluation

Clubfoot deformity has four components: cavus, forefoot adductus, hindfoot vows, and equinus (Figure 1). Patients should be thoroughly examined for underlying

Figure 1 Clinical photograph of an infant with idiopathic clubfoot demonstrates the characteristic deformities of cavus, metatarsus adductus, hindfoot varus, and

equinus.

etiologies, especially neurologic or muscular disorders. In a patient with idiopathic clubfoot, it is not necessary to obtain radiographs of the feet before proceeding with casting. Forced dorsiflexion lateral images may be helpful later in the casting process, im-

mediately before deciding whether or not percutaneous Achilles tenotomy is neces-

sary (Figure 2}.

Talipes equinovarus may be identified on prenatal ultrasonography as early as gestational week 12,. although the false positive rate is approximately 20%. More

than 50% of infants with prenatally iden-

parent’s lap or at the edge of the table for

application of the lower-leg portion of the cast and then recline into a supine position for extension to a long-leg cast. The percutaneous Achilles tenotomy that is typically performed at the end of the casting process to achieve adequate dorsiflexion may be performed with the patient under local anesthesia in clinic, under conscious sedation, or under gen-

eral anesthesia. Positioning is similar to that for cast application, with the difference that under anesthesia, the anesthesi-

ologist or sedation specialist, rather than

the parents, is positioned at the head of

tified Clubfoot are born with associated

the patient to control the airway.

or other musculoskeletal disorders.5

Special Instrumentlquipmentlr Implants For the typical patient, plaster cast material is preferable to fiberglass. In large children who are difficult to control or

anomalies, primarily neurologic, cardiac,

Procedure

Room SetuplPatient Fashioning Casting is typically performed with the patient lying supine on the table, with the

parents at the head of the patient to provide comfort measures {eg, bottle feeding, toys, singing). The patient's feet are at the edge of the side or foot of the table. Two practitioners are required: one to hold the patient’s toes and the other to apply the cast. Older patients may sit upright in a

Figure ’2

who are very strong, fiberglass may be

used to reinforce the plaster. For tenotomy, some practitioners use a

standard No. 11 or No. 15 blade; we prefer

a 5100 or 6900 eye blade. Sterilized cotton padding is used to dress the wound and pad under the cast following the tenotomy.

Forced dtrrsiflexitm lateral radiographs of two different clubfeet before

percutaneous Achilles tenotomy. A, Apparent dorsiflexion due to midfoot breach is seen, with persistent calcaneal pitch in equinus of 9°; a percutaneous Achilles tenotomy was performed. B, True dorsitlexion of greater than 15" is present, as evidenced by the normal calcaneal pitch;

a percutaneous Achilles tenotomy was not performed, and the patient was placed directly into

a foot abduction brace.

Dr. Nemetlr or an immediatefirmily member has received nonincome support fsuclr as equipment or services), commerciallyr derived lronomria, or other non—research—relatedfunding (such as paid travel)from Biomet. Dr. Noonan or an immediatefamily member has received royaltiesfrom Biomet; serves as a paid consultant to or is an employee of Biomet; lras received research or institutional support from Biomet; and serves as a board member, owner, oflicer, or committee member ofttre Pediatric Orthopaedic Society ofNorth America.

(it 2013 American Academy of Grtlropaedic Surgeons

Section 8: Pediatric Orthopaedics

L

'4:

Figure 3 Clinical photographs show complex Clubfoot. A, At birth, a deep plantar crease [black arrowhead} and posterior crease {white arrowhead) are present. B, After two casts, retraction of the great toe {B} and pronounoed cavus deformity (C) are evident.

Video 105.1 Treatment of Congent Clubfoot. Ignacio V. Ponseti, MD (24 min)

Surgical Technique Serial Casting First, the foot is stretched. One hand is used to abduct the foot (the right hand

for the right foot, the left hand for the left

foot), with the index finger placed along the medial aspect of the foot and the third, fourth, and fifth fingers supporting the plantar aspect of the foot. The contra-

lateral hand is placed with the index fin-

ger behind the lateral malleolus and the thumb over the lateral head of the talus. Care is taken not to apply counterpres— sure over the lateral portion of the calcaneus because this will prevent correction

of the deformity through the subtalar joint, the key to Ponseti correction."

For the first casting, the first rayr should be elevated to correct the cavus deformity. During all subsequent sessions, the first ray should remain elevated, keeping all the metatarsals aligned. This will pre-

vent regeneration of the cavus deformity

and rotation of the talus under the tibia as the foot is abducted. After the foot has been stretched, a cast is applied to maintain the foot in the po— sition of maximum stretch without overstretching. Starting at the toes, the lower

leg is wrapped with two or three layers

of cotton padding over the fingers of the practitioner who is holding the toes. Plaster is applied in two or three layers while the foot is held in the same man— ner as during stretching (supporting the

foot against counterpressure over the lat-

eral head of the talus, although persistent pressure should be avoided so as to not cause pressure sores). With the foot held with an abduction moment across the talar head, the cast is meticulously mold— ed around the malleoli and posteriorly above the calcaneus.

684

The short-leg cast is then extended into

a long-leg cast, up to the groin, with the

knee flexed at 9B“. In larger or stronger children, an anterior splint of four layers of plaster is applied over the knee during circumferential casting to provide additional strength but minimize bulk in the popliteal fossa. Cast material should be trimmed away from around the toes dorsally and along both sides, leaving a plate under the toes, to allow full dorsiflexion but maintain stretch of the toe flexors. The dorsal edge should not be trimmed proximal to the

web space of the toes because a tourni-

quet effect may occur, inducing swelling

of the foot. For complex and teratologic clubfeet, a posterior splint may be applied behind the lower leg and under the foot during cast-

ing. and the knee should be flexed 110° to

120° to prevent pulling back in the cast."r Casts are changed weekly, although more frequent dtanges are possible.“ Typically, four to six casts are required to achieve full correction. Once the foot has reached 60” to 170" of abduction relative to the sagittal plane and if there is less than 15° of dorsiflex— ion, a percutaneous Achilles tenotomy

is performed to correct the remaining equinus deformity. The final cast is ap— plied with the foot in the position of maximum dorsiflexion obtained following

the tenotomy and maximum abduction.

if the practitioner believes the foot is adequately corrected and may not need a tenotomy, a lateral radiograph of the foot in maximum dorsiflexion should be ob-

swollen, red, irritated, and difficult to cast. The patient may have a history of cast slippage or skin sores. The swollen foot will have a persistent plantar crease (Figure 3, A), the great toe may start to retract [Figure 3, B), and the cavus defor-

mity will remain pronounced (Figure 3,

C). At this point, recognition of a complex

clubt is important because modifications to the casting technique are necessary? If the clinician fails to recognize this and forces the abduction, metatarsus abductus will result. If complex clubfoot is recognized earlier, attempts to obtain 170" of abduction should be abandoned, and efforts should be focused on stretching the plantar and posterior contracture. The foot is stretched and held using the fingers of both hands. The thumbs of both hands are placed under the metatarsal heads, dorsiflexing the foot against counterpressure applied by both index fingers over the dorsum of the talar neck (Figure 4). The middle fingers are used to mold behind the malleoli and above the calcaneus posteriorly."' A posterior splint is applied behind the lower leg and under the foot. The knee should be flexed 110° to 120° to prevent pulling back in the cast (Figure 5). A percutaneous Achilles tenotomy is performed once the cavus is corrected and the foot has been abducted 40". Fur— ther abduction usually only deforms the

foot rather than providing additional correction? {Figure 6).

Four to eight casts may be required to achieve correction.

tained; 15“ of dorsiflexion should be pres-

Teratologic Clubfoot

Complex Clubfoot

tions described earlier for complex clubfoot as necessary if retraction of the great toe or accentuation of the cavus deformity is noted. Percutaneous Achilles tenotomy is performed once 40° to 60° of abduction has been obtained.

ent without midfoot breach (Figure 2).

As treatment progresses, changes in the foot morphology may arise that lead to the characterization of a oomplex club— foot. Following the first or second cast, the clinician may notice that the foot is

Casting is performed according to the Ponseti technique, using the modifica-

(El 2013 American Acadmy of Drfhopaedic Sat-gems

Chapter 105: Treatment of Clubfoot Using the Ponseti Memo-:1

Figure 4

Clinical photograph shows modified Ponseti casting technique for a complex clubfoot as seen medially (A) and anteriorly {B}.

Percutaneous Achilles Tenotomy Once the foot has reached the appropri-

ate degree of abduction (40° for complex

clubfoot, 60° to 70° for idiopathic clubfoot,

40° to 60° for teratologic clubfoot}, a per-

cutaneous Achilles tenotomy is indicated if the foot does not dorsiflex sufficiently (5° for complex clubfoot, 10° for terato—

logic clubfoot, 15° for idiopathic clubfoot).

A forced dorsiflexion lateral radiograph

helps to differentiate true ankle dorsifleion from apparent dorsiflexion due to midfoot breach, although it is always preferable to err on the side of performing the tenotomy [Figure 2). If the tenotomy is performed under local anesthesia, either topical lidocaine cream or an injection of lidocaine is administered. Topical anesthetic should be placed at least 20 minutes before the procedure. If injecting lidocaine, a minimal amount ((0.05 mL} should be injected to prevent obscuring palpation of the tendon margins. In some cases, it may be preferable to administer local anesthetic into the tenotomy site after the procedure.El The tenotomy site is prepared in a sterile manner. An assistant holds the leg with the knee flexed 90° and the foot in dorsi-

flesrion under light tension; excessive ten-

sion may obscure the tendon. The blade is inserted from a medial approach, immediately anterior to the

Achilles tendon, 1 to 1.5 cm above the

insertion of the Achilles on the calcaneus. A common pitfall is to fail to recognize that the insertion of the Achilles tendon is more proximal because of calcaneal elevation and thus the tenotomy site is more proximal. The blade should be inserted parallel to the tendon, taking care to avoid the posterior tibialis artery. This artery lies anterior to the tendon, be-

.

t . .1

Figure 5 Clinical photograph shows retraction of the foot within the cast in a patient with spina bifida. Note that the toes are no longer visible beyond the distal end of the cast.

hind the medial malleolus, and may be the only artery supplying the foot."J Once

the blade tip passes the lateral aspect of the Achilles tendon, the blade is turned

90° to make contact with the tendon {Figure '7', A). Alternatively the blade may be inserted at a 45° angle to the skin with the blade pointing posteriorly, toward the tendon. Once the blade has been inserted deeply enough to transect the tendon, the handle is lifted anteriorly, bringing the blade into contact with the tendon (Figure '5', B}.

The tendon is then transected in an anterior-to-posterior direction, taking care not to pull the blade through the tendon (and then potentially through the overlying skin]; instead, the clinician’s

contralateral finger or thumb is used to push the tendon through the blade. Cutting the tendon in this manner, as op-

posed to drawing the knife through the tendon, helps avoid inadvertent skin and

tendon penetration. An increase in dorsiflexion of 15° to 20° should be obtained (less in the complexfteratologic club— foot), and a "pop" is often noted. A defect should be palpable in the tendon.

@ 2013 American Academy of Unhopaedic Surgeons

Figure 6 Clinical photograph shows overabduction of the forefoot and iatrogenic deformity caused by abduction of a complex clubfoot beyond 40°. This deformity will

correct if the shoe is maintained at 40° of abduction during bracing.

Pressure is applied to stop any bleed-

ing, and the leg is cleansed with sterile water to remove any sterilizing solution that may cause chemical irritation of the infant’s skin. After residual bleeding has ceased, the lower leg is wrapped with sterile cotton padding and a short-leg plaster

cast is applied while the foot is held in

maximum dorsiflexion and abduction. The popliteal fossa is inspected for a high posterior trim line, which could lead to vascular embarrassment. The shortleg cast is extended into a long-leg cast

up to the groin with the knee flexed 90°.

The cast material is trimmed away from around the toes.

Complications Vascular

Vasospasm may occur following percutaneous tenotomy and forced dorsiflex685

Section 8: Pediatric Orthopaedics

A Figure '5" Illustrations demonstrate two techniques for percutaneous Achilles tenotomy in clubfoot deformity. A, In the first technique, the blade is inserted parallel to the tendon, followed by rotation of the blade to make contact with and transect the tendon. B, In an alternative technique, the blade is inserted at a 45° angle to the skin. The handle is then lifted anteriody to bring the blade into contact with the tendon and perform the transection.

Shoes for clubfeet should be externally rotated on the bar as far as the maximum abduction obtained during cast correction—ideally, 170° for idiopathic clubfeet, 4D“ to 50° for complex clubfeet,

and 40" to F0“ for teratologic clubfeet. The heels of the shoes are placed at shoulder width. In unilateral cases, the unaffected foot is abducted 30° (Figure Ill). Front-

Figure 8 Clinical photograph of an infant’s

foot following release of dorsiflexion during

casting after percutaneous Achilles tenotomy

Figure El Clinical photograph shows a heel sore following cast removal in a patient with spina bifida who was undergoing Ponseti casting for clubfeet.

for clubfoot. Pallor of the second and third

toes is seen; the first, fourth, and fifth toes

demonstrate return of blood flow. Perfusion of the seoond and third toes returned within

seconds.

ion, resulting in pale digits (Figure 3). Typically, reperfusion will occur once

the excessive dorsiflexion applied during

casting is released and the cast relaxes slightly. If reperfusion does not occur, the cast should be removed and reapplied. Parents should be advised to expect a small amount of blood spotting (no

larger than 2 cm in diameter) on the pos-

terior portion of the cast. Increased or prolonged bleeding should be evaluated because transection of the lateral vessels {lesser saphenous vein andfor peroneal artery) may have occurred? Pseudoaneurysm has been reported following percutaneous Achilles tenotomy.11 636

Cast Sores Pulling back in the cast can result in pres-

sure sores. Children with spina bifida may be especially susceptible because they typically have stiff feet with insensitive skin that predisposes to pressure sores (Figure 9).

Fractures Tibial fractures may occur in children with spina bifida.2

Postoperative Care and

entry shoes should be used for complex clubfeet; ankle-foot orthoses attached to an articulated bar should be used for teratologic clubfeet. The foot abduction brace is worn full time for 3 months, followed by nighttime and naptime wear until 4 years of age. Im-

proved compliance with recommended

brace wear has been demonstrated when close telephone and}for clinic follow-up is used to address problems with tolerance of brace wear.” Recurrence occurs in 30% of patients who do not wear the brace as recommended. Intolerance of the bar and shoes may oc-

cur if the foot is incompletely corrected

or the bar and shoes do not fit properly, or if the child excessively plantar flexes the foot, lifting the heel within the shoes.

Rehabilitation

The final cast, following percutaneous

Achilles tenotomy, should be left in place

for 3 weeks before removal to allow for healing of the tendon.12 After removal of the final cast, the child is placed in a foot

abduction brace. Multiple models of brac— es exist; some are specifically designed for use in children with clubfeet.

Recurrences are addressed by repeat casting. Repeat tenotomy may be indicated if less than 15° of dorsiflexion is present after repeat casting (c5° for complexfteratologic clubfeet). Repeat percutaneous tenotomy, which is performed only if the tendon is discretely palpable, should be done in the operating room. if the tendon is scarred and diffi-

(El 2013 American Acadmy of flrthopaedic 51113130115

Chapter 105: Treatment of lClubfoot Using the Ponseti Method

I

__-..._..

Figure 10 Photographs of foot abduction braces used following Ponseti casting for clubfoot. A, Positioning of the shoes on the bar. Affected feet are abducted to the degree of maximum correction. In this case, the right foot is abducted Til”; the unaffected (left) foot is abducted 30". B, Foot abduction brace that uses an articulated bar to allow independent movement of the legs.

cult to palpate, an open tendon dissection

and posterior release may be the more definitive approach. The use of a differ-

ent brace construct (front-entry shoes, articulated bar, ankle-foot orthoses, or a

combination of these) may prevent recur— rence after recasting. In instances of persistent recurrence

:- Good education of caregivers and

close follow-up improve compliance

with the recommended use of the foot abduction brace.

ous Achilles tenotomy, Achilles ten-

don lengthening, posterior release,

andfor anterior tibialis tendon transfer as necessary. A wide posterior and medial release should be avoided in

soft-tissue surgery is indicated. Achilles tendon lengthening and posterior release is used for equmus that is refractory to repeat percutaneous tenotomy. Transfer of the anterior tibialis tendon to the third cuneiform corrects persistent varus and

patients with residual foot deformity

because this can lead to overcorrec—

tion. Selectively releasing only those aspects involved in the recurrence

is performed once the first cuneiform has

of age; an Achilles tendon lengthening may be performed at the same time if indicated.

will avoid this pitfall.

References

1. Ianiclci IA, Narayanan UG, Harvey B, Roy A, Ramseier LE, Wright IG: Treatment of

neuromuscular and syndrome-associated {nonidiopathic} clubfeet using the Ponseti method. IPedfafr Drtlrop 2UD9;29{4}: 393-392

Pearls

- Pronafion of the forefoot should be

avoided during abduction; this will

I

re-create the deformity.

