0340985003 Orthopaedics

OPERATIVE ORTHOPAEDICS

This page intentionally left blank

OPERATIVEORTHOPAEDICSThe Stanmore Guide

Edited by

Timothy Briggs MD MBBS (Hons) MCH (Orth) FRCS (Eng) FRCS (Ed) MD (Res)

Royal National Orthopaedic Hospital Trust, Stanmore, UK

Jonathan Miles MBCHB FRCS (Tr & Orth)


William Aston BSC MBBS FRCS (Tr & Orth) (Edinb)


First published in Great Britain in 2010 byHodder Arnold, an imprint of Hodder Education,part of Hachette UK, 338 Euston Road, London NW1 3BHwww.arnoldpublishers.com/www.hodderarnold.com

© 2010 Edward Arnold (publishers) Ltd

All rights reserved. Apart from any use permitted under UK copyrightlaw, this publication may only be reproduced, stored or transmitted, inany form, or by any means with prior permission in writing of thepublishers or in the case of reprographic production in accordance withthe terms of licences issued by the Copyright Licensing Agency. In theUnited Kingdom such licences are issued by the Copyright LicensingAgency: Saffron House, 6-10 Kirby Street, London EC1N 8TS

Hachette Livre UK’s Hodder Headline’s policy is to use papers that arenatural, renewable and recyclable products and made from wood grownin sustainable forests. The logging and manufacturing processes areexpected to conform to the environmental regulations of the countryof origin.

Whilst the advice and information in this book are believed to be trueand accurate at the date of going to press, neither the author[s] nor thepublisher can accept any legal responsibility or liability for any errors oromissions that may be made. In particular (but without limiting thegenerality of the preceding disclaimer) every effort has been made tocheck drug dosages; however it is still possible that errors have beenmissed. Furthermore, dosage schedules are constantly being revised andnew side-effects recognized. For these reasons the reader is stronglyurged to consult the drug companies' printed instructions beforeadministering any of the drugs recommended in this book.

British Library Cataloguing in Publication DataA catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication DataA catalog record for this book is available from the Library of Congress

ISBN 978 0 340 985 007

1 2 3 4 5 6 7 8 9 10

Commissioning Editor: Gavin JamiesonProject Editor: Joanna SilmanProduction Controller: Joanna WalkerCover Designer: Helen TownsonIndex: Jan Ross

Typeset in 9.5pt Berling Roman by Phoenix Photosetting, Chatham, KentPrinted and bound in Spain by Graphycems

What do you think about this book? Or any other Hodder Arnold title? Please visit our website at www.hodderarnold.com

www.arnoldpublishers.com/

www.hodderarnold.com

www.hodderarnold.com

This book is dedicated to all hard-working orthopaedic trainees whose enthusiasm for learning andpatient care was our motivation for creating this book.

Tim Briggs, Jonathan Miles, Will Aston

Contents

Contributors ixPreface xiAcknowledgements xiii

1 Anaesthesia in orthopaedic surgery 1Hui Yin Vivian Ip and Michael Cooper

2 Tumours 6William Aston and Timothy W R Briggs

3 Surgery of the cervical spine 14Raman Kalyan and David J Harrison

4 Surgery of the thoracolumbar spine 26Mathew Shaw and Sean Molloy

5 Surgery of the peripheral nerve 45Gorav Datta, Max Horowitz and Mike Fox

6 Surgery of the shoulder 59Omar Haddo and Mark Falworth

7 Surgery of the elbow 79Deborah Higgs and Simon Lambert

8 Surgery of the wrist 100James Donaldson and Nicholas Goddard

9 Surgery of the hand 114Norbert Kang, Robert Pearl and Lauren Ovens

10 Surgery of the hip 145Jonathan Miles and John Skinner

11 Surgery of the knee 172Lee David and Timothy W R Briggs

12 Soft tissue surgery of the knee 200Jonathan Miles and Richard Carrington

13 Surgery of the ankle 218Laurence James and Dishan Singh

14 Surgery of the foot 230Simon Clint and Nick Cullen

15 Limb reconstruction 258Robert Jennings and Peter Calder

16 Paediatric orthopaedic surgery 267Russell Hawkins and Aresh Hashemi-Nejad

17 Amputations 293William Aston and Rob Pollock

Index 301

viii Contents

Contributors

William Aston BSc MBBS FRCS (Ed) (Tr & Orth)

Consultant Orthopaedic Surgeon, Royal NationalOrthopaedic Hospital Trust, Stanmore, UK

Timothy W R Briggs MCH (Orth) FRCS (Ed)

Medical Director and Consultant OrthopaedicSurgeon, Royal National Orthopaedic Hospital Trust,Stanmore, UK

Peter Calder MBBS FRCS (Eng) FRCS (Tr & Orth)


Richard Carrington MBBS FRCS (Orth)


Simon Clint BSc MBBS FRCS (Tr & Orth)

Specialist Registrar, Royal National OrthopaedicHospital Trust, Stanmore, UK

Michael Cooper BSc MBCHB FRCA

Department of Anaesthetics, Royal NationalOrthopaedic Hospital Trust, Stanmore, UK

Nicholas Cullen BSC MBBS FRCS (Tr & Orth)

Consultant Foot and Ankle Surgeon, The RoyalNational Orthopaedic Hospital Trust, Stanmore, UK

Lee A David MBBS MRCS (Eng) FRCS (Tr & Orth)

Consultant in Trauma and Orthopaedic Surgery,Maidstone and Tunbridge Wells NHS Trust,Maidstone, UK

Gorav Datta MD FRCS (Tr & Orth)


James Donaldson MBBS BSc MRCS

Specialist Registrar, Royal National OrthopaedicHospital Trust Rotation, Stanmore, UK

Mark Falworth FRCS (Eng) FRCS (Orth)

Consultant Shoulder Surgeon, Royal NationalOrthopaedic Hospital Trust, Stanmore, UK

Mike Fox MBBS


Nicholas Goddard FRCS

Consultant Orthopaedic Surgeon, Royal Free Hospital,London, UK

Omar Haddo BMedSci MBBS FRCS (Tr & Orth)

Consultant Orthopaedic Surgeon, WhittingtonHospital, London, UK

David J Harrison MB BS BSc (Hons) AKC FRCS

Consultant Orthopaedic Surgeon, Spinal DeformityUnit, Royal National Orthopaedic Hospital Trust,Stanmore, UK

Aresh Hashemi-Nejad FRCS FRCS (Orth)

Consultant Orthopaedic Surgeon and ClinicalDirector, Royal National Orthopaedic Hospital Trust,Stanmore, UK, and Honorary Senior Lecturer,University College London, London, UK

Russell Hawkins BSc MBBS MRCS (Eng) FRCS (Tr & Orth)


Deborah Higgs FRCS (Tr & Orth)

Royal National Orthopaedic Hospital Trust, Stanmore,UK

Max Horowitz MBBS


Hui Yun Vivian Ip MBCHB MRCP FRCA


Laurence James BSc MBBS MRCS (Eng) FRCS (Tr & Orth)

Foot and Ankle Fellow, Royal National OrthopaedicTrust, Stanmore, UK

Robert Jennings MBBS BSc MSC MFSEM (UK) FRCS ED

(Tr & Orth)


Raman Kalyan MRCS MD FRCS (Tr & Orth) DNB ORTH

D ORTH (Eng)

Clinical Lecturer/Specialist Registrar, Royal NationalOrthopaedic Hospital Trust, Stanmore, UK

Norbert Kang MBBS MD FRCS (Plast)

Consultant Plastic and Hand Surgeon, Royal FreeHospital, London, UK

Simon Lambert BSc FRCS FRCSEdOrth

Consultant Orthopaedic Surgeon, The Shoulder andElbow Service, Royal National Orthopaedic Hospital,Stanmore, UK

Jonathan Miles MBCHB FRCS (Tr & Orth)


Sean Molloy MRCS MSc (Orth Eng) FRCS (Orth)

Consultant Orthopaedic Spinal Surgeon, RoyalNational Orthopaedic Hospital Trust, Stanmore, UK

Lauren Ovens MbChb MRCS

Specialist Registrar Plastic Surgeon, Royal FreeHospital, London, UK

Robert Pearl BSc FRCS (Tr & Orth)

Specialist Registrar Plastic Surgeon, Royal FreeHospital, London, UK

Rob Pollock BSc FRCS (Tr & Orth)


Matthew Shaw MBBS FRCS


Dishan Singh FRCS (Tr & Orth)

Consultant Foot and Ankle Surgeon, Royal NationalOrthopaedic Hospital Trust, Stanmore, UK

John Skinner MB BS FRCS (Orth)

Consultant Orthopaedic Surgeon and HonorarySenior Lecturer, Royal National Orthopaedic HospitalTrust, Stanmore, UK

x Contributors

Preface

Operative Orthopaedics: The Stanmore Guide aimsto provide practical instruction in electiveorthopaedic surgical procedures. Each chapter hasbeen written by a consultant orthopaedic surgeonand a trainee. It covers the list of proceduresidentified by the Specialist Advisory Committeeas key in the field of orthopaedic surgery andpresented as they are laid out in the trainingsyllabus.

It provides an explanation of orthopaedicsurgery from preoperative planning and consent,through approaches and operative technique topostoperative care. Each procedure is described ina simple and consistent format to enable thereader to describe and carry out safe, evidence-based approaches and common operations. Itcontains key references and sample viva questions.

This guide will serve junior trainees as theyenter their surgical training and will acts as arevision tool for trainees sitting the FRCS (Tr &Orth) examination, which has evolved into aformat emphasizing the importance of surgicalprocedures and the relevant anatomy.

The variety of equipment and instrumentsavailable to today’s orthopaedic surgeons is mind-boggling. The one essential tool for a surgeon intraining is an understanding of the basictechniques, upon which all procedures depend.The consistent and organized style of this bookwill teach these techniques and enable its readersto think logically and ‘keep a steady nerve’ in the potentially stressful situations ofindependent operating and the FRCS (Tr & Orth)examination.

Acknowledgements

Thank you first and foremost to all of the traineesand consultants who have given generously oftheir time, knowledge and experiences to producesuch informative writing in each chapter.

Hodder Arnold have supported us admirablyfrom the first idea right through to finalpreparation of the book and their contribution has

been vital to provide clear and well-illustratedguidelines for the reader.

A huge thank you to our respective wives andfamilies for putting up with us during this project.

Final thanks go to Professor Briggs for havingthe idea of writing this book in the first place –another professorial idea conceived in the bath!

Anaesthesia in orthopaedic surgery1

Hui Yin Vivian Ip and Michael Cooper

Introduction 1Preoperative assessment and guidelines 1Intraoperative techniques 3

Postoperative care 4Viva questions 5

INTRODUCTION

The orthopaedic patient cohort is medicallydiverse. Patients come from the extremes ofage, they may have complex causal pathologyand, as they age, the patients develop multisystemco-morbidity. The breadth of surgical inter -vention is great, ranging from procedures such asarthroscopy causing minimal physiologicaldisturbance, to procedures that test, and oftensurpass, the physiological reserve of an individualpatient. As such, the conduct of an individualanaesthetic is customized to the medical demandsof the patient, the requirements for the surgicaltechnique and the limitations of the institution inwhich the surgery occurs.

PREOPERATIVE ASSESSMENT ANDGUIDELINES

This is the process of assessing the relevance,severity and treatment of the patient’s medicalpathologies. This allows referral for bettertreatment (‘optimization’) and quantification ofthe risk of adverse perioperative events, includingdeath, to be discussed and documented. Factorsspecific to anaesthesia, such as a possible difficultairway, may also be considered. Central guidelinesexist to inform the ordering of preoperativelaboratory tests.

FASTING

In elective surgery, standard local fasting timesmust be adhered to. A typical regimen is given inTable 1.1. Food includes milk and fresh fruitjuices.

Table 1.1 Fasting times

Typical foodsSolidfood

Water Breastmilk

Formulamilk

Fastingtime

6 hours 2 hours 4 hours 6 hours

In trauma it is assumed that gastric emptyingstops at the time of injury. Fasting time iscalculated as time of intake to time of trauma. Thesituation is further complicated by opiateanalgesics that prolong gastric emptying andrender fasting times difficult to interpret. In thesecircumstances the need to proceed with surgicalintervention may override fasting policy andsurgery proceeds.

AIRWAY

A range of bedside tests exist that aim to predictdifficulties in maintaining an airway or intubatingan anaesthetized patient. Individual tests performpoorly and are not relevant here. Of particularrelevance in orthopaedic surgery are thechallenges that a rigid cervical column or an

unstable cervical column may cause. Thechallenge of rigidity may be a difficult airway anda difficult laryngoscopy. The challenge of anunstable column is to prevent cord injury. Bothare initially assessed with plain radiography.Specialized investigations to delineate pathologyinclude computed tomography (CT) andmagnetic resonance imaging (MRI).

CARDIOVASCULAR ASSESSMENT

This is aimed at quantifying the ability of thecardiovascular pump to increase work to matchperioperative metabolic demands. It is anassessment of reserve and of the risk of adverseevents such as an acute coronary syndrome. Keyclinical markers are described below.

Exercise tolerance

For patients having major, non-cardiac surgery,inability to climb two flights of stairs confersincreased risk of major postoperativecomplications but is not predictive of mortality.

Previous myocardial infarction

There is a risk of recurrent perioperativemyocardial infarction (MI), which has a 60 percent mortality rate. The longer surgery can bepostponed after an MI, the lower the rate ofrecurrent MI (Table 1.2).

are especially useful for patients who are unableto perform exercise ECG due tomusculoskeletal disease or severecardiopulmonary disease. Perfusion defects ofthe myocardium under physiological stressindicate coronary insufficiency.

• Cardiopulmonary exercise testing – this is adynamic test that predicts the patient’sanaerobic threshold. As such it tests respiratoryand cardiac reserve. It reflects other factors suchas motivation, mobility and nutrition. It can beused to predict the risk of surgery and obviatethe need for other tests such as angiography orechocardiography.

• Coronary angiography – this is used to visualizecoronary arterial flow and disease. This is oftenthe end point of coronary investigation and mayallow treatment by stenting and angioplasty atthe same time.

Hypertension

Stage 3 hypertension (systolic blood pressure [BP]=180 mmHg or a diastolic BP =110 mmHg)should be controlled prior to surgery. A recentmeta-analysis found that patients with mild ormoderate hypertension and no evidence of end-organ damage were at no increased perioperativerisk. End-organ damage includes left ventricularhypertrophy (ECG criteria), a history ofcerebrovascular accident (including transientischaemic attacks), renal insufficiency and retinalchanges.

Heart murmurs

The valve pathology underlying murmurs mayhave significant implications for anaesthetictechnique. Lesions that limit the cardiac output(most famously aortic stenosis) can causeprofound hypotension as the heart cannotincrease cardiac output to maintain bloodpressure as vascular resistance drops. This is mostmarked with neuroaxial anaesthesia and can causemorbidity due to organ hypoxia. For example,coronary perfusion may become critically lowresulting in an acute coronary syndrome.Echocardiography is useful to determine thenature and the severity of the valve lesion.

2 Anaesthesia in orthopaedic surgery

Table 1.2 Percentage risk of recurrent myocardialinfarction (MI) at different times post MI

Time since MI Risk of recurrent MI<3 months 5.7 per cent4–6 months 2.3 per cent>6 months 1.5 per cent

Typical investigations used to quantify cardiacreserve are listed below.• Exercise electrocardiogram (ECG) – helps to

determine any coronary flow limitation whencardiac work increases.

• Thallium scintigraphy and dobutamine stressechocardiography – these dynamic ‘stress tests’

RESPIRATORY ASSESSMENT

Preoperative assessment determines the severityand potential reversibility of respiratorypathology. Disease states limit gas flow, gasexchange or both. The end point of respiratorydisease is hypoxaemia and tissue hypoxia. This canprecipitate organ failure with serious adverseoutcomes. Common pathologies are describedbelow.

Asthma

Stable asthma is usually benign. However, someanaesthetic agents can trigger bronchospasm andare avoided. Conversely, some result inbronchodilation and are favoured. Assessmentshould include spirometry and peak flowmeasurements. Preparation may includebronchodilator premedication, e.g. salbutamol.Some anaesthetists choose a regional technique toavoid airway instrumentation and opiate use.

Chronic obstructive airways disease

Gas flow and exchange are limited. These patientsare at risk of postoperative respiratory failure dueto atelectasis and segmental lung collapse. Thiscauses hypoxaemia. Assessment should includespirometry (a forced expiratory volume in 1second greater than 1 indicates an ability to clearsecretions), oximetry (and perhaps arterial bloodgases) and an assessment of exercise ability. Abaseline chest radiograph may be useful but is byno means mandatory. An ECG may show signs ofright heart strain and is also indicated as this groupis likely to have coexistent cardiovascular disease.Preoperative and postoperative chest physio -therapy is essential. Anaesthetists will tendtowards regional anaesthesia in respiratorycripples to minimize the chances of postoperativerespiratory failure. Opiates are a potent source ofrespiratory depression and, coupled to sedationand pain, can be a powerful trigger for respiratorydecompensation.

Respiratory tract infection

This is often viral. Upper respiratory tractinfection is most common. Patients with

productive cough or objective symptoms(pyrexia, fatigue, myalgia, anorexia) should onlyproceed if it is an emergency surgery. The risk oflaryngospasm and bronchospasm is increased.Viral myocarditis may also occur, leading tocardiac failure or even death in the perioperativeperiod. Guidelines commonly suggest a 4- to 6-week delay from the start of respiratory tractinfection to elective surgery.

Groups at special risk

Cerebral palsy patients may have poor bulbarfunction and weak cough, which puts them at riskof aspiration, and they have a higher incidence ofpostoperative respiratory tract infection. This isexacerbated by any cognitive impairment thatreduces their ability to cooperate withphysiotherapy and interventions such as non-invasive ventilation. Low tone neuromuscularsyndrome patients are at risk of postoperativerespiratory failure and plans will include intensivecare, possible postoperative ventilation andtracheostomy formation. Of note, volatileanaesthesia is usually avoided in this group due tothe risk of rhabdomyolysis, renal failure andhyperkalaemic cardiac arrest.

RECOMMENDED REFERENCES

Biccard BM. Relationship between the inability toclimb two flights of stairs and outcome aftermajor non-cardiac surgery: implications for thepre-operative assessment of functional capacity.Anaesthesia 2005;6:588–93.Howell S, Sear J, Foex P. Hypertension,hypertensive heart disease and perioperativecardiac risk. Br J Anaesth 2004;92:570–83.National Institute for Health and ClinicalExcellence. Preoperative Tests: the Use of RoutinePreoperative Tests for Elective Surgery. Available at:www.nice.org.uk/Guidance/CG3 (accessed 8April 2009).

INTRAOPERATIVE TECHNIQUES

Discussion of the selection and conduct ofindividual techniques is beyond the scope of thischapter. The technique chosen is dependent on

Intraoperative techniques 3

www.nice.org.uk/Guidance/CG3

the patient, hospital, procedure, surgeon andanaesthetist. There is little conformity of opinion.

GENERAL ANAESTHESIA

This is the most common option and is entirelyappropriate for most procedures, environmentsand patients. It is a balanced technique ofanalgesia, muscle relaxation and sedation. This isconfirmed by data review as exemplified by recentpublications concerning primary jointreplacement.

PERIPHERAL REGIONAL ANAESTHESIA

This is the placement of local anaesthetic adjacentto individual nerves or plexus of nerves toproduce a zone of sensory and motor block. Thismay be the only mode of anaesthesia. Morecommonly, it is a pain-relieving adjunct to generalanaesthesia or sedation. As such, opiate use isminimized and patients may actually mobilizeearlier. Clearly, there may be conflict withmasking neurological injury. Heavy-handedanaesthesia may produce prolonged motor blockto the detriment of the patient. Increasingly thismodality is preferred for primary arthroplasty,with clinical spill into other techniques.

NEUROAXIAL LOCAL ANAESTHESIA

For lower limb procedures, spinal, epidural orcombined spinal–epidural blocks can providecomplete analgesia and motor block. As above,they may be used alone or in conjunction withsedation or general anaesthesia. They are often thetechnique of choice in those with respiratorydisease in an effort to minimize opiate-inducedrespiratory embarrassment. Outcome evidence ispoor. However, there is some literature base tosupport this practice. They are a valuable tool toreduce opiate use and have been associated with alower incidence of deep vein thrombosis andlower perioperative blood loss. This may no longerbe valid in light of new advances in thrombo -embolic prophylaxis and other anaesthetictechniques available to modulate perioperativeblood loss. However, these techniques are animportant part of a multimodal approach to fasttrack surgery.

Contraindications

• Refusal• Local or systemic infection• Allergy to agents used• Coagulopathy• Anticoagulants (relative contraindication)

increase the risk of haematoma at the site ofinfiltration, around nerves or in the epiduralspace. Aspirin is not a contraindication

LOCAL ANAESTHESIA

Some body surface procedures are amenable tosurgery using local infiltration alone.

POSTOPERATIVE CARE

ANALGESIA

Simple analgesics

These can be very effective for mild and moderatepain. Common drugs are paracetamol and non-steroidal anti-inflammatory drugs. Best effect isgained when they are given regularly, ideally aftera loading dose in theatre. In more severe pain, theyare still useful adjuncts with well-documentedopiate-sparing properties.

Oral opiates

These include codeine derivatives, complexagonists such as tramadol and morphinederivatives. These are well recognized for moresevere pain and can be used regularly, withstronger alternatives available for breakthroughpain. Newer derivatives such as oxycodoneprovide excellent pharmacokinetics with twicedaily dosing of modified-release compoundsproviding 24-hour analgesia supplemented byshort-acting versions effective for breakthroughpain.

Systemic opiates

For severe pain, intravenous opiates may be givenas patient-controlled analgesia (PCA). This allowsthe patient to titrate their own dosing. It is

4 Anaesthesia in orthopaedic surgery

effective, safe and popular. Better pain scoresand fewer side effects (nausea, vomiting, andsedation) are regularly received using thismodality of opiate delivery compared withintermittent intra muscular dosing. Other routessuch as transdermal delivery are available. Thesetake a long time to reach a steady plasmaconcentration and are similarly slow to declinewhen discontinued. This inflexibility makes themdifficult to use in the perioperative period. Theyare more suited to long-term use in chronic painsyndromes.

Local anaesthesia

Local anaesthetic techniques may be continuedinto the postoperative period. These provideexcellent analgesia with minimum side effects.However, immobility may be a problem. Well-conducted blocks in units used to managing thesepatients are very successful and do not need todelay mobilization.

OXYGEN

Oxygen therapy should be given to patients withan epidural infusion, or PCA, which containsopiates. This supplemental oxygen maintainsalveolar oxygen tension longer if respiratorydepression and hypoventilation occurs. Supple -mental oxygen used for the first 3 days post -operatively can also minimize the risk ofperioperative ischaemic events. Clearly, patientswith respiratory pathology (respiratory tractinfection, atelectasis, thromboembolism) will berelatively hypoxic and oxygen therapy is anessential.

FLUID MANAGEMENT

The goal of intravenous fluid therapy is tomaintain normovolaemia. This allows adequatecardiac output and, assuming a reasonablehaemoglobin concentration, tissue oxygendelivery. Maintenance water and electrolytes needto be supplied and ongoing blood losscompensated for in the form of blood substitute,or blood itself. Triggers for transfusion vary. Bloodis expensive, immunosuppressant, associated withworse outcome and a vehicle for disease

transmission. However, red cells are vital tooxygen delivery and haemostasis. The trigger willdepend on the predicted continuing blood loss,the patient’s co-morbidities and symptoms.Typically a haemoglobin concentration of 8 g/dL istaken as acceptable.

DISPOSAL

High-dependency care may benefit manyorthopaedic patients. Delivery of this will dependon local protocol and infrastructure. Clearly, thoseat increased risk of organ failure or requiring ahigher level of nursing supervision should beplaced in an appropriate environment.


Fischer HBJ, Simanski CJP. A procedure specificand systematic review and consensusrecommendations for analgesia after total hipreplacement. Anaesthesia 2005;60:1189–202.Fischer HBJ, Simanski CJP, Sharp C, et al. Aprocedure specific systematic review andconsensus recommendations for postoperativeanalgesia following total knee arthroplasty.Anaesthesia 2008;63:1105–23.Fowler SJ, Symons J, Sabato S, et al. Epiduralanalgesia compared with peripheral nerveblockade after major knee surgery: a systematicreview and meta analysis of randomized trials. BrJ Anaesth 2008;100:154–64.

Viva questions 5

Viva questions

1. In patients with hypertension, how would youdetermine whether elective surgery canproceed?

2. What are the contraindications to neuraxialblockade?

3. Why is a respiratory tract infection aproblem?

4. Who should receive oxygen therapy in thepostoperative period?

5. When could an echocardiograph be thepreoperative investigation of choice?

Tumours2

William Aston and Timothy Briggs

Needle biopsy of bone 6Open biopsy of bone 8Excision of bursa 9Excision of benign bone tumour 9

Bone cyst curettage ± bone graft 10Malignant tumour principles 11Viva questions 13

NEEDLE BIOPSY OF BONE

PREOPERATIVE PLANNING

Indications

To obtain a histological diagnosis so that furthertreatment can be planned.

Contraindications

Lesions that are closely related to neurovascularstructures, where a needle biopsy would put thesestructures at risk.

Templating

The needle entry point and tract needs carefulthought and should be planned by the surgeonperforming the tumour resection, as the biopsy

Consent and risks

• Neurovascular injury and infection are the mainrisks

• Possible tumour seeding

Patients should also be warned that a secondneedle biopsy or open biopsy may be necessary ifinadequate tissue for histological diagnosis isobtained.

tract will need to be excised if malignancy isfound.

The type of biopsy needle should also beconsidered. A fine-bore needle, through which anaspiration can be taken, is usually unsuitable tomake a diagnosis in bony lesions, unless pus isaspirated from a sequestrum. A thicker-boreneedle (11G or 13G), capable of boring throughthe outside of the lesion and taking core biopsiessuch as a Jamshidi needle (Fig. 2.1), is preferable.

Figure 2.1 Jamshidi needle

For tumours that have a large soft tissuecomponent or that have destroyed the cortex, aTrucut or Temmo (preloaded) needle can be used.These take a slice of tissue and come in 11 and 14gauges.

Anaesthesia and positioning

Needle biopsy can be done under local, local withsedation or general anaesthesia. For children, hardlesions and lesions which may be difficult toaccess, a general anaesthetic should be used.

Positioning is dependent on the area to bereached and if necessary the imaging modalitybeing used.

SURGICAL TECHNIQUE

Landmarks and incision

The line of the biopsy should be sited in the lineof a possible future surgical incision, so that it canbe excised at the time of surgery (Fig. 2.2). It must

pass directly to the site of the tumour and throughonly the myofascial compartment in which thetumour is located, preferably through muscle andaway from the neurovascular structures at risk. Itshould aim to take a representative sample of thetumour, which can be identified on pre-biopsyimaging. The needle is passed after a simple stabincision in the skin, with a no. 15 blade.

Deep dissection

The needle is passed through the stab incision anddirectly to the area being biopsied, underradiological control if necessary.

Technical aspects of procedure

Multiple core biopsies are needed, aiming tominimize diversion from the tract. If unsurewhether representative tissue has been taken, afrozen section should be undertaken. In caseswhere preoperative imaging is atypical or whereinfection is suspected, samples should also be sentfor microbiology.

The needle should not be passed through thelesion into normal tissue. For lesions close tojoints, the needle must not pass through thecapsule and therefore potentially contaminate thejoint. It may be necessary to drill the bone prior toneedle insertion in sclerotic lesions. Carefulhandling of the specimens is important so as notto destroy the microarchitecture. Discussion withthe histopathologist will elucidate whether theywish to receive the specimen fresh or fixed informalin.

Closure

Use Steri-Strips.

POSTOPERATIVE INSTRUCTIONS

• Neurovascular and routine observations.• Local pressure in the case of vascular lesions.


Saifuddin A, Mitchell R, Burnett S, et al.Ultrasound guided needle biopsy of primary bonetumours. J Bone Joint Surg Br 2000;82:50–4.

Needle biopsy of bone 7

BiopsyDeltopectoralapproach

Figure 2.2 Position of biopsy for proximal humeraltumour – in the line of the deltopectoral approach, butslightly lateral so that the needle passes through thedeltoid muscle and avoids the cephalic vein

Stoker DJ, Cobb JP, Pringle JAS. Needle biopsy ofmusculoskeletal lesions. A review of 208procedures. J Bone Joint Surg Br 1991; 37:498–500.

OPEN BIOPSY OF BONE


Indications

• Patients who are not suitable for a needlebiopsy

• Patients in whom tissue from a needle biopsywas insufficient to make the diagnosis

Open biopsy can be incisional where a sample ofthe lesion is taken or it can be excisional wherethe whole lesion is removed. Excisional biopsy isgenerally reserved for lesions which, on radiology,have diagnostic features of a benign lesion.

Contraindications

Lesions where a satisfactory needle biopsy can beperformed.

Templating

The incision should be planned with the surgeonand be made in the line of the surgical approachthat will be used to remove the tumour.

Thought should be given as to how to localizethe tumour, e.g. with image intensifierintraoperatively if necessary.


Regional/general anaesthesia and patientpositioned to enable good access.

Consent and risks

• Neurovascular injury• Infection• Seeding of the tumour

8 Tumours

SURGICAL TECHNIQUE


The incision should be in the line of a possiblefuture operative approach so that the biopsy tractcan be resected with the specimen.

Dissection

Dependent on the location.


It is important to minimize potentialcomplications of biopsy such as infection andhaematoma as a poorly performed biopsy carriessignificant morbidity. The tourniquet should bedeflated before closure and, if a drain is used, theexit point should be in the line of any furtherincision.

Only one compartment of the limb should beviolated during the approach. Muscles should besplit and meticulous haemostasis applied tominimize haematoma formation and spread offluid through tissue planes. The area to bebiopsied should be carefully exposed, taking carenot to disrupt the capsule or expose more of thetumour than is necessary. If a capsule is openedthen it should be closed carefully.

A representative sample of tissue should betaken to include the transition from normal toabnormal tissue if possible. If there is any doubtthen frozen section should be undertaken toensure a diagnostic specimen.

Closure

Routine.


Neurovascular observations.


Ashford RU, McCarthy SW, Scolyer RA, et al.Surgical biopsy with intra-operative frozensection. An accurate and cost-effective method for

diagnosis of musculoskeletal sarcomas. J Bone JointSurg Br 2006;88:1207–11.Mankin HJ, Lange TA, Sapnnier SS. The hazardsof biopsy in patients with malignant primary boneand soft tissue tumours, J Bone Joint Surg Am1982;64:1121.Pollock RC, Stalley PD. Biopsy of musculoskeletaltumours – beware. A NZ J Surg 2004;74:516–19.

EXCISION OF BURSA


Indications

Chronically infected or thickened bursae.

Templating

Plan and approach depends on site.


• Regional or general as appropriate• Positioning as appropriate.

SURGICAL TECHNIQUE


Depend on location.

Superficial dissection

Through skin and tissue planes taking care not todisrupt the bursa if chronically infected.

Deep dissection

Removal of entire bursa carefully protectingsurrounding soft tissues.

Consent and risks

Risks are dependent on the location of the bursa.General risks, such as infection, apply as well asstiffness of the surrounding soft tissues due toremoval and postoperative scarring.


Depend on the location.

Closure

Routine.


Routine and neurovascular observations.

EXCISION OF BENIGN BONE TUMOUR


Common indications

• Impending fracture, e.g. aneurysmal bonecyst

• To prevent further bony destruction and/orfunctional loss in aggressive lesions – e.g. giantcell tumour

• Mechanical symptoms – osteochondroma• Pain – osteoid osteoma• Risk of malignant transformation.

Contraindications

No definitive characterization of the lesion oneither imaging or pathology.

Templating

The approach depends on access required toperform resection and reconstruction if necessary.


Usually general anaesthesia and routinepositioning.

Consent and risks

Depend on anatomical location and pathology ofthe lesion.

Exision of benign bone tumour 9

SURGICAL TECHNIQUE


As per preoperative plan.

Dissection

The exposure is dependent on the anatomicallocation and whether the plan is to performcurettage of the lesion (intralesional excision) orto excise it (marginal excision) and reconstruct it.It is usually unwise to attempt tumour excisionand reconstruction through ‘minimally invasive’approaches.


Again, these depend on procedure and location. Ifen bloc resection is planned then reconstructionoptions need to be available, including anyautograft or allograft necessary, in conjunctionwith any hardware for fixation. If curettage isplanned, graft or adjuvant treatments, such ascement, liquid nitrogen or phenol, may berequired to fill/treat the resulting cavity.

Necessary imaging modalities need to beavailable, such as computed tomography forlocalization of an osteoid osteoma or imageintensifier to localize a larger lesion.

Closure

Routine – procedure dependent.

POSTOPERATIVE CARE ANDINSTRUCTIONS

• Routine• Weightbearing and physiotherapy regimen –

depend on procedure.

RECOMMENDED REFERENCE

Malawer MM, Dunham W. Cryosurgery andacrylic cementation as surgical adjuncts in thetreatment of aggressive (benign) bone tumours.Clin Orthop Relat Res 1991;262:42.

10 Tumours

BONE CYST CURETTAGE ± BONE GRAFT


Indications

• Risk of fracture or repeated fracture• Failure of other methods of treatment, such as

a steroid injection into the cyst.

Contraindications

If radiology is not classical of a bone cyst, thenhistopathological diagnosis should be sought.

Operative planning

Planning of the approach to allow good access tothe whole cyst while not threatening the physis ornearby neurovascular structures.


General anaesthesia; positioning depends on theaccess required.

SURGICAL TECHNIQUE


Utilization of a recognized surgical approach inmost cases.

Dissection

Dissection to bone, following describedapproaches and avoiding neurovascular structures,exposing the periosteum over the length of thecyst. The image intensifier is often necessary tolocate the lesion or to confirm the position andextent of the cavity.

Consent and risks

• General risks and that of recurrence• Depend on the location


Once the cyst has been located, a 2.5 mm drill bitis used to drill (at 5–10mm intervals) the outlineof a cortical window through which curettage isgoing to take place. By drilling it confirms thepresence of the cyst and avoids stress risers in thebone or the propagation of a fracture. The holesare joined up with a small osteotome or saw blade(Fig. 2.3).

Once the cyst is entered, thorough curettage cantake place, attempting to remove tissue from allbone surfaces. A communication is made from thecyst to the medulla of the bone to allow the cyst tofill with blood (which reduces recurrence rate).Screening with an image intensifier (Fig. 2.4)confirms that the whole cavity has been treated.

If the cyst is close to the growth plate, thecortical window is made distant to the physis;curettage of the growth plate is avoided as thismay lead to a growth disturbance. The cyst can begrafted with a cancellous or corticocancellousautograft from the ileum, tibia or fibula. Anallograft may also be used to fill the defect.

The cortical window, if large enough, may bereplaced and held with a screw or periostealsutures.

Closure

Routine.


Restoration of the range of motion ofneighbouring joints is undertaken as soon aspossible. Weightbearing status is dependent on theanatomical location and the size of the defect.


Aboulafia AJ, Temple HT, Scully SP. Surgicaltreatment of benign bone tumors. Instr CourseLect 2002;51:441–50.

MALIGNANT TUMOUR PRINCIPLES


Common indications

• Excision of an isolated primary tumour• Excision of a primary tumour with metastatic

disease depending on life expectancy• Excision of isolated metastases• Excision of a fungating tumour for local control• Excision of tumour recurrence.

Contraindications

• Poor life expectancy• Co-morbidities• Malignancies treatable by chemotherapy alone

such as lymphoma.

Malignant tumour principles 11

2.5mm drillholes5–10mmapart

Extent ofcyst

(a)

Holes joinedwithosteotometo create awindow

(b)

Figure 2.3a,b Technique for making a cortical windowfor curettage of a bony lesion

Figure 2.4 Screening the extent of the cavity to becuretted

Operative planning

The tumour, the surrounding compartments andthe whole bone must be satisfactorily imaged toallow adequate planning of the procedure andreconstructive method. This will usually involveplain films, computed tomography and magneticresonance imaging.

Planning of the surgical approach needs toenable sufficient access to remove the tumour andany structures to be sacrificed to ensure tumourclearance with wide margins, which meansremoval of a layer of the normal tissuesurrounding the whole tumour (Fig. 2.5).

Consent and risks

Depend on the anatomical location and magnitudeof the procedure.

Structures at risk and the method ofreconstruction have to be considered. Surgicalapproaches that are not routinely used may haveto be employed and plastic surgical techniquesmay be necessary to provide soft tissue coverageafter resection. In cases of highly vascular tumoursor particularly renal and thyroid metastases,preoperative embolization should be consideredto reduce the intraoperative blood loss.


General or regional anaesthesia as appropriate andpositioning to allow sufficient access.

SURGICAL TECHNIQUE


Depend on anatomical location of the tumour.

Dissection

Dissection must enable removal of the tumour enbloc with a layer of normal tissues surrounding itto provide a wide margin. In some casesneurovascular structures may be preserved andtherefore a marginal excision around thesestructures is performed. Postoperatively, anopinion regarding adjuvant therapy is obtained.However, if cure is sought, and the neurovascularstructures are involved then they must besacrificed. This may mean an amputation orreconstruction of the vessels.


Margins and structures to be sacrificed can usuallybe anticipated from good-quality imaging.However, during the procedure the surgeon needsto decide, based on experience and the feel of thetissues, what has to be sacrificed, in conjunctionwith the imaging.

The parts of the procedure that have the easiestanatomical access are undertaken first. Samplesfrom remaining surrounding tissues are sent forhistology if the resection margin is questionable.Intraoperative frozen section can be used toensure an adequate resection margin if there isany doubt.

12 Tumours

Radicalexcision

Wideexcision

Marginalexcision

Intralesionalexcision

Figure 2.5 Intralesional, marginal, wide and radicalmargins for the excision of bone and soft tissuetumours. (Note the diagram shows a soft tissue lesion)

The wound should be thoroughly washed withwater (as water is highly hypotonic, it may aid inlysis of any spilled tumour cells) after removal ofthe tumour. If any spillage of the tumour orinvasion of the capsule of the tumour has takenplace intraoperatively then after washing, newinstruments, gloves and gowns should be used forreconstruction and/or closure.

If it is found postoperatively on histologicalexamination that an inadequate margin has beentaken then a repeat wide local excision should beconsidered.

Closure

• Routine closure• Drains to be placed in line of incision to

facilitate tract excision if re-excision isnecessary.


• Routine

• Weightbearing and physiotherapy – depend onprocedure.


Enneking WF, Maale GE. The effect ofinadvertent tumour contamination of woundsduring the surgical resection of musculoskeletalneoplasms. Cancer 1988;62:1251.

RECOMMENDED REFERENCES (FORWHOLE CHAPTER)

General information relating to all of the abovetopics can be found in:Enneking WF. Musculoskeletal Tumour Surgery.New York: Churchill Livingstone, 1983.Malawer MM, Sugarbaker PH. MusculoskeletalCancer Surgery Treatment of Sarcomas and AlliedDiseases. Dordrecht: Kluwer AcademicPublishers, 2001.Sim FH, Frassica FJ, Frassica DA. Soft tissuetumours: diagnosis, evaluation and management.J Am Acad Orthop Surg 1994;2:202–11.

Viva questions 13

Viva questions

1. What do you know about the biopsy of atumour?

2. How would you perform a biopsy of a bonylesion?

3. How would you perform a biopsy of a softtissue lesion?

4. How would you choose between a needlebiopsy and an open biopsy?

5. What must be avoided during biopsy?

6. How would you excise a bursa?

7. How would you make a cortical window inbone?

8. How would you treat a benign bone cyst?

9. What are the indications for excision of abenign bone tumour?

10. What considerations have to be taken intoaccount when excising a benign bone tumour?

11. What are the indications for excision of amalignant bone tumour?

12. How would you plan the excision of amalignant bone tumour?

13. What are the principles involved in the excisionof a malignant bone tumour?

14. What is the difference between an open biopsyand an excision biopsy?

15. What does a marginal resection mean?

16. What is the difference between a wide and aradical resection?

17. How would you ensure that you have anadequate biopsy?

18. What do you understand by the term limbsalvage?

19. Why might it not be possible to salvage a limb?

20. Where and by whom should a biopsy be carriedout?

Surgery of the cervical spine3

Raman Kalyan and David J Harrison

Anterior approach to cervical spine (C3–T1) 14Posterior approach to cervical spine (C2–C7) 18Posterior approach to upper cervical spine (C1–C2) 20

Halo vest fixation of the cervical spine 21Viva questions 25

ANTERIOR APPROACH TO THECERVICAL SPINE (C3–T1)


Indications

• Anterior decompression for spinal canal orforaminal stenosis:– Presenting symptoms – myelopathy,

radiculopathy, neurological deficit

Position of arthrodesis

• Maintain the sagittal contour (lordosis) and avoidlocal kyphosis

• During anterior inter-body fusion surgery, the graftor artificial cage selected is wedge shaped withgreater anterior vertebral height

• The rods are contoured into lordotic shape duringposterior fusion/stabilization procedures

– Herniated disc from degenerative or trau -matic causes

– Osteophytes– Bony element (traumatic causes)– Subluxation of the vertebra due to degenera -

tive process– Tumour– Infection– Congenitally narrow canal– Ossification of posterior longitudinal liga -

ment• Anterior intervertebral fusion:

– Degenerative pathology– After anterior decompression for above

indications• Anterior stabilization

– Trauma– Degenerative subluxation– After decompression/fusion

• Cervical disc replacement– Degenerative disc disorders

• Biopsy/excision/drainage of collection– Tumour– Infection.

Halo vest fixation

Cervical spine Clinical range ofmotion

Radiological upperspine (C1–C2) rangeof motion

Radiological lowerspine (C3–C7) rangeof motion

Flexion 45° 15° 40°Extension 55° 15° 25°

Lateral bending 40° 0° 50°

Axial rotation 70° 40° 45°

Risks for fusion/stabilization

• Bone graft donor site morbidity• Non-union/pseudarthrosis: 4–20 per cent in

single level fusion, 25–50 per cent in multilevelfusion

• Implant pull out/failure• Anterior graft migration

Consent and risks

• Dysphagia: 50 per cent in short term; 10 percent long term (more common in multilevelsurgery, longer retraction time, older patients).This complication can be reduce by keepingretraction time to a minimum, using smoothcontour retractors, lower profile plate, goodtissue handling and haemostasis.

• Recurrent laryngeal nerve injury: 0.2 per cent; itproduces paralysis of one side of the vocal cord,and leads to hoarseness of the voice, airwayproblems and aspiration. More common in theright-sided approach. The reason for itsvulnerability on the right side is because of itscourse, as it crosses from lateral towards thetrachea in the midline, in the lower part of theneck. Some consider it to occur due to the dualcompression of the nerve from the self-retainingdeep retractor on the lateral aspect and mediallyby the cuff of the endotracheal tube within thetrachea. This can be avoided by relaxing theretractor often and deflating and reinflating thecuff after application of the retractor

• Other neurological injuries: superior laryngealnerve, hypoglossal nerve, sympathetic nerve andstellate ganglion

• Spinal cord injury• Vascular injury: inferior thyroid artery, common

carotid artery, vertebral artery, internal jugularvein

• Haematoma• Visceral injury: oesophagus, trachea• Infection: 0.5 per cent• Cerebrospinal fluid (CSF) leak and fistula: 0.1 per

cent• Death: 0.1 per cent

Operative planning

An image intensifier should be available from thestart of the procedure. If an operative microscopeis to be used it should be pre-booked. Some preferto use magnification loupes, along with headlightsfor improved illumination of the operative field.

All radiological investigations should beavailable. Check/pre-order the specific implantsand instrumentation.

If iliac bone crest graft is required, then the sideand draping need to be pre-planned; a tri-corticalgraft is best. In high-risk cases, the spinal cordintegrity is monitored intraoperatively usingevoked potentials (somatosensory or motor) andthis needs to be organized.

ANAESTHESIA AND POSITIONING

The operation is performed under generalanaesthesia. The head end of the patient ispositioned opposite to the anaesthetist; therefore,long tubing is needed which requires to be safelyplaced and well secured. The outer end of theendotracheal tube is positioned and fixed awayfrom the side of the incision. Prophylacticantibiotics are given as per protocol.

Place the patient in a supine position on theoperating table with or without Mayfield skullclamp attachment. Head ring and adhesive tapeare used to position the head securely if theMayfield clamp is not used. The Mayfield skullclamp attachment provides a three-point rigidcranial fixation and allows greater flexibility inpositioning of the cervical spine and bettervisualization during imaging. It is particularlyuseful in surgery for cervical spine fracture. Itenables better control of cervical spine positionand allows change in position and manipulationduring surgical procedure.

A rolled up pad or saline bag or sandbag isplaced between the scapulae to enable slightextension of the cervical spine as desired. Thehead is minimally rotated to the opposite side ofthe planned approach to enable better access. Thehead end of the table is tilted up to minimizevenous bleeding. The foot end of the bed mayneed levelling to prevent migration of the patientdown the bed. To enable adequate visualization ofthe lower cervical spine an image intensifier is

Anterior approach to the cervical spine 15

used and for improved access, broad strips (10 or15 cm [4 or 6 inches]) of adhesive are used to pullthe shoulders down and anchor them to theoperation table.

The accessibility of the image intensifier andthe ability to visualize the required field must bechecked. The positioning of the image intensifierand the microscope during the procedure needs tobe planned.

SURGICAL TECHNIQUE

Choosing the side for the approach

For the upper and middle cervical spine, the right-or left-sided approach can be used. Right-sidedapproach is usually preferred by the right handdominant surgeon and vice versa. The site of thepathology (for example in tumour) can some -times influence the choice.

For the lower cervical spine (C6 and below),some prefer the left-sided approach, because ofthe increased risk of injury to the recurrentlaryngeal nerve injury with the right-sidedapproach.

If previous surgery has been carried out on oneside of the neck, then the opposite side will be thepreferred choice of approach.

Choosing the incision

Depending on the number of vertebral levels tobe exposed, the incision can be transverse, obliqueor longitudinal. For fewer vertebral levelstransverse or oblique incisions are used and forbroader exposure longitudinal incision ispreferred.

The cosmetic appearance is better withtransverse and mild oblique incision along theneck’s skin creases/cleavage lines.

Landmarks

Few palpable structures in the anterior aspect ofthe neck, give an approximate estimation ofthe vertebral level and incision (Fig. 3.1). It iscommon practice to use an image intensifier toidentify the level of the incision and the incisionsite is marked.

16 Surgery of the cervical spine

The following guidelines can be applied for thetransverse incision for the approaches to thefollowing vertebral levels:• C3 and C4 level – level of the hyoid bone or

two finger breaths below the mandible• C4 and C5 level – level of the thyroid cartilage• C5 and C6 level – level of the cricoid cartilage• C6 and below – two finger breaths above the

clavicle.

The anterior border of the sternocleidomastoidmuscle and the midline are identified and marked.

Incision

The skin incision extends from the posteriorborder of the sternocleidomastoid muscle to themidline, extending further if necessary.


Structures at risk

• Longitudinal and traversing veins in deep cervicalfascia

Lower borderof mandible

Hyoid bone

Thyroid cartilageCricoid ring

Sternocleidomastoid

C1/2C3/4C4/5

C5/6C6/7

C7/T1

Figure 3.1 Anatomical landmarks and levels in theanterior approach to the cervical spine

The platysma muscle is cut in the same directionas the skin incision or split longitudinally along itsfibres. The platysma is supplied by the cervicalbranch of the facial nerve and it receives itsbranches in the mandibular region, superior to theincision site. However, dividing the platysma doesnot cause any significant morbidity.

The anterior border of the sternocleidomastoidis identified and the deep cervical fascia is incisedmedially. The longitudinal and traversing veinmay need retraction or ligation. The sternocleido -mastoid muscle is gently retracted laterally andthe strap muscles and thyroid gland are retractedmedially. The superior belly of the omohyoid

• Inferior thyroid artery• Carotid sheath (enveloping the common carotid

artery, internal jugular vein and vagus nerve)• Trachea and the oesophagus• Recurrent laryngeal nerve and superior laryngeal

nerve

muscle can be divided if it traverses the operatingfield or if an extensive approach is required.

This dissection exposes the carotid sheath andthe pretracheal fascia (Fig. 3.2). The carotid pulseis palpated and the pretracheal fascia incisedmedial to the carotid sheath using blunt dissection(peanut surgical swab). The carotid sheathenveloping the common carotid artery, internaljugular vein and vagus nerve are retractedlaterally and the trachea and the oesophagus areretracted medially. The prevertebral fascia and thelongus colli muscle are visualized.

Deep dissection

Structures at risk

• Vertebral artery• Sympathetic nerve and stellate ganglion• Spinal cord injury

Anterior approach to the cervical spine 17

Platysma

Deep cervical

fascia

Pretracheal fascia Trachea

Carotid

sheath Sternocleidomastoid

muscle

Thyroid gland

Figure 3.2 Superficial dissection

The prevertebral fascia is incised with bluntdissection to expose the anterior surface of thecervical spine with the two longus colli muscles.The right and left longus colli muscles are strippedsubperiosteally from the anterior vertebral bodies,using cautery and maintaining good haemostasis(Fig. 3.3). The smooth-ended retractor blades areplaced underneath the two longus colli muscles toimprove the exposure; this helps to protect theoesophagus, recurrent laryngeal nerve, trachea andcarotid sheath from injury by the retractors.

The appropriate level is identified using a bentneedle as a marker (bent at about 1 cm to act as astop) seen on a lateral radiograph using an imageintensifier. After the level is identified, the furtherprocedure of decompression, fusion or stabiliza -tion is carried out.

Closure

After removal of the retractors, special attention ispaid to haemostasis of all the layers, as a retractorcould have acted as a temporary tamponade. Also,check for any injury to the visceral structures.

A deep drain is placed with care and kept for 24hours. The platysma is approximated well byinterrupted suture. The subcutaneous layer isclosed by 2–0 Vicryl. Skin is closed bysubcuticular stitches or skin clips. Check forbleeding at the Mayfield clamp pin site and applyOpsite spray or dressing as required.



Prescription of neck collars varies according to thepathology, type of surgery/stabilization andsurgeon’s choice.

POSTERIOR APPROACH TO THECERVICAL SPINE (C2–C7)


Indications

• Posterior stabilization/fusion:– Trauma, degenerative subluxation, after

decompression/fusion• Posterior decompression of the spinal canal or

foraminae stenosis:– (Presenting symptoms – myelopathy,

radiculopathy, neurological deficits)– Degenerative pathology – facet joint arthritis,

osteophytes, ligamentum hypertrophy,instability

– Trauma (instability, bony and disc encroach -ment)

– Others – congenital stenosis, ossification ofposterior longitudinal ligament, tumour, etc.

– (Posterior decompression is preferred toanterior decompression in multilevel (>2levels) degenerative stenosis if suitable)

• Biopsy/excision/drainage of collection:– Tumour– Infection.

Consent and risks

• Haemorrhage: usually caused by straying awayfrom subperiosteal plane and enteringintermuscular plane. Extension of the exposurelateral to facet risks bleeding from the segmentalvessels and venous plexus. Cervical canal alsohas a rich epidural venous plexus which canbleed profusely

• Dural tear• Cord or nerve root damage: (rare). It is important

to use bipolar cauterization while controllingbleeding near the cord and nerve roots. Cord

Longus colli

Intervertebraldisc

Vertebral artery

Longus capitis

Larynx

Prevertebralfascia

Carotid sheath

Figure 3.3 Deep dissection

Operative planning

An image intensifier should be available at thestart of the procedure, for example to check forspine alignment during positioning in patientswho have instability of the cervical spine. Theimage intensifier is also used perioperatively toidentify level, check spinal alignment, and checkimplant, screw and graft position. For otherconsiderations at this stage, see ‘Anterior approachto the cervical spine’ (p. 14).


The operation is performed under generalanaesthesia. The patient is placed in the proneposition on the operating table. The head end ofthe patient is positioned at the opposite side tothe anaesthetist. The long anaesthetic tubing issecured safely.

The head is positioned in a special head ring or brace, or held by a Mayfield skull clampattachment, which provides three-point rigidcranial fixation, allows greater flexibility inpositioning and better visualization duringimaging. The eyes should be protectedappropriately during prone positioning. Duringexposure the neck is positioned in slight flexion, to allow easier dissection and avoid skincreasing.

The spinal stability needs to be taken intoaccount and the spinal alignment to be checkedwith imaging if necessary. As with the anteriorapproach, broad strips (10 or 15 cm [4 or 6inches]) of adhesive tape are used to pull the

handling needs to be kept minimal and caretaken not to plunge instruments into theinterlaminar space. The laminae can besurprisingly thin and fragile

• Vertebral artery injury: (rare). Vertebral artery isat risk when the exposure extends over thetransverse process and in surgery involving C1and C2. Injury bilaterally endangers the bloodsupply to the hindbrain

• General morbidity and mortality are shown to beincreased in patients of older age and those withmyelopathy

shoulders down, and the position of the imageintensifier and microscope is checked. The headend of the table is tilted upwards to minimizevenous bleeding.

SURGICAL TECHNIQUE

Landmarks

Identification of the level is important to avoidunnecessary dissection of the wrong levels. Theexternal occipital protuberance and the longerspinous processes of C2, C7 and T1 vertebrae areeasily palpable landmarks to guide the location ofthe incision. An image intensifier can also be usedto verify the level as needed.

Incision

A midline straight incision centring over theexposure required. The skin in this area is vascularand thick and adrenaline can be injected to reducebleeding.


The fascia is incised at the midline. Retractors andpalpation are used to keep dissection in themidline. The nuchal ligament is split in themidline and the spinous process is reached. Thespinous processes of C3, C4, C5 and C6 arenormally bifid.

Using Cobb elevators and diathermy, furtherdissection is carried out in the subperiosteal planereflecting the paracervical muscles off the spinousprocess and the lamina, either bilaterally orunilaterally as required. The extent of lateralextension depends on the procedure planned, e.g.need to expose the facet joint or transverseprocess.

Structures at risk

Segmental vessels and venous plexi (bleeding ismuch worse if dissection strays from the midline orinto muscle. Lateral extension of the dissectionbeyond the facet joint risks bleeding from thesegmental vessels).

Posterior approach to the cervical spine 19

Deep dissection (Fig. 3.4)

Care should be taken to avoid plunginginstruments into the interlaminar space. Ifrequired, the ligamentum flavum is detached fromthe inferior lamina using a spatula, Kerrison punchor triple zero curette. Further laminotomy,laminectomy or laminoplasty are carried out asneeded.

Closure

• Approximation of fascia with musculature andthe nuchal ligament

• Approximation of the subcutaneous tissue andthe skin. The posterior neck skin is thick and,owing to skin creases, it is better to keep theneck in slight flexion if possible to attain better

Structures at risk

• Dura• Cord and nerve root• Vertebral artery• Epidural venous plexus

approximation, typically with subcutaneoussutures.



POSTERIOR APPROACH TO THE UPPERCERVICAL SPINE (C1–C2)

The approach is very similar to that of the lowercervical spine and it is recommended that thissection is read in conjunction with the previousone.


Indications

• Posterior stabilization and fusion (C1–C2,occipitocervical):– Trauma


Spinousprocess

Trapezius

Fascia

Paracervicalmuscles

Superiorarticularprocess

Anterior tubercleVertebral bodyVertebral artery

Spinalnerve

Posteriortubercle

Lamina

Figure 3.4 Deep dissection

– Degenerative subluxation– Following decompression from other

causes• Posterior decompression:

– Spinal canal stenosis from various aetiologies,e.g. rheumatoid arthritis, trauma,degeneration, tumour.

Operative planning

This is similar to the posterior approach of C2–C7.Three-dimensional computed tomography (CT)reconstruction is needed to plan the appropriateangle for C1–C2 transarticular screw fixation.


See ‘Posterior approach to the cervical spine’ (p. 18).

SURGICAL TECHNIQUE

Landmarks

• External occipital protuberance in the posterioraspect of the skull in the midline (midpoint ofthe superior nuchal line)

• The spinous process of C2 vertebra (the longestin the upper cervical spine).

An image intensifier can also be used to verify thelevel as needed.

Consent and risks

• Similar to posterior approach of C2 to C7• Haemorrhage: the venous plexi are rich around

the C2 nerve root and posterior to C1–C2 facetand they tend to bleed profusely

• Vertebral artery injury: vulnerable at C1 level,passing through the foramen transversarium ofthe C1 it turns medially and runs in the grooveof C1 to pierce the posterior atlanto-occipitalmembrane and enter the foramen magnum

• Nerve injury: the greater occipital nerve (branchof posterior rami of C2), third occipital nerve(branch of posterior rami of C3) and suboccipitalnerve are prone to injury if you stray away fromthe subperiosteal plane, while dissecting laterally


See ‘Posterior approach to the cervical spine’(p. 18). The Cobb elevator and diathermy are usedto separate the musculature from the occiput(superior nuchal line to superior margin offoramen magnum). Subperiosteal dissection iscarried out separating the muscles from the C1and C2 spinous processes and lamina, taking careof the interlaminar spaces, venous plexus andvertebral artery.

Deep dissection

If required, the ligamentum flavum is detachedbetween C1 and C2 and the posterior atlanto-occipital membrane between occiput and C1,using a triple zero curette, spatula or Kerrisonpunch.



HALO VEST FIXATION OF THECERVICAL SPINE


Indications

• Cervical spine trauma (temporary or definitestabilization), e.g. odontoid and upper cervicalspine fracture, fracture of the occipitalcondyles

• External stabilization following surgery as aprimary stabilizer or as an adjuvant, e.g. afterosteotomy for ankylosing spondylitis

• Instability due to infection or tumour

Structures at risk

• Suboccipital venous plexus• Vertebral artery

Halo vest fixation of the cervical spine 21

• Paediatric patients – trauma, post fusion,scoliosis and other pathologies

• Halo traction (halo-gravity traction, halo-wheelchair traction, halo-pelvic traction) –trauma, scoliosis, post surgery, etc.

Contraindications

• Active infection at the pin site area or in thearea of the skin covered by the vest.

• Patients with conditions where pin purchase inthe skull bone is unlikely to provide adequatesupport for the required duration, e.g.rheumatoid arthritis

• Doubt about patient compliance, under -standing and ability to cope, e.g. dementia

• Patients experiencing recurrent, significantfalls.

Consent and risks

• Pin loosening: 36–60 per cent (The pin should be retightened regularly using 8 inch-poundstorque (2–5 inch-pounds torque for children). Itis retightened 48 hours after initial applicationand thereafter every week. If the resistance isnot met after a few full turns, then a fresh pin isapplied in a new adjacent location asappropriate. This complication can be minimizedby selecting appropriate pin insertion site on theskull, adopting perpendicular pin insertion angleand using the correct pin insertion torque

• Pin site infection: 20 per cent• Pin migration and dural puncture• Loss of reduction: More common in anterior

column insufficiency/poor reduction/poorly fitted vest mainly in obese or very thinindividuals

• Pressure sores and skin problems underlying thevest area

• Restricted ventilation and pneumonia• Restricted arm elevation• Scar• Dysphagia: 2 per cent. Can be prevented by

avoiding immobilization at extreme range ofneck extension

Operative planning

TemplatingThe patient’s head circumference and chestcircumference are measured to determine thecrown and vest size, respectively. Themanufacturer of the halo vest provides a roughguidance with regard to selection of the sizes(paediatric, small, medium and large). The haloring can be trialled to check that it provides aclearance all round the head circumference of1–2 cm. Availability of the correct size of thecrown and vest, and other equipment andmaterials, is confirmed.

Three or more people are usually needed forthe application of the vest and for log rolling thepatient, if required. The nature and type of theneck instability should be taken into account bythe surgeon. An image intensifier can be used,if needed, to assess cervical position. A crashtrolley should be available for emergencyresuscitation.


The operation is performed under localanaesthesia, enabling recognition of any changesin the neurological status during the procedureand manipulation. General anaesthesia isoccasionally required if concomitant surgicalprocedures are carried out.

A hard cervical spine collar is applied forprovisional additional support, to improvestability and prevent neurological deterioration.The patient is positioned supine, with the headclose to the edge or beyond the edge of the bed,so that the posterior portion of the ring can bepositioned appropriately. Most modern systemshave either the posterior position of the ring openor curved superiorly to enable easy positioning. Ifslight extension of the cervical spine is desired toimprove alignment, then a saline bag is placedbetween the scapulae.

The positioning of the image intensifier duringthe procedure needs to be planned. Theaccessibility of the image intensifier and the abilityto visualize the required field must be checked.


solution and is infiltrated with local anaestheticsolution.

The pins are positioned in the correspondingholes and advanced through the skin asperpendicular as possible to the skull surface. (Aperpendicular bone–pin interface enablesincreased contact area of the pin tip and so betterpurchase). The patient should gently close theeyes and relax the forehead when the anteriorpins are fixed. This avoids skin tethering andproblems with eyelid closure. Direct insertion ofpins into the skin without a prior skin incision ispreferred. A single-use torque-limiting device,which breaks off when a torque of eight inch-pounds is reached, is available in some halosystems. These are used to advance the pins ifavailable; if not a torque-limiting screwdriver isused.

The pins are tightened in diagonal fashion, byworking on the contralateral pins concurrently(see Fig. 3.6). Each pin is secured using a locknutto prevent loosening. The locknuts are tightenedgently, as over tightening can result in backing outof the pin. After the locknut comes in contactwith the ring, it is tightened further by one-eighthturn with the spanner supplied. If skin tenting isnoted around the pin, a skin release can be

Halo vest fixation of the cervical spine 23

SURGICAL TECHNIQUE

Selection of pin insertion sites

Anterior pin sitesAnterolateral aspect of the skull, about 1 cmsuperior to the supraorbital rim, above the lateraltwo-thirds of the eyebrows (Fig. 3.5). This site isoptimal (relatively safe zone) for the followingreasons: • It is lateral to the frontal sinus, supratrochlear

nerve and supraorbital nerve (structures atrisk)

• It is medial to the temporalis muscle (pinpenetration can lead to pain during masticationand speaking), temporalis fossa (thin bone) andzygomaticotemporal nerve

• There is adequate skull thickness• It is below the equator (largest circumference)

of the skull (prevent cephalad migration).

Posterior pin sites

Postero-lateral aspect of the skull at the 4 o’clockand 8 o’clock positions, roughly diagonal to thecontralateral anterior pins (Fig 3.5). These sitesare:• Below the equator of the skull, but still 1 cm

above the upper tip of the ear• Where the skull is more uniformly thick• Away from at risk neurological and muscular

structures.

Halo application

Appropriate sterile precautions are undertakenduring halo ring application using sterile pins andring. Care is taken to avoid injury to the eyeduring the procedure.

The halo ring is positioned about 1 cm abovethe superior ear tip and eyebrows, but below theequator of the skull. They are temporarilystabilized using three positioning baseplates (Fig.3.6) at the 12 o’clock, 5 o’clock and 7 o’clockpositions. The appropriate locations for the pinsites and the corresponding holes in the ring areidentified. Hair is shaved or trimmed over theposterior pin sites, if required. The skin over thechosen pin site area is prepared with antiseptic

Safe zone

Supraorbital nerveFrontal sinus

Supratrochlear nerve

Figure 3.5 Safe zones for anterior and posterior pinplacement

performed with a scalpel. Now the secured haloring can be used to control and position thecervical spine for further procedures.

Vest application

The posterior and anterior halves of the vest areseparated, but left connected to their respectivetwo upright posts. The bolts, nuts and theconnectors are loosened but dismantling ofvarious parts of the vest is best kept to aminimum, to avoid confusion and save time. Afterthe neck is stabilized to the trunk manually, thetrunk is lifted or log rolled for the placement ofthe posterior vest and the two upright posts.

The anterior vest is applied next. Both halves ofthe vest are connected and tightened to a levelthat will allow two fingers to slide between thevest and chest. The patient should be able tobreathe comfortably. Both the shoulder straps arealso fixed and tightened. The two right posts areconnected loosely to the right connector andsimilarly the left two posts are connected to theleft connector. Both the connectors are thenslackly fixed to the halo ring. The head and neckare positioned and all the bolts and nuts aretightened after placing the posts and connectors inthe appropriate position. Attach the spanner tothe front of the anterior vest for quicker access, todeal with any emergency that requires vestremoval.

An image intensifier may be used to check thecervical spine position and to enable correctionunder image guidance. All of the fixations areretightened when a satisfactory position isachieved.

Halo application in children

Multiple pins and low torque techniques are used.For older children, the torque used for pinapplication is 2–5 inch-pounds. Six pins or morecan be used. For children under 3 years, 10–12pins can be used. A CT scan of the skull helpsto plan pin placements, by avoiding thin boneand suture lines. The pins are hand tightenedonly. Custom-made halo vest components maybe required or a plaster jacket can be appliedinstead.


If an image intensifier was not used, a radiographis used to check the alignment.

Forty-eight hours after application the lockingnuts are unlocked and all of the pins retightenedto 8 inch-pounds. The locking nuts areretightened. The pins and other fixations must berechecked regularly – at least every 2 weeksthereafter. Regular care is required for the pinsites and the skin under the vest. Regularly checkimaging as appropriate, as loss of reduction iscommon. One spanner should always be attachedto the anterior vest and the rest of the applicationtools and spares to be kept by the patient.


Bauer R, Kerschbaumer F, Poisel S. Atlas of SpinalOperations. New York: Thieme MedicalPublishers, 1993.Clark CR. The Cervical Spine, 3rd edn.Philadelphia: Lippincott Raven Publishers, 1998.Nordin M, Frankel VH. Basic Biomechanics of theMusculoskeletal System, 3rd edn. Philadelphia:Lippincott Williams & Wilkins, 2001.


Figure 3.6 Pin sites and temporary positioningbaseplates

Viva questions 25

Viva questions

1. How do you position a patient for anteriorcervical spine surgery?

2. Describe the steps of the anterior cervicalapproach and the reasons behind them.

3. What are the structures at risk in anteriorcervical surgery and how are they avoided?

4. Describe the radiological signs indicatingcervical spine instability.

5. Describe how you will position a patient forthe posterior approach to the cervical spine.

6. What are the structures at risk during aposterior approach to the lower cervical spineand how can they be avoided?

7. What are the structures at risk during aposterior approach to the upper cervical spineand how are they avoided?

8. How do you apply a halo to stabilize thecervical spine?

9. What complications occur in halo stabilizationof the cervical spine?

10. How is a halo vest looked after followingapplication?

Consent and risks

• Mortality: <1 per cent• Respiratory infection (common)

Surgery of the thoracolumbar spine4

Matthew Shaw and Sean Molloy

Thoracic anterior decompression/fixation/fusion 26Thoracic posterior decompression/fixation/fusion 28Scoliosis surgery 30Caudal epidural 36Lumbar decompression/fixation/fusion 37

Lumbar disc surgery 40Facet injection 42Nerve root block 43Viva questions 44

THORACIC ANTERIORDECOMPRESSION/FIXATION/FUSION


Indications

Anterior instrumentation of the spine is indicatedin degenerative, traumatic or pathologicalprocesses that cannot be addressed adequatelywith a posterior approach or by a posteriorapproach alone. These include:• Fractures of the middle and anterior columns,

whereby the vertebral body is unable to takeload thus leading to further collapse/kyphosis(Fig. 4.1)

• Compressive pathologies, including fracture,tumours and disc prolapses compressing thecord anteriorly.

Contraindications

• Poor respiratory function (likely to lead toincreasing morbidity)

• Medical resources not able to deal withcomplications and morbidity of procedure.

Operative planning

Recent radiographs must be available withappropriate scans (computed tomography[CT]/magnetic resonance imaging [MRI]). Thethoracic spine is a common site for wrong levelsurgery, and radiological markers can be used if itis thought that level identification may be aproblem. Appropriate vascular/cardiothoracicadvice and assistance should be on hand.


Anaesthesia is general, with or without the use ofa double lumen endotracheal tube (depending onwhether the lungs need individual intubation).The lateral position is used. A sand or bean bag iscommonly placed underneath the operative site toaid exposure and to open the disc spaces.

The patient is secured using an anteriorsuperior iliac spine (ASIS) support with aposterior support on the lower back. A support isplaced high on the thoracic spine posteriorly and

• Anterior chest wall pain• Major vessel damage: 2–15 per cent• Neurological compromise• Cosmesis of scar• Thromboembolism: <1 per cent• Back pain• Wrong level surgery

the patient further secured using tape fixation andan arm gutter for the top upper limb. Theoperation table should have the ability to be ableto ‘break’ and the patient positioned over this inorder to manipulate the operative sitepreoperatively and intraoperatively.

SURGICAL TECHNIQUE

Landmarks

The approach should go through the bed of therib two levels above the superior vertebra thatneeds to be instrumented. It is possible to extendthe incision to reach an inferior level but muchmore difficult to get higher in the spine once theincision is made.

Approach

An incision is made in line with the selected rib.The fat and superficial muscles are cut in line withthe rib. Occasionally, some muscles can be split inline with their fibres to provide a minimal accessapproach. The periosteum is dissected off the rib(with an elevator) and the rib is circumferentiallyfreed from the underlying soft tissue. Rib cuttersare used to remove the rib and the underlyingpleura is carefully incised and the lung protectedwith a chest pack. A rib spreader is thenpositioned.

The posterior pleura is incised and a planedeveloped protecting the segmental blood supply.The spine, discs and segmental vessels are nowexposed.

Procedure

The segmental vessels in the area of interest mayneed to be sacrificed. The discs are incised andremoved piecemeal, removing the cartilaginousendplates aiding fusion. If performing avertebrectomy/corpectomy, the discs above andbelow the vertebra in question are removedbefore removing it piecemeal. Implants can thenbe positioned.

Closure

On closure, a chest drain is inserted and the chestclosed in layers. First, 1 Vicryl is applied to thepleura and transverse thoracis and then eachindividual layer is sutured. Second, 2-0 Vicryl isplaced into the fat layer and a subcuticular layerapplied to the skin to give the best cosmeticresult.

Postoperative care and instructions

Adequate analgesia is achieved by means ofpatient-controlled analgesia (PCA), intercostalblocks or paravertebral catheter. Neurovascularobservations are continued. The chest drain is lefton free drainage and removed when drainage issatisfactory – this is often taken as less than125–150 mL/24 hours.

A postoperative chest X-ray is mandatory tocheck that the lung is fully inflated.

Thoracic anterior decompression/fixation/fusion 27

Figure 4.1 A thoracic flexion compression fracture withkyphosis

28 Surgery of the thoracolumbar spine

Contraindications

• Respiratory status does not allow for pronepositioning

• Coagulopathy.

Operative planning

Recent radiographs should be available and a CTor MRI scan available in theatre at the time ofsurgery. Identifying the correct level in the thoracicspine is more of a challenge as the reference points

Consent and risks

• Mortality• Infection: 2 per cent• Neurological injury (higher rate in the thoracic

spine as canal dimensions smaller)• Wrong level surgery• Blindness: 0.02–0.2 per cent• Thromboembolism• Respiratory infection• Failure/fracture of fixation


Ikard RW. Methods and complications of anteriorexposure of the thoracic and lumbar spine. ArchSurg 2006;141:1025–34.

THORACIC POSTERIORDECOMPRESSION/FIXATION/FUSION


Indications

• Unstable thoracic fracture (often in associationwith a sternal fracture) (Fig. 4.3)

• Posterior cord compression from a tumour ordegenerative process

• Palliative procedure for an anterior tumour orcompressive pathology, where the patient’scondition does not allow for an anteriorapproach

• Disc pathology as part of costotransversectomy• Coronal or sagittal deformity correction.

Figure 4.2 Thoracic vertebrectomy with posterior stabilization for a solitary metastasis

Thoracic posterior decompression/fixation/fusion 29

Figure 4.3 A fracture dislocation of the thoracic spine stabilized with posterior thoracic rods and screws

of the sacrum or C2 are not there to refer to. It isimportant to check the number of ribs a patienthas on plain X-ray, as these can be used to markthe skin using fluoroscopy prior to incision.


The patient is positioned prone over a Montrealmattress, Jackson table, four-post frame or similar.The arms can be placed by the patient’s side orout in front (depending on the level of surgery andthe need to use X-ray). It is important that theshoulders are not hyperflexed or abducted (<45°abducted and <90° flexed) and there is no

pressure on the patient’s axilla, which could causea nerve palsy. Padding is used under the patient’selbows to avoid an ulnar nerve palsy. There mustbe no pressure on the eyes and, if possible, thetable should be slightly head up to decreasecentral venous pressure.

SURGICAL TECHNIQUE

Landmarks

Figure 4.4 provides useful reference points inidentifying the correct levels. In thin patients, theribs can easily be felt and counted. The vertebra

T2T3

T5

T7

T4/5

T8

T10

T12

T3/4T2/3

T2 Superior border of scapula.T2/3 Suprasternal notch.T3 Medial end of spine of scapula. Spine of T3 is posterior end of oblique

fissure lung.T3/4 Top of arch of aorta.T4 End of arch of aorta. Azygos vein enters SVC.T4/5 Manubriosternal junction. (angle of Louis). Start of arch of aorta.T5 Thoracic duct crosses midline.T7 Inferior angle of scapula.T8 Caval opening in diaphragm. (IVC & right prenic nerve) Left phrenic

pierces diaphragm. Hemi-azygos veins cross to left.T10 Oesophageal opening in diaphragm. (oesophagus, branches of left

gastric vessels, vagus nerves)T12 Aortic opening in diaphragm. (Aorta, azygos vein, hemi-azygos vein,

thoracic duct) Coeliac axis.Splanchic nerves pierce crura. Sympathetic trunk passes behind medialarcuate ligament. Subscostal bundle passes behind lateral arcuateligament.

Figure 4.4 Thoracic structures corresponding to various vertebral levels


prominens can also be used as a reference tocentre the incision. In general, either the ribs orthe spinous processes can be counted to obtainthe correct level.

Incision

An incision is made in the midline, centred on theappropriate vertebra. Note the pedicle entry pointwill be above the spinous process of the vertebracounted and therefore the incision should allowfor this.

Approach

Skin, fat and fascia are incised and haemostasisobtained. The paraspinal musculature is thenstripped from the spine. The orientation of thetransverse processes is more vertical in thethoracic spine and the facets more horizontallypositioned relative to the lumbar spine with thepatient prone.

The important landmarks to identify are thetransverse process, the medial and lateral bordersof the facet joint and the pars. All three landmarksneed to be seen in order to be able to safelyinstrument the spine.

Procedure

The entry point for pedicle screws variesthroughout the thoracic spine. From T12 to T8,the entry point becomes more cranial and moremedial, and then above this it becomes lower andmore lateral again. The medial and lateral bordersof the facet joints give the medial and lateralstarting points for the pedicle screws. In general,this is at the junction of the medial two-thirds andlateral one-third of the joint. All screws are angledmedially. In the craniocaudal plane the pedicleangulation is approximately 90° to the trans-lamina line (a line drawn across the lamina aboveand below the screw insertion).

Decompression can be undertaken using thisapproach. If instrumentation is planned, theauthors prefer to do this before thedecompression begins as this allows someprotection of the neural elements. There are manyways of decompressing the spinal cord; the

authors preferred method is one of piecemealremoval of the spinous process followed byremoving the lamina using an up-cutting punch.The pars should be left intact, with at least 5 mmremaining laterally if instrumentation is notundertaken or this will cause destabilization of thespine.

Closure

Closure is in layers. A drain may or may not beinserted.


Adequate analgesia is provided by means of aPCA or epidural. Neurovascular observations arecontinued, and the patient is allowed to sit up toany angle.

Postoperative X-rays are obtained (chestradiograph may be needed if costotrans -versectomy was performed and a chest draininserted). The patient is initially given a walkingprogramme and a list of exercises. Liftinganything heavier than a kettle is notrecommended for the first 6 weeks.


Cinotti G. Pedicle instrumentation in the thoracicspine. A morphometric and cadaveric study forplacement of screws. Spine 1999;24:114–19.Kim YJ, Lenke LG, Bridwell KH. Freehand pediclescrew placement in the thoracic spine: is it safe?Spine 2004;29:333–42.

SCOLIOSIS SURGERY


Indications

• Severe deformity• Curve progression• Radicular pain or neurological deficit

(degenerative cases)• Back pain failing conservative management

(rare – degenerative cases more common)

Scoliosis surgery 31

Operative planning

Scoliosis surgery is a major undertaking whichshould be performed in specialist centres. Thischapter cannot cover every condition related toscoliosis and their management but aims to givesome general guidelines and advice to theorthopaedic trainee.

Scoliosis is a diverse condition being mainlydivided into degenerative, idiopathic, congenitaland neurological causes. Planning for these groupswill obviously be different but there are somegeneral principles:• All patients should be seen by a specialist

experienced in the treatment of scoliosis. Allpatients should have a full history andexamination including birth and family historyand any other medical problems likely relatingto their scoliosis.

• All patients should initially haveanteroposterior and lateral films of the wholespine. This will help in the overall planning ofsurgery and assess spinal balance. If surgery maybe indicated, the patient should be counselledwith regard to the risks involved and a wholespine MRI performed. This test, in the authors’view, is a mandatory requirement prior tosurgery to exclude abnormalities of the spinalcolumn which could lead to an increase in

• Imbalance can occur in either the sagittal orcoronal planes

• Back pain (fortunately uncommon)• Injury to the thoracic duct• Major vessel injury• Blindness: 0.028–0.2 per centFor posterior procedures:• All of the above complications apply to posterior

approaches to surgery, however, neurologicalcomplications are probably slightly morecommon in the posterior approach and obviouslythere is no risk of damage to the thoracic duct

• Posterior approaches involve a significant scar,which sometimes stretches from T2 to the pelvis

• Blood loss with this approach can beconsiderable if not controlled adequately

• Wound infection rates are probably slightlyhigher with this approach

• Neurological conditions where progression iscertain and respiratory function affected

• Cosmesis.

Contraindications

• Minor curves• When the patient’s expectations do not match

the surgeon’s• Poor respiratory function likely to lead to

prolonged ventilation• Spinal dysraphism, leading to a high rate of

neurological complications (relative).

Choice of approach

• There is an increasing trend towards posterior-only surgery. However, much depends on thecharacteristics of the curve and on the surgeon’straining and preference

• Thorough discectomy is only possible with ananterior approach and thus very stiff curvesmay benefit from anterior release prior toposterior surgery.

• Thoracolumbar/lumbar curves are often treatedwith anterior instrumentation, especially ifthere is no thoracic curve.

• Posterior instrumentation allows fixation to thepelvis – an advantage in long fusions in theelderly and in non-walking patients withneuromuscular-type curves.

Consent and risks

Complications will depend on the approach.Anterior approach for idiopathic scoliosis:• Mortality: 0.03 per cent• Respiratory dysfunction/chest infection• Neurological deficit: complete 0.03%;

incomplete 1.5 per cent• Non-union needing metalwork revision: 5 per

cent• Failure to achieve complete correction with

residual curve or rotation• Damage to sympathetic chain leading to

neurovascular change in the leg• Infection: 1–2 per cent• Inequality of spinal balance and uneven shoulder

height


access to the discs that are to be removed. Anindwelling urinary catheter should be placed preoperatively.

Patients receive a general anaesthetic. Hypo -tension during anaesthesia is advantageous as thismay decrease blood loss. A double lumen endo -tracheal tube is helpful but not always necessary.

Posterior procedureFor posterior procedures, the patient is laid prone,often on a Montreal mattress. This mattress has acentral cut-out that allows the abdomen to hangfree. This decreases the epidural venous pressureand the intraoperative bleeding. Arms should beplaced with the shoulders no more than 90°abducted and the elbows should be bent to nomore than 90°.

Gel pads should be used to pad the medialepicondyles of the elbows to prevent ulnar nerveinjury. The patient’s position should be slightlyhead up to decrease venous pressure around thehead and there should be no pressure around theeyes. Cut-out foam or gel head supports are usefulin controlling the head while avoiding pressure onthe eyes.

Pillows should be placed underneath thepatient’s legs with the knees slightly bent. In allspinal procedures, mechanical deep veinthrombosis (DVT) prophylaxis should beconsidered.

SURGICAL TECHNIQUE

Anterior procedure

LandmarksPrior to surgery, the appropriate planning X-raysshould have been performed and the levels offusion decided. It is common for anteriorprocedures to be combined with posteriorprocedures and the anterior procedure maysimply involve a release and removal of theproposed discs or may involve instrumentation.

Ribs should be counted on a plainanteroposterior X-ray. Ribs should then becounted up from T12 if this is palpable. The ribbed that should be entered should be two levelsabove the superior vertebra being instrumenteddue to the downward slope of the rib cage. For

neurological complications. These includesyrinx, cord tethering and Chiari malformationsof the brainstem.

• Following a (normal) MRI scan, patients areagain counselled with regard to the risks andbenefits of surgery. A multidisciplinary team isneeded, especially in the neurological scoliosisgroup.

• Patients need to be medically assessed if theyhave co-morbidities.

• Paediatric review is important and social issuesneed to be resolved before surgery, as do theissues of care following the procedure.Recovery is often lengthy in these patients.

• Lung function tests are useful as well as a chestX-ray and electrocardiogram (ECG).Anaesthetic involvement is required early tooptimize the patient preoperatively.

• Bending scoliosis films should be performedprior to surgery. The purpose of thisinvestigation is to assess the flexibility of thecurve which will in turn help the surgeondecide which levels need to be fused. Curvesare tremendously variable in their shapes aswell as their flexibility. This is dependent on thepatients’ underlying condition as well as the ageof the curve.

• Cord monitoring should be used during theprocedure and an intensive care bed should bebooked prior to the procedure.


Anterior procedureThe patient is positioned in the lateral positionwith the convexity of the curve facing upwards.The patient should be placed over a ‘break’ in thetable in order that this can be manipulated duringthe procedure. A sandbag should be placed underthe apex of the curve. The patient should besupported on the table by means of a side supportbehind the pelvis and behind the shoulder blades.The patient is padded with gel mats in order toavoid local nerve compression syndromes. Apillow is placed between the patient’s legs.

Elastoplast tape is used to secure the patient onthe table. The patient is then rolled back slightlyto allow ease of access to the surgeon. Openingthe convexity of the curve allows for ease of


entering the pleural cavity, the costal cartilage isincised and the abdominal musculature dividedinferomedially to allow exposure of the lumbarlevels. Care must be taken to avoid damage to theperitoneum. The retroperitoneal fat is entereddeep to the costal cartilage, and the peritoneumthen reflected anteriorly with careful fingerdissection and the use of gauze swabs as necessary.Dissection is carried down to the spine, anterior tothe psoas muscle. The diaphragm is divided withelectrocautery, leaving a peripheral cuff of around2 cm of diaphragm to repair to later. Markingsutures may be inserted to help the repair later.The great vessels and viscera are carefullyreflected anteriorly and protected with bluntretractors throughout the procedure.

ProcedureOnce the spine is exposed, individual segmentalvessels can be tied, cauterized or preserved. Discmaterial is then removed piecemeal until theposterior longitudinal ligament is seen.Sympathetic nerves should be preserved ifpossible.

It is important to appreciate the rotation in thespinal column as this considerably alters thenormal anatomy and whereabouts of the spinalcanal. Cartilaginous endplates are removed using aCobb, osteotome or curette. Ideally, bonyendplates should not be breached as this markedlyincreases blood loss.

When performing an anterior release orinstrumenting the spine anteriorly, the removal ofdisc material provides an excellent fusion bed.The removed rib can be broken into pieces andused as autograft. When instrumenting the spine itis important to understand the rotation of thecurve and the relationship of the vertebral body tothe spinal canal. In the thoracic spine rib heads area good guide to the screw insertion point and givethe posterior margin at which the screw can beinserted. Following disc removal it is possible toguide screws in parallel with the endplates of thevertebra being instrumented.

In correcting scoliosis it is important to achievea ‘cadence’ of screw insertion with the apical screwbeing most posterior. This will assist in thederotation of the spine. Bicortical fixation isbeneficial and aids stability. Following screw

example, if T9 needed to be instrumented and thiswas the most superior level, the incision should bemade through the bed of the seventh rib (Fig.4.5).

The authors find it useful to use a marking penand to mark the spinous processes of thethoracolumbar spine. The incision is then markedinside the extremes of the curve.

ApproachAn incision is made in line with the proposed rib.Skin, fat and muscle are incised in line with therib. Haemostasis is obtained and self-retainers areplaced. The periosteum is split on the rib andretracted off the rib. The rib is circumferentiallycleared of periosteum and followed posteriorly asfar back as possible. Anteriorly, the rib is exposedto the costochondral junction, and then cut andremoved. The underlying pleura is exposed andcarefully incised, opening the chest and exposingthe lung. Wet chest packs can be used to retractthe lung superiorly. The posterior pleura is thenvisible and this is incised taking care not todamage the underlying segmental vessels.

If the planned release or instrumentation willcross the thoracolumbar junction, the diaphragmwill need to be taken down. Either before or after

Pleura over esophagus

Pleura overazygos vein

Pleura overintercostal

vein

Incision inpleura

Intercostalmuscle

External suface ofretracted rib

Pleura overparavertebralganglion

Pleura overmedial endof rib

Figure 4.5 The selection of rib level in anterior scoliosissurgery


insertion a rod is applied. The screw and rod areapplied to the convexity of the curve and thereforecompression in between individual screws aidsreduction (Fig. 4.6). Following reduction, thescrew heads are given a final tighten.

ClosureThe posterior pleura may be left open or closeddepending on the surgeon’s preference. The chestwall is closed in layers and a chest drain insertedand sutured in.

Posterior procedure

LandmarksIt is vital to identify the appropriate levels in thethoracic spine. C7 is usually the most prominent

spinous process around the neck and this canoften be palpated. It is possible to count downfrom this level to identify the most superiorvertebra that will be instrumented. Alternatively,an X-ray can be used or a shorter incision madeand the ribs identified intraoperatively andcounted upwards from T12.

IncisionAn incision is made to the required level aspreviously described.

DissectionThe subcutaneous fat and fascia are incised. Thespinous processes are identified and subperiostealdissection is performed. This is extremely

Figure 4.6 Anterior scoliosis correction


trajectory is more horizontal in the curveconcavity and more vertical in the curve convexitybecause of the associated rotation of the spine inscoliosis. Spinal cord monitoring is mandatorythroughout this procedure.

Screws need not be inserted at every level.Screw sizes are usually between 5 mm and 7 mmin diameter and vary in length from around 25mm to 50 mm. Every surgeon will have aparticular construct which he or she uses. In theupper thoracic spine, pedicle screws can be usedalone or in combination with lamina, pedicle ortransverse process hooks.

Before rod placement, de-cortication isextremely important. Facets are destroyed andlamina de-corticated in order for fusion to occur.Rods are then inserted. There are several ways toreduce the spine, and the authors’ preferredmethod is by derotation of the constructsequentially from superior to inferior.

Pedicle screw fixation is a very powerfultechnique for reducing spinal deformity (Fig. 4.7).

important with such large wounds, as dissection inthe wrong plane will lead to excessive bleeding.

Gauze is used to pack the wounds on each sideto limit blood loss. Gel foam combined withadrenaline can also help in this regard. Dissectionis carried out laterally in the lumbar spine to thetransverse processes in order that pedicle screwentry points can be identified. In the thoracicspine, the dissection is carried laterally to identifythe transverse processes and the lateral edges ofthe facet joints.

ProcedurePedicle screw fixation in scoliosis is challenging.Rotation makes for difficult pedicle screwplacement. In the sagittal plane, screw angles canbe judged from a 90° line to the lamina above andbelow the level being instrumented. In thetransverse plane, screw angles may be judged froma Kocher placed on the spinous process. Thistechnique gives a guide to the amount of rotationin a particular segment. In general, the screw

Figure 4.7 Posterior scoliosis correction


have a CT scan to identify the position of themetalwork.


Baig MN. Vision loss after spine surgery: review ofthe literature and recommendations. NeurosurgFocus 2007;23:E15.Weiss HR, Goodall D. Rate of complications inscoliosis surgery – a systematic review of the PubMed literature. Scoliosis 2008;3:9.

CAUDAL EPIDURAL


Indications

• Acute/chronic sciatica• Spinal stenosis (though they are more

commonly treated with nerve root blocks orlumbar epidurals).

Contraindications

• Coagulopathy• Previous failed procedures.

Operative planning

All X-rays and scans should be in theatre at thetime of surgery; a preoperative MRI scan is oftenperformed.


There are many different ways of performing thisprocedure. A caudal epidural can be performedunder local, sedation or general anaesthesia. Theauthors recommend a short general anaesthetic,with the patient positioned prone over a Montrealmattress.

Consent and risks

• Failure of procedure to work• Epidural haematoma• Temporary loss of bladder and bowel function

Cross-links can be added to the construct toincrease strength and load sharing. Manyalternatives exist for bone grafting with somesurgeons preferring local bone graft alone whereasothers use a variety of bone graft substitutes/allograft and types of bone morphogenic protein(not to be used in the growing spine).

ClosureThe spine is closed in layers with a watertightclosure being of great importance.

Thoracoscopic anterior correction

This technique is not commonly used. It offers theability, by means of a minimal access approach, tocorrect scoliosis with the use of a thoracoscope.This leaves the patient with four 2 cm cutsoverlying the ribs laterally, which certainly gives agood cosmetic result. This technique has a steepand long learning curve with extended operatingtimes in the initial phase. Some concerns remainwith regard to the degree of correction obtainedand the success of fusion with this approach.


• Neurovascular observations and analgesia areused as needed.

• Oral intake begins with clear fluids and signs ofileus are watched for.

• Postoperative haemoglobin and renal functionlevels are checked.

• The chest drain is removed when 24-hourdrainage is satisfactory, e.g. <125 mL.

• The patient can sit to any angle and mobilize aspain allows.

• Postoperative chest and spine X-rays are taken.• Some surgeons fit their patients with a custom-

moulded thoracolumbar orthosis for up to 6months postoperatively. This requires casting afew days after surgery, once the patient canstand for 10–15 minutes.

• Neurological injury – in patients waking upwith complete motor and sensory loss thehardware should be removed immediately, withadequate blood pressure maintained, andsteroids should be considered. Patients in whomroot compression/injury is suspected should

Caudal epidural 37


The patient can be discharged on the day ofsurgery, once they can pass urine postoperatively.An outpatient review of the result of the epiduralis arranged in 4–6 weeks.

LUMBARDECOMPRESSION/FIXATION/FUSION


The area of spinal fusion is controversial and adiscussion of all the arguments for and against itsuse in spinal practice is beyond the scope of thischapter. It is fair, however, to state that there is no

SURGICAL TECHNIQUE

Landmarks

The insertion point for the caudal needle lies atthe most superior margin of the gluteal cleft andis felt as a ‘defect’ or opening in the sacrum, thesacral hiatus.

Procedure

Fluoroscopy is used in a lateral position to checkthe needle position, and 5 mL of Omnipaque 300,mixed with an equal volume of saline, is insertedand an epidurogram taken (Fig. 4.8). Once theneedle is seen to be in a good position, the localanaesthetic mixed with steroid is injected.

Figure 4.8 An epidurogram from a caudal epidural

ideal solution for back pain and most procedureswith or without fusion are performed for legsymptoms. Fusion is needed in cases of instabilityor where decompression is likely to causeinstability in the long term.

Indications

• Spondylolisthesis• Lumbar spinal trauma• Spinal stenosis associated with instability or

degenerative disc disease• Degenerative deformities.

Contraindications

• Smoking (may lead to non-union)• When the patient’s expectations are not in line

with the surgeon’s views• Waddell’s abnormal illness behaviours, e.g.

widespread non-anatomical pain, pain on axialcompression or rotation, straight leg raise whichimproves with distraction and general over-reaction to pain

• Back pain is the main symptom (proceed withcaution).

Operative planning

• A full history and examination is taken fromthe patient. Specifically, symptoms of spinalstenosis, nerve root compression, involvementof bladder and bowels are enquired about

• Plain X-rays are taken to exclude deformity andfracture, and to use as a baseline for levelsintraoperatively

Consent and risks

• Nerve injury: 1 per cent• Cauda equina injury: 0.1 per cent• Infection: 1–2 per cent• DVT/pulmonary embolism: 1 per cent• Improvement in symptoms: 85 per cent for leg

pain; no change 10 per cent; worsening 5 percent

• Non-union: 5 per cent• Dural tear


• An MRI scan is ordered preoperatively. Bloodtests may be indicated preoperatively toexclude infection where discitis is suspected.Scans should be reviewed with the patient. Allforms of conservative treatment must beexhausted before spinal fusion is considered.The patient’s expectations must be managed in order to achieve the best result. It is sensiblefor the surgeon to meet the patient severaltimes pre operatively.

