Chapter 43: Orthopedic Surgery

1. The main principle of internal fixation for fracture care (most commonly intramedullary nails or plate and screw fixation) is to create a stable construct that will allow the fracture to heal in proper alignment.

2. Often, in open fractures, definitive treatment of the fracture is delayed until the wound is sufficiently cleaned and healthy soft tissue is available to cover the fracture.

3. When compartment syndrome is suspected, emergent fasciotomy must be performed in which the overlying tight fascia is released through long incisions. These must be done as soon as possible because the damage to muscles and nerves will result in irreversible necrosis and contractures causing severe loss of function.

4. Fractures of the scapula often result from significant trauma and can be associated with injuries to the head, lungs, ribs, and spine.

5. The shoulder is one of the most commonly dislocated joints and most dislocations are anterior. Posterior dislocations are associated with seizures or electric shock.

6. Humeral shaft fractures occur from direct trauma to the arm or from a fall on an outstretched arm, especially in elderly patients. The radial nerve spirals around the humeral shaft and is at risk for injury, therefore a careful neurovascular exam is important.

7. Hemorrhage from pelvic trauma can be life threatening. An important first line treatment in the emergency room is the application of a pelvic binder or sheet that is wrapped tightly around the pelvis to control bleeding.

8. In spinal injury spinal stability must be assessed, and the patient immobilized until his spine is cleared. CT scan is more reliable in assessing spine injury than plain radiographs.

9. Spinal cord injuries should be triaged to trauma centers since trauma center care is associated with reduced paralysis.

10. According to the CDC and the National Health Interview Survey approximately 50 million adults (22% of the US population) have been diagnosed with some form of arthritis. This number is projected to grow to an astounding 67 million adults by 2030 (or 25% of the U.S. population).

11. Weight loss of as little as 11 pounds has been shown to decrease the risk of developing knee osteoarthritis in women by 50%. Similarly, patients who engage in regular physical activity have been found to have lower incidence of arthritis.

12. Smaller incisions come with the disadvantage of decreased visualization intra-operatively and associated risks of component malposition, intraoperative fracture and nerve or vascular injury. The only documented benefit of minimally invasive techniques appears to be improved cosmesis.

Orthopedic surgery is a specialty with which every physician should be familiar. Anyone who cares for patients in an outpatient or emergency room setting will find that the majority of presenting complaints involve the musculoskeletal system. A basic understanding of musculoskeletal anatomy is assumed, and understanding the principles of care for musculoskeletal trauma is essential.

For physicians, the field of orthopedics offers an array of subspecialties with such diversity that it seems that “there is something for everyone.” Trauma specialists have the satisfaction of physically putting complex fractures back together. Sports medicine offers remarkably rapid recovery in athletes who have suffered fibrocartilage tears with ever improving arthroscopic techniques and instrumentation. Spine surgeons see remarkable results from their minimally invasive microscopic techniques, while also managing massive deformities with new instrumentation and open surgery. Joint reconstruction is one of our most exciting subspecialties, working with orthopedic bioengineers to develop improved designs, biomaterials, and minimally invasive surgical approaches to return function faster for patients crippled by arthritis and injury. Musculoskeletal oncology offers the intellectual challenge of arriving at appropriate differential diagnoses as well as the technical challenge of limb salvage and major reconstructive surgery. ­Pediatric orthopedics is an especially challenging and rewarding subspecialty because of the remarkable ability of children to heal even severe injuries rapidly and completely. The incredible array of congenital and developmental disorders makes pediatrics a uniquely intellectually challenging field as well. The authors hope that our readers will share our enthusiasm for orthopedic surgery and all of its subspecialties: trauma, sports, spine, joint replacement, musculoskeletal oncology, and pediatric orthopedics.

Introduction

Musculoskeletal injuries resulting from trauma include fractures of bones, damage to joints, and injuries to soft tissues. Long bone fractures can be described as transverse, oblique, spiral, segmental, or comminuted (Fig. 43-1). The goals of treating musculoskeletal injuries are to restore the normal anatomy, immobilize injured extremities for both pain relief and to allow for healing, and to repair or reconstruct these injuries to restore function.

Fractures frequently result from high energy trauma as well as from falls onto an extremity (Fig. 43-2).The majority of fractures can heal well with immobilization, which stabilizes the fracture while new bone forms at the fracture site. Methods of immobilization can vary and depend on the fracture being treated. The most common tool used in orthopedics to treat fractures is immobilization with a splint or cast, and their proper application is important to successfully treat the injury without causing additional problems. A successful splint contains adequate padding on the underlying skin, and particularly over bony prominences, to prevent pressure or burns that can be caused by plaster. Splints, which are not circumferential, are preferred for acute injuries because they allow room for swelling which inevitably occurs after a fracture.

Fractures that are displaced or angulated require closed reduction to properly realign the bone. This is done using analgesia, local or general anesthesia, and often muscle relaxation. Reduction is performed with axial traction and reversal of the mechanism of injury in order to restore length, rotation, and angulation. A splint is then applied and can be gently molded to help hold the reduction in place. It is important to obtain X-rays after a close reduction to verify acceptable alignment of the fracture, and to perform a neurovascular exam to ensure the splint is not too tight.

For certain fractures, splint or cast immobilization alone is not enough and in these instances internal fixation is used. The main principle of orthopedic implants for fracture care is to create a stable construct that will allow the fracture to heal in proper alignment. Screws can be placed across a fracture to create compression at the fracture site, which promotes healing. Plates can be placed on the cortex of bones and held with screws, which creates a long area of fixation to stabilize the fracture. Intramedullary rods are commonly used for long bone fractures, such as the femur and tibia (Fig. 43-3A). Prior to their placement, the marrow in the canal is usually removed with a reamer. The rod is then inserted into the canal. Screws can then be placed across the cortices of the bone through holes in the rod proximal and distal to the fracture to create a locked construct that further stabilizes the rod (Fig. 43-3B). In situations where patients are severely injured and cannot safely undergo surgery, or when the soft tissues are too swollen or injured to allow for surgical incisions to be safely made, an external fixation device can be used to temporarily immobilize the fracture. External fixators involve pins placed in bone proximal and distal to the fracture through healthy tissues that are connected by strong rods on the outside extremity, creating a stable construct.

Open Fractures

An open fracture occurs when the bone breaks through the skin. These typically result from high energy injuries and are often associated with significant damage to the surrounding soft tissues and contamination of the wound (Fig. 43-4A). These injuries require immediate irrigation and debridement in the operating room and treatment with antibiotics to prevent wound infections and osteomyelitis (Fig. 43-4B). They can also cause injuries to surrounding vessels and nerves, which must be addressed as well. Often, definitive treatment of the fracture is delayed until the wound is sufficiently cleaned and healthy soft tissue is available to cover the fracture.

Compartment Syndrome

Compartment syndrome is an orthopedic emergency caused by significant swelling within a compartment of an injured extremity that jeopardizes blood flow to the limb. Increased pressure within the compartment compromises perfusion to muscles and can cause ischemia or necrosis. Patients complain of pain and numbness, and passive stretch of muscles within the compartment causes severe pain. While the diagnosis is based on clinical exam, pressures can be measured with needles placed into the compartment, which is necessary in unconscious patients who will not show these exam findings. When compartment syndrome is suspected, emergent fasciotomy must be performed in which the overlying tight fascia is released through long incisions. These must be done as soon as possible because the damage to muscles and nerves will result in irreversible necrosis and contractures causing severe loss of function.

Clavicle Fractures

Fractures of the clavicle are one of the most common fractures in orthopedics. They typically occur following a fall onto the shoulder and the majority of clavicle fractures occur in the middle third of the clavicle. Since the bone is subcutaneous, the fracture is often evident on inspection. Most clavicle fractures can be treated nonoperatively with a sling, range of motion ­exercises, and gradual return to normal activities. Fractures that are significantly displaced and shortened, or that penetrate the skin, are treated with open reduction internal fixation, typically with plate and screw fixation.

Distal clavicle fractures are less common and may occur along with coracoclavicular ligament ruptures. These injuries can be more troublesome and are at risk for nonunion if the bone ends are not in contact. If there is displacement of the fracture, surgical management is often recommended.

Acromioclavicular (AC) joint injuries occur from either a fall directly onto the shoulder or onto an outstretched hand and can result in tears of the acromioclavicular and coracoclavicular ligaments. A step-off, or separation, of the AC joint may be apparent on radiographs. The majority of these injuries can be treated with a sling and gentle range of motion. Injuries resulting in severe displacement of the clavicle may require open reduction and surgical repair.

The sternoclavicular (SC) joint is the only articulation between the upper extremity and the axial skeleton, and injuries to this joint are rare. Anterior dislocations occur more frequently and closed reduction can be attempted, followed by sling immobilization. Posterior SC joint dislocations can be dangerous, resulting in pulmonary or neurovascular compromise, and closed reduction under general anesthesia is recommended with a vascular surgeon present in case of vascular injury.

Scapula Fractures

Fractures of the scapula often result from significant trauma and can be associated with injuries to the head, lungs, ribs, and spine. Most scapula fractures are treated nonoperatively with the exception of fractures to the glenoid. As with most intra-articular fractures, displacement of the articular surface of the glenoid is an indication for open reduction and internal fixation.

Shoulder Dislocations

The shoulder is one of the most commonly dislocated joints and most dislocations are anterior. They are often associated with injuries to the labrum (Bankart lesion), impression fractures of the humeral head (Hill-Sachs lesion), and rotator cuff tears. Posterior dislocations are associated with seizures or electric shock. Adequate radiographs are required to diagnose a shoulder dislocation, with the axillary view being the most critical. If proper X-rays are not performed then dislocations can be missed and can result in significant debilitation of the shoulder. Dislocation of the shoulders can be managed with closed reduction followed by a short period of sling immobilization.

Proximal Humerus Fractures

Proximal humerus fractures occur most frequently in elderly patients following a fall onto the shoulder, though they can also occur following high-energy trauma. They have historically been classified by the number of fracture fragments using the Neer classification, which divides the proximal humerus into 4 parts: the humeral head, greater and lesser tuberosities, and the humeral shaft. Treatment is determined by the displacement of the fracture fragments, the amount of angulation of the fracture, and the amount of comminution (which means multiple fracture fragments). If there is suspicion of an intra-articular fracture, a computerized tomography (CT) scan is often indicated. The majority of proximal humerus fractures is minimally displaced and can be treated with sling immobilization, followed by early shoulder motion and pendulum exercises. Displaced fractures and fractures involving the humeral head are at increased risk for osteonecrosis and therefore surgery is often recommended. If there is adequate bone stock and the fracture can be successfully reduced, open reduction internal fixation with plate and screw fixation is the treatment of choice. Older patients with osteoporotic bone and comminuted fractures are typically treated with a prosthetic replacement of the humeral head, or a hemiarthroplasty.

Humeral Shaft Fractures

Humeral shaft fractures occur from direct trauma to the arm or from a fall on an outstretched arm, especially in elderly patients. The radial nerve spirals around the humeral shaft and is at risk for injury, therefore a careful neurovascular exam is important. Most radial nerve injuries are neuropraxias, or stretching of the nerve, and function typically returns in 3 to 4 months. The majority of humeral shaft fractures can heal with nonsurgical management if they are within an acceptable degree of angulation. They are treated with a coaptation splint or functional bracing, which consists of a plastic clamshell brace with Velcro straps. Close follow-up with serial radiographs is important to verify healing of the fracture, and gentle motion exercises are begun within 1 to 2 weeks. Fractures with significant angulation are most commonly treated with open reduction and plate fixation, with care to protect the radial nerve as it often lies close to the fracture site. Intramedullary nailing can also be performed, though it carries the risk of shoulder pain from the nail insertion.

Distal Humerus Fractures

Fractures of the distal humerus result from falls onto the elbow or onto an outstretched arm. Supracondylar fractures are most common, occurring above the elbow joint and do not involve the articular surface. Those minimally displaced can be treated with a posterior long arm splint, with the elbow typically flexed to 90 degrees. Fractures involving the articular surface are treated with plate fixation, and depending on the fracture pattern may require 2 plates, one placed medially and one posterolaterally. As with other intra-articular fractures, the goals of treatment are anatomic reduction of the joint surface with stable fixation, restoration of the anatomic alignment of the joint, and early range of motion. Severely comminuted fractures, especially in the elderly, may be treated with a total elbow replacement, which involves replacing the joint surfaces of the distal humerus, proximal ulna, and radial head with prosthetic components. Fractures about the elbow are notorious for developing stiffness and therefore early motion of the elbow is paramount to a successful outcome. Range of motion should be started as soon as the patient can tolerate therapy.