2.

cast removal to identify subtle pulling

method for the treatment of clubfoot as— sociated with myelomeningocele. I Bone Irn'nf Snrg Ant asasnrreaaamssa 3. Lourenco AF, Morcuende IA: Correc—

The foot should be assessed before back within the cast.

- After cast removal, the foot is examined and casting is adapted to correct the deformities identified in accor-

er) than others.

- The features of a complex clubfoot

must be recognized early in the casting process, and the casting technique 5110111111 be appropriately modified t0

correct the persistent cavus deformity

and prevent further deformity associated with overabduction.

Gerlach DI, lBurnett CA, Limpaphayom N, et 31: Early results of the Ponseti

tion of neglected idiopathic club foot by the Ponseti method. I Bone Ioint 5mg Br 2W;39[3]:323-331.

dance with the expected progression of correction, with an understanding that some feet correct slower {or fast-

tals of Treatment. New York, NY, Oxford

T".

4.

Garg B, Dobbs MB: Use of the Ponseti

method for recurrent clubfoot following posteromedial release. Indian I Orthap 2003;42t1}:63-?2. 5. Mammen L, Benson CB: Outcome of fetuses with clubfeet diagnosed by

prenatal sonography. I Ultrasound Med

2004;23(4):49?-Eflfl.

(El 2013 American Academy of Urtlropaadic Surgeons

Medical Publications, 1996. Ponseti IV, Zhivkov M, Davis N. Sinclair M, Dobbs MB, Morcuende IA: Treatment

- Recurrences should be treated early with repeat casting, using percutane—

refractory to repeated casting, limited

ossified, usually between 3 and 4 years

6. Ponseti IV: Congenital Clubfoot: Fundamen-

of the complex idiopathic clubfoot. Clin Orlftop Relat Res 2006;451:171-126. 3.

Morcuende IA, Abbasi D, Dolan LA, Pon-

seti IV: Results of an accelerated Ponseti protocol for clubfoot. I Padfalr Grtlrap 2005;2fif5):623-626. 9.

Dobbs MB, Gordon IE, Walton T,

Schoeneclcer PL: Bleeding complications following percutaneous tendoachilles tenotorny in the treatmmt of clubfoot deformity. I Psdiatr {Jr/tbsp 2004:2491): 353-352 10. Greider TD, Siff SI, Gerson P, Donovan

MM: Arteriography in club foot. I Bone Joint Sarg Am 1982;64{6}:83?-340. 11. Burghardt RD, Herzenberg IE, Ranade A: Pseudoaneurysm after Ponseti percutaneous Achilles tenotomy: A case report. I Pediatr Orthop 2BDB;28(3):366-369. 12. Mangat KS, Kanwar R, Johnson K, Korah

G, Prem H: Ultrasonographic phases in gap healing following Ponseti-type Achilles tenotomy. I Bone Iofnt Surg Am

moonstone-1461

13. Hobbs NIB, Rudzki IR, Purcell DB, Walton T, Porter KR, Gurnett CA: Fac-

tors predictive of outcome after use of the Ponseti method for the treatment of

idiopathic clubfeet. I Bone Iofnt Surg Am 2004;Bfi[1}:22-21

Video Reference 105.1

Ponseti IV: Video: Mutant of Congen-

ital Clulg‘oot. Rosemont, IL, American

Academy 0f Orthopaedic Surgeons: 2002.

63'?

Chapter 106

Treatment of

Tarsal Coalitions Scott }. Mubarak, MD

Patient Selection

Patients who present with tarsal coalitions have myriad presenting symptoms,

but the most common include foot pain,

foot deformity, and a history of an injury or multiple injuries to the ankle or foot. The orthopaedic surgeon must always be suspicious of a tarsal coalition in a teen-

ager with multiple ankle sprains.

The history should alert the orthopaedic surgeon to the possibility of a coalition, but the physical examination will all but confirm its presence. A stiff flatfoot is the hallmark of a foot with a tar-

sal coalition. This is especially dramatic

in presentation when the pathology is unilateral (Figure 1). The findings for a calcaneonavicular coalition are restricted subtalar motion; a palpable, often ten— der, bony ridge in the sinus tarsi; and

restricted plantar flexion of the affected

foot compared with the unaffected siclel'3 (Figure 1, B). A patient with a talocalca-

neal coalition may present with a tender bony prominence around the sustentaculum tali {just below the medial malleolus) and, of course, restricted subtalar

motion. Any of these findings should

prompt further diagnostic imaging, as discussed below.

In my opinion, nonsurgical treatment

of a symptomatic tarsal coalition does

not benefit the patient long term. Periods of immobilization may provide tempo— rary relief but do not address the altered mechanics that can cause adjacent joint degeneration. I also believe that patients

with coalitions are at risk for future foot!

ankle injuries due to the coalitions. I recommend excision in all young patients.

Preoperative Imaging

Much has been written about diagnostic imaging of tarsal coalitions. Both the calcaneonavicular and talocalcaneal coali-

tions have radiographic signs named for

dence on a CT. Sometimes MRI will show fibrocartilaginous coalitions not seen on CT scan. The spectrum of each type of coalition as seen on diagnostic imaging is detailed in two articles. Upasani et al3 described calcaneonavicular coalitions {Figure 3),

and Rozanslcy et al‘I described talocalcaneal coalitions (Figure 4).

Procedure

Room SetuplPatient Positioning The patient's foot should be positioned near the end of the operating table in

such a way that the surgical team can be

them: the anteater sign {Figure 2, A} and

seated for the procedure. The patient's entire limb is prepared and draped from the anterior superior iliac spine distally.

of both feet and, if at all possible, three-

Speclal Instrurnents!Equipmentlr Implants A C—arm should be available if needed to identify the subtalar joint with a talocalcaneal coalition and for complete removal of a calcaneonavicular coalition. Useful instruments include Kerrison rongeurs

present. MRI may be useful for a patient

speed burr [3 or 4 mm], which is helpful for a large talocalcaneal coalition. Additional helpful instruments include Freer

the C—sign (Figure 2, E}, respectively.2 Plain radiographs can be helpful screen— ing tools, but I believe that all patients going to the operating room for resection of a coalition should have a CT scan dimensional reconstructions of those images. These images are extremely useful not only to delineate the extent of the coalition in three dimensions but also to ensure that multiple coalitions are not with stiff talar motion but no obvious evi-

(3 or 4 mm), osteotomes, and a high-

Figure 1 Clinical photographs of a patient with a unilateral calcaneonavicular coalition. In the supine position, the affected foot [arrows] fails to form an arch (A) and has diminished plantar flexion {B}.

Dr. Mubarak or an immediatcfirnrily member has stock or stock options field in Rhino Pediatric Orthopedic Designs.

(El 2013 American Academy of Grthopaedic Surgeons

639

Section 8: Pediatric Drthopaedics elevators, small Hohmann retractors, Bo-

vie electrocautery, and an Allis clamp.

Surgical Technique A sterile tourniquet is placed on the proximal thigh. After Esmarch exsanguination and tourniquet inflation, the initial foot incision is made.

Figure 2

Radiographs demonstrate typical findings of a tarsal coalition. A, The

calcaneonavicular coalition is demonstrated on the internal rotation oblique view {arrow}.

B, The C-sign, observed on a lateral view, indicates a talocalcaneal coalition. This sign is present when the posterior margin of the talus appears to be continuous with the sustentaculum tali (arrows). The C-sign can also be seen in flexible flatfoot.

Calcaneonavicular Coalition Resection The approach for calcaneonavicular excision follows the technique described by Mubarak et a].I An oblique modified Ul— lier incision is made over the site of the coalition, along the Langer lines (Figure 5, A). The location of this incision is just distal to the sinus tarsi overlying the coalition. This incision is taken down to the level of the extensor digitorurn brevis (EBB) fascia, with careful dissection to

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avoid the lateral branches of the super-

ficial peroneal nerve. After releasing the

origin, the EDB is elevated from proximal to distal. The coalition should be visible beneath the reflected EDB (Figure 5, B). The three—dimensional CT reconstructions obtained preoperatively should be available in the operating room to aid in

delineating the appropriate plane of dis-

section {Figure 5, C). Prior to resection, the surgeon should

identify the synchondrosis junction between the calcaneus and the navicular. A curet or rongeur can be used to

unroof the periosteum, revealing the cartilaginous interface (synchondrosis) Figure 3 Classification of calcaneonavicular coalition {circled} according to Upsani et al"' based on three-dimensional CT reconstruction images.

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(Figure 6, A). This line should mark the center of the resection. Next, the cal-

caneocuboid and talonavicular joints should be identified. Two Freer elevators used as retractors are placed around the coalition into these joints. With the joints protected, the resection can proceed. Initially, a 1-cm osteotome can be used to

resect the coalition. As the depth of the bridge is approached, a 0.5—cm straight Lambotte osteotome is used (Figure 6,

B). Care must be taken to not damage the

underlying cuboid, which may be promi-

nent, or the head of the talus. This normal cuboid prominence is present with a type 1 (forme fruste) coalition? In more com-

Figure 4 Classification of talocalcaneal coalitions according to Rosansky et al'} based on coronal and three-dimensional CT scans.

plete coalitions, the cuboid has a truly cuboid shape and therefore is less likely to be injured by the osteotome in the field of resection. Once the wedge is removed, subsequent dissection is performed with 3- or 4-mm Kerrison rongeurs until the resection is complete {Figure 6, C). A gap of about 1 cm x 1 cm is usually required before stopping. Fluoroscopic images should be obtained at this time. The most

(El 2013 American Academy of flrthopaedic Sn-Igemts

Chapter 106: Treatment of Tarsal Coalitions

Figure 5 Calcaneonavicular coalition resection: approach and exposure. A, Clinical photograph shows a plan nccl reverse DI licr incision, within the Langer lines. B, Intraoperative photograph shows the extensor digitorum brevis elevated off the coalition by proximal release at its origin. The coalition is visible directly beneath the elevated muscle. C, Example of a three-dimensional CT sca n; such images are invaluable for ensuring that the intended plane of dissection is the correct one.

C

D

Figure I5 Calcaneonavicular ooalition resection. A, Photomicrograph of a svnchond rosis retrieved during surgical resection of a calcaneonavicular coalition (Ca = calcaneus, Co = coalition, N = navicular]. E, a small Lambottc osteotorne is used to remove the first wedge of

bone. (2, Final resection of the coalition is performed with Kerrison rongeurs. True excision is confirmed with a range-of-motion examination and an internal oblique fluoroscopic image {D}.

helpful view is the internal oblique view (Figure 6, D).

The hindfoot range of motion is now examined and compared with the pre— operative measurements. Near normal

range-of-mofion values should not be

expected at this point, but the surgeon should be able to visualize that the calcaneus and navicular now move indepen— dently. The fat graft is harvested (see below}

and prepared for insertion. The fat should

(fl) 2013 American Academy of firthopasdic Surgeons

be tucked into the gap; there should be enough fat to fill the gap complete (Figure 7,. A). The EDB fascia is then su-

tured back into its normal position with

G 1‘r’icrvl {Ethicon} absorbable sutures (Fig-

ure 7', B). The BBB fascia must be sutured 691

Section 8: Pediatric Orthopaedics

Figure '? Intraoperative photographs demonstrate calcaneonavicular coalition excision: Fat graft. Intraop-erative photographs show the fat graft placed within the cavity,' (A) and the extensor digitorum brevis repaired back to its origin (B).

A

Flexor d 59 itamm Ian 9'15

Figure 8 Illustrations show talonavicular coalition: approach and exposure. A, A curvilinear incision is marked out overlying the coalition. B, The tibialis posterior tendon is retracted dorsally. The flexor digitorum longus is usuallyr retracted plantarly. C, Once the deep flesor digitorum longus sheath is incised, the coalition is exposed, and small Hohmann retractors

C back down appropriately or the normal contours of the foot will be altered. leav—

ing a less cosmetic result. The skin is approximated with a 3-0 Vicryl suture.

followed by a running subcuticular skin

closure with a 3-D Monocryl {Ethicon}

suture. Adhesive skin closure strips are then applied to the wound, followed by a sterile dressing. The patient is placed in a synthetic short-leg cast, which is split to allow for swelling. The tourniquet is de692

are placed Praliifliflll}? and distally.

flated, and the graft site wound is closed as described in the Fat Graft Harvest section. Talocalcaneal Coalition Resection An incision is made over the sustentaculuIn tall about 1.5 to 2 cm distal to the medial malleolus {Figure 3,. A). Often, a

palpable prominence can be felt approxi— mately 1.0 to 1.5 cm inferior to the medial malleolus. The incision should be long

enough to expose the medial facet and often the entire subtalar joint. My preferred technique" is based on the technique first

described by Dlney and Asher? The incision is taken sharplyr through the skin. Where the path of the incision is

inferior to the saphenous vein, the cross-

ing branches of the vein should be identified and coagulated with a Bovie cautery. The tendons of the tarsal tunnel are then identified within their sheaths The pos-

o 2013 American Academy of flrthopaedic 51113130115

Chapter 106: Treatment of Tarsal Coolitions

h:l

a.

Figure 9 Images demonstrate talonavicular coalitiq resection. A, Initial resection is performed with an osteotome. Illustration {B} and intraoperative photograph {C} show the completed resection. Resection is not complete until the posterior facet is visualized and motion can be seen to occur within the subtalar joint.

terior tibial tendon should be freed from its sheath and retracted dorsally. The flexor digitorum longus tendon is identified in its sheath by extending the toes

and observing movement of the tendon

within its sheath. The sheath is incised in

line with its fibers, and the tendon can be

retracted plantarly as needed for the exposure of the coalition (Figure 8, B). The deep sheath is then incised, exposing the middle facet coalition.

To completely wow the coalition, further

dissection posteriorly is necessary. The flexor hallucis long-us lies just below the coalition and the neurovascular bundle just posterior. Small Hohmann retractors are then placed around the coalition (Figure 8, C). With good exposure, the surgeon should be able to identify the borders of the medial facet proximally and distally. In all coalitions except the completely osseous coalitions (type IV: representing 11% of talocalcaneal coalitions), a synchondrosis is visible.“ Check-

ing the preoperative three-dimensional

CT scan is exceptionally helpful at this

time. The surgeon can easily become "lost” during the resection if the relationship of the synchondrosis plane relative to the true subtalar joint is not well understood. A combination of osteotomes, Kerrison rongeurs, and high-speed burrs are now

used to remove the coalition. I prefer to start with osteotomes (Figure 9, A). The

amount of bone resected and the plane in which it is resected depend on the type of coalition and the extent of involvement of the sustentaculum and talus. Some coalitions can be very large (up to 3 cm in length and 2 cm in depth). Once the coalition is identified, resection is con-

tinued until the articular cartilage of the joint is visualized anteriorly and posteriorly (Figure 9, B and C}. This is especially

crucial posterior-1y. My experience is that if a small posterior hook is left unresect— ed, it will continue to restrict subtalar

motion. The advantage of being able to see the entire medial coalition cannot be overstated; a complete resection must be performed to ensure maximal benefit to the patient. The range of motion of the hindfoot is assessed continually throughout the resection. A Freer elevator can be inserted around and through the middle facet clefect into the posterior facet to liberate capsular adhesions and ”free up" the joint. Great care is taken to not strip the inter— osseous ligament. Dnce range of motion is significantly improved and the entire posterior facet is visualized, the surgeon may stop the resection. The fat graft is harvested as described below and prepared for insertion. The fat graft should fill the space of the resection (Figure ID). The graft is held in place with a Freer elevator while the overlying layer (the tendon sheath] is closed with a No. 1 Vicryl suture. The skin edges are approx-

Figure 10 The harvested fat is plaoed within the spaoe left following resection of the coalition.

This is an easier location for obtaining the fat, but the scar is more obvious to the

patient. The size of the fat graft required is generally 3 cm x 1 cm x 1 cm for calcaneonavicular coalition resections and

slightly smaller for talocalcaneal coalition resections.

imated with a 3-D 1ivficryl suture, and a

A 4-cm incision is made in the gluteal crease and taken through the dermis only. Elevation of the dermis off the fat proximally in the buttock is then per-

and the graft site wound is closed as de-

hole the skin. This dissection should be performed to approximately 1 cm on all sides of the wound. Once this has been done, an Allis clamp is clamped on the fat at one corner of the wound. With the help of traction on the fat, a 3-cm-long x l-cm-wide x 1-cm-deep fat graft is resected. The fat is passed off in a moistened sponge. The wound is packed off until after the foot wound is closed. After closure of the foot wound and removal of the

running 3-H Monocryl suture is placed in the subcutaneum. Adhesive skirt closure strips cut to one-third length are placed over the foot. The tourniquet is deflated, scribed below. The patient is placed in a synthetic short-leg cast, which is split to allow for swelling.

Fat Graft Harvest

After resection of the coalition, a fat graft is obtained. I prefer to harvest the fat graft from the gluteal crease on the ipsilateral

side. This leaves a very cosmetic scar, and

there is always enough fat in this region, even in the thinnest of patients. In obese patients, abdominal fat from the lower abdominal crease can be considered.

