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Surgery_Schwartz. of the spinous process by the paraspinal muscle forces (Fig. 43-31). The fracture is treated nonoperatively with analgesics and a soft collar.FRACTURES OF THE THORACIC AND LUMBAR SPINEThoracic Lumbar Spine InjuryThe ribs stabilize fractures of the thoracic spine, making these fractures more stable than similar fractures of the lumbar spine. Neurologic injuries are more common in the thoracic and proxi-mal lumbar spine because of the presence of the spinal cord, which ends at the L2 level, as well as the small spinal canal diameter of the thoracic spine.Compression FractureCompression fractures result from osteoporosis as well as trauma. Compression fractures involve a fracture of the anterior part of the vertebral body without associated posterior cortex fracture. Thoracolumbar compression fractures are treated non-operatively with braces and analgesics.Burst FractureBurst fractures are caused by falls and high-energy automo-bile accidents. The posterior cortex fracture (middle


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Surgery_Schwartz. fractures are treated non-operatively with braces and analgesics.Burst FractureBurst fractures are caused by falls and high-energy automo-bile accidents. The posterior cortex fracture (middle column involvement) differentiates the burst fracture from a compres-sion fracture. The injury may be associated with neurological deficits due to retropulsion of bone into the canal. A vertical lamina fracture may contain an invaginated segment of the dura mater with accompanying nerve root injury and dural tear. Wid-ening of the pedicle in an AP view of the spine will indicate a burst fracture. CT scan will define the bony injury, and an MRI will show compression of the neural elements and any injury to the posterior ligaments.Treatment is nonoperative with an orthoses and mobiliza-tion of the patient if the fracture is stable. Surgery is done for decompression and destabilization of the spine if the patient has neurologic deficits or if the fracture is unstable.Seatbelt Injuries (Flexion


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Surgery_Schwartz. patient if the fracture is stable. Surgery is done for decompression and destabilization of the spine if the patient has neurologic deficits or if the fracture is unstable.Seatbelt Injuries (Flexion Distraction Injuries)A seatbelt injury occurs when there is acute forward flexion of the trunk and anterior (i.e., seatbelt) restraint. The pelvis and upper torso move forward, and failure of the spine under tension begins with the posterior elements. Tearing of the dorsal fascia, the interspinous ligament, dislocation of the facets, and tearing of the discs occurs. Seatbelt injury may be bony or ligamen-tous (Fig. 43-32). The bone of the spinous process, the lamina, the pedicles, and the vertebral body fail in tension (“chance Figure 43-32. Seatbelt injuries (flexion-distraction injuries) can be bony or ligamentous.Figure 43-31. Fracture of the transverse process of C6 or C7.Brunicardi_Ch43_p1879-p1924.indd 190222/02/19 10:41 AM 1903ORTHOPEDIC SURGERYCHAPTER 43fracture”). The bony


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Surgery_Schwartz. can be bony or ligamentous.Figure 43-31. Fracture of the transverse process of C6 or C7.Brunicardi_Ch43_p1879-p1924.indd 190222/02/19 10:41 AM 1903ORTHOPEDIC SURGERYCHAPTER 43fracture”). The bony injury could be stable. Flexion distraction injuries involving the soft tissue, with injury to the posterior spine elements, are usually unstable. This unstable injury will require internal fixation and fusion with bone grafting. This spine injury may be associated with a colon injury, especially in children.Fracture Dislocations of the SpineFracture dislocations of the spine displace the bony elements by translation or rotation, resulting in canal narrowing and nerve injury.Reduction of the displaced bones is the best way to improve the canal dimensions.Patients with fracture dislocations of the spine and par-tial nerve function can recover. Fracture dislocations are treated operatively with surgical stabilization.Disc HerniationDisc herniation, most common between ages of 20 and 50, can


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Surgery_Schwartz. the spine and par-tial nerve function can recover. Fracture dislocations are treated operatively with surgical stabilization.Disc HerniationDisc herniation, most common between ages of 20 and 50, can occur in the cervical, thoracic, or the lumbar spine, and consists of a tear of the annulus allowing the nucleus pulposus material to extrude through the annulus and enter the canal, pressing on the exiting nerve or the “traversing” nerve roots. In the cervical spine, spinal cord compression can occur.Symptoms of most disc herniations resolve within 8 weeks as the nerve root accommodates and inflammation recedes. The bulk of the extruded nucleus pulposus resorbs over time. When symptoms persist beyond 6 to 8 weeks, surgery with excision of the involved disc and decompression of the nerve roots may be indicated.In cervical disc herniation, an anterior approach to the spine is performed with dissection through a transverse incision on the neck. Dissection is carried between the trachea,


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Surgery_Schwartz. may be indicated.In cervical disc herniation, an anterior approach to the spine is performed with dissection through a transverse incision on the neck. Dissection is carried between the trachea, esopha-gus medially, and the carotid sheath laterally. The disc is then removed. The disc space is usually filled with bone graft to fuse the vertebrae. A locking screw low profile titanium plate is then attached to the vertebrae.Posterior decompression and laminotomy exposes the pos-terior elements of the spine. A portion of the lamina is removed to allow access to the canal to correct foraminal impingement or to remove lateral disc herniations. While the posterior approach does not require fusion with plates and screws, central disc her-niation cannot be managed through a posterior approach since the spinal cord cannot be safely retracted.In thoracic spine disc herniation, the posterior approach is contraindicated because it may lead to paralysis.For lumbar disc herniation, a midline


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Surgery_Schwartz. since the spinal cord cannot be safely retracted.In thoracic spine disc herniation, the posterior approach is contraindicated because it may lead to paralysis.For lumbar disc herniation, a midline incision is used, and laminotomy allows visualization of the lateral recess. Retraction of the dura allows visualization of the traversing nerve roots as well as of the disc fragment.Cauda Equina SyndromeCauda equina syndrome is uncommon and occurs from a central disc herniation (Fig. 43-33). This can be a difficult diagnosis to make; however, it is a true emergency, and a delay in diagnosis can lead to permanent impairment. The patient will complain of back pain with bilateral leg pain. Bladder and bowel diffi-culty such as incontinence and frequency, saddle anesthesia, decreased perianal sensation, impotence, diminished rectal tone, and motor deficits. MRI will show a central disc herniation. Treatment is with urgent diagnosis and urgent surgical decom-pression. The results are better if


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Surgery_Schwartz. impotence, diminished rectal tone, and motor deficits. MRI will show a central disc herniation. Treatment is with urgent diagnosis and urgent surgical decom-pression. The results are better if the decompression is done within 48 hours of onset of symptoms. A central disc herniation causing cauda equina should be differentiated from a postero-lateral disc herniation. The posterolateral disc herniation usu-ally affects a nerve root and can be treated conservatively, at least initially. In the case of central disc herniation, it affects the cauda equina (the lumbosacral nerve roots), and this is a surgical emergency. Spontaneous recovery does not occur, and the outcome is catastrophic, including permanent loss of bowel and bladder control as well as the ability to have an erection if treatment is delayed.Spinal StenosisA loss of hydration of the discs causes loss of disc height and bulging of annular tissue and the ligamentum flavum, which effectively narrows the canal (spinal stenosis).


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Surgery_Schwartz. is delayed.Spinal StenosisA loss of hydration of the discs causes loss of disc height and bulging of annular tissue and the ligamentum flavum, which effectively narrows the canal (spinal stenosis). Osteophyte for-mation on the facet joints can also cause nerve impingement. Cervical stenosis can cause myelopathic symptoms (hyper-reflexia, problems with fine hand dexterity, balance problems resulting in gait disturbance, weakness, and pain). In patients with low back pain and gait disturbance, obtain an MRI of the cervical spine to rule out cervical myelopathy. Pathology of the lumbo-sacral spine does not cause gait disturbances.Lumbar stenosis causes neurogenic claudication (pro-gressive pain, weakness, and numbness in the legs). The clau-dication symptoms result from standing and walking, which increases lumbar lordosis. Extension of the spine decreases the spinal canal diameter as well as the foramen size and worsens the condition. The symptoms resolve with sitting and bending


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Surgery_Schwartz. which increases lumbar lordosis. Extension of the spine decreases the spinal canal diameter as well as the foramen size and worsens the condition. The symptoms resolve with sitting and bending forward (i.e., over a shopping cart) (Fig. 43-34). Flexion of the spine increases the spinal canal diameter as well as the foramen size and decrease the symptoms. The patient may have a normal neurologic exam, and it is important to study the vascular status of the patient and differentiate between neurologic and vascular claudication. Examine the pulses, prescribe a noninvasive vas-cular study if necessary. In general, walking causes the symp-toms for both conditions, and standing relieves the vascular claudication symptoms. Spinal stenosis is treated with NSAIDs, epidural steroid injections, and physical therapy. Resistant cases may require surgical decompression.Spinal stenosis usually occurs in patients over 50 years of age. With degenerative spondylolisthesis or scoliosis, fusion with


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Surgery_Schwartz. and physical therapy. Resistant cases may require surgical decompression.Spinal stenosis usually occurs in patients over 50 years of age. With degenerative spondylolisthesis or scoliosis, fusion with instrumentation is usually required to prevent progression of the deformity.Figure 43-33. Image showing central disc herniation affecting the cauda equina and the classic posterolateral disc herniation affecting a nerve root.Brunicardi_Ch43_p1879-p1924.indd 190322/02/19 10:41 AM 1904SPECIFIC CONSIDERATIONSPART IIBack Pain and Degenerative Disc DiseaseBack pain occurs in the majority of adults but is usually self-limited, resolving in 1 to 2 weeks. Chronic unremitting back pain may suggest the possibility of infection, malignancy, or metastatic disease.While radiographs are one option in the management of disabling low back pain, they are ineffective at ruling out malig-nancy, and radiographic findings correlate poorly with symp-toms. Patients with severe degenerative symptoms may have


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Surgery_Schwartz. management of disabling low back pain, they are ineffective at ruling out malig-nancy, and radiographic findings correlate poorly with symp-toms. Patients with severe degenerative symptoms may have no pain, while others with mild degenerative findings complain of severe pain. The potential for secondary gain and psychiatric problems and the unpredictable results of spine fusion add to the difficulty of diagnosis and choosing a treatment plan.Intervertebral disc replacement prostheses are experimen-tal in the treatment of degenerative disc disease. The potential for loosening, creation of wear debris, and bone loss complicat-ing revision surgery are concerns, as are the proximity of the device to the spinal canal and the great vessels.ScoliosisScoliosis is a lateral curvature of the spine. Lateral bending of the spine is always accompanied by rotational deformity (coupling).In order to measure the severity of scoliosis, lines are drawn along the endplates of the vertebral bodies at


