Gowned and Gloved

GOWNED AND GLOVED
ORTHOPAEDICS
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GOWNED AND GLOVED
ORTHOPAEDICS:
INTRODUCTION TO
COMMON PROCEDURES
Neil P. Sheth, MD
Instructor
Department of Orthopaedic Surgery
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania
Jess H. Lonner, MD
Director of Knee Replacement Surgery
Booth Bartolozzi Balderston Orthopaedics
Pennsylvania Hospital;
Medical Director
Philadelphia Center for Minimally Invasive Knee Surgery
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1600 John F. Kennedy Boulevard
Suite 1800
Philadelphia, PA 19103-2899
GOWNED AND GLOVED ORTHOPAEDICS:

INTRODUCTION TO COMMON PROCEDURES ISBN: 978-1-4160-4820-6
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
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dose or formula, the method and duration of administration, and contraindications. It is the
responsibility of the practitioner, relying on their own experience and knowledge of the patient, to
make diagnoses, to determine dosages and the best treatment for each individual patient, and to take
all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the
Editors assume any liability for any injury and/or damage to persons or property arising out or
related to any use of the material contained in this book.
The Publisher
Library of Congress Cataloging-in-Publication Data
Gowned and gloved orthopaedics : introduction to common procedures /

[edited by] Neil P. Sheth, Jess H. Lonner. — 1st ed.
p. ; cm. — (Gowned and gloved)
Includes bibliographical references and index.
ISBN 978-1-4160-4820-6
1. Orthopedics—Textbooks. I. Sheth, Neil P. II. Lonner, Jess H. III. Series.
[DNLM: 1. Orthopedic Procedures—methods. WE 190 G723 2009]
RD731.G69 2009
617.4′7—dc22
2008011021
Acquisitions Editor: James Merritt

Developmental Editor: Andrea Vosburgh
Publishing Services Manager: Joan Sinclair
Design Direction: Gene Harris
Working together to grow

libraries in developing countries
Printed in China www.elsevier.com | www.bookaid.org | www.sabre.org
Last digit is the print number: 9 8 7 6 5 4 3 2 1
DEDICATION
To the medical students who inspired the concept behind this text.
To my mentors, many of whom were involved with this project—
thank you for your direction and guidance throughout the years
and for getting me to this point in my career.
Most important, to my family and friends—thank you
for your unconditional support of my academic endeavors.
NPS
To the students and residents who are considering a career in

orthopaedic surgery—you are our future. I hope this book
piques your interest and moves you to make a difference in
this great specialty.
To the surgeons and residents who motivated, inspired,
and taught me when I was learning the trade.
Most important, to my greatest joys—my wife, Ami,
and our sons, Carson and Jared.
JHL
CONTRIBUTORS
JOSEPH A. ABBOUD, MD DAVID J. BOZENTKA, MD

Clinical Assistant Professor Associate Professor
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
The University of Pennsylvania Health System University of Pennsylvania School of Medicine;
Philadelphia, Pennsylvania Chief
JAIMO AHN, MD, PHD Penn Presbyterian Medical Center
Instructor Philadelphia, Pennsylvania
Hospital of the University of Pennsylvania KINGSLEY R. CHIN, MD
Philadelphia, Pennsylvania Assistant Professor of Orthopaedics
NIRAV H. AMIN, BS Hospital of the University of Pennsylvania
Medical Student Philadelphia, Pennsylvania
Drexel University College of Medicine
Philadelphia, Pennsylvania GREGORY K. DEIRMENGIAN, MD
Instructor
JOSHUA D. AUERBACH, MD Department of Orthopaedic Surgery
Instructor Hospital of the University of Pennsylvania
Department of Orthopaedic Surgery Philadelphia, Pennsylvania
Philadelphia, Pennsylvania DEREK DOMBROSKI, MD
Instructor
KEITH D. BALDWIN, MD, MSPT, MPH Department of Orthopaedic Surgery
Instructor Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania DEREK J. DONEGAN, MD
Instructor
PEDRO BEREDJIKLIAN, MD Department of Orthopaedic Surgery
Associate Professor Hospital of the University of Pennsylvania
University of Pennsylvania School of
Medicine JOHN L. ESTERHAI, MD
Philadelphia, Pennsylvania Professor
KAREN J. BOSELLI, MD University of Pennsylvania School of Medicine;
Instructor Chief of Orthopedics
Department of Orthopaedic Surgery Department of Surgery
Hospital of the University of Pennsylvania Veterans Affairs Medical Center
Philadelphia, Pennsylvania Philadelphia, Pennsylvania
ANDREA L. BOWERS, MD JOHN M. FLYNN, MD

Instructor Associate Professor
Hospital of the University of Pennsylvania University of Pennsylvania School of Medicine;
Philadelphia, Pennsylvania Associate Chief
Department of Pediatric Orthopaedics
The Children’s Hospital of Philadelphia
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viii Contributors
THEODORE J. GANLEY, MD G. RUSSELL HUFFMAN, MD, MPH

Assistant Professor Assistant Professor
University of Pennsylvania School of Medicine; University of Pennsylvania Sports Medicine Center
Orthopaedic Director of Sports Medicine Philadelphia, Pennsylvania
Department of Pediatric Orthopaedic Surgery
The Children’s Hospital of Philadelphia CRAIG L. ISRAELITE, MD
Philadelphia, Pennsylvania Assistant Professor
JONATHAN P. GARINO, MD University of Pennsylvania School of Medicine
Associate Professor Philadelphia, Pennsylvania
University of Pennsylvania School of Medicine; KRISTOFER J. JONES, MD
Director Instructor
Adult Reconstructive Service Department of Orthopaedic Surgery
Penn Presbyterian Medical Center Weill Cornell Medical College
Philadelphia, Pennsylvania Hospital for Special Surgery
New York, New York
ALBERT O. GEE, MD
Instructor JULIA A. KENNISTON, MD
Department of Orthopaedic Surgery Instructor
Hospital of the University of Pennsylvania Department of Orthopaedic Surgery
Philadelphia, Pennsylvania Hospital of the University of Pennsylvania
DAVID L. GLASER, MD
Assistant Professor SAFDAR N. KHAN, MD
Department of Orthopaedic Surgery Orthopaedic Resident
University of Pennsylvania School of Medicine; Department of Orthopaedic Surgery
Chief University of California at Davis
Shoulder and Elbow Service Sacramento, California
Penn Presbyterian Medical Center
Philadelphia, Pennsylvania ERIC O. KLINEBERG, MD
Assistant Professor
R. BRUCE HEPPENSTALL, MD, BSC, MA Department of Orthopaedic Surgery
(HON.) University of California at Davis;
Professor and Vice Chair for Clinical Affairs Assistant Professor
University of Pennsylvania School of Medicine; University of California at Davis Medical Center
Department of Orthopaedic Surgery Sacramento, California
Hospital of the University of Pennsylvania;
Department of Orthopaedic Surgery ANDREW F. KUNTZ, MD
Pennsylvania Hospital Instructor
Philadelphia, Pennsylvania Department of Orthopaedic Surgery
B. DAVID HORN, MD Philadelphia, Pennsylvania
Assistant Professor
Department of Orthopaedic Surgery J. TODD R. LAWRENCE, MD, PHD
University of Pennsylvania School of Medicine; Instructor
Assistant Surgeon Department of Orthopaedic Surgery
Department of Orthopaedic Surgery Hospital of the University of Pennsylvania
The Children’s Hospital of Philadelphia Philadelphia, Pennsylvania
Contributors ix
JESS H. LONNER, MD DAVID I. PEDOWITZ, MD, MS

Director of Knee Replacement Surgery Instructor
Booth Bartolozzi Balderston Orthopaedics Department of Orthopaedic Surgery
Pennsylvania Hospital; Hospital of the University of Pennsylvania
Medical Director Philadelphia, Pennsylvania
Philadelphia Center for Minimally Invasive Knee
Surgery STEPHAN G. PILL, MD, MSPT
Philadelphia, Pennsylvania Instructor
JONAS L. MATZON, MD Hospital of the University of Pennsylvania
Hospital of the University of Pennsylvania MATTHEW L. RAMSEY, MD
Philadelphia, Pennsylvania Associate Professor
SAMIR MEHTA, MD Thomas Jefferson University;
Assistant Professor Shoulder and Elbow Service
Department of Orthopaedic Surgery Rothman Institute
University of Pennsylvania School of Medicine; Philadelphia, Pennsylvania
Chief, Orthopaedic Trauma Service
Department of Orthopaedic Surgery SUDHEER REDDY, MD
Hospital of the University of Pennsylvania Instructor
J. STUART MELVIN, MD Philadelphia, Pennsylvania
Instructor
Department of Orthopaedic Surgery ERIC T. RICCHETTI, MD
Hospital of the University of Pennsylvania Instructor
SAMEER NAGDA, MD Philadelphia, Pennsylvania
Attending Orthopaedic Surgeon
Anderson Orthopaedic Clinic SCOTT A. RUSHTON, MD
Arlington, Virginia Assistant Clinical Professor
CHARLES L. NELSON, MD University of Pennsylvania School of Medicine;
Associate Professor Director
Department of Orthopaedic Surgery Pennsylvania Hospital Spinal Reconstructive Fellowship
University of Pennsylvania School of Medicine Pennsylvania Hospital
Philadelphia, Pennsylvania Philadelphia, Pennsylvania;
Medical Director
ENYI OKEREKE, PHARMD, MD Center for Spinal Disorders
Associate Professor Lankenau Hospital
Chief, Foot and Ankle Division Wynnewood, Pennsylvania
University of Pennsylvania School of Medicine WUDBHAV N. SANKAR, MD
Philadelphia, Pennsylvania Instructor
NIRAV K. PANDYA, MD Hospital of the University of Pennsylvania
Hospital of the University of Pennsylvania BRIAN J. SENNETT, MD
Philadelphia, Pennsylvania Assistant Professor
Penn Sports Medicine Center
x Contributors
NEIL P. SHETH, MD KEITH L. WAPNER, MD

Instructor Clinical Professor
Hospital of the University of Pennsylvania University of Pennsylvania School of Medicine;
Philadelphia, Pennsylvania Adjunct Professor
DAVID R. STEINBERG, MD Drexel University College of Medicine;
Associate Professor Director, Orthopaedic Foot and Ankle Fellowship
University of Pennsylvania School of Medicine; Pennsylvania Hospital
Director, Hand and Upper Extremity Fellowship Philadelphia, Pennsylvania
Chief, Hand Surgery BRENT B. WIESEL, MD
Veterans Affairs Medical Center Instructor
Philadelphia, Pennsylvania Georgetown University School of Medicine
Attending Surgeon
WILLIAM TALLY, MD Department of Orthopaedic Surgery
Orthopaedic Spine Fellow Georgetown University Hospital
Pennsylvania Hospital Washington, DC
JESSE T. TORBERT, MD, MS

Instructor
PREFACE
Over the past decade, the field of orthopaedic surgery has become increasingly competitive
from the perspective of a medical student. There are approximately 550 orthopaedic resi-
dency positions that are available for more than 1,500 student candidates.
Most medical students interested in pursuing a career in orthopaedic surgery will
rotate through at least one orthopaedic sub-internship during their fourth year of school.
Every year, students ask about the appropriate resources that they should use to prepare
for these rotations, and often they are directed toward an anatomy atlas and a fracture
handbook. However, most students spend nearly 90% of the day in the operating room,
and their education is predominantly based on passive learning or occasional attending/
resident formal teaching. On a busy service, teaching may not be the primary goal or it
is done on the fly in the operating room.
The Gowned and Gloved series is designed to provide medical students, junior resi-
dents, and other members of the surgical healthcare team a resource to enable them to
be more proactive about their intraoperative learning. This text offers a roadmap for the
most common orthopaedic operative procedures. Each chapter presents a patient case, an
algorithmic approach to patient evaluation, the pertinent applied surgical anatomy, and
the sequence of steps used to treat the given pathoanatomy.
While referring to this text, please recognize that each individual attending surgeon
will prefer his or her own variations or modifications of what is described. This text is
geared toward providing readers a foundation on which to build their knowledge base for
the surgical treatment of common orthopaedic problems. We hope that this publication
assists you in optimally preparing for the operating room as you start your career in the
exciting field of orthopaedic surgery.
NEIL P. SHETH, MD
JESS H. LONNER, MD
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ACKNOWLEDGMENTS
We would like to thank the professional and enthusiastic staff at Elsevier, but particularly
Jim Merritt and Andrea Vosburgh, who were with us from the start and put in countless
hours to see this book through to completion.
Ultimately, this book never would have been possible without the commitment of
the attending surgeons and residents who contributed chapters for this project. We are
indebted to each of you for your participation.
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FOREWORD
In his outstanding oratory Aequinimitas, delivered to the graduating class of the University
of Pennsylvania in 1898, Sir William Osler stated, “The first essential of a physician is to
have his nerves well in hand.” The quote is particularly appropriate to medical students
and junior residents entering the operating room to observe and assist with operations
that they have never seen or infrequently encountered. Certainly we all remember those
experiences and the anxiety that these procedures provoked when, as junior members of
the orthopaedic hierarchy, we were asked to observe or assist in these surgeries. How
fitting that Neil Sheth and Jess Lonner have edited such an outstanding volume of surgical
procedures that can be studied and learned in a straightforward and approachable manner.
This text will provide much surgical knowledge to those early in their careers and will
tremendously increase their understanding and appreciation for the procedures at which
they will be assisting.
Orthopaedic surgery has evolved into a specialty driven by technology and rapidly
improving surgical techniques. As one example, the advent of less invasive surgery that
began with arthroscopic procedures has now spread to all areas of orthopaedic surgery.
This text clearly explains the rationale for various surgical exposures and covers all ana-
tomic areas as well as the fields of pediatrics, trauma, joint replacement, spine, and sports
medicine. The procedures are well illustrated and precisely and succinctly demonstrated.
The medical student or resident reviewing the surgical procedure that he or she will be
scrubbing in on will effectively and quickly become familiar with the surgical approaches
and the associated anatomy. There existed a real need for this text to provide this informa-
tion in such a comprehensive yet user-friendly manner.
This text will be a great asset to the orthopaedic library of surgical techniques, but
it will also be helpful as a guide to all levels of residents and even faculty members. With
the subspecialization in orthopaedic surgery today, a text that covers a wide array of surgi-
cal approaches is necessary to educate all of us. Much credit goes to Dr. Sheth and Dr.
Lonner for assembling a diverse group of authors, combining faculty, residents, and
fellows, leading to this fine text. It is a needed addition that will be a great learning tool
for both those in training and those doing the training.
THOMAS P. SCULCO, MD
Professor and Chair, Department of
Orthopaedic Surgery
Weill Cornell Medical College;
Surgeon-in-Chief
Hospital for Special Surgery
New York, New York
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CONTENTS
1. Basic Surgical Principles for Orthopaedic Procedures ........ 1

Neil P. Sheth and Jess H. Lonner
I. SHOULDER AND ELBOW

2. Arthroscopic Subacromial Decompression . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Karen J. Boselli and David L. Glaser
3. Rotator Cuff Repair ......................................................... 19

Eric T. Ricchetti and Matthew L. Ramsey
4. Bankart Repair: Open and Arthroscopic ........................... 34

Andrew F. Kuntz and Joseph A. Abboud
5. Arthroscopic Superior Labrum Anterior Posterior

(SLAP) Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Brent B. Wiesel and G. Russell Huffman
6. Total Shoulder Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

7. Cubital Tunnel Release and Ulnar Nerve

Transposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Julia A. Kenniston and David R. Steinberg
8. Open Reduction and Internal Fixation of Adult Distal

Humerus Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Sameer Nagda and Neil P. Sheth
II. HAND
9. Trigger Finger and Trigger Thumb Release . . . . . . . . . . . . . . . . . . . . . 91
Jonas L. Matzon and David R. Steinberg
10. Carpal Tunnel Release ..................................................... 97

Jonas L. Matzon and David J. Bozentka
11. Open Reduction and Internal Fixation of Distal

Radius Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Jonas L. Matzon and Pedro Beredjiklian
III. SPINE
12. Anterior Cervical Diskectomy and Fusion ...................... 115
William Tally and Scott A. Rushton
13. Lumbar Microdiskectomy .............................................. 127

Derek J. Donegan and Kingsley R. Chin
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xviii Contents
14. Posterior Lumbar Fusion for Degenerative

Spondylolisthesis/Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Safdar N. Khan and Eric O. Klineberg
I V. P E LV I S A N D A C E TA B U L U M
15. Open Reduction and Internal Fixation of Posterior
Wall Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Keith D. Baldwin, Jaimo Ahn, and Samir Mehta
16. External and Internal Fixation of Symphysis Pubis

Widening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Nirav H. Amin, Jaimo Ahn, and Samir Mehta
V. H I P
17. Hip Decompression and Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Gregory K. Deirmengian and Jonathan P. Garino
18. Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Kristofer J. Jones, Stephan G. Pill, and Charles L. Nelson
19. Hip Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

J. Stuart Melvin and R. Bruce Heppenstall
VI. KNEE
20. Quadriceps and Patellar Tendon Repair ......................... 217
Karen J. Boselli, Albert O. Gee, and Craig L. Israelite
21. Arthroscopic Meniscectomy ........................................... 228

Andrea L. Bowers and Brian J. Sennett
22. Anterior Cruciate Ligament Reconstruction . . . . . . . . . . . . . . . . . . . 237

J. Todd R. Lawrence and Brian J. Sennett
23. Total Knee Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Stephan G. Pill, Neil P. Sheth, and Jess H. Lonner
VII. LOWER EXTREMITY

24. Intramedullary Nail Fixation of Femoral Shaft
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Andrew F. Kuntz and Jonathan P. Garino
25. Open Reduction and Internal Fixation of Supracondylar

Femur Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Nirav K. Pandya and Craig L. Israelite
26. Open Reduction and Internal Fixation of Tibial Plateau

Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Jesse T. Torbert, Jaimo Ahn, and John L. Esterhai
Contents xix
27. Intramedullary Nail Fixation of Tibial Shaft Fractures . . . . 314

Albert O. Gee and Craig L. Israelite
VIII. FOOT AND ANKLE

28. Open Reduction and Internal Fixation of Ankle
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Derek Dombroski and Enyi Okereke
29. External Fixation of Tibial Plafond (Pilon) Fractures . . . . . . 335

Sudheer Reddy and Enyi Okereke
30. Achilles Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344

31. Hallux Valgus (Bunion) Correction ................................ 352

David I. Pedowitz and Keith L. Wapner
I X . P E D I AT R I C S
32. Closed Reduction and Percutaneous Pinning of
Supracondylar Humerus Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Wudbhav N. Sankar and B. David Horn
33. In Situ Pinning of Slipped Capital Femoral Epiphysis . . . . . 375

Nirav K. Pandya and Theodore J. Ganley
34. Posterior Spinal Fusion for Adolescent Idiopathic

Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
Joshua D. Auerbach and John M. Flynn
Index ........................................................................................ 397
C H A P T E R
1
Basic Surgical Principles for
Orthopaedic Procedures
Neil P. Sheth and Jess H. Lonner
This text is a compilation of surgical techniques used to treat the most common trauma-
based or disease-based pathologies in orthopaedic surgery. The following guidelines are
applicable to all orthopaedic surgical procedures and are presented here to avoid redun-
dancy in the following chapters. Please keep these principles in mind as you read each
section.
I. Each surgical patient should be properly identified in the holding area (by
name, date of birth, or medical record number). The correct operative site
should be marked and confirmed prior to transporting the patient to the operating
room. Once in the operating room, the patient is once again identified with
the operating room staff, and the site of surgery is confirmed in reference to
the documented operative consent form in the chart. This is termed a “pause for
safety” or “time-out,” and it must be performed prior to starting any surgical
procedure.
II. Make sure that the patient does not have a latex allergy prior to entering the
operating room. If there is a documented allergy, it is imperative that all
equipment used during the case, including Foley catheters, gloves, and tubing, be
latex free.
III. Many longer cases or those with anticipated blood loss require the placement of
a Foley catheter using sterile technique. It is typically removed on postoperative
day 1 but may be left in place in specific instances.
IV. All patients should receive preoperative intravenous antibiotics approximately 30
to 60 minutes prior to the start of a case. Typically, 1 gram of cefazolin (Ancef),
a first-generation cephalosporin, is the antibiotic of choice. The dose and choice
of antibiotics can be adjusted according to weight and comorbidities. In patients
with a penicillin allergy, IV vancomycin or clindamycin may be used as a
substitute.
V. Prior to intubation, make sure that blood products are available for the patient if
needed (e.g., bilateral total knee arthroplasty). In addition, it is important to check
preoperative laboratory results, making sure that the patient is not coagulopathic
and at an increased risk of bleeding or has a metabolic abnormality (e.g., hyper-
kalemia) that was not addressed preoperatively.
VI. Many cases involving the extremity use a tourniquet for minimizing blood loss
during the operation. Procedures around the hip or the shoulder (e.g., total hip
arthroplasty) are too proximal to allow for the use of a tourniquet. Typically, the
tourniquet is set to 250 mm Hg and 350 mm Hg for the upper and lower extremi-
ties, respectively. The tourniquet is placed as high up on the extremity as possible
to avoid interference with the sterile operative field. A typical formula used to
determine the tourniquet setting is 100 mm Hg above the systolic blood
pressure.
VII. An elastic Esmarch bandage or elevation of the extremity for 5 minutes can be
used for limb exsanguination prior to tourniquet inflation. The tourniquet should
not be inflated for longer than 120 minutes due to a risk of compartment syndrome
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2 C H A P T E R 1 Basic Surgical Principles for Orthopaedic Procedures
or limb ischemia. If the tourniquet is needed for a longer period, it should be

deflated for 10 minutes at the 120-minute time point, and then reinflated for up
to an additional 120 minutes.
VIII. Before positioning, prepping, and draping the patient, ensure that the scrub tech-
nician is ready with the back table, all equipment is present, and the overhead
operating room lights are in position.
IX. Both the upper and lower extremities are typically held in position for prepping
with the use of a candy cane device (see images in individual chapters). Other
devices may also be used to hold the limb steady while prepping. Some surgeons
prefer to have the limb held by a person.
X. There are several prepping options available; however, many institutions use a
Betadine scrub followed by a Betadine prep solution to sterilize the operative site.
It is important to allow the Betadine to dry because it is bacteriostatic only when
it has adequately dried. Other options include chlorhexidine-based or alcohol-
based solutions, especially for patients with a Betadine or iodine allergy.
XI. Another important prepping principle is to prep the desired area from clean to
dirty. In other words, start prepping over the proposed incision site and extend
the prep area towards the periphery (i.e., the groin, axilla, or distal portion of the
extremity).
XII. Several types of drapes exist and most draping techniques are attending and case-
specific. In general, it is important to drape out as wide an area as possible to be
prepared for extensile exposures to treat potential intraoperative complications.
Inherent to proper draping is adequate patient positioning. Positioning of the
patient on the operating room table is crucial to maintaining a stable position
during the case and allowing sufficient surgical exposure.
XIII. In general, a nonsterile 1010 or 1015 drape is placed circumferentially around the
proximal portion of the operative extremity. Once the limb has been adequately
prepped, a down sheet is placed under the operative extremity to provide a barrier
between the patient and the sterile field. A series of impervious drapes, including
stockinettes, U-drapes, extremity drapes, and site-specific drapes (e.g., shoulder
drape), are then used to secure a sterile surgical field. Many attending surgeons
are very particular about draping and the order in which specific drapes are used.
It is best to learn how to appropriately drape a patient from the attending or senior
resident on your service.
XIV. Many attendings use an adhesive iodine-based drape called Ioban, which is placed
directly on the skin of the surgical site. It is used to add an additional layer of ste-
rility and also seals off the space between the operative area and the surrounding
drapes.
XV. At the conclusion of a case, several wound closure options are available. Prior to
closing the wound, it is important to irrigate the wound copiously with sterile
saline using a bulb syringe. A pulse lavage may also be used to irrigate the wound
for specific cases such as total joint arthroplasty or contaminated open fractures.
Typically, deep fascial layers are closed using a large caliber, absorbable, braided
suture (e.g., 1 Vicryl). The more superficial subcutaneous tissue layer is closed
using a smaller caliber, absorbable, braided suture (e.g., 2-0 Vicryl). The skin is
closed with a subcuticular closure using a small-caliber, absorbable, nonbraided
monofilament suture (e.g., 4-0 Biosyn) or skin staples. Nylon suture may also be
used for reapproximating the skin edges with the use of horizontal or vertical
mattress knots.
XVI. Dressing the wound can be accomplished using other options; the preference of
the attending is usually followed. In general, the closed wound is cleaned with
saline and dried thoroughly prior to applying a dressing. A subcuticular closure is
C H A P T E R 1 Basic Surgical Principles for Orthopaedic Procedures 3
typically dressed with Steri-Strips followed by a nonadherent petroleum jelly

(Vaseline)–impregnated gauze (i.e., Adaptic), whereas wounds closed with skin
staples are dressed with Adaptic only. At this point, the operative site is covered
with a combination of 4 × 4 gauze pads, ABD pads, and tape. Foam or Medipore
tape is frequently used to minimize the amount of patient discomfort at the time
of tape removal. It is important to place the tape without any skin tension to avoid
shearing of the skin when changing the dressing. If an Ace bandage is applied, ask
the attending if the entire limb should be wrapped (to reduce the risk of distal
swelling) or just the surgical site. It is paramount that the limb is completely dry
and the bandage is not wrapped too tightly to avoid blistering or skin necrosis.
S E C T I O N
I
SHOULDER AND ELBOW
CHAPTER 2 Arthroscopic Subacromial Decompression 7
CHAPTER 3 Rotator Cuff Repair 19
CHAPTER 4 Bankart Repair: Open and Arthroscopic 34
CHAPTER 5 Arthroscopic Superior Labrum Anterior Posterior (SLAP) Repair 44
CHAPTER 6 Total Shoulder Arthroplasty 55
CHAPTER 7 Cubital Tunnel Release and Ulnar Nerve Transposition 70
CHAPTER 8 Open Reduction and Internal Fixation of Adult Distal Humerus Fractures 81
2
Shoulder and Elbow

C H A P T E R
Arthroscopic Subacromial
Decompression
Karen J. Boselli and David L. Glaser
Case Study
A 46-year-old, right hand–dominant female presents with right shoulder pain, which has
gradually developed over the past 2 months. She describes pain at the “top” of her shoul-
der, radiating down her upper arm but not below the elbow. She complains of only mild
difficulty with overhead lifting activities. The pain is worse with activities such as combing
her hair or reaching for her back pocket. Recently, she has also started to experience night
pain. She has tried nonsteroidal anti-inflammatory medications, with minimal relief. She
completed an 8-week course of physical therapy, prior to which she received two cortisone
injections; the first provided 1 month of relief and the second only 2 weeks. A scapular
outlet radiograph and a magnetic resonance imaging scan are presented in Figure 2-1.
BACKGROUND
I. Impingement syndrome is a term used to describe the common condition that
involves impingement of the humeral head and rotator cuff beneath the coracoac-
romial (CA) arch of the shoulder.
A B
Figure 2-1
A, Anteroposterior view with 30-degree caudal tilt. B, Scapular (supraspinatus) outlet view. (A, From DeLee
JC, Drez D, Miller MD [eds]: DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, 2nd ed.
Philadelphia, Saunders, 2003; B, from Canale ST: Campbell’s Operative Orthopaedics, 10th ed. Philadelphia, Mosby,
2003.)
8 S E C T I O N I Shoulder and Elbow
II. Anatomy
A. The rotator cuff consists of four muscles originating from the scapula and
inserting on the humeral head: anteriorly, the subscapularis (originating at the
subscapular fossa and inserting on the lesser tuberosity); superiorly, the supra-
spinatus (originating at the supraspinatus fossa and inserting on the greater
tuberosity); and posteriorly, the infraspinatus (originating at the infraspinatus
fossa and inserting on the greater tuberosity), and the teres minor (originating
at the lateral border of the scapula and inserting on the greater tuberosity).
B. The CA arch consists of the coracoid process, acromion, and the CA ligament
(Fig. 2-2). This osseoligamentous complex overlies the head of the humerus,
preventing upward displacement from the glenoid fossa.
C. The subacromial bursa separates the supraspinatus tendon from the overlying
CA arch and the deep surface of the deltoid muscle.
D. With the arm in a neutral position, the greater tuberosity (where the supra-
spinatus tendon inserts) lies anterior to the CA arch. With forward flexion and
internal rotation, the subacromial bursa and supraspinatus tendon become
entrapped between the anterior acromion/coracoid and greater tuberosity.
III. Charles Neer, MD, popularized the concept of impingement in 1972, after per-
forming a cadaveric study that demonstrated a characteristic ridge of bone on the
undersurface of the anterior process of the acromion. He proposed that these spurs
were caused by repeated impingement of the rotator cuff and humeral head. He
noticed that the anterior one third of the acromion seemed to be the offending
structure in most cases.
IV. The impingement of the humeral head and rotator cuff leads to a series of changes
within the shoulder. Neer described a continuum of impingement, starting with
chronic bursitis and progressing to complete tears of the rotator cuff. His three
stages are outlined in Table 2-1.
A B
Figure 2-2
A, The coracoacromial (CA) arch, created by the coracoid, acromion, and CA ligament. B, The position of
the rotator cuff musculature beneath the arch is demonstrated. (A, From Krishan SG, Hawkins RJ: Rotator cuff
and impingement lesions in adult and adolescent athletes. In DeLee JC, Drez D, Miller MD [eds]: DeLee & Drez’s
Orthopaedic Sports Medicine: Principles and Practice, 2nd ed. Philadelphia, Saunders, 2003; B, redrawn from Matsen
FA III, Arntz CT: Subacromial impingement. In Rockwood CA Jr, Matsen FA III [eds]: The Shoulder. Philadelphia,
Saunders, 1990.)
C H A P T E R 2 Arthroscopic Subacromial Decompression 9
Shoulder and Elbow

TABLE 2-1 Stages of Subacromial Impingement Syndrome
Stage Age (years) Pathology Clinical Course Treatment

I <25 Edema and hemorrhage Reversible Conservative
II 25–40 Fibrosis and tendinitis Activity-related pain Therapy/acromioplasty
III >40 Acromioclavicular spur and Progressive disability Acromioplasty/repair
rotator cuff tear
Data from Azar FM: Shoulder and elbow injuries. In Canale ST (ed): Campbell’s Operative Orthopaedics, 10th ed.
Philadelphia, Mosby, 2003.
A. Stage I occurs in younger individuals and involves edema and hemorrhage

within the subacromial bursa. The patient may have palpable tenderness at the
greater tuberosity and anterior edge of the acromion, with painful abduction
between 60 and 120 degrees.
B. Stage II involves chronic inflammation with thickening and fibrosis of the
subacromial bursa, biceps tendon, and supraspinatus tendon. Symptoms are
generally not reversible with activity modification. Pain interferes with sleep,
work, and activities of daily living.
C. Stage III is chronic impingement, resulting in rotator cuff tears, biceps tendon
ruptures, and bony changes. Patients typically complain of significant night
pain and weakness. Range of motion (ROM) may be limited, muscle atrophy
may be present on physical examination, and radiographic changes may be
present at the anterior acromion and humeral head.
TREATMENT PROTOCOLS
I. Treatment Considerations
A. Patient age
B. Activity level
C. Presence or absence of concomitant rotator cuff tear
D. Presence or absence of other associated shoulder pathology, especially
instability
E. Source of pain. For an arthroscopic subacromial decompression to be success-
ful, impingement syndrome must be the primary source of the patient’s pain.
F. Differential diagnosis, which includes acromioclavicular (AC) arthritis, gleno-
humeral arthritis, rotator cuff tear, instability (with secondary impingement),
early adhesive capsulitis, and calcific tendinitis. Cervical spondylosis with nerve
root irritation and suprascapular nerve injury can also mimic the symptoms of
impingement.
II. Initial Approach
A. Clinical presentation
1. History. Patients with impingement syndrome provide a history of insidious
onset of pain exacerbated by overhead activities. Pain is often referred to
the deltoid insertion. Other symptoms may include night pain and pain with
internal rotation (such as reaching for the back pocket).
2. Physical examination. A thorough examination of the shoulder and neck is
necessary to correctly diagnose impingement syndrome.
a. Check ROM bilaterally and test the strength of each of the rotator cuff
muscles. Patients with impingement syndrome may have weakness of
flexion, abduction, and external rotation due to pain. They may also have
weakness secondary to a rotator cuff tear.
b. Check for impingement signs, using the following provocative maneu-
vers. These signs are highly sensitive but not very specific for diagnosing
impingement syndrome.
(1) Neer’s sign is pain with maximum passive shoulder elevation and
internal rotation, with the scapula held stabilized.
(2) Hawkins’ sign is pain with passive forward elevation to 90 degrees
and maximum internal rotation with the elbow flexed to 90
degrees.
(3) Neer’s impingement test involves injection of the subacromial space
with local anesthetic, and observing for a decrease in pain with these
provocative tests. Relief of symptoms is a positive impingement test
and is suggestive of impingement syndrome.
B. Radiographic features
1. Plain radiographs may show spurring of the acromion or calcification of the
CA ligament.
2. A 30-degree anteroposterior caudal tilt view can be used to visualize ante-
rior-inferior acromial spurs.
3. A scapular outlet or supraspinatus outlet view can be used to demonstrate
the morphology of the acromion. The patient is positioned for a scapular
lateral view (or Y view), with the beam tilted 5 to 10 degrees caudally (Fig.
2-3; see Fig. 2-1A).
a. Type I = flat
b. Type II = curved
c. Type III = hooked
4. Magnetic resonance imaging is frequently used to rule out any concomitant
shoulder pathology, such as a rotator cuff or labral tears.
III. Nonoperative Treatment Options
A. Nonoperative treatment must always be attempted first in the management of
impingement syndrome. Two thirds of patients can have significant relief with
nonoperative measures, and 91% of patients with a type I acromion have a
satisfactory result.
B. Options include:
1. Nonsteroidal anti-inflammatory drugs or acetaminophen
2. Activity modification, avoiding forward flexion beyond 90 degrees
3. Physical therapy including rotator cuff strengthening and scapular
stabilization
4. ROM exercises
5. Corticosteroid injections
I II III
Figure 2-3
Diagram of the three types of acromial morphology, based on the scapular outlet view. (Redrawn from Jobe
CM: Gross anatomy of the shoulder. In Rockwood CA Jr, Matsen FA III [eds]: The Shoulder. Philadelphia, Saunders,
1990.)
Shoulder and Elbow

TREATMENT ALGORITHM
History, physical examination, radiographs
Positive for impingement Negative for impingement—

Work up and manage appropriately
NSAIDs, physical therapy 6 weeks If demonstrates

other pathology
Improved Not improved Consider MRI
If consistent
with
Home exercise program • Change NSAID impingement
• Subacromial corticosteroid injection
• 6 more weeks of physical therapy
Improved
May be candidate for
Not improved subacromial decompression
SURGICAL ALTERNATIVES AND INDICATIONS FOR ARTHROSCOPIC

SUBACROMIAL DECOMPRESSION
I. Open acromioplasty is the only surgical alternative to arthroscopic subacromial
decompression.
II. Operative Treatment
A. Arthroscopic acromioplasty provides objective good to excellent results in
The impingement test is
more than 70% of patients, with subjective satisfactory results in more than
conducted in the office
90% of patients. by injecting 5 mL of
B. Arthroscopic treatment is often favored due to minimal soft tissue trauma, lidocaine into the
excellent surgical visualization, and easier rehabilitation. subacromial space of
C. The use of arthroscopy for subacromial decompression also allows the surgeon the patient’s affected
to identify additional pathology and perform additional procedures such as shoulder. The patient is
rotator cuff repair or distal clavicle excision. re-examined 5 minutes
D. Operative treatment should be considered for the following patients: postinjection to see if
1. Patients with chronic impingement who have failed at least 3 to 4 months there is relief of his or
of nonoperative treatment. Some believe that surgery should be delayed her symptoms. Symptom
until the patient has failed at least 9 months of nonoperative treatment. relief indicates a positive
impingement test.
2. Patients whose pain is relieved with impingement test
3. Younger patients with refractory stage II impingement. Subacromial decom-
pression should be approached with caution in younger athletic individuals,
because primary impingement syndrome is less common in patients younger
than 25 years of age. Usually, these patients have secondary impingement
due to altered shoulder kinematics without any primary pathology in the
subacromial space.
4. Patients undergoing other procedures for conditions in which impingement
is likely
RELATIVE CONTRAINDICATIONS
I. Medically unstable patients
II. Massive, irreparable rotator cuff tear. Disruption of the CA arch in patients with
massive, irreparable rotator cuff tears can lead to superior migration of the humeral
head and rotator cuff arthropathy.
III. Internal rotation contracture. This should be corrected prior to surgery.
Patients with restricted motion, especially those with an internal rotation
CAUTION SHOULD ALSO BE contracture, may have a suboptimal outcome following subacromial decompres-
TAKEN WITH PATIENTS WITH sion. The patient’s inability to externally rotate worsens the impingement due to
CONCOMITANT CERVICAL the tendency of the greater tuberosity to impinge on the acromion even after
SPONDYLOSIS, BECAUSE surgery.
OUTCOMES MAY BE WORSE IV. Glenohumeral degenerative joint disease
THAN IN THOSE PATIENTS
WITHOUT CERVICAL SPINE
PATHOLOGY. GENERAL PRINCIPLES OF SUBACROMIAL DECOMPRESSION
I. The main principles of the original procedure, as described by Neer, are as
follows:
A. Resection of the CA ligament
B. Removal of the anterior lip of the acromion
C. Removal of the part of the acromion anterior to the anterior border of the
clavicle
II. Although initially described by Neer as an open procedure, the basic principles of
the arthroscopic procedure are unchanged.
Documenting the range

COMPONENTS OF THE PROCEDURE
of motion of both Positioning, Prepping, and Draping
shoulders once the
patient is under I. After induction of anesthesia, both upper extremities are examined for
anesthesia is ROM and stability. Some surgeons request that you record the preoperative
recommended. ROM.
II. The patient is placed in the beach chair or lateral decubitus position. (See Chapter
4 for details on the lateral decubitus position.)
III. If the patient is placed in the beach chair position, the torso should be approxi-
mately 45 degrees relative to the horizontal and the arm and shoulder, completely
off the edge of the table to allow full shoulder ROM. The head, neck, and body
should be appropriately stabilized (Figs. 2-4 and 2-5).
Propionibacter acnes IV. Patients are typically placed under general anesthesia for the procedure, but this
bacteria commonly is often coupled with regional anesthesia in the form of an interscalene nerve block
colonize the skin of the of the affected side.
axilla and are a potential V. The skin should be shaved over the surgical site (anterosuperior approach), as well
source of postoperative as the axilla.
infection. VI. The patient is prepped and draped according to the standard surgical principles
described in Chapter 1.
VII. Once the draping is completed and the skin incision has been marked, place Ioban
over the exposed skin.
Figure 2-4
Beach chair position. (From Canale ST [ed]: Figure 2-5
Campbell’s Operative Orthopaedics, 10th ed. Beach chair position with the arm suspended for
Philadelphia, Mosby, 2003.) prepping.
Shoulder and Elbow

Figure 2-6
Fully draped-out shoulder with extremity held in
mechanical arm-holding device.
VIII. Several points during the procedure require the arm to be held or supported. This
can be done using an assistant, padded Mayo stand, or a mechanical arm-holding
device. The mechanical arm-holding device has become the most popular way to
support the arm (Fig. 2-6). It consists of a sterile articulated extension that attaches
to the arm at the level of the wrist and forearm via a sterile disposable sleeve. The
extension connects to a universal ball joint that is suspended from the operating
table. A foot pedal allows the ball joint to be unlocked and the arm to be placed Does your attending have
in the optimal position. Releasing the pedal locks the ball joint and arm in the a preference regarding
selected position. patient position?
Establishing the Portals

Mark out the superficial bony anatomy including the spine of the scapula, acromion, distal
clavicle, AC joint, and coracoid process (Fig. 2-7).
Figure 2-7
Superficial bony anatomy is identified and marked
on the patient including the acromion, the
acromioclavicular joint, and the coracoid process.
The anticipated location of the posterior and lateral
portals have also been marked. (From Miller M,
Cooper D, Warner J [eds]: Review of Sports Medicine
and Arthroscopy, 2nd ed. Philadelphia, Saunders, 2002.)
Applied Surgical Anatomy
PLACING THE POSTERIOR I. For routine subacromial decompression, three portals are generally used: anterior,
PORTAL TOO MEDIALLY posterior, and lateral (Fig. 2-8).
RISKS INJURY TO THE II. The exact location of the posterior portal varies depending on what needs to be
SUPRASCAPULAR NERVE, AND visualized during the case. It is generally considered the “viewing portal” and lies
PLACEMENT TOO LATERALLY approximately 2 cm medial and 2 to 4 cm inferior to posterolateral tip of the
RISKS INJURY TO THE acromion. In this location, feel for the soft spot of the glenohumeral joint while
AXILLARY NERVE. internally and externally rotating the humeral head. This is the interval between
the infraspinatus and teres minor and is the location where the arthroscope should
enter the joint.
Does your attending vary III. The anterior portal is usually the “instrument portal” and should be created under
the location of the direct visualization from the joint. However, its anticipated location should be
anterior portal based on marked on the skin to have a rough idea of the location. This is usually about 2 cm
the type of procedure medial and 1 cm inferior to the anterolateral border of the acromion (or halfway
(e.g., subacromial between the tip of the acromion and the coracoid process). In general, it is in line
decompression vs. distal with the AC joint.
clavicle excision vs. IV. Some surgeons may inject a mixture of lidocaine and epinephrine at the portal
rotator cuff repair)?
sites prior to incision to minimize bleeding. Others inject saline into the joint with
a spinal needle prior to introducing the trochar to distend the joint and minimize
the risk of trauma to the articular cartilage.
Remember that the V. The posterior incision is made with an 11-blade. Using the blunt trochar
scapula is oriented 30 and cannula, gently “pop” through the deltoid fascia. Aim toward the coracoid
degrees anterior to the (slightly medial), keeping the hand parallel to the lateral border of the acromion
coronal plane, and and parallel to the floor. Gently “pop” through the capsule to enter the glenohu-
therefore this is the meral joint.
direction in which the VI. Remove the blunt trochar from the cannula and insert the camera. Focus the
trochar should be camera on the anterior glenohumeral joint, and try to visualize the “triangle”
inserted.
where the anterior portal will be formed—between the glenoid labrum (medial),
the tendon of long head of the biceps (superior), and the middle glenohumeral
ligament and tendon of the subscapularis (inferior) (Fig. 2-9). Using a spinal
needle, enter the skin at the location previously marked, and aim toward the center
Figure 2-9
Location of the anterior portal, as viewed through an
Figure 2-8 arthroscope with the patient in the lateral decubitus
The posterior and lateral portals used for arthrosco- position. The humeral head is in the upper right
pic subacromial decompression. Note that the lateral corner, the long head of the biceps is marked with a
portal is in line with the posterior border of the thick arrow, and the middle glenohumeral ligament is
clavicle. (From Harner CD: Arthroscopic subacromial marked with a thin arrow. The portal should be
decompression. Op Tech Orthop 1:229–234, 1991.) placed in the center of this triangle.
Shoulder and Elbow

of this triangle until the capsule is pierced. Remove the needle, make the anterior PLACE THE ARM IN
incision with an 11-blade, and use a blunt trochar or plastic cannula to enter the ADDUCTION TO MINIMIZE
joint through the same location. THE RISK TO THE
VII. Mark the lateral portal prior to the start of the procedure, usually with the use of MUSCULOCUTANEOUS NERVE
a spinal needle, under direct visualization of the subacromial space. Place it about DURING ESTABLISHMENT OF
3 to 4 cm lateral to the lateral edge of the acromion, in line with the posterior THE ANTERIOR PORTAL.
border of the clavicle. To perform successful subacromial decompression, the
lateral portal must allow for full triangulation of the undersurface of acromion; REMEMBER THAT THE
this is why it is important to establish the portal under direct visualization. AXILLARY NERVE ENTERS
THE DEEP SURFACE OF THE
Diagnostic Arthroscopy and Subacromial Decompression DELTOID ABOUT 5 CM
LATERAL AND DISTAL TO THE
I. During the diagnostic arthroscopy, the scope should be in the posterior portal. ACROMION.
Most surgeons have their own systematic way of inspecting the entire joint for
any abnormalities—this inspection should include the biceps tendon, glenohu-
meral articulation, glenohumeral ligaments, subscapularis tendon, glenoid labrum,
rotator cuff, and axillary/subscapular recess.
II. After completion of the diagnostic portion of the procedure, it is necessary to
insert the scope into the subacromial space. Remove all instruments from the joint
and place the blunt trochar back into the cannula.
III. Insert the instrument through the posterior portal, aiming superiorly toward the
posterior acromion—the trochar will gently hit bone. Pull back the instrument
slightly, aim the instrument slightly inferior, and gently slide into the subacromial
space. Sweep the trochar back and forth across undersurface of the acromion to
help remove any adhesions of the subacromial bursa.
IV. Some surgeons drive the trochar all the way across the subacromial space
and through the anterior portal until the instrument exits at the skin. A plastic
cannula can then be inserted over the instrument and easily drawn back into
the subacromial space. Other surgeons prefer to insert the anterior cannula
directly into the subacromial space through the previously established anterior
incision.
V. A shaver is placed through the plastic cannula into the anterior portal, and an
initial limited bursectomy is performed. This initial bursectomy is necessary for
patients with an inflamed, thickened bursa to clear the field of vision and establish Remember that the
a lateral portal. Be careful with the shaver, because it can easily cause bleeding lateral portal is the main
from a hyperemic bursa. instrument portal for the
VI. After the initial bursectomy, the lateral portal can be established. Starting from acromioplasty—it must
the previously marked skin entry point, use a spinal needle to approximate the be placed so that full
angle of entry. The skin marking, however, is not “set in stone”; the angle of the triangulation of the
spinal needle should be adjusted to allow for full triangulation of the acromion undersurface of the
and the skin incision should be modified accordingly. anterior acromion can
VII. From the lateral portal, use the shaver or electrocautery device to complete the be performed.
bursectomy. Methodically sweep the instrument back and forth to clear the tissue.
Below the bursa, expose the rotator cuff to check for any bursal-sided tears (Fig.
2-10).
VIII. After completion of the bursectomy, there should be improved visualization of the
anterior acromion, AC joint, and CA ligament. The undersurface of the acromion,
however, is still covered by periosteum—the entire undersurface of the anterolat-
eral acromion must now be cleared of soft tissue using electrocautery. The anterior
acromial surface must carefully be exposed by removal of any deep deltoid
attachments. This allows for visualization of any anterior-inferior acromial
osteophytes. BLEEDING FROM THE
IX. The CA ligament should also be sectioned or detached from its acromial attach- ACROMIAL BRANCH OF THE
ment using the shaver or electrocautery. This is most easily accomplished with THORACOACROMIAL ARTERY
CAN OCCUR DURING
the instrument in the lateral portal. Be aware that the acromial branch of the
SECTIONING OF THE
thoracoacromial artery, which lies near the anteromedial acromion, can be injured
CORACOACROMIAL LIGAMENT.
during sectioning of the CA ligament. If the anterior cannula has been placed
A B
Figure 2-10
A, Completion of bursectomy with electrocautery. B, Exposure of bony ridge along the anterior acromion.
properly at the level of the AC joint, it can be used as a landmark (to prevent any
shaving medial to this point).
X. The critical portion of this procedure involves bony resection of the undersurface
of the anterior acromion. Adequate biplanar visualization is needed to judge the
amount of bone that has been removed. This is achieved with visualization from
both the posterior and lateral portals.
A. Starting with the scope in the posterior portal, a burr is placed through the
lateral portal. The acromial resection starts at the anterolateral corner, where
the burr is used to remove 5 mm of bone. As the bone is removed, an audible
sound from the burr is heard.
B. After the anterolateral portion is completed, work medially and posteriorly
All anterior-inferior spurs toward the mid-acromion. The amount of bone resected should be tapered
and osteophytes need to toward the mid-acromion (Fig. 2-11).
be carefully removed.
C. The burr, which is approximately 5 mm in diameter, can be used to judge
the amount of bone that has been removed and the amount of space
available.
XI. The scope is now switched to the lateral portal, and the burr placed in the
posterior portal. If the instrument is flush with the undersurface of both
the anterior and posterior acromion, adequate decompression has been
achieved.
XII. If the surfaces are not flush, additional bone needs to be resected. The posterior
surface is used as a “cutting block” to indicate the amount of additional anterior
bone resection that is necessary—the burr is then taken along the anterior acro-
mion until the entire undersurface is uniplanar.
Figure 2-11
Burr is entering the subacromial space through the
lateral portal, and an anterolateral resection of bone
is performed.
Shoulder and Elbow

XIII. After completion of the procedure, place the scope back in the lateral portal to
examine the subacromial space and confirm adequacy of the decompression. An
arthroscopic impingement test can be performed by flexing and internally rotating
the shoulder while checking for any remaining sites of impingement. If any such
sites remain, they should be addressed with a burr.
XIV. In patients with concomitant symptomatic AC arthritis, the surgeon should
perform a distal clavicle excision. The details of this procedure are beyond the
scope of this chapter.
Wound Closure
I. The portals are closed using nylon suture or Biosyn. The wound is dressed fol-
lowing the surgical principles outlined in Chapter 1.
II. A sling is provided for comfort.
POSTOPERATIVE CARE AND GENERAL REHABILITATION

I. Patients are generally discharged home on the day of surgery after a period of
recovery in the short procedure unit.
II. If the patient has received an interscalene block for pain control, he or
she should be warned about the possible increase in pain while the block
wears off. Patients should appropriately premedicate with oral narcotics
when the block is beginning to diminish. Oral analgesia is usually sufficient for
postoperative pain control, and oral antiemetic agents can be provided if
necessary.
III. Patients are usually discharged home in a sling and may start pendulum exercises
of the shoulder as soon as their surgical pain subsides—usually within 2 days. This
helps ensure that some passive ROM is retained in the immediate postoperative
period.
IV. Strengthening exercises are delayed until full range of motion has been restored.
COMPLICATIONS
I. Technical Problems and Pitfalls with Acromioplasty
A. Adequate bone must be removed to alleviate the impingement. This includes
the anterior lip of the acromion and any portion of the acromion that lies
anterior to the anterior clavicular border. Inadequate removal occurs more
often in arthroscopic than open subacromial decompression.
B. As discussed, when the burr enters the subacromial space from the lateral
portal, it must be parallel to the undersurface of the acromion. If the lateral
portal is placed too inferiorly, the burr enters the subacromial space at an acute
angle to the acromion—this risks bisecting the acromion during bony resec-
tion. If the lateral portal is placed too superiorly, the instrument will not be
able to reach the anterior surface of the acromion to complete resection of the
bony ridge.
C. The CA ligament must be resected and a portion removed to prevent the cut
edge from scarring back to acromion.
II. Wound infection
III. Nerve injury
SUGGESTED READINGS
Altchek DW, Warren RF, Wickiewicz TL, et al: Arthroscopic acromioplasty. Techniques and
results. J Bone Joint Surg Am 72:1198–1207, 1990.
Bigliani LU, Levine WN: Current concepts review: Subacromial impingement syndrome. J Bone
Joint Surg Am 79:1854–1868, 1997.
Bigliani LU, Morrison DS, April EW: The morphology of the acromion and its relationship to
rotator cuff tears. Orthop Trans 10:228, 1986.
Gartsman GM, Hasan SS: What’s new in shoulder and elbow surgery. J Bone Joint Surg Am
99:230–243, 2006.
Neer CS II: Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A pre-
liminary report. J Bone Joint Surg Am 54:41–50, 1972.
3
Shoulder and Elbow

C H A P T E R
Rotator Cuff Repair

Case Study
A 65-year-old, right hand–dominant male presents with a 5-year history of right shoulder
pain. He has had gradual progressive difficulty with activities of daily living and is now
limited significantly by pain and weakness in his right shoulder. The patient has pain at
night, which can interrupt his sleep, and also complains of increased pain with overhead
activities. He denies any specific injury that initiated the onset of symptoms and denies
any neck pain or associated radiating symptoms (numbness, tingling, pain) down his arms.
The patient has tried several nonoperative treatments, including nonsteroidal anti-inflam-
matory medications; activity modification; physical therapy; and multiple, intermittent
corticosteroid injections into his shoulder. These have only provided temporary symp-
tomatic relief, and their effect has lessened as his symptoms have progressed. The man is
now retired and lives at home by himself without a caregiver. A coronal magnetic reso-
nance imaging scan is presented in Figure 3-1.
BACKGROUND
I. Rotator cuff disease is a common cause of shoulder pain, with an
incidence of rotator cuff tears ranging from 5% to 40%, which increases
with age.
II. The rotator cuff consists of four muscles originating from the scapula and
inserting on the humeral head: anteriorly, the subscapularis (originating
Figure 3-1
Coronal magnetic resonance imaging scan of the
right shoulder.
at the subscapular fossa and inserting on the lesser tuberosity); superiorly,

the supraspinatus (originating at the supraspinatus fossa and inserting on the
greater tuberosity); and posteriorly, the infraspinatus (originating at the
infraspinatus fossa and inserting on the greater tuberosity), and the teres minor
(originating at the lateral border of the scapula and inserting on the greater
tuberosity).
III. Each rotator cuff muscle provides a particular shoulder motion based on its loca-
tion around the glenohumeral joint.
A. Subscapularis: internal rotation and adduction
B. Supraspinatus: abduction
C. Infraspinatus: external rotation
D. Teres minor: external rotation
IV. Rotator cuff tears typically occur at the tendinous insertion of the rotator cuff
muscles on the humeral head. The supraspinatus is the most commonly torn
tendon.
V. Rotator cuff tears can be described based on their depth (partial-thickness
or full-thickness), anterior-posterior extent (in centimeters), age (acute, chronic,
or acute on chronic), and whether they involve one or more tendons.
VI. Pain, weakness, or both, in the affected shoulder are the most common presenting
When a shoulder complaints in patients with rotator cuff tears. Symptoms may begin without an
dislocation occurs in an injury or after only minor trauma in patients with chronic degenerative tears.
older patient (>40 years Acute rotator cuff tears may also be associated with a more severe acute event such
of age), always think
as a shoulder dislocation in an older patient. Patients typically localize their pain
about an associated
rotator cuff tear (most
to the anterior or lateral shoulder, and discomfort is usually worsened with use of
commonly subscapularis the arm, particularly overhead activities. Pain is often the worst at night, awaken-
with an anterior ing patients from sleep. Weakness may be from the tear itself or from guarding
dislocation). due to pain. Tear size does not always correlate with function, because patients
with large tears can often have good motion and strength.
If weakness is profound VII. Physical examination of the affected shoulder may demonstrate muscle
in a patient with a rotator atrophy, depending on the chronicity of the injury. Acute tears show no changes,
cuff tear following a whereas chronic injuries show atrophy in the affected rotator cuff muscles. Active
dislocation or other range of motion (ROM) is typically decreased due to either weakness or pain,
severe shoulder trauma, but passive ROM is usually normal. Strength of the shoulder should also be
always assess for an examined in elevation, abduction, external rotation, and internal rotation to
associated brachial plexus assess for weakness or pain in each of the rotator cuff muscles. Specific changes
injury (axillary or in ROM and strength can help determine the part of the rotator cuff involved.
suprascapular nerve most
For example, increased passive external rotation with weak internal rotation
commonly injured).
(lift-off test and abdominal compression test) suggests a subscapularis tear, whereas
weakness in elevation/abduction with passive ROM greater than active ROM
Glenohumeral arthritis suggests a supraspinatus tear. A careful examination of the cervical spine should
and adhesive capsulitis
also be performed to rule out any abnormalities, including radiculopathy and
(frozen shoulder) are
major causes of degenerative joint disease, that may cause referred pain or weakness in the
restriction of both active shoulder.
and passive range of VIII. Although rotator cuff tears can be significantly disabling, many patients are asymp-
motion in the shoulder. tomatic and never require treatment. Treatment should therefore be aimed at
patients with symptomatic disease. For the majority of patients with symptomatic
rotator cuff tears unresponsive to nonoperative treatment, definitive surgical inter-
vention consists of rotator cuff repair.
IX. Approximately 70% to 100% of patients attain adequate pain relief following
rotator cuff repair, with functional improvement somewhat less predictable (70%
to 80% of patients). Recurrence rates generally increase based on the size of the
tear, with single tendon repairs having a 20% recurrence rate and two tendon
repairs having a 50% recurrence rate. Results of arthroscopic repair seem to be
equivalent to results of open repair.
C H A P T E R 3 Rotator Cuff Repair 21
Shoulder and Elbow

TREATMENT ALGORITHM
Shoulder pain
History and physical examination, plain

radiographs, and MRI
No tear (rotator cuff tendinopathy,

Rotator cuff tear
impingement syndrome, etc.)
Acute tear Chronic tear
Rotator cuff repair Nonoperative management (4–6 months):

Activity modification
Physical/occupational therapy
NSAIDs
Corticosteroid injection
Failed nonoperative management Success
Surgery (one or more of the following):

Rotator cuff repair
Subacromial decompression
Rotator cuff débridement
Tendon transfer
Note: This algorithm is a guideline for management of rotator cuff tears. The decision What is your attending’s
to ultimately proceed with surgical repair depends on multiple other factors, including treatment algorithm for
patient age and activity level and the status of the rotator cuff (e.g., size and age of tear, shoulder pain secondary
amount of tendon retraction, muscle quality), which are evaluated on an individual to a rotator cuff tear?
basis.
TREATMENT PROTOCOLS
I. Treatment Considerations. All of the considerations below play an important
role in the decision-making process of treating patients with rotator cuff tears. For
example, older patients with chronic, degenerative tears and a primary complaint
of pain tend to be the most responsive to nonoperative treatment. Young, active
patients with an acute tear and a primary complaint of weakness are best treated
with early (less than 3 months from injury) surgical repair.
A. Patient age
B. Activity level
C. Overall health
D. Status of the rotator cuff: size and age of tear, amount of tendon retraction,
and muscle quality
E. Patient expectations
II. Imaging Modalities
There are three types of
acromion morphologies: A. Plain radiographs should be assessed for the following features:
type I is flat, type II is 1. Cystic changes at greater tuberosity
curved, and type III is 2. Humeral head elevation with decreased space between it and the acromion
hooked (refer to Chapter (acromiohumeral distance)
2). 3. Acromial morphology (e.g., evidence of prominent spurs on the undersur-
face of the anterior acromion potentially causing impingement)
B. Arthrography
1. Once contrast is injected into the glenohumeral joint, plain radiographs are
taken.
2. With a full thickness rotator cuff tear, contrast is seen escaping from the
joint through the tear site (geyser sign); however, tear size is difficult to
determine, and partial-thickness tears cannot be detected.
3. This imaging modality was the former gold standard but is less often used
due to the availability of magnetic resonance imaging (MRI).
C. Ultrasound
1. Advantages: noninvasive, dynamic, inexpensive, and can be performed in an
outpatient setting
ALWAYS QUESTION PATIENTS 2. Disadvantages: operator dependent and unable to assess muscle atrophy or
REGARDING A HISTORY OF A fatty replacement of the muscle
PACEMAKER, METAL IN THE D. MRI
EYE, ANEURYSM CLIPS, OR 1. Imaging study of choice to evaluate the rotator cuff
OTHER METAL IMPLANTS 2. Highly accurate (93% to 100%) in detecting full-thickness tears; can assess
IN THE BODY PRIOR TO
tear size, tendon retraction, muscle atrophy, and related intra-articular
OBTAINING A MAGNETIC
pathology
RESONANCE IMAGING (MRI)
SCAN.
3. Disadvantages: expensive, patient tolerance (claustrophobia), contraindi-
cated in patients with pacemakers, metal in their eye, or aneurysm clips
A. The literature shows successful nonoperative treatment in 33% to 92% of
patients with symptomatic tears, and approximately 50% to 60% of patients
report a satisfactory result.
B. Initial treatment strategy
2. Activity modification (participating in low-impact activity, avoiding offend-
ing motions)
3. Heat (chronic pain) and cold (acute flare-up) therapy
4. Physical and occupational therapy
a. Physical therapy is aimed at eliminating any subtle stiffness and strength-
ening of the rotator cuff and parascapular muscles.
(1) Typically a home exercise program can be taught.
(2) Aqua therapy can be used for exercises and decreasing stress across
muscles and joints due to the buoyancy effects of water.
(3) Ultrasound: heat effect
b. Occupational therapy is aimed at teaching alternative ways of accomplish-
ing activities of daily living that may be impaired or elicit symptoms.
INTRA-ARTICULAR STEROIDS C. Subacromial corticosteroid injection
MAY INCREASE ENDOGENOUS 1. Injections are considered if adequate progress has not been made after 4 to
GLUCOSE LEVELS 6 weeks of physical therapy. Usually injected in combination with a local
POSTINJECTION; THEREFORE, anesthetic (lidocaine and/or bupivacaine).
PATIENTS WITH DIABETES 2. Steroids can decrease pain that may be limiting a patient’s ability to perform
SHOULD BE MADE AWARE
exercises.
THAT CLOSE POSTINJECTION
3. An injection can be repeated after several months if it gives symptomatic
GLUCOSE MONITORING MAY BE
REQUIRED.
relief, but no more than three injections per year (4-month intervals) should
be given.
Shoulder and Elbow

SURGICAL PROCEDURES COMMONLY PERFORMED WITH ROTATOR CUFF
REPAIR AND SURGICAL ALTERNATIVES TO ROTATOR CUFF REPAIR
I. Subacromial Decompression
A. Subacromial impingement is frequently seen in association with rotator cuff The coracoacromial
tears. Irritation or inflammation from this contact may be a contributing cause ligament may be a
of pain and tendon injury in patients with rotator cuff tears and, therefore, primary restraint to
should also be addressed at the time of surgery. The coracoacromial (CA) liga- superior elevation of the
ment should be preserved in patients with an irreparable or large rotator cuff humeral head in patients
tear, however, if concerned about the healing potential of the repair. Refer to with significant rotator
Chapter 2 for details regarding subacromial impingement and decompression. cuff deficiency, such as
B. If performed, subacromial decompression is typically done before the rotator those with irreparable
rotator cuff tears.
cuff repair.
Therefore, resection may
II. Acromioclavicular (AC) Joint Resection (Distal Clavicle Excision) lead to superior elevation
A. The AC joint is frequently found to be symptomatic in older patients with of the humeral head and
rotator cuff tears due to arthritic changes. Symptoms include tenderness to further worsening of
palpation over the AC joint, as well as pain with cross-body adduction of the shoulder function.
shoulder. Arthritic changes are noted on plain radiographs and/or MRI.
Imaging findings alone, however, are not sufficient to justify surgery because Distal clavicle osteolysis,
many patients with arthritic changes are asymptomatic. commonly seen in weight
B. A symptomatic AC joint can be surgically addressed (open or arthroscopically) lifters, is another cause of
at the time of rotator cuff surgery with a distal clavicle excision that acts to acromioclavicular joint
remove one end of the irritating joint surface. tenderness.
III. Long Head of the Biceps Tenotomy or Tenodesis
A. Subacromial impingement from rotator cuff disease can affect the long head of Acromioclavicular (AC)
the biceps tendon, leading to potential irritation or inflammation that may be a joint stability is a result of
pain generator in addition to the rotator cuff. The biceps tendon can also become a series of surrounding
symptomatically painful from instability within the bicipital groove, traumatic ligaments. The AC
injury, or primary age-related degeneration with or without impingement. ligaments encircle the
B. Symptoms include tenderness to palpation over the location of the long head joint and primarily
of the biceps in the bicipital groove. provide anterior-posterior
stability. The
C. A symptomatic long head of the biceps tendon can be surgically addressed
coracoclavicular ligaments
(open or arthroscopically) at the time of rotator cuff surgery by performing a
(the conoid [medially]
tenotomy (detachment of the tendon origin from the superior labrum and and the trapezoid
glenoid) or a tenodesis (the tendon origin is released and sutured or anchored [laterally]) run from the
to the proximal humerus, typically in the bicipital groove). coracoid to the distal
IV. Rotator Cuff Débridement clavicle and primarily
A. Débridement is considered an option for partial-thickness rotator cuff tears in provide vertical and
which the tear extends only partially through the depth of the tendon. It may medial-lateral stability.
be either on the outer, bursal side of the tendon or on the inner, articular side
of the tendon. BE CAREFUL NOT TO RESECT
1. The degenerated or frayed tendon is débrided away (typically arthroscopi- TOO MUCH OF THE DISTAL
cally) and can be performed with or without subacromial decompression. CLAVICLE DURING A DISTAL
2. Débridement is typically only considered in tears that are less than 50% of CLAVICLE EXCISION BECAUSE
tendon thickness, whereas tears that are more than 50% are more likely to THIS CAN DESTABILIZE THE
BONE BY VIOLATING THE
be surgically repaired.
STABILIZING LIGAMENTS OF
B. Débridement has also been used as a surgical option in combination with sub-
THE CLAVICLE. THE LIMIT OF
acromial decompression (without CA ligament resection) in patients with EXCISION IS TYPICALLY LESS
irreparable rotator cuff tears. THAN 2 CM.
V. Tendon Transfer
A. Tendon transfer may be considered in patients with refractory pain and weak-
ness and an irreparable rotator cuff tear with an otherwise normal glenohu-
meral joint. The goal is to restore overhead function.
B. When tendon transfer is used for irreparable anterosuperior rotator cuff defects
(subscapularis), a pectoralis major transfer can be performed, whereas for
irreparable posterosuperior rotator cuff defects (supraspinatus/infraspinatus/
teres minor), a latissimus dorsi transfer can be performed.
C. Tendon transfers typically work only for patients with mild to moderate weakness.
Does your attending
always perform a If a patient has severe weakness or paralysis with inability to raise his or her arm
subacromial overhead, a tendon transfer will not likely restore effective overhead function.
decompression when a
rotator cuff tear is
SURGICAL INDICATIONS FOR ROTATOR CUFF REPAIR
present? When does
he or she consider I. Failed nonoperative treatment (minimum 3 to 4 months)
débridement alone or II. Failed surgical alternative
tendon transfers versus A. Subacromial decompression (avoid CA ligament resection in patients with
surgical repair for a large or irreparable rotator cuff tears; previously mentioned).
rotator cuff tear?
B. Rotator cuff débridement
III. Prominent or progressive rotator cuff weakness
Pain is typically the IV. Acute, full-thickness tear in young, active patient
principal indication for V. Acute subscapularis rupture. This is commonly seen in patients older than 40 years
surgery in patients
of age who sustain an anterior shoulder dislocation.
failing nonoperative
management, because
pain relief is more RELATIVE CONTRAINDICATIONS TO ROTATOR CUFF REPAIR
reliably achieved than
improvement in function. I. Current or recent infection
II. Massive, irreparable rotator cuff tear
III. Advanced glenohumeral arthritis requiring arthroplasty
IV. Medically instability. The patient is unable to safely tolerate the stress of
surgery.
GENERAL PRINCIPLES OF ROTATOR CUFF REPAIR

I. The rotator cuff plays an important role as a dynamic stabilizer of the shoulder,
providing humeral head depression, humeral rotation, shoulder abduction, and
glenohumeral joint compression.
A. Its role in creating a compressive effect at the glenohumeral joint (i.e., pulling
the humeral head into the glenoid) helps provide a stable glenohumeral fulcrum
during active arm motion. This fulcrum allows the deltoid muscle to act as an
effective abductor and elevator of the shoulder, rather than simply pulling the
humeral head superiorly.
B. If the compressive effect is significantly lost due to a rotator cuff tear, the
resultant loss of a stable fulcrum and superior subluxation of the humeral head
may prevent effective arm elevation.
II. The rotator cuff also has an integral role in maintaining force couples in multiple
planes of the shoulder. For example, balanced force couples in the transverse plane
exist between the subscapularis anteriorly and the infraspinatus and teres minor
posteriorly. Disruption of these couples by a significant rotator cuff tear can
potentially result in abnormal shoulder kinematics that, again, lead to an unstable
fulcrum at the glenohumeral joint, abnormal humeral head excursion, and impaired
shoulder function.
III. The goal of rotator cuff repair is to restore the insertion of the torn tendon(s) on
the greater and/or lesser tuberosities of the humeral head, with the aim of decreas-
ing shoulder pain and/or improving function.
IV. Tears that are not repaired may potentially progress in size, leading to irreversible
changes in the muscle-tendon unit, including tendon retraction, tissue thinning,
muscular atrophy, and fatty replacement. Early repair of acute tears or prompt
repair of more chronic tears that fail nonoperative management can help avoid
these problems.
V. Regardless of technique, the rate-limiting step for recovery from rotator cuff
surgery is the successful healing of the rotator cuff tendon back to bone. Although
improvement in both pain and function have been shown even when the tendon
does not heal following rotator cuff repair, the most optimal results occur when
the rotator cuff successfully heals.
Shoulder and Elbow

VI. Tendon mobilization, or freeing of the scarred tendon from adhesions to sur-
rounding structures, is as important as the surgical repair of the torn tendon(s) to
the tuberosity. This allows the muscle-tendon unit to properly glide and function, IN A MINI-OPEN APPROACH
preventing postoperative stiffness and excessive tension on the repair that could FOR ROTATOR CUFF REPAIR,
lead to rerupture. THE DELTOID MUSCLE IS SPLIT
VII. In open surgery, the anterior deltoid origin is taken down to gain access to the THROUGH A SMALL OPEN
rotator cuff. A secure repair of the deltoid is essential, because one of the most INCISION WITHOUT TAKING
troublesome complications of open rotator cuff repair is damage to or detachment DOWN THE ORIGIN AND
of the deltoid. Arthroscopic rotator cuff repair has the advantage of not violating AVOIDING THE NEED FOR
the deltoid and avoiding these potential complications. DELTOID REPAIR. HOWEVER,
INADVERTENT INJURY TO THE
DELTOID DUE TO EXCESSIVE
COMPONENTS OF THE OPEN PROCEDURE RETRACTION MAY OCCUR.
The following steps have been focused to describe repair of a full-thickness supraspinatus
tear, the most commonly torn rotator cuff tendon. In general, similar steps are also used MOST OPEN REPAIRS OF
SUBSCAPULARIS TEARS ARE
for repairs of anterior or posterior rotator cuff tears or multitendon tears.
PERFORMED USING THE
DELTOPECTORAL APPROACH
Positioning, Prepping, and Draping BECAUSE IT PROVIDES MORE
ANTERIOR EXPOSURE.
I. The patient is positioned in the beach chair position (refer to Chapter 2 for details
on positioning).
The deltoid is composed
II. Prepping and draping is done according to the surgical principles outlined in of three heads with
Chapter 1. anterior, lateral, and
posterior fibers. It
Surgical Approach and Applied Surgical Anatomy originates from the
clavicle anteriorly,
I. The most common approach for open rotator cuff repair is the anterosuperior acromion laterally, and
approach. For patients undergoing revision surgery with a prior anterosuperior scapular spine posteriorly
incision, the previously made incision should be used. and inserts on the deltoid
II. The skin incision is made approximately 6 to 10 cm along Langer’s lines, extend- tuberosity of the
ing from approximately 2 cm lateral to the coracoid anteriorly to the lateral aspect humerus. The muscle is
innervated by the axillary
of the anterior one to two thirds of the acromion posteriorly (Fig. 3-2).
nerve. The deltoid split
III. Following the skin incision, subcutaneous flaps are raised and the deltoid from the anterolateral
is exposed. A 3- to 5-cm deltoid split is made along the direction of the corner of the acromion
takes advantage of the
natural separation
between the anterior and
lateral fibers.
Figure 3-2
Anterosuperior incision marked out.
Figure 3-3 Figure 3-4

Deltoid exposure and split. Exposed rotator cuff tear.
THE DELTOID SPLIT CAN BE deltoid fibers from the anterolateral corner of the acromion, moving distally. A
MOVED MORE POSTERIORLY, stay suture is placed at the end of the split to prevent extension. Split
STARTING AT THE MIDDLE OF extension can potentially lead to axillary nerve damage because the nerve
THE ACROMION, FOR LARGER passes approximately 5 to 6 cm distal to the lateral edge of the acromion
TEARS THAT EXTEND MORE (Fig. 3-3).
POSTERIORLY. EXTENSION OF IV. The deltoid origin is then elevated off the anterior acromion. This is elevated as
THE DELTOID MUSCLE SPLIT
far medially as the start of the AC joint and is dissected around the anterior edge
MUST NOT BE MADE MORE
of the acromion laterally. The anteroinferior acromion is exposed to elevate the
THAN 5 CM DISTALLY TO
AVOID DENERVATION OF THE
entire CA ligament with the anterior deltoid origin, so that both structures stay
MUSCLE. together as one flap for later repair.
V. With the anterior acromion exposed, an acromioplasty can be performed if there
are any prominent spurs on the undersurface of the anterior acromion. An osteo-
tome or saw is used to remove excess bone and create a smooth, flat undersurface.
The acromioplasty also exposes the AC joint, and a distal clavicle excision can be
performed if the AC joint was tender preoperatively.
VI. The subacromial bursa is removed to directly visualize the rotator cuff and the
site of the tear (Fig. 3-4).
Tendon Edge Débridement and Tendon Mobilization

I. Débridement and mobilization of the torn rotator cuff tendon is performed
to allow the retracted tendon to be repaired back to its insertion site on the greater
tuberosity tension-free. Mobilization occurs by freeing all adhesions between the
torn tendon and the surrounding tissues.
AVOID GOING MEDIAL TO THE
A. The torn tendon edges are débrided to remove any bursal or fibrous tissue and
BASE OF THE CORACOID stimulate healing. This usually removes 1 to 2 mm of tissue and should leave
BECAUSE OF THE RISK OF behind a thick tendon edge that can hold sutures.
SUPRASCAPULAR NERVE B. With the edge prepared, temporary sutures are placed at the torn end to
INJURY. provide traction while mobilizing the tendon.
C. The bursal side of the tendon is first released during mobilization, separating
the tendon from the acromion and the deltoid. This may include dividing the
coracohumeral ligament and releasing the tendon from the base of the coracoid
if the tendon is scarred to these structures.
D. If the supraspinatus is torn and medially retracted, it may be scarred to the
AVOID GOING MORE THAN
medial aspect of the adjacent rotator cuff tendons (subscapularis anteriorly and
1 CM MEDIAL TO THE GLENOID
infraspinatus posteriorly). The intervals between these two tendons and the
RIM BECAUSE OF THE RISK OF
SUPRASCAPULAR NERVE supraspinatus should be released.
INJURY. E. The articular side of the tendon is mobilized by releasing capsular attachments
that may be tethering the tendon (Figs. 3-5 and 3-6).
II. If the tendon of the long head of the biceps is noted to be significantly damaged,
a tenotomy or tenodesis to the proximal humerus is performed at this point.
Shoulder and Elbow

Coracoid
A B
Figure 3-5
Schematic of tendon mobilization. A, Mobilization
from the base of the coracoid on the bursal side of
the tendon. B, Mobilization on the articular side of
the tendon by releasing capsular attachments. (From
Miller M, Cooper D, Warner J: Review of Sports Figure 3-6
Medicine and Arthroscopy, 2nd ed. Philadelphia, Intraoperative view of tendon mobilization.
Saunders, 2002.)
Rotator Cuff Repair

I. The greater tuberosity is prepared for tendon repair by removing any soft tissue
over it and smoothing any irregular bony prominences.
II. The tendon is then repaired to the greater tuberosity with the arm in a neutral
position at the side. Heavy, nonabsorbable sutures are used and passed in a tran-
sosseous manner through the tendon edge and then through the bone of the
greater tuberosity (Fig. 3-7). The sutures should exit the bone at least 2 cm distal Suture anchors may also
to the greater tuberosity to bring the tendon edge down both medially and later- be used to repair the torn
ally and restore the normal footprint of the rotator cuff. Simple and/or modified tendon back to bone,
Mason-Allen stitches are used. rather than transosseous
sutures. What is your
III. Once the tendon is repaired back to the greater tuberosity, interval releases that
attending’s technique for
were made between the torn tendon and the intact rotator cuff (subscapularis and
open rotator cuff repair?
infraspinatus) can be sutured closed.
Deltoid Repair and Wound Closure

I. Following rotator cuff repair, the shoulder is pulse lavaged with saline with or
without antibiotics. The deltoid origin and CA ligament that were taken down
together in a flap are then repaired back to bone using heavy, nonabsorbable
sutures. A modified Mason-Allen stitch is used to anatomically repair these tissues
to the anterior acromion (Fig. 3-8).
II. The deltoid split should be sutured closed.
III. The subcutaneous tissue and skin is closed in standard fashion and the wound is
dressed (refer to Chapter 1 for further details).
A B
Figure 3-7
Transosseous rotator cuff repair using heavy, nonabsorbable sutures passed through the tendon edge (A)
and then through the greater tuberosity (B).
Figure 3-8
Deltoid following repair.
COMPONENTS OF THE ARTHROSCOPIC PROCEDURE

The following steps have been focused to describe repair of a full-thickness supraspinatus
tear, the most commonly torn rotator cuff tendon. In general, similar steps are also used
for repairs of anterior or posterior rotator cuff tears or multitendon tears.
Positioning, Prepping, and Draping

I. The patient is again placed in the beach chair position. Refer to Chapter 2 for a
description of positioning. Chapter 1 outlines the surgical principles used for
standard prepping and draping.
II. Shoulder arthroscopy and arthroscopic rotator cuff repair can also be performed
in the lateral decubitus position. An inflatable bean bag can be used to place the
patient in this position, with the operative extremity facing up. A traction device
What is your attending’s is then set up on the bed to pull traction on the arm at approximately 30 to 40
preferred patient position
degrees of abduction. Usually 10 to 12 pounds of traction are added to open up
for arthroscopic rotator
the glenohumeral joint. (See Chapter 4 for a description of the lateral decubitus
cuff repair?
position.)
Arthroscopic Portal Placement

I. Multiple portals are used for an arthroscopic rotator cuff repair. Bony landmarks
are drawn out on the skin with a marker to establish the location of each portal.
These landmarks include the acromion, scapular spine, clavicle, the location of
the AC joint, and the coracoid process (Fig. 3-9).
II. Anterior, posterior, and lateral portals are in general always used during arthros-
copy, and additional portals are added as necessary for rotator cuff repair. The
posterior portal is used for evaluation of the glenohumeral joint and subacromial
space with the arthroscope. When used during arthroscopic rotator cuff repair,
the anterior portal is primarily used for instrumentation and suture passing in the
subacromial space. Refer to Chapter 2 on establishing arthroscopic portals. The
lateral portal is placed in the subacromial space and is also used for instrumenta-
tion and suture passing during rotator cuff repair. It is a primary portal for knot
tying.
III. Anterolateral and posterolateral portals are added if needed and are placed 1 to
2 cm anterior or posterior to the lateral portal, respectively. These portals are used
for instrumentation and suture management during rotator cuff repair.
Diagnostic Arthroscopy and Additional Procedures

I. All arthroscopic rotator cuff repairs begin with a thorough inspection of the gle-
nohumeral joint to identify the rotator cuff tear, as well as to identify and treat
other pathology.
Shoulder and Elbow

Figure 3-9
Bony landmarks and arthroscopic portals marked out
on skin prior to incision. (From Miller M, Cooper D,
Warner J: Review of Sports Medicine and Arthroscopy,
2nd ed. Philadelphia, Saunders, 2002.)
A. The posterior portal is established and the arthroscope is placed in the gleno- AS IN THE OPEN PROCEDURE,
humeral joint. All areas of the glenohumeral joint should be inspected in a IF THE TENDON OF THE LONG
systematic fashion. HEAD OF THE BICEPS APPEARS
B. The origin of the long head of the biceps at the superior glenoid and labrum TO BE SIGNIFICANTLY
is often the first structure identified. Other significant structures to identify DAMAGED DURING INTRA-
include the labrum, glenohumeral ligaments, rotator cuff tendons, and the ARTICULAR INSPECTION, AN
articular surfaces of the glenoid and humeral head. An articular-sided or full- ARTHROSCOPIC TENOTOMY OR
thickness supraspinatus tear can be seen superolaterally, off the tendon’s inser- TENODESIS TO THE PROXIMAL
HUMERUS CAN BE
tion on the humeral head (Fig. 3-10).
PERFORMED.
II. After the glenohumeral joint has been fully inspected and other pathology has
been addressed, the arthroscope is placed in the subacromial space for evaluation.
The subacromial space is also initially entered through the posterior portal.
III. For most chronic and acute full-thickness rotator cuff tears, a subacromial decom-
pression is performed. Viewing from the posterior portal, with an arthroscopic
shaver placed in the subacromial space through the lateral portal, a subacromial
bursectomy is performed. Removing the bursa allows full visualization of the
rotator cuff tear and also exposes the undersurface of the acromion (Fig. 3-11).
A B
Figure 3-10
Arthroscopic views from the glenohumeral joint of a rotator cuff tear with uncovering of the glenoid (A)
and humeral head (B).
Figure 3-11
Arthroscopic view from the subacromial space of a
rotator cuff tear with uncovering of the humeral
head.
FOR LARGE CHRONIC ROTATOR IV. The undersurface of the acromion is further cleaned off using the shaver or an
CUFF TEARS (TWO AND THREE arthroscopic radiofrequency device, and the CA ligament can be released off the
TENDONS) WHERE TENDON anterior acromion if not contraindicated.
HEALING IS NOT GUARANTEED, V. If there are any prominent spurs on the undersurface of the anterior acromion
MAINTAINING THE INTEGRITY making it curved or hooked in shape, an anterior acromioplasty is performed. This
OF THE CORACOACROMIAL is done using an arthroscopic burr placed in the lateral and/or posterior portals.
(CA) ARCH IS CRITICAL. IN The burr is used to shave away the excess bone anteriorly, creating a smooth, flat
THIS CIRCUMSTANCE, AN undersurface of the acromion.
ACROMIOPLASTY SHOULD
VI. As in the open procedure, the acromioplasty also exposes the AC joint, and a distal
NOT BE PERFORMED IF IT
clavicle excision can be performed arthroscopically if the AC joint is symptomatic
REQUIRES RELEASE OF THE
CA LIGAMENT.
preoperatively. (Refer to Chapter 2 for details on subacromial decompression.)
Tendon Edge Débridement and Tendon Mobilization

I. Débridement of the torn tendon edges can be done following the subacromial
decompression using the arthroscopic shaver. Any bursal or fibrous tissue should
be removed to stimulate healing and leave behind a thick tendon edge that can
hold sutures.
II. Depending on the size and mobility of the tear, tendon mobilization is performed
to allow the retracted tendon to be repaired back to its insertion site on the greater
tuberosity tension-free. Similar to the open procedure, mobilization occurs by
freeing all adhesions between the torn tendon and the surrounding tissues.
A. Traction sutures can be placed at the tendon edges or an arthroscopic grasping
AS IN THE OPEN PROCEDURE, device can be used to provide traction while mobilizing the tendon.
AVOID GOING TOO MEDIAL B. Using a shaver or small periosteal elevator through the lateral portal, subacro-
DURING THE ARTHROSCOPIC
mial adhesions are released to mobilize the bursal side of the tendon.
RELEASES BECAUSE OF THE
C. Intra-articular or capsulolabral adhesions are released by re-entering the gle-
RISK OF SUPRASCAPULAR
NERVE INJURY.
nohumeral joint with the arthroscope in the posterior portal and using similar
instrumentation to mobilize the articular side of the tendon.
Rotator Cuff Repair

I. The rotator cuff tear should be optimally visualized and mobilized at this point, and
based on the tear pattern, the appropriate repair technique is determined.
II. Suture anchors are typically used to repair the tendon back to bone and
can be made of metal or a bioabsorbable material. The anchors are placed at the
greater tuberosity, just off the articular surface of the humeral head, and have
suture loaded in them that can be passed through the tendon for repair.
Shoulder and Elbow

A. The greater tuberosity is prepared for anchor placement with an arthroscopic
shaver and/or burr to remove any soft tissue and smooth any irregular bony
prominences. Aggressive decortication of the tuberosity is not necessary and
can weaken the strength of the anchors in the tuberosity.
B. Suture anchors are placed, typically through the anterolateral portal. A spinal
needle can be used to determine the correct orientation of anchor placement
prior to making the portal.
C. Depending on the size and pattern of the rotator cuff tear, one or more anchors
are used and placed approximately 1 cm apart, starting from the point of least
tension and moving toward the point of greatest tension (typically posterior to
anterior). The anchors are loaded with a heavy, nonabsorbable suture prior to
placement and are either screwed or malleted into the bone.
III. A number of different arthroscopic techniques and instruments are available to
facilitate suture passing through the torn rotator cuff tendon prior to tying. The
details of these procedures are beyond the scope of this chapter; however, tear
pattern often dictates the techniques and instruments used. All of the available
portals may be needed to facilitate suture passing, with the arthroscope typically
placed in the posterior or lateral portal.
IV. Once all sutures have been passed, they can be sequentially tied to bring the torn
tendon back to the greater tuberosity to be held via the anchors. Just as with the
open procedure, the goal is to restore the normal footprint of the rotator cuff.
The tendon is generally repaired with the arm in a neutral position at the side if
possible.
V. Several arthroscopic knot-tying techniques can be used to secure the suture;
however, the details of these techniques are beyond the scope of this chapter. In
general, sliding knots must be made outside of the shoulder and then passed into
the subacromial space through one of the portals with an arthroscopic knot pusher.
Once down on the tendon, the knots are then tightened, locked, and the suture
cut.
VI. Depending on tear pattern and size, different knot types may be used including
simple, horizontal mattress, and modified Mason-Allen stitches. In addition, newer
techniques, such as double row repairs and transosseous-equivalent repairs, are
continually being developed in order to best restore the normal footprint of the What is your attending’s
rotator cuff. technique for arthro-
scopic rotator cuff repair?
VII. Once all sutures have been tied, stability of the repair should be confirmed by
When does he/she con-
visualization through both the subacromial space (tendon outer surface) and gle- vert to an open repair?
nohumeral joint (tendon undersurface) prior to closure (Fig. 3-12).
A B
Figure 3-12
Arthroscopic views from the subacromial space of the rotator cuff tears following repair, in Figure 3-10 (A)
and Figure 3-11 (B).
Portal Closure
The arthroscopic portals are closed in standard fashion, and the wounds are dressed (refer
to Chapter 1).

I. Most patients, whether undergoing open or arthroscopic surgery, can go home
the day of surgery. Patients should remain overnight for observation if their pain
CAUTION MAY BE NEEDED IN is not adequately controlled.
PATIENTS UNDERGOING II. Initial postoperative pain management is best achieved with oral narcotics and/or
ARTHROSCOPIC ROTATOR an interscalene nerve block placed just prior to surgery. Patient-controlled anal-
CUFF REPAIR. THEY MAY gesia may be used if the patient remains in the hospital overnight.
HAVE LESS DISCOMFORT III. Shoulder rehabilitation following rotator cuff repair has some variations depend-
POSTOPERATIVELY COMPARED ing on the size of the tear and the quality of the repair. In addition, the period of
WITH THOSE UNDERGOING shoulder immobilization may vary based on the same factors, as well as surgeon
MORE TRADITIONAL OPEN preference. However, some general guidelines are as follows:
REPAIR AND MAY WANT TO
A. The first week after surgery, the arm remains in the abduction sling at all times
DO MUCH MORE WITH THE
when out in public or in bed. The sling can be removed only for showering,
SHOULDER THAN IS INITIALLY
DESIRED.
dressing, and for gentle shoulder pendulum exercises. Active ROM exercises
can only be done with the hand, wrist, and elbow.
B. Passive shoulder ROM exercises are started as early as 2 to 4 weeks after surgery.
These include passive supine forward flexion and passive supine external rota-
tion, with continued pendulums. For smaller tears with good-quality tissue,
some surgeons may start these passive exercises immediately after surgery.
C. The shoulder is protected in the sling for up to 4 to 6 weeks after surgery, with
large tears protected longer.
D. Active assisted and active ROM exercises are started anywhere from 6 to 10
weeks postoperatively. Exercises begin in the supine position and progress to
the seated or standing position. All planes of motion are used at this point,
including forward flexion, abduction, external rotation, and gentle internal
rotation. The contralateral arm or a cane is used for active assisted activities.
Caution is essential as the patient progresses from passive to active assisted to
active ROM to avoid compromising the repair. Exercises should not be painful,
and progress to active ROM should be stopped or slowed if pain is
encountered.
E. By week 10, a strengthening program can generally be started. Comfortable,
active ROM must be achieved prior to beginning strengthening. Resistance
bands are first used for strengthening, with progression to light free weights
and eventually machines as tolerated. Again, overaggressive or premature
strengthening should be avoided to prevent compromising the repair, with pain
serving as a guide.
What is your attending’s IV. Return to sports activities and/or manual labor varies depending on the size of the
rehabilitation protocol tear, quality of the repair, and rehabilitation potential of the patient, but may take
following rotator cuff
6 to 9 months. Complete healing of the repair and return of full strength may take
repair?
more than 12 months.
COMPLICATIONS
I. Persistent pain (e.g., inadequate subacromial decompression, AC joint arthritis,
painful long head of the biceps)
II. Infection
III. Incomplete healing of rotator cuff tear
IV. Recurrent rotator cuff tear
V. Stiffness, adhesive capsulitis (frozen shoulder)
VI. Deltoid detachment or denervation
VII. Nerve injury (axillary, suprascapular)
Shoulder and Elbow

SUGGESTED READINGS
Craig EV: Master Techniques in Orthopaedic Surgery: The Shoulder, 2nd ed. Philadelphia, Lip-
pincott Williams & Wilkins, 2003.
Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Phila-
delphia, Lippincott Williams & Wilkins, 2007.
Norris TR: Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American
Academy of Orthopaedic Surgeons, 2002.
C H A P T E R
4
Bankart Repair: Open and Arthroscopic
Andrew F. Kuntz and Joseph A. Abboud
Case Study
A 29-year-old, right hand–dominant female who works as a teacher presents as an out-

patient for evaluation. Two weeks prior to her appointment, she dislocated her right
shoulder while changing her clothes. At that time, closed reduction of her shoulder was
successfully performed in the local emergency department, and she was placed in a sling
for immobilization. History reveals approximately six previous dislocations, with the first
occurring 8 years earlier following a fall down stairs. On physical examination, there is no
gross deformity about the shoulder. Range of motion is unable to be fully tested due to
patient guarding. Anterior apprehension and relocation tests are positive. Otherwise, there
is no evidence of rotator cuff or cervical spine pathology, and her neurovascular examina-
tion is intact. Radiographs following the most recent glenohumeral reduction reveal no
fractures or bony abnormality. A magnetic resonance arthrogram obtained subsequent to
her recent dislocation is shown in Figure 4-1.
BACKGROUND
I. General
A. Glenohumeral anatomy and biomechanics may result in significant joint insta-
bility. The glenohumeral joint is the most mobile large joint in the body and
is the most frequently dislocated. Shoulder dislocations account for approxi-
mately 50% of all native joint dislocations.
B. Most shoulder dislocations are anterior, occurring eight to nine times more
frequently than posterior dislocation. Inferior (luxatio erecta) and superior
dislocations are very rare.
Figure 4-1
Axial cut from a magnetic resonance arthrogram
showing a medially displaced Bankart lesion (arrow).
34 nedasalamatebook@gmail.com 66485438-66485457
C H A P T E R 4 Bankart Repair: Open and Arthroscopic 35
Shoulder and Elbow

C. Traumatic injury is responsible for approximately 95% of all dislocations. A
direct blow to the shoulder, or in the case of an anterior dislocation, trauma
to the arm with the shoulder in a position of abduction, extension, and external
rotation are the most common mechanisms.
D. The recurrence rate is multifactorial and is related to age at initial injury and
the amount of force required for dislocation. Several studies have shown greater
than 90% recurrence in patients younger than 20 years of age at initial disloca-
tion. This number decreases to 10% in patients older than 40 years of age.
II. Shoulder Anatomy
A. The glenohumeral joint gains little stability from the bony anatomy. Only 25%
of the humeral head articulates with the flat glenoid at one time. Therefore,
joint stability is a function of both static and dynamic stabilizers. Static stabiliz-
ers include the labrum, capsule, and associated ligamentous structures, negative
intra-articular joint pressure, and adhesive and cohesive forces of the synovial
fluid. Dynamic stability is a function of the rotator cuff, biceps tendons, and
periscapular muscles.
B. The glenoid labrum deepens the glenoid 50%. This improves contact between
the humeral head and glenoid so that 75% of the humeral head is in contact
with the glenoid and labrum at a given time.
C. The shoulder capsule is thin and lax with little inherent stability. However,
three capsular thickenings/ligaments play an integral role in providing shoulder
stability (Fig. 4-2). The superior glenohumeral ligament serves as a restraint
Subacromial bursa (subdeltoid)

Long head of biceps brachii tendon
Coraco-acromial ligament
Acromion Coracoid process
Deltoid Subscapular bursae
Supraspinatus
Fibrous membrane
Glenoid cavity
Synovial membrane
Infraspinatus
Figure 4-2
Lateral view of right gleno-
Glenoid labrum humeral joint and surrounding
Teres minor muscles with proximal end of
humerus removed. (From Drake
Subscapularis
RL, Vogl W, Mitchell AWM:
Teres major Gray’s Anatomy for Students.
Philadelphia, Churchill Livingstone,
2005.)
Latissimus dorsi
Pectoralis major
Long head of triceps
brachii
Short head of biceps brachii

and coracobrachialis
to inferior translation and anterior/posterior stress with the arm at 0 degrees

of abduction. The middle glenohumeral ligament limits external rotation with
arm in midabduction. Once the arm is abducted greater than 45 degrees, the
anterior inferior glenohumeral ligament complex acts to limit anterior and
posterior humeral head translation.
D. The rotator cuff, a dynamic stabilizer, provides a compressive force to the
glenohumeral joint throughout its range of motion.
III. Bankart Lesion
A. No single pathologic lesion is responsible for recurrent shoulder instability. In
A Bankart lesion is the 1906, Perthes described detachment of the anterior glenoid labrum as the
traumatic detachment of “essential” lesion of instability. In 1938, Bankart described two types of acute
the anterior-inferior shoulder dislocations, including forced anterior translation of the humeral
glenoid labrum. With this head. He found that following this mechanism, tearing the anterior glenoid
lesion, there is also labrum and detachment of the capsule and periosteum from the scapular neck
disruption of the anterior was common. From this description, traumatic detachment of the glenoid
capsuloligamentous labrum came to be known as the “Bankart lesion.”
complex.
B. Although not an “essential” lesion for shoulder instability, the Bankart lesion
is found in up to 97% of shoulders following traumatic dislocation.
TREATMENT ALGORITHM
Shoulder instability
Radiographs: AP, scapular Y, axillary

Consider West Point and Stryker notch views
MR arthrogram
Bankart lesion
No prior treatment Failed conservative management or

first-time dislocation in young athlete
• Physical therapy
• Periscapular muscle strengthening Open or arthroscopic
• Proprioceptive training Bankart repair
• Orthosis
TREATMENT PROTOCOLS
I. History and Physical Examination
A. Patient evaluation in the emergency department or outpatient setting is critical
in formulating a treatment plan following acute shoulder dislocation or recur-
rent instability. Examination begins by obtaining a history with a focus on
determining the number and frequency of previous dislocations as well as arm
position, amount of force, and activity resulting in dislocation.
B. Along with obtaining the proper history, a physical examination is always per-
formed. When examining a patient with an acute shoulder dislocation, the
following physical examination components are essential:
1. Observation of shoulder and extremity resting position. Anterior disloca-
tions typically result in humeral external rotation, whereas posterior disloca-
tions result in internal rotation.
2. Inspection and palpation about the shoulder may reveal a depression beneath
the lateral deltoid and/or prominence of the humeral head anteriorly.
Shoulder and Elbow

3. Careful and thorough neurovascular examination must be documented for ALWAYS ASSESS THE MOTOR
all patients presenting with a shoulder dislocation. This must include evalu- FUNCTION OF THE AXILLARY
ation of the motor function of the axillary nerve through demonstration of NERVE IN A PATIENT WITH AN
deltoid contraction. Evaluation of axillary nerve sensory function alone is ACUTE GLENOHUMERAL
unreliable and potentially misleading. DISLOCATION.
C. In the outpatient setting, physical examination of a patient with recurrent
instability should include the following components:
1. Evaluation of the cervical spine
2. Comparison to the contralateral shoulder, assuming there is no history of
bilateral instability
3. Inspection for muscle atrophy and/or asymmetry
4. Palpation for tenderness
5. Active and passive range of motion assessment in all planes of motion
(including observation for possible scapular winging)
6. Strength testing
7. Neurovascular assessment
8. Provocative tests for shoulder instability:
a. Load and shift test. This demonstrates anterior/posterior translation of
the humerus.
b. Sulcus test. This demonstrates inferior translation of the humerus as a
result of longitudinal humeral traction.
c. Anterior apprehension test. This test is performed with the patient
lying supine with the arm in 90 degrees of abduction. Beginning with
the arm in neutral rotation, external rotation causes patient apprehension
because the tendency of the humeral head is to subluxate/dislocate ante-
riorly. This maneuver should be performed carefully to avoid in-office
dislocation.
d. Jobe’s relocation test. Applying a posterior-directed force over the
humeral head during an apprehension test provides comfort and relief
for the patient. NEVER ACCEPT INADEQUATE
II. Radiographic Evaluation IMAGING OF THE SHOULDER.
A. An acute shoulder dislocation requires evaluation with three views of the AN AXILLARY OR EQUIVALENT
shoulder, including anteroposterior (AP), transscapular, and axillary views. The VIEW IS MANDATORY WHEN
EVALUATING A PATIENT WITH
axillary view is critical in ruling out dislocation and confirming reduction. If
AN ACUTE GLENOHUMERAL
an axillary view or equivalent (Velpeau view) cannot be obtained, computed DISLOCATION.
tomography (CT) imaging of the shoulder is required.
B. Several other specialized radiographic views may be helpful in determining
treatment for a patient with recurrent shoulder instability. These include: A Hill-Sachs lesion is a
depression fracture of the
1. Both an AP radiograph with the shoulder in internal rotation and a Stryker
posterior lateral humeral
notch view can be useful in the evaluation for the presence of a Hill-Sachs head, resulting from the
lesion. humeral head resting on
2. The West Point view is useful in evaluating the glenohumeral joint for the anterior glenoid rim
fracture and/or calcification of the anterior inferior glenoid rim. secondary to an anterior
C. A CT can be helpful in further evaluating the presence and extent of a Hill- dislocation. This lesion
Sachs lesion and/or a glenoid rim fracture. is present following 35%
D. Magnetic resonance arthrography has become the imaging study of choice in to 40% of first-time
the setting of shoulder instability as it gives the best minimally invasive evalu- dislocations, as well as
ation of the soft tissues about the shoulder. Injection of contrast medium into in 80% of recurrent
the glenohumeral joint serves to delineate the soft tissue structures, increasing dislocations.
the ability to diagnose defects of the labrum and capsule.
III. Classification A Bankart lesion
associated with a glenoid
A. There is no formal classification system used to categorize Bankart lesions
rim fracture is referred to
and/or shoulder instability. As a result, glenohumeral instability should be as a bony Bankart lesion.
described using the following parameters:
1. Direction: unidirectional, bidirectional, or multidirectional
2. Subluxation versus dislocation
3. Temporal: acute, subacute, or chronic (>6 weeks)
4. Amount of force required for dislocation

5. Patient age
6. Patient mental status
7. Patient comorbidities
B. Bankart lesions typically involve only detachment of the anterior-inferior
glenoid labrum, as well as disruption of the anterior capsuloligamentous struc-
tures. Occasionally, there is osseous involvement with an associated anterior-
inferior glenoid rim fracture.
IV. Treatment of Acute Glenohumeral Dislocation
A. Management of an acute shoulder dislocation should focus on prompt, atraumatic
joint reduction. Reduction should be performed following intra-articular local
anesthetic injection or conscious sedation. Many reduction techniques have been
described; however, use of traction and countertraction is often successful.
B. Following shoulder manipulation, joint reduction must be confirmed radio-
graphically. Subsequently, the patient should have the shoulder immobilized
temporarily. Classic immobilization includes a sling and swathe. With this
method of immobilization, length of immobilization has no effect on rate of
What is your attending’s
recurrence. Recently, there has been interest in the effectiveness of immobili-
immobilization protocol
following an acute
zation in a position of humeral external rotation in reducing recurrence rate.
shoulder dislocation? This is based on the finding that immobilization in adduction and internal
rotation results in separation and displacement of the anterior labrum.
C. The patient should follow up with an orthopaedic surgeon within 1 week follow-
ing an acute shoulder dislocation and successful relocation. At that point, further
imaging such as CT and/or magnetic resonance imaging (MRI) may be ordered
to assess for a Bankart lesion, soft tissue disruption, and bony pathology.
V. Nonoperative Treatment Alternatives
A. Rehabilitation and physical therapy, with a focus on periscapular muscle
strengthening, are the principal nonoperative treatments for recurrent shoul-
der instability in patients with Bankart lesions. A successful combination of
periscapular muscle strengthening and proprioceptive training can result in the
ability to function without surgical intervention.
B. Orthoses that limit shoulder abduction and external rotation are also available
and can be used to supplement physical therapy and rehabilitation.
SURGICAL ALTERNATIVES
I. Alternative surgical options typically address shoulder instability and not labrum
or capsule pathology. The following listed procedures are alternatives that were
historically popular for treating patients with anterior shoulder instability.
II. Putti-Platt Procedure
A. In this procedure, the subscapularis tendon and joint capsule are incised verti-
cally, the lateral capsule is sutured to the glenoid labrum, the medial capsule
is imbricated, and then the subscapularis is advanced laterally.
B. Currently, the Putti-Platt procedure is rarely indicated due to enhanced under-
standing of shoulder biomechanics and the common occurrence of severe
postoperative posterior glenoid wear.
III. Magnuson and Stack Procedure
A. Anterior shoulder instability is addressed with advancement of the anterior
capsule and subscapularis tendon laterally on the humerus.
B. One of the main disadvantages of the Magnuson and Stack procedure is the
common external rotation deficit postoperatively.
IV. Latarjet Procedure
A. Anterior inferior glenoid rim fractures can increase anterior shoulder instabil-
ity. When a large portion of the glenoid is involved (>25% of glenoid surface
area), surgical intervention to address the bony defect is indicated. Due to the
altered glenoid appearance, the “inverted pear” analogy has been used to
describe this situation.
Shoulder and Elbow

B. The Latarjet procedure involves transfer of the entire coracoid process to the
anterior glenoid to address local bone loss.
C. Despite this, some surgeons have used this procedure successfully for primary
treatment of instability without bone loss.
V. Bristow Procedure
A. The Bristow procedure is a modification of the Latarjet procedure and involves
transfer of only the tip of the coracoid to the anterior glenoid rim.
B. Indications for this procedure also include shoulder instability in the presence
of an anterior inferior glenoid osseous defect.
SURGICAL INDICATIONS FOR BANKART REPAIR

I. Shoulder instability with evidence of a Bankart lesion on MRI
II. Failed nonoperative treatment
A. Physical therapy and/or rehabilitation
B. Orthoses
III. Shoulder instability that prevents return to activity
IV. Single anterior shoulder dislocation in a young (<25-year-old) athlete Does your attending
A. This is a controversial concept and may be considered a relative indication for operate on patients with a
operative treatment. Bankart lesion following
B. Many surgeons believe that Bankart repair is indicated following first-time a single shoulder
dislocation in this population due to the high incidence of recurrence. Addi- dislocation? If not, then
what rehabilitation
tionally, although not absent, surgical risks have decreased with the increased
protocol is used?
use of arthroscopic technique.
RELATIVE CONTRAINDICATIONS TO BANKART REPAIR

I.Current or recent infection
II.Multidirectional instability
III.Significant glenohumeral arthritis
IV. Voluntary subluxation and/or psychological issues that contribute to shoulder
instability (absolute contraindication)
V. Medical comorbidities that preclude surgical treatment
GENERAL PRINCIPLES OF BANKART REPAIR SURGERY

I. The major goal of Bankart repair surgery is to restore function of the static stabi-
lizers of the shoulder in order to reduce the incidence of recurrent shoulder The major goal of
instability. Bankart repair attempts to restore the anterior-inferior labrum so that Bankart repair surgery is
it can act as a “bumper” to avoid anterior humeral head translation. to restore function of the
II. Open repair of a Bankart lesion is a time-tested procedure with an overall success static stabilizers of the
rate of 90% to 95%. This procedure involves an anterior approach to the shoulder shoulder, whereas the
to repair the capsulolabral structures to the glenoid through use of drill holes or goal of rehabilitation is to
suture anchors. restore dynamic stability.
III. The decision to repair a Bankart lesion arthroscopically is one based on surgeon
experience and comfort. In general, there is a steep learning curve associated with
arthroscopic surgical fixation of these lesions. Compared with open Bankart repair,
arthroscopic surgery has the advantage of being able to achieve anatomic labral
repair without surgical takedown of the subscapularis tendon. As a result, patients
typically do not experience a decrease in external rotation as they may after open
surgery. Additionally, arthroscopic surgery is typically associated with less post-
operative pain and a shorter hospital course. The main disadvantage of arthroscopic
surgery is historically higher rates of recurrence. However, with improving instru-
mentation and arthroscopic fixation anchors, recurrence rates are approaching that
of open surgery.
IV. Regardless of whether a Bankart repair is performed as an open or arthroscopic
procedure, an examination of shoulder stability is performed under anesthesia
prior to starting surgery. The examination as described earlier is performed on

the operative shoulder and compared to the contralateral side. Under anesthesia,
joint stability can be assessed in the absence of patient guarding.
V. Most surgeons begin with diagnostic arthroscopy of the affected shoulder, regard-
less of whether the Bankart repair is performed open or arthroscopically. Diag-
nosis of lesions such as a large anterior inferior glenoid defect or an engaging
Hill-Sachs lesion (in which a Hill-Sachs lesion engages the glenoid during range
of motion, resulting in instability) often require open treatment. Humeral avulsion
of the glenohumeral ligaments (HAGL lesion) must also be treated with an open
procedure. However, a superior labrum anterior posterior (SLAP) lesion, which
may be concomitantly present, must be addressed arthroscopically. (Refer to
Chapter 2 for diagnostic arthroscopy.)
COMPONENTS OF OPEN BANKART REPAIR

Refer to Chapter 2 for details regarding patient positioning, prepping, and draping for
the beach chair position. Also, refer to Chapter 6 for the anterior surgical approach to the
shoulder. The procedure by which the labrum is attached to the glenoid rim is the same
technique used for the arthroscopic method described below.
COMPONENTS OF ARTHROSCOPIC BANKART REPAIR

Patient Positioning, Prepping, and Draping
I. Prior to beginning an arthroscopic Bankart repair, the anesthesiologist may provide
an interscalene nerve block to decrease postoperative pain. The procedure is typi-
cally performed under general anesthesia.
II. Arthroscopic Bankart repair can be performed using the beach chair or lateral decu-
bitus position. This chapter focuses on using the lateral decubitus position.
III. For the lateral decubitus position, the patient is placed on a bean bag on a standard
operating room table. In a coordinated effort involving the anesthesiologist,
nursing staff, and the surgeon, the patient is rolled into the lateral decubitus posi-
tion with the operative extremity oriented toward the ceiling. The contralateral
arm is placed on an armboard and an axillary roll is placed under the nonoperative
arm. The lower extremity that rests against the table should be padded at the level
of the proximal fibula and ankle. For female patients, care must be taken to avoid
undue pressure on the breasts. Entrapment of the genitalia during positioning
must be avoided in male patients. Once the patient is in proper position, the bean
bag is connected to suction. The operative extremity is then suspended using a
candy cane and prepped in the usual fashion (Fig. 4-3). (Refer to Chapter 1 for
surgical principles for prepping and draping.)
Figure 4-3
Patient positioning in the lateral decubitus position.
Once properly positioned, the arm is suspended for
prepping.
Shoulder and Elbow

Traction is applied to the operative extremity to Intra-articular view of dual anterior portals with
provide joint distraction. Here the arm is placed in the inferior portal placed just proximal to the
a sterile sling and secured in place using Coban. subscapularis tendon. (From Miller M, Cooper D,
Warner J: Review of Sports Medicine and Arthroscopy,
2nd ed. Philadelphia, Saunders, 2002.)
IV. With the shoulder prepped and draped, the operative extremity is placed in a dis-
traction arm holder (Fig. 4-4). The arm holder is then connected to the traction
setup and approximately 10 to 12 pounds of traction is applied.
Establishment of Arthroscopic Portals and Diagnostic Arthroscopy

I. Refer to Chapter 2 for establishing arthroscopic portals and diagnostic
arthroscopy.
II. In addition to the standard arthroscopic portals, Bankart repair often requires a
second anterior portal inferior and medial to the previous portal. This portal is
placed at the superior aspect of the subscapularis tendon. There should be a
minimum of 3 cm between the anterosuperior and anteroinferior portals to avoid
overcrowding of instruments (Fig. 4-5).
Bankart Lesion Repair

I. Once the diagnostic arthroscopy is complete, the size of the Bankart lesion must
be assessed.
II. The labrum is mobilized from the anterior neck of the scapula (Fig. 4-6). This
can be performed with arthroscopic instruments, a rasp, or with a Cobb elevator.
Figure 4-6
Mobilization of the anterior inferior labrum from the
anterior scapular neck is accomplished with a Cobb
elevator.

