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Surgery_Schwartz_12502
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to prevent stiffness. Repair of ligament or meniscus injuries may also be indicated at the time of surgery. Knee stiffness and osteoarthritis are common complications of these injuries. The goal of the surgery is to restore joint stability and alignment.Tibial Shaft FracturesTibial shaft fractures are the most common long bone frac-tures and occur following high-energy trauma, direct blows, and severe twisting injuries. Trauma and direct blows to the Figure 43-18. Tibial plateau fracture classification.Brunicardi_Ch43_p1879-p1924.indd 189122/02/19 10:40 AM 1892SPECIFIC CONSIDERATIONSPART IItibia result in transverse or comminuted fracture patterns, while torsional injuries cause spiral fractures. Fractures with minimal angulation can be treated with reduction and casting, followed by transition to a functional brace and slow return to weight-bearing. Such fractures may need to be immobi-lized for several months since these fractures can be slow to heal. Most tibial shaft
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Surgery_Schwartz. to prevent stiffness. Repair of ligament or meniscus injuries may also be indicated at the time of surgery. Knee stiffness and osteoarthritis are common complications of these injuries. The goal of the surgery is to restore joint stability and alignment.Tibial Shaft FracturesTibial shaft fractures are the most common long bone frac-tures and occur following high-energy trauma, direct blows, and severe twisting injuries. Trauma and direct blows to the Figure 43-18. Tibial plateau fracture classification.Brunicardi_Ch43_p1879-p1924.indd 189122/02/19 10:40 AM 1892SPECIFIC CONSIDERATIONSPART IItibia result in transverse or comminuted fracture patterns, while torsional injuries cause spiral fractures. Fractures with minimal angulation can be treated with reduction and casting, followed by transition to a functional brace and slow return to weight-bearing. Such fractures may need to be immobi-lized for several months since these fractures can be slow to heal. Most tibial shaft
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Surgery_Schwartz_12503
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Surgery_Schwartz
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by transition to a functional brace and slow return to weight-bearing. Such fractures may need to be immobi-lized for several months since these fractures can be slow to heal. Most tibial shaft fractures, especially comminuted and angulated fractures, are treated with an intramedullary nail placed down the tibial canal, with interlocking screws placed proximally and distally. Weight-bearing can begin soon after surgery. Proximal third tibial fractures are challenging and can result in malalignment, usually valgus and apex anterior angulation. Knee pain is common after intramedullary rod placement. Plate and screw fixation can also be used; how-ever, since the tibia is subcutaneous, hardware placed along the shaft can increase the risk of wound complications, mak-ing intramedullary nailing the preferred treatment. Fibula shaft fractures often occur along with tibial shaft fractures, though they usually heal well without surgery. Tibial frac-tures, both closed and open, can be
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Surgery_Schwartz. by transition to a functional brace and slow return to weight-bearing. Such fractures may need to be immobi-lized for several months since these fractures can be slow to heal. Most tibial shaft fractures, especially comminuted and angulated fractures, are treated with an intramedullary nail placed down the tibial canal, with interlocking screws placed proximally and distally. Weight-bearing can begin soon after surgery. Proximal third tibial fractures are challenging and can result in malalignment, usually valgus and apex anterior angulation. Knee pain is common after intramedullary rod placement. Plate and screw fixation can also be used; how-ever, since the tibia is subcutaneous, hardware placed along the shaft can increase the risk of wound complications, mak-ing intramedullary nailing the preferred treatment. Fibula shaft fractures often occur along with tibial shaft fractures, though they usually heal well without surgery. Tibial frac-tures, both closed and open, can be
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Surgery_Schwartz_12504
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Surgery_Schwartz
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nailing the preferred treatment. Fibula shaft fractures often occur along with tibial shaft fractures, though they usually heal well without surgery. Tibial frac-tures, both closed and open, can be associated with compart-ment syndrome. Patients usually have pain out of proportion with swelling of the leg and pain with passive stretch. Com-partment pressure within 30 mmHg of the diastolic pressure is diagnostic of compartment syndrome.Tibial Plafond (Pilon) FracturesThe tibial plafond is the distal tibial articular surface of the ankle joint. Pilon fractures are typically high-energy injuries that usu-ally result from axial compression. These injuries can cause significant soft tissue injury, severely comminuted intra-articular and metaphyseal fragments (Fig. 43-19A,B), and wound heal-ing problems, making these fractures very difficult to treat. Due to the soft tissue injury, these fractures are initially treated with external fixation until the swelling subsides, which may take
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Surgery_Schwartz. nailing the preferred treatment. Fibula shaft fractures often occur along with tibial shaft fractures, though they usually heal well without surgery. Tibial frac-tures, both closed and open, can be associated with compart-ment syndrome. Patients usually have pain out of proportion with swelling of the leg and pain with passive stretch. Com-partment pressure within 30 mmHg of the diastolic pressure is diagnostic of compartment syndrome.Tibial Plafond (Pilon) FracturesThe tibial plafond is the distal tibial articular surface of the ankle joint. Pilon fractures are typically high-energy injuries that usu-ally result from axial compression. These injuries can cause significant soft tissue injury, severely comminuted intra-articular and metaphyseal fragments (Fig. 43-19A,B), and wound heal-ing problems, making these fractures very difficult to treat. Due to the soft tissue injury, these fractures are initially treated with external fixation until the swelling subsides, which may take
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Surgery_Schwartz_12505
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Surgery_Schwartz
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problems, making these fractures very difficult to treat. Due to the soft tissue injury, these fractures are initially treated with external fixation until the swelling subsides, which may take several days to weeks. The wrinkle test is helpful in this situation to assess when the soft tissues are amenable to defini-tive fixation. A CT scan is usually obtained after the fracture is stabilized by an external fixator. The CT scan will clearly define the fracture fragments and helps in planning the surgical approach and fixation. Minimal incision techniques and mini-mal fixation are becoming popular in some situations. The main goal of surgery is to restore the articular surface. Fixation of the fibula in order to maintain and establish anatomic length is done in some cases. Bone grafts or bone substitutes may be used to fill the void in the metaphyseal region. A variety of fixation techniques may be used including plates to stabilize the metaphysis to the diaphysis. Patients are kept
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Surgery_Schwartz. problems, making these fractures very difficult to treat. Due to the soft tissue injury, these fractures are initially treated with external fixation until the swelling subsides, which may take several days to weeks. The wrinkle test is helpful in this situation to assess when the soft tissues are amenable to defini-tive fixation. A CT scan is usually obtained after the fracture is stabilized by an external fixator. The CT scan will clearly define the fracture fragments and helps in planning the surgical approach and fixation. Minimal incision techniques and mini-mal fixation are becoming popular in some situations. The main goal of surgery is to restore the articular surface. Fixation of the fibula in order to maintain and establish anatomic length is done in some cases. Bone grafts or bone substitutes may be used to fill the void in the metaphyseal region. A variety of fixation techniques may be used including plates to stabilize the metaphysis to the diaphysis. Patients are kept
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Surgery_Schwartz_12506
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bone substitutes may be used to fill the void in the metaphyseal region. A variety of fixation techniques may be used including plates to stabilize the metaphysis to the diaphysis. Patients are kept non–weight-bearing for many months until the fracture heals. Despite best efforts, patients may suffer from ankle pain and stiffness, arthri-tis, wound healing problems, infection, nonunion, and some patients may eventually require ankle fusion. Early fixation of pilon fractures with plates can increase the incidence of wound complications significantly.Ankle and Subtalar DislocationsAnkle Dislocations. The ankle joint is a complex hinge joint comprised of the distal tibial plafond, medial malleolus, and lateral malleolus and their articulation with the talus. Several ligaments also contribute to the stability of the ankle joint, including the deltoid ligament medially, the syndesmotic liga-ments between the tibia and fibula, and the anterior talofibular, posterior talofibular, and
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Surgery_Schwartz. bone substitutes may be used to fill the void in the metaphyseal region. A variety of fixation techniques may be used including plates to stabilize the metaphysis to the diaphysis. Patients are kept non–weight-bearing for many months until the fracture heals. Despite best efforts, patients may suffer from ankle pain and stiffness, arthri-tis, wound healing problems, infection, nonunion, and some patients may eventually require ankle fusion. Early fixation of pilon fractures with plates can increase the incidence of wound complications significantly.Ankle and Subtalar DislocationsAnkle Dislocations. The ankle joint is a complex hinge joint comprised of the distal tibial plafond, medial malleolus, and lateral malleolus and their articulation with the talus. Several ligaments also contribute to the stability of the ankle joint, including the deltoid ligament medially, the syndesmotic liga-ments between the tibia and fibula, and the anterior talofibular, posterior talofibular, and
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Surgery_Schwartz_12507
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Surgery_Schwartz
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to the stability of the ankle joint, including the deltoid ligament medially, the syndesmotic liga-ments between the tibia and fibula, and the anterior talofibular, posterior talofibular, and calcaneofibular ligaments laterally. Dislocations of the ankle joint result from a severe twisting injury and often occur with fractures. At times, dislocations FibulaTibiaTalusABFigure 43-19. A. Tibial pilon fracture with comminution. B. Pilon fracture and its main fracture fragments.Brunicardi_Ch43_p1879-p1924.indd 189222/02/19 10:40 AM 1893ORTHOPEDIC SURGERYCHAPTER 43can place significant pressure on the overlying skin and can cause neurovascular compromise; therefore, prompt reduction is extremely important followed by splinting.Subtalar Dislocations. Subtalar dislocations can be medial or lateral, depending on the position of the foot. The medial dislocation is more common. Lateral dislocations are less com-mon, can be open, and are more likely to be associated with fractures.
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Surgery_Schwartz. to the stability of the ankle joint, including the deltoid ligament medially, the syndesmotic liga-ments between the tibia and fibula, and the anterior talofibular, posterior talofibular, and calcaneofibular ligaments laterally. Dislocations of the ankle joint result from a severe twisting injury and often occur with fractures. At times, dislocations FibulaTibiaTalusABFigure 43-19. A. Tibial pilon fracture with comminution. B. Pilon fracture and its main fracture fragments.Brunicardi_Ch43_p1879-p1924.indd 189222/02/19 10:40 AM 1893ORTHOPEDIC SURGERYCHAPTER 43can place significant pressure on the overlying skin and can cause neurovascular compromise; therefore, prompt reduction is extremely important followed by splinting.Subtalar Dislocations. Subtalar dislocations can be medial or lateral, depending on the position of the foot. The medial dislocation is more common. Lateral dislocations are less com-mon, can be open, and are more likely to be associated with fractures.
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Surgery_Schwartz_12508
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or lateral, depending on the position of the foot. The medial dislocation is more common. Lateral dislocations are less com-mon, can be open, and are more likely to be associated with fractures. Irreducible lateral subtalar dislocations may occur from a trapped tibialis posterior tendon, which will block the reduction. The main complication of subtalar dislocations is subtalar arthritis.Ankle FracturesAnkle fractures are very common and result from a twisting injury to the ankle. The patterns of ankle fractures depend on the direction of force and the position of the foot and ankle at the time of injury. The goals of treating ankle fractures are to restore the anatomy of the ankle joint and to restore the length and rota-tion of the fibula. Initial treatment includes closed reduction and placement of a well-padded splint in order to protect the skin. Swelling can be a significant problem, so elevation of the foot is encouraged. Surgery may be delayed until the skin condition permits.
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Surgery_Schwartz. or lateral, depending on the position of the foot. The medial dislocation is more common. Lateral dislocations are less com-mon, can be open, and are more likely to be associated with fractures. Irreducible lateral subtalar dislocations may occur from a trapped tibialis posterior tendon, which will block the reduction. The main complication of subtalar dislocations is subtalar arthritis.Ankle FracturesAnkle fractures are very common and result from a twisting injury to the ankle. The patterns of ankle fractures depend on the direction of force and the position of the foot and ankle at the time of injury. The goals of treating ankle fractures are to restore the anatomy of the ankle joint and to restore the length and rota-tion of the fibula. Initial treatment includes closed reduction and placement of a well-padded splint in order to protect the skin. Swelling can be a significant problem, so elevation of the foot is encouraged. Surgery may be delayed until the skin condition permits.
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Surgery_Schwartz_12509
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placement of a well-padded splint in order to protect the skin. Swelling can be a significant problem, so elevation of the foot is encouraged. Surgery may be delayed until the skin condition permits. Fractures of the ankle may be:1. Isolated malleolar fractures, usually the lateral malleolus or the medial malleolus.2. Bimalleolar fractures that involve the lateral and medial malleolus. Please note that the deltoid ligament may be in-jured instead of the medial malleolus.3. Trimalleolar fractures that involve the lateral malleolus, medial malleolus, and posterior malleolus.Lateral Malleolus Fractures. Isolated fractures of the lateral malleolus with less than 3 mm displacement and no talar shift may be stable. An external rotation stress radiograph or a grav-ity test is used to assess the competency of the deltoid ligament, with the goal of the test to exclude deltoid injury. If the patient has a deltoid injury, in addition to the fibular fracture, then the patient will need surgery.
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Surgery_Schwartz. placement of a well-padded splint in order to protect the skin. Swelling can be a significant problem, so elevation of the foot is encouraged. Surgery may be delayed until the skin condition permits. Fractures of the ankle may be:1. Isolated malleolar fractures, usually the lateral malleolus or the medial malleolus.2. Bimalleolar fractures that involve the lateral and medial malleolus. Please note that the deltoid ligament may be in-jured instead of the medial malleolus.3. Trimalleolar fractures that involve the lateral malleolus, medial malleolus, and posterior malleolus.Lateral Malleolus Fractures. Isolated fractures of the lateral malleolus with less than 3 mm displacement and no talar shift may be stable. An external rotation stress radiograph or a grav-ity test is used to assess the competency of the deltoid ligament, with the goal of the test to exclude deltoid injury. If the patient has a deltoid injury, in addition to the fibular fracture, then the patient will need surgery.
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Surgery_Schwartz_12510
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competency of the deltoid ligament, with the goal of the test to exclude deltoid injury. If the patient has a deltoid injury, in addition to the fibular fracture, then the patient will need surgery. The fracture will require anatomic reduction in order to restore normal ankle joint congruity. The talus can sublux laterally following lateral malleolus fractures, and even 1 millimeter of talar shift decreases the surface contact between the talus and the tibia by 40%, increasing the risk of developing arthritis. Open reduction and internal fixation of the fibula is usually done with plate and screws.Medial Malleolar Fractures. An isolated fracture of the medial malleolus is usually an avulsion-type injury. Minimally displaced fractures can be treated with a cast or walking boot, while displaced fractures are usually fixed with screws.Bimalleolar Fractures. Fractures to both the medial and lat-eral malleoli usually require surgery. These injuries are more unstable, and the talus will
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Surgery_Schwartz. competency of the deltoid ligament, with the goal of the test to exclude deltoid injury. If the patient has a deltoid injury, in addition to the fibular fracture, then the patient will need surgery. The fracture will require anatomic reduction in order to restore normal ankle joint congruity. The talus can sublux laterally following lateral malleolus fractures, and even 1 millimeter of talar shift decreases the surface contact between the talus and the tibia by 40%, increasing the risk of developing arthritis. Open reduction and internal fixation of the fibula is usually done with plate and screws.Medial Malleolar Fractures. An isolated fracture of the medial malleolus is usually an avulsion-type injury. Minimally displaced fractures can be treated with a cast or walking boot, while displaced fractures are usually fixed with screws.Bimalleolar Fractures. Fractures to both the medial and lat-eral malleoli usually require surgery. These injuries are more unstable, and the talus will
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Surgery_Schwartz_12511
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fractures are usually fixed with screws.Bimalleolar Fractures. Fractures to both the medial and lat-eral malleoli usually require surgery. These injuries are more unstable, and the talus will often sublux or completely dislo-cate laterally. They are treated by reducing and fixing both malleoli during surgery. Occasionally, the posterior articular surface of the distal tibia, or posterior malleolus, can be frac-tured as well, resulting in a trimalleolar ankle fracture. Often it is a small fragment and does not need to be fixed; however, if it involves a significant amount of the articular surface, the posterior malleolus should be fixed with screws placed either anteriorly, posteriorly, or with an antiglide plate. In all ankle fractures, especially in ones associated with deltoid rupture, a syndesmotic injury should be considered. After the fixation of the fractures, an intraoperative external rotation stress test will diagnose syndesmotic injury.Syndesmosis Injuries. The syndesmosis
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Surgery_Schwartz. fractures are usually fixed with screws.Bimalleolar Fractures. Fractures to both the medial and lat-eral malleoli usually require surgery. These injuries are more unstable, and the talus will often sublux or completely dislo-cate laterally. They are treated by reducing and fixing both malleoli during surgery. Occasionally, the posterior articular surface of the distal tibia, or posterior malleolus, can be frac-tured as well, resulting in a trimalleolar ankle fracture. Often it is a small fragment and does not need to be fixed; however, if it involves a significant amount of the articular surface, the posterior malleolus should be fixed with screws placed either anteriorly, posteriorly, or with an antiglide plate. In all ankle fractures, especially in ones associated with deltoid rupture, a syndesmotic injury should be considered. After the fixation of the fractures, an intraoperative external rotation stress test will diagnose syndesmotic injury.Syndesmosis Injuries. The syndesmosis
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Surgery_Schwartz_12512
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Surgery_Schwartz
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a syndesmotic injury should be considered. After the fixation of the fractures, an intraoperative external rotation stress test will diagnose syndesmotic injury.Syndesmosis Injuries. The syndesmosis is comprised of several ligaments between the distal tibia and fibula that pro-vide stability to the ankle joint by resisting axial, rotational, and translational forces. The syndesmosis can be disrupted at the time of ankle fractures and requires special attention (Fig. 43-20). Widening of the space between the distal tibia and fibula after fixing the fractures is indicative of a syndesmo-sis injury, and an intraoperative external rotation stress radio-graph can be helpful for evaluation. Such injuries are treated with one or two screws placed laterally from the fibula into the tibia, parallel to the ankle joint. Patients are kept non–weight-bearing for several weeks. The screws are often removed after 3 to 6 months, though they can be left in place and are typically
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Surgery_Schwartz. a syndesmotic injury should be considered. After the fixation of the fractures, an intraoperative external rotation stress test will diagnose syndesmotic injury.Syndesmosis Injuries. The syndesmosis is comprised of several ligaments between the distal tibia and fibula that pro-vide stability to the ankle joint by resisting axial, rotational, and translational forces. The syndesmosis can be disrupted at the time of ankle fractures and requires special attention (Fig. 43-20). Widening of the space between the distal tibia and fibula after fixing the fractures is indicative of a syndesmo-sis injury, and an intraoperative external rotation stress radio-graph can be helpful for evaluation. Such injuries are treated with one or two screws placed laterally from the fibula into the tibia, parallel to the ankle joint. Patients are kept non–weight-bearing for several weeks. The screws are often removed after 3 to 6 months, though they can be left in place and are typically
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Surgery_Schwartz_12513
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the tibia, parallel to the ankle joint. Patients are kept non–weight-bearing for several weeks. The screws are often removed after 3 to 6 months, though they can be left in place and are typically asymptomatic.Maisonneuve FracturesA Maisonneuve fracture is a fracture of the proximal fibula associated with fracture of the medial malleolus or rupture of the deltoid ligament. There is always an associated syndesmotic injury (Fig. 43-21). Diagnosis may be difficult, and the injury may be missed. These injuries require surgical treatment with fixation of the syndesmosis by screws from the fibula to the tibia.Calcaneal FracturesCalcaneal fractures usually occur following a fall from a height and are often associated with other injuries, including lum-bar spine fractures. There is a high incidence of compartment Figure 43-20. Ankle fracture with syndesmotic injury (white arrow).Brunicardi_Ch43_p1879-p1924.indd 189322/02/19 10:40 AM 1894SPECIFIC CONSIDERATIONSPART IIsyndrome of the foot
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Surgery_Schwartz. the tibia, parallel to the ankle joint. Patients are kept non–weight-bearing for several weeks. The screws are often removed after 3 to 6 months, though they can be left in place and are typically asymptomatic.Maisonneuve FracturesA Maisonneuve fracture is a fracture of the proximal fibula associated with fracture of the medial malleolus or rupture of the deltoid ligament. There is always an associated syndesmotic injury (Fig. 43-21). Diagnosis may be difficult, and the injury may be missed. These injuries require surgical treatment with fixation of the syndesmosis by screws from the fibula to the tibia.Calcaneal FracturesCalcaneal fractures usually occur following a fall from a height and are often associated with other injuries, including lum-bar spine fractures. There is a high incidence of compartment Figure 43-20. Ankle fracture with syndesmotic injury (white arrow).Brunicardi_Ch43_p1879-p1924.indd 189322/02/19 10:40 AM 1894SPECIFIC CONSIDERATIONSPART IIsyndrome of the foot
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Surgery_Schwartz_12514
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of compartment Figure 43-20. Ankle fracture with syndesmotic injury (white arrow).Brunicardi_Ch43_p1879-p1924.indd 189322/02/19 10:40 AM 1894SPECIFIC CONSIDERATIONSPART IIsyndrome of the foot associated with calcaneal fractures. These injuries are often intra-articular and can result in collapse of the weight-bearing posterior facet of the calcaneus. The Bohler angle, which is normally between 20° and 40°, would be reduced or even flattened. CT scans are useful to better visualize the fracture pattern. Some fractures can be treated nonoperatively in a well-padded splint with patients being kept non–weight-bearing for up to 12 weeks. Displaced intraarticular fractures can be treated surgically once the swelling subsides and the wrinkle test is positive. Surgery can be done with lag screws or with plate and screw fixation. Despite adequate treatment, calcaneal fractures can be debilitating injuries, leading to significant heel pain and arthritis. The outcome of surgery depends on