(fl) 2013 American Academy of Grilmpaedic Surgeons

fonned, with care taken to not button-

tourniquet, the buttock wound is closed

subcutaneously with U and 3-0 Vicryl sutures, and a running subcuticular

693

Section 8: Pediatric Orthopaedics closure of the skin is performed with a 3-0 Monocryl suture. I usually also use several 0 Vicryl skin retention sutures to prevent dehiscence because of the stretch on this wound. Adhesive skin closure strips are placed over the wound, and a dressing is applied.

Pearls

Complications

-

Early problems include occasional wound dehiscence from the buttocks if retention sutures are not used. Wound infections are extremely rare. Possible long-term problems include continued pain, stiffness, and deformity

(usually pes valgus). If the pain persists,

further workup, including CT scans, may

be necessary to rule out coalition recurrence or incomplete removal.

Postoperative Care and

Rehabilitation

A below-knee synthetic cast is applied and univalved. All patients are admitted overnight for pain control and observation. The patient is made weight hearing as tolerated and is encouraged to walk on the cast. The patient returns at 1 week for cast closure and at around 2 to 3 weeks for cast removal, after which patients are

encouraged to begin active ankle and subtalar motion. They are counseled to expect that the foot will not feel "normal" for up to 6 months. At 6-week follow-up,

the patient is cleared for activities as to]erated. Some patients may require physical therapy if return of motion is slow. The patient is seen at 3 months, 6 months,

and 1 and 2 years postoperatively for ex— amination. Radiographs are obtained at approximately 1 year postoperatively.

I For each type of resection, understanding the subtypes [as shown in Figures 3 and 4] will help avoid pitfalls. -

In type I calcaneonavicular coalitions,

the cuboid prominence should not be excised; it is not pathologic.

In

talocalcaneal

coalitions,

three-

dimensional CT reconstructions are invaluable to help avoid becoming lost and resecting too much normal talus or calcaneus. ' Type II and V talocalcaneal coali-

tions have a posterior component The

preoperative My preferred method is the "triple C" (calcaneal-cuboidcuneiform} osteotomyfJr

References 1.

coalition: Treatment by excision and fat graft. I Pediatr Orthop 2009;29t5):413-426. 2.

ankle. Radiology 1994;193{3):347-351. 3.

normal subtalar joint will soon present itself. l Severe preoperative pes valgus will not improve after resection. The family must be consulted on this impor-

tant point before any surgery. I When lateral anklex'foot pain or defor-

Upasani W, Chambers RC, Mubarak SI:

Analysis of calcaneonavicular coalitions using multi-planar three-dimensional computed tomography. I Child Orthop 2003;2(4):301-301

tion.

al fluoroscopic images may help. The

Lateur LM, Van Hoe LR, 1it"an Ghillewe

ICU: Gryspeerdt SS, Baert AL, Dereyrnaeker GE: Subtalar coalition: Diagnosis with the C sign on lateral radiographs of the

posterior facet must be visualized to ensure complete resection of the coali*- Type IV talocalcaneal coalitions do not have a visible physis to guide the resection. The anterior and posterior borders of the coalition should be identified and visualized and small Hohmann retractors inserted. The surgeon should begin with small rongeurs (eg, Kerrison] and proceed along the line connecting the Hohmann retractors. intraoperative later-

Mubarak 5], Patel PN, Upasani W Moor MA, Wenger DR: Calcaneonavicular

4.

Rozansky A, 1Farley E, Moor M, Wenger

DR, Mubarak S]: A radiologic classifica-

tion of talocalcaneal coalitions based on 3D reoonslruction. J Child Orthop 2010:4{2):129-135. 5. Gantsoudes GD, Roocroft II-I, Mubarak 5]: Treatment of talocalcaneal coalitions. I Pediatr Orthop 2012333301307. 6. Dlney BW, Asher MA: Excision of symp— tomatic coalition of the middle facet of the talocalcaneal joint. I Bone [obit

Surg Am 193?;fi9(4):539-544. 7.

Rathjen KE, Mubarak S]: Calcaneal-

cuboid-cuneiform osteotomy for the correction of valgus foot deformities in children. I Pedintr Urihop 1998;18{6): ”5-5732.

mity is still present at E to 12 months postoperatively, I recommend correction. About 20% of calcaneonavicu— lar coalitions need further corrective surgery because of deformity present

(it 2013 American Acadmy of Drthopaedic Sui-gems

Chapter 107 Lower Extremity Surgery in Children

With Cerebral Palsy Nirao K. Pandya, MD

Henryr {3. Chambers, MD

Introduction

Cerebral palsy {CP} is an abnormality of

motor function that results from an insult to the brain during early development. The musculoslceletal manifestations of this disorder are progressive. Surgical management of the lower extremity in

GMFCS E & R between 6'" and 12" birthday: Descriptors and illustrations

GMFCS Level I museum-ammunWJMcmdhbstflsIflIMllflfll atflqflflmpfiumguflflnflta

these patients requires a thorough understanding of the indications for these

procedures and how the procedures will affect the functional status of these patients. Surgery should be delayed as long as possible l(until the patient is older than 6 years), and spasticity management

Mullah-d

6&1.c Lmlll

(Hawthmmfldmm Wmarflnmmwm finglmgdntumndhllammgonm mmMmhommorcMImu-L Wmmmmuflmawm mwmtuummmmmm mmmmmmom

should be used as an adjunct to surgery. Wu multiple deformities exist, single-

stage surgery is recommended to prevent decompensation from unbalanced correction. Traditionally, the patient with CP is classified based on the Gross Motor Functional Classification System {GMFCS),' which assigns patients with CF to one of five functional groups based on self-initiated ambulatory function and postural con— trol (Figure l). The Functional Mobility Scale (FlrI'S)1 also rates ambulatory ability at 5 m, 50 m, and 500 m, giving a more dynamic assessment of a patient's mohfl-

mmflifinflrasmmm

GMFCS Lmllll

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GMFCS Level IV

MHHMHMIIVMM

“mommmhmm

mockiommummm

ity (Figure 2).

mmmwmmdmyoramw mmmmmmmh

The combination of these two scales can help to define quickly and re— producibly the ambulatory status of patients with CP. This is important, because the type of surgery recommended

hmndflmuvminw

Wmmmmm

GMFCS Level V

Mocamdhamm

for the patient with CP depends largely

on whether the patient is ambulatory

honour-rum ' Infidel-1m “museums.

(GMFCS levels I through III) or nonambulatory (levels IV and V). Whereas

the goals of surgery in the ambulatory patient are to improve or maintain the patient's ability to walk, nonamhulatory surgery is performed to increase comfort, positioning, sitting balance,

and posture. Using ambulatory proce— dures in a nonambulatory child (and vice versa} may lead to significant loss of function.

Figure 1 The Gross Motor Function Classification System {GMFCS} for cerebral palsy. A, Levels I through III {ambulatory}. B, Levels N and V (nonambulatory). E at: R = expanded

and revised. [fit Kerr Graham, Hill Reid and Adrienne Harvey, The Royal Children's Hospital, Melbourne, Australia. Date from Falisano R, Rosenbaum E Walter 5, Russell D, Wood E,

Galuppi B: Development and reliability of a system to classify gross motor function in

children with cerebral palsy 199?;39[4]:214-223 and data from CanChild Centre for Childhood

Disability Research Insh'tute for Applied Health Sciences, Ontario, Canada.)

Dr: Pantiya or an immediatefamily member serves as a board member, owner, oflicer, or committee member of the Pediatric Orthopaedic Society of North America. Dr: Chambers or an immediate fizmiiy member serves as a paid consultant to or is an employee ofAHergan, Mere Pharmaceuticals, and Orthopediatrics, and serves as a board member, owner; ofiicer; or committee member of the American Academy of Orthopaedic Surgeons, the American Academyfor Cerebral Palsy and Deteiopmentat Medicine, and the Pediatric Orthopaedic Society ofNorth America.

(it 2013 American Academy of Drthopaedic Surgeons

695

Section 8: Pediatric Orthopaedics

Ere

"i“.

Independent on levelslrlavts:

abnormality present, (2) the soft-tissue

and bone components that may be causing the ambulatory dysfunction, (3) the appropriate procedures to correct the gait abnormalities based on the anatomic con-

E Mouthut 5 mmmmm

Men! on all Mann:

no: not use any waiting tilt or red any lelp from am

pam ohm walking overall surfaces irxlading uneven M nulls elc. and in sounded m

must consider the following: (1) the gait

tractureslimbalances leading to them,

and [4) that rotational abnormalities need

to be corrected more aggressively in the

t Ems)

mummasnmadmmlwm at

patient with CP than in the nonneuromuscularly impaired patient. Honambulatory Patients Nonambulatory patients with CF also

{knows-liner“

can undergo procedures around the hip, knee, and ankle; however, the options are

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Figure 2 The Functional Mobility Scale for cerebral palsy. [IE Kerr Graham, Bill Reid and Adrienne Harvey, The Royal Children's Hospital, Melbourne, Australia}

not as extensive as those for the ambulatory patient. In the hip, spastic subluxation or dislocation with severe acetabular dysplasia can be present. This can lead to difficulty in sitting and transfers and can exacerbate scoliosis. A combined adductor, psoas, and proximal hamstring lengthening, open reduction and capsulorrhaphy of the hip, pericapsular pelvic osteotomy, and femoral shortening varus derotation osteotomy (particularly in patients with increased valgus and femoral anteversion] can manage this problem. In the knee, severe flexion contractures that

interfere with sitting and hygiene can be corrected with distal hamstring length— ening. Finally, deformities of the foot in nonambulatory patients can be corrected as in ambulatory patients (Table 1), resulting in a foot that can rest plantigrade on a wheelchair platform.

Soft-Tissue Lengthening Procedures

Ambulatory Patients The clinician must have a thorough un-

derstanding of gait analysis when evalu-

ating the ambulatory patient with CP. Once the appropriate gait abnormality is identified, the correct surgical procedure can be chosen. Common gait abnormalities seen in the ambulatory patient with CF include scissoring gait (excessive hip adduction), crouch gait (excessive hip flexion, knee flexion, and ankle dorsi—

flexion), jump gait (excessive hip flexion,

knee flexion, and ankle plantar flexion),

stiff-knee gait (swing-phase knee stiffness due to an overactive rectus femoris muscle), and recurvatum gait {knee hy-

perextension due to equinus contracture). At the level of the foot, ambulatory patients also may have a pure ankle equinus deformity (excessive ankle plantar flexion), equinovarus deformity [exces-

sive ankle plantar flexion with an overac-

596

tive tibialis posterior or tibialis anterior),

or pes planovalgus deformity {overactive

peroneals andfor bony deformity). The surgical options for the components of the gait abnormalities mentioned above are shown in Table 1. The ambulatory patient with CP also may have rotational abnormalities (lever-

arm disease] at the Eve] of the hip and knee (eg, increased femoral anteversion, internalfexternal tibial torsion} that may

require corrective surgery. Unlike the typically developing patient, who may be able to compensate for these rotational abnormalities, the patient with CP requires correction via proximal or distal femoral osteotomies andfor tibial dero-

tational osteotomies to preserve ambulatory function. Therefore, before determining the ap— propriate surgical procedure in an ambulatory patient with CE. the clinician

Adductor Lengthening Indications

The indications for adductor tenoto-

mya are scissoring gait and spastic hip subluxationfdislocation. Preoperative Imaging

No preoperative imaging is required unless the adductor tenotomy is part of

a larger procedure for spastic hip

subluxationfdislocation. In that case, im-

aging includes AP and frog-leg lateral views of the pelvis and bilateral hips and possibly CT with three—dimensional reconstructions. Surgical Technique For this procedure, the patient is positioned supine. The perineum is draped free. A transverse incision is made over the palpably tight adductor longus tendon, one fingerbreadth distal to the

groin crease. The fascia overlying the ad-

(E) 2013 American Academy of flrthopaedic Sir-1312mm

Chapter 10?: Lower Extremity Surgery in Children With Cerebral Palsy ductor longus tendon should be opened

with the leg in extension than in flexion,

should be used to isolate the adductor longus tendon, passing the clamp from medial to lateral. The tendon should be cut as proximal to its attachment to the pelvis as possible with an electrocautery. After the adductor longus tendon has been transected, the surgeon should encounter the anterior branch of the obturator nerve overlying the adductor brevis tendon inferiorly, the pectineus muscle superior— ly, and the gracilis muscle mediallyr (Fig-

with a right-angle clamp and transected

(Figure 3, A}, and a right-angle clamp

ure 3, B). If an intraoperative test confirms

that abduction of the leg is hindered more

the gracilis muscle also can be isolated

{Figure 3, C}. If further abduction is desired, the adductor brevis can be isolated

Postoperative Care and Rehabilitation Postoperatively, the patient is placed in Petrie casts with a bar between the legs

tained to prevent hematoma formation. The wound should be closed in layers.

The initial incision should not extend too

are performed, hemostasis should be ob—

Typical Abnormalities and Potential Surgical |I‘ilptions in Ambulatory Patients with Cerebral Palsy Abnormality

Potential Surgical Treatments

Hip adduction contracture

Adductor tenotomy

Hip flexion contracture

Psoas release at pelvic brim

Knee flexion contracture

Distal hamstring lengthening Distal femoral extension osteotomy with patellar tendon advancement

Knee recurvatum

Ankle plantar tlexor lengthening

Stiff-knee gait

Rectus femoris transfer

Eguinus contracture

Ankle plantar flexor lengthening Posterior tibialis lengthening Split posterior tibial tendon transfer

Split anterior tibialis transfer Ankle plantar flexor lengthening Pes planovalgus deformity

tion and inadvertent transaction of the branches of the obturator nerve.

with a right-angle clamp and transected as well. The goal should be to obtain 45” of abduction. Lying below the adductor brevis, the large adductor magnus and its overlying posterior branch of the obturator nerve must be preserved to maintain the ability to adduct. After all tenotomies

Table 1

Equinovarus deformity of the foot

Complications

Complications include hematoma forma-

Peroneus brevis lengthening

Calcaneal lengthening osteotomy (:I: mneilonn osteotomy}

Calcaneal sliding osteotomyr is: cuboid and cuneiform osteotomy} Subtalar arth rodesis

Triple arthrodesis

or into an abduction brace, which is worn full time for 4 weeks and then worn at

night for 6 months. Pearl

far laterally beyond the lateral border of the adductor longus tendon to avoid encountering the femoral neurovascular bundle.

Distal Hamstring Lengthening Indications Indications for distal hamstring lengthening‘l include crouch gait, jump gait, and knee flexion contracture. The surgeon must be cautious when performing hamstring lengthening in ambulatory patients. The patient should have a popliteal angle greater than 40" combined with a posterior pelvic tilt. If the patient has an anterior pelvic tilt, then there may

be worsening of the gait after hamstring

lengthwise

Surgical Technique The patient is positioned supine if this

procedure is performed with other sur-

geries or prone if performed as an isolated procedure. If the patient is supine, medial and lateral incisions can be made;

if the patient is prone, a single midline incision is used. The incision(s) should

begin 1 to 2 cm proximal to the knee joint and extend proximaily for 5 to 7' cm (Figure 4, A). For the two-incision technique,

the incisions should be placed slightly

anterior to the hamstring tendons, which

Figure 3 lntraoperative photographs demonstrate the surgical technique for adductor lengthening. A, The adductor longus tendon is shown with its overlying fascia identified before tenotomy. B, The anterior branch of the obturator nerve is identified with a hemostat. C, The gracilis tendon is identified before tenotomy. (Reproduced with permission from Saw yer JR: Cerebral palsy, in Canale ST, Beaty IH, eds: Campbell's Operative Orthopaedics, ed 11. Philadelphia, PA, Mosbnlsevier, Ellfl'i'fi. pp 1333-1399.)

(it 2013 American Acndmy of Drtbopaedic Surgeons

69'?

Section 8: Pediatric Orthopaedics

,Ix / ll'lElSlfll’l

Une of division

of deep fascia

A Figure 4 Illustrations demonstrate surgical technique for distal hamstring lengthening using a single midline incision. A, The approach. B, Transection of the tendon overlying the semimembranosus muscle belly {in forceps}. Two cuts have been made in the muscle belly to gain additional length.

should be palpably tight with the leg extended. Dissection on the medial side of the leg should be taken posterior to the sartorius muscle {the most superficial muscle) to open the fascia overlying the gracilis muscle. The tendon overlying the gracilis muscle belly should be cut with a knife or electrocautery; Deep to the gracilis, the semitendinosus tendon should be encountered and the fascia over the muscle opened, followed by cutting of the tendon overlying the muscle belly or a Z-lengthening if additional length is re— quired. The deepest, broadest muscle that will be encountered is the semimernbranosus muscle; its fascia should be opened as well, followed by transection of the tendon overlying the muscle belly. Two cuts can be made in the tendon if necessary (Figure 4, B}. After all tendons have been cut, straight-leg raising can be per-

sected. Both wounds can now be closed in a layered fashion.

