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Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv

Section I: Upper Extremity

1. Open Rotator Cuff Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1
Mark K. Bowen
2. Open Anterior Shoulder Stabilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8
Jacques A. Denker and Daniel D. Buss
3. Coracoid Transfer for Glenohumeral Instability (Latarjet Procedure) . . . . . . . . . . . . . . . . . . . .  14
Todd C. Moen and Paul J. Ghattas
4. Shoulder Arthroscopy and Subacromial D
­ ecompression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  19
Jacques A. Denker and Daniel D. Buss
5. Arthroscopic Rotator Cuff Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  25
Juan Marcelo Giugale, Albert Lin, and Stephen Rabuck
6. Arthroscopic Shoulder Stabilization (Bankart Repair) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  30
Sara Edwards
7. Proximal Humerus Fracture: Open Reduction and Internal Fixation. . . . . . . . . . . . . . . . . . . . .  35
Geoffrey S. Marecek and Caroline Tougas
8. Proximal Humerus Fracture: H
­ emiarthroplasty/Reverse Shoulder A
­ rthroplasty. . . . . . . . . .  40
Christopher Kim and Grant E. Garrigues
9. Total Shoulder Arthroplasty: Anatomic and Reverse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  45
Anup A. Shah and Allen Deutsch
10. Humeral Shaft Fracture—Open Reduction and Internal Fixation . . . . . . . . . . . . . . . . . . . . . . . .  52
Rueben Nair and Bradley R. Merk
11. Radial Head Fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  58
Chirag M. Shah and Brian J. Hartigan
12. Olecranon Fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  63
Nickolas G. Garbis and Brian J. Hartigan
13. Distal Humerus Fractures—Open Reduction Internal Fixation . . . . . . . . . . . . . . . . . . . . . . . . . .  69
Geoffrey S. Marecek and Brian J. Hartigan
14. Forearm Diaphyseal Fractures: ­Radius and Ulna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  75
Michael S. Gart and David M. Kalainov
15. Forearm Fasciotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  83
Michael S. Bednar and Frank J. Gerold
16. Open Carpal Tunnel Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  87
Charles Carroll IV and Patrick Palsgrove
17. Base of Thumb Metacarpal Fractures: ­Operative Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  92
Michael S. Gart, Matthew A. Bernstein, and David M. Kalainov
18. Distal Radius Fractures: Open Reduction and Internal Fixation . . . . . . . . . . . . . . . . . . . . . . . . .  98
Chirag M. Shah

vii
viii     Contents

19. Distal Radius Fractures: Traditional Bridging External Fixation . . . . . . . . . . . . . . . . . . . . . . . . . 107

Michael S. Gart, Franklin Chen, and David M. Kalainov
20. Extensor Tendon Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Michael S. Bednar and Frank J. Gerold
21. Flexor Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Michael S. Bednar and Frank J. Gerold
22. Second through Fifth Metacarpal Fractures: Operative Repair. . . . . . . . . . . . . . . . . . . . . . . . . . 122
Michael S. Gart and David M. Kalainov

Section II: Lower Extremity

23. Total Hip Arthroplasty: Hybrid and U
­ ncemented . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Lalit Puri and Douglas E. Padgett
24. Internal Fixation of Hip Fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Roshan P. Shah and Steven H. Stern
25. Hip Fracture: Hemiarthroplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Lalit Puri and Douglas E. Padgett
26. Hip Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Luke Spencer-Gardner and Rafael J. Sierra
27. Intramedullary Nailing of Femoral Shaft F­ ractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Scott D. Cordes
28. Knee Arthroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Gordon W. Nuber and Steven H. Stern
29. Anterior Cruciate Ligament Surgery: Two ­Incision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Shawn Sahota and Gordon W. Nuber
30. Anterior Cruciate Ligament Surgery: ­Endoscopic Bone – Patella Tendon – Bone Graft . . . . . 183
Jason Koh and Steven H. Stern
31. Anterior Cruciate Ligament Surgery with Hamstring Autograft (Traditional Interference
Screw and All-Inside with Graft Link) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Jason Koh and Seung Jin Yi
32. Total Knee Arthroplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Lalit Puri and Steven H. Stern
33. Medial Unicompartmental Knee Arthroplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Mark M. Dolan
34. High Tibial Osteotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Stephen G. Manifold and Giles R. Scuderi
35. Supracondylar Femoral Osteotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Stephen G. Manifold and Giles R. Scuderi
36. Lateral Tibial Plateau Fracture: Open R
­ eduction and Internal Fixation. . . . . . . . . . . . . . . . . . . 218
Daniel J. Fuchs and Bradley R. Merk
37. Intramedullary Nailing of Tibial Shaft F­ ractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Scott D. Cordes
38. Operative Treatment of Patella Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Mark E. Easley and Giles R. Scuderi
39. Extensor Mechanism Injuries: Quadriceps Ruptures and Patella Tendon Ruptures. . . . . . . . . 236
Mark E. Easley and Giles R. Scuderi
40. Tibial Fasciotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Daniel B. Gibbs and Bradley R. Merk
 Contents     ix

41. Ankle Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Daniel J. Fuchs and Armen S. Kelikian
42. Ankle Fractures: Open Reduction and Internal Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Milap S. Patel and Anish R. Kadakia
43. Achilles Tendon Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Steven A. Kodros
44. Chevron Bunionectomy for Hallux Valgus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Daniel J. Fuchs and Armen S. Kelikian
45. Hammer Toe Correction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Daniel J. Fuchs and Armen S. Kelikan
46. Morton’s Neuroma Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Steven A. Kodros
47. Proximal Fifth Metatarsal Jones’ Fractures: ­Internal Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Steven A. Kodros

Section III: Spine

48. Lumbar Discectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Srdjan Mirkovic and Mark T. Nolden
49. Anterior Approach to the Cervical Spine: ­Discectomy, Fusion, and Vertebrectomy. . . . . . . . 288
Serena S. Hu
50. Posterior Lumbar Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Jay M. Zampini
51. Spinal Lumbar Decompression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
Srdjan Mirkovic and Mark Nolden
52. Anterior Lumbar Interbody Fusion: T ­ raditional ALIF and Less Invasive Lateral ­
Interbody Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Kirkham B. Wood
53. Cervical Disc Replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Daniel G. Kang and K. Daniel Riew
54. Percutaneous Pedicle Screw Insertion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Robert K. Eastlack
55. Idiopathic Scoliosis: Posterior Spinal I­nstrumentation and Fusion. . . . . . . . . . . . . . . . . . . . . . . 324
Michael Glotzbecker and Daniel Hedequist

Section IV: Pediatrics

56. Slipped Capital Femoral Epiphysis: In-Situ Hip Pinning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Rachel Mednick Thompson
57. Clubfoot Surgery: Posterior Medial-Lateral Release. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Vineeta T. Swaroop
58. Distal Humerus Supracondylar Fracture: R
­ eduction and Pinning. . . . . . . . . . . . . . . . . . . . . . . . 337
Vineeta T. Swaroop
59. Hip Aspiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Benjamin J. Shore
60. Femoral and Tibial Traction Pin Placement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Bradley R. Merk and Patricia M. Rose