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Surgery_Schwartz. Lateral bending of the spine is always accompanied by rotational deformity (coupling).In order to measure the severity of scoliosis, lines are drawn along the endplates of the vertebral bodies at either end of the curve, and the angle formed when these lines intersect determines the magnitude of the curve.Scoliotic curves are classified as congenital, degenera-tive, metabolic (mucopolysaccharidoses), neurogenic (cerebral palsy), and myogenic curves (muscular dystrophy). Idiopathic scoliosis is the most common form and represents a spectrum of genetic disease.Adults with scoliosis may present with axial pain and imbalance in posture. Treatment for scoliosis may include anti-inflammatory medications, therapy, and activity modification. In severe cases with objective deformity, surgical correction of the deformity may be indicated.Idiopathic ScoliosisThe majority of idiopathic scoliosis curves become apparent during adolescence and progress during skeletal growth. Ini-tial management


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Surgery_Schwartz. of the deformity may be indicated.Idiopathic ScoliosisThe majority of idiopathic scoliosis curves become apparent during adolescence and progress during skeletal growth. Ini-tial management consists of observation. Rapidly progressing curves are treated with braces. Brace treatment is recommended for curves between 20 and 40 degrees. For patients with large curves, surgical intervention may be needed using rods with grafting and fusion.Neuromuscular ScoliosisNeurologic conditions such as polio and cerebral palsy can lead to “uncompensated” scoliosis curves where the patient is unable to lean with his upper body to restore balance. Scoliosis correc-tion surgery may be needed to facilitate sitting balance and to avoid skin breakdown caused by pelvic obliquity.JOINT RECONSTRUCTIONIntroduction to ArthritisArthritis refers to a large number of medical conditions, includ-ing osteoarthritis, rheumatoid arthritis, septic arthritis, and post-traumatic arthritis. Each has the potential to lead


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Surgery_Schwartz. to ArthritisArthritis refers to a large number of medical conditions, includ-ing osteoarthritis, rheumatoid arthritis, septic arthritis, and post-traumatic arthritis. Each has the potential to lead to loss of articular cartilage lining the joints. According to the CDC and the National Health Interview Survey, approximately 55 million adults (22% of the U.S. population) have been diag-nosed with some form of arthritis. This number is pro-jected to grow to an astounding 67 million adults by 2030 (or 25% of the U.S. population).Arthritis causes pain, loss of range of motion, decreased ability to perform work duties or participate in social functions, and decreased quality of life. The number of individuals suffer-ing from arthritic conditions will continue to rise as the “baby boomer” generation enters old age and the prevalence of obesity rises in the U.S. population, as age and obesity are two major factors in the onset of arthritis.Examination of the PatientA thorough history and


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Surgery_Schwartz. enters old age and the prevalence of obesity rises in the U.S. population, as age and obesity are two major factors in the onset of arthritis.Examination of the PatientA thorough history and physical examination is indicated for all orthopedic patients. Patient history should include loca-tion, quality, severity, timing, and radiation of pain along with any referred pain, associated signs and symptoms, modify-ing factors, or prior treatments, including both conservative and surgical measures. Other details within the history and physical examination are equally important in establishing a diagnosis and successfully developing a treatment plan. If you listen carefully to your patients, they will often tell you their diagnosis.For example, location of “hip pain” can narrow a dif-ferential diagnosis. Patients with activity-related groin pain often are found to have hip arthritis, whereas patients with 10Figure 43-34. Person is seen bending over shopping cart to improve


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Surgery_Schwartz. a dif-ferential diagnosis. Patients with activity-related groin pain often are found to have hip arthritis, whereas patients with 10Figure 43-34. Person is seen bending over shopping cart to improve symptoms.Brunicardi_Ch43_p1879-p1924.indd 190422/02/19 10:41 AM 1905ORTHOPEDIC SURGERYCHAPTER 43peritrochanteric pain (lateral hip pain) may be suffering from trochanteric bursitis. The importance of listening and focusing on the patient’s description of location and type of pain cannot be overemphasized.Physical examination should begin by observing the patient’s gait, both with and without assistive devices if pos-sible. This demonstrates the extent of the patient’s functional deficit and the effect of the patient’s pain. Typical gait pat-terns include antalgic gait due to pain, or a “Trendelenburg gait” (Fig. 43-35) where abductor weakness may lead to a poor outcome following total hip arthroplasty. Other aspects of the exam include assessment of leg length discrepancy, joint


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Surgery_Schwartz. a “Trendelenburg gait” (Fig. 43-35) where abductor weakness may lead to a poor outcome following total hip arthroplasty. Other aspects of the exam include assessment of leg length discrepancy, joint con-tractures, skin changes, assessment for prior surgical incisions to identify prior treatments or plan future surgical approaches, neurovascular status, and strength, as well as range of motion. These details document functional status and help to formulate a differential diagnosis. Patients with “hip pain” may have lumbar spinal stenosis, radiculopathy, or vascular disease that may play a large role in their presentation. Once an appropriate physi-cal examination is performed, weight-bearing radiographs are needed. Advanced imaging, including CT and MRI, are rarely indicated in the initial workup. Once a diagnosis is made, spe-cific treatment directed towards the patient’s condition can be initiated. The goals of treatment are to improve pain, preserve motion, and maximize patient


Surgery_Schwartz

Surgery_Schwartz. workup. Once a diagnosis is made, spe-cific treatment directed towards the patient’s condition can be initiated. The goals of treatment are to improve pain, preserve motion, and maximize patient function, independence, and qual-ity of life.Nonoperative Management and Prevention of ArthritisNonoperative measures to treat arthritis include weight loss, activity modification, rest, physical therapy, NSAIDs, bracing, and assistive devices such a cane or walker. These treatments have the potential to decrease symptoms and improve function and quality of life. For example, holding a cane on the opposite side of the symptomatic extremity reduces the forces across the hip joint and subsequently decreases hip pain (Fig. 43-36). In nearly all cases, it is best to treat patients nonoperatively prior to recommending surgery.Health and exercise can also play a role in the prevention of arthritis. Weight loss of as little as 11 lbs (5 kg) has been shown to decrease the risk of developing knee


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Surgery_Schwartz. prior to recommending surgery.Health and exercise can also play a role in the prevention of arthritis. Weight loss of as little as 11 lbs (5 kg) has been shown to decrease the risk of developing knee osteoarthritis in 11women by 50%. Similarly, patients who engage in regu-lar physical activity have a lower incidence of arthritis. However, despite nonoperative treatment, surgical intervention may be required to effectively manage patient symptoms.InjectionsJoint injections are commonly performed into the knee and shoulder. Common injections into the knee include corticoste-roids and hyaluronic-acid gels. Corticosteroid injections can decrease inflammation within the joint. These injections are usually administered in combination with a local anesthetic, such as lidocaine, in order to provide more immediate relief for both diagnostic and therapeutic purposes. If the patient has immediate relief of pain with injection of the joint, this localizes the source of the patient’s pain to the


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Surgery_Schwartz. more immediate relief for both diagnostic and therapeutic purposes. If the patient has immediate relief of pain with injection of the joint, this localizes the source of the patient’s pain to the joint and may assist with diagnosis. Diagnostic hip injections are particularly helpful in distinguishing pain resulting from hip versus lumbar spine pathology. Any benefit received is therapeutic for the patient. Hyaluronic acid injections in the knee are frequently used and are commonly referred to as “viscosupplementation.” The viscosity of the synovial fluid is increased by hyaluronic acid, but its role and mechanism are not well defined yet. There is a risk of joint infection, cartilage injury from the needle, hemarthrosis, and failure to receive benefit. Short-term altered glucose metabolism in diabetic patients is common with cor-ticosteroid injections. The efficacy of hyaluronic acid injec-tions has been questioned by recent evidence summarized in the American Academy of Orthopaedic


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Surgery_Schwartz. in diabetic patients is common with cor-ticosteroid injections. The efficacy of hyaluronic acid injec-tions has been questioned by recent evidence summarized in the American Academy of Orthopaedic Surgeons’ Clinical Practice Guidelines.Figure 43-35. Trendelenburg Gait resulting from weakness of abductor muscles.Figure 43-36. Holding the cane on the opposite side of the pathol-ogy is beneficial in decreasing arthritis pain in the hip.Brunicardi_Ch43_p1879-p1924.indd 190522/02/19 10:41 AM 1906SPECIFIC CONSIDERATIONSPART IISurgical Management of ArthritisThe most commonly performed procedure for arthritis of a major joint is arthroplasty, or joint replacement. Joint replace-ments, including hip and knee arthroplasty, are considered two of the most successful procedures performed in all of surgery. However, nonarthroplasty options exist and are typically per-formed for certain indications and goals.Osteotomy. Osteotomy is cutting of the bone to change the position of the fragments,


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Surgery_Schwartz. of surgery. However, nonarthroplasty options exist and are typically per-formed for certain indications and goals.Osteotomy. Osteotomy is cutting of the bone to change the position of the fragments, thereby improving rotation, align-ment, or angulation. Osteotomy can be performed for both con-genital and acquired deformities that contribute to the patient’s pain or development or progression of disease. Pelvic and femo-ral osteotomy can be utilized in the treatment of developmen-tal dysplasia of the hip. The position of the acetabulum can be altered with pelvic osteotomies in order to provide more appro-priate coverage of the femoral head, which is typically deficient anteriorly and laterally. Femoral osteotomies can be performed to correct version and varus/valgus deformity of the femoral neck. Osteotomies are performed to obtain more normal align-ment and coverage of the femoral head within the acetabulum to prevent or delay future disease.An osteotomy commonly used in the knee is a