Complications Complications from this procedure include sciatic nerve transection and sciatic nerve palsy from excessive extension. Postoperative Care and Rehabilitation

A knee immobilizer or knee rangeofmotion brace should be placed in the amount of flexion that can be achieved comfortably without stretching the adatic nerve. The patient is allowed to bear weight as tolerated with the cast. The immobilizer is kept in place for 4 weeks, and then the patient is allowed to return to a stretching program.

formed to provide an additional amount of lengthening. Forceful extension should

Pearl The sciatic nerve should be monitored

damage. Lengthening of the lateral hamstrings

Lengthening of the

not be performed, to avoid sciatic nerve

is rarely indicated; however, if necessary, attention is turned to the lateral incision,

if a two-incision technique is used, or to the lateral aspect of the incision, if a sin-

Figure 5 Illustration shows the transection of the tendon overlying the gastrocnemius and soleus muscle in gastrocnemius-soleus lengthening.

the biceps tendon that is opened, and the

tendon overlying the muscle belly is tran-

gle midline incision is used. For the twoincision approach, the incision is made anterior to the biceps tendon to avoid the peroneal nerve. Dissection is carried down to the level of the fascia overlying

carefully postoperatively.

Gastromemius-Soleus

Indications Lengthening of the gastrocnemiussoleus5 is indicated for equinus contrac-

ture, jump gait, and recurvatum gait

secondary to gastrocnemius—soleus contracture. Generally, the gastrocnemius should be the only muscle lengthened in

diplegia, whereas the gastrocnemius and

(fl) 2013 American Academy of flrtfropaedic 51113130115

Chapter 10?: Lower Extremity Surgery in Children With Cerebral Palsy soleus should be lengthened in hemiple— gia. Actual lengthening of the Achilles

tendon by Z lengthening should be dis-

couraged in ambulatory patients because of the risk of overlengthening and weakening of the muscles. Surgical Technique The patient is positioned supine. A posteromedial incision is made over the middle third of the leg, posterior to the calf muscles. Blunt dissection should be used to develop the plane above the gastroc— nemius and soleus muscles. The fascia overlying the gastocnemius and soleus

muscles is opened. and the tendons over-

lying these muscles are released from medial to lateral under direct visualization, with the foot held in maximal dorsiflexion (Figure 5). Care should be

taken to preserve the muscle underly-

ing the tendons. The sural nerve should

be identified. Further dorsiflexion can be performed after the release, and spreading of the underlying muscle should be visualized. The wound is closed in a lay— ered fashion. Complications Complications include Achilles tendon rupture and sural nerve injury. Postoperative Care and Rehabilitation Patients are placed in a short-leg weight-

bearing cast with the foot in a neutral

position for 4 to 6 weeks. The patients then may be transitioned to an ankle-foot

Figure 6 lllustraticms demonstrate the surgical technique for posterior tibial tendon

lengthening A, The incision [desired line). B, Transection of the tendon overlying the muscle

belly.

perficial peroneal nerve. The peroneus longus tendon is identified, and the

fascia overlying the tendon is opened. The peroneus longus tendon is retracted inferiorly, and the fascia overlying the peroneus brevis tendon is opened. The tendon overlying the muscle belly

Surgical Technique The patient is positioned supine, with a bump under the hip. An approximately 3-cm incision over the medial border of the tibia at the junction of the middle and distal one third of the leg is made (Figure 6, A). The posterior border of

Postoperative Care and Rehabilitation Because this procedure rarely is per-

the tibia is palpated, and dissection is carried down to the deep posterior compartment of the leg, the fascia of which is opened. The flexor digitorum longus muscle, which lies medial to the posterior tibialis tendon at this level, is encountered. The flexor digitorum longus tendon is retracted posteriorlyc. and the fascia overlying the posterior tibial tendon is encountered and opened. The tendon overlying the posterior tibial

be performed through the medial in-

should be dictated by the larger proce-

with a knife [Figure 6, B). The wound is

Peroneus Brevis Lengthening Indications Peroneus brevis lengthening" is indicated

Pead If gastrocnemius-soleus lengthening is

orthosis for maintenance of correction,

based on disease severity.

Pearls

- Overaggressive dorsiflexion of the

foot after release should be avoided to prevent a complete tear of the Achilles tendon. I If an associated peroneus brevis lengthening is being performed, the incision also can be made laterally.

*- Posterior tibialis lengthening also can cision.

for p25 planovalgus.

Surgical Technique

The patient is positioned supine. A posterolateral incision is made over the distal one third of the leg. Care is taken to identify and protect the su-

is transected, and foot is placed in in-

version to provide further lengthening. The wound is closed in a layered fash— lDI'l. Complications

The primary complication is superficial peroneal nerve injury.

formed in isolation, postoperative care

dure that is performed.

performed concomitantly, it can be per-

formed within the same incision before the peroneus brevis lengthening

Posterior Tibial Tendon Lengthening Indications Posterior tibial tendon lengthening’ is indicated for equinovarus.

(El 2013 American Academy of Grthopaedic Surgeons

muscle belly should then be transected closed in a layered fashion.

Complications Complications of posterior tibial tendon

lenthening include inadvertent lengthen:ing of the flexor digitorum longus and

injury to the posterior tibial artery and tibial nerve.

Postoperative Care and Rehabilitation Because this procedure rarely is performed in isolation, postoperative care 699

Section 8: Pediatric Orthopaedics

inguinal

. _

Quadratus lumborum

Psoas minor

Psoas major

Iliacus

lnguinal ligament

A

B

'1"

Psoas

_

tendon

it

i

'.

l

3-1:”

Medal

D

rs. I1

new:

lateral

E

Figure '7 Illustrations demonstrate the surgical technique for psoas lengthening at the pelvic brim. A, The anatomy of the psoas and iliacus muscle at the pelvic brim. B, Palpation of the femoral artery during the superficial dissection. C, After division of the iliac fascia, the femoral nerve is encountered. D, The femoral nerve is retracted medially} revealing the psoas tendon. E, The psoas tendon is isolated, taking care to preserve the iliacus muscle, and transected at the pelvic brim.

shmfldbedictatedbythelargerprooe-

dure that is performed.

Pearl When opening the deep posterior compartment, the flexor digitorum longus muscle is first encountered. An error can be made if this muscle is assumed to be the posterior tibial tendon.

Psoas Release at the Pelvic Brim

Indications Indications for psoas release at the pelvic brimfl are hip flexion contractors and spastic hip subluxationfdislocation. Preoperative Imaging

No imaging is required unless this is part of a larger procedure for spastic hip subluxationfdislocation, which calls for 7'00

AP and frog-leg lateral views of the pelvis and bilateral hips and possibly CT with three-dimensional reconstructions.

Surgical Technique The patient is positioned supine for this

procedure. The lower extrenuty is draped

completely free. The femoral artery is palpated and marked, and an oblique incision is made parallel and slightly distal to the anterior hip flexion crease {Figure '3'“, A and B}. Dissection is taken down to the iliac fascia, which is divided

vertically lateral to the femoral artery

(Figure T, C). The femoral nerve is en-

countered and retracted medially toward the femoral sheath with a Penrose drain (Figure T} D). The iliopsoas muscle is en—

countered in the depth of the wound [Figure '1’, D]. The medial border of the muscle

is identified and rolled laterally to expose the inner wall of the pelvis. Flexion and external rotation of the hip will relax the muscle and expose the psoas tendon (Figure 7, E). The tendon is isolated with a

right-angle forceps and cut at the lovel of the pelvic brim, avoiding the h'ansacfion

of any iliacus muscle fibers. The wound is closed in a standard layered fashion.

Complications Complications include hematorna forma-

tion and damage to the femoral neuro-

vascular bundle.

Postoperative Care and Rehabilitation

Because this procedure rarely is performed in isolation, postoperative care should be dictated by the larger procedure that is performed.

(fl) 2013 American Academy of Drflropoedic Sui-gems

Chapter 10?: Lower Extremity Surgery in Children With Cerebral Palsy Pearl It is of utmost importance to retract the inguinal ligament proximally and palpate the rim of the pelvis to make certain that the location for release of the psoas tendon is at the level of the pelvic brim. There are other approaches to lengthening above the pelvic brim, and the same considerations should be made. Soft-Tissue Transfer Procedures Rectus Femoris Transfer to the

Hamstrings

Indications Rectus femoris transfer to the ham-

strings" is indicated for stiff-knee gait.

Surgical Technique

The patient is positioned supine. A longi— tudinal incision is made in the midthigh region from the superior pole of the patella extending proximally 10 cm (Figure 8}. Dissection is carried down to the deep fascia over the rectus muscle, which

is opened. The tendon of the rectus is isolated from the vastus intermedius, and its insertion on the superior pole of the patella is freed. Entering the knee joint should be avoided. A medial incision over the hamstrings is made distally, and dis-

section is taken down to the level of the semimembranosus and semitendinosus. The proximal aspect of the semitendinosus is sutured to the semirnembranosus at its musculotendinous junction. The

semitendinosus is transected distally.

A tunnel is prepared under the adipose tissue to allow the rectus tendon to be passed from the anterior to the medial

incision, and an}; impediments to ten-

vicular to the tip of the medial malleolus

tus should be passed through the tunnel. The free end of the semitendinosus is passed through the rectus tendon using a Pulvertaft technique with heavy non— absorbable suture securing the transfer. This transfer should be fixed in about 20° of flexion. The wound is closed in a standard fashion.

sheath is identified and opened in its entirety from its insertion on the navicular to the tip of the medial malleolus. Care should be taken to free the tendon within its sheath proximallyr beyond the incision with scissors. The inferior portion of the tendon is split and detached from its navicular insertion. A second incision approximately 5 cm in length is made over the medial border of the tibia at the junction of the middle and

don gliding should be cut free. The rec-

Complications The primary complication is inadequate excursion of the rectus tendon from teth-

(Figure 9, A]. The posterior tibial tendon

ering of the tendon in the wound tunnel. Postoperative Care and Rehabilitation

The patient is placed in a knee immobilizer for 3 weeks and is allowed to bear

weight as tolerated. Range-of-motion

exercises should be started as soon as tolerated.

Feed The gracilis and fascia lata also can be used as a potential transfer point for the

l

rectus.

Split Posterior Tibial Tendon Transfer Indications Split posterior tibial tendon transfer“ is indicated for dynamic equinovarus, particularly hindfoot varus. Surgical Technique

The patient is positioned supine. Four in-

cisions are used in this surgery. Attention

is first turned to an incision directly,r over

the medial border of the foot from the na—

Figure 3 Illustration shows the incision used for rectus transfer and illustrates the new line of pull of the rectus tendon after transfer.

Posterior tibial tendon

Figure 9 illustrations demonstrate the surgical technique for split posterior tibial tendon transfer. A, The four incisions used are shown. B, Preparation of the posterior

tibial tendon before transfer to the lateral side of the foot. C, The completed transfer of the posterior tibial tendon to the peroneus brevis is shown.

(it 2013 American Acadmy of Urtiropaedfc Surgeons

Section 8: Pediatric Orthopaedics Surgical Technique

The patient is positioned supine, with a

bump placed under the flank on the ipsilateral side. The leg is draped completely free, with care taken to include the iliac

Figure 1!] Preoperative AP radiograph of a patient with Gross Motor Functional Classification System level V cerebral palsy with spastic hip subluxation.

distal one third of the leg {Figure 9, A). The posterior border of the tibia is palpated, and dissection is carried down to the

deep posterior compartment of the leg. The fascia overlying the deep posterior compartment should be opened, and the

flexor digitorum muscle should be retracted posteriorly. An umbilical tape can be

placed between the two arms of the posterior tibialis muscle and retrieved with a tendon passer, which is placed within the posterior tibialis sheath and pulled into the posterior compartment. The tape

can then be used to divide the tendon by

pulling proximally. Alternatively, the fas-

Figure l] Postoperative A l’ radiograph of the patient in Figure 1:] after proximal soft—tissue lengthening, varus derotational osteotomy, and acetabuloplasty for spac hip subluxation.

third incision under the peroneal retinaculum into the sheath of the peroneus brevis tendon. With the foot held in the neutral position, the posterior tibial tendon is sutured to the peroneus brevis tendon using a heavy nonabsorbable suture (Figure 9, C). The lateral wounds are closed in a standard fashion. Complications

Complications include neurovascular damage when passing the split tendon posterior to the tibia, and inadvertent transaction of the posterior tibial tendon.

cia overlying the posterior tibial tendon should be opened longitudinally, and the split tendon pulled proximally into this wound. The split in the tendon is carried

The patient is put in a short—leg weight— bearing cast for 4 to En weeks, followed by

ure 9, B).

Preoperative gait analysis is helpful to

PI‘DlallY with a scissors to the musculotendinous junction of the muscle (FigA third incision is made behind the

Postoperative Care and Rehabilitation

an ankle-foot orthosis. Pead

ensure that the tibialis anterior is not the

lateral malleolus (Figure 9, A}. The inci-

deforming force.

be encountered and opened. A tendon

Bone Procedures Combined Procedure for Spastic Hip SubluxationiDislocation

sion should extend from the tip of the malleolus to a point 5 to 7 cm proximal. The peroneal tendon sheaths should

passer is taken from the proximal medial wound into the wound. The tendon passer should be directly in contact with the posterior surface of the tibia to avoid the neurovascular bundle. The split posterior

tibial tendon should be passed from the

proximal medial wound to the lateral wound using the tendon passer (Figure 9, B). The tendon should be passed anterior to the peroneal tendons. At this point, both medial wounds

should be closed in a standard fashion to avoid manipulation of the foot after tendon transfer. A fourth incision is made overlying the peroneus brevis tendon from the tip of the lateral malleolus to the base of the fifth metatarsal. The split portion of the

posterior tibial tendon is passed from the 7'02

The combined procedure”12 is indicated for spastic hip subluxationfdislocation. The combined procedure includes ad— ductor tenotomy, psoas lengthening, proximal hamstring tenotomy, acetabu-

loplasty, varus derotational osteotomy of the femur, and hip open reduction and

capsulorrhaphy.

crest in the operative field. The first incision is made in the perineum to perform the adductor tenotomy as described previously. A second anterior incision is made 1 cm lateral to the iliac crest and extending distally; ending medial to the anterior supe— rior iliac spine. A standard Smith Petersen approach is perforrmd, with the iliac

apophysis elevated off the inner and outer table. The iliac wing is stripped subperiosteally down to the sciatic notch both medially and laterally. The lateral exposure allows full visualization of the sciatic notch, and the medial exposure allows

full visualization of the flI‘ltEI'lOI' inferior

iliac spine {AlIS}. Attention is turned to the distal aspect of the wound, and the di-

rect and indirect heads of the rectus musde are released and reflected distally. The capsule is opened through a T—shaped incision for subsequent capsular repair. The ligamentum teres is removed, the transverse acetabular ligament is transected, and any other obstructions to reduction are removed, including lengthening the psoas tendon. Psoas lengthening also can be performed through this incision. A third incision is made over the lateral aspect of the proximal thigh, from just below the tip of the greater trochanter and extending distally s cm. The femur should be subperiosteally exposed. The femoral neck anteversion should be palpated through the anterior incision. A Kirschner wire [K-wire} should be placed

perpendicular to the femoral shaft in line with the femoral neck anteversion, and

a second K—wire should be placed in the center of the femoral neck in relation to the perpendicular wire to obtain a neck— shaft angle of 110° post fixation, based

on preoperative planning (Figure 11, A).

The chisel for the blade plate should be seated toward its desired depth in the femoral neck, and care should be taken

Preoperative Imaging

AP and frog-leg lateral radiographs of the

pelvis and bilateral hips are needed {Fig-

ures 10 and 11}. Three-dimensional CT is

to not penetrate the calcar. Rotational Kwires are placed in the femur to aid in the planning of derotation. Three cuts are made with a saw: one perpendicular

to the femoral shaft proximally, a second

optional

cut in line with the chisel to remove a me-

Implants Implants used in the combined proce— dure include the pediatric blade plate and the pediatric locking compression plate.

lateral edge of the proximal fragment to allow for medialization. The blade plate

dial wedge, and a third cut that bevels the

is placed into the femoral neck, and the

plate is reduced to the bone with a clamp.

(fl) 2013 American Academy of flrthopaedic 51113130115

Chapter 10?: Lower Extremity Surgery in Children With Cerebral Palsy Prior to securing the clamp, the appropri-

ate rotation of the distal fragment should be set using the rotational K-wires.

Screws are placed in a compression mode in the blade plate. Alternatively, the chisel can be kept in place until the pelvic oste— otomy has been performed. Attention is once again turned to the anterior incision. Five nonabsorbable sutures should be placed in the T-shaped capsulotomy but not tied. A K—wire is planed 0.5 to 1.0 cm above the lateral aspect of the acetabulum at the planned level of the acetabular osteotomy

(Figure 12, B) and checked under fluoros-

copy. This is a bending acetabuloplasty, so only the lateral cortex of the pelvis is cut except at the anterior (A115) and posterior (sciatic) corners of the osteotomy.