Anchor placement. A bioabsorbable suture anchor is Completed Bankart repair with anterior glenoid
inserted through the anterior canula. labrum secured in anatomic position with three
suture anchors.
The labrum must be released at least to the 6 o’clock position to perform an ana-
tomic repair with proper tension.
SUTURE ANCHORS MUST BE III. The glenoid rim is often sclerotic, and therefore preparation may be necessary.
PLACED AT THE PERIPHERY OF This is accomplished with a shaver or burr until the subchondral bone is exposed
THE GLENOID ARTICULAR
and a bleeding bed of bone for labral adherence is established.
SURFACE. THE TENDENCY IS
IV. The first suture anchor is placed as far inferior on the glenoid rim as possible
TO PLACE ANCHORS TOO
FAR MEDIALLY. through the anteroinferior portal (Fig. 4-7). Anchor placement is critical, with
optimal placement at the articular surface edge.
V. Depending on the type of anchor used, one or both limbs of the suture are
retrieved through the anteroinferior portal. A suture-passing device is then used
to capture the capsulolabral tissue with the retrieved suture. The suture is tied to
secure the capsulolabral tissue to the glenoid.
VI. The previous steps are repeated as additional anchors are placed along the glenoid
face, from inferior to superior. Commonly, three anchors are required. However,
the number of anchors required to achieve a stable repair is determined by the
size of the lesion (Fig. 4-8).
VII. Once all anchors have been placed and the labrum and associated capsule are
secured to the glenoid, laxity of the anterior capsule is assessed and capsular placa-
tion is performed as needed.
Portal Closure
The portals are closed in standard fashion, and a sterile dressing is applied (see Chapter
1). A sling is used to immobilize the limb postoperatively.
POSTOPERATIVE CARE
I. Most patients, whether undergoing open or arthroscopic surgery, can go home
the day of surgery. Patients should remain overnight for observation if their pain
is not adequately controlled.
II. Initial postoperative pain management is best achieved with oral narcotics and/or
an interscalene nerve block placed just prior to surgery. Patient-controlled analge-
sia may be used if the patient remains in the hospital overnight.
III. Shoulder rehabilitation following Bankart repair typically occurs in three phases,
with each phase lasting approximately one month.
A. The first phase involves shoulder immobilization with a sling. Shoulder pen-
dulum exercises are started postoperative day 1, as are elbow, wrist, and hand
Shoulder and Elbow

range-of-motion (ROM) exercises. Patients must avoid shoulder abduction and
external rotation.
B. The second phase involves full shoulder active ROM exercises with protected
abduction and external rotation.
C. The final phase of rehabilitation includes periscapular muscle strengthening.
IV. Rehabilitation following open Bankart repair is typically more aggressive to avoid
excessive stiffness. Exercises follow the same progression as outlined above;
however, active assisted ROM begins during the first postoperative week.
V. Full return to activity and sports can be expected at approximately 6 months after
surgery.
COMPLICATIONS
I. Infection
II. Recurrent shoulder instability. This can be a result of the following:
A. Failure of labral repair
B. Nonanatomic labral repair secondary to inadequate immobilization
III. Axillary or musculocutaneous nerve damage
IV. Humeral head articular surface damage. This occurs from prominent metal suture
anchors on the glenoid articular surface.
V. Loose suture anchor in the glenohumeral joint
VI. Reactive synovitis or bone cyst formation. This occurs secondary to bioabsorbable
suture anchors.
SUGGESTED READINGS
Bottoni CR: Anterior instability. In Johnson DL, Mair SD (eds): Clinical Sports Medicine. Phila-
delphia, Mosby, 2006, pp 189–199.
Pearle AD, Cordasco FA: Shoulder instability. In Vaccaro AR (ed): Orthopaedic Knowledge Update
8. Rosemont, IL, American Association of Orthopaedic Surgeons, 2005, pp 283–294.
Phillips BB: Recurrent dislocations, Shoulder section. In Canale ST (ed): Campbell’s Operative
Orthopaedics, 10th ed. Philadelphia, Mosby, 2003, pp 2397–2422.
Su B, Levine WN: Arthroscopic Bankart repair. J Am Acad Orthop Surg 13:487–490, 2005.
C H A P T E R
5
Arthroscopic Superior Labrum
Anterior Posterior (SLAP) Repair
Brent B. Wiesel and G. Russell Huffman
Case Study
A 30-year-old, left hand–dominant male presents with a 6-month history of left shoulder
pain, which began after he landed on his left arm while playing ice hockey. The pain is
activity related and exacerbated by the use of his left arm for overhead activities or throw-
ing. His symptoms have progressed to the point where he can no longer participate in
recreational hockey and softball. A brief course of nonsteroidal anti-inflammatory medica-
tions failed to relieve his pain fully, and physical therapy has exacerbated his symptoms.
On physical examination, he has full range of motion and no atrophy about the left shoul-
der. He has positive O’Brien and Mayo sheer tests. He has pain but no apprehension when
his arm is placed in abduction and external rotation, and his pain is relieved when a pos-
teriorly directed force is applied to his anterior shoulder. Radiographs of the left shoulder
are normal and a coronal oblique T1-weighted magnetic resonance imaging scan with
intra-articular contrast is shown in Figure 5-1.
BACKGROUND
I. Injuries to the intra-articular attachment of the long head of the biceps tendon
were originally described by Andrews et al in 1985. This entity was further
defined and classified by Snyder et al in 1990. The authors described four types
of pathologic lesions and named them superior labral anterior and posterior
(SLAP) tears.
Figure 5-1
Coronal oblique T1-weighted magnetic resonance
imaging scan with intra-articular contrast of the left
shoulder. (From Miller MD, Osborne JR, Warner JJP,
Fu FH [eds]: Shoulder Arthroscopy in MRI—Arthroscopy
Correlative Atlas. Philadelphia, Saunders, 1997.)
C H A P T E R 5 Arthroscopic Superior Labrum Anterior Posterior (SLAP) Repair 45
Shoulder and Elbow

II. Since that time, SLAP tears have been increasingly recognized as a common cause
of shoulder pain in throwing athletes, as well as any young individual who suffers
a traction or compression injury to the shoulder.
III. In overhead throwing athletes, there are two mechanisms that combine to result
in injury to the posterosuperior glenoid labrum:
A. The inciting event is proposed by some to arise from excessive traction on the
posterior inferior joint capsule during the follow-through phase of throwing.
This repetitive microtrauma may lead to hypertrophy of the posterior band of
the inferior glenohumeral ligament.
1. This thickening of the posterior inferior capsule can be demonstrated on
physical examination as a loss of glenohumeral internal rotation with the
arm in 90 degrees of abduction and the scapula stabilized to prevent scapu-
lothoracic motion.
2. The posterior capsular abnormality initiates a chain of pathologic motion
that results in abnormal posterior-superior translation of the humeral head
during the late-cocking phase of throwing. This translation places increased
stress on the superior labrum and biceps anchor and can lead to type II
SLAP tears. This is known as the peel-back mechanism.
B. The second mechanism is that of internal impingement. In positions of gleno-
humeral abduction and external rotation (e.g., the late cocking phase of throw-
ing), the posterior superior rotator cuff and humeral head articular margin
come in contact with the posterosuperior glenoid labrum. With repetition, this
contact leads to type II tears of the posterosuperior glenoid labrum and articu-
lar-sided rotator cuff tears. This is further exacerbated in the presence of pos-
terior inferior glenohumeral capsular contracture.
TREATMENT PROTOCOLS
A. The presentation of patients with SLAP lesions can be quite variable, and the
diagnosis should be considered in all patients younger than 50 years of age with
intra-articular shoulder pain.
B. The most common presenting symptom is shoulder pain with a clear history
of an injury or inciting event.
C. Most injuries typically occur from falls on an outstretched hand, weight lifting,
eccentric abduction and external rotation, automobile accidents, contact sports,
and overhead sports (baseball, softball, volleyball, tennis, swimming).
D. Patients may also describe mechanical symptoms (catching or popping) with
overhead activity.
E. Throwing athletes with SLAP tears often present with shoulder pain and a loss
of accuracy and velocity.
F. On physical examination, it is important to rule out other common causes of
shoulder pain such as impingement, instability, and acromioclavicular joint
pathology.
G. We have found the O’Brien, Mayo sheer, and apprehension tests to be the
most useful physical examination maneuvers in diagnosing SLAP tears.
1. For the O’Brien test (active biceps compression test), the patient places the
arm in 90 degrees of forward flexion, 20 degrees of adduction, and active
full internal rotation (thumb pointing toward floor). The examiner then
provides a downward force on the patient’s forearm as the patient raises his
or her arm toward the ceiling. If this reproduces the patient’s shoulder pain,
the patient is asked to full externally rotate the arm (thumb pointing toward
ceiling), and the downward force is reapplied. For a positive test, the pain
is experienced with the arm in internal rotation and is relieved with external
rotation.
2. In the Mayo sheer test (also known as the dynamic labral sheer test), the
patient’s elbow is placed at his or her side and flexed 90 degrees. The exam-
iner then puts the arm in maximal passive external rotation and gradually
abducts the arm while placing a hand over the posterior aspect of the shoul-
der to stabilize the scapula. A patient with a positive test experiences increas-
ing pain with abduction between 60 and 120 degrees. A positive test may
include pain, pain and a click, or simply a click.
3. Although Jobe’s apprehension testing is classically used to diagnose shoul-
der instability, patients with SLAP tears often have pain without a sensation
of instability when the arm is placed in the abducted, externally rotated
position. This test is most easily performed with the patient supine on an
examination table to stabilize the scapula. This pain is relieved if a posteri-
orly directed force is applied to the humeral head.
H. Intra-articular local anesthetic is helpful in localizing symptoms to the gleno-
humeral joint. Three milliliters of anesthetic is injected anteriorly through the
rotator interval and provocative testing is repeated. If the examination returns
to normal (with the exception of mechanical symptoms) after administration
of local anesthetic, then even with negative imaging modalities, the diagnosis
of glenoid labrum tears may be made based on patient demographics, history,
and physical examination.
I. Overhead athletes with SLAP lesions typically exhibit increased gleno-
humeral external rotation and diminished internal rotation compared with
the contralateral shoulder in 90 degrees of shoulder abduction. A shift in
rotational arc is normal; however, a decrease in the total rotational arc com-
pared to the contralateral shoulder is manifested as excessively diminished
internal rotation (i.e., to a greater degree than the gain in external rotation).
This is known as a glenohumeral internal rotational deficit (GIRD) and can
precipitate an injury to the thrower’s superior glenoid labrum, rotator cuff,
and elbow.
II. Imaging
A. Patients with SLAP tears typically do not have any abnormalities on plain
radiographs, although a small subset of patients may have concurrent acromio-
clavicular joint sprains at the time of the glenoid labrum tear.
B. Magnetic resonance imaging (MRI) is the most useful imaging modality for
the evaluation of SLAP tears.
1. The diagnosis is made when fluid is visualized between the superior glenoid
rim and the labrum on the oblique coronal images.
2. The addition of intra-articular contrast has been reported to increase the
sensitivity of MRI in detecting SLAP tears.
3. We have found that a clear history of a traumatic event in a patient younger
than 40 years of age and pain on provocative physical examination testing
to be more sensitive in making the diagnosis than MRI scans, even when
the MRI is interpreted by experienced musculoskeletal radiologists.
However, the specificity of the MRI remains high, and this is a useful
adjunct to define the tear and associated injuries.
III. Nonoperative Treatment
A. Rest, activity modification, preservation of motion, and periscapular and rotator
cuff strengthening are initially indicated for SLAP tears.
B. However, the symptoms from glenoid labrum tears often do not improve with
nonoperative treatment. In many cases physical therapy exacerbates the patient’s
pain.
C. In a patient with a possible SLAP tear, but an uncharacteristic history or physi-
cal examination, a trial of physical therapy is warranted, because many of the
other potential diagnoses improve with therapy. If the patient’s pain does not
improve, then it is more likely that they have a SLAP tear.
D. For overhead athletes with an internal rotation deficit, sidelying sleeper
stretches that isolate the posterior capsule both preoperatively and postopera-
tively are important.
Shoulder and Elbow

TREATMENT ALGORITHM
Patient with intra-
articular shoulder pain
Classic physical exam findings consistent with

SLAP tear with or without positive MRI scan
No Yes
Arthroscopy
with SLAP
Trial of repair as
physical indicated
therapy
Resolution of pain Consider diagnostic arthroscopy

Patient unlikely to have SLAP tear with SLAP repair as indicated
SURGICAL INDICATIONS AND CONTRAINDICATIONS

I. Indications
A. Arthroscopic SLAP repair is indicated in patients younger than 40 years of age
with the characteristic history and physical examination findings of a SLAP
tear.
B. For patients with intra-articular shoulder pain without the characteristic physi-
cal examination findings, who have failed conservative treatment, including a
trial of physical therapy, arthroscopy of the involved shoulder is indicated. A
SLAP tear can then be appropriately addressed if identified at the time of
surgery.
II. Contraindications
A. Patients with asymptomatic lesions found incidentally on MRI scans should
not undergo SLAP repair.
B. SLAP lesions found at the time of shoulder arthroscopy to treat other pathol-
ogy should generally either be left alone or addressed with débridement. This
is especially true in patients older than 40 years of age and those without the
characteristic finds of a SLAP tear on physical examination.
GENERAL PRINCIPLES OF SLAP REPAIR

I. Classification of SLAP tears is performed intraoperatively using the classification
described by Snyder et al (Fig. 5-2).
II. SLAP tears are treated with arthroscopic fixation only. Open repair is not an
option for treatment of tears requiring surgical intervention.
III. The operative management of tears is based on their classification.
A. Type I tears involve fraying or degeneration of the superior labrum without
detachment of the labrum or the biceps anchor. Treatment consists of débride-
ment of the frayed tissue.
B. Type II tears consist of detachment of the superior labrum and biceps anchor
from the glenoid rim. Treatment consists of anatomic repair of the labral-
biceps anchor complex back to the glenoid rim using suture anchors as described
below.
C. In Type III tears there is detachment of the superior labrum from the glenoid
rim without involvement of the biceps anchor. These tears can be débrided
unless the tear involves greater than one third the width of the labrum, in which
case the labrum is repaired in a manner similar to type II tears.
Type I Type II
Type III Type IV

Figure 5-2
The classification of arthroscopic superior labrum anterior posterior (SLAP) tears as described by Snyder
et al. (Adapted from Miller MD, Osborne JR, Warner JJP, Fu FH [eds]: Shoulder Arthroscopy in MRI—Arthroscopy
Correlative Atlas. Philadelphia, Saunders, 1997.)
D. Type IV tears involve a bucket-handle tear of the superior labrum extending

into the biceps tendon.
1. If the tear of the biceps tendon involves less than one third of the tendon,
it can be debrided and the labral component can be managed like a type III
tear.
2. If more than one third of the biceps is involved but the tendon appears
healthy, the biceps split is repaired with side-to-side sutures and the labrum
is repaired to the glenoid rim. If the biceps tendon is degenerative, than a
biceps tenodesis or tenotomy should be performed.
IV. In patients older than 40 years of age, SLAP tears are often encountered at the
time of arthroscopy for the treatment of other shoulder pathology (especially
Shoulder and Elbow

rotator cuff disease). In these patients, the tear should not be addressed if the
biceps anchor is stable and the biceps tendon is in good condition. If there is
instability of the biceps anchor or degeneration of the tendon, a biceps tenotomy
or tenodesis should be considered.

Note that all arthroscopic photos demonstrating the operative technique are of the left
shoulder viewed from the posterior portal in the lateral decubitus position. SLAP repair,
like other arthroscopic shoulder procedures, may be performed in either the beach chair
or lateral decubitus position. We use the lateral decubitus position because the traction
applied to the arm creates a larger working area within the joint and allows superior access
to the posterior labrum when needed.

I. Refer to Chapter 4 for complete details on lateral decubitus positioning.
II. The patient is prepped and draped in standard fashion using the surgical principles
described in Chapter 1.
Portal Placement and Diagnostic Arthroscopy

I. Prior to incision, we use a skin marker to define the posterior lateral and anterior
lateral borders of the acromion. The V is defined by the posterior border of the CARE MUST BE TAKEN WHEN
clavicle and the anterior border of the scapular spine (in the region of the ARTHROSCOPICALLY
arthroscopic portal described by Neviaser), and the coracoid process. DIAGNOSING ABNORMALITIES
II. A standard posterior portal is established. In cases in which a posterior glenoid OF THE BICEPS ANCHOR
labrum tear is suspected, the posterior incision is placed more laterally in line with BECAUSE SOME PATIENTS
HAVE NONPATHOLOGIC
the lateral border of the acromion process.
REDUNDANCY IN THIS AREA.
III. A spinal needle is then used to localize the anterior rotator interval portal, which GENERALLY, IF THE GLENOID
is established via an outside-in technique. On the skin surface the portal is located RIM THAT IS EXPOSED WHEN
slightly lateral and superior to the coracoid process and is roughly in line with and SUPERIOR TRACTION IS
inferior to the acromioclavicular joint. The portal should enter the joint in the APPLIED TO THE BICEPS
triangle defined by the biceps tendon and the superior border of the subscapularis TENDON IS COVERED WITH
muscle. We prefer to make a skin incision using an 11-blade scalpel and then CARTILAGE, THEN IT IS THE
penetrate the joint capsule with a metal switching stick that can be used as a probe PATIENT’S NATURAL
during the diagnostic arthroscopy (Fig. 5-3). ANATOMY. IF TRACTION ON
IV. A standard diagnostic arthroscopy is performed (see Chapter 2). THE PROXIMAL BICEPS
V. If a SLAP lesion is suspected, the attachment of the biceps tendon to the superior EXPOSES BONE, THEN THIS IS
A PATHOLOGIC FINDING
glenoid rim is carefully examined by placing the probe at the attachment site and
INDICATIVE OF A SLAP LESION.
using it to pull the biceps tendon superiorly (Fig. 5-4).
Figure 5-3
A switching stick is used to establish the anterior
interval portal via an outside-in technique.

Probing of the biceps attachment demonstrates a The probe is placed on the superior aspect of the
type II arthroscopic superior labrum anterior biceps tendon and used to pull the tendon into the
posterior (SLAP) tear. joint to check for degeneration or subluxation.
VI. For all patients with biceps anchor pathology, it is important to examine the
proximal biceps tendon closely. To do this, the probe is placed on the superior
surface of the tendon and an inferior and medially directed force is applied to
What are your
pull the proximal portion of the tendon into the joint for inspection. Significant
attending’s indications for
a biceps tenotomy versus fraying of the portion of the tendon that resides in the bicipital groove or medial
a tenodesis for proximal subluxation of the tendon over the superior border of the subscapularis might
biceps pathology? direct the surgeon to perform a biceps tenodesis or tenotomy instead of a SLAP
repair (Fig. 5-5).
VII. If a SLAP lesion is identified, it is classified and the decision is made as to whether
it is reparable. If a repair is to be performed, the number and location of the
anchors are determined.
SLAP Repair
I. If the SLAP lesion is to be repaired, a 6-mm arthroscopic cannula is introduced
over the switching stick in the anterior portal.
II. An anterior superior portal is then established via an outside-in technique.
A. This portal is located just off the anterior lateral edge of the acromion and
enters the joint just anterior to the leading edge of the supraspinatus tendon
behind the biceps tendon in the rotator interval. A 5-mm cannula is introduced
TO PROTECT THE LABRUM via this portal (Figs. 5-6 and 5-7). With this technique, the supraspinatus
DURING THIS STEP, IT IS tendon is not violated.
IMPORTANT THAT THE B. However, for more posterior glenoid labrum lesions, a direct lateral portal in
SHAVER’S TEETH ARE the myotendinous junction of the supraspinatus may be necessary (portal of
ORIENTED ONLY TOWARD Wilmington). When used, this portal must be small and medially placed (just
THE GLENOID. against the acromial edge) to prevent injury to the supraspinatus tendon.
III. A 4.2-mm arthroscopic meniscal shaver is then inserted via the anterior
The dense bone of the superior portal and used to debride any frayed tissue. The shaver is then placed
glenoid rim allows the between the superior labrum and the glenoid rim and run at high speed on forward
anchors used in this to create a bed of fresh bone where the labrum will attach (Fig. 5-8). Preparation
location to be smaller in of the superior glenoid articular margin may also be performed with an arthroscopic
size (3 to 4 mm) than burr.
those inserted into the IV. An arthroscopic anchor is then inserted via the anterior superior cannula and
humeral head for rotator placed on the glenoid rim at the posterior aspect of the tear (Fig. 5-9). We prefer
cuff repairs (5 to 8 mm).
to use the Mini-Revo anchor (Linvatec, Largo, Florida).
Shoulder and Elbow

A spinal needle is used to localize the anterior A 6-mm cannula is placed through the anterior
superior portal just anterior to the leading edge of portal and a 5-mm cannula is placed via the anterior
the supraspinatus tendon but posterior to the biceps superior portal.
tendon.

An arthroscopic shaver is used to create a bed of A suture anchor is placed on the glenoid rim at the
exposed bone where the labrum will be reattached. posterior aspect of the tear.
V. The suture strand that is closest to the labrum is retrieved through the anterior
cannula using a crochet hook (Fig. 5-10).
VI. An 18-gauge spinal needle is inserted via Neviaser’s portal (located at the
apex of the V formed by the distal clavicle and the spine of the scapula) and
passed through the joint capsule and the superior labrum above the anchor. It is
important that the surgeon be able to identify the needle between the capsule
and the superior labrum. This is accomplished by passing the needle through the
capsule and then backing it up slightly and passing it through the labrum instead
of passing it through both structures in a continuous manner (Figs. 5-11 and
5-12).
VII. An 0-Prolene suture is then threaded through the spinal needle and retrieved out
the anterior portal using the crochet hook (Fig. 5-13).
VIII. The strand of suture from the anchor is then attached to the Prolene suture
via a simple knot, and the Prolene and anchor suture strands are pulled back
into the joint, through the labrum and out Neviaser’s portal along with the spinal
needle.

The suture strand closest to the labral tissue is A spinal needle is inserted through the superior
retrieved out the anterior portal using a crochet capsule via Neviaser’s portal.
hook. This will be the post-strand for the
arthroscopic knot.
IX. The suture is pulled out the anterior superior cannula. Because this strand passes
through the labrum, it serves as the post for an arthroscopic sliding knot (Fig.
5-14).
What type of knot does
X. An arthroscopic knot of the surgeon’s preference is tied via the anterior lateral
your attending prefer to
fix the superior labrum? cannula and used to compress the labrum to the glenoid rim (Fig. 5-15).
XI. The steps are repeated to place as many anchors as needed moving from posterior
to anterior along the glenoid rim. In general, two to three anchors are used for
isolated SLAP repairs.
XII. If the tear extends anterior to the biceps tendon, the anchors can generally be
inserted via the anterior portal and a penetrating grasper can be inserted via the
same cannula to pass the post-strand through the labrum in place of the spinal
needle.

The needle is then directed through the superior An 0-Prolene suture is threaded down the needle
labrum. and retrieved out the anterior portal.
Shoulder and Elbow

The suture is used to shuttle the post-strand of the An arthroscopic knot is used to secure the labrum
suture anchor through the labral tissue. The post- to the glenoid rim.
strand is then retrieved out the anterior superior
portal.
Wound Closure
The arthroscopic portals are closed in standard fashion, and a sterile dressing is applied
(see Chapter 1). The arm is placed in a sling for postoperative immobilization (Fig.
5-16).
POSTOPERATIVE MANAGEMENT
I. All SLAP repairs are performed on an outpatient basis.
II. The patient is instructed to keep the operative arm in a sling for 3 weeks except
when performing active finger, wrist, and elbow range of motion exercises and
gentle Codman exercises of the shoulder.
III. At 3 weeks, the sling is discontinued and the patient begins a passive range-of-
motion program with the therapist.
IV. Once full range of motion has been regained, generally at 6 weeks, the patient
begins a progressive strengthening program.
V. The patient is allowed to return to sports at 3 months unless they are involved in
overhead throwing.
Figure 5-16
Following completion of the repair, the biceps
attachment is probed to make sure that it is secure.
This repair required two anchors that were both
placed via the anterior superior cannula.
VI. Gentle throwing is initiated at 4 months and the patient progresses to competitive
What postoperative
protocol does your throwing between 6 and 9 months after surgery.
attending follow after an VII. For overhead athletes with preoperative internal rotation deficits, it is important
arthroscopic superior to emphasize posterior capsular stretching throughout the postoperative course.
labrum anterior posterior
repair?
COMPLICATIONS
I. Shoulder stiffness. For this reason, it is important to begin early pendulum
exercises followed by passive range of motion with a therapist at 3 weeks.
II. Continued pain. In this situation, it is important to consider alternative
diagnoses.
III. Infection
SUGGESTED READINGS
Andrews JR, Carson WG Jr, McLeod WD: Glenoid labrum tears related to the long head of the
biceps. Am J Sports Med 13:337–341, 1985.
Burkhart SS: Superior labrum anterior and posterior lesions. In Norris TR (ed): Orthopaedic
Knowledge Update Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic
Surgeons, 2002, pp 543–549.
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: spectrum of pathology.
Part II: Evaluation and treatment of SLAP lesions in throwers. Arthroscopy 19:531–539,
2003.
Mileski RA, Snyder SJ: Superior labral lesions in the shoulder: Pathoanatomy and surgical manage-
ment. J Am Acad Orthop Surg 6:121–131, 1998.
Neviaser TJ: Arthroscopy of the shoulder. Orthop Clin North Am 18:361–372, 1987.
Snyder SJ, Karzel RP, Del Pizzo W, et al: SLAP lesions of the shoulder. Arthroscopy 6:274–279,
1990.
Tennet TD, Beach WR, Meyers JF: A review of special tests associated with shoulder examination.
Part II: Laxity, instability and superior labral anterior and posterior (SLAP) lesions. Am J
Sports Med 31:301–307, 2003.
6
Shoulder and Elbow

C H A P T E R
Total Shoulder Arthroplasty

Case Study
A 70-year-old, right hand–dominant female presents with a 5-year history of right shoul-
der pain. She has had gradual progressive difficulty with activities of daily living and is
now limited significantly by pain and stiffness in her right shoulder. The patient has pain
at night, which keeps her awake on a regular basis. She denies any specific injury that initi-
ated the onset of her symptoms and denies any neck pain or associated radiating symptoms
(numbness, tingling, pain) down her arms. She has tried several nonoperative treatments,
including nonsteroidal anti-inflammatory medications; activity modification; physical
therapy; and multiple, intermittent corticosteroid injections into her shoulder. These have
provided her only with temporary symptomatic relief, and their effect has lessened as her
symptoms have progressed. She is now retired and lives at home by herself without a
caretaker. True anteroposterior and axillary lateral views of her right shoulder are pre-
sented in Figure 6-1.
A B
Figure 6-1
True views of the shoulder. A, Anteroposterior. B, Axillary lateral.
BACKGROUND
I. Arthritis, by definition, means intra-articular inflammation, although inflamma-
tion may not always be present in the disease. The term is more accurately
described as articular cartilage degeneration, which may be a result of several dif-
ferent causes. The most common etiology of glenohumeral arthritis is osteoar-
thritis, but other diseases, such as rheumatoid or inflammatory arthritis,
osteonecrosis, rotator cuff arthropathy, and post-traumatic or postsurgical arthri-
tis, can also be a cause. The different etiologies of glenohumeral arthritis may
dictate different treatment options, but total shoulder arthroplasty (TSA) may be
a final surgical option in all forms of the disease.
II. Glenohumeral arthritis occurs in as many as 20% of adults and is much less
common than arthritis of the hip or knee. Osteoarthritis, the most common form,
occurs more often in women than men, and is more likely in patients older than
60 years of age.
III. Pain in the affected shoulder is the most common presenting complaint in patients
with glenohumeral arthritis. Shoulder stiffness is also a frequent problem, and
patients may note a sensation of crepitus with shoulder movement. Symptoms
usually begin gradually and are chronic and progressive. Discomfort is typically
worsened with activity, and patients may awaken at night from pain, particu-
larly if they sleep on the affected shoulder. Functional limitations may be evi-
dent, including an inability to perform overhead activities or reach behind the
back or under the opposite axilla with the affected arm. In the case of inflamma-
tory arthritis, the associated synovitis may cause considerable swelling and
inflammation.
IV. Physical examination of the affected shoulder may demonstrate mild shoulder
Adhesive capsulitis
(frozen shoulder) is atrophy from disuse. Although often nonspecific, posterior joint line tenderness
another major cause of is typical in osteoarthritis, while anterior and lateral tenderness is seen more fre-
restriction of both active quently in inflammatory arthritis. Range of motion (ROM), both active and
and passive range of passive, is typically restricted in glenohumeral arthritis, usually in multiple planes.
motion in the shoulder Decreased external rotation is commonly seen in osteoarthritis from anterior
and must be ruled out. capsular contracture and articular derangement. Specific patterns of restricted
motion may also be related to prior trauma or surgery, such as a loss of external
A patient’s inability to
rotation in patients with previous surgical stabilization for anterior shoulder insta-
externally rotate includes bility. Pain and crepitus in the glenohumeral joint may be elicited with active or
the following differential passive motion. Muscle strength testing should assess the rotator cuff, deltoid, and
diagnosis: (1) posterior other shoulder girdle muscles. A careful examination of the cervical spine should
dislocation of the also be performed to rule out any abnormalities, including radiculopathy and
shoulder, (2) adhesive degenerative joint disease that may cause referred pain, stiffness, or weakness in
capsulitis, or (3) the shoulder.
glenohumeral arthritis. V. For the majority of patients with painful arthritis unresponsive to nonoperative
treatment, definitive surgical intervention consists of TSA. Although TSA can
provide both pain relief and improvement of function, pain relief is more reliably
achieved. Therefore, pain relief, not restoration of function, should be the primary
goal of surgery. Shoulder replacement can be performed to replace both the
humeral head and glenoid (TSA) or the humeral head alone (hemiarthroplasty),
depending on the degree of glenoid degeneration, integrity of the rotator cuff,
and age of the patient.
VI. Approximately 90% or more of patients can be expected to attain good or excellent
pain relief following TSA, and prosthesis survivorship is greater than 90% at 10
years.
VII. Newer prostheses include the humeral head resurfacing implant without a stem
and the reverse shoulder prosthesis used in patients with irreparable rotator cuff
deficiency. However, long-term results are still needed to determine the ultimate
utility of these implants.
C H A P T E R 6 Total Shoulder Arthroplasty 57
Shoulder and Elbow

TREATMENT ALGORITHM
Shoulder pain
treatment algorithm for
shoulder pain secondary
True AP and axillary radiographs, ⫾ MRI
to arthritis?
Diagnosis (OA, osteonecrosis, RA, etc.)
Nonoperative management (6 –12 months):

NSAIDs/G-CS*
Corticosteroid injection
Viscosupplementation
Failed nonoperative management
Total shoulder arthroplasty

Surgical alternatives to total shoulder arthroplasty:
Arthroscopic/open débridement/capsular release/
subacromial decompression
Arthroscopic/open synovectomy
Interposition arthroplasty
Arthrodesis
Resection arthroplasty
Hemiarthroplasty or resurfacing arthroplasty
*Glucosamine–chondroitin sulfate
TREATMENT PROTOCOLS
I. Treatment Considerations. All of the following considerations play an impor-
tant role in the decision making process of treating patients with glenohumeral
arthritis:
A. Patient age
B. Activity level
C. Overall health
D. Degree of joint involvement
E. Integrity of the rotator cuff
F. Patient expectations
II. Nonoperative Treatment Options
A. Initial treatment strategy
2. Glucosamine–chondroitin sulfate oral supplementation
3. Activity modification (e.g., low-impact activity, discontinuation of manual
labor) THERAPY CAN BE
4. Weight loss CHALLENGING IF THE
5. Heat (chronic arthritic pain) and cold (acute flare-up) therapy ARTICULAR SURFACE IS
6. Physical, occupational, and aqua therapy SEVERELY DEGENERATED,
a. Physical therapy and aqua therapy are aimed at regaining motion and BECAUSE STRETCHING AND
strength. These techniques typically include gentle passive motion/ STRENGTHENING ACROSS A
COMPROMISED ARTICULAR
stretching and isometric strengthening (deltoid, rotator cuff, scapular
SURFACE CAN INCREASE
muscles). Aqua therapy decreases stress across muscles and joints because
SYMPTOMS.
of the buoyancy effects of water.
b. Ultrasound: heat effect
INTRA-ARTICULAR STEROIDS c. Occupational therapy is aimed at teaching alternative ways of accom-

MAY INCREASE ENDOGENOUS plishing activities of daily living (ADLs) that may be impaired and pro-
GLUCOSE LEVELS viding assistive devices.
POSTINJECTION. THEREFORE, B. Intra-articular corticosteroid injections
PATIENTS WITH DIABETES 1. Corticosteroids are considered if initial treatments have been ineffective,
SHOULD BE MADE AWARE but are of variable benefit.
THAT CLOSE POSTINJECTION 2. Typically, these are more useful for symptomatic relief in inflammatory
GLUCOSE MONITORING MAY BE arthritis than in osteoarthritis.
REQUIRED. 3. Injections can be performed at 4-month intervals (no more than 3 per year)
if they are helpful.
VISCOSUPPLEMENTATION IS C. Intra-articular hyaluronic acid injections (viscosupplementation)
CURRENTLY NOT FDA 1. This is an alternative for patients who have been unresponsive to other
APPROVED FOR USE IN
nonoperative therapies, but results are variable, with fewer data on its use
OSTEOARTHRITIS OF THE
SHOULDER. THE PATIENT MUST
in the shoulder than in the hip and knee.
BE INFORMED OF THIS OFF- 2. It involves a series of three to five injections administered 1 week apart.
LABEL USE OF THE PRODUCT
IF ITS USE IS BEING SURGICAL ALTERNATIVES TO TOTAL SHOULDER ARTHROPLASTY
CONSIDERED.
I. Arthroscopic Procedures
A. Débridement
1. Indicated for mild to moderate glenohumeral arthritis without structural
alteration of the joint. Patients with mechanical symptoms due to loose
bodies, degenerative labral tears, or small humeral head lesions from osteo-
necrosis are most likely to benefit from this treatment.
2. Débridement has a limited role in the absence of true mechanical symptoms
The following make up and its benefit is not as clear as in the knee.
the borders of the rotator 3. Arthroscopy may have an additional diagnostic benefit by revealing previ-
interval: supraspinatus ously unrecognized degenerative changes.
superiorly, subscapularis B. Capsular releases
inferiorly, coracoid 1. Indicated for mild to moderate glenohumeral arthritis associated with
process medially, and limited motion, particularly external rotation.
long head of the biceps 2. Anterior capsulolabral structures are released for decreased external rota-
and humeral head
tion, including the rotator interval, while posterior capsulolabral structures
laterally.
are released for decreased internal rotation.
3. Passive manipulation under anesthesia is also performed after soft tissue
The coracoacromial
releases to further increase motion and disrupt tight tissues. This technique,
ligament may be a
primary restraint to however, is not effective as an isolated procedure for chronic loss of motion
superior elevation of the from osteoarthritis.
humeral head in patients C. Subacromial decompression
with significant rotator 1. Some pain complaints in patients with arthritic shoulders may be due to
cuff deficiency, such as inflammation or bursitis in the subacromial space, or acromial impingement.
those with irreparable 2. Subacromial decompression can include a subacromial bursectomy, cora-
rotator cuff tears. coacromial (CA) ligament resection, and anterior acromioplasty.
Therefore, resection may D. Synovectomy
lead to superior elevation 1. Can be used in patients with early stage inflammatory arthropathies or
of the humeral head and
osteoarthritis with synovitis
further worsening of
2. Can provide pain relief and improved function, but the synovitis can recur,
shoulder function.
requiring a repeat procedure
3. May protect the rotator cuff from attritional tearing that can occur with
chronic inflammatory arthritis
II. Open Procedures
A. Resection arthroplasty
1. Resection arthroplasty is indicated for more severe infections, fractures, or
failed TSA. The humeral head is resected and a pseudoarthrosis forms that
allows some shoulder function.
2. Function is generally better if the rotator cuff attachments to the proximal
humerus can be preserved.
Shoulder and Elbow

B. Interposition arthroplasty and biologic glenoid resurfacing
1. Use of a biologic tissue placed between the humeral head and glenoid; the
more modern technique of glenoid resurfacing involves suturing the bio-
logic tissue directly to the glenoid, with or without humeral head replace-
ment (hemiarthroplasty) or resurfacing.
a. Biologic tissue choices: anterior capsule, autogenous fascia lata, Achilles
tendon allograft, human dermal collagen allograft, or meniscal allograft
b. A surface replacement implant may be used for the humeral head that
removes minimal bone (lacks the intramedullary stem of a traditional
humeral head replacement).
2. Indications
a. Young, active patients who may wear out or loosen a standard shoulder
replacement
b. Rheumatoid arthritis patients
c. Patients with rotator cuff tear arthropathy or irreparable cuffs and eccen-
tric glenoid wear
d. Revision arthroplasties with glenoid removal and poor glenoid bone
stock
C. Arthrodesis (surgical fusion)
1. Indicated as a salvage procedure in patients with recurrent or indolent infec-
tion, significant loss of deltoid and/or rotator cuff function, other severe
soft tissue deficiencies (e.g., CA arch deficiency), brachial plexus palsy, per- What surgical alternatives
sistent symptomatic instability, or multiple failed surgeries. would your attending
2. The recommended position of shoulder fusion is 30 degrees of abduction, consider for a given
30 degrees of forward flexion, and 30 degrees of internal rotation. pattern of arthritis?
SURGICAL INDICATIONS FOR TOTAL SHOULDER ARTHROPLASTY

I. End-Stage Degenerative Joint Disease
A. Most common etiologies
1. Osteoarthritis
2. Osteonecrosis (Fig. 6-2)
3. Rheumatoid arthritis
4. Post-traumatic arthritis
5. Arthritis of dislocation
6. Postsurgical arthritis (e.g., postinstability stabilization)
7. Rotator cuff arthropathy
A B
Figure 6-2
True views of a shoulder with end-stage osteonecrosis. A, Anteroposterior. B, Axillary lateral.
B. Other etiologies that may result in end-stage joint deterioration

1. Crystalline arthritis
a. Calcium pyrophosphate dehydrate deposition disease
b. Gout
c. Apatite deposition disease (“Milwaukee shoulder”)
2. Inflammatory arthritis
a. Juvenile idiopathic arthritis
b. Spondyloarthropathies
(1) Ankylosing spondylitis
(2) Reiter’s syndrome
(3) Psoriatic arthritis
(4) Enteropathic arthritis
3. Dialysis arthropathy
4. Neuropathic arthropathy (Charcot arthropathy)
5. Hemophilia arthropathy
6. Postinfectious arthritis
C. Clinical presentation
1. Worsening pain over time
2. Pain that awakens from sleep
3. Decreased active and passive shoulder ROM (external rotation commonly
affected)
4. Decreased ability to perform ADLs
D. Radiographic features and diagnostic criteria
OSTEOARTHRITIS RHEUMATOID ARTHRITIS

1. Asymmetric joint space narrowing 1. Symmetric joint space narrowing
(typically posterior glenoid wear) (typically central glenoid wear)
2. Sclerosis 2. Periarticular osteopenia/osteoporosis
3. Subchondral cysts 3. Joint erosions
4. Osteophyte formation (inferior 4. Ankylosis
humeral head common)
II. Failed Treatment

A. Activity modification (e.g., low-impact activity, discontinuation of manual labor)
B. Weight loss
C. Nonsteroidal anti-inflammatory drugs, acetaminophen, and/or glucosamine–
chondroitin sulfate
D. Physical, occupational, or aqua therapy
E. Heat (chronic arthritic pain) and cold (acute flare-up) therapy
F. Intra-articular injections (corticosteroids or viscosupplementation)
G. Previous surgical alternative treatment
RELATIVE CONTRAINDICATIONS TO TOTAL SHOULDER ARTHROPLASTY

I. Current infection (absolute)
II. Recent infection
III. Concomitant rotator cuff and deltoid dysfunction
IV. Neuropathic arthropathy (Charcot arthropathy)
V. Severe brachial plexopathy
VI. Intractable shoulder instability
VII. Young and active patient. It wears out faster.
VIII. Medically unstable. The patient is unable to safely tolerate the stress of surgery.
GENERAL PRINCIPLES OF TOTAL SHOULDER ARTHROPLASTY

I. The glenohumeral joint is a ball-and-socket joint with the greatest ROM of any
joint in the body.
Shoulder and Elbow

II. Although the glenohumeral joint is a congruent articulation with less than 2 mm
of mismatch between the radius of curvature of the glenoid and humeral head,
only one third of the humeral head is covered by the glenoid.
III. Normal anatomic relationships of the glenoid and humeral head include the
following:
A. Glenoid version ranging from 7 degrees of retroversion to 10 degrees of antever-
sion, with an average of 5 degrees of upward tilt. The glenoid surface is pear-
shaped, with the superior half approximately 20% narrower than the inferior
half.
B. Humeral head retroversion, relative to the transepicondylar axis of the distal
humerus, ranging from 25 to 40 degrees (average, 30 degrees). The articular
surface of the humeral head is inclined an average of 130 degrees superiorly
relative to the humeral shaft. The center of the humeral head is also offset
medially and posteriorly relative to the center of the humeral shaft.
C. The greater tuberosity (GT) and the lesser tuberosity (LT) of the humeral
head are located laterally and medially, respectively, to the bicipital groove and
are the attachment sites of the rotator cuff tendons (GT: supraspinatus, infra-
spinatus, teres minor; LT: subscapularis).
D. The GT is 5 to 10 mm below the top of the humeral head.
IV. The goal of TSA is to establish normal relationships about the glenohumeral joint
and to restore a smooth articulation between the humeral head and glenoid. This
has the primary objective of providing pain relief, with a secondary benefit of
increased function. Establishing normal glenohumeral relationships places the
rotator cuff and other soft tissues at their most efficient tension and provides
optimal results.
V. A TSA consists of a humeral component and a glenoid component. The humeral
component is made of metal, typically a cobalt chrome head with a titanium stem,
and the glenoid component is made of ultra-high-molecular-weight polyethylene.
VI. The success of TSA is far more dependent on proper soft tissue functioning and
balance than hip and knee replacements because the glenohumeral joint has far
less bony constraint.
A. The status of the rotator cuff is a key component of proper soft tissue function-
ing around the prosthesis. If the rotator cuff is deficient and the humeral head
shows superior migration on radiographs, the glenoid will not be concentrically
loaded following TSA. This leads to eccentric superior wear on the glenoid
component and possible mechanical loosening and failure of the glenoid. Glenoid component
B. The glenoid is subjected to significant shear forces due to the lack of bony loosening is the most
constraint and a replacement component may loosen prematurely as a result. common complication
The glenoid component appears to be the weak link in implant survival, typi- in total shoulder
cally wearing out or loosening prior to the humeral component. arthroplasty.
VII. The amount of glenoid bone stock available for resurfacing is another important
factor in TSA. Significant glenoid erosion may prevent placement of a glenoid
component due to a lack of bone stock or may alter glenoid version. Abnormal
version must be corrected to neutral during surgery so that the glenohumeral
articulation becomes concentric. For example, posterior glenoid wear seen in
osteoarthritis is typically corrected to neutral version with anterior reaming, or
less commonly with posterior bone grafting.

I. Once the patient is positioned and under full anesthesia, passive shoulder ROM,
particularly external rotation at the side, should be noted.
II. The patient is placed in the beach chair position (see Chapter 2 for details).
III. The operative upper extremity is prepped and draped in standard fashion accord-
ing to the principles outlined in Chapter 1. Draping should allow access to the
Figure 6-3
Deltopectoral incision marked out.
medial clavicle proximally and to the wrist distally. A Foley catheter should be
placed prior to the start of the case.
IV. Mark the skin incision (deltopectoral) using a sterile marker (Fig. 6-3).
Surgical Approach and Applied Surgical Anatomy

The deltoid muscle is I. The most common approach for TSA is the deltopectoral approach. For patients
innervated by the axillary undergoing revision surgery with a prior deltopectoral incision, the previously
nerve. The pectoralis made incision should be used.
major muscle is
II. The skin incision is made approximately 10 to 15 cm long, marked from the tip
innervated by the medial
of the coracoid proximally to the deltoid tuberosity distally, and it is centered over
and lateral pectoral
nerves. the interval between the deltoid laterally and the pectoralis major medially.
III. Once the skin and the subcutaneous tissues have been exposed, the first structures
to identify are the cephalic vein, deltoid, and pectoralis major. The cephalic vein
rests in a groove between the deltoid (lateral) and pectoralis major (medial),
marking the deltopectoral interval (Fig. 6-4).
The conjoined tendon IV. As a major draining vein of the arm, the cephalic vein should be preserved and
originates from the can be retracted either medially or laterally. Lateral retraction is generally pre-
coracoid process. It is ferred because of the many branches to the cephalic vein that come in on the
composed of the short lateral side. Medial retraction places less tension on the vein but sacrifices the
head of the biceps and numerous lateral feeding vessels.
the coracobrachialis V. The cephalic vein and deltoid are retracted laterally and the pectoralis major is
(both supplied by the retracted medially to expose the underlying clavipectoral fascia and the conjoined
musculocutaneous nerve). tendon (Fig. 6-5).
Figure 6-5
Figure 6-4 Deltoid retracted laterally (left retractor) and the
Deltopectoral interval exposed with the deltoid pectoralis major retracted medially (right retractor)
laterally (left), pectoralis major medially (right), and to expose the conjoined tendon with the
the cephalic vein pointed out between the two. clavipectoral fascia overlying it.
Shoulder and Elbow

A B
Figure 6-6
Exposure of the subscapularis tendon with the conjoined tendon first mobilized (A, arrow), then retracted
(B) medially to expose the subscapularis. The quadrilateral space is
bordered by the following
structures: superior, teres
minor; inferior, teres
VI. The clavipectoral fascia is then incised just lateral to the conjoined tendon and major; medial, long head
retracted to expose the subscapularis tendon. The incision should be taken up to, of the triceps; and lateral,
but not through, the CA ligament because of its role in superior restraint of the surgical neck of the
humeral head (see earlier; Fig. 6-6). humerus or lateral head
of the triceps. The
VII. The subscapularis and other rotator cuff muscles can be inspected in this position
posterior humeral
for evidence of a tear. Rotator cuff tears are rare in association with osteoarthritis circumflex artery
(5% to 10%). accompanies the axillary
VIII. Several important neurovascular structures can be identified in this position as nerve through this space.
well. The musculocutaneous nerve enters the undersurface of the conjoint tendon
approximately 5 to 8 cm distal to the coracoid process and can be digitally pal- The primary blood
pated, whereas the axillary nerve should be palpated just below the inferior border supply to the humeral
of the subscapularis tendon as it heads posteriorly through the quadrilateral space. head is the arcuate artery,
The anterior humeral circumflex vessels also run along the inferior edge of the a branch of the anterior
subscapularis and are clamped, cut, and tied off or coagulated once exposed (Fig. humeral circumflex
6-7). artery.
IX. To expose the glenohumeral joint, the subscapularis tendon must be released (Fig.
6-8). Depending on the amount of external rotation loss that is present, the tendon CARE MUST BE TAKEN TO
AVOID INJURY TO THE
AXILLARY AND
MUSCULOCUTANEOUS NERVES
EITHER BY EXCESSIVE
RETRACTION OR DIRECT
INJURY.
Figure 6-7
Subscapularis tendon exposed with the anterior
humeral circumflex vessels pointed out.
Figure 6-8
Release of the subscapularis tendon.
Figure 6-9
Exposure of the humeral head following dislocation.
Note the worn articular surface and presence of
osteophytes.
is released differently. If the deficit is mild (external rotation > 30 degrees at the
side), the tendon can be incised intratendinously (approximately 2 cm medial to
the LT) and repaired anatomically or an LT osteotomy can be performed with
subsequent bone-to-bone repair. For a moderate deficit (−30 degrees < external
rotation < 30 degrees), the tendon is released at the LT and advanced and repaired
medially at closure. Rarely, a severe deficit is present (external rotation < −30
degrees), and a Z-plasty lengthening of the tendon is performed. However, this
procedure weakens the muscle.
X. Release of the anterior and inferior joint capsule also improves external rotation
and helps with surgical exposure.
XI. The humeral head can now be dislocated by simultaneous adduction, external
rotation, and extension. This exposes the humeral head for preparation and implant
insertion (Fig. 6-9).
Humeral Head Preparation

I. Osteophytes are removed from the humeral head to improve exposure and to allow
identification of the anatomic neck. This allows the natural version of the humerus
to be determined prior to humeral head resection.
II. A humeral head cutting guide is next positioned to make the humeral head oste-
otomy. Cutting guides can be intramedullary or extramedullary, or a freehand
technique can even be used.
III. The humeral head cut is made to recreate the natural version of the humeral head
(average, 30 degrees of retroversion) and should exit through the anatomic neck.
The cut should be close to the rotator cuff insertions superiorly and posteriorly
without violating the insertions (Fig. 6-10).
IV. The humeral canal is prepared and trialed to find the appropriately fitting stem.
Canal preparation typically consists of the use of reamers and progressively larger
broaches to open up the canal.
V. Trial humeral head sizing allows appropriate sizing of the glenoid component.
The trial humeral head should be removed for glenoid exposure and preparation,
but the trial stem should be left in place to prevent humeral shaft fracture (Fig.
6-11).
Shoulder and Elbow

A C
Figure 6-10
A, The humeral head being cut with an oscillating
saw. B, The cut head removed, and the remaining
proximal humerus shown. C, The humeral head
B component should be similar in size to the resected
native head when implanted.
Figure 6-11
A, Humeral canal preparation begins with the use
of an entry reamer to find the intramedullary canal.
B, Once the canal has been prepared, the trial
A humeral stem can be placed.
Glenoid Exposure and Preparation

I. The arm is abducted, externally rotated, and extended to relax the posterior joint
capsule and retract the humerus posteriorly. Any remaining anterior
joint capsule should be released off the glenoid to further improve exposure (Fig.
6-12).
Figure 6-13
Reaming of the glenoid.
Figure 6-12
Exposure of the glenoid.
The long head of the II. The labrum is circumferentially removed and the long head of the biceps is
biceps originates on the released if it is partially torn or tethered in the bicipital groove.
superior labrum and III. The glenoid can now be prepared by reaming to subchondral bone (Fig. 6-13).
supraglenoid tubercle. Neutral version should be recreated. Therefore, an eccentrically worn glenoid
should be reamed more opposite the side of wear.
IV. The prepared glenoid should be checked for penetration through the deep cortical
bone. If the cortex is violated, bone grafting is needed.
V. Two common glenoid components are currently used, a pegged design and a
keeled design, and both are cemented into place. Drilling guides are used to drill
holes in the glenoid following reaming to appropriately accept one of the two
designs (Fig. 6-14).
VI. The cement is ready to use when its consistency is between being too runny and
MAKE SURE THE CEMENT IS too hard. The cement is placed on the glenoid surface, followed by the glenoid
NOT TOO HARD BEFORE
component. The component must be held in position on the glenoid with forceful
CEMENTING IN THE GLENOID
pressure until the cement has completely hardened to prevent component move-
COMPONENT.
ment as the cement hardens and expands (Fig. 6-15).
Humeral Head Trialing and Component Placement

I. Once the glenoid is complete, the humerus is redislocated for humeral head
trialing.
Figure 6-14
Glenoid prepared to accept keeled design following Figure 6-15
drilling. Glenoid component in place following cementing.
Shoulder and Elbow

II. The humeral head component should be similar in size to the resected native head IT IS CRITICAL THAT ALL
and should be well centered on the cut surface of the proximal humerus, with OSTEOPHYTES BE REMOVED
coverage of the cut surface maximized and overhang of the component FROM THE PROXIMAL
minimized. HUMERUS TO APPROPRIATELY
III. A trial implant is placed and assessed for adequate fit by reducing the humerus SIZE THE HUMERAL HEAD.
and checking for joint laxity and soft tissue tensioning. An ideal prosthesis provides
a stable joint with appropriate soft tissue tension. This can be assessed checking
posterior translation. The prosthesis should allow for approximately 50% to 100%
posterior translation of the head when a posterior force is applied, with spontane-
ous reduction of the head when the force is removed.
IV. Once the proper sized humeral head is selected, the humeral component is assem-
bled (consisting of both the stem and humeral head) and implanted.
The prosthesis can be cemented into place or impacted without cement using a
press-fit technique (Fig. 6-16).
V. Patients with poor bone quality and a large diaphysis-to-metaphysis diameter ratio
are at increased risk of fracture with press-fit implantation, and should have the
humeral prosthesis cemented into place.
Wound Closure
I. Once the components have been secured in place, the shoulder is pulse lavaged
Does your attending use
with saline. A drain may be used to drain the shoulder and minimize the likelihood
a drain postoperatively?
of a postoperative hemarthrosis. Why or why not?
II. The subscapularis is repaired according to how it was released (see above);
tendon-to-tendon (intratendinous) or bone-to-bone (LT osteotomy) anatomic
repair, medial repair to bone (LT release with medialization), or Z-plasty and
lengthening (Fig. 6-17). The external rotation that can be obtained before tension IF THE ROTATOR INTERVAL IS
is placed on the subscapularis repair is noted and used to direct postoperative CLOSED, THE ARM SHOULD BE
rehabilitation. HELD IN EXTERNAL ROTATION
TO AVOID LIMITING EXTERNAL
III. Typically, the rotator interval is then closed with a heavy suture, followed by loose
ROTATION POSTOPERATIVELY.
closure of the deltopectoral interval with a couple of interrupted sutures.

Humeral head implant in place. Subscapularis tendon following repair.
Figure 6-18
Anteroposterior radiograph of a shoulder following
total shoulder arthroplasty.
IV. The subcutaneous tissue and skin is closed in standard fashion.

V. A sterile dressing is placed over the incision, and the arm is placed in a sling.
VI. Typically, patients have an anteroposterior radiograph of the shoulder taken post-
operatively in the recovery room (Fig. 6-18).

I. Postoperative management includes pain control and prophylaxis against infection
as well deep venous thrombosis.
II. Initial postoperative pain management is best achieved with patient-
controlled analgesia and/or an interscalene nerve block placed just prior to
surgery.
How long does your III. At least 24 hours of postoperative prophylactic antibiotics are administered.
attending use antibiotics IV. Unless contraindicated, some form of pharmacologic anticoagulation is typically
in the postoperative given for deep venous thrombosis prophylaxis. Prophylaxis can be augmented with
period? compression stockings, mechanical compression devices for the lower extremities,
and early mobilization.
What does your V. In the typical patient with osteoarthritis, physical therapy is started on postopera-
attending use for deep tive day 1 and is dictated in part by the amount of tension-free external rotation
venous thrombosis that was obtained following subscapularis repair in the operating room (see previ-
prophylaxis in the ous discussion).
postoperative period? A. The first 6 weeks of therapy consist of daily exercises for hand, wrist, and elbow
ROM.
B. Shoulder exercises during this time include pendulums, passive supine forward
flexion without limitation, and passive supine external rotation limited to the
tension-free amount observed in the operating room (typically about 30
degrees).
VI. The arm is maintained in a sling at all times during the first 2 weeks after surgery,
except during physical therapy exercises and personal hygiene. After 2 weeks, the
sling can be removed at home, and unweighted ADLs can be performed with the
arm at the side.
VII. Three weeks postoperatively, cross-body adduction stretches are added to stretch
the posterior capsule, as well as light isometric external rotation strengthening. A
1-pound weight limit is given for ADLs.
VIII. Six weeks postoperatively, internal rotation strengthening is started, external rota-
tion strengthening is advanced, and limits on passive external rotation are
eliminated.
Shoulder and Elbow

IX. Deltoid strengthening begins approximately 3 months after surgery, when the POSTOPERATIVE PHYSICAL
rotator cuff shows adequate strength. THERAPY AND REHABILITATION
X. Return to sports activities such as golf is permitted at 4 months, but heavy weight PROTOCOLS CAN VARY
lifting activities and vigorous sports should be avoided. DEPENDING ON THE BONE
XI. Maximal recovery takes approximately 1 year. AND SOFT TISSUE QUALITY
XII. Plain radiographs are taken at yearly intervals to assess for component position AT THE TIME OF SURGERY.
and loosening. RHEUMATOID PATIENTS
TYPICALLY HAVE POORER
QUALITY BONE AND SOFT
COMPLICATIONS TISSUES AND REQUIRE A
SLOWER PROGRESSION IN
I. Stiffness
THERAPY AND MORE MOTION
II. Instability or dislocation RESTRICTION EARLY ON TO
III. Subscapularis detachment or rupture ALLOW FOR ADEQUATE
IV. Nerve injury (axillary, musculocutaneous, brachial plexus) HEALING.
V. Glenoid loosening
VI. Periprosthetic fracture (humeral shaft most commonly)
VII. Infection
VIII. Rotator cuff tear
SUGGESTED READINGS
Abboud JA, Getz CL, Williams GR: Shoulder arthroplasty. In Garino JP, Beredjiklian PK (eds):
Core Knowledge in Orthopaedics: Adult Reconstruction and Arthroplasty. Philadelphia,
Elsevier, 2007.
Craig EV: Master Techniques in Orthopaedic Surgery: The Shoulder, 2nd ed. Philadelphia,
Lippincott Williams & Wilkins, 2003.
Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, 2nd ed.
Philadelphia, Lippincott Williams & Wilkins, 2007.
Norris TR: Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American
Academy of Orthopaedic Surgeons, 2002.
C H A P T E R
7
Cubital Tunnel Release and Ulnar Nerve
Transposition
Julia A. Kenniston and David R. Steinberg
Case Study
A 48-year-old, right hand–dominant male, a concert violinist, presents to the clinic com-
plaining of intermittent paresthesias in his right hand affecting his ring and small fingers
along with pain at his medial elbow and medial forearm of 6 months’ duration. These
symptoms affect him mostly after playing his violin and occasionally when he wakes up
in the morning. He also reports “clumsiness” in his fingers, which he has never experi-
enced before. He denies trauma to his right arm and any medical problems, including
diabetes, hypothyroidism, or history of cancer. He claims to be healthy and exercises
regularly and denies smoking or use of alcohol. He is concerned that this problem will
affect his career.
BACKGROUND
I. Cubital tunnel syndrome is a phrase used to describe symptoms related to the
Carpal tunnel syndrome
is seen in 40% of patients compression or traction of the ulnar nerve around the elbow. It is the second most
with cubital tunnel common compressive neuropathy in the upper extremity, after carpal tunnel
syndrome. syndrome.
II. Although the cubital tunnel is limited to the elbow, any ulnar neuropathy in the
mid-arm to mid-forearm (10 cm proximal and 5 cm distal to elbow joint) is
included in the phrase “cubital tunnel syndrome.”
III. The cubital tunnel is an anatomic passageway through which the ulnar nerve
travels around the elbow with the following anatomic borders:
A. Anterior: medial epicondyle
B. Posterior: olecranon
C. Floor: medial collateral ligament
D. Roof: arcuate ligament (also known as cubital tunnel retinaculum or triangular
ligament)
IV. Ulnar Nerve Anatomy (Fig. 7-1)
A. The ulnar nerve is derived from the medial cord of the brachial plexus and
receives contributions from C8, T1, and occasionally C7.
B. The nerve travels along the anterior arm, traverses the medial intermuscular
As it courses down the septum at the arcade of Struthers adjacent to the medial head of the triceps
forearm, the ulnar nerve muscle and continues in the posterior compartment. At the elbow, the nerve
lies between the flexor
enters the cubital tunnel and passes between the two heads of the flexor carpi
carpi ulnaris and the
flexor digitorum
ulnaris (FCU) and exits under the deep flexor pronator aponeurosis to lie deep
profundus. to the flexor digitorum superficialis (FDS), FCU, and superficial to the flexor
digitorum profundus (FDP).
C. At the medial epicondyle, the sensory fibers to the hand and the motor fibers
to the intrinsics are superficial, whereas the motor fibers to the FCU and FDP
are deep. This may explain why the FCU and FDP are relatively protected in
cubital tunnel syndrome.
C H A P T E R 7 Cubital Tunnel Release and Ulnar Nerve Transposition 71
Shoulder and Elbow

Median nerve
Ulnar nerve
Radial nerve
Humeral head
of pronator
teres
Deep branch Flexor carpi
of radial nerve ulnaris (cut)
Supinator Ulnar head of
pronator teres
Superficial branch
of radial nerve Flexor digitorum
Pronator teres superficialis (cut)
(cut)
Figure 7-1
Anterior Nerves of the anterior forearm. (From Drake RL,
interosseous Flexor digitorum
profundus Vogl W, Mitchell AWM: Gray’s Anatomy for Students.
nerve
Philadelphia, Churchill Livingstone, 2005.)
Brachioradialis
tendon (cut) Dorsal branch
(of ulnar nerve)
Flexor carpi Flexor carpi
radialis tendon ulnaris tendon
(cut) (cut)
Palmar branch
(of median Palmar branch
nerve) (of ulnar nerve)
D. Anatomic variations exist with regard to ulnar nerve innervation, including

sensory branches and the number of muscle motor branches.
1. Sensory
a. The dorsal sensory branch emerges approximately 5 cm proximal to the
pisiform and supplies the dorsal-ulnar hand and dorsal aspect of the ulnar
one and one half digits. This differentiates cubital tunnel syndrome from
ulnar tunnel/Guyon’s canal nerve compression.
b. The palmar cutaneous branch of the ulnar nerve is located proximal to
Guyon’s canal and supplies sensation to the ulnar palm and palmar aspect
of the ulnar one and one half digits. This nerve is at risk for injury in a
carpal tunnel release.
c. The palmar branches from the superficial ulnar nerve may also supply
sensation to the ulnar palm and palmar aspect of the ulnar one and one
half digits.
2. Motor (the following muscles require motor innervation from the ulnar
nerve)
a. FCU
b. FDP; digits four and five
c. Palmaris brevis
d. Adductor pollicis
e. Deep head of flexor pollicis brevis
f. Abductor digit minimi
g. Flexor digiti minimi brevis
h. Opponens digit minimi
i. Third and fourth lumbricals The ulnar nerve does not
j. Dorsal interossei (four muscles) innervate any structure in
the upper arm.
k. Palmar interossei (three muscles)
E. The blood supply is derived from branches of the brachial artery (superior and
inferior ulnar collateral artery) and the posterior recurrent ulnar artery, a
branch of the ulnar artery.
Figure 7-2
Potential sites of compression of the ulnar nerve at
the elbow. (From Gelberman RH: Operative Nerve
Repair and Reconstruction. Philadelphia, JB Lippincott,
1991. Illustration by Elizabeth Roselius, copyright 1991.
Reprinted with permission.)
V. Possible Sites of Compression (Fig. 7-2)

A. Area of the intermuscular septum
1. Arcade of Struthers: musculofascial band 8 to 10 cm proximal to medial
epicondyle extending from the medial head of the triceps to the medial
intermuscular septum
2. Medial intermuscular septum: area of the intermuscular septum that becomes
thick and flares distally as it inserts onto the medial epicondyle
3. Medial head of the triceps: may compress the nerve if it becomes hypertro-
phied (e.g., bodybuilders) or if it snaps over the medial epicondyle, causing
friction neuritis
Delayed ulnar neuropathy B. Medial epicondyle. This may cause compression or excessive traction forces
occurring years after a on the ulnar nerve by valgus or varus deformity from a previous supracondylar
supracondylar humerus humerus fracture or by osteophytes in an arthritis elbow.
fracture, typically with C. Epicondylar groove
a progressive valgus 1. Space-occupying lesion may cause compression with mass effect.
deformity, is referred to 2. Shallow groove increases risk of nerve subluxation.
as tardy ulnar nerve palsy. 3. External compression may result from leaning on a flexed elbow for a pro-
longed period of time.
D. Arcuate ligament: roof of cubital tunnel
E. Osborne’s fascia
1. Proximal fibrous edge of the FCU
2. Most common cause of nerve compression
Osborne’s fascia is the F. Anconeus epitrochlearis. This accessory muscle arises from the medial olecra-
most common cause of non and triceps and inserts into the medial epicondyle. It is found in 10% of
ulnar nerve compression patients undergoing cubital tunnel release.
about the elbow. G. Deep flexor pronator aponeurosis
DIAGNOSIS
I. Physical Examination
A. Check elbow range of motion (ROM) (functional ROM is 30 to 130 degrees)
and carrying angle (normal range is 7 to 15 degrees).
B. Palpate the elbow and cubital tunnel to exclude mass lesions.
C. Examine the hand for muscle wasting and resting position of digits.
D. Test muscle function and strength (cross fingers, hand grip, pinch, and Froment
sign).
E. Examine sensation in the hand to differentiate cubital tunnel syndrome from
Discuss the concept ulnar tunnel syndrome.
behind threshold and F. Perform threshold testing (Semmes-Weinstein monofilament or vibration
innervation density nerve
testing).
testing with your
physician.
G. Check innervation density (static and moving two-point discrimination).
H. Check cervical ROM and associated pain/radiculopathy.
Shoulder and Elbow

II. Clinical Findings
With elbow flexion, the
A. Paresthesia and numbness in the ring and small finger, which may worsen with volume of the cubital
elbow flexion tunnel decreases by 55%,
B. Altered threshold testing, which occurs early in disease with changes in mono- the pressure increases
filament and vibration testing sevenfold, the nerve is
C. Decreased two-point sensation, which occurs late in disease and reflects axonal placed on traction, and it
degeneration after chronic nerve compression/traction injury elongates approximately
D. Tenderness to palpation at the medial elbow 5 to 8 mm. These factors
E. Tinel’s sign. Paresthesias in the ulnar nerve distribution with percussion of the exacerbate cubital tunnel
nerve at level of the medial epicondyle symptoms with elbow
flexion.
F. Elbow flexion test. Symptoms are reproduced within 3 minutes with elbow in
full flexion and wrist in full supination and extension.
G. Intrinsic muscle weakness and wasting with “clumsy fingers” Poor prognosis correlates
most closely with
1. Motor symptoms occur after sensory changes and reflect disease progression
intrinsic atrophy.
2. Weak grip strength
3. Wartenberg’s sign: inability to adduct the small finger
4. Froment sign: flexion of thumb interphalangeal joint during attempt to hold A Martin-Gruber
anastomosis may mask
paper with thumb and index finger
muscular symptoms
5. Inability to cross fingers as motor fibers from
6. Clawing of ring and small finger the median nerve
III. Diagnostic Testing communicate with the
A. Electromyography/nerve conduction velocity ulnar nerve.
1. Distal latencies
a. Sensory latencies greater than 3.2 msec Does your attending
b. Motor latencies greater than 4.2 msec require an
c. Often normal at wrist with cubital tunnel syndrome electromyogram prior to
2. Nerve conduction velocity less than 50 m/sec surgery?
3. Abnormal electromyography results: associated with poor surgical outcomes
B. Imaging studies
1. Plain radiographs: may reveal osteophytes or other osseous causes of
compression
2. Magnetic resonance imaging: may reveal space-occupying lesions or edema
within the nerve or enlargement of the nerve
3. High-resolution ultrasound: may be useful to evaluate morphologic changes
within the ulnar nerve secondary to compression or traction
IV. Differential Diagnosis
A. Cervical disk disease/radiculopathy
B. Thoracic outlet syndrome
C. Spinal tumor
D. Syringomyelia
E. Amyotrophic lateral sclerosis
F. Guillain-Barré syndrome
G. Ulnar tunnel syndrome (Guyon’s canal): dorsal hand sensation remaining
intact
H. Systemic causes: diabetes, hypothyroidism, alcoholism, malnutrition, cancer
V. Treatment Considerations
A. Other causes of symptoms: rule out
B. Concomitant carpal tunnel syndrome: necessary to consider simultaneous
release
C. Patient compliance
D. Worker’s compensation
E. Occupation
F. Prognosis
1. Age
2. Comorbidities
3. Duration of nerve compression
4. Severity of symptoms
5. Worse prognosis with impaired two-point discrimination, severe weakness,

and muscle atrophy
TREATMENT ALGORITHM
When does your Ulnar nerve compression in cubital tunnel

attending decide to
operate?
Intermittent symptoms Constant symptoms Constant symptoms

No muscle weakness No muscle weakness Sensory and motor deficit
Conservative EMG (±) EMG (+)

management NCV (+) NCV (+)
Fails conservative Surgery less

Surgery
management predictable
Surgery
TREATMENT PROTOCOLS
I. Nonoperative
A. Splint elbow in 70 degrees of flexion
B. Soft elbow padding
C. Activity modification: avoid repetitive elbow flexion/pronation, direct com-
pression
D. Nonsteroidal anti-inflammatory drugs
II. Operative
A. In situ decompression: unroof cubital tunnel and release compression sites
1. Indications
a. Mild ulnar nerve compression with mild symptoms
b. Mild slowing on nerve conduction velocity study
c. No tenderness directly over the bony medial epicondyle
d. No subluxation of nerve
e. Normal bony anatomy
2. Advantages
a. Minimal damage to vascular supply of the ulnar nerve
b. No damage to ulnar nerve and branches
c. No postoperative immobilization required
3. Disadvantages
a. Potentially higher recurrence rate
b. Risk of nerve subluxation
4. Contraindications
a. Severe cases of compressive neuropathy (e.g., post-traumatic compres-
sion secondary to perineural scarring)
b. Space-occupying lesion
c. Chronic subluxation of nerve
B. Anterior transposition of ulnar nerve
1. Indications
a. Unsuitable bed for ulnar nerve
b. Space occupying mass
c. Anconeus epitrochlearis
Shoulder and Elbow

d. Heterotopic ossification
e. Significant tension on ulnar nerve with elbow flexion
f. Exacerbation of symptoms or subluxation of the nerve with elbow flexion
g. Elbow deformity secondary to valgus elbow or post-traumatic etiology
h. Valgus instability at elbow
2. Advantages. This procedure transfers the ulnar nerve to a region of less scar
and eliminates tension on the ulnar nerve when the elbow is in flexion by
moving the nerve anteriorly.
3. Disadvantages. This procedure is more technically demanding and has the
potential to devascularize the nerve and damage small nerve branches (e.g.,
FCU proximal motor branch).
4. Types of anterior transposition
a. Subcutaneous: places nerve anterior between subcutaneous tissue and
muscle
(1) Less dissection and technically uncomplicated
(2) Ulnar nerve may be vulnerable in patients with minimal subcutane-
ous fat
b. Intramuscular: nerve buried within the flexor-pronator muscle
(1) Moderate muscle dissection
(2) Potential for increased scarring as nerve placed within muscle at right
angles to fibers and is subject to traction forces
c. Submuscular: nerve buried deep to flexor-pronator muscle
(1) More extensive dissection leads to an increased risk of postoperative
scar tissue formation.
(2) Initially the nerve lies in an unscarred anatomic plane not subject to
traction forces compared with the intramuscular transposition.
(3) Postoperative immobilization may increase the risk of forming flexion
contractures at the elbow.
C. Medial epicondylectomy
1. Indications
a. Nonunion of epicondyle fracture with cubital tunnel symptoms
b. Shallow groove for ulnar nerve
c. Ulnar nerve subluxation
d. Concomitant medial epicondylitis
2. Advantages. This procedure results in a more thorough decompression and
causes minimal damage to the vascular supply and small nerve branches off
the ulnar nerve.
3. Disadvantages
a. Allows greater anterior migration of the ulnar nerve with elbow flexion
b. Potential for elbow instability if collateral ligaments are damaged
c. Potential for nerve vulnerability at epicondylectomy site
d. Increased risk of elbow stiffness/flexion contracture
e. Fails to release potential sites of compression distally
f. Technically challenging with regards to an accurate amount of bone to
excise
4. Contraindications
a. Throwing athletes due to increased stresses on the medial elbow How does your attending
b. Patients involved in activities requiring intensive movements of elbow decide which procedure
to perform?
flexion-extension
GENERAL PRINCIPLES OF ULNAR NERVE DECOMPRESSION AND

SUBCUTANEOUS NERVE TRANSPOSITION
I. The cubital tunnel is the main restraint for the ulnar nerve as it courses around
the elbow joint and has multiple potential sites of nerve compression. Maximum
strain occurs when the elbow is held in flexion because the volume of the cubital
tunnel decreases by 50%.
II. The initial symptoms consist of sensory change and progress to weakness. If
muscle atrophy is present, the result from surgical intervention is less
predictable.
III. Cubital tunnel syndrome must be differentiated from C8 radiculopathy or ulnar
tunnel syndrome to ensure appropriate treatment.
IV. The goal of surgery is to decrease pain and symptoms associated with
ulnar neuropathy and to prevent muscular weakness and progression of the
disease.
V. It is important to assess all potential compression sites and to completely release
the nerve while preventing the creation of new sites.
VI. In situ decompression preserves vascular supply but may not provide a sufficient
release, whereas an anterior transposition more thoroughly decompresses the
nerve but increases the risk of compression at a new site and subsequent vascular
compromise.

I. The patient is placed in a supine position on the operating table with a hand table
attachment.
II. The arm is prepped and draped in standard fashion with the use of a tourniquet.
A sterile tourniquet may be used if an adequately sized sterile field cannot be
secured (Fig. 7-3). (Refer to Chapter 1 for surgical principles of prepping and
The surgical dissection is draping.)
carried out 8 to 10 cm III. Using a sterile marker, the surgical incision is marked out after identifying the
proximal to the medial medial epicondyle and the ulnar nerve (Fig. 7-4).
epicondyle to identify the IV. The operative extremity is exsanguinated with an Esmarch and the tourniquet is
arcade of Struthers. If it inflated to the preset value (Fig. 7-5).
is not located within
10 cm, it is unlikely to be
the cause of compression Ulnar Nerve Decompression and Subcutaneous Nerve Transposition
and does not need to be
released. I. Make a skin incision midway between the medial epicondyle and the olecranon
starting 8 to 10 cm proximal to and 5 to 7 cm distal to the medial epicondyle. The
THE MEDIAL ANTEBRACHIAL incision is slightly posterior to the ulnar nerve.
CUTANEOUS NERVE MAY II. If possible, identify and protect the posterior branch(es) of the medial antebrachial
CROSS THE ELBOW ANYWHERE cutaneous nerve.
FROM 6 CM PROXIMAL TO
6 CM DISTAL TO MEDIAL
EPICONDYLE. THIS NERVE
INNERVATES THE SKIN OVER
THE MEDIAL EPICONDYLE AND
OLECRANON. DAMAGE TO THIS
NERVE MAY CAUSE SCAR
TENDERNESS AND NUMBNESS
AS WELL AS A PAINFUL
NEUROMA.
Figure 7-4
Figure 7-3 Incision marked out with a straight line, the ulnar
Right arm with tourniquet and 1010 drape over a nerve indicated by a dotted line, and the medial
hand table. epicondyle indicated by a circle.
Shoulder and Elbow

Figure 7-5
Esmarch bandage exsanguination of the limb.
III. Mobilize thick skin flaps to expose the medial intermuscular septum and fascia
over the flexor-pronator muscle origin using tenotomy scissors. Next, identify the
ulnar nerve.
IV. Incise the fascia immediately posterior to the medial intermuscular septum along IT IS IMPERATIVE TO IDENTIFY
the course of the ulnar nerve. AND PROTECT THE MOTOR
V. Identify Osborne’s fascia and divide the fibroaponeurotic covering of the epicon- BRANCH TO THE FLEXOR
dylar groove (Fig. 7-6). CARPI ULNARIS, BECAUSE IT
MAY BE THE ONLY BRANCH
VI. Mobilize the ulnar nerve and protect the branches to the elbow joint, FCU, and
INNERVATING THE FLEXOR
FDP. The motor branch of the FCU should be identified and protected while
CARPI ULNARIS.
articular branches to the elbow capsule may be sacrificed.
VII. Protect the ulnar nerve while dividing the aponeurosis between the two heads of
the FCU. Bluntly dissect the muscle fibers of the two heads of the FCU to ensure
that the nerve is completely unroofed and there are no fibrous bands distally
causing compression (Figs. 7-7 and 7-8).
Figure 7-6
Osborne’s fascia indicated by forceps.
Figure 7-8
Figure 7-7 Complete in situ release of ulnar nerve.
Flexor carpi ulnaris aponeurosis at forceps tips.
VIII. Evaluate the decompression by assessing the nerve in extension and in

flexion. If the nerve subluxates in flexion or appears to be stretched tightly
over the medial epicondyle, additional surgical procedures should be
considered.
IX. Identify the intermuscular septum and mobilize the ulnar nerve proximally; protect
the ulnar nerve with a vessel loop.
X. Be sure to identify the leash of vessels at the distal end of the intermuscular
septum and cauterize them to prevent excessive bleeding prior to excising a
portion of the intermuscular septum and creating a new compression point (Figs.
7-9 and 7-10).
XI. Create a fasciodermal sling from fascia overlying the flexor-pronator muscle. Make
sure that the sling is sufficiently large and broad so as to not create a new com-
pression site. Transpose the ulnar nerve anterior to the sling and suture the deep
subcutaneous tissue to the fasciodermal sling using absorbable sutures, such as 2-0
Vicryl (Figs. 7-11 and 7-12).
Wound Closure
I. Release the tourniquet and achieve hemostasis with bipolar electrocautery prior
to closing the wound.
II. Close the subcutaneous layer in standard fashion (see Chapter 1); close the skin
with a subcuticular closure.
Figure 7-10
Figure 7-9 Proximal release of ulnar nerve protected with vessel
Intermuscular septum. loop.
Shoulder and Elbow

Figure 7-12
Transposition of ulnar nerve anterior to sling.
Figure 7-11
Fasciodermal sling.

Wound closed and Steri-Strips applied. Postoperative soft dressing.
III. Dress the wound in standard fashion, and apply a soft dressing (Figs. 7-13 and
7-14).
IV. A sling may be used for comfort postoperatively.
POSTOPERATIVE REHABILITATION
I. In Situ Decompression/Subcutaneous Transposition/Medial Epicondylec-
tomy
A. No immobilization
B. Early ROM When does your
II. Intramuscular Transposition attending begin to
A. Immobilize elbow at 90 degrees flexion with full pronation. mobilize the elbow? Does
B. Begin ROM exercises after 1 to 3 weeks of immobilization. he or she like to use a
continuous passive
III. Submuscular Transposition
motion machine for the
A. Immobilize elbow at 45 degrees flexion in neutral to slight pronation. elbow?
B. Begin ROM exercises after 1 to 3 weeks of immobilization.
COMPLICATIONS
I. Infection
II. Incomplete release of the ulnar nerve
III. Creation of a new compression site
IV. Injury to the posterior branches of medial antebrachial cutaneous nerve
V. Recurrent ulnar nerve subluxation
VI. Elbow instability
VII. Elbow stiffness/flexion contracture
VIII. Medial epicondylitis
IX. Heterotopic ossification
SUGGESTED READINGS
Bainbridge C: Cubital tunnel syndrome. In Berger RA, Weiss APC (eds): Hand Surgery. Philadel-
phia, Lippincott Williams & Wilkins, 2004, pp 887–896.
Bozentka DJ: Cubital tunnel syndrome pathophysiology. Clin Orthop 351:90–94, 1998.
Eversmann Jr WW: Medial epicondylectomy for cubital tunnel compression of the ulnar nerve. In
Strickland JW (ed): Master Techniques in Orthopaedic Surgery, The Hand. Philadelphia,
Lippincott Williams & Wilkins, 1998, pp 293–302.
Posner MA: Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad
Orthop Surg 6:282–288, 1998.
Posner MA: Compressive ulnar neuropathies at the elbow: II. Treatment. J Am Acad Orthop Surg
6:289–297, 1998.
Szabo RM: Entrapment and compression neuropathies. In Green DP, Hotchkiss R, Pederson W,
Wolfe S (eds): Green’s Operative Hand Surgery, 4th ed. Philadelphia, Elsevier, 2005,
pp 1422–1429.
Terry GC, Zeigler TE: Cubital tunnel syndrome. In Baker CL, Plancher KD (eds): Operative
Treatment of Elbow Injuries. New York, Springer, 2002, pp 131–139.
8
Shoulder and Elbow

C H A P T E R
Open Reduction and Internal Fixation of

Adult Distal Humerus Fractures
Sameer Nagda and Neil P. Sheth
Case Study
A 53-year-old, right hand–dominant male presents after a fall on a flexed left elbow. He
had immediate pain and swelling after the fall, and he complains of numbness in his hand
and has difficulty moving his elbow. On physical examination, there are no open wounds
but there is significant swelling with a gross deformity of the elbow. Any palpation or
motion of his elbow causes severe pain. The forearm and wrist are nontender, and there
is no pain with passive stretch of the fingers. The motor examination is intact in the
median, ulnar, and radial nerve distribution. Objectively, the sensory examination is intact,
and there is a 2+ radial pulse distally. This is an isolated injury with no evidence of ten-
derness about the proximal humerus and shoulder. Anteroposterior and lateral radiographs
of the left elbow are presented in Figure 8-1.
BACKGROUND
I. Fractures about the elbow include distal humerus, olecranon, coronoid, and
radial head fractures. These fractures can be difficult to identify and plain radio-
graphs may often present only subtle findings with significant underlying injuries.
This chapter focuses on the diagnosis and treatment of adult distal humerus
fractures.
II. Distal humerus fractures comprise approximately 0.5% of all fractures in adults.
Although these fractures are not extremely common, they often present as severe
injuries. Patients may be a victim of polytrauma. Thus, evaluation using the
Advanced Trauma Life Support (ATLS) protocol is necessary to stabilize the
patient and diagnose associated injuries.
III. There is no universally accepted classification that is widely used for describing
distal humerus fractures. The AO and the OTA classifications are the most widely
used by trauma surgeons. A type A fracture is extra-articular, a type B fracture
partially includes the articular surface, and a type C fracture includes the articular
surface with complete dissociation of the articular fragments from the humeral
shaft. However, these fractures are better defined with use of a computed tomog-
raphy (CT) scan.
TREATMENT PROTOCOLS
I. Treatment Considerations. All of these considerations play an important
role in the decision-making process of treating patients with a distal humerus
fracture.
A. Patient age (concomitant osteoporosis)
B. Activity level
A B
Figure 8-1
Anteroposterior (A) and lateral (B) views of a closed distal humerus fracture.
C. Arm dominance
D. Intra-articular extension
E. Overall health (able to tolerate surgery)
F. Integrity of the elbow soft tissue envelope
G. Neurovascular status
H. Patient expectations
II. Initial Evaluation
The radial nerve courses
around the humerus in A. A thorough history and physical examination are critical to the assessment of
the radial groove. The elbow fractures. The mechanism of injury can be a fall on an outstretched hand
nerve pierces the lateral or a fall directly onto the elbow. Typically, an axial load with the arm flexed
intermuscular septum more than 90 degrees results in a distal humerus fracture.
approximately 13 cm B. Fractures of the distal humerus that are a result of high-energy trauma require
proximal to the level of close attention with a high suspicion for possible open injuries. In addition,
the joint. Radial nerve high-energy fractures result in fracture comminution and intra-articular
injuries are highly extension.
associated with Holstein- C. Patients who sustain this injury due to high-energy trauma require a thorough
Lewis type spiral ATLS evaluation for associated injuries. Assessment of the elbow should docu-
fractures.
ment if the fracture is open and the status of the initial neurovascular examina-
C H A P T E R 8 Open Reduction and Internal Fixation of Adult Distal Humerus Fractures 83
Shoulder and Elbow

tion. With proximal extension of the fracture line, injury to the radial nerve
should be suspected.
D. Distal humerus fractures with a spiral component are termed Holstein-Lewis
fractures and have a higher rate of associated radial nerve injury.
E. Although compartment syndrome is not commonly associated with these frac-
tures, concomitant neurovascular injury may be present. Early identification
of neurovascular injuries results in more emergent operative treatment.
F. Every patient should at minimum have an anteroposterior and lateral radio-
graph of the involved elbow. Additional oblique radiographs can also help with
understanding the fracture pattern. Any fracture that extends into the elbow
joint requires a CT scan to help delineate the fracture fragments and develop
a more comprehensive preoperative plan.
A. Conservative treatment is considered an option when surgical intervention is
not possible due to comorbidities.
B. It may be used as a treatment for nondisplaced extra-articular fractures. Non-
operative treatment is contraindicated in cases of neurovascular compromise.
C. Distal humerus fractures can be treated with a long-arm cast with the elbow
in no more than 90 degrees of flexion. Flexion of more than 90 degrees can
compromise blood vessels and impair distal blood flow and venous return.
D. Radiographs should be obtained after 1 week to demonstrate lack of displace-
ment and confirm adequate position of the distal humerus.
E. The duration of immobilization should be 6 to 8 weeks or until there is radio-
graphic evidence of fracture healing.
F. Patients typically require extensive therapy to regain elbow range of motion Does your attending
(ROM) with loss of terminal extension being the most common residual consider any additional
patient scenarios as
deficit.
candidates for
G. Intra-articular fractures are usually not considered for nonoperative treatment
nonoperative treatment?
due to the increased risk for fracture displacement.
SURGICAL ALTERNATIVES TO OPEN REDUCTION AND INTERNAL FIXATION OF

DISTAL HUMERUS FRACTURES
I. Spanning Elbow External Fixator
A. Used to provide fracture stability for acute high-energy distal humerus
fractures
B. Typically used when there is significant soft tissue envelope compromise
C. Treatment of choice for open fractures (grade II and higher)
D. Time to conversion for definitive fracture fixation: should be dictated by the
soft tissues
E. Can be left in place for approximately 2 weeks before converting to definitive
fixation
II. Hinged Elbow External Fixator
A. A treatment modality that provides fracture stability while allowing for elbow
ROM
B. Typically used for high-energy distal humerus fractures with soft tissue
swelling
C. Can be used as definitive fracture fixation
III. Total Elbow Arthroplasty
What surgical alternatives
A. This is considered an option for severely comminuted intra-articular fractures
would your attending
in elderly patients with osteoporotic bone.
consider for a given
B. Elbow replacement has demonstrated good to excellent results with regard to fracture pattern?
pain relief, elbow ROM, and return of function.
TREATMENT ALGORITHM

Distal humerus fracture/deformity
distal humerus fractures?
Radiographs, CT scan
Physical exam
Closed fracture,
Open fracture significant soft tissue Good soft tissue envelope
swelling
Delayed ORIF vs. Simple Partially

Irrigation and extra- intra- Comminuted
débridement hinged external
fixation articular articular intra-articular
fracture fracture fracture
(OTA A) (OTA B)
External fixation vs. ORIF
based on severity of soft
tissue injury Evaluate patient age
and bone quality
Younger Older patient,

patient osteoporotic bone
ORIF vs. total elbow

ORIF
arthroplasty
SURGICAL INDICATIONS FOR OPEN REDUCTION AND INTERNAL FIXATION OF

I. Displaced extra-articular distal humerus fractures
II. Intra-articular humerus fractures
III. Fractures that have failed nonoperative treatment
IV. Concomitant neurovascular injury
V. Distal humerus fractures associated with an elbow dislocation
RELATIVE CONTRAINDICATIONS TO OPEN REDUCTION AND INTERNAL

FIXATION OF DISTAL HUMERUS FRACTURES
I. Current infection (absolute)
II. Recent infection
III. Severe soft tissue envelope compromise
IV. Medically unstable. (Patient is unable to safely tolerate the stress of surgery.)
GENERAL PRINCIPLES OF OPEN REDUCTION AND INTERNAL FIXATION OF

I. The goal of open reduction and internal fixation (ORIF) is to achieve fracture
reduction, congruency of the articular surface, and reconstitution of both the
medial and lateral humeral columns (Fig. 8-2).
Shoulder and Elbow

Lateral Medial
column column
Olecranon
Radial Coronoid fossa
fossa fossa
Medial
epicondyle
Lateral Lateral
epicondyle epicondyle
Trochlea Trochlea
A Capitellum B
Figure 8-2
Anterior (A) and posterior (B) views of the medial and lateral columns of the distal third of the
humerus. (From Browner BD, Jupiter JB, Levine AM, Trafton PG [eds]: Skeletal Trauma: Basic Science,
Management, and Reconstruction. Philadelphia, Saunders, 2003.)
II. A construct stable enough to allow early elbow ROM is critical to obtaining a
favorable clinical outcome.
III. ORIF achieves rigid internal fixation to avoid shear stress and postoperative frac-
ture displacement.
IV. Distal humerus fractures typically require a preoperative CT scan of the elbow to
understand the intra-articular component of the fracture and help with preopera-
tive planning.
V. Preservation of the soft tissue envelope surrounding the elbow is crucial in pre-
venting infection.
VI. The level of swelling and soft tissue injury should be used to determine timing of
intervention and conversion to definitive fixation if external fixation is initially
chosen for treatment.
VII. Reduction of the medial and lateral condyles should be done first prior to securing
them as a single unit to the humeral shaft.
VIII. Distal humerus fracture fixation is typically done using dual plating. The first
option utilizes medial and lateral column precontoured plates. The second option
includes 90/90 plating where one plate is placed on the medial column and the
second plate is placed posteriorly on the lateral column.

I. Distal humerus fractures can be treated operatively in the prone, supine, or lateral
position. In this chapter, we focus on the lateral position with the use of a paint
roller.
II. The patient is placed in the lateral position with the unaffected side down.
A paint roller is placed at the middle portion of the table on the opposite
side of the affected elbow. Place a tourniquet on the arm in standard
fashion.
III. The operative elbow is then draped across the body so that the olecranon points
toward the ceiling. Standard prepping and draping procedures are followed until
a sterile operative field has been attained (See Chapter 1 for surgical principles of
Figure 8-3
Lateral positioning of the elbow using a paint
roller. (From Miller M, Cole B: Textbook of
Arthroscopy. Philadelphia, Saunders, 2004.)
THE LATERAL ASPECT OF THE prepping and draping.) The incision is marked out using a sterile marker and the
ELBOW IS ALWAYS TOWARD tourniquet is inflated prior to starting the procedure (Fig. 8-3).
THE HEAD, WHEREAS THE IV. Prior to making an incision, make sure to be oriented as to what is lateral and
MEDIAL ASPECT OF THE medial. Also, make sure that the image intensifier is in the proper location and
ELBOW IS TOWARD THE FEET that adequate radiograph imaging can be obtained.
WHEN USING THE LATERAL
DECUBITUS POSITION.
Surgical Approach
I. A midline incision is made across the dorsal surface extending both proximal and
distal to the elbow joint. The incision is slightly curved medial or lateral at the
level of the olecranon.
II. Exposure is obtained through the subcutaneous tissues, making sure that thick soft
tissue flaps are created.
III. Next, the fascia overlying the triceps tendon is visualized. A longitudinal incision
is made in the triceps fascia and it is dissected free from the medial and lateral
edges of the tendon.
IV. Next, the ulnar nerve is located on the medial side of the elbow and traced proxi-
mally (to the medial intermuscular septum) and distally (to the first motor branch
to the flexor carpi ulnaris muscle).
V. Once the nerve is adequately mobilized, a Penrose drain or a rubber vessel loop
is placed around the nerve for safe repositioning during the case.
Does your attending
prefer using a different
VI. Access to the elbow joint can be gained through several different approaches. In
technique to access the this chapter we discuss the use of a chevron (V-shaped) olecranon osteotomy. The
elbow joint? tip of the olecranon is typically predrilled so that the tip can be resecured to the
shaft of the ulna prior to wound closure.
VII. After the osteotomy has been completed, the distal humerus as well as the articular
surface of the elbow joint can be visualized.
Fracture Reduction
I. Most distal humerus fractures are reduced with provisional fixation using K-wires.
The main condylar fragments are secured together so that the entire distal humerus
can be re-attached as a unit to the humeral shaft.
II. Once K-wires have allowed for provisional fixation, the fixation construct
must be determined. In this chapter, we use the medial and lateral 90/90 plating
technique.
III. Regardless of the technique used for fixation, the condylar fragments are
secured to the shaft of the humerus using several screws. Interdigitating screws
from both medial to lateral and vice versa allow for a more stable fixation
construct.
IV. After fracture fixation is adequate via visual inspection, the fracture can be
assessed using fluoroscopy. Once sufficient reduction is attained, the elbow can
be taken through a ROM to assess fixation stability. This evaluation of intraopera-
Shoulder and Elbow

A B
Figure 8-4
Postoperative radiographs demonstrating medial and lateral column fixation with 90/90 plating technique.
A, Anteroposterior. B, Lateral.
tive stability helps determine the appropriate postoperative rehabilitation

protocol.
V. The wound is now irrigated and the olecranon osteotomy is reduced to the ulnar
shaft. A 6.3-mm cannulated screw is placed through the predrilled cortex and is
used to secure the osteotomy.
VI. In standard fashion, a large-caliber, braided, absorbable suture is used to reap-
proximate the edges of the triceps fascia over the triceps tendon and the medial
and lateral distal humeral plates.
VII. Prior to wound closure, the ulnar nerve is routinely transposed anteriorly at the
time of distal humerus fracture fixation. (Refer to Chapter 7 for ulnar nerve trans-
position technique.)
Wound Closure
I. The wound is closed in layers in standard fashion and the wound is dressed accord-
ingly (see Chapter 1 for wound closure principles).
II. A posterior splint is typically placed for comfort and temporary immobilization of
the elbow postoperatively (Fig. 8-4).
POSTOPERATIVE REHABILITATION
I. Most attending physicians place patients in a splint for a short period of time
after surgery, typically 10 to 14 days. Caution should be exercised with the
length of postoperative immobilization. Elbow stiffness can result fairly quickly
with prolonged immobilization. In general, immobilization should not exceed 3
weeks.
II. The staples are removed 14 days postoperatively. The wound should be assessed
for any persistent drainage.
III. Once the patient exhibits pain-free ROM, therapy should be focused on regaining
full ROM. At a minimum, the functional ROM should be the goal.
IV. In general, patients are made weight bearing as tolerated once there is radio-
graphic evidence of fracture healing. Typically, patients are asked not to return
to sporting activities until 6 months postoperatively.
COMPLICATIONS
I. Wound infection
II. Septic elbow
III. Failure of fixation (early or late)
IV. Ulnar nerve injury (neurapraxia or more severe injury)
V. Osteotomy nonunion
VI. Forearm compartment syndrome (rare)
SUGGESTED READINGS
Anglen J: Distal humerus fractures. J Am Acad Orthop Surg 13(5):291–297, 2005.
Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humerus fractures
in elderly patients. J Bone Joint Surg Am 79:826–832, 1997.
O’Driscoll SW, Jupiter JB, Cohen MS, et al: Difficult elbow fractures: Pearls and pitfalls. Instr
Course Lect 52:113–134, 2003.
S E C T I O N
II
HAND
CHAPTER 9 Trigger Finger and Trigger Thumb Release 91
CHAPTER 10 Carpal Tunnel Release 97
CHAPTER 11 Open Reduction and Internal Fixation of Distal Radius Fractures 104
C H A P T E R
9
Trigger Finger and Trigger Thumb
Release
Jonas L. Matzon and David R. Steinberg
Hand
Case Study
A 55-year-old female with a history of diabetes mellitus presents with left long finger pain.
The pain is located in the palm and has been present for several months. She cannot recall
any trauma or inciting event. Occasionally, as she flexes or extends the finger, it catches
or pops. Her symptoms are worse in the morning when she awakens, and occasionally the
long finger is stuck in a flexed position. She finally decided to come to the hand surgeon’s
office today because the finger has started to lock in flexion (Fig. 9-1). With gentle
manipulation, she can massage the finger back into an extended position.
BACKGROUND
I. Trigger finger, or stenosing flexor tenosynovitis, is a very common problem that
is characterized by the inability to flex or extend the digit. It can occur in any digit
but is most commonly seen in the thumb, followed by the ring, long, small, and
index fingers.
II. Primary stenosing flexor tenosynovitis is idiopathic, affects women approximately
four times more than men, and is seen in infants. The peak incidence is between
55 and 60 years of age, and involvement of several fingers is not unusual. The
lifetime incidence of primary flexor tenosynovitis in adults older than 30 years of
age is about 2.2%.
III. Secondary stenosing flexor tenosynovitis occurs in patients with rheumatoid
arthritis, diabetes mellitus, hypothyroidism, renal disease, gout, and other connec-
tive tissue diseases.
IV. Normally, the flexor tendons (flexor digitorum profundus, flexor digitorum super-
ficialis, flexor pollicis longus) glide through the fibro-osseous flexor pulley system
without difficulty in both finger flexion and extension (Fig. 9-2).
Figure 9-2
Lateral and volar views of the fibro-osseous pulley
system. (From Wolfe SW: Tenosynovitis. In Green DP,
Hotchkiss RN, Pederson WC, Wolfe SW [eds]: Green’s
Figure 9-1 Operative Hand Surgery, 5th ed. Philadelphia,
Left long finger in trigger position. Churchill Livingstone, 2005.)
92 S E C T I O N I I Hand
A. The pulleys are fascial condensations that overlie the flexor tendon and
sheath.
The A2 and A4 pulleys B. Each digit has five annular and three cruciate pulleys. The thumb has two
are vital in preventing
annular pulleys and one oblique pulley, which is in continuity with the adductor
tendon bowstringing.
pollicis insertion.
V. However, in trigger finger digits, there is a discrepancy in size between the flexor
The A1 pulley is involved tendon and the tendon sheath, which leads to mechanical impingement. This is
in stenosing flexor
exaggerated during power grip or any finger flexion, when high angular loads
tenosynovitis.
occur at the distal edge of the A1 pulley.
VI. There are two types of trigger finger—nodular and diffuse.
A. Nodular tenosynovitis is caused by thickening of the tendon on the distal edge
of the A1 pulley and has a distinct nodule. It responds better to injections and
nonsteroidal anti-inflammatory drugs (NSAIDs).
B. Diffuse tenosynovitis is caused by diffuse thickening of the flexor ten-
osynovium, and the pathology is not contained to one specific loca-
tion.
VII. Trigger digits can usually be diagnosed by history and physical examination alone.
Patients may complain of stiffness of the fingers, often in the morning on awaken-
ing. When triggering or pain is present, patients may localize it to the proximal
interphalangeal joint, even though the actual pathology occurs more proximally.
On examination, tenderness is usually localized to the palmar base of the involved
digit. Depending on the severity of the condition, crepitus, catching, or locking
can be felt.
A. It is important to differentiate between nodular and diffuse stenosing
tenosynovitis.
B. The differential diagnosis includes locking due to impingement of the collat-
eral ligaments on a prominent metacarpal head condyle, flexor digitorum pro-
fundus avulsion/rupture, metacarpophalangeal dislocation, and extensor tendon
rupture.
VIII. Although triggering has been classified into various systems, no one uniform
classification system dictates treatment. The following classification is preferred
by Green.
A. Grade I (pretriggering): pain, history of catching that is not demonstrable, and
tenderness over A1 pulley
B. Grade II (active): demonstrable catching but active extension
C. Grade III (passive): demonstrable catching requiring passive extension (IIIA)
or inability to actively flex (IIIB)
D. Grade IV (contracture): demonstrable catching with fixed flexion contracture
at the proximal interphalangeal joint
IX. Congenital Trigger Thumb
A. Pathology usually involves a thickened tendon as opposed to the annular sheath
in adults. Notta’s node is the pathologic nodular tendon thickening found at
surgery.
B. Bilateral incidence is 25% to 33%.
C. If it does not respond to nonsurgical modalities, surgical release is required.
TREATMENT PROTOCOLS
I. Nonoperative Treatment
A. Most primary trigger digits in adults can be treated successfully by nonopera-
tive methods, but this is contraindicated in infants and children.
B. In mild cases, activity modification and splinting in extension during sleep may
be successful.
C. NSAIDs should be included in the initial treatment of all trigger digits unless
contraindicated secondary to patient comorbidities.
C H A P T E R 9 Trigger Finger and Trigger Thumb Release 93
D. Splinting
1. Various splinting techniques have been used. Some hand surgeons advo-
cate immobilizing the metacarpophalangeal joint in 0 to 15 degrees of
flexion while allowing free motion at both the proximal and distal inter-
phalangeal joints. Others prefer simple distal interphalangeal immobili-
How does your attending
zation.
like to splint trigger
2. Splinting is effective in approximately 55% to 66% of patients but is con- digits?
traindicated for locked digits.
E. Corticosteroid injection
1. An injection is indicated in early (usually <4 to 6 months) primary flexor
Hand
tenosynovitis of a single digit.
2. Injections are less successful in secondary, diffuse, and chronic flexor
tenosynovitis.
3. A single corticosteroid injection is effective in relieving symptoms in 47%
to 87% of patients. If symptoms persist after a single injection, then surgical
release is indicated. Some attending hand surgeons perform two or three
injections prior to surgical intervention. How many injections
4. Recurrence of triggering following injection is approximately 27% in just does your attending
1 year. If symptoms were relieved after injection but then recurred, another perform prior to
progressing to surgical
injection can be attempted. However, no more than three injections should
management?
be given per year.
5. The injection technique varies per attending surgeon. In general, a 1:1
combination of lidocaine and corticosteroid is injected into the tendon
sheath with a 27-gauge needle under sterile conditions (Fig. 9-3). What type of
6. Many types of corticosteroids exist, but betamethasone is usually preferred corticosteroid does your
because it is water soluble and therefore does not precipitate. It also results attending prefer for
in less fat necrosis. Risks of any corticosteroid include transient rises in injecting the tendon
sheath?
blood and urine glucose, skin depigmentation, and flare reaction.
A. Surgical release has a success rate of greater than 90%.
B. Indications include failed nonoperative treatment, a locked digit, and congeni-
tal trigger digits.
C. Options: open and percutaneous release
1. Open surgical release of the A1 pulley is the gold standard.
2. Recently, percutaneous release has gained some popularity, but its use still
remains controversial.
a. This method can be performed in the office, decreasing costs and recov- What are your
ery time. attending’s thoughts
b. There is an increased incidence of complications and inadequate release regarding the role of
percutaneous release?
of the A1 pulley.
Ethyl chloride Figure 9-3

Technique for trigger finger injection. (From Wolfe
SW: Tenosynovitis. In Green DP, Hotchkiss RN, Pederson
45° WC, Wolfe SW [eds]: Green’s Operative Hand Surgery,
5th ed. Philadelphia, Churchill Livingstone, 2005.)
TREATMENT ALGORITHM
Trigger finger
Early stage, no locking Late stage, locking, or

failed conservative
management
NSAIDs, splinting, Corticosteroid

activity modification injection
Surgical release
Recurrence of A1 pulley
GENERAL PRINCIPLES OF TRIGGER FINGER RELEASE

I. The goal of trigger release is to release the A1 pulley to allow the flexor tendons
to glide smoothly.
II. Adequate decompression should prevent recurrence of the trigger finger.