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Foreword
At a time when the means by which surgeons
in practice and training access information is
undergoing a sea change, this book—the second
edition of Key Techniques in Orthopedic Surgery—
redefines value in a text book. Having access to
and learning the material in this book will give
an orthopaedic surgeon the key information
needed to perform the most common operations
in orthopaedics: all in one place in a condensed,
well-organized, standardized, and useful format
compiled from authoritative sources.
The book is succinct in how it presents content
yet broad in scope. It is organized according to
the key procedures in orthopaedics and includes
upper extremity and hand, hip, knee, ankle
and foot, spine and pediatric procedures. Adult
reconstructive procedures, pediatric procedures,
sports medicine, and trauma procedures are all
included. The chapters are organized simply yet
elegantly: indications; contraindications; preop-
erative preparation; special instruments, patient
positioning, anesthesia; tips and pearls; what
to avoid; postoperative care issues; and most
importantly, step-by-step operative technique.
The chapters are well illustrated and the tech-
niques outlined are both state-of-the-art and yet
“generalizable” to most surgeons’ practices.
The success of this book is partly due to its
underlying concept—to provide a succinct,
well-organized, useable book targeting common
x
procedures. However, much of the success of the
book is also a result of the expertise, rigor, and
clear thinking of its editor, Dr. Steven Stern, and
to the in depth of knowledge and experience of
its contributing authors. Distilling procedures
down to their essential features—the key to this
book—can only be done by capable authors and
great editors. The authors chosen for each chap-
ter also have a wealth of clinical expertise which
is particularly noticeable in the “tips and tricks”,
“what to avoid”, and “operative technique” sec-
tions of each chapter.
Different readers may use this book differently.
For those who read it cover to cover and commit
the material to memory, it will provide a phe-
nomenal foundation of knowledge for the most
common orthopaedic procedures. For those who
want a trustworthy quick reference source be-
fore performing a procedure, this book will fit
the bill beautifully.
The fact that this book is now in its second edi-
tion is not a surprise after the success of the
first. I am certain that many surgeons and their
patients will be the beneficiaries of this terrific
resource.
Daniel J. Berry, MD
L. Z. Gund Professor of Orthopaedic Surgery
Mayo Clinic
Rochester, Minnesota
Preface
The more things change, the more things stay
the same. The world in general, and surgery
in particular, has seen significant change over
the 15 years since the first edition of Key Tech-
niques in Orthopaedic Surgery was published.
We have all witnessed the dizzying pace of
many technological advances over this peri-
od. Incisions have gotten smaller, instruments
have become more sophisticated, implant de-
signs have been enhanced, and materials have
improved. However, these developments have
not changed the basic tenets of most surgery.
It remains essential to get the indications
­“correct,” plan in advance for the instruments
that will be required, appreciate the relevant
anatomy, try an avoid the procedure’s common
pitfalls, and understand how to optimally posi-
tion the patient. Above all, it remains essential
for the surgeon to achieve adequate visualiza-
tion of the surgical field—whether by direct
visualization or indirectly via arthroscopic or
fluoroscopic technique. All of these things are
essential in helping to achieve the best clinical
result possible.
Thus, the goal of this second edition is to build
on the topics presented in the first edition. As
the pace of surgical evolution proceeds in a
non-linear fashion, readers will note that some
chapters have been added to the book to reflect
changes that have occurred over time. Other
chapters have been modified to reflect current
thinking, while others have remained basically
unchanged.
The book is designed to offer clear and con-
cise information on the surgical procedures
covered. It is designed to be a “quick read”
and thus does not attempt to cover the depth
of information that more comprehensive sub-
specialty textbooks might offer. Rather, it is
intended as an introduction or refresher for
medical students, residents, nurses, physician
assistants and orthopaedic surgeons. Since
each chapter focuses on the essential issues
and surgical steps associated with a specific
procedure, it may be particularly helpful as a
concise resource that can be reviewed just pri-
or to a surgical procedure.
As with the first edition, the chapters are all
structured the same following a “cookbook” out-
line format. Each chapter includes:
1. Indications: lists the common indications
for the procedure.
2. Contraindications: lists the common con-
traindications for the procedure.
3. Preoperative Preparation: special instru-
ments, positioning, and anesthetic options;
lists the common issues associated with
these topics.
4. Tips and Pearls: lists special tips that the
authors feel are especially helpful to keep
in mind in conjunction with the procedure.
5. What to Avoid: lists common pitfalls to try to
avoid that are associated with the procedure.
6. Postoperative Care Issues: lists common
issues in postsurgical care associated with
the procedure.
7. Operative Technique: lists common basic
steps necessary to perform the orthopaedic
procedures; many procedures have optional
or alternative steps that may be indicated or
required depending on the clinical situation.
It must be remembered that orthopaedics is a
surgical art that continues to change and evolve.
Thus, the techniques in these chapters represent
one method of performing each procedure at the
time they were written. Many readers will em-
ploy appropriate variations to the listed steps in
order to adapt them to their own surgical tech-
nique. The individual chapter authors have also
modified and refined the techniques presented
in this text as the field of orthopaedics evolves.
Thus, these steps are not designed to be slavishly
followed without regard for the clinical situation.
Rather, they serve as a general outline or guide-
book in performing these particular procedures.
In no way do the authors or the text attempt to
define the listed operative techniques as repre-
sentative of the only, best, or standard way of per-
forming surgery. In a similar manner, the other
sections of the book should not be construed as
representative of the only, best, or standard way
of dealing with a particular clinical situation. As in
all aspects of medicine, clinical judgement should
always be employed in each individual situation.
xi
xii     Preface
Because the book is not designed to be all en-
compassing, we encourage readers to augment
this book with subspecialty texts of their choos-
ing. Furthermore, the book attempts to review
common orthopaedic procedures that are em-
ployed to treat common orthopaedic problems.
Therefore, the techniques listed may be less appli-
cable to complex, revision, or other unusual cases.
Finally, our senior editor (S.H.S., sole editor of
the 1st edition) would like to suggest his own
“pearl” that he thinks is applicable to almost all
of the techniques in this book, and one that he
has frequently told to residents and medical stu-
dents. It has always been his thought that most
orthopaedic procedures are relatively easy and
straightforward, if appropriate visualization can
be achieved. In fact, the most technically adept
surgeons that he has worked with were those
that were the most skilled in achieving excel-
lent surgical exposure. Thus, he has always felt
that (in most cases) “if you can see it, you can do
it.” It is hoped that the techniques in this book
will aid the reader in achieving the necessary
exposure and visualization, so they too can “see
it” and “do it.”
Steven H. Stern
Christopher M. Bono
Matthew D. Saltzman
Acknowledgments
As with the first edition, we would like to
acknowledge all of the authors who have con-
tributed their time and effort to make this book
possible. Agreeing to author a book chapter is a
“labor of love” and we are most appreciative of
everyone’s contribution.
As our senior editor, Steve Stern, is no longer
in active clinical practice, he was assisted by two
co-editors—Chris Bono and Matt Saltzman. He
wishes to publically thank them for their efforts,
expertise and willingness to take on the task of
editing a text book with him. Matt is a shoul-
der specialist at Northwestern University and fo-
cused on the upper extremity chapters. Chris is
a spine specialist at Harvard Medical School and
edited all of the spine chapters. Their excellent
help and clinical expertise was invaluable and
immensely appreciated. It allowed Steve to fo-
cus on the lower extremity chapters— his area of
focus when in clinical practice. Steve would also
like to thank his wife, Sharon, and his children,
Anna, Jackie and Rebecca. He appreciates their
constant support and love as they have jour-
neyed through life together.
We wish to also specifically acknowledge
two people at Theime who were instrumental
in making this book possible. William Lams-
back (Executive Editor) had the initial inspi-
ration and vision for this second edition of
Key Techniques in Orthopaedics. His leader-
ship and support was essential in making this
project possible. Sarah Landis’s (Managing
Editor) tireless help on this project deserves
special mention and thanks. She has helped
on all phases of the book from chapter coor-
dination to editing. While she has commonly
explained to editors that she is not “clinical,”
you would never know that from the insight
she has shown in helping make this text come
to fruition. Simply, the book would not have
occurred without her help. We owe her a debt
of gratitude and thanks.
Chris Bono would like to first thank his friend,
Steve Stern, for inviting him to participate in the
production of this textbook. For allowing him
the time to devote to academic endeavors such
as this, Chris thanks his wife Terri, and children,
Alissa, Annabella, and Christopher.
Matt Saltzman would also like to thank Steve
Stern for the wonderful opportunity to work
on this book. He would like to thank all of the
authors of the chapters that he served as editor
for—their hard work and timeliness is very much
appreciated. Matt also wishes to acknowledge
his amazing wife Mari who somehow defies
logic by maintaining a busy neurology practice
while simultaneously providing so much for
their daughters, Sydney and Ava.
xiii
Contributors