With a straight osteotome approximately the size of the femoral head, an osteotomy

is made through the lateral cortex

(Figure 13, A and B). A Kerrison rongeur

can be used to complete the cuts at the corners. At this point, a curved osteotome

Figure 12 Illustrations show planning for the combined procedure for spastic hip subluxationiFdislocation. A, The preoperative proximal femoral deformity noted in patients

with spastic hip subluxationfclislocation with coxa valga is shown. B, The intended path of the acetabuloplasty, {1.5 to Lil cm above the aoetabulum through the greater sciatic notch and the anterior inferior iliac spine is shown.

(1.9 to 2.5 cm wide) is directed toward

the triradiate cartilage, just at the medial aspect of the triradiate cartilage. After confirming correct placement, a wider osteotome is used to widen the osteotomy site. A blunt laminar spreader is placed in the posterior portion of the osteotomyr and opened 1.0 to 1.5 cm. The wedge that was removed from the proximal femur is then placed to keep the osteotomy open. Alternatively, wedges from the iliac crest can be used. Gentle pressure opens the osteotomy laterally 1.0 to 1.5 cm (Figure 13, C). No further fixation of these grafts is necessary (Figure 13, D and E).

The hip is reduced with abduction and internal rotation, and the capsule is repaired with the sutures placed previously. The iliac apophysis is repaired with a heavy absorbable suture. The vastus lateralis and tensor fascia lata also are repaired with a heavy absorbable suture through the lateral wound. Standard

wound closure can be performed. Complications

Complications include sciatic nerve palsy, osteonecrosis, iatrogenic fracture, and loss of hip reduction. Postoperative Care and Rehabilitation Although many authors suggest no immobilization is necessary, we place these patients in a one-and—one-half hip spica for 2 to 3 weeks postoperatively for pain relief while positioning the child in the immediate postoperative period.

- When exposing the outer table of the

pelvis, the surgeon should pay special

*I

attention to fully visualizing the sciatic notch posteriorly so that the osteotomy can be made easily.

After the hip is reduced, an assistant

should maintain the leg in abduction and internal rotation to prevent dislocation in the cast [if the surgeon chooses to use a spica cast}.

Proximal Femoral Rotational Dsteotomy Indications Indications for the proximal femoral rotational osteotomy1m are increased femoral anteversion and lever-arm syndrome. Preoperative Imaging

AP and frog—leg lateral radiographs of the pelvis and bilateral hips are taken. Threedimensional CT with torsional profile is

optional. Implants

The implants required for proximal femoral rotational osteotomy include a pedi— atric blade plate and a pediatric locking compression plate. Surgical Technique The patient is positioned prone, with a bump under the hip. The prone position is used so that intraoperative internal and external rotation of the

hips can be measured with the knees

ifli 2013 American Academy of firthopaedic Surgeons

fined 90". A straight lateral incision is

made over the lateral aspect of the proximal thigh from just below the tip of the greater trochanter and extending distally 6 cm. The vastus lateralis should be elevated, and the femur should be sub—

periosteallyr exposed and protected with

retractors. A K-wire should be placed

perpendicular to the femoral shaft in line with the femoral neck anteversion. Another K—wire is placed in the distal femur. This K—wire should be rotated the appropriate number of degrees away from the proximal pin, based on preoperative planning, to achieve 10" to 20° of femoral anteversion postoperatively. If a blade plate is the desired method of fixation at this point, the surgical technique described previously for the spastic! dislocated hip procedure is followed, starting with chisel placement. Of note, only a transverse osteotomy (at or below the level of the lesser trochanter) is

necessary. The appropriate derotation is performed. If a locking compression plate is used, a 6-hole plate generally is preferred. The proximal two or three holes of the plate are placed above the area of the intended transverse osteotomy (at or below the level of the lesser trochanter), and screws

are drilled and measured. The transverse osteotomy is made, the distal fragment is derotated, the proximal portion of the

plate is secured to the proximal frag703

Section 8: Pediatric Orthopaedics

C Figure 13

Illustrations demonstrate the surgical technique for a bending acetabuloplasty. Anterior (A) and lateral (B) views show the

intended path of the acetabuloplasty. A straight No. 1 and curved No. 2 osteotome are used to perform the acetabuloplasty and correction of the coxa valga with a varus derotational osteotomy. C, Lateral view shows a curved osteotome directed toward the triradiate cartilage to perform the bending acetabuloplasty. Anterior (D) and lateral (E) views show the bicortical graft taken from the iliac crest and used to hold open the acetabuloplasty.

ment with the predrilled screws, and

the distal fragment is finallyr secured to the distal three holes of the plate with a clamp. These locking or oortical screws are placed, and an intraoperative exami— nation ensuring correction of the internal rotation {decreased} and external rota-

tion {increased} of the hip is performed on the operating room table (Figure 14).

Standard wound closure is performed after the vastus lateralis and tensor fascia lata are closed with a heavy absorbable suture.

Complications Complications of this pmcedure include nonunion/malunion, overcorrection, and

for 4 to a weeks. If bone quality is deemed to be appropriate, several authors have

suggested not using a spica cast.

Peafl Care must be taken to full},F expose the femur subperiosteall},F at the level of the osteotomy so that appropriate rotation can occur. Tibial Derotational Osteotomy Indications Tibial derotational osteotomym‘ is indicated for tibial torsion and lever-arm syndrome. Preoperative Imaging

angular deformity.

AP and lateral radiographs of the

Postoperative Care and Rehabilitation A one-and-one—half hip spica cast is used

dimensional CT with torsional profile is

7'04

knee, tibia, and ankle are taken. Three—

optional.

Figure 14 Postoperative rill radiograph of a patient after proximal femoral rotational osteotomjtr for increased femoral anteversion with plate fixation.

Implants The implants required for this procedure are a {Ev-hole 35-min compression plate and K—wires.

(fl) 2013 American Acadmy of firthopaedic Sui-gems

Incision

In"

IJIOIIIIIICII

Chapter 10?: Lower Extremity Surgery in Children With Cerebral Palsy

T-incisian in

Figure 15 Illustrations show the surgical technique for distal tibial;r fibular derotational osteotomv. The approach to the fibula (A) and the approach to the tibia (B) are shown. C, Rotational K-wires are placed in the tibial segments. D, The crossed Iii-wires are placed across the osteotorny site for fixation in younger patients. E, Postoperative AP radiograph of a patient after distal tibial derotational osteolnornyr for tibial torsion

D Surgical Technique The patient is positioned supine, with a bump under the hip. If the surgeon is con-

templating making more than a 20° to 30° derotation, a fibular osteotomyr should be

considered. An incision directlyr over the fibula is made first. The fibula is exposed subperiosteally, taking care to protect the superficial peroneal nerve. A transverse osteotomy is made in the fibula, 3 to 4 cm

extending from the ankle crease proxi— mallv (Figure 15, B). The tibialis anterior is reflected medially off the tibia. The

tibia is exposed in a subperiosteal fash-

ion at the level of the intended osteoto-

my. Two rotational K—wires, one placed

distally just proximal to the physis and one placed pror-tirnallg.F away from the UStEfltDm}? site, are placed in the tibia in a perpendicular fashion {Figure 15, C).

above the ankle joint (Figure 15, A).

The distal wire is rotated away from the

for fixation in a younger child, is made lateral to the anterior border of the tibia,

(Figure 15, D).

Attention is turned to the anterior aspect of the tibia. An incision approximately 10 cm in length, if using a plate for fixation, or 5 cm in length, if using K—wires

proximal wire such that the intended degree of rotational correction based on preoperative templating can be visual— ized when the distal fragment is rotated If a compression plate is used, the prosci-

(El 2013 American Academy of Unhopaedfc Surgeons

mal three holes above the osteotomjr are drilled and measured. The plate is removed and the traitsverse osteotomy perpendicular to the tibia is made with an oscillating saw. The distal fragment is rotated. The proximal portion of the plate is secured to bone, the distal fragment is reduced to the plate, and the screws

are placed in a compression fashion (Figure 15, E]. If K—wire fixation is chosen in lieu of a compression plate (in young children with good bone quality), the crossed K—wires can be placed across the osteotomyr (Figure 15, D). The pins are bent, cut, and placed out of the skin. A drain is plaoed. Standard wound closure follows

in a layered fashion.

Section 8: Pediatric Orthopaedics

Figure 16 Illustrations demonstrate the surgical technique for a distal femoral extension osteotomy. A, A distal cut is made perpendicular to the blade plate chisel and the proximal cut is made perpendicular to the famm. B. Medial and latetal Krackow sutures are placed in the patellar tendon for advancement C, The patellar tendon is advanoed under the periosteal flaps, with the flaps repaired over the tendon.

Complications

Complications include nonunion! malunion, compartment syndrome, overcorrection or undercorrection. and hardware irritation (if a plate is used).

Postoperative Care and Rehabilitation

A short-leg non—weight-bearing cast is used for 4 weeks (if present, pins are pulled at 4 weeks), followed by a short-

leg weight-bearing cast for an additional 4 weeks.

Pearl

Patients are at risk for compartment syn-

drome and should be monitored closely postoperatively. Distal Femoral Extension Dsteotonty With Patellar Tendon Advancement Indications

This procedure15 is indicated for knee flexion contracture and crouch gait. Preoperative Imaging

AP and lateral radiographs of the knee are taken. Implants The implants required for this procedure include a pediatric blade plate (90") or distal femoral locking plate and 3.5— or 4.5-mm screws. Surgical Technique

The patient is positioned supine, with a

bump under the hip. An incision is made over the lateral aspect of the distal femur,

taking care to stay proximal to the knee joint and the distal femoral physis. if it

still is open. This incision should be pos-

terior to the vastus lateralis. The distal femur is exposed in a subperiosteal fashion, and a K—wire is placed perpendicular to the femur. This K—wire should be placed just proximal to the distal femoral physis. If a blade plate is being used, the chisel is impacted into the bone just proximal to 706

the K—wire previouslyr placed. This chisel

should be perpendicular to the tibia at the knee joint to correct the flexion de~ formity of the osteotomy. At this point, the appropriate anterior wedge of bone based on preoperative planning should be cut from the distal femur (Figure 16, A}. The chisel is removed. and the blade plate is impacted into the distal fragment. Bone that may be present posteriorly on the distal fragment is removed, and the

blade plate is secured to the proximal fragment with screws placed in a compression mode. A second anterior incision is made over the tibial tubercle and patella. Dissection is taken down to the level of the patellar tendon. The medial and lateral retinacula are divided to isolate the patellar tendon. The tendon is dissected free from its inferior attachment at the level of the tibial

tubercle. The periosteum distal to the tu-

rupture. sciatic nerve palsy, compartment syndrome, and symptomc hardware. Postoperative Care and Rehabilitation

A knee range-of—motion brace is placed and kept in approximately 10° to 2U” of flexion for 2 weeks. Motion is advanced

gradually over the ensuing 4 to 6 weeks until the osteotomies have healed.

Pearls I

In a skeletally immature patient, the

surgeon can imbricate the patellar tendon without cutting it or distal-

izing the tibial tubercle. This can be

achieved by rotating the tendon over a clamp and suturing the tendon on top of itself, using nonabsorbable sutures.

I Keeping the knee slightly flexed until swelling has resolved will prevent stretching of the nerve.

bercle is divided in a T-shaped fashion to expose the tibia. The patellar tendon is advanced distally until the inferior pole of the patella is at the joint line (Figure 16, B). The tendon is repaired with a

Calcaneal Lengthening Dsteotomy Indications lCalcaneal lengthening osteotomy'firl't' is indicated for pes planovalgus foot.

periosteal flaps that were created {Figure

AP. lateral, oblique. and Harris radio-

nonabsorbable. heavy suture under the 16, C). [n a skeletally immature patient,

patellar tendon advancement is achieved in this way. In a skeletally mature pa— tient, a block of the tibial tubercle with

the tendon attached is moved distally and

secured with screws. Most patients who

require this surgery are skeletally mature and will require this distaliaation of the tibial tubercle. The goal is to have the in— ferior pole of the patella at the level of the Blumensaat line on the lateral radiograph. The repair is reinforced with a tension

band construct through the inferior aspect of the patella and the proximal tibia. The wound is closed in a layered fashion. Complications Complications

include

nonunionl'

malunion, anterior knee pain, tendon

Preoperative Imaging

graphs of the feet are taken. Threedimensional CT scan is optional. Surgical Technique The patient is positioned supine. with a

bump under the hip. An incision is made

over the lateral border of the foot from the midportion of the calcaneus to the level of the calcaneocuboid joint. Dissection should proceed plantar to the sural nerve; the peroneus brevis tendon is iden-

tified and lengthened. A second incision

is made medially over the talonavicular joint. The talonavicular joint capsule is exposed, and an elliptical portion of it is removed. Attention is turned again to the lateral incision. The calcaneus is subperiosteally exposed 2 to 2.5 cm proximal to the calcaneocuboicl joint. The calcaneocu-

(it 2013 American Academy of flrthopaedic 51113130115

Chapter 10?: Lower Extremity Surgery in Children With Cerebral Palsy

Figure 1'? Illustrations demonstrate the surgical technique for calcaneal lengthening osteotomy. A, The intended path of the osteotomy for calcaneal lengthening is shown, exiting between the anterior and middle facets. B, The calcaneal lengthening osteotomy after placement of the graft.

boid joint is pinned in a reduced position prior to making the osteotomy. A transverse osteotomy is made in the calcaneus (Figure 17, A) after confirmation of the

appropriate position with fluoroscopy. A laminar spreader is used to open the osteotomy site, and a trapezoidal piece of allograft or autograft is placed into the osteotomy (Figure 1?, B). A K—wire can be passed across the osteotomy (if additional fixation is necessary), bent, and placed

out of the skin. Attention is returned to the medial incision, and the talonavicular joint capsule is imbricated with a nonabsorbable suture. The talonavicular capsulorrhaphy is not necessary in all cases. A closing-wedge osteotomy of the medial cuneiform is performed to plantar flex the medial ool— urrm. Both wounds are closed in a layered fashion. Complications Complications

include

malunionf

nonunion and inadvertent lengthening of the peroneus longus, leading to iatro— genic dorsal bunion. Postoperative Care and Rehabilitation A short-leg non-weight-bearing cast is used for 4 weeks (pins are pulled at 4 weeks), followed by a short-leg weightbearing cast for an additional 4 weeks. An ankle-foot orthosis then may be used, depending on disease severity.

Peads I Because this osteotomy is inherently stable, no fixation generally is needed.

' Care should be taken to protect the calcaneus on its dorsal and plantar as— pect with retractors when making the osteotomy.

- If residual forefoot supination is present, a plantar-based opening-wedge osteotomy of the medial cuneiform can be performed to plantar flex and pronate the foot.

Calcaneal Sliding Dstectorny

the Achilles as well as between the calcaneus and peroneal tendons. Hohmarmtype retractors are placed in these areas to protect the soft tissues. Suhperiosteal dissection is performed in the path of the intended osteotomy, which should be parallel to the posterior facet and perpendicular to the calcaneus in a lateral-tomeclial direction {Figure 18, A).

An oscillating saw is used to cut through the lateral cortex of the calcaneus. The osteotomy is completed with an osteotome (Figure 18, B}. The distal fragment is slid

AP, lateral, oblique, and Harris radio-

medially approximately 1 cm. Correction of the hindfoot valgus should be noted. Two K—wires are placed from the dormlateral foot to the medial-plantar portion of the osteotomy. The pins are cut and bent over the skin. The incision is extended distally, and the lateral aspect of the cuboid bone is

dimensional CT is optional.

under the cuboid, protecting the perone-

Indications

Calcaneal sliding osteotomy1w is another procedure indicated for pes planovalgus foot. Preoperative Imaging

graphs of the feet are taken. Three-

Surgical Technique The patient is positioned supine, with a bump under the hip. An incision from the posterosuperior aspect of the calcaneus to its plantar-anterior surface is made. Dissection is taken plantar to the sural nerve from the distal plantar aspect of the calcaneus to the proximal-superior aspect near the tuberosity in an extraperiosteal fashion. A Key elevator is used to dissect the soft tissue bEt'i'i-FEEI'I the calcaneus and

(El 2013 American Academy of Urthopaedic Surgeons

exposed. A Hohmann retractor is placed

us longus tendon. A vertical osteotomy is performed in the cuboid. Attention is turned to the medial aspect of the foot. The tibialis anterior tendon is identified and dissected off the medial cuneiform. A plantar-based closing-wedge osteotomy is performed and the resected bone is removed. A K—wire is placed from the lateral aspect of the foot to the level of the cuboid osteotomy. The resected bone is placed into the cuboid osteotomy site to perform an opening-wedge osteotomy, 70?