I. The patient is placed in a supine position with the operative arm placed on a hand
table.
II. The hand is prepped and draped in standard fashion (see Chapter 1). Once ade-
quately prepped and draped, a marking pen is used to mark the incision.
A. Either transverse or longitudinal incisions can be used depending on the sur-
geon’s preference. Typically, however, longitudinal incisions are used for the
fingers, while a transverse incision is used for the thumb.
B. The proximal edge of the A1 pulley almost always coincides with the distal
palmar crease in the small and ring rays. The proximal palmar crease indicates
the proximal edge of the index ray, while a point half way between the two
creases is indicative for the middle ray. For the thumb, the proximal edge of
the A1 pulley is directly deep to the metacarpophalangeal joint flexion crease
(Figs. 9-4 and 9-5).
III. The arm is exsanguinated (Fig. 9-6), and the tourniquet inflated in standard
fashion (see Chapter 1) prior to starting the case.
Figure 9-4
Incisions marked out for left trigger thumb and ring
trigger finger release.
C H A P T E R 9 Trigger Finger and Trigger Thumb Release 95
Hand
Figure 9-6
Esmarch exsanguination.
Figure 9-5
Incisions with respect to palmar creases. (From
Wolfe SW: Tenosynovitis. In Green DP, Hotchkiss RN,
Pederson WC, Wolfe SW [eds]: Green’s Operative Hand
Surgery, 5th ed. Philadelphia, Churchill Livingstone,
2005.)
Surgical Release of the A1 Pulley FOR A TRIGGER THUMB

I. Anesthetize the skin overlying the incision using lidocaine (local injection). RELEASE, THE SUPERFICIAL
COURSE OF THE RADIAL
II. Make the skin incision using a 15-blade scalpel.
DIGITAL NERVE ACROSS THE
A. Care must be taken to avoid crossing any flexor crease with the incision because
SURGICAL FIELD MAKES IT
this can cause contractures on wound healing. EXTREMELY VULNERABLE TO
B. The incision must remain superficial. A deep incision risks injury to the digital INJURY.
neurovascular bundle.
III. After the skin has been incised, use blunt tenotomy scissors to spread longitudi-
nally directly onto the flexor tendon to expose the flexor sheath. Carefully retract Ask your attending to
the digital neurovascular bundles using small right angle retractors. The proximal discuss the concept of
and distal edge of the A1 pulley should be directly visualized. If the edges cannot tendon bowstringing and
be seen, further blunt dissection is required. the role of the A2 and A4
pulleys in preventing this
IV. Next, incise the A1 pulley directly over the flexor tendon using a 15-blade. Fre-
phenomenon.
quently, there is apparent anatomic continuity between the A1 and A2 pulley, so
care must be taken to avoid incising the A2 pulley, which is vital in preventing
bowstringing. Often, the palmar aponeurosis pulley (a few millimeters proximal Studies have show that as
to the A1 pulley) must also be released. much as 25% of the A2
V. Passively flex the digit or have the patient do it actively to confirm that the pulley can be divided
sheath has been adequately released and that there is no further triggering without detrimental
(Fig. 9-7). effect.
VI. Deflate the tourniquet and achieve meticulous hemostasis by electrocautery.
VII. Close the incision with 5-0 nylon suture using simple or horizontal mattress
knots.
WOUND DRESSING AND POSTOPERATIVE CARE

I. The wound is dressed in standard fashion with a soft dressing.
II. The digits are left free, and early finger motion should be encouraged.
III. Sutures are usually removed 7 to 10 days postoperatively.
A B
Figure 9-7
Close-up (A) and full hand (B) views of flexor tendon after A1 pulley release.
COMPLICATIONS
I. The overall incidence of complications is low.
II. The most common complications are digital nerve transection, A2 pulley injury
with potential bowstringing, recurrence, painful scars, and reflex sympathetic
dystrophy.
SUGGESTED READINGS
Patel MR, Bassini L: Trigger fingers and thumb: When to splint, inject, or operate. J Hand Surg
[Am] 17:110–113, 1992.
Saldana MJ: Trigger digits: Diagnosis and treatment. J Am Acad Orthop Surg 9:246–252, 2001.
Tan V, Daluiski A: Tendon. In Beredjiklian PK, Bozentka DJ (eds): Review of Hand Surgery.
Philadelphia, Saunders, 2004.
Wolfe SW: Tenosynovitis. In Green DP, Hotchkiss RN, Pederson WC, Wolfe SW (eds): Green’s
Operative Hand Surgery, 5th ed. Philadelphia, Churchill Livingstone, 2005.
C H A P T E R
10
Carpal Tunnel Release
Jonas L. Matzon and David J. Bozentka
Hand
Case Study
A 49-year-old female secretary presents to a hand surgeon complaining of numbness in

her right thumb, index, and long fingers, which she has had for several months. She had
similar symptoms when she was pregnant approximately 15 years ago, but they resolved
following the delivery of her child. The symptoms are worse at night and when she is
performing repetitive activities, such as typing. Recently, she has become more concerned
regarding her condition because the symptoms have become constant. She also feels more
clumsy than usual and has been dropping objects with her right hand (Fig. 10-1).
BACKGROUND
I. Carpal tunnel syndrome (CTS), or median nerve compression at the wrist, is the
most common compression neuropathy.
II. The carpal canal is defined by the hamate and triquetrum ulnarly, the scaphoid
and trapezium radially, and the transverse carpal ligament volarly. The canal
contains the median nerve along with nine tendons (four tendons of the flexor
digitorum superficialis, four tendons of the flexor digitorum profundus, and one
tendon of the flexor pollicis longus). The flexor carpi radialis tendon does not lie
within the carpal canal (Fig. 10-2).
III. The median nerve lies just deep to the transverse carpal ligament. Most
commonly, the median nerve gives off the motor recurrent branch radially
and beyond the distal edge of the flexor retinaculum, but many variations exist
(Fig. 10-3).
Figure 10-1
Right hand thenar atrophy.
Palmaris longus tendon

Ulnar artery Flexor retinaculum
Ulnar nerve Median nerve
Flexor carpi radialis tendon
Flexor digitorum
superficialis tendons Flexor pollicis longus tendon
Carpal tunnel Abductor pollicis longus tendon

Flexor digitorum
profundus tendons Extensor pollicis brevis tendon
Extensor carpi ulnaris tendon Cephalic vein

Radial artery
Basilic vein Extensor pollicis longus tendon
Extensor digiti minimi tendon Extensor carpi radialis longus tendon
Extensor carpi radialis brevis tendon
Extensor digitorum tendons
Extensor indicis tendon
Flexor retinaculum
Carpal arch
Carpal tunnel
Figure 10-2
Cross section of wrist demonstrating the carpal tunnel, Guyon’s canal, and their respective contents. (From
Drake RL, Vogl W, Mitchell AWM: Gray’s Anatomy for Students. Philadelphia, Churchill Livingstone, 2005.)
A B C
D E
Figure 10-3
Median nerve variations in the carpal tunnel. A, Extraligamentous; B, subligamentous; C, transligamentous;
D, ulnar take-off of motor branch; E, motor branch lying on top of transverse carpal ligament. (From
Mackinnon SE, Novak CB: Compression neuropathies. In Green DP, Hotchkiss RN, Pederson WC, Wolfe SW [eds]:
Green’s Operative Hand Surgery, 5th ed. Philadelphia, Churchill Livingstone, 2005.)
C H A P T E R 1 0 Carpal Tunnel Release 99
IV. Multiple causes of CTS exist. ACUTE CARPAL TUNNEL

A. Anatomic abnormalities (aberrant muscles, masses) SYNDROME (USUALLY
B. Inflammatory disorders (gout, rheumatoid arthritis, infection) SECONDARY TO FRACTURES
C. Metabolic disease (diabetes mellitus, hypothyroidism) AND FRACTURE DISLOCATIONS
D. Fluid imbalances (hemodialysis, pregnancy) ABOUT THE WRIST) IS
E. Trauma (hematomas, distal radius fractures, lunate dislocations) CONSIDERED A SURGICAL
F. Positional factors (extreme flexion and extension decrease the carpal canal EMERGENCY AND REQUIRES
size) IMMEDIATE DECOMPRESSION.
V. The diagnosis is typically made based on the patient history and physical
Hand
examination. Sensation about the
VI. Classically, carpal tunnel syndrome presents gradually with pain and paresthesias thenar eminence of the
of the palmar aspect of the radial 31/2 digits of the hand. palm should be normal
A. Symptoms are commonly exacerbated by prolonged or repetitive activities because the palmar
involving the wrist and hand, such as driving or typing. cutaneous branch of the
median nerve originates
B. Pain and numbness are often worse at night.
5 cm proximal to the
C. Chronic or severe compression can result in decreased thumb abduction carpal tunnel and does
strength from thenar muscle atrophy and weakness. not travel within the
D. Patients may complain of clumsiness and/or weakness, which is usually second- canal. As a result, the
ary to decreased sensation but can be related to decreased strength. palmar cutaneous branch
VII. Physical Examination is not involved.
A. Sensory function
1. Abnormal two-point discrimination is greater than 7 mm.
Ask your attending to
2. Semmes-Weinstein monofilament and vibration tests are the most
discuss the use of two-
sensitive. point discrimination and
B. Motor function Semmes-Weinstein
1. Assess for thenar atrophy. filament testing for
2. Test abductor pollicis brevis strength. diagnosing carpal tunnel
C. Provocative maneuvers, which rely on reproduction of symptoms in the median syndrome.
distribution
1. Tinel’s sign: percussion over the median nerve at the wrist
The carpal compression
a. Sensitivity: 60%
test is the most sensitive
b. Specificity: 67% and specific test for
2. Phalen’s maneuver: wrist flexion held for 60 seconds diagnosing carpal tunnel
a. Sensitivity: 75% syndrome.
b. Specificity: 47%
3. Carpal canal compression test: direct compression over the volar aspect of
the forearm at the level of the wrist crease for 60 seconds
a. Sensitivity: 87%
b. Specificity: 90%
VIII. The diagnosis as well as severity of CTS can be confirmed by electromyogram/
nerve conduction velocity (EMG/NCV). When does your
A. Distal motor latency greater than 4.0 msec or asymmetry of greater than 1.0 attending order
electromyograms?
msec between hands
B. Distal sensory latency greater than 3.5 msec or asymmetry of 0.5 msec between
hands
C. In severe CTS, fibrillation potentials and positive sharp waves in the thenar
muscles
IX. Differential Diagnosis
A. Cervical spine radiculopathy
B. Diffuse peripheral neuropathy
C. Proximal median nerve neuropathy
D. Ulnar neuropathy
E. Thoracic outlet syndrome
F. Overuse syndromes
TREATMENT ALGORITHM
CTS signs and symptoms:

pain, paresthesias, weakness,
atrophy
Physical examination
and EMG/NCV
Mild/moderate CTS: Severe CTS:

intermittent symptoms weakness, atrophy, or
constant symptoms
Nighttime splinting,
Corticosteroid
activity modification,
injection
NSAIDs
Recurrent or Carpal tunnel

persistent symptoms release
NONOPERATIVE TREATMENT
I. Nonoperative management is the initial mode of treatment in mild to moderate
CTS. It is most successful in patients with intermittent symptoms for less than 10
months and with no motor weakness or thenar atrophy.
II. Oral nonsteroidal anti-inflammatory drugs should be considered to help reduce
synovitis.
III. Medical management of underlying systemic diseases is an important first
step.
IV. Activity modification, ergonometric tips, and nerve gliding exercises can also help
treat symptoms of CTS.
V. Splinting
A. The wrist should be immobilized in the neutral position because this maximizes
canal size and minimizes canal pressure.
B. The splint is typically worn at night and occasionally during the day during
What is your attending’s activities that aggravate the symptoms.
splinting protocol? C. Because the functional position of the wrist is in 30 degrees of extension, some
attending physicians advocate only nighttime splinting.
VI. Corticosteroid injections may be administered into the carpal tunnel.
A. Injections typically result in transient relief in 80% of patients but only 22%
remain symptom-free at 18 months.
B. The injection technique varies per the attending surgeon. In general, a 1 : 1
combination of lidocaine and corticosteroid is injected into the ulnar bursa within
IF PARESTHESIAS ARE
the carpal tunnel using a 25-gauge needle. The injection site is 1 cm proximal
ELICITED, WITHDRAW THE
to the distal wrist flexion crease, ulnar to the palmaris longus tendon, in line with
NEEDLE TO PREVENT
INJECTING DIRECTLY INTO THE
the ring finger, and at a 45-degree angle directed distally (Fig. 10-4).
MEDIAN NERVE. C. Dexamethasone has been recommended because it has been found to have less
deleterious effects if injected directly into the nerve.
OPERATIVE INDICATIONS AND TREATMENT OPTIONS

I. Surgical release is indicated in patients with persistent or progressive symptoms
despite nonoperative management and in patients with a severe neuropathy. A
Figure 10-4
Carpal tunnel injection.
Hand
severe neuropathy manifests as constant symptoms, motor weakness, or thenar
atrophy.
II. Success usually correlates with improved pain and numbness.
III. Postoperative improvement is dependent on severity of the neuropathy. Despite
surgical release, EMG values usually do not return to normal postoperatively and
may take several months.
IV. Operative options include open and endoscopic release.
A. Open surgical release of the carpal tunnel remains the gold standard.
B. Endoscopic release
1. This was introduced to decrease incision size and surgical dissection, result-
ing in less postoperative discomfort, with earlier return of grip strength and
earlier return to work.
2. Decreased visualization makes nerve injury and/or incomplete release more
common.
3. Details regarding endoscopic technique are beyond the scope of this book.
CONTRAINDICATIONS TO CARPAL TUNNEL RELEASE

I. Carpal tunnel release is a relatively safe procedure.
II. Contraindications include active infection or medical comorbidities that prevent
clearance for surgery.
GENERAL PRINCIPLES OF CARPAL TUNNEL RELEASE

I. The goal of carpal tunnel release is to decompress the median nerve as it travels
under the transverse carpal ligament.
II. Be cautious of anatomic variants (e.g., transligamentary recurrent motor branch)
to avoid inadvertent nerve injury.
III. The most common cause for failure of carpal tunnel release is inadequate release.
The release must extend proximally to the level of the antebrachial fascia to ensure
complete decompression of the median nerve.
IV. Hemostasis prior to wound closure is crucial in avoiding hematoma formation and
continued nerve compression.

I. The patient is placed supine on the operating room table with a hand table and
is prepped and draped in standard fashion (see Chapter 1).
II. Once the draping is complete, a sterile marker is used to mark the incision (Fig.
10-5).
A. Incisions may vary per attending surgeon. In general, a straight or slightly
curvilinear incision is drawn ulnar to the thenar crease and palmaris longus
Figure 10-5
Carpal tunnel incision with the proximal mark
indicating the location of palmaris longus.
tendon, in line with the long axis of the ring finger, approximately 2 to 3 cm
in length, and ending distal to the transverse wrist crease.
B. Do not draw your incision beyond Kaplan’s cardinal line to prevent injury to
Have your attending the palmar arch.
explain the significance of III. Exsanguinate the arm and inflate the tourniquet as per the principles outlined in
Kaplan’s cardinal line. Chapter 1.
What landmarks does he
or she use to plan the
surgical incision? Carpal Tunnel Release
I. Anesthetize the skin overlying the incision using a 1:1 mixture of 1% lidocaine
and 0.25% bupivacaine (Marcaine), both without epinephrine.
II. Make the skin incision using a 15-blade scalpel just through the dermis until the
Often, small branches of
the palmar cutaneous
subcutaneous fat is visualized.
branch of the median and III. Minimize any superficial bleeding using bipolar electrocautery.
ulnar nerves are IV. Sometimes, muscle fibers are encountered superficially. These are typically fibers
encountered at this level of the palmaris brevis muscle, which is innervated by a branch of the ulnar
and are protected. nerve.
V. After the skin has been incised, spread down to the palmar fascia using tenotomy
Blunt dissection is taken scissors.
between the palmar fascia VI. Insert a small, self-retaining retractor. The palmar fascia is incised and two small
and transverse carpal right-angle retractors are used to retract the fatty tissue to visualize the flexor
ligament to prevent retinaculum. Further blunt dissection is needed to visualize the distal edge of the
injury to a potential ligament.
transligamentous motor VII. Next, carefully incise the flexor retinaculum from distally to proximally along its
branch of the median ulnar side using a 15-blade.
nerve. VIII. Using tenotomy scissors, release the most proximal portion of the flexor retinacu-
lum and the antebrachial fascia.
AVOID MAKING THE IX. Under direct visualization, confirm that the flexor retinaculum has been com-
RETINACULAR INCISION TOO pletely released. Gently explore the carpal canal to rule out any extrin-
RADIAL TO PROTECT THE sic compression on the median nerve, such as a space-occupying lesion
MEDIAN NERVE AND ITS
(Fig. 10-6).
BRANCHES. AVOID MAKING
X. Achieve meticulous hemostasis using bipolar electrocautery.
THE INCISION TOO ULNAR TO
PROTECT THE CONTENTS OF XI. Close the incision with 5-0 nylon using simple or horizontal mattress knots (Fig.
GUYON’S CANAL (THE ULNAR 10-7).
NERVE AND ARTERY). A SMALL
RIM OF LIGAMENT IS LEFT ON
Wound Dressing and Postoperative Care
THE HOOK OF THE HAMATE TO
LIMIT SUBLUXATION OF THE I. Dress the wound in standard fashion with a soft dressing (Fig. 10-8).
CANAL CONTENTS. II. Leave the digits free and encourage early finger motion.
III. Limit simultaneous wrist and finger flexion to prevent volar subluxation of the
median nerve and flexor tendons.
IV. Suture removal typically occurs 5 to 10 days postoperatively.
Hand
Carpal tunnel after release with median nerve visible. Wound closure.
Figure 10-8
Postoperative dressing.
POSTOPERATIVE REHABILITATION THE RETINACULUM MUST BE

I. Patients are encouraged to increase use of the operative hand as tolerated in the INCISED VERY GENTLY
BECAUSE THE MEDIAN NERVE
postoperative period.
CAN LIE DIRECTLY
II. Patients are sent to formal occupational therapy, if needed, to increase wrist range UNDERNEATH, AND ANY
of motion and improve intrinsic hand and grip strengthening. INADVERTENT DAMAGE TO THE
NERVE CAN HAVE
COMPLICATIONS DEVASTATING CONSEQUENCES
FOR THE PATIENT.
I. The most common complication is incomplete release of the transverse carpal
ligament.
II. Rarely, nerve (median, ulnar) or vascular (superficial arch) injury can occur.
III. Repeat surgical release of the carpal tunnel is generally associated with poor
results.
SUGGESTED READINGS
Cranford CS, Ho JY, Kalainov DM, Hartigan BJ: Carpal tunnel syndrome. J Am Acad Orthop Surg
15:537–548, 2007.
Mackinnon SE, Novak CB: Compression neuropathies. In Green DP, Hotchkiss RN, Pederson
WC, Wolfe SW (eds): Green’s Operative Hand Surgery, 5th ed. Philadelphia, Churchill
Livingstone, 2005.
Ranjan G: Nerve. In Beredjiklian PK, Bozentka DJ (eds): Review of Hand Surgery. Philadelphia,
Saunders, 2004, pp 84–87.
Szabo RM, Steinberg DR: Nerve entrapment syndromes at the wrist. J Am Acad Orthop Surg
2:115–123, 1994.
C H A P T E R
11
Distal Radius Fractures
Jonas L. Matzon and Pedro Beredjiklian
Case Study
A 74-year-old, left hand–dominant retired female presents to the emergency department

with a painful and deformed left wrist. The patient was walking when she tripped over a
curb and fell onto her outstretched left hand. She experienced immediate pain and defor-
mity of her left wrist and was taken directly to the hospital by her husband. On arrival,
she was complaining only of pain in her left wrist. She denied any loss of consciousness.
She is neurovascularly intact and has only minor skin abrasions on her left elbow.
Radiographs taken in the emergency department are shown in Figure 11-1.
BACKGROUND
I. Distal radius fractures represent approximately one sixth of all fractures treated
in the emergency department.
A B
Figure 11-1
Posteroanterior (A) and lateral (B) radiographs demonstrating a left distal radius fracture.
C H A P T E R 1 1 Open Reduction and Internal Fixation of Distal Radius Fractures 105
Hand
Figure 11-2
Frykman classification of distal radius fractures. (From
Fernandez DL, Wolfe SW: Distal radius fractures. In Green
DP, Hotchkiss RN, Pederson WC, Wolfe SW [eds]: Green’s
Operative Hand Surgery, 5th ed. Philadelphia, Churchill
Livingstone, 2005.)
II. There are three peak age distributions for distal radius fractures:
A. Children 5 to 14 years: usually secondary to trauma
B. Males younger than 50 years of age: usually secondary to trauma
C. Females older than 40 years of age: usually insufficiency fractures
III. Risk factors for distal radius fractures in the elderly include female gender,
decreased bone mineral density, early menopause, ethnicity, and heredity.
IV. Fractures are best classified in terms of displacement, angulation, articular involve-
ment, and comminution.
A. Many eponyms have been used to describe specific fracture patterns.
1. Colles’: dorsally angulated extra-articular fracture
2. Smith’s: volarly angulated extra-articular fracture
3. Barton’s: articular shear fracture (dorsal or volar)
4. Chauffeur’s/Hutchinson’s: radial styloid fracture
B. Many classification systems are used to categorize distal radius fractures.
1. Frykman’s, shown in Figure 11-2
2. Melone’s, shown in Table 11-1
Table 11-1 Melone Classification
I Minimally displaced
II Comminuted/stable
Displaced medial complex
Dorsal: die-punch, Barton
III Displaced medial complex as a unit
Displaced radial shaft fragments
IV Wide separation or rotation of medial fragments
Extensive soft tissue and periarticular damage
From Beredjiklian P, Bozentka D (eds): Review of Hand Surgery. Philadelphia, Saunders, 2004.
TREATMENT PROTOCOLS
A. Fracture classification and severity
B. Neurovascular status
C. Condition of soft tissue envelope
D. Associated injuries
II. Initial Treatment
A. Obtain a thorough history, including mechanism, patient age, occupation, and
hand dominance.
B. Perform a detailed physical examination.
1. Visually evaluate the soft tissues around the wrist. Look for abrasions and
determine if the fracture is open or closed.
2. Examine the neurovascular function of the extremity.
a. Assess the vascular status by palpating the radial pulse and checking for
capillary refill.
b. Test anterior interosseous nerve function by asking the patient to flex
the thumb interphalangeal joint.
c. Test posterior interosseous nerve function by asking the patient to extend
the thumb.
d. Test ulnar nerve function by having the patient cross the index and
middle fingers or spread the fingers apart widely against resistance.
e. Check sensation to light touch and two-point discrimination in the radial,
ALWAYS CHECK FOR ulnar, and median nerve distributions.
SNUFFBOX PAIN TO EVALUATE
3. Assess the patient’s ability to contract the extensor pollicis longus muscle.
FOR ASSOCIATED SCAPHOID
4. Evaluate the forearm for possible compartment syndrome.
FRACTURE.
5. Check ipsilateral shoulder, elbow, and carpal bones for associated injuries.
6. Perform a total body trauma assessment, including contralateral upper
extremity, bilateral lower extremities, and spine.
C. Obtain adequate radiographs.
1. Wrist: posteroanterior, lateral, and oblique views
2. Forearm (including elbow): anteroposterior and lateral views
D. Perform fracture reduction (closed).
1. Under sterile conditions, provide anesthesia with 1% lidocaine without
epinephrine via a hematoma block.
2. Hang the arm from finger traps for approximately 5 to 10 minutes.
3. Manipulate the distal fragment into better alignment using traction and
If the fracture is then thumb pressure over the distal fragment.
intra-articular, consider E. Immobilization
obtaining a computed
1. Maintain the reduction while applying a sugar-tong splint with the wrist in
tomography scan to assist
in preoperative planning. neutral position
2. Check postreduction radiographs for adequate length and alignment.
3. Recheck the status of the neurovascular examination following fracture
NEUROLOGIC DETERIORATION
reduction.
OF MEDIAN NERVE FUNCTION
AFTER FRACTURE REDUCTION F. The patient may be discharged home and asked to follow up with a hand
SUGGESTS ACUTE CARPAL surgeon on an outpatient basis.
TUNNEL SYNDROME, WHICH IS III. Nonoperative Treatment
A SURGICAL EMERGENCY. A. Historically, conservative management has been the mainstay of treatment.
REMOVE THE SPLINT AND B. Indications
REASSESS THE NEUROLOGIC 1. Nondisplaced fractures
EXAMINATION. IF THERE IS NO 2. Low-demand elderly patients with significant comorbidities
IMPROVEMENT, PERFORM 3. Stable fractures that meet the following criteria:
ACUTE SURGICAL a. Volar tilt: less than 10-degree change
DECOMPRESSION OF THE
b. Radial inclination: less than 5-degree change
CARPAL TUNNEL IN THE
c. Radial length: less than 2-mm change
OPERATING ROOM.
d. Articular step-off: less than 2 mm
Radial inclination = 22° Radial height = 11mm
Hand
A B
Ulnar variance
Palmar Tilt = 11°

C
Figure 11-3
Normal radiographic parameters, shown in A, B, C,
and D. (From Beredjiklian P, Bozentka D [eds]: Review D
of Hand Surgery. Philadelphia, Saunders, 2004.)
C. A sugar-tong splint should be maintained until swelling has decreased. It is Normal radiographic
then converted to a long-arm cast for 3 weeks, which is finally converted to a parameters: volar tilt = 11
short-arm cast for an additional 3 weeks. degrees, radial inclination
D. Nondisplaced and stable fractures may be treated in a short cast alone. = 22 degrees, radial
E. Close radiographic follow-up is required to monitor alignment and fracture length = 11 mm. These
parameters are used to
displacement. Inadequate reduction may lead to fracture malunion (Fig.
determine the adequacy
11-3). of fracture reduction.
SURGICAL ALTERNATIVES AND INDICATIONS

I. Operative Treatment
A. The goal is anatomic reduction of the distal radius.
B. Surgery is the treatment of choice in unstable or comminuted fractures due to
difficulty maintaining reduction nonoperatively. Operative treatment also
allows for earlier mobilization.
II. Indications
A. Unstable/displaced articular fractures
B. Impacted articular fractures
C. Open fractures
D. Radiocarpal fracture dislocations
E. Failed closed reductions
III. Surgical Options
A. Closed reduction and percutaneous pinning
1. Considered for reducible extra-articular fractures and simple intra-articular
fractures without metaphyseal comminution
Ask your attending to 2. Requires good bone quality, so it is generally reserved for younger
discuss the concept of
patients
ligamentotaxis and how it
applies to the reduction B. External fixation or hybrid fixation: relies on ligamentotaxis to indirectly
of distal radius fractures. control fracture fragments
C. Open reduction and internal fixation (ORIF)
IV. ORIF Approaches
A. Dorsal
1. Advantages
a. Avoids neurovascular structures
b. Dorsal plates to provide buttress against fracture displacement and
collapse
2. Disadvantages
a. Potential for hardware prominence
b. Extensor tendon irritation and potential rupture
B. Volar
1. Advantages
a. Fixed volar plating that transfers the load stress from the articular surface
to the intact radial shaft
Which approach does b. Anatomic reduction of volar cortex that restores radial length, radial
your attending prefer to
inclination, and volar tilt
use and how is the
decision influenced by
2. Disadvantages
specific fracture patterns? a. Increased risk of neurovascular injury
b. Flexor tendon irritation and potential rupture
SURGICAL ALGORITHM
Displaced fractures Undisplaced fractures
Unstable Stable Cast immobilization
Volar Closed
column reduction
disruption
Volar Percutaneous External

plating pinning fixator or
± pinning and/or dorsal volar ⫹ dorsal
plating plating
± Bone graft
From Beredjiklian P, Bozentka D (eds): Review of Hand Surgery. Philadelphia, Saunders, 2004.
GENERAL PRINCIPLES OF DISTAL RADIUS FRACTURE FIXATION

I. The distal radius consists of three independent articular surfaces: scaphoid facet,
lunate facet, and sigmoid notch.
II. The ulnar head articulates with the sigmoid notch and attaches to the triangular
fibrocartilage complex.
III. The goal of operative treatment for distal radius fractures is to restore the articular
surface and the normal anatomic relationships of the distal radius as well as to
regain wrist mobility.
Hand
IV. The distal radius has a radial inclination averaging 22 degrees, a volar tilt averaging
11 degrees, and a radial length averaging 11 mm.
V. The fracture usually occurs due to the force exiting through the metaphyseal bone
of the distal radius (path of least resistance). The approach used depends on the
nature of the fracture.
VI. Because most of these injuries occur in older patients with poor quality bone,
locking plate technology may be required.
VII. Bone grafting is often required if there is severe comminution, poor bone quality,
or significant articular impaction.
VIII. Rigid internal fixation is required to allow for early mobilization and attainment
of wrist range of motion.

I. The patient is placed supine on the operating room table.
II. A hand table is attached to the bed on the appropriate side.
III. A mini-fluoroscope machine is positioned to come in parallel to the hand
table.
IV. The wrist is prepped and draped in standard fashion as outlined in Chapter 1 (Fig.
11-4).
V. Once the extremity is draped, a sterile marker is used to mark the incision.
A. Volar approach: longitudinal incision directly over the distal aspect of the
flexor carpi radialis (Fig. 11-5).
B. Dorsal approach: longitudinal incision centered over the ulnar aspect of
Lister’s tubercle (Fig. 11-6)
VI. The arm is exsanguinated and the tourniquet is inflated prior to starting the case
(see Chapter 1 for details).

Tourniquet placement. Volar incision.
Figure 11-6
Dorsal incision.
Surgical Exposure
I. Volar Approach
A. Make the skin incision using a 15-blade scalpel.
B. Minimize any superficial bleeding using bipolar electrocautery.
C. After the skin has been incised, dissect down to the flexor carpi radialis (FCR)
using blunt tenotomy scissors. Spread longitudinally on the FCR tendon to
avoid injuring the tendon.
D. Develop the interval between the FCR (ulnar) and the radial artery (radial).
AVOID GOING TOO DISTALLY E. Bluntly with right angle retractors, move the flexor pollicis longus and the deep
AND CUTTING THE WRIST flexors ulnarly to visualize the underlying pronator quadratus muscle.
CAPSULE/LIGAMENTS WHEN F. Insert a self-retaining retractor while taking care to protect the radial artery.
MAKING THE L-SHAPED G. With a 15-blade scalpel, make an L-shaped incision in the pronator quadratus
INCISION.
along its radial and distal borders.
H. Use a key elevator to subperiosteally elevate the pronator quadratus muscle
Ask your attending about from the surface of the volar radius.
the advantages of the I. It is now possible to examine the fracture under direct visualization.
specific plates that are II. Dorsal Approach
used to stabilize the distal
A. Make the previously defined skin incision using a 15-blade scalpel.
radius.
B. Minimize any superficial bleeding using the bipolar electrocautery.
C. Elevate small skin flaps, and then insert a self-retaining retractor.
D. Identify the extensor retinaculum (Fig. 11-7) and then incise along the third
dorsal extensor compartment (extensor pollicis longus).
E. Retract the extensor pollicis longus tendon radially and cut down to bone.
F. Subperiosteally using a 15-blade, elevate the deep layer of the dorsal compart-
ments off the radius both radially and ulnarly (Fig. 11-8). Make sure not to
enter the compartments or to visualize the tendons.
Figure 11-7
Superficial dissection with extensor retinaculum Figure 11-8
exposed. Subperiosteal elevation of the dorsal compartments.
G. It is now possible to visualize the fracture directly.

H. Using an instrument such as a rongeur, remove Lister’s tubercle.
Fracture Reduction and Fixation

I. Bring in the mini-fluoroscope machine to visualize the fracture radiographically.
II. Adequately reduce the fracture using standard fracture reduction techniques;
confirm with fluoroscopy image.
III. Place the plate on the distal radius and once again verify its position using
Hand
fluoroscopy (Fig. 11-9).
IV. When adequately positioned, fix the plate to the distal radius with screws.
Wound Closure and Dressing

I. Deep Closure
A. Volar approach. Repair the pronator quadratus with a nonabsorbable braided
suture (e.g., 2-0 Vicryl).
B. Dorsal approach. Repair the extensor retinaculum with a nonabsorbable
braided suture (e.g., 2-0 Vicryl). The extensor pollicis longus should be
transposed subcutaneously to rest above the retinacular repair to prevent
rupture.
II. Typically, close the incision with a smaller gauge monofilament suture (e.g., 5-0
nylon suture) using simple or horizontal mattress knots.
III. Dress the wound in standard fashion (see Chapter 1). A volar wrist splint is applied
with the wrist in 30 degrees of extension. The dressing and splint stays on until
the patient returns for a follow-up visit.
POSTOPERATIVE CARE
I. Typically, patients are admitted to the hospital overnight for pain control.
It is important that they keep the extremity elevated above heart height
to prevent excessive swelling.
II. The patient returns to the office approximately 7 to 10 days postoperatively, and
sutures are removed at that time.
III. Physical therapy and activity depend on the fracture pattern and the stability
achieved after fixation. Usually, after the first follow-up visit, active forearm and
wrist motion is started. A removable thermoplastic wrist splint is used between
therapy sessions.
A B
Figure 11-9
AP (A) and lateral (B) fluoroscopic views of a distal radius fracture following dorsal plate fixation.
IV. At 6 to 8 weeks postoperatively, the patient has usually regained most of his or
her wrist motion.
RESULTS AND COMPLICATIONS

I. Functional outcomes are correlated with comminution and associated carpal bone
injuries.
II. When complications occur after distal radius ORIF, they can be divided into early
and late.
A. Early
1. Median nerve dysfunction
2. Ulnar nerve injury
3. Distal radioulnar joint instability
4. Compartment syndrome
B. Late
1. Post-traumatic arthritis of the radiocarpal joint and/or the distal radioulnar
joint
2. Ulnocarpal abutment syndrome
3. Extensor tendon rupture
4. Malunion
5. Nonunion
6. Chronic regional pain syndrome (also known as reflex sympathetic
dystrophy)
SUGGESTED READINGS
Chou KH, Sarris I, Papadimitriou NG, Sotereanos DG: Fractures of the hand, wrist, and forearm
axis. In Beredjiklian PK, Bozentka DJ (eds): Review of Hand Surgery. Philadelphia, Saunders,
2004, pp 101–126.
Fernandez DL, Wolfe SW: Distal radius fractures. In Green DP, Hotchkiss RN, Pederson WC,
Wolfe SW (eds): Green’s Operative Hand Surgery, 5th ed. Philadelphia, Elsevier, 2005.
Nana AD, Joshi A, Lichtman DM: Plating of the distal radius. J Am Acad Orthop Surg 13:159–171,
2005.
Ruch DS: Fractures of the distal radius and ulna. In Bucholz RW, Heckman JD, Court-Brown (eds):
Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia, Lippincott Williams &
Wilkins, 2006, pp 909–964.
Smith DW, Henry MH: Volar fixed-angle plating of the distal radius. J Am Acad Orthop Surg
13:28–36, 2005.
S E C T I O N
III
SPINE
CHAPTER 12 Anterior Cervical Diskectomy and Fusion 115
CHAPTER 13 Lumbar Microdiskectomy 127
CHAPTER 14 Posterior Lumbar Fusion for Degenerative Spondylolisthesis/Stenosis 136
C H A P T E R
12
Anterior Cervical Diskectomy and
Fusion
William Tally and Scott A. Rushton
Case Study
A 45-year-old woman with a 3-month history of left arm pain radiating into the thumb
presents to clinic. She has had intermittent neck and left shoulder pain for approximately
1 year, which has also been insidiously worsening over the past 3 months. There is no
history of trauma, and she works in an office setting. Currently, she is a nonsmoker, and
her left arm pain is alleviated by placing her arm over her head. Recently she has noted
some difficulty with using her left hand. The pain is worsening with lateral bending of
Spine
her neck or quick rotational motions.
Detailed physical examination reveals decreased cervical range of motion. There is
no evidence of shoulder girdle atrophy, and shoulder range of motion is within normal
limits. Sensory examination reveals slight decrease in light touch and pin prick along the
lateral forearm and thumb on the left. Motor examination demonstrates four fifths left
wrist extensor strength and a decreased brachioradialis reflex. Tandem gait and Romberg
testing are normal; Hoffman’s sign is negative. An initial lateral cervical spine radiograph
and an axial and sagittal magnetic resonance imaging scan are depicted in Figure 12-1.
BACKGROUND
I. Cervical degenerative disk disease (DDD) is highly prevalent in the aging popula-
tion. Changes that occur over time in the intervertebral disks, posterior elements
(e.g., facets joints, ligamentum flavum, spinal canal), and overall alignment of the
cervical spine result in the entity known as cervical spondylosis.
II. The natural history of cervical spondylosis is a slowly progressive stepwise neu-
rologic deterioration with long intervening periods of stable function. With severe
degenerative changes, cervical alignment may also begin to worsen with loss of
the natural cervical spine lordosis.
III. In general, patients with cervical spondylosis are initially treated conservatively
and may present with a wide spectrum of symptoms, ranging from mild to severe.
More severe cases may require surgical intervention to prevent irreversible pro-
gression of disease and functional deterioration.
IV. Anterior cervical diskectomy and fusion (ACDF) is considered the gold standard
for the surgical treatment of cervical spondylosis. The three main pathologies
encountered in candidates for ACDF are DDD with disk herniation, spondylosis,
and myelopathy.
A. DDD, also called a “soft disk” herniation, may result in radiculopathy or radiat-
ing pain down the upper extremity beyond the level of the elbow. This occurs
due to chemical irritation or mechanical compression of a nerve root as it exits
from a foramen. Radiculopathy often responds to physical therapy or transfo-
raminal steroid injections. ACDF can be considered when there is progressive
neurologic deficit due to nerve root compression.
B. Spondylosis or degeneration of a spinal motion segment occurs throughout the
cervical spine. When this degeneration leads to loss of the normal lordosis of
the cervical spine or compromise of the space available for the spinal cord,
surgical intervention may be required.
116 S E C T I O N I I I Spine
A
B
Figure 12-1
A, Lateral cervical spine film showing spondylosis at
C5-C6. Note the disk-osteophyte complex at the
posterior aspect of the vertebral bodies. B, Axial and
C, sagittal T2 magnetic resonance imaging scan
C sequence showing the disk herniation with significant
foraminal encroachment.
C. Myelopathy translates into pathology of the spinal cord. Severe spondylosis

and/or large disk herniations can compromise the cross-sectional area of the
spinal canal, leading to direct compression of the spinal cord. With spinal cord
compression, patients typically present with clinical signs such as gait abnor-
malities (e.g., wide-based gait), hyperreflexia, upper motor neuron signs (e.g.,
positive Hoffman’s sign), and complaints of hand clumsiness (e.g., difficulty
buttoning a shirt).
D. In general, myelopathy is not responsive to conservative measures, and approx-
imately one third of patients progress rapidly, one third progress slowly, and
Hoffman’s sign is elicited one third do not progress. There is no reliable means to predict which category
by flicking the tip of the any given patient will fall. ACDF is the procedure of choice if the compression
long finger while the is anterior and localized to the intervertebral disk space.
patient’s hand is E. The initial evaluation begins with a detailed history. Information regarding the
completely relaxed; a duration of symptoms as well as subjective complaints of upper extremity
positive sign is elicited numbness, tingling, weakness, and difficulty with fine motor skills and gait
when the patient’s
must be obtained. Make sure to document if the patient has any bowel or
thumb flexes at the
bladder dysfunction, either retention or incontinence.
interphalangeal joint.
F. The physical examination should concentrate on observing the patient’s gait,
cervical range of motion, and documenting a thorough upper and lower extrem-
Ask your attending what ity neurologic examination with a focus on muscle strength, sensation, and
additional physical deep tendon reflexes. Upper motor neuron signs such as a Hoffman’s sign may
examination findings are be indicative of spinal cord compression and myelopathy.
indicative of cervical
G. Initial imaging calls for anteroposterior, lateral, and oblique plain radiographs
spondylosis and
of the cervical spine. Radiographs are evaluated for disk height, osteophyte
myelopathy.
formation, foraminal narrowing/stenosis, and anterior or posterior vertebral
C H A P T E R 1 2 Anterior Cervical Diskectomy and Fusion 117
body translation. If there is concern regarding cervical spine instability, flexion

and extension radiographs should be obtained.
H. With a clinical picture of DDD and a high suspicion for disk herniation or
cervical myelopathy, magnetic resonance imaging (MRI) is the study of choice.
The MRI is assessed for disk desiccation, which is indicative of DDD and loss
of disk height, disk herniation, spinal canal compromise, and spinal cord signal
change or myelomalacia.
V. Risk Factors for Disease Progression
A. Genetic factors. These are being identified more and more as the leading risk
for spondylosis and DDD.
B. Cervical spine injury
C. Environmental. The greatest risks are smoking, vibratory activities such as
driving, and heavy lifting.
VI. Nonoperative Treatment
A. A soft disk herniation with radiculopathy is usually self-limited and, if the patient
can tolerate the symptoms, usually completely resolves. Adjunctive physical therapy
often helps relieve muscle spasm and stiffness as well as preventing disuse atrophy.
Cervical collars have no role in this scenario. Transforaminal epidural steroid injec-
Spine
tion is a treatment option that may facilitate this process; however, these injections
are not as innocuous or effective in the cervical spine as in the lumbar region.
B. Although cervical spondylosis is also often successfully treated with time and
physical therapy, it is usually much more resistant to these measures. Again, Ask your attending about
cervical collars play no role, and transforaminal injections are controversial. In the role of conservative
general, they are not usually effective in the short term and rarely is there treatment in the
long-term efficacy. Given their complication rate and lack of good results, most management of cervical
surgeons may not advocate injection therapy prior to surgery. disk disease. At what
C. Myelopathy is somewhat more controversial with respect to conservative care. point does he or she
Some surgeons identify upper motor neuron signs as absolute indications for advocate the use of
surgical intervention. Other surgeons are willing to observe the patient for transforaminal steroid
injections?
signs of progression.
TREATMENT ALGORITHM
Neck pain
History and physical exam
Myelopathy
Axial neck pain Radiculopathy
neurologic deficit
AP and AP and
lateral cervical lateral cervical
AP and lateral cervical radiographs radiographs radiographs
MRI and MRI and
flexion/extension flexion/extension
radiographs radiographs
Degenerative disk disease

without canal or foraminal Positive for disk herniation
stenosis
Negative for disk herniation spinal cord signal
foraminal stenosis Change/cord compression
Observation, NSAIDs,
physical therapy Observation, NSAIDs,
physical therapy, Candidate for ACDF
epidural steroid injections
ALTERNATIVES, INDICATIONS, AND CONTRAINDICATIONS
I. Surgical Alternatives to ACDF. There are several surgical alternatives to ACDF

that exist for treating the spectrum of cervical disc disease. The description of each
of these options is beyond the scope of this text. The list below depicts the most
common alternatives but is not meant to be an exhaustive list.
A. Anterior diskectomy
B. Posterior foraminotomy and microdiskectomy
C. Anterior uncinectomy and foraminotomy
Ask your attending for D. Anterior corpectomy and fusion
which patient scenarios
E. Posterior laminectomy and fusion
the surgical alternatives
F. Laminoplasty
listed are typically used.
G. Total disk arthroplasty
II. Surgical Indications for ACDF
A. Failed conservative treatment for at least 6 weeks
B. Large herniated nucleus pulposus
C. Persistent radicular symptoms
D. Disabling motor weakness (e.g., wrist drop)
E. Progressive neurologic deficit
F. Static neurologic deficit with associated radiculopathy or retractable pain
G. Cervical spine instability
H. MRI changes in spinal cord signal (myelomalacia)
I. Space available for the cord (small cross-sectional area)
III. Contraindications to ACDF
A. Current infection
B. Systemic infection
C. Cervical kyphotic deformity (requires additional posterior stabilization)
Ask your attending if D. Three or more cervical levels involved
there are additional E. Inflammatory arthritis (may require additional posterior stabilization)
patient scenarios that F. Instability (may require additional posterior stabilization)
should be considered as
G. Axial neck pain with no radiculopathy
contraindications for
H. Medical comorbidities (patient unable to safely tolerate stress of surgery)
anterior cervical
diskectomy and fusion. I. Carotid stenosis (severe atherosclerotic disease)
J. Patients that smoke (relative contraindication)
GENERAL PRINCIPLES OF ANTERIOR CERVICAL DISKECTOMY AND FUSION

I. The major goals of ACDF are as follows:
A. Decompression of neural elements (spinal cord or nerve roots)
B. Protection of the neural elements from injury and further deterioration
C. Restoration of cervical lordosis (restore sagittal balance of the cervical spine)
D. Alleviation of radicular symptoms
E. Alleviation of axial neck pain (contraindications to surgery if present without
radiculopathy)
II. Adjacent level disease may be present at the time of office evaluation. In some
situations, it may be prudent to address advanced degeneration at asymp-tomatic
levels at the time of the index procedure. The patient should be counseled that
this may result in pain postoperatively because these levels were previously
asymptomatic.
III. The anterior surgical approach to the cervical spine is typically performed on the
left side of the patient. The recurrent laryngeal nerve lies in the tracheoesophageal
groove in a more predictable fashion on the left side.
IV. The superior and inferior end plates must be exposed to subchondral bone
while maintaining a parallel relationship in both coronal and sagittal planes.
Graft choices are autograft or allograft fibula or iliac crest, metallic cages, and
bone substitutes such as poly-ethyl-ethyl-ketone (PEEK) spacers. Finally, correct
graft sizing is critical to avoid kyphosis if undersized and overdistraction if too

large. Overdistraction anteriorly puts significant stress on the posterior structures
and usually results in facet joint pain.
V. All posterior osteophytes must be resected to accomplish central decompression.
This may require removal of the posterior longitudinal ligament depending on
the extent of the pathology.
VI. Anterior plating is almost routinely done during ACDF for graft stabilization.
There are several plate options available. Statically locked plates have a mechanism
in which the screw and plate act as a fixed angle device. This is a very rigid con-
struct and allows minimal motion across the operative site. Regardless of the plate
chosen, it is imperative that there is no impingement into the adjacent disk spaces
as this will lead to rapid adjacent level degeneration.
VII. Intraoperative neuromonitoring is routinely done in most institutions when
performing an ACDF. Baseline signals should be obtained during prepositioning
and verified after each episode of patient manipulation. Currently the standard
neuromonitoring modalities include free-run electromyography (EMG), transcu-
taneous motor evoked potential (tcMEP), and somatosensory evoked potential
(SSEP).
Spine
VIII. Free-run EMG monitors muscle belly electrical activity in a continuous mode.
This is an extremely sensitive modality that gives feedback on nerve irritation and
stimulation during the procedure. It is critical to keep in mind that this modality
is motor only and gives information regarding a nerve that is actively being
injured. An acutely transected nerve does not result in EMG changes in the short
term and thus such an injury cannot be reliably documented by this test alone.
IX. tcMEP is an evocative test in which the patient’s motor cortex is electrically
stimulated by scalp electrodes and the resulting muscle-evoked EMG is recorded.
The amplitude and wave forms are analyzed against baseline and changes
reported to the surgeon. This modality is an extremely sensitive marker for spinal
cord injury; however, it is not very specific and is fraught with false-positive
results.
X. SSEP monitors the posterior aspect of the spinal cord. This modality involves
direct stimulation of a peripheral nerve while monitoring sensory cortex response
via scalp electrodes. This modality has been found to be both sensitive and specific
for clinically identifiable neurologic injury.
XI. The three modalities in concert are used to provide information on nerve
root injury (EMG) and spinal cord function (tcMEP with SSEP). If neurologic
monitoring detects a change in root or cord function during the case, the
initial step is to reverse the maneuver previously accomplished. Additionally, Ask your attending what
steroid protocol is used in
the mean arterial pressure should be elevated to greater than 90 mm Hg. If the
the event of an acute
attending surgeon and the neurophysiologist believe that the neurologic change
spinal cord injury in the
represents a real injury to the cord, an intravenous steroid protocol should be operating room.
initiated.

I. The patient is placed in the supine position on a radiolucent table.
II. A towel roll or inflatable A-line bag is placed perpendicularly under the shoulders.
The roll and headboard should be adjusted to place the neck in slight extension.
III. The upper extremities are tucked and wrapped at the sides. Ensure that there is
adequate ulnar nerve padding and that the forearms are in neutral supination/pro-
nation (Fig. 12-2).
IV. Four-inch silk tape should be stretched from the lateral deltoids down to the foot
of the bed. Adequate tension should hold the shoulders in the anatomically
depressed position. Attempting to obtain more depression by increasing tension
A B
Figure 12-2
Pictures of patient positioned showing (A) extension and (B) patient tucked and taped.
only increases the risk to the brachial plexus while accomplishing little in the way
of better exposure.
V. The anterior neck and the iliac crest is prepped and draped in standard fashion
Surgical Approach
I. Mark out the skin incision with a sterile marker prior to starting. The side of
approach should be discussed with the attending surgeon. The incision should
cross midline for 2 to 3 mm and extend approximately 4 cm laterally following
Langer’s lines (Fig. 12-3).
II. Typically, a local anesthetic with epinephrine is injected along the length
of the incision. This step helps with postoperative pain control while also decreas-
ing skin and subcuticular bleeding, which can be considerable in the neck.
III. Sharply incise the skin with a 15-blade. Continue with sharp dissection through
the subcutaneous fat layer until the platysma muscle is visible (Fig. 12-4).
IV. Next, develop the plane between the platysma and the overlying fat using blunt
dissection. It is important to maintain hemostasis during every step.
V. Sharply incise the platysma in line with the skin incision. Repeat the sweeping
dissection using a Ray-Tec sponge and fingertip to develop the plane between the
platysma and the underlying superficial cervical fascia.
VI. Identify the interval between the sternocleidomastoid (SCM) muscle laterally and
sternohyoid muscle medially. The anterior jugular vein usually lies in the depres-
sion. If the vein is small, it can be ligated; if it is large, it should be mobilized lat-
erally with the SCM muscle. The SCM muscle is invested by the superficial
Figure 12-3
The neck with levels drawn over anatomic
landmarks. The patient’s head is oriented to the
right.
Spine
A B
Figure 12-4
A, Superficial dissection through skin and subcutaneous tissue. B, The platysma is identified as the next layer.
cervical fascia. Dissection into deeper layers of the fascia allows for deeper access
as well as superior/inferior extensile exposure.
VII. Using toothed forceps and Mayo scissors, lift the fascia anteriorly and begin to
bluntly dissect. As the fascia becomes thinner, coagulate any small vessels that are
identified. This is an extremely vascular area, so all dissection should be accom-
plished by spreading, not cutting. Once the fascia is penetrated, SCM muscle fibers
should be identified laterally while the thicker fascial aponeurosis is visible medi-
ally. At this point, attention should be focused on extending the fascial release
superiorly and inferiorly.
VIII. Once thorough release of the superficial cervical fascia is complete, the
pretracheal fascia is encountered. This fascia surrounds the trachea and thyroid
and does not need to be entered. During this mobilization, the goal is to develop The three fascial layers
the potential space between the pretracheal fascia medially and the carotid sheath encountered in the
laterally. By palpating the carotid pulse, and keeping these structures lateral, there anterior cervical spine
are no worrisome structures in the plane of dissection. approach are the
superficial cervical fascia,
IX. The posterior margin of this potential space is defined by the alar fascia, which is
pretracheal fascia, and the
intimate with the prevertebral fascia. Bluntly dissect down to this level while being
prevertebral fascia.
mindful of the location of the carotid sheath.
X. At this point, appendiceal retractors are placed over the SCM and carotid sheath
laterally. A second appendiceal retractor is placed medially to retract the larynx,
esophagus, and sternohyoid muscle medially. BE CAUTIOUS WITH
XI. The anterior spine with its overlying longus colli muscles is now visible (Fig. 12- DISSECTION AROUND THE
5). Identify the disk space of interest, which appears whiter than the vertebral LONGUS COLLI MUSCLE DUE
bodies. Additionally, the disk bulges upward, and the bodies are recessed. Place a TO THE POTENTIAL FOR
localizing spinal needle into the disk space, remove the retractors, and obtain a INJURY TO THE SYMPATHETIC
lateral fluoroscopic image. At the C6-C7 and C7-T1 levels, it may be necessary CHAIN AND VERTEBRAL
to mark a higher level due to the interference of the shoulders with obtaining a ARTERY. INJURY TO THE
clear radiograph (Fig. 12-6). SYMPATHETIC CHAIN MAY
XII. Once the level is confirmed, reinsert the appendiceal retractors and mark the disk LEAD TO HORNER’S
SYNDROME, WHICH IS A
space with Bovie cautery. Mobilize the longus muscles off the spine from the
CONSTELLATION OF PTOSIS,
midbody above to the midbody below the level staying subperiosteal dissection. MIOSIS, AND ANHIDROSIS.
Care should be taken to stay below the muscle to avoid injury to the cervical
Figure 12-5
Exposed spine with a spinal needle in place within
the desired disk level.
Figure 12-6
Marker film demonstrating the spinal needle in the
C4-C5 disk space.
sympathetics. Additionally, mobilization should only proceed laterally to the

margins of the vertebral body to avoid injury to the vertebral artery.
Diskectomy and Graft Placement

I. Place a retractor with the smooth blade under the longus colli on the esophageal
side and a toothed blade under the longus colli on the carotid side. Assemble the
retractor, remove the appendiceals, and open the retractor. Ensure the blades stay
below the longus muscles at all times during the procedure.
II. Insert 14-mm Caspar pins into the waist of the superior and inferior vertebral
bodies surrounding the disk of interest. Apply the grasshopper self-retaining
retractor over the pins and open it until it is snug and then open two more clicks.
Inform the neurophysiologist that the spine is distracted and motor testing should
be checked (Fig. 12-7).
III. Ask the anesthesiologist to deflate and repressurize the endotracheal tube
cuff. With the retractors in place, it has been shown that tracheal endothelial
pressures reach critical levels and that by repressuring the cuff, this risk is
minimized.
Figure 12-7
Retractors in position.
IV. Using a 15-blade on a long handle, incise along the superior and inferior end plate
margins and vertically at the uncovertebral joints within the disk space. Always
use the blade in a lateral to medial direction to minimize risk to surrounding
structures.
V. Using a pituitary rongeur, remove as much disk material as is easily grasped
through the defect created in the annulus fibrosus.
VI. The remaining disk and cartilaginous end plates are then mobilized using a 3-0
curette along the subchondral end plates. Continue until the bulk of the disk
material is removed.
VII. In most cases, there is an overhanging osteophyte from the inferior lip of the
superior endplate that interferes with clear visualization and access to the posterior
disk space. Using a 2-mm Kerrison rongeur, resect this osteophyte back parallel
to the endplate. Care should be taken not to violate the end plate during this
maneuver (Fig. 12-8).
VIII. Once good visualization is obtained, remove any remaining disk until the posterior
annulus and/or posterior osteophyte is reached.
IX. Using a curved 3-0 curette, work in a posterior to anterior and lateral to medial
direction to completely expose clean subchondral bone along the entire slope of
Spine
the joints.
X. Use a 5-mm acorn or round cutting burr to remove any posterior osteophytes.
This allows for good surface contact for the graft (Fig. 12-9).
XI. Once the osteophyte has been thinned and the posterior longitudinal
ligament is visible along the entire width of the disk space, remove the remaining
osteophytes.
XII. Care should always be taken not to plunge posteriorly as the spinal cord is in
intimate contact with the underlying posterior longitudinal ligament. By inserting
the tip of the Kerrison rongeur parallel to the end plate and rotating the tip
underneath the vertebral margin, a cleaner amputation of the posterior annulus
and osteophyte is possible.
XIII. The central decompression is completed when a micronerve hook passes freely
from lateral margin across to the contralateral margin under both the superior
and inferior end plates.
XIV. At this time, attention should be directed toward the foramen on the symptomatic
side. It is preferable to delay the foraminotomy until last because a dense vascular Ask your attending how
and when he or she
cuff surrounds the shoulder of the exiting nerve root and it is quite easy to injure
prefers to perform a
this microvascular structure, causing significant bleeding. foraminotomy.
XV. After thorough bony decompression, repeat palpation out along the nerve to
ensure that there is no retained disk material along the nerve and that all osteo-
phytic compression has been relieved. As you work further out along the nerve,
keep in mind that the vertebral artery runs vertically just lateral to the exit of the
foramen proper (Fig. 12-10). Therefore, the tip of the Kerrison rongeur must not

Partially removed overhanging osteophyte. Pre and post posterior osteophyte resection.
Figure 12-11
Graft recessed.
Figure 12-10
Depiction of artery and nerve anatomy.
Does your attending penetrate out the bony margin of the foramen, or vertebral artery injury is
prefer autograft or possible.
allograft? Are there any XVI. Trial spacers are available in various size intervals generally ranging from 5
patients that should up to 10 mm. The spacer is inserted using light taps with a mallet until the fit is
receive autograft (e.g., snug, not tight. Once the size is chosen, autograft is harvested from the iliac
smokers)? What crest.
technique does your XVII. Insert the graft with the same force as the spacer. If more effort is required, stop
attending physician prefer and recheck the sizing. Insertion is not complete until the anterior margin of the
for harvesting autograft? graft is countersunk below the anterior vertebral body (Fig. 12-11).
XVIII. Relax the Caspar pin distractor and ask the neurophysiologist to recheck motor
signals. If there are any changes in the patient’s neurologic status, remove the graft
and re-evaluate the situation.
Plating/Stabilization
I. Remove the Caspar pins and distractor and back-fill the pin holes with bone
wax.
II. Next, plane down any anterior osteophytes that prevent the plate from
lying flat against the vertebral bodies. Remember that the esophagus is intimate
with the plate and that any excessive anterior prominence will result in
dysphagia.
III. Size the plate such that the screw holes are minimally covering the vertebral body
above and below. Care should be taken to ensure that the plate does not override
the margins of the adjacent disk spaces because this impingement leads to rapid
adjacent level degeneration.
IV. Have an assistant hold the plate steady while you insert the screws. In some
systems, pilot holes are necessary, whereas in others, the screws are self-
drilling. In general, 14-mm screws are used, but different-sized screws may be
necessary depending on patient anatomy. The screws should be angled slightly
convergent toward, but not crossing, the midline. In addition, the superior screws
are angled slightly upward, whereas the inferior screws are angled slightly down-
ward (Fig. 12-12).
A C
Spine
B
Figure 12-12
A, Anterior cervical plate. B, Spine model demonstrating proper placement of an anterior cervical plate.
C, Intraoperative view of plate placement. D, Postoperative lateral radiograph of an anterior cervical plate in
proper position.
V. Re-evaluate the plate position with respect to the midline, superior, and inferior
vertebral bodies. Secure all four screws if the position is adequate. Take a final
fluoroscopic image and have the neurophysiologist obtain a final motor test.
Wound Closure
I. Ensure that all retractors are removed from the wound and that the wound is
irrigated.
II. Make sure to achieve hemostasis prior to closing the wound. Most surgeons insert
a Penrose or a small Jackson Pratt drain to minimize postoperative hematoma
formation.
III. There is no distinct fascial layer that requires reapproximation. Close the subcu-
taneous layer and skin in a standard fashion, using a subcuticular closure for the
skin (see Chapter 1 for details; Fig. 12-13).
POSTOPERATIVE CARE Ask your attending how

long the hard collar
I. Most patients are placed in a hard Philadelphia or Miami J collar prior to extuba- should stay in place.
tion. Following extubation, it is imperative that a detailed upper and lower extrem-
Figure 12-13
Healed anterior cervical wound.
ity neurologic examination be performed and documented in the patient’s

chart.
II. The patient is placed on appropriate postoperative antibiotics for 24 hours.
III. Deep venous thrombosis is rare, and sequential compression boots should be used
while in bed. Pharmacologic anticoagulation is contraindicated following spine
surgery due to the risk of an epidural hematoma.
IV. A liquid diet should be ordered for the next meal, and it can be advanced to house
if the patient can tolerate swallowing. It is not uncommon for a mechanical soft
diet to be needed for one or two meals postoperatively due to transient
dysphagia.
COMPLICATIONS
I. Transient dysphagia is the most common complication and almost always resolves
completely.
II. Dysphonia is a less common complication that also usually resolves, but not as
quickly. In most cases, improvement is noted prior to hospital discharge. However,
if the patient is still dysphonic at follow-up, a laryngoscopy is indicated to ascertain
vocal cord paresis versus paralysis.
III. Postoperative hematoma is a rare but life-threatening complication. The evolution
is usually slow, with the patient complaining of difficulty swallowing that is not
improving and possibly worsening. This is followed by difficulty breathing. Unfor-
tunately, there is often a rapid progression from difficulty breathing to airway
compromise, so quick recognition and treatment is paramount. The airway should
be protected by intubation on the floor followed by hematoma evacuation in the
operating room. If intubation is not possible, it may be necessary to open the
wound at bedside to relieve the pressure and allow intubation.
IV. Infection is a rare complication, but it can occur. Any infection is from an esopha-
geal injury until proven otherwise. A swallowing study is indicated to evaluate for
leaks.
V. Any neurological change in the postoperative period warrants repeat plain radio-
graphs and an MRI.
SUGGESTED READINGS
Albert TJ, Murrell S: Surgical management of cervical radiculopathy. J Am Acad Orthop Surg
7:368–376, 1999.
Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg
9:376–388, 2001.
Rhee JM, Riew KD: Cervical spondylotic myelopathy: Including ossification of the posterior lon-
gitudinal ligament. In Orthopaedic Knowledge Update 3. Rosemont, IL, American Academy
of Orthopaedic Surgeons, 2006, pp 235–251.
C H A P T E R
13
Lumbar Microdiskectomy 1
Derek J. Donegan and Kingsley R. Chin
Case Study
A 44-year-old male presents to the clinic with an 8-week history of low back and left
lateral leg pain. He complains of subjective leg weakness and numbness over the lateral
malleolus, the lateral aspect of the foot, and the web space between his fourth and fifth
toes. On presentation, his back pain has nearly resolved, and his weakness has markedly
Spine
improved. His pain continues to be aggravated by activity and alleviated by rest. He
describes the pain as a nagging, aching, and burning sensation with radiation from the left
buttock to the outside part of the ankle and extending to the outside aspect of the left
foot. He has participated in a low back stabilization program with physical therapy, taken
nonsteroidal anti-inflammatory drugs daily, and received three epidural steroid injections.
Axial and sagittal magnetic resonance imaging scans are presented in Figure 13-1.
BACKGROUND
I. Lumbar disk herniations are typically a result of a herniated disk fragment from
the nucleus pulposus of the disk. In normal conditions, this nucleus is in the disk
center secured by the surrounding annulus fibrosis. When this fragment of nucleus
herniates, it irritates and/or compresses the adjacent nerve root and incites an
inflammatory reaction. The inflammatory mediators and the mechanical compres- Radiculopathy refers to
sion lead to pain, weakness, and paresthesias along the dermatomal distribution the group of compressive
of the involved nerve root and can be characterized by the term radiculopathy. This symptoms occurring in a
radicular pain syndrome in the distribution of the L4-S3 is also known as specific dermatomal
distribution.
sciatica.
A B
Figure 13-1
Axial (A) and sagittal (B) magnetic resonance imaging scan, of a L5-S1 herniated disk.

TABLE 13-1 Motor and Sensory Components of Posterolateral Disk Herniations
Disk Herniation Nerve Root Sensory Deficit Motor Deficit Reflex Changed
L3-L4 L4 Posterolateral thigh, Quadriceps Decreased patellar
anterior knee, and Hip adductors tendon and tibialis
medial leg anterior tendon
L4-L5 L5 Anterolateral leg, dorsum Gluteus medius Decreased tibialis
of foot, and great toe EHL posterior tendon
EDL/EDB
L5-S1 S1 Lateral malleolus, lateral Gluteus maximus, Decreased Achilles
foot, heel, and web of peroneus longus and tendon
fourth and fifth toes brevis,
gastrocnemius-soleus
complex
EDB, extensor digitorum brevis; EDL, extensor digitorum longus; EHL, extensor hallucis longus.
II. Most people experience back pain during their lifetime, but approximately 5% of
males and 2.5% of females experience actual lumbar radiculopathy as a conse-
quence of nerve root compression or irritation.
III. The typical history of lumbar disk herniation is of repetitive lower back and
buttock pain that is relieved by rest. This pain is suddenly exacerbated by a flexion
episode, with the sudden appearance of leg pain being much greater than back
pain. Most radicular pain from nerve root compression caused by a herniated
nucleus pulposus is evident by leg pain equal to or greater than the degree of back
Lumbar disk herniation is
pain. The pain is usually intermittent and is exacerbated by activity, especially
characterized by leg pain
greater than or equal to sitting, straining, sneezing, or coughing, and is relieved by rest. Other symptoms
back pain. include weakness and paresthesias along the same myotome and dermatome,
respectively.
IV. Physical examination findings in patients with lumbar disk herniations are char-
acteristic to the level of disk herniation and nerve root involvement. A postero-
lateral disk herniation at the L4-L5 level typically causes impingement of the
traversing nerve root, L5. Far lateral (foraminal or extraforaminal) disk herniations
typically impinge on the exiting nerve root, L4. The patient may have a positive
straight leg raise with hip flexion, keeping the knee extended. Patients may also
exhibit objective weakness and paresthesias in the distribution of the involved
nerve root. Table 13-1 summarizes the main motor and sensory components
involved with posterolateral disk herniations at common lumbar disk levels.
Magnetic resonance V. More than 95% of the ruptures of the lumbar intervertebral disks occur at the
imaging is the imaging
L4-L5 level.
modality of choice for the
diagnosis of a herniated
VI. When a herniated disk is suspected based on history and physical examination,
disk. magnetic resonance imaging is the imaging modality of choice for diagnosis. Plain
lumbar radiographs have little utility.
VII. Herniated disks can be either contained or noncontained.
A. A contained disk herniation occurs when the disk material herniates through
the inner annulus but not the outer annulus. The disk material, although con-
tained, can still distort the path of the nerve.
B. A noncontained disk herniation occurs when the disk material penetrates both
the inner and outer layers of the annulus. The material can therefore reside
beneath the posterior longitudinal ligament, can penetrate through it, or can
be sequestered as a free fragment.
VIII. Cauda equina syndrome consists of the combination of saddle anesthesia, bilateral
ankle areflexia, loss of rectal tone, bilateral lower extremity weakness, and possible
bowel and bladder dysfunction with retention or incontinence. Cauda equina can
CAUDA EQUINA SYNDROME IS
be caused by massive extrusion of a disk involving the entire diameter of the
A SURGICAL EMERGENCY.
lumbar canal and is considered a surgical emergency.
C H A P T E R 1 3 Lumbar Microdiskectomy 129
IX. The main goal of lumbar microdiskectomy is symptomatic relief of leg pain. Back
pain is often not relieved and is not an indication for microdiskectomy.
TREATMENT ALGORITHM
Low back pain with lumbar radiculopathy
Imaging of lumbar spine:

• AP/lateral/oblique radiographs
• MRI
• CT scan (not routine)
• Myelography (not routine)
Diagnosis of herniated lumbar disk
Spine
Conservative management Failed a minimum of 6–8 weeks of
conservative management
• Rest
• Body mechanics/posture
education Alternatives to lumbar Lumbar
• Medications: NSAIDs, oral microdiskectomy microdiskectomy
steroids, muscle relaxants,
TCAs
• Physical therapy
• Epidural steroid injections • Percutaneous diskectomy
• Endoscopic diskectomy
• Chemonucleolysis
• Laparoscopic diskectomy
• Stereotactic lumbar
microdiskectomy
NONOPERATIVE TREATMENT OPTIONS

I. Rest
A. Two days of rest have been shown to be better than longer periods in returning
to work.
B. Lying in the semi-Fowler position (lying with a pillow between both legs while
flexing both the hips and knees) should relieve most of the pressure on the disk
and nerve roots.
C. As pain diminishes, the patient should be encouraged to begin nonstrenuous
activities.
II. Education in Proper Posture and Body Mechanics
A. “Back school” is a class regarding proper back ergonomics.
B. This class is beneficial in decreasing the amount of time lost from work with
acute exacerbations, but does little to decrease the incidence of recurrence of
symptoms.
III. Medications
A. Narcotics and muscle relaxants can help with the pain and paraspinal muscle
spasms. However, these should be prescribed with caution, especially in the
instances of chronic back and leg pain where drug addiction and increased
depression are frequent.
B. An oral steroid (methylprednisone—“steroid dose pack”) taper may be pre-
scribed acutely as a potent anti-inflammatory agent.
C. Nonsteroidal anti-inflammatory drugs are often a good adjunct to the conser-

vative treatment approach.
D. Tricyclic antidepressant agents such as amitriptyline may be beneficial in
reducing sleep disturbances and anxiety as well as providing pain relief without
the need for narcotics.
IV. Physical Therapy
A. Exercises should be fitted for the individual symptoms and not forced as an
absolute group of activities.
B. Patients whose pain is eased from passive extension can benefit from passive
extension exercises rather than passive flexion, whereas patients whose pain is
eased with passive flexion can benefit from passive flexion exercises rather than
passive extension.
C. All exercises that exacerbate painful symptoms should be avoided.
D. Exercises should focus on strengthening the abdominal and lumbar paraspinal
muscles and stretching the hamstrings. These modalities allow load transfer
from the spinal column and intervertebral disks to the surrounding supporting
structures.
E. The benefit of most physical therapy programs lies in the promotion of good
At which point in his or posture and body mechanics.
her treatment algorithm V. Epidural Steroid Injections
does your attending send A. Injecting the combination of a long-acting steroid with an epidural anesthetic
patients for epidural such as methylprednisone and lidocaine, bupivacaine, or procaine into the
injections? How epidural space of the affected nerve root may provide pain relief for up to
successful have epidural several months.
injections been in his or B. Most studies show a 60% to 85% short-term success rate but injections are
her practice? most effective within 6 weeks of symptom onset.
C. Better results are found in patients with subacute or chronic leg pain with no
prior surgery.
D. Epidural steroid injections tend to offer prolonged pain relief without excessive
narcotic use.
E. The complication rate is approximately 5% and consists of failure to inject
into the epidural space, intrathecal injections with inadvertent spinal anesthe-
sia, transient hypotension, difficulties voiding, severe paresthesias, cardiac
angina, headache, retinal hemorrhage, facial flushing, generalized erythema,
and bacterial meningitis.
F. Contraindications include presence of current infection, neurological disease,
hemorrhagic of bleeding diathesis, cauda equina syndrome, and a rapidly pro-
gressing neurologic deficit.
G. Typical protocols involve a series of three injections each at 7- to 10-day
intervals.
Ask your attending about SURGICAL ALTERNATIVES TO LUMBAR MICRODISKECTOMY

alternatives to I. Percutaneous Diskectomy
microdiskectomy.
A. Automated percutaneous diskectomy
1. Through an incision 8 to 12 cm from the midline, an automated percutane-
ous diskectomy device is placed through a cannula inserted in the center of
the symptomatic disk under fluoroscopic guidance and uses suction and
cutting to remove the appropriate disk material.
2. Indications are similar to those for a lumbar microdiskectomy (discussed
later).
3. Contraindications include lumbar stenosis, lateral recess stenosis, or syno-
vial joint cysts.
B. Percutaneous laser diskectomy
1. This technique is identical to the automated percutaneous diskectomy tech-
nique. Once there is access to the disk space, a laser is used to remove the
appropriate disk material.
2. Indications are similar to those for lumbar microdiskectomy (discussed later).

3. Contraindications include previous history of lumbar surgery, lumbar ste-
nosis, facet hypertrophy, and a free disk fragment.
II. Percutaneous Endoscopic Diskectomy
A. This technique is similar to the automated percutaneous diskectomy technique.
However, direct visualization is obtained with the use of an angled rigid endo-
scope, and the disk can be removed using forceps.
B. Indications are similar to those for lumbar microdiskectomy and include con-
tained or small noncontained disk herniations.
C. Contraindications include severe motor deficits, rapidly progressive neurologic
deficits, cauda equina, segmental instability, previous history of lumbar surgery,
large noncontained disk herniations, sequestered disks, spinal stenosis, spon-
dylolisthesis, tumors, and post-traumatic root compression.
III. Lumbar Chymopapain Chemonucleolysis
A. This procedure is typically performed under local anesthesia and sedation with
the patient in the prone or lateral decubitus position. An 18-gauge needle is
inserted 8 to 11 cm from the midline and directed toward the affected disk
space. Needle placement is confirmed with the use of fluoroscopy. Once the
Spine
needle position is confirmed, chymopapain is injected over approximately a 4-
minute period.
B. Indications are similar to those for microdiskectomy and include contained and
noncontained disk herniations.
C. Contraindications include an allergy to papain or papaya, cauda equina syn-
drome, disk migration, central or lateral recess stenosis, severe spondylolisthe-
sis, history of diskitis, peripheral neuropathy, pregnancy, and previous
diskectomy at the same level.
IV. Laparoscopic Diskectomy
A. The procedure is performed by either a transperitoneal approach or a retro-
peritoneal approach. Each type involves the use of laparoscopic ports that are
used to insert instruments and visualizes the affected disk space. Once the disk
space is visualized, the disk is removed under direct visualization.
B. Transperitoneal laparoscopy is performed with the patient in the supine posi-
tion, and the retroperitoneal approach is performed with the patient in the
lateral decubitus position.
C. Indications are similar to those for microdiskectomy and include leg pain
greater than back pain, radicular signs and symptoms, and 6 weeks of failed
conservative management,
D. Contraindications include disk fragments that have completely migrated below
the level of the disk space.
V. Stereotactic Lumbar Microdiskectomy
A. This procedure is typically performed with the patient in the prone position
on a computed tomography scan table under local anesthesia and sedation. The
stereotactic system is used with computed tomography guidance to mark the
target and entry points. Once confirmed, a trocar is placed along the target
path. The position of the trocar tip is confirmed via computed tomography
imaging and the procedure continues with the use of a nucleotome to aspirate
the appropriate disk material.
B. Indications are similar to those for microdiskectomy and include radicular signs
and symptoms with corresponding imaging, as well as symptoms of diskogenic
back pain without significant radicular symptoms.
C. Contraindications include spondylosis, spondylolisthesis, spinal stenosis, and
marked facet hypertrophy.
SURGICAL INDICATIONS FOR LUMBAR MICRODISKECTOMY

I. Indications for surgical treatment are not clearly delineated, because long-term
results greater than 2 years between nonoperative and operative treatment are
equivalent with surgery being more favorable for short-term outcomes. Therefore,
Patients must fail
conservative management surgery is an elective choice except in cases of cauda equina syndrome.
before exploring surgical II. Relative indications include:
options. A. Patients demonstrating progressive neurologic deficit during a period of
observation.
What duration of B. Patients with persistent bothersome lumbar radiculopathy despite conservative
conservative management management for a period of 6 to 8 weeks.
does your attending
prefer before proceeding
RELATIVE CONTRAINDICATIONS FOR LUMBAR MICRODISKECTOMY
with surgical
intervention? I. Patients who have back pain after their lumbar radiculopathy has resolved are not
good surgical candidates for operative treatment. Surgical intervention is not
Back pain as the primary geared toward curing a patient’s back pain.
symptom is a relative II. It is of utmost importance to ensure a complete workup is done prior to proceed-
contraindication for ing with surgery to ensure the diagnosis of a lumbar herniated disk is accurate and
lumbar microdiskectomy an alternative pathology has not been missed.
unless the patient has III. Patients that have undergone an inadequate period of conservative treatment are
substantial leg symptoms not considered to be good surgical candidates. The natural history demonstrates
correlating with a single that 85% of patients with a herniated disk have resolution of their symptoms
lumbar herniated disk within 3 months.
and understands that
microdiskectomy may not
help the back pain. GENERAL PRINCIPLES OF LUMBAR MICRODISKECTOMY
I. Anatomy
A. Vertebrae (Fig. 13-2)
1. Posteriorly, the bony arches encircle the spinal canal and consist of the
transverse processes, facet joints, two pedicles, two laminae, and the spinous
process.
2. The facet joints are composed of the superior and inferior articulating sur-
faces of the vertebrae below and above, respectively.
B
Ligamentum
flavum
Interspinous
ligament
Supraspinous
ligament
Vertebral anatomy
C Pedicle
Transverse process
Superior articular
process
Spinous process
Inferior articular process

Figure 13-2
Vertebral anatomy. A, Sagittal view. B, Oblique view of the lumbar vertebrae, showing ligamentum flavum
thickening in the caudad extent of intervertebral space and in the midline. C, Oblique view of single lumbar
vertebra. (From Miller R: Miller’s Anesthesia, 6th ed. Philadelphia, Churchill Livingstone, 2005.)
3. The neural foramen is adjacent to the pedicles and the facet joints and marks
the exit of the corresponding nerve root.
B. Intervertebral disk
1. The disk provides support and allows for movement while resisting exces-
sive movement.
2. The disk is composed of the nucleus pulposus, which is typically soft and
surrounded by the annulus fibrosis, which is tough and fibrous.
3. Each disk is bonded to the vertebral body above and below by a thin cartila-
ginous bridge referred to as the end plate. This end plate is vascular and is
responsible for disk nutrition. The end plate also supports the disk and
decreases the risk of disk herniation and maintains its shape.
C. Ligaments
1. Each disk is reinforced anteriorly and posteriorly by the anterior and pos-
terior longitudinal ligaments, respectively.
2. The laminae are connected by the ligamentum flavum, and the spinous
processes are connected by the interspinous ligament and the supraspinous
ligament.
D. Nerves
Spine
1. The cauda equina is the fanning bundle of the lumbar and sacral nerve roots
exiting the spinal cord.
2. The cord typically terminates at the level of L1 or L2, which is termed the In the lumbar spine, the
conus medullaris. corresponding nerve exits
below its vertebral body;
3. The exiting nerve root in the lumbar spine is numbered according to the
therefore the L4 nerve
pedicle above (i.e., the L4 nerve root passes below the L4 pedicle between root exits below L4 at the
the L4-L5 disk space). L4-L5 disk space.
II. General Principles
A. Lumbar microdiskectomy is considered the gold standard for surgical treat- An Andrews table allows
ment of a herniated lumbar disk. for decreased bleeding due
B. Microdiskectomy requires an operating microscope with a 400-mm lens, special to minimizing epidural
retractors, a variety of small-angled rongeurs, and microinstruments. venous engorgement and
C. The patient is placed in the prone position typically on an Andrews table. opens the interlaminar
D. The patient position allows the abdomen to hang free, which minimizes epi- space, making
dural venous dilation and bleeding. decompression easier.
E. Fluoroscopy is used to confirm the appropriate disk space.
F. The procedure is typically performed on an outpatient basis. ALWAYS CONFIRM THAT THE
G. There is less postoperative pain secondary to the limited dissection utilized. APPROPRIATE DISK SPACE IS
BEING EXPOSED.

I. After induction of general anesthesia, the patient is placed in the prone position
on an Andrews table with all bony prominences well padded (Fig. 13-3).
II. The lumbar spine is prepped and draped in standard fashion (see Chapter 1).
Figure 13-3
The patient is shown prone on an Andrew’s table.
Surgical Approach
I. Using a 22-gauge spinal needle and fluoroscopy, the affected disk space is local-
ized. The iliac crest can be used to correlate to the spinous process of the fourth
lumbar vertebra.
II. The skin and soft tissues are then infiltrated with 20 mL of 1% lidocaine and
1 : 200,000 epinephrine.
III. Next an incision, approximating the width of the surgeon’s index finger, is made
approximately 1 cm lateral to the midline of the spine on the side toward the
herniated disk at the appropriate level.
IV. Using a Cobb elevator, the subcutaneous layers are elevated off the lumbodorsal
fascia.
V. Then an incision 0.5 mm lateral to the spinous process and in line with the skin
incision is created through the lumbodorsal fascia.
VI. Using the Cobb elevator, the erector spinae muscles are elevated off the associated
laminae and spinous processes.
VII. A speculum retractor system is then placed in the wound using the leading edge
of the beveled side of the speculum. The instrument is positioned using a back-
and-forth clockwise and counterclockwise rotation while slowly advancing it
through the soft tissue planes (Fig. 13-4).
VIII. Once docked against the facet and lamina, using the assistance of a microscope
and pituitary rongeur, the intervening soft tissue inside the cannula is removed
until the interlaminar space is identified.
IX. A lateral fluoroscopic view is then taken with the speculum in place to confirm
the location relative to the desired disk space.
X. If necessary, a laminotomy is performed to allow access to the disk space. At the
L5-S1 level, bone resection is rare due to the large interlaminar space.
Disk Excision
I. Extraforaminal disks are then excised from outside the spine.

II. The dura and nerve roots are then exposed and retracted away from the herniated
disk.
III. A probe is used to locate the annular defect, and a pituitary rongeur is used to
remove any loose fragments. It is important to remove all of the loose disk frag-
ments to minimize the recurrent disk herniation.
IV. The canal space beneath the nerve root and dura are then explored for loose disk
fragments, and the foramen is probed to ensure adequate space for the nerve
root.
V. Forced irrigation is then placed into the disk space through the annular defect to
remove any additional loose disk fragment.
Figure 13-4
Intraoperative lateral fluoroscopy image
demonstrating a speculum retractor in place and
marking the appropriate disk space.
Wound Closure
I. The wound is then copiously irrigated and hemostasis is achieved.

II. The lumbodorsal fascia is then closed in standard fashion (see Chapter 1) to
achieve a watertight closure.
III. The subcutaneous layer is closed in standard fashion and the skin edges are
opposed with a subcutaneous closure (see Chapter 1). The lesion is covered with
a sterile dressing.
IV. Toradol 30 mg is typically administered intravenously for postoperative pain.
POSTOPERATIVE CARE AND REHABILITATION

I. Mobilization is started immediately after surgery. ANTICOAGULATION FOLLOWING
II. Pain is controlled with oral narcotics and muscle relaxants. SPINE SURGERY IS
III. Anticoagulation for deep venous thrombosis prophylaxis is contraindicated. CONTRAINDICATED DUE TO
THE RISK OF DEVELOPING AN
IV. Isometric abdominal and lower extremity exercises are started.
EPIDURAL HEMATOMA, AND
V. Patients are instructed to minimize sitting and riding in a vehicle initially and STUDIES HAVE SHOWN THAT
increase as pain permits. LEG COMPRESSION DEVICES
Spine
VI. The patient is advised to return to “back school” at postoperative week 4 PROVIDE ENOUGH PROTECTION
to 6. AGAINST DVT.
VII. Lifting, bending, and stooping are prohibited for the first several weeks but are
gradually restarted after postoperative week 6.
VIII. Lower extremity strengthening exercises can be instituted postoperative weeks 8
Ask your attending about
to 12.
his or her postoperative
IX. Return to work mostly depends on the work requirements for each individual, but
rehabilitation protocol.
range anywhere from 2 to 3 weeks up to 3 months.
COMMON COMPLICATIONS OF LUMBAR MICRODISKECTOMY

I. Wound infection
Symptoms of a dural tear
II. Postoperative diskitis include a headache that is
III. Dural tears worse when upright and
IV. Thrombophlebitis alleviated by lying flat.
V. Nerve root injury
VI. Pulmonary embolism
VII. Cauda equina syndrome
VIII. Pyogenic spondylitis
IX. Injury to abdominal blood vessels
X. Injury to abdominal viscera
SUGGESTED READINGS
Chin KR, Adams SB, Khoury L, Zurakowski D: Patient behavior patterns if given access to their
surgeon’s cellular telephone. Clin Orthop 439:260–268, 2005.
Chin KR, Michener TA: Prospective of a 3-blade speculum cannula for minimally invasive lumbar
microdiscectomy. J Spinal Disord Tech 19:257–261, 2006.
Chin KR, Sundram H, Marcotte P: Bleeding risk with ketorolac after lumbar microdiscectomy.
J Spinal Disord Tech 20:123–126, 2007.
Williams KD, Park AL: Lower back pain and disorders of intervertebral discs. In Canale ST (ed):
Campbell’s Operative Orthopaedics, 10th ed. Philadelphia, Mosby, 2003, pp 1955–2028.
C H A P T E R
14
Posterior Lumbar Fusion for
Degenerative Spondylolisthesis/Stenosis
Safdar N. Khan and Eric O. Klineberg
Case Study
A 69-year-old female dance instructor with a 3-year history of back and leg pain presents
to the clinic. She complains predominantly of leg pain, which is greater than the back
pain. She has some radicular symptoms with burning and numbness and “shooting pains”
down the back of her legs to the soles of the feet. She is, however, able to find a position
of comfort. When sitting in a chair at home, she has minimal back symptoms and no leg
pain. On sitting up or standing, she has worsening of her back pain, and her leg pain
begins after standing or walking for only a few moments. She is able to walk farther when
leaning forward or holding onto a shopping cart. She denies any bowel or bladder dys-
function. The patient has had physical therapy and lumbar epidural steroid injections,
which initially relieved the pain, but the past few injections have led to no significant
relief. Anteroposterior and lateral radiographs of the lumbar spine are presented in
Figure 14-1.
BACKGROUND
I. The term spondylosis is defined as nonspecific degenerative changes in the archi-
tecture of the spine and surrounding soft tissues. These degenerative changes may
lead to anterior or posterior movement of one vertebral body on the subsequent,
lower vertebral body. This is known as spondylolisthesis. With long-standing
disease, the degenerative process may result in stenosis or narrowing of the spinal
canal.
II. Degenerative spondylolisthesis is extremely common at the L4-L5 level, with 1
to 3 mm of vertebral body translation occurring in nearly 40% of asymptomatic
patients. The pathogenesis is primarily related to chronic intervertebral disk
degeneration and segmental and rotational instability with facet joint arthrosis. As
the disk degenerates, the spinal segment loses some of its stability and is able to
The L4-L5 level is the translate both anterior and posterior with flexion and extension. This eventually
most common level results in mechanical back pain, with relief of symptoms while sitting or lying
for degenerative down, but exacerbation of pain with sitting up or walking (spinal segment moves
spondylolisthesis.
to a new position).
C H A P T E R 1 4 Posterior Lumbar Fusion for Degenerative Spondylolisthesis/Stenosis 137
Spine
A B
Figure 14-1
Anteroposterior (A) and lateral (B) radiographs of the lumbar spine show degenerative spondylolisthesis of L4
over L5.
III. Degenerative spondylolisthesis rarely progresses beyond 25% anterolisthesis due Remember to take a
to intact posterior elements in contrast to congenital spondylolisthesis. thorough history and ask
IV. The degenerative process rarely becomes symptomatic before 50 years of age and questions specifically
disproportionately affects women, especially black women, with a male-to-female directed toward
differentiating vascular
ratio of 1 : 6.
claudication from
V. Degenerative spondylolisthesis is generally asymptomatic; however, it can be neurogenic claudication.
associated with symptomatic spinal stenosis, which is the most common reason
for lumbar surgery in patients older than 65 years of age.
VI. Patients typically complain of low back pain and radicular or referred leg pain, A complete physical
and it may produce symptoms of classic neurogenic claudication. examination should
VII. In central stenosis with resulting neuroclaudication, patients detail activity-related include evaluation for
myelopathy (clinical signs
lower extremity pain or heaviness, which diminishes with spinal flexion. These
demonstrating spinal cord
patients usually note increased activity tolerance when ambulating in a flexed impingement).
position (e.g., walking with a cane or shopping cart). Remember to have all
VIII. Lateral recess stenosis usually heralds itself with monoradicular symptoms. The patients tandem walk and
nerve root most commonly involved is L5. These monoradicular symptoms may ask them specifically
or may not be related to activity or positional changes. about difficulty in
performing fine motor
tasks such as buttoning
shirts, and so on.
TREATMENT ALGORITHM
Primarily neurogenic claudication

with back pain
History and physical examination,

plain radiographs, flexion-extension
radiographs, and MRI
Degenerative No spondylolisthesis/stenosis
spondylolisthesis/stenosis
Unstable Stable
Nonoperative management
Posterior spinal decompression NSAIDs
and fusion Epidural corticosteroid injection
Posterior spinal decompression

alone
Note: This algorithm is a guideline for management of degenerative spondylolisthesis

with stenosis.

axial back pain without
any leg pain? TREATMENT PROTOCOLS
I. Treatment Considerations. All of these considerations play an important
role in the decision-making process of treating patients with degenerative
spondylolisthesis/stenosis.
A. Patient age
B. Activity level
C. Overall health
D. Amount of leg pain compared with back pain
F. Sagittal and coronal imbalance
II. Patients with leg pain, minimal back pain, and a stable spondylolisthesis may only
need decompressive surgery. Relief can be dramatic in patients with primarily
lower extremity claudication symptoms. Similarly, the operative approach may
vary. Younger patients may benefit with reconstruction of the anterior column
and restoration of the lumbar lordosis, whereas older patients usually benefit with
faster posterior-only procedures.
III. Imaging Modalities
A. Plain radiographs should be assessed for the following features:
1. Global lumbar lordosis, soft tissue shadows, fractures of the pars interar-
ticularis, and tumors
2. Sagittal and coronal alignment
3. Evidence and extent of spondylolisthesis as classified by the Meyerding
classification
a. Grade I: less than 25% anterolisthesis

Do not forget to assess
b. Grade II: 25% to 50% anterolisthesis active adolescent patients
c. Grade III: 50% to 75% anterolisthesis with back pain for pars
d. Grade IV: 75% to 100% anterolisthesis interarticularis fractures
e. Grade V: more than 100% anterolisthesis (spondyloptosis) with 30-degree oblique
4. Pedicle morphology (e.g., size, orientation) radiographs (“Scottie
B. Flexion-extension radiographs. Standing lumbar flexion-extension radiographs dog” view) and/or bone
reveal the extent of listhesis (translation) and correlate to the degree of poste- scans (Fig. 14-2).
rior element incompetence. The listhesis may also be stable in older patients.
In these patients, the anterior column has gone on to fuse with the degenera-
tion of the anterior disc.
C. Computed tomography (CT) scan with or without myelography
1. Useful when additional bony detail is needed to assess the degree of stenosis
and facet joint involvement joints.
2. CT myelography is used in revision cases to evaluate stenosis proximal and
distal to the previously fused segment when instrumentation scatter makes
using magnetic resonance imaging (MRI) difficult.
D. MRI
Spine
1. MRI is the imaging modality of choice to evaluate the disc space, interver-
tebral disk morphology, and spinal nerves relative to their foramina.
2. Axial MRI scans linked to the sagittal views reveal areas of intervertebral
disk herniation and stenosis (central vs. lateral vs. foraminal vs. far
lateral).
Superior articular process Pars fracture
Figure 14-2
Radiograph of lumbar region of vertebral column, oblique
view (“Scottie dog”). A, Normal. B, Fracture of pars
A interarticularis. (From Drake RL, Vogl W, Mitchell AWM:
Gray’s Anatomy for Students. Philadelphia, Churchill
Pedicle Pars interarticularis Livingstone, 2005.)
3. Facet signal changes can be seen on T2-weighted scans, and this correlates
explain the different types with unstable spondylolisthesis.
of spinal stenosis and 4. Note: MRI scans are taken with patients supine; the actual amount of spinal
their clinical compression may be worse as the patient stands and the listhesis becomes
presentations. more evident. Also, reduction of the spondylolisthesis in the MRI scanner
may suggest that simple patient positioning in physiologic lordosis on the
ALWAYS QUESTION PATIENTS operating table may reduce the listhesis.
FOR A HISTORY OF A IV. Nonoperative Treatment Options
PACEMAKER, METAL IN THE A. Initial treatment strategy
EYE, ANEURYSM CLIPS, OR 1. Nonsteroidal anti-inflammatory drugs or acetaminophen
OTHER METAL IMPLANTS IN 2. Activity modification (i.e., participating in low-impact activity, avoiding
THE BODY PRIOR TO offending motions)
OBTAINING A MAGNETIC 3. Heat and cold therapy, modalities such as iontophoresis, and ultrasound
RESONANCE IMAGING SCAN. 4. Physical and occupational therapy
a. Physical therapy should focus on eliminating stiffness and strengthening
the paraspinal muscles.
(1) Typically a home exercise program can be taught.
(2) Aqua therapy can be used for exercises and decreasing stress across
muscles and joints due to the buoyant effects of water.
b. Occupational therapy is aimed at teaching alternative ways of accom-
plishing activities of daily living that may be impaired or elicit
symptoms.
B. Epidural corticosteroid injection
1. Injections are considered if adequate progress has not been made after 4 to
6 weeks of physical therapy.
a. Steroids are typically injected in combination with a local anesthetic
(lidocaine and/or bupivacaine).
b. Targeted steroid injections can be performed at various foramina, which
may be both therapeutic (relieve pain) and diagnostic (differentiates
between L5 and S1 intervertebral disk involvement) in patients with back
and leg pain and multilevel stenosis. This may aid in determining future
levels of decompression/fusion.
2. Steroids can decrease pain that may be limiting a patient’s ability to perform
exercises.
3. An injection can be repeated after several months if it gives symptomatic
relief, but no more than three injections per year should be administered.
4. Although prolonged relief may not be possible with epidural injections, they
can give patients some short-term relief and better define the disease process
and prognosis for any surgical intervention.
Radicular leg pain is SURGICAL INDICATIONS FOR LUMBAR DECOMPRESSION/FUSION FOR

typically the principal DEGENERATIVE LUMBAR SPONDYLOLISTHESIS/STENOSIS
indication for surgery
in patients who fail I. Failed nonoperative treatment (minimum 3 to 6 months)
nonoperative II. Prominent or progressive lower extremity weakness
management. Surgical III. Acute foot drop due to massive disk herniation in young, active patients (see
intervention has a more Chapter 13 for details on treatment of acute disk herniations)
predictable outcome
regarding relief of leg
than relief of isolated
axial back pain.
RELATIVE CONTRAINDICATIONS TO LUMBAR DECOMPRESSION/FUSION FOR
DEGENERATIVE LUMBAR SPONDYLOLISTHESIS/STENOSIS
I. Current or recent infection (e.g., diskitis or osteomyelitis)
II. Local skin problems (e.g., decubitus ulcers)
III. Medical instability. Patient is unable to safely tolerate the stress of sur-
gery.
GENERAL PRINCIPLES OF LUMBAR DECOMPRESSION/FUSION FOR

DEGENERATIVE LUMBAR SPONDYLOLISTHESIS/STENOSIS
I. Decompressive lumbar laminectomy with posterolateral fusion with pedicle screw
instrumentation for degenerative spondylolisthesis/spinal stenosis usually results
in significant relief of neurogenic claudication. The key portion of the procedure
is decompression of the neural elements; fusion prevents continued motion or
worsening of motion once the posterior elements have been removed.
II. Preoperative imaging with CT scans, MRI, or CT myelograms (revision cases) is
mandatory to visualize the degree and location of the spinal stenosis. Imaging
studies must correlate with the patient’s symptoms.
III. The goals of lumbosacral segmental instrumentation are to reduce deformity and
to provide stability, thus increasing the chances for successful posterolateral fusion.
The pedicle is the strongest portion of the vertebra; thus, it is the ideal anatomic
structure for three-column spinal fixation. DO NOT ASSUME THAT ALL
IV. Intraoperative radiographs are mandatory to confirm appropriate levels for decom- PATIENTS HAVE FIVE LUMBAR
pression and fusion. Sacralization of the lowest lumbar segment can lead to confu- VERTEBRAE. SOME PATIENTS
sion with regard to determining the correct level of surgery. MAY HAVE SACRALIZATION OF
Spine
A LUMBAR VERTEBRA.
V. Pedicle screw pullout strength is a function of bone mineral density; a preoperative
dual-energy x-ray absorptiometry scan indicating less than 0.45 g/cm2 of bone
density predicts pedicle screw loosening. Screw purchase may be increased with
triangulated (convergent) placement of bilateral pedicle screws at a single level.
VI. Because the pedicle is the strongest part of the vertebral body where screw pur-
chase is optimal, adding long screws do not promote greater stability. It is advis-
able to stay 0.5 cm from the anterior cortex to avoid perforation. Screw length
and vertebral body depth can be measured on preoperative CT scans.
COMPONENTS OF THE DECOMPRESSIVE LAMINECTOMY AND

POSTEROLATERAL FUSION WITH PEDICLE SCREW PLACEMENT
I. The patient is typically placed in the prone position on a Jackson table
(Fig. 14-3) with the abdomen hanging free and decompressed. This position
Figure 14-3
Jackson spine table for prone patient positioning.
Figure 14-4
Patient in the prone position prior to prepping and
draping.
decreases the mean central venous pressure, leading to decreased engorgement of

the epidural veins and diminished intraoperative blood loss.
The iliac crests II. The patient may also be placed in a kneeling position, but this position should be
correspond to the L4-L5 avoided if considering fusion because this will decrease lumbar lordosis.
disc space. This surface III. Patients are typically placed under general anesthesia for the procedure. Care must
anatomic landmark aids be taken to ensure that no pressure is on the orbits because postoperative vision
in determining the loss is a catastrophic complication.
appropriate incision level. IV. The skin should be shaved over the surgical site and the iliac crests palpated.
V. All bony prominences are well padded, including the knees and the ankles. Remem-
ber to place padding in the axilla as well as the elbows. Ideally, the arms should
be placed with the shoulders and elbows at less than 90 degrees of flexion to
prevent an axillary or ulnar nerve neurapraxia (Fig. 14-4).
VI. Neuromonitoring is often used when spine fusion is planned with pedicle screw
fixation. Make sure that the neurophysiologist has adequately placed the appropri-
ate leads prior to prepping the patient. (See Chapter 34 for details on nerve
monitoring and spine surgery.)
VII. Once adequately positioned, the surgical field is prepped and draped in standard
fashion according to the surgical principles outlined in Chapter 1.
VIII. Next mark the skin incision using a sterile marker utilizing the iliac crests as an
anatomic landmark.
Surgical Approach
I. An incision is made over the midline, most frequently over L4-L5 and extending
the length of the area to be decompressed.
II. The dissection is carried down to the fascia, and self-retaining retractors
are positioned. Using a Cobb elevator and Bovie cautery, the fascia is incised on
either side of the midline and reflected laterally to the facet joints. Care must be
taken not to violate the capsules of the facets not involved in the final fusion
levels.
III. A Kocher clamp is placed on a preselected spinous process and a Woodson
probe placed on the undersurface of the corresponding lamina. Once this is
done, an intraoperative lateral radiograph is taken to delineate the exact fusion
level.
IV. Once the fusion level is confirmed, a far lateral dissection then ensues with strip-
ping of the posterior spinous musculature, including the multifidus muscles from
the appropriate transverse processes.
V. The muscles are stripped from medial to lateral using a Cobb to assist in
retracting. The Bovie tip is kept visualized at all times and stay on bone to avoid
plunging into the spinal canal. Steady, sweeping motions are used to peel
the musculofascial layers off the spine. The spinous process, lamina, pars interar-
ticularis, facet joints, and transverse process are exposed at each lumbar level
requiring fusion.
VI. Once adequate exposure has been accomplished, the spinal canal can be
decompressed.
Decompression and Pedicle Screw Placement

I. Decompression is initiated with removal of the interspinous ligament using a
heavy rongeur. Use a large Leksell to remove the superior spinous process and
half of the inferior spinous process for adequate exposure.
II. Begin thinning the lamina on both sides with a high-speed burr. Then, begin
decompressing the central stenosis with a Kerrison rongeur. Leave the ligamen-
tum flavum as a temporary shield over the dura.
III. Decompression with a Kerrison rongeur is done in a caudal to cephalad
manner. Be mindful of the pars interarticularis on each side to avoid
fractures.
IV. A medial facetectomy aids in lateral recess decompression. The medial aspect of
the inferior facet may be removed with a sharp 1/4-inch osteotome, and the under-
lying superior facet may be removed with a Kerrison rongeur. Remove the liga-
mentum flavum and bone bilaterally out to the level of the pedicle.
Spine
V. A Woodson probe is used to feel the pedicle from within the canal.
Adequate decompression should allow the tip of the probe to pass into the
foramina.
VI. Once the decompression has been completed, pedicle screw fixation and postero-
lateral spine fusion can be attempted. REMEMBER FOR LUMBAR
VII. Classically, the entry point to the pedicle is defined by the intersection of a horizontal PEDICLE SCREW PLACEMENT,
line in the midline of the transverse process and a vertical line in the inferior lateral MEDIAL ANGULATION
facet margin. The horizontal line is 1 to 2 mm below the facet joint line and the INCREASES BY 10 DEGREES
PER LEVEL, FROM 0 DEGREES
vertical line should be 2 to 3 mm lateral to the lateral pars and must be angulated
AT THE UPPER LUMBAR LEVEL
laterally as one moves caudally in the lumbar spine.
TO 30 DEGREES AT L5.
VIII. A 4-0 burr is then used to decorticate the entry point. A pedicle probe is used to
proceed through the pedicle and the vertebral body. The screw path may be
tapped, and a ball-tipped probe is used to feel the inferior, medial and lateral walls Note that lateral recess
for cortical cutout. decompression is best
IX. Screws can then be inserted. If there is any doubt to the nature of the interpedicu- performed by the surgeon
lar tract, fluoroscopic guidance can be used. from the opposite side of
X. Alternatively, a “canoe technique” may be used to place pedicle screws. In this the table.
technique, a rongeur is used to bite off the facet osteophytes at its junction with
its corresponding pars interarticularis. Then, a unicortical bite (“canoe”) is care- ONCE PEDICLE SCREW
fully made with a rongeur on the exposed dorsal surface of the transverse process. PLACEMENT AND
A curette is then used to decorticate the transverse process from lateral to medial, DECOMPRESSION IS
taking care not to break the transverse process. Continuing medially, at the junc- COMPLETE, MAKE SURE TO
tion of the transverse process, pars interarticularis, and the facet joint, the pedicle OBTAIN ANOTHER SET OF
entry site is carefully breached. A ball-tipped probe is then used to feel for cortical INTRAOPERATIVE
cutout followed by pedicle screw placement. POSTEROANTERIOR AND
XI. Intraoperative electromyographic potentials measured by neuromonitoring are LATERAL RADIOGRAPHS. YOU
used to ensure appropriate position of the pedicle screws. Threshold value norma- MAY CHANGE THE
ORIENTATION OF YOUR
tive data is as follows:
PEDICLE SCREWS BASED ON
A. 0 to 4 mA: high likelihood of pedicle wall breach
THESE FINAL RADIOGRAPHS
B. 4 to 8 mA: possible pedicle wall breach (Fig. 14-5).
C. More than 8 mA: no pedicle wall breach
XII. The wound is thoroughly irrigated with a pulse irrigator.
XIII. The next step is rod placement. The pedicle screw head may be monoaxial
(uniplanar) or polyaxial (multiplanar) depending on the instrumentation system
used. Similarly, precontoured rods or intraoperatively contoured rods may be
used.
XIV. Short rods are placed between two adjacent pedicle screws. The rod is secured to
the pedicle screw with the use of an end cap. The end caps are tightened using a
torque wrench.
Figure 14-5
Lateral postoperative radiograph of a posterolateral
fusion at the L4-L5 level.
XV. The transverse processes of the fused levels are decorticated with a 4-0 burr. Be
careful not to fracture the transverse processes.
XVI. Bone graft (iliac crest bone graft vs. bone morphogenetic protein) is placed in the
lateral gutter over the decorticated transverse processes.
Wound Closure
I. After thorough irrigation with a pulse irrigator, adequate hemostasis is achieved
and a subfascial drain is placed prior to closing the wound.
II. The wound is closed in standard fashion with a Biosyn subcuticular closure used
for reapproximating the skin, and a sterile dressing is applied (see Chapter 1 for
details).
POSTOPERATIVE CARE
I. The drain is removed on postoperative day 2 or when the drain output is less than
30 mL per shift.
II. Postoperatively, patients are encouraged to ambulate with help as soon as
possible.
III. Remember to order standing radiographs (AP and lateral) when able.
IV. The use of a postoperative orthosis is arguable. A lumbar corset for comfort may
be given to the patient when out of bed.
V. Deep venous thrombosis chemoprophylaxis is not required due to the risk of epi-
dural hematoma formation. Sequential compression devices are placed on both
lower extremities while the patient is in the hospital.
VI. Follow-up in 4 weeks with repeat anteroposterior and lateral standing lumbar
spine radiographs. In the interim, tell patients that they should not do any bending,
twisting, or lifting more than 5 pounds.
COMPLICATIONS
I. Nerve/spinal cord injury
II. Inadequate decompression
III. Infection
IV. Iatrogenic durotomy
V. Incidental durotomy. If this occurs, a watertight seal should be obtained either
primarily with a 6-0 Prolene suture or with a facial graft. Fibrin glue (cryoprecipi-
tate, thrombin, and calcium) can be placed over the defect. The patient should be
on complete bed rest for 24 hours after the procedure and monitored for a dural
leak. If there is a dural leak, the patient typically presents with a headache when
sitting up. If in doubt, whether intraoperatively or in the postoperative period, a
neurosurgical consult should be obtained.
SUGGESTED READINGS
Bell G: Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopae-
dic Surgeons, 2002.
Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical versus nonsurgical treatment for lumbar
degenerative spondylolisthesis. N Engl J Med 356:2257–2270, 2007.
Spine
S E C T I O N
IV
PELVIS AND ACETABULUM
CHAPTER 15 Open Reduction and Internal Fixation of Posterior Wall Fractures 149
CHAPTER 16 External and Internal Fixation of Symphysis Pubis Widening 159
C H A P T E R
15
Posterior Wall Fractures
Keith D. Baldwin, Jaimo Ahn, and Samir Mehta
Case Study
A 23-year-old man presents to the trauma center after being involved in a motor vehicle
collision. When he arrived in the resuscitation bay, airway, breathing, circulation, dis-
ability, and exposure were assessed according to the Advanced Trauma Life Support
(ATLS) protocol. The patient is tachycardic but normotensive, warm, and well perfused.
There is no stridor or wheezing, and the respiratory rate is slightly tachypneic. A detailed
secondary survey is conducted and is significant for hip and groin pain, obvious deformity
of the left lower extremity compared to the right (shortened and internally rotated), and
visible discomfort with attempted range of motion of the left hip. Two large-bore intra-
Pelvis and Acetabulum

venous catheters are placed, intravenous fluid is started, and laboratory studies are obtained.
Radiographs of the chest and pelvis are taken. A dislocated left hip is noted on the antero-
posterior (AP) pelvic radiograph. Sedation is given and the hip is reduced in the resuscita-
tion bay. The patient is taken to computed tomography for evaluation, and postreduction
images (Fig. 15-1) are obtained. A distal femoral traction pin is placed. The patient has
no additional operative injuries and is admitted for definitive stabilization of the posterior
wall fracture within 24 to 72 hours based on his medical progress.
A B
Figure 15-1
A, Anteroposterior radiograph of the pelvis demonstrating a left hip dislocation with a posterior wall
fragment. B, A postreduction computed tomography scan depicts a concentrically reduced hip joint with a
minimally displaced posterior wall fracture.

150 S E C T I O N I V Pelvis and Acetabulum
The Judet-Letournel
BACKGROUND
classification for
acetabular fractures is I. Posterior wall fractures are the most common type of acetabular fractures and
divided into elementary comprise approximately 50% of all acetabular fractures (associated and elementary
and associated fracture patterns) in most published series.
patterns. Elementary II. The amount of injury to the posterior wall is typically dictated by such factors as
fracture patterns include mechanism of injury, position of the femoral head within the acetabulum, position
the following: posterior of the lower extremity at time of impact, patient age, bone quality, and energy
wall, posterior column, imparted to the patient.
anterior wall, anterior III. Posterior wall fractures are sometimes colloquially referred to as “dashboard
column, and transverse. injuries.”
Associated fracture
IV. Posterior wall fractures are associated with posterior dislocations of the hip joint
patterns consist of the
following: T-type,
between 40% and 70% of the time in various series.
posterior column/ V. An isolated posterior wall fracture can be classified as an “elementary” fracture
posterior wall, transverse/ pattern in the Judet-Letournel classification of acetabular fractures.
posterior wall, anterior VI. Posterior wall fractures can also occur as a part of more complex fracture patterns,
column/posterior so when a posterior wall fracture is detected, the entire pelvic ring should be
hemitransverse, and assessed.
associated both column. VII. A low threshold should be maintained to assess the entire pelvic ring and
acetabulum.
Sciatic nerve injury is VIII. The posterior wall can be best visualized on an obturator oblique radiograph of
present in as many as the pelvis.
30% of posterior hip IX. An isolated femoral head dislocation without an associated fracture of the posterior
dislocations. wall is a rare occurrence (10% in the highest series). More often, dislocation of
the femoral head results in a fracture of the posterior wall (tension-type failure).
IF RADIOGRAPHS REVEAL A X. Post-traumatic injury to the sciatic nerve can occur up to 30% of the time with a
FRACTURE-DISLOCATION OF posterior wall fracture-dislocation.
THE FEMORAL HEAD WITH
AN ASSOCIATED POSTERIOR
WALL FRACTURE, THEN AN INITIAL TREATMENT
IMMEDIATE ATTEMPT AT A
CLOSED REDUCTION IS I. Treatment Considerations
WARRANTED. A. Energy imparted to the patient
B. General trauma survey including standard ATLS protocol
C. Thorough secondary survey, including detailed neurovascular examination
D. Evaluation and documentation of rectal tone
E. Vaginal examination to rule out open fractures of the pelvic ring
F. Urgent reduction and maintaining reduction of a dislocated femoral head
A. General trauma survey
1. ATLS protocol
a. Adequate resuscitation
b. Maintain hemodynamic stability
c. Circumferential sheet or commercial pelvic binder to reduce pelvic
volume
2. Evaluate soft tissue
3. Ultrasound examination or other visceral/abdominal organ system
evaluation
4. Standard radiographs (lateral cervical spine, anteroposterior chest, antero-
posterior pelvis)
5. Dislocated femoral head should be addressed urgently with reduction
B. Neurovascular evaluation
1. Vascular assessment by palpation or Doppler
a. Dorsalis pedis artery
b. Posterior tibial artery
c. Popliteal artery
d. Have a low threshold for performing ankle brachial indices in light of a
dislocated hip or other abnormal physical examination finding
C H A P T E R 1 5 Open Reduction and Internal Fixation of Posterior Wall Fractures 151
A B
Figure 15-2
Iliac oblique (A) best demonstrates the posterior column (light blue) and anterior wall (purple). Obturator
oblique (B) best demonstrates the anterior column (green) and posterior wall (red).
2. Neurological assessment: sciatic nerve

a. Motor: foot dorsiflexion for anterior tibialis muscle
b. Sensation: webspace between the first and second toe
C. Additional imaging
1. AP pelvis radiograph (if not obtained with initial trauma workup)
2. Judet radiographs
a. Iliac oblique (45-degree external rotation) radiograph to visualize the
following structures:
(1) Posterior column

(2) Anterior wall A THOROUGH NEUROLOGICAL
b. Obturator oblique (45-degree internal rotation) radiograph to visualize EXAMINATION OF THE
the following structures (Fig. 15-2): INVOLVED EXTREMITY IS
(1) Anterior column MANDATORY, WITH
(2) Posterior wall DOCUMENTATION OF SCIATIC
3. Computed tomography (CT) NERVE FUNCTION, BECAUSE
a. Should be obtained with the femoral head reduced in the acetabulum THE NERVE IS AT RISK FOR
b. Fine-cut CT scan (usually 1.5 3 mm) is recommended through the region IATROGENIC INJURY AS WELL.
of concern
c. Demonstrates complexity of fracture CONSIDER OTHER DASHBOARD
d. Allows for assessment of marginal fracture impaction (Fig. 15-3) INJURIES SUCH AS POSTERIOR
e. Identifies presence of intra-articular fragments (Fig. 15-4) CRUCIATE LIGAMENT
RUPTURE.
f. Helps rule out associated femoral head or neck fractures
Figure 15-3
Axial computed tomography scan demonstrating
marginal impaction (arrow). The marginal
impaction needs to be reduced, similar to opening
a door along its hinges, before reduction of the
posterior wall component. The void left by
impaction of the subchondral surface into the soft
cancellous bone may need to be filled with allograft
or autograft. Marginal impaction often indicates the
region where the anterior femoral head was in
contact with the posterior wall. There may be a
corresponding defect of the femoral head.
Figure 15-4
Axial computed tomography scan demonstrating an
incarcerated fragment with nonconcentric reduction
(arrow). Debris within the articulation of the femoral
head with the acetabulum can prevent accurate and
concentric reduction of the femoral head.
TREATMENT ALGORITHM
RADIOGRAPHICALLY, Hip dislocated?

INVOLVEMENT OF BETWEEN
Y N
25% AND 40% OF THE
POSTERIOR WALL IMPLIES AN
Urgent reduction Gross hip Y Surgical
UNSTABLE POSTERIOR WALL
FRACTURE. under sedation? instability? stabilization
N Y N
Surgery Distal Evolving Y Surgical

for urgent femoral neurologic stabilization
reduction traction injury?
Definitive Intra-articular Y Surgical

stabilization fragments? stabilization
Nonconcentric Y Surgical
reduction? stabilization
Greater than 2 mm Y Surgical

step-off in weight- stabilization
bearing region?
Nonoperative
management
I. Indications
A. Small posterior wall fracture with no history of dislocation or instability
B. Examination under anesthesia (with fluoroscopy) that reveals a stable hip joint
with no subluxation or dislocation
C. Stable neurologic examination
D. Radiographic criteria
1. Concentric reduction
2. No intra-articular or incarcerated fracture fragments
3. Less than 2 mm of articular weight-bearing surface displacement
Figure 15-5
The roof arc angle is constructed by a vertical line
through the rotational center of the acetabulum and
a second line through the point where the fracture
crosses the radiographic dome. The roof arc angle is
the angle formed by the intersection of these lines.
4. Roof arc angle greater than 45 degrees on three radiographic views (Fig.
15-5)
5. Subchondral arc of 10 mm by CT
II. Management
A. Unstable posterior wall fractures
1. Distal femoral traction can be considered in patients who are not surgical
candidates.
2. Usually approximately 10 to 15 pounds of traction is needed.
3. Duration is 3 to 4 weeks.
4. Progressive weight bearing is typically started at 6 weeks.
5. Frequent radiographic assessment is required to assess for fracture
displacement.
B. Stable posterior wall fractures

1. Touch-down weight bearing is appropriate.
2. Sixty-degree hip flexion precautions should be taken.
3. Weekly radiographic assessment for loss of reduction is necessary.
4. Progress the patient to full weight bearing at 6 to 12 weeks following the
injury.
5. Physical therapy for abdominal strengthening, low back exercises, and quad-
riceps training of involved limb are usually helpful adjuncts in obtaining an
optimal functional outcome.
OPERATIVE TREATMENT
I. Indications
A. Irreducible fracture-dislocation
B. Unstable hip
1. Gross instability
2. Inability to maintain reduction
3. Greater than 25% to 40% of posterior wall involvement on CT (Fig. 15-6)
C. Incarcerated fragments
D. Evolving neurologic injury
E. Greater than 2 mm of articular surface displacement
II. Relative Contraindications to Surgical Treatment
A. Severe soft tissue injury (Morel-Lavalle lesion)
B. Visceral injury
C. Local or systemic infection
D. Severe osteoporosis
E. Medical comorbidities
III. Timing
A. Surgical emergency
1. Open acetabular fracture
2. Evolving neurologic injury
3. Vascular compromise
4. Irreducible dislocation
A B
C D
Figure 15-6
An atypical unstable posterior wall fracture. The computed tomography scan (A) shows less than 25% of the
posterior wall involved. However, the patient had a history of femoral head dislocation acutely reduced and
unstable hip on fluoroscopic examination in the operating room. B is a preoperative anteroposterior pelvis
radiograph. The postoperative Judet view radiographs (C and D) reveal a small fragment fixation contoured
and balanced over the small posterior wall piece. However, given the size and peripheral nature of the
fragment, an additional spring plate (circle) was used to enhance fixation.
B. Delayed surgical stabilization

1. Open reduction and internal fixation performed within 24 to 96 hours of
presentation if stable
2. Optimize operating room environment
3. Preoperative planning
4. Soft tissue management
RELEVANT SURGICAL ANATOMY

I. Palpable Surface Landmarks
A. Posterior superior iliac spine
B. Greater trochanter
C. Femoral shaft
II. Superficial Surgical Anatomy
A. Gluteus maximus
B. Tensor fascia lata
C. Trochanteric bursa
D. Inferior gluteal nerve
III. Deep Surgical Anatomy
A. Retraction of the gluteus medius reveals the gluteus minimus and the short
external rotators (including the quadratus femoris).
B. Overlying the quadratus femoris is the sciatic nerve.