Elbow Dislocations

Dislocations of the elbow are common and typically occur posteriorly after a fall on an outstretched hand. A dislocation results in injury to the joint capsule and rupture of the lateral collateral ligament, though the medial collateral ligament can also be involved. They may even be associated with a fracture of the radial head, coronoid, or the epicondyles of the humerus. Simple elbow dislocations should be urgently reduced with the patient under sedation and treated briefly in a posterior long arm splint. Stiffness of the elbow is a common complication following elbow dislocations and therefore short-term immobilization (about 7–10 days) and early range of motion is recommended.

Dislocations associated with fractures may be treated surgically if there is any instability of the elbow joint. A severe injury, known as the “Terrible Triad,” includes an elbow dislocation, a radial head fracture, and a coronoid fracture. These are unstable injuries and require repair of the torn lateral collateral ligament (LCL), fixation or replacement of the radial head, and possible fixation of the coronoid depending on the size of the fracture fragment.

Radial Head Fractures

Most fractures of the radial head can be treated nonoperatively, simply with a sling for 1 to 2 days followed by motion exercises. However, if there is a displaced fracture or if the fracture blocks pronation or supination of the forearm, then surgery is recommended. If the fracture can be well reduced, it is fixed with 1 or 2 screws. If the radial head is fractured into multiple pieces, the treatment of choice is a radial head replacement with a ­metallic implant. Excision of the radial head can also be performed, but this is reserved for elderly patients with limited demands and may contribute to elbow instability or wrist symptoms over time.

Olecranon Fractures

Olecranon fractures occur following a fall directly onto a flexed elbow. Nondisplaced fractures are treated with a splint in 45 to 90 degrees of flexion for a short time followed by range of motion exercises to prevent stiffness. Because the triceps inserts on the olecranon, the pull of the muscle often displaces the fracture, causing a loss of the ability to actively extend the elbow, and therefore should be fixed surgically. Simple transverse fractures can be fixed with a tension band construct, which consists of cerclage wiring passed through the ulna and wrapped in a figure-of-8 fashion around 2 pins placed proximally into the olecranon, creating a compressive force across the fracture to promote healing. Comminuted fractures are treated with plate and screw fixation. Because of the subcutaneous location of the olecranon, this hardware can be irritating to the patient and may need to be removed after the fracture has healed.

Forearm Fractures

Forearm fractures are common injuries that result from high energy trauma or from falls onto an outstretched arm. Both bone forearm fractures often require surgery with plate and screw fixation. The radius has a bow and rotates around the straight ulna for proper pronation and supination of the forearm, and therefore this anatomic relationship needs to be restored to maintain function. An isolated fracture of the ulna shaft, or a “nightstick fracture,” occurs from a direct blow to the side of the forearm. These can usually be treated in a cast, though fractures that are angulated or displaced can be treated with open reduction and plate fixation. A Monteggia fracture is an ulna shaft fracture along with a radial head dislocation. The radial head dislocation may be missed without radiographs of the elbow and therefore a fracture of the ulna should raise suspicion of this injury. These injuries require surgery to fix the ulna fracture with plate and screw fixation and to reduce radial head. A Galeazzi fracture is a radial shaft fracture with disruption of the distal radioulnar joint (DRUJ) at the wrist. After the radius is fixed with plate and screw fixation, the DRUJ is assessed for stability and may need wires placed across the joint temporarily.

Pelvic Fractures

Pelvic fractures are indicative of high energy trauma and are associated with head, chest, abdominal, and urogenital injuries. Hemorrhage from pelvic trauma can be life threatening and patients can present with hemodynamic instability, requiring significant fluid resuscitation and blood transfusions. The bleeding that occurs is often due to injury to the venous plexus in the posterior pelvis, though it can also be due to a large vessel injury such as a gluteal artery. Immediate resuscitation is critical and these patients may require surgical exploration or interventional radiology embolization to stop the bleeding. An important first-line treatment in the emergency room is the application of a pelvic binder or sheet that is wrapped tightly around the pelvis to help control bleeding. An external fixator may also be placed in the operating room. Other associated injuries are bladder and urethral injuries that manifest with bleeding from the urethral meatus or blood in the catheter and need to be assessed with a retrograde urethrogram.

The pelvis is a ring structure made up of the sacrum and the two innominate bones that are held together by strong ­ligaments. Because it is a ring, displacement can only occur if the ring is disrupted in two places. This may occur either from fractures of the bones or tears of the ligaments. There are three main fracture patterns that occur from trauma to the pelvis. An anteroposterior force to the pelvis causes an “open book” injury pattern in which the pelvis springs open, hinged on the intact posterior ligaments with widening of the pubic symphysis. A lateral compression pattern results from a crush injury that causes fractures to the ileum, sacrum, and pubic rami. Vertical shear injuries are very unstable since they result from disruption of the strong posterior pelvic ligaments and are associated with significant blood loss and visceral injuries. Fractures of the sacrum may be difficult to see on x-ray and therefore CT scans are often needed to visualize the fracture pattern. The sacral nerves pass through foramen in the sacrum and therefore fractures that are close to this foramen can result in nerve injuries.

Treatment of pelvic fractures depends on the fracture pattern. Stable, minimally displaced fractures can be treated nonoperatively with protected weight bearing. Open book injuries in which the pubic symphysis is widened and the posterior pelvic ligaments are also injured need to be fixed surgically, which is typically performed with screws placed percutaneously through the ileum into sacrum to stabilize the pelvis posteriorly and a plate and screws over the pubic symphysis to stabilize it anteriorly. Displaced sacral fractures and iliac wing fractures are treated with screws or plates, while pubic rami fractures can usually be managed nonoperatively. While most pelvic fractures are caused by high energy trauma, elderly patients with osteoporotic bone can also suffer pelvic fractures after a fall, usually fracturing the pubic rami. Since these are stable injuries, they can be managed nonoperatively with protected weight bearing.

Acetabular Fractures

The acetabulum forms the socket of the hip joint, and fractures occur when the femoral head is driven into it in the setting of high energy trauma. CT scans are important to visualize the fracture pattern. These fractures often require surgery in order to restore a congruent, stable acetabulum, because incongruity of the hip can lead to early degenerative changes and osteoarthritis. These are best treated in the hands of experienced orthopedic trauma surgeons.

Hip Dislocations

Hip dislocations almost always result from high energy trauma and most commonly occur posteriorly. They can cause injury to the sciatic nerve, which runs directly posterior to the hip joint, and may be associated with a fracture of the acetabulum or femoral head. Hip dislocations need to be emergently reduced because of the risk of osteonecrosis of the femoral head when reduction is delayed. They can usually be reduced in the emergency room with adequate sedation and muscle relaxation, but sometimes patients need general anesthesia to aid in the reduction. If this is unsuccessful, or if a fracture fragment gets trapped inside the joint, then an open reduction is performed. Hip dislocations that are associated with a femoral head fracture are at increased risk for osteonecrosis of the femoral head and posttraumatic osteoarthritis.

Hip Fractures

Hip fractures are an extremely common injury seen in orthopedics and are associated with significant morbidity and mortality. They most often occur in elderly patients after grounds level falls, are much more common in women than men, and occur more commonly in patients with osteoporosis. Patients who suffer hip fractures are at increased risk for many complications, including deep vein thrombosis, pulmonary embolism, pneumonia, deconditioning, pressure sores, and even death, as the mortality rate in the first year following a hip fracture is around 25%. One of the most important reasons for performing surgery is to prevent these complications, and getting patients out of bed and walking as soon as possible diminishes their risk. Therefore, surgery is almost always the treatment of choice for hip fractures, and the type of surgery performed is determined by the anatomic location of the fracture and the fracture pattern. Surgery should be performed as soon as possible, typically within 24 to 48 hours; however, since many of these patients suffer other comorbidities, they must be properly medically optimized before surgery. The goals of surgery are to minimize pain, restore hip function, and allow early mobilization, the importance of which cannot be overemphasized. The functional outcome for patients following a hip fracture is largely based on their level of mobility and independence before their injury. Many patients become less independent, may require assistive devices to help them walk, and some may require a long-term nursing or rehabilitation facility.

Femoral Neck Fractures

Femoral neck fractures occur with the capsule of the hip joint. The blood supply to the femoral neck and head comes from branches of the medial and lateral femoral circumflex arteries, which run along the femoral neck, and therefore fractures in this area put the vascular supply at risk and can lead to osteonecrosis. Femoral neck fractures that are nondisplaced have a low risk of disruption of blood flow and therefore can be treated with in situ internal fixation. Three cancellous screws are placed through a small incision over the lateral proximal femur, directed up through the femoral neck and into the femoral head. Patients can usually begin protected weight bearing immediately after surgery. Displaced femoral neck fractures will likely disrupt the blood supply and therefore need to be treated with a prosthetic replacement. Most commonly a hemiarthroplasty is performed in which the femoral neck and head are replaced with a metal stem into the femoral canal and a metal head (Fig. 43-5A). Patients who have severe osteoarthritis of the hip joint and had significant arthritic hip pain before their fracture may receive a total hip replacement, in which the acetabulum is also replaced with a prosthesis, typically a plastic cup inside a metal shell (Fig. 43-5B). Patients can begin weight bearing immediately after surgery.

Intertrochanteric Hip Fractures. Intertrochanteric hip fractures occur between the greater and lesser trochanters of the proximal femur. Because the blood supply to this area is abundant, osteonecrosis is uncommon and therefore these fractures can be fixed with internal fixation. Displaced fractures need to be realigned, and this involves placing the patient on a fracture table where traction and rotation can be applied to the affected leg to reduce the fracture. There are two devices that can be used. A sliding hip screw includes a large screw placed from the lateral cortex of the proximal femur across the fracture and into the femoral neck and head, followed by a side plate along with lateral cortex of the femur, which is then fixed to the shaft with screws. A cephalomedullary nail includes a nail placed down the medullary canal from the piriformis fossa and a large screw that engages the nail as it is passed from the lateral cortex up into the neck and head. Both devices form stable constructs (though the cephalomedullary nail is preferred for certain fracture patterns) and allow protected weight bearing postoperatively.

Subtrochanteric Hip Fractures. Subtrochanteric hip fractures occur in the proximal femoral shaft just distal to the lesser trochanter in an area of high biomechanical stresses. While they can occur in elderly patients after a fall, they are also seen in high energy trauma. Because of the forces of muscles attached to the fractured segments, they tend to be significantly displaced and it can be difficult to reduce these fractures. They are most often treated with a long cephalomedullary nail that includes a screw distally to lock the nail in place and prevent rotation of the femur. Fractures that cannot be reduced closed on a fracture table or that are severely comminuted require open reduction followed by a cephalomedullary nail or by a plate and screws that is placed over the lateral cortex of the femoral shaft. In most cases, protected weight bearing can begin soon after surgery.

Femoral Shaft Fractures

Fractures of the femoral shaft are caused by high energy trauma and may be associated with other severe injuries. Long bone fractures, such as femoral shaft fractures, put these patients are risk for complications such as thromboembolic events and acute respiratory distress syndrome (ARDS), and therefore it is important to fix these quickly, typically within 24 hours. They are most commonly fixed with an intramedullary nail that can be placed antegrade (from the piriformis fossa or greater trochanter down the canal) or retrograde (through an incision into the knee joint and up the canal), with screws placed through proximal and distal holes to lock the nail in place, creating a stable fixation to allow weight bearing. Trauma patients who are hemodynamically unstable or who have other life-threatening injuries are treated temporarily with an external fixator until they can safely undergo surgery.

Distal Femur Fractures

Distal femur fractures are the result of a fall from a height or from high-energy trauma. They can also occur in elderly patients with osteoporotic bone after a fall onto the knee. While nondisplaced fractures in the elderly may be treated nonoperatively with a hinged knee brace and motion exercises, most require surgery. These fractures can involve the articular surface of the knee joint, so anatomic reduction of the joint surface is crucial. They are fixed with plates and screws placed over the medial or lateral cortex, depending on the fracture pattern, and early knee range of motion is encouraged to prevent stiffness. These intra-articular fractures require the patient to be nonweight bearing until the fracture shows signs of healing.

Knee Dislocations

Dislocation of the knee is a rare but devastating injury that can be limb-threatening. When the knee dislocates, the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) are torn, and various degrees of injury occur to the LCL, medial collateral ligament (MCL), posterolateral corner, joint capsule, and menisci. The danger however is due to the close proximity of the popliteal artery that runs directly behind the knee, which may kink or suffer a tear of the intimal wall when the knee dislocates. A neurovascular exam is extremely important, followed by immediate reduction of the knee and repeat exam of the pulses. If there is evidence of diminished or absent pulses, an angiogram must be performed, and vascular surgery may need to perform emergent vascular repair. With regard to the ligamentous injuries, an MRI will identify what structures have been torn. Because a dislocation causes so much damage to the knee, multiligamentous reconstruction is recommended in order to stabilize the knee joint. Stiffness and instability of the knee are common complications after this injury.