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Surgery_Schwartz. neck. Osteotomies are performed to obtain more normal align-ment and coverage of the femoral head within the acetabulum to prevent or delay future disease.An osteotomy commonly used in the knee is a proxi-mal tibia osteotomy. An adult patient who presents with iso-lated medial compartment knee arthritis and associated varus deformity would be a candidate for a valgus-producing (high tibial) osteotomy. An osteotomy that realigns the knee into slight valgus has the potential to off-load the medial com-partment, slow disease progression, and prevent or delay the need for further procedures (unicompartmental or total knee arthroplasties).Arthrodesis. Arthrodesis is a treatment option for severe arthritis where the overlying articular cartilage is removed and two opposing bones heal together with the use of hardware (internal or temporary external fixation) often supplemented by bone graft. After successful arthrodesis, no motion is possible through the joint and the source of pain is


Surgery_Schwartz

Surgery_Schwartz. with the use of hardware (internal or temporary external fixation) often supplemented by bone graft. After successful arthrodesis, no motion is possible through the joint and the source of pain is removed. Arthrodesis of large joints, such as the knee, shoulder, or hip, are typically explored as an option in the face of infection, in older adult, low-demand patients or in young, active patients who are con-sidered too young for a joint replacement (out of concern for component wear and the need for early revision). Arthrodesis can also serve as a “last resort” procedure in orthopedics when joint preserving treatments fail due to fracture or infection. Ankle arthrodesis is the primary procedure performed in adult patients with traumatic arthritis of the ankle.Joint Arthroplasty/Joint Replacement. Joint arthroplasty is the most common option for patients suffering from pain associated with arthritis in a joint. The surfaces of the bones are replaced after removing the damaged articular


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Surgery_Schwartz. arthroplasty is the most common option for patients suffering from pain associated with arthritis in a joint. The surfaces of the bones are replaced after removing the damaged articular cartilage. The amount of bone and the determination of how to make the bone cuts is made based on preoperative radiographs and templating, cutting guides, anatomic measurements, and soft tissue/ligament balancing. The cut bony surfaces are covered with new compo-nents, usually made of metal, ceramic, or polyethylene. These new components are sized to appropriately match the patient, based on templated preoperative radiographs, intraoperative measurements, and examination for stability, leg length, align-ment, and range of motion.If all compartments or surfaces of the joint are replaced, the arthroplasty is referred to as a total joint arthroplasty. In comparison, if only one surface or compartment of the joint is replaced, it is referred to as hemiarthroplasty (hip, shoulder) or unicompartmental


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Surgery_Schwartz. is referred to as a total joint arthroplasty. In comparison, if only one surface or compartment of the joint is replaced, it is referred to as hemiarthroplasty (hip, shoulder) or unicompartmental arthroplasty (knee). Total hip and knee arthroplasties are considered among the most successful of all surgical procedures performed in terms of patient outcome and improvement in pain.Hip Arthroplasty Background Hip arthroplasty is utilized for end stage arthri-tis in the hip that has failed a reasonable trial of nonoperative measures (Fig. 43-37). Conventional hip arthroplasty commonly refers to total hip arthroplasty where both the femoral head and acetabulum are replaced or resurfaced, respectively. Finally, hemiarthroplasty describes the replacement of the femoral head and neck with a stemmed femoral component in isolation. The acetabulum is not addressed surgically.History of Hip Arthroplasty The history of hip arthroplasty (hip replacement) may be broken down into “Pre-Charnley” and


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Surgery_Schwartz. femoral component in isolation. The acetabulum is not addressed surgically.History of Hip Arthroplasty The history of hip arthroplasty (hip replacement) may be broken down into “Pre-Charnley” and “Post-Charnley” eras, referring to the significant contri-butions of Sir John Charnley to the evolution of hip arthro-plasty. Prior to Charnley’s contributions, hip arthroplasty consisted of a variety of procedures with highly variable results. Early attempts at relieving hip pain were made with interpositional arthroplasty, where tissue layers, plastic, or metal were placed between the worn articular surfaces. Frac-ture of the interposed material or loosening of components often led to failure.Later attempts introduced stemmed components to improve fixation. One of the earliest femoral components was designed by Austin-Moore. This prosthesis replaced the femoral head and neck with a metal component secured into the femoral shaft with a stem extending down the diaphysis. This prosthesis was


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Surgery_Schwartz. was designed by Austin-Moore. This prosthesis replaced the femoral head and neck with a metal component secured into the femoral shaft with a stem extending down the diaphysis. This prosthesis was utilized in hemiarthroplasty for many years and served as Figure 43-37. Osteoarthritis femoral head. Note erosion of weight-bearing cartilage and peripheral osteophytes.Brunicardi_Ch43_p1879-p1924.indd 190622/02/19 10:41 AM 1907ORTHOPEDIC SURGERYCHAPTER 43a step in the development of total hip arthroplasty with the later addition of the acetabular component.Surgical Approaches to the Hip A variety of approaches to the hip joint have been utilized in joint arthroplasty, includ-ing anterior approach (Smith Petersen), anterolateral approach (Watson-Jones), lateral approach (Hardinge), and posterior approach (Kocher Langenbach). Each approach contains a unique set of advantages and disadvantages. The following is a brief summary of the most common approaches that are utilized in total hip


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Surgery_Schwartz. approach (Kocher Langenbach). Each approach contains a unique set of advantages and disadvantages. The following is a brief summary of the most common approaches that are utilized in total hip arthroplasty.Anterior approach (Smith Petersen): This approach is an internervous and intermuscular approach. It utilizes the inter-nervous plane between the femoral nerve and superior gluteal nerve. Superficially, the plane between the sartorius (femo-ral nerve) and tensor fasciae lata (superior gluteal nerve) is dissected in the deep layer and the plane between the rectus femoris (femoral nerve) and gluteus medius (superior glu-teal nerve) is dissected. Advantages to this approach include supine positioning, use of intraoperative fluoroscopy for acetabular component positioning, and discontinuation of all ambulatory assistive devices 1 week earlier than other approached. Downsides include difficult preparation and placement of the femoral component with higher rate of femoral fracture/femoral


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Surgery_Schwartz. of all ambulatory assistive devices 1 week earlier than other approached. Downsides include difficult preparation and placement of the femoral component with higher rate of femoral fracture/femoral component revision, higher rate of wound complications, and lack of a true extensile approach.Posterior approach (Kocher–Langenbach): The posterior approach is a muscle-splitting approach without an interner-vous plane. After incising the skin and subcutaneous fat, the fascia lata is incised along with the gluteus maximus. The short external rotators are exposed and dissected, includ-ing the piriformis, superior and inferior gemelli, obturator internus and externus, and quadratus femoris. This allows internal rotation of the hip along with flexion and adduction to dislocate the hip. The posterior approach with posterior soft tissue repair has no increased rate of dislocation com-pared to the anterior approach. The posterior approach is extensile and provides excellent exposure of both the


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Surgery_Schwartz. approach with posterior soft tissue repair has no increased rate of dislocation com-pared to the anterior approach. The posterior approach is extensile and provides excellent exposure of both the femur and acetabulum for complex and revision cases.Lateral approach (Hardinge): While there have been many modifications to the original Hardinge approach, first described in 1982, most involve releasing the anterior one-third of the gluteus medius, underlying minimus, abductor tendon, and vastus lateralis distally in one sleeve off of the greater trochanter. The capsule is then incised to expose the hip joint. Care must be taken to protect the superior gluteal nerve during this exposure, which lies 5 cm proximal to the tip of the greater trochanter.Exposure of the acetabulum is excellent with the modified Hardinge approach, which is extensile. However, access to the posterior column is limited compared to the posterior approach. The increased risk of postoperative Trendelenburg gait, other


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Surgery_Schwartz. modified Hardinge approach, which is extensile. However, access to the posterior column is limited compared to the posterior approach. The increased risk of postoperative Trendelenburg gait, other pathologic gait, and heterotopic ossification compared to all other approaches to the hip have made it far less commonly performed than the posterior approach. Minimally invasive total hip arthroplasty is associated with decreased visualiza-tion intraoperatively and associated risks of component malposition, intraoperative fracture, and nerve or vascular injury. In fact, the only documented benefit of minimally inva-sive techniques appears to be a smaller incision, but with increased soft tissue tension intraoperatively comes the risk of compromised wound healing and periprosthetic joint infection.Bearing Surfaces in Hip Arthroplasty The most common combination of bearing surfaces used in total hip arthroplasty is a metal (generally cobalt chrome) or ceramic prosthetic head, articulating


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Surgery_Schwartz. Surfaces in Hip Arthroplasty The most common combination of bearing surfaces used in total hip arthroplasty is a metal (generally cobalt chrome) or ceramic prosthetic head, articulating with a polyethylene liner. Metal on metal (MOM) articulations have largely been abandoned in total hip arthro-plasty as they are associated with production of metal ions that deposit in solid organs, pseudotumors that are locally destruc-tive to soft tissue/bone, and risk of early failure (Fig. 43-38). Ceramic on ceramic articulations have the lowest friction of all current bearing combinations. However, ceramic may fracture or squeak in ceramic on ceramic total hip arthroplasties.Alignment of Hip Arthroplasty Components Proper align-ment of hip arthroplasty components is vital to a successful procedure and patient outcome. Surgeons aim for appropriate alignment of components to restore a functional and stable range of motion. This is accomplished with combined version of the femoral and acetabular


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Surgery_Schwartz. and patient outcome. Surgeons aim for appropriate alignment of components to restore a functional and stable range of motion. This is accomplished with combined version of the femoral and acetabular components, appropriate abduc-tion of the acetabular components, and staying true to Sir John Charnley’s principles: establishing a low friction articulation, 12Figure 43-38. Failed ceramic on metal hip arthroplasty components. Note the metallic staining on the ceramic femoral head.Brunicardi_Ch43_p1879-p1924.indd 190722/02/19 10:41 AM 1908SPECIFIC CONSIDERATIONSPART IImedializing the acetabular component and center of rotation and restoring abductor length and tension with restoration of appropriate length and femoral offset. Inappropriate placement of components can lead to early failure, accelerated component wear, dislocation, need for revision surgery, as well as poor patient outcomes and satisfaction.Knee Arthroplasty Background Knee arthroplasty is indicated for end-stage