• An anaesthetic assessment may be neededpreoperatively. A cell saver should beconsidered for extensive fusions and ifdeformity correction is to be performed, spinalcord monitoring should be undertaken


The patient should be preferably positioned proneand on a Montreal mattress or Jackson frame. Themattress has a central cut-out, allowing theabdomen to be free during the operation. Thismay well contribute to limiting blood loss. Iffusion is not planned the spine can be flexed tofacilitate the decompression. The arms are placedon arm boards with the shoulders at 90°. It isimportant to check that there is no pressure onthe eyes or the ulnar nerves at the elbow and thatthe shoulders are safely positioned.

Anaesthetic is general, postoperative pain reliefcan be augmented with an intraoperative epiduraland the catheter can be left in postoperatively.Hypotensive anaesthesia is useful in reducingintraoperative blood loss.

SURGICAL TECHNIQUE

Landmarks

For a guide to surface anatomy please see Figure4.9 – note that the thoracic levels relate to thescapula and thus will change if the arms are not bythe sides. In addition, the level of the top of theiliac crests varies from the L3/4 disc to the L4/5disc, especially with transitional lumbosacralvertebrae, and correlation with plain X-rays isimportant. X-ray guidance can be used at the startof the operation to mark levels and, once a level isconfirmed, it is possible to count up or down onthe spinous processes.

Lumbar decompression/fixation/fusion 39

Soft tissue is stripped off the spine laterallyuntil the transverse process is clearly seen. AHolman retractor can be placed over the lateraledge of the transverse process to aid in retraction.The pedicle in the lumbar spine corresponds tothe junction of the transverse process, superiorfacet and the pars. The superior facet can beremoved to aid visualization of the pedicleentry point as long as this is not at the top level ofthe fusion. Bleeding must be controlled at alltimes.

Procedure

Once dissection is complete, it is important to useX-ray guidance to mark the correct level. This canbe done by means of a marker on a spinousprocess or pedicle.

Once the level is identified, screws can beinserted as necessary. Screws are inserted at theconfluence of the pars, transverse process andfacet (see Fig. 4.11, p. 36). Following screwinsertion, rods can be inserted and distraction orcompression applied as needed. Followinginstrumentation, decompression can beundertaken if required.

There are many ways of performing thisprocedure, and the authors’ preference is to use aburr and an osteotome to remove the lamina.Nerve roots are then explored and anundercutting facetectomy can be performed usingan osteotome or up-cutting punch. It is importantthat nerves are decompressed both in the lateralrecesses and out through the foramen. Theforamen can be enlarged by applying distractionthrough the screw construct.

Dural breach occurs in up to 5 per cent ofprocedures and can be repaired using 5-0 Prolenesuture by means of an interrupted or continuoustechnique. Other options include blood, fascia orfat patches, dural ‘glues’ or membranes designedto seal dural leaks, such as DuraGen.

The wound is closed in layers. If a dural leak has

Structures at risk

• Dura• Nerve root

Incision

Following adequate positioning of the patient andlevel identification, a midline longitudinal incisionis made.

Dissection

Subcutaneous tissues, fat and fascia are incised inline with the skin. Haemostasis is obtained. ACobb retractor is used to put the paraspinalmusculature under tension. Diathermy is thenused to resect the musculature off the posteriorvertebra. On an initial first pass the muscles aredissected from the spinous processes and laminaeonto the medial border of the facets. It isimportant not to damage the facet joints andwhile performing a fusion, the superior facet jointin the fusion should be protected and notviolated.

The wound is packed on each side and deeperretractors inserted. When performing an instru -mented fusion it is important that the pedicleentry points are clearly seen. In the lumbar spinethis involves the visualization of the pars, andthe junction of the transverse process and thefacet.

T3

T7

L4

S2

Figure 4.9 Anatomical levels in the lumbar spine


Operative planning

An MRI scan is performed prior to surgery. PlainX-rays are useful in assessing transition levels inthe lumbar sacral spine. Symptoms should bereviewed prior to surgery, as there is a goodchance that the patient will have improved sincelast being seen in clinic.


General anaesthesia is used. Hypotension duringthe anaesthesia procedure is useful as this mayreduce epidural bleeding. The patient can bepositioned in one of several ways, and the authors’preference is to position the patient in the kneesto chest position (Fig. 4.10). This position isinitially difficult to master but has the advantageof opening the interspinous spaces and allowingeasier access to the disc in question. The patient’sknees are moved so they are under the patient’sabdomen and a box is placed underneath thechest. Side supports are used to stabilize thepatient. A bar is placed behind the patient’sbuttocks to support the trunk. Positioning of thepatient on a Montreal mattress, a Wilson frame ora Jackson table is also acceptable.

In the knees to chest position it is important toadequately pad the patient’s pressure pointsincluding ulna nerves, shoulders, knees and feet.The eyes must be free of obstruction.

SURGICAL TECHNIQUE

Landmarks

The authors prefer to mark the level pre- andintraoperatively. A needle is placed in theprepared skin at the point which it is estimatedthat the target level sits. A cross-table lateral X-ray

• Epidural haematoma• Dural tear: 5 per cent• Infection: 1–2 per cent• Wrong level surgery: <1 per cent• Cauda equina: 0.01 per cent• Ongoing pain• Post-discectomy instability leading to back pain• Blindness

occurred it is advisable to either not insert a drainor if a drain is inserted to have it on free drainageto encourage the leak to seal. Maintain the patientsupine for 24–48 hours following the operation toencourage healing of the tear and to avoid thecomplication of low-pressure headache. Mobiliza -tion should not begin until the patient can sitwithout headache.


Neurovascular observations are undertaken, anddrains, if used, are removed at 24 hours. The patientmay mobilize as able and can sit to any angle (ifthere is no dural leak). Analgesia, postoperativebloods and X-rays are recom mended.


Malter AD, McNeney B, Loeser JD, et al. 5-yearreoperation rates after different types of lumbarspine surgery. Spine 1998;23:814–20.

LUMBAR DISC SURGERY


Indications

Lumbar discectomy is indicated for patients whohave failed 6 weeks of conservative measures inthe treatment of an acute disc prolapse. Earlysurgery may be indicated for patients who areincapacitated by pain or in those who have painfulmotor loss or symptoms of cauda equina.

Contraindications

• Coagulopathy• Waddell’s abnormal behaviour signs (relative)• Neurological symptoms not matching MRI and

clinical findings.

Consent and risks

• Nerve root injury: 1 per cent

Figure 4.10 The knees to chest position for lumbar discectomy

is taken. The needle is adjusted and inserted ontothe spinous process of the correct level. Anestimate of disc level can be taken from thesurface landmarks (see Fig. 4.9, p. 39).

Incision

The level involved is marked with a needle, andthe skin incision is centred on the marker.

Approach

The fat and fascia are incised in line with the skin.Diathermy is then used to dissect the musculatureoff the posterior elements of the spine.Haemostasis is obtained. The soft tissue is sweptlaterally using a Cobb elevator. The outer aspectsof the facet joints are identified.

It is important for the operating surgeon to beable to identify the important landmarks as well asthe correct level. The lamina of the vertebra abovethe disc is identified and the inferior edgedelineated. The ligamentum flavum should beidentified and then incised. A McDonald elevatorcan be used to protect the underlying dura. If it isdifficult to expose the dura, or there is a verynarrow interlaminar window, it is sometimeshelpful to start removing the inferior border of thesuperior lamina. The ligamentum inserts into theunderside of the lamina and therefore once theattachment has been released the ligamentumopens like a ‘curtain’. Once the canal has beenopened it is important to again check the operative

level and therefore cross-table fluoroscopy is usedwith a McDonald elevator in the canal.

An interlaminar window is then developed. Insome cases very little bone needs to be removed inthis process. In arthritic spines the dissection canbe difficult and a substantial amount of bone isresected. It is important not to remove more thanone-third of the facet as this may cause instabilitywarranting further procedures.

The dura is carefully exposed and, as thewindow is expanded, the nerve root is found andprotected. Before the disc material is removed, itis essential that the nerve root is identified.Sometimes the disc lies below the posterior

Lumbar disc surgery 41

Ascendingarticularprocess

Descendingarticular

process ofproximalvertebra

Spinal nerve

Herniated disc

Caudaequina

Posteriorlongitudinalligament(with overlyingveins)

Figure 4.11 The operative view in lumbar discectomy


longitudinal ligament (PLL) and at other times,with large prolapses, the disc will have ‘brokenthrough’ this layer. When the PLL is not breachedthis will need to be incised before the disc isremoved.

Procedure

Nerve root retractors are used to protect both thecauda equina and the nerve root as the disc isincised. The disc is then removed piecemeal. Theamount of disc that is removed from the discspace is highly variable and surgeon dependent.

For large discs it can be very difficult to retractthe cauda equina enough to expose the disc. Inthese cases it is sensible to extend the size of theinterlaminar window and possibly even performhemi- or total laminectomy. This manoeuvre willthen allow adequate retraction and visualizationof the disc and nerve root.

The authors like to wash out the operative fieldwith saline and insert an epidural catheter for a‘one shot’ epidural for postoperative pain relief.The catheter is then removed.

Closure

The fascia is closed with continuous 1 Vicryl andthe fat opposed with 2-0 Vicryl. Then 3-0Monocryl is applied to the skin with Steri-Stripsand an Opsite dressing.

MINIMAL ACCESS SURGERY

Over the past decade there has been a drive byindustry and surgeons to perform proceduresthrough smaller incisions in the hope that byminimizing local trauma to the tissues, recoveryimproves and postoperative pain reduces.

The term microdiscectomy has been coined fordiscectomies using a microscope. This improvesvisualization of anatomy through a smallerincision. The basic technique remains the same.

Newer retractors are also becoming morewidely available. These retraction tubes allow forincisions of 2–3 cm and often have inbuilt lightsand even cameras to improve visualization. Theseretractors may come more into widespread use inthe next few years.

DISC REPLACEMENT SURGERY

Over the past 2 decades there has been increasinginterest in the use of lumbar disc replacement.Several types exist using different bearing surfacesincluding metal on metal and metal onpolyethylene. Centres of rotation can be fixed ormobile. The long term outcome of these prosthesesis still unknown and the authors advice is to usethese with care; fusion still remains the mostwidely accepted treatment for discogenic lowerback pain. Disc replacements are inserted via ananterior extraperitonneal approach which isbeyond the scope of this chapter.


Neurovascular observations and analgesia asrequired are provided. The patient is allowed to sitto any angle and should be seen in the clinic in6–8 weeks.


Tafazal SI, Sell PJ. Incidental durotomy in lumbarspine surgery: incidence and management. EurSpine J 2005;14:287–90.Weinstein JN, Tosteson TD, Lurie JD et al. TheSpine Patient Outcomes Research Trial (SPORT)JAMA. 2006;296(20):2441–2450.

FACET INJECTION


Indications

• Lower back pain with facet joint arthrosis• Pain in the lower back on extension• Failure of conservative treatments, including

physiotherapy.

Contraindications

• Coagulopathy• Inability to tolerate injections or have

anaesthetic/sedation.

Nerve root block 43

NERVE ROOT BLOCK


Indications

• Known nerve compression, seen on MRI, notresponding to normal analgesics or conservativetreatments

• As a diagnostic test for an equivocal MRI scan• Patient in the acute phase of a disc prolapse in

severe pain and unable to mobilize.

Contraindications

• Coagulopathy• Inability to tolerate injections or have

anaesthetic/sedation.

Operative planning

All patients should have at least a plain X-rayprior to the procedure. In reality most patientshave an MRI scan before injection. Nerve rootblocks can be instigated on a clinical basis alone ifthere is delay in obtaining an MRI.


Patients are placed prone. The procedure can beperformed under local anaesthesia, sedation orgeneral anaesthesia.

SURGICAL TECHNIQUE

Procedure

The authors’ preferred approach is to use CTfluoroscopy and an experienced radiologist toperform this procedure, but it can be performedin theatre using X-ray guidance. A 22G spinalneedle is manoeuvred, via a posterolateralapproach, into the spinal foramen. Omnipaque

Consent and risks

• Failure of treatment/short-lived effect (high risk)• Infection (uncommon)

Operative planning

All patients should have at least a plain X-rayprior to the procedure. In reality, most patientshave had an MRI scan before injection.


Patients are placed prone. The procedure can beperformed under local anaesthesia, sedation orgeneral anaesthesia.

SURGICAL TECHNIQUE

Approach and procedure

The authors’ preferred method is to perform facetblocks under CT control with an experiencedradiologist. Without this facility, blocks can beperformed with fluoroscopy in theatre. The angleof the C-arm needs to be adjusted in order toallow for the obliquity of the facets in the lumbarspine. Needles can be placed within the facet jointand checked by means of insertion of Omnipaquedye. The authors advocate performing up to threebilateral levels in one sitting; 2 mL of localanaesthetic and steroid combined are introducedinto the facet joints.


Neurovascular observations are carried out. Thepatient is allowed home when comfortable (sameday) and asked to keep a post-procedure paindiary. A clinic appointment is made for 6 weeks toreview symptoms.

Consent and risks

• Failure of treatment/short-lived effect (high risk)• Infection (uncommon)


Viva questions

1. Describe the relevant surgical landmarks whenplanning an anterior approach to the T10vertebral body.

2. What are the indications for performing ananterior approach to the spine?

3. Describe where the segmental blood supply ofthe vertebral body lies in relation to the disc.

4. At what level of the thoracic spine does theinferior border of the scapula lie when thearms are by the sides? Where, in relation to thespinous process, does the corresponding pedicleof the same vertebra lie?

5. Describe what steps you would take tominimize wrong level surgery in the thoracicspine.

6. What role do chest drains have in thoracicspinal surgery?

7. What factors are involved in selecting patientsfor scoliosis surgery?

8. Give a brief account of the preoperativemanagement of a patient due to undergoscoliosis surgery.

9. Describe the positioning and the peripheralnerves at risk from prone positioning of apatient.

10. Which nerve runs in the lateral recess at theL5/S1 level?

11. Describe your intraoperative and postoperativemanagement of a dural tear.

12. What might be the presentation andmanagement of an acute epidural haematoma?

13. Describe the approach for a lumbar discectomy.

14. What nerve root would be compressed by anL4/5 far lateral disc?

15. An L4/5 left-sided paracentral disc protrusionwill impinge on which nerve root?

16. What is the incidence of nerve root injury witha discectomy?

17. Describe the orientation of the facet joints atdifferent levels of the spine.

18. Following temporary success of facet blocks,which other radiological procedure can beperformed with potential for longer-lastingbenefit?

19. Which nerve root leaves the spinal canal viathe L4/5 foramen

dye can be used as a position check, beforeinjecting local anaesthetic and steroid locally.


As per facet injections.


Wagner AL. Selective nerve root blocks. Tech VascInterv Radiol 2002;5:194–200.

Surgery of the peripheral nerve5

Gorav Datta, Max Horowitz and Mike Fox

Carpal tunnel decompression 45Ulnar nerve decompression at the wrist 48Ulnar nerve decompression at the elbow 51

Principles of surgery on peripheral nerves 53Principles of brachial plexus surgery 56Viva questions 58

CARPAL TUNNEL DECOMPRESSION


Indications

• Median nerve compression neuropathy at thewrist

• As part of a fasciotomy for compartmentsyndrome/decompression after distal radialfracture

• Drainage of sepsis.

Contraindications

• Active overlying skin infection• Uncertainty over diagnosis – may warrant

further investigation before proceeding.

Consent and risks

• Nerve injury: median nerve injury <1 per cent;palmar cutaneous nerve injury <1 per cent

• Radial artery injury: <1 per cent• Failure to relieve symptoms: 1–10 per cent; the

incidence is highest in heavy/repetitive manualworkers

• Pillar pain: quoted at up to 10 per cent, this istenderness around the site of ligament release

• Scar tenderness: the incidence is reduced bymassage in the postoperative period

• Complex regional pain syndrome (rare)• Infection

Operative planning

History and clinical examination remain themainstay of diagnosis. It is essential to examine theentire limb as well as the cervical spine to excludea ‘double-crush’ lesion. Nerve conduction studiesare useful and should be available on the day ofsurgery. They are considered essential in cases ofrecurrent carpal tunnel syndrome and complexupper limb lesions. Prolonged sensory latency isthe earliest and most reliable nerve conductionabnormality. Magnetic resonance imaging (MRI)is rarely indicated, unless there is clinical evidenceof a space-occupying lesion causing thesymptoms. Conventional radiography is notgenerally indicated. Consideration should be givento extraneous causes such as diabetes mellitus,rheumatoid and other arthritides, amyloidosis andthyroid dysfunction; where appropriate these mayalso require investigation prior to operation.


The procedure may be carried out under local,regional or general anaesthesia. Most primarydecompressions are performed under localanaesthesia. A local anaesthetic consisting of 1 percent lidocaine and 0.5 per cent bupivacaine in a1:1 mixture is infiltrated into the wound prior tosurgical draping. General anaesthesia is usuallyreserved for revision procedures.

The patient is positioned supine on anoperating table and the arm is positioned on anarm table in supination, with a padded lead hand

used to maintain finger extension. A tourniquet isinflated to 250 mmHg. In obese patients, aforearm tourniquet is recommended.

SURGICAL TECHNIQUE

Landmarks

The tendon of palmaris longus (absent in about 10per cent) is easily seen and palpated by opposingthe thumb and little finger and then flexing thewrist to around 30°. The distal end of the tendonbisects the anterior surface of the carpal tunnel.Other useful landmarks include the thenar skincrease (running at the base of the thenareminence) and the transverse skin crease of thewrist joint (running parallel to the joint line). Thetransverse wrist crease marks the proximal borderof the flexor retinaculum. If the thumb isoutstretched to 90° a parallel line drawn acrossthe palm in line with its distal border representsthe surface marking of the superficial palmar arch:this is known as Kaplan’s cardinal line (Fig. 5.1).

Incision

The incision runs a few millimetres to the ulnarside of the thenar skin crease, in the line of thelong axis of the ring finger. This ensures that anyscarring is well away from the median nerve and

46 Surgery of the peripheral nerve

ensures that proximal extension avoids the palmarcutaneous branch of the median nerve. The extentis from the distal volar wrist up to a fewmillimetres proximal to the superficial palmararch. In revision surgery, the proximal extent isincreased: this is curved to run along the ulnar sideof the palmaris longus tendon (Fig. 5.2). Thisavoids crossing the wrist joint crease at a rightangle and, once again, minimizes any damage tothe palmar cutaneous branch of the median nerve.

Dissection

The exposure continues in line with the skinincision until the superficial palmar fascia isexposed deep to subcutaneous fat. Occasionallythe belly of flexor pollicis brevis (FPB) issuperficial to the fascia and is divided. The fibresof the superficial palmar fascia are incised in thesame line.

Retraction of the skin flaps will reveal the

Structures at risk

• Palmar cutaneous branch of the median nerve isat risk if the skin incision is angled to the radialside of the forearm

• Deep motor branch of the median nerve (due tovariation in its course) – staying on the ulnarside of the median nerve minimizes the risk ofdamaging the structure

• Superficial palmar arch• Median nerve

FRC

PL

PCN R

M

KH

U

Figure 5.1 Surface anatomy of the wrist and hand. K,Kaplan’s cardinal line; M, median nerve; R, recurrentmotor branch; PCN, palmar cutaneous nerve; U, ulnarnerve; H, hook of hamate; PL, palmaris longus tendon;FCR, flexor carpi radialis tendon

Motor branchof medial nerve Palmar cutaneous

branch of mediannerve

Palmarislongus

Mediannerve

Figure 5.2 Extended incision for revision/complex carpaltunnel decompression

insertion of palmaris longus into the flexorretinaculum. If it is in the way, it can be retractedto the radial side: this exposes the median nerve.Careful dissection through the flexor retinaculumis recommended until the nerve is visualized. AMcDonald tissue dissector is passed between theplane of the flexor retinaculum and the mediannerve. The dissector must be used with cautionand should elevate the retinaculum and not pressdown on the nerve. The flexor retinaculum isincised with a scalpel, cutting down onto theMcDonald tissue dissector, which lies over thenerve and protects it (Fig. 5.3).

The nerve is released from proximal to distal. Inrevision surgery the nerve should be dissected outproximal to the wrist crease. The perivascular fatpad is the distal border of the flexor retinaculum.This must be retracted to visualize the distal endof the ligament to ensure complete decom -pression. The proximal end of the wound shouldalso be retracted to ensure complete release underdirect vision with either tenotomy scissors or ablade.

The deep motor branch of the median nervecan have a variable course. Usually, it arises on theradial side of the median nerve as the nerve exitsthe carpal tunnel. The nerve continues radially,entering the thenar muscles between abductorpollicis brevis and FPB. However, variations mayinclude a motor branch arising from the mediannerve within the carpal tunnel, running distally topierce the retinaculum supplying the thenarmuscles. Bearing this in mind during the

Carpal tunnel decompression 47

dissection, it is prudent to stay on the ulnar side ofthe median nerve to prevent damage to the motorbranch.

External neurolysis need only be performed ifthe nerve is adherent to adjacent structures.Internal neurolysis is not performed.

The tourniquet should be released prior towound closure. It is important to check forreperfusion of the nerve and to ensure adequatehaemostasis before skin closure.

Extensile measures

These are generally not necessary for standardcarpal tunnel surgery and are reserved for specificindications.

ProximalThe approach may be extended proximally toexpose the median nerve in the forearm. This maybe required in cases of fracture fixation withconcomitant carpal tunnel decompression.Extension is gained between the tendons of flexorcarpi radialis and palmaris longus. The nerve lieson the deep surface of flexor digitorumsuperficialis in the forearm. The median nerve isretracted to the ulnar side and pronator quadratusincised to access the distal radius.

DistalThe incision may be extended distally with azigzag incision (Brunner incision) to access anydigit, providing a complete palmar exposure. Thisis useful in procedures requiring the drainage ofsepsis.

Closure

Skin closure is performed with 4-0 interruptednylon sutures. An occlusive dressing is applied,followed by a compressive hand dressing. Thecompression dressing should allow immediatemobilization of the fingers and wrist and shouldnot be excessively bulky.

ENDOSCOPIC DECOMPRESSION

Endoscopic decompression may be performedthrough the Brown two-portal or the Agee singleportal technique. The main proven benefits of the

Transversecarpal

ligamentMediannerve

Figure 5.3 Release of the flexor retinaculum

endoscopic procedure are restoration of normalgrip and absence of a painful scar in the earlypostoperative period. The procedure, however, hasa steep learning curve with complications rangingfrom nerve injury and an inability to seeanatomical variations to incomplete release.


The bandage is removed 3–7 days followingsurgery. The sutures are removed and advice onscar massage given 10–14 days postoperatively. Itis imperative that patients are encouraged tomobilize their fingers from day 3 onwards. Theyshould also be counselled that it takes 6 weeks toregain their pinch grip and 3 months to achieve apower grip.


Cobb T, Dalley B, Posteraro R, et al. Anatomy ofthe flexor retinaculum. J Hand Surg Am1993;18:91–9.Graham B. The value added by electrodiagnostictesting in the diagnosis of carpal tunnel syndrome.J Bone Joint Surg Am 2008;90:2587–93.Green DP. Green’s Operative Hand Surgery, 5thedn. Philadelphia: Elsevier, 2005.Hankins CL, Brown MG, Lopez RA, et al. A 12-year experience using the brown two-portalendoscopic procedure of transverse carpalligament release in 14,722 patients: defining anew paradigm in the treatment of carpal tunnelsyndrome. Plast Reconstr Surg 2007;120:1911–21.Rotman MB, Donovan JP. Practical anatomy of thecarpal tunnel. Hand Clin 2002;18:219–30.Smit A, Hooper G. Elective hand surgery inpatients taking warfarin. J Hand Surg Br2004;29:206–7.Steinberg DR. Surgical release of the carpaltunnel. Hand Clin 2002;18:291–8.Thoma A, Veltri K, Haines T, et al. A systematicreview of reviews comparing the effectiveness ofendoscopic and open carpal tunnel decom -pression. Plast Reconstr Surg 2004;113:1184–91.Upton ARM, McComas AJ. The double crush innerve entrapment syndromes. Lancet 1973;ii:359–62.


ULNAR NERVE DECOMPRESSION ATTHE WRIST


Decompression of the ulnar nerve at the wrist is arelatively uncommon procedure. Nerve com -pression may be associated with space-occupyinglesions, anomalous muscles or trauma. It isimperative that the patient is examined from thecervical spine downwards, and clinical findingsshould be correlated with neurophysiology.

Indications

• Decompression of the canal of Guyon• Ulnar nerve repair at the wrist (e.g. laceration).

Contraindication

Active overlying skin infection.


The procedure may be carried out under local,regional or general anaesthesia. A local anaestheticconsisting of 1 per cent lidocaine and 0.5 per centbupivacaine in a 1:1 mixture is infiltrated intothe wound prior to surgical draping. Thereshould be a low threshold for general anaesthesiaif more than a simple exploration is beingconsidered.

The patient is positioned supine on anoperating table and the arm is positioned on anarm table in supination, with a padded lead handused to maintain finger extension. A tourniquet isinflated to 250 mmHg.

Consent and risks

• Nerve injury• Vascular injury• Infection• Failure to relieve symptoms• Stiffness• Scar tenderness and hypersensitivity

SURGICAL TECHNIQUE

Landmarks

The hypothenar eminence and transverse wristskin crease are important surface landmarks. Thebony landmarks of Guyon’s canal (Table 5.1) arepalpated and marked; the hook of hamate lies 1cm radial and distal to the pisiform, which is easilypalpated at the base of the hypothenar eminence.

Table 5.1 Boundaries of Guyon’s canal

Floor Pisohamate and pisometacarpalligaments, flexor retinaculum andopponens digiti minimi

Roof Volar carpal ligament and palmarisbrevis

Medial wall Pisiform, flexor carpi ulnaris andabductor digiti minimi

Lateral wall Flexor digiti minimi, hook of hamateand flexor retinaculum

Proximal extent Flexor retinaculum

Distal extent Fibrous arch of the hypothenarmuscles

Ulnar nerve decompression at the wrist 49

Incision

The incision lies in between the two landmarks(hook of hamate and pisiform) and runs distally forapproximately 4 cm and proximally for 3 cm (Fig.5.5). It is curved to the ulnar side, on crossing thewrist flexor crease, to overlie the tendon of FCU.


The subcutaneous fat is incised to the deep fasciaof the forearm. The tendon of flexor carpi ulnaris(FCU) is identified and the fascia is incised on itsradial border. The FCU tendon is retracted to theulnar side revealing the ulnar nerve and artery(the artery lies radial to the nerve). If necessary,the incision is followed proximally to release thedistal aspect of the antebrachial fascia.

Deep dissection

Once the nerve and artery are identifiedproximally, they are traced distally where theyenter Guyon’s canal. The volar carpal ligament isincised taking care not to damage the nerve orartery (Fig. 5.6). The hook of hamate is thenidentified. Incising the edge of the hypothenarmuscles reveals the deep motor branch as itcontinues around the hook of hamate.

Incising the volar carpal ligament, the palmarisbrevis muscle and the hypothenar fibrous tissuewill decompress the ulnar nerve within Guyon’scanal. The nerve need not be completelycircumferentially dissected out as this maydevascularize it. Distally, the interval between thepisohamate and pisometacarpal ligaments isexplored for any masses, fibrous bands or fracturefragments. The superficial branch passessuperficial to the fibrous arch of the hypothenarmuscles. The ulnar artery must be examined atthis point to ensure that it is free of aneurysm orthrombus – it should be smooth and not tortuous.

Structure at risk

A crossing cutaneous nerve between the ulnarnerve and the skin exists in 15 per cent of casesand must be protected.

4th commondigital nerve

Ulnar properdigital

nerve to thesmall finger

Hypothenarmuscle

Deep motorbranch

of the ulnarnerve

Pisohamateligamnet

Ulnarnerve

Ulnarartery

Pisifrom Palmar carpalligament

Thenar muscle

Figure 5.4 The relations of Guyon’s canal

Despite the ability to accurately diagnose thesite of compression, surgical decompressionshould involve exposure of the nerve from thedistal forearm to the hand distal to thebifurcation. The commonest causes ofcompression are ganglia, other space-occupyinglesions, fracture fragments and a thrombosed ulnarartery. The tourniquet should be deflated toensure that there is no iatropathic injury of theulnar artery and to achieve haemostasis.


Extensile measures

The incision may be extended proximally to theforearm. The deep fascia is incised on the radialborder of FCU. A plane is developed between theFCU and the flexor digitorum superficialis (FDS),retracting the FCU to the ulnar side, revealing theulnar nerve.

Closure

Skin closure is performed with 4-0 interruptednylon sutures and a bulky, compressive handdressing is applied.


The bandage is removed 3–7 days followingsurgery, and active finger motion is encouragedat all times. Sutures are removed at 10–14 dayspostoperatively.


Green DP. Green’s Operative Hand Surgery, 5thedn. Philadelphia: Elsevier, 2005.Polatsch DB, Melone CP, Beldner S, et al. Ulnarnerve anatomy. Hand Clin 2007;23:283–9.Waugh RP, Pellegrini DV. Ulnar tunnel syndrome.Hand Clin 2007;23:301–10.

Flexor carpi ulnaris

Ulnar nerve

Ulnar artery

Figure 5.5 The incision for ulnar nerve decompression at the wrist

Volar carpalligament

Ulnar nerveand artery

Flexorcarpi ulnaris

Figure 5.6 Incision of the volar carpal ligament

ULNAR NERVE DECOMPRESSION ATTHE ELBOW


Indications

• Ulnar nerve compression with or withoutrecurrent subluxation of the nerve

• Exploration of the ulnar nerve in trauma.

Contraindication

Active overlying skin infection.

Operative planning

A full neurological examination of the upper limbmust take place. This should include anexamination of the cervical spine as well aseliciting Tinel’s sign at the elbow and wrist. Unlikein carpal tunnel disease, neurophysiologicalexamination should be performed in almost allcases.

It is the authors’ preferred choice to manage themajority of cases with simple decompression. Otheroptions include partial medial epicondylectomy ornerve transposition procedures (which can besubcutaneous or submuscular). Partial medialepicondylectomy can be useful where there issignificant extrinsic pressure on the nerve (e.g. anosteophyte). Transposition remains controversialbecause of an increased incidence of haematomaand infection without convincing improvements inresults.

Consent and risks

• Nerve injury to the ulna, median or the medialantebrachial nerve (the commonest at 4 percent)

• Medial elbow tenderness: 10 per cent• Failure to relieve symptoms and recurrence: 10

per cent• Elbow stiffness: 5–10 per cent• Elbow instability associated with medial

epicondylectomy: 1–5 per cent

Ulnar nerve decompression at the elbow 51


The procedure may be carried out under regionalor general anaesthesia.

The authors prefer a medial approach as thisavoids incision directly over the nerve. It alsoallows early visualization of the medialantebrachial cutaneous nerve of the forearm. Thepatient is positioned supine on an operating tableand the arm is positioned on a padded arm table,in supination, with the shoulder externallyrotated. If a posterior approach is used, the patientis positioned in the lateral decubitus position withthe arm placed in front of the chest, resting on apadded arm gutter. If a tourniquet is used it isinflated to 250 mmHg. The authors do notroutinely use a tourniquet as pre-infiltration withlocal anaesthetic mixed with adrenaline providesexcellent postoperative analgesia as well as a clearfield for surgical dissection.

SURGICAL TECHNIQUE

Landmarks

The olecranon can easily be palpated posteriorlyas it is a subcutaneous structure. Similarly themedial epicondyle is easily palpated. The nerveruns between these two structures and is at itsmost superficial at this point. Figure 5.7 shows therelations of the ulnar nerve at the elbow.

Tricepsmuscle

Arcade ofStruthers

Medial intermuscularseptum

Ulnar nerve

Articular branch

Cubital tunnel retinaculum(Osborne’s ligament)

Motor branchto FCU

Osborne’sfascia

Flexorcarpi

ulnarismuscle

Flexor-pronatormass

Olecranon

Brachial artery

Brachial nerve

Medial epicondyle

Biceps muscle

Figure 5.7 The relations of the ulnar nerve

Medial approach

The medial incision starts 5 cm proximal to themedial epicondyle and extends distally to liemedial to the ulna distal to the elbow joint. It isadvisable to place the skin incision anterior to themedial epicondyle so that the nerve does not liedirectly under the skin wound. This preventsscarring directly over the nerve and the medialcutaneous nerve of the forearm branch can bevisualized. It is also less likely that a painfulmedial pressure area will occur. Subcutaneoustissues are reflected proximally and distallyexposing the cubital tunnel retinaculum.

Posterior approach

This is recommended for the identification of thenerve in complex elbow trauma.

A longitudinal incision is made in the midlineapproximately 5 cm above the olecranon. Theincision is curved laterally around the lateral sideof the olecranon process and then curved mediallyso that the incision lies over the middle of the ulnadistally. Curving the incision laterally moves thesuture line away from the midline and avoids anypotential pressure area over the olecranon process.The subcutaneous tissues are then dissectedmedially to expose the medial epicondyle. Theadvantage of the posterior approach is thatfrequently patients may have other elbowdisorders requiring surgery (e.g. rheumatoidarthritis) and further incisions may be performedthrough the same scar. The disadvantage is thatconsiderable dissection is necessary to expose themedial side adequately.

Deep dissection

The ulnar nerve is identified proximal to thecubital tunnel by blunt dissection. It is firstreleased at the arcade of Struthers (the hiatus inthe medial intermuscular septum through whichthe ulnar nerve enters the posteriorcompartment). The roof of the cubital tunnel isOsborne’s ligament (the cubital tunnelretinaculum) proximally and Osborne’s fascia(the deep component of the aponeurosis of thetwo heads of FCU) distally. The nerve is followeddistally and Osborne’s ligament is incised from


proximal to distal. The veins lying on the dorsalsurface of the medial intramuscular septumshould be identified and coagulated. The nerve istraced into the two heads of the FCU to ensurerelease distally. At this stage it is important toidentify and protect the motor branch to the FCU.

The nerve should not be dissected from itsgroove as this may lead to subluxation anddevascularization. After release, the elbow ismoved through its full range; the nerve should belax in full extension and should remain in thegroove in full flexion. Residual adherentstructures should be released and if subluxation isa problem then medial epicondylectomy orsubcutaneous transposition should be considered.

Medial epicondylectomy

This procedure is useful in patients with a medialepicondyle fracture non-union or space-occupyinglesions within the cubital tunnel (e.g. medialosteophyte, exostosis or ganglion). Routinedecompression is performed, after which thecommon flexor origin is elevated off the medialepicondyle in a subperiosteal manner.. A sleeve isleft around the bone to ensure smooth closure andhaemostasis. A partial medial epicondylectomy isperformed with a narrow osteotome; bone waxcan be placed on the exposed cancellous bone.The periosteal sleeve is closed over the epicondylestump with a heavy Vicryl suture; this should bedone in full extension so that an extension lag isavoided.

The anteroinferior medial collateral ligamentsmust be avoided and no more than 20 per cent ofthe depth of the epicondyle should be excised toprevent elbow instability.

Subcutaneous transposition

The theory behind transposing the nerve is toreduce tensile stress on the nerve. This occursduring traction on the nerve in flexion and leads toan increased intraneural pressure and flattening ofthe nerve around the medial epicondyle. Thisincreased pressure may cause temporaryischaemia.

The medial intramuscular septum must bedivided to ensure tension-free transposition. It is

essential that the longitudinal vascular supply ofthe nerve is left intact and that the motorbranches are protected and allowed to move withthe main body of the nerve.

Once the nerve is decompressed and easilytransposable anterior to the medial epicondyle, asubcutaneous fascial flap is elevated with a scalpel.The nerve is placed anterior to the deep surface ofthe flap and the distal flap edges are sutured todeep dermal tissue with an absorbable 3-0 Vicrylsuture. The wound is then closed as normal.

Closure

The wound is closed with interrupted 2-0 Vicrylsutures for the subcutaneous layer and a runningsubcuticular monofilament suture for skin. If atourniquet has been used it should be released andfollowed by meticulous haemostasis. A steriledressing should be applied and then a compressivedressing over it.


Dressings are removed at 3–4 days. Range ofmotion exercises within the limits of comfortshould be started at the same stage. Active handand wrist motion is encouraged at all times.

The wound should be checked at 2 weeks andthe patient advised on appropriate care of the scar.Heavy lifting should be avoided for 1 month. It isimportant to counsel the patient that not allsymptoms may be relieved by the surgery and thatrecovery may take up to 6 months.


Catalano LW, Barron OA. Anterior subcutaneoustransposition of the ulnar nerve. Hand Clin2007;23:339–44.Mowlavi A, Andrews K, Lille S, et al. Themanagement of cubital tunnel syndrome: a meta-analysis of clinical studies. Plast Reconstr Surg2000;106:327–34.O’Driscoll SW, Jaloszynski R, Morrey BF, et al.Origin of the medial ulnar collateral ligament. JHand Surg Am 1992;17:164–8.Osterman AL, Spiess AM. Medial epicon -dylectomy. Hand Clin 2007;23:329–37.

Principles of surgery on peripheral nerves 53

Waugh RP, Zlotolow DA. In situ decompression ofthe ulnar nerve at the cubital tunnel. Hand Clin2007;23:319–27.

PRINCIPLES OF SURGERY ONPERIPHERAL NERVES


The aims of surgery are:• To confirm a diagnosis and establish prognosis• To restore function• To relieve pain.

Indications

• Closed traction injury of the brachial plexusleading to severe paralysis

• Associated nerve and vascular injury• Nerve injury with an associated fracture

requiring early internal fixation• Increasing progression of a neurological injury

or an entrapment neuropathy• Failure of recovery of a lesion within an

expected timeframe• Failure of recovery in conduction block within

6 weeks of injury• Persistent pain following injury• Severe paralysis of a nerve following blunt

trauma.

Contraindications

• Active infection• Function unaffected by nerve injury.

Operative planning

Earlier surgery following nerve injury permitseasier identification of tissues (due to less scar

Consent and risks

• Infection• Nerve damage/failure of repair• Vascular injury• Specific to the site of operation, e.g. local

structures at risk

tissue) and therefore any repair is easier as it ispossible to visualize and match the arrangementof the cut ends of the nerve fascicles. The resultsof prompt repair are also markedly better due thefavourable biological environment for nervehealing. A nerve stimulator should be available.Magnification of at least three times with loupes ishelpful. If nerve grafting is likely to be performed,a suitable donor graft should be identifiedpreoperatively and the patient made aware of theneed.


Surgical procedures involving the exploration/repair of peripheral nerves should be performedunder general anaesthesia, with antibiotic cover tominimize the chance of any postoperativeinfection. Where possible, a tourniquet is used toachieve a completely bloodless field, facilitatingease of identification of structures. Rememberthat after approximately 15 minutes of ischaemia,nerve conduction becomes abnormal so anytourniquet should be released when stimulating anerve.

SURGICAL TECHNIQUE

Incision

The course of cutaneous nerves should always beremembered when planning a skin incision. Apainful neuroma may result from a transectedcutaneous nerve and lead to considerablemorbidity to the patient.

Nerve assessment

When nerves have been damaged and surgery hasbeen delayed, a neuroma will have formed. Theconsistency of a neuroma is important whenassessing nerve injury, as a hard neuroma mayrepresent an abundance of connective tissue andlittle in the way of nerve tissue. Making an incisionthrough the damaged epineurium permitsvisualization of any nerve bundles present, andstimulation of the nerve proximally. This may givesome indication as to likely recovery. Stimulatingthe nerve proximally and recording from thenerve distally gives the best guide for recovery. An


absence of recording distally is a relativeindication to resect and repair the nerve,depending on the macroscopic fascicular structureseen. Care should be taken not to undertakeexcessive mobilization, as this may lead todevascularization of a nerve.

Bipolar diathermy should be used at all timeswhen coagulating blood vessels around nerves.

METHODS OF REPAIR

Primary repair

The ends of an injured nerve are cut backprogressively until the cut surfaces show bulginghealthy nerve bundles. An end-to-end anastomosisis performed, which is possible if the resection gaphas been small, little mobilization of the nerve hasbeen necessary, and the nerve is not under tension.Flexing a nearby joint reduces tension on a nerve,and extra length can be gained by transposition(e.g. anterior transposition of the ulnar nerve) of anerve. The two principal types of primary repairare epineural repair and fascicular repair.Epineural repair is technically less demanding andfaster to complete. Fascicular repair (Fig. 5.8) isperformed if there has been a clean transection ofa nerve trunk (e.g. in the brachial plexus). In eachmethod of repair the true epineurium is exposed.In a fascicular repair the matched bundles areopposed and sutured with perineurial 11-0 nylonsutures and then 10-0 nylon sutures are passedthrough the perineurium and epineurium. This isdone circumferentially to complete the repair. Inan epineurial repair (Fig. 5.9), the fasciculargroups in the nerve ends are matched as closely aspossible and the ends are then sutured with 10-0nylon sutures through the epineurium. An initialsuture is placed at each of the lateral ends of thenerve, with interrupted sutures subsequentlyplaced on the anterior and posterior aspect of thenerve to complete the repair.

Nerve grafting

Cable grafts (Fig. 5.10) are the gold standard forbridging gaps between two cut ends of a nervewhere primary repair is not possible. Nervebundles are matched to bundles; this is achievedby viewing and matching the nerve ends either

Principles of surgery on peripheral nerves 55

using loupes or a microscope, using magnificationto get the best possible match. Cable grafts consistof multiple cutaneous nerve strands from a donornerve. The commonest donor nerves used are themedial cutaneous nerve of the forearm and thesural nerve in the lower limb. As many grafts asrequired are used to give good coverage of the cutface of the nerve. The length of the graft should beapproximately 15 per cent longer than the gap tobe bridged. The grafts can either be fixed with atissue glue or sutured in place. If a gap to bebridged is greater than 10 cm, grafting is unlikelyto be of great benefit.

If a nerve has been severely damaged to theextent that repair and grafting are not possible,nerve transfer (neurotization) is performed: adistal nerve is reinnervated using an intact donorproximal nerve.


After nerve decompression, patients are told toleave their bulky dressings in place until theyhave a wound inspection 2 weeks postoperatively.Instruction to begin early hand and fingermobilization is encouraged in upper limb surgery.

Figure 5.8 Fascicular nerve repair

Figure 5.9 Epineural repair Figure 5.10 Cable nerve grafting

After nerve repair and grafting, the limb isgenerally protected in a plaster with a sling (orcrutches in the lower limb) for a period ofbetween 3 and 6 weeks. Either outpatient orinpatient therapy (as in the case of a brachialplexus repair) is required to overcome anyresidual stiffness and deformity. This may includeappropriate splintage and is often multi -disciplinary, with occupational therapy,physiotherapy and pain team input.

PRINCIPLES OF BRACHIAL PLEXUSSURGERY


The principles of brachial plexus surgery aresimilar to those of other peripheral nerveoperations (see previous section).

The five roots of the brachial plexus lie in theposterior triangle of the neck between scalenusanterior and scalenus medius muscles. Injuriesbetween the posterior root ganglion and the spinalcord are termed preganglionic. The three trunks ofthe brachial plexus lie in front of one another andin the posterior triangle of the neck. The divisionsof the plexus lie posterior to the clavicle. Themedial, lateral and posterior cords of the plexusare related to the second part of the axillary arterydeep to pectoralis minor.

Indications

• Section/rupture/avulsion of the plexus• Associated vascular and nerve injuries• Open wounds• Compressive neuropathy.


The procedure is performed under generalanaesthesia, with the patient supine and the headelevated to approximately 30°.

SUPRACLAVICULAR APPROACH TO THEBRACHIAL PLEXUS

• Cervical and brachial plexus (root/trunk)surgery


• Spinal accessory nerve surgery• Suprascapular nerve surgery• Sympathetic chain surgery.

Landmarks

The landmarks for the supraclavicular approachare those of the posterior triangle of the neck. Thebase is formed by the clavicle, the medial border isformed by the medial border of thesternocleidomastoid muscle, and the lateral borderby the edge of the trapezius muscle.

Incision

The skin incision is made approximately onefinger’s breadth above the clavicle in line with thebone. Care must be taken not to damage thesupraclavicular nerves, as a painful neuroma maydevelop.

Dissection

Skin flaps are raised exposing the apex of theposterior triangle superiorly and the clavicleinferiorly. Next the plane between externaljugular vein and the sternocleidomastoid isdeveloped, with the omohyoid muscle displayedinferiorly in the wound. The muscle is divided andreflected. Deep to the fat pad, the transversecervical artery is present and is at risk; it is ligated.The phrenic nerve is visualized running acrossscalenus anterior. The nerve is followedproximally, revealing C5. The deep cervical fasciais incised and C5 and C6 are seen emergingfrom the lateral aspect of scalenus anterior; C7is visualized between scalenus anterior and theupper trunk. The lower trunk is seen followingdivision of scalenus anterior. C8 and T1 arevisualized by following the plane between thesubclavian artery and the lower trunk.

Structure at risk

• Supraclavicular nerves

INFRACLAVICULAR APPROACH TO THEBRACHIAL PLEXUS

Indications

• Complete exposure of brachial plexus (whencombined with supraclavicular approach)

• Infraclavicular brachial plexus repair.

Dissection

Essentially this is analogous to the deltopectoralapproach to the upper humerus. The differencelies in mobilizing the cephalic vein medially anddetaching and reflecting the pectoralis minormuscle from the coracoid process. In a fullexposure, the pectoralis major insertion on thehumerus may also be detached.

FIOLLE DELMAS APPROACH

Indications

The Fiolle Delmas approach combines thesupraclavicular and infraclavicular approaches andis useful in an extensive injury to the plexus.

Incision

The platysma, with skin flaps is elevated and themid-portion of the clavicle is exposed superiorlyand inferiorly. An extension is made of the collarincision to expose the supraclavicular portion (Fig.5.11). This extension starts at around the mid-portion of the supraclavicular incision and extendsdistally over the mid-portion of the claviclerunning over the delto-pectoral groove to theaxilla. It is a true extensile approach and can becontinued distally, if necessary, as the anteriorapproach to the humerus. When the infra clavi -cular is combined with the supraclavicularapproach, full exposure is given from the secondpart of the subclavian artery to the terminalportion of the axillary artery, with exposure of thebrachial plexus from the spinal nerves to terminalbranches of the plexus.

Dissection

A clavicular osteotomy may be required to

Principles of brachial plexus surgery 57

facilitate access, especially if there is a vascularinjury. In this case a plate should be precontouredand holes predrilled for easy fixation at the end ofthe procedure, remembering that the bone will beshortened by the thickness of the saw blade.Distally the pectoralis major muscle is detachedfrom the humerus in its upper portion or, ifrequired, its entirety. The muscle is then reflectedmedially exposing the clavicle, pectoralis minormuscle and the clavipectoral fascia (Fig. 5.12).The pectoralis minor muscle is divided at itstendon taking care not to damage themusculocutaneous nerve. The subclavius muscle isdivided with the suprascapular vessels (onceligated). This exposes the entire plexus andvasculature from the first rib to the axilla.


Following nerve repair/transfer, the limb mayrequire immobilization in a cast for 3 weeks afterwhich the patient can start motion progressively.In the case of brachial plexus surgery, a sling isapplied with a body strapping for 3 weeks,followed by readmission for a week at 6 weekspost index operation to start the rehabilitationprocess.

Figure 5.11 Incision for the Fiolle Delmas approach tothe brachial plexus


Birch R, Bonney G, Wynn Parry CB. SurgicalDisorders of the Peripheral Nerves. London:Churchill Livingstone, 1998.

Henry HK. Extensile Exposure, 2nd edn.Edinburgh: Churchill Livingstone, 1957.Tupper JW, Crick JC, Mattich LR. Fascicular nerverepairs. Orthop Clin North Am 1988;19:57–69.


Subclavian vein

Deltoid

Subclaviusdivided

Pectoralis majordivided

Pectoralis minorFigure 5.12 Dissection in the Fiolle Delmasapproach to the brachial plexus

Viva questions

1. Describe the landmarks and incision for acarpal tunnel decompression.

2. Describe the main structures at risk in a carpaltunnel decompression.

3. What are the sites of compression of the ulnarnerve at the elbow?

4. What are the surface landmarks for Guyon’scanal?

5. Which structures commonly cause ulnar tunnelcompression neuropathy at the elbow?

6. Describe the techniques used in primary nerverepair.

7. What options are available if primary repair isnot possible?

8. What are the principal considerations forsuccessful nerve transfer surgery?

9. What are the priorities in gaining functionafter brachial plexus injury?

Surgery of the shoulder6

Omar Haddo and Mark Falworth

Diagnostic shoulder arthroscopy 59Anterior acromioplasty – open 62Arthroscopic subacromial decompression 64Acromioclavicular joint excision 65Rotator cuff repair – open/arthroscopic 66

Acromioclavicular joint reconstruction – modified Weaver–Dunn 69

Shoulder stabilization – open 71Anterior repair for instability – arthroscopic 74Total shoulder replacement 75Viva questions 78

DIAGNOSTIC SHOULDERARTHROSCOPY


Common indications

Diagnosis is often made on the basis of history,examination and investigations. However,diagnostic shoulder arthroscopy remains a usefultool in the armament of the orthopaedic surgeonas some pathologies remain difficult to diagnosewith standard non-invasive investigations.Diagnostic arthroscopy therefore offers theopportunity to establish or confirm a diagnosis

with the possibility to proceed to treatment withthe appropriate consent.

Diagnostic arthroscopy is most frequently usedfor:• Undiagnosed shoulder pain• Complex instability, including humeral avul-

sion of the glenohumeral ligaments (HAGL)lesions

• Small/partial thickness rotator cuff tears.

Contraindications

• Infection of overlying skin• Lack of proper arthroscopic instrumentation• Gross osteoarthritis is a relative contra -

indication.

Consent and risks

• Nerve injury: the musculocutaneous nerve(anterior portal) and the axillary nerve (lateralportal) are most at risk. The suprascapular nervecan be damaged by the inexperiencedarthroscopist

• Chondral or labral injuries: relatively uncommon• Fluid imbalance due to fluid extravasation• Infection: very rare• Vascular injury: very rare


• Internal rotation 30°• Flexion 30°• Abduction 30°

Shoulder Range of motionExternal rotation 80°

Internal rotation 90°

Flexion 180°

Abduction 180°

Operative planning

Recent radiographs and when relevant, ultra -sound, computed tomography (CT) and magneticresonance (MR) images (± arthrograms), shouldbe available. Although only basic equipment isnecessary for a diagnostic procedure standardequipment should be available so that therapeutictreatment can be undertaken if necessary. Thisincludes:• Camera with imaging and recording equipment• Xenon light source• Fluid management system (pump set at 30–70

mmHg)• 5 mm 30° scope with high-flow sleeve• Shaver• Vaporizer• Arthroscopic instruments• Cannulas• Arthroscopic implants.


General anaesthesia is preferred with the use of aninterscalene block if certain procedures areplanned. The choice of patient positioning is verymuch surgeon dependent:

• If the lateral position is used, the patient shouldbe as far back towards the edge of the table aspossible, with 15° of posterior tilt (horizontalglenoid). Front and back supports are requiredto secure the patient. The patient’s head isplaced in a gel ring. Four kilograms oflongitudinal skin traction is applied with thearm in 30–50° abduction and 20–30° forwardflexion (Fig. 6.1). The brachial plexus should bepalpated to ensure that it remains soft and thatexcessive traction is not being applied

• If the beach chair position is used, theappropriate operating table (with removablelateral corner) is required. The patient’s head isappropriately secured. Traction can be addedbased on surgeon preference. This approach ishelpful if progressing to an open procedure.

The surgical field is prepared with a germicidalsolution and waterproof drapes are used withadhesive edges to provide a seal to the skin.

SURGICAL TECHNIQUE

Landmarks

• Spine of the scapula• Posterolateral corner of the acromion, lateral

acromion, and anterolateral corner of acromion• Distal clavicle and acromioclavicular joint

(ACJ)• Tip of the coracoid.

Portals

The accurate placement of arthroscopic portals isessential in shoulder arthroscopy. A variety ofportals can be used. The commonest viewingportal is the posterior portal. A stab incision to theskin is placed 2 cm medial and 2 cm inferior to theposterolateral corner of the acromion. Thiscorrelates to a palpable soft spot which denotesthe plane between the infraspinatus and teresminor.

To access the glenohumeral joint, the scope isaimed inferomedially towards the tip of thecoracoid. The glenoid rim and the humeral headcan be palpated and the scope can be pushedbetween them. A popping sensation is usually felt

60 Surgery of the shoulder

Traction

Figure 6.1Positioning andtraction for shoulderarthroscopy

as the joint is entered. Once the posterior portal isestablished all other portals are made using anoutside-in technique in which a spinal needle isused to determine the exact location and angle ofentry into the joint.

A standard low anterior portal can also be usedfor passing instruments into the joint. It is placedabove the lateral half of the subscapularis butmedial to the medial biceps pulley. Once theneedle has been placed in the appropriate positionthe portal is made using a size 11 scalpel, which isinserted in the same direction as the needle takingcare to avoid the long head of the biceps (LHB).

To enter the subacromial space, the sameposterior portal skin incision is used; however, thescope is aimed superolaterally towards theanterolateral corner of the acromion. The scope

must enter the bursa and show the acromion andthe bursal aspect of the cuff clearly. If cobweb-liketissue is seen, then the scope is outside the bursaand should be repositioned. This is important asthe bursa helps to contain the irrigation fluid, thuslimiting soft tissue swelling around the shoulder.

The lateral portal is 5 cm (three fingers breadth)distal to the acromion and 1 cm anterior to themid-lateral line (in line with the posterior line ofthe ACJ). This portal is used for instrumentationof the subacromial space (Fig. 6.2).

Other portals can be made on demand. Theseinclude the anterosuperolateral, accessoryanterior, accessory lateral, accessory posterior andNeviaser (superior) portals. A cannula may beused if proceeding to a therapeutic procedure.Clear cannulas are recommended as they allowvisualization and aid in suture management.

Procedure

With the scope in the posterior portal, theglenohumeral joint is assessed first. By using theLHB tendon as a reference, the camera is adjustedso that the image is shown in the correct supero -inferior plane. The authors recommend thefollowing systematic way of assessing theshoulder:• The LHB should first be assessed at its insertion

at the superior glenoid tubercle. By raising thearm in 90° abduction and 90° external rotation,the presence of a SLAP (superior labrum fromanterior to posterior) tear can be assessed as thelabrum rolls off the glenoid rim (peel-backsign). The scope can then be turned laterallyand the intra-articular portion of the LHB,and that portion of the biceps tendon thatlies within the inter-tubercular grove, can beassessed.

• The stability of the LHB can then be visualizedby internally and externally rotating theshoulder. The medial sling/pulley can then beinspected before examining the subscapularistendon, superior glenohumeral ligament androtator interval in more detail. The sub scapu laris

A systematic approach is essential if pathology isnot to be missed.

Diagnostic shoulder arthroscopy 61

Lateralportal

Posteriorportal

Anteriorportal

2 cm2 cm

Figure 6.2 Common arthroscopic portals

tendon insertion can be best visualized with thearm in internal rotation.

• By gently withdrawing the scope and lookinglaterally, the posterior pulley of the LHB can beviewed and then the supraspinatus andinfraspinatus tendons can be examined. Thebare area and any Hill–Sachs lesions can now beidentified.

• As the arthroscope is taken further inferiorly itenters the inferior recess. The reflection of theinferior capsule and the posterior band of theinferior glenohumeral ligament (hammockeffect) can be seen. By then rotating the scope,the posterior inferior labrum can be visualizedand then the entire posterior and superiorlabrum examined before assessing the chondralsurfaces of both the humeral head andglenoid.

• The anterior stabilizing structures can now beexamined. Superiorly the sublabral foramen,labrum and the middle glenohumeral andanterior band of the inferior glenohumeralligaments can all be visualized.

• An anterior portal can be made through therotator interval for the introduction of a probefor further assessment of any soft tissuepathology or if any glenoid bone loss needs tobe further assessed.

• The subacromial space should then beexamined. Superiorly the acromion is seen,anteriorly the coracoacromial ligament andinferiorly the bursal side of the rotator cuff. Thepresence of bursal side rotator cuff tears,impingement lesions and acromial and ACJpathology can all be assessed.

This is just one example of a systematic assess -ment of arthroscopic shoulder anatomy. Eachsurgeon can develop their own system, however, itis essential that all surgeons are familiar witharthroscopic anatomy and normal variations.

Closure

Portals can be left unsutured or closed withsubcuticular 3/0 Monocryl sutures.


If the procedure is purely diagnostic no sling isnecessary. The patient is encouraged to mobilizeas soon as possible.


Levy O, Sforza G, Dodenhoff R, et al. Evaluationof the impingement lesion: pathoanatomy andclassification. Arthroscopic evaluation of theimpingement lesion: pathoanatomy and classifica -tion. J Bone Joint Surg Br 2000;82B(Suppl 3):233.

ANTERIOR ACROMIOPLASTY – OPEN


Common indications

• Impingement with failure of conservativemanagement

• In association with: rotator cuff repair, shoulderarthroplasty, malunion of greater tuberosityfracture.

Contraindications

Relative: Irreparable cuff tear to avoid superiorescape of the humeral head. (A limiteddecompression can be undertaken).

Consent and risks

• Infection• Neurovascular injury• Stiffness• Fracture of the acromion: can occur if the

osteotomy is performed in the wrong plane or ifexcess bone is resected

• Detachment of the deltoid• Failure of procedure: wrong indications,

incomplete decompression, missed cuff tear


Operative planning

Recent radiographs and, if necessary, ultrasound orMRI for rotator cuff assessment.


Anaesthesia is usually general, regional orcombined. Where general anaesthesia is usedalone, local anaesthetic is recommended for painrelief. The patient is in the beach chair position. Asmall sandbag is put under the operated shoulder.An arm board can be attached to the side of thetable to rest the arm on. The surgical field isprepared and adequately draped.

SURGICAL TECHNIQUE

Landmarks

• Acromioclavicular joint• Anterolateral corner of acromion• Tip of the coracoid.

Incision

This procedure is rarely performed as an isolatedopen procedure as it is most commonly per -formed arthroscopically or in association with alarger open procedure. As such, the skin incisionwill be dictated by the other procedure, however,if it is to be performed as an isolated openprocedure, a 2–3 cm anterosuperior incision ismade over the anterior acromion.

Dissection

The incision is continued through subcutaneousfat and down to deltoid fascia. The anteriordeltoid raphe is split in the line of its fibres. Theanterior acromion is located and then anosteoperiosteal flap raised such that a strongdeltoid repair can be performed at the end of theprocedure.

Procedure

Deep to the anterolateral tip of the acromion isthe coracoacromial ligament. A swab can be usedto sweep the soft tissue medially further exposing

the ligament and separating its medial borderfrom the clavipectoral fascia. An oscillating saw isused to excise the anteroinferior acromion. Theosteotomy is aimed so that it is in continuationwith the undersurface of the acromion (Fig. 6.3).The bony fragment, with its attached coraco -acromial ligament, is excised. Traction is appliedto the patient’s arm and the under surface of theacromion is smoothed using bone nibblers. Theunderlying rotator cuff should then be examinedfor any associated pathology.

Anterior acromioplasty 63

Figure 6.3 Thecorrect orientationfor the acromionosteotomy

Closure

A good deltoid reconstruction is essential. If thequality of the osteoperiosteal flaps is poor, atransosseous repair using no. 2 Ethibond isperformed followed by subcutaneous 2/0 Vicryland 3/0 Monocryl to skin.


Passive/active-assisted exercises are started fromday 1 to 90° forward elevation and 30° externalrotation for 3 weeks increasing to full range by 6weeks. Strengthening exercises can be started at 6weeks and repetitive overhead exercises at 3months.


Bigliani LU, Morrison D, April EW. Themorphology of the acromion and its relationshipto rotator cuff tears. Orthop Trans 1986;10:228.

Neer CS. Anterior acromioplasty for chronicimpingement syndrome in the shoulder – apreliminary report. J Bone Joint Surg Am1972;54:41–50.

ARTHROSCOPIC SUBACROMIALDECOMPRESSION


See ‘Anterior acromioplasty – open’ (p. 62).

SURGICAL TECHNIQUE

See ‘Diagnostic shoulder arthroscopy’ (p. 60) forpositioning and portals.

Procedure

The arthroscopic pump is set between 30 mmHgand 70 mmHg. The arthroscope is introducedthrough the posterior portal and a diagnosticarthroscopy performed. It is then introduced intothe subacromial bursa. The bursal surface of thecuff is inspected to confirm the presence of animpingement lesion (inflammation, rougheningand fibrillation). Next, the undersurface of theacromion is examined for a corresponding ‘kissing’lesion. The acromion can be further assessed usingan arthroscopic probe for any acromial hooks orspurs. The coracoacromial ligament is alsoinspected.

The lateral portal is used for instrumentation. Aspinal needle is used for the outside-in techniqueof portal placement. Although this portal is at thelevel of the axillary nerve, the nerve is not usuallythreatened as the instruments are aimedproximally towards the acromion. No cannula isrequired.

Soft tissue resection and haemostasis can beperformed with an electrocautery probe/vaporizer. The soft tissue on the undersurface ofthe acromion is then resected and the

Structure at risk

• Acromial branch of the coracoacromial artery

coracoacromial ligament detached. The lateraledge of acromion must be exposed to ensureadequate lateral decompression.

A barrel burr/shaver is used for bone resection.If the acromion has a lateral down-slope then alateral bevel is performed. The decompression isthen performed by excising the anterioracromion, from lateral to medial. The acromialbranch of the coracoacromial vessel is at risk atthis stage. Anterior resection is usuallyapproximately 4 mm (the width of the burr) oruntil the anterior deltoid attachment is reached.Medially, the resection is limited by the ACJ. Theundersurface of the acromion is then chamfered,to smooth out any ridges (Fig. 6.4).

Further refinement of the acromioplasty can beperformed by placing the arthroscope in thelateral portal and the shaver posteriorly. Anyresidual bone can be resected using the posterioracromion as a ‘cutting-block’, thus creating a flatundersurface to the acromion.

Closure

See ‘Diagnostic shoulder arthroscopy’ (p. 60).


See ‘Anterior acromioplasty – open’ (p. 62).


Lateral excisionand chanfer

Anteriorexcision

CA ligamentexcised

Figure 6.4 Arthroscopic subacromial decompression;CA, coracoacromial


Levy O, Sforza G, Dodenhoff R, et al. Evaluationof the impingement lesion: pathoanatomy andclassification. Arthroscopic evaluation of theimpingement lesion: pathoanatomy andclassification. J Bone Joint Surg Br 2000;82B(Suppl3):233.Gartsman GM. Arthroscopic acromioplasty forlesions of the rotator cuff. J Bone Joint Surg Am1990;72:169–80.

ACROMIOCLAVICULAR JOINTEXCISION


Indications

• Symptomatic ACJ arthritis not responsive toconservative treatment

• Large inferior osteophytes with secondaryimpingement

• Symptomatic ACJ intra-articular disc tear.

For contraindications/consent and risks/operativeplanning/anaesthesia and positioning, see‘Anterior acromioplasty’ (p. 62).

SURGICAL TECHNIQUE

Open

ApproachIf performed in combination with an openacromioplasty the same approach as previouslydescribed is made, although the incision andsubsequent dissection, will need to be extendedmedially. If performed in isolation, a 2–3 cm strapincision is made over the distal clavicle and then atransverse incision is made in the delto-trapezoidal fascia to expose the ACJ.

ProcedureRetractors are placed to expose the distal clavicleand then an oscillating saw is used to resectenough distal clavicle such that there is a 10 mmgap between the medial acromion and the

resected distal clavicle (Fig. 6.5). Care must betaken not to resect too much distal clavicleotherwise distal clavicular instability can occur.Any osteophytes on the undersurface of theacromion are trimmed with bone nibblers and anyresidual meniscus removed.

ClosureThe superior acromioclavicular ligament anddelto-trapezoidal fascia is then repaired. Ifperformed in association with an acromioplasty,the deltoid is repaired in the manner alreadydiscussed.

Arthroscopic

ApproachSee ‘Arthroscopic subacromial decompression’(p. 64). An anterior portal is required. This is firstlocalized with the insertion of a needle. Thisportal is 2–3 cm inferior to the level of the ACJ.

ProcedureThe ACJ is identified through the arthroscope bypalpating the distal clavicle. A shaver or vaporizercan be used through the lateral portal to exposethe ACJ. Scar tissue and the remnants of themeniscus are resected and any inferior osteophytesexcised. To ensure adequate visualization of theACJ the fibrofatty tissue in the region of thescapular spine and distal clavicle should beresected. An anterior portal is made using anoutside-in technique ensuring accurate placementof the portal such that ACJ excision is possible.

Acromioclavicular joint excision 65

1cm

Figure 6.5 Excision of the acromioclavicular joint

Operative planning

Recent radiographs, ultrasound or MRI.

Anaesthesia

Anaesthesia is usually combined general andregional.

Landmarks

• Acromioclavicular joint• Anterolateral and posterolateral corners of

acromion• Tip of coracoid.

SURGICAL TECHNIQUE – OPEN

Positioning

The patient is in the beach chair position. A smallsandbag is put under the shoulder. An arm boardcan be attached to the side of the table to rest thearm on. The surgical field is prepared andadequately draped.

Incision

An anterosuperior approach is used. An 8 cmincision is made just posterior to the anterior

Structure at risk

The axillary nerve is approximately 5 cm distal tothe lateral acromion and therefore the inferior limitof any incision must not extend beyond this point.This position corresponds to the lower limit of theinferior reflection of the subdeltoid bursa.

Consent and risks

• Infection• Neurovascular injury• Stiffness• Failure of the repair• Recurrence• Continued weakness/cuff-related pain


A barrel burr is used to excise the distal claviclefrom inferior to superior and from lateral tomedial. To ensure that adequate bone is resected,especially posteriorly, the entire circumference ofthe resected distal clavicle must be visualized.This is often only achieved if both the anteriorand posterior acromioclavicular ligaments areexcised. However, care must be taken not toexcise the superior acromioclavicular ligament orto resect too much bone as this can destabilize thejoint. The aim is for approximately 10 mm of boneresection from the medial acromial facet to thedistal clavicle. This can be assessed by measuring itagainst the width of the shaver.

ClosureSee ‘Arthroscopic subacromial decompression’(p. 64).


See ‘Arthroscopic subacromial decompression’(p. 64).


Flatow EL, Duralde XA, Nicholson GP, et al.Arthroscopic resection of the distal clavicle with asuperior approach. J Shoulder Elbow Surg1995;4:41–50.

ROTATOR CUFF REPAIR – OPEN/ARTHROSCOPIC


Common indications

• Shoulder pain, including night pain• Loss of function or quality of life• Traumatic rotator cuff tear• Failure of conservative management of a

chronic rotator cuff tear.

Contraindications

Degenerative changes of the glenohumeral joint –‘rotator cuff arthropathy’.

aspect of the ACJ and is directed towards theanterolateral corner of the acromion and downthe anterior deltoid raphe. A smaller incision canbe performed if an arthroscopic decompressionhas already been performed such that a mini-openprocedure can be undertaken.

Dissection

The deltoid is bluntly split at the anterior raphe(junction of the anterior and middle thirds). Thedeltoid is detached off the anterior acromion withan osteoperiosteal sleeve. The bursa is splitlongitudinally. The inferior reflection of the bursadenotes the position of the axillary nerve whichcan be palpated and avoided thereafter (Fig. 6.6).The coracoacromial ligament is detached from theundersurface of the acromion.

Procedure

Anterior acromioplasty (± ACJ excision) can becarried out as required. The size of the tear ismeasured and traction sutures are placed throughthe cuff. The cuff is then mobilized sequentially,initially with blunt dissection, however, a sharprelease of the superior capsule and thecoracohumeral ligament may be necessary. Inmassive retracted tears anterior and posteriorinterval slides may also be necessary. These can alsobe performed arthroscopically such that only a

mini-open approach need be adopted. The con -figura tion and tension of the mobilized cuff tear isthen assessed in order to plan the repair.

A shallow bony trough/footprint is preparedusing an osteotome (or burr in a mini open) at thelevel of tendon insertion. This should be made justlateral to the articular surface. The method of thetendon repair is determined by the operatingsurgeon.

Single and double row anchor repairs can beundertaken depending on the size of the tear oralternatively a transosseous suture repair can beperformed. In the latter method the tendon isrepaired with a no. 2 Ethibond Mason Allensuture. In each method the aim is to achievehealing of the tendon to the footprint.

Closure

A good deltoid reconstruction is essential. If thequality of the osteoperiosteal flaps is poor atransosseous deltoid repair, using no. 2 Ethibond,is performed. The deltoid raphe should be closedwith 2/0 Vicryl and then 2/0 Vicryl for closure ofthe subcutaneous tissues and 3/0 Monocryl toskin.

SURGICAL TECHNIQUE – ARTHROSCOPIC

Positioning

The beach chair or lateral positions can beadopted.

Portals

Posterior, anterior, lateral and accessory lateralportals are often required. The superior Neviaserportal can be useful for passing sutures throughthe cuff, particularly in massive tears.

Procedure

Glenohumeral arthroscopy is performed and anyconcurrent pathology assessed and treated asnecessary. The cuff is then assessed with respect toits size, shape and mobility. The arthroscope isthen inserted into the subacromial space and asubacromial decompression (± ACJ excision) isperformed as necessary. Any releases are then

Rotator cuff repair 67

Inferior reflectionof subdeltoid bursa

Axillarynerve

Figure 6.6 Therelationship of thesubdeltoid bursa tothe axillary nerve

undertaken and the footprint is prepared with thevaporizer and burr.

Various techniques are described for tendonfixation. The type of anchor and whether a singleor double row fixation is used remains debatable.However, the principle is to have a large contactarea between the tendon and the bone toencourage healing. To achieve this a variety ofarthroscopic instruments are required.

The suture anchor is inserted percutaneouslyor through the superolateral portal, such that thecorrect bone entry angle is achieved. Duringanchor placement the choice of viewing portalis often determined by the size of the tearwith small or partial tears requiring an intra-articular camera position and larger tearsrequiring visualization from the subacromial space.The sutures can now be passed using antegradetechniques, using suture passers, or with retrogradetechniques where penetrators or suture shuttlinginstruments are used. When passing sutures aposterior or lateral viewing portal is useddepending on the size and location of the tear.

Sutures are placed approximately 1 cm apart.Suture management is critical in rotator cuff repairsas it is easy to confuse or tangle the sutures. To avoiddifficulties only two sutures should be used perportal and if a cannula is not used then sutures mustbe passed through the same portal together to avoidinterposing soft tissue when tying knots. Knot tyingis done under direct vision in the subacromial space.For large and massive tears, side to side convergencesutures can be used to reduce the size of tear (Fig.6.7). The final construct can be viewed from boththe subacromial space and the glenohumeral jointto ensure footprint reconstruction.

Closure

Sutures are only used with cannula portals,otherwise Steri-Strips suffice.


• Small and medium tears:– Sling for 6 weeks– Passive/active assisted exercises to 30°

external rotation (if no subscapularis tear)and elevation to 90° for first 6 weeks

– Passive overhead elevation at 6 weekswith further increase in external rotation as able

– Active exercises once range is normal andstrengthening at 12 weeks.

• Large/massive tears:– Immobilize in sling (± abduction pillow)

sling for 6 weeks– Passive/active assisted exercises elevation to

90° and external rotation to 0° in thepresence of a subscapularis repair, otherwise30° for first 6 weeks

– Passive overhead elevation at 6 weeks withfurther increase in external rotation as able

– Active exercises at 12 weeks andstrengthening at 16 weeks.

These regimens can be modified depending on thesurgeon’s choice.


Sano H, Yamashita T, Wakabayashi I, et al. Stressdistribution in the supraspinatus tendon afterrepair – suture anchors versus transosseousfixation. Am J Sports Med 2007;35:542–46.


Figure 6.7 Side to side sutures used to reduce the sizeof a rotator cuff tear

Originaltear size

Side to sidesutures

reduces sizeof tear

ACROMIOCLAVICULAR JOINTRECONSTRUCTION – MODIFIED WEAVER–DUNN


Indications

• Chronic type IV–VI ACJ dislocation• Chronic type III in the young, athletic, manual

worker, dominant side (surgery on Grade III ACjoint dislocation is more controversial thanconservative treatment and is very muchsurgeon dependent).

Contraindications

Unreliable patient (important due to post -operative restrictions).

Operative planning

Radiographs – anteroposterior, 30° cephalic,axillary ± stress views – are required.


Anaesthesia is usually general, regional orcombined. Where general anaesthesia is usedalone, local anaesthetic is recommended forpostoperative pain relief.

The patient is placed in the beach chairposition. A small sandbag is put under theshoulder. An arm board can be attached to theside of the table to rest the arm on. The surgicalfield is prepared and adequately draped.

Consent and risks

• Infection• Neurovascular injury• Stiffness• Failure of the procedure or recurrence

Landmarks

• ACJ• Anterolateral corner of the acromion• Tip of coracoid

SURGICAL TECHNIQUE

The technique will vary depending on whether anacute or chronic injury is being addressed. Acuteinjuries do not require a ligament transferprocedure as part of the reconstruction. Chronicinjuries are best managed with a biologicalreconstruction which is supplemented by anotherfixation device until healing has occurredapproximately 3 months post repair.

Approach

A strap incision, 1 cm medial to the ACJ, andextending down to the coracoid.

Procedure

The delto-trapezoidal fascia is incisedlongitudinally along the distal clavicle with anextension across the superior acromioclavicularcapsule/ligament and further laterally over theanterior acromion. The deltoid fibres are elevatedoff the clavicle and, at the acromion, anosteoperiosteal flap is raised to aid later repair. Thecoracoacromial ligament is defined by sweepingbluntly laterally with a swab. It is then detachedfrom the acromion with a sliver of bone. It is thenmobilized down to the coracoid and a whipstitchapplied to the ligament with no. 2 Ethibond. Thedistal 1 cm of the clavicle is excised obliquely withan oscillating saw. The bone fragment is retainedfor later autologous bone graft.

The clavicle is reduced to its anatomical positionby reducing the arm back up to the clavicle and byfurther reducing the clavicle downwards andforwards. This position must be maintained priorto the ligament transfer. This can be achieved by anumber of techniques, including a Bosworthscrew, three strands of PDS cord (Johnson andJohnson) looped around the coracoid and clavicleor, with a TightRope reconstruction device(Arthrex Inc; Naples, FL, USA).

Acromioclavicular joint reconstruction 69

Once held in the reduced position two 2 mmdrill holes are then made in the superior cortex ofclavicle. The bony fragment of theacromioclavicular ligament is passed into theintramedullary canal and the two sutures arepassed through the holes, tensioned and tied (Fig.6.8). An autograft from the resected distal clavicleis then used to graft any redundant space aroundthe transferred ligament.

In acute cases (<3–4 weeks post injury) thecoracoclavicular ligaments and superioracromioclavicular capsule/ligament can berepaired and then supplemented with one of thestabilizing techniques described above. AWeaver–Dunn ligament transfer is not required.

Closure

A good delto-trapezoidal reconstruction isessential. If the quality of the anterior acromialosteoperiosteal flap is poor a transosseous repairusing No. 2 Ethibond is performed and in caseswith significant superior migration of the clavicleany redundant delto-trapezoidal fascia canundergo a ‘double-breasted’ repair with 1 Vicryladding further superior support to the

reconstruction; 2/0 Vicryl is used for closure ofthe subcutaneous tissues and 3/0 Monocryl is usedfor skin.


• Six weeks in a sling with passive, and activeassisted, forward elevation to 90° and externalrotation to 30°

• Progress to active shoulder movement, belowshoulder height, from 6 weeks with passivestretching above shoulder height at 10 weeks

• Strengthening at 12 weeks (if a Bosworth screwis used shoulder movement must be restrictedto below shoulder height until the screw isremoved at 3 months).


Fraser-Moodie JA, Shortt NL, Robinson CM.Injuries to the acromioclavicular joint. J Bone JointSurg Br 2008;90:697–707.Weaver JK, Dunn HK. Treatment of acromio-clavicular injuries. J Bone Joint Surg Am1972;54:1187–93.


Figure 6.8 Acromioclavicular joint reconstruction

SHOULDER STABILIZATION – OPEN


Primary indication

• Recurrent instability: traumatic structural (typeI) and atraumatic structural (type II)

• Relative indication: acute traumatic dislocation.

Contraindications

• Muscle patterning instability (type III)• If used in isolation in the presence of a large

glenoid bone defect• Unsuitable for anaesthesia.

Operative planning

Recent radiographs and CT/MRI arthrogramshould be available to the surgeon. Examinationunder anaesthetic ± diagnostic arthroscopy shouldbe performed prior to the procedure.

SURGICAL TECHNIQUE –ANTEROINFERIOR STABILIZATION


Anaesthesia is usually general, regional orcombined. Where general anaesthesia is usedalone, local anaesthetic is recommendedpostoperatively to aid pain relief.

The patient is placed in the beach chairposition. A small sandbag is put under the medialscapula of the operated shoulder (this helps toexternally rotate the shoulder and ‘open’ theanterior shoulder joint). An arm board can beattached to the side of the table to rest the arm

Consent and risks

• Infection• Stiffness, particularly loss of external rotation• Recurrence• Subscapularis detachment.• Neurovascular injury

on. The surgical field is prepared and adequatelydraped.

Examination under anaesthesia

The humeral head is translated anteriorly andposteriorly, the direction noted and its excursion isgraded:• 1 – minimal• 2 – to the edge of the labrum• 3 – dislocates.

Landmarks

• Tip of the coracoid• Axillary fold.

Incision

The skin incision runs in the deltopectoral groove,from the coracoid to the axillary fold (with thearm adducted and internally rotated).


The subcutaneous tissue is reflected with sharpand electrocautery dissection, exposing thedeltopectoral interval which is marked by a fattystreak and the cephalic vein. The fascia overlyingthe interval is divided and the cephalic veinlateralized with the deltoid muscle. The deltoidand pectoralis major are then defined with sharpand electrocautery dissection.

Deep dissection

A retractor can be placed over the coracoidprocess to enhance the exposure and the

Structure at risk

• Musculocutaneous nerve – in danger fromexcessive traction

Structure at risk

• Cephalic vein

Shoulder stabilization 71

clavipectoral fascia is then split vertically startingjust lateral to the coracoid. This exposes theconjoint tendon. If required, the lateral third ofthe conjoint tendon can be divided to allow betterexposure (by not detaching the coracoid or thetendon fully, the musculocutaneous nerve isprotected from excessive traction). A self-retaineris placed between the coracoid/conjoint tendonmedially and the deltoid muscle laterally.

The arm is externally rotated to expose thesubscapularis muscle. The upper two-thirds of thesubscapularis can then be tenotomizedapproximately 1 cm from its insertion in the lessertuberosity and dissected free of the underlyingcapsule. This plane is more easily found inferiorlyand becomes easier as the dissection progressesmedially. Alternatively, the subscapularis can besplit horizontally and retracted, exposing theunderlying capsule.

Procedure

The capsulorrhaphy must now be undertaken.This can be performed either laterally or medially.It is the authors’ preference to perform thismedially as we feel it gives a more accurateanatomical reconstruction and a morereproducible elimination of the axillary pouch.

To achieve a large inferior capsular shift thecapsule must be dissected off all of its muscularattachments inferiorly and, indeed, postero -inferiorly in cases of marked laxity. This is bestachieved with McIndoe scissors. A bone lever canthen be placed inferior to the humeral neck thusprotecting the axillary nerve. Depending on thedegree of laxity the capsulorrhaphy can involveeither a vertical capsular incision or, in cases ofgreater laxity, a medially based ‘T’.

The capsule is split vertically 7–10 mm fromthe glenoid rim, with a further horizontal incisionmade midway along the capsule as necessary (Fig.6.9). Two stay sutures are placed to mark thesuperior and inferior apices of the flaps. A Fakudaretractor is used to displace the humeral headposteriorly such that the anterior labrum isexposed. The presence of a Bankart lesion, and thedegree of capsule–labral disruption, can now bevisualized.

The anterior glenoid neck is decorticated usinga narrow osteotome or burr and anchors are used

to reattach the anterior labrum to thedecorticated area of the glenoid neck. Thecapsular flaps are overlapped so that the inferiorflap is taken superiorly and medially such that it issutured to the medial capsule. A double-breastedsuture technique using 1 Vicryl should be used.The superior flap is then sutured inferiorly takingcare not to medialize the flap otherwise externalrotation will be restricted. The rotator interval isthen closed (Fig. 6.10).

During the repair, the arm should be held in30° of external rotation and abduction so that therepair is not over tightened thus causing


Subscapularissplit

Figure 6.9 The medial ‘T’-shaped capsular incision

Inferiorcapsular shift

Figure 6.10 Medially based inferior capsular shift

postoperative stiffness. Adequate stability and agood passive range of motion should be confirmedbefore the wounds are closed.

If a large, engaging Hill–Sachs lesion is presenta bone block procedure (Bristow–Latarjet or iliaccrest bone graft) will be required to increase thedepth of the glenoid to prevent recurrentdislocation. A soft tissue procedure alone will notbe adequate to restore stability.

Closure

If previously tenotomized, the subscapularisshould be repaired with no. 2 Ethibond.Thereafter, a layered closure using 2/0 Vicryl forthe subcutaneous tissues and 3/0 Monocryl to skinis used.

SURGICAL TECHNIQUE – POSTERIORSTABILIZATION

Cases of posterior instability will warrant aposterior reconstructive procedure.


Anaesthesia is usually general, regional orcombined. The patient is positioned in the proneposition.

Incision

A 15 cm posterior vertical incision which extendsover the spine of the scapula in the plane of theACJ gives good access to posterior structures ofthe shoulder.

Dissection

Posteriorly, the deltoid has a tendinous insertionon to the posterior spine of the scapula. This canbe incised and reflected inferiorly giving good

Structures at risk

The posterior circumflex humeral artery and axillarynerve run together in the quadrilateral space, belowteres minor. It is therefore safe provided that thecorrect plane of dissection is used.

access to the underlying infraspinatus and teresminor tendons. More laterally an osteoperiostealflap should be raised off the posterior lateralcorner of the acromion with, if necessary, a furtherextension down the posterior deltoid raphe.

The interval between the infraspinatus andteres minor can be developed by blunt dissectionexposing the posterior capsule.

Procedure

The procedure for the repair of a posterior labralinjury and /or capsular laxity is similar to thatdescribed for an anteriorly based injury. A medialor laterally based capsulorrhaphy can beperformed although we favour the former for thereasons described earlier.

Closure

The infraspinatus and teres minor do not needformal closure; however, meticulous repair of thedeltoid should be undertaken. Thereafter 2/0Vicryl to superficial tissues and 3/0 Monocryl toskin is advocated.


A polysling with body belt is used for the first 4weeks. At 4 weeks, the body belt is removed andpendular exercises started. At 6 weeks passivestretching exercises are undertaken aiming for fullelevation but only half the external rotation of thecontralateral side by 3 months. Strengtheningexercises are begun at 6 weeks. Contact sportsmust be avoided for 6–9 months.


Itoi E, Hattakeyama Y, Kido T, et al. A newmethod of immobilisation after traumatic anteriordislocation of the shoulder: a preliminary study. JShoulder Elbow Surg 2003;12:413–15.Gill TJ, Micheli LJ, Gebhard F, et al. Bankartrepair for anterior instability of the shoulder. Longterm outcome. J Bone Joint Surg Am 1997;79:850.Lewis A, Kitamura T, Bayley JIL. The classificationof shoulder instability; new light through oldwindows. Curr Orthop 2004;18:97–108.

Shoulder stabilization 73

Rowe CR, Zarins B, Ciullo JV. Recurrent anteriordislocation of the shoulder after surgical repair.Apparent causes of failure and treatment. J BoneJoint Surg Am 1984;66:159–68.te Slaa RL, Wijffels MP, Brand R, et al. Theprognosis following acute primary glenohumeraldislocation. J Bone Joint Surg Br 2004;86:58–64.

ANTERIOR REPAIR OF INSTABILITY –ARTHROSCOPIC


For primary indication/contraindications/consentand risks/operative planning, see ‘Shoulderstabilization – open’ (p. 73).


Anaesthesia is usually general, regional orcombined. Where general anaesthesia is usedalone, local anaesthetic is recommended post -operatively for pain relief. The patient is in thebeach chair or lateral position (see ‘Diagnosticshoulder arthroscopy’ (p. 60)).

Landmarks

See ‘Diagnostic shoulder arthroscopy’ (p. 60).

SURGICAL TECHNIQUE


As for open stabilization.

Portals

A standard posterior viewing portal is used toassess the labral and capsular pathology.

Using an outside-in technique, an antero -superolateral portal is placed at the junction of theanterior border of the supraspinatus tendon andthe upper rotator interval. It should allow a 45°angle of approach to the superior labrum. Thiswill provide both an anterior viewing portal andan accessory portal for SLAP repairs or for suturemanagement. A further anterior portal is placedjust above the subscapularis tendon. This is placed

such that angle of approach allows accurate sutureanchor placement. This can be best assessed usingthe anterosuperior viewing portal. A clear cannulais recommended for better visualization.

Procedure

Glenohumeral arthroscopy is carried out. Thedegree of tissue separation and amount of anterioror inferior capsular laxity are assessed. The drive-through sign is noted. This reflects the easewith which the scope is passed between thehumeral head and the glenoid and is a sign ofsignificant laxity. The Bankart lesion is releasedaround to the 6 o’clock position on the glenoid,with sharp elevators. A sufficient release isconfirmed by grabbing the inferior tissue with amanipulator and elevating it superiorly against theglenoid rim.

The anterior glenoid (2–6 o’clock) isdecorticated with a rasp and shaver (ensure thatsuction is clamped during this stage). An anchor isplaced at the 5 o’clock position on the glenoidrim. A suture is passed through the tissueinferiorly using a penetrator or suture shuttletechnique. The amount of tissue included in thesuture is critical as it will dictate the degree ofstability following the repair. To help reduce thelabral tissue back to the glenoid rim the knot canbe tied with the arm in flexion and internalrotation. Capsular plication (weaving of suturesthrough the capsule) can also be performed incases of marked capsular laxity. Further anchorsare placed at 4 o’clock and 3 o’clock positions toapproximate the labrum and perform a distal toproximal shift of the capsule (Fig. 6.11).

Closure

3/0 Monocryl to cannula portals.


See ‘Shoulder stabilization – open’ (p. 73).


Hobby J, Griffin D, Dunbar M, et al. Isarthroscopic surgery for stabilisation for chronic


shoulder instability as effective as open surgery? Asystematic review and meta-analysis of 62 studiesincluding 3044 arthroscopic operations. J BoneJoint Surg Br 2007;89:1188–96.

TOTAL SHOULDER REPLACEMENT


Common indications

• Osteoarthritis• Inflammatory arthritis• Avascular necrosis• Trauma: four-part proximal humeral fractures• Postinfective arthritis• Instability arthropathy• Cuff tear arthropathy• Arthritis secondary to glenoid dysplasia or

epiphyseal dysplasia.

Contraindications

Active infection.

Operative planning

Recent radiographs must be available withCT/MRI/bone scan as required.


Anaesthesia can be general, regional or combined.Where general anaesthesia is used alone,additional local anaesthetic infiltration or patient-controlled anaesthesia is recommended for painrelief. Antibiotics are given at induction.

The patient is placed in the reclining beachchair position and pulled to the side to allowextension and rotation of the arm. A smallsandbag is put under the shoulder. The surgicalfield is prepared and draped.

Landmarks

• Acromioclavicular joint• Anterolateral/posterolateral corners of

acromion• Coracoid.

SURGICAL TECHNIQUE

Deltopectoral

Incision From coracoid toward the axillary fold, extendinglaterally to the anterior arm.


Structure at risk

• Cephalic vein

Consent and risks

• Infection• Neurovascular injury• Stiffness• Aseptic loosening• Fracture• Revision

Total shoulder replacement 75

Biceps

Direction of shift

AIGHLPIGHL

Anchors

Figure 6.11 Capsulolabral reconstruction with anterior inferior glenohumeral ligament reconstruction (AIGHL). PIGHL, posterior IGHL.

The subcutaneous tissue is reflected with sharpand electrocautery dissection exposing thedeltopectoral interval, which is marked by a fattystreak and the cephalic vein. The fascia overlyingthe interval is divided and the cephalic veinlateralized with the deltoid muscle. In a tightshoulder the pectoralis major tendon can bereleased at its superior border taking care not toinjure the underlying biceps tendon.

Deep dissection

To enhance the exposure a retractor can be placedover the coracoid process and then the clavi -pectoral fascia is split vertically starting just lateralto the coracoid, extending the incision just lateralto the conjoint tendon and its muscle belly.

To improve external rotation the coraco -humeral ligament should also be released at itscoracoid origin. The deltoid is then mobilizedfrom the tissues of the subacromial space andretracted posterolaterally. Provided that theretractors are placed above the inferior subdeltoidbursal reflection the axillary nerve should be safe.If better access is required, as may be the casewith a medialized glenoid, the lateral third of theconjoint tendon can be divided to allow betterexposure or alternatively a coracoid tip osteotomycan be performed. However, care should be takennot to retract the conjoint tendon excessively asthis could put the musculocutaneous nerve at risk.The arm is externally rotated to expose thesubscapularis muscle.

The anterior circumflex humeral vessels, whichare found at the inferior border of thesubscapularis tendon, are then ligated. Theaxillary nerve can then be exposed so that itsposition is known and avoided during theremainder of the procedure.

The degree of external rotation that can beachieved should now be assessed. If this is deficientthen a subscapularis lengthening procedure may berequired. This may involve a layered subscapularistenotomy or ‘Z plasty’ and this will need to be

Structures at risk

The axillary and musculocutaneous nerves are indanger from excessive traction.

planned at this stage. If external rotation isadequate the subscapularis tendon is thentenotomized 1 cm medial to its humeral insertionand raised on stay sutures. This can be taken as onelayer with the underlying capsule. In order tolengthen the subscapularis the rotator interval willneed to be incised and then the capsule will needto be released from the glenoid neck.

As the capsule is incised an inferior capsularrelease can be performed, and provided that theaxillary nerve has already been identified the nerveshould not be at risk. A blunt retractor can beplaced inferiorly to protect the nerve and then thehumeral head is dislocated anteriorly by applyinggentle external rotation to the arm. The LHBtendon should be inspected and tenotomized ortenodesed as necessary.

The head is then prepared by removing anyosteophytes so that the true anatomical neck of thehumerus is identified. The head can now beprepared for the shoulder replacement; thepreparation will vary depending on the implant andwhether a resurfacing type prosthesis is to be used.For the purpose of this description, a standardstemmed implant will be used. An oscillating saw isused to resect the humeral head at its anatomicalneck. If this has been adequately demarcatedduring your preparation it can be done freehandotherwise jigs should be used such that the heightand version of the resection is appropriate. Theresected humeral head is then used as a guide forthe size of the subsequent humeral headreplacement. With the head resected the remainderof the circumferential glenoid release can beperformed and the glenoid inspected.

Once the capsule is released there should beadequate space to approach the glenoidperpendicular to its face such that glenoidpreparation can be achieved with the appropriateimplant jigs. The process of this preparation willvary according to the implant, however, to assessthe true version of the glenoid it is useful to placea narrow retractor down the anterior glenoid neckso that the axis of the glenoid is known prior todefinitive glenoid preparation.

The humerus is now prepared usingsequentially sized rasps and when the appropriatesize is established a trial prosthesis can beconstructed and inserted into the humerus. After


reducing the implant the surgeon should checkthe offset, version and soft tissue tension of thetrial prosthesis and if satisfactory the definitiveprosthesis can be implanted.

Anterosuperior

IncisionAn 8 cm incision is started just posterior to thefront of the ACJ, directed towards theanterolateral corner of the acromion and downthe anterolateral deltoid.


The deltoid is bluntly split at the anterior raphe(the junction of anterior middle third of thedeltoid). The deltoid is detached off the anterioracromion with an osteoperiosteal sleeve. This isextended medially to the ACJ. The subdeltoidbursa is split longitudinally palpating the inferiorbursal reflection which denotes the position of theaxillary nerve.

Deep dissectionThe coracoacromial ligament is detached from theundersurface of the acromion. Anterioracromioplasty and ACJ excision can be carried outif required.

Procedure

Blunt soft tissue release is carried out around thecuff. The coracohumeral ligament is released at itscoracoid origin. This improves the externalrotation. With the arm in external rotation, a boneretractor is inserted on the medial side of thehumeral neck, marking the inferior border of thesubscapularis muscle. This is detached laterally

Structure at risk

• Axillary nerve

Structure at risk

• Axillary nerve – 5 cm below the lateral acromion(below the inferior reflection of the subdeltoidbursa).

from its insertion to the lesser tuberosity togetherwith the capsule. Stay sutures are inserted.