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Surgery_Schwartz. of compartment Figure 43-20. Ankle fracture with syndesmotic injury (white arrow).Brunicardi_Ch43_p1879-p1924.indd 189322/02/19 10:40 AM 1894SPECIFIC CONSIDERATIONSPART IIsyndrome of the foot associated with calcaneal fractures. These injuries are often intra-articular and can result in collapse of the weight-bearing posterior facet of the calcaneus. The Bohler angle, which is normally between 20° and 40°, would be reduced or even flattened. CT scans are useful to better visualize the fracture pattern. Some fractures can be treated nonoperatively in a well-padded splint with patients being kept non–weight-bearing for up to 12 weeks. Displaced intraarticular fractures can be treated surgically once the swelling subsides and the wrinkle test is positive. Surgery can be done with lag screws or with plate and screw fixation. Despite adequate treatment, calcaneal fractures can be debilitating injuries, leading to significant heel pain and arthritis. The outcome of surgery depends on
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Surgery_Schwartz_12515
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or with plate and screw fixation. Despite adequate treatment, calcaneal fractures can be debilitating injuries, leading to significant heel pain and arthritis. The outcome of surgery depends on the com-minution of the fracture and degree of articular involvement. The more fragments seen on a CT scan, the worse the outcome for the patient. Wound complications are a problem for calca-neal fractures with the risk being even higher in diabetics, smok-ers, and in open fractures. Open calcaneal fractures have a high rate of amputation.Talus FracturesFractures of the talus commonly result from forced dorsiflexion of the ankle, causing the talar neck to impact on the anterior distal tibia. The dominant blood supply is the artery of the tarsal canal. The blood supply to the talus can be jeopardized after a displaced fracture and may lead to osteonecrosis (Fig. 43-22), which is an unfortunately common complication following talus fractures. The incidence of osteonecrosis depends on the degree
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Surgery_Schwartz. or with plate and screw fixation. Despite adequate treatment, calcaneal fractures can be debilitating injuries, leading to significant heel pain and arthritis. The outcome of surgery depends on the com-minution of the fracture and degree of articular involvement. The more fragments seen on a CT scan, the worse the outcome for the patient. Wound complications are a problem for calca-neal fractures with the risk being even higher in diabetics, smok-ers, and in open fractures. Open calcaneal fractures have a high rate of amputation.Talus FracturesFractures of the talus commonly result from forced dorsiflexion of the ankle, causing the talar neck to impact on the anterior distal tibia. The dominant blood supply is the artery of the tarsal canal. The blood supply to the talus can be jeopardized after a displaced fracture and may lead to osteonecrosis (Fig. 43-22), which is an unfortunately common complication following talus fractures. The incidence of osteonecrosis depends on the degree
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Surgery_Schwartz_12516
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after a displaced fracture and may lead to osteonecrosis (Fig. 43-22), which is an unfortunately common complication following talus fractures. The incidence of osteonecrosis depends on the degree of displacement of the fracture. The Hawkin’s sign is a sub-chondral lucency that is seen on the mortise X-ray at 6 weeks and indicates that there is vascularity of the talus. This indicates that there is no avascular necrosis. Nondisplaced fractures are treated with a cast and have a 15% risk of osteonecrosis, while displaced fractures are often treated surgically with screw fixa-tion. There is a high risk of osteonecrosis, ranging from 30% to 100%. Subtalar arthritis is the most common complication from this injury. Varus malunion that results from inadequate reduc-tion is the most preventable complication. This complication leads to a decreased subtalar range of motion and eversion. With varus malunion, the patient will walk with the foot internally rotated.Foot FracturesThe tarsal bones,
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Surgery_Schwartz. after a displaced fracture and may lead to osteonecrosis (Fig. 43-22), which is an unfortunately common complication following talus fractures. The incidence of osteonecrosis depends on the degree of displacement of the fracture. The Hawkin’s sign is a sub-chondral lucency that is seen on the mortise X-ray at 6 weeks and indicates that there is vascularity of the talus. This indicates that there is no avascular necrosis. Nondisplaced fractures are treated with a cast and have a 15% risk of osteonecrosis, while displaced fractures are often treated surgically with screw fixa-tion. There is a high risk of osteonecrosis, ranging from 30% to 100%. Subtalar arthritis is the most common complication from this injury. Varus malunion that results from inadequate reduc-tion is the most preventable complication. This complication leads to a decreased subtalar range of motion and eversion. With varus malunion, the patient will walk with the foot internally rotated.Foot FracturesThe tarsal bones,
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complication. This complication leads to a decreased subtalar range of motion and eversion. With varus malunion, the patient will walk with the foot internally rotated.Foot FracturesThe tarsal bones, including the navicular, the cuboid, and the three cuneiform bones, link the hind foot to the metatarsals and provide mechanical stability to the arch of the foot. Isolated fractures to these bones are rare and are often treated nonopera-tively with a cast or boot. Cuboid fractures are also known as “nutcracker fractures” and may indicate a Lisfranc injury. Stress fractures of the navicular can be occult, and a diagnosis may be challenging to make in a patient that complains of foot pain. An MRI may be needed for diagnosis. Treatment is often a short leg non–weight-bearing cast. The Lisfranc ligament, which con-nects the second metatarsal base to the medial cuneiform, is an important stabilizer of the midfoot. Lisfranc injuries can be seen following torsional forces to the foot or from
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Surgery_Schwartz. complication. This complication leads to a decreased subtalar range of motion and eversion. With varus malunion, the patient will walk with the foot internally rotated.Foot FracturesThe tarsal bones, including the navicular, the cuboid, and the three cuneiform bones, link the hind foot to the metatarsals and provide mechanical stability to the arch of the foot. Isolated fractures to these bones are rare and are often treated nonopera-tively with a cast or boot. Cuboid fractures are also known as “nutcracker fractures” and may indicate a Lisfranc injury. Stress fractures of the navicular can be occult, and a diagnosis may be challenging to make in a patient that complains of foot pain. An MRI may be needed for diagnosis. Treatment is often a short leg non–weight-bearing cast. The Lisfranc ligament, which con-nects the second metatarsal base to the medial cuneiform, is an important stabilizer of the midfoot. Lisfranc injuries can be seen following torsional forces to the foot or from
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Surgery_Schwartz_12518
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ligament, which con-nects the second metatarsal base to the medial cuneiform, is an important stabilizer of the midfoot. Lisfranc injuries can be seen following torsional forces to the foot or from crush injuries. These injuries can be missed and often require surgery because anatomic reduction is extremely important for a successful outcome. Open reduction and internal fixation is the technique used for Lisfranc fractures. Primary arthrodesis is often used for purely ligamentous injuries. The main complication of Lisfranc injuries is posttraumatic arthritis. Metatarsal fractures similarly result from twisting or crush injuries and most can be treated Figure 43-21. Maisonneuve fracture showing proximal fibular fracture and associated ankle injury with disruption of syndesmosis.Figure 43-22. Displaced talar neck fracture. Notice the interrup-tion of the blood supply in the talus.Brunicardi_Ch43_p1879-p1924.indd 189422/02/19 10:40 AM 1895ORTHOPEDIC SURGERYCHAPTER 43nonoperatively
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Surgery_Schwartz. ligament, which con-nects the second metatarsal base to the medial cuneiform, is an important stabilizer of the midfoot. Lisfranc injuries can be seen following torsional forces to the foot or from crush injuries. These injuries can be missed and often require surgery because anatomic reduction is extremely important for a successful outcome. Open reduction and internal fixation is the technique used for Lisfranc fractures. Primary arthrodesis is often used for purely ligamentous injuries. The main complication of Lisfranc injuries is posttraumatic arthritis. Metatarsal fractures similarly result from twisting or crush injuries and most can be treated Figure 43-21. Maisonneuve fracture showing proximal fibular fracture and associated ankle injury with disruption of syndesmosis.Figure 43-22. Displaced talar neck fracture. Notice the interrup-tion of the blood supply in the talus.Brunicardi_Ch43_p1879-p1924.indd 189422/02/19 10:40 AM 1895ORTHOPEDIC SURGERYCHAPTER 43nonoperatively
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talar neck fracture. Notice the interrup-tion of the blood supply in the talus.Brunicardi_Ch43_p1879-p1924.indd 189422/02/19 10:40 AM 1895ORTHOPEDIC SURGERYCHAPTER 43nonoperatively with a hard-soled shoe and weight-bearing as tolerated. The base of the fifth metatarsal, however, warrants close attention. Fifth metatarsal fractures at the metaphyseal-diaphyseal junction (fourth and fifth metatarsal articulation) are called Jones fractures. These fractures can jeopardize blood flow, are at risk for nonunion, and may be associated with cav-ovarus hindfoot. Jones fractures need close follow-up to assess for healing if treated by short-leg cast and non–weight-bearing. In athletes and active young patients, screw fixation is usually used to stabilize the fracture. Injuries to the metatarsal-phalangeal joints and phalangeal fractures can be treated symptomatically or with buddy taping with weight-bearing as tolerated in a hard-soled shoe.SPORTS MEDICINEIntroductionSports medicine deals
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Surgery_Schwartz. talar neck fracture. Notice the interrup-tion of the blood supply in the talus.Brunicardi_Ch43_p1879-p1924.indd 189422/02/19 10:40 AM 1895ORTHOPEDIC SURGERYCHAPTER 43nonoperatively with a hard-soled shoe and weight-bearing as tolerated. The base of the fifth metatarsal, however, warrants close attention. Fifth metatarsal fractures at the metaphyseal-diaphyseal junction (fourth and fifth metatarsal articulation) are called Jones fractures. These fractures can jeopardize blood flow, are at risk for nonunion, and may be associated with cav-ovarus hindfoot. Jones fractures need close follow-up to assess for healing if treated by short-leg cast and non–weight-bearing. In athletes and active young patients, screw fixation is usually used to stabilize the fracture. Injuries to the metatarsal-phalangeal joints and phalangeal fractures can be treated symptomatically or with buddy taping with weight-bearing as tolerated in a hard-soled shoe.SPORTS MEDICINEIntroductionSports medicine deals
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joints and phalangeal fractures can be treated symptomatically or with buddy taping with weight-bearing as tolerated in a hard-soled shoe.SPORTS MEDICINEIntroductionSports medicine deals with the prevention and treatment of inju-ries related to sports and exercise. These injuries encompass various areas in the musculoskeletal system. In recent years, sports-related injuries have increased, and the sports medicine field has been expanding. There are multiple factors leading to this increase in sports-related injuries. They include athletes participating in one sport year-round, more “weekend warriors” participating in sporting activity, and increased expectations for higher performance.The orthopedic subspecialty of sports medicine treats a broad spectrum of patients, ranging from children who have just started participating in their first sports to the specialized care of professional athletes. Medical treatment of athletes, recreational or professional, can be complex as shortand
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Surgery_Schwartz. joints and phalangeal fractures can be treated symptomatically or with buddy taping with weight-bearing as tolerated in a hard-soled shoe.SPORTS MEDICINEIntroductionSports medicine deals with the prevention and treatment of inju-ries related to sports and exercise. These injuries encompass various areas in the musculoskeletal system. In recent years, sports-related injuries have increased, and the sports medicine field has been expanding. There are multiple factors leading to this increase in sports-related injuries. They include athletes participating in one sport year-round, more “weekend warriors” participating in sporting activity, and increased expectations for higher performance.The orthopedic subspecialty of sports medicine treats a broad spectrum of patients, ranging from children who have just started participating in their first sports to the specialized care of professional athletes. Medical treatment of athletes, recreational or professional, can be complex as shortand
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who have just started participating in their first sports to the specialized care of professional athletes. Medical treatment of athletes, recreational or professional, can be complex as shortand long-term outcomes are influenced by the higher demand that athletes put on their bodies. Additionally, the orthopedic sports medicine specialist does not only treat the patient’s injuries but also has to consider the patient’s attempted return to his or her previous level of activity. “Getting back in the game” is sometimes subject to pressure and competing interests from third parties (e.g., team members, coaches, parents, fans). This can make the athlete’s treatment and the rehabilitation a chal-lenging process.Surgical intervention for ligament and cartilage injuries in sports medicine patients is usually done using arthroscopic techniques. The most frequently injured joints are the shoulder, knee, and hip. Therefore, treatment of common injuries in these joints will be the scope of this
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Surgery_Schwartz. who have just started participating in their first sports to the specialized care of professional athletes. Medical treatment of athletes, recreational or professional, can be complex as shortand long-term outcomes are influenced by the higher demand that athletes put on their bodies. Additionally, the orthopedic sports medicine specialist does not only treat the patient’s injuries but also has to consider the patient’s attempted return to his or her previous level of activity. “Getting back in the game” is sometimes subject to pressure and competing interests from third parties (e.g., team members, coaches, parents, fans). This can make the athlete’s treatment and the rehabilitation a chal-lenging process.Surgical intervention for ligament and cartilage injuries in sports medicine patients is usually done using arthroscopic techniques. The most frequently injured joints are the shoulder, knee, and hip. Therefore, treatment of common injuries in these joints will be the scope of this
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is usually done using arthroscopic techniques. The most frequently injured joints are the shoulder, knee, and hip. Therefore, treatment of common injuries in these joints will be the scope of this section.SHOULDERRotator CuffRotator cuff injuries are among the most common reasons to visit an orthopedic sports specialist. Often, these injuries are associated with forceful or repeated overhead and pulling movements. The rotator cuff provides shoulder movement and glenohumeral joint stability, and injuries can typically lead to pain, weakness, and restricted movement of the arm. Over recent years, improvement of surgical indications, operative techniques, and rehabilitation protocols has led to better out-comes. Studies suggest that arthroscopic techniques are equal or superior to open techniques for most indications. Contro-versies surrounding rotator cuff repair remain and include use of acromioplasty, enhancement of healing with orthobiologics (Fig. 43-23), singlevs. double-row
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Surgery_Schwartz. is usually done using arthroscopic techniques. The most frequently injured joints are the shoulder, knee, and hip. Therefore, treatment of common injuries in these joints will be the scope of this section.SHOULDERRotator CuffRotator cuff injuries are among the most common reasons to visit an orthopedic sports specialist. Often, these injuries are associated with forceful or repeated overhead and pulling movements. The rotator cuff provides shoulder movement and glenohumeral joint stability, and injuries can typically lead to pain, weakness, and restricted movement of the arm. Over recent years, improvement of surgical indications, operative techniques, and rehabilitation protocols has led to better out-comes. Studies suggest that arthroscopic techniques are equal or superior to open techniques for most indications. Contro-versies surrounding rotator cuff repair remain and include use of acromioplasty, enhancement of healing with orthobiologics (Fig. 43-23), singlevs. double-row
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techniques for most indications. Contro-versies surrounding rotator cuff repair remain and include use of acromioplasty, enhancement of healing with orthobiologics (Fig. 43-23), singlevs. double-row fixation, and the treatment ABrotator cuff teargreater tuberosity/RC attachment siterotator cuff repairCFigure 43-23. Imaging and treatment of rotator cuff tears. A. Magnetic resonance imaging coronal T2 image showing a full-thickness and moderately retracted tear (arrow) of the supraspinatus tendon. B. Arthroscopic image showing the supraspinatus tendon tear as viewed from a posterior portal during the surgery. C. Arthroscopic image showing completion of repair of the supraspinatus tendon tear using suture anchors imbedded in the greater tuberosity of the humerus and attached sutures that capture and reduce the torn tendon to its native insertion site.Brunicardi_Ch43_p1879-p1924.indd 189522/02/19 10:40 AM 1896SPECIFIC CONSIDERATIONSPART IIof massive or large tears. Rehabilitation
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Surgery_Schwartz. techniques for most indications. Contro-versies surrounding rotator cuff repair remain and include use of acromioplasty, enhancement of healing with orthobiologics (Fig. 43-23), singlevs. double-row fixation, and the treatment ABrotator cuff teargreater tuberosity/RC attachment siterotator cuff repairCFigure 43-23. Imaging and treatment of rotator cuff tears. A. Magnetic resonance imaging coronal T2 image showing a full-thickness and moderately retracted tear (arrow) of the supraspinatus tendon. B. Arthroscopic image showing the supraspinatus tendon tear as viewed from a posterior portal during the surgery. C. Arthroscopic image showing completion of repair of the supraspinatus tendon tear using suture anchors imbedded in the greater tuberosity of the humerus and attached sutures that capture and reduce the torn tendon to its native insertion site.Brunicardi_Ch43_p1879-p1924.indd 189522/02/19 10:40 AM 1896SPECIFIC CONSIDERATIONSPART IIof massive or large tears. Rehabilitation
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capture and reduce the torn tendon to its native insertion site.Brunicardi_Ch43_p1879-p1924.indd 189522/02/19 10:40 AM 1896SPECIFIC CONSIDERATIONSPART IIof massive or large tears. Rehabilitation after surgery plays an important role to restore strength, motion, and function and, ultimately, to return the patient to his or her previous level of activity. The standard rehabilitation protocol is made up of three consecutive stages: immobilization, passive exercise, and active exercise. Immobilization can be established by using a sling, and passive exercises should be initiated by the therapist in the first 4 to 6 weeks after surgery. The therapist moves the arm in different positions to improve range of motion (ROM) while providing support. After 4 to 6 weeks, active exercises can be gradually introduced. At 8 to 12 weeks, muscle strength and improvement of arm control are increased by starting a strength-ening exercise program.Shoulder InstabilityThe most common etiology for
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Surgery_Schwartz. capture and reduce the torn tendon to its native insertion site.Brunicardi_Ch43_p1879-p1924.indd 189522/02/19 10:40 AM 1896SPECIFIC CONSIDERATIONSPART IIof massive or large tears. Rehabilitation after surgery plays an important role to restore strength, motion, and function and, ultimately, to return the patient to his or her previous level of activity. The standard rehabilitation protocol is made up of three consecutive stages: immobilization, passive exercise, and active exercise. Immobilization can be established by using a sling, and passive exercises should be initiated by the therapist in the first 4 to 6 weeks after surgery. The therapist moves the arm in different positions to improve range of motion (ROM) while providing support. After 4 to 6 weeks, active exercises can be gradually introduced. At 8 to 12 weeks, muscle strength and improvement of arm control are increased by starting a strength-ening exercise program.Shoulder InstabilityThe most common etiology for
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be gradually introduced. At 8 to 12 weeks, muscle strength and improvement of arm control are increased by starting a strength-ening exercise program.Shoulder InstabilityThe most common etiology for shoulder instability is related to trauma, especially shoulder dislocation. After a shoulder has dislocated, it becomes vulnerable to repeat episodes of instability and may develop into a chronic problem. Most of the shoulder’s stability is provided dynamically by the rotator cuff and stati-cally by the shoulder capsule and ligaments. The most com-mon dislocation is in the anterior-inferior direction. Typically, patients with an anterior dislocation present with pain and an externally rotated shoulder. Younger patients are more sus-ceptible to suffer from repeat dislocations than older patients. The position of the humeral head with respect to the glenoid and other bony pathology can be identified with radiographs. Views from different angles should be obtained to thoroughly evaluate the
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Surgery_Schwartz. be gradually introduced. At 8 to 12 weeks, muscle strength and improvement of arm control are increased by starting a strength-ening exercise program.Shoulder InstabilityThe most common etiology for shoulder instability is related to trauma, especially shoulder dislocation. After a shoulder has dislocated, it becomes vulnerable to repeat episodes of instability and may develop into a chronic problem. Most of the shoulder’s stability is provided dynamically by the rotator cuff and stati-cally by the shoulder capsule and ligaments. The most com-mon dislocation is in the anterior-inferior direction. Typically, patients with an anterior dislocation present with pain and an externally rotated shoulder. Younger patients are more sus-ceptible to suffer from repeat dislocations than older patients. The position of the humeral head with respect to the glenoid and other bony pathology can be identified with radiographs. Views from different angles should be obtained to thoroughly evaluate the
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The position of the humeral head with respect to the glenoid and other bony pathology can be identified with radiographs. Views from different angles should be obtained to thoroughly evaluate the patient; an anterior-posterior (AP) view, a glenoid (axillary) view, and a “Y” view of the shoulder are recom-mended in assessing this injury. Immediate reduction of the glenohumeral joint is paramount to the initial treatment of this injury. Repeat radiographs should be attained to ensure that the humeral head is appropriately positioned. As soft tissue struc-tures are typically damaged in these injuries, an MRI can be obtained to evaluate these structures.Relocation of the shoulder is generally accomplished with the patient in supine position and the arm under gentle traction and slight abduction. Some sedation is helpful as it relaxes the patient’s musculature. Whether or not to immobilize a first-time-dislocated shoulder remains controversial, as does the position of immobilization.
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Surgery_Schwartz. The position of the humeral head with respect to the glenoid and other bony pathology can be identified with radiographs. Views from different angles should be obtained to thoroughly evaluate the patient; an anterior-posterior (AP) view, a glenoid (axillary) view, and a “Y” view of the shoulder are recom-mended in assessing this injury. Immediate reduction of the glenohumeral joint is paramount to the initial treatment of this injury. Repeat radiographs should be attained to ensure that the humeral head is appropriately positioned. As soft tissue struc-tures are typically damaged in these injuries, an MRI can be obtained to evaluate these structures.Relocation of the shoulder is generally accomplished with the patient in supine position and the arm under gentle traction and slight abduction. Some sedation is helpful as it relaxes the patient’s musculature. Whether or not to immobilize a first-time-dislocated shoulder remains controversial, as does the position of immobilization.