C. Sciatic nerve and the piriformis are intimate. Aberrant muscle bellies of the
piriformis or anatomic variants of the sciatic nerve need to be taken into
account when performing the piriformis tendon tenotomy.
IV. Vascular Anatomy
A. The medial femoral circumflex artery provides the major blood supply to the
femoral head.
B. This artery is at risk with dissection or resection of the quadratus femoris.

I. The patient can be positioned in either the prone or lateral position on a radiolu-
cent table.
A. The lateral position is more familiar to most surgeons.
B. Prone positioning often helps facilitate reduction and plate application.
C. In this chapter, the authors describe prone positioning (Fig. 15-7).
II. The involved limb should be draped free into the sterile field.
III. Fluoroscopic imaging should be used to confirm that appropriate views can be
obtained intraoperatively prior to starting the case. The surgical field should be
prepped and draped in standard fashion according to the surgical principles out-
lined in Chapter 1.

Surgical Exposure
I. In a Kocher-Langenbach approach exposure for isolated posterior wall fractures,
an 8- to 10-cm skin incision is made from the tip of the greater trochanter distally
along the shaft of the femur. A second incision (approximately 12 to 18 cm) is
made from the posterior sacroiliac spine to the tip of the greater trochanter. The
two incisions should meet (Fig. 15-8).
II. The tensor fascia lata is split to the level of the tip of the greater trochanter. The
superior skin incision is then carried down to the fascia of the gluteus maximus,
Figure 15-7
Prone positioning for the Kocher-Langenbach
approach to the acetabulum. The patient is being Figure 15-8
positioned on a special operating table (Profx, OSI An 8- to 10-cm skin incision is made
Medical, California) designed in particular for pelvic from the tip of the greater trochanter
and acetabular surgery. The involved limb is on the distally along the shaft of the femur. The
patient’s right side. The table allows for control of second incision (approximately 12 to
the limb and can flex the knee and extend the hip to 18 cm) is made from the posterior
take tension off of the sciatic nerve. Furthermore, sacroiliac spine to the tip of the greater
the table is radiolucent. Alternatively, and more trochanter. The two incisions should
commonly, the procedure can be performed on meet at the area indicated. The incision
a radiolucent table (e.g., Jackson table). line above is shown.
which is incised in line with the superficial skin incision. The gluteus maximus
muscle belly is then bluntly divided, maintaining hemostasis.
III. The trochanteric bursa is excised, and the hematoma that is typically present is
removed.
IV. The gluteus medius is retracted superiorly, revealing the gluteus minimus and the
short external rotators. The gluteus minimus is débrided to the level of the supe-
rior gluteal neurovascular bundle.
V. The sciatic nerve is identified and its course followed to assess any anomalous
anatomy. The sciatic nerve rests on the quadratus femoris muscle, which should
be identified. Iatrogenic injury to this muscle may damage the medial femoral
circumflex artery.
VI. The piriformis tendon and conjoint tendon (superior gemellus, obturator internus,
and inferior gemellus) are tenotomized and tagged for later repair.
VII. The knee is bent to 90 degrees and the hip is extended, which minimizes tension
on the sciatic nerve. A retractor can be placed anterior to the sciatic nerve, but
with great care.
VIII. After subperiosteal elevation of the greater sciatic notch and quadrilateral surface,
the posterior wall fracture is exposed. The fracture should then be débrided. Be
cautious not to devascularize the fracture fragments by disrupting their capsular
blood supply.
IX. If intra-articular fragments are present that need to be removed, traction
on the leg along with pharmacologic relaxation (paralysis) allows access to the
joint.
Fracture Reduction
I. The fracture should be reduced under direct visualization, with the assistance of
a ball-spike pusher and K-wires for provisional stabilization. Prior to definitive
reduction, any marginal fracture impaction should be addressed.
II. Lag screws may be placed perpendicular to the fracture plane if necessary to
maintain reduction.
III. A buttress plate is the mainstay of fixation. One or two 3.5-mm pelvic reconstruc-
tion plates may be necessary. The plates are usually between six to eight holes in
length, and the plates need to be undercountered prior to application. As the
screws are placed into the plate, it contours to the bone and provides the desired
buttress effect. It is important to balance the plate well along the posterior wall
fragment so that it is well contained by the force of the plate.
IV. The screws placed should be directed away from the joint. Two screws in the
proximal portion of the plate and two screws in the distal portion of the plate are
usually sufficient in terms of fixation.
V. Once the posterior wall fragment is reduced, the limb should be taken through a
range of motion to assess any restrictions. Fluoroscopic imaging should also be
used to confirm the extra-articular placement of the screws.
VI. The wound should be thoroughly irrigated at this point. Any necrotic
muscle should be débrided as this is a potential source of heterotopic
ossification. The tenotomized tendons, piriformis, and conjoint tendons
are repaired using a large-caliber, nonabsorbable, braided suture. A layered
closure in standard fashion over drains should be performed (see Chapter 1 for
details).
POSTOPERATIVE CARE AND COMMON COMPLICATIONS

I. Postoperative Evaluation
A. Assess sciatic nerve function.
B. Assess neurovascular status.
C. Obtain postoperative hemoglobin and manage drain output.
II. Surgical Wound Infection

A. Higher risk when postoperative hematoma occurs
B. Higher risk with coexisting abdominal and or visceral organ damage
C. Higher risk when local soft tissue compromised
III. Heterotopic Ossification
A. Occurs in approximately 20% of cases where no prophylaxis is initiated
B. Prophylaxis
1. Indomethacin 25 mg three times daily PO for 6 to 8 weeks
2. Radiation therapy (1 dose 700 cGy within 48 hours of surgery)
C. Most commonly occurs with extended iliofemoral exposure; Kocher-
Langenbach is the second most common.
IV. Post-traumatic Arthritis
A. Up to 20% occurrence in anatomically reduced posterior wall fractures
B. Risk factors
1. Greater than 2 mm of articular step-off
2. Marginal impaction
3. Femoral head impaction
4. Cartilage necrosis
5. Posterior wall resorption
C. Aseptic necrosis (osteonecrosis)
1. Between 5% and 10% of posterior wall fractures
2. Limited association between surgical approach and development of avascu-
lar necrosis

A
B
C D
Figure 15-9
A to C, Postoperative anteroposterior and Judet radiographs following fixation of an unstable posterior wall
fracture. Due to the size of the posterior wall component, an atypical construct with two small fragment
plates was used in this case. D, The axial computed tomography scan reveals reduction of the posterior wall
articular surface with less than 2 mm of step-off and a concentric reduction of the femoral head.
3. Often related to energy imparted at time of injury (e.g., impaction of

femoral head or dislocation)
V. Thromboembolitis
A. Mechanotherapy and pharmacotherapy
B. Early mobilization
REHABILITATION
I. Touch-down weight bearing begins immediately postoperatively. If there is bilat-
eral lower extremity involvement, it may be necessary to consider wheelchair
transfers or a pressure unloading seating system.
II. No hip flexion precautions are necessary.
III. Pharmacologic thromboprophylaxis is mandatory.
IV. Lower extremity strengthening exercises are essential for obtaining an optimal
functional outcome.
V. At 6 weeks postoperatively:
A. Assess radiographs (Fig. 15-9).
B. Progress from touch-down weight bearing to full weight bearing over the
course of the subsequent 6 weeks.
VI. The patient should be transitioned to full weight bearing by 12 weeks
postoperatively.
VII. Physical therapy, including abdominal strengthening and low back programs along
with aquatic therapy, is also useful adjunct treatment in the postoperative
period.
SUGGESTED READINGS
Buchholz RW, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults,
6th ed. Philadelphia, Lippincott Williams & Wilkins, 2006.
Koval KJ, Zuckerman JD: Handbook of Fractures, 3rd ed. Philadelphia, Lippincott Williams &
Wilkins, 2006.
Thompson JC: Netter’s Concise Atlas of Orthopaedic Anatomy. Teterboro, NJ, Medimedia USA,
2002.
Tile M, Helfet D, Kellam J: Fractures of the Pelvis and Acetabulum. Philadelphia, Lippincott
Williams & Wilkins, 2003.
C H A P T E R
16
External and Internal Fixation of
Symphysis Pubis Widening
Nirav H. Amin, Jaimo Ahn, and Samir Mehta
Case Study
A 35-year-old male involved in a motor vehicle collision is taken to an emergency depart-

ment and evaluated in the resuscitation bay. Following a general trauma survey utilizing
the Advanced Trauma Life Support (ATLS) protocol, the patient is hemodynamically
stable but isolated orthopedic injuries are noted. On physical examination, the patient
complains of pain through the anterior aspect of the pelvis along with pain on palpation.
There are no open injures and both lower extremities are neurovascularly intact. An
anteroposterior (AP) pelvis radiograph demonstrates a pubic symphysis disruption

(Fig. 16-1).
BACKGROUND
I. The incidence of pelvic ring injuries is approximately 20/100,000 to 37/100,000 Approximately 40% of
and represents 0.3% to 6% of all fractures; 20% occur in patients with polytrauma. patients who have a
Pelvic fractures are often the result of high-energy, blunt forces such as motor pelvic fracture have an
intra-abdominal source of
vehicle collisions or falls from a height. Therefore, patients with these fractures
bleeding.
require an emergent and thorough evaluation.
II. Treatment can be surgical or nonsurgical, but emphasis should be placed on
reconstituting a stable pelvic ring that allows appropriate transfer of weight from
the axial skeleton (lower extremities) to the appendicular skeleton (spine and
pelvis).
III. As compared with the extremities, the pelvis has greater soft tissue constraints
and protects vital nonmusculoskeletal organs. Therefore, treatment of pelvic
ring injuries often requires techniques that differ from those used in the
extremities.
Figure 16-1
Pelvis anteroposterior radiograph with increased
widening of the pubic symphysis consistent with an
injury of the anterior pelvic ring given the patient’s
mechanism of injury. The right sacroiliac joint also
shows some potential widening. The remainder of
the pelvic ring, including the sacrum, the acetabuli,
and the proximal femora, show no fractures or
dislocations. A computed tomography scan would
further evaluate these regions of interest.

IV. Some basic mechanisms of injury include an anteroposterior directed force, which
can cause external rotation of a hemipelvis relative to the sacrum; a laterally directed
force, which can cause internal rotation; and a cephalad or caudad force vector,
which can cause a “vertical shear” of the injured hemipelvis. All these mechanisms
may cause disruption of the posterior, anterior, or both portions of the pelvic
ring.
ANATOMY
I. Bony Anatomy. The pelvis is composed of three bones: one sacrum and two
innominate bones, which in turn form from the fusion of the immature ischium
(posteroinferior); ilium (superior); and pubis (anteroinferior). The acetabulum
forms at the junction of these three bones. Important bony prominences and
landmarks include the anterior superior iliac spine, anterior inferior iliac spine,
iliac crest and fossa, posterior superior iliac spine, ischial spine, ischial tuberosity,
inferior and superior pubic rami, pectineal eminence, and pubic tubercle (Fig.
16-2).
II. Ring Stability. The bony pelvis is stabilized primarily by the pubic symphyseal
ligaments anteriorly and the posterior and interosseous ligaments posteriorly. The
pubic symphysis is composed of a complex of hyaline cartilage, fibrocartilage, and
fibrous tissues. The sacroiliac (SI) joints are composed of both hyaline and fibro-
cartilage. The SI joints are stabilized by anterior, posterior, and interosseous liga-
ments; the latter are the strongest ligaments in the body. The anterior and posterior
elements of the pelvis are further stabilized relative to each other through sacro-
spinous (AP and rotational vectors) and long and short sacrotuberous (vertical
vector) ligaments. From an inlet view, the sacrum forms an inverted keystone or
suspension bridge (Fig. 16-3) that has inherent stability when the surrounding
structures are in continuity; with loss of bony or ligamentous constraints, the
sacrum tends to displace anteriorly (the bridge will fall). From an outlet view (Fig.
16-4), the sacrum forms the keystone of an arch that transfers weight from the
spine to the acetabuli.
III. Nonmusculoskeletal Structures. The pelvis has an intimate and constrained
relationship with a number of structures including branches of the lumbosacral
plexus, main and terminal branches of the iliac vascular system, lower gastrointes-
THE MOST COMMON NERVE tinal tract, and genitourologic structures including the bladder and urethra.
INJURED IS L5, AND THE
Knowledge of this anatomy is critical to the complete evaluation of the patient,
SECOND MOST COMMON IS S1.
as well as for surgical management.
INITIAL MANAGEMENT
Absence of intra- I. General Trauma Survey

abdominal or A. ATLS protocol, general resuscitation, and attendance to life-threatening
intrathoracic bleeding in issues
a patient with shock B. Initial evaluation of head/neck and thoracoabdominal injuries typically before
indicates the pelvis as a extremities
likely source. C. Application of sheet or pelvic binder to stabilize pelvis if injury is suspected
D. Further evaluation and workup of noted or suspected injuries. The hemody-
ANGIOGRAPHY SHOULD BE namically unstable patient represents a complex clinical scenario requiring
CONSIDERED IF HEMORRHAGE multiple points of evaluation and decision-making (see Treatment
CONTINUES DESPITE A Algorithm).
REDUCTION OF THE PELVIC II. Pelvic and Related Musculoskeletal Physical Examination
VOLUME. A. Inspect the skin for open wounds or bruising
B. Assess AP and lateral pelvic stability by gentle compression. Gross instability
should not be further exacerbated by forceful examination; equivocal stability
may be additionally assessed using image intensification.
C. Inspect and palpate both hips and lower extremities to assess range of
motion.
C H A P T E R 1 6 External and Internal Fixation of Symphysis Pubis Widening 161
Anterior Posterior
Anterior superior
iliac spine
Articular
part
Abdominal part
Anterior inferior
iliac spine Greater sciatic notch Pelvic part
Linea terminalis
Lesser sciatic notch
Pubic tubercle
Ischial tuberosity
Articular surface for
pubic symphysis
A Obturator foramen
Posterior Anterior

Anterior superior
iliac spine
Anterior inferior
iliac spine
Greater sciatic notch Acetabulum
Pubic tubercle
Ischial spine
Obturator canal
Lesser sciatic notch
Obturator membrane
Ischial tuberosity
B
Figure 16-2
Right pelvic bone. A, Medial view. B, Lateral view. (From Drake RL, Vogl W, Mitchell AWM: Gray’s Anatomy
for Students. Philadelphia, Churchill Livingstone, 2005.)
Anterior longitudinal
ligament
Lumbosacral Iliolumbar ligament
ligament
Anterior sacro-iliac
ligament
Intervertebral disc Ilium
Figure 16-3
The posterior pelvic ring can be thought of as a suspension bridge in cross-section. The sacrum is an inverted
keystone or represents a suspension bridge–like arrangement of the posterior pelvic ring. Loss of the
ligamentous support allows the bridge to “fall” or results in an anterior displacement of the sacrum. (From
Drake RL, Vogl W, Mitchell AWM: Gray’s Anatomy for Students. Philadelphia, Churchill Livingstone, 2005.)
Large ecchymoses over
the thigh, buttocks, or
sacrum may suggest
Morel-Lavalle lesion
(internal degloving injury
Pubic symphysis
with shearing of the skin Body of pubis
from the subcutaneous Pubic arch
fat). The high risk of
infection associated with
operating through this
lesion can have an impact
on both surgical timing
and exposure options.
Ischial tuberosity
Significant blood loss
from pelvic trauma is Sacrotuberous
ligament
more likely to be venous Coccyx
rather than arterial. Figure 16-4
An outlet view of the pelvis depicting the sacrum as the keystone of the pelvis. (From Drake RL, Vogl W,
Mitchell AWM: Gray’s Anatomy for Students. Philadelphia, Churchill Livingstone, 2005.)
IN INJURIES REQUIRING
PLACEMENT OF A SUPRAPUBIC
CATHETER, ENCOURAGE
UROLOGISTS OR
TRAUMATOLOGISTS TO
MAINTAIN A SAFE DISTANCE D. Perform careful pelvic and lower extremity neurologic assessment because
FROM POTENTIAL SURGICAL lumbar and sacral plexus injuries are not uncommon.
INCISIONS FOR RING FIXATION. E. Difficulty in palpating peripheral pulses in the lower extremities or abnormal
THE SAME IS TRUE IF THE
Doppler signals necessitate obtaining ankle brachial index measurements.
PATIENT REQUIRES A
III. Assessment of Associated Structures
DIVERSION (COLOSTOMY) OF
THE GASTROINTESTINAL
A. In men, blood at the urethral meatus, a boggy or high-riding prostate, or
TRACT SECONDARY TO INTRA- scrotal hematoma suggests urologic injury and may require cystography or
ABDOMINAL INJURY. urethrography prior to Foley catheter placement.
B. In women, blood at the urethral meatus, vaginal tears, or difficulty with Foley
catheter insertion suggests urologic injury.
Displaced rami fractures C. Vaginal bleeding associated with a pelvic fracture may indicate an open frac-
and sacroiliac joint ture. Gynecologic evaluation is a necessity in these patients.
disruptions are at higher D. Evaluation and documentation of rectal tone is mandatory in patients with a
risk for urethral injuries.
pelvic ring injury.
TREATMENT ALGORITHM
Check airway:
Injury Oxygen suction, position; intubation;
cervical spine control
Check breathing:
Chest tubes: Oxygen
Check circulation:
IV lines, crystalloid, blood; control external loss;
abdominal assessment; pelvic assessment;
assess for instability
Hemodynamically Hemodynamically Hemodynamically Hemodynamically

stable, with a unstable, with an unstable, with a stable, with an
stable pelvis unstable pelvis stable pelvis unstable pelvis
Continue assessment Blood replacement; cervical spine, Continue assessment

and treatment chest, AP spine radiographs and treatment
Circumferential pelvic compression Operative fixation of

Peritoneal lavage pelvis for patient mobility

and comfort, if required
Urgent transport to OR
Positive Negative
External fixation of pelvis
Laparotomy Patient still unstable

Patient stable Peritoneal lavage
Rule out coagulopathy,

Patient stable other injury; continue
Positive Negative
with replacement
Laparotomy
Patient still unstable Patient still unstable
Pelvic packing: no coagulopathy No coagulopathy: other cases
Patient still unstable

Angiography
Large vessel disorder Small vessel disorder
Surgical control Embolization
Patient stable
AP, anteroposterior; ED, emergency department; IV, intravenous; OR, operating room. (Data from Browner
BD, Levine AM, Jupiter JB, et al: Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries, 2nd ed.
Philadelphia, Saunders, 1998.)
Sacroliac joint Note vertical relationship between

sacrum and iliac wings
Iliac wing
Note en face view of

Pubic obturator foramen
symphysis Ischium

Anteroposterior view of the pelvis. Outlet view of the pelvis.
IMAGING STUDIES
Physiologic widening of I. Standard Radiographic Views

the pubic symphysis that A. AP radiographs (Fig. 16-5). Anterior fractures, symphyseal injuries, significant
occurs normally and SI displacement, and iliac wing injuries are readily seen; can demonstrate 90%
naturally during of pelvic fractures. Sacral injuries can also be described but less frequently.
pregnancy should not be B. The outlet view, or 40-degree cephalad view (Fig. 16-6), is useful for assess-
mistaken for an anterior ment of vertical displacement of the hemipelvis. A widened sacroiliac joint and
ring injury. fractures of the sacrum (including neural foramina) may be visualized.
C. The inlet view, or 40-degree caudad view (Fig. 16-7), assesses AP displacement
of the SI joint, sacrum, or iliac wing. Rotational deformities of the hemipelvis
can also be evaluated.
D. Judet views are used to evaluate acetabular fractures (see Chapter 15 for
details).
II. Cross-Sectional and Reconstructed Images
A. Computed tomography scans with fine cuts and reconstruction may reveal
minimally displaced fractures especially of the posterior ring and may provide
additional resolution regarding fracture fragments.
B. Magnetic resonance imaging is largely reserved for assessment of ligamentous
injuries or intrapelvic soft tissue structures and rarely indicated in acute trau-
matic injuries.
FRACTURE CLASSIFICATION
I. Anatomic. The Letournel system is a descriptive system based on the location of
the fracture.
II. Mechanism
A. Penal first introduced a mechanistic classification system in 1961 composed of
lateral compression (LC), anterior-posterior compression (APC), and the verti-
cal shear (VS).
Note anteroposterior relationship

between sacrum and iliac wings
Note the view of

bony brim of
Figure 16-7 pelvic inlet
Inlet view of the pelvis.
Note symphysis joint and
symmetry of iliac wing
about the sacrum
B. Young and Burgess (1986) further subdivided LC into the following three
types.
1. Pubic rami fractures with impaction of the SI joint
2. Pubic rami fractures with internal rotation and posterior disruption (iliac
wing fracture or varying degrees of anterior SI impaction and posterior SI Different Young and
Burgess types appear to
disruption depending on location of impact on ilium)
be associated with certain
3. LC fracture on one side with an associated APC (external rotation) fracture injury patterns:
on contralateral side anterior-posterior
C. APC fractures were divided into three subtypes. compression with
1. Anterior ring widening with intact posterior elements. hemorrhage as well as
2. Anterior widening of the SI joint, external rotation of the ilium, and disrup- thoracic, urologic, and
tion of sacrotuberous and sacrospinous ligaments. head injuries; vertical
3. Complete anterior and posterior SI joint disruption. shear with hemorrhage;
D. One of the strengths of this system is that it is predictive of associated injuries and lateral compression
and may aid in the initial evaluation and stabilization of the patient. with thoracic injuries.
III. Stability
A. Buchholz in 1981 and Tile in 1988 created a system based on stability.
B. The Tile classification is divided into three types (Fig. 16-8).
1. Type A: stable
a. 1: Avulsion
b. 2: Minimally displaced ring
2. Type B: rotationally unstable
3. Type C: rotationally and vertically unstable
C. The OTA/AO scheme presents a variation where:
1. Type A: stable

a. 1: Avulsion
b. 2: Impaction
c. 3: Transverse sacral/coccygeal fracture
A Type B1.1 B1.2 B1.3
B B2.1 (ipsilateral) B2.1 (locked symphysis) B2.1 (tilt)
C Type B2.2 D Type C

Figure 16-8
Tile classification of pelvic ring disruptions. This classification system is potentially predictive of
stability. (From Koo H, Leeridge M, Bhandari M, et al: Interobserver reliability of the Young-Burgess and Tile
classification systems of fractures of the pelvic ring. OTA [poster], 2002.)
2. Type B: partially stable

a. 1: Unilateral/partial radiographic change in external or internal
rotation
b. 2: Bilateral/partial injury
3. Type C: unstable
a. 1: Unilateral/complete
b. 2: Bilateral/complete-incomplete
c. 3: Bilateral/complete
D. One of the strengths of this system is that it helps guide treatment options.
SURGICAL ALTERNATIVE: EXTERNAL FIXATION

I. Three options exist for external fixation of the pelvis as either a temporizing
solution until the patient is hemodynamically stable for definitive fixation or
as a definitive solution based on the fracture pattern and type of surgery
required.
A. Anteriorly based external fixation constructs
1. ASIS or iliac wing
2. AIIS or supra-acetabular (author’s preferred method)
B. Posteriorly based external fixation constructs may be necessary in the AO/OTA
type C injuries and are performed with a C-clamp or Hannover frame.
II. Goals
A. Improve stability of pelvis by placing a frame referenced to the site of injury
(anterior or posterior).
B. Decrease pelvic volume and limit blood loss.
C. Recreate “ring” structure to pelvis.
D. Restore continuity of axial skeleton to appendicular skeleton.
E. Maintain access to abdominal and urologic structures for operative treatment.
F. Provide pain relief and assist in mobilization of patient for nursing care and
physical therapy.
G. Limit intrapelvic hardware in patients for future childbirth.
GENERAL PRINCIPLES OF PUBIC SYMPHYSIS INJURIES

I. Isolated pubic symphysis injuries are usually stable and rarely need operative
management. Patients may bear weight as tolerated until the injury has healed and
pain relief has reached a plateau.
II. Significantly displaced anterior injuries (e.g., disruption of the pubic symphysis)
indicate potential concomitant posterior ring injury and may require stabilization
and fixation.
III. Stable posterior ring injuries (minimal displacement or rotation, impaction type
injuries) with mild anterior injuries (e.g., less than 2.5 cm of symphyseal diastasis)
may also be considered for nonoperative treatment.
IV. Seemingly stable posterior ring injuries with significant anterior displacement
(e.g., greater than 2.5 cm of symphyseal diastasis) or with unacceptable rotational
displacement may be candidates for surgical stabilization.
V. Injuries with unstable posterior and anterior elements require anterior and/or
posterior stabilization and fixation.
Anterior Inferior Iliac Spine (Supra-Acetabular) External Fixation

I. The patient is placed in the supine position on a radiolucent operating room table.
The abdomen and thorax are draped into the surgical field but the lower extremi-
ties are not. Laterally, the patient is prepped down to the table (to include the
possibility of SI joint fixation).
Figure 16-9
Anteroposterior, inlet, and outlet pelvic radiographs showing placement of supra-acetabular pins for anterior
external fixation.
II. Fluoroscopic imaging is obtained prior to prepping and draping to ensure that
Judet, inlet, and outlet views, as well as an AP image, can be obtained.
III. Once the patient is adequately positioned and fluoroscopic imaging is in place,
the patient is prepped and draped in standard fashion according to the surgical
principles outlined in Chapter 1.
IV. A roll-over modified outlet view is obtained to define the region of the supra-
acetabulum. The supra-acetabular region is then localized with a K-wire.
V. The K-wire is then overdrilled with a cannulated drill (usually 3.5-mm in size)
through the anterior cortex only.
VI. A roll-over–inlet view is obtained to confirm the direction of drilling toward the
posterior inferior iliac spine.
VII. A 5-mm Schanz pin is slowly inserted by manual power. Multiple images are
obtained to confirm the direction and location of the pin. Usually, the pin is

inserted to a depth of at least 70 to 80 mm.
VIII. The same technique is repeated on the contralateral side.
IX. A carbon graphite bar is used to connect the two Schanz pins. The pelvis is reduced BE SURE TO DOCUMENT A
prior to tightening of the clamps. DETAILED VASCULAR AND
X. If there is continued posterior widening of the sacroiliac joint, consideration for NEUROLOGIC STATUS BEFORE
the placement of a percutaneous iliosacral screw is made. AND AFTER REDUCTION
XI. Postoperative radiographs are shown in Figure 16-9. ATTEMPTS.
Open Reduction and Internal Fixation

I. Patient Positioning, Prepping, and Draping
A. The patient is placed in a supine position on a radiolucent table with the chest,
abdomen, and lateral flanks prepped into the field. The extremities do not need
to be prepped into the field, but traction should be maintained with a traction
pin in patients with cephalad displacement of the hemipelvis.
B. Fluoroscopic imaging is obtained prior to prepping and draping to ensure that
inlet, outlet, and AP images can be obtained.
C. Once the patient is adequately positioned and fluoroscopic imaging is in proper
place, the patient is prepped and draped in standard fashion according to the
surgical principles outlined in Chapter 1.
II. Surgical Exposure (Modified Pfannenstiel Approach)
A. With a 15-blade, a transverse incision is made approximately 1 cm proximal to
the superior border of the pubic symphysis centered with respect to the umbi-
licus. The length of the incision is approximately 5 to 6 cm.
B. The incision can be carried laterally just past the external inguinal ring.
C. Dissection through the subcutaneous tissue yields identification of the aponeu-
rotic fibers of the external oblique and anterior rectus fascia.
D. The spermatic cord/round ligament (females) is identified. Pay careful atten-
tion to the spermatic cord/round ligament during the surgical approach to
avoid injury to these structures.
E. Next, an incision is made along the linea alba (between the heads of the rectus
abdominis), extending distally onto the symphysis pubis.
THE “CORONA MORTIS” IS AN F. The posterior rectus sheath is carefully incised so as to not injure the prostatic
ANATOMIC VARIANT IN WHICH venous plexus and bladder (typically identified by overlying fat).
THERE IS A VASCULAR G. The bladder is protected by interposing a lap sponge, malleable retractor, or
CONNECTION BETWEEN THE both between the surgeon and the structure.
OBTURATOR AND THE H. The symphyseal ligament is débrided where it is torn, and the margins of the
EXTERNAL ILIAC ARTERY. ligament are defined sharply.
FAILURE TO IDENTIFY AND I. The pubic rami are exposed lateral to the symphysis via subperiosteal dissec-
LIGATE THIS CONNECTION tion along the posterosuperior and posterior surface. During this dissection,
COULD RESULT IN anterior attachment of both heads of the rectus is maintained (traumatic dis-
INADVERTENT DISRUPTION
ruptions of the rectus attachment are sometimes seen and should be repaired
AND SIGNIFICANT
after fixation of the symphysis).
(POTENTIALLY FATAL)
BLEEDING. A CORONA MORTIS J. If a corona mortis is present, it should be addressed prior to extending the
OCCURS IN AT LEAST 30% OF dissection further or beginning reduction maneuvers. It can be ligated or
PATIENTS, ALTHOUGH SOME coagulated.
SERIES SUGGEST A HIGHER III. Reduction
NUMBER. A. Once adequately exposed, a sharp Weber clamp may be applied anteriorly
engaging the pubic tubercles.
1. Predrilling small pilot holes (with a 2.5- or 2.0-mm bit) may aid in secure
application of the clamp.
2. Both rotational and flexion-extension deformities may be corrected in this
manner.
3. If greater force is required or the bone is osteoporotic, a Farabeuf or Jung-
bluth clamp may be applied anteriorly and secured with 3.5-mm screws
(details of this technique are beyond the scope of this discussion).
4. The larger screw-assisted clamps are often required if there is posterior
displacement of the hemipelvis or if the fracture is being reduced after some
healing has occurred (delayed fixation).
B. Reduction is assessed by fluoroscopic AP, inlet, and outlet views using both
anterior and posterior anatomy to gauge reduction quality and restoration of
ring structure.
IV. Fixation
A. Fixation is typically performed with a single six- or eight-hole 3.5-mm pelvic
reconstruction plate. The plate may need to be slightly contoured to fit the
symphysis.
B. The plate is placed superiorly and slightly posteriorly. Four to six screws are
placed in the plate. The goal with screw fixation is to use the longest screws
possible as screw fixation is, in part, dependent on screw length. This requires
screws to be angled to reach the most bone (Fig. 16-10). Care should be taken
not to extrude the screws through the anterior or posterior aspects of the
anterior ring.
C. A second plate may be applied anteriorly if the patient is felt to be unstable.
Usually, this anterior plate is two or three holes. However, this is often only
utilized for revision situations.
Figure 16-10
Anteroposterior, inlet, and outlet radiographs after open reduction and internal fixation of a pubic symphyseal
injury. Note the contour of the plate as well as the length of the screws utilized for fixation.
V. Closure
A. The wound is irrigated and drains are placed deep and superficial to the rectus
abdominis muscle.
B. The wound is closed in standard fashion according to the surgical principles
outlined in Chapter 1.
C. Bladder injuries should be addressed prior to definitive closure of the incision.
D. It is important to repair the heads of the rectus muscle to their distal attach-
ments if a surgical or traumatic detachment is recognized.
POSTOPERATIVE CONSIDERATIONS
I. Postoperative Care
A. Careful monitoring of neurovascular status
B. Obtaining postoperative radiographs including AP, inlet, and outlet views. If
there is a concern for secondary injury, then a computed tomography scan
should be obtained.
C. Postoperative resuscitation as necessary
D. Deep venous thrombosis prophylaxis with consideration of preoperative vena-
caval filter if indicated (particularly in those patients with an associated long
bone fracture)
E. Early mobilization
F. Physical therapy for range of motion, strengthening, and gait training, includ-
ing an abdominal and low back program
II. Weight-bearing Status
A. Uninvolved lower extremity may be weight bearing as tolerated.

B. Involved lower extremity is touch-down weight bearing for at least 6 weeks.
C. Progress from touch down to full weight bearing from 6 to 12 weeks assuming
radiographic and clinical signs of healing.
D. If bilateral unstable pelvic fractures have been fixed, patients should not be
mobilized until radiographic evidence of fracture healing is noted. Once there
is evidence of fracture healing, the less injured side is advanced to partial weight
bearing by the 8th to 12th week.
COMPLICATIONS
I. Increased infection risk with the following:
A. Associated abdominal and pelvic visceral injuries
B. Contusion or shear injury to soft tissues
C. Postoperative hematoma formation
II. Abnormal or continuous bleeding from fracture and/or subsequent surgical
procedures
III. Deep vein thrombosis or thrombophlebitis
IV. Intrapelvic or intra-abdominal compartment syndrome
V. Thromboembolic events due to disruption of the pelvic venous vasculature and
prolonged immobilization
VI. Dyspareunia
VII. Malunion: chronic pain, gait instability, limb length equalities, sitting difficulties,
pelvic outlet obstruction, and low back pain
VIII. Nonunion, which is rare, but occurs more frequently in patients younger than 35
years of age. Chronic pain, gait instability, and nerve root irritation may occur.
Further surgery using bone graft and alternative fixation constructs may be needed
for union.
IX. Hardware failure, which is common. When the symphyseal ligament heals
and the fractures unite, there is some motion (normal) at the pubic symphysis.
This motion can lead to either screw loosening or plate breakage. Patients
should be warned of this preoperatively. If this does occur after the patient
heals, it is usually not a surgical emergency and can be addressed only if
symptomatic.
SUGGESTED READINGS
Browner B, Jupiter J, Levine A, Trafton P: Skeletal Trauma: Fractures, Dislocations, Ligamentous
Injuries, 3rd ed. Philadelphia, Saunders, 2002.
Bucholz RW, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults,
6th ed. Philadelphia, Lippincott Williams & Wilkins, 2006.
Koval KJ, Zuckerman JD: Handbook of Fractures, 3rd ed. Philadelphia, Lippincott Williams &
Wilkins, 2006.
Thompson JC: Netter’s Concise Atlas of Orthopaedic Anatomy. Medimedia USA, 2002.
Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, 3rd ed. Philadelphia,
Lippincott Williams & Wilkins, 2003.
S E C T I O N
V
HIP
CHAPTER 17 Hip Decompression and Grafting 173
CHAPTER 18 Total Hip Arthroplasty 184
CHAPTER 19 Hip Fractures 196
C H A P T E R
17
Hip Decompression and Grafting
Gregory K. Deirmengian and Jonathan P. Garino
Case Study
A 45-year-old male is referred to the office by his primary physician with an insidious
onset of right groin pain of 2 months’ duration. He explains that the pain is moderate
in severity and aching in nature, and it radiates to the anteromedial thigh. It has not
responded to a 3-week trial of nonsteroidal anti-inflammatory drugs (NSAIDs). The pain
seems to be exacerbated by activity and improves but is not completely resolved with rest.
The patient is normally active and plays tennis twice a week but has not been able to
participate since the pain began. The patient has a past medical history significant only
for Crohn’s disease, which has led to hospital admission and administration of intravenous
and oral steroids multiple times in the past, most recently 3 months ago. The patient lives
with his wife and two children, and he drinks four beers per day on average. Physical
examination is significant for an antalgic limp and concordant pain with flexion and inter-
nal rotation. Laboratory studies are within normal limits. Figure 17-1 shows an antero-
posterior (AP) radiograph and a magnetic resonance imaging scan of the right hip.
Hip
A B
Figure 17-1
Plain anteroposterior (A) and coronal (B) magnetic resonance imaging scan of the right hip. (Modified from
Wiesel SW, Delahay JN: Principles of Orthopaedic Medicine and Surgery. Philadelphia, Saunders, 2001.)

174 S E C T I O N V Hip
BACKGROUND
I. Osteonecrosis of the femoral head is a pathologic process characterized

by osteocyte death that results in a decline in structural bone integrity.
When a sufficient degree and duration of force beyond the threshold of
the weakened subchondral bone is applied, femoral head collapse occurs.
With time, motion and force applied to the incongruent joint surface leads to
osteoarthritis.
II. Osteonecrosis of the femoral head is relatively common, with 20,000 new
cases diagnosed each year. The diagnosis accounts for 5% to 10% of total
How does your attending hip replacements per year in the United States. The male-to-female distribution
manage the asymptomatic
is 4:1 and the mean age of onset is in the 30s. Bilateral disease has been reported
hip in cases of bilateral
osteonecrosis with a in as many as 80% of atraumatic cases. It is relatively common for a patient
symptomatic contralateral to present with symptomatic osteonecrosis of one hip and asymptomatic osteone-
hip? crosis of the contralateral hip that is diagnosed based on a high level of
suspicion.
III. The natural history of osteonecrosis of the femoral head demonstrates clinical
and radiographic progression to collapse and possible degenerative joint dis-
ease requiring surgery. The typical time frame is 2 to 3 years from the onset
of symptoms. There are no clear factors associated with more rapid
progression.
IV. Etiology
A. Traumatic
1. Hip dislocation. The incidence of osteonecrosis is 10% to 25%. Negative
predictors include severe injury, associated femoral neck and acetabular
fractures, and delayed reduction (>12 hours).
2. Femoral neck fracture. The incidence of osteonecrosis is 15% to 50%.
Negative predictors include severity of initial displacement and malreduc-
tion after open reduction and internal fixation.
3. Minor contusive trauma. This risk factor is not as common but has been
reported.
B. Atraumatic
1. Corticosteroids. These account for 10% to 30% of cases. Trends suggest
that higher doses in short durations pose a higher risk of osteonecrosis than
lower doses administered for a longer time period. It is likely that the risk
of osteonecrosis increases once the aggregate amount of corticosteroids over
a patient’s lifetime exceeds 2.0 grams.
2. Alcohol. This accounts for 10% to 40% of cases. Consumption of more
than 400 mL of alcohol per day is associated with a 10-fold increased risk
of osteonecrosis.
3. Hemoglobinopathies. Associated disorders include sickle cell disease, hemo-
globin SC disease, and thalassemias.
4. Dysbarism (Caisson’s disease), which affects tunnel workers and deep sea
divers
The two most common 5. Pregnancy
atraumatic causes of 6. Hyperlipidemia
osteonecrosis are steroid 7. Gaucher’s disease
use and alcohol 8. Systemic lupus erythematosus
consumption. 9. Idiopathic
V. Vascular Anatomy, Pathophysiology, and Pathogenesis
A. Vascular anatomy (Fig. 17-2)
1. The extracapsular arterial ring is formed posteriorly by a large branch of
the medial circumflex femoral artery and anteriorly by branches of the
lateral circumflex femoral artery.
2. The ascending cervical arteries, also known as the retinacular arteries, arise
from the extracapsular arterial ring. They penetrate beneath the hip capsule
C H A P T E R 1 7 Hip Decompression and Grafting 175
Lateral epiphyseal arterial group

Subsynovial intracapsular
arterial ring
Ascending cervical Figure 17-2
arteries Blood supply of the femoral head and neck. (From
Medial
femoral Canale ST [ed]: Campbell’s Operative Orthopaedics,
circumflex 10th ed. Philadelphia, Mosby, 2003.)
artery Extracapsular
arterial ring
and travel along the femoral neck, where they send branches into the
metaphysis. The superior retinacular arteries are the main source of blood
supply to the femoral head.
3. The subsynovial intra-articular ring is formed by the ascending cervical
arteries at the junction of the femoral neck and articular cartilage of the
femoral head. They sprout epiphyseal branches, which enter the femoral
head.
4. The artery of the ligamentum teres is a branch of the obturator artery and
a minor contributor to femoral head blood supply in adults.
B. Pathophysiology Specific bones that have a
1. The microcirculation of the femoral head is tenuous and vulnerable. tenuous blood supply
2. Diminution or disruption of the extraosseous or intraosseous sources of include the talar body,
blood leads to bone ischemia and eventual necrosis. proximal pole of the
3. The level and extent of occlusion determines the number, size, and location scaphoid, odontoid
of femoral head zones involved in the necrosis. process, and femoral
C. Pathogenesis. Vascular occlusion leads to ischemia and osteocyte necrosis by head.
one of three mechanisms.
1. Vascular disruption occurs with fractures and dislocations.
2. Extravascular compression is due to marrow adipose deposition and lipocyte
hypertrophy, leading to an increase in the extravascular intraosseous pres-
sure with resulting decreased blood flow and venous drainage. Adipose
deposition results from the use of alcohol and corticosteroids, hyperlipid-
emia, and Gaucher’s disease.
3. Intravascular congestion is due to thrombotic occlusion and fat emboli
resulting from hypercoagulability, hemoglobinopathies, and pregnancy.
VI. Imaging and Classification
Hip
A. Radiographs
1. Early stages are characterized by heterogeneous areas of mottled sclerosis
and lucency, usually in the anterosuperior femoral head.
2. Later stages are characterized by subchondral fracture and collapse (crescent
sign).
3. End-stage disease is characterized by signs of secondary osteoarthritis.
B. Bone scan
1. In the acute infarction phase, the ischemic segment shows photopenia.
2. In the repair phase, the diseased segment shows a signal “hot spot.”
C. Magnetic resonance imaging
1. Early stages show low signal intensity on both T1-weighted and T2-
weighted images.
2. More advanced stages show low signal intensity on T1-weighted images and
alternating “ribbons” of low and high signal intensity on T2-weighted images.
D. The University of Pennsylvania system for staging osteonecrosis is given in
Box 17-1.
VII. Differential Diagnosis
A. Synovitis. Presentation can resemble stage 0 osteonecrosis.
B. Trochanteric bursitis. Presentation can resemble stage 0 osteonecrosis.
C. Labral tear. Presentation can resemble stage 0 osteonecrosis.
BOX 17-1. University of Pennsylvania System for Staging

Osteonecrosis
Stage Criteria
0. Normal radiographs and magnetic resonance imaging (MRI) scan
I. Normal radiographs and abnormal MRI
A. <15% of the femoral head affected
B. 15% to 30% of the femoral head affected
C. >30% of the femoral head affected
II. Cystic and sclerotic radiographic changes
A. <15% of the femoral head affected
B. 15% to 30% of the femoral head affected
C. >30% of the femoral head affected
III. Crescent sign on radiographs, with no articular flattening
A. <15% of the articular surface
B. 15% to 30% of the articular surface
C. >30% of the articular surface
IV. Femoral head flattening
A. <15% of the articular surface and <2 mm depression
B. 15% to 30% of the articular surface or 2 to 4 mm depression
C. >30% of the articular surface or >4 mm depression
V. Joint narrowing or acetabular changes
A. Mild
B. Moderate
C. Severe
VI. Advanced degenerative changes
D. Transient osteoporosis. Magnetic resonance imaging changes are more diffuse,

and typically a homogeneous high signal is seen acutely on T2-weighted
images.
E. Femoral neck stress fracture
F. Metastatic disease
TREATMENT PROTOCOLS, ALTERNATIVES, INDICATIONS,

AND CONTRAINDICATIONS
I. Conservative Treatment. Indications include early-stage to middle-stage I
lesions and absence of medical clearance for surgery.
A. Limited weight bearing, pain control, and close clinical follow-up with radio-
graphic imaging and magnetic resonance imaging are necessary.
B. Risk factors, including steroids (when medically possible) and alcohol, should
be avoided.
C. Medications such as those in the bisphosphonate and statin classes may help
delay disease progression.
D. Late stage I lesions and beyond are less likely to be successfully treated by this
method.
II. Core Decompression with and without Bone Grafting
A. Core decompression is a technique that involves drilling the medullary bone
of the femoral head to decrease pressure and improve circulation.
B. When successful, the technique provides pain relief and prevents disease
progression.
C. Under most circumstances, it is necessary to remove necrotic bone and replace

it with nonvascularized or vascularized bone graft to improve the chances of a
successful clinical outcome. As a general guideline, core decompression without
bone grafting should only be considered for the smallest lesions.
D. Examples of nonvascularized bone graft include cancellous allograft chips, The success rate of core
structural allograft, iliac crest autograft, and femoral head allograft (as described decompression for
below). Examples of vascularized bone graft include a vascularized free fibula femoral head
bone graft. osteonecrosis can be
E. The success rate of the technique varies widely in the literature, but the best quoted to patients as
estimate of success rate is approximately 66%. 66%.
F. Indications include stage IA, IB, IIA, and IIB (pre-subchondral collapse lesions).
Vascularized free fibula bone grafting should be considered in younger patients
with extensive disease in an attempt to maximize the chances for success and
to avoid a total hip arthroplasty (THA).
G. Contraindications include any degree of collapse and stage III to VI, which are
predictors of poor outcome after treatment by core decompression. Larger
lesions (stage IC and IIC) are more difficult to manage with core decompres-
sion alone and require bone grafting.
III. Osteotomy
A. Several osteotomy procedures have been attempted with varying degrees of
success. Specifics are beyond the scope of this chapter.
B. The goal of such procedures is to reorient the joint surface such that the line
of force through the joint is redirected across healthy bone.
C. Examples include intertrochanteric osteotomy and transtrochanteric rotational
osteotomies.
D. Indications include late presubchondral collapse and early postsubchondral
collapse lesions.
E. Contraindications. Less invasive options are available for disease stages less
severe than late presubchondral collapse. Osteotomy techniques are not suc-
cessful if a significant degree of collapse or arthritic changes are present.
IV. Resurfacing Arthroplasty
A. This technique is an option for younger patients with disease that precludes
an attempt to preserve native bone but lacks acetabular involvement requiring
THA.
B. The potential advantage is the ability to save bone stock for future revision as
well as preservation of more native anatomy and hip biomechanics.
Hip
C. Specific complications include femoral neck fracture and loss of prosthetic Acetabular and femoral
fixation. resurfacing arthroplasty
D. Indications include young patients with stage III and IV and early stage V has more recently re-
osteonecrosis of the femoral head. emerged as bone-
E. Contraindications include middle to late stage V and stage VI with acetabular conserving means of
involvement, active infection, concomitant osteoporosis, and insufficient managing osteonecrosis
femoral head bone stock due to collapse or cystic degeneration that would of the hip, although long-
compromise fixation. term outcomes of these
V. THA new designs are not yet
A. Although it is the least bone-sparing option, THA represents a reliable means available.
of treating the pathology and reproducibly reducing hip pain.
B. THA also serves as an excellent salvage option for other failed attempts at
treatment, such as core decompression and resurfacing arthroplasty.
C. Indications include stage III to VI osteonecrosis. At this time, THA is likely
the best option for patients with stage VI osteonecrosis.
D. Contraindications include stage I and II osteonecrosis, which should be treated
with other nonarthroplasty options. Lack of medical clearance also precludes
patients from management with THA.
TREATMENT ALGORITHM
What is your attending’s Osteonecrosis

osteonecrosis of the
femoral head?
Stage I Stage II Stage III Stage IV/V Stage VI
⫺ symptoms ⫹ symptoms ⫹ symptoms ⫹ symptoms ⫹ symptoms
Core
Observation Resurfacing Total hip
decompression Osteotomy
Medication arthroplasty arthroplasty
± bone grafting
* * * * *
Core
Resurfacing Total hip
decompression
arthroplasty arthroplasty
± bone grafting
* = Salvage
GENERAL PRINCIPLES OF CORE DECOMPRESSION

I. Preoperatively, it must be ensured that signs of femoral head collapse, representing
advanced disease, are absent.
II. In combination with elimination of risk factors such as alcohol and steroids, core
decompression serves to reverse the cycle of decreased vascularity and increased
pressure within the femoral head.
III. The least invasive and most common means of accessing the center of the femoral
head is laterally, through a small skin incision and an osteotomy of
the lateral cortex of the proximal femur, just large enough to accommodate the
trephine.
IV. Under anteroposterior (AP) and lateral fluoroscopic guidance, the most appropri-
ately sized trephine is advanced to the lesion under multiple passes, and the con-
tents of the cores are removed and examined on a back table. Bone that appears
pathologic (hard, dense, and homogeneous) is sent to pathology, and bone that is
medullary in appearance is saved and later reintroduced into the femoral head void
as bone graft.
V. Postoperatively, patients’ weight bearing must be restricted for several months to
avoid a proximal femur fracture through the iatrogenic stress riser.
VI. Postoperatively, some patients experience immediate relief due to the decreased
pressure within the femoral head.

I. The patient is placed in the supine position on a fracture table (Fig. 17-3). The
fracture table is used to ease fluoroscopy and positioning of the hip in space. The
traction device of the fracture table is not needed for the procedure. The orienta-
tion of personnel and equipment is of great importance in making sure the pro-
cedure runs smoothly (Fig. 17-4).
II. Prior to transferring the patient to the fracture table, a perineal post is
properly placed and the patient is shifted inferiorly until the perineum is up
Figure 17-3
Operative setup with fluoroscopy on a fracture table.
Fracture table
Surgeons
Figure 17-4
Instruments Diagram of the operative setup.
Fluoroscope machine
Anesthesia
against the post. The feet are padded well with Webril and secured in the foot
holders.
III. The nonoperative leg is positioned in a flexed, abducted, and externally rotated
position to accommodate the fluoroscope machine between the patient’s legs. The
operative leg is positioned in line with the axis of the body and internally rotated
15 degrees to make the femoral neck parallel to the ground. The internal rotation
accounts for the natural anteversion of the femoral neck and allows for a true AP
radiograph of the hip to be taken during the procedure.
IV. The upper extremity on the ipsilateral side of the hip lesion is well padded and
secured over the patient’s chest (see Fig. 17-3). At this point, the fluoroscope is
Hip
properly positioned and images are obtained to make sure that an AP and lateral
view of the hip is well visualized (Fig. 17-5).
Figure 17-5
Fluoroscopic hip images after operative setup.
Figure 17-6
Shower curtain setup. Figure 17-7
Percutaneous Steinmann pin insertion site.
PLACING THE NONOPERATIVE V. A shower curtain drape is typically used to maintain a sterile field. Two poles
LEG IN A HYPERFLEXED/ positioned at both ends of the patient are positioned prior to the start of the
HYPERABDUCTED/EXTERNALLY case.
ROTATED POSITION PUTS IT VI. The operative field is defined with 1010 drapes, taking care to maintain a wide
AT RISK FOR THIGH surgical field, and then sterilized.
COMPARTMENT SYNDROME. VII. Draping is performed by securing sterile blue towels to the inner borders of the
10 ¥ 10 drapes. The blue towels and sterile field are now covered with Ioban, and
EXCESSIVE PRESSURE ON the entire field is then covered with the shower curtain drape, which is then
THE PERINEUM FROM THE secured to the shower curtain poles. (Fig. 17-6).
PERINEAL POST MAY RESULT
IN A PUDENDAL NERVE PALSY
POSTOPERATIVELY. Surgical Exposure
I. The lateral femoral starting point is localized through percutaneous insertion of
PLACING THE STARTING POINT a 1/8-inch Steinmann pin under fluoroscopic guidance (Fig. 17-7). The starting
TOO LOW IN THE DIAPHYSEAL
point should be superior to the diaphyseal femoral cortex. The angle of the Stein-
CORTEX CAUSES A STRESS
mann pin should aim toward the lesion, as determined by preoperative imaging.
RISER THAT MAY LEAD TO A
SUBTROCHANTERIC FRACTURE
AP and lateral fluoroscopic views verify the correct starting point and angle of
EITHER INTRAOPERATIVELY OR approach (Fig. 17-8).
POSTOPERATIVELY. II. A 2- to 3-cm skin incision is centered around the Steinmann pin entry site. The
pin can be removed at this point to ease the surgical approach. While obtaining
hemostasis, the subcutaneous soft tissues are sharply dissected to the level of the
fascia using a scalpel. The fascia can be clearly identified by removal of soft tissue
using a Cobb elevator. This is helpful at the conclusion of the procedure when
Figure 17-8
Fluoroscopic images demonstrating the Steinmann pin starting point and angle.
Figure 17-9
Trephine.
closing the wound. It is important to avoid overdissection, which may lead to fascia
devitalization.
III. A small longitudinal incision is made in the fascia in line with the fibers, and it is
extended proximally and distally as needed. Just deep to the fascia is the vastus
lateralis muscle. A Cobb elevator is used to separate the vastus lateralis muscle in
line with its fibers. This minimizes the degree of trauma to the muscle and allows
access to the base of the greater trochanter and lateral femoral cortex.
Osteonecrosis Lesion Localization, Decompression, and Grafting

I. The Steinmann pin is reintroduced into the wound and repositioned on the
lateral femoral cortex. A wire driver is used to advance the Steinmann pin into
the femoral head lesion under fluoroscopic guidance. Try to avoid breaching
the chondral surface of the femoral head and allowing the pin to violate the hip
joint.
II. A 9- to 10-mm cannulated anterior cruciate ligament drill is used over the Stein-
mann pin to create an opening in the lateral femoral cortex to allow other instru-
ments to easily traverse the path to the lesion. A trephine (Fig. 17-9) is introduced
over the guidewire, through the lateral cortical opening, and advanced by hand to
the lesion. The first trephine used is typically a smaller size instrument (e.g.,
8 mm). A second, larger trephine (9 mm) is advanced by hand through the lesion
in a controlled manner, taking care to prevent breaching the chondral surface into
the hip joint (Fig. 17-10).
III. The contents of the first trephine are removed and examined. The bone removed
Hip
from this trephine is typically viable cancellous bone. This bone is placed in saline
on the back table and maintained for insertion into the lesion.
IV. After the second trephine has traversed the lesion, it is removed from the
wound, and the contents are examined on the back table (Fig. 17-11). The extracted
bone consists of dense necrotic bone that is secured from the osteonecrosis
lesion. This bone is removed from the trephine and sent to pathology for
analysis.
Figure 17-10
Fluoroscopic images demonstrating femoral head lesion trephinization.
Osteonecrotic Normal
bone bone
Figure 17-11
Trephinization contents.
V. The smaller trephine (8 mm) is reintroduced into the tunnel created from the
lateral femoral cortex to the osteonecrosis lesion. A cannula is placed into the
trephine, and pressure is maintained on the bone graft with the cannula while
the trephine is slowly removed. This allows the bone graft to fill the femoral head
defect.
Wound Closure
A wheatlander (self-retaining retractor) is placed in the subcutaneous soft tissue to expose
the fascia. The fascial layer, the subcutaneous soft tissue, and dermal layer are closed in
standard fashion (see Chapter 1). The skin edges are approximated with staples and then
secured with a sterile dressing and a Tegaderm.

I. Patients are routinely admitted to the hospital overnight for pain control and
physical therapy clearance, but they are typically discharged home on the first
postoperative day.
II. Patients with bilateral surgery and elderly patients with unilateral surgery may
require a short stay at a rehabilitation facility.
III. Patients are made 50% weight bearing for 6 weeks to protect the vulnerable sub-
chondral bone, after which their weight-bearing is advanced. Patients who receive
bilateral core decompressions are made 50% weight bearing bilaterally or are
required to exhibit “four-point gait” for 6 weeks.
IV. The pathology specimen is followed to confirm the suspected diagnosis of
osteonecrosis.
V. Patients are followed in the office setting both clinically and radiographically for
disease progression, and salvage procedures are considered if the disease process
progresses despite the core decompression.
COMPLICATIONS
I. Infection
II. Hematoma
III. Persistent pain (due to preexisting arthritis, persistent osteonecrosis, occult
fracture)
IV. Postoperative trochanteric bursitis
V. Postoperative/intraoperative fracture
VI. Postoperative femoral head collapse
SUGGESTED READINGS
Barrack RL, Rosenberg AG: Master Techniques in Orthopaedic Surgery: The Hip, 2nd ed. Phila-
delphia, Lippincott Williams & Wilkins, 2006.
Callaghan JJ, Rosenberg AG, Rubash HE: The Adult Hip. Philadelphia, Lippincott Williams &
Wilkins, 2007.
Wiesel SW, Delahay JN: Principles of Orthopaedic Medicine and Surgery. Philadelphia, Saunders,
2004.
Hip
C H A P T E R
18
Total Hip Arthroplasty
Kristofer J. Jones, Stephan G. Pill, and Charles L. Nelson
Case Study
A 58-year-old obese female presents with right hip pain that has gradually developed over
the past 5 years. She reports that the pain wraps around the right hip, “shoots into the
groin,” and occasionally radiates down the thigh to the inside part of the knee. The pain
has significantly limited her from activities of daily living. The pain disrupts her sleep
most nights, and now she reports increasing difficulty getting into and out of her car and
putting on her shoes. Prolonged standing and walking also exacerbate the pain. She is now
limited to ambulating four blocks due to hip pain and started using a cane in the contra-
lateral hand 1 month ago. She denies morning stiffness or pain in other joints. She cannot
recall any preceding traumatic injury to the area and states that she has been taking up to
six ibuprofen tablets per day, which has provided mild relief. Her right hip has 70 degrees
of flexion, 10 degrees of internal rotation, and a 10-degree flexion contracture. The right
leg is 2 cm shorter than the left but is otherwise neurovascularly intact. An effort at weight
loss, physical therapy, and over-the-counter supplements has failed to provide relief. She
presents to your office desperate for a solution to her problems. An anteroposterior (AP)
radiograph of the right hip is presented in Figure 18-1.
BACKGROUND
I. Osteoarthritis (OA), also known as degenerative joint disease, is the most prevalent
form of arthritis, and it is a leading cause of physical disability worldwide. Approxi-
mately 16 million people in the United States have osteoarthritis and 1 in 3 people
older than 60 years of age suffer from the disease.
Figure 18-1
Anteroposterior view of the right hip.

C H A P T E R 1 8 Total Hip Arthroplasty 185
II. OA of the hip is characterized by focal articular cartilage degeneration, most

often in the weight-bearing portion of the joint. As localized areas of hyaline
articular cartilage degenerate, resultant forces experienced at these particular sites
increase across the hip. Ultimately, joint failure occurs when progressive cartilage
loss leads to bony remodeling and significant alterations in stress forces across the
joint.
III. Patients with OA of the hip classically present with insidious pain, typically char-
acterized as a dull ache that is elicited with activity and relieved by rest. This pain
can be localized to the groin or inguinal region, and in some cases, on the side of
the buttock or upper thigh. Patients typically experience decreased range of motion
as well as joint instability.
IV. OA of the hip is one of the leading causes of patients presenting with a painful
hip; however, it is important to rule out inflammatory arthritic conditions (rheu-
matoid and psoriatic arthritis), tumors, infection, crystalline arthropathies (gout
and pseudogout), and osteonecrosis, because the treatment protocol largely varies
according to the diagnosis.
V. Total hip arthroplasty (THA) is indicated in patients suffering from hip joint
degeneration from any number of causes. Persistent joint pain and physical dis-
ability following a trial of conservative treatment (weight reduction, low-impact
aerobic exercise, aquatic therapy, pharmacologic therapy) are the primary reasons
for performing the procedure. Approximately 250,000 THA procedures are per-
formed in the United States on an annual basis, with long-term follow-up studies
demonstrating 96% success rates at 10 years.
VI. Several important factors determine the appropriateness of THA. The overall
goals of surgical intervention are to relieve pain and improve function
through the restoration of joint stability and anatomic alignment of the lower
extremity.
VII. The presence of significant medical comorbidities may preclude surgical interven-
tion. Ultimately, the risks of perioperative mortality must be weighed against the
expected functional gains following THA.
TREATMENT ALGORITHM
Hip
Hip pain
Radiographs
Diagnosis
No treatment Failed nonoperative treatment

or early stage or end-stage degeneration
• NSAIDs Aquatic Alternatives to THA: THA

• G-CS* therapy • Arthroscopic débridement
• Activity • Hip arthrodesis
modification • Proximal or acetabular
• Weight loss osteotomy
*Glucosamine–chondroitin sulfate
TREATMENT PROTOCOLS
I. Treatment Considerations. The following factors should be weighed when
determining whether surgical intervention is in the best interest of the patient.
A. Patient age
B. Presence/absence of medical comorbidities
C. Symptom severity (pain, decreased range of motion, instability, muscle
weakness)
D. Limitation in functional ability
E. Extent of arthritic changes/deformity
F. Expected activity level
A. Weight reduction. Nonpharmacologic therapy remains a mainstay of OA of
the hip. Given the association between obesity and the development and pro-
gression of OA, weight loss should be emphasized from the first office visit.
B. Low-impact exercise. A low-impact exercise program has the potential to
increase aerobic capacity, muscle strength, and endurance, thereby optimizing
hip function and facilitating weight loss.
C. Aquatic therapy. In patients with symptomatic arthritis, formal aquatic therapy
programs can improve symptoms and functional range of motion.
D. Pharmacologic therapy. Pharmacologic intervention can be used to augment
exercise and physical therapy regimens. Drug treatment should be individual-
ized according to symptom severity, medical comorbidities, drug side effects,
therapeutic cost, and patient preferences.
1. Acetaminophen
2. Nonsteroidal anti-inflammatory drugs (NSAIDs). Clinicians may use con-
ventional NSAIDs or cyclooxygenase-II inhibitors for patients who are at
risk for developing gastrointestinal toxicity or bleeding.
E. Glucosamine and chondroitin sulfate oral supplementation. These dietary sup-
plements are derivatives of glycosaminoglycans, which are naturally occurring
compounds found in articular cartilage. Recent meta-analyses have demon-
strated that these dietary supplements may have a small analgesic in mild OA.
F. Intra-articular glucocorticoid injections. Intra-articular steroid injections of
the hip have not been studied extensively, so there is no clear consensus on the
benefit of this procedure. When combined with local anesthetics, an injection
may be of benefit in localizing the pain to the hip joint in patients who may
have pain referred from other sites (e.g., lumbar spine).
G. Intra-articular hyaluronic acid (viscosupplementation) injections. Although vis-
cosupplementation has proven to be useful for patients with early to moderate
arthritic changes of the knee, these injections are not currently approved for
the treatment of osteoarthritis of the hip.
SURGICAL ALTERNATIVES TO TOTAL HIP ARTHROPLASTY

I. Arthroscopic Débridement
A. Initial arthroscopic examination can help the surgeon identify the precise loca-
tion and extent of chondral degeneration and identify additional pathology that
may not have been clearly observed with radiographic or advanced imaging.
Arthroscopic débridement of the hip facilitates the removal of inflammatory
mediators, degenerative cartilage, and loose bodies. Débridement with chon-
dral abrasion, as well as loose body removal, is occasionally useful in the man-
agement of early to moderate arthritis, with associated mechanical symptoms,
that is not suitable for more aggressive procedures such as THA.
B. Indications
1. Early arthritis
2. Mechanical symptoms
3. Duration of symptoms less than 1 year
II. Hip Arthrodesis

A. Given the fact that current technologic advances in the field of THA have not
been perfected to meet the everyday demands of young, active patients in need Optimal hip arthrodesis
of surgical intervention, hip arthrodesis remains a feasible option for some position is 20 to 30
patients. The limitations of THA in this patient population are largely due to degrees of hip flexion,
the limited lifespan of the implants. The downfalls of hip arthrodesis include neutral to 5 degrees of
the potential for new onset of ipsilateral knee pain and back pain (up to 60% adduction, and neutral to
in one long-term study), as well as difficulties with various activities of daily 5 degrees of external
living such as putting on socks and shoes. rotation.
B. Indications. This operation is ideally suited for young, active laborers who are
motivated to return to work.
1. Unilateral hip arthritis
2. Age younger than 35 years
3. No evidence of degenerative changes or preexisting pain in the lumbar
spine, ipsilateral knee, or contralateral hip
4. Failed treatment for septic arthritis
C. Contraindications
1. Bilateral hip arthritis
2. Ipsilateral knee instability
3. Pain or radiographic abnormalities of the ipsilateral knee, contralateral hip,
or lumbar spine
4. Neurologic deficits (e.g., cerebral palsy)
III. Osteotomy
A. There are several hip osteotomy options with the primary goal being to transfer
loading forces from a degenerative area of the hip to a healthier region, pre-
venting disease progression and preserving viable remaining articular cartilage.
This goal is achieved through the repositioning of the femoral and/or acetabu-
lar articular surfaces, ultimately resulting in improved anatomic alignment of
the hip and reconstitution of hip biomechanics.
B. Two classes of hip osteotomies
1. Reconstructive osteotomy: the operative correction of an existing hip defor-
mity to prevent the formation of degenerative changes
2. Salvage osteotomy: operative correction of a hip with preexisting pathology
that can not yet be classified as end-stage degenerative disease
C. Types of osteotomies
1. Proximal femoral osteotomies
Hip
a. Varus osteotomy
(1) Goal of the procedure: to improve femoral head containment within
the acetabulum to reduce femoral head extrusion and redirect forces
medially
(2) Indications
(a) Hip instability
(b) Proximal femoral deformity
b. Valgus osteotomy
(1) Goal of the procedure: to increase articular congruency between the
femoral head and acetabulum, resulting in decreased stress forces at the
superolateral aspect of the acetabulum
(2) Indications
(a) Degenerative changes in the superolateral or medial acetabulum
(b) More than 60 degrees of hip flexion and more than 20 degrees of
adduction
2. Pelvic osteotomies. A number of pelvic osteotomies can be utilized to redi-
rect abnormal forces at the hip and establish congruency between the
femoral head and acetabulum. Young patients with a longstanding history
of developmental dysplasia of the hip and resultant hip arthritis largely
benefit from these procedures. The most common pelvic osteotomies
include the Ganz periacetabular osteotomy, Salter-single innominate,
Salter
Pemberton
Steel
Sutherland
Chiari
Dial
Figure 18-2
Several different pelvic osteotomies. (From Garino JP, Beredjiklian P [eds]: Core Knowledge in Orthopaedics:
Adult Reconstruction and Arthroplasty. Philadelphia, Mosby, 2007.)
Sutherland-double innominate, and Steel-triple innominate osteotomies. A

detailed discussion of these procedures is beyond the scope of this chapter
(Fig. 18-2).
SURGICAL INDICATIONS FOR TOTAL HIP ARTHROPLASTY

A. Most common causes
1. Osteoarthritis
3. Osteonecrosis
B. Other conditions that may result in end-stage joint deterioration
1. Diseases leading to osteonecrosis of the femoral head
a. Sickle cell disease
b. Gaucher’s disease
c. Alcoholism
d. Systemic lupus erythematosus
e. Chronic steroid use
2. Inflammatory arthritides
C. Radiographic features and diagnostic criteria

1. Eccentric joint space narrowing 1. Symmetric joint space narrowing
2. Bony sclerosis 2. Periarticular osteopenia/osteoporosis
3. Subchondral cyst 3. Joint erosion
4. Osteophyte formation 4. Ankylosis
II. Failed Nonoperative Treatment

A. Activity/behavioral modification
B. Low-impact aerobic exercise
C. Weight loss
D. Physical therapy
E. Ambulatory assistive devices (cane or walker)
F. Pharmacologic therapy (NSAIDs, cyclooxygenase-II inhibitors)
G. Dietary supplements (glucosamine–chondroitin sulfate)
CONTRAINDICATIONS TO TOTAL HIP ARTHROPLASTY

I. Absolute Contraindication: active infection (local or systemic)
II. Relative Contraindications
A. Morbid obesity
B. Neurologic dysfunction
C. Severe medical comorbidities (patient unable to safely tolerate the stress of
surgery)
GENERAL PRINCIPLES OF TOTAL HIP ARTHROPLASTY

I. THA stability is a function of component positioning, component sizing/fit,
abductor complex/soft tissue tension, and component fixation.
II. Proper alignment of the acetabular and femoral components is typically 20 to 30
degrees of acetabular anteversion, 35 to 40 degrees of acetabular inclination (theta
angle), and 10 to 15 degrees of femoral stem anteversion (Fig. 18-3).
III. Improper alignment can lead to anterior instability (increased acetabular antever-
sion), posterior instability (retroverted cup or stem), trochanteric impingement
(decreased theta), or superior instability (increased theta angle). The end point of
instability is hip dislocation.
IV. The primary arc range of motion of the hip contributes to stability and depends
on the head-to-neck diameter ratio, as well as any modifications made to the neck
Hip
Coronal tilt
(theta angle)
Figure 18-3
Acetabular cup position in coronal and sagittal
Anteversion plane. Coronal tilt (also known as theta angle)
angle should be 35 to 40 degrees. In the sagittal plane,
cup anteversion should be 20 to 30 degrees.
(From Miller MD: Review of Orthopaedics, 4th ed.
or cup (e.g., acetabular augmentation and neck collars). The greater the head-to-
neck ratio, the greater the range of motion prior to neck impingement on the
acetabular component.
V. The excursion distance is defined as the distance the head must travel to lever out
once the neck impinges on the acetabular component. The excursion distance is
typically half the diameter of the head. A larger diameter head has a larger excur-
sion distance and thus confers greater hip stability.
VI. The hip abductor complex (gluteus medius and minimus) tension must be main-
tained for optimal hip stability.
VII. Any process that interferes with proper soft tissue function or coordination, such
as stroke, dementia, delirium, or cerebellar dysfunction, can increase the risk of
hip instability.
VIII. Obtaining optimum component fixation depends on the size and depth of the
implants’ pores, minimizing gaps between the bone and implants as well as the
quality of the host bone (e.g., prior irradiation leads to an increased risk of
loosening).
IX. The femoral and acetabular components can be cemented or noncemented. The
disadvantage of cement is that it can fatigue and has no ability to remodel, leading
to microfracture and failure. Cemented cups fail at a higher rate than cemented
stems because cement is less able to resist shear and tension than compression.
The bone ingrowth and remodeling in noncemented components is dynamic and
life-lasting.
X. Current cementing technique is considered “third generation,” which includes
vacuum treatment for porosity reduction, pressurization, precoated stems, and
centralization to avoid mantle defects. A mantle defect is a place in a cement
column where the prosthesis touches the bone and serves as an area of concen-
trated stress associated with a higher loosening rate. A cement mantle of 2 mm
around the entire prosthesis is generally recommended.
XI. A noncemented porous coated stem may be more appropriate in young active
patients due to the risk of cement failing over time.
XII. There are two different techniques for implant fixation: press fit and
line-to-line. In press fit, the implant is slightly larger than the reamed size, creating
compression hoop stresses for temporary fixation. In line-to-line fit, the same
diameter implant as the reamer is used and extensive porous coating provides the
initial interference “scratch” fit. Screws provide initial fixation of the acetabular
cup.
XIII. Safe acetabular screw placement is ensured by using quadrants based on the ante-
rior superior iliac spine and center of the acetabulum. Posterior-superior is the
safe zone; posterior-inferior is safe for screws less than 20 mm (sciatic nerve);
anterior-inferior may injure the obturator nerve, artery, or vein; and anterior-
superior is the “zone of death” (external iliac vessels) (Fig. 18-4).
XIV. One of the major problems facing THA today is osteolysis secondary to wear
particles being generated at the articulating surface. Traditional articular bearings
for THA are “hard on soft” (metal on polyethylene), although some newer bear-
ings are “hard on hard” (metal on metal or ceramic on ceramic), which have better
wear properties.

I. There are several approaches to the hip that dictate patient position. The follow-
ing is a description of the posterolateral approach.
II. The patient is positioned in a lateral decubitus position with the operative hip up.
Padded lateral holders are used against the sacrum and anterior superior iliac spine
Line B
Safe Zone
Risk: sciatic nerve
superior gluteal Line A
nerve and vessels
Posterior ASIS
Superior
Posterior Anterior
Inferior Superior
Safe if screws <20 mm Risk: External Iliac

Risk: sciatic nerve artery & veins
Inferior gluteal Avoid screws
nerve & vessels
Internal pudendal
nerve & vessels
Anterior
Inferior
Risk: Anterior inferior

obturator nerve,
artery & vein
Avoid screws
Figure 18-4
Acetabular zones for screw insertion. Line A is formed by drawing a line from the anterior superior iliac spine
(ASIS) to the center of the acetabular socket. Line B is then drawn perpendicular to A, also passing through
the center of the socket. The posterior-superior quadrant is the preferred zone for screw insertion. (From
Hip
Miller MD: Review of Orthopaedics, 4th ed. Philadelphia, Saunders, 2004.)
to hold the patient in place. Make sure that the operative leg can be flexed to 90 If an extremity holder is
degrees to enable intraoperative assessment of hip stability. not available, hold the leg
III. Place an axillary roll as well as padding under bony prominences of the contralat- at the ankle in external
eral lower extremity. rotation in a stable
IV. The extremity is prepped and draped in standard fashion as outlined in Chapter fashion to lock the
1 (Fig. 18-5). extremity and help avoid
contamination during
prepping.
Surgical Approach and Applied Surgical Anatomy
I. Mark the borders of the greater trochanter (superior, anterior, and posterior),
femoral shaft, and vastus ridge.
II. Draw an 8- to 10-cm line centered over the posterior one third of the greater
trochanter and curve it posterosuperiorly at the level of the tip of the greater
trochanter (the incision should be straight when the hip is flexed to 90 degrees)
(Fig. 18-6). In most patients, approximately one third of the incision extends above
and two thirds below the greater trochanter. Make sure to increase the length of
the incision as necessary, based on patient size, deformity, and soft tissue
tension.

The right lower extremity suspended, with body in The incision is individualized according to the
lateral decubitus position. approach used.
III. Incise through skin and subcutaneous tissues with a 10-blade.

IV. Insert self-retaining retractors or rakes to assist in finding the level of the fascia
lata.
V. Make small flaps with either a scalpel or a Cobb with a sponge to obtain a clear
margin of fascia, which facilitates closure at the end of the case.
VI. Use the scalpel or Bovie to make a small puncture in the fascia lata over the bare
area at the tip of the greater trochanter where there are no subfascial muscular
attachments.
VII. Use a scalpel or Mayo scissors to split the fascia. Start by spreading under the
fascia to clear its undersurface, and then push the scissors in a direction parallel
to the orientation of the fascia. The decussating fibers of the underlying gluteus
maximus proximally dictate the direction in which the fascial incision should be
extended.
VIII. A Charnley retractor may be used at this point for improving visualization,
and is placed under the split fascia. In this chapter, a Charnley retractor
is not used, and a series of other retractors are used to gain adequate
exposure.
IX. Split the gluteus maximus to expose the underlying trochanteric bursa over the
trochanter.
X. Perform a bursectomy for better visualization if necessary.
XI. Palpate the piriformis tendon and then locate the gluteus medius. Internally rotate
the leg to place the short external rotators on stretch and move the posterior tro-
chanter further away from the sciatic nerve.
XII. Place a C-retractor or double-angle Hohmann retractor under the gluteus medius
(over the gluteus minimus) and place it over the anterior lip of the acetabulum
(may use a Cobb to help identify the correct plane).
XIII. Insert an Aufranc retractor distally, just proximal to the quadratus femoris muscle
and under the inferior aspect of the femoral neck.
XIV. Use a Bovie to dissect the piriformis and conjoined tendon off of their insertions
on the greater trochanter. Now define the plane between the piriformis and the
gluteus minimus and reposition the C-retractor under the minimus and over the
anterior lip of the acetabulum.
XV. Next, make a capsulotomy (trapezoidal or rectangular shaped) to gain access to
the hip joint.
The conjoined tendon is XVI. Tag the external rotators and capsule with heavy suture for later repair prior to
the confluence of the closure. At this stage, release the posterior inferior capsule along the inferior
superior and inferior femoral neck.
gemellus muscles and the XVII. Now the hip can be dislocated by internally rotating and adducting the leg.
obturator internus It may be necessary to release some inferior capsule prior to dislocating
tendon.
the hip.
Figure 18-7
The femoral head is removed after resection of the
neck.
XIII. Use a femoral neck retractor to elevate the proximal femur out of the wound.
XIX. Flex the knee to 90 degrees and internally rotate the hip so that the leg is perpen-
dicular with the ground.
XX. Identify the lesser trochanter, and use the Bovie to mark the level of the neck cut,
which is usually approximately 10 to 15 mm above the lesser trochanter. The exact
level of the neck cut should be determined on preoperative templating.
XXI. Make the femoral neck cut using a reciprocating saw blade (complete cuts with
an osteotome).
XXII. The neck cut can be made in two directions (transverse and vertical) to avoid
cutting the greater trochanter.
XXIII. Use a sweetheart forceps to grab and remove the femoral head once the cuts are
complete; use a ligamentum teres knife as needed to assist in femoral head removal
(Fig. 18-7).
Acetabular Preparation
I. Position retractors onto the anterior lip of the acetabulum, under the transverse
acetabular ligament, and posterosuperiorly.
II. Once the acetabulum is adequately exposed, use a long-handled knife or Bovie to
remove the acetabular labrum and remnants of the ligamentum teres.
III. Use a small reamer (usually six to eight sizes less than the templated size), and ream
in a medial direction until the inner table of the tear drop is exposed (Fig. 18-8).
Hip
IV. Once medialized appropriately, use increasingly larger reamers in a direction to
obtain anteversion of 20 to 25 degrees and an inclination angle of 40 to 45
degrees.
V. Insert the acetabular component with the screw holes placed in the posterior-
superior quadrant of the acetabulum (Fig. 18-9).

Reaming of the acetabulum is performed. Acetabular shell with clustered screw holes.
VI. Insert optional screws if more fixation is needed. Safe screw placement can be
ensured if one memorizes the four zones for acetabular screw insertion.
VII. Insert a trial liner and screw it in place and remove all retractors.
Femoral Preparation
I. Flex the hip and knee to 90 degrees and internally rotate the hip so the leg is
perpendicular to the floor.
II. Use a femoral neck retractor under the proximal femur to lift it out of the
wound.
III. Clear off the medial aspect of the greater trochanter with a Bovie.
Ask your attending to IV. Use a box osteotome to open the piriformis fossa, and then use a canal finder to
discuss how to determine locate the femoral canal.
if a stem is in varus on a V. Use the smallest broach and mallet to advance the broach in line with the patient’s
radiograph.
natural femoral anteversion in reference to the calcar. Be sure to apply steady
lateral pressure to prevent the stem being placed in a varus position.
VI. As the broaches become more difficult to advance, be sure to mallet down slowly
to dissipate hoop stresses.
VII. Continue to broach until there is a tight fit between the broach and canal and
rotational stability is achieved.
Trial Reduction
I. Start trialing with an 0-head and a standard offset neck, or make adjustments based
on preoperative templating (Fig. 18-10).
II. The assistant then reduces the hip by applying manual traction and external
rotation.
III. Once reduced, check to make sure there are equal leg lengths.
IV. Check stability in extension and external rotation followed by flexion and internal
rotation.
V. Make necessary adjustments until a stable hip has been reconstructed.
Wound Closure
I. Pulse irrigate the femoral canal, acetabulum, and wound.
II. Insert the final acetabular liner in the correct orientation and mallet it into place
with the impactor.
III. Insert the final femoral stem, again tapping slowly to dissipate hoop stresses.
IV. Place the final femoral head onto the stem and tap gently with a mallet and head
pusher.
V. Reduce the hip and pulse irrigate the wound again prior to closure.
VI. When repairing the capsule and external rotators, use a 2-0 drill bit to make two
holes in the greater trochanter. Using a Hewson suture passer, pass the sutures
Figure 18-10
Head trials are applied to the stem.
tagging the superior capsule and piriformis through the superior hole, and pass
the sutures from the inferior capsule and conjoint tendon through the inferior
hole. Pull the sutures to approximate the capsule and external rotators to the
medial surface of the greater trochanter and tie the sutures together.
VII. Approximate the fascia, subcutaneous layer, and skin in standard fashion (see
Chapter 1 for details).
VIII. Apply a sterile dressing, and place an abduction pillow between the patient’s legs
prior to transferring the patient from the operating room table.
POSTOPERATIVE CARE AND GENERAL REHABILITATION Compression devices

prevent venous stasis by
I. Postoperative management includes pain control and prophylaxis against infection improving blood return
as well as deep venous thrombosis. to the heart, and they
II. Common medications used for deep vein thrombosis prophylaxis include warfarin also stimulate the release
(Coumadin), low-molecular-weight heparin, aspirin, unfractionated heparin, of fibrinolytic factors by
dextran, and mechanical compression devices (e.g., stockings, Venodynes). endothelial cells lining
III. Prophylactic antibiotics can be used for up to 24 hours postoperatively. Cefazolin the vessels.
(Ancef), 1 g, can be given every 8 hours for 1 day to prevent surgical site
infection. Early postoperative
IV. General rehabilitation is aimed at early mobilization to facilitate faster recovery infection is typically the
and also aid in the prevention of deep venous thrombosis formation. result of direct
inoculation of the
operative site, whereas
COMPLICATIONS late infections are usually
the result of
I. Infection hematogenous spread to
II. Nerve injury (e.g., sciatic or femoral nerve) the prosthetic joint from
III. Vessel injury (e.g., external iliac vessels from screws placed in the anterior-superior a distant site.
quadrant of the acetabulum)
IV. Periprosthetic fracture (typically femur)
V. Early or late hip dislocation
VI. Heterotopic ossification
VII. Loss of cement fixation
VIII. Osteolysis and aseptic loosening
SUGGESTED READINGS
Hip
Berry DJ: Primary total hip arthroplasty. In Chapman MW (ed): Chapman’s Orthopaedic Surgery.
Kusuma SK, Garino JP: Total hip arthroplasty. In Garino JP, Beredjiklian P (ed): Core Knowledge
in Orthopaedics: Adult Reconstruction and Arthroplasty. Philadelphia, Mosby, 2007, pp
108–146.
McPherson EJ: Adult reconstruction. In Miller MD (ed): Review of Orthopaedics, 4th ed. Phila-
delphia, Saunders, 2004, pp 266–284.
Pellici PM, Tria AJ, Garvin KL: Orthopaedic Knowledge Update: Hip and Knee Reconstruction
2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000.
C H A P T E R
19
Hip Fractures
J. Stuart Melvin and R. Bruce Heppenstall
Case Study 1
A 76-year-old female presents with left groin pain and inability to bear weight on the left
lower extremity after suffering a fall from standing. She normally ambulates without
assistance and denies prior hip pain. Her left lower extremity is 3 cm shorter than the
right and is held in external rotation. There is marked groin pain with attempted passive
hip range of motion. She denies having had a syncopal event or any loss of consciousness.
The physical examination reveals the hip fracture to be an isolated injury. The motor and
sensory examinations are intact and the vascular status of the limb is within normal limits.
Anteroposterior (AP) and lateral radiographs of the left hip are presented for two different
fracture patterns that may result from a similar mechanism of injury: a femoral neck frac-
ture (Fig. 19-1) and an intertrochanteric hip fracture (Fig. 19-2).
A B
Figure 19-1
Anteroposterior (A) and lateral (B) radiographs of the left hip demonstrating a displaced femoral neck
fracture.
C H A P T E R 1 9 Hip Fractures 197
A B
Figure 19-2
Anteroposterior (A) and lateral (B) radiographs of the left hip demonstrating an intertrochanteric fracture.
Case Study 2
A 47-year-old man presents to the trauma bay after falling 20 feet from a ladder. The
patient is awake and alert and complains of left thigh pain. The left leg is shortened and
there is an obvious varus deformity of the proximal thigh. The skin is intact, and the motor
and sensory examinations are within normal limits. There is a palpable dorsalis pedis pulse.
There was no loss of consciousness. An AP radiograph taken in the trauma bay is presented
in Figure 19-3.
BACKGROUND
I. Hip fractures are common injuries most often seen in the geriatric population.
Hip
These fractures have an impact that reaches far beyond the obvious orthopaedic
Figure 19-3
Anteroposterior view of the hip demonstrating a
displaced subtrochanteric fracture.
injury and consume a large proportion of health care resources. Approximately

50% of patients who were independent prior to a hip fracture are unable to regain
independence. The 1-year mortality rate for these fractures ranges from 15% to
20%.
II. The term hip fracture may refer to a fracture of the femoral neck, intertrochan-
teric femur, or subtrochanteric femur. The location of the fracture within one of
these anatomic regions is important and dictates the potential treatment
options.
III. In elderly patients, hip fractures are most often low-energy fractures related to
osteoporosis. Thus, hip fractures are more common in women.
IV. In younger patients, hip fractures occur infrequently. When they do occur, they
are most often due to high-energy trauma or are pathologic fractures secondary
to a bone tumor.
V. Approximately 300,000 hip fractures occur annually in the United States. With
the aging population, the number of hip fractures is expected to double by the
year 2050.
VI. The major goals of treatment of hip fractures are as follows:
A. Relief of pain
B. Restoration of function
C. Early mobilization
Femoral Neck Fractures

I. Nondisplaced or Impacted Femoral Neck Fractures
A. Approximately 8% to 15% of nondisplaced fractures become displaced without
treatment.
B. Less than 8% of nondisplaced fractures progress to osteonecrosis of the femoral
head.
C. Less than 5% of non-displaced fracture progress to a nonunion.
II. Displaced Femoral Neck Fractures
A. Osteonecrosis occurs in 15% to 33% of cases.
B. Nonunion occurs in 10% to 30% of cases.
III. Anatomy
A. The femoral neck is an intracapsular structure. On average, the femoral neck
The average femoral and head are anteverted 10 ± 6 degrees and the neck-shaft angle is typically
neck-shaft angle is 130 ± 130 ± 7 degrees.
7 degrees.
B. The vascular supply to the femoral head is defined as follows (Fig. 19-4):
1. Arteries traverse the length of the femoral neck and may be disrupted in a
fracture of the femoral neck, contributing to the risk of osteonecrosis or
nonunion. Extracapsular hip fractures (intertrochanteric and subtrochan-
teric) have a negligible risk of osteonecrosis.
2. An extracapsular arterial ring is formed at the base of the femoral neck by
contributions from the lateral and medial femoral circumflex arteries.
Lateral epiphyseal arterial group

Subsynovial intracapsular
arterial ring
Figure 19-4 Ascending cervical

Blood supply to the femoral head. (From Canale ST arteries
Medial
[ed]: Campbell’s Operative Orthopaedics, 10th ed. femoral
Philadelphia, Mosby, 2003.) circumflex
artery Extracapsular
arterial ring
Ascending cervical branches from this ring pierce the capsule and run along
the femoral neck as the retinacular arteries. These retinacular arteries form
a subsynovial ring at the base of the femoral head and pierce the femoral
head as the epiphyseal branches.
3. The lateral epiphyseal arteries from the posterior-superior ascending cervi-
cal branches arise from the medial femoral circumflex artery to supply the The posterior-superior
majority of the femoral head. ascending cervical
4. The artery of the ligamentum teres, a branch of the obturator artery, sup- branches from the medial
plies a small portion of the femoral head in adults, although it contributes femoral circumflex artery
a great deal to the femoral head blood supply in children younger than 4 supply the majority of the
femoral head.
years of age.
IV. Fracture Classifications
A. Anatomic location
1. Subcapital
2. Transcervical
3. Basicervical
B. Pauwels classification
1. This classification is based on the angle formed by the fracture line in the
femoral neck and a horizontal line.
a. Type I: 30 degrees
b. Type II: 50 degrees
c. Type III: 70 degrees
2. An increasing angle leads to higher shear forces and instability across the
fracture site.
C. Garden classification. This classification is based on the degree of fracture
fragment displacement (Fig. 19-5).
Hip
Type I Type II Figure 19-5
Garden classification of femoral
neck fractures. (From Kyle RF:
Fractures of the hip. In Gustilo RB,
Kyle RF, Templeman DC [eds]:
Fractures and Dislocations. St Louis,
Mosby, 1993.)
Type III Type IV
1. Type I: incomplete or impacted

2. Type II: complete and nondisplaced
3. Type III: complete with partial displacement
4. Type IV: completely displaced
Intertrochanteric Hip Fractures

I. Intertrochanteric (IT) fractures are the most common hip fracture in
the elderly and are most often related to osteoporosis. When they occur in
younger patients, they are secondary to high-energy trauma or pathologic
fracture.
II. Anatomy
A. IT fractures occur between the greater and lesser trochanters with occasional
extension into the subtrochanteric region.
An intact calcar femorale B. These fractures occur through cancellous bone and thus possess great healing
or posteromedial cortex is potential. The nonunion rate is less than 2%.
the defining factor for C. The calcar femorale is an area of dense cortical bone at the posterior-medial
classifying an aspect of the proximal femur that acts as a strong strut to transfer load from
intertrochanteric the femoral neck to the intertrochanteric region and is critical for stability.
fracture’s stability.
The integrity of this region is the basis for whether a fracture is considered
stable or unstable.
III. Fracture Classifications
A. Boyd and Griffin
1. Type I: fracture line extends along the intertrochanteric line—stable
2. Type II: fracture line extends along the intertrochanteric line with commi-
nution and displacement—stable
3. Type III: fracture at level of the lesser trochanter with posteromedial com-
minution—reverse obliquity—unstable
4. Type IV: intertrochanteric fracture with subtrochanteric extension—
unstable
B. Evans
1. Divided into stable and unstable fracture patterns with stability dependent
on continuity of the posteromedial cortex
2. Reverse obliquity fractures—inherently unstable
C. Orthopaedic Trauma Association
Subtrochanteric Hip Fractures

The proximal fragment in
I. Subtrochanteric (ST) fractures occur in a zone extending from the lesser trochan-
subtrochanteric fractures
is usually flexed,
ter to 5 cm distal to the lesser trochanter.
abducted, and externally II. These fractures are notoriously difficult to treat because of the powerful
rotated due to the pull of muscle forces acting on the fragments as well as the tremendous stress that
the psoas, gluteus medius, is normally placed through this region. The proximal fragment is typically
and short external flexed, abducted, and externally rotated while the distal fragment is typically
rotators, respectively. adducted.
III. When seen in young patients, ST fractures are due to high-energy trauma or
Approximately 10% of pathologic fracture. In the elderly, they are often related to osteoporosis.
subtrochanteric fractures IV. Fractures may also occur at the site of screw placement for a femoral neck fracture
are a result of gunshot if the inferior screw is placed too low as this creates a cortical defect and results
wounds. in a stress riser.
V. Anatomy
A. The medial and posteromedial cortices of the ST femur experience the highest
compressive stresses in the body. The lateral cortex is under a high degree of
tensile stress.
B. These fractures occur at the corticocancellous junction. The high composition
of cortical bone and subsequently the decreased vascularity impairs the capacity
for healing of these fractures when compared with the abundant cancellous
bone of the IT region.
VI. Fracture Classifications
A. Fielding. This is an anatomic classification based on location of the fracture.
1. Type I: at the level of the lesser trochanter
2. Type II: less than 2.5 cm below the lesser trochanter
3. Type III: 2.5 to 5 cm below the lesser trochanter
B. Seinsheimer. This system incorporates factors affecting stability and offers
management guidelines.
1. Type I: nondisplaced
2. Type II: two-part fractures. Subtypes based on fracture pattern and
displacement.
3. Type III: three-part spiral fracture. Subtypes based on type of fracture
fragments.
4. Type IV: comminuted
5. Type V: IT extension
C. Russell-Taylor. This classification is based on integrity of the piriformis fossa.
It was designed to guide treatment of intramedullary nails using a piriformis
fossa starting point.
1. Type I: intact piriformis fossa
a. A: lesser trochanter attached to the proximal fragment
b. B: lesser trochanter detached from the proximal fragment
2. Type II: fracture extending into piriformis fossa
a. A: stable posterior-medial buttress
b. B: comminution of lesser trochanter
D. Orthopaedic Trauma Association
RADIOGRAPHIC ASSESSMENT
I. For all hip fractures, an AP of the pelvis, internal rotation AP, and cross-table
lateral radiographs of the affected hip should be obtained.
II. For femoral neck fractures, magnetic resonance imaging is indicated if plain radi-
ography fails to reveal a fracture and suspicion is high for an occult fracture or
stress fracture of the femoral neck. Bone scans may also show increased uptake
with occult or stress fractures of the hip.
III. Magnetic resonance imaging may also be required for pathologic fractures to
Hip
evaluate the proximal femur for soft tissue extension of an underlying bone
tumor.
TREATMENT ALGORITHM
Groin pain, obvious proximal thigh

deformity, or shortened, externally
rotated leg
AP pelvis, internal rotation AP and lateral

hip radiographs (consider MRI if tumor or
stress fracture suspected)
Diagnosis of hip fracture
Operative candidate?
No Yes
Traction, hip spica,

Fracture
or early bed-to-
type?
chair mobilization
Subtrochanteric Femoral neck

fracture fracture
Timely medical evaluation

and intramedullary nail, Physiologically young, Elderly
cephalomedullary nail, active patient patient
or 95° fixed angle plate
Emergent open or closed Nondisplaced

reduction with cancellous with adequate Displaced
lag screw fixation or bone quality
sliding hip screw
Timely medical
No pre-existing Pre-existing
Intratrochanteric evaluation and
hip pain or hip pain or
fracture cancellous lag
acetabular acetabular
screw fixation
arthritis arthritis
Unstable Stable
fracture fracture Timely medical Timely medical
pattern pattern evaluation and evaluation and
hemiarthroplasty total hip
arthroplasty
Timely medical Timely medical evaluation
evaluation and and sliding hip screw
cephalomedullary or cephalomedullary
sliding hip screw sliding hip screw
TREATMENT PROTOCOLS
A. Patient age
B. Activity level prior to injury. Nonambulators may be considered nonoperative
candidates.
C. Location of fracture within the femoral neck. Low neck fractures abutting the
intertrochanteric region (basic cervical) may be treated as IT fractures because
of similar bone quality and vascular status.
D. Displaced femoral neck fractures. Displaced fractures have a much higher rate
Ask the patient about
of nonunion and osteonecrosis, making arthroplasty (partial or total hip replace- preexisting hip pain
ment) a more predictable treatment option. because this may indicate
E. Presence and severity of acetabular osteoarthritis. Preexisting acetabular osteo- preinjury hip
arthritis makes total hip arthroplasty (THA) the best treatment option. osteoarthritis.
F. Associated injuries
G. Timing of surgery. Surgery is indicated within 96 hours after injury if the
patient is medically stable.
H. Overall health status. Nonoperative treatment methods may be considered if
the surgical risk is excessively high secondary to patient comorbidities.
I. Fracture stability. Stability of IT and ST fractures is based on the integrity of
the posteromedial cortex.
J. Fracture pattern. Reverse obliquity fracture patterns are unstable by definition
and are best treated as ST fractures.
II. Nonoperative Treatment
A. Surgical treatment is the standard of care for all hip fractures. Nonoperative treat-
ment is to be considered only when the risk of surgery outweighs the benefit.
B. Treatment options include skeletal traction, Buck’s skin traction, application
of a hip spica cast, or non–weight bearing with acceptance of the ensuing
proximal femoral deformity.
C. For ST fractures, skeletal traction after closed reduction is the most common
nonoperative treatment protocol. Closed reduction is performed with a distal
femoral transcondylar Steinmann pin by flexing the hip to 90 degrees, correct-
ing the external rotation deformity, and applying traction to decrease abduc-
tion. Traction is typically applied for 12 to 16 weeks.
D. Regardless of treatment modality, early bed-to-chair mobilization is para-
mount and should begin as soon as pain permits to prevent complications of
prolonged recumbency.
SURGICAL ALTERNATIVES, INDICATIONS, AND CONTRAINDICATIONS

Nondisplaced or Impacted Femoral Neck Fractures
I. In situ pinning with multiple cancellous lag screws
A. This is the preferred treatment for nondisplaced femoral neck fractures. Three
screws are placed parallel in an inverted triangle configuration.
B. Advantages
Hip
1. Quicker procedure
2. Minimal soft tissue damage
C. Disadvantages
1. Less rigid fixation
2. Potentially creates a stress riser in the subtrochanteric region of the proxi-
mal femur
II. Sliding hip screw and side plate
A. If a sliding hip screw and side plate is used, a derotational pin may be placed
parallel to the sliding screw to avoid rotation of the head fragment.
B. Advantages
1. Greater biomechanical strength
2. Allows for compression across fracture site with weight bearing
3. Minimizes the creation of a stress riser in the subtrochanteric region
C. Disadvantages
1. Requires a larger exposure
2. Potential for rotational malalignment at time of screw placement
Displaced Femoral Neck Fractures

I. Open or closed reduction with multiple cancellous lag screws or sliding hip
screw
A. Surgical stabilization with cancellous screws should be urgently performed for

young patients with a high-energy injury and good bone quality.
B. This may also be performed after timely medical evaluation for highly func-
tional elderly patients with good bone quality and minimal osteoarthritis.
II. Hip Hemiarthroplasty (see Chapter 18 for femoral stem insertion)
A. This involves replacement of the femoral head and neck with a femoral pros-
thesis and is the treatment of choice for elderly patients with lower functional
demands, poor bone quality, and minimal acetabular osteoarthritis.
B. Unipolar and bipolar prosthesis are considered to have similar functional
outcomes.
C. Cement to secure the prosthesis to bone should be considered for patients with
osteoporosis.
D. Advantages
1. Decreased operative time compared with THA
2. Increased stability due to larger femoral head size
3. Immediate weight bearing
4. Lower rates of reoperation compared to multiple cannulated screws or
sliding hip screw
E. Disadvantages
1. May lead to erosion of acetabular cartilage
2. Femoral stem loosening
III. Total Hip Arthroplasty (THA; see Chapter 18 for details)
A. THA involves the replacement of the femoral head and neck as well as the
articular surface of the acetabulum. This treatment option should be consid-
ered in the following scenarios:
1. Elderly patients with preinjury hip pain or significant radiographic evidence
of osteoarthritis
3. Paget’s disease involving the acetabulum
4. Salvage procedure for failed open reduction and internal fixation or
hemiarthroplasty
B. Advantages: very good and predictable long-term functional results and relief
of pain
C. Disadvantages
1. Higher dislocation rate when compared with hemiarthroplasty or primary
THA for osteoarthritis
2. Requires a longer surgical time with greater blood loss
Intertrochanteric Hip Fractures

I. Sliding Hip Screw
A. Historically the most common method of operative fixation
B. The plate is available in fixed angles from 130 to 150 degrees and should be
matched to the native anatomy.
C. Advantages
1. Ease of application
2. Broad surgeon familiarity
3. Relatively less expensive
4. Allows compression at the fracture site with weight bearing
D. Disadvantages
1. Greater tensile stress on the screw due to longer lever arm of a plate placed
on the lateral femur
2. Greater screw sliding, which can lead to medialization of distal fragment
3. Failure rate of 10% for fixation, most often in unstable fractures due to
errant screw placement or failure of the screw to slide in the plate
II. Cephalomedullary Sliding Hip Screw
A. Has become the most common method of operative fixation
B. Uses a sliding screw or helical blade placed through an intramedullary nail
C. Advantages
1. Shorter lever arm for the lag screw, which decreases tensile stress on the
screw
2. Avoids excessive screw sliding, because the proximal fragment would abut
the nail before it would abut a side plate
3. Placed through a limited skin incision, requiring minimal dissection and
thus less tissue trauma and blood loss
D. Disadvantages
1. Early generation devices associated with a higher rate of femoral shaft frac-
tures at the tip of the nail or interlocking screws
2. No demonstrated clinical advantage over the sliding hip screw and side plate
for stable IT fracture
3. More expensive device
III. Hip Hemiarthroplasty (see Chapter 18 for femoral stem insertion)
A. This is not usually indicated for primary treatment of IT fractures; however, What is your attending’s
it may be indicated after failed internal fixation. preference for operative
treatment of
B. If using to primarily treat an IT fracture, a calcar replacing implant must be
intertrochanteric
used. Consideration must also be given to reattachment of the greater trochan- fractures?
ter to restore abductor function.
Subtrochanteric Hip Fractures

I. Intramedullary Nail
A. Intramedullary fixation is the preferred treatment.
B. First-generation interlocking nails (centromedullary) are indicated when both
trochanters are intact.
C. Second-generation interlocking nails with a locking screw that extends into the
femoral neck (cephalomedullary) offer more stable fixation and are indicated
when the lesser trochanter is displaced or comminuted.
D. Advantages
1. Potential for closed treatment with preservation of fracture hematoma and
blood supply to fracture fragments
2. Decreases the moment arm on the implant compared with a lateral plate
and thus decreases the tensile stress on the implant
3. Reaming the canal in preparation of the implant, which provides internal
bone graft
Hip
E. Disadvantages
1. Placement of an intramedullary implant, which can be technically
demanding
2. Possible need for the fracture site to be opened to facilitate reduction and
guide pin insertion, thus lessening benefits of closed intramedullary
fixation
II. Ninety-Five–Degree Fixed Angled Device
A. Historically the most common device used for operative fixation
B. Has a fixed angle construct, which provides rigid fixation
C. Advantages
1. Offers a treatment option for fractures with comminution of the trochanters
that may make intramedullary implant insertion difficult
2. Provides for multiple points of proximal fixation
D. Disadvantages
1. Technically very demanding
2. Extensive soft tissue dissection
3. High risk of implant failure due to tremendous stress applied to the plate
laterally
III. Sliding Hip Screw
A. Indicated only for very proximal fractures
B. Sliding of the screw to allow medialization of the distal fragment, which
reduces bending moment on fracture and implant
C. Necessity for sliding mechanism to cross the fracture site to lessen the risk of
implant failure
D. Essential to reconstruct the posteromedial cortex to decrease the stress on the
device
GENERAL PRINCIPLES FOR PARALLEL CANCELLOUS LAG SCREW FIXATION

OF NONDISPLACED FEMORAL NECK FRACTURES
I. Typically, three screws are placed in an inverted triangle configuration. The first
screw is inserted inferiorly along the calcar to control inferior displacement. The
second screw is placed posterosuperiorly along the neck to prevent posterior dis-
placement. The third screw is placed anterosuperiorly.
II. A fourth screw may be placed posteriorly for additional support in the presence
of posterior comminution.
III. Lag screw threads should be in the femoral head and not remain crossing the
fracture site. This impedes fracture compression.
IV. It is important to place the screws above the level of the lesser trochanter at the
comparable point on the lateral femoral cortex. This prevents the formation of a
stress riser along the lateral cortical-cancellous junction, which may lead to a
subsequent fracture.
V. Acceptable reduction
A. Valgus angulation is more mechanically stable and can be accepted more so
than varus angulation.
B. Try to avoid posterior translation of the neck while maintaining anteversion
on lateral radiograph.
C. Assess for comminution posteriorly and place pins appropriately.
D. The convexity of the femoral head should form a shallow S-shaped curve with
the concavity of the femoral neck on all fluoroscopic views. A C-shaped curve
or sharp apex on fluoroscopic views indicates malreduction.
E. The Garden alignment index is a method of assessing adequacy of reduction.
For an adequate reduction, the primary compression trabeculae of the femoral
neck should form an angle of 160 to 180 degrees with the femoral shaft on
both an AP and lateral radiograph (Fig. 19-6).
COMPONENTS OF THE PROCEDURE: CLOSED REDUCTION AND PARALLEL

CANCELLOUS LAG SCREW FIXATION OF NONDISPLACED FEMORAL
NECK FRACTURES
Positioning
I. Patient positioning is on the fracture table. See Chapter 17 for positioning on the
fracture table.
Figure 19-6
Garden alignment index. (From
DeLee JC: Fractures and dislocations
of the hip. In Rockwood CA Jr,
Green DP [eds]: Fractures in Adults,
2nd ed. Philadelphia, JB Lippincott,
1984.)

Fluoroscope positioning for anteroposterior Fluoroscope positioning for lateral fluoroscopy of
fluoroscopy of hip. hip.
II. Positioning of fluoroscope machine (Figs. 19-7 and 19-8)

A. The fluoroscope should be positioned between the patient’s legs for AP and
lateral views of the hip. The lateral is obtained by swinging the fluoroscope
along its axis beneath the operative leg.
B. Ensure that adequate unobstructed AP and lateral views of the fracture can be
obtained prior to draping. Mark the position of the fluoroscope for these views
by placing tape on the floor.
Closed Reduction
I. Begin by disengaging the fracture, which is achieved via traction, flexion, and The anterolateral
external rotation. These maneuvers are performed by using the traction gears or approach to the hip is in
the intermuscular plane
through manipulation of the position of the traction boot.
between the tensor fascia
II. Next, obtain the reduction through slow extension, abduction, and internal rota- lata and the gluteus
tion. The adequacy of the reduction should be checked with fluoroscopy using the medius muscles. This is
guidelines set forth in the previous section on acceptable reduction. not an internervous plane
III. If reduction cannot be achieved in a young patient, proceed to open reduction via because they are both
an anterior-lateral approach to the hip. innervated by the
superior gluteal nerve.
Hip
Prepping and Draping
See Chapter 17 for details on prepping and draping.
Surgical Approach and Applied Anatomy

I. Begin by marking the angle of the femoral neck in the AP plane and the
femoral shaft in the lateral plane on the skin. A sterile pen is used to trace a
K-wire positioned appropriately in the AP and lateral plane. When making
the skin marks, make sure that all screws will be superior to the lesser
trochanter.
II. The incision should extend 1.5 cm superiorly and inferiorly to the point where
these lines cross. Make the incision with a 15-blade and use a Bovie to incise the
subcutaneous fat and fascia in line with the incision.
Screw Placement
I. Three screws should be placed parallel along the femoral neck in an inverted
triangle configuration. For placement of the first screw, drive a guide pin
at an angle of 130 to 135 degrees along the inferior neck on the AP fluoroscopic
view and in the center of the neck on the lateral fluoroscopic view to within
1 cm of subchondral bone. Slightly more valgus may be acceptable for
A B
Figure 19-9
Anteroposterior (A) and lateral (B) postoperative radiographs of hip following parallel cancellous screw
fixation.
valgus-impacted fractures, taking care that the entry point is above the lesser
trochanter.
II. Using the inverted triangle guide, drive the second and third guide pins along the
posterosuperior and anterosuperior neck, respectively. Use an army-navy retractor
as needed to avoid catching the IT band and fascia in the drill.
III. Remove the pin guide and measure the screw lengths with the depth gauge. Using
the screwdriver, place the appropriate length cannulated lag screws in the same
order as they were drilled. Ensure that the threads of the lag screws do not cross
the fracture line when fully seated, because this will prevent compression across
the fracture line.
IV. Take final AP and lateral fluoroscopy images (Fig. 19-9).
V. See Chapter 18 for insertion of the femoral component only (hemiarthroplasty)
and THA for treatment of displaced femoral neck fractures.
Wound Closure
I. For all procedures, the wound is copiously irrigated with sterile saline and hemo-
stasis is achieved prior to closure.
II. The wound is closed in layers and staples are used to reapproximate the skin edges
GENERAL PRINCIPLES OF SLIDING HIP SCREWS: INTERTROCHANTERIC

HIP FRACTURES
I. It is important to place the screw in the center of the femoral head on
AP and lateral views and within 1 cm of subchondral bone. This position
has been shown to decrease the rate of superior screw cutout and varus
collapse.
CALCULATE THE TIP-APEX
II. The tip-apex distance is a method to predict screw cutout and is calculated as the
DISTANCE TO ENSURE PROPER
sum of the distance from the tip of the lag screw to the apex of the femoral head
SCREW POSITIONING.
on both the AP and lateral radiographs (Fig. 19-10).
Xap
Figure 19-10
Calculation of tip-apex
distance. (From Baumgaertner MR,
Xlat Dlat Curtin SL, Lindskog DM, Keggi
Dap
JM: The value of the tip-apex
distance in predicting failure of
fixation of peritrochanteric fractures
of the hip. J Bone Joint Surg
77A:1058, 1995. Reprinted with
permission from The Journal of Bone
and Joint Surgery, Inc.)
Dtrue Dtrue
TAD 5 (X ap ⫻
Dap ) ⫹( X
lat ⫻
Dlat )
III. A tip-apex distance of less than 25 mm is associated with lower rate of screw
cutout.
COMPONENTS OF THE PROCEDURE: CLOSED REDUCTION AND APPLICATION

OF SLIDING HIP SCREW AND SIDE PLATE
Positioning
I. Positioning on the fracture table. See Chapter 17 for patient positioning on the
fracture table.
II. Positioning of the fluoroscope machine. Please see previous section on treatment
of nondisplaced femoral neck fractures.
Closed Reduction
I. To obtain a closed reduction, begin by taking initial AP and lateral fluoroscopy
images.
II. Begin the reduction maneuver by applying traction with the leg in external rota-
Hip
tion. Internally rotate the leg by manipulating the position of the traction boot to
achieve the reduction. Posterior sag of the distal fragment can often be corrected
with placement of a crutch below the distal fragment, whereas excessive varus can
often be corrected with additional traction.
III. Check the reduction with AP and lateral fluoroscopy.

See Chapter 17 for details on prepping and draping.