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Surgery_Schwartz. accelerated component wear, dislocation, need for revision surgery, as well as poor patient outcomes and satisfaction.Knee Arthroplasty Background Knee arthroplasty is indicated for end-stage arthritis that has failed a reasonable trial of nonoperative mea-sures (Figs. 43-39 and 43-40). Knee arthroplasty commonly refers to total knee arthroplasty where the distal femur, tibia, and patella are resurfaced after any remaining articular cartilage and a layer of subchondral bone are resected. A unicompartmental knee arthroplasty consists of replacing one compartment of the knee, most commonly the medial compartment.Surgical Approach to the Knee Total knee arthroplasty is generally accomplished through a medial parapatellar approach. This approach utilizes a longitudinal skin incision extending, on average, 5 cm proximal to the patella to the medial aspect of the tibial tubercle distally. Dissection is carried down to the capsule. To gain access to the joint, an arthrotomy is performed


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Surgery_Schwartz. on average, 5 cm proximal to the patella to the medial aspect of the tibial tubercle distally. Dissection is carried down to the capsule. To gain access to the joint, an arthrotomy is performed medial to the patella extending proximally along the most medial aspect of the quadriceps tendon and distally just medial to the patellar tendon. This approach provides excellent exposure to all three compartments of the knee after patellar dislocation.Once the joint surfaces are adequately exposed, remain-ing articular cartilage and a thin layer of underlying bone are removed prior to placement of prosthetic components. Bone cuts are made based on preoperative templating, cutting guides, ligament balancing, and anatomic measurements (Figs. 43-41 and 43-42).Bearing Surfaces in Knee Arthroplasty The femoral com-ponent consists of a metal prosthetic cap sized to fit the normal shape of the distal femur. The tibia is cut perpendicular to the anatomic and mechanical axis, and a flat, stemmed, metal


Surgery_Schwartz

Surgery_Schwartz. femoral com-ponent consists of a metal prosthetic cap sized to fit the normal shape of the distal femur. The tibia is cut perpendicular to the anatomic and mechanical axis, and a flat, stemmed, metal tray is placed that serves as a base plate for a polyethylene bearing surface. The patella is usually resurfaced with a polyethylene component.Two types of primary total knee arthroplasty systems exist, including cruciate retaining and posterior stabilized systems. As the name implies, with cruciate retaining systems, the PCL is retained in hopes of preserving more normal knee structures and minimizing bone loss, while in posterior stabilized systems the ligament is sacrificed and the components are designed to accommodate for the loss. These two systems have equivalent results in knee arthroplasty.Alignment and Balancing in Knee Arthroplasty Appropri-ate sizing and positioning of the components and balancing of the size and geometry of bony gaps in flexion and extension are essential for


Surgery_Schwartz

Surgery_Schwartz. and Balancing in Knee Arthroplasty Appropri-ate sizing and positioning of the components and balancing of the size and geometry of bony gaps in flexion and extension are essential for a successful knee arthroplasty. Inappropriate com-ponent position can lead to early wear and failure, instability, pain, and stiffness.Computer Navigation, Robotics, and Joint ArthroplastyComputer-navigated joint arthroplasty has the theoretical ben-efit of more accurate and consistent placement of arthroplasty components through intraoperative feedback to the surgeon regarding component position, planned bone cuts, and align-ment. Disadvantages include increased costs of the technology, prolonged operative times, and risk of infection/fracture at the sites of intraoperative sensor placement within bone. Use of Figure 43-39. Valgus deformity. Osteoarthritis of lateral compart-ment right knee.Figure 43-40. Osteoarthritis of both knees. Note varus alignment of right knee and valgus alignment of left knee


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Surgery_Schwartz. of Figure 43-39. Valgus deformity. Osteoarthritis of lateral compart-ment right knee.Figure 43-40. Osteoarthritis of both knees. Note varus alignment of right knee and valgus alignment of left knee (windswept deformity).Brunicardi_Ch43_p1879-p1924.indd 190822/02/19 10:41 AM 1909ORTHOPEDIC SURGERYCHAPTER 43ABFigure 43-41. A. Varus knee with osteoarthritis. B. Right total knee replacement.Figure 43-42. Computer-assisted robotic targeting arm for total knee replacement.Brunicardi_Ch43_p1879-p1924.indd 190922/02/19 10:41 AM 1910SPECIFIC CONSIDERATIONSPART IIcomputer navigation in total joint arthroplasty has been shown to minimize outliers in alignment, but there has been no proven benefit in survival or function secondary to computer-navigated or robotic-assisted joint replacement.Fixation Options in Joint ArthroplastyComponents in hip and knee arthroplasty can be secured with cement or biologic fixation. The cement most commonly used is polymethylmethacrylate (PMMA). PMMA serves


Surgery_Schwartz

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


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Surgery_Schwartz. as older adults, osteoporotic or previ-ously irradiated cement may be a better option. With revision total hip arthroplasty, cement fixation of components has been shown to lead to earlier mechanical failure.Osteolysis and Aseptic Loosening. Osteolysis is a term used to describe abnormal resorption of bone. Osteolysis can be caused by underlying infection, metastatic disease, or in case of joint replacement, the production of wear debris. Even with appropriately positioned components, some wear of the bear-ing surfaces is expected over time. However, wear rates as well as the size and amount of wear debris differs with the bearing surface. Friction in ceramic on ceramic articulations is the low-est of all bearing surfaces; however, there is increased risk of component fracture and postoperative “squeaking.” In metal or ceramic on polyethylene articulations, wear debris is produced, and polyethylene particles are phagocytized by local macro-phages. Activated macrophages lead to an


Surgery_Schwartz

Surgery_Schwartz. “squeaking.” In metal or ceramic on polyethylene articulations, wear debris is produced, and polyethylene particles are phagocytized by local macro-phages. Activated macrophages lead to an osteolytic process and bone resorption. Particulate methylmethacrylate cement debris can also play a role in osteolysis by damaging the polyethylene bearing surface. Osteolysis has been shown to be significantly decreased with the advent and use of highly cross-linked poly-ethylene. Improperly positioned components or patient-related factors such as high impact activities can lead to increased wear. A substantial osteolytic response may occur and lead to compo-nent micromotion and aseptic loosening. Patients who present to clinic with pain following joint arthroplasty and an increas-ing zone of osteolysis in the periprosthetic region frequently need revision surgery (Fig. 43-43). Alternative bearing surfaces continue to be explored in hopes of decreasing component wear, associated osteolysis, and


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Surgery_Schwartz. in the periprosthetic region frequently need revision surgery (Fig. 43-43). Alternative bearing surfaces continue to be explored in hopes of decreasing component wear, associated osteolysis, and aseptic loosening.Complications in Joint ArthroplastyThe risk of any complication following joint arthroplasty proce-dures falls in the range of 5% to 10%. Risks shared by hip and knee arthroplasties include infection, intraoperative or postop-erative fracture, vascular injury, need for intraoperative or post-operative blood transfusion, nerve injury or nerve palsy (most commonly involving the deep peroneal nerve and loss of ankle dorsiflexion), stress shielding, component fracture or wear, and medical complications, including venous thromboembolic dis-ease (DVT and PE), myocardial infarction, or cerebrovascular accident. Complications unique to total hip arthroplasty include dislocation, leg length discrepancy, and iliopsoas impingement or tendonitis.Dislocation Following Hip


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Surgery_Schwartz. infarction, or cerebrovascular accident. Complications unique to total hip arthroplasty include dislocation, leg length discrepancy, and iliopsoas impingement or tendonitis.Dislocation Following Hip Arthroplasty. Dislocation can result from malpositioned components (inadequate com-bined version of the femoral stem and acetabular component; extremes of inclination of the acetabular component), noncom-pliance, cognitive or neuromuscular disorders, compromised soft tissue envelope from revision surgery, fracture, or insuf-ficient restoration of length and/or offset. Comparable disloca-tion rates have been found with anterolateral, lateral, anterior, and posterior with soft tissue repair (approximately 0.5%) approaches. History, physical examination, and 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 neces-sary. Component position should be


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Surgery_Schwartz. treatment of dislocation. Closed reduction can usually be performed with conscious sedation and gentle traction or manipulation. Rarely, open reduction may be neces-sary. Component position should be assessed in patients with multiple dislocations. Patients with recurrent dislocations and suboptimally positioned components may require component revision. Patients with recurrent dislocations and properly posi-tioned components should be considered for conversion to a device with a larger prosthetic head (dual mobility construct) or a constrained total hip arthroplasty implant that provides improved stability.ORTHOPEDIC PATHOLOGY AND ONCOLOGYDiagnosis of Malignant Bone TumorsHistory. Diagnosis of musculoskeletal tumors begins with a thorough patient history. A history of unremitting pain unre-lated to activity or pain that interferes with sleep suggests malig-nancy. Patient age can help in establishing a differential. Round Figure 43-43. Failed total knee replacement. Note subsided,


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Surgery_Schwartz. unre-lated to activity or pain that interferes with sleep suggests malig-nancy. Patient age can help in establishing a differential. Round Figure 43-43. Failed total knee replacement. Note subsided, loose, tibial component.Brunicardi_Ch43_p1879-p1924.indd 191022/02/19 10:41 AM 1911ORTHOPEDIC SURGERYCHAPTER 43blue cell lesions are most likely neuroblastoma in a 5-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 aids in the differen-tial. For instance, giant cell tumor is more common in females, while osteosarcoma is more common in males. Multiple bone involvement may suggest enchondromas (Ollier disease, Maffucci’s syndrome) or osteochondromas (multiple hereditary exostoses).Laboratory Tests. 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


Surgery_Schwartz

Surgery_Schwartz. 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 in the diagnosis of bony tumors. Radiographs can help assess the aggressive-ness 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 is the lesion? (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)? and (d) What is the matrix pattern? Matrix is the acellular interstitial substance produced by tumor cells. Particu-lar attention should be paid to the junction between the tumor and the host bone since this margin can also indicate the aggres-siveness of the tumor. Ewing’s sarcoma has a characteristic “onion skin” periosteal reaction pattern. This reaction pattern


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Surgery_Schwartz. the tumor and the host bone since this margin can also indicate the aggres-siveness of the tumor. Ewing’s sarcoma has a characteristic “onion skin” periosteal reaction pattern. This reaction pattern also occurs in other tumors and infections.OSTEOSARCOMAThe most common primary malignant bone tumor is osteosar-coma (Fig. 43-44). Osteosarcomas are classified as osteoblas-tic, chondroblastic, fibroblastic, telangiectatic, round cell, or MFH-like, according to the predominant cell type. Most osteo-sarcomas present in patients between 10 and 20 years of age. Secondary osteosarcomas occur in older patients in abnormal bone affected by Paget’s disease, radiation, or bone infarct.Intramedullary OsteosarcomaThis is the most common primary sarcoma of the bone. It usu-ally occurs in the distal femur or the proximal tibia in young people. This condition may also occur at the proximal humerus, proximal femur, or pelvis. It usually presents itself as a high-grade extracompartmental disease. It can