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Some sedation is helpful as it relaxes the patient’s musculature. Whether or not to immobilize a first-time-dislocated shoulder remains controversial, as does the position of immobilization. Additionally, some surgeons argue that early surgical repair of capsulolabral structures is appropri-ate as the recurrence rate in the young population is high and may lead to more extensive bony involvement and ultimately more invasive open procedures.Prolonged immobilization is not recommended because this will often lead to substantial stiffness in the shoulder and does not appreciably decrease the redislocation rate. Unfor-tunately, many patients experience recurrent dislocations, in which case surgical stabilization of the shoulder should be con-sidered. Arthroscopic stabilization procedures have been the gold standard treatment for the majority of injuries related to shoulder dislocations, typically a tear of the anteroinferior cap-sulolabral complex (Bankart lesion). There are a subset of
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Surgery_Schwartz. Some sedation is helpful as it relaxes the patient’s musculature. Whether or not to immobilize a first-time-dislocated shoulder remains controversial, as does the position of immobilization. Additionally, some surgeons argue that early surgical repair of capsulolabral structures is appropri-ate as the recurrence rate in the young population is high and may lead to more extensive bony involvement and ultimately more invasive open procedures.Prolonged immobilization is not recommended because this will often lead to substantial stiffness in the shoulder and does not appreciably decrease the redislocation rate. Unfor-tunately, many patients experience recurrent dislocations, in which case surgical stabilization of the shoulder should be con-sidered. Arthroscopic stabilization procedures have been the gold standard treatment for the majority of injuries related to shoulder dislocations, typically a tear of the anteroinferior cap-sulolabral complex (Bankart lesion). There are a subset of
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been the gold standard treatment for the majority of injuries related to shoulder dislocations, typically a tear of the anteroinferior cap-sulolabral complex (Bankart lesion). There are a subset of inju-ries, typically involving large glenoid bony lesions, that require more extensive intervention with a Latarjet procedure or bone grafting. After surgery, the shoulder is temporarily immobi-lized with a sling. When the sling is removed, exercises will be started to rehabilitate the shoulder, improve ROM, and prevent scarring. Strengthening exercises will gradually be added to the rehabilitation plan.Posterior Dislocation of the ShoulderPosterior dislocations of the shoulder are rare and could be missed. This dislocation can occur due to electric shock or sei-zures. Examination of the patient will show limitation in exter-nal rotation of the shoulder. The shoulder will be locked in an internally rotated position. The posterior dislocation could be missed on the AP view of the shoulder,
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Surgery_Schwartz. been the gold standard treatment for the majority of injuries related to shoulder dislocations, typically a tear of the anteroinferior cap-sulolabral complex (Bankart lesion). There are a subset of inju-ries, typically involving large glenoid bony lesions, that require more extensive intervention with a Latarjet procedure or bone grafting. After surgery, the shoulder is temporarily immobi-lized with a sling. When the sling is removed, exercises will be started to rehabilitate the shoulder, improve ROM, and prevent scarring. Strengthening exercises will gradually be added to the rehabilitation plan.Posterior Dislocation of the ShoulderPosterior dislocations of the shoulder are rare and could be missed. This dislocation can occur due to electric shock or sei-zures. Examination of the patient will show limitation in exter-nal rotation of the shoulder. The shoulder will be locked in an internally rotated position. The posterior dislocation could be missed on the AP view of the shoulder,
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will show limitation in exter-nal rotation of the shoulder. The shoulder will be locked in an internally rotated position. The posterior dislocation could be missed on the AP view of the shoulder, and an axillary view should be obtained to avoid missing the injury.Superior Labrum and Biceps TendonThe labrum is a structure that helps to deepen the shoulder socket and stabilize the glenohumeral joint. Additionally, it serves as an attachment point for many of the shoulder ligaments, as well as the long head of the biceps tendon. A superior labrum ante-rior and posterior (SLAP) lesion may occur in the superior part of the labrum, usually anterior and posterior to the attachment of the biceps tendon, with occasional involvement of the biceps tendon in certain cases. Injuries to the superior labrum can be caused by trauma or by repetitive shoulder motion, such as in throwing athletes. Radiographs are generally obtained to evalu-ate for concomitant bony injuries or osteoarthritic changes.
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Surgery_Schwartz. will show limitation in exter-nal rotation of the shoulder. The shoulder will be locked in an internally rotated position. The posterior dislocation could be missed on the AP view of the shoulder, and an axillary view should be obtained to avoid missing the injury.Superior Labrum and Biceps TendonThe labrum is a structure that helps to deepen the shoulder socket and stabilize the glenohumeral joint. Additionally, it serves as an attachment point for many of the shoulder ligaments, as well as the long head of the biceps tendon. A superior labrum ante-rior and posterior (SLAP) lesion may occur in the superior part of the labrum, usually anterior and posterior to the attachment of the biceps tendon, with occasional involvement of the biceps tendon in certain cases. Injuries to the superior labrum can be caused by trauma or by repetitive shoulder motion, such as in throwing athletes. Radiographs are generally obtained to evalu-ate for concomitant bony injuries or osteoarthritic changes.
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labrum can be caused by trauma or by repetitive shoulder motion, such as in throwing athletes. Radiographs are generally obtained to evalu-ate for concomitant bony injuries or osteoarthritic changes. The labrum itself, and other soft tissue, is better visualized with MRI with addition of a gadolinium arthrogram adding sensitivity for labral injury detection (Fig. 43-24). A coronal view MRI will clearly show the condition of the superior labrum.Conservative and operative treatments have had mixed results depending on the patient’s age, activity level, type of tear, and presence of concomitant injuries. If symptoms do not improve with adequate physical therapy and/or nonsteroidal anti-inflammatory drugs (NSAIDs), surgical intervention is usu-ally indicated. Some SLAP injuries involve the biceps tendon, which may require either tenotomy or tenodesis.After surgical repair, the shoulder needs to be immobilized to protect the repair and allow for healing. Usually a sling is used for 4 weeks
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Surgery_Schwartz. labrum can be caused by trauma or by repetitive shoulder motion, such as in throwing athletes. Radiographs are generally obtained to evalu-ate for concomitant bony injuries or osteoarthritic changes. The labrum itself, and other soft tissue, is better visualized with MRI with addition of a gadolinium arthrogram adding sensitivity for labral injury detection (Fig. 43-24). A coronal view MRI will clearly show the condition of the superior labrum.Conservative and operative treatments have had mixed results depending on the patient’s age, activity level, type of tear, and presence of concomitant injuries. If symptoms do not improve with adequate physical therapy and/or nonsteroidal anti-inflammatory drugs (NSAIDs), surgical intervention is usu-ally indicated. Some SLAP injuries involve the biceps tendon, which may require either tenotomy or tenodesis.After surgical repair, the shoulder needs to be immobilized to protect the repair and allow for healing. Usually a sling is used for 4 weeks
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tendon, which may require either tenotomy or tenodesis.After surgical repair, the shoulder needs to be immobilized to protect the repair and allow for healing. Usually a sling is used for 4 weeks after surgery. Then a physical therapy program will gradually start improving range of motion and prevent scar formation and stiffness from developing. As healing progresses, exercises to strengthen the shoulder muscles and the rotator cuff will gradually be added to the program typically around 4 to 6 weeks after surgery. Return to early interval throwing can generally be allowed around 3 to 4 months after surgery.Impingement SyndromesAfter minor trauma or repetitive injury, patients may experi-ence pain and discomfort which can be due to irritation of the tissues in the subacromial space. In many cases these shoulder impingement syndromes are caused by simple bursitis or ten-donitis of the long head of the biceps or supraspinatus tendon. Occasionally, impingement syndromes can progress to
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Surgery_Schwartz. tendon, which may require either tenotomy or tenodesis.After surgical repair, the shoulder needs to be immobilized to protect the repair and allow for healing. Usually a sling is used for 4 weeks after surgery. Then a physical therapy program will gradually start improving range of motion and prevent scar formation and stiffness from developing. As healing progresses, exercises to strengthen the shoulder muscles and the rotator cuff will gradually be added to the program typically around 4 to 6 weeks after surgery. Return to early interval throwing can generally be allowed around 3 to 4 months after surgery.Impingement SyndromesAfter minor trauma or repetitive injury, patients may experi-ence pain and discomfort which can be due to irritation of the tissues in the subacromial space. In many cases these shoulder impingement syndromes are caused by simple bursitis or ten-donitis of the long head of the biceps or supraspinatus tendon. Occasionally, impingement syndromes can progress to
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cases these shoulder impingement syndromes are caused by simple bursitis or ten-donitis of the long head of the biceps or supraspinatus tendon. Occasionally, impingement syndromes can progress to tears of the supraspinatus tendon, which can be confirmed by MRI or ultrasound.The goal of treatment is to reduce pain and restore func-tion. Initial treatment is generally nonsurgical and involves rest, NSAIDs, and physical therapy. If pain is not adequately relieved, an injection of a local anesthetic and corticosteroid may be helpful, for both therapeutic and diagnostic purposes.If conservative treatment does not relieve pain, surgery is recommended, with the goal to excise the bursa and create more subacromial space. Generally, surgery is performed arthroscopi-cally and encompasses bursectomy and subacromial decompres-sion via acromioplasty. If the rotator cuff (supraspinatus tendon) is also injured, arthroscopic repair is usually indicated to restore Brunicardi_Ch43_p1879-p1924.indd
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Surgery_Schwartz. cases these shoulder impingement syndromes are caused by simple bursitis or ten-donitis of the long head of the biceps or supraspinatus tendon. Occasionally, impingement syndromes can progress to tears of the supraspinatus tendon, which can be confirmed by MRI or ultrasound.The goal of treatment is to reduce pain and restore func-tion. Initial treatment is generally nonsurgical and involves rest, NSAIDs, and physical therapy. If pain is not adequately relieved, an injection of a local anesthetic and corticosteroid may be helpful, for both therapeutic and diagnostic purposes.If conservative treatment does not relieve pain, surgery is recommended, with the goal to excise the bursa and create more subacromial space. Generally, surgery is performed arthroscopi-cally and encompasses bursectomy and subacromial decompres-sion via acromioplasty. If the rotator cuff (supraspinatus tendon) is also injured, arthroscopic repair is usually indicated to restore Brunicardi_Ch43_p1879-p1924.indd
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and subacromial decompres-sion via acromioplasty. If the rotator cuff (supraspinatus tendon) is also injured, arthroscopic repair is usually indicated to restore Brunicardi_Ch43_p1879-p1924.indd 189622/02/19 10:40 AM 1897ORTHOPEDIC SURGERYCHAPTER 43function and can be accompanied by a bony resection of the inferior portion of the acromion.The Acromioclavicular JointThe acromioclavicular joint is a gliding synovial joint com-prised of the lateral end of the clavicle and medial facet of the acromion, and it has limited mobility. The joint is stabilized by three ligaments: the superior acromioclavicular ligament, the inferior acromioclavicular ligament, and the coracoclavicular ligament. Injuries to these ligaments are commonly sustained by a lateral blow to the shoulder while playing contact sports such as football and ice hockey and may cause displacement of the joint. An acromioclavicular sprain is also referred to as a shoul-der separation. The least severe, types I and II, are
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Surgery_Schwartz. and subacromial decompres-sion via acromioplasty. If the rotator cuff (supraspinatus tendon) is also injured, arthroscopic repair is usually indicated to restore Brunicardi_Ch43_p1879-p1924.indd 189622/02/19 10:40 AM 1897ORTHOPEDIC SURGERYCHAPTER 43function and can be accompanied by a bony resection of the inferior portion of the acromion.The Acromioclavicular JointThe acromioclavicular joint is a gliding synovial joint com-prised of the lateral end of the clavicle and medial facet of the acromion, and it has limited mobility. The joint is stabilized by three ligaments: the superior acromioclavicular ligament, the inferior acromioclavicular ligament, and the coracoclavicular ligament. Injuries to these ligaments are commonly sustained by a lateral blow to the shoulder while playing contact sports such as football and ice hockey and may cause displacement of the joint. An acromioclavicular sprain is also referred to as a shoul-der separation. The least severe, types I and II, are
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sports such as football and ice hockey and may cause displacement of the joint. An acromioclavicular sprain is also referred to as a shoul-der separation. The least severe, types I and II, are typically treated conservatively. Treatment of type III injuries, where the clavicle is displaced up to 100%, is controversial. Some advo-cate for early surgical intervention, while others recommend symptomatic treatment followed by ligament reconstruction if symptoms persist. Types IV to VI, where the coracoclavicular ligaments are completely torn and the clavicle is significantly displaced, are often treated surgically.KNEEThe knee is the largest joint in the human body and is a pivotal hinge joint, which allows flexion and extension as well as some medial and lateral rotation. The knee bears tremendous axial loads as well as torsional and sheer forces, making it vulnerable to both acute injury and the development of osteoarthritis. In sports, the major stabilizing structures such as the ACL
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Surgery_Schwartz. sports such as football and ice hockey and may cause displacement of the joint. An acromioclavicular sprain is also referred to as a shoul-der separation. The least severe, types I and II, are typically treated conservatively. Treatment of type III injuries, where the clavicle is displaced up to 100%, is controversial. Some advo-cate for early surgical intervention, while others recommend symptomatic treatment followed by ligament reconstruction if symptoms persist. Types IV to VI, where the coracoclavicular ligaments are completely torn and the clavicle is significantly displaced, are often treated surgically.KNEEThe knee is the largest joint in the human body and is a pivotal hinge joint, which allows flexion and extension as well as some medial and lateral rotation. The knee bears tremendous axial loads as well as torsional and sheer forces, making it vulnerable to both acute injury and the development of osteoarthritis. In sports, the major stabilizing structures such as the ACL
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axial loads as well as torsional and sheer forces, making it vulnerable to both acute injury and the development of osteoarthritis. In sports, the major stabilizing structures such as the ACL and the medial collateral ligament (MCL) are frequently injured. Other common knee injuries involve the menisci, posterolateral corner (PLC), posterior cruciate ligament (PCL), and patellofemoral joint.MenisciThe menisci are crescent-shaped pieces of fibrocartilage that provide joint stability, shock absorption, load distribution, and proprioception to the knee. Sudden meniscal tears often happen during sports, usually during contact or twisting injuries to the knee. Symptoms associated with a meniscus tear include pain, swelling, stiffness, catching, and locking of the knee. Radio-graphs are typically obtained to assess for a concomitant bony injury, the presence of (early) osteoarthritis, and leg alignment abnormalities. However, since menisci are radiolucent and are not seen on radiographs, an
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Surgery_Schwartz. axial loads as well as torsional and sheer forces, making it vulnerable to both acute injury and the development of osteoarthritis. In sports, the major stabilizing structures such as the ACL and the medial collateral ligament (MCL) are frequently injured. Other common knee injuries involve the menisci, posterolateral corner (PLC), posterior cruciate ligament (PCL), and patellofemoral joint.MenisciThe menisci are crescent-shaped pieces of fibrocartilage that provide joint stability, shock absorption, load distribution, and proprioception to the knee. Sudden meniscal tears often happen during sports, usually during contact or twisting injuries to the knee. Symptoms associated with a meniscus tear include pain, swelling, stiffness, catching, and locking of the knee. Radio-graphs are typically obtained to assess for a concomitant bony injury, the presence of (early) osteoarthritis, and leg alignment abnormalities. However, since menisci are radiolucent and are not seen on radiographs, an
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obtained to assess for a concomitant bony injury, the presence of (early) osteoarthritis, and leg alignment abnormalities. However, since menisci are radiolucent and are not seen on radiographs, an MRI is obtained to assess the status of the menisci and the soft tissue surrounding the knee joint (Fig. 43-25). Small tears on the outer edge of the meniscus may not cause symptoms, and provided the knee is stable, nonsurgi-cal treatment may be sufficient.The most commonly performed surgical procedure for meniscus tears is partial (subtotal) meniscectomy. However, it has become increasingly clear over recent years that pres-ervation of the load-distributing function of the meniscus is important in preventing the development of early osteoar-thritis. Research into the use of orthobiologics (e.g., micro-fracture of the notch, fibrin clot) for meniscal repairs has expanded the indications for repair rather than excising the torn fragment, especially if the fragment is large. Tears have been
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Surgery_Schwartz. obtained to assess for a concomitant bony injury, the presence of (early) osteoarthritis, and leg alignment abnormalities. However, since menisci are radiolucent and are not seen on radiographs, an MRI is obtained to assess the status of the menisci and the soft tissue surrounding the knee joint (Fig. 43-25). Small tears on the outer edge of the meniscus may not cause symptoms, and provided the knee is stable, nonsurgi-cal treatment may be sufficient.The most commonly performed surgical procedure for meniscus tears is partial (subtotal) meniscectomy. However, it has become increasingly clear over recent years that pres-ervation of the load-distributing function of the meniscus is important in preventing the development of early osteoar-thritis. Research into the use of orthobiologics (e.g., micro-fracture of the notch, fibrin clot) for meniscal repairs has expanded the indications for repair rather than excising the torn fragment, especially if the fragment is large. Tears have been
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micro-fracture of the notch, fibrin clot) for meniscal repairs has expanded the indications for repair rather than excising the torn fragment, especially if the fragment is large. Tears have been reported in virtually all portions of the meniscus, with radial and longitudinal tears being the most common. Menis-cal root tears are less common, but they are increasingly being recognized as devastating injuries that cause serious alterations of knee contact forces. Surgical techniques are developing to repair the root to restore its function. Meniscus transplantation may be an option for young patients with a largely deficient meniscus.ABLIGHTlabral repairglenoidhumeralheadCFigure 43-24. Imaging and treatment of a shoulder glenoid labrum tear. A. Magnetic resonance imaging axial T1 image showing a tear of the posterior superior labrum (arrow). B. Arthroscopic image with the patient in the lateral decubitus position showing detachment of the torn labrum away from the glenoid. C.
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Surgery_Schwartz. micro-fracture of the notch, fibrin clot) for meniscal repairs has expanded the indications for repair rather than excising the torn fragment, especially if the fragment is large. Tears have been reported in virtually all portions of the meniscus, with radial and longitudinal tears being the most common. Menis-cal root tears are less common, but they are increasingly being recognized as devastating injuries that cause serious alterations of knee contact forces. Surgical techniques are developing to repair the root to restore its function. Meniscus transplantation may be an option for young patients with a largely deficient meniscus.ABLIGHTlabral repairglenoidhumeralheadCFigure 43-24. Imaging and treatment of a shoulder glenoid labrum tear. A. Magnetic resonance imaging axial T1 image showing a tear of the posterior superior labrum (arrow). B. Arthroscopic image with the patient in the lateral decubitus position showing detachment of the torn labrum away from the glenoid. C.