I. Under image intensification, mark the skin incision by using a guide pin placed BE CAREFUL OF PERFORATING
on the skin parallel to the femoral neck on the AP view and femoral shaft on the BRANCHES OF THE PROFUNDA
lateral view. An incision is carried 10 cm distally along the lateral femur from the FEMORIS ARTERY. THESE
point where these lines cross. VESSELS TYPICALLY PIERCE
II. Incise down through the subcutaneous tissue to the level of the fascia. Make a THE LATERAL INTERMUSCULAR
longitudinal incision in the fascia in line with the incision. Split the vastus lateralis SEPTUM AND CAN LEAD TO A
GREAT DEAL OF BLEEDING IF
between the muscle fibers and get down to bone. Stay approximately 0.5 cm from
THEY ARE INADVERTENTLY
the lateral intermuscular septum to avoid perforating vessels from the profunda
DISRUPTED.
femoris artery. Reflect the vastus lateralis superiorly with a Bennett retractor.
10 mm
Figure 19-11
Alignment guide demonstrating proper placement of
guidewire. (From Baumgaertner MR: Compression Hip
Screw Plates Technique Manual. Memphis, Smith &
Nephew Richards, 1996.) 135
Placement of Screw and Side-Plate

I. Using the angle guide, select the appropriate plate angle that will place a screw
parallel to the femoral neck in the center of the femoral head on AP and lateral
views. The 135-degree plate is the most commonly used plate. Higher angle plates
increase the risk of placing the screw below the lesser trochanter, increasing the
risk of fracture.
BEWARE OF GUIDEWIRE II. Under image intensification, use the wire driver and plate angle guide to drive a
ADVANCEMENT INTO THE HIP threaded guidewire to within 1 cm of subchondral bone in the center of the
JOINT AND PELVIS WHEN femoral head on AP and lateral views. Assess the tip-apex distance at this time and
REAMING OR DRILLING OVER
replace the guidewire if it is greater than 25 mm (Fig. 19-11).
THE GUIDEWIRE.
III. Next, measure the screw length from the length of the guidewire and ream over
the guidewire to the appropriate length per the specific device. Beware of guide
pin advancement into the joint.
IV. Tap over the guidewire and insert the appropriate length screw over the guide-
wire. Use firm continuous pressure to place the screw within 1 cm of subchondral
bone. Avoid levering on the screw as it is being inserted.
V. Align the screwdriver handle parallel with the shaft of the femur when the screw
is seated. This will align the key mechanism with the side plate. Most often a
RELEASE TRACTION PRIOR TO
“keyed” system is used in which the side plate captures the lag screw and prevents
PLACING FEMORAL SHAFT
rotation of the screw but allows sliding along the barrel of the plate.
SCREWS TO ALLOW FOR
FRACTURE IMPACTION.
VI. Place the side plate over the screw and secure it to the lateral femur.
VII. Place a clamp around the femur and sideplate to hold the plate to the femur and
release traction on the leg to allow fracture impaction and sliding.
VIII. Now, insert 4.5-mm cortical screws to fill the holes of the sideplate making sure
to obtain bicortical purchase. The clamp may be released after two screws have
been secured. Retighten all screws prior to closure (Fig. 19-12).
Wound Closure
The wound is closed in standard fashion according to the surgical principles outlined in
Chapter 1.
GENERAL PRINCIPLES OF CEPAHLOMEDULLARY SLIDING HIP SCREW

PLACEMENT: INTERTROCHANTERIC AND SUBTROCHANTERIC HIP FRACTURES
I. A cephalomedullary sliding hip screw is placed typically using a greater
trochanteric starting point. The starting point for ST fractures may be slightly
Figure 19-12
Anteroposterior and lateral view
of sliding hip screw and side-
plate. (From Canale ST [ed]:
Campbell’s Operative Orthopaedics,
10th ed. Philadelphia, Mosby, 2003.)
more medial due to the higher tendency of these fractures to fall into a varus
position.
II. A short cephalomedullary screw can be used for IT fractures, whereas a long device
must be used for ST fractures.
III. A screw and side plate can be used for standard IT fractures; however, their use
is contraindicated in reverse obliquity IT fractures and ST fractures.
IV. The proximal fragment of an ST hip fracture is likely to be in flexion, abduction,
and external rotation. A small open anterior incision may be needed to manipulate
the proximal fragment while placing the guidewire. If adequate reduction cannot
be achieved, then use an extension of the lateral incision to visualize the fracture
site.
V. Also, use the tip-apex distance with this device to minimize screw cutout in the
postoperative period.
COMPONENTS OF THE PROCEDURE: CLOSED REDUCTION AND

CEPHALOMEDULLARY SLIDING HIP SCREW PLACEMENT
Hip
Positioning
I. Patient positioning is on the fracture table. See Chapter 17 for positioning on the
fracture table.
II. Positioning of the fluoroscope machine. Refer to the previous section on treatment
of nondisplaced femoral neck fractures.
Closed Reduction
I. To obtain a closed reduction, begin by taking initial AP and lateral fluoroscopy
images.
II. Begin the reduction maneuver by applying traction with the leg in external rota-
tion. Internally rotate the leg by manipulating the position of the traction boot to
achieve the reduction. Posterior sag of the distal fragment can often be corrected
with placement of a crutch below the distal fragment, whereas excessive varus can
often be corrected with additional traction. This is especially important with
intramedullary devices because varus makes obtaining the starting point more
difficult. If excessive varus cannot be corrected, consider a sliding hip screw or
open reduction.
III. Check the reduction with AP and lateral fluoroscopy.
IV. Have the leg placed in neutral or slight adduction to facilitate access to the greater
trochanter starting point.

See Chapter 17 for prepping and draping.
Surgical Approach
I. This section will detail the greater trochanter starting point. The appropriate
starting point depends on the specific device, but usually it is at the superior
tip of the greater trochanter in the AP projection and at the junction of the
anterior third and posterior two thirds of the greater trochanter in the lateral
projection.
II. Place a 3.2-mm K-wire percutaneously on the anticipated starting point. Use fluo-
roscopy to guide the insertion of the K-wire to the correct position. The starting
point for percutaneous K-wire placement in obese patients is often located more
proximally.
III. Make a 2-cm longitudinal incision at the K-wire skin entry point and bluntly
dissect to the entry point on the greater trochanter. The guidewire is advanced
from the starting point down to the level of the lesser trochanter.
Placement of the Cephalomedullary Sliding Hip Screw

I. Place a tissue protector and a conical reamer to the starting point to
open the medullary canal over the guide pin. Alternatively, a curved awl under
fluoroscopy may be used to locate the starting point and prepare the proximal
femur.
II. Once the entry reamer has opened up the proximal femur, pass a ball-tipped
guidewire down the femoral shaft; this guides the flexible reamers while reaming
the femoral canal. Reaming may not be necessary in elderly individuals who have
large-diameter canals.
III. See Chapter 24 for details regarding placement of an intramedullary nail. The
remainder of this section will focus on placing the lag screw through an already
properly placed intramedullary nail component.
IV. When positioned appropriately, insert the screw sleeve guide and incise the
skin where this guide contacts the skin. Dissect down through the iliotibial
band and vastus lateralis to bone. Advance the sleeve guide to bone and stabilize
the screw sleeve guide to ensure that it is flush to bone. Next, drill the lateral
cortex.
V. Replace the screw sleeve guide and place a K-wire sleeve guide. This centrally
positions the K-wire within the hole in the lateral wall. Now, advance a 3.2-mm
K-wire to subchondral bone. Check K-wire placement on AP and lateral
fluoroscopy.
VI. Measure the screw depth from the K-wire and drill the screw path to within 1 cm
of subchondral bone. Ensure that the K-wire does not advance into the joint.
Compression at the fracture site can be achieved by selecting a screw 5 mm shorter
than measured.
VII. Now insert the screw and ensure that it is free to slide. Tighten the set screw and
then loosen it a quarter-turn. The set screw allows sliding but not rotation of the
lag screw. Insert the end cap.
VIII. Finish by placing locking screws using the targeting guide. If a long nail is used,
distal locking screws should be placed using free hand perfect circle technique
(Fig. 19-13). (See Chapter 24 for perfect circles technique.)
Wound Closure
The wound is closed in standard fashion according to the surgical principles outlined in
Chapter 1.
A B
Figure 19-13
Anteroposterior (A) and lateral (B) postoperative views of cephalomedullary sliding hip screw used to treat a
subtrochanteric fracture.
POSTOPERATIVE CARE AND GENERAL REHABILITATION OF HIP FRACTURES

and deep venous thromboembolism.
II. Twenty-four hours of postoperative antibiotics should be administered.
III. Unless contraindicated, systemic anticoagulation with warfarin or low-molecular-
weight heparin should be administered for 2 to 6 weeks.
IV. Pharmacologic treatment is augmented with compression stocking, a mechanical
compression device, and early mobilization.
V. Physical therapy or out-of-bed mobilization is started on postoperative day 1.
VI. Weight-bearing status in the elderly is controversial.
A. Elderly patients with decreased upper extremity strength often have difficulty
Hip
maintaining partial or non–weight-bearing protocols. Additionally, partial or
non–weight-bearing protocols may generate considerable force across the hip.
Thus, many believe that weight bearing as tolerated is the most appropriate Ask your attending about
recommendation to mobilize these patients early. the patient’s
B. For younger patients whose fractures are often pathologic or higher energy postoperative weight-
with comminution, weight-bearing status depends on stability of fracture and bearing status and
internal fixation. thromboprophylaxis.
COMPLICATIONS
I. Infection
II. Malunion
III. Nonunion
IV. Osteonecrosis (femoral neck fracture)
V. Screw cutout of the femoral head (sliding hip screw and cephalomedullary
devices)
VI. Hardware failure
VII. Intra-articular screw placement
VIII. Continued pain and stiffness
IX. Subtrochanteric femur fracture (cancellous lag screws)
X. Periprosthetic fracture (short cephalomedullary sliding hip screw)

XI. Leg length discrepancy (comminuted subtrochanteric fractures)
XII. Deep vein thrombosis and pulmonary embolus
SUGGESTED READINGS
Bucholz RW, Heckman JD, Court-Brown C: Fractures in Adults, 6th ed. Philadelphia, Lippincott
Williams & Wilkins, 2006, pp 1753–1844.
Canale ST (ed): Campbell’s Operative Orthopaedics, 10th ed. Philadelphia, Mosby, 2003, pp
2873–2938.
Koval KJ, Zuckerman JD: Hip fractures: I. Overview and evaluation and treatment of femoral-neck
fractures. J Am Acad Orthop Surg 2:141–149, 1994.
Koval KJ, Zuckerman JD: Hip fractures: II. Evaluation and treatment of intertrochanteric hip frac-
tures. J Am Acad Orthop Surg 2:150–156, 1994.
S E C T I O N
VI
KNEE
CHAPTER 20 Quadriceps and Patellar Tendon Repair 217
CHAPTER 21 Arthroscopic Meniscectomy 228
CHAPTER 22 Anterior Cruciate Ligament Reconstruction 237
CHAPTER 23 Total Knee Arthroplasty 251
C H A P T E R
20
Quadriceps and Patellar Tendon Repair
Karen J. Boselli, Albert O. Gee, and Craig L. Israelite
Case Study 1
A 29-year-old male recreational basketball player presents to the emergency department

with a chief complaint of left knee pain. He reports that during a pick-up game, he landed
“off-balance” on his left knee after a jump shot. His knee buckled, and he noticed immedi-
ate swelling. He was unable to bear weight on the knee after the injury and noted that he
was unable to straighten the leg. When prompted, the patient reports a 3-month history
of “jumper’s knee” for which he had been using a Cho-Pat strap and anti-inflammatory
medications. Physical examination reveals a grossly swollen and slightly ecchymotic left
knee, with a palpable defect at the level of the patellar tendon. A lateral radiograph is
presented in Figure 20-1.
Case Study 2
A 54-year-old obese man comes to the emergency department complaining of right knee
pain after slipping and falling at work as a firefighter. He has since been unable to bear
Figure 20-1 Knee

A lateral radiograph of the knee demonstrating
patella alta. (From McRae R, Esser M: Practical
Fracture Treatment, 4th ed. Edinburgh, Churchill
Livingstone, 2002.)

218 S E C T I O N V I Knee
Figure 20-2
Sagittal magnetic resonance imaging scan of the
knee. The arrow is pointing to a complete rupture
of the quadriceps tendon.
weight. He recalls a tearing sensation in his knee at the time of his fall but does not recall
any direct trauma. He has a history of diabetes, for which he takes oral hypoglycemic
agents. On examination, he has a large right knee effusion and is lying in the stretcher
with his knee extended. He is able to flex his knee slightly but is unable to actively extend
it or raise his leg from the bed. There is a palpable depression over the superior aspect of
his patella, with moderate ecchymosis. A magnetic resonance image of the right knee is
presented in Figure 20-2.
BACKGROUND
I. The most common disruption of the extensor mechanism of the knee is a trans-
verse patella fracture; this is followed in frequency by quadriceps tendon ruptures,
which are three times more common than patellar tendon ruptures.
II. Quadriceps tendon ruptures occur most commonly in patients older than 40 years
of age, whereas patellar tendon ruptures occur more frequently in young, athletic
patients. Given an increase in activity level and athletic participation in all age
groups, however, it is not uncommon to see patellar tendon ruptures in older
patients.
III. Quadriceps tendon ruptures usually occur transversely within 2 cm of the superior
pole of the patella, and they propagate distally and transversely into the medial
and lateral retinacula. Patellar tendon tears generally occur at the insertion site of
the tendon onto the inferior pole of the patella. They are less frequently seen as
avulsions from the tibial tubercle or as intrasubstance tears.
IV. As a general rule, ruptures do not occur in healthy tendons; more often a rupture
occurs as the result of repetitive microtrauma. When prompted, patients often
report preexisting knee pain or tendinitis. In an athlete who does not give a history
of prior knee pain, there was likely a subclinical process contributing to degenera-
tion and tendinopathy.
V. Systemic medical conditions can contribute to the degeneration of the tendon and
make it more susceptible to injury. This is especially true of the quadriceps tendon.
These conditions may include lupus, gout, rheumatoid arthritis, chronic renal
failure, obesity, and diabetes mellitus. Bilateral injuries are also more common in
C H A P T E R 2 0 Quadriceps and Patellar Tendon Repair 219
patients with these conditions because they are predisposed to systemic weakening
of collagen.
VI. Quadriceps and patellar tendon ruptures have been associated with systemic
steroid use as well as previous local steroid injections into the tendon.
VII. Mechanism of injury. Most commonly, the quadriceps or patellar tendon is rup-
tured by an eccentric violent contraction of the quadriceps muscles with the knee
partially flexed.
A. With a quadriceps tendon rupture, the patient may have been attempting to
prevent a fall or regain balance during a fall.
B. With a patellar tendon rupture, the injury may occur during a strenuous con-
traction of the quadriceps during athletic activity.
C. Ruptures may occur during less strenuous activities in patients whose tendons
are weakened by systemic illness or administration of steroids.
D. Rarely, the quadriceps or patellar tendon can be injured by a direct penetrating
trauma. Tendon disruption can also occur after total knee arthroplasty, and
has been reported after anterior cruciate ligament reconstructions with patellar
tendon autograft harvest.
TREATMENT ALGORITHM
Quadriceps tendon injury Patellar tendon tear
Confirmed by history,
Partial tear Complete tear physical examination,
and imaging studies
Nonoperative treatment: Surgical repair

• Immobilize knee in extension Surgical repair
for 4–6 weeks
• Ice, compression, and
pain management
Progression to
complete tear
TREATMENT PROTOCOLS
I. Treatment Considerations Knee
A. Accurate diagnosis
B. Identification of systemic medical illnesses
C. Timing of tear—acute versus chronic rupture
D. Extent of tear—partial versus complete rupture
A. Clinical presentation
1. History
a. Diagnosis of extensor mechanism ruptures can be difficult and is often
delayed.
b. With acute ruptures, patients give a history of immediate pain and inabil-
ity to bear weight on the injured extremity. Some report an audible pop
or tearing sensation at the time of injury.
c. A thorough past medical history should be elicited for any systemic con-
The presence of any
ditions that may predispose the patient to an extensor mechanism rupture.
extension with a complete
quadriceps or patellar Any history of previous knee surgeries and local steroid injection should
tendon rupture indicates also be documented.
that the medial and d. With chronic injuries, patients may not recall a history of trauma. They
lateral patellar retinacula may complain of weakness or instability with single-leg stance.
are intact. 2. Physical examination
a. On inspection and palpation of the knee joint, there is often a large, tense
In the acute setting, hemarthrosis. There may be ecchymosis or a painful, palpable gap in the
aspiration of the knee tendon. The patella may be displaced superiorly or inferiorly.
hemarthrosis and b. The hallmark of a complete injury is the inability to extend the knee (or
administration of 10 mL maintain extension against gravity). If unable to perform a straight-leg
of intra-articular raise against gravity due to pain, the patient may be more comfortable
lidocaine for analgesia sitting at the edge of an examination table and attempting to extend the
assists in obtaining an knee.
accurate physical
c. With a partial injury, the medial and lateral retinacula may be intact,
examination.
allowing some active extension. However, the patient lacks several degrees
of terminal extension.
IT IS POSSIBLE FOR A
d. If physical examination is limited by patient discomfort, consider per-
QUADRICEPS OR PATELLAR
forming an aspiration to decompress the hematoma. Local anesthetic can
TENDON RUPTURE TO OCCUR
CONCOMITANTLY WITH OTHER
also be injected into the joint to facilitate a complete ligamentous
LIGAMENTOUS INJURIES, examination.
WHICH CAN EASILY BE e. In chronic injuries, consolidated hematoma or scar tissue may obscure
MISSED. A THOROUGH a palpable defect in the tendon, making the diagnosis more difficult.
PHYSICAL EXAMINATION IS B. Radiographic evaluation
IMPORTANT, INCLUDING 1. AP and lateral radiographs are most often sufficient in confirming the diag-
EXAMINATION OF THE KNEE nosis of a suspected quadriceps or patellar tendon rupture.
UNDER ANESTHESIA AT THE a. A patient with a quadriceps tendon rupture may have patella baja, and
TIME OF TENDON REPAIR. may have a small bony avulsion fragment from the superior pole of the
patella.
It may be helpful to b. A patient with a patellar tendon rupture may have patella alta, with the
obtain a lateral patella lying superior to Blumensaat’s line on a lateral radiograph with
radiograph of the the knee flexed 30 degrees.
contralateral knee for c. Merchant or tunnel views can also be obtained to rule out patellar dislo-
comparison. cations or osteochondral injuries, if suspected.
d. Patients with chronic quadriceps tendinopathy may show a “tooth sign,”
The Insall-Salvati ratio is or degenerative spurring at the patella.
the ratio between patellar 2. Ultrasound is highly operator-dependent but has been proven to be very
height and patellar accurate in the diagnosis of extensor mechanism injuries. It is also helpful for
tendon length; on a diagnosing this injury in patients with a previous total knee replacement.
lateral radiograph, this 3. Magnetic resonance imaging is an excellent modality for evaluation of
ratio should be 1 : 1. An tendon pathology, especially if the diagnosis is in question. It can differenti-
abnormal ratio indicates ate partial from complete rupture, and can also be used to estimate the size
patella alta or patella baja and extent of the tear. Additionally, it can be used to evaluate other intra-
(increased or decreased
and extra-articular structures for concomitant injuries.
ratio, respectively).
a. Normal tendon has a homogeneous low signal with smooth margins.
b. A ruptured tendon shows discontinuity of the fibers with wavy ends and
Blumensaat’s line is a line an increased T2-signal, representing hemorrhage and edema.
drawn along the roof of
the intercondylar notch,
seen on a lateral TREATMENT OPTIONS
radiograph. This is an
important landmark to I. Nonoperative Treatment
determine the position of A. Conservative management is only indicated for incomplete ruptures. Complete
the patella. ruptures must be managed with surgical restoration of the extensor
mechanism.
B. Nonoperative treatment should be reserved for patients who have normal or
near-normal knee extension strength when compared to the uninjured knee,
and who have evidence of a small partial thickness tear on magnetic resonance
imaging.
C. Treatment usually consists of immobilization with the knee in full extension
for 4 to 6 weeks.
D. The patient should be closely monitored for progression to complete rupture,
which requires prompt surgical treatment.
A. Operative treatment is indicated for acute complete ruptures of the quadriceps
or patellar tendon.
B. Early or immediate repair (provided that the skin is in adequate condition) is
recommended to restore the disrupted extensor mechanism and achieve optimal
functional results. The prognosis for recovery is dependent on the time between
injury and repair. Ideally, the repair should be performed within 10 to 14 days
following the injury to prevent significant scar formation.
C. There are multiple techniques by which the quadriceps or patellar tendon can
be surgically repaired. No studies have shown that one particular technique is
superior to the others.
D. Chronic ruptures are more difficult to repair and may have less favorable
outcomes than acute tears that undergo immediate repair. The remaining
tendon and quadriceps muscle have often undergone degeneration and
contraction, which makes apposition of the tendon back to the patella more
difficult. Treatment of chronic tendon ruptures is beyond the scope of this
chapter.
GENERAL PRINCIPLES OF EXTENSOR MECHANISM REPAIR

I. Goals
A. Successful repair of quadriceps or patellar tendon back to its bony insertion,
or reapproximation of the torn ends
B. Repair of torn retinaculum
C. Restoration of active knee extension while maintaining full knee range of
motion (ROM)
D. Avoiding patella alta or patella baja by tensioning the suture appropriately
E. Cerclage suture for reinforcement of patellar tendon repair as needed
II. The extensor mechanism of the knee consists of the quadriceps musculature
(rectus femoris, vastus lateralis, vastus intermedius, and vastus medialis), the quad-
riceps tendon, the patella, the patellar tendon, the tibial tubercle, and the adjacent
soft tissues.
III. The extensor mechanism originates above the hip joint at the origin of the rectus
femoris muscle on the anterior inferior iliac spine. The remainder of the quadri-
ceps muscles originate on the shaft of the femur.
IV. The individual quadriceps muscles come together distally to form the quadriceps
tendon, which has three laminae, or layers.
A. The anterior (superficial) layer of the quadriceps tendon consists of the rectus Knee
femoris tendon.
B. The middle layer is composed of the vastus lateralis and vastus medialis.
C. The posterior (deepest) layer is formed by the vastus intermedius tendon.
V. The extensor mechanism has several functions. With the leg elevated, the extensor
mechanism serves to extend or straighten the knee joint. With the foot planted
on the ground, the extensor mechanism serves to stabilize the knee joint.
VI. The patella is the largest sesamoid bone in the body. Its purpose within the exten-
sor mechanism is to increase the moment arm of the quadriceps femoris muscle,
thereby providing a mechanical advantage in knee extension.
VII. The adjacent soft tissues about the knee are also important in knee stability and
for proper knee extensor mechanism function.
A. The patellar retinaculum is a fibrous structure consisting of medial and lateral
components, and it serves an important role in patellofemoral joint stability.
B. The iliotibial band supports the extensor mechanism laterally, and it also
When does your
attending prefer to use serves as a patellofemoral joint stabilizer.
cerclage wiring to VIII. Each component of the extensor mechanism plays a critical role in the stability
augment the tendon and function of the knee and therefore is essential to restore during surgical
repair? repair.

I. The patient is placed in a supine position on the operating room table. If intra-
operative fluoroscopy is to be used, consider placing the patient on a radiolucent
Jackson table.
II. The anesthesiologist administers general or regional (spinal/epidural) anesthesia.
A femoral block may be given prior to the start of the case for postoperative pain
control.
III. ROM and ligamentous examination should be performed to check for any motion
deficits or concomitant ligamentous injuries.
IV. A bump should be placed under the ipsilateral hip to minimize hip external rota-
tion, and the leg should be shaved proximal and distal to the knee.
V. A tourniquet is placed high on the proximal thigh of the operative leg, and the
extremity is prepped and draped in standard fashion according to the surgical
principles outlined in Chapter 1 (Fig. 20-3).
VI. The skin incision is marked over the midline of the knee anteriorly (Fig. 20-4).
A. For a quadriceps tendon, the incision should be centered from proximal to
distal on the superior pole of the patella.
B. For a patellar tendon, the incision should extend from the mid-patella to the
tibial tubercle.
his or her choice of
incision for extensor VII. Less commonly, a transverse incision can be used. This is thought to be more
mechanism repair. cosmetic because it follows Langer’s lines; however, it may make exposure more
difficult.
Surgical Exposure
I. Applied Surgical Anatomy
A. The quadriceps femoris consists of the rectus femoris, vastus intermedius,
vastus medialis, and vastus lateralis muscles.
Figure 20-4
Skin incision for quadriceps tendon repair. The bony
Figure 20-3 landmarks have been identified, including the
The operative extremity suspended with the candy borders of the patella and the tibial tubercle. There
cane. The impervious drape has been placed high on is significant ecchymosis due to hematoma at the site
the thigh, just below the level of the tourniquet. of rupture.
B. The extensor mechanism consists of the quadriceps femoris, quadriceps tendon,

patella, patellar tendon, and tibial tubercle.
C. The patella is the largest sesamoid bone, lying within the expansion of the
quadriceps tendon.
D. The lateral retinaculum is an expansion of the vastus lateralis muscle, attaching
to the superolateral patella and proximal lateral tibia.
E. The medial retinaculum is an extension of the vastus medialis muscle, to the
superomedial patella and proximal medial tibia.
F. The blood supply to the quadriceps tendon arises from the descending branches
of the lateral femoral circumflex artery, branches of the descending geniculate
artery, and branches of the medial and lateral superior geniculate arteries. The
superficial tendon is well vascularized; however, the deep layer has a relatively
avascular area that may play a role in tendon degeneration.
G. The blood supply to the patellar tendon arises from the inferior medial and
inferior lateral geniculate arteries, reaching the tendon via the infrapatellar fat
pad and retinacula.
H. The infrapatellar branch of the saphenous nerve exits from the adductor canal,
pierces the sartorius muscle, and courses anteriorly to supply the skin at the
medial and anterior knee, as well as the patellar tendon (Fig. 20-5).
II. The tourniquet is inflated prior to making the incision.
III. An incision is made with a 15-blade through the skin and superficial subcutaneous
tissues. Self-retaining retractors or sharp rakes can then be placed to assist in the
subcutaneous dissection.
Rectus femoris
Cutaneous nerves
of thigh
Vastus
Vastus lateralis
Descending genicular artery,

Iliotibial band articular branch
Superior medial
genicular artery
Descending branch of
Descending genicular artery,
lateral circumflex femoral artery
saphenous branch
Medial patella
Superior lateral
retinaculum
genicular artery
Lateral patellar Saphenous nerve,
retinaculum infrapatellar branch
Biceps femoris tendon
Inferior lateral Knee

genicular artery
Inferior medial
genicular artery
Anterior tibial
recurrent artery
Sartorius
Anterior tibial Saphenous

artery nerve
Great
saphenous vein
Gastrocnemius,
medial head
Figure 20-5
Superficial neurovascular structures of the anterior aspect of the knee. (From Scott WN: Insall and Scott
Surgery of the Knee, 4th ed. Philadelphia, Churchill Livingstone, 2006.)

Exposure of the distal quadriceps tendon, patella, Débridement of soft tissue at the proximal pole of
medial, and lateral retinacula. The distal pole of the the patella, using a curette.
patella should be exposed to facilitate passage of
suture through drill holes.
IV. Thick medial and lateral subcutaneous flaps are developed to identify the extent
of the retinacular tears. This dissection can be performed sharply with a scalpel,
or with the use of dissecting scissors (Fig. 20-6).
V. Once the medial and lateral extents of the retinacular tear are identified, they may
be tagged with an absorbable suture for ease of later repair.
VI. There is usually a large hematoma present from the rupture, which needs
to be removed with copious irrigation. This allows for exposure of the full extent
of the tendon rupture; the torn ends can be identified and mobilized. The joint
should also be inspected for any evidence of articular chondral injury or loose
bodies.
VII. Any frayed or nonviable tissue should be débrided. Small, avulsed bony fragments
that are too small for repair should be excised.
VIII. Depending on the location of the tear, the tibial tubercle, inferior pole of the
patella, or superior pole of the patella are débrided of any remaining soft tissue.
A rongeur, burr, or curette can be used to decorticate the bony insertion, and
create a bleeding bed of bone for tendon healing (Fig. 20-7).
Tendon and Retinacular Repair

I. Once the edges of the torn tendon have been thoroughly débrided back to viable
tissue, the actual repair may be performed. There are several surgical techniques
available for repair; the choice of technique depends on the type of injury and
surgeon preference.
II. If the rupture is in the midsubstance of the tendon, it can be repaired end-to-end
using a heavy nonabsorbable suture.
III. Most often the rupture occurs at the osseotendinous junction, and it is not ame-
nable to end-to-end repair. In this case, the tendon is reattached to its insertion
using heavy suture and bone tunnels.
IV. The tendon should be realigned into its anatomic position to allow for normal
patellar tracking.
his or her choice of
V. Two heavy nonabsorbable sutures are inserted into the tendon using a running
suture pattern and suture
material for repair. locked Krackow stitch (see Fig. 20-9). Although this is a diagram of the
quadriceps tendon, a similar pattern should be used for patellar tendon repair.
The suture should start from the torn tendon edge, travel approximately 2 to 3 cm
CONFIRM THAT THE DRILL until normal healthy tendon is encountered, and then turn back toward the tendon
HOLES HAVE NOT VIOLATED edge. One suture is placed medially within the tendon, and the other is placed
THE ARTICULAR SURFACE BY
laterally.
DIRECT INSPECTION,
VI. Three parallel drill holes, spaced by about 1 cm, are placed along the long axis of
PALPATION, OR FLUOROSCOPY.
the patella using a 2- or 3-mm drill bit. The drill holes should start at the bleeding
Suture in stump
of vastus intermedius
Trough in superior
pole of patella
Figure 20-8
Two depictions of the method of quadriceps tendon repair, using heavy sutures passed through intraosseous
tunnels (dotted lines). The pattern is similar for repair of a patellar tendon rupture. (Adapted from Azar FM:
Traumatic disorders. In Canale ST [ed]: Campbell’s Operative Orthopaedics, 10th ed. Philadelphia, Mosby, 2003.)
bed of bone that was previously created and exit at the opposite pole of the patella.
If the tendon has avulsed from the tibial tubercle, transverse drill holes must be Consider augmentation
placed in the tibial tubercle. of repair for
VII. The patellar tendon should be repaired adjacent to the articular surface and not midsubstance ruptures, or
those in patients with
to the anterior surface of the patella. If the tendon is positioned too anterior, an
systemic illnesses that
increase in patellofemoral contact forces results, yielding patellofemoral pain and
have predisposed them to
premature arthritis. rupture. It should also be
VIII. There are four heavy suture limbs exiting at the torn tendon edge. Using a considered in patients
Hewson suture passer, pass these sutures through the drill holes as shown in Figure who will be managed
20-8. The inner limbs pass together through the center drill hole, and the outer with aggressive early
limbs pass through the medial and lateral drill holes, respectively. range of motion or those
IX. Cerclage Suture Augmentation of Patellar Tendon Repair with excessive tension on
Knee
A. If augmentation of the patellar tendon repair is required, begin by creating a the repair during
transverse drill hole approximately 1 cm posterior to the tibial tubercle. intraoperative range of
B. Another heavy nonabsorbable suture or Mersilene tape is passed through the motion.
tunnel. The suture is then passed superiorly within the quadriceps tendon,
along the superior pole of the patella, and tied. A wire can also be used,
although it will require removal at a later date.
X. Tensioning of Repair
A. Each pair of passed sutures is temporarily secured with a hemostat, applying
gentle tension. The alignment of the patella on the distal femur should be
inspected to ensure proper tracking during ROM (Fig. 20-9).
B. During patellar tendon repair, the patellar height needs to be assessed. The Excessive tensioning of
knee is positioned in 30 degrees of flexion, and the patellar height is measured the patellar tendon suture
may result in patella baja.
from the tibial tubercle to the inferior pole of the patella. This height can be

Tensioning of the quadriceps tendon repair, using Completed quadriceps tendon repair. The knots are
hemostats. The Krackow stitch has been completed visible at the distal aspect of the patella (at the left of
in the quadriceps tendon, and the suture limbs have the image), and should be kept as small as possible.
been passed through drill holes through the patella.
What is your attending’s compared to the unaffected extremity, and the height adjusted by increasing
preferred method of or decreasing tension on the cerclage suture.
estimating patellar height C. If necessary, an intraoperative lateral radiograph can be obtained and compared
during suture tensioning? with the contralateral extremity to ensure appropriate patellar position.
D. Once the correct position is obtained, the sutures are tied. The knee is flexed
to determine the degree of flexion that can be tolerated without causing exces-
sive tension on the repair.
E. Try to avoid excessively large knots, as they may be prominent beneath the
skin and cause difficulty for the patient postoperatively.
F. Oversew the tendon repair with an interrupted #0 or 2-0 absorbable suture, to
approximate any remaining loose ends (Fig. 20-10).
XI. Retinacular Repair
A. The medial and lateral retinacula are repaired using absorbable sutures in an
interrupted fashion. Start at the most medial or lateral extent of the tear, using
the tag sutures that were previously placed.
B. The retinacula should be repaired with the knee held in 30 degrees of flexion,
to prevent limiting postoperative ROM.
Wound Closure
I. If exposed, the patellar paratenon should be closed first using a 2-0 or 3-0 absorb-
able suture.
II. Based on surgeon preference, the tourniquet may be released prior to closure or
once the dressings have been secured. A closed suction drain can be used in the
wound if necessary.
III. The subcutaneous layer and skin are closed in standard fashion (see Chapter 1 for
details). After staples are placed to approximate the skin edges, a sterile dressing
is applied and an Ace wrap is used to wrap the entire extremity.
IV. A knee immobilizer or locked hinge brace is placed on the extremity. Make sure
that the brace is secure prior to the patient awaking from anesthesia.

I. Perioperative antibiotics are continued for 24 hours, or until the Hemovac drain
is removed.
II. Pain should initially be managed with patient-controlled analgesia and later con-
trolled with oral narcotic mediation.
III. Deep vein thrombosis prophylaxis is based on the preference of the attending
physician; warfarin (Coumadin), aspirin, or low-molecular-weight heparin
(Lovenox) are common choices. Sequential lower extremity compression devices

should also be used routinely.
IV. If drains were placed, they are usually discontinued within the first two postopera-
tive days, when the output is sufficiently low.
V. The knee immobilizer is kept in place until postoperative day 2, when the dress-
ings are changed and the wound is inspected to assess appropriate healing.
VI. After the first wound check, a cylinder cast can be placed with the knee in full
extension. Alternately, a reliable patient can be maintained in a locked hinged knee
brace or immobilizer.
VII. Patients are allowed to bear weight as tolerated using crutches for assistance with
ambulation. A physical therapy consult is obtained during the patient’s hospital
stay.
VIII. The remainder of rehabilitation is largely dependent on surgeon preference. For
a quadriceps tendon repair, straight-leg-raise exercises may begin at 3 to 6 weeks,
and the ROM exercises may start at 6 to 12 weeks. For a patellar tendon repair,
isometric quadriceps strengthening may begin immediately, and ROM exercises
may start as early as 2 weeks postoperatively.
IX. With the use of a hinged knee brace, motion may be increased by 10 to 15 degrees
each week for a quadriceps tendon repair and 30 degrees each week for a patellar What is your attending’s
rehabilitation protocol
tendon repair. Full return to strenuous activity should be delayed until 4 to 6
following extensor
months, when ROM has been restored and quadriceps strength has returned to
mechanism repair?
nearly the strength of the contralateral extremity.
COMPLICATIONS
I. Loss of knee motion is the most common complication after extensor mechanism
repair. Specifically, full knee flexion is most commonly affected.
II. Extensor weakness is usually secondary to quadriceps atrophy and is more common
after patellar tendon repair.
III. Other complications may include:
A. Wound infection
B. Wound dehiscence, usually related to superficial location of the large nonab-
sorbable sutures
C. Patellar incongruity with patellofemoral degenerative changes, anterior knee
pain, and arthritis
D. Rerupture of the repaired tendon, requiring revision repair surgery
SUGGESTED READINGS
Azar FM: Traumatic disorders. In Canale ST (ed): Campbell’s Operative Orthopaedics, 10th ed.,
vol. 3. Philadelphia, Mosby, 2003.
Beynnon BD, Johnson RJ, Coughlin KM: Knee. In DeLee JC (ed): DeLee and Drez’s Orthopaedic
Sports Medicine, 2nd ed., vol. 2. Philadelphia, Saunders, 2003.
Ilan DI, Tejwani N, et al: Quadriceps tendon rupture. J Am Acad Ortho Surg 11:192–200, 2003.
Matava MJ: Patellar tendon ruptures. J Am Acad Ortho Surg 4:287–296, 1996. Knee
Siwek CW, Rao JP: Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am
63:932–937, 1981.
C H A P T E R
21
Arthroscopic Meniscectomy
Andrea L. Bowers and Brian J. Sennett
Case Study
A 55-year-old male presents with right knee pain and swelling. Six months ago, he stepped
awkwardly off a curb and noted immediate pain on the inside of his knee. His pain is
intermittent but is much worse with weight bearing, changing directions while walking,
and especially with squatting or pivoting. Sometimes his knee “catches” or feels as if it is
going to give out on him; occasionally it swells. His symptoms have not improved despite
use of nonsteroidal anti-inflammatory medications, icing, and a course of physical therapy
prescribed by his primary physician. Plain radiographs of the knee are unremarkable.
Sagittal and coronal magnetic resonance images of the knee are presented in Figure
21-1.
BACKGROUND
I. The medial and lateral menisci are located within the knee joint between the
femoral condyles and the tibial plateau. The menisci comprise type I collagen and
serve to increase contact area, distribute load, and absorb shock with weight
bearing. Menisci are largely insensate and have a limited blood supply. The
peripheral third of the meniscus (the “red-red” zone) has greater perfusion than
Figure 21-1
Sagittal and coronal T2 magnetic resonance imaging scans demonstrating a medial meniscus tear.
C H A P T E R 2 1 Arthroscopic Meniscectomy 229
the middle (“red-white”) and central (“white-white”) zones. The color of the zones
is based on the vascularity in that region of the meniscus.
II. The knee contains a semicircular lateral meniscus and a larger, oblong medial
meniscus. Both are triangular in cross section. The menisci typically attach via
bony attachments anteriorly and posteriorly. In addition, the medial meniscus is
adherent to the deep portion of the medial collateral ligament and may attach to
the lateral meniscus via the transverse intermeniscal ligament. The lateral menis-
cus occasionally attaches posteriorly by the ligaments of Humphry and Wrisberg
to the femur (see Fig. 23-14).
III. The medial meniscus has less excursion than the lateral meniscus (5 mm vs.
11 mm, respectively) because the knee flexes from an extended position, and the
medial meniscus is three times more likely to tear than the lateral meniscus. An actual tear of the
IV. Tears of the meniscus are generally seen in two different patient populations. One meniscus is distinguished
is the young athlete who sustains a twisting injury and tears an otherwise healthy from degenerative
meniscus. Such tears may also be seen in the setting of a tear of the cruciate or changes on a magnetic
collateral ligaments, and in limited instances, these tears may be amenable to resonance imaging scan
repair. Tears are also seen in the middle-aged or older individual with underlying by communication of the
degenerative changes in the meniscus that render it susceptible to tearing with intra-substance signal
low-energy injury mechanisms. with the edge of the
V. Because of the poor vascular supply in the older patient, the underlying tissue is meniscus.
often incapable of healing, and tears of the meniscus are commonly excised rather
than repaired. Historically, the meniscus was removed entirely; however, follow-
up revealed an alarming incidence of degenerative arthritis after complete menis-
cectomy. Current standard of care is the arthroscopic partial meniscectomy, in
which the tear and degenerative area are trimmed to a smooth peripheral rim,
preserving as much meniscus as is possible.
VI. Goals. The major goals of arthroscopic meniscectomy are as follows:
A. Relief of pain
B. Removal of any mechanical block to motion
C. Débridement to a stable rim of remaining meniscus
D. Preservation of as much uninjured meniscus as possible
E. Documentation of concomitant injury/degeneration of intra-articular
structures
TREATMENT ALGORITHM
Knee pain (history, physical exam)
AP, lateral, sunrise radiographs; MRI Meniscal

repair
Diagnosis:
meniscal tear Yes
Knee
Physiologically ARTHROSCOPIC Red-red zone
No Yes
young, active SURGERY (vascular) tear
No
Conservative management
Yes Partial meniscectomy

NSAIDs Symptoms Persistent pain
Physical therapy
No No Yes
Success Meniscal transplant
TREATMENT PROTOCOLS
Asymptomatic, partial- A. Patient age
thickness tears less than 5 B. Concomitant injury (cruciate or collateral ligament tear)
to 10 mm in length that C. Symptomatology
are stable to probing may D. Size of tear
be treated nonoperatively, E. Location of tear
although there is a F. Orientation of tear
theoretical risk of tear G. Stability of tear
propagation. H. Quality of meniscal tissue
A. Activity modification
B. Nonsteroidal anti-inflammatory drugs
C. Cryotherapy (icing)
D. Physical therapy
SURGICAL ALTERNATIVES TO ARTHROSCOPIC MENISCECTOMY

I. Open Meniscectomy: fallen out of favor due to well-known association between
complete meniscectomy and late osteoarthritis
II. Meniscal Repair
A. Reserved for acute, peripheral tears (outer “red-red” zone) in a non-
degenerative meniscus
B. Ideal candidate: presents with a 1- to 2-cm acute, longitudinal peripheral
(vascular) tear with concomitant anterior cruciate ligament reconstruction
C. Techniques
1. Open repair
2. Inside-out (gold standard)
3. Outside-in
4. All-inside (e.g., sutures, arrows, darts)
III. Meniscal Transplantation: for young symptomatic patients after near-total or
total meniscectomy with minimal degenerative changes in either the medial or
lateral compartments
SURGICAL INDICATIONS FOR ARTHROSCOPIC MENISCECTOMY

I. Symptomatic radial or longitudinal tears in active individuals
II. Meniscal tears that have failed nonoperative management, such as physical therapy
or injections
III. Displaced bucket-handle tears: a longitudinal tear of the central or posterior horn
in which the inner one third, which is still attached to the edges of the periphery
like a handle on a bucket, can displace into the notch (Fig. 21-2)
Figure 21-2
Bucket-handle tear of the medial meniscus (BH MM).
The torn rim of the meniscus displaces toward the
notch between the medial femoral condyle (MFC) and
medial tibial plateau (MTP).
IV. Tears creating a mechanical block to knee range of motion

V. The symptomatic discoid lateral meniscus, with or without a tear
RELATIVE CONTRAINDICATIONS FOR ARTHROSCOPIC MENISCECTOMY

I. Significant comorbidities compromising the safety of a surgical candidate
II. Asymptomatic meniscus tear, particularly when stable (<5 mm, partial thickness,
and displaceable <3 mm)
III. End-stage degenerative joint disease: these patients may be better served with total
knee replacement (see Chapter 23)
GENERAL PRINCIPLES OF ARTHROSCOPIC MENISCECTOMY

I. Arthroscopy involves evaluation of the joint with a small arthroscopic camera
(“scope”) with a fiberoptic light source. The scope itself comes in different diam-
eters and viewing angles. A 30-degree scope is the most frequently used scope in
knee arthroscopy. The 70-degree scope is occasionally used to visualize the pos-
terior joint.
II. The scope is inserted through a small 0.5- to 1-cm portal that penetrates the skin,
subcutaneous tissues, and capsule. The capsule is distended with pressurized sterile
irrigant (saline or lactated Ringer’s) passed through the inflow cannula (which may
be separate or a component of the scope).
III. The internal image is displayed on a screen positioned so the surgeon can com-
fortably view it while examining or manipulating the knee. Still photographs or
video can be taken by the camera to document findings and treatment.
IV. Through a separate portal, a series of probes, shavers, and biters can be introduced
into the joint to treat intra-articular pathology. Care must be taken to avoid iat-
rogenic injury to the articular cartilage or other structures when inserting the
scope or other instruments into the joint (Fig. 21-3).
V. Multiple portals can be made about the knee joint as needed to obtain the correct
approach to the meniscus. In general, the medial and lateral parapatellar portals
are the workhorses of arthroscopic meniscectomy.
VI. The following compartments of the joint should be inspected (Fig. 21-4).
A. Medial compartment
B. Lateral compartment
C. Notch (the central space occupied by the cruciate ligaments)
D. Patellofemoral articulation
E. Suprapatellar pouch
F. Medial gutter
G. Lateral gutter
VII. The order of examination does not necessarily matter, but a systematic, repeatable
examination sequence can ensure that the entire joint is always thoroughly assessed.
Knee
Figure 21-3
Arthroscopic instruments: blunt, probe, cannulae,
biter, shaver, and 30-degree scope.
A B C
D E F
Figure 21-4
Arthroscopic images of the knee. A, Lateral gutter. B, Patellofemoral joint. C, Medial gutter. D, Medial
hemijoint. E, Intercondylar. F, Lateral hemijoint. ACL, anterior cruciate ligament; LFC, lateral femoral
condyle; LM, lateral meniscus; LTP, lateral tibial plateau; MFC, medial femoral condyle; MM, medial
meniscus; MTP, medial tibial plateau; PCL, posterior cruciate ligament.
What sequence does your Documentation of concomitant or incidental findings is a critical element of the
attending use to examine arthroscopic examination.
and treat the knee VIII. Periodically throughout the procedure, the joint may need to be irrigated through
compartments, and why? the outflow cannula to provide egress of accumulated intra-articular blood or
debris and maintain a clear view.
IX. A meniscal tear that meets surgical criteria is either repaired or trimmed with a
series of shavers and biters to a smooth, stable peripheral rim of remaining healthy
meniscus.
What is your attending’s Positioning, Prepping, and Draping

preferred anesthetic for a I. The procedure can be performed under general endotracheal anesthesia,
straightforward partial epidural or spinal, peripheral block, or intra-articular injection with seda-
meniscectomy?
tion.
II. The patient is positioned supine on a standard operating table. To improve
visualization, a valgus (lateral) post or knee holder is utilized. A valgus post
is positioned approximately three fingerbreadths proximal to the knee flexion
crease when the knee is flexed 90 degrees over the side of the table. When
the post is up and a lateral force is applied to the distal extremity, the patient’s
thigh presses against the post and creates a valgus stress on the knee to open
the medial hemijoint (Fig. 21-5). A leg holder allows the knee to flex off the
end of the table and allows valgus and varus forces to be applied to improve
visualization.
Does your attending III. The extremity should be shaved to approximately 6 inches above and below the
routinely apply or inflate knee.
a tourniquet for partial IV. Some surgeons apply a tourniquet to the proximal thigh, which may or may not
meniscectomy? be inflated. A nonsterile 34-inch tourniquet is usually sufficient and is secured over
Webril padding.
V. Prepping and draping are performed according to the general principles out-
lined in Chapter 1. Ask the attending surgeon about his or her prefer-
ences.
A B
Figure 21-5
Lateral post. A, The lateral post is positioned proximal to the knee joint. B, During surgery the arthroscopist
uses his or her own leg to stress the patient’s leg against the draped valgus post and open the medial
hemijoint.

I. The leg is positioned in an extended position on the table. The knee is examined
for an effusion, and the joint capsule is injected with approximately 40 mL of fluid
(either saline or local anesthetic with epinephrine, depending on the type of
anesthesia).
II. The knee is flexed over the side of the table.
III. The surface anatomy of the knee, including the patella, medial and lateral
edges of the patellar tendon, and medial and lateral tibial plateau are palpated
and marked with a marking pen. The lateral and medial parapatellar portal sites
are positioned approximately 1 and 1.5 cm, respectively, away from the patellar
tendon halfway between the distance from the patella to the tibial plateau (Fig.
21-6).
IV. The projected portal sites can be injected with local anesthetic with epinephrine
before the incision is made, to reduce capsular bleeding.
V. An 11-blade is used to create the first portal, first through skin and then BE CAREFUL NOT TO
through subcutaneous tissues into the capsule. The incision can be dilated with a TRANSECT THE MENISCUS
ITSELF WHEN MAKING YOUR
hemostat. The blunt trocar for the scope is introduced and positioned within the
PORTALS WITH AN 11-BLADE.
joint.
Knee
A B C
Figure 21-6
A, Surface landmarks are marked on a prepped and draped knee. B, An arthroscope is introduced via a portal.
C, The surgeon visualizes the internal joint on a viewing screen.
VI. The blunt trocar is removed and the camera is inserted. An inflow cannula
is established, either connected to the scope itself or through a separate
portal.
VII. A second portal is created to allow instruments to be introduced into the joint.
This portal can be created under direct visualization by the camera inserted in the
original portal. This can minimize the risk of iatrogenic injury to the articular
surfaces introduced with blind or forceful portal entry.
Diagnostic Arthroscopy
I. A diagnostic arthroscopy is performed, in which the aforementioned compart-
ments of the knee are systematically inspected and probed. Photographs are taken
of each compartment and any pathology encountered. The order of the examina-
tion varies by surgeon preference, and the following is an example of one
technique.
II. The medial compartment examination is facilitated by applying a valgus force
against the lateral post. The knee can be flexed or extended gently to better visual-
ize specific areas within the compartment. Typically the scope is inserted through
the lateral portal and the probe through the medial portal. The articular surfaces
and the medial meniscus are examined.
III. The modified Gillquist technique can facilitate visualization of the posterior
medial hemijoint. The knee is flexed to 90 degrees, and a varus force is applied to
the tibia. The camera is passed from the lateral portal medial to the posterior
cruciate ligament, levering against the posterior cruciate ligament and away from
condyle, to observe the posterior horn of the medial meniscus and the postero-
medial aspect of the knee.
IV. The camera is carefully withdrawn from the medial compartment into the notch.
The anterior and posterior cruciate ligaments are probed to assess their
integrity.
V. The lateral hemijoint is entered. A varus force or figure-of-four positioning allows
access to the lateral compartment (Fig. 21-7). Again, the articular cartilage and
meniscus are examined. The popliteus tendon can be visualized coursing behind
the posterolateral aspect of the lateral meniscus. The popliteal hiatus is evaluated
for the presence of loose bodies.
VI. The camera is pulled back toward the notch, and then it is advanced up and
forward along the trochlea as the knee is slowly extended. The patellofemoral joint
and suprapatellar pouch can be examined from this position.
VII. Finally, the medial and lateral gutters can be examined by positioning the camera
around and down the sides of the femoral condyles.
VIII. Easy passage of the scope may be restricted by plica, which are remnants from
embryonic joint development. Such plica are typically benign, although the medial
patellar plica in particular can become enlarged and cause pain in the region of
the medial femoral condyle.
Figure 21-7
The figure-of-four position facilitates access to the
lateral compartment.
A B C
Figure 21-8
A, Medial meniscus tear. B, Débridement of tear. C, Trimmed meniscus.
Partial Meniscectomy
I. Attention is turned to the meniscal tear. The entire length of the meniscus is
probed and the margin of the tear is assessed for stability. An attempt should be
made to reduce any portions of the meniscus that are displaced (e.g., parrot-beak
or bucket-handle tears).
II. As a general rule, for the posterior half of the meniscal body and the posterior
horn, the probe/shaver/biter should enter on the ipsilateral side of the knee INTRODUCE INSTRUMENTS
(i.e., medial meniscus, the shaver should enter from the medial portal). For tears INTO THE JOINT WITH SHARP
that are located in the anterior horn and anterior half of the meniscal body, access EDGES ANGLED AWAY FROM
to the tear may be enhanced if the shaver is inserted from the contralateral THE ARTICULAR CARTILAGE TO
portal. AVOID IATROGENIC INJURY TO
THE ARTICULAR CARTILAGE
III. A motorized shaver is used to débride wispy, irregular edges. A biter is used repeat-
ABOVE AND BELOW THE
edly to trim jagged edges. Biters are available with variable-angled necks to achieve
MENISCUS.
access to all parts of the tear.
IV. The shaver and biters are alternated as needed to excise the torn portion of menis- OVERLY AGGRESSIVE
cus and débride to a smooth, stable rim of remaining tissue. Care must be taken DÉBRIDEMENT CAN
to débride enough meniscus to create an even edge without excising too much and DESTABILIZE THE REMAINING
destabilizing remaining tissue. MENISCAL TISSUE.
V. The trimmed meniscus is probed again to verify stability of the remaining segment
(Fig. 21-8).
All components of the
diagnostic arthroscopy
Wound Closure and partial meniscectomy
should be documented
I. The instrument and camera are withdrawn. The inflow is closed and the outflow with photographic images
portal opened to allow drainage of the remaining irrigation. taken with the
II. Some surgeons may choose to instill intra-articular anesthetic at closure. Sterile arthroscope.
dressings are applied per surgeon’s preference.
Does your attending
POSTOPERATIVE CARE AND GENERAL REHABILITATION typically instill anesthetic
or analgesics into the
I. Arthroscopic meniscectomy is commonly performed on an outpatient basis, and joint at the end of the Knee
the patient is sent home the same day. case?
II. Oral narcotic medicines are prescribed for management of postoperative
pain.
III. Cryotherapy can enhance postoperative analgesia and minimize effusion.
IV. Sterile dressings are not removed until a few days postoperatively.
V. In general, patients can bear weight as tolerated immediately on the operative
lower extremity. Early range of motion is encouraged. Physical therapy may be
necessary.
COMMON COMPLICATIONS
I. Iatrogenic intra-articular injury
II. Hemarthrosis
III. Destabilization of the remaining meniscus

IV. Sensory deficit over lateral proximal tibia (infrapatellar branch of the saphenous
nerve)
V. Fluid extravasation into the calf or thigh
VI. Focal osteonecrosis from laser-assisted chondroplasty
SUGGESTED READINGS
Greis PE, Bardana DD, Holmstrom MC, Burks RT: Meniscal injury: I. Basic science and evaluation.
J Am Acad Orthop Surg 10:168–176, 2002.
Greis PE, Holmstrom MC, Bardana DD, Burks RT: Meniscal injury: II. Management. J Am Acad
Orthop Surg 10:177–187, 2002.
McCarty EC, Spindler KP, Bartz R: Meniscal injury. In Vaccaro AR: Orthopaedic Knowledge,
Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 449–451.
Miller MD, Cooper DE, Warner JJP: Review of Sports Medicine and Arthroscopy, 2nd ed. Phila-
delphia, Elsevier, 2002.
C H A P T E R
22
Anterior Cruciate Ligament
Reconstruction
J. Todd R. Lawrence and Brian J. Sennett
Case Study
A 20-year-old female collegiate athlete presents with complaints of left knee pain, swelling,
and a feeling of instability after a twisting injury to her knee that she sustained while she
was playing soccer about 7 weeks ago. She reports hearing and sensing a “pop” at the time
of injury. Her knee became swollen over the course of the next few hours and has been
swollen since that time. Aspiration of her knee by her team physician the next day revealed
a hemarthrosis. She is currently able to ambulate with minimal pain but notes that her
knee feels unstable, as if “the bones are moving places they are not supposed to,” especially
while performing cutting and jumping activities. She denies any locking, catching, or
clicking in the left knee. Physical examination is notable for a mild effusion and positive
Lachman, anterior drawer, and pivot shift tests. No examination findings are suggestive
of patellar pathology, meniscal tears, or other ligamentous injuries about the knee. A
magnetic resonance image of the knee and an intraoperative arthroscopic view of the
ruptured anterior cruciate ligament (ACL) are presented in Figures 22-1 and 22-2.
BACKGROUND
I. Anatomy/biomechanics. The ACL is an intra-articular extrasynovial ligament of
the knee. In the notch of the knee, it courses obliquely from the medial aspect of
the lateral femoral condyle to insert just anterior to and between the intercondylar
eminences of the tibia. In total, it is approximately 33 mm long and 11 mm in
diameter and can resist a load of approximately 2200 newtons. It is thought to
have two functional bundles. The anteromedial bundle is tighter in flexion and
Knee
Figure 22-1
Magnetic resonance imaging scans
demonstrating an anterior cruciate
ligament (ACL) tear. A, A sagittal,
T1-weighted image through the
notch demonstrates a complete
tear of the ACL. B, A sagittal,
T2-weighted image through the
lateral tibiofemoral joint
demonstrates edema in the distal
femur and posterior one third of
the tibial plateau, a characteristic
“bone bruise” pattern of ACL
tears.
A B

Figure 22-2
Intraoperative view demonstrating an ACL tear. An
arthroscopic view of the notch demonstrating a tear
of the ACL from the femoral insertion site. Note the
empty medial wall of the lateral femoral condyle.
resists anterior translation of the tibia on the femur. The posterolateral bundle is
tighter in extension and is more responsible for countering rotational forces. The
primary blood supply is the middle geniculate artery.
II. The most common mechanism of injury responsible for ACL rupture is a non-
contact pivoting injury with the foot firmly planted on the ground. Most patients
report hearing or sensing a “pop” and experience swelling of the knee that occurs
within 6 hours of the injury. If this effusion is aspirated, it typically reveals bloody
fluid referred to as a hemarthrosis.
III. The Lachman test is the most sensitive physical examination maneuver for detect-
ing an ACL tear. The pivot shift test is also useful for assessing rotational instabil-
ity; however, it typically requires general anesthesia in the acute setting because
the patients guard against the test (Figs. 22-3 and 22-4).
IV. Female athletes have a two- to eightfold increased risk of ACL tear compared with
male athletes. The etiology of this is not known but may be due to differences in
neuromuscular control.
V. Chronic ACL deficiency results in a higher incidence of cartilage damage and
meniscal tears compared with ACL-intact knees. Despite this fact, the develop-
Figure 22-4
Pivot shift test. The pivot shift test is useful for
assessing rotational instability. The extremity is held
by the lower leg with the knee in extension, and a
Figure 22-3 valgus force is applied to the knee. In this position,
Lachman test. The Lachman test is the most in an anterior cruciate ligament–deficient knee, the
sensitive physical examination test for anterior tibia is subluxated anteriorly. The knee is slowly
cruciate ligament tears. The knee is held at 30 flexed by the examiner and at about 20 to 30 degrees
degrees of flexion, and an anteriorly directed force of knee flexion, the knee “shifts” or reduces as the
is applied to the proximal tibia while the femur is iliotibial band slips posterior to the axis of rotation
held stationary. The amount of translation and the of the knee. Tibial internal rotation can be used to
nature of the endpoint are assessed. accentuate this effect.
C H A P T E R 2 2 Anterior Cruciate Ligament Reconstruction 239
ment of arthritis in ACL-deficient knees compared with ACL-reconstructed knees

is controversial. Some authors have found that patients who have had their ACL
reconstructed actually have more long-term degenerative changes. They argue
that the ACL-reconstructed knee feels more stable to patients, allowing them to
participate in more activities, but is not biomechanically back to normal, leading
to earlier degenerative changes.
TREATMENT ALGORITHM
Diagnosis of isolated ACL tear
Instability with No instability with

daily activities daily activities
ACL reconstruction Age <30 Age >30
Desires to Sedentary
return to lifestyle;
Physical therapy and
cutting or no cutting
activity modification
jumping or jumping
activities activities
ACL reconstruction Instability with No instability with

desired activities desired activities
Conservative
ACL reconstruction
management
TREATMENT PROTOCOLS
A. Patient age. In patients younger than 30 years of age, surgical reconstruction
is favored. In patients older than 30 years of age, an initial period of rehabilita-
tion followed by reevaluation is favored. Reconstruction is usually only recom-
mended for recurrent instability.
B. Functional demands. A patient’s vocational and recreational demands may
influence the decision to recommend reconstruction. If a patient requires a
stable knee to work, he or she may be a candidate for ACL reconstruction. For
example, the professional athlete may opt for reconstruction, and the patient
with a sedentary lifestyle may not. Formerly active older recreational athletes
may opt to give up cutting and jumping activities and take up straight-ahead
activities such as running or cycling to avoid surgery.
C. Instability. Unstable knees require reconstruction. Knee
D. Patient expectations
E. Associated injuries. Associated ligamentous injuries about the knee, meniscus
tears, or cartilage lesions often necessitate ACL reconstruction to be MENISCUS REPAIR SHOULD BE
successful. PERFORMED IN A STABLE
1. Undiagnosed or untreated posterolateral or posteromedial corner ligamen- KNEE. IN THE ACL-DEFICIENT
tous complex injuries are common causes of ACL reconstruction failure. KNEE, THE ACL SHOULD BE
2. Meniscus repairs in ACL-deficient knees do not heal. It is necessary to RECONSTRUCTED AT THE TIME
OF MENISCAL REPAIR OR AS A
reconstruct the ACL if there is an associated meniscus tear that requires
LATER STAGED PROCEDURE.
repair.
3. Meniscus repairs done in conjunction with an ACL reconstruction have
better healing rates than isolated meniscus repairs.
F. Range of motion. Most surgeons advocate that patients should have regained
full range of motion prior to reconstruction.
G. Time from injury to reconstruction

A. Activity modification. Patients can often function quite well without instability
if cutting and jumping activities, such as basketball and soccer, are replaced
with straight-ahead activities, such as bike riding or running.
B. Bracing. ACL braces are commercially available and can be used as prophylactic
devices to potentially prevent ACL tears or as therapeutic braces in the ACL-
deficient knee. They have been shown only to reduce the incidence of ACL
injury in elite skiers. They may provide some symptomatic comfort to patients
with ACL-deficient knees but cannot biomechanically replace an ACL.
C. Continued physical therapy. A continued program of strengthening and pro-
prioceptive therapy with special attention to the hamstrings can often lead to
continued good functional outcomes.
SURGICAL INDICATIONS
I. An ACL-deficient knee with functional ACL instability
II. Young patients (age <30 years)
III. Patients requiring or desiring a stable knee for cutting, pivoting, or jumping
activities
IV. Multiple ligamentous injuries about the knee
V. Meniscal tears amenable to repair with an associated ACL tear
RELATIVE CONTRAINDICATIONS TO ANTERIOR CRUCIATE

Does your attending have
any absolute indications LIGAMENT RECONSTRUCTION
regarding anterior I. Unwillingness or incapability of participating in the postoperative rehabilitation
cruciate ligament program
reconstruction? Does he
II. Current infection in or about the knee
or she have any absolute
III. Unwillingness to accept the donor site morbidity of autograft harvest or the infec-
contraindications?
tious risk of allograft
GENERAL PRINCIPLES OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

I. The primary function of the ACL is to control anterior translation of the tibia on
the femur throughout the knee range of motion. It also provides rotational control
and contributes to varus and valgus stability of the knee. The goal of ACL recon-
struction is to restore normal knee kinematics, allowing the patient to return to
normal daily activities.
II. With currently available techniques, complete ACL tears cannot be repaired
effectively. The current theories as to why this is the case relate to the fact that
the ACL is an intra-articular structure. The normal healing process, which is
usually initiated with a fibrin blood clot that ideally bridges the tear, is not able
to form properly due to the synovial fluid in the joint. Instead, the torn ends of
the ACL become covered in fibrous tissue and end-to-end healing does not
occur.
III. Because ACL tears cannot be repaired primarily, complete ACL tears must be
reconstructed using tendinous grafts that are routed through the knee usually
using bone tunnels.
IV. Restoration of normal knee kinematics is best accomplished by placing the graft
into the anatomic insertion points in the tibia and femur.
A. Improper positioning of the graft may lead to limitations in range of motion.
B. Placing a graft anterior to its normal axis of rotation makes the graft tight in
flexion, thus potentially limiting flexion. Alternatively, placing a graft posterior to
the axis makes it tight in extension, thus potentially limiting terminal extension.
1. Positioning the femoral tunnel/insertion site too anteriorly may make the
graft tight in flexion, thus potentially limiting knee flexion.
2. Positioning the femoral tunnel too posteriorly is difficult given current

reconstruction techniques. The insertion point of the native ACL starts
close to the posterior wall of the femur, so placement of a graft through a
tunnel makes it difficult to place it too posteriorly.
3. Positioning the tibial tunnel/insertion site too anteriorly may make the graft
tight in flexion, thus potentially limiting knee flexion. In addition, an exces-
sively anteriorly placed tibial tunnel may lead to graft impingement on the
intercondylar notch of the knee as the knee is brought into full extension,
thus limiting terminal extension.
4. Positioning the tibial tunnel/insertion site too posteriorly may make the
graft tight in extension, thus potentially limiting terminal flexion.
V. Restoration of normal knee kinematics is also dependent on proper tensioning of
the graft. The graft should be tensioned as closely to physiometric as possible.
A. In a normal knee, the ACL is nearly isometric from about 90 degrees of flexion
to about 30 degrees of knee flexion. From about 30 degrees to full extension,
the ACL progressively tightens as the screw home mechanism slightly exter-
nally rotates the tibia on the femur.
B. The position of the knee and the tension on the graft during fixation influences
knee kinematics.
1. Overtensioning a graft in 30 degrees of knee flexion may make the graft
excessively tight in full extension, thus limiting extension.
2. Inadequate tensioning may lead to supraphysiologic laxity.
VI. Surgical Variations of ACL Reconstruction
A. There are many choices of graft, and they may be harvested from different
sources. They can be from cadaveric sources, termed allografts, or they can be
harvested from a site on the patient’s body, termed autografts. Autografts are
usually healthy living tissue; however, they carry the potential of donor site
morbidity. Allografts have no donor site morbidity but the quality of the tissue
is somewhat variable and they carry the risk of disease transmission. The risks
of transmission of hepatitis C and human immunodeficiency virus (HIV) are
estimated to be 1 : 150,000 and 1 : 1,700,000, respectively.
B. Several tendon options do exist for reconstructing the ACL. The central 1 cm
of the patellar tendon with a small sliver of attached bone from the patella and
tibial tubercle attachment sites is usually referred to as a bone-patellar tendon-
bone graft; this can be either allograft of autograft. A doubled-over graft consist-
ing of the semitendinosus and gracilis tendons, referred to as a quadrupled
hamstrings graft, is also very popular. This graft may also be either allograft or
autograft. Achilles tendon allograft may be used either with or without the bony
attachment to the calcaneus. Tibialis anterior tendon, again as an allograft only,
is also an option.
C. Grafts differ in their inherent strength; their initial fixation strength; and, for
autografts, their donor site morbidity. The quadrupled hamstrings graft is
inherently stronger than a bone-patellar tendon-bone graft, but the initial fixa-
tion to bone is not as strong. Bone-patellar tendon-bone grafts have superior Knee
initial fixation into host bone, but the donor site morbidity (i.e., anterior knee
pain) is much greater. Some centers advocate using a double-bundle recon- Does your attending
struction procedure, citing data that this procedure more closely reproduces prefer a specific method
natural knee kinematics. However, reconstructing two bundles greatly increases of reconstruction criteria
and what determines the
the complexity of the procedure, and no clinical data exist to prove its superior-
type of graft to use?
ity over conventional single-bundle reconstruction procedures.

This section focuses on the use of autograft bone-patellar tendon-bone reconstruction.
The concepts and steps for hamstrings and other graft sources follow the same sequence,
with minor variations depending on the ever-changing harvest and fixation systems
used.
Examination under Anesthesia
Because of pain and sensation of instability, many patients guard against physical
examination while awake in the office by contracting their hamstrings. Thus, a complete
ligamentous examination should be performed on every patient after induction of
anesthesia.
I. The examination of the ACL should include Lachman, anterior drawer, and pivot
shift tests (see Figs. 22-3 and 22-4).
II. Examination of the other ligamentous structures (e.g., medial and lateral collateral
ligaments, posterior cruciate ligaments; PCLs) about the knee should be per-
formed as well.
III. Particular attention should be given to ruling out any evidence of posterolateral
corner injuries because they are an increasingly common cause of cruciate liga-
ment reconstruction failure and are often missed.
Positioning, Prepping, Draping, and Diagnostic Arthroscopy
I. Prepping and draping of the leg is the same as that described in Chapter 21, except
that a tourniquet is applied to the upper leg, and usually inflated prior to starting
the case.
II. A diagnostic arthroscopy is performed as described in Chapter 21, except that
portal placement is modified slightly. The lateral portal is positioned adjacent to
the lateral edge of the patellar tendon to allow for better visualization and access
to the medial aspect of the lateral femoral condyle, the insertion point of the ACL.
The medial portal is positioned as with the diagnostic arthroscopy, about a centi-
meter medial to the medial edge of the patellar tendon.
III. All intra-articular pathology is usually addressed prior to starting with ACL
reconstruction.
Graft Harvest
This section will describe the technique for the harvest of an autograft bone-patellar
tendon-bone graft from the ipsilateral knee.
I. The following anatomic landmarks are delineated:
A. Superior pole of the patella
B. Medial and lateral extent of patellar tendon
C. Tibial tubercle
D. Posterior-medial aspect of tibia at the level of the tibial tubercle
II. The surgical incision is drawn from 1.5 cm inferior to the superior border of the
patella to the tibial tubercle. The incision starts in the medial one third of the
patellar tendon proximally and proceeds to the lateral one third of the space
between the tibial tubercle and the posteromedial aspect of the tibia.
III. The limb is exsanguinated with the use of an Esmarch and the tourniquet is
inflated prior to starting the case (see Chapter 1 for details).
IV. The skin is incised with a knife, and the dissection is carried to the level of the
paratenon of the patellar tendon.
V. The medial and lateral extent of the tendon is delineated by spreading
vertically with blunt tip scissors, and a self-retainer retractor is placed in the
wound.
VI. The paratenon is incised near the distal midline extent of the tendon with the
scissors. The scissors, which should be kept closed, are passed proximally and
distally to free the paratenon from the underlying tendon and then used to create
a longitudinal cut in the paratenon. The edges of the cut paratenon are then ele-
vated for about 1 cm on each side.
VII. A hemostat is passed from lateral to medial around the patellar tendon to free it
from the underlying fat pad.
Figure 22-5
Harvest of the central one-third bone patellar
tendon bone autograft. The central 1 cm of the
patellar tendon is identified and split longitudinally
to its patellar and tibial insertions. After measuring
A the proper dimensions for the bone plug, the tendon
at the insertion site is cut sharply with a knife and
the surface scored with the oscillating saw. A, The
blade is angled 70 degrees to make the side cuts,
being careful not to sink the blade any further than
needed. B, A 45-degree V cut is made at the end of
the bone plug. This has been shown to decrease the
rate of patellar fracture following harvest.
VIII. The central one third of the patella tendon (10 mm) is identified, measured, and
marked out for the graft harvest. A 15-blade is used to make two vertical incisions
in line with the tendon fibers 10 mm apart in the central portion of the tendon.
Scissors are then used to extend the tendon splits proximally and distally to its
bony insertions. The scissors should be used by bracing the blades open and
pushing, thus facilitating splitting of the tendon fascicles, not by cutting with a
closing motion of the blade.
IX. A safety sling of heavy umbilical tape or the pull-loop on a lap sponge is used to
secure the tendon to the drapes or stockinette.
X. A 15-blade is used to continue the tendon split onto the tibial insertion of bone
for 30 mm to outline a plug of bone 30 ¥ 10 mm. These measurements should be
confirmed with a ruler.
XI. The bony insertion is then removed. A small oscillating saw with a thin, 1-cm-wide
blade is used to score the surface of the bone all the way around this bone plug.
For the sides of the graft, the blade should be angled 70 degrees and cut to a depth
of 1 cm. A V cut is made distally by tilting the blade 45 degrees and using the
corner of the blade to make the cut. A transverse cut is made on the tendon inser-
tion side of the bone plug. A combination of straight and curved osteotomes is
used to carefully dislodge the bone plug (Fig. 22-5).
XII. A pointed Hohman retractor is placed over the superior pole of the patella to
expose the patellar insertion of the tendon.
XIII. The bony insertion onto the patella is then removed in a similar way taking
a 25 ¥ 10-mm bone plug on the patella and using a 60-degree angle along the
sides. Knee
XIV. The patellar tendon and tibial and patellar bony donor sites are left open for the
remainder of the case, and at the end of the procedure the split epitenon is repaired
over the defect with absorbable sutures.
XV. Bone grafting of both the patellar and the tibial bone plug sites can be done with
excess bone trimmed from the grafts, from tibial tunnel drillings or from local
bone graft from the proximal tibia.
Preparation of Graft
I. The graft is secured to the preparation table via the umbilical tape or the pull-loop
of a lap sponge.
II. A high-speed burr is used to reshape the triangular-shaped bone plugs to the
desired diameter cylinder. Usually, the shorter, former patellar bone plug side is
Figure 22-6
Prepared graft. The bone plugs are rounded with a high-speed burr so that they easily pass through the
desired sizing guide. Drill holes and heavy sutures are passed through the bone plugs at 90-degree angles to
one another, two on the patellar side and three on the tibial side. Note that the insertion site of the graft
tendon onto the bone plug for the femoral side has been marked. This makes it easy to confirm that the graft
is fully seated in the femoral tunnel. Note also that the graft is secured to the graft board with a looped
umbilical tape through the whole preparation process to prevent loss of the graft.
shaped to a 9-mm cylinder and the longer, former tibial bone plug is reshaped to
a 10-mm plug. The plugs should fit smoothly, with no binding through the appro-
priate size opening in the sizing block.
III. Any excess or frayed tendon graft is trimmed prior to graft implantation.
IV. Drill holes are made in the bone plugs with the smallest drill bit: two holes in the
9-mm femoral bone plug and three holes in the 10-mm tibial bone plug. Holes
in the tibial plug should be made 90 degrees to one another. The hole closest to
the patellar tendon graft should be anterior to posterior. Ethibond 2-0, or similar
heavy suture, is passed through each hole (Fig. 22-6).
V. Coloring the end of the tendon graft at the insertion onto the patella bone plug
facilitates confirmation that the graft has been fully seated into the femoral
tunnel.
VI. The graft is loaded onto the tensioner and held under tension until ready for
insertion. A wet lap sponge is wrapped around the graft to keep it from drying
out during this time.
Preparation of Tibial and Femoral Tunnels

I. The ruptured ACL stump is removed using an arthroscopic shaver.
A. An aggressive biting instrument can be used initially to break up the large
amount of fibrous tissue. An oscillating shaver can then be used to clean off
both the tibial and femoral insertion sites for the ACL.
B. An inverted J stroke with the shaver is an effective way to clear the femoral
WATCH OUT FOR “RESIDENT’S insertion site. The shaver is held in the notch of the knee with the blade turned
RIDGE.” PLACEMENT OF THE directly upward. While shaving, the blade is pressed up and then curved in an
FEMORAL TUNNEL inverted J pattern toward the lateral femoral condyle, keeping the cutting
REFERENCED ON THIS surface against the bone the whole time. This should be continued until the
STRUCTURE RESULTS IN A back wall of the femur can be clearly seen. A ridge of bone, known as “resident’s
GRAFT THAT IS PLACED TOO ridge,” is usually present in the lateral femoral condyle before the posterior
ANTERIORLY, WITH POTENTIAL wall is identified (Fig. 22-7).
LIMITATIONS IN
C. Débridement of the tibial insertion site with a similar scraping motion of the
POSTOPERATIVE KNEE
shaver is very effective. Care must be taken not to remove or destabilize the
FLEXION.
meniscal insertions or the intermeniscal ligament.
II. Notch plasty. In knees with a narrow notch width, removal of a few millimeters
of the medial aspect of the lateral femoral condyle may be required to improve
visualization and prevent impingement of the graft.
A. In general, the burr should be started off the bone and used with a light touch.
The burr on reverse can be used to smooth any rough edges and to remove
less bone.

View of the notch after the femoral insertion site of View of the notch after the notch plasty. Note the
the anterior cruciate ligament has been removed. increased space available for the graft. Properly
Note the prominent resident’s ridge blocking full executed, one should be able to see the back wall and
visualization of the posterior wall. the medial edge of the articular cartilage of the
lateral femoral condyle in the same arthroscopic
view.
B. To perform the notch plasty, start at the anterior inferior corner of the medial
aspect of the lateral femoral condyle and push into the edge of the articular
surface removing a small amount of bone. Continue up the lateral femoral
condyle, working in thirds. For the posterior third, start posteriorly and work
anteriorly. Is this is done properly, the white line of periosteum at the posterior
aspect of the femoral condyle and the anterior articular edge in the same
arthroscopic view should be visible (Fig. 22-8).
C. The center of the femoral insertion site at about 10 o’clock on a right knee
(2 o’clock on a left knee) can be marked by making a small indentation with
the burr at this point.
III. Preparation of the Tibial Tunnel
A. The length of the tibial tunnel in general must be at least equal to the length
of the patellar tendon on the graft. The total length of the femoral tunnel,
intra-articular graft, and tibial tunnel must be longer than the total length of
the graft. The normal anatomic length of the ACL is about 33 mm. The size
of the femoral tunnel plus the intra-articular distance of the ACL is approxi-
mately equal to the size of the tibial and femoral bone plugs. Therefore, for
the graft not to protrude out of the inferior aspect of the tibial tunnel, the tibial
tunnel must be longer than the length of the patellar tendon graft. Usually,
setting the tibial guide at about 50 to 60 degrees is adequate to give a suffi- Knee
ciently long tibial tunnel to accommodate the graft.
B. If an allograft has been selected, and there is no incision over the anterior tibia, The footprint of the
a longitudinal incision is made over the anteromedial aspect of the tibia appro- anterior cruciate ligament
priately positioned for the tibial guide and dissect down to bone. on the tibia is typically
C. The tibial aiming guide is placed in the joint through the medial portal. The 7 mm anterior to the
aiming guide is placed such that the guidewire enters the ACL footprint 7 mm posterior cruciate
anterior to the PCL and parallel to the posterior border of the anterior horn ligament and is in line
of the lateral meniscus, in the center of the anatomic footprint. The guide pin with the posterior aspect
is drilled into the tibial plateau through the targeting guide. It is necessary to of the anterior horn of
advance slowly when approaching the tibial plateau (Fig. 22-9). the lateral meniscus.
D. The targeting guide is removed, and the guide pin is overdrilled with a 10-mm
acorn reamer. Make sure to advance the drill very slowly when approaching
the tibial plateau. If fine-tuning of tunnel placement is desired, as the reamer
A B
Figure 22-9
View of the aiming guide and guidewire localizing the intra-articular location of the tibial tunnel. Placement
of the guidewire should be approximately 7 mm anterior to the posterior cruciate ligament in line with the
posterior border of the anterior horn of the lateral meniscus in the center of the anatomic footprint of the
anterior cruciate ligament. Note that the insertion sites for the menisci as well as the intermeniscal ligament
have been preserved. A, The guidewire should be advanced just until it emerges from the surface of the tibial
plateau; this is evidenced by a small fat droplet. B, The aiming guide should then be relaxed slightly to
prevent deflection of the guidewire with the aiming tip of the guide.
approaches the tibial plateau, the guide pin is removed, and the reamer is biased
in the desired direction.
E. Both the intra-articular and extra-articular sides of the tibial tunnel are débrided
with a roacher or other aggressive biting instrument. A cannulated plug is
placed into the tibial tunnel to prevent fluid from emptying out of the joint.
F. The shaver is used to remove excess tissue from the intra-articular tibial tunnel
entrance and smooth the posterior aspect of the tibial tunnel at its articular
aperture with a rasping device (Fig. 22-10).
IV. Preparation of the Femoral Tunnel
A. The over-the-top guide is placed through the tibial tunnel or medial portal
and past the PCL. It is hooked on the back wall of the femur. It is rotated away
from the PCL to get past the PCL and extend the leg briefly to get it hooked
on the back wall.
B. The knee is flexed to 90 degrees, and the guide is rotated to the 10 o’clock
position on a right knee (2 o’clock on a left knee), and a guide pin is drilled
Figure 22-10
View of the prepared tibial tunnel demonstrating
proper placement. A 10-mm reamer drill is advanced
over the tibial guide pin to create the tunnel. Soft
tissue around the tunnel is cleared out with a shaver,
and the posterior aperture of the tunnel is smoothed
with a rasping device.
Figure 22-12
Figure 22-11 The femoral tunnel placement is checked prior to
Proper positioning of the over-the-top guide on the
committing to final drilling to ensure that the back
back wall with rotation into proper position and the
wall of the femur is still competent. Once this has
guidewire in place. In this left knee the proper
been confirmed, the tunnel is drilled to a depth of
position is about 2 o’clock.
30 mm.
to, but not through, the second cortex. Then the over-the-top guide and the
cannulated plug are removed, leaving the pin in place (Fig. 22-11).
C. A 9-mm acorn reamer is advanced through the tibial tunnel or medial portal
and past the PCL. The knee is flexed to 90 degrees, and it is reamed just until
a full circle of the reamer has engaged the femur. The reamer is retracted
slightly and the back wall is inspected for competence (Fig. 22-12). If it is intact,
it can be reamed to a depth of 30 mm. Then the reamer and guide pin are
removed.
D. The slotted Beath pin is drilled through the tibial tunnel and up into the
femoral tunnel and out the anterior thigh. The slot is turned so that it is visible.
An interference screw guidewire is placed cleanly through the medial portal
and slid up the slot in the Beath pin into the femoral tunnel. The guidewire
should be pushed in until at least 3 inches are out of the anterior thigh and a
hemostat is placed on both sides of the guidewire still out of the skin.
E. The femoral tunnel is notched with a slotted screwdriver threaded over the
interference screw guidewire (Fig. 22-13).
Knee
Figure 22-13
Beath pin and interference screw guidewire in
femoral tunnel. The slotted Beath pin is passed
through the tibial tunnel and the femoral
interference screw guidewire is passed through the
medial portal and slid up the slot in the Beath pin
into the femoral tunnel. The slotted screwdriver is
then used to notch the femoral tunnel. Great care
must be taken not to catch additional soft tissue
when passing both the Beath pin and the guidewire
through the notch. This will impede passage of the
graft or the femoral interference screw.
Placement and Fixation of Graft
I. Placement of the Graft

A. The graft is retrieved from the back table and the sutures placed from the
femoral bone plug side through the eyelet at the end of the Beath pin. The
Beath pin is pulled out the anterior thigh and the sutures on the graft are
retrieved and wound around a hemostat to make a handle to pull the graft into
place.
B. It is necessary to make certain that the graft is properly rotated so that the
bone plug side is about 11 o’clock on a right knee (1 o’clock on a left knee).
This ensures that the interference screw does not injure the tendinous portion
of the graft as it is inserted. Then the graft is pulled into place. The mark on
the graft indicating the insertion site of the tendon graft onto the bone plug
should be seen just entering the femoral tunnel (Fig. 22-14).
II. Femoral Fixation
A. The knee is hyperflexed, and a 7 × 20-mm interference screw is placed over
the wire from the medial portal to the femoral tunnel.
B. The femoral interference screw is inserted while tension on the sutures coming
out of the anterior thigh is held. This holds the femoral bone plug firmly into
the femoral tunnel.
III. Tibial Fixation
A. The arthroscope is removed from the knee joint. The knee is extended, and
the extra-articular side of the tibial tunnel is exposed. The arthroscope is placed
into the tunnel, and the fit and fill of the bone plug is assessed. If the gap is
greater than or equal to 2 mm, a 9 × 20-mm interference screw is used; other-
wise a 7 × 20-mm screw is used.
B. Under direct visualization, an interference screw guidewire is placed between
the graft and the wall of the tibial tunnel. While tensioning the graft by hand
or with a tensioner and performing a gentle reverse Lachman maneuver, the
tibial interference screw is placed (Fig. 22-15).
IV. The knee is assessed for stability and full range of motion. Once proper
stability is confirmed, the tibial and femoral tensioning sutures are removed.
V. The intra-articular appearance of the graft is assessed by placement of the arthro-
scope back into the knee joint.
Figure 22-14
Femoral fixation. The mark on the graft denoting
the insertion site of the tendinous graft onto the
bone plug indicates that the graft is adequately
seated in the femoral tunnel. While held firmly in Figure 22-15
place, the graft is fixed with an interference screw. View of the graft in place.
Wound Closure
I. All of the fluid is removed from the joint prior to wound closure.
II. Multilayer closure is performed on the tibial tunnel site/graft harvest site incision.
The deep periosteal and paratenon layers are closed with absorbable suture. The
subcutaneous layer and skin are closed in standard fashion (see Chapter 1).
III. The portal sites are closed with one or two subcutaneous stitches with 4-0
absorbable monofilament suture.
IV. A sterile dressing is applied in standard fashion prior to extubating the patient.

I. Postoperative Care. The wounds are dressed with nonadherent dressing, gauze,
and a mild compressive dressing. A circulated water-cooling device and a hinged
knee brace locked in extension are applied to the knee. Most patients are admitted
to the hospital for 24 hours and then discharged home. Patients are allowed to
bear weight as tolerated with their brace locked in extension but are instructed to
ambulate with crutches.
II. The goal of postoperative rehabilitation is restoration of normal joint motion and
strength while allowing for graft healing and incorporation.
III. General Points on Graft Healing and Incorporation
A. Joint motion is beneficial to healing and joint nutrition because synovial fluid
is the only source of nutrition for many cell types in the knee.
B. Some stress on the graft during healing is desirable; however. the stress must
not be disruptive.
C. The weakest time in graft healing is between 4 and 12 weeks after recon-
struction.
D. Early, 2-to-4 week graft failures are usually at the graft fixation points. The presence of an acute
E. Later failures occur at the exit sites of the graft from the bone tunnels or in knee effusion greater that
the midsubstance of the graft. 20 to 30 mL can inhibit
IV. The quadriceps atrophies quickly after surgery and regaining function of the quads quadriceps function
is a major goal of rehabilitation. through a process called
V. Most postoperative protocols emphasize the use of closed chain exercises for ACL reflex inhibition.
rehabilitation. Closed chain exercises place the extremity in contact with a fixed
object and require balancing forces by the other muscles acting on that joint to
stabilize the joint through the range of motion (e.g., a squat). In open chain exer-
cises, the extremity is asked to move a weight applied to the distal part of the
extremity (e.g., knee extension exercises). This can lead to unbalanced muscular
forces around the joints, which in turn places greater stress on the ligaments sup-
porting those joints. As the quadriceps extend the knee, they apply an anterior
displacing load on the tibia, thus tensioning the ACL. Hence, open chain quadri-
ceps-strengthening exercises, which lead to greater stress on the ACL because they
are not balanced by hamstring activity, are to be avoided.
VI. Most orthopaedic surgeons have established detailed week-by-week rehabilitation Knee
protocols. These vary slightly from surgeon to surgeon but generally follow the
overlapping stages outlined below:
A. Immobilization: up to 4 weeks after surgery
B. Protection: up to 6 weeks after surgery
C. Restoration of range of motion: should be restored by 6 weeks after surgery
D. Strength recovery: for up to 9 months after surgery
VII. To return to full sporting activities, the following criteria should be met:
A. Minimum of 5 months since surgery
B. Full range of motion
C. No detectable effusion
D. Quadriceps strength at least 80% of the normal knee
E. Hamstring strength at least 90% of the normal knee
F. Able to perform a one-leg hop at least 80% as far as on the normal knee
COMMON COMPLICATIONS
I. Arthrofibrosis or loss of motion, particularly flexion contracture, is common fol-

lowing ACL reconstruction. Common causes include inadequate postoperative
bracing in extension, improper graft tensioning, improper graft placement leading
to nonphysiometric graft, or intra-articular soft tissue proliferation or adhesions.
A cyclops lesion is a localized form of intra-articular soft tissue fibrosis that occurs
in the anterior notch of the knee at the tibial insertion site of the ACL. It may
prevent full knee extension. Soft tissue mechanical changes secondary to injury or
immobilization may also play a role in loss of motion.
II. Graft donor site morbidity is more common with bone-patellar tendon-bone
autografts than with hamstrings autografts. Anterior knee pain is common with
bone-patellar tendon-bone autografts (17% vs. 11%), and rare cases of patella
fractures and patellar tendon avulsions have also been reported.
III. Infection is a rare complication following ACL reconstruction but is inherent in
all surgical procedures.
IV. Reflex sympathetic dystrophy or complex regional pain syndrome can affect
patients following ACL reconstruction. Intense burning or aching pain along with
swelling, skin discoloration, altered temperature, abnormal sweating, and hyper-
sensitivity to light touch are experienced in the affected area. The exact etiology
of this disorder is still unclear, but it appears to be propagated by a positive feed-
back loop through the sympathetic nervous system.
SUGGESTED READINGS
DeLee JC, Drez Jr D, Miller MD: Orthopaedic Sports Medicine: Principles and Practice. Philadel-
phia, Saunders, 2002.
Miller MD, Cooper DE, Warner JP: Review of Sports Medicine and Arthroscopy, 2nd ed. Phila-
delphia, Elsevier, 2002.
C H A P T E R
23
Total Knee Arthroplasty
Stephan G. Pill, Neil P. Sheth, and Jess H. Lonner
Case Study
A 67-year-old female presents with left knee pain, which has been present for the past 2
years. She now complains of increasing pain with activities of daily living. The pain is
located in the front as well as the “inside” of her right knee. The pain is exacerbated
while descending stairs, and she is now only able to ambulate two to three city blocks
before having to stop due to pain. Minutes after she stops ambulating, the pain im-
proves. She has tried nonsteroidal anti-inflammatory medications, activity modification,
aqua therapy, and three rounds of hyaluronic acid injections, which have provided
minimal relief. She is now retired and lives at home by herself without a caregiver.
Standing anteroposterior (AP), lateral, and merchant views of her left knee are presented
in Figure 23-1.
BACKGROUND
I. Arthritis is defined as intra-articular inflammation, although inflammation may
not always be present. It is more accurately defined as articular cartilage degenera-
tion, which may be caused by several different conditions. Arthritis comprises a
diverse group of disorders, ranging from inflammatory (rheumatoid and psoriatic
arthritis) to degenerative (osteoarthritis), which all culminate in articular cartilage
breakdown. End-stage arthritis is often associated with severe pain and significant
disability. In the case of inflammatory arthritis, the associated synovitis may cause
considerable swelling and inflammation.
II. Patients diagnosed with arthritis commonly have pain in the affected joint, Knee
decreased range of motion (ROM), and potential deformity and instability.
Early on, treatment is generally nonoperative with a focus on patient education,
activity modification, and use of anti-inflammatory medications. Surgical
management may be necessary for severe recalcitrant symptoms such as pain.
Total knee arthroplasty (TKA) is commonly performed for advanced knee
arthritis, with more than 95% of patients achieving good to excellent results at 10
years.
III. Goals. The major goals of TKA are as follows:
A. Relief of pain
B. Restoration of function
C. Reestablishment of proper alignment of the lower extremity
D. Achievement of intrinsic stability
E. Creation of a durable reconstruction
A B
C
Figure 23-1
Standing AP (A), lateral (B), and merchant (C) views of the left knee.
IV. Patients with arthritis may present with involvement of several joints. If a patient
presents with equally painful hips and knees, the hips are usually treated first
because hip motion greatly facilitates surgery of the knee and improves the patient’s
postoperative rehabilitation potential. Additionally, an arthritic hip can cause
referred knee pain; thus, even successful TKA can remain painful if the hip above
is very arthritic.
V. Newer techniques, including minimally invasive knee replacement and surgical
computer-assisted navigation, are in their infancy and have no long-term follow-
up to determine their usefulness at this point.
C H A P T E R 2 3 Total Knee Arthroplasty 253
TREATMENT ALGORITHM
Knee pain
AP,* lateral,* sunrise knee pain secondary to
arthritis?
Diagnosis
(OA, RA, osteonecrosis, etc.)
No treatment or Failed conservative treatment or

early stage end-stage degeneration
NSAIDs/G-CS Physical therapy Steroid Alternatives

Total
Activity Aqua therapy injection to
Knee
modification Visco- Total Knee
Valgus bracing Arthroplasty
supplementation Arthroplasty
Weight loss
• Arthroscopic débridement
• Patellofemoral resurfacing
• High tibial osteotomy
• Distal femoral osteotomy
• Unicompartmental arthroplasty
*Weight-bearing plain radiographs • Arthrodesis
TREATMENT PROTOCOLS
I. Treatment Considerations. All of these considerations play an important role
in the decision-making process of treating patients with knee arthritis.
A. Patient age
B. Activity level
C. Overall health
D. Extent of arthritis
F. Deformity
G. ROM
A. Initial treatment strategy Knee
1. Nonsteroidal anti-inflammatory drug or acetaminophen therapy
2. Glucosamine/chondroitin sulfate oral supplementation
3. Activity modification (low impact activity)
4. Weight loss
5. Physical therapy. Patients referred for physical therapy and aqua therapy
focus on quadriceps isometric strengthening. The quadriceps extensor
mechanism plays a crucial role in optimizing knee function.
B. Valgus knee bracing. Valgus knee braces are typically used for patients with
medial joint arthritis and a varus knee, and they increase the proportional load
across the lateral joint compartment.
C. Intra-articular glucocorticoid injections
D. Intra-articular hyaluronic acid (viscosupplementation) injections
SURGICAL ALTERNATIVES TO TOTAL KNEE ARTHROPLASTY

I. Arthroscopic Débridement
A. Arthroscopic débridement of the knee removes inflammatory mediators,
degenerative cartilage, and meniscal fragments. This has a limited role in the
absence of acute mechanical symptoms.
B. It is generally indicated only for mechanical symptoms superimposed on mild
degenerative arthritis (such as related to an acute meniscal tear).
II. Osteotomy
A. The goal is to transfer the load from a degenerative compartment to a less
diseased compartment to reduce contact pressures and preserve remaining
articular cartilage.
B. Types of osteotomies
1. High tibial osteotomy
a. Goal: to correct varus deformity from medial compartment disease
b. Indications: generally suited for young, heavier patients who are active
laborers or athletic
(1) Age younger than 60 years
(2) Arthritis confined to medial compartment
(3) From 10 to 15 degrees of varus alignment on weight-bearing
radiographs
(4) Preoperative arc of motion greater than or equal to 90 degrees
(5) Flexion contracture less than 15 degrees
(6) Sufficient strength and motivation to use assist devices
c. Contraindications
(1) Narrowing of the lateral joint compartment
(2) Lateral subluxation of tibia on the femur greater than 1 cm
(3) Medial subchondral bone loss greater than 2 to 3 cm
(4) Peripheral vascular disease
(5) Ligamentous instability
(6) Lateral thrust of the knee during gait
(7) Rheumatoid or other inflammatory arthritis
2. Distal femoral osteotomy
a. Goal: to distribute load away from the lateral compartment in the valgus
knee with lateral compartment degeneration
b. Indications: as with high tibial osteotomy, but valgus deformity of 10 to
15 degrees. It is generally suited for young patients who are involved in
heavy labor.
(1) Isolated lateral compartment arthritis
(2) Valgus deformity less than 10 degrees or valgus joint line tilt greater
than 10 degrees
(3) Preoperative arc of motion greater than or equal to 90 degrees
(4) Flexion contracture less than 10 degrees
(5) Either post-traumatic or osteoarthritis as the diagnosis
III. Unicompartmental Arthroplasty
A. Indications
1. Unicompartmental disease (with no radiographic evidence of patellofemoral
disease or clinical evidence of anterior knee pain)
2. Ineligibility for osteotomy
3. Age? (requirements vary by practitioner)
4. Relatively sedentary lifestyle
5. Primary diagnosis of osteoarthritis
B. Preoperative requirements
1. ROM greater than 90 degrees
2. Flexion contracture less than 10 degrees
3. Angular deformity less than 15 degrees, which is correctable to neutral
4. Intact anterior cruciate ligament (ACL) and posterior cruciate ligament
(PCL)
IV. Patellofemoral Arthroplasty (Indications)

A. Isolated patellofemoral arthritis
B. Normal alignment
C. Knee pain localized to the anterior compartment
V. Arthrodesis (Fusion; Indications)
A. Complete joint and soft tissue destruction
B. Neuropathic or Charcot arthropathy not amenable to TKA
C. Failed treatment for septic arthritis
D. Unreconstructable or paralytic extensor mechanism
SURGICAL INDICATIONS FOR TOTAL KNEE ARTHROPLASTY

A. Most common causes
1. Osteoarthritis
2. Rheumatoid arthritis (Fig. 23-2)
3. Osteonecrosis
B. Other disorders that may result in end-stage joint deterioration
1. Hemorrhagic arthropathy
a. Hemophilia (Fig. 23-3)
b. Pigmented villonodular synovitis
Figure 23-2
End-stage joint destruction in a patient with
rheumatoid arthritis.
Knee
Figure 23-3
End-stage hemophilic arthropathy with a flexion
contracture.
3. Primary complaint of anterior knee pain
a. Gout
b. Chondrocalcinosis
C. Clinical presentation
1. Worsening pain over time
2. Pain that wakes the patient from sleep
3. Decreased tolerance for ambulating
D. Radiographic features and diagnostic criteria

1. Eccentric joint space narrowing 1. Symmetric joint space narrowing
2. Sclerosis 2. Periarticular osteopenia/osteoporosis
3. Subchondral cysts 3. Joint erosions
4. Osteophyte formation 4. Ankylosis
II. Failed Nonoperative Treatment

A. Activity modification/low-impact activity
B. Weight loss
C. Orthosis (e.g., medial unloader brace)
D. Physical therapy or aqua therapy (quadriceps strengthening)
E. Nonsteroidal anti-inflammatory drugs and glucosamine/chondroitin sulfate
F. Ambulation assistive device (cane or walker)
G. Injections (steroids or viscosupplementation)
H. Previous surgical alternative treatment
RELATIVE CONTRAINDICATIONS TO TOTAL KNEE ARTHROPLASTY

I. Current or recent infection
II. Young or active patient (wears out faster)
III. Knee extensor mechanism incompetence/disruption
IV. Medical instability (e.g., severe cardiovascular disease)
V. Neuropathic joint (Charcot)
GENERAL PRINCIPLES OF TOTAL KNEE ARTHROPLASTY

I. The knee is composed of three joint compartments: the medial, lateral, and patel-
lofemoral compartments.
II. The normal knee joint functions as a complex hinge, allowing primarily flexion
In the normal knee, 60% and extension, but also rotation and gliding.
of the load is across the
III. The weight distribution across the knee with normal alignment is approxi-
medial compartment and
40% is across the lateral mately 60% through the medial compartment and approximately 40% through
compartment. the lateral compartment. These percentages shift in the presence of knee
deformity.
IV. A varus deformity results from medial compartment degenerative changes. With
degeneration of the medial compartment, the load is further transferred medially,
resulting in increased loading of the medial compartment and disease progression.
This is the most common variation seen in osteoarthritis.
V. A valgus deformity also results from lateral compartment degenerative changes
but can also result in lateral degeneration. The weight-bearing axis shifts laterally
resulting in relatively increased loading through the lateral compartment. This

scenario is often seen in patients with rheumatoid arthritis and is more common
in women than men.
VI. The overall objective TKA is establish a knee aligned with a neutral mechanical
axis (anatomic axis in 5 to 7 degrees) in the standing position with the tibial
component perpendicular to the tibial shaft and the femoral component in 5 to 7
degrees of valgus to the femoral shaft.
VII. An ideal knee replacement should allow for full extension and 115 to 125 degrees
of flexion, although various factors affect ultimate ROM, including preoperative
ROM.
VIII. Normal principles of knee alignment
A. Approximately 9 degrees of valgus from distal femoral condyles to the femoral
anatomic axis compared to the center of gravity just anterior to the vertebral
body of S2.
B. Approximately 3 degrees of varus from tibial plateau to the tibial mechanical
or anatomic axis (Figs. 23-4 and 23-5).
C. The net tibiofemoral angle is approximately 6 degrees of valgus (formed by a
line that intersects the center of the femoral head and the center of the knee
and a line from the center of the knee to the ankle joint).
D. The tibial plateau normally has 7 to 10 degrees of posterior slope.
IX. If the tibial cut is made perpendicular to the tibial shaft and the femoral cut is in
4 to 6 degrees of valgus, then the overall knee alignment should be in 4 to 6 degrees
of valgus if the collateral ligaments are properly balanced.
X. Soft tissue balancing is a critical component and is typically achieved by releasing
soft tissue structures on the “tight” side. Often, removing prominent osteophytes
from the concavity of the deformity is the initial step to balancing the soft tissues
(see Fig. 23-4).
Convex side Concave side Convex side Concave side

of deformity of deformity of deformity of deformity
Knee
Medial release Lateral release

required required
A B
Figure 23-4
Right lower extremity mechanical axis with deformity. A, Varus deformity. B, Valgus deformity. (From Miller
MD: Review of Orthopaedics, 4th ed. Philadelphia, Saunders, 2004.)
Tibial cut Tibial cut

Valgus cut =
angle between
AAF — MAF
Anatomical axis Anatomical axis Anatomical axis
femur — AAF tibia — AAT tibia — AAT
Mechanical axis Mechanical axis Mechanical axis
femur — MAF tibia — MAT tibia — MAT
AAT and MAT AAT and MAT

are coincident are divergent
A Distal Femoral Cut B No Bone Deformity C Bone Deformity

Figure 23-5
Femoral and tibial mechanical and anatomic axes. (From Miller MD: Review of Orthopaedics, 4th ed.
A. With varus knees, medial structures are usually contracted and lateral struc-
tures are relatively lax. Structures are released in order of severity:
1. Deep medial collateral ligament and medial osteophytes
2. Posteromedial capsule
3. Semimembranosus insertion
4. Superficial medial collateral ligament
STRAIGHTENING A SEVERELY
5. Reflection of the medial collateral ligament over the soleus muscle
VALGUS KNEE CAN PUT THE B. With valgus knees, lateral structures are usually contracted and medial struc-
PERONEAL NERVE ON tures are lax. Structures are released according to the preference of the attend-
STRETCH. ing physician, which is usually based on whether the lateral compartment is
tight in flexion or in extension.
1. Posterolateral capsule
2. Iliotibial band
3. Popliteus tendon from the femur
4. Lateral collateral ligament from the femoral condyle
5. Biceps femoris insertion on the fibular head
XI. The ACL is almost always sacrificed but is retained in certain scenarios.
XII. The PCL is retained in cruciate retaining TKAs and can act as a tether in the
presence of deformity. It may need to be released or recessed to achieve adequate
ligament balance.

I. The patient is placed in the supine position.
II. A paint roller device, or other type of leg positioner, is placed at the level of the
calf on the operative side and attached to the bed to allow for varying degrees of
knee flexion during the procedure (Fig. 23-6).
III. The operative extremity is prepped and draped in standard fashion according to
the principles outlined in Chapter 1 (Fig. 23-7).
IV. Prior to prepping the limb, a tourniquet should be placed around the proximal
thigh (Fig. 23-8) (see Chapter 1).
V. A tourniquet may not always be used. Tourniquets should be used cautiously in
the following situations:
A. Previous lower extremity bypass grafting
B. Severe peripheral vascular disease with evidence of calcification of vessels on
preoperative radiographs

Paint roller device allowing adequate knee flexion. Leg holder to allow for sterile prepping of the
extremity.
C. Absent dorsalis pedis and posterior tibial artery pulses

D. Lower extremity lymphedema
E. Previous problem with tourniquet use
VI. See Chapter 1 for detailed prepping and draping as well as use of a tourniquet
(Fig. 23-9).
VII. Mark the skin incision using a sterile marker. Once the draping is completed and
the skin incision has been marked, the limb is exsanguinated (Figs. 23-10, 23-11,
and 23-12).

Tourniquet placement and setup. Prepping of the lower extremity for a total knee
arthroplasty with adequate proximal prepped in area.
Knee
Figure 23-10
Esmarch exsanguination starts distal in the foot.

The Esmarch bandage sequentially progresses up the Esmarch bandage at the top of the knee prior to
extremity for adequate limb exsanguination. tourniquet inflation.
Skin blood flow travels

I. For patients who have had previous knee surgery, it is important to use previously
medial to lateral for the made incisions.
knee; therefore, the most II. If a patient has had multiple knee surgeries, the most lateral incision should be
lateral incision should be used to preserve the blood supply to the skin, which courses medial to lateral.
used. III. If the patient has not had prior knee surgery, then the most common skin incision
is a midline incision extending from three fingerbreadths above the superior pole
of the patella to three fingerbreadths below the inferior pole of the patella (stan-
dard incision). With the recent trend toward minimally invasive surgery, other
techniques are being used more frequently to access the knee joint.
IV. The incision should be extended as necessary to avoid compromising the skin
integrity.
V. Once the skin and the subcutaneous tissues have been exposed, the first structures
to identify are the quadriceps tendon, patella, and patellar tendon. The vastus
medialis obliquus is visualized medially.
VI. The most common approach into the knee joint is a medial parapatellar arthrot-
omy. Newer, minimally invasive approaches, midvastus, subvastus, and quadri-
ceps-sparing, are currently being used but are beyond the scope of this text.
VII. A small muscular band of tissue is sometimes seen proximally above the superior
pole of the patella originating on the anterior cortex of the femur and inserting
on the suprapatellar bursa. This is the articularis genu muscle.
The articularis genu VIII. Once the knee joint is exposed, the anatomic structures shown in Figure 23-13
retracts the suprapatellar should be identified.
pouch to prevent IX. The intercondylar notch is typically cleared at this point of the case. The PCL is
impingement during knee spared but balanced in PCL-retaining TKA; it is completely removed in PCL-
extension.
substituting TKA.
X. Once the ACL is resected and the knee is placed into between 90 and 120 degrees
of flexion, the patella can be subluxated or everted laterally and the structures
shown in Figure 23-14 are easily visualized.
XI. The medial and lateral menisci are excised. A small lumen of the inferolateral
geniculate vessel can often be seen after removing the lateral meniscus.
Tibial Preparation
I. Some surgeons prepare the tibia first, whereas others prepare the femur first.
Does your attending cut
II. Prior to starting the tibial preparation, a few extra steps are often taken to avoid
the tibia or the femur
first? Why?
struggling during the case. The order in which these steps are performed depends
on the surgeon’s preference.
Adductor tubercle
Medial epicondyle
Lateral epicondyle
Trochlear
Lateral femoral condyle

Medial femoral
condyle
Intercondylar notch
Intercondylar eminence
Iliotibial tract
Anterior cruciate
ligament
Gerdy’s tubercle
Tibial tubercle
Patellar tendon
Figure 23-13
Anatomy of the knee. (From Scott WN: Insall and Scott Surgery of the Knee, 4th ed. Philadelphia, Churchill
Livingstone, 2006.)
A. The synovium over the anterior cortex of the femur is removed to allow for
better sizing of the femoral component during femoral preparation.
B. The infrapatellar fat pad may be excised to allow for better exposure of the
tibia. In addition, this allows for better visualization of the patellar tendon,
which helps prevent injury to the tendon when the tibial cut is made. Some
surgeons avoid resecting the fat pad to minimize disruption of the blood supply
to the patella.
Posterior cruciate ligament

Ligament of Humphry Ligament of Wrisberg
Lateral collateral
ligament
Knee
Popliteal tendon
Deep medial
collateral ligament
Popliteal hiatus
(recess)
Lateral meniscus Superficial medial

collateral ligament
Coronary ligament Medial meniscus

(meniscotibial)
Anterior cruciate
ligament
Capsule
Transverse
Figure 23-14
Axial image of the right knee with all structures identified. (From Scott WN: Insall and Scott Surgery of the
Knee, 4th ed. Philadelphia, Churchill Livingstone, 2006.)
Figure 23-15
Tibial extramedullary guide.
C. A subperiosteal sleeve of tissue is released on the medial aspect of the proximal

tibia. Caution: place a retractor subperiosteally to protect the superficial medial
collateral ligament. The deep medial collateral ligament (coronary ligament)
is released routinely.
D. Osteophytes are removed from the perimeter of the tibial plateau.
The tibial alignment III. Two primary types of cutting guides—intramedullary or extramedullary—may be
guide is lined up with the used to make the tibial cut.
tibial shaft. IV. The tibial guide is typically applied so that a cut is made perpendicular to the tibial
shaft in the coronal plane (Fig. 23-15).
V. Most osteoarthritic knees have a varus deformity or medial joint space narrowing.
As a result, the tibial cut usually takes more off the lateral tibial plateau (8 to
10 mm) compared with the medial tibial plateau (3 to 5 mm). The tibial cut is
usually designed to be made with a 3- to 7-degree posterior slope on the tibia.
PROTECT THE COLLATERAL VI. An oscillating saw is used to make the tibial cut, making sure that retractors are
LIGAMENTS WHEN MAKING kept in place to protect the medial collateral ligament, the lateral collateral liga-
THE TIBIAL CUT. ment, and the peroneal nerve. Posterior retractors are carefully inserted to protect
the popliteal vessels.
VII. The tibia is sized to cover the tibia adequately without overhang. Make sure that
tray is placed in the correct degree of rotation, with the center mark on the tibial
tray being in line with the medial edge of the tibial tuberosity.
Femoral Preparation
I. The femoral cut can be done using either an intramedullary or extramedullary
guide. This technique describes the use of an intramedullary guide.
II. A drill is used to find the femoral medullary canal using an entry point in the
intercondylar notch located just anterior to the femoral attachment of the PCL
on the medial femoral condyle.
III. A femoral sizing guide is used to determine the size and rotation of the femoral
component to be implanted.
How does your attending IV. Typically, there is a boom that sits on the anterior cortex to prevent femoral
go about preventing notching. Femoral notching occurs if the anterior femoral condyle cut extends
femoral notching? into the anterior cortex of the femur. This potentially increases the risk of supra-

Femoral rotation guide with anterior boom. Whitesides line.
condylar femur fractures in the postoperative period, depending on the depth of BE CAREFUL NOT TO NOTCH
notching and bone quality (Fig. 23-16). THE FEMUR WHEN MAKING
V. External rotation of the femoral component is critical to create a stable rectangular THE ANTERIOR FEMORAL
flexion gap and enhance patellar tracking. This is done by four principal CUTS.
methods:
A. Posterior condylar referencing (a line 3 degrees externally rotated relative to
the posterior femoral condyles)
B. Whitesides line (a line drawn from the low point of the trochlear groove to
the high point of the intercondylar notch; Fig. 23-17)
C. Epicondylar axis (a line connecting the sulcus of the medial epicondyle to the
How does your attending
lateral femoral epicondyle) check the rotation of the
D. Tension gap (using the perpendicular tibial cut as a reference and tensioning femoral component?
the ligaments in 90 degrees of flexion)
VI. A total of five cuts need to be made: the anterior, posterior, and distal femoral
cuts as well as anterior and posterior chamfer cuts. These are done in different In what order does your
order based on surgeon preference and technique chosen to balance the knee attending make the
(Fig. 23-18). femoral cuts and why?
A. The femoral cuts are made so the component is placed in 5 to 7 degrees of
valgus in reference to the mechanical axis of the femur. The component is
placed in 3 degrees of external rotation allowing for symmetric tensioning of
the collateral ligaments.
B. The femoral component is lateralized to optimize patellar tracking by allowing
the patella to sit in the center of the trochlear groove. A box cut is made if a
posterior stabilized TKA is used (Fig. 23-19).
C. At this stage of the case, some surgeons implant a trial femoral and tibial com- What does your
ponent and place a trial polyethylene tray to assess the stability of the recon- attending look for when
structed knee. Adjustments are made in the size of the implants, ligaments are checking for knee
balanced, or the cuts are remade if needed to ensure stability. stability?
Knee
Figure 23-18
Picture of femoral cuts that need to be made.
Figure 23-19
Box-cutting device in the lateralized position and box
cut being made.
Patellar Preparation
I. The initial patellar thickness may be measured with calipers prior to cutting the
patella (Figs. 23-20 and 23-21).
II. The patella can be prepared with reamers, instrumentation, or by a free-hand
technique, ensuring that at least 10 to 15 mm of patella is remaining to minimize

Calipers for measuring patellar thickness. Patella being cut after thickness measurement.
the chance of patellar fracture. The composite thickness of the patellar component
on the prepared surface should be equal to or 1 to 2 mm less than the original
thickness of the native patella.
III. Currently, the most popular patellar button design used is a three-peg design.
Once the patella is sized, three patellar button holes are drilled using a guide. This How does your attending
guide is placed in a medial position again to maximize patellar tracking in the evaluate and handle
patellar maltracking?
groove of the femoral component.
Cementing
I. Cement is not used by all surgeons when performing a TKA. We describe the
technique by which to cement the components if cement is used.
II. The operating room scrub technician is notified by the surgeon when it is time
to mix the cement.
III. The cement is ready to use when its consistency is between being too runny and
too hard. The cement is placed on the tibial plateau and into the proximal tibial
MAKE SURE THAT THE CEMENT
medullary canal, on the cut surfaces of the femoral condyles, and on the cut surface
IS NOT TOO HARD BEFORE
of the patella. Cement is also placed on the prosthesis components. Prior to hard-
CEMENTING IN THE
ening, the components are held in position until the cement has completely COMPONENTS.
hardened.
IV. All excess cement is removed from the knee joint while waiting for the cement to
set. This is important to minimize the amount of foreign debris in the joint and Ask your attending why it
to minimize third body wear of the polyethylene from impingement (Figs. 23-22 is important to remove all
excess cement from the
and 23-23).
joint.
Wound Closure
I. Once the components have been secured in place, the knee is pulse lavaged with Does your attending use
saline ± antibiotics. A drain may be used to drain the knee and minimize the likeli- a drain postoperatively?
hood of postoperative hemarthrosis. Why or why not?
II. Some surgeons take the tourniquet down at this point to achieve hemostasis, and
others wait until the final dressing has been secured (Fig. 23-24).
III. Typically, the extensor mechanism is closed with a heavy but absorbable suture
and is done so with interrupted simple or figure-of-eight sutures. Some prefer to
run the closure.
IV. The subcutaneous tissue is then closed with a smaller gauge suture.
V. A sterile dressing is placed around the knee and the lower extremity, making sure
to avoid circumferentially wrapping the knee with tape. Typically, a snug Ace wrap
is used to minimize swelling of the extremity in the immediate postoperative
period.
Knee

Cement gun. Cementing of the tibia.
Figure 23-24
Wound closure.
VI. Typically, patients have anteroposterior and lateral radiographs of the knee taken
postoperatively (Figs. 23-25 and 23-26).
What does your
attending use for deep
vein thrombosis POSTOPERATIVE CARE AND GENERAL REHABILITATION
prophylaxis in the
postoperative period?
as well as venous thromboembolism.