Michael S. Bednar, MD Jacques Denker, DO

Chief, Division of Hand Surgery Orthopedic Surgeon
Professor, Department of Orthopaedic Surgery Department of Orthopedics
and ­Rehabilitation Sweetwater Memorial Hospital
Stritch School of Medicine Rock Springs, Wyoming
Loyola University Chicago
Maywood, Illinois Allen Deutsch, MD
Assistant Professor
Matthew A. Bernstein, MD Department of Orthopaedic Surgery
Hand and Upper Extremity Specialist University of Texas Health Science Center at
Barrington Orthopedic Specialists Houston
Schaumburg, Illinois Houston, Texas

Christopher M. Bono, MD Mark M. Dolan, MD

Chief of Spine Service Orthopedic Surgeon
Associate Professor of Orthopaedic Surgery Hope Orthopedics of Oregon
Harvard Medical School Salem, Oregon
Brigham and Women’s Hospital
Boston, Massachusetts Mark E. Easley, MD
Associate Professor
Mark K. Bowen, MD Department of Orthopaedic Surgery
Chief, Division of Sports Medicine Duke University Medical Center
Department of Orthopedic Surgery Durham, North Carolina
Northshore University Health System
Robert K. Eastlack, MD
Chicago, Illinois
Fellowship Director and Clinical Instructor
Department of Orthopaedic Surgery
Daniel D. Buss, MD
Scripps Clinic / University of California San Diego
Sports & Orthopaedic Specialists
San Diego, California
Minneapolis, Minnesota
Sara Edwards, MD
Charles Carroll IV, MD
Orthopaedic Surgeon
Associate Professor of Clinical Orthopedic Surgery
Anderson Knee and Shoulder Center
Northwestern University Feinberg School of
California Pacific Medical Center
Medicine
San Francisco, California
Chicago, Illinois
Daniel J. Fuchs, MD
Franklin Chen, MD
Foot and Ankle Fellow
Hand and Upper Extremity Specialist
Department of Orthopaedic Surgery
Edison-Metuchen Orthopaedic Group
Baylor University Medical Center
Franklin, New Jersey
Dallas, Texas
Scott D. Cordes, MD
Nickolas G. Garbis, MD
Assistant Professor of Orthopedic Surgery
Assistant Professor
Northwestern University Medical School
Shoulder and Elbow Division
Chicago, Illinois
Department of Orthopaedic Surgery
Loyola University Medical Center
Maywood, Illinois

xiv
 Contributors     xv

Grant E. Garrigues, MD Daniel Hedequist, MD

Section Head, Shoulder Reconstruction Associate Professor
Co-Director, Upper Extremity Trauma Surgery Department of Orthopaedic Surgery
Department of Orthopaedic Surgery Boston Children’s Hospital
Duke University Medical Center Harvard Medical School
Durham, North Carolina Boston, Massachusetts

Michael S. Gart, MD Serena S. Hu, MD

Fellow Professor and Vice Chair
Hand & Upper Extremity Surgery Chief, Spine Service
OrthoCarolina Hand Center Department of Orthopedic Surgery
Charlotte, North Carolina Stanford University
Redwood City, California
Frank J. Gerold, MD
Hand Fellow Anish R. Kadakia, MD
Department of Orthopaedic Surgery and Associate Professor, Orthopedic Surgery
Rehabilitation Program Director, Orthopedic Foot and Ankle
Stritch School of Medicine Fellowship
Loyola University Chicago Northwestern University
Maywood, Illinois Department of Orthopedic Surgery
Northwestern Memorial Hospital
Paul J. Ghattas, DO Chicago, Illinois
Orthopaedic Surgeon
W.B. Memorial Carrell Clinic David M. Kalainov, MD
Dallas, Texas Clinical Professor of Orthopaedic Surgery
Northwestern University Feinberg School of
Daniel B. Gibbs, MD Medicine
Resident Physician Chicago, Illinois
Department of Orthopaedic Surgery
Northwestern University Feinberg School of Daniel G. Kang, MD
Medicine Assistant Professor
Chicago, Illinois Orthopedic Surgery
Madigan Army Medical Center
Juan Marcelo Giugale, MD Tacoma, Washington
Clinical Fellow
Hand and Upper Extremity Division, Department Armen S. Kelikian, MD
of ­Orthopedic Surgery Professor
University of Pittsburgh Medical Center Department of Orthopedics
Pittsburgh, Pennsylvania Northwestern University Medical School
NorthShore University Health Care
Michael Glotzbecker, MD Chicago, Illinois
Assistant Professor
Department of Orthopaedic Surgery Christopher Kim, MD, FRCSC
Boston Children’s Hospital Instructor
Harvard Medical School Orthopaedic Sports Medicine
Boston, Massachusetts Department of Orthopaedic Surgery
Saint Louis University
Brian J. Hartigan,† MD St. Louis, Missouri
Clinical Instructor
Department of Orthopaedic Surgery
Northwestern University Medical School
Chicago, Illinois
†
deceased
xvi     Contributors

Steven A. Kodros, MD Todd C. Moen, MD

Associate Professor of Clinical Orthopaedic WB Carrell Memorial Clinic
Surgery Dallas, Texas
Department of Orthopaedic Surgery
Northwestern University Medical School Rueben Nair, MD
Chicago, Illinois Fellow
Orthopaedic Surgeon
Jason Koh, MD, MBA Sports Medicine
Board of Directors Chair of Orthopaedic Surgery Steadman Hawkins Clinic Denver
Director, Orthopaedic Institute Denver, Colorado
NorthShore University HealthSystem
Clinical Professor, University of Chicago Pritzker Mark T. Nolden, MD
School of Medicine Spine Surgeon
Adjunct Professor, Northwestern University Orthopaedic Medical Director
Feinberg School of Medicine NorthShore Spine Surgery Center
Evanston, Illinois Department of Orthopaedic Surgery
NorthShore University Healthcare System
Albert Lin, MD Chicago, Illinois
Assistant Professor
Department of Orthopaedic Surgery Gordon W. Nuber, MD
University of Pittsburgh Medical Center Professor of Clinical Orthopedic Surgery
Pittsburgh, Pennsylvania Department of Orthopedic Surgery
Feinberg School of Medicine
Stephen G. Manifold, MD Northwestern University
Orthopedic Surgeon Chicago, Illinois
Bayhealth Kent General Hospital
Dover, Delaware Douglas E. Padgett, MD
CS Ranawat Chair and Chief
Geoffrey S. Marecek, MD Adult Reconstruction and Joint Replacement
Associate Chief of Orthopaedic Surgery Hospital for Special Surgery
LAC+USC Medical Center New York, New York
Assistant Professor of Clinical Orthopaedic
Surgery Patrick Palsgrove, MD
Keck School of Medicine Physician Assistant
University of Southern California--Los Angeles Department of Orthopaedic Surgery
Los Angeles, California NorthShore University HealthSystem
Evanston, Illinois
Bradley R. Merk, MD
Professor of Orthopaedic Surgery Milap S. Patel, DO
Feinberg School of Medicine Clinical Instructor
Northwestern University Department of Orthopedic Surgery
Chicago, Illinois Northwestern Memorial Hospital Feinberg
School of M­ edicine
Srdjan Mirkovic, MD Chicago, Illinois
Associate Clinical Professor of
Orthopedic Surgery Lalit Puri, MD, MBA
Northwestern University Feinberg Chief of Adult Reconstruction
School of Medicine Vice-Chairman Clinical Excellence
Chicago, Illinois NorthShore Orthopaedic Institute
Attending Spine Surgeon NorthShore University HealthSystem
NorthShore University Health Care Systems Evanston, Illinois
Evanston, Illinois
Spine Consultant
Chicago Bears
 Contributors     xvii