Patella/Extensor Mechanism Injuries

The extensor mechanism is comprised of the quadriceps tendon, the patella, and the patella ligament and functions to extend the knee. Injuries can result after a fall directly onto the knee or from forcible contraction of the quadriceps. It is important to examine the knee for the ability to actively extend the knee, since quadriceps tendon ruptures, patella fractures, or patella ligament ruptures can result in a loss of active knee extension, requiring surgery. Nondisplaced patella fractures can be treated nonoperatively with a cast or knee immobilizer, holding the knee in full extension, and weight bearing is permitted. Displaced or comminuted fractures require surgery with either tension band wiring or screws. Acute osteochondral fractures can be managed with internal fixation (Fig. 43-6A and B). Quadriceps tendon and patella ligament ruptures with loss of active knee extension are treated with suture repair. After surgery, the knee is held in extension and knee flexion is slowly increased over several weeks using a hinged knee brace.

Patella dislocations are common injuries that occur when the femur is forcibly internally rotated on an externally rotated tibia while the foot is planted on the ground. They typically dislocate laterally and often relocate spontaneously. Patients present with a significant knee effusion and on physical exam may elicit a positive apprehension test, in which a lateral force to the patella elicits pain and the sensation of an impending dislocation. Dislocated patellas can be reduced by extending the knee and manual reduction, and are treated with temporary knee immobilization. There is a high risk for recurrent dislocations, which may require surgical intervention. Osteochondral injuries to the trochlear groove and patella may be managed with the Draenert technique of autologous osteochondral transplant (Fig. 43-7A and B).

Tibial Plateau Fractures

The tibial plateau is comprised of the articular surfaces and underlying cancellous bone of the medial and lateral plateaus of the proximal tibia. Fractures of the plateau result from axial loads sustained in falls from a height or high energy trauma, and are often associated with injuries to the menisci and cartilage of the knee. Fractures can involve the medial, lateral, or both plateaus with significant comminution, angulation, and depression, creating a challenging injury to fix. A CT scan is important to visualize the intra-articular involvement of the fracture. Minimally displaced fractures may be treated nonoperatively with strict nonweight bearing until the fracture heals. Fractures associated with displaced articular fragments require surgery in order to restore the smooth contour of the articular surface. They are treated with plates and screws placed medially, laterally, or both. Since there is often a depression of the cancellous bone, bone graft or bone substitutes may be needed to buttress the articular surface and restore the anatomic alignment of the tibia. Patients are kept strictly nonweight bearing for several weeks until the fracture begins to heal, though early range of motion is encouraged. Repair of ligament or meniscus injuries may also be indicated at the time of surgery. Knee stiffness and osteoarthritis are common complications of these injuries.

Tibial Shaft Fractures

Tibial shaft fractures are the most common long bone fractures and they occur following high energy trauma, direct blows, and severe twisting injuries. Trauma and direct blows to the tibia result in transverse or comminuted fracture patterns, while torsional injuries cause spiral fractures. Fractures with minimal angulation can be treated with reduction and casting, followed by transition to a functional brace and slow return to weight bearing, and may need to be immobilized for several months since these fractures can be slow to heal. Most tibial shaft fractures, especially comminuted and angulated fractures, are treated with an intramedullary nail placed down the tibial canal, with interlocking screws placed proximally and distally, and weight bearing can begin soon after surgery. Plate and screw fixation can also be used, however since the tibia is subcutaneous, hardware placed along the shaft can increase the risk of wound breakdown, and therefore intramedullary nailing is the preferred treatment. Fibula shaft fractures often occur along with tibial shaft fractures, though they usually heal well without surgery.

Tibial Plafond (Pilon) Fractures

The tibial plafond is the distal tibial articular surface of the ankle joint. Pilon fractures are typically high energy injuries from axial compression or a shear force. These injuries can cause significant soft tissue injury, severely comminuted intra-articular fragments, and wound healing problems, making these fractures very difficult to treat. Due to the soft tissue injury, these fractures are initially treated with external fixation until the swelling subsides, which may take several days to weeks. The goals of surgery are to restore the articular surface, fix the fibula in order to maintain and establish anatomic length, bone graft any cancellous bone defects, and stabilize the distal tibia with plate and screw fixation. Patients are kept nonweight bearing for many weeks until the fracture heals. Despite best efforts, patients may suffer from ankle pain and stiffness, arthritis, wound healing problems, infection, nonunion, and some patients eventually need ankle fusion in the future.

Ankle Dislocations

The ankle joint is a complex hinge joint comprised of the distal tibial plafond, medial malleolus, and lateral malleolus and their articulation with the talus. Several ligaments also contribute to the stability of the ankle joint, including the deltoid ligament medially, the syndesmotic ligaments between the tibia and fibula, and the anterior talofibular, posterior talofibular, and calcaneofibular ligaments laterally. Dislocations of the ankle joint result from a severe twisting injury and often occur with fractures. At times, dislocations can place significant pressure on the overlying skin and can cause neurovascular compromise, therefore prompt reduction is extremely important followed by splinting.

Ankle Fractures

Ankle fractures are very common and result from a twisting injury to the ankle. The patterns of ankle fractures depend on the direction of force and the position of the foot and ankle at the time of injury. The goals of treating ankle fractures are to restore the anatomy of the ankle joint and to restore the length and rotation of the fibula. Initial treatment includes closed reduction and placement of a well-padded splint in order to protect the skin. Swelling can be a significant problem so elevation of the foot is encouraged. If surgery is to be performed, it is usually delayed 1 to 2 weeks until the swelling decreases to limit the risk of wound healing problems.

Lateral Malleolus Fractures

Isolated fractures of the lateral malleolus require anatomic reduction of the fracture in order to restore normal ankle joint congruity. The talus can sublux laterally following lateral malleolus fractures, and even 1 millimeter of talar shift decreases the surface contact between the talus and the tibia by 40%, increasing the risk of developing arthritis. Closed reduction and casting can be successful, however if the fracture cannot be adequately reduced, then open reduction internal fixation of the fibula is done with plate and screw fixation.

Medial Malleolar Fractures

An isolated fracture of the medial malleolus is usually an avulsion-type injury. Minimally displaced fractures can be treated with a cast or walking boot, while displaced fractures are fixed with screws placed up through the tip of the malleolus.

Bimalleolar Fractures

Fractures to both the medial and lateral malleoli often require surgery. These injuries are more unstable and the talus will often sublux or completely dislocate laterally. They are treated by reducing and fixing both malleoli during surgery. Occasionally, the posterior articular surface of the distal tibia, or posterior malleolus, can be fractured as well, resulting in a trimalleolar ankle fracture. Often it is a small fragment and does not need to be fixed, however if it involves >25% of the articular surface it should be fixed with screws placed either anteriorly or posteriorly.

Syndesmosis injuries

The syndesmosis is comprised of several ligaments between the distal tibia and fibula that provide stability to the ankle joint by resisting axial, rotational, and translational forces. The syndesmosis can be disrupted at the time of ankle fractures and requires special attention. Widening of the space between the distal tibia and fibula after fixing the fractures is indicative of a syndesmosis injury and it is treated with 1 or 2 screws placed laterally from the fibula into the tibia, parallel to the ankle joint. Patients are kept non-weight bearing for several weeks. The screws are often removed after 12 weeks, though they can be left in place and are typically asymptomatic.

Calcaneal Fractures

Calcaneal fractures occur following a fall from a height and are often associated with other injuries, including lumbar spine fractures. These injuries are often intra-articular and can result in collapse of weight-bearing posterior facet of the calcaneous. CT scans are useful to better visualize the fracture pattern. Most fractures can be treated nonoperatively in a well-padded splint and patients are kept nonweight bearing for up to 12 weeks. Displaced intraarticular fractures can be treated surgically once the swelling subsides with lag screws or with a thin plate and screw fixation. Despite adequate treatment, calcaneal fractures can be debilitating injuries, leading to significant heel pain and arthritis.

Talus Fractures

Fractures of the talus commonly result from forced dorsiflexion of the ankle, causing the talar neck to impact on the anterior distal tibia. The blood supply to the talus can be jeopardized after a fracture and may lead to osteonecrosis, which is an unfortunately common complication following talus fractures. Nondisplaced fractures are treated with a cast and have a 15% risk of osteonecrosis, while displaced fractures are often treated ­surgically with screw fixation. There is a high risk of osteonecrosis, ranging from 30% to 100%, and a high risk of arthritis.

Foot Fractures

The tarsal bones, including the navicular, the cuboid, and the three cuneiform bones, link the hind foot to the metatarsals and provide mechanical stability to the arch of the foot. Isolated fractures to these bones are rare and are often treated nonoperatively with a cast or boot. The Lisfranc ligament, which connects the 2nd metatarsal head to the medial cuneiform, is an important stabilizer of the midfoot. Lisfranc injuries can be seen following torsional forces to the foot or from crush injuries. These injuries often require surgery since anatomic reduction is extremely important for a successful outcome. Metatarsal fractures similarly result from twisting or crush injuries and most can be treated nonoperatively with a hard-soled shoe and weight bearing as tolerated. The base of the 5th metatarsal, however, warrants close attention. Fractures at the metaphyseal-diaphyseal junction of the proximal 5th metatarsal (Jones fractures) can jeopardize blood flow and are at risk for nonunion. Therefore, Jones fractures need close follow-up to assess for healing and may need screw fixation. Injuries to the metatarsal-phalangeal joints and phalangeal fractures can be treated symptomatically or with buddy taping with weight bearing as tolerated in a hard-soled shoe.

Sports Medicine

Sports medicine deals with the prevention and treatment of injuries related to sports and exercise. These injuries encompass various areas in the musculoskeletal system. In recent years, sports-related injuries have increased and the sports medicine field has been expanding. The growth in sports and sports-related injuries has likely to do with: a) that athletes participate in sport-specific training year round (and in multiple sports) rather than just seasonal training, b) that there has been an increase in “weekend warriors,” c) that patients have become more aware of physical fitness, are better educated, and have higher performance expectations, and d) that more people undertake recreational activities.

The orthopedic subspecialty of sports medicine treats a broad spectrum of patients, ranging from children who have just started participating in their first sports to the specialized care of professional athletes. Medical treatment of athletes, recreational or professional, can be complex as short- and long-term outcomes are influenced by the higher demand that athletes put on their bodies. Additionally, the orthopedic sports medicine specialist does not only treat the patient’s injuries, but also has to consider the return to activity in a later stadium. “Getting back in the game” is sometimes subject to pressure from third parties (e.g., team members, coaches, parents, fans), which makes treatment and the rehabilitation a challenging process.

Surgical intervention for ligament and cartilage injuries in sports medicine patients is usually done using arthroscopic techniques. The most frequently injured joints are the shoulder, hip and knee. Therefore, treatment of common injuries in these joints will be the scope of this paragraph.

Rotator Cuff

Rotator cuff injuries are among the most common reasons to visit an orthopedic sports specialist. Often, these injuries are associated with either forceful or repeated overhead or pulling movements. The rotator cuff provides shoulder movement and glenohumeral joint stability and injuries typically lead to pain, weakness and restricted movement of the arm. Over recent years, the treatment of the rotator cuff injuries has considerably improved with regard to indication for surgery, surgical techniques and rehabilitation protocols. With the introduction of arthroscopy, shoulder surgery has become less invasive with all advantages associated. Currently, it has been established that arthroscopic techniques are equal or superior to open techniques for most indications. Controversies surrounding rotator cuff repair remain and include, but are not limited to, use of acromioplasty, enhancement of healing with orthobiologics (Fig. 43-8), single- vs. double-row fixation and the treatment of massive or large tears. Rehabilitation after surgery plays an important role to restore strength, motion and function and to enable the patient to return to sports. Typically, rehabilitation is made up of three consecutive stages: immobilization, passive exercise, and active exercise. Immobilization and passive exercise usually start in the first 4 to 6 weeks after surgery. Immobilization can be established by using a sling and passive exercise should be initiated by the therapist. The therapist moves the arm in different positions to improve range of motion (ROM) while providing support. After 4 to 6 weeks, active exercises can be gradually introduced. At 8 to 12 weeks, muscle strength and improvement of arm control are increased by starting a strengthening exercise program.