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image showing a tear of the posterior superior labrum (arrow). B. Arthroscopic image with the patient in the lateral decubitus position showing detachment of the torn labrum away from the glenoid. C. Arthroscopic image demonstrating repair of the labrum to its attachment site using anchors in the glenoid and sutures that fixes the labrum to the glenoid.Brunicardi_Ch43_p1879-p1924.indd 189722/02/19 10:41 AM 1898SPECIFIC CONSIDERATIONSPART IIThe paradigm of treatment of torn menisci is shifting thanks to the development of superior surgical techniques, use of orthobiologics, and promising first results with root repair and meniscus transplantations. Nowadays, physicians are well informed on the significance of meniscal preservation when there is potential for healing.Directly after surgery, the knee is immobilized with a brace and weight-bearing is protected to allow the meniscus to heal. When healing is complete, range of motion and strength will need to be regained. Physical
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Surgery_Schwartz. image showing a tear of the posterior superior labrum (arrow). B. Arthroscopic image with the patient in the lateral decubitus position showing detachment of the torn labrum away from the glenoid. C. Arthroscopic image demonstrating repair of the labrum to its attachment site using anchors in the glenoid and sutures that fixes the labrum to the glenoid.Brunicardi_Ch43_p1879-p1924.indd 189722/02/19 10:41 AM 1898SPECIFIC CONSIDERATIONSPART IIThe paradigm of treatment of torn menisci is shifting thanks to the development of superior surgical techniques, use of orthobiologics, and promising first results with root repair and meniscus transplantations. Nowadays, physicians are well informed on the significance of meniscal preservation when there is potential for healing.Directly after surgery, the knee is immobilized with a brace and weight-bearing is protected to allow the meniscus to heal. When healing is complete, range of motion and strength will need to be regained. Physical
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surgery, the knee is immobilized with a brace and weight-bearing is protected to allow the meniscus to heal. When healing is complete, range of motion and strength will need to be regained. Physical therapy is an integral com-ponent of healing and return to play, which usually is allowed between 4 and 6 months after surgery.Collateral LigamentsThe MCL is the most frequently injured knee ligament, which usually occurs after excessive valgus stress of the knee. In more severe injuries, tearing of the meniscus and ACL can also occur, which is known as the “unhappy triad.” This is most often seen in contact sports with a lateral blow to a planted leg, causing a significant valgus force.The MCL has good healing potential, and grade I and II injuries usually improve with bracing and activity modifica-tion. Grade III injuries may also improve with conservative treatment, and often these injuries are initially treated non-operatively. The majority of MCL injuries occur in the mid-substance or
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Surgery_Schwartz. surgery, the knee is immobilized with a brace and weight-bearing is protected to allow the meniscus to heal. When healing is complete, range of motion and strength will need to be regained. Physical therapy is an integral com-ponent of healing and return to play, which usually is allowed between 4 and 6 months after surgery.Collateral LigamentsThe MCL is the most frequently injured knee ligament, which usually occurs after excessive valgus stress of the knee. In more severe injuries, tearing of the meniscus and ACL can also occur, which is known as the “unhappy triad.” This is most often seen in contact sports with a lateral blow to a planted leg, causing a significant valgus force.The MCL has good healing potential, and grade I and II injuries usually improve with bracing and activity modifica-tion. Grade III injuries may also improve with conservative treatment, and often these injuries are initially treated non-operatively. The majority of MCL injuries occur in the mid-substance or
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Grade III injuries may also improve with conservative treatment, and often these injuries are initially treated non-operatively. The majority of MCL injuries occur in the mid-substance or at the femoral insertion side. There is a small subset of tibial-sided grade III tears that are associated with worse clinical outcome following conservative treatment, and therefore surgical repair is often recommended. Recon-struction is rare because surgical repair is usually effective in restoring the MCL. LCL injuries are much less common than MCL ligament injuries, but, similarly, most are man-aged conservatively.With return of range of motion and normal gait pattern, patients are functionally progressed towards return to sports. A functional brace during sports is often advised.Cruciate LigamentsThe cruciate ligaments are situated centrally within the intercon-dylar notch of the knee. The biomechanical function of both the ACL and the PCL is complex and three-dimensional, but both play an
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Surgery_Schwartz. Grade III injuries may also improve with conservative treatment, and often these injuries are initially treated non-operatively. The majority of MCL injuries occur in the mid-substance or at the femoral insertion side. There is a small subset of tibial-sided grade III tears that are associated with worse clinical outcome following conservative treatment, and therefore surgical repair is often recommended. Recon-struction is rare because surgical repair is usually effective in restoring the MCL. LCL injuries are much less common than MCL ligament injuries, but, similarly, most are man-aged conservatively.With return of range of motion and normal gait pattern, patients are functionally progressed towards return to sports. A functional brace during sports is often advised.Cruciate LigamentsThe cruciate ligaments are situated centrally within the intercon-dylar notch of the knee. The biomechanical function of both the ACL and the PCL is complex and three-dimensional, but both play an
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cruciate ligaments are situated centrally within the intercon-dylar notch of the knee. The biomechanical function of both the ACL and the PCL is complex and three-dimensional, but both play an important role in providing anteroposterior and rota-tional stability of the knee.ACL tears are a common sports injury, especially in sports involving sudden stopping and cutting (e.g., soccer, basketball) or contact (e.g., football). A torn ACL will result in altered knee biomechanics and kinematics and thus can potentially lead to the early development of degenerative changes. Since a torn ACL will not heal on its own, surgical ACL reconstruction is generally the treatment of choice in patients who are young and active. Patients with a more sedentary lifestyle and who experi-ence no persisting or disabling instability in daily life may be effectively treated with conservative management (i.e., bracing and physical therapy).ABCFigure 43-25. Imaging and treatment of a knee lateral and meniscus
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Surgery_Schwartz. cruciate ligaments are situated centrally within the intercon-dylar notch of the knee. The biomechanical function of both the ACL and the PCL is complex and three-dimensional, but both play an important role in providing anteroposterior and rota-tional stability of the knee.ACL tears are a common sports injury, especially in sports involving sudden stopping and cutting (e.g., soccer, basketball) or contact (e.g., football). A torn ACL will result in altered knee biomechanics and kinematics and thus can potentially lead to the early development of degenerative changes. Since a torn ACL will not heal on its own, surgical ACL reconstruction is generally the treatment of choice in patients who are young and active. Patients with a more sedentary lifestyle and who experi-ence no persisting or disabling instability in daily life may be effectively treated with conservative management (i.e., bracing and physical therapy).ABCFigure 43-25. Imaging and treatment of a knee lateral and meniscus
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disabling instability in daily life may be effectively treated with conservative management (i.e., bracing and physical therapy).ABCFigure 43-25. Imaging and treatment of a knee lateral and meniscus tear. A. Magnetic resonance imaging sagittal T2 image of the knee showing a displaced bucket-handle lateral meniscus tear (arrow). B. Arthroscopic image showing the remnant rim of the lateral meniscus prior to reduction and fixation of the torn bucket-handle fragment. C. Arthroscopic image after the torn segment is reduced and fixed to the remaining meniscus and the lateral capsule using suture.Brunicardi_Ch43_p1879-p1924.indd 189822/02/19 10:41 AM 1899ORTHOPEDIC SURGERYCHAPTER 43A patient with an ACL tear typically presents with pain and swelling, instability, loss of ROM, joint line tenderness (if there is an associated meniscus injury), and discomfort while walking. The Lachman’s exam is the best clinical test for an ACL tear. Radiographs are obtained to evaluate joint condi-tion
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Surgery_Schwartz. disabling instability in daily life may be effectively treated with conservative management (i.e., bracing and physical therapy).ABCFigure 43-25. Imaging and treatment of a knee lateral and meniscus tear. A. Magnetic resonance imaging sagittal T2 image of the knee showing a displaced bucket-handle lateral meniscus tear (arrow). B. Arthroscopic image showing the remnant rim of the lateral meniscus prior to reduction and fixation of the torn bucket-handle fragment. C. Arthroscopic image after the torn segment is reduced and fixed to the remaining meniscus and the lateral capsule using suture.Brunicardi_Ch43_p1879-p1924.indd 189822/02/19 10:41 AM 1899ORTHOPEDIC SURGERYCHAPTER 43A patient with an ACL tear typically presents with pain and swelling, instability, loss of ROM, joint line tenderness (if there is an associated meniscus injury), and discomfort while walking. The Lachman’s exam is the best clinical test for an ACL tear. Radiographs are obtained to evaluate joint condi-tion
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(if there is an associated meniscus injury), and discomfort while walking. The Lachman’s exam is the best clinical test for an ACL tear. Radiographs are obtained to evaluate joint condi-tion and possible associated osseous injuries. To visualize the ACL and other soft tissue in the knee, an MRI should be obtained. Although an MRI is not required to make the diag-nosis, the information it provides is invaluable with regard to objectifying anatomic characteristics by taking measurements, assessing concomitant injuries, and presurgical planning in gen-eral (Fig. 43-26).Reconstruction is performed with use of a tendon-graft that will replace the native ACL. Commonly used graft sources include the patellar, hamstrings, and quadriceps tendons. These tendons can be harvested from the same knee (i.e., autografts) during the same procedure. Alternatively, a cadaver graft (i.e., allograft) can be used. Both have their associated benefits, including the absence of donor site morbidity with an
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Surgery_Schwartz. (if there is an associated meniscus injury), and discomfort while walking. The Lachman’s exam is the best clinical test for an ACL tear. Radiographs are obtained to evaluate joint condi-tion and possible associated osseous injuries. To visualize the ACL and other soft tissue in the knee, an MRI should be obtained. Although an MRI is not required to make the diag-nosis, the information it provides is invaluable with regard to objectifying anatomic characteristics by taking measurements, assessing concomitant injuries, and presurgical planning in gen-eral (Fig. 43-26).Reconstruction is performed with use of a tendon-graft that will replace the native ACL. Commonly used graft sources include the patellar, hamstrings, and quadriceps tendons. These tendons can be harvested from the same knee (i.e., autografts) during the same procedure. Alternatively, a cadaver graft (i.e., allograft) can be used. Both have their associated benefits, including the absence of donor site morbidity with an
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(i.e., autografts) during the same procedure. Alternatively, a cadaver graft (i.e., allograft) can be used. Both have their associated benefits, including the absence of donor site morbidity with an allograft and better healing potential with an autograft. As such, it is important to have a discussion with the patient and provide the necessary information for them to make an informed decision regarding graft type.Injuries of the PCL are less common than other knee ligaments. Frequently seen causes are a bent knee hitting a dashboard in a car accident or falling on a knee that is bent during running. A rupture of the PCL is usually better tolerated than ACL rupture, since many tears (i.e., grades I and II) have the potential to heal on their own and do not result in much knee instability. Most grade I and II injuries are treated non-operatively. Combined PCL/PLC, PCL/MCL, and grade III PCL injuries do present a challenge with regard to appropriate management. Chronic PCL-deficient
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Surgery_Schwartz. (i.e., autografts) during the same procedure. Alternatively, a cadaver graft (i.e., allograft) can be used. Both have their associated benefits, including the absence of donor site morbidity with an allograft and better healing potential with an autograft. As such, it is important to have a discussion with the patient and provide the necessary information for them to make an informed decision regarding graft type.Injuries of the PCL are less common than other knee ligaments. Frequently seen causes are a bent knee hitting a dashboard in a car accident or falling on a knee that is bent during running. A rupture of the PCL is usually better tolerated than ACL rupture, since many tears (i.e., grades I and II) have the potential to heal on their own and do not result in much knee instability. Most grade I and II injuries are treated non-operatively. Combined PCL/PLC, PCL/MCL, and grade III PCL injuries do present a challenge with regard to appropriate management. Chronic PCL-deficient
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Most grade I and II injuries are treated non-operatively. Combined PCL/PLC, PCL/MCL, and grade III PCL injuries do present a challenge with regard to appropriate management. Chronic PCL-deficient (grade III) knees have an increased incidence of osteoarthrosis, particularly in the patel-lofemoral and medial knee compartments. Indication for sur-gery is influenced by age, activity level, and the presence of concomitant injuries. Different surgical techniques have been proposed; the most common are the “inlay” technique and the transtibial technique.The goal of cruciate ligament (both ACL and PCL) reconstruction is to restore native knee kinematics, provide the patient with the best potential for a successful outcome, and to prevent the development of long-term complications, such as osteoarthrosis.Posterolateral CornerCritical structures of the posterolateral corner are the LCL, pop-liteus tendon, and popliteofibular ligament. These structures each contribute to the static and dynamic
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Surgery_Schwartz. Most grade I and II injuries are treated non-operatively. Combined PCL/PLC, PCL/MCL, and grade III PCL injuries do present a challenge with regard to appropriate management. Chronic PCL-deficient (grade III) knees have an increased incidence of osteoarthrosis, particularly in the patel-lofemoral and medial knee compartments. Indication for sur-gery is influenced by age, activity level, and the presence of concomitant injuries. Different surgical techniques have been proposed; the most common are the “inlay” technique and the transtibial technique.The goal of cruciate ligament (both ACL and PCL) reconstruction is to restore native knee kinematics, provide the patient with the best potential for a successful outcome, and to prevent the development of long-term complications, such as osteoarthrosis.Posterolateral CornerCritical structures of the posterolateral corner are the LCL, pop-liteus tendon, and popliteofibular ligament. These structures each contribute to the static and dynamic
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CornerCritical structures of the posterolateral corner are the LCL, pop-liteus tendon, and popliteofibular ligament. These structures each contribute to the static and dynamic stability of the knee and are commonly seen in combination with other ligamentous injuries, most notably the ACL. It is important to evaluate the PLC after any knee injury as a deficient PLC causes altered knee biomechanics and subsequently increases the stress on sur-rounding stabilizing structures. As such, it has been shown that a deficient PLC is a primary cause of graft failure in cruciate ligament reconstruction.Acute high-grade injuries of the PLC with obvious defi-cient structures require surgical intervention. Since primary repair becomes increasingly difficult as time between injury and surgery increases, a cut-off of 2 to 3 weeks is usually the limit to repair the deficient structures. With more chronic PLC injuries or midsubstance tears, reconstruction is recommended to restore knee
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Surgery_Schwartz. CornerCritical structures of the posterolateral corner are the LCL, pop-liteus tendon, and popliteofibular ligament. These structures each contribute to the static and dynamic stability of the knee and are commonly seen in combination with other ligamentous injuries, most notably the ACL. It is important to evaluate the PLC after any knee injury as a deficient PLC causes altered knee biomechanics and subsequently increases the stress on sur-rounding stabilizing structures. As such, it has been shown that a deficient PLC is a primary cause of graft failure in cruciate ligament reconstruction.Acute high-grade injuries of the PLC with obvious defi-cient structures require surgical intervention. Since primary repair becomes increasingly difficult as time between injury and surgery increases, a cut-off of 2 to 3 weeks is usually the limit to repair the deficient structures. With more chronic PLC injuries or midsubstance tears, reconstruction is recommended to restore knee
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increases, a cut-off of 2 to 3 weeks is usually the limit to repair the deficient structures. With more chronic PLC injuries or midsubstance tears, reconstruction is recommended to restore knee stability.HIPFemoroacetabular ImpingementFemoroacetabular impingement (FAI) is a pathologic condi-tion that refers to impingement of the anterior femoral head-neck junction against the anterosuperior acetabular labrum. This is frequently caused by abnormal bony offset at the femoral head-neck junction and is called CAM impingement, which usually affects young males. On the other hand, a Pincer lesion usually occurs due to abnormal acetabular version and excessive anterolateral acetabular bony rim coverage, or a combination of these, which usually occurs in females. Recognition of FAI can be clinically and radiologically dif-ficult. However, familiarity with this disorder is essential AxyzBCDEFigure 43-26. Magnetic resonance imaging of a torn anterior cruciate ligament (ACL). A–C. Proton
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Surgery_Schwartz. increases, a cut-off of 2 to 3 weeks is usually the limit to repair the deficient structures. With more chronic PLC injuries or midsubstance tears, reconstruction is recommended to restore knee stability.HIPFemoroacetabular ImpingementFemoroacetabular impingement (FAI) is a pathologic condi-tion that refers to impingement of the anterior femoral head-neck junction against the anterosuperior acetabular labrum. This is frequently caused by abnormal bony offset at the femoral head-neck junction and is called CAM impingement, which usually affects young males. On the other hand, a Pincer lesion usually occurs due to abnormal acetabular version and excessive anterolateral acetabular bony rim coverage, or a combination of these, which usually occurs in females. Recognition of FAI can be clinically and radiologically dif-ficult. However, familiarity with this disorder is essential AxyzBCDEFigure 43-26. Magnetic resonance imaging of a torn anterior cruciate ligament (ACL). A–C. Proton
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clinically and radiologically dif-ficult. However, familiarity with this disorder is essential AxyzBCDEFigure 43-26. Magnetic resonance imaging of a torn anterior cruciate ligament (ACL). A–C. Proton density sagittal cuts, showing antero-posterior tibial insertion site length measurement “x,” intra-articular ligament length measurement “y,” and ACL inclination angle measure-ment “z.” Oblique (in the same plane as the ACL runs) coronal cuts showing a complete ACL tear with separate images of a PL bundle tear (D) and an anteromedial bundle tear (E).Brunicardi_Ch43_p1879-p1924.indd 189922/02/19 10:41 AM 1900SPECIFIC CONSIDERATIONSPART IIbecause FAI can lead to labral tears, cartilage delamination, and, if untreated, osteoarthritis.Commonly, patients present with anterior groin pain exacerbated by activities involving hip flexion or pain over the greater trochanter, as well as grinding or popping. Patients report pain with flexion and internal rotation, and after pro-longed sitting.
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Surgery_Schwartz. clinically and radiologically dif-ficult. However, familiarity with this disorder is essential AxyzBCDEFigure 43-26. Magnetic resonance imaging of a torn anterior cruciate ligament (ACL). A–C. Proton density sagittal cuts, showing antero-posterior tibial insertion site length measurement “x,” intra-articular ligament length measurement “y,” and ACL inclination angle measure-ment “z.” Oblique (in the same plane as the ACL runs) coronal cuts showing a complete ACL tear with separate images of a PL bundle tear (D) and an anteromedial bundle tear (E).Brunicardi_Ch43_p1879-p1924.indd 189922/02/19 10:41 AM 1900SPECIFIC CONSIDERATIONSPART IIbecause FAI can lead to labral tears, cartilage delamination, and, if untreated, osteoarthritis.Commonly, patients present with anterior groin pain exacerbated by activities involving hip flexion or pain over the greater trochanter, as well as grinding or popping. Patients report pain with flexion and internal rotation, and after pro-longed sitting.
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by activities involving hip flexion or pain over the greater trochanter, as well as grinding or popping. Patients report pain with flexion and internal rotation, and after pro-longed sitting. On examination, there is a decrease in internal rotation that appears out of proportion to the loss of the other ranges of motion, and flexion can also be limited. The impinge-ment test, elicited by 90° of flexion and adduction and internal rotation of the hip, is almost always positive, signified by pain in the groin region.The imaging findings of FAI can be seen on plain radio-graphs, CT scan, MRI, and magnetic resonance angiography. Some of the abnormalities seen include abnormal lateral femo-ral head/neck offset seen as a lateral femoral neck bump, os acetabuli, synovial herniation pits, acetabular over-coverage, hyaline cartilage abnormalities, and labral tears.Treatment of FAI has traditionally been surgical and has evolved from open surgical treatment with acetabuloplasty, to combined
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Surgery_Schwartz. by activities involving hip flexion or pain over the greater trochanter, as well as grinding or popping. Patients report pain with flexion and internal rotation, and after pro-longed sitting. On examination, there is a decrease in internal rotation that appears out of proportion to the loss of the other ranges of motion, and flexion can also be limited. The impinge-ment test, elicited by 90° of flexion and adduction and internal rotation of the hip, is almost always positive, signified by pain in the groin region.The imaging findings of FAI can be seen on plain radio-graphs, CT scan, MRI, and magnetic resonance angiography. Some of the abnormalities seen include abnormal lateral femo-ral head/neck offset seen as a lateral femoral neck bump, os acetabuli, synovial herniation pits, acetabular over-coverage, hyaline cartilage abnormalities, and labral tears.Treatment of FAI has traditionally been surgical and has evolved from open surgical treatment with acetabuloplasty, to combined
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over-coverage, hyaline cartilage abnormalities, and labral tears.Treatment of FAI has traditionally been surgical and has evolved from open surgical treatment with acetabuloplasty, to combined open-arthroscopic–assisted techniques, to all arthroscopic techniques. Hip arthroscopy is becoming increas-ingly popular and is being more frequently applied for this indi-cation. This popularity is largely the result of studies reporting on improvement of functional outcome measures with follow-up of 10 years in some studies and with relatively low compli-cation rates.SPINESpinal TraumaIn spinal injury, spinal stability must be assessed and the patient immobilized until the spine is cleared. CT scan is more reliable in assessing spine injury than plain radiographs. In patients with ankylosing spondylitis, an MRI is the best study to rule out occult fracture and epidural bleeding. When neurologic deficits are present a decompressive procedure may be indi-cated. In spinal cord compression, prompt
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Surgery_Schwartz. over-coverage, hyaline cartilage abnormalities, and labral tears.Treatment of FAI has traditionally been surgical and has evolved from open surgical treatment with acetabuloplasty, to combined open-arthroscopic–assisted techniques, to all arthroscopic techniques. Hip arthroscopy is becoming increas-ingly popular and is being more frequently applied for this indi-cation. This popularity is largely the result of studies reporting on improvement of functional outcome measures with follow-up of 10 years in some studies and with relatively low compli-cation rates.SPINESpinal TraumaIn spinal injury, spinal stability must be assessed and the patient immobilized until the spine is cleared. CT scan is more reliable in assessing spine injury than plain radiographs. In patients with ankylosing spondylitis, an MRI is the best study to rule out occult fracture and epidural bleeding. When neurologic deficits are present a decompressive procedure may be indi-cated. In spinal cord compression, prompt
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an MRI is the best study to rule out occult fracture and epidural bleeding. When neurologic deficits are present a decompressive procedure may be indi-cated. In spinal cord compression, prompt decompression should be performed. Spinal cord injuries should be triaged to trauma centers since trauma center care is associated with reduced paralysis.Occipital Cervical DislocationMotor vehicle accidents can cause dislocation of the occiput on the condyles of the atlas (C1). Most patients with this injury suffer cervical cord injury and do not survive. Traction on the spine is contraindicated. Treatment consists of stabilization and fusion in situ using a screw plate from the mid cervical spine to the occiput.Fractures of C1 (Jefferson Fracture)Fracture of the C1 ring was described by Jefferson in 1920. The thin anterior and posterior rings of the C1 vertebra fracture with axial loads. C1 fracture causes the lateral masses of C1 to spread, which can be visible on an open-mouth view. A
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Surgery_Schwartz. an MRI is the best study to rule out occult fracture and epidural bleeding. When neurologic deficits are present a decompressive procedure may be indi-cated. In spinal cord compression, prompt decompression should be performed. Spinal cord injuries should be triaged to trauma centers since trauma center care is associated with reduced paralysis.Occipital Cervical DislocationMotor vehicle accidents can cause dislocation of the occiput on the condyles of the atlas (C1). Most patients with this injury suffer cervical cord injury and do not survive. Traction on the spine is contraindicated. Treatment consists of stabilization and fusion in situ using a screw plate from the mid cervical spine to the occiput.Fractures of C1 (Jefferson Fracture)Fracture of the C1 ring was described by Jefferson in 1920. The thin anterior and posterior rings of the C1 vertebra fracture with axial loads. C1 fracture causes the lateral masses of C1 to spread, which can be visible on an open-mouth view. A
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in 1920. The thin anterior and posterior rings of the C1 vertebra fracture with axial loads. C1 fracture causes the lateral masses of C1 to spread, which can be visible on an open-mouth view. A lateral view of the C-spine may show the fracture; however, this injury could be missed due to inadequate visualization of the occipitocervical junction. CT scan is the ideal study for a Jefferson Fracture. The transverse ligament may be ruptured with a Jefferson fracture, and this will render the fracture unstable, which can cause injury to the spinal cord (Fig. 43-27). Jefferson fractures may be associ-ated with other spine fractures. This injury is rarely associated with neurologic injury. The treatment of a Jefferson fracture is based on the integrity of the transverse ligament. The integrity of the transverse ligament is assessed by the amount of C1 lat-eral mass displacement determined by open-mouth radiograph and CT scan. Significantly displaced fractures (less than 7 mm) indicate
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Surgery_Schwartz. in 1920. The thin anterior and posterior rings of the C1 vertebra fracture with axial loads. C1 fracture causes the lateral masses of C1 to spread, which can be visible on an open-mouth view. A lateral view of the C-spine may show the fracture; however, this injury could be missed due to inadequate visualization of the occipitocervical junction. CT scan is the ideal study for a Jefferson Fracture. The transverse ligament may be ruptured with a Jefferson fracture, and this will render the fracture unstable, which can cause injury to the spinal cord (Fig. 43-27). Jefferson fractures may be associ-ated with other spine fractures. This injury is rarely associated with neurologic injury. The treatment of a Jefferson fracture is based on the integrity of the transverse ligament. The integrity of the transverse ligament is assessed by the amount of C1 lat-eral mass displacement determined by open-mouth radiograph and CT scan. Significantly displaced fractures (less than 7 mm) indicate
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of the transverse ligament is assessed by the amount of C1 lat-eral mass displacement determined by open-mouth radiograph and CT scan. Significantly displaced fractures (less than 7 mm) indicate disruption of the transverse ligament. An increase in the atlanto-dense interval (ADI) may indicate a transverse ligament injury. Normally, the ADI is less than 3 mm, as seen on the lat-eral view. An unstable injury with a rupture of the transverse ligament may need a posterior C1-C2 fusion.Bracing with a cervicothoracic orthosis or a halo ring and vest is the recommended treatment for nondisplaced and mini-mally displaced fractures; significantly displaced unstable frac-tures require more definitive surgical treatment.Fractures of C2 (Odontoid Fracture)Half of normal cervical rotation occurs at the atlantoaxial joint. The odontoid (Dens) is a small bony process which arises from the body of C2, and articulates with the body of C1 (the Atlas). There are three types of odontoid fractures (Fig.