Stephen Rabuck, MD Chirag M. Shah, MD

Clinical Assistant Professor Clinical Instructor of Orthopaedic Surgery
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
University of Pittsburgh Medical Center Northwestern University Feinberg School of
Pittsburgh, Pennsylvania Medicine
Chicago, Illinois
K. Daniel Riew, MD
Professor Roshan P. Shah, MD, JD
Department of Orthopaedic Surgery Assistant Professor
Columbia University Medical Center/New York Department of Orthopaedic Surgery
­Presbyterian Columbia University
New York, New York New York, New York

Patricia M. Rose, MMSc Benjamin J. Shore, MD, MPH, FRCSC

Physician Assistant Assistant Professor
Orthopaedic Surgery Department of Orthopaedic Surgery
Northwestern Memorial Hospital Harvard Medical School
Chicago, Illinois Boston Children’s Hospital
Boston, Massachusetts
Shawn Sahota, MD
Physician Rafael J. Sierra, MD
Department of Orthopaedic Surgery Professor
Northwestern University Department of Orthopedic Surgery
Chicago, Illinois Mayo Clinic
Rochester, Minnesota
Matthew D. Saltzman, MD
Associate Professor Luke Spencer-Gardner, MD
Department of Orthopaedic Surgery Assistant Director of Clinical and Translational
Northwestern University Feinberg School of Research
Medicine Hip Preservation Center
Chicago, Illinois Baylor University Medical Center
Dallas, Texas
Giles R. Scuderi, MD
Vice President Steven H. Stern, MD
Orthopedic Service Line Clinical Associate Professor
Northwell Health Department of Orthopaedic Surgery
Fellowship Director Northwestern University Feinberg School of
Adult Reconstruction Medicine
Lenox Hill Hospital Chicago, Illinois
New York, New York
Associate Professor of Orthopedic Surgery Vineeta T. Swaroop, MD
Hofstra - Northwell Health School of Medicine Assistant Professor
Hempstead, New York Department of Orthopaedic Surgery
Northwestern University Feinberg School of
Anup A. Shah, MD Medicine
Orthopedic Sports Medicine and Shoulder Ann & Robert H. Lurie Children’s Hospital of
Reconstruction Chicago
Kelsey-Seybold Clinic Chicago, Illinois
Assistant Clinical Professor of Orthopedic
Surgery
Baylor College of Medicine
Houston, Texas
xviii     Contributors

Rachel Mednick Thompson, MD Kirkham B. Wood, MD

Assistant Professor, Department of Orthopaedic Professor Orthopaedic Surgery
Surgery Department Orthopaedic Surgery
Associate Director, UCLA/OIC Center for Cerebral Stanford University
Palsy Palo Alto, California
David Geffen School of Medicine at UCLA
Orthopaedic Institute for Children Jay M. Zampini, MD
Los Angeles, California Instructor of Orthopaedic Surgery
Harvard Medical School
Caroline Tougas, MD Division of Spine Surgery
Orthopaedic Trauma Fellow Brigham and Women’s Hospital
University of Southern California Boston, Massachusetts
Los Angeles, California

Seung Jin Yi, MD

Orthpaedic Surgeon
Florida Orthopaedic Institute
Tampa, Florida
1
Open Rotator Cuff Tendon Repair
Mark K. Bowen

Abstract ²² Radiographic changes of AC joint arthritis.

While modern arthroscopic techniques for repair ²² Exposure optimization of a retracted
of rotator cuff tears have increasingly replaced supraspinatus tendon in chronic or massive
the need for an open approach, there are cases rotator cuff tears.
where it may be necessary. This chapter outlines
the critical components of a safe and successful
open procedure. It is most commonly chosen in Contraindications
settings of revision repair, massive two and three
tendon tears, and situations where augmenta- 1. Active soft-tissue or glenohumeral infection.
tion is considered. Postoperative protocols are 2. Neuropathic joint.
typically dictated by repair size considerations 3. Chronic axillary nerve injury.
rather than others associated with the approach. 4. Failed prior surgical treatment with associ-
ated deltoid insufficiency (relative).
Keywords: open approach, massive rotator cuff 5. Degenerative arthritis (relative); consider
tear, repair augmentation, revision surgery combining rotator cuff repair with shoulder
arthroplasty.
6. Patient’s overall medical condition
Indications (relative).
7. Parkinson’s disease or other diseases
Rotator Cuff Repair that cause uncontrolled muscle activity
(relative).
1. Patients with chronic shoulder pain or
8. Patient unable to comply with postoperative
weakness with a documented rotator cuff
rehabilitation.
tear that have failed nonsurgical manage-
ment (rest, local modalities, nonsteroidal
anti-inflammatory drugs, physical ther-
apy, and judicious subacromial cortisone
Preoperative Preparation
injections). 1. Physical examination to include assessment
2. Acute, traumatic full-thickness rotator cuff of AC joint tenderness and/or pain with
tears. shoulder adduction.
3. Symptomatic partial-thickness rotator cuff 2. Obtain radiographs:
tears greater than 50%. a. Anteroposterior (AP) in plane of
4. Revision rotator cuff repairs. scapula (true AP).
5. Augmentation (xenograft) for deficient b. AP shoulder (check distal clavicle for
tendon. “spurs”).
c. Axillary view (check for os acromiale,
glenohumeral arthritis).
Associated Acromioclavicular Joint Resection
d. Supraspinatus outlet view (assess acro-
²² Acromioclavicular (AC) joint tenderness on mion shape [types I–III], spinoacromial
physical examination. angle).

1
2 1 Open Rotator Cuff Tendon Repair
e. 25-degree caudal tilt (“Rockwood view”)
(optional).
3. Magnetic resonance imaging (MRI): helps
evaluate extent (“full” vs. “partial” thick-
ness) of rotator cuff tears, and presence of
muscle atrophy or tendon retraction; ob-
serve mass effect of acromion and AC joint
on supraspinatus tendon (impingement).
Special Instruments, Position, and
Anesthesia
1. Small sagittal or oscillating saw for bone
resection.
2. A 1.6-mm drill bit for deltoid reattachment.
3. Small, half-circle curved free Mayo needle
and #2 braided nonabsorbable suture.
4. A 5-mm round burr and broad flap rasp to
“fine-tune” acromioplasty.
5. Semi-sitting or beach chair position. The pa-
tient is moved as close to the side of the table
as possible while still being stable. A bean-
bag-type McConnell head holder (McConnell
Surgical Mfg., Greenville, TX) or AMSCO “cap-
tain’s chair” is useful to secure and stabilize
the head in a safe neutral position. Care must
be taken to pad all bony prominences.
6. The head may be secured gently with a pad-
ded strap or tape across a pad on the fore-
head. Care must be taken to avoid the strap
or tape from sliding down over the eyes.
7. The procedure can be done with either gen-
eral or interscalene block anesthesia.
Tips and Pearls
1. With modern techniques, training, expe-
rience, and utilization of readily available
equipment and implants, arthroscopic re-
pairs are possible and in most cases easier
and preferable to open repairs. Open rotator
cuff repair may be useful when performing
augmentation (xenograft) for a deficient
tendon.
2. A thorough preoperative evaluation is criti-
cal to a successful rotator cuff repair. A com-
plete physical examination, review of plain
radiographs, and MRI provide meaningful
information to plan surgery and counsel
patients preoperatively. The size of tear and
the degree of tendon retraction and muscle
atrophy can suggest the degree of difficulty
in attempting to repair the rotator cuff and
the possible need for postoperative abduc-
tion brace immobilization.
3. Check passive range of motion preopera-
tively and under anesthesia. Gentle shoul-
der manipulation may be necessary to
release capsular adhesions. If adhesive cap-
sulitis is severe, consider a staged manipu-
lation and subsequent rotator cuff repair to
minimize postsurgical loss of motion.
4. Mobilization of the rotator cuff tendon
along its superior and inferior surfaces and
release of a contracted coracohumeral lig-
ament are important to minimize undesir-
able tension on the tissue and repair.
5. Define the anterior and posterior aspects of
the rotator cuff tear and advance and secure
these areas first. This closes the tear and re-
lieves tension on the repair at the tuberosity.
6. A secure deltoid repair to the acromion is
as important as the rotator cuff repair in re-
storing shoulder strength and function.
What to Avoid
1. Make sure the patient is properly positioned
on the operating room table. Maintain a
stable, neutral cervical position and avoid
excessive brachial plexus traction. Ensure
proper padding of all bony prominences to
minimize risk of neuropraxias.
2. Avoid fracturing the acromion during either
the acromioplasty or deltoid reattachment.
3. Do not mistake the flimsy bursal tissue for
the rotator cuff tendon and use it in the cuff
repair.
4. Avoid inadequate or insecure repair of the
deltoid to the acromion.
Postoperative Care Issues
1. A sling or abduction pillow is used postoper-
atively to protect the rotator cuff repair. The
choice of postoperative protection depends
on the type of patient, the quality of the ten-
don tissue, the tension on the sutures, and
the adequacy of the cuff and deltoid repair.