Section 8: Pediatric Orthopaedics Nether A, Fulford GE, Stewart K: Treat-

ment of valgus hindfoot in cerebral palsy by peroneus brevis lengthening. Dev Mari Child Neural 1934:26(3):335-340. Majestro TC, Ruda R, Frost HM: Intramuscular lengthening of the posterior tibialis muscle. Clio Orthop Relef Res 19?l,:?9:59-60.

Sutherland DH, Zilberfarb IL, Kaufman KR, 1tiiyatt MP, Chambers HG: Psoas

release at the pelvic brim in ambulatory patients with cerebral palsy: Operative technique and functional outcon'Ie. J Pediatr Orthop 199?;1?{5}:563-5?ll. Sutherland DH, Santi M, Abel MP:

Treatment of stiff-knee gait in cerebral palsy: A comparison by gait analysis of distal rectus femoris transfer versus proximal rectus release. I Pediatr Orthop 1990;10(4):433-441.

Figure 18 Illustrations demonstrate the surgical technique for calcaneal sliding osteotomy. A, The recommended location of the osteotomy in the calcaneus for sliding correction. B, Completion of the calcaneal osteotomy with an osteotome. C, An opening-wedge osteotomy of the cuboid can be performed for additional lateral column correction. D, Residual forefoot supination can be corrected with a plantar-based closing-wedge osteotomy of the medial cuneiform.

and the K—wire is advanced across the

osteotomy. A K—wire is placed across the medial closing-sedge osteotomy, on the medial aspect of the foot.

Complications Complications after calcaneal sliding osteotomy include lateral wound necrosis and nonunionfrnalunion. Postoperative Care and Rehabilitation

The patient wears a short-leg non— weight—bearing cast for 4 weeks {pins are pulled at 4 weeks}, followed by a short-leg weight-bearing cast for an additional 4 weeks. An ankle-foot orthosis then may be used, depending on disease severity. Pearls - Meticulous closure of the lateral wound must be performed to prevent wound complications. i The calcaneal osteotomy must have two smooth surfaces for appropriate sliding to occur. I An osteotome is used to complete the medial cut to prevent damage to neurovascular structures.

in A gastrocnemius-soleus recession

andfor peroneus lengthening also may be necessary as an adjunct to this bony procedure.

' If additional lateral column lengthening is needed, an opening-wedge

cuboid osteotomy can be performed {Figure1fl,C}.

' Residual forefoot supination can be corrected with a plantar-based closing-wedge osteotomy of the medial cuneiform l{Figure 13, D].

References 1.

Palisano R, Rosenbaum P, Walter 5, R115sell D, Wood E, Galuppi E: Development

and reliability of a system to classify

gross motor function in children with cerebral palsy. Dev Med Child Norroi 199?:39(4):214-223. 2.

Graham HK, Harvey A, Rodda J, Nat-

trass GR, Pirpiris M: The Functional Mobility Scale [FMS]. ,l Pediatr Orthop

2004:24t5}:514-52tl.

3. Presedo A, Uh CW, Dabney KW, Miller

F: Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy. J Bone Joint Surg Am 2005;5{4}:

332-341. 4. Chang W, Tsirilros AI, Miller F, et al: Distal hamstring lengthening in ambulatory children with cerebral palsy: Primary versus revision procedures. Gait Posture 2004;19t3}:295-304. 5. Iavors IR, Klaaren HE: The 1|Ir'ulpius procedure for correction of equinus deformity in cerebral palsy. I Pediair Orthop 193?;F(2}:191-193.

1t]. Green NE, Griffin PP, Shiavi R: Split posterior tibial-tendon transfer in spastic cerebral palsy. I Bone joint SurgAm 1983;5(6):748-?54. 11. Mubarak S], Valencia FG, Wenger DR: One-stage correction of the spastic dislocated hip: Use of pericapsular acetabuloplasty to improve coverage. I Bone Joint Surg Am 1992:?4t9}:134?—1351 12. Elmer EB, Wenger DR, Mubarak S],

Sutherland DH: Proximal hamstring

lengthening in the sitting cerebral palsy patient. I Pediatr Orthop 1992:1213): 329-336.

13. Staheli LT, Corbett M, Wyss C, King H: Lower-extremity rotational problems in children: Normal values to guide management. 1 Bone Joint Surg Am 1935;6?(l):39-41 14. Gage JR, DeLuca PA, Renshaw TS: Gait

analysis: Principle and applications with emphasis on its use in cerebral palsy. Instr Course Lari 1996;45:491-507.

15. Novacheck TF, Stout IL, Gage JR, Schwartz MH: Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy: Surgical technique. I Bone Joint Surg Am 2009;91(Supp1 2):2?1-286. 16. Mosca VS: Calcaneal lengthening for valgus deformity of the hindfoot: Results in children who had severe, symptomatic flatfoot and skewfoot. J Bone faint Surg Am 1995;??(4):50tl-512. 1?. Rathjen KB, Mubarak S]: Calcaneal— cuboid-cuneiform osteotomy for the correction of valgus foot deformities in children. I Pcdiatr Orflzop 1998;18{fi): ”5-282.

c: 2013 American Acadmy of Drfhopaedic Sui-gems

Index A

Achilles tendon rupture repair acute, 505 chronic!neglected, 506—50?

complications, 507—508 pearls, 508 Acromioclavicular (AC) joint reconstruction complications, 34 patient selection, 31 pearls, 34

postoperative care and rehabilitation, 34 preoperative imaging, 31—32 room setup!patient positioning, 32 special instruments 1’equipment, 32 surgical technique, 32—34 Amputations Chopart, 555 Lisfranc, 554—555

midfoot, 551—556 transtibial, 545—549 Ankle arthroscopy

complications, 487—488 contraindications, 485

indications, 485

outcomes, 488 patient selection, 485 pearls, 488

postoperative care and rehabilitation, 488 preoperative imaging, 485

room setup Ipatient positioning, 486 special instruments! equipment, 486

surgical technique, 4845—4817r Ankle fractures, surgical treatment of complications, 448 instruments fequipmentl'rimplants, 44:5 patient selection, 443—444 pearls, 449

postoperative care and rehabilitation, 448 preoperative imaging, 444—445

room setup1'patient positioning, 445

surgical technique, 445-448 Ankle ligament reconstruction anesthesia, 500 closure, 503

complications, 503

contraindications, 499 indications, 499

patient positioning, 499—500

patient selection, 49.9

pearls, 503 postoperative care, 503 preoperative imaging, 499 surgical technique, 500—503 Anterior cervical corpectomy and fusion (ACCF) approach, 565 central decompression, 569-520 closure, 5'72 complications, 572 contraindications, 563—564 deep exposure, 566—56? disk removal, 562—568 end-plate preparation, 571

(it 2013 American Academy of Urtlropaedr'c Surgeons

foraminal decompression and uncinate resection, 570 graft, 564, 521 indications, 563

initial corpectomy, 569 patient positioning, 564 patient selection, 563—564 pearls, 5172

postoperative care and rehabilitation, 522 preoperative imaging, 564 screw sizing, 521

special instrumentsfequipmentf implants, 564 surgical technique, 565—522

Anterior cervical diskectomy and fusion (ACUF) complications, 561 contraindications, 559 indications, 559 patient selection, 559 pearls, 561-562

postoperative care and rehabilitation, 561 preoperative imaging, 559 room setup,3 patient positioning, 560

special instrumentalequipment!implants, 560 surgical technique, 560-561

Anterior cruciate ligament reconstruction, double-bimdle closure, 114 complications, 114—115 contraindications, 109 femoral fixation, 114

femoral tunnel, anteromedial, 113—114 femoral ttmnel, posterolateral, 113

graft preparation, 112 indications, 109 patient selection, 109 pearls, 115

portals and diagnostic arthroscopy, 111-112 postoperative care and rehabilitation, 115 preoperative imaging, 109

room setup! patient positioning, 111

soft-tissue débridement, 112-113

surgical teclmique, 111—114 tibial fixation, 114

tibial tunnels, 113 Anterior cruciate ligament reconstruction, pediatric complications, 122 conclusions! results, 122-123

distal fixation, 121 graft preparation, 119 knee balance, 119-120 lateral approach, 120 patient selection, 118 pearls, 122

postoperative care and rehabilitation, 122 preoperative imaging, 118 proximal fixation, 121

room setup] patient positioning, 118 surgical technique, 118—121 tibial tunnel preparation, 120—121 Anterior cruciate ligament reconstruction, single-bundle transtibial technique closure, 99—100 complications, 100 contraindications, 95

diagnostic arthroscopv and notch preparation, 92—93

graft harvest, 96—9?

graft passage and interference screw fixation, 99 graft preparation, 97 indications, 95 patient selection, 95 pearls, 101

B

Ball-tipped guide rod, 432

Banksrt lesions, arthroscopic and open repair of complications, 14-15 contraindications, 9 indications, 9

patient selection, 9 pearls, 15 postoperative care and rehabilitation, 15 preoperative imaging, 9

postoperative care and rehabilitation, 100—101 preoperative imaging, 95

room setup/patient positioning, 96 special instruments}f equipment}fimplants, 96

surgical technique, 96—100 tibial tunnel placement, 93—99 Anterior cruciate ligament reconstruction, two-tunnel

technique

complications, 10'? femoral and tibial insertion site preparation, 105 femoral tunnel placement, 106 graft choice, 103 graft harvest and preparation, 105

graft passage and fixation, 10'?

patient selection, 103

pearls, 102—108 portals and incisions, 104-105 postoperative care and rehabilitation, 1013‘r preoperative imaging, 103-104 room setup/ patient positioning, 104 special instruments! equipment/ implants, 104 tibial tunnel placement, 106—1017F Anterior lumbar il'ltEl'bOdy fusion complications, 622-628 contraindications, 625

diagnosis, 625

indications, 625

patient selection, 625 pearls, 623-629 postoperative care and rehabilitation, 628 preoperative imaging, 625-626 room setup} patient positioning, 626 special instruments! equipment! implants, 626-627 surgical technique, 62'? APL suspensionplasty, 296—298 Arthritis basal joint of thumb, 295—304

septic arthritis of hip, pediatric 653 subtalar arthrodesis, 515—518 tibiotalar arthrodesis, 509—514 Arthroplasty. See specific procedure ArthI'OSC'DP‘y

special instrumentsttecluipmentfimplants, 10

surgical technique for arthroscopic repair, 10—12 surgical technique for open repair, 12-14

Basal joint arthritis of the thumb, surgical treatment of

APL suspensionplasty, 296-293 complications, 303 LEE arthroplasty, 298-301 patient selection, 295 pearls, 303 postoperative care and rehabilitation, 303 preoperative imaging, 295—296 surgical technique, 296—303 thumb TMC arthroscopyn. 301—303 Biceps tenotomy and tenodesis complications, 28 contraindications, 25 indications, 25 patient selection, 25 postoperative care and rehabilitation, 23 preoperative imaging, 25—26 room setupl'r patient positioning, 26 surgical decision making, 26 surgical technique, 26—23 Boyd and Anderson two—incision approach for distal biceps repair, 44

Bryan—Money triceps—reflecting approach for total elbow arthroplastv, 226—22?

C

Calcaneal fractures, open reduction and internal fixation of

assessing the peroneal tendons, 463 complications, 464 contraindications, 459 definitive fixation, 463

delayed wound healing Iwound dehiscenoe, 464 indications, 459 mobilization of the fragments, 462

pathoanatomv, 460

ankle, 435—489 anterior cruciate ligament doublebundle reconstruction,

patient selection, 459 pearls, 464—465

anterior cruciate ligament reconstruction, 92—93 Bankart repair, 10—12

posttraumatic subtalar arthritis, 464

111—112

elbow, 203—209 femoroacetabular impingement, 55—53 medial meniscal root tears, 23—178

meniscectomy, 61

patellofemoral arthritis, 132

pediatric anterior cruciate ligament reconstruction, 113—121 rotator cuff disorders, 159—168 rotator cuff tears, partial-thickness, 3—8 subacromial decompression and distal clavicle resection,

150 superior labrum anterior-to—posterior tears, 12-24

710

postoperative care and rehabilitation, 464 preoperative imaging, 459460

reduction of the anterior process, 462—463 reduction of the articular surface, 462 resolution of soft—tissue swelling, 460—461

room setup,»r patient positioning, 461 special instruments]equipmentrrimplants, 461 split tongue—type variant patterns, 462 surgical technique, 461—464 wound closure, 463

Calcaneal lengthening osteotomy, 206—20? Calcaneal sliding osteotaomy, 207—208

lCialcaneonavicular coalition resection, 690—692

Carpal ganglionectomv, 290

(El 2013 American Acadmy of Drtlropaedic Sat-gems

room setup,1patient positioning, 35

Carpal tunnel release (CTR)

approach, 236

complications, 240

electrodiagnostic testing, 235

surgical technique, 35%?

Clubfoot, treatment using Ponseti method complex clubfoot, 684 complications, 685-636

open, 23t5r—23'i'r outcomes, 235 patient positioning, 236 patient selection, 235 pearls, 240

contraindications, 683

evaluation, 683 indications, 683 patient selection, 633 pearls, 63? percutaneous Achilles tenotomjc 635 postoperative care and rehabilitation, 636—687 serial casting, 684 special instruments]equipment!implants, 683 surgical technique, 634—635

postoperative care and rehabilitation, 240 revision, 239—240

single-incision endoscopic {modified Agee technique},

237—233 surgical technique, 236—240 hvo-incision endoscopic (Chow technique}, 239 Carpal nmnel syndrome (CTS), 235, 239—240 Cerebral palsy, lower extremity surgeryr in children with

adductor lengthening, 696—691?r bone procedures, 702—208

calcaneal lengthening osteotomy; 7'0? calcaneal sliding osteotomy, 702—708

combined procedure for spastic hip subluxationf dislocation, 702—203

distal femoral extension osteotomyr with patellar tendon

advancement, T0640? distal hamstring lengthening, 692-698 Functional Mobilityr Scale, 696 Gross Motor Function Classification System, 695 lengthening of the gastrocnemius-soleus, 696-699 pearls, 5'03 peroneus brevis lengthening. 699 posterior tibial tendon lengthening, 699—1700 proximal femoral rotational osteotomv, T03—‘i'05

teratologic Clubfoot, 634 vascular complications, 635—636

Compartment syndrome of the leg, fasciotomjg.r for complications, 372 patient selection, 3?1 pearls, 3573

postoperative care and rehabilitation, 322—323 surgical technique, 371—3?2 Complex regional pain syndrome {CH-‘8) distal radius fractures, 266—26?

partial pahnar fasciectomy, 309 Cubital tunnel syndrome, surgical treatment of anterior submuscular transposition, 245 complications, 246 contraindications, 242

electrodiagnostic testing, 241—242 endoscopic decompression {Hoffmann technique), 242-243 indications, 242 intramuscular transposition, 245

proximal femoral rotational osteotom].r with patellar tendon

medial epicondlvlectomy, 245 open decompression, 242

advancement, 206

psoas release at the pelvic brim, 200—?01

rectus femoris transfer to the hamstrings, 701

soft-tissue lengthening procedures, 696—201 soft-tissue transfer procedures, 701—702 split posterior tibial tendon transfer, 702 tibial derotational osteotomy; 705—706 Cervical laminoplast}r complications, 588—589 contraindications, 585 indications, 585 laminar closure, 539 patient selection, 535 pearls, 589

postoperative care and rehabilitation, 539' preoperative imaging, 535—53? room seppatient positioning, 53? special instruments! equipment!implants, 537 surgical technique, 5317—533 types of laminoplasty, 535 Chondrolysis, complication of Bankart repair, 14

patient selection, 241—242 pearls, 246

physical examination, 24]

postoperative care and rehabilitation, 243, 246

preoperative imaging, 242 room setup1' patient positioning, 242 in situ decompression, 242—243

special instruments!equipment}rimplants, 242 subcutaneous anterior transposition, 244-245

transposition techniques and medial epicondylectomy, 243—246 Cuff tear arthropathy, reverse total shoulder arthroplasty for complications, 200-201 contraindications, 1915‘r indications, 19?r patient selection, 19'? pearls, 201 postoperative care and rehabilitation, 201

preoperative imaging, 1917—198

Chopart amputation, 555

room setup}patient positioning, 198

Clavicle fractures, open reduction and internal fixation of complications, 3? contraindications, 35 indications, 35

surgical technique, 198—200 D

.