If biceps tenodesis is required, a stay suture isplaced and the tendon cut. The humeral head isdislocated anteriorly with external rotation andextension. A Bankart skid is placed between theglenoid and the head. Osteophytes are excised. Abone spike is inserted on the medial side of thehumeral neck, under the subscapularis to protectthe axillary nerve. Humeral and glenoidpreparation is then performed as previouslydescribed.

ClosureThe subscapularis tendon is repaired using no. 2Ethibond with the arm held in a position of 30°external rotation. This prevents over-tightening ofthe tendon repair. A deltoid repair is thenperformed to the anterior acromion if theanterosuperior approach was used. A 2/0 Vicryl tothe subcutaneous tissues and 3/0 Monocryl to skincompletes the closure.


A polysling is used for 6 weeks. Passive and activeassisted exercises to 90° of forward elevation andexternal rotation to 0° for 6 weeks. Full passivemovement to re-establish full range thereafterfollowed by active ranging and strengtheningexercises as able.


Boileau P, Walch G. The three-dimensionalgeometry of the proximal humerus. Implicationsfor surgical technique and prosthetic design. JBone Joint Surg Br 1997;79:857–65.Gartsman GM, Roddey TS, Hammerman SM.Shoulder arthroplasty with or without resurfacingof the glenoid in patients who have osteoarthritis.J Bone Joint Surg Am 2000;82:26–34.Neer CS. Replacement arthroplasty forglenohumeral osteoarthritis. J Bone Joint Surg Am1974;4:351–9.Torchia ME, Cofield RH, Settergren CR. Totalshoulder arthroplasty with the Neer prosthesis:long-term results. J Shoulder Elbow Surg1997;6:495–505.

Total shoulder replacement 77


Viva questions

1. Describe the deltopectoral approach. Whatstructures are at risk?

2. Describe the posterior approach to theshoulder.

3. What are the advantages and disadvantages ofthe anterosuperior approach?

4. Describe the anatomy of the axillary nerve.

5. Describe the portals in shoulder arthroscopy.

6. What is the pathophysiology of impingement?

7. Describe how you would do an arthroscopicsubacromial decompression.

8. What are the indications for ACJ excision?

9. How do you classify cuff tears?

10. What are the indications for rotator cuffrepair?

11. What are the complications from rotator cuffrepair?

12. Describe your management of ACJ dislocation,including classification.

13. What are the indications for operativestabilization of the shoulder?

14. How would you classify shoulder instability?

15. Would you do open or arthroscopicstabilization?

16. What approach would you use for totalshoulder replacement?

17. What are the indications for shoulderreplacement?

18. Would you replace the glenoid and why?

19. What are the complications of total shoulderreplacement?

20. In what position would you arthrodese ashoulder?

Surgery of the elbow7

Deborah Higgs and Simon Lambert

Elbow arthrolysis 79Total elbow replacement 87Radial head replacement 89Tennis/golfer’s elbow release 92

Elbow arthroscopy 95Elbow aspiration/injection 97Viva questions 98

The surgical approaches to the elbow may form asequence of dissections using segments of, or thewhole of, a single utility dorsal approach. If thisstrategy is followed for the lesser procedures then,should further surgery be required, the risk ofvascular compromise of the skin due to multipleincisions is reduced.

ELBOW ARTHROLYSIS


Indications

• Post-traumatic capsular contracture of theulnohumeral (medial column), radiocapitellar

(lateral column), and proximal radioulnar joints(anterior and posterior compartments)

• Degenerative contracture of anterior andposterior compartments

• Intracompartmental adhesiolysis, usually of theradiocapitellar compartment

• In association with intra-articular correctiveosteotomy of the distal humerus, proximalulna, or radial head

• In association with joint replacement arthro -plasty of the elbow, including lateral compart -ment resurfacing and radial head replacement.

Contraindications

• Vascular compromise of the limb• Infection (generalized or of the limb)• Compromised skin in the region of the surgical

incision• Inability of the patient to understand the

postoperative rehabilitation programme• Contraindication to regional nerve blockade;

previous nerve trauma or palsy (particularly ifincomplete nerve lesion) at the elbow or moreproximally.

Consent and risks

• Ulnar nerve injury: 10 per cent transient ulnarneuritis; 1 per cent tardy ulnar nerve palsy;<1 per cent acute permanent lesion

• Infection: < 1 per cent


• There is no fixed position of arthrodesis• Many authors recommend 90°• There is evidence that 110° is best for activities of

daily living but 60° may suit work activities

Range ofmotion

Functionalrange of motion

Flexion 150° 130°

Extension 0° 30°

Pronation 80° 50°

Supination 80° 50°

Figure 7.1 Patient position

80 Surgery of the elbow

Operative planning

Anteroposterior and lateral (in flexion andextension) radiographs, less than 6 months old,should be available.

For articular surface lesions a computedtomography (CT) arthrogram is desirable. Itshould be possible to readily convert from anarthroscopic procedure to an open procedure (seepositioning and incision sections).


Anaesthesia is usually general, augmented byinfraclavicular regional nerve blockade if notcontraindicated (see above). An initial dose ofantibiotic is given intravenously. The antibiotic ofchoice depends on local policy, but a commonchoice is cefuroxime (1.5 g in the adult). Note: ifintraoperative biopsies are to be obtained todiagnose sepsis then the antibiotic is withhelduntil the biopsy obtained.

The patient is placed in the lateral decubitusposition with the operated arm uppermost.Padded lumbar and pelvic supports are used.

A Carter–Brain gutter or well-padded drapesupport is used to cradle the arm, allowing theforearm to move freely in the vertical position,permitting access to the dorsal aspect and bothsides of the elbow, and to the anteriorcompartment by external rotation of the shoulder(Fig. 7.1). Of note in this position: the ulnar nerveis always on the side of the elbow facing the feetof the patient (assuming there has been noprevious operation on the ulnar nerve).A padded narrow tourniquet (inflation to 200mmHg is usually sufficient) or a S-MARTbandage/tourniquet is used. At least 15 cm of thedorsal aspect of the arm is required for ease of

• Heterotopic ossification: 10 per cent• Recurrence: more common in post-traumatic

stiffness syndrome, less common in degenerativeor inflammatory contractures

• Failure to achieve desired result (due tosurface/topographical articular lesions)

• Need for further surgery, including jointreplacement arthroplasty

access. The elbow should be sufficiently mobilefor appropriate movement intraoperatively. Thehand, forearm, and arm to the axilla are preparedwith a germicidal solution. Waterproof drapes areused with adhesive edges to provide a seal to theskin. An antibacterial adhesive skin drape isapplied.

SURGICAL TECHNIQUE

Arthrolysis can be performed open or arthroscopically.

OPEN ARTHROLYSIS

The choice of approach is governed by whichcompartment is to be accessed:• For the lateral side of the anterior and posterior

compartments: the lateral column (Morrey)approach. This can be extended proximally intoa lateral approach to the humerus, and distallyinto a Kocher-type approach to the radial headand neck. The anterolateral compartment isreadily accessible (see ‘Radial headreplacement’, p. 90)

• For the medial side of the anteriorcompartment: the direct medial approachanterior to the ulnar nerve (see ‘Tennis/golfer’selbow release’, p. 93)

• For the anterior compartment alone, e.g. forlengthening of the biceps tendon: the anteriorapproach. This is a lazy-S incision respectingthe flexure crease of the elbow, passing frommedial to the tendon of the biceps proximallyover the brachial neurovascular bundle, to the

Incision

Figure 7.2 Anteriorapproach

Radialnerve

Ulnarnerve

Incision

7.5 cm

6 cm

7.5 cm

Figure 7.3 Trans-tricipital approach – skin incision

Elbow arthrolysis 81

continued distally parallel to the crest of the ulna(not crossing it or on it) for approximately 6 cm(Fig. 7.3).


The triceps tendon is more correctly anaponeurosis. There is a superficial sheet having amedian vertical aponeurotic extension, betweenthe lateral and medial heads of the triceps, whichleads to the deep head. This sheet is the guide tothe dissection of the triceps.

The lateral and medial musculotendinousboundaries of the triceps are revealed by epifascialdissection in the proximal part of the wound.Minimal epifascial dissection is used distal to theolecranon over the subcutaneous border of the ulna,sufficient only to see the deep antebrachial fasciaover anconeus. Medial dissection is continued,

Structure at risk

• Ulnar nerve

medial side of the ‘mobile wad’ (Henry) distally(Fig. 7.2)

• For the dorsal (olecranon fossa) compartmentand ulnar nerve: the dorsal trans-tricipitalapproach.

TRANS-TRICIPITAL APPROACH

Landmarks

• Midline of the humerus• Lateral epicondyle• Radial head• Tip of the olecranon• Crest of the proximal ulna.

Incision

The incision is made in a curvilinear fashiontowards the tip of the olecranon starting about 7.5cm proximal to the olecranon, skirting on itslateral side, leaving between 0.5 cm and 1 cmbetween the incision and the lateral border of theolecranon (to avoid placing the incision on theweightbearing skin of the elbow). The incision is

Medialhead

Lateral head

Ulnarnerve

Incision

Brachioradialis

Anconeus

Extensorcarpi ulnaris

Flexorcarpi ulnaris

Ulna

Figure 7.4 Trans-tricipital approach – deep dissection


border of the lateral head of triceps and theproximal border of the anconeus. Dissectionwithin the lateral head of triceps is to be avoided.The triceps is split between the nerve and bloodsupply to the medial head (a segmental branchcan occur very distally) and the nerve to the lateralhead, both derived from the radial nerve. The deephead nerve supply is more proximal and is out ofthe surgical field. The ulnar nerve is protected bykeeping dissection lateral and then deep to themedial head of the triceps, using the muscularbulk as a protection for the nerve (Fig. 7.4).

It is important to know where the ulnar nerveis if dissection of the medial capsule is likely, butthe nerve does not need to be mobilized forsimple olecranon fossa debridement, or when theradiocapitellar joint is the only compartmententered.

The ulnar nerve is identified throughout itscourse, behind the medial condyle, noting theaxial vessel and the vena comitans on the deep(articular) surface of the nerve in the cubitalsulcus. The fibrous arch between the two bonyorigins of the flexor carpi ulnaris (FCU) is incised,the incision being carried into the muscle forabout 2 cm (Fig. 7.4), marking and protecting thenerve branch to the FCU, which arises proximal tothe elbow, and allowing ready displacement of thenerve from the cubital sulcus without tension.

Proximal dissectionThe triceps aponeurosis is incised in the midlineand undermined to define the vertical sheetbetween the two superficial heads of the triceps.

The dissection is then taken down the lateralside of this sheet, i.e. in the inter vascular/interneural plane to the deep head of the triceps.The superficial heads are parted for about 6 cm,uncovering the filmy layer between them and thedeep head. The deep head is then incised (theonly muscular incision required in this technique)noting the deep transverse epicondylar vesselsunder the muscle at the proximal margin of thefat pad in the olecranon fossa. The vessels arecauterized. The fat pad is excised and theolecranon fossa exposed. A posterior capsulec -tomy is performed and any olecranon osteophytesremoved. An Outerbridge–Kashiwagi procedurecan now be planned (see below).

sufficient to reveal the ulnar nerve immediatelysubjacent to the medial border of the tricepsabout 6–7 cm proximal to the medial epicondyle.

Deep dissection

This approach respects the nerve supply to theanconeus (an important contributor to elbowstability): this is a distal branch of the radial nervewhich crosses the interval between the distal

Structures at risk

• Ulnar nerve

Extensor carpiulnaris

Lateralepicondyle

Triceps

AnconeusIncision

Figure 7.5 Dissection for lateral column and anteriorcompartment between the anconeus and the extensorcarpi ulnaris


Supplementary dissection for the anteriorcompartment using a transhumeral approach(the Outerbridge–Kashiwagi procedure)An aperture is made through the distal humerususing a high-speed burr, directing the bur radiallyand proximally: the medial humeral column isthinner and flatter than the lateral column, so thetranshumeral opening should be directed radiallyimmediately medial to the lateral column to avoidiatrogenic medial column fracture. The apertureshould exit anteriorly immediately behind the tipof the coronoid process (Fig. 7.6).

The diameter of the aperture should be nomore than half the transverse diameter of thehumerus at this level. The anterior capsule of theradiocapitellar joint, the coronoid tip, and most ofthe anteromedial capsule can be removed throughthe aperture, using elbow flexion to bring thecapsule into the aperture. It is inadequate forrelease of the medial capsule and the anteriorband of the ulnar collateral ligament should notbe incised, to avoid iatrogenic valgus instability.

Distal dissectionThe antebrachial fascia is incised parallel to andabout 1 cm lateral to the crest of the ulna over theanconeus. The dissection is taken under the fasciabut outside the anconeus to the crest and then, onbone, down to the supinator crest, the annularligament and capsule of the proximal radioulnarjoint, lifting the anconeus away from the capsuleand radial head, but preserving the posterior bandof the lateral collateral ligament (to maintainstability in varus strain) (see Fig. 7.4).

This completes the exposure for the olecranonfossa and the posterolateral (radiocapitellar)compartment, permits excision of the radial headif needed, and facilitates adhesiolysis of theulnohumeral surfaces.

Dissection for the lateral column and anteriorcompartment: the lateral column andKocher-type approachesThe attachment of the lateral head of the triceps tothe dorsal aspect of the humerus is maintained.Epifascial dissection around the lateral epicondylarridge and lateral condyle, cauterizing several septalvessels, permits palpation of the entire ridge to theradiocapitellar joint. The common extensor originis dissected by incision into the apex of the ‘axilla’of the musculotendinous fibres, so raising the fibresin an epiperiosteal fashion. The capsule is exposed.The common extensor muscles are split in theinterval between the anconeus and extensor carpiulnaris (ECU), or between the ECU and theextensor digitorum communis (EDC). The formersplit is safer: the posterior interosseous nerveterminates within the EDC. The dissection is takendown to the radiocapitellar joint capsule bysplitting the deeper fibres of the EDC andelevating them from the capsule (Fig. 7.5). Thecapsule is then incised parallel to the condylarridge and carried to the annular ligament. This canbe incised if the radial head is to be removed (analternative approach for this resection). Ananterior capsulectomy can then be performedwhile preserving the anterior band of the lateralcollateral ligament.

There are now two ‘windows’: one into theposterior compartment, and one into theanterolateral compartment, through a single skinincision.

Incision overlateral epicondylarridge

Supinator

Figure 7.7b Deep disection showing incision over lateralepicondylar ridge.

Radialhead

Capitellum

Olecranon

Elbow capsule,opened

Figure 7.7c Exposure of radial head.

Extensorcarpi ulnaris

Triceps

Anconeus

Incision

Brachioradialis

Figure 7.7a Incision maintaining lateral head of tricepsand anconeus in continuity.

Figure 7.6 Outerbridge–Kashiwagi procedure

(b) (c)

(a)


Med tri

Med caps

Ulnarnerve

Radialhead

Olecranon

Lateralolecranon

Figure 7.8 Cross-section showing mobilization ofmedial head of triceps

Figure 7.9 X-ray of total elbow replacement showingthe repositioned fragment of olecranon elevated withtriceps


(Fig. 7.8). There are now two longitudinal sleevesof musculotendinous-fascial tissue, exposing theolecranon.

Further medial capsulotomy permits resectionof the medial ulnar osteophyte if present andcomplete dislocation of the elbow for anteriorarthrolysis and total elbow replacement (Fig. 7.9).

Technical aspects

Where total capsulectomy has been required incases such as post-traumatic contracture, hetero -topic ossification and myositis ossificans, thecollateral ligaments are often released. The elbowis therefore unstable. Fixed splintage is counter -productive. Dynamic splintage is required: ahinged external fixator is indicated if theligaments cannot be reattached and should be

Supplementary dissection for massivearthrolysis and capsular release (as for totalelbow replacement)If it is anticipated that this degree of exposure willbe needed it is not necessary to perform a separatelateral column exposure: the extensile lateralexposure will permit anterior capsulectomy.

The distal (antebrachial) and proximal(brachial) incisions are linked by incising thelateral capsule, reflecting the posterior band of thelateral collateral ligament, so exposing theradiocapitellar joint. The lateral head of thetriceps and the anconeus are thus in continuity,with the remaining capsule deeply attached to themuscle envelope (Fig. 7.7). The radial head can beresected.

Mobilization of the medial head of tricepsand medial capsule; dislocation of the elbowjointA narrow osteotome is used to create a series ofosteo-periosteo-fascial shingles (small, superficialshards of bone which remain attached to thetricipital aponeurosis) from the olecranonelevating the medial triceps aponeuroticattachment from the ulna, working from lateral tomedial, and distally until the cortical crest of theulna. The periosteo-antebrachial fascia is thensharply dissected from the crest in continuity withthe olecranon shingles. The medial head of thetriceps is now in continuity with the medialantebrachial fascia, with a medallion of olecranonbony shingles centrally. As the sleeve is invertedthe ulnar nerve is taken out of the cubital sulcusand is protected within a muscular envelope


full-radius resector and electrocautery. Any loosebodies are removed. The coronoid fossa is re-created, using the resector and a burr for any bonyhypertrophy. The coronoid tip is removed if thereis evidence of coronoid impingement. Theresector is used to strip the capsule proximally, offthe distal humerus, for approximately 2.5 cmproximal to the olecranon fossa until the fibres ofbrachialis come into view proximally. To completethe release a 1 cm capsulotomy of the anteriorcapsule medial to lateral is required.

Using the direct posterior and posterolateralportals the posterior compartment is debridedsimilarly. The scope enters through theposterolateral portal and the resector or burrthrough the direct posterior portal to completethe procedure. Careful release of the contracture,with a full-radius resector, releases theposteromedial and posterolateral gutters. Bewareof the ulnar nerve in close proximity medially.Manipulation of the elbow is used to achievemaximum extension.

Closure

• A drain is placed in the direct posterior portaland the portals closed with absorbable sutures.

• Occlusive dressings are applied.• The elbow is splinted in maximum extension.


The arm is rested on pillows at chest height for 48hours. The bandage is reduced at 24 hours and thedrain is removed. A Tubigrip bandage is applied. Ifthere is uncertainty about elbow stability aremovable extension splint may be applied, to beworn between exercise periods.

Active assisted sagittal full-range motionexercises are performed for 20 minutes four orfive times a day. Fist gripping and forearmprosupination are undertaken as comfort permits.Supervised physiotherapy for the neck, shoulderand hand is undertaken.

Active unassisted movement is permitted by 6weeks and axial weightbearing at about 12 weeks.Passive motion of the elbow may be indicated forrecalcitrant/recurrent arthrofibrosis. However,continuous passive motion equipment is difficult

retained for about 8 weeks, before application of aremovable hinged brace for a further 4 weeks. Ifthe ligaments can be restored to their optimaltension an external hinged removable brace can beused. Re-fixation of the ligaments to theirfootprint origins is facilitated by one of the severalvarieties of anchors that are available. The elbowmust be stable enough to permit full-rangeassisted sagittal motion with gravity eliminatedimmediately after the operation.

Closure

The olecranon osteo-periosteo-fascial medallion isrepaired by transosseous non-absorbable sutures(no. 2 gauge) to the olecranon. A suction drain isplaced deep to triceps. The triceps aponeurosisand antebrachial fascia are closed with the elbowflexed at 90° flexion using absorbable braided no.1interrupted sutures (continuous suturing reducesthe ‘give’ of the tendon during assisted motion).• The skin is closed with a dermal supporting

absorbable 3/0 suture and an absorbable 4/0continuous subcuticular suture plus Steri-Strips.

• An occlusive dressing is applied with the elbowin 90° of flexion.

• A bulky wool and crepe bandage dressing isapplied in two layers.

ARTHROSCOPIC ARTHROLYSIS

Landmarks

• Lateral epicondyle• Radial head• Tip of the olecranon.

Approach

The usual portals (as described in the arthroscopysection, p. 95) are used. In principle thearthroscopic portals respect the same incisions, i.e.the portals are placed in the line of the standardskin incisions to permit extension into an openapproach as required.

Using the anteromedial and anterolateralportals, fibrous tissue can be resected from theanterior part of the joint, using a combination of a

Figure 7.10 Radial head and tip olecranon excised

Total elbow replacement 87

Types of replacement

Total elbow arthroplastyThere are two types:• Unconstrained surface replacements – two-part

devices consisting of metal articulating withhigh-density polyethylene. They do not have asnap-fit, link, or pin connection. Examples areCapitellocondylar and Kudo

• Semi-constrained – two-part or three-partprosthesis that have a metal-to-high-densitypolyethylene articulation, which may beconnected with a locking pin or with a snap-fitdevice. They have built-in varus and valguslaxity to dissipate forces. Examples are CoonradMorrey and Discovery.


As for elbow arthrolysis.

SURGICAL TECHNIQUE

Landmarks /incision/dissection

The trans-tricipital approach is used (see ‘Elbowarthrolysis’, p. 81).

Procedure

Preparation of distal humerus and proximalulnarThe forearm is rotated laterally to allow exposureof the distal humerus. The radial head and tip of

to apply accurately, particularly in the unstablejoint. A continuous patient-controlled analgesicinfusion, or continuous infraclavicular regionalanaesthetic infusion are commonly required.


Hertel R, Pisan M, Lambert S, et al. Operativemanagement of the stiff elbow: sequentialarthrolysis based on a transhumeral approach. JShoulder Elbow Surg 1997;6:82–8.Mansat P, Morrey BF. The column procedure: alimited lateral approach for extrinsic contractureof the elbow. J Bone Joint Surg Am1998;80:1603–15.

TOTAL ELBOW REPLACEMENT


Indications

Total elbow replacement is indicated in painfulconditions of the elbow which have failedconservative management.

The most frequent underlying conditions are:• Osteoarthritis• Inflammatory arthritis and other arthropathies• Avascular necrosis• Trauma.

Contraindications

Infection (generalized or of the limb)

Operative planning

Recent radiographs must be available. Availabilityof the implants must be checked by the surgeon.

Consent and risks

• Nerve paraesthesiae: 11 per cent• Infection: 7 per cent• Instability with unlinked implants: 5–20 per cent• Loosening (semi-constrained): 5 per cent• Instability (unconstrained): 9 per cent• Fracture: humerus: 5 per cent; ulna: 5 per cent

Figure 7.11 Use of guide, fossareamer and oscillating saw toprepare the humerus

Figure 7.12 A high-speedburr is used to identifythe humeral canal

Figure 7.13 Raspingthe humeral canal

Figure 7.14 Trial of thehumeral component


aligned with the humeral canal. The medialborder should lie along the medial trochlea. Theguide should also align with the anatomic internalrotation of the trochlea, which approximates theflat surface posterior and just proximal to theolecranon fossa. Using a fossa reamer, a hole iscreated and an oscillating saw is used to removethe remains of the trochlea, along the linespreviously marked, allowing access to themedullary canal of the humerus (Fig. 7.11).

The canal is identified with a high-speedrotating bur at the proximal aspect of theresection of the olecranon fossa in a proximaldirection (Fig. 7.12). Open the medullary canal toa size sufficient to allow a humeral rasp (about4 mm).

The humeral rasps are now used to prepare thehumeral canal (Fig. 7.13). Serial rasps increasing insize are used until cortical resistance is met. If arasp is unable to be advanced fully, use an implantcorresponding to the largest size of rasp whichwas fully introduced.

The medial and lateral portions of thesupracondylar columns must be preserved duringthe preparation of the distal humerus. They act aspoints of reference to ensure satisfactoryorientation and alignment. The trial prosthesis isinserted until the margins of the prosthesis areexactly level with the epicondylar articularsurface margin on the capitellar and trochlearsides (Fig. 7.14). Further small pieces of bone areremoved with rongeurs or bone nibblers from thedistal humerus to aid proper seating of thecomponent.

A high-speed burr is used at an angle of roughly55° from the vertical in a posterior and distaldirection to remove subchondral bone to identifythe ulnar medullary canal. Serial rasps are

olecranon, along a line tangent to the posterior-most portion of the olecranon articulation, areexcised with an oscillating saw (Fig. 7.10).

To mark the humeral saw cuts, the olecranonfossa guide is available on the instrument set. Toorientate the guide, the shaft of the fossa guide is

Figure 7.15 Rasping of the ulnar metaphysic

Figure 7.16 Implanted components

Radial head replacement 89

The arm is held in extension until the cementhas cured, and then the humeral device can bearticulated with the ulnar component.

Closure

As for elbow arthrolysis.


Two further doses of the same antibiotic given oninduction are given intravenously. The drain isremoved at 24 hours and the compressive dressingremoved. Supervised physiotherapy allowingactive and gravity extension, active and passiveflexion and pronation and supination. The patientis advised against heavy lifting. At 6 weeks,strengthening exercises are begun.

Follow up is recommended at 6 weeks, 6months and 1 year after surgery. Continuation offollow-up is typically at yearly intervals. Thepatient should be cautioned to return to clinic ifthere is pain or functional deterioration.


Bryan RS, Morrey BF. Extensive posteriorapproach to the elbow joint: a triceps sparingapproach. Clin Orthop Relat Res 1982;(166):188–92.Connor AN. Biomechanics of total elbowarthroplasty. Semin Arthroplasty 1998;9:25–31.An KN, Morrey BE. Biomechanics of the elbow.In: Morrey BF, ed. The Elbow and Its Disorders, 2ndedn. Philadelphia: WB Saunders, 1993.Shahane SA, Stanley D. A posterior approach tothe elbow joint. J Bone Joint Surg Br1999;81:1020–2.

RADIAL HEAD REPLACEMENT


Indications

• Valgus instability (due to medial collateralligament instability) with type III radial headfractures

introduced into the medullary canal of the ulnaruntil cortical resistance is met (Fig. 7.15). As withthe humerus the size of implant used correspondswith the largest size of rasp fully inserted.

The appropriate rasps are used to shape theproximal ulna as needed.

After the proximal ulna and distal humerushave been prepared, a trial will evaluate the elbowfor complete flexion and extension. Themedullary canals are cleaned with pulsatile lavageand the canals dried. A cement restrictor isinserted into both canals. A cement gun is used forretrograde insertion of low-viscosity cement intothe canals. If the components are cementedseparately, the ulnar component is inserted first.The centre of the ulnar component is aligned withthe centre of the sigmoid fossa. The humeralcomponent is impacted down to a point thatallows articulation of the device and theplacement of the axle and the locking clip orinterlocking axis pins (if a partially constraineddevice is used) (Fig. 7.16).

Radius

Tricepsbrachi

OlecranonAnconeus

Extensor carpiulnaris

Figure 7.17 The incision and surface anatomy of thelateral approach to the radial head

Dissection

The incision is continued through subcutaneousfat and through the fascia between triceps andorigins of the extensor carpi radialis longus(ECRL) and brachioradialis. An interval isdeveloped between the triceps posteriorly and theorigins of ECRL and brachioradialis anteriorly. Inthe proximal end of the wound, the radial nervemust be avoided in the interval between thebrachialis and brachioradialis muscles. Thecommon origin of the extensor muscles isremoved from the lateral epicondyle togetherwith a thin flake of bone, using a small osteotome.Reflecting the common origin distally exposes the

Structures at risk

• Radial nerve• Posterior interosseous nerve (PIN)


move the fingers distally until a depression is felt.The radial head lies within a palpable depressiondistal to the lateral epicondyle. On pronating andsupinating the forearm, it can be felt to move.

Incision

The skin incision extends approximately 5 cmproximal to the lateral epicondyle, and continuesdistally, over the epicondyle, along theanterolateral surface of the forearm forapproximately 5 cm (Fig. 7.17).

• Radial head fracture with distal radioulnar jointinstability (Essex–Lopresti injury).

Contraindications

• Vascular compromise of the limb• Compromised skin in the region of the surgical

incision.

Operative planning

Anteroposterior and lateral radiographs, less than6 months old, should be available. Availability ofthe implants must be checked by the surgeon:• Silicone replacement – can be used as a

temporary spacer (uncemented)• Vitallium prosthesis – provides more stability

than silicone replacement and does not causesynovitis. Need to be careful not to ‘overstuff’the joint as this can lead to pain and loss ofextension (cemented or uncemented).


See ‘Elbow arthrolysis’ (p. 80).

SURGICAL TECHNIQUE

There are two options. The distal dissection forthe proximal radioulnar joint as described for thetrans-tricipital approach (see ‘Elbow arthrolysis’,p. 83) or the lateral column approach as describedbelow.

LATERAL APPROACH (MORREY)

Landmarks

The lateral epicondyle, radial head and tip of theolecranon. Palpate the lateral epicondyle and

Consent and risks

• Nerve injury• Infection• Vitallium prosthesis: aseptic loosening, implant

impingement, component retrieval difficult• Silicone replacement: fatigue failure, giant cell

synovitis inflammation which may persist afterimplant removal

Forearmsupinated

Forearmpronated

Supinator

Posteriorinterosseous

nerve

Bicepstendon

Figure 7.18 Anatomy of the posterior interosseousnerve

Annularligament

Capitellum

Commonextensor origin

BrachioradialisLateral

epicondyle

Triceps

Anconeus

SupinatorRadial head

Figure 7.19 Lateral approach

Figure 7.20 The radial neck cut

Radial head replacement 91

radial head trial should be chosen to match thediameter of the articulation surface of the nativeradial head. If the radial head diameter is betweentwo available sizes, the smaller of the two radial

radiohumeral joint. The PIN is vulnerable as itenters supinator and must be protected (Fig.7.18).

The origins of the brachioradialis and ECRLmuscles are elevated subperiosteally and thecapsule incised to expose the lateral aspect of theelbow joint. By incising the capsule anterior to theradial humeral ligamentous complex, (overlyingthe radial head) in line with the radius, the lateralcollateral ligament is avoided. However, theincision must not stray too far anteriorly as theradial nerve runs over the anterolateral portion ofthe elbow capsule (Fig. 7.19).

The annular ligament is incised longitudinallybefore transecting the radial neck with anoscillating saw using a radial cutting jig (Fig. 7.20).Exposure distal to the annular ligament risksdamaging the PIN and is avoided. The cut surfaceof the proximal radius should be smooth andeven, so that contact between it and the collar ofthe prosthesis is complete.

The proximal radial medullary canal is preparedwith burs or rasps to accept the implant stem. The

Figure 7.21 Trial reduction to test range of motion


months or more in active work. Follow-up isrecommended at 6 weeks, 6 months and 1 yearafter surgery. Continuation of follow-up istypically at yearly intervals. The patient should becautioned to return to clinic if there is pain orfunctional deterioration.


Ates Y, Atlihan D, Yildirim H. Current concepts inthe treatment of fractures of the radial head, theolecranon, and the coronoid. J Bone Jt Surg Am1996;78:969

TENNIS/GOLFER’S ELBOW RELEASE


Indications

Tennis/golfer’s elbow release is indicated whenconservative management has failed.

Patients with tennis elbow have reproducibletenderness at the common extensor origin, withreproduction of symptoms upon resisted wristextension with the elbow in extension. Non-operative treatment with anti-inflammatories,counterforce bracing and up to three steroidinjections to the site of maximal tenderness canachieve success in up to 95 per cent of cases.

In golfers, elbow pain and tenderness arelocalized to the common flexor origin. Pain isreproduced by resisted forearm pronation andwrist flexion. Non-operative treatment is similarto that for tennis elbow but usually more difficultto treat.

Consent and risks

• Failure• Nerve injury: 1 per cent• Infection• Heterotopic ossification at surgical site: 10 per

cent• Posterolateral instability: if there is excessive

debridement of the collateral ligament origins aswell as the origins of the extensor muscles fromthe lateral epicondyle

heads should be used. A trial is inserted to ensurethat contact with the capitellum is satisfactory. Toprevent excessive wear of the capitellum from‘overstuffing’, the proximal edge of the prosthesisshould be level with the lateral edge of thecoronoid. The elbow is taken through a range offlexion, extension and rotation (Fig. 7.21). If thisis satisfactory, the final prosthesis is inserted.

Closure of lateral approach

The annular ligament is repaired with anabsorbable suture. The common extensor origin isreattached to the lateral epicondyle withtransosseous sutures. A suction drain is inserted.Superficial closure utilizes absorbable sutures toapproximate the subcutaneous fat, then acontinuous absorbable subcuticular suture withSteri-Strips. An occlusive dressing is applied and acompression dressing is used around the elbow.


Two more doses of the same antibiotic given oninduction are given intravenously. The drain andcompression dressing are removed at 24 hours.Gentle active mobilization of the elbow is begununder supervision.

Return to work is allowed after around 6 weeksfor sedentary jobs, but may be delayed to 3

Figure 7.22 Skin incision

Extensor longus

Lateralepicondyle

Deep fascia

Extensoraponeurosis

Aponeurosis

Epicondyle

Lateralepicondyle

Lateralepicondyle

Resectionbrevis

Extensoraponeurosis

Extensor carpiradialis longus

Extensor carpiradialis brevisdegeneration

Decorticationanterior lateral

condyle

Synovialopening

Figure 7.23 Extensor origin release

Tennis/golfer’s elbow release 93

posterior to the ECRL lies the extensoraponeurosis, the anterior edge of which may beabnormal. The ECRL is then dissected sharply offthe anterior ridge and displaced anteromedially toexpose the ECRB. ECRB is inferior to the origin ofthe ECRL and deep to the EDC. The borderbetween the ECRB and EDC is often poorlydefined.

Deep dissectionDegenerate tissue is excised, taking care not torelease any normal looking tendon. The abnormal

Operative planning

Recent anteroposterior and lateral radiographs ofthe elbow should be available to rule out lateralcompartment arthrosis (tennis elbow).Calcification may be visible in the flexor origin inlongstanding golfer’s elbow.


Anaesthesia is usually general, regional orcombined. The supine position is used with thearm placed on an arm board. A tourniquet or anS-MART bandage/tourniquet is used.

The elbow should be sufficiently mobile forappropriate movement intraoperatively. Thesurgical field is prepared with a germicidalsolution. Waterproof drapes are used withadhesive edges to provide a seal to the skin.

SURGICAL TECHNIQUE

Extensor origin release (tennis elbow)

LandmarkThe lateral epicondyle.

IncisionA 4–5 cm gently curved skin incision is madecentred over the lateral epicondyle (Fig. 7.22).

Superficial dissectionThe incision is continued through subcutaneousfat and down to fascia. The fascia overlying theposterior edge of the ECRL is incised and elevatedto expose the extensor carpi radialis brevis(ECRB), which lies beneath the ECRL. Just

Ulnar nerve

Flexor carpi ulnarisarcade

Resectiondegeneratedtendon

Degeneratedtendon

Figure 7.24 Flexor origin release


Closure of medial approachThe defect in the flexor–pronator origin is closedwith absorbable sutures. Superficial closureutilizes absorbable sutures to approximate thesubcutaneous fat, then a subcuticular continuousabsorbable suture.

An occlusive dressing is applied, followed by abulky wool and crepe bandage dressing in two layers.


Dressings are reduced at 48 hours. Earlymobilization of the elbow should be encouragedin all patients.

Follow-up is recommended at 6 weeks, with awound check by the primary care practitioner at 2weeks. The patient should be cautioned to returnto the clinic if there is pain or functionaldeterioration.

tissue may appear fibrillated or discoloured andmay contain calcium deposits. The anterior lateralcondyle is decorticated with an osteotome or bonenibbler to enhance blood supply (Fig. 7.23).

Closure of lateral approachThe defect between the posterior edge of the ECRLand the extensor aponeurosis is repaired with anabsorbable suture to restore the normal anatomicposition. Superficial closure utilizes absorbablesutures to approximate the subcutaneous fat, then asubcuticular continuous absorbable suture.

An occlusive dressing is applied, followed by abulky wool and crepe bandage dressing in twolayers.

Postoperative care and instructionsDressings are reduced at 48 hours. Early range-of-motion exercises are begun, followed bystrengthening exercises. Strenuous activity isresumed within pain limits at 8–10 weeks and fullpower should have returned by 3 months. Follow-up is recommended at 6 weeks, with a woundcheck by the primary care practitioner at 2 weeks.

Flexor origin release (Golfer’s elbow)

LandmarkThe medial epicondyle.

Incision

A 3–4 cm longitudinal skin incision is made justposterior to the medial epicondyle. This avoidssensory branches of the medial antebrachialcutaneous nerve anterior and distal to the medialepicondyle.

DissectionThe incision is continued through subcutaneous fatand down to fascia exposing the common flexororigin. Partial debridement of the flexor carpiradialis (FCR), excising abnormal tissue is usuallyall that is required (Fig. 7.24). Any normal tissueattached to the medial epicondyle is left intact.

Structures at risk

• Medial antebrachial cutaneous nerve

Elbow arthroscopy 95


Anaesthesia is general or combined with regional.The lateral decubitus position is used, the positionbeing maintained by side supports. The tourniquetis applied high around the arm, and the armplaced over a bolster applied to the bed. Theelbow should be free to flex to 90° with the handpointing towards the floor.

The TV monitor is placed on the opposite sideof the patient. The surgical field is prepared witha germicidal solution. Waterproof drapes are usedwith adhesive edges to provide a seal to the skin.

SURGICAL TECHNIQUE

Landmarks

Bone landmarks are outlined with a marker pen:• Lateral epicondyle• Radial head• Tip of the olecranon• Medial epicondyle.

Portals

The direct lateral portal is located in the soft spotat the centre of the triangle formed by the lateralepicondyle, radial head and tip of the olecranon(Fig. 7.25). This portal traverses the anconeusmuscle. The elbow is initially distended throughthis portal.

The distal anterolateral portal

This portal is usually established first after elbowdistension. It is used for instrumentation as well asvisualization of the lateral aspect of the radialhead. With the elbow flexed to 90° the portal islocated 3 cm distal and 1–2 cm anterior to thelateral epicondyle. This should bring the portaljust anterior and proximal to the radiocapitellararticulation. The skin incision is made with ano. 11 blade and a haemostat used to bluntlydissect down to the joint capsule.

Structure at risk

• The radial nerve


Stahl S, Kaufman T. The efficacy of an injection ofsteroids for medial epicondylitis. A prospectivestudy of 60 elbows. J Bone Joint Surg Am1997;79:1648–52.Sevier TL, Wilson JK. Treating lateralepicondylitis. Sports Med 1999;28:375–80.

ELBOW ARTHROSCOPY


Indications

Elbow arthroscopy is indicated in a variety ofpainful conditions of the elbow. The mostfrequent are:• Debridement for osteoarthritis• Osteochondritis dissecans of capitellum• Arthrolysis• Removal of loose bodies• Synovectomy or synovial biopsy• Pyarthrosis• Radial head resection• Diagnostic.

Contraindications

• Infection of overlying skin• Bony or severe fibrous ankylosis.

Operative planning

Recent radiographs and, where taken, magneticresonance (MR) images and MR arthrograms,should be available.

The correct equipment must be available andthis should be checked by the surgeon. A 30° 4mm arthroscope should be used. The water flowshould be controlled with an inflow pump.

Consent and risks

• Nerve injury• Infection: <1 per cent; risk is very low, so

prophylactic antibiotics are not recommended

Radial nerve

Mid-lateralportal

Lateralantebrachial

cutaneousnerve Anterolateral

portal

Midanterolateralportal

Proximal anterolateralportal

Posteriorantebrachialcutaneous nerve

Lateralepicondyle

Figure 7.25 Lateral elbow arthroscopy portals


This portal allows visualization of the anteriorelbow including the anterior joint capsule, medialcondyle, coronoid process, trochlea, capitellumand radial head. The joint should already bedistended with fluid and the ulnar nerve identifiedbefore establishing this portal. The portal isestablished using a longitudinal skin stab incisionand blunt dissection 2 cm proximal to the medialepicondyle and immediately anterior to theintermuscular septum. The trochar is insertedover the anterior surface of the humerus aimingtowards the radial head. Contact is maintainedwith the anterior surface of the humerus to avoidneurovascular damage. The ulnar nerve lies 4 mmfrom the portal. The median nerve lies 7–20 mmfrom portal with the elbow in flexion.

The posterolateral portal

This is 3 cm proximal to the olecranon tip and justlateral to the border of the triceps tendon.

Structures at risk

The posterior antebrachial or lateral brachial nervescan be damaged with deep incisions.

• Ulnar nerve• Medial brachial cutaneous nerve• Medial antebrachial cutaneous nerve• Brachial artery

This portal traverses the extensor carpi radialisbrevis muscle. A blunt trocar is used to enter thejoint with the portal driven toward the centre ofthe trochlea. The elbow joint must be distendedprior to and kept at 90° flexion, during trocarinsertion since extension brings the radial nervecloser to the joint (3–7 mm).

The proximal anterolateral portalThis is located 2 cm proximal and 1 cm anterior tothe lateral epicondyle. It is further from the radialnerve than other anterolateral portals. It allows forexcellent views of the anterior radiohumeral andulnohumeral joints as well as the anterior capsularmargin.

The anteromedial portal

Some surgeons prefer to establish this portal first.The elbow should be flexed to 90° as the portal isestablished. It is situated 2 cm anterior and 2 cmdistal to the medial epicondyle. It must be placedunder direct vision: the median nerve lies 1–2 cmanterior and lateral to this portal.

The proximal anteromedial portal

Structures at risk

• Median nerve

Structure at risk

• Median nerve

Ulnar nerveMedial antebrachialcutaneous nerve

Superomedialportal

Medialepicondyle

Anteromedialportal

Brachialartery

Mediannerve

Figure 7.26 Medial portals in elbow arthroscopy

Elbow aspiration/injection 97

the radioulnar and radiocapitellar articulations plusthe annular ligament. Extending the elbow revealsmore of the capitellum and forearm rotationexposes more of the radial head. The anterolateralgutter and capsule should also be examined.

Next, the direct lateral portal is established. Viathis portal, the radial head (concave) is viewed,articulating with the capitellum (convex). Thearticulation between the olecranon and thetrochlea is also well seen.

Finally, through the posterolateral portal, theolecranon fossa, olecranon tip and posteriortrochlea are examined. Loose bodies andosteophytes are sought, particularly on theolecranon tip.

Specific instruments can be used for removal ofloose bodies or debridement.

Closure

Non-absorbable suture is used to close the skindefects. Occlusive dressings are applied. Wool andcrepe bandage pressure dressing is used.


The pressure dressing is removed at 48 hours. Thepatient mobilizes the elbow fully following adiagnostic arthroscopy.


O’Driscoll SW, Morrey BF. Arthroscopy of theelbow. J Bone Jt Surg Am 1992;74:84–94.

ELBOW ASPIRATION/INJECTION

Indications

• Inflammatory arthritis and other arthropathies• Suspected infection• Haemarthrosis.

Consent and risks

• Nerve injury: 1 per cent• Infection: 1–2 per cent in osteoarthritis,

5 per cent in rheumatoid arthritis

The direct posterior portal

This is 3 cm proximal to the olecranon tip and2 cm medial to the posterolateral portal. It isestablished under direct vision with thearthroscope in the direct lateral portal (Fig. 7.26).

Procedure

A systematic approach is essential if pathology isnot to be missed. About 15–25 mL of fluid isinstilled into the joint, to distend the capsule,through the direct lateral portal using an 18Gneedle. Backflow of fluid confirms correctplacement. The anterolateral portal is established(see above) and the arthroscope and cannulainserted. The capsule medial to the articulation isexamined first. Medial laxity can be assessed bysupinating the forearm and applying valgus stressto the elbow in varying degrees of flexion. Flexingand extending the elbow allows the trochlear tobe viewed. The radioulnar articulation is observedas the forearm is rotated and, for coronoidimpingement, as the elbow is fully flexed.

The anteromedial portal is established underdirect vision and the arthroscope introduced to view

Structure at risk

The ulnar nerve, if placed too medially.

Approach

The elbow can be entered either ulnarly orradially, but the radial approach is preferred inorder to avoid ulnar nerve injury

Landmarks

Radial head, lateral epicondyle, and tip of theolecranon (anconeus triangle) (Fig. 7.27).

Procedure

The skin is prepared with a germicidal solution.Prior to needle insertion, the elbow is flexed andthe forearm pronated to protect the radial nerve.An 18G needle is inserted into the joint, throughthe soft spot at the centre of the anconeustriangle. With this approach the needle willpenetrate only the anconeus and joint capsule.

If the needle hits bone, it should be withdrawnslightly and redirected at a slightly different angle.If performing an injection, it is wise to aspiratefirst to ensure the needle is not in a blood vessel.

Structure at risk

• Radial nervePOSTOPERATIVE CARE ANDINSTRUCTIONS

An occlusive dressing is applied. Mobilization ofthe joint depends on the underlying reason foraspiration/injection.


Holdsworth BJ, Clement DA, Rothwell PN.Fractures of the radial head – the benefit ofaspiration: a prospective controlled trial. Injury1987;18:44–7.


Lateral epicondyle

Radial head

Olecranon process

Figure 7.27 Landmarks for elbow aspiration

Viva questions

1. How do you approach diagnosing and thetreatment of a painful elbow?

2. What are the indications, benefits anddrawbacks for total elbow replacement?

3. How do you further investigate an elbowreplacement shown to be loose on X-ray?

4. What are the treatment options for a 50-year-old man with symptomatic osteoarthritis of theelbow?

5. Describe the anatomy of the ulnar nervearound the elbow.

6. Describe the anatomy of the posteriorinterosseous nerve around the elbow.

7. What complications do you warn the patientabout prior to elbow replacement? What aretheir incidences?

8. What are the indications for arthrolysis?

9. What is your postoperative management postarthrolysis?

10. Which approach do you use for total elbowreplacement?

11. What factors influence whether you use asemi-constrained or resurfacing type totalelbow replacement?

12. What are the contraindications to total elbowreplacement?

Viva questions 99

13. How would you manage someone after totalelbow replacement?

14. Which nerves can be injured in elbow surgery?

15. What factors contribute to loosening in totalelbow replacement?

16. Describe the portals used in elbow arthroscopy.

17. What structures are at risk from each portal?

18. What are the advantages/disadvantages ofradial head replacement versus radial headexcision?

19. What approach would you use for a radialhead replacement?

20. What are the complications associated withradial head replacement?

Surgery of the wrist8

James Donaldson and Nicholas Goddard

Wrist arthroscopy 100Wrist arthrodesis 102De Quervain’s decompression 106Excision of the distal ulna (Darrach procedure) 108

Ulnar shortening 109Ganglion excision at the wrist 111Viva questions 113

WRIST ARTHROSCOPY


Indications

• Triangular fibrocartilage complex (TFCC;‘the meniscus of the wrist’) repair ordebridement

• Carpal instability – diagnostic or arthroscopicassistance in reduction and treatment

• Distal radius or scaphoid fractures – reducefracture and treat associated TFCC tears

• Chondral lesions• Dorsal ganglion excision• Bone excision procedures – loose body removal,

radial styloidectomy, excision of the distalulna

• Kienbock’s disease – lunate excision ordebridement of head of capitate

• Synovectomy or synovial biopsy, adhesionrelease, etc.

Contraindications

• Infection of overlying skin• Lack of proper instrumentation

Operative planning

Recent radiographs ± magnetic resonance (MR)images should be available. The proper equipmentmust be available; usually 2.5–3.0 mm scope andany specific, procedure-dependent equipment.


Anaesthesia is general with a supine position andthe shoulder abducted, placing the arm on a hand

Consent and risks

• Nerve injury: 1–2 per cent• Infection: <1 per cent; deep infection/septic

arthritis (0.04 per cent); prophylactic antibioticsnot recommended.

• Haematoma: 0.2 per cent• Tendon injury: 0.15 per cent• Chronic regional pain syndrome: 0.5 per cent• Compartment syndrome of the forearm

associated with fluid extravasation: 0.01 per cent


• Dorsiflexion: 10–20° (neutral in rheumatoid)• Ulnar deviation: 0–5°

Wrist Range of motionDorsiflexion 80°

Palmarflexion 90°

Radial deviation 20°

Ulnar deviation 35°

Pronation 75°

Supination 80°

table. Finger traps are applied to the index andlong fingers and tied to a drip-stand. The elbow isflexed to 90° and up to 4.5 kg of counter-tractionapplied to the arm (depends on sex and weight).

The dorsal wrist veins are marked out beforeexsanguination and inflating the tourniquet.Gravity-assisted inflow of irrigation fluid is used.

SURGICAL TECHNIQUE

Landmarks

• Bony – Second and third carpometacarpal joints– Distal radioulnar joint (DRUJ)– Lister’s tubercle– Radial styloid in the anatomical snuff box– Neck of the capitate

• Tendinous– Extensor carpi ulnaris– Extensor pollicis longus– Extensor digitorum communis.

Approach

The portals are named according to the wristcompartments on either side of them. Thecommonly used portals are all on the dorsalsurface of the wrist. Before their creation, theyshould be drawn on prior to fluid injection andwrist distension.

A minimum of two portals are used; the mostcommon ones used are portal 3–4 for thearthroscope and portal 4–5 or portal 6/R for theinstruments (Fig. 8.1).• The 1–2 portal is between the extensor carpi

radialis brevis (ECRB) and the abductor pollicislongus (APL).

Structures at risk

• The radial artery and dorsal branch of the radialnerve – restrict the portal to the dorsal andproximal part of the snuff box to reduce the risk.

Wrist arthroscopy 101

TH

STT

6U

6R

4–5

1–2

3–4

Radialmidcarpal

Ulnarmidcarpal

Figure 8.1 Radiocarpal and mid-carpal portals

• The 3–4 portal is between the extensor carpiradialis longus (ECRL) and the extensor pollicislongus (EPL), 1 cm distal to Lister’s tubercle.This is commonly the first portal marked inplace and the site for injection of saline into thewrist in order to distend the capsule. The scopeis then inserted in line with the dorsal radialslope.

• The 4–5 portal is between extensor digitorumcommunis (EDC) and extensor digiti minimi(EDM), 1 cm distal to the DRUJ line.

• The 6/R portal is radial to the extensor carpiulnaris (ECU) at the level of the ulnar styloid.

• The 6/U portal is ulnar to the ECU at the levelof the ulnar styloid.

• The mid-carpal portal is in the scaphocapitateinterval, 1 cm ulnarwards and 1 cm distal to 3–4portal.

Saline (± adrenaline) are injected, to distend thecapsule, using an 18G needle at an arthroscopicportal site. This is usually done at the 3–4 portaland with the wrist pronated and in ulnardeviation. The needle is removed and the skinincised. Blunt dissection is used to penetrate thecapsule: a small haemostat is easiest to use. Thecannula and blunt obturator are inserted, andinflow irrigation established.

Procedure

This is dependent on the indication. As always, anorganized pattern ensures identification ofpathology and normal structures within the wrist.

Closure

Steri-Strips are sufficient to close the skin defectsand a compression bandage is then applied.


The patient is usually advised to mobilize

Structure at risk

• Dorsal ulnar cutaneous nerve

according to comfort; this may depend on thespecific pathology treated.


Nagle DA, Benson LS. Wrist arthroscopyindications and results. Arthroscopy 1992;8:198.Warhold LG, Ruth RM. Complications of wristarthroscopy and how to prevent them. Hand Clin1995;11:81.Whipple TL, Marotta JJ, Powell III JH. Techniquesof wrist arthroscopy. Arthroscopy 1986;2:244.

WRIST ARTHRODESIS


Indications

• Post-traumatic arthritis• Joint destruction secondary to infection or

tumour resection• Rheumatoid arthritis• Failed arthroplasty or limited fusion• Scapholunate advanced collapse (SLAC) or

scaphoid non-union advanced collapse (SNAC)wrist

• Spastic flexion contracture• Kienbock’s disease.

Contraindications

• Skeletal immaturity• Elderly patients or sedentary lifestyle, where a

replacement may be more appropriate.

Consent and risks

• Subsequent re-operation: metalwork removal forpainful hardware (15 per cent); or non-union (2per cent with AO plate fixation), with or withouthardware failure (common)

• Complex regional pain syndrome (CRPS) andpersistent pain: up to 10 per cent

• Nerve damage and neuroma formation: 1 percent

• DRUJ pain: 1–3 per cent• Carpal tunnel syndrome: 2–4 per cent

102 Surgery of the wrist


Anaesthesia is general and the supine position isused; a hand table, tourniquet and imageintensifier are required.

SURGICAL TECHNIQUE – FULL FUSION

Landmarks

• Styloid process• Lister’s tubercle• DRUJ• Third metacarpal.

Incision

A dorsal approach is used: a longitudinal incisionin line with the distal radius and the thirdmetacarpal, centred on the DRUJ (Fig. 8.3).

Wrist arthrodesis 103

Operative planning

The surgeon must decide between full and partialwrist fusion (both described below). Considerneed for bone grafting – autologous bone from thedistal radius or iliac crest is usually sufficient,unless there is severe bone loss. Ulnocarpalimpaction may necessitate radial lengthening atthe same time.

Position of fusion is: 10–20° of dorsiflexion and0–5° of ulna deviation allows for maximum gripstrength. In rheumatoid arthritis, a more neutralposition may be preferred. In bilateral wristfusions, both wrists are fixed in neutral, allowingmaximal function. The equipment must beavailable – an AO, titanium, precontoured, wristfusion dynamic compression plate (Synthes) iscommonly used (Fig. 8.2).

The advantages of using a dynamic compressionplate (DCP) are:• Good stability, less need for bone grafting and

good fusion rates• Different sizes – straight, short carpal bend,

long carpal bend. All have tapered edges and arefilled with recessed screw heads (2.7 mm screwsin distal four holes; 3.5 mm holes in proximalfour holes).

• Infection: 1–2 per cent; local woundcomplications: 4 per cent

• Extensor tenosynovitis: 5–7 per cent• Ulnar abutment: 1–2 per cent• Intrinsic muscle contracture: 3–5 per cent

Figure 8.2 AO wrist fusion plates

Figure 8.3 Dorsal incision for wrist arthrodesis

Dissection

Full-thickness skin flaps are developed mediallyand laterally. The extensor retinaculum is incised,using a straight incision on the radial border of thefourth compartment. The approach continuesbetween the EPL (third compartment), which is

Structures at risk

• Dorsal veins and superficial nerves – theseshould be identified and protected

• Posterior interosseous nerve – see below

retracted radially, and the EDC (fourthcompartment) which is retracted ulnarly. Oncethe EPL is retracted, Lister’s tubercle is excised(using an osteotome or bone nibblers) to allow flatplate apposition.

The posterior interosseous nerve is identified asit enters the fourth compartment just proximal tothe extensor retinaculum and a 2 cm segment isexcised. The ECRB tendon may need to bereleased off the third metacarpal for plateapposition. An H-shaped capsulotomy is createdto access the wrist joint (Fig. 8.4).

Following measurement and tapping, a 2.7 mmscrew is inserted. The two remaining metacarpalscrews are inserted in a similar manner. The wristfusion is compressed with a 3.5 mm screw, oncompression mode, in the second most distal holein the radius. The remaining three proximal radialscrews are inserted with the usual method. Oftena screw is inserted into the capitate through theremaining hole. Any remaining defects are filledwith bone graft and a check radiograph (Fig. 8.5)is obtained.

Closure

The capsule is approximated, as far as possible,with Vicryl. The extensor retinaculum is closedwith Vicryl over the plate but under the extensortendons. Vicryl is also used to suture the fat, andan appropriate suture closes the skin. A volarplaster slab is applied.

SURGICAL TECHNIQUE – PARTIALFUSION

The ‘four corner’ fusion (capitate–hamate–triquetrum–lunate fusion) is indicated in SLAC


(a)

(b)

Carpal bones

Ulna

Radius

Figure 8.4 (a) Approach to the wrist joint. (b) Axialview showing the approach between the third andfourth compartments

Figure 8.5 Radiographic and intraoperative views of theAO wrist fusion plate

Procedure

The articular surfaces are denuded of cartilageusing rongeurs and burrs, exposing cancellous bonein the radioscaphoid and radiolunate joints, and theintercarpal joints (scaphocapitate, lunocapitate andtriquetrohamate). Any gaps are filled withcancellous bone harvested from the excised boneand distal radial metaphysis as necessary.

The precontoured plate is applied and bonyedges are contoured as necessary to allow goodapposition. The distal end of the plate shouldreach the mid-shaft of the third (or occasionallysecond) metacarpal. The most distal screw hole isdrilled with a 2 mm drill, in the dorsal to volardirection, in the middle of the metacarpal.

wrist, SNAC wrist or mid-carpal instability. Thelandmarks, basic approach and structures at riskare similar to those of full wrist fusion.

Incision

A ‘lazy S incision’, slightly ulnar-sided, is made onthe dorsum of the wrist.

Dissection

The extensor retinaculum is incised on the ulnarside of the fourth compartment. The posteriorinterosseous nerve is resected and an H-shapedcapsulotomy is used as in full fusion or,alternatively, a radially based oblique flap can becreated for exposure of the joint (Fig. 8.6).

Procedure

If radioscaphoid arthrosis is present, the scaphoidis excised, preserving the bone to be taken for lateruse as cancellous graft. If unstable, the lunate canbe reduced to neutral position using a K-wire as ajoystick; equally the capitate, hamate, triquetrumand lunate may be stabilized with volar placed K-wires. A Spider Limited Wrist Fusion (KMI) plate(Fig. 8.7) may be used as follows:

Wrist arthrodesis 105

Figure 8.7 A spider plate

Figure 8.6 Exposure of the carpal bones

• A reamer is used to create a trough on the fourbones, which are reamed to a depth so as not tocause impingement dorsally

• The articular surfaces are removed withrongeur or bone nibbler

• Cancellous bone is used to pack the cavity

• Two screws are placed in each bone underimage intensifier control.

Other fixation methods include K-wires, staples orheadless screws.

Closure

See ‘Surgical technique – full fusion’ (above).


• The volar slab is removed at 2 weeks (it can beleft longer if the bone quality is poor). Aremovable slab is required for the following 3weeks in the case of partial fusion.

• Hand therapy and finger exercises arecommenced 1 week after surgery.

• Union is usually achieved by 3 months.


Barbier O, Saels P, Rombouts JJ, et al. Long-termfunctional results of wrist arthrodesis inrheumatoid arthritis. J Hand Surg Br 1999;24:27.Chung K, Watt A, Kotsis S. A prospectiveoutcomes study of four-corner wrist arthrodesisusing a circular limited wrist fusion plate for stageII scapholunate advanced collapse wrist deformity.Plastic and Recon Surg 2006;118:433–42.Haddad RJ, Riordan DC. Arthrodesis of the wrist:a surgical technique. J Bone Joint Surg Am1967;49:950.Watson H, Goodman M, Johnson T. Limited wristarthrodesis. Part II Intercarpal and radiocarpalcombinations. J Hand Surg Am 1981;6:223–33.Zachary SV, Stern PJ. Complications followingAO/ASIF wrist arthrodesis. J Hand Surg Am1995;20:339–44.

DE QUERVAIN’S DECOMPRESSION


Indications

• Stenosing tenosynovitis of the APL andextensor pollicis brevis (EPB) in the first dorsalcompartment

• Failed conservative treatment (injection, thumbspica: success rate up to 70–80 per cent).

Contraindication

Infection of overlying skin.

Operative planning

Awareness of potential anatomical variations inthe first dorsal compartment is important (Fig.8.8).


The authors prefer general anaesthesia. Thesupine position is used with a hand table andtourniquet. Local anaesthesia can be used as analternative ± tourniquet.

SURGICAL TECHNIQUE

Landmarks

• Bony: radial styloid, scaphoid tubercle, Lister’stubercle

• Tendinous – APL and EPB – lie over the lateralaspect of the distal radius. They represent theradial border of the anatomical snuffbox.

Incision

One of the following three skin incisions may beused:• Transverse: 2 cm incision over the first dorsal

compartment, 1 cm proximal to tip of radialstyloid. Higher risk of nerve injury

• Oblique: from dorsal to volar – allows forextension distally

Consent and risks

• Nerve injury and/or neuroma formation:superficial radial nerve branches (2 per cent)

• Failure of symptomatic relief: 5 per cent• Tendon instability, subluxation or adherence: <1

per cent


• Longitudinal: better exposure but creates alonger area in which skin may potentially tetherto cutaneous nerves and tendons.

Dissection

Sharp dissection follows the line of the chosenincision through dermis but not into superficialfat. Blunt longitudinal dissection is now usedthrough the fat, whichever skin incision wasselected, identifying and protecting branches ofthe superficial radial nerve, usually deep tosuperficial veins.

Procedure

The tendons are identified proximally within theincision and the first dorsal compartment openedwith a longitudinal incision (Fig. 8.9) on the dorsalside, leaving a flap of palmar sheath to preventsubluxation.

The APL and EPB are lifted out of their groovewith a tendon hook. If they cannot be easilyfreed, septae, ‘aberrant’ tendons and separate com -partments are sought.

If the procedure is done under local anaesthesia,the tendons are replaced and the patient asked tomove their thumb to demonstrate adequatedecompression and independent movement.Instability is checked for and corrected, ifnecessary, by loosely opposing the edges of thetendon sheath.

Structures at risk

• Branches of superficial radial nerve – protectedby using blunt dissection

• Superficial veins

De Quervain’s decompression 107

Abductor pollicis longus tendonusually inserts on the base of the

first metacarpal

Often the abductor pollicislongus has an additional insertion

with a separate tendonExtensor pollicisbrevis tendon

Figure 8.8 First dorsal compartment anatomy

First dorsalcompartment

Figure 8.9 First dorsal compartment

Closure

The tourniquet is released and haemostasisachieved. The skin is closed with a subcuticularsuture. Pressure dressing is applied to the area anda thumb spica may be applied to controlpostoperative pain and swelling (authors’preference).


The pressure dressing is removed after 48 hours.Thumb and hand movements are initiated andincreased according to comfort. The thumb spicais removed at 2 weeks.


Harvey FJ, Harvey PM, Horsley MW. DeQuervain’s disease: surgical or nonsurgicaltreatment. J Hand Surg Am 1990;15:83.Witt J, Pess G, Gelberman RH. Treatment of DeQuervain tenosynovitis: a prospective study of theresults of injection of steroids and immobilizationin a splint. J Bone Joint Surg Am 1991;73:219.Kay NR. De Quervain’s disease: changingpathology or changing perception? J Hand Surg Br2000;25:65.Giles K. Anatomical variations affecting thesurgery of De Quervain’s disease. J Bone Joint SurgBr 1960;42:352–55.Littler JW, Freedman DM, Malerich MM.Compartment reconstruction for de Quervain’sdisease. J Hand Surg Am 2002;27:242.

EXCISION OF THE DISTAL ULNA(DARRACH PROCEDURE)


Indications

• Pain relief following DRUJ disruption andincongruity – commonly for symptomaticmalunion of Colles fractures in elderly patients

(younger patients may do better with a Sauvé–Kapandji or hemi-resection arthroplastyprocedure)

• Rheumatoid disease• Salvage operation following other failed DRUJ

procedures.

Contraindications

• Young and high-demand patients• Congruent DRUJ.

SURGICAL TECHNIQUE

Incision and dissection

A common approach (Fig. 8.10) is a longitudinalincision along the subcutaneous border of the ulnathrough the interval between the ECU and the

Structures at risk

• Dorsal sensory branch of ulnar nerve• Ulnar artery and nerve

Consent and risks

• Outcomes vary depending on primary pathologyand operative indication

• Decreased grip strength is expected and found innearly all following the procedure

• Pain, instability and subluxation of the ECU overthe ulnar stump: 5–40 per cent

• Radioulnar impingement: convergence – 60 percent radiographically but symptomatic in 5–10per cent


Figure 8.10 Approach to the distal ulna

flexor carpi ulnaris (FCU). The authors prefer anincision between the fifth and sixth compart ments.The periosteum is incised longitudinally andreflected off the distal ulna; Hohmann retractorsare then carefully placed around the ulna.

Procedure

The dissection is followed by resection of 1–2 cmof the distal ulna. Aim for minimal amount ofbone resection that eliminates radioulnar contactat the sigmoid notch. A common error is too greata bone resection leaving an unstable andtroublesome protrusion of the distal ulna.

It is important to leave soft tissue attachmentsand the TFCC at the ulnar styloid (Fig. 8.11). Thiscan be achieved by subperiosteal dissection of theulna styloid or preserving the styloid itself.Remnants of the TFCC are opposed to the capsuleand radius. Ensure full rotation is achieved beforeclosure.


Darrach W. Partial excision of lower shaft of ulnafor deformity following Colles fracture. Ann Surg1913;57:764–65.Peterson MS, Adams BD. Biomechanical evalua -tion of distal radioulnar reconstructions. J HandSurg Am 1991;18:338.

ULNAR SHORTENING


Indications

Ulna positive variance:• Acquired:

– Distal radial fracture– Essex-Lopresti type injury– Traumatic distal radial growth arrest– Resection of the radial head

• Congenital:– Idiopathic ulnar impaction syndrome– Madelung deformity (often in conjunction

with other procedures).– Development of degenerative changes in the

TFCC, DRUJ, ulnar head and articularsurfaces of the lunate and triquetrum owingto ulnar abutment.

Contraindications

• Advanced osteoarthritis (OA) or significantmalalignment of the DRUJ

• Relative contraindications – smokers (higherincidence of delayed and non-union) or non-compliant patient.

Consent and risks

• Non-union and delayed union: 0–4 per cent withoblique cuts; 8–15 per cent with transverse cuts

• Prominent metalwork and tendonitis fromhardware irritation necessitating removal: up to55 per cent

• Nerve damage, commonly dorsal sensory branchof the ulnar nerve: 1–2 per cent

Ulnar shortening 109

Darrach

Figure 8.11 Resection and soft tissue preservation inthe Darrach procedure

Closure

Haemostasis is achieved followed by closure inlayers with Vicryl. Subcuticular or interruptedsutures are preferred for skin closure.


A volar slab is used for 2 weeks, followed by earlyactive exercises.

Operative planning

Radiograph (90° shoulder abduction/90° elbowflexion) of the wrist is required to estimateamount of ulnar positive variance. Themeasurement should indicate the length ofexcision required to achieve a final ulnar varianceof neutral or –1 mm.


Anaesthesia can be general or with an axillaryblock; a tourniquet is applied. The supine position,with a hand table and image intensifier, is used.

SURGICAL TECHNIQUE

Incision

A longitudinal incision over the subcutaneousborder of the ulna is started distally 3–4 cm from theulnar styloid and continued proximally for 10 cm.

Dissection

Dissection is simply continued straight down tothe ulna, between the ECU and FCU. Sub -periosteal dissection exposes the ulna (Fig. 8.12).

Procedure

A six-hole, 3.5 mm DCP is held against the ulna (adorsal side position can be easier but a volarposition reduces the prominence of themetalwork) with the distal end just proximal to

Structures at risk

• The dorsal sensory branch of the ulnar nerve ispresent at the distal extent of the incision. Itstransection should be avoided to prevent painfulneuroma formation

• CRPS (Chronic Regional Pain Syndrome): up to 5per cent

• Reduced grip strength: variable depending on theprimary pathology.

the sigmoid notch of the ulna. The two distalscrews are inserted in the standard fashion. Theosteotomy site is marked at the middle of theplate with a longitudinal diathermy mark forrotational orientation. The most distal screw isloosened and the second screw is removed,allowing the plate to be swung out of the way byhinging on the distal screw.

An oblique osteotomy is fashioned from aproximal ulna to a distal radial direction.Continuous saline irrigation reduces heatproduction (and non-union rate); the distalosteotomy is created first. After measuring thethickness of bone to be removed, a free saw bladeis placed in the first osteotomy cut and a parallelosteotomy is cut proximally removing therequired amount of bone. The osteotomy isreduced and the plate swung around onto theulna. The first screw is tightened and the secondscrew is replaced. The remaining screws areinserted using the dynamic compressiontechnique (Fig. 8.13). An inter-fragmentary screw,at 90° to the plate, can also be used.

Closure

A standard closure of the skin in layers isundertaken. A below elbow cast is applied.


The cast is left on for 4–6 weeks then athermoplastic splint used until the osteotomy has


Figure 8.12 Approach between the extensor carpiulnaris and flexor carpi ulnaris

united. Strenuous activities are avoided untilevidence of bony union is seen.


Chen NC, Wolfe SW. Ulna shortening osteotomyusing a compression device. J Hand Surg Am2003;28:88.Chun S, Palmer AK. The ulnar impactionsyndrome: follow up note of ulnar shorteningosteotomy. J Hand Surg Am 1993;18:46–53.Rayhack JM, Gasser SI, Latta LL, et al. Precisionoblique osteotomy for shortening of the ulna. JHand Surg Am 1993;18:908–19.

GANGLION EXCISION AT THE WRIST

The commonest site for a wrist ganglion is on thedorsum of the wrist arising from the scapholunateligament; the second commonest site is volar,arising from the scapho-trapezoid joint.


Indications

• Symptomatic:– Pain (often worse with repeated use)– Enlarging– Feeling of abnormal sensation or weakness

• Cosmesis• Failed aspiration (success rate 35–50 per cent

with needle aspiration and immobilization for 3weeks).

Contraindications

Uncertain diagnosis, e.g. potential malignantlesion.


General anaesthesia is preferred as it is associatedwith lower recurrence rates than local anaesthesia.A tourniquet is applied and the forearm and handpositioned on a hand table.

Consent and risks

• Numbness and scar sensitivity: 15–28 per cent• Recurrence: variable depending on location; 5–

20 per cent• Nerve injury and neuroma formation: superficial

branch of radial nerve in dorsal ganglia: 2–5 percent; palmar cutaneous branch of median nervein volar ganglia: 1–2 per cent

• Vascular injury: 4–5 per cent radial artery injuryrequiring repair with volar ganglia

• Stiffness: rare• Scapholunate instability: rare

Ganglion excision at the wrist 111

(a) (b) (c)

Figure 8.13 Surgical technique for ulnar shortening using a dynamic compression plate

SURGICAL TECHNIQUE – DORSALGANGLION OF THE SCAPHOLUNATELIGAMENT

Consideration is first given to using arthroscopictechniques. These involve less surgical dissectionand scarring allowing more rapid return toactivities. They also allow identification andmanage ment of any other intra-articular wristpathology. Potential risks include damage totendons if not visualized adequately and higherrecurrence rates than open procedures.

Incision

A transverse incision of appropriate length iscreated over the ganglion (Fig. 8.14).

Dissection

The extensor retinaculum overlying the ganglionis incised. The EPL and ECRB tendons areretracted radially and EDC tendons retractedulnarly, exposing the ganglion.

Structures at risk

• Dorsal sensory branches of radial nerve – thesemust be identified and protected.

Procedure

The ganglion and its stalk are mobilized withsharp and blunt dissection down to the jointcapsule. The capsule is opened along the border ofthe radius and proximal pole of the scaphoid.Care must be taken to visualize and excise thestalk from the superficial portion of the ligamentwithout cutting the scapholunate ligament (Fig.8.15) and causing scapholunate instability.

Some authors advocate identification andcauterization of terminal branches of the posteriorinterosseous nerve as it runs past the fourth dorsalcompartment, to reduce the incidence ofneuroma.

Closure

The joint capsule is left open and haemostasisachieved after tourniquet release. Vicryl is used toclose the retinaculum and subcuticular suture toclose the skin. A volar splint is applied.

Structures at risk

• The scapholunate ligament: see below• Terminal branches of the posterior interosseous

nerve: see below


Figure 8.14 Skin incision for dorsal ganglion excisionFigure 8.15 Excision of the ganglion and its stalk fromthe scapholunate ligament

Viva questions 113

Viva questions

1. How many dorsal compartments are found atthe wrist and what are their contents?

2. Which nerve and artery are at risk duringsurgical release of the first dorsalcompartment?

3. What is the optimal position for wristarthrodesis?

4. Between which dorsal wrist compartments doyou classically approach through to access thewrist joint?

5. What is a ‘four corner’ fusion?

6. Name and describe the common wristarthroscopy portals?

7. Dorsal wrist ganglions usually arise from whichligament?

8. What is the recurrence rate following excisionof a volar wrist ganglion?

9. Describe the radiographic features of a wristwith scapholunate advanced collapse.

10. What is the non-union rate in total wristfusions?

11. What are the main functional disadvantageswith the Darrach procedure?

12. What alternatives are there to the Darrachprocedure in younger and higher-demandpatients?

13. What is chronic regional pain syndrome? Whatis the incidence after wrist or hand procedures?

14. When should an ulnar shortening osteotomynot be performed?

15. What is the most significant factor influencingthe rate of non-union in an ulnar shorteningosteotomy?

16. What is the significance of the posteriorinterosseous nerve in wrist procedures?

17. Where is the posterior interosseous nerveidentified at the wrist?

SURGICAL TECHNIQUE – GANGLION OFTHE SCAPHO-TRAPEZOIDAL JOINT

Incision

A longitudinal incision is created over theganglion.

Dissection and procedure

The artery is retracted radially and the gangliondissected down its stalk to its origin (usually thescapho-trapezoidal joint). The ganglion is excisedwith a small portion of surrounding capsule.


Immobilization of the wrist is continued for 2weeks then range of movement exercises areinitiated.


Luchetti R, Badia A, Alfarano M, et al.Arthroscopic resection of dorsal wrist ganglia andtreatment of recurrences. J Hand Surg Br2000;25:38.Mehdian H, McKee M. Scapholunate instabilityfollowing dorsal wrist ganglion excision. IowaOrthop J 2005;25:203–6.Nelson CL, Sawmiller S, Phalen GS. Ganglions ofthe wrist and hand. J Bone Joint Surg Am1972;54:1459.

Structure at risk

• The radial artery: identification and mobilizationis vital (may course through the ganglion).

Structure at risk

• The palmar cutaneous branch of the mediannerve

Surgery of the hand9

Norbert Kang, Robert Pearl and Lauren Ovens

Dupuytren’s surgery 114Synovial cyst treatment 119Arthrodesis in the hand 121Arthroplasty in the hand 124Extensor tendon repair 127Flexor tendon repair 131

Tendon transfers 134Soft tissue reconstruction 137Trigger finger surgery 141Trigger thumb surgery 142Viva questions 143

DUPUYTREN’S SURGERY


Indications

Patients are ready for Dupuytren’s surgery if theyhave a flexion deformity that is interfering withtheir activities of daily living. Using the ‘table-toptest’ (i.e. inability to get the hand flat on the table)or specific degrees of flexion deformity (e.g. =30°at the proximal interphalangeal [PIP] joint) as anindication for surgery is unhelpful as they mayover- or underestimate the need for surgery.

Operative planning

It is vital to record the range of movement,vascularity and sensation in the digits preopera -tively so that a comparison can be madepostoperatively.

There are three common procedures:• Fasciotomy (either open or needle) or

segmental fasciotomy• Fasciectomy• Dermofasciectomy.

FASCIOTOMY

This is a procedure to divide rather than excise theDupuytren’s cord tissue. It can be done under

direct vision (open fasciotomy), percutaneously(needle fasciotomy) or by excising a shortsegment of cord tissue – also under direct vision(segmental fasciotomy).

Indications

• Discrete Dupuytren’s cord• Metacarpophalangeal (MCP) joint flexion

deformity• Patient unwilling or unsuitable for major

operative procedure• Needle fasciotomy can be performed under

local anaesthesia and is particularly useful forpatients who wish to avoid or are unsuitable forgeneral anaesthesia.

Contraindications

• Diffuse Dupuytren’s disease• PIP joint flexion deformity – there is a

significant risk of neurovascular injury• Patient unable or unwilling to comply with

indefinite night-splintage with the digit in fullextension.

Consent and risks

Injury to the neurovascular bundle (reduced withopen/segmental fasciotomy).


Local anaesthesia, upper limb blockade or generalanaesthesia can be used. The arm should be placedsupine on an arm table or arm board. It is helpfulto use a tourniquet for open and segmentalfasciotomy; no tourniquet is required for needlefasciotomy.

Surgical technique

LandmarksThe cord to be divided is palpated and marked.

Needle fasciotomyA green hub (21G) hypodermic needle is passedthrough the skin into the cord. Only the first 2–3mm of the tip are inserted under the skin. The tipof the needle is then used like a knife (Fig. 9.1).Small sweeping movements are made with theneedle tip to divide the cord tissue.Simultaneously, the digit is pushed into extension.If successful, a tearing sound is often heard as thedivided cord tissue is torn in half allowing thefinger to extend. The skin over the cord often tearsopen for a few millimeters as well.

Open fasciotomyThe skin is opened formally, through alongitudinal incision made over the course of thecord tissue. The incision is made sufficiently longto allow direct visualization of the cord andadjacent structures. The cord tissues are dividedwith a scalpel while forcibly extending the digit. Ifsuccessful, the cord tissues are torn in halfallowing the finger to extend.

Segmental fasciotomyThe procedure is the same as open fasciotomybut, in addition, a short segment (approximately1 cm) of cord tissue is excised in the belief thatthis reduces the risk of recurrence.

Closure

After needle fasciotomy, the puncture wounds areallowed to heal by secondary intention. For openand segmental fasciotomy, the skin is closed withabsorbable sutures (e.g. 5/0 Vicryl rapide).


All patients undergoing fasciotomy should beallowed to mobilize their digits freely aftertreatment. However, all patients will need to weara splint at night indefinitely to keep the treateddigit in full extension. Otherwise, the flexiondeformity will recur within a few weeks.

FASCIECTOMY

Indications

Any degree of involvement with Dupuytren’scontracture including recurrent disease and MCP,PIP and distal interphalangeal (DIP) joint flexiondeformity.

Contraindications

• Diffuse Dupuytren’s disease with extensive skininvolvement (pits and fixed skin over cords)

• Multiple previous fasciectomies withsubsequent recurrence of flexion deformities

Dupuytren’s surgery 115

Figure 9.1 Needle fasciotomy: (a) needling of fascia and (b) postoperative appearance

(a) (b)

• Patient with severe Dupuytren’s diathesis(multi-digit involvement, radial disease,bilateral, family history and plantarinvolvement or Peyronie’s disease)

• Patient unwilling or unable to comply withhand therapy postoperatively

• Heavy smoker and unwilling to stop smokingpreoperatively.


Fasciectomy can be performed under localanaesthesia (maximum of two digits), upper limbblockade or general anaesthesia. The arm shouldbe held supine on an arm table with a lead hand.All surgery should be carried out undertourniquet with loupe magnification.

Consent and risks

• ‘White finger’ due to injury to the vascularsupply followed by necrosis of the finger

• Paraesthesia or anaesthesia due to injury to thenerve supply (10 per cent risk if redo procedure)

• Infection• Skin flap necrosis• Loss of flexion• Recurrence of Dupuytren’s followed by

recurrence of the flexion deformity

SURGICAL TECHNIQUE

Landmarks

A straight line incision is marked over the midlineon the volar aspect of the affected digit beginningat the distal finger crease. This is extendedproximally to the mid-palmar crease. A furthertransverse incision is marked across the palmfollowing the line of the mid-palmar crease. Thelength and position of the transverse incision isdetermined by the position and number of digitswhich are being treated (Fig. 9.2).

Incision

The transverse incision is created beforeproceeding into the digits. All incisions should befull thickness.

Dissection

Thin skin flaps should be developed above thecords. Particular care must be taken to avoid

Structures at risk

• Neurovascular bundles• Skin edges of the flaps

116 Surgery of the hand

Figure 9.2 Fasciectomy. (a) Skoog’s straight line incision. (b,c) Z-plasty marked out and performed

(a) (b) (c)

button-holing the skin when there is significantpitting or skin involvement. Ensure that the skinflaps are thick enough to be viable (ideally justthicker than sub-dermal) but thin enough so thatnot too much cord tissue is left in the hand (toavoid recurrence).

For fingers with significant flexion deformitiesdue to a pretendinous cord, it is often helpful tocarry out a fasciotomy after opening the palm.This allows the finger to be extended andsimplifies access to the rest of the digit.

Procedure

Any longitudinal cord tissue should now beexcised, leaving the transverse fibres of the palmaraponeurosis in place where possible. Theneurovascular bundles should be visualized in thepalm on either side of the flexor tendon. The restof the dissection is directed at freeing theneurovascular bundles from the cord tissue onboth sides of the finger by a combination of bluntand sharp dissection. Once both bundles havebeen skeletonized as far as the DIP joint, any softtissues remaining between the skin and the tendonsheath can be excised and discarded.

Any remaining flexion deformity must now beassessed (e.g. from a boutonnière deformity at thePIP joint, volar plate contracture, shortening ofthe flexor sheath or volar skin shortage). In manycases, it is due to a combination of all of thesefactors. Boutonnière deformities respond well tosplintage in full extension for 1 week. Volar platecontractures require either passive manipulationof the PIP joint or sharp release of the volarplate/check-rein ligaments.

‘White fingers’ need to be detected. Thetourniquet must be released before beginningclosure to check perfusion of the digit and carryout haemostasis. If the finger fails to perfuse, thenboth vessels need to be visualized to ensure thatthey are in continuity. You only need one intactartery to perfuse the digit. If the vessels are intactbut the digit is still white, the digit is allowed to

Structure at risk

• Neurovascular bundles

flex to its former position for 5–10 minutes. If thisfails, the surgeon can try bathing the vessels in afew drops of verapamil (2.5 mg/mL) or glyceryltrinitrate (5 mg/mL). It is important to tell theanaesthetist before doing this. If the vessels havebeen divided, they will need to be repaired bysomeone experienced in microvascular techni -ques.

Closure

Treatment of any skin shortage in the digitrequires closure of the skin with a Z-plasty. Theideal Z-plasty for closure has a 30° angle and is aslarge as possible. It is not necessary to locate thetransverse limb of the Z-plasty at the flexorcreases – this simply makes planning difficult.Often, only one Z-plasty is required to allowsufficient lengthening of the volar incision toallow comfortable closure. The skin of the finger isclosed with interrupted or continuous absorbablesutures (e.g. 5/0 Vicryl rapide).

The transverse palmar incision should be leftopen. If the maximum width of this incision doesnot exceed 1.5 cm it will heal by secondaryintention within 2 weeks. Leaving the palm openalso simplifies closure of the hand and reduces therisk of a haematoma by allowing free drainagefrom the dissected areas.


All patients undergoing fasciectomy should beallowed to mobilize their digits freely aftertreatment unless they have a significantboutonnière deformity and/or needed significantmanipulation/release of the PIP jointintraoperatively. This latter group of patientsshould be splinted continuously in full extensionfor 1 week. Thereafter, all patients must use asplint at night for 3 months to keep the treateddigit(s) in full extension.

DERMOFASCIECTOMY

This is a fasciectomy with excision of theproximal digital skin. The aim is to excise all thesoft tissues except the tendon/tendon sheath andthe neurovascular bundles on the volar side of theproximal part of the finger. The resulting defect is

Dupuytren’s surgery 117

then resurfaced with a full-thickness skin graft.The aim is to remove any tissue that may result insubsequent recurrence of a longitudinal cord volarto the axis of flexion of the digit.

Indications

As for fasciectomy (p. 115) but with addedindications:• Recurrent disease• Severe diathesis• Extensive skin involvement.

Contraindications

• Inexperienced surgeon• Patient unwilling or unable to comply with

hand therapy postoperatively• Heavy smoker and unwilling to stop smoking

preoperatively.


Dermofasciectomy can be performed afterinfiltration of local anaesthetic (single digit only),upper limb blockade and general anaesthesia. Thearm should be placed supine on an arm table witha lead hand.

Surgical technique

As for fasciectomy (p. 116). The neurovascularbundles must be freed from all the soft tissues andskeletonized from the palm to the fingertip. Afterexcising all the soft tissues between the skin andthe tendon sheath, the skin on the volar side of theproximal segment of the finger is also exciseddown to the mid-lateral line (Fig. 9.3).

Correction of the flexion deformity is nowchecked as for a fasciectomy (p. 116). Haemostasisand perfusion of the digit are also now checked as

Consent and risks

As for fasciectomy and:• Loss of the full-thickness graft• Loss of flexion• Infection• Scarring at the donor site for the skin graft

for a fasciectomy (p. 116). Then a full-thicknessgraft of appropriate size is harvested from theforearm or groin and secured to the finger with 4/0or 5/0 Vicryl rapide. The authors’ preferredapproach is to anchor the four corners of the graftand then secure all the edges of the graft with acontinuous over and over suture of 5/0 Vicrylrapide. The middle of the graft is then secured tothe tendon sheath with two or three quiltingsutures of 5/0 Vicryl rapide to reduce the tendencyfor the graft to slide around. This improves the takeof the graft and reduces haematoma formation.


The hand should be splinted with the digits in fullextension for 1 week continuously. The splint and


Figure 9.3 (a) Dermofasciectomy of little and ringfingers and (b) 3 months postoperatively with healedgraft

(a)

(b)

dressings are then removed and the graft is checked.If it is pink and secure, then the patient can begin tomobilize the digit with the assistance of a handtherapist. Patients will still need to splint the digit atnight for 3 months in full extension.


Hall PN, Fitzgerald A, Sterne GD, et al. Skinreplacement in Dupuytren’s disease. J Hand SurgBr 1997;22:193–7.Hueston JT. Recurrent Dupuytren’s contracture.Plast Reconstr Surg 1963;31:66–9.McFarlane RM. Patterns of the diseased fascia inthe fingers in Dupuytren’s contracture. Displace -ment of the neurovascular bundle. Plast ReconstrSurg 1974;54:31–44.van Rijssen AL, Werker PM. Percutaneous needlefasciotomy in Dupuytren’s disease. J Hand Surg Br2006;31:498–501.

SYNOVIAL CYST TREATMENT


Long-term follow-up of ganglia has nowdemonstrated that the majority of ganglia shouldbe treated non-surgically in the first instancebecause 50 per cent of ganglia will resolvespontaneously within a few years and themorbidity of surgical excision is significant. Thisdoes not mean that ganglia should never be treatedbut patients should be informed appropriately andover-enthusiastic reliance on surgical excisionshould be avoided. In specific cases, simultaneoustreatment of the underlying pathology (e.g.arthrodesis of a DIP joint for osteoarthritis) willremove the ganglion and the cause for the ganglion.

Indications

• Pain (may be caused by underlying pathology)• Impaired function (if a ganglion is large enough

it may catch on clothing)• Cosmesis. This is probably the most common

reason for patients to seek help.

Contraindications

There are no absolute contraindications fortreating a ganglion.


This depends on the site of the ganglion and thepreference of the patient. Anaesthesia isunnecessary for aspiration of a ganglion. Forexcision of a ganglion in the digit, most cases canbe treated under local anaesthesia. However,excision of a ganglion at the wrist should betreated under regional block or generalanaesthesia as the dissection is often involved. Atourniquet should be used in all cases.

SURGICAL TECHNIQUE

Aspiration of ganglia

The largest gauge needle compatible with comfortfor the patient is attached to a 2 mL syringe –typically, a blue hub (23G) needle. The needle isplunged into the ganglion with one swiftmovement and aspiration begun immediately. Ifthe contents will not enter the syringe, the needleis extracted and the contents manually expressedthrough the small puncture hole. Injecting a smallamount of Adcortyl (5 mg) into the ganglion/adjacent tissues reduces post-treatment inflamma -tion and discomfort.

Flexor sheath ganglia

Landmarks and incisionTypically, the ganglion arises from the A2 pulley atthe level of the proximal finger crease. Atransverse incision, directly over the ganglion, isused.

Consent and risks

• Bleeding• Infection• Recurrence• Joint instability• Stiffness• Troublesome scars

Synovial cyst treatment 119


The ganglion is excised en bloc with (if necessary)a small cuff of the flexor sheath.

ClosureThe skin is approximated with interrupted 5/0Vicryl rapide sutures. A light dressing is applied,which will not impede movement and allowsimmediate mobilization.

Mucous cysts

Landmarks and incisionTypically, the ganglion arises dorsally from thejoint capsule of the DIP joint. As it enlarges, itemerges on either the ulnar or radial side of thefinger in the interval between the terminalextensor tendon and the collateral ligament of thejoint (Fig. 9.4). The skin over the mucous cyst isoften very thin. Therefore, attempts to separatethe skin from the ganglion wall are frequentlyfruitless. The surgeon can decide to either excisethe skin with the ganglion or simply make alongitudinal incision over the ganglion knowingthat it will burst.

Structure at risk



Whether or not an ellipse of skin was excised withthe ganglion, excision of the rest of the ganglionwall is often an academic exercise because theremnant is usually so flimsy. Excise whateverremains of the ganglion wall (piecemeal ifnecessary) down to the DIP joint. Any obviousosteophytes should also be removed with a bonenibbler as this improves cosmesis.

ClosureThe skin is closed with interrupted 5/0 Vicrylrapide sutures. If an overly large ellipse of skinhas been excised, it will be difficult to close theskin directly. The options then are to use a smallsplit-thickness skin graft or a local flap –converting an operation of dubious value (excisinga mucous cyst) into an operation with a multi -tude of potential complications! If the defect isvery small and no important structures areexposed, then allowing the wound to heal bysecondary intention may be acceptable. The fingeris dressed lightly, which allows immediatemobilization.


The hand is elevated to reduce pain and swelling.Any bulky dressings are removed after 48–72hours. The hand/finger is mobilized, with the helpof a hand therapist, as quickly as possible.


Dias JJ, Dhukaram V, Kumar P. The natural historyof untreated dorsal wrist ganglia and patientreported outcome 6 years after intervention. JHand Surg Eur Vol 2007;32:502–8.Green DP, Hotchkiss RN, Pederson WC (eds).Green’s Operative Hand Surgery (5th edn).Edinburgh: Elsevier, 2005.

Structure at risk

• Terminal extensor tendon – injury will causemallet deformity


Mucouscyst

Terminaltendon

(a) (b)

Figure 9.4 A mucous cyst

ARTHRODESIS IN THE HAND


Indications

An arthrodesis is a very reasonable salvagetreatment for certain joints and for certainsituations, which can restore pain-free form andfunction in one operative step. Indications include:• Pain• Instability• Deformity• Failed arthroplasty• Joints where arthroplasty is not desirable/

possible

Certain joints respond well to arthrodesis becauseof the functional requirements of the hand. Othersdo less well (see operative planning – below).

Contraindications

• Poor skin cover over the joint• Active infection in the upper limb – inserting

metalwork should be avoided• Non-compliant patient – the joint needs to be

immobilized for 8 weeks after surgery to allowbony union

• Smoking is a contraindication because of poorwound healing.

Operative planning

Distal interphalangeal jointPatients do very well after arthrodesis of thesejoints because joint replacements do very badly

Consent and risks

• Damage to any of the adjacent structures (e.g.tendons, neurovascular bundles, damage to thenail bed in DIP joint fusion)

• Infection• Malunion• Non-union (up to 10 per cent – especially the

DIP joint)• Stiffness of adjacent joints and fingers• Flexor and/or extensor adhesions.

here and the loss of range of movement at the DIPjoint has little effect on overall hand function. DIPjoint arthrodesis is a particularly useful treatmentfor rupture of the flexor digitorum profundus(FDP) tendon, chronic mallet deformity or painfularthritis of the DIP joint (with or withoutdeformity) and chronic mucous cyst.

Proximal interphalangeal jointArthrodesis of the PIP joints results in significantimpairment of hand function but is still areasonable option to deal with chronic pain andinstability, especially for the little and ring fingers.This is because PIP joint replacements doparticularly badly in the little and ring fingers.

Interphalangeal (IP) joint of the thumbThe IP joint of the thumb responds very well toarthrodesis.

Metacarpophalangeal jointThe MCP joints of the fingers should not bearthrodesed as this results in very significant im -pair ment of function. In contrast, arthrodesis of theMCP joint of the thumb is an excellent procedurewhich significantly enhances hand function.

Carpometacarpal (CMC) jointThe first CMC joint should not be fused, as thiswill result in very significant impairment of handfunction. The second and third CMC jointsnormally behave as if they are fused, therefore,arthrodesis of these joints is seldom necessary. Thefourth and fifth CMC joints are surprisinglymobile in normal hands. Nevertheless, arthrodesisis a reasonable solution to problems of chronicpain and instability (typically after trauma).


Local anaesthetic digital block with fingertourniquet is suitable for IP joint, DIP joint or PIPjoint arthrodesis. Regional block or generalanaesthesia with arm tourniquet is suitable forarthrodesis of the thumb MCP joint or CMC joints.

SURGICAL TECHNIQUE

Several different techniques are available forarthrodesis of a joint (e.g. K-wires, interosseous

Arthrodesis in the hand 121

wires, screws, plates and staples). Differentmethods of fixation are more or less suitable forparticular joints and in particular situations.Regardless of the technique, the usefulness of thearthrodesis is determined by the final position ofthe bones after fusion (Table 9.1). Also, thearthrodesed digit will be shorter by the amount ofbone that needs to be removed to allow thearthrodesis to be performed.