Shoulder Instability

The most common etiology for shoulder instability is related to trauma, especially shoulder dislocation. After a shoulder has dislocated, it becomes vulnerable to repeat episodes of instability and may develop to being a chronic problem. Most of the shoulder’s stability is provided by the rotator cuff and shoulder capsule. The most common dislocation is in the anterior-inferior direction, although posterior dislocations do occur. Typically, patients with an anterior dislocation present with pain and an internally rotated shoulder. Younger patients are more susceptible to suffer from repeat dislocations than older patients.^6,7,8 The position of the humeral head with respect to the glenoid and other bony pathology can be identified with radiographs. Views from different angles should be obtained to thoroughly evaluate; an anterior-posterior (AP) view, along with glenoid (axillary) view, and a “ Y” view of the shoulder are recommended in assessing this injury. Since most of the shoulder’s stability is provided by soft tissue, usually this is also injured. Following successful reduction magnetic resonance imaging (MRI) should be obtained to identify underlying causes and concomitant ­injuries.

Relocation of the shoulder is generally accomplished with the patient in supine position and the arm under gentle ­traction and slight abduction. Some sedation is helpful as it relaxes the patient’s musculature and relieves the pain. Whether or not to immobilize a first-time-dislocated shoulder or not, remains controversial, as well as the position of immobilization or the early surgical repair of capsulolabral structures. Prolonged immobilization is not recommended since this will often lead to substantial stiffness in the shoulder and does not appreciably decrease the redislocation rate. A small minority of patients with atraumatic multidirectional instability can generally be treated with shoulder rehabilitation. Unfortunately, many patients experience recurrent dislocations, in which case surgical stabilization of the shoulder should be considered. Many open stabilizing procedures have been described and, depending on etiology, many are still being applied such as the open Bankart repair, Latarjet procedure, remplissage and humeral head restoration. However, arthroscopic soft-tissue restoration has been the front-line treatment for recurrent instability. After surgery, the shoulder is temporarily immobilized with a sling. When the sling is removed, exercises to rehabilitate the ligaments, improve ROM and prevent from scarring, will be started. Strengthening exercises will gradually be added to the rehabilitation plan.

Superior Labrum and Biceps Tendon

The labrum helps to deepen the socket and stabilizes the glenohumeral joint. Additionally, it serves as an attachment point for many of the shoulder ligaments, as well one of the biceps tendons. A superior labrum anterior and posterior lesion may occur in the superior part of the labrum, usually anterior and posterior to the attachment of the biceps tendon, with occasional involvement of the biceps tendon in certain cases. Injuries to the superior labrum can be caused by trauma or by repetitive shoulder motion. Radiographs are generally obtained to evaluate for concomitant injuries or osteoarthritic changes. The labrum itself, and other soft tissue, is better visualized with MRI with addition of a gadolinium arthrogram adding sensitivity for labral injury detection (Fig. 43-9).

Conservative and operative treatments have had mixed results depending on the patient’s age, activity level, type of tear and presence of concomitant injuries. If symptoms do not improve with adequate physical therapy and/or nonsteroidal anti-inflammatory drugs (NSAIDs), surgical intervention is usually indicated. Some SLAP injuries involve the biceps tendon, which may require either tenotomy or tenodesis.^10,11

After surgical labrum repair, the shoulder needs to be immobilized to protect the repair and allow for healing. Usually a sling is used for 4 weeks after surgery. Then a ­physical therapy program will gradually start improving ROM and prevent from scar formation and stiffness to develop. As healing progresses, exercises to strengthen the shoulder muscles and the rotator cuff will gradually be added to the program around 4 to 6 weeks after surgery. Return to early interval throwing can generally be allowed around 3 to 4 months after surgery.

Impingement Syndromes

After minor trauma or repetitive injury, patients may experience pain and discomfort which can be due to irritation of the tissues in the subacromial space. In many cases these shoulder impingement syndromes are caused by simple bursitis or tendonitis of the long head of the biceps or supraspinatus tendon.⁵ Occasionally, impingement syndromes can progress to tears of the supraspinatus tendon, which can be confirmed by MRI or ultrasound.

The goal of treatment is to reduce pain and restore function. Initial treatment is generally nonsurgical and based on rest,NSAIDs, and physical therapy. If pain is not relieved, an injection of a local anesthetic and a cortisone preparation may be helpful.

If conservative treatment does not relieve pain, surgery is recommended, with the goal to excise the bursa and create more subacromial space. Generally, surgery is performed arthroscopically and encompasses bursectomy and subacromial decompression via acromioplasty. If the rotator cuff (supraspinatus tendon) is also injured, arthroscopic repair is usually indicated to restore function, sometimes is accompanied by a bony resection of the inferior portion of the acromion.

The Acromioclavicular Joint

The acromioclavicular joint is a gliding synovial joint and not very mobile. The joint is stabilized by three ligaments: the superior acromioclavicular ligament, the inferior acromioclavicular ligament, and the coracoclavicular ligament. Injuries to these ligaments are commonly sustained playing contact sports such as football and ice hockey and may cause displacement of the joint. An acromioclavicular sprain is referred to as a shoulder separation and type I and II are usually treated symptomatic. Controversy exists however regarding early or delayed surgical reconstruction for type III tears. Frank tearing of the coracoclavicular ligaments, associated with significant displacement, is oftentimes reconstructed surgically.

The knee is the largest joint in the human body and is a pivotal hinge joint, which allows flexion and extension as well as a medial and lateral rotation. The knee bears tremendous axial loads as well as torsional and sheer forces, making it vulnerable to both acute injury and the development of osteoarthritis. In sports, the major stabilizing structures such as the ACL and the medial collateral ligament (MCL) are frequently injured. Other frequent knee injuries are to the menisci, posterolateral corner, the posterior cruciate ligament (PCL) or patellofemoral.

Menisci

The menisci are crescent-shaped pieces of fibrocartilage shaped that provide joint stability, shock absorption, load distribution, and proprioception. Sudden meniscal tears often happen during sports, usually during contact or while squatting and twisting the knee. Typical symptoms associated with meniscus injury are pain, stiffness and swelling, catching or locking of the knee, buckling or “ giving way” and impaired ROM. Radiographs are typically obtained to assess possible concomitant injuries, the presence of (early) osteoarthritis, and leg alignment. However, since menisci do not show on radiographs, an MRI is obtained to assess the status of the menisci and the soft tissue surrounding the knee joint (Fig. 43-10). Small tears on the outer edge of the meniscus may not cause symptoms and—provided the knee is stable—nonsurgical treatment may be sufficient.

The most commonly performed surgical procedure for meniscus tears is partial (subtotal) meniscectomy. However, it has become increasingly clear over recent years that preservation of the load-distributing function of the meniscus is important in preventing from development of early osteoarthritis. Research into the use of orthobiologics (e.g. microfracture of the notch, fibrin clot) for meniscal repairs has expanded the indications for repair over (subtotal) meniscectomy.15–19 Tears have been reported in virtually all portions of the meniscus, with radial and longitudinal tears being the most common. Tears of the root of the meniscus are less common, but are increasingly being recognized as devastating injuries that cause serious alterations of knee contact forces. Surgical techniques are developing to repair the root to restore its function.20,21 Meniscus transplantation may be an option for young patients with a largely deficient meniscus.22

The paradigm of treatment of torn menisci is shifting thanks to the development of superior surgical techniques, use of orthobiologics and promising first results with root repair and meniscus transplantations. Physicians must be further educated on the significance of meniscal preservation when there is potential for healing.

Directly after surgery, the knee is immobilized with a brace and weight bearing is protected to allow the meniscus to heal. When healing is complete, ROM and strength will need to be regained. Physical therapy is an integral component of ­healing and return to play, which usually is allowed between 4 to 6 months after surgery.

Collateral Ligaments

The MCL is the most frequently injured knee ligament, which usually occurs after excessive valgus stress of the knee. Oftentimes, this is associated with (medial) meniscus injury and sometimes with an ACL. The combination of MCL, medial meniscus, and ACL injury is also known as the “unhappy triad” and occurs most commonly in contact sports.

The MCL has good healing potential and grade I and II injuries usually improve with bracing and activity modification. Grade III injuries may also improve with conservative treatment and often these injuries are treated non-operatively initially. The majority of MCL injuries occur in the mid-substance or at the femoral insertion side. There is a small subset of tibial sided grade III tears though, that is associated with worse clinical outcome and surgical repair is more often advocated. Reconstruction is rare, since surgical repair is usually effective in restoring the MCL. Lateral collateral ligament (LCL) injuries are much less common than MCL ligament injuries, but similarly most often managed conservatively.

With return of ROM and normal gait pattern, patients are functionally progressed towards return to sports. A functional brace during sports is advised.

Cruciate Ligaments

The cruciate ligaments are situated centrally within the intercondylar notch of the knee. The biomechanical function of both the ACL and the PCL is complex and three-dimensional, but to simplify: both play an important role in providing antero-posterior and rotational stability of the knee.

ACL tears are a common sports injury, especially in sudden cutting and stopping sports (e.g. soccer, basketball) or contact sports (e.g. football). A torn ACL will result in altered knee biomechanics and kinematics and thus potentially lead to the early development of degenerative changes in the knee joint. Since a torn ACL will not heal without surgery, surgical ACL reconstruction is generally treatment of choice in patients who are young and active. Patients with a more sedentary lifestyle and who experience no persisting or disabling instability in daily life, may be effectively treated with conservative management (i.e., bracing and physical therapy).

A patient with an ACL tear typically presents with pain and swelling, instability, loss of ROM, joint line tenderness (with associated meniscus injury), and discomfort while walking. Radiographs are obtained to evaluate joint condition and possible associated osseous injuries. To visualize the ACL and other soft tissue in the knee however, an MRI should be obtained. Although an MRI is not required to make the diagnosis, the information it provides is invaluable with regard to objectifying anatomic characteristics by taking measurements, assessing concomitant injuries and presurgical planning in ­general (Fig. 43-11).

Reconstruction is performed with use of a tendon-graft that will replace the native ACL. Commonly used graft sources are the patellar tendon, the hamstrings and the quadriceps tendon. These tendons can be harvested from the same knee (i.e., autografts), during the same procedure. Alternatively a donor graft (i.e., allograft) can be used. Both have their own subset of pros and cons, with the most important pro being absence of donor-site morbidity for allograft and better healing potential for autograft.

Injuries of the PCL are less common than other knee ligament injuries. Frequently seen causes are a bent knee hitting a dashboard in a car accident or falling on a knee that is bent during running. A rupture of the PCL is usually better tolerated than ACL rupture, since many tears (i.e., grade I and II) have the potential to heal on their own and do not result in much knee stability problems. Most Grade I and II injuries are treated nonoperatively. Combined PCL/PLC and PCL/MCL and Grade III PCL injuries however, do present a challenge with regard to management decision-making. Chronic PCL-deficient (Grade III) knees have an increased incidence of osteoarthrosis, particularly in the patellofemoral and medial knee compartments. Indicationfor surgery is influence by age, activity level, and presence of concomitant injuries. Different surgical techniques have been proposed; the most common are the “ inlay” technique and the transtibial technique.

The goal of cruciate ligament (both ACL and PCL) reconstruction is to restore native knee kinematics, to provide the patient with the best potential for a successful outcome and to prevent from the development of long-term complications, such as osteoarthrosis.

Posterolateral Corner

Critical structures of the posterolateral corner (PLC) are the LCL, popliteus tendon and popliteofibular ligament. These structures each contribute to the static and dynamic stability of the knee and are commonly injured concomitant with other ligamentous injury, mostly together with the torn ACL.38 The importance of closely evaluating the PLC after knee injury is demonstrated by the fact that a deficient PLC causes altered knee biomechanics and subsequently increases stress on surrounding stabilizing structures. As such, it has been shown that a deficient PLC is a primary cause of cruciate ligament reconstruction failure.

Acute high-grade injuries of the PLC with obvious deficient structures require surgical intervention. Since primary repair becomes increasingly difficult as time between injury and surgery increases, a cut-off of 2 to 3 weeks is usual to either repair or reconstruct the deficient structures. With more chronic PLC injuries, reconstruction is recommended to restore knee stability.

Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a pathologic condition that refers to impingement of the anterior femoral head-neck junction against the anterosuperior labrum. This is frequently caused by abnormal bony offset at the femoral head-neck junction, abnormal acetabular anteversion or excessive anterolateral acetabular bony rim coverage (Pincer lesion), and combined CAM-Pincer lesions. Recognition of FAI can be clinically and radiologically difficult. However, familiarity with this disorder is essential, as FAI can lead to labral tears, cartilage delamination, and if untreated, osteoarthritis.

Commonly, patients present with anterior groin pain exacerbated by activities involving hip flexion or pain over the greater trochanter as well as grinding or popping. Patients report pain with flexion and internal rotation and after prolonged sitting. On examination, there is a decrease in internal rotation that appears out of proportion to the loss of the other ranges of motion and there is limited flexion. The impingement test, elicited by 90 degrees of flexion, adduction and internal rotation of the hip, is almost always positive.