Surgery_Schwartz

Surgery_Schwartz. or the proximal tibia in young people. This condition may also occur at the proximal humerus, proximal femur, or pelvis. It usually presents itself as a high-grade extracompartmental disease. It can metastasize to the bone, which is called a “skip lesion,” but the lung is the primary site of metastases. Long term survival is 75% with adequate treatment. The response to chemotherapy (98% necrosis of the Table 43-1Common locations of bone tumorsFEMURDistal posteriorParosteal osteosarcomaDistal anteriorPeriosteal osteosarcoma, periosteal chondroma or chondrosarcoma, myositis ossificansTIBIAAdamantinoma, chondromyxoid, fibromaHANDS AND FEETEnchondroma, exostosisCalcaneusUnicameral bone cyst, lipoma, chondroblastoma, osteosarcomaSPINEAnteriorMetastatic, myeloma, Paget’s disease, vascular malformation, giant cell tumorPosteriorOsteoid osteoma, osteoblastoma; aneurysmal bone cystPELVISMetastatic, myeloma, chondrosarcoma, giant cell tumor, aneurysmal bone cyst, Paget’s disease, Ewing’s


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Surgery_Schwartz. malformation, giant cell tumorPosteriorOsteoid osteoma, osteoblastoma; aneurysmal bone cystPELVISMetastatic, myeloma, chondrosarcoma, giant cell tumor, aneurysmal bone cyst, Paget’s disease, Ewing’s SarcomaSACRUMChordoma (midline), chondrosarcoma, giant cell tumor, aneurysmal bone cyst, lymphomaRIBSMetastatic, myeloma, fibrous dysplasia, chondrosarcomaTable 43-2Tumor location in boneEpiphysisChondroblastoma, clear cell chondrosarcoma, giant cell tumor (GCT), infection, dysplasia epiphysealis hemimelica (DEH)MetaphysisMost common site of involvementDiaphysisF-Fibrous dysplasia, EG-Eosinophilic Granuloma, N-Nonossifying Fibroma, O-Osteoid osteoma, M-Myeloma, A-Adamantinoma, S-Simple Bone Cyst, H-Histiocytosis, I-InfectionFigure 43-44. Osteosarcoma.Brunicardi_Ch43_p1879-p1924.indd 191122/02/19 10:41 AM 1912SPECIFIC CONSIDERATIONSPART IItumor after chemotherapy is a good sign) and the stage of the disease determines the prognosis. Young patients may present with pain and swelling,


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Surgery_Schwartz. 10:41 AM 1912SPECIFIC CONSIDERATIONSPART IItumor after chemotherapy is a good sign) and the stage of the disease determines the prognosis. Young patients may present with pain and swelling, with X-rays showing plastic lesions in some areas of destruction with periosteal reaction called “Codman’s Triangle.” X-rays may show bone formation with a sunburst appearance. MRI should involve the entire bone to diagnose the skip metastasis. CT scans of the chest are usually done to find primary metastases. Alkaline phosphatase is usu-ally high. Diagnosis is typically confirmed with a biopsy, which is done after staging the tumor. Proper biopsy technique should be employed, which includes longitudinal incisions. As a gen-eral rule, the biopsy should be done by the same surgeon who will provide the definitive treatment for the patient. Treatment of osteosarcoma will be preoperative chemotherapy and wide resection, followed by postoperative chemotherapy.Parosteal OsteosarcomaParosteal


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Surgery_Schwartz. the definitive treatment for the patient. Treatment of osteosarcoma will be preoperative chemotherapy and wide resection, followed by postoperative chemotherapy.Parosteal OsteosarcomaParosteal osteosarcoma is a low-grade surface osteosarcoma that appears as if it were stuck on the bone, especially in the pos-terior distal femoral metaphysis (80%). The differential diagno-sis includes osteochondroma and myositis ossificans. Treatment consists of wide excision. The prognosis is 95% 5-year survival as it is a low-grade tumor.Periosteal OsteosarcomaPeriosteal osteosarcoma is a high-grade tumor. It 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 chemotherapy and wide surgical excision. The 5-year survival rate is 80%.Paget’s SarcomaPaget’s sarcoma is a rare complication of Paget’s disease. In Paget’s disease with


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Surgery_Schwartz. reaction. Treatment is chemotherapy and wide surgical excision. The 5-year survival rate is 80%.Paget’s SarcomaPaget’s sarcoma is a rare complication of Paget’s disease. In Paget’s disease with multiple bone involvement, osteogenic sar-coma, fibrosarcoma, chondrosarcoma, and MFH have occurred, most often in the pelvis, but also in the femur, humerus, spine, and skull. This malignant transformation occurs in less than 1% of patients. The patient will complain of new onset pain and swelling. The physician must have a high index of suspicion in patients with Paget’s who previously had no pain. Imaging may demonstrate osteolytic areas and loss of normal fatty marrow and multifocal lesions. Treatment of Paget’s sarcoma is chemo-therapy and wide surgical excision. The prognosis is poor, and the 5-year survival rate is less than 10%.Radiation-Induced SarcomaThe three criteria for diagnosis of radiation-induced sarcoma are (a) histology different from the original lesion, (b) sarcoma develops


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Surgery_Schwartz. 5-year survival rate is less than 10%.Radiation-Induced SarcomaThe three criteria for diagnosis of radiation-induced sarcoma are (a) histology different from the original lesion, (b) sarcoma develops in the irradiated field, and (c) a 3to 5-year latent period between radiation and sarcoma development. Radiation for carcinoma of the breast and cervix can result in osteosar-coma, chondrosarcoma, fibrosarcoma, or MFH. Treatment is a combination of chemotherapy and surgery.EWING’S SARCOMAEwing’s sarcoma is the second most common primary bone tumor in patients under 25 years of age. The typical presenta-tion is a tumor in the diaphysis of long bones, especially the femur. It can also be seen in the pelvis, the proximal tibia, and proximal humerus, and it is usually seen in young white males. It has a t(11:22) translocation and positive CD99. The patient may have pain and fever with an elevated sedimentation rate and WBC count; the condition may be confused with an infection. An “onion


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Surgery_Schwartz. It has a t(11:22) translocation and positive CD99. The patient may have pain and fever with an elevated sedimentation rate and WBC count; the condition may be confused with an infection. 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. 43-45). 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.CARTILAGE-FORMING TUMORSChondrosarcomasChondrosarcomas typically occur in male patients over 40 years of age, and they 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 preexisting lesions such as exostoses or enchondromas. Pelvis, shoulder, and ribs are common locations.


Surgery_Schwartz

Surgery_Schwartz. or dedifferentiated neoplastic cartilage. Secondary chondrosarcomas may also develop in preexisting lesions such as exostoses or enchondromas. Pelvis, shoulder, and ribs are common locations. Chondroid or “popcorn” cal-cifications are typical on radiographs. Clear cell chondrosar-coma and mesenchymal chondrosarcoma occur in younger patients (second to fifth decades of life). Clear cell chondro-sarcomas are low-grade lesions that often affect the epiphyses. The dedifferentiated chondrosarcoma is a high-grade chondro-sarcoma with a less than 10% survival rate. It has a biomor-phic histology, with a chondroid component and a high-grade spindle cell component.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.FIBROUS LESIONS OF BONEDesmoplastic


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Surgery_Schwartz. or radical resection is recommended. Pelvic and scapular chondrosarcomas have a high recurrence rate, and adjuvant chemotherapy does not improve survival rates.FIBROUS LESIONS OF BONEDesmoplastic FibromaDesmoplastic fibroma is a rare tumor occurring in the mandible, femur, pelvis, radius, or tibia in young adults. It presents as a painful lesion. Radiographs show a metadiaphyseal “soap bubble” appearance and endosteal scalloping. Histology resembles Figure 43-45. Ewing’s sarcoma.Brunicardi_Ch43_p1879-p1924.indd 191222/02/19 10:41 AM 1913ORTHOPEDIC SURGERYCHAPTER 43desmoid tumors or fibromatosis. Recommended treatment is wide excision to avoid recurrence.Malignant Fibrous Histiocytoma of BoneMFH occurs in the metadiaphysis of long bones after condi-tions like nonossifying fibromas and bone infarcts. It may pres-ent with pain or by a pathologic fracture. Radiographs typically show destructive lesions with soft-tissue extension. Histology resembles osteosarcoma with pleomorphic


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Surgery_Schwartz. and bone infarcts. It may pres-ent with pain or by a pathologic fracture. Radiographs typically show destructive lesions with soft-tissue extension. Histology resembles osteosarcoma with pleomorphic spindle cells, his-tiocytes, and giant cells, but no neoplastic osteoid formation. Treatment is chemotherapy and wide surgical excision.Malignant Vascular TumorsHemangioendothelioma. Hemangioendothelioma is a malig-nant neoplasm arising from vascular endothelium in long bones and most often occurs in the lower extremity. 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 +/radiation therapy 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 older adult males. Histology


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Surgery_Schwartz. 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 older adult 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 malig-nancy usually seen in older adult males; chronic vascular stasis is a risk factor. Histology reveals vascular channels with ana-plasia. Treatment is wide excision, or if the tumor is surgically inaccessible, radiation.MISCELLANEOUS TUMORSGiant Cell Tumor of BoneGiant cell tumor is a benign aggressive tumor. Fifty per-cent of these tumors occur around the knee, especially at the distal femur and the proximal tibial. Giant cell tumors may also occur in the distal radius, proximal humerus, and pelvis (especially the sacrum ala) in women 20 to 40 years of age. Presenting complaints include pain