Landmarks and incisions

• DIP and thumb IP joint – an ‘H’ or ‘Y’ incisionover dorsum of joint or a mid-lateral incision forplating (Fig. 9.5).

• PIP joint – longitudinal incision over dorsum ofjoint.

• Thumb MCP joint – longitudinal incision overdorsum of joint.

• CMC or intercarpal arthrodesis – longitudinalincisions over the dorsum of the relevant joint.

Fusion techniques

This depends on the joint. Image intensifiercontrol (preferably using a mini-C-arm) isabsolutely essential to ensure that any metalworkgoes in the right place.

Distal interphalangeal jointThe terminal extensor tendon is detached fromthe base of the distal phalanx, exposing the joint.The collateral ligaments are excised and the volarplate detached from the base of the distal phalanx.This allows the joint to be disarticulatedcompletely. The joint surfaces are removed with asaw or bone nibbler to expose the cancellous bone

and create matching surfaces, ensuring that thereare two flat surfaces with the correct angulation(i.e. 0–10°). For fixation, 90–90° wiring isprobably the easiest technique. Tension bandwiring is also acceptable but technically moredifficult to do (Fig. 9.6). Other acceptablealternatives include a Lister loop (although the K-wire needs to be removed at 8 weeks), Herbert orcannulated screw fixation and plating.


Table 9.1 Arthrodesis positions in the hand

Thumb Index Middle Ring LittleDIP joint N/A 0–10° 0–10° 0–10° 0–10°

PIP joint N/A 30° 30–40° 40–50° 50°

IP joint 0–20° N/A N/A N/A N/A

MCP joint 0° Do not fuse Do not fuse Do not fuse Do not fuse

CMC joint Do not fuse 0° 0° 0° 0°

N/A, not applicable.

Figure 9.5 Incisions for access to DIP joint

Proximal interphalangeal jointA longitudinal split in the extensor tendon or aChamay approach (distally based ‘V’ shapedincision in the central slip; Fig. 9.7) can be used toexpose the PIP joint. The joint is disarticulated byexcising the collaterals and detaching the volarplate. The joint surfaces are removed with a saw ora bone nibbler to create two flat surfaces with thecorrect angulation (Table 9.1).

As for the DIP joint, there is no preferredmethod for fixation. Any of the techniques which

are used for the DIP joint are also suitable for thePIP joint. The authors’ preference is to use atension band technique.

Metacarpophalangeal joint of the thumbThe joint is exposed through a longitudinal split inthe extensor tendon and disarticulated by excisingthe collateral ligaments and detaching the volarplate. The joint surfaces are excised. The authors’preference for arthrodesis of the thumb MCPjoint is a tension band wire technique.

Arthrodesis in the hand 123

(d)

(c)

(b)

(a) Figure 9.6 Methods of distalinterphalangeal (DIP) joint fusion.(a) ‘90–90’ wiring. Twointerosseous wires of 0.35 to 0.45gauge dental wire passed at 90°to each other. (b) Tension bandwiring using two 1.1 mm K-wiresand a 0.35–0.45 gauge dentalwire. (c) Lister loop with a single1.1 mm K-wire and a 0.35–0.45gauge dental wire. The K-wiremust be removed at 4 weeks.(d) Plating of the DIP joint with amini-plate (the most difficulttechnique)

(a) (b)

Figure 9.7(a) Chamay approach. (b) Longitudinal split

Carpometacarpal jointThe extensor tendons are retracted from over theCMC joints and soft tissue excised to expose thespecific joint. The image intensifier confirms thatthe correct joint has been identified. The jointsurfaces are excised and bone graft is inserted. Thegraft is harvested from the distal radius. Bonesubstitute (e.g. hydroxyapatite) can also be used.The joint is secured with an oblique K-wire passedthrough the base of the respective metacarpal andthe corresponding trapezoid, capitate or hamate.The wire is buried and removed after 8 weeks.

Closure

The extensor tendons are repaired with 4/0 or 5/0PDS interrupted or continuous sutures. Thetourniquet is released and haemostasis achievedwith bipolar diathermy. The wound is washed outwith saline and closed with interruptedabsorbable 4/0 or 5/0 Monocryl sutures and asubcuticular 5/0 Monocryl or 4/0/5/0 Vicrylrapide suture.

Interrupted, non-absorbable sutures on thedorsum of the hand and fingers should be avoidedas they leave very unsightly suture marks.


A light dressing is used and removed after 48–72hours to allow active mobilization of the joints oneither side of the treated joint. A splint must beused to immobilize the joint for 8 weeks.• Scars are massaged from 2 weeks onwards.

Coban elastic bandage is applied to reduceswelling at about 2 weeks post-surgery.


Allende BT, Engelem JC. Tension band arthrodesisin the finger joints. J Hand Surg Am 1980;5:269–71.Green DP, Hotchkiss RN, Pederson WC (eds).Green’s Operative Hand Surgery (5th edn).Edinburgh: Elsevier, 2005.Lister G. Intraosseous wiring of the digitalskeleton. J Hand Surg Am 1978;3:427–35.Pechlaner S, Hussl H, Kerschbaumer F. Atlas ofHand Surgery. Stuttgart: Thieme, 2000.

Sennwald G, Segmuller G. The meta carpo -phalangeal arthrodesis of the thumb according tothe tension-band principle: indications andtechnique. Ann Chir Main 1983;2:38–45.

ARTHROPLASTY IN THE HAND


The decision to operate must not be made on thebasis of the X-ray appearances alone. However,function is not always the only consideration.Although it is generally not a good idea toperform an arthroplasty in patients who havegood function, some patients still ask for surgeryto ‘improve’ the appearance of their hands.

Indications

• Painful or stiff joints unresponsive to medicaltreatment

• Deformity and/or loss of range of movementaffecting activities of daily living

• Failure of conservative measures. Before thiscan be said, patients must have had an adequatetrial of:– Regular non-steroidal anti-inflammatory

drugs (NSAIDs) and splintage– Steroid injections (administer at least one or

two of these)– Using home or work aids– Appropriate alterations to their home or

work circumstances• To ‘improve’ the appearance of the hand• MCP joint in preference to PIP joint• Index or middle finger PIP joints

Contraindications

• Absent or poor flexor or extensor tendonfunction

• Absent or poor nerve function (e.g. peripheralneuropathy)

• Patients with significant vascular compromise(e.g. scleroderma, Raynaud’s phenomenon)

• Patients with poor skin cover over the joint• Patient unwilling or unable to comply with

postoperative hand therapy


• Heavy smoker and unwilling to stop preopera -tively

• DIP joint – an arthrodesis is recommended• PIP joint of ring and little fingers – joint

instability is often worse in these digits.

Operative planning

The choice is between a replacement arthroplastyor a resurfacing/interposition arthroplasty. A re -placement arthroplasty excises the joint completelyand replaces it with an artificial or autologous joint(usually taken from the foot). Artificial joints dobetter in older/lower-demand patients. A resurfacing/interposition arthroplasty is less destructive andtries to restore the normal shape of the joint usingeither autologous or artificial materials and is moresuitable for young or active patients.

In general, replacement arthroplasty works bestfor the MCP joints and not the PIP joints. If PIPjoint arthroplasty must be considered, then this isbest done in the index and middle fingers only.DIP joint arthroplasty is rarely successful. Thesepatients are better served by an arthrodesis.

Many types of artificial material have beendescribed for replacement arthroplasty. The onlymaterial that has withstood the test of time issilicone, e.g. Swanson’s implant (Fig. 9.8). Thetechnique for insertion is described here.


Local, regional or general anaesthesia can be used.The position is supine with the hand on an arm table.

Consent and risks

• Flexor tendon/neurovascular injury• Instability (only for PIP joint arthroplasty)• Recurrent deformity (affects one-third of

arthroplasties)• Dislocation, loosening or fracture of the implant

(implant failure affects one-third of implants)• Infection necessitating removal of implant• Loss of range of movement• Ongoing pain• Dislocation, fracture or extrusion of the implant

(7–15 per cent).• Silicone synovitis

Arthroplasty in the hand 125

Figure 9.8 Swanson’s implant in place

SURGICAL TECHNIQUE

Metacarpophalangeal joint

Landmarks and incisionA longitudinal incision (straight or curvilinear) ismade over the dorsum of the joint. Any curvaturein the incision is usually towards the radialside. This makes it easier to access and reef theradial saggital bands of the extensor hood. Reefingof the extensor hood allows ulnar subluxation ofthe extensors to be corrected in rheumatoidarthritis.

DissectionThe skin and subcutaneous fat are widelydegloved over the joint to expose the extensortendons and the saggital bands. The sagittal bandsare divided longitudinally on the radial side,leaving a minimum 2–3 mm fringe along the edgeof the extensor tendon: this allows the bands to bereefed at a later stage. The extensor mechanism isnow freed from the underlying capsule andretracted ulnarly. The joint capsule is often flimsyin these patients and it is often easiest to simplyexcise it. After excising the capsule and anyassociated synovial tissue, any remnants of thecollateral ligaments can also be excised.

ProcedureThe volar plate must be freed from the neck of themetacarpal to allow the base of the proximalphalanx to come into correct alignment with themetacarpal. The metacarpal head is now excisedwith an oscillating saw. In the rheumatoid patient,the metacarpal head is often excised with a slightradial tilt to help correct any ulnar drift. Theamount of bone excised is determined by the needto accommodate intrinsic muscle tightness: the

tighter the intrinsics, the more bone that needs tobe excised (up to a limit – excessive shortening isbest avoided). The base of the proximal phalanx isnot excised unless there is severe deformity.However, any osteophytes must be removed withbone nibblers since these may interfere with flexion.

The base of the proximal phalanx is now piercedwith an awl. This opening is enlarged and themedullary cavities of the proximal phalanx andmetacarpal are now reamed by hand usingprogressively larger reamers. Sizers are used todetermine the correct size of Swanson’s implantwhich should be used. In general, the largestimplant that fits should be selected. The implant fitswhen the long stem fits snugly in the metacarpaland the short stem fits snugly in the proximalphalanx. There should be no compression of themid-section with the fingers in extension. Generally,size 3 or 4 implants are used for the MCP joints.

The sizer is removed and the wound is washedout with saline. The appropriate permanentimplant is inserted using a ‘no touch’ technique.The implants are usually supplied with stainlesssteel ‘grommets’. These should not be used.

ClosureIt is not necessary to formally repair the collateralligaments – scar tissue forms rapidly around theimplant and confers some stability to the joint.The sagittal bands are repaired with 4/0 or 5/0PDS and are reefed as necessary if there issignificant subluxation of the extensor tendonsinto the ulnar gutters.

The skin is then closed with absorbable sutures.The author recommends using interrupted 5/0Monocryl for the dermis (to approximate thewound edges) then a running subcuticular 5/0Monocryl suture for final closure.

PROXIMAL INTERPHALANGEAL JOINT

Landmarks and incisionA longitudinal incision (straight or curvilinear) ismade over the dorsum of the joint.

DissectionAfter the incision is made, the skin andsubcutaneous fat are widely degloved over thejoint to expose the extensor tendon and the lateral

bands. To reach the joint, the central slip of theextensor tendon can be split longitudinally or aChamay approach used (see Fig. 9.7). It isimportant to preserve the central slip insertionwhichever method is used.

As with the MCP joint, the capsule of the PIPjoint is usually very flimsy and excised togetherwith any associated synovium. If possible, thecollateral ligaments and volar plate are preservedto maintain the stability of the joint. However,sometimes these structures are grossly damagedand it is necessary to excise/detach them torestore the correct alignment of the proximal andmiddle phalanges.

Procedure

The head of the proximal phalanx is now excised,at neutral, using an oscillating saw. Care is takennot to damage the flexor tendon on the volar sideof the joint. The base of the middle phalanx is notnormally resected except in severe deformity.However, osteophytes must be nibbled away asthese may interfere with flexion. Sizing andreaming of the middle and proximal phalanges isperformed in the same way as for the MCP joint.For the PIP joint a size 1 or 2 implant is usuallyused.

ClosureThe longitudinal split in the extensor tendon orthe Chamay flap is repaired with a continuous 4/0or 5/0 PDS suture. In all other respects, closure isthe same as described for MCJ arthroplasty.


• MCP joint: Patients are placed in a resting splintor bulky bandage for 3–5 days. This is thenreplaced with alternate-day flexion (MCP jointsat 70–90°) and then extension (MCP joint atneutral) splints for 24-hour periods. After 4weeks these splints are worn at night only and

Structure at risk

• Flexor tendon


the patient mobilizes the hand during the daywith protective splinting only.

• PIP joint: The digit is placed in a T-bar splint.This keeps the PIP joint in full extension andthe MCP joint flexed at 60° for 6 weeks at nightand at rest. During the day, the patient isencouraged to begin immediate, regular, activemobilization of the PIP joint out of the splint.

The emphasis in therapy for both MCP and PIPjoint arthroplasty is early, supervised, active andpassive movement.


Swanson AB. Silicone rubber implants forreplacement of arthritic or destroyed joint in thehand. Surg Clin North Am 1968;48:1113–27.Swanson AB. Flexible implant arthroplasty forarthritic finger joints: rationale, technique andresults of treatment. J Bone Joint Surg Am1972;54:435–7.Takigawa S, Meletiou S, Sauerbier M, et al. Long-term assessment of Swanson implant arthroplastyin the proximal interphalangeal joint of the hand.J Hand Surg Am 2004;29:785–95.

EXTENSOR TENDON REPAIR


Injuries to the extensor apparatus of the hand arecommon and non-surgical intervention is oftenthe best form of treatment for some of thecommoner injuries – especially in the finger. Thekey to a successful outcome is recognition of thespecific injury and selection of the appropriateform of surgical repair, splintage and/or earlymobilization required to deal with the particularproblem. Treatment differs depending on the zoneof injury (Fig. 9.9; Table 9.2) and whether thepatient presents early (within a few days) or late(weeks or months later). In all cases, appropriatehand therapy and splintage is more importantthan any surgery in restoring full function.

Indications and operative planning

• Zone 1 – a mallet deformity. If it is open, thewound should be washed out as the DIP joint is

often opened as well. The skin is then closed(converting an open mallet injury into a closedmallet injury) but the extensor tendon shouldnot be repaired. Surgical repair is usuallyfruitless and leaves sutures close to the skinwhere they often extrude. If 12 weeks ofdedicated and consistent splintage fails, thenthe patient should either accept the position orconsider arthrodesis of the DIP joint. Anavulsion fracture of the insertion of the terminalextensor tendon also results in a malletdeformity. This fracture does not need surgicalfixation regardless of the size of the fragmentand the appearances on an X-ray.

Extensor tendon repair 127

Zone 1

Zone 2

Zone 3

Zone 4

Zone 5

Figure 9.9 The zones of the extensor tendon

Zone Description of tendon anatomy1 The terminal tendon formed from the

convergence of the two lateral bands

2 Lateral bands held together by the triangularligament

3 Insertion of the central slip into the proximalphalanx

4 Central slip and intrinsic tendons

5 Extensor hood

6 Over the metacarpals

7 Over the wrist

8 In the forearm

Table 9.2 Anatomy of the extensor tendon

• Zone 2 – injuries to the extensor apparatus inzone 2 result in a mallet deformity and aretreated as for injuries in zone 1.

• Zone 3 – injury to the central slip results in aboutonnière deformity and is often a latepresentation. If this is an open injury and thedamage to the central slip is recognized acutely,then it is worth considering surgical reinsertionof the central slip. The lack of soft tissue forreattachment means a mini-Mitek bone anchoror a ‘washing-line’ will need to be used tosuture the tendon to the bone (see below fordetails of the surgical technique). Even if thecentral slip is reinserted surgically, the patientwill need the same splintage and hand therapypostoperatively as for a closed injury. Therefore,there is a strong argument for not doinganything other than closing the skin as in zones1 and 2. If the presentation is delayed orchronic, the PIP joint is statically splinted in fullextension for 3 weeks followed by treatmentwith a Capener (dynamic) splint for another 3weeks. Only if this fails should surgery beconsidered to reinsert/reef the central slipand/or to mobilize the lateral bands which willhave slipped volar to the axis of movement ofthe PIP joint.

• Zone 4 – injuries in zone 4 behave like injuriesin zone 3. However, there is now sufficienttendon material to consider surgical repairusing interrupted horizontal mattress sutures of4/0 PDS.

• Zone 5 – injuries in zone 5 result in an extensorlag which can be very debilitating. Patientsusually do very well after surgical repair of thetendons in this zone followed by early activemobilization (see below for mobilizationregimen).

• Zones 6–8 – in these zones, the extensortendons are more rounded, making a surgicalrepair much easier.

Contraindications

• Active infection – the repair will rupture andthe tendon will become adherent

• Skeletal instability – unstable fractures must befixed at the same time as any tendon repair

• Fixed joints

• Delayed presentation (more than 6–8 weeks) ofextensor ruptures in zone 6, 7 and 8 can rarelybe repaired primarily because the tendon endswill have retracted and shortened

• Attrition ruptures – tendon grafts or transfersare required and may or may not be possible

• Smoker• Poor social or psychological circumstances.

Patients who do not understand their injury andcannot/do not comply with the hand therapythat is required after a tendon injury seldomregain full function of the affected part. Thisoften includes very young children

• If there is 20 per cent (or less) division or loss ofthe extensor apparatus at any level then theskin should be closed and the tendon injuryignored.


For finger injuries up to zone 5, a ring block issufficient. For more proximal injuries, in zones 6–8, a general anaesthesia or regional block is used.Positioning is supine with an arm table and atourniquet appropriate to the part affected.

SURGICAL TECHNIQUE


If there is a skin laceration over the injuredextensor tendon then it can be incorporated into

Consent and risks

• Scars: it is often necessary to extend the woundsto gain access to the tendon ends

• Splintage and physiotherapy: the patient will nothave full use of the affected hand for 8–10weeks. This may have significant economicconsequences. The importance of compliancewith the postoperative physiotherapy must bestressed

• Infection• Rupture: 5 per cent• Adhesions: a particular problem if there is an

underlying fracture.• Bowstringing: in zone 7 injuries


any incision after suitable debridement of thewound edges. Incisions are extended proximallyand distally as needed to gain access to the tendonends. This is particularly necessary in zones 6, 7and 8 where the proximal ends may haveretracted a considerable distance.

‘Zig-zag’ or ‘lazy-S’ incisions are preferred asthese heal better when making long incisions overthe dorsum of the hand and wrist.

Dissection

Skin and subcutaneous fat are incised and thenskin flaps are elevated. These can be retracted withskin hooks or held in place with ‘stay’ sutures. Thedorsal veins and nerves are always preservedwhere possible.

The extensor tendons are identified and care istaken to preserve the paratenon.

Procedure

• Zones 1 and 2 – the tendon injury is treatednon-operatively.

• Zone 3 – where appropriate, the central slip canbe reinserted using a mini-Mitek anchor or a‘washing-line’ (Fig. 9.10). Two mini-Miteks areinserted into the base of the middle phalanx.

Structures at risk

• Edges of the skin flaps• Dorsal veins and nerves

The PIP joint is fully extended and the centralslip secured with the two strands of suture.Alternatively, a 0.35–0.45 gauge dental wire isinserted across the base of the middle phalanx.The wire is formed into a loop close to thebone, leaving enough of a gap to allow thepassage of multiple sutures under the wire. Thewhole wire now acts as a suture anchorallowing multiple sutures to be passed into thecentral slip and under the ‘washing line’.

• Zones 4 and 5 – the extensor tendon is flat, sohorizontal mattress sutures using 5/0 or 4/0PDS are best for the repair. The repair isaugmented with a continuous, over and oversuture of 5/0 PDS to keep the tendon ends tidy(Fig. 9.11). In zone 5, any lacerations to thesagittal bands must be repaired with 5/0 PDS toprevent the extensor tendon subluxing into theradial or ulnar gutters.

• Zones 6–8 – the ends of the tendon areminimally trimmed and repaired with amodified Kessler core suture, using a 3/0 or 4/0PDS. If necessary, the core suture can be furtheraugmented with a single horizontal mattresssuture of 4/0 PDS. A continuous epitendinoussuture is then placed around the circumferenceof the repair using 5/0 or 6/0 PDS (Fig. 9.12).

Extensor tendon repair 129

Mini-Mitek

‘Washing-line’(0.35–0.45 gauge dental wire)

Figure 9.10. Reinserting the central slip with mini-Miteanchors or a ‘washing line’

Figure 9.11 Repair of an extensor tendon in zones 4and 5

This also augments the repair and helps to keepthe tendon ends tidy. A round-bodied needle ispreferred for both core and epitendinoussutures to reduce the chance of cutting the coresuture accidentally.

If a primary repair of the extensor tendon cannotbe performed (e.g. delayed presentation or loss oftendon substance) an interposition tendon graft ortendon transfer must be used, e.g. with palmarislongus tendon. A Pulvertaft weave (Fig. 9.13)must be used to secure the tendon graft to theends of the tendon as this is strong enough toallow early mobilization.

In Zone 7, free excursion of the repairedextensor tendon is confirmed under theretinaculum. If necessary, the retinaculum isdivided to allow free movement of the tendon butpreserving as much of it intact as possible preventslater bowstringing.

The repair is now tested by passively flexingand extending the finger. There must be no gapingof the repair and it must glide freely through thefull excursion of the tendon.

Closure

The tourniquet is released and haemostasisachieved. The wound is washed out with salineand closed with interrupted absorbable 4/0 or 5/0Monocryl sutures and a subcuticular 5/0Monocryl suture. Interrupted, non-absorbablesutures are avoided on the dorsum of the handand fingers as this leaves very unsightly suturemarks.

Mepitel is applied to the wound together withdressing gauze and Velband before placing thehand and forearm in a volar slab plaster of Pariswith the fingers in full extension. The plastershould be set before the patient comes off theoperating table.


The authors use the Norwich regimen for injuriesin zones 5–7. The plaster of Paris is replaced witha thermoplastic splint the day after surgery.Passive and active extension is commencedstraight away, protected in the splint for 4 weeks.For a further 4 weeks, the patient removes thesplint for active extension and active flexion of theIP joint/MCP joint, but wears it at all other times.

For central slip injuries (zones 3 to 4) the fingeris placed in a cylinder splint (PIP joint static inextension, DIP joint free) for 3 weeks and then 3further weeks in a Capener splint.


Abouna JM, Brown H. The treatment of malletfinger. The results in a series of 148 consecutivecases and a review of the literature. Br J Surg1968;55:653.


(a)

(b)

(c)

Figure 9.12 Zones 6–8 extensor tendon repair. (a)Kessler stitch, (b) epitendinous suture and (c)augmentation with a horizontal mattress suture

Figure 9.13 A Pulvertaft weave

Lange RH, Engber WD. Hyperextension malletfinger. Orthopedics 1983;6:1426.Newport ML, Williams CD. Biomechanicalcharacteristics of extensor tendon suturetechniques. J Hand Surg Am 1992;17:111.Newport ML, Pollack GR, Williams CD.Biomechanical characteristics of suturetechniques in extensor zone IV. J Hand Surg Am1995;20:650–6.Stuart D. Duration of splinting after repair ofextensor tendons in the hand. A clinical study. JBone Joint Surg Br 1965;47:72.Sylaidis P, Youatt M, Logan A. Early activemobilization for extensor tendon injuries. TheNorwich regime. J Hand Surg Br 1997;22:594.Wehbé MA, Schneider L. Mallet fractures. J BoneJoint Surg Am 1984;66:658.

FLEXOR TENDON REPAIR


Indications and operative planning

• Zone 1 – the technique for flexor repair in zone1 depends on how close to the insertion theFDP has been divided. If the tendon is dividedclose to the bone (e.g. FDP avulsion) then itmay be necessary to use a suture anchor such asa mini-Mitek to secure the tendon end.

• Zone 2 – proximal zone 1 and zone 2 repairs ofthe FDP tendon are similar. The aim is to repairthe tendon but to avoid any bulkiness at therepair site to allow the tendon to glide withinthe flexor sheath. If the repair is done badly itwill be too bulky and may trigger, rupture orjam in position unless the flexor sheath isopened. Special care must be taken with repairsof FDS in this zone (see below).

• Zone 3 – zone 3 repairs are easier to performbecause there is no tight flexor sheath tocontend with and the tendon ends are larger.Distal zone 3 repairs may catch on the A1pulley, which may need to be divided.

• Zones 4–5 – repairs in these zones are the sameas repairs of the extensor tendons in zones 6–8.

• Complete division – primary repair of a flexortendon rupture should be performed as soon aspossible. Unlike the extensor tendons, surgical

intervention of some form is always necessarywhen the flexor tendons have been divided.

• Timing of repair – there is good evidence thatthe outcome of primary repair is superior whencarried out as quickly as possible (within 72hours). There is a particular urgency in carryingout a repair of the flexor tendons (as comparedwith extensor tendons) because the flexorpulleys will eventually collapse/fill with scartissue after 3–4 weeks. Any tendon repair willthen need to reconstruct the pulleys as well,making surgery more complicated thannecessary.

• Particular tendons – the flexor muscle bellies(especially flexor pollicis longus – FPL) have atendency to shorten quickly. This may makeprimary repair of a tendon impossible. The ringand middle fingers are particularly prone toavulsion injuries of the FDP tendon. Repair ofcombined injuries of flexor digitorumsuperficialis (FDS)/FDP tendons in the littleand ring fingers are particularly prone toformation of adhesions. Therefore, considera -tion should be given to repairing just the FDPtendon in these digits.

• Zone of injury – as for extensor tendons, thesurgical technique for repair of flexor tendonsvaries depending on the zone of injury (Fig.9.14).

Flexor tendon repair 131

Zone 1(distal toFDS insertion)

Zone 2(A1 to FDSinsertion)

Zone 3(forearm)

Zone 3(palm)

Zone 4(carpal tunnel)

Figure 9.14 The zones of flexor tendon injury. FDS,flexor digitorum superficialis

• Partial division of flexor tendons – there is goodevidence that inserting sutures into a tendonresults in necrosis of the tendon substance.Therefore, the use of sutures should be avoidedfor any partial tendon injury involving less than50 per cent of the diameter of the tendon.Instead, we recommend trimming the edges ofthe tendon laceration to prevent triggering (ifany is present) followed by supervisedmobilization in a splint as for a complete flexortendon division for the next 8 weeks.

Contraindications

• Active infection• Skeletal instability• Fixed joints• Delayed presentation (more than 3–4 weeks)

can rarely be repaired primarily as the tendonends will have retracted and shortened and theflexor pulleys will have collapsed.

• Attrition ruptures• Smoker• Poor social or psychological circumstances• Partial tendon rupture of less than 50 per cent

should not be repaired• Delayed presentation.

Consent and risks

• Scars: it is often necessary to extend the woundsto gain access to the tendon ends

• Splintage and physiotherapy: patients will nothave full use of the affected hand for 12 weeks.The importance of compliance with thepostoperative physiotherapy must be stressed

• Infection• Adhesions: a particular problem when there is an

underlying fracture. Overall, there is a 5 per centtenolysis rate

• Rupture: zone 2 finger flexors – 5 per cent, FPLrepair – 12 per cent

• Bowstringing: may not be evident for some yearsafter the original event. It may occur if it provesnecessary to divide the flexor sheath completelyin order to repair the tendons. A subsequentpulley reconstruction will then be required

• Neuroma formation


For isolated FDP injuries, it is often possible toperform a repair under digital nerve block with afinger tourniquet. For FPL, FDS and moreproximal flexor injuries, general anaesthesia or aregional block is necessary because of the need foran arm tourniquet. The arm is positioned in thesupine position with an arm table.

SURGICAL TECHNIQUE


The Bruner (zigzag) incision (Fig. 9.15) ispreferred. If there is a laceration then it can beincorporated into the incision after suitabledebridement of the wound edges. Bruner incisionsare marked out and the skin and fat are inciseddown to the level of the flexor sheath using a no.15 scalpel blade and/or tenotomy scissors.

Dissection

Structures at risk

• Edges of the skin flaps• Neurovascular bundles


Figure 9.15 Suggested Bruner incisions to approachthe flexors

The flaps can be retracted with skin hooks or heldin place with ‘stay’ sutures. A ‘window’ is openedin the flexor sheath by creating zigzag flaps.Ideally, the window should be as small as possibleand should be positioned only between theannular pulleys to allow maximum preservation ofthe pulley system.

If the flexor sheath is opened with zigzag flapsit is usually possible to repair the sheath with aslightly larger diameter by approximating the tipsof the flaps. This will allow any reconstructedpulley system to accommodate a more bulky, lessthan perfect, tendon repair.

Procedure

Tendon retrievalIf a tendon has been fully divided, flexion of thefinger or thumb normally delivers the distal endinto the wound. If the proximal end of the tendonhas retracted it can sometimes be retrieved bypassing a small curved artery clip into the flexorsheath. If this proves impossible, then the palm ofthe hand must be opened and the tendons pushedup into the finger with forceps. If the laceration isin the wrist or palm, it may be necessary to extendincisions even more proximally to find the tendonends. Once retrieved, a 20G (blue-hub) needlecan be passed through the tendon ends to preventthem from retracting again until the repair iscomplete.

Tendon suture techniqueZone 1 – If there is a very short stump of tendon(<1 cm), then it is possible to repair the tendon byinserting 4/0 or 5/0 PDS sutures as a half-Kesslerproximally and horizontal mattress distally.Multiple sutures can be inserted to increase thestrength of the repair since there is no concernabout the bulk of the repair getting caught inthe flexor sheath. When the tendon is avulsedand/or there is a fracture of the distal phalanx,then alternative methods of fixation must beconsidered, e.g. suture the tendon to theremnants of the periosteum or use a sutureanchor such as two mini-Miteks. If there is afracture, then mini-plate fixation is the best optionto repair the fracture, using the plate as a sutureanchor.

Flexor digitorum superficialis distal to themetacarpophalangeal jointIf the FDS is injured where it is beginning toflatten out or after it has split into its two terminalslips, then horizontal mattress sutures must beused to repair the tendon because there will notbe enough tendon substance for a modifiedKessler core suture. Each terminal slip must berepaired separately. If there is room for it, anepitendinous suture using 5/0 or 6/0 PDS can beused to tidy the ends of the repair. Note that incombined FDS/FDP injuries of the little and ringfingers there is an argument for not repairing theFDS tendon to avoid creating two bulky tendonrepairs, both of which will be unable to glide inthe flexor sheath.

FDP, FPL and FDS proximal to themetacarpophalangeal jointThe tendon ends are approximated and held inposition by transfixing them with a 20G needle.The ends of the tendon are minimally trimmedand the back wall of the repair is begun with acontinuous 5/0 or 6/0 PDS over and over suture.A modified Kessler core suture is now insertedusing 4/0 or 3/0 PDS, taking particular care tobury the knot. The core suture can now beaugmented with a single horizontal mattresssuture using 4/0 PDS. The anterior part of theepitendinous suture is then completed (Fig. 9.16).The core suture should always be over-tightenedto prevent gaping when early active mobilizationis started postoperatively. A round-bodied needleshould also be used to reduce the risk of cuttingthe core suture accidentally. There must be nogaping of the repair and it must glide freelythrough the full excursion of the tendon when therepair is complete. Any pulleys restricting theglide of the tendon should be divided in a zigzagfashion or excised altogether.

Closure

All wounds are washed out with saline and closedwith interrupted absorbable 4/0 or 5/0 Vicryl rapidesutures. Unlike the dorsum of the hand, suturemarks are not so much of a problem on the volarside because of the thicker epidermis. Therefore,subcuticular sutures do not have to be used.

Flexor tendon repair 133

Mepitel, dressing gauze and Velband bandageare applied and the hand and forearm are placedin a dorsal plaster of Paris with the fingers flexedat 90° at the MCP joint and the wrist in neutral.The plaster should be set before the patient comesoff the operating table.


Early active mobilization begins on day 1following the Belfast regimen. The plaster of Parisis replaced with a thermoplastic splint thefollowing day. Full passive flexion is commencedin all digits. The repaired tendon is allowed tocommence immediate, controlled, active flexionand extension.

All exercises are performed in the splint for thefirst 4 weeks. After 4 weeks, the patient canremove the splint, but only to do exercises. At allother times, the splint remains in place. No passiveextension is permitted for 8 weeks.


Kessler I, Nissim F. Primary repair withoutimmobilization of flexor tendon division withinthe digital sheet. Acta Orthop Scand 1969;40:587–601.Kleinert HE, Kutz JE, Ashbell TS, et al. Primaryrepair of lacerated flexor tendons in ‘No Man’sLand’. Proceedings, American Society for Surgeryof the Hand. J Bone Joint Surg Am 1967;49:577.

Silfverskiold KL, Anderson CH. Two newmethods of tendon repair: an in vitro evaluation oftensile strength and gap formation. J Hand SurgAm 1993;18:58–65.Sirotakova M, Elliott D. Early active mobilizationof primary repairs of the flexor pollicis longustendon with two Kessler two strand core suturesand a strengthened circumferential suture. J HandSurg Br 2004;29:531–5.Small JO, Brennan MD, Colville J. Early activemobilisation following flexor tendon repair onZone 2. J Hand Surg Br 1989;14:383–91.

TENDON TRANSFERS


Tendon transfers are useful to restore handfunction in patients where a primary tendonrepair is difficult or impossible. The essence of agood transfer is to keep it simple and to plancarefully. The authors recommend listing allfunctions (absent and present) to allowformulation of a plan. An example is given inTable 9.3.

Indications

• Nerve palsies – Tendon transfers are particularlyuseful for isolated nerve palsies. For a transferto be possible, the hand or upper limb must


(a) (b) (c) (d) (e)

Figure 9.16a–e Steps in the repair of flexor tendons

have sufficient numbers of functioning tendonswhich can be used for the transfer withoutadversely affecting overall hand function.Therefore, patients with a global loss of nervefunction (e.g. cerebral palsy) will always do lesswell.

• Delayed presentation of tendon rupture –Tendon transfers may be necessary to restorefunction even in delayed presentations becauseof shortening of the muscle bellies afterrupture.

Contraindications

• If the joint which the tendon is intended tomove is not fully supple

• If the part of the hand/upper limb which is tobe moved by the tendon is not fully sensate

• If the tissue bed through which the transfer willpass is poorly vascularized and/or heavilyscarred (e.g. under a skin graft)

• If the transfer results in loss of an essentialfunction

• If the power of the transferred muscle is lessthan 5 (Medical Research Council [MRC]grade). This is because any transferred muscleloses at least 1 grade after the transfer

• If the amplitude of the transferred muscle is notsimilar to the muscle that it is replacing. Forexample, finger flexors have an excursion ofabout 70 mm. Wrist extensors/flexors have anexcursion of only 30–40 mm. This is not a goodmatch

• Before 9–12 months have elapsed after anymotor nerve repair. If motor recovery has notoccurred by this time, then it is very unlikely tooccur and a tendon transfer is justified

• Where other procedures would be morebeneficial, e.g. for delayed presentation of anFDP laceration or avulsion, a tendon graft or anarthrodesis of the DIP joint may be thepreferred options. Similarly, a flexor rupture inzones 1 and 2 for patients with rheumatoidarthritis is usually best treated with a tendongraft.

Consent and risks

• Donor site morbidity: patients may experienceweakness or some loss of function after harvestof a tendon. For example, after harvest of theextensor indicis proprius (EIP), patients mayexperience an extensor lag at the index fingerMCP joint

• Additional scarring: after harvest of thetendons/grafts

• Rupture: this is a particular risk if a Pulvertaftrepair has not been used for the tenorrhaphyand/or when an interposition, free tendon grafthas been used to lengthen any donor tendon(resulting in two tendon repairs)

• Patients must be warned of the prolongedrehabilitation that must be followed after anytendon transfer (8–12 weeks) during which theywill be unable to use their hand normally

Tendon transfers 135

Table 9.3 Planning for an anterior interosseous nerve injury

Tendons present Tendons absent Suggested optionsAll extensors + brachioradialis (BR) Flexor pollicis longus (FPL) FDS from ring to FPL

BR to FPL

Arthrodesis interphalangeal joint

Pronator teres FDP to index Suture FDP middle to FDP index

Flexor carpi ulnaris (FCU) Pronator quadratus Do not replace

Flexor digitorum profundus (FDP) tolittle, ring and middle

Flexor digitorum superficialis (FDS)

Flexor carpi radialis (FCR)


Most transfers are performed under general orregional anaesthesia. Patients should be supine,and the arm should be placed on a hand table. Useof an arm tourniquet is essential.

SURGICAL TECHNIQUES

Over many years, hand surgeons have developedstandard combinations of transfers to deal withspecific nerve palsies.• For a high radial/posterior interosseous palsy:

– Palmaris longus (PL) to extensor pollicislongus (EPL) to restore thumb extension

– Flexor carpi radialis (FCR) or flexor carpiulnaris (FCU) to extensor digitorum com -munis (EDC) to restore finger extension. Forposterior interosseous palsy, FDS from ring ormiddle finger to EDC is preferred instead

– Pronator teres (PT) to extensor carpi radialislongus or brevis (ECRL/ECRB) to restorewrist extension

• For a low median palsy:– FDS from ring finger or EIP or abductor digit

minimi (ADM) (Huber) to abductor pollicisbrevis (APB). Palmaris longus can also beused to improve abduction

– Loss of the lumbricals may result in clawingof the index and middle fingers. The bestsolution is a dynamic transfer using FDS fromthe ring finger split into two slips inserted

• Infection• Neuroma: the superficial branch of the radial

nerve is a particular problem because of itspropensity to neuroma formation

• Recurvatum deformity (essentially a swan-neckposture) due to hyperextension of the PIP jointafter harvest of the FDS in patients withhyperextensible joints

• Damage to adjacent tendons or pulleys• Imbalance of the transfer, i.e. too tight or too

loose• Tendon imbalance due to spontaneous recovery

of normal functions if the tendon transfers wereperformed too early (i.e. before 9–12 monthsafter repair of a motor nerve)

into the A2 pulleys of index and middlefingers (i.e. a Zancolli lasso)

• For a high median palsy:– FDS from ring finger or EIP or ADM to APB

for an opponensplasty as in a low median palsy– The FDP from ring or little fingers can be

side-to-side sutured to the FDP of index andmiddle fingers to restore finger flexion

– BR or FDS from ring or little finger to FPLfor thumb flexion

– If clawing is present, then a Zancolli lasso asfor a low median palsy. Alternatively, a PLfree tendon graft from the transverse carpalligament to the radial lateral bands of theindex and middle fingers for a staticextension block

• For a low ulnar palsy:– The best solution for clawing is a Zancolli

lasso– FDS from the middle or index finger to

adductor pollicis for weak adduction– EIP to extensor digitorum minimi (EDM)

corrects Wartenberg’s deformity• For high ulnar palsy:

– Suture of FDP middle and index side-to-sideto FDP little and ring fingers.

– FDS from middle or index to adductorpollicis if adduction is weak.

Other technical aspects of tendontransfer

When measuring the length of donor tendonrequired for transfer, remember that 2–3 cm oftendon are required to perform the Pulvertaftweave. A Pulvertaft weave is one of the keys to agood transfer because the repair is sufficientlystrong to allow early mobilization. Getting thecorrect tension in the transferred tendon isanother key point. The joint should be positionedwhere the transfer will be at its maximum lengthand the tendon is then sutured under maximumtension. Unfortunately, this is not always possibleif the donor tendon is too short. Therefore, it isimportant to carry out a tenodesis test to ensurethat an overly tight transfer has been avoided.That said, all repairs should be ‘over-tensioned’ onthe table to allow for a small amount ofsubsequent ‘stretching’ of the tendon.


Closure

All wounds are closed in layers with absorbablesutures using interrupted 4/0 or 5/0 Monocryl todermis and 4/0 or 5/0 Vicryl rapide as asubcuticular stitch. Mepitel, dressing, gauze andVelband bandage are applied as needed and thehand and forearm are placed in a resting volarplaster. The plaster should be set before thepatient wakes up.


After 24–48 hours, the plaster is removed and thepatient can be placed in an appropriatethermoplastic resting splint which can be removedby the patient and therapist to allow earlymobilization to begin. The precise rehabilitationregimen depends on the tendons which have beentransferred. However, in all cases, one of the keysto a successful outcome is the ability to beginearly active mobilization. In order for this tohappen, any tenorrhaphy must be sufficientlystrong to allow this mobilization to occur.


Green DP, Hotchkiss RN, Pederson WC (eds).Green’s Operative Hand Surgery (5th edn).Edinburgh: Elsevier, 2005.

SOFT TISSUE RECONSTRUCTION


For the purposes of this handbook, the focus is onthree areas:• The operative correction of aberrant scarring• The use of split thickness skin grafts• The use of full thickness skin grafts

Indications

• Primary wound closure cannot be achieved• Primary wound closure can be achieved but

may result in functional impairment• Allowing a wound to heal by secondary

intention will result in functional impairment.For example, leaving tendons exposed whichwould result in their desiccation and necrosis

• There is aberrant scarring. Examples include:webbed volar scars from poorly placedincisions, burns or other traumatic scarring (Fig.9.17).

Contraindications

• Active infection. Beta-haemolytic streptococci,in particular, will dissolve any graft. Otherbacteria will reduce the likelihood of the grafttaking and can result in a patchy take

Soft tissue reconstruction 137

Figure 9.17 Soft tissue reconstruction needed for (a) skin loss after sepsis, (b) burns or (c) a poor volar scar

(a) (b) (c)

• Smoking. Expect a 40 per cent increase inwound healing complications in any patientwho smokes

• Long term steroid use. Particularly inrheumatoid arthritis (relative contraindication)

• Peripheral vascular disease or similar e.g.Buerger disease, scleroderma or severe Raynaud

• Previous radiotherapy to the hand• Recipient site unsuitable. Grafts will not take

on bare bone or tendon unless these areas arevery small (<5 mm diameter) in which case thegrafts can survive by ‘bridging’

• Donor site problems.

Operative planning

There are three main techniques to master:• The Z-plasty: an operation which involves the

transposition of two triangular skin flaps ofequal dimension to lengthen a scar or change itsdirection. There is a risk of necrosis of the flapsif they are poorly designed.

• Split thickness skin grafts: if an SSG is used, itis often a temporary biological dressing ratherthan for definitive skin cover.

• Full thickness skin grafts (FTG): these can beused for definitive skin cover anywhere on thehand except the pulps of the fingers andthumb.


The form of anaesthesia depends on the size ofgraft that needs to be harvested and the area

Consent and risks

• Scarring: particularly with split skin graftingwhich leaves large, unsightly scars

• Infection• Flap necrosis: this is nearly always the result of

technical error (e.g. flaps too narrow, closure tootight) but may also be a consequence ofinfection

• Graft loss• Prolonged healing: a split skin graft (SSG) donor

site may take months (or even years) to heal ifthe patient and donor site are poorly selected

where it is needed. Local anaesthesia is suitablefor harvesting small grafts and for surgery to thedigits. However, patients may be more grateful fora general anaesthetic when harvesting large graftsand operating on multiple areas (e.g. harvest aFTG from the groin for use in the hand) and onthe palm of the hand. The hand is placed in thesupine position on an arm table. A tourniquet isessential for any surgery involving the use of flapsor grafts in the hand.

SURGICAL TECHNIQUE

Z-plasty is used when there is a need to changethe direction and/or length of a scar. The bestexample of its use is to correct a webbed volarscar. Z-plasty can also be used to lengthen a scarafter Dupuytren’s fasciectomy (see Fig. 9.2,p. 116).


In most cases, a 30° or 60° angle is used for the flapdesign. A 60° angle achieves more lengthening ofthe scar but a 30° angle is often easier to transpose.The width of the base of the flap in relation to itslength is important in determining flap survival.The longer and narrower the flap, the less likely itis to survive. The flaps are marked out as shown inFigure 9.2 (p. 116).

It is a myth that the limbs of the Z-plasty mustbe aligned to fall in the skin creases – skin creasesexist because the fingers flex. When the fingerscease to flex, the creases disappear. The Z-plasty isbest placed where it is needed.


The flaps are raised with a small amount ofsubcutaneous fat to ensure that the subdermalplexus is uninjured. When raising the flaps, theunderlying anatomy must be considered. Forexample, it is very easy to divide the neurovascularbundle when raising the Z-plasty flaps after aDupuytren’s fasciectomy.

Procedure

• The first stage is to raise one flap and transposeit across the scar. This ensures that the design is


right for the second flap before you commityourself to raising it.

• If the design is right then the two flaps shouldautomatically transpose themselves across thescar when the finger straightens.

• The flaps are tacked into the correct cornersand any dog-ears ignored. (These will flatten ina few weeks anyway.)

Closure

Interrupted or continuous, absorbable, 4/0 or 5/0Vicryl rapide sutures are used for closure. Do notuse non-absorbable sutures in the hand. There isno difference in wound healing after skin closureusing absorbable and non-absorbable sutures inthe hand. Patients find it very painful to have non-absorbable sutures removed so avoid using them.

Split thickness skin graftsA small SSG (<3 cm × 3 cm) can be harvestedwith a hand-held knife. However, ideally, apowered dermatome should be used to harvest allSSGs (Fig. 9.18).


The first decision is the amount of SSG needed.This is best worked out in terms of the length andwidth of the defect which needs to be covered. Amarginally larger area than you think you willneed should always be taken (approximately 1 cmbeyond is about right). It is easy to trim the SSGdown to size but harvesting more graft is always aproblem. Ensure the correct settings are selected

on the hand knife or dermatome. Typically, theSSG should be between 0.2 mm and 0.4 mm thick.The thicker the SSG, the less it will contract, butthe longer it will take for the donor site to healand the more obvious the donor site scar.

Harvesting

Liquid paraffin is applied to the skin and the knife.This acts as a lubricant and prevents the blade fromcatching on the skin. If the blade catches ratherthan cuts, it will tear the SSG or result in holeswhere you do not want them. It is also criticallyimportant to ensure that the skin at the donor siteis under tension. The best way to do this is to havean assistant who can squeeze the thigh or armwhile you concentrate on harvesting the skin. Arapid sawing motion is used to harvest the skin witha hand-knife, keeping the blade flat with respect tothe skin and not pressing too hard or the graftthickness will increase. If a powered dermatome isused, the machine does the sawing for you. The aimis to harvest in one smooth action.

Meshing the skin increases the area which canbe covered with a given size of SSG. It alsoincreases the take rate by allowing free drainage ofhaematoma and seroma. It is possible to mesh skinby hand but using a skin mesher is quicker andneater. However, once it has taken, meshed skincontracts even more than a sheet graft. Analternative is to perforate it with multiple stabsusing a no. 15 blade to allow haematoma andseroma to ooze through.

The donor site is dressed with Mefix adhesivedressing applied directly to the wound. Gauze,

Soft tissue reconstruction 139

Figure 9.18 A Watson hand knife (a) and an air-powered dermatome (b) for harvesting split skin grafts

(a) (b)

Velband and crepe are applied over this to absorbany exudate.

Grafting

The SSG is applied shiny side down onto aprepared wound bed and secured with absorbable4/0 or 5/0 Vicryl rapide either as interrupted orcontinuous sutures. The same sutures are used to‘quilt’ the SSG onto the wound bed to reduceshearing movements, improve contact with thewound bed and improve haemostasis under thegraft. The SSG is dressed with Jelonet and a layerof gauze. A bulky bandage (Velband and crepe) isapplied and the hand immobilized with a plasterof Paris. The graft should be reviewed in 2–3 days.

Full thickness graftThe best donor sites for a FTG are the groin andpost-auricular sulcus because these areas are wellhidden. However, skin taken from these sites has apoor colour match with the skin of the hand.Therefore, a FTG applied to the hand will alwaysbe obvious as a dark area with a different texture.In males, a FTG from the groin is also likely to behairy resulting in obvious problems when appliedto any part of the hand unless a concerted effort ismade to remove the hair follicles before the FTGis used.


An assessment of the area of FTG needed is made,using a piece of paper as a template. The templateis transferred to the donor site to mark out asimilar area of skin. If harvesting a FTG for a caseof Dupuytren’s dermofasciectomy, multiple smallpieces of FTG may be needed (Fig. 9.19).

Harvesting

The outlines of the pieces of skin that you intendto take are scored with a no. 15 scalpel blade. Thisensures that you do not lose the outline of theindividual pieces of skin. Lift up one corner of theellipse that you intend to raise and grip this withan artery clip. This saves your hand from gettingtired and allows the graft to be held firmly overyour index finger while harvesting the graft. Fatshould be removed from the graft as it is harvested.This avoids the need to de-fat the graft after it hasbeen detached from the donor site.

The donor site is now closed with a couple ofinterrupted 4/0 Monocryl sutures and completedwith a continuous over and over suture of 4/0Monocryl into the dermis locked at both endswith a buried knot. Once the dermal suture isknotted the suture simply continues with a 4/0Monocryl subcuticular suture.

Grafting

Any remaining fat on the graft is removed using apair of tenotomy scissors. This is a very tedious butvery important step. The more fat there is on yourFTG, the less likely it is to take. The FTG issecured to the recipient site with a couple ofinterrupted 4/0 or 5/0 Vicryl rapide sutures.Securing the grafting is completed with acontinuous over and over suture at the edge, using4/0 or 5/0 rapide. It is important to add quiltingsutures to the centre of the graft to preventhaematoma formation and shearing movements.Copious quantities of Vaseline ointment are nowspread onto the graft and a Jelonet and gauzedressing is applied. The graft should be reviewedin 5–7 days.


Figure 9.19 (a) Templating, (b) marking and (c) planning incision for multiple full thickness grafts for Dupuytren’sdermofasciectomy

(a) (b) (c)


• Z-plasty: the patient can mobilize their handimmediately unless a graft was also used. Evenif the last 2–3 mm of the tips of the flaps do notsurvive, the wounds should go onto heal bysecondary intention without compromising thefinal outcome.

• SSG: the graft is left undisturbed for 48–72hours. If it is pink after that, then it has takenand gentle mobilization can begin. The donorsite on the thigh or arm is left undisturbed until10–14 days have passed and the patient says itis no longer painful. If the dressing is taken offtoo early, newly formed epithelium will rip offwith the dressing. Once a continuous layer ofepithelium is present at both recipient anddonor sites, the patient applies a thick layer ofVaseline to both areas. The SSG has no glandsand will quickly dry out, crust, flake and crack ifnot protected in this way.

• FTG: the hand is immobilized for 1 week in aplaster of Paris to further minimize shearingforces that would interfere with graft take. At 5–7 days, all the dressings are removed and thegraft inspected. If graft take is complete, thencopious quantities of Vaseline ointment must beapplied daily for the next 3 months by whichtime the glands in the graft will have started tofunction and it can self-moisturize.


McGregor AD, McGregor IA. FundamentalTechniques of Plastic Surgery and Their SurgicalApplications, 10th edn. Edinburgh: ChurchillLivingstone, 2000Thorne CH, Bartlett SP, Beasley RW, et al. (eds).Grabb and Smith’s Plastic Surgery, 5th edition.New York: Lippincott-Raven, 1997.

TRIGGER FINGER SURGERY


The diagnosis of triggering is normally easy tomake but overt triggering is sometimes absent andthe patient only gives a history of pain on flexion

of the digit which may be confused with orconcurrent with arthritis. Trigger finger is commonin patients over the age of 50, diabetics andrheumatoid patients. Where overt triggering isabsent but pain is present, the use of steroidinjections is particularly efficacious.

Indications

• Persistent triggering (not relieved by steroidinjections).

• Acutely locked finger.

Contraindications

• Presence of infection• Triggering in a patient with rheumatoid arthritis

(RA). A rheumatoid patient with triggeringneeds steroid injections or a synovectomy.Release of the A1 pulley in RA patients maymake ulnar drift worse by creating furtherchanges in the alignment of the tendons.


Local anaesthesia is used with the patient supine,the arm on an arm table and a tourniquet applied.

SURGICAL TECHNIQUE


The proximal border of the A1 pulley lies at theneck of the corresponding metacarpal (Fig. 9.20),roughly at the level of the mid-palmar crease. A1.5 cm long, transverse, incision is made in thecrease over the corresponding metacarpal.

Surgical dissection

Blunt dissection is performed through thesubcutaneous fat and palmar fascia, using tenotomy

Consent and risks

• Infection• Injury to the tendon and neurovascular bundles• Recurrence• Stiffness/loss of flexion

Trigger finger surgery 141

scissors, to expose the flexor sheath. It is rarelynecessary to visualize the neurovascular bundlesrunning parallel to the flexor tendons: in any case,these should be protected by the retractors.

The proximal edge of the A1 pulley is identifiedand the pulley is then divided longitudinally witha scalpel taking particular care to stay over themidline of the tendon to avoid the risk of damageto the neurovascular bundles.

The patient is then asked to flex and extend thedigit several times to test for any residualtriggering. The arm tourniquet is released, thewound washed out with saline and haemostasisachieved.

Closure

Skin closure is with interrupted absorbablesutures. A bulky dressing is applied to the hand for24–48 hours. This can then be de-bulked by thepatient to allow the fingers to flex freely.


Active mobilization of the hand is commencedimmediately. The bulky dressing should be takendown after 24–48 hours to facilitate this.


Doyle JR, Blythe WF. The finger flexor tendonsheath and pulleys: anatomy and reconstruction.

In: AAOS Symposium on Tendon Surgery in theHand. St Louis: Mosby, 1975:81–7.Idler RS. Anatomy and biomechanics of the digitalflexor tendons. Hand Clin 1985;1:3–11.

TRIGGER THUMB SURGERY


Indications

• Persistent triggering not relieved by steroidinjections. Administer at least one, sometimestwo injections before going ahead with surgeryand wait 3 months after each injection to assessoutcome

• Locked thumb in an adult• Locked thumb in a child (usually noticed at �2

years) unresolved for �12 months. Thirty percent of trigger thumbs in infants will resolvewithin the first year after it is noticed. Flexioncontractures do occur but these will correctthemselves spontaneously if the triggeringresolves or if surgical release is performedbefore the age of 3.

Contraindication

Presence of infection.


A1 pulley

Nodule ontendon

Nodule ontendon

Recurrence

Trauma to tendon Surgical release of A1 pulley

Steroid injection around A1 pulleyreduces inflammation allowing the

nodule to pass under the pulley

Figure 9.20 Trigger finger


Local or general (in child) anaesthesia is used withan arm board and tourniquet.

SURGICAL TECHNIQUE

Landmarks, incision and dissection

In the thumb, the proximal border of the A1pulley is at the level of the proximal digital skincrease over the MCP joint. A 1–1.5 cm transverseincision is created in the crease. Tenotomy scissors

Structures at risk

• Digital nerves and arteries – these are close tothe skin in the thumb

• Ulnar attachments of the A1 pulley – theirdivision may lead to bowstringing of the FPL

Consent and risks

• Infection• Injury to the tendon and neurovascular bundles• Recurrence• Stiffness/loss of range of movement• Bow-stringing due to accidental division of A1

pulley and oblique pulley (more likely if the A1pulley is divided through its ulnar attachment)

are used for blunt dissection through thesubcutaneous fat and palmar fascia to expose theFPL tendon sheath and A1 pulley. The digitalnerves and vessels running parallel to the FPLtendon are identified and protected with right-angle retractors The A1 pulley is identified and theradial attachment of the pulley is dividedcompletely with a scalpel from proximal to distal.

The thumb is then flexed and extended severaltimes to test for any residual triggering. The armtourniquet is released and haemostasis is achieved.The wound is washed out with saline.

Closure

The skin is closed with 5/0 Vicryl rapideinterrupted or subcuticular sutures. A lightbandage should be applied which does notinterfere with movements of the thumb.


Active mobilization of the hand and thumb isbegun immediately after surgery. Heavy use of thehand is avoided for 1–2 weeks.


Ger E, Kupcha P, Ger D. The management oftrigger thumb in children. J Hand Surg Am1991;16:944–7.

Trigger thumb surgery 143

Viva questions

1. Why perform a dermofasciectomy rather thana fasciectomy for Dupuytren’s disease?

2. How do you deal with any residual flexion ofthe digit after excision of all diseasedDupuytren’s cord tissue?

3. What are the possible complications of afasciectomy?

4. Describe a permanent solution for a painfuldistal interphalangeal joint with mucous cyst ina 50-year-old manual worker.

5. An elderly woman with rheumatoid arthritiscomes to you with a painful unstable thumbmetacarpophalangeal joint. Describe yourmanagement.

6. A man of 30 with a history of psoriaticarthropathy attends your clinic with painfuland deformed distal interphalangeal jointsaffecting all fingers of both hands. How wouldyou treat this?


7. A woman of 40 attends your clinic with ahistory of an untreated pilon fracture of thePIP joint of her right little finger, dominanthand, 10 years ago. The finger is painful,angulated and has restricted (20–40°) activeflexion. What surgical options would you giveher?

8. A 50-year-old builder attends your clinic witha painful right index finger carpometacarpaljoint. He punched a fellow builder 5 years agoand heard a loud ‘click’ at the time. Since then,he has experienced increasing movement atthe joint associated with pain on lifting heavyobjects. What options would you offer him?

9. Describe the management and treatmentoptions for a young manual worker with apainful, stiff, proximal interphalangeal jointafter previous trauma with evidence of markedjoint deformity on X-ray.

10. A young woman presents with a painless butstiff index finger metacarpophalangeal jointafter an infection. What surgical options wouldyou present to her?

11. Describe the surgical management of a manualworker with a laceration in zone 6 and loss ofextension of the thumb and index finger of hisdominant hand?

12. What is the management of a closed malletinjury in a 16-year-old rugby player?

13. A 60-year-old woman presents with a passivelycorrectible boutonnière deformity of her index

and middle fingers of her dominant hand 1year after a fall in the street. How would youtreat this?

14. A 50-year-old lawyer with rheumatoid arthritishas suddenly lost extension of his little andring fingers of his non-dominant hand. Whatoptions can you offer him?

15. How do you manage an isolated division of theflexor digitorum profundus tendon in the littlefinger of a dominant hand?

16. Describe the operative steps involved in therepair of a combined flexor digitorumsuperficialis/flexor digitorum profundus tendoninjury in zone 2 of the ring finger of a 30-year-old painter and decorator?

17. A patient presents with a tight volar web scarafter Dupuytren’s fasciectomy. How would youcorrect this?

18. You have decided to carry out a correction of acongenital camptodactyly of the little finger.The finger is now straight but it is obvious thatthere is a shortage of skin on the volar side ofthe finger which contributed to the flexiondeformity in the first place. How would youcorrect this?

19. Describe the risks and pitfalls in themanagement of trigger finger.

20. Describe your management of an acutelylocked trigger thumb.

Surgery of the hip10

Jonathan Miles and John Skinner

Primary total hip arthroplasty 145Revision total hip arthroplasty 156Hip resurfacing 161Hip arthrodesis 163Excision hip arthroplasty (Girdlestone procedure) 165

Femoroacetabular impingement surgery 165Hip arthroscopy 168Hip arthrography 170Viva questions 171

PRIMARY TOTAL HIP ARTHROPLASTY


Indications

Total hip arthroplasty is indicated in painfulconditions of the hip that have failed conservativemanagement. These are too numerous to list inthis book but the most frequent underlyingconditions are:• Osteoarthritis• Inflammatory arthritis and other arthropathies• Avascular necrosis• Trauma.

Contraindications

• Infection (generalized or of the limb)• Absolute dysfunction of the abductor complex,

including profound neurological disease.

Young age is a relative contraindication, though inthe highly symptomatic patient replacement shouldbe discussed with and performed by an appro -priately experienced surgeon.

Consent and risks

• Mortality: 0.3 per cent• Nerve injury: 1 per cent• Infection: 1–2 per cent in osteoarthritis, 5 per

cent in rheumatoid arthritis• Thromboembolism; deep vein thrombosis: 2 per

cent• Pulmonary embolism: 1 per cent• Dislocation: 3 per cent• Heterotopic ossification: 10 per cent (though the

majority are asymptomatic)• Limb length discrepancy: 15 per cent• Loosening: revision surgery is required for

loosening in up to 10 per cent at 15 years• Component failure: stem fracture, locking

mechanism failure in uncemented cups andother failures of components are rare, butrecognized, complications


• External rotation 0–10°• Flexion 20–25°• Adduction 0–5°

Hip Range of motionExternal rotation 60°

Internal rotation 40°

Flexion 125°

Extension 0°

Adduction 25°

Abduction 45°

Operative planning

Recent radiographs must be available. Templatesshould be routinely used to indicate theappropriate site for the femoral neck cut andprovide a guide to implant placement and sizing.Availability of the implants must be checked bythe surgeon.


Anaesthesia is usually general, regional orcombined. An initial dose of antibiotic is givenintravenously. The antibiotic of choice dependsupon local policy, but a common choice is asecond-generation cephalosporin or a combina -tion of gentamicin and flucloxacillin.

The lateral position is used and requires well-fixed supports abutting the lumbar spineposteriorly and the bony pelvis anteriorly (Fig.10.1). The pelvis should be vertically orientated; ifit is not vertical, the operating table can be tiltedto properly align the pelvis.

Bony prominences must be carefully padded.The hip should be sufficiently mobile forappropriate movement intraoperatively. Thesurgical field is prepared with a germicidalsolution. Waterproof drapes are used with adhesiveedges to provide a seal to the skin. The foot and legare covered with a stockinette. If a lateral approachis to be used, a sterile ‘leg bag’ should be used tomaintain sterility when the hip is displaced.

SURGICAL TECHNIQUE

The two common approaches are the posteriorand lateral approaches.

Posterior approach (extensile)

LandmarksThe greater trochanter is palpated, particularlynoting the posterior border.

IncisionA 15 cm skin incision is made with its midpointlying over the posterior half of the greatertrochanter (Fig. 10.2). The proximal extent of theincision is curved posteriorly, to lie in the line ofthe fibres of gluteus maximus. The distal portionlies along the femoral shaft.

146 Surgery of the hip

Figure 10.1 The lateral position for hip surgery

Greatertrochanter

Figure 10.2 The skin incision for the posterior approachto the hip

Gluteusmaximus

Vastuslateralis

Fascialata

Figure 10.3 Dissection of the posterior approach to thehip

Superficial dissectionThe incision is continued through subcutaneousfat and down to fascia lata. Beginning distally, thefascia lata is incised in line with the skin incision,overlying the lateral femur. Proximally thiscontinues beyond the greater trochanter, in aposterior direction, to incise in line with theunderlying fibres of the gluteus maximus. Thefibres of the gluteus maximus are gently split,using diathermy to coagulate the inevitablebleeding vessels. The incision should run from 6cm to 8 cm above the greater trochanter down tothe insertion of the gluteus maximus tendon onthe posterior femur (Fig. 10.3).

A self-retaining retractor is inserted, such as aCharnley retractor.

Deep dissection

Structures at risk

• Sciatic nerve: see below• Inferior gluteal artery: lying below piriformis. If it

is cut, immediate supine repositioning of thepatient and abdominal approach to tie off theinternal iliac artery may be required to arrest thehaemorrhage

• Obturator arterial branches: present withinquadratus femoris

The trochanteric bursa is now visible, covering theshort external rotators and lying below theposterior border of gluteus (Fig. 10.4). This can beswept off the short external rotators, using bluntor sharp dissection.

At this point the sciatic nerve can be visualized.Aggressive dissection around the nerve is notrecommended, certainly in primary arthroplasty itis unnecessary and just increases the risk ofdamaging the epineurial vessels, creating ahaematoma and neuropraxia. The sciatic nerveexits the sciatic notch and passes into theposterior thigh overlying the short externalrotators.

The sciatic nerve exits below piriformis and lieson the following muscles, running from superiorto inferior (Fig. 10.5):• Gemellus superior• Obturator internus• Gemellus inferior• Quadratus femoris.

The nerve then runs down underneath the gluteusmaximus’ tendon at its femoral insertion.

An assistant now internally rotates the extendedhip and flexes the knee, stretching the shortexternal rotators, making them easier to divide.This also increases the distance between the sciaticnerve and the site of division of these shortmuscles. Strong, non-absorbable, braided stay

Primary total hip arthroplasty 147

Tendon of gluteusmedius Fascia lata

Short external rotators

Greater trochanter

Vastus lateralis

Quadratusfemoris

Fascia lata

Gluteusmaximus

Fat over shortrotators

Figure 10.4 Deep dissection of theposterior approach

sutures (e.g. no. 2 Ethibond) are inserted into thetendons of obturator internus and piriformis, justbelow their insertion into the femur, i.e. asanteriorly as possible. Visible vessels within theoperative field are coagulated: typically these lie onthe tendon of piriformis and within the substanceof quadratus femoris. The short external rotators,from piriformis down to gemellus inferior, aredivided as close to their insertion onto the femuras possible. If further room is required, the divisioncan be carried on further distally. If the quadratusfemoris is divided, it should be done around 5 mmaway from its insertion into the femur so that acuff is left to repair it back on to.

The muscles are allowed to ‘flop’ over thesciatic nerve, providing some protection for itthroughout the rest of the operation. This exposesthe posterior capsule of the hip joint. To improvevisibility, the interval between the superior part ofthe hip capsule and the gluteus minimus isidentified and dissected free with blunt dissectionor scissors. This view is maintained by inserting aHohmann retractor in the interval to displace thegluteus minimus superiorly. The capsule is incisedtransversely to gain access. The visible portion ofcapsule can be excised or preserved and laterrepaired. The visible portion of the acetabularlabrum is excised.

Lateral approach

Landmarks• Central landmark – the greater trochanter• The anterior superior iliac spine and the

femoral shaft are also palpable and act as usefulreference points.

IncisionA straight 15 cm incision is created, parallel to thefemoral shaft and centred on the anterior half ofthe greater trochanter (Fig. 10.6).

Superficial dissectionThe incision is continued through subcutaneousfat and down to fascia lata. The fascia lata isincised in line with the skin incision overlying thelateral femur (Fig. 10.7). At this point a self-retaining retractor is inserted.

Deep dissection

The incision continues in line with the skinincision. This begins proximally within the fibresof the gluteus medius and must be limited to apoint 3 cm above the tip of the greater trochanterto avoid damage to the superior gluteal nerve. The

Structures at risk

Superior gluteal nerve – between the gluteusmedius and minimus; this may be as close as 3 cmabove the tip of the greater trochanter.


Gluteusmedius

Greatertronchanter

Quandratusfemoris

Sciatic nerve

Ischialtuberosity

Inferiorgemellus

Superiorgemellus

Obturatorinternus

Piriformis

Figure 10.5 The path of the sciatic nerve over theexternal rotators of the hip

Greatertrochanter

Figure 10.6 The skin incision for the lateral approach tothe hip

incision continues distally, in the line of the fibresof the gluteus medius and across the greatertrochanter, entering the vastus lateralis. The fibresof the vastus lateralis overlying the greatertrochanter are split.

The incision develops an anterior flap, consistingof the anterior fibres of the gluteus medius andgluteus minimus above the greater trochanter andthe anterior fibres of the vastus lateralis lying overand below the greater trochanter. This is elevated offthe greater trochanter subperiosteally, with either ascalpel or cutting diathermy. A cuff of gluteusmedius is left posteriorly on the greater trochanter,allowing reattachment at the time of closure.

The incision progresses anteriorly, detaching theinsertion of the gluteus medius and minimus ontothe greater trochanter, to reveal the capsule of thehip. The anterior flap is retracted by placing aHohmann retractor. The capsule is incised in a Tshape, with the downstroke of the T lying in linewith the femoral neck and the bar of the Trunning under the femoral head (Fig. 10.8).• Dislocation and retractor positioning – This

must be done gently as excess force can fracturethe femur (typically a spiral fracture runningfrom the subtrochanteric region down theshaft). In younger patients, the ligamentumteres can remain intact, preventing fulldislocation; if this occurs it can be easily dividedwith a scalpel. If the dislocation is difficult,further capsule can be excised; remove anymore visible labrum and remove any acetabularosteophytes with nibblers or an osteotome. If

the hip can still not be removed with minimalforce, division of the femoral neck in situ andremoval the head with a corkscrew isrecommended.

• Posterior approach dislocation and retraction –The hip joint can now be dislocated. This isperformed by placing the hip in adduction andflexion then internally rotating it, bringing thecalf to lie vertically and the foot pointingtowards the ceiling. A bone hook can becarefully passed around the femur, at the levelof the lesser trochanter, and used to ease thefemoral head away from the acetabulum.

• Lateral approach dislocation and retraction –The hip can be dislocated with adduction,flexion and external rotation, again with a bluntbone hook around the femoral neck. The leg isthen placed in the leg bag, i.e. the foot pointingto the floor, on the opposite side of theoperating table.

Procedure

Structures at risk

• Femoral nerve – injudicious placement ofanterior retractors may, rarely, damage thefemoral nerve

• Sciatic nerve – vulnerable posteriorly• Obturator arterial branches – large branches are

present below the transverse acetabularligament; cutting them should be avoided


Tendon ofgluteus medius

Fascialata

Figure 10.7 Dissection of the lateral approach to the hip

Joint capsule Greater trochanter

Vastuslateralis

Fascia lata

Gluteusmedius

Figure 10.8 Deeper dissection of the lateral approach

Hohmann retractors are inserted around thesuperior and inferior aspects of the femoral neck,supporting and stabilizing the proximal femur andexposing the whole of the intertrochanteric line.Any soft tissues along this line are removed untilthe superior portion of the lesser trochanter isseen.

The planned femoral osteotomy site is markedwith an osteotome. A number of hip replacementsets have a specific instrument to aid identificationof the right site for this osteotomy; use of a trialprosthesis or a rasp as a guide is recommended inthose sets without a neck cutting guide. This isparticularly important with collared stems.Templating will have provided a guide to theheight above the lesser trochanter that theosteotomy should pass through the calcar(typically, this is around 15 mm above the lessertrochanter). An oscillating saw is used to performthe osteotomy, with the Hohmann retractorsprotecting the surrounding soft tissues. The cut ismade with the saw blade 45° to the femoral shaftand in the plane of the tibia. If the line of theosteotomy passes into the greater trochanter, theosteotomy is stopped before entering thetrochanter and a second osteotomy carriedvertically down from the piriformis fossa to meetthe lateral extent of the first osteotomy (Fig.10.9). The femoral head is removed and kept incase of its later requirement as graft.

Acetabular preparation

Any soft tissues overhanging the acetabulumaround its circumference, including the labrum,are excised. It is vital to obtain a clear view aroundthe whole acetabulum. The transverse acetabularligament is identified, lying across the inferiorboundary of the acetabulum; if it is large this mayneed careful division, which should be done withthe blade directed laterally towards the acetabularroof. Any remaining ligamentum is also excised.Preservation of the transverse acetabular ligamentis advocated by some surgeons who use cementedacetabular components: it helps to preventinferior cement extrusion. If using the posteriorapproach, sharp Hohmann retractors are placedover the anterior wall, to lever the femuranteriorly, and under the transverse acetabularligament to expose the whole acetabulum for itspreparation. In the lateral approach, the proximalfemur is levered posteriorly rather than anteriorly.

Within the acetabulum the medial wall isdefined. This is sometimes visible as a flat plate ofcortical bone which can be seen inferiorly. If it isnot, it is covered in osteophytes or soft tissue,which should be gently removed with anosteotome or curette to reveal the floor. This is animportant step as definition of the medial wallallows proper and safe ‘medialization’, providingmaximum cover of the cup when it is inserted.

Sharp, hemispherical, cheese-grater reamers arenow used to remove the remaining acetabularcartilage and expose subchondral bone. Beginningwith the smallest reamer, reaming is directedmedially and stopped regularly to ascertain thedepth of reaming. The desired depth is up to, butnot through the true medial wall (the flat corticalbone of the quadrilateral plate). The acetabulumis enlarged with increasing sizes of reamers, notincreasing the depth but just the width. This isperformed in the desired alignment of theacetabular component to be inserted. Theappropriate alignment is 45° from the horizontaland 15–20° of anteversion (Fig. 10.10). The aim iscreation of a hemisphere, removing all cartilagebut preserving as much subchondral bone aspossible.

If the acetabular component to be used is ofuncemented design, a trial is inserted at thecorrect angle to assess the coverage and stability.


Figure 10.9 A typical neck cut

The cemented implants also have trials, allowingfor a cement mantle. At this point any excessosteophytes around the acetabulum (that maylead to impingement) are often apparent. Thesecan be removed with nibblers or an osteotome.The component is inserted using the appropriatetechnique. It is worthwhile to ensure that thepelvis has remained vertical, as any malposition ofthe patient will transfer into improper angulationof the implant, with consequent risk of instability.

Technical points in uncemented cup insertion• The uncemented cup relies on a secure fit to

confer initial stability.• In the press-fit technique an implant 1–2 mm

larger than the last reamer is used. This can beaugmented with screws as necessary.

• The line-to-line technique uses an implant ofthe same size as the last reamer and relies onaugmentation with screws to obtain fixation.

• If fixation is not solid and stable, even afterscrews have been used a switch to a cementedcup is recommended.

• Screws holes are aligned to coincide with thesafe zone, described below. Pilot holes shouldbe drilled, their depth ascertained with anangled depth gauge and screws inserted with auniversally jointed screwdriver and a screwholder to control the direction.

• Screw augmentation, if to be used, should bedone with care and awareness of the safe

quadrants. These are defined by a first linepassing inferiorly from the anterior superioriliac spine, through the centre of theacetabulum and a second line perpendicular tothe first, again passing through the middle ofthe acetabulum. This creates four quadrants(Fig. 10.11).

When all of the screws are properly seated, theliner can be inserted. The use of a 10° or 20°elevated rim can be selected if using apolyethylene liner. It should be remembered thatthis reduces the arc of motion and should not bean automatic action. Trials are available andshould be used if there is any doubt. It is usual forthe elevated lip to be situated posterosuperiorly or

Structures at risk

Posterior superior – the safe zone• At risk – sciatic nerve and superior gluteal

neurovascular bundlePosterior inferior – safe if screws < 20mm• At risk – inferior gluteal and internal pudendal

neurovascular bundlesAnterior superior – avoid screws• At risk – external iliac vesselsAnterior inferior – avoid screws• At risk – anterior inferior obturator

neurovascular bundle


(a)

45°

10° to 20°(b)Figure 10.10 Acetabular reaming(a) 45° from vertical and (b) 10°–20° ofanteversion

more posteriorly if a posterior approach has beenused.

Technical points in cemented cup insertion• Many acetabular components have a lip

augment, which should be correctly orientatedin the posterior to superior area. If the cup hasa flange (which can help to prevent cementextrusion), this will need to be trimmed to thesize of the reamed acetabulum.

• Drill holes into the ilium and ischium, but notthe quadrilateral plate, and enhance the cementfixation. The bone surface is washed withpulsatile lavage and dried thoroughly. Manyacetabular components have pegs on the medialsurface; these are designed to ensure a uniformcement mantle of around 3 mm.

• The cement should be introduced from acement gun with a short nozzle. It is firstintroduced to the keyholes in the ilium andischium. This is done with the nozzle hardagainst the bone, to increase the pressure. It isthen introduced to the rest of the acetabulumand pressurized with an impactor: most sets

have a polypropylene impactor to pressurizethe cement into the acetabular bone.

• The surgeon should be aware of the propertiesof the cement that is being used to ensure thatthe cement and component are inserted at theappropriate time. It is vital that the componentis held perfectly still while the cement is curing.Care should be taken to ensure that theintroducer is able to be released without undueforce, to reduce the stresses on the cement tocomponent interface.

• Any excess cement should be removed.

Femoral preparationIn the posterior approach the assistant extendsand internally rotates the hip while supporting theleg with the knee flexed. In the anterior approach,the leg is maximally adducted and the hipexternally rotated; the knee is flexed to positionthe lower leg in the leg bag drape.

An entry point is created in the proximal femur,with a box chisel, to allow the insertion ofreamers; it must be correctly situated to preventvarus malposition of the component. The starting


ASIS

AnteriorSuperior

AnteriorInferior

PosteriorSuperior

Risk: External illiacartery and veinsAvoid screws

PosteriorInferior

Safe zoneRisk: Sciatic nervesuperior gluteal

nerve and vessels

Risk: Anterior inferiorobturator nerveartery and veinAvoid screws

Safe if screws <20mmRisk: sciatic nerveinferior glutealnerve and vesselsinternal pudendalnerve and vessels

Figure 10.11 The quadrants ofacetabular screw positioning. Redrawnwith permission from Miller (2004)Review of Orthopaedics. Philadelphia:Saunders

point is further posterior than anterior, to allowfor the anterior bow in the femur. It must also belateral, so that it lies directly over the lateralmargin of the medullary canal (Fig. 10.12). Thisallows instruments to run towards the medialfemoral condyle, preventing varus malpositioningof the femoral component. This usually gives astarting point which enters the proximal portionof the greater trochanter.

The femur is initially prepared with a taperedreamer to remove a cone of medullary bonewithin which rasping is begun. The smallestreamer is inserted into the medullary canal. Thereamer is allowed to run down the lateral cortex,thus following the medullary canal, but the tip ofthe reamer should be angled slightly medially, as iftrying to come out through the medial femoralcondyle. This is, again, to prevent eventual varusmalposition of the femoral component. If thereamer will not follow the canal, further boneneeds to be removed from the greater trochanter.The entry point position and angle should bechecked and adjusted if necessary. The usualrequirement is for removal of cancellous bonefrom the greater trochanter with a curette.Sequentially larger tapered reamers are then usedto increase the diameter, until contact withcortical bone is felt. At this point, the reamerbecomes more stable within the femur, such thatthe instrument and bone move as one.

The next step is shaping of the proximal femurto receive the implant, whether it is to becemented or uncemented, with particular carepaid to the anteversion of the rasp within theproximal femur. This is done with rasps. The rasps

are positioned to provide around 15° ofanteversion. In the posterior approach, this is doneby angling the medial side of the rasp downwards15°; in the lateral approach it is angled 15°upwards. Rasps are used to the point wherestability can be achieved with the definitivecomponent.

Technical points in uncemented steminsertion• The rasps used are specific to each stem design.• The version must be precisely controlled

throughout rasping.• A small rasp is used to begin with and the size

increased until stability is achieved. Impactionis with controlled hammer blows, watching theprogress of the impactor. When the rasp stopsprogressing, it should not be impacted furtheras this may lead to proximal femoral fracture.When stable, the rasp is a tight fit within thecanal and rotation of the component rotates thefemur with no ‘toggle’ between the two.

• The templated size should be borne in mind.• Excessive anteversion will tend to give a poor

fit. Selection of a prosthesis several sizes smallerthan that achieved on templating may indicatethis to be the case.

• The depth of the rasp is noted. This should besuch that the cutting teeth are at or just belowthe level of the neck cut.

• Trial reduction is carried out, with a variety ofoffset options available on most uncementedsystems (see below for details).

• The rasp is removed and the definitiveprosthesis can be inserted, following the versionof the rasps. The canal is not washed out, as thebone swarf aids in union across the implant tobone interface.

Technical points in cemented stem insertion• The rasps allow for a 2–3 mm cement mantle to

be created between the component and bone.The technique is similar to that in uncementedstems, with increasing size of rasp used untilstability is achieved.

• If using a collared stem, the final broach is sunkto the required depth and the ‘calcar cutter’ isused. This attaches over the final rasp and


Anterior

Posterior

Figure 10.12 The box chisel ‘starting point’ in femoralpreparation

provides a smooth, stable neck cut at the levelupon which the collar will be supported.

• The height of the final rasp can be gauged inrespect to both the greater trochanter and themedial extent of the femoral neck cut. It is vitalto be able to reproduce these relationshipswith the definitive stem, when it is cemented insitu.

• Trial reduction is carried out (see below fordetails).

• A cement restrictor is used to occlude themedullary canal distally. The depth of insertionis obtained by measurement against the finalrasp used, aiming for 1–2 cm of clearance toallow for distal cementing. The canal must nowbe thoroughly washed with pulse lavage, using along nozzle to clean debris and fat from theentire length of the prepared bone. Suction isused to remove the saline cleaning solution. Thecanal is then dried and packed with swabs or apreformed absorbent sponge.

• Cementation is performed with a double mix ofpolymethylmethacrylate cement, using acement gun with a long nozzle. The cement isintroduced when it is of sufficient viscosity(when the cement does not stick to thesurgeon’s glove, the required viscosity has beenreached – typically after around 2–3 minutes).

• The nozzle is introduced up to the cementrestrictor then cement is pumped firmly tointroduce it into the canal. The cement gun isnot withdrawn, rather it is allowed to be pushedout by the cement as it fills the canal. Use ofsuction removes the fluid extruded from thecanal.

• When the cement reaches the proximal femur,the nozzle is withdrawn and cut. A proximalcement pressurizer is placed over the remainingnozzle and reintroduced into the femoral canal,occluding the proximal femur. Further cementis introduced under pressure, as the restrictoroccludes the femoral cavity, for around 30seconds.

• The definitive stem should be checked andcorrectly assembled on its introducer. Thecorrect time for introduction of the stem isdetermined by the type of cement and ambienttemperature conditions. It is usually at around4–6 minutes.

• The cement gun and pressurizer are removedand the femoral component is introduced in thecorrect version and manually inserted to thecorrect depth. The version must remainconstant and the movement is a smooth, evenapplication of force. If the stem will not reachthe desired depth with manual pressure, amallet can be used on the introducing handle toseat the implant at the correct depth. The endresult should be a reproduction of the depth ofthe trial at time of rasping.

• The implant must be held perfectly still withinthe femur until the cement has cured, typicallyafter 10–12 minutes.

Trialling and reductionTrial reduction is a vital step in total hipreplacement (THR). The assessment is essentiallyof stability, range of motion and leg length.

Reduction is carried out with appropriate trialcomponents, usually consisting of the last rasp leftin situ and a trial head. Reduction is via thesurgical assistant applying in-line tractionfollowed by rotation of the head into theacetabulum. The traction is assisted by thesurgeon pushing on the femoral head with aconical pusher. If reduction cannot be achieved, ashorter femoral head and/or a neck with less offsetis selected and the manoeuvre repeated.

Once the THR trial is reduced, assessment ismade of the stability. The position of the headwith respect to the greater trochanter is notedand compared with that on preoperativetemplating.

The hip is passed through a functional range ofmotion and must not dislocate in any position.The hip can then be forced into non-physiologicalpositions to assess the point at which dislocationcan occur. In the lateral approach, the hip shouldremain in joint even when the leg is replaced inadduction and external rotation, back into thesterile ‘leg bag’. In the posterior approach, the hipis tested in slight adduction and forced internalrotation; the degree of internal rotation todislocation should be noted and should be no lessthan 40°.

The tissue tension is assessed by the ‘shuck test’– the femur is pulled sharply downwards and thedegree of telescoping of the femoral head away


from the acetabular socket is noted. Any morethan a few millimetres of movement suggests thatinstability may be present. In this case, furthertrial with a longer trial femoral head isrecommended.

The lateral tissue tension can be assessed withthe ‘lateral shuck test’. A dislocation hook ispassed around the femoral neck and thecomponent sharply pulled laterally. Again,excessive movement indicates instability and theneed for a higher offset neck to be used.

The operated leg is placed against the oppositeleg in order to compare leg length. Grossdifferences suggest incorrect head selection. Notethat stability and range of motion are of higherimportance than subtle differences in leg length,but lengthening of the operated leg to greater than1 cm longer than the other leg is associated withsignificant patient dissatisfaction.

If a stable hip is not achievable in a functionalrange of motion, consideration must be given tothe following factors:• Component position – are the stem and socket

in the right degree of version? Is the cupsufficiently medialized? Is the stem at thecorrect height? If they are not, they may needto be repositioned.

• Use of a lip augment on the acetabulum. Inuncemented acetabula, exchange of the liner isrelatively simple. The use of a 10° or 20° lipaugment can prevent dislocation.

• Use of a larger femoral head will increase thestability of the hip.

• The use of a constrained prosthesis is a lastresort and not usually appropriate in primaryhip surgery.

Closure of posterior approachIf the capsule has been preserved, it is sometimespossible to repair this directly, using a heavyabsorbable suture. Proper repair of the shortexternal rotators to the shaft of the femur is vitallyimportant. The rotators should be intact and easilyidentified by the sutures passed through theirtendons prior to their division. If these sutures areleft long at the time of their insertion, they can beused to reattach the muscles. If not, four suturesare secured to the cut ends of the short externalrotators.

A small (e.g. 2.5 mm) drill is passed through thegreater trochanter, from anterior to posterior, inthe line of attachment of the small externalrotators (Fig. 10.13). A suture passer is thenpassed through the drill hole, opened and used topull one of the sutures through – both ends of thesame suture are pulled through the one hole.Three further drill holes are created and the threeremaining sutures pulled through.

Both ends of the upper two sutures are thentied to each other, then the same procedurecarried out with the lower two sutures. This isdone with the leg in around 10° of abduction andonly a few degrees of external rotation, whichallows approximation of the tendon to the greatertrochanter without causing a fixed rotationdeformity. The split fibres of the gluteus maximusare loosely approximated with absorbable sutures.

If a surgical drain is to be used, it is insertednow. Closure of the fascia lata is performed withthe hip in slight abduction. Superficial closureutilizes absorbable sutures to approximate thesubcutaneous fat, then cutaneous sutures orsurgical staples. An occlusive dressing is applied.

Closure of lateral approachIf the capsule is repairable, this is performed first.The gluteus medius anterior and posterior flapsare approximated. These are then tightly suturedtogether with the leg in around 10° of abduction.

Superficial closure uses the same technique asthat for the posterior approach.


4 drill holes

Figure 10.13 Position of drill holes for reattachment ofthe short external rotators


The patient is returned to the supine position andan abduction pillow inserted between the legs.Any straps present on these pillows should not beused, due to the risk of peroneal nerve damage.Precautions against thromboembolism should beused. Common options include aspirin, lowmolecular weight heparin, graduated compressionstockings and foot or calf intermittentcompression pumps. Early mobilization should beencouraged in all patients. Two further doses ofthe same antibiotic given upon induction aregiven intravenously. Haemoglobin levels should bemonitored and transfusion considered asnecessary.

Weightbearing is begun immediately in thosepatients with a cemented stem, regardless of thecup used. Six weeks of avoidance of weightbearingis recommended in many uncemented stemarthroplasties, though some are permitted earlypartial or even full weightbearing. The patient isallowed to walk but asked to avoid crossing of thelegs or excessive flexion of the hips. To this end,they are provided with a raised toilet seat andinstructed to avoid low seats. Particular care isrecommended when putting on socks and shoes –a common cause of early dislocation. Return towork is allowed after around 6 weeks for sedentaryjobs, but may be delayed to 3 months or more inactive work. Follow-up is recommended at 6weeks, 6 months and 1 year after surgery.Continuation of follow-up is typically at 5 years,10 years, 15 years and then at yearly intervals. Thepatient should be cautioned to return to clinic ifthere is pain or functional deterioration.


Barrack RL, Mulroy RD Jr, Harris WH. Improvedcementing techniques and femoral componentloosening in young patients with hip arthroplasty.J Bone Joint Surg Br 1992;74:385–9.Charnley J. Arthroplasty of the hip: a newoperation. Lancet 1961;1:1129–32.Hardinge K. The direct lateral approach. J BoneJoint Surg Br 1982;64:17–9.Lidwell OM, Lowbury EJ, Whyte W, et al. Effectof ultraclean air in operating rooms on deep sepsis

in the joint after total hip or knee replacement.BMJ 1982;285:10–4.Murray DW, Carr AJ, Bulstrode CJ. Whichprimary total hip replacement? J Bone Joint SurgBr 1995;77:520–7.Pellicci PM, Bostrom M, Poss R. Posteriorapproach to total hip replacement using enhancedposterior soft tissue repair. Clin Orthop Relat Res1998;(355):224–8.The Swedish Hip Arthroplasty Register. Online.Available at: www.jru.orthop.gu.se.

REVISION TOTAL HIP ARTHROPLASTY

This section refers extensively to sections in theprimary hip arthroplasty section and is notintended as a standalone text to enable allsurgeons to revise all hips. It aims to provide someuseful directions as to appropriate techniques thatcan be applied to solve some problems, but cannotcover all potential problems.


Indications

Revision hip replacement is indicated for painfulfailure of a primary arthroplasty. The mostcommon causes are:• Aseptic loosening of the socket and/or stem• Deep infection (see later section)• Instability, resulting in recurrent dislocation• Fracture of either the implant or the proximal

femur.

Contraindications

• Continuation of preoperative pain after hiparthroplasty (this suggests that the originaldiagnosis may have been wrong and warrantsfurther investigation).

• Pain-free loosening is a relative contraindica -tion, except in cases associated with significantand progressive osteolysis.

Consent and risks

• Nerve injury: 3–7 per cent.


www.jru.orthop.gu.se

Operative planning

Revision arthroplasty is more challenging thanprimary surgery so requires even more preciseplanning. Recent radiographs are essential. ‘Judetviews’ can be very helpful in assessing acetabularbone loss. If there is significant bone loss, a fine cutcomputed tomography (CT) scan is used to assessand quantify it. The patient should have been seenin outpatients recently so that the functionalstatus has been noted. This is as vital as theosseous imaging in decision making.

The soft tissue status must be assessed and anysigns of infection need investigation and treat -ment. It is not always necessary to revise all com -ponents in aseptic failures; consideration shouldbe given to keeping any well fixed and functionalprosthetic component. If the prosthesis is infected,a two-stage procedure is preferred (see below).

Templating should be carried out with greatcare. It is necessary to be prepared for unexpectedfindings at the time of surgery and a wide range ofimplants should be available to the surgeon.

There are a number of extra instruments whichcan be useful in revision procedures. The surgeonshould consider ordering any, or all of thefollowing, in particular:• Image intensifier• Extraction instruments for the existing implant• Bone allograft, for morcellized or block grafting• Cement removing osteotomes and ultrasonic

cement removal systems• Supplementary metalwork, including cabling

systems, trochanteric fixation devices,acetabular reconstruction rings and plates,cages, mesh and even computer-aided design/computer-aided manufacturing (CAD CAM)implants

• Thin, curved osteotomes for removing cement -less hips.

• Infection: quoted up to 30 per cent, 5 per cent isa more commonly accepted figure

• Thromboembolism: 3 per cent• Dislocation: 7 per cent• Aseptic loosening: 10–30 per cent at 10 years• Fracture• Limb length discrepancy


This is the same as in primary arthroplasty, exceptthat the initial antibiotic dose is usually delayeduntil after microbiological samples have beentaken.

SURGICAL TECHNIQUE

Approach

Either the posterior or lateral approach can beused. Some surgeons argue that the posteriorapproach is best for posterior acetabular defects.

A trochanteric osteotomy can be required,particularly in highly complex revisions or inremoval of a well-fixed cementless stem. Thegreater trochanter is removed with gluteus mediusand minimus attached, allowing it to be mobilizedwell out of the way. The length of the osteotomyrequired is dependent on the implant that you aretrying to get out and may be as long as the implantitself, which can be judged with image intensifieror from preoperative planning (Fig. 10.14).

Identification of the sciatic nerve is important,particularly in the posterior approach. The nervecan be isolated by carefully passing a vascularsloop around it, thus ensuring that its location isknown at all times.

Revision total hip arthroplasty 157

Figure 10.14 An ‘extended’ trochanteric osteotomy

Procedure

Following dislocation, the femoral head of amodular component is removed with a head andneck separator. Many implants have a specificextraction device and, if available, these should beused.

Removal of a cemented stemIt is sometimes possible to simply pull the implantout of the cement mantle. If this is not the case,some of the proximal cement mantle will need tobe removed from the lateral margin of theimplant. This is almost always necessary ifremoving a curved femoral stem. This is usuallyrelatively easily achieved with cementosteotomes.

The rest of the cement can be left in situ at thistime as it tamponades bleeding from the femoralcanal. When cement is to be removed, it is done

with cement osteotomes and an ultrasonic cementremover. The cement restrictor must also beremoved.

Removal of a cementless stemThis can be very difficult in well-fixed stems,particularly if extensively coated.

The use of specialized, flexible osteotomes orhigh-speed burs is recommended. Care must betaken to avoid unnecessary breach of the proximalfemoral cortex. Following removal, the femoralcanal is packed with swabs to tamponadebleeding.

Assessing femoral bone lossThe two most commonly used grading systems arethe Paprosky and the American Academy ofOrthopedic Surgeons (AAOS) systems. Table 10.1shows the Paprosky system together with possiblesolutions.