The imaging findings of FAI can be seen on plain radiographs, CT scan, MRI, and MRA. Some of the abnormalities seen include abnormal lateral femoral head/neck offset seen as a lateral femoral neck bump, os acetabulae, synovial herniation pits, acetabular over-coverage, hyaline cartilage abnormalities, and labral tears.

Treatment of FAI has traditionally been surgical and has come from open surgical treatment with open acetabuloplasty, and later open procedures through a transtrochanteric approach and combined open-arthroscopy assisted techniques to full arthroscopic approaches. Hip arthroscopy is becoming increasingly popular and being more frequently applied for this indication. This popularity is largely the result of studies reporting on improvement of functional outcome measures with follow-up up to 10 years, with low complication rates in several large study populations.

Spinal Trauma

In spinal injury spinal stability must be assessed, and the patient immobilized until his spine is cleared. CT scan is more reliable in assessing spine injury than plain radiographs. When neurologic deficits are present a decompressive procedure may be indicated. In spinal cord compression, prompt decompression should be performed. Animal models of spinal cord injury suggest that prompt decompression can lead to objective improvement of recovery. Spinal cord injuries should be triaged to trauma centers since trauma center care is associated with reduced paralysis.

Occipital Cervical Dislocation

Motor vehicle accidents can cause dislocation of the occiput on the condyles of the atlas (C1). Most patients with this injury suffer cervical cord injury, and do not survive. Traction on the spine is contraindicated. Treatment consists of stabilization and fusion in situ using a screw plate from the mid cervical spine to the occiput.

Fractures of C1 (Jefferson Fracture)

Fracture of the C1 ring was described by Jefferson in 1920. The thin anterior and posterior rings of the C1 vertebra fracture with axial loads. C1 fracture causes the e lateral masses of C1 to spread, which is visible on a through- the- mouth AP X-Ray image of the cervical spine. This injury is rarely associated with neurologic injury. Bracing with a cervicothoracic orthosis or a halo ring and vest is the recommended treatment for a Jefferson fracture.

Fractures of C2 (Odontoid Fracture)

Half of normal cervical rotation occurs at the atlanto-axial joint. The odontoid (Dens) is a small bony process which arises from the body of C2, and articulates with the body of C1 (the Atlas). Odontoid fractures are most often type I fractures (an avulsion fracture off the tip of the dens). Type I fractures occur when there is tension applied to the alar ligaments (which span from the tip of the odontoid to the skull bypassing the C1 vertebra). Type I fractures are stable and managed nonoperatively.

A type II fracture, at the base of the odontoid, results from lateral loading forces. Operative stabilization is the preferred treatment since immobilization in a halo vest results in nonunion rates ranging from 20% to 80%. Transfixing the odontoid fracture with a screw maintains rotational movement. Posterior fusion of C1 on C2 with sublaminar wiring resulting in decreased range of motion is another option.

Type III fractures extend into the body of C2, below the origin of the odontoid process. Type III fractures are generally treated with halo brace. (Anderson and D’Alonzo)

Hangman’s Fractures of C2

Hangman’s fractures result from sudden extension forces on the neck and occur between the superior and inferior facets (pars interarticularis) of C2. Treatment is simple immobilization in a halo vest. Higher energy injuries causing severe extension forces can dislocate the C2-3 facet complex and damage the C2-3 disc. Such fractures can compromise the spinal canal, and death can occur from compromise of respiration. Significantly displaced Hangman’s fractures are managed by internal fixation and bone grafting between C2 and C3.

Compression Fracture of the Cervical Spine

In C3 to C7 an axial load can cause fracture of the endplate while preserving the posterior cortex of the vertebral body. These fractures generally heal well, and are treated nonoperatively with analgesics and a cervical brace.

Burst Fractures of the Cervical Spine

Diving accidents are the classic cause of Burst fractures of the cervical spine. The axial load when an unrestrained passenger in an automobile accident strikes the windshield the posterior cortex of the vertebral body fractures leading to displacement of bony fragments into the canal injuring the spinal cord. Burst fractures are treated surgically by anterior debridement of the fracture and reconstruction using a bone graft strut stabilized with a plate and screws.

Unilateral and Bilateral Facet Dislocation

Another injury associated with motor vehicle accidents is facet dislocation. A restrained passenger can suffer forced flexion with distraction resulting in dislocation of the facets. The diagnosis can be made on lateral radiographs. Treatment consists of axial traction with cranial tongs, graduated application of weight, and periodic X-Rays. The patient is kept awake for safety concerns. When reduction is attained, patients are taken to surgery for posterior fusion with interspinous process wiring or a screw plate.

Clay-Shoveler’s Injury

Clay-Shoveler’s injury can result from a motor vehicle accident or from shoveling soil or clay. The injury (of C6, C7, T1, and T2) is the result of avulsion fracture of the spinous process by the paraspinal muscle forces. The fracture is treated nonoperatively with analgesics and a soft collar.

Thoracic Lumbar Spine Injury

The ribs stabilize fractures of the thoracic spine, making these fractures more stable than similar fractures of the lumbar spine. Neurologic injuries are more common in the thoracic and proximal lumbar spine because of the presence of the spinal cord, which ends at the L2 level.

Compression Fracture

Compression fractures result from osteoporosis and abnormal bone density as well as trauma. Compression fractures involve a fracture of the superior or inferior endplate without associated posterior cortex fracture. Thoracolumbar compression fractures are treated nonoperatively with braces and analgesics.

Burst Fracture

Burst fractures are caused by falls and high energy automobile accidents. One or both endplates and the anterior cortex of the vertebrae with an associated fracture of the posterior cortex. The posterior cortex fracture differentiates the burst fracture from a compression fracture and results in retropulsion of bone into the canal, which can cause nerve injury. A vertical lamina fracture may contain an invaginated segment of the dura mater with accompanying nerve roots, and posterior surgery can result in dural tear or nerve injury.

If nerve injury is noted, treatment is an anterior exposure and removal of the fractured anterior elements (corpectomy) and a strut graft is placed. A laterally placed plate and screws add stability to the construct.

Seatbelt Injuries (Flexion Distraction Injuries)

A seatbelt injury occurs when there is acute forward flexion of the trunk and anterior (i.e. seatbelt) restraint. The pelvis and upper torso move forward, and failure of the spine under tension begins with the posterior elements. Tearing of the dorsal fascia, the interspinous ligament, dislocation of the facets, and tearing of the discs occurs. The bone of the spinous process, the lamina, the pedicles, and the vertebral body fail in tension (“Chance Fracture”).

In flexion distraction injuries through soft tissue, posterior internal fixation and bone graft is recommended. “Chance fractures” are treated with bracing.

Fracture Dislocations of the Spine

Fracture dislocations of the spine displace the bony elements by translation or rotation resulting in canal narrowing and nerve injury.

Reduction of the displaced bones is the best way to improve the canal dimensions.

Patients with fracture dislocations of the spine and partial nerve function can recover. Fracture dislocations are treated operatively with surgical stabilization.

Disc Herniation

Disc herniation, most common between ages of 20 and 50, can occur in the cervical, thoracic, or the lumbar spine, and consists of a tear of the annulus allowing the nucleus pulposus material to extrude through the annulus and enter the canal, pressing on the exiting nerve or the ‘traversing’ nerve roots. In the cervical spine, spinal cord compression can occur.

Symptoms of most disc herniations resolve within eight weeks as the nerve root accommodates and inflammation recedes. The bulk of the extruded nucleus pulposus resorbs over time. When symptoms persist beyond six to eight weeks, excision of the involved disc and decompression of the nerve roots may be indicated.

In cervical disc herniation an anterior approach to the spine is performed with dissection through a transverse incision on the neck. Dissection is carried between the trachea and the carotid sheath. The disc is then removed. The disc space may be bone grafted to fuse the vertebrae. A locking screw low profile titanium plate is then attached to the vertebrae.

Posterior decompression and laminectomy exposes the posterior elements of the spine. A portion of the lamina is removed to allow access to the canal to correct foraminal impingement or to remove lateral disc herniations. While the posterior approach does not require fusion with plates and screws, central disc herniation cannot be managed through a posterior approach since the spinal cord cannot be safely retracted.

For lumbar disc herniation a midline incision is used and laminectomy allows visualization of the lateral recess. Retraction of the dura allows visualization of the traversing nerve roots as well as of the disc fragment.

Spinal Stenosis

A loss of hydration of the discs causes loss of disc height and bulging of annular tissue and the ligamentum flavum which effectively narrows the canal (spinal stenosis). Osteophyte formation on the facet joints can also cause nerve impingement. Cervical stenosis can cause myelopathic symptoms (hyperreflexia, ataxia, balance problems, weakness, and pain).

Lumbar stenosis causes neurogenic claudication ­(progressive pain, weakness, and numbness in the legs). The claudication symptoms result from standing and walking which increases lumbar lordosis. The symptoms resolve with sitting and bending forward (decreasing lumbar lordosis).

Spinal stenosis is treated with epidural steroid injections and physical therapy. Resistant cases may require surgical decompression and stabilization with plates and screws.

Spinal stenosis usually occurs in patients over 50 years of age. With degenerative spondylolisthesis or scoliosis fusion procedures with instrumentation may be required to prevent progression of the deformity.

Back Pain and Degenerative Disc Disease

Back pain occurs in the majority of adults but is usually self-limited resolving in one to two weeks. Chronic unremitting back pain suggests the possibility of infection, malignancy, or ­metastatic disease.

While radiographs are one option in the management of disabling low back pain, they are ineffective at ruling out malignancy, and radiographic findings correlate poorly with symptoms. Patients with severe degenerative symptoms may have no pain, while others with mild degenerative findings complain of severe pain. The potential for secondary gain and psychiatric problems and the unpredictable results of spine fusion add to the difficulty of diagnosis and choosing a treatment plan.

Intervertebral disc replacement prostheses are now used to treat degenerative disc disease. The potential for loosening, creation of wear debris, and bone loss complicating revision surgery are concerns, as are the proximity of the device to the spinal canal and the great vessels.

Scoliosis

Scoliosis is a lateral curvature of the spine. Lateral bending of the spine is always accompanied by rotational deformity ­(coupling).

In order to measure the severity of scoliosis lines are drawn along the endplates of the vertebral bodies at either end of the curve and the angle formed when these lines intersect is magnitude of the curve.

Scoliotic curves are classified as congenital, degenerative, metabolic (mucopolysaccharidoses), neurogenic (cerebral palsy), and myogenic curves (muscular dystrophy). Idiopathic scoliosis is the most common form, and represents a spectrum of genetic disease.

Adults with scoliosis may present with axial pain and imbalance in posture. Treatment for scoliosis may include ­medications, therapy, and activity modification. In severe cases with objective deformity surgical correction of the deformity may be indicated.

Idiopathic Scoliosis

The majority of idiopathic scoliosis curves become apparent during adolescence and progress during skeletal growth. Initial management consists of observation. Rapidly progressing curves are treated with braces. Brace treatment is recommended for curves between 20 and 40 degrees. For patients with large curves, surgical intervention may be needed using rods with grafting and fusion.

Neuromuscular Scoliosis

Neurologic conditions such as polio and cerebral palsy can lead to ‘uncompensated’ scoliosis curves where the patient is unable to lean with his upper body to restore balance. Scoliosis correction surgery may be needed to facilitate sitting balance, and to avoid skin breakdown caused by pelvic obliquity.

Introduction to Arthritis

Arthritis refers to a large number of medical conditions, ­including osteoarthritis, rheumatoid arthritis, septic arthritis, and post-­traumatic arthritis. Each has the potential to lead to loss of articular cartilage lining the joints. According to the CDC and the National Health Interview Survey approximately 50 million adults (22% ofthe U.S. population) have been diagnosed with some form of arthritis. This number is projected to grow to an astounding 67 million adults by 2030 (or 25% of the U.S. population).

The number of individuals suffering from arthritic conditions will continue to rise as the ‘baby boomer’ generation enters old age and with the rise in obesity in the U.S. population, as age and obesity are two major factors in the onset of arthritis.

Conservative Management and Prevention of Arthritis

Conservative measures to treat arthritis include weight loss, activity modification, rest, bracing, physical therapy, pain management, and assistive devices such as canes or walkers. Conservative measures have the potential to decrease symptoms and improve function and quality of life. These measures can successfully manage a patient’s condition and avoid a surgical procedure. Osteoarthritis symptoms tend to be intermittent in nature or associated with high impact activities. Initially treat all patients with conservative measures and avoid surgery if possible

Conservative measures can also play a role in the prevention of arthritis. Weight loss of as little as 11 pounds has been shown to decrease the risk of developing knee osteoarthritis in women by 50%. Similarly, patients who engage in regular physical activity have been found to have lower incidence of arthritis.