2. Three phases of rehabilitation—time in
each stage depends on tendon quality and
assessment of repair:
a. Phase 1. Passive range of motion: includes
pendulum saw and tummy rub exercises.
b. Phase 2. Active-assisted range of motion
exercises and gentle cuff isometrics.
c. Phase 3. Active range of motion and re-
sistance exercises.
Operative Technique
Approach
1. Position the patient on the operating room
table as outlined earlier.
2. Prepare and drape the entire arm and
shoulder girdle “free.”
3. Carefully outline prominent anatomic land-
marks: coracoid process, clavicle, AC joint,
acromion, and scapular spine.
4. Draw the planned skin incision with a
marker. The incision should extend 2 inch
from the lateral aspect of the anterior third
of the acromion toward the lateral tip of
the coracoid process acromion halfway be-
tween the anterolateral and posterolateral
corners of the acromion. Place the skin inci-
sion in Langer’s lines that parallel the later-
al border of the acromion (Fig. 1.1).
5. If an excision of the distal clavicle is indicated,
move the incision approximately 1 cm medi-
al to the standard incision (Fig. 1.1).
6. Infiltrate the skin and subcutaneous
tissue with 1:200,000 concentration of
epinephrine.
7. Incise the skin and subcutaneous tissue
down to the deltoid fascia. Develop the pre-
fascial plane to expose the entire anterolat-
eral corner of the acromion and the lateral
aspect of the deltoid. If AC joint excision is
planned, dissect further medially to expose
the distal 2 cm of the clavicle.
8. Split the deltoid muscle in the raphe between
the anterior and middle deltoid. Begin at the
anterolateral corner and extend the dissec-
tion distally 2 to 3 cm. The direction of the
split is approximately perpendicular to the
skin incision. Consider placing a stay suture
to avoid injuring the terminal branches of
the axillary nerve (Fig. 1.2a).
1 Open Rotator Cuff Tendon Repair 3
9. Starting from the split, release the deltoid
subperiosteally along the anterior acromi-
on using an electrocautery. Start several
millimeters back from the anterior edge of
the acromion (Fig. 1.2a). Bovie electrocau-
tery is more effective than sharp scalpel
dissection for this step.
10. Release the superficial and deep deltoid
fascia. Tag these with heavy nonabsorbable
suture, which aids retraction and deltoid re-
pair. Carefully coagulate the acromial branch
of the thoracoacromial artery that is usually
encountered near the anterolateral acromi-
on between the superficial and deep deltoid.
11. Completely detach the coracoacromial lig-
ament, usually along with the deep deltoid
fascia, from its attachment on the acromi-
on (Fig. 1.2b). It is not necessary to dissect
these out separately.
12. Extend the deltoid release past the AC joint.
Expose the distal clavicle when distal clavi-
cle excision is planned (Fig. 1.2a).
13. Release bursal adhesions with a blunt in-
strument or an index finger.
Fig. 1.1 Skin incision. The incision should extend 4 cm from the
lateral aspect of the anterior third of the acromion toward the lat-
eral tip of the coracoid process halfway between the anterolateral
and posterolateral corners of the acromion. Place the skin incision
in Langer's lines that parallel the lateral border of the acromion
(a). Note that if excision of the distal clavicle is planned, the skin
incision should be positioned approximately 1 cm medial to the
standard incision (b).
4 1 Open Rotator Cuff Tendon Repair
Acromioplasty
14. Protect the rotator cuff with a blunt retrac-
tor, such as a medium chandler. Perform an
acromioplasty utilizing either a sagittal saw
or a sharp osteotome (Fig. 1.3). The wedge of
bone excised should be the full width of the
acromion from the medial to lateral:
a. The goal of the acromioplasty is to shape
the acromion so its undersurface is flat
from anterior to posterior and medial
to lateral. After surgery, the acromion’s
undersurface should have a smooth
contour for optimal subacromial con-
tact. There should be no ridges or sharp
spikes of bone, nor should there be ante-
rior overhang of the acromion.
b. The deep deltoid fascia attachment to the
lateral acromion can be used as a land-
mark to judge the amount of acromion
resected. After an acromioplasty, the ac-
romion should be flush with the deep del-
toid attachment to the lateral acromion.
Fig. 1.2 (a) Deltoid exposure. Split the deltoid
muscle in the raphe between the anterior and
middle deltoid. This incision should begin at
the anterolateral corner and extend distally 2
to 3 cm. The direction of the split is approx-
imately perpendicular to the skin incision.
Consider placing a stay suture to avoid injuring
the terminal branches of the axillary nerve.
Starting from the split, you should release
the deltoid subperiosteally along the anterior
acromion using an electrocautery. Extend
the incision along the clavicle when a distal
clavicle excision is planned. (b) Lateral view of
deltoid detachment. Completely detach the
coracoacromial ligament, usually along with
the deep deltoid fascia, from its attachment on
the acromion.
Fig. 1.3 (a) Acromioplasty. Perform the
acromioplasty utilizing either a sagittal saw or
sharp osteotome. This should create a flat or
slightly angled-up acromion. Note the position
of the retractor which serves to protect the
rotator cuff. (b) Acromioplasty (lateral view).
Lateral view of acromioplasty creating a type I
acromion.
15. Use a burr or file to smooth the undersur-
face of the acromion.
Rotator Cuff Repair
16. Identify the subacromial bursa and perform
a complete subdeltoid bursectomy. Rotating
the arm internally and externally exposes
the rotator cuff tendons.
17. Assess the size of the rotator cuff tendon tear,
the precise rotator cuff tendon anatomy, the
shape of the tendon tear, the tendons in-
volved, the degree of tendon retraction, the
anterior and posterior extent of the tear, and
the quality of the tendon available for repair.
18. Tag the torn edges of the rotator cuff with
heavy nonabsorbable suture. Assess the
need for mobilization of the tendon.
19. Several methods are useful in mobilizing
the rotator cuff:
a. Release and excision of the subacromial
and subdeltoid bursa.