Paprosky grade Diagram Treatment optionsType I – has an intact metaphysis andisthmus

Typically treated with a primaryimplant

Type II – has metaphyseal damagebut an intact isthmus

Long stem cemented implant; distallyfixed uncemented stem

Table 10.1 Paprosky classification of femoral defects at revision hip surgery

Revision total hip arthroplasty 159

Type IIIA – distal fixation can beachieved at the isthmus, despitedamage to the isthmus and themetaphysis

Long stem cemented implanted withimpaction allograft; long stemdistally fixed uncemented stem

Type IIIB – damage to the metaphysisand isthmus prevent distal fixationfrom being achieved

Long stem cemented implant withmorcellized and corticocancellousstrut graft; long stem distally fixeduncemented stem withcorticocancellous strut graft; massivetumour prosthesis proximal femoralreplacement

Type IV –extensive metaphysealdamage and an eroded isthmus

Proximal femoral replacement

Removal of a cemented socketIf the acetabular component is loose, it will oftencome free with minimal effort, typically alongwith the majority of its cement attached.

In a well-fixed socket, a curved osteotome isused to develop a plane between the cup and thecement. Alternatively, a pilot hole can be drilledinto the centre of the component and a slap-hammer screwed into it. Once loose, the socket isremoved and the cement is then removedpiecemeal with small osteotomes. This methodgives the least bone loss and minimizes thelikelihood of acetabular fracture.

If the above method also fails, the acetabularsocket is cut into quarters with a power saw andcan then be removed. It is important that allcement is also removed.

Removal of an uncemented socketIf the cup is well-fixed, it should be rememberedthat it may not need to be removed. In this case,the liner can be removed but this must be donecarefully to avoid damage to the liner to socketlocking mechanism. If the locking mechanism isstill functioning, a simple liner exchange can beperformed, remembering that the replacement

liner need not be of the same internal diameter orhave the same augment or ‘lip’ size’. A con -troversial measure, in a well-fixed socket with adestroyed or obsolete locking mechanism, iscementation of a smaller liner within the shell.

If there is significant osteolysis behind the screwhole in the socket, it is possible to applymorcellized bone graft through the screw holes toaid in reducing this. If the socket is to be removed,any screws are removed first. The well-fixedsocket is carefully removed by developing a plane

between the bone and the implant with curvedosteotomes. Care must be taken to avoid excessbone loss.

The use of a suitable removal system, such asExplant (Zimmer, Warsaw, IN, USA), can mini -mize the bone destruction.

Assessing acetabular bone lossThe most commonly used grading system is theAAOS system. Table 10.2 shows the AAOSsystem together with possible solutions.


Table 10.2 American Academy of Orthopedic Surgeons (AAOS) classification of acetabular bone lossat revision hip surgery

AAOS grade Diagram Treatment options

Segmental Small defects, allowing for 70 per cent implant to bonecontact, require no additional treatment; larger defectscan require the use of structural allograft or asymmetricacetabular shells, e.g. the S-ROM oblong (DePuy, Warsaw,IN, USA); Loss of the medial wall can be managed with amalleable mesh and morcellized allograft as long as thereis peripheral support

Cavitatory If small, these are usually reamed to provide contact in 70per cent or more of the bone surface. An uncemented cupwith screw augmentation is a typical prosthesis used;larger defects require grafting – this can be withmorcellized graft obtained from fresh frozen femoral headallograft. It can need structural graft, again usuallyobtained from femoral head or distal femoral allograft,fixed with screws or a buttress plate

Combined The segmental defect is first reconstructed to provide astable rim; persisting cavitatory loss is grafted withmorcellized allograft

Pelvicdiscontinuity

This is a difficult problem, requiring reconstruction withplates and screws or even an entire acetabular allograft;CAD CAM sockets can be very useful to provide fixationto the ilium, ischium and pubis

CAD CAM, computer-aided design/computer-aided manufacturing.

Revision of infected implants

If the revision is for infection, this is usually carriedout in two stages. The initial stage is removal of allimplants and cement. It is vital that multiplesamples from around all implants are sent formicrobiological assessment. The whole surgical fieldshould be thoroughly debrided and then washedout with a minimum of 6 L of saline pulsatile lavage.

A polymethylmethacrylate cement spacer isthen inserted. This can be preformed or can bemade with moulds of varying sizes. The cementshould contain heat-stable antibiotics, such asgentamicin or tobramycin. Closure is performedand the patient may mobilize, although usuallyonly partially weightbearing.

The patient should be followed up clinically andhave regular checks of inflammatory markers.Postoperative antibiotics can be given once themicrobiological sensitivities have been received.These cases often require combination antibiotictherapy. Once the inflammatory markers arenormal, the second stage can be undertaken, withreconstruction depending on the extent of femoraland acetabular bone loss. Particular care must betaken with the soft tissues as multiple procedureswill often have taken their toll on the surroundingmusculature. Many surgeons prefer the use of acemented stem in this situation as extra antibioticscan be added to decrease the chance of recurrence.

CLOSURE AND POSTOPERATIVE CARE

These are broadly in line with the guidelines forprimary hip arthroplasty. It may be necessary toconsider additional precautions, particularly inlimitation of range of motion and weightbearing.It is usual to continue antibiotics untilmicrobiological results are available.


Gruen TA, McNeice GM, Amstutz AC. ‘Modes offailure’ of cemented stem-type components: aradiographic analysis. Clin Orthop Relat Res1979;(141):17–27.Jasty M, Harris WH. Total hip reconstructionusing frozen femoral head allografts in patientswith acetabular bone loss. Orthop Clin North Am1987;18:291–9.

Valle CJ, Paprosky WG. Classification and analgorithmic approach to the reconstruction offemoral deficiency. J Bone Joint Surg Am2003;85(Suppl 4):1–6.

HIP RESURFACING

Hip resurfacing can be more challenging thanTHR but shares many similar principles. Details ofthe approach can be found in the section on THRabove.


Indications and contraindications

The indications and contraindications for surfacereplacement of the hip are the same as those forTHR. In addition, there are further contraindica -tions that reflect the need to maintain the femoralneck:• Femoral head cysts >1 cm diameter• Osteoporosis – recommended to investigate

with dual energy X-ray absorptiometry (DEXAor DXA) in perimenopausal women/high-riskgroups

• Neck length of <2 cm• Significant lateral head–neck remodelling• Head:neck ratio <1.2.

Operative planning

Recent radiographs and templating are essential.The surgeon should have a guide available tocheck the compatibility of the femoral andacetabular components.


This is performed as for THR.

Consent and risks

• The risks and consent are equivalent to THR• In addition the risks of femoral neck fracture or

intraoperative conversion to THR (e.g. due tonotching or size mismatch) must be mentioned

Hip resurfacing 161

SURGICAL TECHNIQUE

Surface replacement is possible through any ofthe common approaches to the hip. The posteriorapproach is commonly used and the followingdescription is based on it.

The dissection is exactly as described in theTHR section. In order to gain visibility around thewhole of the femoral neck, some further steps areapplied:• The quadratus femoris should be released prior

to dislocation.• The gluteus maximus tendon can be released

off its insertion into the linea aspera, allowingmore rotation and visualization.

• The capsular incision is much more significant.This is essential in order to allow 360°visualization of the neck to check that notchingis not going to occur.

• The capsulotomy is carried out from superior toinferior around the femoral neck, carrying ondown the inferior neck as far as can bevisualized.

• This incision is then carefully continued withheavy ‘capsulotomy’ scissors, releasing thecapsule inferiorly and medially. Great care istaken to stay close to the bone of the femoralneck.

• The hip is dislocated and the capsulotomycontinued until the capsule is released rightaround the femoral neck, such that the headand proximal femur can be viewed all the wayaround (Fig. 10.15).

Femoral head displacement

In order to gain sight of the acetabulum, thefemoral head must be displaced. If there are anyparticularly large osteophytes, these should beremoved at this stage. A pocket is created for thefemoral head, lying under the gluteus medius andupon the iliac wing above the acetabulum. Thiscan be created by sweeping a blunt periostealelevator or bone spike under the gluteus medius.Once a sufficient pocket is created, the leg islowered sufficiently to place a sharp retractor overthe anterior lip of the acetabulum. This is used tolever the femur anteriorly as the leg is droppeddown onto the table and the head is guided intothe pocket created for it.

If the head is very large, it can be debulkedfurther by the initial stages of femoral headpreparation (described later) prior to displacing itinto the pocket created.

Acetabular preparation

This is very similar to the technique described inthe section on THR for uncemented cup insertionand the position is the same. Care should be takennot to over-ream the acetabulum as the implantsare press-fit and cannot be augmented withscrews. In addition, selection of the femoral headsize is guided by the size of the acetabularcomponent as they must fit together.

Femoral preparation

Femoral shaping is done to create a cut surfacewhich will fit with the femoral component. Avariety of jigs are available depending upon theimplant manufacturer and reference to theindividual technical guides is recommended. Theyall aim to place a guidewire in the centre of theneck, in both the anteroposterior and mediolateralplanes. This entry point will be some way abovethe fovea, which does not correspond to themidpoint of the neck. This critical step can behelped by drawing a line up the centre of theposterior and lateral margins of the neck andcarrying this up onto the head as a guide. Theposition to aim for is equal to the nativeanteversion and 0–10° of valgus compared withthe patient’s femoral neck.


Figure 10.15 Extensive release of the hip capsule toallow full delivery of the femoral head into the wound

Once the guidewire is passed, a jig is placedover it and swept around the entire neck to ensurethat there is clearance around the whole diameter,i.e. it will not be notched. If the entry point orangle is incorrect, the guidewire is removed andreplaced.

Once the guidewire is correctly positioned apost drill is used to create a central hole for thepost to be inserted into the femoral head. This isthen the guide for further cuts. Again, equipmentvaries but all have specific cutters and reamers forshaping of the proximal femur. Care should betaken that the size chosen fits with the acetabularcomponent and that notching is prevented. If asignificant notch is created, the surgeon mustchange to a total hip replacement. While cuttingand shaping, drapes should be placed over thesurrounding soft tissues to prevent bone swarffrom entering tissue planes.

A profile reamer is then used to shape the headand a step drill to create around six holes in thebevelled edge, to act as cement keys. The intendedfinal resting place of the component is marked onthe femoral head–neck junction.

The head is thoroughly washed with pulsednormal saline and the appropriate head iscemented in situ, typically with low viscositycement. It is impacted up to the previouslycreated mark to ensure that it is in place. The hipis reduced and assessed for stability.

At closure, the gluteus maximus tendon andquadratus femoris are closed, then closure is as inTHR. Postoperative care and complications arealso equivalent to total hip replacement.

HIP ARTHRODESIS


Below is a description of one common techniquealthough there are many described in theliterature.

Indications

Hip arthrodesis is rapidly becoming a procedureof historical interest only as improvements inTHR allow implantation in younger patients. Ithas limited indications now but was used in young

adults in order to allow return to manual labour.Continuing indications are:• Failed arthroplasty• Sequelae of infection, particularly tuberculosis• Sickle cell anaemic arthropathy.

Contraindications

• Contralateral hip disease• Ipsilateral knee disease• Pre-existing lower back pain• Inflammatory arthropathy – relative.

Operative planning

Planning of the position of fusion is vital. Theposition is:• Flexion of 20–25°• Rotation neutral to 10° of external rotation• Adduction of 0–5°.

A variety of techniques can be used, with intra-articular or extra-articular fusion achieved.



SURGICAL TECHNIQUE

Approach

The lateral approach is used, as described in theprimary arthroplasty section. The patient ispositioned supine, rather than in the lateral

Consent and risks

• Lower back pain: 60 per cent• Leg length discrepancy: 100 per cent (typically

up to 5 cm)• Knee pain: 45 per cent• Failure of fusion: 2 per cent clinically but up to

30 per cent radiographically• Malpositioning (it has been shown that the rates

of back pain are higher in malpositioned hips)The patient must understand that walking will beabnormal and running impossible. There is asignificant reduction in walking speed and increasein energy expenditure.

Hip arthrodesis 163

position; a sandbag is placed under the ipsilateralbuttock. This position allows for more accurateassessment of leg length and, upon removal of thesandbag, the surgeon can perform a Thomas’ testat the end of the fusion in order to assess theposition of arthrodesis.

Procedure

The gluteus medius and minimus complex is leftattached to the greater trochanter and theiranterior and posterior borders defined carefully.An oscillating saw is used to create an osteotomy,separating the greater trochanter from theproximal femur. The abductors remain attached tothe greater trochanter. The greater trochanter andabductor complex are reflected upwards; this mayrequire some dissection of the undersurface of theabductors away from the superior capsule.

The acetabulum is dissected of soft tissues,carefully defining from the sciatic notch at theback, around the superior border and round to theanterior border. A blunt Hohmann retractor isinserted into the sciatic notch (this protects thesciatic nerve and the superior gluteal vessels) andanother is hooked around the iliopectinealeminence anteriorly. A horizontal osteotomy iscarefully created between the two retractors,running just above the superior surface of theacetabulum. This can be begun with an oscillatingsaw but should be completed with an osteotometo reduce the danger of sciatic nerve injury.

A corresponding horizontal surface is createdon the top of the femoral head by removing asmall portion of the head with an oscillating saw.Curettes are used to remove any areas ofpersistent cartilage on the femoral head and theacetabulum. A retractor is inserted into the pelvicosteotomy and used to lever the osteotomy anddisplace the distal portion approximately 1 cmmedially with respect to the proximal ilium. Byremoving the sandbag from under the buttock,the position for arthrodesis can be accuratelyassessed.

The cobra plate is attached over the osteotomysite; this only requires one screw into the pelvisand one into the femur at this stage. Carefulpalpation of the pelvis, patella and malleoli iscarried out to confirm the correct position of theleg before the arthrodesis. The author

recommends the use of an image intensifier at thisstage to further confirm positioning.

The flexion position of 20–25° is confirmed byperforming the Thomas test. The greatertrochanter is then repositioned at the anatomicalsite. This can now be attached back onto thefemur with a screw through the greater trochanterand the cobra plate (Fig. 10.16). The remainingscrew holes are drilled and further cortical screwsinserted to strengthen the arthrodesis.

Closure

Closure is similar to the lateral approach for totalhip replacement: a layered closure followed by thesurgeon’s choice of skin closure.


Thromboembolism should be prevented by earlymobilization and the addition of chemical ormechanical measures in patients at increased risk.Two further doses of the antibiotic given atinduction should be given at 8 hours and 16 hoursafter surgery.

Early mobilization is non-weightbearing, withthe aid of crutches. Radiographic signs of union


Figure 10.16 A hip arthrodesis with cobra plate

are sought before a return to weightbearing isallowed. This often takes around 3 months. If thepatient has significant shortening, i.e. greater than15 mm, a shoe raise insert can be provided andused as the patient deems necessary.


Murrell GA, Fitch RD. Hip fusion in young adults.Using a medial displacement osteotomy and cobraplate. Clin Orthop Relat Res 1994;(300):147–54.Sponseller PD, McBeath AA, Perpich M. Hiparthrodesis in young patients: a long term followup study. J Bone Joint Surg Am 1984;66:853–9.

EXCISION HIP ARTHROPLASTY(GIRDLESTONE PROCEDURE)


Indications

• It is a last resort operation and used as a salvageprocedure, generally in patients with resistantinfections or comorbidities which necessitate aquick operation.

• Sepsis of either THR or the native hip• Aseptic loosening of THR• Painful hip conditions in a patient otherwise

immobile, particularly in degenerative neuro -muscular conditions.



Consent and risks

• Nerve injury• Limb length discrepancy: it is usually 3–12 cm,

depending on resection• Recurrence of infection (if a septic indication):

10 per cent• Nearly all will be reliant on walking aids after

surgery; many have poor function but most havegood pain relief

SURGICAL TECHNIQUE

One of the approaches for THR is selected. If thehip is septic, a thorough washout and debride -ment of infected tissue is essential.

The excision is carried out as in THR femoralhead resection. All non-viable bone should beresected but results are best if as much proximalfemur as possible is maintained, so it is advisablenot to be overly aggressive in the excision.


This is similar to THR in many respects. Tractionis often used for the first 2 weeks after surgery.Almost all patients will require walking aids andshoe raises.

FEMOROACETABULAR IMPINGEMENTSURGERY


Indications

• Pain and/or restricted range of motionassociated with a recognized anatomicaldeformity.

This can be of two types: cam or pincer; these canalso coexist (Fig. 10.17). The cam deformity of thefemur is also referred to as a ‘pistol grip’deformity. The most typical presentation is groinpain worse on prolonged flexion e.g. sitting. Theimpingement test of the hip is usually positive.(The hip is held in 90° flexion and passivelyinternally rotated and adducted.)

Contraindications

• Active infection• Moderate or severe existing arthritis on

radiographs.

Femoroacetabular impingement surgery 165

Operative planning

Recent radiographs must be available – antero -posterior views of the hip and a shoot-through

Consent and risks (as applicable to openfemoroacetabular impingement surgery)

• DVT: <1 per cent• Infection: <1 per cent• Femoral neck fracture: incidence related to

amount of femoral ‘bump’ removed• Avascular necrosis of the femoral head: unknown

incidence (many studies of open surgery show 0per cent)

• Heterotopic ossification: 3 per cent• Progression to frank osteoarthritis: up to 100 per

cent

lateral with the leg in maximal internal rotationbest demonstrate the anatomy. Magneticresonance imaging (MRI), MR arthrography orarthroscopy are often used to examine for labralpathology. Conventional arthrography and localanaesthetic injection are frequently used toprovide evidence that the pain is originating in thehip.

The surgeon must decide the approach to betaken. There are three common options:• The arthroscopic approach (see ‘Hip

arthroscopy’, next section).• The lateral open approach, using a trochanteric

flip osteotomy, as popularized by Ganz. The hipis then dislocated to reveal the impingement.

• A more recent approach has been a ‘mini-open’modified Smith–Peterson approach. This hasthe advantage of visualization withoutdislocation of the hip. This approach isdescribed below, as an example.


Normal

Pincer

CAM

Mixed

Figure 10.17 The common variants of femoroacetabular impingement


Anaesthesia is general with supine positioning.The use of an intraoperative image intensifier isoptional.

SURGICAL TECHNIQUE

Landmarks

The anterior superior iliac spine is palpated. Slightexternal rotation of the hip aids location of theinterval between the tensor fascia lata andsartorius.

Incision

A 7–10 cm incision is created, running from justbelow the anterior superior iliac spine, running inthe border between the tensor fascia lata andsartorius. This should not stray medially into thearea overlying sartorius and it is preferable tocreate the incision a few millimetres lateral to theborder of sartorius to ensure that this does notoccur. The direction of incision is towards thelateral border of the patella.


Dissection is continued through fat and superficialfascia. The lateral femoral cutaneous nerve isidentified, running over the fascia between thetensor fascia lata and sartorius. The nerve isretracted medially and the fascia incisedbetween the two muscle bellies. This provides aninterval with the muscle belly of the tensorfascia lata laterally and that of the sartoriusmedially.

The dissection is continued down between thetensor fascia lata and sartorius, until the direct andreflected heads of the rectus femoris areidentified.

Structure at risk

• Lateral femoral cutaneous nerve

Deep dissection

The reflected head of the rectus femoris isidentified and dissected off its origin on thesuperior acetabular margin. Its fibres also blendwith the anterior hip capsule and these fibres aredissected free from the capsule. The direct head isretracted medially to reveal the iliopsoas tendon.This also requires dissection free from the capsuleas it is attached by the iliocapsularis tendon.Subsequently, this too can be retracted medially.

The underlying capsule is exposed and can beincised in line with the femoral head–neckjunction. This is most easily identified at theanteromedial portion of the femoral head as theimpingement bump in a cam-impinging hip willprevent palpation of the head–neck junctionlaterally. Thus, it is advisable to begin the incisionmedially and proceed laterally.

PROCEDURE

The osteoplasty of the head–neck junction iscarried out with a small (10–15 mm) osteotome.An assistant internally and externally rotates thehip to allow complete excision of the bump.The resection is directed distally to produce abevelled resection, restoring the offset betweenthe femoral head and neck. This creates a ‘V’-shaped valley over the anterior head–neckjunction. The depth of the valley can be assessedby bringing the hip back into the position of theimpingement test. The aim is a gain in bothinternal rotation and flexion of the hip by over10°. If the valley is not deep enough, it can befurther deepened in a similar manner. The aim iscomplete excision of the protuberant bump, untilthe remaining femoral head is spherical and no

Structures at risk

• Femoral nerve and artery – these lie medial tothe sartorius, anterior to the pectineus muscle.They will not be damaged if dissection is lateraland deep to the sartorius

• Medial femoral circumflex artery – 1 cm proximalto the lesser trochanter, underlying the iliopsoastendon. If not identified and accidentallydamaged, profuse bleeding can be expected

Femoroacetabular impingement surgery 167

longer impinging on the anterior acetabular rim.Similarly, if there is evidence of pincerimpingement, the acetabular osteophytes orcalcified labral tissue can be removed with anosteotome and excised.

Bleeding from exposed bone can be reduced byapplication of bone wax. The wound is thoroughlyirrigated and any loose bone and cartilagecarefully removed.

Closure

• The capsulotomy is closed with absorbablesuture.

• The reflected head of rectus femoris isreapproximated with absorbable suture.

• The tensor fascia lata–sartorius interval is closedwith absorbable suture.

• Skin closure.


The patient may begin mobilization as soon ascomfortable – this should be touch-weightbearing, with crutches, for 6 weeks. Activeflexion is avoided for 6 weeks to allow healing ofthe reflected head of rectus femoris. Activeabduction is begun straight away. Mobilizationwithout crutches is slowly begun after 6 weeks.High-impact sports, including running, are notpermitted for 6 months.

HIP ARTHROSCOPY


Indications

Hip arthroscopy is indicated in a variety of painfulconditions of the hip. The most frequent are:• Undiagnosed hip pain in the young• Osteoarthritis• Labral pathology• Osteochondral defect• Removal of loose bodies• Synovectomy or synovial biopsy.

Contraindications

• Infection of overlying skin• Lack of proper instrumentation. The

instruments are specific to hip arthroscopy andsurgery should not be attempted withoutfluoroscopy, appropriate portal instruments, along arthroscope (30° or 70°) and distractionequipment

• Gross osteoarthritis is a relative contra -indication.

Operative planning

Recent radiographs and, where taken, MR imagesand MR arthrograms, should be available. Theequipment must be available; this should bechecked by the surgeon.


Anaesthesia is general, and the supine position isused. A peroneal post is well padded and theninserted to provide counter-traction. The hip andknee are extended and the hip slightly externallyrotated. The foot is placed in a foot holder on atraction table. This should have a simplemechanism for internal or external rotation as it isuseful for an assistant to be able to move the hipduring arthroscopy.

Under fluoroscopic control the hip joint isdistracted, aiming for 10 mm of opening. Thesurgical field is prepared with a germicidalsolution and draped.

Consent and risks

• Nerve injury: <1 per cent. The lateral femoralcutaneous nerve (anterolateral portal) or thefemoral nerve (anterior portal) are at risk

• Vascular injury: <1 per cent• Infection: <1 per cent. As risk is very low,

prophylactic antibiotics are not recommended• Trochanteric bursitis: 1 per cent• Iatrogenic injury/failure: 2 per cent Injury to

articular cartilage or labrum is possible. A smallnumber of patients cannot be sufficientlydistracted for arthroscopy to be performed


SURGICAL TECHNIQUE

Landmarks

The greater trochanter is palpated and outlinedwith a cutaneous marker. Lines should be markedto indicate the anterior, middle and posteriorthirds of the greater trochanter. The anteriorsuperior iliac spine is also palpated and marked.

Approach

A variety of portals have been described. Thedetails of most are beyond the scope of this book.

The ‘workhorse’ portals are two lateral portals(described below), although anterior portals canbe added in specific situations. The anterior portalis created at the intersection of a line descendingvertically from the anterior superior iliac spineand a line passing horizontally from the pubicsymphysis.

The lateral portals are created just above thesuperior surface of the greater trochanter hencethey are sometimes known as superolateralportals. Using a long, 14 G spinal needle, anapproach is made lying just above the anteriorthird of the greater trochanter (Fig. 10.18).Fluoroscopy can be used at this stage to confirmentry into the joint.

The approach must be relatively flat (i.e.parallel to the floor) to avoid the superioracetabular labrum. Normal saline is injectedthrough the needle, both to confirm entry and to

further distend the joint. Another 14 G spinalneedle is passed over the superior edge of thegreater trochanter, this time in line with theposterior third. It should be passed at the sameangle. A guidewire is placed through each spinalneedle and the needles removed. Dilators are thenused to enlarge the portal in a controlled mannere.g. a 5 mm, 7 mm then 10 mm dilator.

The final dilator is removed and thearthroscopic cannula is inserted into the anteriorportal. A similar process is completed with themore posterior portal. The two portals aregenerally referred to as the anterolateral and thelateral portals, to avoid confusion with trueanterior portals and the rarely used and moredangerous posterior portals. Initially, theanterolateral portal will be used for introductionof instrumentation and the lateral portal willcontain the arthroscope.

Either a 30° or 70° arthroscope can be used.Some authors advocate a 70° scope as it canovercome some of the limitations in the viewingfield with hip arthroscopy. The water flow shouldbe controlled with an inflow pump on theposterior portal and an outflow integrated withinthe anterior cannula.

Procedure

A systematic approach is essential if pathology isnot to be missed. The author recommendsbeginning posteriorly, following the posteriorlabrum and acetabulum. The arthroscope is thendrawn superiorly, again specifically viewing theacetabulum and its labrum, then anteriorly.

Throughout the process the femoral head canalso be viewed centrally, as the acetabular labrumis seen in the periphery of the view. A hookedprobe is introduced and used to assess the softtissues, particularly the labrum and the articularcartilage.

Specific instruments can be used for removal ofloose bodies or debridement of labral tissues (Fig.10.19).

Closure

Non-absorbable suture is used to close the skindefects.

Hip arthroscopy 169

Figure 10.18 Entry to the hip joint


The patient is fully weightbearing as tolerated.Specific precautions are rarely required.


Mason JB, McCarthy JC, O’Donnell J, et al. Hiparthroscopy: surgical approach, positioning, anddistraction. Clin Orthop Relat Res2003;(406):29–37.McCarthy JC, Lee JA. Hip arthroscopy:indications, outcomes, and complications. J BoneJoint Surg Am 2005;87:1137–45.McCarthy JC, Lee JA. Hip arthroscopy:indications, outcomes, and complications. InstrCourse Lect 2006;55:301–8.

HIP ARTHROGRAPHY


Indications

• Osteoarthritis/rheumatoid arthritis – to assessthe degree of cartilage loss

• Sequelae of paediatric disorders, particularlydevelopmental dysplasia of the hip and Perthesdisease

• Impingement syndrome• Assessment of loose total hip implants,

including aspiration in suspected sepsis.

Contraindications

• Contrast allergy• Uncontrolled bleeding dyscrasias.

Operative planning

Preoperative anteroposterior and lateral views ofthe pelvis and hip should be available. Afluoroscope and contrast need to be available.


Hip arthrography is uncomfortable. It isrecommended that it is performed under at leastsedation but a short general anaesthetic ispreferred. The supine position is used. The hip isplaced in the position of maximum joint volumeto aid injection:• 10° abduction• 10° flexion• 10° internal rotation.

The fluoroscope is positioned over the hip.

SURGICAL TECHNIQUE

Landmarks

Three centimetres below the mid-inguinal point.

Procedure

Using a long, 22G spinal needle an approach ismade through the above landmark, perpendicularto the skin. A ‘pop’ is felt as the needle penetratesthe capsule. The correct position is checked byinjecting a small amount of contrast and checkingthat it is intra-articular with fluoroscopy. Once theposition is confirmed, several millilitres of contrastare injected and the needle is removed. The hip ismanipulated to distribute the contrast throughoutthe joint.

Imaging is performed; a typical series includes:• Anteroposterior hip


Figure 10.19 Arthroscopic debridement

• Anteroposterior in internal and externalrotation in flexion and extension

• Shoot-through lateral.

If impingement is suspected, an image in flexionand internal rotation is taken.

If the arthrogram is taken for planning anosteotomy, live screening can be used to locate aposition of best fit of the femoral head in theacetabulum. This is particularly useful in cases ofPerthes disease.

If imaging a total hip implant, digitalsubtraction can be used by taking a plain viewprior to injection of contrast and overlaying it onthe contrast anteroposterior view. This will showareas of contrast intrusion around the implant

while removing the image of the implant andcement.


The patient may fully weightbear immediately.Risks are very low, with infection and contrastreaction both significantly <1 per cent.


O’Neill DA, Harris WH. Failed total hipreplacement: assessment by plain radiographs,arthrograms, and aspiration of the hip joint. J BoneJoint Surg Am 1984;66:540–6.

Viva questions 171

Viva questions

1. How does revision surgery differ wheninfection is suspected?

2. What are the indications, benefits anddrawbacks for hip arthrodesis?

3. What are the surgical options for a 50-year-oldman with symptomatic osteoarthritis of thehips?

4. Describe the anatomy of the sciatic nervearound the hip.

5. How do you classify bone loss around afemoral/acetabular component of a hipreplacement?

6. What complications do you warn the patientabout prior to hip replacement? What are theirincidences?

7. What are the indications for Girdlestone’sprocedure?

8. When would allograft be used in hipreplacement? What types of allograft are usedand why?

9. Which approach do you use for total hipreplacement and why?

10. What factors influence your choice of hipimplant for total hip replacement?

11. What are the contraindications to total hipreplacement?

12. What factors affect the quality of the cementmantle in cemented hip replacement?

13. Which nerves can be injured in hip surgery?

14. What factors contribute to dislocation in totalhip replacement?

15. Describe the portals used in hip arthroscopy.

16. How do you perform a hip arthrogram?

17. What are the potential advantages of hipresurfacing over total hip replacement?

18. What imaging would you consider beforerevising a total hip replacement?

19. What are the options for reconstruction ofcavitary bone loss in acetabular revisionsurgery?

20. How can femoroacetabular impingement betreated surgically?

Surgery of the knee11

Lee David and Timothy W R Briggs

Primary total knee replacement 172Revision total knee replacement 182Patellofemoral knee replacement 187Unicompartmental knee replacement 189

Distal femoral osteotomy 192Proximal tibial osteotomy 194Knee arthrodesis 197Viva questions 199

PRIMARY TOTAL KNEE REPLACEMENT


Indications

Total knee replacement is indicated in thetreatment of pain and deformity from thefollowing conditions, when non-operativemanagement has failed or is futile:• Degenerative osteoarthritis• Post-traumatic osteoarthritis• Rheumatoid arthritis• Other degenerative and inflammatory arthro -

pathies.

Contraindications

• Active or recent local or generalized infection• Critical arterial ischaemia• Non-functioning extensor mechanism• Severe neurological disorders (relative)• Age (relative). Very young or very old patients

should be carefully selected depending onseverity of arthritis, level of symptoms andquality of life.

Severe deformity or instability may be a contra -indication to the use of an unconstrained,condylar implant and may require the use of asemi-constrained and stabilized or a constrained,hinged prosthesis.

Consent and risks

• Infection: 1–2 per cent• Bleeding: approximately 1.5 L on average; it has

local or general effects. Haematoma formationincreases the risk of wound problems,arthrofibrosis and infection. Hypovolaemia andanaemia may cause cardiovascular, cerebral orrenal complications

• Venous thromboembolism – below knee deepvein thrombosis (DVT) occurs in approximatelytwo-thirds of patients following total kneearthroplasty. The risk of fatal pulmonaryembolism (PE) is approximately 0.1 per cent. Theprevention of DVT and PE remains a controversialtopic but it is almost universally accepted thatmechanical thromboprophylaxis should be usedand that chemical thromboprophylaxis should beused in high-risk groups

• Neurovascular injury can be caused by directlaceration, traction or pressure. Discrete arterialdamage is rare (approximately 0.05 per cent) butmust be recognized and dealt with immediately.Distal arterial thromboembolism must bepromptly recognized, pressure dressings releasedand a vascular surgical opinion sought. Common

Range ofmotion

Position ofarthrodesis

Flexion 150° 10–15°

Extension 0–(–5)°

Int/Ext Rotation 10° 10°

5-9°Valgus

Figure 11.1 The mechanicaland tibiofemoral axes of thelower limb

Primary total knee replacement 173

establish the mechanical axis of the leg (Fig. 11.1).It is imperative that the patient’s symptomsshould correlate with the radiographic findings.Templating of preoperative radiographs should beperformed if possible, and it is the responsibility ofthe surgeon to ensure that the required implantsare available.

There are many implants available for totalknee replacement, and it is the surgeon’sresponsibility to ensure that he or she is familiarwith the implants used, that all necessaryequipment is available and that the appropriaterange of sizes are readily to hand.


Anaesthesia is usually general, regional orcombined, depending on the preferences of the

OPERATIVE PLANNING

Clinical examination should pay careful attentionto alignment, deformity, instability, range ofmovement and extensor mechanism function.Scars should be carefully noted and a distalneurovascular assessment must be performed.

Recent weightbearing anteroposterior, lateraland skyline patella radiographs must be availableand long-leg alignment views may be helpful to

peroneal nerve injury has an incidence ofapproximately 0.5 per cent and should initiallybe managed by release of pressure dressings withexploration indicated if caused by haematoma. Ifcaused by traction, equinus deformity should beprevented and nerve conduction studies may beperformed at a later date

• Fractures: the risk of fracture is increased inosteoporosis and rheumatoid arthritis. Significantnotching of the anterior distal femoral cortexincreases the risk of postoperative periprostheticfracture. Excessive patella resection duringresurfacing increases the risk of patella fracture.Intraoperative fractures usually requireimmediate fixation and the use of stemmedimplants

• Extensor mechanism injury – avulsion of thepatella tendon is a disastrous complication andmust be avoided as it severely compromises theoutcome following total knee replacement. Inthe event of this occurring, the tendon must bereattached to the tibial tuberosity and protected,although the result is usually poor

• Stiffness may be caused by true arthrofibrosisbut other causes, including infection andmechanical problems, e.g. ‘overstuffing’ the knee,patellofemoral maltracking or inadequate boneresection must be ruled out. Treatment dependson the underlying problem

• Instability may be caused by unequalflexion/extension gaps, soft tissue imbalance,ligamentous insufficiency, insufficient insertthickness, polyethylene wear or patellofemoralmaltracking. Treatment depends on cause

• Wear• Loosening• Pain

Figure 11.2 Themedial parapatellarapproach to the knee

174 Surgery of the knee

DISSECTION

Dissection continues in the midline, until thequadriceps tendon is identified. The medial andlateral skin, subcutaneous fat and deep fasciashould be reflected in matching thick flaps toallow exposure of the quadriceps tendon, medialpatella retinaculum and patella tendon.

The medial parapatellar incision is extendedfrom the quadriceps tendon proximally, throughthe medial parapatellar retinaculum and along the

Structures at risk

The medial collateral ligament (MCL) may bedamaged during medial release. The risk of this canbe minimized by careful subperiosteal release eitherusing a periosteal elevator or coagulating diathermy.

The patella tendon may be damaged duringexcision of the fat pad, which can be prevented byalways cutting away from the tendon itself. Thepatella tendon may be avulsed at its insertion tothe tibial tubercle during eversion of the patellaand flexion of the knee. This is a disastrouscomplication and can be prevented by extendingthe deep dissection proximally, dividing any lateralplicae and by performing a lateral parapatellarrelease to allow eversion of the patella. Externalrotation of the tibia also relaxes the extensormechanism.

anaesthetist and surgeon and the patient’s co-morbidities.

The patient is positioned supine on theoperating table with a lateral thigh support andfoot bolster, allowing free flexion and extension ofthe knee. Pressure areas should be protected withgel pads. Provided that there are no contra -indications (e.g. arterial calcification) a paddedpneumatic tourniquet is applied around the thighas proximally as possible and secured. A dose ofan appropriate antibiotic is administered intra -venously prior to the inflation of the tourniquet.The skin in the area of the incision should beshaved immediately prior to surgery. The limb isexsanguinated and the tourniquet inflated to thedesired pressure, with the tourniquet time clearlydocumented.

The surgical field is prepared with an antisepticsolution. The foot should either be thoroughlyprepared or wrapped with an impervious ‘shutoff’ drape. Appropriate waterproof drapes shouldbe carefully applied. An antibacterial, transparentadhesive drape is applied to the surgical field.Ideally, the incision should be marked with asterile pen.

SURGICAL TECHNIQUE

By far the most common approach to the kneejoint in total knee arthroplasty is the medialparapatellar approach, which is discussed below.The subvastus, midvastus and direct lateralapproaches are used much less frequently. Otherextensile approaches are discussed in the section‘Revision total knee replacement’.


The position of the patella, patella tendon, andtibial tubercle should all be noted. An anteriormidline longitudinal incision is made, usually withthe knee in flexion. The incision needs to be longenough to allow adequate exposure and avoidexcessive skin stretching: this runs proximally,from the level of the tibial tubercle forapproximately 20 cm, although the length isheavily dependent on the patient’s build.


In the vast majority of cases, the bony cuts canbe made in the conventional manner with the useof standard instrumentation. Whether the femoralor tibial cut is made first depends on the surgeon’spreference and type of prosthesis used.

Femoral cutsThe femur should be prepared with the use of anintramedullary alignment jig if at all possible. Thetibial cut can be made by using intra- orextramedullary alignment jigs, depending on thesurgeon’s preferred method and the degree ofextra-articular deformity of the tibia. There isevidence to show that intramedullary referencingof the tibial cuts is more accurate but it has alsobeen shown to increase the risk of fat embolism.

Femoral preparation is undertaken with theknee flexed and the patella everted. A large drill-bit is used to create entry point in the distalfemoral canal at a point approximately 1 cmanterior to the insertion of the PCL within thetrochlear notch. The entry point can be slightlywidened with a rotational movement of the drill.The intramedullary rod should be inserted intothe canal with care, especially if a previous totalhip replacement has been performed. The distalfemoral cutting jig is positioned over the rod andadjusted so that the distal cut is set at a 5–9°valgus angle to the appropriate side of the knee tobe replaced (Fig. 11.3). Ideally, this should bechosen to match the anatomical axis of thecontralateral limb, if normal.

The distal cutting jig is secured with two orthree pins which should be fully inserted toensure that the saw is not hampered and to allowthe saw blade to make ample excursion tocomplete the cut. The amount of distal femoral

• The common peroneal nerve is in danger frominjudicious lateral retractor positioning

• Popliteus tendon can be divided during posteriorfemoral condylar or tibial bone cuts

• The popliteal vessels and tibial nerve can be atrisk during posterior osteophyte removal,posterior capsular release, PCL resection andwhen cutting the posterior tibial cortex with thesaw, if not protected. The anatomy of thepopliteal artery in relation to the knee joint isextremely variable

medial border of the patella tendon distally (Fig.11.2). There should be at least a 3 mm cuff ofquadriceps tendon left attached to vastus medialisand a cuff of medial retinaculum attached to thepatella to allow adequate closure.

The medial capsule is released subperiosteallyoff the proximal tibia to gain exposure to themedial compartment. In a varus knee, this dis -section should include the deep medial collateralligament and extend to the posteromedial corner.In a valgus knee this medial release should beminimized to the anteromedial corner in order togain adequate exposure.

With the knee in extension, the patella iseverted and the knee flexed. The retropatellar fatpad may be partially or fully excised if necessary.The visible remnants of the medial and lateralmenisci may be resected at this stage and theanterior cruciate ligament (ACL) must be dividedand resected. If a posterior cruciate substitutingimplant is to be used the posterior cruciateligament (PCL) can be resected now by dissectingit from its femoral attachment with diathermy.Osteophytes may be debrided at this stage.

PROCEDURE

The primary goals of surgery are pain relief,restoration of function and longevity of theprosthesis. The immediate technical aims of theoperation are: anatomical alignment, good range ofmotion, good stability and ligamentous balancingthroughout the range and good patella tracking.Achievement of all these goals can only be accom -plished by accurate bone cuts, equal flexion/extension gaps, correct soft tissue balancing,adequate fixation of implants and by addressingany patellofemoral problems, while minimizing therisk of any adverse intraoperative events. Thesurgeon must appreciate that a total knee replace -ment is as much a soft tissue operation as a bonyprocedure.

Bone cuts

Structures at risk

• The MCL must be carefully protected during bonecuts

• Patella tendon

α

Lone axis of femur

5–9°valgus

Cut

IM referencing

α

Figure 11.3 Distal femoral resection

1 Will lead to overstuffing3 Will notch femur

1 2 3

Figure 11.4 The anterior femoral cut


is not oversized. When the desired size isestimated, marker holes are made on the distalfemur through the appropriate holes on the jig, toenable positioning of the distal femoral cuttingblock. The distal femoral cutting block should bepositioned in slight external rotation and someimplants have the marker holes set at 3° ofexternal rotation on the distal femoral sizing jig.This can be checked by correlation with thetransepicondylar axis or Whiteside’s line. Thereasons for this are explained below.

The cutting block of the estimated size isplaced onto the cut surface of the distal femur,with pegs sitting into the previously drilledmarker holes. In order to avoid notching of thedistal femur during cutting, a cutting guide,commonly referred to as an ‘angel wing’, can beplaced through the chosen cutting slot to estimatethe exit point of the anterior cut (Fig. 11.4). Thecutting block is firmly impacted until seated flatonto the cut surface of the distal femur andsecured with obliquely placed pins. Again, the softtissues must be carefully retracted during theplacement of instrumentation. If there is anydifficulty in seating either the sizing jig or cuttingblock, the surgeon must check that all osteophytesare removed, that there is adequate meniscalresection, that the bone cuts are complete andthat the soft tissues are retracted sufficiently. Theanterior cut should be made first, followed by theposterior condyles, anterior chamfer and finallyposterior chamfer cuts. If it is apparent that therewill be significant notching of the distal femur thecutting block should be removed and the sizingreassessed (Fig. 11.4). If there is a possibility of

resection performed depends upon the thicknessof the implant and any fixed flexion deformitypresent (see later) but is usually at least 9 mm.Most jigs are slotted to allow for accurate sawblade advancement and have multiple slots andholes at different levels to allow adjustment of theamount of distal femoral resection desired. It isimperative that the medial and lateral soft tissuesare retracted and protected with either Hohmannor Trethowan retractors. The cut bone surfaceneeds to be of sufficient surface area and qualityto allow adequate fixation with either a cementedor uncemented femoral component and mustexpose trabecular bone. If the distal femur isparticularly sclerotic in parts, a ‘second pass’ withthe saw blade may be required to achieve a flatsurface, but one must bear in mind that repeatedpasses with a power saw generates heat, necrosisand metal debris from the jig.

The distal femur must then be sized to enableplacement of the appropriate cutting block. Sizingjigs generally work on an anterior or posteriorreferencing system, using either the anterior distalfemoral cortex or the posterior femoral condylesas the baseline, measuring the amount ofanteroposterior resection required accordingly.The typical sizing jig has an anterior stylus thatmust be seated down onto the anterior cortex, andit may be necessary to remove the overlyingsynovium in order to ensure that the component

Cut

Perpendicular

Long axis of tibia

Figure 11.5 The tibial cut


from the more abnormal medial compartment. Ina valgus knee the amount of tibial resection can bemore difficult to estimate, but should generallyextend to the level of the tip of the fibula head onthe lateral side. When at the correct height, asconfirmed with a stylus passed through the slot onthe tibial cutting block and onto the tibial plateau,the cutting block can then be fixed with pins,advanced closer to the tibial surface, locked inplace and the intramedullary rod removed.

The angle of the tibial cut can then be checkedwith an extramedullary alignment rod. Ifextramedullary referencing alone is used, the rodshould be in line with the anterior tibial spine andthe distal tip of the rod should lie just medial tothe centre of the ankle joint (as this is where themechanical axis of the limb passes). Usinganatomical landmarks in the foot, such as thesecond metatarsal, is less reliable as rotation canoccur within the hindfoot and midfoot. Withextramedullary referencing, the anteroposteriorslope of the tibial cut can be introduced either byuse of an angled cutting block or by adjustment ofthe extramedullary jig itself. If the femoral cutshave already been made, the tibia can beexternally rotated and subluxed anteriorly toallow exposure of the entire articular surface ofthe tibia. If the PCL must be preserved, a smallportion of bone adjacent to the PCL attachmentcan be protected with a broad retractor andpreserved during the tibial cut.

After the tibial resection is complete, theremaining meniscal remnants can be excised andthe tibial component is sized and, following a trialof the components, the tibia can be prepared toaccept the stem or keel of the prosthesis. Thetibial component should lie in slight internalrotation on the tibia, with the midpoint of thetibial baseplate being in line with the medial thirdof the patella tendon to optimize patellofemoraltracking.

Flexion/extension gapsThe femoral and tibial cuts should be made suchthat the rectangular spaces created are the same inboth full extension and 90° of flexion (Fig. 11.6).The fact that the mediolateral tibial slope in thecoronal plane is 3° to the perpendicular meansthat the posterior femoral bone cut in flexion

minor notching occurring, this should becontrolled and any sharp edge of anterior cortexshould be smoothed off with the saw or a bonefile. The cut bone fragments can then be removedwith knife and forceps and the posterior condylarcuts can be removed with a broad osteotome. Thedistal femur is then examined to ensure that thecuts are complete. Large posterior osteophytesapparent on the preoperative lateral radiograph orevident after bone cuts can be removed by liftingup the femur and carefully using a broadosteotome or saw under direct vision.

Tibial cutThe tibial cut should be made perpendicular tothe axis of the tibia in the coronal plane with ananteroposterior slope of approximately 3° in thesagittal plane (Fig. 11.5). If intramedullaryreferencing is used, the entry point should bemade with a drill at the centre point of the tibia.The intramedullary rod should be insertedcomfortably into the tibial canal and the cuttingblock adjusted in a varus knee to allow resectionof approximately 10 mm from the more normallateral compartment and approximately 2 mm

(a)

x x

Femur flexed 90°

Flexion gap should equalextension gap i.e. x = y

(b)

y y

Transepicondylaraxis

3°

Figure 11.7 The effect of external rotation of thefemoral cutting block

Figure 11.6 Flexion and extension gaps


should be in 3° of external rotation in order toobtain two parallel surfaces in flexion (Fig. 11.7).Some prostheses use the principle of atensiometer in flexion and extension to establishthe correct bone cuts in order to obtain equalflexion and extension gaps whereas others usespacer blocks or trial inserts.

The most common problems are:• Tight in extension, flexion satisfactory

– Solution: increase distal femoral resection.Release posterior capsule off femur. Recess orresect the PCL. Beware of raising the jointline with excessive distal femoral resection.

• Tight in flexion, extension satisfactory– Solution: downsize the femoral component

by re-cutting the distal femur (beware ofnotching the femur when downsizingimplants). Increase the anteroposterior tibialslope.

• Tight in flexion and extension– Solution: increase tibial resection. Beware of

losing too much tibial surface area.• Loose in flexion and extension

– Solution: increase thickness of insert. Bewaregross ligamentous instability.

Varus deformityThis is by far the most common deformity in theosteoarthritic knee. Bone loss is usually from the

Soft tissue balancing

Clearly, achieving anatomical alignment and equalflexion/extension gaps is a combination of accuratebone cuts and correct soft tissue balancing.Correcting malalignment and fixed flexiondeformity improves the biomechanics of the knee,minimizes wear and therefore loosening, andsubsequently improves the long-term outcome andlongevity of the prosthesis.

Soft tissue balancing is essentially required inthree scenarios; varus deformity, valgus deformity,fixed flexion deformity. Fixed flexion deformity canbe present in a varus or valgus knee. The releasesinvolved can be performed at different stages ofthe operation; initial releases to gain exposure,further releases to establish flexion/extension gapsand final release after trialling of implants.


insert is needed to achieve stability, the PCL mayneed to be recessed or resected to allow fullextension. Occasionally, the lateral collateralligament needs to be released off the femur and ifthere is severe fixed deformity with associatedfixed flexion, the posterolateral capsule and lateralhead of the gastrocnemius must be released offthe femur.

Fixed flexion deformityFixed flexion deformity is caused by contractureof the posterior structures of the knee andposterior distal femoral osteophytes. If fixedflexion is present the amount of distal femoralresection needs to be increased by approximately1 mm for every 2–3° of fixed flexion present toincrease the extension gap. This is limited by thefact that increasing distal femoral resectionelevates the joint line. If there is severe fixedflexion deformity, it is usually necessary to resectthe PCL. The posterior capsule can be releasedsubperiosteally with a curved osteotome follow -ing bone cuts. Posterior condylar osteophytes canbe excised with an osteotome and removedcarefully with Kocher forceps (Table 11.1).

Patella

Whether the patella should be resurfaced is still acontroversial issue. Some surgeons alwaysresurface, some never resurface and some do if

Varusdeformity

Osteophytes, deep medial collateralligament, superficial medial collateralligament, pes anserinus, posteriorcruciate ligament, posteromedialcapsule, semimembranosus

Valgusdeformity

Osteophytes, lateral capsule, iliotibialband, popliteus, lateral collateralligament, posterior cruciate ligament,intermuscular septum, biceps tendon,lateral head of gastrocnemius

Fixed flexiondeformity

Distal femoral resection, posteriorosteophytes, posterior capsule, posteriorcruciate ligament

Table 11.1 The stages of soft tissue releases indeformity correction

medial tibial plateau. An important part of themedial release involves excision of the medialosteophytes from the distal femur and proximaltibia with either an osteotome or bone nibbler. Asdescribed above, the preliminary soft tissuerelease is performed during the initial exposureand involves the medial capsule and deep MCL,released subperiosteally off the proximal medialtibia from anterior to posterior using either aperiosteal elevator or diathermy. The next stageshould be extension of the medial release distallyto release the superficial MCL and pes anserinus.If further releasing is required, one shouldconsider releasing the PCL as this can often be adeforming force.

Valgus deformity

This is the most common deformity inrheumatoid arthritis and can occur inosteoarthritis. Bone loss is usually from the lateralfemoral condyle. A lateral parapatellar approach israrely required. It is commonly necessary to use aPCL sacrificing implant or, if the MCL is non-functional it may even be necessary to use aconstrained prosthesis. There should be minimalmedial releasing only to allow exposure, due toattenuation of the medial stabilizing structures.Osteophytes should be removed from the distalfemur and proximal tibia. The distal femoral cutcan be set at 5° to ‘overcorrect’ the deformity. Thelateral patellofemoral ligament may need to bereleased to allow eversion of the patella. Thelateral border of the tibia should be demarcatedwith a knife or diathermy to release the lateralcapsule. If the knee is tight laterally in extension,which is common, the iliotibial band should bereleased off Gerdy’s tubercle. If the knee is tightlaterally in flexion, which is less common, thepopliteus tendon should be released. The PCL canbe a deforming force and at this stage if alignmentcannot be corrected the PCL should be released.If there is attenuation of the MCL and a thick

Structure at risk

The common peroneal nerve is at risk followingcorrection of a fixed valgus and fixed flexiondeformity.


Where total knee arthroplasty is performedfollowing a previous patellectomy, a PCLsubstituting implant should be used in order toavoid excessive anterior subluxation of the femuron the tibia due to an already relatively attenuatedextensor mechanism.

Implantation of prosthesis

Condylar knee replacement systems can becemented, uncemented or a hybrid design thatusually has a cemented tibial component and anuncemented femur. Uncemented implants nowoften have a hydroxyapatite coating. Thepolyethylene insert can either be modular ormonoblock (all polyethylene or metal backed),and can be of fixed or mobile bearing design.

In cemented knee arthroplasty, two mixes ofantibiotic-impregnated polymethylmethacrylate(PMMA) bone cement should be used. Thesurgeon should be familiar with thebiomechanical properties of the cement and itsmixing technique. Following satisfactory trials, theselected components are checked by the surgeonand opened. The knee is flexed and the patellaeverted allowing the tibia to be subluxedanteriorly, with a Hohmann retractor or similar,and the prepared surface of the tibia exposedmedially and lateral with spiked retractors. Theknee is washed out thoroughly with normal salinepulsed lavage in order to expose the bonetrabeculae and maximize the mechanical fixationof the cement. If sclerotic bone surfaces arepresent, a small drill can be used to make multiplesmall ‘key holes’. When intramedullaryreferencing has been used, many surgeons insert abone block into the medullary canal to reduceblood loss. The knee should be thoroughly driedwith suction and swabs. The cement can then bemixed and the whole surgical team should changethe outer layer of gloves. In most situations,cementing of both components can be performedsimultaneously, but on occasions it may bedesirable to perform cementing of thecomponents separately with different mixes ofcement.

To ensure a satisfactory and efficientcementation process, everything should beprepared and ordered in a logical fashion. The

there are patellofemoral symptoms or if theretropatellar surface is severely affected.

The vast majority of patella buttons used arepolyethylene. There are two types of patellabutton – onlay and inlay. As the respective namessuggest, these designs utilize a prosthesis that isimplanted either onto or into the resectedretropatella surface. To resurface the patella, theknee should be extended and the patella fullyeverted. Peripheral osteophytes can be removedwith a bone nibbler to demarcate the actualarticular surface. The thickness of the patellashould be measured and the amount ofbone/cartilage removed should approximatelycorrespond to the thickness of the implant,although if there is severe damage it may be less.Resecting too little bone runs the risk ofoverstuffing the knee and if a sclerotic surface isleft behind, fixation is compromised, whereasresecting too much increases the risk of fracture.Many implants now have calibrated clamps andjigs that help indicate the correct resection level.

To avoid an increase in the ‘Q’-angle andtherefore reduce the likelihood of maltracking,the patella button should be slightly medializedand both the femoral and tibial componentsshould be lateralized and slightly externallyrotated. When trialing the implants and checkingthe patellofemoral tracking the ‘rule of nothumbs’ should be employed, i.e. the knee shouldbe put through a range of movement and thepatella should not sublux laterally even before themedial parapatellar reticulum is closed andwithout the use of a guiding thumb to ‘aid’tracking. If the patella maltracks laterally, a lateralparapatellar retinacular release is usually required.This should be performed with a diathermy (as itmay lead to significant bleeding and bruisingpostoperatively), and should be carried out fromdistal to proximal and from deep to superficial.There are often palpable fibrous bands and releaseof these is sometimes enough. To enable therelease to be performed, the patella is liftedanterolaterally with the knee in extension. Ifpossible, the superior lateral geniculate arteryshould be preserved to avoid devascularization ofthe patella. Superficial releasing with a resultantsubcutaneous flap and undermining of the lateralskin should be avoided.


reduces the chance of stitching the drain in whenclosing the medial parapatellar retinaculum.

The actual closure technique varies withsurgical preference but it is important that therepair is watertight and that range of motion ismaintained with no patella maltracking. Closureof the knee in flexion ensures that the correcttension is achieved. The deep layer is closed witha heavy suture (e.g. no. 1 Vicryl), by means of acontinuous repair of the quadriceps tendon,interrupted repair of the parapatellar retinaculumand continuous repair of the medial capsule topatella tendon. The deep fascia can be closed as aseparate layer if desired or the subcutaneous fatcan be opposed with deep interrupted sutures.The deep dermal layer is closed with a continuousabsorbable suture to allow tension-free closure ofthe skin with surgical staples or a continuousabsorbable subcuticular suture. A sterile occlusivedressing and a padded compression bandage isapplied and the drain secured with adhesive tape.


Regular neurovascular, cardiovascular andrespiratory observations are mandatory. Urineoutput, temperature and drainage should also bemonitored. Adequate analgesia should beadministered. Mechanical and, if indicated,chemical thromboprophylactic measures aretaken. Two further doses of prophylacticantibiotics are administered at 8 hours and 16hours after surgery. The use of a reinfusion drainallows for autologous blood transfusion.Haemoglobin levels should be checked 24–48hours after the procedure. Any drains, urinarycatheters, epidural lines and intravenous cannulaeshould be removed as soon as appropriate to avoidunnecessary portals of infection. Pressuredressings should be reduced and ice applied. Fullweightbearing and active range of motionexercises should be commenced as soon aspossible. The wound should be inspected andcheck radiographs performed prior to discharge.The patient must be declared safe for dischargeand for routine cases should be able to straight legraise and flex the knee from 0° to 90°.

Skin clips should be removed 10–14 days aftersurgery and an outpatient appointment should be

tibial component is usually implanted first.Cement can be applied onto the tibial surfaceeither via a gun with short nozzle or with aspatula. The tibial component is positioned in thecorrect orientation and firmly seated with a softimpactor and hammer. Excess cement is removed.A trial insert is then applied to the tibial baseplateand the femur lifted up. Cement can be applied toboth the exposed distal femur and implant, but asit is difficult to remove cement from the posterioraspect of the knee following implantation, in thisregion it is preferable to place the cement ontothe prosthesis rather than onto bone. The femoralcomponent must be positioned carefully inrelation to the distal femur; in particular flexion ofthe femoral component should be avoided. Thefemoral component must be firmly impactedand any excess cement should be removed.The knee is then fully extended and axialcompression applied (note: hyperextension leadsto uneven cement pressurization and may causeposterior ‘lift-off’ of the tibial baseplate). If thepatella is resurfaced the orientation should bechecked and once positioned, the patella iscompressed and held with a clamp. The knee canthen be flexed again and any further cementextruded can be removed quickly. The knee isthen extended and further axial compressionapplied. The trial insert is removed and thebaseplate inspected to ensure that there is nocement or soft tissue present which may impedethe insert. The definitive insert can then bepositioned correctly and impacted fully using theappropriate instrumentation.

In uncemented knee arthroplasty, there must begood bone stock and accurate bone cuts in orderto allow good primary press fit and secondaryosseointegration of the implant.

Closure

Once the cement has set, the knee can be washedout again with pulsed lavage. Some surgeonsprefer to deflate the tourniquet and gainhaemostasis prior to closure. However, mostsurgeons favour closure of the knee over areinfusion drain and application of a pressurebandage prior to deflating the tourniquet. If adrain is used, placing the drain in the lateral gutter


• Periprosthetic fracture• Infection.

Contraindications

• Medically unfit for surgery or anaesthetic• Active or recent local or generalized infection• Critical arterial ischaemia• Non-functioning extensor mechanism• Unexplained pain• Insufficient skin coverage (relative)• Severe neurological disorders (relative)• Age (relative) – very elderly patients should be

carefully selected depending on severity ofsymptoms, quality of life and options available.

OPERATIVE PLANNING

A thorough history and examination is essential torule out pain referred to the knee from elsewhereand to assess the level of pain and functionaldisability. Special consideration should be given topotential risk factors and realistic goals identified.

The examination should pay careful attentionto ligamentous instability, range of movement and

Consent and risks

All of the risks and complications of primary totalknee replacement occur at increased ratesfollowing revision knee arthroplasty. The overallcomplication rate for revision knee replacement isapproximately 25 per cent, while the outcome issignificantly inferior to the results of primary totalknee replacement. In revision for infection, the bestresults for eradication rate are in the region ofapproximately 95 per cent.• Infection (or failure to eradicate)• Bleeding• Venous thromboembolism• Wound problems• Neurovascular injury• Fractures• Extensor mechanism injury• Stiffness• Instability• Wear• Loosening• Pain

arranged approximately 6 weeks post operatively.Ideally, patients undergoing total knee arthro -plasty should be followed up for life with serialradiographs, but in reality this is rarely possible.


Anonymous Knee Replacement: A Guide to GoodPractice. British Orthopaedic Association andBritish Association for Surgery of the Knee:London, 2002.Bargren JH, Blaha JD, Freeman MAR. Alignmentin total knee arthroplasty. Clin Orthop Relat Res1983;173:178.Dorr LD, Boiardo RA. Technical considerations intotal knee arthroplasty. Clin Orthop Relat Res1986;205:5.Scuderi GR, Insall JN. Total knee arthroplasty.Clin Orthop Relat Res 1992;276:26.Scuderi GR, Insall JN, Windsor RE, et al.Survivorship of cemented knee replacement. JBone Joint Surg Br 1989;71:798.

REVISION TOTAL KNEE REPLACEMENT

This section is not intended as a comprehensiveguide to revision of all knee replacements butcovers the principles of revision knee arthroplastyand refers extensively to the section ‘Primary totalknee replacement’ (p. 172).


Indications

Revision total knee replacement is indicated in thetreatment of pain, stiffness or instability from afailed total knee arthroplasty. The cause of failuremust be diagnosed prior to embarking on revisionsurgery. There may be several causal factorspresent in combination. The common causes offailure and indications for revision are:• Aseptic loosening• Polyethylene wear• Osteolysis• Ligamentous instability• Patellofemoral dysfunction• Mechanical stiffness

Revision total knee replacement 183

other extensile approaches may be required togain adequate exposure.


All scars should be marked with a sterile pen. Ifpossible, a generous midline incision is used. Ifthere are multiple longitudinal incisions in frontof the knee the most lateral scar should be used toavoid necrosis of the intervening strip of skin dueto the fact that the blood supply passes frommedial to lateral. The incision needs to be longenough to allow adequate exposure and avoidexcessive skin stretching. It may be desirable toexcise the old scar.


Skin flaps should be kept as thick as possible andshould not be undermined. The quadriceps andpatella tendons should be defined. It may benecessary to extend the incision until ‘virgin’tissue is found, in order to find the correct tissueplane.

Deep dissection

The standard medial parapatellar approach isusually performed initially but an alternative isthe Insall approach, which extends longitudinally

Structures at risk

• The medial collateral ligament is at risk fromaggressive synovectomy and medial release

• The patella tendon is usually thickened, tight andat risk of avulsion. The patella tendon andquadriceps tendon should be thinned down byexcision of any thickened fibrous tissue and thearticulating surface of the patella should beexposed. If the patella does not evert or subluxeasily, one or more of the measures below needsto be performed

• All other important structures around the kneeare at greater risk of injury during revisionsurgery than in the primary procedure due toscar tissue, difficulty in exposure and stiffness orlaxity

extensor mechanism function. Infection must beexcluded. Scars should be carefully noted and adistal neurovascular assessment must beperformed. If the skin over the knee is of poorquality it may be necessary to consult a plasticsurgeon.

Recent weightbearing anteroposterior, lateraland skyline patella radiographs must be availableand long-leg alignment views are helpful inguiding alignment. Computed tomography mayoccasionally help. It is absolutely essential that acause for the failure is found. Templating ofpreoperative radiographs should be performed ifpossible and it is the responsibility of the surgeonto ensure that the required implants are available.

The choice of implant is extremely importantand is essentially governed by the degree of boneloss and ligamentous instability present. In mostcases, due to osteolysis in the metaphyseal regionand suboptimal surfaces for fixation, stemmedimplants are used, which can either be cementedor uncemented and press-fit with flutes forrotational stability. Small, contained defects canbe filled with cement or bone graft butuncontained defects need to be restored withaugments or wedges. Massive bone loss mayrequire a distal femoral or proximal tibialendoprosthetic replacement. The use of a PCLsubstituting design is usually recommended. Ifthere is some degree of ligamentous laxity a semi-constrained implant with a high post should beused to give valgus/varus stability but in the caseof MCL deficiency a rotating hinged prosthesisshould be used. Infected total knee replacementsshould ideally be revised as a two-stage procedure.


See ‘Primary total knee replacement’ (p. 173). Theoperation is likely to last longer than a primaryknee replacement, leading to more physiologicaldisturbance. It can be helpful to exsanguinate theleg after preparation and draping to savetourniquet time.

SURGICAL TECHNIQUE

Although many revision procedures can beperformed via the medial parapatellar approach,as described in primary total knee arthroplasty,

(a) (b)Figure 11.8 (a) quadriceps snip;(b) quadriceps turndown


border of the patella tendon and lateralparapatellar retinaculum. To reduce subsequentblood loss, it can be performed using diathermy.Full thickness lateral release should be avoided ifpossible, but if this is necessary to gain exposurethe superior lateral geniculate artery should be leftintact and the lateral parapatellar retinaculumshould be closed later.

Quadriceps snipThis involves a lateral incision into the quadricepstendon from the proximal extent of the standardmedial parapatellar approach (Fig.11.8a). Aquadriceps snip can be performed in combinationwith a more distal lateral release, provided thatthe superior lateral geniculate artery is preserved.

Quadriceps turndownThis consists of an incision passing distally andlaterally from the proximal extent of the standardmedial parapatellar approach (Fig. 11.8b). Thesuperior lateral geniculate artery should bepreserved. The inverted V thus formed can be

over the patella at the junction of the medial one-third and lateral two-thirds. The medialretinaculum is dissected subperiosteally off thepatella to allow a cuff for repair. It is usuallynecessary to perform an extensive synovectomy inorder to improve exposure and to recreate thesuprapatellar pouch and medial and lateralgutters. The fat pad is excised. Medial releaseshould be performed to allow exposure to thetibia. There is usually a plane visible between thepseudocapsule and normal tissue and this can bedeveloped with knife or diathermy and thepseudocapsule carefully pulled away undertension. As the PCL is usually sacrificed, this canbe performed following implant removal.

Lateral parapatellar releaseIt is almost always necessary to perform a lateralparapatellar release to allow eversion of thepatella. It is usually beneficial to perform thelateral parapatellar release early on. The releaseshould be performed from deep to superficial andfrom distal to proximal, alongside the lateral

6cm long

Figure 11.9 Tibial tubercle osteotomy (leaving thelateral soft tissues undisturbed)

Revision total knee replacement 185

depends on the amount of bone loss andligamentous instability present.

Implant removalSafe and careful implant and cement removalshould involve preservation of as much bone stockas possible. It is necessary to use fine, sharposteotomes and it may be helpful to have cement-splitting osteotomes, a thin saw blade, Gigli sawand burr available. If a modular polyethyleneinsert is present it can be removed prior to thecemented components. It is usually preferable toremove the femoral component first as thisfacilitates easier extraction of the tibialcomponent. With adequate retraction, thebone–cement interface should be carefullydisrupted with osteotomes of appropriate width.If the implant is well fixed it may be safer todisrupt the implant–cement interface and removethe cement separately. Only when fully loosened,should the implant be removed with theappropriate extraction device using a longitudinaldistraction force. The tibial component can beremoved in a similar manner. The tibialcomponent should never be ‘levered’ out of bone.It is usually necessary to remove the cement fromaround the tibial keel and stem with cement-splitting osteotomes or gauges. If a polyethylenepatella button has been used it should be removedif significantly worn, in cases of infection, or ifthere is a patellofemoral problem. Metal-backedpatella components can be very difficult toremove and are often best left if possible.

ReconstructionFollowing successful removal of implants andcement, any fibrous membrane on the distalfemur and proximal tibia is carefully removedwith a small, sharp curette and bone nibblers.Ideally, the remaining bone surfaces should consistof trabecular bone to allow optimum cementa -tion. Any small, contained, cavitatory defects canbe filled with morsellized bone graft or cementbut larger, uncontained, segmental defects need tobe reconstructed with augments or wedges (Fig.11.10). Where there is massive bone lossextending into the metaphyseal region a modularendoprosthetic implant may need to be used withdistal femoral or proximal tibial replacement and

closed as a Y, thereby advancing the quadricepstendon and patella distally.

Tibial tubercle osteotomyThis requires an osteotomy of approximately 6 cmof the tibial tuberosity, hinging on the lateral softtissues in order to maintain vascularity (Fig. 11.9).The osteotomy can be elevated in a case of patellabaja. The osteotomy may be performed with a sawor sharp osteotome from the medial side andshould be wide enough to include the patellatendon insertion, tapering distally along with theanatomy of the tibial tubercle. It needs to be fixedwith screws or wires at the end of the procedure.

Procedure

The ultimate goals of revision knee replacementare pain relief, functional stability and eradicationof infection, if present. In order to achieve thesegoals, the important factors are: preservation ofbone stock, reconstruction of defects, adequatefixation of implants, ligamentous balancing andrestoration of the joint line. The choice ofprosthesis is of crucial importance and essentially

Augmentsand

wedges

Massivebone loss

=endopposthesis

Small andcontained

=cement orbone graft

Figure 11.10Reconstructiveoptions for bone lossin revision kneesurgery


Thought must constantly be given to achievingequal flexion and extension gaps (see ‘Primarytotal knee replacement’, p. 175) and to restorationof the joint line. If the knee is looser in flexionthan extension, the femoral component is upsizedwith posterior augmentation. If the knee is loosein extension compared with flexion, the distalfemur is augmented. This is preferred to using athicker insert and elevating the joint line. Thelevel of the joint line should be approximately onefingerbreadth below the inferior pole of thepatella or at the level of the meniscal scar.

Some revision knee systems incorporateanteroposterior offset options for the femoralcomponent and mediolateral offset options for thetibial component. Final trials should be performedwith all trial stems, augments and wedges in placeand the thickness of insert can be determined andfinal ligamentous releases performed. If the patellais to be revised, care must be taken with furtherresection. It is commonplace to cement the tibialcomponent first and use a separate batch ofcement for the femur.

Two-stage revision for infectionRevising a total knee replacement for infection iseven more challenging. Two-stage revisionmaximizes the chance of eradicating infection,although some units report good eradication rateswith one-stage revision and better functionaloutcome.

At the first stage, all implants and cement areremoved. Aggressive debridement is performedwith excision of all infected looking tissue andmultiple fluid and tissue samples are sent tomicrobiology and histopathology. The knee isthoroughly washed out. It may be helpful toperform preliminary bone cuts at this stage. Apremoulded antibiotic-impregnated cementspacer is inserted and lightly cemented in place toavoid displacement. Appropriate antibiotics arecontinued and inflammatory markers checked ona regular basis. The knee should be mobilized topreserve range of motion if possible. Whenconfident that infection has been eradicated, thesecond stage revision can be performed withimplantation of the definitive prosthesis.Occasionally, if not settling, the first stage mayneed to be repeated.

this necessitates the use of a constrained, rotating-hinged device.

The tibia should be prepared first with the kneeflexed, the proximal tibia exposed and subluxedanteriorly and the patella everted if possible. Thecanal is opened with a drill. Sequential reamersare used to the desired stem length until there isgood endosteal engagement of the reamer. Usingstable intramedullary referencing, which may bein the form of an intramedullary rod and sleeve,the proximal tibia is then resected to the correctlevel. If a tibial cutting jig is used with an inherentanteroposterior slope, the rotation should bereferenced from the medial third of the tibialtubercle. Tibial resection should usually beconservative, but depends on the previousresection level and bone stock. If a flat, level cutcannot be achieved a wedge may be used.

Attention is then turned to the femur. Thecanal is prepared as above. Distal femoral cuts aremade with intramedullary referencing and acutting jig. If the condyles are resected at differentlevels, the additional resection must becompensated for by an augment of that size. Thefemoral anterior, posterior and chamfer cuts arethen performed with the cutting block positionedin the correct rotational orientation. This can beestimated from the transepicondylar axis or byreferencing from a spacer block placed onto theflat proximal tibial surface. This is essential toensuring a symmetrical flexion gap. Again,augments can be used to make up differences inresection levels of the posterior condyles.

Patellofemoral knee replacement 187

osteoarthritis when non-operative or moreconservative operative management has failed.

The lateral facet of the patella and trochlea aremost commonly involved and there is commonlysome degree of dysplasia, malalignment or laxitypresent as a predisposing factor.

Contraindications

General contraindications to knee arthroplasty(see ‘Primary total knee replacement’, p. 172).• Tibiofemoral osteoarthritis• Inflammatory arthritis.

Operative planning

Recent weightbearing anteroposterior, lateral andskyline patella radiographs must be available andSchuss views may be helpful. Schuss views areanteroposterior weightbearing X-rays taken withthe knee in 30° of flexion and may be moresensitive in picking up tibiofemoral osteoarthritis.It is essential that the symptoms and signs shouldbe consistent with patellofemoral osteoarthritis. Itis sometimes necessary to perform magneticresonance imaging or arthroscopy to assess therest of the joint surfaces, although in most casesthe decision can be made from the history,examination and plain radiographs. Occasionally,however, the final decision is made at the time ofoperation.


Anaesthesia, positioning, preparation and drapingare similar to that for primary total kneereplacement.

Consent and risks

• See ‘Primary total knee replacement’ (p. 172)• Progression of arthritis may require revision to

total knee arthroplasty (5 per cent incidence at 5years)

• Specific problems with the patellofemoralarticulation include: patella fracture; lateralsubluxation; impingement; anterior knee pain

Closure

Routine cases can be closed in a similar fashion toprimary knee replacements. Occasionally,especially after repeated revision cases orfollowing infection, closure can be difficult and it may even be necessary to considergastrocnemius muscle flap coverage and skingrafting, where the assistance of a plastic surgeonmay be required.


If a standard approach has been used, in asepticcases, the postoperative regimen is similar to thatfollowing primary knee replacement. The resultsof microbiology samples must be obtained.

If a quadriceps turndown or tibial tubercleosteotomy has been performed, flexion should belimited for approximately 6 weeks to allow thetendon or osteotomy to heal and activequadriceps extension should be avoided.


Back DL, David L, Hilton A, et al. The SMILESprosthesis in salvage revision knee surgery. Knee2008;15:40–4.Hanssen AD. Managing the infected knee: as goodas it gets. J Arthroplasty 2002;17(Suppl 1):98–101.Rand JA. Revision total knee arthroplasty usingthe total condylar III prosthesis. J Arthroplasty1991;6:279–84.Saleh KJ, Rand JA, Ries MD, et al. Revision totalknee arthroplasty. J Bone Joint Surg Am2003;85(Suppl 1).Younger AS, Duncan CP, Masri BA. Surgicalexposures in revision total knee arthroplasty. J AmAcad Orthop Surg 1998;6:55–64.

PATELLOFEMORAL KNEEREPLACEMENT


Indications

Patellofemoral replacement is indicated in thetreatment of pain from isolated patellofemoral


should be an adequate cuff to ensure a good softtissue repair. The retropatellar fat pad can beincised or partially excised to facilitate eversion ofthe patella and it may be necessary to perform alateral parapatellar release. Osteophytes may bedebrided at this stage.

Procedure

The aims of the operation are pain relief, goodpatella tracking and patellofemoral stability. Thisis achieved by accurate bone resection, correctalignment of implants and parapatellar soft tissuebalancing.

PatellaTo resurface the patella, the knee should beextended with the patella fully everted and heldwith a clamp. Peripheral osteophytes can beremoved with a bone nibbler to demarcate thearticular surface. It is often difficult to accuratelyassess the amount of patella to be resected, as thearticular cartilage wear is usually not uniform. Ifthe median ridge is of normal height, the thicknessof the patella should be measured and the amountof bone and cartilage removed should correspondto the thickness of the implant. If there is severedamage, a measured resection technique isunreliable. In this situation, the insertions of thequadriceps tendon and the lateral border of thepatella tendon can be exposed carefully with adiathermy and used as reliable landmarks.Resection 2 mm above this plane results in 66 percent of the original patella thickness being leftbehind. Resecting too little bone runs the risk ofoverstuffing the knee and if a sclerotic surface isleft behind, fixation is compromised, whereasresecting too much increases the risk of fracture. Aclamp is then applied and used as a cutting guide.The amount of resection should be carefullyinspected and adjusted if necessary. There willusually be more bone resected from the medialthan lateral facet and the remaining cut surfacemay be sclerotic. This can be roughened with asaw or burr and small drill holes made to improvecement fixation. The patella is then subluxed oreverted and the knee flexed to allow the distalfemur to be prepared. Care must be taken toavoid fracture of the patella during flexion if theremaining patella is thin.

SURGICAL TECHNIQUE

Patellofemoral replacement should be performedvia a medial parapatellar approach.


The position of the patella, patella tendon, andtibial tubercle should all be noted. An anteriormidline longitudinal incision is made with theknee in flexion. It is not usually necessary toextend the excision as far distally as in total kneearthroplasty, but it needs to be long enough toallow eversion of the patella and adequateexposure of the distal femur.


The medial and lateral skin, subcutaneous fat anddeep fascia should be reflected in a thick flap toallow exposure of the quadriceps tendon, medialpatella retinaculum and patella tendon and toallow mobilization of the patella.

Deep dissection

The medial parapatellar incision is extended fromthe quadriceps tendon proximally, through themedial parapatellar retinaculum and along themedial border of the patella tendon distally. There

Structures at risk

• The anterior horns of the medial and lateralmenisci should be carefully preserved, unlikewith total knee replacement where they aresacrificed. The incision at the level of the jointline must be done with great care not to extendinto meniscal tissue

• The medial femoral condyle can be damagedduring the medial parapatellar approach

• If the patella tendon is contracted, there may bea risk of patella tendon avulsion from the tibialtubercle during eversion of the patella. This canbe prevented by extending the deep dissectionproximally, dividing any lateral plicae and byperforming a lateral parapatellar release to alloweversion of the patella

Unicompartmental knee replacement 189

UNICOMPARTMENTAL KNEEREPLACEMENT


Indications

Unicompartmental knee replacement is indicatedin the treatment of painful osteoarthritis whennon-operative management has failed. Thefollowing criteria must be met:• Osteoarthritis mainly confined to one

compartment• Varus or valgus deformity must be correctable

to normal• Fixed flexion deformity less than 10°• Minimum flexion of 105°• Intact knee ligaments.

Contraindications

• General contraindications to knee arthroplasty(see ‘Primary total knee replacement’, p. 172)

• Inflammatory arthritis• Failure to meet criteria above• Patellofemoral osteoarthritis – relative. This is a

controversial and debatable issue, with someevidence showing no detrimental effect of thepresence of patellofemoral osteoarthritis onresults.

Consent and risks

• Most risks and complications of primary totalknee replacement can occur inunicompartmental knee replacement

• The rate of conversion to total knee replacementis around 3 per cent at 3 years

• Medial knee pain is common and usually resolveswith time. Persistent anteromedial knee painmay be associated with a degree of MCL damageintraoperatively

• Dislocation of the insert can occur with mobilebearings, especially if ACL laxity is present

• Progression of arthritis may require revision tototal knee replacement. Although this can berelatively straightforward, there is often

FemurTo expose the distal femur, two Hohmannretractors are placed medially and laterally.The anterior surface of the distal femur isexposed by excising the overlying synoviumwith coagulating diathermy. The femoralcomponent should sit flush with the anteriordistal femur without notching, with the correctdegree of rotation to ensure restoration of thelateral ridge and good tracking. The implantshould not be situated too far distal within thenotch, as this can cause impingement and catchingof the patella in full flexion. The femoral bonecuts can be based on either intramedullary orextramedullary referencing. Individual implantsrely on different anatomical landmarks forrotational alignment, e.g. long axis of tibia,transepicondylar axis of distal femur, and specificinstruction manuals should be referred to. Mostbone cuts are made using sizing jigs and cuttingguides.

Trials are then performed and tracking assessed.Final adjustments and preparations can then bemade including lateral parapatellar release ifnecessary. Components are cemented in place.

Closure

If a lateral parapatellar release has been performeda drain should be inserted. The knee should beclosed in flexion in a similar manner to a primarytotal knee replacement.


As for primary total knee replacement.


Ackroyd CE, Newman JH, Evans R, et al. TheAvon patellofemoral arthroplasty: five-yearsurvivorship and functional results. J Bone JointSurg Br 2007;89:310–15.Cartier P, Sanouiller JL, Khefacha A. Long-termresults with the first patellofemoral prosthesis.Clin Orthop Relat Res 2005;(436):47–54.


of the patella tendon and proximally up to themedial parapatellar retinaculum. The medialcapsule is dissected subperiosteally off theproximal tibia to gain exposure to the medialcompartment. The dissection should not extendbeyond the anteromedial corner and should notinvolve any release of the MCL. The medialportion of the fat pad can be excised. The anteriortwo-thirds of the medial meniscus can be excisedat this point, with the posterior horn removedlater following bone cuts. This should giveadequate exposure of the medial compartmentand it should be possible to inspect the ACL,patellofemoral joint and lateral compartment.

This operation can usually be performedthrough a relatively minimally invasive approach,with the skin incision being used as a ‘mobilewindow’ to gain access to the femur or tibia withvarying degrees of knee flexion. However, ifexposure is difficult, the skin incision and deepdissection should be extended to allow the patellato be subluxed laterally, although it should notusually be necessary to involve the quadricepstendon or vastus medialis.

Procedure

Osteophytes on the medial tibial plateau andfemoral condyle are excised. The exact nature andsequence of bone preparation is dependent on theimplant used and manufacturer’s recom -mendations but the aims are the same as in anyknee arthroplasty; anatomical alignment, equalflexion/extension gaps, optimum range of motionand good fixation of implants.

The tibial cut is usually made first, withextramedullary referencing and a tibial cuttingguide. The vertical cut is performed, with areciprocating saw, just medial to the ACLinsertion. The horizontal cut utilizes an oscillating

Structures at risk

• The MCL must be protected throughout• The ACL is at risk during the sagittal tibial cut

with the reciprocating saw and should beretracted

• The patella tendon can be damaged duringreaming of the femoral condyle

OPERATIVE PLANNING

Recent weightbearing anteroposterior, lateral andskyline patella radiographs must be available andstress views may be helpful. It is essential that thesite of pain should correlate with radiographicfindings. It is sometimes necessary to performmagnetic resonance imaging or arthroscopy toassess the integrity of the ACL and the rest of theknee, although in most cases the decision can bemade by the history, examination and plainradiographs. However, the final decision is made atthe time of operation.


This is essentially similar to that described fortotal knee replacement. However, asunicompartmental knee replacement is usuallyperformed via a less invasive approach, the use ofregional anaesthesia can be avoided, if desired, bythe administration of local anaesthetic into thewound and deep tissues. Some surgeons prefer touse a leg holder with the knee flexed, the hipabducted and the leg over the side of theoperating table or the foot of the table removed.This allows the knee to be stressed and canimprove exposure.

SURGICAL TECHNIQUE

Medial unicompartmental kneereplacement

Landmarks and incisionWith the knee flexed, a longitudinal incision ismade along the medial border of the patellatendon from patella to tibial tubercle and can beextended proximally or distally as required.

DissectionThe incision is deepened along the same line andthe medial border of the patella and tendonidentified. It is continued along the medial border

significant bone loss, especially around the tibialbaseplate and it may be necessary to use a stemand wedge

Centre offemoral head

Parallel toIM canal

Figure 11.11 Componentalignment inunicompartmental kneereplacement

Unicompartmental knee replacement 191

cemented and medial unicompartmental kneereplacements are usually mobile bearing.

ClosureClosure is done in layers, with continuousabsorbable sutures and a continuous subcuticularsuture or staples to the skin. It is not usuallynecessary to use a drain.

Lateral unicompartmental kneereplacement

This is much less commonly performed thanmedial unicompartmental knee replacement. Itcan either be performed via a midline approachwith the patella everted, or a direct lateralparapatellar approach. The procedure itself isanalogous to that of medial unicompartmentalsurgery. Due to the increased excursion of thelateral compartment during knee movement, theuse of a fixed bearing is required.


Patients should be encouraged to mobilize theknee and weightbear as quickly as possible. Asthere is minimal soft tissue disruption, the patientshould recover function relatively quickly.


Koskinen E, Eskelinen A, Paavolainen P, et al.Comparison of survival and cost-effectivenessbetween unicondylar arthroplasty and total kneearthroplasty in patients with primaryosteoarthritis: a follow-up study of 50,493 kneereplacements from the Finnish ArthroplastyRegister. Acta Orthop 2008;79:499–507.Murray DW, Goodfellow JW, O’Connor JJ. TheOxford medial unicompartmental arthroplasty: aten-year survival study. J Bone Joint Surg Br1998;80:983–9.Steele RG, Hutabarat S, Evans RL, et al.Survivorship of the St Georg Sled medialunicompartmental knee replacement beyond tenyears. J Bone Joint Surg Br 2006;88:1164–8.

saw, perpendicular to the long axis of the tibia.The wedge of tibia can then be removed with aKocher forcep.

The femoral preparation uses femoralintramedullary alignment and the tibial cut as acombined reference (Fig. 11.11). The flexion gapis set by making the posterior condylar cut first.The initial reaming of the distal femur is thencarried out in order to position the trials in placeand the flexion and extension gaps are equalizedby taking more bone off the distal femur.

Final trials and preparations can then be madeand the definitive implants inserted. If there isimpingement of the bearing anteriorly on thefemoral condyle in full extension, the condyle canbe fashioned to allow clearance. The majority ofunicompartmental knee replacements are


Operative planning

Recent weightbearing anteroposterior, lateral andskyline patella radiographs must be available.Long-leg alignment films must be performed andstress views may be helpful. It is essential that thesymptoms and signs should correlate withradiographic findings. It is sometimes necessary toperform magnetic resonance imaging orarthroscopy to assess the integrity of the ligamentsand the state of the joint surfaces. Althoughinstability has historically been thought of as acontraindication to osteotomy, it may beperformed as a precursor to or in association withligament reconstruction, as correcting any bonymalalignment is an important part in stabilizingthe knee. Templating of the alignment films isimportant to have an idea of the correctionrequired. Each millimetre of opening correspondsto 1° of correction.


General anaesthesia is used. Regional anaesthesiacan be avoided, if desired, by the administration oflocal anaesthetic into the wound and deep tissues.The patient is positioned supine on the operatingtable. Provided that there are no contraindica -tions, a tourniquet is applied as proximally aspossible. An image intensifier is neededthroughout the operation.

Prior to preparation and draping, in order toreference the mechanical axis of the limb, thecentre of the femoral head can be screened withthe image intensifier and a radio-opaqueelectrocardiogram (ECG) sticker is placed on theskin directly overlying the centre of the femoralhead. If a tri-cortical wedge of iliac crest bonegraft is to be used the iliac crest must beprepared, draped and exposed to allow bone graftharvesting.

• Infection• Bleeding• Venous thromboembolism• Neurovascular injury

DISTAL FEMORAL OSTEOTOMY


Distal femoral osteotomy is used to correct valgusdeformity of the knee and consists of a varusosteotomy which may either be a medial closingwedge or a lateral opening wedge. The authors’preference is the lateral opening wedge varusosteotomy and this is described below.

Indications

Distal femoral osteotomy is indicated in thetreatment of pain and deformity caused by valgusosteoarthritis in relatively young patients whennon-operative management has failed.

It can also be used to correct malunionfollowing supracondylar fractures of the femur.

Contraindications

• Distal lower limb ischaemia• Significant medial or patellofemoral

osteoarthritis• Flexion limited to less than 90°• Fixed flexion deformity greater than 15°• Inflammatory arthritis• Osteoporosis• Inability to comply with the rehabilitation

protocol.

Consent and risks• Delayed/non-union• Inadequate/loss of correction• Failure of fixation• Stiffness• Iliotibial band irritation• Progression of arthritis may require revision to

total knee replacement. Although this can berelatively straightforward, it may be advisable to remove the metalwork at a separate operationprior to performing total knee replacement

• There may be difficulty in achieving the desiredvalgus intramedullary alignment of the distalfemoral bone cut following distal femoralosteotomy

Shift ofmechanical axisto medialcompartmentOpening wedge

Lateral openingwedge

osteotomy

Mechanicalaxis passes

through lateralcompartment

Figure 11.12 Lateral openingwedge distal femoral osteotomyin a valgus knee

Distal femoral osteotomy 193

continued anteriorly and posteriorly around thefemur. Insertion of the appropriate retractorsanteriorly and posteriorly gives good exposure ofthe distal femur.

Procedure

The ECG sticker placed over the femoral head ispalpated through the drapes and an alignment rodcan be placed to lie between this point and thecentre of the articular surface of the ankle joint.When the osteotomy is opened by the correctamount, the mechanical axis is shifted to thedesired point, i.e. the centre of the medial tibial

Structures at risk

• The popliteal artery must be protected by thesubperiosteal retractor throughout theprocedure. The risk of major arterial injury maybe reduced by performing the osteotomy withthe knee in flexion as the artery moves awayfrom the posterior femur

• The medial distal femoral cortex should be leftintact. If breached, a staple can be inserted tomaintain stability

SURGICAL TECHNIQUE

The aim of a varus osteotomy is to correct valgusmalalignment, shift the mechanical axis to themedial compartment and offload the diseasedlateral compartment (Fig. 11.12). The goal is toovercorrect to a tibiofemoral angle of 0°. A distalfemoral osteotomy should be used rather than aproximal tibial osteotomy as this achieves ahorizontal joint line.


An opening wedge osteotomy is performed via alateral approach to the distal femur. A longitudinalincision is made over the lateral aspect of thethigh in the supracondylar region. Correctplacement of the incision site is ensured byscreening with the image intensifier.

Dissection

The incision is deepened along the same line untilthe fascia lata is exposed. The fascia lata is splitand the vastus lateralis can either be divided orincised and lifted off the femur at its posteriorborder. Any blood vessels encountered should becoagulated and subperiosteal dissection is



As for proximal tibial osteotomy.


Backstein D, Morag G, Hanna S, et al. Long-termfollow-up of distal femoral varus osteotomy of theknee. J Arthroplasty 2007;22(Suppl 1):2–6.Brouwer RW, Raaij van TM, Bierma-Zeinstra SM,et al. Osteotomy for treating knee osteoarthritis.Cochrane Database Syst Rev 2007;18:CD004019.Puddu G, Cipolla M, Cerullo G, et al.Osteotomies: the surgical treatment of the valgusknee. Sports Med Arthrosc 2007;15:15–22.

PROXIMAL TIBIAL OSTEOTOMY


Proximal tibial osteotomy is used to correct varusdeformity of the knee and consists of a valgusosteotomy which may either be a lateral closingwedge or a medial opening wedge. The authors’preference is the medial opening wedge valgusosteotomy and is described below.

Indications

Proximal tibial osteotomy is indicated in thetreatment of pain and deformity caused by varusosteoarthritis in relatively young patients whennon-operative management has failed.

Contraindications

• Distal lower limb ischaemia• Significant lateral or patellofemoral

osteoarthritis• Significant bone loss from the medial tibial

plateau• Flexion limited to less than 90°• Fixed flexion deformity greater than 15°• Inflammatory arthritis• Osteoporosis• Inability to comply with rehabilitation

protocol.

plateau. This improves the efficiency of the use offluoroscopy, minimizes X-ray exposure and helpsto minimize operation time.

A first guide wire is inserted with the powerdriver from the lateral cortex in a medial andslightly caudal direction. The wire should emergein the metaphyseal region of the distal femur atthe junction of the medial femoral condyle andthe supracondylar ridge. A second wire is thenintroduced to lie exactly superimposed on the firston a true anteroposterior fluoroscopic image,indicating that the wires are exactly parallel to thejoint surface. This second wire can be introducedthrough a parallel guide.

The osteotomy can then be performed with anoscillating saw, using either the guide wires orcutting jig to help control the saw. The saw isplaced on the proximal side of the wires andadvanced approximately two-thirds of thedistance across the femur under fluoroscopiccontrol. Care must be taken not to penetrate themedial cortex. The osteotome is then used tocomplete the osteotomy through the anterior andposterior cortices, but should stop approximately1 cm short of the medial cortex. The blade of theosteotome can be marked at a level wherepenetration of the far cortex will not occur andthis marking can be observed carefully as theosteotome advances.

The osteotomy is then opened with distractionosteotomes using a screwdriver underfluoroscopic control. When the osteotomy isopened, metal wedges can be gently inserted intothe osteotomy to the desired level. The amount ofcorrection can be checked with the imageintensifier using the alignment rod as previouslydescribed. A locking plate with interpositionwedge of the desired size is then inserted into theosteotomy in the correct position and screwsinserted and checked with fluoroscopy. Theopening wedge can be filled with bone graft orcalcium triphosphate wedges.

Closure

Closure is performed in layers with continuousabsorbable sutures and a continuous subcuticularsuture or staples to the skin. It is not usuallynecessary to use a drain.

Mechanical axis passes

medially

Medial opening

wedge osteotomy

Shift of mechanicalaxis to lateralcompartment

Openingwedge

Figure 11.13 Medial opening wedge proximal tibialosteotomy in a varus knee

Proximal tibial osteotomy 195


A medial opening wedge valgus osteotomy isperformed via an anteromedial approach to theproximal tibia. A longitudinal or oblique incisionis made over the anteromedial aspect of theproximal lower leg in the region of the insertion ofthe pes anserinus and 3 cm medial to the lowerborder of the tibial tubercle.

Dissection

The incision is deepened until the fascia overlyingthe pes is exposed. The fascia is incised and thepes anserinus is reflected posteriorly, with thesuperficial medial collateral ligament. Any bloodvessels encountered should be coagulated andsubperiosteal dissection is continued anteriorlyand posteriorly around the tibia. Insertion of theappropriate retractors anteriorly and posteriorlygives good exposure of the proximal tibia andprotects the patella tendon anteriorly with thepopliteal artery and tibial nerve posteriorly.

Operative planning

As for distal femoral osteotomy.


As for distal femoral osteotomy.

SURGICAL TECHNIQUE

The aim of a valgus osteotomy is to correctmalalignment, shift the mechanical axis to thelateral compartment and offload the diseasedmedial compartment (Fig. 11.13). The goal is tocorrect to a tibiofemoral angle of 5–9°. Theadvantages of an opening wedge valgus osteotomyinclude the fact that there is no need for a fibularosteotomy, there is more control over thecorrection and that it may correct instabilityin anterior or posterior cruciate ligamentdeficiency by adjustment of the tibial slope. It hasthe disadvantage of creating a degree of patellabaja.