Postoperative AP radiograph. Postoperative lateral radiograph.
II. Initial postoperative pain management is best achieved with either an indwelling
How long does your
epidural catheter or patient-controlled analgesia. attending use antibiotics
III. At least 24 hours of postoperative prophylactic antibiotics are administered. in the postoperative
IV. Unless contraindicated, systemic anticoagulation with either low-molecular- period?
weight heparin or adjusted-dose warfarin is recommended (target international
normalized ratio of 2.0 to 2.5).
V. Pharmacologic treatment is augmented with compression stockings, a mechanical
compression device, and early mobilization.
VI. Physical therapy is started on postoperative day one to achieve the best possible
functional knee outcomes for ROM, extremity strength, knee stability, and pain
control.
VII. Interventions that attempt to preserve knee motion include the use of a knee
immobilizer and pillows under the operative foot while in bed to maintain full What protocol does your
extension and avoid flexion contracture formation. attending use for
VIII. Continuous passive motion devices also assist in achieving ROM. continuous passive
motion postoperatively?
COMPLICATIONS
I. Infection
II. Deep vein thrombosis
III. Pulmonary embolus
IV. Femoral or tibial component loosening
V. Periprosthetic fracture (femoral or tibial shaft)
VI. Instability or TKA dislocation
VII. Neurovascular injury (popliteal vessels, peroneal nerve, tibial nerve)
SUGGESTED READINGS
Barrack R, Booth RE, Lonner JH, et al: Orthopaedic Knowledge Update: Hip and Knee Recon-
struction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006.
Lonner JH: A 57-year-old man with osteoarthritis of the knee. JAMA 289:1016–1025, 2003.
Lotke PA, Lonner JH: Master Techniques in Orthopaedic Surgery: Knee Arthroplasty, 2nd ed.
Pagnano MW, Clarke HD, Jacofsky DJ, et al: Surgical treatment of the middle-aged patient with
arthritic knees. Instr Course Lect 54:251–259, 2005.
Knee
S E C T I O N
VII
LOWER EXTREMITY
CHAPTER 24 Intramedullary Nail Fixation of Femoral Shaft Fractures 271
CHAPTER 25 Open Reduction and Internal Fixation of Supracondylar Femur Fractures 286
CHAPTER 26 Open Reduction and Internal Fixation of Tibial Plateau Fractures 301
CHAPTER 27 Intramedullary Nail Fixation of Tibial Shaft Fractures 314
C H A P T E R
24
Intramedullary Nail Fixation of Femoral
Shaft Fractures
Andrew F. Kuntz and Jonathan P. Garino
Case Study
A 47-year-old male presents to the trauma bay via ambulance after being struck by a
motorcycle while crossing the street. He has had a loss of consciousness and has no recol-
lection of the accident. The Advanced Trauma Life Support (ATLS) primary survey
reveals an intact airway, adequate breathing, and normal circulation with a Glasgow Coma
Scale score of 10. The secondary survey reveals stable vital signs, a small scalp laceration,
and a gross deformity of the left thigh. The patient’s neurovascular status is within normal
limits, with a normal sensory and motor examination and 2+ pedal pulses on the left lower
extremity. Radiographs of the left femur are shown in Figure 24-1.
BACKGROUND
I. A femoral shaft fracture is defined as any fracture occurring between 5 cm distal

to the lesser trochanter and 5 cm proximal to the adductor tubercle.
II. Femoral shaft fractures occur most commonly in young men and elderly
women following high-energy trauma and low-energy falls, respectively.
Pathologic fractures should be suspected when the level of trauma is not consistent
with the fracture pattern and typically occur at the metaphyseal-diaphyseal
junction. Runners and military recruits have the highest incidence of stress
fractures.
III. Several systems exist for classifying femoral shaft fractures. The AO/OTA system
is comprehensive and commonly used for research and investigational purposes.
The Winquist and Hansen system (Fig. 24-2) addresses bony stability based on
the degree of fracture comminution.
A. Type 0 fractures are transverse or oblique fractures without comminution.
B. Type I fractures are minimally comminuted, with greater than 75% cortical
diameter contact.
C. Type II fractures have at least 50% cortical contact.
D. Type III fractures are severely comminuted, with greater than 50% but less
than 100% comminution.
Lower Extremity
E. Type IV fractures are completely comminuted with no cortical contact.

IV. In most cases, a detailed description of the fracture as it appears radiographically
and clinically conveys appropriate information between members of the health
care team. A thorough description should include fracture location, alignment,
displacement/translation, angulation, shortening, degree of comminution, and soft
tissue status.
272 S E C T I O N V I I Lower Extremity
A B
C
Figure 24-1
Anteroposterior radiographs of the proximal (A) and distal (B) femur, and a single lateral radiograph (C)
showing a severely comminuted midshaft femur fracture.
C H A P T E R 2 4 Intramedullary Nail Fixation of Femoral Shaft Fractures 273
Figure 24-2
Winquist and Hansen classification system
0 I II for femoral shaft fractures. (From Browner
B, Jupiter J, Levine A, Trafton P [eds]:
Skeletal Trauma: Basic Science, Management,
and Reconstruction, 3rd ed. Philadelphia,
Saunders, 2003.)
Lower Extremity
III IV
TREATMENT ALGORITHM
Femur Fracture
Radiographs: Femur AP and lateral, hip AP and

lateral, knee AP and lateral, AP pelvis
Assess neurovascular function of extremity
Close-reduce fracture and stabilize with traction
Patient unstable Patient unstable for Patient stable

for surgery prolonged surgery for surgery
and/or open wound
grossly contaminated
Skeletal traction until Intramedullary

patient stabilized for nail fixation
definitive fracture fixation External fixator
placement
TREATMENT PROTOCOLS
A. Associated injuries and patient stability
B. Fracture pattern, configuration, and severity
C. Neurovascular status
PATIENTS WITH FEMUR D. Condition of soft tissues
FRACTURES CAN LOSE UP TO 2 II. Initial Approach
TO 3 LITERS OF BLOOD INTO A. Femur fractures often follow high-energy mechanisms of injury and occur in
THE THIGH. THIS MAY BE THE
polytrauma patients. As a result, evaluation of a patient with a femur fracture
CAUSE OF HYPOTENSION IN A
TRAUMA PATIENT WITH AN
should always begin with a thorough trauma survey and evaluation following
ISOLATED FEMUR FRACTURE. the ATLS protocol. When evaluating the patient, mechanism of injury must
be considered to tailor suspicion for associated injuries.
B. Although a femur fracture may be very obvious following high-energy trauma,
it is important to conduct a consistent and thorough physical examination on
all trauma patients. Coexisting fractures and other musculoskeletal injuries are
THE INCIDENCE OF FEMORAL common in the patient with a femur fracture. For example, ipsilateral femoral
NECK FRACTURES IN THE neck fractures occur in conjunction with femoral shaft fractures in 2.5% to
SETTING OF AN IPSILATERAL 10% of cases. However, 30% of ipsilateral concurrent femoral neck fractures
FEMORAL SHAFT FRACTURE IS are missed. Likewise, patients with a femoral shaft fracture following motor
AS HIGH AS 10%. vehicle collision have up to a 60% incidence of intra-articular knee pathology
(i.e., ligamentous and soft tissue injury).
Ankle-brachial indices are C. Carefully examine all soft tissues about the fracture site, paying close attention
obtained by taking the to ecchymosis, lacerations, puncture wounds, and tissue loss. Coordinate exam-
blood pressure at the ination of the affected limb(s) with the trauma survey to minimize manipulation
ankle and comparing it and movement of the extremity. Open fractures should be irrigated and
with a blood pressure débrided of gross contamination at the bedside and dressed with sterile saline–
taken at the elbow. A moistened gauze prior to operative fixation in the operating room.
ratio of the two pressures D. Assess the vascular status of the extremity by palpating the dorsalis pedis and
less than or equal to 0.9 posterior tibial pulses. A handheld Doppler should be used if pulses are not
is suggestive of a vessel palpable. All patients with a femur fracture should have an ankle-brachial index
injury or an intimal flap measured to evaluate the limb for possible vascular injury. Vascular injury
tear.
represents an emergency, and it requires a vascular surgery consultation and
possibly angiography. In the absence of pulses, the fracture should be reduced Twelve percent of
and held in place with traction, followed by reassessment of the vascular status patients do not have a
of the extremity. dorsalis pedis pulse due
E. Carefully perform a neurologic examination of the affected extremity, includ- to normal anatomic
ing motor and sensory function. Joint range of motion is often limited due to variation.
pain and fracture deformity.
F. Complete, orthogonal radiographs of the entire femur, ipsilateral hip, and ALWAYS PERFORM AND
ipsilateral knee in addition to an anteroposterior (AP) pelvis must be obtained. DOCUMENT A COMPLETE
Many trauma patients also have a computed tomography scan of the abdomen NEUROVASCULAR
and pelvis, which should be reviewed carefully to evaluate the bony pelvis and EXAMINATION FOR ANY
proximal femur. Particular attention should be paid to the femoral neck. TRAUMA PATIENT.
G. Once a femur fracture has been identified, the extremity should be maintained
in skeletal traction, unless the patient is immediately being taken to the operat- FEMUR FRATURES THAT ARE
ing room for fixation. NOT PLACED IN SKELETAL
H. If fracture fixation will be achieved with an intramedullary (IM) nail, the radio- TRACTION MAY RESULT IN
graphs must be inspected carefully to verify that the femoral canal size and EXCESSIVE BLEEDING INTO
THE THIGH FASCIAL
geometry will accommodate an IM nail.
COMPARTMENTS. ON
III. Nonoperative Treatment
SUBSEQUENT FRACTURE
A. Nonoperative management of a femur fracture has an extremely limited role REDUCTION AND FIXATION,
in adults. Operative management is the standard of care. Therefore, nonopera- THE COMPARTMENTS TAKE ON
tive treatment must be justified and is generally reserved for nonambulatory, A CYLINDRICAL SHAPE, A
severely debilitated individuals (paraplegics) and patients with medical comor- SMALLER VOLUME, AND MAY
bidities that absolutely preclude anesthesia or surgery. RESULT IN HIGHER
B. Nonoperative care involves skeletal traction for 6 weeks, followed by a cast INTRACOMPARTMENTAL
brace. The goal is to restore femoral length, reduce the deformity, decrease PRESSURES AND
muscle spasms, and minimize thigh volume and therefore blood loss. COMPARTMENT SYNDROME.
C. With similar goals in mind, skeletal traction is routinely used as a temporary
measure until operative fracture fixation can be achieved. A distal femoral A DISTAL FEMORAL TRACTION
or proximal tibial traction pin may be used. Careful evaluation of the knee PIN IS PLACED FROM MEDIAL
ligaments and proximal tibia must exclude trauma to these structures if a proxi- TO LATERAL TO MINIMIZE RISK
mal tibial pin is to be used. Following traction pin placement, weight is applied OF DAMAGE TO THE FEMORAL
and limb length and fracture reduction are assessed with AP and lateral ARTERY. A PROXIMAL TIBIAL
TRACTION PIN IS PLACED
radiographs.
FROM LATERAL TO MEDIAL TO
D. Knee stiffness, limb shortening, fracture malunion, prolonged hospitalization,
MINIMIZE RISK OF DAMAGE TO
and skin and respiratory complications are all associated with prolonged non- THE PERONEAL NERVE.
operative treatment.
ALWAYS CHECK FRACTURE
SURGICAL ALTERNATIVES TO INTRAMEDULLARY NAIL FIXATION REDUCTION AFTER PLACEMENT
AND/OR MANIPULATION OF
I. External Fixation SKELETAL TRACTION.
A. The goal is to gain rapid, temporary, stable fixation of fracture fragments.
B. As a general rule, external fixation is used only as definitive fracture fixation in
the pediatric population. In the adult population, the main advantage of exter- WHEN THERE IS AN EXTREMITY
nal fixation is the ability to rapidly stabilize a fracture in a clinically unstable WITH A FEMUR FRACTURE AND
patient. Pin tract infection and knee stiffness are the most common complica- A CONCOMITANT IPSILATERAL
tions of prolonged external fixation treatment. VESSEL INJURY, IT IS
C. Indications include: NECESSARY TO STABILIZE THE
1. Femur fracture requiring stabilization in a hemodynamically unstable patient FRACTURE FIRST SO THAT THE
VASCULAR REPAIR IS NOT
2. Open fracture with contamination of the femoral canal, which will require
DISRUPTED WHILE TRYING TO
repeated surgical débridement REDUCE THE FRACTURE.
3. Ipsilateral lower extremity vascular injury requiring surgical repair
Lower Extremity
II. Fracture Plating

A. The goal is to provide definitive fracture fixation.
B. Plating techniques have fallen out of favor for treatment of most femoral shaft
fractures due to a higher overall complication rate when compared with IM
nailing. However, use of minimally invasive and submuscular plating tech-
niques increases healing potential by minimizing soft tissue damage. When
femoral fracture plating is indicated, methods that minimize soft tissue damage
should always be used.
C. There are no absolute indications for plating a femoral shaft fracture. However,
relative indications include:
1. Ipsilateral femoral neck fracture
2. Small or nonanatomic intramedullary canal
3. Periprosthetic fracture
4. Concomitant exposure for vascular repair
SURGICAL INDICATIONS FOR INTRAMEDULLARY NAIL FIXATION

I. IM nail fixation has become the standard of care for treating femoral shaft
fractures.
II. With open fractures, IM nail fixation can be used for treatment of Gustilo and
Anderson type I and II fractures. Type III fractures without significant contamina-
tion can also be treated with an IM nail. (See Chapter 26 for details regarding the
Gustilo-Anderson classification.)
III. There are no absolute indications for retrograde IM nailing of a femur fracture.
Relative indications for using a retrograde IM nail include:
A. Ipsilateral femoral neck fracture
B. Ipsilateral acetabular fracture
C. Ipsilateral patella fracture
D. Floating knee (ipsilateral tibial shaft fracture)
E. Clean traumatic knee arthrotomy/through-knee amputation
F. Bilateral femur fractures
G. Periprosthetic femur fracture proximal to a total knee arthroplasty
When does your H. Distal femur fracture
attending prefer
I. Obese/extremely muscular patient
retrograde nailing to
antegrade nailing?
I. Pregnant patient
K. Polytrauma patient undergoing simultaneous laparotomy
CONTRAINDICATIONS TO INTRAMEDULLARY NAIL FIXATION

I.Active local or systemic infection
II.Open physes
III.Current external fixation of fracture greater than 2 weeks
IV. Femoral deformity that prevents IM nail placement
V. IM nailing is generally contraindicated in type IIIA and type IIIB open
fractures
VI. Prior anterior cruciate ligament reconstruction (contraindication for retrograde
IM nail placement)
GENERAL PRINCIPLES OF INTRAMEDULLARY NAIL FIXATION

I. The major goal of IM nail fixation of femur fractures is to provide definitive frac-
ture treatment with minimal soft tissue disruption.
II. IM nail fixation technology has evolved greatly during the past half decade.
As a result, indications for IM nail fixation have expanded. Currently, IM nail
fixation is the standard of care for treatment of femoral shaft fractures. This is due
in part to extremely high rates of union (98% to 99%) and low risk of infection
(<1%).
III. In patients clinically stable for surgery, the goal is to obtain intramedullary fixation
within 24 hours of injury. Delayed treatment is associated with increased pulmo-
nary and thromboembolic complications, prolonged rehabilitation, and greater
hospital costs.
IV. An IM nail is a load-sharing internal splint. Therefore, the stability of
the fracture-implant construct is a function of fracture configuration, nail
size, number of locking screws used, and distance from the screws to the fracture
site.
V. As with most orthopaedic implants, a race between bone healing and
implant failure exists. Initially, load endured by the implant increases in relation
to fracture comminution. As fracture healing occurs, load is transferred to the
femur. Implant failure can occur with excessive loading or through fatigue over
time.
VI. The biomechanical properties of an IM nail depend on inherent material
properties, nail shape, diameter, and anterior bow. These factors must be
taken into consideration for each individual patient to achieve the most stable
fixation construct and to minimize the risk of failure and postoperative
complications.
A. The most commonly used materials in nail construction are stainless steel and
titanium. Of the two, titanium has a lower modulus of elasticity, which more
closely resembles bone.
B. Nail shape influences the extent of cortical contact and implant rigidity.
C. Nail diameter affects bending rigidity and nail fit. Bending rigidity is propor-
tional to nail diameter to the third power in a solid circular nail. Torsional
rigidity is function of nail diameter to the fourth power.
D. Both the femur and IM nails have an anterior bow, which places the anterior
cortex of the femur and the convex side of the nail under tension. The lateral
femoral cortex is also under tension due to lateral femoral bowing. The average
radius of curvature of anterior femur is 120 cm. However, the radius of anterior
curvature of available IM nails ranges from 180 to 300 cm. When selecting a
specific IM nail, it is important to remember that a smaller difference between
femoral and implant curvature results in easier nail insertion but decreased
stability. Conversely, a greater difference in curvature increases contact forces
and friction between the implant and the bone but with a consequent increased
risk of fracture during nail insertion.
VII. During the process of obtaining fracture fixation with an IM nail, it is critical to
reduce the fracture prior to IM nail insertion. IM nails should not be used to Damage to the
achieve fracture reduction. posterosuperior and
VIII. Nail starting position is critical to maintaining proper reduction and posteroinferior
minimizing risk of intraoperative fracture. Typically, entry is gained through retinacular vessels during
either the piriformis fossa or the tip of the greater trochanter. Entry at the piriformis entry nail
tip of the greater trochanter has become more common due to relative ease. insertion may result in
However, piriformis fossa entry has the advantages of more direct access to the osteonecrosis of the
femoral canal. Entry at the piriformis fossa carries the risk of damage to branches femoral head. (See
Chapter 17 for details on
of the medial femoral circumflex artery and should never be used in pediatric
osteonecrosis.)
patients.
IX. IM nails can be inserted with or without femoral canal reaming. Femoral canal
reaming allows for the placement of a larger nail with increased bending and tor-
sional rigidity and increases the contact area between implant and cortical bone.
Reaming also significantly decreases endosteal blood supply but results in increased
blood flow in the surrounding soft tissues. There is a theoretical risk of increased
nonunion following reaming in the setting of open fractures with significant soft
tissue loss. Reaming results in deposition of autologous medullary contents at the
fracture site. This may be the reason for increased time to union and an increased
incidence of nonunion in femoral fractures treated without reaming. One of the
most common reasons for placement of an unreamed nail is that reaming can cause
embolization of marrow contents, which may have severe consequences in poly-
Lower Extremity
trauma patients or patients with pulmonary compromise. However, the use of

reamers with sharp, deep cutting flutes, conical heads, and narrow shafts decreases
the risk of embolization.
X. Nails can be placed statically locked, dynamically locked, or unlocked. The term
locked describes fixation of the nail with screws placed through cortical bone and
the nail itself. The use of interlocking screws depends on fracture location, con-
figuration, and stability. Placement of screws in multiple planes decreases fragment

motion. Unlocked nails guide motion in the direction of the long axis of the
femoral canal. With this construct, friction alone decreases nail motion. Friction
between implant and bone is influenced by nail shape, diameter, curvature, and
femoral canal geometry. When interlocking screws are placed but there is decreased
contact between implant and cortical bone, compressive loads on the femur are
transferred to the interlocking screws, which can result in four-point bending and
hardware failure. Screw dynamization allows for axial compression but limits rota-
tion. Dynamization is considered in the setting of nonunion but is not indicated
in the acute setting.
COMPONENTS OF THE PROCEDURE: ANTEGRADE INTRAMEDULLARY

NAIL FIXATION
I. Antegrade IM nail fixation of femoral shaft fractures can be performed in
either a supine or lateral decubitus position. Some surgeons prefer having the
patient supine on a fracture table. (See Chapter 17 for fracture table setup.)
The supine position offers the advantages of easier setup and distal screw
placement, improved fracture alignment, and minimal pulmonary compromise.
The lateral position allows easier access to the piriformis fossa. Additionally, the
procedure can be carried out on a fracture table or radiolucent operating room
table. Use of a radiolucent table offers the advantages of easier setup and the
potential for multiple surgeries to be performed simultaneously on the polytrauma
patient.
II. Prior to prepping, AP and lateral images of the hip and fracture site are obtained.
Adjustments to the patient’s position can be made at this point to allow adequate
space for the image intensifier to obtain the necessary views.
III. This section of the chapter will focus on antegrade nailing performed in the supine
position on a radiolucent table. In this position, a small bump is placed under
the calf and knee. The leg is held elevated off the table and prepped from iliac
crest to toes in standard fashion according to the principles outlined in Chapter
1 (Fig. 24-3).
Fracture Reduction
I. Closed reduction of the fracture is attempted prior to beginning surgery. A com-
bination of traction and external manipulation techniques can be used. Manual
traction or continual in-line traction maintained through a traction device on the
A B C
Figure 24-3
A, Patient positioned supine on a radiolucent table, with the lower portion of the extremity slightly elevated.
B, Prepping. C, Lower extremity prepped and draped.
radiolucent table is critical in obtaining and maintaining fracture reduction. Frac-

ture reduction is verified with fluoroscopy.
II. If closed reduction of the fracture fragments cannot be obtained, the fracture site
must be opened during the procedure. When open reduction is required, soft
tissue interposition at the fracture site is removed; bone fragments blocking reduc-
tion are also removed.
III. Extreme care must be taken during reduction to verify not only proper length
and angulation at the fracture site but also overall rotation of the lower
extremity.
Canal Entry, Guidewire Insertion, and Reaming

I. Surgery begins with an incision over the tip of the greater trochanter, in line
with the femoral shaft. The incision is carried 6 to 10 cm proximal to the
trochanter to allow access to the tip of the trochanter or the piriformis fossa.
Following skin incision, the underlying fascia and abductor musculature are split
longitudinally.
II. Next, a guide pin is placed and starting position is verified with AP and lateral
fluoroscopic images. For piriformis fossa entry, the tip of the guide pin should lay
in the center of medullary canal in both projections. A starting position too medi-
ally increases the risk of femoral neck fracture. Entry through the trochanter is
confirmed with the tip of the guide pin at the tip of the trochanter on both projec-
tions, pointing toward the center of the femoral canal. Once the guide pin position
is confirmed, the femoral canal is entered with a cannulated drill (Fig. 24-4).
Alternatively, an awl may be used to gain entry. With the femoral canal open, the
guide pin is removed.
III. Next, a flexible guidewire is inserted into the femoral canal (Fig. 24-5). A ball-
tipped guidewire is used to facilitate reamer retrieval in the case of a broken
reamer. Prior to inserting the guidewire, a subtle bend is typically placed at the
tip of the guidewire to aid in passage of the guidewire at the fracture site and to
direct its positioning in the distal femur. As the guidewire is advanced distally, its
location is confirmed with fluoroscopy.
IV. Fracture reduction is confirmed, or if needed, regained prior to passage of the
guidewire beyond the fracture site. Once the fracture is reduced, the guidewire is
advanced distally until the tip rests at the distal femoral physeal scar.
Lower Extremity
A B
Figure 24-4
Entry of the femoral canal. A, Lateral projection showing guide pin position. B, Anteroposterior projection
showing cannulated drill entry through the tip of the greater trochanter.
A B
Figure 24-5
Guidewire insertion. A, The flexible guidewire is inserted using a T-handle chuck. B, Position of the
guidewire is confirmed in the proximal femur. Note the slight bend in the distal 2 cm of the guidewire, which
aids in directing the guidewire at the fracture site and in the distal femur.
V. With the guidewire in proper position, the length of the nail is measured.
Typically, a second guidewire is placed at the level of canal entry and clamped
at the same level as the first guidewire. The free end of the second guidewire
is then measured, giving the length of the IM nail required. Alternatively, a
measuring guide can be inserted over the guidewire to measure the required nail
length. In the setting of severe fracture comminution, it is a good idea to measure
the size of the nail on the opposite femur to closely approximate leg length,
because it is easy to shorten or lengthen the operative extremity in this
circumstance.
VI. Next, if reaming is desired, canal reaming begins with the smallest end-cutting
reamer available (usually 8.5 or 9.0 mm). Reamer position is confirmed with fluo-
roscopy on the first pass. When backing the reamer out of the canal, the guidewire
must be stabilized to prevent its removal.
VII. The remaining reamers are side-cutting reamers that are used to expand the width
of the IM canal. Initially, subsequent reamers are increased in 1.0-mm increments.
ALWAYS PROTECT THE SKIN Once cutting of cortical bone is encountered (reamer “chatter”), reamers are
AND SOFT TISSUES DURING increased in 0.5-mm increments. This minimizes heat generation and the possibil-
CANAL ENTRY AND REAMING ity of reamer incarceration. Ultimately, the canal must be reamed to 1.0 or 1.5 mm
(FIG. 24-6). more than the proposed nail diameter.
Nail Placement
I. Nail placement can occur once the guidewire is in position. If reaming was per-
formed, the ball-tipped guidewire must be exchanged for a straight, smooth guide-
wire prior to nail insertion.
II. The nail must be assembled onto the insertion handle. Each manufacturer has
different instrumentation. However, it is always important to confirm proper
assembly, nail laterality, nail size, and antegrade versus retrograde nail use prior
to inserting the nail.
III. With the proper guidewire in place, the nail is inserted over the wire.
Depending on the curvature of the nail, the nail may have to be rotated during
insertion. For nails with a large anterior bow inserted through the tip of the greater
trochanter, the nail is started with the convexity of the bow medial, and then
externally rotated to anatomic position (Fig. 24-7). During nail insertion, fluo-
roscopy is used to verify nail alignment and to avoid comminution at the
fracture site.
A B
Figure 24-6
A, A large retractor is used to protect the soft tissues during canal entry. B, A reamer is inserted over the
guidewire.
A B C
Figure 24-7
Antegrade nail insertion. The nail is started with the bow convex medial (A) and then rotated as it is malleted
into position (B). In the final position (C), the bow is convex anterior.
Locking Screw Placement ALWAYS DOUBLE CHECK LIMB

I. With the nail in place, locking screws are placed, depending on fracture location ROTATION AND LENGTH
and configuration. Proximal locking screws are generally placed using the guide BEFORE PLACEMENT THE
FINAL SET OF INTERLOCKING
on the nail insertion handle (Fig. 24-8). Distal locking screws are placed using
SCREWS. ALSO, MAKE SURE
THAT THE FRACTURE IS NOT
DISTRACTED PRIOR TO
LOCKING THE NAIL INTO
POSITION.
Figure 24-8
The insertion handle is used as a guide to proximal
locking screw placement. Here, a hole is drilled for
the proximal screw.
Lower Extremity
perfect circles technique. (See Chapter 19 for details on locking screw placement
using perfect circles).
II. With the nail secured in proper position, the insertion handle is removed. A
proximal end cap can be placed at the surgeon’s preference. Final nail position is
confirmed using fluoroscopy, with special attention paid to the proximal and distal
aspects of the nail as well as fracture site alignment.
Wound Closure
I. Following wound irrigation and verification of adequate hemostasis, the fascia in
the proximal wound is closed as a distinct layer. The remainder of the proximal
wound as well as the incisions for interlocking screws are closed in the typical
layered fashion with suture alone or a combination of suture and staples for skin
closure.
II. All wounds are dressed with sterile dressings in standard fashion. No splint or
compressive dressings are required.
III. Final AP and lateral radiographs of the entire femur must be obtained, preferably
with the patient remaining in the operating room, to verify fracture reduction and
hardware position.
COMPONENTS OF THE PROCEDURE: RETROGRADE INTRAMEDULLARY

NAIL FIXATION
I. Retrograde IM nailing is performed on a radiolucent table with the patient in a

supine position. The entire extremity is prepped, in the same fashion as that
described above and illustrated in Figure 24-3.
II. Proper positioning must allow for 40 to 60 degrees of knee flexion. Inability to
obtain this degree of knee flexion makes guidewire passage, reaming, and nail
insertion extremely difficult. However, placing the knee in hyperflexion brings the
patella deep into the trochlear grove, again making canal entry difficult. There-
fore, a radiolucent triangle or a bolster is used to maintain proper knee flexion.
Fracture Reduction
Initial fracture reduction is attempted in the same manner as for antegrade nailing. (See
the previous section.)
Canal Entry, Guidewire Insertion, and Reaming

I. The femoral canal is accessed through the knee via either a patellar tendon-
splitting approach or an incision medial to the patellar tendon. There is a greater
incidence of postoperative anterior knee pain with splitting of the patellar tendon.
The patellar-splitting approach begins with a percutaneous incision through the
patellar tendon, extending distally from the inferior pole of the patella. In the
tendon-sparing approach, a midline skin incision is made and followed by a median
parapatellar arthrotomy.
II. Following the median parapatellar approach, the tendon is retracted laterally, and
blunt dissection of the fat pad exposes the ACL. Alternatively, a finger can be
Blumensaat’s line is a line inserted through the split patellar tendon to palpate the intercondylar notch.
drawn along the roof of III. With the intercondylar notch exposed, a guide pin is inserted. On the AP fluo-
the intercondylar notch, roscopic image, the guide pin should line up with the center of the femoral
seen on a lateral canal. On the lateral image, the guide pin is placed at the tip of the V formed by
radiograph.
Blumensaat’s line (Fig. 24-9).
IV. Once the guide pin is successfully positioned, it is advanced 5 to 10 cm into the
proximal femur. Again, guide pin placement is confirmed with fluoroscopy. Next,
Figure 24-9
Anteroposterior (A) and lateral (B) fluoroscopic
images showing retrograde guide pin insertion. Note
A
placement of the guide pin at the tip of Blumensaat’s
line (arrows) on the lateral view. (From Herscovici D
Jr, Whiteman KW: Retrograde nailing of the femur
using an intercondylar approach. Clin Orthop Relat Res
332:98–104, 1996.)
a cannulated straight entry reamer is inserted over the guide pin and used to open
the canal. Extreme care must be used to protect the patellar tendon when passing
the guide pin, guidewire, and reamers. With the canal opened, the straight reamer
and guide pin are removed and a flexible ball-tipped guidewire is inserted into the
femoral canal. At this point, guidewire advancement, fracture reduction, and ALWAYS PROTECT THE
reaming are all performed following the principles outlined above for the ante- PATELLAR TENDON DURING
grade procedure. CANAL ENTRY AND REAMING.
Nail Placement
I. The nail and insertion guide are assembled in a similar fashion to that described
previously.
II. The IM nail is inserted in the femoral canal, from distal to proximal. Fluoroscopy
is used to verify fracture reduction and nail position and length. As mentioned A NAIL THAT RESTS PROUD TO
earlier, careful attention must be paid to femoral length, limb rotation, and nail THE ARTICULAR SURFACE IN
insertion depth. The proper length retrograde nail rests 3 to 5 mm deep to the THE KNEE HAS DEVASTATING
articular surface and extends so that the tip lies at the level of the lesser trochanter. EFFECTS ON THE CRUCIATE
LIGAMENTS AND ARTICULAR
Seating of the nail 3 to 5 mm deep to the articular surface should be confirmed
CARTILAGE.
with fluoroscopy and manual palpation.
Lower Extremity
Locking Screw Placement

I. Similar to the antegrade nail, the locking screws closest to the insertion handle
are placed using the insertion handle guides. As a result, the distal locking screws
are placed in this fashion. The proximal locking screws are placed using perfect
circles technique. Due to the extensive musculature about the proximal femur, a
larger incision and more soft tissue dissection must be carried out to place the
proximal interlocking screws.
II. Once acceptable fracture reduction, limb length, and limb rotation have been
achieved and the nail is locked in place, the insertion handle is removed.
Wound Closure
I. Prior to any wound closure, the knee must be irrigated with copious amounts of
sterile saline to remove all debris from the joint.
II. Next, the patellar tendon or parapatellar arthrotomy is closed with absorbable
suture. Layered closure of the patellar tendon is usually performed with closure
of the paratenon layer being the most important. The insertion site and locking
screw incisions are closed in layered fashion as described in Chapter 1.
III. All wounds are dressed with a sterile dressing and a light compression dressing is
placed over the knee to help minimize joint effusion.
IV. Final AP and lateral radiographs of the entire femur must be obtained, preferably
with the patient remaining in the operating room, to verify fracture reduction and
hardware position.
POSTOPERATIVE CARE
I. Weight-bearing status following IM nail fixation depends on both fracture stabil-
ity and overall patient status. An IM nail is a load-sharing device. Therefore, the
extent a patient is allowed to bear weight postoperatively depends on the degree
of cortical contact at the fracture site.
II. Overall patient condition permitting, all patients need to be out of bed as quickly
What is your attending’s as possible after surgery in order to minimize pulmonary complications, pressure
preferred deep vein sores, and general deconditioning.
thrombosis prophylaxis III. All patients require deep vein thrombosis (DVT) prophylaxis postoperatively.
regimen? Generally, the DVT prophylaxis regimen selected is based on the patient’s ambu-
latory status, medical comorbidities, and history of DVT.
IV. Postoperative pain is managed using a combination of oral and intravenous pain
medication. Patient-controlled analgesia is typically well tolerated and effective.
V. Hip and knee range-of-motion exercises are started early. Knee range of motion
is particularly important following retrograde nail insertion.
VI. Fracture healing is monitored with serial radiographs, and weight-bearing status
is progressed based on the extent of healing.
VII. Hardware is removed in cases of failure, infection, nonunion, or pain due to
prominence.
COMPLICATIONS
I. DVT or pulmonary embolism
II. Acute respiratory distress syndrome
III. Infection
A. Less than 1% incidence in closed fractures
B. Generally low incidence in types I, II, and IIIA open fractures
C. Significantly increased in types IIIB and IIIC open fractures
IV. Delayed union or nonunion
V. Malunion
VII. Heterotopic Ossification
A. Overall incidence: 25%
B. Higher incidence in patients with brain injury
C. Most often clinically irrelevant
VIII. Hip pain (more common following antegrade nailing)
IX. Knee pain (more common following retrograde nailing)
X. Neurovascular injury (10% incidence of pudendal nerve injury with use of

fracture table)
XI. Compartment syndrome (very low probability)
SUGGESTED READINGS
Bong MR, Kummer FJ, Koval KJ, Egol KA: Intramedullary nailing of the lower extremity: Biome-
chanics and biology. J Am Acad Orthop Surg 15:97–106, 2007.
Browner BD, Caputo AE, Mazzocca AD, Wiss DA: Femur fractures: Antegrade intramedullary
nailing. In Wiss, DA: Master Techniques in Orthopaedic Surgery: Fractures, 2nd ed. Phila-
delphia, Lippincott Williams & Wilkins, 2006, pp 323–350.
Ostrum RF, Farrell ED: Femoral shaft fractures: Retrograde nailing. In Wiss, DA: Master Tech-
niques in Orthopaedic Surgery: Fractures, 2nd ed. Philadelphia, Lippincott Williams &
Wilkins, 2006, pp 351–360.
Ricci WM: Femur: Trauma. In Vacarro AR (ed): Orthopaedic Knowledge, Update 8. Rosemont,
IL, American Academy of Orthopaedic Surgeons, 2005, pp 425–431.
Lower Extremity
C H A P T E R
25
Supracondylar Femur Fractures
Nirav K. Pandya and Craig L. Israelite
Case Study
A 35-year-old male presents to a level one trauma center after sustaining a gunshot wound
to his left lower extremity. The otherwise healthy patient was on his way to work when
he was shot by an unknown assailant and was immediately unable to bear weight. The
patient was rushed to the hospital by the police, and he has a visible deformity of his left
distal femur. There is an entry wound in the proximal thigh with no exit wound. The
patient’s neurovascular examination is within normal limits, and this is an isolated injury.
Anteroposterior (AP) and lateral radiographs of the distal femur are shown in Figure
25-1.
A B
Figure 25-1
Anteroposterior (A) and lateral (B) views of the distal femur.
C H A P T E R 2 5 Open Reduction and Internal Fixation of Supracondylar Femur Fractures 287
BACKGROUND
I. Supracondylar femur fractures are less common than fractures of the proximal
femur, accounting for only 4% to 7% of all femur fractures. These injuries typi-
cally affect patients of all ages, although a distinct bimodal age distribution does
exist: younger patients 20 to 30 years of age, and elderly patients older than 65
years of age.
II. The specific mechanism of injury varies based on the age of the patient but is In younger patients,
generally due to an axial load with a concomitant varus, valgus, or rotational force. supracondylar femur
In younger patients, these injuries are generally the result of a high-energy mecha- fractures are high-energy
nism such as a motor vehicle crash, gunshot wound, or fall from a height, in which injuries, and the clinician
other ipsilateral bony injuries are common. In elderly patients (many of whom should have a high
have osteoporotic bone), these fractures can result from a minor fall onto a flexed suspicion for other
knee. associated injuries.
III. Supracondylar fractures are those defined as involving the distal femoral metaphy-
sis proximal to the femoral condyles (the region encompassing the last 9 to 15 Which classification
centimeters of the femur). Multiple classification systems exist, including the Neer system does your
classification, which takes into account the degree and direction of condylar dis- attending use for
placement, and the Seinsheimer classification, which focuses on articular disrup- supracondylar femur
fractures, and what
tion. The most commonly used system is the AO/OTA classification system (Fig.
information about the
25-2), which includes three major groups (A, extra-articular; B, partial articular/ fracture does he or she
unicondylar; C, complete articular/bicondylar). like to hear when called
IV. Because of the fracture mechanism, associated injuries are a common with a consult?
occurrence with supracondylar femur fractures. These include more proximal
injuries to the femur and acetabulum as well as more distal ligamentous
THE PROXIMITY OF THE
and bony injuries (particularly tibial plateau fractures). In addition, injuries
FEMORAL ARTERY MEDIALLY,
to the popliteal artery can occur (particularly if there has been a knee
AND THE POPLITEAL ARTERY
dislocation). Alternatively, if there is a disruption of the medial femoral POSTERIORLY, TO THE DISTAL
cortex, the femoral artery can be injured as it passes through the adductor canal. FEMUR CAN LEAD TO
Although rare, compartment syndrome of the thigh can also occur with these VASCULAR INJURY IN THESE
injuries. In addition, only about 5% to 10% of supracondylar femur fractures are FRACTURE PATTERNS.
open.
V. Treatment options are numerous for these fractures and include nonoperative
(i.e., casting, traction) and operative options such as joint spanning external
fixation; lateral plating, including percutaneous/minimally invasive options (i.e.,
95-degree condylar blade plating, condylar compression screw and side-plate, and
condylar buttress plate); antegrade nailing; and retrograde nailing. The type of
fracture (open vs. closed), the fracture pattern, status of other injured extremities,
condition of the soft tissue envelope, patient health, patient size, and neurovascular
status of the patient all play a role in determining the optimal method of
treatment.
INITIAL TREATMENT
A. Fracture classification (AO/OTA) and severity
B. Status of soft tissues (closed versus open; Gustilo classification)
C. Neurovascular status
D. Associated musculoskeletal injuries
E. Injuries to other organ systems
F. Patient’s preinjury functional status (e.g., ambulatory vs. nonambulatory, inde-
Lower Extremity
pendent vs. dependent, as in nursing home residence)

A. History
1. A thorough Advanced Trauma Life Support (ATLS) assessment of the
patient must be performed.
2. Patient mechanism of injury should be documented.
A1 A2 A3
B1 B2 B3
C1 C2 C3
Figure 25-2
The AO/OTA classification system of distal femoral fractures. A, Extra-articular. B, Partial articular/
unicondylar. C, Complete articular bicondylar. (From Browner B, Jupiter J, Levine A, Trafton P [eds]: Skeletal
Trauma: Basic Science, Management, and Reconstruction, 3rd ed. Philadelphia, Saunders, 2003.)
3. Complaints of pain in other extremities and/or neurologic symptoms must

Many supracondylar be documented.
femur fractures present to 4. Prior history of pain in the affected extremity and/or prior surgical proce-
the trauma bay, and basic dures/hardware may be relevant.
Advanced Trauma Life 5. Patient’s preinjury functional status, prior neurologic deficits, overall health,
Support principles should and specific use of anticoagulant medications is important information in
not be forgotten.
the surgical decision process.
B. Physical examination
1. Conducting a careful examination of the entire affected extremity above and
below the fracture site is essential to look for associated injuries (i.e., femoral
neck, femoral shaft, tibial plateau).
2. Swelling of the knee with gross deformity is usually present.
3. A detailed examination of wounds looking for open fractures and gross
contamination should be performed.
4. Tenderness to palpation (if tolerated by the patient) at the fracture site with
crepitus is apparent.
5. A thorough neurovascular examination documenting distal pulses (use
Doppler if necessary) and any motor/sensory deficits should be performed.
6. Although rare, compartment syndrome of the thigh can present with this
A femur fracture may
fracture pattern; this is a devastating complication if not diagnosed early.
result in a 2- to 3-liter
C. Laboratory studies blood loss in the thigh.
1. Perform a preoperative laboratory workup (complete blood count, Chem-7, Monitoring the patient’s
coagulation labs, type and screen). hemoglobin may be
2. Monitor hemoglobin due to blood loss, which can occur with these high- required, especially in
energy injuries. elderly patients.
D. Imaging
1. AP and lateral radiographs of the distal femur and knee at the injury site
are required.
2. An AP radiograph of the pelvis as well as the ipsilateral hip, femoral shaft, and
tibia and fibula should always be performed to rule out associated bony injuries.
3. If there is difficulty assessing the intra-articular extent of the injury, 45-
degree oblique radiographs can aid in visualization, as can manual traction
views (if tolerated by the patient).
4. Some surgeons obtain images of the contralateral extremity to provide a
comparison with the injured extremity for reconstruction.
5. Computed tomography scans with three-dimensional reconstructions of the
distal femur and knee are important in intra-articular fracture patterns, and
they may be critical for effective preoperative planning (Fig. 25-3).
6. If history is suggestive of a knee dislocation associated with a distal femoral
fracture, angiography should be performed to rule out a vascular injury, Contraindications to
although it should not delay operative treatment. tibial traction pins
include ligamentous
7. In addition, if clinical concern exists for ligamentous or meniscal injury to
injury to the knee and
the knee, magnetic resonance imaging can be performed as well, although young (pediatric) age
it is not mandatory. (proximity of the
E. Preoperative stabilization proximal tibial physis).
1. All open wounds should be irrigated and sterilely dressed.
2. If the fracture is open, tetanus and appropriate intravenous antibiotics ALWAYS CAREFULLY
should be administered. DOCUMENT A PREREDUCTION
3. The injured extremity should be gently reduced and splinted in a long leg splint AND POSTREDUCTION
or knee immobilizer to provide temporary immobilization and fracture stability. NEUROVASCULAR
4. If there will be a delay going to the operating room, a tibial traction pin can EXAMINATION TO ENSURE
be placed in the emergency room or trauma bay to temporarily stabilize and THAT ANY NEUROVASCULAR
reduce the fracture, keep the extremity out to length, and reduce blood loss. STRUCTURES HAVE NOT
5. Appropriate pain management, deep vein thrombosis prophylaxis, preop- BECOME ENTRAPPED IN THE
FRACTURE SITE AS A RESULT
erative medical/cardiac clearance, and informed consent for the procedure
OF THE REDUCTION.
should be obtained.
TREATMENT PROTOCOLS
Lower Extremity
A. Nonoperative treatment options include traction and fracture/cast bracing.
B. Traction is generally indicated for patients who have unstable, displaced frac-
tures for whom the risk of an operation is too great given their medical comor-
bidities (i.e., recent myocardial infarction).
A B
Figure 25-3
Computed tomography scans of various
supracondylar femur fractures. A, Coronal CT scan
demonstrating metaphyseal comminution of a
supracondylar femur fracture with extension into the
intercondylar notch. B, Coronal CT scan of a
comminuted supracondylar femur fracture with
extension of the fracture from the diaphysis to the
articular surface. C, Coronal CT scan of the distal
C femur demonstrating an extra-articular supracondylar
femur fracture with intra-articular extension.
C. For impacted, nondisplaced fractures (or in patients who are nonambulatory),

temporary immobilization in a knee immobilizer followed by fracture/cast
bracing is an option. An acceptable reduction maintains the normal axis of the
lower extremity.
D. With the advances in anesthesia techniques, the ease of external fixator applica-
tion, and the development of minimally invasive implants, operative fixation
has become the standard of care.

A. Surgical intervention is indicated for all displaced intra-articular fractures,
open fractures, fractures with vascular compromise, contralateral femoral frac-
tures, polytrauma, fractures with ipsilateral tibial shaft injuries (“floating knee”),
concomitant tibial plateau injuries, pathologic fractures, and associated liga-
mentous injury to the knee.
B. The time to surgery is dependent on the type of fracture (open vs. closed),
status of the patient (isolated injury versus polytrauma), and the experience of
the surgeon and his or her team.
C. In open fractures or polytraumatized patients, treatment should be undertaken
as soon as possible, with a joint spanning external fixator helping to stabilize
the fracture quickly and efficiently.
D. In patients with associated vascular injuries, the extremity should be first sta-
bilized with external fixation, and then the vascular repair can be performed.
The definitive operative treatment can be performed at a later date (typically
within 2 weeks).
E. Closed, isolated injuries have a multitude of options to choose from
including inter-fragmentary and buttress screws, plates, and nails (Fig.
25-4).
F. Lateral plating is most commonly used and will be described in this chapter
(Fig. 25-5).
G. If a lateral condylar buttress plate has been used in a patient with osteoporotic
bone with a significant amount of comminution of the medial cortex, a small What is your attending’s
medial condylar buttress plate can be used (with or without bone graft) to algorithm for choosing
prevent varus deformity. particular implants?
ALTERNATIVES TO OPEN REDUCTION AND INTERNAL FIXATION OF

SUPRACONDYLAR FEMUR FRACTURES
I. Skeletal Traction
A. Indicated for patients with have unstable, displaced fractures for whom the risk
of an operation is too great given their medical comorbidities (i.e., recent
myocardial infarction)
B. Tibial traction pin
II. Fracture/Cast Bracing
A. For impacted, nondisplaced fractures (or in patients who are nonambulatory),
temporary immobilization in a knee immobilizer followed by fracture/cast
bracing is an option.
B. An acceptable reduction maintains the normal axis of the lower extremity.
III. External Fixation
A. A joint spanning external fixator is appropriate in individuals who may be too
unstable medically to undergo a prolonged procedure.
B. Compromised soft tissue status (i.e., open fractures) may also necessitate exter-
nal fixation placement to allow for soft tissue healing necessary prior to open
reduction internal fixation.
C. Ipsilateral vascular injury may also necessitate joint spanning external fixation
to protect any vascular repair.
SURGICAL INDICATIONS FOR OPEN REDUCTION AND INTERNAL FIXATION OF

Lower Extremity
SUPRACONDYLAR FEMUR FRACTURES

I. Failed Nonoperative Treatment
A. Skeletal traction or fracture/cast bracing leads to unacceptable reduction with
malunion/nonunion.
B. Patient continues to have intractable pain with nonoperative treatment.
Figure 25-4
Supracondylar femur fracture treated with retrograde nailing. A and B, Preoperative films. C and D,
Postoperative films.
A B
Figure 25-5
AP (A) and lateral (B) postoperative radiographs of a supracondylar femur fracture treated with a lateral plate.
II. Displaced intra-articular fractures. It is essential to re-establish articular

congruency.
III. Open fractures
IV. Fractures with neurovascular compromise
V. Polytrauma patients (e.g., patients with contralateral femoral fractures,
ipsilateral tibial shaft or tibial plateau fractures, or ligamentous injuries to the
knee)
VI. Pathologic fractures
RELATIVE CONTRAINDICATIONS TO OPEN REDUCTION AND INTERNAL

FIXATION OF SUPRACONDYLAR FEMUR FRACTURES
I. The patient is medically unstable for surgery or unable to tolerate prolonged
procedure (unable to safely tolerate the stress of surgery).
II. Current or recent infection
Lower Extremity
III. Open fracture with significant soft tissue compromise (i.e., adequate soft tissue
coverage of wound cannot be achieved)
IV. Vascular injury requiring immediate repair (i.e., stabilize with external fix-
ation)
SURGICAL ALGORITHM
Supracondylar femur
fracture
Open Closed
Operating room
(irrigation and
débridement)
Polytrauma Isolated
Displaced Non-displaced
Stable patient Unstable patient Conservative

(i.e., casting,
traction)
External fixation/IM rod
IM nail, lateral
plating, or
compression Stable patient
screw
GENERAL PRINCIPLES OF LATERAL PLATING FOR SUPRACONDYLAR

FEMUR FRACTURES
I. Goals
A. Articular surface reduction
B. Reduction of the articular surface to the metaphyseal fragment
C. Stable fixation of the entire fracture internally
D. Fracture healing and return to activity
II. Anatomy and Plate Placement
A. The supracondylar region of the femur is defined as extending from the distal
9 cm to the distal 15 cm of the femur.
B. The following anatomic principles are essential to understanding proper plate
position.
1. The anatomic axis of the lower extremity typically has 5 to 9 degrees of
valgus (tibiofemoral).
2. When looking at the femur in the sagittal plane, the femoral shaft is actually
in line with the anterior half of the condyles rather than lying midway
between the anterior and posterior halves of the condyles.
3. The lateral condyle projects more anteriorly than the medial condyle.
4. The medial metaphyseal surface is angulated approximately 25 degrees from
the sagittal plane, whereas the lateral metaphyseal surface is angulated
approximately 10 degrees.
5. The condyles are wider posteriorly than anteriorly (a trapezoid shape).
C. With an understanding of the distal femoral anatomy, lateral plates can be
placed properly by following the slope of the lateral metaphyseal surface and
placing the plate along the anterior aspect of the condyle to align with the
femoral shaft to obtain proper screw purchase.
D. The surgeon must understand the following deforming forces on the fracture
site to aid in the reduction (Fig. 25-6):
1. The quadriceps and hamstrings produce a shortening force on the femur.
2. The gastrocnemius muscles create a posterior force.
Figure 25-6
A, Representation of the supracondylar region of the femur. B, Typical distracting forces acting on the
fracture site. (From Browner B, Jupiter J, Levine A, Trafton P [eds]: Skeletal Trauma: Basic Science, Management,
and Reconstruction, 3rd ed. Philadelphia, Saunders, 2003.)
3. Placing the knee in slight flexion (via a bump at the fracture site) during the
course of the operation relaxes the gastrocnemius, and its deforming forces,
and aids in reduction.

I. The patient is placed supine on a radiolucent fracture table so that both AP and
lateral images can be obtained throughout the case.
II. The fluoroscope machine is positioned such that it can enter the operative field
contralateral to the operative side.
III. The fluoroscope machine monitor should also be placed on the contralateral side
or at the foot of the bed so that the surgeon can easily view the fluoroscopic
imaging during the course of the operation.
IV. A bump is placed under the ipsilateral hip to help place the femur in a neutral
position.
V. The entire limb should be prepped and draped from the toes to the ipsilateral Does your attending
prefer to prep with
pelvis to permit proximal and distal extension of the incision (as well as allowing
alcohol?
distal manipulation of the leg).
VI. Therefore, only a sterile tourniquet can be used (if the attending desires) after the
patient has been fully prepped and draped depending on the proximal extent of What method does your
attending prefer to use
Lower Extremity
the fracture and limb length.

VII. The operative extremity is prepped and draped in standard fashion according to for draping the leg?
the principles in Chapter 1. A sterile tourniquet is placed after prepping and
draping.
VIII. Traction radiographs in the AP and lateral plane should be taken to achieve pro-
visional alignment of the fracture prior to starting the case.
Surgical Exposure
I. The specific surgical approach utilized for the case can vary based on the fracture
type and severity.
II. An extensile lateral approach is most commonly used (described below) although
minimally invasive, medial, and anterolateral approaches have also been
described.
III. Prior to the surgical incision, a sterile marking pen can be used to mark the
planned course of the operation.
IV. Generally, a straight posterolateral incision is made over the thigh starting
as proximally as needed and extending distally over the lateral femoral condyle
(anterior to the lateral collateral ligament); if distal extension is needed, the
incision can be carried over the knee to a point distal and lateral to the tibial
tubercle.
V. After dissecting through subcutaneous fat, the next layer that is encountered is the
fascia lata.
VI. The fascia should be incised in line with its fibers and the skin incision.
VII. At the distal end of the fascial incision, the iliotibial band should be incised (the
incision continues through the joint capsule and synovium to expose the lateral
femoral condyle).
A NUMBER OF PERFORATING VIII. The vastus lateralis muscle is now identified under the fascia lata.
BRANCHES CROSS THE IX. By following the muscle posteriorly, the lateral intermuscular septum is
LATERAL INTERMUSCULAR identified.
SEPTUM, AND THEY MUST BE
X. The vastus lateralis should then be dissected away from the lateral intermuscular
IDENTIFIED AND LIGATED.
septum and retracted anteromedially.
XI. Subperiosteal dissection can then be used to completely expose the bone and
free it from the overlying muscle with as little soft tissue dissection as necessary
(Fig. 25-7).
Figure 25-7
Lateral exposure of the femur. A, Femur. B, Lateral
intermuscular septum. (From Canale ST [ed]:
Campbell’s Operative Orthopaedics, 10th ed. Philadelphia,
Mosby, 2003.)
Reduction of the Articular Surface
I. The articular surface can now be adequately visualized and reduced.

II. Utilizing the fact that there should be at least five screw holes above the most
proximal aspect of the fracture, the appropriate length plate that will be used to
stabilize the fracture is chosen.
III. Provisionally the plate is placed on the distal femur to aid in the planning of where
K-wires and/or screws will be used in the periphery of the plate (anterior and
distally) to reduce the articular surface.
IV. A combination of screws and K-wires is used to reduce the articular surface of the
fracture (ensuring that the fixation takes into account the eventual position of the
plate).
V. Typically, each individual condyle is reconstructed followed by securing the con-
dyles to each other.
VI. The screws should be placed lateral to medial, and perpendicular to the
fracture lines, except in the case of a coronal plane split of the condyle
(Hoffa fracture), in which case a single screw can be placed from anterior to
posterior.
Reduction of the Shaft to the Articular Surface When, if ever, does your
attending like to use a
I. After appropriate reduction of the articular surface, the plate is placed femoral distractor to aid
along the shaft of the distal femur matching the contour of the bone to the during surgery, and does
plate. he or she like to have
bone graft available to fix
II. Periarticular locking plates have a distal segment in which there are a cluster of
any large bony defects?
holes to transfix the condylar segment to the plate.
III. A temporary fixation pin can be placed through one of the distal holes
to aid in holding the plate to the bone and allow for provisional fracture
fixation.
IV. Using a guide, a K-wire can now be drilled through one of the distal holes in the
plate, advancing the K-wire until it reaches (but does not pass through) the medial
femoral cortex.
V. The length of the cannulated locking screw that will be inserted over the K-wire
can now be measured using a depth gauge.
VI. After determination of the proper length screw, the screw is inserted over the
guidewire (make sure that it is not necessary to predrill the screw if it is
self-tapping). When using a
VII. The above steps are performed using an AP image from the fluoroscope combination of locking
machine. and nonlocking screws,
VIII. The fluoroscope machine can now be rotated to the lateral position to use nonlocking screws
first to reduce the plate
ensure that proper sagittal alignment has been achieved with the distal locking
to bone or to create
screw. compression (“lagging the
IX. The plate is now centered on the femoral cortex laterally, and another temporary screw”) across the
fixation pin can be placed in one of the more proximal holes (i.e., the second most) fracture site, and then use
of the plate. locking screws. Using
X. Another temporary fixation pin can then be placed in a hole close to the fracture locking screws prior to
site but in a slightly proximal position. nonlocking screws
XI. The condylar (distal) screws can now be placed using a combination of locking prevents the plate from
and nonlocking screws. being reduced to bone
XII. When placing the condylar screws, it is necessary to predrill to just short of the and/or compression being
medial cortex and use a measuring guide/depth gauge to determine the length of created across the
fracture site.
Lower Extremity
screw that should be inserted.

XIII. The screw is placed on a screwdriver and inserted through the plate.
XIV. It is necessary to ensure that good purchase is obtained within the bone and that
the screw has not been cross-threaded in the plate.
XV. After the condylar screws are placed (number and order based on attending prefer-
ence), attention can be turned to the region proximal to the condyles utilizing a
WHEN DRILLING THROUGH THE combination of locking and nonlocking screws for securing the plate to the
BONE, THE FIRST LOSS OF femoral shaft.
RESISTANCE THAT IS FELT IS XVI. A drill is used to create a path for the screws (drill to just past the medial cortex).
THE DRILL PASSING THROUGH Then the drill is removed and a depth gauge is used to measure the appropriate
THE FIRST CORTEX. THE NEXT length screw that will be needed.
RESISTANCE FELT IS THE XVII. Once again, the screw is placed using a screwdriver (Fig. 25-8).
SECOND CORTEX. THE SECOND XVIII. The final reduction is confirmed in both the AP and lateral planes using the fluo-
LOSS OF RESISTANCE IS THE roscope machine.
DRILL PASSING THROUGH THE
CORTEX AND THROUGH THE
BONE. Wound Closure
I. A Hemovac drain may be placed by the surgeon if there is concern for a large
How does your attending hematoma in the operative space postoperatively.
decide the number and II. The fascia is typically closed with a heavy suture and is done with simple inter-
order of screws to place? rupted or figure-of-eight sutures.
What is his or her III. The subcutaneous layer and skin are closed in standard fashion (see Chap-
philosophy with regard to ter 1).
locking versus nonlocking
VI. A sterile dressing is then placed around the wound with an extension around the
technique (and the
number of locking or
knee joint.
nonlocking screws to V. The tourniquet is deflated after the dressings are secure.
use)? VI. Based on the nature of the injury and attending preference, some surgeons
elect to keep the patient immobilized in a knee immobilizer or a long leg
splint.
What is your attending’s VII. Typically, patients have formal AP and lateral radiographs taken of the distal
preference for deep vein femur postoperatively.
thrombosis prophylaxis,
weight-bearing status,
knee range of motion, POSTOPERATIVE CARE
and length of antibiotics
postoperatively? I. Postoperative care is largely dictated by factors such as the patient’s comorbidities
and the surgeon’s satisfaction with the intraoperative fixation.
II. Postoperative management includes pain control, antibiotics, postoperative radio-
graphs, and physical therapy.
III. Patients are typically admitted to the hospital for several days.
IV. Patients can begin work with the physical therapist the next day and are generally
kept non–weight bearing.
V. Some attendings keep their patients in a knee immobilizer, whereas others transi-
tion their patients to a cylinder cast prior to discharge. Others use a continuous
passive range of motion machine while the patient is at rest.
VI. Patients are discharged home or to rehabilitation facilities based on their progress
with physical therapy and their overall medical status.
COMPLICATIONS
I. Due to the difficult nature of this fracture, multiple complications can occur in
the intraoperative and postoperative period.
II. Injuries to neurovascular structures (particularly due to their proximity
to the distal femur) can occur frequently and must be recognized and dealt with
early.
III. As with any operation, infection is a major risk postoperatively, and it can be
lessened with the use of sterile technique and proper perioperative antibiotic
administration.
IV. Fracture malreduction may occur, particularly with highly comminuted
fractures.
V. Hardware failure may occur at any point in the postoperative period due to
both patient (e.g., poor compliance with weight-bearing restrictions, poor bone
quality) and/or the operative technique (e.g., surgeon experience, improper
hardware).
Figure 25-8
Steps in the fixation of
supracondylar femur fracture. A,
Preoperative. B, Articular surface
reduction. C, Postoperative lateral
plating performed. (From Browner
B, Jupiter J, Levine A, Trafton P
[eds]: Skeletal Trauma: Basic Science,
Management, and Reconstruction, 3rd
ed. Philadelphia, Saunders, 2003.)
4.5-mm screws
6.5-mm screws
Lower Extremity
VI. Nonunion and malunion can occur as well and may require additional future
operative intervention or bone stimulators.
VII. Finally, knee stiffness is a common complication of these injuries, and can be
averted with an early range of motion protocol.
SUGGESTED READINGS
Bucholz RW, Heckman JD, Court-Brown C: Fractures of the distal femur. In Bucholz RW,
Heckman JD, Court-Brown C (eds): Rockwood and Green’s Fractures in Adults, 6th ed.
Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1915–1968.
Canale ST: Fractures of the lower extremity. In Canale ST (ed): Campbell’s Operative Orthopae-
dics, 10th ed. St. Louis, Mosby, 2003, pp 2805–2825.
Marti A, Fankhauser C, Frenk A, et al: Biomechanical evaluation of the less invasive stabilization
system for the internal fixation of distal femur fractures. J Orthop Trauma 15:482–487,
2001.
C H A P T E R
26
Tibial Plateau Fractures
Jesse T. Torbert, Jaimo Ahn, and John L. Esterhai
Case Study
A healthy 28-year-old male is brought to the emergency department by ambulance after

falling off his bike. He was traveling at a high speed on a dirt trail when he landed on his
right foot, felt his knee buckle, and heard a pop. He felt immediate right knee pain and
was unable to bear weight. He denies any loss of consciousness and any other areas of
pain. He does not complain of any distal lower extremity weakness or paresthesias.
The patient’s vital signs are within normal limits. The initial trauma evaluation and
exam of the spine and uninvolved extremities is negative. The right knee has a moderate
effusion, with no skin abrasions or lacerations. There is tenderness to palpation on the
lateral knee joint line. Knee range of motion and anterior, posterior, varus, and valgus
stability testing are deferred secondary to extreme pain. The neurovascular exam, includ-
ing motor, sensation, and pulses, is intact. Anteroposterior (AP) and lateral radiographs
and a coronal computed tomography scan of the right knee are presented in Figure
26-1.
BACKGROUND
I. Tibial plateau fractures are most often caused by high-speed motor vehicle crashes
and falls from a height. These fractures also may result from relatively low-energy
Lower Extremity
Figure 26-1
Anteroposterior and lateral radiographs and coronal computed tomography (CT) image of the right knee
demonstrate a Schatzker type II split/depression fracture. The lateral joint line depression with a nondisplaced
lateral split fracture is evident on the CT.

falls in elderly patients. The fracture typically results from direct axial compres-
The medial articular
surface and underlying sion, often with a valgus, and less often with a varus deforming force; the
plateau are stronger than lateral plateau is most often involved. Factors affecting fracture pattern include
the lateral counterparts. position of the knee at impact, energy of impact, valgus/varus forces, and bone
This, in addition to the quality.
common valgus force II. Fractures are classified according to the Schatzker classification (Fig. 26-2).
component, results in a A. Type I fractures are split fractures of the lateral tibial plateau. Lateral meniscus
high frequency of lateral tears may be associated with this type and may prevent fracture reduction.
plateau fractures. B. Type II fractures are split/depression fractures.
C. Type III fractures are pure central depressions of the lateral plateau.
D. Type IV fractures involve the medial plateau with split fractures often referred
to as type IVA and depression fractures referred to as type IVB.
E. Type V is a fracture of both the medial and lateral plateau, which often has
the appearance of an inverted V.
F. The metaphysis and diaphysis are continuous in type V fractures, whereas type
VI fractures display dissociation between the metaphysis and the diaphysis with
varying degrees of comminution. Fractures classified as a Schatzker IV or
higher are typically considered high-energy injuries.
III. Tibial plateau fractures are often associated with soft tissue injuries. In closed
fractures, soft tissue injury can be graded using the Tscherne classification described
later. The degree of soft tissue injury associated with open fractures is often graded
using the Gustilo and Anderson classification, which is also discussed later. Injury
to the soft tissue envelope has been considered by many to be the most important
Type I Type II
Type III Type IV
Type V Type VI
Figure 26-2
Schatzker classification of tibial plateau fractures. (From Schatzker J, McBroom R, Bruce D: The tibial plateau
fracture. The Toronto experience 1968–1975. Clin Orthop Relat Res 138:94–104, 1979.)
C H A P T E R 2 6 Open Reduction and Internal Fixation of Tibial Plateau Fractures 303
factor in treatment choice, surgical complications, and functional outcome.

Damage to the soft tissue is the most common contraindication to early surgical
intervention; surgical delay until soft tissue condition improves (usually 1 to 3
weeks) minimizes complications such as wound dehiscence and wound infection.
Often in the case of severe injury, external fixation methods are used, either as a
temporary fixation method or definitive treatment, to avoid surgical dissection
through areas of injured soft tissue.
A. Tscherne classification of soft tissue injuries
1. Grade 0: Absent or minimal soft tissue damage
2. Grade I: Superficial abrasions or contusions
3. Grade II: Deep contaminated abrasions, contusions, or impending compart-
ment syndrome
4. Grade III: Extensive contusion or crush with severe muscle damage, com-
partment syndrome, degloving injuries, or major blood vessel injury
B. Gustilo and Anderson classification of open fractures
1. Grade I: Wound less than 1 cm long, usually a clean puncture through
which a spike of bone has pierced the skin; there is little soft tissue damage
and no sign of crush injury. Grade I fractures are considered to be the result
of low-energy injuries. Initial antibiotic treatment should be a first-genera-
tion cephalosporin.
2. Grade II: Wound more than 1 cm long, without extensive soft tissue damage;
there may be slight or moderate crush injury and moderate wound contami-
nation. Grade II fractures are considered to be the result of medium energy
injuries. Initial antibiotic treatment should be a first-generation
cephalosporin.
3. Grade III: Extensive damage to soft tissues, including skin, muscles, and
neurovascular structures; the cause is often high-velocity trauma or severe
crush injury. Grade III fractures are considered to be the result of high-
energy injuries. Initial antibiotic treatment should be a first-generation
cephalosporin and gentamicin. Penicillin is added for soil-contaminated
injuries such as barnyard injures.
a. IIIA: Soft tissue coverage of the fracture is adequate.
b. IIIB: Extensive injury or loss of soft-tissue with periosteal stripping,
exposed bone, massive contamination; often flap coverage is needed after
irrigation and débridement.
c. IIIC: Any open fracture associated with an arterial injury requires
repair. THE POPLITEAL ARTERY
IV. Ligament, meniscal, neurovascular injuries, and compartment syndrome are TRIFURCATES JUST BELOW
common in tibial plateau fractures. Anterior cruciate ligament and posterior cruci- THE KNEE INTO THE ANTERIOR
ate ligament injuries have been found in approximately one third and one fourth AND POSTERIOR TIBIAL AND
of tibial plateau fractures, respectively. Collateral ligament injuries have been PERONEAL ARTERIES; THE
reported to occur in 7% to 43% of cases. Posterolateral corner and posteromedial TRIFURCATION IS AT RISK IN
TIBIAL PLATEAU FRACTURES.
complex injuries have been found in approximately one fourth and one sixth of
THE PERONEAL NERVE IS AT
tibial plateau fractures, respectively. Neurovascular structures at risk include the
RISK LATERALLY AS IT
common peroneal nerve and the popliteal, anterior tibial, posterior tibial, and TRAVELS AROUND THE NECK
peroneal arteries. Vascular injuries are common after fracture dislocations of OF THE FIBULA.
the knee.
V. Compartment syndrome is not uncommon, especially in higher energy (type IV
to VI) fractures. The signs and symptoms of compartment syndrome include the
following:
A. Firmness of compartment
Lower Extremity
B. Pain (out of proportion to what one would expect, especially with passive range
of motion of toes or ankle)
C. Paresthesia PAIN TO PASSIVE STRETCH IS
THE MOST SENSITIVE CLINICAL
D. Pallor (pale color)
TEST FOR DIAGNOSING
E. Poikilothermia (cold distal extremity compared to the contralateral side)
COMPARTMENT SYNDROME.
F. Pulselessness
VI. If the surgeon believes that compartment syndrome is likely to develop postopera-
tively, fasciotomies can be performed at the time of open reduction and internal
fixation (ORIF).
VII. Four fascial compartments exist in the lower leg:
A. The anterior compartment contains the tibialis anterior, extensor digitorum
longus, extensor hallucis longus, and peroneus tertius, which are supplied by
THE SUPERFICIAL PERONEAL the deep peroneal nerve.
NERVE PIERCES THE FASCIA B. The lateral compartment encloses the peroneus longus and brevis, which are
AND LIES SUPERFICIAL TO IT supplied by the superficial peroneal nerve.
IN THE DISTAL THIRD OF THE C. The superficial posterior compartment consists of the gastrocnemius, soleus,
LEG. THIS PORTION OF THE and plantaris.
NERVE IS AT RISK WHEN THE D. The deep posterior compartment contains the tibialis posterior, flexor digito-
FASCIA OVER THE ANTERIOR rum longus, flexor hallucis longus, and popliteus. Both posterior compartments
AND LATERAL
are innervated by the tibial nerve.
COMPARTMENTS IS INCISED
VIII. A commonly used technique to release these compartments is the double incision
FOR COMPARTMENT
SYNDROME. SEVENTY-FIVE
four-compartment fasciotomy. The anterior and lateral compartments are released
PERCENT OF THE TIME, THE through a lateral-based skin incision with care taken to avoid injuring the super-
SUPERFICIAL PERONEAL ficial peroneal nerve. Often these compartments can be released through the
NERVE REMAINS IN THE lateral incision used for ORIF, or by extending the lateral incision. The posterior
LATERAL COMPARTMENT compartments are released through a skin incision one inch medial to the medial
BEFORE EXITING THROUGH THE edge of the tibia, staying anterior to the posterior tibial artery. The superficial
DEEP FASCIA, AND 25% OF posterior compartment is exposed by skin retraction. The deep posterior compart-
THE TIME IT TRAVELS INTO ment is visualized by retracting the superficial compartment posteriorly. The
THE ANTERIOR COMPARTMENT saphenous nerve and vein and posterior tibial vessels and nerves must be
PRIOR TO EXITING.
protected.
INITIAL TREATMENT
A. Fracture pattern/classification
B. Intra-articular displacement
C. Stability to varus/valgus stress
D. Condition of soft tissue envelope
E. Associated ligamentous injuries
F. Neurovascular injuries
G. Age and medical condition of the patient
II. Initial Assessment
A. Assess the radiographs for fracture pattern and the presence of dislocation; be
sure that AP and lateral radiographs of the entire tibia, knee, and any other
Be sure to document suspicious or painful areas are performed and are considered to be adequate.
vascular and neurologic 1. If dislocation is present, perform a quick but thorough physical examination
examinations before and focusing on neurovascular status; then attempt to reduce the knee without
after a fracture reduction delay. This may require analgesia and conscious sedation.
attempt. 2. Further imaging may be helpful after initial assessment.
a. Addition of scans to plain radiographs can be very helpful and has been
shown to increase the interobserver agreement on fracture classification
diagnosed and change the operative treatment plan approximately 25%
of the time.
b. Approximately 50% to 90% of tibial plateau fractures have significant
associated ligamentous or meniscal injuries, for which magnetic reso-
nance imaging is the test of choice. The addition of magnetic resonance
imaging to radiographs and computed tomography has been shown to
result in a change in treatment in 19% to 23% of tibial plateau
fractures.
B. Evaluate the neurologic status of the extremity.
1. Assess the peroneal nerve by testing active dorsiflexion of the ankle and
dorsal first web space sensation.
2. Assess the tibial nerve by testing active plantarflexion of the ankle and
plantar foot sensation.
C. Examine the vascular status of the leg by palpating the dorsal pedis and poste-
rior tibial arteries.
1. If the pulse cannot be palpated, attempt Doppler localization.
2. If the pulse is weak to palpation, the ankle-brachial index can be determined
by dividing the systolic pressure at the ankle by the systolic pressure at the
arm. An ankle-brachial index below 0.9 is abnormal, and a vascular workup
should be initiated.
D. Evaluate soft tissues around the knee.
1. Determine if the fracture is open or closed.
2. If closed, assess the soft tissue status using the Tscherne classification.
3. If open, classify the injury using the Gustilo and Anderson classification.
4. Assess the compartments of the leg for firmness and pain with passive
plantar and dorsiflexion of the toes.
E. To stabilize the fracture and provide pain relief, place a posterior splint from
the proximal thigh to the plantar surface of the foot. The knee is bent slightly
because at full knee extension or flexion, the intracapsular volume is decreased.
Slight flexion allows the knee to better accommodate the hemarthrosis second-
ary to the intra-articular fracture.
TREATMENT PROTOCOLS
I. Goals of Treatment
A. Creation of stable restoration of mechanical axis and axial alignment
Restoration of the
B. Creation/maintenance of anatomic reduction of the articular surface mechanical alignment of
C. Allowing for soft-tissue healing the lower extremity is the
D. Prevention of post-traumatic arthritis most important
E. Creation/maintenance of knee stability component of treating
F. Prevention of knee stiffness tibial plateau fractures.
II. Nonoperative Treatment
A. Indications for nonoperative treatment include:
1. Nondisplaced or minimally displaced fractures without comminution
2. Stable fractures
3. Stable knees (intact ligamentous structures)
4. Patients with significant medical comorbidities
B. A successful outcome is dependent on restoration of the mechanical alignment,
knee stability, and early motion.
C. Non–weight bearing or partial weight bearing (depending on the fracture)
in a hinged knee brace for approximately 6 to 8 weeks with early range of
motion and progression to full weight bearing is a common treatment
algorithm.
D. Long leg casting is reserved for the patient that can tolerate non–weight
bearing in 30 degrees of flexion and would have a beneficial outcome.
Leg musculature atrophy and knee flexion contracture are potential side
effects.
E. Radiographs should be obtained after 1 week and at regular intervals to dem-
onstrate lack of displacement and progression of fracture healing.
III. Operative Treatment
A. Absolute indications for surgical treatment
1. Open fracture
Lower Extremity
2. Presence of compartment syndrome

3. Presence of concomitant vascular injury
B. Relative indications for surgical treatment
1. Intra-articular step-off (>2 mm)
2. Unstable fractures
3. Presence of ligamentous injury resulting in knee instability
C. Hardware
1. Screws. Large diameter (e.g., 7.3-mm) cannulated screws alone can be used
for simple split fractures that can be anatomically reduced in a closed
manner.
2. Screws and plates (unlocked and locked)
a. Open reduction is necessary for most type II and III fractures that require
surgical fixation.
b. Newer plate designs are low profile, anatomically contoured, and designed
to reduce soft tissue complications due to the tenuous soft tissue
envelope.
c. Superior screws are placed in a subchondral “raft” configuration.
d. In many systems, distal screws may be placed percutaneously, sometimes
utilizing a targeting guide.
3. Less invasive stabilization system (LISS): This particular locking plate was
designed for a less invasive surgical approach. The primary indication is
PIN OR WIRE PLACEMENT
type V and VI fractures with significant soft tissue injury. The plate is placed
14 MM BELOW THE ARTICULAR
through a proximal incision and slid distally under the anterior compart-
SURFACE MINIMIZES
PLACEMENT OF HARDWARE IN
ment muscles in order to minimize dissection through damaged soft tissue.
THE KNEE JOINT AND THE The distal screws are placed through stab incisions.
POTENTIAL FOR SEPTIC KNEE 4. External fixation
ARTHRITIS. ALSO, THE a. Half-pin, thin-wire, or hybrid (combination of half-pin and thin-wire)
TIBIOFIBULAR JOINT HAS BEEN external fixators have the advantages of limited soft tissue dissection,
SHOWN TO COMMUNICATE ability to treat comminution at the meta-diaphyseal region, and the
WITH THE KNEE JOINT, SO ability to correct malalignment. In addition, thin-wire fixation allows the
AVOIDING TRANSFIBULAR capture of small proximal fragments that cannot be captured by screw
WIRE PLACEMENT IS and plate fixation. The disadvantages of external fixation include the
RECOMMENDED.
possibility of pin-related infections and problems related to external
bulkiness of the construct.
b. External fixators that span the knee can be used temporarily to allow soft
tissue healing. In rare situations, definitive fixation can consist of span-
ning external fixators with limited internal fixation.
5. Combination of 2 and 4.
TREATMENT ALGORITHM
Tibial plateau fracture diagnosed with radiograph
Open fracture/compartment
Closed fracture
syndrome/vascular injury
Immediate irrigation and débridement/

Further imaging, as needed fasciotomy/vascular repair and ORIF or
(CT/MRI) external fixation if patient and soft-tissue
conditions allow
Nondisplaced/stable
Displaced/unstable fracture,
fracture, medically unstable
ligamentous injury
patient
Nonoperative Minimal soft- Severe soft-

treatment tissue injury tissue injury
Delay definitive surgery until soft-

Surgical treatment tissue condition allows, consider
temporary external fixation
GENERAL PRINCIPLES OF OPEN REDUCTION AND INTERNAL FIXATION OF

TIBIAL PLATEAU FRACTURES
I. Goals. The major goals of operative fixation of tibial plateau fractures are as
follows:
A. Creation of stable restoration of mechanical axis and axial alignment
B. Creation/maintenance of anatomic reduction of articular surface
C. Prevention of post-traumatic arthritis
D. Allowing for soft-tissue healing
II. Screw/Plate Configurations
A. Type I (lateral plateau split) fractures are typically treated with ORIF using a
lateral plate. Closed reduction may be attempted and if anatomical reduction
is achieved on fluoroscopy, percutaneous screws may be acceptable. The advan-
tage of ORIF is that an arthrotomy can be made through the incision, and the
joint surface can be visualized and anatomically reduced.
B. Type II (lateral plateau split and depression) and type III (lateral plateau
depression) fractures require reduction of the depressed surface and stabiliza-
tion, typically with a lateral plate.
C. Type IV (medial plateau) fractures typically require a medial plate due to the
large forces placed on the medial plateau and the high energy associated with
these fractures.
D. Type V (medial and lateral plateau) fractures can be treated with medial and
lateral plates. To limit soft tissue dissection, a single locking lateral plate can
be used to fix both medial and lateral plates if the surgeon believes that it will
provide enough stability to the medial fracture, but typically the medial plateau
fracture requires stronger fixation.
E. Type VI (medial and lateral plateau with dissociation between the metaphysis
and the diaphysis) fractures require articular reconstruction, fixation of the
articular segment to the tibial shaft using a single plate (in more stable, trans- What is your attending’s
verse fractures), double plates (in oblique fractures with increased shear forces preference for fixation
across them), external fixation (in higher energy, highly comminuted fractures based on the fracture
with significant soft-tissue injury), or a combination of plates and external pattern/classification?
fixation.

Anesthesia Considerations
General anesthesia is preferred; local blocks and spinal anesthesia are generally contrain-
dicated due to their ability to mask signs and symptoms of compartment syndrome
postoperatively.

I. The patient is placed supine on a radiolucent table.
II. A tourniquet can be placed as high as possible on the thigh, although this may not
be inflated when severe soft tissue injuries are present.
III. If autologous bone grafting is an option, drape out the ipsilateral iliac crest.
IV. The operative field should extend to the mid-thigh, allowing the placement of a
femoral distractor if needed, and distally enough to allow for tibial placement of
the femoral distractor or placement of distal screws in a long plate.
Lower Extremity
V. Several tightly folded sterile sheets taped together or a sterile radiolucent

triangle allow knee flexion to facilitate exposure and visualization of the articular
surface.
VI. Anteroposterior, lateral, and oblique fluoroscopic views should be easily obtain-
able with the fluoroscope machine coming in from the opposite side of the table
(Fig. 26-3).
Figure 26-3
The operating room setup is shown. Note that the
fluoroscope machine is coming in from the opposite
side, and the screen is placed inferiorly and will be
visible to the surgeon and assistant when the leg is
lowered on the table.
VII. The leg should be prepped and draped in standard fashion according to the prin-
ciples outlined in Chapter 1.
Closed Reduction versus Open Reduction

I. If the fracture appears to be amenable to percutaneous screw fixation, closed
REMEMBER THAT A TORN reduction may be attempted by either applying manual traction with varus or
MENISCUS THAT IS valgus force (for lateral or medial plateau fractures respectively), or by using a
INTERPOSED IN THE FRACTURE femoral distractor.
SITE MAY ACT AS A BLOCK TO
II. If adequate reduction is achieved, a fracture reduction clamp can be placed through
REDUCTION.
the skin to obtain compression across the fracture site.
III. The fracture can then be stabilized with several large lag screws with washers if
Washers are used to help warranted; often screws are placed just below the articular surface to provide
distribute the force of the support for the plateau.
implanted screw against
IV. If closed reduction does not result in adequate reduction and stabilization, ORIF
the cortex over a larger
should be performed.
surface area. Washers are
particularly helpful in
patients with osteoporotic Open Reduction and Internal Fixation
bone.
I. Lateral Plateau
A. Place the tightly folded sterile sheets or the sterile radiolucent triangle under
the knee to create enough flexion so that the iliotibial band is at or posterior
to the axis of knee rotation.
B. If a femoral distractor will be used, it should be applied at this time. The
proximal pin is placed superior to the lateral condyle of the femur and the distal
pin distally on the lateral aspect of the tibia. Mild distraction helps neutralize
valgus forces present in the lateral plateau.
C. A midline, lateral parapatellar, or hockey-stick incision is typically used. The
L-shaped hockey-stick incision allows a shorter incision when placing a lateral
plate.
D. The proximal portion of the hockey-stick incision is just distal and parallel to
Gerdy’s tubercle is the the joint line; the distal extent of the incision varies depending on the amount
insertion site of the of exposure needed, but runs lateral to the tibial tubercle in order to avoid
iliotibial band and the damage to the patellar ligament.
origin of the tibialis E. In the typical lateral plateau fracture, the plate is placed anterior and medial
anterior muscle. Gerdy’s to Gerdy’s tubercle (the insertion site of the iliotibial band on the lateral proxi-
tubercle is an important
mal tibia); therefore, the dissection should remain anterior and medial to the
landmark when fixing
tubercle. If greater lateral exposure is needed, the iliotibial band insertion can
lateral tibial plateau
fractures. be reflected off Gerdy’s tubercle in continuity with the fascia of the anterior
compartment of the tibia and subsequently repaired (Fig. 26-4).
F. The origin of the extensor muscles is released from the anterolateral aspect of
the proximal tibia to visualize the fracture and provide exposure for plate
placement.
G. The anterior horn of the lateral meniscus can be detached from the tibia to
improve articular visualization but must be repaired prior to closing. An inci-
Vastus medialis
muscle
Vastus lateralis
muscle Quadriceps femoris
tendon
Iliotibial tract
Tibial collateral
ligament
Fibular collateral
ligament
Semitendinosus
Patellar ligament
Gracilis
Sartorius
Figure 26-4
Fibrous membrane of the knee joint capsule. (From Drake RL, Vogl W, Mitchell AWM: Gray’s Anatomy for
Students. Philadelphia, Churchill Livingstone, 2005.)
sion is made through the meniscotibial ligament, making sure to leave a cuff
on the tibia. Holding sutures are passed through the meniscus and can be used
for maneuvering as well as repair. The bony joint surface can then be visualized
(Fig. 26-5).
H. In a split/depression fracture, the lateral fragment can often be hinged open,
exposing the depressed articular surface, allowing impaction and elevation of
the articular surface. Alternatively, in a depression fracture or if the anterior
split is minimally separated, a cortical window may be placed below the depres-
sion, allowing impaction and elevation of the depressed surface. The resulting
void is then filled with bone graft.
I. The lateral plateau fragment is reduced to the rest of the tibia with a large
reduction clamp.
J. The plate is placed directly against the anterolateral portion of the proximal
tibial and may be held in the optimal position temporarily with K-wires (see
Figure 26-5
The hockey-stick incision and the lateral plate. The
plate is held in place with K-wires over which screw
holes are drilled. Just superior to the plate, the
Lower Extremity
lateral meniscus is tagged with suture and elevated

with traction. The articular surface of the tibia is
then visualized.
Figure 26-6
Anteroposterior and lateral intraoperative radiographs after lateral plate fixation.
Fig. 26-5). The distal portion of the plate may be placed in a submuscular
manner prior to final positioning of the proximal portion of the plate.
K. Screws are aimed lateral to medial to secure the plate to the bone.
L. First the superior screws are placed parallel, just beneath the joint surface (in
what is called a “raft” configuration) to provide support to the joint surface.
The first screw can be a lag screw if compression across the fracture site is
desired. Subsequent raft screws may be locking screws to provide increased
stability.
M. Cortical screws are preferred when fixing the plate to the diaphyseal portion
of the tibia.
THE MEDIAL PLATEAU IS N. Fluoroscopic images are taken in the operating room to confirm adequate
CONCAVE COMPARED WITH reduction and proper screw and plate positioning prior to wound closure (Fig.
THE CONVEX LATERAL 26-6).
PLATEAU. IT IS IMPORTANT TO O. The extensor muscles are then placed over the plate, and the meniscal detach-
REMEMBER THIS AND AVOID ment, arthrotomy, and fascia are subsequently repaired in standard fashion. If
PENETRATING THE JOINT
the development of compartment syndrome is a concern, the fascia can be left
WHEN PLACING SUBCHONDRAL
unrepaired and the fasciotomy can be extended distally. A drain may also be
SCREWS FROM LATERAL TO
MEDIAL.
placed deep to the fascia to help remove any blood collection in the postopera-
tive period.
II. Medial Plateau (not required for this patient with only lateral plateau
involvement)
A. A medial plate is typically placed through a posteromedial approach because
the midline incision requires excessive retraction and soft tissue stripping. Also,
when using medial and lateral plates, separate incisions should not be placed
IN THE MEDIAL APPROACH,
DISSECTION AND RETRACTION too close to each other. Therefore the lateral parapatellar or hockey-stick inci-
REMAIN ANTERIOR TO THE sion is used because a midline incision would leave a narrow skin bridge
MEDIAL HEAD OF THE between the two incisions.
GASTROCNEMIUS TO AVOID B. The posteromedial incision is made from the medial epicondyle along the
INJURY TO THE medial collateral ligament to its insertion on the posterolateral border of the
NEUROVASCULAR BUNDLE, tibia (Fig. 26-7).
WHICH IS LOCATED C. The semimembranosus, gracilis, and sartorius tendons can be retracted distally.
POSTEROLATERAL TO THE The semitendinosus can either be retracted or released and tagged for repair.
MEDIAL HEAD. IN ADDITION, D. The medial head of the gastrocnemius is retracted posteriorly.
KNEE FLEXION RELAXES THIS
E. The joint surface can be viewed through an incision made in the capsule.
BUNDLE, MINIMIZING THE
F. The medial plateau fragment is reduced to the rest of the tibia with a large
CHANCE OF INJURY.
reduction clamp.
Adductor tubercle
Semimembranosus
Patellofemoral ligament
Posterior oblique
Anterior joint capsule

Semitendinosus
Superficial medial
collateral ligament
Sartorius (cut)
Gracilis
Figure 26-7
Medial aspect of the knee. (From Scott WN: Insall and Scott Surgery of the Knee, 4th ed. Philadelphia, Churchill
Livingstone, 2006.)
G. The plate is placed directly against the fracture fragment and may be held in What is your attending’s
the optimal position temporarily with K-wires and then screws are placed. preference regarding
H. The capsule and semimembranosus are repaired if released. surgical exposure for
I. The soft tissue and skin are then closed in layers in standard fashion. lateral and medial tibial
plateau fractures?
Wound Closure
Discuss with your
I. Once the fascia has been addressed, the wound is irrigated and closed in standard attending the concept of
fashion according the principles in Chapter 1. surgical exposure and
II. The wound is dressed in standard fashion and is secured with sterile Webril. potential difficulties for
III. Due to the risk of compartment syndrome, casting is avoided. Instead, a hinged implantation of a total
knee brace locked in extension, a knee immobilizer, or a posterior long leg splint knee replacement in the
is utilized to allow for proper compartment monitoring. future through the same
incision.
POSTOPERATIVE CARE
I. There is often a patient-controlled analgesia pump for pain control. Do not give
the patient a basal rate of analgesia from this pump to avoid masking increased
pain medication requirement resulting from a potential compartment syndrome.
II. Deep vein thrombosis and perioperative antibiotic prophylaxis should be
administered.
Lower Extremity
III. The knee should be protected in a hinged knee brace until there is evidence of
adequate healing.
IV. Continuous passive motion, to prevent the common complication of knee stiffness,
can be started on the first postoperative day and increased slowly as tolerated.
V. Physical therapy strengthening with protected or non–weight bearing should be
started as soon as pain is well controlled.
Figure 26-8
Postoperative AP radiograph.
VI. Progression of weight-bearing status depends on the fracture pattern, stability of

the fixation, and the degree of fracture healing.
VII. A postoperative AP radiograph is presented in Figure 26-8.
COMPLICATIONS
I. The most common complications that occur in nonoperative patients are those
related to immobilization: pneumonia, urinary tract infection, and deep vein
thrombosis. Also malunion, traumatic arthritis, and compartment syndrome can
occur in the nonoperative patient.
II. Surgical Complications
A. The complication rate for surgical treatment of tibial plateau fractures has been
reported to range from approximately 25% to 50%.
B. Knee stiffness. Decreased range of motion is the most common complication
and can be minimized or prevented with stable surgical treatment and early
range of motion.
C. Symptomatic hardware. The incidence of discomfort attributed to hardware
ranges from 10% to 50%. Hardware can be removed when union has occurred
and the soft tissue status allows, usually 1 year after surgery.
D. Infection. The most frequent severe complications are related to wound dehis-
cence and deep infection. This is why the initial evaluation of the soft tissue
injury is so important. Historically, deep infection following ORIF of the tibial
plateau averages about 25%; however, recent studies that use contemporary
ORIF techniques and minimize soft tissue trauma report no deep wound infec-
tions. The incidence of septic knee infections with the use of small wire fixators
is approximately 10%.
E. Compartment syndrome. This may occur following the treatment (open or
closed) of tibial plateau fractures. Morbidity can be minimized with careful
surveillance and rapid fasciotomies if indicated. Also, fasciotomies at the time
of ORIF can be performed if there is concern.
F. Knee arthritis. Many surgeons once assumed that post-traumatic osteoarthritis
was an inevitable consequence of severe tibial plateau fractures. However,
studies from Sweden (Lansinger, 1986) and Iowa (Weigel, 2002) suggest that
joint deterioration is not prevalent at long-term follow-up.
G. Nonunion. Reported rates of union are good, approaching 100% regardless of
surgical method used (ORIF vs. external fixation).
H. Malunion. Contemporary ORIF techniques have been reported to have a 5%

incidence of malunion compared with 20% in the literature older than 10 years.
Poor functional results have been correlated with greater than 10 degrees of
varus or valgus deformity.
I. Nerve injury. Peroneal nerve injury can occur during the injury or during
operative treatment. Careful dissection on the lateral side of the tibial and
careful placement of small wire fixators is warranted.
I. Deep vein thrombosis/pulmonary embolism. The incidence of deep vein
thrombosis after operative treatment of tibial plateau fractures is approximately
5% to 10%. Pulmonary embolus has been reported in 1% of patients.
SUGGESTED READINGS
Chan PS, Klimkiewicz JJ, Luchetti WT, Esterhai JL, et al: Impact of CT scan on treatment plan
and fracture classification of tibial plateau fractures. J Orthop Trauma 11:484–489, 1997.
Egol KA, Koval KJ: Fractures of the proximal tibia. In Bucholz RW, Heckman JD, Court-Brown
C (eds): Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia, Lippincott Williams
& Wilkins, 2006, pp 1999–2036.
Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five
open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am
58:453–458, 1976.
Holt MD, Williams LA, Dent CM: MRI in the management of tibial plateau fractures. Injury
26:595–599, 1995.
Hoppenfeld S, deBoer P: The knee. In Surgical Exposures in Orthopaedics. Philadelphia, Lippincott
Ip D: Trauma to the lower extremities. In Orthopedic Traumatology—A Resident’s Guide. Berlin,
Springer, 2006, pp 291–426.
Koval KJ, Helfet DL: Tibial plateau fractures: Evaluation and treatment. J Am Acad Orthop Surg
3:86–94, 1995.
Lansinger O, Bergman B, Korner L, Andersson GB: Tibial condylar fractures. A twenty-year follow-
up. J Bone Joint Surg Am 68:13–19, 1986.
Marsh JL, Hartsock L: Fractures of the tibial plateau. In Baumgaertner MR, Tornetta P (eds):
Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL, American Academy of Ortho-
paedic Surgeons, 2005, pp 419–430.
Stannard JP, Martin SL: Tibial plateau fractures. In Stannard JP, Schmidt AH, Kregor PJ (eds):
Surgical Treatment of Orthopaedic Trauma. New York, Thieme, 2007, pp 713–741.
Tscherne H, Oestern HJ: A new classification of soft-tissue damage in open and closed fractures.
Unfallheilkunde 85:111–115, 1982.
Weigel DP, Marsh JL: High-energy fractures of the tibial plateau. Knee function after longer
follow-up. J Bone Joint Surg Am 84-A:1541–1551, 2002.
Yacoubian SV, Nevins RT, Sallis JG: Impact of MRI on treatment plan and fracture classification
of tibial plateau fractures. J Orthop Trauma 16:632–637, 2002.
Lower Extremity
C H A P T E R
27
Intramedullary Nail Fixation of Tibial
Shaft Fractures
Albert O. Gee and Craig L. Israelite
Case Study
A 50-year-old male presents to the emergency department after tripping and falling down
the bottom two steps of his basement stairs. He does not recall the exact way in which he
fell but reports that his right foot got caught during the fall and he twisted his leg. He is
complaining of severe right lower leg pain and an inability to bear weight. He denies
hitting his head or any loss of consciousness. He reports that he is otherwise healthy with
no chronic medical problems. The patient has obvious bruising and mild swelling centered
on the midportion of the right leg down to the ankle. The skin is intact without any abra-
sions or lacerations. There is tenderness over the junction of the middle and distal one
third of the tibia with a noticeable deformity. The calf is soft to palpation, and there is
no pain with passive range of motion of the ankle or toes. The neurovascular examination
is within normal limits. The secondary survey reveals no other tender areas on palpation
and no other gross deformities. Initial radiographs are presented in Figure 27-1.
A B
Figure 27-1
Anteroposterior (A) and lateral (B) views of the tibia and fibula that show a spiral fracture of the distal one
third of the tibial shaft and fracture of the proximal portion of the fibula.
C H A P T E R 2 7 Intramedullary Nail Fixation of Tibial Shaft Fractures 315
BACKGROUND
I. Tibial shaft fractures are defined as fractures that occur 5 cm distal to the tibial
plateau and 5 cm proximal to the tibial plafond.
II. Tibial shaft fractures are the most common type of long bone fracture.
The incidence is about 26 tibial diaphyseal fractures per 100,000 people per
year.
III. These fractures are more common in males than in females, with an approximate
4 : 1 male-to-female ratio.
IV. The average age of a patient with a tibial fracture is 37 years. For males, the
approximate average age is 31 years, and for females, it is 54 years.
V. The mechanism of injury for tibial shaft fractures varies widely. Anything from
simple falls to severe crushing mechanisms can be responsible for this type of
fracture. It is important to distinguish between high-energy and low-energy mech-
anisms, because this has a direct relationship with the extent of the associated soft
tissue injury and method of acute treatment. High-energy mechanisms include
motor vehicle crashes and severe crush injuries. Lower energy mechanisms include
indirect injury patterns such as a twisting injury that results in a torsional force
and a spiral fracture pattern, as well as stress fractures that have an insidious onset
and usually occur from overuse (e.g., extensive running seen with military recruits).
Penetrating trauma from a gunshot injury can be divided into low-velocity (hand-
guns) versus high-velocity (shotguns, assault weapons) missiles, where the high-
velocity missiles can cause a significant amount of soft tissue disruption and bony
comminution.
VI. Tibial shaft fractures can be associated with other injuries. In as many as 30% of
cases, there is a concomitant injury elsewhere on the body. Commonly associated
orthopaedic injuries include:
A. Ipsilateral fibula fracture (occurs in as many as 80% of tibial shaft fractures)
B. Second-level injury to the distal or proximal metaphyseal region of the frac-
tured tibia (which may include intra-articular fractures)
C. Ligamentous injury to the knee, including possible knee fractures and/or
dislocations
D. Ipsilateral femur fractures, especially with high-energy trauma (the so-called
“floating knee” injury)
E. Ipsilateral foot and ankle injuries, which may be missed if not detected early,
because this area commonly is covered up with splinting material
F. Associated nerve and vessel injuries, which may be apparent at initial presenta-
tion or develop over the course of the patient’s hospitalization and subsequent
treatment
VII. There are many classification schemes that have been developed for tibial
shaft fractures. These include descriptive classifications such as open versus
closed injury, anatomic location of the fracture, and fracture configuration, as
well as more systematic classifications such as the Orthopaedic Trauma
Association (OTA) classification, the Tscherne classification of closed tibial shaft
fractures, which describes the soft tissues about a tibial fracture, and Gustilo and
Anderson classification of open fractures (see Chapter 26 for classification
details).
OPEN FRACTURES ARE

INITIAL TREATMENT
ORTHOPAEDIC EMERGENCIES
I. Treatment Considerations AND NEED TO BE ADDRESSED
IN THE OPERATING ROOM AS
Lower Extremity
A. If a high-energy mechanism of injury is likely, begin with the Advanced Trauma

Life Support (ATLS) protocol to systematically evaluate all associated injuries, SOON AS POSSIBLE.
especially those that are life or limb threatening. FRACTURES AS A RESULT OF
GUNSHOT WOUNDS ARE NOT
B. Assess the neurovascular status of the injured extremity.
CONSIDERED OPEN
C. Determine the fracture classification and severity of the fracture pattern.
FRACTURES.
D. Evaluate the condition of the soft tissue envelope surrounding the fracture.
II. Initial Approach. Emergency care of associated life-threatening and limb-

threatening injuries must be identified and addressed first and foremost.
A. Associated life-threatening injuries incurred secondary to high-energy trauma
must take precedence, and the patient must be stabilized prior to any definitive
management of the tibial fracture.
B. Arterial compromise, compartment syndrome, and open fractures represent
limb-threatening conditions that must be addressed emergently. Most often,
emergent surgical intervention is required.
1. Repair or bypass of injured vessels to restore circulation
2. Release of tight compartments (fasciotomies)
3. Thorough irrigation and débridement of open fractures
4. Below-knee amputations of the severely mangled extremity if there is no
realistic chance of limb salvage
C. If none of the above emergent conditions exist and the tibial fracture is an
isolated injury, the surgeon’s attention can be focused on definitive manage-
ment of the injury.
D. Clinical examination begins with a thorough history.
1. Location of pain
2. Absence of sensation in the injured extremity, which may be an indicator
of neurologic compromise
3. Timing of the injury
4. Mechanism of injury
5. Previous injuries and baseline preinjury level of function of the involved
extremity
6. Social history, which is important because smoking has been associated
with an increased frequency of wound-healing and fracture-healing
complications
E. Physical examination. Evaluate the affected extremity in terms of fracture loca-
tion, extent of injury to the soft tissues, neurovascular status, and associated
injury above and below the injury to the tibia.
F. Imaging. This consists of orthogonal radiographic views of the full length of
the injured tibia and fibula and should also include orthogonal views of both
the joint above and below the level of the injury (knee and ankle joints).
1. Radiographs of the contralateral extremity can be used for templating for
possible intramedullary (IM) nail length and diameter preoperatively.
2. Occasionally computed tomography (CT) and magnetic resonance imaging
(MRI) may provide additional information, especially if there is a concern
for an associated tibial plateau fracture (CT) or a high suspicion for an
occult stress fracture of the tibia (MRI).
TREATMENT PROTOCOLS
A. All nonemergent treatments of tibial shaft fractures should begin with provi-
sional reduction and splinting. This can be converted to functional casting,
which can serve as the definitive management of the fracture in cases of low-
energy nondisplaced fractures as long as satisfactory alignment is maintained.
1. Acceptable alignment includes:
a. Less than 1 cm shortening
b. Less than 5 degrees of varus or valgus angulation in the coronal plane
c. Less than 10 degrees of flexion or extension in the sagittal plane
d. No rotational malalignment. However, in general, external rotation is
better tolerated than internal rotation.
2. Weekly radiographs of the tibia are recommended to monitor maintenance
of alignment until consolidation of the fracture is evident.
B. If, however, unsatisfactory reduction is achieved, there is interval loss of reduc-
tion, or the fracture pattern is unstable, then surgical treatment is indicated.

A. Surgical treatment options include IM nailing, external fixation, and open
reduction with plate and screw fixation.
B. The most commonly performed surgical fixation for tibial shaft fractures is IM
nailing.
1. Indications include all tibial diaphyseal fractures unless they are too proxi-
mal or too distal on the shaft, and/or they extend to the level of either
articular surface. In these situations, the nail is unable to gain sufficient
contact with cortical bone within the larger diameter of the metaphysis,
which is crucial for fracture alignment and stabilization.
2. Other contraindications for IM nailing include a very narrow canal
(<6 cm diameter), patients with previous anatomical abnormalities of the
tibial shaft that would make the placement of a straight intramedullary
nail impossible, gross contamination of the intramedullary canal, and the IN THE EVENT OF AN ARTERIAL
presence of a total knee implant that prevents appropriate entry into the INJURY, IT IS IMPORTANT TO
tibia. OBTAIN TEMPORARY FIXATION
C. External fixation is usually reserved for fractures in which there is severe soft OF THE TIBIA FRACTURE WITH
tissue injury (e.g., Gustilo and Anderson grade III open fractures), where skel- AN EXTERNAL FIXATOR. THIS
etal fixation is maintained while the soft tissues are given the opportunity to AVOIDS MANIPULATION OF THE
heal. External fixation may be performed while soft tissue or vascular restora- EXTREMITY ONCE THE VESSEL
tion procedures are performed (e.g., flap coverage or vascular repairs) prior to HAS BEEN REPAIRED AND
conversion to more definitive internal fixation. This is also the treatment of THUS PREVENTS PLACEMENT
OF TENSION ACROSS THE
choice for unstable patients who cannot undergo a prolonged surgical proce-
REPAIR SITE.
dure for purposes of temporary fracture fixation.
D. Plate and screw fixation is usually reserved for proximal and distal tibial
fractures, which, as mentioned previously, are difficult to treat with an IM
nail.
TREATMENT ALGORITHM
Amputation
• Arterial injury
• Compartment syndrome
• Open fracture
Diagnose and treat limb-threatening injuries Specific surgical treatment
Provisional reduction and splinting

Fracture stabilization
Unstable, displaced fracture

IM nail
Stable, nondisplaced fracture
Nonoperative treatment: Cast or Operative

External fixator
functional bracing treatment
Loss of reduction
Lower Extremity
Open reduction and internal fixation:

Plate and screws
Adapted from Trafton PG: Tibial shaft fractures. In Browner B, Jupiter J, Levine A, Trafton P (eds): Skeletal
Trauma: Basic Science, Management, and Reconstruction, 3rd ed. Philadelphia, Saunders, 2003.
GENERAL PRINCIPLES OF INTRAMEDULLARY NAILING OF TIBIAL

SHAFT FRACTURES
I. The tibia is the larger of the two bones in the leg and is the predominant weight-
bearing bone. The fibula bears about 10% to 13% of weight in the leg, and it
distally makes up the lateral aspect of the ankle joint.
II. The successful treatment of tibia fractures requires conscientious management of
both the bony injury and the soft tissue envelope.
III. Almost all tibial shaft fractures can be treated using IM nailing techniques.
IV. The goal of IM nailing is to use the nail as an internal splinting device to restore
anatomic alignment of the tibia, paying attention to all three-dimensional planes
(coronal, sagittal, and axial). This construct involving the IM nail, and its inter-
locking screws, hold the tibia in normal alignment while the fracture is allowed
to heal.
V. The most common method for IM nailing of tibial shafts involves reaming of the
IM canal prior to nail insertion.
A. This allows placement of a larger diameter nail, which has increased stiffness
Would your attending
ream the intramedullary and decreased rate of hardware failure.
(IM) canal prior to IM B. There is some concern about reaming the IM canal as it decreases or damages
nail insertion in the case the endosteal blood supply to the tibia, although this has not been shown to
of an open tibial fracture? have a negative impact on the healing of the fracture. In fact, reamed nails have
been shown to have faster healing times when compared with unreamed
Intramedullary nailing is nails.
favored by most centers VI. Patients with tibial shaft fractures, especially those with high-energy trauma,
for the treatment of tibial must be monitored closely throughout their hospitalization for development
shaft fractures so that of compartment syndrome with regular neurovascular and compartment
patients can be examinations.
ambulatory soon after
operative fixation.
COMPONENTS OF THE PROCEDURE: ANTEGRADE INTRAMEDULLARY NAILING
OF A TIBIAL SHAFT FRACTURE
I. Usually general anesthesia or spinal anesthesia is appropriate, although spinal
anesthesia may result in residual nerve block, which can distort the neurologic
examination postoperatively. In patients who have experienced high-energy
trauma, spinal anesthesia may make it more difficult to detect an impending com-
partment syndrome.
II. The patient is placed in the supine position on a Jackson or radiolucent table.
III. An appropriately sized tourniquet is placed around the proximal thigh, and the
extremity is prepped and draped in standard fashion according to the principles
outlined in Chapter 1 (Figs. 27-2 and 27-3).
Figure 27-2
Operating room setup. The operative leg is
suspended using a Betadine-soaked gauze toes strap
from a candy cane prior to sterile prep of the leg.
Figure 27-3
Operating room setup. After prepping with an
appropriate antiseptic agent, the leg is draped using
sterile drapes. Note how the proximal thigh drapes
are additionally sealed off using Ioban adhesive to
ensure that the drapes do not move and contaminate
the sterile field. Also, note that the knee is flexed
over a radiolucent triangle which properly positions
the leg during intramedullary nailing.
Exposure and Entry Site Preparation

I. Place the knee flexed approximately 45 degrees on the radiolucent triangle (see
Fig. 27-3).
II. Use a sterile skin marker to mark out the incision, which is centered over the long
axis of the tibia and placed just medial to the patellar tendon. The length of the
incision should extend from approximately the midportion of the patella to the
level of tibial tubercle (Fig. 27-4).
III. The tourniquet is inflated in a standard manner prior to making the
incision.
IV. The incision is made with a 15-blade, and the soft tissues are dissected down with
sharp dissection or electrocautery to the level of the paratenon overlying the
patellar tendon. Some surgeons use a
V. The incision is taken down through the patellar tendon until tibial bone is felt at patellar tendon splitting
the distal extent of the incision. The proximal dissection should be taken down to approach to expose the
the level of the deep fascia to avoid violating the knee joint. The infrapatellar fat proximal starting point
pad is pushed posteriorly into the joint, and the patella tendon is usually retracted on the tibia. Which
method does your
laterally to allow exposure of the entry site on the anterosuperior aspect of the
attending prefer?
tibia.
VI. At this point, the guide pin is used to localize the starting point on the tibia. This
is done under fluoroscopic guidance. The ideal starting point is just medial to the
lateral tibial spine on the anteroposterior (AP) view and immediately anterior to
the articular surface of the tibial plateau on the lateral projection (Figs. 27-5 and
27-6).
Lower Extremity
Figure 27-4
Incision marked out over the proximal tibia and knee.
Notice how the tibial tubercle is marked out (dotted
half circle) and the incision starts at the level of the Figure 27-5
tubercle and extends proximally to midportion of the Finding the entry point with the guide pin under
patella. fluoroscopic guidance.
Figure 27-6
The entry portal for an intramedullary Lateral Medial
tibial nail. The optimal nail entry site on
the anteroposterior image is just medial
to the lateral tibial spine and, on the
lateral view, adjacent and anterior to the
B
articular surface. Tibial IM nail starting
point in the axial (A), AP (B), and lateral
(C) planes. (From Trafton PG: Tibial shaft
fractures. In Browner B, Jupiter J, Levine
A, Trafton P [eds]: Skeletal Trauma: Basic
Science, Management, and Reconstruction,
3rd ed. Philadelphia, Saunders, 2003.)
A
Anterior
C
VII. Once the optimal entry site is achieved, an entry reamer is placed over the guide
pin and is used to ream the proximal portion of the tibia to a depth of approxi-
mately 4 to 5 cm.
Fracture Reduction, Intramedullary Reaming, and Passing the Nail

IF THE TIBIAL CANAL IS I. After adequate reduction of the fracture, a ball-tip guidewire is advanced from the
REAMED WHILE THE
entry point across the fracture and down into the distal tibial metaphysis. The
TOURNIQUET IS INFLATED,
THERE IS AN INCREASED RISK
ball-tip wire should be perpendicular to the tibial plafond to ensure that the distal
OF BONE THERMAL NECROSIS. fragment is not is varus or valgus malalignment.
II. Be sure to deflate the tourniquet prior to reaming the canal. A preset time limit
of 15 or 20 minutes can be put on the machine to remind the surgical team to
take down the tourniquet.
III. Reaming of the canal is achieved over this guidewire using a series of cannulated
power reamers.
IV. The distal position of the ball-tip guidewire position can be checked using fluo-
roscopy. Then a measuring device, which is calibrated by the manufacturer to take
measurements off the guidewire, can be used to measure the length of the nail
that is appropriate. (If such a measuring tool is not available, then use an identical
ball-tip guidewire; calculate the length of the nail by subtracting the length of
exposed guidewire from the total length of the wire.)
Many surgeons release V. Reaming over the guidewire is started using a tissue protector sleeve to keep the
the tourniquet while reamer from damaging the soft tissues at the entry point. Manual reduction of the
reaming the fracture should be held when the reamer passes through the fracture site (Fig.
intramedullary canal. Ask 27-7).
your attending what his
VI. To prevent the reamer from becoming incarcerated in the canal, once the reamer
or her preference is and
why. is started, it should be maintained in the “on” position while within the IM canal.
Also, the reamer should never be placed in the reverse direction.
VII. Reaming should occur after reduction and proper alignment of the fracture.
An end-cutting reamer is first used to open the canal the length of the ball-tip
guidewire. This is followed with a set of side-cutting reamers to expand the IM
canal. The final reamer diameter is approximately 1.0 to 1.5 mm larger than the
final nail size. The approximate nail size can be determined by measuring the
diameter of the isthmus (narrowest point of the tibia) during preoperative
planning.
VIII. “Chatter” (contact of the reamer with the inner cortex of the tibial shaft) is heard
as the reamer size approaches the canal diameter. Do not ream greater than 2 to
4 mm beyond the diameter when chatter is first encountered.