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Surgery_Schwartz. of the transverse ligament is assessed by the amount of C1 lat-eral mass displacement determined by open-mouth radiograph and CT scan. Significantly displaced fractures (less than 7 mm) indicate disruption of the transverse ligament. An increase in the atlanto-dense interval (ADI) may indicate a transverse ligament injury. Normally, the ADI is less than 3 mm, as seen on the lat-eral view. An unstable injury with a rupture of the transverse ligament may need a posterior C1-C2 fusion.Bracing with a cervicothoracic orthosis or a halo ring and vest is the recommended treatment for nondisplaced and mini-mally displaced fractures; significantly displaced unstable frac-tures require more definitive surgical treatment.Fractures of C2 (Odontoid Fracture)Half of normal cervical rotation occurs at the atlantoaxial joint. The odontoid (Dens) is a small bony process which arises from the body of C2, and articulates with the body of C1 (the Atlas). There are three types of odontoid fractures (Fig.
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atlantoaxial joint. The odontoid (Dens) is a small bony process which arises from the body of C2, and articulates with the body of C1 (the Atlas). There are three types of odontoid fractures (Fig. 43-28). Type I fractures are the most common and are avulsion fractures off the tip of the dens. Type I fractures occur when there is tension applied to the alar ligaments (which span from the tip of the odontoid to the skull bypassing the C1 vertebra). Type I frac-tures are stable and managed nonoperatively.Type II fractures, at the base of the odontoid, results from lateral loading forces. Operative stabilization in patients with a high risk of fracture nonunion is the preferred treatment since immobilization in a halo vest results in nonunion rates ranging 89Figure 43-27. Jefferson fracture with and without ligamentous injury. Note the increased ADI and the potential compression of the spinal cord (orange color).Brunicardi_Ch43_p1879-p1924.indd 190022/02/19 10:41 AM 1901ORTHOPEDIC
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Surgery_Schwartz. atlantoaxial joint. The odontoid (Dens) is a small bony process which arises from the body of C2, and articulates with the body of C1 (the Atlas). There are three types of odontoid fractures (Fig. 43-28). Type I fractures are the most common and are avulsion fractures off the tip of the dens. Type I fractures occur when there is tension applied to the alar ligaments (which span from the tip of the odontoid to the skull bypassing the C1 vertebra). Type I frac-tures are stable and managed nonoperatively.Type II fractures, at the base of the odontoid, results from lateral loading forces. Operative stabilization in patients with a high risk of fracture nonunion is the preferred treatment since immobilization in a halo vest results in nonunion rates ranging 89Figure 43-27. Jefferson fracture with and without ligamentous injury. Note the increased ADI and the potential compression of the spinal cord (orange color).Brunicardi_Ch43_p1879-p1924.indd 190022/02/19 10:41 AM 1901ORTHOPEDIC
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with and without ligamentous injury. Note the increased ADI and the potential compression of the spinal cord (orange color).Brunicardi_Ch43_p1879-p1924.indd 190022/02/19 10:41 AM 1901ORTHOPEDIC SURGERYCHAPTER 43from 20% to 80%. The risk of nonunion includes displacement greater than 5 mm, angulation greater than 10 degrees, age over 50 years, smoking, and delayed diagnosis more than 4 weeks. Nonunion occurs due to interruption of the blood supply. Trans-fixing the odontoid fracture with a screw maintains rotational movement. Posterior fusion of C1 on C2 is another option, but this results in decreased cervical spine rotation; 50% of rotation of the cervical spine comes from C1 and C2 joint.Type III fractures extend into the body of C2, below the origin of the odontoid process. The cancellous bone is rich in blood supply and usually heals well. Type III fractures are gen-erally treated with a halo brace.Hangman’s Fractures of C2Hangman’s Fractures are a bilateral fracture of the
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Surgery_Schwartz. with and without ligamentous injury. Note the increased ADI and the potential compression of the spinal cord (orange color).Brunicardi_Ch43_p1879-p1924.indd 190022/02/19 10:41 AM 1901ORTHOPEDIC SURGERYCHAPTER 43from 20% to 80%. The risk of nonunion includes displacement greater than 5 mm, angulation greater than 10 degrees, age over 50 years, smoking, and delayed diagnosis more than 4 weeks. Nonunion occurs due to interruption of the blood supply. Trans-fixing the odontoid fracture with a screw maintains rotational movement. Posterior fusion of C1 on C2 is another option, but this results in decreased cervical spine rotation; 50% of rotation of the cervical spine comes from C1 and C2 joint.Type III fractures extend into the body of C2, below the origin of the odontoid process. The cancellous bone is rich in blood supply and usually heals well. Type III fractures are gen-erally treated with a halo brace.Hangman’s Fractures of C2Hangman’s Fractures are a bilateral fracture of the
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bone is rich in blood supply and usually heals well. Type III fractures are gen-erally treated with a halo brace.Hangman’s Fractures of C2Hangman’s Fractures are a bilateral fracture of the pars inter-articularis (Fig. 43-29). The spinal canal is usually widened, and neurological deficits rarely occur (Fig. 43-30). It results from sudden extension forces on the neck. Treatment is simple immobilization in a halo vest. Higher energy injuries causing severe extension forces can dislocate the C2-3 facet complex and damage the C2-3 disc. Significantly displaced Hangman’s fractures are managed by internal fixation and bone grafting between C2 and C3. When the fracture is severely angulated, it may indicate a flexion distraction injury, and traction on the C-spine may exacerbate the injury.Compression Fracture of the Cervical SpineIn C3 to C7 an axial load can cause fracture of the endplate while preserving the posterior cortex of the vertebral body. These fractures generally heal well and
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Surgery_Schwartz. bone is rich in blood supply and usually heals well. Type III fractures are gen-erally treated with a halo brace.Hangman’s Fractures of C2Hangman’s Fractures are a bilateral fracture of the pars inter-articularis (Fig. 43-29). The spinal canal is usually widened, and neurological deficits rarely occur (Fig. 43-30). It results from sudden extension forces on the neck. Treatment is simple immobilization in a halo vest. Higher energy injuries causing severe extension forces can dislocate the C2-3 facet complex and damage the C2-3 disc. Significantly displaced Hangman’s fractures are managed by internal fixation and bone grafting between C2 and C3. When the fracture is severely angulated, it may indicate a flexion distraction injury, and traction on the C-spine may exacerbate the injury.Compression Fracture of the Cervical SpineIn C3 to C7 an axial load can cause fracture of the endplate while preserving the posterior cortex of the vertebral body. These fractures generally heal well and
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Fracture of the Cervical SpineIn C3 to C7 an axial load can cause fracture of the endplate while preserving the posterior cortex of the vertebral body. These fractures generally heal well and are treated nonopera-tively with analgesics and a cervical brace.Burst Fractures of the Cervical SpineBurst Fractures of the cervical spine usually result from axial loads such as in diving and motor vehicle accidents. The injury results in displacement of bony fragments into the canal, injur-ing the spinal cord. Burst fractures are treated surgically by anterior decompression (corpectomy) and reconstruction using a bone graft strut stabilized with a plate and screws.Unilateral and Bilateral Facet DislocationThis injury is usually associated with motor vehicle accidents. A restrained passenger can suffer forced flexion with distrac-tion resulting in dislocation of the facets. The diagnosis can be made on lateral radiographs. Unilateral facet dislocation can be missed on an X-ray. It usually shows
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Surgery_Schwartz. Fracture of the Cervical SpineIn C3 to C7 an axial load can cause fracture of the endplate while preserving the posterior cortex of the vertebral body. These fractures generally heal well and are treated nonopera-tively with analgesics and a cervical brace.Burst Fractures of the Cervical SpineBurst Fractures of the cervical spine usually result from axial loads such as in diving and motor vehicle accidents. The injury results in displacement of bony fragments into the canal, injur-ing the spinal cord. Burst fractures are treated surgically by anterior decompression (corpectomy) and reconstruction using a bone graft strut stabilized with a plate and screws.Unilateral and Bilateral Facet DislocationThis injury is usually associated with motor vehicle accidents. A restrained passenger can suffer forced flexion with distrac-tion resulting in dislocation of the facets. The diagnosis can be made on lateral radiographs. Unilateral facet dislocation can be missed on an X-ray. It usually shows
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forced flexion with distrac-tion resulting in dislocation of the facets. The diagnosis can be made on lateral radiographs. Unilateral facet dislocation can be missed on an X-ray. It usually shows less than 25% sublux-ation on an X-ray, and it affects the nerve roots. Bilateral facet dislocation will have more than 50% subluxation on an X-ray and may cause severe spinal cord injury. Treatment consists of closed reduction with axial traction utilizing cranial tongs, grad-uated application of weight, and periodic X-rays. The patient is kept awake for safety concerns. A closed reduction should not be done if the patient is not awake. Facet dislocations could be associated with disc herniation. An MRI is the study of choice to rule out disc herniations and should be done prior to reduc-tion in an unconscious patient or prior to open reduction and/or surgical fixation. When a reduction is obtained, the patient is taken to surgery for fusion, which may be performed anteriorly Figure
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Surgery_Schwartz. forced flexion with distrac-tion resulting in dislocation of the facets. The diagnosis can be made on lateral radiographs. Unilateral facet dislocation can be missed on an X-ray. It usually shows less than 25% sublux-ation on an X-ray, and it affects the nerve roots. Bilateral facet dislocation will have more than 50% subluxation on an X-ray and may cause severe spinal cord injury. Treatment consists of closed reduction with axial traction utilizing cranial tongs, grad-uated application of weight, and periodic X-rays. The patient is kept awake for safety concerns. A closed reduction should not be done if the patient is not awake. Facet dislocations could be associated with disc herniation. An MRI is the study of choice to rule out disc herniations and should be done prior to reduc-tion in an unconscious patient or prior to open reduction and/or surgical fixation. When a reduction is obtained, the patient is taken to surgery for fusion, which may be performed anteriorly Figure
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in an unconscious patient or prior to open reduction and/or surgical fixation. When a reduction is obtained, the patient is taken to surgery for fusion, which may be performed anteriorly Figure 43-28. The three types of Odontoid fractures.Figure 43-29. Lateral view shows displaced hangman’s fracture.Figure 43-30. Hangman’s fracture cross-section view shows wid-ening of the canal, and therefore the spinal cord is not affected.Brunicardi_Ch43_p1879-p1924.indd 190122/02/19 10:41 AM 1902SPECIFIC CONSIDERATIONSPART IIor posteriorly. Anterior surgery is necessary if the patient has an associated herniated disc.Clay-Shoveler’s InjuryClay-shoveler’s injury can result from a motor vehicle accident or from shoveling soil or clay. The injury (of C6, C7, T1, and T2) is the result of avulsion fracture of the spinous process by the paraspinal muscle forces (Fig. 43-31). The fracture is treated nonoperatively with analgesics and a soft collar.FRACTURES OF THE THORACIC AND LUMBAR SPINEThoracic
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Surgery_Schwartz. in an unconscious patient or prior to open reduction and/or surgical fixation. When a reduction is obtained, the patient is taken to surgery for fusion, which may be performed anteriorly Figure 43-28. The three types of Odontoid fractures.Figure 43-29. Lateral view shows displaced hangman’s fracture.Figure 43-30. Hangman’s fracture cross-section view shows wid-ening of the canal, and therefore the spinal cord is not affected.Brunicardi_Ch43_p1879-p1924.indd 190122/02/19 10:41 AM 1902SPECIFIC CONSIDERATIONSPART IIor posteriorly. Anterior surgery is necessary if the patient has an associated herniated disc.Clay-Shoveler’s InjuryClay-shoveler’s injury can result from a motor vehicle accident or from shoveling soil or clay. The injury (of C6, C7, T1, and T2) is the result of avulsion fracture of the spinous process by the paraspinal muscle forces (Fig. 43-31). The fracture is treated nonoperatively with analgesics and a soft collar.FRACTURES OF THE THORACIC AND LUMBAR SPINEThoracic
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of the spinous process by the paraspinal muscle forces (Fig. 43-31). The fracture is treated nonoperatively with analgesics and a soft collar.FRACTURES OF THE THORACIC AND LUMBAR SPINEThoracic Lumbar Spine InjuryThe ribs stabilize fractures of the thoracic spine, making these fractures more stable than similar fractures of the lumbar spine. Neurologic injuries are more common in the thoracic and proxi-mal lumbar spine because of the presence of the spinal cord, which ends at the L2 level, as well as the small spinal canal diameter of the thoracic spine.Compression FractureCompression fractures result from osteoporosis as well as trauma. Compression fractures involve a fracture of the anterior part of the vertebral body without associated posterior cortex fracture. Thoracolumbar compression fractures are treated non-operatively with braces and analgesics.Burst FractureBurst fractures are caused by falls and high-energy automo-bile accidents. The posterior cortex fracture (middle
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Surgery_Schwartz. of the spinous process by the paraspinal muscle forces (Fig. 43-31). The fracture is treated nonoperatively with analgesics and a soft collar.FRACTURES OF THE THORACIC AND LUMBAR SPINEThoracic Lumbar Spine InjuryThe ribs stabilize fractures of the thoracic spine, making these fractures more stable than similar fractures of the lumbar spine. Neurologic injuries are more common in the thoracic and proxi-mal lumbar spine because of the presence of the spinal cord, which ends at the L2 level, as well as the small spinal canal diameter of the thoracic spine.Compression FractureCompression fractures result from osteoporosis as well as trauma. Compression fractures involve a fracture of the anterior part of the vertebral body without associated posterior cortex fracture. Thoracolumbar compression fractures are treated non-operatively with braces and analgesics.Burst FractureBurst fractures are caused by falls and high-energy automo-bile accidents. The posterior cortex fracture (middle
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fractures are treated non-operatively with braces and analgesics.Burst FractureBurst fractures are caused by falls and high-energy automo-bile accidents. The posterior cortex fracture (middle column involvement) differentiates the burst fracture from a compres-sion fracture. The injury may be associated with neurological deficits due to retropulsion of bone into the canal. A vertical lamina fracture may contain an invaginated segment of the dura mater with accompanying nerve root injury and dural tear. Wid-ening of the pedicle in an AP view of the spine will indicate a burst fracture. CT scan will define the bony injury, and an MRI will show compression of the neural elements and any injury to the posterior ligaments.Treatment is nonoperative with an orthoses and mobiliza-tion of the patient if the fracture is stable. Surgery is done for decompression and destabilization of the spine if the patient has neurologic deficits or if the fracture is unstable.Seatbelt Injuries (Flexion
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Surgery_Schwartz. fractures are treated non-operatively with braces and analgesics.Burst FractureBurst fractures are caused by falls and high-energy automo-bile accidents. The posterior cortex fracture (middle column involvement) differentiates the burst fracture from a compres-sion fracture. The injury may be associated with neurological deficits due to retropulsion of bone into the canal. A vertical lamina fracture may contain an invaginated segment of the dura mater with accompanying nerve root injury and dural tear. Wid-ening of the pedicle in an AP view of the spine will indicate a burst fracture. CT scan will define the bony injury, and an MRI will show compression of the neural elements and any injury to the posterior ligaments.Treatment is nonoperative with an orthoses and mobiliza-tion of the patient if the fracture is stable. Surgery is done for decompression and destabilization of the spine if the patient has neurologic deficits or if the fracture is unstable.Seatbelt Injuries (Flexion
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patient if the fracture is stable. Surgery is done for decompression and destabilization of the spine if the patient has neurologic deficits or if the fracture is unstable.Seatbelt Injuries (Flexion Distraction Injuries)A seatbelt injury occurs when there is acute forward flexion of the trunk and anterior (i.e., seatbelt) restraint. The pelvis and upper torso move forward, and failure of the spine under tension begins with the posterior elements. Tearing of the dorsal fascia, the interspinous ligament, dislocation of the facets, and tearing of the discs occurs. Seatbelt injury may be bony or ligamen-tous (Fig. 43-32). The bone of the spinous process, the lamina, the pedicles, and the vertebral body fail in tension (“chance Figure 43-32. Seatbelt injuries (flexion-distraction injuries) can be bony or ligamentous.Figure 43-31. Fracture of the transverse process of C6 or C7.Brunicardi_Ch43_p1879-p1924.indd 190222/02/19 10:41 AM 1903ORTHOPEDIC SURGERYCHAPTER 43fracture”). The bony
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Surgery_Schwartz. patient if the fracture is stable. Surgery is done for decompression and destabilization of the spine if the patient has neurologic deficits or if the fracture is unstable.Seatbelt Injuries (Flexion Distraction Injuries)A seatbelt injury occurs when there is acute forward flexion of the trunk and anterior (i.e., seatbelt) restraint. The pelvis and upper torso move forward, and failure of the spine under tension begins with the posterior elements. Tearing of the dorsal fascia, the interspinous ligament, dislocation of the facets, and tearing of the discs occurs. Seatbelt injury may be bony or ligamen-tous (Fig. 43-32). The bone of the spinous process, the lamina, the pedicles, and the vertebral body fail in tension (“chance Figure 43-32. Seatbelt injuries (flexion-distraction injuries) can be bony or ligamentous.Figure 43-31. Fracture of the transverse process of C6 or C7.Brunicardi_Ch43_p1879-p1924.indd 190222/02/19 10:41 AM 1903ORTHOPEDIC SURGERYCHAPTER 43fracture”). The bony
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can be bony or ligamentous.Figure 43-31. Fracture of the transverse process of C6 or C7.Brunicardi_Ch43_p1879-p1924.indd 190222/02/19 10:41 AM 1903ORTHOPEDIC SURGERYCHAPTER 43fracture”). The bony injury could be stable. Flexion distraction injuries involving the soft tissue, with injury to the posterior spine elements, are usually unstable. This unstable injury will require internal fixation and fusion with bone grafting. This spine injury may be associated with a colon injury, especially in children.Fracture Dislocations of the SpineFracture dislocations of the spine displace the bony elements by translation or rotation, resulting in canal narrowing and nerve injury.Reduction of the displaced bones is the best way to improve the canal dimensions.Patients with fracture dislocations of the spine and par-tial nerve function can recover. Fracture dislocations are treated operatively with surgical stabilization.Disc HerniationDisc herniation, most common between ages of 20 and 50, can
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Surgery_Schwartz. can be bony or ligamentous.Figure 43-31. Fracture of the transverse process of C6 or C7.Brunicardi_Ch43_p1879-p1924.indd 190222/02/19 10:41 AM 1903ORTHOPEDIC SURGERYCHAPTER 43fracture”). The bony injury could be stable. Flexion distraction injuries involving the soft tissue, with injury to the posterior spine elements, are usually unstable. This unstable injury will require internal fixation and fusion with bone grafting. This spine injury may be associated with a colon injury, especially in children.Fracture Dislocations of the SpineFracture dislocations of the spine displace the bony elements by translation or rotation, resulting in canal narrowing and nerve injury.Reduction of the displaced bones is the best way to improve the canal dimensions.Patients with fracture dislocations of the spine and par-tial nerve function can recover. Fracture dislocations are treated operatively with surgical stabilization.Disc HerniationDisc herniation, most common between ages of 20 and 50, can
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the spine and par-tial nerve function can recover. Fracture dislocations are treated operatively with surgical stabilization.Disc HerniationDisc herniation, most common between ages of 20 and 50, can occur in the cervical, thoracic, or the lumbar spine, and consists of a tear of the annulus allowing the nucleus pulposus material to extrude through the annulus and enter the canal, pressing on the exiting nerve or the “traversing” nerve roots. In the cervical spine, spinal cord compression can occur.Symptoms of most disc herniations resolve within 8 weeks as the nerve root accommodates and inflammation recedes. The bulk of the extruded nucleus pulposus resorbs over time. When symptoms persist beyond 6 to 8 weeks, surgery with excision of the involved disc and decompression of the nerve roots may be indicated.In cervical disc herniation, an anterior approach to the spine is performed with dissection through a transverse incision on the neck. Dissection is carried between the trachea,
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Surgery_Schwartz. the spine and par-tial nerve function can recover. Fracture dislocations are treated operatively with surgical stabilization.Disc HerniationDisc herniation, most common between ages of 20 and 50, can occur in the cervical, thoracic, or the lumbar spine, and consists of a tear of the annulus allowing the nucleus pulposus material to extrude through the annulus and enter the canal, pressing on the exiting nerve or the “traversing” nerve roots. In the cervical spine, spinal cord compression can occur.Symptoms of most disc herniations resolve within 8 weeks as the nerve root accommodates and inflammation recedes. The bulk of the extruded nucleus pulposus resorbs over time. When symptoms persist beyond 6 to 8 weeks, surgery with excision of the involved disc and decompression of the nerve roots may be indicated.In cervical disc herniation, an anterior approach to the spine is performed with dissection through a transverse incision on the neck. Dissection is carried between the trachea,
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may be indicated.In cervical disc herniation, an anterior approach to the spine is performed with dissection through a transverse incision on the neck. Dissection is carried between the trachea, esopha-gus medially, and the carotid sheath laterally. The disc is then removed. The disc space is usually filled with bone graft to fuse the vertebrae. A locking screw low profile titanium plate is then attached to the vertebrae.Posterior decompression and laminotomy exposes the pos-terior elements of the spine. A portion of the lamina is removed to allow access to the canal to correct foraminal impingement or to remove lateral disc herniations. While the posterior approach does not require fusion with plates and screws, central disc her-niation cannot be managed through a posterior approach since the spinal cord cannot be safely retracted.In thoracic spine disc herniation, the posterior approach is contraindicated because it may lead to paralysis.For lumbar disc herniation, a midline
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Surgery_Schwartz. may be indicated.In cervical disc herniation, an anterior approach to the spine is performed with dissection through a transverse incision on the neck. Dissection is carried between the trachea, esopha-gus medially, and the carotid sheath laterally. The disc is then removed. The disc space is usually filled with bone graft to fuse the vertebrae. A locking screw low profile titanium plate is then attached to the vertebrae.Posterior decompression and laminotomy exposes the pos-terior elements of the spine. A portion of the lamina is removed to allow access to the canal to correct foraminal impingement or to remove lateral disc herniations. While the posterior approach does not require fusion with plates and screws, central disc her-niation cannot be managed through a posterior approach since the spinal cord cannot be safely retracted.In thoracic spine disc herniation, the posterior approach is contraindicated because it may lead to paralysis.For lumbar disc herniation, a midline
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since the spinal cord cannot be safely retracted.In thoracic spine disc herniation, the posterior approach is contraindicated because it may lead to paralysis.For lumbar disc herniation, a midline incision is used, and laminotomy allows visualization of the lateral recess. Retraction of the dura allows visualization of the traversing nerve roots as well as of the disc fragment.Cauda Equina SyndromeCauda equina syndrome is uncommon and occurs from a central disc herniation (Fig. 43-33). This can be a difficult diagnosis to make; however, it is a true emergency, and a delay in diagnosis can lead to permanent impairment. The patient will complain of back pain with bilateral leg pain. Bladder and bowel diffi-culty such as incontinence and frequency, saddle anesthesia, decreased perianal sensation, impotence, diminished rectal tone, and motor deficits. MRI will show a central disc herniation. Treatment is with urgent diagnosis and urgent surgical decom-pression. The results are better if
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Surgery_Schwartz. since the spinal cord cannot be safely retracted.In thoracic spine disc herniation, the posterior approach is contraindicated because it may lead to paralysis.For lumbar disc herniation, a midline incision is used, and laminotomy allows visualization of the lateral recess. Retraction of the dura allows visualization of the traversing nerve roots as well as of the disc fragment.Cauda Equina SyndromeCauda equina syndrome is uncommon and occurs from a central disc herniation (Fig. 43-33). This can be a difficult diagnosis to make; however, it is a true emergency, and a delay in diagnosis can lead to permanent impairment. The patient will complain of back pain with bilateral leg pain. Bladder and bowel diffi-culty such as incontinence and frequency, saddle anesthesia, decreased perianal sensation, impotence, diminished rectal tone, and motor deficits. MRI will show a central disc herniation. Treatment is with urgent diagnosis and urgent surgical decom-pression. The results are better if
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impotence, diminished rectal tone, and motor deficits. MRI will show a central disc herniation. Treatment is with urgent diagnosis and urgent surgical decom-pression. The results are better if the decompression is done within 48 hours of onset of symptoms. A central disc herniation causing cauda equina should be differentiated from a postero-lateral disc herniation. The posterolateral disc herniation usu-ally affects a nerve root and can be treated conservatively, at least initially. In the case of central disc herniation, it affects the cauda equina (the lumbosacral nerve roots), and this is a surgical emergency. Spontaneous recovery does not occur, and the outcome is catastrophic, including permanent loss of bowel and bladder control as well as the ability to have an erection if treatment is delayed.Spinal StenosisA loss of hydration of the discs causes loss of disc height and bulging of annular tissue and the ligamentum flavum, which effectively narrows the canal (spinal stenosis).