Consent and risks

Progression of arthritis may require revision to totalknee replacement. Although this can be relativelystraightforward, it may be advisable to remove themetalwork prior to performing total kneereplacement.

There may be problems caused by patella baja.Other specific complications include:

• Infection• Bleeding• Venous thromboembolism• Common peroneal nerve injury (usually

associated with fibular osteotomy in closingwedge proximal tibial osteotomy).

• Major arterial injury• Compartment syndrome• Lateral tibial plateau fracture• Delayed/non-union• Inadequate/loss of correction• Overcorrection• Failure of fixation• Stiffness

Step cut toavoid tubercle

Figure 11.14 A step cut to avoid tibial tuberosity


cutting jig to help control the saw. The saw isplaced on the distal side of the wires and advancedapproximately two-thirds of the distance acrossthe tibia under fluoroscopic control. Care must betaken not to penetrate the lateral cortex. Theosteotome is then used to complete theosteotomy through the anterior and posteriorcortices, but should stop approximately 1 cmshort of the lateral cortex. The blade of theosteotome can be marked at a level wherepenetration of the far cortex will not occur andthis marking can be observed carefully as theosteotome advances.

The osteotomy may pass above the insertion ofthe patella tendon, but if it crosses the anteriortibial cortex at the level of the tibial tuberosity itmay be necessary to make a step cut beneath thetuberosity from the transverse osteotomyproximally to ensure that the tuberosity andpatella tendon insertion remain intact (Fig.11.14).

The osteotomy is then opened with distractionosteotomes using a screwdriver underfluoroscopic control. When the osteotomy isopened, metal wedges can be gently inserted intothe osteotomy to the desired level. The amount ofcorrection can be checked with the imageintensifier using the alignment rod as previouslydescribed. A locking plate with interposition

Procedure

The ECG sticker placed over the femoral head ispalpated through the drapes and an alignment rodcan be placed to lie between this point and thecentre of the articular surface of the ankle joint.When the osteotomy is opened by the correctamount, the mechanical axis is shifted to thedesired point, i.e. at the junction of the medialtwo-thirds and lateral third of the articular surfaceof the tibia. Using an alignment rod to show themechanical axis improves the efficiency of the useof fluoroscopy, minimizes X-ray exposure andhelps to minimize operation time. It is imperativethat a ‘true’ anteroposterior radiograph of theknee is obtained in order to gauge theanteroposterior slope of the tibia.

A first guide wire is inserted, with the powerdriver, from the medial cortex in a lateral andslightly cephalad direction. The wire shouldemerge in the metaphyseal region of the proximaltibia at the level of the tip of the fibula head. Asecond wire is then introduced to lie exactlysuperimposed on the first on a trueanteroposterior fluoroscopic image, indicating thatthe wires are exactly parallel to the joint surface.This second wire can be introduced through aparallel guide.

The osteotomy can then be performed with anoscillating saw, using either the guide wires or a

Structures at risk

• Popliteal artery: the risk of major arterial injurymay be reduced by performing the osteotomywith the knee in flexion as the artery movesaway from the posterior tibia

• Patella tendon• Superficial MCL• The lateral tibial cortex should be left intact. If

breached, a staple should be inserted laterally tomaintain stability

• The lateral tibial plateau can be fractured if theanterior cortex has not been fully osteotomizedprior to distraction of the osteotomy. If thisoccurs, the osteotomy should be advanced andthe fracture stabilized with one or moreinterfragmentary screws from the lateral side

Knee arthrodesis 197

Fisher DE. Proximal tibial osteotomy 1970–1995.Iowa Orthop J 1998;18:54–63.

KNEE ARTHRODESIS


Indications

The most common indication for knee arthrodesisis as a salvage procedure in failed revision kneearthroplasty either where infection has beenresistant to eradication or when there is a non-functioning extensor mechanism.

In the past and currently still in some parts ofthe world, knee arthrodesis is more commonlyperformed in patients with post-infective arthritis,tuberculosis, poliomyelitis and severe trauma.

Contraindications

• Critical arterial ischaemia• Extensive bone loss (relative)• Ipsilateral hip arthrodesis (relative).

Operative planning

The indication for arthrodesis, severity of boneloss and adequacy of soft tissue coverage all needto be taken into account prior to deciding onwhether the arthrodesis should be a single orstaged procedure, an intramedullary orextramedullary fixation and whether it isnecessary to enlist the help of a plastic surgeon.

Consent and risks

• Infection (or failure to eradicate existinginfection)

• Bleeding• Venous thromboembolism• Wound problems• Neurovascular injury• Fractures• Delayed or non-union• Pain• Immobility• Risk of subsequent amputation

wedge of the desired size is then inserted into theosteotomy in the correct position and screwsinserted and checked with fluoroscopy. Theopening wedge can be filled with bone graft orcalcium triphosphate wedges. Autograft is stilladvocated for larger corrections or revisionprocedures.

Closure

Closure is undertaken in layers with continuousabsorbable sutures and a continuous subcuticularsuture or staples to the skin. It is not usuallynecessary to use a drain.


Regular neurovascular observations should beperformed and the patient carefully monitored forsigns of compartment syndrome. Adequateanalgesia is administered. Mechanical and chemicalthromboprophylaxis is recommended. Two furtherdoses of prophylactic antibiotics are administeredat 8 hours and 16 hours postoperatively. Thewound should be inspected and check radiographsperformed prior to discharge. If the fixation isstable, range of motion exercises are encouragedfrom day 1 postoperatively. Patients should remainnon-weightbearing in a hinged knee brace for 2weeks. Repeat radiographs are taken and clipsremoved at this stage. Touch weightbearing only iscommenced in a hinged knee brace for a further 4weeks. If radiographs are satisfactory at 6 weeks,partial weightbearing can be commenced and if theosteotomy has united at 12 weeks the patient canbuild up to full weightbearing.


Brinkman JM, Lobenhoffer P, Agneskirchner JD,et al. Osteotomies around the knee: patientselection, stability of fixation and bone healing inhigh tibial osteotomies. J Bone Joint Surg Br2008;90:1548–57.Coventry MB, Ilstrup DM, Wallrichs SL. Proximaltibial osteotomy. A critical long-term study ofeighty-seven cases. J Bone Joint Surg Am1993;75:196–201.


approximately 15° of flexion, 7° valgus and 10°external rotation. Bone graft may be used ifdesired. Compression must be achieved with theexternal fixator. Any form of external fixator canbe used, from simple monoaxial fixators to finewire frames.

Intramedullary fixationBone cuts are made as above. The femoral andtibial intramedullary canals are reamed. The distalfemur/proximal tibia can be reamed in aconcave/convex fashion to increase contactsurface area. Fixation can be achieved either witha long nail or with a two-part nail with alocking device between the femur and tibiawhich can also provide compression and correctalignment. The nail can be locked proximally anddistally.

Closure

In some cases closure can be difficult.Occasionally, especially after repeated revisioncases or following infection, closure can be such achallenge that it may even be necessary toconsider gastrocnemius muscle flap coverage andskin grafting, where the assistance of a plasticsurgeon may be required.


The amount of weightbearing allowed depends onthe stability of fixation, but generally touchweightbearing should be commenced imme di -ately, gradually built up to partial weightbearingover approximately 6 weeks and to fullweightbearing over the next 6 weeks.


Conway JD, Mont MA, Bezwada HP. Arthrodesisof the knee. J Bone Joint Surg Am 2004;86:835–48.Wiedel JD. Salvage of infected total knee fusion:the last option. Clin Orthop Relat Res2002;(404):139–42.

The patient should be thoroughly counselledbefore the operation.


See ‘Revision total knee replacement’ (p. 183).

SURGICAL TECHNIQUE

This depends on indication, type of fixation andneed for bone grafting.


A longitudinal, anterior midline incision is used,usually through a previous total knee replacementscar.

Dissection

The quadriceps tendon and patella tendon aresplit and a patellectomy performed. Asynovectomy can be carried out and ligamentsreleased or divided to gain exposure.

Procedure

The goals of arthrodesis are pain relief, eradicationof infection and sound bony fusion in the correctalignment. In order to achieve these goals theimportant factors are: good apposition of healthybone surfaces, preservation of bone stock andstable fixation with compression.

Implants are removed as described in thesection ‘Revision total knee replacement’ (p. 185).It is important to preserve as much bone aspossible. Bone surfaces must be viable. In thepresence of infection, it is usually desirable toperform a two-stage procedure with the firststage involving thorough debridement, insertionof an antibiotic-impregnated cement spacer andtemporary fixation. Second stage involves thedefinitive arthrodesis. This is commonly achievedin one of two ways.

External fixationThe tibia is cut perpendicular to the long axis. Thefemur is cut to enable apposition at

Viva questions 199

Viva questions

1. What are the risks and complications of totalknee arthroplasty?

2. What are the contraindications to total kneereplacement?

3. Which total knee replacement would youchoose and why?

4. Discuss the advantages and disadvantages ofposterior collateral ligament retaining andsacrificing total knee replacement.

5. Describe how you would address an imbalancein flexion/extension gaps.

6. What releases would you perform to correctalignment in a valgus knee?

7. How do you deal with a fixed flexion deformityduring total knee replacement?

8. What measures do you take to ensure correctpatella tracking in primary total kneereplacement?

9. How would you manage a patient with apainful knee replacement?

10. Describe the modes of failure of total kneereplacement.

11. What extensile approaches are available inrevision knee arthroplasty?

12. What is your rationale for choosing an implantin revision knee arthroplasty?

13. What are the treatment options for a 50-year-old man with medial compartmentosteoarthritis?

14. What criteria need to be met for a medialunicompartmental knee replacement?

15. How would you select the ideal patient for apatellofemoral replacement?

16. How would you ensure adequate realignmentin proximal tibial osteotomy?

17. Why is a distal femoral osteotomy preferred toproximal tibial osteotomy in a valgus knee?

18. Discuss the pros and cons of opening versusclosing wedge proximal tibial osteotomy.

19. What are the indications for knee arthrodesis?

20. Describe the general principles and fixationoptions in arthrodesis.

Soft tissue surgery of the knee12

Jonathan Miles and Richard Carrington

Knee arthroscopy 200Arthroscopic meniscal knee surgery 204Lateral patellar retinaculum release 207

Cartilage reconstruction surgery 208Anterior cruciate ligament reconstruction 210Viva questions 216

KNEE ARTHROSCOPY


Indications

Knee arthroscopy is used as a diagnostic andinterventional tool in a wide variety of conditions.Because of advances in other imaging modalities,particularly magnetic resonance imaging (MRI), itis becoming less common for arthroscopy to beused for diagnosis alone. The frequent indicationsinclude:• Meniscal tears• Cruciate ligament injury• Chondral defects• Removal of loose bodies• Washout of sepsis• Synovectomy, including cases of pigmented

villonodular synovitis• Patella realignment procedures• Intra-articular knee fracture assessment and

reduction.

Contraindications

• Infection – particularly cellulitis over thepotential portal sites

• Ankylosis of the knee• Rupture of the joint capsule (allows

extravasation of the irrigation fluid).

Operative planning

Any preoperative imaging should be available.Appropriate instrumentation should be availableand checked by the surgeon, including thearthroscope, camera, light lead, arthroscopicinstruments, irrigation fluid pump and the ‘stack’,which must include a functioning light source andmonitor. The arthroscope used for kneearthroscopy has a 4 mm diameter and 30° viewingangle.


Anaesthesia is usually general, though regionalanaesthesia is acceptable. The position is supine. Aside support can be used, at the level of the upperto mid thigh, to provide a lever when opening upthe medial compartment.

Consent and risks

• Venous thromboembolism: <1 per cent• Septic arthritis: <1 per cent• Superficial wound infection: <1 per cent• Neuropraxia (secondary to tourniquet use): <1

per cent• Effusion: virtually universal and can last for

several months

Range ofmotion

Position ofarthrodesis

Flexion 0° 0–20°

Extension 140° (10° ext rot)

An appropriately padded tourniquet is appliedand inflated at the level of the upper thigh. If thepatient is hirsute, the anterior knee is shaved. Thesurgical field is prepared with a germicidalsolution. Waterproof drapes are used withadhesive edges to provide a seal to the skin. Thefoot and lower leg are covered with a stockinette.The arthroscope is connected to the camera andlight source. With the arthroscope applied againsta clean white swab, the white balance buttonis pushed to prevent colour casts (unwantedcolour tints affecting the picture) during thearthroscopy.

SURGICAL TECHNIQUE


The first stage of any arthroscopy is vital andoccurs before any incision is made. The knee isassessed for its full range of movement (whichincludes any hyperextension) and stability of itsligaments. The patella height and tracking arenoted.

Landmarks

The patella, patella tendon, medial and lateraljoint lines are palpated carefully with the knee inaround 70° of flexion.

Portals

All arthroscopy requires at least two portals withby far the most common two being theanterolateral and anteromedial portals (Fig. 12.1).The anterolateral portal is almost always createdfirst and other portals can be created under directvision.

The anterolateral portal is created 1 cm abovethe lateral joint line and 1 cm lateral to the lateralborder of the patellar tendon. This corresponds toa level just below the inferior pole of the patella.It can be palpated by pushing a thumb against theangle between the lateral border of the patella andthe anterolateral border of the upper tibia. If thethumb is left on the upper tibial border, theincision can be made just above the thumb toguide the surgeon to the correct position. It is bestdone with a pointed, rather than curved, blade,

with the blade facing away from the patellatendon. A vertical incision or horizontal incision isacceptable. If using a horizontal incision, once theskin is breached the blade is turned to facevertically upwards to perform the capsulotomy.This reduces the risk of damaging the lateralmeniscus.

The anteromedial portal is created under directvision with the arthroscope viewing the medialcompartment. It lies 1 cm above the medial jointline and 1 cm medial to the medial border of thepatellar tendon. A 16G needle is inserted at thispoint, facing slightly downwards towards the tibia.This can be visualized directly to ensure that itexits just above the medial meniscus. If it doesnot, it can be withdrawn and replaced correctly.Once the correct entry point has been identified,the needle is withdrawn and the scalpel used toenlarge the portal in the same fashion as theanterolateral portal.

The superomedial portal is 2 cm above thesuperior pole of the patella, in line with themedial border of the patella. It was historicallyused for an outflow cannula. These are rarely usednow, as modern pumps obviate their use.

Knee arthroscopy 201

Anteromedialportal

Anterolateralportal

Anterolateralportal

Fig. 12.1 The three common knee arthroscopy portals

The superolateral portal is 2 cm above thesuperior pole of the patella, in line with the lateralborder of the patella. It can be used insuprapatellar synovectomy or in surgery forpatellar maltracking.

The posteromedial portal is 1 cm above theposteromedial joint line, in line with the lateralborder of the medial femoral condyle. Thisrepresents the ‘soft spot’ between the tendonof semimembranosus, the medial head ofgastrocnemius and the medial collateral ligament.The portal is created with the knee in 90° flexion,allowing the saphenous nerve to fall out of thesurgical field. It can be used to visualize theposterior cruciate ligament (PCL) or posteriorhorn of the medial meniscus or in totalsynovectomy of the knee. It utilizes a longitudinalskin incision to avoid neurovascular damage.Following skin incision, an artery clip is used todissect down to and through the capsule.

The posterolateral portal is placed in a softpoint between the lateral head of gastrocnemius,the lateral collateral ligament and theposterolateral tibial plateau. It is very infrequentlyused, but can be used to visualize the posteriorhorn of the lateral meniscus or retrieve a loosebody from the posterior compartment of theknee. Again, a longitudinal incision is used.

Structures at risk

• Common peroneal nerve, running lateral to thelateral head of gastrocnemius, 15 mm below theportal

• Lateral superior and inferior geniculate arteries,passing just below and above the incision site,respectively

Structures at risk

• Sartorial branch of the saphenous nerve• Long saphenous vein: can be transilluminated by

the arthroscope to help its identificationThese structures pass together, approximately 1 cmbehind the portal incision.

202 Soft tissue surgery of the knee

Insertion of the arthroscope

This is the only step of arthroscopy which must becarried out blind: it must be done with great careto prevent gouging of the articular surfaces. Theanterolateral portal is created as described above.The trochar and sleeve are inserted at 70° of kneeflexion. Firm, gradual pressure is applied untilthere is a reduction in resistance, indicating thatthe trochar has passed through the joint capsule.At this point the knee is extended to around 20°of flexion and the trochar advanced, passingthrough the patellofemoral joint. Its intra-articularposition can be confirmed by sweeping thearthroscope gently from side to side – it can be feltto be beneath the patella. If it is outside the kneejoint, it will not sweep from side to side. Theposition of the arthroscope should be confirmedbefore removing the trochar, introducing thecamera and turning on the saline inflow.

Arthroscopic inspection of the knee

It is good practice to follow the same ‘route’around the knee as this helps to prevent anyomissions. It is the authors’ practice to address anypathology as it is located, rather than to proceedwith a full inspection before beginningintervention. Table 12.1 gives a suggested route,which many surgeons find the most effective one.

Closure

The portals are closed with either single nylonsutures or adhesive paper stitches. Adhesivedressings then wool and crepe are applied beforethe tourniquet is deflated.

POSTOPERATIVE CARE

Weightbearing mobilisation is begun early,together with range of motion exercises. Anti-thromboembolism stockings are recommended

Structures at risk

• Articular cartilage• Anterior horn of lateral meniscus

Knee arthroscopy 203Table 12.1 Arthroscopic inspection of the knee

Step Area of inspection Position of knee Position of arthroscope Structures to inspect Technical notes1 Suprapatellar pouch 20° flexion Upright/upside down Synovium; loose bodies Turning the arthroscope through all angles

allows visualization of the synoviumthroughout the whole cavity

2 Lateral gutter 20° flexion Upright Loose bodies Best inspected at this stage so that it isnot forgotten after tibiofemoral jointinspection

3 Patellofemoral joint 20° flexion Upright/upside down Medial + lateral patellafacets; synovial plica;trochlea; patella tracking

The arthroscope is turned upside down toinspect the patellar cartilage and keptupright to view the trochlea. It must bewithdrawn to just inferior to the patellato view tracking

4 Medial gutter 20° flexion Upright Loose bodies

5 Medial compartment 90° flexion initially30° flexion to view theposterior horn

Normal/viewing laterallyto improve visualizationof the posterior horn

Medial femoral condyle;medial tibial plateau;medial meniscus; loosebodies; creation of medialportal

Viewing the posterior horn is easier withthe knee straighter and with thearthroscope swung to look laterally

6 Intercondylar notch 90° flexion Upright Anterior cruciate ligament(ACL); posterior cruciateligament; loose bodies;both posterior horns

In ACL surgery, the portals are created alittle closer to the patella tendon toimprove access to the notch

7 Lateral compartment Figure-four position Upright/viewing medially Lateral femoral condyle;lateral tibial plateau;lateral meniscus; loosebodies; popliteus tendon

Move the knee into the figure-fourposition with the arthroscope in the notch(Fig. 12.2). Drive into the lateralcompartment as it opens and comes intoview.

for 6 weeks. The wool and crepe are removed 24hours after surgery, to increase mobility. Suturesare removed at 10–14 days after surgery.


Jaureguito JW, Greenwald AE, Wilcox JF, et al.The incidence of deep venous thrombosis afterarthroscopic knee surgery. Am J Sports Med1999;27:707–10.Kim SJ, Kim HJ. High portal: practical philosophyfor positioning portals in knee arthroscopy.Arthroscopy 2001;17:333–7.Kramer DE, Bahk MS, Cascio BM, et al. Posteriorknee arthroscopy: anatomy, technique, applica -tion. J Bone Joint Surg Am 2006;88:110–21.

Moseley JB, O’Malley K, Petersen NJ, et al. Acontrolled trial of arthroscopic surgery for osteo -arthritis of the knee. N Engl J Med 2002;347:81–8.

ARTHROSCOPIC MENISCAL KNEESURGERY


See ‘Knee arthroscopy’ (p. 200) for further detailsof consent and operative planning, as well aspostoperative care.

Indications

• Acute tears of the meniscus – radial,longitudinal, complex and bucket-handle forms(Fig. 12.3)

• Degenerative tears of the meniscus (commonlyposterior horn of medial meniscus)

• Meniscal repair – in non-degenerative,longitudinal tears within 3 mm of the periphery(i.e. within the vascular zone of the meniscus).

SURGICAL TECHNIQUE

Partial menisectomy

Partial menisectomy is the most commonprocedure performed by trainees throughout thedeveloped world and is considered a required skillby trainers and programme directors. It must bepart of a full diagnostic arthroscopy, as describedin the previous section.


Fig. 12.2 The figure-four position for lateralcompartment viewing

Bucket-handle tearRadial tear Longitudinal tear

Fig. 12.3 The common forms of acute meniscal tear

Initial inspection of the meniscus can oftenreveal the presence, though not extent of a tear.The smooth outline of the meniscus will be lost.The first stage is to probe the meniscus with anarthroscopic probe. The probe is inserted underthe meniscus and the hook turned to pointupwards, into the meniscus; the probe iswithdrawn and will catch any inferior tear thatwas not previously visible.

Large posterior horn tears and even displacedbucket-handle tears can flip into the intercondylarnotch and will not be seen unless specificallylooked for in the posterior part of the notch. Usingthe probe, the surgeon can determine the extentof the tear and decide on the boundary betweenunstable, torn meniscal remnants and well-fixed,stable, meniscal rim (Fig. 12.4).

The meniscus can be resected using a numberof instruments. The author prefers to use simplepunches for the majority of the resection and usean arthroscopic shaver to smooth over the finalremnant. An ‘upbiter’ is very useful duringresection of very posterior tears, particularly of themedial meniscus (Fig. 12.5).

The resection should be careful andmethodical, leaving all stable meniscus behind.After resection, the meniscus must be probedagain to ascertain that all remaining meniscus isstable.

Bucket-handle tear surgery

A bucket-handle tear is a large, longitudinal tear inwhich the internal portion is mobile and can flipover and become stuck in the intercondylar notch.It is three times as common in the medial as thelateral meniscus. The following discussion uses themedial meniscus as an example, though theprinciples are transferrable to the lateral meniscus.

Entry of the arthroscope into the medialcompartment can be difficult. Careful creation ofan anteromedial portal, as described, isrecommended, followed by use of a probethrough this portal to gently push the displacedfragment medially. This will usually afford a goodview. Assessment can be made as to whether thetear is repairable (see the following section).

A probe is used to define the attachments of thetear, both posteriorly and anteriorly (Fig. 12.6). Apunch is used to detach 90 per cent of the tear at

Arthroscopic meniscal knee surgery 205

Medial femoralcondyle

Torn medialmeniscus

Arthroscopichook probe

Medial tibial plateau

Fig. 12.4 Use of an arthroscopic probe to show ahorizontal tear

Posteriorresection

Bucket handle tear

Anteriorresection line

Fig. 12.6 Resection points of a bucket-handle medialmeniscal tear.

Fig. 12.5 An ‘upbiter’ is useful in posterior hornresection

its posterior origin. It is easiest to do this with anupbiter curved to the left for a left medialmeniscus and to the right for a right medialmeniscus. A straight punch or side-biter is used toresect completely through the anteriorattachment. A strong, locking arthroscopic grasperis introduced through the medial portal andlocked onto the middle of the torn remnant. Theremnant is removed with a ‘crocodile roll’ – thegraspers are rolled over several times whilecarefully watching with the arthroscope.

Once the meniscal remnant has been freed, it isremoved through the medial portal. In large tears,this portal often requires enlargement. Carefulinspection of the meniscal remnant is carried out,with debridement of any further unstable tissue.

Meniscal repair

Repair is possible if the tear is within 5 mm of theperiphery, but more commonly undertaken if thetear is within 3 mm of the periphery, i.e. withinthe vascular zone. In order to be worthy of repair,the tear should be between 8 mm and 30 mm long.

The results of meniscal repair are better inpatients with a concurrent anterior cruciateligament (ACL) reconstruction than in repairalone. Repair should not be undertaken in a kneewith ligament injury that has not been repaired. Avariety of methods are described includingoutside-in, inside-out and all-inside suturing (Fig.12.7). In addition, meniscal darts can be used. Thedetails of this surgery are beyond the scope of thisbook. Sutures are placed, usually vertically, about3–4 mm apart from each other.

Most surgeons recommended avoidance ofweightbearing for around 4 weeks after surgery,particularly avoiding weightbearing in flexion.

Discoid meniscus surgery

Discoid malformation more frequently affects thelateral meniscus and is bilateral in one-fifth ofcases. The majority are stable, i.e. have peripheralattachments to the rim. These are treated bypartial menisectomy, if symptomatic, to create amore normal meniscus.

If a discoid meniscus becomes suddenly painful,it is likely that it is torn and should be examinedand treated as such. The rarer unstable, orWrisberg variant, discoid meniscus is hypermobiledue to absent peripheral attachments. These areusually treated by complete excision as there is nostable rim to leave in situ.

POSTOPERATIVE CARE

See ‘Knee arthroscopy’ (p. 200).Meniscal repair has a more controversial

rehabilitation regimen. The author uses a brace,limited to 0–60° range for 1 month then full rangeof motion within the brace for a further 2 months.Return to sports is gradual following the initial 3months in the knee brace.


Fabricant PD, Jokl P. Surgical outcomes afterarthroscopic partial meniscectomy. J Am AcadOrthop Surg 2007;15:647–53.


(a) (b) (c)

Fig. 12.7 Meniscal repair: (a) outside-in; (b) inside-out; and (c) all-inside technique

Min S, Kim J, Kim LM, et al. Correlation betweentype of discoid lateral menisci and tear pattern.Knee Surg Sports Traumatol Arthrosc2004;10:218–22.Rankin CC, Lintner DM, Noble PC, et al. Abiomechanical analysis of meniscal repairtechniques. Am J Sports Med 2002;30:492–7.

LATERAL PATELLAR RETINACULUMRELEASE


Indications

Lateral release of the patella is indicated inpatients with a tight lateral patellar retinaculumwho meet the following criteria:• Anterior knee pain• Positive patella tilt test – less than 5°• Failure of conservative measures, including

physiotherapy specifically to strengthen thequadriceps and hamstrings.

Associated conditions that may worsen thesymptoms include chondromalacia patellae,patella alta, abnormal Q angle and trochlearhypoplasia, but these alone are not sufficientto perform a lateral release. In cases ofmalalignment, it may need to be combined withmore advanced procedures, including osteotomyor tibial tubercle transfer. It can also be performedin conjunction with medial patellofemoralligament reconstruction and vastus medialisadvancement.

Contraindications

Lateral release is not indicated in patients withgeneralized hypermobility or patellar hyper -mobility – it will worsen the symptoms.

Operative planning

Very careful history and examination is requiredto elucidate the features. Plain radiography,including patella views, is essential. Ifmalalignment is suspected, reconstructioncomputed tomography is useful.


See ‘Knee arthroscopy’ (p. 200).

SURGICAL TECHNIQUE

Open lateral release

Landmarks• Lateral border of the patella• Gerdy’s tubercle (insertion of the iliotibial band

on the lateral tibia).

IncisionA straight incision is created 1 cm from the lateralborder of the patella, running from the level of thesuperior pole of the patella to 1 cm above Gerdy’stubercle. The incision is carried down to thelateral retinaculum.

TechniqueThe superficial lateral retinaculum is incised inline with the skin incision. The deeper fibres andsynovium are not incised. The surgeon nowassesses whether the release has been sufficient. Ifthe patella is now able to be tilted 45° or morelaterally it is sufficient.

If the release is insufficient, the superficialretinaculum is dissected off the deep retinaculumfor 2 cm on the lateral side of the incision. Thedeep retinaculum can now be incised parallel tothe superficial retinacular incision but 2 cmfurther lateral. If this is required, the lateralportion of the superficial retinaculum is suturedto the medial edge of the deep retinaculum – thishelps to lessen haemarthrosis.

ClosureThe subcutaneous fat is opposed with interruptedsutures and the skin closed with the surgeons

Consent and risks

• The complications are essentially those of anyknee surgery: bleeding, infection, thrombosis andnumbness, whether carried out open orarthroscopically

• Mention of haemarthrosis should be made inparticular as it is very common and can be major

• Medial subluxation is a rare, late complication

Lateral patellar retinaculum release 207

chosen method. Occlusive dressing and heavywool and crepe bandages are applied.

Arthroscopic lateral release

TechniqueA complete arthroscopy is carried out first – thelateral release is done last as it causes bleeding. Atourniquet is not used as it interferes with patellartracking and causes more bleeding postopera -tively.

A horizontal line is drawn laterally from thesuperior pole of the patella and another line 1 cmaway from the lateral border of the patella. Aneedle is inserted into the knee joint at the levelwhere these lines cross.

Release is carried out, with cautery, runningfrom the needle to the anterolateral portal; it iscontinued until subcutaneous fat is seen fromwithin the knee.

ClosureThe portals are closed with either single nylonsutures or adhesive paper stitches. Adhesivedressings then wool and crepe are applied.


Weightbearing is begun immediately. The wooland crepe are removed after 24–36 hours andrange of motion exercises are begun early (toprevent lateral adhesions within the knee). Thepatient is referred to physiotherapy to reinstatemedial quadriceps exercises.


Kolowich PA, Paulos LE, Rosenberg TD, et al.Lateral release of the patella: indications andcontraindications. Am J Sports Med 1990; 18:359–65.

Structures at risk

• The superior geniculate arteryThe needle serves as a proximal limit of the releaseto prevent damage to the artery and subsequentbleeding that cannot be controlled arthroscopically.

Mulford JS, Wakeley CJ, Eldridge JD. Assessmentand management of chronic patellofemoralinstability. J Bone Joint Surg Br 2007;89:709–16.

CARTILAGE RECONSTRUCTIONSURGERY


Indications

• Articular cartilage injury (most common on themedial femoral condyle)

• Osteochondritis dessicans (most common onthe lateral part of the medial femoral condyle)

• Atraumatic osteonecrosis of the knee.

Contraindications

• Degenerative knee changes – none of thetechniques developed to date are successful onosteoarthritic lesions

• Age over 55 years – poor cartilage regenerationand may be more suitable for arthroplastytechniques

• Active infection.

Operative planning

Details of previous imaging and surgery should beavailable. Suitable equipment for the chosentechnique of chondroplasty consists of:• Microfracture picks / K-wire (microfracture)• Plug harvest and implant equipment (mosaic -

plasty)• Chondrocytes (ACI).

Consent and risks

• As for ‘Knee arthroscopy’ (p. 200)• Unpredictable outcome (worse if longstanding

injury or high body mass index)• Donor site morbidity (mosaicplasty and

autologous chondrocytes transplants [autologouschondrocyte implantation; ACI])

• Need for second procedure (ACI)



See ‘Knee arthroscopy’ (p. 200).

SURGICAL TECHNIQUE

Debridement

• Simple removal of loose chondral material andsmoothing of the damaged edges.

• ‘Roughening’ of the underlying, subchondralbone may allow clot formation and encouragefibrocartilage formation.

• May be suitable for small lesions.

Microfracture

Following debridement, an awl is inserted into theipsilateral arthroscope portal and used to createmicrofractures in the subchondral bone at thedefect (Fig. 12.8). The microfractures are 5 mmapart and approximately 5 mm deep. This allowspenetration of the tidemark and the release ofpluripotential cells from the cancellous bone. Thisproduces a more pronounced and longer-lastinghealing response than abrasion alone and increasesthe prospect of fibrocartilage formation at thedefect.

Mosaicplasty

Small plug grafts are taken from a non-weightbearing area of the knee, typically the

peripheral areas of the superior trochlea, andgrafted into the defect until it is filled. Grafts aretaken with a core drill and are 4–8 mm indiameter and 20 mm deep. Matching cores areremoved from the defect and the graft plugsimpacted in a mosaic pattern (Fig. 12.9).

Care must be taken to leave the graft plugsflush with the surrounding cartilage. The defectsbetween the plugs fills in with fibrocartilage.Results are variable and highly dependent on theskill of the surgeon. There are questions over itsuse in defects over 4 cm2.

Autologous chondrocyte implantation

Autologous chondrocyte implantation isperformed as a two-stage procedure. The firststage is arthroscopic and includes a diagnosticarthroscopy and debridement of any chondralflaps around the area of chondral damage. Thisshould be done to provide a rim of stable orhealthy cartilage all around the lesion and isessential for attachment of the graft. At the end ofthe first stage arthroscopy, small segments ofhealthy cartilage are harvested from the outerborder of the anterosuperior femur, usually on themedial side of the trochlea. This is performed witha small gouge to loosen the segment and rongeursto retrieve it. A venous blood sample is taken toscreen for infectious diseases.

The chondrocytes can be prepared in a numberof ways and can be provided suspended in

Cartilage reconstruction surgery 209

Fig. 12.8 Microfracture of a chondral injury of themedial femoral condyle

Fig. 12.9 Femoral condylar defect treated withmosaicplasty

solution or can be implanted onto a membranousmatrix. This usually takes 3–6 weeks. The steps ofpreparation are similar in each technique:collagenases dissolve the matrix to leave thechondrocytes, then the cells are washed and put ina culture medium derived from the patient’sserum. The cells adhere to a culture surface andproliferate to provide a large number of healthychondrocytes.

The second procedure is carried out once thechondrocytes have been grown and returned. Thisis a larger procedure and is performed open. Theincision is dependent on the site: for example amedial femoral condyle defect requires an 8 cmmedial parapatellar incision. The defect is exposedand any further loose material is debrided. Thedefect is then covered with an appropriatelyshaped membrane which is stitched or glued inplace. If the cells are embedded on the membrane,this is the final stage; if the cells are in suspension,the liquid is injected under the membrane. Thewound is closed in layers.


Movement encourages chondrocyte growth, soafter ACI or mosaicplasty, the patient is rested forup to 2 weeks, in either a bulky dressing or acylinder plaster, then passive mobilization isbegun. In all cases, the patient is allowed to toe-touch weightbear for 6–8 weeks, to reduce theforce on the grafts. Running is not allowed for 6months and contact sports for 12 months afterACI or mosaicplasty.


Briggs TWR, Mahroof S, David LA, et al.Histological evaluation of chondral defects afterautologous chondrocyte implantation of the knee.J Bone Joint Surg Br 2003;85:1077–83.Hangody L, Kish G, Karpati Z, et al. Mosaicplastyfor the treatment of articular cartilage defects:application in clinical practice. Orthopaedics1998;21:751–6.Steadman JR, Briggs KK, Rodrigo JJ, et al.Outcomes of microfracture for traumaticchondral defects of the knee: average 11 yearfollow-up. Arthroscopy 2003;19:477–84.

ANTERIOR CRUCIATE LIGAMENTRECONSTRUCTION


Indications

Anterior cruciate ligament reconstruction isindicated in patients with symptomatic instabilityof the knee with a proven ACL rupture. Specificindications include:• High-level athlete (consider early reconstruc -

tion, without rehabilitation phase)• Inability to return to sports, particularly those

which involve twisting on a planted foot (e.g.rugby, football, racquet sports).

• Ongoing instability, giving way and painresistant to a dedicated ACL rehabilitationphysiotherapy programme.

Operative planning

Careful examination and judicious use ofinvestigations are essential, both to confirm thepresence of ACL rupture and to search forassociated injuries, particularly associatedligament injury. In many cases, surgery will havebeen preceded by a diagnostic arthroscopy andtreatment of any associated irreparable meniscaltear.

Consent and risks

• Knee stiffness (due to arthrofibrosis, inaccuratetunnel placement or insufficient notchplasty)

• Arthrofibrosis: more common if earlyreconstruction used, rather than delayed

• Knee pain• Kneeling difficulty (higher risk if bone–patellar-

tendon–bone (B-T-B) technique is used• Ongoing instability (11–25 per cent symptomatic,

60–89 per cent asymptomatic)• Failure to return to previous level of sport (up to

30 per cent)• Graft failure: impingement or enlargement of the

tunnel with time (typically 2 years)• Degeneration: found in 75 per cent of patients

beyond 10 years after surgery


The operation notes from prior surgery shouldbe available, along with results of previous MRIsor other imaging. If there is an associated meniscaltear, consideration should be given to concurrentrepair, as the results are improved in conjunctionwith ACL reconstruction.


General or regional anaesthesia is used. Thepatient is positioned supine with a side support orleg holder to hold the knee in supported flexion.

SURGICAL TECHNIQUE

The two common methods of reconstruction arewith a B-T-B graft or a hamstring tendon graft.The harvesting of both grafts is described, alongwith the method of reconstruction via an opentechnique with B-T-B and an arthroscopictechnique with the hamstrings graft.

As always, careful examination underanaesthesia is essential. The technique and portalsof the arthroscopy are in common with thatdescribed in the previous sections. It is wise tocarefully inspect the PCL and popliteus tendon incase of associated PCL or posterolateral cornerinjury.

B-T-B graft, open technique

LandmarksMidline – superior pole of the patella, tibialtuberosity.

Incision and dissectionA midline incision is created from the superiorpole of the patella to just below the tibialtuberosity. Dissection is continued to reveal theparatenon, which is then incised to expose thewhole of the patella tendon. The central portion(usually 10 mm unless it is a narrow tendon – inwhich case use one-third of its width) of thetendon is dissected free for its entire lengthbetween the patella and the tibial tuberosity.

This dissection is continued across the patellafor 30 mm proximally and the tibial tuberosity 30mm distally. These incisions mark the sites of bonecuts for harvesting of proximal and distal blocks(Fig. 12.10).

Procedure

With a 2 mm drill, drill two holes around 10 mmdeep, in the centre of each area of bone betweenthe dissected margins – these will be used to passsutures for control of the graft at insertion. Usinga narrow oscillating saw and then an osteotome(8–10 mm wide), dissect a block from the patellaof 25 mm length. The osteotomes are directed 45°towards the midline when performing the cuts, inorder to create a trapezoidal graft shape. Caremust be taken to avoid a graft which is too deep,risking subsequent patella fracture, or too thin,risking failure of fixation of the graft. The aim iscreation of a block 25 mm long, 8 mm wide and5–8 mm deep. The bone block is trimmed to auniform size and two heavy sutures are passedthrough the previously drilled holes.

The same technique is used to create two holesin and harvest the tuberosity bone block, which

Structures at risk

• Anterior horns of the medial and lateral menisci,just posterior to the fat pad

• PCL: the olive-tipped drill passes over the PCL inthe notch and it requires protection

Anterior cruciate ligament reconstruction 211

Patella

Tibialtubercle

Patellatendon

Fig. 12.10 Bone–patellar-tendon–bone graft harvest

should be of a similar size and shape. It is againtrimmed and one heavy suture passed throughone of the drilled holes (Fig. 12.11).

The graft is sized with a tunnel sizer, aiming fora snug but not too tight fit. If the grafts are ofsignificantly different sizes, different tunnelwidths can be used for the reconstruction; if thisis done the tibial tunnel must be the larger one.The length of the entire graft and width of thetwo bone blocks should be written down and thegraft wrapped in a saline-soaked gauze.

A self-retaining retractor is placed in the defectin the patella tendon, revealing the fat pad belowit. The fat pad is then excised, revealing a goodview of the notch and lateral wall of the notch (i.e.medial wall of the lateral femoral condyle) inparticular. The ACL remnant, if present, isexcised. It may be adherent to the PCL and caremust be taken to avoid damage to the PCL whenit is dissected free. The lateral wall is cleared ofany further soft tissues and the back of the lateralwall indentified with a hook.

To prepare the proximal tibia for tunnelcreation, the area of tibia medial to the patellatendon is exposed. Using subperiosteal dissectiongood bone exposure is obtained so that the tunneljig will not slip. The ACL tibial tunnel jig is set at50° and the aiming device placed at the posteriorACL stump, just anterior to the PCL. This is inline with the anterior attachment of the lateralmeniscus (Fig. 12.12).

An ACL guidewire is drilled, through the jig,entering the knee just in front of the medial tibialspine; the jig will sit just anterior to the PCL. Theguidewire is over-drilled with the tunnel drill ofappropriate size for the graft – the reamings aresaved to graft the patella defect from the graftharvest at the end of the procedure. A tunnel raspis used to smooth any sharp bone edges present at

the joint surface. A probe is used to carefullyidentify the posterior wall of the lateral femoralcondyle from within the notch. The guidewire ispassed through the tibial tunnel with the kneeflexed to 90° and drilled into the lateral wall ofthe notch at the isometric point of the ACL origin(Fig. 12.13). It is drilled through until it passesthrough the skin of the anterolateral thigh.

The position of the tunnel in the femur isabsolutely critical. Its position is as posterior aspossible without causing blowout of the posteriorwall. This can be guided using an ‘over the topguide’. These have an extension which passesaround the posterior margin of the lateral condyleand provides a measure for insertion of theguidewire into the lateral wall. For example, if thetunnel is to be 8 mm, the over the top guide willcreate an offset of 5 mm from the posterior wall.This will leave 1 mm of posterior wall behind the4 mm radius of the tunnel.

The position of the tunnel on the lateral wall istraditionally described by the position of the clockface. It is at 10.30 or 1.30 on the clock facedepending on whether it is the left or right knee.

The femoral tunnel is drilled with theappropriate sized tunnel drill passing over theguidewire (Fig. 12.14). The length of the tunnelshould be just over that of the length of the boneplug to be used in the tunnel – this is usually35 mm. Again, any graft is saved and any roughedges smoothed with a tunnel rasp.


Harvested patellar tendon

Drill holes in plugs

Fig. 12.11 The harvested bone–patellar-tendon–bonegraft

Posterior

Anterior

Lateralmeniscus

Medialmeniscus

Tibialtunnel

PCL

Anterior hornattachment

Fig. 12.12 Site of the tibial tunnel for anterior cruciateligament reconstruction. PCL, posterior cruciateligament

Returning to the graft, the junction of bone andtendon of the femoral block is marked with asurgical pen – the femoral block should be thesmaller of the two. The two strong sutures in thefemoral block are inserted into the eye of theguidewire and a Jacob chuck attached to the tip ofthe guidewire in front of the thigh. The guidewireis pulled through and the sutures recovered. Asecond suture is passed through the tibial boneblock – this should be either a strong, braidednon-absorbable suture or a steel wire.

The graft is firmly, but smoothly, pulled throughinto position, keeping the knee at 90° of flexion


(a) (b)

Fig. 12.13 The isometric point forthe femoral tunnel insertion: (a) anterior view; and (b) lateral view

Fig. 12.14 Drilling the femoral tunnel through the tibialtunnel

and the cortical margin of the graft facingposteriorly in the tunnel. Inspection within theknee will reveal when the marking on the femoralplug has reached the margin of the femoraltunnel. An interference screw guidewire is passedanterior to the graft within the femoral tunnel toa depth of at least 25 mm. An interference screwof appropriate size is then passed over theguidewire to secure the graft within the femur.The position and security is checked by cyclingthe knee through flexion and extension severaltimes.

The knee is held at 30–40° with the tibia inslight external rotation, to secure the graft in thetibia. While the graft is tensioned, a furtherinterference screw is inserted. The abolition of thepivot shift phenomenon can be checked at thisstage. The graft saved from the tunnels is packedinto the defects in the patella.

ClosureThe paratenon is closed with interrupted,absorbable sutures over the tendon. The tendonitself is not closed as this would shorten thepatella tendon. A small drain is inserted and theskin is closed. Adhesive dressings then a wool andcrepe dressing are applied.

HAMSTRING, ARTHROSCOPICTECHNIQUE

Landmarks

• Tibial tuberosity• Patellar tendon.

tendons themselves. Dissecting scissors are used todevelop the plane between the gracilis andsemitendinosus tendons and the underlyingmedial collateral ligament.

Procedure

The tendons are then pulled forward with thescissors and a tendon hook passed over them inturn. It is recommended that a length of surgicaltape is passed over semitendinosus, which is thenreleased but freely rediscovered via pulling on thetape.

The tendons of gracilis and semitendinosus aredissected free of soft tissue attachments in turn.The tendons are harvested in turn with a tendonstripper. The gracilis tendon is held taught and thestripper carefully pushed over it, keeping thestripper parallel to the tendon. It is advanced untilthe tendon is released from its muscle belly, andthen the same method is used to release thetendon of semitendinosus.

The tendons can then be dissected free of thepes medially, carefully preserving as much graftlength as possible. This will give a graft of twotendons which are joined at one end and free atthe other. Alternatively, the graft can be preparedin situ. Muscle tissue is scraped off the tendons.The two tendons are looped over a strong sutureand folded in half. The four strands are suturedtogether, using a whip stitch, for 30 mm at eitherend (Fig. 12.16). The graft is then tensioned, inorder to prevent stretching in situ. If a tensiometeris available, it is usually tensioned to 80 N (20 lb)for 10 minutes. Next, the graft is measured: mostare 8–10 mm, with 7 mm being a minimumacceptable diameter.

The knee is positioned in 90° of flexion. Thetibial jig is passed through the medial portal andpositioned as for B-T-B reconstruction, with itsaiming device passing through the previously



A diagnostic arthroscopy is carried out to identifyand treat associated injuries. The anteromedialportal is kept anterior, close to the patella tendon,in order to allow good visualization of the notch.The lateral wall is cleared with an arthroscopicshaver or a small curette. An arthroscopy hook isused to carefully identify the posterior wall.

A 50 mm incision, parallel with the patellartendon, is created 20 mm medial to the tibialtuberosity. It should begin 60 mm below the jointline. Fat and deep fascia are dissected to reveal thetendons of the pes anserinus (Fig. 12.15).

An incision is created over the upper border ofthe tendons, taking care not to damage the

Structure at risk

The sensory branch of the saphenous nerve canoften be seen traversing the wound at the site ofgraft harvesting – it should be preserved if possible.

Sartoriusmuscle

Gracilistendon

Semitendinosustendon

Pes anserinus

Fig. 12.15 Anatomy of the pes anserinus

Whip stitching

30 mm30 mmGraft

Fig. 12.16 Prepared hamstringgraft for anterior cruciateligament reconstruction

created graft harvest incision. With thearthroscope in the anterolateral portal, the tibialtunnel guidewire is inserted and its entry pointinto the knee confirmed to be within the posteriorportion of the tibial stump on the tibial surface.The tibial tunnel is then drilled and any debris atits entrance into the knee cleared with anarthroscopic shaver. The guidewire is then drilledinto the correct position in the lateral wall, as inthe B-T-B technique.. This is again drilled to30–35 mm depth, debris is removed and theposterior margin of the tunnel is checked.

The guidewire is threaded with the suturesfrom one end of the graft and pulled through theskin. The graft is pulled into place, until the 30mm of whip stitch has entered the femoral tunnel,as viewed with the arthroscope. The graft can befixed in situ with an interference screw, with asimilar technique to that described in ‘B-T-B graft,open technique’ (p. 211).

Alternatively, a transfixion pin method can beused to introduce and fix the graft in the femoraltunnel. In this method a transfix guide is inserted 30mm into the femoral tunnel and the cannulatedguide is advanced to the lateral aspect of the thigh.The skin and iliotibial band are incised and thecannulated guide advanced to the lateral femur. ABeath pin is drilled through the guide, through thefemur and out through the medial skin. Thecannulated guide and sidearm are removed and thelateral cortex is drilled to accept the head of the

transfix screw. The Beath pin is left captured withinthe guide in the femoral tunnel. A thin wire ispassed over the end of the Beath pin and thenpulled through the femur and the guide, using ahandle attached to the Beath pin medially. Whenthe guide is pulled out of the femoral tunnel, theguidewire is pulled with it, through the tibial tunneland out of the anterior tibial cortex (Fig. 12.17).

The graft can be looped over the wire and thetwo ends of the wire pulled apart to introduce thegraft, through the tibial tunnel and into thefemoral tunnel. When the wire passes freely fromside to side, the graft has been fully advanced. Atransfix pin passed over the wire, which is heldtight, will now pass through the loop in the twograft strands, thus fixing it in the femoral tunnel(Fig. 12.18).

The position of the graft is checkedarthroscopically and the graft fixed in the tibialtunnel as described in ‘B-T-B graft, opentechnique’ (p. 211).

Closure

Closure of wounds is with a combination ofinterrupted, absorbable deep sutures and thesurgeon’s chosen skin closure. The arthroscopyportals and exit wounds of guidewires can beclosed with adhesive paper closure sutures alone.Adhesive dressings and a wool and crepe dressingare applied.


(a) (b) (c)

Fig. 12.17 (a) Wire is advanced through femoral tunnel, (b) graft introduced into the femur and (c) transfix pinpassed through the graft


The patient is not put into a brace, rather earlysupervised range of motion exercises are begun. Adrain, if used, is removed at 24 hours after surgery.At this time the bulky dressing is removed, leavingadhesive dressings over the wounds. With the aidof a physiotherapist, range of motion exercises arebegun. The patient can be discharged once theyhave achieved a range from 0–90°. The woundsare inspected and sutures removed at 2 weeksafter surgery.

The physiotherapist supervises gentle exercise,using closed chain exercises only for the first 6weeks. After 6 weeks, the use of a rowing machineand exercise bike is permitted. The range ofmotion is increased up to full at around 12 weeks.After this period more aggressive exercise canbegin. Running is not permitted for the first 3months and contact sports not for the first 8months after surgery. The use of proprioceptiveexercises is encouraged and maintenance exercises


used to keep the thigh and calf musculatureoptimal.


Frank CB, Jackson DW. Current concepts review –the science of reconstruction of the anteriorcruciate ligament. J Bone Joint Surg Am1997;79:1556–76.Salmon LJ, Russell VJ, Refshauge K, et al. Longterm outcome of endoscopic anterior cruciateligament reconstruction with patellar tendonautograft. Am J Sports Med 2006;34:721–32.Williams RJ, Hyman J, Petrigliano F, et al. Anteriorcruciate ligament reconstruction with a four-strand hamstring tendon autograft. J Bone JointSurg Am 2004;86:225–32.Woo SL, Kanamori A, Zeminski J, et al. Theeffectiveness of reconstruction of the anteriorcruciate ligament with hamstrings and patellartendon: a cadaveric study comparing anteriortibial and rotational loads. J Bone Joint Surg Am2002;84:907–14.

Viva questions

1. What equipment is required to perform adiagnostic arthroscopy?

2. Define the anatomy of the posterior kneearthroscopy portals.

3. Which structures are at risk in the posteriorportals for knee arthroscopy?

4. What are the indications for meniscal repair?

5. Which techniques do you know for meniscalrepair?

6. How are discoid lateral menisci classified?

7. What treatment do you use for a discoid lateralmeniscus?

8. Which associated anatomical findings worsen atight lateral retinaculum?

9. What are the advantages and disadvantages ofarthroscopic over open lateral release?

10. What are the common indications for cartilagereconstruction surgery?

11. Describe the procedure of microplasty to themedial femoral condyle.

12. What are the advantages of autologouschondrocyte implantation over microplasty?

13. How are the cells provided for autologouschondrocyte implantation?

14. What risks do you describe to a patientconsenting for anterior cruciate ligamentreconstruction?

15. Describe the anatomy of the pes anserinus.

16. How are the hamstrings harvested for ananterior cruciate ligament graft?

17. What is the minimal acceptable graft thicknessfor anterior cruciate ligament reconstruction?

Viva questions 217

18. Where are the isometric points for the originand insertion of an anterior cruciate ligamentgraft?

19. What position is the knee held in while ananterior cruciate ligament graft is tensionedand fixed?

20. Describe your postoperative regimen afteranterior cruciate ligament reconstruction.

Surgery of the ankle13

Laurence James and Dishan Singh

Ankle arthrodesis 218Ankle arthroplasty 220Ankle arthroscopy 222

Surgery for Achilles tendinopathy 224Surgery for peroneal tendinopathy 226Viva questions 228

ANKLE ARTHRODESIS


Indications

• Arthropathy failing conservative management• Failed arthroplasty• Tumour reconstruction• Sequelae of infection, particularly tuberculosis• Avascular necrosis of talus• Neuropathic joint• Neurological conditions (resulting in insta -

bility).

Contraindications

• Infection• Degeneration of subtalar and midfoot joints.

Operative planning

Planning of the position of fusion is vital. Theposition is:• 0° dorsiflexion• 0–5° valgus hindfoot (varus positioning restricts

midtarsal mobility)• 5–10° external rotation (note: observe

contralateral limb).

Posterior displacement of the talus allows forgreater ease of ‘rollover’ at the end of the stancephase.


This is performed as for ankle replacement.

Consent and risks

• Failure of fusion: <2 per cent• Malpositioning• Metalwork prominence: may require further

surgery• Nerve injury is rareThe patient must understand that walking will notreturn to normal. There is a significant reduction inwalking speed and increase in energy expenditurecompared with normal.


• Neutral flexion• 0–5° valgus• 5–10° external rotation

Movement Range of motionDorsiflexion 0–20°

Plantarflexion 0–45°

SURGICAL TECHNIQUE

Arthrodesis can be performed arthroscopically(see ‘Ankle arthroscopy’, p. 223), or via anterior(see ‘Ankle arthroscopy’, p. 221) and lateraltransmalleolar open approaches. Internal fixationwith screws, intramedullary nails and plates areused to give a good hold and adequatecompression (Fig. 13.1). Thorough preparation ofall joint surfaces is vital. This is achieved byremoval of remaining articular cartilage andexposure of subchondral bleeding cancellous boneto aid biological union.

For surgical principles of joint surfacepreparation (see Chapter 14).

Lateral transmalleolar approach

Landmarks• Tip, anterior and posterior border of fibula• Base of fourth metatarsal• Anterior to sural nerve.

DissectionA longitudinal incision is made directly overlateral aspect of fibula, of sufficient length to avoidtension on the soft tissue flap. Distally the incisionis angled toward the base of the fourth metatarsalto allow greater access to the ankle joint.

Procedure

Subperiosteal dissection of the fibula is carried out,protecting the peroneal tendons posteriorly anddistally at all times. This also avoids damage to thesural nerve. The joint line is identified, using animage intensifier, and is marked on the skin. Thefibula is cut obliquely with a saw (superolateral toinferomedial ending at the level of the tibialplafond) and finished with an osteotome. Thefree distal end of the fibula is then reflectedinferiorly and freed of soft tissues andligamentous attachments. Care is taken not todivide the peroneal tendons at the tip of the distalfibula. Capsulotomy then allows access to jointsurface. The bone of the distal fibula can then beused to harvest cancellous bone graft and thesurgeon’s choice of fixation is performed. For anisolated ankle fusion, with good quality bone,cannulated screws can be used. For poorer qualitybone, or if the subtalar joint is to be included, aretrograde (pantalar) nail is a better choice (Fig.13.2).

Structures at risk

• Peroneal tendons• Sural nerve

Ankle arthrodesis 219

Anklefusion

Figure 13.1 Arthrodesis with screw fixation Figure 13.2 Arthrodesis with nail fixation

Closure

A layered closure is followed by the surgeon’schoice of skin closure for open techniques. Nylonto skin is used to close arthroscopic fusion portals.


Thromboembolism should be prevented by earlymobilization and the addition of chemical ormechanical measures in patients at increased risk.Two more doses of the antibiotic given atinduction should be given at 8 hours and 16 hoursafter surgery.

Early mobilization is non-weightbearing, withthe aid of crutches. Radiographic signs of unionare sought before unprotected full weightbearingis allowed; this often takes around 3 months.


Buck P, Morrey BF, Chao EY. The optimumposition of arthrodesis of the ankle. J Bone JointSurg Am 1987;69:1052–62.Kitaoka HB, Patzer GL, Felix NA. Arthrodesis forthe treatment of arthrosis of the ankle andosteonecrosis of the talus. J Bone Joint Surg Am1998;80:370–9.Mann RA. Arthrodesis of the foot and ankle. InRA Mann and MJ Coughlin (eds). Surgery of theFoot and Ankle. St Louis: Mosby Year Book, 1993.Mann R, Rongstad AM. Arthrodesis of the ankle: acritical analysis. Foot Ankle Int 1998;19:3–9.Scranton PE. An overview of ankle arthrodesis.Clin Orthop Relat Res 1991;268:268–96.

ANKLE ARTHROPLASTY


Indications

Total ankle arthroplasty is indicated in painfulconditions that have failed conservativemanagement. The most frequent indications are:• Osteoarthritis• Inflammatory arthritis and other arthropathies.

Contraindications

• Ankle joint infection• Avascular necrosis of a large part of the talar

body• Severe deformity that would not allow for good

biomechanical function and lead to greaterwear of the ultrahigh molecular weightpolyethylene (UHMWPE) insert (greater the15° varus/valgus deformity)

• Poor soft tissues• Heavy manual occupation.

Operative planning

Assessment of the soft tissues, as well as vascularand neurological examination are mandatory onthe day of surgery. Recent weightbearingradiographs must be available.

Availability of the implants and operative setsmust be checked by the surgeon. Prophylacticantibiotics are administered on induction (theantibiotic of choice depends on local policy, but acommon choice is cefuroxime).


Anaesthesia is usually general, regional orcombined. A thigh tourniquet is used. The supineposition is used with appropriate padding wherenecessary. Occasionally a sand bag under theipsilateral buttock allows for greater ease ofsurgery. The knee should always be exposed andprepared (with a germicidal solution) to allow forintraoperative orientation of the implant.

The ankle should be sufficiently mobile forappropriate movement intraoperatively. Water -

Consent and risks

• Loosening: revision surgery is required forloosening in up to 10 per cent at 10 years(approximately).

• Malpositioning• Fracture: up to 10 per cent though they fare well

with appropriate identification and management.• Wound problems, pain and stiffness: 5 per cent• Deep vein thrombosis (DVT)/pulmonary

embolism/infection: 1 per cent

220 Surgery of the ankle

proof drapes are used with adhesive edges toprovide a seal to the skin.

SURGICAL TECHNIQUE

Landmarks

These should be marked preoperatively:• Tendons – tibialis anterior, extensor hallucis

longus, extensor digitorum longus• Dorsalis pedis – note: this is absent in 10 per

cent of the population• Cutaneous branches of the superficial peroneal

nerve (variable course).

Incision

The anterior approach to the ankle is used. Theskin is incised in the midpoint between the medialand lateral malleoli – from 3 cm above, extending5 cm below the palpable ankle joint and avoidingcutaneous nerves where encountered.

Dissection

The extensor retinaculum is divided in the lineof the incision. Large skin flaps are avoidedto reduce the risk of necrosis. The approach isthen developed either between the extensorhallucis longus (EHL) and the extensor digitorumlongus (EDL) or (more commonly) between thetibialis anterior and the EHL. The key isprotecting the dorsalis pedis artery and deepperoneal nerve – identification (and protection) ofthese structures more proximally, before theycross at the ankle joint itself may be required. Alongitudinal capsulotomy is then performed.

Procedure

Several ankle prostheses are commerciallyavailable and the individual operative techniqueshould be referred to. Although the designs vary,the principles of adequate bone preparation and

Structures at risk

• Dorsalis pedis artery• Deep peroneal nerve

implant positioning are the same. In general terms,an extramedullary guide is placed on the anteriorsurface of the tibia, in line with the crest andpassing though the line of the second metatarsalray distally – anatomical axis. This is strapped inplace. The joint line is then identified and a fin isplaced between the talus and tibia through thecentre of the cutting block. Pins are used to fix thecutting guide to the tibia. This block ensuresparallel cuts in the distal tibia and talar dome,without altering the joint line height –approximately 2–3 mm is resected from eachsurface. Guides then size the tibial and talarcomponents, such that an appropriate sizedwindow and accurate anterior and posteriorchamfer cuts are made to the tibia and talus,respectively. Trial components and spacer (toassess stability and range of movement) are usedprior to actual prosthesis placement.

Pitfalls to avoid include:• Varus/valgus positioning of tibial and talar

cutting guides, which can also lead to abnormalsaggital plane tilting – early loosening.

• Anterior/posterior placement of talar or tibialcomponents – early loosening.

• Notching of medial and lateral malleoli duringtibial cuts – fracture.

• Fracture of the anterior tibial cortex whencreating window to allow for tibial post duringinsertion of component.

Newer-generation systems are uncementedwith three components (semi-constrained/mobilebearing), thus minimizing bone loss, stressesacross components and early failure. Commonlyused prostheses include: STAR (ScandinavianTotal Ankle Replacement), Beuchal–Pappas,Ramses and Agility.


Patients are placed in a non-weightbearing, belowknee plaster of Paris (changed at 2 weeks forwound inspection). Adequate pain relief and DVTprophylaxis are planned prior to departure fromtheatre.

Physiotherapy is commenced within 24–48hours. Patients commence weightbearing after4–6 weeks following clinical and X-ray review.

Ankle arthroplasty 221

A return to work (and driving) would beexpected after 3 months. Follow up isrecommended at 6 weeks, 6 months and 1 yearafter surgery. Continuation of follow up istypically at 5 years, 10 years, 15 years then atyearly intervals. The patient should be cautionedto return to clinic if there is pain or functionaldeterioration.


Carachiolo B. Design features of current totalankle replacements: implants and instruments. JAm Acad Orthop Surg 2008;19:530–40.Hopgood P, Kumar R, Wood PL. Arthrodesis forfailed ankle replacement. J Bone Joint Surg Br2006;88:1032–8.Spirt AA, Assal M, Hansen ST Jr. Complicationsand failure after total ankle arthroplasty. J BoneJoint Surg Am 2004;86:1172–8.Wood PL, Deakin S. Total ankle replacement: theresults in 200 ankles. J Bone Joint Surg Br2003;85:334–41.

ANKLE ARTHROSCOPY


Indications

• Undiagnosed ankle pain in the young• Osteoarthritis• Osteochondral defect• Removal of loose bodies• Synovectomy or synovial biopsy• Impingement syndromes (bony and soft tissue)• Arthrofibrosis (e.g. post traumatic)• Fracture• Meniscoid lesions• Septic arthritis.

Contraindications

• Infection of overlying skin• Lack of proper instrumentation• Gross osteoarthritis is a relative contra indica -

tion• Severe oedema.

Operative planning

It is vital that the patient is examined beforetransfer to theatre. This allows for identification andmarking of structures vulnerable to damage duringportal insertion intraoperatively. These include:• Tibialis anterior and EHL tendons• Dorsalis pedis artery and associated deep

peroneal nerve• Traction on second and fourth toes usually

demonstrates medial and lateral branches of thesuperficial peroneal nerve

• Saphenous vein and nerve• Medial and lateral malleoli.

Recent radiographs and, where taken, magneticresonance (MR) images, should be available.

The equipment must be available; this shouldbe checked by the surgeon. Usually a 2.7 mm 30°arthroscope and 3.5 mm shavers are required.Water pressure is set at 50 mmHg.


Anaesthesia is usually general with intraoperativelocal anaesthetic infiltration into the joint at theend of the procedure. The supine position is used,with the hip flexed and a well-padded supportunder the thigh. The ankle distractor is appliedwith the knee at 90° of flexion and the ankle in aneutral position. Adequate padding avoids damageto skin and neurological structures. Too muchtraction (>15 kg) and excessive time can lead toirreversible nerve damage.

The surgical field is prepared with a germicidalsolution. Waterproof drapes are used withadhesive edges to provide a seal to the skin.

SURGICAL TECHNIQUE

The ankle joint is filled with 20 mL of saline to aidaccess and avoid chondral surface damage. Smalllongitudinal skin incisions are made, then blunt

Consent and risks

• Nerve injury: <1 per cent• Vascular injury: <1 per cent• Infection: <1 per cent. Risk is very low, so

prophylactic antibiotics are not recommended


dissection (with a clip) used to breech the anklejoint, thereby avoiding damage to the superficialnerves – unlike knee arthroscopy where a blade ispassed directly into the joint.

Creation of portals

A number of portal sites are described (Fig. 13.3).The central anterior portal is best avoided becauseof a high risk of neurovascular damage.

Structures at risk

• Nerves: deep peroneal, superficial peronealbranches, sural, tibial

• Arteries: dorsalis pedis, posterior tibial artery

• Anteromedial portal – this lies medial to tibialisanterior. The joint line is initially identified bypalpation and then a white needle is insertedinto the joint to confirm the level. The needle isdirected slightly superiorly to pass over the talardome. The arthroscope and introducing trocharshould be able to be swept across the joint frommedial to lateral.

• Anterolateral portal – this lies lateral toextensor peroneus tertius and the neurovascularbundle (dorsalis pedis and deep peronealnerve), avoiding the superficial nerves markedout preoperatively. The light source within thejoint can be used as a guide, this will also helpto identify the dorsal lateral branch of thesuperficial peroneal nerve which is at risk. Awhite needle is inserted as outlined above

• Posterolateral portal – this is located lateral tothe Achilles tendon 1 cm above the tip of fibula.Insert prior to posteromedial portal – risk ofsural nerve damage.

• Posteromedial portal – this is just medial toAchilles tendon at the level of theposterolateral portal. Flexor hallucis longus isused to sweep away the tibial nerve andposterior tibial artery – the main structures atrisk.

Posterior portals are not as frequently used(because of the increased risk of neurovasculardamage), but are helpful in visualizing theposterior ankle and subtalar joints.

Procedure

A systematic approach is essential if pathology isnot to be missed. Initially the whole of the talardome is inspected – ankle plantar flexion aidsvisualization of the posterior dome. The talar neckis then examined. Pathology on the correspondingarticulating surface of the tibia is also documented,as well as the anatomy of the anterior aspect oftibia. The medial and lateral gutters are theninspected. Key features to identify include:• Medial malleolus• Deltoid ligament• Lateral malleolus• Anterior and posterior tibiofibular ligaments• Anterior talofibular ligament• Syndesmosis.

Ankle arthroscopy 223

Antero-medialportal

Antero-centralportal

Antero-lateralportal

Tibialis ant.

EHL

EDL andperoneus

tertius

Figure 13.3 Typical portal positioning (anterior aboveand posterior below)

Closure

Non-absorbable suture is used to close the skinincisions.


The patient is fully weightbearing – as tolerated –unless the patient has a microfracture of anosteochondral defect, where range movement isencouraged in a non-loading manner so as toprotect the developing fibrocartilage plug.

Specific precautions are rarely required.


Ferkel RD, Karzel RP, Del Pizzo W, et al.Arthroscopic treatment of anterolateralimpingement of the ankle. Am J Sports Med1991;19:440–6.Ferkel RD, Zanotti RM, Komenda GA, et al.Arthroscopic treatment of osteochondral lesionsof the talus: Long-term results. Am J Sports Med2008;36:1750–62.Niek van Dijk C, van Bergen CJ. Advancements inankle arthroscopy. J Am Acad Orthop Surg2008;16:635–46.Tryfonidis M, Whitfield CG, Charalambous CP, etal. Posterior ankle arthroscopy portal safetyregarding proximity to the tibial and sural nerves.Acta Orthop Belgica 2008;74:370–3.

SURGERY FOR ACHILLESTENDINOPATHY


There is an ever increasing incidence of tendonproblems, most commonly seen in recreationalrunners (racket sports, track and field, volleyballand football) and competitive runners, who are10 times more affected than age-matchedcontrols.

Despite preventive measures, 7–8 per cent oftop level athletes experience the problem at somestage in their career. The long-term prognosis isgood with 84 per cent fully recovered at 8 years;94 per cent remain asymptomatic.

Indications

Diagnosis is key. There are three common patternsof tendon pathology:• Overuse (non-insertional) tendinopathy – this

has a gradual onset classically with morningpain and stiffness that eases with activity andreoccurs at rest later. Associated with anincrease in activity, change of surface or changeof footwear/poor footwear.

• Partial and complete ruptures – there is asudden onset of severe pain, marked disabilityand these ruptures are 10 times more commonin males. With peak incidence in the 30s and40s. Patients often describe hearing a ‘pop’ andfeel an impact in the back of the leg or heel.

• Insertional tendinopathy (enthesopathy) – thiscan be mistaken for a number of pathologiesincluding retrocalcaneal bursitis, Haglanddisease (painful retrocalcaneal bursitis and abony prominence), Achilles bursitis.

Be aware of the systemic enthesopathies/rheumatoid arthritis and spondyloarthro -pathies; it is an area where misdiagnosis iscommon and the differential diagnoses include:– Posterior ankle impingement syndrome– Accessory soleus– Deep posterior compartment syndrome– Sever’s disease– Stress fracture– Inflammatory arthropathy– Neurogenic referred pain.

Contraindications

Active infection.

Operative planning

Non-operative managementOnce the diagnosis has been made, consideration

Consent and risks

• 12 per cent complications (54 per cent woundrelated)

88 per cent return to function after a 6- to 12-month treatment programme.


is given to whether operative treatment is the bestoption for the patient. These include:• Older patients and those with low activity levels• Those able to tolerate a rehabilitation regimen,

which have an overall success rate of 75–85 percent.

• Achilles rupture with a 10 mm gap when theankle is in neutral and complete apposition ofthe ends with plantar flexion on ultrasound;treatment with 3 cm of hindfoot elevation for 8weeks in a below knee cast and then a 1 cmelevation for an additional 3 months (75 percent rate of return to normal function).

Poor outcomes occur in 17.5 per cent, theseinclude:• Ongoing pain• Lengthening dysfunction• A reduced calf size• Re-rupture in 6.4 per cent.

For tendinopathies in the absence of rupture con -servative management should include eccentricheel drops (Alfredson’s painful eccentric heel-dropprotocol): • Three sets of 15 repetitions twice daily, 7/7, for

12 weeks• Exercise until pain free then add load to create

pain (up to 60 kg).

There is a 90 per cent cure rate. Bursae are treated with non-steroidal anti-

inflammatory drugs (NSAIDs), intrabursalcortisone injections and deep friction massage.Biomechanical treatment includes heel lifts. Othertreatments include sclerosant injections, nitricoxide, corticosteroids and electrophysical agents.

Operative managementA rapid return to function and reduced long-termpain.


• General anaesthesia with local infiltration.• Thigh tourniquet.• Prone position with ankles resting of pillow.

SURGICAL TECHNIQUE

There is much debate about open versuspercutaneous repair. The open technique is

described here, as an example. Ancillaryprocedures can be used to augment treatment;their details are beyond the scope of this book. Theprocedures include: calcaneoplasty, bursectomy,osteotomy and debridement of the tendon.

Landmarks

• Midpoint of the calcaneal tuberosity posteriorlywhere tendo-Achilles inserts

• Medial and lateral aspects of tendon tracedproximally to bellies of gastrocnemius toidentify aponeurosis.

Incision

A 5–10 cm incision is created (at the level of thedefect) along the medial border of the Achillestendon. This avoids the sural nerve and allowsaccess to plantaris.

Dissection

• Directly deepen to paratenon.• Open paratenon and debride tendon.• Thick flaps are vital for healing.

Procedure

It is necessary to address peritendinous adhesionsand excise intratendinous lesions. A modifiedKessler box suture is recommended. This consistsof two standard Kessler sutures, at 90° to eachother, ensuring the ends are tied inside notoutside. It is best to use 1/0 PDS: this ensuresgood strength and slides easily. The repair iscompleted with a continuous epitendinous suture(3/0 Vicryl). A number of techniques aredescribed for repair of tendon defects, including:• Turn down flaps – this involves a centrally based

fascial flap developed from the proximalsegment and turned distally though 180° beforesuturing.

Structure at risk

• Sural nerve

Surgery for Achilles tendinopathy 225

• V-Y advancement – a V-shaped incision is madein the aponeurosis. The limbs of the ‘V’ shouldbe 1.5 cm longer than the gap to be filled. Theintermediate segment is advanced distally andthe proximal segment is closed as a ‘Y’ in thelengthened position (Fig. 13.4).

If the repair or augment is too compromised theflexor hallucis longus, peroneus brevis or anallograft made of polyglycol or carbon fibre can beused.

Closure

Closure is performed in thick layers with a non-absorbable suture for the tendon repair.Absorbable suture is used for the paratenon andskin closure.


Initially immobilize in equinus cast with strictelevation and neurovascular observation. This isfollowed by 6 weeks’ non-weightbearing withserial casting to return the ankle to a plantigradeposition. At 6 weeks, conversion to a removableboot allows the patient to fully weightbear andcommence physiotherapy for another 6 weeks.The functional outcome is assessed in clinic at 3months.


Hufner TM, Brandes DB, Thermann H, et al.Long-term results after functional nonoperativetreatment of Achilles tendon rupture. Foot AnkleInt 2006;27:167–71.Manoli A, Graham B. The subtle cavus foot. FootAnkle Int 2005;26:256–63.Oyedele O, Maseko C, Mkasi N, et al. Highincidence of Os peroneum in cadavers. Clin Anat2005;19:605–10.

SURGERY FOR PERONEALTENDINOPATHY


The peroneus longus originates from the lateraltibial condyle and head of fibula to insert onthe first metatarsal base and medial cuneiform.The peroneus brevis originates from the middleone-third of the fibula and tibia to insert on thebase of the fifth metatarsal. Remember, at theankle the peroneus brevis is sandwichedbetween bone and the peroneus longus – ‘brevis tobone’.


(a) (b) (c)

Figure 13.4 V-Y advancement forrepairs with defect

Indications

A history of sprains is common. Other causesinclude: trauma, inflammatory arthritides, fibulaanatomy (shallow fibular groove, sharp lateralridge), hypertrophied peroneal tubercle, lateralankle instability and peroneus quartus(overcrowding). Developmental varus hindfootalignment is associated with increased incidenceof peroneal disorders:• Tenosynovitis (a static mass on examination)• Tendinosis (a mass moving with the tendon,

through sheath)• Tears (present with pain and weakness)• Subluxation (palpation along the length of the

tendons noting any deviation of their course)• Os peroneum syndrome: ossified in 20 per cent

population. Articulates with inferior margin ofcuboid. May be degenerative/ osteochondritis orfractured, leading to pain in the plantar/lateralaspect of the foot.

• Eventually pain-related functional weaknesswill lead to deformity.

Contraindications

Varus deformity related to underlying peronealweakness rather than tendinopathy.

Operative planning

Radiographs are helpful, however MRI andultrasound show: brevis flattening, thickening,nodules, tears, fluid in the peroneal sheath,dislocation, and the retrofibular groove anatomyin good detail (18 per cent have a shallow orconvex surface). The presence of fluid around anormal tendon on imaging indicates tenosynovitis.

Depending on the quality of proximal anddistal tendon, orthoses (lateral posting) andphysiotherapy are usually successful. Conservativemanagement of peroneal subluxation has <50 percent success.


General with local infiltration, or spinal/epiduralcan be used. The patient is positioned prone witha thigh tourniquet and a sandbag under theipsilateral buttock or, more usually, the lateralposition with adequate supports and protectionbetween leg pressure points.

SURGICAL TECHNIQUE

Landmarks

The tip of the fibula to the base of the fifthmetatarsal.

Incision

A longitudinal incision parallel to the posteriorborder of the fibula. Distally, the incision is curvedtowards the base of the fifth metatarsal.

Dissection

Dissection is straight down, directly to the tendonsheath. Thick tissue flaps are reflected underminimal tension. The sheath is divided longitu -dinally and as posteriorly as possible, to aid repairand reduce scar tissue irritation when the tendonsare mobilized under stress. Tendon hooks are usedto isolate, deliver and clear individual tendons ofadhesions.

Procedure

Surgical management for tendinopathy includessoft tissue procedures such as synovectomy,debridement or tubularization of tears. If greaterthan 50 per cent of the tendon is intact, repair isadvocated; less than 50 per cent tenodesis isrecommended. Tendon transfer of flexordigitorum longus to peroneus brevis or anautograft using gracilis can maintain function.

Bony procedures include:

Consent and risks

• Sural nerve injury during dissection and skinclosure

• Painful scar• Late re-rupture/subluxation• Fracture to tip of fibula/disruption of

retinaculum• Tendinous adhesions

Surgery for peroneal tendinopathy 227

• Deepening of the peroneal groove – using a 4.5mm drill, a longitudinal hole is made in theposterior third of the tip of fibular, then theposterior cortex is ‘stoved in’ to deepen theperoneal groove. The retinaculum is thenrepaired and a calcaneal osteotomy can beperformed if required. The tendons can also bererouted behind the calcaneofibular ligament asan alternative to the deepening procedure.

• A partial thickness distal fibular osteotomy –this is rotated posteriorly (Kelly procedure).

• Distal fibular sliding graft (Duvriesmodification) can also be carried out (Fig.13.5).


Tubularization of tears/bony procedures (4 weeksplaster of Paris, 4 weeks brace).


Dombek MF, Catanzariti AR. Peroneal tendontears: a retrospective review. J Foot Ankle Surg2003;42:250–8.Manoli A, Graham B. The subtle Cavus foot. FootAnkle Int 2005;26:256–63.


Peroneus brevistendon

Peroneus longustendon

Wedge of bonedriven backward

Lateralmalleolus

Figure 13.5 Bone block procedures

Oyedele O, Maseko C, Mkasi N, et al. Highincidence of os peroneum in cadavers. Clin Anat2005;19:605–10.Porter D, Torma J. Peroneal subluxation inathletes. Foot Ankle Int 2005;26:436–41.

Viva questions

1. What are the indications, benefits anddrawbacks of ankle arthrodesis?

2. What are the treatment options for a 40-year-old man with symptomatic osteoarthritis of theankle?

3. Describe the anatomy of anterior anklearthrotomy?

4. What complications do you warn the patientabout prior to ankle replacement? What aretheir incidences?

5. What are the contraindications to anklereplacement?

6. Describe the portals used in arthroscopy.

7. How do you perform an ankle arthroscopy?

8. What are the complications of anklearthroscopy and how can they be minimized?

9. How would you fuse an ankle?

10. Describe the follow up and complications youmight expect following ankle arthrodesis?

11. What types of ankle arthroplasty are you awareof?

12. What are the principles of the prosthesis used?

13. Describe the technique of ankle arthroplasty.

14. What are the common pitfalls and how canthey be avoided?

Surgery for peroneal tendinopathy 229

15. Describe an approach to the peroneal tendons.

16. How might you address peroneal tendonsubluxation operatively?

17. What is the most common approach to theAchilles tendon?

18. Describe the technique for direct repair of theAchilles tendon?

19. How might you augment a tendo-Achillesrepair, e.g. in a patient with tendonloss/shortening?

20. What are the common indications for operativemanagement of peroneal and Achilles tendondisorders?

Surgery of the foot14

Simon Clint and Nick Cullen

Principles of foot and ankle arthrodesis 230Hallux valgus correction 232FIrst metatarsophalangeal joint cheilectomy 241First metatarsophalangeal joint arthrodesis 242Ingrowing toenail surgery 244Interdigital neuroma 245

Lesser toe deformities 246Lesser metatarsal (Weil) osteotomy 249Fifth toe soft tissue correction (Butler procedure) 250Hindfoot arthrodesis 252Calcaneal osteotomy 255Viva questions 257

PRINCIPLES OF FOOT AND ANKLEARTHRODESIS


Arthrodesis is a commonly used techniquethroughout the foot and ankle. Although theapproach, position and fixation used are specificto each joint fused, the principles and techniquesare common throughout the region and should bewell understood. Individual arthrodeses will bedealt with in the relevant sections.

Indications

• Painful arthropathy of a joint – given the largenumber of adjacent joints in the foot, it can beuseful to localize the source of pain with aradiologically guided injection of the proposedjoint preoperatively

• Deformity of a joint affecting the position ofthe remaining foot – often associated with con -genital or acquired tendon or neuromuscularconditions.

Contraindications

• Active infection• Critical ischaemia• Multiple adjacent arthrodeses (relative contra -

indication).

Consent and risks

• Prolonged postoperative treatment: the jointmust be immobilized until union andunprotected weightbearing avoided, which maytake about 3 months in the hindfoot or ankle.

• Infection and wound healing problems:dependent on surgical technique and soft tissuehandling as well as patient factors.

• Cutaneous nerve damage: given thesubcutaneous and variable location of cutaneous


• The positions of arthrodesis are covered in therelevant sections.

Joint/movement Range of motionSubtalar joint inversion 10°

Subtalar joint eversion 5°

Transverse tarsal joint adduction 20°

Transverse tarsal joint abduction 10°

Combined foot supination 30°

Combined foot pronation 15°

First metatarsophalangeal jointflexion

30°

First metatarsophalangeal jointextension

60°

Principles of foot and ankle arthrodesis 231

cartilage and subchondral plate must be removed,maintaining the contour of the joint. This is bestachieved with a variety of sharp chisels working ina methodical manner from superficial to deep.Power tools generate unwanted heat and shouldbe avoided. As the joint is prepared, a laminarspreader is gradually advanced into the joint toopen it up. Pituitary rongeurs and Kerrisonlaminectomy rongeurs are useful to access thedeep recesses of the joint safely. Once all jointsurfaces are removed, the surface area of bleedingbone should be increased by various methods.Using a chisel to cross-cut the surface andapplying a slight twist on removal can producebone ‘petals’ to good effect.

The joint should be positioned in the desiredposition and, if needed, provisionally held with aK-wire. A careful confirmation of the positionwith respect to the limb alignment and the rest ofthe foot must be undertaken to ensure asatisfactory outcome. It is unusual, unless bonydestruction has occurred, to requiresupplementary bone graft. If required, sufficientquantities can usually be harvested locally fromthe calcaneus, medial malleolus or proximal tibiawithout need to prepare the iliac crest.

Rigid fixation and compression of the jointmust be achieved. This is usually done with someform of compression screw or screws. However, incertain situations other forms of fixation, such asstaples, intramedullary devices or externalfixations may be appropriate. Satisfactorycompression can be tested by carefully inserting afine chisel into the joint and twisting – thereshould be no give.

Careful, tension-free wound closure is critical.A soft tissue layer should be closed over the jointprior to skin closure. The joint is immobilized in aback-slab to protect the fusion and soft tissues.


The leg should be elevated until swelling hassubsided. Mobilization should avoid weight -bearing on the joint. In the forefoot, a wedge-typeshoe may be sufficient but usually a non-weightbearing cast should be used. Unprotectedweightbearing should be avoided until there isclinical and radiological evidence of union.


General anaesthesia is usually required. A thightourniquet is required to allow exposure of thelimb to above the knee. This allows accurateassessment of alignment. A supportive bolsterunder the calf is useful to allow free access to thefoot.

SURGICAL PRINCIPLES

The general principles are to mobilize the joint toallow correction of any deformity and completeaccess to the joint surfaces. The surfaces areprepared, maintaining the joint shape andcongruity while exposing bleeding cancellousbone. The joint is then held rigidly in the requiredposition of arthrodesis.

Careful placement of incisions of adequatelength is vital to prevent undue soft tissue damageand tension. Most joints are relatively superficialso adequate soft tissue cover is vital.

The capsule and surround soft tissues need tobe released to allow full access to the joint and tocorrect any deformity. Most deformities can becorrected with an adequate mobilization butoccasionally bone resection is required.

The joint surfaces need to be carefullyprepared. First, any peripheral osteophytes shouldbe removed to expose the true joint. Second, the

nerves in the foot, inadvertent damage andsubsequent painful neuroma formation can occur.

• Non-union: absolute risk is dependent ontechnical and patient factors. Most patients havea 5–10 per cent risk of non-union and ongoingpain for most procedures. This is increaseddramatically in smokers (up to sevenfold), thosewith poor perfusion, active infection or diabetes

• Malunion: technique dependent. Malunions maybe symptomatic, requiring footwear adaptationsor revision surgery, or may be asymptomatic andtolerated

• Development of arthropathy in neighbouringjoints – common over time but may represent theprogression of unrecognized early joint disease

• Alteration of gait – dependent on number andlocation of arthrodeses


Hardy MA, Logan DB. Principles of arthrodesisand advances in fixation for the adult acquiredflatfoot. Clin Podiatr Med Surg 2007;24:789–813.

HALLUX VALGUS CORRECTION


There are a multitude of procedures described forthe correction of hallux valgus deformity, someconsidered historical and others in current use. Inorder to select the correct procedure for a specificpatient, an understanding of the spectrum ofhallux valgus deformities must exist.

Indications and choice of procedure

The strongest indication for operativeintervention in hallux valgus is pain. This pain islocated over the bunion and usually only felt withshod feet. Pain present when barefoot or underthe metatarsal head suggests another source of thepain should be sought. Footwear problems due toextreme deformities are a relative indication.Operating solely for cosmetic or fashion reasons isgenerally not recommended.

On examining the patient, the neurovascularstatus of the patient must be examined along withthe overall hindfoot and foot alignment. Jointmobility is assessed: hypermobility of the firsttarsometatarsal joint (TMTJ) is associated with anincreased risk of postsurgical recurrence.

Contraindications

Patients with significant pre-existing degenerativechange in the metatarsophalangeal joint (MTPJ)will usually not benefit from realignment surgeryand should be offered arthrodesis. (See ‘Firstmetatarsophalangeal joint arthrodesis’, p. 242.)

The presence of a bunion is not an indication forsurgery.

232 Surgery of the foot

Patients with hypermobility or instability of thefirst TMTJ are likely to have a recurrence after asimple osteotomy. These deformities might bebest treated with a first TMTJ arthrodesiscombined with a lateral release (see Lapidusprocedure below).

Consent and risks

There is considerable variation, depending on thespecific procedure: details of operation-specificrisks are detailed within the operative techniquesbelow. General complications are listed here.• Foot shape: most procedures will result in a

narrower forefoot with a straighter hallux.However, this may still preclude the wearingof many fashionable shoes

• Stiffness: most procedures which violate theMTPJ are associated with varying degrees ofpostoperative stiffness. This can be particularlytroublesome with the Scarf osteotomy due tothe degree of soft tissue mobilization

• Recurrence of deformity: usually associatedwith poor technique, attempting to push theindications of a procedure too far or notrecognizing complicating factors (laxity,increased distal metatarsal articular angle[DMAA], congruent joint, etc.)

• Overcorrection and hallux varus: usuallyoccurs due to overenthusiastic soft tissuecorrection or excessive displacement of thecapital fragment. Excessive medial eminenceexcision or the excision of the fibularsesamoid in a McBride release also predisposeto hallux varus.

• Nerve damage and neuroma formation:damage to the dorsomedial or plantar nervesis possible with most procedures and cancause painful neuroma formation

• Transfer metatarsalgia: anything that altersthe relationship between the first and lessermetatarsals in the sagittal plane can lead topainful overloading of the lesser metatarsals,usually the second. This can occur intechniques that result in excessive shorteningor elevation of the metatarsal head. It can alsooccur with defunctioning of the hallux, asoccurs with a Keller procedure

Hallux valgus correction 233

Operative planning

RadiologyAll patients presenting with hallux valgus shouldhave weightbearing anteroposterior (AP) andlateral radiographs of both feet obtained. Variousradiographic angles and measurements arefrequently used to define the anatomical locationand magnitude of the hallux deformity which canaid surgical planning (Fig. 14.1). These include:• Hallux valgus angle (HVA) – the angle between

the anatomical axes of the first metatarsal andthe proximal phalanx

• First–second intermetatarsal angle (IMA) – theangle between the anatomical axes of the firstand second metatarsals

• DMMA – the angle between a line drawn fromthe medial and lateral borders of the articularsurface of the distal metatarsal and theanatomical axis of the metatarsal

• Interphalangeal angle – angle between theproximal and distal articular surfaces of theproximal phalanx of the hallux

• Joint congruity – the medial and lateral bordersof the joint surface of the metatarsal andphalanx are identified. The first MTPJ is said tobe congruent if the lateral and medial bordersof the two joint surfaces align. If they do not,the joint is incongruent (Fig. 14.2)

• Presence of degenerative changes in the first MTPJ• Signs of first TMTJ instability – these include

opening up of the first TMTJ on the lateral viewand widening of the gap between thefirst/second metatarsal bases.

• Congruent deformities require an osteotomythat incorporates rotation to correct therelationship of the articular surface to the axisof the metatarsal.

• Mild deformities can be corrected with a singlemetatarsal osteotomy (e.g. biplanar Chevron ormodified Scarf – see below) with or without theaddition of a phalangeal osteotomy (Akinosteotomy – see below).

• Severe deformities occasionally require acombined proximal and distal metatarsalosteotomy (see proximal metatarsal osteotomybelow).

• Most authors categorize incongruent halluxvalgus based on broad categories of severity.Such categories are not absolute but act asgeneral guidelines to help define the limits ofcertain procedures and to help in the selectionof the correct treatment. Table 14.1 showstypical figures.


All hallux valgus surgery can be performed undera regional (ankle) block or general anaesthesia. Abloodless field is provided by a thigh or ankletourniquet. The patient is positioned supine andthe whole foot and ankle prepared.

IMA(a)

(b)(c)

HVADMAA

Figure 14.1 Radiographicassessment of hallux valgus. (a)Intermetatarsal angle (IMA). (b)Hallux valgus angle (HVA). (c)Distal metatarsal articular angle(DMAA)

SURGICAL TECHNIQUES

Given the huge range of surgical proceduresdescribed for hallux valgus, it is not within thescope of this book to describe them all. We shalltherefore concentrate on those procedurescommonly performed. Each procedure isdescribed individually but in practice severaltechniques, such as the metatarsal osteotomy,Akin osteotomy and lateral soft tissue release, maybe performed in combination.

First metatarsophalangeal joint softtissue release

A soft tissue release is rarely performed inisolation. However, it is part of many proceduresso a detailed understanding is important.

Specific indications• Incongruent, mild hallux valgus with normal, or

near normal IMA• In combination with another procedure (see

below).

A soft tissue release attempts to balance out thesoft tissues around the first MTPJ. With a valgusdeformity, the medial tissues become attenuatedand those on the lateral side contracted. Theoriginal McBride procedure was more extensive,including excision of the lateral sesamoid, and wasassociated with a high rate of hallux varus. Theprocedure has been altered so many times that theterm ‘modified McBride’ is misleading and shouldbe avoided.

IncisionStarting on the medial side, a medial longitudinalincision is made, centred over the metatarsal headand extending from the shaft of the proximalphalanx to the distal shaft of the metatarsal.

Dissection

Structure at risk

• Dorsomedial sensory nerve

Consent and risks

• Overcorrection and hallux varus: caused byexcessive soft tissue release and excessive medialplication

• Excessive medial plication can also lead to jointstiffness

• Nerve damage: the common digital nerve is deepto the inter-metatarsal ligament and can bedamaged


Table 14.1 Categorization of hallux valgus severity*

Angle measured Normal Mild Moderate SevereHVA <15° 15–20° 20–40° >40°

IMMA <9° 9–11° 11–16° >16°

DMAA <6°

*After Coughlin, Mann, Saltzman. Surgery of the Foot and Ankle. Philadelphia: Mosby Elsevier, 2007.

Incongruent joint Congruent joint

Figure 14.2 Assessment of first metatarsophalangealjoint congruity


Dissection is continued down to capsule andthen a dorsal flap is carefully elevated toidentify the dorsal nerve adherent to the capsuleon the dorsomedial aspect. This is repeatedon the plantar side, dissecting around the capsuleto create a small pocket. A longitudinalcapsulotomy is performed and any adhesionsreleased.

Surgical techniqueUnless a distal metatarsal osteotomy is also to beperformed, the prominent medial eminence of thehead can now be removed. This is done with a fineoscillating saw, aiming to cut in line with themedial shaft starting 2–3 mm from the medialsulcus (Fig. 14.3).

Attention is now turned to the first web space.A 3 cm incision is centred between the metatarsalheads in the first web space then bluntlydissecting down to the level of the heads. Insertinga laminar spreader or self-retainer between theheads allows identification of the lateral sesamoidand the insertion of adductor hallucis into itslateral edge. Using a size 15 blade, the capsule isreleased from the dorsal aspect of the sesamoidthen the blade advanced to the insertion of

adductor hallucis into the phalanx. The insertionof adductor hallucis is released from the phalanxthen, working proximally, the remaining tendon isreleased from the sesamoid. Deep to this is theinter-metatarsal ligament which runs from thesecond metatarsal to the lateral sesamoid, not thefirst metatarsal itself. This is carefully divided fromthe sesamoid, taking care to preserve theneurovascular bundle which lies directlyunderneath. The lateral capsule (metatarso-sesamoid ligament) is then incised longitudinally,after which the articular surface of the lateralsesamoid can be inspected and should bereducible underneath the metatarsal head. Theretractor is removed and confirmation that the toecan be passively overcorrected is sought.

Returning to the medial side, the metatarsalhead should be reducible onto the sesamoids. Iftoo much resistance is encountered, a bonyprocedure is required to correct the deformity.Subsequent capsular plication is designed to takein excess capsule, not pull the sesamoid complexover.

Using an absorbable suture, the excess capsuleis ‘double-breasted’ while holding the MTPJflexed. This is done by passing a stitch through thedorsal capsule from outside, medial to theextensor tendon and avoiding the identified nerve.The needle is then passed from outside the plantarcapsule, just medial to the sesamoid then reversedto come from inside out. It is finished by exitingthrough the dorsal capsule, near the earlier entrypoint. As the suture is tightened, the dorsalcapsule should double-breast over the plantarcapsule. Plication is checked to ensure that it isnot too tight by flexing and extending the joint.