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Surgery_Schwartz. the proximal tibial. Giant cell tumors may also occur in the distal radius, proximal humerus, and pelvis (especially the sacrum ala) in women 20 to 40 years of age. Presenting complaints include pain and pathologic fracture. Imaging reveals eccentric, epimetaphyseal lytic lesions erod-ing the subchondral bone. Histology reveals multinucleate giant cells and mononuclear stromal cells. An abundance of giant cells in the field can help establish the diagnosis, and the nuclei of giant cells appear the same as the stroma cells (all nuclei look similar) (Fig. 43-46). Giant cell tumors must be differentiated from the Brown tumor of hyperparathy-roidism. While both have giant cells, hyperparathyroidism affects multiple areas, and the serum calcium is not normal. Epiphyseal lesions such as chondroblastoma should also be part of the differential diagnosis. These tumors can occasion-ally metastasize to the chest. Primary malignant giant cell tumor has a poor prognosis. Treatment of giant cell


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Surgery_Schwartz. should also be part of the differential diagnosis. These tumors can occasion-ally 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 adjuvants such as cryosurgery, phenol, or polymethylmethacrylate bone cement may help decrease recurrence rates. After pathologic fractures, wide excision with reconstruction or amputation may be required.Adamantinoma and Osteofibrous DysplasiaAdamantinomas are low-grade malignant tumors usually seen in the tibia (Fig. 43-47). Adamantinomas are capable of metas-tasizing to the lung. The patient may present with pain and/or bowing of the tibia. X-ray reveals multiple lucent lesions on the cortex of the tibia. Histology reveals a biphasic tumor with nests of epithelial cells and fibrous stroma (see Fig. 43-46). Osteofibrous dysplasia is considered the precursor to ada-mantinoma and should be


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Surgery_Schwartz. of the tibia. Histology reveals a biphasic tumor with nests of epithelial cells and fibrous stroma (see Fig. 43-46). Osteofibrous dysplasia is considered the precursor to ada-mantinoma and should be part of the differential diagnosis. Osteofibrous dysplasia is a benign lesion, usually occurring in children, at the anterior tibia, which is treated with obser-vation. The treatment of adamantinoma is with wide surgical excision.Figure 43-46. Giant cell tumor.Figure 43-47. Typical location of adamantinoma.Brunicardi_Ch43_p1879-p1924.indd 191322/02/19 10:41 AM 1914SPECIFIC CONSIDERATIONSPART IIPrimary Lymphoma of BonePrimary lymphoma accounts for about 5% of all neoplasms of bone. Long bone involvement is more frequent than spine. Lym-phoma of bone typically occurs in males in their forties. Histol-ogy reveals large B cell lymphomas. Treatment is a combination of chemotherapy and radiation. Surgery may be required for stabilization of pathologic fractures.ChordomaChordoma arises from


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Surgery_Schwartz. Histol-ogy reveals large B cell lymphomas. Treatment is a combination of chemotherapy and radiation. Surgery may be required for stabilization of pathologic fractures.ChordomaChordoma arises from notochordal remnants in the sacrum. It is usually midline in location. These tumors are found in middle-aged to older men and presents with bladder and bowel symptoms due to involvement of the cauda equina. Visual-ization of the lesion may be difficult because of the bowel gas shadow. Diagnosis may be delayed. An MRI shows a destructive extensile midline lesion with a large soft tissue mass. Histology shows epithelioid cells arranged in cords with vacuolated foamy physaliferous cells. These cells are keratin positive. 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. Local recurrence is common.Multiple MyelomaMyeloma, the most common primary bone malignancy, is a pro-liferative


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Surgery_Schwartz. Urinary diversion and colostomy may be needed for loss of bladder and bowel control. Local recurrence is common.Multiple MyelomaMyeloma, the most common primary bone malignancy, is a pro-liferative disorder of B cells with plasma cells producing immu-noglobins. These plasma cells have a classic eccentric nucleus giving a “signet ring” appearance (Fig. 43-48). Evidence of monoclonal protein in the serum and/or urine (Bence Jones proteinuria), and hypercalcemia, renal insufficiency, anemia, or bone disease are usually present.Presenting symptoms in myeloma range from bone pain and osteopenia to focal lytic lesions with pathologic fractures and hypercalcemia. Myeloma protein 1-α stimulates osteo-clast formation. Osteoclast activating factors increase recep-tor activator of nuclear factor κB ligand (RANKL) in the bone marrow. RANKL induces osteoclast differentiation and acti-vation. Myeloma cells inhibit osteoblast differentiation and activity. Serum and urine electrophoresis detect the M


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Surgery_Schwartz. (RANKL) in the bone marrow. RANKL induces osteoclast differentiation and acti-vation. Myeloma cells inhibit osteoblast differentiation and activity. Serum and urine electrophoresis detect the M protein. Workup also includes complete blood cell count, erythrocyte sedimentation rate, calcium levels, renal function assessment, β2-microglobulin levels, and a skeletal survey. X-ray will show multiple punched out lytic lesions. Bone scans may be cold in about 30% of cases. The SPEP, UPEP, and bone marrow biopsy are helpful in diagnosis. Histology will show atypical plasma cells with eccentric nuclei, its appearance resembles a “signet ring (Fig. 43-49).” Plasmacytoma is a solitary tumor with a negative bone marrow biopsy, usually treated with radiation to the lesion. Myeloma is treated with bisphosphonates, chemo-therapy, stem cell transplantation, and radiation therapy. Surgi-cal stabilization and irradiation is done for pathologic fractures or impending fractures. Many patients with


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Surgery_Schwartz. bisphosphonates, chemo-therapy, stem cell transplantation, and radiation therapy. Surgi-cal stabilization and irradiation is done for pathologic fractures or impending fractures. 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 ver-tebroplasty. If there is instability or if there is neural compres-sion, surgical stabilization may be required.METASTATIC BONE TUMORSMetastatic 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, lung, thyroid, kidney, and prostate. In patients older than 40 years of age, metastases and myeloma are the most common causes of destructive lesions in bone. The most common site of involve-ment is the axial skeleton, especially the thoracic spine, and proximal ends of long bones, especially


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Surgery_Schwartz. are the most common causes of destructive lesions in bone. The most common site of involve-ment is the axial skeleton, especially the thoracic spine, and proximal ends of long bones, especially the proximal femur. Lung 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. The tumor activates osteoclasts and causes destruction of the bone, a mechanism that involves the RANK/RANKL pathway. The patient may present with pain, pathologic fractures, or the manifestation of hypercalcemia. Workup of a patient with a suspected metastatic disease to bone and an unknown primary tumor should include CT of the chest, abdomen, and pelvis. The extent of the disease is evaluated by bone scans (myeloma and thyroid are usually cold in bone scans), mammography, tumor markers, serum, and urine electrophoresis (SPEP and UPEP). A biopsy may be nec-essary to rule out primary bone lesions if the


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Surgery_Schwartz. (myeloma and thyroid are usually cold in bone scans), mammography, tumor markers, serum, and urine electrophoresis (SPEP and UPEP). A biopsy may be nec-essary to rule out primary bone lesions if the primary site is not identified. Treatment of bone tumors depends on the diagnosis, as metastatic tumors are treated differently than primary bone tumors. Metastatic tumors are usually treated by bisphospho-nates and by surgical stabilization with postoperative radiation if warranted. Primary bone tumors are usually treated by wide excision with chemotherapy in high-grade tumors (chondrosar-coma are treated only with wide excision). Radiation therapy can be used in Ewing’s.Multiple myelomaEccentricnucleusSignet ring appearanceFigure 43-48. Signet ring.Figure 43-49. Multiple Myeloma showing the eccentric nuclei and the signet appearance of cells.Brunicardi_Ch43_p1879-p1924.indd 191422/02/19 10:41 AM 1915ORTHOPEDIC SURGERYCHAPTER 43PEDIATRIC ORTHOPEDICSBirth InjuriesNeonatal Brachial


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Surgery_Schwartz. the eccentric nuclei and the signet appearance of cells.Brunicardi_Ch43_p1879-p1924.indd 191422/02/19 10:41 AM 1915ORTHOPEDIC SURGERYCHAPTER 43PEDIATRIC ORTHOPEDICSBirth InjuriesNeonatal Brachial Plexus Palsy. Injury of the brachial plexus during delivery occurs in 2 births in every 1000. Large birth weight, forceps delivery, breech presentation, and pro-longed second stage of labor with shoulder dystocia are risk factors. Brachial plexus injury usually represents a stretch injury on the nerve roots of the upper or lower plexus.Upper plexus injuries (Erb-Duchenne) are lesions mani-fested by weakness of shoulder abductors and external rota-tors as well as the elbow flexors (Fig. 43-50). The hand is not involved. It has a good prognosis, if the biceps function is pres-ent early.In lower plexus injury, the hand is involved, with defor-mity of the fingers. An ipsilateral Horner’s Syndrome consist-ing of ptosis, myosis, anhidrosis, and enophthalmos may occur indicating a preganglionic


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Surgery_Schwartz. plexus injury, the hand is involved, with defor-mity of the fingers. An ipsilateral Horner’s Syndrome consist-ing of ptosis, myosis, anhidrosis, and enophthalmos may occur indicating a preganglionic injury of the T1 cervical sympathetic nerve. This condition has a poor prognosis.Management is therapy and gentle, passive range-of-motion exercises to preserve motion in the shoulder and prevent muscle contractures and joint incongruency in the early neonatal period while awaiting return of neurologic function and motor reinnervation. Early surgical intervention for the brachial plexus is indicated in infants who did not recover elbow flexion by 3 months of age, as they are anticipated to have a poor chance of full recovery.Surgical intervention includes microsurgical repair proce-dures in the form of neurolysis, nerve transfer, or nerve grafts. Later orthopedic reconstruction such as muscle rebalancing procedures may be considered to improve function around the shoulder.Cerebral


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Surgery_Schwartz. in the form of neurolysis, nerve transfer, or nerve grafts. Later orthopedic reconstruction such as muscle rebalancing procedures may be considered to improve function around the shoulder.Cerebral Palsy. Cerebral palsy results from an injury to the brain, which may be associated with mental impairment. Cere-bral palsy is classified as spastic, athetotic, or 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 lengthen-ing procedures, release of contractures, and tendon transfers to maintain motion and function.Figure 43-50. Erb’s point.Reserve zone(resting zone)Proliferative zoneHypertrophic zoneZone ofmaturationZone ofdegenerationWWeaWeWeaWeaWeaWeaWeaWWWWWWWWWWWWWWWkkzkzkzkzkkzkzkzkzkzkkkkkkkk zkkkkkzkkoWeak zoneZone ofprovisionalcalcificationFigure 43-51. Different zones of the growth plate.Hip dislocation or subluxation results from unbalanced