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Surgery_Schwartz. impotence, diminished rectal tone, and motor deficits. MRI will show a central disc herniation. Treatment is with urgent diagnosis and urgent surgical decom-pression. The results are better if the decompression is done within 48 hours of onset of symptoms. A central disc herniation causing cauda equina should be differentiated from a postero-lateral disc herniation. The posterolateral disc herniation usu-ally affects a nerve root and can be treated conservatively, at least initially. In the case of central disc herniation, it affects the cauda equina (the lumbosacral nerve roots), and this is a surgical emergency. Spontaneous recovery does not occur, and the outcome is catastrophic, including permanent loss of bowel and bladder control as well as the ability to have an erection if treatment is delayed.Spinal StenosisA loss of hydration of the discs causes loss of disc height and bulging of annular tissue and the ligamentum flavum, which effectively narrows the canal (spinal stenosis).
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is delayed.Spinal StenosisA loss of hydration of the discs causes loss of disc height and bulging of annular tissue and the ligamentum flavum, which effectively narrows the canal (spinal stenosis). Osteophyte for-mation on the facet joints can also cause nerve impingement. Cervical stenosis can cause myelopathic symptoms (hyper-reflexia, problems with fine hand dexterity, balance problems resulting in gait disturbance, weakness, and pain). In patients with low back pain and gait disturbance, obtain an MRI of the cervical spine to rule out cervical myelopathy. Pathology of the lumbo-sacral spine does not cause gait disturbances.Lumbar stenosis causes neurogenic claudication (pro-gressive pain, weakness, and numbness in the legs). The clau-dication symptoms result from standing and walking, which increases lumbar lordosis. Extension of the spine decreases the spinal canal diameter as well as the foramen size and worsens the condition. The symptoms resolve with sitting and bending
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Surgery_Schwartz. is delayed.Spinal StenosisA loss of hydration of the discs causes loss of disc height and bulging of annular tissue and the ligamentum flavum, which effectively narrows the canal (spinal stenosis). Osteophyte for-mation on the facet joints can also cause nerve impingement. Cervical stenosis can cause myelopathic symptoms (hyper-reflexia, problems with fine hand dexterity, balance problems resulting in gait disturbance, weakness, and pain). In patients with low back pain and gait disturbance, obtain an MRI of the cervical spine to rule out cervical myelopathy. Pathology of the lumbo-sacral spine does not cause gait disturbances.Lumbar stenosis causes neurogenic claudication (pro-gressive pain, weakness, and numbness in the legs). The clau-dication symptoms result from standing and walking, which increases lumbar lordosis. Extension of the spine decreases the spinal canal diameter as well as the foramen size and worsens the condition. The symptoms resolve with sitting and bending
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which increases lumbar lordosis. Extension of the spine decreases the spinal canal diameter as well as the foramen size and worsens the condition. The symptoms resolve with sitting and bending forward (i.e., over a shopping cart) (Fig. 43-34). Flexion of the spine increases the spinal canal diameter as well as the foramen size and decrease the symptoms. The patient may have a normal neurologic exam, and it is important to study the vascular status of the patient and differentiate between neurologic and vascular claudication. Examine the pulses, prescribe a noninvasive vas-cular study if necessary. In general, walking causes the symp-toms for both conditions, and standing relieves the vascular claudication symptoms. Spinal stenosis is treated with NSAIDs, epidural steroid injections, and physical therapy. Resistant cases may require surgical decompression.Spinal stenosis usually occurs in patients over 50 years of age. With degenerative spondylolisthesis or scoliosis, fusion with
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Surgery_Schwartz. which increases lumbar lordosis. Extension of the spine decreases the spinal canal diameter as well as the foramen size and worsens the condition. The symptoms resolve with sitting and bending forward (i.e., over a shopping cart) (Fig. 43-34). Flexion of the spine increases the spinal canal diameter as well as the foramen size and decrease the symptoms. The patient may have a normal neurologic exam, and it is important to study the vascular status of the patient and differentiate between neurologic and vascular claudication. Examine the pulses, prescribe a noninvasive vas-cular study if necessary. In general, walking causes the symp-toms for both conditions, and standing relieves the vascular claudication symptoms. Spinal stenosis is treated with NSAIDs, epidural steroid injections, and physical therapy. Resistant cases may require surgical decompression.Spinal stenosis usually occurs in patients over 50 years of age. With degenerative spondylolisthesis or scoliosis, fusion with
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and physical therapy. Resistant cases may require surgical decompression.Spinal stenosis usually occurs in patients over 50 years of age. With degenerative spondylolisthesis or scoliosis, fusion with instrumentation is usually required to prevent progression of the deformity.Figure 43-33. Image showing central disc herniation affecting the cauda equina and the classic posterolateral disc herniation affecting a nerve root.Brunicardi_Ch43_p1879-p1924.indd 190322/02/19 10:41 AM 1904SPECIFIC CONSIDERATIONSPART IIBack Pain and Degenerative Disc DiseaseBack pain occurs in the majority of adults but is usually self-limited, resolving in 1 to 2 weeks. Chronic unremitting back pain may suggest the possibility of infection, malignancy, or metastatic disease.While radiographs are one option in the management of disabling low back pain, they are ineffective at ruling out malig-nancy, and radiographic findings correlate poorly with symp-toms. Patients with severe degenerative symptoms may have
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Surgery_Schwartz. and physical therapy. Resistant cases may require surgical decompression.Spinal stenosis usually occurs in patients over 50 years of age. With degenerative spondylolisthesis or scoliosis, fusion with instrumentation is usually required to prevent progression of the deformity.Figure 43-33. Image showing central disc herniation affecting the cauda equina and the classic posterolateral disc herniation affecting a nerve root.Brunicardi_Ch43_p1879-p1924.indd 190322/02/19 10:41 AM 1904SPECIFIC CONSIDERATIONSPART IIBack Pain and Degenerative Disc DiseaseBack pain occurs in the majority of adults but is usually self-limited, resolving in 1 to 2 weeks. Chronic unremitting back pain may suggest the possibility of infection, malignancy, or metastatic disease.While radiographs are one option in the management of disabling low back pain, they are ineffective at ruling out malig-nancy, and radiographic findings correlate poorly with symp-toms. Patients with severe degenerative symptoms may have
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management of disabling low back pain, they are ineffective at ruling out malig-nancy, and radiographic findings correlate poorly with symp-toms. Patients with severe degenerative symptoms may have no pain, while others with mild degenerative findings complain of severe pain. The potential for secondary gain and psychiatric problems and the unpredictable results of spine fusion add to the difficulty of diagnosis and choosing a treatment plan.Intervertebral disc replacement prostheses are experimen-tal in the treatment of degenerative disc disease. The potential for loosening, creation of wear debris, and bone loss complicat-ing revision surgery are concerns, as are the proximity of the device to the spinal canal and the great vessels.ScoliosisScoliosis is a lateral curvature of the spine. Lateral bending of the spine is always accompanied by rotational deformity (coupling).In order to measure the severity of scoliosis, lines are drawn along the endplates of the vertebral bodies at
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Surgery_Schwartz. management of disabling low back pain, they are ineffective at ruling out malig-nancy, and radiographic findings correlate poorly with symp-toms. Patients with severe degenerative symptoms may have no pain, while others with mild degenerative findings complain of severe pain. The potential for secondary gain and psychiatric problems and the unpredictable results of spine fusion add to the difficulty of diagnosis and choosing a treatment plan.Intervertebral disc replacement prostheses are experimen-tal in the treatment of degenerative disc disease. The potential for loosening, creation of wear debris, and bone loss complicat-ing revision surgery are concerns, as are the proximity of the device to the spinal canal and the great vessels.ScoliosisScoliosis is a lateral curvature of the spine. Lateral bending of the spine is always accompanied by rotational deformity (coupling).In order to measure the severity of scoliosis, lines are drawn along the endplates of the vertebral bodies at
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Lateral bending of the spine is always accompanied by rotational deformity (coupling).In order to measure the severity of scoliosis, lines are drawn along the endplates of the vertebral bodies at either end of the curve, and the angle formed when these lines intersect determines the magnitude of the curve.Scoliotic curves are classified as congenital, degenera-tive, metabolic (mucopolysaccharidoses), neurogenic (cerebral palsy), and myogenic curves (muscular dystrophy). Idiopathic scoliosis is the most common form and represents a spectrum of genetic disease.Adults with scoliosis may present with axial pain and imbalance in posture. Treatment for scoliosis may include anti-inflammatory medications, therapy, and activity modification. In severe cases with objective deformity, surgical correction of the deformity may be indicated.Idiopathic ScoliosisThe majority of idiopathic scoliosis curves become apparent during adolescence and progress during skeletal growth. Ini-tial management
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Surgery_Schwartz. Lateral bending of the spine is always accompanied by rotational deformity (coupling).In order to measure the severity of scoliosis, lines are drawn along the endplates of the vertebral bodies at either end of the curve, and the angle formed when these lines intersect determines the magnitude of the curve.Scoliotic curves are classified as congenital, degenera-tive, metabolic (mucopolysaccharidoses), neurogenic (cerebral palsy), and myogenic curves (muscular dystrophy). Idiopathic scoliosis is the most common form and represents a spectrum of genetic disease.Adults with scoliosis may present with axial pain and imbalance in posture. Treatment for scoliosis may include anti-inflammatory medications, therapy, and activity modification. In severe cases with objective deformity, surgical correction of the deformity may be indicated.Idiopathic ScoliosisThe majority of idiopathic scoliosis curves become apparent during adolescence and progress during skeletal growth. Ini-tial management
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of the deformity may be indicated.Idiopathic ScoliosisThe majority of idiopathic scoliosis curves become apparent during adolescence and progress during skeletal growth. Ini-tial management consists of observation. Rapidly progressing curves are treated with braces. Brace treatment is recommended for curves between 20 and 40 degrees. For patients with large curves, surgical intervention may be needed using rods with grafting and fusion.Neuromuscular ScoliosisNeurologic conditions such as polio and cerebral palsy can lead to “uncompensated” scoliosis curves where the patient is unable to lean with his upper body to restore balance. Scoliosis correc-tion surgery may be needed to facilitate sitting balance and to avoid skin breakdown caused by pelvic obliquity.JOINT RECONSTRUCTIONIntroduction to ArthritisArthritis refers to a large number of medical conditions, includ-ing osteoarthritis, rheumatoid arthritis, septic arthritis, and post-traumatic arthritis. Each has the potential to lead
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Surgery_Schwartz. of the deformity may be indicated.Idiopathic ScoliosisThe majority of idiopathic scoliosis curves become apparent during adolescence and progress during skeletal growth. Ini-tial management consists of observation. Rapidly progressing curves are treated with braces. Brace treatment is recommended for curves between 20 and 40 degrees. For patients with large curves, surgical intervention may be needed using rods with grafting and fusion.Neuromuscular ScoliosisNeurologic conditions such as polio and cerebral palsy can lead to “uncompensated” scoliosis curves where the patient is unable to lean with his upper body to restore balance. Scoliosis correc-tion surgery may be needed to facilitate sitting balance and to avoid skin breakdown caused by pelvic obliquity.JOINT RECONSTRUCTIONIntroduction to ArthritisArthritis refers to a large number of medical conditions, includ-ing osteoarthritis, rheumatoid arthritis, septic arthritis, and post-traumatic arthritis. Each has the potential to lead
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to ArthritisArthritis refers to a large number of medical conditions, includ-ing osteoarthritis, rheumatoid arthritis, septic arthritis, and post-traumatic arthritis. Each has the potential to lead to loss of articular cartilage lining the joints. According to the CDC and the National Health Interview Survey, approximately 55 million adults (22% of the U.S. population) have been diag-nosed with some form of arthritis. This number is pro-jected to grow to an astounding 67 million adults by 2030 (or 25% of the U.S. population).Arthritis causes pain, loss of range of motion, decreased ability to perform work duties or participate in social functions, and decreased quality of life. The number of individuals suffer-ing from arthritic conditions will continue to rise as the “baby boomer” generation enters old age and the prevalence of obesity rises in the U.S. population, as age and obesity are two major factors in the onset of arthritis.Examination of the PatientA thorough history and
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Surgery_Schwartz. to ArthritisArthritis refers to a large number of medical conditions, includ-ing osteoarthritis, rheumatoid arthritis, septic arthritis, and post-traumatic arthritis. Each has the potential to lead to loss of articular cartilage lining the joints. According to the CDC and the National Health Interview Survey, approximately 55 million adults (22% of the U.S. population) have been diag-nosed with some form of arthritis. This number is pro-jected to grow to an astounding 67 million adults by 2030 (or 25% of the U.S. population).Arthritis causes pain, loss of range of motion, decreased ability to perform work duties or participate in social functions, and decreased quality of life. The number of individuals suffer-ing from arthritic conditions will continue to rise as the “baby boomer” generation enters old age and the prevalence of obesity rises in the U.S. population, as age and obesity are two major factors in the onset of arthritis.Examination of the PatientA thorough history and
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enters old age and the prevalence of obesity rises in the U.S. population, as age and obesity are two major factors in the onset of arthritis.Examination of the PatientA thorough history and physical examination is indicated for all orthopedic patients. Patient history should include loca-tion, quality, severity, timing, and radiation of pain along with any referred pain, associated signs and symptoms, modify-ing factors, or prior treatments, including both conservative and surgical measures. Other details within the history and physical examination are equally important in establishing a diagnosis and successfully developing a treatment plan. If you listen carefully to your patients, they will often tell you their diagnosis.For example, location of “hip pain” can narrow a dif-ferential diagnosis. Patients with activity-related groin pain often are found to have hip arthritis, whereas patients with 10Figure 43-34. Person is seen bending over shopping cart to improve
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Surgery_Schwartz. enters old age and the prevalence of obesity rises in the U.S. population, as age and obesity are two major factors in the onset of arthritis.Examination of the PatientA thorough history and physical examination is indicated for all orthopedic patients. Patient history should include loca-tion, quality, severity, timing, and radiation of pain along with any referred pain, associated signs and symptoms, modify-ing factors, or prior treatments, including both conservative and surgical measures. Other details within the history and physical examination are equally important in establishing a diagnosis and successfully developing a treatment plan. If you listen carefully to your patients, they will often tell you their diagnosis.For example, location of “hip pain” can narrow a dif-ferential diagnosis. Patients with activity-related groin pain often are found to have hip arthritis, whereas patients with 10Figure 43-34. Person is seen bending over shopping cart to improve
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a dif-ferential diagnosis. Patients with activity-related groin pain often are found to have hip arthritis, whereas patients with 10Figure 43-34. Person is seen bending over shopping cart to improve symptoms.Brunicardi_Ch43_p1879-p1924.indd 190422/02/19 10:41 AM 1905ORTHOPEDIC SURGERYCHAPTER 43peritrochanteric pain (lateral hip pain) may be suffering from trochanteric bursitis. The importance of listening and focusing on the patient’s description of location and type of pain cannot be overemphasized.Physical examination should begin by observing the patient’s gait, both with and without assistive devices if pos-sible. This demonstrates the extent of the patient’s functional deficit and the effect of the patient’s pain. Typical gait pat-terns include antalgic gait due to pain, or a “Trendelenburg gait” (Fig. 43-35) where abductor weakness may lead to a poor outcome following total hip arthroplasty. Other aspects of the exam include assessment of leg length discrepancy, joint
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Surgery_Schwartz. a dif-ferential diagnosis. Patients with activity-related groin pain often are found to have hip arthritis, whereas patients with 10Figure 43-34. Person is seen bending over shopping cart to improve symptoms.Brunicardi_Ch43_p1879-p1924.indd 190422/02/19 10:41 AM 1905ORTHOPEDIC SURGERYCHAPTER 43peritrochanteric pain (lateral hip pain) may be suffering from trochanteric bursitis. The importance of listening and focusing on the patient’s description of location and type of pain cannot be overemphasized.Physical examination should begin by observing the patient’s gait, both with and without assistive devices if pos-sible. This demonstrates the extent of the patient’s functional deficit and the effect of the patient’s pain. Typical gait pat-terns include antalgic gait due to pain, or a “Trendelenburg gait” (Fig. 43-35) where abductor weakness may lead to a poor outcome following total hip arthroplasty. Other aspects of the exam include assessment of leg length discrepancy, joint
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a “Trendelenburg gait” (Fig. 43-35) where abductor weakness may lead to a poor outcome following total hip arthroplasty. Other aspects of the exam include assessment of leg length discrepancy, joint con-tractures, skin changes, assessment for prior surgical incisions to identify prior treatments or plan future surgical approaches, neurovascular status, and strength, as well as range of motion. These details document functional status and help to formulate a differential diagnosis. Patients with “hip pain” may have lumbar spinal stenosis, radiculopathy, or vascular disease that may play a large role in their presentation. Once an appropriate physi-cal examination is performed, weight-bearing radiographs are needed. Advanced imaging, including CT and MRI, are rarely indicated in the initial workup. Once a diagnosis is made, spe-cific treatment directed towards the patient’s condition can be initiated. The goals of treatment are to improve pain, preserve motion, and maximize patient
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Surgery_Schwartz. a “Trendelenburg gait” (Fig. 43-35) where abductor weakness may lead to a poor outcome following total hip arthroplasty. Other aspects of the exam include assessment of leg length discrepancy, joint con-tractures, skin changes, assessment for prior surgical incisions to identify prior treatments or plan future surgical approaches, neurovascular status, and strength, as well as range of motion. These details document functional status and help to formulate a differential diagnosis. Patients with “hip pain” may have lumbar spinal stenosis, radiculopathy, or vascular disease that may play a large role in their presentation. Once an appropriate physi-cal examination is performed, weight-bearing radiographs are needed. Advanced imaging, including CT and MRI, are rarely indicated in the initial workup. Once a diagnosis is made, spe-cific treatment directed towards the patient’s condition can be initiated. The goals of treatment are to improve pain, preserve motion, and maximize patient
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workup. Once a diagnosis is made, spe-cific treatment directed towards the patient’s condition can be initiated. The goals of treatment are to improve pain, preserve motion, and maximize patient function, independence, and qual-ity of life.Nonoperative Management and Prevention of ArthritisNonoperative measures to treat arthritis include weight loss, activity modification, rest, physical therapy, NSAIDs, bracing, and assistive devices such a cane or walker. These treatments have the potential to decrease symptoms and improve function and quality of life. For example, holding a cane on the opposite side of the symptomatic extremity reduces the forces across the hip joint and subsequently decreases hip pain (Fig. 43-36). In nearly all cases, it is best to treat patients nonoperatively prior to recommending surgery.Health and exercise can also play a role in the prevention of arthritis. Weight loss of as little as 11 lbs (5 kg) has been shown to decrease the risk of developing knee
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Surgery_Schwartz. workup. Once a diagnosis is made, spe-cific treatment directed towards the patient’s condition can be initiated. The goals of treatment are to improve pain, preserve motion, and maximize patient function, independence, and qual-ity of life.Nonoperative Management and Prevention of ArthritisNonoperative measures to treat arthritis include weight loss, activity modification, rest, physical therapy, NSAIDs, bracing, and assistive devices such a cane or walker. These treatments have the potential to decrease symptoms and improve function and quality of life. For example, holding a cane on the opposite side of the symptomatic extremity reduces the forces across the hip joint and subsequently decreases hip pain (Fig. 43-36). In nearly all cases, it is best to treat patients nonoperatively prior to recommending surgery.Health and exercise can also play a role in the prevention of arthritis. Weight loss of as little as 11 lbs (5 kg) has been shown to decrease the risk of developing knee
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prior to recommending surgery.Health and exercise can also play a role in the prevention of arthritis. Weight loss of as little as 11 lbs (5 kg) has been shown to decrease the risk of developing knee osteoarthritis in 11women by 50%. Similarly, patients who engage in regu-lar physical activity have a lower incidence of arthritis. However, despite nonoperative treatment, surgical intervention may be required to effectively manage patient symptoms.InjectionsJoint injections are commonly performed into the knee and shoulder. Common injections into the knee include corticoste-roids and hyaluronic-acid gels. Corticosteroid injections can decrease inflammation within the joint. These injections are usually administered in combination with a local anesthetic, such as lidocaine, in order to provide more immediate relief for both diagnostic and therapeutic purposes. If the patient has immediate relief of pain with injection of the joint, this localizes the source of the patient’s pain to the