.

intramedullary nailing, 36—3?

dleefieivam syndrome. See First dorsal extensor compartment

patient selection, 35

Deep venous thrombosis (DVT)

pearls, 33 .

plate fixation, 35—36

postoperative care and rehabilitation, 32-33 preoperative imaging, 35

(it 2013 American Academy of Urthopaedic Surgeons

meniscal repair, 72 , cectomy 64

. . . ’ . Diaphyseal femur fractures, mtramedullary nailing of complications, 410

211

contraindications, 40?

indications, 40?

patient selection, 40? pearls, 410

postoperative care and rehabilitation, 410 preoperative imaging, 400‘r

room setup /patient positioning, 40'?r special instruments/ equipment Iimplants, 407 surgical technique, 407—410 Digital mucous cyst excision complications, 291, 294 contraindications, 293 indications, 293 patient selection, 293 pearls, 294 postoperative care and rehabilitation, 294 preoperative imaging, 293

surgical technique, 294 Discoid meniscus, 64

Distal biceps repair complications, 46

patient selection, 43 pearls, 46

postoperative care and rehabilitation, 46 preoperative imaging, 43 special instruments! equipmentI implants, 43 surgical technique, 43-46

Distal clavicle resection, 151

Distal femoral fractures, surgical fixation of approaches, 416-417»r complications, 420

contraindications, 413 indications, 413 patient selection, 413

patient selection, 263 pearls, 268 placement of distal fixator pins, 265—266

placement of proximal fixator pins, 265

postoperative care and rehabilitation, 26? preoperative imaging, 264 surgical technique, 264-266

Distal radius fractures, open reduction and internal fixation

with volar locking plate complications, 261 patient selection, 259 pearls, 261

postoperative care and rehabilitation, 261 preoperative imaging, 259 surgical technique, 259—261 Dupulvtren disease, partial palmar l‘asciectomjir for addressing joint contracture, 300 complications, 303—309 contraindications, 305

fasciectoinj,r types, 30? incisions, 30? indications, 305 initial dissection, 307 pearls, 309

postoperative care and rehabilitation, 309 preoperative imaging, 305 preoperative planning, 306 recurrence and extension of disease, 309 room setupf patient positioning, 305—306 special instruments,»lequipment, 306 surgical technique, 306—307 tissue excision, 302—303 wound closure, 303

pearls, 420

plate insertion, 418-420

postoperative care and rehabilitation, 420 preoperative imaging, 413 reduction techniques, 412-418 room setup} patient positioning, 414—415 special instruments! equipment! implants, 415 surgical technique, 415—420 timing, 413—414

Distal humerus fractures, open reduction and internal fixation

of complications, 223

contraindications, 219 indications, 219

olecranon osteotomyt. 221 paratricipital approach, 220—221 patient selection, 219 pearls, 224

postoperative care and rehabilitation, 223—224 preoperative imaging, 219 reduction and fixation, 221—222

surgical technique, 220—223 triceps peel, 221 triceps split, 22] Distal metatarsal osteotomy, 536—537

Distal radius fractures, external fixation of

closed reduction and adjunctive procedures, 264—265 complications, 266—26? contraindications, 263

indications, 263 outcomes, 267—268 patient positioning and setup, 264

712

Elastic intramedullary nailing in pediatric femur fractures complications, 669 pearls, 669

special instrummtsfequipment,limplants, 662-668 surgical technique, 663-669

Elbow arthroplasty. See Total elbow arthroplasty (TEA)

Elbow arthroscopy accessory posterolateral portal, 2017 anatomy, 203-204 anesthesia, 204

anterolateral portal, 206 anteromedial portal, 205 arthroscopic synovectomy, 208-209

complications, 209 contraindications, 204

diagnostic arthroscopy, 20?

direct lateral portal, 206 equipment, 204

indications, 204

lateral decubitus position, 205 loose bodies, 2017-208 patient positioning, 204—205 patient selection, 204 pearls, 209 portal placement, 205—20? posterior portal, 206 posterolateral portal, 207 prone position, 205 proximal anterolateral portal, 206

proximal anteromedial portal, 205-206

(El 2013 American Acadmy of Drthopaedic Sui-gems

Electrodiagnostic testing carpal turmel syndrome, 235-236

fixation of the radial fracture, 3?9—3-30 fixation of the ulnar fracture, 330

patient positioningi'rroom setup, 326 patient selection, 375—326 pearls, 333 postoperative care and rehabilitation, 383 preoperative imaging, 376 preoperative planning, 3'76

cubital tunnel syndrome, 241—242

Electromyographic (EMS) studies, 235, 236 Ellman classification system, for partial thickness rotator cuff tears, 4

Endoscopic decompression (Hoffmann technique), 242—243 Extended trochanteric osteotomy, revision total hip arthroplasty via complications, 333 contraindications, 334 exposure, 335

indications, 333-334

osteotomy, 335—333 patient selection, 333-334 pearls, 333-339 postoperative care and rehabilitation, 333

provisional reduction of the radial fracture, 323—3179 surgical technique, 376—331 wound closure, 330—331 Fracture—dislocation patterns, 460

Fractures

flexion—type, 632—633 forearm, 325—334 lateral condvle fractures of the distal hurrrerus, 641—646 open, 633—639

pediatric femur, 663—622

preoperative imaging, 334

preoperative planning, 334-335 special instruments! equipment,i'implants, 335 F

pediatric radial and ulnar shaft, 642-652

supracondvlar humerus, 633—640 type IV, 633 Frozen shoulder, arthroscopic management of complications, 156—1557Jr patient selection, 153 pearls, 15'}r

Femoral derotation osteotomyr complications, 674 contraindications, 673

indications, 6'33

patient selection, 623 pearls, 625

postoperative care and rehabilitation, 674-625 preoperative imaging, 623 room setup 1patient positioning, 6173 surgical technique, 623—624

Femoral neck fractures, open reduction and internal fixation of complications, 397 fixation in the older patient, 392r instruments fequipmentl'rimplants, 393—394 patient selection, 393 pearls, 393

postoperative care and rehabilitation, 39? preoperative imaging, 393 surgical technique, 394-392r Femoroacetabular impingement (FM), arthroscopic management of

postoperative care and rehabilitation, 15? preoperative imaging, 153—154 surgical technique, 154—156 Functional Mobility Scale for cerebral palsy, 696

G

Ganglion cysts of the wrist and hand, excision of arthroscopic ganglionectomy, 239 carpal ganglionectomy, 29D complications, 293—291 contraindications, 233 dorsal wrist ganglionectomy, 293 indications, 232—233 instruments! equipment, 233

mucous cyst excision, 290 open dorsal wrist ganglionectomjx 233-239 open volar wrist ganglionectomy, 239 patient presentation, 23'}r patient selection, 237-233 pearls, 291 postoperative care and rehabilitation, 291 preoperative imaging, 233 radial-side ganglionectomy, 239 retinacular cyst excision, 239—290

complications, 53

contraindications, 55 indications, 55 patient selection, 55

pearls, 53

postoperative care and rehabilitation, 53 preoperative imaging, 55 room setup Ipatient positioning, 55—56

room setup! patient positioning, 233 surgical technique, 233—290

special instruments;fequipmentIimplants, 56

surgical technique, 56-53 First dorsal extensor compartment release complications, 249—250 patient selection, 24? pearls, 251

postoperative care and rehabilitation, 250-251 preoperative imaging, 24? room setup 1’patient positioning, 24'?r

special instruments! equipment! implants, 247Ir

surgical technique, 247-249

Forearm fractures, open reduction and internal fixation of approach for radial fixation, 373 complications, 331—333 evaluation, 376

(El 2013 American Academy of Urthopaedic Surgeons

ulnar-side ganglionectomy, 239 wound closure, 239

lIt]astrocnemius-soleus lengthening, 693-699 Golfer’s elbow. See Medial epicondylitis

Gross Motor Function Classification System, 695

H

Hallux valgus, osteotomies for complications, 533-539 contraindications, 535 distal metatarsal osteotomy, 536-53? indications, 535 patient selection, 535—536 pearls, 539

postoperative care and rehabilitation, 539 Z713

preoperative imaging, 536 proximal metatarsal osteotomy, 537—533 room setup/patient positioning, 536 special instruments 1'equipment Iimplants, 536 surgical technique, 536—538 Hemiarthroplasty, hip direct anterior approach, 329—330 direct lateral approach, 321-322 Hip arthroplasty, direct anterior approach contraindications, 325 indications, 325 patient selection, 325 pearls, 331 postoperative care and rehabilitation, 330—331 preoperative imaging, 325

room setup!patient positioning, 325—326 special instruments,»f equipment Iimplants, 326 surgical technique, 326—330 Hip arthroplasty, via a direct lateral approach complications, 322 contraindications, 319

indications, 319

patient selection, 319

pearls, 323 postoperative care and rehabilitation, 322-323 preoperative imaging, 319 room setup! patient positioning, 319 special instruments! equipment, 319 surgical technique, 319—321

Hip arthroplasty, via small-incision enhanced posterior softtissue repair complications, 319r contraindications, 313

hemiarthroplasty, surgical technique, 316—31? indications, 313

patient selection, 313

pearls, 31:?r postoperative care and rehabilitation, 31? preoperative imaging and planning, 313 room setup! patient positioning, 313 SIEPSTR approach, 316 special instruments! equipment, 313 surgical technique, 313—317

I

Infection anterior cruciate ligament reconstruction, 100 Bankart repair, 14 cervical larninoplasty, 538 clavicle fractures, 32

cubital tunnel syndrome, 246 cuff tear arthropathv, 201

distal radius fractures, 261, 266

Dupuytren disease, 303 hip arthroplasty, 322 meniscal repair, '72

total elbow arthroplasty, 230 total shoulder arthroplastyr for osteoarthritis, 196 transforaminal lumbar interbodjg.r fusion, 620

Instrumented lumbar fusion complications, 614—615 contraindications, 611

indications, 61]

patient selection, 611 pearls, 615

postoperative care and rehabilitation, 615 714

preoperative imaging, 611 room setup] patient positioning, 612 special instruments]equipment;rimplants, 612 surgical technique, 612—614 lntertrochanteric fracture fixation complications, 404 contraindications, 401 indications, 401

patient selection, 401 pearls, 405—405 postoperative care and rehabilitation, 404 preoperative imaging, 401 room setupI patient positioning, 401—402 special instruments fequipment, 402 surgical technique for cephalomedullarv nail, 402—403 surgical technique for sliding hip screw, 403—404 lntramedullary (1M) nailing, 36—31?

I(

Kvphosis line concept, 585—536

L

Lao-ninoplasty, types of, 535

Lateral conde fractures of the distal humerus, reduction and fixation of complications, 644 patient selection, 641 pearls, 644 postoperative care and rehabilitation, 644 preoperative imaging, 641

special instruments}reqflpmentfimplants, 54:2

surgical tectmique, 642-644 Lateral epicondvlitis, open treatment of complications, 40 patient selection, 39 pearls, 41 postoperative care and rehabilitation, 40—41 preoperative imaging, 39 room setup] patient positioning, 39 special instruments!requipment!implants, 39 surgical technique, 39 Letournel classification system, 385

Ligament reconstruction tendon interposition (LRI'I) arthroplasty, 295, 298—301 Lisfranc amputation, 554—555 Lobenhoffer approach, 424—429 Long head of the biceps tendon (LHBT), 25—29

Lumbar laminectomv

complications, 609—610 contraindications, 60’?r indications, 60? patient selection, 60? pearls, 610

postoperative care and rehabilitation, 610 preoperative imaging, 60? room setup,»l patient positioning, 6017‘r surgical technique, 608—609 Lumbar microdiskectomyr complications, 605 contraindications, 601 indications, 601 patient selection, 601 pearls, 605

postoperative care and rehabilitation, 605 preoperative imaging, 601 room setup! patient positioning, 601-602

© 2013 American Academy of Drthopaedic Sat-gems

surgical technique, 61—64

special instruments 3'equipment Iimplants, 601 surgical technique for, 602-604

surgical technique for far-lateral, 604—605

M

Mayo classification system, 215 Medial epicondylectomy, 245 Medial epicondylitis, open treatment of complications, 40 patient selection, 39 pearls, 41

vertical tears, 63

Metacarpal fractures, surgical fixation of

metacarpal head fractures, 284-285 metacarpal neck fractures, 282-283 metacarpal shaft fractures, 233-284 patient selection, 282 pearls, 285 postoperative care and rehabilitation, 235 preoperative imaging, 232 Metatarsophalangeal (MTP) joint arthrodesis alternative treatments, 531 complications, 533 contraindications, 531 indications, 531 patient selection, 531 pearls, 533

postoperative care and rehabilitation, 40—41 preoperative imaging, 39 room setupfpatient positioning, 39 special instruments! equipment/ implants, 39 surgical technique, 39—40

Medial meniscal root tears {MIvIRTsL repair of complications, 26

diagnostic arthroscopv, 74—25

patient selection, 23 pearls, 27 portals and incisions, '74

postoperative care and rehabilitation, 533 preoperative imaging, 531 special equipment and implants, 531—532 surgical technique, 532—533 Microfracture complications, 81 contraindications, 29 indications, 29 patient selection, 79

posteromedial portal, 2'5 postoperative care and rehabilitation. 76—7? preoperative imaging, 23—74 repair of, 73—78

room setup!patient positioning, 74 special instruments;f equipment Iimplants, 7'4 surgical technique, 24—26

Medial patellofemoral ligament reconstruction, for recurrent patellar instability

pearls, 32 postoperative care and rehabilitation, 81—32 preoperative imaging, '79 surgical technique, 80—31 Midfoot amputations complications, 555 contraindications, 551

complications, 123—129 contraindications, 125 indications, 125

imaging, 552

indications, 551

patient positioning,»r examination, 126

laboratory,F and diagnostic tests, 551—552

patient selection, 125 pearls, 129—130

patient selection, 551 pearls, 555

postoperative care and rehabilitation, 129 preoperative imaging, 125 surgical technique, 126-123 Meniscal repair complications, 21—22 contraindications, 67 indications, 67 patient selection, 6? pearls, 22

postoperative care and rehabilitation, 72 preoperative imaging, 6? room setup /patient positioning, 68 special instruments! equipmentIimplants, 63—69

surgical technique, 69—21 Meniscal root tears, 53 Meniscectomy arthroscopy, til

complications, 64 diagnosis, 60 discoid meniscus, 64

displaced bucket-handle tears, 63

evaluation and tear morphology, 61-62 horizontal cleavage tears, 62-63 meniscal root tears, 63

patient selection, 60

pearls, 65 preoperative imaging, 60-61 radial tears, 62 setup!equipment, 61

(fl) 2013 American Academy of Urthopasdic Surgeons

postoperative care and rehabilitation, 555—556 preoperative evaluation, 551-553 room setup2' patient positioning, 553 surgical tedmique, 553-555

Milch classification system, 641 Motor root palsies, 539 Mucous cyst excision, 290

Multimodal pain management, 354

Myerson classification system, 468

N

Navicular stress fractures, surgical treatment of complications, 529—530 patient positioning, 527—523 patient selection, 52? pearls, 53D

preoperative imaging, 52? surgical teclmique, 523—529

Nerve conduction studies (MES), 235, 236

O

Ellecranon fractures, open treatment of complications, 2]? excision, 216

open reduction and internal fixation, 216-217

patient selection, 215—216

pearls, 218 postoperative care, 2117—213 Z715

preoperative imaging, 216 room setup]patient positioning, 216 special instniments/r equipment 1'implants, 216 surgical technique, 216—212

Dlecranon osteotomy, 221 Osteoarthritis, total shoulder arthroplast}.ir for

approach, 192—193

closure, 195—196 complications, 196—192

glenoid component placement, 194—195 glenoid exposure, 194 humeral preparation, 193—194

patient selection, 191 pearls, 196 postoperative care and rehabilitation, 196 preoperative imaging, 191

room setup Ipatient positioning, 191—192 special instruments,»f equipmentI implants, 192 surgical technique, 192—196 Gsteocbonclral lesions of the talus (OL'Is), arthroscopic treatment of

classification of, 491-493 complications, 496 diagnostic imaging, 491 equipment, 493 pearls, 496 postoperative care, 496 setup 2patient positioning, 493 surgical technique, 493-496 treatment options 2indications, 492-493

Osteochondritis dissecans (0CD) lesions, surgical treatment of comorbidities, 93

patient selection, 663 pearls, 662, 669, 620

postoperative care and rehabilitation, 662 preoperative imaging, 663 submuscular plating, 663 surgical technique, 664—666, 668—620

trochanteric intramedullar}ir fixation, 669—620 Peroneus brevis lengthening, 699 Phalangeal fractures, open reduction and internal fixation of complications, 226—228, 2313 patient selection, 225 pearls, 22B

phalangeal condvlar fractures, 225—223 phalangeal shaft fractures, 223-231] postoperative care and rehabilitation, 226

surgical technique, 225—226, 229-239 Ponseti method, 633-632

Posterior cervical forarninotompr complications, 522 contraindications, 525 indications, 525 patient selection, 525 pearls, 522

postoperative care and rehabilitation, 522 preoperative imaging, 525 room setup2 patient positioning, 525 surgical technique, 525—522

Posterior cervical laminectomv and fusion complications, 532—583 dural injury, 583

lateral mass instrumentation, 533

neurologic complications, 582—533

patient selection, 65-56 pearls, 93 preoperative imaging, 66-62

patient selection, 529 pearls, 533 postlaminectomy kyphosis, 533

restorative procedures, 90-93 room setupllpatient positioning, 32 surgical technique, 82—93

room setup1 patient positioning, 529—581

reparative procedures, 66—99

treatment decisions, 85

P

Patellar tendon injuries, surgical treatment of acute patellar tendon repair, 140-141 complications, 143-144

extensor mechanism disruptions after total knee

arthroplasty, 143-144 patient selection, 133 pearls, 145 postoperative care and rehabilitation, 144—145 preoperative imaging, 136—139 Patellofemoral arthritis, realignment for complications, 133 diagnostic arthroscopv, 132 examination under anesthesia, 132 patient selection, 131 pearls, 134

postoperative care and rehabilitation, 133-134 preoperative imaging, 131 room setup 1patient positioning, 132 special instruments! equipment!r implants, 132 surgical technique, 132—133

Pediatric femur fractures, fixation of

Ellgtlilillilllttfziiidulla fiymfling, 662—669 indications 663 I?