b. Release of the coracohumeral ligament,
which is a thick band of tissue between
the coracoid process and the insertion of
the supraspinatus tendon (Fig. 1.4).
20. Minimally trim the torn tendon so fresh
21. Once the tendon has been adequately mo-
22. Inspect the biceps tendon. Occasionally if the
Fig. 1.4 Releasing the coracohumeral ligament. The coraco-
humeral ligament, which is a thick band of tissue between the
coracoid process and the supraspinatus tendon, can be released
to mobilize the rotator cuff.
1 Open Rotator Cuff Tendon Repair 5
c. Longitudinal releasing incisions in the
anterior tendon (in the rotator interval)
or posterior tendon can help to advance
the supraspinatus (Fig. 1.5a,b).
d. In large, chronic tears, consider intra-ar-
ticular release of the adhesions between
the capsule and the rotator cuff (Fig. 1.6).
After sharply releasing the capsule, use
a blunt elevator to lift the muscle ten-
don tissue off the glenoid neck. Take care
when dissecting superior and posterior to
avoid injuring the suprascapular nerve as
it passes around the spinoglenoid notch.
tendon is available for insertion to the bone.
bilized, prepare an area of bone between
the articular surface of the humeral head
and the greater tuberosity to serve as the
bed for the rotator cuff repair (Fig. 1.7a).
Use rongeurs, curettes, or a motorized burr
to create a bleeding surface to optimize ten-
don healing. Take care not to create troughs
or weaken the cortical bone.
biceps tendon is completely torn, it can be
used to augment deficient and larger rotator
cuff tears. If the biceps tendon is significant-
ly degenerated, consider tenotomy or tenod-
esis of the tendon at the bicipital groove.
Fig. 1.5 (a) Longitudinal releasing incisions.
Longitudinal releasing incisions in the anterior
tendon (in the rotator interval) or posterior
tendon can help advance the supraspinatus.
(b) Closure of the interval. The interval is closed
after the tendon is repaired to bone.
Another random document with
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 En waereld draeijen, dat je lui zult suizebollen.
Uri. Hoe! spot gy met de kunst? Fi. ô Neen: ’k vertel geen grollen.
Eel. Zwyg. Mogt ik uw dispuut in ’t net beschreven zien;
Dan wist ik raad om u te helpen. Uri. ’t Zal geschiên.
Raas. En ’t myne zal ik, als het af is, laaten drukken
By and’re dingen. ô Ik heb nog duizend stukken;
Het vierkant tegen ’t rond des cirkels heb ik wis,
Beneven ’t oost en west. Uri. Iets dat ’er nog niet is
Heeft deeze snappert. Vent, dat kan men nimmer vinden.
Raas. Ik weet nu de oorsprongk ook van alderhande winden.
Uri. Het laatste zy zo: maar het eerste weet gy niet;
’t Getal is surdiesch, en dat’s altyd in ’t verdriet.
An. Ik bid u laat dien twist tog met malkander vaaren.
Ei drinkt de questie af. Uri. Dat doe ik altyd gaeren.
Myn heer ik merk gy zyt een zeer verstandig man;
Maar wat oploopend. Zo ’k u ergens dienen kan,
Ik ben uw dienaar. Ik verzoek u, wees te vreeden.
Raas. ’k Dacht niet dat Urinaal zo gaauw was; maar zyn reden
Behaagt my, schoon ik die somtyds wat zwak bevind.
Doktoor vergeef my tog myn gramschap, ’k ben uw vrind.
Uri. ’k Zal al myn’ vindingen u graag kommuniceeren,
Al woudt gy zelf met my in poortaard laboreeren,
Of vette beemster klei gemengd met geest van zout,
Waar mê men keijen kan veranderen in goud.
Raas. Doktoor, dan zal ik u een stuk fortificatie
Doen zien, verdienende op het hoogst elks admiratie
Ik zal u toonen hoe men steeden defendeert.
Uri. Gy hebt de wiskunst dan geheel en al geleerd?
Raas. Weg met die ezels die een bort uit durven hangen!
Zwyg, zwyg kolegies der Mathezis: ’k zou je vangen
Door propozities, en door demonstraatzies van
Myn prins Euklides, dien wiskunstelyken man!
En vind ik eens het geen ik byna heb begrepen,
 Zult gy de huizen voort zien zeilen, puur als schepen.
Ik maak machienen, die heel fors zyn van geweld:
Daar een man duizend mê kan jaagen over ’t veld.
Weg brandspuit! en kameel! lantaarens! moddermolen!
’k Heb beter dingen; maar ik hou ze nog verholen;
’t Is waar gy zyt bedacht tot nut van stadt en land.
Maar wat’s een brandspuit? ’k heb een blaasbalg, die den brand,
Al was hy nog zo groot, ten eersten uit zal blaazen.
In ’t kort: ’k heb dingen daar zich elk om zal verbaazen.
Fi. Geleerde heer, ik bid, betoon me zoo veel gunst,
En leer me uit liefde mê een beetje van je kunst!
Al zou het maar alleen die fraaije blaasbalg weezen:
Want had ik die, ik zou nooit voor geen armoe vreezen.
Raas. Verstaat ge iets van de kunst? Fi. Och neen ik, niet een beet.
Maar ’k weet een kunsje dat jy zekerlyk niet weet.
Raas. Wat kunst? Fi. De beenen al zo murw als ’t vleisch te kooken.
Uri. Wat zegt gy! deeze kunst kon dienen in myn stooken!
Leer my die. ’k Wys u dan hoe dat men kalcineert,
En poortaard van een hond tot zilver laboreert:
Hoe ’t vuur het zilver uit de keijen weet te dwingen.
Fi. De keijen mogten me dan voor de harsens springen:
De blaasbalg van dien heer gelykt my beter, vriend.
Raas. Ik leer die kunst niet dan aan iemand, die my dient.
Wat zoudt ge ’er ook mê doen? Fi. Twee gekken, die hier raazen,
’k Meen dien Doktoor, en jou, voort uit de kamer blaazen;
Opdat ik met gemak zou eeten van dien ham.
Raas. Was ik uw heer, ik sloeg u ’t lichaam blaauw en lam.
Filipyn willende van den ham snyden.
ô Starren! zon en maan! dat is een slecht spectakel.
Al ’t ingewand is uit den ham! dat’s een mirakel!
Eel. Wat is ’t? Fi. Och! och! de loop der starren is verkeerd!
Daar zie je ’t zwoort en ’t been, al ’t spek is geëklipseerd!
Waard. Het swoord en ’t been! wie droes heit dan het spek
gestolen?
Fi. Dat draaijt al met de zon en waereld als een molen.
Raasbollius ontkleedt zich, en gaat te bedt in zyn onderkleeren.
Ik moei me met geen spek, ’k gaa slaapen, ik heb vaak.
Waard. Waar pikken is het spek? Fi. Loop heen, en zoek het,
snaak.
Waard. ’k Kan niet bedenken hoe dat komt; het schynen droomen;
’t Is of de duvel daar den ham heit weggenomen!
Fi. Hoor hospes, weet je wat? gaa in dien kring eens staan,
Vraag waar de ham is, aan de starren en de maan.
Waard. Jy bruid je moer wel; ’k moet den ham nu al vast missen.
Eel. Patientie hospes, ’t is een pots, men kan ’t wel gissen.
Uri. Ik wensch de heeren wel te slaapen, goeden nacht.
Eel. „Loop jy nu nâ de stal, span ’t rytuig in: maar zagt;
„Op dat het niemant merk’. Fi. „Dat zal niet nodig weezen,
„Het staat al reed. Ik heb den Waard daar flus beleezen
„Dat hy het doen zou. Eel. Goed. Waard. Zoo ik het word gewaar,
Wie dat die potsen bakt, zoo zellenwe malkaêr
Gevoelig spreeken!
Anzelmus tegen Eelhart.
Wil de zaak wel overdenken.
Opdat my dat proces niet hind ’ren kan of krenken.
Eel. Myn heer, ’k zal pleiten dat gy u verwond’ren zult.
Ik zal het winnen met de kosten, heb geduld.
An. Ik wensch u goeden nacht. Eel. En u gerust te slaapen.

TWINTIGSTE TOONEEL.
Eelhart, Filipyn, Waard. Raasbollius op ’t bed.

Filipyn. Nu zyn wy eindelyk ontslagen van die aapen.