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Surgery_Schwartz. prior to recommending surgery.Health and exercise can also play a role in the prevention of arthritis. Weight loss of as little as 11 lbs (5 kg) has been shown to decrease the risk of developing knee osteoarthritis in 11women by 50%. Similarly, patients who engage in regu-lar physical activity have a lower incidence of arthritis. However, despite nonoperative treatment, surgical intervention may be required to effectively manage patient symptoms.InjectionsJoint injections are commonly performed into the knee and shoulder. Common injections into the knee include corticoste-roids and hyaluronic-acid gels. Corticosteroid injections can decrease inflammation within the joint. These injections are usually administered in combination with a local anesthetic, such as lidocaine, in order to provide more immediate relief for both diagnostic and therapeutic purposes. If the patient has immediate relief of pain with injection of the joint, this localizes the source of the patient’s pain to the
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more immediate relief for both diagnostic and therapeutic purposes. If the patient has immediate relief of pain with injection of the joint, this localizes the source of the patient’s pain to the joint and may assist with diagnosis. Diagnostic hip injections are particularly helpful in distinguishing pain resulting from hip versus lumbar spine pathology. Any benefit received is therapeutic for the patient. Hyaluronic acid injections in the knee are frequently used and are commonly referred to as “viscosupplementation.” The viscosity of the synovial fluid is increased by hyaluronic acid, but its role and mechanism are not well defined yet. There is a risk of joint infection, cartilage injury from the needle, hemarthrosis, and failure to receive benefit. Short-term altered glucose metabolism in diabetic patients is common with cor-ticosteroid injections. The efficacy of hyaluronic acid injec-tions has been questioned by recent evidence summarized in the American Academy of Orthopaedic
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Surgery_Schwartz. more immediate relief for both diagnostic and therapeutic purposes. If the patient has immediate relief of pain with injection of the joint, this localizes the source of the patient’s pain to the joint and may assist with diagnosis. Diagnostic hip injections are particularly helpful in distinguishing pain resulting from hip versus lumbar spine pathology. Any benefit received is therapeutic for the patient. Hyaluronic acid injections in the knee are frequently used and are commonly referred to as “viscosupplementation.” The viscosity of the synovial fluid is increased by hyaluronic acid, but its role and mechanism are not well defined yet. There is a risk of joint infection, cartilage injury from the needle, hemarthrosis, and failure to receive benefit. Short-term altered glucose metabolism in diabetic patients is common with cor-ticosteroid injections. The efficacy of hyaluronic acid injec-tions has been questioned by recent evidence summarized in the American Academy of Orthopaedic
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in diabetic patients is common with cor-ticosteroid injections. The efficacy of hyaluronic acid injec-tions has been questioned by recent evidence summarized in the American Academy of Orthopaedic Surgeons’ Clinical Practice Guidelines.Figure 43-35. Trendelenburg Gait resulting from weakness of abductor muscles.Figure 43-36. Holding the cane on the opposite side of the pathol-ogy is beneficial in decreasing arthritis pain in the hip.Brunicardi_Ch43_p1879-p1924.indd 190522/02/19 10:41 AM 1906SPECIFIC CONSIDERATIONSPART IISurgical Management of ArthritisThe most commonly performed procedure for arthritis of a major joint is arthroplasty, or joint replacement. Joint replace-ments, including hip and knee arthroplasty, are considered two of the most successful procedures performed in all of surgery. However, nonarthroplasty options exist and are typically per-formed for certain indications and goals.Osteotomy. Osteotomy is cutting of the bone to change the position of the fragments,
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Surgery_Schwartz. in diabetic patients is common with cor-ticosteroid injections. The efficacy of hyaluronic acid injec-tions has been questioned by recent evidence summarized in the American Academy of Orthopaedic Surgeons’ Clinical Practice Guidelines.Figure 43-35. Trendelenburg Gait resulting from weakness of abductor muscles.Figure 43-36. Holding the cane on the opposite side of the pathol-ogy is beneficial in decreasing arthritis pain in the hip.Brunicardi_Ch43_p1879-p1924.indd 190522/02/19 10:41 AM 1906SPECIFIC CONSIDERATIONSPART IISurgical Management of ArthritisThe most commonly performed procedure for arthritis of a major joint is arthroplasty, or joint replacement. Joint replace-ments, including hip and knee arthroplasty, are considered two of the most successful procedures performed in all of surgery. However, nonarthroplasty options exist and are typically per-formed for certain indications and goals.Osteotomy. Osteotomy is cutting of the bone to change the position of the fragments,
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of surgery. However, nonarthroplasty options exist and are typically per-formed for certain indications and goals.Osteotomy. Osteotomy is cutting of the bone to change the position of the fragments, thereby improving rotation, align-ment, or angulation. Osteotomy can be performed for both con-genital and acquired deformities that contribute to the patient’s pain or development or progression of disease. Pelvic and femo-ral osteotomy can be utilized in the treatment of developmen-tal dysplasia of the hip. The position of the acetabulum can be altered with pelvic osteotomies in order to provide more appro-priate coverage of the femoral head, which is typically deficient anteriorly and laterally. Femoral osteotomies can be performed to correct version and varus/valgus deformity of the femoral neck. Osteotomies are performed to obtain more normal align-ment and coverage of the femoral head within the acetabulum to prevent or delay future disease.An osteotomy commonly used in the knee is a
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Surgery_Schwartz. of surgery. However, nonarthroplasty options exist and are typically per-formed for certain indications and goals.Osteotomy. Osteotomy is cutting of the bone to change the position of the fragments, thereby improving rotation, align-ment, or angulation. Osteotomy can be performed for both con-genital and acquired deformities that contribute to the patient’s pain or development or progression of disease. Pelvic and femo-ral osteotomy can be utilized in the treatment of developmen-tal dysplasia of the hip. The position of the acetabulum can be altered with pelvic osteotomies in order to provide more appro-priate coverage of the femoral head, which is typically deficient anteriorly and laterally. Femoral osteotomies can be performed to correct version and varus/valgus deformity of the femoral neck. Osteotomies are performed to obtain more normal align-ment and coverage of the femoral head within the acetabulum to prevent or delay future disease.An osteotomy commonly used in the knee is a
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neck. Osteotomies are performed to obtain more normal align-ment and coverage of the femoral head within the acetabulum to prevent or delay future disease.An osteotomy commonly used in the knee is a proxi-mal tibia osteotomy. An adult patient who presents with iso-lated medial compartment knee arthritis and associated varus deformity would be a candidate for a valgus-producing (high tibial) osteotomy. An osteotomy that realigns the knee into slight valgus has the potential to off-load the medial com-partment, slow disease progression, and prevent or delay the need for further procedures (unicompartmental or total knee arthroplasties).Arthrodesis. Arthrodesis is a treatment option for severe arthritis where the overlying articular cartilage is removed and two opposing bones heal together with the use of hardware (internal or temporary external fixation) often supplemented by bone graft. After successful arthrodesis, no motion is possible through the joint and the source of pain is
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Surgery_Schwartz. neck. Osteotomies are performed to obtain more normal align-ment and coverage of the femoral head within the acetabulum to prevent or delay future disease.An osteotomy commonly used in the knee is a proxi-mal tibia osteotomy. An adult patient who presents with iso-lated medial compartment knee arthritis and associated varus deformity would be a candidate for a valgus-producing (high tibial) osteotomy. An osteotomy that realigns the knee into slight valgus has the potential to off-load the medial com-partment, slow disease progression, and prevent or delay the need for further procedures (unicompartmental or total knee arthroplasties).Arthrodesis. Arthrodesis is a treatment option for severe arthritis where the overlying articular cartilage is removed and two opposing bones heal together with the use of hardware (internal or temporary external fixation) often supplemented by bone graft. After successful arthrodesis, no motion is possible through the joint and the source of pain is
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with the use of hardware (internal or temporary external fixation) often supplemented by bone graft. After successful arthrodesis, no motion is possible through the joint and the source of pain is removed. Arthrodesis of large joints, such as the knee, shoulder, or hip, are typically explored as an option in the face of infection, in older adult, low-demand patients or in young, active patients who are con-sidered too young for a joint replacement (out of concern for component wear and the need for early revision). Arthrodesis can also serve as a “last resort” procedure in orthopedics when joint preserving treatments fail due to fracture or infection. Ankle arthrodesis is the primary procedure performed in adult patients with traumatic arthritis of the ankle.Joint Arthroplasty/Joint Replacement. Joint arthroplasty is the most common option for patients suffering from pain associated with arthritis in a joint. The surfaces of the bones are replaced after removing the damaged articular
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Surgery_Schwartz. with the use of hardware (internal or temporary external fixation) often supplemented by bone graft. After successful arthrodesis, no motion is possible through the joint and the source of pain is removed. Arthrodesis of large joints, such as the knee, shoulder, or hip, are typically explored as an option in the face of infection, in older adult, low-demand patients or in young, active patients who are con-sidered too young for a joint replacement (out of concern for component wear and the need for early revision). Arthrodesis can also serve as a “last resort” procedure in orthopedics when joint preserving treatments fail due to fracture or infection. Ankle arthrodesis is the primary procedure performed in adult patients with traumatic arthritis of the ankle.Joint Arthroplasty/Joint Replacement. Joint arthroplasty is the most common option for patients suffering from pain associated with arthritis in a joint. The surfaces of the bones are replaced after removing the damaged articular
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arthroplasty is the most common option for patients suffering from pain associated with arthritis in a joint. The surfaces of the bones are replaced after removing the damaged articular cartilage. The amount of bone and the determination of how to make the bone cuts is made based on preoperative radiographs and templating, cutting guides, anatomic measurements, and soft tissue/ligament balancing. The cut bony surfaces are covered with new compo-nents, usually made of metal, ceramic, or polyethylene. These new components are sized to appropriately match the patient, based on templated preoperative radiographs, intraoperative measurements, and examination for stability, leg length, align-ment, and range of motion.If all compartments or surfaces of the joint are replaced, the arthroplasty is referred to as a total joint arthroplasty. In comparison, if only one surface or compartment of the joint is replaced, it is referred to as hemiarthroplasty (hip, shoulder) or unicompartmental
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Surgery_Schwartz. arthroplasty is the most common option for patients suffering from pain associated with arthritis in a joint. The surfaces of the bones are replaced after removing the damaged articular cartilage. The amount of bone and the determination of how to make the bone cuts is made based on preoperative radiographs and templating, cutting guides, anatomic measurements, and soft tissue/ligament balancing. The cut bony surfaces are covered with new compo-nents, usually made of metal, ceramic, or polyethylene. These new components are sized to appropriately match the patient, based on templated preoperative radiographs, intraoperative measurements, and examination for stability, leg length, align-ment, and range of motion.If all compartments or surfaces of the joint are replaced, the arthroplasty is referred to as a total joint arthroplasty. In comparison, if only one surface or compartment of the joint is replaced, it is referred to as hemiarthroplasty (hip, shoulder) or unicompartmental
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is referred to as a total joint arthroplasty. In comparison, if only one surface or compartment of the joint is replaced, it is referred to as hemiarthroplasty (hip, shoulder) or unicompartmental arthroplasty (knee). Total hip and knee arthroplasties are considered among the most successful of all surgical procedures performed in terms of patient outcome and improvement in pain.Hip Arthroplasty Background Hip arthroplasty is utilized for end stage arthri-tis in the hip that has failed a reasonable trial of nonoperative measures (Fig. 43-37). Conventional hip arthroplasty commonly refers to total hip arthroplasty where both the femoral head and acetabulum are replaced or resurfaced, respectively. Finally, hemiarthroplasty describes the replacement of the femoral head and neck with a stemmed femoral component in isolation. The acetabulum is not addressed surgically.History of Hip Arthroplasty The history of hip arthroplasty (hip replacement) may be broken down into “Pre-Charnley” and
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Surgery_Schwartz. is referred to as a total joint arthroplasty. In comparison, if only one surface or compartment of the joint is replaced, it is referred to as hemiarthroplasty (hip, shoulder) or unicompartmental arthroplasty (knee). Total hip and knee arthroplasties are considered among the most successful of all surgical procedures performed in terms of patient outcome and improvement in pain.Hip Arthroplasty Background Hip arthroplasty is utilized for end stage arthri-tis in the hip that has failed a reasonable trial of nonoperative measures (Fig. 43-37). Conventional hip arthroplasty commonly refers to total hip arthroplasty where both the femoral head and acetabulum are replaced or resurfaced, respectively. Finally, hemiarthroplasty describes the replacement of the femoral head and neck with a stemmed femoral component in isolation. The acetabulum is not addressed surgically.History of Hip Arthroplasty The history of hip arthroplasty (hip replacement) may be broken down into “Pre-Charnley” and
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Surgery_Schwartz_12587
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femoral component in isolation. The acetabulum is not addressed surgically.History of Hip Arthroplasty The history of hip arthroplasty (hip replacement) may be broken down into “Pre-Charnley” and “Post-Charnley” eras, referring to the significant contri-butions of Sir John Charnley to the evolution of hip arthro-plasty. Prior to Charnley’s contributions, hip arthroplasty consisted of a variety of procedures with highly variable results. Early attempts at relieving hip pain were made with interpositional arthroplasty, where tissue layers, plastic, or metal were placed between the worn articular surfaces. Frac-ture of the interposed material or loosening of components often led to failure.Later attempts introduced stemmed components to improve fixation. One of the earliest femoral components was designed by Austin-Moore. This prosthesis replaced the femoral head and neck with a metal component secured into the femoral shaft with a stem extending down the diaphysis. This prosthesis was
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Surgery_Schwartz. femoral component in isolation. The acetabulum is not addressed surgically.History of Hip Arthroplasty The history of hip arthroplasty (hip replacement) may be broken down into “Pre-Charnley” and “Post-Charnley” eras, referring to the significant contri-butions of Sir John Charnley to the evolution of hip arthro-plasty. Prior to Charnley’s contributions, hip arthroplasty consisted of a variety of procedures with highly variable results. Early attempts at relieving hip pain were made with interpositional arthroplasty, where tissue layers, plastic, or metal were placed between the worn articular surfaces. Frac-ture of the interposed material or loosening of components often led to failure.Later attempts introduced stemmed components to improve fixation. One of the earliest femoral components was designed by Austin-Moore. This prosthesis replaced the femoral head and neck with a metal component secured into the femoral shaft with a stem extending down the diaphysis. This prosthesis was
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Surgery_Schwartz_12588
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Surgery_Schwartz
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was designed by Austin-Moore. This prosthesis replaced the femoral head and neck with a metal component secured into the femoral shaft with a stem extending down the diaphysis. This prosthesis was utilized in hemiarthroplasty for many years and served as Figure 43-37. Osteoarthritis femoral head. Note erosion of weight-bearing cartilage and peripheral osteophytes.Brunicardi_Ch43_p1879-p1924.indd 190622/02/19 10:41 AM 1907ORTHOPEDIC SURGERYCHAPTER 43a step in the development of total hip arthroplasty with the later addition of the acetabular component.Surgical Approaches to the Hip A variety of approaches to the hip joint have been utilized in joint arthroplasty, includ-ing anterior approach (Smith Petersen), anterolateral approach (Watson-Jones), lateral approach (Hardinge), and posterior approach (Kocher Langenbach). Each approach contains a unique set of advantages and disadvantages. The following is a brief summary of the most common approaches that are utilized in total hip
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Surgery_Schwartz. was designed by Austin-Moore. This prosthesis replaced the femoral head and neck with a metal component secured into the femoral shaft with a stem extending down the diaphysis. This prosthesis was utilized in hemiarthroplasty for many years and served as Figure 43-37. Osteoarthritis femoral head. Note erosion of weight-bearing cartilage and peripheral osteophytes.Brunicardi_Ch43_p1879-p1924.indd 190622/02/19 10:41 AM 1907ORTHOPEDIC SURGERYCHAPTER 43a step in the development of total hip arthroplasty with the later addition of the acetabular component.Surgical Approaches to the Hip A variety of approaches to the hip joint have been utilized in joint arthroplasty, includ-ing anterior approach (Smith Petersen), anterolateral approach (Watson-Jones), lateral approach (Hardinge), and posterior approach (Kocher Langenbach). Each approach contains a unique set of advantages and disadvantages. The following is a brief summary of the most common approaches that are utilized in total hip
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Surgery_Schwartz_12589
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Surgery_Schwartz
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approach (Kocher Langenbach). Each approach contains a unique set of advantages and disadvantages. The following is a brief summary of the most common approaches that are utilized in total hip arthroplasty.Anterior approach (Smith Petersen): This approach is an internervous and intermuscular approach. It utilizes the inter-nervous plane between the femoral nerve and superior gluteal nerve. Superficially, the plane between the sartorius (femo-ral nerve) and tensor fasciae lata (superior gluteal nerve) is dissected in the deep layer and the plane between the rectus femoris (femoral nerve) and gluteus medius (superior glu-teal nerve) is dissected. Advantages to this approach include supine positioning, use of intraoperative fluoroscopy for acetabular component positioning, and discontinuation of all ambulatory assistive devices 1 week earlier than other approached. Downsides include difficult preparation and placement of the femoral component with higher rate of femoral fracture/femoral
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Surgery_Schwartz. approach (Kocher Langenbach). Each approach contains a unique set of advantages and disadvantages. The following is a brief summary of the most common approaches that are utilized in total hip arthroplasty.Anterior approach (Smith Petersen): This approach is an internervous and intermuscular approach. It utilizes the inter-nervous plane between the femoral nerve and superior gluteal nerve. Superficially, the plane between the sartorius (femo-ral nerve) and tensor fasciae lata (superior gluteal nerve) is dissected in the deep layer and the plane between the rectus femoris (femoral nerve) and gluteus medius (superior glu-teal nerve) is dissected. Advantages to this approach include supine positioning, use of intraoperative fluoroscopy for acetabular component positioning, and discontinuation of all ambulatory assistive devices 1 week earlier than other approached. Downsides include difficult preparation and placement of the femoral component with higher rate of femoral fracture/femoral
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Surgery_Schwartz_12590
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Surgery_Schwartz
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of all ambulatory assistive devices 1 week earlier than other approached. Downsides include difficult preparation and placement of the femoral component with higher rate of femoral fracture/femoral component revision, higher rate of wound complications, and lack of a true extensile approach.Posterior approach (Kocher–Langenbach): The posterior approach is a muscle-splitting approach without an interner-vous plane. After incising the skin and subcutaneous fat, the fascia lata is incised along with the gluteus maximus. The short external rotators are exposed and dissected, includ-ing the piriformis, superior and inferior gemelli, obturator internus and externus, and quadratus femoris. This allows internal rotation of the hip along with flexion and adduction to dislocate the hip. The posterior approach with posterior soft tissue repair has no increased rate of dislocation com-pared to the anterior approach. The posterior approach is extensile and provides excellent exposure of both the
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Surgery_Schwartz. of all ambulatory assistive devices 1 week earlier than other approached. Downsides include difficult preparation and placement of the femoral component with higher rate of femoral fracture/femoral component revision, higher rate of wound complications, and lack of a true extensile approach.Posterior approach (Kocher–Langenbach): The posterior approach is a muscle-splitting approach without an interner-vous plane. After incising the skin and subcutaneous fat, the fascia lata is incised along with the gluteus maximus. The short external rotators are exposed and dissected, includ-ing the piriformis, superior and inferior gemelli, obturator internus and externus, and quadratus femoris. This allows internal rotation of the hip along with flexion and adduction to dislocate the hip. The posterior approach with posterior soft tissue repair has no increased rate of dislocation com-pared to the anterior approach. The posterior approach is extensile and provides excellent exposure of both the