Arthritis causes pain, loss of range of motion, decreased ability to perform work duties or participate in social functions, and decreased quality of life. Despite conservative therapy, frequently more invasive treatments are needed to effectively manage the patient’s symptoms.

Examination of the Patient

A thorough history and physical examination (H&P) is indicated for all orthopedic patients. Patient history should include location, quality, severity, timing, and radiation of pain along with any referred pain, associated signs and symptoms, ­modifying factors, prior treatments, including both conservative and surgical treatments. Other details within the H&P are equally important for diagnostic purposes and to successfully develop a treatment plan. If you listen carefully to your patient, they will often tell you their diagnosis. Location of “hip pain” can narrow a differential diagnosis. Patients with activity related groin pain often are found to have hip arthritis, whereas patients with peri-trochanteric pain (lateral hip pain) may be suffering from trochanteric bursitis. The importance of listening and focusing on the patient’s description of location and type of pain cannot be overemphasized.

Physical examination should begin by observing the patient’s gait, both with and without assistive devices if possible. This demonstrates how significantly the patient is affected functionally and the effect of the patient’s pain. Typical gait patterns include a “Trendelenburg gait” where abductor weakness may lead to a poor outcome following total hip arthroplasty. Other aspects of the exam include assessment for leg length discrepancy, joint contractures, skin changes, assessment for prior surgical incisions to evaluate for prior treatments or to plan future surgical approaches, neurovascular examination, strength and range of motion. These details document functional status and help to formulate a differential diagnosis. Patients with ‘hip pain’ may have lumbar spinal stenosis, radiculopathy, or vascular disease that may be playing a large role in their presentation. Once an appropriate physical examination is complete, weight-bearing radiographs are needed. Advanced imaging, including CT and MRI are rarely indicated in initial work up of patients. Once a diagnosis is made, specific treatment directed towards the patient’s condition can be initiated. The goals of treatment are to improve pain, preserve motion and to maximize patient function, independence, and quality of life.

Injections

Joint injections are commonly performed into the knee and shoulder. Common injections into the knee include corticosteroids and Hyaluronic-acid gels. Corticosteroid injections can decrease inflammation within the joint. These injections are usually administered in combination with a local anesthetic, such as Lidocaine, in order to provide more immediate relief for both diagnostic and therapeutic purposes. If the patient has immediate relief of their pain symptoms with injection of the joint, this localizes the source of the patient’s pain to the joint and may assists with diagnosis. At the same time any benefit received is therapeutic for the patient. Hyaluronic acid injections have become popular and are commonly referred to as “viscosupplemenation.” The exact mechanism of these injections is not known, however patients may benefit from these injections by increasing the viscosity of the synovial fluid. The injections do not lead to articular cartilage repair. There is a risk of joint infection, cartilage injury from the needle, hemarthrosis, and failure to receive benefit. A theoretical risk of altered glucose metabolism in diabetics also exists with corticosteroid injections.

Surgical Management of Arthritis

The most commonly performed procedure for arthritis of a major joint is arthroplasty, or joint replacement. Joint replacements, including hip and knee arthroplasty are considered two of the most successful procedures performed in all of surgery. However, other nonarthroplasty options exist. These are ­typically performed for specific diagnoses under specific indications.

Osteotomy

Osteotomy is cutting the bone to change the position of the fragments in order to improve length, rotation, alignment, or angulation. Osteotomy can be performed for both congenital and acquired deformities that are thought to be contributing to the patient’s pain or development or progression of disease. Pelvic and femoral osteotomy can be utilized in treatment of developmental dysplasia of the hip. With this procedure the position of the acetabulum can be altered in order to provide more appropriate coverage of the femoral head, which is usually deficient anteriorly and laterally. Femoral osteotomies can also be performed to correct anteversion and varus/valgus deformity of the femoral neck. Osteotomies are performed to obtain more normal alignment and coverage of the femoral head within the acetabulum to prevent or delay future disease.

An osteotomy commonly used in the knee is a proximal tibia osteotomy. An adult patient who presents with isolated medial compartment knee arthritis and associated varus deformity would be an ideal candidate for valgus (high tibial) osteotomy. An osteotomy that realigns the knee into slight valgus has the potential to off-load the medial compartment, slow disease progression and prevent or delay the need for more invasive procedures (unicompartmental or total knee arthroplasties).

Arthrodesis

Arthrodesis is a treatment option for severe arthritis where the overlying articular cartilage is removed and the two opposing bones are allowed to heal together. After successful arthrodesis no motion is possible through the joint and the source of pain is removed. Arthrodesis of large joints, such as the knee, shoulder or hip, are typically explored as an option in the face of infection, in elderly, low demand patients or in young and active patients who are considered too young for a joint replacement (concern for component wear and need for early revision). Arthrodesis can also serve as a “last resort” procedure in orthopedics, when joint preserving treatments fail, fracture, infection, etc. Arthrodesis requires removal of overlying articular cartilage from bone and frequently the use of autograft or allograft bone and the use of hardware for internal fixation or temporary external fixation.

Joint Arthroplasty/Joint Replacement

Joint arthroplasty is considered the final option for patients suffering from pain associated with arthritis in the joint. The surfaces of the bones are replaced after removing the damaged articular cartilage. The amount of bone and the determination of how to make the bone cuts is made based on pre-operative radiographs and templating, cutting guides, computer navigation, and anatomic measurements. The cut bony surfaces are covered with new components, usually made of metal, ceramic, or polyethylene. These new components are sized to appropriately match the patient, based on templating pre-operative radiographs, intra-operative measurements, and examination for stability, leg length, alignment, and range of motion.

If all compartments or surfaces of the joint are replaced, the arthroplasty is referred to as a total joint arthroplasty. In comparison, if only one surface or compartment of the joint is replaced, it is referred to as hemiarthroplasty (hip, shoulder) or unicompartmental arthroplasty (knee). Total hip and knee arthroplasties are considered the most successful of all surgical procedures performed in terms of patient outcome and improvement in pain.

Hip Arthroplasty

Background

Hip arthroplasty is utilized for end stage arthritis in the hip that has failed a reasonable trial of non-operative measures (Fig. 43-12). Conventional hip arthroplasty commonly refers to total hip arthroplasty where both the femoral head and neck are replaced. Hip resurfacing is a form of hip arthroplasty, used in younger patients with end stage arthritis. Resurfacing of the femoral head is performed with a metal cap (without performing a femoral neck cut and placing a stemmed femoral component) and the acetabular surface is replaced with a metal cup. Resurfacing functionally achieves the same result as a total hip arthroplasty, however it preserves femoral bone for later conversion to total hip arthroplasty if necessary. Finally, hemiarthroplasty describes the replacement of the femoral head and neck with a stemmed femoral component in isolation. The acetabulum is not addressed surgically.

History of Hip Arthroplasty

The history of hip arthroplasty (hip replacement) may be broken down into a “Pre-Charnley” era and a “Post-Charnley” era, referring to the significant contributions of Sir John Charnley to the evolution of hip arthroplasty. Prior to Charnley’s contributions, hip arthroplasty consisted of a variety of procedures with highly variable results. Early attempts at relieving hip pain were made with interpositional arthroplasty, where tissue layers, plastic, or metal were placed between the worn articular surfaces. Fracture of the interposed material or loosening of components often led to failure.

Later attempts introduced stemmed components to improve fixation. One of the earliest femoral components was designed by Austin-Moorem. This prosthesis replaced the femoral head and neck with a metal component secured into the femoral shaft with a stem extending down the diaphysis. This prosthesis was utilized in hemiarthroplasty for many years and served as a step in the development of total hip arthroplasty with the later addition of the acetabular component.

Surgical Approaches to the Hip

A variety of approaches to the hip joint have been utilized in joint arthroplasty, including anterior approach (Smith Petersen), anterolateral approach ­(Watson-Jones), lateral approach (Hardinge), and posterior approach (Kocher Langenbach). Each approach contains a unique set of advantages and disadvantages. Below, a comparison of the anterior and posterior approaches is made.

Minimally invasive total hip arthroplasty has been advocated in recent years. Theoretical benefits include improved cosmesis, decreased soft tissue damage, and decreased blood loss, quicker postoperative recovery and a shorter hospital stay. However, smaller incisions come with the disadvantage of decreased visualization intra-operatively and associated risks of component malposition, intraoperative fracture, and nerve or vascular injury. In fact, the only documented benefit of minimally invasive techniques appears to be improved cosmesis.

A greater trochanteric osteotomy can be performed in order to mobilize the abductors. This can improve exposure to the acetabulum and femur and can be useful particularly in ­revision cases.

Bearing Surfaces in Hip Arthroplasty

The most common combination of bearing surfaces used in total hip arthroplasty is a metal femoral head (generally cobalt chrome), articulating with a polyethylene liner. Ceramic and metal are alternative bearing surfaces commonly utilized in total hip arthroplasty, either used in combination with a polyethylene acetabular liner (ceramic on poly or metal on poly) or in metal on metal and ceramic on ceramic articulations. Metal on metal and ceramic on ceramic articulations have the advantage of lower friction and decreased wear rates in comparison to metal on polyethylene articulations. Metal on metal articulation is utilized commonly in hip resurfacing, however its use in total hip arthroplasty is controversial. Metal on metal articulation has many advantages, including lower wear rates and decreased associated osteolysis. The surgeon also has the ability to use a larger femoral head, thus achieving a greater femoral head to neck ratio and providing the patient a greater arc of motion prior to impingement and subsequent dislocation. Metal on metal (MOM) articulations have been associated with production of metal ions, pseudotumors, hypersensitivity reactions, and early failure when used in total hip arthroplasty (Fig. 43-13). Metal ions pose a theoretic risk of causing problems with pregnancy or a theoretic risk of cancer. Studies have failed to demonstrate a statistical increase in cancer in patients who have MOM articulations in comparison to metal on poly articulations. Ceramic on ceramic articulations have the lowest wear rate and friction of all current bearing combinations. However, ceramic has poor mechanical properties and can lead to component fracture due to its comparatively brittle nature.

Alignment of Hip Arthroplasty Components

Proper alignment of hip arthroplasty components is vital to a successful procedure and patient outcome. Surgeons aim for appropriate alignment of components to restore a functional and stable range of motion. This is accomplished with combined anteversion of the femoral and acetabular components, appropriate abduction of the acetabulum and focus on staying true to Sir John Charnley’s principles: establishing a low friction articulation, medializing the acetabular component and center of rotation and restoring abductor length and tension with restoration of appropriate length and femoral offset. Inappropriate placement of components can lead to early failure, accelerated component wear, dislocation, need for revision surgery and poor patient outcome and satisfaction.

Knee Arthroplasty

Background

Knee Arthroplasty is indicated for end stage arthritis within the knee that has failed to respond to a reasonable trial of non-operative and conservative measures. (Figs. 43-14 and 43-15) Knee arthroplasty commonly refers to total knee arthroplasty where the distal femur, tibia, and patella are resurfaced after any remaining articular cartilage and a layer of subchondral bone are resected. A unicompartmental knee arthroplasty consists of replacing one compartment of the knee, most commonly the medial compartment, for unicompartmental disease. Similarly, isolated replacement of the patellofemoral joint can be performed for end stage patellofemoral arthritis

Surgical Approach to the Knee

Total knee arthroplasty is generally accomplished through a medial parapatellar approach. This approach utilizes a longitudinal skin incision, usually midline over the patella, extending on average from 5 cm proximal to the patella to the tibial tubercle distally. Dissection is carried down to the capsule where a medial parapatellar arthrotomy is performed to gain access to the joint. This approach provides excellent exposure to all three compartments of the knee after patellar dislocation. On occasion, a lateral parapatellar arthrotomy is warranted and this can be performed safely. In the event that the patella does not dislocate, the arthrotomy can be extended proximally through the quadriceps. This has no effect on patient outcome.

Once the joint surfaces are adequately exposed, remaining articular cartilage and a thin layer of underlying bone are removed prior to placement of prosthetic components. Bone cuts are made based on pre-operative templating, cutting guides, computer navigation, and anatomic measurements (Figs. 43-16 and 43-17).

Bearing Surfaces in Knee Arthroplasty

The femoral component consists of a metal prosthetic cap designed and sized to fit the normal shape of the femoral condyles. The tibia is cut perpendicular to the anatomic and mechanical axis and a flat, stemmed, metal tray is placed, which most often articulates with a polyethylene liner. The patella is resurfaced with a polyethylene component. Options exist for a mobile bearing knee ­arthroplasty. With this design the polyethylene component is not fixed rigidly to the metal tibial tray and has the ability to more highly conform to the femoral component through the range of motion arc with designed ability for motion in its articulation with the tibial tray. Although excellent results have been published, this design has not been proven to lead to improved outcome or decreased component wear.