ClosureThe rest of the capsule is then closed withabsorbable sutures prior to skin closure.

Scarf osteotomy

The scarf osteotomy is a powerful and versatileosteotomy allowing correction of all of the axes of thehallux valgus deformity; it is a technicallychallenging procedure with a steep learning curve. Itis named after a joiners’ technique, used to connecttwo beams.

Medial sulcus

Figure 14.3 Excision of medial eminence of firstmetatarsophalangeal joint

Specific indications• Moderate or severe hallux valgus• Hallux valgus with an increased DMAA• Revision surgery.

Specific contraindications• Poor bone stock or osteoporosis increasing the

risk of fracture.

IncisionA medial approach, as described above, isperformed. However, the incision continuesproximally until approaching the TMTJ.

Consent and risks

• Fracture: given the length of the osteotomy,fracture, either intraoperatively orpostoperatively can occur (3–5 per cent)

• MTPJ stiffness: especially if the metatarsal isinadvertently lengthened

• Malunion: care must be taken to ensure all cutsare in the correct direction in all three planes

• Troughing: this occurs when the shaft cortex ofone fragment collapses into the cancellous boneof the other fragment (Fig. 14.4). This results inelevation of the metatarsal head and rotation ofthe osteotomy. It is more common where there ispoor bone stock. By ensuring the ends of theosteotomy are in dense metaphyseal bone, ratherthan the diaphysis, the risk can be reduced

Dissection

Dorsally, the capsule and dorsal periosteum isreleased from the distal half of the bone, exposingthe dorsal surface. Plantarwards, great care is takento not damage the vascular leash entering thehead on the plantar surface of the neck (Fig.14.5).

Surgical techniqueThe periosteum is only elevated from theproximal third, dissecting away from the neck. Aminimal excision of the medial eminence isperformed in line with the shaft, aiming to justexpose cancellous bone. At this point it isadvisable to draw out the planned osteotomy, onthe medial aspect of the bone (see Fig. 14.5). Thelongitudinal arm begins at a point 3 mm from thedorsal cortex, 5 mm proximal to the dorsalarticular edge. This then extends proximally andplantarwards to a point 3 mm from the plantarsurface and 10 mm from the TMTJ. Twohorizontal 60° limbs are then added to the ends toexit the nearby cortices. The distal horizontal limbshould be perpendicular to the second metatarsalshaft; we advise drawing a line connecting the

Structures at risk

• Dorsomedial sensory nerve• Blood supply to first metatarsal head


Figure 14.4 Troughing of Scarf osteotomy

3 mm3 mm

5 mm10 mm

Figure 14.5 Scarf osteotomy and plantar vascularsupply of the metatarsal head


medial point of origin of the distal first metatarsalcut running perpendicular to the secondmetatarsal shaft and on through the lateral raysthe metatarsal head that it passes through (usuallythe fourth) can be used as a reference for the cut.Palpating the fourth metatarsal head, another lineis drawn on the dorsal surface, from the distal armacross the dorsal surface towards the fourth.

Once satisfied with the planned osteotomy, anoscillating saw is used to score the cortex for thelongitudinal arm. After a starting point is made,the blade is angled plantarwards, in the plane ofthe shafts of the metatarsals. Maintaining thisangle, the whole length of the longitudinal arm iscut, penetrating only the medial cortex; the lateralcortex is then softly cut in the same plane. Nextthe distal arm is cut, maintaining the slight plantarangle and aiming for the fourth metatarsal head asplanned. The proximal cut should now be cutparallel or slightly divergent to this – if the cutsconverge, the osteotomy will not displace. Theosteotomy should now be mobile. If not, all cutsare checked for completion and the two fragmentsgently freed with a MacDonald dissector, startingproximally.

The osteotomy is now displaced as required.This is facilitated by a ‘push–pull’ action, graspingthe proximal fragment with a towel-clip whilepushing the distal fragment laterally. Theosteotomy should displace laterally andplantarwards. The reduction is then held with aclamp. The reduction is checked by observing theposition of the medial sesamoid: it should lieunder the medial metatarsal head. Once thereduction is satisfactory, a K-wire is inserted alongthe lateral edge of the proximal fragment into thehead and a stepped bone clamp will preventdisplacement.

The osteotomy is secured with two screws –headless, variable pitch compression screws areideal. The first screw should start from thedorsolateral aspect of the distal end of theproximal fragment and aim towards the medialsesamoid. This must be intraosseous to avoidsesamoid damage. A second screw can then beused in a dorsoplantar direction to secure theproximal extent of the osteotomy. The proximalscrew should be bicortical.

After fixation, the prominent medial cortex of

the proximal fragment can be bevelled flush withthe shaft.

ClosureClosure of the capsule should be performed asdescribed previously.

Akin osteotomy

Specific indications• Hallux inter-phalangeus deformity, where the

deformity occurs distal to the MTPJ• In combination with a metatarsal osteotomy to

correct residual phalangeal deformity.

Specific contraindicationsAkin osteotomy in isolation will not correct jointincongruity or an increased IMA so should not beused alone in these cases.

IncisionA medial longitudinal incision is performed,starting just proximal to the interphalangeal joint(IPJ) and extended past the medial eminence ofthe metatarsal. This can be incorporated into theincision for a metatarsal osteotomy if required.

DissectionA longitudinal capsular incision is made andextended proximally to incise the periosteum ofthe phalanx. This is then carefully elevated,allowing the placement of retractors superiorlyand inferiorly.

Surgical technique

If required, the medial eminence of the metatarsalcan be excised, as above. The osteotomy is a closingwedge osteotomy, performed with an oscillatingsaw from the medial side; the lateral cortex is leftintact. Particular care should be taken to avoiddamage to the long flexor inferiorly. It is easy toovercorrect the deformity, so it is wise tounderestimate the size of the wedge and check the

Structure at risk

• Flexor hallucis longus tendon


Figure 14.6 Akin osteotomyOsteotomy for staple fixation Osteotomy for screw fixation

result. The alignment of the osteotomy depends onthe planned means of fixation (Fig. 14.6).

If a staple is used, the first cut should be parallelto the proximal joint surface. The second cut isparallel to the base of the nail, aiming to convergebefore the lateral cortex, leaving it intact. Thewedge is removed and the osteotomy closed. Ifthere is resistance, the lateral cortex can becautiously weakened with the saw, but should notbe breached. Using the planned staple as a guide,entry holes are drilled using a fine K-wire and thestaple inserted. After insertion the joint isinspected to ensure that it is not penetrated by thestaple. Postoperative radiographs can bemisleading in this regard because of the convexnature of the joint surface.

If a cannulated compression screw is to be used,the osteotomy will be angled to allowcompression. A screw will be inserted over aguidewire passing from the medial edge of theproximal flair of the phalanx, exiting distally inthe lateral cortex.

ClosureThe capsule is closed with absorbable sutures priorto skin closure. A forefoot dressing is applied.

Chevron osteotomy

The chevron osteotomy is a relatively simpleosteotomy for the correction of mild halluxvalgus.

Specific indications• Mild (and moderate – see below) hallux valgus

deformity

• Congruent hallux valgus deformity as theosteotomy does not disturb the balance of thejoint – using a biplanar chevron (see below).

Specific contraindicationsDue to technical limits of the procedure, it shouldbe reserved for deformities with an IMA <12°HVA <30° and DMMA <15°. Attempting to pushthe indications further increases the risk ofavascular necrosis of the capital fragment.

Incision and dissectionA standard medial approach is made to themetatarsal head (see above).

Surgical techniqueThe medial eminence is resected in a planeparallel to the medial border of the foot,

Consent and risks

• Avascular necrosis of the capital fragment: up to20 per cent in some series. Probably techniquedependent with increased avascular necrosisseen with extensive soft tissue stripping andrelease and with excessive displacementsattempted

• Malunion: if the osteotomy is angled tooproximally, shortening of the first metatarsal willoccur with translation. Similarly, if theosteotomy is angled dorsally the metatarsal headwill be elevated. Both of these technical errorswill alter the relationship of the first metatarsalhead to that of the lesser metatarsals and maylead to transfer metatarsalgia


beginning at the sulcus. A lateral release is notroutinely performed due to the increased risk ofavascular necrosis. The chevron osteotomy is a V-shaped cut of approximately 60° with the apex atthe centre of the metatarsal head (Fig. 14.7).Because the plane of the cuts is crucial, it can beuseful to place a K-wire in this central point,running parallel to the sole of the foot and thedistal articular surface of the metatarsal. This wirecan be then be used as a cutting guide to positionthe limbs of the chevron. The most crucial cut isthe plantar limb, which must exit the plantarsurface of the metatarsal in an extra-articularposition to avoid damage to the sesamoidarticulation. Several authors advocate a morehorizontal plantar limb (see Fig. 14.7) to attemptto preserve the plantar blood supply (see ‘Scarfosteotomy’ above). The dorsal limb is then cut atapproximately 60° to the first cut. Aftercompletion of the cuts, the capital fragment canbe translated laterally by up to 30 per cent of itswidth to correct the hallux valgus.

If there is an increased DMMA, the joint can bereorientated by means of a biplanar chevron. Bytaking a small (1–2 mm) wedge from thesuperomedial and inferomedial aspect of thelimbs, the fragment can be displaced laterally butrotated medially, correcting the DMMA as may berequired in a congruent hallux valgus.

Although inherently a stable osteotomy, mostsurgeons hold the osteotomy with a K-wire orscrew inserted from a dorso-proximal to plantar-distal direction. Care must be taken not to leaveany fixation proud of the joint to avoid damage tothe sesamoid articulation.

ClosureCapsular closure is as above.

Lapidus procedure

Specific indications• Hallux valgus deformity in the presence of

instability of the first TMTJ• Moderate to severe incongruent hallux valgus

deformity• Salvage procedure for previous failed hallux

valgus surgery• Arthritis of the first TMTJ.

Specific contraindicationsGiven the shortening of the first ray that occurswith Lapidus, the procedure should not beperformed on patients with short first metatarsals.

Surgical technique

The Lapidus procedure involves first TMTJarthrodesis; this should be performed with thepreviously described lateral soft tissue release,excision of the medial eminence and plication ofthe medial capsule. The medial incision for theMTPJ can be continued proximally to the TMTJ.Alternatively, a separate medial incision can bemade centred over the joint. The joint is usuallydeep to a vein, crossing from dorsal to plantar andsome authors advocate preserving it to reduce

Structure at risk

• Tibialis anterior tendon

(b)

(a)

Figure 14.7 Chevron osteotomy. (a) Classic chevronosteotomy, risking damage to plantar blood supply tometatarsal head. (b) Modified chevron osteotomy topreserve plantar blood supply to metatarsal head

postoperative swelling. The joint can be identifiedwith the aid of a needle and opened to mobilizethe joint. Care must be taken to avoid damage tothe tendon of tibialis anterior, which lies on theinferomedial aspect of the joint. Using traction onthe toe, the joint can be opened and preparationof the joint performed as detailed in ‘Principles offoot and ankle arthrodesis’ (p. 230). Once thepreparation has begun, there is enough room toinsert a laminar spreader.

Several authors describe a Lapidus procedure asa closing wedge arthrodesis. However, this isusually not required. By careful preservation ofthe joint shape the base of the metatarsal canusually be displaced medially and slightlyinferiorly with digital pressure, thereby reducingthe IMA and overcoming the elevation of themetatarsal head caused by shortening of the joint.A good correction coincides with the appearanceof a ‘step’ on the medial side. Once reduced, thejoint is provisionally held with a K-wire beforechecking the position. If further correction isrequired, minimal resection of the inferolateralaspect of the metatarsal base is performed.

The arthrodesis can be secured by means ofscrews or a custom plate. To use screws, a 3.5 mmglide hole is drilled from the dorsum of themetatarsal, starting 15–20 mm from the joint andslightly laterally, aiming for the cuneiform. It isimportant to avoid aiming too plantarwards,which results in a poor hold on the cuneiform.The cuneiform is then drilled, using a 2.5 mm drillin standard AO fashion. Prior to inserting thescrew, an oval groove in the transverse planeshould be created (using a small burr orcountersink) to accommodate the head of thescrew and avoid breaking the dorsal corticalbridge. Once tightened, a second screw can beinserted from the cuneiform to the metatarsal, ina parallel sagittal plane to the first screw.

ClosureThe soft tissues are closed over the fusion prior toskin closure.

Specific postoperative instructionsIf satisfactory fixation is achieved and the patientis compliant, they may mobilize postoperativelyin a forefoot-offloading wedge shoe for 12 weeks.

Otherwise a non-weightbearing cast can be usedto protect the arthrodesis.

Proximal (basal) metatarsal osteotomy

The proximal metatarsal osteotomy is usuallyperformed in combination with a lateral softtissue release, excision of medial eminence andmedial capsule closure, as described above.

Specific indicationsCorrection of moderate to severe hallux valgus,especially when associated with a large IMA. Bymaking an osteotomy at the base of themetatarsal, larger corrections of IMA can be madethan by operating more distally.

Specific contraindicationsCongruent deformities (if used in isolation) – asthe osteotomy does not alter the relationshipbetween the anatomic axis of the metatarsal andthe distal articular surface, it will not alter theDMMA. However, it may be of use whencombined with a distal osteotomy to correct acongruent deformity with increased IMA (adouble osteotomy).

IncisionA dorsal incision is made over the base of themetatarsal, avoiding any superficial cutaneousnerves.

Surgical techniqueThe osteotomy is ideally placed about 1 cm fromthe TMTJ in metaphyseal bone to provide a broadarea for union. A dome osteotomy or closing oropening wedge osteotomies can be performed.

Consent and risks

• Malunion: any misorientation of the plane of theosteotomy can result in significant accidentalmisplacement of the metatarsal head

• Overcorrection: given the power of thisosteotomy to realign the shaft, overcorrectionand hallux varus can be troublesome, especiallywhen combined with an aggressive lateralrelease


First MTP joint cheilectomy 241

The lateral closing wedge will tend to shorten themetatarsal. There are various plates designed to fixthe opening wedge osteotomies.

The coronal plane of the osteotomy is vital – itshould be perpendicular to the plane of themetatarsal. If the blade is directed too medially,the head will be elevated and if directed toolaterally it will be depressed. In the sagittal plane,the blade should be positioned perpendicular tothe sole then angled slightly proximally. Once cut,the osteotomy can provisionally be reduced andthe position checked. If satisfactory the osteotomyis fixed with two screws or a screw and wire.

Keller procedure

This involves excision of the medial prominenceof the metatarsal and the proximal third of thephalanx to relax the lateral structures and allowcorrection of the toe, which is then held with atemporary K-wire. Although once commonlyperformed, its generally unsatisfactory resultshave caused it to fall out of favour. The patient isleft with a floppy great toe and, by defunctioningthe hallux, is prone to overload their lesser rayswith resultant pain. However, it can be consideredin the older, minimally ambulatory patient whohas footwear problems or in those patients whosesoft tissues or general fitness precludes a moreaggressive procedure.

GENERAL POSTOPERATIVE CARE ANDINSTRUCTIONS

• The foot is dressed with a standard forefootdressing, extending above the ankle.

• The foot is elevated for 72 hours to reduceswelling.

• The patient may mobilize, fully weightbearing,in a forefoot-offloading wedge shoe for 6 weeks.

• After skin wounds have healed, the patient istaught passive mobilization of the MTPJ toreduce stiffness.


Barouk LS. Scarf osteotomy for hallux valguscorrection. Local anatomy, surgical technique, andcombination with other forefoot procedures. FootAnkle Clin 2000;5:525–58.

Barouk LS. Forefoot reconstruction. Paris: Springer-Verlag, 2005.Weil LS. Scarf osteotomy for correction of halluxvalgus. Historical perspective, surgical technique,and results. Foot Ankle Clin 2000;5:559–80.

FIRST METATARSOPHALANGEAL JOINTCHEILECTOMY


Hallux rigidus, or degenerative arthritis of the firstMTPJ, is a common condition. Although in itsearly stages it can be managed with conservativemeasures, such as footwear and activitymodifications, patients often require operativeintervention. Cheilectomy, from the Greek for lip,cheilos, addresses both the pain and stiffness foundin this condition.

Indications

• Mild to moderate degenerative changes in thefirst MTPJ with pain and stiffness, failing torespond to conservative management

• More advanced degenerative changes in apatient unwilling to lose joint movement(patient must be counselled that there may beimprovement in movement but only limitedimprovement in pain)

• Prominent dorsal osteophytes causing footwearproblems.

Contraindications

Advanced degenerative changes with loss of jointspace.

Consent and risks

• Failure or recurrence of symptoms: especially ifthe degenerative changes are more extensivethan appreciated preoperatively or if insufficientresection is performed

• Instability of first MTPJ: especially if resectionexceeds 35 per cent of joint surface

• Damage to dorsal cutaneous nerve and neuromaformation


• Regional or general anaesthesia• Ankle or thigh tourniquet• Supine on operating table.

SURGICAL TECHNIQUE

Landmarks

• The MTPJ of the great toe is easily palpable• Extensor hallucis longus (EHL) tendon.

Incision

A 5 cm dorsal incision is made along the medialborder of EHL centred over the first MTPJ.

Dissection

The underlying extensor hood is incised in linewith the incision but leaving a cuff of tissue on themedial side of the tendon to avoid violating thetendon sheath and reducing the risk of adhesions.The joint capsule is incised and the joint exposedby dissection medially and laterally. Alternatively,a medial approach, as described in first MTPJarthrodesis, may be used.

PROCEDURE

A full synovectomy is performed and any loosebodies removed. Flexing the joint fully allowsinspection of the joint surface. In mild andmoderate disease, the damage is usually limited tothe dorsal aspect. Ideally, the resection shouldextend from just dorsal of the edge of the viablecartilage to just proximal of the dorsalprominence of the head. However, care should betaken to ensure that this resects 20–30 per cent ofthe joint (Fig. 14.8).

Note on resection level (Fig. 14.8): a commoncause for failure of cheilectomy is insufficientresection. A minimum of 20 per cent of thearticular surface must be removed, even if thisincludes normal joint surface, to ensure adequatemovement. Exceeding 35 per cent is likely todestabilize the joint.

The dorsal prominence is resected with a saw orosteotome and satisfactory dorsiflexion (ideally

60°) is confirmed. Any prominent osteophytes areremoved from the dorsal phalanx and the medialand lateral aspect of the head, and the joint isirrigated to thoroughly wash out. Bone wax canbe used sparingly to reduce bleeding andadhesions.

Closure

Careful closure of the capsule with interruptedVicryl precedes skin closure. A forefoot dressing isapplied to above the ankle.


The foot is elevated for 48 hours. The patient fullyweightbears on a postoperative shoe andaggressive active and passive mobilization beginsonce skin healing has occurred


Coughlin MJ, Shurnas PS. Hallux rigidus. Gradingand long-term results of operative treatment. JBone Joint Surg Am 2003;85:2072–88.

FIRST METATARSOPHALANGEAL JOINTARTHRODESIS


Once a patient has developed severe halluxrigidus, a cheilectomy is unlikely to address the


Figure 14.8 First metatarsophalangeal joint cheilectomy– minimum and maximum resection levels

First MTP joint arthrodesis 243

problem. Although various arthroplasties areavailable, most either have limited long-termresults or are associated with high failure rates.Arthrodesis of the joint provides a reliablesolution to the pain of advanced arthritis of thejoint.

Indications

• Painful arthropathy of first MTPJ notresponding to conservative treatment and notsuitable for less invasive treatment (e.g.cheilectomy)

• Severe first MTPJ deformity in the presence ofdegenerative changes

• Salvage of failed first ray surgery.

Absolute contraindications

• Active infection• Limb ischaemia or poor perfusion.

Relative contraindication

Previous IPJ arthrodesis or pre-existing IPJdegenerative changes.


• Regional or general anaesthesia• Ankle or thigh tourniquet• Supine on operating table.

Consent and risks

(see also ‘Principles of foot and ankle arthrodesis’,p. 230)• Malunion: excessive extension can cause

defunctioning of hallux and transfermetatarsalgia. Excessive flexion can causeincreased wear and pain in the IPJ. Excessivevalgus can cause pressure on the second toe

• Damage to dorsal cutaneous nerve and neuromaformation

• Unable to wear high heels after surgery: thismust be stressed to women considering operation

• Minimum of 6 weeks protected weightbearing

SURGICAL TECHNIQUE

Landmarks

The MTPJ of the great toe is easily palpable.

Incision

A straight medial midline incision is made,centred over the MTPJ.

Dissection

This is continued straight down to the jointcapsule, without developing flaps. The capsule isincised in line with the skin incision and freeddorsally over the metatarsal head and sufficientlyaround the phalangeal base to allow its surface tobe delivered. Alternatively, the approachdescribed for cheilectomy may be used.

Procedure

The surfaces are prepared in a manner outlined in‘Principles of foot and ankle arthrodesis’ (p. 231).Given the joint’s small size it is not possible, orreally necessary, to use a laminar spreader.Furthermore, the concave surface of the phalanxmakes the use of chisels difficult; a curette or bonenibbler may be more useful, Various dome-shapedreamers may also be used, but care should betaken to avoid removal of excessive bone, whichwill lead to shortening.

Note about sagittal position of arthrodesis (Fig.14.9): several textbooks state a fixed value for theposition of first MTPJ arthrodesis, e.g. 25–30°extension. This can be confusing as it may beunclear if this refers to the angle relating to thefloor or the metatarsal shaft. Furthermore, theangle to the metatarsal depends on the pitch of themetatarsal, i.e. whether the foot is planus or cavus.It is therefore preferred to arthrodese the joint in arelative position to a simulated floor. Using a flatsurface to push up against the sole of the foot,assess the position of the pulp of the hallux withregard to the surface. If a finger can be pushedunder the pulp the toe is too extended. If there isno space for any flexion of the IPJ the position istoo flexed. An ideal position allows a small amountof movement with downward pressure on thedistal phalanx.

The joint is positioned as required andprovisionally held with a K-wire. The sagittalposition of the toe is then assessed with regard toa flat surface as outlined above. The coronalposition should be of sufficient valgus to avoid themedial border of the toe rubbing upon the toe-box of a shoe but not so much that there isimpingement of the hallux against the second toe;10–15° HVA is usually appropriate. There shouldbe no rotational deformity.

In primary surgery with good bone stock, thearthrodesis can be secured with two crossedscrews. The first is inserted with a lag technique tocompress the joint; the second provides aderotational function. Alternatively, a custom-made plate may be used.

Closure

• Careful closure of the capsule with interruptedVicryl precedes skin closure.

• A forefoot dressing is applied to above theankle.


The foot is elevated for 72 hours. A reliablepatient can mobilize in a wedge shoe to offload

the forefoot until evidence of clinical andradiological union. If there is concern about thecompliance of the patient, a cast may be used.


Coughlin MJ, Shurnas PS. Hallux rigidus. J BoneJoint Surg Am 2004;86(Suppl 1):119–30.

INGROWING TOENAIL SURGERY


A multitude of operations exist to deal withingrowing toenails, or onychocryptosis. Chemicalablation with phenol of either part or all of thenail matrix is associated with lower recurrencerates than surgical ablation in most series.

Indications

Painful onychocryptosis or recurrent infections.

Contraindications

• Severe digital vascular compromise is anabsolute contraindication

• Active infection is a relative contraindication.


Figure 14.9 Coronal position ofarthrodesis of the firstmetatarsophalangeal joint. Notethat the phalanges are parallel tofloor, allowing clearance of toepulp

Too flexed

Too extended

Correct position

Ingrowing toenail surgery 245

All blood is carefully cleared from the field andall exposed skin protected with petroleum jelly. Acotton bud is soaked in phenol and inserted alongthe exposed nail bed, under the ungual fold, andleft for 60 seconds. This process is repeated oncemore then the whole area irrigated with copiousamounts of saline. The tourniquet is released anda toe dressing applied.


The foot is elevated for 48 hours then the dressingsare reduced. The wound is then washed in tepidboiled salted water twice a day using a babytoothbrush, sweeping in a proximal to distaldirection. When showering the patient is instructedto aim the spray directly over the wound.


Herold N, Houshian S, Riegels-Nielsen P. Aprospective comparison of wedge matrix resectionwith nail matrix phenolization for the treatmentof ingrown toenail. J Foot Ankle Surg 2001;40:390–5.

INTERDIGITAL NEUROMA


Indications

Proven, symptomatic interdigital (Morton’s)neuroma in the third (80–90 per cent) or second(10–20 per cent) web space failing to respond toconservative treatment.

Contraindications (relative)

• Vague symptoms or unusual location• Other causes of metatarsalgia• Lack of response to accurate injection of lesion.

Consent and risks

• Failure or recurrence: up to 20 per cent,dependent on technique and diagnosis andclosely related to short incision surgery

Recurrence may be better treated with totalmatrix ablation.


Toenail surgery can be effectively performed underdigital block with or without additional sedation.A bloodless field is established with the use of adigital tourniquet secured with an artery forcep.

SURGICAL TECHNIQUE

The affected nail border is elevated from the nailbed and surrounding skin by blunt dissection withforceps. The nail border is then cut using a bladeor scissors underneath the ungual fold (Fig.14.10). Grasping the fragment with an arteryforcep and using a rotating movement, the nailborder is carefully avulsed in its entirety, completewith the widened germinal base. The nail grooveis then carefully curetted.

Consent and risks

• Recurrence: less than 5 per cent• Infection: superficial infection commonly

dependent on postoperative care• Phenol burns: rare

Nailmatrix

Figure 14.10 Partial matrix ablation –line of excision for nail border


May be performed under general or regionalanaesthesia. The patient is positioned supine withan ankle or thigh tourniquet to provide abloodless field.

SURGICAL TECHNIQUE

Landmarks

The dorsal aspect of the affected web space.

Incision

A longitudinal incision is placed over the dorsumof the foot, starting in the web space andextending 3–4 cm proximally. (An insufficientincision is commonly found in recurrent cases andis to be avoided.)

Dissection

Taking care to avoid the dorsal digital nerves,dissection is carried down to the metatarsal headsand a laminar spreader is used between themetatarsal heads to place the transversemetatarsal ligament under tension. A Macdonalddissector is placed under the ligament which isthen divided under direct vision. The laminarspreader is then advanced into the wound to openup the intermetatarsal space.

Procedure

Structure at risk

• Common digital artery

Structure at risk

• Dorsal digital nerves

• Scar pain (especially with plantar incision)• Interdigital numbness: common but rarely

troublesome• Vascular damage and digital ischaemia: risk if

multiple web space explorations are undertaken

Plantar pressure will usually deliver the neuromainto the wound. Sometimes it will be obscured bya bursa which requires excision. Taking care toprotect the common digital artery, the neuroma isretracted proximally and the two true digitalnerves are divided. The nerve is then traced asproximally as possible and then divided undertraction such that the cut end is proximal to theweightbearing area of the foot. The specimenshould be sent for histology for confirmation ofthe diagnosis.

Closure

After release of the tourniquet, haemostasis isobtained. Skin is closed in a single layer and aforefoot bandage is applied.


The patient should elevate the foot for 48 hours.They may mobilize, weightbearing as tolerated, ina postoperative flat shoe.


Mann RA, Reynolds JD. Interdigital neuroma: acritical clinical analysis. Foot Ankle 1983;3:238–43.

LESSER TOE DEFORMITIES


The decision-making process for correction oflesser toe deformities must take into account thetype of deformity and whether it is fixed orflexible. A detailed examination of the deformitymust be made in the awake patient prior tosurgery. The position of the toe in the standingand lying position must be noted and anydeformity assessed for a fixed component. Anysubluxation or dislocation of the MTPJ must beidentified. There is some confusion in theliterature regarding toe deformity nomenclature.For the purposes of this book we have used thefollowing terms:


Lesser toe deformities 247

• Mallet toe – a flexion deformity of the distal IPJ(DIPJ), often resulting in a callosity on the tipof the toe.

• Hammer toe – a flexion deformity of theproximal IPJ (PIPJ), often associated withhyperextension of the DIPJ and anaccommodative hyperextension of the MTPJ.

• Claw toe – a term usually reserved for multipletoes and often associated with an underlyingneurological condition. The primary deformityis one of hyperextension of the MTPJ withsecondary flexion of the PIPJ.

Indications

• Painful lesser toe deformity not responding toconservative treatment

• Severe lesser toe deformity causing footwearproblems and not responding to footwearmodification.

Contraindications

• Vascular insufficiency• Local infection• Undiagnosed underlying neurological condition

(relative).

Consent and risks

• Infection: <1 per cent• Neurovascular damage: <1 per cent• Vascular insufficiency of the digit following

correction of a severe or long-standingdeformity: may require further shortening oraccepting a slightly flexed position

• Recurrence of deformity• Swelling• Non-union of arthrodesis: 20–50 per cent of PIPJ

arthrodeses in some series formed a fibrousunion, but this does not correlate withpostoperative dissatisfaction

• Malunion of arthrodesis: hyperextension of thejoint or varus/valgus deformity often poorlytolerated

• Loss of movement or function of the toe,depending on procedure performed


Anaesthesia can be regional or general. If surgeryis limited to the interphalangeal joints a digitalblock can be used. A supine position is used, withthe foot at the end of the table.

SURGICAL TECHNIQUES

Percutaneous flexor digitorum longustenotomy

Indication Flexible mallet deformity

IncisionHolding the toe to put the flexor tendon undertension, a size 15 blade (or tenotomy blade ifavailable) is used to make a 2–3 mm incision overthe DIPJ flexor crease.

Procedure

With the blade facing away from theneurovascular bundle, the tightened tendon ispalpated with the blade and divided. The toe isthen released to check the degree of correction.

ClosureFormal closure of the wound is not required.

DIPJ arthrodesis

IndicationFixed mallet deformity

IncisionAn elliptical incision is made over the DIPJ andcarried down to bone, excising the extensortendon. Care is taken to avoid damage to the nailmatrix distally.

Structure at risk


Procedure

Facing the blade away from the neurovascularbundles the collateral ligaments are divided,allowing deliverance of the condyles of the middlephalanx into the wound. Using a bone cutter, thecondyles are excised at the metaphyseal flair. Thearticular surface of the distal phalanx is thendecorticated. Under direct vision, the flexordigitorum longus tendon in the base of the woundis divided and the degree of correction is assessed.A double-ended K-wire is advanced in anantegrade direction through the distal phalanx,aiming to come out just below the nail bed. Thejoint is then reduced and the wire advanced intothe middle phalanx to secure the joint.

ClosureThe wound is best closed with non-absorbablemattress sutures to secure the skin and extensortendon en masse.

Flexor tendon transfer (Girdlestoneprocedure)

The principle of this procedure is to re-create theaction of the intrinsic muscles in flexing the MTPJand extending the IPJs.

Indications• Flexible hammer deformity• Flexible claw toe deformity.

IncisionA 5 mm transverse incision is made over theproximal flexor crease.

Procedure

Structure at risk


Structure at risk


Following blunt dissection down to the flexorsheath, the sheath is incised in a longitudinalmanner. Of the three tendons seen, the flexordigitorum longus (FDL) is the central one. Apercutaneous FDL tenotomy is performed at thelevel of the DIPJ (see above) and the FDL isdelivered out of the proximal wound. The tendonis split into two halves along its length. On thedorsum of the toe, a longitudinal incision is madeover the proximal phalanx. A small artery forcepis used to bluntly dissect down one side of thephalanx, remaining close to the extensorexpansion, and exiting the toe through the plantarwound. The forcep is used to grasp one half of thedivided FDL tendon and deliver it to the dorsum,repeating the manoeuvre on the other side.Holding the MTPJ in about 20° flexion, both endsof the tendon are sutured to the extensor tendon,using an absorbable suture. The toe is released toensure that the correction is being held. If there isjudged to be some residual tightness in the MTPJ,a dorsal release may be performed (see below). AK-wire may be used to protect the repair.

ClosureSkin wounds are closed with appropriate sutures,usually non-absorbable suture material.

PIPJ arthrodesis

IndicationFixed hammer deformity or claw toe deformity

IncisionAn elliptical incision is made over the PIPJ andcarried down to bone excising the extensortendon.

Procedure

Facing the blade away from the neurovascularbundles, the collateral ligaments are divided,allowing deliverance of the condyles of theproximal phalanx into the wound. Using a bonecutter, the condyles are excised at the

Structure at risk



Lesser metatarsal (Weil’s) osteotomy 249

metaphyseal flair. Sufficient bone must beremoved to allow the toe to be straightenedwithout undue tension on the tissues, especiallythe neurovascular bundles. The plantar plate isreleased from the middle phalanx allowing itsbase to be delivered. The articular surface is thendecorticated using a nibbler. A double ended K-wire is advanced in an antegrade direction throughthe middle and distal phalanges, aiming to comeout just below the nail bed. The joint is thenreduced and the wire advanced into the proximalphalanx to secure the joint.

ClosureThe wound is closed with a non-absorbablemattress sutures to secure skin and extensortendon en masse. If the MTPJ remains extended, adorsal release (see below) should be included toavoid a ‘cock-up’ deformity.

MTPJ release

IndicationHyperextension of the MTPJ with or withoutsubluxation.

Incision

A 3 cm incision is made in line with themetatarsal, centred over the MTPJ. If two adjacentjoints are being addressed, the incision should bemade in the web space. Attempt should be madeto protect the dorsal veins and sensory nerves.

ProcedureRelease of the joint should occur in a stepwisemanner and stop when satisfactory releaseachieved. The extensor digitorum longus (EDL)and extensor digitorum brevis (EDB) to the toe(EDL lies medial to EDB) are identified and theirtightness assessed. If tight, the EDB may bedivided but the EDL should be z-lengthened. Adorsal capsul otomy is performed then, with theblade facing away from the neurovascular bundles,

Structures at risk

• Dorsal veins• Dorsal sensory nerve branches

progressive capsular and collateral releases areperformed both medially and laterally. In long -standing deformities, adhesions may exist betweenthe plantar capsule and the metatarsal head whichshould be released. Once satisfactory release isachieved, the EDL should be repaired withabsorbable suture and the wound closed. If, despitemaximal release of the MTPJ, the joint cannot bereduced, a metatarsal osteotomy should beconsidered. (see ‘Lesser metatarsal [Weil’s]osteotomy’, below).


After all lesser toe surgery the tourniquet shouldbe released prior to waking the patient and the toeobserved. If reperfusion is slow, releasingexcessively tight dressings and hanging the footover the side of the table usually allows the toe toreperfuse. If the toe remains white and a K-wirehas been inserted, gently bending the arthrodesedjoint will relieve excess tension on the bloodvessels.

All patients can fully weightbear on a flatpostoperative shoe. K-wires, if used, should beremoved at 4–6 weeks.


Coughlin MJ. Lesser-toe abnormalities. J BoneJoint Surg Am 2002;84:1446–69.

LESSER METATARSAL (WEIL’S)OSTEOTOMY


Historically, the Helal osteotomy was a populartreatment for lesser metatarsal overload andsubluxed lesser MTPJs. This has largely beenreplaced by the Weil osteotomy, as popularized byBarouk.

Indications

• Overload of a metatarsal head secondary to arelatively long metatarsal

• Reduction of a chronically subluxed ordislocated MTPJ.

Contraindications

• Gross deformity of the joint• Vascular insufficiency or infection.


See ‘Lesser toe deformities’ (p. 247).

SURGICAL TECHNIQUE

Incision

A 4 cm incision is made over the metatarsal, or inthe interspace if two adjacent osteotomies are tobe performed.

Dissection

The extensor tendons are retracted out of the wayand the dorsal capsule of the MTPJ released.Protecting the neurovascular bundles, thecollaterals are released to allow the proximalphalanx to be displaced plantarwards.

ProcedureA Macdonald dissector or custom made headelevator is inserted under the metatarsal head.Using a fine saw blade, an osteotomy is made,starting 2 mm below the dorsal surface of the headand continuing proximally, parallel to the sole ofthe foot (Fig. 14.11). Using a fine osteotome orMcDonald, the head fragment is freed up to allow

Structure at risk


Consent and risks

• Ongoing forefoot pain: often related to the useof an excessively long screw

• MTPJ stiffness: some degree is very common• ‘Floating toe’: stiff hyperextension of the MTPJ

preventing the toe from touching the floor• Infection: <1 per cent• Avascular necrosis and non-union: rare• Neurovascular damage: rare

it to retract proximally the desired amount. Thefragment can then be fixed with a small screw, thelength of which usually decreases from 14 mm inthe second metatarsal to 11 mm in the fifth. Theexcess dorsal bone overhanging the head can thenbe trimmed to ensure that the proximal phalanxcan freely dorsiflex.


The patient is asked to mobilize in a heelweightbearing shoe. Once wounds have healed,passive and active range of motion exercises canbegin and the toe can be strapped down toprevent hyperextension.


Barouk LS. Forefoot Reconstruction. Berlin:Springer-Verlag, 2005.Helal B. Metatarsal osteotomy for metatarsalgia. JBone Joint Surg Br 1975;57:187–92.Trnka HJ, Mühlbauer M, Zettl R, et al.Comparison of the results of the Weil and Helalosteotomies for the treatment of metatarsalgiasecondary to dislocation of the lessermetatarsophalangeal joints. Foot Ankle Int1999;20:72–9.

FIFTH TOE SOFT TISSUE CORRECTION(BUTLER PROCEDURE)


Indications

• Moderate or severe overriding fifth toe withpain and callosity or footwear problems


Figure 14.11 Orientation of Weil osteotomy of thelesser metatarsal and screw placement

Fifth toe soft tissue correction 251

• Failure of footwear adaptations and otherconservative measures

Contraindications

Digital ischaemia or poor perfusion.


Regional or general anaesthesia is required asdigital anaesthesia is insufficient. The patient ispositioned supine with an ankle or thightourniquet to ensure a bloodless field.

SURGICAL TECHNIQUE


A double-racquet incision is drawn to ensurecorrect placement. The dorsal limb of the incision

Structure at risk

• Neurovascular bundles of the fifth toe

Consent and risks

• Neurovascular damage and risk of toe ischaemia:reduced be careful dissection and avoidance oftraction or manipulation of the toe

• Recurrence of deformity: rare

should follow the line of tension along theextensor tendon. The plantar limb should belonger and heading laterally (Fig. 14.12). The skinis incised with care and the neurovascular bundlesidentified and protected.

Procedure

The tight extensor tendons are divided then thejoint capsule exposed. The tight dorsal capsuleand usually the collateral ligaments requirerelease. Sometimes the plantar capsule is adherentand needs to be dissected off. The toe should nowassume the required position.

Closure

The skin is closed without tension. The dorsalincision assumes a V to Y position and the plantarincision a Y to V position. The tourniquet must bereleased to ensure adequate perfusion of the toeprior to the end of anaesthesia. No taping orsplintage is required.


The patient can mobilize fully weightbearing on apostoperative shoe.


Cockin J. Butler’s operation for an over-riding fifthtoe. J Bone Joint Surg Br 1968;50:78–81.

(a) (b)

Figure 14.12 Butler procedure –position of skin incision. (a) Dorsaland (b) plantar views

HINDFOOT ARTHRODESIS


The three joints of the hindfoot, the subtalar (ST),calcaneocuboid (CC) and talonavicular (TN)joints, can be arthrodesed individually or incombination, depending upon the indication.However, as all three joints work in unison, fusionof one will affect the others. As the normalhindfoot swings into varus during gait, Chopart’sjoints (TN and CC) are locked in position toprovide a firm platform. Therefore, a subtalarfusion must avoid varus to leave Chopart’s jointsrelatively mobile and avoid fixed supination of thefoot. Similarly, fusion of the TN joint in isolationfixes the CC joint and greatly reduces themovement of the ST joint. Therefore, inarthrodesing one or more of these joints, attentionto the position of all three must be taken.

The ultimate aim of any hindfoot fusion is toprovide a pain-free, stable hindfoot and a footthat can be placed flat on the floor for weight -bearing.

Indications

(See also ‘Principles of foot and ankle arthrodesis’,p. 230.)• Painful arthropathy of one or more hindfoot

joints secondary to degenerative, inflammatoryor traumatic causes not responding toconservative management. In such casesisolated fusion of the affected joint can beconsidered.

• Fixed deformity of the hindfoot not amenableto soft tissue correction and/or osteotomy.Historically, this was primarily for paralyticconditions, especially poliomyelitis. Hindfootfusions are now more commonly performed fortibialis posterior dysfunction, rheumatoidarthritis and congenital neuromusculardisorders. In such cases a double fusion of theTN and CC joints, or a triple fusion of all threejoints is indicated.

• Gross instability of the hindfoot with bonydestruction, as seen in rheumatoid arthritis orCharcot’s joints in people with diabetes.

Contraindications

• Active infection or ischaemia of the limb is anabsolute contraindication.

• A more proximal uncorrected deformity is arelative contraindication. It is difficult to judgehindfoot alignment if there is a more proximaldeformity. Furthermore, if a proximal deformityis subsequently corrected, the hindfootalignment may be rendered incorrect. It istherefore prudent to address proximaldeformities first.

• Ipsilateral ankle fusion is a relativecontraindication – the patient must becounselled that a combined ankle and hindfootfusion will result in a loss of normal gait andpossibly the need for footwear adaptations towalk.


(See also ‘Principles of foot and ankle arthrodesis’,p. 231.)

For isolated subtalar fusion a lateral decubitusposition, with the operative side up, allowsexcellent access and visualization. For TN ordouble/triple arthrodeses, a supine position isoptimal. The use of a bolster under the calf allowsfree access around the foot.

Consent and risks

(See also ‘Principles of foot and ankle arthrodesis’,p. 230.)• Non-union: the TN joint is especially prone to

non-union. This is likely to be due to its curvedsurface and extensively cortical compositionmaking adequate visualization and preparationtechnically difficult. Obtaining adequate rigidfixation can also be difficult compared with theST joint

• Malunion: due to incorrect positioning orfixation failure. A malunion preventing thepatient from placing the foot flat on the floor,often with overload of the lateral border, is verypoorly tolerated by the patient and oftenrequires revision


Hindfoot arthrodesis 253

SURGICAL TECHNIQUE

Landmarks

• Utility lateral approach – tip of fibula and baseof fourth metatarsal

• Anterior approach – EHL and tibialis anteriortendons

• Anteromedial approach – tibialis anterior andposterior tendons.

Incision

The incision(s) used will depend upon the jointsto be addressed. For isolated TN arthrodesis ananterior approach allows excellent visualization.For isolated ST and/or CC joint fusion, a utilitylateral approach is used. For a triple fusion, theutility lateral in combination with an antero -medial approach to the TN joint allows wide skinbridges (Fig. 14.13).

The utility lateral approach allows excellentvisualization of the ST and CC joints. It ispreferable to the traditional Ollier incision asthere is less risk to the branches of the superficial

Structures at risk

• Sural nerve (utility lateral approach)• Superficial peroneal nerve (utility lateral

approach)• Saphenous nerve and vein (anteromedial

approach)

peroneal nerve. A straight incision is made fromthe tip of the fibula towards the base of the fourthmetatarsal. This should lie between the suraland peroneal nerves but care must be taken,especially distally. The incision can be stopped atthe CC joint if access to only the subtalar joint isrequired.

The anterior approach is an extension of theapproach used to access the ankle. A straightincision between the tendons of extensor hallucislongus and tibialis anterior is made over the TNjoint and the extensor retinaculum carefullyincised. This gives excellent access to the medialand lateral extents of the surprisingly broad TNjoint.

Alternatively, if performing a triple fusion, ananteromedial incision between the tendons oftibialis anterior and posterior allows a wider skinbridge. Care must be taken of the saphenous veinand nerve, which lie in this plane. It is harder toaccess the far lateral extent of the TN jointthrough this incision and access through thelateral incision may be required.

Dissection

The utility lateral incision is deepened to passabove the peroneal tendons to the subtalar joint.By releasing the insertion of extensor digitorumbrevis and elevating this with a distally based flap,the sinus tarsi and CC joint can be visualized. Intriple arthrodeses, after preparation of the CC andST joints, the lateral aspect of the TN joint can beaccessed from the lateral side.

Superficialperoneal

Sural Extensorhallucis longus

A

BTibialisanterior

Tibialisposterior

Figure 14.13 (a) Approaches for hindfoot arthrodesis – utility lateral approach. (b) Approaches for hindfootarthrodesis – anterior (A) and anteromedial (B) approach to talonavicular joint

Procedure

Once exposed and mobilized the selected jointsshould be meticulously prepared as detailed in‘Principles of foot and ankle arthrodesis’ (p. 231).With regard to the TN joint, the full extent of thejoint must be realized for successful fusion. It iseasy not to prepare deep enough (one should seethe spring ligament in the depth of the wound) orlaterally enough. During subtalar preparation, theposterior facet is prepared first. When the tendonof FHL (identified by moving the toe) isvisualized, preparation is deep enough. Great careshould be taken, however, as deep to the FHL isthe tibial neurovascular bundle. After preparationof the posterior facet, the medial facet can beprepared. Damage to the structures posterior tothis, and the head of the talus superiorly, must beavoided. Once all of the required joints have beenprepared, they need to be held in the requiredposition of arthrodesis. For the ST joint, theoptimum position is 5° of valgus. However, ifthere is rigidity of the midfoot from alongstanding deformity, 5° of valgus may notallow the foot to be placed flat on the floor.Therefore, the position of the weightbearing footshould be confirmed by using a flat surface priorto fixation of the ST joint. A varus position mustbe avoided.

The ideal position of arthrodesis of the TNjoint is one of ‘talar neutral’ – that is, with thedomed talar head central in the navicular. In thisposition the long axis of the talus should passthrough the long axis of the first metatarsal. Caremust be taken not to extend or flex the TN jointand the foot should be perpendicular to the tibiawith the ankle in neutral. Again, the position ofthe foot flat on the floor must be checked and asuboptimal position may have to be accepted toachieve this. The CC joint position will bedictated by the other joints and therefore fixedlast.

Various methods of ST joint fixation have beendescribed. Our preferred method is to place alarge diameter (8 mm) cannulated compression

Structure at risk

• Tibial neurovascular bundle

screw from the posterolateral aspect of thecalcaneum into the talus to cross the posteriorfacet at 90°. This avoids possible impingementproblems from a screw inserted from the talarneck. The entry point is in a line down from thelateral margin of the Achilles tendon, just abovethe plantar skin of the heel. Too plantarwards orcentral an entry point may cause painfulprominence of the screw head. Usually, a singlescrew is sufficient. The TN joint can be fixed usinga retrograde screw from the medial edge of thenavicular into the talar neck. Care must be takento ensure a good bite is obtained medially withoutintruding upon the NC joint. Further fixation canbe obtained with a screw from the anterior surfaceof the navicular. Screw fixation of the CC joint,antegrade from the anterior process of thecalcaneum or retrograde from the cuboid, cansometimes be difficult. In which case, compressionstaples or a low profile plate can be used.

Closure

All wounds should be carefully closed, ensuring agood soft tissue layer is closed over the joints priorto skin closure. If an anterior approach has beenused, the retinaculum must be carefully repaired.The leg is then placed in a back-slab.


(See also ‘Principles of foot and ankle arthrodesis’,p. 231.)

The patient is kept in a non-weightbearing castfor 6 weeks or until early radiological signs ofunion are seen. They can then begin to graduallyincrease their weightbearing. A cast should beretained for 3 months or until there is solidradiographical and clinical evidence of union.


Davies MB, Rosenfeld PF, Stavrou P, et al. Acomprehensive review of subtalar arthrodesis. FootAnkle Int 2007;28:295–7.


Calcaneal osteotomy 255

CALCANEAL OSTEOTOMY


Indications

A calcaneal osteotomy is rarely indicated inisolation. It is usually performed as part of a softtissue correction of a hindfoot deformity toprotect the reconstruction and reconstitute themechanical axis of the hindfoot. Commonly usedexamples are a medial displacement osteotomy aspart of a tibialis posterior reconstruction and aclosing wedge or lateralizing osteotomy as part ofa pes cavus correction. Occasionally an osteotomymay be used to correct a post-traumatic deformityof the calcaneum, but this is often done incombination with a subtalar arthrodesis as there isusually associated joint disruption.

Contraindications

• Active infection or critical ischaemia of thelimb is an absolute contraindication.

• A more proximal uncorrected deformity is arelative contraindication. It is difficult to judgehindfoot alignment if there is a more proximaldeformity. Furthermore, if a proximal deformityis subsequently corrected, the hindfootalignment may become incorrect. It is thereforeadvisable to address proximal deformities first.

Consent and risks

• Neurovascular damage: the sural nerve is in thezone of the incision and must be avoided. On themedial extent of any osteotomy, theneurovascular bundle is close by and can beinjured with aggressive use of power tools

• Malunion: usually due to technical errors injudging the degree of correction but also due tohardware failure

• Non-union: rare due to large surface area ofcancellous bone

• Recurrence of deformity, especially if thedeforming soft tissues are not correctly balancedor there is a progressive neuromuscular condition


• General or spinal anaesthesia with a thightourniquet allowing exposure to above the kneeto judge alignment satisfactorily.

• Most soft tissue procedures require access toboth the medial and lateral sides of thehindfoot. Therefore, position the patientsupine, with a removable sandbag under theipsilateral buttock.

SURGICAL TECHNIQUE

The calcaneal osteotomy is usually performed firstas part of any soft tissue correction of the hindfootto avoid accidental damage to the correction.

Landmarks

• Anterior border of tendo-Achilles• Junction of dorsal and plantar skin of heel.

Incision

Some authors advocate an oblique lateral incisionover the line of the proposed osteotomy.Unfortunately, this coincides with the course ofthe sural nerve and puts it at risk. We thereforeadvise an extensile lateral incision, commonlyused for calcaneal fixation, as the sural nerve isprotected in the elevated flap. This also allowsbetter visualization of the calcaneum. The inferiorlimb of the incision runs along the junction of theplantar and dorsal skin. The superior limb extendssuperiorly in line with the anterior border of thetendo-Achilles (Fig. 14.14). The extent of theexposure required is less than for calcanealfixation but the insertion of tendo-Achillessuperiorly and plantar fascia inferiorly should bevisualized.

Dissection

The incision is carried straight down to bone andthe flap elevated in the subperiosteal layer withminimal trauma to the soft tissues.

Structure at risk

• Sural nerve

Procedure

For both medial and lateral displacement andlateral closing wedge osteotomies, the angle of theosteotomy is the same, at about 45° to the plantarsurface of the foot (Fig. 14.15). It runs anterior tothe insertion of tendo-Achilles to superior to theinsertion of the plantar fascia. Trethowan bonelevers are placed to protect these two structuresand guide the osteotomy line. Using an oscillatingsaw, the lateral wall is cut and the saw advanceduntil it reaches the medial wall.

The medial wall is cautiously weakened bybouncing the saw off the wall and the osteotomycompleted using of a broad osteotome with care toavoid any pressure on the medial soft tissues.Once completed, the osteotome is carefullytwisted to mobilize the fragment and a dissector

Structures at risk

• Tendo-Achilles• Plantar fascia

used to free the medial periosteum. The tuberosityfragment can then be displaced, either medially orlaterally; this is performed with the ankle in aplantar flexed position. Displacement will dependupon the degree of correction required, 1 cm isusually sufficient. The position can usually beprovisionally ‘locked’ by holding the foot in aplantigrade position. Once the surgeon is confidentwith the correction, a guidewire from a cannulatedscrew system can be inserted, under fluoroscopicguidance, from the lateral aspect of the tuberosityinto the anterior fragment. Care must be taken toensure that the wire enters the anterior calcaneumand does not penetrate medially. Once satisfiedwith the position, a single cannulated screw issufficient to hold the osteotomy. Alternatively, astepped plate may be used.

A lateral closing wedge can be added to thelateral displacement osteotomy, if required, toallow increased correction; the thickness of thewedge will depend upon the correction desired.Using minimal force, an attempt is made to closethe wedge prior to fixation.

Closure

Closure of the flap must be meticulous andwithout tension. Deep Vicryl sutures andinterrupted nylon sutures are satisfactory. The legshould be immobilized once the soft tissuecomponent is completed.


The leg should be elevated for 72 hours untilswelling has subsided. The leg is then placed in anon-weightbearing cast for a duration usuallydictated by the soft tissue correction. Theosteotomy usually heals within about 6 weeks.


Dwyer FC. Osteotomy of the calcaneum for pescavus. J Bone Joint Surg Br 1959;41:80–6.Evans D. Calcaneo-valgus deformity. J Bone JointSurg Br 1975;57:270–8.Trnka HJ, Easley ME, Myerson MS. The role ofcalcaneal osteotomies for correction of adultflatfoot. Clin Orthop Relat Res 1999;365:50–64.


Figure 14.14 Extensile lateral approach to os calcis

Tendoachilles

Plantar fascia

Figure 14.15 Alignment of calcaneal osteotomy

Viva questions 257

Viva questions

1. Describe how you can maximize the union ratefor a midfoot arthrodesis.

2. In the context of hallux valgus deformity, whatis congruency and how does it affect yourdecision-making process?

3. What radiographs do you use to assess halluxvalgus deformity, what angles do you measureand how does this influence your choice ofoperation?

4. What surgical approach do you use for a firstmetatarsal osteotomy and what are theimportant structures at risk?

5. Describe the blood supply to the firstmetatarsal head. How can your choice of halluxvalgus procedure affect the blood supply?

6. What structures do you need to identify inperforming a lateral release in a hallux valgusdeformity?

7. In a scarf osteotomy, what is ‘troughing’ andhow does the design of your osteotomyinfluence occurrence?

8. Why is a Keller’s procedure generally poorlytolerated by patients and when would youconsider performing one?

9. What are the key differences between a Weil’sand a Helal’s osteotomy of the lessermetatarsals?

10. What is the difference between a claw toe,mallet toe and a hammer toe?

11. Describe the mechanics of a Girdlestonetendon transfer for the lesser toes and whenyou would perform this.

12. How do you assess the severity of halluxrigidus and how does this influence yourtreatment options?

13. What is the optimum position of arthrodesis ofthe first metatarsophalangeal joint (MTPJ) andhow would you assess this intraoperatively?

14. Describe the anatomy of a toenail. How doesthis knowledge help in the treatment ofingrowing nails?

15. What is a Morton’s Neuroma and where is itmost commonly found?

16. How does movement of the subtalar joint ingait affect movement of the Chopart joints(talonavicular and calcaneocuboid)?

17. Describe your understanding of the concept of‘Talar neutral’ and why is this useful inassessing foot position?

18. What surgical approach do you use to reachthe subtalar joint, what are the landmarks andwhat structures are at risk?

19. What structures are at risk during a calcanealosteotomy?

20. When would you consider performing alateralizing calcaneal osteotomy?

Limb reconstruction15

Robert Jennings and Peter Calder

Principles of limb reconstruction 258Surgical techniques 259Femoral lengthening 261

Tibial lengthening 263Principles of deformity correction 263Viva questions 265

PRINCIPLES OF LIMBRECONSTRUCTION

When subjected to slow, steady traction, underthe appropriate conditions, living tissue becomesmetabolically activated and is able to regenerate.This ‘tension-stress’ effect was described byProfessor Gavril Abramovich Ilizarov from Kurganin western Siberia, who pioneered the field oflimb reconstruction from the early 1950s anddeveloped the highly successful techniques thatare still in use today.

Callus, formed at a corticotomy site, can bedistracted at speeds of up to 1 mm per day and,reliably, form new bone in the process of‘distraction osteogenesis’. Once the goal length isachieved, a period of consolidation is requiredbefore fixator removal. This takes approximately30–40 days per centimetre of lengthening toprevent bowing or fracture. Anecdotally, themaximum, safe distraction possible per procedureis 20 per cent of the original length of the bonebeing lengthened.

Distraction osteogenesis requires:• Stability• Maintenance of blood supply• A latency period (5–7 days)• Appropriate rate of distraction (0.75–1 mm per

day)• Appropriate rhythm (frequency) of distraction

(0.25 mm, 6–8 hourly).

BIOMECHANICS

• Monolateral rail:– Cantilever loading– Concentrated high stress on near cortex

• Circular frame:– Beam loading– More even distribution of stress across

cortices.

METHODS TO IMPROVE STABILITY

• Wire:– Increase diameter (1.8 mm for adult, 1.5 mm

for child)– Increase tension (130 Nm for adult, 110 Nm

for child)– Increase crossing angles (Fig. 15.1)

Use of all-wire fixation across a diaphysis is lessattractive, due to risks to soft tissues. Hence, hybridfixation with half-pins and wires is preferred.

90° 45°

Figure 15.1 ‘Crossing angles’: stability (a) > (b)

Surgical techniques 259

SURGICAL TECHNIQUES


Indications

• Tibial/ femoral lengthening• Long bone deformity correction.

Contraindications

• Non-compliant patient• Adjacent joint instability• Skin infection• Significant soft tissue contractures• Poor vascularity• Pregnancy• Smoker – relative.

Operative planning

Recent radiographs must be available. Theseshould include full leg length views, in theanteroposterior plane, of both lower limbs withthe patellae facing forwards and appropriatelateral views. The mechanical and anatomical axesneed to be assessed on both legs. If both legs are‘abnormal’, standard angles are used forcalculations.

Consent and risks

• Duration of treatment must be emphasized(c.40 days/cm)

• Pain: post-surgical, chronic dull ache duringdistraction is common

• Pin site problems: inflammation; soft tissueinfection; osteomyelitis

• Joint stiffness or subluxation• Soft tissue contractures• Vascular injury• Neurological injury: perioperative; postoperative

stretching• Premature/delayed/non-union• Hardware failure• Late bowing• Fracture• Deep vein thrombosis/pulmonary embolism

– Opposing ‘olive’ wires– Increase number of wires

• Half-pin:– Increase diameter– Hydroxyapatite coating– Increase crossing angles (multiplanar)– Decrease distance of external construct to

bone– Near and far positions (Fig. 15.2)– Increase number

(a) (b)

Figure 15.2 ‘Near and far’ fixation: stability (a) > (b)

• Ring:– Decrease diameter (note: allow at least 2 cm

clearance for swelling)– Fix bone in middle (compromise with

eccentrically positioned tibia)– Near and far positions– Increase number (including ‘dummy’ rings)

• Attachments:– Use ‘slotted’ bolts – high surface area of

contact with wire– Build ring to wire, if necessary – decrease

bend on wire.

260 Limb reconstruction

Leg length discrepancyAssessment from history, examination andradiological findings. Care must be taken todifferentiate true from apparent causes of leglength discrepancy.

Angular deformityClinical and radiographical examination allowscalculation of the centre of rotation of angulation(CORA; Fig. 15.3). This is present at theintersection point of proximal and distalanatomical axes.

A decision is made as to whether the deformityrequires surgical correction. This is based on theseverity of deformity and the presence or absenceof associated factors.

Common causes of apparent leglength discrepancy

• Scoliosis• Hip instability or dislocation• Fixed hip adduction• Fixed knee flexion• Equinus deformity of the ankle

Indications for surgical correction ofangular deformity

• Mechanical axis deviation (MAD) (Fig. 15.4)• Rotational malalignment• Translation• Leg length discrepancy

Proximal anatomicand mechanical axis

CORA

Distal anatomicaland mechanical axis

Figure 15.3 ‘CORA’ (centre of rotation of angulation) –mechanical and anatomical axis

MAD

LDFA=92°

MAD= 41mm

Figure 15.4 Mechanical axis deviation (MAD)

The next decision is the appropriate site forosteotomy. Osteotomy performed at the CORAwill not result in translation (Fig. 15.5); osteotomyaway from the CORA will produce translation.Note: if the hinge is not on the bisector line (Fig.15.6) or the CORA is not on the anatomical axis,osteotomy at any level will result in translation.

SURGICAL TECHNIQUE

Wire insertion

• Aseptic ‘no hands’/‘Russian’ technique• Alcohol-soaked gauze used to coat and hold wire• Low heat generation is ensured via short,

intermittent bursts with the wire driver• Wire tapped with mallet, when through

contralateral skin.

Femoral lengthening 261

Half-pin insertion

• Stab skin incision• Blunt dissection to bone• Soft tissue protecting drill guide• Both cortices pre-drilled• Low heat generation – intermittent drilling• Saline to cool and wash out swarf (decreases

infection risk).

Wire/Half-pin placement

• ‘Safe corridors’ – avoid neurovascular structures• Avoid crossing compartments, if possible• Soft tissues on stretch, e.g. quadriceps in

flexion, hamstrings in extension (helpspostoperative mobility).

Corticotomy

• Low energy• Minimal incision, to admit osteotome• Periosteum incised and preserved, when

possible• A row of holes are pre-drilled with a 4.8 mm

drill, with saline used for cooling. Thistechnique allows low heat generation, reducingcorticotomy site bone necrosis

• An osteotome is used to join holes, with a twistto break the posterior cortex.

Note: latent period: 5–7 days; quarter turns: 3–4times per day (0.75–1 mm/day).

FEMORAL LENGTHENING


See ‘Principles of limb reconstruction’ (p. 259).

(a) (b)

Figure 15.5 With the hinge placed along the ‘bisectorline of the CORA’, there will be no translation

Figure 15.6 With the hinge placed off the ‘bisector line of the CORA’, translation will result


SURGICAL TECHNIQUE

Corticotomy

LandmarksJunction of the proximal metaphysis anddiaphysis – 1.5 cm distal to lesser trochanter.

Incision and dissection• Image intensifier control• Adequate longitudinal incision (to admit 8 mm

osteotome).

Either:• Anterior approach – between sartorius and

tensor fascia lata (TFL), then through vastusintermedius and rectus femoris

Or:• Lateral approach – through TFL and split vastus

lateralis

Corticotomy technique as above.

Procedure

• Monolateral rail (Fig. 15.7):– If no risk of joint subluxation– Three half-pins proximal and, at least, three

distal to corticotomy.• Circular frame:

– If risk of joint subluxation– Span knee/pelvis– Arches/two-thirds rings to allow mobility– Same principles as above.

Lengthening intramedullary nailInternal lengthening nails have increased inpopularity since becoming fully implantable,without the need for an external component fortheir extension. These newer nails have someadvantages over the cumbersome externalsystems, most notably the lack of pin siteassociated problems, improved cosmesis andbetter patient tolerance. However, full weight -bearing is not advisable until the regenerated boneis mature and, inadvertent, rapid extension is asignificant risk. Currently, the most popular designof lengthening nail in the UK is the‘ISKD’ (Intramedullary Skeletal KineticDistractor, Orthofix; Fig. 15.8), with types

Figure 15.7 Radiograph of femoral limb reconstructionsystem (LRS) rail

Figure 15.8 Radiograph of femoral IntramedullarySkeletal Kinetic Distractor (ISKD)

Principles of deformity correction 263

available for both femur and tibia. Elongation ofthe internal mechanism is achieved by alternatingrotation of the limb and measured with a hand-held monitor.

TIBIAL LENGTHENING (FIG 15.9)


See ‘Principles of limb reconstruction’ (p. 258).

SURGICAL TECHNIQUE

Corticotomy

LandmarksJunction of the proximal metaphysis anddiaphysis, c.1.5 cm distal to tibial tuberosity.

Incision and dissection• Image intensifier control• Adequate longitudinal incision over anterior

tibial crest (to admit 8 mm osteotome)

Figure 15.9 Tibial Ilizarov frame for lengthening

• Periosteum incised, then lifted off medially andlaterally with blunt dissection

• Corticotomy technique as above.

Procedure• Two rings per bone segment (near and far)• Two wires/half-pins per ring• Four connecting, threaded rods between rings

(Fig. 15.10)• Fibular osteotomy

– Mid-diaphyseal avoids neurovascular struc -tures

• Fix fibula (proximal and distal), to avoid jointsubluxation.

Figure 15.10 Radiograph of tibial Ilizarov frame forlengthening

PRINCIPLES OF DEFORMITYCORRECTION


Operative planning

The initial decision is between acute and gradualcorrection of the deformity:

• Acute– Mild deformity– Opening or closing wedge– Plate and screws– Intra-medullary (IM) nail– External fixation

• Gradual– More severe deformity– Less risk of neurological damage– Potential for revision of correction protocol– Distraction osteogenesis– Circular frame e.g. Ilizarov or hexapod type

(e.g. Taylor Spatial Frame)– Monolateral fixator: on convex side –

distraction at osteotomy site (See Fig. 15.5page 261); on concave side – compression atosteotomy site therefore requires wedgeexcision.

SURGICAL TECHNIQUE

Example: Simple, tibial diaphyseal deformitycorrection with a circular frame.• Application of proximal and distal rings (see

above; Fig. 15.11)• Osteotomy at CORA (see above)• Ilizarov method

– Inter-ring connections with hinges alongbisector line of CORA (Fig. 15.12).

• Taylor Spatial Frame (TSF) method (Figs 15.13and 15.14)– Inter-ring connections with six oblique,

adjustable struts (‘virtual hinge’)


Figure 15.12 Radiograph of a simple Ilizarov frameconstruct used to correct deformity in a congenitallyshort tibia

Figure 15.13 Tibial Taylor Spatial Frame

Figure 15.11 ‘Near and far’ ringswith osteotomy at centre of rotationof angulation (CORA), hinge alongbisector line

Viva questions 265

Online computer programme

• Requires: postoperative radiograph measure -ments– Frame measurements (ring sizes/initial strut

lengths)• Delivers: pre- and post-correction images

– Corrective protocol.


• Latency period (5–7 days)• Gradual correction period• Consolidation period• Removal of frame when clinically and

radiologically appropriate.


De Bastiani G, Aldegheri R, Renzi-Brivio L, et al.Limb lengthening by callus distraction(Callotasis). J Pediatr Orthop 1987;7:129–34.Cole JD, Justin D, Kasparis T, et al. Theintramedullary skeletal kinetic distractor (ISKD):first clinical results of a new intramedullary nailfor lengthening of the femur and tibia. Injury2001;32(suppl 4):SD129–39.Paley D, Herzenberg JE. Principles of DeformityCorrection. Berlin: Springer, 2001.Paley D, Herzenberg JE, Tetsworth K, et al.Deformity planning for frontal and sagittal planecorrective osteotomies. Orthop Clin North Am1994;25:425–65.Rozbruch SR, Ilizarov S. Limb Lengthening andReconstruction Surgery. New York: Informa, 2007.

Figure 15.14 Radiograph of tibial Taylor Spatial Framefor deformity correction

Viva questions

1. What are the causes of leg length discrepancy?

2. What problems are associated with leg lengthdiscrepancy?

3. How do you assess length discrepancy of thelower limbs?

4. What are the differences between true,apparent and functional leg lengthdiscrepancy?

5. What are the treatment options for leg lengthdiscrepancy in both adults and children?

6. What are the relative percentage contributionsto normal growth of all of the lower limbphyses?

7. How can you predict the magnitude of leglength discrepancy at skeletal maturity?

8. What are the problems associated with shoeraises?

9. What problems may occur as a consequence ofacute shortening procedures?

10. Who was Professor Gavril Abramovich Ilizarov?

11. What problems may occur due to leglengthening procedure?

12. What are the prerequisite factors necessary forsuccessful leg lengthening?

13. What are the reasons for leaving a ‘latencyperiod’ prior to commencing distraction?

14. What are the advantages and disadvantages oflengthening intra-medullary nails?

15. Give the causes of lower limb deformity.


16. How do you assess the degree of lower limbdeformity?

17. Draw a ‘Selenius graph’.

18. What options are available for correcting lowerlimb deformity in both adults and children?

19. What are the consequences of hingemisplacement when applying an Ilizarov framefor deformity correction?

20. What are the advantages of using a ‘TaylorSpatial Frame’ rather than an Ilizarov frame fordeformity correction?

Paediatric orthopaedic surgery16

Russell Hawkins and Aresh Hashemi-Nejad

Epiphysiodesis 267Developmental dysplasia of the hip – closed

reduction 269Developmental dysplasia of the hip – open reduction 271Developmental dysplasia of the hip – pelvic

osteotomy 273Developmental dysplasia of the hip – proximal

femoral osteotomy 276

Slipped upper femoral epiphysis – pinning 278Slipped upper femoral epiphysis – osteotomy 280Tendo-Achilles lengthening 281Congenital talipes equinovarus correction 284Surgical treatment of Perthes disease 287Principles of surgery in cerebral palsy 289Viva questions 291

EPIPHYSIODESIS


Epiphysiodesis involves destruction of the physisto allow equalization of leg length discrepancy(LLD) in children. As most growth occurs aroundthe knee, the distal femoral and/or the proximaltibial and fibular physes are targeted depending onthe predicted remaining growth.

Indications

• Predicted true LLD 2–5 cm at maturity• May be used to treat LLD >7 cm through

lengthening of the short limb andepiphysiodesis of the long limb.

Contraindications

• Apparent LLD• LLD <1.5 cm• Localized infection• Tumour• Closed physis.

Operative planning

Various methods exist to determine the LLD atmaturity and to guide the timing and type ofepiphysiodesis (distal femoral and/or proximaltibial):• Green–Anderson growth remaining method:

estimates growth potential in the distal femoraland proximal tibial physes at various skeletalages separately for girls and boys.

• Moseley straight line graph: a logarithmicrepresentation of the Green–Anderson method.

• Menelaus arithmetic method: assumes growthof 10 mm/year from distal femur and 6 mm/year from the proximal tibia and that girls reachmaturity at 14 and boys at 16 years.

• Eastwood–Cole method: a graphicrepresentation of the arithmetic method buttakes into account non-linear changes in LLD.Bone age is more reliable than chronological

Consent and risks

• Neurovascular injury: <1 per cent• Infection: <1 per cent• Fracture: <1 per cent• Angular deformity: <1 per cent• Residual LLD: 80 per cent patients within 1 cm

268 Paediatric orthopaedic surgery

age in determining growth remaining and can becalculated using the Greulich and Pyle method.This involves comparison of a left hand and wristradiograph with a known standard.


General anaesthesia is used, together withintravenous antibiotic prophylaxis. The patient ispositioned supine with the knee slightly flexedover a small sandbag. A pneumatic thightourniquet is used. An image intensifier is requiredand a gonadal shield should be appropriatelyplaced.

SURGICAL TECHNIQUE

Landmarks

The image intensifier is used to mark theorientation of the physis in the frontal plane andthe midpoint of the physis in the lateral plane.

Approach

A 1–2 cm longitudinal incision is centred over themidpoint of physis medially and laterally. A largerincision is made laterally to identify and protectthe common peroneal nerve if performingproximal fibular epiphysiodesis.

Dissection

Sharp dissection is continued down to bone.

PROCEDURE

Physeal cartilage is removed using a 4.5 mmdiameter drill under image guidance: a singleentry point is made in the lateral cortex in linewith the physis on the frontal view and at itsmidpoint on the lateral view. This minimizesweakening of the cortex and the risk ofsubsequent fracture. The drill is advancedtransversely along the line of the physis in thefrontal view until the tip reaches its midpoint(Fig. 16.1).

Using the same entry point each time, the drillis tilted 30° first anteriorly then posteriorly andadvanced to the halfway mark to remove a fan-

shaped area of physeal cartilage (Fig. 16.2). Thistechnique is then repeated on the medial side. Theswarf should be inspected to ensure removal ofphyseal cartilage. Further curettage of theepiphyseal surface is performed to remove anyremaining physeal cartilage.

Closure

Layered closure using absorbable subcuticularmaterial to skin.


• Mobilize full weightbearing with crutches forcomfort for up to 2 weeks.

• Radiographs at 3 months then periodically untilmaturity to assess physeal closure and leglengths.


Atar D, Lehman WB, Grant AD, et al. (1991)Percutaneous epiphysiodesis. J Bone Joint Surg Br1991;73:173.Eastwood DM, Cole WG. A graphic method fortiming the correction of leg-length discrepancy. JBone Joint Surg Br 1995;77:743–7.Menelaus MB. Correction of leg length

Figure 16.1 The trajectory of the drill should bechecked periodically using the image intensifier toensure obliteration of the physis

DDH – closed reduction 269

Figure 16.2 The drill is inserted inthe mid-sagittal line of the femurthen angled anteriorly andposteriorly by 30° using the sameentry point

discrepancy by epiphyseal arrest. J Bone Joint SurgBr 1966;48:336–9.Snyder M, Harcke HT, Bowen JR, et al. Evaluationof physeal behaviour in response to epiphysiodesiswith the use of serial magnetic resonance imaging.J Bone Joint Surg Am 1994;76:224–9.

DEVELOPMENTAL DYSPLASIA OF THEHIP – CLOSED REDUCTION


Although often combined with an arthrogram andsoft tissue releases, technically this remains aclosed procedure as the capsule is not opened.Adductor and psoas releases are performed via anopen medial approach, the technical details ofwhich are provided in the ‘Developmentaldysplasia of the hip – open reduction’ section(p. 271).

The optimum timing of reduction is subject todebate: waiting for the capital femoral epiphysisto appear reduces the risk of avascular necrosisalthough, conversely, early reduction suggests abetter long-term outcome.

Indications

• 6–18 months old child with developmentaldysplasia of the hip (DDH)

• Failed treatment with Pavlik harness.

Contraindications

Child <6 or >18 months.

Operative planning

Imaging studies are requested depending on theexpected presence of the ossific nucleus:• Dynamic ultrasound if <6 months to determine

alpha and beta angles, reducibility and capsularlaxity.

• Plain anteroposterior (AP) pelvis and froglateral radiographs if >6 months. Note anydelayed appearance of ossific nucleus, Shenton,Hilgenreiner and Perkins lines, acetabular indexand Tonnis grade.

Consent and risks

• Application of spica plaster in the humanposition (Fig. 16.5); subsequent care must beexplained to parents

• Avascular necrosis: 5–10 per cent• Re-dislocation: <5 per cent• Further surgery: 20 per cent• Neurovascular injury and infection: <1 per cent

(if arthrogram and soft tissue releasesperformed)

• Risk of conversion to open reduction: 10–20 percent. Greater risk for high-riding dislocation


General anaesthesia is used. The patient ispositioned supine at the end of a radiolucenttable, to allow image intensifier access. Thesurgeon stands between flexed, abducted andexternally rotated hips.

SURGICAL TECHNIQUE

Examination under anaesthesia (EUA) andarthrogram are first performed to assess reductionand the need for adductor longus, gracilis andpsoas release.

Landmarks

Adductor longus muscle – palpable in the child’sgroin (Fig. 16.3).

The hip is reduced with a combination offlexion, abduction and anterior displacementwithout excessive force. Soft tissue releases shouldbe considered if this does not occur easily. If thehead appears to stand out from the acetabulum onthe arthrogram, this suggests a block to reductionsuch as an infolded labrum. A conversion to openreduction may therefore be required.

The stability is assessed within the safe zones offlexion and abduction. Typically, a stable positionis 90° of flexion and 30–50° of abduction.Extreme positions increase the risk of avascularnecrosis and must be avoided.

A well-padded spica plaster is carefully appliedin the human position before final radiographicconfirmation of reduction (Fig. 16.4).


Femoral neurovascularbundle

Sartorius

Profundafemoris

Medialfemoriscircumflexvessels

Pectineus

Adductor longus

Gracilis

Figure 16.3 Adductor longus and its relationships

Figure 16.4 Child plastered in the ‘human position’

Procedure

A 22G spinal needle is introduced beneath thepalpable adductor longus tendon in the groin andadvanced cranially towards the ipsilateral scapularuntil the tip is felt to traverse the hip capsule. Theposition is confirmed with image intensifier beforeinstilling 0.5 mL of diluted contrast.


• Plaster check prior to discharge.• Limited slice CT at 2/52 to confirm

maintenance of reduction.• Convert to abduction brace at 10/52.• Wean out of brace after further 6/52.

Depending on acetabular development, nighttime bracing may continue for up to 1 year.

DDH – open reduction 271


Harcke HT, Kumar SJ. Current concepts review –the role of ultrasound in the diagnosis andmanagement of congenital dislocation anddevelopmental dysplasia of the hip. J Bone JointSurg Am 1991;73:622–8.Kalamchi A, MacEwen GD. Avascular necrosisfollowing treatment of congenital dislocation ofthe hip. J Bone Joint Surg Am 1980;62:876–88.Malvitz TA, Weinstein SL. Closed reduction forcongenital dislocation of the hip. Functional andradiographic results after an average of thirtyyears. J Bone Joint Surg Am 1994;12:1777–92.Ramsey PL, Lasser S, MacEwen GD. Congenitaldislocation of the hip: use of the Pavlik harness inthe child in the first six months of life. J Bone JointSurg Am 1978;58:1000–4.Severin E. Contribution to knowledge ofcongenital dislocation of the hip joint: late resultsof closed reduction and arthrographic studies ofrecent cases. Acta Chir Scand Suppl 1941;63:1–42.

DEVELOPMENTAL DYSPLASIA OF THEHIP – OPEN REDUCTION


Open reduction deals directly with soft tissueobstruction facilitating relocation of the hipwithout excessive force.

Indications

• Children 6–18 months with: obstruction toclosed reduction (psoas tendon, contractedcapsule, ligamentum teres, transverse acetabularligament, and inverted limbus), an unstable safezone, previous failed closed or open reduction

• Children presenting over 18 months.

Contraindications

Children less than 6 months old.

Operative planning

Radiographs as per closed reduction.


General anaesthesia with intravenous antibiotics.The patient is positioned supine at the end of aradiolucent table. The surgeon stands between thepatient’s legs for a medial approach or on theoperative side for an anterior approach. An imageintensifier is required.

SURGICAL TECHNIQUE

A medial approach is used if the patient is lessthan 12 months old; an anterior approach, via abikini incision, is preferred if the child is older.

MEDIAL APPROACH

Landmarks

Adductor longus tendon – palpable in the groin,approximately 2 cm lateral to the labia/scrotum.

Incision

A 2.5 cm, vertical skin crease incision is centred onthe palpable tendon of adductor longus.


Structures at risk

• Anterior and posterior divisions of obturatornerve

Consent and risks

• Application of spica plaster; subsequent caremust be explained to parents

• Neurovascular injury: <1 per cent• Infection: <1 per cent• Avascular necrosis: 5 per cent• Re-dislocation: 1 per cent• Further surgery for dysplasia or LLD: 10–15 per

cent

Gluteus mediusRectus femoris (cut)

Sartorius

Anterior hip capsule

Tensor fascialata

Figure 16.5 Anterior approach to the right hip


second line is then dropped vertically downwardsfrom the ASIS. Next, a 5 cm bikini line incision ismarked 2 cm inferior and parallel to the inguinalligament, one-third of it medial and two-thirdslateral to the vertical line.


The interval between sartorius and tensor fascialata is developed to reach the rectus femoris andgluteus medius.

Deep dissection

The interval between the rectus femoris andgluteus medius is dissected and the straight headof the rectus femoris is detached from the anteriorcapsule. It may then be retracted medially to allowpsoas tenotomy and L-shaped anterior arthrotomy(see Figure 16.5).

PROCEDURE

Obstructions to reduction are removed asnecessary; pulvinar is extracted, the transverseligament is released and the ligamentum teresexcised if obstructive. Adductor releases areperformed, via a separate groin incision, tofacilitate reduction as required.

The redundant capsule is tightened withcapsulorrhaphy following reduction. Using theimage intensifier, the position of maximumstability is identified; the hip is placed in 30° of

Structure at risk

• Lateral cutaneous nerve of the thigh

The fascia overlying the tendons of adductorlongus and gracilis is opened along their lengthand fractional lengthening tenotomies areperformed. Adductor magnus and brevis areexposed with blunt dissection. Branches of theobturator nerve are identified on the superficialsurface of the adductor brevis and are protected.

Deep dissection

The plane between the adductor magnus andbrevis is dissected to access the lesser trochanter.A psoas tenotomy is performed under directvision avoiding the medial femoral circumflexvessels which pass over the medial surface of thepsoas tendon distally.

A medial arthrotomy is made above the vesselsand the acetabular attachment of the ligamentumteres is divided and used as a traction aid torelocate the femoral head. It is then sutured to theanterior inferior capsule.

ANTERIOR APPROACH

Landmarks

• Anterior superior iliac spine (ASIS)• Pubic tubercle.

Incision

The line of the inguinal ligament is markedbetween the ASIS and the pubic tubercle. A

Structure at risk

• Medial circumflex femoral artery

DDH – pelvic osteotomy 273

developmental dysplasia of the hip. A long termreview. J Bone Joint Surg Br 2000;82:17–27.

DEVELOPMENTAL DYSPLASIA OF THEHIP – PELVIC OSTEOTOMY

Various techniques exist for pelvic osteotomy inDDH and an account of them all is beyond thescope of this chapter. Therefore, only the Salterand Pemberton types will be described further.

SALTER OSTEOTOMY

Preoperative planning

Indications• Acetabular dysplasia; acetabulum faces

anterolaterally causing deficient anteriorcoverage in extension and deficient superiorcoverage in adduction

• Congruent hip• 18 months to 6 years (as it requires flexibility of

symphysis pubis).

Contraindications

• Bilateral DDH (uncovers contralateral hip)• Congruent reduction not achievable on EUA

arthrogram.

Consent and risks

• Overall risks: <5 per cent• Neurovascular injury: 1 per cent• Limited weightbearing/crutches• Infection: <1 per cent• LLD: gains 1 cm with Salter osteotomy• Triradiate cartilage growth arrest (Pemberton

osteotomy)• Failure of graft• Hardware breakage• Residual dysplasia (retroversion)• Secondary degeneration: lateralization of joint

increases joint reaction force (Salter)• Further surgery (removal of hardware, salvage

procedures)

internal rotation, flexion and abduction then eachof these positions is removed in sequence todetermine positioning in plaster and the need forfuture surgery.

Femoral osteotomy or an acetabular proceduremay be undertaken concomitantly if severedysplasia is present in an older child.

Closure

• Layered closure ensuring reconstruction ofrectus femoris.

• Skin is closed with absorbable subcuticularmaterial followed by a waterproof dressing.

A well-padded spica plaster is carefully applied inthe stable safe zone of flexion and abductionbefore final radiographic confirmation ofreduction. This should be in greater than 90° offlexion without forced flexion and abductedbetween 30° and 60°.


• Plaster check prior to discharge.• Limited slice CT at two weeks to confirm

maintenance of reduction.• Spica removal at ten weeks and mobilization

allowed.• Follow up at three months with radiographs.


Ferguson AB Jr. Primary open reduction ofcongenital dislocation of the hip using a medianadductor approach. J Bone Joint Surg Am1973;55:671–81.Morcuende JA, Meyer MD, Dolan LA, et al. Longterm outcome after open reduction through ananteromedial approach for congenital dislocationof the hip. J Bone Joint Surg Am 1997;79:810–17.Tonnis D. An evaluation of conservative andoperative methods in the treatment of congenitaldislocation of the hip. Clin Orthop 1976;119:76–88.Zadeh HG, Catterall A, Hashemi-Nejad A, et al.Test of stability as an aid to decide the need forosteotomy in association with open reduction in


Operative planningCongruency confirmed with EUA arthrogram.

Anaesthesia and positioningGeneral anaesthesia is used, together withintravenous antibiotics. The patient is positionedsupine with an ipsilateral sandbag in a positionsuitable for image intensifier access.

Surgical technique

Anterosuperior coverage is achieved at the expenseof posterior coverage by flexing the acetabularfragment. Typically, the lateral centre edge anglewill increase by 10°. It is performed via an anteriorapproach (see ‘Developmental dysplasia of the hip– open reduction’, p. 272) extending the bikiniincision proximally over the iliac crest to allowsplitting of the iliac apophysis and subperiostealexposure of the ilium to reach the sciatic notch.

Procedure

An osteotomy is performed between the sciaticnotch and midway between the ASIS and anterior

Structures at risk

• Sciatic nerve – Rang retractors are placed in thesciatic notch keeping them closely applied tobone to protect the nerve

• Devascularization/denervation of abductors

Figure 16.6 Salter osteotomy

Figure 16.7 Radiograph showing left Salter osteotomyand ‘winking sign’

inferior iliac spine (AIIS) using a Gigli saw. Thisshould appear to be parallel to the acetabularsurface on AP images. Hinging on the symphysispubis, the acetabulum is rotated anteriorly andlaterally to gain coverage while avoidingretroversion.

A wedge of bone from the iliac wing is insertedperpendicular to the weightbearing axis. The‘winking sign’ should be noted on an imageintensifier (foreshortening of ipsilateral obturatorforamen) and the position held with two threadedSchantz pins across the osteotomy. Imageguidance is used to advance the pinsproximodistally beginning just proximal to theASIS and aiming for the triradiate cartilage (Figs16.6 and 16.7).

DDH – pelvic osteotomy 275

Closure

• Layered closure ensuring repair of the iliacapophysis

• Absorbable subcuticular material to skin.

Postoperative instructions

Plaster spica for those under 6 years. Limitedweightbearing with crutches for 6–8 weeks if over6.

PEMBERTON OSTEOTOMY


Indications• Double diameter dysplastic acetabulum• Congruent hip• Open triradiate cartilage• Close to normal range of motion• No degeneration• Normal proximal femoral morphology• Paralytic hip disorders/Ehlers–Danlos syndrome

(posterior coverage is maintained, conferringstability).

Contraindications• Poor range of motion (flexion, abduction and

internal rotation will be further diminished)• Closed triradiate cartilage• Congruent reduction not achievable• Centre of rotation of head and acetabulum

coincide.

For consent and risks/preoperative preparation/anaesthesia and positioning, see Salter osteotomy(p. 273).

Figure 16.8 Pemberton osteotomy

Surgical technique

The Pemberton osteotomy reduces the volume ofa large-diameter acetabulum making the centre ofrotation of both femoral head and socketcoincident. The acetabulum is displaced forwardsand laterally hinging on the triradiate cartilage(Fig. 16.8). The autograft is stable and fixation istherefore not required. The approach andexposure are performed as per the Salterosteotomy.

ProcedureThe osteotomy is made 10–15 mm superior to theAIIS passing a curved osteotome posteriorly toreach the ilioischial and iliopubic limb of thetriradiate cartilage (midway between sciatic notchand posterior acetabular rim). The acetabulum ishinged on the triradiate to improve coverage.Corticocancellous graft is harvested from the iliacwing and inserted into the osteotomy site.Posterior stability negates the need for internalfixation.

ClosureAs per Salter osteotomy.

Postoperative instructions

As per Salter osteotomy.


Colemann SS. The incomplete pericapsular(Pemberton) and innominate (Salter) osteo -tomies. Clin Orthop 1974;98:116–23.Pemberton PA. Pericapsular osteotomy of theilium for treatment of congenital subluxation and


dislocation of the hip. J Bone Joint Surg Am1965;47:65–86.Salter RB. Innominate osteotomy in the treatmentof congenital dislocation and subluxation of thehip. J Bone Joint Surg Br 1961;43:518–39.Thomas SR, Wedge JH, Salter RB. Outcome atforty five years after open reduction andinnominate osteotomy for late presentingdevelopmental dysplasia of the hip. J Bone JointSurg Am 2007;89:2341–50.

DEVELOPMENTAL DYSPLASIA OF THEHIP – PROXIMAL FEMORAL OSTEOTOMY

The varus derotation osteotomy (VDRO) is thecommonest type performed for DDH.


Indications

• Persistent dysplasia following DDH (coxavalga, anteversion)

• Congruent reduction in abduction and internalrotation

• Reasonable sphericity (lateral portion of headintact).

Contraindications

• Limited range of motion (abduction andinternal rotation)

• Active infection• Pelvic procedure more appropriate (centre-

edge angle [CEA] <15°)• Previous avascular necrosis is a relative

contraindication with less predictable results• Be aware that VDRO will compound an

existing negative LLD.

Consent and risks

• Plaster spica if under 6 years• Limited weightbearing with crutches if over

6 years• Bleeding

Operative planning

An EUA and arthrogram is performed to confirmadequate range of motion and concentricreduction; >15° abduction is required for a varusfemoral osteotomy. The type of fixation deviceand degree of fixed angle is decided (e.g. bladeplate/Coventry pin and plate; 90° or 130° angle).


• General anaesthesia• Supine with ipsilateral buttock sandbag• Intravenous antibiotic prophylaxis• Image intensifier.

SURGICAL TECHNIQUE

A lateral approach to the subtrochanteric regionof the proximal femur is used to avoidcompromise to the vascular supply to the femoralhead.

Landmarks

The predicted trajectory of the chosen devicealong the femoral neck is planned and markedusing the image intensifier.

Incision

A 10 cm longitudinal wound is used, runningalong the lateral aspect of the proximal femurfrom the metaphyseal flare of the greatertrochanter to the proximal femoral diaphysis.

• Neurovascular damage: 1 per cent• Infection: <1 per cent• Delayed/non-union: 1–5 per cent (greater risk

with increasing age)• Failure of hardware: <1 per cent• Incomplete correction• LLD: inevitable with closing wedge varus

osteotomy• Joint degeneration• Further surgery (removal of hardware, complex

arthroplasty)

DDH – proximal femoral osteotomy 277

then completed using an osteotome. A guidewireis inserted transversely into the anterolateralcortex distal to the future position of the plate.

The leg is adducted to close the varus osteotomyand the guidewire is used as a joystick to externallyrotate the distal shaft into a satisfactory position onfluoroscopy (Fig. 16.9). Congruent alignment ofthe lateral cortices should be checked to ensureseating of the plate. The plate is applied over thelag screw and the distal shaft is reduced onto theplate and held with a Hey–Groves clamp whilemaintaining correct orientation. Four bicorticalscrews are inserted to fix the plate before removalof the guidewire. The degree of correction andposition of hardware is confirmed with imaging.

Closure

• Layered absorbable closure of vastus lateralisthen fascia lata.

• Subcuticular absorbable material to skin.


• Mobilize partial weightbearing• Increase weightbearing status at 6–8 weeks

after union confirmed clinically andradiographically.


Blockey NJ. Derotation osteotomy in themanagement of congenital dislocation of the hip.J Bone Joint Surg Br 1984;66:485–90.Kasser JR, Bowen JR, MacEwen GD. (1985)Varus derotation osteotomy in the treatment ofpersistent dysplasia in congenital dysplasia of thehip. J Bone Joint Surg Br 1985;67:195–202.


The longitudinal incision is continued throughsuperficial fat and the fascia lata, in line with theskin incision.

Deep dissection

The posterior insertion of vastus lateralis isdetached from the posterior intermuscularseptum and reflected anteriorly to expose thelateral surface of proximal femur. The periosteumis incised longitudinally and elevated at site of thepredicted osteotomy.

PROCEDURE

Beginning from the lateral cortex just inferior tothe flare of the greater trochanter, a guidewire ispassed up the femoral neck, under image control,without breaching the physis. The trajectory shouldaim to restore a normal neck-shaft angle of 130°.

The wire is measured and over-drilled beforeinsertion of the cannulated lag screw. Under imageguidance, the proximal osteotomy is madeperpendicular to the shaft in the subtrochantericregion using an oscillating saw.

The second osteotomy is made beginning atsame entry point on the lateral cortex with thesaw tilted inferiorly creating a medially basedwedge with a lateral apex. The medial cortex is

Structures at risk

• Perforating branches of profunda femoris artery– these should be identified and cauterizedwhere necessary

Figure 16.9 Stages in varusderotation osteotomy. (a) Valgus,anteverted proximal femur. (b)Screw placed under imageguidance. (c) Medially basedclosing wedge osteotomyperformed from lateral side. (d)Varus producing osteotomy closedand held with plate followingderotation


Operative planning

• An AP and Billings lateral of both hips – it isbilateral in 25 per cent of cases (Figs 16.10 and16.11)

• Endocrine work up if at younger end of agespectrum


• General anaesthesia is used.• Patient is positioned supine on a radiolucent

table; care is taken when transferring, preparingand draping the unstable hip to prevent furtherdisplacement.

• Intravenous antibiotic prophylaxis is given.• Image intensifier.

SURGICAL TECHNIQUE

An aspiration of the hip is first performed underimage guidance for pain relief and to decompressthe retinacular vessels.

Landmarks

The image intensifier is used to delineate the jointand proximal femur.

Williamson DM, Benson MKD. Late femoralosteotomy in congenital dislocation of the hip. JBone Joint Surg Br 1988;70:614–8.

SLIPPED UPPER FEMORAL EPIPHYSIS– PINNING

Manoeuvres to reduce the epiphysis are associatedwith a high incidence of avascular necrosis (40 percent); pinning in situ therefore aims to preventfurther displacement, promote physeal closureand minimize future secondary degeneration.

Slips are described as stable if weightbearing ispossible or unstable if weightbearing is notpossible even with crutches.


Indications

• Grade I–II slip (Southwick angle <60°).Bilateral pinning is performed if there is:– Evidence of bilateral slip– Endocrinopathy– Younger end of age spectrum (10 years –

girls, 12 years – boys).

Contraindications

• Advanced avascular necrosis• Active infection.