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Surgery_Schwartz. zkkkkkzkkoWeak zoneZone ofprovisionalcalcificationFigure 43-51. Different zones of the growth plate.Hip dislocation or subluxation results from unbalanced muscle forces in many cerebral palsy patients. Early treatment consists of soft tissue releases in the form of adductor tendon releases, iliopsoas releases, and immobilization in an abduction brace.In older children with severe deformity, bony procedures in the form of open reduction and femoral or acetabular osteoto-mies are usually required. Femoral head resection is considered to be a salvage procedure in nonambulatory patients with pain-ful dislocated hips.Knee flexion contractures are treated with hamstring muscle lengthenings and immobilization in knee extension braces.Foot and ankle deformities are treated even in nonambu-latory 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,


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Surgery_Schwartz. 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 GrowthInjury, inflammatory disease, and developmental disorders in actively growing bones requires special attention to preserve the growth plates. The pediatric skeleton is incompletely ossi-fied making the diagnosis of an injury difficult, since signifi-cant 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 is divided into spe-cific zones: the reserve zone, the zone of proliferation, and the hypertrophic zone. The hypertrophic zone has three phases: the maturation zone, the degenerative zone, and the zone of calcification (Fig. 43-51).Injury or insult


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Surgery_Schwartz. the zone of proliferation, and the hypertrophic zone. The hypertrophic zone has three phases: the maturation zone, the degenerative zone, and the zone of calcification (Fig. 43-51).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 meta-bolically 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 appear in a predict-able order and can help determine “bone age.”Brunicardi_Ch43_p1879-p1924.indd 191522/02/19 10:41 AM 1916SPECIFIC CONSIDERATIONSPART IIPediatric FracturesIn a pediatric patient, the epiphyseal growth plate is unossified and weak and is at risk of fracture. Reduction and stabiliza-tion of epiphyseal fractures is critical to minimize permanent growth disturbances and deformity. Fractures near the growth plate have significant


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Surgery_Schwartz. and is at risk of fracture. Reduction and stabiliza-tion of epiphyseal fractures is critical to minimize permanent growth disturbances and deformity. Fractures near the growth plate have significant potential to remodel. For example, 80% of the growth of the humerus occurs from the proximal humeral growth plate; therefore, severely displaced proximal humeral fracture can remodel in the younger age group.Classification of Growth Plate InjuriesSalter and Harris described a useful classification for epiphyseal fractures (Fig. 43-52). 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. A Salter-Harris type III fracture occurs through the epiphysis and exits through the growth plate, while a Salter-Harris type IV fracture extends through the physis from the metaphysis into the epiphy-sis. A Salter-Harris type V fracture is


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Surgery_Schwartz. through the epiphysis and exits through the growth plate, while a Salter-Harris type IV fracture extends through the physis from the metaphysis into the epiphy-sis. A Salter-Harris type V fracture is a crushing injury to the physis. Type III and type IV involve the joint.Treatment of growth plate fracture requires anatomic reduction of the fragments, closed or open. If internal fixation is used, avoid placing the hardware across the growth plate to minimize the chance of injury and premature growth plate clo-sure. When hardware needs to be placed across the physis, it should be limited to smooth K-wires. The most common com-plication is a physeal arrest resulting in leg length discrepancy (LLD) and/or angular deformity. Complete arrest will lead to LLD. Partial arrest will result in angulation in the area of the bar, bridge, and fusion. If less than 50% of the physis is involved and the patient has two years of growth remaining, the bar is usually resected with interposition of fat


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Surgery_Schwartz. in the area of the bar, bridge, and fusion. If less than 50% of the physis is involved and the patient has two years of growth remaining, the bar is usually resected with interposition of fat graft. If the bar (fusion area) is more than 50%, the surgeon will complete the arrest on the same side and will do a contralateral epiphysiodesis on the other extremity.Distal femur physeal fractures are known to have a high rate of leg length discrepancy and angular deformity. The injury will need an anatomical reduction and close follow-up. Parents need to be counseled about the poor prognosis associated with these fractures.Diaphyseal Injuries in a Pediatric PatientLong bone 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. Older children do not remodel as well. A 10° angulation in both bones of the forearm in a


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Surgery_Schwartz. deformity within the plane of an adjacent joint is often completely remodeled by the growth of the child. Older children do not remodel as well. A 10° angulation in both bones of the forearm in a child over an age of 10 years may cause significant limitation of rotation of the forearm. When internal fixation of a diaphyseal fracture is required, fixation through the physis is avoided.Fractures of the Pediatric HipFractures of the pediatric hip can occur with high-energy trauma, and there is a high rate of avascular necrosis. Pedi-atric 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.” Closed or open reduction and internal fixation is done in fractures with severe displacement. Avascular necrosis is the most common complication after hip fractures. The incidence depends on the age of the patient and the type of


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Surgery_Schwartz. fixation is done in fractures with severe displacement. Avascular necrosis is the most common complication after hip fractures. The incidence depends on the age of the patient and the type of the fracture. Children between 3 and 8 years old with very proximal fractures such as transphyseal fractures have the highest incidence of avas-cular necrosis.Fractures of the Femoral ShaftConsider child abuse if a femoral shaft fracture occurs before the walking age. Femoral shaft fractures in a child younger than 6 months are usually treated by a Pavlik harness or spica cast. A child between 6 months and 5 years with an acceptable shortening of the femur is usually treated by an immediate spica cast. The child between 5 years and 11 years is usu-ally treated by surgery. If the fracture is transverse, flexible IM nails may be used, especially if the child weighs less than 100 lbs (45 kg). If the fracture is too proximal or too distal, or if the fracture is comminuted and unstable, a submuscu-lar


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Surgery_Schwartz. flexible IM nails may be used, especially if the child weighs less than 100 lbs (45 kg). If the fracture is too proximal or too distal, or if the fracture is comminuted and unstable, a submuscu-lar bridge plate is usually used; alternatively, an external fix-ator may also be used, especially in multiple trauma patients. If the patient is older than 11 years, an interlocking IM rod with a lateral trochanteric entry is used. Insertion of IM rod in younger children can cause avascular necrosis of the femoral head due to interruption of the blood supply. Refracture of the femur is a risk after using an external fixator. Overgrowth of the injured femur with leg length discrepancy can occur in children between 2 and 10 years of age.Figure 43-52. Classification of growth plate injuries.Brunicardi_Ch43_p1879-p1924.indd 191622/02/19 10:41 AM 1917ORTHOPEDIC SURGERYCHAPTER 43Pediatric Ankle FracturesPediatric ankle fractures include several types. Salter-Harris type I and type II usually


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Surgery_Schwartz. 191622/02/19 10:41 AM 1917ORTHOPEDIC SURGERYCHAPTER 43Pediatric Ankle FracturesPediatric ankle fractures include several types. Salter-Harris type I and type II usually involve the fibula, and the fracture may not be apparent. The patient may present with pain and swelling. Salter-Harris type III usually involves fracture of the medial malleolus or avulsion of the anterior inferior tibiofibular ligament from the tibia. It is called a Tillaux fracture. Tillaux fractures occur because the lateral part of the ankle is not fused and it is weak. Triplane fractures are complex ankle fractures in older children as a result of partial closure of the growth plate, and they appear as a Salter II in the lateral view and as a Salter III in an AP view (Fig. 43-53). Salter-Harris I and II fractures are usually managed with casting. Salter-Harris III or IV fractures are usually managed by closed or open reduction and internal fixation. Smooth percutaneous pins or screws are utilized, avoiding


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Surgery_Schwartz. are usually managed with casting. Salter-Harris III or IV fractures are usually managed by closed or open reduction and internal fixation. Smooth percutaneous pins or screws are utilized, avoiding the physis.Pediatric Elbow FracturesManagement of pediatric elbow fractures is complex. Famil-iarity with the timing of the ossification centers’ appearance aids in diagnosis. Distal humeral physeal separation can occur from child abuse and can be mistaken for an elbow dislocation. A lateral condylar fracture of the elbow is a significant injury, and when it is displaced it will need anatomical surgical reduc-tion. Medial epicondyle fractures of the elbow are usually treated conservatively unless they are severely displaced. It is associated with elbow dislocation in 50% of cases. When the elbow is reduced, the fragment may lodge in the joint itself and must be removed and fixed. In supracondylar fractures of the humerus (Fig. 43-54), the neurovascular status of the extrem-ity must be


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Surgery_Schwartz. elbow is reduced, the fragment may lodge in the joint itself and must be removed and fixed. In supracondylar fractures of the humerus (Fig. 43-54), the neurovascular status of the extrem-ity must be assessed carefully before, during, and after treat-ment. The anterior interosseous nerve could be injured, and the patient may not be able to make an “OK sign” (Fig. 43-55). The brachial artery may also be injured. Closed reduction, pos-sible open reduction, and percutaneous pinning is usually done for these fractures. The procedure should be done emergently if there is concern about the vascular status of the extremity. Close follow-up for maintenance of reduction and neurovas-cular status is needed.DEVELOPMENTAL DISEASEDevelopmental Dysplasia of the HipDevelopmental dysplasia of the hip (DDH) involves a spectrum of disease that includes dysplasia, subluxation, or dislocation of the hip. Teratologic hip dislocation is a different entity in which the hip is dislocated in utero and


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Surgery_Schwartz. hip (DDH) involves a spectrum of disease that includes dysplasia, subluxation, or dislocation of the hip. Teratologic hip dislocation is a different entity in which the hip is dislocated in utero and irreducible on neonatal examination, usually associated with neuromuscular conditions and genetic syndromes. Developmental dysplasia of the hip is most often seen in firstborn females with a positive family history or with breech birth.Untreated hip dislocations can lead to a dysplastic acetab-ulum, and they should be recognized and treated early. New-borns are examined for hip instability within the first 72 hours HumerusFigure 43-54. Supracondylar fracture of the humerus.Figure 43-55. Unable to make the “OK” sign due to interosseous nerve injury.Figure 43-53. Triplane fracture of the ankle in children.Brunicardi_Ch43_p1879-p1924.indd 191722/02/19 10:42 AM 1918SPECIFIC CONSIDERATIONSPART IIof life. Ortolani’s test consists of gentle elevation and abduction of the femur causing a