Two types of primary total knee arthroplasty systems exist, including cruciate retaining and posterior stabilized systems. As the name implies, with cruciate retaining systems, the posterior cruciate ligament (PCL) is retained in hopes of preserving more normal knee kinematics and femoral rollback with flexion, while in posterior stabilized systems the ligament is sacrificed and the components are designed to accommodate for the loss. These two systems have equivalent results in knee arthroplasty.

Alignment and Balancing in Knee Arthroplasty

Appropriate alignment of the components and balancing of the flexion and extension gaps are essential for a successful result in knee arthroplasty. Inappropriate component position can lead to early wear and failure, knee instability, pain, and post-operative stiffness with poor range of motion. The surgeon must perform appropriate soft tissue balancing and bone cuts to accomplish this and subsequently must place the appropriate sized components, usually replacing the exact amount of bone and cartilage that was removed to create the articulation, and restore stability. The knee must be stable to varus and valgus stress at all points through the range of motion arc and still be able to attain a full range of motion arc from full extension to deep flexion.

Computer Navigation and Joint Arthroplasty

Computer navigated joint arthroplasty has the theoretical benefit of more accurate and consistent placement of arthroplasty components through intraoperative feedback to the surgeon regarding component position, planned bone cuts and alignment (Fig. 43-18). In theory this would lead to improved patient outcomes (Fig. 43-19A and B). Negatives include increased costs of the technology and prolonged operative times. Use of computer navigation in total joint arthroplasty has been shown to provide statistically significant improvement in accuracy of component placement. Use of computer navigation will likely increase in the future as technology continues to improve.

Fixation Options in Joint Arthroplasty

Components in hip and knee arthroplasty can be secured into position with cement or biologic fixation. The cement most commonly used is polymethylmethacrylate (PMMA). PMMA serves as a grout between the component and the bone surface. Components secured without cement are grit blasted or porous coated to allow bony ongrowth or ingrowth, respectively. Hydroxyapatite can also be utilized on the implant surfaces to promote bone ingrowth or ongrowth through osteoconductive properties. A majority of hip joint arthroplasty components are now secured without cement where initial fixation of components is accomplished through press fit techniques. In knee arthroplasty, cement utilization is generally preferred. In hip replacement patients where biologic fixation would be unreliable such as an elderly, osteoporotic patient, or patients with prior radiation, cement may be a better option. With revision total hip arthroplasty, cement fixation of components has been shown to lead to earlier mechanical failure.

Osteolysis and Aseptic loosening

Osteolysis is a term used to describe abnormal resorption of bone. Osteolysis can be caused by underlying infection, metastatic disease, or in the case of joint replacement, the production of wear debris. Even with appropriately positioned components, some wear of the bearing surfaces is expected. However, the wear rates and the size and amount of wear debris with the different bearing surfaces can be quite different. The wear rate of ceramic on ceramic articulations is the lowest of all bearing surfaces, however there is increased risk of component fracture and postoperative “squeaking.” In metal on polyethylene articulations, wear debris is produced and polyethylene particles are phagocytized by local macrophages. “Activated” macrophages lead to an osteolytic process and bone resorption. Particulate methylmethacrylate cement debris can also play a role in osteolysis. Improperly positioned components or patient related factors such as high impact activities can lead to a high wear rate. A substantial osteolytic response may occur and lead to component micromotion and aseptic loosening. Patients who present to clinic with pain following joint arthroplasty and an increasing zone of osteolysis in the periprosthetic region frequently need revision surgery (Fig. 43-20) Alternative bearing surfaces continue to be explored in hopes of decreasing or completely preventing wear of components and associated osteolysis and aseptic loosening.

Complications in Joint Arthroplasty

The risk of any complication following joint arthroplasty procedures falls in the range of 5% to 10%. Risks shared by hip and knee arthroplasties include infection, intra-operative or post-operative fracture, vascular injury with need of intra-operative or post-operative blood transfusion, nerve injury or nerve palsy (most commonly involving the deep peroneal nerve and loss of ankle dorsiflexion), periprosthetic fracture, stress shielding, component fracture or wear, and medical complications, including venous thromboembolic disease (DVT and PE), myocardial infarction, or cerebrovascular accident. Complications unique to total hip arthroplasty include dislocation, leg length discrepancy, iliopsoas impingement, or tendonitis.

Dislocation Following Hip Arthroplasty

Dislocation can result from malpositioned components (inadequate combined anteversion of the femoral neck and acetabulum, excessive ab- or adduction of the acetabular component), non-­compliant patients, those with cognitive or neuromuscular disorders, inadequate soft tissue repair or excessive soft tissue loss from surgeries or revision surgery, fracture, improper restoration of length, and/or offset. Historically, there has been significant debate as to the role of the surgical approach and incidence of hip dislocation following hip arthroplasty. However, comparable dislocation rates have been found with anterolateral(0.70%), lateral (0.43%), and posterior with soft tissue repair (1.01%) approaches. Dislocation is often the result of poor patient compliance with post-operative restrictions, neuromuscular or cognitive conditions, or excessive soft tissue loss. History, physical examination and appropriate radiographs are vital to proper treatment of dislocation. Closed reduction can usually be performed with conscious sedation and gentle traction or manipulation. Rarely, open reduction may be necessary. Patients with multiple dislocations should be assessed for improperly positioned components. Patients with recurrent dislocations and improperly positioned components may need revision of the component. Patients with recurrent dislocations and properly positioned components should be considered for conversion to hemiarthroplasty or to a constrained total hip arthroplasty which provides improved stability.

Diagnosis of Malignant Bone Tumors

History

Diagnosis of musculoskeletal tumors begins with a thorough patient history. A history of unremitting pain, unrelated to activity, or pain that interferes with sleep, suggests malignancy. Patient age can help in establishing a differential. Round blue cell lesions are most likely neuroblastoma in a five-year old, Ewing’s sarcoma in a 10-year old, lymphoma in a 20-year old, and myeloma in a 60-year old. Gender also adds information, for instance, giant cell tumor is more common in females, osteosarcoma in males. Multiple bone involvement may suggest fibrous dysplasia, enchondromas (Ollier disease, Maffucci’s syndrome), or osteochondromas (multiple hereditary exostoses).

Laboratory Test

Laboratory tests determine the level of cellular turnover (lactate dehydrogenase [LDH]) or of bone destruction (calcium, alkaline phosphatase). Elevated Prostate-specific antigen (PSA) suggests prostate cancer.

Imaging

Radiographic studies are critical to the diagnosis of bony tumors. Radiographs can help assess the aggressiveness of the tumor. Four questions should be addressed when assessing radiographs: (a) Where is the tumor—in which bone (Table 43-1) and in which part of the bone (Table 43-2)? (b) What is the tumor doing to the bone (clinical behavior)? (c) What is the bone doing to the tumor (biologic response)? (d) What is the matrix pattern? Matrix is the acellular interstitial substance produced by tumor cells. Particular attention should be paid to the junction between the tumor and the host bone since this margin can also indicate the aggressiveness of the tumor. Ewing’s sarcoma has a characteristic ‘onion skin’ periosteal reaction pattern. This reaction pattern also occurs in other tumors and infections.

The most common primary malignant bone tumor is osteosarcoma (Fig. 43-21). Osteosarcomas are classified as osteoblastic, chondroblastic, fibroblastic, telangiectatic, round cell, and MFH-like, according to the predominant cell type. Most ­osteosarcomas present in patients between 10 and 20 years of age. Secondary osteosarcomas occur in older patients in abnormal bone affected by Paget’s disease or radiation.

Parosteal Osteosarcoma

Parosteal osteosarcomas occur in women ages 20 to 50, “pasted on” the surface of the posterior distal femoral metaphysis. The preferred treatment is wide surgical excision.

Periosteal Osteosarcoma

Periosteal osteosarcoma occurs on the anterior surface of the distal femur or proximal tibia. The lesion appears chondroblastic on histology. Radiographs show scalloping of the underlying cortex with a ‘sunburst’ periosteal reaction. Treatment is wide surgical excision.

Paget’s Sarcoma

Paget’s sarcoma is a rare complication of Paget’s disease. In Paget’s disease with multiple bone involvement, osteogenic sarcoma, fibrosarcoma, chondrosarcoma, and MFH have occurred, most often in the pelvis, but also in the humerus, femur, spine, and skull. Imaging may demonstrate osteolytic areas, and loss of normal fatty marrow and multifocal lesions. Treatment of Paget’s sarcoma is surgical excision, but the prognosis is poor.

Radiation-Induced Sarcoma

The three criteria for diagnosis sarcoma of radiation induced sarcoma are: (a) histology different from the original lesion, (b) sarcoma develops in the irradiated field, and (c) 3 to 5 year latent period between radiation and sarcoma development. Radiation for carcinoma of the breast and cervix can result in osteosarcoma, chondrosarcoma, fibrosarcoma, or MFH. Treatment is a combination of chemotherapy and ­surgery.

Ewing’s sarcoma is the second most common primary bone tumor in patients under 30. The typical presentation is a tumor in the diaphysis of the femur in a young white male. An “onion skin” periosteal reaction may be seen on radiographs. A large soft-tissue extension from the primary bone tumor may be seen and histology reveals a small round blue cell tumor (Fig. 43-22). Diagnosis is confirmed with bone marrow biopsy specimen. Bone scan can identify multiple lesions. Treatment is chemotherapy and surgery or radiation therapy for spine or pelvic lesions.

Chondrosarcomas

Chondrosarcomas typically occur in male patients over 40 years of age, and are the third most common primary bone malignancies. Primary chondrosarcomas can form clear cell, mesenchymal, or dedifferentiated neoplastic cartilage. Secondary chondrosarcomas may also develop in pre-existing lesions such as exostoses or enchondromas. Pelvis, shoulder, and ribs are frequent locations. Chondroid or “popcorn” calcifications are typical on radiographs. Clear cell chondrosarcoma and mesenchymal chondrosarcoma occur in younger patients (second to fifth decades of life). Clear cell chondrosarcomas are low-grade lesions that often affect the epiphyses.

The treatment of chondrosarcoma is surgical excision, since cells are not chemosensitive or radiosensitive. For high-grade lesions, wide or radical resection is recommended. Pelvic and scapular chondrosarcomas have a high recurrence rate and adjuvant chemotherapy does not improve survival rates.

Desmoplastic Fibroma

Desmoplastic fibroma is a rare tumor occurring in the mandible, femur, pelvis, radius, or tibiain young adults. Radiographs show a metadiaphyseal “soap bubble” appearance and endosteal scalloping. Histology resembles desmoid tumors or fibromatosis. Recommended treatment is wide excision.

Malignant Fibrous Histiocytoma of Bone

MFH occurs in the metadiaphysis of long bones after conditions like nonossifying fibromas and bone infarcts. Radiographs typically show destructive lesions with soft-tissue extension. Histology resembles osteosarcoma with fibroblasts, histiocytes and giant cells, but no neoplastic osteoid formation. Treatment is wide surgical excision.

Malignant Vascular Tumors

Hemangioendothelioma

Hemangioendothelioma is a malignant neoplasm arising from vascular endothelium in long bones. Radiographs show a metadiaphyseal lytic lesion with a “soap bubble” appearance. Histology reveals eosinophilic cells in a basophilic stroma. Lesions may be multifocal. Treatment ­consists of curettage for low-grade lesions and wide excision for high-grade lesions.

Hemangiopericytoma

Hemangiopericytoma is usually a solitary lesion occurring in the soft tissues or the axial skeleton and proximal long bones in middle-aged or elderly males. Histology reveals branching “staghorn” vascular spaces. The tumor cells resemble cells normally seen adjacent to capillaries. Treatment is wide excision.

Angiosarcoma of Bone

Angiosarcoma is a soft tissue malignancy usually seen in elderly males. Histology reveals vascular channels with anaplasia. Treatment is wide excision, or if inaccessible surgically, ­radiation.

Giant Cell Tumor of Bone

Giant cell tumor occurs in the knee, distal radius, proximal humerus, and pelvis in women 20 to 40 years of age. Presenting complaints include pain and pathologic fracture. Imaging reveals eccentric, epimetaphyseal lytic lesions eroding the subchondral bone. Histology reveals multinucleate giant cells and mononuclear stromal cells (Fig. 43-23). These tumors can occasionally metastasize to the chest. Primary malignant giant cell tumor has a poor prognosis. Treatment of giant cell tumors is with curettage and high-speed burr. Recurrence rates are high with simple curettage, and the use of cryosurgery, phenol, or polymethylmethacrylate bone cement may help decrease recurrence rates. After pathologic fractures, wide excision may be required. In tumors that are inaccessible surgically, radiation may be indicated.