A tissue protector sleeve is used to protect the skin The nail is placed over the guidewire and malleted
and underlying soft tissues while reaming the tibial down the tibial canal using the nail-inserting jig.
canal. This jig aids in proximal interlocking screw
placement once the nail has been fully advanced
down the tibia.
IX. Once reaming is complete, the appropriately sized nail is placed over the guide-
wire. The nail should be as long as possible without causing distraction at the
fracture site or sitting too proud at the level of the proximal tibia. Once the nail
is advanced as far down the shaft as possible using manual pressure, a mallet
can be used to advance the nail the remainder of the way (Fig. 27-8). If the
nail does not advance with each blow of the mallet, the nail should be backed
out; either the canal needs to be reamed further or a smaller diameter nail must
be used.
Interlocking Screw Placement and Wound Closure

I. Interlocking screws are used both proximally and distally through the nail to retain
alignment and rotational control of the fracture.
II. The proximal screws are easily placed through the jig that is used to insert the
nail, which has appropriately aligned insertion guides with corresponding holes in
the nail. The appropriately sized drill bit is used to drill both cortices of the
proximal tibia. The screw length can usually be obtained from the drill bit which
has a calibrated surface such that when the second cortex is penetrated, the number
on the drill bit gives the approximate screw length.
III. For the distal interlocking screws, the fluoroscope machine, in a lateral projection,
must be aligned exactly perpendicular to the IM nail within the tibia to produce
a perfect circular projection of the holes in the nail (this is referred to as perform-
ing “perfect circles”).
IV. Once this is achieved, an instrument such as a hemostat is used to target the holes
in the nail so that a skin incision can be made just above this on the skin (Fig. 27-
9). Next, the hemostat is used to bluntly dissect the soft tissues down to the tibial
bone where the screw will be inserted.
V. The appropriately sized drill bit on a power drill is placed into the incision and
placed against the bone. Again, the fluoroscope machine is used to ensure that the
tip of the drill is lined up with the hole in the nail, and then the tibia is drilled
bicortically and through the desired hole in the nail sitting within the tibial
canal.
Lower Extremity
VI. Once the second cortex is passed by the drill bit, a measuring guide, which is cali-
brated with the length of the drill bit, can be used to obtain the correct screw
length. The drill bit is left in place while the screw is loaded on a screwdriver to
obtain an idea of the trajectory in which the screw must be placed. When the
operator is ready, the drill bit is pulled, and the screw is placed down and tightened
appropriately.
A B
Figure 27-9
A, The circular finger hole on a hemostat is used as a radio-opaque targeting guide in conjunction with the
image intensifier to localize the incision on the skin over the distal tibia where the interlocking screws will be
placed (B).
WHEN TIGHTENING THE VII. This process is repeated for the second distal screw.
INTERLOCKING SCREWS, BE VIII. When all of the interlock screws are placed, check an AP and lateral projection at
CAREFUL NOT TO both the distal and proximal ends of the nail to ensure that the screws have been
OVERTIGHTEN THEM, placed into the nail properly.
ESPECIALLY IN OSTEOPOROTIC IX. The wounds are then closed using heavy nonabsorbable braided suture
BONE. IT IS POSSIBLE TO (e.g., 0-Vicryl) to bring the deep tissues together, especially in the incision made
ADVANCE THE SCREWS
over the anterior knee. Next the skin is closed using a smaller gauge nonabsorbable
BEYOND THE OUTER CORTEX
IN POOR-QUALITY BONE.
braided suture (e.g., 2-0 Vicryl ) placed into the subcutaneous dermal layer with
inverted, interrupted knots. The skin is then closed in standard fashion (Fig.
27-10).
X. Before leaving the operating room, the leg should be checked to ensure that there
is no rotational malalignment.
POSTOPERATIVE CARE
I. Pain control is achieved in the immediate postoperative period with intravenous
narcotics via a patient-controlled analgesic pump in patients who have the mental
capacity to control their own medication delivery.
II. Most surgeons place the patient’s leg in a posterior splint for the first several days
after surgery. Then depending on the extent of bony contact at the fracture site,
the patient may no longer need any external support or may need further stabiliza-
tion with a fracture brace or possibly a long leg cast.
Ask your attending what III. Perioperative antibiotics are given for the first 24 hours after surgery.
he or she uses for deep IV. Deep vein thrombosis prophylaxis is achieved using both chemical and mechanical
venous thrombosis modalities. These may include subcutaneous low-molecular-weight heparin injec-
prophylaxis after tibial tions, warfarin, or aspirin as well as sequential compression devices placed on both
nailing.
of the lower extremities.
Figure 27-10
Skin closure is usually achieved with skin staples
after the deep layers are closed with a Vicryl suture
using inverted subcutaneous knots.
V. Weight-bearing status depends on the extent of the bony contact at the fracture
site. If there is extensive comminution and little good bone to bone contact, the
patient must be made non–weight bearing on the operative extremity for 4 to
6 weeks until evidence of satisfactory healing is appreciated on follow-up
radiographs.
VI. Closely monitor the patient in the immediate postoperative and postinjury period
for an associated compartment syndrome.
COMPLICATIONS
I. Knee pain is the most common complication after tibial nail and is of unclear eti-
ology. Proposed causes of knee pain include prominence of the nail, heterotopic
ossification of the patellar tendon, and intra-articular damage to menisci during
nail placement.
II. Neurovascular injury can also be seen after IM nailing of the tibia.
A. Nerves that have been injured include peroneal, tibial, sural, and saphenous
nerves.
B. These nerve palsies often recover on their own.
III. Vascular Damage. In rare instances, there have been injuries to the popliteal
artery as well as the posterior tibial and peroneal arteries, which have been caused
during cross-screw placement proximally and distally.
IV. Hardware Failure
A. The nail and/or the screws can break after placement as they undergo weight
bearing.
B. The rate of breakage of the nail and screws is related to size, with larger nails
and screws being less susceptible to failure.
C. Broken nails are often associated with a tibial nonunion.
V. Malunion or Nonunion of the Tibia
A. Malunions can be seen with very proximal or distal fractures that have been
treated with IM nails.
B. Tibial shaft fractures can take from 12 to 20 weeks to heal. For delayed or poor
fracture healing, some surgeons dynamize the IM nail by taking out some of
the interlocking screws so that fracture site sees more compression with weight
bearing. Fibular osteotomy is another possibility for increased compression at
the tibial fracture site.
VI. Infection. The infection rate after tibial nail insertion is estimated at 0% to 5%
for closed fractures.
SUGGESTED READINGS
Court-Brown CM: Fractures of the tibia and fibula. In Bucholz RW, Heckman JD, Court-Brown
C, et al (eds): Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia, Lippincott
Higgins T, Templeman D: Fractures of the tibial diaphysis. In Baumgaertner MR, Tornetta P (eds):
Orthopaedic Knowledge Update: Trauma 3, 3rd ed. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2005, pp 431–440.
Trafton PG: Tibial shaft fractures. In Browner B, Jupiter J, Levine A, Trafton P (eds): Skeletal
Trauma: Basic Science, Management, and Reconstruction, 3rd ed. Philadelphia, Saunders,
2003.
Lower Extremity
S E C T I O N
VIII
FOOT AND ANKLE
CHAPTER 28 Open Reduction and Internal Fixation of Ankle Fractures 327
CHAPTER 29 External Fixation of Tibial Plafond (Pilon) Fractures 335
CHAPTER 30 Achilles Tendon Repair 344
CHAPTER 31 Hallux Valgus (Bunion) Correction 352
28
Foot and Ankle

C H A P T E R

Ankle Fractures
Derek Dombroski and Enyi Okereke
Case Study
A 53-year-old female trips going down the garage stairs on her way to work. She falls
approximately 4 feet and twists her right foot on impact. Unable to bear weight on her
right lower extremity, she is brought to the emergency department by ambulance. On
arrival at the hospital, she is initially evaluated by the emergency department staff and
radiographs are obtained. On examination, her right ankle is mildly swollen and she is
tender to palpation over both lateral and medial malleoli. The right lower extremity is
neurovascularly intact. Radiographs are presented in Figure 28-1.
BACKGROUND
I. Ankle fractures are common orthopaedic injuries that occur through rotational
mechanisms, whereas high energy axial loading results in fractures through the
distal tibia (pilon fracture; see Chapter 29).
II. Ankle injuries often require radiographs for evaluation. The Ottawa rules deter-
mine if a patient requires radiographs. The rules are based on pain near one of
the malleoli plus one of the following:
A. Age older than 55 years
B. Inability to bear weight
C. Bone tenderness at the posterior edge or tip of either malleoli
III. A thorough history and physical examination must be obtained. The history
should focus on the mechanism of injury and previous ankle injuries. Evaluate the An isolated medial
ankle for open wounds, gross deformity requiring prompt reduction, and neuro- malleolus fracture should
vascular status of the extremity. Patients who are victims of high-energy trauma raise the suspicion for a
require an evaluation following the Advanced Trauma Life Support (ATLS) pro- proximal fibula fracture,
tocol. Special attention must also be given to diagnosing associated injuries and which is known as a
fractures. Maisonneuve fracture.
IV. There are multiple classification systems to communicate the specific fracture
patterns and help determine treatment options. The Lauge-Hansen classification
system is based on reproducible fracture patterns in cadaveric studies. It is based
on the position of the foot when the injury force is applied (supination or prona-
tion) and the direction of the force (external rotation, abduction, or adduction). The most common
The Danis-Weber/AO classification system (Fig. 28-2) is based on the level of the mechanism of an ankle
fibula fracture in relation to the syndesmosis. Type A fractures are below the fracture is from forced
syndesmosis, type B fractures are at the syndesmosis, and type C fractures start external rotation with the
ankle held fixed in
above it. Additionally, involvement of the medial malleolus and position of the
supination (supination-
talus within the mortise is of the utmost importance. The AO classification is an external rotation).
expansion of the Danis-Weber system.
V. At a minimum, radiographs should include anteroposterior (AP), lateral, and
mortise views of the ankle as well as AP and lateral views of the tibia and fibula.
328 S E C T I O N V I I I Foot and Ankle
A B
Figure 28-1
Anteroposterior (A), lateral (B), and mortise (C)
views of the right ankle show a bimalleolar ankle
fracture with medial displacement of the talus and
C
widening of the syndesmosis.
C H A P T E R 2 8 Open Reduction and Internal Fixation of Ankle Fractures 329
Foot and Ankle

Figure 28-2
Type A Type B Danis-Weber classification based on
the level of the fibular fracture. (From
Canale ST [ed]: Campbell’s Operative
Orthopaedics, 10th ed. Philadelphia,
Mosby, 2003.)
Type C
A mortise view is an
Note the level of the fibula fracture (Weber), the symmetry of the mortise, the anteroposterior
radiograph of the ankle
medial clear space, and any syndesmotic widening.
with the foot in 15
VI. Evaluation of radiographs should focus on ankle instability. High-level fibula degrees of internal
fractures are typically associated with disruption of the syndesmosis, resulting in rotation.
instability.
A 1-mm lateral talar shift
NONOPERATIVE TREATMENT OF ANKLE FRACTURES in the mortise reduces
tibiotalar contact by more
I. Nonoperative treatment in cast immobilization is reserved for nondisplaced frac- than 40%.
tures around the ankle, which maintains stability of the ankle joint.
II. Conservative nonsurgical treatment may also be considered for patients who are Stress views (external
hemodynamically unstable or are not good surgical candidates secondary to their rotation of the foot while
comorbidities. taking an anteroposterior
III. General fixation principles for ankle fractures depend on ankle stability, which is ankle radiograph) of the
linked to the integrity of the deltoid ligament. A shift in the position of the talus ankle can uncover an
in the mortise is the most important sign of instability. Medial malleolar tender- unstable ankle fracture
ness is an indirect indication of mortise instability. that may otherwise
appear stable.
TREATMENT ALGORITHM
Ankle pain
Ottawa ankle rules fulfilled?
No Yes
Radiographs
No
with fracture?
WBAT,
Yes
early ROM
Stable Unstable Unstable

fracture Swelling No swelling
Splint until
swelling
Cast Open reduction
resolves
immobilization Internal fixation
(up to 3
weeks)
WBAT, weight bearing as tolerated.
SURGICAL INDICATIONS FOR ANKLE OPEN REDUCTION AND INTERNAL

FIXATION
I. Absolute surgical indications for the surgical treatment of ankle fractures
include:
A. Open fractures
B. Fracture dislocations
C. Bimalleolar fractures
D. Trimalleolar fractures
E. Disruption of the mortise (talar shift)
II. Relative indications include a deltoid ligament sprain or complete tear which is
supported by medial malleolus tenderness to palpation.
CONTRAINDICATIONS TO SURGERY
I. Polytrauma patients who are medically compromised should wait for medical sta-
bilization prior to operative treatment.
II. Significant ankle swelling that may compromise wound healing requires a period
of icing, elevation, and immobilization prior to fixation. Evidence of skin wrinkling
over the ankle usually indicates that the soft tissues will allow for surgical
intervention.
III. High-energy injuries may result in shearing at the dermal-epidermal junction,
causing fracture blisters to form. Surgical fixation should not be undertaken in the
setting of blisters. (See Chapter 29 for details regarding fracture blisters.)
IV. Any evidence of overlying infection such as cellulitis requires treatment before
surgery.
GENERAL PRINCIPLES OF ANKLE OPEN REDUCTION AND INTERNAL FIXATION

I. Fracture fixation focuses on anatomic reduction, stable fixation, and early range
of motion.
Foot and Ankle

II. When treating bimalleolar fractures, the lateral malleolus is typically addressed
first. Although there are many techniques to achieve fixation, a common approach
is to use interfragmentary lag screws and a one-third tubular plate. Once the fibula
is brought out to length, the medial malleolus is fixed next, and the syndesmosis
is fixed last, if necessary.
III. Once the distal fibula is stabilized with a lag screw, the fracture is considered
stable, but the addition of a plate adds rotational stability. Thus it is a neutraliza-
tion plate.
IV. It is necessary to pay attention to the bone stock on radiographs and be cognizant
of osteoporosis in elderly patients. Fractures through osteoporotic bone may Does your attending
require the use of a locking plate for adequate fixation. remove hardware? If so,
V. Syndesmotic screws can break when patients advance to full weight bearing. when?
The superficial peroneal

COMPONENTS OF THE PROCEDURE nerve is located 12 cm
proximal to the tibiotalar
joint and may be marked
for reference.
See Chapter 29 for patient positioning, prepping, and draping (Fig. 28-3).
Lateral Malleolus Exposure and Fixation

I. Make an incision midline over the distal fibula starting proximal to the fracture Extensile approaches are
and ending at the distal tip of the fibula. Initially, the incision should go through a rule for trauma cases.
the skin to the subcutaneous tissue.
II. Using the entire incision, continue the incision down to bone using sharp dissec-
tion. To avoid injury to the superficial peroneal nerve, dissect over the distal
fibula. Pulling traction on the
III. With the fracture exposed (Fig. 28-4), remove any hematoma or nonviable soft calcaneus and rotating
tissue from the fracture site. Any frayed periosteum around the fracture ends also the foot aids in the
needs to be débrided. reduction.
IV. Next, reduce the fracture and hold it with a tenaculum (Fig. 28-5).
V. Place a lag screw perpendicular to the fracture site. Overdrill the sliding hole Six cortices above and
(3.5-mm drill bit) and then drill the threaded hole (2.7- or 2.5-mm drill bit) for a below the fracture are
3.5-mm cortical screw. The fracture is now considered stable. adequate stabilization.
VI. To control rotation, place a one-third tubular plate along the lateral cortex Screws close to and far
away from the fracture
(Fig. 28-6).
are more biomechanically
VII. Depending on the obliquity of the fracture, a 7- to 10-hole plate may be used. stable.
Proximally, anticipate cortical screws with bicortical purchase (drill, depth gauge,
There are alternative

fixation strategies that
may be used for fibula
fractures such as locking
plates or posterior
antiglide plates. When
does your attending use
these options for fixation?
Figure 28-3
Ankle prepped and draped with landmarks identified,
including a 12-cm landmark for the superficial Figure 28-4
peroneal nerve. Distal fibula fracture exposed.
Figure 28-6
Lateral malleolus after plating. The lag screw is
Figure 28-5 visible on the anterior surface.
Fluoroscopy of a lateral malleolus fracture reduction
being held with a tenaculum.
screw placement). The distal most screws will be cancellous and unicortical so that
the joint is not violated.
THE SAPHENOUS VEIN AND
POSTERIOR TIBIAL TENDON
ARE LOCATED ANTERIOR AND Medial Malleolus Reduction
POSTERIOR TO THE MEDIAL
MALLEOLUS, RESPECTIVELY. I. Identify the bony landmark of the medial malleolus.
BE CAREFUL NOT TO INJURE II. Mark out an incision over the center of the medial malleolus in line with the tibia
THESE STRUCTURES DURING (Fig. 28-7).
THE SURGICAL EXPOSURE. III. Next, dissect down to bone using Metzenbaum scissors.
IV. The distal medial malleolar piece may be reflected allowing visualization of the
PERCUTANEOUS SCREW articular cartilage (Fig. 28-8).
PLACEMENT CAN LEAD TO V. Débride the fracture site of any hematoma or interposing soft tissue.
NEUROVASCULAR INJURY OR VI. Reduce the fracture with a tenaculum under direct visualization and fluoroscopy.
MALREDUCTION. A small drill hole can be placed proximal to the fracture site on the medial malleo-
lus to assist in using a tenaculum for fracture reduction.
Screws should ideally be VII. Drill the medial malleolus with a 2.5-mm drill bit perpendicular to the fracture.
placed perpendicular to For a single, large medial malleolus piece, two 4.0-mm cannulated cancellous
the fracture line. screws can be used. The first screw is a lag screw.
Figure 28-8
The medial malleolus in relation to the posterior
tibialis tendon, which can block reduction if
Figure 28-7 entrapped. (From Canale ST [ed]: Campbell’s
Medial malleolus drawn on skin with anticipated Operative Orthopaedics, 10th ed. Philadelphia, Mosby,
incision marked. 2003.)
Foot and Ankle

VIII. After placing the first screw (lag screw), place a second screw in parallel to control
rotation.
Syndesmotic Fixation
I. After fixation of the medial malleolus, test the interosseous ligament by pulling Usually, supination-
laterally on the fibula with a tenaculum and observing the medial clear space of external rotation injuries
the mortise under fluoroscopy. If there is widening of the medial clear space (a do not have a syndesmotic
positive Cotton test), the syndesmosis should be fixed. injury.
II. Syndesmosis stabilization is generally achieved with a 4.5-mm cannulated
screw.
III. Syndesmosis screws can be incorporated in the neutralization plate holes. When
not placed in the plate, the angle of the screw is between 25 and 30 degrees, aiming Does your attending use
posterolateral to anteromedial. one versus two screws or
IV. Ideally, these screws are 2.5 cm proximal to the plafond and parallel to the joint three versus four cortices
in the horizontal plane. for syndesmotic fixation?
Wound Closure and Splinting

I. Now thoroughly irrigate the wound prior to closure.
II. Use an absorbable suture (such as 2-0 braided, absorbable suture) to approximate
soft tissue over all of the hardware.
III. After a subcuticular layer of 2-0 braided, absorbable suture, the skin can then be
closed according to your attending’s preference—horizontal mattress sutures with
3-0 nylon, running subcutaneous absorbable sutures, or even staples. Be aware
that if an ankle is fixed acutely, then swelling should be anticipated when closing
(i.e., too tight a closure can lead to complications).
Place the posterior splint
IV. After closure, the wound is dressed in a standard fashion (see Chapter 1 for with the knee flexed to
details). relax the gastrocnemius
V. A posterior splint is placed for immobilization with the ankle in neutral muscles, making it easier
dorsiflexion. to keep the ankle in a
VI. The leg should be elevated postoperatively to minimize swelling. neutral position.

I. The initial postoperative period involves about 6 weeks of protected weight
bearing. Generally, the patient is switched from a splint to a short leg cast within
the first couple of days after surgery after swelling subsides. The first 4 weeks are
non–weight bearing. This status is then advanced for 2 to 4 weeks, with walking When does your
only. Finally, weight bearing proceeds as tolerated after 3 months. Full activity attending allow weight
bearing on the ankle?
may be resumed 6 months postoperatively.
II. If a syndesmotic screw was placed, often the patient is scheduled for an elective
removal of hardware before full activity is resumed. Thirty percent of
III. Postoperative protocols are more conservative (i.e., longer non–weight-bearing syndesmotic screws break
periods) in patients with comorbidities such as diabetes. with full weight bearing.
COMPLICATIONS
I. Stiffness
II. Arthritis
III. Malunion
IV. Nonunion
V. Nerve injury (superficial peroneal nerve)
VII. Infection
SUGGESTED READINGS
Baumgartner MR, Tornetta P, III: Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 2005.
Michelson JS: Ankle fractures resulting from rotational injuries. J Am Acad Orthop Surg 11:403–
412, 2003.
Wiss D: Masters Techniques in Orthopaedic Surgery: Fractures, 2nd ed. Philadelphia, Lippincott
Williams & Wilkins, 2006.
29
Foot and Ankle

C H A P T E R
External Fixation of Tibial Plafond

(Pilon) Fractures
Case Study
A 47-year-old male fell 20 feet from a ladder while roofing, landing directly on his right
lower leg. He noticed immediate pain, swelling, and a deformity of his right leg. He was
unable to bear weight and was directly transported to the emergency department for
evaluation. Examination of the leg reveals a deformity, significant swelling, and ecchymo-
sis along the anteromedial aspect of the extremity. There is no evidence of an open wound.
The lower extremity compartments are soft and compressible, and there is no pain with
passive stretch of the right foot. The neurovascular examination is within normal limits.
Anteroposterior (AP) and lateral radiographs of the right ankle are presented in Figure
29-1.
BACKGROUND
It is important to
I. Tibial plafond fractures (pilon) involve the weight-bearing portion of the distal differentiate these injuries
tibia, including both the articular surface and the distal tibial metaphysis. They from ankle fractures,
account for approximately 3% to 10% of all fractures of the tibia and less than which can also involve
1% of all lower extremity fractures. the articular surface of
II. Pilon fractures typically result from high-energy injuries, usually a fall from a the distal tibia (typically
height or a motor vehicle collision resulting in forced dorsiflexion. The mecha- the medial malleolus) but
nism of injury involves an axial loading injury in which the talus is compressed are primarily low-energy,
against the distal tibia (Box 29-1). rotational injuries.
Figure 29-1
Anteroposterior (A) and lateral
(B) radiographs of the right
leg. (Adapted with permission from
Müeller ME, Allgöwer M, Schneider
R, Willenegger H [eds]: Manual of
Internal Fixation: Techniques
Recommended by the AO-ASIF
Group, 3rd ed. New York, Springer-
Verlag, 1991, p 279.)

Box 29-1. Mechanism of Injury: Rotational versus Axial Loading Fractures

Axial Rotational
Rapid rate of load application Slow rate of load application
High energy Low energy
Proximal displacement of talus Translational displacement of talus
Severe soft tissue injury Minimal soft tissue injury
Minimal comminution
III. The defining characteristic of this injury is the additional involvement of the
supra-articular metaphyseal region, which demonstrates varying degrees of impac-
tion. Because they are severe, high-energy injuries, pilon fractures are frequently
open injuries with significant soft tissue compromise. Approximately 10% to 30%
are open injuries with degloving or maceration of the overlying soft tissue enve-
lope. As a result, treatment for these injuries has been historically difficult, with
significant complications such as nonunion, infection, wound complications, and
post-traumatic arthritis.
IV. Tibial plafond fractures are classified according to the Ruedi-Allgower classifica-
tion (Fig. 29-2).
Outcomes following pilon A. Type I fractures are nondisplaced, cleavage type fractures.
fractures are closely B. Type II fractures are displaced but demonstrate little comminution of the
correlated with the articular surface or adjacent metaphysis.
fracture type. C. Type III injuries are displaced with significant impaction of the metaphysis.
INITIAL TREATMENT
A. A detailed history needs to be obtained regarding the mechanism of injury in
order to assess the severity and also to differentiate it from a rotational injury.
The mechanism of injury can also point towards associated injuries that should
Figure 29-2
Ruedi-Allgower classification of tibial plafond fractures. (From Thordarson DB: Complications after treatment of
tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 8:253–265, 2000.)
C H A P T E R 2 9 External Fixation of Tibial Plafond (Pilon) Fractures 337
Foot and Ankle

Figure 29-3
Fracture blisters. Note the difference in appearance
between the clear-fluid (blue arrow) and the blood-
filled blister (red arrow). (From Browner B, Jupiter J,
Levine A, Trafton P [eds]: Skeletal Trauma: Basic
Science, Management, and Reconstruction, 3rd ed.
Figure 29-4
Computed tomography scans
demonstrating coronal and axial
imaging of tibial plafond fracture.
not be missed during the primary survey. Information such as the height of a BEWARE OF CONCOMITANT
fall or the speed of a vehicle during a motor vehicle crash is important in BUT LESS SEVERE INJURIES.
determining the energy transmitted to the patient during the event. ALWAYS PERFORM A
B. A thorough neurovascular examination, including presence or absence of the THOROUGH HISTORY AND
dorsalis pedis/posterior tibial pulses, sensation, motor function, open wounds, PHYSICAL EXAMINATION ON
swelling, blisters (location, size, and type), and bruising, needs to be performed ANY PATIENT WHO HAS
and documented. SUSTAINED A TRAUMATIC
C. Fracture blisters often develop in patients with tibial plafond injuries due to INJURY TO AVOID MISSING
ADDITIONAL INJURIES.
the energy of the injury. They represent separation of the dermal-epidermal
junction. They can be of two types: clear-fluid (serous) and blood-filled (hem-
FRACTURE BLISTERS SHOULD
orrhagic) blisters (Fig. 29-3). Clear-fluid blisters are less severe and re-epithe-
BE LEFT INTACT GIVEN THAT
lialize more quickly.
THEY ARE STERILE. THEY
II. Imaging SHOULD BE COVERED WITH A
A. Standard AP, lateral, and mortise radiographic views centered on the ankle NONADHERENT DRESSING. IF
joint should be obtained. THEY RUPTURE, THEY SHOULD
B. Full-length tibial films should also be obtained to determine the proximal BE UNROOFED AND COVERED
extent of the injury. WITH A NONADHERENT
C. Radiographic imaging of the knee and foot should also be obtained to rule out DRESSING.
any associated injuries.
D. Computed tomography scans can provide additional insight into the extent and It is important to obtain
pattern of tibial plafond injuries and guide surgical treatment (Fig. 29-4). axial, coronal, and sagittal
reconstruction images on
the computed
tomography scan of the
INDICATIONS AND CONTRAINDICATIONS FOR TREATING TIBIAL fracture to obtain a better
PLAFOND FRACTURES understanding of the
fracture pattern.
I. Given that tibial plafond fractures are generally high-energy injuries, significant
disability including limb deformity, arthritis, wound complications, gait abnor-
malities, and persistent pain can all ensue if these injuries are not treated in a
timely fashion.
II. Nearly all tibial plafond injuries need to be addressed surgically, unless the condi-
tion of the patient precludes surgical intervention (medical comorbidities, other
injuries).
III. In the rare instance of a nondisplaced fracture, a tibial plafond fracture could
potentially be treated nonoperatively.
I. Closed Reduction with Immobilization in Plaster
A. This is used primarily as a temporizing measure prior to surgical treatment.
B. All pilon fractures on initial evaluation and treatment should be reduced and
splinted if the tibiotalar articulation is malaligned. This helps reduce the initial
degree of swelling and also allows the soft tissue injuries to be addressed.
C. Closed treatment is recommended only for those patients with nondisplaced
fractures or for debilitated patients with fractures.
II. Traction
A. Traction is another nonoperative option that relies on ligamentotaxis (the
natural pull of the ligaments) to realign the fracture. However, it does not
address the articular comminution and displacement.
B. Traction requires the placement of a calcaneal pin and application of 15 to 20
pounds of longitudinal traction. Alternatively, a talar neck pin can be placed if
a concomitant calcaneal fracture is also present.
C. Traction is not recommended as definitive treatment unless the patient is a
poor surgical candidate.
TREATMENT ALGORITHM
Tibial plafond fracture
History/physical examination
Imaging (radiographs/CT scan)
Treatment
Surgical Nonsurgical
External fixation Splint immobilization/traction
Definitive fixation
COMPARTMENT SYNDROME IS
AN ORTHOPAEDIC EMERGENCY. GENERAL PRINCIPLES OF TIBIAL PLAFOND FRACTURE EXTERNAL FIXATION
DISCUSS WITH YOUR
ATTENDING THE BEST WAY TO I. Timing of Surgery
MONITOR AND DIAGNOSE A A. For open injuries, emergent treatment with thorough irrigation and débride-
PATIENT WITH AN IMPENDING ment of wound is required followed by initial fracture stabilization with exter-
COMPARTMENT SYNDROME
nal fixation.
AND THE REQUIRED
B. Whether the injury is open or closed, the patient must be closely monitored
TREATMENT.
for compartment syndrome, which results from increased pressure within the
Foot and Ankle

fascial compartments of the lower extremity. Monitoring in the immediate post-
operative period is required following surgical stabilization of the fracture.
C. Definitive treatment of tibial plafond fractures should be conducted once the
soft tissue envelope has recovered and will tolerate surgical intervention (e.g.,
healing of blisters and reduction of swelling). This typically occurs 1 to 2 weeks
following the injury. Furthermore, coverage of any exposed bone or soft tissue
through skin grafting or flaps should be conducted at the time of or prior to
definitive fixation.
II. Operative Principles
A. Classic principles of pilon fixation
1. Restoration of lateral column length by fibular fixation (using plate fixation
to bring the fibula out to length)
2. Anatomic reduction of the articular surface
3. Bone grafting of metaphyseal defects (if required)
4. Buttress plate medially to prevent varus collapse of the distal tibia
B. External fixation may be a temporizing measure used to allow for the soft tissue
envelope to be properly addressed. Many pilon fractures have been successfully
treated with external fixation as the definitive treatment, especially in the acute
setting. External fixation maintains length of the distal extremity, allows for
adequate reduction of the articular surface, and minimizes soft tissue manipula-
tion, which may lead to future wound complications.
COMPONENTS OF THE PROCEDURE How long does your

Positioning, Prepping, and Draping attending use antibiotic
prophylaxis for patients
I. Preoperative antibiotics are given prior to the start of the procedure. For open with open fractures?
injuries, patients should receive antibiotics as dictated by the severity of the open
injury along with tetanus prophylaxis.
II. Lay patient supine on the operating room table. A 3-L bag or rolled towels should
be placed under the ipsilateral hip to internally rotate the limb and facilitate expo-
sure of the lateral side of the leg (i.e., fibular fixation).
III. The limb is prepped and draped in standard fashion as outlined in Chapter 1 (Figs.
29-5 and 29-6). A lower extremity tourniquet is typically used for this case.
Management of Soft Tissue Injuries

I. Careful attention should be paid to the soft tissue envelope to avoid potential
wound complications and future infection.
Figure 29-5
Foot suspended for prepping.
Figure 29-6
Operative site sealed off by
extremity drape.
IF A WOUND CANNOT BE II. Gentle handling of the soft tissues, short tourniquet time, and careful débridement
CLOSED PRIMARILY OR of wounds should be performed.
WITHOUT A SIGNIFICANT III. Open wounds should be thoroughly irrigated and débrided.
DEGREE OF TENSION, IT
SHOULD BE LEFT OPEN AND
CLOSED AT A LATER TIME OR External Fixation
TREATED WITH A FREE FLAP.
I. Plate Fixation of the Fibula. The goal of this aspect of the procedure is restora-
IN GENERAL, SOFT TISSUE
tion of the lateral column length. This should be done at the time of the initial
DEFECTS ALONG THE DISTAL
THIRD OF THE TIBIA SHOULD
external fixation of the tibia.
BE TREATED WITH FREE-FLAP A. Make a posterolateral incision directly over the fibula but anterior to the pero-
COVERAGE. neal tendons; this is the best surgical approach.
B. Carry the dissection down to the level of the fibula, expose the fracture ends,
and débride any fracture hematoma.
PLACEMENT OF THE FIBULAR
C. Using a pointed reduction clamp, bring the fracture fragments into apposition
INCISION IS CRITICAL TO
AVOIDING POTENTIAL SOFT
and reduce the fracture.
TISSUE COMPROMISE IN THE D. Depending on the fracture pattern, place a lag screw to secure fixation of the
FUTURE WHEN PLANNING fracture fragments (fracture pattern must be oblique). However, transverse
DEFINITIVE FIXATION. IDEALLY, fibular fracture patterns also occur and are not amenable to lag screw fixation
A 7-CM SKIN BRIDGE SHOULD (Fig. 29-7).
BE PRESENT BETWEEN THE
FIBULAR AND TIBIAL
INCISIONS WHEN DEFINITIVE
FIXATION IS UNDERTAKEN.
BEWARE OF THE SUPERFICIAL

PERONEAL NERVE, BECAUSE
ITS COURSE BECOMES
SUPERFICIAL APPROXIMATELY
12 TO 15 CM PROXIMAL TO
THE ANKLE JOINT ON THE
LATERAL SIDE OF THE LOWER
LEG.
Figure 29-7
Lag screw fixation. (From Browner B, Jupiter J, Levine A, Trafton P [eds]: Skeletal Trauma: Basic Science,
Management, and Reconstruction, 3rd ed. Philadelphia, Saunders, 2003.)
Foot and Ankle

E. The implant of choice is typically a one-third tubular plate to serve as a but-
tress plate to maintain fibular length. Place three screws (3.5-mm cortical
screws) proximally and distally to secure fixation of the fibula. Alternatively,
use a 3.5-mm dynamic compression plate for higher diaphyseal fractures.
II. External Fixation of the Tibia
A. This is performed in the acute setting.
B. An ankle joint-spanning technique is most commonly used. This consists of a
distal calcaneal pin (placed from medial to lateral) and two half-pins placed in
the proximal tibia.
C. The joint-spanning external fixator allows for length and alignment to be main-
tained, while also allowing swelling to resolve and stabilizing injured soft tissues.
BE CAREFUL NOT TO PLUNGE
D. Tibial pin placement THROUGH THE POSTERIOR
1. Initial tibial pin placement should be just proximal to the zone of injury and CORTEX OF THE TIBIA WHILE
proximal to the zone of potential future plate placement. PLACING THE EXTERNAL
2. Pin placement should be at an approximate 30-degree angle to the antero- FIXATION PINS TO AVOID
posterior axis of the tibia, just off the medial crest of the tibia and perpen- INJURY TO THE
dicular to the plane of the anteromedial aspect of the tibia. NEUROVASCULAR BUNDLE.
3. Make a stab incision with a scalpel at the desired location. Use a hemostat
to bluntly dissect down to the tibia.
Does your attending
4. Place an appropriately sized drill bit and drill guide directly on the bone
prefer predrilling the
prior to drilling. Use fluoroscopy prior to drilling to confirm location. Once cortex or just using the
drilled, place an appropriately sized threaded half-pin Repeating this process, self-tapping external
place a second pin proximal to the first pin in a parallel fashion. Alterna- fixator pins for insertion?
tively, place a self-drilling, self-tapping pin. Secure each half-pin with bicor-
tical fixation.
PIN PLACEMENT IS FROM
E. Calcaneal pin placement MEDIAL TO LATERAL TO AVOID
1. Place a centrally threaded pin from medial to lateral parallel to the ankle INJURY TO THE
joint and perpendicular to the anatomic axis of the tibia. NEUROVASCULAR BUNDLE
2. Position it within the calcaneal tuberosity, where the bone is dense. Posi- POSTERIOR TO THE MEDIAL
tioning should also be posterior to the sagittal axis so that a dorsiflexion MALLEOLUS.
moment is created when the external fixation frame is constructed.
F. Frame construction
1. The first step is to connect bar-to-pin clamps to the tibial pins and to either
end of the calcaneal pin.
2. Next, connect a bar between the two clamps on the tibial side to give stabil-
ity to the tibial pins, which should be positioned approximately 3 cm above
the skin to accommodate swelling and allow skin care. This establishes the
tibial bar portion of the frame construct.
3. Attach two bar-to-bar clamps to the tibial bar.
4. Once this is complete, select two appropriately sized bars to span the length
from the calcaneus to the tibia and attach each of the bars to the bar-to-bar
clamps on the tibial bar and to the bar-to-pin clamp on either side of the
calcaneal pin (Fig. 29-8).
Pin-bar Bar-bar
clamp clamp
Figure 29-8
Pin-bar and bar-bar clamps.
Figure 29-9
Final external fixation frame construct.
5. Once the frame has been assembled, apply traction and reduction maneu-
vers as needed to properly align the fracture. The alignment should be
confirmed with fluoroscopy. All clamps should be tightened once the align-
ment is satisfactory (Fig. 29-9).
III. Definitive Surgical Fixation
A. Definitive surgical fixation should be performed once the soft tissue swelling
has sufficiently resolved. This is typically 7 to 14 days following the initial injury,
when skin wrinkling has reappeared, indicating a reduction in swelling.
B. Although definitive surgical fixation is beyond the scope of this chapter, it involves
the placement of a medial or anterolateral tibial plate to restore articular congru-
ity and to restore stability to the metaphyseal portion of the tibia (Fig. 29-10).
POSTOPERATIVE IMMOBILIZATION AND REHABILITATION

I. Immobilization and rehabilitation following tibial plafond injuries need to be
individualized to the specific injury, because the nature of the fracture pattern and
severity of the injury are variable.
Figure 29-10
Definitive fixation of a pilon fracture (open reduction and internal fixation) with a medial tibial plate and
fibular plate. The external fixator was left in place to provide additional stability.
Foot and Ankle

II. For external fixators, antibiotic coverage should be continued for 48 to 72 hours
following treatment. If the patient is undergoing several débridements, the patient
should be kept on antibiotic coverage until after the final operative procedure.
Cleansing of the pin sites can begin 48 hours after the external fixator is placed
using a 50 : 50 saline-hydrogen peroxide mixture. The patient is kept non–weight
bearing while the fixator is in place.
III. Most patients remain non–weight bearing for 6 to 8 weeks while fracture consoli-
dation is occurring. Range-of-motion exercises can begin once soft tissue swelling
has subsided, typically at 2 weeks.
IV. Fracture union generally occurs by 10 to 16 weeks, and once radiographic evidence
of fracture consolidation has been obtained, the patient can be progressed to full
weight bearing.
COMPLICATIONS OF TREATING TIBIAL PLAFOND FRACTURES

I. Complications of treating tibial plafond fractures include wound necrosis, mal-
union, nonunion, post-traumatic arthritis, gait abnormalities, stiffness, and persis-
tent pain.
II. Pin tract infections can occur from the external fixation frame.
III. Careful attention should be paid to the soft tissue envelope to avoid wound com-
plications and potential infection. Open wounds should be thoroughly irrigated
and débrided. Traumatized soft tissue and bony fragments should be handled
carefully to avoid these complications.
SUGGESTED READINGS
Bartlett CS III, Weiner LS: Fractures of the tibial pilon. In Browner B, Jupiter J, Levine A,
Trafton P (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed.
Philadelphia, Saunders, 2003, pp 2257–2306.
DiGiovanni CW, Benirschke SW, Hansen ST Jr.: Foot injuries. In Browner B, Jupiter J, Levine A,
Trafton P (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed.
Philadelphia, Saunders, 2003: pp 2375–2492.
Mazzocca AD, Caputo AE, Browner BD, et al: Principles of internal fixation. In Browner B, Jupiter
J, Levine A, Trafton P (eds): Skeletal Trauma: Basic Science, Management, and Reconstruc-
tion, 3rd ed. Philadelphia, Saunders, 2003: pp 195–249.
Surgical Approaches to Internal Fixation (CD-ROM). Memphis, TN, Smith and Nephew, Inc,
2006.
Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention management
strategies. J Am Acad Orthop Surg 8:253–265, 2000.
C H A P T E R
30
Achilles Tendon Repair
Case Study
A 45-year-old male presents to the emergency department with an acute episode of pain
and swelling in the region of his right calf. He is unable to ambulate on that leg. He states
that he was recently playing softball and while running to first base, he felt a “pop” in his
right calf. He describes the incident as if he were hit with the ball in his heel. On clinical
examination, there is a palpable defect in the Achilles tendon and a positive Thompson
test. A magnetic resonance imaging scan of the patient’s right leg is shown in Figure
30-1.
BACKGROUND
I. Acute Achilles tendon ruptures are a common athletic injury and most frequently
occur in men between 30 and 40 years of age. Achilles injuries commonly occur
in poorly conditioned athletes—“weekend warriors.”
II. Most patients describe a discrete incident of pushing off or landing on a plan-
tarflexed foot. They often also report a sensation of “popping” or of being hit by
Figure 30-1
Magnetic resonance imaging scan demonstrating a
midsubstance tear of the Achilles tendon (arrow).

C H A P T E R 3 0 Achilles Tendon Repair 345
Foot and Ankle

an object while trying to sprint, jump, or participate in activities requiring sudden
The Achilles tendon
acceleration. There is, however, usually no contact. receives a majority of its
III. Most Achilles tendon injuries occur in a hypovascular area (watershed area) blood supply from the
approximately 4 to 6 cm proximal to the calcaneal insertion site. Approximately anterior paratenon that
15% of patients report a prodromal episode of antecedent pain or stiffness that contains richly
reflects tendon degeneration prior to rupture. Tendon rupture is thought to be vascularized fatty tissue.
due to repetitive microtrauma from activity coupled with the hypovascularity of Disruption of this aspect
the watershed region. of the paratenon can lead
to a compromise of blood
supply to the tendon.
INITIAL TREATMENT
A. Acute Achilles ruptures can be diagnosed by performing a thorough history
and physical examination.
B. Most patients describe a singular incident of a misstep or push off leading to
an audible “pop” accompanied by acute pain, difficulty walking, and swelling
in the posterior heel region.
C. On physical examination, one should look for:
1. Presence of a palpable gap along the course of the Achilles tendon and pain
on palpation
2. Reduced plantar flexion strength
3. Swelling and ecchymosis in the posterior heel region
4. Inability to perform a heel rise on the affected side
D. The Thompson test is a classical physical examination test performed to diag-
nose Achilles ruptures (Fig. 30-2).
1. The patient should kneel on a chair or lie prone on an examination table
with the feet extended beyond the edge of the chair or table.
2. The examiner squeezes calf distal to area of maximal calf girth on the injured
and uninjured sides.
3. On the uninjured side, squeezing of the calf causes plantarflexion of the In approximately 20% to
foot. On the injured size, plantarflexion is absent (positive Thompson 25% of cases of Achilles
sign). tendon ruptures, the
E. Although uncommon, one must be wary of a partial rupture that can obscure initial diagnosis is missed.
physical examination findings. In addition, a palpable gap may not be present In this scenario, the
following an acute event since the defect is occupied by a hematoma. The clinician should obtain
Thompson test can result in a false-positive finding if accessory ankle plantar imaging studies to clarify
flexors (posterior tibial and flexor digitorum longus muscles) are squeezed the diagnosis.
A B
Figure 30-2
Technique of Thompson test to diagnose a ruptured Achilles tendon. A, Patient kneels on chair, and
gastrocnemius-soleus muscle complex is grasped with the hand. B, With intact muscle-tendon unit, the ankle
will plantar flex. With ruptured Achilles tendon, the foot typically will not plantar flex (positive Thompson
sign). (From Coughlin M, Mann R [eds]: Surgery of the Foot and Ankle, 7th ed. Philadelphia, Mosby, 1999.)
Kager’s
triangle
Figure 30-3
Kager’s triangle. A, In a normal lateral radiograph,
Kager’s triangle is formed in an area posterior to the
lateral malleolus. The borders are the anterior aspect of A
the Achilles tendon, the posterosuperior aspect of the
calcaneus, and deep flexors of the foot. B, After rupture,
sharp definition of triangle is obliterated. (From
Coughlin M, Mann R [eds]: Surgery of the Foot and
Ankle, 7th ed. Philadelphia, Mosby, 1999.)
along with the gastrocnemius/soleus complex. Plantar flexion strength also may
not be significantly impaired due to recruitment of other plantar flexors (pos-
terior tibial and flexor digitorum longus muscles).
II. Imaging
A. Radiographs can reveal calcifications within the Achilles that reflect antecedent
tendinopathy and loss of Kager’s triangle (Fig. 30-3).
B. Sonography is a useful and inexpensive test in the acute setting as it can
determine the size of the tendon defect following rupture. However, it is
operator-dependent.
C. Magnetic resonance imaging is an expensive test but is superior in its ability
to detect partial tendon injuries and preexisting tendinopathy (see Fig. 30-1).
I. Nonoperative treatment is primarily reserved for older, sedentary individuals with
significant comorbidities and poor skin integrity.
II. Proponents of nonoperative treatment emphasize the risk of wound necrosis,
infection, and nerve injury with surgical repair.
III. The mainstay of nonoperative treatment is immobilization.
A. Initial nonoperative treatment consists of a posterior splint for 2 weeks to allow
hematoma consolidation.
B. Continued immobilization can then be maintained in a removable boot with
an elevated heel or in a short-leg cast for 6 to 8 weeks (Fig. 30-4).
C. Patients are graduated to gentle range-of-motion exercises, with progressive
resistance exercises started at 8 to 10 weeks, with a return to running activities
by 4 to 6 months.
D. Patients should be informed that with nonoperative treatment, maximal plan-
tarflexion strength could take approximately 1 year and that residual weakness
will likely persist.
Foot and Ankle

A B
Figure 30-4
Technique of casting for nonsurgical treatment of Achilles tendon rupture. A, With the patient sitting, the
foot is placed in gravity equinus. B, Below-knee or above-knee casts are placed with the foot in gravity
equinus. (From Coughlin M, Mann R: Surgery of the Foot and Ankle, 7th ed. Philadelphia, Mosby, 1999.)
IV. Ultrasonography may be obtained initially to confirm tendon apposition at 20

degrees of plantarflexion. If a diastasis remains when the foot is 20 degrees plan-
tarflexed, then surgery is indicated (Fig. 30-5). Surgical indications and contrain-
dications for Achilles tendon repair include:
ABSOLUTE INDICATIONS CONTRAINDICATIONS

Acute rupture Older age
Probable rupture Inactivity
Large partial rupture Poor health
Rerupture Poor skin integrity
Systemic disease
From Coughlin M, Mann R (eds): Surgery of the Foot and Ankle, 7th ed. Philadelphia, Mosby, 1999.
A B
Figure 30-5
Tendon apposition may be confirmed with ultrasonography. A, Diastasis (arrows) present with foot in neutral
position. B, Tendon ends apposed with foot in 20 degrees of plantarflexion (arrowheads). (From Saltzman CL,
Tearse DS: Achilles tendon injuries. J Am Acad Orthop Surg 6:316–325, 1998. Courtesy of Hajo Thermann, MD,
Hannover, Germany.)
TREATMENT ALGORITHM
Achilles tendon injury
History/physical examination
Imaging
Treatment
Surgical Nonsurgical
Primary Achilles repair Immobilization for

6–8 weeks, then
graduated ROM
exercises
GENERAL PRINCIPLES OF ACHILLES TENDON REPAIR

I. Supporters of surgical repair indicate that, compared with nonoperative treatment,
there is a lower rerupture rate (2% vs. 18%), improved strength, and a higher rate
of return to athletic activity.
The opposite leg can be II. Early, gradual return to activity can be achieved following surgical repair without
draped out to measure increasing the risk of rerupture.
the resting III. The main goal of surgical treatment is restoration of length and tension to the
gastrocnemius-soleus Achilles tendon by approximating the tendon ends.
complex length, because
the goal of surgery is to
restore the resting length
of the Achilles tendon. COMPONENTS OF THE PROCEDURE
Does your attending
I. Place the patient in the prone position on the operating room table. A 3-L saline
drape out the uninjured
leg as a comparison? bag could be placed under the contralateral hip to externally rotate the affected
Does he or she use a extremity and facilitate exposure of the Achilles tendon. Alternately, the patient
medial or lateral can be placed in the supine position.
surgical approach to II. The operative limb is prepped and draped in standard fashion and a tourniquet is
the tendon? applied to the proximal thigh (Fig. 30-6). (See Chapter 1 for details.)
III. A size 9 sterile glove is typically placed over the toes and the heel of the operative
limb. Ioban, Betadine-impregnated adhesive, is used to seal off the glove/foot from
MEDIAL LONGITUDINAL
INCISIONS ARE GENERALLY the operative site.
PREFERRED TO EXPOSE THE IV. A marking pen is used to mark out a paramedian incision spanning the region of
ACHILLES TENDON TO AVOID the tendon rupture.
INJURY TO THE SURAL NERVE,
WHICH COURSES ALONG THE
LATERAL ASPECT OF THE
Exposure and Débridement of Tendon Ends
TENDON. THE SURAL NERVE I. Make a paramedian incision approximately 10 cm long medial to the Achilles
CROSSES THE LATERAL tendon (approximately 5 mm to 1 cm medial to the medial border of the Achilles
BORDER OF THE ACHILLES tendon).
TENDON APPROXIMATELY
II. Develop full-thickness medial and lateral flaps to the level of the paratenon of the
10 CM PROXIMAL TO THE
Achilles. Do not make the flaps superficial to the paratenon to avoid undermining
CALCANEUS.
the blood supply to the skin flaps.
Foot and Ankle

Intraoperative prone positioning with the operative Exposure of the ruptured tendon ends.
leg sealed with an impervious U-drape.
III. Deepen the incision directly down to the paratenon and longitudinally incise the
paratenon to expose the ruptured tendon ends (Fig. 30-7).
IV. Plantarflex the ankle to expose and approximate the tendon ends. Remove the
hematoma and débride the tendon ends as needed.
Surgical Repair of Achilles Tendon

I. Use a nonabsorbable suture such as a number 2 Ticron (U.S. Surgical, Norwalk,
Connecticut) and place a Krackow stitch (running, locking stitch; Fig. 30-8) in
each tendon end. (Note: the top loop of the stitch goes through the midsubstance
of tendon and not on top of the tendon; Fig. 30-9.)
II. Tie the ends of the nonabsorbable suture to the corresponding ends of the other
tendon fragment, ensuring that knots are anterior to the tendon so they do not
eventually abrade the skin.
III. Augment the repair at the point of actual tendon apposition using a running or
interrupted absorbable suture, such as a 2-0 Vicryl suture.
IV. Close the paratenon with absorbable suture, such as a 2-0 Vicryl, using a running The technique of tendon
or interrupted stitch (Fig. 30-10). repair (suture type and
method) as well as the
closure are attending
Wound Closure dependent. What is your
I. Close the wound in standard fashion. attending’s preferred
II. Place a nonadhesive dressing on the wound with overlying gauze or ABD pads repair method and
(see Chapter 1). closure?
POSTOPERATIVE IMMOBILIZATION AND REHABILITATION

I. The leg is placed in a posterior splint in slight plantar flexion to relieve tension
on the repair.
Figure 30-8
Placement of Krackow stitch in proximal and distal
ends of Achilles tendon.
A B C
Figure 30-9
A and B, Modified Bunnell or box-type suture technique may be used to approximate the ruptured Achilles
tendon. This technique brings the tendon into apposition, but tendon repair does not have significant
strength. C, Krackow technique of double-lock suture to repair the ruptured Achilles tendon. (From Coughlin
M, Mann R [eds]: Surgery of the Foot and Ankle, 7th ed., Philadelphia, Mosby, 1999.)
II. At the first postoperative visit, usually 7 to 10 days after surgery, place the patient
in a removable boot.
III. The patient should be allowed to bear weight as tolerated starting at this first
As with the repair itself, postoperative visit as long as the wound is dry.
postoperative protocol is IV. Physical therapy is started after the first postoperative visit with instructions to
attending dependent. begin progressive strengthening and stretching exercises.
Some prefer to use a cast V. The time required to achieve maximum dorsiflexion symmetric to the normal side
in the early postoperative is usually 2.5 to 3 months.
period. Be sure to ask VI. The removable boot is discontinued at 2.5 to 3 months and is replaced by a heel
your attending his or her
lift in a pair of sneakers or a shoe.
preferred postoperative
VII. Return to sporting activity is variable and is dependent on the strength of the
rehabilitation protocol.
repair and postoperative recovery. This may take as long as 9 to 12 months.
COMPLICATIONS OF ACHILLES TENDON REPAIR

I. Complications of Achilles tendon repair are primarily related to the subcutaneous
nature of the Achilles tendon. Wound dehiscence or wound necrosis is the most
common complication related to surgical treatment. Meticulous handling of the
soft tissues is essential to avoid this problem. It is also necessary to make full-thick-
ness medial and lateral flaps to avoid compromising blood supply to the skin
flaps.
Figure 30-10
Final Achilles repair.
Foot and Ankle

II. Additional complications include residual plantarflexion weakness, stiffness, rerup-
ture (lower rerupture rate with operative treatment), and nerve damage. It is
important to counsel patients undergoing either operative or nonoperative treat-
ment about the risks and complications of each treatment so that they can make
educated decisions regarding their care.
SUGGESTED READINGS
Coughlin MJ: Disorders of tendons. In Coughlin MJ, Mann RA (eds): Surgery of the Foot and
Ankle, 7th ed. Philadelphia, Mosby, 1999, pp 786–861.
Maffulli N: Rupture of the Achilles tendon. J Bone Joint Surg Am 81:1019–1036, 1999.
McGarvey WC: Achilles tendon injuries: Acute and chronic. In Richardson EG (ed): Orthopaedic
Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic
Surgeons, 2004, pp 91–102.
Saltzman CL, Tearse DS: Achilles tendon injuries. J Am Acad Orthop Surg 6:316–325, 1998.
C H A P T E R
31
Hallux Valgus (Bunion) Correction
David I. Pedowitz and Keith L. Wapner
Case Study
A 42-year-old female with a 4-year history of worsening medial-sided left great toe pain
presents to the clinic. She states that she used to wear 3- to 4-inch heels daily but began
to wear lower heels and flats a year ago due to discomfort. She is a partner in a large
consulting corporation and particularly has symptoms in her work shoes and also while
playing tennis; sandals do not cause a problem. She tried an over-the-counter “bunion
strap,” but this did not fit into her shoes. On physical examination, she has a deformity,
which could be corrected to neutral. There is moderate pain over the prominent medial
eminence and a normally constituting arch on standing. She is interested in having the
problem surgically corrected. Her initial weight-bearing anteroposterior (AP) radiograph
is presented in Figure 31-1.
Figure 31-1
Anteroposterior weight-bearing radiograph of the
left foot demonstrating a severe great toe deformity
and medial prominence.

C H A P T E R 3 1 Hallux Valgus (Bunion) Correction 353
Foot and Ankle

BACKGROUND
I. The term bunion commonly refers to a prominence on the medial side of the
metatarsophalangeal joint (MTPJ) of the great toe that becomes irritated, painful,
and symptomatic; it is not a specific anatomic structure. The term serves to
describe a bony or soft tissue prominence, which can be from the accumulation
of dense, irritated bursal and fibrous tissue around the joint.
II. Bunion should not be confused with the term hallux valgus. When a structure
is in “valgus” it is meant to be pointing away from the midline. Hallux valgus
is a lateral deviation of the great toe (great toe points toward the lesser toes—
away from the center of the body) at the MTPJ. A medial prominence and
hallux valgus often coexist, but a bunion refers only to the medial prominence. Understand that there is
On the other hand, hallux valgus is a structural abnormality of the bones and joints a difference between the
of the first ray with a complex etiology that has numerous biomechanical terms bunion and hallux
implications. valgus.
III. Hallux valgus may result from a multitude of causes, which are divided into
extrinsic and intrinsic etiologies. The principal extrinsic cause of hallux valgus is
related to shoe wear. The incidence of hallux valgus has been shown to be higher
in shoe-wearing societies than in those that do not wear shoes. Women’s shoe
wear is often implicated as the cause of the high prevalence of this deformity in
females. In general, the outline of a man’s foot is comparable to the outline of his
shoes. Women’s shoes, however, do not conform to the outer dimensions of the
foot, and are generally much narrower than the forefoot, resulting in compression
of the entire forefoot in the end of the shoe. In addition, as the height of the heel
rises, force impacting the great toe into a narrow shoe increases exponentially, review the intrinsic causes
leading to lateral deviation of the great toe. for hallux valgus. A
IV. Hypermobility of the first ray at the metatarsal cuneiform joint, metatarsus primus simplified version of the
varus (first metatarsal angled toward the midline), and abnormal metatarsal length pathomechanics of the
are intrinsic causes of hallux valgus formation. Hyperpronation and/or relatively hallux valgus deformity
tight Achilles tendon leads to pronation of the first ray, causing stress on the would be useful in
medial aspect of the toe during normal gait. understanding the
V. Deformity Biomechanics surgical treatment.
A. With valgus deviation of the great toe, the pull of the adductor hallucis muscle
(originating laterally in the forefoot—to insert on the lateral proximal phalanx) The adductor hallucis
and flexor hallucis longus tendons causes lateral deviation of the base of the muscle originates on the
proximal phalanx on the metatarsal head, which pushes the first metatarsal into lateral aspect of the
greater varus (toward the midline) (Fig. 31-2). forefoot and inserts on
B. The medial capsule becomes lax, and the lateral structures around the joint the lateral aspect of the
become contracted. The transverse metatarsal ligament anchors the sesamoids proximal phalanx.
(small bones at the level of the first MTPJ located within the flexor hallucis
brevis tendons) to the second metatarsal, thus the sesamoids stay in place while
the head of the first metatarsal moves medially, flattening the normal ridge
between the two bones known as the crista.
C. The result is mechanical derangement of the first MTPJ, including a
prominent medial eminence, lateral subluxation of the base of the proximal
phalanx, dissociation of the first metatarsal sesamoid complex, pronation of
the hallux, and an increased angle between the first and second metatarsals
(Fig. 31-3).
CLINICAL AND RADIOGRAPHIC EVALUATION Patients who have

continued first
I. The patient with a bunion complains of swelling redness and pain on the metatarsophalangeal joint
inner aspect of the foot at the level of the MTPJ. Pain is more pronounced (MTPJ) pain with shoe
when wearing shoes and diminishes when barefoot (if pain does not diminish removal should be
out of shoe wear, one should be suspicious of arthritis at the first MTPJ, known suspected to have first
as hallux rigidus). Patients complain that they have difficulty finding a good fit in MTPJ arthritis or hallux
rigidus.
shoes.
Extensor
hallucis
longus
tendon
Head width
stays normal
Adductor hallucis Flexor hallucis brevis

Figure 31-2
Demonstrates normal and valgus deviation of great toe with deforming forces. (From Coughlin MJ, Mann RA,
Saltzman CL: Surgery of the Foot and Ankle, 8th ed. Philadelphia, Mosby, 2007.)
II. Physical examination of a patient with hallux valgus still requires a thorough foot
and ankle examination, including observation of gait to assess for other structural
abnormalities. During physical examination, careful attention is paid to range of
motion of the first MTPJ, signs of arthritis, and whether the deformity is passively
correctable.
III. Careful attention should be paid to the character of the bunion (soft tissue or
Weight-bearing bony) as well as any prominent calluses, skin ulcers, or vascular changes in the
radiographs in the hallux.
evaluation of hallux
IV. Radiographs include weight-bearing AP and lateral views. It should be noted that
valgus are essential to
weight-bearing views are essential. Hallux valgus has a dynamic component to it
reveal the dynamic nature
of the deformity. such that a severe deformity may appear mild to moderate without weight
bearing.
V. The first objective of radiographic evaluation is assessing the congruity of the joint
and whether there are degenerative (arthritic) changes, because this will govern
surgical treatment.
Interphalangeal
angle
Hallux valgus
angle
Distal
metatarsal
articular
Figure 31-3 angulation
Commonly measured angles for hallux valgus
Intermetatarsal
deformity. (From Pedowitz W: Bunion deformity. In
angle
Pfeffer G, Frey C [eds]: Current Practice in Foot and Ankle
Surgery. New York, McGraw Hill, 1993.) 50% 75%
M L
Sesamoid
Angles of deformity subluxation
Foot and Ankle

Example of a congruent joint. Example of an incongruent joint.
A. A congruent joint is one in which the articular surfaces of the metatarsal head
and the proximal phalanx match up (Fig. 31-4).
B. An incongruent joint is one in which the articular surfaces do not perfectly
overlie each other (Fig. 31-5).
C. Hallux rigidus can be assessed by looking for osteophyte formation, joint space
narrowing, subchondral sclerosis, and subchondral cyst formation at the first
MTPJ.
VI. After congruence and degenerative changes have been assessed, numerous angles
should be noted on the AP radiograph (see Fig. 31-3). Standard measurements
include the following four angles:
A. One–two (1–2) intermetatarsal angle
1. Angle between first and second metatarsals
2. Should be less than 9 degrees
B. Hallux valgus angle
1. Angle between axis of first metatarsal and proximal phalanx
C. Distal metatarsal articular angle
1. Angle between shaft of metatarsal and a line drawn between the medial and
lateral extents of the articular surface of the first MTPJ
D. Interphalangeal angle (degree of hallux valgus interphalangeus)
1. Angle between shaft of the proximal phalanx and distal phalanx BE SURE TO ENSURE THAT
2. Should be less than 10 degrees PATIENTS HAVE TRIED
CONSERVATIVE MEASURES.
ONCE THESE HAVE FAILED,
TREATMENT PROTOCOLS PATIENTS’ EXPECTATIONS FOR
SURGERY ARE USUALLY MORE
I. Conservative Management REALISTIC. ADDITIONALLY, A
A. The first approach to a bunion deformity is almost always nonoperative. In DEFORMITY THAT IS
general, it is usually favorable to modify the shoe before modifying the foot. ASYMPTOMATIC AND SIMPLY
B. Shoe wear modification is successful in many mild bunions and hallux valgus COSMETICALLY
deformities. This includes selecting shoes with a wide toe box and avoiding UNACCEPTABLE SHOULD BE
high heels (>2 inches). In selected cases, the toe box can be stretched by a APPROACHED WITH GREAT
professional to alleviate pressure on a prominent deformity. Medial arch sup- CAUTION. SURGICAL
ports to facilitate correcting a pronation deformity may also be helpful. INTERVENTION SHOULD NOT
BE PERFORMED ON
C. Generally speaking, over the counter “bunion straps” that pull the toe into
ASYMPTOMATIC TOES TO
a more varus posture are not successful in providing significant relief of ACCOMMODATE SHOEWEAR.
symptoms.
II. Surgical Indications

A. Operative treatment is indicated for symptomatic deformities that have failed
to respond to conservative measures.
B. Provided that the patient is a good surgical candidate from a medical stand-
point, the deformities then need to be evaluated based on their severity to
determine which procedure or procedures are appropriate.
C. There are dozens of surgical procedures for the correction of hallux valgus and
a bunion deformity. The following algorithm and discussion are based on the
most commonly performed procedures but are not exhaustive.
III. Surgical Contraindications
A. Current or recent infection
B. Medical comorbidities (i.e., patient unable to safely tolerate the stress of
surgery)
C. Nonhealing ulcer overlying proposed surgical approach
SURGICAL ALGORITHM
The next step in hallux valgus evaluation is classifying the deformity on the basis of the
aforementioned criteria. An algorithm developed by Mann provides a general outline for
classification of these deformities and thus surgical treatment.
Hallux valgus
Congruent joint Incongruent joint Degenerative joint disease
Akin procedure and Fusion,

exostectomy, Keller procedure,
chevron, or DSTP or prosthesis
IM angle < 13° IM angle >13° IM angle > 20° Hypermobile

HV angle < 30° HV angle < 40° HV angle > 40° first MC joint
Chevron (age < 50 yr),

DSTP with or without DSTP with proximal DSTP with proximal
Fusion of first MC
proximal crescentic crescentic osteotomy, crescentic osteotomy,
joint and DSTP
osteotomy, or or Mitchell procedure or MTP joint fusion
Mitchell procedure
IM, intermetatarsal; HV, hallux valgus; STP, soft tissue procedure; MTPJ, metatarsophalangeal joint;
MC, metatarsocuneiform. (Modified with permission from Mann RA: Decision-making in bunion surgery. In Green
WB [ed]: Instructional Course Lectures 39. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1990, pp
3–13.)
GENERAL PRINCIPLES FOR CORRECTING HALLUX VALGUS

I. All procedures for hallux valgus corrections can be classified as either bony or soft
tissue procedures.
II. The soft tissue procedure is a lateral release with a medial capsulorrhaphy.
III. The bony procedures include a simple exostectomy and proximal, shaft, or distal
osteotomies as well as fusions.
A. Distal osteotomies are just proximal to the metatarsal head and are for more
mild deformities (e.g., chevron, biplanar chevron).
B. Proximal and shaft osteotomies are generally reserved for more severe deformi-
ties as they are performed closer to the base of the metatarsal and can achieve
Foot and Ankle

greater correction (e.g., proximal crescentic or Mann procedure, proximal
chevron, Ludloff etc.).
C. Fusion procedures are reserved for cases of first MTPJ arthritis (first MTPJ
arthrodesis) or hypermobility of the first ray in which a Lapidus (first metatar-
socuneiform [MTC] joint fusion) procedure is performed.
IV. For simplicity, only the distal soft tissue procedure, distal chevron, proximal cres-
centic osteotomy, and Lapidus procedures will be discussed below.

I. The patient is placed supine on a regular operating room table. The foot plates
Does your attending have
on most operating room tables are radiolucent. a preference as to what
II. Following administration of anesthesia, local anesthesia is typically provided in type of tourniquet should
the form of a popliteal block, ankle block, or digital block, depending on the nature be used? Ask him or her
of the procedure. to explain the theory
III. The limb is then prepped and draped in standard fashion as per the details in behind the Esmarch
Chapter 1. tourniquet.
IV. Once prepped and draped, the proposed incision is marked on the skin using a
sterile marking pen.
V. An Esmarch tourniquet is placed on the distal fibia prior to making the
incision.
Surgical Approach and Procedure

I. Distal Soft Tissue Procedure (DSTP; Modified McBride Procedure)
A. With medial deviation of the first metatarsal head, the medial joint capsule
becomes lax, the sesamoids subluxate laterally, and the lateral soft tissues of
the MTPJ become contracted. The distal soft tissue procedure is shown in
Figures 31-6 and 31-7.
B. An incision is made between the first and second metatarsal heads (webspace)
with a 15-blade.
C. Blunt finger dissection is used to expose the adductor hallucis tendon on the
lateral side of the great toe. The tendon is released from the base of the proxi-
mal phalanx and no longer acts as a valgus-deforming force.
A B C
Figure 31-6
A, The initial skin incision is made in the web space between the first and second metatarsals. B, A Weitlaner
retractor is used to expose the conjoined adductor tendon, which is released. C, The lateral sesamoid is freed
up but not routinely excised. (From Coughlin MJ, Mann RA, Saltzman CL: Surgery of the Foot and Ankle, 8th
ed. Philadelphia, Mosby, 2007.)
Dorsal digital nerve
Does your attending Plantar digital Tibial sesamoid

A nerve
prefer releasing or pie- B
crusting the lateral Figure 31-7
capsule? Have the A, The medial incision is made in midline, beginning at the midportion of the proximal phalanx and
attending explain both continuing proximally 1 cm beyond the medial eminence. A clamp is used to elevate the dorsomedial
techniques and their cutaneous nerve, which must be protected. B, Diagram demonstrating the medial capsular incision, which
advantages and begins 2 to 3 mm proximal to the base of the proximal phalanx. A second incision is made 3 to 8 mm more
disadvantages. proximal to remove a flap of tissue. The size of the flap is determined by the severity of the deformity. (From
Coughlin MJ, Mann RA, Saltzman CL: Surgery of the Foot and Ankle, 8th ed. Philadelphia, Mosby, 2007.)
The “modification” in the D. Next, adhesions on plantar and lateral side of the fibular sesamoid are addressed
modified McBride
and released with blunt dissection.
procedure is that the
E. The transverse metatarsal ligament as well as the lateral MTPJ capsule is
fibular sesamoid is no
longer resected as released. The contracted lateral capsule may also be released by pie-crusting.
originally described by F. Next, the adductor hallucis tendon is resecured to the capsule, and the medial
McBride. Resection of capsule is tightened. A small section of capsule may need to be removed after
the fibular sesamoid can any bony correction.
result in a painful tibial G. The toe must then be held in a neutral posture to ensure scarring and healing
sesamoid and a drift into in a neutral position. Typically, this means a bunion spica dressing changed
a varus deformity. weekly for 8 weeks to prevent recurrent soft tissue stretching into valgus.
II. Medial Exostectomy (Silver Procedure)
THE DORSOMEDIAL AND A. A simple resection of the bony prominence (medial eminence) and repair of
PLANTARMEDIAL CUTANEOUS the medial capsule can be done for a simple bunion without a hallux valgus
NERVES ARE AT RISK IN THIS deformity. The medial eminence of the first metatarsal head is within the first
DISSECTION. IF THEY ARE MTPJ and therefore the capsule of the joint must be opened to take off the
INJURED, A PAINFUL PLANTAR bony prominence. It must be repaired following resection to prevent valgus
OR DOSAL NEUROMA MAY instability (Fig. 31-8).
RESULT AND WILL CAUSE
B. The incision is made with a 15-blade and is centered over the MTPJ extending
IRRITATION WITH SHOE WEAR.
approximately 1.5 cm proximally and 1 cm distally.
TO AVOID THIS PROBLEM,
THICK FLAPS ARE ELEVATED C. The dissection is carried down bluntly to the level of the medial capsular tissues
ONLY ONCE, AFTER THE and elevated in a plantar and dorsal manner.
SUPERFICIAL DISSECTION IS D. A medial capsulotomy is performed, and the shape is often surgeon-dependent.
DOWN TO THE CAPSULAR Often an inverted L shape, with the long arm dorsal and the short arm extend-
LEVEL; THE NERVES ARE ing dorsal to plantar at the proximal extent of the long limb, is used. This
EXTRACAPSULAR AND CAN configuration is used so that the plantar and distal capsule, which is strongest,
TYPICALLY BE VISUALIZED is spared.
WITHIN THESE FLAPS. E. If one is looking straight at the articular surface of the first metatarsal head from
distal to proximal, there is a sagittal sulcus, or groove, a couple of millimeters
Have your attending lateral to its medial aspect. The medial eminence is typically resected with a
explain the sagittal sulcus microsagittal saw along this natural plane in line with the first metatarsal shaft.
and how it is used as a F. The medial capsule is then repaired with the toe held in neutral.
landmark for medial III. Distal Chevron (Austin Osteotomy)
prominence resection. A. The medial exposure and exostectomy are followed as outlined previously.
However, the initial exostectomy is made medial to and not in line with the
After bony resection on first metatarsal shaft (see later discussion).
the medial prominence, a B. To make a distally based “<” shape, a 50-degree osteotomy centered on a point
small section of the 1 cm proximal to the apex of first metatarsal articular surface is made in two
medial capsule is removed cuts (Fig. 31-9).
to address any capsular C. The metatarsal head fragment is then translated laterally about 4 mm and
redundancy.
confirmed with the use of fluoroscopy.
Foot and Ankle

Sagittal
sulcus
Figure 31-8
Excision of the medial eminence in line with the
medial aspect of the metatarsal shaft. (From Coughlin
MJ, Mann RA, Saltzman CL: Surgery of the Foot and
Ankle, 8th ed. Philadelphia, Mosby, 2007.)
D. The osteotomy may be left alone, pinned, or a screw may be placed across it NO DISSECTION SHOULD BE
for fixation. PERFORMED ON THE LATERAL
E. Once the head piece is translated, the remaining overlying bone at the distal aspect SIDE OF THE METATARSAL
of the metatarsal is resected in line with the rest of the shaft of the metatarsal. HEAD IN THIS PROCEDURE.
(This is different than resecting the medial prominence at the sagittal sulcus.) BECAUSE THE MEDIAL SIDE
IV. Proximal Crescentic Osteotomy (Mann Procedure) HAS BEEN COMPLETELY
A. This procedure is indicated when one has a moderate to severe deformity and STRIPPED OF ITS SOFT TISSUE,
an incongruent joint. LATERAL DISSECTION CAN
LEAD TO AVASCULAR
B. This procedure is combined with DSTP and a medial exostectomy.
NECROSIS OF THE
C. A longitudinal incision is made over the first metatarsal cuneiform joint using METATARSAL HEAD.
a 15-blade. It is important to fully expose the base of first metatarsal.
D. A guidewire from the small cannulated screw set is placed 2 cm distal to the
joint and is advanced from distal to proximal aiming toward the plantar aspect
of the first metatarsal base. It is then retracted halfway.
E. At a location 1 cm distal to the joint, a crescentic osteotomy (apex distal) is
made with a curved crescentic saw blade. The saw should be perpendicular to
the remaining guidewire and about 120 degrees anterior to the shaft of the
metatarsal.
Figure 31-9
More bone is removed from the dorsomedial and
plantar medial limb of the osteotomy to allow
realignment of a congruent metatarsophalangeal joint
articulation with lateral translation of the capital
fragment. (From Coughlin MJ, Mann RA, Saltzman
CL: Surgery of the Foot and Ankle, 8th ed. Philadelphia,
Mosby, 2007.)
F. Once the osteotomy has been completed, the metatarsal is shifted laterally and
the K-wire is advanced across the osteotomy site. This can be confirmed with
fluoroscopic imaging.
G. A countersunk cannulated screw is then placed over the K-wire for fixation of
the osteotomy.
CARE MUST BE MADE TO V. Lapidus Procedure (First MTC Fusion)
AVOID ANY INJURY TO THE A. This procedure is indicated when hypermobility of the first ray is found on
NEUROVASCULAR BUNDLE, clinical examination. It is also often combined with distal procedures.
INCLUDING THE SUPERFICIAL B. The incision is made directly over the MTC joint using a 15-blade.
PERONEAL NERVE AND C. Once fully exposed, the joint surfaces are débrided with curettes and rongeurs
DORSALIS PEDIS ARTERY, to remove any remaining articular cartilage.
WHICH IS JUST LATERAL TO D. Sometimes there is a wedge-shaped defect in the medial cuneiform. When this
THE EXTENSOR HALLUCIS
defect exists, a laterally and dorsally based wedge of bone graft (autograft or
LONGUS TENDON IN THE
allograft) is placed between the two prepared surfaces. This directs the first
LATERAL ASPECT OF THE
INCISION.
metatarsal into a more varus position and allows for more plantarflexion of the
first ray which has a tendency to dorsiflex due to joint instability.
E. The prepared surfaces are fixed either with a medially based plate and screws
There is no one “correct” from medial to lateral into the first metatarsal and medial cuneiform, or with
fixation method for free screws transfixing the fusion site.
osteotomies and fusions.
The decision is usually
based on surgeon Wound Closure, Dressings, and Immobilization
experience and comfort.
In some cases K-wires are I. Skin closure is surgeon specific but is often simple interrupted nylon or silk
placed across an sutures.
osteotomy and pulled in II. If pins are used they are held with a needle driver at the level of the skin and bent
the office at 3 to 4 weeks. 90 degrees before being cut (a Fraser tip suction cannula can also be used to bend
Other surgeons may the wire).
prefer small III. Strips of nonadherent dressing or petroleum gauze are wrapped around the pins.
interfragmentary screws IV. A series of 4 ¥ 4 gauze pads and a sterile cotton mesh (Kerlix/Kling type) wrap
for fixation. holds down the dressing.
V. A bunion spica dressing, composed of half-inch silk tape, is then wrapped around
the forefoot and great toe with the great toe held in varus and supinated (to prevent
soft tissue drift into valgus and pronation) (Fig. 31-10).
VI. This dressing is changed weekly to ensure proper soft tissue healing in the correct
alignment.
A B
Figure 31-10
A, Immediate postoperative dressing. B, Dressing used for the remainder of treatment. (From Coughlin MJ,
Mann RA, Saltzman CL: Surgery of the Foot and Ankle, 8th ed. Philadelphia, Mosby, 2007.)
Foot and Ankle

COMPLICATIONS
I. There is no one “most common” complication shared by all of the aforementioned
procedures, but recurrent deformity, hallux varus (overcorrection), infection,
osteonecrosis (Chevron), nonunion, stiffness, transfer metatarsalgia, and degen-
erative arthritis can occur.
II. Unfulfilled patient expectations should also be considered a complication of hallux
valgus correction and can be mitigated with proper preoperative counseling,
ensuring patients have undergone a reasonable trial of conservative management,
and keeping to strict criteria for operative intervention.
III. Soft tissue infection. The foot is at a disadvantage compared with many other
surgical areas; it is often in the dependent position leading to persistent swelling
and ecchymosis, and there is very little soft tissue coverage over areas of surgical
trauma. This presents an environment where superficial infection can evolve rela-
tively easily. It can typically be treated with oral antibiotics but must be recognized
early.
IV. Recurrence is not common but is a complication that is seen with all of the above
mentioned procedures. A variety of revision procedures are available to address
the problem depending on its etiology.
SUGGESTED READINGS
Campbell JT: In Richardson EG: Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont
IL, American Academy of Orthopaedic Surgeons, 2004, pp 3–16.
Coughlin MJ, Mann RA: Hallux valgus. In Coughlin MJ, Mann RA, Saltzman CL: Surgery of the
Foot and Ankle, 8th ed. Philadelphia, Mosby, 2007, pp 181–363.
Mann RA: Disorders of the first metatarsophalangeal joint. J Am Acad Ortho Surg 3:34–43, 1995.
S E C T I O N
IX
PEDIATRICS
CHAPTER 32 Closed Reduction and Percutaneous Pinning of Supracondylar Humerus Fractures 365
CHAPTER 33 In Situ Pinning of Slipped Capital Femoral Epiphysis 375
CHAPTER 34 Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis 384
C H A P T E R
32
Closed Reduction and Percutaneous
Pinning of Supracondylar
Humerus Fractures
Pediatrics
Wudbhav N. Sankar and B. David Horn
Case Study
A 6-year-old boy presents to a children’s hospital emergency department with a painful

and swollen right elbow. The child had been playing with his friends after school when
he fell about 8 feet from the monkey bars, landing onto his outstretched right hand. He
had immediate pain and swelling in his elbow and his parents rushed him to the emergency
department. On arrival, the patient is quite uncomfortable. The child is keeping his elbow
relatively straight, and he has difficulty flexing it. He has palpable radial and ulnar pulses
and sensation is intact, but there is slight weakness of flexion of the interphalangeal joint
of the thumb. Anteroposterior (AP) and lateral views of his right elbow are presented in
Figure 32-1.
BACKGROUND
I. Supracondylar humerus fractures are a common elbow injury, constituting

approximately 70% of all hospitalizations for pediatric elbow fractures. The peak
incidence is 5 to 7 years of age, and boys are more commonly affected than
girls.
Figure 32-1
Anteroposterior and lateral views
of the elbow.

366 S E C T I O N I X Pediatrics
A B C
Figure 32-2
Gartland classification of supracondylar humerus fractures. A, Type I. B, Type II. C, Type III.
II. The vast majority of supracondylar humerus fractures in children (98%) are exten-
sion-type fractures. The mechanism of injury is most often a fall on an out-
stretched hand with the elbow in full extension. With the elbow locked in this
position, all of the energy is transmitted to the distal humerus, causing a hyper-
extension force at the fracture site. Depending on the fracture severity, the distal
fragment can displace posteriorly, and the proximal shaft can be forced anteriorly,
sometimes “buttonholing” through the brachialis muscle. The minority of supra-
condylar humerus fractures (2%) are flexion-type injuries, which result from a fall
onto a flexed elbow. These fractures reduce in extension, and their treatment is
not addressed in this chapter.
III. Fractures are classified according to the Gartland classification (Fig. 32-2).
A. Type I fractures are nondisplaced.
B. Type II fractures are displaced with an intact posterior cortical hinge.
C. Type III fractures are more than 100% displaced, and they suggest that the
anterior (and on occasion, the posterior) periosteum has been completely
torn.
IV. Neurovascular injuries are commonly associated with supracondylar humerus frac-
Neurologic injuries occur tures in children. Nerve injuries occur in at least 7% of cases, with the anterior
in at least 7% of interosseous nerve most commonly affected. Radial nerve injuries can also be seen,
supracondylar humerus particularly in those fractures that are posteromedially displaced. The brachial
fractures. artery is also at risk, because it can be either impaled or stretched from anterior
displacement of the proximal fracture fragment. Only 1% of supracondylar frac-
tures are open.
V. Type I fractures are inherently stable and can be treated with short-term immo-
bilization. All type III and displaced type II fractures require reduction and stabi-
lization. Casting or traction is rarely used for these injuries because of the risks of
malunion and neurovascular compromise. In most cases, stabilization is achieved
by the technique of closed reduction and percutaneous pin fixation (CRPP).
INITIAL TREATMENT
A. Fracture classification and severity
C. Condition of soft tissues
C H A P T E R 3 2 Supracondylar Humerus Fractures 367
II. Initial Approach BE SURE TO DOCUMENT A

A. Assess vascular status of the limb by palpating the radial pulse. CAREFUL NEUROVASCULAR
1. If pulse cannot be palpated, attempt Doppler localization. EXAMINATION, INCLUDING
2. If the extremity is still pulseless, decide if hand is either “pink” or “white” ANTERIOR INTEROSSEOUS
based on capillary refill and overall perfusion. NERVE (AIN), MEDIAN, RADIAL,
B. Examine the neurologic function of the extremity. AND ULNAR NERVE FUNCTION
1. Test the function of the anterior interosseous nerve by asking the patient WHENEVER EXAMINING A
to flex the thumb interphalangeal joint. PATIENT WITH A
2. Test radial nerve function by assessing wrist and thumb extension. SUPRACONDYLAR HUMERUS
Pediatrics
FRACTURE. REMEMBER THAT
3. Test ulnar nerve function by having the patient either cross the fingers or
THE AIN IS PURELY A MOTOR
spread them apart widely.
NERVE AND HAS NO SENSORY
C. Evaluate the soft tissues around the elbow. FUNCTION.
1. Determine whether the fracture is open or closed.
2. Look for anterior ecchymosis or a “pucker” sign indicating severe fracture
displacement and potential buttonholing of the anterior shaft through the
brachialis muscle.
D. Be sure that adequate radiographs are taken not just of the elbow but also of
the forearm and wrist to rule out associated fractures.
E. For displaced fractures (types II and III), place the patient in a posterior splint
in 30 to 40 degrees of flexion. Flexing the elbow more than 45 degrees can TOO MUCH FLEXION OF THE
compromise blood flow to the hand. ELBOW DURING
F. Nondisplaced fractures (type I) may be placed immediately into a long arm IMMOBILIZATION CAN IMPAIR
cast or a posterior splint if swelling is excessive. BLOOD FLOW TO THE HAND.
TREATMENT PROTOCOLS
A. No surgery is indicated for Gartland type I fractures and minimally displaced
type II fractures.
B. Long arm casting is appropriate, with the elbow at no more than 90 degrees
of flexion. Too much flexion can kink the blood vessels and impair distal blood
flow and venous return.
C. Radiographs should be obtained after 1 week to demonstrate lack of displace-
ment and confirm adequate position of the distal humerus.
D. The duration of immobilization should be 3 to 4 weeks.
E. Patients should be seen 2 to 4 weeks after cast removal to be sure that range
of motion and strength are returning normally.
II. Operative Treatment (CRPP)
A. Surgery is indicated for type II and type III fractures (displaced), open frac-
tures, polytrauma, or any case with neurovascular compromise.
B. The timing of surgery is dictated by vascular and soft tissue status (see Surgical
Algorithm).
C. Radiographs should be taken 1 week postoperatively to confirm adequate frac-
ture alignment.
D. Three to 4 weeks after surgery, the cast should be removed and repeat elbow
radiographs should be taken to assess fracture callus. Pins can usually be
removed at this time.
E. Patients should be seen 2 to 4 weeks after cast removal to be sure that range
of motion and strength are returning normally.
SURGICAL INDICATIONS
I. Most Gartland Type II Fractures
A. Closed reduction and casting can be attempted, but reduction is often difficult
to maintain without additional pin fixation.
B. Fractures with any significant degree of extension should be treated
operatively.
II. All Gartland type III fractures

III. Any open fracture or a fracture resulting in neurovascular compromise
IV. Any Gartland type II or III fracture in a polytrauma patient
SURGICAL ALGORITHM
How does your attending Type II or type III supracondylar humerus fracture
treat a supracondylar
humerus fracture with a
pink but pulseless hand? Palpable pulses, neurologically intact, Open fracture, no pulse, nerve injury,
and no soft-tissue compromise or soft-tissue compromise
CRPP, within 24 hr CRPP ⫾ irrigation and débridement, emergent
GENERAL PRINCIPLES OF CLOSED REDUCTION AND PERCUTANEOUS PINNING

OF SUPRACONDYLAR HUMERUS FRACTURES
I. Goals. The major goals of CRPP of supracondylar humerus fractures are as
follows:
A. Re-establishment of proper alignment of the distal humerus
B. Achievement of stable fixation
C. Avoidance of iatrogenic injury to surrounding neurovascular structures, par-
ticularly the ulnar nerve
II. Normal Elbow Alignment
A. On a lateral view of the elbow, a line drawn along the anterior border of
the distal humerus should pass through the middle third of the capitellum
(Fig. 32-3).
B. On an anteroposterior (AP) view of the elbow, the angle between a line drawn
down the shaft of the humerus and the physeal line between the lateral condyle
A
C
Figure 32-3
Radiographic lines that may be demonstrated on a lateral radiograph of the elbow. A, The capitellum of the
distal humerus is angulated anteriorly approximately 30 degrees. This may be demonstrated by drawing a line
parallel to the midpoint of the shaft of the distal humerus; where that line intersects with a line drawn
through the midpoint of the capitellum indicates the anterior inclination of the capitellum. B, The anterior
humeral line is drawn down the outer edge of the anterior cortex of the distal humerus. As the line is drawn
distally through the capitellum, it should pass through the middle of the capitellum. C, The anterior coronoid
line is drawn along the coronoid fossa of the proximal ulna and is then continued proximally. It should just
touch the capitellum anteriorly. The line lies posterior to the most anterior portion of the capitellum if the
capitellum is angulated anteriorly. If the capitellum is angulated posteriorly, the line no longer touches the
capitellum. (From Green NE, Swiontkowski MF [eds]: Skeletal Trauma in Children, 2nd ed. Philadelphia, Saunders,
1998.)
Figure 32-4
Pediatrics
Baumann’s angle is formed between a line that
follows the metaphysis of the lateral side of the distal
humerus (i.e., the physis of the capitellum) and a line
B perpendicular to the axis of the humerus. (From
Green NE, Swiontkowski MF [eds]: Skeletal Trauma in
Children, 2nd ed. Philadelphia, Saunders, 1998.)
and the distal humeral metaphysic is called Baumann’s angle (Fig. 32-4). The
normal Baumann’s angle is 65 to 80 degrees. Although there is a large variation
in Baumann’s angle between individuals, it should remain consistent between
the left and right side.
C. With the elbow in full extension, the angle formed between the upper arm and The anterior humeral
the forearm is called the carrying angle. The normal carrying angle is 10 to 18 line and Baumann’s angle
degrees. are used to judge the
D. After CRPP of a supracondylar humerus fracture, it is important that all of adequacy of fracture
these relationships are re-established. reduction.
III. Pin Configuration
A. Pins are placed percutaneously to transfix both fracture fragments and achieve
stable fixation.
B. Controversy exists over the most optimal pin configuration to use for fracture
fixation.
1. Biomechanical studies have shown that two crossed pins create a more stable
construct compared to two lateral entry pins.
2. Use of a medial entry pin, however, puts the ulnar nerve at risk.
3. Several clinical studies have suggested that two lateral entry pins are just as
efficacious as crossed pins and avoids risk to the ulnar nerve.
4. In cases of severe fracture displacement or persistent instability following
pinning, a third lateral entry pin should be added.
C. Regardless of preferred pin configuration, it is important that each pin:
1. Achieves bicortical purchase
2. Captures both the proximal and distal fragment
3. Is adequately separated from the other pin(s) at the fracture site

I. The patient is placed in the supine position.
II. The fluoroscope machine is reversed so that the larger side (the image intensifier)
is on the bottom. The fluoroscope machine is then brought in alongside the
Figure 32-5
Operating room setup. The fluoroscope machine is
positioned parallel to the bed, the patient’s elbow is
placed across the fluoroscope machine platform, and
the monitor is moved to the contralateral side.
operating table from the foot of the bed. The height is adjusted so that the
machine can serve as a hand table for the procedure. Often, the patient needs to
be pulled over so that the entire arm can lie on the fluoroscope machine and can
therefore be imaged.
III. The monitor for the fluoroscope machine should be placed on the other side of
the table so that it can be well visualized during surgery (Fig. 32-5).
IV. Place a drip sheet under the patient’s arm on top of the fluoroscope machine
platform to avoid staining the machine during the preparation.
V. Most surgeons do not routinely place a tourniquet, but ask your attending if he
or she would like to use one for the case.
VI. Typically, the arm is held by hand as it is prepped and draped in standard fashion
(see Chapter 1).
Closed Reduction of the Fracture

I. AP and lateral views of the elbow are taken using fluoroscopy to confirm adequate
visualization of the elbow and to reassess the initial fracture pattern.
II. The first step in fracture reduction is to apply longitudinal traction with the elbow
in extension. This helps disengage the proximal fragment from the brachialis
muscle. If traction does not restore length, then the “milking maneuver” is often
used to dislodge the shaft from the anterior soft tissues. This technique involves
massaging the brachialis muscle from proximal to distal over the end of the but-
tonholed portion of the distal humeral shaft.
III. Once length is restored, medial or lateral translation of the distal fragment is cor-
rected under fluoroscopic control.
IV. After reduction has been achieved in the coronal plane (AP view), a flexion
reduction maneuver is performed. With the surgeon’s thumb placed on the
olecranon, the distal fragment is pushed forward while flexing the elbow to 120
degrees and simultaneously pronating the wrist to tighten the periosteal hinge
(Fig. 32-6).
V. With the elbow held in flexion, a shoot through AP view of the elbow, called a
Jones view, is taken using the fluoroscope machine.
VI. If proper alignment has been maintained in the coronal plane, the arm is externally
rotated at the shoulder to obtain a lateral view of the distal humerus. Usually the
Flexion of the elbow surgeon rotates the entire arm as a unit by placing one hand on the upper arm
helps maintain fracture while the other hand holds the wrist pronated and the elbow hyperflexed. This
reduction. helps maintain the fracture reduction while you position the elbow for the lateral
view.
VII. In assessing fracture reduction on the lateral, be sure that the anterior humeral
line intersects the middle of the capitellum. If the line passes anterior to the capi-
tellum, it means that there is persistent extension at the fracture site. The surgeon
may repeat the flexion reduction maneuver as necessary until proper alignment
Figure 32-6
Pediatrics
Flexion-reduction maneuver. The elbow is flexed
while the wrist is pronated and the surgeon’s thumb
applies pressure to the olecranon.
has been achieved. If the fracture is irreducible in spite of repeated attempts, open
reduction may be necessary.
VIII. Once the fracture is reduced, the elbow is rotated back to the Jones view, while
still holding the arm as a unit, in preparation for percutaneous pinning.
Percutaneous Pin Fixation

I. For children who weigh 20 kg or less, 0.062-inch (1.6-mm) smooth Kirschner
wires are used for fracture fixation. Fractures in children who weigh more than
20 kg are stabilized with 0.078-inch (2.0-mm) smooth wires. In small children,
0.45-mm K-wires may be used.
II. With the elbow still held flexed as for a Jones view, palpate the lateral epicondyle.
This is the largest bony prominence on the outside of the elbow.
III. With the K-wire loaded up on a wire driver, the surgeon places the pin on the tip
of the lateral epicondyle and confirms the starting point with another Jones view
(Fig. 32-7). The trajectory is adjusted so that the pin crosses the fracture site and
engages a sufficient amount of the medial cortex. If the use of two lateral entry
pins is planned, be sure to position the first pin to leave room for the second.
Often this requires aiming the first pin about 1 cm proximal to the fracture site
so that there is space more proximally for the second pin.
Figure 32-7
Elbow is held in a Jones view while the first pin is
advanced through the lateral epicondyle.
IV. The pin is advanced slowly at first to get started and then at full speed. A “give”
should be felt as the K-wire goes through the first cortex. The resistance
then decreases through the cancellous bone but then increases again when the
pin hits the second cortex. The pin is advanced just through the second cortex.
If the surgeon does not feel the pin pass through the second cortex, then the pin
has not been correctly placed. The pin position is checked with another Jones
view.
V. Using the same technique as before, the arm is rotated for the lateral view. The
pin position is checked under fluoroscopy. The pin should be seen going up the
shaft of the bone and should not exit anteriorly or posteriorly until past the frac-
ture. If the pin has been errantly placed, the surgeon rotates back to the Jones
view and tries again.
VI. After the first pin has been correctly placed, the elbow can be rotated back to an
AP view. Because one pin now transfixes the fracture, the elbow can be gently
extended. This makes visualization of the fracture reduction much easier. Reassess
Baumann’s angle to ensure that the fracture is well aligned.
VII. A second and sometimes third pin now needs to be added. If the attending prefers
Does your attending all lateral entry pins, then the previous steps are repeated to add the additional
prefer crossed or lateral pin(s). If the attending prefers a crossed pin technique, then a medial entry pin
entry pins? needs to be placed.
VIII. To place a medial entry pin, the elbow is brought into extension. This reduces
the risk that the ulnar nerve will subluxate anteriorly. The medial epicondyle
(the largest bony prominence on the inside of the elbow) is palpated. A small
1-cm incision is made over the top of the medial epicondyle, and a hemostat
is used to spread down to bone. This helps ensure that the ulnar nerve remains
BE SURE TO EXTEND THE
in its normal position behind the medial epicondyle and reduces the risk of
ELBOW BEFORE PLACEMENT
OF A MEDIAL PIN, BECAUSE injury from the medial pin. Proper starting position and trajectory are checked
THIS REDUCES THE RISK OF using the fluoroscope machine, and the pin is advanced as before across the
ULNAR NERVE INJURY. fracture site.
IX. After all of the pins have been placed, the surgeon should gently flex, extend,
and rotate the elbow under live fluoroscopy to confirm stable fracture fixation
(Fig. 32-8).
X. If pulses were not detectable prior to CRPP, perfusion is reassessed by
palpating the radial pulse, checking capillary refill, and evaluating overall perfusion
Figure 32-8
Anteroposterior and lateral fluoroscopic views of the elbow after closed reduction and percutaneous pin
fixation.
of the hand. If pulses cannot be palpated, a sterile Doppler is used to try to find
the pulse. If a pulse still cannot be found and the hand is pink, some surgeons
defer arterial exploration and closely monitor the patient postoperatively. If there
are no pulses and the hand is white, vascular surgery is often consulted, and the
artery must be explored.
Dressings and Immobilization

I. The pins are held with a needle driver at the level of the skin and bent 90 degrees
Pediatrics
before being cut.
II. Strips of nonadherent dressing or petroleum gauze are wrapped around the
pins.
III. Gauze and sterile Webril are used to dress the elbow.
IV. After all of the drapes have been removed and the remaining skin washed of any
residual Betadine, the elbow is immobilized.
V. Webril is used to wrap the entire arm with the elbow held in roughly 60 degrees
of flexion. Again, hyperflexing the elbow can constrict blood flow to the hand
(Fig. 32-9). Postoperatively, does
VI. Some surgeons apply a long arm cast immediately (which may be bivalved while your attending use a cast
or a splint for
the patient is asleep), whereas others place the patient in a posterior splint if they
immobilization?
are concerned about swelling.
POSTOPERATIVE CARE
I. Postoperative management includes pain control, antibiotic prophylaxis against
infection, and neurovascular monitoring.
II. Typically, acetaminophen with codeine or oxycodone elixir are used for pain
control.
III. Patients should be assessed postoperatively for proper functioning of the anterior
interosseous, median, radial, and ulnar nerves.
IV. Patients are monitored closely overnight for compartment syndrome. Increasing
analgesic requirements and pain with passive stretch of the fingers are the earliest
clinical signs. Later, paresthesias, cool fingers, and poor capillary refill can be
seen.
Figure 32-9
Postoperatively, a long arm cast is applied in
approximately 60 degrees of flexion.
A. If there are any concerns about compartment syndrome, the cast should be
split or the splint loosened.
B. If concern persists after removal of the splint or cast, the compartment pres-
sures should be measured.
V. Patients are usually discharged on postoperative day one.
COMPLICATIONS
I. The most common complication following CRPP of supracondylar humerus frac-
tures is malunion from inadequate fracture reduction. Usually, the fracture is in
varus resulting in a decreased carrying angle. This cubitus varus deformity is most
noticeable in extension and is usually a cosmetic rather than a functional
disability.
II. As previously discussed, the anterior interosseous nerve and the radial nerve are
at risk from the initial injury. The ulnar nerve can be injured iatrogenically from
the use of a medial entry pin. Most nerves recover spontaneously by 12 weeks after
the initial injury.
III. Compartment syndrome is the most devastating complication of supracondylar
humerus fractures. Patients should be closely monitored for excessive pain and
increasing analgesic requirements. If any concern exists, compartment pressures
should be measured and fasciotomies performed for those compartments with
pressures greater than 30 mm Hg.
SUGGESTED READINGS
Gartland JJ: Management of supracondylar fractures of the humerus in children. Surg Gynecol
Obstet 109:145–154, 1959.
Kasser JR, Beaty JH: Supracondylar fractures of the distal humerus. In Kasser JR, Beaty JH (eds):
Fractures in Children, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2001, pp
543–590.
Otsuka NY, Kasser JR: Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg
5:19–26, 1997.
Waters PM: Injuries of the shoulder, elbow, and forearm. In Abel MF (ed): Orthopaedic Knowledge
Update: Pediatrics 3, 3rd ed. Rosemont, IL, American Academy of Orthopaedic Surgeons,
2006, pp 306–309.
C H A P T E R
33
In Situ Pinning of Slipped Capital
Femoral Epiphysis
Nirav K. Pandya and Theodore J. Ganley
Pediatrics
Case Study
A 13-year-old obese boy presents to a children’s hospital emergency department in the

summer complaining of right-sided groin and thigh pain. The boy had noted the acute
onset of right groin pain while playing with his friends the day before, and he thought he
had “pulled” his groin muscles. The patient’s parents brought him to the emergency
department because the pain has not improved and he cannot bear weight on his right
leg. They note that he has no known medical problems and has never had problems with
his extremities before. The patient is lying supine on a stretcher, and his right leg appears
externally rotated. On examination, the patient has extremely limited internal rotation,
and with hip flexion the leg externally rotates and abducts. Anteroposterior (AP) pelvis
and frog-leg lateral radiographs of both hips are shown in Figure 33-1.
BACKGROUND
I. Slipped capital femoral epiphysis (SCFE) is one of the most common disorders of
the adolescent hip, primarily affecting individuals between the ages of 10 and 16
years. Males are two to three times more likely to be affected than females, and
the majority of patients fall in greater than the 95th percentile for their weight.
In addition, African Americans are more likely to be affected, and there is an
increased incidence of SCFE in the summer months. The risk of eventual slip in
the contralateral hip has been reported to be as high as 25% in some series, with
a history of endocrine abnormalities raising the risk to nearly 100%.
A B
Figure 33-1
Anteroposterior pelvis (A) and frog-leg lateral (B) views of the hips.

II. In this condition, the capital femoral epiphysis displaces posteroinferiorly in rela-
A slipped capital femoral
epiphysis in a patient who tion to the femoral neck. Although the exact etiology is unknown, it is postulated
is younger than 10 years that the pathology lies in the zone of hypertrophy of the growth plate. It is thought
of age, older than 16 that this area is weakened by rapid pubertal growth or endocrine abnormalities
years of age, or nonobese (hypothyroid, growth hormone treatment, renal failure), leading to the epiphysis
warrants an endocrine displacing and causing pain.
workup; the realization III. SCFE is classified based both on chronology and extent of disease:
that the contralateral slip A. Acute: sudden onset of pain, less than 2 weeks
rate nears 100% applies B. Chronic: pain greater than 2 weeks
in this situation. C. Acute on chronic: pain greater than 2 weeks, with sudden acute increase in
pain
D. Stable: able to ambulate
E. Unstable: unable to ambulate
F. Grade I: displacement of epiphysis less than 30% of the femoral neck width
G. Grade II: displacement between 30% and 60%
H. Grade III: displacement greater than 60%
IV. Osteonecrosis of the femoral head is the dreaded complication of SCFE, and it
Patients with unstable can occur in up to 10% to 15% of patients with SCFE (particularly unstable slips).
slipped capital femoral
Osteonecrosis may be secondary to the initial traumatic injury to the blood vessels
epiphyses are treated
urgently and are taken to supplying the femoral head at the time when the slip occurs. Hemorrhage in the
the operating room in a joint capsule compressing epiphyseal blood flow at the time of the acute slip or
timely fashion. repeated forceful manipulations may also contribute to this condition. Emergent
in situ (without reduction) pinning has been found to decrease these rates.
V. The standard treatment of a stable SCFE is in situ pinning with one or two can-
nulated screws. For an unstable SCFE, there has been a trend toward using two
screws. The role of reduction in SCFE treatment has evolved, and newer literature
indicates that spontaneous gentle reduction that occurs when the patient is placed
on the fracture table is safe. There is an increasing amount of support for open
surgical dislocation of the hip, arthrotomy, and reduction of the most severe
slips.
INITIAL TREATMENT
A. SCFE classification and severity
C. Risk of contralateral slip
AS MANY AS 15% OF II. Initial Approach
PATIENTS WITH A SLIPPED A. History
CAPITAL FEMORAL EPIPHYSIS 1. Assess patient age and mechanism of injury (if any).
PRESENT ONLY WITH KNEE 2. Determine duration of patient’s symptoms (acute, acute on chronic, or
PAIN, SO ANY ADOLESCENT chronic).
PRESENTING TO THE OFFICE
3. Assess whether the patient has been able to bear weight (stable vs.
WITH KNEE PAIN WARRANTS A
HIP EXAMINATION.
unstable).
4. Assess the patient for history of contralateral hip pain or knee pain.
B. Physical examination
1. Assess (if weight bearing) patient gait/limp.
2. With the patient supine, the affected extremity is usually externally rotated.
3. The patient generally has little to no internal rotation of the hip and pain
with any attempted hip internal rotation.
4. The patient’s hip abducts and externally rotates during hip flexion.
5. A complete examination of both extremities (neurovascular status) is
necessary.
C. Laboratory studies. If the patient is younger than 10 years of age, older than
16 years of age, nonobese, or has a family history of endocrine disorders, then
consider an endocrine workup and/or consult.
C H A P T E R 3 3 In Situ Pinning of Slipped Capital Femoral Epiphysis 377
Figure 33-2
Klein’s line drawn along the superior border of the
femoral neck that does not intersect the epiphysis on
the right (indicating a slipped capital femoral
epiphysis) as opposed to the normal, contralateral
side.
Pediatrics
D. Imaging
1. An AP pelvis and frog-leg lateral radiographs that adequately show both hips
on one film are essential for the initial workup.
2. Klein’s line. This line, drawn along the superior portion of the femoral neck,
should intersect a small portion of the epiphysis in a normal hip. The
absence of intersection indicates inferior displacement of the epiphysis in
relation to the femoral neck (Fig. 33-2).
3. A frog-leg lateral radiograph may show posterior displacement of the epiph-
ysis in relation to the femoral neck.
4. Make sure to image other areas of the involved extremity (knee, ankle) as
dictated by the physical examination or history to rule out other trauma/ Always assess the
pathology. contralateral hip when
5. If radiographs are negative with a high clinical suspicion of SCFE, a mag- examining radiographs in
netic resonance imaging scan can diagnose a preslip condition with increased a patient with a suspected
metaphyseal signal next to a widened growth plate. slipped capital femoral
epiphysis.
E. Weight bearing
1. Make patient immediately non–weight bearing on the affected side.
2. Crutches can be used for ambulation if the contralateral side is unaffected.
F. Aspiration of joint. The role of ultrasound to document a hip joint effusion
and aspirating an acute hemarthrosis for the scenario of an unstable SCFE until
the operating room is available is controversial.
TREATMENT PROTOCOLS
A. There is a limited role for nonoperative treatment.
B. It is historically used only for stable slips.
C. Treatment options include traction or hip spica casting with closed reduction.
D. There have been unfavorable results in the literature with nonoperative treat-
ment leading to recurrent slips, chondrolysis, osteonecrosis, and skin ulcers.
II. Operative Treatment (In Situ Pinning)
A. Surgery is indicated as the gold standard for both stable and unstable slips.
B. The timing of surgery is dictated by the stable versus unstable nature of the
slip (see Surgical Algorithm).
C. The role of reduction is controversial. No reduction is warranted in stable slips,
whereas spontaneous/gentle reduction on a fracture table is acceptable for What does your
unstable slips. attending think about
D. Pinning of the contralateral hip based on patient age, contralateral hip pain, other treatment options,
endocrine/metabolic risk factors, family history, and risk of leg length discrep- including open surgical
ancy (recent evidence supporting contralateral hip pinning in general) may be dislocation of the hip,
bone peg epiphysiodesis,
performed at the same time.
and femoral neck
E. Pin removal is indicated only if the patient becomes symptomatic in the
osteotomy?
future.
SURGICAL ALTERNATIVES TO IN SITU PINNING OF SLIPPED CAPITAL

FEMORAL EPIPHYSIS
I. Open Reduction and Internal Fixation via Surgical Dislocation of the Hip
A. Treatment option for unstable slips
B. Believed not only to decompress the joint via an arthrotomy but also to prevent
early degenerative changes
C. Larger procedure with greater risks
II. Bone peg epiphysiodesis
III. Femoral Neck Osteotomy
A. Indicated to restore the normal relationship of the femoral head to neck and
theoretically to decrease the risk of future degenerative joint disease
B. Also can be used to treat malunion of a chronic slip
SURGICAL INDICATIONS FOR IN SITU PINNING OF SLIPPED CAPITAL

FEMORAL EPIPHYSIS
I. Failed nonoperative treatment. The patient continues to have pain and inability
to bear weight.
II. Stable slips
III. Unstable slips
IV. Treatment of contralateral (nonslip) side. The patient must have risk factors for
contralateral slip (e.g., endocrine disorder, family history of endocrine disorder,
age younger than 10 years or older than 16 years, nonobese, at risk for leg length
discrepancy).
RELATIVE CONTRAINDICATIONS TO IN SITU PINNING OF SLIPPED CAPITAL

FEMORAL EPIPHYSIS
I. The patient is medically unstable to proceed to the operating room.
II. There is current or recent infection.
III. Surgeons are unable to obtain adequate stability using pinning technique based
on patient anatomy or prior surgical procedure.
SURGICAL ALGORITHM
Over what time frame SCFE

does your attending
prefer to pin an unstable
versus a stable slip? Does
he or she routinely pin
the contralateral hip? STABLE UNSTABLE
(able to bear weight) (unable to bear weight)
• Make non–weight-bearing • Make non–weight-bearing and admit
• Arrange for OR in • Take to OR on a more urgent
an elective fashion basis
Risk factors for

contralateral slip
Yes No
Bilateral Unilateral
pinning pinning
GENERAL PRINCIPLES OF IN SITU PINNING OF SLIPPED CAPITAL

FEMORAL EPIPHYSIS
I. Goals
A. Prevention of further displacement of the femoral epiphysis in relation to the
femoral neck
B. Induction of closure of the physis
C. Avoidance of iatrogenic injury to the hip joint/femoral head (chondrolysis,
osteonecrosis, femoral neck fracture)
Pediatrics
II. Screw Placement/Configuration
A. Screws are placed through small skin incisions to achieve stability.
B. The screw should cross the center of the growth plate, and it should be per-
pendicular to the growth plate in both the AP and lateral projections (center
placement).
C. Because the epiphysis has slipped posteroinferiorly in relation to the femoral
neck, an anterior neck entry point is essential to allow center placement.
D. The screw should not enter the hip joint (checked on multiple radiographic What are your
views and under live fluoroscopy), should be at least 8 mm from subchondral attending’s preferences
bone, and should not cause femoral neck fracture. for single versus double
E. If two screws are used, the second screw should be placed inferior to the first. screw fixation?