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Surgery_Schwartz_12591
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Surgery_Schwartz
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approach with posterior soft tissue repair has no increased rate of dislocation com-pared to the anterior approach. The posterior approach is extensile and provides excellent exposure of both the femur and acetabulum for complex and revision cases.Lateral approach (Hardinge): While there have been many modifications to the original Hardinge approach, first described in 1982, most involve releasing the anterior one-third of the gluteus medius, underlying minimus, abductor tendon, and vastus lateralis distally in one sleeve off of the greater trochanter. The capsule is then incised to expose the hip joint. Care must be taken to protect the superior gluteal nerve during this exposure, which lies 5 cm proximal to the tip of the greater trochanter.Exposure of the acetabulum is excellent with the modified Hardinge approach, which is extensile. However, access to the posterior column is limited compared to the posterior approach. The increased risk of postoperative Trendelenburg gait, other
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Surgery_Schwartz. approach with posterior soft tissue repair has no increased rate of dislocation com-pared to the anterior approach. The posterior approach is extensile and provides excellent exposure of both the femur and acetabulum for complex and revision cases.Lateral approach (Hardinge): While there have been many modifications to the original Hardinge approach, first described in 1982, most involve releasing the anterior one-third of the gluteus medius, underlying minimus, abductor tendon, and vastus lateralis distally in one sleeve off of the greater trochanter. The capsule is then incised to expose the hip joint. Care must be taken to protect the superior gluteal nerve during this exposure, which lies 5 cm proximal to the tip of the greater trochanter.Exposure of the acetabulum is excellent with the modified Hardinge approach, which is extensile. However, access to the posterior column is limited compared to the posterior approach. The increased risk of postoperative Trendelenburg gait, other
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Surgery_Schwartz_12592
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Surgery_Schwartz
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modified Hardinge approach, which is extensile. However, access to the posterior column is limited compared to the posterior approach. The increased risk of postoperative Trendelenburg gait, other pathologic gait, and heterotopic ossification compared to all other approaches to the hip have made it far less commonly performed than the posterior approach. Minimally invasive total hip arthroplasty is associated with decreased visualiza-tion intraoperatively and associated risks of component malposition, intraoperative fracture, and nerve or vascular injury. In fact, the only documented benefit of minimally inva-sive techniques appears to be a smaller incision, but with increased soft tissue tension intraoperatively comes the risk of compromised wound healing and periprosthetic joint infection.Bearing Surfaces in Hip Arthroplasty The most common combination of bearing surfaces used in total hip arthroplasty is a metal (generally cobalt chrome) or ceramic prosthetic head, articulating
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Surgery_Schwartz. modified Hardinge approach, which is extensile. However, access to the posterior column is limited compared to the posterior approach. The increased risk of postoperative Trendelenburg gait, other pathologic gait, and heterotopic ossification compared to all other approaches to the hip have made it far less commonly performed than the posterior approach. Minimally invasive total hip arthroplasty is associated with decreased visualiza-tion intraoperatively and associated risks of component malposition, intraoperative fracture, and nerve or vascular injury. In fact, the only documented benefit of minimally inva-sive techniques appears to be a smaller incision, but with increased soft tissue tension intraoperatively comes the risk of compromised wound healing and periprosthetic joint infection.Bearing Surfaces in Hip Arthroplasty The most common combination of bearing surfaces used in total hip arthroplasty is a metal (generally cobalt chrome) or ceramic prosthetic head, articulating
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Surgery_Schwartz_12593
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Surgery_Schwartz
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Surfaces in Hip Arthroplasty The most common combination of bearing surfaces used in total hip arthroplasty is a metal (generally cobalt chrome) or ceramic prosthetic head, articulating with a polyethylene liner. Metal on metal (MOM) articulations have largely been abandoned in total hip arthro-plasty as they are associated with production of metal ions that deposit in solid organs, pseudotumors that are locally destruc-tive to soft tissue/bone, and risk of early failure (Fig. 43-38). Ceramic on ceramic articulations have the lowest friction of all current bearing combinations. However, ceramic may fracture or squeak in ceramic on ceramic total hip arthroplasties.Alignment of Hip Arthroplasty Components Proper align-ment of hip arthroplasty components is vital to a successful procedure and patient outcome. Surgeons aim for appropriate alignment of components to restore a functional and stable range of motion. This is accomplished with combined version of the femoral and acetabular
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Surgery_Schwartz. Surfaces in Hip Arthroplasty The most common combination of bearing surfaces used in total hip arthroplasty is a metal (generally cobalt chrome) or ceramic prosthetic head, articulating with a polyethylene liner. Metal on metal (MOM) articulations have largely been abandoned in total hip arthro-plasty as they are associated with production of metal ions that deposit in solid organs, pseudotumors that are locally destruc-tive to soft tissue/bone, and risk of early failure (Fig. 43-38). Ceramic on ceramic articulations have the lowest friction of all current bearing combinations. However, ceramic may fracture or squeak in ceramic on ceramic total hip arthroplasties.Alignment of Hip Arthroplasty Components Proper align-ment of hip arthroplasty components is vital to a successful procedure and patient outcome. Surgeons aim for appropriate alignment of components to restore a functional and stable range of motion. This is accomplished with combined version of the femoral and acetabular
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Surgery_Schwartz_12594
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Surgery_Schwartz
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and patient outcome. Surgeons aim for appropriate alignment of components to restore a functional and stable range of motion. This is accomplished with combined version of the femoral and acetabular components, appropriate abduc-tion of the acetabular components, and staying true to Sir John Charnley’s principles: establishing a low friction articulation, 12Figure 43-38. Failed ceramic on metal hip arthroplasty components. Note the metallic staining on the ceramic femoral head.Brunicardi_Ch43_p1879-p1924.indd 190722/02/19 10:41 AM 1908SPECIFIC CONSIDERATIONSPART IImedializing the acetabular component and center of rotation and restoring abductor length and tension with restoration of appropriate length and femoral offset. Inappropriate placement of components can lead to early failure, accelerated component wear, dislocation, need for revision surgery, as well as poor patient outcomes and satisfaction.Knee Arthroplasty Background Knee arthroplasty is indicated for end-stage
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Surgery_Schwartz. and patient outcome. Surgeons aim for appropriate alignment of components to restore a functional and stable range of motion. This is accomplished with combined version of the femoral and acetabular components, appropriate abduc-tion of the acetabular components, and staying true to Sir John Charnley’s principles: establishing a low friction articulation, 12Figure 43-38. Failed ceramic on metal hip arthroplasty components. Note the metallic staining on the ceramic femoral head.Brunicardi_Ch43_p1879-p1924.indd 190722/02/19 10:41 AM 1908SPECIFIC CONSIDERATIONSPART IImedializing the acetabular component and center of rotation and restoring abductor length and tension with restoration of appropriate length and femoral offset. Inappropriate placement of components can lead to early failure, accelerated component wear, dislocation, need for revision surgery, as well as poor patient outcomes and satisfaction.Knee Arthroplasty Background Knee arthroplasty is indicated for end-stage
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Surgery_Schwartz_12595
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Surgery_Schwartz
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accelerated component wear, dislocation, need for revision surgery, as well as poor patient outcomes and satisfaction.Knee Arthroplasty Background Knee arthroplasty is indicated for end-stage arthritis that has failed a reasonable trial of nonoperative mea-sures (Figs. 43-39 and 43-40). Knee arthroplasty commonly refers to total knee arthroplasty where the distal femur, tibia, and patella are resurfaced after any remaining articular cartilage and a layer of subchondral bone are resected. A unicompartmental knee arthroplasty consists of replacing one compartment of the knee, most commonly the medial compartment.Surgical Approach to the Knee Total knee arthroplasty is generally accomplished through a medial parapatellar approach. This approach utilizes a longitudinal skin incision extending, on average, 5 cm proximal to the patella to the medial aspect of the tibial tubercle distally. Dissection is carried down to the capsule. To gain access to the joint, an arthrotomy is performed
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Surgery_Schwartz. accelerated component wear, dislocation, need for revision surgery, as well as poor patient outcomes and satisfaction.Knee Arthroplasty Background Knee arthroplasty is indicated for end-stage arthritis that has failed a reasonable trial of nonoperative mea-sures (Figs. 43-39 and 43-40). Knee arthroplasty commonly refers to total knee arthroplasty where the distal femur, tibia, and patella are resurfaced after any remaining articular cartilage and a layer of subchondral bone are resected. A unicompartmental knee arthroplasty consists of replacing one compartment of the knee, most commonly the medial compartment.Surgical Approach to the Knee Total knee arthroplasty is generally accomplished through a medial parapatellar approach. This approach utilizes a longitudinal skin incision extending, on average, 5 cm proximal to the patella to the medial aspect of the tibial tubercle distally. Dissection is carried down to the capsule. To gain access to the joint, an arthrotomy is performed
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Surgery_Schwartz_12596
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Surgery_Schwartz
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on average, 5 cm proximal to the patella to the medial aspect of the tibial tubercle distally. Dissection is carried down to the capsule. To gain access to the joint, an arthrotomy is performed medial to the patella extending proximally along the most medial aspect of the quadriceps tendon and distally just medial to the patellar tendon. This approach provides excellent exposure to all three compartments of the knee after patellar dislocation.Once the joint surfaces are adequately exposed, remain-ing articular cartilage and a thin layer of underlying bone are removed prior to placement of prosthetic components. Bone cuts are made based on preoperative templating, cutting guides, ligament balancing, and anatomic measurements (Figs. 43-41 and 43-42).Bearing Surfaces in Knee Arthroplasty The femoral com-ponent consists of a metal prosthetic cap sized to fit the normal shape of the distal femur. The tibia is cut perpendicular to the anatomic and mechanical axis, and a flat, stemmed, metal
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Surgery_Schwartz. on average, 5 cm proximal to the patella to the medial aspect of the tibial tubercle distally. Dissection is carried down to the capsule. To gain access to the joint, an arthrotomy is performed medial to the patella extending proximally along the most medial aspect of the quadriceps tendon and distally just medial to the patellar tendon. This approach provides excellent exposure to all three compartments of the knee after patellar dislocation.Once the joint surfaces are adequately exposed, remain-ing articular cartilage and a thin layer of underlying bone are removed prior to placement of prosthetic components. Bone cuts are made based on preoperative templating, cutting guides, ligament balancing, and anatomic measurements (Figs. 43-41 and 43-42).Bearing Surfaces in Knee Arthroplasty The femoral com-ponent consists of a metal prosthetic cap sized to fit the normal shape of the distal femur. The tibia is cut perpendicular to the anatomic and mechanical axis, and a flat, stemmed, metal
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Surgery_Schwartz_12597
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Surgery_Schwartz
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femoral com-ponent consists of a metal prosthetic cap sized to fit the normal shape of the distal femur. The tibia is cut perpendicular to the anatomic and mechanical axis, and a flat, stemmed, metal tray is placed that serves as a base plate for a polyethylene bearing surface. The patella is usually resurfaced with a polyethylene component.Two types of primary total knee arthroplasty systems exist, including cruciate retaining and posterior stabilized systems. As the name implies, with cruciate retaining systems, the PCL is retained in hopes of preserving more normal knee structures and minimizing bone loss, while in posterior stabilized systems the ligament is sacrificed and the components are designed to accommodate for the loss. These two systems have equivalent results in knee arthroplasty.Alignment and Balancing in Knee Arthroplasty Appropri-ate sizing and positioning of the components and balancing of the size and geometry of bony gaps in flexion and extension are essential for
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Surgery_Schwartz. femoral com-ponent consists of a metal prosthetic cap sized to fit the normal shape of the distal femur. The tibia is cut perpendicular to the anatomic and mechanical axis, and a flat, stemmed, metal tray is placed that serves as a base plate for a polyethylene bearing surface. The patella is usually resurfaced with a polyethylene component.Two types of primary total knee arthroplasty systems exist, including cruciate retaining and posterior stabilized systems. As the name implies, with cruciate retaining systems, the PCL is retained in hopes of preserving more normal knee structures and minimizing bone loss, while in posterior stabilized systems the ligament is sacrificed and the components are designed to accommodate for the loss. These two systems have equivalent results in knee arthroplasty.Alignment and Balancing in Knee Arthroplasty Appropri-ate sizing and positioning of the components and balancing of the size and geometry of bony gaps in flexion and extension are essential for
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Surgery_Schwartz_12598
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Surgery_Schwartz
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and Balancing in Knee Arthroplasty Appropri-ate sizing and positioning of the components and balancing of the size and geometry of bony gaps in flexion and extension are essential for a successful knee arthroplasty. Inappropriate com-ponent position can lead to early wear and failure, instability, pain, and stiffness.Computer Navigation, Robotics, and Joint ArthroplastyComputer-navigated joint arthroplasty has the theoretical ben-efit of more accurate and consistent placement of arthroplasty components through intraoperative feedback to the surgeon regarding component position, planned bone cuts, and align-ment. Disadvantages include increased costs of the technology, prolonged operative times, and risk of infection/fracture at the sites of intraoperative sensor placement within bone. Use of Figure 43-39. Valgus deformity. Osteoarthritis of lateral compart-ment right knee.Figure 43-40. Osteoarthritis of both knees. Note varus alignment of right knee and valgus alignment of left knee
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Surgery_Schwartz. and Balancing in Knee Arthroplasty Appropri-ate sizing and positioning of the components and balancing of the size and geometry of bony gaps in flexion and extension are essential for a successful knee arthroplasty. Inappropriate com-ponent position can lead to early wear and failure, instability, pain, and stiffness.Computer Navigation, Robotics, and Joint ArthroplastyComputer-navigated joint arthroplasty has the theoretical ben-efit of more accurate and consistent placement of arthroplasty components through intraoperative feedback to the surgeon regarding component position, planned bone cuts, and align-ment. Disadvantages include increased costs of the technology, prolonged operative times, and risk of infection/fracture at the sites of intraoperative sensor placement within bone. Use of Figure 43-39. Valgus deformity. Osteoarthritis of lateral compart-ment right knee.Figure 43-40. Osteoarthritis of both knees. Note varus alignment of right knee and valgus alignment of left knee
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Surgery_Schwartz_12599
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Surgery_Schwartz
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of Figure 43-39. Valgus deformity. Osteoarthritis of lateral compart-ment right knee.Figure 43-40. Osteoarthritis of both knees. Note varus alignment of right knee and valgus alignment of left knee (windswept deformity).Brunicardi_Ch43_p1879-p1924.indd 190822/02/19 10:41 AM 1909ORTHOPEDIC SURGERYCHAPTER 43ABFigure 43-41. A. Varus knee with osteoarthritis. B. Right total knee replacement.Figure 43-42. Computer-assisted robotic targeting arm for total knee replacement.Brunicardi_Ch43_p1879-p1924.indd 190922/02/19 10:41 AM 1910SPECIFIC CONSIDERATIONSPART IIcomputer navigation in total joint arthroplasty has been shown to minimize outliers in alignment, but there has been no proven benefit in survival or function secondary to computer-navigated or robotic-assisted joint replacement.Fixation Options in Joint ArthroplastyComponents in hip and knee arthroplasty can be secured with cement or biologic fixation. The cement most commonly used is polymethylmethacrylate (PMMA). PMMA serves
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Surgery_Schwartz. of Figure 43-39. Valgus deformity. Osteoarthritis of lateral compart-ment right knee.Figure 43-40. Osteoarthritis of both knees. Note varus alignment of right knee and valgus alignment of left knee (windswept deformity).Brunicardi_Ch43_p1879-p1924.indd 190822/02/19 10:41 AM 1909ORTHOPEDIC SURGERYCHAPTER 43ABFigure 43-41. A. Varus knee with osteoarthritis. B. Right total knee replacement.Figure 43-42. Computer-assisted robotic targeting arm for total knee replacement.Brunicardi_Ch43_p1879-p1924.indd 190922/02/19 10:41 AM 1910SPECIFIC CONSIDERATIONSPART IIcomputer navigation in total joint arthroplasty has been shown to minimize outliers in alignment, but there has been no proven benefit in survival or function secondary to computer-navigated or robotic-assisted joint replacement.Fixation Options in Joint ArthroplastyComponents in hip and knee arthroplasty can be secured with cement or biologic fixation. The cement most commonly used is polymethylmethacrylate (PMMA). PMMA serves
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Surgery_Schwartz_12600
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Surgery_Schwartz
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Options in Joint ArthroplastyComponents in hip and knee arthroplasty can be secured with cement or biologic fixation. The cement most commonly used is polymethylmethacrylate (PMMA). PMMA serves as a grout between the component and the bone surface. Components secured without cement are grit blasted or porous coated to allow bony on growth or ingrowth, respectively. Hydroxyapatite can also be utilized on implant surfaces to promote bone ingrowth or ongrowth through osteoconductive properties. A majority of hip joint arthroplasty components are now secured without cement, where initial fixation of components is accomplished through press fit techniques. In knee arthroplasty, cement utilization is generally preferred. In hip replacement patients where biologic fixation is unreliable, such as older adults, osteoporotic or previ-ously irradiated cement may be a better option. With revision total hip arthroplasty, cement fixation of components has been shown to lead to earlier mechanical
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Surgery_Schwartz. Options in Joint ArthroplastyComponents in hip and knee arthroplasty can be secured with cement or biologic fixation. The cement most commonly used is polymethylmethacrylate (PMMA). PMMA serves as a grout between the component and the bone surface. Components secured without cement are grit blasted or porous coated to allow bony on growth or ingrowth, respectively. Hydroxyapatite can also be utilized on implant surfaces to promote bone ingrowth or ongrowth through osteoconductive properties. A majority of hip joint arthroplasty components are now secured without cement, where initial fixation of components is accomplished through press fit techniques. In knee arthroplasty, cement utilization is generally preferred. In hip replacement patients where biologic fixation is unreliable, such as older adults, osteoporotic or previ-ously irradiated cement may be a better option. With revision total hip arthroplasty, cement fixation of components has been shown to lead to earlier mechanical
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Surgery_Schwartz_12601
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Surgery_Schwartz
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as older adults, osteoporotic or previ-ously irradiated cement may be a better option. With revision total hip arthroplasty, cement fixation of components has been shown to lead to earlier mechanical failure.Osteolysis and Aseptic Loosening. Osteolysis is a term used to describe abnormal resorption of bone. Osteolysis can be caused by underlying infection, metastatic disease, or in case of joint replacement, the production of wear debris. Even with appropriately positioned components, some wear of the bear-ing surfaces is expected over time. However, wear rates as well as the size and amount of wear debris differs with the bearing surface. Friction in ceramic on ceramic articulations is the low-est of all bearing surfaces; however, there is increased risk of component fracture and postoperative “squeaking.” In metal or ceramic on polyethylene articulations, wear debris is produced, and polyethylene particles are phagocytized by local macro-phages. Activated macrophages lead to an
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Surgery_Schwartz. as older adults, osteoporotic or previ-ously irradiated cement may be a better option. With revision total hip arthroplasty, cement fixation of components has been shown to lead to earlier mechanical failure.Osteolysis and Aseptic Loosening. Osteolysis is a term used to describe abnormal resorption of bone. Osteolysis can be caused by underlying infection, metastatic disease, or in case of joint replacement, the production of wear debris. Even with appropriately positioned components, some wear of the bear-ing surfaces is expected over time. However, wear rates as well as the size and amount of wear debris differs with the bearing surface. Friction in ceramic on ceramic articulations is the low-est of all bearing surfaces; however, there is increased risk of component fracture and postoperative “squeaking.” In metal or ceramic on polyethylene articulations, wear debris is produced, and polyethylene particles are phagocytized by local macro-phages. Activated macrophages lead to an
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