Ossifying Fibroma and Adamantinoma

Ossifying fibroma occurs in the anterior cortex of the tibial diaphysis of young males. Radiographs have a soap bubble appearance. Patients may present with pain but often the diagnosis is incidental on radiographs. Histology resembles fibrous dysplasia, but with osteoblastic rimming. Ossifying fibroma may be a precursor to adamantinoma.

Adamantinomas are low grade malignancies capable of metastasis seen in the tibia. Histology reveals a tubular, basaloid, squamoid, or spindled pattern (Fig. 43-24). While ossifying fibroma is benign, careful monitoring is needed because they may be a precursor of adamantinoma. The treatment of adamantinoma is with wide surgical excision.

Primary Lymphoma of Bone

Primary lymphoma accounts for about 5% of all neoplasms of bone. Long bone involvement is more frequent than spine. Lymphoma of bone typically occurs in males in their forties. Histology reveals large B cell lymphomas. Treatment is a combination of chemotherapy and radiation. Surgery may be required for stabilization of pathologic fractures.

Chordoma

Chordoma arises from notochordal rests in the sacrum. These tumors are found in middle-aged to older men and presents with bladder and bowel symptoms. An MRI shows a destructive lesion with a large soft-tissue mass. Histology shows epithelioid cells arranged in cords with vacuolated physaliferous cells. Treatment is surgical excision and muscle flaps and a mesh for reconstruction. Urinary diversion and colostomy may be needed for loss of bladder and bowel control.

Multiple Myeloma

Myeloma, the most common primary bone malignancy, is a proliferative disorder of B cells, with plasma cells, evidence of monoclonal M protein in the serum and/or urine, and hypercalcemia, renal insufficiency, anemia, or bone disease. A solitary myeloma lesion in bone is known as a plasmacytoma (Fig. 43-25). Presenting symptoms in myeloma range from bone pain and osteopenia, to focal lytic lesions with pathologic fractures and hypercalcemia. Myeloma protein 1-alpha ­stimulates osteoclast formation. Osteoclast activating factors increase receptor activator of nuclear factor κB ligand (RANKL) in the bone marrow. RANKL induces osteoclast differentiation and activation. Myeloma cells inhibit osteoblast differentiation and activity. Serum and urine electrophoresis detect the M protein. Work up also includes complete blood cell count, erythrocyte sedimentation rate, calcium levels, renal function assessment, and β-2-microglobulin levels, and a skeletal survey. Bone scans may show a false-negative result in more than two-thirds of patients and a dual energy X-ray absorptiometry scan. Plasmacytoma is usually treated with radiation to the lesion. Myeloma is treated with chemotherapy, stem cell transplantation, and radiation therapy. Many patients with myeloma develop a vertebral compression fracture. Kyphoplasty can be useful in providing pain relief. The risks of cement extravasation and related complications are lower with kyphoplasty than with vertebroplasty. If there is instability or if there is neural compression, surgical stabilization may be required.

Metastatic bone tumors are more common than primary bone tumors. Metastatic tumors affect the lung, liver, and bone. Cancers that commonly metastasize to bone are breast, prostate, lung, thyroid, and kidney. In patients older than 40 years of age, metastases and myeloma are the most common lesions in bone. The most common site of involvement is the axial skeleton and proximal ends of long bones. Bronchogenic and renal cell carcinomas can metastasize distal to the knee and elbow. Malignant cells are able to detach from one location and set up a focus at a distant site. Work up of a patient with suspected metastatic disease to bone should include CT of chest, abdomen, and pelvis, mammography, tumor markers, serum, and urine electrophoresis, and bone scans.

Brachial Plexus Palsy

Injury of the brachial plexus during delivery occurs in two births in every 1000. Large birth weight, forceps delivery, breech presentation, and prolonged labor are risk factors. Brachial plexus injury usually represents a stretch injury on the nerve roots. Management is therapy and passive exercise to preserve motion in the shoulder while awaiting return of neurologic and motor function. Surgical repair of injured nerve roots and trunks may be required in severe cases.

Cerebral Palsy

Cerebral palsy results from an injury to the brain which may be associated with mental impairment. Cerebral palsy is classified as spastic, athetotic, ataxic, and may present with spasticity, hemiplegia, diplegia, or scoliosis. The typical cerebral palsy patient is hyperreflexic with increased muscle tone and spasm. Treatment includes tendon lengthening procedures, release of contractures, and tendon transfers to maintain motion and function.

Hip dislocation or subluxation results from unbalanced muscle forces in many cerebral palsy patients. Treatment consists of abductor tendon releases. When soft tissue releases are unsuccessful, tendon balancing procedures may be combined with open reduction of a hip joint and acetabular reconstruction and osteotomy of the proximal femur. Knee contractures are treated with hamstring lengthening.

Foot and ankle deformities are treated even in nonambulatory patients to facilitate shoe wear. The most common foot deformity in cerebral palsy is an equinovalgus foot caused by heel cord contracture and peroneal spasm. Tendon balancing is usually necessary and bony reconstruction may also be needed in severe cases.

Skeletal Growth

Injury, inflammatory disease, and developmental disorders in actively growing bones requires special attention to preserving the growth plates. The pediatric skeleton is incompletely ossified making diagnosis of an injury difficult, since significant portions of the skeleton are invisible on radiographs. The epiphysis, generally containing an articular surface, is found at the ends of the long bone. The physis or growth plate is found beneath the epiphysis. The physis has six specific zones: the reserve zone, the zone of differentiation, the zone of proliferation, the zone of maturation, the hypertrophic zone, and finally, the zone of calcification.

Injury or insult to the growth plate can lead to premature growth arrest or angular deformity of the limb. Surrounding the metaphyseal and diaphyseal bone, is the periosteum. This metabolically active layer of tissue synthesizes new bone onto the diaphyseal and metaphyseal bone and provides circumferential growth of the bones.

Ossification centers in the epiphysis and appear in a predictable order, and can help determine “bone age.”

Pediatric Fractures

In a pediatric patient, the epiphyseal growth plate is unossified and at risk of fracture. Reduction and stabilization of epiphyseal fractures is critical to minimize permanent growth disturbances and deformity.

Classification of Growth Plate Injuries

Salter and Harris described a useful classification for epiphyseal fractures. A Salter-Harris Type I injury is a simple transverse fracture through the physis. A Salter-Harris Type II fracture contains a component of fracture through the growth plate in continuity with a fracture of the metaphysis. Salter-HarrisType III fracture occurs through the physis and exits through the growth plate. While a Salter-HarrisType IV fracture line extends through the physis from the metaphysis into the epiphysis. A Salter-Harris Type V fracture crushes the physis itself.

Treatment of growth plate fracture requires anatomic reduction of the fragments. Internal fixation avoids placing hardware across the growth plate to minimize the chance of premature growth plate closure.

Diaphyseal Injuries in a Pediatric Patient

Long bones diaphyseal fractures are generally treated closed. Pediatric patients are capable of extensive remodeling so that an angular deformity within the plane of an adjacent joint is often completely remodeled by the growth of the child. When internal fixation of a diaphyseal fracture is required, the physis is avoided.

Fractures of the Pediatric Hip

Pediatric patients with hip fractures may be treated with a spica cast. The spica cast includes the abdomen, lower back, pelvis, and lower limb, and derives its name from the resemblance of the plaster wrap over the hip to wheat (“spica”).

Fractures of the Femoral Shaft

Femoral shaft fractures in a child younger than six years old may be managed with a spica cast. Femur fractures in patients older than six years of age can be managed by internal fixation with a flexible intramedullary nail. Children 14 years of age are treated with an adult style intramedullary reamed nail. Extra-articular fractures of the distal femur or proximal tibia are managed in a long leg cast.

Pediatric Ankle Fractures

Salter-Harris I and II fractures are managed with casting. Salter-Harris III or IV fractures are managed by closed reduction and internal fixation with percutaneous pins or screws. Smooth pins are used, and the physis is avoided unless necessary for stability.

The Tillaux (Salter-Harris Type II) fracture involves a fracture through the lateral epiphysis and the lateral physis. In these patients the growth plate is in the process of closing and open reduction and internal fixation is needed. The “triplane” fracture (Salter-Harris Type IV) is managed by closed reduction with percutaneous pinning.

Pediatric Elbow Fractures

Management of pediatric elbow fractures is complex. A fracture of the distal humeral epiphysis can be misdiagnosed as a dislocation of the elbow. Familiarity with the timing of the ossification centers’ appearance aids in diagnosis. Treatment is closed reduction and percutaneous pinning.

Injury to the brachial artery, the radial, ulnar, and medial nerves are possible. Neurovascular exam is required before, during, and after treatment. Close follow-up for maintenance of reduction and neurovascular status is needed.

Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) is seen in firstborn females with a positive family history, and breech birth.

Untreated hip dislocations can lead to a dysplastic acetabulum. Newborns are examined for hip instability within the first 72 hours. Ortolani’s test consists of gentle elevation and abduction of the femur causing a palpable click in the relocation of a dislocated hip. Barlow’s test is gentle adduction and ­depression of the femur which causes a palpable click as a hip slips into a dislocated position. Infants with a dislocated or dislocatable hip will have apparent length discrepancies of the femur when hip is positioned in 90 degrees. Since the bones are not yet ossified, X-ray images of the acetabulum and femoral head are not reliable for diagnosis. Ultrasound can often demonstrate a dislocated or dislocatable hip. Early treatment with abduction and flexion in a Pavlik harness can result in a normal hip joint.

Treatment of DDH

In a child with a dislocatable hip, a Pavlik harness can maintain the hips in flexion and abduction. Avoid severe abduction to avoid avascular necrosis of the head. For mild to moderate dysplasia, 6 to 12 weeks in a Pavlik harness is sufficient. In severe disease, adductor tenotomy may be needed.

If treatment is delayed, open reduction may be necessary. Through an anterior approach the pulvinar can be removed and the femoral head located. Adductor tenotomy and femoral shortening may be indicated. Osteonecrosis of the femoral head can result from open reduction resulting in pain and decreased motion. Some patients with severe DDH may require pelvic osteotomy creating an acetabular shelf, or a varus osteotomy of the proximal femur, or a combination of the two.

Legg-Calvé-Perthes Disease

Osteonecrosis of the proximal femoral epiphysis can cause flattening of the femoral head called Legg-Calvé Perthes disease. The typical patient is a 7-year-old male who presents with groin or knee pain, decreased hip motion, and a limp. ­Treatment includes traction, physical therapy, abduction exercises, and crutches. Femoral and pelvic osteotomies may be needed in extreme cases.

Slipped Capital Femoral Epiphysis

Children ages 10 to 16 years old can develop displacement of the epiphysis on the femoral neck with no history of injury. Slipped capital femoral epiphysis(SCFE) is associated with African American heritage, obesity, and is more common in boys than in girls. One-quarter of cases are bilateral. Patients generally present with groin and anterior thigh or even knee pain and decreased motion. In pediatric patients with knee pain, assess the ipsilateral hip as well.

Treatment for slipped capital femoral epiphysis patients is percutaneous screw fixation through the femoral neck to engage the epiphysis. Reduction of the slipped epiphysis is not recommended because of an increased risk of avascular necrosis. One screw is adequate to prevent further slip.

Lower Extremity Rotational Abnormalities

Intoeing can result from femoral anteversion, tibial torsion, and metatarsus adductus. Remember that a mild degree of intoeing is normal in young children 3 to 5 years of age.

Excessive internal rotation of the femur will usually correct by age 8. Severe rotation with functional impairment that does not correct by age 10 or 11 may require rotational femoral osteotomy.

Bilateral intoeing gait in one- and two-year-old children can result from tibial torsion which generally will completely resolve without treatment.

Metatarsus adductus in infants will also resolve spontaneously in most cases.

Congenital Talipes Equinovarus

Club foot is a common problem associated with contractures of the medial tendons of the foot, a tight Achilles tendon, and contractures of the ankle, hindfoot, and midfoot. Talipes ­equinovarus can be corrected by sequential corrective casting of the foot. A successful program of casting may be complete in one to five months. In patients with severe disease or who initiate treatment after nine months of age, surgical release of contracted soft tissues may be necessary.

Osgood-Schlatter Disease

Osgood-Schlatter disease is a common problem most often seen in athletically active adolescents. This disorder is characterized by ossification in the distal patellar tendon at the point of its tibial insertion. This disorder is thought to result from mechanical stress on the tendinous insertion. Radiographs show calcified ossicles within the tendon at its insertion. The disease presents with severe local pain and tenderness in the area of the tibial tubercle.

Treatment for the disease is activity restriction. If the symptoms are improved, athletic participation can be resumed. Symptoms regress after skeletal maturity or the discontinuance of active athletic participation.

Entries highlighted in bold are key references.

Trauma

Sports

Spine

Joint Reconstruction

Orthopedic Oncology

Pediatric Orthopedics