Consent and risks

• Limited weightbearing/crutches• Avascular necrosis: 0–5 per cent but higher if

unstable slip• Chondrolysis: 10 per cent (greater risk for African

Caribbeans, females and poor technique)• Fracture: <1 per cent• Infection: <1 per cent• Failure of hardware• Further slip (associated with inadequate screw

advancement)• LLD: 1.5 cm difference on average• Joint degeneration• Further surgery (removal of hardware/osteotomy/

arthrodesis/complex arthroplasty)

25°

Figure 16.10 Patient positioning for Billings lateralradiograph. The hip is abducted, externally rotated andelevated 25° on a foam wedge

SUFE – pinning 279

PROCEDURE

A guidewire is passed under image intensifiercontrol to avoid malposition and joint penetration.After measuring and over-drilling the wire, apartially threaded 6.5–7.5 mm diameter cannulatedscrew is inserted. A reverse cutting thread is usedfor easier subsequent removal. Despite an increasein shear strength across the physis using multiplescrews, the use of a single screw diminishes the riskof chondrolysis and avoids the disproportionatecomplication rate of multiple screws.

The passage of guidewire, drill and screwshould be performed under image guidance toavoid joint penetration. The screw tip shouldreach the centre of the epiphysis, 5 mm from thearticular surface with a minimum of three to fourthreads crossing the physis to provide adequatefixation. At completion, live screening of the hip isperformed to ensure solid fixation of the epiphysisand confirm screw position.

Closure

Subcuticular absorbable material is used to closethe stab incision.


Range of motion exercises are begun on the firstpostoperative day. Mobilization is then:• Fully weightbearing with crutches for 2–3

weeks if slip is stable• Partial weightbearing until healed if unstable.

Assessment is carried out at 6–8 weeks for clinicaland radiological evidence of union and to ensurethat there has not been any further slip. Sportingactivities are prohibited until physeal closureoccurs. Following physeal closure, screw removalis recommended.


Givon U, Bowen JR. Chronic slipped femoralepiphysis: treatment by pinning in situ. J PediatrOrthop B 1999;8:216–22.Loder RT, Aronson DD, Dobbs MB, et al. Slippedcapital femoral epiphysis. Instr Course Lect2001;50:555–70.

Incision

As pinning is performed percutaneously, theplanned trajectory of the screw is marked in twoplanes using the image intensifier bearing in mindthe course of important neurovascular structures.The entry point of the screw should not be distal tothe lesser trochanter as this creates stress risers andincreases the incidence of fracture. Preoperativemarking also limits the number of guidewire passesnecessary to achieve a satisfactory screw position,further decreasing the chance of guidewiremisplacement and minimizing the risk of fracture.Because the epiphysis is relatively posterior andinferior to the neck, a more anterior entry point isrequired. Optimum screw position, should avoidthe posterior neck and posterior superior epiphysisto preserve the blood supply to the femoral headand minimize the risk of avascular necrosis.

Dissection

Tissues are dissected bluntly down to bone.

Figure 16.11 Illustration of Billings lateral radiographshowing slip


Preoperative preparation

Preoperative AP and lateral radiographs are usedto confirm the degree of slip and plan orientationof the osteotomy. Slings and springs are usedpreoperatively for three weeks if acute or acute onchronic.


• General anaesthesia• Intravenous antibiotic prophylaxis• Supine on radiolucent table• Image intensifier.

SURGICAL TECHNIQUE

Landmarks and approach

The osteotomy is performed via an anteriorapproach (see ‘Developmental dysplasia of thehip – open reduction’, p. 272). Particular caremust be taken not to disturb the posterior capsuleor forcefully manipulate the slip to preservevascularity to the femoral head.

PROCEDURE

Following longitudinal capsulotomy, the epiphysismust be correctly identified as the anteriorlydisplaced neck may be mistaken for it. Twoosteotomies are required:• First, an osteotomy is performed perpendicular

to the neck at the level of the physis takingmore anteriorly to create a wedge. The aim is toleave a convex surface for later reduction andshorten the neck by 3–4 mm. Over-shorteningwill lead to instability. Care must also be takento avoid driving instruments into the posteriorcapsule, compromising the blood supply.

• Second, an osteotomy is made in the long axisof the neck to remove the bony beak on the sideof the slip, again taking care not to breach theposterior capsule. Any remaining callus is

• Slip progression• LLD: 1–2 cm shortening• Further surgery (removal of hardware/complex

arthroplasty)

Loder RT, Richards BS, Shapiro PS, et al. Acuteslipped capital femoral epiphysis. The importanceof physeal stability. J Bone Joint Surg Am1993;75:1134–40.Phillips SA, Griffiths WEG, Clarke NMP. Thetiming and reduction of the acute unstable slippedupper femoral epiphysis. J Bone Joint Surg Br2001;83:1046–9.

SLIPPED UPPER FEMORAL EPIPHYSIS– OSTEOTOMY

An open reduction with osteotomy serves torestore the head-neck angle with subsequentimprovement in hip biomechanics. This aims toprovide good future function, minimize or delaythe onset of painful secondary degeneration andnormalize proximal femoral anatomy for futurehip replacement. Osteotomy can be performed atvarious levels (intracapsular and extra capsularneck, intertrochanteric and subtrochanteric) withgreater correction achievable at the site ofdeformity (more proximally). Although theseproximal osteotomies have been associated with agreater risk of avascular necrosis, a Dunn or Fishcuneiform osteotomy performed with meticuloustechnique, as described below, can achieveexcellent results.


Indications

• Slip >60°• Chronic/acute on chronic or unstable slip• Open physis.

Contraindications

Closed physis (Southwick intertrochantericosteotomy may be more appropriate).

Consent and risks

• Avascular necrosis: 10–48 per cent• Chondrolysis: 10–12 per cent• Infection: <1 per cent

Tendo-Achilles lengthening 281

the treatment of severe slipped capital femoralepiphysis after skeletal maturity. J Bone Joint SurgBr 2006;88:1379–84.Dunn DM, Angel JC. Replacement of the femoralhead by open operation in severe adolescentslipping of the upper femoral epiphysis. J BoneJoint Surg Br 1978;60:394–403.Fish JB. Cuneiform osteotomy of the femoral neckin the treatment of slipped capital femoralepiphysis. J Bone Joint Surg Am 1984;66:1153–68.Loder RT. Unstable slipped capital femoralepiphysis. J Pediatr Orthop 2001;21:694–9.

TENDO-ACHILLES LENGTHENING


Various methods for tendo-Achilles lengthening(TAL) exist and may be used in conjunction withother procedures. Percutaneous methods such asthe Hoke and DAMP (distal anterior, medialproximal, also called a White slide) technique andopen methods such as the Baker and Vulpiustechniques are described (Figs 16.12–16.14). Thechoice depends on the cause, the individualpatient and the surgeon’s preference.

carefully removed with a spoon from theposterior capsule.

Shortening the neck, removing the beak andelevating the posterior capsule allows tension-freereduction of the epiphysis. The epiphysis isreduced onto the neck by placing the leg inflexion, abduction and internal rotation. Ifinsufficient bone has been removed, the epiphysiswill not reduce easily and posterior structures willbe placed under tension increasing the risk ofavascular necrosis. Shortening and wedging of theneck should cause the epiphysis to overlap theneck anteriorly giving a mushroom appearance.Restoration of the Shenton line and a valgushead–neck angle of 20° should be ensured usingthe image intensifier.

While an assistant maintains position, a lateralstab incision is made according to the predictedtrajectory of cannulated screw followed by bluntdissection down to the lateral cortex of theproximal femur. A guidewire is then advancedacross the osteotomy to hold the epiphysis. Imagesare checked in two planes to confirm a satisfactoryposition before definitive screw insertion. Similarto pinning in situ, the entry point should not bebelow the lesser trochanter and screw tips shouldbe 5 mm short of the articular surface.

Dynamic screening allows confirmation of botha solid fixation and satisfactory positioning ofhardware.

Closure

• Layered closure including capsular repair withabsorbable material



• Bed rest with slings and springs for 5 days.• Mobilize 15 kg weightbearing 8 weeks. Increase

weightbearing status at 8 weeks, afterconfirming union clinically and radiographic -ally.


Biring GS, Hashemi-Nejad A, Catterall A.Outcomes of subcapital cuneiform osteotomy for Figure 16.12 Hoke percutaneous tenotomy

Indications

• Fixed equinus deformity, defined as an inabilityto dorsiflex the ankle sufficiently to allow heelcontact without compensation in the remainderof the limb or spine. Often, this correlates withdorsiflexion less than 5° and is seen in variousconditions such as cerebral palsy, congenitaltalipes equinovarus (CTEV), congenital verticaltalus, Charcot–Marie–Tooth (CMT), pes planusand intractable toe-walkers

• Failure of conservative treatment• To achieve stump coverage during Chopart’s

amputa tion for congenital malformation of thefoot.

Contraindications

• Rigid bony deformity• Pseudoequinus: a false clinical appearance of

equinus caused by plantar flexion of the midand forefoot (plantaris deformity).

Medical co-morbidity is not a contraindication aspercutaneous techniques can be performed underlocal anaesthesia.

Consent and risks

• The most predictable outcome following TAL is inpatients with spastic hemiplegia. The leastpredictable scenario is seen with percutaneousprocedures in patients with diplegia. The twomost frequently encountered problems are over-lengthening and recurrence. The former tends tooccur following percutaneous procedures on theconjoined tendon whereas recurrence isassociated with recession of the gastrocnemiusor soleus aponeurosis.

• Neurovascular damage: the sural nerve inparticular is at risk

• 1 per cent for percutaneous techniques• 5 per cent for open techniques• Plaster immobilization/limited mobility• Complete tendon rupture (percutaneous)• Wound problems/infection (open): 1 per cent• Recurrence (Baker and Vulpius): <5 per cent• Over-lengthening leading to crouched gait: more

likely following percutaneous procedures andassociated with uncontrolled lengthening in anolder child

• Repeat lengthening: more likely in a youngerchild and patients with hemiplegia

• Further surgery (hamstring, psoas or selectivegastrocnemius lengthening most often requiredin patients with diplegia)


Figure 16.13 Distal anterior,medial proximal (DAMP) procedure

Figure 16.14 Diagram demonstrating two techniques ofgastrocnemius recession. (a) Baker slide (b) Vulpiustechnique

Tendo-Achilles lengthening 283

Preoperative assessment

Silverskiold test under anaesthetic differentiatesbetween pure gastrocnemius tightness (increasedankle dorsiflexion with knee flexion) and com -bined tightness of gastrocnemius and soleus(limited dorsiflexion in knee flexion andextension).


• General anaesthesia or local anaesthesia forpercutaneous techniques

• Prone for open or supine for percutaneoustechniques

• High pneumatic thigh tourniquet.

SURGICAL TECHNIQUE

Percutaneous techniques

Both Hoke and DAMP procedures are used totreat combined gastrocnemius–soleus tightness.The advantages are improved healing and theoption of local anaesthesia. However, thesetechniques are associated with an increasedincidence of over-lengthening and inadvertentcomplete tenotomy.

Hoke technique

Three points are marked on the tendo-Achilles at1 cm, 3 cm and 6 cm from its calcaneal insertion. Ano. 15 blade scalpel is inserted longitudinally inthe midline of the tendon at each markedlevel then turned through 90° in the desireddirection to perform the hemisection whilethe ankle is dorsiflexed to control the correction.The hemisections are performed on themedial half proximally and distally and thelateral half in the middle incision (see Fig. 16.12,p. 281).

Structures at risk

• Tibial nerve – at risk proximally• Sural nerve – laterally• Flexor hallucis longus muscle – distally

DAMP technique

Two 1.5 cm skin incisions are made postero -medially, one 2 cm from the calcaneal insertionand another 5 cm proximal to it. The anterior two-thirds of the tendon is divided distally and themedial half to two-thirds proximally. (This isbecause of the 90° rotation of tendon fibres in thedistal third of the leg.)

The tendon is divided progressively whiletensioning the tendo-Achilles until it yields 5–10°of dorsiflexion. The medial fibres slide over thelateral fibres, giving length in continuity with athinned portion of tendon distally and a squarecut proximally (see Fig. 16.13, p. 282).

OPEN TECHNIQUES

These have the advantage of controlledlengthening but carry a greater risk of recurrence.

Incision

A 7 cm longitudinal incision is made, 10 cmproximal to the calcaneal insertion positioned1 cm medial to the midline to avoid the suralnerve.

Dissection

The sural nerve and short saphenous vein areretracted if encountered or may be avoidedaltogether by raising a full thickness lateral flap.The paratenon is incised longitudinally in themidline to avoid the skin incision, and the medialand lateral edges of the gastrocnemius aponeurosisare exposed.

BAKER SLIDE PROCEDURE

Although considered a selective gastrocnemiuslengthening, fibres of the soleus aponeurosis arealso incised distally. However, this does not lead toover-lengthening as seen in procedures on the

Structures at risk

• Sural nerve• Short saphenous vein

conjoined tendon owing to controlled lengtheningand inherent stability.

The medial and lateral thirds of the aponeurosisare incised transversely 12 cm above the calcanealinsertion. A similar incision is then performed acrossthe middle third at least 3 cm proximally to allowside to side contact after lengthening. A tongue andgroove pattern is created by joining the proximaland distal cuts with two longitudinal incisions (seeFig. 16.14, p. 282). Dorsiflexion of the ankle allowsslide-lengthening of the aponeurosis and reveals anyremaining fibres which require incision.

The underlying muscle fibres of soleus arerevealed as the aponeurosis is lengthened. Furtherlengthening should not be performed once 10° ofdorsiflexion is achieved on the table, and 3/0absorbable sutures are placed across thelongitudinal portions of the aponeurosis.

VULPIUS PROCEDURE

This is used to treat combined gastrocnemius-soleus tightness when plaster immobilization isnot desirable. Instead of a tongue and groovelengthening, an inverted ‘V’ incision is made inthe aponeurosis of both the gastrocnemius andthe soleus (see Fig. 16.14, p. 282).

Closure

• Tension-free layered closure with buried knotsto avoid skin irritation.


With the exception of the Vulpius technique, abelow knee plaster is applied in a plantigradeposition. A dorsiflexed position must be avoidedto prevent a calcaneus deformity.


Mobilize weightbearing as tolerated in cast for fourweeks if used. Convert to night-time splint at fourweeks and continue for six months. Use guidedphysiotherapy to maintain position and preventrecurrence.


Baker LD. Surgical needs of the cerebral palsypatient. J Bone Joint Surg Am 1956;38:313–23.


Borton DC, Walker K, Pirpiris M, et al. Isolatedcalf lengthening in cerebral palsy. J Bone Joint SurgBr 2001;83:364–70.Graham HK, Fixsen JA. Lengthening of thecalcaneal tendon in spastic hemiplegia by thewhite slide technique. J Bone Joint Surg Br1988;70:472–5.

CONGENITAL TALIPES EQUINOVARUSCORRECTION

PONSETI TECHNIQUE


IndicationsFlexible CTEV.

Contraindications• Rigid clubfoot• Age over 7 years is a relative contraindication as

results are notably worse.

Operative planningThe deformity can be graded using variousmethods. Dimeglio suggests a 20-point scoring

Consent and risks

• Neurovascular injury (any open procedure)• Complete Achilles tenotomy• Plaster impingement/skin ulceration• Infection (open procedures)• Stiffness• Recurrent deformity: long-term splintage

required• Deformity due to incorrect or incomplete

correction, overcorrection or recurrence, e.g.cavus, rocker-bottom, longitudinal breach,flattening and lateral rotation of talus

• 1 cm limb shortening, 2 cm decreased calf girthand smaller shoe by 1 or 1/2 sizes are commonsequelae

Do not expect a completely normal foot; althoughthe Ponseti technique yields good clinical results,foot malformations still exist and can be seenradiographically.

Congenital talipes equinovarus correction 285

system with four grades of severity whichcorrelates with an increasing resistance tocorrection. The Pirani score helps to predict theneed for Achilles tenotomy and is based upon theseverity of deformity in the midfoot and hindfootwith a total maximum score of 6. Eighty-five percent of patients with scores over 5 will requiretenotomy.

Anaesthesia and positioningNo anaesthesia or sedation required unless thepatient is extremely uncooperative. An assistant isessential.

Surgical technique

Casting is performed weekly, correcting all threecomponents of the deformity in a predeterminedsequence prior to additional operative procedures.At least three toe to groin casts are required overa period of 7–10 weeks depending on the severityof deformity.

Castings• Cavus: caused by a relative pronation of the

forefoot due to a plantar flexed first ray. Thefirst ray is elevated with pressure beneath thefirst metatarsal head to supinate the forefootand align it with the varus hindfoot. Forcedpronation of the foot is avoided as this willworsen the cavus.

• Varus and adductus: Correction of theabnormally internally rotated calcaneus isachieved by external rotation using the lateraltalar head as the fulcrum. The cuboid andanterior calcaneus are displaced laterally byapplying medial pressure to the navicularanterior to the ankle and pushing the posteriorcalcaneus medially by lateral pressure posteriorto the ankle, ensuring the talar head does notexternally rotate. In severe cases, the navicularmay not fully reduce although abduction ofthe cuneiforms more distally will allowcorrection and the navicular–cuneiform jointswill remodel. Once the calcaneocuboidalignment is restored with the anterior calcaneuslateralized, correction of varus can be achieved.The cast must be toe to groin with the knee in90° of flexion to maintain abduction andexternal rotation. This will also treat any

associated internal tibial torsion if present.Midfoot pronation must again be avoided toprevent cavus deformity and a midfoot breach.

• Equinus: With the hindfoot varus corrected,serial casts are applied in a progressivelydorsiflexed position. This usually requires two tothree casts to achieve 15° of dorsiflexion and60° of external rotation. Dorsiflexion is achievedvia pressure beneath the midfoot rather than themetatarsals to avoid rocker-bottom feet.

Additional proceduresTendo-Achilles lengthening: If dorsiflexion of 15°is not achieved, then a percutaneous tenotomyunder local anaesthesia is indicated. This ispreferable to posterior ankle and subtalarcapsulotomy as contraction of scar tissue inthis region will lead to progressive loss ofdorsiflexion.

Lateral transfer of the tibialis anterior tendon tothe lateral cuneiform may be required forpersistent supination.


The final cast is left in situ for three weeks thenassessment made for residual equinus; 90 per centof patients will require Achilles tenotomy.

Denis Browne boots are worn fulltime for 2–3months then at night only for 2–4 years or untilage 7. These maintain 15° of dorsiflexion (to avoidequinus) and 60° external rotation (to preventvarus, adductus and in-toeing). High-top shoes areworn during the day to maintain position.

Periodic evaluation should be performed by anexperienced clinician to assess the relationshipbetween the hindfoot and forefoot, the attitude ofthe heel, and range of ankle motion.Anteroposterior and lateral radiographs shouldalso be obtained.

EXTENSIVE SOFT TISSUE RELEASE VIATHE CINCINNATI INCISION


Indications• Failed Ponseti treatment: 50 per cent may

relapse at an average age of 2.5 years.

Remanipulation and casting with or withoutAchilles tenotomy followed by splintage maybe successful although extensive soft tissuereleases are required in resistant cases

• Rigid clubfoot• Walking on lateral border of foot/internally

rotated gait• Posteriorly placed lateral malleolus (a reflection

of uncorrected internal calcaneal rotation)• Parallelism of talus and calcaneus on AP and

lateral radiographs.

ContraindicationsPrevious releases via alternative incisions.

Preoperative assessment• AP and lateral radiographs required for

assessing the talocalcaneal angle.• Dimeglio and Pirani scores.

Anaesthesia and positioningGeneral anaesthesia is used with addition of anintravenous prophylactic antibiotic. The patient ispositioned prone with a high thigh tourniquet.

Surgical technique

LandmarksThe base of the first metatarsal, medial malleolusand lateral malleolus is palpable.

Incision (the Cincinnati incision)An 8–9 cm extensile, transverse incision across theposterior ankle (at the level of the tibio-talarjoint) is created. This begins at the base of the first

Consent and risks

• Neurovascular damage: see below• Plaster immobilization/impaired mobility/long-

term splintage• Residual deformity• Recurrence and further surgery• Wound irritation over the Achilles tendon,

particularly rubbing on shoes• Avascular necrosis of the talus• Arthritis of the hindfoot and midfoot• Ankle and subtalar stiffness


metatarsal, curves below the medial malleolus,rises slightly to traverse the Achilles tendon andcontinues over the lateral malleolus to terminatedistal and medial to the sinus tarsi.


The proximal subcutaneous flap is raised offunderlying tissues for around 3 cm to allowproximal visualization.

Deep dissection

This begins laterally with incision of thecalcaneofibular ligament and superior peronealligament to allow dissection of the peronei off thecalcaneus without damaging them. The lateraltalocalcaneal ligament and lateral capsule ofsubtalar joint are then released. The posteriortibial neurovascular bundle is retracted anteriorlyto allow further release of the posterior ankle andsubtalar capsule and the posterior talofibularligament. Subsequent posterior retraction of thetibial neurovascular bundle allows division of thesuperficial tibiocalcaneal part of deltoid. The deepportion of the tibiotalar portion of the deltoidligament is left intact to prevent excessive subtalartranslation and flat foot deformity.

The tibialis posterior tendon sheath is openedalong its length from above the medial malleolusto the navicular to allow Z-lengthening of thetendon at least 2.5 cm proximal to the medialmalleolus. The nearby posterior tibial neuro vascu -lar bundle is protected to avoid its transection.

Dissection continues medially, into the arch ofthe foot, to release the lacinate ligament, theplantar aponeurosis and small plantar muscles,

Structures at risk

• Posterior tibial nerve and vessels• Deep tibiotalar portion of the deltoid ligament• Medial and lateral plantar nerves

Structures at risk

• Sural nerve laterally• Superficial venous structures below the lateral

malleolus

Surgical treatment of Perthes disease 287

including abductor hallucis. Beneath the navicular,the master knot of Henry (intersection of the flexorhallucis longus [FHL] and flexor digitorum longus[FDL]) is taken down, taking care not to damagethe medial and lateral plantar nerves either side ofit. The sheaths of the FDL and FHL are openedand tendon Z-lengthening performed to preventflexion contracture of the toes when the ankle isdorsiflexed. This is done sufficiently proximally toallow the lengthened portions to be covered bytendon sheath. Conjoint lengthening is analternative if the tendons are too small to performZ-lengthening. This step may be unnecessary astoe contractures will often stretch out over time.

The talonavicular joint is freed to mobilize thenavicular laterally and releasing all of itsattachments; keeping hold of it via the distal endof tibialis posterior tendon will avoid handling thearticular cartilage. The dorsal talonavicularligament and the spring ligament can then bereleased. Release of the bifurcate ligament and thetalocalcaneal interosseous ligament will allowexternal rotation of the anterior calcaneus.

Finally, the quadratus plantae is stripped off thecalcaneus to release the long plantar ligament, theplantar calcaneocuboid ligament and inferiormedial capsule of the calcaneocuboid joint withoutdamaging the peroneus longus tendon. Theextensive soft tissue releases should result in theplane of the foot being at 90° to the bimalleolaraxis with the talus beneath the tibia and slighthindfoot valgus. If the mortise is not fully reduced,tibiofibular ligament release then tibiofibularsyndesmosis release can be carried out if the talus istoo wide anteriorly. Stabilization with K-wires isthe final stage, one passing along the medial columnto hold the talonavicular joint and one across thelateral column to hold the calcaneocuboid joint.

ClosureTendon sheaths over all over-lengthened tendonsare closed. The medial and lateral extensions ofthe Cincinnati incision are closed, withouttension, using absorbable sutures to thesubcutaneous and subcuticular layers. Theposterior, central portion of the wound is left opento heal by secondary intention. If blanching ofwound edges following tourniquet release isnoted, position in less dorsiflexion.

Apply plaster of Paris from the toes to the mid-thigh with a neutral or slightly plantar flexed footand the knee flexed to 90°.


The cast is changed at 10 days after surgery, toinspect wound. It is removed, along with the K-wires, at 6 weeks. Denis Browne boots areprescribed for the next 12–18 months.

Physiotherapy (for mobility, to promote tarsalgrowth and preserve cartilage) is continued for atleast 6 months.


Ponseti I. Congenital Clubfoot: Fundamentals ofTreatment. USA: Oxford University Press, 1996.Crawford AH, Marxen JL, Osterfield DL. TheCincinnati incision: a comprehensive approach forsurgical procedures of the foot and ankle inchildhood. J Bone Joint Surg Am 1982;84:1355–8.Dimeglio A, Benshahel H, Souchet P, et al.Classification of clubfoot. J Pediatr Orthop B1995;4:129–36.McKay DW. New concept of and approach toclubfoot treatment: section II – correction of theclubfoot. J Pediatr Orthop 1983;3:10–21.Pirani J, Outerbridge HK, Sawatzky B, et al. Areliable method of clinically evaluating a virginclubfoot. 21st World Congress of SICOT, Sydney,Australia, 18–23 April, 1999.

SURGICAL TREATMENT OF PERTHESDISEASE

Perthes disease occurs as a result of a temporarycessation in the blood supply to the femoral headleading to avascular necrosis. It is commonly seenbetween the ages of 4 and 8 years although shouldbe suspected from 2 to 12 years of age. Althoughmore common in boys by a factor of four, it maybe more severe in girls.

Presenting symptoms comprise hip or referredknee pain, stiffness, limping and a short leg. Thedisease progresses through the four phases of

ischaemia (causing collapse and sclerosis),fragmentation, reossification and remodelling,which take place over a 4-year period.

However, development of the hip is frequentlyabnormal leading to incongruency, alteredbiomechanics and accelerated secondarydegeneration. Prognosis is dependent on age andseverity of disease at presentation, and treatmentfalls into the three broad categories ofobservation, containment and salvage, dependingalso on the phase of disease.


Indications

The type of treatment largely depends upon thecapacity to remodel and therefore age. Below theage of 6 years, there is high potential forremodelling and therapy therefore tends to beconservative. Above 8 years, further remodelling islimited and treatment is more aggressive in orderto correct deformity and extend the longevity ofthe native hip.

Between the ages of 6 and 8 years, theindications for either a conservative approach orcontainment procedures depend upon bone ageand remodelling potential, the presence of ‘at-risk’signs for the viability of the femoral head andwhether the hip is congruent or containable. Thesurgical options for containable hips are a varusosteotomy of the proximal femur and/or a Saltertype pelvic osteotomy.

Salvage procedures are indicated if hingeabduction occurs (Fig. 16.15), where theovergrown and uncontained anterolateral portionof the femoral head abuts the lateral rim of theacetabulum. In this situation valgus extensionosteotomy (VGEO) of the proximal femur isindicated, which will medialize the centre ofrotation of the hip and make it congruent in theweightbearing position. The medial column mustbe of sufficient height after reossification and abetter outcome is expected in younger patientswhere the triradiate cartilage remains open. Thiswill allow deformity correction, a betterfunctional range of movement, improvement ofleg length and abductor function.


Contraindications

Containment procedures are contraindicated ifhips are not congruent or containable.

Operative planning

Various classification systems exist to guidetreatment and predict the prognosis of Perthesdisease.

Consent and risks

The natural history of the disease must beexplained to the child and parents. It should beemphasized that the aim is to improve symptomsand to achieve a spherical and contained femoralhead to maximize and prolong native joint function.However, secondary degenerative changes maycontinue to occur at an unpredictable andaccelerated rate ultimately leading to total jointarthroplasty or arthrodesis.• An older presentation, particularly in girls, is

associated with a worse outcome• Stiffness/contractures• Other risks pertain to the type of procedure

being performed. See the relevant sections onDDH for the risks associated with pelvic andfemoral osteotomies

Figure 16.15 Illustration of hip arthrogram showinghinge abduction, where dye pools medially in abduction

Principles of surgery in cerebral palsy 289

Catterall grouped patients as I–IV, althoughlarge intra- and inter-observer error has beenshown with this method. The Herringclassification correlates with prognosis accordingto the degree of collapse of the lateral capitalfemoral epiphysis during the fragmentation phaseusing the AP radiograph of the pelvis.

The Stulberg classification (1–5) is made duringthe reossification phase and predicts the end resultof Perthes dependent on the relative shapes of thefemoral head and acetabulum. Increasing gradecorrelates with the likelihood of secondaryosteoarthritis with Stulberg 5 hips likely torequire total hip replacement before age 50 years.

Head at risk signs include Gage’s sign (a lytic‘rat bite’ at the periphery of the physis),calcification lateral to the epiphysis, lateralsubluxation of the femoral head and horizontalinclination of the physis.

Arthrography will determine the congruency ofthe hip in various positions and whether anappropriate range of movement is possible toperform the relevant femoral osteotomy (Fig.16.15). Significant abduction is required for a varusosteotomy and adduction for a valgus osteotomy.


• General anaesthesia• Supine• Intravenous prophylactic antibiotics.

SURGICAL TECHNIQUE

• For varus osteotomy, the technique as describedin the section ‘Developmental dysplasia of thehip – femoral osteotomy’ (p. 276) is used,employing the derotation component if required.

• For valgus osteotomy, a similar technique isused as for varus osteotomy, the differencebeing the orientation of the osteotomy to give alaterally based wedge to achieve the desiredrealignment.

• Pelvic osteotomy – see ‘Salter osteotomy’(p. 273).


As per the type of procedure performed. Regularperiodic clinical and radiographic review is

required to determine the presence ofdeterioration and the need for further surgery.


Bankes MJK, Catterall A, Hashemi-Nejad A.Valgus extension osteotomy for ‘hinge abduction’in Perthes disease: results at maturity and factorsinfluencing the radiological outcome. J Bone JointSurg Br 2000;82:548–54.Catterall A. The natural history of Perthes disease.J Bone Joint Surg Br 1971;53:37–53.Coates CJ, Paterson JMH, Catterall A, et al.Femoral osteotomy in Perthes disease. Results atmaturity. J Bone Joint Surg Br 1990;72:581–5.Herring JA, Kim HT, Browne R. Legg–Calvé–Perthes disease. Part I: classification of radiographswith use of the modified lateral pillar and Stulbergclassifications. J Bone Joint Surg Am 2004;86:2103–20.Herring JA, Kim HT, Browne R. Legg– Calvé–Perthes disease. Part II: prospective multicentrestudy of the effect of treatment on outcome. JBone Joint Surg Am 2004;86:2121–34.

PRINCIPLES OF SURGERY INCEREBRAL PALSY


Cerebral palsy results from an insult to theimmature brain and its effects are variable. It maybe classified anatomically (hemiplegic, diplegic ortotal body involvement) or physiologically(spastic, athetoid, ataxic or mixed). The spasticform is most common; a combination of muscleweakness and spasticity leads to a progressivesequence of dynamic deformity, fixedcontractures, bony deformity and jointsubluxation or dislocation. Depending on theseverity, intervention may be indicated at anypoint during this continuum to optimize energyconsumption during gait, to perform activities ofdaily living, to facilitate standing or seated transferand to maintain hygiene. Maximum functionrequires a straight spine over a level pelvis,congruent, mobile hips, mobile knees andplantigrade feet.


Cerebral palsy is typically treated in one ofthree phases:• Dynamic contractures – casting and/or

botulinum toxin (BTX) injection• Fixed contractures – muscle balancing

techniques such as releases, lengthening andtransfers

• Bony deformity and joint incongruence –osteotomies.

Decisions around timing of surgery are difficult.Allowing maturation will improve certainty aboutthe gait pattern and reduce the risk of recurrentdeformity at the price of an increased chance offixed deformities and multilevel operations beingrequired. Surgery in the younger child may be lesstechnically demanding but can lead to repeatsurgery year on year. In addition, single leveloperations may reveal further problems: acommon example is a crouched gait occurringafter Achilles tendon release due to unrecognized,concomitant tight hamstrings. Throughout allstages physiotherapy helps to reduce fixeddeformity and occupational therapy can adaptequipment to accommodate existing deformity.

SURGICAL TECHNIQUES IN MUSCLECONTRACTURES

Botulinum toxin A injections

Botulinum toxin A inhibits the release ofacetylcholine from the nerve terminal at theneuromuscular junction, causing decreasedmuscle activity in a dose-dependent manner. Itmay be administered under local or generalanaesthesia or sedation. It should be placed deepto the muscle fascia in a dose appropriate for thepatient and the number of injection sites required.The injection volume must be sufficient to allowdiffusion to end-plate zones which may bescattered, particularly in the sartorius and gracilis.

Localize injection sites using palpation andanatomical knowledge; accuracy is improvedwith electrical stimulation or ultrasound guidance.Combine injection with casting, orthoses andguided physiotherapy to maximize the benefits.

Contraindications• Myasthenia gravis

• Aminoglycoside antibiosis• Non-depolarizing muscle relaxants• Pseudobulbar palsy• Gastro-oesophageal reflux or frequent chest

infections.

SURGICAL TECHNIQUE

Muscle balancing techniques

Adductor psoas and gracilis release is commonlyindicated for the classic flexion adductioncontracture and scissoring gait seen in cerebralpalsy. Muscle imbalance combined with infrequentweightbearing causes structural changes at the hip(increased anteversion, posterolateral acetabulardysplasia) leading to posterolateral migration,pelvic obliquity and scoliosis. This is morecommonly seen in quadriplegic patients andreleases are performed early (3–4 years) to preventdeterioration. Muscles should be releasedsequentially during the procedure and performedbilaterally to prevent a windswept deformity.Releases are also commonly combined withproximal varus femoral osteotomy at age 5.

Hamstrings may be released proximally ordistally to improve flexion contracture at theknee. Equinus deformity at the ankle is verycommon and is treated with tendo-Achillesrelease (see p. 281 for details). Knee and anklereleases are performed in a walking child between4 and 6 years old.

Another common problem is the thumb inhand deformity treated with adductor pollicisrelease and is performed in the older child.Tendon transfers such as tibialis anterior or tibialisposterior are often used in balancing the foot incombination with bony surgery.

Consent and risks

• Local: pain, temporary weakness in adjacentmuscles

• General: mild generalized weakness, urinaryincontinence, constipation, dysphagia andaspiration pneumonia

Parents and patients should be warned of itstemporary effect of 12–16 weeks and the risk ofrecurrence and further procedures.

Viva questions 291

OSTEOTOMY AND JOINT CONTAINMENT

Hip containment

Quadriplegic patients should be monitoredregularly for hip subluxation and dislocation,which tends to occur between 18 months and 6years. Hips at risk are those with limitedabduction with uncovering of <50 per cent onradiography. At-risk hips may be treated withadductor, psoas and hamstring release although amore aggressive approach may be considered.Subluxed hips (>50 per cent uncovered) aretreated with soft tissue releases and varusproximal femoral osteotomy.

Early dislocated hips may be treated with openreduction; however, this may not be possible andpoor conformity between the head andacetabulum may lead to early failure. A varusderotational osteotomy with soft tissue releasesand/or shortening may be more appropriate. Thiscan be combined with pelvic osteotomy.

Late dislocations require either resurfacing ortotal joint arthroplasty; a large articulation ispreferred to confer stability. Alternatively, aGirdlestone excision arthroplasty may beconsidered.

Triple arthrodesis of the ankle

Various foot and ankle deformities are seen incerebral palsy such as planovalgus, equinovalgus,equinovarus and calcaneovalgus. Triple arthrodesisis indicated for symptomatic degeneration anduncontrolled deformity. Despite frequentcomplications such as residual deformity,pseudarthrosis, pain and progressive intertarsal

and tarsometatarsal arthritis, the response tosurgery is good.

Scoliosis surgery

Scoliosis is more common in quadriplegic andnon-ambulatory diplegic patients. The risk ofprogression is related to age at presentation andhip problems. Curves are likely to reach 50° ifpresent by age 5. Bracing is seldom preventive.Nutrition must be optimized preoperatively andpatients must be monitored closely postopera -tively for respiratory complications.

Indications for surgery are curves >40° orprogression >10° per annum. Ambulatory patientsreceive posterior fusion whereas non-ambulatorypatients require additional anterior fusion andpelvic fixation.


Gage JR. The Treatment of Gait Problems inCerebral Palsy. Cambridge: Cambridge UniversityPress, 2004.McCarthy JJ, D’andrea LP, Betz RR, et al. Scoliosisin the child with cerebral palsy. J Am Acad OrthopSurg 2006;14:367–75.Owers KL, Pyman J, Gargan MF, et al. Bilateralhip surgery in severe cerebral palsy. J Bone JointSurg Br 2001;83:1161–7.Ramachandran M, Eastwood DM. Botulinumtoxin and its orthopaedic applications. J Bone JointSurg Br 2006;88:981–87.Skoff H, Woodbury DF. Management of the upperextremity in cerebral palsy. J Bone Joint Surg Am1985;67:500–3.

Viva questions

1. What are the clinical signs of hip instability inthe newborn?

2. What are Hilgenreiner and Perkins lines andwhat is their relevance?

3. What are the relative advantages anddisadvantages of the anterior and medialapproaches to the paediatric hip indevelopmental dysplasia of the hip?

4. Describe the Smith–Petersen approach to thepaediatric hip?

5. What are the indications for varus proximalfemoral osteotomy in developmental dysplasiaof the hip?

6. How does a varus proximal femoral osteotomyaffect range of hip movement and leg lengths?


7. What structures are at risk during a Salterpelvic osteotomy?

8. What are the indications and contraindicationsof the Pemberton pelvic osteotomy?

9. What is the ideal screw position when pinninga slipped upper femoral epiphysis? What risksare associated with this procedure?

10. What are the indications for prophylacticpinning of the contralateral hip in slippedupper femoral epiphysis?

11. How does the blood supply to the femoralhead change throughout childhood?

12. What are the treatment options for avascularnecrosis following slipped upper femoralepiphysis?

13. What is your approach to the treatment ofPerthes disease in a 7-year-old child?

14. What classification systems do you know forgrading the severity and predicting theprognosis of Perthes disease?

15. What are the component deformities of clubfoot and which structures are tight?

16. Which structures are at risk during extensivesoft tissue release of congenital talipesequinovarus via the Cincinnati approach?

17. How would you distinguish between a tighttendo-Achilles complex and gastrocnemiustightness?

18. What methods can you describe to determinewhen epiphysiodesis should be performed?

19. How much growth per year can be expectedfrom each of the four main physes in thelower extremity in adolescence?

20. What is your approach to the orthopaedicassessment and treatment of the child withcerebral palsy?

Amputations17

William Aston and Rob Pollock

Above knee amputation 293Below knee amputation 296Lesser toe amputation 297

Foot/ray amputations 297Viva questions 300

ABOVE KNEE AMPUTATION


Indications

‘Dead, dangerous or damn nuisance’ (Apley). Thisessentially means that if a limb is not viable due todisease or trauma, a danger to the patient due toinfection, crush injury or tumour, or non-functional as a result of a congenital abnormalityor trauma and not amenable to other treatmentmodalities, then amputation should beconsidered.

Indications by percentage are:• Peripheral vascular disease – 55 per cent

• Diabetes – 25 per cent• Trauma – 10 per cent• Tumour – 5 per cent• Infection/congenital – 5 per cent.

Contraindications

Inability to gain consent in a well-orientatedpatient in time, place and person.

Consent and risks

• Neurological pain• Phantom limb sensation• Flap demarcation and necrosis necessitating

stump revision or vac pump application

Ideal amputation stump lengths, including the shortest and longest to allow adequate prostheticfitting and the increased energy expenditure by level

Amputation Ideal level – shortest (S)/longest (L) Increased energy expenditureTransradial Proximal 2/3 – distal 1/3 junction

S – 3cm distal to biceps insertionL – 5 cm above wrist joint

Not applicable

Transhumeral Middle 1/3 of humerusS – 4 cm below axillary foldL – 10 cm above olecranon

Not applicable

Transfemoral Middle 1/3 of femurS – 8 cm below pubic ramusL – 15 cm above medial joint line

65 per cent

Transtibial 8 cm for every 1 m of heightS – 7.5 cm below medial joint lineL – Allow adequate soft tissue coverage

25 per cent

294 Amputations

Operative planning

Anteroposterior and lateral radiographs are usedfor templating to determine the necessary boneresection level and clinical examination is vital toplan satisfactory soft tissue closure with skin thatis sensate and that will heal normally. A priority isadequate blood supply to the soft tissues toenable this. Ideal and minimal resection levelsshould be taken into account (see p. 293). Flaplengths and their positioning, may have to bealtered to accommodate skin problems or tumourexcision. By doing this it may be possible toprevent a more proximal amputation.


General anaesthesia is used, with the patientpositioned supine. There is some evidence tosuggest (and is the authors’ preference) thatepidural anaesthesia, local anaesthetic infiltrationof the nerves prior to transection and goodanalgesia in the immediate postoperative period,is effective in reducing the significant problem ofpostoperative neurological pain.

If a tourniquet can be used in the non-ischaemic limb then it should, but must bedeflated prior to wound closure to ensure thatadequate haemostasis has been achieved. Atourniquet should not be used in an ischaemiclimb.

SURGICAL TECHNIQUE


The bone transection point is marked as perplanning/templating. Equal anterior and posteriorflaps are marked on the thigh, with their apices at

• Dermatological problems related to the scar andthe skin–prosthesis interface

• Problems with prosthetic fitting related to thesize/shape/length of the stump and theassociated soft tissues

• Joint contractures• Choke syndrome: venous outflow obstruction in

the distal part of the stump due to prostheticconstriction

the midpoint medially and laterally, at the level ofanticipated bony transection. The lengths of theflaps combined must be greater than the width ofthe limb.

An easy way to do this (Fig. 17.1) is to pass asuture length around the limb at the level oftransection. This length is then halved and placedaround the anterior portion of the thigh at thetransection level, then mark the medial and lateralapices of the flaps at the ends of the suture. Thesuture is then halved in length again andmeasured distally from the transection point inthe midline anteriorly and posteriorly to mark themaximal extent of the flaps. By marking aquadrant of a circle between each of these fourpoints, two semicircular flaps of correct length aredrawn onto the anterior and posterior aspects ofthe leg.


The incision follows the line as marked verticallydown through the skin, subcutaneous fat and

Transection point

I/2 length

I/4 length

Figure 17.1 Amputation flap marking for equal anteriorand posterior flaps. (a) Measurement of circumferenceof limb at bony transection point with a suture –length. (b) Marking medial and lateral apices. (c)Marking extent at flaps

Above knee amputation 295

through the deep fascia to form the skin flaps. Atall times careful soft tissue handling techniquesshould be used.

Deep dissection

The quadriceps muscle is divided, straight downto bone, in the line of the incision. The femoralcanal is identified medial to the femur and theartery and vein ligated within it. These should bedouble tied proximally and if necessary atransfixion suture used. The periosteum is incisedat the level of resection and the femur transectedusing a saw, ensuring protection of the soft tissues.A rasp is used to smooth the sharp edges of thecut bone and prevent high pressure areas in thestump. The sciatic nerve is identified andtransected, with a sharp blade under gentletraction, so that the end retracts proximally. Anycutaneous nerves encountered should also betransected in a similar fashion. The sciatic nervehas a significant artery running within it andtherefore should be ligated, but this is notnecessary for other nerves. The hamstringcompartment is divided and the leg removed. Thewound should be washed thoroughly and thetourniquet released to ensure adequatehaemostasis.

Assessment of the flaps is carried out and anynecessary trimming of muscle. In a non-ischaemiclimb the quadriceps and the hamstrings can besutured (myodesis) through drill holes, to thebone, under slight tension. The deep muscle fascia

is sutured together over the end of the bone (Fig.17.2). A drain is inserted and the superficial fascial,fat and skin layers closed separately. The skin canbe closed with absorbable or non absorbablesutures as tissue healing should be normal.

In the ischaemic limb care should be taken tokeep the skin and muscle flap as onemyocutaneous flap and any tension on the tissuesshould be avoided, due to potential compromiseof the vascular supply and therefore myodesisshould not be used. Instead the muscle can simplybe sutured to the periosteum (myoplasty) or thedeep fascial layers of the muscle masses besutured together over the end of the bone. Draininsertion and layered closure is as above, exceptthe skin should be closed under no tension andinterrupted non-absorbable sutures used.

A suitable stump dressing should be securelyapplied, and this should remain in place for thefirst 5 days.


In order to avoid large amounts of redundant softtissue the muscle flaps and skin flaps should bedebrided as appropriate. However, a cylindrical,soft, well-padded soft tissue mass over the stumpis desirable. In some cases, such as when atypicalflaps are used, the stump may be left large onpurpose to allow for possible skin demarcationand the potential for refashioning and closure. Toavoid large dog-ears a stepwise approach toclosing the flaps is advised, starting by opposing

(a)

Myodesis sutures

Superficialmuscularfascial sutures

Deep musclefascia sutures

(b)

Figure 17.2 Femoral amputation stump – closure in layers. (a) myodesis sutures to bone. (b) Muscle fascial layerclosure

296 Amputations

the middle of the flaps and subsequently halvingthe distance between sutures for each layer. Scarsplaced directly over bony prominences with littleor no intervening soft tissue must be avoided as itwill lead to scar adherence to the bone and skinbreakdown.

Closure

As described above.


• The drain is taken out when there is minimaldrainage, typically 48–72 hours.

• Dressings to be changed, under asepticprecautions at 3–5 days, looking specifically forsigns of infection or skin flap demarcation.

• Specialist physiotherapy referral for stumpbandaging and rehabilitation should be madepreoperatively and start as soon as the wound issatisfactory.

• Prosthetic referral can also be made preopera -tively or postoperatively if appropriate.

• Definitive prosthetic fitting is often 4–6 monthsafter surgery, when the stump has matured.

• A temporary prosthesis can be used within aweek of surgery.

BELOW KNEE AMPUTATION


Similar principles as for above knee amputationwith specific reference to the ideal stump lengthsset out above (see p. 293).

SURGICAL TECHNIQUE


In the non-ischaemic limb, equal flaps are markedout in a similar way to above knee amputation; inthe ischaemic limb a long posterior flap (Fig. 17.3)is used as the posterior blood supply issignificantly better.


As for above knee amputation.

Deep dissection

Generally as for above knee amputation. Theanterior tibial artery and vein are encountered,with the deep peroneal nerve in the anterior com -part ment, the superficial peroneal nerve in thelateral compartment and the posterior tibial andperoneal artery and veins with the tibial nerve inthe deep posterior compartment. Nerves andvessels should be ligated and/or transacted as forabove knee amputation.


The same rules regarding soft tissuereconstruction and closure apply in the ischaemicand non-ischaemic limb as for above kneeamputation.

The fibula should be transacted obliquelyapproximately 2 cm proximal to the tibialtransection and the ends smoothed.

Closure


Transectionpoint

Outlineof skin flaps

Figure 17.3 Tibial – long posteriorflap

Foot/ray amputations 297



COMPLICATIONS


LESSER TOE AMPUTATION


Similar principles as for above knee amputation.

SURGICAL TECHNIQUE


For an amputation at the base of the toe/proximalphalanx a tennis racquet incision can be used (Fig.17.4). More distally the principle of a short dorsaland longer plantar flap is applied.

Dissection

Full thickness myocutaneous flaps are created,down to periosteum. Division of the flexor andextensor tendons allows them to retractproximally. The neurovascular bundles are soughtto allow transection of stretched digital nerves andtying off of the vessels. The bone is transected andsmoothed off with a rasp. Care must be taken withclosure of the muscle and fascia over the stump.


When amputating the second toe it is best to tryto leave as much of the proximal phalanx aspossible to avoid drift of the hallux into valgus.

Hallux amputation

As for lesser toe except a posteromedially basedflap is used to swing into the defect.

Closure

Interrupted non-absorbable sutures.


Dressings are changed, with aseptic precautions,at 3–5 days, looking specifically for signs ofinfection or skin flap demarcation.

FOOT/RAY AMPUTATIONS


Similar principles as for above knee amputation.

SURGICAL TECHNIQUE – DEPENDENT ONTYPE/LEVEL OF AMPUTATION

Border ray amputation – first or fifth ray

Landmarks and incisionA tennis racquet incision is used, based on themetatarsal (Fig. 17.5). With the proximal extentof the incision coming up to the level of thetarsometatarsal joint.Figure 17.4 Toe amputation – tennis racquet incision

298 Amputations

DissectionCreate one full thickness flap, down to bone, toprevent devascularization of the flap. Once thebone has been reached, subperiosteal dissectioncontinues. The bone is transected, at the base ofthe appropriate metatarsal, sloping the cut to theshape of the foot and to minimize pressure on theskin. Tendons are cut under tension and allowedto retract, ligate arteries and transect nerves.

Technical aspects of procedureRemoval of the ray may be made easier if themetatarsophalangeal joint is disarticulated firstand the metatarsal is removed separately. Note,during disarticulation of the first metatarso -phalangeal joint, the penetrating branch of thedorsalis pedis should be preserved (approximately1 cm distal to the joint).

ClosureA single layer of non-absorbable suture is used.

Central ray amputation

Landmarks and incisionDorsal incision with tennis racquet around thetoe.

Superficial dissectionSkin and fat to bone.

Deep dissectionSubperiosteal dissection is done. Transection ofthe base of the metatarsal leaving a remnant istechnically easier than disarticulation at the

cuneiform joints. Dissect out from proximal todistal removing the intrinsics either side.

Technical aspects of procedureIf two rays are to be removed then place theincision between the metatarsals. The secondray is relatively immobile and therefore if thethird and forth rays are to be removed thenan osteotomy at the base of the fifth may berequired to enable closure of the wound.Protected weightbearing for 4 weeks should beperformed.

ClosureInterrupted non-absorbable sutures.

Transmetatarsal (midtarsal) amputation

Landmarks and incisionA long plantar and shorter dorsal flap is used (Fig.17.6). The dorsal flap begins at the level of theintended transection and curves distally as comesmedially. The plantar flap starts at the level of themetatarsal heads and curves to meet the dorsalincision medially and laterally.

DissectionSkin and fat are incised in line with the skin. Themetatarsophalangeal joints should be dis articu -lated and toes removed. The levels of transectionof the metatarsals are marked and cut and edgessmoothed. The tendons are stretched and cut sothat they retract proximally. Similarly, the nervesare divided proximally and the digital arteriesligated then divided.

Technical aspects of procedureLonger flaps are required medially, due toincreased thickness of the foot.

ClosureInterrupted non-absorbable single layer closure isall that is required.

Midfoot amputations

These amputations use exactly the sameprinciples as above. As opposed to a midtarsalamputation, these amputations do not leave any

Figure 17.5 Tennis racquet incision for excision of firstray

Foot/ray amputations 299

of the metatarsals behind. The Lisfrancamputation is at the level of the tarsometatarsaljoints and the Chopart amputation at the level ofthe midtarsal joints. Lisfranc and Chopartamputations have a tendency to go into anequinovarus deformity with time.

Hindfoot amputation – Symeamputation

When considering performing a Symes amputa -tion, a below knee amputation must also beconsidered. A below knee amputation gives asuperior cosmetic result, enables better prostheticfitting and subsequent function. However, what aSymes does provide is a short leg and a stumpwhich can be used to mobilize short distances,such as going to the bathroom in the middle of thenight, without having to hop or apply a prosthesis.

Landmarks and incisionA single posterior heel flap is used. The incision isfrom the tip of the lateral malleolus across theankle joint to 2 cm below the medial malleolus. Itcontinues vertically down around the heal, andback to the tip of the lateral malleolus (Fig. 17.7).

DissectionSkin and fat are incised in line with the skin. Allstructures are then transected down to bone. The

talus is excised by placing the foot in equinus andsequentially dividing the anterior capsule, deltoidligament and calcaneofibular ligament, taking careto preserve the posterior tibial artery. Afterdivision of the posterior capsule and the tendo-Achilles, the foot is removed by shelling out thecalcaneus and preserving the posterior flap.

The distal tibia is transected 0.6 cm from thejoint line, cut so that it will be parallel to theground, and the edges rounded off (see Fig. 17.7).The tendons are cut and allowed to retractproximally, as are the medial and lateral plantarnerves. The anterior tibial and posterior tibialarteries are ligated just proximal to the edges ofthe flap. The heal pad is brought forward, over the

(a) (b)Figure 17.6 Transmetatarsalamputation: (a) incision; (b) after closure

Front of ankle joint

Tibial transectionTip of

Malleolus

Figure 17.7 Syme amputation: incision and tibialtransection point

300 Amputations

cut surface of the tibia, and sutured through drillholes on the anterior surface of the tibia.

Technical aspects of procedureThe skin flap should not be excessively trimmedas it may devascularize it. The dog-ears willresolve over time, with bandaging or furtherprocedure.

ClosureA drain is inserted and the skin closed over it,using interrupted nylon sutures.

POSTOPERATIVE CARE ANDINSTRUCTIONS (FOR ALL FOOT/RAYAMPUTATIONS)

• Partial or non-weightbearing is dependent onthe procedure.

• Physiotherapy/prosthetic referral isrecommended at an early stage.


Byrne RL, Nicholson ML, Woolford TJ, et al.Factors influencing the healing of distalamputations performed for lower limb ischaemia.Br J Surg 1992;79:73–5.

Falstie-Jensen N, Christensen KS, Brochner-Mortensen J. Long posterior flap versus equalsagittal flaps in below-knee amputation forischaemia. J Bone Joint Surg Br 1989;71:102–4.Hagberg E, Berlin OK, Renstrom P. Function afterthrough-knee compared with below-knee andabove-knee amputation. Prosthet Orthot Int1992;16:168–73.Halbert J, Crotty M, Cameron ID. Evidence forthe optimal management of acute and chronicphantom pain: a systematic review. Clin J Pain2002;18:84–92.Harris RI. Syme’s amputation: the techniqueessential to secure a satisfactory end-bearingstump. Can J Surg 1964;7:53–63.Hudson JR, Yu GV, Marzano R, et al. Syme’samputation. Surgical technique, prostheticconsiderations, and case reports. J Am Podiatr MedAssoc 2002;92:232–46.Malawer MM, Sugarbaker PH. MusculoskeletalCancer Surgery Treatment of Sarcomas and AlliedDiseases. London: Kluwer Academic Publishers,2001.Pardasaney PK, Sullivan PE, Portney LG, et al.Advantage of limb salvage over amputation forproximal extremity tumours. Clin Orthop RelatRes 2006;444:201–8.

Viva questions

1. What are the indications for amputation?

2. What are the ideal amputation levels in longbones and why?

3. How does the surgical technique differ whenperforming an amputation on an limb withvascular disease?

4. How would you decide on the appropriate levelfor an amputation?

5. Describe above or below knee, or toe or foot/rayamputations.

6. How do you transect a nerve?

7. What are the complications associated withamputation? How can these complications beminimized?

8. What measures would you take to minimizepostoperative pain?

9. How would you decide between a Syme and abelow knee amputation?

Index

A1 pulleytrigger finger 141, 142trigger thumb 143

AAOS classification of acetabular bone loss at revisionhip surgery 160

abductor pollicis longus (APL)in de Quervain’s decompression 106, 107in wrist arthroscopy 101

above elbow (transhumeral) amputation 293above knee (transfemoral) amputation 293,

293–6acetabular dysplasia 273acetabulum

in hip arthrodesis, preparation 164in hip resurfacing, preparation 162in total hip arthroplasty

preparation 150–1removal of prosthetic component 159–60technical points about insertion of prosthetic

component 151–2trial insertion of prosthetic component 150–1

see also femoroacetabular impingement surgeryAchilles tendon

in calcaneal osteotomy 255, 256lengthening 281–4

in talipes equinovarus 285tendinopathy 224–6

acromioclavicular jointexcision 65–6reconstruction 69–70

acromioplasty, open anterior 62–4adductor(s), hip

adductor longus anatomical relationships (in surgeryfor developmental dysplasia of hip) 270

release in cerebral palsy 290adductor pollicis release in cerebral palsy 290adductus deformity in talipes equinovarus 285adhesions, flexor tendon repair 132age see children; infants; older and elderly peopleairway

chronic obstructive disease 3preoperative assessment 1–2

Akin osteotomy 237–8American Academy of Orthopedic Surgeons (AAOS)

classification of acetabular bone loss at revision hipsurgery 160

amputations 293–300arm 293foot 297–300leg 293–7

anaesthesiaexamination under see examination under

anaesthesiapostoperative 5pre/intraoperative 4Silverskiold test under 283

analgesia 4–5anconeus in elbow arthrolysis 82, 83angiography, coronary 2angular limb deformity 260ankle 218–29

arthrodesis see arthrodesisarthroplasty 220–2arthroscopy 222–4range of motion 218

annular ligament in radial head replacement 91arm amputation 293arthritis

degenerative see osteoarthritisrheumatoid, trigger finger 141

arthrodesis (fusion)ankle 218–20, 230–2

triple, in cerebral palsy 291cervical spine, risks 15foot 230–2

distal interphalangeal joints 247–8first metatarsophalangeal joint 242–4first tarsometatarsal joint 239–40hindfoot 252–4proximal interphalangeal joints 248–9

hand 121–4hip 163–4knee 197–8lumbar spine 37malunion see malunionnon-union see non-unionthoracic spine

anterior 26–8posterior 28–30

wrist 102–6arthrography, hip 170–1

Perthes disease 289

arthrolysis, elbow 79–87arthroscopic 86–7open 80–6

arthropathy, footneighbouring joint following arthrodesis 231painful, arthrodesis for 230, 243, 252

arthroplasty (joint replacement)elbow, total 87–9hand 124–7hip see hip replacementknee see knee replacementshoulder, total 75–7

arthroscopy, diagnostic, shoulder 59–62arthroscopy, interventional (± diagnostic)

ankle 220–2, 222–4elbow 95–7

arthrolysis 86hip 168–70knee 200–4

in anterior cruciate ligament reconstruction 211,213–15

autologous chondrocyte implantation 209–10lateral patellar retinaculum release 206meniscal surgery 204–7

shoulderacromioclavicular joint excision 65–6instability repair 74–5rotator cuff repair 66, 67–8subacromial decompression 64–5

wrist 100–2articular capsule see capsulearticular cartilage reconstruction, knee 208–9articular congruity (joint congruity), hallux valgus 233aspiration

elbow 97–8hand ganglion 119

assessment, preoperative 1–3asthma 3atlas (C1), posterior approach 20–1attachments in limb reconstruction 259avascular necrosis

of capital fragment in Chevron osteotomy 238of femoral head (in Perthes disease) 287

axillary nervein rotator cuff repair 67

injury risk 66in total shoulder replacement, injury risk 76, 77

axis (C2), posterior approach 18–21

Baker slide technique 281, 283–4Beath pin, ACL reconstruction with hamstring graft

215

below elbow (transradial) amputation 293below knee (transtibial) amputation 293, 296–7bending scoliosis films 32biceps, long head (LHV), arthroscopic assessment

61–2biomechanics of limb reconstruction 258biopsy, bone 6–9bone anchors, extensor tendon repair 128, 129bone cutting see osteotomybone–patellar tendon–bone (B–T–B) graft for ACL

reconstruction 211–13bone tumours see tumoursbotulinum toxin A injections in cerebral palsy 290Boutonnière deformities 117, 128bow-stringing

flexor tendon repair 132trigger thumb surgery 143

brachial plexus surgery 56–8brachioradialis in radial head replacement 90, 91Bruner incisions see zig-zag incisionsB–T–B graft for ACL reconstruction 211–13bucket-handle tear 205–6bursa

Achilles 225excision 9

Butler procedure 250–1

cable grafts 54–5calcaneal osteotomy 255–6calcaneocuboid (CC) joint arthrodesis 252, 253,

254callus formation at corticotomy site 258cam deformity of femur 165cancer 11–13capitate–hamate–triquetrum–lunate fusion 104–5capsule

in elbow arthrolysis 82, 83, 84, 85mobilization of medial capsule 85release 85

in hip resurfacing 162in shoulder instability, capsulorrhaphy 72in total shoulder replacement, release 76

cardiopulmonary exercise testing 2cardiovascular system, preoperative assessment 2carotid sheath in anterior approach to cervical spine 17carpal bones, exposure in partial wrist fusion 105carpal tunnel decompression 45–8carpometacarpal joint arthrodesis 121, 124cartilage

articular (knee), reconstruction 208–9physeal, removal (in pediatric leg length

discrepancy) 268

302 Index

castings in Ponsetti technique 285Catterall classification, Perthes disease 289caudal epidural 36–7cavus deformity in talipes equinovarus 285cemented prosthetic component in total hip

replacementacetabular (cup/socket)

removal 159technical points about insertion 152trial insertion 151

femoral steminsertion 153–4removal 158

cemented prosthetic component in total kneereplacement 180–1

cement removal in revision surgery 185cementless (uncemented) prosthetic component in

total hip replacementacetabular (cup/socket)

removal 159–60technical points about insertion 151–2trial insertion 150

femoral steminsertion 153removal 158

cementless (uncemented) prosthetic component intotal knee replacement 181

centre of rotation of angulation (CORA) 260tibial diaphyseal deformity 264

cerebral palsy 3, 289–91cervical spine 14–25

anterior approach to C3-T1 14–18halo vest fixation 121–4posterior approach to C1-C2 20–1posterior approach to C2-C7 18–20range of motion 14

cheilectomy, first metatarsophalangeal joint 241–2Chevron osteotomy 238–9children 267–92

halo application 24scoliosis 32trigger thumb 142

choke syndrome, above knee amputation 294chondrocyte implantation in knee, autologous 209chronic obstructive airways disease 3Cincinnati method 285–7circular frame 258

deformity correction 264femoral lengthening 262

circumflex femoral artery, medial see femoralcircumflex artery

clavicle in acromioclavicular joint reconstruction 69

claw toe 247surgery 248–9

closed reduction, developmental dysplasia of hip 269–71clubfoot (talipes equinovarus) 284–7cobra plate, hip arthrodesis 164collateral ligament, medial, damage in total knee

arthroplasty 174in revision surgery 183

common extensor origin see extensor origincommon flexor origin in golfer’s elbow release 92, 94compression plate, dynamic see dynamic compression

platescompression screws, foot/ankle arthrodesis 231computer programme (online), limb deformity

correction 265congenital positive ulnar variance 109congenital talipes equinovarus correction 284–7contractures, muscle, in cerebral palsy 290coracoacromial ligament in acromioclavicular joint

reconstruction 69coronary angiography 2corticotomy 261

callus formation at site of 258in femoral lengthening 262in tibial lengthening 263

cruciate ligamentanterior

damage in medial unicompartmental kneereplacement 190

reconstruction 210–16posterior, implant as substitute 180

cuneiform, lateral, tibialis anterior tendon transfer to 285cutaneous nerve

amputation above knee 295foot/ankle arthrodesis, damage 230–1

cystbone, curettage ± bone graft 10–11synovial see ganglion

DAMP method (percutaneous tenotomy) 281, 283Darrach procedure 108–9De Quervain’s decompression 106–8decompression (non-spinal)

De Quervain’s 106–8of nerve (and structures causing compression)

carpal tunnel 45–8postoperative care and instructions 55ulnar see ulnar nerve

subacromial arthroscopic 64–5decompression (spinal canal; foraminal stenosis etc.)

cervical, anterior 14cervical spine, posterior 18

Index 303

decompression (spinal canal; foraminal stenosis etc.) –contd

lumbar 37–40thoracic


deformitiesin cerebral palsy 290lesser toes 246–9limb, correction 263–5see also specific types of deformity

degenerative arthritis see osteoarthritisdeltoid

in open anterior acromioplasty 63in open shoulder stabilization 71, 73in rotator cuff repair 67in total shoulder replacement 76, 77

deltopectoral approach, shoulder arthroplasty 75–7dermofasciectomy, Dupuytren’s 117–19derotation femoral osteotomy for developmental

dysplasia of hip 276–8developmental dysplasia of hip see hipdiaphyseal deformity, tibial 264digits see fingers; toesdisc(s), intervertebral

lumbar 40–2scoliosis 31

discoid meniscus surgery 206dislocation (pathological), hip, in cerebral palsy 291dislocation (surgical)

elbow, for anterior arthrolysis 85hip, for resurfacing 162

distal metatarsal articular angle (DMAA) 233, 238,239, 240

distraction osteogenesis 258DMAA (distal metatarsal articular angle) 233, 238,

239, 240dobutamine stress echocardiography 2donor site

in skin grafts 140full thickness skin grafts 140split thickness skin grafts 139–40

in tendon transfers, morbidity 135dorsalis pedis artery damage, ankle arthroplasty 221Dupuytren’s surgery 114–19dural breach, lumbar spine surgery 39, 40Duvries modification (distal fibular sliding graft)

228dynamic compression plates

ulnar shortening 110wrist arthrodesis 103, 104

dysphagia risk, cervical spinal surgery 15

Eastwood–Cole method 267–8ECG, exercise, preoperative 2echocardiography, dobutamine stress 2elbow 79–99

amputation above and below (transhumeral andtransradial) 293

arthrolysis see arthrolysisarthroscopy see arthroscopyaspiration/injection 97–8total replacement 87–9ulnar nerve decompression at 51–3

elderly see older and elderly peopleelectrocardiogram (ECG), exercise,

preoperative 2endoscopic carpal tunnel decompression 47–8epicondylectomy, medial 52epicondylitis

lateral (golfer’s elbow) 92–5medial (tennis elbow) 92–5

epidural, caudal 36–7epineural repair 54epiphysiodesis 267–9epiphysis, slipped upper femoral 278–81equinovarus correction, congenital 284–7equinus deformity

Achilles lengthening 282in talipes equinovarus 285

examination under anaesthesiadevelopmental dysplasia of hip – open reduction

270knee (in arthroscopy) 201

anterior cruciate ligament reconstruction 210shoulder stabilization 71

excision hip arthroplasty 165exercise ECG, preoperative 2exercise testing, cardiopulmonary 2exercise tolerance, preoperative assessment 2extension gaps, total knee replacement 177–8extensor(s), knee, injury risk in total knee

replacement 173extensor carpi radialis brevis (ECRB)

in tennis elbow surgery 93in wrist arthroscopy 101, 104

extensor carpi radialis longus (ECRL)in radial head replacement 90, 91in tennis elbow surgery 93in wrist arthroscopy 102

extensor carpi ulnaris (ECU)in distal ulna excision 108in elbow arthrolysis 83in ulnar shortening 110in wrist arthroscopy 101, 102

304 Index

extensor digiti minimi (EDM) in wrist arthroscopy102

extensor digitorum brevis (EDB) inmetatarsophalangeal joint release 249

extensor digitorum communis (EDC)in elbow arthrolysis 83in tennis elbow surgery 93in wrist arthroscopy 101, 102, 104

extensor digitorum longus (EDL) inmetatarsophalangeal joint release 249

extensor origin, commonin elbow arthrolysis 83in tennis elbow release 92, 93

extensor pollicis brevis (EPB) in de Quervain’sdecompression 106, 108

extensor pollicis longus (EPL), in wrist arthroscopy101, 102, 103–4

extensor tendon repair, hand 127–31external fixation, knee arthrodesis 198

facet injection 42–3fascicular repair 54fasciectomy, Dupuytren’s 115–17

with proximal digital skin excision 117–18fasciotomy, Dupuytren’s 114–15fasting 1femoral artery damage

developmental dysplasia of hip surgery 277femoroacetabular impingement surgery 167

femoral circumflex artery damage, medialin developmental dysplasia of hip surgery 272in femoroacetabular impingement surgery 167

femoral nerve damagefemoroacetabular impingement surgery 167total hip arthroplasty 149

femoroacetabular impingement surgery 165–8femur

amputation through (transfemoral/above kneeamputation) 293, 293–6

avascular necrosis of head of (in Perthes disease)287

cam and pincer deformity 165condylar defect, mosaicplasty 209developmental abnormalities 288epiphysis, slipped upper 278–81in hip resurfacing

head displacement 162preparation 162–3

lengthening 261–3in total hip arthroplasty

bone loss, assessment 158osteotomy see osteotomy

shaping 153stem insertion in 153–4

tunnel for ACL reconstructionB–T–B graft 212–13hamstring graft 214

in unicompartmental knee replacement, preparation 191

femur, osteotomydistal 192–4

in primary total knee replacement 175–6in revision total knee replacement 186in valgus deformity 192–4

proximalin cerebral palsy 291in developmental dysplasia of hip 276–8in hip arthrodesis 164in Perthes disease 288, 289in slipped upper femoral epiphysis 280–1in total hip arthroplasty 150

trochanteric, in total hip arthroplasty 157fibula

in ankle arthrodesis, subperiosteal dissection 219

in below knee amputation 296in peroneal tendinopathy surgery 227, 228

figure-four position, knee arthroscopy 204fingers

joint replacement 124–7trigger 141–2

Fiolle–Delmas approach to brachial plexus 57fixation

ankle/foot arthrodesis 219, 231cervical, with halo vest 121–4knee arthrodesis 198lumbar 37thoracic


see also stabilization and specific instrumentsflaps, amputation

above knee 294–6foot/ray 298, 299, 300lesser toe 297

flexion deformityof interphalangeal joints of foot see hammer toe;

mallet toeof knee, fixed, total knee replacement with 179

flexion gaps, total knee replacement 177–8flexor carpi ulnaris (FCU)

in distal ulna excision 109in elbow arthrolysis 82in ulnar shortening 110

Index 305

flexor digitorum longus (FDL)percutaneous tenotomy 247tendon transfer 248

flexor digitorum profundus (FDP), repair 131, 133flexor digitorum superficialis (FDS), repair 131, 133flexor origin, common, in golfer’s elbow release

92, 94flexor pollicis longus (FPL), repair 131, 133flexor sheath ganglion 119–20flexor tendon repair, hand 131–4flexor tendon transfers, foot 248fluid management, postoperative 5foot 230–45

amputations 297–300arthrodesis see arthrodesisdeformity in cerebral palsy 290pediatric 284–9range of motion 230

foraminal stenosis, decompression see decompressionfour corner wrist fusion 104–5fracture risk

in ankle arthroplasty (of tibial cortex) 221in Scarf osteotomy for hallux valgus 236in total knee arthroplasty 173see also microfracture

full thickness skin grafts to hand 138postoperative care 141

fusion see arthrodesis

ganglion (synovial cyst)hand 119–20wrist 111–13

gastrocnemiuslengthening 283recession techniques 282tightness, ± soleus tightness 283, 284

general anaesthesia 4geniculate arteries, damage in knee arthroscopy 202

in lateral patellar retinaculum release 208Girdlestone procedure (excision hip arthroplasty)

165Girdlestone procedure (flexor tendon transfer) 248glenohumeral joint, arthroscopic assessment 60–1gluteal artery, inferior, damage in total hip arthroplasty

147gluteal nerve, superior, damage in total hip arthroplasty

148gluteus maximus tendon in hip resurfacing 161golfer’s elbow 92–5gracilis

release in cerebral palsy 290tendon for ACL reconstruction 214

graftsbone, after bone cyst curettage 10–11bone–patellar tendon–bone, for ACL reconstruction

211–13hamstring, for ACL reconstruction 211, 213–15nerve 54–5

postoperative care and instructions 56skin, hand 138, 139–41

great toe see halluxGreen–Anderson growth remaining method 267guidewires

in for ACL reconstruction with hamstring graft 214in femoral distal osteotomy 194in femoral preparation for hip resurfacing 162, 163

Guyon’s canal, ulnar nerve decompression in 48

haemorrhage/bleeding riskcervical spinal surgery 18, 21total knee replacement 172

half-pin in limb reconstruction 259insertion and placement 261

hallux (great toe)rigidus, cheilectomy 241–2valgus correction 232–41varus risk in valgus surgery 232, 234

halo vest fixation, cervical spine 121–4hammer toe 247

surgery 248–9hamstrings

graft for ACL reconstruction 211, 213–15release in cerebral palsy 290

hand 114–44arthrodesis 121–4arthroplasty 124–7deformity in cerebral palsy 290

harvestingfull thickness skin grafts 140split thickness skin grafts 139–40

heart murmurs 2Hill–Sachs lesion, shoulder stabilization 73hindfoot (rearfoot)

amputation 299–300arthrodesis 252–4

hip 145–71arthrodesis 163–4arthrography see arthrographyarthroscopy 168–70developmental dysplasia 267–78

closed reduction 269–71open reduction 271–3pelvic osteotomy 273–6proximal femoral osteotomy 276–8

306 Index

dislocation in cerebral palsy 291range of motion 145resurfacing 161–3

hip replacement/arthroplastyexcision 165total 145–56

arthrography 171lateral approach 148–9, 155posterior approach 146–8, 155postoperative care 156preoperative planning 145–6revision of 156–61

Hoke percutaneous tenotomy 281, 283humerus

amputation through 293elbow arthrolysis via 83in total elbow replacement 87–9in total shoulder replacement 76–7tumour, biopsy 7see also transhumeral approach

hypertension 2

Ilizarov, Gavril Abramovich 258Ilizarov frame/method

tibial diaphyseal deformity 264tibial lengthening 263

implants see prosthesesinfants, trigger thumb 142infection

joint replacementhip 161knee 186

respiratory 3infraclavicular approach to brachial plexus 57ingrowing toenail 244–5injection

elbow 97–8facet 42–3

insertional Achilles tendinopathy 224instability

correction see stabilizationknee, risk in total knee replacement 173tarsometatarsal joint (first) 232, 233

intercondylar notch arthroscopy 203intermetatarsal angle , first–second 233interosseous nerve

anterior (AIN), tendon transfer for injury to 135posterior (PIN)

palsy, tendon transfers 136in radial head replacement 91

interphalangeal angle 233interphalangeal joints (IP/IJP) of foot

arthrodesis 248–9distal

arthrodesis 247–8flexion deformity see mallet toe

proximal, flexion deformity see hammer toeinterphalangeal joints (IP/IJP) of hand

distal (DIP)arthrodesis 121, 122arthroplasty 125mucous cyst 120

proximal (PIP)arthrodesis 121, 123arthroplasty 125, 126, 127

thumb, arthrodesis 121intervertebral discs see discsintramedullary nail see nail fixationISKD lengthening nail 262–3

joints see entries under arthr-; articular and specific joints

Keller procedure 232, 241Kelly procedure 228knee(s) 172–217

amputation above (transfemoral) 293, 293–6amputation below (transtibial) 293, 296–7arthrodesis 197–8arthroscopy see arthroscopyrange of motion 172, 200soft tissues 200–17

balancing in total knee replacement 178knee replacement/arthroplasty

patellofemoral 187–9total 172–82

operative planning 173–4postoperative care and instructions 181–2preoperative planning 172–3revision 182–7technique 174–82

unicompartmental 189–91lateral 191medial 190–1

knees to chest position, lumbar disc surgery 40Kocher-type approach, elbow arthrolysis 83

Lapidus procedure 239–40laryngeal nerve (recurrent), injury in cervical spinal

surgery 15leg

amputations 293–7length discrepancy 260

children 167Legg–Calvé–Perthes disease 278–9

Index 307

limb reconstruction 258–66deformities 263–5principles 258–9see also amputations; arm; leg

local anaesthesiaintraoperative

body surface procedures 4neuroaxial 4

postoperative 5longitudinal ligament, posterior, in lumbar disc surgery

41–2lumbar spine

decompression/fixation/fusion 37–40disc surgery 40–2

lung function tests, scoliosis 32

malignant tumour 11–13mallet deformity 127, 128mallet toe 247

surgery 247–8malunion

in arthrodesis in foot/ankle 231hindfoot 252lesser toes 247

in Chevron osteotomy for hallux valgus 238in Scarf osteotomy for hallux valgus 236

mattressscoliosis 32thoracic spinal surgery 29

Mayfield skull clamp in cervical spine surgery 15, 19mechanical axis deviation 260median nerve

in carpal tunnel decompression 47injury risk 46, 47

palsies, tendon transfers 136Menelaus arithmetic method 267menisci, arthroscopic surgery 204–7meshing skin (with split thickness skin grafts to hand)

139metacarpophalangeal joint

arthrodesis 121thumb 121, 122

arthroplasty 125, 125–6postoperative care and instructions 126–7

flexor tendon repair distal to 133flexor tendon repair proximal to 133

metaphyseal damage in hip replacement, grading158–9

metatarsalamputation through 298osteotomy

lesser 249–50

proximal (basal) 240–1metatarsalgia, transfer 232metatarsophalangeal joint (MTPJ)

firstarthrodesis 242–4cheilectomy 241–2soft tissue release 234–5

in flexor tendon transfer 248release 249

microdiscectomy 42microfracture in cartilage reconstruction in knee 209midcarpal portals 101midfoot amputation 298–9midtarsal amputation 298minimal access surgery

lumbar discs 42scoliosis 36

mini-Mitek anchors, extensor tendon repair 128, 129monolateral rail/fixator 258

deformity correction 264femoral lengthening 262

Montreal mattresslumbar spinal surgery 38scoliosis 32thoracic spinal surgery 29

Morrey approach, radial head replacement 90mosaicplasty, knee 209Moseley straight line graph 267mucous cysts, digital 120murmurs, heart 2muscle in cerebral palsy

balancing 290contractures 290

myocardial infarction, preoperative 2

nail (toe), ingrowing 244–5nail fixation

ankle arthrodesis 219femoral lengthening 262–3knee arthrodesis 198

needle biopsy of bone 6–7needle fasciotomy, Dupuytren’s 114, 115neoplasms see tumoursnerve (peripheral) 45–58

in amputationsabove knee 295below knee 296

grafts see graftsinjury (neurological injury) risk

Achilles lengthening 283ACL reconstruction with hamstring graft 214ankle arthrodesis 219, 230–1

308 Index

ankle arthroscopy 223calcaneal osteotomy 255carpal tunnel decompression 46cervical spinal surgery 15developmental dysplasia of hip surgery 271, 272,

274elbow arthrolysis 79femoroacetabular impingement surgery 167foot arthrodesis 230–1ganglion excision at wrist 112hallux valgus correction 232hip arthroplasty 148, 149hip arthroscopy 168knee arthroscopy 202rotator cuff repair 66scoliosis surgery 36shoulder arthroplasty 76, 77shoulder arthroscopy 59ulnar shortening 110

palsies, tendon transfers 134–7repair (following injury)

methods 54–5postoperative care and instructions 56

surgery 45–58principles 53–6

nerve rootsblock 43damage

cervical spine surgery 18–19lumbar spine surgery 39

neuroaxial anaesthesia 4neurological injury/surgery see nerveneuroma formation risk 54

in ganglion excision at wrist 111in hallux valgus correction 232in tendon transfers (hand) 136

neurotization 55neurovascular bundles, Dupuytren’s fasciectomy 116

see also nerve; vascular damagenon-union (arthrodesis), foot/ankle 231

lesser toes 247hindfoot 252

obstructive airways disease, chronic 3obturator arterial branches, damage in total hip

arthroplasty 149obturator nerve damage in dysplasia of hip surgery

271, 272older and elderly people

knee surgery contraindicationscartilage reconstruction 208total knee arthroplasty 182

wrist arthrodesis 102olecranon

elbow arthrolysis 85, 86elbow arthroplasty 88

olecranon fossaelbow arthrolysis 82, 83elbow arthroplasty 88

online computer programme, limb deformitycorrection 265

open biopsy of bone 8–9open reduction

developmental dysplasia of hip 271–3slipped upper femoral epiphysis 280

opiates, postoperative 4–5os peroneum syndrome 227osteoarthritis (degenerative arthritis)

hallux, cheilectomy 241–2patellofemoral, contraindicating unicompartmental

knee replacement 189osteochondritis dissecans, cartilage reconstruction 208osteogenesis, distraction 258osteoporosis, hip resurfacing 161osteotomy (bone cutting)

calcaneal 255–6in cerebral palsy 291femoral see femur, osteotomyfibular, in peroneal tendinopathy 228in hallux valgus 235–9, 240–1metatarsal see metatarsalpelvic, developmental dysplasia of hip 273–6tibial see tibiaulnar shortening 110

Outerbridge–Kashiwagi procedure 83overuse Achilles tendinopathy 224oxygen therapy, postoperative 5

paediatrics see childrenpain

foot arthropathy, arthrodesis 230, 231, 243, 252hallux valgus 232postoperative relief 4–5

Paprosky classification of femoral defects at revisionhip surgery 158–9

parapatellar incision in total knee arthroplasty, medial174–5

parapatellar release in revision total knee arthroplasty,lateral 184

patellalateral release 207–8resurfacing

patellofemoral replacement 188total knee replacement 179–80

Index 309

patellar tendon damagein patellofemoral arthroplasty 188in total knee arthroplasty 174

in revision surgery 183patellofemoral joint arthroscopy 203patellofemoral knee replacement 187–9patellofemoral osteoarthritis contraindicating

unicompartmental knee replacement 189patient-controlled analgesia 4–5pedicle screws

scoliosis 35thoracic spine 30

pelvic discontinuity with total hip arthroplasty 160pelvic osteotomy, developmental dysplasia of hip

273–6Pemberton osteotomy 275–6percutaneous tenotomy techniques

Achilles tendon 281, 282, 283flexor digitorum longus 247

peripheral nerve see nerveperipheral regional anaesthesia 4peroneal nerve damage

common, in knee arthroscopy 202deep, in ankle arthroplasty 221superficial, in ankle arthroscopy 223

peroneal tendinopathy 226–8Perthes disease 278–9pes anserinus in ACL reconstruction with hamstring

graft 214pes equinovarus correction 284–7physeal cartilage removal (in pediatric leg length

discrepancy) 268pin(s)

halocomplications 22positioning/advancement/tightening 23selection of insertion sites 23

Schantz, in Salter osteotomy 274transfix, in ACL reconstruction with hamstring graft

215see also half-pin; pinning

pincer deformity of femur 165pinning in slipped upper femoral epiphysis 278–80pistol deformity of femur 165plaster spica in developmental dysplasia of hip 269,

270, 271, 273, 275plates

hip arthrodesis 164ulnar shortening 110wrist arthrodesis 103, 104, 105

platysma muscle in anterior approach to cervical spine17

polymethylmethacrylate (PMMA) cementtotal hip arthroplasty

femoral stem 154spacer in revision surgery 161

total knee replacement 180Ponsetti technique 284–5

failed 285–6popliteal artery damage

distal femoral osteotomy 193proximal tibial osteotomy 196

postoperative care 4–5preoperative assessment 1–3prostheses/prosthetic components/implants

ankle arthroplasty 221elbow replacement (total) 87finger joint replacement 125hip replacement (total)

acetabular components (cup/socket) 150–2acetabular components (cup/socket), removal

159–60failure 145femoral components (stem) 153–4femoral components (stem), removal 158

knee replacement (total) 173, 180–1removal 185in revision surgery 183

patellofemoral replacement 189posterior cruciate ligament-substituting 180radial head replacement 90

pseudoequinus, Achilles lengthening contraindicated282

psoas release in cerebral palsy 290Pulvertaft weave

extensor tendon repair 130tendon transfer 136

quadratus femoris in hip resurfacing 161quadratus plantae muscle in Cincinnati incision for

talipes equinovarus 287quadriceps snip and turndown, revision total knee

replacement 184–5

radial nerveinjury in ganglion excision at wrist 111, 112palsy, tendon transfers 136

radiocarpal portals 101radiographic assessment

hallux valgus 233limb reconstruction 259

radionuclide scan (scintigraphy), thallium 2radius

amputation through 293

310 Index

head replacement 89–92range of motion

ankle 218cervical spine 14elbow 79foot 230hip 145knee 172, 200shoulder 59wrist 100

rasps, femoral (for stem insertion) 153ray of foot, amputation 297reaming, acetabular, total hip arthroplasty 150rearfoot see hindfootrectus femoris in femoroacetabular impingement

surgery 167recurvatum deformity risk, tendon transfers (hand)

136reduction

in developmental dysplasia of hipclosed 269–71open 271–3

in slipped upper femoral epiphysis, open 280in total hip arthroplasty, trial 154–5

regional anaesthesia, peripheral 4respiratory assessment 3resurfacing

hip 161–3patella see patella

retraction in total hip arthroplasty 149rheumatoid arthritis, trigger finger 141ribs, scoliosis surgery 32–3, 33rings in limb reconstruction 259

tibial diaphyseal deformity 264risk groups, special 3rods, scoliosis 34, 35rotator cuff repair 66–8

Salter osteotomy 273–5saphenous nerve damage, ACL reconstruction with

hamstring graft 214saphenous vein damage, short, Achilles lengthening

283scapholunate ligament, ganglion 111, 112scaphotrapezoid joint, ganglion 111, 113Scarf osteotomy, hallux valgus 235–7Schantz pins in Salter osteotomy 274sciatic nerve

in amputation above knee 295in Salter osteotomy 274in total hip arthroplasty 147

in revision surgery 157

scintigraphy, thallium 2scoliosis 30–6

cerebral palsy 291idiopathic 31

screws (fixation)ankle/foot arthrodesis 219, 231

hindfoot 254metatarsal osteotomy (lesser toes) 250scoliosis 33, 35slipped upper femoral epiphysis 279thoracic spine 28total hip arthroplasty, acetabular component 151

removal 160segmental fasciotomy, Dupuytren’s 115semitendinosus tendon for ACL reconstruction 214shoulder 59–78

diagnostic arthroscopy 59–62range of motion 59stabilization 71–5

anterior (arthroscopic) 74–5anteroinferior (open) 71–3posterior (open) 73–4

total replacement 75–7silicone radial head replacement 90Silverskiold test under anaesthesia 283skin grafts, hand 138, 139–41skull clamp in cervical spine surgery 15, 19Smith–Peterson approach to hip, modified 166soft tissues

fifth toe, correction 250–1hand, reconstruction 137–41knee see kneemetatarsophalangeal joint (first), release 234–5in talipes equinovarus, release 285–7

soleus and gastrocnemius tightness, combined 283,284

spastic hemiplegia, Achilles lengthening outcome 282special risk groups 3spica plaster in developmental dysplasia of hip 269,

270, 271, 273, 275Spider Limited Wrist Fusion plate 105–6spinal cord damage in cervical spine surgery 18–19spine (vertebral column) 14–44

in cerebral palsy 291cervical see cervical spinethoracolumbar 26–44

split thickness skin grafts to hand 138, 139–40postoperative care 141

stabilizationcervical spine, risks 15in limb reconstruction, methods to improve stability

258–9

Index 311

stabilization – contdshoulder see shouldersee also fixation

sternocleidomastoid muscle in anterior approach tocervical spine 17

stiffnessin hallux valgus correction 232knee replacement with 173

stitches see suturesStullberg classification, Perthes disease 289subacromial space

arthroscopic assessment 61, 62arthroscopic decompression 64–5

subcutaneous transposition of ulnar nerve 52–3subdeltoid bursa

in rotator cuff repair 66, 67in total shoulder replacement 76, 77

subperiosteal dissection of fibula for ankle arthrodesis219

subscapularis lengthening in total shoulderreplacement 76

subtalar (ST) joint arthrodesis 252, 253, 254supraclavicular approach to brachial plexus 56suprapatellar pouch, arthroscopy 203sural nerve damage

Achilles lengthening 283Achilles tendinopathy surgery 225ankle arthrodesis 219calcaneal osteotomy 255

sutures (stitches)above knee amputation 295extensor tendon repair in hand 129, 130flexor tendon repair in hand 133rotator cuff repair 67total hip arthroplasty 155total knee replacement 181wrist arthrodesis 104

swallowing difficulty (dysphagia), risk in cervical spinalsurgery 15

Swanson’s implant 125Syme amputation 299–300synovial cyst see ganglion

talar component in ankle arthroplasty 221talipes equinovarus correction 284–7talonavicular (TN) joint arthrodesis 252, 253, 254tarsometatarsal joint (TMTJ), first

arthrodesis 239–40hypermobility or instability 232, 233

Taylor Spatial Frame, tibial 264tendinopathy

Achilles 224–6

peroneal 226–8tendo-Achilles see Achilles tendontendon repair, hand 127–34

extensor 127–31flexor 131–4

tendon ruptureAchilles 224, 225tendon transfer and risk of 135tendon transfer in delayed presentation of 135

tendon transfersfoot 248

for muscle balancing 290in talipes equinovarus 285

hand 134–7tennis elbow 92–5tennis racquet incision

lesser toe amputations 297ray amputation 297

tenotomy, percutaneous see percutaneous tenotomythallium scintigraphy 2thoracic spine

anterior decompression/fixation/fusion 26–8posterior decompression/fixation/fusion 28–30

thoracoscopic anterior correction 36thromboembolism risk

ankle arthrodesis 220hip arthrodesis, prophylaxis 164total knee replacement 172

thumbdeformity in cerebral palsy 290interphalangeal joint arthrodesis 121metacarpophalangeal joint arthrodesis 121, 122trigger 142–3

tibiain amputation of hindfoot 299, 300amputation through (trans-tibial/below knee

amputation) 293, 296–7diaphyseal deformity 264lengthening 263osteotomy/bone cuts 194–7

in medial unicompartmental knee replacement190–1

in primary total knee replacement 177in revision total knee replacement 185for varus deformity 194–7

prosthetic component in ankle arthroplasty 221tunnel for ACL reconstruction

B–T–B graft 211hamstring graft 215

tibial artery and nerve in ankle arthroscopy 223tibialis anterior tendon transfer

in cerebral palsy 290

312 Index

in talipes equinovarus 285tibialis posterior tendon

lengthening 286transfer in cerebral palsy 290

toesgreat see halluxingrowing toenail 244–5lesser

amputation 297deformities 246–9fifth, soft tissue correction 250–1metatarsal osteotomy 249–50

transfemoral (above knee) amputation 293, 293–6transfer metatarsalgia 232transfixion pin method, ACL reconstruction with

hamstring graft 215transfixion suture, above knee amputation 295transhumeral amputation 293transhumeral approach in elbow arthrolysis 83transmalleolar approach to ankle arthrodesis, lateral

219–20transmetatarsal amputation 298transradial amputation 293transtibial (below knee) amputation 293, 296–7transtricipital approach to elbow arthrolysis 81–6trial insertion

in total hip arthroplasty, acetabular component150–1

in total knee arthroplasty 181trial reduction, total hip arthroplasty 154–5triangular fibrocartilage complex (TFCC)

in distal ulna excision 109repair or debridement 100

triceps in elbow arthrolysis 81, 82, 83, 84, 85trigger finger 141–2trigger thumb 142–3triple arthrodesis of ankle in cerebral palsy 291trochanteric osteotomy in total hip arthroplasty 157troughing of Scarf osteotomy 236tubercle osteotomy, tibial, in revision total knee

replacement 185tumours (bone and soft tissue) 6–13

benign, excision 9–10biopsy 6–9cystic, curettage ± bone graft 10–11malignant 11–13

turn down flaps, Achilles tendon defects 225

ulnadistal, excision 108–9proximal, in elbow arthroplasty 87–9shortening 109

ulnar nervedecompression

at elbow 51–3at wrist 48–50

in elbow arthrolysis 82injury 79

palsies, tendon transfers 136in ulnar shortening, injury 110

uncemented prostheses see cementless prostheticcomponent

valgus deformityhallux 232–41knee

distal femoral osteotomy 192–4total knee replacement 179

valgus osteotomyfemoral, in Perthes disease 288tibial 194–7

varus deformityhallux, risk in valgus surgery 232, 234knee

proximal tibial osteotomy with 194–7total knee replacement with 178–9, 179

in talipes equinovarus 285varus femoral osteotomy

developmental dysplasia of hip 276–8Perthes disease 289valgus deformity 192–4

varus/valgus positioning of tibial and talar cuttingguides 221

vascular damage/injuryAchilles lengthening 283in cervical spine surgery 15, 19developmental dysplasia of hip surgery 277femoroacetabular impingement surgery 167knee region

in arthroscopy 202, 208distal femoral osteotomy 193lateral patellar retinaculum release 208proximal tibial osteotomy 196total knee replacement 172–3

Scarf osteotomy for hallux valgus 236total hip arthroplasty 147, 149

venous thromboembolism see thromboembolism riskvertebral artery root damage in cervical spine surgery

19vertebral column see spineVitallium radial head replacement 90volar plate contracture 117Vulpius procedure 281, 284V–Y advancement, Achilles tendinopathy 226

Index 313

Wadell’s abnormal illness behaviour, lumbardecompression/fixation/fusion 38

Weaver–Dunn acromioclavicular joint reconstruction,modified 69–70

web-based (online) programme, limb deformitycorrection 265

Weil’s osteotomy 249–50White slide (DAMP method) 281, 283wires in limb reconstruction 258–9

insertion and placement 260, 261see also guidewires

wrist 100–13arthrodesis 102–6arthroscopy 100–2

ganglion excision 111–13range of motion 100ulnar nerve decompression at 48–50

Z-plasty/Z-lengtheningDupuytren’s fasciectomy 116soft tissue reconstruction

foot 286, 287hand 138, 138–9

zig-zag (Bruner) incisionscarpal tunnel decompression 47extensor tendon repair 129flexor tendon repair 132

zygapophyseal (facet) joint injection 42–3

314 Index

0340985003 Orthopaedics

Documents

Transcript of 0340985003 Orthopaedics