I. The patient is placed on a radiolucent table in the supine position (some surgeons
use a fracture table).
II. The fluoroscope machine typically enters the operative field on the contralateral
side of the operative extremity.
III. The fluoroscope machine monitor should be placed on the contralateral side so
that the surgeon can easily view the fluoroscopic imaging during the course of the
operation.
IV. Ioban can be used to cover the perineal region to ensure additional sterility of the
operative site (Fig. 33-3).
V. A nonsterile impervious U-drape can then be placed as proximal as possible to
cover the gluteal region, and a drip sheet is placed under the patient’s leg to What are your
prevent staining of the operative table during the prep. attending’s preferences
for prepping and draping
VI. Refer to Chapter 1 for general instructions for prepping and draping (Fig.
the patient?
33-4).
Figure 33-3
Operating room setup. Patient placed supine on the
operating table, fluoroscope machine and monitor Figure 33-4
opposite the operative side, and perineal region The patient fully prepped and draped prior to
covered with Ioban. surgical incision.
A B
Figure 33-5
A, A guidewire is placed on the anterior thigh until it is (B) radiographically confirmed to be in line with the
central axis of the femoral epiphysis and is perpendicular to the physis.
Determination of Pin Entry Point/Skin Incision

I. The leg is slightly rotated internally to ensure that the patella is facing the ceiling
Determining the proper and is parallel with the floor.
skin incision/entry point II. A guidewire is placed on the anterior thigh until it projects over the center of
is a critical step to the
the epiphysis and is perpendicular to the physis on the fluoroscopic AP image
success of in situ pinning.
(Fig. 33-5).
III. The marking pen is used to draw the position of the guidewire on the skin. The
line is divided into four equal segments with lines numbered “0” to “4.”
IV. A small lateral skin incision is made in the region of the “1” for a grade I slip
(displacement of the epiphysis less than 30% of the width of the femoral neck).
V. Alternatively, the fluoroscope machine can be switched to a lateral view, and the
guidewire can be placed on the lateral aspect of the thigh until it is in line with
the central axis of the femoral epiphysis in this view. A line can be drawn along
the guide wire in this position. The intersection of the two drawn lines indicates
the position of the skin incision.
VI. A curved hemostat is used to spread through the soft tissues until reaching bone
(anterior aspect of the femoral neck). This position is confirmed fluoroscopically
(Fig. 33-6).
A B
Figure 33-6
A, Cross hatches marking possible skin incisions 0 to 4. Entry point “1” chosen (for a grade I slip) to make a
small lateral skin incision. B, A hemostat is used to spread through the soft tissue until encountering bone.
In Situ Pinning
I. A guidewire is then drilled into the femur under fluoroscopic guidance, ensuring
that the wire is perpendicular to the growth plate in both the AP and lateral pro-
jections, crosses the physis, and remains at least 8 mm from subchondral bone
(Fig. 33-7).
II. The guidewire is then left in place, and a depth gauge is used over the guidewire
to determine the length of the cannulated screw that will be used to pin the hip
(Fig. 33-8).
Pediatrics
III. After determination of the screw length, a cannulated drill bit is placed over the
guidewire to create a path for the cannulated screw. This is performed with the
drill under fluoroscopic guidance (Fig. 33-9).
IV. The drill is then removed (leaving the guidewire in place). The proper length
7.3-mm cannulated screw is then placed over the guidewire and advanced until it
crosses the physis; stop when the screw is approximately 8-mm from subchondral
bone and when 8- to 10-mm of screw threads (three or four threads) are engaged
in the epiphysis and have crossed the physis (Fig. 33-10).
V. Final AP and lateral fluoroscopic images are taken to ensure correct screw place-
ment (screw crosses the center of the physis, is perpendicular to the physis in the
AP and lateral planes, is 8 mm from subchondral bone, does not enter the hip
joint, and has not caused a femoral neck fracture).
VI. Prior to removal of the guidewire, the fluoroscope machine is placed in the “live”
setting and the hip is taken from maximum internal rotation to maximum external
Figure 33-7
A, A guidewire is inserted through skin incision
(B and C) under fluoroscopic guidance in line with
the center of the physis in both the anteroposterior
C
and lateral projections.
Figure 33-8
Depth gauge used to measure the length of the
cannulated screw that will be used.
Figure 33-9
Creation of a path for cannulated screw under
fluoroscopic guidance.
PLACING THE HIP THROUGH A rotation. During rotation, the tip of the screw appears to move closer to subchon-
RANGE OF MOTION UNDER
dral bone, and then begins to move away from it. The point at which the screw
LIVE FLUOROSCOPY PRIOR TO
goes from approach to withdrawal from the subchondral bone demonstrates the
CLOSING THE SKIN ENSURES
THAT THE SCREW DOES NOT
true position of the screw within the epiphysis (i.e., when it stops appearing as if
ENTER THE HIP JOINT AND the screw is moving into the hip joint). This allows for confirmation that the screw
THAT THE REDUCTION IS has not penetrated the hip joint (Fig. 33-11).
STABLE. STATIC VII. The guidewire is then removed, and the wound is irrigated with a bulb
ANTEROPOSTERIOR AND syringe.
LATERAL IMAGES CAN BE VIII. The incision is closed and dressed using a Tegaderm in standard fashion (Fig.
DECEPTIVE, AND A SCREW 33-12). (See Chapter 1.)
ENTERING THE JOINT CAN BE
MISSED.
POSTOPERATIVE CARE
I. Postoperative management includes pain control, antibiotics, and physical
therapy.
II. Patients are generally admitted overnight for pain control and crutch training.
III. Twenty-four hours of postoperative antibiotics are typically administered.
IV. The patient can begin work with physical therapy the next morning and is gener-
ally partially weight bearing on the operative leg with crutches (four-point gait is
used if both hips were pinned).
V. The majority of patients are discharged home on postoperative day 1.
Figure 33-10
Cannulated screw is passed over the guidewire.
Pediatrics
A B
Figure 33-11
Final anteroposterior (A) and lateral (B) radiographs demonstrating screw configuration.
A B
Figure 33-12
The incision is closed with an absorbable suture (A), and a sterile dressing is applied (B).
COMPLICATIONS
I. The most common surgical complication of in situ pinning is violation of the hip
joint that is not realized intraoperatively.
II. Potential sequelae of SCFE include osteonecrosis, leg length discrepancy
(unilateral SCFE), proximal femoral deformity, and risk of degenerative joint
disease later in life.
SUGGESTED READINGS
Aronsson DD, Loder RT, Breur GJ, Weinstein SL: Slipped capital femoral epiphysis: Current
concepts. J Am Acad Orthop Surg 14:666–679, 2006.
Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance
of physeal stability. J Bone Joint Surg Am 75:1134–1140, 1993.
Schultz WR, Weinstein JN, Weinstein SL, Smith B: Prophylactic pinning of the contra-lateral hip
in slipped capital femoral epiphysis. J Bone Joint Surg Am 84A:1305–1314, 2002.
C H A P T E R
34
Posterior Spinal Fusion for Adolescent
Idiopathic Scoliosis
Joshua D. Auerbach and John M. Flynn
Case Study
A 15-year-old otherwise healthy male presents with a diagnosis of “scoliosis,” for which
he has been treated in a brace for approximately 3 years. At the time of his initial diagnosis,
the patient was 12 years old and had no significant back pain or other associated symptoms.
Despite bracing, however, his major thoracic curve had progressed to 61 degrees from T7
to L2 (Fig. 34-1), and his minor curve measured 17 degrees from T2 to T6. Side-bending
films reveal a correction of the major curve to 31 degrees, and correction of the minor
curve to 11 degrees. The patient presents for definitive treatment of the curve.
BACKGROUND
I. Adolescent idiopathic scoliosis (AIS) is defined as a curvature of the spine that
measures greater than 10 degrees on the posteroanterior radiograph. The inci-
dence of AIS in the general population is estimated to be 1% to 3%, but the pro-
portion of patients with larger curves that may require treatment ranges from
0.15% to 0.30%.
II. The etiology of AIS is currently unknown (hence, “idiopathic”), although
several theories have been suggested to explain its origin. There is strong evidence
to suggest that AIS has a genetic component. Other theories that have received
some attention include structural and biomechanical changes in the disc and
muscle, central nervous system changes, melatonin, and, more recently,
genetics.
III. AIS is a three-dimensional spinal deformity, with alterations in rotation as well as
the coronal and sagittal planes. Although the etiology of initial curve inception
remains unknown, curve progression may be explained by the Heuter-Volkmann
law, which states that spinal growth is slowed by mechanical compression and
accelerated by distraction or reduced compression. Thus, curve progression may
propagate over time with an increasing magnitude and, often, rotational
component.
IV. The most commonly used classification system to characterize AIS is that
described by Lenke et al, which is a comprehensive, treatment-oriented,
highly reliable system. In this classification scheme, there are six major curve
types, three lumbar modifiers (based on the relationship between the location
of the apical vertebra and the central sacral vertical line), and a thoracic sagittal
alignment modifier. For details and a more comprehensive description, refer to
the original article by Lenke et al (additional details are in the Suggested
Readings).
C H A P T E R 3 4 Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis 385
Pediatrics
A B
Figure 34-1
Initial posteroanterior (A) and lateral (B) preoperative
scoliosis radiographs. C, Initial preoperative standing
C
clinical photograph.
V. The Lenke classification was designed not only to determine which patients
require surgery, but also which curves within the deformity (i.e., what levels are
involved in the fusion) need to be fused to produce a balanced, stable spine in the
coronal and sagittal planes. For example, in the curve described in the case study,
the thoracic curve is the primary curve, and it is structural because it does not
correct on bending to below 25 degrees. Therefore, this structural curve is inflex-
demonstrate how the
ible and requires surgery. The minor curve is nonstructural and therefore does Cobb angle is measured.
not need to be included in the fusion construct. Once it is determined which curve
needs to be fused, the surgeon must then decide which levels of the curve to fuse.
Back pain may be present
in as many as 23% of Although the ultimate construct chosen by the surgeon is determined on a case-
patients with adolescent by-case basis, a general rule for posterior spinal fusion is that the fusion usually
idiopathic scoliosis. If extends from the neutrally rotated vertebrae above to the neutrally rotated verte-
significant back pain brae below, with the lower vertebrae balanced over the sacrum. In most cases, the
exists, or if there are any Cobb angle of the curve is included into the fusion construct (1 or 2 levels above
red flags in the history and below to get to the neutral or stable vertebrae).
(e.g., night pain or weight
loss) or abnormalities on
physical examination,
consider workup for INITIAL EVALUATION
another potential source
for the pain (e.g., spinal
infection or tumor). A. Risk factors for curve progression (is the child still growing?)
1. Age
2. Gender
3. Menarche
4. Tanner grading
5. Triradiate cartilage
6. Risser stage
7. Clinical appearance (rotation, rib hump, thoracic hypokyphosis, truncal
balance)
B. Ability to tolerate bracing regimen (i.e., compliance)
C. Cosmesis
D. Medical comorbidities
A. Take a thorough history, being sure to account for the following:
1. Low back pain
2. Functional limitations
3. Self-esteem issues, including perception of deformity
4. Scoliosis Research Society (SRS-22) scores (functional outcomes assessment
What assessment tools questionnaire)
does your attending use 5. Prior treatment
to evaluate patients with 6. Family history of scoliosis
adolescent idiopathic 7. Growth spurt
scoliosis? 8. Neurologic symptoms
B. Perform a thorough physical examination, being sure to account for the
following:
1. Spine flexibility/range of motion in flexion, extension, lateral bending, and
axial rotation
2. Neurologic examination (deep tendon reflexes, abdominal reflex)
a. L4 reflex: patellar tendon
BE SURE TO EVALUATE FOR b. S1 reflex: Achilles tendon
POSSIBLE “WARNING SIGNS”
c. Abdominal reflex: asymmetrical contraction of the rectus abdominuis
THAT THE CURVE MAY BE A
when the examiner scratches the patient’s belly. This is a possible indi-
MANIFESTATION OF ANOTHER
UNDERLYING DISEASE
cation of intraspinal pathology (i.e., tumor, infection) that requires
PROCESS THAT MAY WARRANT further evaluation.
FURTHER IMAGING, SUCH AS 3. Lower extremity pulses
MAGNETIC RESONANCE. SOME 4. Midline tenderness
CLASSIC WARNING CRITERIA 5. Hairy patches over sacrum or lower lumbar spine, indicative of
INCLUDE LEFT THORACIC diastematomyelia
CURVES; MALE SEX; 6. Pelvic asymmetry in standing position
NEUROLOGIC ABNORMALTIES, 7. Shoulder asymmetry
INCLUDING ASYMMETRIC 8. Rib hump deformity
ABDOMINAL REFLEX; AND A
9. Limb length discrepancy (and apparent limb length discrepancy)
RAPIDLY PROGRESSIVE CURVE.
10. Presence of pigmented lesions and subcutaneous tumors
C. Radiographic evaluation
1. Posteroanterior standing 36-inch cassette

2. Lateral standing film with arms folded across chest
3. Side-bending films (can use traction films, or bolster side-bending films at
the curve apex)
4. Further imaging (i.e., computed tomography, bone scan, magnetic reso-
nance imaging considered on an individual basis)
TREATMENT PROTOCOLS
Pediatrics
I. Nonoperative treatment with bracing is indicated in the following:
A. Curves greater than 25 to 45 degrees on initial presentation
B. Curves greater than 20 degrees with documented progression (e.g., >5
degrees)
C. Patients with significant growth remaining (Risser 0 to 2)
D. Patients with significant spinal decompensation
II. Operative indications in adolescents
A. Actively growing child presenting with a 40- to 45-degree or larger curve
B. Progression in a child undergoing nonoperative treatment and a 40-degree or
larger curve
C. Curves more than 50 to 60 degrees in a mature adolescent
III. Operative treatment (posterior spinal fusion):
A. Preoperative surgical templating FUSIONS ENDING AT L4 OR L5
1. Using the Lenke curve (see Suggested Readings for additional details) clas- HAVE A HIGHER RATE OF BACK
sification as a general guide, determine which curves within the deformity PAIN AT LONG-TERM FOLLOW-
need to be fused (i.e., identify structural curves). UP. THEREFORE, THE DISTAL
2. Plan proximal and distal fusion levels to achieve a balanced, stable spine FUSION LEVEL SHOULD BE AS
centered over a level pelvis. HIGH IN THE LUMBAR SPINE
B. Posterior spinal fusion (PSF): neutral vertebra to neutral vertebra. There are AS POSSIBLE TO SAVE THE
several fixation options available. Most surgeons use a combination of the fol- MAXIMUM NUMBER OF
lowing devices: LUMBAR MOTION SEGMENTS
WHILE STILL ACHIEVING A
1. Transverse process hooks
BALANCED SPINE ADHERING
2. Sublaminar wires
TO ESTABLISHED PRINCIPLES.
3. Pedicle hooks
4. Pedicle screws
SURGICAL ALGORITHM
What type of thoracic

Adolescent with scoliotic curve
fixation does your
attending use in an
uncomplicated flexible
History and physical examination curve? Hooks? Pedicle
screws? Sublaminar
wires?
AP and lateral standing radiographs
Bending radiographs
MRI for specific cases What type of spinal cord
monitoring does your
attending use?
Transcranial motor-
Curve 25° Curves 25° –45° Curve 45° evoked potential
monitoring?
Somatosensory-evoked
Surgical correction potential monitoring?
Observation Bracing
of the curve Both?
Figure 34-2
Posteroanterior and lateral
radiographs demonstrating hybrid
construct with claw hook
proximally, combination of
sublaminar cables and thoracic
pedicle screws in the thoracic
spine, and lumbar pedicle screws.
GENERAL PRINCIPLES OF POSTERIOR SPINAL FUSION FOR ADOLESCENT

IDIOPATHIC SCOLIOSIS
I. Goals. The major goals of PSF used to treat AIS are as follows:
A. Prevention of progression of spinal deformity
B. Safe curve correction using multimodal spinal cord monitoring techniques
when feasible
C. Achievement of a solid bony fusion
D. Achievement of a balanced spine (coronal and sagittal planes) over a level
pelvis
E. Fusion of the minimal number of motion segments as possible to achieve the
above goals
II. The following are the three most common type of PSF constructs used:
A. All-hook construct. Sublaminar or pedicle hooks are used as the sole fixation
methods throughout the construct.
B. Hybrid construct. This construct uses a combination of hooks, pedicle screws,
and sublaminar wires (Fig. 34-2).
1. Typical construct consists of a claw construct at the proximal aspect (i.e.,
down-going transverse process hook at top of construct, up-going trans-
verse process hook at bottom of claw, usually one or two levels below top
fixation point).
2. Sublaminar wires and pedicle hooks at the curve apex spine.
3. Pedicle screws at the base of the construct in the lumbar spine.
C. All-screw construct: Pedicle screws placed at all fixation points throughout the
construct.

I. Neuromonitoring, anesthesia, and nursing teams place electrodes, intravenous
lines, an arterial line, and a Foley catheter with the patient in a supine position
prior to starting the case.
II. In preparation for the patient to be “flipped” onto the Jackson table in a prone
position, several steps are taken first:
A. If the patient is female, it may be necessary to protect the nipples as well as
prominent iliac crests with Tegaderm (nonabrasive) tape.
B. Place one bolster in line with the patient’s anterior superior iliac spine.
C. Place a second bolster in line with the middle of the chest.
D. Place gel pads over uncovered bolster areas that will come into contact with
the patient’s skin.
Pediatrics
Patient in prone position on Jackson table with Patient positioning with additional gel pads placed
appropriate padding. under the lower extremities, allowing for knee
flexion.
E. The anesthesia team places a foam pad over the face of the patient and removes
the breathing tube.
IF THE ABDOMEN IS NOT LEFT
III. Acting in concert, the team gently “flips” the patient into a prone position onto
TO HANG FREELY DURING THE
the Jackson table. The patient lies supine with well-padded bolsters over the iliac PROCEDURE, THEN VENOUS
crest and chest (Fig. 34-3). RETURN TO THE HEART IS
IV. Place additional gel pads under the proximal thighs. DECREASED. THIS RESULTS IN
V. Place several pillows under the legs of the patient to keep the knees off of the table. INCREASED VENOUS
The legs are flexed at the knees with a pillow or bump under the leg (Fig. 34-4). CONGESTION OF THE VENOUS
VI. Ensure that the patient’s abdomen is freely hanging and not compressing the PLEXUS AROUND THE SPINE
inferior vena cava, which could result in reduced venous return and increased AND THUS AN INCREASED
bleeding in the surgical field. POTENTIAL FOR BLOOD LOSS.
VII. Positioning of the Arms
A. Ensure that the arms are abducted and flexed almost to but not beyond 90
degrees, because this may place unwanted traction on the brachial plexus (Fig.
34-5).
B. There should be, however, enough room for the surgeon and surgical assistant
SOMATOSENSORY-EVOKED
to stand below the patient’s elbows during the case. POTENTIALS CAN DETECT
C. Place elbows either under a pillow or custom-foam pad to prevent ulnar nerve BRACHIAL PLEXOPATHY
compression during the case SECONDARY TO ARM
D. Make sure the patient is level on the table and that adequate lumbar lordosis POSITIONING DURING
has been restored. If necessary, gel pad and bolster height, or additional pillows SCOLIOSIS SURGERY (MOST
underneath the thighs, can be adjusted to ensure proper lordosis. COMMONLY, ULNAR NERVE).
VIII. Once in the prone position, it is necessary to shave the patient along the midline,
often including the base of the neck/hairline when instrumentation is planned for MAKE SURE TO OBTAIN A
the upper thoracic spine. BASELINE LEVEL OF MOTOR
IX. The surgical field should be prepped and draped in standard fashion according to FUNCTION PRIOR TO STARTING
the surgical principles outlined in Chapter 1 (Fig. 34-6). THE PROCEDURE (FIG. 34-7).
Figure 34-5
Image demonstrating proper arm positioning while
in the prone position on a Jackson table.
Figure 34-6
Patient prepped and draped with Ioban covering of
the surgical field.
Figure 34-7
Neurophysiologist setup at the side of the operating
room for neuromonitoring.
Surgical Exposure (“Stripping the Spine”)

I. Mark out the intended incision in a straight line from approximately C7 to the
middle of the sacrum. In most cases, a straight incision can be made and the patient
will still end up with a straight scar postoperatively. In more severe curves,
however, it may be necessary to gently curve the incision to end up with a straight
scar.
II. Using a 10-blade, cut through skin only. Use a Bovie to dissect through the tough
dermis of the back. Continue to use a Bovie to dissect down to the fascia, or the
“white line” overlying the supraspinous ligament and apophyseal caps of the
spinous processes.
III. Once the white line is exposed from top to bottom, take a Kelly clamp and spread
over each spinous process individually while the surgeon uses the Bovie to dissect
down through the apophyseal cartilage, being sure to stay midline (Fig. 34-8). If
the Bovie strays to either side of the middle of the cartilage cap, there is an
increased risk of bleeding from the surrounding musculature. Use the Bovie to
then connect the lines between spinous process splitting. During this portion of
the dissection between the spinous processes, it is critical to not let the Bovie
plunge deep as the dura lies beneath.
Pediatrics
Posterior surgical approach to the spine. A Bovie Cobb elevators are used to dissect away the
cautery is being used to dissect through the thick paraspinal musculature. This is called “stripping the
apophyseal cartilage typically encountered in spine.”
pediatric spine cases.
IV. The assistant then takes a Cobb elevator and gently pushes the split cartilage cap
toward the side of the surgeon, who uses the Bovie to subperiosteally dissect the
ipsilateral paraspinal musculature and fascia off the spinous processes and laminae.
In the surgeon’s hand should be a Cobb elevator to assist in placing the tissues on
tension, and in the other hand should be the Bovie and suction (Fig. 34-9). In the
assistant’s hand should be Cobb elevators putting the tissue under tension. In the
first “stage” of this dissection, this process is continued until the laminae are dis-
sected clean. Then the assistant and the surgeon switch roles and the other side
is similarly dissected. Sometimes the surgeon and the assistant simultaneously strip
the paraspinal musculature (Fig. 34-10). In that case, each individual surgeon has
Suboccipital muscles
Splenius muscle
Longissimus muscle
Erector spinae
muscles Iliocostalis muscle
Spinalis muscle
Deep group
Intrinsic muscles
True back muscles innervated by posterior rami of spinal nerves
Figure 34-10
Illustration of paraspinal musculature covering the spine. (From Drake RL, Vogl W, Mitchell AWM: Gray’s
Anatomy for Students. Philadelphia, Churchill Livingstone, 2005.)
a Cobb in one hand and the Bovie in the other, and a second assistant is required
to hold the suction (cell saver).
V. In the second “stage” of the exposure, the dissection continues out laterally beyond
the facet joints, and the final “stage” carries the dissection out laterally beyond the
transverse processes. Alternatively, all stages of the exposure can be performed on
the first pass. Care must be taken once the dissection extends beyond the facet
joint, in between transverse processes, because there is usually an increase in the
amount of bleeding in this area due to the proximity of the segmental lumbar
vessels that supply the paraspinal musculature.
Facetectomy
I. Facetectomy is performed to remove facet cartilage along the spine that can
facilitate bony fusion. Failure to perform this step leaves facet articular cartilage
intact, which may impede bony fusion by enabling contact and possibly motion
between two cartilaginous surfaces. Facetectomy is also performed to more clearly
define the bony anatomy for placement of pedicle hooks and thoracic pedicle
screws.
II. Using a semilunar-shaped osteotome (or quarter-inch osteotome), identify and
outline the inferior articular facet.
III. Once the edges are outlined, remove this bone and cartilage with a curette and a
rongeur. Then use a small curette to scrape off the remaining articular cartilage
of the facet joint so that bleeding bony surfaces are apposed.
Basics of Instrumentation Techniques

I. Transverse Process Hook
A. Following proper exposure, place the transverse process “finder” (similar to
canal finder) around the superior aspect of the transverse process to clear off
soft tissue that would impede hook placement.
B. Place the hook at the top of the transverse process and then slowly rotate the
hook around, taking care not to fracture the transverse process. Special care
must be taken in patients with compromised bone quality to prevent transverse
process fracture (Fig. 34-11).
Figure 34-11
Middle hook claw constructs in the superior thoracic spine. (From Kim DH, Henn FS, Vaccaro AR, Dickman
CA [eds]: Surgical Anatomy & Techniques to the Spine. Philadelphia, Saunders, 2006.)
II. Pedicle Hook

A. Following proper exposure, place the pedicle hook “finder” underneath the
pedicle.
B. Place the pedicle hook finder initially at the level of the pedicle at a 45-degree
angle to the surgical field. Then once you have cleared the lamina, the sur-
geon’s hand should be brought into a position more level with the plane of the
operative field.
C. Be sure to be completely underneath the pedicle, and do not split the lamina
during insertion of the finder. This creates poor fixation and possibly a laminar
Pediatrics
fracture.
D. Now secure the pedicle hook in place.
III. Pedicle Screw
A. Starting points for each thoracic pedicle screw can be determined based on
established bony landmarks (see Suggested Readings for additional details). A
detailed description of the technique is beyond the scope of this text.
B. In general, the starting point for lumbar pedicle screws is usually at the junc-
tion of the pars interarticularis, the transverse process, and the lateral border
of the inferior articular facet.
C. General steps for pedicle screw placement:
1. Once the starting point is identified, use a rongeur or a burr to start the hole.
Then, use the gear shifter with the tip pointed outward for the first 20 mm.
Use a wiggling and gentle twisting motion to advance the gear shifter. Use
your nondominant hand to exhibit controlled use of the gear shifter and to
prevent plunging. After reaching the 20-mm mark, remove the gear shifter,
turn it 180 degrees, replace the gear shifter with the tip aimed medially in
the same trajectory of the channel already created, and continue to slowly
advance. Use intraoperative fluoroscopy or computed tomography to ensure
proper trajectory in both the sagittal and coronal directions. Immediately
on removing the gear shifter, insert FloSeal, a thrombogenic paste, into the Motor testing should be
pedicle channel to assist in maintaining hemostasis. repeated after each
2. Take a probe to feel for intact walls laterally, medially, superiorly, inferiorly, pedicle screw is placed to
ensure that the screw is
and ventrally to evaluate for possible pedicle breech. This step is followed
not impinging on the
by tapping the tract, using a depth gauge, and securing the pedicle screw spinal cord.
(Fig. 34-12).
Basics of Curve Correction Techniques

I. A variety of curve correction techniques exist in clinical practice, and the method
chosen is highly dependent on the surgeon. Some of the more common techniques
include cantilever, distraction/compression, rod derotation, direct vertebral rota-
tion, and translation. The basic principles of the rod rotation maneuver for the
correction of thoracic scoliosis with a combined hypokyphosis in the sagittal plane
using a 90 degrees counterclockwise rod rotation technique will be presented.
Figure 34-12
Insertion of an end cap used to secure a pedicle
screw to the posterior fusion rod. (Courtesy of
Dr. B. Lonner.)
Figure 34-13
Curve distraction between two points of pedicle
screw fixation along the posterior fusion
rod. (Courtesy of Dr. B. Lonner.)
II. The first rod placed is responsible for a large part of the ultimate correction
that is achieved. The rod is precontoured to match the patient’s scoliosis by
first using a flexible template rod. The rod is then secured into the fixation points
on one side of the curve. Next, using rod derotators, the rod is rotated in such
THE MEAN ARTERIAL
a way so as to reverse the rotational component of the curve, usually in a
PRESSURE IS TYPICALLY
MAINTAINED ABOVE 75 TO counterclockwise fashion. As a result, the scoliosis curve is then rotated from a
80 MM HG DURING curve in the coronal plane to a curve in a plane 90 degrees from where it started
CORRECTION TO MAXIMIZE (i.e., the sagittal plane). In other words, the rod that is originally contoured to fit
THE PERFUSION OF THE the scoliosis curve becomes the kyphosis curve in the sagittal plane following
SPINAL CORD. IT IS ALSO derotation.
IMPORTANT TO CHECK MOTOR III. After templating for length and shape, the second rod is then placed.
SIGNALS DURING AND AFTER IV. Next, sequential compression and distraction maneuvers are used to fine-tune the
CORRECTIVE MANEUVERS TO correction, with the goal being to straighten the curve and to achieve a level ver-
ENSURE THAT THERE HAS tebrae at the distal fusion level (Fig. 34-13).
BEEN NO SPINAL CORD
V. Once the final correction has been achieved, set screws are placed into the fixation
COMPROMISE.
points, followed by final screw tightening.
Wound Closure
I. Once all instrumentation is placed and final screw/wire tightening has taken place,
and copious irrigation and hemostasis is performed, the deep fascia is closed in
standard fashion (see Chapter 1). It is critical to achieve a watertight fascial
closure.
II. Following placement of the deep sutures of the lumbar fascia, place a running 0-
Vicryl suture in a caudal to cranial direction.
III. The subcutaneous layer and skin are closed in standard fashion, using a subcuticu-
lar closure for the skin. A sterile dressing is then placed along the length of the
back to cover the wound.
Does your attending
IV. Before the patient is flipped into the supine position, AP and lateral films
prefer placement of a
postoperative drain? are taken, which must include the most proximal and distal aspects of the
construct.
V. Once it is confirmed that all instrumentation is in place, the patient is flipped
Be sure to achieve supine and extubated.
meticulous hemostasis VI. The final step before the patient is brought to the postanesthesia care unit is a
prior to commencing wake-up test, where the patient is instructed to move the feet and toes to
closure. command.
POSTOPERATIVE CARE
When does your
I. The decision whether to use a brace postoperatively is surgeon-dependent. In
attending use a brace
postoperatively?
most cases, spinal fixation is rigid and there is no need for postoperative
immobilization.
Pediatrics
A B C
Figure 34-14
Postoperative posteroanterior (A) and lateral (B) scoliosis radiograph demonstrating posterior spinal fusion
with thoracic pedicle screw instrumentation from T6-L2. C, Postoperative clinical photograph.
II. Postoperatively, patients should return at 6 weeks for assessment of the wound
and radiographic evaluation of the hardware.
III. Postoperative radiographs should be taken at the following times:
A. Prone film in the operating room after all instrumentation is inserted and
before patient is flipped into the supine position and awakened from surgery
to ensure proper placement of all instrumentation.
B. Standing posteroanterior and lateral film should be taken prior to discharge
from hospital in brace (if a brace is prescribed; Fig. 34-14).
C. Postoperatively, at 6 weeks
D. At 6 months
E. At 1 year
COMPLICATIONS
I. The most worrisome intraoperative complication is a spinal cord injury that mani-
fests as a new-onset neurologic deficit. The most common maneuvers that put the
cord at risk are distraction during the corrective maneuvers, hypotension, and cord
contusion from placement of instrumentation.
II. Other complications include:
A. Infection
B. Pseudarthrosis
C. Painful hardware
D. Loss of correction
SUGGESTED READINGS
Akbarnia BA, Segal LS: Infantile, Juvenile, and Adolescent Idiopathic Scoliosis. In Spivak JM,
Connolly PJ (eds): Orthopaedic Knowledge Update (OKU): Spine, 3rd ed. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 2006, pp 443–458.
Kim YJ, Lenke LG, Bridwell KH, et al: Free hand pedicle screw placement in the thoracic spine:
Is it safe? Spine 29:333–342, 2004.
Lenke LG, Betz RR, Harms J, et al: Adolescent idiopathic scoliosis: A new classification to determine
extent of spinal arthrodesis. J Bone Joint Surg Am 83-A:1169–1181, 2001.
Vaccaro AR, Albert TJ: Spine Surgery: Tricks of the Trade, 2nd ed. New York, Thieme, 2003.
INDEX
Note: Page numbers followed by f indicate figures; t, tables; b, boxes.
A Achilles tendon (Continued) AIS. See Adolescent idiopathic scoliosis

tears/rupture (Continued) Alcohol consumption, and osteonecrosis of femoral
ACDF. See Anterior cervical diskectomy and fusion surgery for head, 174, 188
(ACDF) contraindications to, 347 Allograft
Ace bandage, 3 indications for, 347 for ACL reconstruction, 241
Acetabular cup, in total hip arthroplasty principles, 348 definition, 241
anteversion angle, 189, 189f Thomson test for, 345, 345f Anconeus epitrochlearis, and ulnar nerve compression
theta angle (coronal tilt), 189, 189f treatment at elbow, 72
Acetabular fractures algorithm for, 348 Angiography, in lower extremity, indications for,
anterior column, 150 nonoperative, 346–347 289
anterior wall, 150 ultrasound, 347, 347f Ankle
associated fractures, 150 watershed (hypovascular) region, 345 injury, with tibial shaft fracture, 315
complex patterns, 150 ACL. See Anterior cruciate ligament instability, 329
elementary patterns, 150 Acromioclavicular (AC) joint mortise view, 327, 328f, 329
Judet-Letournel classification, 150 resection, for rotator cuff repair, 23 radiographic evaluation, Ottawa rules for,
posterior column, 150 stability, ligaments contributing to, 23 327
posterior wall, 150 Acromioclavicular (AC) ligaments, 23 stress view, 329
case study, 149, 149f Acromiohumeral distance, 22 Ankle fracture(s)
epidemiology, 150 Acromion bimalleolar, treatment, 331
imaging, 151, 151f, 152f anatomy, 8, 8f case study, 327, 328f
neurovascular evaluation with, 150–151 morphology classification, 327, 329f
open reduction and internal fixation, 149–158 assessment, 7f, 10, 10f, 22 epidemiology, 327
anatomical considerations in, 154–155 types, 10, 10f, 22 fixation, principles, 329
complications, 156–158 Acromioplasty. See also Subacromial decompression open reduction and internal fixation
fracture reduction technique for, 156 pitfalls, 17 complications, 333
positioning for, 155, 155f technical problems, 17 contraindications to, 330
postoperative care for, 156–158 Adhesive capsulitis (shoulder), 20, 56 indications for, 330
prepping and draping for, 155 Adolescent idiopathic scoliosis lateral malleolus exposure and fixation in, 331,
rehabilitation for, 158 bracing for, 387 331f, 332f
surgical exposure for, 155–156, 155f case study, 384, 385f medial malleolus reduction in, 332–333,
and posterior hip dislocation, 150 classification, 384–386 332f
roof arc angle with, 153, 153f curve progression in, 384 positioning for, 331
stable, management, 152 risk factors for, 386 postoperative care for, 333
surgical anatomy, 154–155 definition, 384 prepping and draping for, 331, 331f
surgical treatment differential diagnosis, 386 principles, 330–331
contraindications to, 152 epidemiology, 384 rehabilitation for, 333
delayed, 153 etiology, 384 splinting in, 333
emergent, 152 history taking for, 386 syndesmotic fixation in, 333
indications for, 152 neurologic examination for, 386 wound closure in, 333
timing, 152–153 physic examination for, 386 radiography, 327–329, 328f
treatment posterior spinal fusion for, 387 treatment
algorithm for, 151 algorithm for, 387 algorithm for, 329
considerations for (decision making for), all-hook construct for, 388 nonoperative, 329
150 all-screw construct for, 388 Ankylosing spondylitis, 188
initial approach, 150–151 arm positioning in, 389, 389f glenohumeral joint, 60
nonoperative, 151–152 complications, 395 knee in, 256
unstable, 151, 153, 154f curve correction techniques for, 393–394, 394f Anterior apprehension test, for shoulder instability,
management, 152 facetectomy in, 392 37
transverse, 150 hybrid construct for, 388, 388f Anterior cervical diskectomy and fusion (ACDF),
Acetaminophen, for osteoarthritis of hip, 186 instrumentation techniques for, 392–393, 392f 115–126
Achilles tendon monitoring during, 388–389, 390f alternatives to, 118
blood supply to, 345 pedicle hook placement in, 393 case study, 115, 116f
repair pedicle screw placement in, 393, 393f complications, 126
complications, 350–351 positioning for, 388–389, 389f contraindications to, 118
débridement of tendon ends in, 348–349 postoperative care for, 394–395 diskectomy technique for, 122–124,
incision for, 348 postoperative radiography in, 395, 395f 122f–123f
positioning for, 348, 349f prepping and draping for, 388–389, 390f goals, 118
postoperative immobilization with, 349–350 principles, 388 grafts for
prepping and draping for, 348, 349f spinal cord injury in, 395 choices, 118
principles, 348 spinal cord perfusion during, 394 placement, 122–124, 124f
rehabilitation after, 350 surgical exposure for, 390–392, 391f plating/stabilization, 119, 124–125, 125f
surgical approach for, 348–349, 349f transverse process hook placement in, 392, 392f sizing, 118–119
technique for, 349, 349f, 350f wound closure in, 394 imaging after, 126
wound closure in, 349 radiographic evaluation, 386–387 indications for, 115–116
tears/rupture treatment intraoperative monitoring in, 119
case study, 344, 344f algorithm for, 387 osteophyte resection in, 119, 123, 123f
epidemiology, 344 considerations for (decision making for), 386 positioning for, 119
history taking for, 344, 345 initial approach, 386–387 postoperative care for, 125–126
imaging, 346 nonoperative, 387 prepping and draping for, 119–120, 120f
immobilization for, 346, 347f operative principles, 118–119
missed diagnosis, 345 indications for, 387 surgical approach, 120–122, 120f–122f
partial, 345 preoperative surgical templating for, 387 surgical indications for, 118
physical examination for, 345 warning criteria, and differential diagnosis, 386 wound closure, 125, 126f

398 Index
Anterior cruciate ligament Arthritis (Continued) Baumann’s angle, 369, 369f

anatomy, 237–238 glenohumeral joint (Continued) Betadine
biomechanics, 237–238 epidemiology, 56 allergy, 2
chronic deficiency, 238–239 etiology, 56 for preoperative prep, 2
diagnostic arthroscopy of, 242 inflammatory, 56, 60 Betamethasone injection, for trigger finger, 93
examination, under anesthesia, 242 nonoperative treatment, 60 Blood products, 1
functions, 240 physical examination for, 56 Blumensaat’s line, 220
injuries, with tibial plateau fractures, 303 postinfectious, 60 Bone scan
reconstruction psoriatic, 60 of hip fractures, 201
ACL stump removal in, 244, 245f and range of motion, 56 of osteonecrosis of femoral head, 175
allograft for, 241 treatment algorithm for, 57 Box-type suture technique, for Achilles tendon repair,
autograft for, 241 inflammatory, 188, 251 350f
complications, 250 of knee, 256 Boyd and Griffin classification, of intertrochanteric
considerations for (decision making for), knee in, 256 hip fractures, 200
239–240 juvenile idiopathic, 188 Brachial artery injury, with supracondylar humerus
contraindications to, 240 of knee, 256 fracture in children, 366
femoral tunnel preparation for, 246–247, 247f of knee, case study, 251, 252f Brachial plexus injury, 20
graft for post-traumatic, after open reduction and internal Bristow procedure, 39
Achilles tendon, 241 fixation of posterior wall fractures, 157–158 Bunion
bone-pateller tendon-bone, 241, 242–243, 243f psoriatic, 188, 251 clinical presentation, 353
donor site morbidity, 250 knee in, 256 definition, 353
fixation, 248, 248f treatment, 251–252 and hallux valgus, differentiation, 353
harvest, 242–243, 243f Arthrography, of rotator cuff tears, 22 physical examination for, 354
placement, 248, 248f Arthroscopy treatment
positioning, 240–241 diagnostic conservative approach, 355
preparation, 243–244, 244f in Bankart lesion repair, 41 surgical
quadrupled hamstrings, 241 in knee, 234, 242 contraindications to, 356
tensioning, 241 in rotator cuff repair, 28–29, 29f indications for, 356
tibialis anterior tendon, 241 in shoulder, 15 Bunion spica dressing, 360, 360f
types, 241 in superior labral anterior and posterior (SLAP) Bunnell suture technique, for Achilles tendon repair,
indications for, 240 tear repair, 49–50, 50f 350f
notch plasty for, 244–245, 245f of knee compartments, 231–232, 232f
positioning for, 242 diagnostic, 234
postoperative care for, 249 figure-of-four position for, 234, 234f C
prepping and draping for, 242 for subacromial decompression, 7–18
principles, 240–241 Aseptic necrosis, after open reduction and internal Caisson’s disease, and osteonecrosis of femoral head,
procedure for, 241–249 fixation of posterior wall fractures, 157–158 174
rehabilitation for, 249–250 Autograft Calcar femorale, 200
and restoration of normal knee kinematics, for ACL reconstruction, 241 Canoe technique, for pedicle screw placement in
240–241 definition, 241 lumbar spine, 143
sequelae, 238–239 Axillary nerve Capsular release, arthroscopic, for glenohumeral
surgical variations, 241 anatomy, 15 arthritis, 58
tibial tunnel preparation for, 245–246, 246f injury, intraoperative, risk factors for, 14 Carpal compression test, 99
wound closure in, 249 motor function, assessment, in shoulder dislocation, Carpal tunnel
tear 37 anatomy, 97, 98f
associated injuries, 239 median nerve variations in, 97, 98f
case study, 237, 237f, 238f Carpal tunnel release, 97–103, 103
complete B case study, 97, 97f
healing, 240 complications, 103
reconstruction, 240 Back pain, 128–129 contraindications to, 101
diagnostic maneuvers for, 238, 238f in adolescent idiopathic scoliosis, 386 endoscopic, 101
epidemiology, 238 after scoliosis surgery, 387 incisions for, 101–102, 102f
mechanism of injury in, 238 with lumbar degenerative spondylolisthesis/ indications for, 100–101
treatment stenosis, 136, 137 open, 101
algorithm for, 239 Back school, 129 positioning for, 101
considerations for (decision making for), Bacteriostatic agents, for preoperative prep, 2 postoperative care for, 102
239–240 Bankart lesion prepping and draping for, 101
nonoperative, 240 bony, 37 principles, 101
protocols for, 239–240 case study, 34, 34f recovery after, 101
in total knee arthroplasty, 258, 260 descriptors for, 37–38 rehabilitation for, 103
Anterior interosseous nerve, anatomy, 71f history taking for, 36 technique for, 102, 102f, 103f
Antibiotics pathology, 36, 38 wound dressing after, 102, 103f
preoperative intravenous, 1 physical examination for, 36–37 Carpal tunnel syndrome
prophylactic, after total hip arthroplasty, 195 radiographic evaluation, 37 acute, 99, 106
Anti-inflammatory drugs, for lumbar disk herniation, repair case study, 97, 97f
129–130 arthroscopic, 39–42 causes, 99
AO/OTA. See Orthopaedic Trauma Association diagnostic arthroscopy in, 41 clinical presentation, 99
classification portal closure in, 42 and cubital tunnel syndrome, co-occurrence, 70
Arcade of Struthers, and ulnar nerve compression at portal placement in, 41, 41f diagnosis, 99
elbow, 72 technique for, 41–42, 41f, 42f differential diagnosis, 99
Arcuate ligament, 70 complications, 43 electromyography in, 99
and ulnar nerve compression at elbow, 72 contraindications to, 39 nerve conduction velocity in, 99
Arm-holding device, mechanical, 13, 13f open, 39–40 physical examination for, 99
Arthritis, 55–56. See also Osteoarthritis; Rheumatoid patient positioning for, 40–41, 40f, 41f severity, determination, 99
arthritis (RA) postoperative care for, 42–43 treatment
clinical presentation, 251 prepping and draping for, 40–41 algorithm for, 100
definition, 251 rehabilitation for, 43 corticosteroid injections for, 100, 101f
degenerative, 251 surgical indications for, 39 nonoperative, 100
enteropathic, 188 surgical principles, 39–40 operative
knee in, 256 treatment indications for, 100
of first metatarsophalangeal joint, 353, 354–355 algorithm for, 36 options for, 101
glenohumeral joint nonoperative, 38 splinting for, 100
clinical presentation, 56, 60 protocols for, 36–38 Cauda equina, anatomy, 133
crystalline, 60 surgical alternatives for, 38–39 Cauda equina syndrome, 128
enteropathic, 60 Barton’s fracture, 105 Cefazolin (Ancef), preoperative intravenous, 1
Index 399
Cervical spine. See also Anterior cervical diskectomy Corticosteroid injection(s) (Continued) Distal humerus fractures (Continued)
and fusion (ACDF) intra-articular (Continued) with spiral component, 83
arterial anatomy, 123–124, 124f for osteoarthritis of hip, 186 total elbow arthroplasty for, 83
degenerative disk disease, 115–116 subacromial, 22 treatment
with disk herniation, 115–117, 116f for trigger finger, 93, 93f algorithm for, 84
evaluation for, 116–117 Cubital tunnel, anatomy, 70 considerations for (decision making for), 81–82
imaging, 116–117 Cubital tunnel retinaculum, 70 nonoperative, 83
magnetic resonance imaging, 117 Cubital tunnel syndrome operative, 83–88
with myelopathy, 115–117 and carpal tunnel syndrome, co-occurrence, 70 type A, 81
nonoperative treatment, 117 case study, 70 type B, 81
physical examination for, 116 clinical presentation, 73 type C, 81
progression, risk factors for, 117 diagnosis, 72–73 Distal metatarsal articular angle, 354f, 355
with spondylosis, 115, 116f differential diagnosis, 73 Distal radius fractures
treatment electromyography in, 73 age distribution, 105
algorithm for, 117 imaging studies, 73 case study, 104, 104f
nonoperative, 117 nerve conduction velocity in, 73 classification, 105, 105f, 105t
surgical alternatives for, 118 physical examination for, 72 epidemiology, 104–105
neural anatomy, 123–124, 124f prognosis for, 73–74 eponyms for, 105
soft disk herniation, 115, 117 treatment fixation, principles, 109
spondylosis, 115, 116f algorithm for, 74 imaging, 106
nonoperative treatment, 117 by anterior transposition of ulnar nerve, 74–75 immobilization, 106
Charcot arthropathy, glenohumeral joint, 60 decision making about, 73–74 open reduction and internal fixation, 104–112
Chauffeur’s fracture, 105 by in situ decompression, 74, 76 complications, 112
Chiari osteotomy, 188f by medial epicondylectomy, 74–75 dorsal approach, 108, 110–111, 110f
Chondrocalcinosis, anterior knee pain in, 256 nonoperative, 74 fracture reduction and fixation technique for,
Chondroitin sulfate, oral supplementation, for operative, 74–80. See also Ulnar nerve decompression 111, 111f
osteoarthritis of hip, 186 Cubitus varus, after surgical treatment of positioning for, 109
Chymopapain chemonucleolysis, for lumbar disk supracondylar humerus fracture in child, 374 postoperative care for, 111–112
herniation, 131 prepping and draping for, 109, 109f
Clavicle, distal results, 112
excision D volar approach, 108, 109f, 110
limit of, 23 wound closure, 111
for rotator cuff repair, 23 Dashboard injuries, 150 physical examination for, 106
osteolysis, 23 Débridement, arthroscopic, for glenohumeral reduction (closed), 106
Clindamycin, preoperative intravenous, 1 arthritis, 58 risk factors for, 105
Cobb angle, 386 Deep flexor pronator aponeurosis, 70 scaphoid fracture associated with, 106
Colles’ fracture, 105 and ulnar nerve compression at elbow, 72 treatment
Compartment syndrome Deep vein thrombosis algorithm for, 108
in lower extremity, 275, 312 with operative treatment of tibial plateau fracture, considerations for (decision making for), 106
as surgical emergency, 338–339 311, 312 initial, 106
in pediatric patient, with supracondylar humerus prophylaxis, after total hip arthroplasty, 195 nonoperative, 106–107
fracture, 374 Degenerative joint disease indications for, 106
of thigh, with supracondylar femoral fracture, 287 of glenohumeral joint operative, 107–108
with tibial plafond fractures, 338–339 end-stage, 59, 59f algorithm for, 108
with tibial plateau fractures, 303–304 precautions with, 12 indications for, 107–108
with tibial shaft fracture, 316, 318 of hips, end-stage, 188 options for, 108
Complex regional pain syndrome, after ACL of knees, end-stage, 231, 255–256 Dorsalis pedis pulse, 274–275
reconstruction, 250 Deltoid muscle Drapes/draping, 2
Computed tomographic (CT) myelography, of anatomy, 25 Dressing, wound, 2–3
lumbar spondylolisthesis/stenosis, 139 innervation, 62 Durotomy, incidental, in lumbar decompression/
Computed tomography (CT) in rotator cuff repair, 25–26, 25f–26f fusion surgery, 145
of lower extremity, indications for, 316 Dexamethasone injection, for carpal tunnel syndrome, Dysbarism, and osteonecrosis of femoral head, 174
of lumbar spondylolisthesis/stenosis, 139 100, 101f Dysphagia, postoperative, with anterior cervical
pelvic, 164 Diabetes mellitus diskectomy and fusion, 126
in trauma patient, 151, 151f, 152f and intra-articular corticosteroid injection, 22 Dysphonia, postoperative, with anterior cervical
of shoulder instability, 37 and quadriceps tendon rupture, 218 diskectomy and fusion, 126
of supracondylar femoral fractures, 289, 290f Dial osteotomy, 188f
of tibial plafond (pilon) fractures, 337, 337f Dialysis arthropathy, glenohumeral joint, 60 E
Conjoined tendon (shoulder), 62 Distal humerus fractures
Conus medullaris, 133 case study, 81 Elbow
Coracoacromial (CA) arch classification, 81 flexion, and symptoms of cubital tunnel syndrome,
anatomy, 8, 8f diagnosis, 81 73
and impingement of humeral head and rotator cuff, hinged elbow external fixator for, 83 fractures about, 81
7, 8. See also Subacromial impingement imaging, 83 normal alignment, 368–369, 368f, 369f
Coracoacromial (CA) ligament, anatomy, 8, 8f, 35f initial evaluation, 82–83 range of motion, 72
Coracobrachialis muscle, anatomy, 35f injuries associated with, 81, 82 Elbow flexion test, 73
Coracoclavicular ligaments, 23 mechanism of injury in, 82 Electromyography (EMG), neuromonitoring with,
Coracoid process, anatomy, 8, 8f, 35f neurovascular injury with, 83 during anterior cervical diskectomy and fusion,
Corona mortis, 168 open reduction and internal fixation 119
Corticosteroid(s) complications, 88 Epicondylar groove, and ulnar nerve compression at
and osteonecrosis of femoral head, 174, 188 contraindications to, 84 elbow, 72
and patellar tendon rupture, 219 dual plating in, 85 Esmarch exsanguination, for total knee arthroplasty,
and quadriceps tendon rupture, 219 fracture reduction technique, 86–87 259, 259f, 260f
Corticosteroid injection(s) goals, 84–85 Evans classification, of intertrochanteric hip fractures,
adverse effects and side effects, 93 indications for, 84 200
for carpal tunnel syndrome, 100, 101f 90/90 plating in, 85 Excursion distance, 190
epidural positioning for, 85, 86f
for cervical soft disk herniation, 117 prepping and draping for, 85–86 F
for lumbar degenerative spondylolisthesis/ principles, 84–85
stenosis, 140 radiography after, 87f Femoral artery injury, with supracondylar femoral
for lumbar disk herniation, 130 rehabilitation for, 87–88 fracture, 287
intra-articular surgical alternatives to, 83 Femoral head
for glenohumeral arthritis, 58 surgical approach for, 86 blood supply to, 198–199, 198f
and glucose levels, 22 wound closure, 87 fracture-dislocation, with associated posterior wall
for knee arthritis, 253 spanning elbow external fixator for, 83 fracture, 150
400 Index
Femoral head (Continued) Femoral shaft fracture(s) (Continued) Gerdy’s tubercle, 308
osteonecrosis intramedullary nail fixation (Continued) Geyser sign, 22
case study, 173, 173f principles, 276–278 Glenohumeral internal rotational deficit (GIRD), in
differential diagnosis, 175–176 results, 276 overhead throwing athletes, 46
diseases causing, 188 retrograde Glenohumeral joint
epidemiology, 174 complications, 284 anatomy, 35, 35f, 61
etiology, 174 femoral canal entry in, 282 arthritis, 20
imaging, 175 femoral canal reaming in, 282–283 clinical presentation, 56
natural history, 174 fracture reduction in, 282 epidemiology, 56
pathogenesis, 175 guide pin insertion in, 282, 283f etiology, 56
pathology, 174 locking screw placement in, 283–284 inflammatory, 56
pathophysiology, 175 nail placement in, 283 intra-articular corticosteroid injections for, 58
slipped capital femoral epiphysis and, 376 positioning for, 282 intra-articular hyaluronic acid injections for, 58
staging, 175, 176b postoperative care for, 284 nonoperative treatment, 57–58, 60
treatment. See also Hip(s), decompression and prepping and draping for, 282 occupational therapy for, 58
grafting wound closure in, 284 physical examination for, 56
algorithm for, 178 statically locked, 277–278 physical therapy for, 57
conservative, 176 surgical alternatives to, 275–276 and range of motion, 56
by core decompression with/without bone timing, 276 treatment algorithm for, 57
grafting, 176–182 unlocked, 277–278 ultrasound therapy for, 57
by osteotomy, 177 pathologic, 271 degenerative joint disease
by resurfacing arthroplasty, 177 plating, 275–276 end-stage, 59, 59f
by total hip arthroplasty, 177 skeletal traction for, 275 precautions with, 12
vascular anatomy, 174–175, 175f trauma survey with, 274 dislocation, acute, treatment, 38
Femoral neck treatment functional characteristics, 60–61
anatomy, 198–199, 198f algorithm for, 274 instability, 34
vascular anatomy, 174–175, 175f considerations for (decision making for), 274 descriptors for, 37–38
Femoral neck fracture(s) initial approach, 274–275 stabilizers, 35
basicervical, 199 nonoperative, 275 Glenohumeral ligaments, stabilizing functions, 35–36
case study, 196, 196f Femur. See also Slipped capital femoral epiphysis Glenoid, and humeral head, anatomic relationships,
classification, 199–200, 199f distal, fractures. See also Supracondylar femoral 61
displaced, 198 fracture(s) Glenoid cavity, anatomy, 35f
surgical alternatives for, 203–204 classification, 287, 288f Glenoid labrum
treatment, 203 fractures. See Femoral neck fracture(s); Femoral anatomy, 35, 35f
hip hemiarthroplasty for, 204 shaft fracture(s); Supracondylar femoral traumatic detachment, 36. See also Bankart lesion
impacted, 198 fracture(s) Glenoid rim fracture
surgical alternatives for, 203 mechanical and anatomic axes, 257, 258f and Bankart lesion, 37
in situ pinning with multiple cancellous lag screws supracondylar region, anatomy, 294–295, 295f radiographic evaluation, 37
for, 203–204 Fibrous membrane, of shoulder, anatomy, 35f Glucosamine, oral supplementation, for osteoarthritis
nondisplaced, 198 Fibula of hip, 186
acceptable reduction, 206, 206f distal Gout, anterior knee pain in, 256
closed reduction and parallel cancellous lag fracture, 331, 331f Great toe
screw fixation of, 206–208, 207f, 208f stabilization, in fracture treatment, 331 normal, 354f
Garden alignment index for, 206, 206f fracture valgus deviation. See also Hallux valgus
parallel cancellous lag screw fixation of, level, 327, 329f biomechanics, 353, 354f
principles, 206 in relation to syndesmosis, 327, 329f Gustilo and Anderson classification
surgical alternatives for, 203 with tibial shaft fracture, 314f, 315 of open tibial plateau fractures, 302, 303
osteonecrosis, 198 proximal, fracture, 314f of tibial shaft fractures, 315
and osteonecrosis of femoral head, 174 with medial malleolus fracture, 327 Guyon’s canal, anatomy, 98f
radiographic assessment, 201 weight-bearing by, 318 Guyon’s canal nerve compression, 71
sliding hip screw and side plate for, 203–204 Fielding classification, of subtrochanteric hip
subcapital, 199 fractures, 201
transcervical, 199 Finger(s) H
treatment, considerations for (decision making for), A1 pulley, 94, 95f
202–203 surgical release of, for trigger finger, 95, 96f Hallux rigidus, 353
Femoral neck-shaft angle, 198 fibro-osseous pulley system, 91–92, 91f, 94, 95f radiographic evaluation, 355
Femoral shaft fracture(s) Flexor carpi ulnaris (FCU), 70, 71 Hallux valgus
classification, 271, 273f tendon, anatomy, 71f angles measured for, 353, 354f, 355
comminuted, case study, 271, 272f Flexor digitorum profundus (FDP), 70, 71 biomechanics, 353, 354f
definition, 271 anatomy, 71f and bunion, differentiation, 353
description, 271 Flexor digitorum superficialis (FDS), 70 case study, 352, 352f
epidemiology, 271 anatomy, 71f causes, 353
external fixation, 275 Floating knee injury, 291, 315 extrinsic, 353
imaging, 275 Foley catheter, 1 intrinsic, 353
intramedullary nail fixation Foot correction
antegrade, 278–282 injury, with tibial shaft fracture, 315 Austin osteotomy for, 358–359, 359f
femoral canal entry in, 279, 279f soft-tissue infection in, 361 biplanar chevron procedure, 356
femoral canal reaming in, 280 Forearm, anterior, nerves of, 70–71, 71f bony procedures, 356–357
fracture reduction in, 278–279 Fracture blisters, with tibial plafond (pilon) fractures, chevron procedure, 356
guidewire insertion in, 279–280, 280f 337, 337f complications, 361
locking screw placement in, 281–282, 281f Froment sign, 73 distal chevron procedure, 358–359, 359f
nail placement in, 280, 281f Frozen shoulder, 20, 56 by distal osteotomy, 356
positioning for, 278, 278f Frykman classification, of distal radius fractures, 105, distal soft-tissue procedure, 356, 357–358, 357f,
prepping and draping for, 278, 278f 105f 358f
surgical approach for, 279 dressings for, 360, 360f
wound closure in, 282 G by first metatarsocuneiform joint fusion, 357,
biomechanics, 276–277 360
contraindications to, 276 Ganz periacetabular osteotomy, 187 by fusion, 357
dynamically locked, 277–278 Garden alignment index, 206, 206f Lapidus procedure, 357, 360
and femoral canal reaming, 277 Garden classification, of femoral neck fractures, Ludloff procedure, 357
and implant failure, 277 199–200, 199f Mann procedure, 357, 359–360
indications for, 276 Gartland classification, of supracondylar humerus medial exostectomy for, 358, 359f
interlocking screws for, 278 fractures, 366, 366f modified McBride procedure, 357–358, 357f,
nail starting position for, 277 Gaucher’s disease, and osteonecrosis of femoral head, 358f
piriformis fossa entry for, 277 174, 188 positioning for, 357
Index 401
Hallux valgus (Continued) Hip(s) (Continued) Impingement syndrome, in shoulder, of humeral head
correction (Continued) painful, causes, 185 and rotator cuff, beneath coracoacromial arch, 7,
prepping and draping for, 357 range of motion, 189–190 8. See also Subacromial impingement
principles, 356–357 stability, factors affecting, 189–190 Impingement test, in subacromial impingement, 11
by proximal and shaft osteotomy, 356–357 Hip fracture(s), 196–214 Infection(s)
proximal chevron procedure, 357 case studies, 196–197, 196f, 197f after tibial nail insertion, 323
proximal crescenteric procedure, 357, 359–360 complications, 213–214 postoperative
Silver procedure, 358, 359f definition, 198 with anterior cervical diskectomy and fusion, 126
soft-tissue procedures, 356–357 epidemiology, 198 with tibial plateau fracture reduction and
wound closure in, 360 functional outcomes with, 198 fixation, 312
definition, 353 intertrochanteric prophylaxis, after total hip arthroplasty, 195
physical examination for, 354 anatomical considerations with, 200 soft-tissue, in foot, 361
radiographic evaluation, 354–355, 355f case study, 196, 197f wound, after open reduction and internal fixation
recurrence, 361 cephalomedullary sliding hip screw for, 204–205 of posterior wall fractures, 157
treatment, surgical cephalomedullary sliding hip screw placement Inflammatory arthritis, of hip, 188
algorithm for, 356 for, principles, 210–211 Infraspinatus muscle
contraindications to, 356 classification, 200 anatomy, 8, 19–20, 35f
indications for, 356 closed reduction and application of sliding hip shoulder motion provided by, 20
Hallux valgus angle, 354f, 355, 356 screw and side plate for, 209–210, 210f, 211f Innervation density testing, 72
Hawkins’ sign, 10 closed reduction and cephalomedullary sliding Insall-Salvati ratio, 220
Hemarthrosis hip screw placement for, 211–212 Intermetatarsal angle, one-to-two (1–2), 354f, 355,
definition, 238 epidemiology, 200 356
in knee, with ACL rupture, 238 hip hemiarthroplasty for, 205 Interphalangeal angle (degree of hallux valgus
Hematoma, postoperative, with anterior cervical pathophysiology, 200 interphalangeus), 354f, 355
diskectomy and fusion, 126 sliding hip screw for, 204 Ioban, 2
Hemiarthroplasty, shoulder, 56 principles, 208–209 Iodine allergy, 2
Hemoglobinopathy, and osteonecrosis of femoral tip-apex distance for, 209, 209f Irrigation, wound, before closure, 2
head, 174 stability, 200
Hemophilia arthropathy surgical alternatives for, 204–205
in glenohumeral joint, 60 treatment, 203 J
in knee, 255, 255f mortality rate for, 198
Hemorrhage, with pelvic injury, 160 osteoporotic, 198 Jackson table, 141–142, 141f
Heterotopic ossification, after open reduction and patterns, and treatment, 203 positioning adolescent patient on, 388–389, 389f
internal fixation of posterior wall fractures, 157 postoperative care for, 213 Jobe’s apprehension testing, 46
Heuter-Volkmann law, 384 radiographic assessment, 201 Jobe’s relocation test, for shoulder instability, 37
Hill-Sachs lesion rehabilitation for, 213 Joint(s)
pathology, 37 reverse obliquity pattern, treatment, 203 congruent, 355, 355f
radiographic evaluation, 37 stability, and treatment, 203 incongruent, 355, 355f
Hip(s). See also Slipped capital femoral epiphysis; subtrochanteric Judet-Letournel classification, of acetabular fractures,
Total hip arthroplasty anatomical considerations with, 200–201 150
arthrodesis, 187 case study, 197, 197f Judet radiographs, 151, 151f
decompression and grafting, 173–183 cephalomedullary sliding hip screw placement Juvenile rheumatoid arthritis (JRA), glenohumeral
bone grafts for, 176–177 for, principles, 210–211 joint, 60
complications, 182 classification, 201
contraindications to, 177 closed reduction and cephalomedullary sliding
decompression technique for, 181–182, 181f, 182f hip screw placement for, 211–212, 213f K
goals, 176 95-degree fixed angle device for, 205
grafting technique for, 182 distal fragment, 200 Kager’s triangle, 346, 346f
indications for, 177 intramedullary nail fixation for, 205 Kaplan’s cardinal line, 102
operative setup for, 178, 179f nonoperative treatment, 203 Klein’s line, 377, 377f
osteonecrosis lesion localization in, 181 proximal fragment, 200 Knee. See also Anterior cruciate ligament; Meniscus
positioning for, 178–179, 179f, 180 sliding hip screw for, 205–206 (pl., menisci); Posterior cruciate ligament
postoperative care for, 178, 182 surgical alternatives for, 205–206 alignment, 256, 257
prepping and draping for, 179–180, 180f treatment, 203 anatomy, 222–223, 223f, 233, 233f, 256, 260, 261f,
principles, 178 treatment 308–309, 309f, 310, 311f
rehabilitation for, 182 algorithm for, 202 anterior, neurovascular anatomy, 223, 223f
results, 178 considerations for (decision making for), 202–203 arthritis in
success rate, 177 goals, 198 case study, 251, 252f
surgical exposure for, 180–181, 180f nonoperative, 203 clinical presentation, 256
wound closure in, 182 protocols for, 202–203 diagnostic criteria for, 256
degenerative joint disease, end-stage, 188 types, 198 post-traumatic, 312
dislocation, 149, 149f weight-bearing status after, 213 radiographic features, 256
and osteonecrosis of femoral head, 174 Hoffman’s sign, 116 treatment, 251–252. See also Total knee
posterior Holstein-Lewis fractures, 83 arthroplasty
and posterior wall fractures, 150 Humeral head algorithm for, 253
sciatic nerve injury in, 150 blood supply to, 63 considerations for (decision making for), 253
fractures. See Femoral neck fracture(s); Hip contact with glenoid labrum, 35 nonoperative, 253, 256
fracture(s) and glenoid, anatomic relationships, 61 arthrodesis, for arthritis, 255
hemiarthroplasty Humerus. See also Distal humerus fractures; arthrofibrosis, after ACL reconstruction, 250
for femoral neck fracture, 204 Supracondylar humerus fracture(s) arthroplasty. See also Total knee arthroplasty
for intertrochanteric hip fractures, 204 distal patellofemoral, 255
osteoarthritis, 203 lateral column, 84, 85f unicompartmental, 254
arthrodesis for, 187 medial column, 84, 85f arthroscopic débridement, 254
arthroscopic débridement for, 186 Hutchinson’s fracture, 105 biomechanics, 256
case study, 184, 184f Hyaluronic acid, intra-articular injection compartments, 256
clinical presentation, 185 for glenohumeral arthritis, 58 arthroscopic examination, 231–232, 232f
differential diagnosis, 185 for knee arthritis, 253 degenerative joint disease, end-stage, 231, 255–256
epidemiology, 184 for osteoarthritis of hip, 186 diagnostic arthroscopy of, 234, 242
nonoperative treatment, 189 Hyperlipidemia, and osteonecrosis of femoral head, examination, under anesthesia, 242
osteotomy for, 187–188 174 extensor mechanism. See also Patellar tendon;
pathology, 185 Quadriceps tendon
treatment, 251–252 I anatomy, 221, 223, 223f
algorithm for, 185 components, 221
considerations for (decision making for), 186 Iliotibial band, 222 functions, 221–222
nonoperative, 186 insertion site, 308 repair, principles, 221–222
402 Index
Knee (Continued) Lumbar spine Magnetic resonance imaging (MRI) (Continued)

hemorrhagic arthropathy, 255, 255f anatomy, 132–133, 132f of shoulder, 10
injury computed tomography, 139 of slipped capital femoral epiphysis, 377
with supracondylar femoral fracture, 287, 289, CT myelography, 139 of superior labral anterior and posterior (SLAP)
291 degenerative spondylolisthesis/stenosis tears, 46
with tibial shaft fracture, 315 case study, 136, 137f of tendon pathology in knee, 220
medial meniscus tear, case study, 228, 228f clinical presentation, 136, 137 Magnuson and Stack procedure, 38
osteotomy decompression/fusion surgery for, 138 Maisonneuve fracture, 327
for arthritis, 254 complications, 144–145 Mayo sheer test, 45–46
distal femoral, 254 contraindications to, 140 Medial epicondyle, and ulnar nerve compression at
high tibial, 254 decompression technique for, 143 elbow, 72
pain pedicle screw placement in, 143–144, 145 Medial epicondylectomy, for cubital tunnel
anterior, causes, 256 positioning for, 141–142, 141f, 142f syndrome, 75
secondary to arthritis posterolateral fusion technique for, 143–144, Medial intermuscular septum, and ulnar nerve
case study, 251 144f compression at elbow, 72
treatment algorithm for, 253 postoperative care for, 144 Medial malleolus fracture, and proximal fibular
slipped capital femoral epiphysis and, 376 prepping and draping for, 142 fracture, 327
with tibial nail, 323 principles, 141 Median nerve
posterolateral corner injuries, 242 surgical approach for, 142–143 anatomy, 71f, 97, 98f
in rheumatoid arthritis, 255, 255f surgical indications for, 140 motor branch, variants, 97, 98f
soft tissues, 221–222 wound closure in, 144 palmar cutaneous branch, 99
balancing, in total knee arthroplasty, epidemiology, 136 variations in carpal tunnel, 97, 98f
257–258 imaging, 138–140 Melone classification, of distal radius fractures, 105,
stability, 221–222 Meyerding classification, 138–139 105t
stiffness, with operative treatment of tibial plateau posterior lumbar fusion for, 136–145 Meniscectomy
fracture, 311, 312 treatment algorithm for, 229
valgus deformity, 256–257, 257f algorithm for, 138 arthroscopic
varus deformity, 256, 257f considerations for (decision-making for), anatomical considerations in, 233–234, 233f
weight distribution across, 256–257 138 compartments examined in, 231–232, 232f
Knee bracing, valgus, 253 nonoperative, 140 complications, 235–236
Krackow stitch/technique, for Achilles tendon repair, disk herniation, 127, 127f contraindications to, 231
349, 349f, 350f chymopapain chemonucleolysis for, 131 goals, 229
clinical presentation, 128 indications for, 230–231
contained, 128 instruments for, 231, 231f
L laparoscopic diskectomy for, 131 positioning for, 232, 233f
noncontained, 128 postoperative care for, 235
Laboratory data, preoperative check, 1 percutaneous diskectomy for prepping and draping for, 232
Lachman test, 238, 238f automated, 130 principles, 231–232
Latarjet procedure, 38–39 endoscopic, 131 rationale for, 229
Latex allergy, 1 laser, 130–131 rehabilitation after, 235
Latissimus dorsi muscle, anatomy, 35f physical findings in, 128 surgical alternatives to, 230
Leg pain, 127–129 physical therapy for, 130 surgical approach for, 233–234, 233f
with lumbar degenerative spondylolisthesis/ posterolateral, motor and sensory components, technique for, 234, 234f, 235, 235f
stenosis, 137, 140 128, 128t wound closure in, 235
Lenke classification, of adolescent idiopathic scoliosis, and radiculopathy, 127–128 complete, sequelae, 229
384–386, 387 and sciatica, 127–128 considerations for (decision making for), 230
Limb exsanguination, before tourniquet inflation, 1 treatment open, 230
Limb positioning, 2 algorithm for, 129 partial, 229, 235
Limb prep, 2 medications for, 129–130 Meniscus (pl., menisci)
Load and shift test, for shoulder instability, 37 nonoperative, 129–130 anatomy, 228–229
Long head of biceps patient education about posture and body functions, 228
anatomy, 35f mechanics in, 129 injuries, with tibial plateau fractures, 303
intra-articular attachment, injuries to, 44. See also by rest, 129 lateral, 228–229
Superior labral anterior and posterior (SLAP) surgical alternatives for, 130–131 anatomy, 228, 229
tear(s) flexion-extension radiographs, 139 excursion, 229
tenodesis, for rotator cuff repair, 23 intervertebral disk, anatomy, 133 medial, 228–229
tenotomy, for rotator cuff repair, 23 ligaments, anatomy, 133 anatomy, 228, 229
Long head of triceps, anatomy, 35f magnetic resonance imaging, 139–140 excursion, 229
Lower extremity nerve roots, 133 tear, case study, 228, 228f
angiography in, indications for, 289 nerves, anatomy, 133 perfusion, 228–229
compartment syndrome in plain radiographs, 138 tears
signs and symptoms, 303–304 oblique view, 139, 139f bucket-handle, 230, 230f
with tibial plateau fractures, 303–304 vertebrae epidemiology, 229
exsanguination, 259, 259f, 260f anatomy, 132–133, 132f repair, 230
fascial compartments in, 304 number, 141 treatment
four-compartment fasciotomy in, 304 vertebral sacralization in, 141 algorithm for, 229
neurological assessment, 275, 304–305 Luxatio erecta, 34 considerations for (decision making for),
vascular status, assessment, 274–275, 305 230
Lumbar microdiskectomy nonoperative, 230
anatomical considerations in, 132–133, 132f M Metatarsophalangeal joint(s)
case study, 127, 127f congruent, 355, 355f
complications, 135 Magnetic resonance arthrography, of shoulder first
contraindications to, 132 instability, 37 arthritis, 353, 354–355
disk excision technique for, 134 Magnetic resonance imaging (MRI) treatment, 357
goal, 129 of cervical degenerative disk disease, 117 arthrodesis, 357
indications for, 131–132 of femoral neck fractures, 201 derangement, 353, 354f
positioning for, 133, 133f of hip fractures, 201 incongruent, 355, 355f
postoperative care for, 135 of knee, indications for, 289 Metatarsus primus varus, 353
prepping and draping for, 133 of lower extremity, indications for, 316 Methylprednisone, oral, for lumbar disk herniation,
principles, 133 of lumbar spondylolisthesis/stenosis, 139–140 129
rehabilitation after, 135 of osteonecrosis of femoral head, 175 Meyerding classification, of lumbar spondylolisthesis,
stereotactic, 131 pelvic, 164 138–139
surgical alternatives to, 130–131 precautions for, 140 Morel-Lavalle lesion, 153, 161
surgical approach for, 134, 134f of rotator cuff tears, 22 Muscle relaxant(s), for lumbar disk herniation,
wound closure for, 135 safety precautions with, 22 129
Index 403
N Patellar tendon (Continued) Plain radiography

repair (Continued) of hip fractures, 201
Narcotics, for lumbar disk herniation, 129 tensioning, 225–226 iliac oblique view, 151, 151f
Neer, Charles, 8 wound closure in, 226 of lumbar spine
Neer classification, of supracondylar femoral rupture with pars interarticularis fracture, 139, 139f
fractures, 287 associated injuries, 220 Scottie dog view, 139, 139f
Neer’s impingement test, 10 chronic, 221 of lumbar spondylolisthesis/stenosis, 138–139
Neer’s sign, 10 epidemiology, 218 obturator oblique view, 151, 151f
Neuropathic arthropathy, glenohumeral joint, imaging, 220 of osteonecrosis of femoral head, 175
60 mechanism of injury in, 219 of pelvis, 164, 164f
Nonsteroidal anti-inflammatory drugs (NSAIDs) pathology, 218 in trauma patient, 151, 151f
for lumbar disk herniation, 130 physical examination for, 220 of rotator cuff tears, 22
for osteoarthritis of hip, 186 repair of shoulder
Notta’s node, 92 goals, 221 anteroposterior view with caudal tilt, 7f, 10
principles, 221–222 scapular (supraspinatus) outlet view, 7f, 10, 10f
risk factors for, 218–219 of shoulder dislocation, 37
O treatment of slipped capital femoral epiphysis, 377, 377f
algorithm for, 219 Stryker notch view, 37
Obesity, and quadriceps tendon rupture, 218 considerations for (decision making for), 219 of superior labral anterior and posterior (SLAP)
O’Brien test, 45 nonoperative, 220–221 tears, 46
Operating room, preoperative preparation, 2 operative, 221 of supracondylar femoral fractures, 289
Orthopaedic Trauma Association classification Patient(s) of tendon pathology in knee, 220
of femoral shaft fractures, 271 identification, 1 Velpeau view, 37
of intertrochanteric hip fractures, 200 positioning, intraoperative, 2 West Point view, 37
of pelvic ring disruptions, 165–166 Pause for safety, preoperative, 1 Popliteal artery, injury
of subtrochanteric hip fractures, 201 Pauwels classification, of femoral neck fractures, 199 in intramedullary nail fixation of tibial shaft
of supracondylar femoral fractures, 287, 288f PCL. See Posterior cruciate ligament fracture, 323
of tibial shaft fractures, 315 Pectoralis major muscle with supracondylar femoral fracture, 287
Osborne’s fascia, and ulnar nerve compression at anatomy, 35f Posterior cruciate ligament
elbow, 72 innervation, 62 injuries, with tibial plateau fractures, 303
Osteoarthritis, 251. See also Arthritis Pediatric patient(s). See also Adolescent idiopathic in total knee arthroplasty, 258, 260
diagnostic criteria for, 188 scoliosis; Slipped capital femoral epiphysis Posterior tibial artery injury, in intramedullary nail
epidemiology, 184 supracondylar humerus fracture fixation of tibial shaft fracture, 323
glenohumeral joint case study, 365, 365f Pregnancy, and osteonecrosis of femoral head, 174
clinical presentation, 60 closed reduction and percutaneous pinning for, Prep, preoperative, principles, 2
diagnostic criteria for, 60 365–374 Profunda femoris artery, intraoperative perforation,
epidemiology, 56 Peel-back mechanism, 45 prevention, 209
radiographic features, 60 Pelvic fractures Propionibacter acnes, 12
of hip. See Hip(s), osteoarthritis anterior-posterior compression, 164, 165 Psoriatic arthritis, 188
of knee associated injuries, 165 Pubic symphysis. See Symphysis pubis
diagnostic criteria for, 256 classification, 164–166 Pulmonary embolism, with operative treatment of
radiographic features, 256 Letournel system, 164 tibial plateau fracture, 312
radiographic features, 188 Young and Burgess, 165 Putti-Platt procedure, 38
Osteonecrosis, end-stage, of glenohumeral joint, 59, complications, 169
59f epidemiology, 159 Q
Osteotomy external fixation, 166
hip, 187–188 anterior inferior iliac spine (AIIS) (supra- Quadriceps muscle(s)
reconstructive, 187 acetabular), 166–167, 167f anatomy, 221, 222, 223f
salvage, 187 imaging, 164, 164f isometric strengthening, for knee arthritis, 253
pelvic, 187–188, 188f lateral compression, 164, 165 Quadriceps tendon
proximal femoral management, 159 anatomy, 222–223, 223f
valgus, 187 mechanism of injury in, 159, 160 blood supply to, 223, 223f
varus, 187 open reduction and internal fixation, 167–169, laminae (layers), 221
OTA/OA classification, of pelvic ring disruptions, 168f repair
165–166 postoperative care for, 169 anatomical considerations in, 222–223
Ottawa rules, 327 and postoperative weight-bearing, 169 complications, 227
stability, classification, 165–166 positioning for, 222, 222f
vertical shear, 164 postoperative care for, 226–227
P Pelvic osteotomy(ies), 187–188, 188f prepping and draping for, 222
Pelvic ring rehabilitation after, 226–227
Paraspinal musculature posterior, 160, 162f skin incision for, 222, 222f
anatomy, 391f stabilizers, 160 surgical exposure for, 222–224, 224f
“stripping,” in scoliosis surgery, 390–391, Pelvic ring injury(ies), 159, 159f technique for, 224–226, 225f
391f classification, 164–166 tensioning, 225–226, 226f
Pars interarticularis fracture, in lumbar spine, plain imaging, 164, 164f wound closure in, 226
radiographs, 139, 139f initial management, 160–162 rupture
Patella, 221, 223 mechanism of injury in, 159, 160 associated injuries, 220
thickness, measurement, 264, 264f stability, classification, 165–166, 165f case study, 217–218, 218f
Patella alta, 220 treatment, algorithm for, 163 chronic, 221
case study, 217, 217f Pelvis epidemiology, 218
Patella baja, 220 anatomy, 160, 161f, 162f imaging, 220
Patellar retinaculum (pl., retinacula), 221 bony, 160, 161f mechanism of injury in, 219
lateral, 223, 223f plain radiography pathology, 218
medial, 223, 223f anteroposterior view, 164, 164f physical examination for, 220
repair, 226 inlet view, 164, 164f repair
surgical exposure, 223–224, 224f outlet view, 164, 164f goals, 221
Patellar tendon Pemberton osteotomy, 188f principles, 221–222
anatomy, 222–223, 223f Penicillin allergy, 1 risk factors for, 218–219
blood supply to, 223, 223f Peroneal artery injury, in intramedullary nail fixation treatment
repair of tibial shaft fracture, 323 algorithm for, 219
cerclage suture augmentation of, 225 Peroneal nerve injury, with operative treatment of considerations for (decision making for), 219
complications, 227 tibial plateau fracture, 312 nonoperative, 220–221
postoperative care for, 226–227 Phalen’s maneuver, 99 operative, 221
rehabilitation after, 226–227 Pigmented villonodular synovitis, knee in, 255 protocols for, 219–220
technique for, 225 Pivot shift test, 238, 238f Quadrilateral space, 63
404 Index
R Rotator cuff tear(s) (Continued) Shoulder dislocation(s) (Continued)

locations, 20 radiographic evaluation, 37
Radial nerve massive irreparable, precautions with, 11 recurrence, 35
anatomy, 71f, 82 partial-thickness, 20 superior, 34
injury physical findings with, 20 traumatic, 35
with Holstein-Lewis type spiral fractures, 82 recurrence, 20 and Bankart lesion, 36
with supracondylar humerus fracture in children, tendons involved in, 20 treatment, immobilization after, 38
366 treatment, 20, 21–22 Sickle cell disease, and osteonecrosis of femoral head,
Radiculopathy, definition, 127 considerations for (decision making for), 21 188
Radius, distal. See also Distal radius fractures initial strategy for, 22 SLAP tears. See Superior labral anterior and posterior
normal radiographic parameters for, 107, 107f nonoperative, 22, 24 (SLAP) tear(s)
Rectus femoris muscle, anatomy, 221 occupational therapy for, 22 Slipped capital femoral epiphysis
Reflex sympathetic dystrophy, after ACL physical therapy for, 22 acute, 376
reconstruction, 250 by subacromial corticosteroid injection, 22 acute on chronic, 376
Reiter’s syndrome, 188 surgical procedures, 23–24 bone peg epiphysiodesis for, 378
glenohumeral joint, 60 treatment algorithm for, 21 case study, 375, 375f
knee in, 256 without repair, progression of pathology with, 24 chronic, 376
Renal failure, chronic, and quadriceps tendon Rotator interval, 58 classification, 376
rupture, 218 Ruedi-Allgower classification, of tibial plafond (pilon) complications, 376
Rheumatoid arthritis (RA), 251 fractures, 336, 336f contralateral hip in, 377
diagnostic criteria for, 188 Russell-Taylor classification, of subtrochanteric hip slip rate, 375, 376
glenohumeral joint fractures, 201 slip risk factors, 378
diagnostic criteria for, 60 treatment, 378
radiographic features, 60 endocrine work-up for, 376
of knee, 255, 255f
diagnostic criteria for, 256
S epidemiology, 375
etiology, 376
radiographic features, 256 Sacrum, as keystone of pelvis, 160, 162f femoral neck osteotomy for, 378
and quadriceps tendon rupture, 218 Salter single-innominate osteotomy, 187, 188f history taking for, 376
radiographic features, 188 Saphenous nerve imaging, 377, 377f
Rotator cuff. See also Rotator cuff repair; Rotator cuff anatomy, 223, 223f in situ pinning for, 377
tear(s) infrapatellar branch, 223, 223f complications, 383
anatomy, 8, 19–20 SCFE. See Slipped capital femoral epiphysis contraindications to, 378
débridement, 23 Schatzker classification, of tibial plateau fractures, goals, 379
as dynamic stabilizer of shoulder, 24 302, 302f indications for, 378
and maintenance of force couples in shoulder, 24 Sciatica, definition, 127 operating room setup for, 379, 379f
muscles of, 19–20 Sciatic nerve pin entry point/skin incision for, 380, 380f
Rotator cuff repair, 19–33 assessment, 151 positioning for, 379, 379f
arthroscopic, 28–32 injury postoperative care for, 382
additional procedures in, 28–30, 30f with posterior hip dislocation, 150 prepping and draping for, 379, 379f
diagnostic arthroscopy in, 28–29, 29f post-traumatic, 150 principles, 379
portal closure in, 32 Scoliosis. See Adolescent idiopathic scoliosis screw placement/configuration in, 379
portal placement for, 28, 29f Scottie dog, 139, 139f surgical alternatives to, 378
positioning for, 28 Seinsheimer classification technique for, 381–382, 381f–383f
prepping and draping for, 28 of subtrochanteric hip fractures, 201 open reduction and internal fixation for, 378
repair technique, 30–31, 31f of supracondylar femoral fractures, 287 physical examination for, 376
subacromial decompression in, 29–30, 30f Semmes-Weinstein monofilament test, for carpal risk factors for, 376
tendon edge débridement in, 30 tunnel syndrome, 99 sequelae, 383
tendon mobilization in, 30 Short head of biceps, anatomy, 35f stable, 376
complications, 32 Shoulder. See also Total shoulder arthroplasty treatment, 376
contraindications to, 24 anatomy, 35–36, 35f treatment algorithm for, 378
general rehabilitation after, 32 arthrodesis, for glenohumeral arthritis, 59 treatment
goals, 24 external rotation, decreased, differential diagnosis, algorithm for, 378
indications for, 24 56 considerations for (decision making for), 376
mini-open approach for, 25 hemiarthroplasty, 56 initial approach, 376–377
open impingement syndrome, of humeral head and nonoperative, 377
deltoid repair in, 25, 27, 28f rotator cuff, beneath coracoacromial arch, 7, 8. operative, 377
positioning for, 25 See also Subacromial impingement unstable, 376
prepping and draping for, 25 instability treatment, 376
procedure for, 25–27, 25f–27f Bankart lesion and, 36 treatment algorithm for, 378
surgical anatomy, 25–26, 25f–26f descriptors for, 37–38 Smith’s fracture, 105
surgical approach, 25–26, 25f–26f provocative tests for, 37 Somatosensory evoked potentials, neuromonitoring
tendon edge débridement in, 26 recurrent, 36, 37 with
tendon mobilization in, 26, 27f internal rotation contracture, precautions with, during anterior cervical diskectomy and fusion, 119
transosseous technique for, 27, 27f 11–12 during scoliosis surgery, 389
wound closure in, 27 interposition arthroplasty and biologic glenoid Spinal cord
postoperative care with, 32 resurfacing, for glenohumeral arthritis, 59 compression, 116
principles, 24–25 range of motion injury, in scoliosis surgery, 395
recovery after, 24 arthritis and, 56 perfusion, in scoliosis surgery, 394
results, 20 documentation, 12 Spondyloarthropathy(ies), 188
surgical alternatives to, 23–24 restriction, causes, 20 glenohumeral joint, 60
surgical procedures performed with, 23–24 rotator cuff tear and, 20 knee in, 256
tendon transfer for, 23–24 resection arthroplasty, for glenohumeral arthritis, Spondylolisthesis
Rotator cuff tear(s) 58 definition, 136
acute, 20 stabilizers, 23, 35–36, 35f lumbar degenerative. See Lumbar spine,
acute on chronic, 20 strength, rotator cuff tear and, 20 degenerative spondylolisthesis/stenosis
age, 20 Shoulder dislocation(s) Spondylosis
anterior-posterior extent, 20 acute, treatment, 38 cervical spine, 115, 116f
asymptomatic, 20 anterior, 34 definition, 136
case study, 19, 19f mechanism of injury in, 35 Spur(s), acromioclavicular, in subacromial
chronic, 20 associated injuries, 20 impingement, 8, 9t
clinical presentation, 20 inferior, 34 Staples, for wound closure, 2–3
depth, 20 in older patient, rotator cuff tear associated with, Steel triple-innominate osteotomy, 187–188, 188f
full-thickness, 20 20 Steinmann pin, 180–181, 180f
imaging, 22 posterior, 34 Stenosing flexor tenosynovitis. See Trigger finger
incidence, 19 prevalence, 34 Subacromial bursa, anatomy, 8, 35f
Index 405
Subacromial decompression Supracondylar femoral fracture(s) (Continued) Supracondylar humerus fracture(s), in pediatric
arthroscopic, 7–18 epidemiology, 287 patient (Continued)
advantages, 11 external fixation, 291 radiographic evaluation, 367
applied surgical anatomy for, 14–15 fracture/cast bracing for, 291 treatment
arm support during, 13, 13f imaging, 289, 290f considerations for (decision making for), 366
case study, 7 lateral plating, 291, 293f initial approach for, 367
complications, 17 anatomical considerations in, 294–295 nonoperative, 367
draping for, 12, 13f complications, 298–300 operative, 367
general rehabilitation after, 17 goals, 294 by type, 366
for glenohumeral arthritis, 58 plate placement in, 294–295 Supraspinatus muscle
indications for, 11 positioning for, 295 anatomy, 8, 19–20, 35f
patient positioning for, 12, 12f postoperative care for, 298 shoulder motion provided by, 20
pitfalls, 17 prepping and draping for, 295 Sutherland double-innominate osteotomy, 187, 188f
portals for, placement, 13, 13f, 14, 14f principles, 294–295 Suture(s), for wound closure, 2
postoperative care for, 17 reduction of articular surface in, 297, 299f Symphysis pubis
prepping for, 12, 12f reduction of shaft to articular surface in, injuries, 166
results, 11 297–298, 299f widening, case study, 159, 159f
technical problems in, 17 surgical exposure for, 296, 296f Synovectomy, arthroscopic, for glenohumeral
technique for, 15–17, 16f wound closure in, 298 arthritis, 58
wound closure for, 17 mechanism of injury in, 287 Synovial membrane, of shoulder, anatomy, 35f
principles, 12 open reduction and internal fixation Systemic lupus erythematosus (SLE)
for rotator cuff repair, 23 algorithm for, 294 and osteonecrosis of femoral head, 174, 188
Subacromial impingement, 7–8 alternatives to, 291 and quadriceps tendon rupture, 218
clinical presentation, 9–10 complications, 298–300
differential diagnosis, 9 contraindications to, 293
history taking for, 9 indications for, 291–293 T
impingement test in, 11 positioning for, 295
physical examination in, 9–10 postoperative care for, 298 Tape, for wound dressing, 3
radiographic features, 10 prepping and draping for, 295 Tardy ulnar nerve palsy, 72
stages, 8–9, 9t steps in, 297–298, 299f Teres major muscle, anatomy, 35f
treatment, 9–10 surgical exposure for, 296, 296f Teres minor muscle
algorithm for, 11 wound closure in, 298 anatomy, 8, 20, 35f
considerations for (decision making for), 9 physical examination for, 289 shoulder motion provided by, 20
nonoperative, 10 preoperative stabilization, 289 THA. See Total hip arthroplasty
operative. See also Subacromial decompression retrograde nailing for, 291, 292f Theta angle, 189, 189f
contraindications to, 11–12 skeletal traction for, 291 Thomson test, 345, 345f
indications for, 11 trauma survey with, 289 Threshold testing, 72
surgical alternatives for, 11 treatment Thromboembolism, after open reduction and internal
Subscapular bursae, anatomy, 35f considerations for (decision making for), 287 fixation of posterior wall fractures, 158
Subscapularis muscle initial approach, 287–289 Throwing athletes
anatomy, 8, 19–20, 35f nonoperative, 289–290, 291 glenohumeral internal rotational deficit in, 46
shoulder motion provided by, 20 operative, 291 postoperative management for, 54
Sulcus test, for shoulder instability, 37 algorithm for, 294 superior labral anterior and posterior (SLAP) tears
Superior labral anterior and posterior (SLAP) tear(s), options for, 287 in, 45
44 vascular injury associated with, management, 291 clinical presentation, 45
arthroscopic repair vascular injury with, 287 postoperative management for, 54
complications, 54 Supracondylar humerus fracture(s), in pediatric Thumb, A1 pulley, 94, 95f
contraindications to, 47 patient Tibia
diagnostic arthroscopy in, 49–50, 50f case study, 365, 365f alignment, 316
indications for, 47 closed reduction and percutaneous pinning for mechanical and anatomic axes, 257, 258f
portal placement in, 49, 49f algorithm for, 368 stress fracture, occult, 316
positioning for, 49 complications, 374 weight-bearing by, 318
postoperative management for, 53–54 dressings for, 373 Tibial plafond (pilon) fracture(s), 327
prepping and draping for, 49 elbow alignment after, 369 associated injuries, 336–337
principles, 47–48 goals, 368 axial loading, 335, 336b
technique for, 49, 50–52, 50f–53f immobilization after, 373, 373f case study, 335, 335f
wound closure in, 53 indications for, 367 classification, 336, 336f
case study, 44, 44f neurovascular injury in, 374 closed reduction and immobilization in plaster,
classification, 47, 48f operating room setup for, 369–370, 370f 338
clinical presentation, 45 pin configuration for, 369 and compartment syndrome, 338–339
diagnosis, maneuvers used in, 45–46 positioning for, 369–370 complications, 336, 343
history taking for, 45 postoperative care for, 367, 373–374 epidemiology, 335
imaging, 46 prepping and draping for, 369–370 external fixation
mechanism of injury in, 45 principles, 368–369 calcaneal pin placement in, 341
in patients more than 40 years old, 48–49 technique for, 370–373, 371f, 372f as definitive treatment, 339, 342, 342f
physical examination for, 45–46 compartment syndrome with, 374 frame construction in, 341–342, 341f, 342f
treatment displaced, 366, 366f operative principles for, 339
algorithm for, 47 initial treatment, 367 plate fixation of fibula in, 340–341
nonoperative, 46 epidemiology, 365 positioning for, 339, 339f
protocols for, 45–46 extension-type, 366 prepping and draping for, 339, 340f
type I, 48f flexion-type, 366 principles, 338–339
treatment, 47 Gartland classification, 366, 366f technique for, 340–342
type II, 48f Gartland type I, treatment, 367 as temporizing treatment, 339
treatment, 47 Gartland type II tibial pin placement in, 341
type III, 48f surgical indications for, 367, 368 timing of surgery for, 338–339
treatment, 47 treatment, 367 fracture blisters with, 337, 337f
type IV, 48f Gartland type III history taking for, 336–337
treatment, 48 surgical indications for, 368 imaging, 337, 337f
Supracondylar femoral fracture(s) treatment, 367 lag screw fixation, 340, 340f
associated injuries, 287 malunion, 374 mechanism of injury in, 335, 336–337, 336b
case study, 286, 286f mechanism of injury in, 366 neurovascular examination with, 337
classification, 287, 288f neurovascular examination for, 367 postoperative immobilization, 342–343
compartment syndrome with, 287 neurovascular injury associated with, 366, 374 rehabilitation for, 343
definition, 287 nondisplaced, 366, 366f rotational, 335, 336b
distracting forces on, 294–295, 295f initial treatment, 367 soft-tissue injuries with, management, 339–340
406 Index
Tibial plafond (pilon) fracture(s) (Continued) Tibial shaft fracture(s) (Continued) Total knee arthroplasty (Continued)
traction for, 338 intramedullary nail fixation (Continued) tibial preparation in, 260–262, 262f
treatment hardware failure in, 323 wound closure in, 265–266, 266f
algorithm for, 338 indications for, 317 Total shoulder arthroplasty, 55–69
contraindications to, 338 intramedullary reaming in, 318, 320–321, 321f anteroposterior radiograph of shoulder after, 68,
indications for, 337–338 neurovascular injury in, 323 68f
nonoperative, 338 principles, 318 applied surgical anatomy for, 62–64, 62f–64f
Tibial plateau fracture(s) vascular injury in, 323 case study, 55, 55f
case study, 301, 301f with ipsilateral femoral fracture, 291, 315 complications, 69
causes, 301–302 malunion, 323 contraindications to, 60
classification, 302, 302f mechanism of injury in, 315 glenoid component, 61
closed, soft-tissue injuries associated with, 302–303 nerve injury with, 315, 316 glenoid exposure and preparation, 65–66, 66f
closed versus open reduction for, 308 nonunion, 323 goals, 56, 61
compartment syndrome with, 303–304 open, emergent management, 315, 316 humeral component, 61
external fixation, 306 plate and screw fixation, 317 humeral head exposure and preparation, 63–64,
imaging, 316 soft-tissue injury associated with, 315 64f, 65f
initial assessment, 304–305 with supracondylar femoral fracture, 291 humeral head trialing and component placement,
less invasive stabilization system (LISS) for, 306 treatment 66–67, 67f
ligamentous injury with, 303 algorithm for, 317 indications for, 59–60
malunion, 313 considerations for (decision making for), 315 pain relief after, 56
mechanism of injury in, 302 initial approach, 316 positioning for, 61
neurovascular injury with, 303 nonoperative, 316 postoperative care for, 68–69
nonunion, 312 operative, 317 prepping and draping for, 61–62, 62f
open vascular injury with, 315, 316, 317 principles, 60–61
classification, 302, 303 Tibiofemoral angle, 257 prostheses for
soft-tissue injuries associated with, 302–303 Tile classification, of pelvic ring disruptions, 165, long-term results with, 56
open reduction and internal fixation 165f types, 56
anesthesia for, 307 Time-out, preoperative, 1 rehabilitation for, 68–69
complications, 312–313 Tinel’s sign, 73, 99 results, factors affecting, 61
goals, 307 Tip-apex distance, for sliding hip screw, 209, 209f surgical alternatives to, 57, 58–59
hardware for, 306 TKA. See Total knee arthroplasty arthroscopic, 58
complications, 312 Tooth sign, 220 open procedures, 58–59
removal, 312 Total hip arthroplasty surgical approach for, 62–64, 62f–64f
lateral plateau, 307, 308–310, 309f, 310f acetabular and femoral components wound closure, 67–68, 67f
medial plateau, 307, 310–311, 311f alignment, 189, 189f Tourniquet
nerve injury in, 313 cemented, 190 deflation-reinflation, 2
operative setup for, 307, 308f noncemented, 190 inflation time, 1–2
plates for, 306 acetabular preparation for, 193–194, 193f, 194f placement, 1
positioning for, 307, 308f alternatives to, 185, 186–188 setting for, 1
postoperative care for, 311–312 anatomical considerations in, 191–193 and total knee arthroplasty, 258–259, 259f, 260f
postoperative radiography in, 312, 312f bearings, wear properties of, 190 Transcutaneous motor evoked potentials (tcMEP),
prepping and draping for, 307 case study, 184, 184f neuromonitoring with, during anterior cervical
rehabilitation for, 311–312 cementing technique, 190 diskectomy and fusion, 119
screw/plate configurations for, 307 complications, 195 Trauma, and osteonecrosis of femoral head, 174
screws for, 306 component fixation, 190 Trauma survey, 150, 160, 274
wound closure in, 311 contraindications to, 185, 189 with distal femoral fracture, 287–289
preoperative stabilization, 305 for femoral neck fracture, 204 Triangular ligament, 70
soft-tissue injuries associated with, 302–303 femoral preparation for, 194 Triceps muscle, medial head, and ulnar nerve
classification, 302–303 goals, 185 compression at elbow, 72
with supracondylar femoral fracture, 287, 291 implant fixation Tricyclic antidepressants, for lumbar disk herniation,
treatment line-to-line fit technique, 190 130
algorithm for, 306 press fit technique, 190 Trigger finger
considerations for (decision making for), 304 indications for, 185, 188–189, 203 case study, 91, 91f
goals, 305 and osteolysis secondary to wear particles, 190 classification, 92
nonoperative, 305 for osteonecrosis of femoral head, 177 clinical presentation, 92
complications, 312 positioning for, 190–191, 192f differential diagnosis, 92
operative, 305–306 postoperative care for, 195 diffuse, 92
hardware for, 306, 312 prepping and draping for, 191, 192f epidemiology, 91
vascular injury with, 303 principles, 189–190 nodular, 92
Tibial shaft fracture(s) rehabilitation after, 195 primary, 91
associated injuries, 315 screw insertion, acetabular zones for, 190, 191f recurrence
treatment, 316 stability, factors affecting, 189–190 after corticosteroid injection therapy, 93
case study, 314, 314f surgical approach for, 191–193, 192f, 193f prevention, 94
classification, 315 trial reduction in, 194, 194f release
compartment syndrome with, 316, 318 wound closure for, 194–195 A1 pulley, 95, 96f
definition, 315 Total knee arthroplasty complications, 96
emergent conditions with, 316 anatomical considerations in, 260, 261f incisions for, 94, 94f, 95f
epidemiology, 315 cementing technique for, 265, 265f open, 93
external fixation, 317 complications, 267 percutaneous, 93
imaging, 316 considerations for (decision making for), 253 positioning for, 94
intramedullary nail fixation, 317 contraindications to, 256 postoperative care for, 95
antegrade femoral preparation in, 262–263, 263f, 264f prepping and draping for, 94, 94f, 95f
complications, 323 goals, 251, 257 principles, 94
entry site preparation in, 319–320, 319f, 320f indications for, 231, 251, 255–256 wound dressing for, 95
fracture reduction in, 320 patellar preparation in, 264–265, 264f secondary, 91
guide pin in, 319–320, 319f positioning for, 258, 259f treatment
interlocking screw placement in, 321–322, 322f postoperative care for, 266–267 algorithm for, 94
intramedullary reaming in, 318, 320–321, 321f postoperative radiography in, 266, 266f corticosteroid injection for, 93
nail passage over guidewire in, 321, 321f prepping and draping for, 258–259, 259f nonoperative, 92–93
positioning for, 318, 318f principles, 256–258 operative, 93
postoperative care for, 322–323 rehabilitation after, 266–267 protocols for, 92–93
prepping and draping for, 318, 318f, 319f results, 251 splinting for, 92–93
skin incision for, 319, 319f skin incision for, 259, 259f Trigger thumb
wound closure in, 322, 322f surgical alternatives to, 254–255 congenital, 92
contraindications to, 317 surgical approach for, 260 release, 91–96
Index 407
Tscherne classification Ulnar nerve decompression, and subcutaneous nerve V

of soft-tissue injuries, with tibial plateau fractures, transposition
302, 303 complications, 79–80 Vaginal bleeding, with pelvic fracture, 162
of tibial shaft fractures, 315 positioning for, 76 Vancomycin, preoperative intravenous, 1
Two-point discrimination test, for carpal tunnel prepping and draping for, 76, 76f Viscosupplementation
syndrome, 99 principles, 75–76 for glenohumeral arthritis, 58
rehabilitation after, 79 for knee arthritis, 253
technique for, 76–78, 77f–79f for osteoarthritis of hip, 186
U wound closure in, 78, 79f
Ulnar nerve palsy, tardy, 72
Ulnar nerve Ulnar neuropathy, in mid-arm to mid-forearm, 70. W
anatomy, 70–71, 71f See also Cubital tunnel syndrome
variants, 71 Ulnar tunnel syndrome, differential diagnosis, 71, 72, Wartenberg’s sign, 73
anterior transposition 73 Whitesides line, 263, 263f
for cubital tunnel syndrome, 74–75 Ultrasound Winquist and Hansen classification, of femoral shaft
intramuscular, 75, 79 of Achilles tendon tears/rupture, 347, fractures, 271, 273f
subcutaneous, 75, 79 347f Wound(s)
submuscular, 75, 79 of knee extensor mechanism, 220 closure, 2–3
blood supply, 71 of rotator cuff tears, 22 dressing, 2–3
compression at elbow. See also Cubital tunnel Urethral injury, 162 irrigation, 2
syndrome Urologic injury, 162 Wrist, anatomy, 97, 98f
potential sites of, 72, 72f
motor branches, 71, 71f
sensory branches, 71, 71f

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GOWNED AND GLOVED

GOWNED AND GLOVED ORTHOPAEDICS:

Library of Congress Cataloging-in-Publication Data

Gowned and gloved orthopaedics : introduction to common procedures /

Acquisitions Editor: James Merritt

Working together to grow

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To the students and residents who are considering a career in

JOSEPH A. ABBOUD, MD DAVID J. BOZENTKA, MD

ANDREA L. BOWERS, MD JOHN M. FLYNN, MD

THEODORE J. GANLEY, MD G. RUSSELL HUFFMAN, MD, MPH

JESS H. LONNER, MD DAVID I. PEDOWITZ, MD, MS

NEIL P. SHETH, MD KEITH L. WAPNER, MD

JESSE T. TORBERT, MD, MS

nedasalamatebook@gmail.com 66485438-66485457 xiii

1. Basic Surgical Principles for Orthopaedic Procedures ........ 1

I. SHOULDER AND ELBOW

3. Rotator Cuff Repair ......................................................... 19

4. Bankart Repair: Open and Arthroscopic ........................... 34

5. Arthroscopic Superior Labrum Anterior Posterior

6. Total Shoulder Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

7. Cubital Tunnel Release and Ulnar Nerve

8. Open Reduction and Internal Fixation of Adult Distal

10. Carpal Tunnel Release ..................................................... 97

11. Open Reduction and Internal Fixation of Distal

13. Lumbar Microdiskectomy .............................................. 127

14. Posterior Lumbar Fusion for Degenerative

16. External and Internal Fixation of Symphysis Pubis

18. Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

19. Hip Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

21. Arthroscopic Meniscectomy ........................................... 228

22. Anterior Cruciate Ligament Reconstruction . . . . . . . . . . . . . . . . . . . 237

23. Total Knee Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

VII. LOWER EXTREMITY

25. Open Reduction and Internal Fixation of Supracondylar

26. Open Reduction and Internal Fixation of Tibial Plateau

27. Intramedullary Nail Fixation of Tibial Shaft Fractures . . . . 314

VIII. FOOT AND ANKLE

29. External Fixation of Tibial Plafond (Pilon) Fractures . . . . . . 335

30. Achilles Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344

31. Hallux Valgus (Bunion) Correction ................................ 352

33. In Situ Pinning of Slipped Capital Femoral Epiphysis . . . . . 375

34. Posterior Spinal Fusion for Adolescent Idiopathic

Index ........................................................................................ 397

or limb ischemia. If the tourniquet is needed for a longer period, it should be

typically dressed with Steri-Strips followed by a nonadherent petroleum jelly

SHOULDER AND ELBOW

CHAPTER 2 Arthroscopic Subacromial Decompression 7

CHAPTER 3 Rotator Cuff Repair 19

CHAPTER 4 Bankart Repair: Open and Arthroscopic 34

CHAPTER 5 Arthroscopic Superior Labrum Anterior Posterior (SLAP) Repair 44

CHAPTER 6 Total Shoulder Arthroplasty 55

CHAPTER 7 Cubital Tunnel Release and Ulnar Nerve Transposition 70

Shoulder and Elbow

Shoulder and Elbow

Stage Age (years) Pathology Clinical Course Treatment

A. Stage I occurs in younger individuals and involves edema and hemorrhage

Shoulder and Elbow

History, physical examination, radiographs

Positive for impingement Negative for impingement—

NSAIDs, physical therapy 6 weeks If demonstrates

Improved Not improved Consider MRI

SURGICAL ALTERNATIVES AND INDICATIONS FOR ARTHROSCOPIC

Documenting the range