216

postoperative care and rehabilitation, 533

preoperative imaging, 5'29

special instrumentsfequipment}implants, 581 Surgical technique, 581—582 vascular complications, 562

Posterior tibial tendon lengthening, 699-200 Posterior wall acetabular fractures, open reduction and internal fixation of associated injuries, 385-386 classification of, 365 complications, 390 early management of dislocation, 336 equipment! implants, 336

exposure, 366—382 implant selection, 386 intra-articular fragments, 332 marginal impaction, 382 pearls, 39D postoperative care and rehabilitation, 39G preoperative imaging, 336 preoperative planning and patient positioning, 336 provisional fixation, 383 surgical technique, 386—390 wound management, 388—390

Posttraumatic osteoarthritis, 37 Posttraumatic subtalar arthritis, 4-64

Propionibactrfium areas, 14 Proximal femoral rotational osteotomy, 203—205 Prom'mal femoral rotational 95152131i2 with patellar tendon advancement, 206

(El 2013 American Acadmy of firthopoedic Sui-gems

Proximal fifth metatarsal fractures, open reduction and

complications, 143—144

extensor mechanism disruptions after total knee arthroplasty, 143

internal fixation of approach, 473—474

patient selection, 138 pearls, 145

complications, 473 contraindications, 473

postoperative care and rehabilitation, 144—145 preoperative imaging, 133—139

guide pin positioning and drilling, 474-476 indications, 473 patient selection, 473 pearls, 479—430

postoperative care and rehabilitation, 478—479 preoperative imaging, 473

room setup /patient positioning, 473 screws, 477—473

special instruments! equipmentX implants, 473 surgical technique, 473—473 Proximal humerus fractures, hemiarthroplasty for complications, 137—133 contraindications, 133 history and physical examination, 133

humeral prosthesis positioning, 185—186 indications, 183 patient selection, 1133

pearls, 138

postoperative care and rehabilitation, 188 preoperative imaging, 183—184

room setup1’patient positioning, 184 special instruments7equipment!implants, 184 surgical technique, 184—187 tuberosity handling, 134—185 tuberosity reduction and fixation, 136-137

Proximal humerus fractures, fixation of assessment of reduction, 130

complications, 130—131

contraindications, 175 definitive fixation, 150

exposure, 177—173

extensile maneuvers, 173

humeral head support, 175I indications, 175

patient selection, 175 pearls, 181—182 postoperative care and rehabilitation, 181 preoperative imaging, 175 provisional fixation, 17? reduction maneuvers, 178—179 room setup for fluoroscopic imaging!patient positioning, 175—176 special instrumentsI equipment! implants, 176—177 surgical technique, 177—130 Proximal humerus fractures, percutaneous pinning of complications, 172 contraindications, 169 indications, 169 patient selection, 169 pearls, 173

postoperative care and rehabilitation, 172-173 preoperative imaging, 169 room setup /patient positioning, 169—170 special instnunents/ equipment /implants, 170 surgical technique, 170—172 Proximal metatarsal osteotomy, 537—533

Psoas release at the pelvic brim, 700—701

0

Quadriceps injuries, surgical treatment of chronic quadriceps repairs, 141—143

(fl) 2013 American Acadmy of firthopaedic Surgeons

tendon repair, 139—140

R

Radial and ulnar shaft fractures, intramedullarjyr fixation of in

skeletally immature patients complications, 651—652 contraindications, 648 indications, 647—643 patient selection, 647—643 pearls, 652

postoperative care and rehabilitation, 652 preoperative imaging, 648 room setup] patient positioning, 648 special instruments]equipment;rimplants, 643—649 surgical technique, 649—651

Radial head fractures, open treatment of complications, 214 patient selection, 211

pearls, 215 postoperative care, 214—215 preoperative imaging, 211 room setupI patient positioning, 211

special instruments]equipmentsrimplants, 211—212

surgical technique, 212—214

Rectus femoris transfer to the hamstrings, 7D] Retinacular cyst excision, 239—290

Revision total knee arthroplasty, via quadriceps snip clinical results, 361 complications, 361 contraindications, 359 indications, 359 patient selection, 359 pearls, 361

postoperative care and rehabilitation, 361 room setup1’ patient positioning, 359 special instruments!equipment!implants, 359 surgical technique, 359-360

Revision total knee arthroplasty, via tibial tubercle osteotomy complications, 365 contraindications, 363 indications, 363 patient selection, 363

pearls, 365—366

postoperative care and rehabilitation, 365

preoperative imaging, 363 room setup7 patient positioning, 363

special instruments!equipment!implants, 364

surgical technique, 364-365

Rnckwoo-d classification system, 31

Rotator cuff disorders, arthroscopic repair of

anchor placement and suture passage, 164-165 closure, 166

complications, 166

contraindications, 160

indications, 160

intra-articular artl'nroscop}r and débridement, 162

lcnot tying, 165 lateral-row repair, 165-166

marginal convergence sutures, 164 717

patient selection, 159—160 pearls, 16?

postoperative care and rehabilitation, 166—16? preoperative imaging, 160 special instruments/ equipment Iimplants, 161 subacromial bursectomv and acromioplasty, 162—163 surgical technique, 161—166 tear characterization and mobilization, 163

tips for portal placement, 162 tuberositj,r and tendon preparation, 163—164 Rotator cuff tears, arthroscopic repair of partial-thickness bursal-side tears, 6 classificafion of, 4 complications, 6—?” contraindicafions, 3 diagnostic arthroscopy, 4 indications, 3 patient selection, 3 pearls, 2’ postoperative care and rehabilitation, 'i"

preoperative imaging, 3 repair of, 4-6

room setup/patient positioning, 3

special instruments! equipment, 4

surgical technique, 4-6

transosseous-equivalent technique, 5-6

5

Scaphoid fractures, open reduction and internal fixation of complications, 222-223 dorsal approach, 272—2173 patient selection, 269—228

pearls, ass—274

postoperative care and rehabilitation, 273

preoperative imaging, 269 room setup Ipatient positioning, 2'28 special instrumentsf equipment,4"implants, 2'10 surgical technique, 2178-2172

volar approach, 220472

Scapular notching, 200 Seebauer classification system, 198

Septic hip, incision and drainage of complications, 655-656 patient selection, 653 pearls, 656 postoperative care and rehabilitation, 656 preoperative imaging, 653 room setup /patient positioning, 653

special instruments!equipment}implants, 653 surgical technique, 654-655

SIEPSTR approach, 316

Single-incision endoscopic CTR {modified Ages technique},

232-238 Slipped capital femoral epiphvsis (SCFE), percutaneous in situ fixation of complications, 660—661 patient selection, 65? pearls, 662 postoperative care and rehabilitation, 661-662 preoperative imaging, 65? room setup! patient positioning, 657—659 surgical technique, 659—660 Snyder classification system, 1'? Spastic hip subluxa tion Idislocation, combined procedure for, 702—783 Split posterior tibial tendon transfer, 201-202 713

Stenosing tenosvnovitis. See Trigger finger Subacromial decompression, arthroscopic acrornioplasty and subacromial decompression, 150—151 complications, 152

diagnostic arthroscopy, 150

distal clavicle resection, 151

examination under anesthesia, 150 patient selection, 149 pearls, 152 postoperative care and rehabilitation, 152 preoperative imaging, 14!? room setupl' patient positioning, 149 special instrumentsfequipmentfirnplants, 149 surgical technique, 150—152

Subtalar arthrodesis complications, 5]? contraindications, 515 deformity correction, 516—51?r implants, 515 indications, 515 outcomes, 512—518 patient selection, 515 pearls, 518

postoperative care and rehabilitation, 51? preoperative imaging, 515

setup,I' patient positioning, 515 surgical technique, 515—511?r Superior labrum anterior-to-posterior (SLAP) tears, arthroscopic repair of alternative repair techniques and considerations, 21—22 cannula placement, 2D complicafions, 22—23 contraindicafions, 18 diagnosfic arthroscopy, El} indicafions, 18 patient selecfion, 18 pearls, 23 postoperative care and rehabilitation, 23

preoperafive imaging, 18

range of mofion goals following repair, 23

room setup1' patient positioning, 19 special instruments!r«equipmentsrimplants, 19-20

surgical considerations, 18-19

surgical technique, 20-22 suture anchor placement, 20-21

Supracondvlar humerus fractures, closed and open reduction of dressing and casting, 63? flexion-type fractures, 632—638 fracture fixation, 636—637

fracture reduction, 634-636

lateral-entry vs. amenial-entryr pins, 63?

nonsurgical management, 634 open fractures, 638-639 patient evaluation, 633-634

pearls, 639

postoperative care and rehabilitation, 639

room setup]patient positioning, 634 surgical technique, 634—637 type W fractures, 638 Surgical debridement, general principles of postoperative care and rehabilitation, 369 surgical technique, 369

(it 2013 American Acadmy of Drthopaedic Sat-gems

Talus fractures, surgical management of anatomy, 451 classification of, 452

complications, 455

contraindications, 452

indications, 452

instrumentsfva-quipmentrrimplants, 453-454

mechanism of injury, 451-452 patient positioning, 453 patient selection, 452 pearls, 455—456 postoperative care and rehabilitation, 455 preoperative imaging, 452-453 surgical technique, 454—455

Tarsal coalitions, treatment of

calcaneonavicular coalition resection, 690—692 complications, 694 tat graft harvest, 693—594 patient selection, 689

pearls, 694 postoperative care and rehabilitation, 694 preoperative imaging, 639 room setup!patient positioning, 689 special instruments! equipment;f implants, 639-691} surgical technique, 690—694 talocalcaneal coalition resection, 692—693

Tarsometatarsal joint, arthrodesis of anatomy, 519 complications, 523—524 contraindications, 519 indications, 519 patient selection, 519 pearls, 524

postoperative care and rehabilitation, 524 surgical technique, 519—523 Tarsometatarsal joint fracturedislocations, open reduction and internal fixation of complications, 4TB patient selection, 46? pearls, 429

postoperative care and rehabilitation, 420 preoperative (diagnostic) imaging, 462—468 room setup ,w’patient positioning, 468 special instruments/ equipment Iimplants, 463—489 surgical technique, 469—470 Tennis elbow. Sec lateral epicondvlitis Thoracic pedicle screws, placement of closure, 596-59? complications, 597 contraindications, 591

gearshift probing, 594—595

incision and exposure, 592—593 indications, 591 patient selection, 591 pearls, 593 pedicle sounding, 595—596

postoperative care and rehabilitation, 59S preoperative imaging, 591 room setup ,w’patient positioning, 591—592 special instruments1 equipment! implants, 592 starting point and trajectory, 593-594 surgical technique, 592-59? Thrower’s elbow. See Medial epiconclylitis Tibial diaphyseal intramedullary nailing approach and start site, 430

(fl) 2013 American Academy of Urthopaaiic Surgeons

complications, 435

contraindications, 429 fracture reduction, 43] incision closure, 434—435 indications, 429 interlocking screw enhancement, 434

patient selection, 429 pearls, 435 postoperative care and rehabilitation, 435 preoperative imaging, 429 room setup! patient positioning, 429 special instrumentsfequipment;r implants, 429—430 surgical technique, 430—435 Tibia] plafond, open reduction and internal fixation of complications, 441—442 contraindications, 45'?

definitive surgery, 440—441 implants, 441

index surgery; 433-44D indications, 43? patient selection, 43'? pearls, 442

postoperative care and rehabilitation, 442 preoperative imaging, 43? room setup}!l patient positioning, 433 sequence of reduction, 441 surgical technique, 438—441 Tibial plateau fractures, open reduction and internal fixation of alternative treatments, 421

anterolateral approach, 423—424 approaches, 422 classification of, 421 complications, 425—42? contraindications, 421 indications, 421

Lobenhoffer approach, 424—425 patient selection, 421 pearls, 422r

postoperative care and rehabilitation, 42'?Ir preoperative imaging, 421—422 room setup2' patient positioning, 422 special instruments]equipment;rimplants, 422—423 surgical technique, 423-425 Tibial spine fractures in children, surgical reduction and fixation of complications, 681 contraindications, 6?? indications, 6??

patient selection, 67?

pearls, 681—632 postoperative care and rehabilitation, 681 preoperative imaging, 67?

room setup1 patient positioning, 622—628 special il'lSlI‘tJJI'lEfltSfequipment!implants, 623 surgical tecl'lnique, 673-681 Tibiotalar arthmdesis

contraindications, 599 general principles of, 509—510 indications, 599

outcomesfcomplications, 512-514

patient positioning, 510 patient selection, 509 pearls, 514 postoperative care, 514 preoperative imaging, 509

719

special instruments /equipmentIimplants, 510 surgical technique, 510—512 Total elbow arthroplasty (TEA) bone preparation, 228—229 Bryan-heiorre},r triceps-reflecting approach, 226-22?r complications, 230—231 contraindications, 225 indications, 25 patient selection, 225 pearls, 231

postoperative care and rehabilitation, 231 preoperative evaluation, 225 preoperative imaging, 225

preoperative planning, 225

room setup /patient positioning, 225—226 surgical technique, 226—229 triceps-sparing approach, 2217—223 Total knee arthroplasty, via the medial parapatellar approach arthrotomy, 342—343 bone resection, 343

complications, 344

contraindications, 341

implantation of components, 343-344 indications, 341 patellar eversion and additional exposure, 343 patient selection, 341 pearls, 344 posteromedial soft-tissue release, 343 postoperative care and rehabilitation, 344 preoperative evaluation, 341 room setup/patient positioning, 342

special instruments!equipment, 342

surgical technique, 342-343 Total knee arthroplasty, via the mhfi-subvastus approach applicability, 355—356 complications, 356 concerns about minimally invasive, 355 contraindications, 351 femoral and tibial preparation, 352—354 incision and arthrotomy, 351—352 indications, 351 learning curve, 356 mobilization, 354—355 multimodal pain management, 354

patellar mobilization, 352 patient selection, 351

pearls, 355 postoperative care and rehabilitation, 354

room seppatient positioning, 351 special instruments! equipment;r implants, 351 surgical technique, 351—354 trialing, balancing, and final preparation, 354 Total lcnee arthroplasty, via small—incision midvastus approach closure, 349 complications, 349 component insertion, 349 contraindications, 345 distal femoral resection, 346—34? exposure, 346

femoral sizing and anterior-posterior resection, 343 , 'fimlizlailc5if!1:32:11, 348—349 patellar preparation, 343

patient positioning, 345 patient selection, 345 pearls, 350

720

postoperative care and rehabilitation, 350

preoperative imaging, 345 special instruments, 345—346 surgical teclmique, 346-349 tibial preparation, 342-348 Total shoulder arthroplasty for osteoarthritis, 191—193 Transforaminal lumbar interbody fusion (‘I'LIFJ complications, 620-622

contraindications, 617 indications, 617 infection, 620 patient selection, 61? pearls, 622

pedicle screw malposition, 621 postoperative care and rehabilitation, 622 postoperative radiculopathy, 621 preoperative imaging, 61? pseudarthrosis, 621

room setup! patient positioning, 611ir special instrumentalrequipment,»|rimplants, 617 surgical technique, 613—620 Transtibial amputation complications, 548 contraindications, 545 indications, 545 patient selection, 545

pearls, 549 postoperative care and rehabilitation, 548—549 preparation for a bone-bridge procedure, 547—548 room setup,1patient positioning, 545—546 special instrumentsfequipmentr' implants, 546 surgical technique, 546—547 Triceps peel, 221 Triceps split, 221 Trigger finger release anatomy; 254 complications, 256 contraindications, 254 indications, 253—254 patient selection, 253-254 patients with diabetes, 253

patients with distal triggering, 253

patients with P1P contracture, 253 patients with rheumatoid arthritis, 253 pearls, 256

postoperative care and rehabilitation, 256 preoperative imaging, 254 release of the central digits (ring or long finger), 254—256 special populations! situations, 253

trigger thumb release, 256 Two-incision endoscopic CIR (Chow technique], 233—239

Ulnar collateral ligament (UCL) reconstruction complications, 52 contraindications, 50 indications, 49—50

patient positioning]special equipment, 50 patient selection, 49—50

pearls, 53 postoperative care and rehabilitation, 52—53

preofiaml ue 565:5?

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(it 2013 American Acadmy of Drihopaedic Sui-gems

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AMERICAN ACADEMY on ORTHDPAEDIC SURGEDNS