Eel. Hoe is het hospes, is myn rytuig klaar of niet?
Waard. ô Ja. Myn knecht blyft op, hy zal op uw gebied
U aanstonds helpen: maar je moet een fooitje geeven.
Eel. Wat hebben we verteert?
Waard. „Dat’s vyf.... en twee maakt zeven,
Neen, ja... neen... vyf en twee maakt zeven, niet goê lien?
En tien maakt zeventien, en drie maakt twintig gulden.
Fi. Hier hangt de schaar uit. Eel. Ik moet dat voor deez’ tyd dulden.
Daar ’s acht rijksdaalders, en een gulden voor den knecht.
Waard. Ik dankje, heer, voor goê betaaling, ’t is zo recht.
Ik gaa nâ bed. Gy zult wel uit het huis geraaken,
’k Moet slaapen: want ik heb twee nachten moeten waaken.
Ik wensch myn’ heeren en de juffers goeje reis.

EENENTWINTIGSTE TOONEEL.
Eelhart, Filipyn. Raasbollius op ’t bed.

Filipyn. Wat drommel, geefje zo den vent zyn’ vollen eisch?

Eel. ’k Wou dat heer Raasbol sliep; ik zou myn lief gaan haalen.
Fi. Ik hoor hem snorken.
Eelhart gaat na de kamerdeur van Izabel.
Ik zal dan niet langer draalen.
Wy zyn al veilig lief! myn lief, myn medeminnaar slaapt!

TWEE-ENTWINTIGSTE TOONEEL.
Izabel, Katryn, Eelhart, Filipyn. Raasbollius op ’t bed.

Izabel. Kom vluchten wy dan ras! wat’s dat! Fi. ’t Is niets, hy gaapt.
Iza. Hebt gy myn goed, Katryn? kom, rasjes rep uw’ voeten.
Och! hy ryst op! ik zal weer in myn’ kamer moeten?
Izabel en Katryn loopen weer in haar kamer.
 DRIE-ENTWINTIGSTE TOONEEL.
Raasbollius, Eelhart, Filipyn.

Raasbollius springende in zyn onderkleêren van ’t bed.

Waar’s dokter Urinaal? myn zeer geleerde vriend?
Zyt gy ’t heer advokaat! dat komt zoo wel als ’t dient!
Ik ben genegen nog een uur drie vier te praaten.
Eel. Ik moet nâ bed myn heer. Raas. Ik zal u niet verlaaten,
Voor dat ik u een zaak, die ik daar heb gedroomd,
Of liever die my nu zo in de zinnen koomt,
Eens klaar vertoond heb. Eel. Maar myn heer, ik dien te rusten.
Raas. Daar ’s aan gelegen. Eel. Heer, het zal my weinig lusten.
Raas. ’t Is dienstig voor het land. Eel. Al was het nog zo goed.
Raas. Gy zult verwonderd staan. Eel. Denk dat ik slaapen moet.
Raas. Om zulken zaak zult gy het slaapen haast vergeeten.
Eel. Spreek op! zo gy perfors wilt hebben dat wy ’t weeten.
Raasbollius rangeert eenige stoelen.
Ik heb een zek’re schans, recht vierkant, fraaij en sterk
Gepraktizeerd, waarop de vyand drie jaar werk
Zal vinden, eer hy die met stormen in kan neemen;
En om met woorden u niet aan het oor te teemen;
Zal ik ze timmeren op ’t midden van de vloer.
Eel. „’k Wou dat je met je schans voort naar sint felten voer.
Fi. „Wat of hy doen wil? ’k kan ’t me zeker niet verzinnen?
„Wat drommel of hy met die stoelen zal beginnen!
„Hy haalt de kussens, van zyn bed, wel seldrement,
„Wie heeft zyn leeven zulk een malle quast gekend!
Raasbollius na dat hy stoelen en beddegoed op malkander
gestapeld heeft.
Daar staat myn schans, die kan geen vyand ooit genaaken.
Hier stel ik myn kanon, om op hem los te braaken...
 En aan dien hoek maak ik myn sterkste ravelyn...
En daar een halve maan, vlak onder die gordyn...
En ginds een horenwerk... al die my komt bespringen,
Zal die bedekte weg terstond tot wyken dwingen.
Fi. Wel loop eens in uw’ schans, en defendeer ze dan;
Ik zal eens zien of ik ze alleen niet winnen kan.
Raasbollius klimmende boven op zyn schans.
Wel aan!
Filipyn hem omhalende.
Daar leit de brui! Raas. ô Schelm, ik zal ’t u betaalen!
Zult gy myn mooije schans op die manier omhaalen!
Op deeze wys wordt nooit een sterkte g’attakeerd.
Filipyn hem gooijende met kussens.
Heel goed! nu leer ik jou hoe dat men bombardeert.
Raas. Gy zyt een ezel, vent! ik toon het maar door stoelen,
Hoe dat het weezen moet. Eel. Ik prys myn heers gevoelen.
Raas. Maar merkt gy in den grond de bouwkunst van die schans?
Eel. ô Ja. Raas. Dan ziet gy wel dat nooit een vyand kans
Kan vinden, om zich zelf daar meester van te maaken?
Eel. Gewis. Raas. En zulk een muur kan bom noch kogel raken.
Eel. Dat is onmogelyk. Raas. Begrypje ’t nou niet net?
En hebt gy op ’t geheim der vinding wel gelet?
Eel. Niet al te wel. Raas. Wel hoor, ik bouw een muur van veêren.
Laat daar de vyand vry zyn best op kanonneeren,
De kogels smooren, en zy maken nooit een bres.
Fi. Myn heer, je bent een man als Aristoteles!
Raas. Dat is een vinding, he! Fi. Ja wonderbaarlyk aartig;
Maar maakt ze niet gemeen, die kunst is al te waardig.
Eel. „’k Word raazend zo de gek my hier nog langer bruidt!
Raas. Nu gaa ik naar myn Oom, en slaap ter degen uit.
Raasbollius binnen.
 VIERENTWINTIGSTE TOONEEL.
Filipyn, Eelhart.

Eelhart. Flippyn, my dunkt gy moest de kaers maar uit gaan

blaazen;
Dan zal ik met ’er haast, en zonder veel te raazen,
In ’t donker Izabel geleiden naar de deur.
Fi. Wacht liever tot hy slaapt, want zo die goê sinjeur
Eens schielyk weêr quam, ’t zou ’er houden, gy moogt vreezen.
Eel. Ik zal dat waagen; ik wil hier niet langer weezen.
Fi. Fiat, ik blaas hem uit.
’t Tooneel wordt schielyk donker, door het uitblaazen van de
kaers.
Eel. Kom lief, nu is het tyd!

VYFENTWINTIGSTE TOONEEL.
Izabel, Eelhart, Filipyn, Katryn.

Zy dwaalen door de kamer, in ’t donker.

Eelhart. Zyt gy ’t myn lief? Fi. Wie heb ik daar? myn heer, ben jy ’t?
Iza. Waar is de deur Flippyn? Fi. Ik ken de deur niet vinden.
Wat droes, wy loopen hier gelyk een party blinden.

ZESENTWINTIGSTE TOONEEL.
Tys, Fop, Filipyn, Eelhart, Izabel, Katryn.

Tys. Het is hier donker, en ze zyn al in den slaap.

Fop slypende twee messen over malkander.
Ik geef hem met dit mes terstond een groote jaap.
Tys. Ik zal den ham terstond eens annetomizeeren.
Fi. „Och hou je stil myn heer, ’k hoor dieven, ’k wil ’t je zweeren!
Fop. Ik zel hem moffelen, en sneijen van malkaêr.
Fi. „Och! hoor je ’t wel myn heer? daar is een moordenaar.
Iza. Ach lief! wat raad! och! och! men poog de deur te krygen!
Tys. Maar elk de helft dan van den buit? Fop. Ja, wil maar zwygen,
Waar staat hy? Tys. In dien hoek.
Filipyn kruipt in de kist.
„Och! och! ze meenen my!
„Ik voel de kist, daar moet ik in, zo raak ik vry.
Eel. „Hou my maar vast myn lief! Iza. „Katryn hou my van achter.
Eel. „Flippyn waar zyt ge? spreek! Iza. Myn Eelhart spreek wat
zachter.
Fop en Tys doen de kist open.
Filipyn springt uit de kist.
Hou dieven! dieven! brand! help! help! ik word vermoord!
Fop. Wie duvel springt daar uit de kist! kom gaanwe voort.
Raasbollius van binnen.
Alarm! alarm! gints komt de vyand zich vertoonen!
Tys knielende.
Och booze vyand, och! och! och! och! wil ons verschoonen!
Eel. Staa vast, ô schelm! Fop. Help! help! hy krygt me by myn gat.
Fi. Moord! dieven! dieven! moord!
Raasbollius van binnen.
A sa bescherm de stadt!