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Surgery_Schwartz. in children.Brunicardi_Ch43_p1879-p1924.indd 191722/02/19 10:42 AM 1918SPECIFIC CONSIDERATIONSPART IIof life. Ortolani’s test consists of gentle elevation and abduction of the femur causing a palpable click in the relocation of a dis-located hip. Barlow’s test is gentle adduction and depression of the femur, which causes a palpable click as the hip slips into a dislocated position. In older infants (older than 3 months), limited abduction of the involved hip is an important finding. Infants with a dislocated or dislocatable hip will have apparent length discrepancies of the femur when the hip is positioned at 90° (Galeazzi test).Since the bones are not ossified at birth, X-ray images of the acetabulum and femoral head are not reliable for diag-nosis. Ultrasound is the imaging modality of choice in the neonatal period and can often demonstrate a dislocated or dislocatable hip.Treatment of DDHThe main goal in the treatment of DDH is to achieve stable concentric reduction of the


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Surgery_Schwartz. of choice in the neonatal period and can often demonstrate a dislocated or dislocatable hip.Treatment of DDHThe main goal in the treatment of DDH is to achieve stable concentric reduction of the hip.• Neonate to 6 months: Early treatment with abduction and flexion in a Pavlik harness for 6 to 12 weeks is usually suf-ficient. Avoid severe abduction and flexion in the Pavlik har-ness to avoid the risk of avascular necrosis of the femoral head and femoral nerve palsy.• Children 6 to 18 months: Closed reduction and application of hip spica cast is indicated in this age group and in those children who failed Pavlik harness treatment.• Children older than 18 months: Open reduction and cap-sulorrhaphy is indicated in this age group. A variety of procedures, including femoral shortening and pelvic osteoto-mies, are done in older age groups and in more severe cases. Osteonecrosis of the femoral head is a possible complication of treatment and can result in pain and decreased range of


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Surgery_Schwartz. and pelvic osteoto-mies, are done in older age groups and in more severe cases. Osteonecrosis of the femoral head is a possible complication of treatment and can result in pain and decreased range of motion.Legg-Calvé-Perthes DiseaseOsteonecrosis of the proximal femoral epiphysis can cause flattening of the femoral head called Legg-Calvé Perthes disease. The age at presentation is between 4 and 8 years of age and occurs more in males, usually affecting one side. Younger age at presentation (less than 6 years old) will have a better prognosis. The patient presents with groin or knee pain, decreased hip motion, and a limp. Treatment includes traction, physical therapy, abduction exercises, and crutches. Restoration of range of motion is important. Femoral and pelvic osteotomies may be needed in extreme cases and in older children.Slipped Capital Femoral EpiphysisChildren ages 10 to 16 years can develop displacement of the epiphysis on the femoral neck with no history of injury. The


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Surgery_Schwartz. in extreme cases and in older children.Slipped Capital Femoral EpiphysisChildren ages 10 to 16 years can develop displacement of the epiphysis on the femoral neck with no history of injury. The slippage occurs through the weak zone (hypertrophic zone) of the growth plate. When slippage occurs in young patients, check for endocrine disorders such as hypothyroid-ism, renal osteodystrophy, and growth hormone deficiency. Slipped capital femoral epiphysis (SCFE) is associated with African-American heritage and obesity, and it is more com-mon in boys than in girls. One-quarter of cases are bilateral. In patients with endocrine etiology, the condition is usually bilateral. Patients generally present with groin and anterior thigh pain, and the patient may have antalgic gait and a limp. Patient may present with knee pain that can lead to missing the diagnosis. In pediatric patients with knee pain, the ipsi-lateral hip should be assessed as well.Examination of the patient will show obligatory


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Surgery_Schwartz. present with knee pain that can lead to missing the diagnosis. In pediatric patients with knee pain, the ipsi-lateral hip should be assessed as well.Examination of the patient will show obligatory external rotation with flexion and loss of internal rotation of the hip. Obtain AP and frog leg lateral views of both the hips.Slipped epiphysis is classified as either stable or unstable on the basis of the patient’s ability to bear weight. It is classi-fied as stable if the patient is able to bear weight and the risk of osteonecrosis is less than 10%. It is classified as unstable if the patient is unable to bear weight even with crutches, and the incidence of avascular necrosis is high.Treatment for slipped capital femoral epiphysis patients is percutaneous screw fixation through the femoral neck to engage the epiphysis, causing the growth plate to close. Reduc-tion of the slipped epiphysis is not recommended because of an increased risk of avascular necrosis. One screw is usually adequate


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Surgery_Schwartz. to engage the epiphysis, causing the growth plate to close. Reduc-tion of the slipped epiphysis is not recommended because of an increased risk of avascular necrosis. One screw is usually adequate to prevent further slip.Lower Extremity Rotational AbnormalitiesIntoeing can result from femoral anteversion, tibial torsion, and metatarsus adductus. Mild degree of intoeing is normal in young children 3 to 5 years of age.Excessive internal rotation of the femur will usually cor-rect by age 8. Severe rotation with functional impairment that does not correct by age 10 or 11 may require rotational femoral osteotomy.Tibial torsion is the most common cause of intoeing in toddlers and could be bilateral. The condition usually resolves without treatment.Metatarsus adductus in infants will also resolve spontane-ously in most cases.Congenital Talipes Equinovarus (Clubfoot)Clubfoot is a congenital disorder, and its etiology is not known. Clubfoot is a common problem associated with con-tractures of


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Surgery_Schwartz. spontane-ously in most cases.Congenital Talipes Equinovarus (Clubfoot)Clubfoot is a congenital disorder, and its etiology is not known. Clubfoot is a common problem associated with con-tractures of the medial tendons of the foot, a tight Achilles tendon, and contractures of the ankle, hindfoot, and midfoot. The foot is usually small, and it is in the equinus, varus, cavus, and adduction position. Talipes equinovarus can be corrected by sequential corrective casting of the foot. The serial manip-ulation and the casting technique is called the Ponseti tech-nique, and it has a high success rate. A successful program of casting may be complete in 1 to 5 months. In patients with severe disease or who initiate treatment after 9 months of age, surgical release of contracted soft tissues may be necessary. The procedure is called posteromedial soft tissue release and tendon lengthening.Osgood-Schlatter DiseaseOsgood-Schlatter disease is a common problem most often seen in athletically active


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Surgery_Schwartz. necessary. The procedure is called posteromedial soft tissue release and tendon lengthening.Osgood-Schlatter DiseaseOsgood-Schlatter disease is a common problem most often seen in athletically active adolescents, especially in sprint-ers and jumpers. It is a traction apophysitis of tibial tubercule (Figs. 43-56 and 43-57). One must know the difference between the epiphysis, apophysis, and physis. This disorder is charac-terized by ossification in the distal patellar tendon at the point of its tibial insertion, and it is thought to result from mechani-cal stress on the tendinous insertion. The disease presents with severe local pain and tenderness in the area of the tibial tubercle. Radiographs may show calcified ossicles within the tendon at its insertion.Brunicardi_Ch43_p1879-p1924.indd 191822/02/19 10:42 AM 1919ORTHOPEDIC SURGERYCHAPTER 43Treatment for the disease is activity restriction and anti-inflammatory drugs. The majority of patients improve with con-servative treatment,


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Surgery_Schwartz. 191822/02/19 10:42 AM 1919ORTHOPEDIC SURGERYCHAPTER 43Treatment for the disease is activity restriction and anti-inflammatory drugs. The majority of patients improve with con-servative treatment, and athletic participation can be resumed. Usually, symptoms regress after skeletal maturity or after activ-ity modification. In refractory cases, surgery in the form of ossicle excision is rarely done.BIBLIOGRAPHYEntries highlighted in bright blue are key references.TraumaBhandari M, Devereaux PJ, Tornetta III P, et al. Operative man-agement of displaced femoral neck fractures in elderly patients: an international survey. J Bone Joint Surg Am. 2005;87(9):2122-2130.Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid frac-tures. J Bone Joint Surg Am. 2001;83(4):483-488.Bone LB, Johnson KD, Weigelt J, et al. Early vs. delayed stabiliza-tion of femoral fractures. A prospective randomized study. J Bone Joint Surg Am.


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Surgery_Schwartz. J Bone Joint Surg Am. 2001;83(4):483-488.Bone LB, Johnson KD, Weigelt J, et al. Early vs. delayed stabiliza-tion of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. 1989;71:336-340.Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg Am. 2002;84-A(suppl 2):43-47.Burgess AR, Eastridge BJ, Young JWR, et al. Pelvic ring disrup-tions: Effective classification system and treatment protocols. J Trauma. 1990;30(7):848-856.De Ugarte DA, Morizono K, Elbarbary A, et al. Comparison of multi-lineage cells from human adipose and bone marrow. Cells, Tissue, and Organs. 2003;174:101-109.Dragoo JL, Samimi B, Zhu M, et al. Tissue-engineered cartilage and bone using stem cells from human infrapatellar fat pads. JBJS. 2003;85-B:740-747.Ebraheim N, Cooper J, Siddiqui S. Compartment syndrome book-let. University of Toledo Medical Center. March 1, 2018. Avail-able at:


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Surgery_Schwartz. cells from human infrapatellar fat pads. JBJS. 2003;85-B:740-747.Ebraheim N, Cooper J, Siddiqui S. Compartment syndrome book-let. University of Toledo Medical Center. March 1, 2018. Avail-able at: www.utoledo.edu/med/cme/pdf/Compartment%20Syndrome%20Booklet%20and%20Post%20Test%20water marked.pdf. Accessed August 14, 2018.Ebraheim N, Cooper J, Corba L. Synopsis of fractures and dislo-cations. University of Toledo Medical Center. March 1, 2018. Available at: www.utoledo.edu/med/cme/pdf/Synopsis%20of%20Fractures%20and%20Dislocations%20Booklet%20and%20Post%20Test%20Watermarked.pdf. Accessed August 13, 2018.Ebraheim N, Lea J, Cooper J, Corba L. Orthopaedic emergencies booklet. University of Toledo Medical Center. March 1, 2018. Available at: www.utoledo.edu/med/cme/pdf/Orthopedic%20Emergencies%20Booklet%20and%20Post%20Test%20Water marked.pdf. Accessed August 14, 2018.Frankle MA, Herscovici D, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and