ZEVENENTWINTIGSTE TOONEEL.
Waard, Urinaal, Raasbollius in zyn onderkleêren, Tys, Fop,
Filipyn, Eelhart, Izabel, Katryn.

Altemaal in ’t donker dwaalende.

Waard. Wat’s hier te doen? Raas. Terstond te loopen naar de
wallen,
Eer dat de vyand hier de stadt komt overvallen.
Waard. Breng licht! breng licht!

ACHTENTWINTIGSTE TOONEEL.
Waard, Urinaal in zyn onderkleêren, Raasbollius, Tys, Fop,
Filipyn, Eelhart, Izabel, Katryn, Anzelmus, Griet met licht.

Het tooneel moet schielyk licht worden, zo als zy met kaersen

opkomen.
Anz. Wat wil dit oproer, en geraas!
Fi. ’t Zyn dieven! hoor je ’t niet? Raas. A sa trompetters blaas!
Urinaal vat Izabel.
Ik heb ’er één. Iza. Myn heer laat los wy zyn geen dieven!
Uri. Ik laat u niet eer los voor zulks my zal gelieven.
An. Waar zyn de schelmen? Uri. ’k Heb ’er al een in myn macht.
Iza. ô Hemel ’k zie myn voogd! laat los! laat los! Uri. Al zacht,
Ge ontspringt my niet. Gy zult niet uit myn’ handen komen.
Anzelmus Izabel by de kaers beziende.
Laat my den dief eens zien, ha! ha! nu moogt gij schroomen!
Zyt gy de dief? zyt gy de dief? ô Izabel!
ô Schandvlek van ’t geslacht! ontaarde! ik ken u wel!
Gy zult dat vluchten in een mans habyt betreuren.
Foei! foei! ik zal u dat gewaad van ’t lichaam scheuren!
En uw lichtvaerdigheid zo teug’len, dat elk één
Zich spieg’len zal aan u! Eel. Wat wilt gy doen?
Anz. Ik meen,
Haar aanstonds te Uitrecht in een beterhuis te zetten,
Om haar het vluchten in ’t toekomend te beletten,
Indien zy met myn neef zich aanstonds niet verbind.
Raas. Hoe ik haar trouwen? neen; ’k ben daar niet toe gezind.
An. Hoe waarom? Raas. Vraagt gy dat? wel ik heb uitgevonden
De schoonste inventie, daar geleerden lang naar stonden;
Zodat ik al zo ryk zal weezen in één jaar,
Als al de vorsten van Europa met malkaâr.
Uri. Dat zal de spiritus van poortaard zyn? Raas. ’k Moet zwygen.
Uri. Ei sterf niet met de kunst! Raas. Gy zult die kunst wel krygen,
Wanneer ik dood ben; hoop maar op myn testament.
Anz. Gy zyt een groote gek, dat zie ik nu in ’t end.
’k Beloof u, ’k zal u plaats in ’t zelfde huis doen maaken,
Daar Izabel, omdat zy zich heeft laaten schaaken,
In zitten zal, tot dat uw zinnen zyn bedaard.
Raas. Ik leg ’t in kennis. Hoort wat hy daar heeft verklaard.
An. Heer advokaat wat moet ik doen in deeze dingen?
Eel. Zet hem in ’t beterhuis, hy moet u niet ontspringen.
Maar geef uw nicht aan hem, dien zy zoo teer bemint.
An. Het laatste is iets dat ik nog niet geraaden vind.
Zou ik haar aan een schelm, een guit, een lichtmis geeven?
Iza. Ik kan, noch wil, noch zal, met iemand anders leeven!
Ja sluit my op; betoon me uw haat en dwinglandy;
De straf zal volgen op uw’ wreede tiranny.
An. Zwyg obstinaate, zwyg. ’k Wil u niet langer hooren.
Foei, zyt ge uit ons geslacht, lichtvaerdige! gebooren!
Eel. Gy zyt in misverstand, myn heer, bedwing u wat,
Ik ben haar minnaar. An. Gy! Eel. Ja, ’k zal dien lieven schat,
Dien gy my door uw haat en gramschap wilt berooven,
Beschermen. An. Advokaat, hoe kan ik het gelooven!
Eel. Ja, ’k ben een advokaat. Myn eerelyken naam,
Dien gy zo vuil beklad, dat ik my uwer schaam,
Zult gy weêr zuiveren. An. Ik kan ’t u niet bewyzen.
Zyt gy een eerlyk heer, zo moet gy zelfs mispryzen
’t Geen gy gedaan hebt. Eel. Wat?
An. Hoe wat? myn nicht geschaakt.
Eel. Dat heb ik niet gedaan. Iza. ’k Ben uit uw’ dwang geraakt
 En weggevlucht, daar hy gantsch niet van heeft geweeten.
An. Hebt ge uit uw’ eigen wil uw’ plicht dan dus vergeeten!
Iza. ’k Ben hem hier by geval ontmoet. An. Hoe is dat waar?
Eel. Ja, en wy zyn zo vast verbonden aan malkaêr,
Dat maar alleen de dood die trouwe min kan scheijen.
’k Zal u beschermen lief, hou moed, en wil niet schreijen!
Anzelmus, ’k zweer, gy zyt zeer qualyk onderrigt,
Ik heb my altyt wel gequeeten in myn plicht.
Gaa mê nâ Amsterdam, ’k beloof u aan te toonen,
Dat zo veel gruuw’len in myn zuiver hart niet woonen,
En gy misleid zyt. Ik betuig ’t u, met ontzag.
An. Indien gy waarheit spreekt, en zo op uw gedrag
Dan niets te zeggen valt, voeg ik my naar de reden.
Eel. Indien gy ’t anders vindt, myn heer, ik ben te vreeden
Den band van deeze min te breken. An. Nu, wel aan,
Op die konditie zal ik morgen met u gaan.
Gy zult haar trouwen zo wy alles wel bevinden.
’k Zal morgen dit geval doen weeten aan myn’ vrinden.
Waard. De dieven zyn ’t nu licht door dat gebrui ontsnapt.
Fi. Ze zyn licht in een hoek, maak dat men ze betrapt.
Fop en Tys. Ha! ha!
Waard. Hoe, lach je lui? Fop. Wel ja, daar zyn geen dieven.
’t Quam dat je met den ham ons flus niet wout gerieven,
Wy hebben hem gevild, hy leit daar in die kist.
Dat’s voor die pots van laatst. Wa. Jou guiten vol van list!
Daar meen ik jou lui ook een potsje voor te speelen,
Dat kan ik fraaij. Tys. Ja, al zo goed als ’t haver steelen.
Kat. Myn heer, vergeef je my myn misdaad niet? An. Katryn,
Zo alles wel is, zal ’t u ook vergeeven zyn.
Wy zullen morgen vroeg naar Amsterdam vertrekken.
Fi. Ik zal my dezen nacht vermaaken met die gekken,
En bombardeeren met boetelje, kan, en fluit,
Ter eere van myn heer, en zyn aanstaande bruid.
Raas. ’k Zal met myn’ blaasbalg (ha! ’k moet lachen om die
dwaazen!)
Het heele beterhuis aan duizend stukken blaazen.
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